Foam Rolling Technique

As most of you know, a very important part of our practice is the treatment of soft tissue dysfunction. This may be in the form of a muscle “knot”, chronic scar tissue, or post-surgical stiffness. We have many names ie “the doctors of knotology” and “the Marquis de Sade” to name a few. In spite of the many terms of endearment, at OrthoWell, we get our patients better- Faster! because of our approach. A very important part of your recovery has to do with your home program. Every conditioning program should include stretching, strengthening, cardio, and a close fourth should be self-massage and/or self-mobilization. Many of you have experienced “the twins” (my double tennis ball massager) as well as the foam roller. It is important to address your chronic “knots”, scar tissue, and muscle sensitivities in order to promote optimal tissue dynamics and to prevent future pain syndromes related to poor tissue dynamics.

The following video highlights our foam rolling strategy for your lower extremities. Each muscle group should receive 5-10 passes along the foam roll. The amount of weight you impart upon the roll will be dictated by your tolerance. Yes, this should hurt! Only mild to moderate pain, nothing severe. Use your arms and opposite leg to control the pressure being applied. Try to identify key areas along the way that may need additional passes. Yes, over time, the pain will subside and your pressure will increase. Consistency is the key. Ideally, stretching and self-massage should happen daily. Here is a run down of what is happening in the video.

1. In the first part of the video, I am treating the quadriceps. Longer muscles need more attention. Perform 5-10 passes each at the upper end, middle, and lower end of the muscle.

2. Turn 45 degrees and perform the same treatment at the junction between the quadriceps and iliotibial band(ITB). Pay close attention to the lower end near your patella.

3. Turn another 45 degrees and, in the same manner, treat directly along all three aspects of the ITB.

4. Next, turn over and treat your upper glute area. Cross one leg over the other as shown. The leg that is crossed is the side you are treating. Perform 5-10 passes.

5. Move down to the hamstrings and treat the upper, mid, and lower ends. Place your opposite leg on top of the treatment leg in order to impart more pressure.

6. Next, treat the calf muscle. Place the opposite leg on top for more pressure. Treat the entire length of the calf. You can also perform an up/down ankle movement in order to help glide the stiff tissue while imparting pressure onto the roll.

7. Finally, treat the inner thigh or adductor muscle group. It may be easier to use the 6” roll to treat this area effectively. You can purchase a white 6” roll which is the same material as the 4” or you may purchase the black roll which is firmer than the white.

Keep on rollin’

 

 

Graston Technique and Scar Tissue

The first step in treatment is to identify scar tissue.  Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation.  Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion.  Picture below.

During palpation, fibrosis will feel gritty or knotted.  At OrthoWell/WalkWell, we use instrument assisted soft tissue mobilization (IASTM) and manual scar release techniques to “break up” restrictions.  This deep massage creates a reactive inflammation which “jump starts” healing.  Keep in mind that inflammation can occur without healing, but healing cannot occur without inflammation. During the inflammatory stage, scar tissue can be reabsorbed by the body.  During the fibroblastic phase of healing, the damaged tissue is replaced by new collagen.  This new collagen is reformatted through proper exercise.  This “process” can take 3-6 months in chronic cases.  So what does the research tell us about IASTM?


Instruments of Assisted Soft Tissue Mobilization

Craig Davidson et al in “Morphologic and functional changes in rat Achilles tendon following collagenase and GASTM”, J Am College Sports Med, 1995;27 showed increased fibroblast proliferation in the  IASTM group and stated that “the study suggests that IASTM may promote healing via increased fibroblast recruitment.”

Gale Gehlsen et al in “Fibroblasts responses to variation in soft tissue mobilization pressure”, Med Sci Sports Exer, 1999;31:531-535 showed morphological evidence indicating that “the application of heavy pressure during IASTM promoted more fibroblastic proliferation compared to light or moderate pressure.”

Mary Loghmani et al in a 2006 research project at Indiana University (pending publication) revealed that “ligaments treated with IASTM were found to be 31% stronger and 34% stiffer than untreated ligaments” using Graston Technique instruments.

As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of soft tissue lesions is the proper release of scar tissue.  Rehabilitation is accomplished through the functional integration of deep massage, strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program.  Correcting biomechanical deficiencies with foot orthotics is also a consideration.

Most physical therapists do an adequate job of treating pain.  Acute pain usually resolves with the most innocuous of therapy interventions.  However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner.  At OrthoWell/WalkWell, we do just that!

David Graston’s SASTM technique:

 

Graston Technique demonstration:

 

GRASTON versus Scar Tissue!! Any bets??

The first step in treatment is to identify scar tissue. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. Picture below.

During palpation, fibrosis will feel gritty or knotted. At OrthoWell/WalkWell, we may use Graston’s instrument assisted soft tissue mobilization (IASTM)  to “break up” restrictions. This deep massage creates a reactive inflammation which “jump starts” healing. Keep in mind that inflammation can occur without healing, but healing cannot occur without inflammation. During the inflammatory stage, scar tissue can be reabsorbed by the body. During the fibroblastic or re-growth phase of healing, the damaged tissue is replaced by new collagen. This new collagen is reformatted through proper exercise. This “process” can take 3-6 months in chronic cases. So what does the research tell us about IASTM?


Instruments of Assisted Soft Tissue Mobilization

Craig Davidson et al in “Morphologic and functional changes in rat Achilles tendon following collagenase and GASTM”, J Am College Sports Med, 1995;27 showed increased fibroblast proliferation in the IASTM group and stated that “the study suggests that IASTM may promote healing via increased fibroblast recruitment.”

Gale Gehlsen et al in “Fibroblasts responses to variation in soft tissue mobilization pressure”, Med Sci Sports Exer, 1999;31:531-535 showed morphological evidence indicating that “the application of heavy pressure during IASTM promoted more fibroblastic proliferation compared to light or moderate pressure.”

Mary Loghmani et al in a 2006 research project at Indiana University (pending publication) revealed that “ligaments treated with IASTM were found to be 31% stronger and 34% stiffer than untreated ligaments” using Graston Technique instruments.


As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of soft tissue lesions is the proper release of scar tissue. Rehabilitation is accomplished through the functional integration of deep massage, strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration.

Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!

Graston Technique:

The Missing Link – SCAR TISSUE

 

Scar Tissue

All physical therapy is NOT created equal. As a physical therapist with 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston’s New IASTM and Active Release Technique for more information.

As a result of 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!