Corrective exercises are common exercises organized to improve how one moves and feels during workouts and even in everyday life. To better comprehend, one must know and understand the four phases of the Corrective Exercise Continuum (CEx): inhibiting, lengthening, activating, and integrating. This discussion will describe each of the four phases and their benefits.

Overhead Squat Assessment

At this point, you might wonder how to determine which muscles to apply the corrective exercise techniques to. Well, it’s determined through the overhead squat assessment (OHSA), which looks for movement impairments. Movement impairments are generally due to overactive and underactive muscles that can be shortened or lengthened. For example, when some present with a functional bilateral knee valgus movement impairment, this is mostly likely due to overactive and shortened adductor complex, biceps femoris (short head), gastrocnemius, soleus, tensor fascia latae (TFL), and vastus lateralis and underactive and legnthened anterior tibialis, gluteus maximus and medius, medial hamstring complex, posterior tibialis, and vastus medialis oblique (Fahmy, 2022). Another commonly seen movement impairment is when the feet are slightly externally rotated from overactive and shortened biceps femoris (short head), gastrocnemius (lateral), and soleus and underactive and legnthened anterior tibialis, gluteus maximus and medius, medial hamstring complex, posterior tibiialis, and medial gatrocnemius (Fahmy, 2022). See pictures below for examples.

Phase 1: Inhibitory Techniques

Inhibitory techniques through self-myofascial rolling are utilized in the first phase of the NASM Correct Exercise Continuum to reduce the unwanted nervous system activity within a muscle that can lead to movement impairments (Fahmy, 2022).  A common tool is a foam roller, which lessens tension and soothes the neuromyofascial tissue through local mechanical and global neurophysiological changes (Fahmy, 2022).   With that said, the motivation for encouraging athletes to perform the inhibitory phase through self-myofascial rolling could be simply for tension and pain reduction and improved tissue movement for stretch tolerance.  To take a deeper dive into neuromuscular anatomy, when mechanoreceptors (Golgi tendon organs) are stimulated by the pressure of the foam roller, a reduction of muscle spindle activity within overactive and shortened muscles is allowed, thus providing greater stretch tolerance and optimal movement quality (Starzak et al., 2020).  

Corrective exercise inhibitory techniques are generally introduced as self-myofascial rolling using a foam roller, myofascial balls, or myofascial rollers (Fahmy, 2022).  However, other methods may be incorporated as inhibitory techniques: instrument-assisted soft tissue mobilization, massage guns, cupping, and myofascial flossing (compression bands) (Fahmy, 2022).

Self-Myofascial Rolling of Overactive Muscles

Self-myofascial rolling should be applied to the overactive muscles to inhibit muscle spindle activity, decrease tension, and improve range of motion (ROM) (Fahmy, 2022; Starzak et al., 2020).  According to Fahmy (2022), the practical approach should first begin with the objective of targeting overactive muscles by slowly rolling over the length of the muscle tissue for 30 seconds to 120 seconds and pausing at the tender spots for 30–60 seconds until the tenderness has diminished while taking slow and meaningful breaths.  The second part of the approach incorporates the active movement of the joint while using the foam roller across the muscle tissue (Fahmy, 2022).  The theory behind this method, which allows increased ROM, is partly from reciprocal inhibition due to the contraction of the antagonistic muscle (Fahmy, 2022).  In other words, when the foam roller is applied to the quads and the individual flexes and extends the knee, activating the hamstrings during knee flexion allows the quads to relax, taking the knee into a deeper ROM and further lengthening the quads.  Other components contributing to improved ROM are increased fluid circulation, breakdown of fibrous bands between the myofascial layers, and reduced viscosity (Fahmy, 2022). 

The Benefits of Self-Myofascial Rolling

The benefits of self-myofascial rolling (SMR) are parallel to the positive effects of massage therapy.  The difference is that the individual performs self-myofascial rolling, and the response to the rolling can be altered through the individual's perception to meet their desired outcome.  The expected benefits of SMR are improved joint range of motion, alleviation of painful trigger points, decreased delayed onset muscle soreness (DOMS), and promotion of muscle recovery (Hjert & Wright, 2020).  Fahmy (2022) explains that SMR inhibits the overactive muscles, which helps correct muscle imbalances by decreasing neuromuscular hypertonicity and relaxing muscles, thus leading to improved neuromuscular efficiency and optimal length-tension relationships. 

Phase 2: Lengthening Technique (Static Stretching)

After using inhibitory techniques on the overactive and shortened muscles, the next step is to elongate the shortened muscle groups. This can be done through static stretching, which involves gently stretching the muscle for 30-60 seconds. This allows the muscle to relax and lengthen. Static stretching has several physiological benefits, such as reducing muscle spindle activity and increasing muscle compliance through changes in fascicle angles and orientation.

Stretching can be beneficial for muscle tissue by reducing overactivity. However, it is crucial to avoid stretching if the muscle is already overactive and lengthened. In such cases, stretching can worsen the dysfunction instead of correcting it. Conversely, if the muscle is overactive and shortened, stretching can be an effective approach to promote lengthening and improve muscle length-tension relationships (Fahmy, 2022).

Phase 3: Activation Techniques

To address the issue of underactive and lengthened muscles, isolated strengthening exercises can be performed. In the case of bilateral knee valgus, the following muscles need to be activated: anterior tibialis, gluteus maximus & medius, hamstring complex (medial), posterior tibialis, and vastus medial oblique (VMO) (Fahmy, 2022). Glute bridges can be done to activate the gluteus maximus, while hip abduction wall slides can activate the gluteus medius. The recommended variables for isolated strengthening are 3-5 days a week, 1-2 sets for 15-20 repetitions at a tempo of 4/2/1 (4 seconds eccentric, 2 seconds isometric hold, 1 second concentric) (Fahmy, 2022).

So, when wanting to improve the function of underactive muscles, it is essential to strengthen them through isolated exercises that target those specific muscles. Isolated muscle strengthening helps to correct those muscle imbalances and increase intramuscular coordination, which is achieved by recruiting motor units more effectively, synchronizing them, and improving the speed at which they fire (Fahmy, 2022).

Phase 4: Integrated Exercise

The fourth phase of the corrective exercise continuum is called Integrated Exercise. This phase is crucial in retraining the human movement system by instilling a functionally coordinated pattern. By doing so, it ensures the maintenance of the length-tension relationship of the muscles, which significantly reduces the risk of injuries (Fahmy, 2022).

To apply integrated execise to bilateral knee valgus compensation one would first start with sagittal plane movements that can progress to multiplanar movements. For example, stationary banded squats (mini band around the knees) followed by progressing to lateral side stepping in the squat position with a band around the knees. Additional integrated dynamic movement progression could include swissball wall squats, lunge to balance, step-up to balance, single-leg squat, wall jumps, and skater hops.

The recommended variables for integrated strengthening are 3-5 days a week, 1-2 sets for 10-15 repetitions under control.

Sport Preparation

Boucher et al. (2021) reported an uptick in high school female sports-related injuries due to a lack of preventative strategies.  All too often, the mentality is that injuries will occur in sports, thus neglecting the usage of preventive strategies (Boucher et al., 2021).  However, there is a push for incorporating functional or global movement assessments as part of the preparticipation physical evaluation to identify movement impairments for early corrective exercise intervention that will optimize movement quality (Boucher et al., 2021).  Maximizing the quality of movement through the correct exercise continuum will improve performance and results and provide resistance to injury by enhancing the human movement system (Fahmy, 2022).  Athletes participating in the corrective exercise continuum will have guidance to ensure that muscles and joints work synergistically to optimize sport-specific movements and maintain musculoskeletal balance throughout all seasons (Boucher et al., 2021; Fahmy, 2022).

Merging Corrective Exercise Integration into the Global Training Approach

The global training approach only covers some aspects of an athlete's human movement system.  For continued positive adaptations in global training, the process will require integrating a corrective exercise program (Boucher et al., 2021).  For example, an athlete may receive feedback from an athletic trainer that a muscle is not working optimally, such as the gluteus medius; however, simply strengthening the gluteus medius may not be enough to allow optimal neuromuscular efficiency (Fahmy, 2022).  The corrective exercise continuum works to reteach optimal movement patterns through the four techniques, which can be performed before other training regimes or as an individual training session (Fahmy, 2022). 

References

Boucher, B., Rich, A., Gobert, D., Gardner, B., Metzner, P., King, C., & Buse, M. (2021). The effectiveness of a functional movement assessment and 4-week exercise training program for female high school athletes. Journal of Strength and Conditioning Research, 35(1), 102–110. https://doi.org/10.1519/jsc.0000000000002549

Fahmy, R. (2022). NASM essentials of corrective exercise training. Jones & Barlett Learning.

Hjert, C. S., & Wright, C. J. (2020). The effects of self-myofascial release foam rolling on muscle soreness or pain after experiencing delayed onset muscle soreness: A critically appraised topic. International Journal of Athletic Therapy and Training, 25(6), 294–298. https://doi.org/10.1123/ijatt.2019-0078

Hughes, G. A., & Ramer, L. M. (2019). Duration of myofascial rolling for optimal recovery, range of motion, and performance: A systematic review of the literature. International Journal of Sports Physical Therapy, 14(6), 845–859. https://doi.org/10.26603/ijspt20190845

Starzak, M., Makaruk, H., Makaruk, B., Wiśniowski, P., Annastarzak, & Monikazajac. (2020). The foam rolling of quadriceps decrease the kinematics of step during a 30-m sprint run. Journal of Physical Education and Sport, 20(1), 206– 213.

Article by Denise Fisher 06/27/2024

Certified & Licensed Athletic Trainer

Corrective Exercise Specialist

Emergency Action Plan

How does Grand Valley High School prepare for sports emergencies involving the student-athlete?

At the beginning of the sports season, the coaches and I plan a time to review the emergency action plan with the student-athletes.  I use a program called Anyone Can Save a Life http://www.anyonecansavealife.org/ developed by the Minnesota State High School League.  The reason why I chose this program is that it has easy-to-follow steps that involve the athletic trainer, coaches, and student-athletes to prepare them for immediate action to respond to life-threatening emergencies with simple steps:

1.    Calling 911 to alert the Emergency Medical System (EMS)

2.    Early cardiopulmonary resuscitation (CPR)

3.    Early use of an automated external defibrillator (AED)

4.    Early transition to EMS

The program assigns the coaches and student-athletes into teams; each team is vital in responding to emergencies.  For example, Team 1 is the 911 team.  Team 1 will review the following questions on what they need to know.  Where is the closest cell phone or landline?  What is the school's address, and where is the emergency located on GV's campus?  What is the best access point for the ambulance to arrive for both practice and events?  The next step for Team 1 is to assign the team their roles, such as having two students call 911, two more students meet the ambulance at the access point, and lastly, two more students locate the athletic trainer and athletic director.

A team approach is needed to respond to an emergency to avoid panic and confusion.  So, why would we involve a student-athlete when adults are present?  First, there are times when only one coach is conducting the practice, and what happens when it is the coach who is having an emergency?  That is why I feel it is essential to empower student-athletes to know how to respond to an emergency without panic or confusion.  Educating the student-athlete may also help them in their personal lives should they face a life-threatening emergency with a loved one, friend, or a witness to someone in need. 

AEDin3 Challenge

  The AEDin3 challenge is a new initiative by University Hospitals that demonstrates the capability of a person to get the AED, apply pads, and deliver the first shock in under 3 minutes.  The challenge is to bring awareness to the importance of detailed preparation and potential gaps in the EAP, such as needing a key card to enter the building or simply knowing the location of the nearest AED to the emergency.

When we practice the EAP "Anyone Can Save a Life," I also review in detail and practice the AEDin3 challenge and the importance of having access to an AED in less than 3 minutes.  What I have learned this past fall season is that many of the student-athletes needed to understand where the AEDs are located and what they look like.  That was an ah-ha moment for many and illustrated the importance of planning, learning, and practicing emergency action plans. 

Pregame EAP Meeting

In addition to the EAP training with GV's student-athletes, the CVC started a mandatory Pregame Emergency Action Plan Meeting with coaches, officials, and athletic trainers before all sporting contests.  OHSAA may also make the Pregame Emergency Action Plan Meeting a state-wide initiative.  Figure 1 is an example of the EAP meeting for XC Meets. 

Figure 1

CVC Pregame EAP Meeting

Grand Valley High School Emergency Action Plans:

Information for Coaches

Article by Denise Fisher 10/27/2023

Certified & Licensed Athletic Trainer

Corrective Exercise Specialist

Self-myofascial Rolling

Myofascial means muscle (myo) and its association to the connective tissue (fascia) .

Introduction

Self-myofascial rolling (SMR) is a technique that is used to improve myofascial restriction and control or down regulate the autonomic nervous system through the use of a foam roller, hand-held roller, or massage ball (Fahmy, 2022).  SMR compresses the targeted myofascial tissue, allowing local mechanical changes and global neurophysiological responses (Fahmy, 2022), which will be described in more detail during this discussion.  Ideally, SMR should be deliberate with a moderate to slow pace for a repetition of 4–6 rolls across the targeted muscle, and trigger points should be held for 30-60 seconds (Fahmy, 2022).  After the general tension is reduced, one can also perform an active range of motion of the distal joint of the target muscles and cross-fiber friction by rolling the muscle perpendicularly across the roller.  These added movements help to facilitate further local and global effects of SMR. 

Effectiveness of SMR in Current Literature

Pre-Exercise SMR Effectiveness

Pre-exercise SMR is a warm-up option that may help to increase one's range of motion (ROM), decrease myofascial restriction and associated pain, and improve performance without adverse effects on muscle strength, jump heights, and sprint time, as seen with static stretching immediately before exercise (Behm & Wilke, 2019). However, it is important to maintain an objective point of view regarding the effects of SMR on ROM because there is no true agreement among researchers on the effectiveness, as each study is different concerning intervention protocols, type of roller or instrument, evaluation methods, and participant characteristics (de Souza et al., 2019).  The type of foam roller or massage roller is an important variable to consider concerning the amount of pressure being applied to the muscle and fascia, which was reported by de Souza et al. (2019) during their research because of a more pronounced increase in dorsiflexion ROM following SMR with a massage stick to the calf muscles. 

  Short-term benefits of SMR may last up to 20 minutes, and even 5–10 seconds of SMR has been shown to improve ROM, yet the consensus on the parameters of SMR is one to three sets of 30–60 seconds rolls (Pagaduan et al., 2022).  The increase in ROM from SMR is believed to be due to the mechanical effects that reduce myofascial restrictions and increase blood flow.  When blood flow is increased to a muscle, the fascial inflammation and restriction will also improve, which helps with decreasing pain (Pagaduan et al., 2022).  The pressure of the foam roller on the soft tissue modulates pain through mechanisms such as the gait control theory (afferent central nociceptive pathways) (Fahmy, 2022), which means the body will sense the pressure from the foam/ massage roller first over the slow pain signals, thus overriding the pain sensation and improving stretch tolerance (Pagaduan et al., 2022).

The combined effects of increased blood flow and decreased pain sensation are thought to be the reasons one may demonstrate performance improvements following SMR (Pagaduan et al., 2022).  According to Behm & Wilke (2019), studies have demonstrated SMR to enhance performance through improved strength, power, sprint speed, neuromuscular control during functional movement patterns, and proprioception of lower extremity joints.  However, some studies demonstrate less impressive effects of pre-exercise SMR on performance, except for sprint performance and flexibility (Wiewelhove et al., 2019).  Yet, caution should be noted when reviewing studies that demonstrate sprint performance improvements following SMR since there are limited studies, of which only a couple shows a depicted positive effect (Wiewelhove et al., 2019).

Another consideration is recognizing the potential for a placebo or a warm-up effect of pre-exercise SMR on performance (Jo et al., 2018).  According to Jo et al. (2018), with regard to their study on fatigue protocol, the placebo effect may be a reasonable conclusion as to why the fatigued subjects performed better following the SMR compared to the control, meaning that the subjects may have developed a psychosomatic interference allowing them to think they should improve their performance following SMR, thus leading to improved performance.  The other consideration is the warm-up effect caused by the body position utilizing isometric contraction of muscles during the SMR because it requires one to support their body while rolling on the foam roller (Jo et al., 2018).  This effect warms up the muscles, thus increasing blood flow and possibly enhancing flexibility and mobility (Jo et al., 2018). 

Post-Exercise SMR Effectiveness

When describing the post-exercise effectiveness of SMR, the main focus will be on recovery.  According to Wiewelhove et al. (2019), post-exercise SMR provides a more advantageous response to sprint and strength performance recovery than passive recovery.  The physiological benefits of post-dynamic exercise SMR are through systemic biomechanical effects, such as increased circulating neutrophil and new mitochondria for healing, decreased plasma creatine kinase levels indicating less muscle damage, and fewer active heat-shock proteins and inflammatory immune cytokines (Wiewelhove et al., 2019).  Additionally, one’s perception of pain and muscle soreness may be lessened, which helps with short-term recovery (Wiewelhove et al., 2019). 

However, just like the concern for a placebo effect with pre-exercise SMR, as suggested by Jo et al. (2018), there is also a consideration for a placebo effect regarding post-exercise SMR when enhancements of performance recovery are reported (Wiewelhove et al., 2019).  However, this could also be due to an error in methodology that renders the study's findings inaccurate (Wiewelhove et al., 2019). 

Yet, the research on post-exercise SMR is still promising with regard to decreasing perceived pain (Wiewelhove et al., 2019).  An intriguing point to keep in mind is that post-exercise muscle soreness leads to changes in the connective tissue, which then turns on the touch and pressure-sensitive receptors that increase pain signals during movements that stretch or compress tissues (Wiewelhove et al., 2019); however, when SMR is used following exercise, it provides benefit by reducing the delayed onset muscle soreness (DOMS) by stimulating central pain-modulatory systems and decreasing connective tissue adhesions with no negative effects on muscle function (Adamczyk et al., 2020).  Another positive result of SMR post-exercise is increased blood flow to the tissue, which provides an environment for waste removal and nutrient absorption (Adamczyk et al., 2020). 

Conclusion

The literature shows promising effects of both pre- and post-exercise SMR.  The use of pre-exercise SMR appears to be an effective method for short-term improvements in flexibility with no detrimental effects on muscle performance (Ferreira de Oliveira et al., 2022; Wiewelhove et al., 2019).  Post-exercise SMR  demonstrates effectiveness for recovery and circulatory enhancements (Adamczyk et al., 2020).  In some circumstances, pre- and post-exercise SMR has been shown to improve sprinting performance and flexibility and lessen pain sensation (Adamczyk et al., 2020; Wiewelhove et al., 2019).  However, it's imperative to take the physiological mechanisms of SMR lightly as they are not sufficiently understood. Further research is needed to have a consensus on protocols, benefits, and possible adverse effects of both pre-post exercise SMR (Wiewelhove et al., 2019). 

Article by Denise Fisher 10/27/2023

Certified & Licensed Athletic Trainer

Corrective Exercise Specialist

References

Adamczyk, J., Gryko, K., & Boguszewski, D. (2020). Does the type of foam roller influence the recovery rate, thermal response and doms prevention? PLOS ONE, 15(6), e0235195. https://doi.org/10.1371/journal.pone.0235195

Behm, D. G., & Wilke, J. (2019). Do self-myofascial release devices release myofascia? rolling mechanisms: A narrative review. Sports Medicine, 49(8), 1173–1181. https://doi.org/10.1007/s40279-019-01149-y

de Souza, A., Sanchotene, C., Lopes, C., Beck, J., da Silva, A., Pereira, S., & Ruschel, C. (2019). Acute effect of 2 self-myofascial release protocols on hip and ankle range of motion. Journal of Sport Rehabilitation, 28(2), 159–164. https://doi.org/10.1123/jsr.2017-0114

Fahmy, R. (2022). NASM essentials of corrective exercise training (2nd ed.). Jones & Bartlett Learning.

Ferreira de Oliveira, R., Mota, G. R., Carvalho, W., Bertochi, G., & Sasaki, J. (2022). Effect of single and multiple sessions of self-myofascial release: Systematic review. Revista Brasileira de Medicina do Esporte, 28(4), 358–367. https://doi.org/10.1590/1517-8692202228042021_0114

Jo, E., Juache, G., Saralegui, D., Weng, D., & Falatoonzadeh, S. (2018). The acute effects of foam rolling on fatigue-related impairments of muscular performance. Sports, 6(4), 112. https://doi.org/10.3390/sports6040112

Pagaduan, J., Chang, S.-Y., & Chang, N.-J. (2022). Chronic effects of foam rolling on flexibility and performance: A systematic review of randomized controlled trials. International Journal of Environmental Research and Public Health, 19(7), 4315. https://doi.org/10.3390/ijerph19074315

Wiewelhove, T., Döweling, A., Schneider, C., Hottenrott, L., Meyer, T., Kellmann, M., Pfeiffer, M., & Ferrauti, A. (2019). A meta-analysis of the effects of foam rolling on performance and recovery. Frontiers in Physiology, 10. https://doi.org/10.3389/fphys.2019.00376

Corrective exercise is an organized process that includes the identification of movement dysfunctions, an action plan, and the implementation of a corrective strategy to help one move more efficiently.

Inactive Youth

The youth population's decreased physical activity negatively impacts health and society. According to the National Center for Chronic Disease Prevention and Health Promotion (2022), 77% of high school students fail to achieve good aerobic physical activity. The potential risk factors affecting the health of inactive youths are cardiovascular diseases, metabolic diseases, cancer, depression, poor psychosocial health, and decreased cognitive function (Walker et al., 2018). There is a significant impact on our society when youths are diagnosed and treated for health manifestations of physical inactivity, which in large creates an economic burden for the rising cost of medical care and medication (Walker et al., 2010). 

What are Length-tension Relationships, and how do they correspond to Force-Couple Relationships in the human muscular system?

Understanding these relationships and correcting postural dysfunctions will help you perform more optimally.

Before answering this question, I would like to explain the difference between open and closed kinetic training.

The benefits of open and closed kinetic training regarding the shoulder complex are important to understand when developing a strength program because they will allow one to decide the program's focus: correcting specific imbalances versus increasing global strength and stability. For instance, open kinetic chain (OKC) exercises stimulate muscles in isolation, and closed kinetic chain (CKC) exercises stimulate muscles by co-activating surrounding muscle groups. OKC does not have a fixed distal segment, enabling free movement that is not fixed to an object (Prokopy et al., 2008). Muscle activation is also customarily proximal to the distal segment, and the distal part is usually the hands or feet. An example of an OKC is standing cable rows. CKC has a fixed distal segment when met with resistance (Prokopy et al., 2008). An example of a CKC is floor push-ups. In CKC exercises, the extremity muscle activation is sequential from distal to proximal.

For swimmers, dryland strength training will be composed of open and closed kinetic chain exercises. Upper extremity OKC exercises allow a swimmer to strengthen underworked muscles aiding in injury prevention. A great example in swimmers is strengthening the weak external rotators (ER) because the internal rotators (IR) become overdeveloped from the repetitive front crawl technique. The OKC exercises are also beneficial for strengthening the scapular muscles and correcting imbalances. In contrast, the CKC exercises target both agonist and antagonist muscle groups and greater joint stability, significantly increasing strength around the shoulder complex, which reduces the risk of injury during CKC exercises (Moradi Shahpar et al., 2019). 

Shahpar et al. (2019) studied the response of an eight-week open and closed dryland training program on muscle torque of the internal and external shoulder rotators in swimmers. Participants in the study were forty-five healthy male swimmers between the ages of 18-25. The swimmers were divided into the OKC group, the CKC group, and a control group. Except for the control group, each performed its prescribed exercises three times a week for eight weeks. Pre and post-measurements of peak torque of the internal and external shoulder rotators were completed using the isokinetic HUMAC NORM machine at various speeds of 60, 120, and 180 degrees. The study's results demonstrated improvements in both internal and external shoulder rotator torque. However, there was a substantial difference between open and closed kinetic training, with open kinetic training showing more significant improvements in enhancing internal and external shoulder torque. 

Both forms of training have a purpose in injury prevention, rehabilitation, and strength programs. The focus of dryland programs should include anterior and posterior muscle balancing, muscle endurance, strength building, improvement of joint stability, and neuromuscular control, which is addressed when including both OKC and CKC exercises (Moradi Shahpar et al., 2019). If the individual only did OKC exercises, they would lose out on the benefits of CKC, which increase proprioception, joint stability, and overall strength gains of surrounding muscles (Moradi Shahpar et al., 2019). 

Examples of a closed kinetic chain push-up plus exercise and an open kinetic chain shoulder external rotation exercise with a theraband. Images are from Medbridge.

Article by Denise Fisher

References

Moradi Shahpar, F., Rahnama, N., & Salehi, S. (2019). The effect of 8 weeks of open and closed kinetic chain strength training on the torque of the external and internal shoulder rotator muscles in elite swimmers. Asian Journal of Sports Medicine, 10(2). https://doi.org/10.5812/asjsm.82158

Prokopy, M. P., Ingersoll, C. D., Nordenschild, E., Katch, F. I., Gaesser, G. A., & Weltman, A. (2008). Closed-kinetic chain upper-body training improves the throwing performance of NCAA division I softball players. Journal of Strength and Conditioning Research, 22(6), 1790–1798. https://doi.org/10.1519/jsc.0b013e318185f637

THIS INFORMATION IS FOR EDUCATIONAL PURPOSES ONLY. FOR MORE INFORMATION, PLEASE WORK WITH A REGISTERED SPORTS DIETICIAN.  

Increasing Muscle Mass

My first suggestion for an athlete would be to focus on their diet and make quality choices. I would encourage the athlete to establish an ideal and reasonable nutrition plan that provides adequate caloric intake and appropriate food consumption with timing (See Figure 2) to support their needs and improve their performance, strength, and power, which most likely will require assistance from a sports dietician. Andersen et al. (2005) research showed positive results in muscle hypertrophy of type I and II muscle fibers when young, physically active adult males consumed two servings of 25 grams of protein immediately before and after resistance training for 14 weeks at three times a week. Andersen et al. (2005) suggest that the mechanism for the increase in muscle hypertrophy is due to a positive protein balance, which means the rate of protein synthesis was more significant than protein breakdown.  

Morton et al. (2017) conducted a systematic review of the effect on skeletal muscle from different levels of protein intake, which indicated that an increase in the ingestion of protein at 0.5 and 3.5 g/kg/day was associated with increased muscle mass and this was shown to occur with and without weight training. Research has also established that adding protein with a higher amount of the amino acid leucine could help provide a more remarkable environment for muscle protein synthesis (Smith-Ryan & Jose, 2013).  Foods high in leucine are chicken breast, lean beef, and greek yogurt (Jeukendrup & Gleeson, 2019). So, with that said, it is safe to say that food should always come first before considering supplements.   However, other influences must be considered, such as age, genetics, lifestyle characteristics (sleep and stress management), and current and past training history. All these components and one's daily nutrition will play a role in their success and ability to attain performance goals.

Supplement Regimen

 I frequently get questions about multivitamins, "Mega" multivitamins, Creatine, and Whey protein supplements, so here is what I know:

First, "mega" multivitamin supplements do not help increase muscle mass, strength, and power. Taking a "mega" multivitamin/mineral supplement may also fall into the category of unsafe supplementation and is not needed when an individual is consuming a well-round whole foods diet with ideal amounts of macro and micronutrients. The added expense of buying a "mega" multivitamin could go towards purchasing high-quality foods; however, there are times when recommended dietary allowance (RDA) multivitamin may have a purpose that is important for specific stages in life or those that struggle with nutritional challenges (Garthe & Maughan, 2018). For instance, vegans or athletes with a particular medical condition may require medical guidance on multivitamins (Garthe & Maughan, 2018). One may also want to consume an RDA multivitamin as an insurance policy to benefit their overall health if they lack adequate intake for the day.  

Figure 1 below illustrates how athletes should manage their nutritional development through the years.  

Whey Protein

Whey protein would be a good supplement for athletes, pending they are getting most of their calories and protein from quality food sources. However, supplementing with whey protein may be helpful when it is hard to ingest the required amount of protein through food alone or simply for convenience.  Smith-Ryan & Jose (2013) reported that consuming 20-30 grams of whey protein from isolates or hydrolysates before, during, and after exercise has effectively increased anabolic activation.  For instance, an athlete may consider consuming 20-25 grams of protein (food sources or whey) with each meal, which may include co-ingesting a small amount of protein with carbohydrates during exercise, followed by a post-exercise feeding of 20-25 grams and possibly another protein feeding before bed to maintain a positive protein balance for muscle protein synthesis (van Loon, 2013).  

Creatine

Creatine (Cr) would be a relatively safe supplement for athletes. As stated by Smith-Ryan & Jose (2013), all humans are consumers of Cr, which supplies high-intensity, short-duration exercise, i.e., sprinting, so it is a supplement that would be appropriate for many forms of exercise. Cr can be found in foods such as beef, pork, and fish or through a powder supplement that is mixed into a liquid, and either form is highly bioavailable (Smith-Ryan & Jose, 2013).   

The benefits of Cr are its effectiveness in improving lean body mass, strength, and high-intensity exercise (Kerksick et al., 2018). Additionally, and somewhat theoretically, Cr supplementation helps to increase its storage in the skeletal muscle (the primary area of storage for creatine in the body) to fuel anaerobic power activities, thus improving the efficiency of the phosphocreatine energy system (Smith-Ryan & Jose, 2013).  Nevertheless, severe adverse effects of Cr are absent in clinical trial studies on Cr, which is a tremendous outcome for a supplement that may enhance performance and lean body mass (Smith-Ryan & Jose, 2013).  

A con of Cr is that some individuals are poor or non-responders, which is influenced by the person's genotype (Smith-Ryan & Jose, 2013). Another point to consider is the quality of the product and additional components that make the Cr product less pure.  

A practical application to adding Cr monohydrate salt to an athlete's regimen would be to consider starting at 0.3 grams per kilogram of body weight daily post resistance training to improve strength and lean body mass (Smith-Ryan & Jose, 2013). Rawson (2018) indicated two Cr supplementation strategies: short-term ingestion at 20 grams daily for five days or 3-5 grams daily for four weeks to achieve maximal muscle creatine levels. Continuous intake of Cr at a low dose can safely be accomplished at 3-5 grams per day or through dietary sources, which yields about 0.7 grams of creatine per six ounces of meat (Rawson, 2018). Additionally, athletes may consider consuming a post-workout meal or supplement that contains a combination of protein, carbohydrates, and Cr supplement, which has been shown in research to promote greater hypertrophy results than just proteins and carbohydrates alone (Smith-Ryan & Jose, 2013).    

Guidance on Ergogenic Aids

The marketing of supplements does a great job highlighting products and making them look too good to be accurate and allowing the illusion that they may demonstrate erogenic benefits; however, I would encourage all athletes not to fall for the marketing scheme because safety, quality, validity, and effectiveness matter (See Figure 3). Additionally, products may not be approved by governing bodies, and taking a product with hidden additives may place the athlete at risk of falling into a category of doping or illegal substance use. I recommend that every athlete works with a sports dietician familiar with high school and collegiate protocols on supplementation usage.   

Figure 1

Stages in the athletic, educational, and nutrition development of the young athlete

Note.  The image was derived from Garthe & Maughan (2018).

Article by Denise Fisher

References

Andersen, L. L., Tufekovic, G., Zebis, M. K., Crameri, R. M., Verlaan, G., Kjær, M., Suetta, C., Magnusson, P., & Aagaard, P. (2005). The effect of resistance training combined with timed ingestion of protein on muscle fiber size and muscle strength. Metabolism, 54(2), 151–156. https://doi.org/10.1016/j.metabol.2004.07.012

Burke, L., Deakin, V., & Minehan, M. (2021). Clinical sports nutrition (6th ed.). McGraw Hill Education Australia.

Burke, L. M. (2017). Practical issues in evidence-based use of performance supplements: Supplement interactions, repeated use and individual responses. Sports Medicine, 47(S1), 79–100. https://doi.org/10.1007/s40279-017-0687-1

Garthe, I., & Maughan, R. J. (2018). Athletes and supplements: Prevalence and perspectives. International Journal of Sport Nutrition and Exercise Metabolism, 28(2), 126–138. https://doi.org/10.1123/ijsnem.2017-0429

Heffernan, S., Horner, K., De Vito, G., & Conway, G. (2019). The role of mineral and trace element supplementation in exercise and athletic performance: A systematic review. Nutrients, 11(3), 696. https://doi.org/10.3390/nu11030696

Jeukendrup, A., & Gleeson, M. (2019). Sport nutrition (3rd ed.). Human Kinetics.

Kerksick, C. M., Wilborn, C. D., Roberts, M. D., Smith-Ryan, A., Kleiner, S. M., Jäger, R., Collins, R., Cooke, M., Davis, J. N., Galvan, E., Greenwood, M., Lowery, L. M., Wildman, R., Antonio, J., & Kreider, R. B. (2018). Issn exercise & sports nutrition review update: Research & recommendations. Journal of the International Society of Sports Nutrition, 15(1). https://doi.org/10.1186/s12970-018-0242-y

Morton, R. W., Murphy, K. T., McKellar, S. R., Schoenfeld, B. J., Henselmans, M., Helms, E., Aragon, A. A., Devries, M. C., Banfield, L., Krieger, J. W., & Phillips, S. M. (2017). A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. British Journal of Sports Medicine, 52(6), 376–384. https://doi.org/10.1136/bjsports-2017-097608

Rawson, E. S. (2018). The safety and efficacy of creatine monohydrate supplementation: What we have learned from the past 25 years of research. Sports Science Exchange, 31(185), 1–6.

Smith-Ryan, A. E., & Jose, A. (2013). Sports nutrition and performance enhancing supplements. Linus Learning.

van Loon, L. J. (2013). Protein ingestion prior to sleep: Potential for optimizing post-exercise recovery. Sports Science Exchange, 26(117), 1–5.

Viribay, A., Burgos, J., Fernández-Landa, J., Seco-Calvo, J., & Mielgo-Ayuso, J. (2020). Effects of arginine supplementation on athletic performance based on energy metabolism: A systematic review and meta-analysis. Nutrients, 12(5), 1300. https://doi.org/10.3390/nu12051300

Figure 2: Periodization and Timing of Macronutrients

Figure 3: Dietary Supplements

University Hospitals

Sports Nutrition Services for Athletes

Click on the link for more information about UH Sports Nutrition Services for Athletes

Most studies I have read refer to low-fat chocolate milk (CHOC), as a 3:1 or 4:1 ratio of carbohydrates and protein (Loureiro et al., 2020). Commercial recovery beverages have almost the same ratio of carbohydrates and proteins and similar amounts of electrolytes, which is another reason why CHOC is favorable to many athletes and highly recommended by experts (Loureiro et al., 2020; Saunders, 2011).  

 CHOC consumption is promoted for endurance athletes because it helps to replenish glycogen (fuel for energy) stores in the muscle and liver quickly, and the protein in CHOC helps with muscle protein synthesis (rebuilding) (Loureiro et al., 2020). However, after long endurance training, CHOC must be consumed with additional carbohydrates to meet the need for maximal muscle glycogen replenishment (Loureiro et al., 2020). According to Smith-Ryan & Jose (2013), the timing of CHOC consumption should be directly after a workout, which has been shown to provide more remarkable training adaptation through its short-term effectiveness in replenishing glycogen stores and resynthesizing protein, which is agreed by Loureiro et al. (2020) and Saunders (2011), who encourages CHOC to be ingested within 30 minutes of finishing a workout. Spaccarotella & Andzel (2011) suggested drinking low-fat CHOC directly after exercise and during the recovery period every hour.  

There needs to be more documentation discussing CHOC as the recovery drink for strength training and power athletes. However, Born et al. (2019) examined the importance of carbohydrate plus protein ingestion during and after a resistance workout, which was proved by the enhanced anabolic response of muscle mass gain and strength when athletes consumed CHOC versus a carbohydrate drink (Born et al., 2019). Smith-Ryan & Jose ( 2013) indicated that strategically consuming CHOC in the timeframe surrounding (before and after) resistance exercise will increase muscle protein synthesis (MPS) and active anabolic pathways after the resistance training.  

The research findings are compelling, and using CHOC before and after resistance, strength, or power training is an excellent option for athletes. Even more appealing is that it is readily available, inexpensive, and safe. I recommend CHOC to most athletes, pending their tolerance to dairy products. 

Article by Denise Fisher

Born, K. A., Dooley, E. E., Cheshire, P., McGill, L. E., Cosgrove, J. M., Ivy, J. L., & Bartholomew, J. B. (2019). Chocolate milk versus carbohydrate supplements in adolescent athletes: A field based study. Journal of the International Society of Sports Nutrition, 16(1). https://doi.org/10.1186/s12970-019-0272-0

Loureiro, L. R., de Melo Teixeira, R., Pereira, I. S., Reis, C. G., & da Costa, T. M. (2020). Effect of milk on muscle glycogen recovery and exercise performance: A systematic review. Strength & Conditioning Journal, 43(4), 43–52. https://doi.org/10.1519/ssc.0000000000000595

Pritchett, K., Bishop, P., Pritchett, R., Green, M., & Katica, C. (2009). Acute effects of chocolate milk and a commercial recovery beverage on postexercise recovery indices and endurance cycling performance. Applied Physiology, Nutrition, and Metabolism, 34(6), 1017–1022. https://doi.org/10.1139/h09-104

Saunders, M. J. (2011). Carbohydrate-protein intake and recovery from endurance exercise: Is chocolate milk the answer? American College of Sports Medicine, 10(4).

Smith-Ryan, A. E., & Jose, A. (2013). Sports nutrition and performance enhancing supplements. Linus Learning.

Spaccarotella, K. J., & Andzel, W. D. (2011). The effects of low fat chocolate milk on postexercise recovery in collegiate athletes. Journal of Strength and Conditioning Research, 25(12), 3456–3460. https://doi.org/10.1519/jsc.0b013e3182163071