Orthopedic Massage....What are we doing.

So this post is inspired by my frustration at some of the myths that perpetrate the massage industry through poor education, misinformation, poor training and subsequently are passed on to the general public. Orthopedic Massage is a science based practice based largely on evidence. While our understanding of what exactly is happening during treatment sometimes is incomplete, we try very much to keep within the boundaries of plausible science. As new information comes out we adapt and keep moving. Here are some of the tenets my practice as an orthopedic therapist is based on.

1.    While we use physical assessment during our intake, that assessment is primarily concerned with postures that avoid pain and general notation of physical differences. Our treatment is not based on fixing, changing or improving posture.  Structure does not always follow function. People can have poor posture and no pain or poor posture and pain. Unless a posture has been adopted to avoid pain and gives information about the causality, then it has little bearing on treatment. It is merely something to note. On the same token, imaging also has little information to lend to this people without pain are riddled with so called dysfunction. This does not mean we ignore it, but it is not absolute. 

2.       Homeostasis happens whether you are there or not. Most conditions are self resolving, we cannot change the body, what we can do is set the ideal conditions for change, and interact with the nervous system in such a way that we try to communicate that the crisis is over. 

3.      Pain is neurogenic and an output of the brain.  Pain is one of the body's few ways of communications with you, but that communication does not always mean damage. Some of the few areas of research that have been confirmed tell us that touch does help with pain mediation. We touch with the understanding we are not 'fixing' but more likely influencing processing.

4.      Nothing in the body goes to waste, there are no toxins or buildups of lactic acid that need to be dealt with through manual therapy. Lactic acid is an important chemical necessary for long term metabolism, and even your earwax is an mild insecticide.

5.      Other than scar tissue, which is slightly less functional than regular tissue and produced by inflammation, there are no adhesions in the traditional sense that need to be broken down.  It does not make sense that our body would just ‘gum up’. The natural movement of the body resolves most issues. Areas that are shortened should be approached from a neural perspective. 

6.      The body heals itself through it’s natural movements and function. The heart alone is not responsible for pumping all of the blood through the body, muscle pumping also aids, which is why movement is so strongly tied to our health.

7.     The likely hood of benefit, is always greater if the body is in control rather than a passive operation.

8.   Techniques where you  ‘re-damage’ tissues in order to promote healing such as frictions are outdated. 

9.  Stretching is not actually lengthening muscles, but conditioning them to the feeling of length. In muscle tonicity there is relaxed and contracted. (please see pain in neurogenic)

10.   Ice is an analgesic…it is not for swelling. RICE is made for emergency care to help manage pain and fluid soon after injury. There has been some confusion about this lately, as new information has come out the effect of ice on capillary beds. However, if you just got hit in the head with a hockey puck, please follow your protocol of RICE until an emergency worker arrives, nothing about emergency protocol has changed. Inflammation in general is not bad for you, it is part of the natural process of healing. Ice is also contractile so if you are applying ice to something that hurts, think about why your applying it, because it is also contracting the muscles in the area. 

 And this I am throwing in on principle...you do not need water after a massage, but it is nice! 

Marketing based on poor scientific conclusion about manual therapy, that makes the patient think there is something wrong with them that may only be fixed though intervention, is far more damaging that the problems they seek help for. Absolutely patients need a care continuum in their health care that involves manual therapy, but if we are not treating posture, imbalance, adhesions or muscle length, it might be hard to understand what we are doing. And while the question remains open on a biological level as to what is happening step by step, I view my job as an orthopedic therapist as that of a facilitator. I move people in a relaxed state, through the use of skin/muscle stimulation and passive, active and resisted ranges of motions while giving a safe place to explore and educate about mild to medium level pain. For many people this increases their range of motion and decreases their pain on the table, as well as off, which allows them to get back to moving in ways that are normal for them. 

Because Orthopedics is mostly concerned with increased ROM, we are looking at measurable results, that bring us away from more CAM practices. 


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Treating Plantar Fasciaitis

In this post we are going to talk about an orthopedic massage treatment for Plantars fascitis. Before we get down to the nitty gritty, however I want to discuss the pathology on the whole.

Plantar fasciitis has been previously classified as an inflammatory condition, hence the 'itis' at the end of the name. The literal translation of the medical language is foot part inflammation. Recent studies have concluded that its not really an inflammatory condition at all. Its is very important to understand however in treating this condition, that while it is not an inflammatory condition itself, there may be inflammation present especially post exercise or you may cause inflammation by working on it. Not being classified as an inflammatory condition does not exclude it from inflammation.

Clinically in my experience with sports massage, it has turned into a bit of a blanket term meaning pain in the bottom of the foot. The classic presentation is specifically pain in the AM after the tissue has contracted over night, however I have frequently had people come in with diagnosis from physicians where pain is during exercise or after only. If you are treating plantar fascia you also need to be aware of the risk of heel spurs and their contraindications.

People who have started training programs, had a recent weight gain, are pregnant, work standing all day, are logging a lot of miles, and who have inflammatory conditions are all at risk for Plantar fasciitis. Plantar fasciittis is one of the most common foot complaints.  Technically what is happening is the plantar fascia is being over stretched or over taxed for a number of reasons and is tearing at the most delicate part of the connective tissue in the leg, the plantar fascia. Tears can be small and irritating or in the worst case scenario, a full rupture. You can find out more about plantar fascia in my brief description here.

For the purposes of this treatment we will be treating as if we have performed a full body treatment with the focus on the lower leg. In progressive treatments I would then do a full body with the focus on the leg above the knee as well, and then a full body with the focus on treating plantar fascia at the hip...etc. Plantar fascia is rarely a foot problem, however it has been my experience that patients get the most initial relief from treating the lower leg, so that is where we will start.

Start your client in prone and with general Swedish massage. When ever possible I try to mix in as much general treatment as possible so that the client can benefit from the systemic benefits of massage as well as the focused ones. As you work towards the legs be aware of what you are touching, feel for anything that seems tighter or ropy-ier than it should be. Use this extended Swedish time as a palpitation exploration and add it to your full assessment. You are always going to start on the side with less pain so you can have a comparison of that persons 'normal' to dysfunction. Between each larger technique, I always return to Swedish massage to assess and sooth the tissue.

Once you have reached the lower leg warm the tissue with Swedish work.  After the tissue has been warmed, then move to deeper work such as trigger point and deep tissue on the whole of the lower leg structures. At this point, move to passive active release moving laterally to medially via anatomical structures. Starting at the peroneus muscles, anchor into the tissue with a thumb/finger/elbow at the origin and move the structure through its range of motion. Work down the whole length of the muscle doing this passive active release. (in some cases I would do this for gastrox and solus as well but usually I progress to straight active release)

Now that the client knows the motion of the peroneals, I as them to take the motion over on their own. As they evert/invert I again work my way down the length of the muscle, stopping of course for any thing that causes too much pain or discomfort. All motions and pressure are to remain within clients comfort level. After working the peroneals, then move onto the gastrox and solus active releases in the same manner. Start at the proximal attachment and move distally towards the Achilles. You can access deep into the muscle bellies from the sides and from the center of the tissue. Here is a video to help understand the process. Its important to note that at some points of the ROM in the active release there may be discomfort. That is fine, the client is in control of the motion and ask them to move slowly and carefully expressing that you will not increase the pressure.

 Using active release as the massage allows greater muscle pumping properties to the tissue, helps approximate muscle length and through conscious movement helps the client be more aware of movement patterns. It also puts the client in control of work that could be quite sensitive otherwise.

After the active release has been performed, and the client can move through the range of motion pain free, I move on to stretching. Using a number of different kinds of stretches is very helpful in when treating plantar fasciitis because each muscle presents its own challenges. For both gastrox and solus I use a pnf version of stretching. I stretch them separately, by putting them into their lengthened position and having the client resist the stretch for the count of 10, and then repeat that cycle until the desired length is achieved. For both tibialis posterior and the peroneal muscles I do the same, although much more delicately. You of course to do this must know exactly what the action of the muscle is.

S curve bowing of the achilles

After the active stretching I move on to stretching the tissue manually with fascia work and bowing. Sometimes because a client has a bone structure that prevents full ROM this is the most effective way across the board, however the calves on the whole are very strong muscles, my strength can never compare to theirs so using the clients own power is always safer and more effective generally as a means of tissue movement, which is why I perform both active release and fascia work. For this I manually pull the bulk of the muscles away from the bone, by anchoring the ankle and pulling the tissue towards or away from me in long steady movements. Sometimes it can be helpful to do this through a hot wet towel. In fascia work this would be a form of bowing. At the achilles I can bow laterally, medially or both in an s curve.

Once the calf work is completed I work around the heel, you can work around the heel with your fingertips encouraging the tissue towards the site of the pain. In school I learned then to do deep work on the plantar fascia at the site of pain, but have since abandoned that technique as too painful and too risky to the tissue. Clients would literally sweat on the table as you put the foot into flexion and dug away at the tissue. Instead I recommend this technique which is a variation of the work with the foot in flexion but far less painful.

Drop the foot off the table in prone so that the toes hang off . The heel will be just about level with the edge of the table. Stand so that you are facing the end of the table and the clients feet. Squat down or kneel so that you are  not using strength, but body mechanics and grasp the heel firmly with both hands and with medium pressure pull the foot into flexion and drag the tissue down. It is important to note I am not rubbing the surface of the skin but, letting the skin move me towards the toes.

After all of these steps are completed I would close with Swedish massage working my way back up the leg and moving onto the next side. Once that side is completed I would ask the client to turn over and work the anterior lower leg muscles in the same fashion, following the same protocol, of Swedish, active and stretching.  In my clinic we would also follow this up with a supportive taping for that plantar fascia.

For many people the initial treatment will bring considerable relief if the diagnosis is correct, however the condition is not 'fixed'. It is very important to continue maintenance, change behavior, and seek help in the form of strengthening. Any time the body lays down splinting or pulls tight in this manner its usually looking for extra support and you have to ask yourself 'why?'.  Giving your client a home care plan that works for them is also very important. Most people get stuck with plantar fascia issues because they are treating the plantar aspect rather than the problem, and only taking preventive measures, such as wearing a night sock. Full treatment constitutes a change in behavior, strengthening, manual therapy and a good home care program.

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NY, NY 10017

Being effective in Acute and Subacute states of healing.

If you are working with people in pain one of the worst things you can do as a therapist is be ineffective, but how do you be effective when your patient is in a stage of healing where you cannot use deep pressure or move their limbs around? Its easy to treat low back trigger points when you can apply some pressure, but what about when you can't?

This blog is devoted to something I do a lot of: working in the acute/subacute stage of healing. In school for orthopedics, we were taught that working in acute was cautioned, and that you were to use techniques such as lymphatic drainage, and working compensatory muscles (which for many therapists translates to 'far away from the injury') to treat patients while managing their expectations. And all of that is still true, however there is a lot more you can do too. These guidelines are taught with public health in mind, and by no means am I recommending that you blow by them, however it after you have been working for a while you might find that there are some other things that you can do as well. They don't break the rules, they just can't be explained in the rule because it would leave to much of a grey area open in treatment. Today we will look at low back as an example and in the next blog at the knee.

First off get your thinking cap on. Try in your assessment to separate the injury itself from the symptoms of the injury. Every injury has a symptom picture, however some of the aspects of the the injury are more secondary reflexes the body uses to protect and heal itself. Lets look at an example:

A client comes in with low back pain, slightly left of the spine at the SI joint. Yesterday, they were lifting an object and turning at the same time, and they felt a click in the left low back and now they cannot move. You are reasonably sure based on the symptom picture that they have sprained or subluxed an SI joint, but of course they can't move to do special testing. Palpating the site reveals there is heat over the joint but no palpable swelling and the low back is pretty fixed and seems splinted, as do the gluts. Other than the pain, there are no CI's and they called their doctor and said it was fine to have a treatment.

So now what? Well for me the splinting and the actual injury are two separate things. The injury is that the joint has moved out of place and it might still be out of place. The side effect of this injury is that the body neurologically saying "oh boy, things are really unstable, we had better build some more structure for this guy fast or things might fall apart". Most of the pain is actually caused by the splinting pulling on the injured joint.

To treat this type of injury, I start by making a plan based on the injury. In this case it's that swollen hot joint that is being pulled on by gutes, quadratus lumborum, and the psoas/iliacus. Reducing the splinting would help take the tension off the joint, lower the tone of the fascia, and allow fluid movement in the area to boost healing. But all my text books say don't manually remove splinting by force. So now what?

First I would try and get the tone down by working compensatory. Managing pain is awful; it stresses the body out and often leads to more pain. Getting your client into a relaxed state through working the cervical muscles is a great start. You can do this in prone so that you client does not have to roll over on the table. focus on getting the shoulders to relax and the scalenes moving.  This will signal to the body that its not time to 'fight or flight' this should help not just relax the tone, but also reduce the pain.

Continue with your treatment working towards the site of the pain, in this case that is the whole lower back. As you get to the site of the splinting you will have to switch to lymphatic work. If you don't have lymphatic training, you can substitute it with very gentle and slow feather light gliding touch over the skin. While you gently massage, you should be assessing the tone. You will probably notice while you are working in this area that although your client is breathing (I hope;) the low back and gluts are not moving much. When you watch your client breathe, the chest goes up, but the air stops in the thoracic spine. This is due to the splinting, and while you, as a therapist, should not attempt to remove this manually, the patient can remove it on their own, thereby lowering their own tone, activating the normal muscle pumping and relieving some of their pain.

I want to stress that during this process your job is not to apply pressure in anyway, your hand contact is only enough to palpate the muscle, to cue the client as to where the air should move, and asses the tone. Placing your finger tips on the lateral edge of quadratus lumborum (make sure its the side of the muscle not downward) palpate just deep enough to feel the muscle, your client should feel no pain at your touch. Then ask your client to take a long slow breath. If the air does not move down to where the lower back expands, que them by saying, "I want you to breath into where my hand is". As they breathe in and out, slowly expanding the area, you will likely notice that the tone in the low back falls as does the pain level.  This process could take up to five minutes on each quadratus lumborum. This same technique can also be used along the iliac crest (or any area where the client can move air such as the cervical spine)following the line of the top the glutes as the pelvic floor and iliac spine are also affected by breathing. If at any time your client responds with pain, immediately discontinue. For some cases I will aso put a pillow under the stomach to limit the amount of belly expansion and increase back expansion. Never push the client past where they want to go, at all times they should be in control of this activity.

What is happening? A few things actually. In one sense maybe you are doing nothing, but your clients slow steady breathing stimulates the parasympathetic system, and it reduces the symptoms by proxy. Secondarily, sometimes pain is manifested due to immobility. Your body uses immobilization in order to protect injured parts and when it proprioceptively realizes an area is not moving, it sends a signal back up saying "hey this bit is damaged, its not moving at all, we had better produce some pain so this guy knows not to do anything stupid". Getting the air to move normally in that area signals the start of movement and so leads the body to believe that things are on their way to ok. And lastly, your lymph system and some of your circulatory system, whether you know it or not, is driven by muscle pumping. When you approximate the air flowing into an area, you are also working the fluids like pumping a bellows, which is how the body in the end will heal itself.

If you are at all confused about a symptom picture, anything red flags, or feel in anyway unsure, always refer out. I find it extremely helpful to be as upfront with subacute clients that walk through the door by managing their expectations. During the consent I will almost always say something along the lines of "it sounds like _____ is happening, but I am not a doctor. We have to treat conservatively until you find out exactly what is going on. We can probably get you more comfortable while you wait however". Usually if it was nothing that serious, you have helped them a great deal and the next time you see them it will be to finish up the work that is headed for chronic. If the problem has not subsided, you have done no harm but performed your job as a supportive healthcare provider, by encouraging them to get a diagnosis from a qualified professional. Good luck!.


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Orthopedic Massage Therapy Treatment for Bursitis.

So this weekend as the cold temperatures finally broke, I decided to hit the pavement for a run and enjoy the beautiful weather. The only problem is I actually hit the pavement.  Two miles from home, I tripped over a grate, and pitched forward. Failing to get my hands up in time, I landed square on my knee cap. Technically it would be the medial base of my patella, which slammed the apex into the patellar  tendon and underlying bursa with tremendous force. It was excruciating. Over the following few days, I have had pain on quads contraction, swelling around and below the patella, and low back pain due to the gait change. Given my current condition, I thought I would take this time to do some bursitis treatment and review.

A Bursa is a fluid filled sac that is often found in the body that buffers surfaces that might otherwise cause too much friction, thus damaging the body as one structure passes over the other. They are usually found in joints, where a tendonous attachment has to pass over a bony prominence.  The knee has many bursa, due to its complexity, as does the hip at the greater trochanter and ishial tuberosities, and the Achilles at the point of attachment to the heel etc. Almost anywhere you find a bony prominence and tendons you will find a bursa. To visualize how it works it is something like this.

In a clinical setting, bursitis can often be confused with tendinitis, and they are actually pretty similar. Tendinitis is the inflammation of the tendon sheath, which is a similar structure to the bursa.  But rather than being just under the tendon, a tendon sheath wraps around the whole structure to provide a similar function.

Both tendinitis and bursitis can be caused by over use, which means that the ‘sac’ has become inflamed.  Bursitis however is often characterized by an impact to the overlying structure, the trauma of which causes swelling and inflammation.  In some cases antibiotics or anti-inflamitories might be used, depending on the severity of the case.

In clinical evaluation, clients will have pain on movement, the muscles around the area may be splinted, and heat and tenderness might be but are not necessarily present.  In cases such as the knee, the bursa can sometimes be seen as it puffs out around the patella.  However, if the bursa is under many layers of muscle, such as at the greater trochanter, it might not be, so it is often misdiagnosed.  Taking a good subjective client history can help to determine what you are really dealing with, as it can inform you to activities that would point one way or the other. Did your client recently fall? Is he/she an athlete that uses a repeated motion?

Following that up with your objective ROM,  and muscle testing, will further confirm your analysis.  Active resisted testing of the suspect structure is extremely helpful. Tendinitis usually has a pain response that is constant on active resisted exercises such as “speed tests”, and while bursitis also reports pain on active resisted, the pain increases with contraction as the structure continues to contract over the bursa. It’s necessary to be clear that the pain is where the bursa is located, not in the joint or referral. It’s also relevant  to use a pain scale to chart the pain increasing with contraction.

Once you have assessed that you do have a case of bursitis, rather than joint pain or tendinitis, treatment through massage is extremely helpful.  For the purposes of this treatment we will look at bursitis of the knee in sub-acute and then add on a few chronic suggestions.

Like all other orthopedic  treatments, bursitis of the knee begins with your assessment of the primary injury and also the compensatory ones. In this case the low back is irritated by the antalgic gait (a form of stride shortening due to pain). We are going to work general to specific, starting on the opposite side of the injury. That means I am starting on the back in prone position or the low back first (depending on your time constraints) and on the low back side that is not in pain.  In order to perform this safely without aggravating the bursa further while the client lies face down, you would pillow the affected knee so that it does not make hard contact with the table.  I usually use a pillow under the hips with multiple leg bolsters.  After treating the low back with massage, trigger point and whatever else was in your general treatment plan, you would move next to the posterior aspect of the unaffected leg, which has likely been overworked to compensate for the leg with the bursitis.  Next you would move to the posterior aspect of the, affected leg, paying special attention to the structures that cross the knee. Hamstrings, gastrox, and ITB are all suspect to have pain and dysfunction because they, like the patellar tendon, cross the knee and are either getting too much movement, or too little, while the body protects that bursa.

At this point you would have your client move carefully to the supine position, once again pillowing them for comfort. Next you would want to treat the front of the unaffected leg in the same way you normally would. For the affected leg, you will want to work toward the bursa using general massage techniques. Be careful not to apply too much pressure to structures that could compress the bursa, such as quads (and ITB by torquing the knee). Gentle stroking techniques and techniques such as cupping can be used up and around the knee to encourage fluid movement. The tissue will warm quickly and the increased circulation should aid in lymph movement provided you are gentle.

I would then recommend moving on to other techniques while applying ice.  Rather than put the ice directly across the tendon, which will cause muscle contraction, I will have prepared an ice ring made from a towel that will sit over the knee cap, making minimal contact with the muscle and maximum contact with the bursa.  (Here is where the treatment would diverge if the bursitis was chronic and not inflamed, but sticky with scar tissue)

While the bursa and surrounding tissue ice for a few minutes, I will shift my focus from gentle stroking, to trying to lengthen the structures that cross the knee, without compressing the bursa. I might choose gentle fascia work of those structures, being careful to move towards the patella, or deeper sentimental work. The goal here is to ease compression of the bursa in order to lessen the irritation. Because the client is favoring the leg, it’s likely not moving as much, which in turn will cause a contraction of the tissue. It is then our job to act as an external muscle pump and mimic the body’s normal functions, to ease the tension.

 I would finish by removing the ice ring, and once again moving to gentle stroking techniques towards the knee to re-warm the tissue and flush it. Always moving from general to specific to general again.

In my clinic we also tape supportively with fascia movement tape, so we would do a taping that looks something like this to help with drainage. 

NOTE:If the client was in chronic and the bursa was adhered, instead of ice I would use gentle fascia work around the patella as well as patellar mobilizations to access the tissue under the patella,  stretching and more aggressive lengthening  techniques, but the essential treatment would be the same.

The treatment for bursitis is very easy,  provided you understand the underlying pathology and have a plan to organize your treatment properly.  Clients often get diagnosed by chiropractors and practitioners who are not familiar with soft tissue problems. so do not take anything for granted in your interviews. Good luck!

For more information please see Body Mechanics Orthopedic Massage

Biceps Tendonits- A clear view

Technology is fantastic (when it works) I recently invested in some to allow me to talk to clients in a clearer way. Since I have it at my finger tips, quite literally, I thought that I would take the time to explain Biceps Tendinitis from an Orthopedic point of view. We will go over both the anatomy of the injury and a basic treatment principles.

Biceps tendinitis is an equal opportunity injury. By that I mean that you will find it in mothers lifting heavy babies, factory workers, athletes such as tennis players, massage therapists, and even office workers reaching for heavy books on their desks. Across the board what connects all these things is the repeated over loading of the biceps tendon,  irritation of the synovial membrane encasing it, and irritation of the transverse humeral ligament.  Clients with biceps tendinitis will report pain at the bicipital groove, point tenerness at the same location, pains or aches into the arm and shoulder, and often have hard rope-y muscles around the area. The speeds test should be used to confirm your assessment. 

In treating biceps tendinitis its essential to understand the anatomy fully, because although the suffix "itis" tells you that it is an inflammatory condition, the anatomy of the shoulder lends special complications to the treatment. By fully understanding the anatomy, you can quite effectively treat.

Let's take a look at what is so special about the shoulder anatomy for the biceps. Here are images that will help you understand what makes this different than your normal "itis" treatment. The first view is a highlighted isolation shot of the biceps tendon and attached muscle. As the muscle turns to tendon you can see it travel up into the bicipital groove, passing below the transverse humeral ligament and into the shoulder where it attaches at the supra-glenoid tubrical. The second image is what is really interesting. That same anatomy shot from above gives you a clear idea that this is not just about swelling from overloading, but also about space and angles. If that tendon becomes so inflamed that it cannot in fact pass easily through the "tunnel" formed by the anatomy, it will friction along it, which in turn creates more inflammation. There are 3 factors at play here which can be directly effected by massage, the width of the tendon passing through (is it irritated?), the health of the ligament (is it swollen from repeated impact and abuse) and the angle at which the tendon passes through the "tunnel" (which can effect both the tendons inflammation and the ligaments) Your intake should help you decide what the aggravating factors are, and there by the main problem, which might be 1 or all of the contributing factors.  

You will want to determine if the client is in acute, sub-acute or chronic before the treatment. Treatments in the early stages can be used to help speed healing, and re-educate clients about alignment, but it is the later stages that can be used to correct problems. For this the injury must be in chronic. Someone who has had the injury for a length of time but has reoccurring flairs is considered chronic as well. 

During treatment you will want to pillow the shoulders into the correct anatomical position, relive any trigger points, use active release to strip out the muscle and activate the muscle pump to restore circulation. When you begin to work the biceps tendon, I recommend ending the process with a biceps stretch. I usually do this by hanging the arm off the table and using gentle pnf techniques which will lower the pain response to the tender tissue at the anterior of the shoulder. The goal here is a nice long lean biceps tendon, that fits well through the anatomical structures. For this particular type of "itis" treatment sometimes I recommend the use of ice, not because there is inflammation present, but because as a side effect ice causes contraction. Imagine trying to thread a needle with a fuzzy thread? almost impossible, but if we get that thread wet, it is  a lot easier. Be careful however to ice only at the point where the transverse ligament is, as ice can contract the entire length of the muscle the long way, causing other complications and frictions against the bone. Over aggressive use of ice or inappropriate use of ice can cause just as many problems as what you are treating. 

In many other "itis" treatments you will want to use heat rather than ice in the chronic stages (which sounds counter intuitive), but again knowing the anatomy is essential. If a structure is shortened in chronic, and rubbing across a bone, contracting the structure would be in no way beneficial, and would in fact cause more damage. 

After the treatment take the time to explain to your client how to align their shoulder during their aggravating tasks for the least possible irritation. Many relapses can be avoided by simple client education. 

The biceps tendinitis is VERY treatable through massage and has a high success rate because for most people, letting the arm rest is less of a problem than say, resting the achilles.  Provided you understand what is really going on to create the problem in the first place, this should be a staple go to 'success' in your massage practice. 

For more information please see NYC sports massage
by Beret Kirkeby

Rom: Where we begin to compare the subjective to the objective

If you are looking to be a little more thorough in your technique for massage assessment but don’t really know where to start, simple range of motion is a great place. During your interview process with a client you should have covered such topics as: Where does it hurt? What is the quality of the pain? When did it start? How did it start? Does it radiate? What is the pain on a scale of 1-10? Is there any compensatory issues? Aggravators?  Relievers? This is your subjective information.  Some of us cover a little more, some of us cover a little less, but this is how your client ‘feels’ about his or her pain/condition.

It is very important information, but keep in mind the body is not cut and dry.  Injury is not always where the pain is, nor does structural abnormality add up to pain either. It is only by combining the different tools that we have, that we can begin to scrape the surface and make educated guesses about what is really going on in the body.

Range of motion is a huge assessment tool that is really undervalued. For the most part, when we think of range of motion, we think of boring dry numeric assessment of how many degrees of motion is normal or abnormal, and while that information is important, for most therapists, it matters little if the arm has 3 degrees less rotation, or 8 degrees.  Once we know something is limited, whether normal or over-mobile, it is in comparing that information with the rest of the data we have learned that ROM really becomes a valuable tool.

You will want to divide your range of motion up into two categories. Normal ROM for an average person, and normal ROM for ‘that’ person.  In your first assessment you will compare their ROM with what you know to be normal for others. Recording this information will give you a baseline by which to measure your client.  As time progresses and you learn how their body works, you will begin to measure them by what is ‘normal’ for them.  It is important to understand the distinction between these two things, because for your client, normal may not be normal at all. . Lack of moment or over-mobility may also be completely normal for a client and not add up to any relevant pain. In the case of injuries, however, it often can be.

Once you have made both a verbal assessment and a physical one you will start to overlay the two sets of information and compare what you have learned.  Comparing what the client ‘feels’ to what we observe is where the real value is. The more areas of assessment we have to compare, such as ROM, palpation, verbal assessment, passive ROM, and special test etc…the more likely we are to gain an accurate picture of what is going on in a particular body.

I will give you a brief example of how it works:

A client comes in complaining of low back pain. It is chronic and constant, and he has been receiving 30 minutes of massage on his low back for 3 weeks, once a week with no change. He has been to his doctor and been cleared to see you. He is a runner, in good physical health and has no history of back injury.  He is now afraid he has a disk problem, and has stopped activity for fear of seriously hurting himself, which has aggravated the pain.  Because he has come to your clinic, you do a full assessment, including ROM of the surrounding area (low back and legs) Even though he complains that he has low back pain, he has no limited movement in any direction of his lumbar spine. If anything, he is over -mobile. Now you think to yourself, “that does not seem right, someone with low back pain should be tight and trigger pointy”. So you perform the ROM for his legs and while you find most things pretty normal, you realize that he has almost no mobility in his IT bands and gluts.

By comparing the two sets of data we can start to build a picture of the probable cause for the client. If you had just had the one set of verbal information to go on, you would have massaged his lower back like everyone else. If you had just done the ROM with no verbal information, you would likely assume that perhaps the limited mobility is normal for that client, but since we know he stopped running recently, and we know exercise warms the tissue, we can draw the conclusion that the symptoms were aggravated by withdrawing from activity.  Because you draw from the compared data, you treat both the lower back and the legs with massage, stretching and fascia work, which eases the symptoms for your client.  As you learn more tools you can add them in, such as tests for disc problems as a rule out, but remember, this is an educated guess, not a diagnosis. 

Sometimes things are not so clear but the more you practice the more you will realize how complex the body is and the rules you were taught often do not apply at all, as biology is not rule based, but biology based. There are, however, patterns in many of the things you will encounter. Getting familiar with ROM and using it as an assessment tool is just one step forward in giving you a tiny peek under the hood.  Good luck building your tool box!

For more information on Orthopedic Massage please see  Orthopedic Massage NYC
by Beret Kirkeby

Why we start treatment by getting to the other side. Orthopedic Protocol

I have been teaching a lot recently and it has gotten me thinking about what I want to say in my blogs. Recently, I have become incredibly aware of how lucky I was with my initial training and the early part of my career. I have been blessed enough to go to a 2800+ hour Orthopedic program and then travel the world learning more,  I have almost always worked with medical company's or for insurance claims, seeing clients that had issues that there was no guide book for. I was also lucky enough to do this early enough in my career that I did not know how little I knew, and it gave me free range to experiment with what worked for me, not just with what I had been taught as a base.

For the rest of my blogs I am going to change the focus from the general public, to speaking to other therapists. Teaching here in NYC has shown me that the information I was given freely, is not given to others freely and I want to share what I have. Some of the information will seem obvious to some, but here in the states therapists can either have very little training or quite a lot of training. By no means do I reserve the right to tell people what to think.  However, I can present a structure based on my training and experience on how to think like an orthopedic massage therapist. .

    Starting on the other side........

When you have finished all of your assessments and are ready to treat your client, how do you decide where to start? If a client has back pain do you jump right to the pain point? If they came in for a pulled hamstring do you start with the back because that is where you always start?

 Starting on the other side is a basic orthopedic principle. For some of you this will be a basic principle tried and true, but for some you will never have heard of it.  All this means is that after you assess your client, whatever the probable problem is, you are meant to begin treatment on the opposite side of the body. For example, if the client comes in with a problem in their right leg, the treatment starts with the left leg. It begins an important practice in orthopedic treatment, as using your treatment as an assessment protocol. Starting on the opposite side allows you to do three things.

1. Use your massage to asses what the 'normal' tissue and ROM is, thereby using it to compare to the dysfunctional side, making more objective decisions about your treatment.
2. Decide on a depth of reasonable pressure on the patient's healthy tissue.
3. Get the client used to your touch so that you can work in more sensitive areas that they might guard and get them into a relaxed state with the muscle pump 'on'.

This all seems straight forward when you first think of it, but can get a little confusing if you think on it too much. Obviously if its a limb problem, such as the left arm, you would begin on the right, etc. But issues with the body are not always cut and dry. Take these for example, if the complaint is in the low back, what is the opposite side?

Well, is its low back  right side SI joint, then the opposite side is the left side SI joint. However if its is low back L5-S1 center, and both QL's seem equally tight, then the opposite side is likely glutes. Issues on the main part of the trunk of the body might often use 'up/down'  as the 'opposite side' and that is totally fine. The idea is to start giving yourself a structure to understand the tissue and to gather information as you are treating.

More complexity can be added if you are working with time constraints. You will not always be doing a full body massage. If someone comes in for a 30 minute treatment, and the complaint is a pulled calf muscle, you might only be working one leg, so you might start at hamstring, once again using 'up/down' as opposites, rather than left right. While hamstrings and gastrox are not technically opposite muscles, it still gives you a place to start.

The most valuable information for learning and assessment perhaps comes from using this principle on a micro scale. When you are working for insurance companies, PT's, or chiros, you are often only given 15 min or so to treat. It's really not enough time to reap the benefits of massage, you are just working the prescribed area. In this scenario, I would recommend working 'antagonist/agonist' starting of course with the opposite muscle of complaint. Not only as a beginner does this give you an excellent opportunity to review valuable information about which muscles counteract which movements, but what is fascinating here is you will start to see patterns in pain emerge. You will find that much of the time when you begin with the area that is opposite of the complaint, that the muscle in question will be tight, splinted and in fact the cause of the problem. So when you treat it first, and then move onto the original area of complaint there is no complaint left to treat, other than compensatory issues. And this should get you thinking about pain in general,why it occurs, where it occurs, and how you can rethink you assessments to make them more objective.

Regardless if you are treating whole body, or micro areas, treating on the opposite side is a valuable tool for organization, assessment and gives your client a better treatment on the whole. Even in a relaxation session, small things like this, a can improve a client experience without them ever knowing it was done. Once you start to apply structures in thinking to your treatments, your ability to find patterns within them will quickly develop.

*QL-Quadratus Lumborum
*SI-Sacroilliac Joint
*PT- Physical Therapist

For more information on Orthopedic Massage, or Beret Kirkeby check out Massage NYC
By Beret Kirkeby