Soft Tissue Release

Third Edition

Mary Sanderson

Exam Edition

Lotus
Lotus Publishing
Chichester, England
Publishing

Lotus
Publishing
Soft Tissue intro.indd 1 6/8/12 11:43:33
 Copyright © 2012 by Mary Sanderson. All rights reserved. No portion of this book, except for brief review, may
be reproduced, stored in a retrieval system, or transmitted in any form or by any means – electronic, mechanical,
photocopying, recording, or otherwise – without the written permission of the publisher. For information, contact
Lotus Publishing or North Atlantic Books. First published in 1998 by Otter Publications (ISBN 1 899053 12 3) and
reprinted by Corpus Publishing Limited in 2000 (ISBN 1 903333 00 8).

This edition published in 2012 by

Lotus Publishing
Apple Tree Cottage, Inlands Road, Nutbourne, Chichester, PO18 8RJ

Anatomical Drawings Amanda Williams

Photographs Darren Buss
Model Jeannie Sanderson
Text and Cover Design Wendy Craig
Printed and Bound in the UK by Scotprint

MEDICAL DISCLAIMER: This publication is intended as an informational guide. The techniques described are
a supplement to, and not a substitute for, professional medical advice or treatment.They should not be used to treat
a serious ailment without prior consultation with a qualified healthcare practitioner. Whilst the information herein
is supplied in good faith, no responsibility is taken by either the publisher or the author for any damage, injury or
loss, however caused, which may arise from the use of the information provided.

British Library Cataloguing-in-Publication Data

A CIP record for this book is available from the British Library
ISBN 978 1 905367 37 5

Soft Tissue intro.indd 2 6/8/12 11:43:33

 Contents
List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Part 1 Introduction to Soft Tissue Release (STR) . . . . . . . . . . . 7
Soft Tissue Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Massage and STR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Assessing the Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Part 2 STR – The Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Administering STR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Aids for Applying STR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Part 3 Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
The Pelvic Girdle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
The Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
The Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
The Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
The Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Part 4 Trunk and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
The Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
The Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Part 5 Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
The Shoulder Girdle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
The Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
The Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
The Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
The Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Part 6 Pre- and Post-event Treatment . . . . . . . . . . . . . . . . . . . . 145
Part 7 STR and the Young Athlete . . . . . . . . . . . . . . . . . . . . . . 151
Part 8 STR and Pregnancy/Post-pregnancy . . . . . . . . . . . . . . 153
Part 9 STR and the Older Person . . . . . . . . . . . . . . . . . . . . . . . 154
Part 10 Self-treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Appendix 1 Anatomical Movements . . . . . . . . . . . . . . . . . . . . . 161
Appendix 2 Common Postural Deficiencies . . . . . . . . . . . . . . . 162
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

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 Abbreviations
CEO . . . . . . . . . . . . . . . .common extensor origin
CFO . . . . . . . . . . . . . . . .common flexor origin
CTM . . . . . . . . . . . . . . .connective tissue massage
GAG . . . . . . . . . . . . . . .glycosaminoglycan
ITB . . . . . . . . . . . . . . . . .iliotibial band
LSSM . . . . . . . . . . . . . . .London School of Sports Massage
MET . . . . . . . . . . . . . . .muscle energy technique
MTPJ . . . . . . . . . . . . . . .metatarsophalangeal joint
NMT . . . . . . . . . . . . . . .neuromuscular technique
PIR . . . . . . . . . . . . . . . . .post-isometric relaxation
PSIS . . . . . . . . . . . . . . . .posterior superior iliac spine
RI . . . . . . . . . . . . . . . . . .reciprocal inhibition
RICE . . . . . . . . . . . . . . .rest, ice, compression, elevation
ROM . . . . . . . . . . . . . . .range of movement
RSI . . . . . . . . . . . . . . . . .repetitive strain injury
SCM . . . . . . . . . . . . . . .sternocleidomastoid
SPD . . . . . . . . . . . . . . . .symphysis pubis dysfunction
STR . . . . . . . . . . . . . . . .soft tissue release
TFL . . . . . . . . . . . . . . . .tensor fasciae latae
TMJ . . . . . . . . . . . . . . . .temporomandibular joint
TTH . . . . . . . . . . . . . . . .tension-type headache

Soft Tissue intro.indd 4 6/8/12 11:43:33

 Introduction
Soft tissue release (STR) is a dynamic, participative and versatile
massage technique that contributed to the healing of my own
injury twenty years ago.

Sport has always been a passion of my life and, after taking a

degree in Sports Studies and qualifying to be a massage therapist
with the London School of Sports Massage (LSSM), it became my
career as well as my hobby. Using the massage techniques I had
been trained in, and the expertise I had acquired, I began to have
considerable success not only in preventative work but also in
treating sporting injuries. My professional career flourished. My
fulfilment from sport, however, plummeted when I sustained a
hip injury at the end of 1992. I was blighted with injury myself
and could not run.

I tried various specialists who used differing techniques. I

had a thorough biomechanical assessment that revealed no
significant deficiency so I was not prescribed orthotics. A
chiropractor worked on the sacroiliac joint, which was stiff. One
very impressive physiotherapist gave me an accurate diagnosis:
‘gluteus medius compartment syndrome’. All these were accurate
and valuable assessments but I still could not run. Any massage
I had using deep stroking seemed to irritate the condition, as did
the gluteus medius strengthening exercises. Finally I came across
an American massage therapist who was presenting a course on
advanced massage therapy; he laid me on my side, put a very
strong elbow into my tensor fasciae latae (TFL) and told me to
move my hip. After three years of not being able to run properly
it was almost an immediate transformation. I required further
treatment and specific re-educational exercises to maintain the
change and minimise the recurrence of the problem, but from
that day on I lost the majority of my pain.

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 6 Soft Tissue Release: A Practical Handbook for Physical Therapists

My professional and sporting life turned a new corner together. Soft

tissue release – the combination of movement and manipulation
– put my sporting life back on the road to recovery and sent my
professional life along a new path. Detailed, accurate and technical
work to the soft tissues is often the missing link within physical
therapies. Skilled massage is not the answer to everything but it
is a vital therapy to accompany the others. Many injuries are due
to minor soft tissue dysfunction and muscle imbalance and can
be rehabilitated with the right massage.

It is almost a natural development for the experienced massage

therapist to start involving movement as he or she finds ‘stubborn’
areas, so there are probably numerous ways of working in a similar
fashion. In this book, I outline the techniques that I have found
to be successful in my experience over the past twenty-one years.
STR is not intended to exclude traditional massage techniques.
Experience in massage therapy is the foundation of good practice
in STR; involving movement and the active co-operation of the
subject is a positive step forward for the skilled therapist.

My initial introduction to STR was through the LSSM. My

knowledge has grown and evolved in this area of expertise
through my own experience and liaison with other therapists.
This book is not intended for diagnosing injuries, but purely offers
an insight into an efficient method for assessing and treating the
soft tissues.

Mary Sanderson
May 2012

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 Part 1
Introduction to Soft
Tissue Release (STR)
SOFT TISSUE DYSFUNCTION
The Soft Tissues
As well as bones and joints, the musculoskeletal system consists
of soft tissues: these comprise skeletal muscles and connective
tissues such as fascia, tendons and ligaments. Ligaments are a type
of fibrous connective tissue and connect one bone to another, to
form and stabilise a joint. Muscles contract and relax to maintain
posture and to provide movement. They are attached to the
periosteum (the layer of tissue surrounding the bone) by tendons
or aponeuroses, which are thickened extensions of the muscle’s
fascia. Fascia is all-encompassing and packages, supports and
envelops all the body’s muscles and organs. It separates different
muscles yet allows them to glide smoothly beside each other. The
fascial planes provide pathways for nerves, blood vessels and
lymphatic vessels. Fascia therefore plays a key role in maintaining
the health of muscle. If the fascia has been torn or overstressed,
its subsequent loss of elasticity will cause and maintain chronic
tissue congestion.

Overuse Injury
Micro-strains to muscles always occur. If an individual performs
a variety of different movements in everyday life, maintains
controlled dynamic and static posture (control and stability during
movement and static holding positions), rests sufficiently and
has good nutrition, these strains heal and cause no problems.

This is usually not the case, as many people are involved with
repetitive activities. Whether through lifestyle, occupation or
sporting pursuits, repetitive positions and movements continually
stress affected areas, causing micro-tears in them. Secondary
tension arises around these tears to protect them from further use.

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 8 Soft Tissue Release: A Practical Handbook for Physical Therapists

Repair takes place with the formation of collagenous tissue. This

micro-damage, secondary tension and repair can go unnoticed
by the individual. However, as the activity persists over weeks,
months or years, the same tissues are constantly traumatised, so
the tension and fibrous tissue are maintained. The body adapts
to the hypertonicity and its posture becomes altered. As fascia
supports the movements of the muscle, it too can shorten and
become thickened.

Weaknesses, imbalance and reduced function become evident,

but warning signs of potential malfunction are often not heeded
and possibly not even detected until the continual overload
causes a breakdown. This breakdown can take several forms, for
example severe soft tissue trauma such as a hamstring strain, a
variety of tendon injuries, or an annular disc tear.

This is how an overuse injury is sustained but the causes are

famously multifactorial and it is not always easy to determine
which happened first. The numerous precipitating factors that
contribute to an overuse injury include:

• Faulty positions in day-to-day life, such as poor posture in

front of a computer screen; in this instance, the shoulder girdle
and head can become protracted, impairing movement and
function of the region.

• Participating in sports with faulty or incorrect equipment,

such as riding a bike that is incorrectly set up (for example,
the saddle too low), or running long distances on a cambered
road.

• Performing an activity with a bad technique, such as swinging

a golf club incorrectly, which will put unnecessary stress on
certain structures.

• Introducing sudden adaptations to training or a technique, for

example a sudden increase in running mileage.

• Neglecting to warm up adequately, which will impair tissue

resilience to injury.

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 Introduction to Soft Tissue Release (STR) 9

• Insufficient recovery (e.g. lack of rest or poor nutrition) after

an activity, which will impair the body’s ability to heal.

• Sudden movement occurring beyond what the tissues are

capable of in terms of flexibility.

• Muscle balance – relative strength between muscles working

together; if muscles are out of balance, uneven pulling will
occur across a joint, affecting its range of movement (ROM).

• An individual’s specific biomechanics; for example, over-

pronation or supination in the foot may not be correctable
with re-educational exercises alone and could need orthotic
prescription.

• Congenital conditions, such as scoliosis, and previous injury,

which place uneven tension on the body.

• Age – the connective tissues become stiffer with aging, so

injury is more likely and healing is slower.

The following is an example of how an overuse injury can

develop: a distance runner, because of an increase in mileage
on hilly terrain, acquired micro-tears in the quadriceps muscles.
One leg was slightly favoured during running and took longer
to recover; chronic tension developed in the quadriceps, together
with adherence to the iliotibial band (ITB). The gluteus medius on
that side became inhibited as the tensor fasciae latae (TFL) over-
worked and became hypertonic. All this had gone undetected
by the athlete, who continued to train. Before long, however, a
sharp pain developed towards the lateral knee, making running
impossible. The ITB was grating on the lateral condyle of the
femur. The runner perceived the injury to be a recent one in the
knee, but it in fact originated much earlier, in the quadriceps and
gluteal muscles.

A good way to start unravelling this overuse pattern is to check the

position of the pelvis and back, and the balance of the hip, pelvic
and back musculature. From a treatment point of view, it would
be imperative to address the TFL, the ITB and any adherence

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 10 Soft Tissue Release: A Practical Handbook for Physical Therapists

they may have to the vastus lateralis; from a strengthening

point of view, the gluteus medius is likely to need attention to
restore balance and prevent the TFL from over-tightening. After
treatment, some advice can be offered: ensure that the athlete is
stretching adequately after training, investigate what positions
are being adopted at work that will affect the musculature, and
check that there is enough variety and balance in training to
negate the repetitiveness of distance running.

Connective Tissue and Fascia

An understanding of the structure of connective tissue will help
explain why soft tissue techniques, such as STR, have such a
powerful and positive effect in healing and maintaining the
health of the musculoskeletal system. Ligaments, tendons, fascia,
retinacula and periosteums are all forms of connective tissue,
made up of mainly the same structures but in varying proportions
depending on their roles.

Fascia is an all-encompassing array of different layers of

fibrous connective tissue, packaging and surrounding all of
the body’s structures. It consists of two levels: the superficial
or subcutaneous layer, which wraps the whole body from head
to toe, and the deep fascia, which envelops the organs, viscera
and muscles. Myofascia refers to fascia associated with skeletal
muscle. Tendons are the more fibrous extensions of myofascia:
they attach the muscle across a joint to the periosteum.

All connective tissue is composed of a strong, pliable extra-cellular

matrix of collagen, elastin and reticular fibres, surrounded by a
ground substance of water and glycosaminoglycans (GAGs).
The long white fibres of collagen are the chief component of
connective tissue, and their tough strands give the tissue its
shape, strength, resiliency and structural integrity (Juhan,
1998). The matrix is embedded with cells, such as fibroblasts
and chondrocytes that rebuild the tissue when damaged
(Lederman, 2005). The functions of particular connective tissue
are determined by the structure of its extra-cellular matrix and
ground substance. In fibrous connective tissue, such as tendons,
ligaments and fascia, the ground substance contains little fluid
and many fibres of collagen and elastin, forming a tough, stringy

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 Introduction to Soft Tissue Release (STR) 11

material (Juhan, 1987). Tendons have collagen fibres arranged in

parallel formation for strength and rigidity, whereas in ligaments
they are arranged more loosely and in different directions to cope
with multidirectional forces (Lederman, 2005).

The ground substance lubricates the fibres and allows them to

glide over one another (Williams, 1995), providing a medium
for exchange of elements such as oxygen, nutrients and cellular
waste (Juhan, 1987). The ground substance will therefore affect
the health of the cells.

The texture of the ground substance can change from a gelatinous

gel-like substance that limits movement, to a more flexible
state that facilitates it. This property is known as thixotropy.
Movement, soft tissue manipulation, heat and vibration maintain
a porous, hydrated ground substance which allows for gaseous
and nutritional exchange and the smooth gliding of collagen and
elastin fibres.

Injury, chronic stress and immobility cause the ground substance

to dehydrate and harden, leading to the formation of adhesion
and scar tissue. Fibroblasts migrate to the injury site and secrete
collagen. As the tissue continues to be stressed over a period
of time, the collagen thickens and spreads through the fascial
web. The random laying-down of collagen fibres reduces the
lengthening potential and thus limits the movement of connective
tissue (Juhan, 1987).

As all of the skeletal muscles are supported in myofascial tissue,

local injury or stress can lead to body-wide compensatory shifts.
The widespread rigidity of fascial tissue locks the soft tissues
into positions of strain and dysfunction, and pathophysiological
changes unfold. Fascial disruption can cause minuscule shifting
of bones that may irritate joint surfaces and reflexively produce
further soft tissue dysfunction (Chaitow, 1996). Reduced or
altered movement patterns manifest, and the compression of
nervous tissue and blood and lymphatic vessels is compounded.
The restoration of myofascial tissue is fundamental not only
in releasing muscle tension but also in correcting postural
misalignment, reducing neuro-excitability and improving venous
and lymphatic flow.

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 12 Soft Tissue Release: A Practical Handbook for Physical Therapists

Acute and Sub-acute Injury

Major injury can be the result of a direct trauma from an external
force, or may occur as a consequence of repeated micro-tears
(overuse). The severity of injury is judged by the number of fibres
damaged. Tearing of fibres can occur within a muscle or muscles,
and the fascia surrounding the muscle can be torn in more severe
strains. Following any initial injury, RICE (Rest, Ice, Compression,
Elevation) is the recommended first aid. Rest is vital to prevent
further damage, but controlled movement that does not stress
the injured area in the sub-acute phase will encourage collagen
fibres to align along the lines of structural stress (Lederman,
2005). Ice is analgesic and also decreases metabolic activity, as
well as reducing blood and lymph flow where bleeding and
swelling are occurring. Compression should be administered
carefully so as to reduce the development of swelling without
curtailing circulation. Elevation is beneficial where appropriate,
to help venous and lymphatic flow against gravity and also to
minimise swelling.

Ligament Injury
Ligamentous tearing is referred to as a sprain. In this book,
ligaments and joint capsule membranes are generally not
included in the treatment of the soft tissues, although they are
forms of connective tissue. Ligaments can, however, be treated
with STR and are therefore occasionally mentioned. Controlled
exercise and movement have a positive effect on the recovery
of ligaments, as the latter have a relatively poor blood supply
compared to muscles and tendons, so healing is often slow. By
administering appropriate STR, the collagen turnover is increased,
and by ensuring that the muscles, tendons and fascia around the
injury are in good condition, their repair will be enhanced.

Tendon Injury
Tendinopathies present with degrees of pain, swelling, stiffness
and weakness and are often classified as overuse injuries, so
the causative factors need to be addressed alongside treatment.
Tendons are mechanically strong, as they transfer the force of
the contracting muscle to the bone; because of this, however,
they lack elasticity. Tendons are susceptible to weakness when

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 Introduction to Soft Tissue Release (STR) 13

injured, and appropriate release of restrictions will greatly

enhance strengthening programmes. With any tendon injury, it
is necessary to treat the muscle from which the tendon originates,
as well as neighbouring or other relevant soft tissues in the
pattern of release; tendons have on average only 5% stretch
capability compared to the attached muscle, so this needs to be
considered when performing the stretch aspect of STR. Areas of
congestion commonly prevail at the musculotendinous junction.
Particularly where there is inflammation, treatment on the
actual tendon should be limited, but STR is a useful tool, as the
lock is only momentary and can be administered very close to
inflammation without direct irritation. Ice to the inflamed area is
recommended. Often, injury to a tendon is referred to generally
as a ‘tendinopathy’, but the following are commonly defined
tendon conditions:

Tendinitis: Inflammation and scarring of the tendon itself.

Tenovaginitis: The synovial sheath around the tendon is inflamed

and thickened.

Tenosynovitis: Inflammation between the synovial sheath and

the tendon.

Peritendinitis: Inflammation and thickening of the paratenon. (A

paratenon is the membranous tissue around tendons that have
no synovial sheath, for example the Achilles tendon.)

MASSAGE AND STR

Massage Techniques

As well as having its own specific attributes, STR has all the
physiological benefits of traditional massage. Massage can
increase venous and lymphatic drainage. The increase in
interstitial pressure during and after massage allows for easier
fluid absorption so that fresh blood can enter fatigued or
traumatised areas. Adhesive tissues can be mobilised and
scar tissue broken into smaller particles for phagocytosis and
lymphatic absorption to occur. Massage strokes can stretch
muscle fibres longitudinally and improve collagen flexibility.

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 14 Soft Tissue Release: A Practical Handbook for Physical Therapists

There are advanced soft tissue techniques which bring into play
the nervous system to override reflex holding patterns. Performed
correctly, neuromuscular techniques (NMTs) will eradicate
tension areas and scar tissue. STR can sometimes involve this
neuromuscular element, as the STR treatment can on occasion be
painful.

Methods that specifically target the connective tissues are

also highly effective. STR can incorporate the effectiveness of
connective tissue massage (CTM) by addressing the connective
tissues with a ‘CTM’ lock (see page 33).

STR and Research

All tissue has conductive ability. When myofascial disruption

occurs, a reduction in the electric potential is generated. Research
suggests that dense collagen reduces or impedes electrical flow
through the tissue, thus reducing the activity of the local fascial
cells. The thixotropic quality of myofascia means that when it
shortens or thickens, it dries out, and the ground substance turns
from a watery solution which facilitates movement to a less
flexible gel which limits movement.

Application of pressure brings about a change to a solution and

rehydration, where the connective tissue becomes more solute
and less sticky and dense. Removal of the pressure causes a re-
gelling, but the tissues will have improved in both conductive
ability and water content (Oschman, 1997). This boosts electrical
activity and improves the neuromuscular relationship.

Movement is essential to the repair and maintenance of healthy

tissue. It provides direction for deposition of collagen and
encourages vascular regeneration. Movement also lubricates
and hydrates connective tissue by improving the balance in the
ground substance between the GAGs and the water. This will
reduce the potential for adhesion formation (Lederman, 2005).

Research with tissue cultures highlights the importance of both

stress and motion to healing. Lederman (2005) also states that
‘active techniques will stimulate muscle fibre regeneration, a
normal ratio of muscle to connective tissue elements and the
development of neuromuscular connections’. Treatment using a

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 Introduction to Soft Tissue Release (STR) 15

combination of pressure and movement, therefore, should have a

significant positive effect on the quality of the myofascial tissue.
Passive tissues, when worked on, present as relatively soft, and
pressure is diffused by their softness; deep connective tissue
restrictions may not get enough mechanical energy to cause
thixotropic change (Juhan, 1987). If pressure and movement
are applied together with muscular contraction, tissue density
is significantly increased. This in turn increases the pressure
delivery through the myofascial tissue and will enhance the
effectiveness of treatment (Lowe, 1999).

Combining concentric muscle contraction with a specific

broadening pressure into the myofascial tissue facilitates a
greater mobilisation of the connective tissues (Lowe, 1999).
Longitudinal stress may also positively influence the pattern of
myofascial tissue (Cantu and Grodin, 1992), and the application
of longitudinal strokes while the tissue undergoes eccentric
contraction effectively stretches and lengthens the connective
tissues.

It would seem that treatment could be more rapid, and the

pressures applied by the therapist reduced, when pressure and
external movement of the tissues are combined.

Soft tissue release has a fast response in alleviating tissue

restrictions and enhancing tissue health, which suggests a
neurological involvement. An immediate reduction in tissue
tone cannot be explained by mechanical properties alone, but
also involves the autonomic nervous system (Schleip, 2012).

The only currently available research specifically into the

technique of soft tissue release (STR) is a preliminary single case
study on a hemiplegic stroke patient. Barnard (2000) found that
the application of STR to the muscles controlling elbow flexion
and supination increased elbow ROM and reduced elbow flexor
spasticity; ten minutes of passive STR was performed on five
consecutive days, and a 41% improvement in elbow ROM was
observed eight weeks after intervention.

There is a lack of empirical evidence to prove that STR is effective,

so there is huge scope for research into the technique. Palpation
skills are difficult to measure, and therefore, as is often the case,

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 16 Soft Tissue Release: A Practical Handbook for Physical Therapists

research is lagging behind clinical experience and anecdotal

evidence.

Prevention of Injury
Regular stretching and massage help to maintain the ultimate
health of the soft tissues, thereby reducing the possibility of
injury. If areas of malfunction of soft tissue are detected, they
can be dispersed before a more serious injury occurs. Strong
individual muscles will resist stress better than muscles that are
shortened and adhered. In competitive sport, for example, where
intense training is necessary for success, muscles are continually
being shortened, micro-torn and fatigued. Massage will elongate
and nourish the shortened tissues and separate adhesions,
facilitating repair and adaptation to the training. Treatment will
vary according to the intensity and the amount of training, but
in most cases potential problem areas can be detected prior to
dysfunction or reduced performance.

Ice and Intense Training

Micro-tearing is an essential part of training: tissue is torn and

as it is repaired it becomes stronger to cope with the demands of
training. Many elite sports people use ice after intense training
to help move through the stages of repair, so that healing and
recovery are faster and more complete than they would otherwise
have been. Ice should be used directly after training. Massage
treatment should be conducted later, and the length and depth
of the treatment will vary according to how it fits in with intense
training and recovery.

Overuse Injury

When dealing with injuries caused by overuse, massage comes

into its own. With STR, large areas can be assessed fairly quickly,
so severe problems of hypertonicity, muscle shortening, adhesion
and scarring can be detected and addressed, prior to focusing on
a specific spot. Correct usage of STR can separate and re-align
adhesions, break down collagen tissue and lengthen chronically
shortened fibres. With STR it is also possible to specifically
target fascial tissue to reduce pressure on a muscle. All this

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 Introduction to Soft Tissue Release (STR) 17

enables muscles to become nourished, pliable and flexible so

that they may contract and relax without resistance. So, whether
breakdown results from sporting activities such as long-distance
running, or from repetitive everyday pursuits which stress the
musculature, such as sustained postures, a course of treatments
facilitates rebalancing and a return to full function. Where chronic
inflammation is present, ice can be used alongside treatment.

Traumatic Injury
Correct treatment is essential, even in relatively minor injuries
or low-grade strains, to ensure that full mobility and strength
are regained. Massage techniques in conjunction with RICE will
help the healing processes. Massage away from the site of injury
during inflammatory stages is beneficial because it maintains
good circulation, thereby encouraging drainage of any swelling.
For example, in an ankle inversion sprain the calf muscles may
be treated. In the sub-acute and repair phases of healing, careful
use of STR can be effective for encouraging collagen to align in an
orderly fashion. In the case of the ankle this may be treatment to
the peronei muscles and their tendons and to the lateral ligament
complex, as well as maintaining balance by treating all tendons
which cross the ankle. STR, being a functional treatment modality,
is an ideal technique given the necessity for rehabilitation to
consist of active rest. As recovery continues, compensatory
problems may develop. In an ankle sprain, plantar muscles of
the foot may tighten due to subtly altered biomechanics, and
tensions can form in the other leg where limping has occurred.
These problems can be minimised with massage, efficient checks
and STR.

Immobilisation

After periods of immobilisation, such as when a plaster of Paris

cast or a brace has been removed from a limb following a fracture,
STR can be used effectively to reduce scarring and oedema, and
return flexibility with elasticity to the soft tissues. This facilitates
improvements in strength, proprioception and co-ordination.
The same is true of post-operative situations, where incisions and
periods of rest severely affect the condition of the soft tissues.
Any incision will cause scarring, and prolonged rest results in

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 18 Soft Tissue Release: A Practical Handbook for Physical Therapists

loss of strength and reduced function. These situations can often

lead to muscle tissue being shortened yet under-active. STR is an
ideal technique to use in rehabilitation.

STR in Conjunction with Other Therapies

Most injuries contain components of soft tissue damage,

which can cause localised pain and dysfunction, so careful
administering of appropriate massage will contribute to healing
even if other forms of therapy are required. For instance, if there
is a mechanical misalignment or restriction, mobilisations or
adjustments may be necessary to return movement to a joint. In
the case of adverse neurological tension, gliding the nerve at the
tissue interface may be required to release the tension. In both of
these situations, practitioners trained in these skills are needed
for accurate diagnosis and management of the injury. Skilled use
of STR, however, will aid in both of these forms of treatment. If the
soft tissues are free to move in a controlled and separate way, they
will facilitate joint manipulation or nerve mobilisation and help
maintain the effects of the other treatment. Many practices and
clinics have a multidisciplinary approach to injury management,
and STR is an invaluable adjunct to the healing and rehabilitation
process.

Soft tissue expertise is growing all the time, and when using STR
it will prove beneficial to be aware of what specialist soft tissue
and movement practitioners have developed and continue to
develop. An understanding of the anatomy trains (Myers, 1997a,
1997b), for example, may contribute to the releasing of holding
patterns in a case of overuse injury. Knowledge of Robert Schleip’s
high leverage points in the myofascial web could also be useful:
for example, addressing the tissue around the greater trochanter
has an impact on the pelvis as a whole.

Important Considerations

Massage, including STR, is a safe therapy, provided that contra-

indications are understood. There are occasions when massage
is detrimental or dangerous, so an understanding of contra-
indications prior to any massage is imperative. Massage can
have amazing results in preventative care and is highly effective
in treating minor soft tissue injuries or overuse conditions;

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 Introduction to Soft Tissue Release (STR) 19

however, it is necessary to liaise with, or to seek a diagnosis from,

a qualified medical practitioner prior to treating complex injuries
solely with massage. Massage therapists need to recognise their
strengths and limitations. Diagnosis from the medical health care
practitioner, prior to massage, allows an integrated approach
that enables therapists to ensure that the STR treatment suits the
subject’s needs.

As with all massage, it is important to avoid over-treating areas

with STR. When working on particularly congested tissues, there
may be some discomfort during release. Treat systematically and
holistically rather than repeatedly going over the same area or
location of dysfunction. This will minimise any tissue damage
due to the massage itself.

ASSESSING THE SOFT TISSUES

Texture

Experience gives the massage therapist the ability to distinguish

between the various kinds of soft tissue according to how they
feel. When relaxed and in good condition, muscles should
feel soft and pliable. Tendons, being fibrous extensions of the
muscles’ fascia, feel firmer and more ‘stringy’. Where there is
specialised thickening of fascia, such as the iliotibial band and
the thoracolumbar fascia, tissue will also feel firmer and less
resilient.

An overall assessment of relevant tissues is necessary to evaluate

their condition. Many deep muscles are not directly palpable. The
release of superficial muscles so that they are supple and relaxed
enables the therapist to work into and affect the deep muscles.
In some instances, only the border of a muscle may be reached.
This is the case with the quadratus lumborum, where pressure is
attained laterally and directed towards the vertebrae. The stretch
is produced so that the fascia and outer muscle fibres are released,
thereby nourishing and freeing the muscle as a whole.

General variations will occur because of age, sex, fitness, type

of sport or activity the body is subject to, lack of activity, level
of activity or competition, occupation and previous injury.

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 20 Soft Tissue Release: A Practical Handbook for Physical Therapists

However, poor texture may be identified and categorised under

the following headings:

1. Hypertonicity and Muscle Tightness

Tightness in a muscle represents both an increase in tone and a
decrease in the resting length of the muscle. When a muscle is
hypertonic, it has too much muscle tone and will feel rigid, but it
may have either decreased or increased resting muscle length.

Hypertonic muscles which are shortened need to be lengthened.

Skilled use of STR to locate tissue restrictions will facilitate this.
In cases of severe shortening it is advisable to shorten the muscle
prior to locking in with STR and stretching.

On palpation, the fibres feel resistant and rigid and lack

pliability.

2. Scar Tissue
Inflammation and repair result in the formation of a collagenous
scar. Scar tissue is new collagen that has been secreted by
fibroblasts to repair torn tissue. Sufficient recovery, mobility and
strengthening allow this scar tissue to be reabsorbed and replaced
with regenerated tissue. Often, because of the severity of the initial
bleed or insufficient awareness and/or rehabilitation, scar tissue
remains; even minimal scarring can impair function. Initially,
scar tissue binds, protects and supports the area but ultimately
it lacks the mobility, extensibility and strength of the tissue it has
replaced. With this in mind, it is worth considering how not to
break down too much scar tissue in one treatment.

On palpation, scar tissue can feel gritty, stringy or woody, or, in

severe cases, hard and solid.

3. Adhesions
Adhesions are fibrous bands, formed in the same way as scar
tissue, which inhibit movement between tissues that should be
moving separately from each other. Following inflammation and
the ensuing healing, there is heightened metabolic activity as the
scar tissue is being formed. During this process, fibrin is deposited
to ‘glue’ the wound, but local changes such as curtailed circulation
and an increase in metabolic waste can cause the early granular
tissue to become sticky; often the fibrous deposit is not reabsorbed.

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 Introduction to Soft Tissue Release (STR) 21

This usually results in longitudinal bands of adherence. In the

text, ‘separation’ of neighbouring muscle groups is frequently
advised and refers to the separating of adherence that may be
occurring between muscles or bellies within a muscle.

Adhesions may feel woody and stringy, and may ‘flick’ if palpated
transversely. It may be difficult to differentiate a muscle border
from a neighbouring muscle border where their epimysiums are
adhering.

4. Oedema and Swelling

Oedema and swelling are caused by an excess of tissue fluid
following injury and the subsequent inflammatory response.
Chronic swelling can occur where tightness and scarring
compress capillaries and lymphatics, curtailing the flow of fluid
in and out of the area. Ensure that oedema is not indicative of a
more serious medical condition.

The area can feel spongy, and pitting of the tissue may occur.

5. General Rigidity of Superficial Fascia and Myofascia

Rigidity can be identified in superficial fascia and myofascia when
these large body areas feel hard and are difficult to lift and move.
Compartment syndrome occurs where the myofascia becomes so
tight and thickened that, even when the muscle is relaxed, there
is an increased intramuscular pressure causing pain.

Inflammation
Inflammation is the tissue’s initial response to injury and will
present with one or more of the following signs and symptoms:
redness, heat, swelling, pain and reduced function. Working
directly on inflammation should generally be avoided because it
will slow down healing by causing more tissue injury. Working
around the inflammation will ensure that it is well nourished and,
by keeping the surrounding tissues free, encourage the healing
and decongestion of the area. With a large trauma this may not be
possible initially, as the movement aspect of STR will impact on
the acute injury; when chronic inflammation presents in overuse
injuries there is benefit in treating it. The seven-second test is a
useful rule to guide you with treatment.

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 22 Soft Tissue Release: A Practical Handbook for Physical Therapists

Seven-second Test
When treating chronic conditions, such as lateral epicondylitis,
in which a degree of chronic inflammation may be present,
it is sometimes difficult to assess how much direct pressure is
appropriate. It is essential to treat the whole pattern of tissue
restriction, for example the wrist extensors that merge into the
common extensor origin, but it may also be necessary to treat
the localised inflamed area. If an area is proving to be sensitive,
maintain a pressure for seven seconds to avoid irritation by
causing more trauma. If the pain eases or stays the same, then
the area can be worked on. If the pain worsens, there is probably
too much inflammation for that amount of pressure, so the area
should not be worked on directly. If there is any doubt as to
whether tissues have been over-manipulated, ice can be applied
to ensure a positive outcome from the STR treatment.

Muscle Balance

STR can play an important role in restoring muscle balance;

generally, releasing hypertonic tissue facilitates the strengthening
of weak muscle. An understanding of how muscles may be
classified according to their susceptibility to hypertonicity or
inhibition and weakness will enhance treatment programmes.

Muscles can be classified into various categories depending on

their roles within the musculoskeletal system. Some muscles are
chiefly involved with stability and posture, while others are more
directly engaged in providing dynamic movement. Classification
is very useful to the practitioner seeking to restore balance, but
it is important to realise that it is not always clear cut. Muscle
grouping is still a developing area and there are a few different
classification models. Research has classified muscles into local
and global stabilisers and global mobilisers (Bergmark, 1989;
Commerford and Mottram, 2001).

Stabilisers tend to be deep, single-joint muscles that help maintain

posture over sustained periods. They contract alongside other
stabilisers to support and maintain position, or control movement.
They are generally rich in slow-twitch fibres, predominantly
aerobic and slow to fatigue.

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 Introduction to Soft Tissue Release (STR) 23

Local stabilisers are unable to provide significant joint

movement. They contract isometrically to increase joint stiffness
for segmental control of motion. Examples of these are the
transversus abdominis, multifidus, psoas, interspinales, vastus
medialis, lower fibres of the trapezius, and deep cervical flexors.

Global stabilisers function to stabilise and provide some joint

movement. They control the range of movement, generally
through eccentric muscle contraction, and maintain posture
through isometric effort. They can also contribute to movement
through concentric contraction. Examples include the serratus
anterior, posterior two-thirds of the gluteus medius, gluteus
maximus, spinalis, longus colli and oblique abdominals.

Mobilisers tend to be more superficial and provide a larger range

of movement for fast, dynamic requirements. They can perform
under aerobic and anaerobic conditions and contain high levels
of fast-twitch muscle fibres. Examples of these are the levator
scapulae, scalenes, latissimus dorsi, iliocostalis, rectus abdominis,
tensor fasciae latae and hamstrings.

Through dysfunction, local stabilisers are likely to become

inhibited and slow to activate. Global stabilisers are prone to
inhibition that may manifest itself as lengthening and weakening
of the muscles. Stabilisers subsequently become unable to provide
a stable base for other muscles to work from.

Mobilisers, on the other hand, tend to take on the failed stability

role in addition to their own, and, over time, become stressed,
overactive and tight. A dominant tight mobiliser pulling in one
direction, with an inhibited stabiliser unable to maintain position
or control movement against it, will cause imbalance.

Comparative illustration of a
muscle in balance compared
to an inhibited and tight
muscle.
a) muscles in balance,
b) muscle shortened/inhibited.
1 2 3 4
1. Joint
2. Muscle in balance
3. Inhibited muscle
4. Tight muscle a) b)

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 24 Soft Tissue Release: A Practical Handbook for Physical Therapists

This will negatively affect joint alignment and movement. If

maintained, postural misalignment and altered movement
patterns can result in overuse injury.

Neutral joint position and posture together with controlled

motion place minimal strain on the musculoskeletal system and
facilitate its smooth and efficient function. To achieve this, the
stabilisers must activate quickly and effectively enough, and the
mobiliser muscles need to be pliable, relaxed and of adequate
length for their specific activity requirements.

Soft tissue techniques, such as STR, can provide fast and effective
release for tight muscles. By relaxing and lengthening tight
muscles, it becomes easier for the subject to engage the inhibited
muscles.

Clinical experience suggests that one such condition is

patellofemoral maltracking, for which athletes are frequently
prescribed strengthening exercises for the vastus medialis oblique.
These are often ineffective. Releasing tightness in the vastus
lateralis, however, quickly resolved their complaints. Another
very common example of muscle imbalance occurs in the lower
and upper fibres of the trapezius. Tight upper fibres and weak
lower fibres can contribute to neck, shoulder and shoulder girdle
dysfunction. Many people who have experienced poor results
from performing exercises aimed at engaging the lower trapezius
fibres have subsequently responded extremely well once STR has
been applied to release the upper fibres.

Equally, manual therapy alone may not be enough to maintain

tissue changes; specific re-educational exercises play an essential
role in maintaining the beneficial effects of manual therapies
during and following a course of treatment. Correctly prescribed
and monitored re-educational exercises will improve motor
control, strengthen and reactivate inhibited muscles, and
stretch short and tight muscles. Initially an exercise or group
of exercises may be very subtle and specific to the presenting
condition and is normally progressed appropriately to enable
full function. Exercises such as yoga, Pilates, Feldenkrais and the
Alexander Technique are excellent modalities for re-balancing the

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 Introduction to Soft Tissue Release (STR) 25

musculoskeletal system, with a strong emphasis on strengthening,

lengthening, core stability and motor control.

In conjunction with such re-educational regimes, STR can help

restore muscle balance, postural misalignment and efficient
movement patterns.

Yoga asana – Pidgeon.

Yoga asana – Pidgeon

variation.

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 26 Soft Tissue Release: A Practical Handbook for Physical Therapists

Yoga asana – Pidgeon

variation.

Plank.

Side plank.

Progressive side plank.

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 Part 2
STR – The Technique
The technique is administered simply by applying and
maintaining a pressure on, or ‘locking into’, the relevant tissues
while simultaneously stretching away aligning fibres.

ADMINISTERING STR
The Technique – ‘Lock and Stretch!’
First the fibres are located. They are then locked into by applying
an appropriate pressure. This pressure is maintained while a
stretch is produced by moving a limb; the limb can be moved
either by the therapist or by the active participation of the subject.
This produces a powerful release where tissues are adhering.
Movement and localised lengthening of the affected fibres has
occurred, in conjunction with separation or movement of the
lesion with the locking-in pressure.

When conducting a general treatment, the area is initially warmed

with massage strokes and the use of oil or lotion. Alternatively,
the muscles can be warmed up with light passive STR using a
broad locking technique. Progression to specific STR will facilitate
the detection of adhesive tissue, and so should be conducted
even in a maintenance massage. If a problem area is located,
working between the muscle borders to stretch the fascia and
within the muscle itself is necessary. It is not essential to cover
every section of the muscle, as releasing one specific area will
cause neighbouring fibres and fascia to soften and stretch. The
lock should be achieved carefully and maintained while a stretch
is initiated. If working close to bone, the lock should generally
be angled away from the bony surface to avoid crushing of the
tissue and bruising. If in doubt over the acuteness of an injury,
conduct the ‘seven-second test’ (see page 22).

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 28 Soft Tissue Release: A Practical Handbook for Physical Therapists

Benefits of STR Over Stretching Alone

If a fibrous or adhered area is present in a muscle that is
predominantly strong and flexible, a conventional stretch could
simply stretch the area as a whole without the congested area
itself being released. A stretch alone is not enough to separate
the gluing of these particular muscle fibres. Muscles can be
flexible without necessarily being in good condition. With STR,
the specific area can be targeted and locked in place while its
neighbouring tissues are specifically elongated, thereby focusing
on the restriction.

Benefits of STR Over Traditional Massage

Strokes Alone

When administering most massage techniques, the tissues remain

passive while the therapist glides through them or works on and
across them. With STR, a specific position within the tissues is
acquired and it is then the tissues themselves which are moved
and elongated. This makes textural assessment procedures easier.
Therapists can pinpoint specific areas more quickly, particularly
where there may be several muscle layers with fibres going in
different directions. With the stretch, the fibres are re-arranged and
elongated for efficient function. Complex soft tissue dysfunction,
where many muscle groups and holding patterns are involved,
can be remedied because of the specificity of the pressure and the
stretch.

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 STR – The Technique 29

FACTORS TO CONSIDER
1. Types of STR
There are basically three types of STR: passive, active and weight-
bearing. All three involve movement, but in active and weight-
bearing STR it is the subject who produces the movement,
whereas in passive STR it is the therapist. Passive work provides
a good release and can be very relaxing.
Passive STR to the soleus. Lock
in and maintain the pressure
as the therapist dorsiflexes
the foot.

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 30 Soft Tissue Release: A Practical Handbook for Physical Therapists

Active STR is more powerful and should be preceded by passive

work or other massage to warm up the area. Progression to
active work is more energy efficient for the therapist, allowing
concentration to be centred on the application of the pressure.
Many subjects prefer to become actively involved with a particular
release, especially when areas are painful to work with, because
it gives them more personal control.
Active STR to the soleus. Lock
in and maintain the pressure
as the subject dorsiflexes the
foot.

Applying resistance during active STR may enhance the release

in some cases. As the subject attempts to produce a stretch, but
is resisted by the therapist while doing so, isometric muscle

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 STR – The Technique 31

contraction takes place in the antagonist muscles; because of

this, there is an enhanced relaxation in the muscle undergoing
treatment. This effect is known as ‘reciprocal inhibition’ (RI).
Resisted STR to the soleus.

Weight-bearing STR is highly effective in returning an area to full

function. The muscles are under tension, and a degree of eccentric
contraction will be occurring to control the required movement.
Manipulation under this tension may be very severe, and should
therefore be the last stage in any treatment programme.
Weight-bearing STR to the
soleus.

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 32 Soft Tissue Release: A Practical Handbook for Physical Therapists

2. Application of Pressure or ‘Lock’

How the lock is applied, including its direction and angle of
pressure, is important for effective results. The lock can be used
to lengthen or traverse the target fibres. It can also be used to
delve between muscle groups, to isolate tendons or to separate
bellies within a muscle. A form of friction is being created where
pressure is attained, and the movement is made by the subject
either passively or actively. Friction breaks the fibrous tissue
binding the fibres and the movement enables this to happen in
the correct direction to re-align them.
Fingers are used to delve
between the gastrocnemius
and the soleus.

The Achilles is gently grasped

on either side.

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 STR – The Technique 33

One thumb reinforced with the

other to split the bellies of the
gastrocnemius.

Specific Attention to the Fascia

A connective tissue massage (CTM) lock is designed to work
specifically on the connective tissue, by providing a load on
the fascia prior to moving the muscle fibres. Depth should be
attained before slowly gliding the fascia; when there is resistance,
the lock should be moved 2–3 cm further. Once this is achieved, it
is maintained while movement of the muscle fibres occurs.

A connective tissue massage

(CTM) lock;
a) superficial fascia
(subcutaneous layer)
Skin
b) myofascial mobilisation Subcutaneous layer
into fascial layer of muscle.
Muscle
a)

Skin
Subcutaneous layer
b) Myofascia
Muscle

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 34 Soft Tissue Release: A Practical Handbook for Physical Therapists

3. Maintenance of Pressure
Pressure is maintained during the stretch, whatever the type of
lock. The release occurs with the movement made by the subject.
The lock is maintained while the fibres around are moving; this
may cause the lock to jump or flicker, but the movement is still
being produced functionally by the subject, not by moving the
lock.

4. The Stretch
Maximal stretching is not the best way to release specific problem
areas; the stretch should be localised. The basic principle behind
STR is that congested fibres can be targeted more accurately.
In some instances, the stretch may involve only the smallest of
movements. On occasion it is also necessary to shorten a muscle
prior to locking in, to relax the fibres so that an effective lock can
be applied.

There may be many different ways to produce a stretch,

particularly where muscles have more than one action. In some
cases, the therapist may even choose to combine movements;
for example, when treating the biceps brachii, the elbow can be
extended and pronated as the pressure is applied. Where a more
extreme stretch is being attained, the therapist should guide the
subject into one movement and follow it with a further stretch.
For example, in the case of the hamstrings, the hip may be flexed
first as the pressure is applied, and then a further stretch applied
with the extension of the knee.

5. Flexibility

STR is a very useful technique for subjects who require flexibility

for whatever reason. It may be that the muscle or tendon fibres are
shortened because of overuse or imbalance, or perhaps the nature
of the relevant activity necessitates a high level of flexibility, such
as that demanded in gymnastics or martial arts. In these cases,
full stretching should be incorporated within STR only after the
tissues have been worked on thoroughly. It is also important to
note that range of movement must be tested prior to instructing
a subject to move into an extreme stretch.

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 STR – The Technique 35

6. In Conjunction with Muscle Energy

Techniques (METs)

METs can be used to great effect alongside STR. MET refers to

stretching techniques which involve using the subject’s own
muscular energy to help release holding tension. For example,
following an isometric muscle contraction there is a period of
relaxation called ‘post-isometric relaxation’ (PIR). A therapist
experienced in this can use the PIR principle to enhance muscle
relaxation and, therefore, its stretching capability. The use of RI
has already been mentioned with reference to ‘resisted STR’.
MET to the soleus.

7. Discomfort during Application

Where tissues are so severely adhered and fibrous that it may
be painful to separate them, STR has two advantages over other
techniques. Firstly, there is a pleasant, momentary relief when the
pressure is released, even if a new lock is being sought. Secondly,
subjects feel in control of their own discomfort. This may be
particularly the case with high-performance sports people, who
willingly put themselves through painful training sessions for
success in their events!

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 36 Soft Tissue Release: A Practical Handbook for Physical Therapists

AIDS FOR APPLYING STR

Tools
As with all massage, the tools of the trade are the fingers, thumbs,
knuckles, whole hands, forearms and elbows.
The phalange is reinforced to
apply a deeper lock.

A good working posture should be adopted so that deep pressure

can be applied when necessary with minimal strain to the
therapist. The larger superficial muscles with general shortening
are treated first with broader pressure points, such as the broad
ulnar surface, a soft fist or the heel of the hand.
A soft fist provides a broad
surface lock.

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 STR – The Technique 37

A broad ulnar surface.

Prior to working the deeper muscles, the area is assessed and

released from tension so that the superficial muscles can be reached
through with minimal discomfort. Deep work can be done with
a smaller surface area, such as the thumb or knuckle, so that the
force applied is greater. When applying a deeper pressure in this
way, the therapist should always reinforce the lock; this can be
achieved with the weight of the opposing hand, and body weight
behind it, to protect the therapist from joint damage or fatigue.
For experienced practitioners, wooden pegs are available which
fit in the hand and assist in the achievement of deep pressures.
These pegs have to be used sparingly and intelligently, as the
therapist will not be getting the same tissue feedback as from
using hands or elbows.

Ideally, a correctly positioned treatment couch is required for the

delivery of good massage, but STR is a highly adaptive technique
which will test the ingenuity of the therapist. Treatment can be
conducted through clothes, when necessary. This is useful at
sporting events that have no facilities or take place in cold and
exposed conditions, and when time is a limiting factor.

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 38 Soft Tissue Release: A Practical Handbook for Physical Therapists

Tips to Ensure Effective Administering of STR

• Lock slowly and precisely. Avoid poking or crushing the tissue,
to minimise tissue trauma and maximise release.

• Gradually apply the lock to the congested or stuck layer at

a transverse or oblique angle. Always address the superficial
layers first.

• Follow the subject’s breathing. Gain your depth during

exhalation to help maintain relaxation. When working very
deep or in severely congested areas, it may take two or three
exhalations to acquire the lock at the depth you require.

• The adhering tissues will be engaged when the movement

occurs; advising the subject on when to breathe will increase
awareness during movement and help with relaxation.

• Before asking for an active stretch, guide the subject through

a passive one first: this will ensure that the movement is
completed correctly.

• Analyse where to go next and move on slowly.

• Avoid spending too long in any one place. If the tissues do not
seem to be responding, do not keep locking into the same area
– move on.

• Release occurs in many different ways, not just where you are
focusing. Allow your awareness to move beyond the tissue
you are working on.

• Stay in verbal contact with your subject; ask questions like

‘Are you okay?’ and ‘How does that feel?’

Soft Tissue Chapter 2.indd 38 10/8/12 11:23:28

 Part 3
Lower Limb
THE PELVIC GIRDLE

The pelvic girdle is strong and stable, with minimal mobility; it

joins the lower limbs to the spine, transferring the weight of the
body to the legs. The maintenance of good pelvic posture during
sitting, standing or moving is critical in ensuring the efficient
functioning of the area. Balance and strength in the trunk and
hip muscles are key to achieving this.

The lumbosacral junction articulates the sacrum and the lumbar

vertebrae and is vulnerable to injury. The iliolumbar ligament
is a particularly strong ligament that helps to stabilise the
last two lumbar vertebrae. It is a specialised extension of the
thoracolumbar fascia (anterior and middle sections) originating
from the transverse processes of the fourth and fifth lumbar
vertebrae and joining to the posterior inner lip of the iliac crest.
The sacroiliac joint connects the sacrum to the pelvic girdle
and transfers body weight from the trunk to the leg, so it is
important to consider it in any treatment of the area. Superficial
to the sacroiliac joint, the sacroiliac ligament’s sections attach
from the sacrum to the posterior superior iliac spine (PSIS) area.
It is imperative to address the connective tissues around these
areas, as repetitive stress (particularly from sitting, standing and
bending), exacerbated by asymmetrical positioning or activities,
may cause scarring and stiffness; this will affect the stability and
movement of the area, causing lower back and sacral pain, and
possible referred pain to the leg.

Anteriorly, the pelvis joins at the symphysis pubis. Tendinous

fibres of the rectus abdominis, external oblique and adductor
longus overlie the cartilaginous disc. This offers extra strength
and stability to the joint. When presented with osteitis pubis and
symphysis pubis dysfunction (SPD), these are the muscles that
should be treated.

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 40 Soft Tissue Release: A Practical Handbook for Physical Therapists

THE HIP
The enormous strength and musculature of the hip joint is
necessary for catering for dynamic and controlled propulsion.
The hips support the weight of the body; they also transfer the
weight powerfully, to the opposing leg, in a range of different
weight-bearing activities from walking and running to jumping.
Full range of movement, good flexibility and adequate strength
of the hips will encourage a biomechanically efficient and smooth
gait.

Hip Extension
Major Muscles: Gluteus maximus, hamstrings (semimembranosus,
semitendinosus and biceps femoris [long head]) and adductor
magnus (vertical fibres).

Gluteus Maximus
The gluteus maximus is a very strong muscle involved in powerful
hip extension, particularly from a flexed starting position.
Movements such as stair climbing, rising from a seated position
or squat, walking uphill and running (especially fast running,
which requires great drive and power) employ this muscle. As
the gluteus maximus arises from the lower fascia of the back, it is
consequently involved in trunk extension from a flexed position.
It is also an important lateral rotator and will therefore affect
planting of the foot. Static build-up of tension can also occur in
the gluteus maximus because of its contribution to supporting
the body’s weight in the seated position; contraction of the
muscle will take the body’s weight off the ischial tuberosities,
and, since we tend to favour the gluteus maximus on one side
over the other, imbalance can ensue.

The gluteus maximus is prone to inhibition, commonly due to

poor posture and sedentary positions. Imbalance can occur, and
this in turn can cause the hamstrings to overwork in the action of
hip extension and subsequently place more strain on the tissues
of the lower back. STR treatment will enhance the health of the
gluteus maximus to facilitate strengthening programmes. Strains

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 Lower Limb 41

to this muscle are more likely to occur at its origins along the
sacrum and iliac crest and towards its fibrous insertion into the
ITB and gluteal tuberosity.

Superficial hip muscles.

1. Posterior superior iliac
spine 1
2. Gluteus medius
3. Gluteus maximus
2

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 42 Soft Tissue Release: A Practical Handbook for Physical Therapists

Lateral Rotation of the Hip

Major Muscles: Gluteus maximus, posterior fibres of the gluteus
medius, sartorius and deep lateral rotators (piriformis, obturator
internus, obturator externus, gemellus superior, gemellus inferior,
quadratus femoris and psoas major).

Deep hip muscles.

1. Gluteus minimus
2. Piriformis
3. Gemellus superior
4. Obturator internus 1
5. Gemellus inferior
6. Quadratus femoris
2

These muscles are important in stabilising all hip movements

by preventing excessive medial rotation. The piriformis is often
problematic. It is involved in the seated position as an abductor;
it is also an important stabiliser in walking and running, as it
helps maintain stance on the side opposite that of the foot being
lifted. The sciatic nerve runs beneath this muscle and, in about
17% of the population, may actually run through it. The nerve
can become adhered to the tight piriformis and produce sciatic
symptoms (posterior thigh). Sciatica resulting from this situation
is known as piriformis syndrome and responds very well to STR.

Gluteus Maximus and the Deep Lateral Rotators – Treatment

With the subject in a prone position, apply pressure at points off
the gluteal attachments by locking in and moving away from the
iliac crest and away from the sacrum while the subject attempts
to flex the hip by pushing the knee into the table. Given that

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 Lower Limb 43

the lock is precise, a small stretch will be felt. To obtain a more

significant stretch in the muscle as a whole, treat the muscle in a
side-lying position, in which full flexion can be obtained by the
subject actively flexing the hip.
Active STR to the gluteus
maximus in side lying.

Alternatively, with the subject in a prone position and the knee

flexed to 90 degrees, gently rotate the leg medially and laterally.
This will in itself indicate restriction in the hip and/or pelvis. Lock
in appropriately, broad surface first, away from the sacrum, then
away from the iliac crest, each time applying the pressure, then
medially rotating the leg and releasing the pressure to return the

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 44 Soft Tissue Release: A Practical Handbook for Physical Therapists

Passive STR to the gluteus

maximus.

leg to the starting point. Systematically cover the whole of the

gluteus maximus area. Active STR is beneficial particularly if
there is a reduced range of movement, in which case the subject
only moves through a range that is comfortable.
Active STR to the piriformis.

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 Lower Limb 45

Active STR to the piriformis.

Once the muscle is relaxed and stretched, progress to the deep

rotators. Angle your elbow or a knuckle gently through towards
the piriformis, which can be located halfway between the sacrum
and the greater trochanter. Ensure that the relaxation of the
muscles is maintained. The other rotators can also be affected,
although they are difficult to differentiate. The quadratus femoris
can be reached by gliding away from the ischial tuberosity and
under the gluteus maximus. Having attained any one of these
deep pressures, hold the pressure as the hip is medially rotated,
then promptly release the pressure.

Medial Rotation of the Hip

Major Muscles: Anterior fibres of the gluteus medius, gluteus
minimus and TFL, pectineus, adductor longus, adductor brevis,
adductor magnus and piriformis (at a range of more than 90
degrees).

Medial Rotators – Treatment

The gluteus medius and minimus can be treated as one, the
minimus lying directly under the medius. Apply pressure in
the gluteus medius (anterior fibres), away from the iliac crest,
and laterally rotate the leg; apply a deeper pressure to target
the gluteus minimus and again laterally rotate the leg. Another
useful manoeuvre is with the subject supine. Link into the medius
with the fingers of one hand reinforced with the other hand and
slowly pull the fibres transversely very slightly. Lock the subject’s
opposing hip with your knee to stabilise the pelvis while the subject
actively rotates the leg, medially if the posterior fibres are locked

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 46 Soft Tissue Release: A Practical Handbook for Physical Therapists

and laterally if the anterior fibres are locked. It is also possible to

work the TFL effectively here using the same method.

Lumbosacral Junction and Sacroiliac Joint Area – Treatment

Once the hips and lower back have been warmed up, treatment
of this area can commence. Place the subject in a side-lying
position and, using a knuckle to apply a CTM lock away from the
PSIS, instruct the subject to minimally flex the hip; alternatively,
ask the subject to posteriorly tilt the pelvis. Progress to the ‘V’,
between the PSIS and the lumbosacral joint, and apply a CTM
lock, again guiding the subject into hip flexion or a posterior tilt
of the pelvis.
Lock into the lumbosacral
junction as the pelvis is
posteriorly tilted.

Hamstrings
Main Muscles: Semimembranosus, semitendinosus and biceps
femoris.

The hamstrings work with the gluteus maximus to extend the

hip if the knee is mostly or completely extended. They also
assist the gluteus maximus in extending the spine from a flexed
position. If hip extension is not occurring then the hamstrings are
also powerful knee flexors. When the knee is semi-flexed some
rotation can also occur.

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 Lower Limb 47

Hamstring strains are common in sports involving sprinting,

where the muscles are used powerfully. Sprinters in athletics are
renowned for hamstring problems. The sprint starting position
puts huge stress on the three hamstrings, which are working
around two strong movements: the trunk rises from a crouched
position, while the hip extends powerfully to drive the body
forwards. A good sprinter may not be running fully erect until 25
metres into the sprint. Strains occur near the origin or in the belly
of the muscle more commonly than at the insertion points; they
also frequently happen just prior to heel strike as the hamstrings
contract eccentrically to control knee extension.

Hamstrings tend towards hypertonicity, and are often over-

recruited in hip extension at the expense of the gluteus maximus.
Lifestyle factors, such as prolonged sitting and driving, shorten
the hip flexors and lengthen the gluteus maximus, increasing the
susceptibility of the hamstrings to shortening and of the gluteus
maximus to inhibition.

Hamstrings and knee flexors.

1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
4. Gastrocnemius (medial
head)
5. Gastrocnemius (lateral 1 6
head)
6. Gracilis
7. Sartorius 2 7

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 48 Soft Tissue Release: A Practical Handbook for Physical Therapists

Hamstrings – Treatment
There are many different ways of treating the hamstrings, and
it is important to adapt the treatment depending on the size
and condition of the muscles. Generally speaking, they are best
treated from a prone position for the initial investigation. With
the knee flexed to 90 degrees, apply locks towards the origin as
the knee is straightened each time.
Passive STR to the hamstrings
with a broad surface lock.

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 Lower Limb 49

Treat from the tendons of insertion to the origins, locating the

three hamstrings. To acquire a more specific lock, progress
to active STR: delve between the muscle groups to separate
adherence, using a reinforced thumb or phalange; instruct the
subject to extend the knee.
Active STR to the hamstrings
with a reinforced phalange.

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 50 Soft Tissue Release: A Practical Handbook for Physical Therapists

A greater stretch can be achieved in a supine position. Support

the subject’s lower leg on your shoulder and lock in with the
elbow, or use reinforced thumbs or knuckles for a more focused
lock; instruct the subject to extend the knee.
Active STR to the hamstrings
using the elbow.

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 Lower Limb 51

Active STR to the hamstrings

using a knuckle.

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 52 Soft Tissue Release: A Practical Handbook for Physical Therapists

In addition, lock into and direct the lock away from the origin
towards the insertions, and either move the hip into flexion with
your shoulder, or advise the subject to flex the hip; the subject
may need to hold the leg just above and behind the knee and pull
it up into flexion for the best control.
Active STR away from the
hamstrings origin.

The pressure should be attained slowly because any adhesion

will be very sensitive. Combining hip flexion and knee extension
during the same lock can provide a powerful release for the more
flexible subject; this should be performed extremely carefully. It
is also possible to work this area with the subject in a side-lying
position, ensuring that the leg is supported during flexion of the
hip; this can be beneficial for the less flexible subject.

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 Lower Limb 53

Weight-bearing STR to the hamstrings may provide powerful

results. With the subject standing, apply a pressure and guide
the subject into a stretch.
STR to the hamstrings in a
weight-bearing position.

Hip Flexion
Major Muscles: Rectus femoris, sartorius, TFL, pectineus, iliacus,
psoas major and psoas minor (not always present).

All of the hip flexors position the pelvis forwards; if they become
adhered or tight they are less effective in holding the pelvis up in
a neutral position. This can be associated with weak abdominal
muscles and subsequent lordosis. If this is the case, specific
isolated abdominal strengthening is vital, and STR to the hip
flexors will facilitate the strength gains. The psoas is strong and
powerful, and is a major postural muscle. When the insertions are
fixed, the psoas assists in flexing the trunk from a lying position.
During treatment, both sides should always be considered when
presented with any lower back conditions, lordosis or other
postural deficiencies. The iliacus and psoas are often termed the
‘iliopsoas’.

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 54 Soft Tissue Release: A Practical Handbook for Physical Therapists

Deep hip flexors and

quadratus lumborum.
1. Psoas major
2. Quadratus lumborum
3. Iliacus

2
1

Hip Flexors – Treatment

With the subject supine on the table, treat the rectus femoris,
sartorius and TFL by locking in gently but firmly (this can be
ticklish) away from the origin; then instruct the subject to tilt the
pelvis (posterior tilt). A good alternative is to work the flexors
with the subject in a side-lying position. Support the leg well,
lock appropriately and take the leg into extension.
Passive STR to the rectus
femoris.

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 Lower Limb 55

This can be difficult with a heavy leg, but with active work, a good
lock can be maintained and only a tiny amount of hip extension
is needed for an effective release.
Active STR to the rectus
femoris.

With the iliopsoas, extreme care and subject relaxation are essential
for good results. Position the subject in a supine position with the
knees bent; place your fingers at navel level and lateral to the
border of the rectus abdominis (halfway between the last rib and
the linea alba); as the subject exhales, gently drop towards the
muscle, then stop as the subject inhales and wait to go deeper for
the second and maybe even third exhalation. Once the depth has
been reached, angle the fingers slightly medially and you should
feel the psoas. Direct the subject to perform hip flexion, and you
will feel the muscle shortening to confirm your location. If this is
too uncomfortable, release the pressure slightly. Following this,
maintain your lock and instruct the subject to straighten the leg
for STR. Good release also occurs from instructing the subject
to perform a posterior pelvic tilt. You are really only affecting

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 56 Soft Tissue Release: A Practical Handbook for Physical Therapists

the surface of this deep muscle, but by locking the fascia you are
achieving a release in the muscle as a whole.

Keep the subject in the same position to work the iliacus. Slowly
glide over the anterior superior iliac spine and move over the
concavity of the ilium. Lock and instruct the subject to straighten
the leg.
Active STR to the iliacus.

Apply a lock more medially to address the psoas and iliacus as

they merge to form the iliopsoas tendon. Effective release of the
iliacus can be performed in a side-lying position, whereby you
can hook into the muscle and instruct the subject to extend the
hip; ensure the pelvis is maintained in a neutral position.

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 Lower Limb 57

Hip Adduction
Major Muscles: Adductor longus, adductor magnus (oblique
fibres), adductor brevis, gracilis pectineus, gluteus maximus
(lower fibres) and piriformis (at a range of more than 90
degrees).
Adductors.
1. Pectineus
2. Adductor longus
3. Adductor magnus
4. Pectineus (cut)
5. Adductor brevis
4

1 3

2 5

3 2

All the adductors are important in preventing overbalancing

laterally by keeping the thigh pulled inwards during the support
phase of walking and running. Tears in the adductor group are
frequently referred to as ‘groin strain’ and commonly occur
when the adductors are weak in relation to the quadriceps.
Sports involving sprinting or sudden changes of direction are
predisposed to this type of injury. Overuse (such as from horse
riding or football), resulting in hypertonicity, can also induce
problems here. Injury often presents at the muscle origin or at
the musculotendinous junction. Maintenance massage is key
to gaining and maintaining flexibility and strength in the area.
The adductor magnus is the largest and most posterior of the
adductors. Its origin is close to the hamstrings, and the muscle
does assist in hip extension. Often when athletes perceive niggling
‘hamstring pain’ the adductor magnus is the cause. Depending

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on the position of the thigh, the muscle is also involved in medial

or lateral rotation.

Hip Adductors – Treatment

This is frequently a sensitive area to treat even on flexible
people. It is important to ensure relaxation, and this may mean
significantly shortening the muscle prior to locking in. With the
subject in a supine position, hold the flexed knee while the foot
is resting on the table. Apply pressure with the other hand at
points in the muscle, on the borders of the adductor longus and
the pectineus, then passively abduct the leg; alternatively, guide
the subject to abduct the leg into your hand, making sure that the
opposing hip does not rise.
Passive STR to the adductor
longus.

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 Lower Limb 59

Active STR to the adductor

longus (grasp).

Work close to the pubic bone to ensure that the origins are
attended to. For the gracilis, a straight leg stretch may be more
effective, as the muscle also crosses the knee.
Passive STR to the gracilis.

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Passive STR to the gracilis.

To locate the adductor magnus more easily, position the subject

at the end of the table and support the whole leg around your
body to allow for greater manoeuvrability of the hip; this could
be helpful in targeting the adductor magnus, where adding hip
flexion may enhance tissue release. Apply an appropriate lock
and advise the subject to abduct or flex the hip as necessary to
separate adherence. The other adductors can be treated effectively
in this position too: traverse and separate them from each other,
and subtly change the movement as necessary, depending on the
adductor’s secondary movements.
Active STR at the end of the
couch to facilitate greater
movement; useful for adductor
magnus.

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 Lower Limb 61

Active STR at the end of the

couch to facilitate greater
movement; useful for adductor
magnus.

The adductor magnus reacts well to weight-bearing STR – the

subject can be instructed to produce a stretch while standing.
STR to the adductors in a
weight-bearing position.

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Hip Abduction
Major Muscles: Gluteus medius, gluteus minimus, TFL, sartorius,
piriformis (in the seated position) and gluteus maximus (upper
fibres).
Lateral thigh.
1. Gluteus medius 1
2. Gluteus maximus
3. Biceps femoris (long head)
4. Biceps femoris (short
2
head)
5. Tensor fasciae latae 5
3
6. Rectus femoris
7. Iliotibial band
8. Vastus lateralis 4 6

The gluteus medius and minimus support and control the hip
and pelvic tilt, through eccentric contraction, as the body weight
is transferred from one foot to the other during walking and
running. While one foot is off the ground, contraction prevents the
opposing hip from sagging. In many people the gluteus medius
has a tendency to inhibition, partly because of the seated positions
adopted in day-to-day life; in gait the pelvis visibly drops on the
non-weight-bearing side because the gluteus medius is not strong
enough to maintain the pelvis level. STR treatment to the gluteus
medius prior to, and in conjunction with, specific strengthening
exercises will enhance the effectiveness of the programme.

Tensor Fasciae Latae and Iliotibial Band

The tensor fasciae latae (TFL) assists in several movements,
including hip flexion and abduction, and is a medial rotator when
the hip is extended. It is also a weak extensor and lateral rotator

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 Lower Limb 63

of the knee. It aids stability of the hip and stability of the femur
on the tibia in weight-bearing activities. The TFL, along with the
gluteus maximus, runs into a thick band of connective tissue
known as the iliotibial band (ITB), which links the pelvis with
the tibia. The ITB helps to stabilise the extended knee. Overuse
injury is common in this area, as the TFL is predisposed to
hypertonicity and becoming overactive in gait; this can result in
excessive medial rotation of the hip after heel strike, subsequent
weakening of the gluteus medius and increased tension in the
ITB. Restriction between it and the vastus lateralis can occur,
causing the band to rub on the lateral femoral condyle or over
the greater trochanter.

Releasing restrictions in the TFL and ITB is renowned for being

difficult and painful, but precise use of STR can effectively free
even severely adhered areas with minimal discomfort. Problems
here are associated with weakness in the gluteus medius, poor
pelvic posture, tension in the vastus lateralis and weakness in the
adductors.

Hip Abductors and ITB – Treatment

With the subject in a side-lying position, secure the flexed knee
and abduct the hip. Apply pressure away from the iliac crest,
into the gluteus medius, and adduct the hip. Elbows are often
necessary here in cases of severe hypertonicity, or if the leg is
proving heavy to hold, but when used with care should not be
too uncomfortable.
Passive STR to the gluteus
medius.

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Passive STR to the gluteus

medius.

To avoid holding the leg, progress to active STR. Ask the subject
to abduct the hip while keeping the ankles together. Apply a lock
and ask the subject to adduct the hip; if the tissue is under too
much tension as abduction occurs, support the knee with your
other hand while applying the lock.

Treat the TFL in a side-lying position, as in the case of the

abductors and the superficial hip flexors. Lock in with the heel of
the hand or an elbow and adduct the leg.
Active STR to the TFL..

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 Lower Limb 65

Alternatively, lock and instruct the subject to perform a small

amount of hip extension. This area can be very sensitive
and uncomfortable, or ticklish even, so work precisely and
efficiently.

To free up the ITB it is necessary to first release the gluteal muscles

and the TFL, then gently grasp either side of the band and ask the
subject to flex the knee; this will separate adherence between the
ITB and the vastus lateralis. Progress to applying specific CTM
locks and curl right under the posterior border, then the anterior
border, by using one thumb reinforced with the other; after each
lock instruct the subject to flex the knee.
Active STR to the borders of
the ITB and vastus lateralis.

The fascia can be softened by applying a CTM lock across the ITB
while the subject flexes or extends the hip away from the angle of
pressure, still from a side-lying position.

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THE KNEE
The knee has a good range of movement. It is made stable by strong
ligaments and certain musculotendinous structures, in particular
the iliotibial band, sartorius, gracilis, semimembranosus,
semitendinosus, popliteus and quadriceps. The knee is constantly
under stress as weight is transferred from the body to the ground
in running and walking. Overuse can occur, and the knee is
vulnerable to traumatic injury from twisting and turning.

The quadriceps group inserts into the base of the patella and
the ligamentum patellae, then joins the patella to the tibial
tuberosity. Functionally the ligamentum patellae behaves as a
tendon, transmitting the force of the quadriceps to the tibia, and
so is often referred to as the ‘patellar tendon’. There is a band of
retaining connective tissue across the knee that is known as the
patellar retinaculum.

Knee Flexion

Major Muscles: Hamstrings, gastrocnemius, gracilis, sartorius,

popliteus and plantaris.
Medial thigh.
1. Adductor longus
2. Sartorius
Pes
3. Gracilis anserinus
4. Semitendinosus
5. Adductor magnus
6. Semimembranosus
1 4

2 5

3 6

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Except for the popliteus, all of these muscles cross over two joints.
The knee flexors control extension to prevent hyperextension of
the knee during walking and standing. Pain behind the knee can
be due to tightness in any of these muscles, often the hamstrings.
Commonly they can be strained through running, kicking or
dancing. The tendons of insertion of the semimembranosus,
sartorius and gracilis merge to form the pes anserinus, and
congestion in this area can cause medial knee pain. It is important
that all of the tendons around the knee are treated as well as the
entire muscle, to enhance movement and aid stability of the joint.

Knee Flexors – Treatment

With the subject in a prone position and the knee flexed, apply
a broad surface lock and passively straighten the knee; apply
STR to the three hamstring muscles, assessing and releasing
hypertonicity.
Passive STR to the hamstrings
with a broad surface lock.

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 68 Soft Tissue Release: A Practical Handbook for Physical Therapists

Following this, progress to active STR to acquire a more specific

lock, and use a reinforced phalange or thumb, or reinforced
fingers.
Active STR to the hamstrings
with a reinforced phalange.

Gently grasp the tendons of insertion, one at a time, and extend

the knee.

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 Lower Limb 69

STR to the medial hamstring

tendons of insertion (left hand
photo); STR to the biceps
femoris tendon of insertion
(right hand photo).

Gently grasp the pes anserinus and extend the knee. Alternatively,
with the subject in a supine position and the knee slightly flexed,
lock into the tendons with the fingers and maintain each pressure
while the subject extends or flattens the knee into the lock
provided.
STR to the pes anserinus.

The gastrocnemius is primarily released with the other plantar

flexors; the gracilis, with the adductors; and the sartorius as a
whole, with the hip flexors.

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Knee Extension
Major Muscles: Quadriceps group (rectus femoris, vastus lateralis,
vastus medialis [including oblique] and vastus intermedius).

Anterior thigh.
1. Iliacus
2. Tensor fascia latae
3. Sartorius
4. Pectineus 12
5. Adductor longus
6. Rectus femoris
1
8
7. Iliotibial band
8. Adductor magnus 2
9. Gracilis 13
10. Vastus lateralis
11. Vastus medialis 3
12. Psoas major
9
13. Adductor brevis
4
5
5
8
6
10
7
11
8

The rectus femoris works strongly as a knee extensor when the

hip is extended, and is ineffective when the hip is flexed. The
vastus medialis is strong in the final stages of knee extension.
The TFL is also a very weak knee extensor.

The quadriceps is a powerful muscle group, and is exercised

significantly in walking, running and jumping. The rectus
femoris goes over two joints; it is also involved in hip flexion and
therefore has a greater susceptibility to strain. Separating and
localised stretching will help to rebalance the four muscles and
ensure that full function and strength are maintained; this will
not only minimise the possibility of impairment or breakdown
of the quadriceps but also prevent overuse injuries to the knee.

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 Lower Limb 71

There is a danger in working on the quadriceps too soon after a

direct trauma in that there is the possibility of the formation of
myositis ossificans.

Knee Extensors – Treatment

With the subject supine, support the knee in a semi-flexed
position. Extend the knee, apply a lock and flex the knee.
Active STR to the quadriceps
tendon.

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For a more effective stretch, the subject lies supine with the leg to
be worked on over the end of the table, and the other leg flexed
at the hip to protect the back.

Passive STR to the quadriceps.

Apply locks towards the origins and slightly transversely to the

fibres to separate the vastus lateralis from adherence to the ITB,
and to separate the vastus medialis from the sartorius and the
adductors. The stretch in these instances is best achieved with
the subject actively flexing the knee. Side lying is a good way to
work on the rectus femoris by taking the hip into extension (see
Hip Flexion section), and this position is also good for achieving
separation of the vastus lateralis from the ITB with active knee
flexion (see page 65).

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 Lower Limb 73

STR to the vastus lateralis.

Knee Problems
There are certain knee injuries that benefit from STR work. Patella
tracking problems can be helped by releasing the quadriceps and
ensuring that its borders are free from adhesion. By relieving
adhesion and hypertonicity in the lateral thigh and ITB, treatment
may facilitate efficient strength gains in the vastus medialis. This
will enable re-balance to occur.

In the case of a synovial plica, in conjunction with traditional

friction techniques, STR to both the medial retinaculum and the
lateral retinaculum around the knee will break fibrous tissue and
stretch and nourish the surrounding connective tissue; this will
help to reduce compression over the anterior compartment.

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In the event of injury, specific STR to the medial ligament complex

is beneficial. General STR to the quadriceps will relieve stress
placed on the knee in tendinitis problems. Specific minimal STR
to the patellar tendon itself will divide adhesive tissue there. If
Osgood–Schlatter disease has been diagnosed, treatment of the
insertion point should be avoided, but it is necessary to release
the quadriceps from the hypertonicity that is inevitable in strong
muscles attached to a fast-growing skeleton; STR will provide
valuable relief. ITB syndrome can be treated where the band itself
is tight and there is the commonly associated adherence between
it and the vastus lateralis. With this condition, congestion in the
lateral retinaculum must also be considered. Post-knee-surgery
conditions, where muscles are atrophied and range of movement
has been reduced, quickly benefit from active STR. This method is
useful in that the subject can control the range of stretch, and the
muscles and fascia may be freed of fibrous tissue so that efficient
strength gains can be attained.

Knee – Treatment
With the subject in a supine position, systematically apply CTM
locks at points away from the medial and lateral borders of the
patella as the subject flexes the knee.
STR to the medial and lateral
retinaculum.

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STR to the medial and lateral

retinaculum.

Treatment of fibrous areas is necessary, but it is important

to glide into the lock slowly and precisely, as these areas may
be particularly sensitive. Treatment of the medial ligament is
possible using the same procedure. When treating the patellar
tendon, a transverse lock to stretch the tendon sheath needs to be
applied as the subject is guided into knee flexion.
STR to the patellar tendon.

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It is possible to treat the knee with the subject standing; lock

in on either side of the patella to affect the medial and lateral
retinaculum as the subject performs a semi-squat. This dynamic
functional treatment may have quick positive results for patella
tracking problems; the subject can be guided through the correct
technique to ensure that the knee flexes over the second toe.

Plantar Flexion

Major Muscles: Superficial compartment – gastrocnemius, soleus

and plantaris. Deep compartment – tibialis posterior, flexor
digitorum longus and flexor hallucis longus. Lateral compartment
– peroneus longus and peroneus brevis.
Superficial calf muscles.
1. Gastrocnemius
(medial head)
2. Gastrocnemius
(lateral head)
1
3. Soleus
5
4. Tendo calcaneus 2
(Achilles tendon)
6
Deep calf muscles. 3
5. Plantaris
10
6. Popliteus 7
4
7. Tibialis posterior 11
8. Flexor digitorum longus
8
9. Flexor hallucis longus

Intermediate calf muscles. 9

10. Soleus
11. Peroneus longus

The gastrocnemius and soleus are the primary plantar flexors of the
ankle. During the push-off phase in vigorous walking and running,
the gastrocnemius is one of the most powerful muscles in the
body, and the tendo calcaneus (Achilles tendon), which forms the
insertion point for both the gastrocnemius and the soleus, is very
thick and strong. The soleus also contracts statically to maintain
stance. As well as its role in plantar flexion, the gastrocnemius

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flexes the knee, and, because it crosses over two joints, it is

more susceptible to strain. Many overuse problems arise in the
lower leg, and imbalances commonly occur; for example, if the
gastrocnemius is stretched fully with a straight-leg stretch, and the
soleus (because of its attachment below the knee) is not stretched
out completely with a bent-knee stretch, then adherence of these
two muscles can develop. Congestion frequently manifests at the
musculotendinous junction. Compartment syndromes can also
prevail where imbalance occurs.

Plantar Flexors – Treatment

Treat the calf generally with STR. Tension and adhesive tissue will
quickly become evident. With the subject in a prone position and
the ankles over the end of the couch, lock in between the bellies
of the gastrocnemius and either dorsiflex the foot or instruct the
subject to dorsiflex the foot.
Active STR to the
gastrocnemius.

Systematically work the lateral and medial aspects of the

muscle.

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With the knee flexed, deeper and more specific work can be
administered to the soleus; alternatively, rest the subject’s lower
leg on your thigh for more support. The lock can be angled to
separate the soleus and gastrocnemius adherence from the lateral
or medial borders. This can be conducted by working up from
the musculotendinous junction.
Active STR to the soleus.

Once the gastrocnemius and soleus have been released, it is

possible to work through these muscles to affect the deep posterior

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compartment. Position the lower leg vertically and use fingers

to tweeze into the deeper layer, pushing the lower leg into your
supporting shoulder as necessary, but taking care not to crush the
superficial tissue; ask the subject to dorsiflex the foot. With the
subject in a side-lying position, lock in away from the tibia to free
up congestion by the bone; ask the subject to dorsiflex the foot.
Active STR to the deep
posterior compartment.

Achilles Tendon

Achilles tendinopathies can become chronic as a result of overuse.

The causative activity needs to be moderated or stopped, because
the condition can easily become aggravated. A general calf
treatment is important, as congestion in the gastrocnemius and
soleus can often be the reason for problems in the Achilles.

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After the calf treatment, gently pinch the tendon. Lift the
paratenon from the tendon and maintain this grasp as the foot is
dorsiflexed.
Passive STR to the Achilles
tendon.

Alternatively, ask the subject to dorsiflex the foot for active STR.
Apply two or three locks, working from the calcaneus to the
musculotendinous junction in the calf. Effective release of tissue
congestion will facilitate strengthening and re-education.

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Active STR to the Achilles

tendon.

Following surgery for a partial or complete Achilles rupture,

STR works well as part of rehabilitation. Apply STR to the lower
leg as a whole, including the foot, and use the above-mentioned
method to treat the Achilles.

Dorsiflexion
Major Muscles: Tibialis anterior, extensor digitorum longus,
extensor hallucis longus and peroneus tertius (not always
present).

The tibialis anterior is the main dorsiflexor; it also plays

an important stabilising role in maintaining balance as the
distribution of weight changes during locomotion, and it helps
to control planting of the foot. The extensor digitorum longus
plays a role in maintaining balance between plantar flexion and
dorsiflexion. The fascia is thick in the anterior lower leg, so there is
a higher risk of sustaining compartment-syndrome-type injuries
due to overtraining. This could result from a sudden increase in
exercise, particularly on hard surfaces such as in a group exercise
class, from a build-up of running mileage or from walking too
far in unaccustomed heavy shoes. The anterior compartment
tightens and the fascial covering becomes tense, causing a
pressure between it and the muscle. Ultimately, the pressure can
lead to restricted blood supply, pain and loss of function. Rest is
essential in the acute stages.

Dorsiflexors – Treatment
STR using a CTM lock is effective at reducing pressure build-up
from tight fascia in the anterior compartment. It is advisable to
shorten the tibialis anterior prior to locking, as it will prove more

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comfortable when the muscle is tight. Use a knuckle or reinforced

thumb to engage the muscle with a CTM lock towards the points
of origin, and maintain the hold while the underlying muscles
are momentarily elongated with active plantar flexion.
Active STR to the tibialis
anterior.

Work from the ankle up the shin; use fingers to separate the tibialis
tendon and other extensor tendons from under the retinaculum.
STR will cause minimal aggravation and will manage the
problem. Even in severe cases, if the tight compartment is caught
early enough, the need for a fasciotomy may be avoided.

Inversion of the Foot

Major Muscles: Tibialis posterior, tibialis anterior, flexor digitorum
longus, flexor hallucis longus and extensor hallucis longus.

The tibialis posterior helps maintain and control forefoot

positioning, by preventing the medial arch from flattening. Its
tendon attachments are palpable at the medial malleolus and the
navicular. Tenosynovitis can occur with overuse.

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Lateral lower leg.

1. Plantaris
2. Gastrocnemius
(lateral head)
3. Soleus 1
4. Peroneus brevis
5. Tendo calcaneus
(Achilles tendon)
2
6. Tibialis anterior
7. Peroneus longus 3 6
8. Extensor digitorum longus
9. Extensor hallucis longus
10. Inferior extensor 4 7
retinaculum
11. Extensor hallucis brevis
5 8
12. Extensor digitorum brevis

10

12 11

Eversion of the Foot

Major Muscles: Peroneus longus, peroneus brevis and peroneus

tertius (not always present).

Peroneus longus contributes to posture by helping to maintain the

medial arch. The brevis aids the maintenance of the longitudinal
arch. The peronei muscles have a major function in controlling
ankle stability on rough terrain.

Invertors and Evertors – Treatment

With the subject supine, hook under the peroneus longus at
the lateral malleolus and maintain the lock until the subject has
inverted and/or dorsiflexed the foot. Follow the muscle up the
side of the leg. Treatment can also take place effectively in a side-
lying position.

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Active STR to the peroneus

longus.

The brevis can be located around the lateral ankle and is a prime
muscle to consider in ankle inversion sprains.

THE ANKLE

General work to the lower leg and foot needs to be undertaken

with the presentation of any ankle problem. STR to these muscles
is highly beneficial following ankle sprains. It can be used directly
following RICE during the general rehabilitative measures, to
ensure strength gains. It is also useful in the case of a poorly
healed ankle presenting with weakness and instability due to
fibrous tissue and muscle imbalance, even many years after
the initial injury. Inversion sprains are the most common ankle
sprains, affecting the anterior and posterior talofibular ligament
and the calcaneofibular ligament and/or the peronei. Following
the sprain, adherence commonly occurs within the extensor
tendon sheaths, the extensor retinaculum and the ligaments,
which can leave a residual egg-shaped swelling. In this instance,
STR to the ligament is useful, together with work on all the
muscles that evert and dorsiflex the foot. Balance still needs to be
restored wherever the primary damage has occurred. To restore
freedom of movement, lock onto ligamentous tissue as well as
onto and between the tendons; instruct the subject to perform

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an appropriate stretch. Combination movements of flexion,

extension, eversion and inversion work well in separating the
tendons from each other and from the retinaculum, as they take
in all the primary and secondary movements of the muscles.

Once the tissues affecting the ankle have been released and the
joint is moving well, strength training and proprioceptive re-
education exercises become more effective and help to make the
repair permanent. In the case of a major injury such as ligamentous
rupture or bone breakage, healing will always be slow. Swelling,
scar tissue, pain and reduced movement can become permanent
because of the damage and forced immobilisation; STR, as
outlined above, will prove invaluable in regaining ankle mobility
and reducing swelling.
STR to the extensor tendons
at the retinaculum.

Shin Splints

‘Shin splints’ is a general term for chronic pain in the lower leg.
It can develop from the anterior, the posterior and sometimes the
lateral compartment, although more commonly it refers to pain
occurring on the medial tibial border. This is more accurately
defined as ‘medial tibial stress syndrome’.

When there is pain on the medial tibial border, the plantar flexors
require particular attention. Chronic problems are usually caused
by the soleus, flexor digitorum longus and tibialis posterior, and
frequently present in the lower third of the tibia. The injury can
be due to hypertonicity or compartment syndrome of the muscle,
adhesion between the tendon and the bone, inflammation of
the periosteum or an actual stress fracture of the bone. Many
distance runners who suffer with this condition successfully
resort to prescribed orthotics to help correct over-pronation. The

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Active STR to the deep repetitive nature of the sport can make a minor biomechanical
posterior compartment.
deficiency apparent. Whether orthotics are necessary or not, STR
is an indispensable form of treatment for shin splints. STR will
decrease tissue adherence and tension with minimal aggravation
of the inflammation.

Shin Splints – Treatment

Wherever the pain presents, it is imperative to address all of
the lower leg compartments and the foot to help restore muscle
balance. Once the superficial posterior compartment has been
released, address the deep compartment. Glide a thumb or the
fingers medially off the tibia, lock still and dorsiflex the foot.

If there is major discomfort or concern there could be a stress

fracture; remember to conduct the seven-second test (see page
22) to ensure that treatment is only administered around, and
not on, an acutely inflamed area. It is necessary to treat the foot
thoroughly to relieve congestion within the insertion tendons of
the deep posterior compartment; this treatment will also help to
restore balance to the foot and improve its natural posture.

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THE FOOT
The foot is a vital area to maintain. Strong, flexible musculature
will enhance its shock absorbency, minimising the risk of injury.
Control and good movement of the joints in the foot are possible
where the soft tissues are strong and supple. This encourages
efficient and correct planting of the foot and reduces the possibility
of repercussions elsewhere. While standing still, the arches of the
foot are maintained primarily by strong ligaments in the sole.
There are four layers of intrinsic muscles on the plantar surface
that help support the arches of the foot as well as move the toes.
These muscles, together with the long tendons that cross the
ankle, maintain the arches during movement. Thick layers of
connective tissue envelop the muscles and fatty tissue to provide
protection for the foot.

There are many injuries which can occur in the toes, such as turf
toe, which is a sprain to the first metatarsophalangeal joint (MTPJ);
metatarsalgia, which refers to general pain in the forefoot; and
hallux valgus and hallux rigidus, which result from excessive
or deficient mobility in the MTPJ. Once a problem has been
diagnosed, STR can be of huge benefit in relieving discomfort
and can contribute to the development of good foot mechanics
by restoring muscle balance. STR is also invaluable for helping
the traumatised tissues recover following corrective surgery for
hallux valgus.

Toe Flexion
Major Muscles: Flexor digitorum longus, flexor digitorum brevis,
flexor hallucis longus, flexor hallucis brevis, flexor digiti minimi
brevis, interossei, quadratus plantae and lumbricals.

Toe Flexors – Treatment

Release the deep posterior compartment (see page 78) then
address the plantar muscles in the foot; lock in using a knuckle
and ask the subject to extend the toes.

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Toe Extension
Major Muscles: Extensor hallucis longus, extensor digitorum
longus, extensor digitorum brevis, lumbricals and interossei.

Toe Extensors – Treatment

Address the anterior compartment by locking in and plantar
flexing the ankle for a stretch; then progress to treating the tissue
on the dorsal side of the foot. Glide over and tweeze between the
extensor tendons, hold the position and flex the toes.
Passive STR to the extensor
tendons.

Lock onto the tendons and flex the toes, or ask the subject to flex
the toes.

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Toe Abduction
Major Muscles: Abductor hallucis, abductor digiti minimi and
dorsal interossei.

Plantar view of foot (superficial

muscles).
1. Abductor digiti minimi
2. Abductor hallucis
3. Flexor digitorum brevis

Toe Adduction

Major Muscles: Adductor hallucis and plantar interossei.

Plantar Fasciitis

The plantar aponeurosis, or plantar fascia, is a very thick fibrous

band of tissue in the base of the foot which covers the plantar
muscles and is vital in maintaining the longitudinal arches of the
foot. Over-pronation of weak lateral leg muscles can predispose
the plantar fascia to injury: the fascia becomes thickened and
inflamed. Medial pain at its calcaneal attachment, as well as
general tension in the base of the foot, is usual in this condition.

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The plantar fascia helps

to hold the foot arches up
and keep the bones from 1
spreading under the weight of
the body.
1. Plantar calcaneonavicular 2
(spring) ligament
2. Short plantar ligament
3. Long plantar ligament 3
4. Plantar aponeurosis
4

Plantar Fasciitis – Treatment

With problems of the plantar fascia, it is important to treat the
calf, Achilles tendon and plantar muscles. There are usually soft
tissue restrictions here if the plantar fascia is problematic. A CTM
lock is recommended while the toes are extended. Active work
is essential so that a strong lock can be maintained. A strong
knuckle will prove a useful tool in this treatment.
Active STR to the plantar
fascia.

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 Part 4
Trunk and Neck
THE SPINE

The spine consists of thirty-three individual vertebrae: seven

cervical, twelve thoracic, five lumbar, five sacral (fused) and four
coccygeal (fused). Although only small movements occur between
the vertebrae, the combined action of all of them facilitates good
overall spinal mobility. Between the vertebrae are cartilaginous
discs, which make up approximately one-third of the total height
of the spine. The vertebral column is maintained in its upright
posture by strong ligaments and muscles; it has three natural
curves (four if the sacral curve is included), which together with
the intervertebral discs are responsible for absorbing shock.
Flexible, strong muscles will enhance the fluid content of the
discs and allow efficient maintenance of the spinal curvature.

Most people will suffer with backache at some point in their

lives, although maintenance of correct posture can reduce the
likelihood of injury problems. Good spinal posture places minimal
strain on the muscles that maintain the body’s stance. If the body
sways from its neutral position, the movement is counteracted
by muscles which contract eccentrically. If an inefficient posture
is continued, then adaptive responses lead to poor health of
the muscles, muscle imbalance and dysfunction in the form
of reduced muscle strength, loss of spinal mobility, nerve root
irritation and pain generally. Postural adaptation often develops
over many years, and someone may not be aware of a problem
until the tension and imbalance give rise to a traumatic injury,
such as a prolapsed disc.

The position of the pelvis is affected by the abdominal muscles

and spinal extensors as well as the hip flexors and extensors. An
increase in the lumbar lordotic curve will result in tight hip flexors
and back extensors, weak abdominal muscles and a tendency
to compensatory thoracic kyphosis. The side flexors need to be
evaluated with regard to lateral imbalance. Massage therapists

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must be systematic in treating the hips and antagonists with

any presentation of back pain. There are many different types of
stress placed on posture, and the therapist needs to be aware if
the subject suffers from any of these. There may be a structural
problem, such as a leg length discrepancy. Occupational factors,
for example driving for long hours or sitting behind a keyboard,
may be involved. If sports are the cause, the problem could be
repetitiveness, such as in long-distance cycling, or an overload
of one side of the body, such as in golf or tennis. The root of
the problem needs to be addressed and altered if possible.
Maintenance massage of the back area is invaluable. Correct
posture is still not well understood by the general public so,
following treatment, postural awareness should be discussed
along with mobility, stretching and strengthening exercises (see
Appendix 2).

When someone presents with any neurological deficit or acute

symptoms, input from a medical practitioner is essential, and
STR may not initially be appropriate where protective spasm and
severe inflammation are present. Traumatic injuries sustained
from heavy lifting or falling, and sciatic, disc and degenerative
conditions, will benefit from having the soft tissues strong, supple
and in balance; the timing of the introduction of STR should be
carefully considered for maximum benefit. STR can help improve
movement patterns and relieve nerve root irritation.

Spine Extension
Major Muscles: Erector spinae (iliocostalis, longissimus, spinalis),
quadratus lumborum, interspinales, multifidus, semispinalis and
gluteus maximus (from a flexed position).

The contraction of all three muscles on both sides of the erector

spinae is the main contributor to extension of the back. The
iliocostalis (lateral layer) has attachments that run the length
of the spine. The longissimus (middle layer) and the spinalis
(medial layer) attach to the skull and to the cervical and thoracic
vertebrae. There are many complex muscle contractions that
always occur, as the erector spinae also controls flexion of the
spine and stabilises the non-weight-bearing side, to prevent the
pelvis from dropping, during side flexion. The erector spinae is
also critical in maintaining the secondary curve.

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Deep back muscles.

1. Semispinalis capitis
2. Splenius capitis
3. Semispinalis cervicis
4. Spinalis
5. Longissimus thoracis
6. Serratus posterior superior 1
7. Iliocostalis thoracis
8. Serratus posterior inferior
9. Quadratus lumborum 2
10. Thoracolumbar fascia
(deep layer)
3
6
4
7
5
8

10

The transversospinalis muscles are found deep to the erector

spinae; in order, starting with the most superficial, these are the
semispinalis, multifidus, rotatores and interspinales. The deepest
muscles cross only one or two vertebrae.

Spine Side Flexion

Major Muscles: Quadratus lumborum, erector spinae,
intertransversarii, external oblique, internal oblique, rectus
abdominis and multifidus.

Side flexion is produced by the muscles on the side being flexed.

When standing on one leg, the quadratus lumborum acts strongly
on the non-weight-bearing side to stop the pelvis from dropping.
It also stabilises the twelfth rib during forced expiration, by fixing
the origin of the diaphragm. When the quadratus lumborum

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muscles on both sides contract, they are responsible for lumbar

spine extension and stability.

Spine Rotation
Major Muscles: External oblique, internal oblique, multifidus,
rotatores and semispinalis.

During rotation to one side, contraction of the external oblique

on the opposing side and contraction of the internal oblique on
the same side occurs. The external oblique is the most superficial
side muscle and its origins interrelate with the serratus anterior.
The internal oblique muscle runs diagonally in the opposite
direction.

Fascia of the Trunk

The trunk, like the rest of the body, is covered with superficial
and deep fascia. The deep fascia of the neck area is thick and
strong, enveloping the muscles, and supports and connects the
trunk to the muscles of the shoulder girdle and upper limb. There
is a specialised deep layer of fascia in the lower back known as
the thoracolumbar fascia. It consists of three layers located in the
lower thoracic, the lumbar and the sacral regions. The posterior
layer is superficial to the erector spinae, and the latissimus dorsi
partially arises from it. The middle layer is situated between
the erector spinae and the quadratus lumborum. The anterior
and thinnest of the layers is located in front of the quadratus
lumborum. All three layers converge at the lateral border of
the erector spinae. This then extends to form an origin for the
transversus abdominis and internal oblique.

CTM locks are very beneficial in ensuring that the muscle regains
full separation. As many of the lower back muscles in particular
are very strong, the quality of the lock is crucial for any release
to occur.

The deep fascia of the abdomen is thin and elastic to allow

expansion of the chest and abdomen. The lower abdomen consists
of an aponeurosis (external oblique) and a membrane.

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Spine Extensors, Side Flexors and Rotators – Treatment

With the subject in a side-lying position, make a secure reinforced
lock just above the sacroiliac joint close to the spine; advise the
subject how to perform a posterior tilt of the pelvis. The pressure
should be directed slightly towards the head. The pelvic tilt
provides a small stretch but the movement is controlled and
precise.
Active STR to the erector
spinae as the pelvis is
posteriorly tilted.

Although trunk flexion can be used, the movement may prove

too severe for a lock to be maintained. Apply locks and move up
the whole of the lumbar area, then return and treat more laterally
to the initial locks. Treat around the sacroiliac joint with two or
three CTM locks and either a pelvic tilt or flexion of the spine
or hip. For the quadratus lumborum, use one thumb reinforced
with the other; take the depth of the erector spinae and drop in
on the lateral border of the muscle, in between the rib cage and
the pelvis. Maintain this pressure while the subject extends and
adducts the hip and abducts the arm.

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Active STR to the quadratus

lumborum.

Treatment of the erector spinae can continue until you reach

an area not affected by the stretch from the pelvic movement.
This procedure is usually only beneficial around the lumbar
area. For release in the erector spinae further up the back, it will
be necessary to lock as the subject flexes the trunk; instruct the
subject to arch the back or to push backwards into the lock.

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Active STR to the erector

spinae in the thoracic region
– a lock is attained and the
subject arches their back.

Active STR to the erector

spinae using an elbow.

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The direction of pressure in this case should be towards the base

of the trunk.

On occasion, weight-bearing STR may prove to be a useful

technique. STR can be performed with the subject standing and
holding onto a wall or the couch for support; apply a CTM lock
and instruct the subject to flex or side flex the spine. Another
useful position is with the subject on all fours; lock in on either
side of the spine as the subject arches into the ‘angry cat’ stretch,
and release the lock as the subject returns to neutral.
STR to the erector spinae in a
weight-bearing position.

Seated STR also works well, even on the larger individual.

Because the muscles are under tension it is advised to treat the
top layer of the thoracolumbar fascia, rather than trying to delve

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into the extensors. Apply a CTM lock while securing the subject
across the front of the hips, and instruct the subject to side flex or
flex the spine; severe muscle shortening can be relieved because
of the fascial release.
STR to the erector spinae in
seated.

By having the subject’s arm raised on the side being treated, the
stretch on the latissimus dorsi may enhance the STR effect. Also,
with the subject seated, the quadratus lumborum can be targeted
and the subject can side flex.
STR to the QL in seated.

For the thoracic region, working with rotation can prove to be

valuable in restoring correct movement patterns. Use your elbow
to gently engage the semispinalis thoracis, once the superficial

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shoulder girdle muscles have been released, and instruct the

subject to rotate the spine to the same side for a stretch. Also, lock
deep into the laminar groove to address the multifidus muscles;
instruct the subject to rotate to the same side for a stretch.

Spine Flexion
Major Muscles: Rectus abdominis, external oblique, internal
oblique, and psoas major and minor (when the insertions
are fixed).
Abdominal muscles.
1. Rectus abdominis under
anterior rectus sheath
2. External abdominis
oblique (muscular part)
3. External abdominis
oblique (aponeurotic part)
4. Internal abdominis oblique
5. Posterior rectus sheath
6. Linea alba
7. Transversus abdominis
8. Rectus abdominis 1
9. Anterior rectus sheath

2 5

3 6

4 7

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Flexion occurs during concentric contraction of the muscles on

both sides of the spine. The flexors also affect the position of the
pelvis by modifying its tilt and subsequently the curvature of
the lumbar spine. Attachments of the abdominal muscles to the
pelvis, at the symphysis pubis, and muscles within the abdominal
wall are all occasionally torn, with consequent fascial adherence.
Thickening of the fascia can occur with poor posture, leading
to further postural imbalance and weakness. If the spine flexor
muscles are weak, the pelvis drops, the hip flexors and spine
extensors become hypertonic in relation to the spine flexors,
and the lumbar curve tends towards lordosis. Correct, isolated
strengthening of the abdominal muscles is necessary to regain
lost strength.

Spine Flexors and Rotators – Treatment

With the subject in a supine position, treat the rectus abdominis:
start from the origin on the pubis with a CTM lock, then instruct
the subject to perform a very minimal side flexion. Progress to
the outer borders of the muscle on one side, hooking under it
while the subject side flexes. Angle the lock carefully near to the
insertions to avoid bruising from the bone. See the section on
hip flexors for treatment of the psoas (page 54). The external and
internal oblique muscles may be treated in a similar fashion, by
applying pressure as the subject side flexes. Alternatively, use
a side-lying position, in which a trunk rotation can be used to
provide adequate stretch for a release. Locks must be applied
away from the movement, and pressure should be angled to
produce a shallow CTM lock.

Treatment in a seated position is an excellent way to add in a greater

range of movement when addressing the rectus abdominis or the
oblique muscles. Use broad surface locks, such as the whole hand
or a soft fist, and instruct the subject to side flex to the opposite
side. For release of the internal oblique muscle, lock and rotate to
the opposite side for a stretch; for release of the external oblique,
lock and rotate to the same side.

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STR to the oblique muscles.

STR to the oblique muscles.

Compression of the Abdomen

Major Muscles: Transversus abdominis, external oblique, internal

oblique and rectus abdominis.

These muscles increase abdominal pressure and provide a

muscular support for the pelvis, abdomen and viscera.

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Respiration: Inspiration
Major Muscles: Diaphragm, external intercostals, levatores
costarum, serratus posterior and superior, pectoralis minor and
sternocleidomastoid.

Respiration: Expiration
Major Muscles: Transversus abdominis, subcostales, transversus
thoracis, internal intercostals, external oblique, internal oblique,
latissimus dorsi and quadratus lumborum (fixes ribs).

Diaphragm
The diaphragm is a large sheet of muscle that separates the thoracic
and abdominal cavities. As it contracts it is drawn downwards,
and the subsequent change in pressure causes air at atmospheric
pressure to enter the lungs. When it relaxes it returns to its
initial position and air is expelled from the lungs. During forced
expiration, for example during moderate or heavy exercise, the
expiratory muscles become involved in order to drive air out
more quickly. Through their contraction, there is an increase in
abdominal pressure that pushes the diaphragm up more quickly
to expel air faster. The transversus abdominis (the deepest of the
abdominal muscles) is the most powerful expiratory muscle. The
internal and external intercostal muscles criss-cross the ribs and
are responsible for drawing the ribs together (for expiration) and
apart (for inspiration) respectively.

Respiratory Muscles – Treatment

Treatment of the respiratory muscles is beneficial for anyone
who suffers with breathing difficulties. STR will have a positive
effect on asthma sufferers. Athletes will find it can improve their
breathing techniques, as the chest adopts a new lightness and
freedom.

Ensure that the subject is in a comfortable supine position with

the knees and hips flexed. Gently guide your thumb behind and
in front of the lower ribs towards the anterior attachments of the
diaphragm while the subject is slowly inhaling; hold the position
and allow inhalation to finish. Still maintaining the pressure,

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instruct the subject to exhale gently; after exhalation, release the

pressure. For the intercostal muscles, a side-lying position is a
good way of exposing the ribs. Lock in between the ribs, hold the
pressure and instruct the subject to breathe in and to breathe out.
The external intercostal muscles are the most superficial and are
therefore more directly affected by this technique.
Lock into the intercostal
muscles in between the ribs.

THE NECK

The neck flexors are generally weaker than the extensors, which
have to hold the heavy head in an upright position, against gravity.
The extensors are constantly under tension, contracting statically
and eccentrically to maintain posture. Postural deficiencies
can especially occur with repetitive activities or positions, for
example sitting, writing for long periods, painting a ceiling or
engaging in sports such as cycling. The soft tissues can become
micro-torn and tense; as the activity persists, holding patterns
and imbalances prevail. An increase in the cervical curve, forcing
the head forwards, is a common result. Problems manifest as
movement restrictions, headaches, vertigo, tinnitus, and muscle,
joint and nerve pain. Impingement of vertebral arteries and
nerves can occur, which may not necessarily have a muscular
cause, and medical advice needs to be sought if a subject presents
with dizziness or referred pain that is not clearly muscular in
origin.

As well as controlling specific movements, many of the small neck

muscles are involved in maintaining the balance and stability of

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the head on the neck; these cannot be palpated, so they will not be
discussed. The platysma is the most superficial anterior muscle
and is a thin, flat muscle that adheres to the skin.

Seated STR is a good way to start an assessment and treatment,

and the neck flexors can be generally addressed if the head and
neck are protracted. Then, systematically working the agonists
and antagonists will ensure good recovery of chronic neck
tension and side-effects such as tension-type headaches (TTHs).
This will also facilitate a return to good posture and an enhanced
functional capacity.

Because of its extreme mobility, the neck is also vulnerable to

traumatic injury, an example being whiplash. Following such
injury, there will be ligamentous damage, and the neck muscles
will present with extreme tension. This is due to fierce reflex
muscle contractions that protect the head against rapid movement.
Provided that the results of a medical screening are satisfactory,
STR is an indispensable therapy. Degenerative conditions, such
as spondylosis, can also benefit from STR; use of active STR will
ensure that the subject only moves through a range that can be
performed comfortably. Improving movement and posture will
relieve pressure from the facet joints and discs.

Neck.
1. Splenius capitis
2. Trapezius
3. Sternocleidomastoid
4. Temporalis
5. Masseter (deep part)
6. Zygomaticus major
4
7. Masseter (superficial part)
5

1 6

2 7

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Neck Flexion
Major Muscles: Sternocleidomastoid (SCM), scalenus anterior and
longus colli (flex the neck); longus capitis and SCM (flex the neck
and head); rectus capitis anterior (flexes the head on the neck and
stabilises the atlanto-occipital joint).

Neck Side Flexion

Major Muscles: Scalenus anterior, scalenus medius, scalenus

posterior, splenius cervicis, levator scapulae and SCM (side flex
the neck); SCM, splenius capitis, trapezius and erector spinae
(side flex the head and neck); rectus capitis lateralis (side flexes
the head on the neck).

Neck flexion occurs when the SCM muscles on both sides

contract; side flexion to the same side or rotation to the opposite
side occurs when the SCM on one side contracts. When the head
and neck are fixed, the SCM muscles can raise the clavicles and
sternum, thus assisting inspiration. The scalenus muscles, when
contracting bilaterally, also assist in neck flexion; if only one side
contracts, they assist in side flexion to the same side. The brachial
plexus runs between the scalenus anterior and the scalenus
medius.

Neck Flexors and Side Flexors – Treatment

With the subject in a supine position, support the head with one
hand and gently grasp the SCM with the other hand. Maintain
this hold and instruct the subject to extend the neck.
Active STR to the
sternocleidomastoid.

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Active STR to the

sternocleidomastoid.

Alternatively, gently grasp the muscle and passively move the

neck away from this lock into side flexion; or instruct the subject
to rotate the neck to the same side for a stretch. It is vital not
to move too quickly. If the area is particularly congested, apply
pressure to one side of the muscle at a time. Lock into the muscle
origin, moving to two or three new points to free the clavicular
and sternal fibres. STR at the insertion points of the SCM, on the
skull, is necessary, and a CTM lock will prove highly successful
where fascial thickening is often evident; use of the knuckle away
from the bone is helpful in attaining a lock, but move carefully
into position. The scalenus muscles assist with inspiration, so
incorporating breathing will not only help to relax the subject,
but also directly assist with the release. The scalenus muscles can
be treated by first side flexing the neck to the same side during
inhalation, then gliding away from the clavicle with the lock and
moving the head into side flexion to the opposite side during
exhalation. For the scalenus anterior, lock in just laterally to the
SCM; for the scalenus medius, lock in away from the mid-portion
of the clavicle; and for the scalenus posterior, lock in away from
the most lateral point of the clavicle. Because this whole area can
be highly sensitive, treatment should always be slow.

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Passive STR to the posterior

scalenes.

Neck Extension
Major Muscles: Levator scapulae and splenius cervicis (extend the
neck); trapezius, splenius capitis and erector spinae (extend the
head and the neck); rectus capitis posterior major and minor, and
superior oblique (extend the head on the neck).

Neck Rotation
Major Muscles: Semispinalis cervicis, multifidus, scalenus anterior
and splenius cervicis (rotate the neck); splenius capitis and SCM
(rotate the head and the neck); inferior oblique and rectus capitis
posterior major (rotate the head on the neck).

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Deep back and neck muscles.

1. Semispinalis capitis
2. Splenius capitis
3. Semispinalis cervicis
4. Levator scapulae
5. Rhomboid minor
6. Rhomboid major
7. Spinalis 1
8. Longissimus thoracis
9. Splenius cervicis 2
10. Iliocostalis thoracis
11. Latissimus dorsi
3
9

4
10

5
11

Neck Extensors and Rotators – Treatment

There are two main ways to work this area. Firstly, with the
subject in a supine position, support the head with one hand
and lock into the extensor muscles with the other hand as the
neck is flexed, side flexed or rotated. Systematically release the
superficial layers of the whole of the back and side of the neck;
often, only minimal movement is required for an effective result.
Congestion frequently occurs between the trapezius and the
SCM, within the splenius muscles and levator scapulae. These
muscles may be reached by locking in deep to the lateral border
of the SCM as the neck is side flexed to the opposite side, or as
the subject is instructed to flex the head.

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Active STR to the splenius

capitis.

The upper fibres of the trapezius can be addressed using an index

finger reinforced with the middle finger as the neck is flexed or
side flexed to the opposite side. The deeper extensors can be
engaged as the chin is tucked in for a stretch.

Use a CTM lock to engage the suboccipital muscles as the subject

is instructed to tuck the chin in.

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Active STR to the neck

extensors.

Active STR to the suboccipital

muscles.

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Secondly, in a seated position the subject can perform a variety

of movements of side flexion, flexion and rotation as the
therapist provides a specific lock. This is a highly effective way
of introducing functional awareness as the subject is guided into
a stretch.
STR to the upper fibres of the
trapezius.

STR to the upper fibres of the

trapezius using the elbow.

It is important to achieve the pressure gently and precisely or

movement will be difficult. The trapezius and levator scapulae
can be treated highly effectively this way. The insertion point of
the levator scapulae can be targeted by curling under the anterior
fibres of the trapezius, towards the medial border of the scapula;
the subject can then side flex and flex the neck.

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Temporomandibular Joint (TMJ)

There are three main muscles associated with this joint: the
temporalis, masseter and pterygoids. Problems present as a
general aching in the area, restricted or asymmetrical movement,
and clicking. Dysfunction can occur due to trauma, for example
a whiplash injury or a direct blow in a contact sport. Tissue
congestion can develop from a jaw fracture or loss of teeth, or
after major dental surgery during which the mouth has been
forced open for long periods. Chewing on one side of the mouth
or clenching the teeth may cause an overuse injury to develop,
which can lead to pain and headaches.

Temporomandibular joint.
1. Temporalis 1
2. Masseter
3. Lateral pterygoid
(superior head) 2
4. Lateral pterygoid
(inferior head)
5. Medial pterygoid

TMJ – Treatment
With problems in this area it may be necessary to seek specialist
advice, particularly from a dentist, who will check the bite. STR
treatment should initially consist of a general treatment to the neck.
STR to the muscles which move the joint will help reduce pain
and contribute to the re-education of faulty movement patterns;

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often a dentist will suggest a set of exercises, such as placing the

tongue on the upper palate as the mandible is opened.

Apply a CTM lock to the temporalis and ask the subject to open
the mouth.
Active STR to the temporalis.

Then apply a lock to the masseter and again ask the subject to
open the mouth. Reinforce the index finger with the middle
finger to work more deeply and close to the TMJ to target the
pterygoids. Both sides can be treated at the same time initially;
observe carefully how wide the mouth opens and note any
deviation while palpating the tissues. For more specific STR,
perform the lock to one side at a time but avoid over-treating.

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 Part 5
Upper Limb
THE SHOULDER GIRDLE

The scapula is embedded in strong muscles that attach it to the

thorax, thoracic spine, neck and head; its only bony connection
is to the sternum via the clavicle. This arrangement allows the
shoulder girdle to stabilise shoulder movement and facilitate
considerable shoulder mobility.

Muscular imbalance may occur in this area, causing postural

problems, impaired shoulder movement and pain. Dysfunction
in one part of a single muscle, for example an overuse injury
to the upper trapezius, can alter the balance of the girdle as a
whole. Severe shortening and tension in the upper fibres raise
the shoulder girdle, so the lower fibres opposing this movement
lengthen and become inhibited. A common trunk defect occurring
here is thoracic kyphosis. In this condition, the shoulder girdle
protractors tend towards hypertonicity as activities draw the
shoulders forwards; the girdle retractors and trunk extensors
become inhibited. Many activities encourage the development
of this position, for example working at a computer. Straight-
back conditions arise, as an erect posture is forced; in this case,
it is the retractors and back extensors that become tight and the
protractors that become inhibited.

The sternoclavicular and, more frequently, the acromioclavicular

joints can be injured traumatically, particularly in falls. Injury here
can lead to future problems with hypermobility, instability and
loss of strength. STR around these joints can break adhesive tissue
and contribute to healing, reducing the development of chronic
weakness. Maintenance work around the joints to minimise the
possibility of an individual developing degenerative conditions
from overuse is advantageous for anyone involved in throwing
or heavy lifting.

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Shoulder Retraction
Major Muscles: Rhomboid major, rhomboid minor and trapezius
(middle fibres).

The rhomboids and the trapezius work together to produce

retraction. The trapezius also assists in lateral rotation of the
scapulae, and the rhomboids in medial rotation. Both muscles are
important in stabilising the scapulae during shoulder abduction
and adduction. The trapezius has many functions and therefore
plays a crucial role in the overall action of the upper limb.

Superficial back and shoulder

muscles.
1. Infraspinatus
2. Latissimus dorsi
3. Trapezius
4. Posterior deltoid
5. Teres major
6. External oblique
7. Posterior superior iliac
spine

1 4

2 5

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Shoulder Retractors – Treatment

With the subject in a prone position, apply pressure, working
from the lower to the middle fibres. Lock at points away from
the vertebrae, and locate points away from the outer edges of
the muscle and its insertion points on the spine of the scapula.
Instruct the subject to push the shoulder into the table to
produce protraction. As the trapezius is softened, progress to
the rhomboids. Provided that there is sufficient flexibility in the
muscles and range of movement in the shoulder joint, support
the anterior shoulder and move it into medial rotation, placing
the subject’s arm behind the back. This draws the scapula up so
that the rhomboid attachments can be easily located along the
vertical border.
Active STR to the rhomboids.

Pressure near to the vertebral attachments must also be

administered. After each new lock has been applied, the subject
actively protracts by pushing the shoulder into the supporting
hand.

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The rhomboids and trapezius can be targeted effectively from a

seated position using passive or active STR.
STR to the middle fibres of the
trapezius.

Shoulder Elevation
Major Muscles: Trapezius (upper fibres) and levator scapulae.

As well as facilitating elevation, the levator scapulae works with

the trapezius to produce neck extension when both sides contract.
When one side contracts, side flexion occurs. The levator scapulae
also assists in medially rotating the scapula.

Shoulder Elevators – Treatment

With the subject in a prone position, support the anterior shoulder
under one hand and hook over and into the upper fibres of the
trapezius with the other; maintain the lock and depress the
shoulder with the supporting hand.
Passive STR to upper fibres of
the trapezius.

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 Upper Limb 119

Passive STR to upper fibres of

the trapezius.

Working from the head, the trapezius fibres can be targeted as

the therapist cups the shoulder with the other hand and pushes
it down into depression.

The levator scapulae may be treated in a similar way; the insertion

can be located at the superior angle of the scapula by directing the
pressure under the upper trapezius fibres. It may prove easier for
the subject to actively depress the shoulder so that the lock can be

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maintained; lock in with a reinforced thumb and ask the subject

to slide the hand down the side of the leg. This will generally
cause considerable release in the area.

Shoulder Depression

Major Muscles: Subclavius, pectoralis major, pectoralis minor and

trapezius (lower fibres).

The subclavius prevents elevation and protraction of the shoulder

girdle.

Shoulder Protraction

Major Muscles: Serratus anterior and pectoralis minor.

Chest and anterior shoulder

muscles.
1. Platysma
2. Anterior deltoid
3. Pectoralis major
4. Biceps brachii
5. Sternocleidomastoid
6. Subclavius
7. Pectoralis minor
1 5
8. Coracobrachialis
9. Subscapularis
10. Serratus anterior 2 6

3 7

4 8

10

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The serratus anterior is a girdle protractor and is therefore

highly developed in athletes such as boxers and throwers, for
whom punching and throwing require a powerful forward
movement of the scapula. The muscle also plays an important
role, along with the rhomboids and the middle fibres of the
trapezius, in stabilising the scapula against the thorax during
arm movements. It assists the trapezius in lateral rotation of the
scapula. Weakness or inhibition of this muscle can cause medial
winging of the scapula. The serratus anterior requires particular
attention following shoulder dislocation, as it is susceptible to
loss of strength.

The pectoralis minor assists the serratus anterior in protraction,

and also raises the ribs to assist in forced inspiration.

Shoulder Protractors – Treatment

STR to the serratus anterior is most easily administered with the
subject in a side-lying position. The muscle may be targeted using
fingers to lock in across the muscle, so as to avoid crushing tissue
between the ribs. Gently pull the arm back to extend the shoulder
and produce retraction of the shoulder girdle; alternatively, lock
in and instruct the subject to perform active retraction.
Passive STR to the serratus
anterior.

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Passive STR to the serratus

anterior.

Active STR to the serratus

anterior.

Prior to addressing the pectoralis minor, ensure that the pectoralis

major muscle has been released. Use fingers or a reinforced
phalange to target the pectoralis minor away from the coracoid
process; instruct the subject to retract the scapula into the couch.

With the subject in a supine position, the pectoralis minor can

be reached specifically by abducting the arm to 90 degrees and

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gently delving under the pectoralis major, towards the coracoid

process and the origin of the muscle. Once reached, the depth
should be maintained while the subject raises the arm to draw
the scapula upwards.
Active STR to the pectoralis
minor.

Alternatively, a retraction movement can be achieved by the

subject pushing the posterior shoulder or arm down into the
table. Either way, the pressure needs to be released promptly, as
it can be uncomfortable.

Shoulder Girdle in Side-lying and Seated Positions – Treatment

With the subject in a side-lying position and the shoulder
medially rotated, secure the anterior shoulder and use both
your hands to move the scapula. It is important not to force

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this position if the subject has any restriction; treatment should

continue by allowing the arm to relax in front. Once in position,
focused locks and small precise active movements of retraction,
protraction, elevation and depression, together with appropriate
locks, may be highly effective in freeing the girdle as a whole.
Scapula movement, or lack thereof, can be accurately assessed in
this position, so treatment can have rapid results.

With the subject seated, active STR can be easily administered to

the trapezius and rhomboids as the subject protracts by pushing
the shoulder forwards. A resistance can be supplied here to
enhance the release. The lower fibres can be located as the subject
elevates the girdle by shrugging the shoulders. Very dynamic
active STR can be conducted using broad active arm movements
to produce the required shoulder girdle action.

THE SHOULDER
The structure of the shoulder joint allows an excellent range of
movement; however, because of this, it lacks passive stability and
has to rely heavily on the strength of its surrounding muscles.
Any muscular dysfunction, therefore, will affect the strength of
the joint itself. Following injury, STR involving all movements
is necessary so that an imbalance or restriction does not affect
shoulder mobility and strength.

Shoulder Flexion
Major Muscles: Pectoralis major (clavicular fibres), anterior
deltoid, long head of biceps brachii, and coracobrachialis.

The pectoralis major works in conjunction with the anterior

deltoid and the protractors by moving the arm forwards in
pushing, punching and throwing movements. It is also strong in
adduction, particularly in the horizontal plane.

Shoulder Flexors – Treatment

In a supine position, secure the subject’s arm by grasping the
elbow, to ensure relaxation. Treat the pectoralis major by locking
in at points off the sternum and the clavicle, and conduct

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 Upper Limb 125

combination movements of shoulder extension, abduction and

lateral rotation to produce a stretch; alternatively, instruct the
subject to perform a stretch for active STR.
Active STR to the pectoralis
major – lock with a soft fist
as the shoulder is abducted
(horizontal plane, extended
and laterally rotated).

Treat the whole muscle in this way, applying the pressure slowly
in this sensitive area; towards the insertion points, be sure to
angle the lock carefully. Take hold of the subject’s hand and move
the shoulder into lateral rotation: this is a highly effective stretch
that also works well for the anterior deltoid.
Passive STR – lock and
medially rotate the shoulder.

The long head of the biceps and the coracobrachialis can be

treated by first shortening the muscle and locking in, and then
extending the shoulder. Precise locks delving between seemingly
stringy tendons will provide a noticeable release in this
sensitive area.

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Shoulder Extension
Major Muscles: Latissimus dorsi, teres major, posterior deltoid
and long head of triceps brachii.

Shoulder Adduction
Major Muscles: Latissimus dorsi, teres major, pectoralis major and
coracobrachialis.

The latissimus dorsi is the widest muscle of the back and is a

powerful adductor and extensor of the shoulder. With the arms
fixed above the head, it draws the body up, together with the
pectoralis major, for example in the performance of chin-ups and
dips, in the down stroke of the front crawl swimming cycle and
in climbing. Strains can occur at the tendon insertion, where tiny
STR stretching movements incorporating rotation are beneficial.
The teres major, often termed the ‘little helper’ to the latissimus
dorsi, assists the shoulder adduction muscles but is only effective
if the scapula is fixed by the rhomboids. Three of the muscles are
important for shoulder stability: the teres major helps to stabilise
the humeral head in the glenoid cavity; the latissimus dorsi can
influence the movement of the scapula; and the pectoralis major
keeps the arm attached to the trunk.

Shoulder Extensors and Adductors – Treatment

With the subject prone, lock at points along the latissimus dorsi
up to its insertion at the humerus. For the teres major, treat
from the origin at the inferior angle of the scapula, and apply
pressure at points along the muscle to its insertion point. Each
time, lock and take the shoulder into abduction. This can also
be done in a side-lying position, in which it is easier to instruct
the subject to perform active and resisted movements (see page
31). If the therapist hooks under the latissimus dorsi, away from
the serratus anterior, an active flexion movement will provide a
significant stretch to the muscle and fascia. The posterior deltoid
and long head of the triceps brachii can also be treated with
flexion movements.

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Shoulder Abduction
Major Muscles: Medial deltoid and supraspinatus.

Any movement of the humerus in the scapula will involve the

deltoids. The supraspinatus assists the medial deltoid in shoulder
abduction.

Shoulder Abductors – Treatment

Good results can be obtained with the subject seated upright. For
the anterior deltoid, the lock is enforced while the shoulder is
actively extended; for the posterior deltoid, it is enforced while
the shoulder is flexed. The medial fibres can be shortened slightly
and locked into as the arm is adducted, but this is difficult,
particularly when the deltoids are strong. Alternatively, these
muscles may be treated with the subject side lying. Lock into the
anterior fibres of the deltoid and instruct the subject to extend or
laterally rotate the shoulder. Lock into the lateral fibres and ask
the subject to flex or medially rotate the shoulder.
Active STR to the posterior
fibres of the deltoid.

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To treat the medial fibres of the deltoid, first abduct the shoulder,
then lock in away from the acromion; either adduct the shoulder
yourself or ask for active adduction into your supporting hand.
Passive STR to the middle
fibres of the deltoid.

Active STR to the medial fibres

of the deltoid.

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Alternatively, lock in without shortening the muscle first and ask

the subject to push down (adduct); this will provide a subtle STR
effect.

For treatment of the supraspinatus, position the subject prone

with the shoulder slightly abducted. Prior to administering STR to
this muscle, ensure that the upper trapezius has been sufficiently
relaxed; then apply a deep pressure into the supraspinatus by
hooking your fingers into the fossa area as the subject slowly
adducts the shoulder.
Active STR to the
supraspinatus.

Follow this by applying CTM locks at points away from the spine
of the scapula, superior to it, each time guiding the subject into
shoulder adduction.

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Lateral Rotation of the Shoulder

Major Muscles: Teres minor, infraspinatus and posterior deltoid.

Medial Rotation of the Shoulder

Major Muscles: Subscapularis, teres major, latissimus dorsi,

pectoralis major and anterior deltoid.

Rotator Cuff Muscles

The Muscles: Subscapularis, supraspinatus, infraspinatus and
teres minor.

The rotator cuff muscles are essential for keeping the head of the
humerus in the glenoid fossa during shoulder movement. They
also inhibit upward displacement of the head when the biceps,
triceps and deltoids are active. These muscles are vulnerable to
overuse and traumatic injury. Loss of a particular rotation is a
common symptom in shoulder pain.

As the rotator cuff works collectively, work is necessary on all of

these muscles, as well as other muscles involved in rotation, such
as the pectoralis major and the latissimus dorsi, to encourage
rebalance. To test for medial rotation, ask the subject to put the
dorsal hand on the small of the back; to test for lateral rotation,
ask the subject to put the palmar hand on the back of the head.
Posterior shoulder muscles.
1. Supraspinatus
2. Infraspinatus
3. Posterior deltoid
4. Teres minor
5. Teres major

1 3

2 4

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Shoulder Problems
With any dysfunction or reduced range of movement of
the shoulder, it is imperative to address the shoulder girdle
musculature, but in particular the serratus anterior, pectoralis
minor and upper fibres of the trapezius towards the acromion.
Muscle imbalance in the shoulder girdle and subsequent faulty
movement of the scapula are at the root of many overuse
restrictions which develop in the shoulder joint. For example,
shortened hypertonic serratus anterior and pectoralis minor
will draw the scapula forwards and upwards, thus impeding
abduction of the shoulder.

Impingement syndrome refers to the pain and pressure exerted

on the rotator cuff tendons, positioned under the coracoacromial
arch, during shoulder elevation. The impingement can be caused
by overcrowding of the subacromial space and by weakness and
imbalance of the rotator cuff. STR applied to the shoulder girdle
and rotator cuff muscles is extremely beneficial in the early stages
of this condition, but it is essential that the underlying causes,
such as incorrect muscle balance, posture and technique, are
addressed.

Careful treatment of the muscles will alleviate tendinitis. The

supraspinatus tendon (supraspinatus tendinitis) and the long
head of the biceps tendon are the most commonly affected
tendons in shoulder overuse conditions.

‘Frozen shoulder’, or adhesive capsulitis, is where the joint

capsule adheres to itself, commonly on the underside of the
capsule, limiting abduction and rotation. It is generally considered
to be a self-limiting condition which eventually resolves in
around eighteen months. Addressing the rotator cuff muscles, in
particular the subscapularis, can have a positive effect on this
very painful condition. As controlled movement is a positive step
for all healing, gentle STR can work well in alleviating discomfort
and speeding up the healing process.

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Rotator Cuff – Treatment

With the subject in a prone position, apply CTM locks at points
on the scapula, the infraspinatus and teres minor, and perform
passive STR by slowly taking the shoulder into medial rotation.
Once the area is warmed up, guide the subject into active medial
rotation of the shoulder.
Active STR to infraspinatus.

Prior to treating the supraspinatus, it is necessary to first release

the upper fibres of the trapezius. Stand at the side of the couch
and use fingers, reinforced as necessary, to slowly hook into
the supraspinatus fossa, tweezing through the trapezius fibres;
instruct the subject to adduct the shoulder.

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Active STR to the

supraspinatus.

The musculotendinous junction can be treated with the arm

supported and abducted to 90 degrees. The actual insertion
can be easily located by medially rotating the arm to bring the
attachment point to a more forward and superficial position.
With the arm abducted, and additionally with the arm medially
rotated, it is possible to lock as the subject produces a movement;
resisted STR may prove useful.

The subscapularis is best treated with the subject in a supine

position and the arm abducted to 90 degrees. Lock onto the
anterior surface of the scapula and guide the subject into lateral
rotation of the shoulder.

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STR to the subscapularis.

Treatment to the rotator cuff muscles can be very sensitive for

the subject, so each point should not be laboured: rather, the
whole area should be covered slowly and systematically. Active
STR is extremely useful as re-education is occurring; moreover
it ensures movement within the subject’s comfortable range and
not beyond.

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THE ELBOW
Joint stability at the elbow is predominantly provided by the
collateral ligaments and musculature around the elbow. The neck
should be considered during treatment of any overuse injury to
the elbow. Inflammation of the lateral and medial elbow is related
to the muscles that produce wrist movements. Common overuse
problems originate in faulty techniques, and repetitive gripping
and extension of the elbow such as occurs in racquet sports.

Elbow Flexion
Major Muscles: Biceps brachii, brachialis, brachioradialis and
pronator teres.

The brachialis is the primary elbow flexor and controls the

movement during extension. It has the capacity to develop
myositis ossificans, so extreme care should be taken following a
direct trauma. The biceps brachii is a strong supinator as well as
an elbow flexor, and these actions are often performed together.
The muscle also contributes to shoulder flexion and stability of
the shoulder joint, with its long head being more prone to injury.
The brachioradialis as a flexor works strongly when the elbow is
midway between pronation and supination.

Elbow Extension

Major Muscles: Triceps brachii and anconeus.

The triceps is the only muscle on the posterior of the upper

arm. Because the triceps works strongly in fast elbow extension
movements, it is exercised in any pushing movements, for
example dips and push-ups. Punching or throwing can stress the
attachments. Actual strains are rare, but bad technique can cause
pain and tearing, particularly at the musculotendinous junction.
The anconeus controls extension movements.

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Pronation of the Forearm

Major Muscles: Pronator teres, pronator quadratus and
brachioradialis.

The pronator teres works strongly alongside the flexors during

pronation and flexion movements, such as in the grip in horse
riding. The pronator quadratus is stronger if the pronation is
conducted with elbow extension.

Supination of the Forearm

Major Muscles: Biceps brachii, supinator and brachioradialis.

The biceps brachii is the strongest muscle in supination. The

supinator is exercised most strongly if combined with elbow
extension, and has sufficient strength for slow movements with
minimal resistance.

Elbow – Treatment
With the subject supine and the elbow flexed, gently grasp either
side of the belly of the biceps. Extend and pronate to stretch.
Passive STR to the biceps
brachii.

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Passive STR to the biceps

brachii.

Treat the whole muscle, paying particular attention to the origins

and carefully angling the locks because of the sensitivity of the
area. Treat the lateral side, and direct the lock under the biceps
to work the brachialis. With the shoulder fully flexed beside the
subject’s ear, lock into points along the triceps and flex the elbow.
Pay close attention to the tendon attachments. The supinators
and pronators in the forearm can be worked effectively by
incorporating combination movements of supination or pronation
with flexion and extension of the wrist, to separate the muscles
of the forearm.
Active STR to the triceps
brachii.

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THE WRIST
As with the ankle, there is a band of connective tissue that supports
the many tendons which attach across the wrist joint. The space
created underneath the flexor retinaculum is known as the carpal
tunnel. The flexor pollicis longus, flexor digitorum profundus
and flexor digitorum superficialis, as well as the median nerve,
all pass through this tunnel. The posterior retinaculum holds the
tendons of the extensor muscles in place.

Carpal tunnel syndrome is a result of congestion in the tunnel.

Any repetitive actions involving the flexors, such as gripping,
can cause inflammation in the tendons. If numbness and tingling
are present then the median nerve is also affected. STR is effective
for separating the tendons and the adhesions between them and
the retinaculum. Frequently this condition can be successfully
corrected by surgery, but the use of STR at an early stage can
make an operation unnecessary.

Repetitive strain injury (RSI) occurs with overuse, leading to

adherence and inflammation of the tendons in the posterior
compartment. Activities such as typing or playing the piano
repetitively, or racquet sports where the extensors contract
eccentrically to brace and control the force during backhand
shots, can all cause degrees of RSI.

Wrist sprains are common in contact sports, and STR is a good

form of early treatment to ensure good strength gains. With any
wrist problem, a systematic treatment of the whole forearm and
hand is necessary. Abduction, adduction, flexion and extension
need to be considered. At the wrist, STR can separate adherence
between the individual tendons and the retinaculum.

Wrist Extension
Major Muscles: Extensor carpi radialis longus, extensor carpi
radialis brevis, extensor carpi ulnaris, extensor digitorum
communis, extensor indicis, extensor digiti minimi, extensor
pollicis longus and extensor pollicis brevis.

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Pain located at the lateral elbow is often classified under the

umbrella term of ‘tennis elbow’ (‘lateral epicondylitis’). The
term refers to an overuse injury, common in racquet sports and
manual labour, that leads to chronic inflammation of the common
extensor origin (CEO), resulting in fibrous tissue in the tendon or
musculotendinous junction, or at the tenoperiosteal junction. In
conjunction with RICE and stretching, STR is an invaluable tool
in the management of tennis elbow. A general treatment to the
forearm should be conducted prior to focusing specifically on the
adhesive tissue.

Wrist Flexion

Major Muscles: Flexor carpi ulnaris, flexor carpi radialis, palmaris

longus, flexor digitorum superficialis, flexor digitorum profundus
and flexor pollicis longus.

Anterior arm superficial 1

muscles.
1. Anterior deltoid
2. Biceps brachii
2
3. Bicipital aponeurosis
4. Pronator teres 3
5. Brachioradialis
6.* Abductor pollicis brevis
7.* Opponens pollicis 4
8.* Flexor pollicis brevis
9. Palmaris longus 5
10. Flexor carpi ulnaris
11. Flexor retinaculum
12. Palmar aponeurosis 6
13. Flexor digitorum
9
superficialis 13
14. Flexor carpi radialis 7
10 14
* Thenar eminence
8
11

12

Pain located at the medial elbow, where inflammation develops at

the common flexor origin (CFO), is generally known as ‘golfer’s

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elbow’ (‘medial epicondylitis’). It is less common than lateral

elbow pain and usually responds to treatment faster.

Wrist Abduction
Major Muscles: Flexor carpi radialis, extensor carpi radialis
longus, extensor carpi radialis brevis, abductor pollicis longus
and extensor pollicis brevis (jointly produce wrist abduction
[radial deviation]).

Posterior arm superficial

muscles.
1. Triceps brachii
2. Brachioradialis
3. Anconeus 1
4. Extensor carpi ulnaris
5. Extensor carpi radialis
longus 2
6. Extensor digitorum
7. Extensor retinaculum
3
8. Flexor carpi ulnaris

8 5

Wrist Adduction

Major Muscles: Flexor carpi ulnaris and extensor carpi ulnaris

(work together in wrist adduction [ulnar deviation]).

Wrist – Treatment
With the subject in a supine position, apply STR to the extensors
from the wrist to the elbow by locking in and flexing the wrist.
Concentrate on locking between the extensor muscles to stretch
the fascia where congestion and adherence are often present.

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 Upper Limb 141

If there is any form of ‘tennis elbow’, progress to the CEO and

apply a CTM lock as the subject flexes the wrist. Locate points
at the back of the wrist, separating the extensor tendons from
the retinaculum. Avoid irritating any areas of inflammation,
concentrating instead on releasing the congestion around them.
Active STR to the common
extensor tendon.

Treat the flexors in the same manner, but lock and extend the
wrist to release the tension. Applying pressure between the
flexor tendons at the wrist will relieve carpal tunnel syndrome;
this release may be enhanced by incorporating either abduction
or adduction following the wrist flexion.

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Active STR to the common

flexor tendon.

THE HAND
The thenar eminence is formed by the flexor pollicis brevis, the
abductor pollicis brevis and the opponens pollicis. The hypothenar
eminence is formed by the flexor digiti minimi, the abductor
digiti minimi and the opponens digiti minimi. The ‘anatomical
snuffbox’ is a depression in the dorsum of the first metacarpal,
with the extensor pollicis brevis forming its lateral border and the
extensor pollicis longus forming its medial border. De Quervain’s
syndrome is the name given to tenovaginitis or tenosynovitis
affecting the extensor pollicis brevis and the abductor pollicis
longus.

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Finger Flexion
Major Muscles: Flexor digitorum superficialis, flexor digitorum
profundus, lumbricals, interossei and flexor digiti minimi
brevis.

Finger Extension
Major Muscles: Extensor digitorum communis, extensor digiti
minimi, extensor indicis, interossei and lumbricals.

Thumb Flexion
Major Muscles: Flexor pollicis longus, opponens pollicis and
flexor pollicis brevis.

Thumb Extension
Major Muscles: Extensor pollicis longus, extensor pollicis brevis
and abductor pollicis longus.

Thumb Abduction

Major Muscles: Abductor pollicis longus and abductor pollicis

brevis.

Thumb Adduction
Major Muscle: Adductor pollicis.

Opposing Thumb

Major Muscles: Opponens pollicis and flexor pollicis brevis.

Flexion of Metacarpophalangeal Joints with

Simultaneous Extension of Interphalangeal Joints

Major Muscles: Lumbricals and interossei.

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Finger Abduction
Major Muscles: Dorsal interossei, abductor digiti minimi and
abductor pollicis brevis.

Finger Adduction
Major Muscles: Palmar interossei and adductor pollicis.

Opposing Fingers
Major Muscle: Opponens digiti minimi.

The Hand – Treatment

Sprained fingers and thumbs are typical injuries in ball sports
and gymnastics. STR will speed up the healing process and
recovery. To address the thenar eminence, lock into it and instruct
the subject to straighten the thumb in all directions. For the
hypothenar eminence, lock and straighten the little finger. Treat
the extensors over the top of the hand by locking across and in
between them, and flexing the metacarpals; the finger extensors
should be considered in conjunction with the forearm extensors,
and the palmar hand together with the wrist flexors.
Active STR at the thenar
eminence.

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 Part 6
Pre- and Post-event
Treatment
Event Massage
Event massage means treating an athlete with a particular
performance in mind. It can both enhance performance and speed
up the recovery processes afterwards. Its benefits have become
widely recognised to the point that sports massage therapy is
provided alongside other treatments such as physiotherapy at
most major events involving strenuous physical activity; these
include not only sporting events, but dance and movement.
Most professional sporting bodies employ massage therapists,
and many elite sports people have their own therapists to travel
with them to competitions. Recognition of the value of skilled
massage treatment has also infiltrated at club level sports and
amateur dance. Overall the demand for sports massage therapy
at events has increased enormously in recent years.

Pre-event Massage

Pre-event massage may be conducted a few days before an

event; general massage before an event will ensure that the body
is functioning freely and that the athlete maintains the physical
condition which is essential for ‘peaking’ at the all-important
time. Sometimes a particular area is causing concern and the
therapist can use STR to pinpoint and concentrate on this area.
Deep, preventative massage can be conducted up to about two
days before an event, according to client preference; a much more
considered approach must be taken closer to the event, because
any structural re-organisation, autonomic responses or minor
tissue soreness following treatment, might negatively affect
performance.

Many sports people in the competitive arena would prefer not to

have treatment very close to the beginning of their events if they
find that the therapy involved is not conducive to the mental

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state required for optimum performance. This may be the case,

for example, if they find treatment very relaxing at a time when
they are trying to develop a mood of aggression to aid maximum
performance. Evidence also suggests that muscle power may be
inhibited by traditional massage techniques, such as effleurage,
pre-event. There are, of course, no hard and fast rules for this, as
each individual is different. Obviously it is better if the athlete
and therapist have already worked together so that the therapist
understands the mental outlook and individual preferences of
the athlete, as well as the physical aspects involved. The two can
then work towards the actual event in a partnership based on
mutual understanding and trust. If you do not know the person
well, you must be aware that psychological as well as physical
preparation is important, and accept the athlete’s preference
about how soon before an event the treatment should be given.

Pre-warm-up Massage

It is becoming increasingly common for pre-event massage to

take place at the sports venue prior to performance, but in this
case its exact nature will vary widely according to the subject.
An experienced athlete who has trained for an event invariably
knows exactly how they need to feel, physically and mentally, to
perform well. However, this feeling will vary, not only because of
individual character differences but also because of the differing
demands of various events. Some require the athlete to be keyed
up like a coiled spring ready to leap into action; this may be
the case prior to explosive-type events such as weightlifting.
Others, such as archery or shooting, require a relaxed and calm
approach. Thus, some athletes may choose not to have treatment
immediately prior to warming up, while others might be keen
to have it. The type of treatment will therefore depend on both
individual preference and the nature of the event.

Massage After Warm-up or as Part of the Warm-up

Given the constraints and drawbacks of conventional massage
immediately prior to an athletic performance, STR has several
advantages to offer. For one thing, it can be done actively.
Most competitions require a high degree of physical activity,
in which case warm-up procedures involve a progression to

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dynamic movement. Whereas a relaxing massage using deep,

slow effleurage and kneading could be mentally inappropriate
and might physically make an athlete feel lethargic, weak or
too relaxed, STR can be done very dynamically. The therapist
can use active functional work while the athlete performs
the required movements; this participation gives the feeling
of control that is so important in preparation and warm-up,
and avoids the disadvantage of a massage being too mentally
relaxing. It empowers the athlete, as it uses movements within
the functional range that is generally included in the routine
dynamic preparation.

Another advantage of STR treatment at an actual competition

event, where there may be minimal facilities, is its versatility.
It is so easy to improvise with STR and give useful treatment
without a couch. Treatment can quite easily be carried out sitting,
kneeling, or on the ground and this informality mixes well with
the mounting excitement that is part of working and competing
at an event. STR can be conducted, for example on the calves,
with the athlete standing and weight bearing. It can also be
administered through clothes without using oil or lotion; this has
obvious benefits, particularly in cold weather when no shelter is
available.

Yet another advantage of STR in a pre-event situation is its

economy of time. In team sports it would be impossible to give
everyone in the squad a general pre-event massage if you were
the only therapist. By using STR, attention can be given to all
team members, if necessary, as key areas can be treated quickly
and precisely without any time wastage.

Lastly, prior to competition, many sports people would not

want oil or lotion on their skin, and STR is a useful technique for
warming up or releasing the soft tissues without the application
of a lubricant; in racquet sports and kayaking, for example, a good
grip is essential, so having residual lotion on the hands would be
detrimental to these activities.

Pre-event Massage and Injury

Sometimes an athlete may suffer from a minor injury and be
faced with the difficult decision of whether or not to compete

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or perform. For someone at the pinnacle of a career, it can be

devastating to miss an important event because of a minor injury.
Often the decision is made to compete anyway, even if this means
aggravating the injury or giving a disappointing performance.

The final decision lies ultimately with the physiotherapist, the

coach, the athlete and maybe even the doctor. Once the decision
has been made to go ahead, STR may have an important role to
play alongside other interventions, such as taping. The aim of
the treatment is not to cure but to enable the athlete to perform
more comfortably with reduced risk of worsening the injury.
The therapist must help the athlete to manage and alleviate the
symptoms. Exactly which treatment is given will depend on
how imminent the event is. Complete healing needs time, as it
involves biological processes. In many cases the body can react
to initial treatment negatively, as the breakage of scarring and
the separation of adhesions can leave residual discomfort or
inflammation. By definition, time is exactly what is not available
in a pre-event treatment.

If treatment for an injury is administered prior to an event, it

should be made clear to the athlete that the treatment is not a
cure but only an interim measure to help alleviate symptoms.
A controlled approach, rather than a treatment approach, is
therefore adopted.

As an example, consider a middle-distance runner competing at

a top-level competition. The athlete is expected to reach the final,
but a painful condition presents itself, suggesting possible medial
tibial stress syndrome. The cure for this condition could involve
a course of treatment and exercises aimed at the deep posterior
compartment; each of these treatments could leave the athlete
feeling initially sore and unable to run well. In this case, as an
interim measure, careful use of STR could relieve some of the
pressure from the tibia and its inflammation, thus alleviating the
pain, though not actually removing the cause. In conjunction with
periodic icing, gentle treatment to the whole lower leg around
the adhesive tissue would ensure maximal release and minimal
aggravation, which will give the athlete a chance of running as
well as possible. More work should be conducted in and after the

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 Pre- and Post-event Treatment 149

cool-down, and the athlete should be made aware of what needs

to be done for an actual cure in the long term.

In brief, pre-event massage for injury involves a management

approach: it should be non-invasive and non-aggravating, with
the aim of decongesting and aiding movement and function where
possible. It can be used in conjunction with specialised taping
such as unloading techniques which are designed to compress
and protect fibres from overuse. The subject must understand the
limitations of what is being done.

Post-event Massage

The main objectives of post-event massage are to speed up the

subject’s recovery and to ensure maximum return to full function.
It should not be seen as an alternative to cool-down procedures,
although post-event massage will be a good substitute if an
athlete is so exhausted or injured that cool-down exercise is
impossible; this is because massage gently stretches the tissues,
and, like a cool-down, removes waste products from the muscles
by enhancing circulation.

As well as affording both mental and physical relaxation, post-

race massage helps reduce the possibility of injury and enables an
athlete to return to training more quickly than would otherwise
be the case.

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It is important that the subject should understand that post-event

massage is not curative. Immediately after an event is not the
right time to delve into the tissues; the athlete may be exhausted
with micro-traumas and is possibly dehydrated and susceptible
to cramp. Instead, muscles need to be gently relieved of their
congestion by elongating and stretching fibres. The therapist
applies soothing and recuperative massage that makes the
muscles pliant and soft. If there is an actual injury, it is better to
simply apply ice, leaving specific treatment until after recovery
from the event. Use of STR may be minimal or very gentle;
effleurage and kneading strokes should dominate the post-event
massage. This type of post-event massage is often termed as a
‘flush’. If the athlete chooses to have an ice bath to aid recovery,
the massage flush should be conducted first.

To cope with post-event massage, as with pre-event massage,

improvisation, versatility and expertise are necessary because
unpredictable factors invariably arise. For example, weather
conditions may bring about additional problems, and time
management is almost bound to be difficult; sometimes the
therapist may be trying to cope with a queue of cold athletes with
very little shelter available. It is all part of the challenge of event
massage.

Between-event Massage
Occasionally, a therapist is asked to help someone in a situation that
is a combination of post- and pre-event conditions. Examples of
this include: between scenes at a dance performance, a decathlon
competition, and between an individual race and a team relay. In
such cases, a combination of recovery and preparatory techniques
is required. Obviously the therapist will need to use judgement
and experience to assess physical factors and will also need to be
sensitive to the mental state of the subject.

Event massage can be extremely exciting and rewarding; it can

also be emotionally draining, as the therapist shares the athlete’s
hopes, anxieties and anticipations. Ultimately, it is one of the
most rewarding aspects of sports massage.

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 Part 7
STR and the Young
Athlete
Observing young children in natural play is fascinating. They
unselfconsciously utilise many aspects of fitness and conditioning
that promote good overall fitness and balance. This includes
producing bursts of effort, jumping over things, climbing in
playgrounds and up trees, balancing on logs, skipping and
hopping, to name a few. When they fall and hurt themselves,
they generally bounce back very quickly and easily because of
these preventative and re-educational exercises that they perform
without realising their physical value. So, if children are allowed
to enjoy themselves by continuing with varied activities, they are
unlikely to develop chronic pain patterns. It is not advisable for
children to be encouraged into repetitive movements or to be put
under too much emotional pressure.

As they become older, children often become involved with

formal training and coaching in specific sports or other activities
such as dance. This is good for mastering the technical aspects
of a particular activity and for developing the specific physical
attributes needed to perform the activity well; for example,
flexibility is a prerequisite for gymnastics. This early coaching
may mean that they will reach high standards in their given
sports or activities, or that they reach skill levels that bring
them lifelong joy in performing. Good technique also minimises
the risk of injury. It is essential, however, that the coach has a
good knowledge and understanding of the developing body.
Too much force through muscular contraction and impact can
have a detrimental effect on the soft tissues and on the growing
skeleton. Serious signs of pain must be heeded. Good coaches
should also be knowledgeable about when their young athletes
are likely to be going through a growth spurt; training should
possibly be eased off at this time, and more emphasis placed on
co-ordination and recovery. Observing the early signs of growing
pains or overtraining, both physically and mentally, will reduce
the time needed for total rest.

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 152 Soft Tissue Release: A Practical Handbook for Physical Therapists

STR Is a Valuable Technique to Use on Children

1. STR can educate the young person in body awareness. It helps
the person to tune in and locate where a restriction may be,
and to understand that any pain or tightness experienced may
be due to a restriction located more distally. It may also help
with the person’s skill acquisition and the development of
motor co-ordination.

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 STR and the Young Athlete 153

2. STR can provide relief from psychological or emotional stress.

This may be due to being anxious over a competition, worrying
about exams or being concerned about friendship groups at
school. STR can also provide relief from physiological stress,
such as a build-up of tension in the neck and shoulders from
too much texting or carrying heavy school bags!

3. Caught early, STR can help with ‘growing pains’. Sometimes

children develop tight muscles from being very active, and
certain muscles can just ache, particularly at night; STR can
provide fast relief by releasing this tension.

4. With conditions such as Osgood–Schlatter’s and Sever’s

diseases, STR can be used to lengthen and ensure good muscle
group separation, thus easing the traction at the tendon
attachment. In the case of Osgood–Schlatter’s disease, STR is
administered to the quadriceps and patellar tendon; for Sever’s
disease, STR is performed on the gastrocnemius, soleus and
Achilles.

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 Part 8
STR and Pregnancy/
Post-pregnancy
STR can very beneficial for the pregnant woman – the dynamic
nature of the technique makes it easy to use in side-lying and
seated positions. The changing biomechanics as the baby grows,
and adaptation to an altered centre of gravity, mean that the
musculature of the mother-to-be will be susceptible to imbalance.
This tendency is exacerbated by the soft tissue laxity to allow
for childbirth. Labour may also be traumatic, and she is likely to
have weakened abdominals following the birth. Liaise with the
midwife or doctor on any necessary treatment.

STR Is a Useful Technique Through Pregnancy and

Early Parenthood
1. STR can address muscle imbalance and provide re-education
in a neutral posture.

2. The common aches and pains of pregnancy, such as in the

lower back and lumbosacral junction, can be easily relieved.
An extremely useful technique is the ‘angry cat’ stretch in
conjunction with STR (see page 98).

3. STR of the lower back and hips, particularly the adductors and
hip flexors, can help SPD.

4. STR can help in restoring muscle balance following labour. It

can also help in addressing all the early pains of physically
adapting to a newborn baby, such as protracted shoulders
from feeding and lifting, and asymmetrical problems from
carrying the baby on a preferred hip.

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 Part 9
STR and the Older
Person
As we get older our connective tissues harden: water molecules
no longer combine easily with collagen in the connective tissue
matrix and it becomes more dehydrated. Old traumas, repetitive
strains and the growing number of years of adapting to the
postural stresses of life all contribute to the stiffening of the
connective tissues.

Aging Athletes

Many active people quite happily reduce their training, certainly

the intensity of it, as they acquire more pains and restrictions;
they accept the old adage ‘I’m getting older and it is to be
expected.’ However, it should be remembered that movement
is an essential component in maintaining the lubrication of the
connective tissues. Moreover, micro-tearing and repair is how
muscles maintain strength for a particular activity, so movement
should not be discontinued. There is research to indicate that
the older athlete slows down dramatically mainly because the
intensity of training has dropped.

It is therefore advisable to maintain a good level of training,

although it may be wise to reduce some of the more vigorous
contact sports or activities that involve a lot of impact or twisting
and turning. With the older athlete, more emphasis should be
placed on recovery, and STR is a valuable tool for enhancing
tissue repair. The aging athlete should perhaps consider reducing
not so much the intensity of training as the overall amount of
training. For example, reduce the number of actual training
sessions and allocate more time for rest and recovery; this may
include stretching and subtle strengthening such as appropriate
exercises in Pilates.

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 156 Soft Tissue Release: A Practical Handbook for Physical Therapists

STR and General Aging Problems

Many movement restrictions accepted as ‘old age’ can be
alleviated. A common age-related symptom that an older person
may notice is a difficulty in turning the head without rotating the
trunk; this can become apparent, for instance, when reversing the
car. This restriction is usually of gradual onset and is commonly
linked to shortening of the shoulder girdle protractors and
neck flexors, following a lifetime of sitting for long periods
with the shoulders and head protracted. Treatment with STR
to the shortened muscles, along with re-education in postural
awareness, can significantly improve the range of movement and
reduce any associated pain; if caught early, degenerative changes
in the neck can be minimised.

Many older people suffer with osteoarthritis, which is

inflammation of the joints, caused by wearing away of the articular
cartilage. It is worsened by excessive wear, previous injury and
muscle imbalance. There is also a hereditary link, so some people
may be more predisposed to developing the condition.

Movement and addressing muscle imbalance can prove

invaluable in reducing joint pain. Movement encourages the
secretion of synovial fluid. Addressing restrictions in the soft
tissues that act on a joint will help restore improved movement,
which will in turn help with secretion of synovial fluid – a cycle
which will keep the cartilage nourished.

Often someone develops osteoarthritis because of a long-term

imbalance around a joint. A common example is at the knee,
where the quadriceps, primarily the rectus femoris, can become
chronically shortened, a condition exacerbated by a sedentary
lifestyle. Shortened quadriceps restrict knee flexion, and over a
prolonged period of time this altered biomechanics will cause
uneven pressure and wear on the joint surface at the knee, leading
to inflammatory changes. If caught early, and the tension in the
quadriceps is released, future pain from osteoarthritis can be
minimised. If detected later, there is much anecdotal evidence to
support treatment of the quadriceps prior to surgery, to enhance
recovery following a knee replacement.

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 STR and the Older Person 157

STR and Osteoarthritis

1. Do treat all associated muscles that affect movement of the
joint; in particular release hypertonic tissue.

2. During an acute phase, avoid treating the inflamed area at the

joint itself.

3. Do treat around the joint after a period of inflammation, to

release any scar tissue, adhesion and thickened connective
tissue.

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 Part 10
Self-treatment
Correct use of self-treatment will aid in recovering from the stress
of intense training or a tough day at the office! Often a therapist
may not be available, or the lack of time and/or money makes
it impossible to have regular treatment. Frequent short sessions
of self-treatment can make a huge difference in minimising the
risk of injury by easing muscle tension and releasing tissue
restrictions.

STR is easier to administer on yourself than many other massage

techniques because the muscles do not have to be totally relaxed
for treatment to take place. Moreover, because much of the
technique is active, all the subject has to do is locate the problem
area and move into a stretch. The dynamic nature of STR makes
it simple to perform on yourself.

In fact, the treatment is almost instinctive. Someone with a stiff

neck may clutch at the upper trapezius and move the head from
side to side or shrug the shoulder. A little guidance would actually
make this reaction quite effective for relieving the adherence and
hypertonicity. Use of a massage tool, such as a thera cane (like
a shepherd’s crook), can make the self-treatment easier: hook
the thera cane over the shoulder to target the area between the
scapulae as you protract the shoulder girdle.

Self-treatment is also a must for any therapist who is at risk of

developing overuse injuries in the elbows, wrists and thumbs.
These areas are not difficult to reach, so maintenance should be
easy!

The following figures show a few examples of self-treatment, but

they are by no means exhaustive.

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 Self-treatment 159

Rest the hamstrings on up

turned fingers to maintain
a deep lock as the knee is
extended.

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 160 Soft Tissue Release: A Practical Handbook for Physical Therapists

Use fingers to drop in off the

clavicle into pectoralis major
or lock deeper into pectoralis
minor as the shoulder is
horizontally abducted.

Use fingers to hook into the

middle fibres of the trapezius
and the rhomboids as the
shoulder girdle is protracted.

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 Self-treatment 161

Hook into the upper fibres of

the trapezius as the neck is
side flexed.

Use knuckles to lock into the

erector spinae as the spine is
flexed.

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 Appendix 1
Anatomical Movements
Flexion Reduction in joint angle during
movement.
Extension Increase in joint angle during movement.
Abduction Movement away from the midline of the
body.
Adduction Movement towards the midline of the
body.
Medial Rotation Rotation around a longitudinal axis
towards the midline of the body.
Lateral Rotation Rotation around a longitudinal axis away
from the midline of the body.
Circumduction Combination of flexion, extension,
abduction, adduction, and medial and
lateral rotation.
Elevation Movement upwards.
Depression Movement downwards.
Retraction Movement of the scapulae backwards
towards the midline of the body.
Protraction Movement of the scapulae or the head
forwards.
Lateral Rotation Movement of the inferior angle of the
of the Scapula scapula laterally as the acromion moves
into elevation.
Medial Rotation Return of the inferior angle medially as
of the Scapula the acromion moves into depression.
Supination Movement of the palm to face upwards.
Pronation Movement of the palm to face
downwards.
Plantar Flexion Movement of the sole of the foot
downwards.
Dorsiflexion Movement of the top of the foot towards
the anterior of the tibia.
Eversion Turning of the sole outwards so that the
weight is on the inside edge of the foot.
Inversion Turning of the sole inwards so that the
weight is on the outside edge of the foot.
Toe Flexion Movement of the toes downwards.
Toe Extension Movement of the toes upwards.

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 Appendix 2
Common Postural
Deficiencies
SIDE VIEW
Head Position Excessive inward curve (convex) of the
cervical spine, or poking the chin
forwards.
Thoracic Kyphosis Exaggerated concave curve of the thoracic
spine.
Straight Back Reduction in the concave curve of the
thoracic spine.
Lumbar Lordosis Exaggerated convex curve of the lumbar
spine.
Flat Back Reduction in the convex curve of the
lumbar spine.
Pelvic Position Anterior or posterior tilt of the pelvis.
Sway Back Forward position of the pelvis, in either a
neutral or a posteriorly tilted position, in
relation to the back and legs.
Genu Recurvatum Sway-back knees.
Pes Planus and Flat foot and high arch.
Pes Cavus

POSTERIOR VIEW
Head Position Head turned to one side.
Scoliosis Lateral deviation or curve of the spine.
Scapulae PositionsLevel of inferior angles of scapulae. Level
of acromion processes. Scapulae winging.
PSIS Positions Level of posterior superior iliac spines.
Genu Valgum Varum Knock-knee and bow-leg.
and Genu
Foot Position Excessive eversion (pronation) of the mid-
foot, calcaneal eversion or inversion.

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 164 Soft Tissue Release: A Practical Handbook for Physical Therapists

Postural balance.
1. Neck
2. Shoulder girdle
3. Lumbar
4. Pelvis
1
5. Knees
6. Feet 2

The spine.
1. Cervical curve
2. Thoracic curve
3. Lumbar curve
4. Sacral curve
5. Coccyx

Soft Tissue Chapter 7 8 9 10 end.indd 164 6/8/12 12:20:21

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 Index
Achilles tendon, 79 Ice, 16
Adhesions, 20 Iliopsoas, 53
Adhesive capsulitis, 131 Iliotibial band, 62; syndrome, 74
Anatomical movements, 162 Immobilisation, 17
Anatomy trains, 18 Inflammation, 21
Ankle, 84 Injury, acute, 12; ligament, 12; overuse, 7,
16, 57, 77; prevention of, 16; sub-acute,
Carpal tunnel syndrome, 138 12; tendon, 12; traumatic, 17
Compression of abdomen, 102
Connective tissue, 10; massage, 14, 33 Knee, 66; extension, 70; flexion, 66;
problems, 73
Diaphragm, 103 Knuckles, 36
Dorsiflexion, 81
Lateral epicondylitis, 139
Elbows, 36, 135; extension, 135; flexion, Lateral rotation, 42
135 Lock, application of, 32, 34
Longitudinal arches, 89
Fascia, 7, 10, 21, 33; of the trunk, 94 Longitudinal stress, 15
Fingers, 36, abduction, 144; adduction, Lordosis, 53, 91
144; extension, 143; flexion, 143;
opposing, 144 Manual therapy, 24
Flexibility, 34 Massage, 13, 16, 18; after warm-up or
Foot, 87; eversion of the, 83; inversion of as part of the warm-up, 146; between-
the, 82 event, 150; event, 145; post-event, 149;
Forearms, 36; pronation, 136; supination, pre-event, 145, 147; pre-warm-up, 146
136 Medial epicondylitis, 139
Friction, 32 Medial rotation, 45
Frozen shoulder, see adhesive capsulitis Medial tibial stress syndrome, see shin
splints
Gluteus maximus, 40 Mobilisers, global, 22
Golfer’s elbow, see medial epicondylitis Muscle, balance, 22; imbalance, 9;
Groin strain, 57 tightness, 20
Muscle energy techniques, 35
Hamstrings, 46 Myofascia, 10, 11, 21
Hands, 36, 142
Hip, 40; abduction, 62; adduction, 57; Neck, 104; extension, 108; flexion, 106;
extension, 40; flexion, 53 rotation, 108; side flexion, 106
Hypertonicity, 20 Neuromuscular techniques, 14

Oedema, 21
Osgood-Schlatter disease, 74
Osteoarthritis, 156, 157
Over-pronation, 85

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 168 Soft Tissue Release: A Practical Handbook for Physical Therapists

Patella tracking, 73 Tendinopathies, 12, 79

Patellar, retinaculum, 66; tendon, 66, 75 Tennis elbow, see lateral epicondylitis
Pelvic girdle, 39, 91 Tenosynovitis, 13
Peritendinitis, 13 Tenovaginitis, 13
Plantar fasciitis, 89 Tensor fasciae latae, 62
Plantar flexion, 76 Texture, 19
Posterior tilt, 54 Thixotropy, 11, 14
Post-isometric relaxation, 35 Thoracic kyphosis, 91
Postural deficiencies, 163 Thoracolumbar fascia, 94
Posture, 36 Thumbs, 36; abduction, 143; adduction,
Pressure, 27, 34 143; extension, 143; flexion, 143;
opposing, 143
Reciprocal inhibition, 31 Toe abduction, 89; adduction, 89;
Repetitive strain injury, 138 extension, 87; flexion, 8
Research, 14 Tools, 36
Respiration, 103 Training, 16
RICE, 12 Treatment, dorsiflexors, 81; elbow,
Rotator cuff muscles, 130 136; gluteus maximus and the deep
lateral rotators, 42; hamstrings, 48; hip
Sacroiliac joint, 39 abductors and ITB, 63; hip adductors,
Scapula, 115 58; hip flexors, 54; invertors and
Scar tissue, 20 evertors, 83; knee, 74; knee extensors,
Self-treatment, 158 71; knee flexors, 67; lumbosacral
Seven-second test, 21, 22, 27, 86 junction and sacroiliac joint area, 45;
Shin splints, 84 medial rotators, 45; neck extensors
Shoulder, 124; abduction, 127; adduction, and rotators, 109; neck flexors and
126; depression, 120; elevation, 118; side flexors, 106; plantar fasciitis, 90;
extension, 126; flexion, 124; girdle, 115; plantar flexors, 77; respiratory muscles,
lateral rotation of, 130; medial rotation 103; rotator cuff, 132; shin splints, 85;
of, 130; problems, 131; protraction, 120; shoulder abductors, 127; shoulder
retraction, 116 elevators, 118; shoulder extensors
Soft tissue, assessing, 19; dysfunction, 7 and adductors, 126; shoulder flexors,
Spine, 91; extension, 92; flexion, 100; 124; shoulder girdle in side-lying
rotation, 94; side flexion, 93 and seated positions, 123; shoulder
Stabilisers, global, 22 protractors, 121; shoulder retractors,
STR, active, 29, 30; application, 35; 117; spine extensors, side flexors and
benefits, 28; older person and, 155; rotators, 95; spine flexors and rotators,
passive, 29; pregnancy and, 154; 101; temporomandibular joint, 113; toe
technique, 27; tips, 38; types, 29; weight- extensors, 87; toe flexors, 87, wrist, 140
bearing, 29, 31 Turf toe, 86
Stretch, 34
Stretching, 17 Wrist, 138; abduction, 140; adduction,
Swelling, 21 140; extension, 138; flexion, 139; sprains,
Synovial plica, 73 138

Temporomandibular joint, 113 Yoga, 24, 25

Tendinitis, 13, 74 Young athlete, 151

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