Orthopedic Massage Therapy Treatment for Bursitis

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Orthopedic Massage Therapy Treatment for Bursitis

So this weekend as the cold temperatures finally broke, I decided to hit the pavement for a run and enjoy the beautiful weather. The only problem is I actually hit the pavement. Two miles from home, I tripped over a grate, and pitched forward. Failing to get my hands up in time, I landed square on my knee cap. Technically it would be the medial base of my patella, which slammed the apex into the patellar tendon and underlying bursa with tremendous force. It was excruciating. Over the following few days, I have had pain on quads contraction, swelling around and below the patella, and low back pain due to the gait change. Given my current condition, I thought I would take this time to do some bursitis treatment and review.

A Bursa is a fluid filled sac that is often found in the body that buffers surfaces that might otherwise cause too much friction, thus damaging the body as one structure passes over the other. They are usually found in joints, where a tendonous attachment has to pass over a bony prominence. The knee has many bursa, due to its complexity, as does the hip at the greater trochanter and ishial tuberosities, and the Achilles at the point of attachment to the heel etc. Almost anywhere you find a bony prominence and tendons you will find a bursa. To visualize how it works it is something like this.

In a clinical setting, bursitis can often be confused with tendinitis, and they are actually pretty similar. Tendinitis is the inflammation of the tendon sheath, which is a similar structure to the bursa. But rather than being just under the tendon, a tendon sheath wraps around the whole structure to provide a similar function.
Both tendinitis and bursitis can be caused by over use, which means that the ‘sac’ has become inflamed. Bursitis however is often characterized by an impact to the overlying structure, the trauma of which causes swelling and inflammation. In some cases antibiotics or anti-inflamitories might be used, depending on the severity of the case.

In clinical evaluation, clients will have pain on movement, the muscles around the area may be splinted, and heat and tenderness might be but are not necessarily present. In cases such as the knee, the bursa can sometimes be seen as it puffs out around the patella. However, if the bursa is under many layers of muscle, such as at the greater trochanter, it might not be, so it is often misdiagnosed. Taking a good subjective client history can help to determine what you are really dealing with, as it can inform you to activities that would point one way or the other. Did your client recently fall? Is he/she an athlete that uses a repeated motion?

Following that up with your objective ROM, and muscle testing, will further confirm your analysis. Active resisted testing of the suspect structure is extremely helpful. Tendinitis usually has a pain response that is constant on active resisted exercises such as “speed tests”, and while bursitis also reports pain on active resisted, the pain increases with contraction as the structure continues to contract over the bursa. It’s necessary to be clear that the pain is where the bursa is located, not in the joint or referral. It’s also relevant to use a pain scale to chart the pain increasing with contraction.

Once you have assessed that you do have a case of bursitis, rather than joint pain or tendinitis, treatment through massage is extremely helpful. For the purposes of this treatment we will look at bursitis of the knee in sub-acute and then add on a few chronic suggestions.

Like all other orthopedic treatments, bursitis of the knee begins with your assessment of the primary injury and also the compensatory ones. In this case the low back is irritated by the antalgic gait (a form of stride shortening due to pain). We are going to work general to specific, starting on the opposite side of the injury. That means I am starting on the back in prone position or the low back first (depending on your time constraints) and on the low back side that is not in pain. In order to perform this safely without aggravating the bursa further while the client lies face down, you would pillow the affected knee so that it does not make hard contact with the table. I usually use a pillow under the hips with multiple leg bolsters. After treating the low back with massage, trigger point and whatever else was in your general treatment plan, you would move next to the posterior aspect of the unaffected leg, which has likely been overworked to compensate for the leg with the bursitis. Next you would move to the posterior aspect of the, affected leg, paying special attention to the structures that cross the knee. Hamstrings, gastrox, and ITB are all suspect to have pain and dysfunction because they, like the patellar tendon, cross the knee and are either getting too much movement, or too little, while the body protects that bursa.

At this point you would have your client move carefully to the supine position, once again pillowing them for comfort. Next you would want to treat the front of the unaffected leg in the same way you normally would. For the affected leg, you will want to work toward the bursa using general massage techniques. Be careful not to apply too much pressure to structures that could compress the bursa, such as quads (and ITB by torquing the knee). Gentle stroking techniques and techniques such as cupping can be used up and around the knee to encourage fluid movement. The tissue will warm quickly and the increased circulation should aid in lymph movement provided you are gentle.

bursa-iceI would then recommend moving on to other techniques while applying ice. Rather than put the ice directly across the tendon, which will cause muscle contraction, I will have prepared an ice ring made from a towel that will sit over the knee cap, making minimal contact with the muscle and maximum contact with the bursa. (Here is where the treatment would diverge if the bursitis was chronic and not inflamed, but sticky with scar tissue).

While the bursa and surrounding tissue ice for a few minutes, I will shift my focus from gentle stroking, to trying to lengthen the structures that cross the knee, without compressing the bursa. I might choose gentle fascia work of those structures, being careful to move towards the patella, or deeper sentimental work. The goal here is to ease compression of the bursa in order to lessen the irritation. Because the client is favoring the leg, it’s likely not moving as much, which in turn will cause a contraction of the tissue. It is then our job to act as an external muscle pump and mimic the body’s normal functions, to ease the tension.

bursaI would finish by removing the ice ring, and once again moving to gentle stroking techniques towards the knee to re-warm the tissue and flush it. Always moving from general to specific to general again.

In my clinic we also tape supportively with fascia movement tape, so we would do a taping that looks something like this to help with drainage.

NOTE:If the client was in chronic and the bursa was adhered, instead of ice I would use gentle fascia work around the patella as well as patellar mobilizations to access the tissue under the patella, stretching and more aggressive lengthening techniques, but the essential treatment would be the same.

The treatment for bursitis is very easy, provided you understand the underlying pathology and have a plan to organize your treatment properly. Clients often get diagnosed by chiropractors and practitioners who are not familiar with soft tissue problems. so do not take anything for granted in your interviews. Good luck!

For more information please see Body Mechanics Orthopedic Massage

Biceps Tendonitis – A Clear View

Bicep TendinitisTechnology is fantastic (when it works) I recently invested in some to allow me to talk to clients in a clearer way. Since I have it at my finger tips, quite literally, I thought that I would take the time to explain Biceps Tendinitis from an Orthopedic point of view. We will go over both the anatomy of the injury and a basic treatment principles.

Biceps tendinitis is an equal opportunity injury. By that I mean that you will find it in mothers lifting heavy babies, factory workers, athletes such as tennis players, massage therapists, and even office workers reaching for heavy books on their desks. Across the board what connects all these things is the repeated over loading of the biceps tendon, irritation of the synovial membrane encasing it, and irritation of the transverse humeral ligament. Clients with biceps tendinitis will report pain at the bicipital groove, point tenerness at the same location, pains or aches into the arm and shoulder, and often have hard rope-y muscles around the area. The speeds test should be used to confirm your assessment.

In treating biceps tendinitis its essential to understand the anatomy fully, because although the suffix “itis” tells you that it is an inflammatory condition, the anatomy of the shoulder lends special complications to the treatment. By fully understanding the anatomy, you can quite effectively treat.

Let’s take a look at what is so special about the shoulder anatomy for the biceps. Here are images that will help you understand what makes this different than your normal “itis” treatment. The first view is a highlighted isolation shot of the biceps tendon and attached muscle. As the muscle turns to tendon you can see it travel up into the bicipital groove, passing below the transverse humeral ligament and into the shoulder where it attaches at the supra-glenoid tubrical. The second image is what is really interesting. That same anatomy shot from above gives you a clear idea that this is not just about swelling from overloading, but also about space and angles. If that tendon becomes so inflamed that it cannot in fact pass easily through the “tunnel” formed by the anatomy, it will friction along it, which in turn creates more inflammation. There are 3 factors at play here which can be directly effected by massage, the width of the tendon passing through (is it irritated?), the health of the ligament (is it swollen from repeated impact and abuse) and the angle at which the tendon passes through the “tunnel” (which can effect both the tendons inflammation and the ligaments) Your intake should help you decide what the aggravating factors are, and there by the main problem, which might be 1 or all of the contributing factors.

bicep-tendinitis-body-mechanics-2You will want to determine if the client is in acute, sub-acute or chronic before the treatment. Treatments in the early stages can be used to help speed healing, and re-educate clients about alignment, but it is the later stages that can be used to correct problems. For this the injury must be in chronic. Someone who has had the injury for a length of time but has reoccurring flairs is considered chronic as well.

During treatment you will want to pillow the shoulders into the correct anatomical position, relive any trigger points, use active release to strip out the muscle and activate the muscle pump to restore circulation. When you begin to work the biceps tendon, I recommend ending the process with a biceps stretch. I usually do this by hanging the arm off the table and using gentle pnf techniques which will lower the pain response to the tender tissue at the anterior of the shoulder. The goal here is a nice long lean biceps tendon, that fits well through the anatomical structures. For this particular type of “itis” treatment sometimes I recommend the use of ice, not because there is inflammation present, but because as a side effect ice causes contraction. Imagine trying to thread a needle with a fuzzy thread? almost impossible, but if we get that thread wet, it is a lot easier. Be careful however to ice only at the point where the transverse ligament is, as ice can contract the entire length of the muscle the long way, causing other complications and frictions against the bone. Over aggressive use of ice or inappropriate use of ice can cause just as many problems as what you are treating.

In many other “itis” treatments you will want to use heat rather than ice in the chronic stages (which sounds counter intuitive), but again knowing the anatomy is essential. If a structure is shortened in chronic, and rubbing across a bone, contracting the structure would be in no way beneficial, and would in fact cause more damage.

After the treatment take the time to explain to your client how to align their shoulder during their aggravating tasks for the least possible irritation. Many relapses can be avoided by simple client education.

The biceps tendinitis is VERY treatable through massage and has a high success rate because for most people, letting the arm rest is less of a problem than say, resting the achilles. Provided you understand what is really going on to create the problem in the first place, this should be a staple go to ‘success’ in your massage practice.

For more information please see NYC sports massage
by Beret Kirkeby

How to know what pain to not ignore. Pushing yourself to the limits.

As athletes we constantly push our bodies to the limits. Runners want to run longer and faster, lifters want more weight, yogis go for advanced positions, and some of us just do it all. We constantly test our mind and endurance by pushing beyond our comfort zones, and we have learned that often that push comes with a little pain. For most of us that means that when we feel uncomfortable-when we are at that edge where it hurts-we are celebrating our success at fighting the good fight. But if pushing it hurts, how do you know if you are really hurt?

Injuries often come in two forms: sudden injuries such as falls, collisions or tears; and insidious over-use injuries like tendinitis, plantar fasciitis, or knee-tracking issues. Whatever the cause is, its important as an athlete to know when you are really hurt. You should always check with your doctor about any issues you are unsure of, or any complications from pre-existing problems.

Here is how to tell the difference between a little pain and something that will take you out of the game.

1. If exercise makes it worse, not better. Wait, though, you think that sounds straight-forward, right? Well, this also applies to injuries that feel fine WHILE you exercise but begin to hurt a few hours later. Many serious over-use injuries DO NOT hurt while you are performing the activity but only after it is too late. The reason is the tissues warm up and lengthen, causing a deceptive pain feedback. As the muscles cool later in the day or overnight, and begin to lay down tracts of scar tissue, the fibers will contract and cause pain. Injuries like these are a catch-22 as exercise often makes them feel better for a short period of time. Check in with yourself, keep a journal about when and where the pain is occurring. If its always the same….watch out!

2. Pain that is point tender and gets worse while you exercise. Let’s be honest, folks, it is one thing to feel the burn, and totally another to have pain that grows and grows and grows. If your pain is progressive, it is a problem. Pull up; it just is not worth it. Ever hear that phrase “on your last nerve?” Well, you quite literally can be, and some things can’t be fixed. Get it checked.

3. Any time you feel numbness, tingling, or strange sensations in your limbs. Nerves are squirrely, when they are damaged it is not cut and dry. They may report LESS feeling or MORE feeling, but either one is a bad sign. If you are having any neurological systems its time to hit the Doc, not the gym.

4. Anything that hurts so bad the next day that an Advil won’t take care of. Many a great athlete has arrived in my studio hopped up on pain meds looking for relief through a massage, only to be booted out. If the pain is so bad you are digging through your cupboards for pain relief then you need to haul it to a Doc.

5. Injuries that come with a lot of heat and swelling. A little heat and swelling often come with extreme workouts like marathons, but most of you won’t be able to see it or feel it. Normal inflammation that comes with working out will resolve itself shortly after the workout. If it does not, or if you can visibly see swelling and feel the heat, it’s best to get it checked, and refer to your RICE protocol.

6. Any injury that comes with an audible noise. We all pop and grind occasionally, however any injury that comes with a noise and then pain, or alternately a noise and then LACK of feeling, is likely very serious. Be cautious, many muscle tears come with no feeling at all. The nerves are damaged and report back nothing, but you will likely hear the noise and it is accompanied by heat, swelling and sometimes a visible gap in the tissue. If muscle tears are to be repaired surgically , it must be done right away. Don’t wait if you suspect you have a problem.

If you are pushing it to the edge constantly, invest in preventive care or a trainer who can help you navigate this territory. It’s a good idea to get a yearly check up, and see someone regularly who has at least some medical training. You should also invest in an athlete’s emergency kit. No one ever said, “I am sure glad we did not have any band aids or ace bandages on hand for that”. And if you are competing, consider being a local hero and taking a first aid/CPR course at your local Y or community center. For many injuries early intervention is key, and your knowledge could save someones life. Now that is team spirit.

My Frustrations with Swedish Massage

One of my frustrations with Swedish massage is all the rubbing. This doesn’t mean that I believe that rubbing is not good for you. It is. Effleurage, J strokes, cupping (not the Asian kind), all bring a nice hyperemia to the skin. That rosy glow is associated with health, because it does indeed indicate that the blood is moving, and that is well….healthy. In the end, a therapist’s goal is essentially to create healthy tissue that functions as it should. So massage, in many ways, mimics the life of a moving body while you, the recipient of all that rubbing, lie there, semi conscious, smiling and sighing with relief.

Sometimes, however, I think rubbing is not enough, and by that I mean that maybe it‘s too much. Rubbing is a one-way dialogue; like a conversation between the hands and the body where the hands just won‘t shut up. Lost in all that self-centered movement is the listening part. Almost every “bad” massage I have had has been from someone who is rubbing, and not listening.

As therapists, we often talk about active-listening as part of our intake or interview skills, but it extends further than that. Even if the therapist is present for you during the hands-on part, the therapist still might not be listening. When I am working with new therapists, this is perhaps the hardest concept to impart to them. I want them to stop rubbing, essentially even stop moving, and let the client’s muscle do the work. This is hard for them to understand because if movement and pressure cause release, then more pressure should cause more release, right? Maybe not.

If the therapist is truly listening, he or she might feel that the muscle only releases on the exhale. Or maybe there is a flutter-like fan movement that indicates that the muscle is about to release, and the therapist just needs to stay there for a moment and coax it into relaxing. Or the muscle might release right away only to tighten up more, telling you that you should not be treating this person at all and you should refer them out for further diagnosis.

In our efforts to “Do” to “Fix” we often miss the obvious, which is the body is a self-cleaning oven; it is made to heal itself if given the right opportunity, and the right set of ears, aka hands.