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FRICTION THERAPY AND MASSAGE Before beginning treatment, you must fi rst locate the precise area of injury. Often, the client will be able to point right to the injured area, because there is little to no referred pain in the lower leg or foot. When the muscle is strained, the person will experience pain at the medial and posterior segments of the lower leg. If you suspect a tendon injury but the person has diffi culty pinpointing the exact location, use the palpation test described above. Often this injury occurs posterior to the medial malleolus, but it can affect any segment of the tendon. If the muscle is injured, no friction therapy is required. Simply perform deep massage on the calf and give the client the exercises described below. If the tendon is injured, combine the massage and exercises with the following friction protocol. Location and Friction of the Posterior Tibialis Tendon Sit or stand at the client's feet. Hold the foot at the medial arch, place the leg in lateral rotation, and position your fi ngers at the site of the injury (usually just above the medial malleolus). Place your thumb on the lateral side of the lower leg to stabilize your hand, and then use your middle and index fi ngers to apply a squeezing force. Friction in one direction only, moving your whole arm and wrist (not just your fi ngers) and using your thumb as a fulcrum (Image 3). Before you begin the friction treatment, have the client move the foot medially for a moment, as he or she did in the test, to confi rm that you're in the right spot. If the person complains of a sharp, twinging type of pain while you're working, that means you're hitting a nerve that passes posterior to the medial ankle; try doing the stroke in the opposite direction. If you can't fi gure out how to prevent this from happening, discontinue the friction treatment or get someone more skilled at this kind of work to help you. This friction technique breaks up adhesive scar tissue and stimulates the healing process, while preventing unwanted scar tissue from re-forming. Since scar tissue begins to form within minutes of an injury, prophylactic treatment can theoretically begin the same day the injury occurs. However, I generally recommend waiting at least four or fi ve days, unless the therapist is very experienced and knowledgeable in treating these types of injuries. In the fi rst few days, all that is needed to prevent adhesions are two or three well-placed friction strokes; frictioning too harshly or for too long can interfere with the normal healing process. In most cases, you won't see a person for at least several weeks after an injury has occurred, so this is not usually a concern. Include 10–12 minutes of friction therapy in each treatment session. I suggest doing 5–6 minutes of friction, taking a brief break, and then repeating the procedure. Go gently at fi rst, only increasing your pressure slightly if discomfort is minimal. Following the friction therapy, massage the entire leg and foot—as well as the other leg, which has probably been overworked. The client should receive treatment twice a week for 4–6 weeks if the injury is mild, and 8–12 weeks if the injury is severe. As the injury heals, reduce the visits to once a week, then twice a month. When the client no longer experiences pain during daily activities, the tendon is not overly sensitive to the touch, and the injury verifi cation test is negative, treatment can be discontinued. For most posterior tibialis tendon injuries, this combination of deep massage and friction therapy—supplemented by the exercises given below—is successful in bringing about a full recovery. ORTHOTICS For any client who has excessively pronated feet, orthotic devices are a crucial component of treatment. Advise the person to see a sports podiatrist and inquire about orthotics to protect the posterior tibialis muscle and tendon from further strain. EXERCISES The fi rst exercise described here strengthens the posterior tibialis, the second one works on balancing the use of the posterior tibialis and peroneus muscles, and the third one builds strength throughout the calf muscles. These should be started in the second week of treatment and only done if they do not cause pain. Typically, they're done once per day, but you might have enthusiastic clients increase to twice per day after a week or so. visit massageandbodywork.com to access your digital magazine 95