A Little Elbow Grease | Modern Manual Therapy Blog

A Little Elbow Grease

The Pendulum swings both ways and occasionally you have to find a comfortable middle. Many of you who have seen my earliest videos have seen my shift from more aggressive tissue work and release to very light pressure and neurological tricks to reduce tone and threat.

In only two cases out of the thousands of visits I have seen in the past 2 years have I had to give a little elbow grease to finally make the desired change in pain and function.

Case Summary
  • 29 yo female, very active, with pain in her left thigh and numbness radiating to her foot
  • SGIS to the left initially centralized and improved the left hamstring pain, but not the numbness to her foot
  • things we tried
  • light IASTM along the neural patterns
  • RockTape along neural patterns after IASTM and neurodynamic tensioners
  • lumbar manipulation, spinal mobilization with movement (Mulligan)
  • hamstring eccentric loading
    • this had the most effect, but the relief was only for 2-3 days, and not permanent, versus the other techniques had a 1 day relief of the paraethesia and hamstring discomfort
  • SFMA showed some MC issues in ASLR and DS, and rolling patterns were DN, so we worked on those along with teaching her Baby GetUps
  •  general stabilization strategies
  • single leg stance and motor control strategies
    • all of the above again improved her motor control and dynamic balance but not her pain or paraesthesia
  • finally, my intern at the time said tentatively, "How about we try some really aggressive IASTM to her hamstring?"
    • I reluctantly agreed, because we had been seeing her for at least 7 weeks by this time, far greater than my initially projected 6-8 visits
    • we gave the patient informed consent on possible soreness and discoloration, something I used to do regularly, but had not said in a few years
    • after about 7-8 minutes of progressing depth with the EDGE Tool (previously had been using EDGEility only), a lot of the deeper restrictions were smoothing out (whatever this means in lieu of tone and superficial fascia changes, I can only guess)
    • we told her to follow up in 7-10 days
    • fingers crossed
    • She came back with at least 75% improvement in all ADLs, softball, working out, etc, with only mild paraesthesia left in her foot
    • she was keeping up with her neurodynamics and hamstring eccentric loading, along with occasional SGIS to Left or REIS depending on whether or not she had a loss
    • this visit I went even more aggressively and did the entire hamstring instead of just the lateral more restricted/tonic area
    • she said it was quite a bit more uncomfortable, but any time I stopped Tx, the discomfort immediately went away - yellow light
    • HEP to continue as previous and follow up in two weeks
    • two weeks later, she was 100% Sx free and very pleased
    • she said she was pretty discolored for about 1 week, but expected it
  • I can't help but think if she had seen me 4-5 years ago this would have been over in my initially projected 6-8 visits, but this is also only 1 case in the past 2-3 years of my transition to much softer pain free techniques
What's the other case? Similar patient, but only after having discharged her with remaining intermittent LE pain, she bought a stick and started "going to town" as she put it on her involved calf and that's what got her running again.

Thoughts: It is entirely possible both patients "expected" more aggressive manual techniques and had a preference for them. The expectation may have prevented other softer techniques from working. Neuro-mechanically, the increase pressure may have activated different mechanoceptors to reduce tone, thus allowing the peripheral nerves to slide and glide better, or reduce stimulation from an abnormal impulse generating system. Either way, both cases needed a bit of elbow grease.

Keeping it Eclectic and learning through trial and error....


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