resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Women's Hormones: A Western & Eastern Perspective
Sometimes it may seem that you require a degree in medicine to understand hormones and how they function.
Is the New Medicare Reporting Exemption Right for You?
What you've heard is not a rumor – there will be exemptions for providers of Medicare patients, with no penalties assessed for offices that do not do Quality Payment Program (EHR, PQRS, MACRA and MIPS) reporting.
Bill With Confidence: Learn What to Collect
Q: I am trying to understand what I may collect from my patient when there is insurance. Do I have to accept the amount allowed by the plan or may I collect up to my billed amount? Please note, I am not a member of any insurance plan.
A Major Role in Back Pain: The Multifidus
Back pain affects roughly 80 percent of the population at one time or another and is one of the leading causes of doctor visits.
The Visual Error Scoring System: A Concussion Tool
Postural stability and oculomotor function are the most easily recognized physical indicators of neurologic motor dysfunction associated with concussions.
A Daily Strategy for Heavy-Metal Detox
In modern society, we are constantly exposed to heavy metals such as cadmium, lead and mercury. These heavy metals have no essential biochemical roles in our body, and conversely, can cause us a great deal of harm if they build up to toxic levels.
Raditation & Your Smartphone: Is it Worth the Risk?
If radial arteries could talk (and in my experience they can to some extent), they would say, "Step away from the smartphone." At least that is the message I am receiving loud and clear as I feel the pulses of many patients.
Balancing Spring Challenges
As the winter months come to a close and warmer spring weather appears, patients may begin to present with new challenging pattern presentations.
Why I Quit Doing House Calls
My father was a chiropractor who did house calls, so when I became a DC, I figured doing house calls was part of the job. My March article recalled my experience as a small boy, accompanying my dad while he went to patients' homes to treat them.
New Relationships, Old Trauma: AOM & Other Healing Strategies
Being in love is one the most beautiful and enjoyable experiences. Most of us are willing to pay almost any price to have that experience, and still often find it elusive or fleeting. Navigating the ups and downs of loving relationships are often challenging — even for the most psychologically balanced among us.
An Integrated Approach to Chronic Pain
Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction.
Eczema & Acupuncture: A Sound Solution (Part 1)
Eczema affects approximately 3.5 percent of the global population and is one of the most common skin complaints seen by dermatologists.
Universal Design: Principles & Practice
In many respects, universal design serves as the core of ergonomics. It's also a good tool to use when designing a return-to-work program for injured and/or ill patients. Let's take a closer look at universal design and why it should matter to you and your patients.
News in Brief
ACA Adopts New Governance Model; ACA 2017 Awards; CCA Helps Calif. DCs "Share the Love"; $1 Million to Help Advance the Profession; D'Youville Raises the Bar on Anatomy Education; ErRatum.
Clearing Blocks: A Way to Improve Cosmetic Acupuncture
As a Five Element acupuncturist who teaches facial acupuncture classes nationally, I was surprised to learn that one of the basic principles I was taught in school is unfamiliar to most acupuncturists.
Give Yourself the Digital Advantage
When you see this article in the print version of this issue and swear you read it already, don't be alarmed: you probably did. That's because by that time, the May issue will have been available online in digital format for three weeks.
Taking the Chiropractic Message to the Press
"There is no better place on earth to have a news event," the National Press Club boasts, and it's easy to understand why: Every year, the 108-year-old Washington, D.C.-based organization hosts countless press conferences on the hottest topics impacting America and often the world.
An Unexpected Diagnosis: The Result of Lacking Communication
A couple years ago I had a case that showed me the importance of open communication between health practitioners. We need to show up with less fear, and let go of our judgments so we can do better for the patient.
Creating Good Business Buzz
What do patients really think about working with you? Rarely do you hear the whole truth. Those who improve may be candid in their gratitude.
December, 2012, Vol. 12, Issue 12
Learning to Train the Myofascial System
Understanding Tibial Fractures and Medial Tibial Stress Syndrome
By Debbie Roberts, LMT
Are you asking yourself why as a massage therapist you would ever need to know about tibial fractures? I hope that now you are thinking pre-habilitation instead of rehabilitation.Have you ever gotten a client in your office and you said to yourself or to the client, I wish you would have come to see me sooner before this happened. I could have helped with your range of motion and flexibility and maybe that last injury might have been avoided. Our ability to educate about pre-habilitation is a way to get our patients thinking and understanding that we can do so much more before the injury occurs instead of after the fact. As a massage therapist, knowledge about the myofascial system combined with the working knowledge of how the body's mechanics function, is invaluable for practicing pre-habilitation. Moving our client's into understanding training the myofascial system and not the muscular system is the wave of the future.
Training the Myofascial System
Fitness training is all about pre-habilitation so I thought it was important to bring your awareness to what is happening in the fitness industry that relates directly back to us as massage therapists. Recently, I attended two fitness conventions where the buzz was all about the trainer understanding how the myofascial system worked and the importance of training the myofascial system. The topics being discussed were explaining the front fascial lines, the side fascial lines, the back fascial lines and the spiral fascial lines from the book by Tom Myers, Anatomy Trains.
As a trainer and massage therapist, it was an interesting concept on the importance of training the myofascial system and not the muscular system. So, how in the world do you train the myofascial system and what the heck does it have to do with tibial fractures? The way the foot is able to strike the ground and react to ground forces has everything to do with the tightness or stiffness of the joint structures. There are lines of myofascial pull that are either allowing muscular loading or doing muscular loading. Any potential of injury comes from a muscular imbalance around a joint which is not the muscles themselves exactly but the surrounding myofascial system and the lines of pull. If we use screening skills to see the lines of abnormal pull, lines of abnormal motion under loads, and loss of strength in poor anatomical positions then we will be more successful in treating the client.
Sooner or later, every practicing therapist will be asked to treat injuries in the beginning of the lower extremity kinetic chain the foot and ankle. We commonly see patients with plantar fasciitis, heel spurs, calf strains, achilles tendonitis, shin splints, ankle sprains, lower-Leg compartment syndrome and posterior tibial tendinitis. This wave of triathlons for fund raising is helping drive young and old clients into offices more frequently than ever. I recently consulted with an elderly couple who at 70 and 72 decided to do their first ever triathlon. Great opportunity for pre-habilitation!
For the purpose of this article, we're going to take a closer look at an on-going popular problem of tibial fractures and medial tibial stress syndrome. This is a common injury that affects athletes who engage in running sports (triathlon's) or basic activities such as cross country, football, or hiking.
The foot is a complex structure: 26 bones plus tibia and fibula, which makes up 34 joints, all of which need dynamic reactive stability. And there are 30 muscles crossing the ankle and foot joint, 12 which are multi-joint muscles that send their tendons across at the ankle and subtalar joint into the foot. How these muscles function is through a econcentric function, through the use of gravity, momentum and ground reaction force, to use its eccentric load to produce a concentric function in another plane or at another joint ... most all of the lower leg muscles biomechanically function econcentrically. An example of this is how peroneus longus eccentrically loads as the forefoot enters into the ground in what we call a controlled fall. The peroneus decelerates dorsiflexion of the first ray, decelerates midtarsal joint inversion, decelerates subtalar joint eversion, decelerates ankle dorsiflexion, decelerates midtarsal joint inversion, accelerates plantar flexion of the first ray and eversion of the midtarsal joint and accelerates knee extension (Understanding Ankle Sprains, by Gary Gray, www.GrayInstitute.com). Risk factors for developing tibial fractures include increasing activity, intensity, and duration too quickly and the loss of overall mobility and/or stability.
Types of Tibia Fractures
Tibial injury seems to be connected to excessive bending of the tibia during running. When the damage to the tibia is severe enough and continues long enough, a tibial stress fracture will develop. Runners with long-standing cases of “shin splints” that have diffuse pain along the shin but not a sharp, localized, aching pain on the bone should take care not to increase their training load until they have recovered, lest they will do further damage to bone. With repetitive stress, the impact forces eccentrically fatigues the soleus and creates repeated tibial bending or bowing; thus, contributing to medial tibial stress syndrome. The only test is advanced imaging to properly diagnose. But basically if there is pain that doesn't go away and is sharp, they should see a sports medicine doctor.
Research by Irene Davis at the University of Delaware has examined how biomechanical factors affect stress on the tibia. In a pair of studies published in 2006 and 2007, Davis' lab conducted a biomechanical evaluation of female runners who had suffered and recovered from a tibial stress fracture. The researchers compared their impact loading rate, knee stiffness and tibial shock with that of healthy runners who had never suffered a tibial stress fracture. The findings indicated that runners with a history of tibial stress fracture have significantly higher impact loading rates — the rate at which the force of your foot strike ramps up as your foot hits the ground — as well as a stiffer knee and a higher tibial shock, as measured by an accelerometer taped to the shin. Calf strength, impact loading and knee stiffness are all factors that we can actively change with training interventions, so Davis' research provides another promising route for injury prevention.
In my office, I began to see correlating evidence suggesting a pattern of the precipitating factors surrounding lower extremity pain and in some cases before the tibial fractures happened. I gathered this information while treating six different runners.
Runner One: Age 53, avid male distance runner, spiral tibial fracture.
A. Functional Assessment (weight-bearing)
All of the runners had lost their ability to squat below parallel. All of the runner's weight shifted to the side without pain. All of the runners with the exception of one, abducted and pronated while performing the squat. All of the runners had inversion/eversion stiffness on the side of pain. All of the runners had loss of mobility of the subtalar joint, on the side of pain. All of the runners had increased either their distance or pace too quickly. Five of the runners were in motion control shoes, one runner was in stability shoes. None of the runners did any self-myofascial release or spent the appropriate time stretching compared to their work loads. None of the runners stretched on a slant board used for a soleus stretch. None of the runners worked on the mobility of their feet.
Runner one: Presented for therapy five years after the spiral fracture. He presented with S-postural imbalances from sitting at a desk eight hours a day. He related he had a foot issue before fracture. There was limited hamstring range of motion bilaterally, worse on the side of fracture. Had over-pronation of the foot and weakness of anterior tibialis.
Therapy: Myofascial release and PNF stretching to the muscular imbalances. I performed mobilization to subtalar joint and the foot. He is now running now pain-free in a neutral shoe.
Runner two: Presented with Pes Cavus (high-arched foot) and wore high heels to work every day. She had S-postural imbalances and top of the foot pain that would not go away.
Therapy: Referred her out to podiatrist. She was fitted for orthotics. She received injections to help with the fracture pain. I saw her once a week to help release the myofascial restrictions and muscular imbalances around the ankle. I performed mobilization to subtalar joint. She was restricted from running.
Runner three: Presented with a previous back injury and had not been running for a year and a half, this was her first month back running. She attempted her old pace of a six-minute mile when she felt the pain. She had worked out every day with weights. She had gross immobility of her lower extremity.
Therapy: None for her leg, she was placed in a boot and had a follow-up orthopedic visit in eight weeks.
Runner four: Presented with a very stiff and painful subtalar joint. She had loss of foot mobility on palpation. She had just bought new motion control shoes which were to limit her over pronation.
Therapy: I did mobilization to the subtalar joint, isometrics all around the ankle, mobilization to each individual ray of the foot, worked on gastroc-soleus complex for flexibility. I used myofascial release and PNF stretching to the lines of pull. The next run was pain free.
Runner Five: Presented with an anatomical short leg with a rigid, painful flatfoot (pes planus) with the hind part of the foot in valgus position, characteristic of tarsal coalition. He had a pain at the subtalar joint that would not resolve and he was seeing a massage therapist already.
Therapy: Because of the severe placement of his foot, I referred him out to a physical therapist that is also a runner and did gait analysis. The physical therapist has taken over his care.
Runner Six: Presented with a S-postural imbalance and was overweight by 30 lbs, and the foot was in a position of extreme over pronation, too many toes sign with posterior tibial insufficiency.
Therapy: I referred her out to a podiatrist because she wanted to keep running. She was fitted for an orthotic which had to be adjusted three times before the pain discontinued. We saw her once a week while she was training using myofascial release, cupping and PNF stretching to the muscular imbalances. She also practiced yoga twice a week and started more core training. She went on to run 20 miles in Spain.
As massage therapists, our message should be louder that our myofascial skills should be used as prevention to an injury. Using a few simple screens assessing for risk could save our clients hundreds of dollars in rehabilitation costs. You can help by improving your understanding of the working biomechanics of a joint and the myofascial system. Move away from thinking one muscle is the problem and begin to look at the force-coupling relationship that is formed by the myofascial system.
When searching for strategies to prevent tibial stress fractures, we should turn our attention to intrinsic factors, attempting to correct or ameliorate the effects of inadequate bone strength, weak lower leg muscles, high impact loading rates, muscular-myofascial restrictions and the interplay between the ankle and subtalar joints.
Click here for more information about Debbie Roberts, LMT.
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