Soft tissue is everything under your skin that is not bone or organs. Soft tissue massage uses direct action on the muscle, tendons, ligaments and other connective tissue such as fascia. Massage is the best known soft tissue technique, however, there are also a number of other soft techniques that your therapist can incorporate in your treatment.
Your therapist is highly trained in all these techniques to help facilitate the best possible outcome from your treatment and the professional who understands what techniques are right for your body at any given time. Depending on your injury or condition, they may need to use a number of techniques to aid recovery and these are further explained below. You can expect your therapist to use any one or more of these techniques during your treatment and you may also be given some homework in the form of exercises and stretches to do. The therapist’s goal will be to help you heal as quickly as possible.
Soft tissue release ( STR)
STR is a technique whereby the therapist actively stretches muscle fibres, tendons and fascia. It involves repeatedly and quickly stretching small areas of soft tissue by applying precise pressure to the muscle and then moving it to stretch it.
Why do STR?
The primary aim of STR is to remove physical (adhesive) restrictions in the muscle to increase its range of movement and mobility.
What are the effects of STR?
You can expect
- Increased mobility of the area of muscle that has been treated.
- Promotion of optimal scar tissue in the soft tissues injuries, the best possible for that injury.
- Breaking down of fibrous adhesions in the soft tissues
- Improved range of motion in joints
- Improved muscular balance
How is STR done?
Firstly the therapist will either get you to actively contract the muscle, or will passively contract the muscle for your, to a make it ‘shortened’. For example if the hamstrings are being treated then the therapist will ask you to lie face down and then bend you leg at the knee, (active) or they can bend your leg for you, and this shortens your hamstrings (passive).
The therapist will the put some pressure on the muscle, called a lock and this can be done by using their whole hand, knuckles or forearm (broad lock) or by using their fingers or thumb (narrow lock). The type of lock used will be dependent on the size of muscle and the size and depth of the adhesion. While maintaining pressure on the restricted tissues the therapist will either move the nearest joint in order to create a stretch between the lock and the joint (passive STR), or they can ask you, the client to move the joint for them (active STR). In the hamstring example, this will mean straightening the leg from a bent knee position. Usually this is done by the therapist first (passively) then progressing to more active methods where the client actively moves the joint allowing the therapist to apply more pressure. The technique begins with the lock applied closest to the moving joint and then it moved gradually away from the joint but not too far away that the stretch created by the lock is no longer effective. STR can be repeated for up to two minutes but may be less depending on client’s response and the response of the affected tissues.
What discomfort to expect during and post STR treatment?
By the very nature of this treatment, breaking down adhesions, means there will a level of discomfort for the client and the therapist will continue to ask you what level of discomfort you are feeling so they can adjust the pressure suitably. They will most likely use the pain scale of 0 – 10 with 10 being the highest level of pain and will want to apply the pressure in STR at a pain level of approximately 6/10. As all clients’ pain levels are different the level of pain you should be experiencing is that of a ‘nice’ pain or ‘comfortable’ pain. The therapist will adjust the treatment or stop it completely if the pain level becomes ‘uncomfortable’, ‘not nice’, more than 6/10.
Connective tissue massage
Connective tissue massage differs from many other techniques because it treats the body as a whole rather than focussing on specific areas. Just below the skin and covering the whole body (superficial fascia), think of it like your body being in a tight ‘skin’ suit. If there are any restrictions in any part of this fascia it can affect the whole body, the ‘skin’ suit can become tightened not allowing the muscles to move freely, any movements will require a great deal of effort placing a great stress on areas far distant from the area with the problem.
Benefits of connective tissue massage.
Fascia also contains many nerves, blood and lymphatic vessels so any improvement in its condition will inevitably lead to improvements in the circulatory or nervous system and maybe even organ function. The therapist will use connective tissue massage to remove restrictions in the fascia (myofascia) to aid mobility and circulation.
How is connective tissue massage done?
The therapist will work in a methodical way and start with finding and treating superficial adhesions then progressing onto a deeper treatment.
First the therapist will remove any oils on the skin to facilitate a stretch of the tissue. Then they will apply the flat of their hands (or sometimes just fingers or thumbs) to the soft tissue with sufficient pressure to establish a secure contact. Once contact has been established, they will slowly move their hands away from each other, in opposing direction, to see if there are any restrictions in movement. When a restriction has been detected they will hold the tissues at this point until they feel a change in its properties, this usually takes around 30 seconds.
Once the entire chosen area has been treated in this way the therapist will begin to look for adhesions deeper within the fascia. They will do this by ‘pinching’ together the skin and fascia, usually by placing their thumbs together while maintaining contact with the client with the heels of their hands, forming a roll of tissue between their thumbs and fingers. Then, without losing contact or varying the pressure the hands are then moved inwards causing the skin/fascia to form a crescent shape, this position is held until the tissue responds.
Finally, the therapist will grasp the skin/fascia in the same way as before, but instead of holding it, the fingers are ‘walked’ across the area thereby rolling the tissues until as restriction is found. The position is then held until the tissues responds.
What discomfort to expect during and post connective massage treatment?
The client should feel a fairly pleasant sensation during this treatment and minimum discomfort. It is strongly recommended to make sure you fully rehydrate after this treatment.
If you have an old injury that is still causing you problems and therefore has become chronic then the therapist may use transverse frictions. These kneading actions are used to break down or restructure adhesions in muscles, tendons, ligaments and joint capsules. These actions are done across the muscle fibres in s small area.
Why do transverse frictions?
- To increase the mobility of the soft tissues
- Optimise the formation of scar tissue formed during the soft tissue repair
- Assist muscles by removing physical restrictions to movement
What are the effects?
- Physical realignment of collagen fibres
- Removal of excessive scar tissue
- Removal of adhesions
- Reduced congestion in the local area
- Increased local circulation
- Increased range of movement
How are transverse frictions done?
Before the transverse frictions are carried out, the therapist will determine if there is a physical adhesion and it is not a trigger point. They will do this by pressing the area for 10 seconds and will ask you if the pain remains the same or goes away. If the pain remains the same it is not a trigger point and transverse frictions are a suitable treatment for the area.
The treatment can be uncomfortable and the therapist will constantly monitor the client’s reactions and will stop if the client wishes them to do so. During the treatment the therapist will:
- Apply multiple, short frictions at right angles to the fibres being broken down.
- Re-palpate the area every 10-20 seconds to monitor the effects of the treatment on the area and to ensure to monitor client discomfort
- The therapist will massage (effleurage) the area towards the nearest lymph node allowing the client to relax and the lymphatic system to process any waste products that have been mobilised (‘flush’ away the area)
What discomfort to expect during and post transverse friction treatment?
- The treatment can be uncomfortable and even painful so the therapist will constantly communicate with you and you can ask them to stop at any time
- The treatment may result in localised bruising one to two days post treatment and the use of ice on the area is recommended. Use ice on the area until there is a feeling of numbness in the area but not for more than 20 minutes at a time.
Trigger point therapy
A trigger point is a hyperirritable spot within a muscle that often results in reduced range of motion and muscle weakness otherwise known as knots. When the muscle experiences overuse (repetitive movements or poor posture) or injury tight bands of fibres form within the muscle to create a temporary stabilising effect to protect the area and these are known as trigger points (TP). Although TP’s are a protective response to injury , many outlive their usefulness and remain when not needed causing altered movement patterns of the muscle, that was originally adopted to compensate for the injury to remain. This longterm (dysfunctional) altered movement of the muscle can lead to pain either locally or referred and is usually joint related.
How are Trigger Points treated?
TP’s are created by the muscle by a chemical cycle and to treat the TP the chemical cycle needs to be altered. The therapist will so this by applying direct pressure on the TP and in doing so this starves it of oxygen so the muscles fibres no longer have the ability to continue to contract. This leads to a release of tension within the fibres which reduces or releases the taut bands (spasm) that they have created. The spasm is released quickly and often permanently which in turn removes local pain, referred pain and dysfunction.
Before the therapist carries out this treatment they will check that area of pain is a trigger point by pressing on it for 10 seconds. During this time they will ask you if the pain starts to go away or if it stays the same if begins to go away the therapist will have determine that it is TP and is suitable for treatment.
There are two methods of TP treatment:
- The therapist can apply progressive, direct pressure until the client reports pain has reached a level or 7/10. They will continue to apply direct, unaltered, pressure for up to 20 seconds until the client reports that the pain has subsided. The therapist will then gradually apply more pressure bringing the pain level up to a 7/10 and maintain this for another 20 seconds. This can be repeated for up to a minute and a half or until the pain level of 7/10 can no longer be attained.
- The therapist will apply consistent and direct pressure (pain 7/10) for 5 seconds, they then release the pressure while still maintaining contact on the skin. They will then reapply pressure until either the client reports a reduction or absence of pain or until two minutes have passed with no change in pain levels. This method is better for chronic or stubborn TP’s that take more time to release.
After both methods the therapist will ‘flush’ the area using long smooth massage strokes to rid the area of any waste products release during the treatment.
Benefits of Trigger Point therapy
- Increased flexibility and contractibility of the affected muscle
- Improved range or motion
- Reduced local pain
- Reduced referred pain
- Improved circulation
- Increased local and general relaxation
What discomfort to expect during and post trigger point treatment?
Initially, when pressure is first applied, the client will feel pain but this should be a ‘nice’ relieving pain, and the therapist will continue the pressure until the pain has more or less gone away. If the pain is persistent or uncomfortable, more than a 7/10 on the pain scale, the therapist will stop the treatment.
TP treatments can cause localised bruising or discomfort for one or two days post treatment.
Muscle energy techniques (MET’s)
MET’s both are a form of assisted stretching that originated in the 1950’s are were primarily used by osteopaths. Two types that are commonly used are:
- Post-isometric relaxation (PIR)
- Reciprocal inhibition (RI)
It will be personal preference as to which method the therapist will use, however, RI can be used in the early stages of injury as it does not require the contraction of the affected muscles so it is safe to use from an early stage of the healing process.
How do MET’s work?
MET’S aim to lengthen (relax) a muscle that has become tight and hyperactive. Within the muscles there are spindles that contract muscle and at the end of the muscle, in the tendons, there are organs called Golgi tendon organs. The Golgi tendon organs are responsible for sensing the length and tension of the spindles. During the PIR technique the therapist will manipulate the muscle that is tight (the target area) by stimulating Golgi tendons to sense an increase the length of the muscle thereby overriding the muscle spindles and in so doing allowing the muscle to lengthen and relax (autogenic inhibition). During the RI technique the therapist focuses on getting the muscle opposite the muscle that is the target muscle to contract so that the target muscle has to relax and this is known as reciprocal inhibition.
What to expect when receiving Post-isometric relaxation (PIR) treatment.
- The therapist will place you in a comfortable position to be able to deliver PIR to the target muscles.
- They will explain to the client how the treatment is to be carried out and what is expected of them. The therapist will then move the target muscle to a point of stretch (bind) whereby any further will be too uncomfortable for the client and it feels spongy for the therapist. For example, if your hamstrings are tight and receiving this treatment, the therapist will lie you on your back on the couch and raise your leg straight up towards your head to the point that it is uncomfortable for you to go any further.
- They will hold this position for ten seconds so the client is relaxed. The therapist will then ask the client to slowly and progressively perform a contract of the muscle, in our example, they will ask you to push your leg down into their hand to a level of 20 or 30% of maximum strength. The therapist will counteract this contraction to make sure there is no movement (isometric).
- After 10-12 seconds the therapist will ask the client to take a deep breath in and then relax. During this relaxation the therapist will increase the range of motion of the joint to a new point of bind (in our example: moving the leg to greater point of stretch of the muscle by moving the leg towards the head). This can be repeated two or three times always finishing with a new point of bind. The final point of bind is held for 20 – 30 seconds.
- The therapist then slowly returns the limb to its normal position.
What to expect when receiving Reciprocal inhibition (RI) treatment
In this form of MET the opposite muscle, to the one with the injury or dysfunction, is contracted using the principle of reciprocal inhibition. So in our example of the hamstrings being tight, the therapist will get the quadriceps muscles to contract, unlike with PIR when the hamstrings are contracted.
The protocols for the RI are the same with PIR, except:
- The therapist directs the client to slowly and progressively form a 10 second isometric contraction of the muscle opposite to the one being stretched at 20 to 20% of maximum strength. As with PIR the therapist will counteract the contraction to ensure there is no movement.
What are the benefits of PIR and RI
- Great range of motion is achieved my both techniques with little discomfort to the client
- The results are long lasting
- Re-educates muscles to restore a full range of motion.
- Strengthen and repair weak or damaged muscle tissue.
- Reduce muscle pain and stiffness
- In cases of sub chronic injury RI can still be used
- Reduces muscle spasms.
Client safety during PIR/RI application
Therapist must have good body mechanics especially during the isometric stage. They need to prepare and communicate clearly with the clients at all times.
- The client must play an active role in the application of PIR techniques and the therapist will help them develop a level of awareness concerning the muscles being targeted. Clients will be asked to give as much feedback as possible e.g. what they are feeling or levels of fatigue.
- The client must communicate freely with the therapist and endure they tell the therapist if they experience pain or discomfort.
- The client must follow the therapists instructions at all times.