Massage treatment tips for the massage therapist. Great short massage protocols for students, new and advanced massage therapists. The following staff and guest articles are presented here to provide practicing massage therapists and those considering massage as a career choice with thought provoking and relevant massage treatment tips and other massage related topics. It is our desire at get massage smart to offer an open learning center for massage therapists, students of massage therapy, adjunct therapy professionals and everyone else. Touch is the oldest health practice and we are here to help pass it on.
Article by Lisa Arkin RMT
Posted January 25. 2018
Shoulder Impingement Syndrome is much more common than most therapists realize. Inflammation of the suprasinatus tendon is seen within the athletic community frequently. Baseball, softball, volleyball, football, golf, tennis, and swimming produce repetitive over hand motion. In addition, many work environments require repetitive over hand motion, as well.
As manual therapist's we have a wonderful tool in our technique tool box that is especially well suited for working with shoulder impingement syndrome. Ice massage, if you were not properly instructed on how to perform ice massage please read through the following precautions carefully. When supraspinatus tendonitis is relieved efficiently it prevents more serious injury and allows clients and patients to return to work or sport with ease.
The process is a simple one, but does require that the therapist pay close attention to the work. The client or patient will experience an initial sensation of cold, as the work proceeds the cold will transition into burning, then aching which can be stressful for the client. It is help full to explain the process in detail prior to the work. They should be instructed to communicate the experience, when they begin to report burning and aching reassure them that this is beneficial. As the client reports no sensation or numbness the work in that area stops.
In conclusion, ice massage over the supraspinatus tendonus attachment is a complete therapy. As manual practitioners, we are aware that other postural deviation may play a role. If other work is to be done, this therapy should be used near the end of the session.
What percentage of any massage therapists practice is driven to their doorstep due to low back pain (LBP)? Athletes and weekend sports fanatics will eventually experience some form of sports related injury, many of which may lead to sub-acute and chronic LBP. Fortunately the research shows that low back pain is not an indication of disease or serious injury. There are two key trigger point zones to consider one right where it is expected to be in the LB and the other below the top of the pelvis in the area commonly referred to by clients as their butt. These trigger point massage treatment tips are intended to help everyone from a professional athlete to office worker.
SO the point is professional athlete, amateur athlete, weekend sports fanatic and regular Joe’s like us will all likely experience LBP. Many of us licensed massage therapists or registered massage practitioners may have already spent time and money studying Trigger Point Therapies, that’s great news. Most will already have a good handle on what (TrPS) are and those who have not will take their first steps into finding and treating trigger points.
Your client presents with pain they describe it as low back pain. They proceed to point to their hip, buttocks, and hamstrings and then pass over the gluteus maximus hovering between the two SI joints and just above the iliac crest. You may ask if the pain radiates down into the calf or the outside of the foot. If the say no just the hip and LB, then these two (TrPs) will be involved and will reduce the clients discomfort by up to 75% and may possible resolve their discomfort completely for at least a significant period of time.
The key here is to resist the temptation to take your elbow and dig into the piriformis. Yes it may be involved but many therapists are more likely to turn their clients persistent LBP into a to a piriformis entrapment case of Sciatica then they are likely to produce any relief. The goal of this article is to provide massage therapists and massage practitioners with two very simple tools to quickly and safely reduce LBP with a minimum of exertion and a large degree of success. The client base we are concerned with are not presenting with a sciatica relevant referral pain pattern, this is why the choice is to avoid irritating the sciatic nerve by staying away from deep work on the piriformis.
It has been said maybe too often that many therapists over treat and end up having their clients return home in more pain than they were in when they arrived at their office. Unfortunately this actually does happen. The educated use of skilled pressure is important, it is just as important to know when enough is enough.
Remember to always check in with a client and to explain to them exactly what treatment is being performed and why it is being performed. Client education is a key component of a successful massage therapy practice. Athletes are not likely to be put off by minor aches and pains, but it is essential to encourage the rest of us to stay active and keep moving. Research has shown that well over 85% of LBP will resolve itself within a couple of days to weeks when the individual stays active and avoids too much time at rest.
As massage therapists we can improve our client’s odds to just a day or two. So let’s take a closer look at two common trigger points. It will be no surprise to any seasoned therapist that the large bundle of erector spinae muscle group passing along the lumbar vertebra is a key trigger point zone. It is after all located in the low back. The client will appreciate this area being worked because to them this is the spot, the right spot, and exactly where they thought the problem was to begin with.
This key trigger point area is right next to the spine between L4, L5 and right before the muscle crosses over the pelvis and sacrum. The trick to this common trigger point is not to limit your vision of treatment to just the erector spinae. It is important to realize that the latissimus dorsi tendon attaches at L4 and L5 via the thoracolumbar aponeurosis which lies over the erector spinae with the QL just underneath in the same region and are all a part of the trigger point treatment zone. This massage treatment tip is intended to open the therapists' awareness to the quadratus lumborum and thoracolumbar aponeurosis as they are likely to have knots of scar tissue that are also playing a role in the clients aching low back along with the erector spinae bundle.
The erector spinae muscle bundle will be thickest along this region then begins to taper off as the muscle tendon joins the aponeurosis as it crosses over to the sacrum. Just above and below this area and into the tendon are all possible spots for this (TrP) to be located. Each individual client is unique and treating the entire area is recommended. It is not necessary to locate the exact spot, but many times this does happen during a massage session. Pressure on the (TrP) will light up a part of or the entire area where the client has described their pain.
To improve the end result of working these powerful trigger point zones it can be helpful to begin treatment with myofascial stretching of the superficial to deep fascia. Many therapists learn to do this in massage school to begin any massage session. It is important to not only stretch the fascia over the LB but begin the stretch over the neck and shoulders. Now the fascial stretch should be taken across the thoracic area into the LB, then proceed to stretch and lengthen the fascia over the outside of the hip, thigh, over the gluteal and sacral regions as well.
It is important to take time performing the fascial stretching and allow this work to warm up the underlying tissues for deeper treatment. Massage tools, thumbs and elbows can be used to direct controlled pressure into this region. Broad forearm strokes can be used to direct a powerful force directly down on the area and thumbs and tools should be used at an angle pressing toward the spine, both to preserve the therapists’ thumbs and to increase the clients comfort. Discomfort is to be expected but if the client is trying to tolerate extreme pain the work will be counterproductive.
Anything within a couple square inches of L5 and the dimple of the back is the target zone for treating this (TrP). As the area begins to let the therapist in remember to focus the work not only into the erector spinae bundle but the Latissimus dorsi and QL as well. It can be useful when the area is flaccid enough to grab the lattissimus dorsi muscle bundle just under the shoulder and follow it all the way down to the LB region. As you approach the LB focus on the QL and pull the tissue along with the erector spinae bundle up and away from the spine. This is best down without lubricant. Follow the treatment procedure over to the other side before moving on to the next big trigger point zone.
Great we have worked the area the client was most interested in, the right spot in the clients’ eyes. Now let’s talk about the real meat and potatoes, the more likely culprit causing the referred pain across the low back into the hip and down into the hamstrings. The gluteus maximus, but not that point that crosses over the piriformis where many therapists like to dig their elbow in, this is a more subtle location with much more potential to relieve pain.
The massage treatment tip here is to remind therapists how important the gluteus maximus is in LBP and to point out this often over looked area of the muscle. Most therapists will spend time working around the greater trochanter and will work specifically on the origin, insertion and belly of the piriformis which lies directly under the guteus maximus. To find this (TrP) it is important to think gluteus maximus at its origin and to remember that the gluteus medius is just underneath and likely plays a role in the clients LBP.
This is a key (TrP) zone when clients present with LBP pain that they believe is related to Sciatica and/or Sacroiliac joint dysfunction. They may be using these terms because their doctor has diagnosed them with these conditions or they simple picked them up from TV, family members or friends. Either way the focus is treating the gluteus maximus as it attaches to the ilium and angles toward the greater trochanter. Remember we asked the client if the pain referred down the back of the thigh, calf and into the outside of the foot and they said “no, it did not travel that far”. This treatment protocol is for clients that are presenting with persistent sub-acute and/or chronic low back discomfort and pain.
This area is often well padded with fat, especially if the client is not a professional or amateur athlete. This will make the area a little more challenging to work on then with the physically active athletic body type. Do not let this dissuade you from paying close attention, if the myofascial work was performed with specific dedication to this region the (TrP) work will be easier to perform.
If you are not working on an athlete or someone who receives massage treatment regularly it may be beneficial to let your client know that their back pain is radiating from more than the area you just worked. They may feel emotional or be uncomfortable with their buttocks being touched and worked. The butt may hold the same emotional do not touch social concepts that the genitalia hold.
Explain to them that the large muscles that control the movements at the hip are very likely to play a significant role in their overall pain and discomfort. The largest extensor of the body is the gluteus maximus and along with the quadratus femoris are known as the antigravity muscles. The maximus specifically helps us rise from a seated position, climb stairs and jump.
As the muscle groups performing a significant amount of work moving us around in the world they are a key pull point and often will contain scar tissue and deep knots. The client can develop a profound (TrPs) in the gluteus maximus without having the slightest bit of awareness of it until the latent (TrP) is activated by massage. The gluteus maximus has a powerful tendon and is also the tendon for the TFL. The tendon of the gluteus maximus and the tensor fasciae latae passes from the crest of the ilium down toward its insertion on the femur and the tibia via the iliotibial track or band.
The triangular region of the muscle belly that is the source of this important (TrP) is found in the part of the muscle that passes from the crest of the ilium toward the sacrum. Draw a line in your mind from the SI joint toward the tendon of the gluteus maximus as it moves toward the greater trochanter. Now focus the treatment on the inside edge of its most lateral attachment to the iliac crest. This region often presents with the dimple on either side of the sacrum, although not everyone will have superficial dimpling to help guide the work.
The sweet spot that will often mimic the clients described pain pattern in part or in its entirety is about one pointer finger width blow the attachment. Pressure should be strong directly into and toward the upper ridge of the bone. Remember that a part of gluteus medius is under this portion of the gluteus maximus. Thumbs as well as massage tools and the elbow can be utilized to apply pressure, never use the point of the elbow always the flat part of the ulna.
The gluteus medius muscle traverses more laterally than the gluteus maximus muscle bundle, the tendon fibers of the maximus actually cross over part of the gluteus medius as it travels toward its two insertion points. This section of the gluteus maximus may be involved in the clients LBP and the entire area under the crest of the ilium down 2 inches should be included in the treatment as well as the gluteus medius.
Use of a lower table and therapists' body weight can reduce therapist strain, always stay within the clients tolerance, discomfort is to be expected by actual pain needs to be avoided. Some individuals who sit in a chair while they work for long hours may be extremely sensitive and the use of the finger tips with lighter pressure may be all that the client can tolerate. Women during their monthly cycles will also tend to be more sensitive in this area than they would normally be.
Although 75% of the time this spot will elicit the low level ache that the client has been experiencing across the small of the back down the butt and into the hip and hamstrings; 25% of the time this (TrP) will produce sharp and hot pain and should be treated carefully and slowly. A response of sharp and hot pain can indicate that you are on the tendon and a slight movement toward the muscle fibers and belly can reduce the severity of the pain. If the pain remains high work gently through it until it subsides.
Finally it is important to note that not every person will experience reduction of their individual pain pattern. For those who have well developed trigger points in these two key zones, the treatment will produce up to 75% reduction of the original LBP experienced. So the odds are in favor of achieving some significant change for the client. Always communicate clearly and honestly with clients and never make any guarantees as you will not know what group they fall into, and results on the same individual will vary from session to session. To support the clients' ability to stay pain free demonstrate core strengthening mobilization and encourage them to keep moving.
Article by Gretchen Rieger LMT, BS
Posted August 9 2014 Last Update April 12, 2017
This is an interesting question, most therapists will use ROM vigorously when they first graduate Massage School until they realize when working at a Spa, Massage Club or Vacation Destination that their clients do not want to be stretched and participate in joint mobilization or ROM. It seemed so utterly important when being evaluated during a practical exam. Then here they are working with clients in the “Real World” and their clients would rather not have them move their joints around. Now just what does a therapist do to fill the gap in their routine? Here are a few massage tips to help connect with a new client.
The answer to the question has a lot to do with what brings the client into the massage room for a massage. Many times if they are healthy and on vacation they just want to have the most wonderful full body Swedish relaxation massage they have ever had. Is this a “Tall Order”? Yes, but not as hard to achieve as most new to the industry might think.
Quality communication is the key! Look the client in the eyes use their name when you speak to them and ask them what they are looking to get out of this massage session. Add some clarifying questions to find out what they liked most from their favorite session and what they liked least. Now how much additional communication does the massage session need, this depends on the client. If the client continues an ongoing conversation then by all means respond. If you feel you need to be clear about what you are going to do next within the massage treatment, then speak.
Clients are not usually all that hard to read. If they like to talk respond if they like to be silent then return the favor. It may depend on what kind of hands on education you have received, but do not rush the work.
The best tip for a “that was amazing response from a client” is effleurage, effleurage, effleurage, and yes some very full and wonderful petrissage. As a matter of fact make sure it is the most thorough fulling form of the technique that you can imagine. Your imagination and personal style will play an enormous role in achieving this “Tall Order”. A little deep work just where it is needed, firm to deep pressure based on the clients’ preference, a touch of friction, vibration and compression.
This is enough when the client just wants to zone out. Can’t imagine what it feels like to have a client say that was the best massage I have ever had? Keep working at the craft and the compliments will come. Now say their name at least once as you finish the work and end the session. The joy of the work and having the unique opportunity to work in an industry that you really love is often reward enough.
Remember we started this discussion out with a question about ROM in the massage treatment room. So let’s take a closer look at ROM. Another reason a therapist may not use ROM in the massage room is that they never quite got what it was for in the first place. Or it seemed so much easier to do a full body massage without it. It may seem everyday knowledge to some therapists and a little surprising to others that, ROM was a foundational element within Per Henrik Lings “Swedish Medical Gymnastics” also referred to as ”The Swedish Movement Le Cure”.
Exercise was also an element of Ling’s natural gymnastics as
he strove to teach a Nineteenth
Century generation how to overcome injury and continue to compete in
sport. ROM can be a dramatically
effective tool for the Massage Therapist!
This article is intended to revitalize the concept for some and extend
the use of it within the practices of others.
In the Twenty First Century Range of Motion is still a very significant part of helping active individuals stay fit. Knowing the clients current range of motion can help establish the effectiveness of the massage treatment. Clients that come in with a specific reason for the treatment will be more open to the use of pretreatment ROM testing and post treatment ROM testing. Even if the therapist is working within a mostly relaxation client population, when a client indicates that they came in today because of shoulder pain or limited motion or hip pain, give them the opportunity to have the full benefit of your skill and training.
The goal of pretreatment ROM testing is to have the client move the joint within its normal range of motion as far as they can without pain. PF – Range of Motion indicates the clients comfort zone. Knowing what direction the pain or limitation is occurring in will tell the therapist what muscles to design the treatment around. Current research has established that pain can be mitigated with the use of mobilization. Any movement within a joint that can be performed without pain can improve the clients' ability to increase overall mobility in the effected joint.
Early mobilization of an injured limb or spinal column can shorten the duration of the acute condition and improve the quality of the rehabilitation and recovery. Everyone has heard the old adage “move it or lose it”, when it comes to rehabbing a joint or the spinal column the research is clear. The best thing to do is to get moving as soon as possible and as often as possible.
When working with a client who persists with a significant level of pain within the ROM of a joint it is not only favorable but a moral imperative that the client be referred to an appropriate medical practitioner. The client may need more in-depth treatment as well as physical therapy. It is often a physical therapy or Doctors office that will refer a joint replacement or joint injury patient to massage therapy at the appropriate time as part of their recovery and wellness plan.
Now that we have established the usefulness of ROM testing, let’s take a closer look at ROM testing that can be easily and quickly assessed prior to the application of a massage technique or bodywork modality. This discussion will begin with ROM of the shoulder a common area of complaint among massage clients.
To enhance our understanding of observation and range of motion testing it is essential to note that massage therapists do not diagnose. The use of visual observational assessment and ROM is a tool by which an LMT, RMT or MP can acquire information for the purpose of designing and executing a soft tissue massage or bodywork modality session. If a client is interested in a diagnostic examination give them a local referral to an appropriate physician’s office or physical therapy office.
Learning how to visually asses a client’s shoulder is a quick tool that will help establish the muscle or muscle groups that may play a role in the clients discomfort, pain or limited range of motion. The level of an individual massage therapists’ skill at visual assessment will come with time there is a reason we establish massage practices. We will now take a look at Dr. Mark Hutchinson’s shoulder assessment uploaded to youtube.com. This video assessment ROM massage treatment tip was provided by the British Journal of Sports Medicine (BJSM).
Taking a moment to look at a client’s shoulder alignment and
using your palpation skills to determine balance in muscular development as
well as sensitivity & soreness. This will only take a few minutes. Palpation is a skill that will develop in a
massage therapist over time. Learning
how to palpate the muscle tendons and their origins and insertions as well as
bellies is an essential skill.
Pause the video at 1:38 and it can clearly be seen that the right shoulder is raised slightly. Taking a closer look at the left scapula and it is evident that the superior angle, vertebral boarder and inferior angle are clearly visible. His hands are not hanging freely because he is in a seated position, but it is still evident that there is more of the white back wall visible on his right side than his left. The protruding scapula indicates that the left shoulder is being pulled anteriorly and medially in a downward direction.
Now take the video back to about 0:36 and notice that his left pectoralis major is more developed than his right. Again there is more visible white back wall between the arm and chest wall on the right side of the body than the left. This is again indicating that the left shoulder is rolled medially and anteriorly in a downward direction. Take some time and review the video by sliding the static images from anterior to posterior views. There are some other postural indications that can pick up from these images. What do you see?
Dr. Hutchinson’s next video provides a clear guide to shoulder active and passive range of motion with palpation of the glenohumeral joint. Thank you Dr. Hutchinson for this clear presentation and thanks also to the British Journal of Sports Medicine for uploading this video for our use as an example of shoulder range of motion testing.
In conclusion it only takes a few minutes to gain a great deal of knowledge about a particular client’s individual range of motion and pain with motion. Encourage clients to keep moving and seek the appropriate medical care if pain and reduced motion persists. Check back with us at getmassagesmart.com for our next massage treatment tip for the massage therapist.
Article by Gretchen Rieger LMT, B.S.
Posted October 18, 2014 Last Updated April 3, 2017
Foot pain can be experienced by individuals of any age group or occupation. Often found in significantly greater numbers among women over 40, athletes and all individuals between the ages 40 to 60. The treatment protocols offered in this article are well suited for any chronic foot related pain and specifically designed for those experiencing plantar fasciitis.
Foot massage can be a particularly luxurious part of any massage routine and an absolute necessity for those experiencing chronic foot pain. As its name implies Plantar Fasciitis is an inflammation of the Plantar Fascia and clinically referred to as enthesopathy of the plantar aponeurosis. A defining symptom is pain and tenderness in the arch of the foot into the inferior calcaneal region or heel upon rising from sleep in the morning.
Subcalcaneal pain syndrome is thought to be a result of micro tearing of the plantar aponeurosis at the fascial bone interface with the calcaneous due to force over loading. The micro tearing initiates the inflammatory response and a cascade of immunological factors. It seems obvious why athletes are often affected by plantar fasciitis, particularly runners and sports that involve running. Yet it may be plausible that hormonal changes as we ages can play a role in older populations.
The question here is: how can a Massage Therapist support individuals experiencing foot pain or plantar fasciitis? Ice massage has been shown to have a positive effect on acute plantar fasciitis. If a client presents with acute pain, it may be the only therapeutic option that can be performed within the clients’ pain tolerance. Although direct treatment of the volar aspect the foot may be off the table, it is recommended that the stirrup muscles (tibialis anterior and fibularis longus) of the leg and foot as well as the fibularis muscles often referred to as the peroneal muscles be addressed.
Start treatment with myofascial release of the lateral to posterior hip, the fascia lata of the thigh is a focal point of this fascial release through the knee joint and into the leg as it becomes the crural fascia. The fascia lata anchors on the tensor fascia latea tendon or iliotibial band medially and laterally. Address the superficial fascia through the crural region into the Achilles tendon. Paying significant attention the Achilles tendon, if time allows address the gastrocnemius and soleus, while remembering that the fascial thickening of the fascia lata has attachments to the coccyx, sacrum and iliac crest posteriorly.
Anteriorly it has attachments along the inguinal ligament, superior and inferior ramus of the pubis as well as tuberosity of the ischium and sacrotuberous ligament. The fascia lata passes over the gluteus medius to the boarder of the gluteus maximus. Here the fascia splits into two layers one passing superficially and the other deep to the muscle, rejoining at the lower aspect as the belly meets the iliotibial band.
Close attention should be paid to the fascial release of the hip & thigh region. Perform trigger point or neuromuscular therapy on the TFL muscle belly and friction its attachment at the lateral tibia. Continue trigger point work to the fibularis muscles, paying close attention to the fibularis longus. Follow the tendon of the fibularis longus as it passes around the lateral malleolus and crosses the plantar surface of the foot to its insertion at the base of the 1st metatarsal and first cuneiform.
Now direct your focus to the tibialis anterior use a wringing fascial release over the anterior to posterior aspect of the leg. Next use trigger point work along the tibialis anterior and follow tendon down to its insertion attachment at base of the 1st metatarsal and medial plantar surface of the 1st cuneiform. It may not be possible to treat through to the insertion if the client is in an acute pain.
A tool can be used for this next treatment or the knuckles of a loosely closed fist. The focus of this treatment is the plantar fascia from its attachment at the base of the calcaneus to the ball of the foot if the client is prone or form the ball of the foot to the calcaneus if the client is supine. Use a long flat massage stone or fist and draw the work from superior to inferior and from superficial to deep. It is advantageous to perform this work form both the supine and prone positions. Avoid in clients with acute pain.
The plantar aponeurosis and musculature of the volar surface of the foot are thick and tough in adults through their 60’s. Using the knuckles between the metacarpals and the proximal phalanges press in firmly and glide without lubrication from the ball of the foot to the heel, while client is supine. Then from the heel to the ball of the foot while client is prone.
Before turning the client back to the prone position a key component of this work is a trigger point that can be found in the plantar aponeurosis. This point is half way from the ball of the foot toward the calcaneus and in the middle of the foot, just a little bit closer to the medial edge. The image of the plantar surface of the foot shows this trigger point with a red arrow.
A massage tool, thumb or knuckle can be used to apply pressure to this point. This step may be skipped in acute clients. It can also be the focus of a short 10 to 15 minute treatment for plantar fasciitis. You will want to prepare the plantar aponeurosis with deep fascial gliding with a massage tool or knuckles, as previously described. In addition pay close attention to the calcaneal region and apply friction to the Achilles tendon.
This last trigger point within the plantar aponeurosis lies superficial to the attachment points of the stirrup muscles which includes tibialis anterior, tibialis posterior and fibularis longus. This point although labeled a trigger point is unlikely to refer pain. Spend a reasonable amount of time using deep pressure within the clients’ tolerance zone. This is the point within the treatment when client will say you are working on the pain that they have been experiencing.
In conclusion, it can be beneficial to teach the client how to work this point at home on their own. A golf ball or a tennis ball can be used as well as the clients own knuckles or thumbs. If stability is an issue, suggest the client be seated while using either of the balls and make sure they can find this trigger point on their own.
Article by Gretchen Rieger LMT, BS
Posted February 9, 2015 Last Updated March 29, 2017
Figure: Tibialis Anterior highlighted in lime green, Extensor Hallucis Longus highlited in orange, Extensor Digitorum Longus is highlighted in yellow, Fibularis Tertius is highlighted in purple, Fibularis Brevis is highlighted in pink, Fibularis longus is highlighted in baby blue, Soleus is highlighted in cherry red, Gastrocnemius is highlighted in hunter green.
Studies have shown that 30% to 70% of all runners will experience a running related injury. The wide range of conditions that are attributed to the common pain pattern referred to as shin splints can be overwhelming. For the purpose of this massage treatment tip we will limit our definition to tibialis anterior and the anterior compartment of the leg in relation to overuse injuries.
Tibialis Anterior repetitive strain injuries are common among the athletic community and relevant to any running related sport. In the medical arena they would be diagnosed as either tibialis anterior tendinopathy, tibialis anterior tendonitis, or tibialis anterior tendinosis. To complete our picture we need to include a discussion on overuse tendonitis for all the muscles found within the anterior compartment of the tibia, which are extensor hallucis longus, extensor digitorum longus and fibularis tertius.
It is important to point out that if you are working with a patient/client who has edema, rash or the limb is hot to the touch, along with pain they should be immediately referred to their personal physician. Although extremely rare reduced blood flow to the muscle tissue can lead to muscle death. If the individual is reporting a trauma related incident that involves a crushing of the leg musculature they should seek immediate medical attention.
Inflammation and tendinitis of the anterior leg compartment musculature is often the result of excessive repetition within dorsiflexion and extension of the digits along with the force of impact recoil during running or long distance walking. The topography of the terrain traversed can also play a significant role in the causal nature of tibialis anterior tendinosis. Hard, uneven and unstable surfaces may increase the likelihood of developing trigger points within these muscles, fascial inflammation and tendonitis.
Kicking sports tend to add an increased degree of dorsi flexion and extension through the digits, as they are used to transfer force into the ball and provide for direction of that force. This can be coupled with sudden bursts of speed followed by sudden stops. Other consideration may be the type of shoe warn and the age and condition of the foot ware.
An athletes' foot ware may be bound to tightly across the dorsal surface of the foot, ankle or leg allowing for a rubbing action to take place over the fascia and tendons. This consideration increases among individuals who are wearing high top foot ware as in basketball or hiking. Their foot ware may simply be bound to tightly across the foot, taping of the ankle and shin may also lead to increased pain symptoms rather than a reduction of pain especially if the taping is applied to tightly.
Taping of the ankle for support is a common technique used by, physical therapists, athletic trainers and athletes to provide stability and should be considered along with tightness in the soleus, gastrocnemius and plantaris. Tension within the calf muscles will increase tension on the Achilles tendon and crural fascia. The tightness or weakness of the peroneal muscles, as well as tibialis posterior would be considered as part of a thorough assessment for shin splints or anterior leg pain.
Taping can reduce shin pain when applied appropriately and followed by rest or mild exercise activity. Rest, ice and compress is a simple yet appropriate first aid response to acute onset shin splints. Rest is a key component of allowing the inflammatory response and tendinitis a chance to reduce, recover and heal.
Stretching and Strengthening of the tibialis posterior and posterior compartment muscles would be a part of a complete treatment protocol. The best, most effective stretch method that should be considered for both lengthening and strengthening is A.I.S. Active Isolated Stretching the Aaron Mattes Method. A M.E.T or contract and relax method may also be supportive. This would not be undertaken until the acute phase of pain has subsided.
If structural change, degeneration in hip, knee or ankle joint or biomechanics is seen or strongly felt to play a role in chronic shin pain, then a referral for gait analysis and professional custom orthotics or foot ware may be called for. Cryotherapy or ice massage to the tibialis anterior may be the only option when shin pain is acute. A small frozen water bottle may be used if patient/client can tolerate any pressure.
This treatment can be performed by rolling the bottle slowly with moderate pressure from distal to proximal attachment. A soft palpation assessment can identify trigger points and tissue binding as the muscle pulls away from the bone, use slow medium to firm pressure as you roll over these points. Check in regularly with client for sensation feedback. Make sure to take the work only to the burning and achy sensation then stop and roll farther up the shin. You may want to experiment with bottle shapes a nice curvature to the bottle can be useful as well as straight sides. Different leg sizes may require different sized frozen bottles.
If this technique is not tolerated a Dixie cup filled half way and frozen can be used to apply cryotherapy to the muscle using slow circular motion from below the medial malleolus across the anterior ankle and up the tibia thru the proximal attachment of the tibialis anterior. Check in with the client as they experience the stages of cold application cold sensation, stinging, burning and aching and finally numbness. Treatment is complete when they are experiencing a numbing sensation. Application of ice beyond this point may lead to cellular & tissue death. Cryotherapy may be considered for treating both lateral and posterior compartments, as well as when clients present in acute to server pain.
Myofascial release and deep tissue work may be performed on the posterior musculature including the three Achilles tendon muscles gastrocnemius, soleus and plantaris, with special attention to tibialis posterior when client pain threshold will allow. Special focus should be placed on the medial tibia to address tibialis posterior and to the lateral tibia to address the febularis muscles. Next we will look at a complete treatment protocol for sub-acute or chronic shin pain.
The sub-acute and chronic shin splints treatment protocol begins in much the same way as for plantar fasciitis, with myofascial release of the posterolateral hip. The goal is to open the fascia from the hip through the fascia lata of the thigh through the knee and crural fascia of the leg. The treatment should include a detailed consideration of this area paying close attention to the IT band laterally and adductor muscles medially.
When tibial pain is a primary concern the release of the anterior hip, quadriceps group and iliopsoas is a component of a complete treatment protocol. Resent research has found that pelvic stabilization can be a biomechanical causal component of anterior tibial pain. Imbalances between the hip and knee joints follow through from the knee to the ankle joints.
The stirrup muscles include the tibialis anterior, tibialis posterior and fibularis longus, the functional balance of these tendon units provide stability for the arches of the foot. When athletes run stop short and change directions as in team sports they place strain and increase tension on the tibialis posterior tendon which may result in tendonitis and tight muscle fibers within its muscle belly. This tibialis posterior tendinopathy is often referred to as posterior shin splints.
The tibialis posterior originates on the posterior surface of the tibia attaching to the bone and tibial periosteum. The tendon of insertion passes down the posterior tibia moving medially and wrapping under the medial malleolus. It continues to anchor to the tuberosity of navicular and slips pass to sustentaculum tali of calcaneus, plantar surface of all 3 cuneiforms, cuboid and to the base of 2nd, 3rd, and 4th metatarsals.
The belly of the gastrocnemius and soleus muscles must be addressed with deep tissue massage. Follow this with transverse friction of the tibialis posterior tendon from the medial arch under the maleous and along the Achilles tendon. Continue to apply deep tissue massage technique while displacing the belly of the gastrocnemius laterally.
Treat the fibularis longus and brevis muscles with transverse fiction along their tendons of insertion that pass under the lateral malleolus. Continue to apply deep tissue massage technique to the belly of the muscles. Follow the belly to the tendon of origin found on the proximolateral tibia.
Now that the posterior and lateral compartments of the leg have been addressed it is time to treat the tibialis anterior muscle the commonly accepted source of anterior shin splints. Make sure you have used fascial wringing technique before proceeding to use deep (TrP) massage. Palpation of the muscle will establish these fascial adhesions. Thumb, knuckle and pisiform pressure can be applied with directed client dorsi and plantar flexion to increase the intensity and benefit of the (TrP) massage. A tool may be use, with the awareness of location and pressure to prevent injury to the tibial skin and periosteum.
In conclusion it can be beneficial to instruct the patient or client on how to safely perform cryotherapy along the anterolateral shin treating both the tibialis anterior and peroneal muscles. Make sure to cover the four stages of cold sensation and instruct them to stop with initial numbing sensation to prevent cell and tissue death. The clients' use of a handball or racket ball can apply pressure along the tibialis anterior with slow and controlled dorsi and plantar flexion. The tibialis posterior can be treated along the medial tibia with a (TrP) rolling tool like the Tiger Tail from tptherapy.com or use a rolling pin or foam roller. Instruction in A.I.S and strengthening of the ankle, leg and hip musculature will go a long way towards recovery and prevention.
Article by Gretchen Rieger LMT, BS
Posted August 9, 2014 last updated December 1, 2016
The massage therapists' greatest assessment tools are skillful palpation and experienced ROM testing. The more you have the opportunity to practice ROM the greater your understanding of joints, joint capsules, ligaments and tendons will become. Increase your use of muscle testing and ROM every opportunity that presents itself.
Let's do a quick review of the basics. Which form of ROM is always performed first and which form of ROM is always performed last? The goal is to minimize testing changes within the targeted tissue as much as possible. Therefore; active unassisted or free range of motion is the first requested movement.
The uninvolved side provides a visual of the individuals normal. The involved side will indicate changes that have taken place that may be due to repetitive motion, trauma or pathological degenerative issues. On occasion depending on the daily life activities or age of the individual both sides will show some form of change. The complete procedure should be described to the client prior to beginning the ROM test. The client should be prompted to indicate and describe pain, as well as, describe all sensations of limitation to the best of their ability.
Pain is a sensation most often experienced. Some clients/patients will describe a strap like sensation or a sudden stop with no pain. Listen to everything expressed and make sure it is documented. Next or first if required by the specific circumstances, active assisted range of motion may be tested. The goal of all active testing is for the client to stay within their pain free range. Staying within a pain free range will minimize testing changes within the targeted tissues.
It is just as important to see healthy joints in motion and to passively ROM test them. The goal of passive ROM testing is to assess inert tissue, such as bone to bone surfaces, ligaments, cartilage, bursa, joint capsule and fascia. The sensation of freely movable joints doing exactly what they are designed to do will be the foundation of any range of motion education. If you are still in school? Take every advantage of student clinic, friends and family and classroom trades.
Active range of motion allows for observation and descriptions of any pain experienced during the motion or after completion. The therapist can take note of any compensation. Compensation is when the individual utilizes alternative movements to achieve a near approximation of the motion that was requested. The use of alternative motion will indicate muscles and tissues involved, helping to establish the treatment plan.
Active Assisted Range of Motion is utilized under certain conditions. It is most often used when a client has a weakness due to pathology or injury. The therapist would help assist the client as the client actively moves the joint through a pain free range of motion, indicating pain when it arises. The use of light pressure touch over the joint capsule can add palpation of tissue for analysis during active assisted ROM.
Active ROM testing is conducted first or Active Assisted ROM testing, when called for, followed by passive ROM testing. Passive testing allows the therapist to ascertain any adhesions or excessive mobility within the joint's range. During this passive motion the individual being tested should remain as passive as possible, the movement is gentle and any pain or sensation should be reported immediately to the therapist.
If further testing is required for a more detailed understanding of mobility restrictions a second passive ROM may be used. This form of testing would utilize a directed even pressure into the joint. The goal is to assess the joint's end feel, pressure is gradually increased as the joint reaches its end range of motion. The therapist is feeling for resistance to motion and is openly communicating with the individual regarding pain level.
This is where extensive practice while in school can really pay off. Healthy tissue will move freely with no restrictions or pain and end range will be a result of the structural anatomy of the joint being tested. An example of normal painless hard end feel, which is bone to bone, is the elbow in full extension. Next an example of normal painless soft end feel, which is where motion is obstructed by soft muscle tissue, is the elbow in flexion. Where the motion of flexion is stopped by the bulk of the anterior compartment musculature. Last, an example of normal painless spring or stretch end feel, which is where there is a sensation of stretch felt at the end of motion, is lateral trunk flexion.
With practice and experience, the detection of pathological end feel can offer up an enormous amount of information, detailing changes within a joint structure due to injury or degenerative disease. A hard or bone to bone end feel, occurring when the therapist would not expect to feel such hard resistance, can indicate changes in the osseous tissue, joint capsule or misalignment after a fracture. On the other end of the spectrum, an unrestricted end feel yielding a high level of pain, may indicate bursitis and inflammation of the joint capsule.
A very common experience among manual therapists, is a bouncy end feel, which may include the sensation of a contractile spasm. This is a sudden and the hard cessation of movement, including pain, followed closely by a bouncy sensation that may include spasms in specific muscles involved with the range of motion. This type of end feel may indicate a responsive muscle guarding intended to prevent further injury.
A restricted, yet springy end feel near the end of range of motion of a joint, with or without pain, can indicate changes to inert tissues. Such as, cartilage or the meniscus of the tibiofemoral joint. Where the individual would not be able to fully extend the joint.
A soft, yet soggy end feel can indicate edema within the joint or joint capsule. This soggy feel may indicate an acute ligament injury, usually accompanied by moderate to severe pain. A sprain, for example, of an ankle may also include a strain to one or more muscle tendons.
In conclusion, there are a few ROM testing patterns that occur often during the course of a manual therapy practice. Having a clear understanding can facilitate quick identification of tissue injury or pathology and an effective treatment plan or a referral to the most appropriate health care team. A stable, pain free active range of motion indicates healthy strain free contractile tissue.
A stable, yet a painful active range of motion, may indicate a muscle injury that is contracting during motion. Such as, a muscle strain or tendonitis. Either of these injuries are indicated for massage therapy.
On the other hand, an unstable and pain free range of motion, likely indicates a strain or decreased nerve supply to the muscle. This may call for a referral to physical therapy, physiotherapy or physician. At the very least, it is recommended to have the individual see their primary care team for a clearance for further treatment.
An unstable and painful active range of motion result, may indicate a severe muscle injury, dislocation or osseous tissue fracture. A referral to a primary care team is indicated prior to any further testing or treatment. A written clearance would be required for a return to manual therapy and massage.
Make sure a thorough client intake interview is conducted, ruling out any and all contraindications to ROM testing and/or massage therapy. Take advantage of every opportunity to practice with healthy joints while you are still in school. Repetition is the key to building a keen kinesthetic skill set.
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