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.

The homecare exercise regime

When in process of rehabilitation, the work that you do at home is just as important as the work done during the treatment. Its a case of maintaining or continuing what progress was made during the treatment. I think it’s great as it helps to put some control into the hands of the patient so that the condition is manageable. I think we’ve all become accustomed to the philosophy that a person has a treatable condition, they come in to be treated and then they’re better and can continue on without any self-intervention.
As someone that experienced some severe low back issues in the past, I think it’s really important to have solid knowledge as to what is happening and exactly how my home exercises will be improving the condition.
It always seemed to be such an inconvenience though. Something where I had to take time away from my daily activities to do and without a solid understanding as to why I was doing it. People say to me that they just don’t have the time during the day. I think it’s very very important to have even just a little bit of time for yourself during each day. I think that taking that time away and spending it doing the self care is possible. For myself, my favorite thing is to watch a movie. I don’t think of it as watching a movie while I do my stretches. I think of it as stretching while I watch a movie. There is a difference. Watching a good movie is my prime motivation and stretching is just a position that I’m in while I watch the movie. This way, the whole process is more enjoyable and I’m more likely to do it. I have an attention span of about 1 minute. I call it EADD (exercise attention deficit disorder). But watching a movie and stretching is great because time flies so fast. I also play games on my iPad while I’m on the inversion table or I’ll go for a walk in the morning and have a coffee at my destination.
As a therapist, I’m a bit of a talker and usually spend my time talking about what I’m finding and how it is affecting the current condition. Then when it comes to the exercises at the end, I talk about how the exercise will improve the condition that I’ve been talking about during the treatment. Understanding and knowledge makes a person more in control of their condition I believe. It leads them to understand why they are in pain and what message the pain is telling them. It’s no different than having your finger above a candle. Your finger warms up and you pull it away as the low grade pain is telling you a message. An example is the shoulder. If the shoulder falls forward, it may cause a pinching pain when you raise it up. If you feel the pinching pain, then you need to recenter your shoulder so it tracks more efficiently. So it’s my job to tell you what the pain is telling you and what your body is doing and how you can improve your posture/biomechanics to where it is moving more efficiently and the pain is reduced. This makes you more knowledgeable and in control of the condition throughout the entire day.

The importance of Rib and upper back mobility

One constant that I’m finding in a lot of cases from low back pain to shoulder and neck pain is the decreased mobility of the ribs and mid/upper back portion of the spine. The body is intended to maintain some movement in this area, and in it’s absense, can produce symptoms above and below in the shoulder/neck and low back area. As we breath in and out, lean forward, back, side to side and rotate, the ribs will move in relation to each other and the vertebrae of the spine will move in relation to each other. There are several reasons that these areas can stiffen up from immobility of the area, trauma, surgery or past illness (perhaps bronchial or cardiovascular).

The body should be likened to a tree. A tree from the trunk up to the very top has the ability to be flexible along to entire length (obviously more flexible than other areas) but this flexibility is what helps it be strong so when a wind comes up, the forces are distributed along the entire length, so (unless there is an extremely strong wind) it should maintain it’s integrity. Now imagine that you put a metal collar around the middle 2/3d’s of the tree and not allow that portion to flex and reintroduce the wind to the tree. In the absence of the flexibility of the middle 2/3rd’s of the tree, the part of the tree just below now is having to bear the burden that the middle 2/3rd should be doing. The chance of the tree breaking just below the collar increases. Obviously, we will not “break” like a tree but in our instance, the forces inposed on the lower back in absence of good movement in the ribs and mid back will be present.
A person may have very tight shoulders that are pulled forward and a very stiff middle back. When I ask if they can pull their shoulders back, most of the movement involves arching at the lower back to bring the shoulders back. The lower back is an important area and needs to be kept in a neutral position while in a static position as well as movements but is often asked to move out of it’s optimal position to compensate for things like stiff mid back/ ribs or stiff hips.

An area that has become stiff is very difficult often to become aware of as the body is very good at compensating. Personally, I have had an issue with low back pain. My biggest improvement occurred when I worked on mobilizing my ribs, middle and upper back and increased my hip range of motion. Both my hips didn’t extend (move back) very well and my left hip didn’t turn inwards very well and my low back was doing that work. There is only up to 20 degrees of rotation available in the low back so it needs to be used sparingly and shouldn’t be used making up for lack of movement in other joints.
Part of my job is to ensure good movement in the joints that are lacking to the degree that the patient is able to maintain the proper range of motion at home with stretching. Often the less mobile joint is stuck enough that my work is needed to get it going to the point that the patient can maintain it’s flexibility at home.

The second part of the process is often harder and involves the patient being aware now that the joint or body part is now mobile and integrating it into their functional movements such as turning or picking something up or simply walking. A home exercise may be something as simple as sitting and placing your hands on the sides of your abdomen and turning but not allowing your hands to move so that all your movement is in your mid back, just to get the person used to being able to move through the midback.
Each case is different but the philosophy remains the same in that a body’s stability depends very much in it’s systemic flexibility and any rigidity can produce instability.

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.