A Closer Look At Myofascial Release Techniques For Soft Tissue Pathology

Often after various tendon or ligament injuries, it is important to start some form of active or passive range of motion (ROM) through physical therapy to target collagen fiber alignment, strengthening, and prevention of postoperative scarring and adhesions.

One modality I use to aid in this is some form of hands-on or instrument- assisted soft tissue mobilization (IASTM) therapy (such as Graston Technique, Active Release Technique and HawkGrips). Whether the patient has surgery or does not, the same IASTM therapies can be beneficial for inflammation reduction, scar tissue and adhesion reduction, and increasing range of motion.

The theory behind IASTM is not well understood. Suggestions of its effect include:

• Breaking up adhesion or loosening cross-links between connective tissue and fascial layers to increase ROM
• Increasing blood circulation (reducing arterial stiffness) and exchanging fluid/nutrients.
• Reducing muscle soreness (i.e. delayed onset muscle soreness)
• Cellular recruitment of cells (e.g. fibroblasts, macrophages, endothelial cells) for tissue healing through mechanotransduction (mechanical stimulus via pressure to affect biological change and tissue repair)

This all occurs with with little or no detrimental effect on performance.

As patients continue to recover from their aliment, I feel that continued IASTM can be beneficial in controlling the symptoms of their tendinopathy or useful after they graduate from post-op physical therapy. Patients have told me they still get a pain reduction anywhere between three and six months after starting therapy when they implement these techniques on a semi-regular basis. In particular, I have found this helpful for Achilles tendinopathy or after an Achilles rupture repair.

Seeing how patients cannot go to formal PT for the rest of their lives, I have begun implementing or suggesting self-IASTM (otherwise known as self-myofascial release) to patients by way of muscle recovery tools such as foam rollers or trigger point hand-rolling devices. Foam rollers can be beneficial for large muscle groups while patients can use hand-rolling devices on tendons or ligaments where more direct contact at multiple angles to the targeted structure can occur.^1-3 Foam rollers offer the benefit of being able to perform the therapy without the need of a trainer, and achieve a form of stretch without the risks of traditional therapy weakening muscle tissue.

Some helpful hints for targeting the Achilles tendon and gastrocsoleus complex include the following points of emphasis for patients.

• Roll from the heel to the back of the knee.
• Internally and externally rotate the leg in order to target both heads of the gastrocnemius muscle.
• Patients can use foam rollers from proximal to distal (rolling effect) and side to side (stationary roller).
• Smaller diameter rollers allow more contoured targeting of anatomy to structures like the Achilles.
• Patients should roll to comfort. A little pain is good. If the pain is too great, patients should decrease the amount of weight applied to the roller when seated or decrease the pressure applied if hand rolling.
• Having a friend or family member assist patients will help them relax more and enjoy the therapy.
• Although no guidelines exist on use, typically one will perform three to five repetitions for anywhere between 20 and 60 seconds each time. Some suggest spending no more than 20 seconds at a time on a tender spot.

I turned to the literature and articles are scant on this topic for use on post-surgical patients. This was the initial reason I implemented this modality in my practice after Achilles repair. However, with some of the existing literature on the use of this therapy for the hamstrings, quadriceps, gluteals and iliotibial band demonstrating good results (increased range of motion, power/strength and pain/soreness reduction), I feel there is a corollary in adapting foam rollers for ankle tissue therapy.^4-6 One may use foam rollers directly on the Achilles tendon to target a scar and/or the gastroc-soleus complex for increasing ankle range of motion.

The verdict is still out whether my patients will see the benefits from this self-IASTM due to my practice starting self-IASTM only in the last few months. My suggestion to patients is for continued use to improve postoperative stiffness, increase ROM and for post-workout soreness as they begin to return to running and sport activities. I currently have four patients who had Achilles ruptures. They are approximately four to six months post-treatment (two surgical and two conservative). I also have two Achilles tendinosis patients who graduated from six weeks of Graston technique physical therapy and are currently attempting these techniques with help from my local running store (for device selection, instruction and implementation). I hope to report back with successful results.

Questions for discussion: Do you implement any IASTM therapies for patients? Specifically, for what pathology (ligament, tendon, other) do you use IASTM? Does anyone have comments (literature or anecdotally) on self-IASTM through the use of foam rolling or other devices?

Dr. Hood is a fellowship-trained foot and ankle surgeon. Follow him on Twitter at @crhoodjrdpm.

References

1. Button DC, Behm DG. Foam rolling: early study findings suggest benefits. Lower Ext Rev. 2014; 6(4):41-44.
2. Groner C. Acute stretching debate approaches a consensus. Lower Ext Rev. 2012; 4(8):55-61.
3. Groner C. The mechanistic mysteries of foam rolling. Lower Ext Rev. 2015; 7(10): 20-25.
4. Loghmani MT, Whitted M. Soft tissue manipulation: a powerful form of mechanotherapy. Physiother Rehabil. 2016; 1:122.
5. Miners AL, Bougie TL. Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, graston technique, art, eccentric exercise, and cryotherapy. J Can Chiropr Assoc. 2011; 55(4): 269-279. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222702/pdf/jcca-v55-4-269.pdf .
6. Vigotsky AD, Lehman GJ, Contreras B, et al. Acute effects of anterior thigh foam rolling on hip angle, knee angle, and rectus femoris length in the modified thomas test. Peer J. 2015; 3: e1281.