It is difficult to separate the muscle from the tendon as they are incorporated as a functional unit. The tendon is connective tissue comprised of dense, regular connective tissue that continues around the muscle as epimysium as well as through the muscle as perimysium and endomysium.1 Tendon fibers are arranged in parallel to allow the continuation of the force transmission from the contracting muscle to the bone in order for osteokinematics to occur.2 Connective tissue has been found to have more tensile force in a proximal-distal orientation rather than medial-lateral.3 While textbooks teach muscle actions as concentric contractions, most real-world contractions are eccentric in nature in order to control our movement patterns. Eccentric exercise puts more strain on the tissues and when the strain exceeds the tensile strength of the tissue, injury occurs.

Tendon degeneration occurs on a continuum from healthy tendon to tears.4 As the person moves through the continuum, there is the development of symptoms (pain) and loss of stiffness that impairs its ability to transmit forces.4 Structural changes can occur prior to onset of symptoms. Normal tendon typically is comprised of 86.4% normal tendon while asymptomatic tendon may only contain 81.8% with symptomatic tendon only containing 79.5% of normal tissue.5 Fortunately, the patient can move both directions on the continuum.4

Physical therapists have a variety of treatment options available to treat patients. Following the University of St. Augustine for Health Sciences treatment approach via the 18-steps, pain and swelling are the first impairments that are identified and should be addressed.6 Kinesiology tape can be used for a variety of treatment techniques. Application of kinesiology tape has been shown to slow the Ia afferent nerve fibers to reduce pain.7

Tendinopathy can be identified specifically throughout the examination process. Muscle selective tissue tension (MSTT) would have findings of pain during submaximal contraction of the involved tendons while muscle length tests (MLT) would also produce pain as the muscle and tendon lengthen.6 Once tissue specific impairments have been identified, treatment of the tendon can involve instrument assisted soft tissue mobilization (IASTM) in the form of Graston Technique (GT). In early research, it was thought that IASTM helped with pain and healing by increasing microcirculation within the superficial capillary beds.8 GT has also been found to stimulate fibroblasts to lay down new collagen to help heal and re-enforce connective tissue such as tendon.9 Use of GT in a cross-friction pattern has been shown to increase stiffness of ligaments which are also dense, regular connective tissue.10 This technique has also been shown to specifically increase the elastic modulus of tendons by 28.1% allowing for increased range of motion of the joint as well as the ability to withstand more strain.11-12 Treatment can be further augmented by use of kinesiology taping applied distally to proximally in line with the muscle fibers to assist in unloading the tendon.13

As symptoms begin to subside and the emphasis of care is changed to function, exercise becomes the better treatment option. Isometric contractions can be utilized early in the rehab progress to gradual load the tendon to increase its tensile strength.14 Isometric exercise can also be used for analgesic effects through cortical inhibition.14

End-phase rehabilitation as well as prevention should focus on eccentric exercise. Eccentric exercise mimics real-world contraction of muscles and tendons in a functional manner.1, 15 Interestingly, eccentric exercise combined with GT is more effective than eccentric exercise alone.16 However, like any exercise intervention, eccentric exercise success has a correlation with compliance of home exercises.17

SUMMARY
After a thorough examination and evaluation, treatment should initially address any pain or swelling in the involved tendon.6 Direct treatment to the tendon can be applied via GT to increase blood flow while also increasing fibroblast activity to encourage healing.8-12 After application of IASTM, emphasis is placed on lengthening the tissue if it is tight and can be performed with a sustained stretch of 120-240 seconds.3 With the tissue still on stretch, kinesiology tape can be applied to further decrease pain and relax the tissues.7, 13 Finally, treatment sessions end with exercise which is progressed from isometric in the early stages to eccentric activities in the later stages.14-16 This sequencing should assist in progressing the patient from the tendinopathy end of the continuum towards the normal tissue range.4

References
1. Krause F, Wilke J, Vogt L, Banzer W. Intermuscular force transmission along myofascial chains: a systematic review. J Anatomy. 2016;228(6):910-918.
2. Paris SV, Loubert PV. Foundations of Clinical Orthopaedics. St. Augustine, FL: Institute Press, 1999.
3. Stecco C, Pavan P, Pachera P, Caro R, Natali A. Investigation of the mechanical properties of the human crural fascia and their possible clinical implications. Surgical & Radiologic Anatomy. 2014;36(1):25-32.
4. Lawrence D, Cook J, Rio E. The tendinopathy continuum explained. SportEX Medicine. 2014;60:21-26.
5. Docking SI, Rosengarten SD, Daffy J, Cook J. Structural integrity is decreases in both Achilles tendons in people with unilateral Achilles tendinopathy. Journal of Science & Medicine in Sport. 2015;18(4):383-387.
6. Patla CE. E1: Extremity Evaluation and Manipulation. St. Augustine, FL: Institute Press,
7. Konishi Y. Tactile stimulation with kinesiology tape alleviates muscle weakness attributable to attenuation of Ia afferents. Journal of Science & Medicine in Sport. 2013; 16(1):45-48.
8. Nielsen A. Gua sha research and the language of integrative medicine. Journal of Bodywork & Movement Therapies. 2009;13(1):63-72.
9. Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Medicine and Science in Sports and Exercise. 1999;31(4):531-535.
10. Loghmani MT, Warden SJ. Instrument-assisted cross-fiber massage accelerates knee ligament healing. JOSPT. 2009;39(7):506-514.
11. McConnell J, Cruser S, Warder SJ, Bayliss AJ. Instrument assisted soft tissue mobilization alters material and mechanical properties in Achilles tendinopathy. JOSPT. 2016;46(1):A114.
12. Palmer TG, Wilson B, Kohn M, Miko S. The effect of an instrument-assisted soft tissue mobilization technique on talocrural joint range of motion. International Journal of Athletic Therapy and Training. 2016. [epub ahead of print].
13. Farquharson C, Greig M. Temproal pattern of kinesiology tape efficacy on hamstring extensibility. IJOSPT. 2015;10(7):984-991.
14. Rio E, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine. 2015;49(19):1-8.
15. Murtaugh B. Eccentric training for the treatment of tendinopathies. Current Sports Medicine Reports. 2013;2(3):175-182.
16. McCormack JR, Underwood FB, Slaven EJ, Cappaert TA. Eccentric exercise versus eccentric exercise and soft tissue treatment (Astym) in the management of insertional Achilles tendinopathy. Sports Health. 2016;8(3):230-237.
17. Goode AP, et al. Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review. British Journal of Sports Medicine. 2015;49(6):349-356.

Clinician Education: Non-contact ACL tears in females

Much has been made of female being more prone to non-contact tears of the anterior cruciate ligament (ACL) of the knee. These tears, often taking 9 months or more to fully rehabilitate to be able to return to pre-injury activities, has been attributed to a myriad of causes:
larger Q-angles because of the wider female pelvis
weakness of the gluteus medius muscle
hormonal fluctuations due to the menstrual cycle

However, females may be taught from an early age to tear their ACLs. From early childhood, females are taught to cross their legs when they sit. In the lady-like crossing, the hips are adducted and internally rotated leading to connective tissue shortening of the muscles that create this action and connective tissue lengthening of the muscles that prevent adduction and internal rotation.
When these females are asked to perform the NeuroFascial Patterns of a high step march/Trendelenburg test, the non-weight bearing leg will move into the position it has been conditioned to take: hip adduction and internal rotation.
When these same females squat, the hips again adduct and internally rotate. With the leg in a closed-chain pattern during squats, it produces a valgus force and tibial external rotation that increase the risk of injury to the MCL and ACL respectively.
Patient education may be a valuable intervention in these cases by instructing the female patient on proper sitting postures. http://ow.ly/i/otdIR http://ow.ly/i/otdJ0

Many clinicians are still focused on “stretching fascia”. Research shows that fascia requires up to 1997 N/cm2 of force (448.9 pounds of force) to stretch and deform it.(1) Not that clinicians would be able to deform it with manual techniques but the questions becomes if it should be deformed. When a structure or tissue is deformed, it loses its structural integrity. With connective tissues, muscle loses its ability to lengthen or contract due to tearing of the fibers where fascia loses its ability to dissipate electrical discharge to coordinate movement patterns.(2, 3) Our manual techniques do produce mechanical changes, it is on the abnormal collagen crosslinks that form during the inflammatory process that, hopefully, are still immature and malleable. However, there is also an effect via the nervous system provided by sensory input and muscle spindle stretch that can also be utilized to create functional changes and decreasing symptoms.

A review of myofascial grading system finds the range from I-V and encompasses both passive (grades I-III) and active (grades IV-V) techniques. With increases grades, many assume this corresponds with increasing pressure but that is an incorrect assumption; it corresponds with increased tissue tension. If there is significant pressure applied, the brain interprets it as a painful stimuli and will contract the tissues to protect the underlying structures. Even though the techniques are designed to be inhibitory, the patient may present as tighter after the techniques if the self-protection mechanisms have been activated via the nociceptor stimulation.

Here is a review of myofascial release techniques, their purpose and their mechanism of action:

Grade I

Rationale: to decrease pain after acute trauma or in instance of central sensitization (fibromyalgia, complex regional pain syndrome, reflex sympathetic disorder, thoracic outlet syndrome)

Technique: pressure is applied to tissue is passively placed in the position it assumes as it contracts

Mechanism: neurological: autogenic inhibition via decreased tension of the muscle spindle

Basis for: Jones Strain-Counterstrain (SCS), Positional Release Techniques (PRT)

Grade II

Rationale: to decrease pain after acute trauma or in instance of central sensitization (fibromyalgia, complex regional pain syndrome, reflex sympathetic disorder, thoracic outlet syndrome)

Technique: pressure is applied to tissue in a shortened positioned then moved to neutral

Mechanism: neurological: autogenic inhibition via decreased tension of the muscle spindle

Basis for: pin-and-stretch technique

Grade III

Rationale: to improve mobility in areas of myofascial adhesions and mechanical restrictions

Technique: pressure is applied to tissue in a shortened positioned then passively moved to a stretch

Mechanism: mechanical: stretching and shearing of abnormal collagen crosslinks

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

Grade IV

Rationale: to improve mobility in areas of myofascial adhesions, mechanical restrictions or trigger points

Technique: pressure is applied to tissue in a shortened positioned then actively moved to a stretch

Mechanism:   mechanical: stretching and shearing of abnormal collagen crosslinks

Neurological: relaxation of the tissue via reciprocal inhibition

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

Grade V

Rationale: to improve mobility in areas of myofascial adhesions and mechanical restrictions

Technique: pressure is applied to tissue in a lengthened positioned then concentrically contracted

Mechanism: mechanical: stretching and shearing of abnormal collagen crosslinks

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

References

  1. Chaudhry H, Schleip R, et al. Three-dimensional model for deformation of human fasciae in manual therapy. 2008. Journal of the American Osteopathic Association. 108:379-390.
  2. Langevin HM. Connective tissue: a body-wide signaling network? 2006. Medical Hypothesis. 66(6):1074-77.
  3. Ingber DE. Tensegrity and mechanotransduction. 2008. Journal of Bodywork and Movement Therapies. 12(3):198-200.

We are the society that thinks more is better and “no pain, no gain”. However, pain is a warning system in the body. Deep pressure can be applied without being painful but oo much pressure too soon can lead to guarding by the patient which, even though relaxation or inhibitory techniques are being applied, can make the person tighter as a means of self protection.

Fascia, the primary tissue for most manual techniques responds to “gentle, sustained pressure”, according the John F. Barnes’ Myofascial Release Approach. This allows for the patient to adapt and respond to the pressure for adaptive changes to occur rather than forcing changes on the person which equates to trauma.

One common misconception is that the fascia needs to be stretched. Research by Dr. Robert Schliep states we cannot stretch fascia as it would take almost 1400 pounds of pressure to do so. What we are trying to do is to stretch and break down the small collagen cross-links between the skin and the superficial/deep fascias and the muscle. As the tissues are decompressed, they regain the sliding movements which restore mobility. The decompression also elevates pressure of the peripheral nerves so the brain no longer has sensations it interprets as pain.

For those “deep tissue” therapists that doubt the affects of gentle sustained pressure:

Patient Instructions:

Place the tips of your thumbs together and raise your hands above your head

Typical Dysfunctions:
Tight latissimus dorsi = decreased shoulder flexion / lumbar lordosis
Tight pectorals = decreased shoulder abduction (Y’ing)
Weak rectus abdominis = cervical flexion to tension anterior line

Atypical Dysfunction (from seminar in Houston TX):
Picture 1 demonstrates limited right shoulder abduction with hyperabduction on the left. Her torso also laterally flexed to the right.

History:
Patient had “bone scrapping” performed on her right femur when she was 5 years old. A total of 4 vertical scars averaging 3 inches each were placed around her right patellofemoral joint. As she continued age and grow, the scar tissue did not resulting in her movement patterns being pulled to the scar due to the limitation.

Treatment:
Treatment initiated consisted of r 3-4 minutes of scar tissue mobilization via gua sha followed by scar tissue mobilization taping with Rocktape kinesiology tape resulted in substantial changes to her bilateral shoulder mobility.

Discussion:
Scar tissue creates binding of the superficial skin to the superficial layer of fascia to the deep fascia to the muscle. When these adhesions form, it prevents the gliding ability necessary between these tissue for movement to occur. The adhesion can also encapsulate the nociceptors creating chronic pain.
Her right shoulder and trunk were limited due to her right lateral and anterior spiral lines (Anatomy Trains) whereas her left shoulder was affected by both her anterior spiral and anterior functional lines.

From our DVD “Combining Manual Therapy with Kinesiology Taping”:
Steve Middleton, MS, ATC, CSCS, CES, CKTP, FMT discusses the benefits of gua sha and how to incorporate it into your clinical practice:  “Introduction to Instrument Assisted Soft Tissue Mobilization”

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