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  • Clay Van Schoyck

The foot is a crucial and complex piece of anatomy. It's made up of many different active and passive structures that play a role in synchronously absorbing ground reactive forces (GRF), and propulsion of the body.

 

Control & Stability

 

There is a complex, orchestrated interaction between active and passive structures which are overseen and controlled by the nervous system. You've got passive ligamentous structures meant to resist motion, which are also supported through the muscles of the foot, and active tissue which are the muscles creating and absorbing motion. The muscles of the foot further break into two categories. Intrinsic and extrinsic. The former are muscles that begin and end within the foot. The latter (extrinsic) are muscles that still directly insert into the bones and ligaments of the foot, but reach further up the leg proximally.

 

Windlass Mechanism

 

The windlass mechanism is a mechanical model that describes the manner which plantar fascia supports the foot during weight-bearing activities and provides information regarding the bio-mechanical stresses placed on the fascia. As you raise the great toe a shortening occurs of the plantar aponeurosis, and tight packs the bones of the foot. This creates a rigid lever for propulsion. Lowering of the great toe relaxes tension making the foot a supple adapter. It's an ingenious mechanism to shift from push-off, to landing.

 

Foot Troubles

 

Obviously dysfunction of the windlass mechanism may cause issues. For example, examining the windlass mechanism is important in the decision-making process in evaluating and treating plantar fasciitis.

 

Stiff shoes can inhibit the windlass mechanism. Going barefoot or minimalist shoes can be tremendously helpful in allowing the windlass mechanism to operate properly.

 

In treating plantar fasciitis, orthotics can be a temporary measure to reduce symptoms, but should be removed as soon as possible because they impair the windlass mechanism. This can unfortunately manifest other pathologies.

 

Full Body Troubles

 

With impairment of the mechanism that absorbs ground reactive forces the energy is not destroyed, it is rather transferred elsewhere. When measuring a top sprinter GRF of 5x their body-weight could be measured. For a marathon runner, impact duration increased significantly and GRF was 3x body-weight. This is to give you some perspective. With an impaired foot GRF of 3-5x your body-weight could in theory travel towards the knee, hip, and back. This is why we emphasize proper mobility and stability of the ankle and foot respectively. Massage & Bodywork

 

Massage therapy can be helpful to feed the nervous system new, novel information as we work the intrinsic and extrinsic muscles of the foot, as well as more passive structures. This can reduce pain symptoms greatly. Increasing mobility of the ankle and assessing / modulating the big toe & windlass mechanism can also set the foot up for future success.

 

As stated earlier it is important not to be too reliant on orthotics, but that extends to passive therapies as well. The most important element is empowering people to strengthen, stabilize, and rehab on their own. The first step is taking ownership of one’s own pain condition.

https://www.physio-pedia.com/Windlass_test

https://integratedseminarseries.com/2018/03/11/the-short-foot/

  • Clay Van Schoyck

Chances are you have heard of frozen shoulder, or know someone who has had it. Even in our small town of San Luis Obispo I've seen quite a few cases come through my doors. I thought it would be a good time to shed some light on the issue.

 

Overview

Frozen shoulder, or adhesive capsulitis is a thickening, and tightening of connective tissue that make up the shoulder joint's capsule. The tightening restricts movement of the shoulder. In a classic capsular pattern the first movements to become restricted are abduction (moving your arm away from the side of your body), and external rotation (rotating your arm up as if to wave to somebody).

 

In general, symptoms begin gradually, worsen over time, and then resolve within one to three years.

 

Stages

1. Freezing stage: Any movement of your shoulder causes pain, and your shoulder's range of motion starts to become limited.

2. Frozen stage: Pain may begin to diminish during this stage but shoulder is stiffer and using it is often extremely difficult.

3. Thawing stage: Range of motion begins to make improvements.

 

Why

Risk of frozen shoulder increases when recovering from a medical condition, injury, or procedure that prevents you from moving your arm (stroke or masectomy).

 

We know that it occurs most often in people 40 and older, and particularly women. Systemic diseases seem to play a role. Those with diabetes, overactive or underactive thyroids, cardiovascular disease, tuberculosis, and Parkinson's. In fact, one particularly hard case to figure out in my massage clinic happened to coincide with Lyme disease.

 

Treatment

Non-invasive treatment options are available. Physical therapy range of motion exercises can be very helpful to keep and gain motion of the shoulder.

 

More invasive treatments would include steroid injections, injecting sterile water into the capsule can help stretch the joint tissue, and shoulder manipulation where the patient is put under (unconscious) and the doctor moves the shoulder joint to loosen tissue. Surgery is rare but is an option when nothing else works.

 

Massage & Bodywork

Depending on the stage, and cause of the frozen shoulder massage seems to have varied results in my own experience. A quick search of Google Scholar yields few results for treating frozen shoulder with massage therapy. Working the tissue around the joint capsule and using passive / active stretching seems tremendously beneficial. However, if in the first two stages (freezing, and frozen) massage may have little impact besides pain relief.

 

Strategically, as range of motion begins to return I'll begin a more aggressive approach. All treatment is within the client's comfort levels. But we'll begin to push for much more range of motion in the thawing stage.

 

Below is a video of a case this week, shared with permission. Massage treatment was in conjunction with physical therapy. We took a conservative approach. When the shoulder began to show signs of entering the 'thawing stage' we performed Active Release Technique for the joint capsule of the shoulder. The technique involves a downward pressure towards the capsule of the joint with the practitioner's contact (thumb). Arm is place on the knee of the practitioner slowly inching the arm further into abduction with a sustained pressure on the capsule of the joint. The results were outstanding, see for yourself:

 

 

 

 

This case began in January. A full 10 months ago. Luckily it seems to be on the short end of the 1-3 year duration. It's possible to attribute these conservative approaches to shortening the time frame. It is absolutely attributable to these large improvements this week.

  • Clay Van Schoyck

Massage therapists, in my experience, often get asked questions during therapy sessions. Questions such as, “does that feel tight?” Or, “What is a muscle knot? It feels like I have a bunch!” Also in my experience, massage therapists have really bad answers for these questions. Throughout my career I’ve thought about these questions, learned and accumulated a lot of answers. The following is an amalgamation of what I think to be the most likely, and most evidence based answers to some of these common questions. These answers are from many experts who have thought about this much longer than myself. Massage therapists, physical therapists, and PhDs. I’ll link their sources below. But the truth is we don’t fully know. More research needs to be done!

 

Myth-Busting

 

In 2002 a group of researchers out of Canada published a paper about the biomechanics of chiropractic adjustments (Bereznick, Ross & McGill, 2002). The paper demonstrated that the interface between the skin and underlying connective tissues is almost frictionless. This means it is extremely slippery, and that there is virtually no friction between the adjacent tissues. If you’ve paid attention so far, the realization might be hitting you. This has severe ramifications in the way we think about manual therapy!

 

The popular notion among massage therapists is we’re “melting fascia,” and changing connective tissue with our hands. These narratives are pervasive, but not based on any evidence. There’s a reason for this. Much of massage therapy is rooted in tradition. To understand why, we need a brief history. After the introduction of the Food and Drug Act of 1906 (foundation of the FDA), interest in ‘alternative’ forms of healthcare waned. Pharmaceuticals, and other forms of therapy were the mainstream. Research into massage therapy all but stopped. That was an unfortunate turn of events for the massage industry. Luckily we’re back into researching massage therapy as of around 1980, but false ideas have had plenty of time to take hold. Oral traditions, and non-scientific teachings about massage therapy is still upheld in schools and CEU courses today. This needs to be addressed, and unfortunately there is often a ton of push back from other practitioners. I know because I was one of them.

 

I remember not long ago reading these ideas and thinking, “I need to unlearn EVERYTHING I thought I knew.” At the very least I needed to interpret what I knew through a different lens. It’s daunting. To think the knowledge I’ve accumulated over the years is wrong.

 

What Then?

 

The evidence suggests much of benefit we receive from massage, and manual therapy is neurophysiological in nature. We’ll unpack that more later. Basically, it’s based on the client’s brain and nervous system. When we touch someone, the frictionless, sliding skin organ feeds our nervous system tons of new (novel) sensory information. Most therapists look right past the skin organ, and all of the nerves embedded within, towards muscle and other tissues. Other tissues that we are likely affecting less than we think. Remember the sliding, frictionless interface.

 

“The human body has 45 miles of peripheral nerve. Moving nerves therapeutically and strategically helps to maintain their physiological and biological health. Healthy nerves that are well fed and drained through adequate and varied movement do not contribute to pain experiences. Sometimes however, because of many reasons which may involve pathological processes, or through injury long ago, too much of one kind of movement, or not enough variation of movement, nerves can develop tunnel syndromes (a cranky nerve whose tunnel has become a compressive or tensional threat to the neurons inside of it).”

-Diane Jacobs, Dermoneuromodulation

 

With this information in mind, we need to consider the highly innervated, mobile, and force dissipating skin organ, and the miles of nerve traveling towards it from deeper nerve trunks, into more superficial cutaneous nerves in the skin. When touching skin, we’re touching brains. Again, the ramifications this information has to our work are huge! It also implies it’s less about the skill of our hands changing the structure of tissue, and more about the skill of our hands providing therapeutic information, and movement of nerve. Knowing this information alone informs massage therapists in their practice. “No pain, no gain” forms of therapy make sense only if we think we’re changing the structure of fascia with our hands, elbows, and soft-tissue tools. Instead, if we realize every touch is a form of input for the nervous system, we should seek to comfort and relax. It should feel good, and non-threatening. It should also allow for healthy, and safe movement of nerve.

 

Myofascial Therapy

 

Even if we were able to get through the frictionless interface between skin and connective tissue, as mentioned earlier, the very act of changing/deforming fascia structure with our hands is impossible. To explain this we need to discuss the difference between elastic and plastic change. The tissues deform in one of two ways: elastic deformation or plastic. Elastic deformation occurs with smaller force loads. When this happens the tissue deforms slightly, and then immediately recoils to the original state when the force applied is removed. Plastic deformation occurs when the force load is more significant. Meaning, strong enough to deform the tissue well beyond normal. Once the force is removed the tissue does not recoil/return to the original state because the force was sufficient to change the shape and properties of the tissue. What is significant enough force? 1013 lbs of force (460KG) is required even for a 1% change in tissue structure (Chaudhry H, et al. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008;108(8):379-90).

 

You might be thinking, “I’ve seen beneficial results from deep myofascial therapies that were extremely uncomfortable!” Post hoc ergo propter hoc (Latin: “after this, therefore because of this”) is a logical fallacy that stays: “Since event Y followed event X, Event Y must have been caused by event X.” Because beneficial results were obtained from deep, painful myofascial release does not mean the beneficial results were due to the fascia being released. Let me suggest an alternative hypothesis.

 

Descending Noxious Inhibitory Control

 

Descending Inhibitory Control (DNIC) is one of several ways the brain modulates nociception (danger signals in the body) by preventing them from moving up the spinal cord into the brain. Pain expert Lorimer Moseley views DNIC as a way for the brain to “second-guess” the periphery about the threat posed by a particular stimulus. DNIC is triggered by sustained nociceptive input, or a frequent danger signal. One example might be dipping your hand in ice cold water. This would help with pain in your hand due to the extreme temperature. But interestingly, dipping your hand in ice water would also help inhibit pain elsewhere, like that ache in the low back. It is known as “Counter-Irritation.”

 

It gets more complicated. There are factors that can change DNIC. Novelty, and expectation.

 

Novelty means something new. The brain craves new information. If you keep dipping your hand in cold water you won’t keep getting the same beneficial results. Unless you keep dropping the temperature, or increase your submersion time.

 

Expectation is also factor. What do you expect to happen when you dip your hand in the water? It plays a HUGE part. In a study, researchers immersed the hands of participants in cold water, shocked them with an electric blast to the sural nerve, and then measured the level of nociceptive activity in the spine, as well as the self-reported pain level. Importantly, the participants were divided into two groups. The first group, called the “analgesia group”, was told that the cold water immersion would reduce the amount of pain they felt from the shock. The other group, called the “hyperalgesia group” was told the opposite - that cold water immersion would make the pain worse. The analgesia group experienced 77% less pain, and less spinal cord nociceptive activity than the hyperalgesia group, who experienced almost no reductions in pain or spinal cord nociceptive activity. In other words, expectation of relief was a huge factor in determining whether DNIC worked.

 

It could be that expectation of relief from myofascial therapy is the biggest determining factor for results in pain relief. The deep, sometimes painful pressure of myofascial therapy is our ice water. Counter-irritation is a fitting name.

 

This Shouldn't Get Under Your Skin

 

New information and research on massage therapy will continue in the near future. This is good news. We should be open to new information rather than threatened by it. Even if it's uncomfortable and we have to let go of some old ideas. We should always seek the truth.

 

Knowing that the brain and nervous system's role is important in massage therapy has some considerations. The brain takes into account biological, psychological, and social factors when producing pain and tension. Pain is a protective alarm. That is why comfort, and reassurance is important in massage therapy. Clients need to know their bodies are capable of adaptation, resilient, and do not require our hands to "fix" them. Do we really want to feed the brain false information about fascial adhesions, weakness, and reliance on our particular brand of massage therapy?

 

There is too much good massage therapists can do for people. Armed with the right information we can be potent facilitators of healing in our clients. Empowering people by giving them the tools they need to help themselves. If you're not a massage therapist, or another practitioner of some kind, I hope this information gives you some guidance on what to look for in your next massage appointment.

 

References:

Dermoneuromodulation,’ by Diane Jacobs

“Why We Don’t Elongate Fascia,” Academy of Clinical Massage, Whitney Lowe

‘Massage Therapy: Integrating Research and Practice, Trish Dryden & Christopher A. Moyer

https://www.sciencedirect.com/science/article/pii/S0304395906006439