Transcript Soft Tissue Palpation and Manual Therapy

Manual Therapy for Athletes
Bryan Bourcier DPT, ATC, COMT, CSCS
Outline
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Manual Therapy basics
Contraindications
Indications
Spine Mobilizations for Athletes
Upper extremity Peripheral Mobilization
Lower extremity Peripheral Mobilizations
Manual Therapy Basics
• Grading Mobilizations
• Comparable Sign
• Resistance vs Pain
– R1 vs R2
– P1 vs P2
• Grades of Mobilizations
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I – Small amplitude short of resistance
II – large amplitude short of resistance
III – Large amplitude midway between R1 and R2
IV - Small amplitude midway between R1 and R2
V- At R2 High velocity low amplitude
• +, ++, -, -- variations
• IV++ and III++
Contraindications (Red/Yellow
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Fracture (red)
Hypermobility / empty end feel (Yellow)
Pregnancy (yellow)
Cord Compression (Red)
Cancer (Red)
Patient comfort (yellow)
Open wounds (yellow)
Fusions (Red and Yellow)
Manipulation into spasm (Red)
• Treatment Options for Low Back Pain in Athletes
– Ryan C. Petering, MD and Charles Webb, DO
• Despite the high prevalence of low back pain and the significant burden
to the athletes, there are few clearly superior treatment modalities.
Superficial heat and spinal manipulation therapy are the most strongly
supported evidence-based therapies. Nonsteroidal anti-inflammatory
medications and skeletal muscle relaxants have benefit in the initial
management of low back pain; however, both have considerable side
effects that must be considered.
Indications
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Stiffness
Pain management
Scar tissue management
“locking” or “Pinching” (Spine)
Evidence
– When combined with exercise, speed up recovery
– Not better if used without exercise
Common Cervical Spinal Mobilizations for Athletes
• Suboccipital Release
– Concussions
• Traction
• MET
• Soft tissue
What are we treating
Concussion
Whiplash
•neck pain and stiffness,
•headache,
•dizziness
•fatigue
•jaw pain
•activity intolerance
•postural weakness
•visual disturbances
•tinnitus
•increased symptoms with fatigue
•neck pain and stiffness,
•headache,
•shoulder and arm pain
•dizziness
•fatigue
•activity intolerance
•jaw pain
•postural weakness
•visual disturbances
•tinnitus
•back pain
•increased symptoms with fatigue
Subocciptial release
• Long sustained pressure on
suboccipitals.
– Can be done unitlaterally
– Make sure knees are bent
– If too painful, try traction first.
Common Cervical Spinal Mobilizations for Athletes
• Suboccipital Release
– Concussions
• Traction – Manual Vs Mechanical
• MET – when and when not
• Soft tissue – positional release and first rib
Common Thoracic Spinal Mobilizations for Athletes
• CT junction
• Pistol
• Screw
C-T Junction
Have the patient lay on their stomach while placing their
arms above their head.
Once you have the level that you want have the athlete look
to the opposite side hand.
Gently apply pressure on the junction while applying
pressure on the patient’s head and rotating.
Pistol
Make and fist while extending your index
finger and thumb.
Place your fist over the level that you want to
manipulate.
The area where your fingers meet your palm
should lay over the spine.
Index finger and thumb should be over
transverse processes.
Have the patient put their hands on their
neck, with elbows together and knees bent.
Have the patient exhale and while exhaling
push the athlete over your hand as a fulcrum.
Screw
Have the patient lay on their
stomach.
Once you have the level that
you want, place one hand one
the level above and the other
hand on the level below.
The palm of your hands should
be on the level.
Then apply pressure down
while turning your hands
inward.
Common Lumbar Spinal Mobilizations for Athletes
• Rotational Mobilization
– Grade I-III
– Manipulation
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Chicago Roll
Shotgun
SI / IS MET
Leg Pull
A/P
Rotational
Have the athlete lay on their side facing you.
Straighten the bottom leg and push it to the opposite
side of the table.
Bend the top leg and bring it towards you.
Have the patient interlock their arm with yours.
Place your other arm on the bottom part of their back
and over their SI joint.
Rotate their top shoulder down to the table and pull
their hips towards you with the other arm.
Chicago Roll
Have the patient lay on the side of the table nearest
you.
Bring their legs together and to the side of the table.
Put one hand under their back shoulder and the other
hand on the ASIS.
Rotate their shoulder up and towards you while
applying pressure on the ASIS.
Shotgun
Have the patient lay on their back with their
knees bent and feet together.
Then have them squeeze your forearm.
Upper extremity Mobilizations
• Shoulder
– “Fish Flop” (Shoulder pain control)
• Elbow
– Radial Head
• Wrist
– Distal Radial ulnar distraction
Lower Extremity
• Hip
– Lateral glides (FAI)
– AP and PA
• Knee
– Extension with ER and IR (post op and Hamstrings)
• Ankle
– Lateral malleolus glides (Ankle Sprains)
Soft Tissue Palpation and
Manual Therapy
Craig Shannon, MPT, OCS, ATC
TherapyONE
Overview
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Palpation of Structures
Palpation of Movement
Joint Mobilization
Soft Tissue Mobilization
• Multiple Methods
• Improving your sense of touch
Palpation of Structures
• Palpation of Surface Anatomy
• Know your surface anatomy
• Know where structures are in relation to the Spinal Levels
Palpation of Movement
• Spinal Movement
• Joint Movement
• Soft Tissue Movement
Palpation of Spinal Movement
• AROM of all planes of motion
• Feeling for Symmetry
• Feeling for Segmental Restriction or Hypermobility
• Passive mobility testing
• Checking the “R’s”
• Endfeels
Palpation of Joint Movement
• AROM
• Feeling for
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Crepitus
Endfeels
Muscle Guarding
Symmetry
• Special Testing
Soft Tissue Palpation
• What is the Nature of the Injury?
• History and Symptom Patterns
• Mechanism of Injury
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Acute Trauma
Chronic
Postural
Repetitive
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Tear
Adhesion
Crush
Myofascitis
• Type of Injury
• Tissues Involved
• Muscle
• Joint Capsule
• Nerve
Soft Tissue Palpation
• 4 Keys to Soft Tissue Palpation
• Tissue Texture
• Tissue Tension
• Tissue Movement
• Tissue Function
Tissue Texture
• Inflammatory Phase
• 1st 24-72 hours
• Typically swelling is fluid like and easily moveable
• Usually undefined borders
• Sub-Acute Phase
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2-14 days
Increased tension in tissues – Hypertense
Feels Stringy
Borders become more well defined and palpable
Tissue Texture
• Early Chronic
• 2 weeks – 3 months
• Tissues healing through Fibrosis
• Texture transitions from Stringy to Lumpy
• Chronic
• 3 months +
• Tissues become Leathery and Tough
• Altered vascularity and more scar-like
Tissue Tension
• Difficult to be objective
• Must rely on the Contralateral side to compare
• If ROM restricted – tissue tension considered Abnormal
• Must be specific of what structure is involved
• Palpate tissues at rest and with ROM
• Compare surrounding tissue tension
• Clinician will need to develop a Feel for what is Normal
Tissue Movement
• How do the tissues move with each other
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Skin and superficial fascia
Fascia and Muscle
Muscle and Joint Capsule
Nerves and Fascia/Muscle
• Need to learn to palpate to the proper level
• Peeling Onions
• Palpate with and without movement
Tissue Function
• What about the tissues is dysfunctional?
• Weak
• Restricted
• Neurogenic issues (paresthesias)
• The rest of your examination should help tease this out
Joint Mobilization
• What Bryan Said!
Soft Tissue Mobilization
• Massage
• Cross-Friction Massage
• Tool Assisted STM
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ASTM
Graston
SASTM
Knife and Spoon
• Active Release Techniques (ART)
• Myofascial Release
Soft Tissue Mobilization Basics
• Need to develop your sense of touch
• Like putting in golf, shooting a 3, juggling a soccer ball
• Know your Anatomy…Specifically
• What is your targeted tissue or tissues
• Don’t “Press and Guess”
• What is the goal of your treatment?
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Relaxation
Decrease pain
Decrease swelling
Restore tissue mobility
Restore joint or muscle ROM
Improving Palpation Skills
• Need to know what Normal is before you can Identify Abnormal
• Use a Soft Contact to help Identify structures and tissues
• Chiropractic Tricks to improving a sensitive sense of touch
• Hair in a phone book trick
• Nose on a Quarter trick
• Practice and Patience
• You won’t find anything if the tissues are too swollen
• Save the “digging” for treatment
Thank You