Massage Therapy Improves Circulation, Alleviates Muscle Soreness

Newswise — Massage therapy improves general blood flow and alleviates muscle soreness after exercise, according to a study by researchers at the University of Illinois at Chicago.

The study, reported online in advance of print in the Archives of Physical Medicine and Rehabilitation, also showed that massage improved vascular function in people who had not exercised, suggesting that massage has benefits for people regardless of their level of physical activity.

Improved circulation and relief of muscle soreness are common claims made for massage’s benefits, but no studies have substantiated such claims, even though massage therapy is increasingly used as an adjunct to traditional medical interventions, said Shane Phillips, UIC associate professor of physical therapy and principal investigator on the study.

“Our study validates the value of massage in exercise and injury, which has been previously recognized but based on minimal data,” said Nina Cherie Franklin, UIC postdoctoral fellow in physical therapy and first author of the study. “It also suggests the value of massage outside of the context of exercise.”

The researchers had set out to see if massage would improve systemic circulation and reduce muscle soreness after exercise. Healthy sedentary adults were asked to exercise their legs to soreness using a standard leg press machine. Half of the exercisers received leg massages, using conventional Swedish massage techniques, after the exercise. Participants rated their muscle soreness on a scale from 1 to 10.

As expected, both exercise groups experienced soreness immediately after exercise. The exercise-and-massage group reported no continuing soreness 90 minutes after massage therapy. The exercise-only group reported lasting soreness 24 hours after exercise.

Exercise-induced muscle injury has been shown to reduce blood flow. In this study, brachial artery flow mediated dilation (FMD) — a standard metric of general vascular health, measured in the upper arm — was taken by ultrasound at 90 minutes, 24, 48 and 72 hours after exercise.

For the exercise-and massage-group, FMD indicated improved blood flow at all time points, with improvement tapering off after 72 hours. As expected, the exercise-only group showed reduced blood flow after 90 minutes and 24 and 48 hours, with a return to normal levels at 72 hours.

“We believe that massage is really changing physiology in a positive way,” said Franklin. “This is not just blood flow speeds—this is actually a vascular response.”

Because vascular function was changed at a distance from both the site of injury and the massage, the finding suggests a "systemic rather than just a local response," she said.

“The big surprise was the massage-only control group, who showed virtually identical levels of improvement in circulation as the exercise and massage group,” said Phillips.

“The circulatory response was sustained for a number of days, which suggests that massage may be protective,” said Phillips.

For people with limited mobility or those with impaired vascular function, further research may show that regular massage offers significant benefits, the authors say.

Dr. Mohamed Ali, Austin T. Robinson and Edita Norkeviciute of UIC are co-authors on the study.

This work was supported by a Massage Therapy Foundation research grant as well as National Heart, Lung, and Blood Institute grants K23HL85614, RO1HL095701, and HL095701-01A2S, and UIC’s Center for Clinical and Translational Science award UL1RR029879 from the National Center for Research Resources.

LePelley's Tissue Density Grading Scale Grade 0 (Yellow) = Tissue is flaccid, hangs from attachments and has little to no resistance to gravity. Grade 1 (Green) = Tissue is toned yet easily malleable. Grade 2 (Blue) = Tissue is firm, tender if pressed into; muscles may appear and feel as if they are bound together as one. Grade 3 (Red) = Grade 3 TD is tight, rubbery and is strongly resistant to mobilization. Grade 4 (Brown) = Grade 4 TD is hardened, rigid and immobile. Grade 0 (Yellow) – depicts advanced wrinkling; the hanging tissues found on some chins and underarms and the sagging, drooping tissues often noted on persons who have quickly lost a great deal of weight. It is important to note that grade 0 tissues are often found superficially over an area of elevated TD in the 2 to 3 range. It may feel as if the loose tissues have separated from deeper tissues, which in turn are becoming condensed. The deeper tissues are usually tender with moderate palpation, with easily definable borders. Grade 1 (Green) – TD represents normal, healthy tissue that is pain-free, well hydrated and well perfused. It is easy to palpate, identify and differentiate muscles, bones, ligaments and other connective tissue. Usually warm to the touch with no pitting when palpated. Grade 2 (Blue) – TD indicates elevated tissue density. Upon palpation you will find the tissues tight, sometimes hardened and resistant to mobilization. They do not relax easily and are reported to be uncomfortable, even painful. Clients often describe Grade TD 2 tissue as being tight, sore, achy, heavy, stiff and/or painful. However, grade 2 TD can be latent, without complaint of pain or dysfunction until activated by injury, use or palpation. The borders of the affected areas are easy to determine. Grade 3 (Red) – TD can be found in small strands and bands interspersed with other grades of TD, causing much pain and dysfunction, such as that of Carpal Tunnel Syndrome and Tendonitis. Larger areas are often found in a wide variety of conditions, such as Restless Leg Syndrome, MS, Parkinson's, and Fibromyalgia. Grade 3 TD feels firm and rubbery, and is resistant to mobilization. Grade 4 (Brown) – TD is associated with profound dysfunction, for example, curvatures and contractures such as those experienced by persons who are bedridden or extremely sedentary for long periods of time. Painful knots and lumps, and the “bony overgrowth” found in arthritic conditions are composed of grade 4 TD. It is hardened and often believed to be composed of bone.

TDR Massage for Headache Prevention and Relief

By Linda LePelley, RN, NMT

There are many different types of headaches and most of them, while painful and even debilitating, are not considered to be medically serious. As massage therapists, it is not within our scope of practice to diagnose the type or severity of a client's headache, but once we have determined there is no underlying pathological cause, there is much we can do to relieve, and even prevent, their headache pain.

The Tissue Density Restoration (TDR) massage method of headache prevention and relief is based on the belief that the pain being experienced is directly related to the density of the involved tissues. Whatever the headache trigger might be - emotional stress, muscular tension, etc.- it can be relieved by restoring those tissues to a normal, healthy density.

Hyper-dense tissue hurts because the involved nerves are entangled and compressed within them. When a person's scalp, neck and/or shoulders contain areas that are too dense or hardened, normal movements tug and tear at nerves which are no longer able to slide and glide within their surroundings. It is interesting to note that, in the throes of a headache, one may press into the scalp over the area that hurts and find pain experienced inside the head, which can often be palpated on the outside of the skull because, in actuality, that is where it is. The same phenomenon is present in painful knees and joints where a client will state that the pain is inside the kneecap or bone. The locus of pain is found within a dense area of tissue outside of the bone, and can be felt as a firm or hardened spot. Because that nerve has become immobilized and hardened, and is adhered so closely to the bone, it is experienced as being within the bone.

A good gauge of the condition of the head tissues is to press your fingertips into the middle of the forehead at the hairline, then firmly make circular movements. If the back of the scalp moves around with it, you know there is a TD issue. You will often find the hyper-density can be felt down the back of the neck and into the shoulders. This widespread stiffness indicates the tissues have become locally dehydrated, separate layers are adhered to each other and the fascia has lost some degree of elasticity.

The TDR massage treatment for headache consists of first, determining the area of focus, which is the place that hurts the most, and second, warming the tissues to facilitate their becoming softened and mobilized. And then, massaging them until they have been restored to their normal, pain-free density. It is important to remember the TDR massage rules. Do not go over a three on the 1/10 pain scale. Causing pain is counter-productive, it results in localized swelling, which increases the density (creating even less room for the nerves) and therefore, an increased level of pain. And remember to work on the tissue that hurts the most first.

Have your client indicate the area that hurts the most, and while massaging, warm the affected tissues with a heated pad or pillow. Once the area is well warmed, I use a scalp brush, pressing it firmly enough to grip the scalp, and make circular motions until the area responds by softening and becoming more mobile. If you don't have a scalp brush, you can use your rigid fingers to do the same. As the pain subsides, have your client direct you to the next painful areas. Use the fingers of both hands together, press and rub into the scalp as if you were trying to gently lift the tissues away from the bone. As one area responds, softens and is relieved of pain, move slowly to the next, until the entire scalp will move easily.

The nuchal ridge is an area where many people have an extensive buildup of density, within which much pain develops. With the client prone, warm this area for several minutes and then use the scalp massager (or your fingertips) to mobilize the area in large circles. Once you find that the tissues are moving more fluidly, use your full hand and fingers to petrissage the area. Reapply heat as needed to increase mobility. With your fingertips, move into the area of the ears, moving all tissue surrounding them, then gently cup the ears and move them in wide, smooth circles. Work your way down into the neck and shoulders, with the aim of mobilizing and softening all areas. When you find hardened areas, apply more gentle heat and continue movement until tissues are malleable.

For those who are having sinus-related pain, have them lie supine. Warm a small amount of oil in your hands and massage, starting from the neckline and collar bone. Using gentle petrissage, work your way up the throat, below the ears, over the Eustachian tubes, to the chin and cheeks, under the eyes and sides of the nostrils, around the eyes, over the temples and especially the forehead and eyebrows. Follow with light effleurage down all areas worked in reverse, encouraging drainage. Place the palms of your hands over the forehead and make wide, circular movements and slowly work your way up into the hair into the sides and top of head, then all the way back to the mastoid area.

It is important to understand that this can be a time consuming process. It is futile to prescribe a specific time period for the application of these procedures. One must focus on what hurts and treat it until the tissue responds. I surmise that the reason one cannot fit TDR massage into a neat little package of protocols is because each person's condition is different. While two may have the same pain, in the same place, their response to treatment is going to be affected by several factors such as the length of time the condition has been present, how well hydrated they are in general, etc. However, the results of this treatment are significant. Once the tissue has been restored from firm, hypo-hydrated, elevated density to a warm, well-circulating, and well-hydrated condition, the pain has been eradicated.

To prevent their headaches from returning, it is my policy to teach clients how to maintain their restored tissues. I explain to them that by keeping their head, neck and shoulders moving freely, they maintain the appropriate environment for the nerves to exist comfortably. I suggest they massage their scalps vigorously all over when shampooing, and while drying off they should place the towel behind their neck, taking one end in each hand, raking it firmly from side to side and pressing the neck and back of the head into it in an attempt to move the neck and lower scalp tissues around on the skull. For the face, I suggest they use a light facial oil or virgin olive oil, and massage every bit of it, from the hairline at the forehead to the sinuses under the eyes, the cheeks, chin and around the ears, as well as the neck and throat area, down to the collarbones. They should take note of any tender area and continue to gently massage it until it clears up.

Many clients report they have no more headaches after treatment and those who still get them say they have fewer headaches and the ones they do experience are less painful and shorter in duration than before receiving TDR massage and following the maintenance routine.

Sources

1. P. J. Wormald and T. Alun-Jones (1991). Anatomy of the temporalis fascia. The Journal ofLaryngology & Otology, 105, pp 522-524 doi:10.1017/S0022215100116500.
2. "Tissue Density's Relationship to Pain and Dysfunction," Massage Today, April 2012.

Using TDR Massage When Treating Sciatic Nerve Pain

By Linda LePelley, RN, NMT

A new client called, asking to be seen as soon as possible. She was experiencing severe right-sided low back pain. Her chiropractor had sent her to a joint and spine specialist. She was diagnosed with Sciatica and given an injection containing pain relievers and steroids, with no abatement of her pain. Diagnostic tests concluded there were no disc problems, so her doctor gave her permission to seek massage. 

I palpated the tissues of her right sided glutes, pirifomis and hip joint. Together, we determined the precise locations of the pain. I was careful to ascertain that my client agreed with my findings as I went along. For example, I would say, "This spot feels denser than the tissues around it. It feels to me there is a border here where the tissues thicken, how does it feel to you?" And, "I feel a thick strand of tissue right along here, is this tender?" I was able to feel with my fingers the hardened, dense tissue at the places that were hurting her. She guided me to the areas that were the most involved with her pain and discomfort. I generally find the tissues which are most dense will also be the ones which hurt the most, although this is not always the case. While I have consistently found tissues that hurt have elevated tissue density (TD), not all dense tissue hurts. In this case, however, the most firm tissues were the most painful.

I found what felt like a thick, fibrous pad, approx 3' by 5", over the client's SI joint, which she identified as the location of the worst pain. The second worst area, and the one most responsible for my client's inability to lay on her right side, was another thickened mass of dense tissue which had formed over the greater trochanter, approx 9" by 4". Both felt to be variably ¼ to ¾ inches in depth, with the thickest part over the most firm, dense area (I consider these hardened pads to be Adventitious Tissue Structures (ATS) (see "Adventitious Tissue Structures of Elevated Tissue Density," Massage Today, June 2013). Other involved tissue was noted to follow the probable course of the sciatic nerve behind her thigh on down to her knee; also involving a notably tender ATS at the medial aspect of the knee; and finally, the distal lateral portion of her right leg, which felt as firm as a rubber tire.

Tissue Density Restoration (TDR) Massage is based on my observation and theory that musculoskeletal pain and dysfunction increases in direct association with an elevation in TD. I find this method to be very effective. Over my years of clinical observation and experience with TDR Massage, I have developed a few principles of application:

• Follow all standard massage contraindications.
• Do not go over a 3 on the 1/10 pain scale, as reported to you by the client. While you want to use as much movement and pressure as possible, causing pain is counterproductive. You will need to constantly adjust your pressure and speed of work as the tissues warm, soften and respond to the massage.
• Work on the area that hurts the most and as it clears up, move along to the next worse area, until finished. Within this parameter, work from the most medial affected areas out to the more distal. The reason for this is to insure that drainage pathways are clear and to prevent and/or alleviate possible lymphatic blocking, which could result in peripheral edema.
• Apply warmth as much as possible, avoid drafts, use a table warmer, warm pack and any warming tool you are trained and experienced with and is within your scope of practice.
• Try to work on an area no larger than the span of your two hands, fanned out together, at a time. The rationale for this is that I've found it consistently takes about 45 minutes of steady, focused massage for tissues to experience a measurable and lasting release of elevated TD.

Having determined that the worst of my client's pain involved the ATS at the SI joint and the greater trochanter, and using a massage cream with excellent glide; I began massaging the areas with wide handed, circular motions, reminding my client to let me know if her pain level reached or surpassed a 3 on the 1/10 pain scale. At the beginning of a treatment, the overall area may feel uniformly tight and firm. As the tissues warm with the friction of the circular massage movements, the least affected tissues will begin to relax and soften. At this point, the outlines of the hardened, painful areas will become more apparent and easily palpable. As you are able to do so without causing pain, increase the intensity of the pressure and movement. Use your thumbs, knuckles or the ulnar side of your hand to target and focus on the boundaries of the hyper-dense tissue.

As you work, the tissues will eventually begin to feel as if they are becoming smoother, then softer. I checked with my client often, making sure I was still at the right level of pressure and that I was still working on the area that hurt. As dense tissues are warmed and moved, they become softened, resulting in pain relief. So, you will find that over the course of the treatment, the area of focus will often slowly shift into adjacent areas. As you are able to use more pressure and movement, you will find tissues that felt quite firm and solid at the outset become malleable to the point that you will be able to gently grasp and squeeze the area of focus without causing pain. It is at this point that the density of the deeper tissues may be reached through the increased pressure and mobilization you will be able to implement. Eventually, the tissues will be restored all the way to the bone.

Throughout the course of the massage, I explained to my client that my goal was to soften all of the overly dense tissues. As her pain levels and elevated TD areas were relieved, she was amazed to see there was indeed a relationship between the density and pain. I explained to my client that, once cleared, there are things she can do to help prevent the return of the elevated TD. They include staying appropriately hydrated, using warm packs or baths for sore muscles whenever they occur, massaging any area that feels tight and sore, being as active as possible and getting a regular, full body massage.

The worst of my client's pain was resolved at the first massage, giving her a great deal of relief and allowing her to sleep. She had a second massage three days later and then once a week for the next 10 weeks. At the point in time when the thickened pads at the hip and SI joint were no longer palpable, I worked my way down her leg to restore the density, ending at the calf. The tissues are now malleable and pain-free.

Clients often feel proud of the hardness of their muscles; they believe it is a sign of strength. I recall a gentleman who pounded his fist into his thigh, telling me, "This is all muscle! I don't want to lose my muscle, I just want the pain to go away!" I explain that as the tissues become denser, they crowd, engulf, squeeze, and compress the nerves and nerve endings within them. These nerves are no longer able to slide and glide around with movement, so they end up being tugged, pulled and pinched – which hurts and eventually causes dysfunction. My evidence is the repeated observation that dense tissue that hurts is relieved of the pain once it has been restored to an uncompressed state.

TDR Massage Protocol for Pain Relief

By Linda LePelley, RN, NMT

Tissue Density Restoration (TDR) massage was developed in response to my clinical observations over a number of years that musculoskeletal tissues experiencing pain are associated with an elevation in tissue density (TD) and once the elevated TD is reduced, the pain is alleviated.

Wanting to focus on these phenomenons and better understand their nature, I decided to stop doing relaxation massage and limited my practice to clients in pain.

My original focus was directed at determining the components of treatment that are most effective and discarding actions that, at best, do not appear to contribute to improvement or, at worst, are counterproductive. I asked my clients to participate; rather than just laying back and quietly enjoying the massage, they keep me informed about what they are experiencing throughout the treatment. Patterns of duplicable efficacy emerged, resulting in an extremely beneficial protocol.

Questions Remain

Once I determined I had a replicable method of alleviating pain by treating the elevated TD, the questions that remained were:

• Who experiences elevated TD?
• What areas of the body are affected by elevated TD?
• What part does age play, if any?
• Can the improvements achieved be extended beyond short-term relief into a state that can be considered permanent?

The answers I've found are much like the treatment itself; simplistic, easily dismissed by some because they seem too elemental and easy. However, they are consistently reliable. In my experience of actively looking for elevated TD, I've found it happens to everyone in pain. All musculoskeletal pain can be located and felt (in the tactile sense) by a second person, as palpable areas of indurations at the locus of pain. From the toes to the top of the head, elevated TD can be found at any physical location that hurts. The older a person is, the thicker and more compressed the density can be. I suspect the reason has more to do with a buildup over time, rather than degenerative changes of aging. Rather than deterioration, it seems more accurate to describe it as a disorder of accumulation. (Perhaps previous injuries lay a foundation upon which TD builds? Maybe a residue is deposited during the inflammation process which, if not cleared out through normal circulation, attracts mineral deposits over time.) Through close observation and repetition I've found that the more malleable the affected tissue becomes, the longer the relief will last. People can be fully relieved of chronic pain and that relief retained with maintenance massages.

How it Works

I have ideas of how and why TDR massage works, but they are just that, ideas. I am not a pathologist, biochemist or neurologist, nor do I have the time or inclination to acquire the additional education it would require to be able to investigate the physiology involved in the formation of elevated TD. But I don't need to. I trust what I can see, experience and duplicate. I don't have to fully understand the mechanism of the combustion engine to drive a car, but that doesn't impair or hinder my ability to do so. I can leave scientific research to those who have dedicated their education and interest and are qualified to do such work. I suspect that in much the same way that I am impelled to discover how to affect changes in tissue density, a motivated researcher will investigate that explanation one day. I am a nurse massage therapist – my duty, talent and intention is to provide my clients the best possible pain treatment outcomes.

In order to share the method of TDR massage, I use the term, "Protocols". While I do not anticipate changes to these protocols, I think that it's a mistake to declare rules and dogmatically follow them. Doing so fosters resistance to any future perspective or observation that may suggest they need to be adjusted. It also stifles exploration, hinders growth and suppresses conversation and communication. With that said, I've found that by following these directions, the results are reliable and effective.

TDR Massage Protocol

The massage movements I use are abbreviated Swedish – friction effleurage in small, circular areas; using slight petrissage movements, which helps monitor the boundaries and density of the target area as they change throughout the treatment; and vibration, which can be used as the tissues become malleable and are able to be grasped and gently shaken. The smaller the focus area, the sooner it is likely to be resolved.

You will want to measure and document the state of the target area before providing treatment and then again afterwards, using the Tissue Density Grading Scale (TDGS). (See "The Tissue Density Grading Scale: A Communication Tool," Massage Today, March, 2014.) By doing so, you will have an accurate picture of the condition the tissues were in before treatment and proof of the effectiveness of your treatment afterwards.

First, focus on the location of the pain and target the worst spots first. (As tissues soften and the pain begins to resolve, the target area may shift.) Causing pain promotes the localized excretion of inflammatory chemicals which I suspect may play a part in the development of elevated TD. Regardless, there is no reason to exacerbate an already painful condition. The amount of pressure to use at any time will depend on the clients ability to tolerate it without going over a 3 on the 0/10 pain scale. Using the Walton Pressure Scale along with the TDGS will help you determine treatment progress and provide more precise documentation.

Keep the tissues you are working on moving continually. This will usually require working on areas no larger than the span of your two hands at a time. Doing so not only contributes to tissue heating through friction, but I believe that in addition, the movement combined with appropriate pressure, creates a fatigue state that helps soften TD.

Tissue Density Grading Scale Grade 0 (Yellow) = Tissue is flaccid, hangs from attachments and has little to no resistance to gravity. Grade 1 (Green) = Tissue is toned yet easily malleable. Grade 2 (Blue) = Tissue is firm, tender if pressed into; muscles may appear and feel as if they are bound together as one. Grade 3 (Red) = Tissue is tight, rubbery and is strongly resistant to mobilization. Grade 4 (Brown) = Tissue is hardened, rigid and immobile.

Work in a warm location and keep the tissues warm. It is helpful to use a table warming pad, and any other available heat transference devices you are experienced with. (I think the localized increase in temperature that TDR massage induces, combined with constant movement and pressure is the primary means of TD reduction. Perhaps the heat generated melts lipids that have solidified and condensed around nerves and nerve endings.)

I have found that it takes about 45 minutes of consistent, firm, circular massage to begin to affect change at which time you can feel a smoothing of ridges and softening change in the density of the target area. At this time, the client will also state that it feels better. Continue treatment(s) until the indurations are no longer palpable, and tissues are with a Grade 1 on the TDGS.

If the condition requires more than one treatment to resolve, it is best to schedule following treatments as closely as possible. The tissues seem to remain more malleable for a few days following treatment, thereby not requiring as long to respond and soften.

This protocol applies to pain of any size, at any location. When a new client comes seeking relief, I tell them that if I can feel elevated TD at their pain site, I will be able to help them. As one develops their sensitivity to the palpable varieties of tissue densities and becomes adept at restoring it, they will find themselves able to truthfully state, "I feel your pain," and then relieve it.

The Strain of Compression

By Dale G. Alexander, LMT, MA, PhD

In order to enhance the distribution of strain through the kinetic chain between the foot, ankle, leg, knee, thigh, hip joint and pelvis, imagine the lower extremities as circles and columns that are designed to load share the compression of standing and movements of all kinds.

These are concepts that have aided my efforts to assist clients desiring to prevent hip, knee, and shoulder replacements or to improve the quality of their rehabilitation after surgery.

Jon Zahourek, the developer of the Maniken System of Anatomy in Clay, was my inspiration for the circles notion when Lansing Barrett Gresham and I attended a rive-day workshop with him in 1990. During that week, we used clay to form every muscle in the human body and then placed them on a 3 1/2 foot skeleton. It was an amazing experience. However, one might also visualize the lower extremities as composed of articulated column segments. Thousands of clients have been my hands-on teachers guiding me to the experience of how these concepts successfully work to enhance their lives.^1,2

What are the proposed circles and columns that may more evenly distribute compression in the lower extremities? Visualize, if you will, the longitudinal and transverse arches of the foot. The space between and including the tibia and fibula. The angular shape of the femur bordered laterally by the iliotibial band and medially by the muscular band of the gracilis and encased in all the soft tissues of the thigh. The ovoid shape of the pelvis itself with the pubic symphysis and the two sacroiliac joints. And, even the circular shape of the acetabula.

Consider directing your hands-on efforts toward creating a more balanced suspension into the center of each circle or column, thus enhancing the load sharing capacity of the lower extremity upward through the kinetic chain from the feet to the pelvis. In my previous articles, I have described the more superior anatomical and physiological elements that may predispose a posterior slide in the femoral head. Of course, these inferior circular and columnar relationships may also influence hip joint deterioration, especially if trauma to any of these lower extremity joints and soft tissues has occurred.

Who among us hasn't sprained an ankle, twisted a knee, or landed rather unceremoniously on our duff, aka, ischial tuberosity, sacrum, or tail bone. And, if one has had a fracture of any of the bones that intersect with these joints, then the resulting compensations may still be skewing the load sharing. Creating expanded, more normalized, more integrated space is our intent to enhancing the function of this system of interrelated circles and columns:

• Space within the foot.
• Space within the tarsal tunnel.
• Space between the tibia and fibula.
• Space surrounding the femur.
• Space within the pelvic floor and pelvic bowl.
• Space relating to and within the acetabula.

The simple concept to highlight in your awareness is that such trauma injuries (as well as injuries due to repetitive misuse, etc.) may alter the symmetry and structural integrity of these circles and columns and lessen their ability to distribute strain and contribute to the tendency for the femoral head to slip posterior.

Our job is as bodyworkers and massage therapists is to restore the soft tissue balance and suspension of these geometric spatial relationships as best we can. This new perceptual orientation will enhance your ability to mobilize the joints within the feet, ankles, knees, thighs, hips and pelvis.

To aide you in your quest, the golden key is to recognize that by directing your efforts toward mobilizing each of these joints toward their normal range of motion, is the fastest and usually least painful avenue to restore the balance of each circle and column. And, as you facilitate these changes for your clients, visualizing and working from the inside-out is the more natural and effective approach.

To say this another way, realize that soft tissues serve the joints. It is nature's hierarchy. Much of any excessive tension around and between the joints is created because the joint surfaces become stuck in mid-range, prevented from completing their full range of motion and thus are structurally mis-aligned in their proper tracking relationships.³ Restoring appropriate tracking within these joints along with utilizing our additional skill sets for enhancing soft tissue suspension together is a more comprehensive approach for us to aspire toward.

Below, I describe some of the more crucial osseous and soft tissue relationships which are instrumental to the distribution of strain within these circles and columns. Many others are also important; yet, if you master these, your competence to assist your clients will leap forward, as will your income. Increasing your anatomical and physiological knowledge and the depth and breadth of your hands-on skill sets is your best marketing tool. What generates new clients faster than anything else is your clients speaking your name associated with a proclamation that they are feeling and functioning better after working with you!

In the feet, the navicular and cuboid bones counter-rotate in order to unlock the arches during the heel strike and foot flat phases of the walking cycle, thus allowing the foot to adapt to the irregular surfaces of the earth as was necessary before we began to wear shoes. Then they re-rotate to provide a rigid lever during push-off.^3,4 Since the line of joints from the navicular to the cuboid is where the longitudinal and transverse arches intersect, this is a key concept to understanding foot function. Often, one or both bones will become stuck in the mid-range of their rotational motion.

In the ankle, the talus bone has no muscular attachments, so it is often vulnerable to displacement. Mobilizing it positionally in relationship to the mortice structure of the malleoli of the tibia and fibula is another important skill to develop. The talus bone frames much of the tarsal tunnel, the opening through which blood, nerve and lymph supply flow in and out of the foot. Mobilizing its position toward a more balanced perch above the calcaneus bone positively affects both proprioceptive stability and neurovascular supply.

Moving upward to the leg and knee, remember two important goals: mobilizing the proximal head of the fibula then diving into and opening the interosseous membrane between the tibia and fibula is the quick path to re-balancing the column of the leg.

Learning to guide the tibial plateau through a figure eight range of motion is an approach that often allows the femoral condyles to naturally reset in relationship to the concave surfaces of the tibial plateau. This change toward greater joint mobility can be a miracle to a client with a chronic knee misalignment. Similar to the foot bones, the knee must twist to open and then flex forward, initiating the walking cycle. Then it needs to twist back to its original position for there to be stability and power during the extension/push off phase of walking.^3,4 Again, the femoral condyles in relationship to the tibial plateau often become stuck in the middle of their reciprocal counter-rotations.³

Within the thigh, developing an awareness of the lateral and medial intermuscular septa radiating and spiraling outward from the femur is a core anatomical understanding to creating space within this cylinder/circle. Make it a priority to learn to mobilize the range of motion within the hip joints. Visualize the femoral head moving within the acetabulum. Direct your efforts to increase the roll and spin of the femoral head within the socket itself.

In the pelvis, learning to mobilize the pubic symphysis and the sacroiliac joints are exceptionally useful skills along with learning how to release the attachments of the adductors whose fascia blends with that of the pelvic floor muscles. Finally, to complete this holistic view of the body, we come to the relationship between these circles and columns of the lower extremities and the shoulder girdle, which is so often functionally vulnerable to the distortions in this kinetic chain of support.

Allow me to begin with Dr. Richard MacDonald's articulation from osteopathic theory that there exists a contiguous fascial line from the latissimus attachment to the humeral bone through the fascia associated with the sacroiliac joints, then following the lateral hamstrings and peroneal muscle group downward all the way to the lateral ankle/foot. His stated inference was that distortions could begin from above, and refer downward or from below, and refer upward.⁵

One of Ida Rolf's most enduring quotes guides our understanding of this dynamic relationship, if the body is not supported from below then it will endeavor to hang from above.⁶ I believe that the physiological mechanism(s) related to the meaning and understanding of this assertion are principally mediated by the large body reflexes and the flexor/extensor reflex systems, as well as the effects of fascial suspension, vertebral segmental motion, and many other additional variables.

My theory is that the constant activation of these reflexes will invariably distort the smooth range of motion of the shoulder joints adding to the progression of arthritic changes and the deposition of calcium salts. Most clients coming to me considering shoulder joint replacements have complex histories all involving some degree of trauma which most likely initially activated these reflex systems.

As loss of support from below progresses over time, these reflexes begin to insidiously lock the scapulae against the rib cage, often creating some degree of frozen shoulder; while in others, the arms are unconsciously pulled medially against the side of the chest. Both of these actions will add external compression against the expansion of the thorax as a whole, thus also increasing resistance to heart and lung expansion. Then inevitably, the entire general physiology becomes strained without adequate supplies of nutrients, oxygen, and hormones that fresh blood delivers. The elegance of the human design is really all that connected and more.

Please do consider Jon Zahourek's notion of multiple circles and Glenn Gaffney's concept of multi-articulated columns as paradigms for how we may imagine creating a more balanced distribution of strain and load bearing along the kinetic chain of the lower extremities into the pelvis.

Please do consider that mobilizing opposing joints surfaces picks the protective lock of soft tissue spasms. And, yes, many will need a lot of "coaxing to more fully release." Many physiological therapeutic principles and techniques will be needed: fascial spreading and unzippering, muscle energy technique, trigger point therapy, reciprocal inhibition, cross fiber friction, indirect techniques such as strain-counterstrain or its English cousin orthobionomy, and many many others.

References:

1. Anatomy in Clay Learning System, Loveland, CO. Zahourek Systems Inc.
2. Glenn Gaffney, B.S., L.M.T., KMI Structural Integrator, St. Augustine, Fl.
3. Muscle Energy Technique Tutorials with Dr. Richard MacDonald D.O. and assisting at his courses, Upledger Institute,1986 -89.
4. Physical Examination of the Spine and Extremities, Stanley Hoppenfeld, MD, phases in the walking cycle, Appleton-Century-Crofts, 1976.
5. Dr. Richard MacDonald D.O., Functional Anatomy Courses, Upledger Institute, 1988-90.
6. Rolfing: The Integration of Human Structures, Ida P. Rolf, PhD., Santa Monica, CA: Dennis-Brown; 1977.

Exploring Elusive Knee Pain/plica

By Whitney Lowe, LMT

Massage is great for many soft-tissue pathologies. However, sometimes various conditions exist that seem like a common pathology, but then don't respond to the treatment. In some cases, an undiscovered problem may exist.

Let's take a look at the synovial plica, a cause of knee pain that can easily mimic other common knee conditions.

What Is a Plica?

During embryologic development tissues gradually change state as they develop into their fully formed structures. Early in fetal development, bands of tissue separate the knee into different compartments. These bands of tissue gradually shrink as the knee joint fully forms and is eventually surrounded by a synovial capsule. However, in some people, these bands of embryonic tissue persist into adulthood and become sleeves or folds of tissue called synovial folds or plica.¹

The medial side of the knee is one of the most common locations for a plica to develop. When it develops in this region, it is called medial plica syndrome and may cause pain and discomfort during various movements and is often mistaken for other knee pathologies.

While the plica will have existed for the person's entire life, it may become problematic only later as a result of overuse. The plica becomes swollen and fibrotic for several different reasons. The most common reason for plica irritation is chronic overuse. Repetitive motions of the knee cause friction on the plica and it becomes fibrotic and far less flexible. Depending on its location it can become bowstrung across a bony prominence in the knee.

Figure 1: The knee opened up to show location of plica development.Mediclip image copyright (1998) Williams & Wilkins. All Rights Reserved.Other possible factors that can lead to a fibrotic plica, include a direct blow or trauma to the tissue, excessive twisting motions applied to the knee, or intraarticular bleeding or effusion secondary to another injury. Secondary dysfunction, like meniscal damage, may go undetected or misidentified as some other pathology. In rare cases, the plica can become calcified, which causes much greater pain and disrupts tissue mechanics around the knee.²

Once the plica becomes stiff and fibrotic, it can get pinched between the femur and patella during knee extension. The medial side of the knee is the most common site prone to irritation of the plica (Figure 1). The medial patellar plica runs underneath the distal portion of the vastus medialis, called the Vastus Medialis Obliquus (VMO). Pain in the VMO is frequently associated with patellar tracking disorders and tracking disorders are another potential issue that can mask involvement of a synovial plica in the region.¹

The fibrotic changes in the joint can eventually lead to softening and degeneration of the cartilage at the patellofemoral complex. As a result, there may be a cause-effect relationship between the synovial plica and development of chondromalacia patella.¹

Evaluating the Plica

Identifying the presence of a synovial plica is not easy because it can be so easily ascribed to some other pathology. However, there are key characteristics that show up when a plica is present. The primary complaint is intermittent dull aching pain medial to the patella. The pain is usually increased with activity and tends to be more evident during forceful knee extension, such as standing up from a squatting position.

Figure 2: Pain most commonly felt moving from flexion into extension.Sustained flexion usually increases the pain as the plica tissue is pulled taut. Plica pain generally appears during extension motions, but once the knee is static and held in a position of full extension, such as standing, the pain usually decreases. Additional symptoms may include feelings of giving way, snapping, and popping or clicking sounds especially when moving the knee from 90 degrees of flexion into extension (Figure 2).

During palpation, it is common to find general tightness in the knee region, especially within the quadriceps group. The fibers of the quadriceps retinaculum are also likely to be tender. There are deep fascial connections between the distal retinacular quadriceps fibers and the synovial capsule of the knee, so reducing quadriceps tightness is a key treatment goal.

One of the more common findings with many knee injuries is atrophy in the quadriceps group and this is common with plica syndrome as well. The quadriceps, as an anti-gravity muscle group, is prone to rapid atrophy when there is pain or dysfunction at the knee. Evaluate quadriceps atrophy by using a soft tape measure to measure the circumference of the muscle group just superior to the patella and comparing it with the unaffected side.

In some cases there is a distinct taut and palpable band on the medial aspect of the knee that can be rolled under the fingers during palpation of the medial knee. It is not always easily palpable, so this method is not a highly reliant means of determining the presence of a plica.

Another method that may be helpful in identifying the plica is a pain provocation test. This can be performed by holding the knee in about 300 of flexion and pushing the patella in a medial direction. Medial movement of the patella reproduces pain as the plica is pinched between the femur and patella.³ Physical examination of the knee alone is not considered highly reliable to identify the plica, so high-tech diagnostic studies such as MRI may be used.

Treatment of Plica

The synovial plica is usually treated first with conservative treatments such as physical therapy, which will include stretching and strengthening exercises. Stretching helps encourage pliability of all the soft tissues. Strengthening of knee extensor fibers is an initial treatment because they have fascial connections into the capsular tissues, which helps pull the plica tissue out of the way during extension and prevent it from being pinched.⁴ It is also very important for the person to reduce offending activities, such as repetitive flexion and extension movements of the knee.

Nonsteroidial anti-inflammatory drugs (NSAIDS) are commonly used to address inflammatory activity in the knee. Iontophoresis (anti-inflammatory medication applied with electrical stimulation) and phonophoresis (anti-inflammatory medication applied with ultrasound)  can also be used to reduce swelling and manage fibrosis. If these more conservative methods are not effective, intraarticular corticosteroid injections might be used. Surgery is considered the last resort to remove plica tissue.

Role Of the Massage Therapist

There is currently no research regarding massage treatment for plica syndrome. However, a lack of study does not indicate a lack of a role for massage. To determine the effectiveness of massage for any pathology requires considering whether some form of massage would provide a helpful intervention.

We do know that massage is effective in reducing dysfunctional soft-tissue fibrosis in many conditions, and plica syndrome is fibrosis that develops within the synovial fold of the knee joint capsule. It would stand to reason that massage might be helpful in addressing medial plica syndrome by encouraging mobility within the fibrotic or calcified plica. If the plica is caught between the femur and patella, you can push the patella slightly laterally and friction the medial side of the tibiofemoral joint and the area just under the patella.

You might also provide some deep friction along other regions of the medial side of the knee.

Massage would be generally helpful for maintaining proper muscle tone and biomechanical balance of the VMO and distal quadriceps group so that inappropriate tension levels on the knee capsule fiber do not develop.

A critical part of evaluating the appropriateness of massage is to determine if there might be contraindications. In treating plica syndrome, as long as massage is performed within normal pressure levels, there does not seem to be any contraindications to using massage. In fact, massage is more likely beneficial and might reduce the need for surgical intervention.

Conservative treatments like stretching and exercise have some degree of effectiveness. Massage may be a useful adjunct for these treatments. This syndrome offers a good opportunity for further research into a new application for massage.

References:

1. Sznajderman T, Smorgick Y, Lindner D, Beer Y, Agar G. Medial plica syndrome. Isr Med Assoc J. 2009;11(1):54-57.
2. Karaman Ä°, Güney A, Gürbüz K, Bilal Ö, Güney B. Calcific mediopatellar plica: a case report. Eklem Hast ve cerrahisi = Jt Dis Relat Surg. 2013;24(2):117-120.
3. Magee D. Orthopedic Physical Assessment. 6th ed. Philadelphia: W.B. Saunders; 2013.
4. Camanho GL. Treatment of pathological synovial plicae of the knee. Clinics (Sao Paulo). 2010;65(3):247-250.