Deep tissue is also a good technique for this injury because therapists can approach the QL from several angles: With athletes in the prone position, massage therapists can approach the QL from the side, pushing their forearm into the soft tissue between the iliac crest and the last rib, even using the elbow to give the iliac crest cross fiber friction. Or massage therapists can lean over the client and lay their forearm or elbow into the thoracolumbar fascia near the spine and work their way between the iliac crest and the last rib towards the outside of the body. (Therapists should be mindful of their body mechanics here to ensure they don’t slip and fall on the athlete’s injured back!) Therapists can also have the athlete lay in a side-lying position with the affected side up and a pillow between the uninjured side and the table; this position gives massage therapists full access to the QL and makes deep tissue and trigger point work much easier. Trigger points in the QL are common and are usually found just below the QL’s insertion at the last rib. (Massage therapists should be careful to stay on the QL and not stray into the area of the kidneys, which are only partially protected by the lower ribs.) Trigger points in the QL will refer pain to the gluteal muscles, the greater trochanter of the femur, and the region just above the anterior iliac crest. If trigger point work is too painful for an athlete, hot stones are highly effective for relieving pain and reducing tension. Massage therapists should be sure to work the stones into the QL and not simply left on the spine, as this will only help the erector spinae muscles. Stretches are highly effective for mild to moderate back strains, too. Massage therapists should use AC and CRAC stretches by resisting the athlete’s movements with their hands on the iliac crest when they hike their hip (hiking the unaffected side for AC stretches, alternating hiking each side for CRAC stretches). Massage therapists can treat the erector spinae muscles with all the same techniques, although they may have to cover more territory, since the erectors as a group run the length of the spine from the thoracolumbar fascia to the vertebrae of T1 and T2. While therapists may be able to massage a particular strained erector muscle, it is not unusual for a strained erector in the lower back to cause tension in the middle to upper erectors as the muscles working as a group attempt to stabilize the trunk. If there are time constraints during a massage (the athlete wants a full body massage with attention to the lower back, for example), using hot stones over the length of the strained erectors is the fastest way to treat them. Massage therapists can provide a stretch for the erectors in much the same manner as they would the QL, but they can also include an easy passive stretch for the Plantar fasciitis This injury is a common form of tendonitis that affects the foot’s plantar fascia, which spans the distance from the heel to the toes. It is characterized by pain in the arch of the foot or at the heel, particularly in the morning before the fascia of the foot has had a chance to warm up and bear body weight. Although the name of this condition implies inflammation is present (as the ‘itis’ suffix denotes ‘inflammation’), recent studies indicate that more than 50 percent of plantar fasciitis cases are actually instances of a degree of degeneration of the plantar fascia. The degeneration may cause scar tissue to form, causing the plantar fascia to lose mobility. Because of the thickness of the plantar fascia, deep tissue massage is most helpful for treating this injury. However, before performing deep tissue on the plantar fascia itself, massage therapists may want to work the Achilles tendon first, employing petrissage while the athlete is lying in the prone position. (The feet don’t need to hang off the end of the table as is suggested when treating Achilles tendonitis. A bolster inserted at the ankles helps when massage therapists attempt deep tissue on the plantar fascia after massing the Achilles tendon. ) Therapists should petrissage the posterior leg from the tendon at the heel, using fingertips to gently grasp and squeeze the tendon upward, then petrissage two or three inches up the leg towards the knee. Once therapists warm up the Achilles tendon with the athlete in the prone position, they can prepare the plantar fascia for deep work by using their thumbs to strip the soles of the feet from the heel to the base of each toe, making several passes first through the arch
muscle group by using traction on the feet and head (slowly pulling the feet or head away from the body, lengthening the spine). And, although not listed among the techniques in Section I, a gentle compression and vibration with the palm of the hand on the athlete’s sacrum may help release tension of the QL and lower back erectors. One important aspect of lower back pain and strains that is often overlooked is the potential for the psoas major to be involved. Due to the proximity in which the psoas major lies in relation to the QL, trigger points in the psoas muscle can mislead athletes into thinking they have hurt their lower back, when in fact, they have injured their main trunk flexor. To assess the psoas without feeling them, its trigger points will refer pain to the region of the QL itself. Massage therapists should also ask athletes if they experience lower back pain when they flex their trunk as opposed to extending their trunk. If they feel more pain when flexing their trunk, the psoas is involved. Accessing the psoas to work trigger points requires therapists’ fingertips to gently penetrate the rectus abdominal muscle approximately one inch below the navel and one inch lateral to the body’s midline. Accessing the psoas is easier if therapists bring an athlete’s leg into a 45-degree angle and push it slightly towards the midline, which will bring slack to the rectus abdominal muscle. Once therapists feel the psoas just medial to the spine between T12 and L5, they can move their fingers up or down the muscle to search for trigger points. Massage therapists should be sure to check in with an athlete, as psoas work is uncomfortable for many clients. Additional treatment and prevention When athletes have chronic pain, they should try to move into and stay in a position of least pain. Appropriate positions may be lying on their back with their legs elevated, lying on their stomach (sometimes with a pillow under their stomach), or on their side. At the very least, they should avoid sitting in the same position for long periods of time. After athletes recover, they should incorporate core strengthening exercises such as planks and side planks. Using an inversion table to apply traction is an easy way to stretch the lower back muscles. Lower back injuries and strains may afflict any athlete in any sport, although strains tend to occur more in athletes that constantly hyper-extend their back, as baseball players, golfers, gymnasts, and power lifters do. Runners may be prone to lower back injuries as well due to either the compression of the spine from constantly running on hard surfaces or tight hip flexors (such as the psoas, mentioned above). to the first phalange (big toe) and ending with the fifth phalange (little toe). After this, therapists can carefully place an elbow on the heel and slowly repeat each stripping pass, checking in with the athlete about comfort level; this may cause pain. After performing the deep tissue strokes, massage therapists can apply firm thumb pressure perpendicular to the plantar fascia, running thumbs from the arch to the lateral portion of the foot and back again. Therapists can end treatment for plantar fasciitis with a passive stretch. Massage therapists should avoid using a CRAC stretch, because it involves using the injured muscle to assist the stretch, which may aggravate this injury. Additional treatment and prevention Athletes with plantar fasciitis should first take some time off from their sport to allow the plantar fascia to rest. After they return to their sport, athletes should consider professionally molded arch supports to prevent the injury from reoccurring. Another preventative measure is to keep the plantar fascia stretched by rolling a tennis ball or racquet ball under the foot, from the heel to the toes and back again. Athletes should perform this exercise for at least one minute, preferably in the morning or before physical activity. Performing a similar activity with a frozen water bottle after stretching the soleus and gastrocs can help manage pain. Plantar fasciitis afflicts runners more than any other athlete, but may occur in any athlete who runs regularly or performs dynamic foot movements, such as tennis players.
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Book Code: MTX1323
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