Post Operative Myofascial Release

When a person has had surgery, whether it be abdominal, cranial, shoulder, back, hip, knee or any joint surgery, often a neglected portion of the recovery is Myofascial Release of joints and tissues affected by the surgery. Adhesions can occur in the joints or tissues as a result of the surgery itself or the period where the person has to keep themselves, or a portion of their body, immobile during the healing phase immediately after the surgery.

I became acutely aware of this necessity after my heart surgery, where I had a heart valve replaced. To do the surgery, they had to cut through my breast bone to access the heart and do the surgery.  So for the next month, I had to keep my arms and shoulders pulled forward. I wasn’t able to open up my chest and bring my arms up and stretch them back while the sternum repairs itself. As a result, all the tissues around the front of my chest, my upper abdomen and the front of my neck were put in a shortened position for an extended period of time. All the tissues in the front will become adhered to each other and keep the tissues shortened which dramatically alters the center of gravity with the body and the shoulders and neck/head are pulled in a forward position. This is just a quick example of the effects of immobilization after surgery but doesn’t include the effect of the scar tissue created by the surgery itself.

I have seen the same effects with shoulder surgery, back surgery, hip/knee/ankle surgery. A bit portion of the rehab process is the return the joint or body part back to it’s normal mobility with myofascial release and strengthening. A body just wants to move in the manner in which it’s designed to do. That’s the best way to return a body to normal. The techniques are different for scar tissue release, for soft tissue release and for release of tissue surrounding the joints like ligaments, tendons or the capsule that surrounds joint. All can shorten, but all can be returned back to a good functional range of motion.

The principals of Myofascial Release are adhered to (pardon the pun) to create an increase of mobility that is gentle, effective and creates a long term effect. Every release will last a while but it’s so important that the patient has a full understanding of how they are presenting and how they can maintain the work that we do at home. It should never be about depepnding on the therapist to “fix” you. We assess the condition, educate, we begin the process to facilitate and allow the patient to help maintain the progress with home exercises.

What is Myofascia and Myofascial Release

I heard the perfect analogy for what fascia is in the body, from a structural standpoint. Take a jar and put all sorts of little things in it like golf tees, marbles, string, pencils and fill up the jar with it. Then pour in this liquid, to the brim of the jar, that will set, but remains 70 – 80% liquid (as that is what we are). When this liquid sets, it will also be very structurally strong as well as being fluid. Almost like a super-jello. So now in the jar, you have all those items listed above and poured between those spaces is this liquid that will set. When it sets, you can crack the jar and this structural jello will hold the shape of the jar with all the items listed above set within it. What the items listed above represent are our cells and to a larger scale, things like our bones, nerves, muscles, brain, arteries/veins and holds them all in the shape that is what we are.

It is an extremely strong, 3 dimensional, gelatinous web that surrounds everything in our body that allows us to move but also holds us in our shape. It is crucial that it maintains that fluid content in the same way that it is crucial that leather maintains that moistness to remain soft and flexible. If for some reason parts of our fascial system loose that fluid content, it becomes dry, it loses it’s flexibility and pliability and as the fascial system is continuous through the entire body, can affect the biomechanics through the entire body. There is never a predictable way that it can affect the body.

Fascia can lose it’s fluid content for many different reasons including trauma, surgeries (joint replacement/abdominal surgeries/child birth), inflammatory responses (IBS, Crohns,Pneumonia) and chronic longer term shortening of tissues (poor posture, sitting), microtrauma to muscle tissue from heavy activity like biking, running, weight lifting. Shortening of the fascia may have occurred recently or may have occurred as long ago as a traumatic childbirth. The body is able to compensate for where ever the fascial restriction are for a long time before the presentations may occur.

Two of the most common major presentations of fascial adhesions that I see are low back pain from adhesions occurring at the front of the pelvis/hip regions and back/shoulder/posterior neck pain occurring from adhesions forming at the front of the neck and chest area pulling the head and the shoulders forward. When you are pulled forward by fascial adhesions at the front of the body, the muscles that pull you back up (whether they be the low/mid/upper back or the back neck or shoulder muscles) become strained, fatigue and ultimately produce pain and spams.

The main mantra with this work is find the pain but look for the cause elsewhere.

In our original training, we were very symptoms oriented and it took a leap of faith to pull myself away from that to move towards this philosophy but it has been so affective. Deal with the fascial restrictions so the body can move in the manner to which it was designed to do. Just let the body move like it should. That’s what it really wants to do.

How does one release fascia back to it’s original property? That’s worth another blog entry. 🙂

I’m moving.

After 6 years of working at Cedar Hill Sports Therapy, I am relocating to a new office with some of my workmates. The new office is
Good To Go Sports Therapy, located at #106-1175 Cook Street in Victoria. It’s nestled in a great spot in a great building so it will be good to work here. Online booking is available at

goodtogo.cliniko.com/bookings

So you can make an appointment any time of the day and see exactly when I have availability. More news to come.

TMJ and Shoulder/Head Position

I have had people come in with complaints of jaw pain. There can be many reasons for this discomfort. It may come from sudden trauma like impact to that area. It may be from a recent visit to the dentist with work being done or simply having the jaw open for a long period of time. Trigger points (focused hyper-irritable points) in the muscles that move the jaw can refer pain to that area. There has been one consistant factor that I have noticed with people with jaw discomfort and it is the position of the shoulders and head in relation to the rest of the body. Most often the shoulders are rolled in and slightly forward and the head is also in a forward position.
There is an important relationship with head position and jaw position. The more the head is forward, the more the jaw will move back. Do a test on yourself. Gently close your teeth with your jaw relaxed and gently let your teeth touch each other so everything is relaxed and natural. Now jut your head forward slowly until it stops and your lower teeth should feel like they are moving back in relation to the upper teeth. At this point, the jaw joint (just in front of your ear) is being compressed in the same manner that if you were sitting and someone pushed your shoulders down, your spine would be compressed. Keeping the jaw compressed will doing simple actions like talking and chewing can put low grade strain on the joint and eventually causing problems down the line. This all ties in with the general benefits of good posture.
There is an interesting biomechanic that is not well known with the jaw as well. The joint is made up of two parts. One part has small forward and backward motions and the other is the “hinge” type movement that does the main opening part. When the jaw opens, first there is a slight forward movement, the the second joint hinges open (similar to a hinge in a door). The first forward movement is critical for good movement and if there is a “head forward – jaw back” presentation, then the jaw will not be able to make that first crucial jaw forward movement.
A “shoulder forward – head forward – jaw stuck in back position” can start often in the mid to upper back with tissue tightness and joint fixations that can be literally holding a person there making it very difficult for a person to get themselves in a position where they should be. That is where I come in to remind a patient where they should be and release the tissues and joints and give them home care to make it possible for them to be where they should be.
The biggest comment that I get when I reposition a patient to their optimal position is “that just feels weird” but often at the same time, there is better range of motion and less pain. So I tell them to use that as a beacon rather than the weird position that they feel in. Go where there is reduction of symptoms.
Watch out for things that draw your head forward. It is okay for short periods of time but things like computer use and work positions should have some attention paid to them.
Here’s a link to some good pictures of the jaw joint and some of the surround tissue that can become inflamed in the process.

http://www.google.ca/search?q=pictures+of+jaw+joint&ie=UTF-8&oe=UTF-8&hl=en&client=safari#biv=i|17;d|AGhp8EGhpOON2M:

It’s kind of a chicken and egg scenario. In my case, I assume it’s both the chicken and egg and cover both bases. Release the muscles and surrounding connective tissue, make sure the joint is positioned well and moving properly during it’s movement, ensure that the body is positioned well enough that the jaw is not forced into a position and will affect good motion and empower the patient to maintain that good position.

Neck pain and difficulty turning

To follow with my previous post about form and function, I wanted to discuss the problems with neck pain and spasm with difficulty turning the head. Often I might find that there is an imbalance with the shoulders and that the neck is extending the twisting to compensate so that you are looking straight forward. This reaction is subconscious and we don’t realize that we are doing it. We only know that our neck really hurts.

My job would be to help to realign the vertebrae in the neck using tissue release and other techniques to allow the movement necessary to return the neck to it’s original position but also to consider why the shoulders are out of position, forcing the neck to do what it is doing to compensate. There may be something further down that is pulling the shoulders out of position, so we chase the cause as far as it goes so that the trigger doesn’t pull your neck out of position again. As in my last post, part of the success is me and part will be the patient as we stretch, strengthen and create awareness of what they might be doing that causes the trigger to re-occur. Some triggers are completely avoidable, and some are only modifiable (if that’s a real word). It is very difficult to stop doing what we might have been doing for years and years so we need to use discomfort as a reminder that we have fallen into this pattern again. Pain isn’t such a bad thing if we know what it means and how we can change to reduce it.

I have seen a cases where there is a fallen arch in the right foot. This translates to the right pelvis being rotated forward, pulling the whole body forward and turned to the left, so the right low back tightens the pull the body back up right. It often might go too far so that the left shoulder is forward and higher than the right shoulder so your head is tilted to the right. The left neck muscles tighten to pull the head so it is level (subconscious righting mechanism) so the vertebrae in the neck are compressed on the left and open and unstable on the right with there being a possibility of pain occurring on either side for different reasons.

This whole thing can cause foot, knee, hip, low-mid back, shoulder and/or neck pain just because of one little fallen arch. If I only look at your neck, I’m probably not doing you a favour. We need to look at the whole body to see the general picture.

Crazy these bodies we have.

Effective Hip Stretches

I’ve found a web page which has a great hip flexor and hip stretch. I like it as it goes through 3 main types of stretches with good discussion about stretching only to the level that is good with you and that the stretches are held for a long period of time. I always believe that a stretch needs to be held for at least 2 minutes for the tissue to remain in the stretched position. This is a really good long deep stretch.

I believe that when beginning a stretch program, you almost need to do it religiously for at least 2 weeks to a month without expectation of results, as sometimes it takes that long, therefore there isn’t an disappointment for lack of progress during the beginning.

The teacher in the video has been doing this for a long time so don’t be disappointed if you can’t stretch as well as he. Just be patient and stretch as your level. Once a day is nice. Watch some t.v. while you do it. Click on “web page” on the first line of my entry or go to:

Enjoy!!

Form and Function

A really important philosophy that I follow with my treatment is simply to help to return the body back to position in which it is supposed to be in. In this position, the muscles aren’t working hard to hold up the body (as they would be if the body is out of balance) and all the joints and tissue are soft enough that the body moves well in the planes that they are intended to move. If I have someone come in with discomfort, I am aware of the symptoms, but I take myself back to this philosophy with the confidence in the body’s natural ability to self-heal when it is in its optimal position. My success with patients in the past reveals that half the success is what I do and the other half is home care and self awareness of posture to maintain the progression during the last treatment and help the body to normalize to this “new” optimal position.

Being out of position can occur from the feet up to the head. Maybe your foot is rotated out, your pelvis is turned one way or the other. Perhaps the low back had too much of an inward curve or the mid back has too much of an outward curve, or the right shoulder is turned in too much. When things like the above happen, the body is working hard elsewhere to bring the body back up so that you’re not leaning in one direction or another.

I find this philosophy has applied especially to the way that shoulders may be pulled out of position by upper back, and how neck pain occurs due to misaligned shoulders and low back pain reacts to mispositioned pelvis. If your neck hurts, then you don’t connect it to shoulder position. If your back hurts, then you wouldn’t think “hmm, my pelvis may be out of position”. That’s my job. My job, essentially, is to say “hey, your back hurts, and this is what I’m seeing. You should be in this position. I’m going to loosen tissues to make this position easier for you and give you stretches and strengthening exercises so that this good position is easier to hold. And were going to focus on things that you do during the day, that can be contributing to your issues to see what can be changed or altered”. Patient knowledge and education is so important so that you know what we’re doing and why we’re doing it. Otherwise home care and exercises don’t mean anything and you may end up not doing them as you’re not making the connection.