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Lower Extremity - Mopal/CMT - Drs Tim Ray & Rick Ames

Christine: Welcome to the ICSC manipulation principles with Dr. Tim Ray. The we will bring, Dr. Rick Ames in the second half and he is going to  be talking about some motion palpation type stuff and soft tissue stuff as well. We will begin with Dr. Tim Ray and there is so many things for me to-to highlight for his professional career. I almost do not even know where to start.

Tim Ray: Thanks Christine. I appreciate the introduction. I am not going to spend a lot of time talking about myself. I, I would just wanted to say that I have been involved with FICS for a couple of decades and my chores in the International Federations Committee with the games commission, that deals with logistics and selections for International games for FICS. It is really a pleasure to speak with so many different people from so many different countries, and I find that very exciting. I would like to also acknowledge Dr. Brian Nook because he was the one that was really responsible for the majority of the content of this presentation. I have just added a little Tim Ray twist to it and we do this to ensure each presentation covers the same material no matter who is presenting it or where it is being presented.

My portion of this ICSC educational series deals with Basic Biomechanics and Kinesiology of Manipulative Therapy. I will cover some of the foundational principles of Osteo and Arthrokinematics in manual therapy because this will allow us to pr-provide us a baseline of understanding. We will follow in the hands-on section of the program. Understanding these principles allows us to model our clinical practices and prevents us from becoming technicians. We always want you to strive to be a clinician, not a technician. We wish to provide you a practical evidence-based, outcome-driven education, to be able to understand, defend, and appropriately apply this practice or this important aspect of your practice in your care.

According to Sarah Sharman to facilitate movement the body functions as an interdependent, interrelated scheme where the muscular, skeletal, and nervous systems work separately and collaboratively to produce motion. Our care focuses on analyzing the dysfunctional and functional relationships of this regional interdependence.

My good friend and colleague, Dr. Rick Ames, and I will attempt to cover the biomechanical, physiological, and neuromuscular aspects underlying manual therapy. Then, as you move into the hands-on portion, we will stress these concepts of what w-w-we have reviewed today. assessing joint function requires an understanding of what really happens with manipulation or mobilization. And we have to realize that the old historical description of bones, or moving bones back into places is not really valid any longer. But you will see from today’s discussions, the effect of our manual therapy is improved motion and a beneficial alteration of motor control.

So let us start by looking at the osteological mechanics of movement and that is basically turned- termed Osteokinematics. Which is nothing more than a big word that describes how bones and joints move in relation to each other. These types of motions there are basically 3.

The first of these is called translation, which is really linear, and as to say, along a line. But this line is not only straight but can be curved, and then you have rotational movement, which is angular around an axis. But in most cases, particularly in human movement, it is a multi-segmental combination of this translation and rotation. Then this is dictated by the architectural anatomy of the joints that we focus on.

So when we start looking at motion, we have to review the standard references of cardinal planes of motion.  I am sure you are all familiar with this, but we just go through it. Examples of frontal plane motion in-in human motion are things like flexion and extension, plantar, and dorsiflexion.  sagittal plane movements are like lateral flexion, abduction, adduction, inversion, and eversion. And then examples of transverse plane motion are like supination and pronation.

Then with each of these motions, there is a point where there is an axis of motion that occurs. In some cases like in this middle picture where we illustrate the interphalangeal joint, there is a single axis of motion and the single-axis refers to what is called the instantaneous axis of motion. But in other joints like the knee, it is a little more complex because there is a combination of motions that include translation and rotation, and these occur in more than one plane. So when there are multiple axises of rotation, the composite of these axises of motions is called the evolute.

The takeaway from this comes from our motion palpation assessment of a joint in differentially diagnosing normal from abnormal joint motion. It is important to understand the joint-by-joint approach made popular by Gray Cook and Michael Boyle. It essentially states that joint architecture from the foot up alternates between stability and mobility in terms of the motion. Because of this when joint dysfunction results in symptomatic pain, it can often be traced to the joint above or below the pain. A good example of this is when you sprain an ankle, and it loses its mobility because of this. The pain usually shows up in the knee because the knee loses stability in compensating for the lack of mobility in the ankle. I think it is pretty obvious that you can see manipulating the knee would not be the best location for the most effective outcomes.

If we motion palpate joints, we try to evaluate the joint’s ability to displace or resist displacement. And this is a way of n-not only assessing joint stability but also looking for an indication of the joint centration or what is called the close-packed position. We also check to see if there is maximal joint surface contact, the balance between the co-contraction of the agonist and antagonist, and even loading of the joint services. But do not confuse this with a closed-packed exercise or the distal aspect of the extremity is anchored to the ground during the exercise.

We have to look at the open-packed position which really allows us to assess passive range of motion and this allows partial joint contact, and within that, we may be able to feel an imbalance between the agonist and the antagonist and then palpate on even joint motion. But do not confuse this with an open-packed position for an exercise where the distal segment is free like, in a seated leg extension exercise.

Man, if we move to look at Arthrokinematics, another big word, which just describes the way articular surfaces move in relation to each other. We can use this information in helping us differentiate motion between our palpation, whether it be static or dynamic palpation of the joint. But to do that, w-w-we need to look at kinetic chains and realize that when we evaluate somatic dysfunction using Sharman’s approach to regional interdependence. We have to understand that there is more than one kinetic chain. That the nervous, the muscular, and the skeletal systems all have their own kinetic chains, but we are not going to talk about all this today. W-We will stick- stick with the articular chain. And in- within the articular chain, you will notice that there are two sub-chains. The postural and, and the kinetic which are Illustrated in the bottom part of the slide.

The postural chain is more about static posture and it is illustrated by this Brugger illustration that shows changes in pelvic tilt also alter the curves and the curves of the spine and, and then the way that the rib cage moves. And then the kinetic chain is more about evaluating dynamic posture. Man, this shows an example of how excessive pronation creates kinetic changes within the skeleton,  from a functional perspective.

Joints have various degrees of freedom of movement. Most mobile joints have 1, 2, or 3 axises of motion and other joints have none at all. Like our teeth or the sutures of our skull. Each motion is dictated by the joint’s architecture and then that is enhanced or inhibited by the muscles, the ligaments, the Joint capsule, fascia, and of course, the neurological motor control which then supply varying degrees of motion.

In addition to this gross movement, joints have accessory motion or joint play, and this really refers to the flexibility of the joint capsule. This helps the joint maintain optimal position and prevent loss of contact between articular surfaces. So, if we are looking at the actual joint movement, there are 3 fundamental movements, and then the first of these is called the roll, which is pretty much like a tire rolling or, on the ground. But, in anatomical terms, we have to realize that if there is too much roll within an articular surface, that can lead to dislocation.

Then there is glide and slide which is similar to a tire skidding on the ground, or on ice and this is sometimes also called translation. Then anatomically or clinically speaking, the pure slide can create impingement and we see that when the humeral head slide superior and create subacromial impingement, or we can see it in the spine with impingement of the articular facets.

We have spin and swing which is rotation around a stationary axis, and this, we commonly see with hip and shoulder and, and radius motion. But again, in reality, please remember that these occur in a combination in most movements. Roll and glide usually occur in opposite directions to each other. Like we see here with the knee.

Within joint motions, we have to look at the convex-concave rule, which basically states, the fixed end of a convex or a concave joint really determines the direction of accessory motion. Each side has its individual motion. So, when we motion palpated joint, we want to make sure to palpate the motion of the fixed end, as well as the moving end.

As you see in the picture here, if you focus on the green dots, you see each motion has a point where the axis of motion occurs. This is what we term, the instantaneous axis of rotation or motion and in like an interphalangeal joint, this axis of instantaneous or axis of motion never changes. But in reality, in human movement, that rarely ever occurs because movement occurs on different planes. When we have multiple motions in multiple planes, this instantaneous axis of motion is constantly changing. We describe the composite of these constantly changing movements as the evolute.

Most movement, as you can see, is in a curved linear post??? motion. It is always a combination of translation or rotation and that is what commonly happens in most body motions. This freedom of motion gives each joint the capability of having 3 translational, and 3 rotational movements resulting in 6 degrees of freedom of movement in all the cardinal planes. So what this means is joints should exhibit these characteristic movements, flexion, extension, right and lateral flexion, right and lateral rotation, A to P, P to A, lateral to medial, and medial to lateral glide, internal and external rotation, compression, and then a distraction.

I think we all realize that since the body motion is really 3 dimensional. The actual description for 3D motion is called the helical axis of motion. And this describes some curved linear translation without rotation,  and without any, spin associated with it. but again, because the motion curve occurs on a regular surface, there are no real pure planes of motion.

If we switch our attention to the kinetics of motion, which is the branch of biomechanics dealing with the forces causing motion. We really need to review Newton’s Second Law, which is basically force equals mass times acceleration. This relates to our application of thrust with manipulation. We use this in teaching our Chiropractic students, how to use their mass to deliver efficient directions of force during our manipulation courses.

Later in the program, you will learn how to use kinetics in analyzing athletic movements. So, when we review, we have to look at the different types of muscle activations and we commonly have, are aware of this, but we need to review, and have you remembered that different types of forces that muscles can produce are divided into these categories where concentric contraction is muscle force while the muscle are shortening. Eccentric contraction is muscle force while the muscle is lengthening. Isometric contraction is where there is no change in the muscle length, and then I would like you to remember that eccentric contraction produces twice as much force than concentric contraction with half the energy.

If we started this slide by looking at the bottom of the slide  under a length-tension relationships. This refers to the amount of force a muscle can produce in relation to its actin and myosin cross-bridge connections. We see, in a resting state, there are a greater number of actin and myosin connections. When one elongates or shortens a muscle the percentage of cross-bridges decreases along with the amount of force a muscle can create. And this is called active and passive insufficiency. We see this very commonly in a condition called pattern overload. And pattern overload is when you do the, the same exercise or the same movement over and over again, repetitively like a racket swing, jogging, a particular weight lifting exercise, or pitching a baseball, or a, a cricket ball. and then what occurs from this is pattern overload creates these imbalances in length-tension relationships.

I think that most of us think about muscle function in what is, is just the concentric phase of the muscle contraction because that is how we were taught in school. We learned that the origin and then the insertion, and then we learn the concentric function of a muscle.  I feel that this is carried over into our soft tissue techniques because we tend to work on the tight muscles in removing muscle tension, removing trigger points in the hope of balancing the soft tissue to allow appropriate joint centration and appropriate motion of the joint. But what I see many neglecting is the other half of the equation where the antagonist is also involved in co-contraction of the joint and creating joint stability. And I feel that this must be considered as part of our manual therapy. If we do not activate the weak antagonist while releasing the type agonist or vice-versa, how can we assume that there is balance and force available for joint stability and centration?

Research has provided many instances where this reciprocal inhibition of an overactive agonist, neurologically shuts down the neural drive to the antagonist. And this is basically what neurogenic inhibition is. This creates another condition called synergistic dominance and that is when the neural drive of a prime mover is shut down. Then the synergistic muscles that aid in the execution of that movement, now become the prime mover. When that occurs this leads to further decentration of the joint and a higher risk of injury and loss of performance.

The reason why this occurs is not only because of the changes in the length-tension relationships of those muscles but in their coordination of what is called force couples. When you have a synergistic action of muscle groups and this is illustrated in the illustrations on the, on the far right of this slide. In most cases, force couples are considered a gross movement but not that is not true in every scenario. But when you have this scenario of altered length-tension relationships from pattern overload, creating a reciprocal inhibition, and synergistic dominance then you have this agenesis of impairment of performance. I like these charts here because I think they are very informative, but I think the arrow should move in, in both directions since each component of these adaptive responses are the result of the body always sacrificing the quality of motion for the quantity of motion.

Then our neural plasticity, our nervous system creates engrams that quickly learn this dysfunctional movement pattern and then these circles move on to the next stage. Now, regardless if you would know what movement we are talking about. Whether it be everyday movement or athletic movements, there are various forces that act on the musculoskeletal system, and these are composed of tension, compression, stress, shear, torsion, or more times than not a combination of these things take place.

Now, I would like to switch our attention to the articular neurology of, of synovial joints. There is the primary innervation of synovial joints are 3 types of nerves. The primary and accessory articular nerves and then mechanoreceptors, and I want to concentrate on the mechanoreceptors today. We often think of these in our, our, our Kinesio taping techniques because these assist afferent communication through using the skin as a handle or in our internment, instrument assisted techniques. but it is interesting that joints also have a similar innervation like the skin. I find that fascinating because they allow the body to perceive where it is in space. This is critically important in athletic movement because controlling your balance is so critical. Controlling your balance outside your centre of gravity is what I feel is the ultimate athletic skill. Therefore, our optimizing a mechanoreceptor function is really central to what we do.

As you can see, there are 4 types of mechanoreceptors. Types 1 through 3 are found in joints and periarticular tissues. Where type 4 are just free nerve endings surrounding the joints that mediate pain or nociception. When stimulated these type 4 nociceptors do not adapt. They just keep on fire. They just keep on screaming. And then this trigger, triggers muscle tension which then restricts motion from neurogenic inhibition and they get sensitized, and that increases pain perception. The nice thing about types 1 through 3 is that during motion, that stipulates the type 1 through 3 mechanoreceptors and these guys block type 4 nociception from the transmission to higher centres.

The other thing you have to remember is when the joint motion is restricted or immobilized or even when the joint has decreased motion from like pattern overload, this stimulates the type 4 nociceptor firing. And this is where we come in because our osseous manipulation like joint motion and exercise stimulates type 1 through 3 nociceptor activity resulting in presynaptic inhibition of the nociceptor afferent transmission at the spinal cord level so it never really gets to the higher centres. I feel that this is how our manipulation helps relieve joint pain.

So let us take a closer look at these guys. If we look at type 1, Ruffini mechanoreceptors, there are numerous and subcutaneous and fascial connective tissue joint capsules, apophyseal joints to the spine and they are in the TMJ.

The unique thing about these guys is that they are more numerous and proximal joints. They have a low threshold. They are slowly adapting and they are always active even when the joints are mobile. They discharged at a rate of 10 to 20 times a second and have a tonic effect on muscles. Alterations the discharge rate increase or decrease with active or passive manipulation, isotonic or isometric exercise, or when the pressure gradient of a joint is altered sufficiently like we see in when we cavitate a joint.

The other cool thing is they supplement our visual components of balance and those cutaneous mechanoreceptors in the skin. But the alternative, alternative so if you damage the joints capsule, it also causes degeneration of type 1 mechanoreceptors. Then the reverse occurs, this can lead to impairments of posture and balance.

If we look at type 2 Pacinian corpuscles they are, they are kind of strange nerve endings because they have a multilaminate connective tissue capsule and closing the terminal end of the nerve. They are present in periarticular tissue, fibers capsules of the joint, and the periosteum. These guys are a little different because they are more numerous in distal joints as opposed to proximal ones, like the type 1’s. They are low threshold. They are rapidly adapting. And for this reason, they are really inactive when we immobilize the joint. They only become active at the onset of movement, and then they emit a brief high-frequency burst that occurs 20 to 40 milliseconds prior to the type 1’s firing. So there are main function is to signal joint acceleration and deceleration and they have a phasic effect on the muscles.

Then type 3’s are combined to intrinsic and extrinsic ligaments and they are identical to the Golgi tendon organs that were familiar with. They are found in collateral ligaments of the knee, cruciate of the knee, longitudinal and interspinous ligaments of the spine. Their high threshold slowly adapting but like type 2 they are inactive when we immobilize the joint because they only become active at end ranges of motion. So, their function is to mediate breaking reactions, directions of motion, and warn of harmful movements.

Then back to the type 4 nociceptors, they represent a small plexus of unmyelinated pain receptors. Remember that they are active with mechanical deformation,  tension, and chemical or mechanical irritation. When you have  an injury that causes  an  excess of  inflammatory exudate, when the concentration of histamine or bradykinin gets high. These guys set off and they continue firing as mentioned causing muscle tension, increased pain perception and this leads to inactivity from  neurogenic inhibition, and then if unchecked they continue firing into the  upper centers of the brain, and this causes sensitization that we recognize as chronic pain.

So let us move our attention to how we assess joints and we really ask ourselves a lot of questions. How do we assess joints using these biomechanical principles that I have just discussed? let us look at a few theories of why joints become restricted? Why do they lose motion? What exactly causes the joint to lose its freedom of motion? And really the answer we see most often is that it is related to the same type of trauma.

I have, you know, touched on the concept of pattern overload, creating changes in length-tension relationships which then causes adaptations to motor control. But in reality, there are not really a lot of explanations out there and we have not been able to really pin down the precise reasons. Current research does not really explain everything but here are a few of these that I would like to talk about. Paterson and Steinmetz showed that there is a neurological patterning causing decentration of the joint. This is because the brain will pattern quality or quantity of motion over quality of motion and on our brain neuroplasticity quickly creates the engram for the joint function to adapt to the changes that are imposed upon it.

The next research article is by Gattermann and Koch, who really questions this classic chicken or egg question? Is it the joint centration that causes muscle imbalance or is it the muscle imbalance that causes the loss of joint motion? Well, their research agreed with Janda’s explanation that it is really the muscle tension and imbalance that are the causative factors calling causing alteration of joint mechanics. Then Triano created a research paper that proposed a biomechanical or a biomedical model which looks at the mechanical forces acting on the joint that alter its motion and what effect this has on periarticular tissues.

Normal motion occurs when appropriate joint stiffness support centration of the joint when in proportion to the loads applied to it. Triano reported various stresses to cause buckling to articular tissues and these stresses include prolonged postural positions which sort of explains, why we sit here for a long time and then we get up and we feel a little stiff and achy. Well, over time this creates tissue fatigue below the injury threshold, which results in buckling of articular tissues. And then, in addition to this, chronic postural change. You found out that buckling events come from single events like trauma or rapid loading higher than 500 pounds per second. Static postures that have progressively increasing loads, and then he also showed that chronic vibration also reduces the injury threshold and then creates buckling in the soft tissues. But then he went on to prove that we can resolve these buckling events by the application of external forces and actually restore movement through restoring normal movement patterns,  through corrective exercise, and through our manipulation.

As we palpate, we really analyze joint play and joint play as relieved as small discreet ranger motion of passive movement, palpated in the neutral position. We look for the quality of the joints’ resistance to movement, in this neutral, loose pack position. This should have a really small magnitude springy feel to it and when we do not have this springy kind of reaction to our motion palpation, this is one indication of joint dysfunction.

Now, we have all seen these joint range of motion diagrams, and I will go through these rather, rather quickly cause we have seen them before.  but be aware that, you know, there are neutral, active, passive physiological barriers and re- and play zone, elastic barriers joint play zones  Para physiological spaces, and then the absolute and is the anatomical barrier.

Our palpation attempts to analyze is the different aspects of these barriers during motion palpation. Our motion palpation also looks to discriminate differences in tissue, tension, texture and to assess the end range or, and feel of the joint. This is evaluated by applying additional overpressure to the joint at end range where we feel a sense of it increasing restriction to the tissue with firmer resistance until it stops its motion. And we are actually looking to find it as it comes as complete as it can be, but we also have to judge the quality of the end feel. So let us look at the qualities or different qualities of end feel. Some are normal. Some are abnormal. I have listed a few examples as described by Magee. In here you will see that there are normal end feels bone to the bone being like elbow extension. Soft tissue approximation being like elbow flexion or knee flexion and then tissue stretches  similar to when you bend your finger backwards.

But there are also abnormal end feels, and in order to tell the difference between these 2, these are basically very similar to what you would feel in normal end feels. But they occur where you would not see them, within the normal range of motion, where it is not expected, and that is what makes them abnormal. If you have a bone to bone end feel, for instance, in the middle of a range of motion that stops with that end feel, that commonly occurs when we have like osteophytosis.  spasm is, is basically self-explanatory. That is when muscle spasm like you would see in a torticollis  prevents normal range of motion. Then springy block is when you have some type of intra-articular palo-pathology that is very commonly seen in the knee or the TMJ. Then empty is when pain blocks the motion or when the joint have so much hypermobility that they are, there is just excessive range of motion. The last of these, we need to look for is, is capsular patterns and we need to watch for these to tell if our patterns of if these patterns of stiffness are leading to capsular fibrosis. In this feels like a thick tissue stretch but not where you would expected in the range of motion. Capsular patterns, only occur in joints with muscular attachments. So, for instance, in the sacroiliac joint and the distal tibiolo- tibiofibular joint, that is not going to happen there.

It is important to show consistency in evidence for what we find in our motion and palpations. So, so we can provide outcome measures for what we are doing. Currently, w-we have not standardized the process and there are not enough outcome measures to really defend our, our credibility.

Our methods are not as sensitive or reproducible enough to produce reliable outcomes. And so, to better help us show better consistency. One of the tools we would like to introduce you to is algometry. If you are not using it already, this measures pain threshold, and face it, our assessment could be better and this is one tool that can help us. Algometry has excellent reliability and repeatability. Correlates well with other measures and it is a really good tool, to defend and add credibility to our outcomes in ma- manipulative assessment and in our treatment.

Another tool we use to direct our decision-making with what joint to manipulate is what we find in the clinical presentation. As we palpate joints, we look to identify reliable indicators that tell us which joint to manipulate. There is a lot of data out there of indicators that help us identify that, and here are some more reliable studies to help us with what that looks like. We are more familiar with Triano’s review of methods used by chiropractors to determine the site of applying manipulation.  and, and he uses and made famous the parts acronym, which is basically pain asymmetry and bony landmarks,  alterations and range of motion,  and as refers to the postural and kinetic chains that we have talked about. Changes in the tissue whether that be temperature, texture, tone, and then special tests revert back to alterations and motor control with gross movements. The kinematics that we have already discussed. But he was not the first and was not the only one.

Back in 2009, Chase had his acronym called TART, which is very similar tissue, texture and temperature changes, asymmetry of bony landmarks,  range of motion, changes, and tenderness. Even before him,  an osteopath by the name of Dowling had his  STAR acronym which again is very similar. Sensibility changes, tissue texture changes, asymmetry landmarks, and then alterations and ranges of motion.

We recognize motion palpation is larger, largely subjective and that is really a problem for us. It has good inter-rater reliability, but pretty bad inter-rater reliability. This caused us to lose consistency in what we are reporting and how we report it. We need more standardization in our approach along with a mutual understanding of these biomechanical principles in what we are, we are trying to assess. We encourage you to try to become as consistent as you can in your assessment and your reporting.

Another tool we would like you to incorporate is called the Orth tool kit. It is an online app and it has a lot of additional outcome measures for extremities like the lower extremity functional scale, the Foot and Ankle Disability Index, the knee injury outcome score, and lots of different outcome measures for the shoulder, elbow, wrist,  cervical spine, lower back. And it is interactive between you and your patients. It will track your progress and is HIPAA compliant. And I am not sure if you understand what HIPAA compliance is, since that is kind of a thing in the States but that is a regulation that controls how patient health information needs to be protected and who can see it and who cannot. This app that you can see online here is, is fully compliant.

One of our tools. Another one of our tools is in treatment is, is joint mobilization. In my time we kind of ignored mobilization because we wanted to be identified for our manipulation, not mobilization. But as time went on, we realized that mobilization does have it placed in our manual therapy. It is basically a form of non-thrust joint manipulation typically applied within the physiological ranges of motion. their passive, rhythmic, graded movements of controlled depth and rate and they can be applied with fast or slow repetitions at various depths. Movement can be applied singularly or repetitively within or at the physiological range of motion. But the thing that separates it from manipulation is that there is no thrust or impulse. This lack of thrust is really what separates it from grade 5 manipulation that we are familiar with. But it also has the goal of restoring joint mobility.

You will see in this slide that grades 1 and 4 are small amplitude movements at the beginning and end range of joint play, respectively. Then grades 2 and 3 are large amplitude movements at the beginning and mid-range of joint play. At the bottom, grade 5, the one that we all know and love the high velocity, low amplitude thrust at a-anatomical endpoints of the joint. Now, I think I am pretty close to the end of my time here. I think I will stop at this point.  Maybe answer some questions if you have any take a little break and then I will let Dr. Ames take over to  tell you a little bit more about manipulation. Thank you for your time and attention.

Christine: Thanks so much, Tim. That was really just absolutely terrific and very informative. I really love getting that concept of quality of motion over quantity of motion. I think that is a really important concept, particularly with athletes that we need to think about when we are evaluating the kinematic chain, which is a hot topic now. but thank you. I do want to you know, really appreciate all that you have contributed to the sport, to the profession and providing teams for games around the world, for a very long time for FICS., and also your expertise at the University of Western States as associate professor and program director of Sports Medicine, not to mention Colorado Chiro of the year, 2 times. So thank you for all you have done for our profession and for joining us today and helping the students grow and learn more as we kind of dive into sports chiropractic.

Tim: Thank you, Christine, and, and thank all of you out there. It is been a pleasure to have the opportunity to speak with you and I, I hope you learned a lot of things from, from our discussion today.

Rick: I do not have… I needs that [smash noise]… hmm, some reason I am not getting my notes. I am going to stop sharing and, and  change this.

Short break in video:

Christine: welcome back everybody and I would like to introduce Dr Rick Ames,  who will be presenting the last portion of our module today,  functional peripheral joint technique. This once again is getting at you ready for your hands-on module. So just as a reminder, when we see you at your hands-on module, please come appropriately clothes so that we can do all the adjusting techniques on yourself with the upper and lower extremities. If you are doing just an upper program, just a short-sleeve shirt. If you are doing a lower, shorts as well. We will really be looking forward to seeing you all at your hands-on modules and get be working now. At those modules there will be no powerpoints,  it will all be hands-on the entire time. So super exciting content that will be going through with you there.

Dr Ames is a senior lecturer in the discipline of Chiropractic at RMIT University of Melbourne, Australia. There, he teaches diagnosis techniques and management as well. He has graduated from LACC. He has a fellowship in Orthopedics and Neurology. He has worked with National Olympic Weightlifting and Table Tennis teams based out of Melbourne, as well as focusing on treatment and rehabilitation of amateur and professional athletes in his private practice. He has organized health teams of chiropractors there in Melbourne for major sporting events.

Dr. Ames is also coordinated the sports chiropractic and postgraduate programs for RMIT University and Federation Internationale de Chiropratique, FICS. He is actively involved in the presentation of postgraduate seminars and chiropractic as well as publishing numerous articles with sports chiropractic focus. His main clinical practice is emphasizes postgraduate study and research continues to be a sports chiropractic focusing on extremity conditions. He is published and lectured extensively on the management of extremity conditions particularly on how to treat patients in everyday practice, super applicable to today. So welcome Dr. Ames, very excited for you to come all the way from the other side of the world, at a way different times on.

Rick: Thank you, Christine.  hello everybody. These things have changed quite a bit  in the world over the last year and a half, and the last year,  when we are on lockdown here in Melbourne  we had a 5k rule, you could only visit the areas within 5 kilometres of where you live. Well, 4.8 kilometres from where I lived was this  beautiful State Park known as Westerfolds and in  Westerfolds lives what they call a mob of kangaroos. It is really wonderful to be able to walk to there, drive to there and be able to see this  during lockdown. So that is how we will start today. I want to acknowledge first of all, Dr. Brian Nook  who presented a lot of this material at the Madrid seminar back in December 2020. I also want to acknowledge the excellent presentation that Dr. Ray did today.

I thought it was fantastic. A couple of the our final year students who partisan videos that I am going to show in a minute, and  you guys, you are our inspiration. This is what took me from being what I thought was an ordinary chiropractor and to a  much better chiropractor was a seminar  for FICS that they had in Hamilton Island in 1993. It just changed my whole  focus in my whole ideas of, of doing adjusting. There is a- very much we learned a dysfunction-based  functional technique, so they call a couple technique. I tend to call it functional technique  because it is not just straight adjusting  it is  based around the coupled concepts that I am going to be talking about.

Most of us have learned a more traditional approach  where we  diagnose a dysfunction in a joint, and then and then we adjust it. But we can also take some of these coupled concepts and  incorporate those and  improve our ability to  function, and to adjust. The coupled contexts, number 1, Obviously, you are- you want to make sure that you are around the joint capsule.  you want to get as close and into the joint capsules possible when you are doing your  palpation. You want to spring the joint. This is something that you have always learned in your motion palpation,  and Dr. Ray was talking about  with either your joint play or end feel. and you look to find the most restricted position but the other things that you want to do is you can put them in a coupled position. You might add  2 or 3 different positions to that joint and look for the most restrictive position.

You can add muscle contractions so you might be taking a contact around the hip in a flexion position, and you contract the quadriceps, or you contract the psoas. and then the other things that you can do, you can add weight-bearing and sport-specific, so you can do these things in a standing position, you can do them in a position, say a patient who, who was lifting weights. I just happen to use an old wooden stick and get them to simulate a position for  say at the end of a clean and jerk. In that particular position, that is when I do my motion palpation. Use that sport-specific position particularly if they are complaining of pain in that particular position and of course, you adjust then in the position of greatest restriction.

These are what we traditionally learned you know, we learn, you know, kind of adjusting for dysfunction. We looked at open and packed positions, that is when we would do our adjusting. But then like I said, we can add in these other coupled  aspects, and particularly what I liked is that you can, you can bring in your assisted techniques, your drop pieces, your instruments if there is a range of different type of adjusting instruments that are  in our profession and developed by our profession that make it to If we use a coupled concepts and coupled the approach to doing this. that we can add, add those to our- the way we do it.  Technique principles you guys gone over this before, you would have done it in your undergraduate and you should be doing it now.

One of things, the principles that I find that when we do a technique is the same as in sports. We do these pre-performance routines. You watch  any of your athletes. They do pre-performance routines. They go through and they start off in that pre-performance, they imagine what they do, we focus the attention, you execute and then evaluate and we do the same thing. When we do an adjustment we ready ourselves, we should be imagining the anatomy underneath our hands, focusing our attention, concentrating on what we are doing and then you know, the Nike just do it, and many times that is what we do with our manipulations with our adjustments.

Tim talked about this. why these benign pain syndromes develop? Now there is a professional jargon  that is out there. I do not shy away from the fact that I utilize the term that chiropractors called subluxation. I tend to use it  from the gathering consensus approach. and I know in  the book by  Bergmann and Peterson.  they talk they would have turned it subluxation joint dysfunction,  whatever you want to call it. it develops because there is changes usually within the kinetic chain, maybe this dyskinesis. What Tim was talking about  changes in motor control, changes in utilizing synergistic muscles rather than the primary contractors, a post-trauma, whether it is micro-macro trauma in overuse type situations or if there is been pathological change. What the patient ends up with is many times just a benign pain syndrome. You cannot link it to one specific aspect.

I have always, in working in sports, think it is important. We have the professional jargon that we use of a subluxation. What we have to remember is that in the medical profession their definition of a subluxation is at this end of the continuum just below a dislocation. Whereas, usually, we had talked about that subluxation at the other end of the continuum which has that fixation hypermobility type of aspect, neuromechanical aspect. Make sure that when you are discussing  with the practitioners in other professions that  you, you understand what your definitions are and make sure that they understand what their definitions are. So that you talk in the same language, obviously, the contraindications to adjusting, you guys have covered all of this in several different places. Both the red flag and cautions and modifications because you are going to come across all of those in our practice and so you can work through those.

I like using these particular definitions Bergmann, Peterson’s  always had this again, you should know this. You would have covered this in your undergraduate using joint manipulation as the overreaching concept.  For us as chiropractors, we use that specific form of joint manipulation, we call it adjustment. chiropractors typically have been looked at, and utilize the short leverage aspect of, of the adjustment, but we also have many long lever adjustments. Obviously, there is a controlled force, lever direction amplitude, and velocity. I think the big word here is controlled and that is where that  pre-performance routine comes into it, it allows us to do the control.

Tim talked about joint m-mobilization using those grades  developed out of the European  manipulation models Maitland, highly influenced by cattle born and  some of the UK and European approaches to manipulation. We do teach a range of mobilizations. and Tim went through those grades 1 to 4 with the manipulation being in grade five. If you wanted to classify it,  we have got joint manipulation procedures, you know, our mobilizations in our adjustments and also adding traction to do that. Then there is soft tissue manipulation procedures,  I will show you a soft tissue manipulation at the end of this  talk.

So really manipulation that some of the early work by Roston and Wheeler Haines, where they looked at cavitation of the joint and producing that cracking noise that when they separated. So they have, using x-rays they filmed and they found the initial separation 1.8, and as they increase the tension, it jumped to 4.7 and there was a cracking noise. Their idea was that  this traction like said, it tends to invaginate the, the, the  synovial fold and capsule. they a forced a part of the, of the intra-articular pressure drops and this gas bubble forms, and they felt that the collapse of the gas bubble was what produces the audible crack or the cavitation.

However, subsequent studies suggest that there is a different mechanism involved. It is about a refractory period of 20 minutes and that is been  confirmed by other studies, one of things is that during mobilization, so your grades 1 to 4, there, there is no cavitation, and there has been research suggesting that a-at least for a flexion of the metacarpal, phalangeal joint mobilization is not as effective as actually the manipulation with the production of the cavitation for increasing flexion. You know studies by Kramer on the zygapophyseal joints in the spine shows that there are differences  in there looking at side posture, upside joints, downside joints,  gender, and of the fact that there was more cavitation on joints that are sore more gapping in the joints that cavitated. This is it back again from Roston and Wheeler Haines, looking at two types of patients, looking at the  typical one but this one showing a wide preliminary separation. So perhaps somebody that is in either, hypermobile, hypermobililty or generalized hypermobility  in the way in which that cavitation or cracker.

Study by Kawchuck  was very important in that they  show that the  mechanism joint cracking or the cavitation is related to the cavity formation rather than the bubble collapse. That cavity formation is known as tribonucleation process where the opposing surfaces resist separation until the critical point where they separate rapidly into vapor cavities and do not collapse instantaneously. This tribal nucleation so it is a different idea than that collapse of the bubble that was originally  suggested. They found that there is a 20-minute refractory period before the next cavitation.

Start looking at about biomechanics of spinal manipulation. As Tim noted, we are utilizing  these  peak force-time profiles and teaching students on how to  manipulate.  We are looking at, you know, the pre-loading force into the into the phase, into the thrusting phase and then resolution phase and looking at this  change in force or the rate of rise, and we also look at the speed.

Another thing that we look at is something, which I think is important is the incisural dip or this notch that sometimes as the pre-loading force, people get a little bit of a notch and when they let the tension go out of the joint when they are taking an adjustment.  sometimes I, I found that, that can be a painful aspect. So, Herzog did a really nice review on this. The peak and preload forces very dramatically, depending on location, cervical thoracic sacroiliac and whether we are using a hands or using a  adjusting instrument. The treatment forces very dramatically between clinician. Plenty of research that is come up out of Canada in regards to that and the fact that both experience has a big aspect of it and gender may play a part in it as well. The detail force mean to might not be the important characteristic of success while the direction of thrust might be. We have got multiple hypotheses, is not in mention, there are quite a number of hypotheses out there. Many things, have not been proven, we have got lots of information out in or out in the literature that we can look at his background for our manipulation.

This really nice review article that I came across by some osteopaths out of  the UK  looking at the different theories of  changes with particularly spinal manipulative therapy. Again these biomechanical changes that are produced, which Tim Ray talked about, he talked about the buckled motion segments may be entrapment. This has been around awhile, synovial folds are in these voids adhesions, and  then Tim Ray also talked about changes in the musculature, and so their ideas that these changes in spinal biomechanics trigger a change of neurophysiological responses.

You look at this study, they have this what I think is a quite nice, a representation  within the article which looks at  different aspects of activation of mechanoreceptor of nociception and efferent fibers.  Look at  changes in the  alpha and gamma motor neuron excitability as well as cortical, spinal excitability, we look at  autonomic activation.  All of these having an effect on analgesia, and so changes in pain. We have an effect by activation of the sympathetic nervous system and a activation in what is known as the hypothalamic-pituitary-adrenal axis,  which  changes  tissue healing.

One of things they say in the article that has been well established that both the sympathetic nervous system and the HPA axis plays a significant role in modulation acute and chronic inflammation and are involved in pain relief and teal tissue healing processes. Then one that has been around for a while. Looking at the gate mechanism that Tim Ray talked about where we, you know, alter peripheral sensory input. We get this, hypogeusia from segmental inhibition and then again, there is activation of descending pain pathways.

These are all theoretical aspects of particularly pain control that we come along and that we utilize within our background to manipulation.  A couple of things that  neurological conditions and to mention about this particularly in regards to, to neural plasticity. That is the brain learns to be dysfunctional, and that many times it  goes through a maladaptation process that might be associated with some of the chronic pain. Some of the research has shown that the speed of thrust is very important and  I personally think and look at some of the sports psychology that the visualization of positive outcomes. Going back to that pre-performance flowchart.

This visualization that we have both as a practitioner and that we impart into our  patients is very important. Of course you know we talked about particularly so you go back to what Tim Ray was talking about, about those mechanoreceptors that when they are stimulated you get some  inhibition  for better word of the nociception, the nociceptors. Really nice article, in I like to look at different articles that help with my understanding of what happens in clinical practice so there, there is  this idea that if you try change pain without changing  motor control, it is going to result in the return of pain.

Out of  Haavik and Murphy’s article looking at where you have got this abnormal sensory motor integration with altered motor control that by incorporating, in this case spinal manipulation  into  that flow that you end up with appropriate sense of motor integration and accurate motor control which improves your function. There is also an article just lately  by Malayil  in Texas looking at dual-task performance. Looking at both tasks and posture and looking at manipulation of the extremities they used a pattern of adjustments, and found that  it definitely improved the this dual-task performance.

We know then that our manipulation has activated in pain reduction. We know about it activating  mechanoreceptors particularly but normalizing both mechanoreceptors and nociceptors. We know about inhibiting the central transmission of pain, and I do not have a problem with the idea that there may be some placebo effect associated with all of this.

So our therapeutic approaches that, that, that we  use. we want to see decrease in the patient’s symptoms. We want to change objective findings even though some of them are  more subjective, and less objective. One of the ways that we can objectify is perhaps using some of the things out of the Orthotool kit that Tim Ray discussed. When we are looking at adjusting if you are just doing straight adjusting maybe we need to change what we do to fit better with our patients, who are the athletes. So, again those two concepts, dysfunction-based functional technique that is mainly what we are going to be going about. Like I said, you can take some of these coupled concepts and incorporate them into your normal traditional approach to adjusting.

We are going your, your traditional, I have already gone through that, so we are going to look again about the coupled motion contact around the joint capsule, spring the joint, find the most restrictive position add in muscle contraction, add in different aspects of weight-bearing that are perhaps sport-specific, sport-specific position, but also you can add in equipment. So have the patient grab onto a tennis racket. Have the patient grab onto a cricket ball. Have the patient grab onto  a volleyball or water polo ball, or  hockey stick or baseball bat or whatever and during  our motion palpation  assess with that equipment or in the position that they are utilizing within their sport. While we do with this, we feel for springiness in multiple positions. We feel for springing this in coupled positions. We do not just  do it in a neutral position. We might add in flexion-extension, we might add in supination, pronation, we might add in internal, external rotation, and then we can add in those muscle contractions like said we can add in weight-bearing or sport-specific positions on this. We find them most restricted direction of movement and then we adjust the joint in that position with an impulse-type thrust. We started looking at a quick screens, you saw the, the picture that Tim Ray had of the kinetic chain looking at  the changes in kinetic chain with excessive pronation. I started making up some motion palpation approaches for myself.  Basically, I just call it pelvic hip drop. I get them to bend the knee, I may add in a transitory or a sliding action, and then I will add in rotations. So let me just play you this video. Let us see if it will play.

Video

I just found that there were many times where I would have patients with a low back pain, a sacroiliac pain that was not responding to our normal treatments. I started looking at the hip. One of those  general aspects of motion palpation that allows me to say, “Well, the, the low back seems to be moving fine, the sacroiliac seem to be move fine but the hips are moving awfully and therefore  that maybe is where I should be looking at  reintroducing some motion.

Video

The video cut out at the distal tibiofibular joint and that is the subtalar joint. I use with this general kinetic chain palpation. It lets me focus on which joint I should be paying attention to, again we cannot motion palpate every joint on every patient, particularly, if we are going to be looking at function in combination with perhaps pain, but definitely want to focus on function.

When we are looking at hip, we can do a, a range of, of quick screens. We can just do flexion. We could just do internal and external rotation. We could add in abduction and adduction. Brian’s picture here is probably a nice combination where he is got flexion, internal and external rotation.  You can see this is where these coupled theories or the coupled approach comes into it. It is right down into the joint system. It is doing a coupled motion of both flexion and in this case, internal rotation and then flexion and external rotation.  You could do things like extension and internal and external rotations as well. Looking at it is this, you can either do them singularly or then come on down and start doing them as a couple. You spring in this particular around the joint. In this case, you actually work your way around the entire femoroacetabular joint, feeling for the point of greatest restriction. If we wanted to, we could bring in things like the sartorius. We could get the patient to contract the psoas.  We could get the patient to correct to contract the quadriceps. We could get them to contract the hamstrings. We get them to move the foot.

Now bring in a range of different aspects and of course, some of these you can do in a standing position so you throw them up into a weight-bearing position. But you put them up into a weight-bearing position and obviously it is going to be much more difficult to do flexion and most of the joint. But again, you could get the patient to bend the knee, which creates a flexion inside the joint. You look at their particular sport-specific position to do these  motions. So same thing in the knee you know that we, we look at  we can do singular ones but in this case we are doing a flexion with internal and external rotation. You could do this medial to lateral, lateral to medial. This is done in a neutral or in the extended position which you could do the same thing in a flexion position. Same with the fibula we can put the fibula when we are testing A to P, P to A, we can do this in a flexion position, we could also do it in an extended position. Many times I do both of these in a weight-bearing position particularly if patient is  coming in complaining of knee pain in a weight-bearing position and staying with the patella, I have got them in a neutral lying position. You could do all of these in a standing position or in a closer to a sport-specific position.

With the ankle and foot, one of the things I do find that is really important, just thinking about the superior and inferior aspect of the fibula the fact that during the one of the most common  sports injuries, the ankle sprain, particularly the inversion ankle sprain, what we tend to find a lot is an inferior fibula with a posterior fibula and but we have also got to make sure that the what is called syndesmosis is not  compromised. So, doing our motion palpation of compression  also allows us to assess instability in that area.

We could do things in the mortise joint. In this case  we looking at A to P, P to A, in dorsiflexion and plantarflexion.  We are looking at the subtalar joint, one common  conditions you see  patients who were doing lots of running particularly social running,  but also in the  higher levels  in track and field  is a problem at the subtalar joint. The subtalar joint is the one that tends to lose flexibility  in ankle sprains as well as the  talus in the mortise joint they tend to have problems with dorsiflexion.

You know, we can look at  all of these different areas. We can add in dorsiflexion, and plantarflexion  where we look at them. Perhaps we do A to P, P to A, add in dorsiflexions, look at the cuneiforms in the metatarsal, phalangeal joints maybe add dorsiflexion and internal rotation dorsiflexion or plantarflexion external rotation. So again, you can couple all these different motions. Same thing with the toes, just they always get asked about a patient just before they leave the room. They go, “You know I stub my toe and it is it fractured?” best way to tell about a fracture compress the joint, add a bit of rotation if they are really painful, yes this is a good possibility that the toe is fractured.

I tend to find it was actually Mark Charette, a  lecturer on extremity manipulation adjustments that I saw that he had a certain pattern of  fixations and  so I have not really been thinking about that.  I started looking for myself and this is what I found. I found that there tend to be common fixations. I keep those in the back of my mind so when I am doing the quick, quick screen, that is one of the things that I am looking for. Things like an anterior talus after somebody has an inversion sprain, something like a posterior calcaneus, and patient comes in with plantar fasciitis,  things like a medial navicular, post  fracture of the, of the foot. They might have had a fracture dislocation  up at the  tibia-fibula area. Many times you will find this medially fixated  navicular and cuneiforms are associated with that. A quick screen in the upper extremity you can use long, axis traction, you look and feel for tension in the different joints.

Video

All these motion palpations, when we look at doing these as an adjustment, we are going to do the motion palpation, and then many times, we will have the position that we can actually do the adjustments at that time. We want to look at the AC in the SC joints. Looking at these coupled ideas while I have given you single motions here particularly seated, horizontal, abduction, and adduction many times. You might  substitute your fingers for  your thenar, or for your pisiform but I tend to do use the thenar and do the adjustment at that time. I do find that these lend themselves to also using an instrument.

Looking at the glenohumeral joint and this is a really good joint in bringing in many of these coupled ideas.  For instance, you can bring in abduction and external rotation, and while they are in that abducted, externally rotated position, test internal rotation or the same abduction and internal rotation.  Not only test internal rotation but test external rotation. You can utilize this with bringing in equipment which is important.  Doing the different ranges of motion palpation to kind of screen through but also, you can go ahead and test and adjust with an impulse with these patients. I do think in your quick screen of the, of the shoulder,  there is enough information out there, enough research out there, suggesting that dyskinesis of the scapula  system has a big effect regarding a range of particularly overuse conditions. You should always do scapulohumeral rhythm  do it in abduction, do it in flexion , take a look at the clavicle as well.

Quick screen of the elbow  again, you can do it in flexion-extension. You can do medial-lateral, lateral-medial. You could combine the two of these together for the most part. The pictures showing medial-lateral, lateral to medial in an extended position, but you could do this in a flexion position as well.  Same thing with the radial head, A to P, P to A, now we do it both in supination and pronation,  so you should do both actions, and of course, you can  set yourself up while you are doing it,  to do it as an impulse thrust at that time. Same thing I have used to see  I was taught that when people had problem with extension of the elbow, it was always called a posterior ulna. But instead, I found it was quite commonly a superior ulna and it did not shift the olecranon was not centered  within the joint and it was seemed to be shifted superior.

I definitely use this a lot with any of my elbow conditions. Wrist and hand are very easy to do. A lot of much as the ankle and foot, a lot of the coupled ideas, so, like the idea of the A to P – P to A in supination and pronation of the different carpals.  Same thing you can do radioulnar deviation, or looking at distal radioulnar joint and you know, looking at doing it both in supination and pronation.  I tend to find a lot of risk problems has the scaphoid just does not shift well from its lateral position into its medial position and you will find that many times in either or supination or pronation.

Same thing we should look at the metacarpal phases, particularly any of the  athletes that  have sports where they involve equipment, whether you are looking at tennis or hockey sticks or   doing weightlifting,  and again we look at the thumb and finger joints. I have a, a range of different fixations that I have identified as a pattern. You should be doing this yourself, you can use these ones. Keep them in the back of your mind when you are doing work.  Just to quickly finish up here, we have finished looking at the joint adjusting, at motion and using the coupled motions to test the joint and whether if necessary to then adjust then.

We can do our soft tissue adjustments,  Brian Nook was the one who  I first heard talk about what they called grip and rip, which is basically this post-injury collagen-binding so adhesion scars and adhesions in the soft tissue. You can use it on the different muscle systems and on the myofascial  slings.  Myers,  If you have not looked over anatomy trains admires a myofascial slings, you can use it in relationship with that. There is a dysfunction in the tissue flexibility and what we do, we look for the barrier that is there within the tissue and then we can use manual muscle testing or functional muscle testing  to give us an idea just as a contraindication to your, obviously, inflammation and pain. You do not want to do a high velocity, low amplitude thrust.  When you have inflammation or you have particularly damage to the tissue, we are going to take the tissue to the barrier and we apply a high velocity, low amplitude thrust in the direction. I use the drop piece table a lot with this, as I find it just aids my ability to do it.

That is what I have for today. Thank you very much for listening and I  hope I was able to give you something to start in your practice on the week on Monday.

[End]

Lower Extremity Assessment - Dr Pete Garbutt

The below transcript was from the June 2021 recording and may differ slightly from the spoken word from the July 2021 session due to the re-recording of this session and the entire session begin presented by Dr Garbutt.  The content of this module has not changed therefore the below is a reference for candidates until the new transcript is ready.

FICS ICSC LOWER EXTREMITY (LE) Assessment

Thomas: We are going to talk about the lower extremity injuries in sport today. My name is Thomas Jeppesen, and I am a Danish Chiropractor, studied at the AECC, graduated in 1997 and been in private practice in the UK ever since. I completed my ICSSD as it was called at the time, in 2003 and I have been doing a lot of work at FICS events and the other sports events since then, it has been a very big passion. It is something that I really enjoy being part of, because it gets you meeting so many interesting people, learning so many new things, meeting lots of people both athletes, and other chiropractors that you have something in common with already, that are willing to volunteer their time, and I find that quite an amazing thing to happen in chiropractic.

Pete: I completed my chiropractic studies in 1996 at Macquarie University in Sydney. I went on to complete my sports masters in 2000, and FICS diploma ICSSD shortly afterwards. I had the pleasure of being able to travel around the world at sporting events, with FICS and other  sporting teams as well.  I hope that you all get the opportunity and joy of getting involved. Pretty exciting with the Olympics coming up in a couple of years’ time, which will be amazing to  work with.  Recognizing that what we are doing today is going to be just a brief overview of  some of the things you might come across commonly in a lower limb. So,  Thomas is going to start us off, starting at the hip working our way down, and then, I will finish off the presentation a bit later. Thanks, Thomas.

Thomas: We are going to start off with the hip injuries. We are going to go over a femoroacetabular impingement, labral tears, slipped capital femoral epiphysis, avulsion fractures, and groin injuries. These are some of the more common ones we see in everyday sports chiropractic practice. We are starting with the femoroacetabular impingement, FAI. So for femoroacetabular impingement, you have three main types; you got the pincer type, which is a kind of impingement that occurs because of extra bone extends out from the normal rim of the acetabulum and that can crush the the labrum underneath that prominent rim of the acetabulum. Coming up as a tip here and causing pressure that can cause damage to the labrum underneath.

You got the CAM impingement, where the femoral head is not round, and cannot rotate smoothly inside the acetabulum. You get like a bump formed on the edge of the femoral head that grinds the cartilage inside the acetabulum and then it causes stress and harm to the labrum and into the joint itself.

You have a combined type, where you get both, which is actually, according to research, the most common type, that is a bit of both especially common for the chronic type of impingement.

Impingement syndromes are more likely to happen, due to repeated contact between the acetabulum and the femur. In the short term, that causes inflammation or synovitis, and associated pain with that. In the longer term, it can also cause labral tears and progressive damage to the articular surface, and it has been thought that osteoarthritis can be a progression of that, in some cases, but the CAM lesion, the one with the little bump forming on the femur, is often actually an anatomical deformity and not necessarily caused by sport. So you may have that anatomical issue that predisposed you to getting the pain and these problems.

The history that people usually come and complain of, is an intermittent and anterior hip pain, or lateral trochanteric pain, you can have both, and it also can refer pain into the low-back, the buttock region, and into the knee. This problem tends to happen to people from the age of 20 to 50 years of age, where the average age is 33 to 35. So, again it is the main sports time for a lot of people. It does increase with activity, especially with flexion and rotation of the hip, and gives you a very ‘stiff and difficult-to-stretch feeling’.

As things degenerate, the labrum and articular cartilage symptoms gradually get worse and it does tend to get worse with continued athletic activity. also prolonged sitting and walking. Sitting for any length of time makes it feel very stiff and irritated when you get back up again. It is quite a typical symptom.

Often, the athlete describes a dull ache into the anterior groin, which can be a sharp pain. It tends to be like a short sharp pain, if it is a sharp pain and they do get episodes of catching, locking or giving way, especially if you get the labral tears into that as well, as it is a typical thing to happen with labral tears. There is a feeling of discomfort and apprehension, they said if people sit for any length of time, especially with the hip flexed quite a lot.

I work a lot with basketball, one of our basketball players is 27 years old. When he was a new player to the team, he complained about his pain while playing in Spain before. He was complaining that his hip was stiff and achy, and when he was playing, doing certain moves, it was painful. He had an MRI scan and this is the result of the MRI scan. He had bilateral CAM-type femoroacetabular impingement with advanced osteoarthritis of the right hip with subarticular bone marrow oedema, cystic changes, joint effusion and synovitis, intra-articular body formation,  and he had a degenerative labral tear on his right hip, which was of course his worst one. Basically, he had almost no internal rotation and pain was a lot more pronounced if you added flexion, and either internal or external rotation. He managed to play the season and he decided to retire because it was causing so much bother, instead of going to have surgery on his hip as he was not ready for that yet.

Examination for FAI,  tends to show decreased internal rotation, especially in the asymptomatic athlete this can be the only thing you see. If the athlete is symptomatic, it tends to be worse with flexion and internal rotation..

The main investigations would be x-rays or CT scan but if you want to see the labrum you need to go for an MRI of the hip or/and arthography as this a lot better way to see the labrum.

The main test to do is the FADIR test. Could read all those for you but I have got a couple of videos that I have taken from a few different websites. So, I am going to show you a video of how to do this first of all.

WATCH VIDEO – PROBLEMS WITH THE SOUND ON VIDEO

Basically, what they are saying is that for the FADIR test, the sensitivity is 99% but specificity is four (4%), so it is not an accurate test but it is sensitive for any problems that you are getting around the hip. Have your patient lying supine,  and the examiner bends the affected leg 90 degrees and then you do adduction and do internal rotation of the thigh to see whether you get any groin pain associated which is usually indicative of an issue with the hip impingement. You should always compare both sides.

WATCH VIDEO – PROBLEMS WITH THE SOUND ON VIDEO

The McCarthy test is another one, we are going to commentate  that one as well.  These have, let us say, questionable values because they are not very specific for these problems, but they show a general issue and when you put the different tests together, you get an idea.

The main thing you do is that, the practitioner will flex both hips to the maximum, you will then get the patient to hold on to the unaffected leg, and will do external rotation and pull the leg into extension, and move up and down. Same thing with internal rotation of hips and extending it, a positive test would be showing clicking, or pain. If there is clicking it can be an indication of a labral tear as well.

Then, Faber test is just our normal knee bent to 90 degrees, and then externally rotated and we will see how that feels.

Now you are looking at the radiographic exam taken from Brett Jarosz’ article. I will give you details for them later. Brett is an Australian chiropractor who has done quite a bit of research into FAI, and written a couple of articles that are very good.

Just to show here you get both the CAM and pincer lesion here, you have a little lipping of the acetabular rim and you have, what we call, pistol grip deformity, or tilt deformity that is the lump happening on the femur here. If we do a lateral radiographic exam, again you can see the two bits here.

These are the details for Brett Jarosz, an Australian chiropractor who did a couple of articles back in 2012 in the Chiropractic journal of, Australia. Some really nice articles with some good information in there.

Treatment for FAI impingements tend to be, first of all, to decrease loading activities. Modify what they do, modify the bit that causes problems. Then hip mobility stretches, getting in do as much mobility work as you can, get them moving in all directions, slow stretches, increase hip strength and work on proprioception, rest in the painful phases particularly. FIFA which we have taken some of this information from,  we will say that nonsteroidal inflammatories is in the acute phase and can be helpful to get people going. If there is no response within 3 months, FIFA says you should consider surgery, Osteoplasty, where they go in, and they shave off the bone making it smooth and round, so it slides better within each other.

Labral tears, the impingement and developmental dysplasia of the hips are two of the main things that are shown to increase the likelihood of labral tears. They tend to develop gradually due to repetitive microtrauma, but around 25% will occur from a single event trauma. So hip dislocations, road traffic accidents, a hard fall onto the hip, anything like this could bring it on as well.

History is important because there are certain bits that are pathognomonic for this. So if you have got pain and mechanical symptoms tend to be a deep and localized pain in the anterior groin and inguinal region, which can refer into a medial thigh, greater trochanter, or buttock. There tends to be episodes of sharp pain on pivoting and twisting and you get catching when getting up from sitting, whereas with the FAI, tends to be more of an ache, a dual irritation, and you get more of a catching pain with this here. Just a little bit of anatomy, so you can see how you got the acetabular labrum here, and that is where it can get pinched, irritated, and damaged here.

On examination, some of it is the same as for the impingement syndrome. You tend to have pain and combined flexion, adduction, and internal rotation. It is the same tests, the Faber, the FADIR and the McCarthy tests, and you tend to get, if it is a bad tear particularly, clicking with it. But as we said before, none of the tests are very specific, but if you put it together with the history findings, then usually, we can diagnose these things.

Imaging tends to be x-rays or MRI to start off with. They say a pelvic MRI has a relatively low specificity and sensitivity for finding labral injuries. If we do a dedicated hip MRI, you see it a lot better and especially if they put in some contrast into the joint, it is quite easy to see it well. When we do imaging of these types of things, we need to remember that labral tears can be asymptomatic. So it is something to think about, that you can have a tear and some damage without it actually being the problem. So we need to put everything together.

Here, we are looking at a labral tear. You can see with the contrast media in the joint fluid, you can see the damage to the labrum here.

The treatment for labral tears, they can respond to conservative treatment if there is little or no femoroacetabular impingement involved. This is one of the main things. If you have a lot of femoroacetabular impingement involved, surgery is often one of the main things if they want to keep playing sport at quite a high level according to FIFA. They do say that it is worth trying altered loading, hip strengthening, proprioceptive exercises first, and you will find that a lot of people actually will respond well to that.

Slipped Capital Femoral Epiphysis.  I will only talk very briefly on this because it is something we do need to consider in the younger athletes. Tends to happen more in either overweight or tall and thin athletes. It tends to be a gradual onset of hip and knee pain with it as well. In early stages, you might normally feel pain when you are walking and passive hip movements but, again if patients come in with these symptoms, with a lot of pain, and unable to weight bear, it is very important to get them x-rayed, AP and frog leg as soon as possible because they do often need a surgical fixation in order for it to get normal growth and normal function afterwards.

Avulsion fractures of the Pelvis.  This is something that is relatively common in the adolescent athletes, because there is a relative weakness between the apophysis compared to the tendon. Especially in the growth zones of course, and they can occur when an explosive muscular contraction such as sprinting, kicking, jumping, will pull the tendon where it attaches into your apophysis and cause a separation of the apophysis from the bone. It is more common in males than females. We had one of our associate’s sons. Well, he was 13, 14 at the time, and he had been playing sports in school and had groin pain ever since. She asked if I could have a look at him, and he told me that it happened when he was setting off to run when he was playing football. Then he had a lot of pain whenever he was moving. So again, we found, when we put the fingers on the area where he had pain it was very painful. So we had an x-ray done, and it was an avulsion fracture of the AIIS. It is quite common in young athletes.

If you look at this, the apophysis in most of them appears at 13 to 15. lesser trochanter is a bit earlier than that, and it closes for the AIIS (anterior inferior iliac spine) at 16 to 18. The rest 21, 25. It can happen anytime in this time zone here tends to be more towards the earlier because they do close more and more as you grow older.

Most frequent sites affected are the anterior superior iliac spine, the anterior inferior iliac spine, and the ischial tuberosities. According to the British Medical Bulletin, they actually account for up to 16% of sports injuries in children. You can see if you treat adolescent athletes, adolescent sport teams, it is not an unusual thing to be able to pick up. Just to show briefly where the different sites are, abdominal muscle attachment on to the iliac crest, greater trochanter – the abductor, lesser trochanter – the iliopsoas muscle, ASIS – the sartorius muscle, AIIS -rectus femoris, and ischial tuberosity – hamstring muscles. So these are the typical areas where you got the growth plates and where you get the avulsion fractures.

Often, the patient will present with a history of sudden pain during a forceful muscle contraction as we said from kicking, sprinting, gymnastics, anything that where you need that explosive force in.  They will often associate this with a popping sound or sensation when it happens, and the acuity of the history does help with diagnosis as I explained for the young patient I saw. He explained these things and you could put your finger pretty much on it.

On examination, the patient has local tenderness and pain at the site, and often made worse by passive stretching,  activity, or an active contraction of the associated muscle groups and is relieved by rest. According to the medical bulletin from December 2016. The best thing to do is x-rays. You can very easily visualize the fractures on an x-ray. Especially when they are a couple of days old.

Treatment, most of the time we do not need surgical intervention. Rest and gradual recovery and rehabilitation programs are needed. So take it steady. Do not do the things that hurt you, but they do say that if the displacement is more than 30 millimeters, you could consider surgical fixation because it can alter the growth plate, it can alter future growth, and other problems with it as well.

Here we are having a look at the AIIS. You can see the traction bit in here, and ischial tuberosity as well, where you can see that lifting up off the growth plate in there.

Prevention is one of the things that, according to the British Medical Bulletin, is very important to look at. It does take a lot of involvement of sports coaches and even the young people often should get involved, and the parents as well, because the important thing is to reduce the training load during the rapid growth periods. And if you do regular measurements of the height of the athlete every 3 months, you can see when they start growing fast. And then you should alter the training programs to cut it down, and one thing to do is to vary what they do, so they are not doing too much of the same thing but also to say that the quality of the workout is more important than the volume. So make sure that they do the right things and make sure that they don’t do anything for too long.

Groin injuries. Something that is very common. If we are looking at the world conference of groin pain in athletes in 2014, they say it is extremely important to have a systematic approach to this.  Location of pain is really important. If we are looking at a more anterior groin pain, mid-portion of the thigh area, it is often the iliopsoas region. medial groin, often adductors, groin and buttock pain could indicate hip involvement of some kind. the posterior groin, tends to be more the posterior hip or low back. Stress fractures are rare, but it is possible that a femoral neck of pubic bone stress fracture can happen and can give rise to groin pain.

You need to look at the injury mechanism, it tends to be a high force  but subtle  injury and sometimes you get a sound like a pop in it, and the patient has to stop. So they couldn’t keep on running, couldn’t keep on doing what they were doing. If there is no acute pain or injury, look at the training history. If they have changed what they do, how they do it, the amount they do it, or the equipment they use; either shoes or, the weight training equipment  anything that is if they change what they do.

And look at systemic change, ask  for weight loss, fever, fatigue, recent infections because you can get synovitis or malignancies that in particular in younger people or people who have been traveling, that then can cause similar problems, so you should be aware of this.

Examination. You should look at the general hip movement. Find out the back mobility, find out what is affected. You are going to do palpation of the muscles in the region and you do testing for strengths and stability. You check their flexibility. You do a basic neurological examination. and then a palpation of the groin itself. It is also important in these injuries to check for lower extremity problems, the knees, ankles and and also low back because it can also refer to pain in the groin.

For investigation x-ray, MRI, and ultrasound are good but, again, you are going to try to find out what the problem is first, whether it is worth it. But they do say if there is an acute injury and you are suspecting any avulsions, growth plate injuries as well, it is a good idea to consider the MRI because you will see both soft tissue and can see the avulsions on that nicely as well.

Adductor-related groin injuries tend to be often of long-standing medial groin pain when patients come and see us. Often goes a bit down the medial thigh. Palpation gives sharp pain so does resisted adduction, so patients being supine with legs extended and then you do resisted adduction. If you suspect a tear or they are not responding to treatment, you could do an x-ray, MRI, ultrasound. I haven’t really found any people with this whereI wanted to do this, but you should be able to see the injuries on those types of imaging. Treatment is building up gradual strength in the hip and in the legs, to the dynamic stabilization of the pelvis. And we often find 6 to 12 weeks return to play if they follow the schedule.

Iliopsoas-related problems. Usually, patients would describe flexion and external rotation of the hip to be most painful. They find issues for sprinting and kicking. Often the pain is localized to the anterior groin. You will find pain on palpation of the lower abdomen, inferior inguinal ligament anterior hip pain, inferior inguinal ligament again in that area because their iliopsoas tendons go straight underneath it. Often, you will find pain on Thomas test, and decreased strength on ninety degrees hip flex. You put the patient in 90 degrees hip flexion and resist their flexion further. MRI or ultrasound scans are the main ones to show iliopsoas-related problems.

According to FIFA, on this one, there is no evidence-based treatment for this, but keeping up strength and stability in the pelvis and checking pelvic function, I, personally find that we need to look at low-back up to thoracolumbar junction at least because that is where the muscle attaches. So we need to look at everything that is around that iliopsoas muscle to make sure we get this good functioning as possible.

Inguinal-related problems. Patients often describe groin pain up more towards the abdomen or around the pubic tubercle. Many times you do not find pain on the adductor test, and often they will find pain and increased abdominal pressure. So coughing, sneezing, laughing.  You often will find pain on palpation of the abdomen and the inguinal canal especially next to the bony attachment into the symphysis and the pubic bone. Always compare size because again patients can be tender on both sides with these types of things, especially this region because we have got the abdominal muscles inserted in there.

Investigation possible MRI or ultrasound. We had a basketball player a few years ago that came with us from having had the, he had had inguinal surgery and had inguinal hernia surgery on his left hip, and he found that his right hip was playing up now. And we checked him out and he was tender around the area. We treated him just by loosening up the area, getting a better function in the pelvis, hips low-back, and the pain went away and they kept on coming back. So we sent him for an MRI scan. Unfortunately the MRI scan didn’t show anything so we kept him going but then we thought something was wrong so we had another MRI scan and they found it on the second MRI scan. So MRI scans for some reason are not always very accurate on this, I don’t know why, but I thought that was a bit strange. Treatment again is building up pelvic stability, But if symptoms are bad then, or if there is a hernia involved, which they don’t like calling it anymore, then sometimes surgery to create better stability of the abdominal walls to prevent further problems is a good idea.

Pubic-related pain tends to be a central groin pain occasionally into the adductor region where they attach. It can be described sometimes as a diffused pain, often when you press on the symphysis pubis, you will find a localized tenderness in there. Rehabilitation, pelvic strength and stability is a good idea. It is quite common in kicking sports. That there can be radiological changes with no pain. You can get a little exostosis of the bone, you can see the bit of change of shape of the pubic symphysis, so you can have that without, without problems sometimes, so be aware of that.

Returning to play criteria for FIFA, they do say that groin pain is very common in many sports. The goal is to return the athlete to sport without putting them at risk of injury. So it is important to make sure that soft tissues and bones should have healed and should have normal gait ,full pain-free motion, full strength, muscle links within normal ranges, joint stability should be good and there should be no effusion of pain.

So this is what we need to go for, for most injuries, I think, not just groin-related pain. I found it difficult when you are working with sports teams that do not have the same amount of money as some of the big football clubs, that people want to get back early. So we have to be a bit careful to make sure that it is safe for them. So the goal is definitely to return the athletes without putting them at risk for injury. That is one thing we need to look for any injury that that athletes come to us with.

The phase they put for FIFA is phase one, you start when the athlete can weight bear. You do various sports, basic sports specific warm-up. So basically just keeping movement, keeping things going, getting things ready to use. Phase two, you will then increase the intensity of the exercises and increase the duration of the aerobic exercise. You will perform individual sports-specific movements, so there is no impact on any things, it is just the movements you are doing that fits within your sport. Phase three, we start off with individual and partner work. You increase to a 60-minute conditioning and increase in intensity and you do some interval work again, no contact yet. Phase four you start team drills. In football, it will be passing the ball, running, changing direction, and be these types of skills, but, no physical contact with other players for anything. Phase five is full practice in contact again, and they do recommend, which makes sense, to do a full sport cycle or event, simulated before you return to full competition. So warm-up friendly games, these types of things before you go in and you actually go full out.

Prevention: tends to show promising results on building strength of the hips especially the adductors and limit/managed to training volume especially during periods of rapid growth for the younger athletes.

We are going to go over some knee injuries now.

We are going to go over anterior cruciate ligament problems, medial collateral ligament, posterior cruciate ligament, the lateral collateral ligament, patellofemoral maltracking, patellar tendinopathy, patellar dislocation and Osgood-Schlatter.

For the ACL, one of the things with that is that often there is no significant trauma tends to be non-non contact injury. Often it is twisting when the person lands, pivoting or decelerating that causes a problem, they would often describe a snapping or popping sensation. One of the main things for this is to show it tends to be an extensive, rapid swelling due to hemarthrosis because of the intra-articular origins and attachment of the ligament that does give a very large rapid swelling. The athletes often would describe it as a strong sense of something going out of place. You can have either of these, or you can have none of them. It is a bit of a mix but these tend to be the main things. Pain is variable, but the majority are either unable to or reluctant to weight bear straight after the injury.

We are going to show two injury mechanisms here. One of them is from football, in which we see one of the top English players at the time the World Cup collapsed. You see, he sits down,  and he only passed the ball, there was nothing else that happened. We want to get that in a little bit of its closeup and then he gets the ball out, he lands, plants, foot twists, and gets pain. In basketball, see the point guard coming in here jumping up. You can see in a second, he jumps up, when he lands, looks at his left knee as he goes down, and gets ready to push up again, and how that affects the knee.

Slow-motion, there we go. So he jumps up, lands, twists, and then gets it there.  So these are a couple of things where there is no impact involved.

Most useful tests for examination are Lachmans, anterior drawer and pivot shift. Always make sure you compare sides. Some people are looser than others, so it is nice to compare both sides. We are going to go over and show you these tests. and I will describe things as we go along because I do not know why there is no sound on these videos for you.

So Lachmans first of all,  this is an Australian doctor, so I can’t do the accent unfortunately. Just make sure the patient is relaxed, first of all, and then you hold up the tibula and then you are basically pulling the tibia forwards-backwards, and you are going to feel nice, strong end feel, no softness, mushiness at the end of that. So he says, sometimes, if people are a larger size, I would use two hands as well and stabilize it on your leg. So you are going to have a look now so he lift up and put his knee underneath the side to get a bit more control.  You still get the tibia and everything nice and relaxed. Same movement, again making sure that there is a strong end feel to that.

For the anterior drawer test. You got the knee patient lying on supine, knee bent to a 90 degrees, and you tell the patient you got to sit on their foot to stabilize it,  grab both hands underneath the tibial plateau, and you are doing an anterior pull. You want to be feeling a solid endpoint, you can do the posterior draw to see for the PCL at the same time in that position. As we said before, compare sides.

Pivot shift. For that one, it can be a bit of an issue sometimes when, if you get a lot of swelling, a lot of pain because they do not want you to do that.  One of the things you are trying to reproduce is the kind of sensation that they got when it got damaged. So it could be a bit of that apprehension in it. So knee in extension, internal rotation, and then you are pushing the knee into flexion and hip into internal rotation. You often will feel a clunk or a pop or things with that, like, feel it a bit like what the person felt when they injured it.  Now we are going to have a quick look at what it actually looks like, when somebody who has really  got a torn ACL.

Just a quick check on the uninjured knee first.  Now we are going to have a look at the injured knee, the same test as before, so you can see how that tibia just pops forward. There is just no solid end play, just this soft and moving. If you look at the knee, you can see how it pops when he is doing the pivot one. So have a look at this one goes from the subluxated position into its normal position when we are doing this. So that is what the positive tests will look like. Investigations for that tend to be x-rays, and AP lateral skyline and Rosenbourg. Views on AP are important to check for a Segond fracture, which is an avulsion of the lateral tibial plateau.

When you get an ACL injury, it is uncommon to have an isolated injury of the ACLthe   majority will also have other problems like meniscal injuries or bone bruising. So we need to check the different things. On the lateral view, check for an impact sulcus on the lateral femoral condyle, a type of compression fracture there. So we can not have any problems in MRI scans of course. They are very good at seeing any damage to the ligaments and tendons.  Treatment, one thing to realize is that the ACL does not heal. Because it is an intra articular location, it does not heal and it does predispose to instability in the knee. So the key goal for treatment is to restore a sense of stability to the patient. Some people can manage very well without surgery especially if you are not doing a quick change of direction sports or high-impact sports.  Often, you know, you can follow up and do a lot of stability work that can help it so you do not need surgery for that.  The main indications for non-surgical management tends to be that the knee itself is stable. So it is not an unstable knee. So you have enough strength in there to protect yourself, that the patient has a desire to avoid the surgery, at least to start off with. That they are prepared to modify their activities to suit symptoms. So avoiding painful things, especially in the beginning. It suits the less physically active patients better, or patients who are likely to have a poor compliance with a post-surgical rehab because you need to do a lot of rehab to get mobility back and then to build up strength as well after the, after surgery.

Rehab, it is necessary to have a comprehensive program whether you have surgery or not. because you need to have that strength and stability in the knee to protect yourself.

You are very likely, if you return to play before you have built up adequate strength and your muscular control, to predispose the athletes for further instability. As we said before, you make sure that the chances of them having a recurring injury or being injured again. We do not want this. Generally, there tends to be four phases of rehab for ACL tears. Number one, you do a protected and controlled mobilization. So you can do work on the muscles you can do like an electrical stimulation of the quadriceps muscle and you want to try to reduce pain and swelling and restore as much movement as you can into the joint. Phase two is to control training, lower limb and core strength to make sure you stabilize everything around it. So that is not just for your quads, it is your hips, it is your core, it is making sure everything is getting strong and stable.  Number three, you go into the more intensive training, start to include sports specific training, your muscular retraining.  Bit of impact works everything in sync and phase four, you are doing a return to play where you are again having, preferably some personal trial events before you go all out.

Meniscal injuries, this is one of the very common injuries. and some research shows up to 15% of all sports injuries are meniscal damage. FIFA says that 8% of all football injuries are meniscal. 70% of these tend to be the medial meniscus. It is important to have healthy articular cartilage for optimal function in the knee joint. and damage of course can affect the athletes ability to compete and also predispose for other joint degeneration. So possibly osteoarthritis/degenerative changes in the knee. Sometimes, meniscal tears can spontaneously heal, especially the small longitudinal stable and asymptomatic ones. We have three zones in the knee cartilage; red-red, red-white, and white-white. That indicates the amount of vascularity you have in there. And again, if the tears are in the peripheral 10 to 25%, where you have the vascularization, the red-red or the red-white zones, the healing tends to be a lot better. If the patient comes in with a locked knee, so they can not extend it; particularly it tends to lock and cannot straighten it again, it is worth to look a bit deeper because it is often yan unstable tear that goes across several zones and could possibly do with a surgical repair.

Problems tend to be high in females, older athletes and athletes with a history of previous knee injuries.  We often see condral injuries and meniscal tears in association with knee ligament injuries or patellar dislocation. So it is important we check for these at the same time. 75% of athletes who have not had surgery will return to high-impact activity. It is not something that is career-stopping for most people. Tends to be happening from a shearing injury or high compressive loads with twisting often in that as well. So tackling, landing after jumping, kicking to the knee.  Quite a few things can tend to cause problems; like rapid repetitive stepping or squatting on an uneven surface. These types of things. In younger athletes, it is often caused by a traumatic injury. Pain that seems to be intermittent usually occurs with weight-bearing, squatting, twisting or cutting movements. and if it is a medial meniscus, which is most  common, it is usually localized to the medial joint space and if it is the lateral it tends to the lateral joint space.  You can have a displaced bucket handle tear that can cause proper locking of the knee where you can not move it. If the knee is giving way without warning, it can be a sign of an unstable meniscal tear. If we get people to have an MRI scan, we can often pick that up on those but not always properly. Examination first of all, is looking for effusion swelling, checking the movement, palpating the joint space for tenderness, which is one of the most accurate tests actually  64 to 6-74% accurate. Then you have some tests that are specific but not that sensitive; Thessalys, McMurrays and Grind, so we are going to go over at least one or two of these. Thessalys the first one which is the one that they said was the most accurate test in the past for detecting meniscal tears, but then that has been shown in newer research that it does not really better than any of the other ones.  But it is good to put them together with the different tests with the findings as well.

The research shows that all the tests are equally sensitive and not very specific.  The first thing you do is you check the unaffected leg, because you want to make sure you have a baseline to check the other one. Then the point is that you stabilize a patient, get them to bend the knee to about 20 degrees and twist three times each side.  Positive test will be pain or clicking and popping in the knee.  McMurray’s test, which we probably know from before is supine in patients, flex the knee, valgus stress in on the knee and external rotation of the foot moving in and out to feel for any clicking and popping. You will move the leg from flexion into extension and you feel for popping or pain.

The grind test is having the patient lying prone, bend the knee to 90 degrees, stabilize the femur with a bit of a pressure from top to bottom through the tibia and do internal-external rotation, again to check for popping or pain. So neither of these tests are shown to be really specific, but added together, they give up about, you know, a pretty decent specificity adding everything together with history taking. Investigation of choice tends to be an MRI scan, especially after trauma. That could also then identify any associated ligament injuries or bone bruising which often happens if with an acute tear particularly. Looking here, we can see again, nice meniscus here lateral meniscus and you coming in here. I can not see that because all the people involved, but he can see, you can see the lift up here where there is a damage into the, you can see it is nice and smooth the meniscus here you have got that little bit of a white line a bit of damage through the meniscus. Treatment;  rehabilitation tends to start off with avoiding or decreasing activities causing pain, building up strength, endurance and proprioception for the whole lower limb including the core. For younger athletes, or if there is any instability often meniscal repairs the way forward. The old arthroscopic way where they actually trim off the cartilage, cut it off has shown to increase stresses into the knee joint and promote early degenerative changes. So often a meniscal repair is the way forward. The success rate, according to a consultant I spoke to, is around 60%. so it is not massive, really good for the bigger tears, but it seems to work quite well for the smaller tears and the younger you are the better it works. Research is still looking at protein-rich plasma injections whether that can increase healing.

The medial collateral ligament is the most commonly injured ligament in the knee. It goes all across the medial aspect of the knee. Injury seems to be primarily due to an acute valgus stress on a partially flexed knee. So we tend to give you an acute onset of localized medial joint pain, occasionally with swelling around it as well.  Examination; You grade the tear depending on the degree of laxity present with the valgus stress.

So you access it both in 30 degree flexion and in full extension. Grade one is a mild localized tenderness. grade two is a moderate grade where you see a bit of laxity on valgus stress within 30 degree flexion. but a distinct endpoint so it doesn’t have the soft feel and there is no laxity in full extension.  Grade three sprain is more serious and the amount of tenderness can vary a bit, but you have laxity in 30 degree flexion and in full extension as well. Treatment tends to be conservative.  For grade one it settles quickly. Just the movement and isometric exercises. Sometimes you can put some tape on it for stability and comfort,  two weeks return to play. Grade two to three can take 8 to 12 weeks to return to play depending on severity. Occasionally according to FIFA, for this one, it is a good idea to brace them to prevent the final 30 degrees extension early on, for the first week to two weeks, especially if there is quite a bit of instability there just to get rid of the rotation and the pain so they can return to training.

The PCL (posterior cruciate ligament) is much stiffer and wider than the ACL. The main function is to prevent posterior translation of tibia, but it also re-restraints tibial external rotation and both varus and valgus stresses.  The history that people come and complain of is often a high-energy trauma. So fall on a flexed knee, hit the dashboard in a road traffic accident so it needs a lot more power, but it can also happen on a hyperextension or hyperflexion injury. Usually there is no popping or snapping or significant swelling with this. It is not the ligament that is in the knee joint the way that the ACL is and affects that.  Tests are the posterior drawer and the posterior sag. So I think we got a posterior cruciate ligament examination here. We are going to go over that and explain. First we are going to have a look at the same Mark Fulcher here from the FIFA medical network. So if you want to look at these videos, look on YouTube channel FIFA medical network, going on to videos, and you can see this. So again, we do the same as before the anterior drawer, knee flexed 90 degrees, sit on the foot to stabilize it and push back. And again, you are feeling for a solid end feel. So there should not be any give, it should be solid, you should stop and lock.  So the posterior side puts both knees next to each other. And you are looking across where you got the tibial tuberosity is what we can see them sticking up. And you are going to make sure that they are about the same and that it doesn’t sag down under on one leg, which is a typical sign of a PCL tear. Then we are going to do this on a person with actual problems. So check for the laxity sideways. Then we lift it up and you can see that sag where you can see that hyperextension in there. we see it better with both legs up together. But you can really see how -that tibia sags backwards because there is no stability in it.  Treatment; if you only have the PCL involvement, it usually does very well and doesn’t need surgery because it gets stable quite well.

The functional outcome does depend on the amount of laxity present. Rehab seems to be one of the main things; strengthening the quads to restrict the posterior translation, and usually return to play is six to eight weeks. So it is one of those that responds well, if there is no other damage, to conservative treatment.

Lateral collateral ligament is rarely injured in isolation. it does tend to happen with multi-ligamentous injuries in knees, it is something we have to be extra careful with.  there tends to be varus and hyperextension injury. But it can also happen to an AP blow to the tibia while the knee is an extension, so full extension injury. Examination has to be comprehensive. Because there are several structures involved in it, you often get the posterior corner and everything else involved in it. So you do the hyperextension test, the laxity in flexion, dials test, posterior drawer test. So we’ll skip through these as well.  So we take the knee into extension, and you do varus stress with 30 degree flexion and extension to check. So again, same thing as before if there is laxity and extension, you see more serious injury.  So if we suspect a bit of a more serious injury and we expect the posterolateral corner to be involved, you do the dial test, which is lying on the back, knees flexed to 45 degrees to external rotation to start off with and check if it is the same or different. Take it off to 90 degree flexion and do the same thing.  Often, if it is in 45 degrees, it tends to be the posterolateral corner injury and if you get pain with 90 degree flexion there is often a PCL injury involved as well.

Treatment; if there is no laxity, laxity in the, in the ligament, conservative treatment; strength, proprioception and function is enough. If there is laxity, the FIFA says that you should consider an acute repair because there can be a lot of other involved structures. So it is important to make sure that everything gets looked at.

Patellofemoral knee pain; it is very common to get anterior knee pain like patellofemoral. There are two main groups: normal knee group and structural changes. So younger adults tend to be structurally normal but have functional issues: weakness, increased training loads, this type of thing. As you get older it tends to be more due to the pathology; cartilage pathology or wear and tear in the knee.

History is often a diffused poorly localized anterior knee pain that felt deep inside the knee. Usually of an insidious onset. so something that slowly, gradually happens but it can be caused by falling into the knee. Tends to be made worse from walking or running; particularly downhill or downstairs. But it can get a clicking or catching sensation but it doesn’t usually lock the knee. Quick examination of the patellofemoral joint.  So one of things you do is you get people standing on one leg you- you do squat, and you make sure you are checking that they are stable from the pelvis down, you make sure that the knee doesn’t move in or out.  Seeing the wobble is one of the things that you see a lot when there is instability in there, which is one of the parts of that (Patellofemoral maltracking).  Other things we look for, we put the knee in very slight flexion. And we basically, push the patella medially, from lateral to medial and you are moving the knee up and down and you do that in different directions you push down on the kneecap, anterior to posterior to check if there is any pain or any grating.

The main thing to do is to make sure that it reproduces a patient’s problems, and that there is a difference from side to side to show.  Let us say in chronic cases where the pain does not go away again, sometimes in x-ray and MRI check if there are any chondral/osteochondral injuries.

Treatment, there is not really any proven treatment. The aim is to restore normal soft tissue balance of the patella and mobilize lateral structures, to strengthen the vastus medialis and the proximal chain, especially around the hip extensors, hip external rotation and the abdominal wall. I found dynamic tape or sometimes kinesio tape can help especially in earlier stages to to offload some of the pressure, some of the strain for the athletes.

Patellar tendinopathies: infrapatellar is the most common one. and then suprapatellar. Those are two main issues when it comes to patellar tendinopathies. The patient tends to describe a generally well localized anterior knee pain, usually increased by jumping, bounding and hopping. Usually have a gradual insidious onset, you can sometimes experience an acute tearing sensation, but for most people it is something that happens gradually. It tends to get better with warm-ups but get increased stiffness or pain either after activity or next day. Again, we were told that, you got to be a bit aware of, if there is an acute sudden onset of popping and snapping especially those major bruising around the kneecap because you can get a tendon rupture of the infrapatellar tendon or supra patellar tendon or  a partial rupture, so something to keep an eye of on as well.

Ultrasound scan is the best modality for that, usually. Treatment, eccentric exercises are advised, just make sure that patients know that they can be painful to do. generally tend to be more suitable for chronic cases and it is something you need to do lots of repetitions of, it is something that takes quite a bit of time.

Knees strapping or taping has shown variable effect but again I found particularly dynamic tape seems to be a good way to offload this and that 60 to 80% of athletes return to the previous level of support.  Manual therapies tend to be mainly cross friction and soft tissue mobilizations. Shockwave treatment has shown to be of some help with it. Getting people on hydrotherapy on the 0G treadmills at the early stages seems to work nicely for patellar tendinopathies as well.

Prevention; careful management of training, and then if symptoms come back, reduce the training load or maximal loading as well. Isometric strength afterwards to build up stability around the knee.

Patellar dislocations, it is usually quite easy to see when it happens.  Usually follows a twisting injury with the foot planted. So pushing the kneecap, usually, laterally and you can get it from  a blow to the knee as well.  Many times the patella relocates itself as athletes straighten the knee, so it is important to ask them about these questions: what exactly happened when the injury happened.

So the first thing you should try to do is always to relocate the kneecap into the trochlear groove. Treatment, sometimes a short immobilization is recommended. But keeping it mobile, keeping it moving and then building up isometric strength to the legs and hips, in order to help prevent this happening again.

The difference between professional football players when this happens,  so nice little patella dislocation here. And again, what we are doing  for relocating it, is a slow extension of the knee. When you get to that point, the kneecap will usually always pop back in place again. So, here we go, here we go, back in place.  If you are looking at ladies football, you know, sometimes people have to do things themselves to try to get it back in place.  Again, not the same medical help here but maybe women are tougher than men, I don’t know. So let’s just see it a bit closer. Again, off to the side, medial push, kneecap goes off. And again, trying to get it back in place herself still, the pain afterwards.

Osgood Schlatter is quite a common thing for the younger adolescent athletes, more common in boys than girls, and it is estimated that 20% of children will have this at one stage. It is often associated with sports with a lot of running and jumping. It tends to happen from 11 to 15 years of age. And usually the patient will complain of a very localized pain around the tibial tuberosity, aggravated by exercise and pain. One thing to be aware of,  is that pain that does not get better with rest, not using it or that is present at rest, is not consistent with this diagnosis and you need to have things looked at a lot more seriously in that case . Often, there is a point-tenderness on the tibial tuberosity, local swelling, and then there shouldn’t really be any other issues on a knee exam. X-ray, very good for this, you can see that well in the picture and the vast majority of case findings are normal, even if there are some extra large tuberosities, or a bit of a fragmentation. The Apophysis can develop from multiple centers and it can look like a fragmentation, so you should put it together with the tenderness and how the patient described the problem.

Treatment, it is usually self-limiting, goes away on its own, and will settle at the time when the tubercle is, sorry the apophysis has fused onto the tubercle. The symptoms may persist for a couple of years, and again, it is education, it is listening to the problem. So any activity modification that is needed when there is pain you do but there is no need for complete rest. Reducing the number of training sessions or overall sports involvement is usually enough to get rid of the pain.

Change of speaker

Pete: As we hit further south, we are going to jump straight down to the ankle initially and look at sprains now, this is something that most of you will have seen in clinic whether you are heavily involved in sports practice or just regular practice. In fact, many of you will have had these yourselves, within a sprain around the ankle, commonly we will see an inversion sprain, eversion sprain, or what is commonly called a high ankle sprain, or a syndesmosis tear. The inversion sprain being the most common, in fact, it is the most common sporting injury we see. So, ankle sprains whilst most people will get up and jog them off and consider they are simply a moment during a game or an event, we do see ongoing problems that occur as result of ankle sprains. Decreased hip abductor strength a decrease or a change in ankle range of motion, this study spoke very much about the decrease in ankle motion a paper this year by Moisan, had a look at people with chronic ankle instability and found that on heel strike during landing, there was an increase in inversion. We are seeing people with an inversion sprain, actually addressing the ground rather than a neutral position actually closer to rolling their ankle from the start. Be aware that whilst there is a high incidence of recurrence here, Part of it is a biomechanical issue where they have actually started their stride in the level of inversion that is higher than the regular population. Obviously, balance decreases.

Sporting performance is a really interesting one, this paper in 2011, based in China, we may have a look at the level of the various athletes and their history of ankle sprains. What they found was that the higher the level of the athlete, the less ankle sprains they had. So there is a strong correlation between the number of ankle sprains, severity of the ankle sprains and the level of sport the people achieved. The really interesting thing about the study, is that it looked at sports from soccer or football, through to basketball, table tennis, they also included swimming. So even the non-ground athletes you might say, might have an implication to their performance, following ankle sprains. It is certainly an important injury for us to be having a look at and see what we can do from a management perspective. Obviously, with recurrent sprains, one of the implications there is time out of sport. When we have a look at the structures around the ankle, just to give you a little bit to orientation you a little bit, number five and number six here, are anterior talofibular ligament. We have got a superior and an inferior band, it is a very strong ligament, and it needs to be, because it is looking to hold the talus back into that mortise joint. Another important one for the inversion sprain is the calcaneofibular ligament number 10. These are all quite robust, ligaments and the calcaneofibular we will see as part of our assessment shortly. When we rotate around to the back of the ankle, we see our posterior talofibular here, number six, again, quite a robust ligament, holding that talus in place within the mortise joint. Now the Talar Tilt test is one of the ones that we can do when assessing the ankle.

WATCH VIDEO

The sound is not great. We are looking at damage to the anterior talofibular and calcaneal fibular ligament. This ankle here that is testing is a sound ankle. You will see that if there is a limitation as it goes into inversion but what you will also see is that line come up, which is the calcaneal fibular ligament, with those, the peroneal tendon around it. When it switches over to the other side, this is the injured side and you will notice as he takes the calcaneus medially, there is no calcaneal fibular ligament come up so we have damage to that one and increase range of motion there. This is where we are suspecting injury on this side. Now be aware that it is good that the calcaneo fibular ligament is one of their indicators there. You are comparing side to side, but this is a common injury, so we might see athletes with the injury on both sides.

WATCH VIDEO

Alright, the anterior drawer is another one that we look at here for assessing the ankle. The anterior drawer really does rely on comparison to the opposite side. So, be aware that unless you are familiar with checking a lot of athletes here, that you may very well be looking at false positives, if you  have got someone with high movement availability.

So now I am just pulling the calcaneus forward and looking for the amount of laxity that might be there. It is highly reliant on the other side. So just be aware of that when you are using that particular test. As I showed you before, we have got the ligaments there, and these appear to be the main focus of the assessment and also treatment of an ankle sprain. We focus on the inversion sprain here. We see in the picture on the left, the ankle goes over, we see that drive or force down through the fibula look and tearing of those ligaments. On the right hand side though, is something that you all should all be very familiar with just very basic anatomy. When we have a force down over this joint here, these two bones are the same two bones up here. So recognize there are implications at the proximal tibial fibula joint implications at the tibial femoral joint. Because as we go into inversion, the normal coupling of inversion is with tibial external rotation. We have a rapid external rotation of the tibia in relation to the femur. So quite often, what you will find post ankle sprain of an inversion sprain, is you are going to have joint restrictions within that range of motion at the tibia femoral joint, the proximal tibia fibula joint, as well as what you find down here, with the talus and its relationship in the mortise joint and also in relation to the calcaneus. So be aware that as a sports chiropractor, these are areas where you can certainly have an impact on helping with the biomechanics of these patients post ankle sprain, that you need to be having a look at the whole system here. Try not to be myopic and be focused on repairing, pandering to just pain that is down here. The whole system we need to be aware of and ideally we need your hands on some ankles and legs, you will be looking at those types of techniques as well.

What we have, look medially, so eversion sprain, what is commonly termed the deltoid ligament is this collection of ligaments on the medial side of the ankle. The tibio-navicular ligament, a tibio-spring ligament. This is a ligament that has an attachment, which is a soft tissue attachment at the other end. So runs from the tibia and then down to the spring ligament, the spring ligament complex itself is part of the deltoid ligament complex. Where the tibial calcaneal ligament, and the deep posterior tibio-talar ligament. Now, this does not show the anterior tibial tunnel ligament or the superficial posterior tibial tunnel ligament. That is because in some people, they are actually not even there. So be aware that your primary ligament are the ones shown here. The others exist in some patients, not all. We have to look at a dissection here and get to an awareness of how they look in situ and also how big these ligaments are.

We move on to the high ankle sprain syndesmosis injury. These are really important one to be able to identify. Quite often they are not considered until somebody is not resolving from a regular inversion or eversion sprain, they can occur in either. Big thing with your syndesmosis injuries is that whether it is inversion or eversion there is generally a significant dorsiflexion or plantar flexion movement. What happens in both of those, and probably more commonly the dorsiflexion is we see the talus pushed up into the mortise joint separating that tibia and fibula. That is where we get the tearing of the syndesmosis. Three main ligaments through there, and it can be one, two or three of those that tear within the syndesmosis injury.

So, when we are looking at these athletes, you will generally see less swelling in it specifically the dorsiflexion injury. You need to be palpating the tibia and fibula to rule out any fractures, the anterior joint line is going to be tender. You will feel up between the tibia and fibula. Now be aware that when you are looking anteriorly at an ankle. If the pain is low, you may be looking at a talar dome fracture. If the pain is above where the talus is then  that is the area that we are considering for a syndesmosis injury.

The squeeze test is where we squeeze above the mid-calf so essentially what we are doing here is as we squeeze the tibia and fibula high, we are creating separation low. That will disrupt those torn fibers. The Kleiger’s test we are going to have a look at the moment. These patients will also have trouble pushing off or doing a heel raise. But you also want to be checking out their neurovascular status to rule out compartment syndrome, which we will go into a little bit later in the talk as well. So, here is the Kleiger’s test.

WATCH VIDEO – problems with sound

Okay, so he is dorsiflexed, and externally rotated. As he dorsiflexes he is pushing the talus up into that mortise joint, and the patient’s going to be in a lot of pain up in between the tibia and fibula, when you are doing that dorsiflexion and external rotation. With that particular test, you want to be aware of their functional capacity. With that, there is going to be a lot of pain when you are doing the dorsiflexion. We will just roll that again. You will see where we get up to this part, as he stabilizes the tibia and fibula, he is then going to bring that ankle up into external rotation and dorsiflexion. So that is where the patient’s going to give you a bit of a scream. So be aware that it could be painful. Warn the patient that it could be painful, as you are jamming that talus up, looking to separate the tibia and fibula. With these disrupted fibers there, you will often have some left intact, which is obviously what is going to create the pain, and so be aware of where that is at, how long it has been there and you can get onto that early bracing can be useful, but if not, it quite often can go to surgery.

So, moving on from a sprain, looking at fractures, three main types of fracture we are looking at the lower limb are our direct trauma, avulsions, and stress fractures.

The direct trauma ones are pretty obvious. There is an incident involved, there is significant localized pain and generally is trouble weight-bearing after those fractures. One of those is a Lisfranc injury. Now, when we are looking at this particular injury, the Lisfranc joint complex is actually the whole of the tarso-metatarsal row, and so you can see it covered here in gray, that is the area that we are talking about. It is, because that works as a unit, and we can see various types of injuries can occur there. So, as you will see on the diagram here on the left, the actual Lisfranc ligament runs from the medial cuneiform across to the second metatarsal. The second metatarsal sits up in the joint here in between the medial cuneiform, the intermediate cuneiform and the lateral cuneiform. It acts like a keystone in between these. Any disruption to that level there can create any number of shifts or dislocations of the foot, and it makes the Lisfranc injury quite a significant one. Only in the last couple of years, one of the top Australian football players ended his career, because of a Lisfranc injury. See on the right-hand side, one of the mechanisms which will be coming down onto the ball of the foot, which drives that cuneiform down and pushes the metatarsals forward and that is where we get the disruption of the ligament. On X-ray we see on the right there that classic separation between that first column and second column, so our medial and intermediate column within the foot.

Because of the strength in that part of the foot it is quite often a high-speed injuries such as motor vehicle accident or skiing, but can be simply twisting of the foot on a fall or landing on the foot and so you will see some people get these from a relatively innocuous injury, particularly off the sporting field. When they are on the sporting field, it might be a change of direction, type injury that you will see, and  they will get pain in the midfoot, there will be pain lifting the heel off the ground again. The pain is really across the top of the foot, bruising under the foot is a classic one, they give you some suspicion, now particularly early bruising under the foot. Obviously, if somebody has had their foot down with any sort of lower limb injury, we can see settling of blood which starts to drop the foot and toes, but you will see distinct bruising in the arch of the foot with the Lisfranc injury. They will have trouble walking and balancing.

So, we see a picture here. We have got the fracture there of that second metatarsal where the ligaments are involved. and on in diagram B, we see that classic bruising through the arch of the foot that occurs with the Lisfranc injury. When you see that pattern, you see, as a normal blood flowing down as where it falls around the toes, but that classic distinct bruising through that arch is one thing that might make us suspicious of Lisfranc certainly we will get these people off for an x-ray early.

Looking at the avulsion fractures in the lower limb distal fibula is a common one with an inversion ankle sprain. You want to be looking for a very specific pain at the lateral malleolus, and that will certainly be quite distinct on palpation. Be aware that you may have torn ligaments there but generally that is going to be in that ligaments space in between the fibula and the talus.

The proximal fifth metatarsal is the next place where we will often see or more commonly seen avulsion fracture. So, when we are looking at the fifth metatarsal, it is important to recognize where the fractures are that we are looking at. When we look close to the base, this light blue area is where we are going to see avulsion injuries. The Jones fractures in the dark blue area, stress fractures occur in that diaphysis in the red, then shaft and head fractures which are more likely a direct trauma occur further down the fifth metatarsal. Zone one, which is our avulsion area, quite often causes a twisting injury, when the rear foot gets into inversion during plantar flexion. Think basketball, volleyball, someone has landed awkwardly or landed on someone else’s foot after a jump. This is where there will often be sudden pain at the lateral part of the foot, and we are thinking of avulsion injury there. Zone two, which is our Jones fracture. Now with this area here, it is a significant adduction of the foot with a raised heel, so change of direction. Probably the first one of these that I saw was at an indoor soccer match or futsal, and yet very obvious when you saw this kid was in any enormous amount of pain.

Various football codes with fast changing directions use netball and a hard court and frisbee you might sometimes see these, and they can involve the fourth, as well as the fifth metatarsal articulation. We have high non-union right here so just be aware of a fracture, again X-ray early, I want to say early, there might need to be a day or two before it will come up if it is a fairly close fracture, but be aware of that one. With the non-union one, one of the reasons for that is not dissimilar to the scaphoid, we have a blood supply that goes past and then comes back up into the proximal end of the fifth metatarsal. Zone three so we are going to stress fractures through this area where we are thinking runners, others that have accumulated repetitive load in high volumes. But we also see dancers’ fractures or spiral fractures come up with fifth metatarsal on here as well, pretty nasty, you are going to know those pretty quickly, they are in a lot of pain.

They are going to be painful on palpation regardless of where they are, there is going to be pain with weight bearing. So, what we are seeing in the x-ray here on the left-hand side is the Jones fracture. This is the one where we need to be very aware that the blood supply is coming and passing and then coming back up into the base of the fifth metatarsal and we may see non-union there. One of your big tests if you are needing to do further tests for a fifth metatarsal fracture is resisted eversion, they are going to screen pretty quickly.

So with our management from the zone perspective, we have zone one nondisplaced, generally we are going to be looking to manage that conservatively. Just get them into a boot, or even a hard sole shoe can be good enough. They are just protecting that against that further twisting motion of the rear foot. When we are looking at our nondisplaced Jones fracture, it is possible to look at conservative management but if you are dealing with a high-level athlete, most of these athletes are going to go for  surgery early on. Rather than waiting 6 to 8 weeks of actual non-weight-bearing, to then see whether there has been malunion they will be in there, get it operated on and get it pinned, so they can get back to their sport and there is a more definitive time to get them back to their sport. When we are looking at stress fractures in zone three, be aware that some of the recovery times of these particular stress fractures can be up to 20 weeks. This is why, and I’ll talk about stress fractures in a moment, we need to be really aware of what is happening with those, and again, early diagnosis so we can start management with these athletes, so their time off the field is not dramatic. In 20 weeks, if you consider an athlete that might have got a fifth metatarsal stress fracture, that was looking at this sort of management,  anytime in the last 6 months, their chances at the Olympics are gone. Therefore, we need to be aware of these injuries and be managing them early on. I am looking at stress fracture presentations, as I said earlier, it is generally a repetitive activity. Running is probably the most common because the repetitions within running are obviously very high and multiple body loads at a time. There is usually a gradual increase in symptoms, and you will see these are most commonly in elite athletes because they want to continue pushing, they accept a certain amount of pain with their training. So you see this gradual build up by the time they come to you, it is quite often “I have been getting pain for a little while, it just does not seem to go away or worse now, it is impacting my ability”. When we are looking at our  particularly our metatarsal stress fractures. This is going to be the athlete that is running up hills that is saying “This is really starting to hurt” our sprinters on their take offs. There is always going to be very specific tenderness to touch, but consider that a stress fracture or stress reaction is a continuum. This is a really important part of our job as a sports chiropractor when we are looking at not only diagnosing but managing these as well.

When we look at incidence of stress fractures in the lower limb, our high risk here and this is from a football study, certainly, includes runners within that but your high-risk areas your femoral neck, anterior tibia, medial malleolus, lateral process of the talus, navicular, that fifth metatarsal again base at the second metatarsal, and we saw where that sits within those cuneiforms, then the sesamoids under the big toe. Lower risk but also obviously occurs in the postero-medial tibia, fibula. I had a runner with a fibula stress fracture, probably nine months ago. We got her back to running fairly well, but that required quite an extensive period of management of her biomechanics as well as her training load. Femoral shaft is really unusual, pelvis you get those from time to time, particularly in your longer distance runners, Calcaneus I have not seen one of those.

Second to fourth metatarsals, probably even more so in the younger population that I have seen those injuries, basketballers quite a bit. Quite often again, there is an inappropriate loading going on within their movement patterns. Look at the bone stress continuum, bone loading is normal, bone strain is also normal, but it is after the bone strain that we start to see the divergence. On the right-hand side of this continuum we see no damage, strain related  re-modelling and a positive feedback into our bone loading continuum. This is where bones get stronger. It is the normal part of bone-strengthening, to actually have load and strain on them. It is when we go down the bone damage path we start to consider, is this athlete going to move forward or backwards? We get damage-related remodelling so we might get a callus formation on the bone, and that is where, if we go into damage, from their damage repair, we have the altered skeletal properties on the left-hand side here. It can be a positive feedback and strengthening that area, even though it is not the normal standard bone-strengthening pattern, but when we go into the right hand here, where we start to get that imbalance between damage and remodelling. The body is not keeping up with the amount of damage that is being done. This is where recovery times are super important. The accumulation of damage starts to create a stress reaction, the stress reaction turns into a stress fracture, and potentially a complete bone fracture. So as those last three there or last four where we need to be super aware of these athletes, how we are managing them, and what we are doing with their bodies, to help them stay in their sport. Because this is where you can turn a short injury into a long injury very easily with poor management. That is also where we need discussions with the coach. Now, I am a big fan of his picture when I came across it  from the Hamstra-Wright paper and the reference will be in the reference list later. One of the things that we most commonly see when people come across stress fractures in the lower limb is the bottom green one here and extrinsic factors, and that is training load. Everything is about training load. I must have been overtraining, too many miles, and quite often we will see stress reactions, stress fractures. When we are looking at the factors that might be influencing the stress fracture, consider that training loads only one of them. Have a look at the rest of the things with this. We have got nonmodifiable factors sex, race, age, genetics, alignment, prior injury. We are starting to see studies now suggest that gut health might be important as far as how our body is managing that remodelling that recovery process. We might be needing to bring in a sports nutritionist, which is a common one, we see stress fractures keep coming up. But also recognize that we need to be looking at the biomechanics. That is our area of strength. We need to be having to look at why these stress fractures are occurring where they occur.

One of the things that is often ignored with a patient with stress fractures when everyone is focused on the training load is that they forget, there is a reason why the stress reaction occurred at that point. This is where I get a little frustrated when overtraining is blamed all the time. The runner who comes in with the tibial stress fracture on the left-hand side. Well, that is great,  your train load has increased, which may have brought that to the fore, but why is it the left tibia? It turns out that the left leg did not do any more running than the right leg. Recognizing there must be a loading or a mal-loading effect that is creating this differentiation between damage and repair, on the left-hand side, that is not occurring on the right hand side, and that is occurring in the tibia and is not occurring in the metatarsals or in the navicular, which are other areas that we know are subject to stress reactions.  So why is it occurring there? What is happening around that area that may be offloading and what is happening on the other side?  Classic one that I saw a number of years ago now was a patient who had these recurrent stress fractures on the left-hand side, and he had fibula stress fractures and he had tibial stress fractures; he had femoral neck stress fractures; he had fifth metatarsal stress fractures. When we had a look at his movement, one of the first things I picked up in a very basic examination was he had issues with his right ankle. He had previous ankle inversion sprains. He was not loading fully through the right-hand side, so his left side was actually doing all the work. Now, he was not even a track runner. So this athlete was doing mostly long-distance runs, off-road on-road, varying surfaces doing all the right things there. There was this constant focus on what is wrong with these weak left-hand side. Left-hand side was a strong side. It was a side that was having to make up for a right side that was not actually carrying its weight. We need to be super aware of  why the actual stress or the load going to that point, and what areas might not be taking their load, and quite frankly, as chiropractors we hare really well placed to be checking that out all. So recognize your strength in helping manage stress reactions, stress fractures,  it is not just about the training load. We have a significant part to play within a team when we are managing these but make sure you are getting other people on board, talking to the coach, talking to nutritionists,  and not just dismissing these as an overtraining injury.

We have a look at common tendon injuries in the lower limb, our achilles pops up. Thomas spoke earlier about the patellar tendinopathies. With achilles we have got tendinopathies, and ruptured peroneal tendon we can see tendinopathies, and a subluxing peroneal tendon there as well, which is probably more common.

Subluxing peroneal tendon, you will get a ruptured superior peroneal retinaculum. Commonly associated with recurrent inversion ankle sprains, the athlete will feel a pop or flick, with a sense of pain, or instability behind the lateral malleolus. So doing a resisted dorsiflexion, eversion, we will actually see that tendon pop out, it will be quite obvious. You can try them initially with a boot because essentially, to get that to heal it means just not having it not happen again. If it does not happen again, then there is a chance that that peroneal retinaculum can heal. But otherwise surgical intervention is generally fairly simple. The recovery is quite fast, I have had a couple patients go through that in the last six months, and they come back, feeling good and performing well afterwards.  In number 8, we see the peroneal retinaculum superior peroneal retinaculum which is where the subluxing of that tendon will occur. If you have something that dislocates behind their ankle, it will be that peroneal tendon.

Our achilles tendon rupture, these are pretty dramatic. You will often hear a loud crack or a pop. Some people say it sounds like gunshots going off. Quite often the patient will turn around to see who has just kicked them or hit them in the back of their leg, and there is no one there.

More common in older athletes, we can look at surgical vs conservative management there. In recent years, conservative management has certainly been given a lot more airtime. With  conservative management,  what we initially thought was that it depends a lot on the amount of separation. It  is  actually more about how quickly you can actually get these people into a boot afterwards.  Older style management was about having them in a boot for 6 to 8 weeks without any movement, which is, you know, part of what they do post-surgery, but they’re slowly starting to increase the pressure on the tendons post-surgery. What we are seeing more recently is that 3 weeks of strict bracing, and then moving into a movement restrictive brace, where they are able to get some movement happening, it gets a better response to their conservative patients. It is certainly something to consider, depending on the level of your athlete, what their return time might be.

When we are looking at assessing an achilles rupture let us have a look at this video for the assessment.

WATCH VIDEO THOMPSON TEST – You see that there is no real movement through the foot there. The light movement that you see there is actually the long flexes of the toes. Generally speaking, as you move through,  we should see movement of the foot. But obviously none there when we have got that complete rupture.

We are looking at achilles tendinopathy, you will see these often. It is a gradual onset, there will be  pain and swelling around the achilles. Again, it is often going to be associated with a sudden increase in training intensity or duration, and we are well placed to manage these conservatively. There has been plenty of talk in the past about eccentric exercises, isometric exercises, and generally, a mixture of the two I find is going to get a good result with these. But also have a look at why it was that particular achilles that might have been aggravated. Why was it taking the load? When we are starting to look at those sorts of features around an achilles tendinopathy rather than just beating up the achilles that might be sore, we need to look to the structure for some of those clues to how we managed it.

Now, on the left-hand side here, you will see a diagram from a 2004 paper, I believe it was, where they actually talk about a rotation of the fibers of the achilles tendon for around about 15 centimeters (12-15 centimeters) from its attachment to the calcaneus, where we start to get a rotation medially with those fibres. The achilles tendon actually has a role in supinating and inverting the foot, which helps with propulsion from that propulsive moment, not just the plantar flexion of the foot. We are looking at driving into that big toe, driving into that medial column where we get all of our strength in propulsion. The achilles tendon, the shape of it starts to do that. Maybe we need to have a look at, are there other muscles involved in supination or internal rotation of the foot, that may be weak that the achilles is starting to make up for?

We have to look on the right-hand side of the picture here. A wonderful picture of demonstrating achilles tendon, whilst we talked about attachment points of the calcaneus. It actually wraps around the calcaneus and continues into the plantar fascia of the foot. We should consider that our calcaneus is to the calf muscle, what the patella is to the quadriceps. When we are looking at injuries around the knee, we are certainly looking at the infra-patella tendon and its relation to the patella and from the patella up into the quadriceps itself. The calcaneus plays a similar role in allowing the calf muscle or the tricep surae to exert force around a corner. We need to be aware of structures into the foot when we are looking at what might have been creating issues as far as mal-loading of the Achilles tendon, and are we considering the plantar side of the foot, the extensibility of the plantar fascia, the strength of the intrinsic foot flexors as we look into this achilles tendon? So do not just consider where the pain is, where the actual damaged tissue is, but what might have led to the damage of that tissue in that area. As chiropractors, our basic training helps us a lot with looking into these areas.

I will move through the rest of these fairly quickly. Plantar fasciopathy, we have all seen that athletes, non-athletes, it is that classic pain in the morning, first five steps it is really sore, or getting up from rest. Quite often the pain is on the medial side of the heel, foot strengthening is a really important part of managing that. Don’t just look at the painful structure, but what might be offloading or not working to stress that structure out. But also consider that all plantar foot pain is not a fasciopathy. We might have a calcaneal fat pad syndrome. I see plenty of these and people come in talking about their plantar fasciopathy and they actually have got a fat pad syndrome. So consider the pains more likely to be on a heel strike when they are walking rather than mid stance which will be stressing out the plantar fascia. If we squeeze the fat pad, now we have got calcaneus squeeze test which might be looking for fractures within calcaneus. But you all have palpatory skills that well and truly good enough to determine it with squeezing a fat pad over squeezing calcaneus, so squeezing the fat pad and give pain as opposed to stretching the foot into dorsiflexion which will stress the plantar fascia. These people are going to respond more readily to a soft, softer heels in shoes or gel heel cups.  Or there is taping techniques which may be covered in your FICS taping course which are actually very effective for a fat pad syndromes. Your taping for plantar fascia is going to be very different to a fat pad. The proper type will get very good results, also when we are looking at plantar foot pain, consider nerve injuries or tarsal tunnel syndrome, the lateral plantar nerve entrapments, medial calcaneal nerve entrapment as well. As we move through those most of these are soft tissue-based entrapment of the nerves, we are seeing pink here, lateral plantar nerve medial plantar nerve going down here. The previous slide shows your distributions of where you might feel a pain for these. Understand that again, have a poke around, see where the pain is going. Is there any tingling numbness paraesthesia associated with the symptoms that the patients are getting? Consider that the muscles for the foot are very strong when we have that divergence of the tibial nerve into the lateral plantar and the medial plantar nerve, which is between the digitorum brevis and the quadratus plantae muscles. These are strong muscles and any sort of adhesions in through this can certainly create irritation to those nerves. Can be traumatic if someone has landed heavily on that area but certainly be considering these as part of your plantar foot diagnosis. Tarsal tunnel syndrome, is where our posterior tibial nerve passes through what is the flexor retinaculum or tarsal tunnel. This will create a more generalized effect throughout the foot because it will affect both medial and plantar, the medial and lateral plantar nerves. So consider your distribution is a clue to where there might be an issue. Calcaneal nerve you can see it passes posterior the tibial tarsal tunnel, so it is going to be more localised in that medial heel, and you will feel that tenderness medial calcaneus coming around underneath.  Rather than passing underneath the foot or starting underneath the foot. Our calcaneal nerve entrapment,  one of the common things here can be inappropriate footwear. So where the shoe comes up and presses heavily under that medial malleolus certainly be considering that as one of the things that may be driving some of the heel or, generally heel pain with your calcaneal nerve entrapment.  Tinnel test, basically just tapping over the tarsal tunnel, we are not going to worry too much for that. Tap over there and you will see they will get the referral down into the foot over  various areas.

Compartment syndrome, it is super important to be able to identify an acute compartment syndrome. These are medical emergencies. Generally you are going to have a significant trauma associated with a crush-type injury, broken bones, those sorts of things. The patient will be in a lot of pain and the pain will increase rapidly. We are looking for significant pain, we are looking for a rapid change in temperature of the leg, your pallor, paraesthesia pulselessness and paralysis.  This will be a field side diagnosis, this will not walk into your practice. If someone has an acute compartment syndrome, and you are field side, you are there when it happens, you are referring off immediately. The ones that will come into our practice are the exertional chronic compartment syndrome. That is where, again, training load will often be spoken about. and there might have been a recent increase in these but consider again, training load is just one of the features. Particularly if it is happening on one leg, it will often be bilateral but why is it happening there? Why is it happening in a particular compartment? Why is it happening on a particular leg?  what has changed or what can you identify within this athlete that might help work out the whys of what you are looking at with these injuries. We are in a great place to be managing these, like generally soft tissue looks important, but that relationship between the tibia and fibula is super important when looking at compartments in regards to which compartment they are occurring in. From this perspective, muscle tests, nerve referrals are going to clue you into which compartment might be related and how you might need to be looking to manage that, and also what other factors might be related.

We are going to muscle strains and tears and we are just going to run a quick video, which is probably one of the more famous hamstring tears that we have seen in recent times.

WATCH VIDEO:

This is the 2017 World Athletic Championships: Usain Bolt’s last race. We see him tear his hamstring here, as he is about to come through and win the 4×100 relay. There he goes, and classic hopping as there is no propulsion left. Once that tears there it goes, he is not a happy man. So this was the end of his career. A sad way to go out with that race. A hamstring tear is quite often a high-velocity tear. When we look into sports, and again, the figures that you will see on the left-hand side here are football based.  Hamstrings are the most common injury, then we see groin/adductor strains, quads and calves coming in after that.  A lot of focus on hamstrings and how we might look after those. A great paper from the Danish came out last year, where they assessed over 10,000 papers. They came down to 44 of them which were largely randomized controlled trials and systematic analysis. The conclusion that they came to was that there are not a lot of high-quality papers out there.  When we have a look at reducing groin injuries, the FIFA 11+ Program and also the Copenhagen Adductor Stretching Program can reduce groin injuries. Nordic hamstring exercise, pretty good for reducing hamstring injury rates, and we are looking mostly at fascicle length changes there with the a nordic hamstrings. Which also might be why lengthening exercises appear to be superior for return to play for hamstring injuries and also reducing reinjury rates.  One of the things they did make a point of saying is that PRP does not appear to have an impact on return to play or reinjury rates with muscular injuries of the lower limb.

Interesting comments there where they did not make a comment on calf injury diagnostic tests. We are just talking muscle injuries here, diagnostic tests injury prevention or return to play because of the lack of evidence there is in that area. So what is our role? Apply the best available evidence that we have. So the Nordics, the Copenhagen strengthening program, FIFA 11+ then be a sports chiropractor. Ask why. Why did it happen there? Why was it that muscle? Why was it that bone? Why was it that joint? Now outside of our traumatic injuries, with the cumulative  injuries in particular, we need to be asking why and then applying our knowledge of sports chiropractic to look at the system and not just look at the injury or pain site and say how can we help this athlete by finding what area might be not taking it is load? That is creating a mal-loading situation in the area where the tissue is broken down.  Lastly, before finishing up, just another one to be super aware of in the lower limb, our quadriceps contusion or cork.  The big issue there is the development of myositis ossificans. Look for someone who has not got early treatment, they have got knee effusion on the same side, they have got a previous quadriceps injury and their knee flexion less than 180 degrees. Myositis ossificans where we get the bone deposits within the muscle can be a very painful and sometimes career ending injury, which quite often can be avoided by managing these things early.

All, thank you very much for your attention tonight. I know this has been  a long one to sit through, but both Thomas and I appreciate your time, your attention and your involvement in FICS. Excited to see you all sometime in the coming years at some sporting events, hopefully up in your different regions around the world.

 

[End]

 

Lower Extremity - Functional Taping Techniques - Dr Greg Doer

Dr. Gregory H. Doerr:

Hello, I’m Dr. Greg Doerr. This class is going to be associated with more modern taping procedures. What our goal is with this is we’re going to review, basically, a lot of different types of techniques from kinesiology taping to strapping techniques and things along those lines. In particular, we’re going to go through a whole lot of pre-assessment to determine what type of taping technique we’re going to use. We’re going to conceptualize why it is that we’re taping, and critically go through everything from the standpoint of how we apply tape, what’s the current research associated with it. We’re going to spend a decent amount of time on that because that’s one of the things that is a frustration for me. It’s everybody said, “Well, there’s nothing to validate taping.”

However, I love it when people say there’s nothing to validate taping, but they won’t actually say, “By the way, the research articles that were done on taping are not very well performed.” Their methods are of poor design. We’re going to go through at least what is the current literature analysis, which I’ve been fortunate enough to be in some way, shape, or form involved in two of the ones that I’m aware of. I don’t know if there are any more out there at this point. One was done by Dr. Mike Schneider, and one was done by Dr. Phil Page. We’re going to go through everything from that perspective of pretesting associated with different techniques, the theology behind why taping works, as well as showing some hands-on oriented as much as we can via video methods on the application of a few different techniques as we’re going through all of this.

Again, I can be contacted at my email, which is there. The classes that I developed associated with taping is called Functional Taping for Musculoskeletal Injuries. I don’t want to make it sound like that’s the end all be all. I’ve taken almost every taping class that I possibly have ever been able to get my hands on. Because quite frankly, my feeling is knowledge is always power. The more you learn from others, the better you get, the more you evolve. We’re going to go through it, basically, a gambit of what a lot of different people have done. As I’ve said before, if you’ve seen the instrument-assisted class that I did, very few things we’ve ever done is unique. A lot of it is evolution of things that we’ve learned from other people. Or somebody else may have done it, we just never saw them do it before. We’re going to go through a lot. Taping’s been around for a lot of years. Quite frankly, we’ve had a lot of evolutions in taping over the last couple of decades in particular.

Looking at this, there is a ton of different types of taping techniques. We have everything from kinesiology taping and all the different varieties that have come from here, as well as a whole ton of different strapping methods. If we look at kinesiology taping, where it really started was Kenzo Kase with Kinesio tape. He was basically the granddaddy of it all. He started that process back in the ’70s. It really created the first format upon which we could learn how to apply taping. It is one of the taping I’ve done their certification three times. It is one of the classes I will openly admit that allows for the greatest amount of taping. You keep a lot of different structures associated with it. You do get a lot of hands on experience.

However, we evolved a bit with Kevin Jardine, who first of all, in my opinion, created some of the greatest educational component as to the true theory as to why taping is effective. Probably, his greatest attribute to the taping wasn’t necessarily the techniques he did. It was really the science behind and the philosophy behind what we’re doing with taping, which I’ve adopted into almost every aspect of my life, whether it was soft tissue, whether it was taping rehab, manipulation, mobilization, and modalities, and so on and so forth. His methodology or his theology upon how he was applying tape, I adapted and moved it into almost everything that I do clinically. He was also one of the first people to develop these pre-cuts. We see now almost every company has some form of pre-cuts, whether it’s a strip that just rips off. You don’t have to cut it, or pre-cut corners, or whether it was Spider Tech. With Kevin, initially who did a shoulder one, a knee one, a ankle one, a elbow one, a posture one, a low back one, an ITB one. He had a bunch of pre-cuts made. Some of them actually worked out really nicely. Some of them were okay. The reality was is it was an evolution in the taping world to something you no longer had to cut, you just had to know how to apply it.

Then, we also had RockTape came along. They looked at things very differently than what a lot of other people did. Now, we might have been doing it clinically, but they actually start putting it into a format of “Hey, by the way, we’re looking at movement rather than how to tape for rhomboids, which was very Kinesio tape-oriented. Here’s your rhomboid tape job. Here’s your mid trap tape. Here’s your upper trap tape job. Here’s your gastroc and your soleus one.” RockTape looked at it and said, “Well, that’s not really the body works. The body works in movement.” Most of us as clinicians were already doing that, but they were one of the first companies to truly put it into an educational format, which was extremely valuable. My class, really, from an evolutionary standpoint, really just the biggest thing that they did is they added in all the techniques, as well as adding in pretesting to not guess your tape job of work. If your pretest don’t come across positive, your taping is not going to be. We’ll get into that aspect in a brief minute.

We also had a ton of strapping methods. Now, you always had general, everyday athletic taping. I mean, that’s been around since the dawn of time. Unfortunately, the literature doesn’t really support a lot of it, especially from the standpoint of most of it is rigid taping. They found, especially if you’re still using white athletic tape, its effectiveness was about 20 minutes in length. There’s some other people on this list who you may or may not have heard from before.

Jana McConnell to me is the grandmommy of it all. All right. She is probably the most literature-oriented of her taping techniques. She’s gone out of her way to disprove her own theories, which I was not aware of, but apparently she was highly criticized for. My respect for her went through the roof when I found out that she actually was testing her own theology. Because just because something is disproven the way you think it’s working, it doesn’t mean it doesn’t work. It just means your thought process was wrong. You just have to go back to the drawing board. In particular, she was somebody who tested one of great example is patellar tracking disorders. What she did is she said, “Well, I think what I’m doing with my tape job is I’m putting it back into place.” She took X-rays pre and post to see how much did the patella move while the tape was on. It was really indiscernible, so she was like, “Great. I didn’t move the patella so why is it working? Okay, fine.”

She later in life decided, “Well, maybe the X-ray wasn’t sensitive enough. Let’s do an MRI.” She did the MRI. They tested, I believe, it was eight different positions of the patella, and only two of them showed a change and both of those didn’t show a significant change. Again, she disproved the fact that she mechanically was changing the position of the patella, which was creating the improvement. That didn’t mean her patella tracking taping didn’t work. It just meant the mechanical thought process wasn’t. When you eliminate mechanical thought process, the easiest one to go back to is a neurologic thought process, okay? When you start thinking neurologically with taping, it may drastically change the way you apply your tape to begin with.

Mulligan, for those of you who may have been lucky enough to take some of the Mulligan mobilization classes, which were phenomenal, they also did taping techniques to help to support some of those movement processes that they fix with their mobilization techniques. Some of those I use, actually, within my class itself. I just added a little bit more pretesting to it to make sure that that tape job actually is effective.

Tim Brown’s SPRT has been one of my biggest. For those of you who are not aware of who Tim Brown is, he’s a chiropractor, who actually now is a physiatrist and a chiropractor in California. Absolutely brilliant. Probably is the greatest influence on me from a taping perspective. Hands down. I have, with great permission from him, stolen so much of his knowledge and evolved and applied it in as many different ways as I possibly can. If it wasn’t for his base material, which if there’s somebody who evolves faster than anything, it’s Tim. Tim is very, very quick. If you ever get a chance to watch him teach, you go and see him any time. His SPRT, Specific Proprioceptive Response Taping, is by far one of the biggest bangs you can get in the taping world. It turns 8 out of 10 pain into 0 out of 10 pain, or 1 out of 10 pain in the blink of an eye. He used a variety of different tapes. That’s one of the great things. He’s constantly evolving into what it is that he does and how he performs it.

Then, we also have Gray Cook with Functional Movement Taping. He used his movement assessments to assist in creating a tape job to hopefully maintain what was achieved after doing your movement assessment. He actually started looking at pre and post as well. One of my simple examples that I’d like to do with him is somebody who had a mobility issue on a squat. The talus was anterior, they couldn’t get into good dorsiflexion. What did he do? He go and he do his joint mobility with the talus posterior again, then he would apply his tape to theoretically block the talus from becoming superior again, thereby maintaining his mobilization technique. Then, once weight bearing created improvement in a functional movement pattern. That’s what Gray Cook did with functional movement taping.

Again, since then, there’s been countless. You have dynamic tape that has come on the scene as well. They’ve been there for quite some time, where their tape, instead of having unilateral stretches, is now stretching in multiple directions kind of like the way our tissues do, and have had some interesting thing. I love using their tape for deceleration type of injuries like a foot slap on TIB posterior. I like using their methodologies associated with that. All of these tape jobs, all of them have a role in our office, which is why I always say if you take one tape job or one class, you’ve probably missed a lot. There’s very few tape classes that actually give you a gambit of different material. I don’t want to, but I think mine might be one of the only ones that actually includes so many different types of tape with so many different types of methodology. Again, it’s just, to me, taping should be an inclusive thing, not a unilateral “This is what we use.” It should be a lot of different techniques because there’s so many great ones out there.

Now, when we look at the different applications of taping, this goes right to Kevin Jardine’s theology. He did believe there was a neurosensory, a structural, and a microcirculatory aspect of applying tape. Neurosensory speaks for itself. Structural, those were much more mechanical oriented in their taping. Then you had your microcirculatory, which were considered, again, anti-inflammatory. The anti-inflammatory applications, as we’ve gone through literature, are the ones that are the hardest to hold up to the full theology of what they thought. That doesn’t mean they don’t have a place, but we had to change the way as to why we think we’re using them or why we’re applying them. We’ll get through a lot of that literature as well.

Starting with neurosensory, the goal there was simple. Improve afferent efferent communication. For those of you who may have taken the instrument-assisted class through fix, it’s a Ctrl+Alt+Delete. It’s rebooting the system, okay? What we’re trying to do is normalize the tone of the tissue. One of the things that was always interesting in our Kinesio tape certifications that I’ve taken is they go through facilitation relaxation. Tape is not that smart. Just because you placed it from one side to the other and one side to the other, it doesn’t mean your tissue is going to say, “Oh, my God. You went from the origin to insertion. I’m going to facilitate the tissue.” “Oh, I went from insertion to origin. I’m going to relax the tissue.” That’s not what’s happening. You got to remember no matter what, we’re stimulating the sensory receptors within the skin. It’s those sensory receptors, those A-beta fibers that are getting stimulated, reflexively looping within the central nervous system, coming back and changing the tone of the tissue. We’re applying that afferent stimulation. We’re stimulating those A-beta fibers or those receptors. We’re not the ones who facilitate and inhibit based on the orientation of the tape. We’ll get through some of that as literature reviews go through as well.

Structural applications, again, our goal here is much more mechanical. It’s to block injurious range of motions, it’s to improve adaptive postures, getting the shoulders back and down, so that this is a normal posture for us. It’s a biofeedback mechanism, so that we learn that this is where we should be, not here. It also assists us in stabilizing either laxities or instabilities. It could be an anterior translating shoulder or a dislocation. It could be an ankle sprain. It could be a dislocated elbow or something along those lines. All of these instabilities or laxities, we can correct using taping techniques. Interestingly enough, some of them are mechanical, but some of them are actually neurologic fixes as well.

Then our last application is doing things like anti-inflammatory. Those are our microcirculatory applications. Now, the theology between this, and understand, we’re going to talk about theology, but then we’re also going to talk about reality as well. The goal within a microcirculatory application was to promote the movement of stagnant superficial fluid. Thank God, Kevin actually said superficial fluid, okay? Because the reality is how superficial it is is extremely superficial. It helps to remove that stagnant edema of bruising. It assists in removing those chemical irritants and improve oxygenation to injured tissue. Now, here’s where we’re getting into .How deep does that blood perfusion go that were affecting injured tissue? Not too much, okay? That’s where we’re starting to see differences. Now, we can remove chemical irritants, but that’s going to be at a superficial level. It’s not going to be deep. Can we reduce the edema and bruising? Yes, we can at the superficial layer, not at depth, okay? As we go through our literature, we’ll discover a lot more of this as we go along.

Now, what taping techniques can be used for each application? Look. Within neurosensory taping, kinesiology tapes, strapping tapes, there’s a lot of different varieties of tapes that are going to have a neurologic impact. Why is that? It’s on the skin. It doesn’t matter what tape you used, it touched the skin. As soon as it’s touched the skin, you now have a neurologic stimulation. All right. This is going to become very critical when we start looking at the literature as to what we’re using as controls. If it has touched the skin, it has stimulated the neurology. The variety of different kinesiology tapes obviously work wonderful. There are SPRT methods, specific proprioceptive response taping. Again, that’s Tim Brown’s method that have huge neurologic implications. As I said to an extent, every tape job has a neurosensory component because it has been applied to the skin, which means it has stimulated A-beta fibers, okay? There’s no way around that.

Within the structural aspect, those, again, more rigid mechanical type of tape jobs. We can use SPRT like we will demonstrate associated with ankle sprains. McConnell tape jobs that we’ve used for, one of the ones that I use in my class all the time is this fibular head one. A braid posterior fibula mobilizes it anteriorly, uses the tape to keep it in place. McConnell’s tapings, patellar tracking disorder, she’s done them for impingement. Again, her techniques are pretty valuable. They’ve all use strapping tapes, things like Leukotape. Kinesiology tape, when we stretch it over 50%, we start getting a little bit away from the neurologic component of what we’re trying to do, and bring it into more of a mechanical support. We can use those with postural disorders, disc disorders, and things along those lines.

As I said before, functional movement taping, the example I gave with that anterior talus that cooked it. Again, he used strapping tapes in order to achieve that block of an anterior moving talus. Then again, all of our standard athletic taping, our white tape, our strapping tapes, our Cobans, our Elastikons. Elastikon is elastic. Don’t get me wrong. I used to use that a lot prior to my knowledge of kinesiology tape for very simple, similar methodologies. It’s always wonderful how people go down the same pathways just for different reasons. The only problem is Elastikon is very thick and it’s very adhesive. It’s got a much more brutal adhesive. You don’t really want to put it directly on the skin a lot, although you can. It tends to be irritating if you leave it on too long. Obviously, the evolution to kinesiology tape saved a lot of skin. Then lastly, we have our microcirculatory tapings. Now, the reality is for what we’re looking to accomplish, it seems to be much more effective. Basically, the only ones I use for that are kinesiology tapes.

Now, the functional taping for musculoskeletal injuries, again, I call it FTMI. The concept that I’m proud of having developed within taping is more of a concept of evaluation to determine what type of taping technique that’s going to be used. One of the things that always frustrates me, and I’m sure all of you who are taking this class have heard it before. Otherwise, you probably didn’t jump on this one. “Oh, it doesn’t work for me.” “Oh, yes, that taping stuff doesn’t have anything to back it up. There’s no literature to back it up.”

In fact, I once did a 1-hour podcast with a very prominent, for lack of a better way, fitness coach, of putting it in him. He’s not an exercise physiologist, but he is a very prominent personal trainer, fitness trainer. He was one of those guys that came into me and said, “Yes, that taping stuff doesn’t work for me.” I said, “That’s because whoever taped you didn’t know what they were doing.” That’s not to be insulting. It just means all they did was mimic what somebody taught you. It doesn’t mean it’s going to work. You just mimic the tape job that somebody taught you in a class. What I did with him was a very specific line of pretesting. I applied the tape based on that pretesting. All of a sudden… By the way, this was a SLAP tear. It’s a deep internal arrangement injury. He gets up and goes, “What the heck did you just do?” I said, “I don’t know.” He goes, “I felt great after the soft tissue. But now I feel like my shoulder has put total mechanical support. I got full range of motion. I’ve got nothing pitching. I got nothing like this.” I said, “Well, we apply tape the way it’s supposed to be applied for your particular problem,” which was a combination by the way of an SPRT method and a kinesiology taping method. The two of them together created a massive reduction in pain, and basically, smooth mechanics.

Now, of course, as I said, this is an internal arrangement. It’s purely neurological on how we apply it. We’ll go through those as we get through our concepts, and I’ll show some examples as we get to the end of the presentation. Now, through that pretesting, as I said, it determines which taping technique is most effective. Are we using a strapping tape? Are we using kinesiology tape? Are we using a mechanical advantage taping or are we doing a neurologic style of tape? Most importantly to me is, which I hope I never stopped learning, it emphasizes every type of existing taping theory that I have had the pleasure of exposing myself to. With any luck, will continue to expose myself through the rest of my clinical career, hopefully life. It’ll utilize, again, strapping tape. It’ll utilize kinesiology taping. But our emphasis will revolve around kinesiology taping and some SPRT theology, which I have found to be, again, probably the most powerful methodology in all of taping.

Now, to me, as I said before, the one of the most frustrating things to me is, “Oh, that taping stuff didn’t work for me.” Look. I got to be honest. If I’m taping somebody, I already know it’s going to work. That’s not to say every now and then I have somebody who I want to experiment on. An experimentation should be a one to two visit thing. It should not last for hours or weeks and weeks and weeks and weeks of taping somebody, thinking you’re going to get a better response. That’s not going to happen. My Concept 1 is actually don’t tape.

Now, let me demonstrate this, you do an evaluation. Again, I’m going to use a tennis elbow, because it’s the darn easiest one for me to show on this video. I’m sitting here, I’m doing my lovely test for manual muscle test for lateral epicondylitis and I go, “Ouch, that hurts me.” What I’m going to do next is I’m going to reproduce that same test. Now, again, I don’t have three hands. Understand my two hands are doing the testing. I don’t have to and one of my hands is getting tested here. I’m losing one, so “Ouch, ouch, ouch.” I’m going to start doing skin pulls. If it’s a tennis elbow, right over that tendon region. Notice how much pressure I’m doing here. It grabs the skin and tug. I’m not crushing and pulling. It’s gentle. This is neurologic. All we’re trying to do is stimulate those A-beta fibres. It grabs the skin and gently tug it in a direction superiorly, inferiorly, lateral immediately.

Then we can try diagonals. Now, why am I going to go to a diagonal? It’s simple. “Ouch, ouch, ouch.” That’s your 10, okay? I test again and I pulled it, medial. The patient goes, “Oh, it’s like a 7 now.” That’s not good enough for me. It’s got to be a 5 or below. Do it again. “Ouch, ouch, ouch.” I go lateral. “Whoa, that’s dropped to a 5. That’s a lot better than it was before.” “Good. Okay, 5 is good, but I’d love to see a drop more than that.” I go superiorly, test again. No good. I go inferiorly, test again. No good. “I’m out of 5.” Not great. I’m not happy about that. What I’m going to do, I’m going to do my soft tissue treatment over that region because I was going to do it anyway. It’s part of that care. I do my instruments for my hidden stretch or my cross friction. I go through that, I treat. I get to my tendon. I retest, patient goes, “Oh, Well, I’m still like an 8.” I’m going, “That’s not good enough.”

I’ve done my skin pulls and I can’t get greater than a 50% reduction. I’ve done my soft tissue region over that area and I don’t get greater than a 50% reduction. What makes you think applying tape to the region, which is stimulating the same exact receptors that you already tested, is going to make a difference? It’s a waste of your time. It’s a waste of your patient’s time, and a waste of everybody’s money. Again, you do an evaluation, there’s no skin pull, no fascial pull that makes a change. The soft tissue treatment over the involved tissue does not make a difference. Don’t tape it.

Now, let’s do something interesting. Let’s just say I do all that soft tissue treatment over here, test it, now, it’s an 8. However, I go and I treat the soft tissue here, retest it, and it goes, so I go to the flexure component, I treat there. I test again for that lateral, “Oh, that’s like a 2.” I’m going to tape the flexors. I’m not going to tape what I already tested and it didn’t work. This is where it works. Is this the direct connection to the epicondyle for lateral epicondylitis? No, but it’s the other end of the seesaw. Maybe this is driving this, okay? That’s an example of what we might do, but it goes back to Concept 1. Concept 1, don’t tape. I do a soft tissue treatment, it doesn’t do anything. I do a fascial pull, it doesn’t do anything. Tape is not effective on that region. It might be effective somewhere else, but not there. It helps you eliminate that. Rule number one, don’t tape.

Rule number two, I’ve already described it. We do that evaluation. “Ouch, ouch, ouch.” I take my instrument. I do my soft tissue treatment over the region. By the way, let’s stop that and pull back again. “Ouch, ouch, ouch.” I do my skin pulls, it doesn’t make a difference. I don’t get a greater than 5 reduction. However, I do my soft tissue treatment, retest them again. Now they go, “Oh, that’s dropped to a 2.” Well, then all I’m going to do is I’m going to take my kinesiology tape and I’m going to cover a soft tissue treatment right over that region, okay? I could take out my scissors. I’m just going to do a small strip of this. It would be over the entire area that you worked. Maybe I’m just going to apply my nice little tape right over that same region. That is just treated because the tape is going to continue to neurologically stimulate the same receptors that I just treated during my soft tissue treatment. All right? That is one of our big things. If this, then that. Everything we want to do has a reason. If an evaluation produces pain, no skin pulls make a difference. I do the soft tissue treatment over those structures, and all of a sudden, there’s a greater than 50% reduction, neurosensory tape job right over the tissue that you just treated, okay? Concept 2.

Concept 3, this is what I like to call the big bangs. We do our evaluation. “Ouch, ouch, ouch.” I go in and I do a skin pull again. I pull lateral to medial, I retest it. We’ll do this one. Lateral to medial, retest. “Holy cow. If it was a 10 before, I’m going to drop that down to 2 just by pulling on the skin this way.” All right? As soon as I get those, and by the way, your SPRT, especially these neurosensory ones where you’re just doing these skin pulls, these are your big bangs. You’re going to notice drastic change with these type of fascial pulls.

Now, here’s the interesting thing. Fascial pulls are not unique. Every company that I’ve ever taken a class from all has a fascial full technique. Kinesio tape had three or four different ones for the fascial correction. Rock Tape has tweak taping. SPRT has tab taping, which we’ll demonstrate very shortly. All of them have these fascial pulls. The difference is I like to use Tim Brown’s SPRT methodology because it uses strapping tape. It does not releases easily. If you use kinesiology tape to create these fascial corrections, they release much quicker because the skin is elastic and the tape is elastic. It tends to release a lot faster. You might get 6 to 12 hours out of it. In SPRT taping, you can get three to five days out of it.

They are very powerful, and we’re going to go through all that methodology quick. Right now, we want to get our concept set up. Concept 1, don’t tape. Concept 2, neurosensory. When we do a soft tissue treatment over the region and it makes it feel better, drops it from a 10 below 5, we do a neurosensory, no fascial pull makes it better. When we do Concept 3, “Ouch, ouch, ouch.” I pull the skin in a certain direction, and all of a sudden, I dropped from a 10 to a 2, again below 50%. I’m going to use my fascial full methodology and SPRT tab pull.

Concept 4, now, this goes into our fascial sling style of taping. This is all based on Thomas Myers’s work. The interesting thing with fascial sling taping, it’s a lot of tape and it’s a lot of tissue. If you’re going to be doing fascial sling taping, you better know it’s going to work. The ideology of taping an entire lateral line of the lower extremity, that’s going from your ankle and foot all the way up to your hip. That’s just the lower extremity. That’s a boatload to tape. It’s very expensive to do these things.

In particular, when we’re looking at Concept 4, which is fascial sling taping, we’re going to have an evaluation, Most likely, it’s going to be associated with some kind of a movement assessment or athletic activity that produces a pain or a dysfunction. When we do a fascial pull on any part of that fascial line that may be involved, we are not getting a great reduction in symptoms. Again, a 10 to a 5, those skin pulls that we were talking about. We do a soft tissue treatment over a section or the entire fascial plane, and we get a very positive result. We go from a 10, all of a sudden, it drops below 50%. Again, from a 10 below to 5. If that is the case, that is a reason to do fascial sling taping. However, here’s the thing. If you’ve treated the entire fascial sling, is it the entire fascial sling that was dysfunctional or was it just a section of the fascial sling? As a simple example, we’ll go back to this concept. I’m going to come back to the slide in a second.

I want to give you a visualization. Here’s one right from the RockTape seminar, where you can see where we have some lateral line taping on that lower extremity. Okay? We also have a whole ton of taping on the upper extremity. That’s a lot of tape. How do I know that that person needs all of that tape? What I do is I start going back to my soft tissue methodology. I will treat a section of that fascial sling, one section at a time. In other words, if I’m doing that lateral line on the lower extremity, I might go from buttock to knee, knee to malleolus, malleolus down to the foot. I’m going to assess. Based on my soft tissue treatments, I will keep redoing my evaluation test that was provocative.

In other words, let’s just say they squat and they get pain. I’m going to treat, soft tissue-wise, from hip to knee. “Does it make a difference?” “No, I still have it.” I’m going to treat from knee to malleolus. “Does it change?” “No.” I treat from malleolus towards the foot, that lateral line deficit. “Does that make a change?” “No.” Well, guess what? If I actually have done that entire fascial line and I still don’t get a response, why would I take it? However, what if I to hip to knee, no change; knee to malleolus, no change; malleolus to the foot region, and all of a sudden, they get good. All of a sudden, that dysfunction that they showed in their movement assessment no longer exists or it has improved greatly.

Again, if it’s pain, it’s easy to say if it was 10 before it’s 5. But if you can look at somebody and say, “Holy cow. You just went from squatting at 45 degrees. Now, you’re actually dropping all the way into the hole. You’re breaking parallel.” I’m looking at saying, “Impressive. Something we did.” Now, here’s the question since we broke this up into sections, was it doing the entire lateral line of the lower extremity that created the neurologic response or was it just that foot section, malleolus to the foot? Now, I’m saying to myself, “Okay. Well, I know it worked, so I’m going to tape that lateral line.” However, the next visit, I’m doing it in reverse. I’m going to do the soft tissue treatment from foot to malleolus first and see if that’s all I needed. In other words, I do foot to malleolus, they do their squat again, and all of a sudden, it looks perfect. Guess what? I’m only doing the lateral line at the malleolus to the foot. However, if I said, “Oh, no. It’s still not good.”, then I go malleolus to the knee, knee up to the hip, and all of a sudden, it looks good. Guess what? It’s an entire lateral line deficit. But it is so much better to find that all you needed to do was treat a small section than the entire section.

Now, your fascial sling taping becomes a section of the fascial sling that needs to be supported or neurologically stimulated. That is what will save us a boatload of time and money when we’re doing fascial sling taping. I don’t find a lot of fascial sling taping to be my big bangs because, again, a lot of neurology and I get it, it’s the way we move. But usually, it’s a section of our movement pattern or kinetic chain that is dysfunctional, not the entire section. A lot of times we can save a lot of time, both from a soft tissue perspective, as well as a taping perspective, by limiting or normalizing the area that needs to be normalized and rehabbing the entire lateral line. We’ve shown that taping.

Again, fascial sling taping is really based largely on Thomas Myers’s work, Anatomy Trains. In particular, RockTape talked about it. It’s really the central nervous system that’s dictating movement, not the muscles. You’re taping movement patterns, more than literally just a singular muscle. It improves that continuity of how the body moves using the fascial system rather than an individual muscle system in taping processes.

Now, it’s not unusual that these Thomas Myer lines seem to be very similar to acupuncture lines, meridians, which seem to be very similar to the lines that fascial manipulation uses the Stecco work. Luigi Stecco, Antonio and Carlo Stecco have developed in soft tissue treatment. It’s amazing how these all overlap with each other. I don’t think that’s a coincidence. I just think they’re evolutions through time as we’re seeing this stuff. We look more and more at how somebody moves.

The next picture is a perfect example, again, of going through fascial sling taping. Here’s this guy, again, right from the RockTape presentations, where they have somebody go into a squat, and that right shoulder is dipping in. The assumption is that there’s an oblique line deficit in the back going from shoulder to hip. We’re going to support that and bring it back again, so that now that when they squat, they come straight down rather than dipping in. Here is my question. I’ve had a problem with this always. I looked at this and I said, “First of all, how do you know it’s the whole line?”

We’ve already talked about that. What am I going to do here? I’m going to treat from shoulder to scapula, scapula to spine, spine to the opposite hip. That’s what I’m going to look at when I’m doing this. If I find only one section, let’s say I’m treating from shoulder to scap, and all of a sudden, the squat looks beautiful. Well, I’m only taping over the shoulder to the scap. Again, it didn’t work, I go from scap to spine. That didn’t work, I go from spine to the opposite hip. If all of a sudden, now it kicked in, I’m going to tape the whole line the first time. The second time, we’re going to work in reverse, hip to spine, spine to scap, scap to shoulder. This way we find out whether it’s just the hip to the spine section that was involved or whether the whole fascial sling has to be taped.

Now, here’s something more interesting. We’re looking at this saying it’s the backline that’s involved. It’s that posterior oblique line that we have to support. Really? How do we know it’s not the anterior line? How do we know it’s not going from shoulder to hip in the front? Once again, we want to pretest to know this is going to be effective. If I’ve done that whole back line and it doesn’t do anything, guess what I’m going to do next. I’m going to try the front line, that front oblique line. Now, all of a sudden, if that makes a difference and the squat looks beautiful, I’m taping the front line, not the backline. That being said, we also have to understand. I just said tape the frontline. We have to understand the sensitivity about the tape. The front is always more sensitive than the back and the upper above the waist is always more sensitive than below the waist. You have to have that in consideration when you’re applying tape, especially if you’re somebody who does pregnancy taping.

That’s how we’re going to assess specifically, again, our Concept 4, fascial sling taping. First of all, understanding that fascial pull doesn’t make a difference. We tug on things and it doesn’t change it. But when we do a soft tissue treatment over the course of that fascial line… Now, understanding, we’re not doing individual muscles, we’re actually working a line deficit. Is it a section or the entire line that is dysfunctional? Is it the one that looks dysfunctional or is it the other end of the seesaw? Is it the lateral line or is it the medial line? Instead of the back oblique line, is it an anterior oblique line? This is why we need to use soft tissue treatments that simulate the same neurology to determine what is actually purposeful when we’re applying our tape.

Our last concept is concept five. These are our more mechanical ones. These are postural tapings, instability, and laxity tapings. In particular, we’re going to say we’re moving into a particular range of motion or position that increases dysfunction. This could be something as simple as, I put my foot into the plantar flexion and inversion, I strain my lateral ankle ligaments and I go “Ouch!”. However, if I move it up into the dorsiflexion inversion, passively, the person says, “Yes, I don’t feel my ankle hurt so much anymore.” Well, guess what? The ankle strapping is going to be good, not only from the standpoint of protecting the ligaments but also preventing pain on the ligaments.

Let’s take another example. Let’s just say it’s somebody who says “I have a lumbar disc herniation. When I bend forward, I get radiating pain down on my leg.” If I come out of that flexion just a little bit, let’s just say it was 40 degrees, I get radiating pain. I come up in 30 degrees, I don’t get any pain in my leg anymore. I’m applying tape on the lower back, so every single time they hit 30 degrees, the tape is going to pull saying, “If I go any further, I’m increasing intradiscal pressure and I’m going to create radiation.” It is a biofeedback mechanism to ensure that they don’t get into those bad postures.

Somebody who’s at their computer all day long, upper-crossed patterns like this, what we’re going to do is tape them back into depression and retraction so that their head gets back, they stop putting pressure on the discs, pressure on the joints, all the soft tissue function associated, which can also lead to things to thoracic outlet syndrome. Here’s one time where you probably don’t want them to tape into this kind of posture, TOS. They get back and hearing, you hold them there for a few seconds and their hand goes numb, you probably don’t want to tape them there because their hand is going to be numb all day long. In that case, you got to do some soft tissue release before you start taping them into a more dramatic posture. Maybe you tape them into a lesser posture so that the numbness is gone but it is better “posturally” for them so that they’re learning to get into good posture.

Again, when we apply tape associated with these types of Concept 5 structural applications, we have to understand two things. We can use kinesiology tape or we can use strapping tapes. If we’re using kinesiology tape, our tape is going to be stretched over 50%. We’re going to be at 50% or more because that’s when we change from more of a neurologist focus with taping, kinesiology taping to more of a mechanical focus with kinesiology taping. We could also use our strapping techniques. SPRT technique that we talk about for neurologic impulse, we can also use the same impulse to take pressure off the ligament. In other words, shorten it up, hold it in a biomechanical position that takes the stress off of those ligaments, like an ankle strapping that we’ll show later in this presentation. That assists us in holding a proper posture or proper position to take pressure off in the tissues.

Reiterating again, we have Concept 1, which is don’t tape. You have no pretest that tells you that taping is going to be effective on that body part. You have Concept 2. Concept 2 is the neurosensory one. We have skin pulls that don’t make a change, but when we do a soft tissue treatment, all of a sudden, the person goes from, if it was a 10 before, it drops to 5 or below. Then, we can do our neurosensory tape job. We have Concept 3. We find the skin pull that reduces symptoms from a 10 to a 5 or below, and we’re going to do a skin pull using a tab taping, which I will demonstrate shortly, and pull it into that direction. Concept 4 is our fascial sling taping. Again, either we are taping part of a fascial line or an entire fascial line based on our soft tissue responses to a movement assessment, as well as not only testing the line that looks dysfunctional, but the opposite end of that seesaw, that may be what we think is over-dominant, and making sure we treat that one as well to make sure everything gets balanced out, and then taping whichever part of the fascial line that is dysfunctional or the entire fascial line that’s dysfunctional once we know that I can improve it using my soft tissue methodology against stimulating those A-beta fibres and normalize the tone of tissue. Lastly, we have Concept 5, which again is our postural tapings, our disc tapings or instabilities, or laxity tapings.

I want to take some time to actually describe Tim Brown’s work. Because again, this is, to me, one of the greatest evolutions within taping. Dr Tim Brown is from California, he uses every tape under the sun. Leukotape which, by the way, I’m just going to show this really quick. Leukotape is our classic strapping tape. To me, it’s the best strapping tape on the market, but this is our brown rigid strapping tape. It does not stretch, is very sticky, and won’t stretch pretty much in any direction. This is rigid strapping.

We have things like Coverall, which is a white cloth tape. Coverall comes in two and four-inch varieties. It has the backing split in the middle. It’s a very, very thin tape. It’s very sticky, but it’s also a very hypoallergenic tape. We put this a lot over if somebody has a wound, maybe we use a gauze pad. We’ll put this over the gauze pad to hold it to the skin, so it’s very hypoallergenic. It also sticks really well. Again, it does not really stretch lengthwise. However, Coverall does have a unique ability that it does stretch widthwise. That’s going to become effective when we show our ankle strapping, and we do a couple of techniques with orange Coverall that helped give us a little more mechanical support to our ankle strapping tape job.

Now, Tim utilizes, again, all of those different tapes. Kinesiology tape, we’ve already shown. His big thing is he created something that he called the AC tab, the Approximation Compression Tab. To me, it’s my going joke in every single taping class I ever do. On the seventh day, the clouds spread, the sun came down, and it shined on the AC tab and it was good. The AC tab is one of the most powerful things we have in the taping world. It is so much more powerful than just tugging on the skin using a kinesiology tape, like the tweak taping or the fascial corrections that we’ve done in Kinesio tape classes. This has a much longer-lasting effect because of the type of tape that’s used. It does not have the elasticity. It holds the pull much longer than your kinesiology tapes do, or the elasticity of your skin, which will release. It is basically a neuro-proprioceptive technique. However, it can be exceptionally mechanical as well. It does assist in, as we’ve talked about, when you stimulate the neurology, it can correct muscular motor patterns.

Now, why is that AC tab so important? Tim used to use these all the time. This is a little different from what Tim demonstrated to me when I first learned it from him. God knows where he’s evolved himself at this point. I have not had the pleasure of watching him lecture for a few years now, especially since COVID. In that same aspect, he evolved so fast. I’d never be able to keep up with him. However, that AC tab, he would put it on the skin and pull the tab in different directions to find out which vector created the greatest improvement in somebody’s problem. I went a little bit further. I said, “Why am I putting the tape on the skin first? I want to know where I’m putting the tape.” I did it with my fingers. I would grab the skin and tug in different directions during a slew of different activities to find out which one made them feel better.

He put it on the tape, he put it on the skin, and just pulled it and said, “Which way feels better for you?” I tend to do it a little bit more mechanical, not mechanical, but using more mechanical positions or muscle tests or things along those lines while doing the skinfold. Very, very effective at actually getting a true vector that’s going to give you a big bang. Again, his taping techniques are invaluable at reducing pain and restoring proper function. It was tab straight that vector pull of relief. It gives you much, much, better pain relief and movement patterns during injury. Again, because it is a strapping tape, it tends to be really supportive.

Here’s a video on how to make an AC tab, although I got a feeling I’m going to be doing it visually through the webcam anyway. Here is our taping. Now, I’m going to do it along with the video. I’m using that Leukotape, and I’m cutting about, four to six inches. This is about 4 inches. The larger the body part, the bigger your tab is going to be. The smaller the body part, the smaller your tab will be. When we’re ripping, what I’m demonstrating there, you want to make sure that you squeeze your fingers together and pull apart. When you twist, it tends to kink on itself, and then it’s hard to rip it. When you’re making your tab, stick the tape on your finger, have the adhesive facing away from you. You’re going to place your hand palm up. Place the non-sticky part of the tape on your fingers, fold it in half, and then you’re going to squeeze with your thumb. Then, you got a tab.

As I’m placing it here, you can see I’m putting the tab on the skin. What the biggest problem that most people do with tabs is they tend to want to really tug on it so hard. Not about that. You really want to just make sure that you’re giving a light pullover it. The easiest way of creating the greatest amount of skin pull is you’re going to catch the tab, just like I’m showing there. And then, I’m going to put my finger, and I’m going to put it into the skin. I’m going to push down into the skin, and then just gently pull the tab over my finger. You can see just by doing that what kind of a convolution you will develop within the skin. The key there is not overpulling on the tab, but by literally creating that gentle tug that’s going to be the neurology that resets that firing pattern of those tissues and restore its proper function.

Now, when you’re doing a neurosensory style of application with an AC tab, again, our purpose here would then be to restore proper motor function, improve range of motion, improve the ability to move. It’s through that AC tab that we’re able to create that vector. It’s the fascial pull that stimulates the neurology. While you’re still using a strapping tape, the important thing to understand here is if you’ve applied it correctly, it will not limit the range of motion. Fascial pulls for a neurologic application should not limit the range of motion. If it’s a structural application where we’re trying to limit a range of motion using SPRT methodologies, they will have a limited range of motion. We’ll show examples of that as we go along.

Now, with the structural applications, again, that’s used to block an injurious range of motion. You determine the point of pain or dysfunction when it gets created. What you’re doing is, then, creating a hard end feel to remind the patient, “Don’t go past this. I’m going to hurt myself.” I use the disc herniation example earlier. You have pain and radiation, in my slide here, I say at 35 degrees of standing with bending. I bring the patient back to 30 degrees, just to the point where that radiation stops, that’s when I apply my tape. Again, it’s also used to enhance posture. It assists in the retraining of posture patterns. It’s that hard end feels in more severe cases, so a patient knows, “I can’t get past it.” It blocks them a little bit more. Whereas kinesiology tape, they’ll have a soft end feel, they’ll be able to bounce through it. It’s just a biofeedback mechanism that brings them back.

Now, when we’re clinically applying tape, there are a lot of different cuts that we can go through. We have “I” cuts, “Y” cuts, X-cuts, “Fan” cuts. Trust me, this is just the tip of the iceberg. Your creativity is, what, bottlenecks, diamond cuts, and everything under the sun. You’re basically going to cut your take based on what you need to do. I’m not going to use a big two-inch strip on a toe. I might cut part of that tape down to one inch. We call it the bottleneck cut, which I’ll just quickly demonstrate for you. A bottleneck cut, what we’re doing is making a bottle. This is the neck of the bottle, which will fit on a toe, and then the rest of this will fit on the foot. We do this for a thumb as well. When you’re doing something like a De Quervain’s, you might use a bottleneck.

Your cutting is largely going to be based, at least to some extent, on your creativity, understanding you don’t want to get too ridiculous. We’ll show some examples of that when we’re going through some of the literature. I don’t use fan cuts too much anymore. I tend to use more, what I call lantern cuts. When you do a fan cut, there are a lot of tails. There are four of them. When you have that fan cut, it allows for more surface area or clothing or something to rub against it, and therefore pull it off. What I’ve switched to is doing more lantern cuts because now we have one two-inch base, granted I round the corners, and another one, which gives less little surface area things that I can catch on. It’s more adhesive. It’s stuck to the skin better. However, I can create my tails in the middle. You can see there are four tails with this one using a lantern cut. I might put that over an elbow or a knee. Again, this just increases some of the surface areas that you’re able to hit at one time with still keeping the tape in contact with the skin. Also, it can be used for anti-inflammatory tape jobs.

When you’re applying kinesiology tape, the main thing to remember is you’re always going to try and move that joint through its range of motion, unless you are doing structural applications, postural corrections. Again, as I say, you’re going to move the joint through its full range of motion and then complete the taping application on the skin for neurosensory and those anti-inflammatory applications. The, X, the Y, the I, and the fan cuts are most commonly used in the taping world. I tend to use I cuts and Y cuts the most. Hands down. Third would be my lantern cuts and bottleneck cuts.

However, we can do diamond holes as well. Just to give you an example of what that looks like, a diamond cut is literally creating a small little hole within the tape that you might want to put a digit through. I only did one here, but let’s just say you wanted to put a digit through this little hole right here. I’ll use a scissor because that will actually demonstrate it. I can now take a digit right through that hole and apply it to my body. I don’t use a lot of diamond cuts because a lot of the time, whether you’re putting kinesiology tape on the palm or on the foot, guess what? It tends to come off pretty easily. The bottom of the foot sweats a lot, palms sweat a lot. They don’t stick nearly as well. I try and avoid those areas other than for plantar fascia taping for the bottom of the foot. Otherwise, I try and keep things off those highly sweaty areas. Again, there are stickier tapes than others that sometimes do.

When we look at taping width, Leukotape tends to be an inch and a half, although you can find this stuff in two inches. Kinesiology tape is I’ve seen in everything from one-inch, one and a half inch, two-inch, three-inch, and four-inch, so it’s been the gambit of the market. I tend to use two-inch and four-inch. Coverall as well, comes in two-inch and four-inch. Four-inch, I tend to use for very limited things, whether it be kinesiology tape or Coverall, but they are extremely valuable when we do use them.

When we’re applying the tape, the biggest thing, and again, somebody like myself who does a lot of instrument-assisted soft tissue work, we’ve got to make sure that the patient’s cleaned off. I remember having an associate once, who used to say, “I only use RockTape, largely because it’s the only one that seems to stick.” I’m going, “I use RockTape as well, but I don’t use it every day on every single patient for every single thing. It’s the person that’s going to do a triathlon and I’m going to stick RockTape on because I know it’s never coming off.” He was never cleaning the patient off. He was literally using a dry towel and wiping off the sweat, and the tape would come right off. You obviously need to make sure it’s dry. I use rubbing alcohol to clean off my sweat. The skin should be free of oils and dry. If a person is one of those people who literally come in smelling like roses and they had all the rose lotion on their skin, you might want to clean it off first.

Secondly, after you’ve applied it, you got to rub the tape. When you rub the tape, whenever you feel the heat on your fingers, that’s going to tell you right away you’ve activated the heat. An interesting thing with the backings of the kinesiology tape, one side is wax covered and the other side is not. You take the wax cover side and you can go over the edges of the kinesiology tape and you won’t peel it off. If you’re trying to create some of that friction, the worst thing in the world is when you go like this, and all of a sudden, you come back and, “Oh, I got one of the tails. It’s coming off already.”

When you use the backing and you go backward, it won’t do that. It holds pretty nicely. From that perspective, using the backing to rub, or when you get to an edge, just rub it in one direction. Once you have felt that heat, the adhesive has been activated and it will stick better to the skin. If you don’t rub it, it may come off easier. When you’re taping in more moist areas, like we talked about, a palm, back of the foot or bottom of the foot, I should say, sidelines if you’re working sporting events, you may want to use more water-resistant style of tapes.

Bluntly I’ve used a lot of different companies. My day-to-day tapes are very, very different to what I’m describing. I don’t use a lot of those heavily sticky tapes in my day-to-day taping for one major reason. I don’t need somebody to get irritated. If I’m taking it off to do a soft tissue treatment in 2 days, I don’t need to rip off three layers of their skin either. I tend to use tapes that lasts really well for three to five days. I use my really sticky tapes for people who are going into athletic environments, or they’re going to be gone on vacation for a long period of time, or they’re getting into pools, triathlons, Ironman, things like that. That’s when I used my stickier tapes.

My day-to-day tapes. I want them to be able to come off within three to five days without me feeling like I got to rip off half their skin. I also have Tuf-Skin. If I’m working sidelines, I will use Tuf-Skin almost all the time, because just because they came off the sideline doesn’t mean they stopped sweating. I don’t care what the tape is, if they’re sweating profusely, it’s not going to stick. We have to look at that in some aspect. In my office, if you literally walked into my treatment rooms, you would probably see four to five different varieties of tape because each one of them has a valuable situation for me.

The critical aspect of taping is most of our taping classes have taught us to tape where the area of pain is. My honest taping methodology, I tend not to necessarily tape the area of pain, especially when I’m using kinesiology tapes or things like that. Unless I’m doing like a strapping technique, where a disc herniation, or an ankle sprain or something along those lines. A lot of times I’m trying to neurologically improve the mechanics or the firing of the group of muscles controlling a joint, so that they actually move better. A lot of the times, if it’s a patellar tendon pain, I might not even tape the patellar tendon. I might be taping towards tibial torsion. You got to learn what’s the cause of the pain, which is why all these evaluation techniques become so critical. As I said, every single tape job that I teach always has a pretest associated with it.

When we’re doing structural applications with kinesiology tape, just remember theory. It’s a continuous biofeedback mechanism. It’s always telling you, “Oh, I’m in bad posture. I’m in bad posture.” It assists in protecting those injured tissues. It allows them to have greater healing time. It also helps block the adaptation of poor astrocytes. When we’re doing structural applications, remember that the tissue is not being stretched. For instance, I might put somebody into a biomechanically good position, and then apply my tape rather than stretch the tissue and apply the tape.

Just remember this, the more stretch you put in the tape, the less motion is going to occur. The less stress you put on the tape, the more motion will occur. Myself, as a chiropractor, if I’m going to tape myself for postural correction, I need to do less stretch on the tape because I need to be able to protract my shoulders during the course of my adjustments, my soft tissue treatment, and generally, what I do with the patient over the course of the day. I still want to get some of that mechanical correction, but I want it to be less supportive and more biofeedback. Remember, the more you stretch the tape, the more likelihood that you will get your rotation, especially if you stretch at either end of the tape, that’s where you tend to see the most irritation.

The application for neurosensory tape depends with kinesiology tape, actually with all tapes, is to stimulate the Merkel cell. Now, the Merkel cell is one of our, A-beta fibers, one of our sensory organs within the skin and the superficial fascia. The reason that the Merkel cell is the one that we, so to speak, discuss the most with taping is because it’s slow adapting. All of our other ones, our Pacinian, our Meissner, our Ruffini, all of those types of nerve endings are fast adapting. They’ll actually stop firing very quickly, so that you’re not constantly getting a bombardment of information in the central nervous system. However, the Merkel cell continues to bombard the central nervous system with stimulation. It is a slow-adapting organ.

Remember, the Merkel cell is an A-beta fiber, meaning it’s a myelinated large-diameter nerve, and it helps disrupt the stimulus of A-delta and C-fibers. Some of that information is also newer and the way we thought the A-beta fiber was working might be different than one that’s really working. Newer information comes out every day. We’ll talk about that in a slide or two. It also assists in restoring our proper afferent/efferent communication. Again, that’s most of what we’re trying to do is restore proper afferent/efferent communication. Within taping soft tissue. we’re trying to reset nerve pathways.

Here again, here’s our example of some of those, A-beta fibers, we have a Merkel cell, our Meissner, our Pacinian, free nerve endings, and Ruffini. All, but the Merkel there are those fast adapting as we taught. It used to be thought that because the A-beta fiber is a larger axon and it’s myelinated, that it’s faster acting or it travels much faster than the unmyelinated small-diameter nerve endings. There is some research nowadays that does tend to make contrary statements. In other words, they get to the same place pretty quickly. It’s about the same. It’s no longer like “Oh, the A-beta fiber got there first and it closed down a bridge. Now, the A-delta and your C-fibers are no longer able to create stimulus.”

The speed upon which it’s happening might not be correct. However, that doesn’t deter from the fact of what the A-beta fibers are doing. It still stimulates inhibitory neurons that block A-delta and C-fibers. The A-beta fiber is still firing off. It’s still hitting the inhibitory neurons, and that inhibitory neuron is still blocking our A-delta and C-fibers from getting to their endpoint. It’s still doing the same thing we theorized it was doing, which is blocking the transmission of A-delta and C-fibers. We just used to assume it was happening because it got there first. That’s not necessarily true. It’s just still hitting the inhibitory neuron that’s helping to block those pain cycles. Theories might change, the effect is still the same.

Now, when you’re applying a kinesiology tape, just remember that you’re going to put that tissue through a stretch and then apply the tape. Most tape brands are applied at about a 10% stretch on the backing. Some other brands are at 0%. Now, that’s going to come into play in a little while when we talk about what’s the appropriate type of stretch based on an injury. That’s a good question. We’ll try and answer that a little bit later. Again, where, when, what might you stretch the tape a little bit more than just tape are off. Let’s say, you can’t move a tissue like a frozen shoulder. You might apply a little bit more stretch to that tape.

Microcirculatory applications, now this is where the theology of taping has really taken a nosedive. The theory was that these convolutions on the skin create areas of high and low pressure systems, that create almost like rivers to move fluid from point A to point B. The reality is this might not be a hundred percent correct. The truth of the matter is, and we’ll get to the science. We’ll go through it and I’ll be able to fly through it a little bit quicker, is that a lot of this is happening really at the skin level only. The anti-inflammatory application, this decreased pressure, this fluid stasis removal, it only happens at the skin level. At least, that’s what we’re finding currently within the literature. It will be interesting to see as we’re better able to test these things going forward, if maybe we find effects deeper.

The greatest interesting thing that I’ve seen associated with the skin level thing is the duration for which this actually occurs. I have on my back, an anti-inflammatory tape, meaning the kinesiology tape was on there with a failed methodology. I happened to be taking my dry needling and cupping class. We applied cups over an area. I’d taken the tape off. We applied cuffs over the same area that I had the anti-inflammatory taping on. When the session was over, we took the cuff off and the bruise was underneath the cuff, except for where the tails were. I saw, literally, even though the tape had been taken off, it’s still created a hatch work over the area the cuff was applied. To me, it’s saying, “Well, how long is that change in fluid removal or that viscosity of that tissue? How long does that change for?” I don’t have an answer for that yet, but it was really fascinating to me to see that still occurs even when the tape has been taken off. I just don’t know how long that’s going to last yet. We are able to affect these things at the same level. Don’t discount that just because you’re stimulating the skin level, it’s not having a drastic effect somewhere else. We just don’t know all that information yet.

Again, we’re looking at this, this is the Accordion Effect that they theorized was the important aspect of fluid removal. It is not so important. Our microcirculatory applications, here is one thing. They definitely work. How deep their working is our speculation. It is not necessarily validated by our research at this point. We do know that we want to stretch the tissue and the tape when we apply it. However, if you want to get these skin reactions, these skin effects of reducing bruising and swelling at the superficial levels, tapes got to be on for about twelve hours. You can’t just put it on and five minutes later, take it off. Just remember, all of that bruising that happens under the tape that gets removed and that fluid movement that happens under the tape, It’s at the skin level. It is no longer theorized that it’s actually happening at a deeper area. Understanding the fluid, the lymphatic drainage points, nice to know, but I got to be blunt. I don’t know anybody who tapes into the armpit. If you’re applying for a tape job for fluid reduction and you’re moving it all the way to the armpit, yes, nobody does that.

The reality is as long as the lymph system is intact, all you need is to apply the tape to get that fluid moving. The lymphatic system will know where to put it. All you need to do is remove stagnation. The tape helps you do that at the superficial level. Here’s a picture of exactly what will happen to the bruise. Obviously, everything you’re seeing that’s a little bit more skin color, that’s where the tape was, where the bruise still exists, where the tape wasn’t. It does work.

We do have limitations with taping. One of the biggest ones, obviously, body hair. You don’t have to make somebody bawl with kinesiology tape. However, my joke with my patients is, “Look. I can either buzz you now, or I can wax you later. Which do you want to do?” Because when you take that tape off, you’re probably taking some hair with it. Most of my patients were like, “Oh, don’t worry. Just put it on.” By the second visit, they’re going “Please cut me down first”. I say, “I’m not doing it. You’re doing it. I don’t have time to buzz everybody’s hair. Either you do it at home, or when you come in here, I’m handing you my buzzer. You’re clipping your own hair. I’m going to go treat somebody else. I’ll be back in five or ten minutes.”

Another big aspect is I tend to teach a lot of my patients how to tape themselves. I think it’s pretty easy to do. I don’t want to discount that taping isn’t a massive art because trust me, man. I see some people who are just really bad tapers. I look at that as an art form. However, it’s amazing when I teach some of my people how to tape, that they go and they play their sport and they come up to me because I used to be a doctor for a volleyball league before I actually retired, when I started having children from my volleyball career. They come up to me in the middle of the games and go like, “Doc, I don’t get it, man. Every single time you tape me, it lasts my whole matches. Every single time I taped myself, it comes off.” I go, “When did you tape yourself?” “Oh, I just did it before I got on the court.” I’m going “You need to give some time for that adhesive to adhere.” I don’t care what the tape is. You start sweating immediately, it’s coming off a lot quicker than you want, especially when you start doing ballistic movements. My rule of thumb is you want to take forty-five minutes before an activity. If you’re taping during activity, you may need the sprays like we talked about.

Now, the other big one is the willingness of certain people to wear tape. now, TMJ? Yes, good luck. Nobody in the US is going to want to wear TMJ tape. SDM, same thing. Let’s just say if somebody who’s doing sales or something like that, they’re getting in front of people. They want them to listen to what’s coming out of their mouth, not look at what’s on their neck. These things. I’ll give you another wonderful example, more in the athletics or performance areas. I have taken care of high-end musicians. I have taken care of high-end dancers. The reality is everybody’s got an understudy. I don’t want to say it otherwise, but black swan kind of really does exist. I don’t mean that somebody is really trying to kill somebody, but the reality is everybody’s got an understudy. There’s always the next person up and nobody wants to show signs of weakness because that’s a lot in the water, sharks are circling. There are some people who do not want tape on their bodies because they’re afraid of it being visible.

I’ve had dancers saying, “Hey, I just sprained my ankle. I’ve got to do an audition in a week.” I said “All right. We’ll get rid of the swelling. Hopefully, you’ll be able to put enough pressure on it so you can do what you need to do. I’ll have you taped up, so you won’t have to worry about you spraining your ankle again.” She goes, “Oh no, no. You can’t tape my ankle.” I was like, “Iit’s your best chance of getting through this?” She goes, “You don’t understand. If I go in there taped, they’re going to look at me as damaged goods. They’re not going to hire me.” I literally said to him, I was like, “Let’s get out of the box here for a second. You need the tape job. Can you wear black stockings?” “Yes.” “Can you wear legwarmers?” “Yes.” “That’s what you’re doing. I don’t care if it’s 85 degrees out, you’re just going to cover up what’s taped, so they can’t see it.” Simple as that.

Methodology-wise, that’s what you have to be worried about. Some people are not willing to have it visible in public. Athletes are used to it. There’s always next man up in sports, but sports people are used to being taped and still performing, so you don’t really see it too much in an athletic world, that it’s a problem. With the amount of tape that people want, a football player wants a lot more tape on their ankle than a soccer player or a runner. Football players were like “Yes, just give me a suit of armor.” Soccer players are like, “I want to feel the ball. I want to feel the ball through my boot,” which is why their boots are so tight too.

Now, when we look at the indications or the initial difficulties associated with taping, obviously, over-pulling, because that’s really an athletic taping world. You over-pull the tape a bit. Needing to treat both the pain and correct what’s causing the pain, I got to be honest with you. A lot of people are great at taping pain, but they’re not really great at taping the mechanics associated with why it’s happening. That comes down to understanding what’s the injury diagnosis and how to actually take care of it. Proper and muscle evaluation is critical. You got to be able to look at movement patterns. You need to know the lymphatic system, not necessarily from the standpoint that you’re draining it, but you want to know that somebody has got a lymphatic system intact to assist with draining.

The other thing is man, oh, man. I come up with a new tape job every single week. It’s only based on those five concepts. Oh, four concepts. The first one says, don’t tape. You need to unlearn what you think tape can be used for because if you’re going through your proper evaluation, you’re going to find like “Holy cow. That worked? Amazing.” It’s shocking that you will come up with a different methodology of taping the same injury you’ve been taking forever, just based on those four concepts.

Now, we’re going to spend a little time. I’m just going to try and do it as quickly as I can through here because I want to show as many examples of taping as I can. We’ve got about fifteen minutes left. I want to make sure that we have a good understanding of where our current literature is in taping because sadly, it’s not very good. Again, this is with the permission of Phil Page, who allowed me to use a lot of his presentation on this, as to those other companies as well that I’ve given credit for their slides. Phil Page is one of the brightest guys that I know. Obviously, as you can see, has more degrees than any of us really want to know. However, he did a miraculous job on coming up with this meta-analysis on taping as did Dr. Mike Schneider as well.

In the process of this, they reviewed thirty-one websites on kinesiology taping. Again, most of it, if you’re getting your knowledge from a website on taping, oh, boy, that’s salesmanship, that’s not knowledge. Most of them are anecdotal. It’s almost like on Wikipedia to write the paper. It’s not going to be the greatest information in the world. They’re usually of poor quality. They’re usually with an advertising, misleading kind of statement. They use literature freely to benefit themselves, rather than critically to actually give yourselves a base as to why you’re performing things.

I also am not a big fan of saying, “Well, it’s not on literature, therefore don’t use it.” My statement to every single person is this. “Well, there’s nothing on the literature that says that works. I say, “Show me in the literature whether there’s something that says it doesn’t work.” You can’t use literature as a weapon unless you’re willing to accept it on the contrary. Quite frankly, most people that I see use literature as a weapon tend not to use it the other way. In other words, they’ll say, “Oh, there’s nothing that say it works.” “Yes. Where’s the literature that says it doesn’t work?” They’re willing to criticize, but not accept. In those situations, my statement to all of those people is to show me it doesn’t work. Then, tell me the literature that shows me it doesn’t work if you’re going to tell me the literature says it doesn’t work. It’s a contrary statement. You have to look at it in both ways. You have to be on scrutinize literature as much as you’re going to use it as a weapon.

One of the things that, of course, we talked about was convolutions. The kinesiology tape really lift the skin. Well, they’ve done it in both animal studies, and they’ve done it as well in human studies. Basically, there is no research at this point that supports lifting the skin is a benefit, or that lifting the skin occurs when tape is applied. In particular, in this one, they use an ultrasound analysis to look at the difference between skin level and patella. It just didn’t find to make any kind of statistical change.

Does kinesiology tape increase blood flow? Again, through the studies that were done here, they’re showing that only passive ex– They used rabbits to measure lymphatic flow finding only passive exercise with tape increased lymphatic flow. Tape alone wasn’t effective. At the skin level, we are seeing changes in blood flow. However, not at the muscular level. The superficiality of its effect is what it is. It is not a deep effect. We have to consider that if we’re trying to use tape associated with blood flow. Taping alone is not effective.

Do the convolutions matter? The interesting thing is when they tested this, they put convolutions down, and want to see does blood flow makes a difference whether there are convolutions or non-convolutions. They did it over a three-day study. They basically found convolutions have no difference whatsoever in changing the blood flow. This is the study that I struggled with because if you look at those pictures a little closer. It may be hard for you to see on a small screen, but if you’re looking at this on the computer, you’ll notice that this is a tape that’s looking at the bruise. With that bruise, they’re trying to determine whether or not you actually get rid of the bruising by applying the tape.

Now, if you look at this. There are four strips of kinesiology tape that were laid right next to each other. One does not allow for a proper pressure gradient between skin that is taped and skin that is not taped. You’re not creating an effect of, again, using the word weaver, even if it’s at the skin level. I challenge the study a bit because of its methodology, not because it’s basically discounting everything. I think this is a test that needs to be done, and barely not to mention the thickness of the tape isn’t very good either. It’s a little too thick to apply. I think the study, methodology-wise, is a little bit poorly done, it could be better because I see bruising change all the time on the skin. However, do the convolutions matter in reducing that? Based on the results that have been found at this point, the convolutions generate no change in blood flow versus non-convolutions.

Now, one of the other things that we like to look at is, well, patterns, tension, and direction. Does tape application really produce a specific effect? These are pretty colors by the way. Love it. Very visual, great, looks cool, but here are some more of the pretty pictures. I look at some of these and I’m going like it would take me 30 minutes to cut these applications. I got to treat a person in 15. There’s no way I’m doing a lot of these tapes jobs. Some of them are just ridiculous. The fine one in the upper corner there… First of all, a TMJ one is nobody in North America that’s wanting that. I look at the scapular one, I’m like, “Wow. That’s a lot of cutting.” I’m really good at cutting the tape to save time, but that to me looks like we’re going to have some trouble. Does it matter? If it’s really pretty, but it’s 100% effective, “Oh, God. Yes, I’m jumping on. Absolutely.”

Do the patterns matter? Well, there’s not any research to really support the type of pattern as to what’s the critical aspect of the result. Hence, if we look at it, these are all tape jobs from research studies done on the shoulder. This is in the literature. Notice how all of them are different. Not a single one of them is exactly the same. Some will look similar, but even from that aspect, they’re all applied differently. We have no standardization as to the effect of the kinesiology tape because we didn’t take this is the way it was applied. This versus this or this plus this is a variable versus control of just tape or just rehab or just swap tissue to actually see what’s the benefit. We’re not using good controls with a lot of it. Does it make a difference? We don’t really know well.

Does tension make a difference? Now, this is an interesting one. 0%, 10%, 25%, 50%, 80%, 100%. What are we supposed to do? Not a lot of great research at this point to support that one tension is better than another. The only thing we can seem to agree upon is that the greatest amount of studies done at this point to create a neurologic change is somewhere between zero and 25%. But then again, looking at a neurologic outcome, it used to be somewhere between zero and 50%. It’s what most people in studies have been applying tape at. To me, that’s a big variable, zero to 50%, even at zero to 25%, that’s an enormous variable in trying to determine what kind of tension. I tend to be paper off tension, meaning I don’t stretch the tape very much if I’m applying a pure neurosensory style of tape jobs, mainly because of skin irritation. The more stretch the more likely you are to irritate. From that perspective, that’s how I look at this.

Muscle activation. Do we really get a change in effect associated with muscle activation? Well, there are 19 studies that were done. However, they compared kinesiology taping to a ‘sham’ application. Wow, do we not understand how taping is applied? If you applied it to the skin, it stimulated the nerve receptor. There is no such real thing as ‘sham’ taping. If it’s applied to the same region, even though instead of this way, you went this way, across and instead of up and down, it’s still stimulating neurology. It may not stimulate as much neurology, but it’s still stimulating neurology, which then can give you not enough specific change or a change in specificity, the RP rating that actually make it different. No significant difference was associated with the tape jobs. What we’re saying, again, is kinesiology tape does not affect muscle activation in healthy subjects. Another problem with a lot of these studies is they’re done with all healthy individuals.

Can the direction of application inhibit or facilitate? Once again, this was one I remember taking my kinesiology taping and asking our instructor, and our instructor is going like, “No, it doesn’t make a difference.” I’m going, “I think it really subjective.” Direction at this point has not been shown to have an effect on muscle activation. That doesn’t mean somebody might not respond better going from insertion to origin, or origin to insertion, but it’s not based on muscle activation. Can a direction facilitate or inhibit a muscle? Again, no effect on that muscle activation as we just said.

Lymphedema, has taping been effective? Yes. There is some evidence that shows that there is an effect. However, we got mixed results, and no matter what, it’s not as effective as doing our old circular bandage wrapping associated with lymphedema. It’s got a benefit, but it’s nowhere near as beneficial as what we’ve seen already in the literature.

Again, we have does tape convolutions lift the skin and increase blood flow? Does direction of application influences activation? Do tensions provide specific outcomes? Are specific patterns required for specific injuries? As Phil would say, this one’s got myth-busted. All of these at this point, with the current literature, are inconclusive at best. Again, understanding the literature itself is not very good in its methods. Take it with a grain of salt. Don’t think that just because the literature isn’t supporting what you think it does… The methodology for most of these studies is very poorly designed.

If we take a look at the mega-review of the clinical effectiveness of kinesiology tape, again, this was done by wonderful authors right there. They did 17 reviews studies included in this. What they discovered, more than anything, is that pain probably has the greatest benefit with kinesiology taping, and that is a short-term benefit at around. There are a number of studies that have shown benefits. However, within the rest of those things, strength, range of motion (ROM), EMG, proprioception, swelling, mechanical function, all of these aspects did not get great conclusive evidence in reviewing.

Pain disability has definitely had some kind of an effect. Likely through, pain inhibition. In other words, we’re blocking A-delta and C-fiber stimulations through inhibitory interneurons. Placebo effect. Look, I love it. When everybody’s like, “Oh, that’s just a placebo. Why is everybody on the planet talking, at least a clinician, a knowledgeable clinician talking about the psychosocial things, but then, we just go, “Oh, it’s just placebo.” Well, if the psychosocial is such a huge aspect of what we’re doing, why do we discount the placebo? Look, I am the placebo. If you happen to figure that out in the last hour and 25 minutes, I’m upbeat. I’m energetic, I’m smiling. I love what I do. I’m passionate about it. That is the placebo. People like to be around me. I didn’t do anything physically to them to make them better. I’m just happy and energetic.

That’s the placebo. Don’t discount it. Enjoy it, embrace it. Be the freaking placebo. Love it. That doesn’t mean the rest of what you do is useless, it just means you are beneficial to the psychosocial of what we do. That’s not a bad thing. Who wants to be vulnerable? The grumpy doctor who’s putting their hands on it all the time and, “Oh, I hate being here today.” “Oh, man. You feel awful.” That’s not how you’re going to go about doing things. You want to be happy. “Hey, look at that change.” “Look at how much more you can move now.” “Oh, I know that was tender, but how does it feel now?” “Oh, yes. Well, that’s great.” Placebo, man. It’s a good thing.

Pain outcomes. Again, we look at pain perception, visual analog scale, numerical pain index. There are trivial benefits to short-term pain relief. That’s what we’re getting out of this. Again, you could see also in that left lower hand corner, you can see all the different areas that they did these studies on. Pain outcomes or everything from TMJ stuff, Oral/ Maxillofacial surgeries to spinal cord injuries, dystonia, and so on and so forth. There are a lot of things that are happening within this one.

Muscle support outcomes. Again, 14 studies, trivial improvements. Joint support outcomes, trivial improvements. Neurological outcomes, proprioception, balance/postural stability, spasticity, things like that. 11 studies, the bottom line needed a lot more research to make this conclusive. Circulatory outcomes, are unclear, very little evidence, except we know that it has happened at the skin level. That’s about it. Functional outcomes, functional mobility, performance, disability. Some evidence of improved function. Not a lot of great because a lot of times, again, we’re looking at healthy individuals. It’s a challenge from where it is, that we, as clinicians, want to use evidence to assist us in making decisions. Unfortunately, it’s not really there for us to use as a weapon of power. However, I also don’t think it’s there to be a weapon of negativity because the methodology is so poor in these studies.

Does kinesiology tape reduce swelling? It increases the skin’s blood flow. That’s why we see the changes in bruising. Does the tape reduce swelling? We just talked about that. The research is inconclusive. It does have mixed results. There is a benefit. The only problem is that it’s not just as beneficial as the methodologies that had been currently used, like spiral wrap for lymphedema. Just take that into a bit of an account.

Does it reduce swelling? Post ankle acute swelling. It may not have as much benefit on acute swelling as I used to think. Now, I used to use this all the time, but I never used it as a stand-alone. Luckily, I used to use it after I did my assessment of the swelling. Nowadays, I don’t do a lot of acute ankle edema reduction. I go right to my ankle strapping to support the ligament so it doesn’t re-swell, and I’ll use my NormaTec to help push that swelling more back into the lymphatic system rather than using the taping methodology.

Again, does it reduce lymphedema? It’s a benefit, just not as good as other methodologies. There is some reduction in lymphedema, but bandaging is better. Looking at kinesiology taping with certain injuries, like the shoulder impingement. Yes, we’ve shown intermediate relief, less night pain. Is it more effective than a placebo tape job. There we go again. Placebo tape job, sham tape job, no such thing. You don’t understand how taping works if you’re using taping as your control. All right. There is no sham tape job. It’s a really bad methodology. We need to get a better methodology of our research studies in order to improve our outcomes as to why we use tape.

Can kinesiology tape be useful? Hell, yes. It’s useful for a lot of things. In the research, we’ve seen it beneficial for TMJ, whiplash, shoulder impingement, elbow pain, low back pain. I know, I hate those methods. Those are not really diagnosed as this is to me either, I get it. But these are just the way they were described. Anterior knee pain, obviously, patellar tendon thing. ACL reconstructions, knee osteoarthritis. Oh, boy, do I have a great knee osteoarthritis tape job. Total knee replacement, plantar fasciitis. My God. it’s brilliant. Spinal cord injuries, well, I don’t do a lot of spinal cord injuries, so I can’t comment clinically on those myself. Lymphedema, I don’t do a lot of lymphedema work myself. I send that out to physios who do that on a daily basis. I’ll take care of some of the scar tissues, soft tissues, things along those lines. Radiation fibrosis that might develop, that’s more my wheelhouse. I don’t do lymphedema. I send that out myself. Again, there’s a list of other things, dystonia. All of these methodologies had shown that there is a benefit, it’s just important that your studies are great.

Now, let’s look at how do we handle the tape. Obviously, number one, you want to measure and cut it. You want to cut it to the sides and shape up what you’re trying to accomplish. You’re going to remove part of the backing, for taking our little tape job here. We can remove the backing. When I remove the backing, I remember when I took my first kinesiology taping class, they’re like pulling back. I’m like, “What the heck. I’ll sit here all day long.” Break the backing, peel it off, we’re going to apply the tape right to the joint, and then I keep the backing on as long as I can. And then, all I do is peel from here. Then, I can get my taping on my thumb that way. Okay?

First of all, remove the backing. There are two anchors, obviously, a starting point where you want no stretch, and an ending where you want no stretch. I intend to be paper off tensions, so I don’t have a lot of stretches for the neurosensory style of tape jobs. It lessens the amount of irritations I get. Again, apply. Are you’re doing astral taping with more tension or are you doing… Don’t forget to rub the tape to increase the adhesive activation and the amount of tension that you’re using. To me, it’s paper off tension for most things. Unless I’m doing structural tape jobs, then I’ll go over 50%. Some taping companies have little hexagons built-in to the width. I always love to say everybody’s got a gimmick. These tapes got all these freaking patterns. Everybody’s got colors or something cool or whatever. Gimmicks, gimmicks. I don’t care. I just want outcomes. All right. For me, the tape is important for matching an athletes’ uniform. But past that, all the other gimmicks are like, yes, cool, whatever.

Aftercare is critical. It can be used for up to five days. Some people… Trust me, I’m one of those guys. I keep the tape on my body for like 10 days without problems. Be cautious with tape that stretches over 50%. I always say this, if your symptoms get worse or your skin gets very, very itchy, then you need to take off the tape. Do not rip the tape off like a bandage. You want to peel it off slowly. Now, I’m going to do this right now. That tape that we put on before, I already cut that edge when I was rubbing back intentionally. I can show you. What you want to do when you’re doing a tape removal is slowly, I take the skin with one finger and pull it in the opposite direction. With the other, now granted if I have two hands, I have one hand that’s pulling in the opposite direction. You’re going to slowly pull it back, it pulls off the hair much less, and it’s a lot more comfortable for the patient as you’re doing it.

However, one thing I always try and caution my patients on, do not to let your spouse take off your tape because, I promise, they’re going to wax you. I don’t know what it is in the spouses’ genome, and it doesn’t matter if it’s male or female, they love to rip that stuff off like a bandage. It just makes them feel happy by the way they take this. Be cautious when taking off tapes. It should be done slowly. I always say, “Let me take it off. I’m a lot nicer than your partner.

You pull the skin in the opposite direction of the tape removal. Do not take the tape off against the grain. In other words, your hair is going down towards your wrist, don’t pull it off this way, that’s waxing. Down, you’ll save a lot more hair. You can shower and swim with the tape. When you’re drying it, dry it with a towel. Just gently on a towel. Don’t use a hairdryer. It then becomes a second skin. Remember, it’s heat activated. If you use a hot hairdryer on your tape, it’s going to stick a whole lot more. You got to be a little more cautious with that. Also, make sure not to pull the tape too hard in any one direction, otherwise lots of problems.

Now, limitations on kinesiology taping research, obviously, I talked about this. Phil has been instrumental in the understanding the literature. Again, I’m a clinician. I am not a researcher, but he and Mike Schneider stood out at my brain forever. Poor quality and design of the studies, they’re just extremely poorly done. I don’t blame the researchers. They didn’t know any better. Nowadays, we know better. All right. We shouldn’t be doing conduction of studies on healthy individuals or using sham taping as a control. It’s not going to work. Patients, as I said, versus healthy subjects.

Taping application is often based on opinion, not on science. I would love to use patient selection. Like I said, my methodology is using pretest. If we did a study on meniscal tears, we have a confirmed test that does a meniscal tear. Our patient selection is if we correct tibial torsion, does it make them feel better? If it doesn’t, why are you taping them, to begin with, that way? I would like to use patient selection in order to create a proper study of intervention x with tape versus intervention x, as long as we’ve done proper patient selection. That’s number one. There’s obviously lack of mechanistic benchmarks. Again, we created most of our taping based on theory, not on science, at this point. However, I try and base mine on an “if this and that” pretest and the post-test to know that what I did at least affected pain or at least improved range of motion and function.

Kinesiology tape works, but it might have some placebo. Probably, and I agree with this, as much as I have done tape jobs, which by the way, I could put it on and you’re going like, “What did you do to me? I’m feeling great.” To me, it is still not a stand-alone intervention. It is something that you might use as a band-aid in a quick moment, but it should be part of your methodology of treating not the end-all, be-all through the methodology.

It does not inhibit or facilitate. All we do is stimulate nerve receptors and the body normalizes the tissue. It’s the central nervous system that figures out how to do that, not the tape. It does not improve performance or function, at least, to the best of our ability of research at this time. No evidence that it lifts the skin or increases blood flow below the skin. It may reduce swelling, but there are better options out there. Convolutions, patterns, and direction application may not matter. We just don’t know because everybody does different patterns and it’s like we varied. We don’t have research to assure that one way or the other at this point. Some tension might be important, but the problem is, right now, our range is so drastic. We don’t know exactly where we need to fall.

The final thoughts as we would say, pain only, placebo effect, specific application probably doesn’t matter. let’s take at least the last 20 minutes of what we have going on. I’m going to go through a few tape jobs based on the concepts that we’ve just talked about. Now, you’re going to see the concepts in actual action. For the first, what we’re doing is, remember, I skipped Concept 1. Why? Because Concept 1 is don’t tape. I don’t have a pre and a post. Just remember, your pretest did not show you that you should tape. I didn’t get a 50% reduction, I didn’t even bother.

Concept 2, reiterating, is an evaluation procedure that creates the dysfunction or pain, no fascial pull makes if it feel better. What we’ll do is a soft tissue treatment over the involved area or in the above area. It drops by grading in 50%. In that case, we use that basic neurosensory style of the tape job. I’m giving an example here of using an extensor/flexor tendinopathy. We have pain in the region. A manual muscle testing increases the pain, a fascial pull does not relieve it. However, when I do my soft tissue treatment, the manual muscle test reduces pain by at least 50%. Those are basic.

These are pictures. I’m going to show a video as well, so it’s going to be better to see. Here, you can see the tape, I started at the wrist and moved up. Why? Because if I go long, I’m going long into the upper arm rather than going long into the hand and fingers. However, if you measured it properly, it usually doesn’t go too long either way.

Let’s watch this video, and I’ll talk you through it. In this situation, we’re going to do our tendinopathy. We’re just using kinesiology tape. This is Concept 2. We did a muscle test that’s painful, but it doesn’t improve with the fascial pull. I’m pulling on that skin, it’s not making a difference. However, when I do that soft tissue treatment over the area, I get a significant reduction of a thing. What we’re measuring is from the elbow down to the wrist. We’re going to make that cut. We’re going to break the backing off. It’s about two-inch box. We’re going to start at the wrist, and now, we’re going to slowly apply the tape. Watch this. Notice, I haven’t taken the backing off the entire tape. What we’re doing is stretching that tissue, and then just gently paper off tension right off all to the lateral epicondylopathy. There’s a perfect example of a simple neurosensory tape job associated with epicondylopathy.

Now, if I can do this for every muscle in the body, or in every compartment in the body… I don’t like using muscle. I don’t tape muscles. I tape compartments at times, but if I can’t find a mechanical or a fascial pull that makes something better, I’ll do a compartment. But, oh, my God, to say it’s an individual muscle, we’re smarter than that. It’s not individual muscles. It rarely is an individual muscles. It’s not the way the body works, to begin with.

Concept 3, my favorite one. Tim Brown, God bless you, man. An evaluation produces a dysfunction. We do a fascial pull that improves the symptoms. We use that SPRT neurosensory tape job in that direction. If I pull the tape this way, I’m taking the skin and pulling it in that direction in order to create my improvement. It’s based on the evaluation. Whatever position you pulled in, that’s what creates it.

I’m going to give an example of manual force closures. This isn’t really a skin pull. It’s almost a joint pull, but these are manual force closures. This is similar to the work that was done with Diane Lee, as well as professor Andrei Fleming. They’ve both have done manual force closures associated with the side joint. I do mine manually. Professor Fleming actually said, “I couldn’t do weight-bearing,” because he has side joint lacks in places, but it’s been working well for the last 15 years. You might say that, but I don’t think you’re right. Again, I don’t it’s mechanical I think it’s neurologic. I did his methodology which is a non-weight bearing force closure and compared it to mine, and by the way, they’re exactly the same. The results were exactly the same. If one comes up positive that way, it comes up positive in my methodology as well. Again, it goes back to how much of this is mechanical and how much of this is neurologic.

Here’s your pretest. You have a rotational problems at the SI joint. I just rub it this way, in the chiropractic world, we love to say like a left PI ilium or something like that. It doesn’t matter. It’s not what’s PI and what’s AS. It’s just a rotational imbalance. Supine to Sit Test, I’m not necessarily going for verbal description/ I’m going to try and see if we show it a little bit on the video, in the evaluation, or an active straight leg raise test. We’re going to do Supine manual force closures or standing manual force closures to determine if the SI is the critical component to that person’s pain.

Let’s go through that evaluation a little bit here. We’re going to start with the Supine to Sit Test. Now, with this methodology, Supine to Sit Test, it’s basically taking the pelvis, understanding the acetabulum position as well as doing the [inaudible] position as well the SI joint itself in the rotation. If something rotates back, you know you’re going to have the acetabulum raise superiorly. If something rotates anteriorly, the [inaudible] is going to drop down.

This one, however, we’re going to start with an active straight leg raise. Now, the SI joint. Again, Professor Fleming was instability. We, as manual therapists, tend not to do the instability, we tend to do it with imbalances in laxities. Let’s just say that, in this case, we have pain on one of the active straight leg raises that was just down there. We’re going to do a Supine Manuel Force Closure. We’re standing at the left posterior ilium, which means to the right anterior. On the left side, I’m grabbing the PSIS. On the right side, I’m grabbing the ASIS. What I’m doing is counter-rotating. They’re going to reproduce the active straight leg raise. What we’re looking for is either the leg comes up significantly higher, either functionally, or the pain starts higher, or the pain reduces again by at least 50%.

The second part is the Supine to Sit Test. Now, if you’re active straight leg raise test doesn’t composite, it doesn’t mean you shouldn’t do the Supine to Sit Test. I find active straight leg raise only in the more severe cases. A Supine to Sit Test is a screen and your Manual Force Closures weight-bearing are much more effective.

What we’re looking is we’re looking for a leg length. We’re going to say it’s a left short leg. What she’s going to do is eventually comes to a seated position. And then, what she’s going to do, she’s going to use her hands to prop herself up to take all muscle activation out of this. I use the go, 1, 2, 3 to come to seated. Now, she’s going to prop herself up on her hands, and I’m looking to see did that leg, yet no tension don’t pull or tug on the legs. You’re just looking to see what happens as you come to that seated position. In her situation, the left leg got longer. What we’re thinking is, if the pelvis is posterior on the left side, the acetabulum has raised up, which is going to give the appearance of the short leg. As the opposite side has gone anterior, which is going to drop the acetabulum down and it’s going to make it longer.

As she comes to a seated position, remember the normal biomechanics at the SI Joint as you go into flexion is the posterior rotation of the ilium. Since this one is already posterior, there are only a few degrees that occur. It’s not going to go more back, however, this anterior side is going to go to its normal biomechanics, giving the appearance that that short leg, which isn’t moving, is actually getting longer as this long leg is going… It’s shortening because it’s going through its normal biomechanics as the acetabulum raises up.

That’s basically the whole theology of Supine to Sit Test. However, it’s a screen. It is so easy to get screwed up, which is why we got to go to Manual Force Closures weight-bearing plus it to be anatomical for a short leg, it could be a surgery, a fracture, or other things along those lines. I see this all time with replacements, knee; joint replacements, knee, or hip. What the short leg is, it’s actually incorrect. When you do Supine to Sit Test, that left leg looks like it is short, when you go to weight-bearing, it’s actually an anatomical and it really is anterior. Because if the short, to start with, when you go weight-bearing, it was anterior to drop the leg down to come in contact with the floor. That again, is why it’s so important to go to a weight-bearing standing correction.

In this situation, we’re going to bring the patient to standing. We’re going to have her go through a lumbar range of motions. Most of SI joint problems have a lumbar range of motion that creates pain. In most situations, I see extensions and side flexion or the ones that create the most amount of pain, but it could be any of them. It could be flexion, rotation, or could be anything. What you’re going to do is test a range of motion that are painful. Once you know the range of motions that are painful, you tell the patient that’s to 10. What you are going to do now is your manual force closures. You’re going to hold up… The biggest thing when you do your manual force closures weight-bearing is don’t push across. You have to think of it as going off like a pyramid. You’re pushing to a point at a period. One on the PSIS, one on the ASIS, and you’re going to push up correcting that rotational problem. Again, pushing towards the top of the pyramid.

You can see me setting myself up. As I hold that manual force closures, now she’s going reproduce her extension and she’s going to reproduce the motions that are painful. I’m going to say, “If it was a 10 before, what is it now?” Okay? In this situation, when the SI joint is the primary problem, you’re going to drop from a 10 to a 2 in a blink of an eye. These are massive big bang tape jobs. They take a great amount of pain away from a patient and drastically improve the range of motion.

If we look at some of our other methodologies here, there are some pictures on this. I’m going to try and get through a video now on applying this tape. What we’re doing is we’re going to do our tape job. Again, this is a left posterior. We’re going to measure from sacrum to lateral hip. I’m using kinesiology tape as my under tape rather than Coverall, largely because this is an area that moves a lot. Sit to stand, side to side, getting in and out of the car, not to mention your clothing is right there.

The kinesiology tape seems a little more elastic that can move with the body a little bit better. We’re going to measure again, sacrum to lateral hip. We’re going to need two of those cuts. We’ll apply one at a time. Break the base, apply at the sacrum to start with. This is going to go right over the SI joint, and we’re going along the iliac crests, no tension on the tape, and you’re just going to lay it down to the lateral lumbar region.

Now, what we’re going to do is make a tab. Now, we’re going to make our tab. The tab is going to be placed near the SI joint. Remember, this is neurologic. It’s not mechanical. We’re not actually pulling the pelvis forward. All you’re doing is neurologically stimulating that fascial direction. We apply that tab near the PSIS. Now, we’re going to get our second strip of Leukotape. First, we’re going to catch the tab. We’re going to apply that at the sacral level. We’re going to catch the tab. Once, we catch the tab, we’re going to go forward. Remember, you’re going to push into the skin, pull over your finger and right in the picture there or that video, you can see the convolutions that developed. That’s the neurologic stimulation. We’re going to do the same thing on the other side, but use a different vector. This one was the PI side, which we’re trying to get as we go forward. The other side, we’re doing the AS side. We needed this to come backward.

What I like to do is I apply kinesiology tape over the first strip of tape, so it covers up one end of it. Then this again, sacrum going up to the lateral lumbar. We’re going to place a tab again right near that sacroiliac joint, except this time we’re going to catch the tab and pull towards the sacrum. The second strip to Leukotape starts laterally now. Grabs the tab, and now, we’re going to pull right over our finger again, get that convolution in the skin, rip the tape, and now this is our correction for rotational imbalance in the pelvis. I have used this with pregnancy to a ridiculous level. Interesting enough, I see this a lot with dead-lifters, especially when they have underhand/overhand grips. The last thing we want to do with this tape job is take a small strip of Coverall and cover right at the edge of that tape. It just protects it, so pants don’t catch it as they’re going up and down or just in movement.

The next thing that I want to show, also using that same methodology, we’re going to show a Squat Test Eval. In particular, the section that we really want to look at, which I may escape for just a second here. On this one, we’re going to show the tibial torsion that we’re looking for. These are all the different tape jobs that I do on the knees that’s why I’m skipping ahead a little bit here.

Here we go with our tibial torsion one. This works great with any kind of torsional mechanical problem at the knee. This could be somebody who’s a pronator with running. This could be a meniscal tear. It could be any of those different aspects. Sorry. I froze there a second. All right. What I’m doing here is I’m taking one hand on the tibia, and I’m pulling on the skin into external rotation, and on the superior one– Oops, sorry. One second here. I’m just going to pause.

Let’s go back to this one just for a second. Sorry about that little flub. We’re doing an external rotation here. We’re doing an internal rotation at the top. Again, you’re doing this with your skin. Okay? It doesn’t seem to matter what type of meniscal tear it is. It’s been ridiculously effective at decreasing the pressure. Because remember, meniscal tears are flexion, rotation, compression injuries. This is just taking the torsion out of it, helping to take stress off that meniscus. That’s been one of the more effective ones to me. On the squat test, it’s, again, de-rotating on the tibial point. You need external rotation on the femur going into internal rotation. That, to me, has always been a very, very powerful technique.

Here are the pictures of the way we’re going to apply the kinesiology tape, almost like a band pulled around your thigh. We put a tab one medial. As you could see, that tab is actually on the calf. Then we do one at the superior on the thigh. That one’s going to move more towards the lateral aspect of the squat. We’re going to pull across each of the tabs, pulling the tab into external rotation at the tibia and into internal rotation at the thigh. That’s our torsion tape job. This one is a huge big bang, whether it’s a meniscal tear or whether it’s just purely a mechanical problem, because you got a runner who’s a pronator, and the tibia is falling into internal rotation because of the pronation.

This will change a lot of your knee injuries. It’s one of the most important ones that I do, and we’ll show now the video just on how to tape it. For this tape job, I am going to do non-weight bearing. We’re going to put the person from medial to lateral. What I’m going to do with this one is halfway around the thigh, halfway around the calf. We’re going to lay down that tape one section at a time. Again, these are going halfway around. Make sure you do not go all the way around the thigh. We don’t want to create any kind of constriction that creates a blood vascular problem. From here, we’re going to do our tabs. You’re going to have one tab that’s going to sit on that medial aspect of the calf, and one that’s going to be on the lateral aspect of the squat. This first one is the lateral aspect of the squat, and we’re going to grab that tab and pull it from lateral to medial. Again, you’re going to push your finger into the skin and pull that tab right over your finger.

Now, we’re going to do the same thing on the lower part, except instead of going from lateral to medial, now we’re going medial to lateral. You place your tab right on that middle below the calf, grab the tab, and now, we’re going to go pull that tab into external rotation. A lot of the time, on these tape jobs, I’ll actually put Coverall on the edges. Again, not because my tape is ineffective at sticking, but as soon as you put that on, you got a window of opportunity where that tape job can get pulled off so easily. It’s one of those things where I’ll cover off the edges because when they put their clothes back on, pants or whatever it might be, it can catch the tape and quickly peel it off. Not to mention, it’s still on squat aspect so going upstairs, crossing legs, things along those lines, it’s just a little extra protection to make sure that the tape job will last longer.

That basically takes here at Concept 2, Concept 3.

Concept 4, this goes to our fascial sling taping. This is one of the least common ones that I do. I don’t do a ton of fascial sling taping. I don’t find it to be as effective for my patients as I’d like it to be. Theoretically, it sounds great. I just don’t find it to be quite as beneficial as I would like it to be. There is one or two that I have used quite often. I’m going to show you an upper cross tape job that incorporates postural correction as well as stability and diaphragm altogether.

With an upper crossed taping, what we’re looking for is, number one, a flare from the ribs when they’re breathing. There are rounded shoulders. They tend to have a forward head carriage. Usually, when they do a wall angel, when they squeeze down, they can’t do it. Literally, once they get down, they can’t even breathe. They can’t breathe into their abdomen, or you’ll notice their arms are coming forward, they can’t even keep it on the wall, or they overarch in their back or at their head. A lot of those things will happen. You’ll see their hyper lordotic in the cervical spine, hyper lordotic in the lumbar spine, hyper lordotic in the thoracic spine. Again, if you’re an [inaudible] person, you’re going to notice that with multi-segmental extension, you’re either going to be dysfunctional non-painful or dysfunctional painful.

If we’re doing this tape job, it’s going to be a combination of doing our postural correction tape job, as well as the diaphragm tape job. This one, it does require a lot of tape which can be problematic. This is not one that you’re going to use on everybody unless you see everything going that way. Not to mention you’re probably going to have to do some soft tissue work on the diaphragm, and once you notice they breathe better with that, you’ll know this is going to be effective.

Our measurement for this is going to go from one shoulder to the opposite scapula, and then from the scapula around the rib cage to the front. I’ll demonstrate that in just a second. Again, our measurements, shoulder, the scapula, opposite side, and now, we’re going to come all the way around the front, midline, along the ribs. Now, that you have that one measurement, you’re going to fold it in half. In other words, just measure two of them out, and now, you’re just going to cut one cut. Now, I’m rounding the corners on this one, and you’ll see one of the cool things if you have this all folded in half if you’re around the corners there. You round the corners with that one, it’s actually going to get to a point where you’ll cut the tape into two strips. Forgive me. This is just going to just go through a little bit.

Hold on one second. I’m going to just get us to where we need to be here. Okay. The first thing we’re doing is getting them into that good anatomical position. From there, we’re going to take the backing off that tape. Don’t put any tension on the tape until you clear the shoulder. You’re going to come down with about anywhere between the 25 to 75% stretch, depending on how much correction you need to do, to the inferior angle of the scapula, and from there, you stop. You can let the patient relax, you rub the tape just to get its adhesive to activate, and you’re going to do the second one. We’re going to do the same exact same thing. Put the person in a good anatomical position, apply it to the front of the shoulder, you’re going to peel off some of that backing, no stretching until you clear the upper trap, then again, 25 to 75% stretch the interior angle, and now, we’re going to get into the diaphragm. I’m rubbing right where the tape over crosses itself, because that’s where it actually doesn’t stick quite as well.

Now, we’re going to turn them around, putting the arms up overhead, which they’re going to put a little more stretch on the ribs, as well as the diaphragm. Now, we’re going to have to lean back to create more stretch. Now, paper off tension, you’re going to follow the lower rib cage all the way around to the front, and we’re going to do the same thing on the opposite side. Now, every single time this person is doing a rib flare breathing, that tape is going to stretch, which probably mechanically gives some kind of a restriction. It tells him to go easy. But more importantly, it’s a biofeedback mechanism that tells them, “You’re breathing from your ribs, not using your abdominal breathing”.

This is, again, a pretty effective tape job that I’d use a lot on what would be my distance runners, marathoners, things along those lines, where they tend to get apical on their breathing, especially if they’re lower-level functioning, high school kids. A lot, I’ll use this with. But it’s a really effective tape job when you need to bring in both posture, as well as diaphragmatic control at the same time. I do a very similar one for lower crossed syndromes, where we bring in TL junction, diaphragm, and anterior pelvis. We’re trying to bring it back.

The last of our tape jobs or concepts that we want to show examples where our concepts apply. This is moving into a particular range of motion or position that increases the dysfunction. If possible, test the patient holding the good posture and note if there’s changes in symptoms. Again, we’re looking for a 50% change. If you have somebody, again, with that sprained ankle, they go into [inaudible], they’re saying, “Ouch”, you bring them back out, and they say “Well, if it’s [inaudible], I’m a zero”. Great. If I take the stress off the ligaments, you’ll feel better. Applying the tape in the structural application is to help prevent them moving into those dysfunctional range of motions or positions. Again, this is going to be kinesiology tape at a 50% stretch or more or we’re going to use strapping tape for a more rigid end feel.

One of the ones I’m going to demonstrate right now, we’re going to show a couple. But, this is a standard postural taping. This is my go-to, whether I’m using kinesiology tape or Coverall with Leukotape. Your pretesting is going to be simple. Poor posture with rounded shoulders, cervical disk with or without radiation, progressive layers depending on the needs. In other words, I’ll go with harder or longer stretch depending on what that person does. I tend to start with kinesiology tape and I’ll only move into my Leukotape and Coverall if necessary. However, the biggest thing with this is I have my dysfunction, but if I bring it back like this, they’re going like “Oh, wow. That feels good. I like the way that feels.” Even if it’s, “Oh, by the way, when I bring my shoulders back, I go forward before my radiation comes on,” or “I can actually go back into cervical extension with significant less pain.” Those are all good reasons why you should be applying the tape.

Now, in this situation, I’ve done two strips of Coverall. I’d used Leukotape as my tape. I’m going to show you the video, which will now show this done using kinesiology tape. Again, we’re measuring from anterior shoulder to opposite scapula, and this is my go-to. We’ve done the measure, we’re going to do two cuffs like that. Once we’ve measured out our two tapes cuts, and again, normally I would just take a strip, double it up, and then I cut it all at once, so I don’t have to make so many snips. We’re going to break a base about two inches. We’re going to apply that to the front of the shoulder. We don’t want any stretch on this tape until we clear the upper trap, but we also want to put them back into their good anatomical position of depression and retraction of the scapula. Clear the upper trap.

Once you clear the upper trap, I’m putting my hand on that tape and then stretching it from there, down to the interior angle of the scapula. The more stretch you have, the harder the end feel will be. The less stretch, the less end feel there will be. Now, we’re going to do the same exact thing on the opposite side. Once again, clear the upper trap, apply the stretch on the tape, down to the inferior angle, and just paper off tension the rest of the way. All right. That’s the application of a good postural taping technique.

Now, the last tape job that I’m really going to go through is one of my big bangs associated with the shoulder. I use it for impingements all the time. It attacks so many different aspects of shoulder problems. It really handles about 80% of shoulder problems that I see. Come into my office, the only times it’s really ineffective is when there’s postural labral tearing or really severe postural mechanical. Neurologically, it’s going to tend to relocate that or the [inaudible] posterior into the glenoid. If you have postural dysfunction, that’s a problem.

For those of you who are familiar with Mulligan mobilization, we’re going to use that methodology to determine that we can reduce painful motions or restricted motions in abduction. We can use a relocation test, or we can also check to see if upon passive internal rotation, they get… What happens is as they’re doing passive internal rotation, normally, when you get down really low, you should see some translatory problems at the shoulder. When it’s at difficulty, you’re going to see the person as they get right about from if they’re here, when they hit that 90 degree point, you’re going to start seeing the shoulder pop up. As they go a little further, it rolls forward. That is normal when the arm is all the way down. It should not be happening around 90 degrees. We’re seeing that on a passive internal rotation or if they have a passive apprehension test.

Again, showing the pictures here aren’t quite as easy to visualize as if you’re seeing it on the videos, so I’m going to jump right into the video on this one. This is also going to show some of the evaluation with this as well. I’m going to demonstrate a little bit of a Mulligan mobilization not utilizing a mobilization belt. I’m going to use my hands. As I said, relocation test, passive internal rotation limitations, or with severe translation, or seeing an apprehension test come up positive, all of those are significant for this. I’m currently discussing that passive internal rotation. It’s that pop up and over. Passive apprehension, where they just drop away from you. What we’re doing with this one, the critical aspect of doing a Mulligan mobilization, whether you’re using belts or you’re using your hands, is making sure you do not push hard. You are looking for pain or limitation when they do the motion without help. I’m going to cuff my hands. One on the front of the shoulder and one on the inferior angle of the scapula. With a belt, you do this gentle pullback, but I tend to do it with my hands. I like to feel what’s going on.

When you overcorrect this, in other words, you just want to gently put your hand on the skin. If you push hard, you’re going to notice that it actually hurts them. If you’re doing this Mulligan mobilization, they go “Oh, my God. That hurts a lot more,” if they don’t have the [inaudible], you’re pushing too hard while you’re doing it. With my inside hand there, I’m actually cuffing the inferior angle of the scapula and I’m assisting in the lateral rotation of the scapula as he’s moving. As you go through two or three of these, you start feeling the way the joints are moving and it assists you with your hand positions.

This is not a methodology that if you’ve never done it before, you’re going to get results with. It’s something you have to experience a lot, so that you get a little bit better at it, especially if you’re just using your hands. Now, from there, I’m showing you now where my thumb position is, associated with that lateral motion of the inferior angle of the scapula while we’re going through abduction. Now, this tape job is only going to be two strips of tape and be very, very effective. Normally, what you’ll see is they seem to lose a lot of the ratcheting as we’re bringing the arm up, or their pain goes away, and they’ll get all the way up top.

Now, the two strips of tape that we’re going to cut, one is going to be associated with superior translation, and one of them is going to be associated with anterior translation. What we’re going to do is first measure the superior translation. We’re going to measure from the acromion process, just forward to the acromion process, to about an inch or two passing the inferior angle of the scapula. It’s going to be on a diagonal line. We’re going to make a lowercase Y with this. We’re going to do a Y-cut, but a lowercase Y, about four to six inches on the tails. We’re going to tear at the base, a two-inch box, and at the base of each of the tails. And then, we’re going to take off the base in the middle. That tape at the middle point is going to be applied at the posterior cuff.

Now, that’s our start point. It’s the middle of the tape, not at each end. Now, we’re going to put that patient back into a good anatomical position, and we’re going to take one tail at a time and apply that like a teardrop. Make sure you’re not compressing the acromion process. You want to go to either side of it to almost make like a tear that goes around it. If they pop the shoulder up a lot, you might want to stretch it a little bit more. If it’s very minor, it’s a 25% stretch. Now, from there, we’re going to basically make sure they’re staying in their good anatomical position, and we’re going to do a neurosensory straight down. Maybe add a little tug at that inferior angle to keep it secure against the rib cage, and neurosensory down towards the spine. That will help us with the lower trap as well, which is a critical muscle in the lateral rotation of the scapula. It’s assisting with scapular [inaudible].

We get some neurosensory around the posterior cuff, some neurosensory on the lower trap, and we, mechanically, you’re preventing the superior translation. Now, from there, we’re going to do the anterior translation. So we’re going to measure from the anterior shoulder to the medial border of the scapula going around the lateral shoulder. We’ll get a two-inch base. We’re going to apply it to the front of the shoulder covering up the two tails. Now, the stretch here is only from the anterior aspect of the shoulder to the posterior aspect of the shoulder. The stretch is only from glenoid to glenoid. Now, it’s paper off tension the rest of the way. Now, if you cut this properly, you end just at the spine. If you cut it too long, you’re going to go across the spine. Make sure you rub the tape, especially where the tape overlaps to make sure that it sticks. Now, when you do the abduction again with this patient, you’ll notice significant reduction in pain and a much better range of motion as they’re doing it.

The last one that I do have in this presentation now is going to a lower extremity. This is my ankle sprain taping. This is for inversion sprains. Obviously, number one, they have a history of an inversion sprain. Two, palpatory tenderness of ligaments. Three, swelling, edema, bruising might be there, and positive ligament stress tests. The other aspect of this is when you take them out of inversion that’s painful, and you move them passively into dorsiflexion and the eversion, they feel better.

It is basically three strips of tape. Now, yes. There are overlapping amounts on those three strips, but one is to protect the ATFL. Here, we’re putting a tab just in front of the ATFL using Coverall. By the way, Coverall is our under-surface here. Kinesiology tape is not effective. It is too elastic. We want something that does not stretch lengthwise. We’re going to grab that tab and pull it into dorsiflex and eversion, and then lay it down as it comes behind the Achilles to the medial malleolus. We’re going to do this strip. This is what I like to call the dorsiflexion/eversion assist. It’s a diagonal tape job that goes from the medial tibial border, down to the lateral malleolus, underneath the foot to the medial malleolus. This one does not have a tab. We start on the medial aspect of the malleolus from down underneath the foot, and then with a very strong mechanical press, we’re going to push the foot into dorsiflexion and eversion using our shoulder. We’re going to apply a very hard tension on that tape until we get the anterior aspect of the tibia. And then, we’re going to just let the Coverall, I mean the Leukotape, go the rest of the way. It’s going to give us a very strong dorsiflexion and eversion position.

The last one is the classic stirrup, but we’re going to use much better tape than we used to. We’re going to use that Coverall again from two-thirds away up medially to two-thirds away laterally. Place a tab underneath the calcaneal fib ligament. Then, we’re going to grab our second strip of Leukotape starting medially, come down underneath the foot, grab that tab, and end it, again, pushing the foot into your eversion and dorsiflexion. End it at two-thirds away up laterally. The last strip is doing what I like to call “the boot”. It’s a four-inch Coverall. I’m sorry, I have three-inch on that slide, it’s actually four-inch Coverall. What we’re going to do is place it on the bottom of the foot, and then taking the corners one at a time, we’re going to stretch it width-wise around the front of the ankle, and it’s going to create a pattern like that in the front, which actually assists in that tallus. The tallus, it helps prevent it from popping forward. It’s a little bit that mechanical aspect of what we’re doing because you actually stretch the tape to its fullest.

Let’s just show this video. It’s a long one, so bear with me. I’m going to talk through it a bit. This is our inversion ankle sprain. The interesting thing with this tape job, and I know I’m going to screw myself over one of these days, but I’ve actually done this tape job for over twenty-three years. With this tape job on, I’ve never had anybody sprain an ankle in any sport at any time ever. I hate to be in an absolute, but this baby is a big bang. If you can tape it properly, meaning they can’t [inaudible] or invert their foot after this tape job is on, it is an extremely powerful tape job to prevent ankle sprains as well as to help people perform, or even just walk with an acute ankle sprain.

Obviously, in these situations, we’ve eliminated the risk of a fracture. We’ve already done an x-ray. We know that it’s not broken. We’re not referring this to the orthopedist, but we’re handling an inversion ankle sprain. Our first measurement is going to be from the dorsum at the foot of the toes. Using our Coverall, we’re going to come behind the Achilles, and we’re going to go to the medial malleolus. That’s our first strip. Our second strip is measuring from two-thirds the way up on the medial aspect of the tibia. We’re going to measure down towards the lateral malleolus under the foot and up to the medial malleolus. That’s going to be our second cut. For our last strip, it’s going from two-thirds the way up medially to two-thirds the way up laterally. Now, we’re going to make that cut. Now, that’s our three cuts for the mechanical support.

If you notice, there’s a little bit of a curly Q at the end of that. I call it the pigtail. If you fold the tape back on itself, you’ll eliminate that pigtail and then you don’t have to worry about the Coverall cashing itself, and possibly, the two layers adhering too each other and ruining the tape job. And then, just doing that on that other strip as well.

Now, from here, we’re going to start with our first strip. This is for the AFTL, the anterior talofibular ligament. We’re going to peel off our backing. Starting at the dorsum of the foot, we’re going to come towards the lateral malleolus, behind the Achilles, and end it at the medial malleolus. Remember, the ankle has to be in the dorsiflexed/everted position. If we don’t start that way, then this tape job will not be as effective. Now, we’re going to make that AC tab. Put it just distal to the ATFL in front of the lateral malleolus. Now, with our second strip of Leukotape, we’re going to grab the tab. Once you catch the tab, look at how I use my chest and my shoulder. Pull that tab over and end it at the medial malleolus. Do not put any tension on that Leukotape behind the Achilles. We don’t want to crush it.

Now, our second strip. If your patient is struggling with the whole dorsiflex position, you can use a belt to try and let them hold it up for them. It does get in your way sometimes, though. The second strip, we’re going to start this. This is the toughest one to apply because we need to start in the middle of this tape job, not at one end or the other. We’re going to make sure we got a good line of drive first. We’re going to measure right about two-thirds the way up on that medial aspect towards the lateral malleolus. Once you get your line of drive there, you know exactly where it’s supposed to be. Let go of that superior portion and just tap down at that lateral malleolus. Just tap it down.

Now, you’re going to grab both ends with one hand flattening it out, and one and one hand keeping tension on the tape without it wrinkling. Now, we’re going to grab both ends at the bottom and under tension, up to the medial malleolus. If you’re seeing tons of wrinkles while you’re applying this one, it’s literally because you’re not putting enough tension on that Coverall. There’s no tab on this one, so we’re going to start at the medial malleolus, underneath the foot, no tension on the tape at all. Now, once I clear the lateral malleolus or the lateral foot, and I should not be on the [inaudible], now, I’m going to use my shoulder to push that up into dorsiflex and eversion. I’m going to use my thumb to apply a heavy tension on this tape all the way until I get into the anterior aspect of the tibia. I want to be above the ankle mortis joint. Now, you just peel off the rest of the tape and lay it down. All right. That’s the second strip, which we call the dorsiflexion/eversion.

The last strip we’re doing is going to be our stirrup. This is for the CFL. The calcaneal fib ligament. We’re going to take off the backing of the longest strip that we have. We’re going to hold both ends at one time. We’re going to start underneath the foot. Make sure your tape is in line with the malleolus, and you’re just going to tap it at the top and then tap it laterally. Now, you can have one hand that will straighten it out, and now, you’re just going to smoothen it out there. I can use both hands to do the same thing on the medial side. Now, once you’ve done that, you’re going to get your second tab and it’s going to go inferior to the lateral malleolus with the CFL. All right. Now, from here, we have that tab down. We’re going to go from the medial aspect again, starting two-thirds away all the way. You have to be all the way up on that Coverall. No tension on that, no pull on that Leukotape yet. No tape underneath, no pull underneath the foot. Now, you’re going to grab the tab. Now, here’s our tension. We’re going to, again, force that foot into dorsiflex and eversion, pull it up, and lay down the tape.

Now, this is all the mechanical support you need. However, I like adding in that boot that we talked about. It just holds everything together really nicely. We’re going to take our four-inch coverall. We’re going to go about a third of the way up medially and laterally on the measurement. What we’re going to do is take the backing off. Now, just be careful here. You don’t want the tape to fold in on itself because it’s four-inch. It’s really easy to happen. So you see how I put it over my thigh to make sure that it can’t fold in on itself? Now, I’m going to grab both ends, just like we did the stirrup. We’re going to bring that foot into dorsiflexion, come underneath, fix the tape, but now with both hands, you’re going to stretch across the front of the tallus, and the front of the ankle mortis joint, and we’re going to do the same thing on that side. Watch how I stretch it. Stretch it width-wise, stretch it across, and that just cinches up your whole tape job.

Now, with this on, the patient will struggle to put that foot into plantarflexion and eversion. There is one minor caveat. If this happens to be a distance runner, you don’t want to put them into dorsiflexion and eversions because it’s going to create a lot of tibial torsion. If it’s a distance runner, you only want them to be dorsiflexion. Don’t worry about the eversion component of that. The other major thing is, as you saw on this video, it takes a while to do. It takes me about two and a half minutes to do this tape job. All right. That’s from cutting to application. That’s talking about the guy who kind of came up with it. All right. The first time you do it, it could take you five to eight minutes to do this tape job. I highly recommend you practice a lot before you put it on a patient. Otherwise, you’re going to look a little silly. I love torturing my associates as they first start with me in giving them an ankle strapping, like going to treat a patient literally coming back and seeing the sweat beads off their foreheads as they’re still working on that tape job.

That’s pretty much the last of our presentations. I hope I gave you a lot of information on the taping, a review of our literature, and application, as well as showing how those concepts that I gave you in the beginning, how they actually work in an application. Again, my email was in that first slide. If anybody has any questions or concerns, feel free to contact me. I hope that this actually gave you some information that says, “Taping isn’t useless. The problem is the literature isn’t there, because the methodology [inaudible] was done, and we’re, unfortunately, not educated well enough in how to select patients that will get the greatest benefit of taping.” I’m hoping within this presentation, you got an idea of how you can start applying that to yourself. I’m hoping you enjoyed this. Forgive me for the minor screw-up when I had to redo my video. I’m sure that didn’t affect your visualization of the program too badly, but again, I apologize for my failed technology there. I hope you enjoyed this, and I look forward to hopefully getting to see some of you at a class some time in the future. Thanks again.

[End]

Lower Extremity - Emergency Procedures - Trish Donoghue & Dr Nat Sharp

Trish Donoghue: Welcome, everyone. Today’s lecture is about creating a baseline of information for sports chiropractors, allowing us to create an international base of members, understanding the various approaches to emergency procedures. Many of you already know a lot of this information and may be comfortable with it. Treating athletes on the side of the field, It’s a skill set. You are not in your practice. You don’t have a quiet environment to be able to concentrate one-on-one with the athletes. You need to develop the communication skills and develop the techniques to manage multiple things happening around you, manage things spiralling out of control, and have people in your face shouting at you to make a decision.

Much of this content that we are covering today, especially the first part of this session, is basic first aid, but it’s also common sense. I challenge the word common sense. I use that relatively lightly in some respects because I want you to understand that common sense is not common. It is a learned trait. It is something that you learn from experience. So, the main thing I want to point out before we start is never to assume.

  • Never assume that somebody else beside you knows what to do.
  • Never assume that they understand what you are saying.
  • Never assume that they’ve got the same experience as you.

That is going to be your first mistake. Pitch-side when things are going wrong. You need to have the experience, and the only way you will get the experience is to get out there amongst the athletes. Expose yourself to different sports. Expose yourself to different teams and different levels.

If you have any aspirations to work with athletes in an international event, especially a lot of the students doing these courses, you need to get involved now. Volunteer at your local level. You need to get that local experience so that you can start building that rapport with people. Some of the things we’re going to cover today are all about that experience. We will cover the role of the first responder, and we will look at some of the information about the policies and the consensus. We will also look at some of the procedures of when to move and when not to move. Then I will hand it over to Natalie, where we will analyse and break this apart and see what this looks like in real case studies.

Your main thing here is a first responder, especially in the sporting setting, is that person who is making that first decision. Your primary role is to one (1) recognise the dangers around you. When you are on the field, there are many dangers around you and a lot of things coming at you. We need to manage the athlete’s pain and think about the techniques that we would use to manage that pain. One of the techniques I use is the breathing technique. The breathing technique will manage that pain and be able to help you make that assessment. We now need to prevent further injuries, and we will do that by stopping the athlete from moving until we can assess what is going on and then the referral. Never think, especially pitch-side, when you are working with other teams, you know it all. Always seek the advice of your colleagues, where able and where it’s appropriate. Especially for the students, don’t think you know it all. Be willing to listen, be willing to ask for advice, and be willing to seek the approval of someone else.

When you are at the event, you have got to think of the critical information you need. When you are starting as a first responder, this will all be brand-new to you. So, one of the things that I live by is, don’t be afraid to ask silly questions and don’t be afraid to ask dumb questions. I have been known within my career to ask really dumb questions. Every time people laugh at me, I say, “Well, it might be dumb to you, but it won’t be dumb if I make the wrong decision out on the field”. Then they are swift to say, “Okay, your right. It isn’t a dumb question.” So, don’t be afraid to ask those dumb questions. Especially if I have new people working with me, I encourage those questions.

You need to know information for yourself. Don’t assume or don’t take the word of others that they have done the research for you and passed it on correctly. If you are the one on the ground and you are the one looking after a team, make sure you take the time to do your checking. So, some of the things I will be looking for is the nearest hospital. Do I know where that is? Do I know the address of it? If it is a venue that I am not familiar with, I will always have that address written down on my phone because it is easy to forget this when you are on the field.

Think about your triage. Think about what are the types of injuries are. When I call an ambulance or when someone’s calling an ambulance, we need to be clear on the injuries? Who is the person in charge of the event? Who is the person that requires any reporting? If you have to call an ambulance, you have to let the person in charge of the event know or get someone to let them know. So, you need to know who that person is.

I have been lucky enough to be the executive officer for Sports Medicine Australia for eighteen years. I used to say to the teams that I would be putting at events is, “The minute you get to an event, it is your responsibility to find that person in charge and introduce yourself”. They will now know who you are, and then you know who they are by sight. By doing that, you have started to build up a rapport straight away. You have built up that communication to allow them to think they can come to you, “Hi, Trish. Is everything okay,” and they can check in from time to time. So, make sure you take that step can be the difference between having an emergency where you are running around, not knowing what to do, or someone can’t find the person in charge, versus everything going smoothly. Make sure that you have the information that you need. So, if an ambulance has to come into the field of play and you need an ambulance, you know, exactly where that medical tent is, you know the path the ambulance has to take to get into that medical tent.

This next point is an important one that everybody overlooks. I have found over the years; people overlook who has got the keys to that gate. Most sporting fields worldwide are gated and locked so that people can’t drive in or do other things at the field. Who’s got the keys? This is something that you will be asking when you do your pre-checks and when you are at the field. Are the keys to the gate on the ground? If they are not, you have got a problem because you can’t get the ambulance in. So, you need to think of contingencies plans. If we can’t get the ambulance in, we have to get the paramedics out of the vehicle and direct them to where we are. It is imperative to have a bit of a checklist for yourself.  Think about the sort of things that you will need to know when you are in an emergency, and be prepared so that you can make decisions quickly.

At your local and your junior level, you need to get that experience at your junior and senior levels. So, get involved. Don’t restrict yourself to one sport. You get real value, and you find that you get a lot more of your experience when you expose yourself to different sports. I have been lucky enough to shadow some very, very high-profile games and shadow the doctors. Often finding myself in the middle of rucks and having to crawl out backwards while the game is going on. All of that is part of the experience that you build up. Every time you experience something like that, or you get the opportunity to experience something like that, grab it with both hands.

That’s where the real learning starts. That’s where the experience starts.

At that international level, especially when you are working with FICS or if you are lucky enough to be picked for one of the FICS events, one of the requirements as part of the new tiering system is that you would have already had and have been working at that local tier. So, don’t just expect to think to yourself, “I want to work at the World Games, but I don’t want to work the smaller events locally.” You won’t get picked. You need that experience. You need to prove that you have been working at that regional and national level locally before you can qualify for international games. The reason for that is that we need to know that you have got the experience with your communication, athletic skills, team management skills, and you are a team player. So, grab every experience and opportunity to assist with events with both hands. Expose yourself to different sports, even if it is just going along to shadow another doctor. That is where you build up that rapport with your colleagues.

When you are at your sports, the first thing you should do is,  especially if you are regularly working with a team, get hold of all your consensus statements. Work out what your heat policy is. Brett Jarosz outlined very nicely in his lecture the concussion rules. Every sport will have different rules, and different regions around the world have different rules. So, don’t just assume, if you are a first responder in New Zealand, there will be the same rules as the first responder in Europe or Australia. It would help if you got hold of those policies. Have that conversation with the medical staff or the sport and just talk about the policy. Don’t just say, “Can I have your policies?” take them home and throw them on the table or glance at them and go, “Yes, I’m all over this.” Have a look at the policies; discuss it; discuss anything you note in there with the team. Understand what the different reporting requirements are. It is very important to do that based on the sport you are looking after.

Post-event support. This is a big one. You have to make sure that you are taking time to check in on yourself, check in on your players, and check in on your colleagues and the volunteers at the event. I was part of a cycling event which unfortunately went terribly wrong. We lost one of the cyclists, and another cyclist ended up being a paraplegic. That event was a logistic nightmare. It was a road event, and we were in the middle of the bush. We had to get the rescue helicopters in, and all sorts of different things were happening around us. The event also went on to Coroner’s inquest because an athlete died. So, you may understand, while you are at the event, the adrenaline takes over, and you do, you just manage, your training kicks in. But after the event, you need to check in on yourself, and you need to make sure you are okay. Also, check in on your colleagues.

When you are checking in on someone or supporting someone else, you are there as a listener. You are not there to fix anything. You have not got the power to fix their feelings for them. The biggest thing you can do for them is to listen to them. That is where the healing starts by letting someone talk. I must admit I have been in that situation where I have supported someone before, and I listened to the same story about fifteen to sixteen times. By the time this person left my office, I honestly felt like I was at the event, and I could describe every single detail that happened. So, I needed to talk to someone, and I was lucky enough to have some pretty good colleagues around me and some very high up Sports Physicians that I could grab a drink with after work. We went out, and we just debriefed. That helped me and allowed me to continue to support that person because I wasn’t absorbing all of the trauma. So, making sure that you are looking after yourself and take it seriously. We had at that event a team of experience of twenty years plus. Different situations will affect us in different ways, and we need to take the time to check-in and take each situation as it comes.

When you are on the pitch side, and Brett Jarosz touched on this in his lecture, you will use the S.T.O.P. technique. This is your first assessment. This is the assessment on the field. If you are the doctor running onto that field, you need to be able to make a very, very quick decision. When you are running onto the field, you need to know what the rules of the game are. Does the time stop, or do I have to call for the game to be stopped? If you are running onto the field of play, but the game is still playing,  as Brett Jarsoz described, you need to be super aware of what is happening around you because you are just another person on that field. The athletes are focused on the ball and the game, they are not focused on you. You must be aware of everything that is going on around you and getting to that athlete quickly. If you are a first responder on the sideline, you will always be watching the game, ahead of the play and behind the play, and watching for those who don’t look right.

You are making a decision before you even get to that player, what you think it is. So, if you see a player’s head hit the turf and they are not moving, you are already thinking concussion possibility spinal? The impact, with the head hitting the ground, is concussion until ruled out. When you get there, you are going to be stopping that game. We will go through these techniques in the workshops when you do the face-to-face hands-on practical part of this course. You will not grasp these techniques until you are doing them and then practising them out in the field, working at local events. Remember, if you aspire to work at those local events, get involved at those local levels and expose yourself to different things.

Your T.O.T.A.P.S. approach. This is your approach for your sideline. When you are on the field, you have to think that athletes sometimes will not want to come off. They will pull away from you. As Brett Jarsoz rightly said, the longer the player is on the sideline, the less they get paid. But even at that junior level, the player is thinking, “I don’t want to let my teammates down, or am I going to get back on?” So, sometimes you need to tailor the communication you use with the player, “Come on. we are going to go the sideline, and get you checked out, and if we can, we are going to get you back on the field. But you have to come with me”. Stay with them and consider your body language. When you get to the T.O.T.A.P.S. stage, this is where you have a little bit more time on the sideline, and you can focus just on the athlete. You don’t have to worry about what is happening on the field, if a ball is coming at you, or whether a ball will knock you out.

Think about the different questions that you will ask the player about their injuries, observing what’s going on simultaneously and touching. You are doing all of this together. Starting with the non-injured side and moving to the injured side, you need to compare before moving onto the active and passive movement. Before the athlete goes back on the field, they need to pass a skill test for the particular sport and the injured part of the body. Can they use that injured part for the type of movement they will be doing on the field without going into pain?

Natalie Sharp: Hi, everyone. A little while ago, an infographic was going around that was essentially changing our point of view a little bit from the Rest, Ice, Compression, Elevation, Referral (R.I.C.E.R.) approach. Now we look at this differently. P.E.A.C.E. and L.O.V.E. We are moving away from R.I.C.E.R., keeping everything still and highly protected into a state when now, we’re still protecting. Still, we’re introducing movement and a bit of strength work and exercise so that these injuries can heal a little bit quicker. Let us go through and break it down a little bit.

First, when we are looking at the P.E.A.C.E. technique, we are looking at the first one to three days in terms of time frame. The protection we have unloading it for that one to three days. What that is going to do is help minimise some bleeding, minimise some of the swellings, and prevent further injury to the area. We still want to keep the area elevated, so we keep the limb higher than the heart if we can. What that is going to do is it is going to help promote fluid flowing out of the tissue and again decrease that swelling, decreased that bruising. We want to avoid if we can anti-inflammatories in the first one to three days. It’s not fantastic research, ut’s relatively weak, but there is a bit of research describing that anti-inflammatories, especially high-level doses, negatively affects tissue healing. If we can get away with avoiding these anti-inflammatories, everything settles down and heal that little bit quicker.

Again, a similar kind of thought process, is going to limit too much swelling occurs. We can use tape or bandages to compress the area. We don’t want to compress it really tight and limit movement, but light compression will help decrease the amount of swelling in the joints. It will decrease the amount of bleeding coming into the joints and the tissues, leading to bruising.

Another thing that will be really important is educating the athlete about what to expect in terms of their injury. So, what to expect in terms of how long this injury is expected to take to heal, what will be involved in terms of the management, and especially with an athlete, how long roughly they can expect it to be before they can return to play. Because at the end of the day, that will be the big thing that they are most worried about. If you can give them a time frame, even if it is a relatively long-time frame, they know what to expect, and they know that in two to three weeks if they are not back on the field, back on the court, that is completely normal and it is not because their injuries are taking longer than expected. If it’s a six-month recovery, it’s a six-month recovery. While that in itself may be a disappointment, at least they know that that’s the time frame, and that’s what they can expect.

Once we have moved past that 48 to 72 hours, we move into the L.O.V.E. section. So, this is when we want to start loading the injury. We want to work up in a controlled way but relatively quickly, into more your normal daily life activities. That may not mean that we can get into anything sport-specific yet, but if it means, you know in 1 to 3 days I want you to try and start walking in a normal gait pattern, that is going to cut down again that length of time that it takes them to get back. But also, it is going to cut down the amount of compounding factors that potentially will prolong the healing process.

We want to make sure that we keep a positive outlook even if we do have that relatively long time frame in terms of recovery. Look at essentially what is improving every day, even if it’s slow. Be like, “Okay. Yesterday you could have walked five meters before it started hurting. Today, we’re at seven meters. That’s pretty good. That’s a 2-meter gain.” So, if you keep focusing on all the positives, it will keep them in a positive mindset and make sure that they don’t lose interest and lose the will to keep going with their rehabilitation.

We wanted them to start with vascularisation. Essentially, what that is about is we are starting to get some pain-free aerobic activity. That increased blood flow will help things flow into the area, out of the area, and essentially keep all the things that are going to help the injury heal. Going to bring fresh stuff, pump it out, fresh stuff, pump it out. So again, we are increasing that healing time.

Exercise. We want to keep up my ability, strength, and body awareness so that you do not have to retrain your simpler movement patterns as you are doing rehabilitation.

Trish: So, when we are moving to spinal, and we are considering collars, we need to think to ourselves, have you got the training to fit it properly? If you have not done the spinal injury management course, don’t put a collar on. There is a lot of research around the world these days as to the effectiveness of collars. Debates consist of whether they are effective or not, and whether they cut off airflow. Rigid collars that are not fitted correctly result from the incorrect measurement of the neck and not fitting them properly. This is why many experts are against rigid collars because untrained people fitting the collar will hyper-extended the head and cut off the airway. So, many ambulance officers, especially in the Pacific region, are leaning towards the soft collars. So, the main thing here is, and we will go through this in the face-to-face training of the hands-on course, is you need to be trained in how to fit a collar properly. But keep in mind that half of the time, the collars are a placebo effect. That they make the athlete think that they are secure, safe, and they are preventing movement.

When we are at the hands-on session, we will practice this. We will get this right, and take you through the mechanisms of why and how we do this. We are also going to look at the process and what we are doing.

We are going to look at what’s called MILS, which is the Manual In-line Stabilisation. We use this technique to manage the athlete with a suspected spinal injury and get the athlete ready to move.

When you are getting someone ready to move, the key here is that there is no rush. If you have got an athlete who is breathing effectively, managing their pain is the key. Talking to them, controlling their breathing is the very first thing that you need to do. There is no rush to get them off the field. If the game has to stop, it has to stop. Unfortunately, coaches and players sometimes have to wait because if you suspect a spinal injury, you do not want to be in a position for things to go wrong.

When you are choosing the appropriate method of transport, you need to think. Have I got the proper stretches? Have I got the necessary people to help me? If you DO NOT have the necessary team to help you move that athlete, you don’t move them. You call the ambulance. Unfortunately, the game is still stopped, which I know may cause some problems for many people, especially the coaches and the athletes, but that athlete’s well-being is your key.

When you are at the field and introducing yourself, once again, ask them about what equipment they have. I usually do this as part of my pre-checks when I have agreed to work at an event. I will ask the medical staff that has invited me, or I will ask the event coordinators. “Can you just describe for me what equipment you have got?” Have you got a defibrillator?  Have you got a stretcher? and they may say, “Yes. I’ve got a stretcher.” Okay, your next question is. “What sort of stretcher is it? Is it one of those soft orange ones? Is it a hard yellow one?” What you are trying to do is use terminology with event organisers that they will understand. So, I’m not going to say, “Have you got a spinal board,” and they think, “Oh, yes. We got an orange stretcher. Yes, we got a spinal board.” So, straightaway, they thought the orange stretcher was a spinal board. So, I will use things like, have you got a yellow one? Have you got one that pulls apart? Is it an orange one? What type of stretcher is it? Is it floppy? You’ve got to decide. Do they have the appropriate equipment? You can’t transport a patient with a spinal injury on the orange boards. They are not suitable as they don’t support the spine. You have to have one of the rigid boards to support a spinal or transport a spinal injured athlete off the field. The orange stretchers are suitable for fractures or other injuries that athletes might have, but they are not suitable for spinal injury. We are going to look at this, and we will practice this quite a few times when we are doing our practice in the hands-on class.

But how to get somebody onto a board? How do I pick the team to assist me? You need a minimum of 5 to 6 people to do this technique, ideally six because you would want somebody at the head, you want somebody at the feet, and then you have got the three other people at the side.  When I get a team in place, I would also make sure that they are comfortable with the process and that the most experienced person is at the head. If you have two experienced people, I would put my second most experienced person at the head. I would be the one who oversees the whole situation, giving the instructions and keeping an eye on what everybody is doing. That is really important because you need to make sure that people know what they are doing. Sometimes they will start moving too fast, or they won’t be confident. This is when you need somebody being that spotter to watch everybody and monitor what they are doing and whether they are listening and doing what is required correctly.

I have been in situations before where you just need to say stop. Okay, everybody, stop doing what you are doing. Let us go over this again.

This is where your communication comes in. The very first thing I said at the beginning of this session was don’t assume. Don’t assume everybody knows, and don’t leave the athlete out of the conversation. Don’t just talk to your team and tell them what’s going on. Make sure you tell the athlete what’s going on. That is your mechanism for keeping the athlete calm and controlling that athlete’s pain. You have got to include that athlete. If you are moving an athlete and putting them on a board, keeping your voice calm, keeping the athlete calm and making sure your team knows what’s going on is the key to success.

In your slides, we have listed a couple of ethics slides. It is something you can research later. It is not something we are going to go through in great depth today. But for this lesson, these are things you need to be aware of, and you need to make sure you do your own research. Make sure you are very comfortable with the ethics policies, especially at local and international events. We have had a couple of situations at events that have resulted in FICS creating policies. One of these is “Clear Sexual Boundaries between a chiropractor and patient and parent-guardians”. If you are interested in that policy, I am very happy to pass that on to you for your own benefit. Just email admin@ficsport.org, and we would be happy to send it to you.

When working at FICS events, there will be protocols and policies that you will need to sign off on, stating that you have read and understood the policy. You will be required to know the rules, know what to abide by, and know where and when the boundaries are crossed. When working as part of the FICS delegation, you need to make sure that you are a hundred percent across these rules and policies. If they are crossed, what are the reporting requirements are?

We will move on to the second section of this presentation to look at some case studies, break the cases apart, and discuss what we have just covered. So, I will hand it over to Natalie, who is going to take the lead on the second part of this presentation.

Natalie: We may or may not get through all the case studies, but I just wanted to put in a whole range of different scenarios that essentially cover the content we wanted to cover in this lecture. If we don’t get through them all, you will have plenty of time to read through them in your own time. If you got any questions at all, just reach out.

Trish touched on it briefly earlier; this is essentially dealing with an injury on a field, on a court, at an event, which is very different to dealing with the injury that presents to you in the clinic. As Trish mentioned, not only do you have a whole lot more going on, more noise, more people, you may also be dealing with a different type of injury. These sports injuries are what I have tried to touch on more in these cases. These cases are essentially what we might classify as a catastrophic type of injury. So, not necessarily the ones we as chiropractors can do a lot for apart from correct management at the scene and then correct referrals. So, we are not going to go through a minor injury that we may be able to at the time,  treat and get the person back on the field; this is going to be more about what to do when it is an injury that ends the game for this person. So, you know, what they have done and what do we do next.

Saying that, especially in your emergency type situations and if we’re dealing with something like a broken leg or a broken arm or a blown-out knee, there are certain parts, I guess, of our history taking that. I don’t want to say they aren’t as important in the initial stages, but they aren’t things we need to worry about quite so much. So, for example, where we might normally take a family history or medical history, all that type of stuff. In certain situations, that might not be necessary. Any time during this, feel free to jump on the chat if you’ve got questions, comments if you’ve dealt with something the same, and you sort of found something that was an amazing tip that you want to share with the rest of the group that would be wonderful.

Cause 1: Skye. She is a 23-year old female. She is a skateboarder competing at the X Games. She has reported to us in the medical tent after a fall in a half-pipe. So, what we can, I guess, take from that history because that’s essentially all we’ve got. She fell and landed awkwardly on her arm; now it’s sore. In taking the history, keep in mind that because she’s in a half-pipe, she’s fallen from a height with a fair bit of velocity behind her. For people who have seen either skateboarding at the Olympics or skateboarding at the X Games, you know, they’re not just going for a luxurious, leisurely stroll down the sidewalk. They are definitely pushing the boundaries.

Primary assessment, what can we say?  She’s described that she’s got pain located midshaft of her ulna, mid-shaft deformed arm. We can see that there’s a mild deformity there. There’s no open wound. We can take from that mild deformity noted in the left forearm we’re likely looking at some sort of fracture where the pain is located. We’re essentially not going to get it. It’s unlikely to be a wrist injury, and we don’t have an open wound. Going back to the knowledge you have of fractures, If we’ve got an open wound, it’s called an open fracture. So, you know, there is other stuff that we’re going to have to deal with, not so much with Skye at the moment because it’s a nice closed fracture.

Secondary assessment. So, what we’re looking at next, sort of after what we can see, is that there’s significant pain on palpation of the area, and when we are getting to sort of wrist flexion and wrist extension, she’s getting even more pain. So again, thinking that we’re dealing with a mid-shaft forearm closed fracture, potentially something with the interosseous membrane in that forearm to do with that wrist flexion and extension. But essentially, we’re not going to know much more about that interosseous membrane without some imaging. So, while we can speculate, our differential diagnosis is pretty much sticking to either an ulnar fracture, radius fracture, potentially both. You know, we might have that interosseous membrane hanging out in there as well. But as I said, we won’t know without the imaging.

What are we going to do about it? What we want to do is we want to splint and sling that left arm. So, with the splints, you can get, you know, your pre-made ones. You can also, in an emergency, make with something, you know, simple as like some rolled-up newspaper or rolled-up magazine that you can then bandage around to hold that area nice and still. The main thing you want to do with your splinting is to make sure that you are splinting it and slinging the limb in a comfortable position. You don’t want whatever you are applying to the injury to be causing more pain. So, just so long as you can keep it immobile, supported while you essentially send her off for imaging and further management. The different types of further management we might see with her are either just a straight casting if it’s a nice simple fracture or a little more complicated in there, potentially some surgery and then casting.

Case 2:  Gord is a 32-year old ice hockey player. He was checked from behind. So, what that means is that when they have the collision. What that means is he then had a collision with his head onto the boards. At the time of the injury, his head was slightly flexed. He was looking down at the puck on the ice. He stated he heard a crack in his neck, but witnesses reported that he had that short loss of consciousness as he fell. When we arrived at the scene, he had a torticollis deformity. He couldn’t move his neck. He was kind of yet– with his neck splinted. He complained of neck pain with any attempted movement. So, as Trish was saying, the first thing we want to do when you arrive on the scene is to make sure that the game is stopping in this situation. Make sure that there is absolutely no risk of further injury to either Gord or yourself. So, you want to go through a Glasgow Coma Scale. That’s going to make sure that you are ticking off, I guess, his consciousness and responsiveness to people. Again, the airway breathing and circulation assessment were okay because he could tell you about his neck pain. Okay. So, in cervical palpation, he had pain. As soon as we started to try and palpate any portion of his cervical spine, he had pain. He complained of pins and needles in his right arm, and he had decreased grip strength. When we looked at the right hand, the main thing to note, he had neck pain with any movement. So, what this is going to mean is that when we are essentially holding that MILS, that in-line stabilisation until the ambulance arrives because we had a loss of consciousness, we’ve got the pain on any type of palpation. We are holding his head in the position of comfort until that ambulance arrives.

We’re looking at a couple of differentials that we’re looking at; we’re either looking at burst fracture, fracture-dislocation, disc injury, or a burner stinger. Burner stinger is less likely just because of the severe neck pain with any movement. In terms of the cervical disc injury, yes, maybe; because of the trauma, considering the ones higher up on the list. So, as I said, absolutely the first thing we’re going to do is to call that ambulance as we started in the head injury section yesterday. As soon as we sort of got that neck pain, got that loss of consciousness, especially with that torticollis deformity, that goes straight off to the hospital. We’re applying our MILS throughout the entire care process because he had pain with any type of cervical movement. We add bringing the MILS into neutral. We are going to maintain that MILS position in the position that he is most comfortable. As Trish said, we’re getting our team together and ensuring that we’ve got the spinal board, the harder one of these stretches. We will use the log roll technique, securing his head with blocks or straps onto the board. Throughout this entire process, we’re monitoring his vitals and level of consciousness to ensure that nothing is deteriorating.

Case 3: Emily. She is 17 and a netballer.  She’s running around a whole lot during the game. She’s landed awkwardly with an extended right knee while she was trying to intercept a pass. She has collapsed to the ground in extreme pain. When we get to her, we will make sure that the match is stopped. We’re going to get there. As Trish said, we will talk to her, try and get her to calm her breathing so that we can have a conversation with her, helping her manage some of the pain. So, when I was talking to her, she told us that she felt a pop in her knee. As we know, not necessarily an indicator of anything super serious, it can just be the joint capsule, but we’ll see how this plays a part at the moment. There’s no noticeable swelling, bleeding or deformity. So, potentially not looking at broken bones, there’s no wound, and that’s pretty good, and obviously, it hasn’t had time to swell just yet.

However, as we start palpating, we are moving through that T.O.T.A.P.S. type assessment. So, now we’re into the palpation. We got tenderness on palpation medial knee and posterolateral knee. So, we can start thinking about the structures we might be looking to assess. Potentially ACL, MCL, something like that, active range of motion limited in flexion due to pain and passively you might not be able to get a whole lot more. Maybe we will. This athlete could be assisted to standing, but she could not weight bear due to pain and feeling of instability in the knee. So, in this situation, we can support her. Potentially, someone under one arm and someone on the other arm. We can assist her off the court, and the match can continue and further our assessment.

So, we did some ligamentous testing once we got her off, and we didn’t find anything. You might know this. Essentially, there’s not necessarily,  when you’ve got an ACL strainer and ACL tear, we get that splinting of the hamstring. So, there’s not necessarily going always to be an obvious anterior or posterior drawer sign with an acutely injured ACL. So again, there are possible differentials with ligamentous testing because nothing came about. We are definitely going to want to send her off some imaging because of the pain and the instability. So, laying her back down again. Because of the pain and stability were splinting or bracing the knee in a comfortable position. So, you know, we can do that with some tape. If we’ve got a knee brace around, we can pop that on as well. Because we could move her, we don’t necessarily need to call an ambulance just to transport her to the hospital. We can if she’s comfortable enough to essentially ride in the car with parents, friends, or something like that. That is a viable way of getting a case like this to the hospital for imaging. It doesn’t always necessarily mean a straight ambulance call.

Case 4: Jackson is a 25-year old male rugby player. After a tackle, he stayed on the ground, holding his left arm, and appeared in significant pain. When we get there, his left arm is being held in abduction. His shoulder appears squared off, and the humeral head is sitting anteriorly and out of the socket. So, the squared-off sign is something that you may see with an anterior shoulder dislocation. So, it appears squared off essentially because the humeral head is almost stretching out that deltoid muscle at the top of the shoulder, which gives it a more rounded appearance instead of having more squared off. I mean, at the end of the day, if you can see the humeral head sitting anteriorly, it’s pretty obvious what’s going on.

In this situation, though, it’s important to check blood perfusion. You can do that by just pinching fingernails and just watching how quickly the capillary is filled that back up again, and neuro screen. Obviously, with your head of the shoulder sitting out of the joint, we can’t do a full-strength test, but something as simple as grip strength, wiggle your fingers, elbow up and down. Essentially, move what you can to test motor and sensory, nice and easy to test in through there. Yes. So, as I said, blood perfusion and wiggling your fingers there. So DDx, with that squared off and the fact that you can see the humeral head pretty straightforward, you’ve got that anterior shoulder dislocation, but other things that it could have been happening to their clavicle fracture or an AC separation. Obviously, with the clavicle fracture, you are going to get the deformity there. AC separation, you are going to get the step deformity there.

So, we’ve management here, if you are not trained to relocate the joint, because different locations will have different regulations of what you can and can’t do if you haven’t had the training don’t attempt to. You can do more harm. I may let Trish jump in and just a moment and tell you a story there. Again, we want to sling the arm comfortably. Remember you got those three types of slings. You’ve got the regular one. You’ve got the collar and the cuff, and then the support one in through there. Again, we’re going to refer for imaging and further management and potentially referring for joint relocation as well. So, Trish, do you want to jump in to tell the story about your experience.

Trish: I had a Gridiron match which is American football. I was there as the first responder for one of the teams. The athlete was a huge guy who was about 25, and he fell heavily. It was a straightforward dislocation of the shoulder. The young girl from the other team, who was the team first aider, came out, and it was clear she wasn’t comfortable,  so I helped manage the athlete. We got the players on the sideline. My recommendation to the athlete was, you need to go straight to the hospital. It was a complete dislocation. He was in a lot of pain, and the young first aider said to me, we have a young grad chiropractor on the sideline. I will get him to look at it. I looked at her, and I looked at the athlete, and I said to them both, he needs to go to the hospital. No one should be touching that shoulder. Well, the young chiropractor thought otherwise?  With the shoulder being manipulated, I think the whole ground heard this athlete scream for the next 30 seconds. The chiropractor was trying to relocate the joint.  He was manipulating it quite a bit, and the screams were just piercing.

The athlete went to the hospital and had multiple fractures in the joint, going on to surgery. The fractures were diagnosed to have happened after the dislocation itself. So, the main thing here is that you may know how to reduce a fracture, but if you haven’t got that training and it doesn’t go in cleanly, you don’t muck around with dislocations. You refer them. This is where you need to take responsibility for your management because you can do more harm. Remember what you are there for, for the athlete’s care. So, don’t be afraid to refer.

Natalie: So, for those familiar with the World Games, you’ll know Hansel, a beautiful mascot there on the left-hand side. I’ve brought him in as an example of the fact that you potentially aren’t only going to be dealing with athletes at an event. So, your duty of care may cover event staff, event volunteers, spectators. Almost anyone who’s at the event can potentially fall under your duty of care. So, keep in mind that, you know, if you are working and a spectator comes in with some sort of injury that they’ve sustained at the event that you may need to look after them as well. Perfect. So, we’ve got Hansel. It’s a very hot day, you know, World Games. So, it’s outside. He presents to you feeling unwell. He reports dizziness, headache, and nausea. When you ask him what’s going on, he says he hasn’t eaten or drunk as much as he usually would because it’s a long shift, and he’s having an amazing time. So, we get the suit off him. We have a look to see what’s going on. His skin is pale and cool, with slight sweating. His body temperature is slightly elevated, and he’s got a faster heart rate.

So, the fact that he’s still sweating will be necessary when we’re looking at our differentials as what’s going on and then management. But essentially, what’s going on here is his body, trying to cool him down somewhat ineffectively. So, our differential here is quite important. We’re most likely dealing with either heat stress, heat stroke, or dehydration. Management across the three is going to be somewhat similar, but there will be some very important differences. The main difference between heat stress and heat stroke is skin. So heat stress, we’re going to have pale, cold, clammy skin. The body is still attempting to sweat and still attempting to cool down. Once we progress into heatstroke, you are going to find it got dry skin. It’s going to be red. It’s going to be hot. Essentially, the body is always not given up but starting to put blood flow into where it will be much more important. So, the main concern here is to cool him down. So, we want to get him into a comfortable position. We want to whip the skin some more, potentially put a fan on him to try and get cool his body down.

When we’re talking heatstroke, if we did get to that, that’s when you want to apply ice to essentially in like femoral arteries under the armpits because we need to cool these people down fast, and then they’re off to the hospital. Luckily, with Hansel, it’s just mainly heat stress. So, getting some water into him, cooling him down, and then he should be right to go.

While I said, medical history potentially isn’t as important. This is a case that happened where medical history was critical. So, we managed to cool Hansel down. He went back out to continue his shift. Twenty-five minutes later, he comes back in with the exact same symptoms. Well, okay. This is a bit odd. So, we now started questioning him further. We said, “Are you on any medications?” And it turns out he just started some antidepressants. What does that do? It increases photosensitivity. So essentially, because of the medication he was on, he was more likely to get back into that heat stress situation faster. So essentially, we followed the same protocol, water, cooling down, made him feel a ton better, but we did not send him back out this time. We got the volunteers’ manager, spoke to her and advised her that he was finished for the day. We made sure that he had somebody to take him home. So, because of how easily he was slipping back into sort of this heat stress situation. We didn’t want him to drive himself home. So, he called one of his buddies. They came, picked him up and took him home.

Case 5: Wayne is another one of our event staff. This is another case that happened. Many of these guys who work at events work super hard, and they don’t stop or eat. So, when he comes in, he had been setting up temporary fencing on the beach, and he’s whacked his toe with his shovel. So, he comes in, “Hey guys, how’re you going? Look at my toe.” So, we look down.

His toe was completely covered in sand because we were working at a beach volleyball event and blood. So, primary assessment. Primary assessment, he is still able to weight bear. Keep in mind that we have gloves on this part of the assessment because we’re dealing with blood. So, it’s essential that PPE (Personal Protective Equipment) stuff when dealing with any type of bodily fluid. You’ve got gloves on to protect, not only you but them as well.

The first thing we did was rinsed it with saline to get the tiny tubes that hopefully you’ve got in your first aid kit, squirted that all around so that we could see what was going on. We could see that his toenail on the big toe was about to fall off, and there was a 2-centimetre laceration on the medial side of the toe which was continuing to bleed. We’ve got gloves on, so we’re okay to do some palpation around the area. Palpation of the toe was pain-free, and we could move the joints pain-free as well. So essentially, differential we were dealing with the laceration, we can see it. Keep in mind the different types of wounds. You are going to have your lacerations. You are going to have your abrasions which may be a bit larger in size. You are going to have puncture wounds or penetration wounds, so different types of wounds. Know what they are and the different types of bandages.

What we did with Wayne, we thoroughly cleaned it. It got more saline bit of disinfectant. We tried to give it a good clean. We put some of those butterfly bandages over the laceration to try and close that wound. We covered it with some non-stick gauze and taped up essentially his entire toe. We sent him off to the local medical centre or hospital to further clean and dress the wounds, potentially giving some stitches through there. This person didn’t stop working because of the wound on his toe; he couldn’t wear shoes. So, every day he was in the medical tent for the cleaning and dressing.

Case 6: Bruce, who’s are 53-year-old male masters powerlifter. He has collapsed with chest pain after his second attempt at a hundred and fifty-kilo deadlift. So, a pretty massive effort he is trying to put in here. When we get to him, he’s reporting pressure-like chest pain, left arm radiations. He has no history of angina or heart condition. So again, in this instance, asking a few medical history questions is very important. He had no loss of consciousness. He’s short of breath, and he’s sweaty. I mean, he’s also going to be sweaty because he’s competing. Although assessing his blood pressure, high blood pressure, high heart rate, the Glasgow Coma Scale is fine. So, in terms of his responsiveness and his cognitive ability, he’s all there.

Looking at the differences between DDxs, we got a heart attack, angina, very difficult to tell the difference between the two, especially if there’s no history of either happening before. Anxiety attack, instead of having that sort of crushing type of chest pain, we’re going to have sharp chest pain and more likely coming on due to extreme stress, not so much an extreme exertion. A heart attack pain is not going to settle. Anxiety attack, the pain is going to settle after about 20 to 30 minutes. We will sit him down, get him to take a few deep breaths, rest, and try to keep him calm. We will loosen any tight clothing, and because he hasn’t had angina or a heart attack before and without angina medication, there is no way to tell the difference. We are calling the ambulance for an immediate hospital transfer and assessment.

Case 6: Harry 15-year-old national surfer. Now we are back down to a junior athlete. One of the points which Trish touched on earlier was the junior athletes. You are not only going to be dealing with the athlete themselves, but we’re also going to be dealing with the parent and their stress and anxiety over the well-being of their child. So, while we’re managing the athlete, we also have to keep in mind that we will have to manage the parent. So, he’s come in with difficulty breathing, no previous history of asthma and no reported allergies. So, while we’re in there having a chat with him and the parent, we can hear that he’s wheezing. He’s not gone cyanotic, Glasgow Coma Scale 15 out of 15. So, you know cognition and that he’s all totally fine but with limitations on what he can speak. He’s got that raised heart rate, and importantly within questioning,  there’s no immediate history of insect sting, food, or medication ingestion. So, it’s unlikely that we’re dealing with some sort of allergy. More likely, just an acute asthma attack.

In terms of how we’re going to manage this, we will sit Harry down and try calming down. Explain to his parent potentially what we think is going on. We are going to grab the blue-grey reliever puffer and a spacer. And what we’re going to do is put one puff of the reliever into the spacer, and we’re going to get Harry to try and take four nice calm breaths. We’re then going to observe him for four minutes. If there’s an improvement in those four minutes, we are essentially finished with our care and speaking with the parent, recommending doctors follow-up for further assessment. If after that four minutes, there was no improvement. You can do one more puff, another four breaths, and monitor for another four minutes. If there’s no improvement after that second four minutes, an ambulance is called off to the hospital because while it’s still asthma, it is that more severe episode of asthma.

Case 7: Sergio 21-year old soccer player. He is tackled from the side, and he collapses in pain, holding his left leg. Potentially, with a soccer player, nothing is going on, but in this situation, as we arrived there, there was an open wound noted middle lower leg, and we can see the bone protruding through the wound. It is pretty obvious what is going on through here. We have either got an open fracture of the tibia or an open fracture of the fibula. In terms of our management, we may want to think about shielding the injury from the sight of athletes, other spectators, and players to keep the environment as calm as possible. We want to splint and support the limb for transport. This might be one of the situations where that orange stretcher is a little more appropriate because we are not dealing with a spinal injury. So, because the stretcher itself is not firm, we want to use it to stretcher the athlete from the field. Once they are off the field, we want to try and keep the wound as clean as possible until the ambulance arrives. They can take them off to the hospital for imaging and management, which will likely be some surgery in through there.

Case 8: Kurt is a 25-year old golfer. He has been stung by a bee on his hand while looking for a golf ball in the grass. Twenty minutes later, he complained of localised pain and swelling, but he’s now getting shortness of breath and tingling in his lips. He has no history of allergic reactions or anaphylaxis to bees. When we start questioning, he starts feeling weak and dizzy and getting a little bit pale on his face. Then we started to get an audible wheeze, and the heart rate was starting to rise. So, we’re now starting to think. Even though he hasn’t had an anaphylactic reaction to bees before, it doesn’t mean that he can’t start as an adult. So, you can have your first anaphylactic reaction to anything as an adult. So, that is going to be pretty high up on our list there.

As this is his first episode, the first thing we will do is call that ambulance. While that ambulance is on its way, we are laying him down comfortably, and we will administer an EpiPen. In first aid courses, you will have covered the use of an EpiPen. Don’t put your finger over the needle, and you will be injecting the EpiPen down into the athlete’s thigh. We are going to keep monitoring his symptoms until the ambulance arrives potentially. Just a side note on that, if you have got a child with an anaphylactic reaction and you don’t have a child’s EpiPen, they say it is okay to administer an adult EpiPen to a child. They will get a higher dose. On the converse side of that, if you are dealing with an adult and you only have a child’s EpiPen again, administer that as well because a smaller dose is still better than nothing.

Case 9: Josie here is a 36-year old female showjumper. She’s been thrown from her horse after a refusal at the jump. The horse refuses to jump over the jump, but the athlete has gone flying. She’s landed on her right side gluteal region. She’s found conscious but unable to move due to pain.

In primary assessment, we should keep in mind the removal of dangers. In this situation, we want to make sure that the horse is clear of the situation. We don’t need them running back in a panic. So, assessing Josie, the right hip appearing abducted and externally rotated. It’s important here to check for blood either from the rectum or vagina. That’s going to indicate internal bleeding and a much more severe injury. Again, Glasgow Coma Scale 15 out of 15. So, we’re not dealing with a head injury here. It’s purely pelvic. Motor and sensory screens appear normal. We may not get a full motor screening but move as much as we can if it’s ankle movement, toe wiggling, checking sensations.

DDx is we’re looking at pelvic fracture, hip dislocation, hip labral tear. Important to note here that we are going to remove that danger again, then call the ambulance. With a pelvic injury, we are not going to remove clothing because that will help split the area while we wait for the ambulance to arrive. While we are waiting, we will continue to monitor Josie’s vital signs and potentially manage the shock and pain, which is the main thing there.

So, these following two slides, these following two cases are our last once. They are dealing with head injuries. I am going to fly through these relatively quickly because you all had such an excellent presentation already on the head injuries. These will give you some ideas of other ways where it can look.

Case 10: Lauren 23-year old female sport climber falling from about 3 meters during a climb. When we get there, she’s conscious. She’s got a 5-centimetre laceration on the left temporal region of the head. Remember that the temporal region is a little bit softer and sort of a little bit more serious. We have noticed that the left ear as well is bleeding. She has difficulty hearing questions at the moment. So again, with the wound, we want to make sure we got proper PPE (Personal Protective Equipment) on.  Difficulty hearing and that battle sign are common symptoms of a temporal skull fracture. We don’t have any altered sensation or pain reporting in the upper or lower limbs. So, that is really great, but we do have a little bit of dizziness reported.

What we want to do is want to make sure again, we will maintain that MILS (Manual in-line Stabilisation Support) until we have got the spinal screen cleared. We are palpating that cervical spine for pain, which thankfully we don’t have any. Motor and sensory assessment of the upper and lower limb path come back fine. We are now going to start some active and passive cervical motion, with just slight pain.

So again, all of these injuries here will be a straight referral to a hospital in terms of our management. We want to make sure that that wound is clean and dressed in non-stick gauze and some bandage. Again, immediate referral to the hospital for imaging, further assessment, including concussion, will come a bit later and management.

Case 10:  Carol she’s a 47-year old female. This is a real case that happened. Forty-seven-year-old female reporting to the medical tent at a World Tour Beach Volleyball event after being hit in the head with a flagpole that came loose from the grandstand. No loss of consciousness was noted at the time of injury. She reported minor pain at the site of impact. No apparent head injury, no bleeding, no deformities, cervical range of motion full and pain-free. Glasgow Coma Scale 15 out of 15. So again, you know, cognitive ability is fully there.

We completed SCAT5, and as was mentioned yesterday, we are completing this SCAT5 not to diagnose, and we cannot sign off on that SCAT5. Essentially, what we are going to do is to complete it and give Carol a copy. We will keep one for our records as well and recommend that she follow up with that SCAT5 to her doctor for further assessment. So, apart from maybe a slight bruise on her head, our assessment of Carol found essentially nothing is going wrong. We want to make sure that we have gone through all the proper procedures, we have a record of what happened, records of our assessment, and further followed up.

[END]

 

Lower Extremity - Functional Soft Tissue Techniques - Dr Greg Doer

Greg Doerr: Hello, I’m Dr. Greg Doerr and it’s my pleasure to actually be doing this introductory presentation on “The Use of Instrument-Assisted Soft Tissue Mobilization.” I actually have about over 23 years of experience with instrument-assisted soft tissue. I’ve been fortunate enough to have lectured on these topics on 6 different continents.

So, it is something that I have quite a lot of experience with, and with any luck in this two-hour presentation, will actually give you enough information to understand why instrument-assisted soft tissue mobilization is an important aspect of what we do as manual therapists, as well as how to integrate it into clinical settings.

The class that I developed is really an offset from Graston Technique, which is where I started with my instrument-assisted experience. I taught for Graston Technique for about a decade before starting my own company, but also in the process of evolving Graston Technique into, instead of a static environment, more of a motion-oriented environment, and eventually bringing things under provocation, which was the evolution of what FAKTR became.

And then the functional soft tissue class really evolved from FAKTR into more of a clinical aspect rather than teaching simply the concepts and the technique of doing it. I turned it into a little bit more into a clinically-oriented class. So, the functional soft tissue class incorporates evaluation as well as doing the instrument-assisted soft tissue, as well as using rehab because my feeling is if you’re just doing the soft tissue without doing some of the rehabs, it’s not that you’re not going to get great results, but I’m looking for long-term stability. And rehab is critical in remodeling those soft tissues, as well as creating new motor pathways and stabilizing the injuries that we’re treating with soft tissue.

So for the purpose of this lecture, we’re really going to focus on the instrument-assisted portion. Again, my largest expertise is going from Graston Technique all the way through FAKTR and functional soft tissue. So, that’s a lot of what I’ll talk about and how it is that I associate it with that.

Now, to begin with, FAKTR was created by myself and Dr. Tom Hyde. We both were teaching for Graston Technique at the same time and largely taught a lot of classes together. Even if I was teaching a Module 2, he was probably teaching a Module 1. We spent a lot of time together, especially between 2000 and 2002, just literally testing the boundaries of what the Graston Technique taught us. Obviously, in that process, we started coming up with wow, if I put things under provocation, we noticed that things responded quicker and had a longer-lasting effect in a positive way than if we just did it in a passive, non-weight-bearing environment.

Since we started doing that, we’ve obviously had contributors from countless numbers of chiropractors, PTs, PhDs. There are three that I listed on the screen here; Warren Hammer particularly, in my opinion, is one of the godfathers of all soft tissue internationally. Phil Paige, who’s, as you can see, a Ph.D. PT ATC. He was hugely important, as well as Mike Schneider, in discussing and coming up with a relevant theory as to how it is we’re affecting things neurologically, not just the old Graston technique thought process which was to break down scar tissue adhesions. There’s more of creating that evolution of the neurological aspect of what it is that we’re doing. Since then, there is nobody, in my opinion, who is not giving you influence to actually improve and evolve upon what you’ve done. I’ve always said in 23 years of teaching now, it’s rare that we really come up with a unique idea. It’s more that we’ve been influenced by others. Or if we do, so to speak, have that unique idea, somebody else is probably doing it. It’s just we’ve never interacted with each other. So, that’s always great when you see two people walking the same pathway without really having any contact with each other. But, the uniqueness of what we do is always a little bit sometimes overblown, but our influences are so vast and expanding. It’s wonderful to be able to evolve things as we learn new information.

Here’s an example of some of what instrument-assisted really started at. We like to think that instrument-assisted soft tissue mobilization is a new thing. Graston Technique, which is really the granddaddy of all of it, it’s really a mid-’90s scenario. In my opinion, the ’90s were a huge evolution into manual therapy whether it was instrument-assisted, whether it was newer techniques that came out there, and you can see they’ve just been evolving ridiculously over the last 25 plus years.

Instrument-assisted soft tissue mobilization is not new. It’s been around for thousands of years. In particular, Gua Sha, which is one of the ones you see in front of you, was some of the first instrument-assisted work that was ever done and at least in recorded history that we can say. Obviously, Gua Sha’s influence on this was much more associated with things like removing stagnant flow. They were looking more from the chi level. Their purpose was to bruise you, and the bruising colors, just like with cupping, gave you an idea of some of the stagnation and what was going on. But that was really, so to speak, the starting point of our instrument-assisted at least in the modern, and by modern, I say a few thousand years era and were a lot of this has evolved from. So, it’s not that what we’ve done is new, it’s been around forever. We have just added to it. Here are some other examples of some of our Gua Sha instruments.

Now, when we started looking at the newer or the modern versions of what we would say instrument-assisted soft tissue mobilization came around, there’s obviously a whole bunch of different companies whether it was Graston Technique, Astym, or sound assisted soft tissue mobilization. All of these are offshoots of Gua Sha in theory. Again, it just became a little bit more westernized. And as that has changed and evolved over the year, we’ve also seen things like HawkGrips developed, a similar set of instruments to the Graston technique. Then all of a sudden you started seeing some of the multi-tools developed.

 Tom and I, in particular, were probably one of the first companies to develop these multi-tools. We created, literally, four instruments, three of them which you can see in front of you. The purpose of it was to literally, not need three instruments to treat one person. It was trying to put all of the different edges that you needed to take care of people, kind of into one environment so you can have it in your hand, like, one instrument, and be able to take care of everything associated with that body part of that injury.

We obviously developed different instruments, much like many other companies do, because sometimes something feels better in one clinician’s hands over another. They have preferences in things along those lines. But that’s been the evolution. I guarantee there are so many companies now that have created their own instruments, and it is far from over. It is just going to keep expanding and going. The great thing is that if you have a great product, it will last the test of time. If you tend to have a lesser product, it tends to go like, “Eh, I don’t really want that anymore.”

Even the functional soft tissue instruments that you see in front of you are an evolution of the initial FAKTR instruments. I changed a lot of it. It was the beveled edges to make them a little bit more comfortable for the clinicians to use, as well as for the patient. So, as I said before, this all came from Tom and I literally working on each other in hotel rooms and finding out that when, for instance, we both have knee injuries that when we’re squatting and provoking our injury, we felt significantly better post-treatment than when we were just doing like sitting on a chair or lying on a table and having the same tissue structures worked at. The difference was we’re like, “Well, why?”

And truth be told, Tom and I were clinicians. I don’t want to say that I’m a researcher or anything like that. Sadly, I’ve been around too many PhDs now, they’re forever in my head, constantly making me ask that question, “Why? Is it valid? Is it because of this or this?” So I question things to a ridiculous level now that when I had my wonderful ignorance of just being a clinician it was like, “Hey, it worked. Who cares?” But that’s what Tom and I started. We started as just clinicians trying to push the envelopes of what we learned in a hotel room, treating each other’s knees, and finding that, “Wow! This is really different.”

Now, Tom was retired at that point. So, I would be taking all of these concepts and theories back to my office and treating my athletes, treating my geriatrics, treating my normal everyday patients, and literally going, “Hey, it worked on the knee. Does it work on a shoulder? Oh my god, yes, it does. Oh, it works on a hip too. Oh, it works on the lower back. It works on the spine.” And it was really just testing every single one of our concepts associated with all the different body parts and the different injuries that we had going on there. I’m the first person to say that, the person who’s teaching you and tells you absolutes, you should probably walk away from that because there’s no such thing as an absolute. There’s no way that your instrument-assisted soft tissue technique is going to work for every condition, every single time, exactly the same way. That’s the beauty of being a clinician. It’s being able to adapt it to the person in front of you, and actually patient selection as to what techniques, concepts, and so on and so forth, are better for that patient over maybe another patient.

This is all being contributed to by a numerous number of PTs, chiropractors, athletic trainers. I mean, at this point, I don’t know if I could actually leave out a profession that has not had an influence on my ability to evolve these concepts and applications. As I said, it did originate with Graston Technique. The important thing is it wasn’t just X marks this part, there’s a plain pain point and treat it. We really started diving into, as early as 2002. What’s the kinetic chain of the injury? If we’re just treating the knee and it’s not getting better, is it the knee, or is the plant leg on somebody who’s also a thrower, and their shoulders are all messed up and it’s just working the whole kinetic chain? These are all the interesting things that sometimes you go through.

As I’ve said, if we had unlimited time in our office, well, then maybe we can treat the entire kinetic chain at one time. Most of us don’t, most of us are clinicians that run on a schedule. And in that case, obviously, we want to start with an asymptomatic body part, and then move through that kinetic chain, as we’re either happy or unhappy with the results, or trying to really clear out an entire problem. Obviously, athletics is one of the common ways that we do that because of the use of the kinetic chain in sport-specific activity.

Now, this is where Tom and I have really put together some kind of an almost like, I don’t like using the word ‘protocols’ cause these aren’t protocols, it’s not this, then this, then this, then this. But almost a format upon which you can apply your soft tissue procedures. Now, I’m saying instrument-assisted, but these are the same concepts that are used from the manual with my hands, and so on and so forth. So, it’s not just instrument-assisted, this is really what I use for almost most of my soft tissue rehab treatments that I have in my office. So, it is a hierarchy. Concept one is a physician of provocation, obviously, that’s the simplest. It’s as simple as, luckily, we’re sharing the screen so you can see my video as well as the PowerPoint but I presume a position of the public patient can be something as simple as, “Oh, I feel my neck pain over here.” Okay. So that could be something like a physician of provocation motion might be, well, it’s not necessarily, “Oh, there’s my pain but every single time I move my wrist, I feel like, Oh there’s my suboccipital but it’s fine at the endpoint but it says I’m going through a movement. Oh, there it is right there as I get to this level.” So sometimes the motion of provocation which by the way is neurologically is much more powerful than just holding a position, adding in resistance. Now we’ll talk about that a decent amount as we go through the process during this lecture. But adding in load is adding in even more neurology.

Now, the other interesting thing when we add resistance is we can also change the morphology of the tissue. And we’ll talk about that in pretty good detail when we hit things like ligaments. And more importantly, tendon injuries. So we going to add in resistance to certain injuries based on what is the problem.

Next is using functional position directivities. Now, this is one of my favorite ones because it’s almost my jump to almost every athlete. “Hey, I only get my pain in the cocking mechanism of throwing.” Well, that’s a functional position. When I get into the hole on a squat, that’s what I feel my hip, my knee, my whatever. So we use those functional positions. “Oh, my elbow balance me but only at the bottom of a push-up.” So I’ll use push-ups, squats, throwing motions. All these different activities that provoke their symptoms, I bring those to the plate immediately, especially in my athletic environment. But it could be geriatric that tells you every single time, “I get in out of the chair, that is when I hurt.” Well, I haven’t reproduced sitting in my chair while I am treating them. I like to turn things into weight-bearing as much as possible.

The ideology of just lying on a table and getting treated is something that I– I don’t want to make it sound like it never happens anymore because again, that would be absolute and we always know absolutes are untrue. But it is my methodology is always trying to get that patient as weight-bearing as possible even if it is only semi-weight-bearing at a point and then bringing them into more weight-bearing. My post-surgical cases might be a little bit different, especially dealing with the shoulders or something like that where we can’t add in load. Let’s just say it’s a rotator cuff repair where we may not be adding a load for 6 to 8 weeks before we really start bringing in some load intervention that could be 10, 12 weeks before we bring in some eccentric loading.

And then lastly is adding in Proprioception. Proprioception, again, is just creating an unstable environment. So, that could be anything from using body blades and perturbation that could be using stability pads or bow shoes or eye joys if you have those vibrations, things along those lines. Just creating an unstable environment for the patient while they’re doing their activity. That’s what the last in the hierarchy, is using in progress.

The algorithm that Tom and I developed, again, back in the early 2000s, which happily I can say that it’s rare I go to a class that people don’t use the same algorithm now. Again, it’s an evolution of where we’re thinking in treatments, whether it’s soft tissue, whether it’s taping, whether it’s manipulation, mobilization, whether it’s rehab. We want to see these things. It’s the greatest way of, as I like to say, creating patient compliance but also showing the patient the value of what it is that you’re doing on a day-by-day basis.

The first thing, obviously, I want to do is test. Then we want to treat with whatever interventions we are using in this particular class. We’re talking about instrument-assisted soft tissue mobilization. Then we are going to retest. So in other words, when I flex my bicep, I got pain, and I treat. And then I flex my bicep again. The way I always like to go about this with my patients is I say, “When you first did the activity, that was a 10.” Then I’m going to treat. I’m going to retest that activity. “What is it now?” We’re always looking for a minimum of a 10 to a 5. Obviously, are there situations where you may not get a 50% of reduction in a single visit? Yes. Things like Stenosis. Well, it’s rare to get a 50% change in Stenosis in a single treatment, okay?

Post-surgically. Well, hopefully, we can reduce pain but are you really going to take a post-surgical knee replacement and all of a sudden go from 90 degrees to 120 degrees in one treatment? Most likely not. There are obviously examples, but what we are looking for in a general population is dropping it from a 10 to a 5. Remember my starting point for every test is always a 10. And then, depending on your schedule, my general rule of them is I don’t retest more than three times in the course of a treatment, otherwise, we are going to start running behind because I do have a relatively busy practice schedule and we do work on basically, 4 to 5 patients an hour. So, I do want to make sure that I’m keeping within my schedule. I don’t like patients waiting in my office either.

Lastly, is using training. Now that brings in our exercise and adjunct therapies, and it also establishes so many different things. It’s everything from re-establishing motor pathways to morphological changes within tissue that we’re trying to be pro-inflammatory with, which we’ll discuss in a few slides, as well as for me, taping is a huge adjunct that I use after treatment. Which there will be another class on that if you’re so interested in looking at that kind of methodology.

So again, testing as I said, we’re going to basically determine that either position of provocation, movement of provocation, resistance, the functional position or activity, or again, the adding of Proprioception. We’re going to look at that and say, “Whatever it was, it’s a 10.” We are going to go through our treatment and we may treat obviously with or without motion, resistance, or Proprioception but it depends on where they fall into that hierarchy. What provokes their symptoms? Or their imbalances or their restriction. It’s not always just about pain, it may involve range in motion reduction or a loss of function. “I can’t break parallel on a squat,” “My knee goes valgus when I do a squat.” Things along those lines.

Now, our treatment time really should be somewhere in that 30 seconds to 2 minutes. The worst place in the world you could ever go to try and learn how to do instrument-assisted soft tissue mobilization is Youtube or social media. What I see on those is frightening at times. I see the amount of particular responses and again, I don’t fear particular responses. Those that do, don’t understand the purpose of what they’re doing or the reason particular responses are showing up. However, I don’t fear. I know it’s part of the normal treatment however, I also know large particular responses. Okay, maybe they happen in your first one to four treatments, but the idea to try and create a particular response for the purpose of creating it? I question whether or not that person may have a good understanding of what they’re trying to accomplish with instrument-assisted soft tissue mobilization because most of what we do is neurologic. Which should not necessarily be pro-inflammatory in its aspect. Again, early on it’s very common to have that. It shouldn’t happen later on.

So, again, after we’ve done our treatment for that 30 seconds to 2 minutes, we’re going to retest. Once again it was a 10 before what is now, re-treat up to 3 times again re-treating and re-testing up to 3 times. And then again, depending on what your problem is or what you’re looking at, you may move up and down that kinetic chain. A tennis elbow being a perfect example. If you got a tennis elbow, most likely you have either a wrist or a shoulder issue. It’s a question of which it is or Scapula stabilization issue. So it could be any of those. But that’s when we might be moving up and down the kinetic chain. You don’t want to ignore the tennis elbow, you want to treat it, but you also want to treat what’s causing that tennis elbow. And then, obviously, add more complex testing. It could be, “Hey, by the way, it was just when I gripped my water bottle, that hurt.” Okay. Well, now maybe we’re going to put a weight in. Now maybe we’ll have him do more of activity like twisting a cap or throwing a ball or lifting a heavier weight. But add in more complex things, doing a push-up.

Then after that, we are going to go into our training program. Now that’s again, restoring our muscles balances training, our movement patterns, and then again, adding in our adjuncts like for me a huge one is kinesiology taping. Although while we’re talking about instrument-assisted, I also use a lot of my shockwave therapies using these same types of concepts. I find that it works really effectively with those of you who may do shockwave as well.

Now, indications. This is one thing that I always find interesting. I know we have to do this just from a standpoint of creating a framework of what you should at least know what is in your real house. There are very few things that I don’t have indications for myself if there is a soft tissue involvement. It’s actually just knowing when not to apply more than anything. So, obviously, your tendinopathies respond extremely well to these types of FAKTR concepts. As well as instrument-assisted soft tissue mobilization or fascial syndrome like an ITB syndrome. My biggest thing, of course, with some of these, is like an ITB Syndrome is like, “I get that’s your pain, that’s not your problem.” So, in those situations, we obviously have to be looking at what mechanics and probably hit imbalances to make sure that we’re correcting our ITB problem, and let’s just hope it stays on one side and it’s not because there’s something bad going on the other side, which then makes this work twice as hard.

Trigger fingers, things going those lines. Other indications, I absolutely love doing nerve entrapment stuff. I have been fortunate enough I finally met Shacklock recently. I find his book to be absolutely one of the best around there. But even Butler’s research studies that I’ve read where it all started in all honesty with nerve flossing. But carpal tunnel syndrome, thoracic outlet, all these other nerve entrapment syndromes whether they’d be true neuropraxic compressions, which obviously carpal tunnel and cubital tunnel are most common ones. Or they make maybe fatal adhesions, in other words, the nerve just isn’t gliding well within their sheaths like a TOS. Again, a TOS can be a true nerve compression but a lot of the time, it’s just being hung up in some tissue. Which is why sometimes we see TOS surgeries not really working too well. As well as if you’re only doing some stretching. Sometimes you really have to release some adhesions within tissue in order to establish POP immobilization between nerve, blood vessels, muscles, fascial sheaths.

Ligament injuries. Of course, the more superficial the ligament injury is the better off you’re going to be. MCLs, AC ligament sprains, my God, these respond so exceptionally well. Ankle sprains are a lot more complicated just because the mechanics that are going on there. But at the same time, if you’re doing a really good rehab program associated with your instrument-assisted work, both from an anti-inflammatory aspect of reducing swelling from the acute ankle sprain, as well as assisting in remodeling the injured ligament which may be pro-inflammatory depending on the pace that you’re in. We’ll talk about that as well in a few slides.

And then, to me, scar tissue and adhesions, which is what instrument-assisted work at least in the modern methodology starting with Graston Technique. That’s why it was developed. It was to actually mobilize scars from two guys who had previous surgeries and were athletic. So, that’s the part where these all came from, was actually post-surgical work. And honestly, I find it to be absolutely invaluable if you are in the office doing post-surgery care.

The interesting one is Edema. Now, massage therapies, physiotherapists have also been utilizing milking versions with their hands for decades and decades and decades. Instruments are phenomenal for that post-surgical and acute swelling. While I know it’s utilized a lot in Lymphedema as well, I got to be blunt, that’s not my wheelhouse. I’m a sports guy, so for the most part I use it for more post-surgical and acute Edema. I tend to refer to my physio-therapist for Lymphedema myself and if they happen to use instruments, fine and dandy but they do it every single minute of their day. Whereas somebody like myself, I might see Lymphedema 5 cases in a month or something along those lines and it’s usually secondary to they’re in for me to see something else. If Lymphedema is really a primary issue, I tend to refer that out to somebody who’s a little bit more vested in that information. Because it is a lot more than just pushing out swelling in an acute ankle sprain.

So, our contraindications, this is one of the things that I get a little crazy about because, this is again, we have to put up a framework of saying “Hey, be aware. Don’t just treat the soft tissue just because you think you’re great at soft tissue. Be aware of these things.” But a lot of these things that we’re throwing up here, I live right outside of New York City in New Jersey and the reality is, cancer is something obviously we see quite a lot. Just because somebody comes in with cancer, it doesn’t mean you’re not getting instrument-assisted soft tissue mobilization. You just got to think, “Okay, is it a lump? That’s a tumor that’s visible?” We don’t use our instruments over that.

But if they have roughly we’ll say something like a Renal Cancer, it doesn’t mean you can’t treat the shoulder. I obviously see a lot of mastectomy work and breast cancer treatments, Lumpectomies, radiations, things along those lines. So, these are the things that are very common to me in my office. There are things however that, a burn scar, well, I was told burn scars it doesn’t really work well with, but I had to try anyway. And the reality is, it truly is a different type of collagen scarring that occurs. I have not found burn scars to react really well to instrument-assisted soft tissue mobilization. An unhealed fracture. Look, if you are co-managing the situation, then you’re fine but obviously, your unhealed fracture should be seen by the MD, the orthopedist. They’re the ones who should be handling an unhealed fracture.

Kidney disfunction. This is one that understanding if soft tissue releases a lot of solutes into the bloodstream. If you’re on dialysis, you got to be careful as to how much you do because the kidney is going to get taxed drastically, the liver even for that from that standpoint. Pregnancy. Look, I live in the United States, there are more lawyers than manual therapists. Whether it be Cairo’s, physios, massage therapist, so on and so forth. Pregnancy, if you look at a pregnant patient you’re liable until they’re 18. That kid’s 18. It’s something that you always have to be worried about but happens to be, even though I’m a sports guy, pregnancy happens to be my second favorite population to take care of in my office. I love them. They respond exceptionally well to almost all the work that we do. And it’s great to have somebody who’s so happy actually seeing you because we’re the only people that are getting them out of pain. Unfortunately, in the medical, I can’t inject them, I can’t give them drugs, so what am I going to do? Usually, they firm out. These are a group of patients that I actually love getting.

Anti-coagulant medications. Remember we already talked that particular response is common, especially in those early visits, first one to four in particular. You need to know whether somebody’s on anti-coagulant medication. Not necessarily that it’s going to say, “I can’t do this on you” but your amount of time that you spend, your duration should be low and your intensity should be low at least for your visit to see how other tissues react. I have had patients with high doses of anti-coagulants that had absolutely no particular response. And I’ve had patients on half a baby aspirin that literally I took one stroke with an instrument the next thing you know there is a line of a particular response. You have to be aware of it. It has to be something you discuss with your patients so that you’re aware of it with each other. Again, to kind of curve your aggression initially with your treatment. Obviously, for any of your inflammatory arthritis, if they’re in an inflamed state, you must reduce the amount of work. However, I may switch to an anti-inflammatory application that, again, we will discuss in the next few slides.

Uncontrolled hypertension. Bluntly, I’ve had more than enough cases of uncontrolled hypertension that have shown up in my office. I am praying when you take your blood pressure, your vital screenings and you actually see this and you ask the patient, “Okay, you didn’t list hypertensive in your intake form. You have a blood pressure of 240/180. Who is monitoring this for you?” “Oh, I didn’t even know I have high blood pressure.” Well, please don’t treat them. Call up their MD and either say, “Do you want to go to the ER or do you want me to send them to your office?” Obviously, the MD 99999 out of whatever number of times, it’s going to be “Send them to the ER” And again, with that level that I just told you something like a 240 and I actually had somebody come on like 240/180. They went right to the ER.

Other problems are contraindications. Reflex and pathetic dystrophy or better understood as Chronic Regional Pain Syndromes. Look, I don’t want to make it sound like you can’t treat these patients, in fact, I do. However, resolution of their problems shouldn’t be the expectation 100% of that time. If you can and it does happen, be thrilled but literally, if you take somebody who’s been living their life as a 6 out of 10 every single day, their lives are an 8 out of 10 and you’re reducing that to a 6 or a 4 out of 10. I think you’re doing your job. You’re helping them stay off medications, you’re allowing them to live their life better, so, that’s fine.

Lymphedema we’ve already talked about. Polyneuropathies, again, are usually caused by other things like diabetes or thyroid issues, or something else along those lines. Right now it’s a vascular scenario. You’re not going to be able to treat those successfully just by doing some instrument-assisted work. Even if you desensitized it, if it’s burning pain, it’s going to return. This is not something that we are going to have a resolution with. Diabetes, obviously again, that’s an endocrine disorder. What are you going to do with soft tissue mobilization? Just be aware that diabetics, they’re going to heal a lot slower. Open wounds, unhealed suture sites, things along those lines, well, guess what? Yes, we’d like those to close. So, it doesn’t mean you can’t do soft tissue work on them but don’t go over the suture site. You got to let that close first and then you can move on and start treating the scar.

Obviously, things like Osteomyelitis where you have a true bone infection. We’re not doing instrument work over that. Varicosities. Now, I’m not afraid of Varicosities myself. Again, I’ve been doing this for over 2 decades. My pressure when I see a varicosity is feather-light but it doesn’t mean in the other region like a calf, for example, I can’t treat it a little bit more aggressively. You just got to be careful over the varicosities. If you have somebody who you suspect with Thrombophlebitis or has a massive family history and they got that deep [inaudible] in their calf when they’re going for walks and things along those lines, get an ultrasound before you start treating that calf aggressively. Because the last thing you want to do is create embolism.

Now, one of the most important things to me with instrument-assisted soft tissue mobilization isn’t just the aspect of getting some healing and treatment. But it’s also really important in clinical decision-making. And I got to say, I don’t like talking in absolute. But this is about as close to absolute as I can see within medicine. So it uses both assessment and treatment. You obviously start to perform your examinations, and your histories and things along those lines, and it’s going to be instrument-assisted. It’s going to be integrated into your treatment. It doesn’t have really protocols. It shouldn’t be a “Do this and this and this.” That’s not being a clinician, that’s basically following a baking recipe.

There shouldn’t be boundaries. I always say your greatest limitation with the patient is your own creativity. Now, that being said, if the patient improves and then drastically drops right back down to square one, I like to call it “The yo-yo effect” I’m good, I’m bad, I’m good, I’m bad, I’m good, I’m bad. And that keeps happening. If it happens consistently within 2 to 4 times, I’m a little bit more towards 4. I like to give things at least 2 weeks to see if that’s going to take into some kind of high gear. But by 2 visits, if I’m seeing that yoyo effect, I’m not happy. By 4 visits, I can tell you right now, I’m already doing my progress about which I do anyway every [inaudible]. But that’s when I might be making my determination of “Okay, now it’s imaging; x-ray, MRIs, CT, whatever it might be, now it’s ultrasound. Now it’s referring out to the ortho, to the MD, I want to get bloodwork.

I have had situations where what seem to be a muscle spasm and then I do mean a threshold spasm. Somebody would walk a certain distance and their back would go into spasm. And we treat it and she was able to get back to that activity again. All of a sudden she hit a certain threshold, and bam! spasms all over again. It turned out once we did bloodwork that her serum calcium was through the roof. She had parathyroid cancer. So, when you see these yo-yos back and forth, back and forth, back and forth, let your spider-sense tingle, man. Your gut is telling you something. It’s probably not a good situation. It may be something as simple as, “You missed the diagnosis, re-assess it.” But it also might be something more serious like, “Uh-oh, I need to refer this out. This is not a situation I should be taking care of.”

By the way, it could just indicate the type of soft tissue that works that you’re doing? FAKTR is what we’re talking about right now, instrument-assisted wise, it just may not be appropriate for that patient. There is no one technic that is appropriate for every human being on the planet. It’s not going to happen that way and if you think so, just wait for the person to walk in that it doesn’t work on. We don’t do the same treatment to every single patient every single time.

So, getting into our treatment responses with instrument-assisted work, we have to be aware. I am so adamant about this, please nobody get upset about this, but you cannot fear your patient’s pain. It is shocking to me how many manual clinicians are terrified of a patient coming in pain. That’s why they’re seeing you “Oh, all we’re going to do today is ice and stim.” What? Are you kidding me? Is that the best you can come up with because somebody’s in acute pain, is ice and stim? We got to think well outside of that box now. You cannot be afraid of your patient’s pain, that is why they’re seeing you. If you’re afraid of it, why is the patient seeing you?

So, pain and discomfort are relatively common with soft tissue treatments. My favorite thing, again, with a patient that comes in and says, “Doc, new patient. Is this going to hurt when you work on it?” I said, ‘Do me a favor. It’s a tennis elbow, right? I want you to squeeze right on that tendon with a little bit of pressure. When you do that, does that hurt?” “Yeah, that does hurt, Doc.” ‘It’s gonna hurt when I touch it too.” All right? I use humor a little bit to deflect things in my office, keep people a little bit more jovial, a little bit happier but it also sets things into play like “Yeah, that might have been a stupid question.”

You can’t be afraid of touching something that might be painful. Now, we can do some things to desensitize the region before we work on it. No problems with that whatsoever, but you can’t just say, “Oh, we got to calm that down. We can’t even touch that region until it calms down a bit.” No, your job is to get in there and workshop these things. Bruising, again, very common it’s not something that should be a problem for you in the first one to four treatments to see it. It’s normal. However, you got to remember particular response is basically our blood vessels, superficially our capillary beds that have stuck between tissue layers that aren’t mobilizing well. When things are not moving, that capillary wall becomes very fragile. As you’re doing your soft tissue treatment, both through compression and shear and things start gliding again, those capillary walls are actually attached via cytoskeleton to those fascial layers. As it starts gliding and moving, capillary walls are going to be torn apart from that cytoskeleton because they become fragile, you’re going to get a [inaudible] response. It is extremely common. It tends to only show up over damaged tissue or tissue that is not mobilizing well. However, you should get that tissue mobilizing pretty well within your first one to four treatments, and therefore, the amount of particular response should decrease drastically.

It doesn’t mean you’ll never see some red dotting. People do things in life. They might sit at a computer 8 hours a day, 10 hours a day. And some of those postural muscles affect the STMs. All these things could develop those adhesions again or that lack of mobility. And you can still get some particular response, but it should be drastically lower. It should be reduction, reduction, reduction as you’re going through treatments. Bruising is not something that should be, if you’re on your 8th treatment with somebody you’re still bruising the stuffing out of people, I’m concerned. I’m looking at this going like, “What else is going on? Are you just constantly re-aggravating this tissue or is there something going on with you physiologically that we have to be concerned about?”

Lastly, as a potential response, this is not the most common thing in the world that happens. It’s called a spontaneous burser release. What these are basically hardened scar tissue that’s attached to viable soft tissue. And what can happen is it can tear apart and literally give a loud audible pop. Again, I’ve been doing this type of work for over 2 decades. Every single time one of these happens I still go like, “Uh-oh.” When you hear this kind of a loud audible pop like an ACL just ruptured, it’s a little unnerving at first but I see invariably one of two responses. That person goes, “Oh my god. What was that? Holy cow! My shoulder feels great! What’d you just do?” I didn’t do anything, it’s just scar tissue ripped away and now you don’t have any more restriction, the pain is gone. It’s a really interesting thing. You’ll see somebody go like, “Oh my god. I just feel great now.” And then, there’s also the negative one. That scar tissue tears apart, you get massive inflammation, and the patient goes, “Oh my god that hurts so bad.” Here’s the difference, it’s inflammation that’s created from that tearing of that scar tissue, however, unlike the injury where it could take weeks for that to get better within a week, 3 to 5 days usually, that inflammation starts calming down and the person starts going like, “Oh, wow! That’s really starting to feel a lot better now.”

So, it’s the treatment response. It’s that duration afterward, you’ll start noticing the person feels a lot better much quicker it was just an initial response that scar tissue tearing away. If you happen to get any of these, I’m really sore afterward. Now, I’m going to give you something that in a few slides when we talk about tendons, I’d like to call it my 7 out of 10 rule regarding post-treatment soreness. But look, whether it’s pain, soreness afterward, whether it’s a particular response or bruising, spontaneous fascial releases that have the inflammatory response, number one, you must discuss these types of things with a patient. If you’ve talked about them with the patient and they look at you and they understand it, you’re going to be in much better shape.

The other thing is you may need to do some very light work. Maybe you’re doing the anti-inflammatory type of work for treatment after that, maybe you’re doing an anti-inflammatory application with instruments, maybe you’re doing more of your icing, maybe you’re doing a rehab technique that is designed more to pump inflammation out rather than doing eccentric loading, maybe you’re using other adjuncts like Normatec in order to help pump out some swelling in the area, or laser or things along those lines. Now, we have 3 major applications when we talk about soft tissue treatments. And I think this, in particular, is a really important thing to go through because I don’t think a lot of people discuss this very well. The way that I look at it, and this is directly from one of my friends from Canada, Toronto. Kevin Jardine came up with this regarding SpiderTech taping, and this is again going back quite a lot of years now, but he talked about things being either neurosensory, structural, or microcirculatory.

Basically, a structural treatment was much more for in taping was from the standpoint of creating postural changes or things along those lines. I looked at it a little bit from the soft tissue perspective, I said, “This is genius.” But this is everything we do whether it’s rehab, whether it’s manipulation, whether it’s modalities, whether it’s soft tissue work, whether it’s taping. Are we trying to be pro-inflammatory, structural, changing the morphology of something? Or we’re trying to do a neurologic response which is what most of what we do is we’re trying to stimulate afferent nerve receptors that allow us to reset things within the central nervous system through reflex loop mechanisms, which we’re going to go through again in a little while, or are we trying to decrease inflammation? And I took those and I said, “Kevin, genius, I’m adapting this to soft tissue.”

Our structural treatments are pro-inflammatory treatments. They’re designed to create fibroblastic proliferation. We want to create collagen synthesis when we go that aggressively. They are obviously heavy deeper strokes. They are faster strokes only if you can maintain your instrument on the tissue. There’s no point in going faster if you’re slipping off it. All you’re going to do is create inflammation everywhere else but where you need to. However, as I said, it may be a slower stroke to stay on the tissue. Just remember, these are designed to create inflammation so a lot of the times when you do your pro-inflammatory treatments, the first thing they will say is, “Wow!” I go and I muscle test something again for a tennis elbow and they’re going like, “Wow, that doesn’t hurt anymore.” I was like, “Wow. What did you do?” I said, “Well, obviously, I healed the tendon injury that you’ve had for the last 12 weeks in the last 30 seconds,” and they look at me going, “You’re really good.” I said, “I numbed your area.”

You got to remember, part of what you’re doing when you do soft tissue work is you’re creating contact anesthesia. So, a lot of that soft tissue work initially, you just numbed it. If you haven’t told the patient “Hey, by the way, in the next hour to two hours, you’re going to start getting sore because the purpose of what you did was to create a focal inflammation.” Why? we’ll talk about that in a little while. “But just remember, we are, at times, trying to be pro-inflammatory. However, there are only four times we’re really trying to be pro-inflammatory.”
Our four situations are tendinopathy or tendinosis, in other words, what we’re trying to do is I like to describe a tendon injury in these situations as a rope that’s fraying from the inside out. My patients get that. So, as I’m doing my tendon treatment, I’m trying to rebuild collagen production inside the tendon. So we’re going to focus on using, interestingly enough, our factor treatment concept three, which is resistance but focusing on eccentric loading. Why are we going to focus on eccentric loading? Eccentric loading increases collagen production. It’s really that simple.

So, the question could also be, “Well, why don’t I just do some soft tissue work and then have them do eccentric loading when they go home?” You can. Here’s the interesting thing. We’re talking about the neurology of what we’re doing. Adding in these therapies together, number one, increasing the amount of neurology that you’re stimulating, secondly, is the ideology of how quickly does collagen production starts after you’re doing your soft tissue treatment. I’m going to actually show you some actual slides that demonstrate the speed upon which collagen production happens with soft tissue treatment. Secondly, ligament injuries. With the ligament injuries, we have to remember it’s non-contractile, however, we do know that fibroblasts and collagen align, in other words, they will line up along the line of strain so what we want to try and do is create the line of strain, the tension on that ligament, while we’re doing our soft tissue treatment because the fibroblasts that we’re proliferating and bringing more to the area and the collagen that’s being produced is going to be produced along those lines of strain. So, with an ankle sprain, I literally will put it into plantarflexion and inversion, obviously, an inversion ankle sprain. I will put that into plantarflexion and inversion and treat in that position. Now, if they can’t wait there, I’ll have them sit down put their foot on a Bosu, and just bring their foot right into that position. If they can wait better, I’ll have them stand on the Bosu and create that position.

Third. Post-surgical or traumatic scars. Again, remember that’s what instrument-assisted in a modern way hat was developed for. Now, you can focus on any and all the concepts here. It really depends on where they are post-surgically. And just remember when you’re doing a post-surgical case and you’re working specifically on that scar, I tend to use what I call a filet stroke. This is a stroke that I actually developed at Graston Technique. Our purpose with this is literally taking tissue and filleting, I’m going to try and show this one as best I can, filleting through it. Almost as if you were doing this type of motion. Almost like an atom in the lab where we’re peeling off layer after layer you treat and pull off, dissect and pull off. So, that layer, it’s going to go within two layers but it’s not going to be thick, it’s got to be the narrowest part of the instrument in order to accomplish that. Those fillet strokes are great because it revascularize the scar. It prevents scar tissue from forming in a negative way within that scar and cross-linking. It revascularizes it so it reduces the coloration of that scar much quicker. In other words, it’ll turn it back to a skin color faster. The raised scars, it’ll also drop them down.

So all of that is extremely powerful things. They have wonderful methodologies of improving the ability for somebody to mobilize much quicker, in other words, they may be able to have less pain. One of the greatest examples I can remember is seeing somebody who was terrified of me working on their scar, but by day four after their surgery, they were in so much post-surgical pain they said, “Just do whatever you can. Whatever. I don’t care. Just do something.” And I did more of my anti-inflammatory work, which we’ll talk about in a little, over that scar and they were off-purchase that’s literally the next day. But in the chronic nature, we’re going pro-inflammatory. We want to mobilize that scar, revascularize it, get it moving again because scars can create a lot of negative neurologic effects in the body, whether it could be pure neurologic paresthesias or hyperesthesias but it also can create dysfunction. In other words, you might have a scar somewhere and the next thing you know, you get dysfunctional in another part of the body.

The coolest one that I can remember in modern history. I had somebody who had laparoscopic surgery on the right side of their body and post-surgery, they actually got tingling numbness and weakness in the opposite hand. It came out right after the surgery. I’d done all my questioning, arm position, things along those lines, were there any cuffs or things along those lines on that arm. No, everything was fine. The real interesting thing was as I was testing for grip strength and kept mobilizing the scar at the same time like pushing and testing the grip strength and the opposite side at the same time, I hit one direction, all of a sudden the grip strength came back. I don’t know. Neurology is weird and it’s interesting but you can’t ignore these scars. So, any type of position that puts provocation into that scar tissue, that’s what you want to use whatever the concept may be.

Then we also have our deep fascial lesions. Now, these are those knots that we’ve talked about forever. Recently, again, another evolution in soft tissue procedures is fascial manipulation. We have those Luigi Seco who developed this now. Carla and Antonio tend to do a lot of the research as well as the evolution of fascial manipulation. I tend to like using concepts for functional positions associated with those deep knots, those stucco points basically, deep fascial layers that have adhered together. What they’re talking about is the use of these hyaluronic acid chains that become longer and longer. They actually turn over on themselves and kink, and it almost creates chewing gum between these deep fascial layers and it creates these knots. These densifications within our soft tissue, the way that you have to disrupt that is by deep pressure and increasing the temperature in that to denature those hyaluronic acid chains. Compress and mobilize them and get these things to actually release. I find it happens quicker using my instruments and adding in more of a complex position; a squat, something along those lines. Something that really mobilizes that tissue for me while I’m working on it. I find that actually speeds up the process of getting rid of some of these densifications within our soft tissue, these knots.

Now, the biggest thing with pro-inflammatory styles of treatments that you have to remember is I like to use my 7 out of 10 rule because patients do not want to tolerate too much pain. I said don’t be afraid of it. I didn’t say be the grand inquisitor. You’re not trying to torture somebody. While the pro-inflammatory treatment is designed to create inflammation, you must follow that 7 out of 10 rule. Meaning, I say this, if I hit something that’s a 7 out of 10, you need to let me know. It’s not that I’m going to hurt you, I just don’t want you to be too sore the next day. The whole purpose of that, again, is to make that patient understand “Hey, look, you’re 7 out of 10. You let me know when you hit it.” It also tells them “I’m not going to hurt you because we actually hit pain.” All right? But it also lets the patient know it’s normal to be sore the following day from this type of treatment. But it gives the patient control again. It allows you to do your job but it gives them patient control.

Remember, when you’re doing these pro-inflammatory time frames if you go 30 seconds that’s a lot. You really should be doing this in about 10 or 15-second bursts and then getting off the tissue reassessing 10, 15-second bursts. Pro-inflammatory treatments rarely should take more than 1 to 2 minutes to accomplish. That doesn’t mean the entire treatment’s done but the pro-inflammatory part of that shouldn’t be much more than a minute, minute and a half, two minutes at most now. When we look at pro-inflammatory treatments, especially associated with ligamentous injuries, we have a cross-fiber massage that’s been done forever on these things. We do cross friction from Cyriax. Well, one of the studies that were done by Terry Loghmani associated with a wrap study was literally doing a transsection of the MCL. Seven days postoperatively, in other words, they let the wound heal. They started using an instrument 3 times a week for 1 minute on that MCL. What they basically discovered was a lot of interesting scenarios associated with the ligament being stronger, stiffer than untreated, and was also able to absorb more energy before failure. And we have the specifics on those in the next couple of slides.

The method was, again, 1 week after the surgery to allow for that wound to heal. They used what was then a GT6, which was the smallest instrument in the Graston Technique arsenal, and the pressure was done using a force plate to understand that that was consistent. They did 1 minute of treatment 3 times a week for 3 weeks. They did do a long-term study as well that increased that 1-minute treatment for 1 times a week for 10 weeks for a total of 30 treatments, not a lot associated with that, but we’ll go through it in a second. So, here are some scanning electron microscope slides that show what a normal knee looks like, and here’s the disrupted MCL. Now, the interesting thing of course is what happens to that MCL once you actually treat it. Now, this is a histological slide where you can see the effect of an untreated tissue, and then to the right side of the screen, you see the treated one. You can see the alignment’s much better, the scar looks much better, and this is what’s happened over that 4-week. This is, again, 1 week of healing of the wound where you did 3 times a week for 1 minute.

Now, the effects on the ligament, the mechanical properties that changed were they found that it was about 43.1% stronger, 39.7% stiffer, and it was 57.1% more energy had to be absorbed in order for it to fail again. So these were actually really, really important from that aspect. Now, the interesting thing is when you look at the 12-week study with 30 treatments, you notice how they evened out the untreated versus the treated. Now, granted, there was still more energy needed before failure, in other words, the likelihood of injuring that tissue again was still better in the 12-week study than it was in the other ones. But the stiffness and the strength of the ligament ended up evening out. What’s the importance of this? If you’re able to get on these injuries early, you can actually create what takes the body 12 weeks to do on its own, you can accomplish it in 4 weeks. How many people don’t want to have 2/3 of the time reduction in recovery of an injury?

So, here are some examples, again, using a scanning electron microscope. Going a caged control all the way to the left, an untreated ligament. You can see the morphology of it. It’s all disrupted. It’s scattered and then you can look at the treated one, where it’s much more organized as well as you can obviously see some disruption there. But in comparison to the untreated side, it’s a drastic difference. Here’s looking at that at it even higher. You can see the treated side. Again, a lot more organized and less chaotic whereas the untreated looks like you’re walking through a spiderweb of crosslinking and adhesions. So, again, our short-term effects using instrument-assisted soft tissue on ligamentous healing were stronger, stiffer, and able to absorb more energy before failure, and the qualitative improvements of the collagen alignment were obviously significantly better.

When you look at the longer-term, okay, they started evening out. It was stiffer, still deficient, may still need more energy in order to fail. However, Terry Loghmani, in her in her discussion did say specifically that, a longer treatment might be needed because they only did one minute. So, they’re looking at this as maybe they needed to do more. Not to mention, you don’t get a wrap to rehab so that’s another challenge as well. Another interesting thing that we always talk about with instrument-assisted soft tissue work is we work on it and all of a sudden you have this red on the skin, and we see where we’re bringing blood to the area. Not 100% accurate. We’re bringing blood to the skin, that is accurate. But the interesting thing with instrument-assisted work was that increased blood flow actually didn’t happen until 24 hours after that treatment session, and it would continue for up to a week following. So that healing response blood coming to the air, bringing oxygen, bringing cells of healing, it actually perpetuates at 24 hours after treatment and continues perpetuating 1 week after the final treatment. That’s pretty amazing.

So, our vascular effects from instrument-assisted work is not only we have that neurologic effect immediately, but we have a vascular effect that can happen to a week after our final treatment. Which, again, is massive in its healing process. We’re getting not only our neurological. We’re not just getting fibroblastic proliferation collagen production, we’re also gettinr. Now, one of the important things to understand when we’re talking about “Are we trying to be anti-inflammatory neurologic or pro-inflammatory” is understanding the amount of pressure. If we’re being pro-inflammatory, we need to use heavier pressure because heavier pressure actually creates greater amounts of fibroblasts in the region. This is a study that was done by Gaenslen that shows lighe created very few fibroblasts; moderate pressure some more came to the area; heavy pressure you can see all that topography. A lot more fibroblasts started showing up in this tissue to create a healing response.

However, heavy pressure needs to be done within patient tolerance. You also have to consider, “Okay, I want to be pro-inflammatory. I know have to be heavy.” Well, what happens if it was an ankle sprain that was 6 months old? I need to do some heavier pressure. What if it’s the ankle sprain that came in 6 minutes after spraining it? Do I have to be pressure? No, my job with my instruments then is to help remodel the tissue better, use that position of provocation putting it in alignment. Because the disruption has already created inflammation. Your job now is to be the traffic cop and help guide it so your pressure is going to be lighter in that acute injury because the inflammation is already there versus the chronic injury where you have to disrupt and create inflammation.

Here’s a simple example. I’m going to show a video quick here of somebody going into an inversion position while we’re just working simply over the ATFL and the CFL, and those ligaments of the lateral ankle. It’s a real simple thing to do. Again, it doesn’t have to be heavy pressure in an acute setting. In a more of a chronic setting, you’re going to use a little bit more pressure but the amount of pressure is going to be based on what your patient can tolerate and also you must consider the cross-sectional area of the tissue. Obviously, something like an achilles tendon will take much more force than, say, a tennis elbow. You don’t have to use as much force or a tendon in a finger. So, always keep in mind the amount of cross-sectional area of that tissue while you’re working on it.

Now, this is an area of you’ll see me working on this using somebody on a Bosu. I gave them a cane in order to help stabilize themselves while they’re weight-bearing, but all we’re going to do is put that person into our plantarflexed in an inverted position as we’re doing right there. And now, you’re going to hold that position w; if we’re treating so this creates the position of provocation, but it’s also adding in some of that proprioception. You can see me doing a very short treatment stroke. This is a little bit deeper because we’re trying to be pro-inflammatory. Now, what I’ve done here is I just added in some motion to that creating eversion, inversion back and forth. The purpose here is to create a little bit more of a neurologic stimulation as I’m working on those specific ligaments and to create a little bit more of an alignment within that tissue.

When we talk about tendons, the difference here is now we have contractile tissue. So, here’s an interesting thing when we looked at cyclic loading, you can see that that slides to the left, that’s cyclic loading. Again, these are chondrocytes so this is not really within a tendon, but these are chondrocytes. You can see cyclic loading all of a sudden created an alignment and not to mention densification of those chondrocytes together after cyclic loading. This is over a 24-hour period. The other major thing to understand not that’s just looking at the loading aspect is the alignment is let’s not forget the effect of eccentric loading with tendons. The amount of tendon production, so what you’re seeing in this bar graph here, I know it might be hard to readjust from looking at your screen is, Langberg had basically looked at eccentric loading of an Achilles tendon and looked at the amount of collagen production before training and after 12 weeks of training.

So you can see in a healthy tissue: negatives or that eccentric loading. It doesn’t really do a lot. It does something but it doesn’t do a ton. But look at what happens in an injured tendon. Look at the amount of collagen production that is produced by an injured tendon with eccentric clothing versus one that’s not training. So, eccentric loading is critical to the absolute production of our type 1 col,lagen. The training schedules for this should be twice a week. Within the literature, what they’ve done is a 12-week process doing 3 sets of 15 heel raises eccentrically, in other words, they use one foot to bring the heel up, and then they slowly drop themselves back down. You can see that in the next picture.

If it doesn’t create any soreness, you’re supposed to actually increase body weight, in other words, use a backpack or something like that containing up to about 20 of your body weight. It’s normal to get soreness with this type of activity for the first 3 to 4 weeks. The reality is if they’re not getting any soreness, you’re supposed to increase the amount of weight that they’re doing this with. Here’s an example of doing knee straight which would be gastroc and knee bent doing soleus for an Achilles tendon. Here again, is that eccentric contraction where on that right side you can see they’re using the toe on the healthy side to drive the heel back up so they don’t have to put all the weight through it. I got to be blunt, I tend to just let them do a toe raise using both legs. The only time I’m really really concerned about literally limiting the amount of concentric loading may be a post-surgical case or somebody who’s in severe pain, but for the most part, I literally have them go up concentrically a little bit quicker and really slow on the eccentric so we’re focusing on it.

Then here’s an example of doing it with lateral epicondylosis. This is for tennis elbow, where they’re gonna come up and then slowly bring themselves down. Then there’s a physical therapist in my area, Tim Tyler, who actually created these protocols for TheraBand using flex bars. This slide shows the pictures on how to set up for an eccentric load associated with tennis elbow. He did the same thing for medial epicondylopathy. Now, this is our interesting thing. I remember taking tests and everybody tIts purpose when you’re going through this kind of a process, you have to remember that the whole aspect of fibroblastic proliferation and collagen synthesis when I was taking boards,” they said, “Oh, that happens about 72 hours. That’s the fibrosis cycle within healing,” and I was like, “Okay. So, 3 days after and I don’t even remember when I was first learning Graston Technique, I was like “So, we’re telling everybody they should exercise but wait a second if fibrosis doesn’t start until 3 days afterward, should we actually have them exercise 3 days after?” Then we got a new literature and this has been great with the fascial congresses and things along those lines that have come into exist and how much great new information we get.

This slide that we have in front of us is from Grinnell. This is showing that literally within an hour of a disruption, we actually get fibroblastic proliferation and collagen synthesis. This study was done within an hour. We also have people like Lan Javin and Sherman who have actually demonstrated using acupuncture needles rather than an instrument-assisted that that actual time frame drops to a minute. So, within a minute of doing your soft tissue work, I like to give it the nice little r amange within a minute to an hour, you’re actually getting fibroblastic proliferation and collagen synthesis. Hence, you want to add the two together as quickly as possible not just for the neurologic perspective of what’s going on, but also for the actual soft tissue remodeling. It happens much much sooner than what we learned in school. Happening within a minute to an hour of that procedure.

We want to create our eccentric loading at the same time we’re doing our soft tissue treatment to maximize the amount of collagen production as well as fibroblastic proliferation that we are creating. That doesn’t mean they might not have to do homework, home exercises, or I might send them to my rehab room afterward to do another set of something. But that’s all part of that process of getting the fastest healing response you possibly can.

Here’s an example of doing some eccentric loading associated with things like a rotator cuff. In this situation, we’re going to look at supraspinatus, we’ll look at posterior cuff, and the biceps So in this particular case, we’re having our patient literally do an eccentric load for the supraspinatus. So, now, he’s taking that arm out to the side. I brought it up to a little bit over 45 degrees but you can see the slow reduction back in. So, he brings it back up. Notice every little resistance on it. He pulls away to create the load and now he’s slowing. Now, what I’m specifically doing with that instrument at this point is doing the my tendon’s junction, but we also have to remember about the way that the supraspinatus, in particular, is going to come across the front of the shoulder and almost goes out like a fan over the whole front of the shoulder.

Here is a posterior cuff, where we’re doing more of that myotendinous region. Then in this case what we’re doing is we’re just changing the position which isn’t going to isolate out our posterior cuff as well but it does give us a little bit more neurologic aspect, and it does expose the myotendinous component of the posterior cuff the infrand so on minor a little bit better so you can see him changing his orientation. Now, what we’re going to shift it to is the biceps. So in this one, we’re going to create our eccentric load by bringing the band behindou come out into a flexed position, again, this is looking more at the long head short head of the biceps. In particular, in this one we’re going into the transverse humeral groove where the long head of the bicep is ; there’s dives into the shoulder joint. I use my one finger to actually get into the tunnel to make sure I’m anatomically where I should be, and then I use the instrument over that to make sure that I stay in the right area.

What I’m doing here is doing the same exact thing except I just switched to a manual method like using cross friction. So, while instrument-assisted is critical and I think responds best to tendon injuries, we can use our hands as well. Now, here’s one we’re showing just using the achilles tendon. With this one, we’re gonna have our patients go up onto their toes. As you can see, they took some of the weight off now they’re gonna shift their weight to he bad side and then slowly drop themselves off, and at this point, I’m doing the lateral asect of the achilles almost like that anterior aspeAthleticsg me work through the medial aspect. I use a finger to get my depth. And then I’m going to change my pressure lighter to be over the Achilles tendon. You don’t want to apply a lot of pressure over the achilles tendon because that’s when you actually create a tendon sheath inflammation. So we want to get a little bit softer when we’re directly on the achilles and a little bit more aggressive when we’re going to that fascial to the anterior aspect of it. t forget to hit those Sharpey fibers as they dive into the periosteum at the calcaneus. These are, again, what I tend to do is maybe 10 or 15 reps and then I retest the patient.

Now, neurosensory, I’ve actually done this from more of a neurologic standpoint. We als. Obviously want to release neurologically, which means normalizing the tone of the gastroc in the soleus complex. So, going from there, those are our pro-inflammatory. Again, just to summarize one more time, the only four times we’re trying to be pro-inflammatory: ligamentous injuries, tenderness injuries, those post-surgical or traumatic scars, and those deep fascial knots that, we talked about we develop in our tissue. A neurosensory treatment. This is basically, I like to say control-alt-delete on the computer. We’re trying to reboot the system. The purpose here is to reset the tone of our tissue. It is a ,much much, which ,is neurologically,where I go crazy when I see YouTube videos. I see them scraping the stuffing out of a forearm and the forearm gets a particular response. I’m going like, “Ohh! Somebody might have gone a little too hard.” Not that the parThe other interesting thing when we add resistance is that ike a particular response, I’m going, “Wow, somebody went a little too aggressive.”

The weight of the instrument should literally be h,ow much you’re doing when you’re doing a nwill add in resistance to certain injuries based on tissue. Obviously, with instrument-assisted work, we tend to wanThissome sort of emollient. For instance, the ones that I use fnearly everyes is a combination of synthetic beeswax and coconut oil, but you need some form of a lubricant. Something preferably that does not scrape off. I know some people use ultrasound gel because it’s really inexpensive, and also it’s water-based so if you’re taping over it, it makes it really easy. But the reality is, ultrasound gel does scrape off really easily so you constantly have to reapply, and at some point, it also might get a little bit uncomfortable for your patient. So just be aware of that. Again, I use the factory emollient that we created. But most of the companies out there havr own form of emollient in some way shape or form. Some people like using Biotone, again, it’s a little bit cheaper than some of the other stuff. It does scrape off a little bit more and absorbs into the skin a little bit more. So whatever it is that you’re using, try and make sure it’s something that doesn’,t absorb into the skin that easily. That you only need a little of in order to coat an area because all it’s trying to do is decrease the friction of your instrument over the tissue.

With a neurosensory treatment, it’s a lighter treatment stroke, weight of slightlynt over the tissue area. This is the large majority of work that we do is neurosensory. We’re just trying to stimulate afferently some of those receptors in the skin in the superficial fascia to reset thef tissue. I like to describe it as balancing seesaws; something’s overactive and something’s underactive. What we’re doing with our instrument soft tissue is we’re just trying to bring it back into play. The biggest thing to remember is, it is not designed to create inflammation. This does not mean you will not create a particular response. It does mean, however, that it should not be your goal. Part—just responses will happen over almost any dysfunctional area. It just is the amount of particular response and the amount of aggression that you’re using. You want to keep this light and easy, and if a particular response happens, again, one, two, three, by the fourth visit, it should be gone.

So, remember your neurosensory treatments control-alt-delete. What we’re trying to do is reboot that neurologic system to reset the tone of that tissue. Underactive; we wake it up, overactive; we calm it down. I know in a lot of techniques and a lot of companies we talk about releasing or facilitating or inhibiting. We don’t do that. We literally create an afferent stimulation. We’re creating a stimulation optors, those nerve receptors, then either reflexively segmentally, or through higher functions up the spinal cord possibly all the way to the brain, we are basically creating those loop mechanisms or stimulate, those loop mechanisms so the central nervous system does what it needs to do to that tissue. We don’t say “I want you to relax.” The central nervous system tells it to relax, we just create some of that afferent stimulation to help it along.

Here’s a good little video showing a tendon sheath and the fascia that surrounds it. You could Area right there, superficial fascia, that surrounds the tendon. And in the next few seconds, you’ll actually see that tendon sheath. See the tendon actually gliding right between the fascial sheath and the tendon. So, of course, what can happen is if you develop some adhesions between there, it’s going to prevent the tendon from moving properly. This can create more fibrosis and scarring, obvious pain. But just remember that fascia is everywhere. It touches and covers every single cell in our body,. Now, this is Siegfried Mense who… I honestly I don’t know at this point if he has retired. The last time I saw him he told me he was, and then I looked him up and he was still working. I got a feeling if you got a brain like his, it’ll never shut down. He is probably the foremost authority on myofascial pain in the world, and he was one of those guys that discovered fascia is not an inert structure. It has a dense network of nerve fibers and it has a close association with those nerve fibers with vascular tissue.

Again, his studies, for the most part, were animal studies. But later on, he also tried to look at cross-sectional area of thoracolumbar fascia in those animal studies and also compare them with human thoracolumbar fascia. The Forbe pretty similar. That’ll be our last slide with him. But what he discovered was innervation by the layers of thoracolumbar fascia that 90% of all of those nerve fibers were located in that superficial layer and he did the thoracolumbar fascia of the low back. He found that the middle layer was composed of much more dense collagen bundles with very few nerves, and the inner layer, again, likewise was pretty much devoid of nerve endings. So, that superficial layer is the layer that has the most abundance of those afferent nerve receptors, and interestingly enough,h it also has a whole lot of sympathetic efferents that come there as well.

What he also found within these fibers was the types. He found a ton of substance ; itome CGRP, free nerve endings were discovered in abundance in those superficial layers. While these there’s also pain, there’s also nociceptive in their orientation. The interesting thing was he found in the middle in the inner layers very little of this. So almost all of those nerve endings showed up in the superficial area. Why is that so important for a manual therapist? Oh, we can get on the superficial layers really easily. It’s almost directly underneath the skin in a lot of situations so that makes our lives a whole lot easiwho do don’t understand the purpose of what they’re doing or whygain, over 90% was in the superficial layer. Here’s the interesting thing over 40% of those nerve fib;ers were sympathetic efferents. Why is that important? How many of you have actually said to your patient when you get stressed that’s why things get worse? Well, this is actually why. Remember, it’s sympathetic efference so this is the sympathetic nervous system as controlled by the central nervous system. The center’s not going the opposite way. This is our brain and our spinal cord all saying, “Hey, by the way, fight or flight fight or flight to the tissue.”

The interesting thing is it helps those central nervous system media events that sympathetic response is creating vasoconstriction, and it’s changing the viscosity of the thoracic, lumbar fascia. So, it’s almost creating a constriction event. When that constriction event happens if you have injured tissue, what is that going to do? If you crush or pressure something that’s injured, it’s going to hurt more. The great thing is because of what we do, we stimulate the autonomic system, that parasympathetic response, using our manual therapies through stimulating those afferent fibers that counteract the effects of sympathetic fibers. So, we can actually through our manual methods effectively shut down that sympathetic efferent effect.

That’s why so many people feel good after manual therapies like, “Oh, my god. I just feel like jello. I wish it would stay that way.” Me too, but unfortunately, not always. There is a reason why we get so much more benefit for patients even from a psychological standpoint through our manual methods. The interesting thing as I said before is “Are humans rats?” Well, on a cross-sectional analysis of the human thoracolumbar fascia, the findings of those nerve endings in the rat TFL were found to be equal proportions in the human thoracolumbar fascia. So, guess what? Rats are humans. Not really, but obviously, the distribution of our nerve and vascularity within those regions is very similar. While we’re saying, “Yes, I get it. It’s an animal study,” guess what? The more we look at it, the more we correct the same kind of proportions of those nerve tissues within human tissue as well.

Now, another hypothesis that we want to look at is from a neurologic standpoint. Some of that is going back to what we just talked about; What’s actually in that superficial fascia, those nerve endings that are there. Well, one of the things in particular was, and this came initially, especially Johansen’s material came straight from Mike Schneider, whpractor Ph.D. at the Universexceptionallyttsburgh. He really helped as well as the scope page in the neurologic aspect of what we’re doing with instrument-assisted soft tissue mobilization. And in particular, Johansen’s looking at the gamma-alpha loop mechanism. He proposed that it’s actually the gamma motor neuron system that influences the system, and it’s through these extensive interconnections in the spinal cord that we accomplish this.

The interesting thing is those sensory afferents is that it is talking about within the skin, the ligaments, the muscles, the tendons, and mechanoreceptors, the superficial fascia, all of those extensive interconnections actually reflex onto or connect with the gamma motor neuron system, not really the alpha motor neuron system. So, our effect of stimulating those A-beta fibers is actually more on the gamma system. Now, why is that important? Through that constant relaying of information gamma, we get this feedback, this interfacial fiber feedback onto the muscle spindles, and it’s therefore changing the reaction time of those tissues. When we stimulate the skin, the fascial ligaments over a joint start to introduce normal motion, which starts to stimulate a lot of this afferent. Well, guess what? When we’re developing factors we’re like, “Wow people are getting better,” but we didn’t know why. Well, this is one of the theories, which why. It’s because we’re stimulating all that neurology. And while creating that barrage of proprioceptive input, that afferent input, that’s what’s resetting the normal tone of the tissue. It’s a control-alt-delete. This is the reboot of the system. It’s almost like that same thing like you smack your thumb, you wave your hand around, and I don’t feel, pain but as soon as I stop, well the trauma’s still there and your thumb starts going “Bop-bop-bop-bong” while you stimulated all those A-beta fibers hence why I don’t feel pain, but as soon as I stop stimulating the A-beta fibers, bam bam bam, the pain is there.

The end result of what we’re doing with our instrument-assisted mobilization especially using things like factory concepts where the person is moving, is resisting, is under load, is in positions, is that we’re probably creating greater stimulation of that A-beta system, that gamma-alpha loop mechanism that’s allowing us to reset the tone of tissues in a much better way. Now, when we looked at Robert Schleip’s work, again, a lot of this stuff was from our first myofascial congress back in I think it was the early 2000s. And Warren Hammer really introduced a lot of this material into soft tissue classes. Basically what Robert Schleip said was that there’s a neurovascular cascade of events that occurs from soft tissue mobilization. Everything from what we’ve talked about with the stimulation of these A-beta fiber stimulations, that gamma motor neuron system by decreasing sympathetic tone, improving vasodilation, and through even endocrine loot mechanisms, and vascular mechanisms by creating vasodilation increasing interstitial fluid. That profusion of blood plasma into this extracellular matrix improves that viscosity

So, looking at these almost one by one, if we have a palpable soft tissue problem or honestly even provoke soft tissue problem through an activity, we do our soft tissue mobilization. That’s going to stimulate those mechanoreceptors, in particular, what we’re looking at is those interstitial and Ruffini nerve endings. We get a change or stimulation to that autonomic nervous system, which improves our local fluid dynamics as we talked about including improving plasma perfusion which improves the viscosity of the tissue, and we see the tissue change in its appearance. That interstitial myofascial receptor, we talked about this earlier as well, stimulating them in the skin and in those joints, tendons, ligaments, and superficial fascia. It’s assumed that when we stimulate those interstitial receptors, we’re actually creating an endocrine response. A hypothalamus tuning is at its fault. It’s a neuromuscular effect. It’s an emotional state, this is also taking in the psychology of an injury, as well as obviously, cortical and endocrine function.

This is why when people get up off a massage table they’re like, “Oh my god, I feel like butter. I’m melting.” That’s that hypothalamic loop of actually creating a global deep and healthy change within the tissue. Again, we have a palpable tight tissue, we go through that soft tissue manipulation, we stimulate those mechanoreceptors, that also influence that automatic autonomic nervous system again, that creates the hypothalamic tuning which creates an endocrine response, changing a global, not just a local tissue, but an entire body change in the palpable response of our tissue.

Another aspect, and this is Chantal and Delaney, talked about fascia as an adaptive organ. Meaning, the ability of your fascia to truly contract. It was always thought of as a nerve, but what has been discovered is that this thoracolumbar fascia actually has visceral smooth muscle cells in it and within those smooth muscle cells, that allows for contraction. Now, obviously, if you’re under sympathetic guess what happens? You get that contraction of tissue and that creates a constriction on injury tissue or pressure on injury tissue, which creates more pain. Now, as we stimulate these nerve receptors in our skin, in our joints, or tendons, and so on and so forth, obviously, we’re getting those smooth muscle cells through an autonomic response to relax. Therefore, reducing the amount of constriction on those issues. So, again, we have a palpable restriction within the tissue, for densification, we do our soft tissue manipulation; that stimulates those mechanoreceptors, we get that parasympathetic response; that creates a relaxation of the interfacial smooth muscle cells creating relaxation of that tissue.

So, in summary, it’s all of these. We have everything from stimulation of mechanoreceptors that will affect both the central nervous system through loop mechanisms, that will affect the autonomic system sympathetically both centrally and peripherally, creating endocrine vascular as well as that smooth muscle cell response. So, of course, I always love to say, “Well, which one are we truly trying to affect?” Guess what? The body does that. All we do is create afferent stimulation. It will decide which pathways if not all of them are stimulated at one time in order to create that palpable change in tissue.

Looking at mechanical load and frequency of soft tissue, what are guidelines for this. Well, you know what? Guidelines still will always come down to the aspect of what is clinically relevant for that patient. However, when we look at things if we’re doing low load low frequency obviously that’s lighter pressure. Active trigger points, acute injuries, painful scars, things along those lines, it’s non-inflammatory. It’s very low, non-inflammatory, desensitization kind of stuff, so that’s our anti-inflammatory application. When we’re looking at things that are pro-inflammatory, heavier pressure; a higher load onto those things. Those are things like tendinosis chronic muscular restriction. Just remember that pro-inflammatory should always be very low duration so that it can actually not over inflame a tissue. It may be high pressure, hopefully, fast enough across the tissue to create a better pro-inflammatory response. However, at the same time, you have to be able to stay on the tissue.

Here are examples of when we look at some of our concepts. For instance, concept number two: motion of provocation. When we’re looking at some of our soft tissue stuff, we can see what’s happening with these slides. So in this example, we’re using the cervical spine and in this situation, we have a patient who is just going through flexion and extension, some rotation, and we’re doing very light pressure. This is going to be concept two, which is using motion, but this is a neurosensory application. Light pressure all we’re trying to do is reset the tone of that tissue, making sure we create the greatest amount of tissue response without creating heavy inflammation in the tissue.

So, as you can see, as we’re doing this we do get hyperemia on that skin. How do I know when it’s time to actually pause and take a test again, is when I see that region that I’m working on has become hyperemic. That is when I want to try and stop for a second, reassess my situation, and then go back and retest and maybe retreat again. How do I know that the hyperemia is the time to retest? As we’ve just talked about, the same A-beta fibers, those same nerve receptors that are creating vasodilation are the same nerve receptors that we stimulate to create those responses, as Robert Schleip, that big slide that we showed showing all the different pathways. So, I want to retest as soon as I get that basal dilation on that global tissue, I want to go and reassess the situation and make sure that I’ve actually created a positive neurological response as well.

Now, as you can see, what I’m doing here we’re doing multiple body parts moving at the same time, creating even more of a neurologic, as well as creating more kinetic chain stimulation. We can also get this down to more focal areas whether it be a suboccipital muscle or whether we’re trying to get as deep as we possibly can to maybe a facet region. Now, I don’t like saying that if I have somebody like my neck very thin, good chance I’m going to get down to upset pretty easily. However, let’s just say I was taking care of an American football player, offensive lineman. Well, that neck could be this big. I am probably not getting onto a facet with that person. So, we have to understand the amount of depth we’re getting still has a neurologic response, but we still want to go through the process of treating those different things and making sure that in that aspect we’ve created as much possible response as we can without creating too much inflammation. These are, again, neurologic in their aspect.

Once we’ve reset the tissue, again, I always like to say “If it was a 10 before, what have we dropped to?” If we’ve dropped from a 10 to a 5 to a 4 to a 3 to a 2, I’m pretty good on that day understanding that I’m a clinician and most likely that patient is on a treatment regimen, in other words, maybe I’m seeing them twice a week for the next two weeks. Well, I don’t have to go from a 10 to a zero on day one because the reality is the more times I keep treating or retesting and retreating, the more likely they are to have a negative treatment response the next day rather than having a just positive outcome that stabilizes over a couple of treatments. So, don’t build roman a day, you don’t have to but always look for a minimum of that 50% change as you’re going through your treatment.

The next one I’m showing here. Again, using factor concept two which is scapular dyskinesia.
So, in this case, I’m looking at really shoulder impingements. One of the most common reasons we’re going to have shoulder impingement is scapular dyskinesia. The biggest thing is how many muscles help control this movement of the scapula. There’s a ton. You got your scapula stabilizers, you’ve got your rhomboid, you’ve got your mid trap, upper trap, lower trap, levator, serratus, lat, all these tissues that are attaching it, teres major. We can keep going on and on as to what’s attaching subscapularis, all of these things that are touching to the scapula. So, my goal here is to neurologically balance out all the seesaws. Again, doing something like this I’m treating the entire upper quadrant, that upper shoulder region, the whole scalp region into the spinal region down into the lat region, back, anterior cervical region, the deltoid region. All of these things are actually playing a role in scapular attachments.

The biggest thing is, just remember this is much, much, much lighter. This is the weight of the instrument on that tissue, and all we are trying to do is create that hyperemia on the skin to reassess. One of the most fascinating things that I have associated with shoulder injuries, which is one of my absolute loves in treating, is that I can have a guaranteed rotator cuff tear. Never touch the rotator cuff from the standpoint of trying to truly get on that rotator cuff but just literally do this very light neurosensory treatment weight of the instrument over that region and that patient will reduce that rotator cuff pain by 50% or more without ever really doing a specific treatment to that rotator cuff just by normalizing the tone of scapular mobility. All the muscles that treat subscapular mobility. Now, you see here I took a smaller instrument out to get a little bit more into something like the subclavius region, anterior cervical fascia, as well as maybe even treating some of those ac ligaments during the course of movement. This is how I would very frequently treat a grade 1 sprain of the AC ligament and then do a little bit more pro-inflammatory specific to those ligaments but neurosensory through the entire upper quadrant.

It doesn’t really matter what area you’re working this also works just as well as doing something on a squat like we’ll do in this next slide. We can see the same exact procedure done for let’s just say a patellar tracking disorder. One of the more interesting things that I’ve seen associated with things like knee injuries whether it be meniscal; meniscal, again, being a very common one, is that normalizing the tone of those tissues creates a drastic drastic response in normalizing the tone of the muscles that are controlling knee movements. And in that aspect when we control those muscles that are causing those knee movements, we normalize their tone of them. Now, all of a sudden, that squat position no longer is painful for the patient even with things like internal arrangements. So, you saw me working on the quad there. Now I’m working on the adductor region while that patient holds the squat position and while he’s holding it, we could have him just going up and down. He’s holding that position. He’s actually strong enough to hold a squat position for a long period of time, but we also want to get onto these posterior structures so now we’re doing the hamstring, as well as the gastric region. And all of these are going to come into play into normalizing the tone of those tissues that are controlling loads on the knee itself.

So even in a squat position, you can see I can get onto the blue. I’m doing this over clothing, purely from the standpoint of video demonstration. Understand I try to instrument on skin on almost all procedures. However, if a patient is wearing spandex, it’s not unusual to be able to treat through spandex I will force them to go instrument on the skin if I’m not happy with the results I’m getting. These are all wonderful examples of how we can normalize in a very short time period. In fact, this entire procedure of like the upper quadrant that we just did for scapular dyskinesia or affecting all of those different compartments in the thigh and the lower leg, we can do this. It takes about 5 minutes of time to get hyperemia on all these issues quickly. It’s amazing how fast we do it. Now, we have the patient going through squat motions so it’s creating more of a neurologic stimulation helping to control-alt-delete and reboot that system. And then once we’ve done this, we can go and start creating some of those more specific areas that may be pro-inflammatory, like maybe we’re doing the coronary ligament or working on an MCL, or the patellar tendon, or the retinaculum associated with the patella, or in this situation, you see me I’m working a hamstring insertion. In particular, it’s a good eccentric load on the hamstring insertion if I went to more of a pro-inflammatory treatment because as he drops into the squat, we’re eccentrically loading the hamstring tendon at the buttock right at that ischial tuberosity.

Now, we have one other application to discuss associated with instrument-assisted soft tissue mobilization, and that application is anti-inflammatory. This, to me, is one of the more unique situations that we have and personally, I think it’s one of the ones that we don’t talk about a lot. In fact, I know one of the challenges I have within the orthopedic world, is a lot of the time they’ll sit there and say “Okay, I don’t want you to see Dr. Doerr for the next 2 weeks because we want to get the inflammation to calm down first before he goes and starts working on it.” and I’m going like “Still don’t get what I do.” They frequently associate the soft tissue work that we do for tendon injuries or ligament injuries we’re trying to be more aggressive, but they don’t understand necessarily the neurologic resetting or the anti-inflammatory aspects of what we do, especially in post-surgical cases. My goal is to literally have that person in my office almost like the same day if possible, but definitely within 24 to 48 hours.

So with anti-inflammatory treatments, our purpose here is to improve superficial blood profusion because that’s basically where we know we’re doing it. We also know from our studies that we can actually increase blood profusion within the tissue but it doesn’t happen for 24 hours after and remember it does perpetuate for a full week following that last treatment. But this is more on the superficial layer that that’s the creating that vasodilation that we talked about neurologically and improving plasma perfusion into that region, helping to pull out chemical irritants. Again, improve the in viscosity of the extracellular matrix as we talked about by improved blood plasma perfusion, reduce edema by opening up capillary bones. We help to move these tissues or this fluid out of there. It’s amazing on things like bursitis. This is one of the more unique things that I will discuss. It’s really very unique with bursitis as well as with things like hyperesthesia as we talked about whether it’s post-surgical pain and/or some of that hyperesthesia that some people really develop within scars. These are extremely light treatment strokes.

Since you’re able to see me. If we’re doing a neurosensory and that’s basically the weight of the instrument as we’re treating, understanding that as we do our instrument-assisted work, which I’ll show a little bit more in a second how our angles and our pressure. That’s the last thing we’ll do. When we’re doing an anti-inflammatory treatment, I almost let the instrument wiggle in my hand, so I barely have a grip on it. And from there, it’s literally feather-light. It’s not even the weight of the instrument as I’m treating. I’m going to look here. The amount of perfusion you’re going to get is so minimal. I’m looking to get that point of very very light hyperemia. A light pink, not even a deep red. Once I’ve achieved that in the global area of  what I am working for, that anti-inflammatory region, I’m done. I’ll stop right there. Anti-inflammatory treatments can be done on a daily basis. They don’t have to be done 2 times a week or once a week or things along those lines.

I’ve had cases where on electron number of cryptos, which is one of my best cases. I apologize I actually didn’t put the pictures into the slide presentation for that. But I had a person who had an egg on their elbow. Was actually a Junior National hockey player and he had taken the elbow to the ice being hit from behind a couple of times. The challenge that he had is this egg was sitting on his elbow for about 2 to 3 months and it was starting to become to a point where he’s limiting his ability to play, especially when he took hits and his elbow might have hit the ground again it was really becoming very painful. So, I did the same type of very low-level application. Very very light over that region. A couple of milking strokes but the milking strokes in itself as you understand, you don’t milk swelling out of a bursa. I mean, you could drain it but you’re not going to milk it out.

So I did one or two of those types of stroke but most of it was this feather-light type of treatment. The interesting thing is I saw that patient 4 days in a row; Monday, Tuesday, Wednesday, Thursday. The interesting thing is on day one, I take an x-ray obviously because the patient in their history is also described as a locking so I’m thinking to myself like a loose body was the first thing that came into my head or possibly some kind of internal arrangement. But on the x-ray, it was completely clear. There was nothing there. By day 2, so much swelling had reduced out of the egg that I felt a palpable ball in there. There was a loose body. The difference was it was fibrous. It wasn’t bony and it hadn’t calcified so it wasn’t showing up on the x-ray. By the 4th day, the egg was gone and all you saw was that little ball that I could move around. Now, he wasn’t looking, he hadn’t locked for months and months so it’s not like I referred him to the surgeon to get that removed. I basically told him “Look, if it starts locking more consistently obviously you want to get the orthopedist involved and this might have to be an arthroscopic surgery to remove the loose body.” But I wouldn’t do surgery on somebody that wasn’t necessarily locking. It wasn’t creating any kind of a problem. So I allowed him to continue on with what he did. Once the swelling was gone, his pain was gone, I know that doesn’t sound great for business management, but one weekend this guy was a hundred percent invariably what I noticed with bursitis is that I can treat them usually by the 4th treatment, bursitis has calmed down.

Now, sometimes I may do that in the real world. I might only see that person twice a week for a two-week period but by the time that two-week period is over, the bursa’s gone. However, I will admit that if that swelling that personal inflammation has not changed within those four treatments, that’s when I bring in my orthopedist to do the injection. I don’t see a reason to keep that person in pain with bursitis if I can get a cortisone injection in there and reduce the pain. The reality is 9 out of 10 times I never even need to do this. It’s actually even higher than that. Almost every bursitis I see calms down within that two-week period using just an anti-inflammatory treatment over it. Again, feather-light. If you go too aggressively you actually inflame the bursa more and also stimulate some nociception. So, it’s feather-light treatment. It should be a non-painful treatment. It has some wonderful benefits on bursal inflammation. However, that’s talking about our feather-light stuff. Again, hyperaesthesia, painful scars bursitis, bruising.

Another quick case, which I wish I could have put in this presentation as well. Unfortunately, I’ll describe what happened with that one. I had an elderly gentleman who came into my office with a… I mean, literally, when he took his shirt off, it looked like he was wearing a black shirt. I don’t mean purple, I mean black. It was truly black. This guy had fallen on ice and landed square on his back. He was in his probably mid to late 70s at that point. It was four weeks ago and it was still black. He had had x-rays, there was nothing that showed up on the x-rays from a fracture standpoint. His pain was just like this deep ache across the back area over the bruised area. So, on him, I did my anti-inflammatory feather-light treatments over the bruise. I treated him once a week for 4 weeks and every week you saw the black and the black all of a sudden turned purple, yellow, green. Then the purple, yellow, green turned to the yellow-green then the yellow-green turned to spotted here and there and skin color again. And it was once a week for four weeks.

I had all of this documented wonderfully on photography and unfortunately, the SD drive on my phone died. It fried and I couldn’t recover the pictures. That was what I was planning on writing that one up as a case study but unfortunately, I lost the images from it. All I had left was my notes which don’t really give it justice then. But again, whether it’s hyperaesthesias from a surgery or a severe bruising that’s creating so much inflammation superficially, it’s creating that thoracolumbar response in the case of the person that I just referred to or bursitis. Those extremely light, those feather-light treatment strokes are ideally what you want to do to reduce the inflammation. However, there are times, again being a sports guy myself, where you’re going to see the acute injuries. The ankle sprains, sometimes post-surgical that you can milk out. Ankles are one of the more common ones where we can milk out the swelling. Again, it’s an anti-inflammatory treatment stroke because we’re pushing the swelling that’s already there out, but not necessarily from the standpoint of those neurologic mechanisms that we’re talking about or had talked about earlier.

The next slide I’m going to show you is actually a video specifically on the reduction of an ankle sprain. This one is acute. This one came in literally within hours of straining an ankle as a baseball player who just rounded the base and took a bad step and went right down on his ankle. So here is an example of an acute. What I would like you all to do is if you can, look at that swelling that’s in the foot. I want you to get a good visualization of that before I even start the video so that you can actually see it. And this is only done. This video is only one treatment stroke. So, take a good look as we go through this video as to what’s happening. A lot of people will ask me as you’re going through this, how painful is this for the patient? The interesting thing is really most of it like where I am right now, you can see that fluid weight starting to develop right in front of my instrument, it almost looks like a snowplow going through snow and pushing it away, it’s a huge response. It’s usually not very painful at that point but as you get up into that extensor retinaculum in the front of the ankle as well as the ankle ligaments that have been damaged, that’s where you’re going to start noticing that as you’re putting that pressure and trapping that fluid because you do have to press in deep enough to trap that fluid and push it out, we can actually create a massive reduction in the amount of swelling. The lovely thing I absolutely love about these ankle sprains, in particular, is they get carried to you and they walk away from you.

When we do the taping seminar, that’s also available through FIX, you’ll also see once we do the ankle strapping is a dramatic change in the ability for somebody to actually weight bear on an injured ligament. But now, take a really good close look. I’m going to go back and forth one more time on this so that you can see it again. Look at how much swelling was pushed out of that foot in just one treatment stroke. Now, how do you know when you’re done with this? It’s very simple you know you’re done when you can no longer push that swelling any further, in other words, I’m pushing up, pushing up, pushing up and it doesn’t seem to go anywhere. In other words, the lymph channels have taken in as much as they can. They won’t accept any more at this point unless you’re going to milk the calf out. A lot of what we do in my office is I will do my acute edema reduction. I’ll get rid of as much swelling in the foot and the ankle as I possibly can, then I put them in my Normatec, which will now push that fluid from their calf into their thigh and back into their lymph channels more proximally so we have less chance of that gravity dependency letting it come back into the ankle. However, it usually only takes a few of these treatments before you start noticing that the ankle swelling is gone. Just for visualization purposes, we’re going to go here. See how much swelling is there? I’m going to play this one more time just so that you can see the amount of swelling that is actually reduced and that fluid wave that develops in front of the instrument. This is one of the more miraculous things we can do with instrument-assisted work that, in all honesty, I personally think does a lot better than hands because her hands are soft and they actually flatten out against the tissue and it allows for fluid to escape. Whereas, the instrument will trap it, capture it, and literally like a squeegee push it along.

So there’s that swelling happening again. You see that fluid wave develop in front of the instrument, and how much less fluid is in the foot as we’re moving along. And then as we get to the end of this one, I’ll show you the pre and post-effect of an ankle. Seeing some swelling, and then literally after one treatment what the ankle looks like. So this one is over. Now, take a good look at that foot again seeing in one treatment stroke how much we’re able to reduce. Now, after treatment, it’ll look like this. You can see on that left side picture, there’s some swelling. You barely see the blood vessels other than after the ankle, the vessels become very prominent. Then look at that picture on the right. You can see all the vascular is very prominent, the malleolus is prominent, that’s after one treatment. Your aspect of the ability to control inflammation is absolutely fantastic using our instrument-assisted. Now, again, how often do we have to do this? It’s very simple. Once the swelling is gone once you can’t push anymore, you’re done doing your anti-inflammatory treatment this way. In fact, I would be then now focusing more on that pro-inflammatory understanding the amount of pressure you need to do is very light because the inflammation has already happened in that ligament. You’re being the traffic cop helping to control the fibroblastic proliferation in collagen production. I’m shifting more now to neurosensory over the calf, over the anterior compartment, over the lateral compartment for the fibularis muscles, as well as doing that very focal treatment over the ligaments on the ATFL and CFL. Again, if the posterior talofib ligament was involved, that’s bad. That’s usually fractured dislocations that have happened. So, most of the ligament ligamentous structures we’re treating here will be the ATFL and the CFL.

Now, the last thing I want to do with the few minutes we have remaining here is through this video, you being able to look at me is I want to show you: number one, the orientation of the instruments as well as that production; how to do it. So, if we take an instrument the, number one thing is obviously you have a treatment edge on your instrument. Now, some of them are double beveled, some of them are single beveled. I double-beveled all of my instruments. There is no single bevel on them anymore, largely because I found that most of what we’re doing is neurologic. How deep do we really need to get to simulate what we’re getting? It’s really a lot more of a superficial response and it’s a lot more patient for the clinicians to hold as well as the patient to go through the treatment. So the first thing that we want to actually demonstrate is you can see that that is flat on my skin. We want the instrument angled up roughly about 30 to 60 degrees. If we say 45 as an average, that’s fine. The important thing as well as while we’re doing this is to notice the instrument doesn’t leave the skin. You don’t do this. That’s irritating. We get a greater neural response by forwarding back.

Now, granted let’s say I’m treating up towards the elbow. 80% of my treatment stroke or pressure is going forward it’s almost like a glide back, pressure glide back, pressure glide back. So, the weight of the instrument is really on the forward glide and on the glide back, it’s not even the weight of the instrument but not getting out of contact with the skin. The faster you go, obviously, we can stimulate more nerve receptors. Notice that my treatment stroke is roughly between about 4 and 6 inches. And if I find something in particular that I really want to focus on, I like to choke up on the instrument and treat it a lot more specifically. That’s generally how you want to necessarily apply your treatment strokes, again, between 30 and 60 degrees for the most part when you’re holding the instrument. The biggest thing for me is I don’t want to see this. I don’t want to see you grabbing an instrument almost like it’s a knife. Most of the time, we’re either holding an instrument with fingertips. Every now and then what I like to do is if my hands are a little bit more tired, you see how I can grab an instrument between my first finger and my middle finger and I can do the same type of treatment stroke without having to grab the instrument. It allows me to actually almost like a lighter contact but the instrument is in greater contact with my skin. I get a lot more feedback from that aspect. When I go to single hand, I like to choke up on the instrument as much as I possibly can. I don’t want to do a single-hand hold holding the instrument here like this because guess what? I gotta hold that instrument a lot harder just to control it.

If I choke up on it I can be right over that area and treat it very specifically. I have the ability to do small little quarter-inch, half-inch treatment strokes while I’m doing this, and I can change my pressure much much easier than if I’m gripping all the way down here. And that’s probably when I teach classes, one of the first things initially that I have to do with the clinicians that are in my class, is they tend to grip the instrument; number one, too hard; number two, they allow too much of the instrument out of their hand while they’re treating. Even if I was in a one-hand hold, what I’ll do is I take my finger, which is where my pressure is coming from, and put it right up to the area of the treatment edge that I’m using. So now, I don’t have to use nearly as much force. Rather if I was all the way back here I gotta press harder with my finger just to make sure I get the same amount of force going through that tissue. Since you’re gripping harder you get less feedback. You don’t feel as much when you’re doing it.

Now, past that, that’s talking about our handholds and as well as the angle for most of our treatment. Now, let’s talk about the application and show that in a little bit. So if we’re doing that neurosensory, weigh in the instrument as we’ve talked about before. A lot of that, again, is forward. The great thing with double-beveled instruments is all I have to do is flip it around and now I’m treating more down towards the wrist, and gliding back. I’m going to do this again until I get my hyperemia. That’s our neurosensory style of an application. However, if we’re going more towards a pro-inflammatory, a pro-inflammatory treatment is usually going to be a small edge of the instrument. Rarely you’re going to do a pro-inflammatory treatment with the broad edge unless it may be a deep fascial knot or something along those lines where you need something that gives you a little bit more leverage in order to accomplish that. But let’s just call this a tennis elbow for what we’re working on. It’s easier for you to visualize that on me. I’m going to pinch or choke up on this instrument, really get my fingers almost like a pencil grip, and now I can get right over that region. Now, in particular, again, if this was tendinopathy, I’d want them doing an eccentric load all at the same time so I’m going to back up for a little bit and I’m going to use just a water bottle as a weight, and then maybe I have them start here. And now, they’re slowly dropping that into an eccentric load as I’m treating right on the tendon. Again, slow down.

I like to say to them if you’re doing a two count up, I want a six count down. Again, your pressure should be enough to get your instrument on the tissue and it has to be fast enough to generate almost that inflammation but it can’t be too fast I keep sliding off the tissue. Right there I was showing you like I’m holding it and doing this all the same time. If I’m a clinician and I have my patient there, one hand is taking the depth of penetration, so in other words, I’m going to go find that tendon. I’m going to find my depth and pull the skin out of the way and then the other hand has got the instrument and is going and doing the treatment. Why do I prefer always using my hand that’s not holding the instrument for that palpatory? Number one, it tells me where I am. Number two, it helps me block things that maybe I don’t want the instruments to slip in like a bony prominence or something along those lines. Three, I don’t have to push through tissue in order to get to my depth. My finger is pushing through the tissue to get to the depth I need to and now I have to use less pressure with my instrument to accomplish the same goal.

So, whatever you do, please always remember to constantly use your hands to find depth, palpation, block things. It also helps you stabilize and make the patient feel a lot more comfortable as you’re working on them. So, that goes to our pro-inflammatory treatments. Again, they are shorter strokes deeper, heavier, usually not that comfortable. They last for about 10 or 15 seconds, get off, reassess the problem again. It dropped from a 10 to a 5, but I only did 30 seconds or 10 seconds let’s go back again, and we’ll test again. We’ll do it up to 3 times. Remember, it’s so critical with the pro-inflammatory applications that you tell your patient “Most likely you will get some soreness within an hour to 2 hours from here. It will probably perpetuate, meaning, it may increase through the next 12 to 24 hours. However, if you’re still sore from the treatment 24 hours later, I’m going to have to decrease my intensity because it’s too much inflammation that we’re treating. It’s okay we’re not damaged, I just don’t want you to get that sore.” Now, granted as you go through subsequent treatments, you’ll get less and less sore as you’re going through. So, that’s how we’re taking care of, again, our pro-inflammatory applications are four conditions: ligaments, tendons, scars; traumatic or post-surgical, and those deep knots. Those are the pro-inflammatory structures that we want to be able to work on.

Lastly is our anti-inflammatory application and how we’re gonna do that. We’re going to stay again at our 30 to 60. The pro-inflammatory we might get up into a 90-degree, but again, we’re looking for deeper stuff. When we’re doing the anti-inflammatory, once again, we’re at that 30 to 60-degree angle. However, our stroke before where we were holding an instrument having it pretty much fully in our hands, nothing out of contact with the prone or anti-inflammatory, I like that instrument to just wiggle on my hand. I don’t want to have full forceful control over it. I want it to barely just glide along. It’s almost like dusting something that’s very very delicate where you don’t want to take a chance of your duster knocking it over so you’re doing it super, super light, super careful. You want to make sure it stays in contact with the skin, as we’ve already talked about, 30 to 60-degree. And now you’re looking for– It might take a little longer. Normally, hyperemia will happen within 30 seconds over a specific area and again it might take you 5 minutes to an entire region. But when we’re doing anti-inflammatory, it could take you 3 to 5 minutes to get hyperemia. And again, it shouldn’t be read, it should be a light pin over that small little region that you’re working on.

Let’s say it’s bursitis on a shoulder, maybe you’re doing the entire delt region. You’re looking for a pink to develop over that area, and just remember in things like bursitis or those bruising, it’s not going to be instantaneous relief. You may get contact anesthesia, yes, but bursitis itself will take a few treatments to get through. The milking ones that we’ve shown where we truly like squeezing the toothpaste out of a tube can be instantaneous. You get rid of the pressure of the swelling on those injured tissues and all of a sudden they don’t have as much pain.

That also has a fantastic benefit from that perspective. All of these things to think about once again while you’re doing your instrument-assisted, summarizing it into something very simplistic. We have 5 major concepts that we want to utilize when using our instrument-assisted. Is there a position that creates their dysfunction? Is it a motion that creates their dysfunction? Is there a resistance that does it? Or are we using that resistance to create remodelings like in ligaments and tendons? Is there a functional position that creates it? Or what happens when we create an unstable surface adding in proprioception? So, again, position, motion, resistance, functional positions, and proprioception. Those are the 5 concepts that we want to utilize with our instrument-assisted.

However, understand it is not an “I’m doing position then motion” No. What is the pitch, oh, it only hurts me when I move this. It only hurts me when I do a squat. Well, you’re going to plug that patient into wherever in that hierarchy they are and do your treatments associated with that. So we have our 5 concepts, we have 3 applications. Are we trying to be pro-inflammatory? Again, only 4 situations; ligaments, tendons, scars, those knots. Are we being anti-inflammatory? bursitis, bruising, hyperaesthesias, some post-surgical type of things. Or do we have an acute swelling? Or are we doing a neurologic reset which, again, is the bulk of our treatment? The bulk of what we do or neurologic resets. Just by balancing out those seesaws, we change the mechanics of our body parts so that everything is functioning like a beautifully orchestrated ballet. And now our body moves much better with significantly fewer problems.

So, within that neurologic, it’s a control-alt-delete. Again, by stimulating those A-beta fibers as we’ve talked about already, we’re able to reboot our system through a number of different pathways that we’ve already discussed; vascular, neurologic, endocrine, all of those come into play here to allow for a palpable change in our soft tissue and for better soft tissue healing. So if there’s one thing in particular that you always want to make sure is in your brain is, what are my 5 concepts? Am I trying to be pro-inflammatory anti-inflammatory? Am I just trying to neurologically reset things? That’s going to tell you the amount of pressure you’re going to use, it’s going to tell you what type of exercises or rehab you may be bringing into this all at the same time, and it will give you the greatest outcome to your instrument-assisted soft tissue procedures.

My name is Dr. Gregory Doerr. I hope that this was stimulating enough to you to either go and find a class yourself to try and learn a little bit more no matter where it is to look at the possible use of instrument-assisted as a tool that you can develop within your practice, not to mention, it does save your hands quite a bit. As well as the great benefits that we get from both pro-inflammatory, anti-inflammatory, and our neurologic levels. If you have any other further questions, my email was on that first post. You’re free to email me if you like. And with any luck, this will become an integral part of your practice like it has for mine. Thank you very much for your time.

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