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Re: TENDINITIS (DTF and) long reply

Those who prefer to cut to the chase, skip to paragraph starting, "There are more distinctions I could quote…"

On 12/2/99, Mel Siff wrote(Vol.1#1571):

"… Presuming that this method breaks down existing adhesions or scarring by retraumatising them, is it not logical that they simply scar again to heal the re-damage?
Of course, then one repeats the friction and the microdamage, and so on, thereby somehow mysteriously facilitating tissue regrowth and not scar formation."

From next Mel post: "…According to traditional theory, the scarred or fibrous tissue that is produced after the injury is tougher than the original healthy tissue, which means that gentle methods should not be able to do anything to remove the apparently offending scarring…Maybe deep cross frictions are simply a type of dynamic trigger point therapy and serve more of a relaxant role than anything else.

The explanations that I have seen so far still leave me unconvinced."
___________________________________________________________

I appreciate your articulate style of being unconvinced, Dr. Siff; gives us plenty of food for thought and studies to boot. Haven’t checked out those myofascial web sites yet, but I surely will. Let me try to briefly explain my understanding of what I’m doin when applying DTF (deep transverse friction) to a muscle, tendon or ligament and the underlying premise as I understand it. It’s not quite what you presented it to be in your recap above and subsequently with the studies you presented, several of which were specifically studying CTM.

From ‘A Physician’s Guide to Therapeutic Massage’ by John Yates, PhD c1990: “Connective Tissue Massage (CTM) describes Elisabeth Dicke’s technique of applying strokes that produce a tangential pull on the skin to a series of reflex zones, or connective tissue zones…considered especially useful in loosening and relaxing tissues preparatory to therapeutic exercises following surgery or trauma and is claimed to have profound effects on the functioning of the autonomic nervous system.” I haven’t been trained in this work, so can’t speak from experience about it.

DTF is a different technique. As you mentioned, James Cyriax (‘Textbook of Orthopaedic Medicine, Vol.2, Treatment by Manipulation, Massage and Injection’) is the grandaddy of this method. At the risk of boring the rest on the list I’ll quote Yates from ‘A Physician’s Guide…’ where he provides few relevant papers on DTF:
“Chamberlain (GJ 1982. Cyriax’s friction massage: a review. ‘Journal of Orthopedic and Sports Physical Therapy’ 4:16-22) discussed both the rationale for maintaining mobility within connective tissue during healing and the case for using friction massage. Corbett (M 1972. The use and abuse of massage and exercise. ‘Practitioner’ 208:136-139) believes it to be the most useful form of massage, effective in chronic supraspinatous tendinitis, some forms of tenosynovitis, ligamentous sprains at the knee and ankle, and medial or lateral epicondylitis at the elbow. Swezey (RL 1983 The modern thrust of manipulation and traction therapy. ‘Semin Arthritis Rheum’ 12:322-331) describes deep friction massage as a specific therapy for tendinitis to restore pain free motion of tendons and at tendinous attachments with epicondylitis and biceps tendinitis as the most common indications. Although Cyriax (JH 1960 Clinical applications of massage in Licht S (ed) ‘Massage Manipulation and Traction’) has described bursitis as a contraindication for deep friction massage, Hammer (WI 1993. The use of transverse friction massage in the management of chronic bursitis of the hip and shoulder. ‘J Manipulative Physiol Ther’ 16(2): 107-111) recommends the use of transverse friction massage in the treatment of chronic bursitis of the hip and shoulder.

MacGregor (M 1971 Manual treatment at the knee ‘Physiotherapy’ 57:207-211) regards deep transverse friction as indispensable...snip..describing deep friction treatment of medial collateral ligament sprain, coronary ligament sprain, medial meniscus tear and patellar tendinitis, he suggests that some lesions at the knee are incurable by any other method.

Askew et al(1983 Objective evaluation of hand function in scleroderma patients to assess effectiveness of physical therapy.'Br J Rheumatol 22;224-232) studied the effect on hand function of a single treatment consisting of paraffin bath, friction massage and active exercise in ten scleroderma patients. All subjects had improved hand function based on objective measurements and criteria. The authors suggest that regular use of this type of treatment may improve hand function by minimizing the contracture, loss of strength, and diminished skin compliance commonly associated with scleroderma.

Li (ZM 1984. 235 cases of frozen shoulder treated by manipulation and massage ‘J Tradit Chin Med’ 4; 213-215) compared 205 cases of frozen shoulder treated by gradual stretching and massage(20 min. every three days) with 30 cases treated by sudden forced manipulation under nerve block anesthesia, followed by daily functional exercises plus massage therapy once every three days. All 205 patients in the first group showed satisfactory improvement with complete recovery (no pain, function as good as a healthy shoulder) in 71.2%. Long term follow up (one to six years) of 63 of these individuals showed these recoveries to be sustained. In the group treated with forceful manipulation, complete recovery (in terms of pain and function) was seen in 3 cases, and improvement in 10 more. Evidence of rupture of the joint capsule was seen on arthroscopic examination in some patients of this group. Li concludes that gradual stretching and massage produce an outcome far superior in both the short and long term, to that of forced manipulation.

Although we have not yet located controlled clinical studies of its use in athletic injuries to prevent and treat fibrosis, anecdotal evidence abounds. Matusezewski (W 1985. Rehabilitative regeneration in sport, parts 1 and 2 ‘SPORTS’ Jan (pt1); June (pt2)), in a discussion of the use of massage in athletic training programs, credits it with prevention of fibrosis and adhesions, and loosening and stretching of tight tendons. Further evidence is provided by Harris (J 1986 Managing massage in the fintess centre. ‘Fitness Management’ Nov/Dec 8-12) who quotes US Olympic competitor Joan Hansen as saying that: “an Achilles tendonitis that used to require six weeks of intense physical therapy now only requires five treatments of cross-fiber massage to completely heal the problem.” ” end Yates quote.

Waldemar Matusezewski (quoted above) was the soft tissue specialist that Charlie Francis employed to work with his athletes during the time he was training Ben Johnson for his Olympic Gold medal. He had previously been the chief of physiotherapy and regeneration at the Polish National Olympic Center.

The best description I have seen for the nature of adhered tissue from overuse is from Vert Mooney, MD in his paper; Overuse syndromes of the uppper extremity: Rational and effective treatment ‘Journal of Musculoskeletal Medicine’ August 98: 11-18;
“A recent book on repetitive motion disorders published by the American Academy of Orthopaedic Surgeons cites a histologic study in which Nirschl proposed that overuse syndromes are not an inflammatory process but instead represent failed repair of disrupted connective tissue. Supporting this theory were biopsy samples from tendons of patients with epicondylitis that showed disorganized collagen; pale haphazardly arranged mesenchymal cells; and excessive amount of matrix tissue; and vascular buds with an incomplete lumen and insufficient elastin. This disorganized mesenchymal tissue has poor potential for healing.

Based on these observations a reasonable goal for healing would be to stimulate an inflammatory mediated process with appropriately oriented fibroblasts (laying down parallel fibers in the tendons, which would increase their strength) and to reduce the amount of matrix tissue through the use of appropriate exercises.

Tendinosis
Rolf and Movin recently reported their opportunity to obtain biopsy samples from patients with Achinlles tendinosis related to overuse. Their findings confirm what Nirschl found in elbow tendons. The surgeons were able to ultrasonically determine the exact location of pain and swelling and obtain a punch biopsy without destroying the tendon. As in Nirschl’s epicondylitis study, the tissue had disorganized collagenous tissue and no inflammatory cells.

An additional finding was a consistent increase in proteoglycan content-up to 40 times more than normal. Besides interfering with normal collagen organization, proteoglycan molecules absorb water; this creates the swelling and distention that causes persistent pain. (Pain resulting from local muscle spasm and mechanical tissue damage, in contrast, is not persistent.)

Thus, it appears that patients with tendon overuse injuries lack the normal process of inflammation and repair, with associated increased vascularity and parallel fibroblastic proliferation. Evidence of an inflammatory repair process is consistently absent.”

His study was for epicondylitis or carpal tunnel syndrome using Michael Leahy’s active release therapy in 29 patients with a 75% success rate at 3 months. Without subsequent strengthening programs, workplace modification there was a gradual deterioration. I left you a copy of this paper at the end of our Restoration Camp. He sites a number of other studies supporting the above description of histopathology of tendinitis, tendinosis, tendovaginitis, , tenosynovitis from overuse. Don’tcha just love medispeak? Variants of important sounding terms for conditions, terms designed, me thinks, to enamour us lay folks with the supreme wisdom of those who use them thus establish a hierarchical separation between those-who-know and those-who-don’t, as anything else...but, I’m digressing.

Back to applied DTF; These descriptions of what happens in adhered tissue support Cyriax’s premise rather well I think. From ‘Textbook of Orthopaedic Medicine, Vol 2’ here are some of Cyriax own words about what DTF is, is designed to do and does rather well, IMO:

“The philosopher who sits in an armchair and considers the question of deep friction in the treatment of painful lesions is driven by apparent logic to the conclusion that it is never called for at all. Clearly, he says to himself, if a structure is already damaged, friction given with penetrating effect can only irritate it the more. Alternatively, friction so administered that it does not reach the lesion is obviously valueless. The essential fact about deep friction is as follows: it applies therapeutic movement over only a very small area. The movement is the more effective for being so concentrated. Indeed, greater movement may easily be imparted locally by the physiotherapists finger than could ever have been obtained by any amount of the most strenuous exercises and it moves those very tissues on which manipulation has no effect. By this means, and by this means alone, massage can reach structures far below the surface of the body…On account of its purely local action, deep friction must be applied to the exact site of the lesion, otherwise it is useless. Indeed, it is harmful, in so far as it hurts the patient without bringing him any eventual benefit….Given properly, deep friction has a four-fold effect. It induces (1) traumatic hyperaemia, (2) movement, (3) increased tissue perfusion and (4) mechanoreceptor stimulation.
Traumatic Hyperaemia. Enhancement of the blood supply diminishes pain. Apparently it acts by increasing the speed of destruction of Lewis’s P-substance, the factor responsible for the pain…In other words, deep massage given to the lesion itself affords temporary analgesia, and during this period treatment can be given that pain would otherwise have prevented.
Movement. By moving the painful structure to and fro, it is freed from adhesions both actually present and in the process of formation….longitudinal frictions merely move blood and lymph along, whereas transverse friction moves the tissue itself…. Transverse friction does not disrupt the fibres beneficially joining the two severed edges of a ligament, since this is moved in imitation of its normal behaviour, but not stretched. The movement induced disengages the fibres about to gain abnormal adherence, eventually binding the ligament to the bone and leading to restricted mobility such that full use of the joint resprains the ligament.
Further effects. …It increases tissue perfusion at the damaged area and stimulates the mechanoreceptor cells. Since impulses from the moving parts take precedence over afferent sensory stimuli, the latter do not get through and pain is relieved.

The main function of muscle is to contract. As it does so it broadens. Hence full mobility in broadening out must be maintained or restored in muscles that have been the seat of inflammation, whether caused by one or by repeated strains. …the effect of deep transverse friction clearly consists in mobilizing the muscle, i.e. separating the adhesions between individual muscle fibres that are restricting movement. If passive restoration of full mobility of a muscle is followed by adequate active use, these adhesions do not reform; cure results.

…To stretch out a muscle does not widen the distance between its fibres; on the contrary, during stretching they lie more closely. Whereas, then, for the rupture of adherent scars about a joint forced movement is required, interfibrillary adhesions in muscle can be broken, not by stretching, but by forcibly broadening the muscle out. Particularly this is true of the fibres of attachment of muscle into bone, where the vicinity of stationary tissue restricts the mobility of adjacent muscle…Indeed, the action of deep transverse friction may be summed up as affording a mobilization that passive stretching or active exercises cannot achieve.

After the friction has restored a full range of painless broadening to the muscle belly, this added mobility must be maintained. To this end, the patient should perform a series of active contractions with the joint placed in a position that fully relaxes the affected muscle, i.e. the position that allows the greatest broadening. Strong resisted movements should be avoided until the scar has consolidated itself; otherwise, started too soon, they tend to strain the healing breach again. Athletes in particular must not return to full sport too early.”

There are more distinctions I could quote, but this is already way too long. Point is that the very specifically applied friction (DTF) must be applied exactly on the precise spot of the lesion (not necessarily on the painful spot, as that can arise from trigger points and other noxious secondary occurrences in the damaged tissues) which requires knowledge of 3 dimensional anatomy and palpatory accuracy, the fingers and clients skin must move as one so that one is rubbing against the underlying muscle, tendon or ligament to adequately penetrate to the level of the adhered tissue. The friction must be given with sufficient sweep to go across all the fibers in the lesion, mechanically freeing the cross linked adhesions. It must reach deeply enough to address the lesion, Cyriax emphasizes that the friction element is paramount, pressure augmenting but not replacing friction. If this is neglected, painful treatments have no curative value. Muscles should be kept relaxed while being given friction to allow deep penetration, except on sheathed tendons wherein the effect is a bit different than muscles, musculo-tendinous areas, unsheathed tendons or ligaments. Ligaments should be worked at both ends of their ROM to free up inappropriate adhesions to the boney attachments. They should be moved passively at first, not stretched.

After treatment, to maintain the added range of painless broadening the client must fully contract the muscle without straining it, as it recovers from the trauma of the work. The joint is placed in a position which fully relaxes the muscle and then some reps of maximal contractions are performed. So if it is a knee or elbow, fully flex it then full contraction of the hamstrings or biceps can be done without straining the injured fibers. If it is a recent injury it is more important not to pull on the fresh fibrous tissue in the healing breach so resistance exercises are not recommended until the scar has consolidated itself.

Cyriax pg 14: “Tendons with a sheath must be kept taut. In tenosynovitis, the roughening is confined to the outer surface of the tendon and the inner surface of its sheath. The friction is intended to smooth off the two gliding surfaces. To this end the tendon must be stretched so that it forms and immobile basis against which to move the sheath. Should the tendon remain lax, it and its sheath are rolled against adjacent structures and little good results.” Idea being that pain occurs when the tendon moves within its rough sheath and friction on stretched tissues smoothes the surfaces of the tendon and sheath off again so they can glide freely. That is not at all the same as passively or actively stretching the body part. Here, since overuse from longitudinal friction is assumed to have caused the condition, exercises are avoided until it recovers. Client is simply asked to avoid any activity which hurts it.

Since nothing is done in the trenches in a vacuum, other protocols and modalities can be used to great effect in conjunction with this method. I often soften the tissues and get the blood flowing with effleurage and kneading first and calm it down with ice after, recommending follow up icings for the next 48 hours and the appropriate exercises until it feels better, then a subsequent DTF treatment, once or twice a week, depending upon how well it recovers from the initial treatment, until the schmutz is cleared out. Usually in my experience it is between 3 and 12 DTF applications depending on how long the adhesion has been hanging out in the tissues, how much tissue is involved, how well the client follows up with the exercises and icing, how quickly they heal in general. Athletes have healthier tissues IMO than sedentary zoftic types. Diabetes will slow down the healing, as will other factors. The electrical stim routine you recommended in Digest 1573 would augment the work, as would the exercise protocols you listed.

One reason I took the ISSA training and exam was to hopefully learn more about savvy choices for exercise protocols to enhance quick return to sport from such an injury. As the healing progresses the muscles can be put under load again, but this must be done well so that re-injury does not set back the recovery. This is where I think your Functional Neuromuscular Training methods might be quite well used. At this point, simple one joint protocols specific to the strained muscle are the choices I’ve been shown, eg: side lying L flyes for infraspinatus tendon, first high volume(12-15 reps) low load, to strengthen it after the initial no load movement phase. Advancing to more complex PNF patterns just under weight of the limb in the early stage, pain free of course, then with more resistance as the lesion recovers, I would think, might speed up recovery to full function in sport even better than the solitary exercises I have shown my clients until now.

One thing is clear, however, passive or CRAC stretching is not the correct choice of follow up exercise for the first stage of healing using these methods. The exercises to broaden the fibers in the day or days subsequent to the DTF are just as important a part of the protocol as the DTF itself and must be done if the next treatment is to be addressing a different layer of the adhered tissue and thereby clear it out further. Without the follow up the progress is much slower. Bringing athletes back to full training asap without re-injury or unnecessary time off from their sport is the part which I think requires refinement.

Michael Leahy uses active release methods to break apart adhesions, then puts athletes under load immediately after the treatment, to good effect as he and his proteges report it. He’s worked successfully with a number of world class Olympic Weightlifters and other athletes, so the proof is in the pudding I guess, but I don’t really understand how the tissue is ready for heavy loads so soon. Although he is asking clients to actively contract the muscle while he holds deep compressions against and across the adhered tissue, the cross links are being broken apart by the combined active movement of the muscle under pressure. Trauma is occurring, so it doesn’t make sense to me, how he can ask an athlete to just go and lift heavy immediately after the work. I can’t convince myself to pay $1800 for a weekend workshop with 100 other folks to learn his 105 moves for the arms and shoulders, though, so I guess I’ll just remain curious unless someone here has a convincing answer for me on that.

I usually recommend that my clients take glucosamine/chondroitin while healing connective tissue, possibly SAM-e if their pocket books can handle both items, or NSAIDs if they use them. Drink plenty of fluids which are important for connective tissue integrity, keep the anti-oxidants in the vitamin regime cause we have surely freed up some radicals if you don’t mind a play on words.

That’s the best explanation I can offer you without starting a veritable dissertation on the topic.

Best Regards,

Di

 

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