By Geoffrey Bishop

Flagstaff, Arizona, sits atop the world, especially this year as we work our way nearer the 2008 Olympics in China. Many of the world’s fastest athletes utilize the hypoxic conditions of this high altitude city to produce more red blood cells in which to carry oxygen to their muscles. They train long and hard, get sore, get up, and do it all over again the next morning. Erik Dalton’s Myoskeletal Alignment is the therapy of choice for many training Olympians this year, and I’m honored to play a small part in their success.

Exhalation & Inhalation

With the only Olympic-sized pool in the country at the training altitude of 7,000 feet, both indoor and outdoor tracks, miles of great roads, single-track trails, and a huge lake, Flagstaff is buzzing with the world’s anticipation of the Olympics. Northern Arizona will see about 500 elite endurance athletes and coaches from the world’s stage in the calendar year leading up to the games. Triathletes come to train and typically do two or three medium to high intensity swim, bike, and run workouts a day. Runners come to train for middle and long distance events, from the 5 km to the marathon, some pounding the earth up to 140 miles a week. Our race walkers are a joy to watch for those therapists interested in gait analysis. Swimmers fill the pool, performing hard paddle-pulls to help endure thestress of hundreds of meters of training a week. All this elite training is done in the context of oxygen deprivation.

As you ascend from sea level, particularly to altitudes over 3,000 feet, the amount of oxygen carried by the hemoglobin in the blood is reduced, resulting in less oxygen being delivered to exercising muscles. As a result, athletes typically find themselves short of breath throughout their time at training camp. For swimmers, this feeling is compounded in the water; water provides an estimated 12 times the amount of resistance as air. Adding hydrostatic pressure, the effort used by assessory muscles in forced inspiration/expiration, to altitude while working out is enormous.

Imagine wrapping your thoracic cavity and abdomen in resistance tubing not, at this point, just about absorption of oxygen within the soft spongy lung. Much of the focus of my work at this point is on educating athletes and improving their breathing. With the efforts put in by these athletes, staying ahead of the aches and pains associated with movement and breathing is the name of the game. The athletes cannot allow themselves to focus on the lack of efficient oxygen/nitrogen transfer during their initial training. They learn to ignore and conquer the discomfort that comes with each breath until the pain recedes slowly. When the headaches, diarrhea, and stomach cramps finally subside after a week or so of altitude training, the athletes begin to excel.

In the absence of proper manual therapy, the months athletes spend at altitude can seem much longer. Some camps can last for as long as three months, creating a dramatic energy drain. These folks need to be able to concentrate on their sport, not their body telling them there is something wrong with the biomechanics of their movement and activities. This year could be the realization of a lifelong dream, standing on the Olympic podium.World-renowned distance running coach Jack Daniels always quips, “One of the biggest benefits of training at altitude is that you learn to hurt a little bit more.” When the body ascends, the concentration of hemoglobin in the blood is reduced, resulting in less oxygen being delivered to working muscles. With a reduced amount of fuel to call on, an athlete has to work harder to achieve the same results, often recruiting other muscles to create movement. When an athlete takes that same workout back to sea level, the routine becomes that much easier.

Keeping in mind that the athletes are “hurting a little bit more,” I try to stay ahead of their pain game. Oftentimes therapists are tempted to treat one area at a time—most often the area of chief complaint or pain. I do not believe it is possible to separate the result of our applied techniques in such a way. In fact, we may not even know we are working on the breathing apparatus when performing a latissimus lengthening technique on a swimmer. However, treating imbalances in longlever muscles like the lats and serratus can create a positive affect on rib mobility and breath, when the intent is there (image 1). I honor therapists who do use these multifaceted techniques and I have witnessed many quality therapists who do understand this application. My time spent with these athletes is too important for random filler strokes and a lot of transitional work. It goes back to intent; “What do I intend to do here?” I try to get the most out of my time by multitasking and thinking about ambidexterity.

Myoskeletal Alignment at High Altitude

While working with Team Timex Ironman athlete Jordan Rapp flushing the latissimus and teres major after a hard swim

Myoskeletal therapy not only addresses aberrant postural patterns, i.e., Janda’s upper and lower crossed syndromes, but also has profound balancing effects between core stabililizers and the global muscles of movement. Although the theory remains the same, in the high country of Arizona many of the techniques have been altered to account for the unique needs of oxygen-deprived athletes.

Testing the firing order of neck flexion/release upper fixators

While working with Team Timex Ironman athlete Jordan Rapp, flushing the latissimus and teres major after a hard swim, I shift my attention to the serratus anterior (assessory breathing muscle lifting ribs). Hooking the fascial slips and proteins of serratus anterior, I ask him to take a few deep respirations, achieving a powerful golgi tendon organ release, as I sweep posterior and medially. This has a positive effect on rib function while encouraging anchoring of the scapula in shoulder movement, thus in effect, reminding the origin of the origin.

A notable substitution pattern of the head/neck flexion firing order will result in suboccipital and SCM firing first cocking the head back

Testing the firing order of neck flexion/release upper fixators. Initiation phase of head on neck flexion. As the athlete looks at his feet, the rectus capitus/coli should fire first, creating a chin tuck.

Encourage the occiput to rotate anteriorly on the atlas

A notable substitution pattern of the head/neck flexion firing order will result in suboccipital and SCM firing first cocking the head back, potentially cramming the occipitalatlanto joint closed on one side or both.

Encourage the occiput to rotate anteriorly on the atlas. As the athlete contracts his longus capitus/longus coli to flex the head and neck, the therapist provides a light stretch to tight suboccipitals. The athlete pushes back into the therapist’s resistance for a count of five seconds, relaxes, and the therapist repositions the athlete’s head into anterior rotation. The therapist releases tight facilitated upper traps and levator scapula by asking the athlete to gently contract of the shoulders toward the ear, as the therapist resists movement of head into extension.

Commonly presenting with atypical breathing patterns, these elite athletes may be unaware of alterations of performance due to conditions such as scalene/diaphragm imbalances, rib/vertebral fixations, and spinal engine breakdown (See The Athlete’s Spinal Engine, page 88).

Upper Crossed Syndrome

Sternoclavicular joint

An easy way to confirm the visual observation of a forward head posture is to test the firing order of neck flexion. With the athlete lying supine, I simply ask him to look at his feet. What we would like to see is the chin tuck first (image 2). If the eyes come anterior, toward the ceiling, before the head flexes on the neck, I assume he has an extensor dominant (ED) neck, tight, facilitated sternocleidomastoid (SCM), suboccipitals and scalenes, inhibiting longus capitus/longus coli, likely accompanied by tight facilitated levator scap and upper trapizius, pec major and minor. This is further confirmed by palpation of tissue texture abnormalities and pain generating guarding responses. In this common substitution pattern, SCM is working first to flex the head on neck (images 3 and 4). The therapist hooks his fingertips between ribs into intercostals and pectoral fascial slipsCoupling this ED neck pattern with upper chest breathing at altitude may prove to be inefficient at best. This pattern reduces space in the chest, as pectoralis major/minor gets involved, resulting in limited expansion of the thoracic basket and wasted energy, which would be better spent on activity.

Sternoclavicular joint. Therapist tests the clavicle’s ability to slide posteriorly. The therapist stands on the athletes right side, facing headwardWith the athlete reaching toward ceiling, the therapist should feel the medial head of the clavicle move posterior on sternum. In the case of limited movement, the therapist applies pressure posterior to medial head of clavicle while drawing arm anterior, after athlete relaxes the reach effort. Repeat, alternating reach and pressure, until some degree of posterior movement is felt at the medial head of clavicle.

The therapist hooks his fingertips between ribs into intercostals and pectoral fascial slips, encouraging superior movement of the rib segment as the client inhales.

The therapist stands on the athlete’s right side, facing headward. With the athlete’s right arm abducted to 90°, palm facing the ceiling, the therapist initiates a facial hook gently at the clavicular head of pectoralis major. Asking the client to rotate the humerus externally, accompanied with an exaggerated inhalation, the therapist sweeps fascia laterally with hand, soft forearm, or fingers. Upon exhalation, the client is asked to internally rotate the humerus, as the therapist continues to sweep laterally. The therapist then relocates working hand or forearm to the pectoralis minor attachments at ribs 3-5 and repeats breath/rotation work. Repeat until a release is achieved, indicated by movement. (Note: caution should be taken to move breast tissue inferiorly with the hypothernar eminance, in an attempt to contact the musculature at ribs 3-5.)


Focusing on upper crossed syndrome, I talk to athletes about what I call rotation/inhalation restrictions. As we inhale, our humerus should naturally rotate externally. In sports such as swimming, cycling, and running, there are components of internal rotation or arm adduction that cause a facilitatory reaction in pectoralis major and minor. Cyclists use this action as they lean far forward and hold their elbows in to limit wind resistance; swimmers as they rotate the upper extremity internally; and runners in arm swing. These activities can bind down the sternoclavicular joint, internally rotate the humerus, and again limit functional movement and space at the upper rib basket (images 5, 6, and 7). The goal in treatment at this point is treating sore, tired rotator cuffs, releasing facilitated pectorals, and bringing space into the anterior thoracic cavity. Once all the facilitated assessory muscles of breathing are addressed, the diaphragm and pelvic floor have the opportunity to activate more effectively, increasing room for breath.

A quick note on psoas tightness. Tight psoas muscles are identified by an accentuation of the lumbar spine and limited hip extension. This finding will likely be accompanied by an inhibition of gluteus maximus. This is a significant finding for two reasons; it points toward hyperlordodic conditions, not providing an optimal anchor for the diaphragm and pelvic floor; and, due to glute max inhibition, limits power in extension of gait. Stretching the psoas and facilitating the gluteus maximus is one of the best ways to help fast runners run faster.

There is no doubt that the athletes training here are going to be sore at the end of a training camp. This soreness should be from exertion however, not aberrant postures and muscle imbalances causing reoccurring injury. Dalton’s Myoskeletal Alignment Techniques enable me, as a soft-tissue therapist, to identify and treat underlying strain patterns, muscle imbalances, and postural inefficiencies, allowing the athletes to concentrate on training their bodies to peak performance.

Geoffrey Bishop is an Advanced Myoskeletal therapist and instructor with Erik Dalton’s Freedom From Pain Institute. In Sedona, Arizona, Bishop instructs Myoskeletal Techniques as part of the core curriculum at Northern Arizona Massage Therapy Institute. He is CEO of Stay Tuned Therapeutics, a pain management and teaching clinic. Have more questions than e-mail Geoffrey Bishop today!