Massage and Movement. Patrick A. Ward, MS CSCS LMT OptimumSportsPerformance.com

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1 Massage and Movement Patrick A. Ward, MS CSCS LMT OptimumSportsPerformance.com

2 Massage and Movement Massage comes in all kinds of varieties. From spa massage, to clinical/treatment based massage, to the more metaphysical types of massage such as energy work. However, no matter what type of massage we are talking about, the general idea that most individuals have about massage is that they come into the room, lie on the table, and the massage therapist does all the work. While this scenario is very true in most massage practices, I d guess probably about 95% of the time, it doesn t have to be that way! In fact, I would argue that keeping massage strictly as a passive modality can oftentimes lessen the benefits that can be achieved. It has been my experience that allowing the client or athlete to be an active participant in the treatment, rather than a passive observer, is a great way to keep them engaged and helps them build better proprioception and awareness to the areas being worked on. The Goal of the Massage Assessment is a very comprehensive topic and this manual is not directed at the topic of how to asses, so I encourage you to please spend a lot of time reading the many textbooks out there on the topic and gaining as much knowledge as you can, as the better assessment process you have the better results you can typically achieve. It is important before any treatment to have an objective or overall goal of what you would like to achieve with your treatment. For this, some sort of assessment whatever you feel comfortable with is a good starting point in developing the thought process of how to approach a specific client or athlete. I often think about soft tissue therapy in the context of movement, as lying on the table and just rubbing on someone may feel good and occasionally there are times when this type of massage is very much needed and indicated; however, the overall goal is always what can we do with the person that will help them function better when they stand up and get back into the game or into real life situations. Assessing and monitoring movements that are painful and or dysfunctional/uncoordinated is a key element to determining your thought process for working with a specific client. Additionally, aside from the testing and assessment, gathering as much information from the client that you can what movements hurt, when does it hurt during the specific movement, does it hurt in other movements, etc are a vital piece to the clinical audit process and will assist you in knowing whether or not you are getting a positive effect with your treatment approach.

3 The Treatment It is customary to treat a few areas, re-test a few of your objective markers, and then treat a few more areas. Any techniques that you are comfortable with will do in the initial treatment process gliding, compression, trigger point therapy, myofascial release techniques, etc. The initial portion of the treatment session commonly consists of first trying to manage some of the tone of the tissue, get a sense for how things feel and respond to your pressure/touch, and a continuation of your assessment (while you are working you are always assessing!). Following the beginning stages of treatment, when I have had some positive results with how the tissue feels, this is when I begin to add in active movements (of course you could use passive movement as well, and in some cases it would be more beneficial to use passive movements prior to active movements) to help the client get a sense of feel for the area that has just been treated and how it now moves and (hopefully) the movement is now pain free if it was painful to begin with. As the client is going through their movement I am simultaneously working on the tissue that is being stressed, either taking tension against the movement (moving towards a sense of bind or resistance) or moving along with the movement (moving towards a sense of ease). The direction that you are working the tissue while the client moves will often depend on several things which produces the best result, which way you want to stress the fibers, etc and oftentimes a few treatments into both ease and bind will be beneficial and the client may comment that one feels more effective or creates a better sense of movement. Once we have gone through a few of the movements with massage, I then always want to re-test my objective markers from my assessment and see how things feel and what sort of change has been made. If we are getting the results that I want, then obviously moving towards more movement training and exercise is the preferred way to go as, again, I feel it is most important to improve the overall function of the individual than to perform passive therapies while lying down on a table.

4 Movement and Massage Examples A few examples of how I perform some of the techniques will help give you an idea of how to use them in your treatment process, and of course if you understand the anatomy of the muscles you are working on, you can take this thought process and perform it on any muscle you want. As you will see in the examples below, I use a variety of different tools in each example elbow, loose fists, thumbs, etc. Do not feel that you need to be limited to the tools that I am using in the pictures. In any of these techniques you may choose to use thumbs, elbows, loose fists, knuckles, etc, depending on what you are most comfortable with, what is more comfortable for the client, or the depth of pressure and layer of tissue you want to address. As I stated earlier, you may choose to go with the movement or against the movement in any of the examples below. A small amount of massage lotion may be used if the client has dry skin, which would make it difficult for you to address the tissue directly. Be very careful with the amount of lotion you use, as too much will cause you to gloss over the tissue and potentially miss stuff, while too little will create too much drag and cause the client to feel skin burn. Typically through these movements you would have the client move through a full range of motion. When the client reaches the end rage of motion the tissue will be at its greatest tension, pushing you out of it to a certain extent. I typically pause at the portion of the muscle that I am stopped at, have them bring the muscle back to a shortened position, slacking the tissue, and then ask them to move through the rage of motion again for another repetition as I continue my stroke. I find that this works best for the larger muscles quadriceps, hamstrings, etc. For the smaller muscles (ex., the calves) I will commonly just work slowly through the entire length of the tissue as they actively go through the range of motion repetitively (ex., dorsi- and plantar-flexion if we are talking about the calves). Depending on what the tissue feels like in certain areas, I may choose to stop and sit on an area for a period of time through the movement or I may choose to focus on and address a small portion of the muscle that feels thick, dense, and/or fibrotic for a few repetitions as they go through the movement. There is no right or wrong here, so you really need to trust your hands with regard to what you are feeling. Through all of these movements both yourself and the client will be moving at a slow pace. This will ensure that you do not miss anything and that you are able to maintain sufficient pressure into the layer of tissue you are attempting to address. The more specific you can be with treatment layers of tissue, specific aspects/areas of each muscle, direction of certain muscles fibers, etc the more effective you will be.

5 Quadriceps Lying Begin with the client in the Thomas Test position, lying toward the end of the table with their Ischial Tuberosities positioned at the edge, one knee flexed towards the chest, stabilized with their own arms, and the other leg hanging relaxed off the table. Take your contact into the tissue and have the client slowly work through knee flexion as you perform a stroke either with the movement, working towards the knee (fig. a and b), or against the movement, working towards the hip (fig. c and d). c d Because the Rectus Femoris is the only quadriceps muscle that crosses the hip and becomes a hip flexor, you may choose to use your non-working hand during this technique also assist the client in slight hip extension to address this tissue.

6 To be more specific about your contact and the quadriceps heads you are addressing, ask the client to first extend the knee and contract the quadriceps, or perform light manual resisted knee extension, so that you can see the Rectus Femoris, Vastus Lateralis, and Vastus Medialis contract. Once you know where these heads are, you may choose to angle your stroke to affect these fibers to a greater extent. Quadriceps Seated The stroke for this technique is similar to the quadriceps lying technique, with the difference being that the client is positioned in a seated position with their legs hanging off the end of the table. Have the client slowly go through knee flexion as you work either with or against the movement. Muscle testing will help you to see the three more superficial heads of the quadriceps Rectus Femoris, Vastus Lateralis, Vastus Medialis allowing you to concentrate your stroke on the fiber direction for any one of those areas of the muscle. a b Additionally, in the seated position the hip is in flexion, causing the Rectus Femoris to be placed on slack. When the Rectus Femoris is on slack, it will be easier to compress through and address the Vastus Intermedius, which lies deep to it, should you feel that it is involved in the clients movement restriction.

7 Hamstrings With the client in the prone position, ask them to move down towards the end of the table so that their foot and ankle hang just of the edge. This will allow them to extend the leg through the full range of motion without the foot getting in the way. Start with the client s leg flexed to 90 degrees and ask the client to slowly extend the knee as you work either with (fig. a) or against (fig. b) the movement. a b A big mistake I see people make with this technique is not addressing the entire musculature. You may choose to stop and focus on a restricted area of the tissue, but examine the entire musculature for restriction before moving on to more specific strokes. Therefore, be sure to work all the way up towards and onto the Ischial Tuberosity, were the hamstring musculature attaches, with your stroke. In order to make the treatment more specific, you may choose to address one of the three heads of the hamstring musculature (or four if we count the short head of the Biceps Femoris as its own head since it does not attach to the Ischial Tuberosity with the others). With the clients knee in 90 degrees of flexion, place one hand on the back of the thigh and use the other hand to ask the client to perform gentle, manual resisted, knee flexion, allowing your palpating hand to feel the heads of the hamstring pop up. From here you can choose to work towards the lateral hamstring (Biceps Femoris) or more medial (Semitendinosus and Semimembranosus). Depending on how medial you are, you may find yourself working on a portion of the Adductor Magnus (which is okay too!) and depending on how lateral you are (commonly if you are using your thumbs for the technique) you may find yourself working through the IT-band and more onto a portion of the Vastus Lateralis which extends back around the thigh and is a much larger muscle than many give it credit for.

8 Calves Position the client prone with the front of their ankle supported on a bolster, ensuring that it is above the ankle high enough so that it does not interfere with plantar or dorsiflexion. Ask the client to begin with their foot in plantar flexion (fig. a), placing the musculature of the Gastrocnemius and Soleus on slack and allowing you to take a firm contact into the tissue. As the client goes through dorsi- and plantar-flexion you may choose to work with or against the movement. a b The bellies of the Gastrocnemius musculature are most accessible as you get closer towards the knee, from about the middle of the lower leg up towards the knee. Resisted plantar flexion allows you to easily see the medial and lateral heads of the Gastrocnemius so that you can have more focused treatment. The belly of the Soleus resides deep to the Gastrocnemius. When working through the middle of the leg, firmer pressure may be needed to compress through the Gastrocnemius muscle to affect the Soleus (Note: This firmer pressure should not result in pain and should allow for freer movement as the two muscles are able to slide over one another more easily). Additionally, the belly of the Soleus extends medially and laterally, poking out from below the sides of the Gastrocnemius. This area of the Soleus can be treated more directly with the thumbs in this technique, as you will be able to get your thumb around the Gastrocnemius much easier than a larger tool like your elbow or fist. Like the hamstring musculature, be sure to work the entire area and don t just treat where the muscle bellies are. Work all the way down towards the Achilles Tendon, where these two muscles attach to the Calcaneus.

9 Some final comments... Using movement with your massage can provide a great segue from treating certain of areas of the tissue with more specific techniques to having the client stand up off the table and perform exercise. By treating some of the tissue while the client is asked to perform movement you move the treatment from a passive modality which may have been needed when you were addressing certain structures to giving the client greater proprioception and awareness of the area that you have just worked on. Additionally, these techniques often give the client a sense of freedom of movement and more confidence to perform exercises in a standing position. This is especially true if a movement that was previously painful is no longer painful. The goal of treatment is not about what happens on the table, but what happens when the client stands up and is asked to perform against gravity, where we exist in our daily lives. No matter what approach you take with massage and soft tissue therapy, the goal should always be to improve the client s functional capacity. Patrick A. Ward, MS CSCS LMT Patrick Ward holds a Masters Degree in Exercise Science and is a Licensed Massage Therapist. Additionally he is a Certified Strength and Conditioning Specialist (CSCS) through the NSCA and a certified Neuromuscular Therapist. Patrick owns and operates Optimum Sports Performance LLC ( in Tempe, Arizona, where he works with professional and amateur athletes as well as general population individuals offering both soft tissue therapy and exercise programming to help them attain greater levels of physical fitness and performance.