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Sports Injuries
Breakthrough Methods in Treatment

By Karta Purkh Singh Khalsa

Originally published in Massage Bodywork magazine, November/December 2008. Copyright 2008. Associated Bodywork and Massage Professionals. All rights reserved.

Let's face it, just about every athlete, from the weekend softballer to the committed marathoner, is eventually going to get some kind of injury. What is done after the injury might be the difference between your clients getting back into the game after it heals or sitting on the sidelines forever.

Bodyworkers have probably been working with sports injuries since the first time a human picked up a ball. And they've gotten very good at treating them. Over the past 40 years, we've made strong strides. Attacking the problem from a lot of angles, many people in many disciplines have contributed their expertise. And the results are pretty impressive.

Still, a nagging problem remains. Your clients get injured. The joint swells up and feels tender for some time. They stay off it and get some bodywork, and, after a while, it begins to feel better and they slowly resume normal workouts. Except it never quite gets back to normal. Sure, they can still play, but that elbow is always a little tighter than they'd like or that ankle has reduced range of motion (ROM). Over the years, the trouble spot gets worse, until the golf game they once enjoyed becomes an exercise in teeth-gritting endurance.

At the Kinesionics Institute, we have been working for 35 years to create a suite of manual therapies, bolstered by some impressive nutritional remedies, energy practices, and directed exercise, to address and heal sports injuries, so weekend hikers can come home still standing on both feet and rise to hike again. It's best to apply these treatments as soon as possible after the injury, but many individuals are helped even after the injury has been stuck in a suboptimal condition for some time.


Pioneers
Throughout the 20th century, many researchers have contributed to the understanding of the role of individual structural muscles and their interplay in the subject of injury rehabilitation. Physical therapists were instrumental in establishing kinesiology as an academic field, cresting with the publication of Henry and Florence Kendall's pioneering book, Muscles: Testing and Function.

Later kinesiologists were largely chiropractors, including George Goodheart, DC, a leading researcher of structure and muscle balance who did his seminal work in the 1960s. He took an intense interest in the work of the Kendalls, and, as a rare artist, made fantastic discoveries by looking at research from a different perspective and synthesizing the information in a novel way that advanced care to a new degree.

As Goodheart began to increase the use of individual structural muscle assessment in his practice, he found some clients had specific muscles that could not maintain their primary mover position under certain circumstances. Goodheart would then often apply his newly discovered origin/insertion technique to the muscles, which quite often would neurologically activate the muscle, stabilize the joint, reduce pain, and improve function. This important discovery--that specific directed manual therapy applied to an individual distressed muscle could improve joint function and initiate the healing of traumatic injury--planted a seed that continues to flower to this day.

A cadre of younger researchers stood on the shoulders of these giants and advanced the field of injury rehabilitation into this century. "Monitoring individual muscles takes the guesswork out of bodywork," says Marge Bowen, licensed massage therapist and practicing kinesiologist in Salt Lake City, Utah, and president of Energy Kinesiology Association.


Muscle Stress Injury And Strain
Successfully helping the body initiate and maintain healing requires a coordinated program that supports continuous healing in the tissues, gets the brain involved throughout the process, and keeps the healing momentum going until everything that was hurt becomes whole again. And that includes a lot. Cellular nutrition, connective tissue recovery, lymph supply, meridian energy, microcirculation, and nerve regulation all have to be completed and get back in sync.

When a muscle is damaged, the harm can be in the form of full or partial tearing of the muscle fibers and tendons. This tearing can also damage small blood vessels, causing bleeding, bruising, and pain. Most sports injuries are sprains, which manifest with swelling, bruising or redness, pain at rest, pain when the specific muscle or joint is used, weakness of the muscle, or inability to use the muscle at all.

For the record, most injuries heal just fine on their own. Clients are out of action for a short while, but, after a brief healing period, things are as good as new. However, some seemingly minor strains end up as lifetime nuisances, while some pretty rough tumbles heal like they never happened. So there's the key question: why doesn't every injury heal properly and completely?

The bottom line is that the body is programmed to heal injuries, but only if other, more essential, survival functions are getting what they need. Any lack of body energy or resources, such as nutrition, and the body will be slow to heal. Occasionally, it heals just enough to be basically functional--clients can walk and drive, but no more football--and just stops, leaving sort-of-well-enough alone.

Enter the chronic tennis elbow. These semi-healed injuries are not just coincidences. The body knows it left half-healed damage in place and would like to heal it, if it could only get what it wants to guarantee that the body's survival needs are met first and that it will have extra available for healing the partly healed elbow. (After all, the tennis elbow, as much as your client would like to use it to play, is hardly necessary to breathe, pump blood, and digest food.)


Strain Treatment
Bodywork may be performed immediately after an injury, but always check with a physician to determine the extent of structural, soft-tissue, and nerve damage before proceeding. Severe damage may not allow bodywork to be done right away.

Standard strain treatment employs the well-known PRICE formula (Protection, Rest, Ice, Compression, Elevation). Sean Riehl, author of the DVD Deep Tissue and Neuromuscular Therapy, and president of Real Bodywork, says the PRICE formula is "most useful in the initial stages."

Kinesionics practitioners concur with this approach. Ice the injured area as soon as possible. For the first 72 hours, apply ice packs (20 minutes every hour while awake) with a barrier between the ice and the skin, with the muscle in a stretched position, and then rest the muscle. (You may apply cautious bodywork in easy intervals between ice applications.)

Gently apply compression with an Ace or similar elastic bandage, which will provide support and decrease swelling. Elevate the injured area to decrease swelling.


Getting Started"Manual therapy in the initial stages can be helpful, but not miraculous," Riehl says. "Bodywork, especially to benefit the lymphatics, can start the next day. It will improve lymph flow and reduce swelling right away and calm the nervous system. Of course, you need to be appropriately cautious with the injured tissue. If you get to it immediately, within three to seven days, you won't get to the stalled out phase. Injuries heal faster with manual therapy than without, doubling the speed of healing, especially with tennis elbow. Aiding the circulation increases the speed of healing."

Mike Blackmore is a sports massage therapist in Eugene, Oregon. He served recently as the traveling massage therapist for the Riverdance troupe tour, where dancers receive massage two or three times weekly. Blackmore likes to allow 72 hours before beginning manual work, to allow pain and swelling to reduce. "Then the benefits include moving in more nutrients and flushing out waste. Plus, we can break adhesions that could inhibit joint movement. We can maintain soft-tissue integrity, restore the muscle back to a healing state, and facilitate recovery," he says.

"Between five and 14 days after the injury, bodywork will aid tissue healing and blood flow, so it is good for fibrotic buildup and to increase the range of motion," Riehl says. "It releases muscular tension around the injury. During sessions, clients will experience noticeable pain reduction and improved range of motion."

Riehl says bodywork works miracles, especially "when the healing is stalled, with low level chronic pain and restricted range of motion."

Spending about 20 minutes working on the injury two to three times per week is a protocol Riehl likes. "The client should feel the benefit of the session, with an 80 percent decrease in pain and 10 percent improvement in chronic discomfort. It's so important to keep the swelling down with lymph work and wrapping," he says.


The Muscle Turns Off
One of the most basic discoveries in the last century's development of kinesiology is the phenomenon of a given isolated structural muscle becoming hypotonic, or "turned off." When a muscle becomes strained, the body seems to reduce the nerve input to the muscle, evidently in an effort to help that specific muscle rest and heal. In effect, the brain dials down the signal it sends to the individual muscle that directs it to contract. Thereafter, the muscle does not participate in the normal movements of the joint, and other muscles in the area compensate to take up the slack and support the structure. This is never perfect because the muscle, one of the component pieces of the joint, is out of action. (Maybe "turned down" would be a better way to understand this, because the muscle seldom loses all tone. Actually it usually has diminished tone.) Still, it's a short-term fix, because, ideally, that injured muscle heals quickly and gets back into action. The brain dials up the nerve signal to the muscle. The muscle turns on--the joint is again fully supported and can be used throughout its entire ROM in any direction. Your client goes back to rugby.

Sometimes, the body is never able to reactivate the hypotonic muscle. Commonly, it's a nutritional shortage. Because the body has a shortage of nutrients and needs to give what it has to the immune system, the liver, and the brain, it can't spare all that is needed to heal the much less important isolated injured muscle, so it heals it enough to get by and leaves it at that. One of the best long-term things we can do to restore healing and prevent future injury is to maintain a good overall nutrition status.

A small percentage of the time, the brain leaves the injured, hypotonic muscle turned off for reasons we do not understand. That's not often, but, with all the injuries you accumulate in a lifetime, they can add up. Your clients' bodies accrue an assortment of these nonsupportive, hypotonic muscles, their structure is not properly biomechanically aligned, and their posture gets a little cranky and creaky. Even more injuries ensue.


Muscle Balance
Our muscular system is a beautiful thing. It's what holds the body together. The bones are just support structures; the muscles, constantly adjusting their tension under the brain's direction, maintain structural stability. The symphony of muscular activation to keep a knee stable while playing soccer is amazing. All the muscles do their part and the brain conducts: clients run, kick, and jump like David Beckham.

But what if one or more of those muscles supporting that crucial hip are not fully neurologically activated? The joint doesn't track quite straight and tissues get compressed and stretched in ways they shouldn't. Getting all the muscles surrounding a joint to come into full neurological activation dramatically reduces the chance of injury on the court.

Deactivated muscles don't hold up their end of the deal. We need to get them reactivated to induce the body to keep the healing process going and to prevent reinjury of the unstable joint when clients do get back on it. If the brain won't allow the muscle to be activated, we need to look deeper for the reason. Here's a big hint: it's usually nutritional, which requires a more in-depth assessment of the body's nutrient needs.

According to Bowen, "The advantage is understanding the proprioceptors and getting them activated to help the muscle function. Most of the usual focus of massage therapy is on overfacilitated (hypertonic) muscles. The advantage of isolating muscles in therapy is that you can also focus on the inhibited muscles."

Pay particular attention to directional massage and cross-fiber technique, the core of this therapeutic package. We can set about to apply a series of manual techniques that act directly on isolated muscles, reconnecting them to the brain, and end up with a nice, tight, straight-tracking joint that will function as well as ever. Add to that a collection of time-tested ancillary techniques to address other aspects of the injury, and you have a toolkit that will greatly enhance your practice. Apply these techniques in any order that fits your case.

"You get to turn on the muscles that are not turned on," Bowen says. "And you calm down the muscles that are working too hard, because the muscles opposing them are not working hard enough. You should look at each individual muscle and especially its needs for lymph, blood, hydration, and detoxification."


Directional Massage
Manual therapy can send a message to the brain to reactivate an isolated hypotonic structural muscle. Apply this technique to all muscles that act across the injured joint. If you have skills that allow you to determine which muscles are hypotonic, focus on those. For at least 90 percent of individual cases, the longitudinal, directional massage movement proceeds from origin to insertion. Apply the technique that way first. If necessary, switch directions. Most of the time, it is pretty obvious which way is working.

"This approach enables a practitioner to identify which muscles and reflexes are involved, then reset them," Bowen says. "This, in turn, aids the body's posture and nervous system to return to a non-injured state. Thus, pain is reduced or eliminated."

You may apply this treatment repeatedly, with caution, during the 72-hour ice period, between ice applications. The sooner you can apply it, and the more often you can repeat it, the faster the muscle will come back online.

The direction of pressure (usually origin to insertion) is the important factor, so any technique you know may have benefit--even simple effleurage, applied in the proper longitudinal direction.

Technique
Start at the origin.

Use the fingertips of one or both hands to go directly into the muscle tissue, perpendicular to the muscle.

With the fingers deeply into the flesh of the muscle, use a short, deep stroke to pull the deep tissue toward the insertion (travel about 1 inch) parallel with the direction of the muscle fibers, taking up only the slack in the skin. Do not allow the fingers to slide along the skin. All movement should be in deep tissue.

Bring the fingertips back out to the surface of the skin, and move the fingertips one inch toward the insertion.

Take the slack out of the skin before beginning the move. Again use direct pressure of the fingertips of one or both hands to go directly into the muscle tissue, perpendicular to the muscle.

Continue in one-inch increments along the entire body of the muscle.

Repeat this process about three times along the entire surface of the muscle. (For wide muscles, such as the latissimus dorsi, this may take 30 minutes, whereas an anterior tibial might take three minutes.)

The effect is a factor of intensity times duration. A deeper, more energetic technique requires less repetition. A softer technique is given in more repetitions. Work to the client's tolerance.

You may add an appropriate topical substance while using the manual technique to enhance the reactivating effect.


Cross-Fiber Treatment
Spastic, or hypertonic, muscles are the contrary to their hypotonic counterparts--they pull too hard. There are a few reasons for this, but the upshot is that they, unmatched by their opposing turned-off muscles, pull the joint out of alignment, causing pain and tracking misalignment.

Technique
Palpate around the joint, distally and proximally, for ropy hypertonic individual muscles.

Apply slow, rhythmic cross-fiber strokes perpendicular to the muscle fibers.

Stay only on the belly of the muscle.

Each session, work for two to three minutes on each of the hypertonic muscles that span the joint.


Counter Torque Tissue Twist
Twisting the soft tissue overlying a limb resets the nerve proprioceptors and helps orient the nervous system to reestablish healing. Use this technique on the limbs above and below the injury.

Technique
Grasp the flesh around the limb.

Rotate the mass of muscular flesh around the long bone (the radius and ulna for elbow injury), while the client rotates the bone in the opposite direction.

Take the rotation to the limit of its comfortable range.

Move along the length of the long bone, repeating the rotation several times along the length.

Repeat the rotation on the limb segment on the other end of the injured joint (humerus for elbow injury).


Longitudinal Chucking
Chucking the structural tissue overlying a limb also resets the nerve propriocepters and engages the nervous system. This technique is for the limbs above and below the injury.

Technique
Grasp the flesh around the limb.

Chuck the muscular flesh along the long bone (the radius and ulna for elbow injury), parallel to the bone, with a quick, snapping motion.

Move along the length of the long bone, repeating the chucking several times along the length. Chuck toward the insertion and toward the origin.

Repeat the chucking on the limb segment on the other end of the injured joint (humerus for elbow injury).


Pulse Balance
There are a lot of potential energy therapies to be used with injury, and all probably have value. "There are reflex techniques that stimulate blood and lymph flow to isolated muscles," Bowen says. "Function can be restored to the muscles by correcting the flow of energy in the meridians."

Kinesionics practitioners find this simple method to be powerful and effective.

Technique
Find a consciously tender spot at the injury site.

Match this with the tender spot in the corresponding matching limb (it will almost always be there).

Balance pulses in the two points by holding with fingers (one hand on each limb) until the subtle pulses in each location equalize.


Treatment For The Whole Injured Person
Blackmore advocates a team approach for chronic injuries, since massage therapists specialize in soft tissues only. "Add a physical therapist to strengthen surrounding tissues and the antagonistic muscles, a personal trainer or athletic trainer with an injury rehabilitation background, and an orthopedic physician. People should go to the type of therapist they have confidence in. In the long term, look at what is causing the injuries. Is it lack of flexibility, lack of strength, or a mechanical issue?"

Riehl, Blackmore, and Bowen are unanimous in their suggestion that injuries don't just involve the body. "Bring awareness and consciousness to the injury, and explore the area internally, to restore energy and blood flow," Riehl says. "I call it 'feeling into your injury,'" he adds.

"Explore the emotional connections with the injured area," Bowen says. "The emotional piece can be identified and diffused by various techniques as well."

Traumatic injuries are no fun, but they can usually heal quickly. And they heal a lot quicker with treatment. We especially want them to heal completely and not drag on for decades, as they so often do. Adding a complete toolkit of manual therapies and assorted natural treatments to your repertoire will boost your success, get a lot of athletes back on the field, and help a lot of people live without chronic pain.

Karta Purkh Singh Khalsa is the director of the Kinesionics Institute, which offers an extensive schedule of courses throughout North America. He is based in Eugene, Oregon.

NOTES
1. Henry O. Kendall and Florence Kendall, Muscles: Testing and Function (Baltimore, Maryland: The Williams Wilkins Company, 1949).
2. Shahram Lotfipour, "Muscle Strain," WebMD. www.webmd.com/a-to-z-guides/muscle-strain (accessed September 2008).
3. Ibid.
4. David Kent, "Keeping It Simple," MassageToday.com. www.massagetoday.com/mpacms/mt/column.php?c_id=2971 (accessed September 2008).




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