Terra rosa issue 18

Terra Rosa

E-magazine

www.terrarosa.com.au Open information for Bodyworkers No. 18, May 2016

Photo by Patty Kousaleos

Iliotibial band syndrome, Isometrics for tendinopathy, Trochanteric Bursitis, Overpronation, Peak performance with CORE Myofascial Therapy, Interview with Dr. Jean-Claude Guimberteau

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Clinical internship program for advanced certification training in CORE Sports & Performance Bodywork at XPE Sports in Boca Raton, FL. See page 54. Photos by Patty Kousaleos

Terra Rosa E-magazine, Issue No. 18, May 2016. www.terrarosa.com.au

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ontents Photo by Patty Kousaleos

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Iliotibial Band Sydnrome

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Be flexible in our theories—Whitney Lowe

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Our methods still get results; it’s our explanations that need updating — Til Luchau

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Extrapolating results from research to hands-on manual therapy should be done with caution—Joe Muscolino

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Empirical evidence is the reality—Robert Baker

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Don’t let one study deter you from work on this area—Art Riggs

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More on ITB research

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Isometrics for Tendon Pain – Practical implementation and considerations — Ebonie Rio, Craig Purdam, Sean Docking & Jill Cook

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An interview with Dr. Jean-Claude Guimberteau

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How I treat Trochanteric Bursitis — Tom Ockler, PT

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Overpronation— Joe Muscolino

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Overselling Overpronation— Jeff Tan

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The Hand-L Massage Tool: From Dream to Reality — Bob McAtee, LMT

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A working experience with CORE Myofascial Therapy — Taso Lambridis, MSc

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Research Highlights

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6 Questions to David Steven

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6 Questions to Bob McAtee

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Iliotibial Band Syndrome There is a view that ITB cannot be stretched and current treatment strategies are outdated, we asked experts on their opinions and treatment options.

Contributions from: Whitney Lowe, Joe Muscolino, Til Luchau, Robert Baker & Art Riggs

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Photo by Patty Kousaleos

Iliotibial Band Syndrome (ITBS) is a common overuse injury common with runners and cyclists, especially when their training levels have recently intensified. It was reported as the second most common running injury and most common reason for lateral knee pain in runners. ITBS can also be associated with court sports, strength training (especially from weight-bearing squats), and even pregnancy. Other contributing factors can be leg length differences. ITBS produces burning pain on the lateral aspect of the knee, and exacerbated by running, especially downhill.

2007, they stressed that there are several basic anatomy of the ITB that had been overlooked:

It is conventionally believed that the pain is caused by the repetitive movement of the “cabled” iliotibial band (ITB) sliding back and forth across the outer surface of the lateral epicondyle. This mainly occurs in 25° to 30° of knee flexion, irritating the ITB or its associated bursa during repetitive activities such as running. Conventional treatment often locates the sore spots around the condyle and performs crossfibre friction with the aim to break down the adhesions, which will enhance fibroblast generation and encourage tissue remodelling.

As ITB is a whole structure, the authors believed that ITB cannot create frictional forces by sliding back and forth over the epicondyle during flexion and extension of the knee. This “illusion of motion” was created by the reciprocal tightening of the anterior and posterior portions of the ITB during knee flexion-extension. They proposed that ITBS is caused by increased compression of the highly vascularized and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. The pain can be related to a chronic increased tension of the ITB caused by increased tension of the TFL or gluteus maximus muscles.

Fairclough et al. questioned this notion that the ITB moves with respect to the lateral epicondyle during knee flexion-extension. In a study published in the Journal of Science and Medicine in Sport in

(1) The ITB is not a discrete structure but a thickened part of the fascia lata which envelopes the entire thigh; (2) It is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands which are not pathological adhesions; and a bursa is rarely present but can be mistaken for the lateral recess of the knee.

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The authors concluded that “ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.”

Another study by Falvey et al.

(2012) conducted an anatomical examination of the ITB on cadavers. They tested stretching routines for ITB, and measuring the actual lengthening of the ITB by implanting strain gauges in the cadavers’ ITB. They concluded

that ITB is very resistant to stretch since it lengthened less than 0.2 percent with a maximum voluntary contraction. Thus, they challenged the idea of stretching the ITB as a treatment for ITBS. They suggested treatment of ITBS should treat the muscular components of ITB and TFL complex.

Many sceptics and internet gurus hailed this study as the definite, claimed that “IT Band Stretching Does Not Work”, “Stop abusing your IT band”, “You can’t stretch the ITB”, “It can not lengthen and it is NOT tight”, “there is no scientific or anatomical reason to believe that any kind of IT band stretch is even possible, let alone an effective treatment”

The conventional view of the iliotibial band friction syndrome. (Illustration based on: Nicholas & Hershman. The Spine and Extremity in Sports Medicine. Mosby, 1995.)

We asked experienced teachers and manual therapists on the implications of these studies, and treatment strategies for ITBS.

References Falvey, E. C., R. A. Clark, A. Franklyn‐ Miller, A. L. Bryant, C. Briggs, and P. R. McCrory. "Iliotibial band syndrome: an examination of the evidence behind a number of treatment options." Scandinavian Journal of Medicine & Science in Sports 20, 4 (2010): 580-587.

A diagram of compartment-like space around the ITB. Based on Muhle et al.

(Radiology, July 1999).

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Fairclough, John, Koji Hayashi, Hechmi Toumi, Kathleen Lyons, Graeme Bydder, Nicola Phillips, Thomas M. Best, and Mike Benjamin. "Is iliotibial band syndrome really a friction syndrome?." Journal of Science and Medicine in Sport 10, 2 (2007): 74-76.

ITB: Be flexible in our theories—Whitney Lowe One of the key hallmarks of practice in musculoskeletal healthcare is the necessity of being flexible in our theories. We must admit that our understanding of biomechanics and pathology may change as research emerges. This concept has been illustrated very well with emerging research about the structure and function of the iliotibial band.

It has become quite popular to treat the iliotibial band with all sorts of the pressure applications, tools, or the latest craze which appears to be foam rolling of the iliotibial band. These concepts have all been built upon the premise of tightness in the iliotibial band contributing to knee or hip pain. Unfortunately, research has demonstrated that these treatments are based on a flawed model of iliotibial band function and pathology.

The most common error that seems to be continually perpetuated by many in the massage and manual therapy communities is the idea of tightness in the iliotibial band which is relieved by extensive pressure applications. These soft-tissue treatments run the gamut from small focused stripping techniques with a thumb, elbow, or pressure tool, to the broad pressure applications applied during foam rolling. Yet in all of these approaches the idea is that deep pressure applied to the iliotibial band will help relax tightness in the iliotibial band, reduce pain, and improve function.

Yet this philosophy ignores key components of anatomy and biomechanics. The iliotibial band functions predominantly as a tendon. Also, the connective tissue that composes this dense band, has very little elasticity. Consequently, the iliotibial band is not designed to stretch and elongate like many people propose. Because the iliotibial band acts as the tendon for two primary muscles, the gluteus maximus and tensor fasciae latae, its primary function is to transmit the tensile forces generated by those muscles. Attempting to get the iliotibial band to feel

loose like muscle tissue is like trying to get the patellar tendon to feel loose like the muscle tissue comprising the quadriceps or hamstring muscles.

Recent biomechanical studies such as the one by Fairclough have also shed new light on pathological conditions which have formerly been blamed on the iliotibial band. For many years the orthopaedic literature has suggested that iliotibial band friction syndrome is a pathology caused by repeated rubbing of the iliotibial band across the lateral femoral condyle during flexion and extension of the knee.

These recent biomechanical studies have shown that the iliotibial band is not as mobile across the epicondyle as once described. The result suggests that the lateral knee pain associated with iliotibial band tightness may have more to do with other motions such as internal tibial rotation than the once described friction from rubbing back and forth across the condyles during flexion and extension.

Our fields of massage and manual therapy are constantly subjected to new fad treatments for addressing a plethora of musculoskeletal pain complaints.

In many of these cases there is some initial excitement and success reported with these treatments, which may often be attributed to the treatment as a novel experience and early placebo effects. When time has passed and demonstrated that anatomical or biomechanical models may be flawed, it’s time to re-evaluate and possibly abandon them in favour of more accurate explanations for what we are attempting to do.

Whitney Lowe has been a massage educator for over 20 years. He researches and authors articles on pain and injury assessment techniques in numerous publications.. See his website for more information www.omeri.com

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Our methods still get results; it’s our explanations that need updating —Til Luchau Thanks for the opportunity to comment on the ITB studies and controversy. I’ve been watching this debate from a distance since the shrill social media posts about it began to appear a few years ago, and now that you’ve called me out, I enter the fray with a bit of caution, since I am a practitioner and trainer of practitioners, and not a researcher or academic per se. But here’s what stands out to me in reading over the studies, posts, and comments: 1. It’s interesting (though not exactly revolutionary) that the Falvey study described the ITB as a thickening of the leg’s surrounding fascia latae, "rather than a discrete entity.” (Of course fascial anatomists have been saying this about all fascial structures for quite some time now, but great to see it in a non-manual therapy study).

Figure 1. Cross section of the human leg (from Gray’s Anat2. Similarly, it’s interesting that the ITB was found to attach to the femur along its entire length. This is omy). different from the impression gained from convening that the ITB was found to be impossible to tional 2-dimensional anatomy illustrations, but is lengthen much by stretching. The ITB is a tendon, consistent with what can be seen in 3D imagery, its thus its function is probably to transmit or to such as the Visible Human Project’s data set (Figure 2, used in our trainings as well as in Tom Myers’ and store tension, rather than modulate tension by lengthening as a muscle belly would. (Interestingly, others), and with cross-sectional images going back here is a small study that suggests foam rolling deto Grey’s 1918 anatomy atlas (Figure 1). In crosscreases jump performance, at least in the short section, the ITB is barely visible, and is seen as the term: http://digitalcommons.sacredheart.edu/ surfacing of a deep inter muscular septum, rather masterstheses/2/, though it does conclude that ITB than a discreet band on the side of the leg. rolling can be beneficial in injury recovery.)

3. It’s fascinating that no ITB bursas were found in 5. It makes sense to me that rolling would not any of the cadaveric specimen. If this holds true for “stretch” the ITB (even if it was stretchable), or dif‐ living bodies (and in those younger than the study’s ferentiate it from its surrounding tissues (which is average age of 76 years old), then it suggests that one of the things we think we’re doing in our Ad‐ explaining lateral knee pain as bursal irritation vanced Myofascial Techniques approach). Greg Lehneeds re-thinking. man (who’s iconoclastic perspectives I do enjoy, 4. Like Joe Muscolino says in his comments, I’m not even though he probably throws a lot of babies out uncertain if results from tissue-stretching and strain with his bathwater) says about this issue "I can’t experiments on elderly cadavers can be directly apfillet a chicken breast with a rolling pin.” In other plied to living bodies of all ages. But it is not surpris- words, mashing the ITB may or may not have some

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Figure 2. Cross-section of the human leg, mid thigh, arrows indicate the location of the ITB which extends deep within the leg via an intermuscular septum that attaches it to the femur along its entire length. Image from the Visible Human Project.

benefits, but stretching or separating it from its surroundings probably aren’t the explanations for why ITB rolling helps (or hurts).

6. This issue aside, in my reading over the abstract and the debates, I don’t find any logic that supports NOT rolling the ITB, unless you’re 1) overdoing it, or 2) doing it right before a performance event involving jumping. In fact, many authors sceptical of the stretching theory allow that there may be addition benefits not explained by stretching. So instead of one of the studies author’s blog post title, "Iliotibial Band: Please do not use a foam roller! , a more logical conclusion might be “Rolling (probably) does NOT stretch the ITB, but don’t over-do it!”

7. In my hands-on practice, I don’t feel much if any stretch when I work with the ITB, though I often think I feel a change in ITB tissue resilience, density, and differentiation. And of course, clients report a change in movement, lateral leg proprioception, and pain as a result of hands- on work, and often, from rolling their ITB’s themselves. There are several possible explanations for what I feel, and for the improvements my clients report, with influences on the nervous system being the primary suspects, and

any actual change in the tissues’ physical properties being secondary.

8. After reading the different views on ITB work, I went and wrote more about my own views as an article for the May-June 2016 issue of the Massage & Bodywork magazine here. (See also the video here https://youtu.be/wYQTcRRugBE) So in conclusion, here’s more evidence to suggest that our tissue-based models of manual therapy’s effects might be less accurate than we thought. But, that doesn’t mean that the old ways don’t get re‐ sults; it just means we need to stay open-minded about our explanations about how they do their good. And once we get clearer about the new models, they’ll doubtless inspire new ways of working that we might not have imagined under the old models.

Til Luchau, Advanced-Trainings.com, is a Certified Advanced Rolfer and the originator of the Advanced Myofascial Techniques series.

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ITB: Extrapolating results from research to hands-on manual therapy should be done with caution—Joe Muscolino I always enjoy research and the conclusions that are reached from the studies, but extrapolating to hands -on manual therapy should be done with caution. As I read the Falvey et al.’s study, it purports to show that: 1. The ITB has little or no ability to stretch, and 2. there is no bursa located between the lateral femoral condyle and the ITB. Therefore, it is unlikely that an ITB friction syndrome exists; and that trying to stretch the ITB, specifically by foam rolling, is not only not a valuable clinical manual/movement therapy technique, but a deleterious one.

My specialty is more macro-kinesiology than microkinesiology as discussed here. But here are my general thoughts and concerns regarding the study's findings and conclusions: 1. The tissue used had an age of 76 +/- 10 years.

This means that all subjects were elderly, the tissue was not representative of younger or even middleaged individuals. Soft tissues in elderly people tend to be less plastic and elastic.

2. Perhaps the presence or lack thereof of a bursa may be influenced by the age of the cadaver subjects.

3. Beyond all this, I never like to make conclusions based on research alone. I love research, but it should not allow us to ignore well-known principles of anatomy/physiology/kinesiology/histology. To wit, all soft tissue is to some degree elastic and plastic. Fascia is more so plastic than elastic, meaning it can be deformed, meaning it can adapt to forces placed upon it. Indeed, the principle of “creep” states that soft tissue is deformable when a sustained force is placed upon it. To state that the ITB cannot be stretched at all is to throw this 8 Terra Rosa E-mag

well-accepted principle away. Certainly, much of the purpose of dense fibrous fascial tissue such as tendons and ligaments (and the ITB is effectively a tendon for the TFL and gluteus maximus) is to have great tensile strength, meaning that it does resist stretch. Otherwise, tendons would stretch every time that a muscle contracted, meaning that the muscle’s contraction force would never be exerted on its attachments. But, having said this, even dense fascial tissue must be somewhat plastic and therefore deformable/stretchable.

4. Given that all soft tissue is somewhat amendable to manual therapy, foam rolling, or massage for that matter, should be somewhat effective. However, given the dense nature of the ITB, I would believe that the manual therapy would have to be performed in a very disciplined manner over a long period of time (months or years) to be effective.

5. In some ways, the conclusion of this study reminds me of the controversy over stretching in general. There are still many people out there who claim in some manner that stretching does not work. Yet, every study I have read shows that IF stretching is done in a disciplined manner over a long period of time, it is effective at increasing flexibility. If the act of placing a tensile (stretching) force can have absolutely no effect upon mechanically deforming fascial soft tissue, then it would seem that we are doomed to becoming ever increasingly tighter and rigid as we age. In a larger picture, this makes no sense to me. I cannot see how movement, whether it is formal stretching or non-formal stretching that occurs as a result of the normal movement of an active lifestyle can have no effect on fascial tissue. Fascial tissue is a mechanical structure that should be able to respond to mechanical forces. To ignore this is to ignore the entire realm of biomechanics.

6. I am actually the last person who should be countering this article's principle tenet because I believe that ITB syndrome does not occur anywhere near as often as it is purported to exist. When ITB friction syndrome does exist, it should be located directly at the lateral femoral condyle (or perhaps at the greater trochanter), but not anywhere along the middle of the ITB, as it is so often claimed to be present. In my opinion, the vast majority of pain anywhere along the ITB (other than the lateral femoral condyle or the greater trochanter) that is blamed on the ITB is actually due to tightness in the underlying vastus lateralis or vastus intermedius. And if this is true, then I would find that foam rolling (or massage) would compress the vastus musculature, which would be a good thing. After all, massage/ manual therapy does work the vast majority of the time by compressing soft tissue. So to claim that foam rolling is deleterious is to effectively negate the entire field of manual therapy. (One can think of the wonderful Gil Hedley “Fuzz Speech� in which he describes the benefit of movement and manual therapy toward decreasing the build-up of fascial tis-

sue.) I realize that the author of the study might not intend to make this claim, but it seems the inescapable conclusion of claiming that pressure from foam rolling should be avoided (unless he is simply ignoring the possible role of the underlying vastus lateralis and vastus intermedius tissue).

All in all, I find that using the results of this study as a basis for the conclusions that 1) ITB friction syndrome does not exist, and 2) manual compression therapy (read: foam rolling) is absolutely ineffective, or worse, deleterious, would be an unsubstantiated reach.

Joseph E. Muscolino, DC, is a chiropractor in private practice in Stamford, CT who employs extensive soft tissue manipulation in his practice. He has been a massage educator for more than 25 years . He is the author of multiple textbooks including The Muscle and Bone Palpation Manual, and the author of multiple DVDs on Manual Therapy. His website is www.learnmuscles.com

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ITB: Empirical evidence is the reality—Robert Baker

First, I want to say – great questions and comments.

It really is confusing when you have such well-done studies like Falvey et al. that present good information that the ITB stretches minimally in cadavers.

My response is that the clinician gets to choose what works and what does not work. The empirical evidence is the reality. If you use a foam roller and use soft tissue techniques, both the patient and you will know what works. Perhaps the first challenge is helping clients discriminate change in the short and medium term, with a long term strategy. Both the foam roller and hands on techniques will likely move Substance P and other neuro-modulators so a short term pain reduction may be present. Now if pain is a factor in increased tone in soft tissue, then perhaps the overall tone of the entire region may reduce. It may also be true that kinematics improve, and muscle activation changes as pain is reduced.

So, the treatment session includes questions about pain reduction, and perhaps observations of gait, step down at 6 inches (15 cm) and maybe other functional tasks. So this clinical assessment of pain and function and duration of change are key areas to understand empirical outcome.

From the research perspective, there is evidence that ITB length does occur with stretching1.

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I have never seen a research project that tested foam roller. However the physiological concept is moving neuro-modulators, and traditional tack and stretch soft tissue methods that we use with our hands and instruments. In the literature, I think expert opinion favours hands-on techniques2. Conceptually, one soft tissue deficit is the bow string effect of the vastus lateral and biceps femoris that I referenced in my review paper. In this case you are trying to normalize the interface between the adjacent soft tissues to reduce that stress among those structures. Another conceptual approach is to look at the overall tone of the soft tissue including the gluteus maximus and TFL to ITB connects. This is based in part on the recent work of Carolyn Eng and colleagues3 looking at the ITB as an energy absorbing structure in swing phase and delivers energy back in stance phase. So in effect, you are normalizing the tone of the ITB as a musculoskeletal structure interacting with the biceps femoris, vastus lateralis, and perhaps other muscles that affect running stride.

The point that I am suggesting is that the ITB functions as more than a physical constraint to the lateral knee and femur. It likely has a proprioceptive role, and may even contribute energy to help running economy. The role of soft tissue mobilization may be to promote better tone among the related

muscles, and reduce pain caused by neuromodulators, trigger points and perhaps adhesions to nearby muscles. If you are looking at improved kinematics by better muscle performance, then the issue of a length change in the ITB is more an academic debate than a primary focus. The soft tissue work readies the muscles to work within their capacity in a pain reduced and overall healthier environment.

Muscle contractions and joint kinematics are the factors to treat. So your body work is trying to assist in muscle performance: well timed, appropriate duration and well balanced. The soft tissue work aims at normalizing muscle tone to improve muscle performance: eccentric and isometric muscle activation from lumbar core through the hip. Reducing pain, trigger points, tension, all normalize muscle tone and muscle readiness. Promoting the lumbar core length tension relationships may be a factor as well, but this is not fully researched.

Your empirical assessment should consider more than simply pain or ITB length, as an improvement is better lowering of the body with fewer trunk, pelvic and knee deviations. Unfortunately, the root factor may be non-visible – strain rate issues. So we have to use kinematic and muscle activation to gauge strain rate. Hamill et al. 4 found significant strain rate issues but not significant strain issues. So you can have a kinetic factor (strain rate) without necessarily a change in length factor. So the question of whether or not the ITB lengthens is not the only consideration, and may be a secondary consideration.

I will close by suggesting that a person cannot be at their best if stressed and irritated, and pulled and pushed while trying to perform. The same is likely true for the ITB. My suggestion is that the ITB works with muscles that cannot perform well in a painful, irritated, push and pull environments. Our techniques should aim to create relaxed muscle tone and hospitable environments where muscle performance is easier for the entire run and entire day.

The foam roller can be gentle or aggressive, so the actual method for the foam roller is based on your goal. If you simply want to move neuromodulators and ease tone, tweak that method so the ITB is nurtured at its own pace. If you want to separate adhesions between neighbouring muscles, perhaps you modify the technique to stretch and isolate those structures as appropriate to any other stretching technique. Creative use of therapeutic balls may be even better. Your clinical empirical evidence seems appropriate to use when assessing these approaches.

References 1. Fredericson M, White JJ, Macmahon JM, et al.

Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil 2002;5:589-92.

2. Fredericson M, Guillet M, Debenedictis L. Innovative solutions for iliotibial band syndrome. Phys Sports Med 2000;2:53-68. doi: 10.3810/ psm.2000.02.693.

3. Eng CM, Arnold AS, Lieberman DE, et al. The capacity of the human iliotibial band to store elastic energy during running. J Biomech 2015;12:3341-8. doi: 10.1016/j.jbiomech.2015.06.017.

4. Hamill J, Miller R, Noehren B, et al. A prospective study of iliotibial band strain in runners. Clin Biomech (Bristol, Avon) 2008;8:1018-25.

Robert Baker is a Doctoral Candidate in Orthopedic and Sports Science at Rocky Mountain University of Health Professions, Provo, UT. His dissertation is on: Comparison of hip muscle electromyography and 3D kinematics in runners with iliotibial band syndrome. He is the President of Emeryville Sports Physical Therapy in Emeryville, CA. He specialised in sports and orthopedic practice with a blended manual therapy and exercise approach.

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ITB: Don’t let one study deter you from work on this area — Art Riggs What an interesting subject! I appreciate and agree with most all the comments of your experts, but after reinforcing some of their statements, I’d like to take a more informal approach to some of the broader issues that we therapists must deal with in interpreting and implementing research studies into our practices and offer a few strategies for work.

Of course I agree with the comments questioning the validity of conclusions about the stretching ability of the ITB from embalmed cadaver studies, and that even if it does not stretch appreciably, that benefits from manual therapy to the ITB can still be achieved and may be due to many other factors such as neuromodulators, trigger points, or release of adhesions. I particularly liked Joe Muscolino’s caveat against extrapolating manual therapy strategies from isolated studies, along with his pointing out that fibrous tissue has different qualities besides just ability to stretch. I’ll add my skepticism of jumping to conclusions from purported “evidencebased” research implying that manual therapy to the band is ineffective and that treating ITBS, “…can only (my emphasis) be properly achieved when the biomechanics of hip muscle function are properly addressed.” Such exclusionary and simplistic implications that stretching and manual work on the ITB is not productive would short-change creative analysis and treatment of a complex situation that our clients desire. I would also suggest a more complex “chicken/egg” feedback loop, where the increased tension and especially pain of ITBS can cause dysfunction of muscles and joints rather than just being a result of their dysfunction.

The narrow conclusions and implications of treatment of the article remind me of other controlled cadaver studies stating that the SI joint is immovable, and quibbling over distinctions between “true” sciatica and apparent “false” sciatica that seems to 12 Terra Rosa E-mag

discount overlap in symptoms and effective treatment.

Of necessity, careful evidence-based research must isolate factors, both of anatomy, symptoms, and treatments. But inference from the study that defines and limits ITBS symptoms as lateral knee pain and implies that since the ITB can’t be stretched, attempts to lengthen are useless, is an example of the pitfalls of improper inference from isolated facts, especially in brief summaries or abstracts.

Abstracts and capsulized summaries often neglect many important descriptions of the methods and conclusions of the studies. A famous comic quipped, “I used speed-reading for Tolstoy’s War and Peace and it only took 45 minutes!!!.....It was about Russia.” More studied reading of the studies and com‐ ments from other researchers exemplify the importance of more careful reading and consideration of experiments and data. As a brief example, the measure of stretch was performed only with tension devices placed 8 cm proximal to the lateral condyle of the knee—questionably an accurate measure of the complex activity of movement of the ITB during activity.

What is the ITB? It is valuable that the authors point out that it is not a discrete anatomical entity but a thickening of the iliotibial tract or fascia latae. So extrapolating causes and treatment from isolated measurement of the ITB seems “a stretch” of throw‐ ing the baby out with the bathwater. ITBS would seem to be much broader in scope and this exemplifies the importance of semantics when anatomy makes its way into everyday speech by laymen. We see this in many other popularizations and simplifications of anatomy. For many people the “glutes” seem only to refer to gluteus maximus rather than the complicated weave of all the posterior pelvic muscles. To the public, the term “abs” refer only to

rectus abdominus rather than the complex relationship between the internal and external obliques, and transversus abdominus, as well as deeper abdominal muscles.

Attempting to isolate the ITB from the more accurate complex of the iliotibial tract and muscular and fascial connections that go both distal to the knee and ascend past the pelvis seems misleading. I think the more functional term “lateral line” (Figure 1) used Ida Rolf, Tom Myers, James Earls and many other structural integrators is much more useful and helpful for planning strategy, and henceforth I will speak to the issues of the term “ITB” with this broader definition.

Pain along the lateral line also seems much more extensive than just lateral knee pain caused from running and other athletic endeavours mentioned in the article; albeit the information that a bursa often does not even exist was very interesting. Many people, including non-athletes report considerable pain on the entire length of the lateral line. I would suggest that a tight and misaligned lateral line may be associated as both a cause and effect of strain patterns descending to foot balance and plantar fasciitis, and ascending upwards to hip and low back pain and stress patterns.

Also, although the lateral line does indeed act like a tendon in contraction of the TFL and gluteus maximus, it is not a tendon and has different cellular composition with properties of collagen and fascia with a capacity to alter its texture in response to manual therapy. Its role is not simply to exert force on the knee joint like a Newtonian physics pulley. In many ways it acts like a postural muscle to enable standing without muscular contraction, providing lateral stability, and has the important role of dissipating and distributing shock from foot plant.

When stress is applied to the lateral line it actually recoils like a spring to augment muscular contraction from above and increase spring in walking and jumping.

Figure 1. The Lateral line.

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Moving Beyond the Study to Applications Since ITBS is so common, I’d like to move beyond the “science” of an isolated study to discuss some issues for treatment. Let’s face it… it is very com‐ mon for clients to come to us seeking manual work with complaints about pain in the lateral line and reporting benefit from manual therapy that go well beyond what would be expected from a placebo effect. We need to be able to work with this issue with understanding and skill.

Alignment of stress through joints and tissue by minimizing torsional strain is at least as important as simple stretching. Effective therapy should consider global issues of joints, fascia, transmission of shock, and the differences in the structure of individuals. A good structural integration approach should consider among others: varus/valgus knee patterns, internal/external femur rotation, anterior/posterior pelvic tilt and stress from factors in feet in pronation/supination and inversion/ eversion.

Addressing ITBS causes and treatments Manual therapy along the entire lateral line in combination with frequent and consistent home programs is an excellent plan, but it is crucial to recognize that alignment of torsional forces is equally important. A tight and painful lateral line can be reacting to very different body structures and activities since tissue and structure thicken according to strain patterns. Assessment of these patterns is crucial for treatment instead of one-size-fits-all unimaginative strokes.

Shock transmission: A varus (bowlegged) knee and a high arched foot in impact related activities will send shock up the lateral aspect of the leg causing thickening of the entire area including vastus lateralus. Working with the feet for more balanced foot plant by mobilizing the lateral and medial arches to dissipate shock is often helpful along with attention to the adductors and medial leg for lateral/medial leg balance.

Strain and overwork of the lateral leg due to valgus knees (knock knees) or over-pronation presents a 14 Terra Rosa E-mag

different problem. This is often a hyper-mobility issue, and soft tissue work would be considerably different from the previous example. The lateral compartments may be compensating in a productive attempt to provide stability, so stretching the ITB may be counter-productive. This is not to imply that thoughtful work on the area should be skipped, but the goals would be to increase circulation, free adhesions, work with trigger points and to work with alignment of the knee and hip. Rather than working to lengthen the ITB, cross-fibre work to break down adhesions and promote tissue health and decrease inflammation would be more effective.

Proximal strain patterns: As the authors note, strain on the ITB is often created from above the knee.

Working with gluteus and TFL as described later can be very beneficial. In addition to lengthening and softening these tight muscles, enabling them to glide over deeper tissues by freeing their anterior and posterior borders with precise compartment separation strokes so they may exert force in a direct line depending upon hip flexion or extension.

Visualize rolling the muscles from side to side in different positions of hip flexion, paying attention to any possible bias for restrictions on each side.

More global issues: Don’t be too muscle specific in treatment; consider broader factors that may influence strain and torsion upon the hip, knee, and feet, including looking at broad fascial strain patterns that may transmit over several body segments.

Shoulder carriage, tight lumbar fascia, quadratus lumborum, or hamstrings that are associated with pelvic tilt can significantly improve distribution of strain.

Clarity in intention with touch The key to softening, lengthening, and aligning fibrous tissues is to grab and stretch the tissue rather than just sliding over it and compressing it. Use lubrication sparingly to enable a good grip and stretch on whatever layer you are working on. The biggest complaint I hear is from too aggressive and painful work. Almost always it is a result of two factors: First, working too fast so tissue does not have enough time to melt and cooperate; this actually can

Figure 2. Stretching the lateral line by adducting leg past mid-line.

result in a rebound that counters your attempt to promote lasting release.

Second, working too vertically and painfully compresses the ITB and other fibrosed tissue against the femur. This is the same drawback with foam rollers that several others mention. We are trying to elongate and align tissue, not squeeze and compress. The only force necessary is to slowly sink into whatever level you wish to free, then to grab without sliding and then apply force distally (rather than proximally since compression from activities “jams” the tissue upwards) at a very oblique angle while also working for alignment.

It is crucial to have clarity on your intention and techniques rather than just performing rote strokes without consideration of the depths of restriction.

Different layers should be able to slide over each other. I teach the following examples in detail in classes, but limitations on space prevent that now.

They are not intended as specific directions but as a conceptual way of working.

Free, align, and lengthen superficial fascia before addressing deeper layers , so it can slide over the fascia lata and consider fascial restrictions above and below the area of lateral pain. Work with broad and soft touch using fingers or palms of the hand to feel the superficial fascia glide over the facia latae.

This can be done in neutral positioning, but adding stretch to the entire complex can be accomplished by adducting the leg across the midline. Examples here demonstrate the supine position (Figure 2) and a more aggressive stretch having the client in

Figure 3. Working on the ITB in side-lying position, putting the ITB on a stretch .

side-lying assisted by gravity with the leg extended and hanging off the table (Figure 3).

After working superficial fascia, sink to the next layer and very slowly “iron” the entire fascia latae by grabbing and sliding with it for length and direction, feeling for wrinkles and thickening and waiting for the tissue to melt. Pin and stretch strokes are an effective strategy using a soft forearm or fists. Rather than just working in a neutral position, lengthening the lateral line by body positioning when working is also very helpful add stretch (Figures 2 & 3).

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Figure 4. Softening the lateral line.

Free and clarify anterior and posterior borders of the ITB by “compartment separation” strokes. Notice if the band seems restricted on one side more than

the other and clarify the boundaries with precise strokes (Figure 5).

Figure 5. Compartment separation strokes along the anterior or posterior border of the ITB.

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Free large groups of muscles and fascia to slide over deep layers, including the femur. Free the lateral line to slide over the deeper vastus lateralus and then roll the whole quadriceps group and lateral compartment around the femur, paying attention to whether if presents a bias to move medially or laterally and working to help it pull in a straight line from the hip to the knee. Grab the entire complex to slide and rotate over deeper tissues and, in turn, visualize sliding all layers to roll around the femur where they seem “stuck” to the bone. (Figure 6).

Figure 6. Grabbing, rolling, and mobilizing the ITB from both deep restrictions and from adjacent, parallel muscles.

aggressive treatment that can increase symptoms. A home program is essential. As others mention, I’m not a big fan of the foam roller although it certainly seems to be popular. So it may be a worthwhile approach for some people, although I think other options are more effective and humane. One limitation with the foam roller is that it is difficult to work in tangential directions (the ball that Bob Baker mentions can solve this and also allows for different levels of inflation to not be painful.) Foam rollers present an all-or-none situation by having all

Soften and elongate the muscles that attach to the ITB, but pay particular attention to freeing them from adjacent or deeper restrictions. Perform muscle separation strokes along anterior and posterior border of the TFL which may be exerting torsion from adhesions along the anterior or posterior border. “Roll” the muscle using precise pressure with a fist or knuckles so it can work freely in different degrees of hip flexion and extension. Also work along the borders of the gluteus maximus, especially at fibrous build up at its lower attachment and to free it to slide easily from adhesion to the deeper rotators (Figure 7).

Home Exercise ITBS needs frequent incremental work; it seems unrealistic to create beneficial change by treating every week or two. Trying to make up for lost time between treatments can result in over-

Figure 7. Soften and elongate the muscles that attach to the ITB.

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Figure 8. Using a Theracane to "iron" dense tissue in different directions down the entire leg.

of one’s weight on the roller which is often too in� tense for a painful ITB, and can also require a fair amount of strength in the shoulder girdle to move the body and maintain a side-plank yoga posture and create back strain. Too aggressive and perpendicular manual work using excess lubrication that prevents grabbing tissue has the same drawback.

The biggest drawback to the roller is that it only compresses tissue (picture a tire rolling over soft ground and leaving an imprint) rather than the allimportant stretching and alignment that are beneficial. For this reason I recommend using a stick of some sort that allows for different directional vectors, variation in pressure, access to adjacent tissue such as lateral hamstrings or quadriceps, and especially, the ability to grab and stretch tissue approximating manual work rather than just compressing.

In the following example (Figure 8), the client is using a Theracane which allows for pinpoint pressure to trigger points from the hip down the entire leg and of course anywhere else on the body. It is also useful to create balance with the adductors while comfortably sitting in a chair. Almost all clients I show this technique to feel it is far more effective and easy to tolerate than foam rollers.

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Good luck! And don’t let one study deter you from work on this area. Clients want and appreciate work whether for ITBS or just to ease strain and tension. Properly performed manual work on the lateral line not only is helpful for treatment of ITBS, but feels worthwhile and actually pleasant to most everyone.

Art Riggs is a certified advanced Rolfer who has been practicing and teaching in the San Francisco Bay area and internationally for over more than 20 years. His graduate studies were in exercise physiology at the University of California in Berkeley. He is the author of Deep Tissue Massage: A Visual Guide to Techniques, now in a second edition and translated into five languages, and the seven volume companion DVD set. He just released a new "Deep Tissue Massage-A Full Body Integrated Approach" DVD set. His website is at www.deeptissuemassagemanual.com.

More on ITB Research Iliotibial band stores and releases elastic energy during running ITB can only found in homo sapiens, and it has been hypothesised that ITB allows us to stand upright. A study from Harvard published in May 2015, examined how the ITB stores and releases elastic energy to make walking and running more efficient. The researchers developed a computer model to estimate how much it stretched ― and by extension, how much energy it stored — during walking and running. They found that ITB’s energy-storage capacity is substantially greater during running than walking, and that’s partly because running is a much springier gait.

We asked Dr. Eng on how she measured the strains of ITB and the difference with the study by Falvey et al.

“In their study, Falvey et al. measured strains in the ITB when the subject's joint angles are static and not changing. I am not surprised that their results suggest small strains in the ITB because they do not account for the muscle/ITB strains occurring when the joints move (e.g., hip and knee flexes for the posterior ITB). These joint angle changes play an important role in determining ITB strains in my study.”

“The ITB is undoubtedly integrated with other muscles and con‐ nective tissues in the limb and this determines the large forces being transmitted through the structure. While some of the forces generated by the muscles at the hip (i.e., gluteus maximus Lead author Carolyn Eng explained the role the ITB plays in locoand tensor fascia lata) may be lost with their connections to motion: One part of the IT band stretches as the limb swings other structures/tendons at the hip, a large portion will still be backward, Eng explained, storing elastic energy. That stored transmitted to the knee via the ITB. Using cadaveric dissections, energy is then released as the leg swings forward during a stride, I determined the percentage of the hip muscles' cross-sectional potentially resulting in energy savings. It’s like recycling energy, area (and hence, force) that inserts on and is transmitted to the replacing muscles with these passive rubber bands makes movITB and my calculations did not include the portions of these ing more economical. There are a lot of unique features in humuscles that insert on bone or other tendinous structures at the man limbs — like long legs and large joints — that are adaptahip.” tions for bipedal locomotion, and the ITB just stood out as something that could potentially play a role in making running and Eng, C. M., Arnold, A. S., Biewener, A. A., & Lieberman, D. E. (2015). possibly even walking more economical. Their calculation The human iliotibial band is specialized for elastic energy storage showed that largest strains in the anterior part of ITB occur in compared with the chimp fascia lata. The Journal of Experimental early swing with ITB stretching 0.9–1.7 cm beyond slack length. Biology, 218(15), 2382-2393.

Meanwhile peak strains in posterior part of ITB occur in late swing, stretching 1.4–3.0 cm beyond slack length.

Questioning the Ober Test

Does the Iliotibial Band Move?

The Ober test is the most commonly recommended physical examination tool for assessment of ITB tightness. Willet et al.

(2016) questioned the validity of the Ober test. They conducted an experiment using embalmed cadavers. They refute the hypothesis that the ITB plays a role in limiting hip adduction during the Ober test and question the validity of these tests for determining ITB tightness. The study suggests that the Ober test assesses tightness of structures proximal to the hip joint, such as the gluteus medius and minimus muscles and the hip joint capsule, rather than the ITB.

A study by Elsing et al. (2013) examined whether the ITB moves relative to the lateral femoral epicondyle (LFE) as a function of knee flexion in both non–weight-bearing and weightbearing positions in asymptomatic recreational runners. Evaluation using ultrasound on the ITBs of 20 male and female asymptomatic recreational runners clearly showed an anteroposterior motion of the ITB relative to the LFE during knee flexion-extension. The ITB does, in fact, move relative to the femur during the functional ranges of knee motion.

Willett, G. M., Keim, S. A., Shostrom, V. K., & Lomneth, C. S. (2016).

An Anatomic Investigation of the Ober Test. The American Journal of Sports Medicine, January 11, 2016.

Jelsing, E. J., Finnoff, J. T., Cheville, A. L., Levy, B. A., & Smith, J. (2013). Sonographic Evaluation of the Iliotibial Band at the Lateral Femoral Epicondyle Does the Iliotibial Band Move?. Journal of Ultrasound in Medicine,32(7), 1199-1206.

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New Books & DVDs Advanced Myofascial Techniques, Volume 2 by Til Luchau is the second of two beautiful, information-packed guides to highly effective manual therapy techniques. Focusing on conditions of the neck, head, spine and ribs Volume 2 provides a variety of tools for addressing some of the most commonly encountered complaints.

With clear step-by-step instructions and spectacular illustrations, each volume is a valuable collection of hands-on approaches for restoring function, refining proprioception, and decreasing pain.

Invaluable for practitioners, teachers, and students of hands-on manual therapies.

Deep Tissue Massage : An Integrated Full Body Approach – Coordinating Deep Tissue and Myofascial Release into a Fluid Bodywork Session by Art Riggs. This extensive new set (seven DVDs, over 9 hours) was created after countless requests from therapists who loved the first set, “Deep Tissue Massage and Myofascial Release” but were having trou‐ ble working the therapeutic philosophy and techniques into a fluid deep tissue massage, especially in a spa setting. Rather than discrete sections like the previous set, we move from A to Z, covering the whole body in a common sequence of beginning in prone, moving to supine with a whole segment devoted to the important side-lying position. Since the focus is upon smooth massage, we spend less time on biomechanics, the great detail on strategies and techniques and anatomy offered in the first set, but still provide a huge number of specific nuts and bolts techniques.

Traumatic Scar Tissue Management, Therapeutic massage principles, practice and protocols by Nancy Keeney Smith and Cathy Ryan.

The management of scar tissue is a huge and growing problem for massage and other manual therapists. Many are afraid to deal with it but research has showed that appropriate massage treatment can have significant results both physically and psychologically. Existing books have chapters on the problem but there is no practical manual available on the subject at the present time which tells the therapist what to do (and what not to do). This book fills that gap, explaining the physiologic and pathophysiologic background, and providing practical guidance about how to help patients.

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A N A T O M Y F O R T H E 2 1 S T C E N T U RY

BIOTENSEGRITY with John Sharkey Sydney, June 2016 Myofascial Trigger Points (MtPs) Versus Neuropathies A unique integrated neuromuscular approach for the treatment of unresolved pain due to MtPs or nerve insults.

2-3 June 2016 This is that one stop workshop that covers everything you need to know about identifying and treating Myofascial Trigger Points and nerve injury.

David G Simons (Travel and Simons), the father of Myofascial Trigger Points was mentor to John Sharkey and wrote the forward to John’s first book (a trigger point manual). Differentiating between neural generated pain and Myofascial Trigger Point pain is essential in providing the correct soft tissue interventions for successful therapeutic outcomes.

The Final Frontier Working within Endangerment sites, providing Manual and Movement Techniques to stay mobile and pain free.

4-5 June 2016 This informative workshop provides therapists with the necessary anatomical and palpatory excellence to expertly navigate the holy grails of the human body (endangerment sites). Providing safe neuromuscular techniques using digital applications guarantees effective therapeutic interventions for soft tissue based chronic pain conditions. Through your newfound anatomical knowledge and unique hands-on clinical pearls each learner will develop a greater appreciation of local and global anatomical connections.

The Theory of Everything—BioTensegrity, anatomy for the 21st century 11-12 June 2016 This workshop is ideally suited to the advanced manual and movement therapist with appropriate clinical experience and a desire to take on fresh new ideas, new models and a new way of thinking. Therapists are warmly encouraged to demonstrate their current screening, assessments and therapeutic applications with John while he will provide feedback and suggestions offering a new vision supported by connective tissue techniques for successful manual and movement interventions for all participants. This workshop provides you, the chronic pain soldier the effective full body kinetic chain ammunition you need in the war on pain.

John Sharkey MSc is a world renowned presenter and authority in the areas of bodywork and movement therapies. He is a Clinical Anatomist (BACA), Accredited Exercise Physiologist (BASES) and Founder of European Neuromuscular Therapy with more than 30 years of experience gained throughout his career working alongside his mentors and colleagues Leon Chaitow, David G. Simons, Stephen Levin MD, Prof. Kevin Sykes. John is recognised as a leading protagonist of BioTensegrity (providing new models and paradigm shifts concerning living movement and anatomy promoting therapeutic interventions for the reduction of chronic pain.

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Isometrics for Tendon Pain – Practical implementation and considerations

By Ebonie Rio, Craig Purdam, Sean Docking & Jill Cook A recent research has demonstrated a positive effect in patellar tendinopathy following isometric exercise.

This articles shares a number of practical considerations in implementing it.

Tendinopathy, pain and dysfunction in the tendon, can be difficult to treat. Traditionally eccentric exercise has been used in the rehabilitation of tendinopathy and has been shown to be superior to concentric only and passive treatments. However, there are many instances where the use of eccentric exercise is unhelpful or in fact detrimental, for example the in-season athlete where adherence is poor or pain may increase. Even those who work with the non-athletic population know that adherence is a challenge as eccentrics are painful to complete 1.

Recent research has demonstrated a positive effect (reduced tendon pain, reduced motor inhibition and improved muscle performance) following isometric exercise in patellar tendinopathy 2,3, supporting the pioneering clinical use by Jill Cook and Craig Purdam4. However, this isn’t quads over fulcrum‌.

Clinicians need to understand a number of concepts around the use of isometric exercise in tendinopathy. The research has been conducted in the patellar tendon, however clinically we are using with other lower limb tendons. Key considerations in22 Terra Rosa E-mag

Fig. 1. Patellar tendon pain commonly felt localised at the inferior pole.

clude; differential diagnosis (how to pick if the tendon is the source of symptoms), how to remove abusive loading and use loading for analgesia and how / when to progress.

Differential diagnosis Patellar tendinopathy (pain in the tendon at the front of the knee) occurs in jumping athletes or those that change direction quickly5. It has two hallmark features:

(1) pain remains very localised to the inferior pole (people can point with one finger and it doesn’t move or spread) (Fig. 1), and (2) dose dependent pain with increasing energy storage tendon load.

A good way of remembering this is that people with patellar tendinopathy can ride a bike without pain because it isn’t energy storage of the patellar tendon but jumping is painful, even though both activities use their quadriceps muscles.

We found differences in the motor responses (termed corticospinal excitability) of people with localized pain compared to people with more diffuse anteFig. 2. Mid-range knee extension. rior knee pain6. Clinically, we also see that the use of heavy isometrics is better in those ments after you address and any changes. Of course that fit the above description of patellar tendinopathere is a bit more to it that cannot be covered here! thy. Those with diffuse anterior knee pain, for exIsometrics for patellar tendinopathy ample patellofemoral pain, often do not tolerate heavy leg extension holds! This clinical consideraWe conducted pilot testing to see what factors were tion is so important. Remember it is a clinical diagimportant in using isometrics. It seems for tendons, nosis and not an imaging based diagnosis. People it needs to be heavy and time under tension is imwith imaging changes in their patellar tendon can portant. We tested lots of combinations and found have pain driven from another source (such as pa5 x 45 seconds (with 2 minutes rest for muscle and tellofemoral pain) – we see this often. central recovery) was effective. It was heavy – 70% of their maximal voluntary quadriceps contraction.

Using brain imaging techniques, we were also able How to remove abusive loading to see that isometrics reduced motor inhibition so not only were people in less pain (a lot less pain) Anything that asks the patellar tendon to store enthey had less inhibition and therefore were 19% ergy and release it is difficult, for example quick stronger! The exercise was conducted on a leg exlunging and change of direction and jumping. tension machine (Fig. 2). We also completed an inTherefore, athletes may need to reduce these types season trial to show that they can be used in-season of activities if their tendon is showing signs of not to reduce pain and allow participation. We have coping. Signs of not coping can be seen in the realso completed an isometric research using the sponse to tendon load 24 hours later. For example Spanish squat belt (see Spanish Squat Exercise) that if someone plays volleyball and the next day they is currently being prepared for journal submission. are no more sore, we would consider this load to be within their capacity7. Whereas, if their pain spiked we would consider the load to be greater than their capacity. This concept is important as is understanding how to improve capacity – find the level of loading that they tolerate and make small incre-

Conclusion Isometric exercise can be used to reduce tendon pain – immediately and without decline in muscle performance when used as tested. The research is Terra Rosa E-mag 23

Spanish Squat Exercise

3. Squat back as deep as possible keeping your spine upright – don’t lean forward. These two pictures show different ranges but both have a straight spine.

This exercise is designed to reduce patellar tendon pain and should be done daily as shown below.

1. Position belt around a sturdy pillar. The belt is long so any size pillar/pole may be used. Just wrap the belt as many times around pillar as needed so that when you step one leg inside each loop, the belt is around upper calf and your toes against pillar as shown. Make sure loops are even.

2. Place legs inside loop (one in each) with toes positioned against the pillar to stop you sliding.

Aim for thighs parallel to ground (e.g. picture on the right) but it is more important that your spine is straight, not how deep you are. Go as deep as you can hold.

Hold this position for 45 seconds five times. Have a two minute rest in between each squat. Don’t come down & up stay squatting down for the whole 45 seconds!

It is possible that the tendon may be slightly uncomfortable, usually early in the first squat, but this improves.

Don’t lean your trunk forward.

currently in patellar tendinopathy with more to follow. It is important to determine whether the tendon is the source of symptoms or at least determine whether they are likely to respond positively to that approach.

References

Ebonie Rio has a PhD and a Masters in Sports Physiotherapy, Bachelor Physiotherapy (Hons) and Bachelor of Applied Science. She is currently a post doctoral fellow at La Trobe University and also work at the Victorian Institute of Sport.

3. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015;49(19):1277-83.

Craig Purdam is the Deputy Director of Athlete Services and the Head of Physical Therapies at the Australian Institute of Sport. He has worked as a clinician in elite sport for over 30 years and has been a physiotherapist to five Olympic Games (1984-2000) .

Sean Docking has a PhD and a Bachelor Health Sciences (Hons) and is currently a Post doctoral fellow at La Trobe University. His research interest is in tendon injury.

Jill Cook is a Professor at La Trobe University Sport and Exercise Medicine Centre. Her research interests are in tendon injury, tendon pathology, sports injuries, and musculoskeletal injuries.

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1. Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26(3):360-6.

2. Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med 2015.

4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.

Br J Sports Med 2009;43(6):409-16.

5. Malliaras P, Cook J, Purdam C, et al. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther 2015:1-33.

6. Rio E, Kidgell D, Moseley GL, et al. Elevated corticospinal excitability in patellar tendinopathy compared with other anterior knee pain or no pain. Scand J Med Sci Sports 2015.

7. Cook JL, Docking SI. "Rehabilitation will increase the 'capacity' of your ...insert musculoskeletal tissue here...." Defining 'tissue capacity': a core concept for clinicians. Br J Sports Med 2015;49(23):1484-5.

Functional Fascial Taping with Ron Alexander

“Evidence-Based Pain Relief” This workshop teaches a fast and simple way for clinicians to reduce pain, improve function, encourage normal movement patterns and rehabilitation of musculoskeletal pathologies in a pain-free environment.

FFT has been shown to have a significant effect on Non-Specific Low Back Pain in a randomised double-blind PhD study. FFT is a non-invasive, immediate, functional and an objective way to decrease musculoskeletal pain.

Presenter: Ron Alexander— STT [Musculoskeletal], FFT Founder and Teacher

A great way to encourage treatments to hold longer

Brisbane 16-17 July 2016 Melbourne 23-24 July 2016 Sydney 30-31 July 2016 Register Now at: www.terrarosa.com.au

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An interview with Dr. Jean-Claude Guimberteau Dr. Jean-Claude Guimberteau is a hand surgeon renowned for his live fascia film Strolling under the Skin. We recently talked with him about his new book.

In Architecture of the Living Fascia, The extracellular matrix and cells revealed though endoscopy, Dr. Guimberteau, a hand surgeon, gives us a direct view from the surface on the skin deep to the bone. Dr Guimberteau is the first person to film living human tissue through an endoscope in an attempt to understand the organisation of living matter.

He discovered that within the extracellular matrix (ECM) there is a continuous, bodywide, multifbrillar network of fibres and fibrils, extending from the surface of the skin to the periosteum. In addition, there are no distinct separate layers within this continuum of living matter.

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What led you to the discovery and study of the architecture of the connective tissue.

I was seeking a technical procedure to reconstruct flexor tendons, when I came upon the sliding system that I termed the MVCAS (Multimicrovacuolar Collagenic Absorbing System). I first used a microscope to understand how it was working. This tissue, which neatly ensures the efficacy of gliding structures and their independence, is composed of a network of collagen fibrils whose distribution seems to be totally disorganized and apparently illogical at a first sight. This impressed me because my Cartesian mind could not come to terms with the idea of chaos and efficiency co-exists perfectly.

This was the starting point for an intellectual voyage that took me far from the beaten track and off

The mobility, flexibility, and elasticity of the fibrillar structures create a gigantic firework display of fibrillar movement.

(From Guimberteau, 2016, Handspring Publishing).

into the largely unknown world of fractals and chaos. an addition of organs linked by a connective tissue but contrary, constituted by a structured fibrillar Dr Guimberteau, you described the "fibrillar" net- mesh in which the organs have developed. The conwork that can be found from the superfical to the nective tissue’s role is far more important than sim� deep. ply connecting, it is in fact the constitutive tissue.

Just take an endoscope and descend slowly from the skin surface until the depth of the bone and you will realize that there is a continuum of fibrillar of variable diameter, irregular, fractal but formed within an uninterrupted continuum. We know now that there is also a microfibrils cytoskeleton framing the cell which is linked to the ECM. The body thus can be described with a real architecture fibrillar at all levels.

We can visualise our body as a global structure with a specific, three-dimensional architecture made up of elements that, while fragile, have a persistent capacity for adaptation.

Through our observations, we see how this elaborate microfbrillar construction, composed of microvacuoles filled with collagen and glycosaminoglycans or with cells, is capable of adapting to all types of constraint in three dimensions, thanks to its mobility and other inherent properties.

You also mentioned that a living form has to be structured, as well as mobile, supple, adaptable and self-sufficient.

Indeed, finding a global fibrillar structure framing the body and structuring the form, already provides an architectural explanation. But when you observe Is this the same as the superficial and deep fascia? that these fibres have an ability to stretch, split, slip, a capacity of adaptability , to absorb stresses, you It is completely different from the superficialis or deep fascia which are only local and functional den- understand that this fibrillar system provides the movement, flexibility, resistance to the force of gravsifications of this fibrillar network. ity and allows morphogenesis.

This opens towards another body concept , a new structure ontology that living human matter is not Terra Rosa E-mag 27

A microvacuole can change shape (adapt) by stretching, widening, or shortening, and still be able to return to its initial shape. These changes occur simultaneously and in synchrony with the movements of the fibrillar system to return to its initial shape. (60 Ă— magnifications). From Guimberteau, 2016, Handspring Publishing).

You made an observation on the effect of manual therapy under the skin. Can you tell us what happened?

But in addition, looking more closely, you can see the vessels with red blood cells in movements and especially the cells changing of shape and having small movements between them. The influence on cytoskeleton is obvious.

We filmed several times, in association with a manual therapist, during surgeries the effects of massage on the skin.

Massage undoubtedly has a mechanical and visible effect on all the structural elements and at least 10 When you move the skin, all the components move cm around the massaged area. together, you can observe the hypodermis and lobules twirling, the underlying sliding system adopting You can see these video sequences on the DVD from all the postures, the fibres intersecting, intertwining, my book Architecture of Human Living Fascia, The without breaking. There is a harmony in motion. extracellular matrix and cells revealed though endoscopy, Handspring Publishing, 2015.

This beautifully illustrated book and DVD introduce Dr Guimberteau's groundbreaking work. He is the first person to publish "movies" showing the structure of the fascia and how the fascia responds to. The book and accompanying DVD provide, for the first time, an explanatory introduction and explanation of these theories and link them to the visual evidence shown in the video.

Available at www.terrarosa.com.au

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New Books & DVDs Healing with Yoga by Jeanine Orbuchay & Dr. Joe Muscolino. This video is designed to allow anyone to practice yoga, either by simply focusing on key parts of the body, or by doing a fullbody practice from start to finish. Additionally, viewers can learn about each part of the body they are interested in, including the location and function of each muscle group, how to palpate it, and how to stretch and strengthen it.

Choose to go straight through an all-levels yoga practice focusing on one muscle group at a time, or watch each anatomy, functionality and palpation description of the muscle groups before each group of yoga poses. Either way you choose to view it, start expanding your experiential understanding of the anatomy of the human body.

The Concise Book of Muscles, 3rd Edition by Chris Jarmey and John Sharkey is designed in quick-reference format to offer useful information about the main skeletal muscles that are central to anatomy, physical therapy, massage, chiropractic, physiotherapy, osteopathy, or any other health-related field. Each muscle section is colour-coded for ease of reference. Enough detail is included regarding each muscle’s origin, insertion, action, and nerve innervation (including the nerve’s common course or path) to meet the requirements of the student and practitioner.

The book also highlights those muscles that are heavily used and therefore subject to injury in a variety of sports and activities, as well as offering a range of exercises that can be used to stretch or strengthen a specific muscle or muscle group.

The Original Body, Primal movement for yoga teachers by John Stirk addresses the physiological experience of yoga. The soft tissue, skeletal, fluid and spatial sensations experienced in practice are considered in sequence and collectively as the reader becomes drawn into a depth of feeling and understanding that lies beyond practice. Yoga teachers are shown how to use a deeper ‘feeling’ to unveil an innate powerful physical wisdom. This includes bringing together anatomical visualisation and imagination, the development of awareness as a movement, and the management of sensation.

This book focuses on honing and harnessing the practitioner’s essential experience in order reveal a more profound style of teaching from within. Teachers are invited to consider the impediments to a deeper practice and will be taken through the common factors inhibiting sensory pathways. These include conditioning, habit, trauma, anxiety, nonessential thought and the effect of technique and methodology in teaching.

Advanced Myofascial Techniques: Migraines & Headaches by Til Luchau.

This DVD shows the complete instructor demonstrations from the popular Advanced Myofascial Techniques: MIGRAINES & HEADACHES course. Includes supplemental techniques not shown in live courses.

Learn Advanced Myofascial Techniques that can dramatically improve your ability to work with all types of headaches and migraines, plus ear and sinus issues, vertigo, and more.

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How I treat Trochanteric Bursitis Tom Ockler, PT

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A diagnosis of trochanteric bursitis can be tricky for several reasons. The US healthcare (sick care) system encourages high volume so accuracy is low on the importance scale. The diagnosis may just be hip pain, or it may actually be trochanteric bursitis.

Regardless, over the years I have found that most times there is no evidence of bursitis. It’s just faster to give it an important sounding diagnosis.

No matter what the diagnosis, the hip requires a thorough investigation to narrow down the actual issue.

To me, it’s quite obvious the trochanteric bursa does not become inflamed for no good reason. To simply calm down the bursa ( treat the symptom) is helpful but if you do not correct the underlying causes for the issue, it will be a lengthy course of treatment at best and at worst, a repeating problem that can effect gait and therefore impart imbalanced forces on the entire lower extremity. A cascade of orthopedic and musculoskeletal sequelae can lead to a chronic pain syndrome.

The most common complaint is that the patient can’t lie on the painful side at night. Sometimes even lying on the non-painful side hurts too, due to the stretching of the ITB and lateral hip muscles over the tender trochanter. It can be aggravated by a fall onto a hard surface like ice, cycling, walking, running, lying on it or nothing that they can think of.

If you’ve ever seen or had an olecranon bursitis, they can be spotted a mile away. This is not the case with a trochanteric bursitis. The trochanteric bursa may not be swollen to the naked eye and even palpation doesn’t give a clue to swelling that you might expect to accompany this diagnosis.

If you have taken my MET 1 course, you know that I start the session assessing for a hypomobile S.I.J., looking for S.I. or I.S. dysfunction and functional leg length issue. In theory, if one leg is behaving longer (functional leg length discrepancy) that alone can put extra tension / pressure on the trochanter by the gluteus medius and minimus as well as the iliotibial band.

I use MET to get a level and symmetrical platform from which to work off of. After the correction and stabilization exercises, I then start poking around.

Literally poking around for tender points—in the gluteus medius, minimus, piriformis, TFL, as well as the trochanter itself. In addition, although they are on the medial aspect of the hip joint, I check out the adductor tendon and the pectineus muscle for tender points. Long term dysfunction of lateral muscles can create a domino effect of the medial muscles and vice versa.

Any and all of these muscles can cause pain and usually indicate tightness and sensitivity to stretch which makes them prime candidates for causing hip pain or actual trochanteric bursitis.

Once a balanced and symmetrical pelvis and sacrum has been achieved with Muscle Energy, I use counterstrain technique. The technique called counterstrain, commonly called strain counterstrain or positional release, is a prime choice for getting rid of these trigger / tender points and returning the muscle spindles and thus the corresponding muscles to normal resting tone. It’s important to check all of these muscle trigger points as any one of them could be causing the pain.

If not already familiar with the strain counterstrain techniques, a great resource is Positional Release Therapy by Kerry J. D’Ambrogio and George B. Roth.

Leon Chaitow ND DO also has an excellent book on Terra Rosa E-mag 31

Positional Release Techniques. Lastly, you could probably type in the particular counterstrain technique you want to see on the YouTube website.

Example below is a Strain counterstrain for the Piriformis muscle.

I will then use Cold laser and / or microcurrent directly over the trochanter to help with the soreness and reduce swelling. Patients can use mild cool packs or NSAIDs to help in the initial few days.

I also recommend a pillow between the knees to keep the femur level with the pelvis while sleeping.

If the patient does a considerable amount of driving and this aggravates the condition, I recommend cutting out a 3” (or 7.5 cm) piece of foam that just fits the lower dimensions of the bucket seat.

Carefully cut the foam as to avoid contacting the slanted sides of the bucket seat. This helps to minimize trochanteric contact with the slanted side of the bucket seat and thus assist in the healing process.

For males, getting the wallet out of the back pocket is a must. Cargo pants are useful here.

On the second visit, provided that the symptoms are way down, I will also teach ITB stretching (the old “hooker stretch”) to help lengthen out the tissues that cross the lateral hip.

The above protocol is so effective that usually by the second session, they can lie on the hip with much less pain and may even be sleeping the night on that side. Two or three visits spread out over a week to 10 days is my norm with these issues.

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If there is no improvement in a few visits, you might want to consider the possibility of a stress fracture or degenerative joint disease. Labral tears may also cause enough dysfunction in the sequential firing of hip muscles that a bursitis can come about as a sequelae of the labral disease. The scour test would be performed at the initial evaluation. Also the FABER test would indicate a more serious hip joint pathology.

Although out of the scope of most bodyworkers, custom, corrective orthotics my be the final piece of the puzzle for persistent repetitive hip pain. A forefoot or rear foot varus deformity for example, can set off a plethora of lower extremity muscle misfiring and contribute to the pain and dysfunction that so often accompanies painful hip syndrome.

Corrective orthotics, ( as opposed to accommodative orthotics which are all too often issued to the trusting patient) can set the subtalar joint to a more neutral position and give a more balanced role to the muscles of the entire lower extremity.

Have a troubling patient? Drop me an email and let me know. I am always happy to shed light or offer a different perspective. tom@tomocklerpt.com

Tom Ockler P.T. has extensive teaching experience throughout the United States, Canada, England and Australia. As a teacher, Tom has earned the nickname "The Patch Adams of Physical Therapy" due to his unique style of injecting humour into complicated subjects. He has developed teaching methods that explain very complicated subjects in easily understandable formats. His two books and DVDs Muscle Energy Technique for Lower Extremities, Pelvis, Sacrum, and Lumbar Spine and Muscle Energy Techniques for the Thoracic Spine, Ribs, Shoulder and Cervical Spine have been hailed by students as the most user friendly and useful Muscle Energy manuals ever.

Overpronation By Dr. Joe Muscolino

Pronation and supination are normal healthy motions of the foot that occur between the tarsal bones. The problem is when our arch structure excessively pronates, in other words, overpronates.

Figure 1 The subtalar joint of the foot. The transverse tarsal joint is also seen. (Muscolino, JE. Kinesiology: The Skeletal System and Muscle Function. 2ed. Elsevier.)

Pronation/Supination

triplanar motions.

Pronation and supination are normal healthy motions of the foot that occur between the tarsal bones.

These motions occur primarily at the subtalar joint between the talus and calcaneus; however, they also occur at the transverse tarsal joint (the transverse tarsal joint is actually composed of two joints: the talonavicular joint medially between the talus and navicular; and the calcaneocuboid joint laterally between the calcaneus and cuboid) (Figure 1).

The principle cardinal plane component motion of pronation is frontal plane eversion. For this reason, it is common to hear pronation described as eversion. However, eversion is only one component of pronation, albeit the largest. Pronation also involves subtalar abduction (effectively lateral rotation) of the foot in the transverse plane, and subtalar dorsiflexion of the foot in the sagittal plane. Similarly, the largest component motion of supination is inversion.

However, supination also involves subtalar adduction (effectively medial rotation) of the foot in the transverse plane, and subtalar plantarflexion of the foot in the sagittal plane.

Pronation and supination each occur in one oblique plane around one oblique axis, therefore they are uniaxial motions; however, because these oblique plane motions occur across all three cardinal planes, pronation and supination are often described as

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Figure 2 The Arch structure of the foot is composed of the medial longitudinal arch, the lateral longitudinal arch, and the transverse arch. (Muscolino, JE. Kinesiology: The Skeletal System and Muscle Function. 2ed. Elsevier.)

Foot pronation causes the arch structure of the foot to drop. The arch structure consists of three arches: the medial longitudinal arch on the big toe side, which is the largest and best known of the arches; the lateral longitudinal arch on the little toe side; and the transverse arch across the metatarsal heads (Figure 2). Whenever any one of these arches collapses, as a rule, the entire arch structure collapses.

Overpronation/Flat Foot Dropping the arch structure of the foot is a natural and healthy posture. It occurs during the gait cycle during midstance when our body weight is directly above the foot. Before much of our world was paved and flat, the ground was often uneven. From a position of full supination, varying the degree of pronation would therefore allow the arch to drop and flatten the necessary amount to mold to the contour of the ground upon which we are standing (Figure 3).

Pronating to drop the arch also allows for shock absorption when striking the ground during walking, running, and jumping. The problem is when our arch structure excessively pronates, in other words, overpronates.

Because overpronation causes the arch structure to drop, it is known in lay terms as flat foot. In scientific terms, it is known as pes planus, which is Latin for “foot flat” (pes cavus is the term for an overly supi‐ nated foot, in other words, an excessively high arch).

There are two types of overpronation/flat foot: rigid flat foot and supple flat foot. With supple flat foot, 34 Terra Rosa E-mag

Figure 3 Varying the degree of supination/pronation allows the foot to mold to the contour of the ground. (Modelled from a figure in Neumann, DA: Kinesiology of the musculoskeletal system: foundations for physical rehabilitation, ed 2, Elsevier.)

which is the more common of the two types, the client’s arch is perfectly healthy when not weightbearing, but upon weight-bearing, the foot pronates excessively and the arch structure collapses. By contrast, a rigid flat foot is always flat/overly pronated, regardless of whether the client is weight-bearing or not (Figure 4).

Causes There are many causes of supple flat foot. Given that the arch structure of the foot is determined by soft tissue pulls of musculature and ligaments, a supple flat foot is caused by either lax ligaments and/or weak musculature that cannot support the arch when the weight of the body passes through the subtalar (and transverse tarsal) joint. Muscles that act to support the arch can be divided into the following groups (Table 1): Supinators (invertors) of the foot – These muscles have their bellies located in the leg. They are the tibialis anterior and the extensor hallucis longus in the anterior compartment; and the Tom, Dick and Harry group: tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles of the posterior deep compartment (Figures 5A and 5B).

“Stirrup Muscles” – The stirrup muscles, whose bellies are also located in the leg, are named

A B

C

Figure 4 Overpronation of the foot, also known as flat foot. A, Supple flat foot when not weight-bearing. B, The same supple flat foot when weight-bearing. C, Rigid flat foot. Note: The contour of the medial longitudinal arch is highlighted in each figure. Courtesy Joseph E. Muscolino DC.

because they support the arch/underside of the foot like a stirrup. They are the tibialis anterior of the anterior compartment (already mentioned above) and the fibularis longus of the lateral compartment (see Figure 5A).

Intrinsic plantar musculature – Muscles of Plantar Layer I group of the intrinsic plantar musculature have attachments into the plantar fascia. By supporting the plantar fascia, they help to support the arch (see Figure 5C). They are the flexor digitorum brevis, abductor hallucis, and abductor digiti minimi pedis.

Lateral rotators of the thigh at the hip joint – This group indirectly supports the arch because it acts to prevent the thigh from medially rotating. When the weight-bearing foot pronates, because the foot is planted on the ground, the calcaneus of the subtalar joint is not fully free to move, therefore the talus

moves as well. This is a closed-chain reverse action of the proximal talus upon the distal calcaneus, and results in medial rotation of the talus. Because the ankle (talocrural) joint does not allow rotation, the tibia medially rotates with the talus; and because the extended knee joint also does not allow rotation, the femur medially rotates with the tibia. Therefore, hip joint lateral rotation musculature can support the arch by acting to brake/prevent medial rotation of the femur/tibia/talus (Figure 5D). Hip joint lateral rotation musculature includes the posterior gluteal musculature, the deep lateral rotator group (piriformis, quadratus femoris, superior and inferior gemellus, and obturator internus and externus), and the sartorius.

It should be mentioned that hip joint abductor musculature can also be important for maintaining the arch of the foot. If this musculature is weak, the thigh can fall into adducTerra Rosa E-mag 35

Table 1 Musculature that supports the arch Leg/Subtalar joint

Foot/Plantar fascia

Thigh/Hip joint

- Tibialis anterior

- Flexor digitorum brevis

- Gluteus maximus

- Extensor hallucis longus

- Abductor hallucis

- Gluteus medius and minimus

- Tibialis posterior

- Abductor digiti minimi pedis

- Piriformis

- Flexor digitorum longus

- Quadratus femoris

- Flexor hallucis longus

- Superior and inferior gemellus

- Fibularis longus

- Obturator internus and externus - Sartorius - Tensor fasciae latae (TFL)

tion, this causes a genu valgus force (abduction of the leg at the knee joint), which tends to result in medial rotation of the thigh, and therefore the leg and talus, promoting arch collapse. Abductors of the hip joint are the gluteal muscles, tensor fasciae latae (TFL), and the sartorius.

Another contributor to overpronation is tight pronator (evertor) musculature (fibularis musculature and extensor digitorum longus), which can pull the foot into pronation on that side, making it more difficult for the supinator musculature to support the arch structure.

Most all fascial ligamentous tissue that is located on the plantar side of the foot helps to support the arch. Most notable are the long and short plantar ligaments, the spring ligament, the intertransverse metatarsal ligaments, and the plantar fascia (Figure 6). If this fascial ligamentous tissue is excessively lax, perhaps due to genetic factors or to forces placed upon it during life, it will not be able to hold the bones in their proper posture, especially during weight-bearing postures, and the arch will collapse.

As stated, the collapsed arch of overpronation essentially occurs because of the inability of the musculature and ligament complex to support the arch structure, especially when bearing weight. Therefore, any factor that increases downward force through the arches will tend to exacerbate this condition. First among these factors is being overweight, which increases the weight that is borne through the arches. Carrying heavy loads/objects acts in a similar manner because the weight of whatever is being carried must ultimately pass through the arches of the feet.

36 Terra Rosa E-mag

Another factor is a turned out posture of the foot.

This usually occurs because of excessively tight baseline tone of deep lateral rotation musculature of the thigh at the hip joint (e.g., piriformis). When walking with a turned out posture, the person’s weight passes more directly over the medial longitudinal arch, increasing the likelihood that it will collapse (Figure 7). Ironically, the baseline tone of the lateral rotation musculature of the hip joint might be tight enough to cause the unhealthy turned out posture of the foot, but not strong enough to prevent the weight-bearing foot from overly pronating as a result of this altered posture.

It is important for the lateral rotation musculature to have a healthy and loose baseline tone, but to be strong enough to contract to prevent overpronation when needed during the gait cycle.

Proper footwear can be another factor. If a person does overly pronate, then wearing shoes that have little or no arch support can allow the excessive pronation to occur. Wearing high-heeled shoes can also exacerbate this problem because they shift body weight to be borne more anteriorly in the foot, increasing force through the transverse arch, causing it to collapse. This will result in weakness of the entire arch structure of the foot, including the medial and lateral longitudinal arches, thereby resulting in overpronation.

Finally, the longer that a client has had an overly pronated foot, the more likely it is that fascial adhesions accumulate that exacerbate the condition by holding the foot in a posture of excessive pronation.

This is especially true for rigid flat foot, but might also become a factor that causes a supple flat foot to gradually transition toward becoming a rigid flat foot.

Figure 5 Muscles that support the arch. A, Superficial view of the anterior leg. B, Deep view of the posterior leg. C, Superficial view of the plantar foot. D, Deep view of the posterior pelvis. (Muscolino, JE. Kinesiology: The Muscular System Manual: The Skeletal Muscles of the Human Body, 2ed. Elsevier.)

Signs and symptoms The first and most obvious sign of overpronation is a flat foot/dropped arch (See Figure 4). The supple flat foot will have an arch when not weight-bearing but will be seen to lose the arch upon weightbearing. A rigid flat foot will be flat whether the person is bearing weight through the foot or not. Because overpronation results in medial rotation of the talus, leg, and thigh, the client’s lower extremity will usually excessively medially rotate when standing (Figure 8A).

Pain does not necessarily accompany this condition, but it often does. A supple flat foot results in the arch excessively dropping each time the foot strikes the ground. This causes the soft tissues on the underside of the foot to be forcefully stretched each time the foot contacts the ground, tugging at their attachments and likely causing either spasms in the plantar intrinsic musculature (due to the muscle spindle reflex) and/or inflammation of the plantar fascia (known as plantar fasciitis). Either of these conditions can cause pain, especially upon weightbearing. Because these tissues attach to the underside of the calcaneus, the stretching forces placed upon them will be transmitted to the calcaneus, possibly leading to a heel spur (due to Wolff’s Law: the deposition of calcium in response to physical stress). Therefore, overpronation is often accompanied by plantar intrinsic musculature spasm, plantar fasciitis, and/or heel spur.

Overpronation can also cause ramifications farther up the client’s body. Dropping the arch tends to in‐ crease genu valgus (knock-kneed) posture, which places increased tension stress to the medial knee and increased compression stress to the lateral knee. Further, if the overpronation is present on only one side, or if it is present to a greater degree on one side than the other, then the pelvis on that side will drop. This places an asymmetrical force on the client’s sacroiliac joints and also often results in a compensatory scoliosis to bring the head back to level (Figure 8B).

Assessment Assessment of overpronation follows from the signs and symptoms of the condition. The most important assessment tools are static and dynamic postural assessment, which will reveal the characteristic dropped arch.

For static postural assessment, have the client stand facing you, a few feet away, and note the height of the arches, including the relative symmetry of the arches of the left and right feet (Figure 9A). Note also the orientation of the patella on each side. Patellar orientation will follow the rotation of the femur/thigh; with overpronation, the patella on that side will be oriented more medially (See Figure 8A).

If a dropped arch is found, postural examination should also look to correlate the presence of genu valgus.

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Figure 6 Fascial ligamentous tissues on the plantar surface of the foot that help to support the arch. Medial view. Note: The intertransverse metatarsal ligaments are not seen.

Static postural assessment can also be done from the posterior perspective. In this case, instead of viewing the arches directly, look at the Achilles’ (calcaneal) tendons; each tendon should be ver‐ tical. With a collapsed arch, the Achilles’ tendon will bow inward instead (Figure 9B). The medial malleolus will also usually be seen to jut inward. If the dropped arch is unilateral or greater on one side than the other, postural examination should include evaluation of a dropped iliac crest and possible compensatory scoliosis as well (See Figure 8B).

Dynamic postural assessment can be even more effective than static postural assessment. With the client facing you, ask the client to march in place. It is important that the client moves slowly and lifts each foot high enough (close to the height of the other knee) so that you have time to observe how much the weight-bearing arch drops each time the foot strikes the ground. If you have enough space, for example a long hallway, the client can be asked to walk while you observe their lower extremities.

As the client walks toward you, assess how much the medial longitudinal arch drops and the patella medially rotates when the foot hits the ground. As the client walks away from you, assess the degree of bowing in the Achilles’ tendons and the excursion of the medial malleolus as the foot hits the ground.

When evaluating pronation motion, keep in mind that when standing, marching, or walking (in other words, upon weight-bearing), the foot should pronate to some degree, and therefore the arch structure should drop somewhat. Because there is not universal consensus on exactly what subtalar joint neutral posture is, and exactly how much pronation is healthy versus unhealthy, it is best to eyeball this 38 Terra Rosa E-mag

Figure 7 Walking with the foot turned out increases weightbearing force directly over the arch of the foot, increasing the likelihood that it will overly pronate. Courtesy Joseph E. Muscolino DC

motion, using your judgment. It is also helpful to compare left and right sides; symmetry should be present.

Passive range of motion assessment of the foot at the subtalar and ankle joints can also be done, with particular attention to the client’s inversion and eversion ranges, Inversion is often limited in clients who overly pronate; eversion is often excessive.

Hands-on palpatory examination should then be done. Check for the presence of tightness and/or myofascial trigger points (TrPs) in the associated musculature. It is important to check all muscles that help to support the arch of the foot (i.e., foot supinators and hip joint lateral rotators and their synergists) because they might develop TrPs as they attempt to control the excessive pronation (see Table 1). Similarly, palpate the antagonists to these muscles (i.e., foot pronators and hip joint medial rotators and their synergists) to see if their baseline tone is contributing directly to the overpronation; if they are tight/overly facilitated, they might be creating forces that pull the foot into excessive pronation. Palpatory examination should also be performed to assess for fascial adhesions within the plantar surface of the foot. Generally speaking, the more fascial adhesions, the more “rigid” the foot is.

Finally, it is important to assess for joint play/ mobilization of the joints of the foot. Because overpronation usually results in “dropping” of the tarsal bones (as the arch structure drops, the tarsal bones drop), it is especially important to assess the motion of the bones to move from plantar to dorsal in direction (Figure 10). Mobilization of the tarsals from plantar to dorsal will usually be restricted in an overpronating foot, especially a rigid flat foot or a

chronic supple flat foot.

A

In addition to physical examination, it is also important to conduct a verbal history to determine whether the client has any habitual postures that might contribute to overpronation. For example, sitting cross-legged with the ankle of one leg placed on the thigh of the other, or driving with the heel of the right foot placed in front of the brake and the thigh turned out so that the toes of the foot are on the gas pedal; these postures tend to promote a turned-out posture of the foot. A habitual pattern of standing on one leg with body weight shifted to that side will tend to increase weight-bearing and therefore physical stress to the foot on that side. Checking the client’s shoes for excessive wear on the lat‐ eral side of the heel can also be helpful.

Medical Diagnosis Overpronation is a dysfunctional postural condition of the musculoskeletal system, so no further medical diagnosis/assessment is usually needed. However, if X-Rays are done, they can support the assessment by showing the dropped posture of the bones of the foot. Both weight-bearing and nonweight-bearing films should be done. A rigid flat foot will demonstrate the dropped arch on both weight-bearing and nonweight-bearing films, whereas a supple flat foot will demonstrate the dropped arch only on the weight-bearing film.

B

Differential assessment When a client presents with overpronation, it is important to differentially assess whether it is due to a rigid or supple flat foot. It is also important, as mentioned, to assess the possible presence of the postural affects of overpronation higher up in the body.

Look especially for genu valgus, medially rotated femur/thigh, and dropped iliac crest on the side of overpronation, as well as a possible compensatory scoliosis.

Manual treatment Because overpronation, whether it is a supple or rigid flat foot, usually does not directly cause pain, and even its effects farther up the body will probably not cause pain for many years or decades, it is likely that the client’s condition will be chronic by the time that it is addressed. For this reason, there is a good chance that it will be stubborn and resistant to treatment. Chronicity, not severity, is usually the biggest determinant to how easily a client’s con‐ dition responds to treatment. With chronicity comes increased fascial adhesions as well as entrenchment of the neural patterning of muscle

Figure 8 Effects higher in the body of overpronation of the right foot. A, Medial rotation of the entire lower extremity; note the orientation of the right patella compared to the left. B, Overpronation often results in a dropped pelvis (iliac crest) on that side as well as a compensatory scoliosis. Courtesy Joseph E. Muscolino DC

Terra Rosa E-mag 39

A

B

Figure 9 Static postural examination of overpronation. A, Anterior view. B, Posterior view. Courtesy Joseph E. Muscolino DC

memory tone. For this reason, treatment of an overly pronating foot must be consistent.

A good guideline for all rehabilitative manual therapy care is to treat the client two times per week until the desired outcomes have been met. Treatment frequency of twice-a-week is not common in the world of massage, but is the norm in all other musculoskeletal rehabilitative fields, and should be adopted if clinical orthopedic massage is being done to remedy a musculoskeletal pathologic condition.

Treating a client once per week might feel good temporarily, but is often ineffective at creating true and lasting improvement.

For a supple flat foot, manual therapy’s role is indi‐ rect. By employing both soft tissue manipulation and stretching, the goal is to loosen tight musculature and eliminate TrPs. This can both relax the baseline tone of muscles that are pulling toward pronation as well as strengthen muscles that support the arch by increasing the efficiency of their contraction. Manual therapy should also be directed to any sequelae of overpronation, such as tight lateral rotation hip joint musculature or tight paraspinal musculature as a result of scoliosis, if present.

For the rigid flat foot, as well as the supple flat foot that is becoming more rigid, manual therapy’s role is more direct. It is performed to loosen fascial adhesions that are locking the bones in a position of pronation. In these cases, deeper soft tissue ma-

Arch Imprint Assessment A fun and instructive assessment for the arch structure of the foot can be done with a little oil and construction paper. Place a film of oil on the plantar surface of the client’s foot and then ask the client to step on colored con‐ struction paper. When the client lifts the foot, an imprint of their arch will be visible on the paper. This can then be repeated for the other foot. These imprints can be shown to the client to demonstrate the posture of their arches (see accompanying figures). When performing this assessment, be sure to instruct the client to place their weight evenly on both feet as they place the oiled-foot down.

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A

Summary of Manual Treatment Protocol for Overpronation 1. Heat, soft tissue manipulation, and stretching of the muscles of the leg/foot (especially the supinators) 2. Heat, soft tissue manipulation, and stretching of the plantar musculature 3. Arthrofascial stretching (joint mobilization) of the foot from plantar to dorsal in direction, especially for a rigid flat foot

B

4. Soft tissue manipulation and stretching of the hip joint musculature (especially lateral rotators, medial rotators, adductors, and abductors) 5. Assess and treat the spine if appropriate (especially for compensatory scoliosis) 6. Strengthen (or refer out to strengthen) the weakened/inhibited musculature

Figure 10 Joint motion palpation (joint mobilization) of the foot with force being directed from plantar to dorsal in direction. A, Reinforced thumb pad contact. B, Pisiform contact. Courtesy Joseph E. Muscolino DC

nipulation into the plantar side of the foot, stretching of the tight muscles, and arthrofascial stretching (Grade IV soft tissue joint mobilization) is called for.

And because stretching is always more effective if the soft tissues are warmed up first, moist heat is also valuable as a modality. Depth of pressure should always begin as light to moderate, but will usually have to transition to being deeper to access long-standing fascial adhesions and deeper tight musculature that are likely with a rigid flat foot or even a chronic supple flat foot.

As important as manual therapy can be for overpronation, it can never fully and permanently resolve the condition. The primary objective of manual therapy is to loosen the tight musculature and other taut soft tissues. However, this only addresses one part of the problem, and usually the lesser part. The other aspect of this condition is the weakness of the musculature that must support the arch structure against the forces that cause overpronation. These muscles must be strengthened. Therefore, referral to a fitness trainer, physical therapist, yoga or Pilates instructor, or the recommendation of specific exercises to strengthen the muscles that support the arch (see Table 1) is imperative (for more on the strengthening of these muscles, see the Self-care for the client section below).

Precautions/contraindications There are a few precautions when working on a client with overpronation. Care must be exercised if working near the fibular head because of the presence of the common fibular nerve; and care must be taken if working the medial ankle region because of the presence of the tibial nerve and artery. If work is being done in the gluteal region for the deep lateral rotators of the hip, be aware of the location of the sciatic nerve near the piriformis and lying superficial to the quadratus femoris.

One precaution and possible contraindication is to be careful when attempting to make any structural change to a middle-aged or elderly person’s foot.

Terra Rosa E-mag 41

A

B

Their tissues are less elastic than a younger person’s; and if they have been overpronating for dec� ades, it is likely that all the tissues throughout their body have adapted to this structure. A good guideline is to exercise caution if the client is over 50 years of age. The older the client, the more slowly and carefully the treatment regimen should be introduced. Changing something as fundamental as the foot’s foundational posture for the body might cause unwelcome compensatory adaptations above.

Beyond these precautions, be sure to gradually transition from light to deep pressure for all clients when working the plantar side of the foot because many people are tender in this region.

Self-care for the client

C

D

When working with a client for the treatment of overpronation of the foot, client self-care is extremely important. Supple flat foot is essentially a condition of weakness of the ligament complex and musculature that support the arch structure of the foot. Therefore, strengthening the weak musculature is imperative if the condition is to be resolved.

The specific musculature that should be assessed and strengthened if weak is given in Table 1. The challenge is that this musculature must be strengthened to the point that it can not only do its originally intended job, but also be strong enough to compensate for the weakened fascial ligament complex. If this is possible, it will require dedication on the part of the client. The major muscle groups to strengthen are the supinators (invertors) of the foot, and the lateral rotators and abductors of the thigh at the hip joint.

One very easy, inexpensive, and low-tech way to accomplish home-care strengthening is to use elastic tubing or bands to provide resistance when performing the exercise (Figure 11). One end of the elastic tube can be stabilized by being placed in a closed door (or by being tied to a stable structure).

The resistance of the exercise is determined by the length of the tube, which is easily altered by changing the distance that the client sits from the door.

As a general rule, these exercises should be performed in four phases. Phase one involves performing the exercises slowly through a short range of motion; phase two is done by moving through the same short range of motion, but quickly. Phase three is performed slowly through a large range of Figure 11 Resistance exercise for overpronation using elastic motion; and phase four is performed by moving tubing. A and B, Performing inversion of the foot at the subtalar quickly through a large range of motion. Begin by joint against resistance. A, Starting position. B, Inversion of the performing each exercise for approximately 15-30 foot. C and D, Performing lateral rotation of the thigh at the hip joint against resistance. C, Starting position. D, Lateral rotation of seconds, gradually working toward 60 seconds.

Once each phase can be comfortably and profithe thigh. Courtesy Joseph E. Muscolino DC 42 Terra Rosa E-mag

ciently performed, direct the client to transition to the next phase. As a general guideline, each phase should be performed approximately 2-4 weeks before the client is ready to graduate to the next phase. Once all four phases have been mastered, your client can begin again, this time with greater resistance.

One excellent self-care exercise for the intrinsic plantar musculature of the foot can be performed with a towel. Instruct the client to be seated, barefooted, with a towel placed in front of them on a hardwood, tile, or linoleum floor. Ask the client to flex their toes, scrunching up and drawing the towel toward them; then relax the toes and release the towel. Have the client repeat this until the entire towel has been drawn toward them (Figure 12).

This exercise can be repeated as desired.

Another excellent exercise for the intrinsic plantar musculature can be performed using marbles or small balls. Instruct the client to be seated, barefooted, with marbles/balls on the floor in front of them. Ask the client to pick up a marble, one at a time, and then place it back down (Figure 13). This can be repeated as long as desired.

Finally, it is important to discuss with the client postures to be avoided, proper shoes or orthotics to wear (for more on orthotics, see the next section, Medical Approach), and if the client is obese, the possibility of losing weight. If you are schooled in orthopedic taping, this modality can also be valuable. The importance of taping is not to temporarily support the arch, but rather to help the client’s nervous system receive proper proprioceptive feedback so that it can begin to re-learn the proper static posture and dynamic acture between pronation and supination.

Medical treatment Overpronation is a postural dysfunction pattern, therefore there really is no “medical” approach. If a podiatrist is consulted, it is likely that orthotics to support the client’s arches and control excessive pronation will be recommended. Generally, orthotics can be divided into two categories: soft and rigid.

Rigid orthotics better control the client’s foot mo‐ tion, but do not provide shock absorption for the joints of the lower extremity and spine; whereas soft orthotics provide excellent shock absorption but do not control the client’s pronation as well. The best orthotic to use will vary from client to client.

There is also the choice of custom made/fitted orthotics that can be quite expensive, versus premade store-bought orthotics that cost far less. Custom fit-

Figure 12 Towel scrunching exercise for the plantar intrinsic musculature. A, Starting position. B, Flex toes and draw towel toward you. C, Relax toes. D, Flex toes and draw towel toward you again. Courtesy Joseph E. Muscolino DC

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Figure 13 Marble pick-up exercise. A, Gripping the marble. B, Picking up the marble. Courtesy Joseph E. Muscolino DC

ted orthotics are superior, but their cost may be prohibitive for the client. Often, store-bought orthotics will work perfectly fine. Again, the decision must be made on a client-by-client basis.

It should be stated that the decision to wear orthotics is a controversial one. Orthotics are a passive brace that do little or nothing to retrain the client’s body to stop overpronating. In fact, it could be argued that they do harm in that they remove the need for the client’s arch support musculature to contract, thereby causing it to further weaken. The same argument could be made for shoes with sturdy arch support. There is merit to this argument. However, if the client’s musculature cannot be retrained, or the client is simply not interested in attempting the retraining program, then a passive support is likely better than the effects of chronically overpronating. If the client is interested in strengthening the arch structure of the foot, then as this goal is being reached, gradually transitioning the client toward minimalist shoes can aid in the demand upon the musculature to strengthen.

Case study Kerrati is a 36 year-old manager who works at a retail store. She came in for wellness massage, but during the postural examination, the therapist noticed that Kerrati’s right arch drops markedly upon weight-bearing. Further, her right iliac crest is low and she has a mild lumbar scoliosis (convexity to the right). Kerrati does not report experiencing pain in her right foot or elsewhere in her body.

After finding the overpronation, the therapist performed a palpatory exam and found tightness in Kerrati’s plantar foot as well as myofascial TrPs in Kerrati’s right-sided tibialis anterior, fibularis longus, gluteus medius, upper gluteus maximus, and piriformis. Tightness was also found in the musculature (erector spinae, transversospinalis, and quad44 Terra Rosa E-mag

ratus lumborum) located in the concavity of the scoliosis, in the left low back. With palpation into these areas, Kerrati experienced tenderness and mild pain. Range of motion examination showed slightly decreased inversion of the right foot. The therapist also performed motion palpation assessment of the tarsal and metatarsal bones on the plantar side of the foot, and found restricted motion generally for the right foot compared to the left, especially when assessing mobilization of the tarsals from plantar to dorsal in direction.

Given the assessment of overpronation of the Kerrati’s right foot, along with the dropped iliac crest and compensatory scoliosis, the therapist recommended two one-hour massages per week for four weeks and one one-hour massage per week for the following four weeks. The therapist also referred Kerrati out to a fitness trainer with the request that the fitness trainer specifically focus on strengthening all the musculature that supports the arch structure of the foot.

With Kerrati lying supine, soft tissue manipulation was performed for the anterior and lateral compartments of the leg for approximately 5-10 minutes, gradually transitioning from mild to deeper pressure. Kerrati was then turned prone and soft tissue manipulation was performed for the posterior compartment of the leg and plantar foot for approximately 5-10 minutes, again gradually transitioning from mild to deeper pressure to access the deep musculature on the posterior side. This was followed by moist heat to the plantar foot and posterior leg for an additional 10-15 minutes while the therapist worked Kerrati’s hip joint lateral rotation, abduction, and adduction musculature, as well as the lumbar spine musculature.

The therapist then stretched Kerrati’s foot into supi‐ nation and pronation, as well as plantarflexion and dorsiflexion. After stretching was done, the thera-

pist performed arthrofascial stretching (Grade IV soft tissue joint mobilization) to Kerrati’s foot, with emphasis placed on mobilizing the tarsal bones from the plantar to dorsal direction. With the remaining time, the therapist worked the client’s other-side lower extremity.

Each session was carried out in a similar manner. As Kerrati gradually improved, increasing depth of pressure and assertiveness of stretching and joint mobilization was employed. Kerrati was given selfcare stretches for her low back and her hip joint deep lateral rotators; and she was told to perform these stretches two to three times per day after a hot shower or other form of moist heat application.

She was also recommended to perform the towel scrunching and marble pick-up exercises for her feet. Finally, proper posture at work and home was discussed, including the recommendation to find shoes with better arch support, with the long-term goal to transition toward minimalist shoes.

At the end of eight weeks, Kerrati’s tarsal and meta‐ tarsal bones were much more mobile, and many of the TrPs in her leg, buttock, and low back were improved. Further, her tenderness to palpation in these regions was diminished approximately 80%.

Kerrati is still working with her trainer, who is reporting that the strength of the targeted muscles is

improving nicely.

For proactive self-care with the goal of continuing to improve the overpronation dysfunction of her right foot, Kerrati continues to receive clinical orthopedic massage once or twice each month and continues to work out with her trainer twice per week. Whether this plan will be successful toward entirely resolving her overpronation will take many months or longer to determine. However, catching this condition relatively early bodes well for improvement and was critically important to correct the compensatory postural changes above.

Joseph E. Muscolino, DC, is a chiropractor in private practice in Stamford, CT who employs extensive soft tissue manipulation in his practice. He has been a massage educator for more than 25 years . He is the author of multiple textbooks including The Muscle and Bone Palpation Manual, The Muscular System Manual, and Kinesiology (Elsevier) and Advanced Treatment Techniques for the Manual Therapist: Neck and Manual Therapy for the Low Back and Pelvis—A Clinical Orthopedic Approach (LWW) and the author of multiple DVDs on Manual Therapy. Joe teaches Continuing Education Clinical Orthopedic Manual Therapy (COMT) Certification workshops around the world and in Australia.

Terra Rosa E-mag 45

Clinical Orthopedic Massage Therapy with Dr. Joe Muscolino Sydney, July 2016 www.terrarosa.com.au

This workshop covers the major clinical orthopedic assessment and treatment techniques (soft tissues & Joint mobilization) for the neck.

This workshop covers major clinical orthopedic assessment and treatment techniques for the lower extremity

15-16 July 2016, Sydney

17-18 July 2016, Sydney

ATMS, AMT, Approved CPE/CEU Points Don’t miss this unique experience to train with Dr. Joe Muscolino.

46 Terra Rosae-magazine, E-mag Terra Rosa

No. 11

"Joe Muscolino is a master of his profession! His broad knowledge on the human body and extensive experience made the workshops interesting and engaging. I would (Decemberhighly 2012) recommend his workshops to any body-worker. I, myself, can't wait for the next one!" Zuzana G, North Sydney.

Overselling Overpronation

By Jeff Tan Overpronation can be used as an excuse for selling food orthosis.

Matt Wallden argued that there is no such thing as a flat foot, only a lazy or deconditioned foot. He further suggested a credit card test and a simple exercise to correct for it.

Recently I was alerted by the internet “fact” that 90% of the general population's feet are over -pronated. Pronation is the motion of the foot as it roles inward after the foot makes contact with the ground.

Overpronation causes the arch of the foot to flatten excessively placing stress and pressure on tissues and ligaments of the foot. Overpronation , flat foot, pes planus, fallen arches has been worried to lead to many foot problems including plantar fasciitis, ankle pain, lower back pain etc.

study published in 1993 evaluated foot morphology and injury risk in 246 male army recruits followed during 12 weeks of intensive training. They found that 20% of trainees with the flattest feet had the lowest injury risk. In contrast, the 20% with the highest arches had a 6-fold greater

injury risk than the flat-footed group. The middle 60% of trainees had an intermediate risk.

This study dispel the notion that flat-footed people are prone to injury during exercise. But people with high arches should be advised to pursue non - weight-

Various websites mainly selling foot orthoses or related products claim 60% and even up to 90% of the population “suffered” from this condition, and should be corrected. However, a medical review on its prevalence found mostly on children, with quite a high variation estimates from less than 1% to as much as 78%.

A Cochrane review concluded that “Flat foot is often unneces‐ sarily treated, being ill-defined and of uncertain prognosis.”

Figure 1 Pronation and supination of the subtalarjoint,

Not all people with overpronation have problems. A

Image By Ducky2315 [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Terra Rosa E-mag 47

bearing exercise, particularly if they have a rigid deformity.

Matt Wallden, an osteopath from the UK, in a publication published in Journal of Bodywork and Movement Therapies, suggested that there’s no such thing as a flat foot, only a lazy or deconditioned foot. He challenged the idea that the necessity on the use of foot support, as “to support a biological structure, in the long term, is to weaken it”.

Matt Wallden proposed using a credit or business card test, which was designed to screen for subtalar joint neutral by podiatrist Michel Joubert. The client in a normal standing posture, place a credit or business card alongside the lateral border of the foot in alignment the lateral malleolus. When the talus is palpated to be in subtalar neutral, this means that the lateral malleolus is in direct vertical alignment above the lateral border of the foot. The distance between the vertical border of the credit card and the lateral malleolus is a measure of the degree of static pronation, which usually ranges from between 5 to 15 mm. The credit card test is an easy and objective test for static subtalar pronation, the distance from lateral malleolus to vertical border of the credit card can be measured in millimetres.

To remedy this condition, Matt proposed the use of a foam roller longitudinal exercise, which “trains the nervous system not doing the job it should do; in combination with a likely concomitant deconditioning of the muscles”.

He described the exercise balancing on an unstable surface as follows: The client lies down on a foam roller in a longitudinal position with knees flexed to support the body and feet flat against the floor. This condition may already create an instantaneous change in the foot posture because the foot needs to balance the body and bears less weight. The next challenge is to ask the client to place her hands across the chest and to lift one foot off the floor. This creates another level of balance challenge and simultaneously unloading the foot. As the foot on the ground needs to establish stability, it automatically attempts neutralize its subtalar position by “switching on” the intrinsic muscles of that foot, leading to the reformation of the arch. The credit card test can be re-evaluated after the exercise.

Note that there various causes of overpronation, and the above exercise is only for training “weak” muscles. When a client has an indication of overpronation that needs to be addressed, the cause 48 Terra Rosa E-mag

Credit Card Test: The distance of lateral malleolus to the vertical border of the credit card card can be a measure of the degree of subtalar pronation.

needs to be tackled first before pursuing with treatments.

References Burns J, Crosbie, J., Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot. Australasia J Podiatric Med, 2006; 40 (3): 61-6.

Cowan DN et al. Foot morphologic characteristics and risk of exercise-related injury. Arch Fam Med 1993 Jul 2 773-777.

Evans, A.M., and Keith R. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Eur J Phys Rehabil Med 47 (2011): 69-89.

Matt Wallden. Don't get caught flat footed – How over-pronation may just be a dysfunctional model.

J Bodyw Mov Ther. 2015 Apr;19(2):357-61.

Image ŠAdvanced-Trainings.com

Advanced Myofascial Techniques With Til Luchau, Advanced-Trainings.com Sydney: Whiplash (25 – 26 Sept 2016) Canberra: Spine, Ribs, & Low Back (28-29 Oct), Advanced Ribs (30 Oct) Tweed Heads: Spine, Ribs, & Low Back (8-9 Oct), Advanced Ribs (10 Oct) Learn cutting-edge techniques that you can use immediately to start solving some of your most difficult client challenges. Entertaining as well as informative, the classes combine experiential learning, 3D anatomy visuals, technique-specific demonstrations, and hours of hands-on supervised table practice.

Til Luchau is the Director of Advanced-Trainings.com. A legend around the USA for his thorough, student-focused approach to trainings, Til brings more than 25 years of knowledge, talent and enthusiasm to these programs. He has trained thousands of practitioners in over a dozen countries on five continents. He is the author of the Advanced Myofascial techniques book (Handspring Publishing).

Terra Rosa E-mag 49

More Info at: www.terrarosa.com.au

The Hand-L Massage Tool: From Dream to Reality

By Bob McAtee, LMT Bob McAtee, the inventor of Hand-L, tells the history behind the famous massage tool.

Massage Tools: Overview A recent blog post on the the Terra Rosa website noted that massage tools “can help enhance the therapeutic effects of a treatment, and tools can also help therapists, preventing them from fatigue and injury. The highest risk for a massage therapist is mainly wrist, fingers, and thumbs injuries. A survey conducted by Terra Rosa a few years ago indicated that 60% of the surveyed massage therapists in Australia have a prevalence of wrist and thumb injuries.”

Enter the Hand-L Massage Tool As we celebrate the 20th anniversary of Hand-L Massage Tool, we thought it would be interesting to have look back. First, by way of introduction to those of you unfamiliar with it, the Hand-L is a patented ceramic pressure tool, ergonomically designed to reduce stress on thumbs, fingers, and wrists. Its unique shape contributes to its comfort and effectiveness.

50 Terra Rosa E-mag

The Hand-L was first introduced to the massage therapy community in 1996, and the updated HandL 2.0 became available in 2014.

The Hand-L 2.0 is made of hand-finished stoneware clay in an attractive “earthtone” colour, glazed at cli‐ ent contact areas for comfort, unglazed on the gripping surface to provide safe, slip-free control even if using oil/lotion/cream. The updated glaze finish on the client contact surfaces has slightly more “drag” than the original to provide better control when working with lubricant on the skin.

The Hand-L works well in many applications, including trigger point work, cross-fibre work, and deep stripping. It’s effective with lubricant on the skin, or through clothing, so it’s ideal for use during chair massage. Many manual therapists use the Hand-L successfully in the application of the “scraping” tech‐ niques of IASTM (Instrument Assisted Soft Tissue

for a massage tool to use in my sports massage practice and for my own self-massage. I had already been a full-time massage therapist for 11 years by then and was noticing the wear-and-tear on my thumbs, fingers, and hands. In those days, there were only a few massage tools on the market (the Knobble, the Theracane, and a variety of T-bar tools) and none of them fit my hand properly or were too large to do the detailed work I needed them for.

Figure 1 One of the original, hand-built prototypes for the Hand-L, 1992.

Manipulation).

The Story of the Hand-L: Bringing an Idea to Fruition Throughout the summer of 1992, I had been looking (a)

(b)

In September of 1992, I woke from a restless dream in the middle of the night with an image fully formed of the “perfect shape� for a massage tool. I rarely remember my dreams, but this was an image so vivid I could not forget it. When morning finally came, I grabbed some clay and proceeded to handbuild several prototypes of what I had "seen" in my dream. Figure 1 shows of the original pieces.

Over the next few months, my friend Greg, a local ceramic artist, gave me access to his studio and his clay to hand-build another 50 or so pieces, all of them slightly different, trying to refine the design.

Each of these pieces had to air-dry, be glazed, and then fired in the kiln, a somewhat time-consuming process. These pictures show the evolution from a one-ended to a two-ended tool, then the addition of non-slip elements, as well as an attempt to make (c)

Figure 2 (a) This is another version of the shape I was trying to recreate from a dream. (b) This version shows the evolution to the two-ended shape, with color added for aesthetics. (c) a different view, to show the added texture (yellow dots) to help provide a non-slip gripping.

Terra Rosa E-mag 51

them visually appealing.

Once I got to the end of my own design capabilities, I enlisted another friend (a sculptor and toy-maker) who helped refine the final design. We finally went into production and started selling the Hand-L in 1996 (4 years after "the" dream).

Start-Up Challenges The greatest challenge for a start-up business is funding, and my situation was no different. I could not afford to go into mass-production of the Hand-L, so had to find a small production studio that could make the tool in batches of 50-100 at a time. I maintained that level of production for several years.

We also had to come up with a design for a retail box, a belt holster, organize an instructional brochure, and solve a million other little issues that go into producing and selling a product. The learning curve was steep!

I applied for a patent on the Hand-L in 1997 and it was awarded January 4, 2000. This allowed me to take the Hand-L to the next level of production and marketing.

Figure 3. Here is the original Hand-L, made of white porcelain clay with the logo stamped into the non-slip grip.

I hope you find the Hand-L as useful in your practice as the tens of thousands of other therapists worldwide who have adopted it.

Features that make the Hand-L unique: 

The original ceramic massage tool.



Ergonomically designed for comfort.



Unique shape maximizes leverage, not strength.



Relieves pressure on thumbs, fingers, and wrists.



Helps prevent overuse injuries.

In 2014, we brought the manufacturing back home The Hand-L tool is now available at: to Colorado. Due to a major change in the manufac- www.terrarosa.com.au turing process, we've made some small design and color changes to the Hand-L that make it even more Read 6 Questions to Bob on page 63. visually appealing, without changing its ergonomics or functionality. We are once again crafting the Hand -L in small batches to help us better control their quality.

52 Terra Rosa E-mag

Register at www.terrarosa.com.au

Sydney, 15-16 October 2016

Sydney, 17-18 October 2016

Fascia of the Pelvic Floor

Fascial Toning

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Sydney, 21 October 2016

Sydney, 22-23 October 2016

A working experience with CORE Myofascial Therapy

By Taso Lambridis, MSc Photo by Patty Kousaleos

CORE Myofascial Therapy was developed by George Kousaleos, a highly experienced Structural Integration Therapist based in Florida, USA who also has a major role with the Athletic Program at Florida State University. George developed the Sports Massage team for the British Olympic Association in preparation for the 1996 Atlanta Games and helped established the Olympic massage therapy standards for the Athens 2004 Olympics.

54 Terra Rosa E-mag

Those who have attended any of his course in Australia over the past 2 years can attest to the fact that George is probably one of the most engaging teachers and has an in-depth knowledge of the myofascial method gained from over 40 years of work in the field of Structural Integration. I recently had the opportunity to be part of a team of soft-tissue therapists who attended a 1 week long training internship run by George in Florida, USA with the added

Photo by Patty Kousaleos

opportunity of working on elite-level college American Football athletes undergoing an 8-week speed training and conditioning program.

As a physiotherapist, I already received my certification in CORE Myofascial Therapy having attended George’s courses in Sydney but the opportunity of working closely with him was too great not to be missed. I was invited due my particular interest in the SIJ and pelvis and for what further knowledge I could provide to the rest of the therapy team. My week-long experience gave me the perfect opportunity to apply the CORE Myofascial Therapy to these professional athletes as well to provide me with some insight into the world of Pro-American Football, better known as the NFL. George had teamed up with Toni Villani, the Director of XPE Sports in Boca Raton, who is considered a ‘speed guru’ and sports trainer, known for getting excellent results and helping a wide range of athletes to achieve a professional status in their chosen sport. George was to provide CORE Myofascial Ther-

apy with the help of a group of 8-10 therapists each week who would receive instruction on structural bodywork. The aim of the CORE Myofascial Therapy was to enhance the athletes’ training performance and recovery but also very importantly to prevent injuries.

30 elite-level, college American Football players would attend an 8-week conditioning program under the guide of Toni Villani and his trainers. These college athletes were hoping to turn professional and would train at XPE Sports in the hope of performing well at the upcoming trials and securing a professional NFL contract.

The NFL Just to give you some background. The NFL is big business and dwarfs any of the Australian footy codes generating billions of dollars with many players earning salaries in excess of the combined salaries of entire NRL teams. For example the current Terra Rosa E-mag 55

Photo by Patty Kousaleos

quarterback at the San Francisco 49’s is on a con‐ tract worth annually $US 11.5 million. In Australia recent interest in the NFL has been generated by an ex-rugby NRL player Jarryd Hayne who switched codes in 2015 aiming to secure a long-term player contract and a spot on the 53-man roster of the 49’s.

Some sobering facts of what it takes to be a professional NFL player will give you some idea of the challenge that Jarryd Hayne faces in order to secure that permanent spot with the San Francisco 49’s since most rookies won’t make it beyond the first 3 years in order to make a decent living out of the sport.

Consider this:

The Combine This is the NFL’s official trial for new recruits where college football players perform physical and mental tests in front of NFL coaches, general managers and scouts; this also includes a series of gruelling medical examination and player interviews to assess their mental aptitude. About 300 athletes are invited each year and their performance at the combine can affect their draft status, salary contract and future careers.

The combine tests include: 

The 40-yard dash,



Bench press repetitions of 225 pounds,



1,093,234 high school players.



Vertical & Horizontal jump,



6.5% will play in college.



Several shuttle & cone drills,



Only 1.6% of college players get drafted by the NFL.



Position specific drills.



Of the 300 rookies making a team, only 150 players make into Year 4.

56 Terra Rosa E-mag

Although there are critics of the combine who question whether these tests reliably measure or predict a player’s success as a pro-NFL player, this has become a major sporting event of its own and is

Photo by Patty Kousaleos

screened on the NFL’s own subscriber TV channel. It covers over 30 hours of coverage over the 4 days and receives between 5-6 million viewers; the 40 yard dash has become the ‘Olympics of the NFL’.

Myofascial Therapy The structural bodywork was performed according to the CORE Myofascial Therapy protocol developed

by George Kousaleos. George’s approach has main‐ tained much of the basic form and method developed by Dr. Ida Rolf and has remained pure by promoting her ideals of Structural Integration. There is a distinct focus on ‘spreading’ the superficial layer of fascia and works in a systematic manner from superficial to deeper layers. This work has to be experienced to fully appreciate its profound effects on an individual’s postural awareness and ease of movement. On a regular basis you could see the look of amazement and the sincere appreciation from the players immediately after the sessions and they would often comment on how the work we gave allowed them to consistently train at the intense levels expected by Toni Villani.

The training in myofascial therapy and learning about structural integration strategies was done in the morning while the athletes were put through their training sessions and then in the afternoon, we conducted the therapy sessions for about 3 hours each day. We had 45 minutes sessions for each athlete which might seem like a luxury but given the size of these athletes and the numbers of athletes attending XPE Sports, we were kept very busy. In order to ensure a uniformity of treatment throughout the 8 weeks, it was explained to us from the start that we were only to use CORE Myofascial Therapy even though we all had extensive clinical experience in treating athletes. In this way, the athletes would receive the same treatment from any of the therapists who happened to be working on them in any given week.

a key role with the Athletic Department) sustain much lower injury rates than other college athletes.

For me personally, myofascial therapy has had profound effects on how I treat patients. Having integrated myofascial release method into my clinical practice for over 10 years, I have found that CORE Myofascial Therapy has given me further insight into the amazing world of fascia and the tools to provide long-lasting beneficial effects to my patients.

Taso Lambridis is a Physiotherapist working in Sydney and is the Director of Spinal Synergy Physiotherapy. He has a BSc in Physiotherapy and MSc in Sports Medicine.

Taso has over 20 years of clinical experience and has a particular interest in treating complex spine problems. He has extensive knowledge on the SIJ and teaches courses to physiotherapists and other manual therapist on an evidence based approach to SIJ Dysfunction. He has been using myofascial release for over 10 years in his own practice and this has greatly enhanced his clinical practice.

I was impressed that given the intensity of training the athletes been put through, for the whole 8 weeks there was not a single injury. It is also worth mentioning that athletes who regularly receive this work at Florida State University (where George has Terra Rosa E-mag 57

Photo by Patty Kousaleos

Maximise Oxygenation

CORE MYOFASCIAL THERAPY with George Kousaleos Sydney, November 2016 "George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy” - James Waslaski LMT; Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage

CORE Myofascial Therapy Certification

CORE Sports and Performance Bodywork

Sydney

Sydney 19,20,21 November 2016

CORE Myofascial Therapy 1: 11,12,13 November 2016 CORE Myofascial Therapy 2: 14,15,16 November 2016

This 3-day seminar will examine the basic styles of performance inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are appropriate for each style of performance, we will focus on developing training and event protocols for endurance, sprint, power, and multi-skilled athletes.

An intermediate to advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clients’ structural body alignment and increase their physi‐ cal performance.

“Getting the basic Myofascial Spreading done on my first day resulted in a dramatic improvement of my body alignment “ Mic, Townsville

George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years.

George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the International Sports Massage Team for the 2004 Athens Olympics.

Terra Rosa 58 Terra Rosa E-mag Your Source for Massage Information AMT , ATMS, IRMA, MAA Approved CEs.

For more information & Registration Visit www.terrarosa.com.au

Recent Research Highlights What is bad for your heart is bad for your tendons Individuals with unhealthy blood cholesterol levels are more likely to have tendon pain or altered tendon structure, according to a new study.

Australian authors Ben Tilley, Jillian Cook and colleagues from Monash University and University of Canberra published “Is higher serum cholesterol associated with altered tendon structure or tendon pain? A systematic review” in the British Journal of Sports Medicine The authors noted that tendon pain occurs in individuals with extreme cholesterol levels (familial hypercholesterolaemia, an established risk factor for coronary heart disease.). Cholesterol also accumulates in tendons. They conducted this review is to investigate whether the association with tendon pain is strong with less extreme elevations of cholesterol.

The review included 17 tendon studies with data from more than 2000 people, and results indicated that there is a relationship between an individual’s lipid profile and tendon health.

“The most interesting finding was that the pattern of cholesterol changes seen with tendinopathy was similar to that which increases cardiovascular disease risk. It seems that what is bad for your heart is bad for your tendons.” …The researchers theorize that cholesterol deposits lead to inflammation of the tendons, and this leads to structural changes that make the area vulnerable to injury and pain. …“However, the more important benefit of identify‐ ing a link between cholesterol and tendinopathy is the potential for early detection of high cholesterol, and management of cardiovascular disease risk, in those presenting with tendon pain.”

A New Muscle "Discovered": The tensor vastus intermedius How many muscles are there in the Human body?

From the Biotensegrity viewpoint there is only one.

However from the clinical anatomy perspective a muscle can achieve autonomy once it can be shown to meet specific criteria. An article published in the journal Clinical Anatomy (March 2016) by a group of researchers in Switzerland claimed that they have "discovered" a "new" muscle in the Quads!

The quadriceps femoris is traditionally described as a muscle group composed of the rectus femoris and the three vasti. However, clinical experience and investigations of anatomical specimens are not consistent with the textbook description. The researchers have found a second tensor-like muscle between the vastus lateralis (VL) and the vastus intermedius (VI), hereafter named the tensor VI (TVI).

A TVI was found in all dissections of 26 cadavers. It was supplied by independent muscular and vascular branches of the femoral nerve and lateral circumflex femoral artery. Further distally, the TVI combined with an aponeurosis merging separately into the quadriceps tendon and inserting on the medial aspect of the patella.

The authors suggest a couple of likely functions of the TVI: By way of its basic orientation — travelling down the outside of the thigh from the hip, crossing the quadriceps tendon on a diagonal to reach the inside aspect of the kneecap — it is probable the TVI plays a role in patellar control.

As the TVI aponeurosis is often fused or closely related to the VI muscle, it may exert tension on this muscle — contributing to the VI function as well.

Hence the name: “tensor of the vastus intermedius”

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Research Highlights To Roll or Not to Roll Self‐myofascial release (SMR) using either a foam roll or roller massager becomes quite popular in Sports and Bodywork. These tools are promoted to enhance recovery and performance. A recent review published in International Journal of Sports Physical Therapy attempt to evaluate the efficacy of these rollers on joint range of motion, muscle recovery, and performance.

The authors searched for peer reviewed publications that measured the effects of SMR using a foam roll or roller massager on joint ROM, acute muscle soreness, DOMS, and muscle performance. A total of 14 research articles were evaluated.

Does self‐myofascial release with a foam roll or roller ‐massager improve joint range of motion with‐ out effecting muscle performance?

Both foam rolling and the roller massage may offer short‐term benefits for joint ROM at the hip, knee, and ankle without affecting muscle performance.

Also, that SMR may have better effects when combined with static stretching after exercise After an intense bout of exercise, does self‐ myofascial release with a foam roller or roller‐ massager enhance post exercise muscle recovery and reduce DOMS? Foam rolling and roller massage after high-intensity exercise does attenuate decrements in lower extremity muscle performance and reduces perceived pain in subjects with a post exercise intervention period ranging from 10 to 20 minutes. Continued foam rolling (20 minutes per day) over 3 days may further decrease a patient's pain level.

Does self‐myofascial release with a foam roll or roller ‐massager prior to activity affect muscle perform‐ ance?

Short bouts of foam rolling (1 session for 30 seconds) or roller massage (1 session for 2 minutes) to the lower extremity prior to activity does not enhance or negatively affect muscle performance but may change the perception of fatigue.

The authors concluded that the current literature measuring the effects of SMR is still emerging. The results of this analysis suggests that foam rolling and roller massage may be effective interventions for enhancing joint ROM and pre and post exercise muscle performance. However, due to the heterogeneity of methods among studies, there currently is no consensus on the optimal SMR program.

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Scalp Massage Can Increase Hair Thickness A new study from Japan evaluated the effect of scalp massage on hair in Japanese males and the effect of stretching forces on human dermal papilla cells in vitro.

Nine healthy men received 4 minutes of standardized scalp massage per day for 24 weeks using a scalp massage device. Total hair number, hair thickness, and hair growth rate were evaluated. The results showed that standardized scalp massage resulted in increased hair thickness 24 weeks after initiation of massage (0.085 ± 0.003 mm vs 0.092 ± 0.001 mm). In vitro, DNA microarray showed gene expression change significantly compared with nonstretching human dermal papilla cells. A total of 2655 genes were upregulated and 2823 genes were downregulated. The analyses also showed increased expression of hair cycle-related genes and decrease in hair loss-related genes. The authors concluded that stretching forces result in changes in gene expression in human dermal papilla cells, and scalp massage transmits mechanical stress to human dermal papilla cells in subcutaneous tissue.

Manual therapy as an effective treatment for fibrosis in a rat model Key clinical features of carpal tunnel syndrome and other types of cumulative trauma disorders of the hand and wrist include pain and functional disabilities which may involve tissue inflammation and/or fibrosis. To understand how massage therapy affects the cellular level, authors Geoff Bove and colleagues examined the effectiveness of modelled manual therapy (MMT) as a treatment in forearm tissues of rats which were induced with repetitive stress injuries. The study was published in Journal of Neurological Science Young adult, female rats were examined: food restricted control rats were trained for 6 weeks before performing the performing a high repetition high force (HRHF) reaching and grasping task for 12 weeks. A group of 11 rats has no treatment (n=11), while another group received modelled manual therapy (n=5) for 5 days per week for the duration of the 12-week of task.

The results showed that rats receiving the manual therapy expressed less discomfort-related behaviour and performed progressively better in the HRHF task. Grip strength, while decreased after training, improved following thereof. Fibrotic nerve and connective tissue changes (increased collagen and TGF-β1 deposition) present in 12-week control

Research Highlights rats were significantly decreased in 12-week after treatment.

The authors concluded that these observations support the investigation of manual therapy as a preventative for repetitive motion disorders.

The benefits of coffee on skeletal muscles Australian loves their coffee and epidemiological studies have revealed an association of coffee consumption with reduced incidence of a variety of chronic diseases as well as all-cause mortality. However there is little attention on its effect on skeletal muscle. A recent review published in Life Science Journal suggesting that coffee has beneficial effects on skeletal muscle.

Coffee has been shown to induce autophagy, improve insulin sensitivity, stimulate glucose uptake, slow the progression of sarcopenia, and promote the regeneration of injured muscle. Coffee consumption has also been shown to attenuate the progression of sarcopenia, the progressive loss of muscle mass and strength with age. Mice who consumed caffeinated coffee in their drinking water over a 4-week treatment period showed greater muscle weight and grip strength.

cross-sectional area of the paraspinal compartment were quantitatively measured from axial images at the level of the transverse processes and the Chronic Pain Grade Scale was used to assess low back pain intensity and disability.

The results of observations showed a shorter length of fascia around the parapsinal compartment was significantly associated with high intensity low back pain and/or disability, after adjusting for age, gender, and body mass index.

The authors concluded that a shorter lumbar paraspinal fascia is associated with high intensity low back pain and/or disability among communitybased adults. Although cohort studies are needed, these results suggest that structural features of the fascia may play a role in high levels of low back pain and disability.

Massage therapy decreases pain and fatigue after Ironman triathlon A study from Brazil published in Journal of Physiotherapy asked the question Can massage therapy reduce pain and perceived fatigue in the quadriceps of athletes after a long-distance triathlon race (Ironman)?

The author concluded that current studies investigating the effects of coffee on skeletal muscle have only utilized animal and in vitro models. No studies have utilized human subjects, any volunteer?

The study recruited 74 triathlon athletes who completed an entire Ironman triathlon race and whose main complaint was pain in the anterior portion of the thigh. The study was a Randomised, controlled trial with concealed allocation, intention-to-treat analysis and blinded outcome assessors. The experiShorter lumbar paraspinal fascia is mental group received massage to the quadriceps, associated with high-intensity lower which was aimed at recovery after competition, and the control group rested in sitting. The outcomes back pain were pain and perceived fatigue, which were reThe thoracolumbar fascia plays a role in stabilization ported using a visual analogue scale, and pressure of the spine by transmitting tension from the spinal pain threshold at three points over the quadriceps and abdominal musculature to the vertebrae. It has muscle, which was assessed using digital pressure been hypothesized that the fascia is associated with algometry. low back pain through the development of increased The trial showed that the experimental group had pressure in the paraspinal compartment, which leads to muscle ischemia. A study from Monash Uni- significantly lower scores than the control group on the visual analogue scale for pain and for perceived versity and colleagues from Australia, published in fatigue. There were no significant between-group the Journal Spine, investigated the relationship between structural features of the thoracolumbar fas- differences for the pressure pain threshold at any of the assessment points. cia and low back pain and disability.

Seventy-two participants from a community-based study of musculoskeletal health underwent Magnetic Resonance Imaging from the T12 vertebral body to the sacrum. The length of the paraspinal fascia and

The authors concluded that massage therapy was more effective than no intervention on the post-race recovery from pain and perceived fatigue in longdistance triathlon athletes.

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1. When and how did you decide to become a bodyworker?

My first visit to a Chiropractor as a 19 year old. I was in first Mining Engineering at UNSW and I was so impressed with the speed I was fixed (1 treatment) that I wanted to be a Chiropractor immediately, especially as I was quite a sceptic going into my first appointment. So I dropped out of Mining Engineering and started Chiropractic the next year.

2. What do you find most exciting about bodywork therapy?

The ability to fix a long term issue and quite often very quickly, especially on a patient who has been unable to use their body properly for some time either an athlete or older person.

3. What are your favourite bodywork books?

My favourite body work books are anything by Donatelli, some great ones on specific sports rehab, any of Stoller’s imaging books and Carla Stecco’s Functional Atlas of the Human Fascial System.

4. What is the most challenging part of your work?

The most challenging part of my work is dealing with with severely degenerative spinal conditions.

5. What advice you can give to fresh manual therapists who wish to make a career out of it?

Advise to new manual therapists is get into good habits with your own body positioning at the start of your career and also be careful not to put exces62 Terra Rosa E-mag

sive load or pressure through your own joints at their end range of movement. Your future longevity depends on getting this right.

6. How do you see the future of manual therapy?

The future of manual therapy will be very strong as more and more patients are looking to minimise prescription medication usage due to their often adverse effects. The keys will be, correct diagnosis, specific treatment, good communication with the patient and good results.

David Steven has been in private practice as a Chiropractor for 21 years in both Balgowlah and Neutral Bay, Sydney. He has the skills and ability to diagnose, treat and fix both spinal and peripheral conditions involving both the bony structures and the connective tissues. He has extensive experience using various modalities including Chiropractic, Acupuncture, Dry Needling, various soft tissue techniques including Active Release Technique, Kinesiotaping and Sports Taping.

He Developed www.stretchIQ.com, a stretch/ strength video database for use by practitioners worldwide.

David has years of experience treating elite athletes including numerous Olympic and Commonwealth athletes from various sports, national rugby league and rugby union. Recently he was appointed Chiropractor at the Polyclinic for the Rio Olympic games 2016

1. When and how did you decide to become a bodyworker?

I came to massage and bodywork via my degree in psychology. I got interested in the work of Willhelm Reich and his theories that “body armoring” blocks emotional energy flow. This led me to study and receive body therapy with Neo-Reichian practitioners. As I saw the benefits of this work in my own life, I decided to pursue the work. One of the prerequisites for the program I was interested in studying was to take a basic massage course. As it turned out, I did not pursue the training in NeoReichian work, but decide to pursue massage and bodywork more generally. My next level massage training was through a school that focused on bodywork (structural integration and emotional release) than just massage.

2. What do you find most exciting about bodywork therapy?

I’m often amazed that after 35 years, I never get bored with the work. Every day brings new challenges, new ways to work with the same clients, and new opportunities to keep learning.

3. What are your favourite bodywork books?

My publisher would be unhappy if I didn’t refer to my own book first ;-): 1. Facilitated Stretching, 4th edition with online video, Robert E. McAtee and Jeff Charland 2. Functional Atlas of the Human Fascial System, Carla Stecco 3. The Muscle and Bone Palpation Manual, Joe Muscolino (one of several of Joe’s titles that I use regu‐ larly) 4. Therapeutic Massage in Athletics, Pat Archer 5. Sport and Remedial Massage Therapy, Mel Cash

4. What is the most challenging part of your work?

I wear many hats (massage therapist, writer, educator, inventor, business owner) and my biggest challenge is carving out the time to keep current in each of these endeavors. I hope to begin work on a new book soon, one that I’ve been thinking about for years, but have not been able to pursue due to other demands on my time. Wish me luck!

5. What advice can you give to fresh manual therapists who wish to make a career out of it?

1. It’s important to realize that it takes time to build the physical and emotional stamina to have a fulltime manual therapy practice. It’s better to go slow, and let the business build organically.

2. Practice good self-care, pay yourself first, don’t let clients control your schedule (this is a hard one), never stop learning, be willing to adapt your work to stay healthy and to stay current.

6. How do you see the future of manual therapy?

I believe we will always have a need for professional practitioners skilled in the art of “touchingon-purpose” to provide relief from pain, to promote physical performance (whether sport or work related), and to provide nurturing contact that humans need to thrive.

Bob McAtee, LMT, CSCS, has been a massage therapist since 1981, specializing in sports massage and soft tissue therapy. Since 1988, Bob has maintained an active, international private practice in Colorado Springs, CO. His clientele includes Olympic and professional athletes, dancers, performers, and recreational athletes, active older adults, stressed office workers, and those suffering soft-tissue injuries. He is the author of Facilitated Stretching, a how-to book about PNF stretching, used by health and fitness professionals worldwide.

Bob invented the patented Hand-L Massage Tool, used by manual therapists worldwide to save their thumbs. For more information, please visit www.stretchman.com

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