A Chain Reaction: From Sever's Disease to Tensor Fascia Latae

By Debbie Roberts, LMT
June 7, 2017

A Chain Reaction: From Sever's Disease to Tensor Fascia Latae

By Debbie Roberts, LMT
June 7, 2017

I believe having an understanding of how human movement is created should be part of our business model.

As a profession we treat clients daily that are in either acute or chronic pain and make assessments based on their movement patterns. Many successful massage therapists develop treatment plans using their old familiar palpatory skills and fall victim to their own subjectivity. Gray Cook in his book titled Movement says, "The most objective professionals are those who know they are not objective and therefore use systems to re-check their work. This bias is a pitfall of human nature." Therefore, having a system of evaluation and assessment in your toolbox is the true way to create an effective rehabilitation plan.

Youth Sports Case Study

I recently had the privilege of developing and overseeing a 21-week pre-conditioning program for a local high school baseball team. In an effort to make sure the team members were fit for conditioning they were screened for any possible biomechanical issues. It was during this process that I met a 17-year-old player with tensor fascia latae (TFL).

While watching his squat evaluation I noticed his right foot pronated, externally rotated, and he shifted his body weight to the left. I asked him if he had ever done anything to his right foot. He said, his right foot was put in a cast in the 5th grade because he had pulled the cartilage away from his heel bone. He also told me he had been diagnosed with Sever's disease at that time.

Sever's Disease

According to the American College of Foot and Ankle Surgeons it is also call calcaneal apophysitis which is a painful inflammation of the heel's growth plate.  It typically affects children between the ages of 8 and 14 years old, because the calcaneous is not fully developed until at least age 14.  Until then, new bone is forming at the growth plate (physis), a weak area located at the back of the heel. When there is too much repetitive stress on the growth plate, inflammation can develop.

One of the causes of Sever's disease is overuse and stress on the heel bone through participation in sports. The heel's growth plate is sensitive to repeated running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track, and basketball, or in this case baseball are especially vulnerable. One of the treatment strategies is immobilization with a cast to promote healing while keeping the foot and ankle totally immobile. As massage therapists we are well aware of the effects of immobilization on the fascial system.

Continued Evaluation

Upon further assessment, I also noticed he could not touch his toes as well on the right side. I asked if he had done anything to his hamstring and he said, he had pulled it when he was in the 8th grade. When I screened for pelvic control using a test called Bird Dog, he showed loss of control with his right arm/left leg extended and weakness with his left arm/right leg extended. He had poor control in a single leg lunge with the left leg forward and loss of stabilization at his core. On the right side his knee caved but his core didn't collapse.

With this assessment I was able to see the chain reaction, and how his past issues had lead him to his current ones. He had experienced the effects of the spiral line first hand — beginning with the loss of mobility in his foot and ankle, to his pulled hamstring in the 8th grade, to the lack of core control, and now to a TFL issue at the age of 17.  No wonder he made the statement, "I hate to run."

For a complete understanding of this chain reaction I recommend Tom Myers' book, Anatomy Trains, specifically his explanation of "The Spiral Line."

Prescribed Treatment

My first task was relieving him of his chief complaint, which was his hip pain upon running. This was accomplished by having him lie down on his side for massage cupping to the TFL, and then the surrounding tissues. I also used heat and slow deep massage therapy to the TFL. Within about 15 minutes he was out of pain. To test for improvement I used the "squat evaluation" as the marker. When he performed a squat without any pain he was thrilled.

Next, we discussed the appropriate stretches for the area that would prevent it from tightening again. We also talked about the importance of the rehabilitation process from the ground up. Ultimately the treatment plan would unravel the entire fascial lines involved, thus creating the stability needed for improvement.

I am now working with him on an individual basis for both massage therapy and personal training. The goal is to get him to foam roll all of the fascial lines involved, thereby stretching where necessary, increasing ankle mobility and foot health, and continuing massage therapy to release the fascial lines of pull.

The Lesson to Learn

Understanding how movement is created is critical in unraveling the chain of events that can (and do) happen to our clients. For massage therapy to work as therapy, having a system in place of checks and balances should be the basic goal. Recognizing and looking for the interrelationship between problematic segments and movement patterns of compensation are important. I believe this understanding will help us create better treatment plans and lead to many more successful outcomes. Happy therapy!