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Section VI: Friction Massage - Upper Extremity (continued)
Upper extremity (continued):
Elbow, wrist and hand (continued):
There is protocol for friction massage for the joint, ligament, muscles and tendons of the elbow,
wrist and hand.
Joint:
Degenerative Joint Disease of the Wrist:
Although this condition is more common in the hand, the joints around the scaphoid bone have
been known to degenerate and become sclerotic. The scaphoid bone is the most vulnerable to
injury of the carpal bones with the capitate being the most fixated bone.
Friction massage can assist in the circulation and freedom of movement to the ligaments and
tendons in the region. This procedure must not be performed at the flexor retinaculum as it can
inflame tissues. It should be performed either distal or proximal to the retinaculum. Cross fiber
massage is medial to lateral and back on the particular tendon sheath. It should not be across the
entire wrist.
Carpal Subluxation:
Any carpal bone can fixate and tilt out of place within the normal context of wrist articulation.
This is most common with the capitate bone.
Friction massage of the surrounding carpal ligaments can assist with healing. The direction of
friction massage is always cross fiber, therefore, medial to lateral and back.
Ligament:
Ulnar Collateral Ligament Injury:
The anterior oblique band of the ulnar collateral ligament is the most commonly injured ligament
of the elbow. Stress to this medial ligament usually occurs during injuries that have occurred
during the act of throwing; baseball, softball, etc.
Once inflammation decreases past the acute phase, then friction massage can be done for
secondary tenosynovitis at the medial epicondyle. Cross fiber massage is medial to lateral and
back.
Muscle:
Brachialis Strain:
This muscle originates in the humerus and inserts into the ulna. It is the main flexor of the elbow.
Because the belly of this muscle crosses the antebrachium of the elbow, it is vulnerable to tear.
Friction massage would be at this site across the antebrachium of the elbow from medial to
lateral and back.
Supinator Strain:
This muscle originates from the lateral epicondyle, radial collateral ligament and the annular
ligament as well as the ulna and inserts into the radius. This muscle supinates the forearm and is
assisted by the biceps for more forceful supination.
6-1
For friction massage, the patient’s forearm is pronated to bring the muscle forward for better
contact. The belly of the muscle is contacted just distal to the antecubital fossa.
Pronator Teres Strain:
This much shorter muscle lays diagonal and originates from the medial epicondyle and the
coronoid process and inserts into the radius. It is also responsible for pronation. This muscle can
easily strain during throwing and tennis.
6-2
For friction massage, with the patient seated, their forearm in supination on a table, the contact is
two inches below the attachment to the ulna/humerus and the direction is medial to lateral and
back.
Tendon: tenosynovitis:
Inflammation and adhesions in the tendon sheath is usually more prominent with the extensor
tendons due to their proximity to the surface. Tenosynovitis can be treated by manual methods
and the location of impingement must be identified. Once inflammation decreases, perform
friction massage. The tendon must be at its most taut so flexion or extension of the wrist must
assist with tension on the sheath. Friction massage at these locations will reduce scar tissue and
adhesions as well as stretch the muscle.
Lateral Epicondylosis (aka. Tennis Elbow):
This is a condition of the extensor tendons, in particular, the extensor carpi radialis brevis and
longus, and extensor digitorum. The extensor carpi radialis brevis is the most commonly injured
tendon at its attachment to the humerus but can also be injured at the head of the radius.
6-3
For friction massage, with the patient seated, their arm on a table, elbow flexed, forearm
pronated; the practitioner contacts the tendon complex at the lateral epicondyle and the direction
of friction massage is up toward the antecubital fossa then down toward the olecranon.
Medial Epicondylosis (aka. Golf Elbow):
This is a condition of the common flexor tendon. The muscles associated with this common
tendon are; the flexor carpi ulnaris, pronator teres, flexor carpi radialis, palmaris longus and
flexor digitorum.
6-4
For friction massage to this general region, with the patient’s arm in full extension and
supination, the medial epicondyle is treated from lateral toward medial and superior, then from
medial toward lateral and inferior.
Intersection Syndrome:
The tendon sheath of the first compartment of the extensor tendons (abductor pollicis longus,
extensor pollicis brevis) and the tendon sheath of the second compartment (extensor carpi
radialis longus and brevis) cross over. Inflammation and tenosynovitis can occur in this second
compartment due to the cross over.
6-5
Once the inflammation subsides, utilize friction massage across the tendon sheath. Massage is
medial and lateral and back.
De Quervain’s Paratenonitis:
This condition affects the first tendon sheath compartment. Part of the treatment is to release the
brachioradialis muscle which adheres to the aponeurosis that attaches it to the extensor
retinaculum. Any tug to the retinaculum will affect the first tendon sheath. Therefore, the
brachioradialis adhesions must be addressed as well as any adhesions in the first tendon sheath.
Once the inflammation settles down, friction massage distal to the radial styloid can be done.
Direction of massage is medial to lateral and back.
Extensor Carpi Ulnaris Tendinosis:
Housed in its own fibro-osseous tunnel, injury can occur to the distal ulna, over the triquetral and
near the attachment of the fifth metacarpal. This condition can be caused or complicated by
lateral epicondylosis.
Once swelling has subsided, friction massage is one of the best means of treatment. The direction
of massage is medial to lateral and back. Attention should be made to the fascia of the forearm,
arm, shoulder and cervical spine as it is all interconnected.
Extensor Carpi Radialis Longus and Brevis Tendinosis:
Also complicated by lateral epicondylosis, swelling and inflammation must be decreased first.
Then friction massage is a good course of treatment. Direction of massage is medial to lateral
and back.
Extensor Tendon Synovitis:
Swelling of the extensor retinaculum and extensor tendon sheaths as a whole is evident through
symptomatology, although swelling is not visible. Treatment for the extensor tendons is less
complex than for flexor tendons due to their accessibility.
If the condition is proximal to the extensor retinaculum, it will respond to friction massage. If the
condition is distal to the retinaculum, then modalities such as galvanic bath, stretching and
strengthening will be preferred. For friction massage to the proximal region, the direction is
medial to lateral and back.
Flexor Carpi Ulnaris Tendinosis:
This condition is common with golf and tennis injuries.
Once swelling subsides, friction massage proximal to the ulnar styloid is recommended.
Direction of massage is medial to lateral and back.
Flexor Carpi Radialis Tendinosis:
This tendon is housed in a sheath that passes under the scaphoid and trapezium and is most
commonly injured at the attachments to the metacarpals. However, synovitis is common with
this tendon sheath.
Once inflammation is reduced, friction massage will be affective in treatment. Direction of
massage is medial to lateral and back.
Flexor Tenosynovitis:
Treatment for the flexor tendons is more difficult than extensor tendons due to their location
deep within the palm of the hand. If the condition is proximal to the flexor retinaculum, it will
respond to friction massage. If the condition originates in the palm of the hand, then manual
methods will be less affective. Fascial release for the flexor digitorum superficialis is at the
proximal aspect of the flexor retinaculum.
Abductor pollicis longus:
This muscle abducts the thumb.
Friction massage is medal to lateral across the tendon at the proximal metacarpal-carpal joint.
Extensor pollicis brevis:
This muscle extends the thumb.
Friction massage is performed at the tendon sheath shared at the lateral wrist (distal radius) or
just slightly before the sheath.
Dorsal interosseii:
These muscles are between the fingers and allow for adduction/abduction of the metacarpals.
6-6
Friction massage can be challenging and best performed on the palmar surface. Direction of
massage is medial to lateral and back.
Section VII: Friction Massage – Lower Extremity
Lower Extremity:
Hip:
The hip joint is a multiaxial ball and socket synovial joint with a strong and dense articular
capsule to aid in its stability. With three axes of rotation, the hip will flex and extend, abduct and
adduct and medially and laterally rotate. As humans evolved into the erect posture, the ligaments
of the hip coiled around the femoral neck concurrently in the same direction. The ligaments run
clockwise and extension tightens all of them, flexion loosens them. It should be noted that
flexion is the most unstable position since all of the ligaments are most lax. When adduction is
added to flexion such as sitting cross-legged, there is a force applied to the femoral shaft enough
to cause posterior dislocation with or without fracture of the posterior margin of the acetabulum.
This can occur more likely to a passenger during the impact of an auto accident. For a more
thorough understanding of the hip and its structure, conditions and treatments, please refer to
Soft Tissue Injury 110, Hip and Knee, Linda Simon, DC.
There is protocol for friction massage to the muscles, tendons and bursa of the hip.
Muscle:
The following muscles attach to the pelvis and hip region. Those with an * are mentioned more
than once. Those bolded are suitable for friction massage:
Flexors:
psoas
iliacus
sartorius
rectus femoris
tensor fascia lata
gluteus medius (anterior fibers)
gluteus minimus (anterior fibers)
pectineus
adductor longus
gracilis
Extensors:
gluteus maximus
posterior fibers of gluteus medius and gluteus minimus
hamstrings (semimembranosis, semitendinosis, biceps femoris).
Abductors:
gluteus medius
*gluteus minimus
*tensor fascia lata
*gluteus maximus
piriformis
Adductors:
adductor magnus
*adductor longus
adductor brevis
*gracilis
*hamstrings
Lateral rotators:
*piriformis
*obturator internus
inferior and superior gamelli
*quadratus femoris
*gluteus maximus
*quadratus femoris (see rectus femoris)
obturator externus
pectineus
obturator internus
*pectineus
*gluteus maximus
*gluteus medius
Medial rotators:
*tensor fascia lata
*gluteus minimus
*gluteus medius.
Rectus femoris:
This muscle has a straight head and a reflected head. The straight head attaches to the ASIS. The
reflected head attaches to a groove above the acetabulum. Part of the quadriceps femoris, it
merges with the quadriceps tendon inserting into the patella. The rectus femoris pulls on the tibia
via the patellar ligament. This muscle is used in climbing, running, jumping and rising from a
chair. It also flexes the thigh at the hip.
7-1
For friction massage of the rectus femoris, the patient is seated, their legs extended. The
practitioner contacts the tendon at the attachment to the ASIS and the frictions direction is
medial to lateral and back on the patient.
Tensor fascia lata (iliotibial band):
This lateral thigh muscle attaches from the anterior of the iliac crest and ASIS to the iliotibial
tract of the lateral inferior tibia and is enclosed within the fascia lata of the lateral thigh. It
abducts and flexes the hip joint and assists in keeping the knee extended in erect posture by
making the iliotibial tract taut. It also steadies the trunk on the thigh and counteracts the
backward pull of the gluteus maximums on the iliotibial tract. The efficiency of this muscle
increases upon abduction. The iliotibial band can move anteriorly creating instability in the
gluteal region and low back.
7-2
Friction massage is the most effective method for treating this condition. The patient is on their
side and the friction pattern is medial to lateral and back on the attachment to the ischial
tuberosity. When the patient stands after this treatment, at least 50% of their pain should be
alleviated. If this is ineffective, look toward the sartorius for the cause.
Adductor longus:
This muscle attaches to the pubis and middle 1/3 of the linea aspera of the femur. It adducts,
flexes and laterally rotates the thigh at the hip joint.
7-3
Friction massage can be performed with the patient supine, their hip abducted. The belly of the
muscle is contacted 3-4 inches inferior to the tendinous attachment to the pubic bone. The
direction of friction massage is medial to lateral on the muscle.
Hamstrings: semimembranosis, semitendinosis, and biceps femoris.
Biceps femoris:
This muscle has long and short heads. The long head attaches from a common tendon with the
semitendinosis to the ischial tuberosity. The short head attaches to the linea aspera and proximal
supracondylar line of the femur. Both heads attach into the fibula head by a common tendon. The
long head extends the thigh at the hip joint. Both heads together, flex the leg at the knee joint and
laterally rotate the leg.
For pure extension the two muscles groups are balanced as synergists and antagonists. During
walking, extension is produced by the hamstrings. During running, jumping, or walking up an
incline, the gluteus maximus is very much a part of the mechanics.
7-4
For friction massage, the common tendon of the hamstrings can received friction massage at the
ischial tuberosity as well as 2 inches below it. The direction is medial to lateral and back. The
patient can be prone, or supine with their hip and knee bent for better access to the attachment.
Semimembranosis:
This muscle attaches from the ischial tuberosity to the medial condyle of the tibia. It extends the
thigh at the hip joint and flexes the leg at the knee joint. Together with the semitendinosis, it
medially rotates the tibia on the femur especially when the knee is in flexion.
Semitendinosis:
This muscle attaches from the ischial tuberosity by a common tendon with the long head of the
biceps femoris to the medial surface of the superior shaft of the tibia. It extends the thigh at the
hip joint and flexes the leg at the knee joint. It works together with the semimembranosus as
mentioned above.
7-5
Friction massage for both the semimembranosis and semitendinosis can be performed for a
spastic hamstring either at the attachment to the ischial tuberosity or 2 inches below it. The
direction of friction is lateral to medial and back. Friction massage can also be performed for
these muscles at the knee and will be covered in Section 8.
Gluteus medius:
This muscle attaches from the external surface of the ilium to the lateral surface of the greater
trochanter. It abducts and medially rotates the thigh and steadies the pelvis so that it does not sag
when the contralateral foot is raised. As abduction increases, the efficiency of this muscle
increases and is most affective at 35 degrees of abduction.
7-6
If fascial restrictions occur at the tendinous attachment of the greater trochanter, friction massage
can be performed. The site is on the lateral surface of the greater trochanter. The patient is prone
and the motion is anterior to posterior and back.
Piriformis:
This muscle attaches from the anterior of the 2nd, 3rd, and 4th lateral masses of the sacrum and the
sacrotuberous ligament to the upper border of the greater trochanter. It laterally rotates the thigh
when the hip is extended and abducts the thigh when the hip is flexed. The piriformis exhibits
inversion of its actions. When the hip is straight, it produces lateral rotation, flexion and
abduction. When it is in extreme flexion, it produces medial rotation extension and abduction.
For friction massage, the attachment to the greater trochanter is palpated and the direction of
friction massage is caudal to cephalid and back.
Bursa:
There are numerous bursa associated with the hip. Bursitis is common and can be treated with
friction massage. Those that can be reached by manual methods are bolded :
trochanteric bursa
bursa of the gluteus medius
bursa of the gluteus minimus
bursa of the obturator externus
bursa of the obturator internus
iliopsoas bursa
iliopectineal bursa
ischiogluteal bursa
bursa of the vastus lateralis.
Trochanteric bursa:
This structure separates the gluteus maximus from the lateral aspect of the greater trochanter.
Trochanteric bursitis is associated with gluteus medius bursitis and gluteus minimus bursitis and
can be caused by either or both concurrently.
Friction massage for chronic bursitis is recommended. The point for cross fiber massage is
inferior to the greater trochanter. The direction of tissue movement is A-P and back on the
patient.
Iliopsoas bursa:
This bursa is under the attachment of the iliopsoas tendon into the lesser trochanter.
Iliopectineal bursa:
This bursa is found between the iliopsoas and the hip joint at the iliopectineal eminence between
the ilium and the pubis.
Iliopsoas bursitis and iliopectineal bursitis can be treated at a common point. During friction
massage, discretion is advised treating the groin region. The point for friction massage for both is
inferior to the lesser trochanter. The direction of tissue movement is along the line of the inguinal
ligament. The patient’s leg is placed in a figure 4 for ease of treatment.
Ischiogluteal bursa:
This bursa is found between the ischial tuberosity and the gluteus maximus.
Friction massage can be performed on the ischial bursa. The patient’s hip is flexed and the cross
fiber massage is directed side to side on the patient. Until the inflammation resides, the patient
should avoid sitting. If this presents as too difficult, a pillow or foam with the center removed
may be necessary so that the patient can sit without discomfort.
Section VIII: Friction Massage – Lower Extremity (continued)
Lower Extremity (continued):
Knee:
The knee joint is the largest and most complicated in the body. A modified hinge type of
synovial joint, it allows for some rotation. The fibrous capsule is mostly loose and thin except for
thickenings of intrinsic ligaments. Two menisci are crescent plates of fibrocartilage interposed
between the femoral and tibial condyles which deepen the articular surfaces of the tibia. The
cruiciate ligaments are within the articular capsule and located between the medial and lateral
condylar joints. The anterior cruciate ligament is weaker and attaches to the tibia anteriorly. The
posterior cruciate ligament is stronger and attaches posteriorly. They function to stabilize the
knee and maintain the contact of the articular surfaces as the joint hinges. The patellar ligament
is a continuation of the quadriceps femoris tendon and connects with the fibrous capsule of the
knee joint. It is important in stability during flexion and extension of the knee and tracking of the
patella. An interosseous membrane runs the length of the tibia and fibula and attaches the two
shafts of these long bones.
The proximal tibiofibular joint is synovial joint covered with hyaline cartilage. It moves slightly
during ankle dorsiflexion. The distal tibiofibular joint is a strong fibrous joint. It is responsible
for stability and strength of the ankle and moves slightly to accommodate the talus during
dorsiflexion. The menisci are important as an elastic coupling mechanism that transmits the
compressive forces between the femur and tibia. They are most efficient during extension when
they are most tightly interposed between the articular surfaces.
The knee has primarily one degree of freedom of movement allowing the limb to be moved
toward or away from the trunk. A second degree of movement is rotation of the long axis of the
leg which occurs only when the knee is flexed. The purpose of this joint is stability and mobility.
In extension, the knee is subjected to severe stress from body weight and stability is vital. In
flexion, mobility is necessary for running as well as guiding the orientation of the foot relative to
the ground surface. A poor degree of interlocking of articular surfaces makes the knee more
vulnerable to sprains and dislocations. Ranges of motion are flexion, extension relative to a
flexed position (there is no absolute extension of the knee), and axial rotation.
There is friction massage protocol for the bone, ligaments, muscles and bursa of the knee.
Bone:
Patella tendinosis:
The soft tissue structures referred to in this condition are the tendons attached to the patella from
the quadratus femoris. Strain in sections of this muscle can lead to shortening of the muscle and
uneven pull on the patella. This will lead to patella rotation and friction from malalignment.
Tendinosis can result in sections of the tendon attachment to this bone.
8-1
Friction massage can be performed around the patella with the patient’s knee in extension. First,
the practitioner contacts the area that needs to be treated. They then must push against the
opposite side of the patella in a direction toward the side being treated in order to get the treating
finger under the patella. Once the patella is riding over the treating finger or T–bar tool, the
direction of friction massage is perpendicular to the direction the patella is being pushed. For
medial and lateral contacts, the direction of tissue movement is inferior to superior and back. For
inferior or superior contacts, the direction of tissue movement is medial to lateral and back.
Ligaments:
Medial Plica Syndrome:
The plica is a synovial structure found in about 60% of the population. A remnant of
mesenchymal tissue near the infrapatellar fat pad around the medial femoral condyle, it appears
in 3 folds. It then extends under the quadriceps tendon to the lateral retinaculum. If the plica
becomes trapped in the patellarfemoral joint as the quadriceps contracts, pain at the inferior of
the patella may lead to a giving away of the knee.
8-2
Friction massage at the medial plica (medial to the patella inferior to the medial retinaculum)
will break down scar tissue. With the patient supine, their knee extended, the practitioner pushes
their patella laterally. The plica is now exposed medially. The direction of friction massage on
the plica is medial to lateral and back.
Medial collateral ligament:
This structure supports the medial aspect of the knee and prevents an increase in valgus deviation
upon injury. Its deeper fibers are attached to the medial meniscus. It is assisted by the sartorius,
semitendinosis and gracilis. During extension it becomes taut and relaxes during flexion. It is the
most commonly injured ligament in the knee.
8-3
Friction massage is affective for grade 1 and 2 injuries and is as follows. The most tender portion
of this ligament must be identified as that is the site for treatment. The patient’s knee is
maximally flexed for the initial part of the treatment. Friction massage is across the ligament
anteriorly to posteriorly and back. Then have the patient maximally extend their knee and repeat
on the most tender aspect of the tendon which may not be the same place initially treated.
Meniscotibial ligament (coronary):
These ligaments attach the menisci to the rim of the tibia. There is the medial coronary and
lateral coronary. They support the meniscus within the joint.
8-4
Friction massage for the medial coronary ligament is performed as follows: The knee is flexed
90 degrees and the tibia is externally rotated. This will expose the medial side of the knee. The
direction of tissue movement is medial to lateral and back. The lateral coronary ligament is rarely
involved but if necessary, the treatment can be performed for the lateral ligament as well in the
same direction.
Muscle:
The following muscles are associated with the knee. Those with an * are mentioned more than
once. Those with a # have been previously covered in section 6. Those bolded are suitable for
friction massage for the knee.
Flexors:
hamstrings (#biceps femoris, #semitendinosis, #semimembranosis)
gracilis
sartorius
popliteus
gastrocnemius
soleus
plantaris.
Extensors:
Quadriceps femoris group (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius).
This group was covered under patella tendinosis.
Medial rotators:
*sartorius
#*semitendinosus
#*semimembranosus
*gracilis
popliteus
Lateral rotators:
*biceps femoris
*popliteus
#tensor fascia lata
Flexors:
Biceps femoris:
The function of this muscle was discussed in section 7 under Hip.
8-5
For friction massage at the knee, the patient can be seated or supine and their legs must be
extended. The contact point is at the lateral side of the fibular head. The direction of friction
massage is anterior to posterior and back on the patient.
Semimembranosis and semitendinosis:
The functions of these muscles were discussed in section 7 under Hip.
Friction massage can be performed in the belly of the muscle on a prone patient with their knee
flexed. The direction of massage is medial to lateral and back on either muscle.
Popliteus:
This muscle flexes and rotates the knee. It unlocks the knee joints at the onset of flexion of the
fully extended knee by rotating the tibia medially on the femur. It is also a lateral rotator of the
femur on the tibia when the foot is fixed on the ground.
8-6
Friction massage to the popliteus can be performed in two areas. The patient crosses their
involved leg at the knee over the thigh of the other leg exposing the tendon of this muscle.
Friction massage can occur anteriorly in the femur attachment. The direction is along the line of
the femur shaft. The other location is at the tibial attachment which is posterior of the lateral
collateral ligament. The direction of friction massage is across the tendon along the line of the
tibial crest.
Gastrocnemius:
This muscle flexes the knee and plantar flexes the ankle. It is unable to exert its full power on
both joints at the same time.
8-7
Friction massage for strain of the gastrocnemius is best performed on the belly of this muscle
with the patient prone. The direction of massage is medial to lateral and back.
Bursa:
suprapatellar bursa
popliteus bursa
subcutaneous prepatellar bursa
subcutaneous infrapatellar bursa
pes anserine
deep infrapatellar bursa.
Pes anserine bursa:
This bursa is at the medial superior tibia under the common attachment of the sartorius/gracilis
tendons and over the medial collateral ligament.
8-8
Friction massage is performed over the tendons and bursa in the direction that is along the shaft
of the tibia. The patient should be seated or supine with their knee flexed.
Section IX: Friction Massage – Lower Extremity (continued)
Lower Extremity (continued):
Ankle and foot
Stability within the ankle is assisted partially by the anatomy of the bones. Most of the stability
of the posterior of the foot is from the ankle joint. Greatest stability in dorsiflexion, this is due in
part to the position of the trochlear of the talus as it fills the mortise formed by the malleoli. The
malleoli grip the talus as it rocks backward and forward during flexion and extension of the
ankle. When in dorsiflexion, the anterior of the trochlear is forced posteriorly spreading the tibia
and fibula slightly apart. It is limited by the interosseous membrane and the anterior and
posterior tibiofibular ligament. In plantar flexion, the trochlear moves forward in the mortise and
the malleoli come together but the grip on the trochlea is not as strong as in dorsiflexion.
The ankle joint, also known as the tibiotarsal joint is a hinge type synovial joint with one degree
of movement in the sagittal plane allowing for flexion and extension. Transverse stability in the
ankle depends upon the tight interlocking of its bony surfaces as well as the medial and lateral
collateral ligaments which stabilize the talus.
To best understand the functional anatomy of the foot, it is necessary to know that the ankle is
the most important joint of the posterior half of the foot. Assisted by axial rotation of the knee, it
is equivalent to a single joint with three degrees of freedom allowing the foot to take any position
in space and to adapt to the surface it contacts.
There are three axes of movement that are perpendicular to one another; transverse axis, long
axis of the leg and long axis of the foot. The transverse axis passes through the two malleoli and
running frontally controls flexion and extension in the sagittal plane. The long axis of the leg
runs vertically controlling adduction and abduction which occurs in the transverse plane. This is
possible because of the axial rotation that is produced in the flexed knee. The long axis of the
foot runs horizontal and lies in the sagittal plane. It controls movements of the sole of the foot
and allows it to face inferiorly, laterally or medially, or pronation/supination.
The joints orient the foot so that the sole is correctly presented off the ground regardless of the
position of the leg and shape of the ground surface. They also alter the shape and curve of the
arches so the foot can adapt to the ground surface. The joints act as shock absorbers between the
ground and the weight bearing foot allowing for greater elasticity in the step.
The ankle is responsible for flexion/extension. The foot can also produce adduction and
abduction. Adduction is described as the toes moving toward the median of the body or point
inward. Abduction is when the toes move away from the median of the body or point outward.
The total range of motion of adduction/abduction is 35-45 degrees. If the knee and hip rotation
are considered, then total range of motion for the foot facing inward or outward is up to 90
degrees. The foot can also move medially into supination or laterally into pronation. The range
of supination is 52 degrees and the range of pronation is 25 degrees.
Adduction in conjunction with supination and extension creates inversion. Abduction occurs in
conjunction with pronation and flexion to create eversion. For more complete understanding of
the foot and ankle, please refer to Soft Tissue Injury 111, Foot and Ankle, Linda Simon, DC.
Bone:
There are treatment protocols for friction massage relating to the ligaments, muscles, tendons and
fascia of the ankle and foot.
Ligament:
Deltoid ligament:
The deep fibers of the medial collateral ligament form the deltoid ligament. It arises from the
medial malleolus and fans out to the navicular, the calcaneonavicular ligament and calcaneus.
The deltoid ligament is comprised of four distinct ligaments; tibionavicular, anterior tibiotalar,
posterior tibiotalar and tibiocalcalcaneal. It strengthens the ankle joint and holds the calcaneus
and navicular against the talus. Also, by supporting the spring ligament it helps to support the
medial longitudinal arch.
9-1
Friction massage occurs at the attachment to the medial malleolus in a direction anterior to
posterior and back.
Anterior talofibular ligament:
This ligament attaches from the lateral malleolus to the talus. It is not very strong and is the most
common site of ankle sprain.
9-2
Friction massage can be performed in two places. One is at the attachment to the lateral
malleolus. The other is at the attachment to the talus. The direction of friction massage to both
ligaments is medial to lateral and back.
Calcaneofibular ligament:
This ligament arises from the lateral malleolus and runs to the lateral calcaneus.
Friction massage can be done at the attachment to the lateral malleolus. The direction of friction
massage is anterior to posterior and back.
Calcaneocuboid ligament:
This thin bands runs over the superolateral of the calcaneocuboid joint.
Friction massage can be performed in the middle of this ligament between the calcaneus and
cuboid bone. The direction of tissue movement is medial to lateral and back.
Anterior tibiofibular ligament:
This ligament runs from the fibular notch of the tibia to the anterior surface of the lateral
malleolus. Its purpose is to stabilize the anterior of the tibiofibular joint.
Friction massage can be done at the distal end of this ligament between the tibia and fibula
anterior on the ankle. The direction of tissue movement is superior to inferior and back.
Muscles:
Peroneus brevis:
This muscle arises from the lateral fibula and intermuscular septum and inserts into base of the
5th metatarsal. It plantar flexes the ankle joint and everts the foot.
Peroneus longus:
This muscle arises from the lateral fibula and inserts into the base of the 1st metatarsal and
medial cuneiform. It plantar flexes the ankle joint and everts the foot. It also helps to maintain
the transverse and lateral longitudinal arches.
9-3
Friction massage can be performed in two regions; one by the tendon at the lateral malleolus, the
other just above that where the tendon begins. Massage is in a pronation/supination direction
with the foot in inversion and dorsiflexion.
Posterior compartment:
Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Tibialis posterior:
This muscle arises from the interosseous membrane, posterior of tibia and medial fibula and
inserts into the navicular and bases of the 2nd, 3rd, and 4th metatarsals. It plantar flexes the ankle
and inverts the foot. It also helps to maintain the medial longitudinal arch.
Flexor hallucis longus:
This muscle arises from the posterior of the fibula, interosseous membrane and intermuscular
septum and inserts into the base of the distal 1st phalanx. It flexes the great toe, plantar flexes the
ankle and helps to maintain the medial longitudinal arch. This push off muscle during walking
and running provides spring to the step.
Flexor digitorum longus:
This muscle arises from the posterior tibia and intermuscular septum and inserts into the distal
phalanges of the 2nd to 5th digit. It flexes all joints of the lateral four toes and plantar flexes the
ankle. It helps to maintain the medial longitudinal arch.
9-4a, 9-4b
Friction massage can be performed for the posterior compartment muscles. The patient’s foot is
inverted and plantar flexed. The muscles can be treated along the bellies and tendons. The
direction of tissue movement is anterior to posterior and back. To better reach the tendon sheath
of the tibialis posterior at the ankle, the patient should place their foot in eversion and
dorsiflexion. There are three regions that can be treated. One is inferior to the medial malleolus
at the talus, the other is posterior to the medial malleolus and the third is just proximal to the
medial malleolus. The direction of massage is anterior to posterior and back.
Anterior compartment:
tibialis anterior
extensor hallucis longus
extensor digitorum longus
Tibialis anterior:
This muscle arises from the lateral tibia, deep leg fascia and interosseous membrane. It inserts
into the medial cuneiform and 1st metatarsal. The tibialis anterior dorsiflexes the ankle and
inverts the foot.
Extensor hallucis longus:
This muscle arises from the anterior fibula and interosseous membrane and inserts into the dorsal
of the distal phalanx of the big toe. It dorsiflexes the ankle and extends the great toe.
Extensor digitorum longus:
This muscle arises from the lateral tibia, anterior tibial surface and interosseous membrane. It
inserts into the middle and distal phalanges of the 2nd -5th toe. The extensor digitorum longus
dorsiflexes the ankle, everts the foot and extends the lateral four toes.
9-5
Friction massage can be performed for the anterior compartment muscles at the region where the
muscle fibers meet the tendon on the anterior shin about 4-5 inches proximal to the ankle.
Direction of tissue movement is anterior to posterior and back.
Section X: Friction Massage – Lower Extremity, Spine and TMJ – and Myofascial Release
Lower Extremity (continued):
Ankle and Foot (continued):
Tendons:
Achilles Tendon:
Gastrocnemius arises from the posterior femoral condyles. There are 2 heads to this muscle, both
combine inferiorly to form the Achilles tendon, the thickest and strongest tendon in the body.
This muscle flexes the knee and plantar flexes the ankle. It is unable to exert its full power on
both joints at the same time. The soleus lies under the gastrocnemius and inserts into the
calcaneus via the Achilles tendon. The soleus plantar flexes the ankle and steadies the leg when
standing. It acts in conjunction with the gastrocnemius.
10-1a
10-1b
Friction massage can be performed in three areas of the tendon. One is on the tendon near the
attachment to the calcaneus. Another is the attachment of the tendon to the belly of the
gastrocnemius muscle. Both are treated with the patient supine, their foot plantar flexed.
Direction of massage is medial to lateral around the tendon. Opposite side of the tendon needs to
be stabilized with the practitioners other hand by counterpressure. The third region for friction
massage is the sides of the tendon, either medial or lateral. If those areas need to be treated, the
patient’s foot is dorsiflexed and stabilized by the practitioner’s knee while treatment occurs.
Plantar fascia:
The plantar aponeurosis is a fibrous expansion of the plantar fascia that covers the sole of the
foot and reaches from the calcaneus to the digits. It helps to support the longitudinal arches of the
foot and holds the parts of the foot together.
10-2
Friction massage for this structure occurs at the attachment to the calcaneus. It is important to
use a T-bar for this treatment as the fascia here is very thick and very wide. The region needs to
be treated in more than one place on the tendon during one visit. The direction of massage is
medial to lateral and back.
Spine:
The muscles and tendons of the spinal structures are not conducive to friction massage. This is
because most of the muscles are either too long to create an effect or too deep to reach with this
soft tissue treatment. The depth of the ligaments also prevents this technique from being as
affective as most other soft tissue techniques for treatment of trigger points, sprain/strain and
myofascial restrictions. Those associated with the pelvis such as the gluteal group have already
been covered. Those associated with the shoulder such as the levator scapula have also been
covered. Myofascial release is a technique much better suited for the spine and its associated
structures and will be covered next in this course.
TMJ:
Temporalis:
The temporalis is a muscle of mastication and responsible for closing the jaw and laterotrusion.
Trigger points here do affect the face and jaw.
Friction massage can be performed just above the mandibular condyle on the temporal bone at
the attachment of the temporalis muscle in a direction of the anterior to posterior and back. This
is beneficial for tendinosis, myofascitis, trismus and contracture of this muscle.
Masseter:
The masseter is a muscle of mastication and is responsible for closing the jaw, laterotrusion and
protrusion as well. This muscle is greatly responsible for much TMJ dysfunction.
Friction massage is very effective in treating the masseter. There will usually be a spasm anterior
to the angle of the jaw along the ramus. It will be tender to palpation and fibers will be
contracted. The friction line should be along the inferior ramus.
For a complete understanding of soft tissue treatment for the spine and TMJ offering function,
conditions and a wide variety of treatments, please refer to Soft Tissue Injury 106, Cervical
Spine, Linda Simon, DC; Soft Tissue Injury 107, TMJ, Linda Simon DC; Soft Tissue Injury 108,
Thoracic Spine, Linda Simon, DC; Soft Tissue Injury 109, Lumbopelvic Spine, Linda Simon,
DC.
Myofascial Release:
The fascia of the body provides for support, protection, separation of tissues; allows for efficient
cellular respiration, metabolism including elimination of toxins, fluid and lymph flow. It is
intimately connected to the musculoskeletal system and adhesions within the fascia can have
affects throughout the body. When the fascia is twisted or torqued due to adhesions or loss of
fluidity in its gel system, the tissues within it become compressed and are incapable of
functioning normally.
10-3
Trauma to this delicate and immense system can lead to limited cellular metabolism, necrosis,
disease, pain and dysfunction of the tissues throughout the body including the musculoskeletal
system. Within the fascia is collagen, elastin and a gel complex made of polysaccharides. The gel
acts as a shock absorber dispersing it throughout the body. If there is any fascial restriction due
to injury or scar tissue, and further trauma occurs, the shock cannot be absorbed throughout the
body and the localized tissues received the brunt of the impact. The greater the restriction in
fascia, the greater can be the injury resulting from an impact. An impact could be sudden and
acute as in a sports injury or it can be repetitive as in tenosynovitis of the forearm from a poorly
designed computer station. In myofascial release, the fascia is freed restoring more normal
motion and the ability to absorb shock.
Myofascial release is a full body technique, the purpose of which is to lengthen the body thereby
providing more space for the proper functioning of skeletal structures as well as nerves, muscles,
blood vessels and organs. Since the fascia is an interconnected system throughout the body, a
twisting and tightening of fascia in the lower back can create a pull on the musculoskeletal
system creating headaches, neck pain and dysfunction as well as stiffness and pain in the local
area of the taut fascia. It is important to understand the significance of the fascial pull and the
necessity of this treatment as a full body technique. Also, the musculoskeletal system that is
affected by tight and twisted fascia develops habituated patterns of functioning in order to
compensate for the new but inappropriate structure due to the fascial restrictions. It is these
behavior patterns that must also be addressed with musculoskeletal rehabilitation and
repatterning of now more normal structure once the fascia has been released.
Myofascial adhesions are not recognized by high tech diagnoses. They are discovered by
examination and evaluation of the patient’s symptoms as well as palpation of restrictions in
tissue movement. A visual analysis of the patient’s frame, palpation of tissue texture, and
craniosacral rhythm can all be used in the diagnosis of fascial restriction. The technique of
myofascial release is a gentle pull of tissues in which the tissues are stretched in opposite
directions at the same time.
This stretching of fascial components will allow for increased blood flow, lymph drainage,
removal of toxins, resetting of appropriate proprioceptor information and the realignment of the
fascial planes.
When the fascial restriction has been identified, gentle pressure is applied to stretch the tissues
pulling the elastin and collagen fibers straight. Force is never used, only gentle pull or gravity
assist. At first, the tissues will seem springy. The tissues must be pulled until the collagenous
barrier is reached. With sustained pressure without movement this barrier will be stretched. It is
this slow and gradual elongation that will allow for the viscous gel substance to increase in its
flow. Once the tissue barrier is freed, the practitioner continues with the elongation process from
barrier to barrier releasing the fascial components. There may be a spontaneous release of
restricted tissues, just allow the body to relax into the freed area as the fascial restrictions release.
Contraindications to myofascial release are as follows:
1. malignancy
2. cellulitis
3. febrile state
4. systemic or localized infection
5. acute circulatory condition
6. osteomyelitis
7. aneurysm
8. obstructive edema
9. acute rheumatoid arthritis
10. open wounds
11. sutures
12. hematoma
13. healing fracture
14. osteoporosis or advanced degenerative arthritis
15. anticoagulant therapy
16. advanced diabetes
17. hypersensitivity of skin