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

The whole process is supposed to happen in 15 minutes.

The whole process is supposed to happen in 15 minutes.

What do I mean by that? I mean that in a lot of spas a fifteen minute turnover is standard practice.  In other words, most spas, if they are busy, are booking therapists with clients hourly with a fifteen minute break in between.  At the end of a treatment the therapist has 15 minutes to:

1. Inform your client how to get up
2. Exit the room
3. Wait for the client to come out
4. Walk the client out
5. Cover homecare/client questions
6. Run back to clean the room and change the sheets
7. Greet your new client
8. Assess them
9. Give them informed consent and give them instructions to get on the table
10. Wait for them to change
11. And finally begin the treatment.

This does not cover any bathroom breaks, late clients, unforeseen circumstances or any water breaks. The average shift being 5 clients long, a therapist often goes for 6 hours without stopping. By no means is this ALL clinics, but it is standard practice for many.

On one hand, as a business owner, I understand the need for efficiency, and for structure. After all, in the end, it is a business and the end goal is to make money, however, as a health care worker, I also feel that it is not possible to meet the needs of my patient with such a schedule.

On the other hand, this is often not the case in private clinics, as private clinicians schedule themselves and are able to take a larger cut of the profit, so obviously their concern is putting out a quality product in a healthy amount of time. There is less pressure to make money fast when there is no one to split the total with.  However, when health care becomes monetized into units of time that must be cut into smaller splits, the pressure is on! Compound that with the fact that many spas and gyms are not run/owned by actual therapist, but are managed by business owners, the end result is likely something that does not meet any standard of client health care. Obviously it is not deliberate, however, health care goals and financial ones sometimes do not align. The situation further degrades as therapists, on long shifts with only 15 minute breaks, are likely at higher risk for burn out and mistakes as the therapists become essentially an assembly line of massage.

So the question becomes, are massage therapists health care, or are we a product? Massage therapy often finds itself straddling this issue as it rides a thin grey line between a luxury item and heath care.  My clinic runs on a 30 minute schedule. It works for me; it allows me enough time with clients to pay the bills and invest in their care. I don’t expect that this schedule will work for everyone, some will need more and some will need less, but in the interest of raising the standards for work environments and for lifting client care, we should work together as professionals to raise awareness for what IS and what IS NOT possible in 15 minutes.

For more information on Massage in NYC find us at our website!
by Beret Kirkeby

Twas the Night Before Marathon Poem.

Twas the Night before Marathon and all through the city,

Not a runner was running, not even the most gritty.

The compression socks and shoes were set with care,

In hopes that come morning lovely weather they would share.

The runners were nestled all snug in their beds,

while visions of sports drinks danced in their heads. 

Now Sprinter! Now Pacer! Now Nubie! Now Runner!

On Veteran, On Triathleate! Lets make this one Funner!

So up to the race course, the runners they flew,

For themselves, and their best time, and for charities too!

When they meet with an obstacle they mount to the sky!

Like they have wings on their feet, oh how swiftly they fly!

How their eyes twinkle! How their cheeks flush!

Hey its 26+ miles! Dear God whats the rush!!!

So tonight as your sleeping, know in your heart that you are ready,

Tomorrow will be thrilling, your endurance will hold steady!

And as you spring from the start and dash out of site,

I wish to you Happy Marathon to ALL and to all a good Night.

Have a wonderful run. We wish you the best from this Amazing experience. Thank you for your dedication and commitment that make this sport great for all levels. 
for more info find us at our NYC Massage program
By Beret Kirkeby

Running Hot and Cold before your Marathon. The power of a contrast bath.

I get asked a lot by athletes 'What can I do to recover faster' or 'What can I do before a race if I am sore'. I almost always bring up contrasts baths. And that almost always that leads them to say 'What is that?'

If I think back to the time of where I first knew of contrast baths, it really brings up images of 80's sports movies where athletes are dunked in big steel tubs of ice, or institutional baths. They are ugly steel contraptions set awkwardly in corners of locker rooms. In today's utterly perfect, slick, performance world I can't remember seeing them anywhere. Instead, we eat a vitamin-filled gummy, or wear cool colored tape for our recoveries; however, the contrast bath should not be over looked. It is a huge tool in recovery, and if you are running with an injury you should not be running with, it might be a game changer.

A contrast bath is a simple rehab tool anyone can use that helps decrease inflammation, decrease pain, decrease swelling, and potentially increase mobility. The bather, moves from a tub of warm water, to a tub of cold water and back for a cycle of 30 minutes. The back and fourth temperature changes from warm to cold, cause your circulatory system to repeatedly vaso-constrict and vaso-dilate. That "squeeze - release" action moves the fluid through your body at an expedited rate....as IF you were exercising but without the actual risk of exercising. 

We all know our blood moves through our body by the hearts pumping mechanism, but it does not move the blood by its power alone. Your muscle movement provides a very strong secondary pump that facilitates fluid movement throughout your body. For example, some of you might have noticed that your legs swell up a bit from lack of  movement when you are on an airplane. 

Plunging your whole body from hot to cold, or part of your body, can mimic the normal muscle movement, and be a very effective way of moving things along, especially if you are too close to race time to risk a massage, or cannot access treatment. In most cities there are bathhouses that have alternating cold hot dips that athletes can utilize for full-body plunges. You can also put one together at home with the use of buckets and thermometers. The bucket version is best for ankles and arms, or you can do a hot/cold compress for harder to reach areas. 

Before we get to the nitty-gritty of the recipe, I should like to add that it‘s very important to check with your doctor if you have any questions about if this is right for you. Anyone with circulatory problems, Reynaud’s, decreased feelings in their limbs or compromised skin should not be doing a contrast bath because it puts you at risk.

Here is the recipe for your contrast bath (if you are at home you will need a thermometer)

30 minute cycle repeating hot/cold and always ending on the hot

3-4 min hot water (100F)

1 min cold water (60F)

Have fun running hot and cold! For more information http://www.bodymechanicsnyc.com/
by Beret Kirkeby