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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 95 CLINICAL E XPLORATIONS TREATMENT STRATEGIES Identifying when a ligament or tendon has been injured is helpful in designing an appropriate treatment strategy. Gentle protected movement is a mainstay in the treatment strategy for both tendon and ligament injuries. For ligament sprains, treatment formerly emphasized maintaining the joint in an immobilized position so the ligament would not be stressed and could appropriately heal. However, recent research has indicated that movement within normal limits is far more effective and beneficial in producing an ideal healing environment for the ligament, so now movement that does not overstress the ligament is strongly encouraged. Treatment for chronic overuse tendon pathologies can be a little counterintuitive. It would seem like the most effective means of healing the collagen degeneration within the tendon would be to completely rest it and allow the tissue to rebuild. Some degree of rest from offending activity is certainly helpful. However, we have now learned that stressing the tendon with certain types of load, especially eccentric muscle load, helps the tendon adapt to the stresses and can lead to quicker recovery. So, despite the fact that injury was caused by excessive use, exercising the tendon is actually a crucial part of the healing process. One of the questions for massage therapists is the role that massage can play in addressing tendon and ligament injuries. Deep friction massage has been used frequently to address chronic overuse tendon disorders. Formerly, it was thought that the primary benefit to this treatment was reducing unhealthy scarring within the torn tendon fibers. Now that we realize most of these tendon disorders involve collagen degeneration and not fiber tearing, that treatment approach does not make sense. Still, we know that deep friction massage does often produce clinically beneficial results for overuse tendon disorders. Although there is still research to be done in this area, one possible explanation is that pressure and movement applied to the tendon may stimulate fibroblast activity and can encourage tissue healing within the damaged collagen matrix of the tendon. Similarly, friction massage is still used to treat tenosynovitis. The primary theory around massage for tenosynovitis is that friction massage can help reduce dysfunctional adhesion and binding between the tendon and surrounding synovial sheath. This has never been confirmed through research, so right now we recognize this treatment strategy as beneficial, but still in need of further investigation. Another important facet of treating any tendon pathology is working on the muscles associated with the injured tendons. In addition to decreasing aggravating activities, tensile loads can be reduced on the tendon by decreasing tightness in the tendon's muscle. A wide variety of massage techniques can be quite effective in achieving that goal. Treating ligament sprains follows a similar track. It is unclear if massage can do anything significant to encourage the healing process of a sprained ligament. It may help to some degree with encouraging tissue regeneration, as with tendons. In addition, a joint that is not properly mobilized during the healing process may develop fibrous adhesions between the healing ligament fibers and adjacent tissues. Frequent friction of the healing ligament, including self-massage multiple times during the day, may help reduce the likelihood that adhesions adversely bind the healing ligament and prevent full range of motion in the future. It is important to remember that ligaments do not contain contractile tissue. As a result, they do not contract. It is not unusual to find massage treatment techniques where the practitioner advocates "releasing" the ligament. We must remember that because ligaments don't contract, they also don't release. In fact, releasing a ligament is probably one of main things you don't want to do because it's primarily designed to be stiff and hold joint contact surfaces in proper orientation with each other. It is important for us to understand how different soft tissues function, what happens to them when injured, and how our massage treatments interface with those tissue disorders. As we continue to learn more about tendon and ligament physiology, we may also develop more appropriate treatment strategies that will help our clients get back to activities even sooner. Notes 1. A. P. Rumian, A. L. Wallace, and H. L. Birch, "Tendons and Ligaments are Anatomically Distinct but Overlap in Molecular and Morphological Features—A Comparative Study in an Ovine Model," Journal of Orthopaedic Research 25, no. 4 (April 2007): 458–64, https://doi.org/10.1002/jor.20218. 2. S. A. Müller et al., "Tendon Healing: An Overview of Physiology, Biology, and Pathology of Tendon Healing and Systematic Review of State of the Art in Tendon Bioengineering," Knee Surgery, Sport Traumatology, Arthroscopy 23, no. 7 (July 2015): 2097–105, https://doi.org/10.1007/s00167-013-2680-z. 3. P. Danielson, "Reviving the 'Biochemical' Hypothesis for Tendinopathy: New Findings Suggest the Involvement of Locally Produced Signal Substances," British Journal of Sports Medicine 43, no. 4 (2009): 265–68, https://doi.org/10.1136/bjsm.2008.054593. Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com.