Muscular strains- not enough treatment techniques!!

[neuromuscular]

I agree with previous posts but you also try trigger point releases with dry needling in the acute stage which can make a huge difference in reducing recovery time.eccentric loading early in the repair stage is essential in conjunction with good biomechanical assessment and appropriate correction.

cheers

The problem with trigger point therapy is that which is the cause and which is the effect.

J Travell did not state this, but just mapped the trigger points.

Postural deviation is helpful in determining the cause /effect.

The latent trigger point is more commonly the problem and not the active trigger point.

Hope you find this helpful.

Best regards,

Neuromuscular

See previous entry.

[physiomitch]

Hi 'neuromuscular'

Thanks for the reply, glad to see we are not all duped by non-evidence based approaches...

I agree with your comments re: evidence for use of myofascial release in treating ankle strains. I think I should quantify this by saying it is not the myofascial release that corrects the ankle strain but the effect of releasing fascial restrictions which cause muscle weakness and stiffness around the ankle. It has been shown that fascia reacts by tightening up when stressed, a natural protective response to injury. We also now that tight fascial sheaths around muscles cause muscles to become weak. This is due to restricting the muscles blood flow and its biodynamics (lack of full range motion).

So the approach to treating an ankle strain is to focus less on the actual injury site (ligaments) and focus on removing any obstacles that can prevent the body repairing the ligaments, ie muscle weakness (including the hip) and fascial tightness of the fascia in the calf/foot.

As for ice, I know we have evidence as to what it does and that is proven, but my quesion has always been has research shown it to speed up recovery from time of injury to full return to activity? That to me is what we should be aiming at, not so much restricting natural reactions to injury, such as inflammation, swelling and pain. Does RICE actually make the body work quicker to repair the damage or does it slow it down? I am not adverse to using ice, usually in 10 second doses, but I feel we need to investigate this further and not be ruled by effects of a treatment, but rather what it does to assist the body to repair itself.

Regarding your ideas on trigger points, this fits perfectly into the fascial module. In my experience, I find that most pain from 'trigger points' is actually in the area which is compensating for a tightness or weakness somewhere else. The general rule of the body is that where there is tightness in fascia there will be weakness in the opposite muscles and vice versa. Example, tight low back fascia = weak abdominals (reciprocol inhibition). So strengthening abdominals is useless without first releasing the lumbar fascia, which will often result in increased abdominal tone anyway. As you know trigger points have been seen to be fascia related not muscle, which is why myofascial release techniques work so well, compared to ischaemic compression and stretch. Muscles do not have a sensory nerve supply. Personally I use a muscle spindle stretch at the end of my treatment to 'stimulate tome', almost like a quick 'kick start' for the muscles as spindles can become too relaxed if the opposite group of muscles' fascia has become too tight.

Thanks for the input again.

Cheers

Physiomitch

[neuromuscular]

I agree that the fascia is a problem in long term pain.

However, I have found that the weak muscle theory is very weak.

Most muscles have been activated by a guarding response which inhibits others and makes them appear weak. I call this a recalbration of the muscle spindle and the golgi tendon organ, although most do not.

For example, in the Trendelenberg test, it is presumed that the gluteals are weak in a positive. However, try this: instead of "strengthening" the supposed weak gluteals try treating the adductor magnus with direct pressure into the muscle fibers at 90 degrees to the muscle fiber. You will see that the gluteals are suddenly very "strong" in the next Trendelenberg test. The hypertonic adductor magnus in a guarding response was inhibiting the gluteals. When one gives exercise to strenghten the supposed weak gluteals, they are giving an exercise that stretchs the adductor magnus. So, even thought they have success in the treatment it is not from the supposed "cure" to strengthen the gluteals.

Muscle problems vs fascia problems is like the difference of what you would prefer to hit in a auto accident. If you had the choice would you rather hit a train, a bus or a micro mini car? Muscles are like hitting a train: fascia is like hitting a car.

In therapy, I have found that if you get the muscular part first, the person returns to anatomical neutral faster or immediately and that pain is reduced the most first. Long term pain is from fascia.

Best regards,

Neuromuscular

[physiomitch]

Hi

It seems we are both in agreement as to the mechanical imbalance, in that where there is weakness there is often opposite muscle weakness (abduction vs adduction), however we are looking at it from 2 different approaches. In your example of the Trendellenberg type weakness, I work with the fascia around the gluts and TFL/ITB, which are often tight, and this restores abduction strength. At the same time I expect to see a release of tension in the adductors as they do not have to over-compensate anymore.

If I look at trigger point therapy from a fascial point of view, I do see correlations, as pressure vertically into a muscle will be affecting the fascial sheath, thus a form of myofascial release is affected. This can have the effect of stimulating reflex loops to opposite muscle groups, thus restoring strength and balance. However, if fascial shortening has taken place in the gluts or the adductors, release is necessary to restore normal ROM and thus strength.

So I have to disagree on one thing, and that is muscles being the 'more important' to treat first, as they depend on fascial integrity for their strength. If the problem is acute and no fascial shortening has occured then your approach will be successful, no doubt, but if fascial sheaths become tight around a muscle, naturally pulling from end to end, the golgi tendon organs will be stretched, hence reciprocol inhibition, but the spindles will be relaxed, thus reducing tone in the short muscle, and this can manifest as weakness on a resistance test, not to mention the blood flow being deminished. In this case release of fasia is vital to restore muscle function.

Similar approach, slightly different roads...nice though to hear someone else thinking functionally, not anatomically.

[neuromuscular]

Hi

It seems we are both in agreement as to the mechanical imbalance, in that where there is weakness there is often opposite muscle weakness (abduction vs adduction), however we are looking at it from 2 different approaches. In your example of the Trendellenberg type weakness, I work with the fascia around the gluts and TFL/ITB, which are often tight, and this restores abduction strength. At the same time I expect to see a release of tension in the adductors as they do not have to over-compensate anymore.

If I look at trigger point therapy from a fascial point of view, I do see correlations, as pressure vertically into a muscle will be affecting the fascial sheath, thus a form of myofascial release is affected. This can have the effect of stimulating reflex loops to opposite muscle groups, thus restoring strength and balance. However, if fascial shortening has taken place in the gluts or the adductors, release is necessary to restore normal ROM and thus strength.

So I have to disagree on one thing, and that is muscles being the 'more important' to treat first, as they depend on fascial integrity for their strength. If the problem is acute and no fascial shortening has occured then your approach will be successful, no doubt, but if fascial sheaths become tight around a muscle, naturally pulling from end to end, the golgi tendon organs will be stretched, hence reciprocol inhibition, but the spindles will be relaxed, thus reducing tone in the short muscle, and this can manifest as weakness on a resistance test, not to mention the blood flow being deminished. In this case release of fasia is vital to restore muscle function.

Similar approach, slightly different roads...nice though to hear someone else thinking functionally, not anatomically.

Dear physiomitch:

I do agree that fascia is a factor that requires therapy. However, in hip pain and low back pain, I have seen no return to anatomical neutral of the innominate bones in the ASIS to ASIS, PSIS to PSIS, ASIS to PSIS (R&L) with hip abduction directly lateral in the coronal plane. After fascia only tretments, the pelvic imbalance remains. Have you tried a four sided assessment with hip abduction pre and post therapy?

I find numerous methods desensitize the area without creating a postural change. What are your findings?

Treating the muscular imbalances always creates a change in the anatomical position of the innominate bones and relief of the pain. Treating fascia after creates a longer term pain reduction.

Hope that this is helpful

My best to you,

Neuromuscular

[physiomitch]

Truth is my approach is a bit more complex than just fascial release. I have found an underlying common denominator in most musculo-skeletal dysfunction and pain and that is the sympathetic nerve cell dysfunction. This dysfunction seems to be a starting point of the body's adaptation to overload or stress, and if this system fails it loses control of the blood flow rate to certain areas of the body resulting in fascial shrinkage, muscle weakness and pain. I usually treat this first to see the effects of restoring function to teh sympathetics, and in most cases (>95%) this restores muscle strength immediately. I then use myofascial release to restore the flexibility, thus giving muscles the 2 main things they need apart from an intact nerve supply, namely good blood flow rate and space in which to operate.

I find this restores muscle balance, pelvic balance and general function in the musculoskeletal system, and because of this pain is relieved. I find there are 2 main types of pain, that from fascial stress due to musculoskeletal dysfunction, and that from poor blood flow control (commonly pain at or after rest, or after too much activity). Pain with movement is more mechanical, thus related more to the myofascial component.

Before I started using myofascial release 16 yrs ago I used to do manual pelvic adjustments which showed similar changes in muscle strength, however it did not last very long, but myofascial release gives a more permanent change in the strength and posture.

In my view if we restore good blood flow rate and fascial integrity, there is very little reason why there should be any pain from a musculoskeletal origin.

[neuromuscular]

Truth is my approach is a bit more complex than just fascial release. I have found an underlying common denominator in most musculo-skeletal dysfunction and pain and that is the sympathetic nerve cell dysfunction. This dysfunction seems to be a starting point of the body's adaptation to overload or stress, and if this system fails it loses control of the blood flow rate to certain areas of the body resulting in fascial shrinkage, muscle weakness and pain. I usually treat this first to see the effects of restoring function to teh sympathetics, and in most cases (>95%) this restores muscle strength immediately. I then use myofascial release to restore the flexibility, thus giving muscles the 2 main things they need apart from an intact nerve supply, namely good blood flow rate and space in which to operate.

I find this restores muscle balance, pelvic balance and general function in the musculoskeletal system, and because of this pain is relieved. I find there are 2 main types of pain, that from fascial stress due to musculoskeletal dysfunction, and that from poor blood flow control (commonly pain at or after rest, or after too much activity). Pain with movement is more mechanical, thus related more to the myofascial component.

Before I started using myofascial release 16 yrs ago I used to do manual pelvic adjustments which showed similar changes in muscle strength, however it did not last very long, but myofascial release gives a more permanent change in the strength and posture.

In my view if we restore good blood flow rate and fascial integrity, there is very little reason why there should be any pain from a musculoskeletal origin.

Dear Physiomitch:

Thank you for your reply.


I have never used the manipulative approach as it would appear to me to create a feedback much like a strain or sprain where the area is at first inhibited and then the prprioceptive sense is fooled to accept an abnormal as normal.
The affect is temporary at best as you menrtion.

I am result driven. I do not use methods taht flatter me as the great healer. If I do not see a change I do not feel that a change has been made.

I have mentioed the assessment that I use as the four sided pelvic bone assessment with hip abduction. Pretherapy the angles are off the normal plane.
Post treatment the angles are in the anatomiclal neutral position. That is my criteria for success. in low back treatment. The other areas such as the ankle are harder to quantify by postural assessment.

I use postural asssessment first and foremost as it is the most objective. If i fool the proprioceptive sense, the muscle strength may appear to be normal until the patient returns to normal activity and then the muscle "strength" may not be so "normal".

I would be most interested in how your therapy corresponds to the comparison using the assessment of the four sided pelvic assessment pre therapy and posttherapy.

The OGI test in Nebraska USA is finding very positive affects of using the assessment. Patients who previously did not respond to any treatment by any discipline are responding to this assessment and the changed therapy resulting.

Thamks again.

My best to you,

Neuromuscular,

[physiomitch]

Hi again

I have never come across the 4 sided pelvic assessment, but I can understand the approach especially in this day and age and the need for objective measures. Personally I trust the muscles themselves for giving me an idea of where things are at physically/posturally. I too do not use manipulation, my treatment for the sympathetics is based on specific application of cold, not as we are taught, based on Frederick Erdman's approach.

I am of the belief that if the muscles are strong, the ROM is normal and equal side to side, and this is backed up by good circulation control, then the body should function pain-free. The great thing about using muscles as a test either through Kinesiology or basic strength tests is the patient is immediately involved and when strength returns or a Kinesiology indicator muscles changes from weak to strong, they can feel something is happening, even though there may not be any change in symptoms initially. I judge improvement by increased strength and flexibility, not symptoms, these will follow basic functional stability.

In essence, as an Acupuncturist/Kinesiology practitionar as well, I am able to improve strength in many ways, including one needle in Pericardium 9 for hip abduction (as an example only..usually 5 elements approach used here), or by stimulating neurovascular or neurolymphatic points for a minute or so. All these can show an improvement in strength, but need to be backed up by blood flow control and soft tissue flexibility. If the pull of muscles is balanced then pelvic posture will be restored, thus I am positive all the angles will be normal, otherwise strength and symptoms will not be restored. Posture follows fascial changes like a shadow, and as fascia is an adaptable tissue and able to shrink, it is the primary suspect in postural changes and thus bony positions.

Out of curiosity, how do you measure the angles of the pelvis?

Regards

[physiomitch]

I take it this is done in supported standing? Do you do actual manual muscle strength tests as well in your assessment?

[neuromuscular]

I take it this is done in supported standing? Do you do actual manual muscle strength tests as well in your assessment?

Dear physiomitch,

The test must be in full support against gravity. The patient must be free standing and have complete control at each progression. The idea is to see how the posture muscles hold against gravity. Each stance must be complete and with the patient in control to his ability.

Most patients will deviate much from anatomical neutral as the foot width stance progresses. Some will appear to come closer to anatomical neutral. However, each will tell you why the patient cannot hold close to anatomical neutral throughout the progression. It will take some time before it falls into place for the practitioner as this is a new direction for them, but it will make sense as it is used.

Unlike the Kendall manual on muscle testing, I have not found muscle testing to be objective. The role of reverse inhibition has not been explored. Although, I have taken seminars on "better" positioning to get the most objective results, I have not found that I can depend on these as an absolute test.

The postural test that I use gives me the most objective information on the patient.

We cannot say that the synergist, antagonist, joint, fascia, etc is not inhibiting the muscle in muscle testing no matter the position or care given. Using an instrument to measure the responses only rules out the practitioner's input, but does not rule out other factors such as reverse inhibition or eccentric contration problems interfering with the muscle testing.

I also do a supine and prone assessment to see if there is a difference in the gravity to non gravity action of the muscles. There often is.

The supine test is of ASIS to ASIS for superior or inferior placement and distance of ASIS to the bench or table or plinth.

The prone test is of the PSIS to PSIS for superior to inferior placement and the distance of the buttocks from the table left compared to right

Hope that this is of benefit to you.

Try these test against your therapy to assess your success in return to anatomical neutral.

My best to you,

Neuromuscular Ed