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CONNECT WITH BEN BENJAMIN ON HIS DR. BEN FACEBOOK GROUP PAGE AND ON MASSAGEPROFESSIONALS.COM. injured, the pain is felt in the anterior lower leg. A tendon injury is generally experienced as a pain or ache on top of the foot, just anterior to the ankle, but may also be felt in the tendon when it crosses in front of the ankle joint. Individuals whose feet are excessively pronated, with the arches falling in medially, are more likely to develop this injury. The anterior tibialis tendon works to hold up the arch, so when the arch pronates, it twists the tendon and places additional strain on it. Another predisposing factor is severe tension in the lower leg muscles, which makes those muscles vulnerable to early fatigue and subjects the tendon to unnecessary stress. Additional contributing factors may include ineffective warming up and running or jumping on concrete surfaces. INJURY VERIFICATION RESISTED DORSIFLEXION Ask the client to dorsifl ex the foot by saying, "Bring your toes toward your head and hold them there." Then, place one hand under the client's heel for support and the other hand on the forefoot just proximal to the toes. Ask the client to hold the foot in that position and not let you move it. Apply great force, trying to pull the foot into plantar fl exion (Image 2). HEEL WALKING From a standing position, have the client lift the balls of the feet off the fl oor, balancing on the heels for a moment and taking a few steps. This can be done either barefoot or in shoes, whichever is more comfortable. One or both of these tests should reproduce or increase the person's pain. To locate the exact area of injury, palpate various places along the tendon and muscle while the client holds the foot in dorsifl exion. Photos by Melinda Bruno. Friction of the anterior Tibialis Tendon Sit at the base of the table facing the affected foot. While stabilizing the foot with one hand, place the tip of your thumb or index fi nger on one edge of the anterior tibialis tendon. Apply a posterior pressure and snap through the tendon in a medial- to-lateral direction (Image 3). Do this for a few minutes, then change positions so that you move through the tendon in the opposite direction. After using friction therapy to break down some of the scar tissue, massage the foot, calf, and shin to enhance circulation into the tendon area. When the injury is in the muscle rather than the tendon, healing often takes longer, because many more fi bers are damaged. Instead of friction, perform cross-fi ber massage (using a lubricant) on the injured structure. Together with the therapeutic exercises described on page 107, this treatment is usually effective within six to eight weeks. TREATMENT CHOICES SELF-TREATMENT This injury often takes a long time to heal on its own because the anterior tibialis muscle-tendon unit is used to walk every day, and thus is constantly irritated. Rest usually helps over four to six weeks, but if the feet are chronically pronated, the injury is likely to recur. The person should not take long walks, hikes, or runs if those activities cause pain. If the pain is severe or persists for more than two weeks, it's important to seek treatment. FRICTION THERAPY AND MASSAGE Friction treatment usually gives relief rather quickly, because the tendon is easily accessible. Typically only four or fi ve treatments are required. ORTHOTICS Clients with chronic anterior tibialis strain related to excessive pronation can benefi t from using orthotic devices—custom molded arch supports made of leather, plastic, hard rubber, or even Styrofoam inserted into the shoe. They help to improve foot alignment so that the body's weight is distributed evenly throughout the foot. For the best results, have the person see a sports podiatrist for custom orthotics rather than buying something at the drugstore. If the strain is rather mild, removing the pressure with the orthotic may be curative as well as preventive. EXERCISES Begin teaching these exercises in the second week of treatment, but only if they can be done without pain. After starting the person off connect with your colleagues on massageprofessionals.com 105