Andrew is a half-marathoner for Stotan Racing.  He arrived at my office with a primary complaint of L hip pain, and secondary complaints of L hamstring and L Achilles pain.  All of which were combining to hinder his training and, of course, his racing.

I began my assessment by observing Andrew’s standing posture.  What was immediately obvious was his left foot progression, which I estimated to be approximately 25˚ away from the midline.  There was no progression of his right foot.  Next, I had him assume a single-leg stance with his right leg as the stance leg.  I asked him to stand on his right foot and raise his left foot off the floor until both his left hip and left knee were flexed to 90˚.  In this position, I observed his left femur adduct across the midline, while his left tibia rotated laterally and his right foot increased its progression to approximately 30˚.  I had him repeat the single-leg maneuver on his contralateral side, and did not observe any femoral adduction, tibial rotation or foot progression.  I was surprised he wasn’t also complaining of left knee pain.

For the next part of the assessment, I put Andrew on the table and assessed his hip joint single-plane movements.

Both L & R AROM hip flexion were limited to 65˚ and 75˚ (NL 90˚), respectively.  PROM testing indicated a soft end-feel on both sides.  RROM testing revealed some L proximal biceps femoris pain.  AROM assessment of hip extension was approximately 30˚ (NL 35-45˚) on both sides.  PROM assessment yielded a soft end-feel on both sides.  RROM assessment (prone with leg straight)  also indicated a painful spot toward the proximal end of the L lateral hamstring (long head of biceps femoris).

AROM of medial hip rotation was approximately 45˚ (NL 35-45˚) on both L and R sides.  PROM yielded soft end-feel on both sides.  RROM did not produce any painful spots.  AROM of lateral hip rotation was restricted on the left, testing out at approximately 40˚ (NL 60˚) with a PROM hard end-feel, and the right testing out WNL with a soft end-feel.

AROM for hip adduction was WNL (NL 30˚) on both sides, with a soft PROM end-feel in both.  RROM testing …no pain.  AROM for hip abduction was WNL on the right with a soft PROM end-feel, and RROM…no pain.  AROM for left hip abduction, however was limited to approximately 30˚ (NL 45˚) with a soft PROM end-feel.

Summary:  Short/tight hip flexors, but primarily L; Capsular restriction of L hip medial rotation; Short/tight hamstrings, primarily L biceps femoris with a proximal strain or scar tissue;   Short/tight L adductor complex.

I began Andrew’s treatment with a joint capsule release routine.  In the supine position, I proceeded with the neutral position femur-hip fascial and joint capsule mobilization and, internal and external joint capsule releases.  It required several sequences to bring Andrew’s L hip lateral rotation to a more normal range of 50˚.  I continued with the iliacus and psoas releases and stretching (during therapy) for this muscle group.

Next, I continued with Andrew in the supine position and tried to get some length back into the hip flexor complex (iliopsoas), utilizing the psoas major/iliacus sequences from the pelvic stabilization (hip) protocol.  This included stretching (during therapy) in the prone position.

I kept Andrew in the prone position and rechecked his PROM end-feel for L lateral hip rotation (remembering that I only achieved 50˚ in the supine neutral position).  It wasn’t as soft as I expected it to be, but it wasn’t hard either.  I checked the RROM for pain, and there wasn’t any, so I proceeded with the lateral hip rotator protocol.  I started with prone joint capsule work to free up Andrew’s L hip external rotation, and got the soft end-feel but not the 60˚degrees I was looking for.  I kept him in the prone position and proceeded with myofascial release and stretching (during therapy)…and finally got the last 10˚.

I then moved to the L adductor complex and reassessed PROM and RROM, which resulted in a soft end-feel and no pain.  I continued with myofascial release and stretching (during therapy) to obtain the last 15˚ of L hip abduction.

Hamstring work completed the therapeutic portion of this session.  I reassessed the active range and both sides were still short/tight, more so on the left.  Passive range was still soft for both sides.  I proceeded with myofascial release and cross-fiber gliding on both sides.  Stretching (during therapy)resulted in Andrew’s R hammy returning to a normal range of 90˚ with no pain, but resulted in some pain on the left, which verified the proximal issue I had identified earlier.  I utilized the multidirectional friction technique, pain-free movement, and eccentric scar tissue alignment.  After three sequences Andrew tested pain-free, so I continued with stretching (during therapy) and was able to achieve an AROM of 85˚ with Andrew’s L hammy.

Last, I reviewed the home stretching techniques for iliopsoas, hamstrings, and adductors, and explained the necessity for stretching in order to maintain the changes we had achieved.

Andrew recently achieved a personal best at the Chicago half-marathon.

Dr. A is a physician who was initially referred to me by her personal trainer.  She had been working out with him for several months but had begun to progressively feel discomfort (pain) in her shoulders and neck.  It finally got to the point where she couldn’t continue exercising.

Dr. A is a rheumatologist and has been practicing for many years.  She was very easy to work with and easily understood everything I was explaining to her.

My initial precautionary tests:  transverse alar ligament test, vertebral artery compression test, and cervical compression/decompression were all negative.   Dr. A had not reported any other symptoms that suggested brachial plexus involvement or multiple crush syndrome, so I moved on to assessing AROM.   All motions, flexion, extension, L&R lateral flexion, and L&R rotation were limited, but this appeared to be due to discomfort, not muscle tightness.  Her posture did not demonstrate any significant upper or lower-cross characteristics.  The PROM testing revealed no hard end-feels. She was complaining of tenderness and tightness and indicating the exact location of each point, even before we tested RROM.

I started to question whether or not this set of symptoms was actually more related to muscle strains from weight lifting too much too soon, or weight lifting with improper technique.  As I began performing myofascial release and cross-fiber gliding/trigger point release techniques, Dr. A acknowledged every tender point as soon as I used any hand/finger pressure at all. Almost all her tender points were located posteriorly, in the trapezius, levator scapula, and rotator cuff muscles; infraspinatus, supraspinatus, teres minor, and subscapularis.

Because pressure seemed to aggravate the tender points, I switched to a modified strain-counter-strain technique (Chaitow) known as integrated neuromuscular inhibition technique (INIT).  What is unique about this technique is that it includes PNF type stretches following the SCS. (To be sure, we shouldn’t be stretching muscles that are already overstretched, and many of her trigger/tender points were in muscles that are typically overstretched.  But, neither her ROM testing nor her postural assessment suggested muscle length imbalances.)

The way I utilized the INIT was to palpate the tender point with enough pressure to elicit a pain response.  This was done to accurately determine the location of the tender point and to create a baseline of discomfort.  As soon as Dr. A responded to a particular tender point, I positionally manipulated the length of the muscle where the tender point was located so that the length of the muscle became shorter than its normal resting length.  As I manipulated her position, I asked her to tell me if or when the discomfort was reduced by 50%, or more.  Most of the time, the pain diminished completely, when I found the correct position.

I held the SCS position for 90 seconds, exaggerating it slightly if the pain seemed to be returning during the 90 second SCS maneuver.  At the end of the 90 second period, I eased her back into a neutral position and utilized the ‘stretching during therapy’ technique to both stretch and test for any remaining discomfort. I assisted Mary in utilizing a ‘reciprocal inhibition’ form of stretching, or more accurately ‘releasing’, for each muscle/group being treated.  My assistance was only supplying the resistance for the post isometric contraction.  At no time did we create any external manual force (manually increasing muscle length) to accomplish the stretch.

If there was any remaining pain, I repeated the procedure.  I performed this protocol on the previously listed muscle groups in both upper quarters.  Mary’s pain was diminished significantly (but not completely) and her ROMs were WNL at the end of the session.  We decided to reschedule to see if we could achieve a pain-free result.

At our next session, Mary reported feeling pretty good for a few days after the initial session, but the tender points returned after 3 or 4 days at the office.  We decided to stop her weight lifting exercises for a while, to see if it was aggravating the tender points.

The tender point pain had diminished compared to that in her initial session, so we thought we were on the right track.   We then repeated the same protocol we had utilized during the first session, achieving similar results.  I then helped Mary learn how to accomplish the PNF stretches, utilizing a single-person technique, which she could accomplish at home.

Our initial work together began several years ago.  Since that time, Dr. A has returned to my office whenever the physical demands of her practice, or her active lifestyle, have resulted in active, painful trigger/tender points.  From the time we began working together, Dr. A has referred more than two dozen patients to my office.

Thank you! Dr. A.

If you are unfamiliar with the term ‘Fascial’, substitute the term ‘Connective Tissue’.  While both muscle and fascia are both considered to be connective tissue, fascia is not the same as muscle, and should be considered to have a multitude of dissimilar characteristics.  One of the primary components of fascia is collagen (fibers).

One way to describe the difference could be to say that muscle’s main job is to create tension through contraction (shortening) and relax (return to its normal resting length), while fascial connective tissue’s main job is to absorb the tension created by muscle and release it in a catapult-type fashion.

Fascia and muscle do not and cannot function independently to create movement, but must function together to facilitate movement.

This is important because muscle and fascia respond to different stimuli in order to maintain functional integrity.  Specifically, as we age, fascial tissue fails to maintain the structural characteristic of its collagen (known as crimp), and becomes ‘flattened’.  Flattened collagen cannot absorb and release tension like crimped collagen can.  As a result, the fascia loses its capacity for absorbing and releasing tension.  This places a much greater load on the muscle (to create, absorb, and release energy in the manner required) to produce movement.  This activity is more than muscle alone can accomplish.  As a result, when the fascia loses its functional integrity, the muscle becomes overloaded.  When this occurs, we can experience a pain response mediated by the central nervous system (CNS).  This pain is not the result of a structural lesion (structural damage).  The pain is the result of a functional lesion which arises from a combination of muscle and movement impairment (loss of proper length/strength balance), which leads to short-lived compensatory movement patterns, eventual decompensation, and finally, pain.

The good news is that we can train both muscle and fascia to maintain their individual functional capabilities, and thereby (in the absence of structural damage) maintain our pain-free movement experience.  However, we must utilize different training (stimulation) concepts and methods for each.

See Fascial Fitness Training

Excerpted from:  (Dalton, E. Myoskeletal Alignment Techniques.  Freedom From Pain Institute.)

The body’s motor system functions as an entity.  It is in principle a wrong approach to try and understand impairments of different parts of the motor system separately, without understanding the function of the motor system as a whole.  Janda, Vladimir, M.D., 1964

Dalton’s Myoskeletal Method: 

The neuro-reflexogenic relationship of muscles, nerves, and joints is at the heart of Myoskeletal Alignment Techniques (MAT).  Any alteration of joint function is carefully monitored by the brain and spinal cord and may influence muscular function.  To understand the fine control of motion, the separate activity of individual muscles is not as important as their coordinated activity within the different movement patterns.

Overapproximation of joint surfaces caused by isometric muscle contraction leads to irritation of the sensitive mechanoreceptors responsible for recording pressure changes in the joint capsule.  Even though these pressure receptors are not nociceptive pain generators in and of themselves, prolonged compressive forces causes local irritation in the surrounding neural tissues, such as the sinovertebral nerve, and those messages are relayed to the spinal cord.  The result of this continued stimulation can be palpated in the spinal groove as fourth-layer fibrosis.

Unfortunately, the manual therapist’s fingers cannot release all the fourth-layer fibrosis at these sites.  Muscles such as the intertransversarii and interspinalis are sometimes impossible to palpate, and these are often the principle culprits creating facet joint locking.  The Myoskeletal answer is to release these tiny muscles by mobilizing the bones to which they attach.

The goal of Myoskeletal Therapy is not to twist the torso, lock down, or “pop” these dysfunctionl  joints into place.  The Myoskeletal system, much like the Muscle-Energy system takes a kinder, gentler approach.  The intent is to create whole body alignment by simply working through the bones to release hypertonic muscles responsible for the vertebral dysfunction, in other words, to work with the vertebral segment as a whole rather than a single unit.

In line with the concept of whole body alignment, the manual therapist must develop a strategy for carrying out the alignment and balancing process.  The Myoskeletal “intent” is always directed at the deepest connective tissue layers…namely the skeletal system.  Because we are anatomically required to work through the myofascia to reach the skeletal system, focusing on these deeper levels guarantees us whole body alignment.  This “bony intent” provides the modern manual therapist with a powerful new tool for creating profound and lasting changes in the bodies of their clients.

The development of the strategy depends on the therapist’s ability to recognize common strain patterns in the human body.  The Myoskeletal method intentionally keeps it simple by focusing on the two most prevalent strain patterns that are constantly and continually presented by clients.  By observing and understanding the mechanisms of these dysfunctional patterns, the therapist can quickly locate and treat the muscle imbalances responsible for creating the asymmetry.  If the client does not present with either of these two patterns, the muscle testing system still differentiates and corrects the existing dysfunctional pattern successfully.  The goal is to always recognize the strain patterns that create most common neck/back dysfunctions and to correct the strain patterns before they become pain patterns.  Unfortunately, some clients do not present until they are experiencing pain.  The goal then becomes to prevent the pain pattern from continuing.

The upper and lower crossed syndromes taught in the Myoskeletal Method were originally described by Vladimir Janda, MD, who named these observations the “proximal and distal crossed syndromes.”  Dr. Janda was the first to clearly illustrate the predictable effects stress has on specific muscle groups and to show how these muscle imbalances distort body structure and function.

An interesting discovery that seems to be present in every client that presents with vertebral misalignment is the finding of gristle-like tissue deep in the lamina groove.  Dr. Philip Greenman summarized this finding:  “Palpable fourth-layer muscle hypertonicity will always be found in the presence of vertebral dysfunction.”  This has become a tremendous diagnostic tool for the type of deep tissue work performed by advanced myoskeletal therapists.

This means that trained myoskeletal therapists should be able to correctly locate vertebral dysfunction simply by directly palpating and assessing fibrosis in the fourth-layer musculature.  The key words associated with correct diagnosis are “fibrosis” and “hypertonicity”.  Vertebral dysfunction will not be present beneath tissue that is simply tight and constricted.  The fibrotic tissue must feel lumpy and hard.

This wonderfully versatile tool becomes the method for simultaneously identifying, testing, and treating vertebral dysfunction, especially the method for correcting facet misalignment by application of direct pressure with the fingers or thumb.

“Whole body” alignment requires that both myofascia and osseous structures be systematically treated to prevent strain patterns from becoming, or continuing as, painful movement patterns.  Optimal body alignment is impossible with the exclusion of structural facet work.

Janda’s original work describing proximal and distal syndromes has grown to include ligament work and continues to be a remarkable guide to understanding typical imbalance patterns.  By identifying these typical imbalance patterns through observation and testing procedures, the modern manual therapist is able to quickly formulate routines that can restore order and bring balance to the body before, and during the presence of pain.

The idea of muscle imbalances is taken a step further to include skeletal alignment techniques.  When short/tight muscles overpower weaker structures, the uneven pulling continually distorts our skeletal framework.   Identifying and treating myoskeletal imbalances, creating symmetry through proper alignment , and then teaching neuromuscular re-education exercises to reinforce  the myoskeletal work is the foundation of the Myoskeletal Method.