Issue link: https://www.massageandbodyworkdigital.com/i/329694
102 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 4 splinting. For Patrick, the work was uncomfortable but tolerable, and he was instructed to speak out if it became more than he could tolerate. Client-practitioner communication is very important in this type of treatment. Immediately after the friction techniques were performed, static knee flexion stretches were used to help encourage further stretching of the involved tissues. This series of extensive friction treatments followed by stretching was repeated three to four times in each treatment session. After the first two treatment sessions, pin and stretch techniques to the distal quadriceps were introduced. The pressure was applied to the injured region while the knee was in extension and maintained as the knee was slowly brought as far into flexion as possible. The amount of knee flexion possible was documented in each treatment session so we could measure improvement in successive treatments. The first four sessions (two per week) showed promising initial results. Patrick tolerated treatment well and complied with a home-care plan his physical therapist gave him to interface effectively with the massage approach. At this point, active engagement lengthening methods were added to the treatment. These techniques involved deep stripping performed during eccentric action (flexion) of the quadriceps muscles (Image 4) and were aimed mainly at the distal quadriceps fibers and retinaculum, but also applied throughout the length of the muscle. Although this technique was more painful for Patrick, it helped him make significant gains in tissue elasticity. ASSESSMENT AND EVALUATION At the time of Patrick's first visit, knee flexion was limited to about 15 or 20 degrees. There was no limitation to knee extension. Initial assessment indicates very dense and fibrous tissue in the area around the distal quadriceps just superior to the patella. Fibrous thickening is very palpable throughout this region as well. Patrick also reports intense pain with palpation using moderate pressure. There is binding restriction at the limit of passive knee flexion, and end range of flexion causes pain. Resisted knee extension produces anterior knee pain. Patrick also senses weakness in the knee and feels he cannot put weight on the knee without it failing. This sensation is caused by a neurological process called reflex muscular inhibition, in which the brain, in an effort to avoid intense pain and further injury, shuts off contraction signals to the affected muscles when they are heavily engaged. TREATMENT STRATEGIES The primary treatment technique for tissue tearing and fibrous scar tissue development is generally deep friction massage. However, in Patrick's case, it is unclear whether that type of treatment will be effective given the amount of scar tissue over such a wide area. It appears unlikely that deep friction alone will be sufficient to achieve the range of motion gains we need, and a number of other treatment procedures will likely need to be included as well. Another factor is that massage is likely to be quite painful and will only work if Patrick is very compliant with all treatment suggestions inside and outside the treatment room. Because of the relatively recent nature of the injury (several weeks old when we started treatment, and considered subacute at this point), it is also clear that the greatest benefits will come from frequent treatments. Patrick came in twice a week for 30-minute massage sessions. Each session began with extensive work on the quadriceps muscle group using gliding techniques to reduce overall tightness and encourage tissue elasticity and optimal tissue health. Following this work, longitudinal stripping was performed throughout the entire anterior thigh region. Because Patrick's quadriceps were large and muscular, it was important to get as much tissue relaxation as possible throughout the entire muscle. Deep transverse friction was then applied to the scar tissue region in the distal quadriceps and retinaculum. Friction techniques were performed over the entire area with moderately deep pressure for several minutes. The pressure level used was enough to produce tissue quality change, but not enough to produce reactive muscle Active engagement stripping on quadriceps. Image courtesy of Whitney Lowe. 4 CLINICAL APPS