Sports Massage Manual

2017
Index
Chapter 1: Overview of Sport Massage

Chapter 2: Assessment

Chapter 3: The muscular system

Chapter 4: The joints of the human body

Chapter 5: Correct use of sport massage

Chapter 6: Massage Techniques

Chapter 7: Basic workout procedures

Chapter 8: Muscle injuries and treatments

Chapter 1

Overview
Massage as a preventative measure against injury.

Contraindications:
• Total
• Partial Total
• Localized
Benefits & Effects:
An Overview of Sports Massage
Massage has many benefits. Two of the most important, being relaxation and invigoration.
Cramp, pulled muscles and chronic pain can sometimes be part of the sport person's life;
massage can render most of the problems significantly less severe. Massage maintains
muscles at their optimum resting length, increase flexibility and can help to lower the incident
of soft tissue injuries.

There are four main types of massage useful to sports people: The First being a specialised
massage for different sports. For the most part runners and tennis players do not sustain
injuries in the same areas; therefore there are massage techniques for tennis elbow and
shoulder strain (tennis players) and others for Achilles tendonitis and shin splints (runners).

The second type of massage is pre-€vent. An athlete would use a massage therapist to
warm up his muscles prior to an event, preserving his energy for the race.

The third type is post- event massage. In this case a massage therapist relaxes the muscles
after training or an event which improves circulation and thereby increasing the flow of
lactic acid back to the liver where it can be synthesized. The lactic acid which builds up
during strenuous exercise can be removed by massage within three hours.

The fourth instance where massage can be beneficial is local problematic areas old injures.
The pain cycle in the musculoskeletal system is triggered when the initial cause produces
muscle spasm, impaired circulation, tension and more pain.
Massage breaks this cycle by relaxing the muscle and improving circulation and
promoting healing.

One of the greatest inhibitors of an athlete's performance is physical and mental tension. A
massage therapist who is aware of this knows that relaxation is one of the foremost benefits of
massage, and although the athlete does not want to tackle a race in-a-state of semi-stupor, a
relaxed athlete has optimum function of his mental, cardio-vascular and muscular system.
Therefore the massage therapist needs to utilize different techniques to suit the situation.

Athletes who do make use of massage as part of their regular training are able to achieve
harder, more strenuous and sustained workouts, results in greater fitness and better
performances. However should one of these athletes incur muscular damage (a muscle tear
for example), during a training session, he may consult his massage therapist who assesses
the injury through exercises and then recommends treatment by ice packs and a complete
diagnosis by a general practitioner. The doctor may prescribe physiotherapy and anti-
inflammatory medication, depending upon the severity of the injury. When immediate
diagnoses and correct treatment is undertaken the recovery time is greatly decreased. Once
relative recovery has taken place the massage therapist should once again continue
treatment to lower the possibility of reflex or protective muscle spasm.

4
 A holistic approach to life in general and sport in particular, is more sensible than a
fragmented one. Whilst sports massage as a specific therapy is certainly advisable, the
systematic massage of the entire body is of utmost importance in ensuring that the sports
person is in peak condition when participating in an event, during, training, at home and at
work.

Sports massage offers athletes an alternative to such severe and drastic options such as steroid
injections and surgery often recommended by medical doctors. Such extreme treatment can
and often does leave the sports person worse off and in some cases never able to participate in
sport again.

Massage as a preventative measure against injury.

Injury and pain are the greatest factors preventing an athlete reaching their full potential.
Regular massage treatments aimed at keeping the muscles at their optimum resting length,
relaxation and reinvigorating the muscles, improving the blood circulation and lymphatic flow
can lower the risk of many soft tissues and associated overuse injuries. Athletes involved in
regular training on a continual basis will benefit tremendously from a full body massage once a
week to prevent lactic acid build up and to assist in preventing soft tissue damage.

Contraindications
Contraindications are cases in which sports massage might or would be detrimental to the
athlete's health and wellbeing, so it is vital to know what they are and understand how to
assess them. It is therefore important to take a full medical history before beginning the
massage. You will need to ask specific questions as well as doing some preliminary checks. A
good way to complete your history taking is to verbally summarize your client's history and
then to add; are there any injuries or conditions that we have not yet covered, and are you
taking any medication? If the client does have a condition, which may be contraindicated, and
you feel they should be referred back to their GP, try to raise the subject without alarming
them. Remind that you are not medically trained.

Total contraindications:

• Any form of infection, disease ex fever

• Under the influence of recreational chugs or alcohol Diarrhea or vomiting
• Chilblains and bums must be avoided during their acute healing phases.
• Never treat unless 1he injury has been diagnosed and trea1ment has been recommended by a
medical practitioner

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Partial Total Contraindications:

• Cardiovascular conditions (Thrombosis, phlebitis, hypertension, hypotension, heart

conditions)
• Haemophilia
• Any condition already being treated by a GP or other complementary practitioner Medical
oedema
• Osteoporosis
• Arthritis
• Nervous I psychotic conditions Epilepsy
• Recent operations Diabetes
• Asthma
• Any dysfunction of the nervous system (Muscular sclerosis, Parkinson's disease. Motor
neuron disease)
• Bell’s palsy
• Trapped I pinched nerve (e.g. sciatica) Inflamed nerve
• Cancer
• Postural deformities Spastic colon Kidney infections Whiplash
• Slipped disc Undiagnosed pain
• When taking prescribed medication Acute rheumatism

Localized:

• Skin diseases
• Undiagnosed lumps and bumps localized swelling
• Inflammation Varicose veins
• Pregnancy (abdomen) Cuts
• Bruises Bursitis Abrasions
• Scar tissues ( 2 years for major operation and 6 months for a small scar) Sunburn
• Hormonal implants
• Abdomen (first few days of menstruation depending on how the client is feeling)
Haematoma
• Hernia
• Recent fractures (minimum 3 months) Cervical spondylitis
• Gastric ulcers
• After a heavy meal

Benefits of Sports Massage

Sports massage benefits athlete’s and people who exercise by assisting them in the process of
overcompensation and adaptation. Exercise places increased stress on the body's systems and
they need to adapt to cope with this. These adaptations affect the muscles, nerves, bones,
tissues and the brain.

Regular exercise in the right measure and at the right frequency enables the body to cope
with the increased stress placed on it (overload) and allows one to exercise at higher
6
 intensities for longer periods of time. This is possibly because while the body is recovering
from exercise it overcompensates to increase its power of resistance to future stress.

Adaptation and overcompensation is specific to the type of activity, and training programs are
based on the principal of specificity - the adaptations will be specific to the type of stress.
E.g.: A sprinter requires bursts of power over short distances; therefore the training program
includes exercises to improve speed. A marathon runner needs a high level of aerobic
efficiency, and therefore needs a training program that will improve endurance.

The manipulation of soft tissues prior to and after exercise promotes physical, physiological
and psychological changes that aid performance and particularly recovery.

The Benefits of Sports Massage are:

• It monitors muscle density and therefore prevents problem areas becoming
injuries.
• It improves circulation to the specific area by creating warmth during the friction of
massage.
• It improves the very slow lymphatic flow.
• The pumping action of massage causes more blood to be drawn to the area thereby
improving the healing process.
• It speeds up toxin and waste removal from the muscle tissue.
• It improves the metabolism of the cell (which increases the exchange of fluids,
nutrients and chemicals across the cell membrane) therefore ensuring healthy muscles.
• It speeds up recovery between training sessions.
• It relieves muscle pain and spasm.
• It breaks down adhesions and scar tissue in muscles.
• It improves flexibility in muscles by stretching and relaxing the muscle.
• It restores suppleness and elasticity.
• It improves the range of motion in tense muscles.
• It balances the autonomic nervous system (ANS) therefore relaxing mind and body.
• Mobilization is the systematic pumping and stretching of a muscle which improves
flexibility, elasticity and decreases muscle tension.

7
The Effects of Sports Massage
Friction

Hands sliding along the skin causes friction, which creates much of the heat derived from
massage. Friction also occurs between all the tissue layers as they are moved against each
other, which generates more heat. Some heat is formed by the opening, of arteries and
capillaries through pumping effect and axonal reflexes caused by massage stimulation. The
improvement in the microcirculation brings more warming blood to superficial layers. The
release of intracellular enzymes like histamine will also create some heat. These warming
effects are beneficial as they increase the metabolism. Despite the many benefits of heat, it is
not one of the main therapeutic benefits of massage, and it can be more easily obtained by
other means like hot packs and saunas.

Pumping

Every stroke made along the flow of the venous and lymphatic systems assists their
circulation. As massage is applied it causes increased pressure in the vessels in front of the
stroke and a subsequent vacuum in those behind. Both these pressure changes assist the flow
of fluid in the venous and lymphatic vessels and will make room for new fluids coming from
deeper tissues. Increase in the return flow will obviously improve arterial blood supply, which
has to refill
the cleared vessels. This does not have very significant benefits if the tissue is in good
condition, although there has been shown to be a measurable improvement in total blood flow
in the massaged parts. When muscles are tense or there is increased pressure in muscle
compartments the circulation is inhibited, not only in the muscles, but also in other tissues like
joints, ligaments and tendons. As blood is rich with oxygen and other substances vital for
repair and growth, the pumping effect achieved with massage is essential to restore normal
tissue condition.

Increased Tissue Permeability

Deep stroking massage techniques create a localized increase in pressure, which causes the
pores in tissue membranes to open, facilitating the exchange of fluids. It improves the removal
of muscle waste like lactic acid, which builds up in the muscles during and immediately after
hard exercise. The highly oxygenated fluids rich in nutrients are then absorbed more easily.
This is necessary to normalize tissue metabolism and to facilitate the repair and build-up of
tissue following training. As a result of increased tissue permeability one can measure the
increase of tissue enzyme levels in the blood after massage.
Stretching

Sportsmen are aware of the importance of stretching, and massage techniques can also
achieve stretching of muscles, tendons and fascia. In addition massage can stretch those other
tissues that cannot be reached by any other method.
There is a distinct difference between the stretching done by a sportsman and that achieved
through massage. Normal stretching exercises treat the muscle, or more usually the muscle
group, as a whole. As the stretch is performed the muscle attachments are drawn away from
each other, causing the fibers to lengthen, and the muscle bundles are brought closer
together.

In massage muscle bundles are pulled longitudinally and are moved transversely. This both
stretches the fibers and moves the bundles apart, thus improving intramuscular circulation
and breaking possible adhesions between the muscle bundles. So, with massage the fibers
can be stretched in all directions and not just in line with the attachments.

Massage has an advantage in that it can be used to stretch muscles regardless of joint range.
The conventional type of stretching carried out by sportsmen is often restricted by the
limitation of normal or restricted joint movement. Stretching with massage is always applied
to localized areas and can be carried out systematically throughout the muscle. This makes it
possible to regulate the amount of stretch applied to different parts depending on the relative
tension found. With normal stretching the less tensile areas give way first and localized tight
areas are stretched less.

With massage it is possible to apply stretching to specific structures like fascia (which
surrounds the muscles) unlike normal stretching which affects all the structures in a
general area equally. Stretching fascia through massage releases muscle tension. This is
particularly important in cases of compartment syndrome where tense fascia causes
increased interfacial pressure.

Breaking

Scar tissue may be present in soft tissues, like muscle, tendons and ligaments, of the
sportsman as a result of past injuries or the gradual build-up of overuse injuries due to
repeated micro trauma. This can cause tension and inflexibility, which may lead to local or
referred problems. Adhesions may occur where fibrous tissue causes different tissues to stick
together due to inflammation as well as micro trauma. This will reduce the tensile property
of tissues and may restrict movement. Deep friction massage is used to break down scar
tissue and adhesions. It will help the return of normal tissue tension, and will restore both
contractile properties and a normal range of movement.
 Fibrosis seldom affects whole muscles in sportsmen, as it is a condition, which tends to affect
inactive muscles, but long-standing tension can imply localized inactivity, which can lead to
atrophy and fibrosis occurring in some sportsmen. It is often not apparent because it can affect
only part of the muscle while other parts continue to work seemingly normally and can even
compensate for it to some extent. The only symptom may be Jong-standing diffused pain,
tension and restricted movement. In sportsmen this condition is more likely to occur in the
postural muscles, for example in the neck and back muscles. This is because these muscles
work mainly isometrically. With massage one can apply an effective stretch on local areas of
the muscle to relieve tension and, by cross friction, to break down fibrosis.

Improved Tissue Elasticity

Excessive repetitive and particularly longstanding isometric type of muscle effort makes
tissues hard and inelastic. This causes the metabolism to suffer; normal tissues begin to waste
and are slowly replaced by fibrotic and less elastic components. This is why hard training does
not necessarily improve performance and can even have a contradictory effect. By kneading
soft tissues it is possible to pull the elastic structures to near their maximal length in all
directions. This is necessary to maintain normal elasticity in tissues, which are continually put
under great stress in certain positions.

Opening Micro-Circulation

Measurements have shown that massage increases total blood flow through the treated part.
This in itself is not significant as active exercises of the muscles increases total blood flow
much more. The important thing is that massage opens arterioles and capillaries, so improving
the exchange of fluid to the tissues. Deep massage causes the release of vasoactive substances
creating a dilation of the vessels, which bring new fluid to the tissues. The size of the vessels
is also controlled by the autonomous nervous system, and it is even possible to increase
microcirculation with just superficial massage, through the reflexes.

Pain Reduction

With intensive training one tends to get excessive muscle tension, which restricts circulation
and deprives the tissues of oxygen. Metabolic waste products accumulate in these tissues,
which causes pain. This is particularly common where tight fascia surrounds the muscles
and there is increased interfacial pressure, which further blocks the circulation. The
mechanical effects of the massage will improve these conditions by increasing circulation
and stretching as described in more detail above.

Long-standing restriction of movement because of pain, splinting, bad posture or other

reasons causes the elastic component of soft tissues to shrink and form into inelastic fibrous
tissues. Because of this, pain arises during normal movement.
 Again the stretching effects of massage are beneficial and result in relief of pain. Massage is
able to reduce pain by reflexes affecting the central nervous system. It causes the release of
endorphins, which abolish pain sensations in the brain. Stimulation of the mechanoreceptors
by massage has been shown to reduce pain and muscle tension. According to 'gate control'
theory this is because stimulation prevents pain impulses going beyond the dorsal horn of
the spinal cord. Perception of pain is also modulated by sensory input to other parts of the
central nervous system, especially the mid-brain. Acupressure therapy is a sophisticated
method of eliminating pain.

Relaxation

Local relaxation of the muscles is achieved by many of the mechanical effects of massage,
like increased warmth, circulation and stretching. Refectory effects are sometimes even
more important in achieving relaxation. Massage stimulates the mechanoreceptors, which
sense touch, pressure, tissue length, movement and warmth in the muscle and other
connective tissues. Reflex pathways via the central nervous system transmit the stimulus
and induce relaxation through efferent pathways to muscles.

Overall tension is dependent on total sensory input to the central nervous system. General
relaxation is better achieved when a large area of the body is treated. This is reached in a
combination of three different types of massage: General tension is maintained by local
stiffness and aches, which can be relieved with deep stroking massage techniques. When
this has been resolved irrelative impulses from problem areas will stop. One is able to
create awareness of relaxation further by soft general massage. There are specific areas
where massage causes relaxation as a reflector response.

Balancing Autonomous Nervous System

Reducing muscle tension and abolishing pain due to musculoskeletal disorders, especially
in the neck, is shown to decrease the recurrence of migraine attacks, lowers high blood
pressure and may stop hyperventilation syndrome. These effects achieved by massage are
due to reduced output from irritated mechanoreceptors from muscles and tendons, which
causes sympathetic nervous system over activity. This will also help get better relaxation
and improves sleep after strenuous exercise. Massage eases abdominal pain in
constipation by stimulating the parasympathetic nervous system and improving the
mobility of the intestines. It may help to normalize bowel function, which is disturbed due
to psychological or physical stress.

Mechanical Effects Refectory Effects

Friction waning Relaxation

Pumping the circulation Pain reduction
Stretching soft tissue Opening microcirculation
Breaking scar tissue Balancing autonomous nervous system
Breaking adhesions
Increased tissue penne ability
Opening microcirculation
Enzyme release
Improved tissue elasticity
9
 Chapter 2

Assessment:
• Medical History
• Testing ROM
• Examination of the body

Terms to describe movement

Terms of location

10
Confidential
Ref

Referred by: _______________

Name: Occupation:
Tel: Day Cell: DOB: _/_/_
Address:
Sex: M/F _____ Exercise and Frequency:
Other Activities:________________________________________
Med. Practitioner: Medication: Allergies:____________

History:

Features of pain:
Source: Radiating: Character:
Severity: Duration: Frequency:
Times of commencement:
Other Factors:
11
 Contraindications

Area treated and treatment

given

Type of injury

Reactions

Home care and exercises

given

I confirm the above to be true.

I undertake this treatment of my own accord and indemnify the therapist against
any claim arising there from.

Signature: ______________________

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Questions to be asked

General and Medical information

1. Have you ever had a professional bodywork / massage session?
2. Do you suffer frequently from stress?
3. Do you frequently experience headaches?
4. Are you pregnant?
5. Are you wearing contact lenses?
6. Are you a diabetic?
7. Do you have high blood pressure?
8. Are you taking any medication?
9. Are you epileptic?
10. Are you currently on a diet?
11. Are you prone to bruising?

Medical information
1. Have you ever had any surgery?
2. Have you had any broken bones in the last two years?
3. Do you have any other illnesses?
4. Do you have any soreness or stiffness in a particular area?
5. Do you have cardiac or circulatory problems?
6. Do you suffer from back pain?
7. Do you have any numbness or stabbing pain anywhere?
8. Do you have any other medical conditions not yet mentioned?
9. Are you allergic to any oils?
10. Are you feeling good or healthy today?

Sports Related Questions

1. What type of sport are you involved in?
2. What position do you play?
3. On what level do you participate?
4. How often do you train?
5. When last did you train?
6. 6. When is your next event?

13
Testing joint Range of motion (ROM)
Neck:
Flexion Chin to chest
Extension Raise chin up and look at the ceiling
Side rotation Turn head to the side, left then right
(45°)
Side flexion Move ear towards shoulder, left then
right (45°\

Shoulder girdle:
Elevation Raise shoulders
Depression Lower shoulders
Abduction Bring shoulders forward
Adduction Push shoulders back

Shoulders:
Flexion Move arm forwards
Extension Move arm backwards
Abduction Move arm outwards
Adduction Move arm inwards

Elbows:
Flexion Bend elbow
Extension Straighten elbow
Forearms:
Supination Turn palm upwards
Pronation Turn palm downwards

Wrists:
Flexion Bend wrist, fingers move towards
palmar surface of forearm
Extension Straighten wrist, fingers move away
from forearm
Radial deviation Bend wrist sideways by moving hand
towards radius
Ulnar deviation Bend wrist by moving hand sideways
towards ulna
Fingers:
Flexion Bend fingers towards palm
Extension Straighten fingers

Trunk:
Flexion Slump forwards (from standing),
bending whole spine
Extension Return to upright and arch back
Rotation Gently twist spine by moving one
shoulder backwards and one forwards,
keeping pelvis still - left then right

14
Hip:
Flexion Bring upper leg forwards
Extension Move upper leg backwards
Abduction Move leg to the side and away from the
body
Adduction Move lea inwards towards the body

Knees:
Flexion Bend the knee
Extension Straighten the knee
.

Ankles:
Plantaflexion Move foot to point toes downwards
Dorsiflexion Move foot to pull toes upwards

Feet:
Inversion Turn the sole of the foot inwards
Eversion Turn the sole of the foot outwards

Toes:
Flexion Bend the toes towards the sole of the
foot
Extension Straighten the toes and bend upwards

Examination Table:

15
 Terms used to describe movement.
FL Flexion Decrease the inner angle of the
joint
EXT Extension Increasing the inner angle f the
joint
ABD Abduction Moving away from the middle of
the body
Add Adduction Moving towards the middle of
the body
Lateral Flexion Side bending ( Neck & Torso)
ROT Rotation Inward Rotating or pivoting around a
Outward long axis
CIRC Circumduction Circular Movement
D.FL Dorsiflexion Flexing the ankle with the foot
moving upwards
P.FL Plantaflexion Flexing the ankle with the foot
moving downwards
Eversion/pronation Turning the sole of the foot
laterally ( outward)
Inversion/supination Turning the sole of the foot
medially ( Inward)
Pronation Rotating the forearm with the
palm turning inward
Supination Rotating the forearm with the
palm turning outward
Elevation Draw upwards (Shoulder & Hip)
Depression Draw downwards ( Shoulder &
Hip)
Protraction Draw forward ( Shoulder)
Retraction Draw backward ( Shoulder)
H.ABD Horizontal Abduction Moving the arm in a horizontal
plane away from the body
H.ADD Horizontal Adduction Moving the arm in a horizontal
plane inwards across the body
RD.ABD Radial deviation / abduction With palm facing forward, hand
moves wrist away from the body
UL.ADD Ulna deviation / adduction With palm facing forward, hand
moves wrist towards the body

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17
Anterior Towards the front of the body
Posterior Towards the back of the body
Ventral Towards the front of the torso
Dorsal Towards the back of the torso
Medial Towards the center of the midline
of the body
Lateral Towards the outside, or away from
the midline of the body
Peripheral Towards the outer surface of the
body
Inferior Below or towards the bottom of the
body
Superior Above, or towards the center of the
body
Proximal Towards the center of the body, or
another Structure
Distal Away from the center of the body,
or another structure
Longitudinal Vertically, along the body
Transverse Horizontally, across the body
Sagittal/Median Towards the plane that divides the
left and right sides of the body
Coronal Towards the plane that divides the
front and back halves of the body
Palmer On or towards the palm of the hand
Planter On or towards the sole of the foot
Dorsal On or towards the back of the hand,
or top of the foot
Axillary Towards the armpit
Caudal Towards the buttocks
Cranial/Cephalic Towards the head
Inguinal Towards the groin

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Chapter 3

The Muscular System

Types of Muscle Tissue
Skeletal muscle is associated with the bony skeleton, and consists of large cells that
bear striations and are controlled voluntarily.
Cardiac muscle occurs only in the heart, and consists of small cells that are striated
and under involuntary control.
Smooth muscle is found in the walls of hollow organs, and consists of small
elongated cells that are not striated and are under involuntary control

19
Special Characteristics of Muscle
Tissue
Excitability, or irritability, is the ability to receive and respond to a stimulus.

Contractility is the ability to contract forcibly when stimulated.

Extensibility is the ability to be stretched.

Elasticity is the ability to resume the cells’ original length once stretched.

Muscle Functions
Muscles produce movement by acting on the bones of the skeleton, pumping
blood, or propelling substances throughout hollow organ systems.

Muscles aid in maintaining posture by adjusting the position of the body with
respect to gravity.

Muscles stabilize joints by exerting tension around the joint.

Muscles generate heat as a function of their cellular metabolic processes.

20
Skeletal Muscle
Gross Anatomy of Skeletal Muscle
Each muscle has a nerve and blood supply that allows neural control and ensures adequate
nutrient delivery and waste removal.

Connective tissue sheaths are found at various structural levels of each muscle: endomysium surrounds
each muscle fiber, perimysium surrounds groups of muscle fibers, and epimysium surrounds whole
muscles.

Figure: Connective tissue wrappings of skeletal muscle.

21
Attachments span joints and cause movement to occur from the movable bone (the muscle’s insertion)
toward the less movable bone (the muscle’s origin).
Muscle attachments may be direct or indirect.
Direct - epimysium fused to periosteum or perichondrium.
Indirect - epimysium extends as a tendon or sheet like aponeurosis attached to periosteum,
perichondrium, or the fascia of other muscles.

Microscopic Anatomy of a Skeletal Muscle

Fiber
Skeletal muscle fibers are long cylindrical cells with multiple nuclei beneath the sarcolemma.
Myofibrils account for roughly 80% of cellular volume, and are the contractile elements of the muscle
cell.
Myofibrils consist of repeating units called sarcomeres (the contractile unit of the myofibril), which have
overlapping myofilaments connected to Z discs at either end of the sarcomere.
The myofilaments that make up the myofibrils consist of thick (myosin) and thin (actin) filaments.
The Z disc is primarily composed of the protein alpha actinin and connected to Z discs of adjacent
myofibrils by intermediate filaments composed of desmin.
The elastic filament titin anchors the thick filaments to Z discs and runs within the thick filaments to the
M line.
Holds thick filaments in place
Helps muscle spring back into shape after contraction or stretching
Dystrophin links thin filaments to the sarcolemma
Nebulin, myomesin, and vimentin are other proteins that bind filaments or sarcomeres together.
Striations are due to a repeating series of dark A bands (anisotropic, polarize visible light) and light I
bands (isotropic, don't polarize visible light).
A bands - where thick and thin filaments overlap
I bands - along Z lines, where only thin filaments are present

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Ultrastructure and Molecular Composition of the Myofilaments

Thick filaments are composed of bundles of myosin molecules, which have a head joined to a tail
by a flexible hinge region.

Thin filaments are composed of strands of f-actin; each f-actin filament is composed of g-actin
subunits. Tropomyosin and troponin is regulatory proteins present in thin filaments

23
24
Physiology of Skeletal Muscle
Fibers

For skeletal muscle fibers to contract:

The fiber must be stimulated by a
nerve ending
An action potential must be generated
along the sarcolemma
The action potential must be
propagated along the sarcolemma
Intracellular calcium levels must rise
to trigger contraction

25
The neuromuscular junction is a connection between an axon terminal and a muscle fiber where
stimulation of the muscle cell to contract occurs.
The neuromuscular junction consists of the plasma membrane of the motor neuron axon terminal, the
synaptic cleft, and the motor endplate.
The motor endplate is part of the sarcolemma where chemically regulated ion channels that respond to
neural stimulation are found. Junctional folds increase the surface area at the motor endplate.
A nerve impulse causes the release of acetylcholine to the synaptic cleft, which binds to receptors on the
motor end plate, triggering a series of electrical events on the sarcolemma.
An action potential, or wave of depolarization of significant strength, opens voltage regulated Ca++
channels in the axon terminal.
Ca++ influx into the axon stimulates fusion of synaptic vesicles with the axon terminal plasma membrane
and the release of neurotransmitter (Ach) in the synaptic cleft.
Ach diffuses across the synaptic cleft, binds to receptors on the motor endplate, and opens chemically-
regulated ion channels in the sarcolemma.
Ach is broken down by acetylcholine esterase, which terminates stimulation of the sarcolemma

When acetylcholine binding with receptors opens chemically-regulated ion channels in the sarcolemma
Na+ ions enter the cell faster than K+ ions exit, which makes the membrane potential slightly less
negative (depolarizes the membrane) This is an end plate potential.
Positively charged ions move across the inside of the sarcolemma into more negative areas - this is a
wave of depolarization. The depolarization can be measured (just like a resting membrane potential) and
is referred to as a graded local potential, or in this specific case, an endplate potential.
Generation of an action potential across the sarcolemma occurs in response to the wave of depolarization
reaching a voltage regulated Na+ channel with sufficient strength to open it.
26
The degree of depolarization required to open a voltage regulated Na+ channel is called threshold
(typically 15 - 20 mV above the resting membrane potential).
The influx of Na+ through voltage regulated channels opens voltage regulated K+ channels.
As K+ leaves the cell it becomes repolarized and can be stimulated again.

Contraction of a Skeletal Muscle

A motor unit consists of a motor neuron and all the muscle fibers it innervates. It is smaller in
muscles that exhibit fine control.

27
The muscle twitch is the response of a muscle to a single action potential on its motor neuron.

Muscle tone is the phenomenon of muscles exhibiting slight contraction, even when at rest, which keeps
muscles firm, healthy, and ready to respond.
Isotonic contractions result in movement occurring at the joint and a change in the length of muscles (the
force remains constant).
Concentric isotonic contractions - The muscle shortens as it moves the load
Eccentric isotonic contractions - The muscle lengthens as it resists the load
Isometric contractions result in increases in muscle tension, but no lengthening or shortening of the
muscle occurs

Muscle Metabolism
Muscles contain very little stored ATP, and consumed ATP is replenished rapidly through
phosphorylation by creatine phosphate, glycolysis and anaerobic respiration, and aerobic respiration.
Muscles will function aerobically as long as there is adequate oxygen, but when exercise demands exceed
the ability of muscle metabolism to keep up with ATP demand, metabolism converts to anaerobic
glycolysis

28
Muscle fatigue is the physiological inability to contract due to the shortage of available ATP.
Oxygen debt is the extra oxygen needed to replenish oxygen reserves, glycogen stores, ATP and creatine
phosphate reserves, as well as conversion of lactic acid to pyruvic acid glucose after vigorous muscle
activity.
Heat production during muscle activity is considerable. It requires release of excess heat through
homeostatic mechanisms such as sweating and radiation from the skin.
Force of Muscle Contraction
As the number of muscle fibers stimulated increases, force of contraction increases.
Large muscle fibers generate more force than smaller muscle fibers.
As the rate of stimulation increases, contractions sum up, ultimately producing tetanus and generating
more force.
There is an optimal length-tension relationship when the muscle is slightly stretched and there is slight
overlap between the myofibrils.

29
Smooth Muscle
Microscopic Structure of Smooth Muscle Fibre’s

Smooth muscle cells are small, spindle-shaped cells with one central nucleus, and lack the coarse
connective tissue coverings of skeletal muscle.
Smooth muscle cells are usually arranged into sheets of opposing fibers, forming a longitudinal layer and
a circular layer.
Contraction of the opposing layers of muscle leads to a rhythmic form of contraction, called peristalsis,
which propels substances through the organs.

Smooth muscle lacks neuromuscular junctions, but have varicosities instead, numerous bulbous swellings
that release neurotransmitters to a wide synaptic cleft.
30
Smooth muscle cells have a less developed sarcoplasmic reticulum, sequestering large amounts of
calcium in extracellular fluid within caveolae in the cell membrane.
Smooth muscle has no striations, no sarcomeres, and a lower ratio of thick to thin filaments when
compared to skeletal muscle, but thick filaments have myosin heads along their entire length.
Smooth has tropomyosin but no troponin; calmodulin binds calcium.
In smooth muscle thick and thin filaments are arranged diagonally, spiral down the length of the cell, and
contract in a twisting fashion.
Smooth muscle fibers contain longitudinal bundles of noncontractile intermediate filaments anchored to
the sarcolemma and surrounding tissues via dense bodies

31
Contraction of Smooth Muscle
Mechanism of Contraction
Smooth muscle fibers exhibit slow, synchronized contractions due to electrical coupling by gap junctions.
Like skeletal muscle, actin and myosin interact by the sliding filament mechanism. The final trigger for
contraction is a rise in intracellular calcium level, and the process is energized by ATP.
During excitation-contraction coupling, calcium ions enter the cell from the extracellular space, bind to
calmodulin, and activate myosin light chain kinase, powering the cross-bridging cycle.
Smooth muscle contracts more slowly and consumes less ATP than skeletal muscle

32
Regulation of Contraction
Neural Regulation:
Autonomic nerve endings release either acetylcholine or norepinephrine.
May see action potentials generated by neurotransmitter binding or may see graded local potentials,
depending on the type of muscle.
May see excitation of certain groups of smooth muscle cells or inhibition of others by the same
neurotransmitter, depending on the receptor subtype present on the surface of the cells.
Hormones and Local Factors:
Smooth muscle may have no nerve supply and only depolarize spontaneously or in response to chemicals
binding to receptors linked to G-proteins.
Some smooth muscle will respond both to neural and chemical stimuli.
Lack of oxygen, histamine, excess carbon dioxide, or low pH, may act as signals for contraction without
stimulating an action potential by affecting Ca++ entry into the sarcoplasm.
Special Features of Smooth Muscle Contraction
Smooth muscle initially contracts when stretched, but contraction is brief, and then the cells relax to
accommodate the stretch.
Smooth muscle stretches more and generates more tension when stretched than skeletal muscle.
Hyperplasia, an increase in cell number through division, is possible in addition to hypertrophy, an
increase in individual cell size.
Types of Smooth Muscle
Single-unit (unitary) smooth muscle, called visceral muscle, is the most common type of smooth muscle.
It contracts rhythmically as a unit, is electrically coupled by gap junctions, and exhibits spontaneous
action potentials.
Multiunit smooth muscle is located in large airways to the lungs, large arteries, arrector pili muscles in
hair follicles, and the iris of the eye. It consists of cells that are structurally independent of each other, has
motor units, and is capable of graded contractions.
Developmental Aspects of Muscles
Nearly all muscle tissue develops from specialized mesodermal cells called myoblasts.
Skeletal muscle fibers form through the fusion of several myoblasts, and are actively contracting by week
7 of fetal development

Myoblasts of cardiac and smooth muscle do not fuse but form gap junctions at a very early stage.
Muscular development in infants is mostly reflexive at birth, and progresses in a head-to-toe and
proximal-to-distal direction.

33
Women have relatively less muscle mass than men due to the effects of the male sex hormone
testosterone, which accounts for the difference in strength between the sexes.
Muscular dystrophy is one of the few disorders that muscles experience, and is characterized by atrophy
and degeneration of muscle tissue. Enlargement of muscles is due to fat and connective tissue deposit.
Connective tissue components of skeletal muscles:
Fascia

Definition: any sheet of connective tissue in the body. Important to sports massage are superficial and
deep fascia. The former is loose connective tissue immediately under the skin, allowing
it to move over underlying structures. Tissue fluids often accumulate here (i.e. swelling) and infections
are fought and spread here.
Deep fascia is denser and tougher. It lies beneath the superficial fascia and surrounds the limb muscles,
holding muscles together. It also holds bundles of muscle fibres together, and wraps individual muscle
fibres. It is also attached to the limb bones and divides groups of muscles into compartments.
"Compartment syndrome" often results from swelling within the deep fascial constraints that increases
compartmental pressure.

Dense connective tissue that attaches bone to bone is called a ligament dense connective tissue that links
muscle to bone is called a tendon.
Tendons are more elastic than ligaments, and have far greater tensile strength than muscles. They allow a
muscle to attach to a precise point on a bone, and contribute greatly to precision movements. They also
allow muscles to pull through small spaces (e.g.: carpal tunnel) and around comers (e.g.:
maleoli of the ankle). Many have synovial sheaths allowing tendons to move freely as their muscles
contract- these can get damaged by repetitive motion (e.g.; wrist of tennis players). Some (e.g.
Achilles) have a false or non - synovial sheath that can get inflamed and cause heel pain, (prevalent in
long - distance runners).
Tendons attach to bone with fibrocartilage. The attachments are often injured in sports (e.g.: tennis
elbow). They have a relatively poor blood supply and also have relatively few cells, therefore repair with
difficulty -particularly in adults.
The point of attachment to the muscle (myotendinous junction) is most commonly where strains or pulls
occur.

Cardiac muscle:
This forms the bulk of the heart and is called the myocardium. The thickness varies throughout the heart
walls. The left ventricle has the thickest wall as blood is pumped from here all over the body. lncn ases in
demand caused by intense exercise increase the size of the muscle.
A cardiac muscle consists of many individual cells joined end to end, an is an involuntary muscle that
contracts rhythmically at a rate determined by a "pacemaker' (specialised muscle fibres in the right atrium
that control the rhythm of the of the electrical impulses that cause the heart beat) The signal for
contraction spreads from one cell to another via special junction regions called "intercalated discs".
Cardiac muscle does not fatigue easily unless the rate of contractions (heart rate) is increased for a
prolonged period without sufficient rest. The resting heart rate averages about 70 beats per minute.

Smooth Muscles:
This typically occurs in sheets or layers in the walls of a great number of hollow tubes in the body - e.g.:
blood vessels and the gut. It allows them to change their calibre (blood vessels) or to propel material
along the lumen (gut). It is an involuntary muscle, which, because of its function, is able to contract over
many hours without fatigue. Smooth muscle fibres are smaller than skeletal muscle fibres. They are
tapered at both ends and each fibre has a single nucleus.

34
Chapter 4
The Joints of the body

Joints are mainly classified structurally and functionally. Structural classification is determined by how
the bones connect to each other, while functional classification is determined by the degree of movement
between the articulating bones. In practice, there is significant overlap between the two types of
classifications.

Terms ending in the suffix -sis are singular and refer to just one joint, while -ses is the suffix for
pluralization.
An articulate facet is generally seen as a small joint, especially used when speaking of the joints of the
ribs.
Structural classification (binding tissue)

Structural classification names and divides joints according to the type of binding tissue that connects the
bones to each other. There are three structural classifications of joints:
• Fibrous joint – joined by dense regular connective tissue that is rich in collagen fibers
• Cartilaginous joint – joined by cartilage
• Synovial joint – not directly joined – the bones have a synovial cavity and are united by the dense
irregular connective tissue that forms the articular capsule that is normally associated with
accessory ligaments.
35
Functional classification (movement)
Joints can also be classified functionally according to the type and degree of movement they allow:
• Synarthrosis – permits little or no mobility. Most synarthrosis joints are fibrous joints (e.g., skull
sutures).
• Amphiarthrosis – permits slight mobility. Most amphiarthrosis joints are cartilaginous joints (e.g.,
intervertebral discs).
• Diarthrosis – freely movable. All diarthrosis joints are synovial joints (e.g., shoulder, hip, elbow,
knee, etc.), and the terms "diarthrosis" and "synovial joint" are considered equivalent by
Terminologia Anatomica. Diarthroses can in turn be classified into six groups according to the
type of movement they allow: arthrodia, enarthrosis, ginglymus, rotary diarthrosis, condyloid
articulation and articulation by reciprocal reception.

Joints can also be classified, according to the number of axes of movement they allow, into nonaxial
(gliding, as between the proximal ends of the ulna and radius), monoaxial (uniaxial), biaxial and
multiaxial. Another classification is according to the degrees of freedom allowed, and distinguished
between joints with one, two or three degrees of freedom. A further classification is according to the
number and shapes of the articular surfaces: flat, concave and convex surfaces. Types of articular
surfaces include trochlear surfaces

36
The synovial membrane (also known as synovium or stratum synoviale) is a specialized connective tissue
that lines the inner surface of capsules of synovial joints and tendon sheath. It makes direct contact with
the synovial fluid lubricant, which it is primarily responsible for maintaining. In contact with the synovial
fluid at the tissue surface are many rounded macrophage-like synovial cells (type A) and Fibroblast-like
(type B) synovial cells. Type A cells maintains the synovial fluid by removing wear-and-tear debris and
type B cells produces hyaluronan among other extracellular components in the synovial fluid.
The synovial membrane is variable but often has two layers
• The outer layer, or subintima, can be of almost any type of connective tissue – fibrous (dense
collagenous type), adipose (fatty; e.g. in intra-articular fat pads) or areolar (loose collagenous
type).
• The inner layer (in contact with synovial fluid), or intima, consists of a sheet of cells thinner than
a piece of paper.
Where the underlying subintima is loose, the intima sits on a pliable membrane, giving rise to the term
synovial membrane.
This membrane, together with the cells of the intima, provides something like an inner tube, sealing the
synovial fluid from the surrounding tissue (effectively stopping the joints from being squeezed dry when
subject to impact, such as running).
Just beneath the intima, most synovium has a dense net of fenestrated small blood vessels that provide
nutrients not only for synovium but also for the avascular cartilage.
In any one position, much of the cartilage is close enough to get nutrition direct from synovium.
Some areas of cartilage have to obtain nutrients indirectly and may do so either from diffusion through
cartilage or possibly by 'stirring' of synovial fluid.
The surface of synovium may be flat or may be covered with finger-like projections or villi, which, it is
presumed, help to allow the soft tissue to change shape as the joint surfaces move one on another.
The synovial fluid can be thought of as a specialised fluid form of synovial extracellular matrix rather
than a secretion in the usual sense. The fluid is transudative in nature which facilitates continuous
exchange of oxygen, carbon dioxide and metabolites between blood and synovial fluid. This is especially
important since it is the major source of metabolic support for articular cartilage. Under normal
conditions synovial fluid contain <100/mL of leucocytes in which majority are monocytes.

37
Synovial joints
Five classes of tissue make up synovial joints:

• Bone
• Cartilage
• Synovium
• Synovial fluid
• Tensile tissues: ligament and tendon, attached at entheses
• Bone

The bone adjacent to a joint consists of an open spongy framework of calcified collagen in a tough outer
shell. Immediately beneath articular cartilage there is a more or less continuous subchondral bony plate
but this is often extremely thin. The bone can withstand thrust forces as long as it is covered in cartilage,
which distributes load evenly. Without cartilage, the spongy bone collapses easily. Bone is a live tissue
constantly remodelling in response to stresses.

Cartilage
Hyaline cartilage

Hyaline cartilage is the skeletal growth tissue. In many, but not all, joints a thin layer remains as the
bearing surface in the adult. Hylaine cartilage is avascular. It contains type II collagen and giant
molecular complexes of a proteoglycan called aggrecan. Loadbearing normally occurs over small areas,
varying with joint position. Cartilage does not normally wear despite decades of use, but will do if its
composition or joint mechanics are abnormal. It can regenerate, and will do so at the margins of damaged
joints as part of the osteochondral swellings known as osteophytes, but loadbearing areas will rarely
rethicken once damaged, so the tissue is unable to restore its normal shape after injury.

Fibrocartilage
Fibrocartilage occurs as intervertebral disc, and as discs, menisci or ring pads in many peripheral joints. It
lacks the combination of collagen II and aggrecan seen in hyaline cartilage and blends in with fibrous
synovial tissue. It will regenerate to fill a space eg. in the case of repairing cartilage defects of the knee; it
has lower mechanical properties compared to hialine.

Synovium
Synovium is the name given to the soft tissue lining the cavities of joints, tendon sheaths and bursae. It is
like other connective tissue packing, being a mixture of fatty, areolar and fibrous tissue. The surface of
synovium is permeable to water, small molecules and proteins, but not to hyaluronan, which is the
38
molecule that makes synovial fluid viscous. This allows synovium to trap synovial fluid within the cavity.
Beneath the surface cell layer is a net of small blood vessels, important in the development of synovial
inflammation. Joint, tendon sheath and bursal synovium all have the same structure.

Synovial Fluid
Normal synovial fluid is clear, colourless and noticeably thick and stringy, like eggwhite. Hence the name
syn ovium (‘with egg’). Its viscous and elastic properties are due to hyaluronan, a long chain
glycosaminoglycan carbohydrate with a molecular mass of about 1 million. Synovial fluid is effectively a
liquid connective tissue. Because there are no fibrous components to it, the water and the hyaluronan
ground substance move around together within the synovial space, whereas in other tissues water moves
and the ground substance stays put. Water diffuses in and out of the synovial cavity more easily than
hyaluronan. The amount of water in a joint depends on passive equilibration of plasma with vascular and
lymphatic compartments, as for all connective tissue fluid. It goes up and down with exercise and rest.
Water can enter the joint rapidly during inflammation but once mixed with hyaluronan cannot leave so
rapidly unless the joint ruptures. If joints are stretched suddenly, even the fluid does not fill all the space
and the lining may jump into the vacuum formed, which is how people "click" their finger joints.

Tendon sheaths and bursae

The synovial lining in these structures is similar to that within joints, with a slippery non-adherent surface
allowing movement between planes of tissue. Synovial tendon sheaths line tendons only where they pass
through narrow passages or retinacula, as in the palm, at the wrist and around the ankle. Elsewhere the
tendon lies in a bed of loose fibrous tissue.
Bursae occur at sites of shearing in subcutaneous tissue or between deeper tissues such as muscle groups
and fascia. Many bursae develop during growth but new or adventitious bursae can occur at sites of
occupational friction.

Ligaments and tendons

Ligaments hold bones together. They are variably elastic. Tendons transmit muscle power to bones and
are inelastic (except in kangaroo legs). Joint "capsules" are composed of a basket work of independently
moving ligaments and tendons associated with sheets of fascia. Some joints, such as the sacroiliac, are
largely surrounded by ligament, others, such as the shoulder, with its rotator cuff, are surrounded by
tendon. Tendons may also pass through joint cavities, e.g. long head of biceps.

39
Chapter 5

Correct use of sport massage

Timing
It is a mistake to give a sportsman his first massage just before a competition. Strong deep massage
induces a high level of relaxation, which might hinder the sportsman's ability to reach top performance.
All people respond in different ways to massage, and so they should get experience during a normal
training period to discover their own requirements. If the sportsman is receiving regular massage he
will often prefer a lighter massage a couple of days before competing, and it is also necessary sometimes
to deal with local trauma just before. Massage treatment should be less relaxing and more stimulating
before competition. Effective deep massage should be applied at least a week before an event to allow
time for the full benefits to be felt.

The best time for massage is just after a hard training session and after competition, before muscle
sensitivity and stiffness sets in. At this stage the massage will be more comfortable and effective than if
there were a long delay, and it will also be easier for the therapist. If the sportsman were to wait several
hours he should try to keep the muscles warm and keep moving. If massage cannot be done the same
day one should at the very least aim to have it the day after.

Frequency
Tissues need time to recover from massage so the full effects can be seen. Recovery can normally take
anywhere between one to three days, but with sensitive people it may even take as long as a week. If the
interval between sessions is too long, the condition, which may have improved could slip back and the
therapist has to start again at the beginning. This is particularly important when training is continued
between treatments.

When serious training is leading towards peak performance the sportsman should discuss and plan with
his trainer and masseur how massage sessions should be fitted in to his training schedule. During
periods of intensive training early in the season, when the sportsman is building up basic strength and
fitness, massage should be given more frequently. This is a hard period of training, and it is important to
let the tissues recover totally as quickly as possible and especially to ensure there are no areas of
excessive tension which could lead to serious injury.

Ideally the sportsman should have massage daily or at least after every hard training session. This is
standard practise for top sportsmen in many Eastern European countries, but for economical and practical
reasons it is not common in the West.
The competitive sportsman should consider having a massage at least once a week. Ideally this should be
done after the hardest training session of the week. Massage should always be followed by one or two
days of lighter training, which should be the case anyway after a hard training session. When massage is
given only once a week it is important to make it deep and thorough, whereas if done more often it should
40
be lighter, and the parts treated can be varied according to the particular needs. Even with very hard
training it is possible to give an overdose of massage if it is applied almost daily with maximal effort.
This will lead to excessive muscle relaxation and difficulties in performing training at high levels.

Amateur or recreational sportsmen who train regularly but may not push themselves to maximum limits
should also consider the use of massage to prevent injury at least twice a month. Many amateurs push
themselves regularly to their maximum effort and actually go through more stress than the top sportsmen
because they do not

Have the same conditioning and may also have occupational stress to cope with. These people should
consider having massage more regularly because they may be at even greater risk of over training and
traumas.

Duration of treatment
The normal duration of a full body massage should be between one and one and half hours, and a half
body between one half and three quarter hours. It is not practical to try and divide this into set times for
individual parts of the body because the condition of the soft tissue will be different in every sportsman.
The therapist often finds areas that require special attention. Which also have to be dealt with during the
time allotted for the whole session. Ability to divide the time between different parts develops quickly
with practise.

It does take at least 1 hour to give a thorough full body massage, and it is not a good practise to try and
squeeze it into less. If one is short of time it is better to give a half body massage and just concentrate on
the most important areas. Over recent years it has become popular to use electro and heat therapies as
initial treatments, which may take up half of the session time. This has led to an unfortunate reduction of
time given to massage, as the total therapy time has remained the same. It is impossible to give massage
with the same effect when so little time is devoted to it. This will lead to an increase in the number of
sessions required, and even then therapies are very different from massage and should not be considered
as equal alternatives, although they may often be good as additional treatments.

Pressure and effort

There is no standard for the amount of pressure one puts into massage. Every sportsman and even each
massage will have different requirements depending in the body type, muscle composition, the training
cycle, the sport, and of course any actual problems the sportsman may have.

If one compares an endurance sportsman with one who uses short bursts of high effort (e.g. sprinters,
weight lifters, wrestlers) very different body and muscle types will be found for the two. In the power
sports, athletes have muscles, which have a larger portion of fast twitch fibres and the muscles are bigger
with more natural tension. In endurance sports they have a higher proportion of slow twitch fibres and
the muscles are smaller, softer and more relaxed. This difference can be quite extreme; for example, the
quadriceps muscle may consist of 90% fast twitch fibres in the sprinter, compared with a marathon runner
who may have 90% slow twitch fibres.

When giving massage to these 2 types of people there are important differences. The power sportsman
will require more effort to reach deeper layers of muscles. One should aim to restore the level of tension
41
natural to the muscle and not try to achieve the same softness as with the endurance sportsman. In sports
requiring fast performance and reaction times, too high a level of relaxation will have a negative effect on
performance.

The endurance sportsman benefits from a high level of relaxation to ensure good circulation over a long
period of exercise and to speed up recovery. Less tension also enables muscles to move more freely and
efficiently resulting in better performance. Massage in this case should be aimed more at relaxation and
softening the muscle.
Unfortunately few sports fall neatly into these 2 categories. Sports like football, basketball, tennis and
boxing matches, which last a long time and require endurance. On the other hand, the sportsman has to
perform many short bursts of high effort and need fast reaction times. Here the muscle type of the
sportsman will be more mixed type between slow and fast twitch fibres. The therapist must become
familiar with the different sports as well as each individual sportsman and adapt the massage accordingly.
It is therefore not good for the sportsman to change his therapist often.

Balanced Treatment
In many sports, like racquet sports, javelin and shot putt, one side of the body is trained harder and
becomes more developed. This will create an imbalance, as the muscles on one side are not only bigger
but also more tense, which will create postural stress. This problem is often taken into account in training
programmes by exercising the weaker side as well. Therapists should also consider this problem and
work to equalise tension on both sides. This is done by working more intensely for a longer time on the
side with excessive tension.

In sports requiring equal effort from both sides of the body, like running, weight lifting and swimming,
the stress from training will be equal on both sides. Trauma or injury however will usually only affect one
side, creating an imbalance because of pain and dysfunction. While effectively treating the traumatised
side and restoring its proper function, it is possible to make it more efficient and stronger than the other
side. If the therapist does not treat the non-traumatised side at all, one may create a severe imbalance
leading to a risk of traumatising the previously healthy side. For example, a weight lifter, who received
treatment to the left triceps muscle due to strain, in the next training session, may strain the right triceps
tendon while doing a heavy bench press.

Imbalance may also exist in antagonist muscles, for example, a sprinter who received treatment for
cramps in the quadriceps muscle was recovering well from that, but at the next hard effort he strained the
hamstring of the same leg. This was due to excessive tension in the whole thigh, but treatment was only
given to the front side, leaving the hamstring vulnerable to injury. So, even when treating a specific
problem, it is essential to treat the opposing muscle as well.

The therapist should always ensure that the treatment is balanced. The sportsman should be treated as a
whole and not only concentrate on specific injury problems.

42
Positioning
It has been a long-standing tradition to use the prone and supine position as standard treatment positions
for massage treatment. Normally these are indeed the best positions for giving maximum relaxation, but
this is not necessarily the case in some conditions. When treating acute back traumas, for example, the
patient may feel considerable pain or discomfort in these positions. This will not only reduce the benefits
of the treatment but may make the condition even worse. If muscles remain contracted for a long time in
a bad position they will be difficult to release. With acute conditions of this kind the therapist should
ask the patient to lie in a position, which gives maximum comfort. This will probably be half side lying,
but in cases of acute neck and shoulder conditions the sitting position may be preferred. Pillows can be
used to give support if necessary. The comfort of the patient should be checked several times,
especially if the treatment takes a long time, and the position should be changed if necessary.
Things to watch out for during post event treatments:

Hyperthermia
Definition: When the rate of heat production exceeds that of heat loss for a sufficient period of time,
resulting from inadequate fluid replacement or from failure of the thermoregulatory systems of the body.

Heat Exhaustion:
Signs/Symptoms: Headache, nausea, hair erection on upper arms and chest, chills, unsteadiness, fatigue,
skin cool and pale, sweating, dizziness, and thirst.

Treatment: Refer to medical unit to be placed in a cool environment and allowed to "sip" water.

Heat Stroke: - Failure of the thermoregulatory systems: Extreme Emergency.

Signs/Symptoms: incoherent speech, acute confusion, aggressiveness, rapid unconsciousness, absence of

sweating (occasionally sweating), weakness, irrational behaviour.

Treatment: Refer to Medical Unit: Decrease the body temperature immediately with cold compresses to
the head and neck, alcohol rubs, place in cool environment.

Thermal Stress Conditions: Hypothermia

Definition: the rate of heat production is exceeded by heat loss: unable to maintain adequate core
temperature: can be worse on cool, wet windy days.

Signs/Symptoms: shivering, euphoria, appearance of intoxication: shivering may stop as core

temperature drops even more. Lethargy, muscle weakness followed by disorientation, hallucination,
combative behaviour, unconsciousness.

43
Chapter 6
Massage Techniques

Effleurage (Superficial):
Long gentle strokes with flat hands at the beginning - introductory, relaxing concluding strokes.

Effleurage (Deep stroking):

Deep strokes are achieved with increased force and by reducing the contact area by using the edge or heel
of the hand, fingers, knuckles, elbow etc.

Longitudinal:
Thumb strokes in direction of muscle used to lengthen and strengthen

Cross fibre:
Broad strokes across muscle fibres to separate internal scar tissue

Petrissage:
Kneading the muscle, to warm, stimulate, increase circulation and drain.

Cross friction:
Deep friction- Movement of the thumbs in opposite directions across the muscles on "tension bands"
without the thumbs sliding over the skin

Compression:
Localised deep pressure on TrP or muscle in spasm

Percussion:
(Tapotement) Using both hands alternately, working very quickly and rhythmically clapping, hacking or
beating.

Jostle-shake:
To loosen muscle

Vibrate:
To stimulate

Wringing:
Keeping the hands close to each other, they move in opposite directions across the muscle.

Thumb circle:
Circular friction on scar tissue

Pummelling:
Bouncing the palms with raised wrists.

44
Choosing Techniques
Prioritise the goals of the massage to determine which techniques you should use and in which order. Be
aware of the effects of various techniques and combinations of techniques and then choose those that will
best achieve your goals.

Deep stroking, kneading and compression facilitate general recovery. A combination of deep stroking and
stretching increases flexibility.
Deep sliding strokes enhance circulation.

As you gain more experience and confidence with a variety of techniques, the more effective and creative
you will become in planning and conducting a successful sports massage session.

Sequence of techniques
Usually, one begins with general techniques such as sliding strokes over a large area, and then moving on
to work on specific or problem areas, then back to general - work (usually percussions).

Sequencing can also involve using one technique in preparation for another. For example, general
kneading and compression before more specific work on a specific muscle or muscle group, followed by
stretching to lengthen the muscle.

Connecting strokes are used after work on a specific area to enhance the awareness of the body as a
whole.

Massage on an area always begins with light strokes, gradually deepening, and finishing with light
strokes once again.

For example:

• Effleurage Petrissage Longitudinal strokes

• Short longitudinal strokes & transverse strokes
• Cross frictions and compressions Petrissage
• Effleurage Percussion Jostle-shake Vibration Effleurage

Pre-Event & Endurance Event Guidelines

This is a short, specific treatment given immediately before (30 minutes - 24 hours) an event. The goal of
treatment is to increase the circulation, flexibility and mental clarity of the client to improve performance.
It does not replace the athletes warm up but complements it.

It is important to know your clients sport or activity and what muscles are used the most. It is also
necessary to assess the athlete's condition and needs prior to treatment. Factors such as temperature,
45
 nervousness, fatigue, hyperactivity should be considered before giving a treatment. If the client is cold
more warming techniques should be used. If they are already warmed up, focus on flexibility. If they
are nervous some soothing strokes may be called for.

The amount and depth of treatment is the most important key to effective treatment. Deep tissue work is
not advised as it may cause too much of an increase in flexibility and it may interfere with the clients
timing and strength. Keep the goal in mind at all times.
Use brisk invigorating variations of sports massage strokes to specific muscles as per sport.
Create long lasting hyperaemia.
Use stretching, PNF if athlete has used them before.
Begin light and gradually increase pressure and speed.
Energise or calm down as needed.
Do not comment on tightness at this point - it may be too negative or depressing.
If an athlete is unprepared or injured or tight to the point of causing an injury, bring this up with caution.
Consider the time remaining before an event. If it is 30 minutes, give a really short (5 - 1O minute
treatment). If it is the day before, you may give a slightly longer treatment.
Be aware of how much massage a client has had previously to an event. This will determine how their
body will react to the treatment.
In endurance sports, concentrate on overall energy and flexibility.
In strength related sports, concentrate on the specific muscle used.
Do not treat stress points I trigger points (TrPs): Use only 24hours before a competition and only if the
athlete is used to having such a treatment before an event.

Post Event Guidelines

Post event treatments are done immediately after an event, usually within 1 - 3 hours. The goal of the
session is to flush the tissue of lactic acid build up and any other bi products of the metabolism. The
intent is to cool down the body and return it to homeostasis. Muscle tension, cramping and inflammation
are also addressed. Remember anyone competing in an event usually gives it their all in terms of effort
and are left extremely fatigued. Massage can reduce the recovery time of such an effort.
Ask the athlete these questions to assess the condition of the person:

1. How much water have you had since the event?

2. How did you do in the event?
3. Are you hurt or feeling tension anywhere?
4. What do you want worked on?
5. Do you feel hot or cold?
6. Is there another event after this?

1. Treatment Suggestions:

1. Use light draining strokes moving towards the heart.

2. Use jostling or vibrations.
3. Use general compression.
4. Start lightly and gradually apply more pressure.
5. Use gentle compressions and light circular friction to aid in circulation and reduce
spasms.
6. Use effleurage and petrissage for lymph drainage.

46
Chapter 7

Warm up
The purpose of a warm up is to prepare the body and mind for more strenuous activity by helping to
increase the body's core temperature, while also increasing the body's muscle temperature; by increasing
the body's muscle temperature you are helping to make the muscle loose, supple and pliable.

An effective warm up will also increase your heart rate and your respiratory rate. This increases blood
flow, which in turn increases the delivery of oxygen and nutrients to the working muscles.

Structuring a warm up:

Start with the gentlest activities.

Key parts of an effective warm up:

• General warm up.
• Static stretching.
• The sport specific warm up.
• Dynamic stretching.

General warm up.

Lightly physical activity taking about 5 - 1O minutes and resulting in a light sweat

The aim is to elevate the heart and respiratory rate, increasing the blood flow and helping with the
transportation of oxygen and nutrients to the working muscles. Also the muscle temperature is increased,
allowing for more effective static stretching.

Static stretching

5 - 10 minutes. Placing the body into a position whereby the muscles or group of muscles to be stretched
is under tension. Start with the muscles and opposing muscles relaxed, and then move to increase the
tension of the muscle. Hold the stretch to allow the muscle to lengthen.

Sport specific warm up

More vigorous activities reflecting the type of movements and actions that will be required during the
sporting event

Dynamic stretching

This is more for muscular conditioning than flexibility, and carries a high risk of injury if used
incorrectly. It should be used under the supervision of a professional sports coach or trainer.

47
Dynamic stretching involves a controlled soft bounce or swinging motion to a force a particular body part
past its usual range of motion. The force of the bounce or swing is gradually increased but should never
become radical or uncontrolled. Keep the dynamic stretches sport specific.

Cool Down
The cool down is just as important as the warm up. If you want to stay injury free it is vital. The main
aim of the cool down is to promote recovery and return the body to a pre-exercise level.

During strenuous exercise your body goes through a number of stressful processes. Muscle fibres,
tendons and ligaments get damaged, and waste products build up within your body.

Most people experience post-exercise soreness the day after a tough workout. The cool down will assist
your body in the repair process. This soreness can be caused by a number of things. Firstly, during
exercise tiny tears (called micro tears) may develop within the muscle fibres. These cause swelling of the
muscle tissues which in turn puts pressure on the nerve endings and results in pain. Secondly, when
exercising, blood carrying nutrients and oxygen is pumped to the working muscles. The nutrients are
used, and the blood pumped back to the heart. However, when exercising stops, the force that pushes the
blood back to the heart stops. The blood and waste products (like lactic acid) stay in the muscles, which
causes swelling and pain. The cool down helps by keeping the blood circulating.

Key parts of an effective cool down:

• Gentle exercise
• Stretching
• Refuelling

Examples of a good cool down:

• 3 to 5 minutes of easy exercise (resembling the type done during your workout)
• Include some deep breathing as part of the easy exercise to help oxygenate your system.
• 5 - 10 minutes of stretching (Static and PNF is best).
• Re-fuel both fluid and food is important. Drink an electrolyte replacement drink and eat easily
digestible food like fruit.

48
The FITT principle
This is a great way of monitoring your exercise program:

• F - Frequency
• I - Intensity
• T – Time
• T - Type

Frequency - How often?

Intensity - How hard do you exercise?
Time - How long do you exercise?
Type - What kind of exercise?

This is most commonly used in the weight loss industry, although it is also used as part of strength and
weight training recommendations.

The standard recommendation is as follows:

Frequency - 3 to 4 times per week

Intensity - Moderate to high.
Time - Anywhere from 15 to 40 minutes
Type - Just about anything

Taking a look at each component:

Frequency - Adjust the number of times you exercise per week to reflect your current fitness level; the
time you have available; goals you may have set etc. Only exercise 3 - 4 times per week. Give your body
time in between to repair and rebuild.

Intensity - The best way to gauge the intensity of a work out is to monitor your heart rate. The most
effective way is to use a heart rate monitor. If you cannot, simply count your heart rate over a 15 second
period. Multiply by 4 and this will give you your exercise heart rate in beats per minutes.

Time - This depends on the type of exercise undertaken. E.g. it is recommended that to improve
cardiovascular fitness you will need at least 20 - 30 minutes of non- stop exercise. For weight loss, more
time is required; at least 40 minutes of weight bearing exercise.

The key to a work out in terms of intensity and time is variety. Don't get stuck in an exercise rut. Have
some long easy sessions (like long walks and light repetitive weights) and other short intense sessions,
like stair climbing or interval training.

Type - Like time this depends on the type of exercise undertaken. E.g. to improve cardiovascular fitness,
then exercises like walking, jogging, swimming, bike riding, stair climbing, aerobics and rowing are
effective. For weight loss, any exercise using the majority of your large muscle groups will be effective.

If you want to lower your risk of injury, do a variety of exercises. This will improve all your major
muscle groups and will make you a more versatile, all-around athlete

49
 Overtraining
Overtraining is the result of giving your body more work or stress than it can handle. Overtraining occurs
when a person experiences stress and physical trauma from exercise faster than their body can repair the
damage. Regular exercise is extremely beneficial to your general health and fitness, but you must
remember that it is exercise that breaks your body down, while it is rest and recovery that makes you
stronger and healthier. Improvements only occur in times of rest. Stress can come from many sources -
family commitments etc. as well as exercise.
Overtraining cannot be tested. There are no tests that can be done to determine overtraining. There are,
however signs and symptoms which can act as a warning bell.

If you recognise 5 or 6 of the following signs and symptoms, it may be time to take a closer look at the
volume and intensity of your work load.

Physical signs and symptoms

'
• Elevated resting heart rate
• Increase susceptibilities to colds and flu
• Increase in minor injures
• Chronic muscle soreness or joint pain
• Exhaustion
• Lethargy
• Weight loss
• Appetite loss
• Insatiable thirst or dehydration
• Intolerance to exercise
• Decreased performance
• Delayed recovery from exercise

Physiological signs and symptoms

• Fatigued, tired, drained, lack of energy

• Reduced ability to concentrate
• Apathy or no motivation
• Irritability
• Anxiety
• Depression
• Headaches
• Insomnia
• Inability to relax
• Twitchy, fidgety or jittery

The most common signs to look for are a loss of motivation in all areas of your life, plus a feeling of
exhaustion.

50
The answer to the problem

Prevention is always better than cure. The following are a few things you can do to prevent overtraining.

• Only make small and gradual increases to your exercise program over a period of time.
• Eat a well-balanced nutritious diet.
• Ensure adequate relaxation and sleep.
• Be prepared to modify your training to suit environmental conditions. For example on a very hot
day swim instead of running
• Be able to monitor other stresses in your life, and make adjustments to suit.
• Avoid monotonous training, by varying your exercise as much as possible.
• Do not exercise during an illness.
• Be flexible and have fun at what you do.

While prevention should always be your aim, at times overtraining will occur and you need to know what
to do to get back on track.
Firstly rest. Anywhere from 3 - 5 days is sufficient, depending on how severe the overtraining is.
A physical and mental rest, don't even think about exercise.
Sleep. Go to bed early and nap whenever you can. Make sure you increase your intake of nutritious foods
and take an extra dose of vitamins and minerals.

After the initial 3 to 5 days rest get back into your routine slowly. Most research states that it is ok to start
off with the same intensity and time, but cut back on frequency.
Sometimes it is good to have a rest whether you are feeling run down or not. It will give your mind and
body time to recover from any problems building up. It will also freshen you up and give you renewed
motivation and help you look forward to exercise again.

51
V02max Defined
As exercise intensity increases so does your uptake of oxygen. So for example the faster you run the
more oxygen you must consume to sustain the pace. Here’s the key:

There comes a point when your body simply cannot increase the amount of oxygen it consumes and
utilises, despite an increase in exercise intensity. This is your V02max.

"The maximum amount of oxygen you can take in and utilize measured in ml, kg &.min".

How does V02max or aerobic power relate to athletic performance and in particular endurance? Good
question.

Imagine your V02max as your "aerobic ceiling". If exercise intensity increases after you have
reached your V02max your body must use predominantly anaerobic (without oxygen) pathways for
energy production. The result?
Lactic acid begins to accumulate rapidly. You can only continue exercising at that level for a few
minutes at most.

The athlete has the potential to maintain a level of work for a prolonged period of time.

In reality lactic acid begins to accumulate rapidly before most individuals hit their V02max. Another
variable - lactate or anaerobic threshold has a large bearing on this.

Factors Affecting V02max

There are 6 major factors that affect your aerobic power:

1. Genetics
Genetics is said to play a 20 - 30% role in V02max.

2. Your age
After the age of 25, V02max decreases by 1% a year. The good news is regular
physical activity throughout life can offset much of the decline.

3. Training status
Athletic training can alter a person's V02max as much as 20% depending on their
lifestyle and fitness habits.

4. Exercise mode
Measure an athlete's V02max on a treadmill test, then a cycle test and finally in a
swimming pool and the results will all differ significantly. Treadmill running has
been shown to produce the highest values.

5. Your gender
Women generally have V02max values that are 15 - 30% lower than men's. This
takes into account differences in bodyweight. With a straight, like-for-like
comparison the difference is even greater.

69
 6. Your body composition
Much of the differences in V02max between men and women are attributed to body
composition. Although there are other biologic differences between the sexes, research
suggest V02max decreases as body fat percent increases.

So can you improve your V02max?

In a nutshell aerobic power can improve 6 - 20% with athletic training. However, the larger gains
usually come from untrained, sedentary individuals. If you are a regular exerciser and particularly if
you consider yourself to be an endurance athlete, chances are endurance training will only make
small improvements in your V02max. Take heart though. You can train specifically to improve your
lactate threshold.
Very few people, even athletes can exercise close to or at their V02max for prolonged periods.

A competitor may well have a higher V02max than you, but with training you can tap more of your
'aerobic potential" than they do. The net result?

You can maintain a faster pace than them for longer, another plus point to remember.

Having a high V02max means nothing if you can't run, swim or cycle very fast when you hit it.
Improving your movement economy so that you are running faster for example, when you hit your
V02max will definitely improve your endurance performance.

The final step is to measure your V02max.

There are 2 types of V02max testing.

• Direct
• Indirect

Direct testing does exactly what its name suggests; a gas analyser is used to measure gas exchange
directly. Indirect testing predicts your V02max based on your performance in a fitness test.

It's less accurate but provides a practical alternative if you don't have $100,000 worth of equipment
and a lab technician handy!

Both indirect and direct tests can be maximal or submaximal. Simply put a maximal test involves
exercising to exhaustion. A submaximal test lasts for a set period of time or distance and is more
suitable for individuals who can't exercise at all (i.e. elderly patients).
Knowing your V02max on its own is useful. But it's far more useful if you know and understand your
lactate or anaerobic threshold as well.

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Heart Rate Monitor Training
Heart Rate Training Zones:

Training zones are based on a percentage window (60 - 70%) of your maximum heart rate. Within each
training zone subtle physiological effects take place to enhance your fitness.

The Energy Efficient or Recovery Zone (60 - 70%):

Training within this zone develops basic endurance and aerobic capacity. All easy recovery running should
be completed at a maximum of 70%. Another advantage to running in this zone is that while you are
happily fat burning you may lose weight and you will be allowing your muscles to re-energise with
glycogen, which has been expended during those faster paced work-outs.

The Aerobic Zone (70 - 80%):

Training in this zone will develop your cardiovascular system. The body's ability to transport oxygen to,
and carbon dioxide away from, the working muscles can be developed and improved. As you become
fitter and stronger from training in this zone it will be possible to run some of your long weekend runs at
up to 75%, so getting the benefits of some fat burning and improved aerobic capacity.

The Anaerobic Zone (80 - 90%):

Training in this zone will develop your lactic acid system. In this zone your individual anaerobic threshold
is found - sometimes referred to the point of deflection (POD). During these heart rates the amount of fat
being utilised as the main source of energy is greatly reduced and glycogen stored in the muscles is
predominantly used. One of the by-products of burning this glycogen is the runner’s worst enemy, lactic
acid. There is a point at which the body can no longer remove the lactic acid from the working muscles
quickly enough. This happens at an individual heart rate for us all and is accompanied by a rapid rise in
heart rate and a slowing of your running pace. This is your anaerobic threshold or POD. Through the
correct training it is possible to delay POD by being able to increase your ability to deal with the lactic acid
for a longer period of time or by pushing the POD higher.

The Red Line Zone (90 - 100%):

Training in this zone will only be possible for short periods of time. It effectively trains your fast twitch
muscle fibres and helps develop speed. This zone is reserved for interval training and only the very fit are
able to train effectively within this zone.

Resting Heart Rate

To determine your resting heart rate (RHR) is very easy. Find somewhere nice and quiet, lie down and
relax. Position a watch or clock where you can see the second hand. After 20 minutes remain where you
are, do not sit up, and determine your pulse rate (beats/min). This is your RHR.

If you have a heart rate monitor then put it on before you lie down. After the 20 minutes check the
recordings and identify the lowest value achieved. This will be your RHR.

As you get fitter your heart becomes more efficient at pumping blood around the body. As a result you will
find your resting heart rate gets lower so you will need to check your RHR on a regular basis (e.g.
Monthly)
Calculating MHR (Maximum heart rate):

The easiest and best known method is to use the formula 220 - age. It is used since it is a simple way to
get a good estimate of MHR.

However, studies show that show MHR varies mostly with age, but the relationship is not a linear one.
Thus the 220 - age formula is slightly inaccurate. For adults under 30, it will overestimate MHR and for
adults over 45 it will underestimate MHR. This is especially true for well-trained over 45s whose MHR
does not reduce as much as with sedentary individuals of the same age.

Calculation of a zone value

The calculation of a zone value, X%, is performed in the following way:

Subtract your RHR from your MHR giving us your working heart rate (WHR)
Calculate the required X% on the WHR giving us "Z"
Add "Z" and your RHR together to give us the final value
Example: The athlete's MHR is 180 and his RHR is 60 - determine the 70% value 0
• MHR - RHR = 180 - 60 = 120
• 70% of 120 = 84
• 84 + RHR = 84 + 60 = 144 bpm
Chapter 8

Name Gastrocnemius
Origin Posterior, medial and lateral femoral condyles
Insertion Via achilles tendon to posterior calcaneum
Action Plantaflex foot and flex knee
Nerve S1 - S2
origin
Pain. TrPs may extend from the instep of the(ipsilateral foot, over the
Pattern posteromedial aspect of the ankle and over the calf and back of
the knee to the lower posterior thigh

Causative Dancers and sprinters - most common. Physical overload and

mal positioning of the foot. Climbing steep slopes, jogging
uphill, riding a bicycle with the seat too low and wearing a cast

Stretch Drop heel off step or stand facing a wall, one leg behind the other
exercises - the heel of the leg to be stretched must remain solidly on the
floor. Also pedal exercise may prevent night cramps.

Strength Calf raises

exercises
Figure

Figure:

Pain (Dark red) Referred from trigger points (X’s) in the right gastrocnemius muscle (Light red). The
essential pain pattern is solid red stripping indicates the spill over extension of the essential pattern, TrP1
in the belly of the medial head, and to a lesser extent TrP2 in the belly of the lateral head, are likely to be
present when the patient has painful nocturnal calf cramps. The two more proximal trigger points, TrP3
and TrP4, project pain higher to the back of the knee
Check List of Gastrocnemius corrective
Actions
POSTURE
• Avoid shoes with high heels
• Avoid excessive resistance of accelerator pedal in car
• Avoid too flat an accelerator pedal in car Provide adequate foot support when seated Avoid
hooking heels on rung of high stool

ACTIVITIES
Avoid smooth leather shoe soles on slippery floor Avoid vigorous kick with toes pointed in crawl stroke
Keep calves and body warm
Avoid tight elastic at top of socks
Avoid excessive uphill walking
Avoid walking on surfaces slanted sideways

HOME THERAPY
Sit in an appropriate rocking chair
Do gastrocnemius/soleus pedal exercise Do gastrocnemius standing Self stretch
Do Lewit post isometric self-stretch for gastrocnemius .·

CALF CRAMPS
Inactivate gastrocnemius TrP1
Passively stretch cramping muscle
Avoid prolonged plantar flexion of foot (in bed)
Try vitamin E supplementation

For all the different massage techniques of the muscles in the leg see
Sport & remedial massage therapy – specific muscles- pg. 163-198
Name Soleus
Origin Head and upper third of posterior tibia and fibula
Insertion Via achilles tendon to posterior calcaneum
Action Plantaflex foot
Nerve S1 - S2
origin
Pain Usually appear primarily in the posterior aspect and
Pattern plantar surface of the heel and often include the
distal end of the achilles tendon. Pain may also
project to an area over the sacroiliac joint on the
same side of the body.
Causative Overload, high heels, running. Can be caused by
wearing shoes with smooth leather soles on a
slippery surface, or walks on soft sand, or on a
laterally slanted surface such as a beach.
Stretch Operator bends the patients knee and stretches.
exercise Self - "Soleus pedal" - One foot completes a
rhythmic cycle of full dorsiflexion, full plantar flexion
and a rest pause, do the other foot.
Strength Same as gastrocnemeus, but with bent knees
exercise

Name Plantaris
Origin Above lateral femoral epicondyle
Insertion Via a long tendon (between soleus and
gastrocnemius) to the posterior medial edge of
calcaneum
Action · Flex knee and Plantaflex foot
Nerve S1 - S2
origin
Pain Refers pain behind the knee and downward over the
Pattern calf as far as the midleg level.
Causative Same as soleus
Stretch Same as soleus
exercise
Strength Same as soleus
exercise
"Shin splints" is an umbrella term used to describe a variety of lower leg problems. The more technical terms for the
injuries that often appear under this heading include acute and chronic exertional compartment syndrome, periostitis,
tibia fractures, and medial tibia stress syndrome.

Aetiology:
Several features make the lower leg susceptible to certain injuries. Before discussing what goes wrong here, it is
worthwhile to take a brief look at the construction of the lower leg and foot.

Anatomy Review: Many muscles in the body are almost entirely separated from their attaching bones, touching only
at the ends of their tendons. Tibialis anterior and posterior, however, attach to the tibia from beginning to end, and
almost along the entire length of the muscle bellies. The tibialis anterior fascia actually blends directly into the
periosteum along the whole bone. The Tibialis posterior attaches to the posterior aspect of the tibia in a similar way;
the endomysia sheath blends directly into the periosteum and interossues ligament of the tibia and fibula. The soleus
muscle also has a long attachment of the medial tibial periosteum.
The musculature of the lower leg is contained in four tough fascial compartments. Each compartment has its own
motor nerve supply. The fascia that wraps around these compartments is so tough and inelastic that if fluid
accumulates beyond a certain point, it can interfere with normal lymph and venous drainage. This traps the excess
fluid inside the fascial sheath. The pressure this causes can be very painful and can damage muscle tissue and nerves.
The other key piece to lower leg function is the shock-absorbing capacity of the feet.
Feet are designed to spread out and rebound with each step. If the foot has inadequate shock absorption - from flat
feet, bad shoes, bad surface to walk, run, or jump on, or any combination of the above, the tibia and the muscles in
the lower leg, especially soleus, tibialis anterior, and tibialis posterior, will absorb a disproportionate amount of the
shock. They are not designed for this job, however, an ongoing stress causes the periosteum to become irritated, the
bone to crack, and the muscles to fray and become inflamed.
Chronic overuse or misalignment may cause the lower leg muscles to accrue some internal micro-tearing along with
general inflammation. The periosteum of the injured tibia may do the same. The difficulty with inflammation in this
area is that there simply is not room within those fascial sheaths to allow for excess fluid retention. Even a small
amount of oedema puts pressure on nerve endings and limits blood flow, which, in a typical vicious circle, makes it
hard for excess fluid to leave the area.
Causes for inflammation in the lower leg include exercising with inadequate foot support or on bad surfaces; unusual
amounts of exercise followed by a period of rest (continued gentle movement would help the fluid to keep moving
out of the area); suddenly changing an exercise routine, or running mostly uphill, downhill, or on uneven surfaces.
Signs and Symptoms:
Pain from shin splints can be mild or sever, and the location varies according to which of the structures has been
damaged. It gets worse with whatever actions the affected muscles do: dorsiflexion, inversion or plantarflexion.
Simple muscle injuries are rarely visibly or palpably inflamed. If the tibia is red, hot, and puffy, suspect a more
severe injury than muscle damage to the lower leg.

Lower Leg Injuries:

Muscle strains are the first step in a series of lower leg injuries, all of which may be referred to as "shin splints". The
following lists other conditions that may fall under this heading, and the serious complications that may follow if
they are not treated.

• Tibia/is anterior, tibia/is posterior injury: The pain associated with these injuries may be familiar to many
people. The ache often runs most of the length of the tibia on the lateral side (for tibialis anterior) or deep in
the back of the calf (for tibialis posterior).

• Medial tibial stress syndrome: This term refers to a muscular injury on the medial side of the tibia, usually
involving the soleus and tibialis anterior.

• Periostitis: This is an inflammation of the periosteum, which may happen with damage to the soleus, the
anterior tibialis, or posterior tibialis muscles. That seamless connection of membranes begins to rip apart, and
the fibres of the muscles pull away from the bone. This condition may sometimes leave the bone feeling
bumpy or pitted; that is where scar tissue has knit the connective tissue membranes back together.

• Stress fractures: These are small hairline fractures of the tibia. They are extremely painful, and nothing heals
them except time. They are frequently the result of "running through the pain". They are best diagnosed by
bone scan, which looks for area of increased circulatory activity. Stress fractures of the tibia do not usually
show up well on x-rays.
• Chronic exertional compartment syndrome: This situation involves the production of excessive fluid in any
of the four compartments of the lower leg. The fluid, which is normally increased by up to 20% with
exercise, puts mechanical pressure on local nerves, causing pain and inflammation. These symptoms are
relieved by rest but recur in a predictable pattern with activity.

• Acute exertional compartmental syndrome: This is a culmination of that vicious circle of oedema that limits
blood flow, which limits the exit of excess fluid mentioned previously. Because the fascia on the lower leg is
such a tough container, the swelling can actually cause tissue death if it is not resolved naturally or with
surgical intervention. Acute exertional compartment syndrome is an emergency situation and should be
treated as quickly as possible.

Treatment:
The typical approach to mild shin splints is to reduce activity and to alternate applications of heat and cold. If the
situation complicates to become chronic or acute exertional compartment syndrome, steroid injections may be
suggested, or surgery may be performed to split the fascia and allow room for those compressed blood vessels that
were unable to do their jobs. This surgery is followed by physical therapy to limit the accumulation of scar tissue
that could bind up the compartments even more tightly than before.
As long as the problem is not too advanced, shin splints indicate massage. The lower leg muscles are impossible to
thoroughly stretch out and clean up with exercise alone, but massage can give them a luxurious inch-by-inch
stretching and broadening that cleanses the tissues more efficiently than anything else. In fact, massage is a excellent
way to prevent shin splints and Periostitis from complicating into exertional compartment syndrome.
For palpably hot, inflamed, painful cases, however, it is necessary to wait until the pain and inflammation have
subsided. Obviously, if someone has too much fluid in a closed area, the last thing needed is a massage to exacerbate
it. What this person really needs, if the pain is not much better in 2 or 3 days, is to see a doctor. Stress fractures and
exertional compartment syndrome are serious problems that require medical attention.

Spasms, Cramps

Definition:

A spasm is an involuntary contraction of a muscle. Chronic spasms are marked by alternating cycles of contraction
and relaxation, whereas tonic spasms are sustained periods of hypertonicity. The difference between spasms and
cramps is somewhat arbitrary; cramps are strong, painful, usually short lived spasms. One could say that tight,
painful paraspinals are in spasm, whereas a gastrocnemius with a charley horse is a cramp. The severity of these
episodes depends on how much of these muscles are involved.
"Spasms" and "cramps" are sometimes used in reference to visceral muscle as well
(i.e. spastic constipation), but this discussion is restricted to the involuntary contraction of skeletal, or, so-called
voluntary muscle.

Aetiology:

Four of the most common situations are addressed here:

• Nutrition:
Calcium and magnesium deficiencies, in addition to causing all sorts of problems later in life, can also make
one prone to cramping, especially in the feet.

• Lschemia:
When a muscle, or part of a muscle, is suddenly or gradually deprived of oxygen, it cannot function properly.
Rather than becoming loose and weak, it becomes tighter and tighter. Often this is a gradual process, but
sometimes it is a sudden and violent reaction to oxygen shortage.

What causes this oxygen deprivation? It can be anything that impedes blood flow into the affected areas.
Considering a typical tight, painful iliocostal is: one of the paraspinal groups of muscles that hold the back erect.
Here is a muscle that is: tight, hard, a little achy, but most of all, overworked. The fibres are shortened and thickened
with the effort of keeping the spine upright, and this makes it harder for the supplying capillaries to deliver the
goods, namely, oxygen. In protest, the iliocostalis draws up even tighter, this further inhibits the influx of oxygen: a
vicious circle of ischemia causing spasm, causing pain, which leads to spasm, and so on. Furthermore, muscles that
are forced to work without oxygen accumulate the chemical by-products of anaerobic combustion. These metabolic
wastes are irritating to nerve fibres and further reinforce the spasm. The whole picture is complicated by the fact that
as postural habits develops; the brain comes to interpret these sensations as being normal. The proprioceptors
eventually reinforce the patterns that cause the problem. This situation can go on for years at a time without any real
relief, until the circle of ischemia-spasm- pain in interrupted.
Pregnancy can be another cause of ischemic cramping. As the fetus lays on the femoral artery Unit where it splits off
from the abdominal branch), it can interfere with blood flow into the leg, prompting a violent contraction of the
gastrocnemius. This is a classic example of an acute cramp or charley horse. Other kinds of circulatory interruptions
or nervous system problems can cause them too, so when making a decision about whether massage is appropriate it
is important to be sure that no underlying pathologic condition, such as cardiac weakness for example, is creating an
oxygen deficiency.
• Exercise-Associated Muscle Cramping:
Amateur and professional athletes often report problems with muscles cramping at or near the end of
vigorous workouts. Dehydration, electrolyte imbalance, and hyperthermia may all be contributing factors, but
these cramps may be primarily due to a Neurologic abnormality that over-excites muscle spindles (the
proprioceptors involved in tightening) while inhibiting the activity of the Golgi tendon organs (the
proprioceptors that allow muscles to let go). The target muscles usually cross two joints, and they cramp
when they are contracted from a shortened position. Stretching the muscles and manipulating the tendons
limits these cramps, but they tend to recur if the athlete is inadequately warmed up or stretched out before
beginning to exercise.

• Splinting:
The last variety of cramps and spasms discussed here is a reflexive reaction against injury. Consider an acute
whiplash. The supraspinous and intertransverse ligaments have been severely wrenched, and the body senses
a potentially dangerous instability in the cervical spine. Of course the postural neck muscles contract; as far
as they are concerned, they are literally keeping the head from falling off. This kind of spasm is an important
protective mechanism. It keeps the injured person from making the kind of movements that could cause
further injury. The muscles create an effective splint; the range of motion of affected joints is generally very
small. The proprioceptors say, "You can move this far; no further".

• Massage:
lschemic or exercise-related cramps indicate massage, as long as the ischemia is not related to a
contraindicating condition. But even when the underlying pathologic condition has been ruled out, massage
must be used with caution. If a therapist tries to "fluff up" a cramping gastrocnemius, the fibres may be
damaged. A better strategy is to stretch the tendons and antagonists of the affected muscle to gently but
quickly persuade the proprioceptors that they may safely allow the muscle to let go. When the problem has
moved out of the acute stage, it is possible to go back and clean up some of the toxic waste left behind,
always at the tolerance of the client.
When tight muscles splint an injured area, massage therapists should not interfere with this protective
mechanism. If they do, the client will probably get up off the table with his newly loosened scalene, but those
muscles will clamp right back down, possibly even more tightly than before.
In time, the ligaments will be ready to take some weight-bearing stress, but the muscles may no longer be
able to let go spontaneously. Now massage can do some real good. By working to soften the hardened muscle
tissue, massage can reduce toxicity, improve blood flow, and speed healing. Spasm as a splinting mechanism
is to be highly respected. When the injury moves into a subacute stage, massage is indicated and will
contribute to a healing process with a minimum of scar tissue, fibrosis, and permanent shortening.

• Strains
Strains are a subject of semantic debates. Some people say that the word strain refers to tendon tears; others
insist it refers only to tendon tears; others insist it refers only to muscle tears. In this text, strains will refer to
an injury to the muscle- tendon unit, with an emphasis on muscles.

• Aetiology:
Muscle strains and other soft tissue injuries occur from specific traumas, but they appear more often in the
context of chronic, cumulative overuse patterns with no specific onset.
When a muscle is injured, the process is essentially similar to tendon and ligament injuries: fibres are torn,
the inflammatory process begins, and fibroblasts flood the area with collagen to knit the injury back together.
Like ligament injuries, strains are graded by severity. First-degree strains are mildly painful but do not
seriously impede function, whereas third-degree strains involve ruptured muscles, and possibly avulsed bony
attachment sites.
Signs and Symptoms:

Symptoms of muscle strain are mild or intense local pain, stiffness, and pain on resisted movement or
passive stretching. Unless it is a very bad tear, no palpable heat or swelling will be present. Muscles, unlike
tendons and ligaments, are not made exclusively of connective tissue, and although this is a good thing in
terms of blood supply, an accumulation of excess scar tissue in muscles has different implications than it
does in tendons and ligaments:

Impaired contractility: Scar tissue can seriously impede the contractility of uninjured muscle fibres. When
the muscle tries to contract, it will be bearing the weight not only of its bony insertion, but also of the fibres
that are disabled by the mass of collagen that binds them up. This significantly increases the chance for
repeated injury, more scar tissue, and further weakening of the muscle.

Adhesions: Collagen that is manufactured around an injury does not immediately lay down in alignment
with the muscle fibres; it is deposited in haphazard form. Randomly arranged collagen fibres tend to bind up
different layers of tissue that are designed to be separate. These areas in which one thing gets stuck to
another are called adhesions. Adhesions can occur wherever layers of connective tissue come in contact with
one another. Adhesions may be within the muscle, as is frequently seen with paraspinals, or between
muscles, when muscle sheaths stick to other muscle sheaths. Hamstrings are a common place to see this
phenomenon. Wherever they occur, adhesions limit mobility and increase the chance of injury.

Treatment:

The management of muscle injuries has taken some giant- steps forward in recent years. Whereas at one
time an injured person would be given a prescription for anti-inflammatory and pain killers, it is now
recognized that early intervention in the healing process can powerfully impact the long-term quality of the
healed tissue.
Although individual specialists will approach musculoskeletal injuries with different tactics, some features
are consistent:

Get an accurate diagnosis: Evaluating muscular injuries requires a thorough patient history and skilled
clinical examination. Other diagnostic procedures (x- rays, bone scans, MRl’s, etc.) may be recommended if
the doctor suspects more than a soft tissue injury.

Control inflammation: Inflammation is a valuable tool in dealing with acute injuries, but it can outlive its
usefulness and end up causing more harm than good. Inflammation can often be controlled by RICE (rest,
ice, compression, elevation), but some physicians now use the "PRICES" protocol, which adds "protection
or prevention" and "support" to the list, or "PRICER" with "referral" being added to the list.

Rehabilitate damaged tissues: This part of the treatment involves exercises that. Add incremental amounts of
weight-bearing stress to the injured muscle to help the scar tissue realign with the original fibres, and to
gradually increase strength and fitness. This might be the most vulnerable time in the process, because
athletes who are eager to resume training may try to go too fast and get injured again, and other people may
neglect the need to exercise and allow scar tissue to accumulate to inefficient levels.
Prevent further injury: Most chronic muscle injuries are related to controllable factors that can be adjusted to
help prevent future problems. These include dealing with muscle imbalances that make one area weaker
while another may be tighter; improving technique within specific sports; making sure that equipment is
appropriate and in good repair; adjusting training schedules so that changes are incorporated slowly; and
taping or bracing vulnerable areas.

Massage:

Skilful, knowledgeable massage can make the difference between a one-time muscle strain that takes a few
weeks to resolve and a painful, limiting, chronically recurring condition that makes it impossible to do some
activity a client used to love. Once a therapist has a clear picture of what structure or structures have been
injured, various kinds of lymphatic drainage techniques can help to limit oedema.
Cross-fibre and linear friction can influence the way old scar tissue matures and new scar tissue lays down.
Passive stretches of healing muscles can also influence the correct alignment of collagen. When massage
therapists apply their skills to the proper formation of scar tissue, the reduction of oedema, the limiting of
adhesions, and the improvement of circulation and mobility, they can help turn an irritating muscle tear
into a trivial event.

Stages of Musculoskeletal Injury

Acute injuries:
The general rule for massage and soft tissue is that massage therapists must respect the acute stage of injury.
Important things are happening during this time, and therapists ought not to interfere. It is during this stage
that the inflammatory reaction begins with the release of chemicals that:
Set up oedema that limits movement.
Call in white blood cells to eat up the debris.
Irritate nerve endings so that the person feels pain and takes the injury seriously.

Some types of massage are appropriate with some types of acute injuries, but they are highly specialised and
not appropriate for casual experimentation.
How long is an acute injury acute? It depends on the injury, but the most commonly accepted guideline is 48
hours.

Subacute injuries:
This is where massage therapists can be most effective. As they strum over the newly formed scar tissue in
an injured tendon or ligament, they are creating an internal environment that is conducive to the best
possible healing. The tension and stretch massage creates will help determine the orientation of new
collagen fibres. Massage will flush out the irritating chemicals that interfere with the inflow of fresh blood.
Massage therapists are instrumental in the rehabilitation of an injured structure so that it will end up looking
and behaving as though it never was hurt at all.

Chronic injuries:
In this stage, massage therapists can still be major contributors to the healing process, but their effectiveness
will be determined by how big, how old, and how accessible the injury is, as well as other variables such as
the diet and lifestyle of the client. These are the situations in which therapists have to use their most
powerful tools: cross-fibre friction, ice, stretching, and movement recommendations, everything that is at
their disposal to rework that gnarled up old scar tissue inside and out.
Sprains

Sprains are tears to ligaments: the connective tissue strapping tape that links bone to bone throughout the
body.

Aetiology:

Sprains, strains, and tendonitis are all injuries to structures that are composed largely of connective tissue
fibres arranged in linear patterns. They have a lot in common in the way of symptoms, healing mechanisms,
and treatment protocols. Thus, much of the information in this segment is applicable to all three conditions.
Their differences will be emphasized here, as well as guidelines for how they may be seen in the same light.

Anatomy Review: Linearly arranged structures such as muscles, tendons, and ligaments are injured when
some of their fibres are ripped. The severity of the injury depends on what percentage of the fibre is
affected. First-degree injuries involve just a few fibres; second-degree injuries are much worse, and third-
degree injuries are ruptures: the entire structure has been ripped through and no longer attaches to the bone.
The process of repairing from muscle, tendon, or ligament tears involves the laying
down of new collagen fibres, not in alignment with the injured structure, but whichever way the
fibroblasts happen to deposit them. The perfect combination of movement, stretching, and weight-bearing
stress in the subacute phase of recovery helps to reorient the fibres in alignment with the uninjured structure.
If this happens in the best possible way, the new scar tissue actually becomes part of the muscle fascia,
tendon, or ligament. However, if a new injury is immobilised, the scar tissue becomes dense and contracted,
pulling on all of the uninjured fibres nearby, and significantly hampering the weight-bearing capacity of the
ligament.

Distinguishing Features:

What makes sprains unique?

Sprains are injured ligaments, not muscles or tendons: Ligaments are the connectors that hold the bones
together. Structurally they are a little different from tendons; the dense linear arrangement of collagen fibres
affords little stretch and almost no rebound. If the ligament is stressed enough to become injured, it tends to
tear before it stretches. And if it does get stretched, it will not rebound to its original length, and it will not
stabilise the joint as well as it did before the injury. This ligament laxity is also seen with chronic injury-
reinjured situations.

Sprains are more serious than strains and tendonitis: Because tendons and muscles tend to be more elastic
and less densely arranged than ligaments, they will stretch before a ligament does. The "line of defence" in
joint injuries are: muscles, tendons, ligaments, joint capsule - so a sprain is one step away from a
dislocation. Furthermore, ligaments do not have the same rich blood supply as muscles, and they are denser
than tendons. Consequently, they do not have the same access to circulation, which makes them slower to
heal than muscles or tendons.

Sprains tend to swell: With a few exceptions, acute sprains swell much more than muscle strains or
tendonitis; this is one way to differentiate between injuries. Swelling is a protective measure that recruits the
body's healing resources and limits movement, which prevents further injury. Ligaments are sometimes
contiguous with the joint capsules of the joints they cross over, so an injury to them will sometimes signal
the joint to swell as well. Ligaments that are not attached to joint capsules swell much less than those that is.
Signs and Symptoms: Acute stage

Acute sprains show the usual sign of inflammation: pain, heat, redness and swelling, with the added
bonus of loss of function because the rapid swelling splints the unstable joint and makes it extremely
painful to move. Inflamed ligaments are especially painful with passive stretches of the structure.
Sprains can happen at almost any Synovial joint, but the anterior talo-fibular ligament of the ankle is
the most commonly sprained ligament in the body.
Ligaments overlying the sacroiliac joint are also very commonly injured, as are various ligaments
around the knees and fingers.

Signs and Symptoms: Subacute Stage

In the subacute stage, signs of inflammation may still be present, but they will have subsided and the
joint will have begun to regain some function. The physiological processes are no longer geared toward
blood clotting and damage control; they have shifted toward clearing out debris and rebuilding torn
fibres. The amount of time that passes between acute and subacute stages varies with the severity of the
injury, but the 24 - to 48 hour rule is usually dependable. It is important to remember, though, that
some injuries can waver back and forth between acute and subacute, especially in response to certain
kinds of activity or massage.

Complications:

Injured ligaments can occasionally lead to more serious problems. Sprains are such a common injury
that it is important for massage therapists to be familiar with all of their repercussions.

Masking symptoms: An acute sprain may mask the symptoms of a bone fracture, especially in the foot.
It is important to have clients get an x-ray to rule out fractures before beginning to work with a
sprained ankle.

Repeated injury: Internal scar tissue (scar tissue that accumulates within a specific structure) that never
remodels just lies there in a big, gummy mass. It can interfere with the function of undamaged fibres. It
can weaken the integrity of the whole structure, which, along with the increase in ligament laxity,
makes repeated injury a very common complication of sprains. This pattern is present with strains and
tendonitis also.

Ligament laxity: A ligament that has been injured, in addition to having torn some fibres, is often
looser than uninjured ligaments. This is because it has been asked to stretch further than it could go,
and ligaments have almost no rebound capability. When a joint becomes unstable because of loose, lax
ligaments, excessive movement of the bones becomes possible. The bones may knock around and
knock together, causing osteoarthritis and a host of other problems.

Treatments:

A long time ago, the recommendations for sprains included hot soaks and total immobilisation. Clearly
both of these strategies were counter-productive: heat increases oedema and the accumulation of scar
tissue, whereas immobilisation prevents the fibres from becoming aligned with the injured structure.
These days RICE therapy is considered the norm, with the emphasis on moving the joint within range
of pain tolerance absolutely as soon as possible. The potential benefits are clear: ice keeps oedema at
bay, limiting further tissue damage from ischemia; compression does the same; elevation also
encourages lymph flow out of an already impacted area.
Introducing movement is exactly what bodies are designed to do to help form scar
86
tissue that strengthens, rather than weakens, an injured ligament. If exercise is overdone, more tearing
accumulates, and more scar tissue is produced. If it is done too little, the scar tissue glues itself in its
original random arrangement, and binds up the undamaged ligament fibres as well, increasing the risk
of further injury. But if it is done just right, exercise and stretching "teach" the new collagen fibres
which way to lie, and they will remodel themselves according to the stresses put on them.
Interestingly, the issue of when exactly to introduce movement and weight-bearing stress is still not
settled; different ligaments seem to have different needs. However, most evidence points toward early
mobilisation as an important part of the rehabilitation of most ligament sprains.

Massage:

Massage is great for sprains. It can reduce adhesions and influence the direction of new collagen fibres
in the healing process. It can address oedema and toxic accumulations from secondary muscle spasm.
Massage will also help with stiffness from the temporary loss of joint function. But most massage must
be done after the acute stage has subsided. Modalities in lymph drainage for dealing with acute sprains
are effective, but it is a highly technical field and not for casual experimentation.

Tendonitis

Definition:

Tendonitis involves injury and inflammation in tendinous tissues. The injury process has a lot in
common with strains and sprains, and in fact these injuries may sometimes be difficult to delineate
from each other.

Aetiology:

Tendonitis can occur anywhere in the tendon, but tears happen most frequently at the tenoperiosteal
junction or the musculotendinous junction. These areas mark the shift of one tissue type into another.
Though the transition may be gradual, this is still a weak point in the structure that is vulnerable to
injury.

Signs and Symptoms:

The symptoms of tendonitis are very similar to those of muscle strains, though they may be more
intense. The acute phase may show some heat and swelling, depending on which tendons are affected.
Most tendon swelling is not visible, with a few exceptions, particularly in the Achilles tendon and the
posterior tibialis tendon at the medial ankle, both of which may swell significantly with injury.
In all stages of tendonitis, stiffness and pain are present on resistive movements and
in stretching. It is easier to sustain a serious tendon tear than a serious muscle tear; muscles are a lot
more elastic than tendons are. This condition has a more distinct acute and subacute stage than muscle
strains.
Treatment:

The quality of the healing of a torn tendon depends largely on what happens between the subacute and
maturation phase of scar tissue development. Although the initial collagen fibres generated by the
inflammatory response lie down randomly during the subacute phase of healing, weight-bearing stress
and stretching cause them to rearrange in alignment with the direction of force once the initial
inflammation has subsided.

87
If an injured tendon gets too little weight-bearing ng stress during its maturation phase, the scar tissue
fibres do not realign, the collagen is of poor quality, and the tendon is permanently weakened and
prone developing adhesions to nearby structures. This condition is often referred to as tendinosis. If the
injured tendon gets too much use during this time it can rip again, go back into an acutely inflamed
state, and accumulate excessive scar tissue. The challenge for the injured person and his health care
team is to figure out how much is just the right amount of weight-bearing stress for the maximum
benefit to injured tendons.
As with muscle and ligament tears, standard medical approaches to this kind of injury often focus on
symptom abatement rather than scar tissue management. Unfortunately, this can create a stubborn,
serious problem out of potentially very minor ones, as the unresolved scar tissue weakens rather than
strengthens the tendon. Fortunately, recent advancements in the understanding of how scar tissue
develops have begun spreading into more mainstream applications, so the "take painkillers and do not
move for 2 weeks" kind of treatment strategies for soft tissue injuries are becoming less and less
common.

Massage:

Tendonitis definitely indicates massage. Again, however, this condition is more serious than a simple
muscle tear, and the acute phase must be respected to allow the body to begin the process of cleaning
up debris and laying down new fibres. Practitioners familiar with lymph drainage techniques may be
able to limit the accumulation of oedema and minimize scar tissue. In the subacute stage, massage will
be valuable not only for the mechanical action it can have on badly placed collagen fibres but for the
circulatory turnover it will stimulate in the area of non-vascularised tendons.
Sprains, strains and tendonitis all respond best to mechanical types of massage in a subacute phase, as
soon as the acute symptoms have passed. This is when direct manipulation can have the most profound
influence over the quality of healing. The
sooner an injury is treated, the more complete resolution a client is likely to have. However, even
years-old injuries respond well to massage if the circumstances are right. It may not be possible to
completely reverse a 10-year-old tendonitis or tendinosis, but any amount of improvement is
significant. For a client who has been living with pain and limitation, any improvement is a lot better
than nothing.

Tendonitis? Tendinosis? Is There a Difference?

Inflammation is not the only cause of tendon pain and weakness. Another term, tendinosis, has been
used to describe tendons that have sustained significant damage but are no longer inflamed.
Tendons with tendinosis may have significant accumulations of disorganised scar tissue, poorly formed
collagen, and a reduction is weight-bearing strength, but the inflammatory process is no longer at work
- that is, until the structure is re-injured.
Massage is frequently suggested for athletes and other persons with tendinosis to stimulate circulation
and improve nutrition in the avascular (lacking blood vessels or having a poor blood supply. The term
is usually used with reference to cartilage) connective tissue structures, as well as to help stretch and
mobilise the damaged tissues.

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Name Origin Tibialis oosterior
lnterosseous membrane and adjacent surfaces of
tibia and fibula
Insertion Plantar side of tarsals, 2na - 4tn metatarsals and
calcaneum
Action Plantaflex and invert foot
Nerve L4 - L5
origin
Pain Pain concentrates primarily over the achilles tendon
Pattern above the heel and has a spillover pattern that
spreads from the TrPs distally through the mid-calf
down the heel and over the entire surface of the foot
and toes.
Causative Chronic postural overload; Running on uneven
surface; Badly worn foot wear. Hyper pronation.
Stretch Dorsiflex and evert the foot at the same time with a
exercise towel
Strength None - but instead of running or cycling the patient
exercise can swim

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Corrective Body Mechanics
A patient with active tibialis posterior TrPs who is a runner or jogger should exercise on a smooth
surface and wear shoes with adequate arch support. Pads should be added to the show beneath the head
of the first metatarsal to correct for a Morton foot structure, if present. If there is Hyperpronation due to
a hypermobile midfoot, a good arch support should be used. If muscle imbalances are present, they
should be corrected.

Corrective Posture and Activities

In patients with painful hyperpronating "runners' feet", the problem may be corrected by exercises to
increase the endurance and aerobic capacity of both the tibialis posterior and peroneus longus muscles.
Walking and running should be confined to smooth, level surfaces.
If the TrP activity responds poorly to treatment, jogging or running as a form of
exercise should be replaced by swimming or bicycling. Initially, corrections made to
the insert of the shoe may be uncomfortable due to referred tenderness from the TrPs, but with the
resolution of the tibialis posterior TrPs, this related tenderness of the sole of the foot disappears.
Whether or not the individual runs or jogs, he or she should always wear a well-fitted shoe that is high
enough to enhance lateral stability of the foot. If the heel counter of the shoe is too wide and loose
(when a finger will slide in between the patient's heel and the shoe), the heel of the shoe should be
made snug by adding pads inside the shoe beside the person's heel. · · • High heels and spike
heels must be avoided. High top shoes may be necessary iu
-other measures do not suffice.

INFO:
Morton Foot Structure

In 1935, Dudley J. Morton, MD., described two structural variations in the foot, one or both of which
appeared regularly among 150 patients complaining of metatarsalgia (aching pain in the metatarsal
bones of the foot. It usually arises beneath the metatarsal heads in the transverse plantar arch. Repeated
injury, arthritis and deformities of the foot are common causes, and corrective footwear and insoles
may be prescribed). The most common variation was hypermobility of the first metatarsal (at the
tarsometatarsal articulation) with laxity of longitudinal plantar ligaments; the other, nearly as common,
was a relatively short first metatarsal bone. Hypermobility of the first metatarsal overloads the tibialis
posterior and flexor digitorum longus muscles. The short first metatarsal configuration tends to
overload primarily the peroneus longus and, less frequently, the peroneus brevis muscle. The peroneus
brevis tendon does not cross the sole of the foot to reach the first metatarsal bone as does the peroneus
longus tendon.

A relatively short first metatarsal occurs commonly (approximately 40% of individuals). In both
conditions described the mechanical fault results in a failure of the first metatarsal bone to carry its
share of body weight (normally at least one third) between heel-rise and toe-off during ambulation.
Athletes with the Morton foot structure who run about 80km (50 miles) or more per week are likely to
develop painful symptoms.

This anatomical configuration causes mediolateral rocking of the foot on the "knife edge" of a line
extending from the heel through the head of the long second metatarsal bone. Travel emphasised the
muscular consequences of this mechanical imbalance in foot dynamics. The muscle imbalance and
overload caused by the Morton foot structure can affect other muscles in addition to the peroneal.

90
Common postural imbalances associated with the Morton foot structure involve the vastus medial is,
gluteus medius, and gluteus minimus.

To examine for the Morton foot structure, the clinician grasps the foot and flexes the joints of the toes
by supporting the heads of the metatarsals with the fingers against the sole of the foot. The dorsal
crease formed by the metatarsophalangeal joint becomes visible. By marking the prominence of each
metatarsal head with a pen, the relative lengths of the five metatarsals become apparent. The second
toe usually stands out as a prominent feature, as seen in Figure 20.48. The locations of the metatarsal
heads are more difficult to mark accurately if the metatarsal bones are bent down with the toes.
Figure 20.5 shows how to examine the plantar surface for a short first, long second metatarsal
relationship. The distal end of the second metatarsal extends farther than the end of the first.
Sometimes the phalanges of the second toe are so short that its tip does not extend beyond the end of
the first toe, even though the second metatarsal is longer than the first. The length of the metatarsal is
the more important factor because it bears body weight. Therefore, the clinician should examine the
first two metatarsals for relative length, not just the toes, when the patient has peroneals TrPs.
Usually, when the first metatarsal is shorter than the second, the web of skin between the second and
third toes is large compared with that between the first and second toes. This finding alerts the
examiner to look at metatarsal length.
Although some individuals have a shorter first metatarsal with normal distribution of body weight on
the metatarsal heads, those with abnormal weight distribution develop calluses. These calluses usually
develop in conjunction with TrPs in the peroneus longus muscle. They occur under the head of the
second metatarsal and

Sometimes under the third and fourth metatarsal heads, this may also carry additional weight. These
calluses further aggravate abnormal weight distribution on the metatarsal heads at the end of stance
phase.

Other calluses also tend to develop: on the medial side of the great toe, towards the end of this toe;
medially beside the head of the first metatarsal; along the lateral border of the sole of the foot
anteriorly; and, sometimes, on the lateral side of the fifth metatarsal.
Duchenne observed that patients with paralysis of only the peroneus longus muscle presented primarily
with painful calluses on the lateral border of the sole of the foot. This reinforces the impression that
when patients develop TrPs that inhibit the peroneus longus and weaken its function, they eventually
develop calluses. The presence of these lateral calluses indicates abnormal lateral forces that rub the
feet against the side of the shoe. Callus formation along both sides of the foot may also depend on shoe
tightness. The callus at the medial side of the first metatarsal head indicates one source of bunions that,
in its early stages, is correctable without surgery by modifying the shoes.

Shoe Examination
Inappropriate shoes aggravate the mechanical instability induced by the Morton foot structure. Even a
proper correction can cause additional trouble in the wrong style of shoe. Examination of the shoes
should include at least the following considerations:

Corrective Actions

If the patient with a Morton foot structure has no calluses and no peroneus longus TrPs with local
twitch responses, a first metatarsal pad may not be required, but the added support might be good
preventative medicine. However, in the absence of calluses, there is a possibility that the sesamoid

91
bones in the tendon of the flexor hallucis brevis muscle under the short metatarsal head may provide
the necessary support. On the other hand, to manage a pain complaint of peroneals origin, the
Morton foot structure usually requires correction.
The principle in correcting for the symptomatic Morton foot structure is to equalize
the forces between the relatively long second and the short first metatarsal bones during toe-off by
adding one, sometime two, thin layers of a supporting pad of firm adhesive felt under the first
metatarsal head. A sole insert cut as illustrated in Figure 20.12A facilitates accurate placement of the
pad. In this way, one insert can serve to correct several shoes. On the medial side of the foot, the insert
should extend beneath the first metatarsal head, almost as far as the interphalangeal joint of the great
toe. The end should coincide with the distal crease of the shoe, about1 cm beyond the
metatarsaophalangeal joint the lateral part of the cut insert should end just short of the lateral four
metatarsal heads so that it adds no support beneath these bones when placed in the shoe

The felt pad can be attached to the underside of the sole insert. (Fig 20.12B) through the use of either
adhesive felt or an additional adhesive such as double- sticky carpet tape. The felt pad should cover the
area under the head of the first metatarsal, extending to the inner (medial) side of the shoe, but not
under any part of the second metatarsal head. The pad should extend over the end of the first metatarsal
head so that it adds support at toe-off, placing the foot on a tripod base, but it should not extend under
the distal phalanx of the great toe. The insert assembly can be held against the foot (Fig 20.12C) to
ensure that the pad covers all of the first metatarsal hand and none of the second metatarsal head.
Lateral displacement of the metatarsal pad only a millimetre or two can make a significant difference in
effectiveness. Since the Morton foot structure is usually (but not always) bilateral, ordinarily both
shoes should be corrected.

The sole insert must be wide enough to prevent its slipping sideways. The insert is ineffective if it
slides laterally inside the shoe, partly underneath the second metatarsal head. For adequate width, a
woman should buy the male size insert. If she wears a size 1O shoe, she should purchase a man's size
10 sole insert.
Similarly, a man who wears a size 10 shoe should purchase a size 12 man's insert. The excess length of
the insole must be trimmed at the heel.
This assembly fits into the shoe. The patient should try on the shoe and test the insert for comfort,
paying special attention to any discomfort during ambulation. The head of the second metatarsal
should feel completely free of pressure.
This is a relatively temporary correction. The felt becomes compressed and the insert may wear out
after several months of use. Even if the foam insole does not
need replacement, it may need an additional layer of felt added to it after a period of use.

With inactivation of the peroneals TrPs and restoration of the exercise tolerance of these muscles, often
less padding is required, but complete elimination of the padding makes the muscles prone to
reactivation of TrPs.

On return visits, the patient's shoe should be checked for the metatarsal -pad correction. The pads can
fall out or slide around in the shoe and may be forgotten when the patient changes shoes or buys a new
pair. Recurrence of peroneals myofascial pain symptoms after many months of relief is often due to
loss of adequate shoe correction.

A permanent "Flying Dutchman" correction (Fig 20.14) requires no maintenance and cannot be
"forgotten" when shoes are changed. To make this correction, a shoe repairman inserts a leather wedge,
with the thick edge medially, 3-mm thick at the inner (medial) edge, between layers of the leather sole
underneath the head of the first metatarsal. For women’s shoes in which the sole does not have at least
two layers of leather, as usually found in men's shoes, the "Flying Dutchman" can be placed between
the existing sole and an added thin rubber sole. Glue-on rubber soles for home use are no longer
generally available, but shoe repairmen have thin black rubber half-soles suitable for this purpose.
92
Badly worn shoe heels should be replaced or a metal cleat or rubber tap added over the worn part. Use
of the sole insert with a corrective first metatarsal pad usually ends or greatly reduces the excessive
lateral heel-medial sole pattern if shoe wear. Patients with just the Morton foot structure need both a
first metatarsal pad and a flat heel. Addition of a pad under the shafts of the middle three or all five
metatarsals may also be helpful.

If a patient with a short first metatarsal bone walks with the toes in rather than the usual position of
slight out-toeing, the first metatarsal pads for correction of the Morton Foot structure may prove
ineffective. For all individuals and for these patients especially, foot problems may be aggravated by
the patient's heel fitting loosely in a shoe heel that is too wide. Adding felt padding to the inside of the
shoe along the sides of the heel usually corrects the problem. Adhesive pads for this purpose can be
found in some shoe stores, and the correction can be made when the shoe is bought.
Sometimes a patient with a Morton foot structure is already using a metatarsal support that seems to
have helped. The support may be retained but only if it does not extend under the head of the second
metatarsal. If the support is too short a first metatarsal pad may be added to lengthen it. Morton
recommended both corrections.

Corrective orthoses can be constructed by competent podiatrists or physical therapists that are aware of
the principles outlined above.

The clinician should insist that the patient bring all pairs of shoes for evaluation and correction. Each
pair may present a different problem for correction. With the Morton foot structure, patients may
prefer to walk in their bare feet or bedroom slippers. Bedroom slippers and sandals with rigid soles
should be discarded.

93
 Tibialis anterior
Name
Lateral surface of the tibia and interosseous
Origin
membrane
Insertion Plantar surface of 181 metatarsal and medial cuneiform

Action Dorsiflex foot and slight supination

Nerve L4 - L5
origin
TrPs refer pain and tenderness primarily to the
anteromedial aspect of the ankle and over the
Pain dorsal and medial surface of the great t o e .
Pattern Sometimes spillover pain may extend from the TrP
downward over the shin to the ankle and foot
anteromedially.
May be activated by the same forces that cause an
ankle sprain or fracture, and by overload sufficient to
induce an anterior compartment syndrome. Most
Causative
likely to be the cause of serious gross trauma than
due simply to overuse (repetitive, micromechanical
trauma).

Cross the involved foot over the other thigh and

Stretch
using the hand to plantar flex and evert the foot
exercise
passively.

Strength Resisted MET stretch on the anterior aspect of foot

exercise while dorsiflexing and everting.

94
95
PNF Stretching Proprioceptive
Neuromuscular Facilitation
Proprioceptive Neuromuscular Facilitation (PNF) is a more advanced form of flexibility training that
involves both the stretching and contraction of the muscle group being target. PNF stretching was
originally developed as a form of rehabilitation, and to that effect it is very effective. It is also excellent
for targeting specific muscle groups, and as well as increasing flexibility, (and range of movement) it
also improves muscular strength.
Warning

Certain precautions need to be taken when performing PNF stretches as they can put added stress on
the targeted muscle group, which can increase the risk of soft tissue injury. To help reduce this risk, it
is important to include a conditioning phase before a maximum, or intense effort is used.

Also, before undertaking any form of stretching it is vitally important that a thorough warm up be
completed. Warming up prior to stretching does a number of beneficial things, but primarily its purpose
is to prepare the body and mind for more strenuous activity. One of the ways it achieves this is by
helping to increase the body's core temperature while also increasing the body's muscle temperature.
This is essential to ensure the maximum benefit is gained from your stretching.

How to perform a PNF stretch

The process pf performing a PNF stretch involves the following. The muscle group to be stretched is
positioned so that the muscles are stretched under tension. The individual then contracts the stretched
muscle group for 5 - 6 seconds while a partner, or immovable object, applies sufficient resistance to
inhibit movement.
Please note; the effort of contraction should be relevant to the level of conditioning.

The contracted muscle group is then relaxed and a controlled stretch is applied for about 30 seconds.
The muscle group is then allowed 30 seconds to recover and the process is repeated 2 - 4 times.

The athlete and partner assume the position for the stretch, and then the partner extends the body limb
until the muscle is stretched and tension is felt.

, · The athlete then contracts the stretched muscle for 5 - 6 seconds and the partner must inhibit all
movement. (The force of the contraction should be relevant to the condition of the muscle. For
example, if the muscle has been injured, do not apply a maximum contraction).

The muscle group is relaxed, then immediately and cautiously pushed past its normal range of
movement for about 30 seconds. Allow 30 seconds recovery before repeating the procedure 2 - 4 times.

Information differs slightly about timing recommendations for PNF stretching depending on whom you
are talking to. Although there are conflicting responses to the questions of how long should I contract
the muscle group for and how long should I rest for between each stretch, I believe (through a study of
research literature and personal experience) that the above timing recommendations provide the
maximum benefits from PNF stretching.

96
Lymph Therapy
The fluids in healthy tissues are constantly changing. Blood rich in oxygen and nutrients is carried in
the arteries and is filtrated through capillaries to the tissues. These essential ingredients are transported
through cell walls and used in the cells metabolic processes. The waste that results from metabolism is
discharged into fluid that passes between cells. Most of these tissue fluids are then returned to
capillaries and are transported away by the venous system. Some tissue fluid, however, is collected by
lymph vessels and is transported via lymph ducts back into the central circulatory through the left
subclavian vein.
Lymph vessels have less pressure than blood vessels and so the circulation is slower and more easily
affected by the force of gravity, which it has to work against. Muscular activity is the primary motive
force in the lymphatic circulation, so inactivity, sitting or standing will slow it down. Isometric
muscle contraction and muscle tension will restrict the circulation. Scar tissue, especially in the area of
a big lymphatic vessel, and infection of lymph ducts will further hinder the flow. The blockage of
lymph flow causes swelling of the tissues, cell metabolism suffers and often pain results.
Lymph therapy aims to improve the circulation of lymph by causing a pumping and suction effect on
the tissues. Lymph massage was introduced by a Danish biologist, Dr Emil Vodder, in 1933.
Technique:

Lymph massage is performed using the pads of the fingers and thumb and/or the palms of the hands.
Both hands are used alternately in a rhythmical way, with a regular increase and decrease in pressure
(0 - 30mm Hg) to create the pumping and suction effect. Circular movements are made by using the
whole arm rather than just hand movements.
The therapist should always start the treatment from the lymphatic nodes on the neck, gradually
moving downwards to the limbs. Big lymph nodes should always be treated first, so when treating a
limb the proximal part is worked on first before continuing downwards. This effectively clears the
system if excess fluid and avoids stagnation, which may be caused if the treatment was carried out the
other way.
Contraindications to massage described before apply similarly to lymph therapy.

Lymph therapy in Sports Massage:

Lymph massage has been used in different kinds of oedematous swelling conditions. It appears to
give good results on swelling affecting the limbs after. Surgery and radiation therapy. Such swelling is
usually due to direct damage to the circulatory system, or scar tissue hindering it. Also swelling due to
impact trauma and aseptic arthritis can be somewhat improved by lymph massage in conjunction with
gentle superficial stroking on surrounding areas.
Lymph therapy is very gentle and is widely used by beauty therapists to improve circulation and
elasticity of the skin. Conventional massage is more effective at treating tense muscles and scar tissue,
which are the most common causes of trouble for the sportsman, so lymph therapy is not often used.
It is a useful technique if restricted to some special inflammatory conditions, which may affect the
sportsman. Lymph therapy can be applied in cases of acute trauma, other than wounds, to improve
circulation in the early stages. Ordinary massage, as well as lymph therapy, can also reduce
oedematous swelling, and comparative studies show that there is no evidence in favour of lymph
therapy.

97
The 4 Phases of Chronic Muscle Injury
Phase 1:

The athlete feels no pain during exercise or regular training sessions, but does feel slight pain or
discomfort on walking after exercise. An athlete, for example, who has a slightly strained calf muscles
and now consults a massage therapist and who has not been having regular massage, may be surprised
to find that the slight muscle strain can easily be detected as an area of tension. Massage is extremely
effective, in this instance, to smooth out tension and facilitate a return to normal flexibility to the
muscle before it worsens into actual injury. Ice massage is also beneficial after treatment by the
massage therapist to encourage healing and strengthening of muscle fibres. The athlete should always
be advised of the importance of a stretching programme before and after each training session, which
will increase flexibility of the muscles and help to alleviate further injury.

Phase 2:

The athlete who has not paid any attention to the tense area previously and who has continued training
as before, may now feel definite tension and pain on waking - which eases after walking around - as
well as twinges of discomfort during training. A massage therapist can once again be of assistance to
work out what may become knots of tension. A course of treatments with the massage therapist and
ice massage, together with a stretching and strengthening programme would be most beneficial.

Phase 3:

The un-treated muscle may now go into reflex muscle spasm to protect the injured area and
surrounding muscles can also become painful. The pain is eased on walking and if the runner is still
proceeding with his training he may compensate for the pain and alter his style of training. This may
lead to a secondary injury in the hamstring or gluteal muscles. The other leg may also be strained if
the style of running has changed drastically, favouring the injured leg. The athlete is now considered
injured and physiotherapy is recommended.

Phase 4:

An athlete who has continued to deny any injury up to this stage will now be in considerable pain
almost constantly and be unable to train for any length of time so therefore regular training will now
come to a halt. Physiotherapy is now almost essential to aid the healing of the injured muscles. The
physiotherapist will use various massage devices, a laser machine and deep cross friction massage on
the injured area. When the physiotherapist has completed treating the athlete, he would be advised to
continue having massage with the massage therapist who would work equally on both legs and all the
muscle groups to ensure that all the tension area previously caused during the injured period are
worked out, as well as ensuring that no reflex muscle spasm occurs when the athlete resumes regular
training.
The Three Phases of Tissue Regeneration
Phase 1: The Inflammatory Phase

The inflammatory phase can last from 48 hours to 5 days. After an injury the tissue if severely
damaged will have ruptured muscle fibres and broken blood vessels which bleed into the area,
coagulating and sealing off of the area. If the blood vessels are not ruptured, the vessels and muscle
fibres dilate due to an increase of histamine to the area - this is the cause of redness, heat and
swelling. The lymph flow to the area decreases to prevent a spread of the infection from the injured
area to the rest of the body. To facilitate the process of healing the phagocytes or white corpuscles
engulf or ingest foreign bodies (the coagulated bleed) to prevent further infection. Thereafter
neovasularisation occurs. This is the re-growth and repair of blood vessels so that a supply of new
blood is available to the area to remove the waste products. During the inflammatory phase the
athlete should rest as much as possible. No massage at all should be used, but ice packs, elevation
and compression would be most beneficial to maintain vaso-constriction and prevent excessive
swelling.

Phase 2: The Fibroplastic Phase

The inflammatory fluid is high in fibrinogen, which forms the fibrin network of scar tissue. During
this phase, which may last up to 3 weeks, the damaged site is restructured, resurfaced and
strengthened by the collagen fibres of the scar tissue. Therefore mild movement and gentle stretching
is possible. Gentle massage to help the aligning of the scar tissue as well as physiotherapy with the
use of electromagnetic treatment is now recommended.
Phase 3: The Remodelling Phase

This phase may last for 6 weeks to 9 months depending upon the severity of the injury. The
physiotherapist may have ceased treatment and the massage therapist can resume with further
massage to prevent secondary damage. The muscle will have decreased flexibility and massage will
assist in overcoming this as well as re- aligning the granulated scar tissue. The muscle now returns to
normal function as the body remodels the muscle to promote sufficient strength and support and
restructures the scar to fit the tissue.
Manual Lymphatic Drainage
Manual lymphatic drainage was discovered in the 1930s by two Danish therapists, Astrid and Emil
Vodder, who were the first to have the courage to massage the superficial lymphatic ganglia. Since
then, thanks to in-depth studies on the lymphatic system, this technique has evolved, and there exists
today many schools of massage, which include lymph draining in their curricula.
The effects of lymph drainage on lymphatic circulation:

The aim of lymph drainage is to help the circulation of the lymph and its flow in the blood circulation.
The lymph flows from the periphery to the centre of the body, gathering in groups of small cisterns in
specific point of the body, both deep and superficial. It then flows into the venous circulation where
the internal jugular vein and the subclavian vein meet (this area is known as the terminus). The lymph
from the left chest, the left arm, and the left half of the head and face flows into the left terminus,
while the remaining areas of the body flow into the right terminus.

Technique:

In order to perform lymph drainage correctly, it is necessary to bear in mind two rules regarding
lymphatic circulation:
The lymph flows much slower than the blood, so it is therefore of the utmost importance to slow down
the rhythm of the massage, performing the movements as if in slow motion. Not adhering to this one
fundamental rule significantly compromises the effect of the treatment, and one risks causing the
lymph to slow down further.
Before draining the lymph in a region of the body, it is always necessary to empty the superficial
lymphatic ganglion into which it flows. To make things easier, I have divided the body surface into
quadrants, each of which responds to a lymphatic ganglion into which flows all the lymph of the
corresponding quadrants. Draining occurs in the direction of the lymphatic ganglion. The sequence of
lymphatic drainage is not difficult to understand: first empty the lymphatic ganglion and then drain the
lymph of the corresponding quadrant. The quadrants closest to the terminus must be drained before
those situated further away.

Fixed Circular Movements:

This method is performed with the fingertips gently pressing the skin and drawing ellipses; there is no
movement up and down the skin and the circular motions start from the wrist. This movement allows
the emptying of the superficial lymphatic ganglia, but it is also used, with some variations, on the face,
the head, the neck, the elbow, the knees, the hands, and the feet.

482
Pumping:

This movement is carried out with the whole hand covering the entire part of the body undergoing
treatment and gently pushing in the direction of the drainage. The rule to be followed is that one
should use minimum pressure and maximum push.
This movement is performed on the arms, the legs, the thighs and the sides of the chest (these are all
curved areas easily covered by the hand). To make things easier, we shall divide the movement into
four phases: put the arch formed by the thumb and index finger on the curved part of the body to be
treated; lean with the whole palm of the hand; push in the direction of the drainage without pressing
with your fingertips and finally lift your hand. Pumping and fixed circular motions are often
performed together, while one hand pumps, the other is in front of it, carrying out fixed circular
motions.

Erogation:

This is a variation of the pumping movements, which involves, at the end of the movement, the
fingers moving towards the outer parts of the body. The erogation movement is only performed on
the arms and the legs and permits a more accurate check on the direction of the drainage.

Rotation:

This movement is performed with the whole palm of the hand, with the fingers slightly open but
relaxed and the thumb extended. Drainage follows the direction of the index finger. You must never
press with your fingertips. At the end of the trust, the thumb draws closed to the other fingers, and
the hand is practically closed. The rotating movement is used on the large flat surface of the body
(the stomach, the back, the chest, and the buttocks).
Drainage of the neck:
This must always be performed at the beginning of each treatment.
Begin by performing gentle stroking on the neck and shoulders.

Perform fixed circular motions starting from the profundus (the hollow just beneath the ear) to the
terminus. Repeat from 3 - 7 times.

Perform more fixed circular motions starting from the back part of the neck to the terminus. Repeat
from 3 - 7 times.
Repeat the same exercise, this time from the middle of the chin towards the
profundus.

Carry out fixed circular motions in the preauricular and postauricular regions. Direct the thrusts
towards the base of the neck. Repeat three times and then perform fixed circular motions once again
from the profundus to the terminus.

Perform the same circular motions on the shoulders (deltoids), on the trapezium, and on the upper
clavicle region, always in the direction of the terminus.

To conclude, massage the profundus and the terminus once again and end the treatment with gently
stroking similar to that performed at the start of the sitting.
Drainage of the legs:

After massaging the neck (exercises 1 - 7) and gently stroking the feet and groin, perform fixed
circular motions on the groin lymph nodes, pushing towards the centre of the groin.

Drain the inside of the thigh (extremely important). The front and the outside of the thigh,
combining pumping and fixed circular motions.

Drain the front of the knee using the pumping technique, and then approach the side and back of
the knee using fixed circular motions, pushing in the direction of the groin.

Drain the back of the leg with erogation movements, using both of your hands, and address the
front of the leg by pumping. You may combine treatment of both areas of the leg by alternating
the hand movements.

Treat the whole foot and the ankle with fixed circles. Light stroking from the foot to the groin will
end the treatment.

Some Don'ts:

Avoid particularly abrupt and rapid movements. Do not press too hard: remember
the rule of minimum pressure and maximum push. Never forget to drain the neck first.
When Advisable:

Manual lymphatic drainage is advised especially in cases of oedema, water retention, the slowing
down of the circulation in general, and the slowing down of the lymphatic circulation in
particular. It is an excellent aesthetic treatment, and together with other techniques it helps reduce
cellulites. Lymphatic drainage is effective also against acne, couperose, the premature aging of the
cells, and thick scaring. In medicine, lymphatic drainage may be an excellent support therapy for
disorders of rheumatic or neurological origins, such as headaches or neuralgia of the trigeminal
nerve.

When Not Advisable:

It is not advisable to perform lymph drainage in the following cases: in patients suffering from
asthma and I or with an inflamed lower stomach; patients suffering from phlebitis, thrombosis and
thrombophlebitis. Lymphatic drainage is not advisable during acute infections, whether viral or
bacterial, for heart failure, or where there is hyperthyroidism, hypertension, or malignant tumours.

To Conclude:

Lymphatic drainage is a particularly delicate treatment and requires precision and gentleness. Do
not be in a hurry; the treatment must last at least 15 minutes and may go on for more than an hour.
You need time and a lot of practice to learn all the different movements. The minimum pressure
and maximum push rule will help you avoid mistakes; if you keep to it you will not harm your
patient.
Treatment of Acute Injuries
When a sportsman suffers an acute musculoskeletal injury at a sporting event it should be a medical
practitioner or therapist who is specialised in sports injuries, and has the proper equipment, who gives
the initial treatment. For most acute injuries the treatment given is fairly similar (RICE).

Rest:

With any acute trauma injury the first thing to so is to rest the affected area. Activity may increase
bleeding, inflammation and induce more swelling. Movement may cause further tearing of soft tissue
so one should not continue exercising, even though with effective early treatment the symptoms may
not be apparent. To allow proper rest it may be necessary to use strapping, slings, castes, collars,
corsets or crutches.

Ice:

Cold applied locally to the site of the injury or muscle cramps is an effective measure against pain as
it reduces conductivity in the nerves and chills pain receptors. It slows blood circulation and stops
bleeding. Cold will stop the inflammatory process and prevent the swelling from effusion. It will also
help release muscle spasm.
When the injury affects the tissue near the surface or at the lower arms or lower legs, cold should be
applied for only 10 minutes at a time. With deep injuries cold can be applied for up to twenty
minutes. The treatment can be repeated when the part starts to warm up again, which will depend on
body and surrounding temperature. One may continue with cold therapy for one to two days
following the injury.
Cold therapy should always be restricted to local injury area only. If it is applied to a large area it may
cause a strong reflex. Opening the blood vessels and increasing the circulation after a short period of
time. This will make the whole initial treatment ineffective. The same will happen if the cold pack is
removed too early; this is a common fault with cold sprays applied for some minutes.
Cold sprays are popular because they are easy to carry. One should avoid the use of cold sprays on
acute traumas because it is practically impossible to effectively cool the deep tissue without causing
the skin to freeze. If using cold sprays one should have a routine method of application including
spraying times with set intervals in between, as recommended by the manufacturer. It is safer and far
more effective to use an ice pack wrapped in a wet towel or iced water. It is also possible to apply
compression at the same time as using ice packs.

Compression:

Compression should be applied to stop bleeding and prevent swelling. One should not just wrap
traumatised area as this will spread the pressure, and if wrapping is applied to a limb it will restrict
blood flow to the extremity. This can be avoided by using a hard pad on the injury site and putting the
wrapping around it so the pressure is concentrated. If ice is not immediately available, one should
apply compression as a first treatment.
Elevation:

The injured part should be kept in an elevated position whenever possible. This is to prevent the
pressure caused by gravity leading to local swelling around the trauma and distal to it in the
extremities.
The result of giving good acute treatment is effective pain relief. By preventing swelling and
inflammatory processes, which cause further tissue damage, RICE treatment will help start the healing
process early. It will also minimise a risk of forming chronic problems like scar tissue and adhesions,
which can restrict movement.
When the injured sportsman us moved to home or a medical centre the injured part should be kept
immobile and be allowed to bear weight. Good treatment immediately following the trauma will leave
no obvious sign of the injury, even though there might be a massive trauma like a total ligament
rupture. In the field of sports it is important to consider the severity of the trauma and not be fooled by
what may appear to be a miraculous recovery. ·

Post-Acute Treatment:

Rest recommended as a post-acute treatment does not always mean bed rest. Usually it means avoiding
weight bearing and resistant and isometric exercises are important to start at a fairly early stage
depending on the trauma and medical · advice. This is to prevent atrophy of muscles and
tendons, adhesions, ligament and joint capsule contraction.
Massage, ultrasound, heat treatments and passive exercises can usually be applied 2 or 3 days after an
acute soft tissue injury, when the risk of swelling and bleeding has decreased. The purpose of post-
acute treatment is to speed up the healing process and to prevent the complications described above.
Heat treatment is commonly recommended in post-acute injuries as well as for general aches and pains,
but the proper use of it is often not explained, which may lead to poor results. Heat should not be
applied for more than a half hour at a time as tissue metabolism begins to suffer if a high temperature
of the tissues has returned to normal. The use of hot and cold every one minute increases circulation to
the autonomic nervous system.
Gentle superficial stroking massage can be applied to strains 2 or 3 days after the injury, and usually
with mild or moderate strains deep stroking and friction techniques can be started after seven days as
fibrous tissue has started to form.
The treatment should always be applied without causing pain, which will ensure that no further tissue
damage is caused by massage. With severe strains medical advice and control should be sought before
starting the treatment.
For the competitive sportsman the time missed from training whilst recovery from the trauma will have
an adverse effect on performance. Every day lost from training due to rest after the trauma will cause a
drop in sporting ability. But it is important that the sportsman does not panic and commence training
before advised to, which may cause chronic conditions and have far more detrimental effect on
performance. Rest alone does not always ensure full and speedy recovery for injuries.
Inflammation:

Inflammation is the body's response to tissue injury caused by pressure, friction, repeated load and
external trauma,
Trauma is associated with a degree of bleeding, which in turn causes swelling and increased
pressure.
Inflammation, sometime accompanied by pus formation, also occurs in response to bacterial
infections.
The inflammatory response leads to impaired and painful mobility of the affected part to enforce rest.
If inflammation goes unchecked, scar tissue will develop.
Inflammation is characterised by:

Vasodilation of the local blood vessels with consequent excess local blood flow.
Increased permeability of the capillaries with leakage of large quantities of fluid in the interstitial
spaces.
Often clotting of the fluid in the interstitial spaces occurs because of excessive amounts of fibrinogen
and other proteins leaking from the capillaries.
Migration of large numbers of granulocytes (neutrophils, eosinophils and basophiles) and monocytes
into the tissues.
Swelling of the tissue cells.

Some tissue products that cause these reactions are: histamine, bradykinin, serotonin, prostaglandins,
reaction products of the blood-clotting systems, and hormonal substances called lymphokinins
(released by sensitised T cells).
The "Walling OFF" effect of inflammation:

The result of inflammation is to "wall off" the area of injury from the remaining tissues.
The tissue spaces and the lymphatics in the inflamed area are blocked by fibrogen clots so that fluid
barely flows through the spaces.
Thus the walling off delays the spread of bacteria or toxic products.
Macrophage and Neutrophil response to inflammation:

Within minutes after inflammation begins those macrophages already present in the tissues begin
their phagocytic action.
When activated by the products of inflammation the first effect is rapid enlargement of each of these
cells.
Next many attached macrophages break loose and become mobile forming the first line of defence
against infection during the first hour or so. v
Within the first hour after inflammation begins large numbers of neutrophils begin to invade the
inflamed area from the blood.
Neutrophils are already mature cells and are this ready to immediately begin their scavenger
functions for removal of foreign matter.
Monocytes will also enter the inflamed tissue but their number in blood is low, the storage pool is
less that neutrophils. They are immature cells (needing 8 hours to sell and produce large numbers of
lysosomes to become active macrophages). Thus monocytes, once in the tissues sell to become tissue
macrophages.
Symptoms of inflammation include:

Swelling caused by accumulation of fluid.

Redness due to increased blood flow.
Local rise in temperature (due to increased blood flow).
Tenderness on touching the affected part.
Impaired function of the affected part because of swelling and tenderness.

Management:

Remove or reverse its cause.

Decrease swelling, to relieve pain, improve mobility and encourage healing.

Cryotherapy

The usual signs of tissue reaction to injury are:

• Inflammation
• Bleeding
• Swelling
• loss of function
• Pain and muscle spasm.
• Injury
• Bleeding
• Pain and tenderness Swelling
• Increased Pressure on Tissue
• Impaired Healing

The above cycle of events occur when soft tissues are injured. If the cycle of events can be broken or
interrupted, healing is enhanced. Thus with soft tissue injury it is important to inhibit or control
bleeding as soon as possible. Treatment should be started immediately.

Once bleeding has been controlled it remains in the tissues and needs to be removed.
This is performed mainly by the lymphatics.
A variable amount of scar tissue forms in the area and constitutes a weak spot in the injured muscle,
tendons or ligament.
Generally the lighter the bleeding the faster the effusion of blood will disappear and the less scar
tissue formation in the injured tissue.
In the case of soft tissue injuries, the extent of bleeding is reduced by rapid cooling, compression of
the affected area, elevating the injured limb and resting it.
ICE Treatment
Physiological effects of cooling the tissue:
Decrease in metabolic rate in the area.
Decrease in circulation due to vasoconstriction in the area.
Local anaesthesia with a reduction in pain.
Decrease in inflammatory response.
Decrease in muscle spasm.
Decrease in flexibility of ligament and tendons.

Local analgesia and decrease in muscle spasm:

Numbness is achieved after a few minutes which tends to raise the pain threshold;
Muscle spasm is usually a direct result of pain, this will reduce if there is less pain;
The speed of nerve impulses is governed by the temperature of the tissues surrounding the receptor
site;
Cooling reduces the conductivity of nerves;
This lessens the sensitivity of the muscle spindle and thus hyper tonicity of reduced;
It is possible that thermoregulatory defence mechanisms prompt the pituitary gland to release
endorphins;
The cold receptors respond to cooling by an increase in discharge rate - this bombards the efferent
(sensory) nerve pathway, preventing the sensation of pain reaching the brain.
Decrease in metabolic rate:

Cold reduces the metabolic rate of cells and decrease their oxygen needs.
If one does not use cold therapy the cells on the periphery of the damaged area will need 02.
Without 02 the cells will die.
This happens 1O - 25 minutes following injury and continues for 12 hours.
This increases the tissue damage and size of the injury (called secondary hypoxic injury).
Applying heat will have the OPPOSITE effect - increase in metabolic rate and thus major demand
for oxygen. This results in greater secondary damage.

Effects on circulation:

Vasoconstriction with decreased blood flow, less bleeding = quicker healing.

Decreased flexibility of ligaments and tendons:

Connective tissue flexibility decreases with cold.

Thus ligaments and tendons are not as elastic as normal.
Thus one must stop cold therapy when introducing flexibility exercises.
When healing is progressing and there is no risk of further bleeding then heat is usually given.
Methods of ice application:
• Ice cubes - slowly moved over the area (ice massage).
• Crushed ice - in plastic or towelling bag with a thin towel placed in between.
• Gel freezer packs - can be reused.
• Packs of frozen food (peas).
• Chemical packs - becomes cold when struck hard to mix the chemicals. There is a danger of
chemical burns if the chemical leaks.
• Iced water - in bucket: immerse the body part. Is useful for ankles and wrists.
• Cold aerosol sprays - produce superficial cooling, but is easy to carry around.

Methods of cooling:

• Ice should never be placed directly on the skin but should be separated by a layer of damp
towelling or something similar to prevent ice burns.
• Neither cold water nor ice packs should be used directly on open wounds.
• A cooling spray may be used when local pain relief is the only objective in areas where the
skin is in close contact with the skeleton (shins, knuckles, ankles).
• Cold water can be used when ice packs are not at hand or if the injury involves larger areas,
which cannot easily, be covered with ice packs.

Use of cryotherapy:

• Cold can be used to treat soft tissue injury in acute, subacute and rehab stages.
• Acute stage - ice for 15 minutes every 1 - 2 hours. At this stage, cryotherapy slows the
metabolic rate, reduces bleeding and fluid exudates and reduces further tissue damage.
• Subacute stage and rehab - 20 to 30 minutes, 3 to 4 times a day. Main uses are to relieve pain
and muscle spasm to allow early active movement.
• Treatment of overuse injuries.

Contraindications:

• An open bleeding wound.

• Deficient circulation in the part.
• Lack of skin sensation.
• Hypersensitivity to cold.
• Extreme pain with application.
 Technique Using tee Pack or Gel Pack:
• Prepare the ice pack by placing approximately 1kg of crushed ice in a plastic or towelling bag;
alternatively, pile the ice onto the towel and fold the ends over. If using a cold pack, remove from
the freezer just before use.
• Ensure that the client is comfortable, well supported and in a suitable position to receive the
treatment.
• Remove any clothing or jewellery from the area.
• Explain the treatment to the client, highlighting· the beneficial effects and the importance of
regular timed application. Explain that pain may be felt or increase initially, but that this will give
way to pins and needles and then numbness.
• Wring out a towel in cold or iced water and place over the injured part. Place the cold pack over
this and wrap a double layer of towelling around the part to hold the pack in place. If intense pain
develops, the ice must be removed for 15-30 seconds and then reapplied.
• Compression should be applied and the part elevated and rested.
• Treat for 15 minutes initially; increasing to 30 minutes in the subacute stage, but this will depend
on the client's tolerance. Pale skin should be red, dark skin will be darker.
• Repeat the procedure every two hours for the first 24 hours after injury, or as often as possible.
• Exercise as explained below.
• Technique using teed Water:
• Fill the container to three quarters full with cold water and ice. Ensure that there is ice floating in
the water throughout the treatment.
• Position the client in a comfortable position; remove all clothing and jewellery around the injury.
• Explain the treatment to the client as in point 4 above.
• Immerse the part in the water and reassure that pain is to be expected initially but that it will
subside. If the pain is intolerable, lift the part out of the water for 15-30 seconds then re-immerse.
• Keep the part immersed until it is numb and red; aim for 20 minutes.
• Remove the part from the water and dry gently.
• Exercise as explained below.

Technique with tee Cube Massage:

• Place a supply of ice cubes in a container.

• Position the client in a comfortable, well supported position; elevate the part if possible.
• Remove all clothing and jewellery from the area.
• Explain the procedure to the client.
• Spread a thin layer of oil over the area.
• Hold the ice cube with folded tissue or lint.
• Move the ice slowly over the part, moving up and down in straight lines; overlap the previous
strokes. Work over and around the injured part. The ice will melt so ensure that there is a towel
under the path to absorb the water.
• Continue working in this way for 20 minutes or so, until the part is red and numb.
• Dry the area gently.
• Exercise as explained below.
Techniques with Cold Spray:

These aerosol sprays are not as effective as other methods, and are generally used for convenience on
the field or play. The part is uncovered and sprayed at a certain distance for a few seconds. It is
important that these sprays are used according to manufacturer's direction, as their mode of
application may vary. If incorrectly applied they can cause ice burns.

Exercises following Cryotherapy:

During the first 24 - 48 hours, ice application is followed by slow, gentle isometric exercise. These
static muscle contractions are performed within the pain free range. As healing progresses, isotonic
movements are performed. The client is instructed to move the joint slowly through to the point just
before pain is felt, to hold a moment and return. All possible joint movements must be practised in
this way. Great care must be taken during the healing process and increase secondary damage.
Remember: Movements must not produce pain. All movements must be within the limit of pain.
Example: Treatment to the injured ankle joint, where injuries are usually to the lateral or medial
ligaments.
Apply cold therapy for up 30 minutes, and then remove.
Static exercise instruction - "I'm going to hold your foot firmly and I want you to pull as hard as you
can against my hand, stop of there is any pain." The resistance against the movement must be even,
and great enough to produce tension within the muscle but to prevent any movement. Initially the
resistance is applied to dorsiflexion (hand applying resistance on the dorsum of the foot), and is then
applied to plantar flexion (hand on the sole of the foot). When these contractions are easy to perform,
inversion and eversion are added. Exercise away from the injury first; i.e. for lateral ligament injury,
perform static inversion first. When this is easy, carefully perform static eversion (this may not be
possible initially). Each contraction is held for 5 - 6 seconds.
Remember: Tension must be developed within the pain free limit.
After 48 - 72 hours or so, depending on the severity of the injury, ice treatment is followed by
isotonic exercise.
Instruction for isotonic movement - pull the foot up slowly towards you (dorsi flexion); stop when
you feel any pain; hold; now move the foot slowly down away from you; (plantar flexion). Repeat for
inversion and eversion and then progress to circumduction. Perform three movements each initially,
increasing by two with each application.

Heat Therapy:

If an injury is treated by heat application in its acute stage the blood vessels expand, and the blood
clotting procedure can be disrupted. The amount of fluid in the tissue increases. This leads to
increased bleeding in the injured area, increased swelling and higher pressure in the surrounding
tissue. This results in severe pain, further damage to tissue and slower healing. Heat treatment should
not be started until 48
72 hours after the injury has occurred. The same applies to massage. Heat can be produced from
many sources:

• Infra-red.
• Ultraviolet radiation
• Hot water bottles I hot packs
• Massage
• Showers
• Baths (whirlpool)
• Paraffin wax
• Ultrasound
 • Short-wave and microwave diathermy

All of the above heat the external tissues. Short wave and microwave diathermy and continuous
ultrasound emit energy to create heat within the deep tissues of the body (muscles, tendons and
ligaments).

Therapeutic effects of heat are:

• Pain relief.
• Relaxation of muscle spasm. By relieving pain, associated muscle spasm and tension are also
relieved. Muscles relax most readily when the tissues are warm.
• Increased extensibility. Heating tissues increases muscle and ligament extensibility, which
enhances easier stretching and facilitates muscle contractility.
• Increased blood supply and metabolism. This results from the dilation of capillaries and
arterioles in the immediate area thus increasing blood flow. The supply of oxygen and
nutrients to the area is increased, and waste products are removed more rapidly. This increase
in metabolism is greatest where the most heat is produced, resulting in speed of healing.
• During muscle work or exercise 10 - 20 times more heat is produced than in a resting muscle.
Thus exercise after injury is an important means of increasing metabolism.

Contraindication of Heat Therapy:

• Areas of defective sensation or hypersensitive skin.

• Heart conditions and blood pressure disorders.
• Thrombosis or phlebitis.
• Bronchitis, asthma, hay fever or heavy colds and fevers.
• Migraine and headache.
• Skin infections and disorders (eczema or psoriasis for example).
• Diabetes.
• Epilepsy.
• After a heavy meal.
• Under the influence of alcohol or drugs.
• Later stage of pregnancy.
• The first couple days of period (especially if heavy).
• Severe exhaustion.
• Recent exposure to UVL (sunburn).
Paraffin Wax

Paraffin wax treatment can be used for the whole body, for the hands and feet or for muscle strains of
the legs and arms. Wax is messy and difficult to apply to certain areas, other forms of heat are easier to
use.

Equipment

When cold, the wax is whitish and solid, but when heated it liquefies and clarifies. Wax is heated in
containers, which vary in size and shape. The larger models have a water jacket and automatic
temperature controls. Wax is heated and maintained at a temperature of 45-49°C. The warm wax is
applied in layers, using a brush or ladle. When treating hands or feet, these can be quickly dipped in
the wax. Each layer of wax is allowed to dry and become white before the next coat is applied. A
build-up of 6 coats is desirable. The area is then wrapped in polythene, greaseproof paper or tinfoil
and care must be taken to cover the floor and clothing before the treatment starts.

The Application of Wax to Body Parts - Uses:

• To relieve pain and stiffness of injured joints.

• To promote relaxation of muscles.
• To increase the extensibility of ligaments and tendons.
• To increase the circulation and promote healing.
• To decrease stiffness in arthritic joints. Exercises given after wax may result in increased
mobility.

Effects

• The heat raises the temperature of the area. This promotes relaxation and relieves pain and
stiffness.
• Heat reduces tension and improves the extensibility of muscles.
• There is an increase in circulation due to vasodilation, hiving hyperaemia and erythema. This
speeds up the healing processes.
• The heat soothes sensory nerve endings relieving pain
• Stimulation of sweat glands and more sweat is produced.
• Stimulation of sebaceous glands and the grease in the wax soften the skin.
• Increases the flexibility of ligaments and tendons.
• Increase in metabolic rate.

Contraindications

• Skin diseases and disorders, particularly verrucae, athlete's foot and eczema.
• Cuts and abrasions; small cuts can be covered with waterproof plasters.
• Severe bruising or swelling or any risk of bleeding.
• Any skin infection.
• Undiagnosed painful areas; seek medical advice.
• Very hairy areas.
• Dangers

Burns of the skin if temperature is too high - 49°C is the correct temperature. (Use a sugar
thermometer if the wax bath is not automatically controlled).
Precautions:

1. Cover all areas not receiving treatment.

2. Test the wax on self before treatment.
3. Do not hold the part in the wax bath.
4. Lay a towel then greaseproof paper or foil under the part.

Treatment Technique:
Preparation of Client:

1. Place the client in a well-supported comfortable position.

Check that all clothing or jewellery in the area has been removed.
Check for contraindications.
4. Cover the floor and protect client's clothing.
5. Was the area thoroughly with warm soapy water, rinse and dry
6. Explain the procedure to the client.

Procedure:

• Check the temperature of the wax on self and on the client.

• Hold the part above the bath if possible, or over a bowl or paper to catch surplus wax. Apply a
thin coat of wax with brush or ladle and allow drying. Repeat 5 – 5 times until the part is well
covered. Work quickly.
• Cover with polythene, greaseproof paper or tinfoil and then wrap in a towel.
• Leave the wax on for around 20 minutes.
• Remove the towel and paper and slide off the wax.
• Pat the area with a tissue to dry.
• Dispose of wax into a boiler or into a bin.
• Follow with other treatments.

Care and Maintenance of Wax:

Wax is supplied as large blocks, which should be covered and kept in a dry cupboard. Check the
blocks before placing in the bath; remove any dirt, hairs etc. After use, the wax may be disposed of
by wrapping in paper and placed in a bin. However this proves to be expensive and the wax may be
re-used of it is cleaned and sterilised.
To clean the wax, take a large metal bowl and pour it into 2 - 3 pints of water. At the end of the day,
place the bowl on a heating plate and bring to the boil. Boil for over 20 minutes and then turn off the
heat.
Leave overnight; the wax will rise to the top and solidify, and the water and other matter will remain
underneath. Prise out the wax and scrape all debris from the underside. It may be necessary to remove
a quarter to a half-inch of the wax. When the wax is clean again, it can be re-used in the wax bath.
Throw away the water and debris in the bowl and wash the bowl thoroughly with hot soapy water.
Infra-Red Treatment

Infra-red us used by therapists to heat body tissues. It may be used to treat localised areas such as
muscle joints, the upper or lower back, or it may be used to heat the body in general. Infra-red rays are
electro-magnetic waves, with wave lengths of between 700nm and 400 000nm. They are given off
from the sun and any hot objects, e.g. electric fires, gas and coal fires, hot packs and various types of
lamps. The lamps that produce infra-red rays can be divided into two main types:

• The non-luminous (called infra-red lamps).

• The luminous (called radiant heat lamps).

Confusion exists regarding these lamps. Both types of lamp emit infra-red rays. The difference lies in
their wave length, which determines their depth of penetration. The non-luminous lamp emits rays of
longer wave length, around 4000nm, while the luminous type emit rays of shorter wave length, around
100nm and include waves from the visible spectrum and UVL. The differing wave lengths produce
slightly different effects when absorbed by body tissues.

The Non-luminous (Infra-Red) Lamp

Many types of non-luminous lamps are produced; all have a non-glowing source that emits infra-red
rays. A common type uses a coil of wire embedded in fire clay, which is placed in the centre of a
reflector. When the lamp is switched on, the wire gets hot and heats the fire clay. The rays are then
emitted from the hot fire clay; they pass through the air and are absorbed by a body placed in their
path. The rays from non-luminous lamps are of longer wave length, are invisible, less irritating and
less penetrating than the short rays from luminous lamps. They may feel hotter at equal distances and
power, due to increased absorption in the top layers of the skin.
These wave lengths are further from visible light and are consequently called far IR.

The Luminous (Radiant Heat) Lamp

These are often called radiant heat lamps, and give off infra-red rays from glowing or incandescent
sources such as hot wires or powerful bulbs. These are also placed in the centre of a reflector. When
the lamp is switched on, the wire glows, giving off infra-red and visible rays and small amounts of
ultra violet rays, some bulbs have filters to cut out some visible rays and ultra violet rays - these bulbs
are usually red in colour. The ray produced by these lamps has a shorted wave length, including some
visible rays, are more penetrating (down to subcutaneous layer) and are more irritating than the rays
from the non-luminous lamps. These wave lengths are nearer visible light and are consequently called
near IR.
Combined Infra-Red and Ultra Violet Lamps

Some lamps are manufactured with two elements, one producing UVL rays and the other producing
infra-red rays. Although the sports therapist does not generally use these lamps, they are found in
some clinics. They can be dangerous in inexperienced or incompetent hands - therapists who do not
distinguish between the two may give long duration of UVL, by pressing the wrong switch.
UVL glows, giving a blue I white colour.
IR gives invisible rays or glows red I orange.

Ultra violet rays are part of the electro magnet spectrum, with shorter wave length than infra-red rays
and visible light rays from 400nm to 10nm. These UVL rays are not used for heating effects but for
other effects such as tanning. Manufacturers produce a wide variety of lamps, tunnels and solariums
(combined UV), and the therapist should be familiar with all lamps in the clinic.

A combined infra-red and ultra violet lamp:

• Examine all lamps carefully and read manufacturer's instructions

• Check stability .
• Check joints and screws for angling the lamp; are they tight and secure?
• How can the angle of the lamp be changed?
• Is there an on/off switch on the lamp or must it be switched on/off at the wall socket?
• Is there an intensity control or must intensity be controlled by increasing or decreasing the
distance?
• Is it in good order? Check plugs reflector, grid etc.
• Is it dual purpose, i.e. IR and UVL? If so, make sure which switch operates IR and which for
UV.

Intensity of Radiation:

• The intensity of radiation will depend on 3 factors:

• The intensity of the lamp.
• The distance between the lamp and the skin.
• The angle at which the ray strike the part.
• The Intensity of the Lamp:
• Lamps vary in output and intensity. Some have control dials for increasing and
• Decreasing intensity; others need to be moved further away. The intensity from infra-red
lamps does not pose any problems, as the client is able to feel if the intensity is too high, and
the distance can be increased or the lamp turned down.
Effects of Infra-Red Treatment: Heating of body tissues:
When infra-red rays are absorbed by the tissues, heat is produced in the area. The rays from luminous
generators penetrate more deeply than those from non-luminous lamps; therefore superficial and
deeper tissues are heated directly. With non-luminous lamps, the top 1mm of the skin is heated
directly but the deeper tissues are heated by conduction.

Increased Metabolic Rate:

The increase in metabolic rate will be greatest where the heating is greatest; with infra-red treatment,
this will be in the superficial tissues where there will be an increase in cellular activity. More oxygen
and nutrients are required and more waste products I metabolites produced. However, is the heating is
prolonged or too intense; protein damage occurs and eventually cell destruction. Therefore gentle mild
heating for 25 - 30 minutes is beneficial but heating over 30 minutes can be damaging.

Vasodilation with increase in circulation:

Heat has a direct effect on the blood vessels - it produced vasodilation and an increase in blood flow in
an attempt to cool the area.
Vasodilation is also produced by stimulation of sensory nerve endings, which cause reflex dilation of
arterioles.
Vasodilation is also produced as a result of the increase in metabolic rate and increase in waste
products. The metabolites have an effect on the walls of capillaries and arterioles, causing dilation.
The heat regulating centres of the brain will be stimulated as body heat rises.
This result in general dilation of superficial vessels to ensure that the body is not overheated.
Increasing the temperature reduces the viscosity of blood, which increases the speed of flow through
the vessels.

• Hyperaemia: is the term used to describe an increase in the flow of blood to the area.

• Erythema: means reddening of the skin due to vasodilation and hyperaemia.

Fall in blood pressure:

General body heating may result in a fall in blood pressure. If the superficial blood vessels dilate, the
peripheral resistance is reduced, and this will result in a fall in blood pressure. (When blood flows
through vessels with small lumen, it exerts a certain pressure on the walls. If the lumen is increased
by the vessels dilating, the pressure on the walls will be reduced).

Increase in Heart Rate:

The increased metabolism and circulation means that the heart must beat faster to meet the demand,
therefore the heat rate increases.

General Rise in Body Temperature:

When one area of the body is heated for a prolonged time, there is a general rise in body temperature
by conduction and convection. The heat will be carried to the surrounding tissues by the blood
circulating through the area.

Increased Activity of Sweat Glands:

As the body temperature rises, the heat regulating centres in the brain are affected. r) The sweat glands
are then stimulated to produce more sweat in order to lose body heat. This increases the elimination
of waste products.

Effects on Muscle Tone:

The skin and subcutaneous fat from a barrier to the conduction of heat, but providing there is little fat,
muscle tissue will be warmed by circulating blood through conduction. The following effects are
produced:

The rise in temperature produces muscle spasm, relieves pain and therefore promotes muscle
relaxation.
The increase in blood flow will provide more nutrients and oxygen, which are required for muscle
contraction. Warm muscles contract more efficiently than cold muscles. The increase in blood flow
will speed up the removal of the resultant waste products, such as lactic acid.

Effect on Joints:

Heat may reduce joint pain. This is due to the relaxing effect on the surrounding structures such as
muscles and ligaments, to the soothing effect on nerve endings and to the increase in circulation.

Effects on Collagenous Tissue (Ligaments and Tendons)

Heat increases the extensibility of collagenous tissue, providing it is simultaneously stretched.

Therefore, to improve the range of joint movement, heat and flexibility exercises are effective.
Effects on Sensory Nerves:

Mild heat has a soothing effect on sensory nerve endings. However, intense heat has an irritating
effect.

Pigmentation:

Repeated and intense exposure to infra-red produces a purple or brown mottles appearance on the area.
This may be due to destruction of blood cells and release of haemoglobin.

Uses:

As a general heating treatment to promote relaxation.

As a localised treatment for relief of joint pain, muscle spasm, pain and tension.
Pre-event to warm the tissues; it must be given for a short time only, around 10 minutes prior to warm
up and stretch exercises, but not instead of. The aim is to improve flexibility and enhance the
contractibility of muscles. Too long an · application will promote relaxation, which is not required
before an event, as the athlete must remain alert and focused. It may be immediately followed by brisk
massage to the appropriate area, and then warm up and stretch exercises must be performed. Use prior
to stretch exercises; it increases extensibility of connective tissue components, enhancing flexibility.
Post-event to aid the recovery of the tissues; gentle heat used in conjunction with massage will speed
up the removal of metabolic waste. This aids muscle recovery, relieves pain and stiffness, and
promotes relaxation. It would be given after cool down and stretch exercises. Mild heat only should be
used and massage may be performed at the same time. Particular care must be taken when considering
the use of heat after an event, because it must not be used if there is any suspicion of inflammation or
injury, when ice would be the treatment of choice. Many therapists perform exploratory massage first,
in order to assess the condition of the tissues. Ice packs should be used if sore, tender areas are found,
but heat would be safe is there were no injuries. Mild heat is given for 15- 20 minutes; the massage
may continue for 30-40 minutes.
After injury, to promote healing and recovery; heat should not be given for the first 72 hours after
injury as it increases metabolic rate resulting in secondary damage, it also produces vasodilation,
increasing the risk of bleeding and swelling. Cold therapy is used in the initial stages. Heat must NOT
be given at any time, if there is extensive bruising or any risk of bleeding.
Mild heat can be applied in the subacute stage to promote healing of any condition, which would
benefit from increased metabolic rate, and increased blood supply. A greater range of movement may
be possible after mild heating of the tissues due to increased flexibility.
Contraindication to infra-red treatments
• Areas of defective skin sensation and hypersensitive skin
• Recent scar tissue (defective sensitivity).
• Extensive bruising or any area where there is a risk of bleeding.
• Any undiagnosed injuries.
• Skin disorders and diseases.
• Heart conditions and blood pressure disorders (high or low).
• Thrombosis or phlebitis or any area of deficient circulation.
• Recent exposure to UVL - sunburn.
• Heavy colds and fevers.
• Migraines and headaches.
• Diabetes, as skin sensitivity may be impaired.
• Any area where liniments or ointments have been applied.

Dangers of Infra-red treatments:

• Burns may be caused:

• If heat is too intense.
• If the client is too neat the lamp and fails to report overheating.
• If the skin sensation is defective and client may not be aware of overheating.
• If the client touches the lamp.
• If the lamp should fall and touch the client, or the bedding; overheating of pillows and blankets
can cause fire and burns.
• Electric shock - from faulty apparatus or water on treatment area producing short circuit.
• Headache - irradiating in the back of the neck and head, or over heating by prolonged exposure
may cause headache.
• Faintness - over heating or extensive radiation may cause a fall in blood pressure, which may
cause fainting.
• Damage to eyes - IR exposure of the eyes and turn away from the lamp. Wear goggles or have
cotton wool over the eyes.

Precautions to be taken when giving infra-red treatment:

• Clean the skin with cologne or wash to remove sebum.

• Ensure safe distance of the lamp from client. This distance depends on the client's tolerance and
the output of the lamp (18-36 inches, 45-90cms).
• Do not place the lamp directly over the client.
• Ensure that lamp is stable, with the head over a foot if lamp has 3 or 5 feet.
• Ensure that the lamp is in good working order and that there are no dents in the reflector.
• Ensure that the flexes are sound and not trailing in a walking area.
• Check for contraindications.
• Carry out a hot and cold sensitivity test.
• Protect the eyes.
• Explain the importance of calling immediately if the client feels too hot.
• Warn the client not to move nearer to nor touch the lamp.
Treatment Technique Preparation of client:

• Place the client in a comfortable position. When treating areas of the back use side lying or
recovery position, well supported by pillows. If treating knees or ankles, use half lying with
pillows supporting the part. If treating the shoulder or the elbow, the client should be seated on
a stool with the arms supported on a pillow.
• Check that all jewellery or metal has been removed from the area.
• Uncover the area: wipe over with cleansing wipes.
• Check for contraindications.
• Explain the treatment to the client; warn him/her not to touch the lamp.
• Carry out a skin sensitivity test using two test tubes, one filled with hot water the other filled
with cold water. Instruct the client to close her eyes. Touch the client with the hot test tube or
the cold test tube, at random over the area. Ask the client if she feels hot or cold. (If the client
cannot tell the difference between hot or cold, she has defective sensation and the treatment
should not be carried out). Carry out the test all over the area to be irradiated.
• Cover the area not receiving treatment.
• Warn the client that warmth should be mild and comfortable, and to call if the heat becomes too
intense.

Procedure:

• Check plug, leads and reflector.

• Switch lamp on, directed toward floor:
• IR takes 10 - 15 minutes to reach maximum output.
• Radiant heat (visible) takes around 2 minutes.
• When maximum intensity is reached, position lamp, ensuring stability (if lamp has 3 feet, place
head of the lamp over one of the feet, ensuring angle joints are secure).
• Make sure that the face of the lamp is parallel with the part so that the rays strike the part at 90°
for maximum penetration, absorption and effect. Do not place the lamp directly over the client,
in case the lamp drops or the bulb shatters.
• Select an appropriate distance, between 45-90 cm. The selected distance depends on 2 factors:
 The intensity of the lamp.
 The client's tolerance. 60cm is a good average.
• Ensure that the rays are not irradiating the client's eyes or face or your own.
• Observe the client throughout the treatment.
• Treatment time: 20 - 30 minutes until the desired effect is obtained. The client should not rise
suddenly after JR treatment, because the blood pressure is lowered and she may feel faint.
• The treatment may be followed by massage, warm up, stretch exercise or electrical treatment.

Heat treatment following injury:

Heat treatment should not be given in the acute stage of injury because the increased metabolic rate and
vasodilation (Increasing blood flow and swelling) produced by heat will increase the extent of the
injury rather than reduce it. Heat must not be used if there is any risk of bleeding either from open
wounds or internally along the tissues. Cold therapy should always be used initially because it
decreases metabolic rate, produces vasoconstriction which will reduce bleeding bruising and swelling,
and also numbs the area which reduces pain.
After 72 hours or so, heat treatment can be given providing there is no further risk of bleeding. If there
is extensive bruising, heat must not be given until healing is well under way and the bruise turns
yellow. This may take 6 - 12 days.
Degrees of erythema:
Mild erythema:
• Appears within 6 - 8 hours and which is still just visible after 24 hours.

Moderate erythema:
• Appears within 4 - 6 hours and disappears within 48 hours.
• Resembles a mild sunburn reaction and a little discomfort may be felt.
• Is followed by a definitive pigmentation and powdery.
• Desquamation usually occurs within 1 - 2 weeks.

Marked erythema:
• Appears within 2 - 4 hours, lasts for 72 - 96 hours.
• Subsequent pigmentation and desquamation are marked with skin peeling on sheets or
flakes.

Intense erythema:
• Appears within 2 - 4 hours, may last a week or more.
• Oedema and exudation of fluid into the tissue layers result in blister formation.

General first aid principles:

• Remove the heat - can use cold running water for example.
• Keep the area clean to prevent infection - cover with a clean (if possible sterile)
dressing.
• If clothing is stuck to the area do not try to peel it off.
• Do not add liniments as this may cause infection, or impeded access to the wound.
• Get the person to a medical facility.
 SPORTS MASSAGE TECHNIQUES

Neuromuscular Technique/Therapy (nmt)

Our bodies continuously endure stresses from trauma, improper body mechanics, poor posture
as well as tension which are most likely psychological or emotional in nature, Regardless of the
nature of the stress – be it mechanical, postural or emotional – the adaptive tendencies of the
body will attempt to compensate for the stress by producing neuromuscular changes.
Many of these changes will result in reduced mobility, pain, fatigue and depression. These
Neuromuscular dysfunctions can be picked up in the soft tissues of the muscular skeletal
systems as:
Contractures, hypersensitive areas, and certain tissue restriction.

Neuromuscular dysfunction is self-perpetuating. Therefore when a certain part of the body is

restricted to movement either by pain or mobility impairments, the body will compensate for
this, resulting in further physiological dysfunction.

NMT identifies soft tissue abnormalities and at the same time manipulates the soft tissue to
normalize its function. And so the continual cycle is broken. Much of the pathological activity
is reversed and overall function is improved

By carefully and systematically examining the muscle and associated soft tissues will help
identify abnormal signs, which will include:

* Postural & Biomechanical deviation

* Congestion in the tissues
* Contracted tissue or taut, fibrous bands
* Nodules or lumps
* Trigger points
* Restrictions between the skin and underlying tissues
* Variations in temperature
* Swelling or oedema
* General tenderness
NMT Treatment:
Assessment and soft tissue manipulation
Postural assessment is also important to determine any postural distortion (this could indicate
an imbalance in the tone of structural muscles and is and indicator of chronic stress patterns}.

TECHNIQUE

The general technique of NMT uses the thumb to move across, along and through the tissues.
Varied amounts of pressure are applied.
Light pressure assesses the superficial tissues and stimulates circulation of lymph and blood.
Deeper strokes assess the deeper structures and stretch the fascia, releasing fibrotic adhesions.
When painful spots are located, pressure is held directly on these points. The depth of the
pressure is determined by the tolerance of your client; this is where your client-therapist
communication is extremely important.
The pressure should be deep enough to evoke a mild amount of discomfort in your client.
Pressure that is too deep will cause your client to tense up and have adverse effects. Pressure
which is too light will be ineffective.
Hold singular pressure for 8-12 seconds. Repeat treatment.

To maintain the effects achieved with NMT, the stresses that causes the soft tissue dysfunction
must be addressed and if possible, eliminated.
Make sure to monitor the areas of dysfunction with follow up NMT sessions and incorporate a
program of regular exercise to improve strength, endurance, posture and stamina.
MUSCLE ENERGY TECHNIQUE (MET)

MET is a valuable massage tool when addressing soft tissue conditions that involve tense or
shortened muscles. Muscle spasms are effectively soothed. Joint mobility can be improved and
lengthened OR weak antagonistic muscles can be toned.

MET can be applied in different ways, depending on the condition of the tissue and the indented
response.
Uses: - Increase joint mobility where constricted contractile tissue restricts movement
- To release hypertonic muscles
- To reduce fibrosis in chronically shortened muscles.
- Determine the nature of the restriction and the direction of maximum limitation.

MET involves the active participation of the client, whom is instructed to contract isolated
muscles against a counterforce (the therapist).

MET= active contraction  Relaxation + subsequent passive stretching (to reduce tightness in
the muscles and increase range of motion (ROM).
This improves flexibility in the related joints.

There are 2 basic restraining (inhibitory) reflexes produced during MET:

POSTISOMETRIC RELAXATION
Directly after an Isometric contraction, there is a brief period of relaxation during which
impulses to the muscles are inhibited.

RECIPROCAL INHIBITION
When muscle acting on a joint is contracted, the muscle responsible for the opposite action on
that joint is inhibited.

Depending on the intended outcome of the treatment, the force applied by the therapist may be:
1. Equal to that of the client, allowing no movement to take place.
2. Be less than that of the client, allowing movement in the range of motion.
3. Overcome the force of the client.
Outcomes:
Relaxing and lengthening hypertonic muscles
Stimulating and strengthening weakened muscles
Lengthening chronically shortened fibrotic muscles

MET also has a variety of ways in which it can be performed, once again depending on the
target tissue, the condition of the client, and the intended outcome of the treatment. Some
variations include:

The starting position

The direction of the client's effort
The amount of effort applied by the client
The length of the effort.
Whether the therapist's force matches, overcomes or is less than the client's force.
How breathing is incorporated.
Whether there is a passive, active or no stretch after the contraction.
Whether or not to stretch through the barrier after a contraction.
Whether or not to repeat the sequence.
Whether to use MET with other techniques or as a separate technique.

MET APPLICATION FOR HYPERTONIC MUSCLES

Hypertonic muscle: usually shortened, frequently containing trigger point and taut bands of
muscle tissue, Involved in joint restriction. These conditions may or may not be painful and
may be the site of an acute or chronic injury.

These conditions are determined during assessment procedures.

There are 3 main variations of MET that are effective in lengthening tense and short muscles.

CONTRACT RELAX/ AGONIST CONTRACT

This is the most commonly used MET. This incorporates the contract-relax technique
incorporating the post isometric relaxation theory: that as soon as an isometric muscle
contraction releases, the muscle is inhibited and relax.

ANTAGONIST CONTRACT
If the muscle tissue is in a sub-acute stage of healing or if there is any pain when the target
muscle contracts, this would then be the preferred technique to use. Antagonist takes
advantage of a physiological process known as reciprocal inhibition.
When a muscle acting on a joint contracts, the muscle that causes the opposite action is
reflexively inhibited.
REMEMBER: If the procedure causes pain STOP!
CONTRACT-RELAX-CONTRACT THE OPPOSITE
This technique also sometimes known as contract-relax-antagonist-contract {CRAC),
combines the previous techniques. To perform this technique, contract the opposite muscle.

PASSIVE POTITIONING TECHNIQUE

This technique is most probably the gentlest of soft tissue massage manipulations when
adhering to mobility restrictions due to pain and soft tissue dysfunction.

This technique involves the gentle, passive movement of a joint into position of maximum
comfort, holding it there for an appropriate time and then very slowly returning to its
normal resting position.

STRAIN-COUNTERSTRAIN

The strain-counterstrain (tender point) technique was developed by Dr. Lawrence Jones.
Jones happened on this technique actually by accident when a patient came into his office in
a great deal of pain. Unable to attend to the client's needs immediately, he instructed his
assistant to take the patient into an available room and make him as comfortable as
possible. The assistant did as instructed. The client was asked to lie down on the
examination bed and was made comfortable by using a number of pillows to help support
the client and position his body in such a way that the pain will be bearable.

When the doctor finally came in, he carefully removed the pillows and gently positioned the
client flat on the table and asked where the pain was. To the patients astonishment he
realized that the pain has disappeared.

After this discovery Dr. Jones used this technique on several different patients by
positioning and supporting them in a virtually pain free, comfortable position. Through this
research Dr. Jones developed this technique Strain-counterstrain.

Dr. Jones then came to the conclusion that when a muscle attempts to move through its
normal range of motion, a premature myotatic reflex {stretch reflex), this causes the muscle
to contract therefore limiting movement.
The contraction is often accompanied by pain and spasms. The theory behind this is that
this pathologic reflex may have been initiated when the joint was in a stretched position and
a panic reaction to return to normal position caused the muscle opposite the stretched
muscles to spasm.

E.g. A person bends over for a short period of time, when attempting to stand
up there is a sharp pain and she is not able to stand up without pain.
There is a position however - somewhere between the bent over position and
the erect position that is pain free.
Diagnosis: An over contraction of the antagonist of the stretched muscle resists any attempt to
return to a normal position. The quick stretch of the antagonistic muscle caused the spindle
cells to report to the central nervous system (CNS) that the muscle was being strained. Once
the reflex has initiated the body has no way to reset it.

Solution: By positioning the joint in a position of comfort, which was usually close to the
position where the spasm occurred, the pain ceases. By holding that position which is normally
a more exaggerated angle than the painful posture, then very slowly and passively return to a
normal position, the muscle shortens and the pain and spasm are eliminated.

It was also noted that most joint problems have associated tender spots. When movement of a
joint is restricted, pressure on the myofascial tender point will be painful. As the joint is moved
into position of maximum comfort, the pain in the tender point will diminish. By monitoring
the sensitivity of the associated tender pints while positioning the joints, the ideal angle for
maximum benefit can be determined.

When client indicates that the painful area is "letting go", the pain and discomfort in the area
will also be relieved.

HOLD THAT POSITION FOR AT LEAST A MINUTE AND A HALF (90 SECONDS) then
slowly returns the body to a neutral position.
SOFT TISSUE RELEASE (STR)

Soft tissue release combines pressure and movement. Pressure is applied to the area with the
muscle relaxed or in shortened position. The muscle is stretched causing the muscle fibers to
lengthen and stretch, releasing adhesions.

There are 4 Techniques which make up the STR technique:

1. FRICTION
This is where the tissue remains still and passive and the movement is made by the therapist.
Frictions will break the adhesions binding the fibers, and the movement causes this to happen
in exactly the right direction, which is needed to re-align them so that they may provide
proper function.

2. STRETCHING
This method allows for the elasticity of the muscle as a whole, where the stretch may not
effectively reach a specific area of tension within it. A stretching routine is an effective
means for a sport session.

With STR, a local area of tight and adhered fibers is locked by an applied pressure and the
tissue is stretched away from that point. It can be extremely effective and produces
immediate results. This stretching makes it possible to release muscle tension.

3. NEUROMUSCULAR
The point where pressure is applied, which is often the same as those used in a NMT
situation. Although it is only held for a few seconds in STR, this has a good neuromuscular
effect. The client has to relax into the pain, instead of contracting the muscle by allowing it to
lengthen instead.

4. DIAGNOSTIC
With normal palpatory (to move slowly and deeply) methods, tissues remain still and passive
and the fingers glide through them to assess any textural changes. Important with STR the
pressure is static and the tissues themselves are moved.

The following is how STR is performed:

1. The lock the area of adhered fibers

2. The key deep focused pressure (into the lock)
3. Open the door stretch the tissues away
 CONNECTIVE TISSUE MASSAGE (CTM)

Connective Tissue massage is not a massage as such but a form of stretching to release the fluids trapped
within the connective tissue between the muscle fibers.
Using CTM techniques any adhesions in the superficial connective tissue layers are broken up and relaxed
through reflexes.

No massage medium is necessary as this technique only involves using the tips and pads of the fingers,
particularly the middle finger. The pressure is dependent upon the angle of the fingers and the depth of
the problem area.

For short distances, the middle finger moves along the area taking up the loose skin ensuring a stretching
effect is achieved before releasing, allowing the skin to return.
For longer distances, more fingers can be used with longer strokes incorporated before releasing the
tissues. Pressure can be applied in both directions and not only towards the heart, ensuring rhythm and
pressure remains constant. Strokes can be repeated between 3 and 10 times to allow for correct skin
reaction.

CTM is useful in sports when a patient has extremely tender and tight muscles; by releasing the
superficial tension the muscles can be softened therefore a II owing further massage treatment to proceed.

PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)

Today this is the most commonly used and most effective therapy system for the rehabilitation of
neurological and soft tissue disorders.
This technique is based on a STRETCH - RELAX or reciprocal inhabitation technique and
may be used in any phase of sports massage where is appropriate. During the application, the
therapist acts as the immovable object as the athlete exerts the action of the appropriate muscle
against the therapist (resistance).

An example of this is: STRETCH FOR HAMSTRINGS

* Client lies in supine position and raises leg up to maximum range.

* Athlete should not raise the leg to a range where he or she experiences pain.
* It should be at a comfortable position in order for the athlete to have increases range of
motion.

Caution:
* PNF stretches should not be performed on an athlete prior to an event if they are not
used to the stretches.

Trigger Point therapy

Definition: Trigger points are hyperirritable nodules associated with dysfunctional contractive
tissue that illicit a pain response when digital pressure is applied.

There are a number of different classifications of trigger points depending on where they are
located and whether or not they refer pain when palpated.

CLASSIFICATION OF TRIGGER POINTS

* Active Myofascial trigger point- Hypersensitive spot associated with a palpable nodule
located in a taut band of muscle that prevents full lengthening of the muscle and refers pain or
other definable sensations to referral areas when digitally compressed.

* Latent Myofascial trigger point- Tender when compressed but does not refer pain to
other areas when digitally compressed.

* Central trigger point -Active or Latent trigger point that is located near the center of the
muscle body, and closely associated with the muscle endplate that activates the muscle.
* Attachment trigger point- Located at musculotendinous junction/osseous attachment of a
muscle, caused by continuous tension of the taut band caused by trigger point. Attachment trigger
points are usually inactivated when central trigger point is inactivated.

* Primary or key trigger point- in one muscle may active a satellite trigger point in another
muscle. By inactivating the key trigger point you also deactivate the satellite trigger point.

* Satellite trigger points - Direct result of malfunctioning of the primary myofascial trigger
point, may appear in the pain referral area/antagonist or synergistic muscle housing primary trigger
point. Deactivating the primary trigger point- deactivating satellite trigger point

.* Associate trigger point- Located in another muscle, forms concurrently and due to the same
overload or abuse that is the source of the primary trigger point.
Deactivating primary trigger point usually does not inactivate the associate trigger point.

PALPATING FOR TRIGGER POINT