Issue link: https://www.massageandbodyworkdigital.com/i/1358392
68 m a s s a g e & b o d y wo r k m ay/ j u n e 2 0 2 1 Belief: Pain down the leg (sciatica) is caused by pressure on the sciatic nerve. Fact: The sciatic nerve consists of five separate nerves wrapped together. There is rarely, if ever, pressure on all of them at once. One or possibly two nerves could be compressed by one or more injured, extruded disks. However, most cases of pain down the leg are caused by injury to structures like the sacroiliac or sacrotuberous ligaments, the hip joint, or the gluteus medius muscle, not just the sciatic nerve or its branches. Belief: When a tendon is chronically injured, we call it tendinitis because the tendon is inflamed. Fact: We now know there are no inflammatory cells when a tendon has been injured for an extended period of time. We now know it to be tendinosis, where the cells are deteriorating. Tendons are connective tissue structures that are primarily composed of collagen and elastin fibers, which lend the structure its strength and also a small amount of flexibility. Primarily designed to transmit a strong tensile (pulling) load from muscle directly to bone, tendons are not designed to be very flexible. Tendinitis refers to a strain or micro-tearing of the tendon, and new studies show a symptomatic degeneration of the tendon with vascular disruption and inflammatory repair response. Conversely, tendinosis is defined as intra-tendinous degeneration due to atrophy (aging, micro-trauma, and vascular compromise). In recent research, most tendinitis complaints have been found to be lacking inflammatory cells. The main issue in these tendon disorders (referred to as tendinosis) appears to be collagen degeneration from overuse. Massage therapy, specifically deep-friction massage, is beneficial, as it stimulates the production of collagen in damaged tendon fibers, rather than only breaking up fibrous scar tissue in chronically inflamed tendons as previously thought. Belief: Most chronic pain and injury is caused by excessive muscle tension. Fact: I've given talks on muscle tension and pain, and even made it the central focus of my book Are you Tense?, yet—in time—I have come to realize that muscle tension is only one piece of the chronic pain puzzle, not the main protagonist. Generally, pain does not originate in the muscles. Massage therapists receive in-depth training on muscles and their function. When something goes wrong in the body or a client presents with pain, it's the first and often only place they look. A therapist might attribute the discomfort to a muscle spasm or an injury to muscle tissues. However, this is often not the case, especially with lasting chronic pain. Muscle spasms are frequently identified as a source of pain, yet, in most cases, they are protective mechanisms and the result of an injury to a tissue other than muscles. For example, if a ligament or nerve root is injured on one side of the low back and you begin to move in a way that adds pressure to those structures, the muscles of the low back will seize and spasm, limiting movement and possible further injury to the ligament or nerve root. The pain associated with an injury to muscle tissue often diminishes within a day or two or up to a week. Muscle strains and micro-tears might occur frequently, yet muscle tissue is also highly vascularized and heals quickly. Where there is ample circulation, there is a larger capacity and efficacy for effective healing. When pain continues for months or years, it is typically indicative of damage to a ligament, tendon, joint, or bursa. These structures are also frequently injured, sometimes increasing with age as seen in joint damage, yet their limited blood supply makes them very slow to heal, if at all. Coupled with the slow healing process, these structures are also in high demand. Without proper treatment, but continued reuse, there can be a re-tearing of scar tissue and painful adhesions can develop between the healing fibers, contributing to ongoing chronic pain. Knowledge about injury to each of these structures, in addition to a thorough understanding of muscle anatomy and function, is essential for effective assessment and treatment of a client's chronic pain. Belief: Working at the site of the pain yields the best results. Fact: The location of a client's pain is often misleading. In many cases, pain is referred from the source of the injury to another part of the body. A client may present with severe and inexplicable upper arm pain and insist on deep pressure directly on the most painful areas in hopes of alleviating the discomfort when the pain is actually coming from somewhere else. We might ask several questions to determine a possible cause, but we also know certain areas are capable of pain referral, including the shoulders, neck, thorax, low back, sacrum, and hip joints. Before jumping into treatment, if it's in your wheelhouse, do a full assessment of the area. For example, there are 12 tests for the shoulder that will usually let you know exactly what is injured, and whether it's a tendon, a ligament, or the joint itself. If you are not well-versed in assessment protocols, remember that pain typically shows up distal to the site of injury. Focus your work on the structures proximal to the pain. Beliefs vs. Facts