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I t p a y s t o b e A B M P C e r t i f i e d : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 103 To perform the technique, position the client in either a supine or side-lying position, as long as the foot can move fully through a range of dorsiflexion and plantar flexion. Have the client dorsiflex the foot, place static pressure on the tibialis posterior, and instruct her to plantar flex the foot (Image 4). Pressure is applied during the concentric phase of contraction (plantar flexion). Allow the client to rest and relieve the pressure while she moves the foot back into dorsiflexion. Repeat the process several times until you have worked the full length of the tibialis posterior muscle with static compression during the concentric plantar flexion. Follow the concentric application with a stripping technique performed during the eccentric or lengthening phase of the muscle. For this technique, have the client in the same side-lying position. You can even have the foot off the end of the table so it can fully move through a range of dorsiflexion and plantar flexion if that works better. Instruct the client to slowly move the foot back and forth (plantar flexion and dorsiflexion). During each dorsiflexion movement, as the tibialis posterior is being elongated, perform a deep stripping technique along the tibial border to the deep posterior compartment muscles (Image 5). Keep in mind that this technique can be painful for the client, especially if a dysfunctional condition like medial tibial stress syndrome exists. However, there are few techniques that are as effective as this in helping to reduce chronic tightness in these muscles and return them to optimal function. Denise was adviced to continue with home-care activities to support the clinical treatment work. Stretching plays an important role in keeping these muscles from experiencing chronic overuse. Because it is difficult to adequately stretch the tibialis posterior muscle, stretching is even more important. In addition to stretching, clients can perform some of the simple active engagement techniques on themselves. The more frequently these muscles are worked, the less they will suffer from cumulative trauma. While the client's self- massage will not be as effective as what you perform in the treatment room, it is still highly valuable in helping to reduce cumulative stress in these tissues. It is also a good idea to have the client examine her footwear. Shoes with inadequate support are a frequent contributing problem to chronic overuse problems like medial tibial stress syndrome. Sometimes orthotics in the shoes can be helpful, but this isn't mandatory and it can be challenging to find an orthotic that is ideally designed for the individual's unique biomechanical foot dysfunction. Medial tibial stress syndrome can be effectively treated with massage if the proper applications are used. However, treatment applications are often not specific enough in accessing the deep posterior compartment muscles, and the massage can wind up being ineffective. Following the above protocols should produce effective resolution to the client's pain. Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe's free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com. Compression with active engagement for the deep posterior compartment. Image courtesy of Whitney Lowe. Stripping with active engagement for the deep posterior compartment. Image courtesy of Whitney Lowe. 4 5