Feature Fluid Motions By helping rowers find their form, PTs reduce injury risk and can improve athletes' performance. By Keith Loria | June 2017 World champion rower Kate MacKenzie dreamed of competing for the United States at the Summer Olympics in Greece in 2004. But the preceding year, she felt a pop in her back while training on the water. It turned out that she'd herniated a disc, which pushed on a nerve, causing weakness and pain. She worried that her bid had come to an end. Still, she began working with a physical therapist (PT). She progressed so much that she went on to win the Olympic trials with partner Sarah Jones and compete for the United States in the women's coxless pair event at the Athens Games. Thanks to that experience, she sought a career in physical therapy. She's now Kate Robbins, PT, DPT, and practices at Athletico Physical Therapy in Howell, Michigan. Greg Spooner, PT, DPT, works in San Diego with the US Navy as a civilian PT by day and after hours at the San Diego Rowing Club boathouse. He also raced competitively after college in Seattle. Rowing, sometimes referred to as crew, is a demanding pursuit that requires propelling oars with great force against the water while sitting in a boat in perfect formation. "It's a sport of biomechanics and conditioning, on top of being a sport of heart and grit," he says. "Few rehab practices out there really know the sport. I'm trying to help rowers get better faster and become more confident along the way." Spooner believes his rower patients appreciate seeing a PT who can understand what it's like to be 300 meters into a 2,000-meter race, feel a back twinge, and knows what to do next. "Being a rower also helps because I am familiar with the different strokes," Spooner adds. "That allows me to effectively target the cause of the pain. When you understand that, you can advise rowers on making an adjustment or modification, and keep them in the boat." Doug Adams, PT, DPT, with ATI Physical Therapy in North Wilmington, Delaware, has worked with many rowers over the years, especially in his role as a sports resident at the University of Delaware. Some of the non-back-related rower issues he encounters are knee and rib injuries related to the challenge of transferring force from the legs to the oar. "I see a lot of anterior knee pain, patella femoral pain syndrome, ITBS [iliotibial band syndrome], and combinations of the 3," Adams say. "What's occurring is that the rowers are engaged in a high-repetition activity, requiring high force, for a long time. This can lead to a breakdown, especially if there are form or positioning errors in how they're doing it. Our objective," he says, "is to improve these athletes' dynamic stability, making sure that during that motion the knee is not collapsing in and that they are not aggravating the involved tissues." Adams's intervention protocol involves improving stability and strength, and working on squatting activities, technique, and form. He also does some taping and positioning modifications. Karen Calara, PT, MSPT, now owner of Aligned and Balanced Rowing in Seattle, started working with rowers when she was in college as part of the sports medicine team at Boston University. Later, when Calara was running her own clinic in Seattle, a coach of elite rowers at Pocock Rowing Center (PRC) asked her if she knew anything about rowing. "This coach was looking for a PT to work with the high-performance team at PRC, and that relationship started me down the path I'm on now," she says. "I work with all ages of rowers, from juniors to senior masters, and all levels—from learn-to-row to elite and national team athletes. Currently, I have the pleasure to work closely with a junior program at Seattle Rowing Center. We track those rowers' growth spurts and conduct regular functional assessments. I write their strength and conditioning programs." Calera also has worked with elite and high-performance athletes along "Boathouse Row" in Philadelphia. Several rowers with whom she's worked have made the US national team and participated in the 2016 Summer Olympics in Rio de Janeiro, the 2016 World Championships in France, and this year's World Championships in the Netherlands. "I first assess all the athletes, so I have baselines on needed measurements," she says. "I work closely with the coaches to determine what we see in each athlete's stroke, and what needs to be improved upon from the standpoints of both injury prevention and performance. I am particularly interested," Calera adds, "in working with senior masters to develop strength and conditioning programs specific to that age group, and to address the challenges of the aging athletes—everything from basics such as getting in and out of the boat to rowing after procedures such as hip and knee replacements, and after conditions such as moderate to severe disc degeneration." The most common injuries to rowers, Calara notes, are back injuries—from simple muscle strains to more complicated disc injuries and even stress fractures. Shoulder and neck pain and muscle strain typically are caused by stroke form issues. Other injuries and conditions include rib stress fractures and ITBS, especially with pain at the knee. Bob Kaehler, PT, MSPT, a 3-time Olympic rower and founder of the endurance sports coaching business Coach Kaehler, has served professional and amateur rowers for more than 25 years. "After low back injuries, the most common rowing-related injuries are stress fractures in the ribs, scapula issues, and hip problems," he says. "Most athletes don't know how to control their trunk and keep their system in control when they strain their extremities." Justin Feldman, PT, DPT, of Feldman Physical Therapy & Performance in Poughkeepsie, NY, was a 4-year rower at Ithaca College and coached for a local rowing club and high school while starting his career as a PT. "Naturally, the rowers in the community felt comfortable coming to me with their rowing issues, because they knew I understood the sport and was positioned to help them," he says. "Over time, that has led to my work with the local collegiate rowing teams, for whom I help address injuries. I've also created prevention and strength-training plans. I am still a competitive master's rower. My patients and clients know that I know the sport, and they see me doing it. As a result, they feel confident that I understand what they are going through." Many rowing injuries that Feldman sees result from technical errors. For that reason, he says, he familiarizes himself with his patients' rowing stroke and establishes solid relationships with their coaches. Back Injuries Low back muscle strain probably is the most common rower injury PTs manage. Back pain also, however, can be the precursor to, or indicative of, more serious problems such as disc injuries or stress fractures. "The low back is rarely at fault for the injury," Spooner says. "There's a high likelihood that the rower has some sort of inflexibility or hypermobility at the hips or ankles, or in the thoracic spine. It's important to look for the true origin of the pain." He recommends incorporating manual therapy techniques, specific exercises, or stretching to increase mobility in those adjacent regions. "Initially, the rower is seeking pain control, so I'll incorporate soft tissue mobilization and joint mobilization to get the local region to ‘calm down,'" Spooner says. "If we are in regatta season, we'll explore what sort of taping methods we can use to stabilize the area and provide a little extra support to try and get the muscle to calm down." Spooner also looks at a rower's strokes on the erg (short for ergometer, or indoor rowing machine), trying to identify specific movement patterns that would benefit from modification. He looks for catch timing (the catch is the initial part of the stroke), core control from mid-stroke to mid-recovery, and overall movement. When Calara is looking at low back problems in an athlete, she conducts an overall standard evaluation that assesses posture, flexibility, joint mobility, range of motion, and muscle strength, and includes neurological and functional movement tests. She also evaluates rowers on the erg to assess their posture and biomechanics through the entire stroke, searching for technical faults in their stroke that may be causing or contributing to the injury. "I usually videotape the erg assessment so we can reference it later. That way, the athlete can see how his or her form is changing as we work together," she says. "I also ask the athlete or his or her coach to send me, if available, on-the-water video of the athlete rowing. This gives me an idea of what is actually happening on the water, especially when the rower is fatigued. Most back injuries are related to poor motion and mechanics of the hip, poor core stabilization, and inadequate strength. If the athlete is unable to get good or adequate motion at the hip during the stroke, he or she will compensate at the back, or even shoulder." If, for instance, the pelvis is unable to roll forward into an anterior pelvic tilt at the catch due to tightness in the hamstrings or IT bands, then the low back may have to flex more to gain length at the catch or front end of the stroke. If the deep core muscles are weak and not properly supporting the trunk through the body swing of the stroke, then the hip flexors have to work harder to keep the trunk supported as the pelvis moves into a posterior tilt. "Often, due to flexibility issues at the front end of the stroke and strength issues on the back end of the stroke, the pelvis rotates very little, while the lumbar spine pivots over it," Calara says. "This can lead to disc and fascial issues, and to stress fractures." Basic interventions includes increasing flexibility and range of motion through myofascial release work (both with the practitioner and by using balls and foam rollers), and long fascial stretching. Calara also recommends exercises for the IT bands and core stabilization exercises. "I focus on creating trunk stability or stiffness while the arms and legs move," she says. "Many of the core exercises are Pilates-based, such as abdominal isometric progressions—marching, kickouts, and scissor kicks. I like these exercises because the back stays stiff via abdominal contractions while the hip flexors are allowed to eccentrically lengthen as the legs move. This is part of the proper motion we are trying to achieve during the body swing of the stroke." (Explanations of these and other exercises mentioned below are easily found via Internet search for anyone not familiar with them.) Often, Feldman says, low and mid-back pain in rowers is caused by poor core and/or postural stability. "The rowing motion requires the body to be mobile and stable at the same time," he explains. "As rowers recover [from the previous stroke] to take the next stroke, they must prepare to absorb all the force of the coming stroke. This is because as they take that next stroke, any weakness they have will cause stress on their back. Since those little stresses add up quickly, they eventually can seriously stress their back." The first step in treatment, he says, is for rowers to make sure they can independently move their hips and lower back. He recommends starting with a hip 90/90 stretch, followed by a segmental cat/cow exercise. "After those mobility and movement drills, I want to get them firing their core," he says. "For this I use crawling drills, followed by goblet squats to groove the pattern, with the added benefit that the bottom of the squat matches the rowing catch position. I then also like to get them doing anti-rotation drills to continue to strengthen their core and be stable in that catch position." Female-Specific Issues Female rowers are more prone to certain injuries than are their male counterparts. Calara, for instance, sees more knee problems in female rowers, such as IT band syndrome and patellofemoral syndrome. This can be attributed to the wider female pelvis and increased Q angle at the knee (the angle between the quadriceps muscles and the patella tendon). The boat's foot stretchers (adjustable footplates to which the rower's shoes are attached) tend to be narrow, which may increase that angle, contributing to issues. "I also see more rib injuries in women than in men, especially in lightweight collegiate and elite athletes," she says. "One reason is that women have less muscle mass and strength than male rowers have to buffer stresses placed on the ribs. For lightweight rowers, who may have dysmenorrhea or even amenorrhea"—menstrual cramps or absence of a menstrual cycle—the ribs may become more susceptible to rib stress fractures. With collegiate and elite female athletes, in particular—regardless of [their] weight—we should be concerned about the effects of dysmenorrhea on bone density in the short and long terms." Because compared with men women tend to have more powerful legs in proportion to their overall weight, smaller abdominal wall systems, and a weaker scapula system, Kaehler says, rowing puts even more pressure on their backs, making a greater percentage of female rowers at risk of back injuries. Youth Matters PTs need to be aware of growth spurts in younger males that can affect the way they row. "Young men grow fast—inches at a time," Calara notes, "and soft tissue lengthening does not keep up with bone growth. That is why young men get tight. If we can keep them on a good stretching program, especially for their legs, they can keep proper posture in the stroke." Growth spurts for young women tend to be more gradual, Calara says, but young female rowers need to work on their standing posture. "I see many young women who stand in swayback posture, or with their weight on 1 leg more than the other," Calara explains. "These postures tighten or shorten the hips—mostly the hip capsules—not allowing for the proper lumbopelvic motion, and thus proper body swing in the stroke. With junior rowers, body awareness and proprioception may not be the best due to their growing bodies, so helping them feel and see proper motion is important." Adams works with local youth rowing clubs and believes teaching proper techniques early on can help prevent future injuries. "We have good coaches, which is really helpful, because they focus on factors such as making sure the rowers know about strength and conditioning principles. They're incorporating core stability, flexibility, and how to move well," he says. "They are learning to focus on some of the intangibles, and maybe not spending as much time in the boats. They're working on some skills that will keep these athletes healthy." Feldman says the most frequent problem he sees with younger rowers is overuse injuries from poor rowing techniques as they are learning the sport. "In these situations, perhaps the primary role of the PT is to help educate rowers on the importance of not adding too much volume as they are growing into the sport," he says. "This will help them avoid injuries." Keith Loria is a freelance writer.