02 Dec Non Invasive Treatment for Soft Tissue Injuries
Soft Tissue Sports Injuries: The ART of Non-Invasive Treatment The Concurrent Application of Active Release Techniques® in the Present Paradigm of Sports Injury Rehabilitation MATT FONTAINE, D.C. All Athletes and Weekend Warriors Have One Thing In Common… Soft Tissue Injuries to muscles, tendons, ligaments, and nerves. Sports and training have the potential to wear us down over time and lead to soft tissue injuries that result in muscle and joint pain syndromes. Soft tissue injuries that limit optimal sports performance are frustrating and can limit or shorten athletic careers or recreational sporting activities. Young athletes tend to ignore their minor injuries, aches and pains thinking that they recover quickly from their pain. Over time the wear down from these injuries catches up with us, usually manifesting with more severe muscle and joint pain syndromes, limitations of activities, and especially sub-optimal sports performance. How Do Overuse Injuries Occur? The following is taken from Dr. Michael Leahy, founder of Active Release Techniques ® Leahy PM. Active Release Techniques Soft Tissue Management System, Manual®. The following formula can explain how repetitive injuries occur, resulting in the cumulative injury cycle: I= NF/AR Where I = insult to injury, N= number of repetitions, F= force or tension applied, A= amplitude of force, R= relaxation time between repetitions. This easily expresses how low load forces applied over thousands of repetitions with little relaxation time can break down tissue. We know this occurs to prime mover muscles that are adaptively placed under constant work load to try to stabilize joints for movement because of weak or inhibited deep small stabilizer muscles. The nervous system will learn movements and tasks as we teach them, whether those tasks are functionally correct or incorrect. Faulty movement occurs due to poor motor control which often occurs following overuse and may be initiated in the presence of pain and/or tissue injury. These faulty patterns become learned by the central nervous system and are often sustained beyond the acute pain phase and contribute to the chronicity of muscle and joint pain syndromes. Many athletes try to base a normal and regular workout session on top of this faulty system. This is very frequently why injuries occur while working out. Over time the body exhausts its capacity to compensate and prevent the tissue injury or inflammation and the symptoms finally surface on a more dramatic note. Thomas Myers, author of Anatomy Trains states “muscles are only separate in photos in anatomy books. In real life they are connected spiraling fascial tissue”. Movement becomes habit, which becomes posture, which becomes structure”. This results in the Cumulative Injury Cycle and the body produces tough, dense scar tissue in the affected area as part of the healing process. This scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up muscles become shorter and weaker, tension on tendons causes tendonitis/ tendinosis, and nerves can become entrapped. This can result in reduced ranges of motion, loss of strength, pain, and often numbness and tingling. Overused muscles (and other traumatized soft tissues) can cause changes to your body in three important ways. They cause acute injuries (pulls, tears, collisions, etc.), they accumulate small tears(micro-trauma), and they become tight which reduces blood flow to cells (hypoxia). Adhesions or scar tissue can be described as fibrous(inelastic) tissue that is formed over damaged tissue in the natural process of the body’s attempt to heal or fix damaged areas from injury. The Phases of Healing and Scar Tissue Formation: After injury, whether from microtrauma, compressions, strain/sprain, or an acute tear the body will: 1. Develop new capillaries around the injury to establish blood flow. 2. Migration and formation of fibroblasts 3. Lay down extracellular matrix ground substance which acts like scaffolding to support newly formed tissue repair. 4. Finally, the maturation and reorganization of the scar tissue. Scar tissue gets laid down in a criss-cross latticed pattern, while normal healthy soft tissue has it’s fibers running in parallel. Thus, the scar tissue must be realigned for it to become truly mature and function like normal pre-injured state soft tissue. Immature scar tissue cannot be loaded in a normal manner without further injury. Currently there are no reliable imaging protocols to identify scar tissue. It must be done via hands on palpation of a skilled practitioner who can detect biomechanical dysfunction. Recent research concludes that hypoxia can lead to cell death, fibroblast proliferation and free radical formation. Free radical production leads to more fibrous adhesion formation. As can be seen below, if damage is continually induced in an area via repetitive stress, the collagen cannot remodel itself in an efficient pattern. The result is the Cumulative Injury Cycle which occurs when the soft tissues of the body change or adapt with time. These changes cause your body to produce tough, dense scar tissue in the affected area as part of the healing process. This scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up:
- Muscles become shorter and weaker.
- Tension on tendons causes tendonitis.
- Nerves can become entrapped.
This can result in reduced ranges of motion, loss of strength, pain, and often numbness and tingling. Non Invasive Treatment for Soft Tissue Injuries Active Release Techniques® is a proven highly effective treatment that locates and breaks down scar tissue caused by soft tissue injuries. ART® is done using a hands-on method of locating and correcting problem areas in and between soft tissues such as muscles, nerves and tendons. The primary principles are; active patient motion, specific contact method and internal gliding of tissues. Simply put, the tissue is placed in a shortened position; the contact is taken with emphasis on tension of the tissue rather than compression. The tissue is placed in motion to lengthen it while the lesion is palpated, held and allowed to release. The main concept is to reestablish proper motion between fascial structures thus reducing fibrous adhesions and reestablishing neural and myofascial glide between tissues. ART® should be a major concurrent component in the treatment of conditions resultant from muscle imbalance, resulting in joint dysfunction, and muscle and joint pain syndromes. It specifically locates and treats the problem areas in the soft tissues. There are some 500 protocols for ART® and they are unique and the technique is patented. They allow providers to identify and correct the specific problems that are affecting each area. Specific Diagnosis and Specific Treatment Allow For Effective Treatment Coach Boyle has said “ the right tool for the job makes all the difference”. All too often athletes with chronic pain continue to suffer even after having physical therapy, joint injections, or surgery because the soft tissue adhesions in the muscles were not detected and treated. A comprehensive approach should include a functional movement screen, followed by appropriate treatment if needed to address soft tissue adhesions and joint dysfunction. These treatments should be accompanied by foam roller exercises, stretches, and movement prep. Properly prescribed exercises to address both mobility and stability and retraining to correct for movement patterns as described by Gray Cook are essential to optimizing sports performance. Utilizing Gray Cook’s Functional Movement Screen as Coach Boyle recommends is a great way to find faulty movement patterns that give you tremendous insight as to which soft tissue may be involved. Once soft tissue restrictions are identified, they must be addressed and properly treated to allow for corrective mobility/ stability exercises to be optimally effective. In cases where soft tissue adhesions are present you must free up tissue gliding between muscle planes to allow stretching to be effective. ART® releases the scar tissue and restores normal internal gliding of muscle layers, making the foam roller and stretching exercises much more effective at improving mobility and preventing future injury. A comprehensive sports medicine approach should include 1.) A team coach for the sport 2.) A strength coach and/or Athletic Trainer 3.) A medical doctor who specializes in sports medicine and 4.) A Chiropractor/ Physical Therapist who is a certified ART® provider. Get the best care you can by incorporating all these people into your team of Human Performance specialists. A Quick Note on Surgery There are times when surgery is necessary. ART® is essential to the overall success of the surgical procedure. Pre-surgical treatments can begin to clear up soft tissue areas that are not functioning properly and may have contributed to the injury in the first place. Post surgically ART® is vital to aiding release of scar tissue and quick recovery of normal muscle function. This aids in the rehabilitation process. If an athlete has had surgery, physical therapy and has not made a complete recovery, it may be time to try ART®. References
- Kumar V & Ramzi Cotran. Robbins Basic Pathology 7th ed. Elsevier; pp 69-77.
- Falanga V, & Kirsner RS. Low oxygen stimulates proliferation of fibroblasts seeded as single cells. J of Cellular Physiology. 1993 Mar; 154(3):506-10.
- Leahy PM, Active Release Techniques: Soft Tissue Management System. 2nd Ed. 2008; pp 8-16.
- Hinz, B. The myofibroblast: paradigm for a mechanically active cell. J of Biomechanics 2010 Jan 5;43(1):146-55.
- 6. The First International Fascia Research Congress. 2007 Harvard Medical School www.fascia2007.com
- 3. The Second International Fascia Research Congress. 2009 Vrije Universiteit http://www.fasciacongress.org/2009/
Special thanks to Dr. Michael Leahy for all his insight into diagnosis and treatment of soft tissue injuries.