The Road Less Traveled: Concepts and Application of Myofascial ReleaseLab Manual

Objectives:

2- Develop confidence in performing specific myofascial release techniques 3- Discuss the role of myofascial release techniques in patient management. 4- Perform a myofascial resiliency assessment. 5- Apply the principles of myofascial release to musculoskeletal impairments.

Resiliency Testing (Robet Fullford D.O.)

o Goal of resiliency testing is to get a gross assessment of the overall fascial mobility of different body regions

o QUALITY is more important than QUANTITY How easy are these body parts to move heaviness/lightness End-feels are still important

o Anatomy, anatomy, anatomy When you find the restriction, start thinking about the anatomy of the restricted

area and the possible restriction. Is it anterior/posterior, deep, superficial, medial, lateral, etc

1. Lower Extremity Internal Rotation (LE IR)a. Pt is supine, practitioner grasps under the heels with both hands b. Initiate a gentle internal rotation motion

i. Assess: ease/quality of motion, where restriction occurs (does entire LE rotate or does it skip a section)

c. Isolate LE into ULE and LLEi. LLE: monitor knee while doing IR at the foot

ii. ULE: monitor pelvis while doing IR at the kneed. Compare bilaterallye. Correlate with other LE measurements in the foot/ankle/knee/hip/pelvis.

1

2. Lower Extremity Leg pull (LE pull) a. Pt is supine, practitioner grasps LE under heel.b. Initiate a caudal traction of the LE

i. Can you sequentially traction to the knee, hip, pelvis, lumbar spine, thoracic spine, etc.

c. Compare bilaterally d. Correlated with other measurements in the foot/ankle/knee/hip/pelvis/lumbar spine.

3. Pelvis (AP Pelvis)a. Pt is supine, practitioner places hands on the ASIS w/ chest centered directly over pelvis,

thumbs/1st finger palpating medial pelvis tissue tension b. Apply a posteriorly directed force unilaterally

i. Note: this is not an SIJ provocation test, much lighter pressure applicationc. Assess resiliency, also pelvis soft-tissue resiliency, correlate these with hip/pelvis

findings

2

4. Lower 6 ribs/diaphragm a. Pt is supine, practitioner places hands on the lateral rib-cage, thumbs along the costal

margin b. Initiate a medially directed force and assess ease of motion and potential restriction

locationc. Correlate with other thoracic testing procedures

5. Thoracic inleta. Practitioner places hands w/ web space on the lateral cervical border, palms placed on

the superior aspect of the shoulder complex w/ fingers draped over clavicle and superior ribs, thumbs posteriorly over CT jx/ribs 1-3

b. Assess tissue texture abnormalities/positioning/etc i. Increased posterior tone, IR clavicle/shoulder complex, etc.

c. Apply an inferiorly directed force towards the feet d. Don’t get too lateral otherwise you’ll miss assessment of the scalenes and other lateral

cervical structurese. Correlate with other cerviothoracic testing procedures

3

Documentation:o 2 suggested different ways you can objectively rate the resiliency

0-10 scale: 0-no motion or ease of motion 5-6: normal healthy adult 10-newborn infant Example: AP pelvis 1/10 R and 3/10 on the L; LE IR 2/10 R and 4/10 on

the L. Post tx these improved AP pelvis 3/10 R and 4/10 on the L, LE IR 4/10 B.

Min-mod-max (+/-) Using these 3 descriptors for ratings, as resiliency improves these

ratings should improve Example: AP pelvis mod + R and mod on the L, LE IR is mod R and min

on the L, post tx AP pelvis min + on the R and min on the L, LE IR is min B.

Utilize your other orthopedic measurements and subjective reports to correlate to the changes in resiliency

Ex: As LE IR resiliency improved the patient’s R knee AROM improved from 100 to 118 deg w/ verbal report of pain reduction from 5/10 to 2/10 at end-range.

So now what?o Assess all points of resiliency to find what appears to be the greatest global restrictiono Work through the general area to find specific area of greatest motion restriction (point

of entry)-radio tuner/frequencyo Think like you are looking for the eye of the hurricane, because if you change that and

remove that restriction all of the other restrictions will change Constant assessment/treatment

interchange is critical to gaining positive outcomes as well as identifying the primary restriction

Often primary and secondary restrictions, if we can get rid of the primary then the secondary will take care of itself.

4

POET3:

o Point of Entry-area of maximal motion restriction T1-Tension: applying localized force taking up slack into the tissue, superficial to

deep (getting to the barrier) T2-Traction: stretch along the long-access of the myofascial elements T3-Twist: applied using radial and ulnar deviations of the wrist/UE/body

(Often forgotten but very effective) Activating Forces-forces that can be utilized to assist with obtaining release

Intrinsic: Respiration, muscle contraction, eye movement Extrinsic: Applied by operator (POET3)

Direct Release (analogy of a junk drawer, either yank on it or shut to open)o Moving into barrier and making tightness tighter

Indirect releaseo Finding the barrier and trying to make tension go away

(Example of quad strain patient, compressing entire leg in 1 visit restored resiliency better than the last 4-5 visits of gentle but more direct)

NOTES:

5

Treatment Techniques:

1. Lumbosacral, spine and pelvis decompression a. Goal: establish symmetrical sacral movements in relationship to innomiates, lumbar

spine, and LEsb. Patient position: Pronec. Practitioner stands at patient’s shoulder, heel of hand on sacral base with digits 2/3 and

4/5 over either sacral border/ILA. Proximal hand on TL jx, recommends MCP of 3 rd digit on T12/L1 precisely.

d. Assess tension patterns, sacral positionse. Tension/compress into the body to the first barrier at each hand, then traction away

from each other and apply radial or ulnar deviation (POET3) f. Treatment is complete when symmetry is gained for SI joint, sacral nutation, and

balanced tension bilaterally through the posterior musculature

2. Prone Sacral Release (PSR)a. Patient position: proneb. Hand contact is along superior sacrum w/ fingers pointing inferior along sacral border

into ILA, other hand on-top and pointing superior (can have middle finger along coccyx depending on your hand/sacrum ratio and patient comfort, otherwise spock hand it.

c. Connect into the superficial fascia and perform anterior and inferior pressure, rocking motion side to side, forward/backward, and oblique to find the max tension

d. Internal/external (hip flex/ext isometrics, UE reaching, etc) to facilitate releasee. Goal is to restore balanced sacral mobility within the pelvis

6

3. Sacrococcygeal/pelvic floor release

a. Patient position is proneb. Practitioner finds

the sacrotuberous ligaments (ischial tuberosity to sacral

ILA) with your thumbs and slide just medially onto the pubococcygeus muscle, remainder of your hands will drape over gluteal muscle group

c. Find maximal point of restriction along the ST ligament/pubococcygeus bilaterally and engage superior/anterior

d. Engage T2-T3 (steering wheel motion) for desired release and follow the releases to balance this tension

e. Goal: balance pelvic diaphragm, ST ligament tension

7

4. Supine LS jx release a. Goal: create positional/movement symmetry in the lumbopelvic complexb. Patient position: supine

i. More comfortable w/ hook-lying but traditional practitioners utilize full supine position. Use what works to the best of your ability

c. Practitioner place supinated hand underneath sacrum. Index finger and ring finger both will align the sacral borders, middle finger down sacral mid-line

d. Opposite hand slides at L4-5 level maintaining horizontal orientation, spinous processes of L4-5 should be in the palm of your hand, paraspinal muscle assessment will occur through thenar eminence and MCP space of palm

e. Using distraction/compression/twisting between hands you can work to decrease tone and restore normalized LS jx flex/ext/SB mechanics

i. By patient lying on your hand it automatically takes up compression into tissueii. You can use a hand up higher at the TL jx as well and separate hands for

traction/twist

8

5. TL junction/posterior rib-cage/diaphragm release a. Patient position: proneb. Hand contact is along each side of TL jx, thumbs vertical along the costal transverse

articulations and remaining hand over lower 6 ribsc. Superficial tissue needs to be released prior to deeper tissued. Use POET3 to find greatest restriction and perform direct/indirect releasese. Goal is to balance tissue mobility/tension superficial to deep

6. Lower Leg Releasea. Patient position: hook-lyingb. Hands on the medial/lateral aspect of the lower leg, thumbs pointing superior towards

knee. c. Contact skin/superficial fascia, perform CW or CCW rotation to find greatest restriction

of motion. Can also induce sup/inf glide, or sup/inf shear, ulnar/radial deviation to align 3D tension pattern

d. Actively patient can utilize DF/PF/INV/EV to assist with releasesi. Instructor notes: can also

ii. Extensor retinaculum: golden ticket

9

7. Anterior Pelvic Releasea. Patient position: supine or hook-lying, depending on comfortb. Place hand along the medial edge of the innominate and heel of hand just superior to

inguinal ligament. POET3 to find greatest barrier working posteriorly into pelvis.c. Follow releases to decrease pelvic tone

i. really good for pelvis scars to clear out way before psoas tension (netter 345)appendectomy, hysterectomy, c-section, bowel surgeries.

d. Modulations: Can add compression/traction, ER/IR through LLE to decrease quad/femoral nn/iliopsoas tension, use of breathing, etc. Can also add contact posteriorly to piriformis, ipsilateral SIJ, iliolumbar ligaments, L4-5.

e. Goal: reduce pelvic fascial tone to restore AP pelvis, SIJ, lumbar spine/hip function

8. Hip scoura. Patient position: supine b. Therapist will flex leg up to 90 deg (or initial barrier), Add and IR to maximize soft-tissue

tension. c. Compress femur posteriorly into capsule and follow from FADIR to FABER motion

working to increase circumference of circle as release occursd. Goal: Restore femur/pelvis mobility, decrease iliacus tone, SIJ mechanics, LS spinee. Avoid anterior impingement of the ant hip capsule or iliacus

10

9. Thoracic inleta. Patient positioned: supine or sittingb. Hands placed w/ web space on the lateral cervical border, palms on the superior aspect

of the shoulder complex w/ fingers drapped over clavicle and ribs 1-2, thumbs posteriorly over CT jx/ribs 1-3

c. Compress inferiorly/medially, along with CW or CCW rotation to find the greatest restriction

d. Can do both a direct or indirect treatment approache. Facilitate releases w/ breathing, spine movement, UE assist, etc.

11

10. AP thoraxa. Patient position: supineb. Posterior hand placement along T1-3, anterior hand along the manubriosternal junction

i. Can do this on lower, middle or upper rib-cage depending on greatest restricted area

c. Assess initial tension pattern/resistance under handsi. Compress sternum, add SG/rot components.

ii. If able, work bottom hand opposite to anterior hand, if not just focus on anterior hand as mobile

iii. Compress hands together, and lean back slightly to work post spinal structure d. Goal is to improve thoracic compliance/mobility through the thorax, mediastinum for

UE, cervical, lumbopelvic dysfunctioni. Patient can use cervical motion, eye motion, breathing to all assist with release

12

Anterior cervical fascial techniques

11. Anatomy

13

a. Superficial i. Runs circumferentially around the neck, can’t hold much tension

ii. Covers mandible to sternal notch, clavicle, AC joint, down the arm, SCM/platysma

iii. Occiput to scapula covering trapezius and deltoidiv. Treatment

1. Anchor along mandible, find area of greatest restriction along sternum/clavicle

2. Use MET, breathing, cervical AROM , UE ER/IR to facilitate release

b. Middlei. Ant/lat in the neck, borders are omohyoid and contains infrahyoid mm

14

ii. Inserts posterior clavicle/scalene tubercle and post sternumiii. Ties into subclavius fascia, connects to clavipectoral fascia, axillary fascia and

into the UE1. Important for venous drainage, often compromised post whiplash

iv. Treatment:1. Contact hyoid (gentle), and distal attachment of middle cervical fascia

a. Clavicle, sternum, scalene tubercle2. Align tension, can use breathing, cervical SB/rotation, UE abd/ER to

facilitate release

c. Deepi. Surrounds spine, deep neck muscles including longus collis, capitus, scalenes

ii. Strong attachment to scalene tubercle, envelops brachial plexusiii. Continues into thorax as endothoracic fascia and pelvic fasciaiv. Treatment

1. Anchor TP from C3-6 to scalene tubercle2. Start w/ head SB towards tx side3. Follow 1st rib w/ exhalation inferiorly and resist superior glide4. Once rib motion ceases, slowly SB head away

12. Clavip ectora l

fascia

15

a. Attaches pec major, pec minor, continuation of middle cervical fascia, axillary fascia, etc.i. Assists w/ connecting thorax to arm

ii. Treatment1. Patient supine, hands use a sandwich grip ant/post to pec major2. Direction is med/superior towards hyoid

a. Confirmation test: one hand on clavipectoral fascia, glide hyoid sup/lat away from tx side, should feel pull

3. Traction via thumb separation, do not compress and work into ease 4. Add UE ABD/ER, breathing, MET, AROM IR/ER, cervical ROM to facilitate

release

16

Contra-indications (John Barnes):

Malignancy Sutures CellulitisHematoma Febrile state Healing fracture at siteSystemic/localized infection Advanced degenerative changes Acute circulatory conditionAnticoagulant therapy Osteomyelitis Advanced diabetesAneurysm Hypersensitivity of skin Recent CVAObstructive edema Open sounds Acute RADown syndrome: head/neck make sure to check stability

Some situations are absolute contraindications, others regionally contraindicated, and yet others are relative. Consider risk vs reward for regional contra-indications.

(for regional contra-indications a knowledge of anatomy can allow you to work in different body areas)

Resources:

Barnes, JF. Myofascial Release Techniques PDF. https://myofascialrelease.com/downloads/ articles/ PediatricMyofascialRelease.pdf. Accessed 10/15/19.

Bookout, M. Eclectic Approach to treatment of headaches and trauma. Course workbook, 2014.

Clark S. Concepts and Principles of Myofascial Release. Course packet. 2009.

Greenman, PE. Myofascial Release Techniques. Pinciples of Manual Medicine (2nd edition) . Baltimore: Williams & Wilkins, 1996. Chapter 11

Nicholas, AS and Nicholas EA. Myofascial Release Techniques. Atlas of Osteopathic Techniques. Baltimore: Lippincott Williams & Wilkins, 2008. Chapter 8.

Ward, RC. Integrated Neuromusculoskeletal Release and Myofascial Release. In RC Ward, et al. (eds). Foundations for Osteopathic Medicine. Baltimore: Lippincott Williams & Wilkins, 2002; Chapter 60.

17

18