Cyriax's Friction Massage:

0196-601 1 /82/0401-0016$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O 1982 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Cyriax's Friction Massage: A Review GAIL J. CHAMBERLAIN, MA, PT* This article reviews the existing literature on connective tissue in an attempt to provide additional substantiation for the use of Dr. James Cyriax's friction massage. Massage has been a part of many cultures over the last several centuries. In its various forms, massage remains as one of the oldest forms of therapy used for many Beard and Wood3 define massage "as certain manipulations of the soft tissues of the body which are most effective when performed with the hands and administered for the purpose of producing effects on the nervous and muscular systems as well as the local and general circulation of the blood and lymph." In the early 1900s, Mennell" advocated the use of specific massage movements called friction for conditions of inflammation and pathological deposit as well as recent ligament and muscle injuries. More recently, Cyriax and Russell8 have employed a technique called deep friction massage to reach the musculoskeletal structures of ligament, tendon, and muscte and provide therapeutic movement over a small area. Cyriax's specific friction massage techniques are based upon the performance of a thorough evaluation. Along with the increasing emphasis in physical therapy on evaluation is the importance of physical therapists understanding why specific treatment procedures are employed. The purpose of this paper is to present Cyriax's rationale and principles for the use of friction massage in treatment regimens along with additional substantiation based upon the development, orientation, and repair process of connective tissue. FRICTION MASSAGE The purpose of friction massage is to maintain the mobility within the soft tissue structures of * Lecturer, Division of Physical Therapy. Stanford University School of Medicine, Stanford, CA 94305. ligament, tendon, and muscle and prevent adherent scars from forming. The massage is deep and must be applied transversely to the specific tissue involved unlike the superficial massage given in the longitudinal direction parallel to the vessels which enhances circulation and return of fluid^.^*'^ Before friction massage can be performed successfully, the correct structure must be found through proper evaluation procedures. The distinction must be made between contractile structures such as the muscle belly, musculotendinous junction, tendon, and tendon-periosteal junction and noncontractile structures such as the joint capsule, bursae, fascia, dura mater, and ligament (Table In addition to finding the right spot, the massage must also be given the most effective way by following these basic principles. 1) The proper location must be found through proper evaluation procedures and palpation of the specific tendon, ligament, or muscle. 2) Friction massage must be given across the affected fibers. The thicker and stronger a normal structure, the more important friction is given strictly across the grain. 3) The therapist's fingers and patient's skin must move as one, otherwise moving subcutaneous fascia against muscle or ligament could lead to blister formation or subcutaneous bruising. 4) The friction massage must have sufficient sweep and be deep enough. 5) The patient must be in a comfortable position. The frequency and duration of treatment varies with the severity and type of the injury. In a recent injury, i.e., ligament sprain, start daily

JOSPT Summer 1982 CYRIAX'S FRICTION MASSAGE: A REVIEW 17 TABLE 1 Cyriax's classification of muscle, tendon, and ligament lesions Structure Function Pathology Treatment Muscle Contraction (broadening) Muscle tearing or minor rupture Deep friction massage transversely Elongation (stretching) of muscle fibers across the fibers to passively Location broaden the muscle and prevent Muscle belly scar tissue from matting muscle Musculotendinous junction fibers together Tendon Active movement of the damaged Tenoperiosteal junction muscle but no passive stretching or resistive movement which will strain the healing breach Place limb in a position that fully relaxes the affected muscle Tendon Tendon with a sheath allows for Tenosynovitis is roughening of Deep friction massage transversal gliding of the tendon the synovial surfaces of long across the tendon; move the tentendons possessing a sheath don sheath on the tendon and movement of the tendon Tendon must be on a stretch to prowithin the sheath is painful vide an immobile base Exercise is contraindicated Tendon Tendon without a sheath trans- Tendonitis or sprain is a tearing Deep friction massage transversely mits power from the muscle of some of the tendon fibers across the tendon to break down belly to the bone with the consequential forma- the scar tion of a painful scar within the tendon or at the tenoperiosteal junction Ligament Ligaments link bone to bone, but Recent sprain is a minor ruptur- Immediate friction massage transallow movement with the mobil- ing or tearing of ligamentous fi- versely across the fibers to mainity taking place at right angles bers tain the mobility of the ligament to the long fibers passively Friction massage does not need to be vigorous as fibroblasts are young and very weakly attached Initially do not increase the range at the joint passively (massage is enough) Chronic sprain has the scar hold- Deep friction massage to establish a ing ligaments abnormally ad- numbing effect of hyperemia herent to the underlyi,ng bones Adhesions may be ruptured by so vigorous use of the joint forced movements or manipulastrains the ligament tion (exceptions: ligaments at the wrist, coronary ligaments at knee, and anterior tibiofibular ligament at ankle respond to friction only) with gentle massage to keep mobility. It is important for the therapist to distinguish between tenderness and pain. Tenderness can be due to deep friction and can persist long after the pain disappears. Pain is elicited by clinical assessment and reassessment. Deep friction massage may be given every other day or when the excess tenderness has worn off. The duration of the treatment varies; for example, with an acute ligamentous injury, the gentle massage performed may last only 1-2 minutes. However, it may well take several minutes to be able to get your fingers on the structure depending on the sever- ity of pain. With deep friction massage, the treatment will last 10-1 5 minutes.' Cyriax's goals are two-fold: to provide movement to the tissue itself and to produce traumatic hyperemia. In the acute injury, the massage consists of gentle passive movements which move the structure but do not detach the healing fibrils from proper formation. The transverse movement is an imitation of the structure's normal mobility by broadening but not stretching or tearing the healing fibers. The movement encourages realignment and lengthening of these fibers.

18 CHAMBERLAIN JOSPT Vol. 4, No. 1 The second goal, traumatic hyperemia, results in the enhancement of blood supply to the area. The hyperemia appears to diminish pain by increasing the speed of destruction of Lewis' P substance, probably due to the release of histamine. Lewis' P factor is an irritative metabolite which produces ischemia when it acc~rnulates.~~~~~~~ The rationale Cyriax proposes for the use of movement in the treatment of soft tissue injuries to muscle, ligament, and tendon is based upon the work of st earn^.^' She observed the fibroblastic activity in the healing of connective tissue as well as possible scar formation, as related to the effect of movement. Her conclusions were that fibrils form almost immediately and that external factors were responsible for the development of an orderly arrangement of the fibrils. Cyriax and Russell8 contend that "gentle passive movements do not detach fibrils from their proper formation at the healing breach, but prevent their continued adherence at abnormal sites." Although there is presently no definitive research relative to friction massage and connective tissue, there certainly have been many cases of patients treated by therapists with positive results. Additional rationale for using friction massage could well be the expansion of Stearn's connective tissue theory through understanding of the anatomy, physiology, and repair process which exist. A discussion of relevant literature is presented so that a physical therapist can achieve an understanding of connective tissue in order to effectively and appropriately use friction massage. CONNECTIVE TISSUE STRUCTURE AND CLASSIFICATION The functions of connective tissue are to provide mechanical support, exchange of metabolites between blood and tissues, storage of energy reserves in adipose cells, protection against infection, and repair after injury through fibroblastic a~tivity.~ Connective tissue consists of cells originating from embryonic mesenchyme and dispersed in an extracellular matrix of fibers and amorphous ground substance or intracellular matrix. The ground substance forms the nonfibrous element of the matrix in which other cells and extracellular matrix are embedded. These cells include fixed cells such as fibroblasts, lipoblasts, myo- blasts, and pigmented cells and wandering cells such as histocytes (macrophages), plasma cells, and mast cells. The fibroblasts or fiber-forming cells are particularly important in friction massage for the part they play in connective tissue repair. These cells are fixed cells found along the bundles of collagen fibers. Fibroblasts synthesize protoglycans for the ground substances and act as precursors to ~ ollagen.~~'~~~~ The fibrous elements of connective tissue include collagen, reticulin, and elastin of which collagen is the most predominant. Collagen is the principal protein in the extracellular matrix which functions to provide substance and strength to all tissue^.^^'^ Connective tissue differs in appearance, consistency, and composition according to the local functional requirements of the region where it lies. Classification of the tissues is based upon the consistency and contribution of various cell types as well as the elements of the ground substance. Connective tissue can be classified as irregular or regular depending upon the amount of parallel orientation present in the fibrous elements. One such classification is shown in Table 2. Under the classification of irregular is loose connective tissue, which has an open network of thin collagen and elastic fibers, interlacing in all directions to give both elasticity and tensile strength to the tissue. Regular connective tissue has a precise arrangement of fibers as in parallel collagenous bundles of tendon which allow flexibility yet offer resistance to tension.4. 15. 16, 25 For example, tendon and ligament consist of regular connective tissue where the collagenous bundles are arranged in a specific pattern to provide for the mechanical requirements of the tissue involved and the direction of the fibers is related to the stress the fibers experience. In regular connective tissue, fibroblasts make up the majority of cells pre~ent.'~~~~'*~ Tendons consist of varying numbers of small tendon bundles of collagen fibers bound by loose connective tissue into larger bundles. Epitendineum, the surface layer of the tendons without sheaths, contain elastic as well as irregularly arrayed collagen fibers. This surface layer does not give the tendon a true free surface, so it does impose a minimal drag on the tendon. Tendons with sheaths have an internal or visceral layer and a parietal synovial layer which are separated by a capillary film of synovial fl~id.'~.'~."~ Ligaments are similar to tendons except the

JOSPT Summer 1982 CYRIAX'S FRICTION MASSAGE: A REVIEW 19 TABLE 2 Classification of connective tissue ' Type of connective tissue Irregular Loose Dense Adipose Fiber content Function Examples Collagen Binds together Widespread Elastin Allows for greater motion Subcutaneous tissue Septa in muscles Mostly collagen Mechanically strong Blood vessel adventitia Ensheaths organs Kidney capsule Very few fibers Storage Widespread Synthesizes Regular Aponeurosis Tendon Ligament * From Mathers et alz5 Mostly collagen Sheets associated with muscle at- External oblique tachments Mostly collagen Attach muscle to bone Biceps tendon Fibers ordered, tendon is strong in tension Mostly collagen Attach bone to bone Medial collateral ligament at knee fibers are not arranged in such a regular fashion. Ligaments are also composed of mostly collagen fibers packed into a parallel alignment but with spiral and oblique arrangements present, too. All ligaments tend to be tough and unyielding yet pliant and flexible, offering no resistance to norma1 mo~ement.~.'~ Muscle fibers are not considered connective tissue, yet the muscle is protected at various levels by connective tissue consisting of collagen and elastic fibers. The entire muscle itself is enclosed by a layer of epimysium. Thin collagenous septa or perimysium invest the bundles or fasciculi of muscle fibers and even finer extensions of connective tissue called endomysium extend from the perimysium inward to surround each muscle fiber (Fig. 1 ). The junction between the ends of the muscle fibers and tendinous attachments is called the myotendinal junction. This is where the connective tissue of the endo-, peri-, and epimysia become fibrous and thicken into the fibrous bundles of tendon. All the various levels of connective tissue within the muscle and the muscle attachments to tendon are continuous with other connective tissue structures; therefore, the connective tissue acts much like a harness when the muscle contract~.~~'~.~~ MECHANICS OF CONNECTIVE TISSUE Collagen provides the basic biological fiber or thread of the soft tissue structures of muscle, ligament, and tendon treated by friction mas- Fig. 1. A longitudinal section of muscle showing the muscle termination into tendon and connective tissue (epimysium, perimysium, and endomysium) at different levels. (Reproduced with permission from Ham") sage. Collagen exists as bundles of parallel fibers which provide rigidity and strength in mechanical tension. During normal physical activity, tendons, muscles, and ligaments are loaded mainly in tension with tendons functioning to transmit muscle forces to bone and fascia, ligaments stabilizing joints, and muscle contraction producing tensile loads on tendons. The mechanical behavior of collagenous tissues when loaded in tension is influenced by the structural orientation of the fibers, the properties of the fibers themselves, and the proportion of collagen to elastin fibers."~'* The orientation of tendon fibers is almost completely parallel which makes the tendon well suited to withstanding high tensile loads. The

20 CHAMBE irlaln JOSPT Vol. 4, No. 1 fibers of ligaments have a less structured orientation; therefore they respond differently in loaded and unloaded situations (Fig. 2). When tendon and ligament fibers are relaxed or unloaded, they appear with a wavy configuration, and as a load is applied, the fibers oriented in the direction of the load straighten out (Fig. 3). This means tendons are able to bear a higher tensile load than ligaments because all the fibers are aligned parallel to the direction of loading.".21 In muscle, remember that all connective tissue structures are continuous with each other, furnishing a harness effect. When a muscle extends beyond its resting length, the tension develops within the connective tissue first. In a muscle contraction, the contraction action initiated by the muscle fiber is transferred to the connective tissue layers and subsequently to the tendon and bone. The connective tissue allows for a certain freedom of movement between the muscle fibers so each fascicle can move independently of each Other.4. 16.17,33 Collagen fibers have a second function; in addition to giving strength in tension, they adapt to the mechanical demands placed upon them. Under shearing and compression loads, there is no change; however, in intermittent tension loads, there is stimulation to the cells to produce additional collagen. This is known as the stretch hypertrophy rule, when a living fibrous tissue structure responds to mechanical loads.12 The proportion of elastic to collagen fibers in tendon and ligament is different and reflects the function of the tissue. Tendon functions to transmit forces to bone or fascia; therefore, the fibroblasts of tendon produce larger amounts of collagen than elastin. Ligaments function to stabilize joints and prevent excess motion and consequently contain fibroblasts which produce less collagen than in tendon.".i2 The proportion of TENDON LIGAMENT Fig. 2. Schematic demonstrating the fiber orientation in tendon and ligament. (Reproduced with permission from Frankel and Nordin1 ') Fig. 3. Electron micrograph of collagen fibers unloaded (A) and loaded (6) in human knee ligaments. (Reproduced with permission from Kennedy et a/.") elastin to collagen fibers in muscle connective tissue varies according to the location of the muscle. For example, the amount of elastic fibers is greatest in those muscles attached to soft tissues such as the tongue.33 CONNECTIVE TISSUE REPAIR The actions of both inflammation and repair are of concern for the therapist evaluating and treating musculoskeletal injuries. The repair process involves not only the connective tissue structure directly involved, ligament, tendon, and muscle, but the connective tissue on the surface surrounding the The connective tissue repair process begins with the inflammatory stages or local reactive process where many leukocytes (the majority being neutrophils) migrate from the capillaries and venules to the area and begin phagocytizing bacteria through the action of hydrolytic enzymes. Monocytes are another leucocyte present in the blood which hypertrophy in the first

JOSPT Summer 1982 CYRIAX'S FRICTION MASSAGE: A REVIEW 2 1 few days and become macrophages to supplement the other macrophages already present in phagocytosis. Mast cells are lymphocytes active in the injured area secreting histamine which may serve to increase vascular permeability and help activate the phagocytosis of damaged cell^.^^'^ In the presence of an inflammatory reaction, there can be significant stimulus for an abnormal production of nonneoplastic fibrous tissue or fibroplasia. The traumatized ischemic tissue containing foreign materials reveals a stimulus for the formation of fibrovascular tissue. Inhibition of the inflammatory reaction is a way of preventing fibroplasia from o~curring.~" The fibroblasts which have tremendous regenerative capacity respond to injury by proliferation and fibrogenesis and appear in the remodeling stage. This is usually within the first 48 hours. By the fourth day, there is a tremendous number of fibroblasts which will not decrease in number until about day 21.5.2233' Stearns3' reports that "an extensive reticulla of fibrils develops around the fibroblasts within 3 to 4 hours as the fibroblasts begin to increase in size and by 48 hours there are fibers." It is the joining together of the fibrils that makes a collagen fiber and the collagen fibers in turn join together through intermolecular cross-linking to form larger collagen unit^.^.^^ Throughout this remodeling process, the physical forces applied through both stress and motion help to modulate the synthesis of proteoglycans and collagen by the fibroblast~.~~.~'~ 35 Immobilization in soft tissue injuries often occurs secondary to pain or edema or as treatment. The lack of movement during connective tissue repair can lead to scar formation and increased pain when the structure is again moved thereby stretching the scar. The devastating effects of immobility upon connective tissue have been demonstrated in many experimental studies.6. 24.28,32.35 If no movement occurs during the repair process, the following changes may occur: a disturbance in the synthesis and degradation equilibrium of collagen, an increase in the cross-links on an intermolecular level, a decrease in the water content of the extracellular matrix, and an increase in the number and thickness of collagen fibers (Fig. 4).'12' All of these changes lead to increased scar formation as the collagen fibers increase in number and thickness and come closer t~gether.~,'~.~~ Movement would appear to inhibit scar formation by several means: 1) stimulating proteo- Fig. 4. Diagram showing free gliding of collagen fibers with applied stress (left) and cross-linking at strategic sites inhibiting the gliding of the collagen fibers with the same stress applied (right). (Reproduced with permission from Woo et a/. 35) glycan synthesis, which lubricates connective tissue and maintains distance between the fibers, 2) orienting the laying down of new collagen fibers through mechanical stress so fibers can resist tensile forces, and 3) preventing intermolecular cross-linking from occurring.'. 3'. 34 All of this provides an expansion of the connective tissue theory as described by Stearns3' CONCLUSION Friction massage is a technique used frequently by physical therapists for soft tissue injuries affecting muscle, ligament, and tendon. The rationale for the importance of maintaining mobility within connective tissue during the healing process has been discussed. Although information from existing literature makes a strong case for the use of friction massage on connective tissue, the need is obvious for more clinical research supporting Cyriax's friction massage technique. The author wishes to gratefully acknowledge Dr. Helen Blood for her many helpful comments, suggestions, and inspiration all of which made this article possible and Carol Sanford for assistance in preparation of this manuscriot. REFERENCES 1. Akeson WH. Amiel D, Mechanic GL. Woo SL, Harwood FL, Hamer ML: Collagen cross-linking alterations in joint contractures: changes in the reducible cross-links in periarticular connective tissue collagen after nine weeks of immobilization. Connect Tissue Res 5:15-19, 1977 2. Amiel D, Akeson WH, Harwood FL, Mechanic GL: The effect of

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