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Some Lessons From Bruises
The palpatory sense that good therapist develops never ceases to amaze. This sense of feeling or seeing inside is the basis of my therapy and my Foundations in Myofascial Release Seminars. I've written about touch frequently, but a revisit is in order.
Many years back a retired professional football player was referred to me for treatment due to knee pain. He had retired from football after his eighth knee surgery. Thirty years had passed and he now described his life as one of pain while standing and needing to use his arms on handrails climb stairs. Still fit at age sixty, he seemed to pride himself in having retained his athletic physique. He made this known to me when I was performing my normal assessment. As I reached his quadriceps, I noticed the remarkable density in both thighs. I mentioned this to him and he made a remark about trying to keep them "in shape". I kept my mouth shut and continued the assessment.
When laying relaxed in supine, the patella should be at its most relaxed state and able to move both medial/lateral and cephalad/caudal with great ease. Needless to say, my client lacked any appreciable movement of either patella. It felt like someone had poured glue under each kneecap. These two signs, increased quadriceps tightness/density and diminished patellar mobility are typically remarkable predictors of knee pain.
As I returned to his quads, I felt around in the depths, finding rather strange scar-like areas. When I quizzed my client a bit, he came to the conclusion that they must have been due to the numerous helmet hits, etc. that he had received over the years. So, I spent a few sessions working away on my findings. After five to six sessions, he came in to tell me that he was doing surprisingly well. His knee pain had greatly diminished, could stand all day without major issues, and could walk up and down stairs without relying on his arm power. He was concerned, though, as he felt that he need to get back into the gym. He was worried that his thighs were getting "flabby"! They lacked the tightness and firmness that he had had for most of his life. What he took for strength was in fact soft tissue restriction. I spent a bit of time trying to explain to him why this "tone" was not a good thing, but I do not believe for one minute he believed me. I am fairly certain that his beliefs got the best of him and he turned to the gym to get back into shape. Despite all, his goals for therapy were met.
Trust what you feel with your hands. Learn to see inside with your hands, as they have much to teach you. Know what "normal" soft tissue feels like, which can only be learned by touching hundreds of people. Seek out those areas of tightness, density, ropy quality, etc. Isolate your pressure into these areas and seek feedback; does palpation here reproduce a portion of your client's pain? Get to know these areas. They have much to teach you.
For Now,
Walt Fritz, PT
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Comment
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Comment by Walt Fritz, PT on February 25, 2012 at 4:02pm
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Questions are good!
My approach pays no attention to trigger points, which is similar to many of the approaches to MFR.
Years ago I worked with a woman who hit a curb while riding her motorcycle. On her way over the handlebars her thigh hit the gas tank and a huge hematoma resulted. The accident had happened years prior to her visiting my office, but she was left with a very large scarred area from the hematoma. The original discoloration had actually remained all of those years. The scarring impaired her range of motion and strength and caused her a good amount of pain. I treated her with MFR for 5-6 sessions and we were able to reduce the size of the scar by approximately 50%. More importantly, her range of motion and strength improved and her pain was greatly reduced. This is the type of scarring I am referring to.
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Comment by Nancy L. Ring on February 25, 2012 at 2:59pm
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Thank you. I knew I was missing something when I read this. I work on athletes. They have been teaching me kinesio taping. I look for anything that I can learn that will help them. Do you think some of that scarring could have been from muscles being torn? Could some of them been trigger points that dried up? Again, I understand, I ask lots of questions, but I like discussing injuries and getting others opinions.
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Nancy, When I speak of scar tissue, I am speaking of the results of injuries and/or chronic conditions, not just surgical incision. The "scars" that I was referring to were all up and down the length of the thigh, not just localized to the knee, where he had had the multiple surgeries. I base my view that the long term scarring down of the muscle and soft tissue of the quad from past injuries created limitations that led to tightness and pain. I concluded this, with this and hundreds of others, by primarily treating this tightness and seeing relief from pain and improvement in functional strength, without ever paying much attention to the surgical scars.
There would be nothing wrong with returning to the gym, but I was referring to his goal of trying to "firm up" his thighs. It was this massive amount of soft tissue density that I believe was the cause of both his pain and weakness. Returning to the gym with a goal of regaining this firmness would not be the best idea. Returning to the gym to improve his overall strength and flexibility without regard for the tightness of the quads that he took for strength would be fine.
I do not feel that his strength was from the scar tissue, I feel that his dense quads were from the scar tissue/tightness. Strength training is only one aspect of an athlete's overall fitness. Flexibility, in my mind, plays at least and equal role.
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I have worked on knee surgery patients before. I have always felt that scar tissue is from the surgical instruments. I use heat to help loosen them. I have found many end up with arthritis afterward. I am trying to figure out, are you thinking the scar tissue is from a past hematoma? From my understanding hematomas create fibrin patches which is a protein that is formed during normal clotting. I know there are 5 different types of scar tissue and that it is made from the connective tissue. I am curious why you thought this scar tissue came from a hematoma and not from surgery? Also why do you think he shouldn't be in the gym? I am confused, mainly because I think you left out some detail, why do you think his strength was from soft tissue restriction and not actual muscle development? I am very curious for I work on many athletes. I try to keep myself knowledgeable on these types of areas that will benefit my clients.
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Good points, Stephen
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Comment by Stephen Jeffrey on February 17, 2012 at 4:39am
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Great post Walt,
Quads yes, but do include working on lateral and medial Knee ligaments and tendons increased propioception = supple and strong.
I find this work done prior to quad work greatly speeds up scar tissue degradation.
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I have a method of placing my flat palms on the near lateral side of their quads as I stand at the table side. I move into the deeper layers until I engage the tighter regions. I then hold this depth as I move my palms lateral to medial. What comes up are the ropy deep restrictions, as well as the presence of the general sense of density. Conversely, at times nothing comes up; no problem. I find this works well even with obese clients.
I have had a fair number of morbidly obese clients over the years and I find I can still make changes.
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Comment by Lori Haagen on February 14, 2012 at 3:55pm
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With a client presenting with knee pain who is obese, her thighs are mostly adipose tissue, so it is very hard to "feel" what is really going on within the myofascial layers. Any suggestions I can try to help in this area (besides the client losing weight, which we've talked about)?
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Learning to reach inside and simply observe, with all of your senses is, to me, the key to making a difference. That, and knowing a modality that can bring about permanent change...
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Jody,
I love that line (and will be using it) "supple is the new strong"!
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