resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Treatment of Type 1 Diabetes Mellitus: The Latest Breakthroughs
There are now more than 29 million diabetics in the U.S. and 10% of them have Type 1. The incidence has been increasing in recent years at an epidemic rate.
Diet, Nutrition and the Context of Risk (Part 2): Food Poisoning
Other than the morbidity and mortality linked to eating too much food, "all-natural" organisms that contaminate our food cause more illness, more hospitalizations and more death than food contaminated by heavy metals, plastics, preservatives, artificial colors, emulsifiers, artificial sweeteners and pesticides combined.
Immunotherapy: Where Molecular Medicine Crosses Into Holistic Thinking
Immunotherapy, and its promise as a cancer treatment, has been in the news a lot in the last few years, and for good reason. Real shifts are happening in oncology and exciting researchers, clinicians, and patients.
2016 Trudy McAlister Foundation AOM Scholars
This year, the Trudy McAlister Foundation (TMF) received a record number of excellent applications for the 2016 scholarship awards and has awarded five scholarships for $2000 each. More information is available on our website: AOMScholarship.org
The Effectiveness of Chinese Medicine in Treating Infertility in the Philippines
Infertility is defined as the inability to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.
How to Bill Evaluation and Management Codes
Q: I am in need for guidance on how to bill evaluation and management (E&M) codes in addition to acupuncture the same date of service, I have never been paid for an exam when done with acupuncture and I believe I am doing it wrong.
Five-Element Reaches Out to Serve the Community
In 2006, a student at the Institute of Taoist Education and Acupuncture (ITEA) approached the administration about an idea for his senior project.
Introducing the Dynamic Chiropractic Digital Edition
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The Liver: The Official of Planning
The Liver, with its paired Official, the Gall Bladder, belongs to the Element Wood within us. Wood grants us the power of birth – new beginnings, growth, breaking through boundaries and surging forward. It is the vigorous, exuberant energy of the spring season.
Bring on the Bitters
Out of all the possible flavor choices with foods, such as sweet, sour, salty, and umami (deliciousness), which would you choose first? Bitter, though not as enjoyable, is also a flavor.
Does Anyone Know You're a Good Chiropractor?
If you had a chance to read the recent article in Time magazine (April 6), you know it provided some good information about the efficacy of chiropractic to the magazine's substantial consumer audience.
We Get Letters & Email
Another Slap in the Face for DCs; I Know Where to Find the Missing Chiropractic Patients; Clarification on Vitamin D Study.
The Eight Extraordinary Confluent Points
The eight extraordinary confluent points are a very popular set of acupuncture points in the modern practice of acupuncture. They are also called the intersection, meeting, command, opening, master, and the flowing and pooling points of the eight extraordinary vessels.
Herbal Medicine Continues to Evolve
Product manufacturers, industry partners, distributors and practitioners work as a collective Traditional Chinese Herbal Medicine (TCHM) community to produce high quality TCHM prescriptions that bring low-risk healthcare to thousands of patients everyday.
Who is Your Ideal Patient?
Being in a healthcare practice requires you to think critically about many things including your equipment, techniques, documentation, financial goals, and the retention of clients and staff.
Case Studies and Answer Analysis for NCCAOM Exam in Foundation of Oriental Medicine
Case studies are very common for acupuncture school students, either in class exams or during taking the national board exam. Most test takers feel they have no idea where they should start and how they should start to analyze those complicated cases.
What Should You Call Your Patients (and What Should They Call You)?
When I walked into the exam room, the new patient looked uneasy, fumbling with his cellphone. He was a huge Polynesian man, probably in his 40s, with unrecognizable island tattoos.
F4CP Campaign Addresses Public Misperceptions of Chiropractic
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Are Herbs Useful for Chronic Pain?
The human nervous system is what makes us special, but our greatest strength also makes us vulnerable: witness the growing incidence of chronic addictions, anxiety, depression, sleep disorders and chronic pain syndromes.
The Good, the Bad and the Successful in Social Marketing
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Shoulder Rehab: The Gait Connection
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Acupuncture at a Pain Clinic
Introduction: Pain is the most comprehensive human experience. The experience of pain is associated with the somatic, emotional and social impact. Pain has not only somatic symptoms, but also psycho-social dimension, especially in case of chronic pain.
Time for World-Wide Growth
Acupuncture is the organically growing around the world. The legislative body in Quatar has said acupuncture is "okay." The United States has five states to go to have every state recognized and regulated.
Day in the Life of an Advanced- Practice DC (Pt. 2)
Let's continue our Q&A with Stephen Perlstein, DC, APC, chair of the New Mexico Chiropractic Association PAC and president of the American Academy of Chiropractic Physicians. Part 1 of this interview appeared in the May 1 issue.
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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