Core3 Massage

I recently finished a book titled “Muscle Pain: Understanding It’s Nature, Diagnosis & Treatment”. It is a dense book, with more of a discussion of the nervous system then muscles.  But, pain is all about the nervous system, and the nerves let us know when things are amiss.

Reading it reminded me that there is much we don’t know about the human body, but also how cool it is. So much going on in there, without us ever knowing . Below are some tidbits I picked up from the book and thought were relevant to my clients. Remember that the information below is based on a body of knowledge is ever growing.

Muscle Soreness: Many of you have experienced post workout/race soreness. This sroeness is probably due to sensitization of muscle nerve endings. Mechanical overload (i.e. a race or a hard workout effort) can cause damage to muscle tissues. Substances are released from the damaged tissue during the repair process. These substances can cause the nerve endings to be sensitive. This sensitization of the muscle nerve endings is most likely what causes your pain – not build up of lactic acid.  And what to do about this muscle soreness? Studies have shown that anti-inflammatory drugs provide little relief. Stretching may temporarily reduce the soreness, or not. One study found that stretching had no effect at all on the overall course of muscle soreness.

Nocturnal Leg Cramps: These cramps occur primarily in the gastrocnemius, the largest and most superficial of the calf muscles. They may result from dehydration or electrolyte imbalance.  Stretching of the gastrocnemius muscle can provide relief.  But it has been found that muscles that are prone to cramping may have what are called trigger points. Trigger points (TPs) occur at the junction of the nerve and the muscle – the motor end plate. Dysfunction here is caused by overload of the muscle, and refers pain to areas other than the TP. When these TP are deactivated and suppressed by regular stretching (and/or massage) the cramps are less likely to recur.

Low Back Pain:  A common pattern with low back pain is weak gluteals and strong (tight) hip flexors.  Gentle stretching (and/or massage) can release the hip flexors, and improve the strength of the gluteals.  (This is due to something called inhibition: a strong/tight muscle – i.e.  hip flexor - can cause the antagonist muscle – the muscle the causes the opposite action to the hip flexor - in this case the gluteals,  to be weak). So,  releasing the hip flexors allow for stronger gluteals and hopefully reduce low back pain. Of course there are many other possible causes of low back pain, but I have found that most of my clients with low back pain have some hip flexor and gluteal issues as well.

More can be said on all of these subjects, and perhaps I will revisit them in future posts. But for now, just food for thought.

These past few weeks I have been reading through a book that was recently published – Running Injuries: Treatment and Prevention by Jeff Galloway and David Hannaford DPM. I found it quite thorough- possibly useful and accessible to the regular runner – once I got over Galloway’s stretching paranoia and his walk/run obsession. 

The sections are grouped by body part (Foot and Toes, The Ankle, The Knee….) and the descriptions of injuries include terminology that runners might use, such as: Outside of the Ankle Mostly – But Can Be on the Inside, Various Pains in the Calf Muscle, or Outside of the Thigh from the Bony Knob on the Outside of the Hip, Going Down…..and so on.

The book was given to me by a client who has been dealing with calf issues for a long time.  Her calf issues (perhaps defined as “Various Pains in the Calf Muscles “) had stopped her from running at all for long periods of time. So, they were frustrating for her.

She is now, thankfully, slowly getting back into running, with her calves feeling good. She saw a podiatrist (discovering that yes she does need to wear her orthotics), as well as came in for regular calf focused massages.  But she also started regularly to do calf raises (as the above book suggests, for those runners with persistent calf issues) to strengthen her calves.

The book, like the New York Times article that I mentioned in my last post http://well.blogs.nytimes.com/2009/12/01/phys-ed-how-to-prevent-stress-fractures/  suggested calf raises as treatment for calf problems. They have you start with working up to 25 regular calf raises, and then progress to doing calf raises with your toes pointed in, and then toes pointed out. The goal is 25 of each (toes in, toes out) to give you a total of 50 calf raises.

Not only do calf raises (and overall calf strength) help to prevent tibial stress fractures (as suggested in the NY Times article), but they also help with overall lower leg health.

And as you may remember, the article also suggested decreasing your stride length as well to help prevent tibial stress fractures.  Likewise, the authors of Running Injuries also suggest: “The most efficient and gentle running form is a “shuffle”: the feet stay close to the ground, touching lightly and with a relatively short stride. When running at the most relaxed range of the shuffling motion, the ankle mechanism does a great deal of the work, and little effort is required  from the calf muscle. But when the foot pushes harder and bounces more, and the stride increase, there are often more aches, pains and injuries.”

So, another plug for shorter stride length. And, as some of you may be out running in the snow and ice, shorter quicker strides help you negotiate the messy stuff – and minimizes your foot slipping.

In my many years of running, I have had 2 stress fractures. One in my tibia and one in my upper femur. Stress fractures are not uncommon in runners, and can be a real drag. Once diagnosed, one has to take 6-8 weeks off  from running to let it heal. Runners don’t like not running. It makes us grumpy and miserable.  (It is at this time that we usually discover the pool or the bike to get our exercise fix, and a few triathletes are born)

As dreaded as stress fractures are, at least once the 6-8 weeks is over, the injury is healed. Then you can gradually start running again, and happiness returns to the runner.

Tibial stress fractures were recently addressed in a NY Times article http://well.blogs.nytimes.com/2009/12/01/phys-ed-how-to-prevent-stress-fractures/  , which is what got me thinking about stress fractures again.  Although it has been over 10 years since my tibial stress fracture, I still fear them.  So any tips on decreasing my, or my client’s, possibility of a stress fracture, grabs my attention.

First of all, the tibia is one of the 2 lower leg bones (http://adam.about.com/encyclopedia/Leg-skeletal-anatomy.htm).  In the article, tibial stress fracture prevention was focused on 2 possibilities: 1) strengthening the calves ( primarily found to help women)  and 2) decreasing your stride length.

Strengthening the calves can be as easy as just adding some calf raises to your strength or stretching routine (I know you all have one). As the article states “…rising up on to your toes and sinking back to the floor 10 or 12 times every day, might be enough.”  So , if you are a female runner, this might be something that you want to add into your daily routine.

The other suggestion is to reduce your stride length.  Back when I was the Assistant XC and Track coach at Bowdoin, this was something that all the runners were taught.  Head Coach Peter Slovenski had all his runner count their strides on a regular basis (I will call 1 stride every time your right or left foot - pick a foot - strikes the ground).  The goal was 90 strikes or more per minute. ( You can also try for 30 or more strides per 20 sec – if you can’t focus for that full minute).

As Peter told me, he based this on work  Jack Daniels, a respected running coach, had done.  He noticed that in the Olympics the runners all had a stride rate of 90-110.  So, these are the fast guy/gals – and they all had a short fast stride.

As the article states “The researchers determined that reducing stride length by about 10 percent seemed to reduce the stress on the tibia enough to lower the risk of a stress fracture. “  So, I am guessing that by counting your foot strikes and trying to increase them, one is on their way to decreasing their stride length by 10%.

Certainly more can be said about stress fractures, but in general they are an injury to respect.  They are usually first identified as a very specific area of pain found when pushing down on the bone.  You will feel it when you run, and can be so painful that it alters your stride, or even so that you just can’t put any weight on the bone. Have it checked out ASAP.  And a reminder – the tibia is only one bone where you can get a stress fracture.  The femur, the bones of the foot, and the spine are other examples of areas where stress fractures can occur – and not only with runners.

With all this said, I hope none of you ever have to suffer from a stress fracture ever – or ever again.

Several weeks ago I went to a massage class that focused on the lower leg and foot called “Neuromuscular Therapy and The Dynamic Foot”. Seemed appropriate, since I recently have been working with several clients on calf  issues, and often am working on someone with foot/lower leg problems.

In general I think that I know a lot about the legs, but there is always more to learn (I learned that the Plantaris muscle  – in the calf – has the longest tendon in the body. See  http://www.criticalbench.com/calve-muscles.htm - the muscle is red and the tendon is white) , or to be reminded of.  This class reminded me of the deep calf muscles that are so hard to palpate. The Soleus is one of these, as is the Tibialis Posterior.

One can palpate the Soleus a bit at the lateral and medial sides (around the larger and more superficial Gastrocnemius).   (You can check this pic to see some of the muscles I am refering too – and in this instance, how the Soleus sort of peaks out at the edges of the Gastrocnemius and the Achilles Tendon  http://www.best-leg-exercises.com/calfmuscle.html )   Also, when one massages deep into the Gastrocnemius, one is indirectly working on the Soleus below it. Sort of like a 2 for 1 massage.

The Tibialis Posterior is even more difficult to access. It can really only be worked on by working on the muscles that lay on top it – the Gastrocnemius and the Soleus.

 The calf, as with other areas of the body, has many layers of muscles. Some muscles are superficial, some deep, and some even deeper.  When I am massaging I am usually working on several different muscles, and not just one.

During a massage I think about all the individual muscles I am working on. I actuallysort of imagine what they look like in my head (I really needed to take a cadaver class – where one dissects a cadaver – so I can get a better idea of what all the muscles really look like). I think about the superficial muscles immediately beneath my hands, as well as the muscles that are even deeper below. Toss in the tendons (which attach muscle to bone) that I palate and the overlying fascia that surround all muscles, and there is a lot to think about.

So when I am massaging you, it is never just one muscle that I am working on. And it is usually not just one muscle that is the problem when you have pain. There is lots going on, and hence lots for me to think about when I am giving you your massage.