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102 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 1 4 Our solution was to apply moderately deep palpation during these same evaluation procedures. Palpating the tissue, while stressing it through active, passive, or resisted movements, puts significantly more stress on the potentially damaged tissues and can give us more clues about the nature of the problem. In Denise's case, pain was slightly reproduced during active movement with palpation, and especially during manual resistance with palpation. The motions that were most painful were active and resisted plantar flexion and inversion. This pattern fit with our suspicion of involvement of the tibialis posterior and/or other deep compartment muscles. Another way to effectively evaluate many lower extremity disorders is to have the person attempt to do some of the range-of-motion evaluations while in a weight-bearing position. They can't all be done effectively in a weight-bearing position, but some can. You'll need to carefully apply your kinesiology knowledge to evaluate which muscles are engaged in concentric or eccentric actions during the various weight-bearing range-of-motion evaluations. For example, if you have the client rise up on tiptoe, that is an active movement that works the plantar flexor muscles concentrically. Coming back to a neutral position, the foot is moving into dorsiflexion, but it is the plantar flexor muscles working eccentrically to get back into a neutral position with the foot flat on the ground. Based on Denise's history, and our findings in physical examination, it appeared most likely that some type of chronic overuse disorder was aggravating muscles of the deep posterior compartment, and their irritation was the source of her pain. Having formulated a good hypothesis about the nature of the tissue injury, we now turned our attention to whether or not massage was appropriate, and if so, what would be the most effective treatment strategies. TREATMENT CONSIDERATIONS Because this condition appears to revolve around musculotendinous dysfunction, massage treatment approaches are likely to be very helpful in addressing the complaint. We must keep in mind, however, that despite having identified the deep posterior compartment muscles as the primary culprit, very few soft-tissue dysfunctions are the simple result of problems in one structure alone. Consequently, our treatment approach addressed a number of other tissues as well. Treatment started with the superficial posterior compartment muscles: the gastrocnemius and soleus. Tightness or dysfunction in either of these muscles can contribute to dysfunction in the deeper posterior compartment muscles. The soleus muscle can also be implicated in many conditions of medial tibial stress syndrome. It is helpful to get the gastrocnemius and soleus as pliable as possible in order to access the deep posterior compartment muscles beneath them. Sweeping cross-fiber and compression broadening techniques are particularly helpful for this purpose (Image 3). After our initial work on the gastrocnemius and soleus, we now focused on the deeper muscles. With muscles like the tibialis posterior that are difficult to access, you have to take advantage of alternative methods to effectively treat that area. An excellent way to access the tibialis posterior and other deep compartment muscles is through active engagement techniques. The active engagement techniques for the posterior compartment muscles take advantage of applying indirect pressure to the muscle while it is engaged in an active contraction. Here are a couple of different ways the deep posterior compartment muscles can be addressed. Traditionally, active engagement techniques are performed by applying some type of broadening technique to the muscle during the concentric contraction. However, the posterior compartment muscles are too small and too far around the back of the tibia to apply a broadening technique during the concentric contraction. A good alternative is to use a static compression technique during the active concentric contraction. This technique works well to help reduce chronic tightness or any myofascial trigger points that may exist in the muscle. CLINICAL APPS Sweeping cross-fiber and compression broadening to the superficial posterior compartment. Image courtesy of Whitney Lowe. 3