Advanced manual techniques are powerful tools that enable the therapist to perform outstanding work.
June 22, 2015 By Jonathan Maister
Advanced manual techniques are powerful tools that enable the therapist to perform outstanding work. However, advanced techniques come with cautions and, in some cases, contraindications. They must be utilized with the knowledge of how and when to implement them.
|Release of the gluteal fascia
Fascia envelops the body like a skin beneath the skin. It sections the body into layers and compartments. Ongoing research is uncovering more about this intriguing tissue – although the experienced therapist needs no persuasion as to its treatment efficacy.
In the sports environment, fascial work is restricted to the training phase and should not be done on game day. The effects are too profound to be incorporated into the athlete’s movement patterns in the short term, but rather, adaptation should happen over the weeks or even months with the athlete and coach’s knowledge. This is even more so for sports such as figure skating, when precise positioning of a skate’s blade is essential.
The traditional treatment for shortened tissue is stretching. However, the brisk and lasting results from fascial work is a strong argument over traditional stretching.
Of primary importance with the shoulder is the pectoral and upper trapezius fascia. Habitual activity, unbalanced resistance workouts and posture tend to protract the shoulders resulting in upper cross syndrome. Fascia moulds to the stresses placed on it, which perpetuates the position.
There are consequences. Firstly, the athlete is more susceptible to thoracic outlet syndrome. The pectoralis minor tendon will shorten (or actually cause the shortening) and thereby impinge on the plexus bundle that lies underneath.
Secondly, the protracted position of the scapulothoracic joint will change the position of the glenoid fossa and tilt the acromion process anteriorly and inferiorly. This is a poor position for shoulder mechanics. In addition, the acromion now reduces the subacromial space predisposing the athlete to tendinitis, impingement and bursitis.
Fascial work to the upper trapezius and pectoral area should alleviate or even resolve these conditions. The physical pressure of the scalenes and pectoralis minor on the nerve bundle will be reduced, and the pull these soft tissues have on the scapulothoracic joint will be corrected hence obviating the consequent conditions and injuries.
The hip and knee
Of primary importance is the gluteal fascia. The gluteus maximus is a powerful muscle which recruits with strenuous closed chain activities (where the distal end of the limb is on a fixed surface and cannot move), such as hill running and stadium step training. Over time, this results in holding in the associated fascia.
The tensor fasciae latae (TFL) and gluteus maximus attach to the iliotibial band (ITB). The TFL generally performs open chain movement (the distal end of the limb is not fixed and is free to move) and is less significant clinically than the gluteals. Regardless, restriction in these muscles increase the tension of the ITB, which in turn increases the friction over the greater trochantor on the femur and lateral epicondyle of the femur. The result is higher risk of greater trochanteric bursitis and ITB friction syndrome.
Admittedly, other variables, such as cambered running surfaces, over-pronation, anatomical predispositions, can play a part. However, at its most basic level, the “tight ITB” is actually a “tight gluteus maximus” muscle.
Fascial work to the gluteal region will make a significant difference even in one session. Techniques such as drainage work, activity modification and diligent stretching (to augment the changes) are essential. But the kingpin technique for these hip-related conditions is fascial work.
The foot and ankle
These joints are inextricably linked and must be treated accordingly. In this instance we are addressing plantar fasciitis. While a host of conditions such as running habits, footwear and over-pronation are factors, most simply put, plantar fasciitis is caused by insufficient ankle dorsiflexion.
Normal walking, and sometimes running, requires at least 10 degrees of ankle dorsiflexion. If restriction in the triceps surae prevents this, the foot compensates to attain the extra dorsiflexion. The fulcrum of the movement shifts anteriorly from the talo-crural joint to the mid-foot, and the arch collapses upward resulting in dorsiflexion occurring in the mid-foot area. Consequently, tissues spanning the arch, as in the plantar fascia, are stressed. Inflammation and even micro tearing of the plantar fascia occurs.
The fascial release of the triceps surae will enable greater flexibility and in a substantially shorter time. Not to be ignored is the kinematics of the talo-crural joint. It is essential that the therapist do mobilizations to ensure the talus and mortice move properly. If the accessory movements are lost at that joint, this too will limit dorsiflexion and fascial work alone is futile.
Direct fascial work entails the therapist using the hand or the forearm. Engage this tissue a level deeper than the skin. Sense the holding of the tissue and proceed to challenge the plastic resistance. Pressure should be firm and movement slow to avoid bruising. The “plastic” quality of the fascia is what you are stretching and this should determine how slow you proceed.
In treating the areas concerned, check the status of the upper trapezius, pectorals, gluteals (and ITB) and triceps surae. By moving around the tissue just deep to the skin in various directions you will get a sense of how pliable it is. With the ITB, strum the posterior distal aspect to determine how restricted it is.
In the case of the upper trapezius, triceps surae and gluteals, use your forearm; with the pectorals, use your hand (place a rolled towel under your supine patient’s thoracic spine to give some “lift”) and proceed to challenge the plastic range. Continue slowly for five to 10 minutes depending on the patient’s tolerance.
Since the process is not comfortable, keep communication open with your patient. The tissue will allow you to stretch it, but don’t force it. If it resists, change the angle by a few degrees, or change position slightly and retry. Forewarn the patient that the area will likely feel tender the next day. So long as the therapist works slowly, bruising should not occur. Treatment has to be modulated in accordance with both the patient’s and tissue’s status.
Initially the athlete’s fascial and scapulothoracic changes may seem to last only a day or two. You will find subsequent treatments easier as the fascia adapts. Also, the body’s position will correct, hence ushering in the changes so desperately needed to make the difference.
The athlete who makes use of a therapist with fascial skills will benefit tremendously. Not only will the athlete’s condition improve, but their performance as well. Thanks to Barbara Marks-Maister and Melanie Tinianov for their photographic assistance, and Michael Grafstein and Belinda Hosey for assisting with the modelling.
Jonathan Maister, is a Canadian certified athletic therapist, massage therapist and certified sport massage therapist. He serves as Ontario vice-president for the Canadian Sport Massage Therapists Association and chairs the Education Committee in the national organization. He can be contacted at jmtherapy@JonathanMaister.com
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