By Jeffrey Addley, Registered Massage Therapist
In sports that require sprinting, such as track and field, soccer and rugby; a hamstring strain injury is especially common. To an athlete this can set them back weeks, if not months in their training.
Often, athletes will experience an immediate decrease in range of motion (ROM), bruising, swelling, and pain with movement. As our bodies are incredibly adaptable to change, a hamstring strain can alter the ability to walk properly, balance, and even stand up from your chair.
As a result, an automatic shifting of weight to the unaffected side will occur in order to alleviate the sense of pain and discomfort that may lead to further injuring the area. Thomas Myers describes this response beautifully when addressing what pain really is in the body; “the sensation accompanied by the motor intention to withdraw.” This instinctive response is not only protective, but very informative to the possible changes that may have occurred along with the injury.
Since a muscle strain is a result of an overstretched or forced overloading contraction on a muscle; that message is not only sent through the muscle tissue, local blood vessels, and nerves, but also along the highly sensitive fascia.
Fascia is described as “interpenetrating and surrounds all organs, muscles, bones, and fibers endowing the body with a functional structure, and providing an environment that enables all body systems to operate in an integrated manner.” This massive network not only creates structure and holds us together, but is also theorized to have six to ten times more mechanoreceptors than in muscle tissue.
Looking at this tissue from a manual therapists standpoint, fascia can be broken down into three main layers: the superficial layer (which lies between the skin and adipose tissue), the deep layer, (extending throughout the body and numerous muscle expansions, bounding ligaments, tendons, and muscle), and the deepest facial layer – the subserous fascia – lying between the serious membrane (a lining of body cavities) and deep fascia. A great example of fascia and its various intertwined layers can be seen in the marbling of a pork shoulder, separating the neighbouring muscle fibers, fascicles, and fat tissue.
Fascial stretch therapy (FST) is a unique table-based therapy that targets tissue – specifically, the superficial and deep layers – by utilizing proprioceptive neuromuscular facilitation (PNF) in combination with gentle low-grade manual joint mobilizations (tractions and glides) deep within the joint capsule. Performed without the use of any lotions or oils, FST is easily applied in a manual therapy session or as a stand-alone therapy, that focuses on the fascial system rather than isolated muscle or fascia, such as with traditional Swedish massage or myofascial release (MFR).
FST uses a unique framework as its main guiding points, known as fascial lines. These twelve myofascial lines are described by Thomas Myers (2008), as “strings of connected fascia that follow postural and movement patterns of the body.” The most recognizable fascial line is the superficial back line (SBL), depicted as travelling from the plantar surface of the feet into the achilles tendon, to the condyles of the femur and meshing into the hamstrings to the sacrotuberous ligament and sacrolumbar fascia. It follows up to the erector spinae muscle group, to the occipital ridge and wrapping over the skull via the epicranial fascia to the supraorbital ridge on the frontal bone. In a 2016 lecture by Dr. Robert Schleip; at the meeting of the European Rolfing Association in Munich, Germany, described supportive findings made on the presence of a number of these fascial lines. Stating that during his ongoing research there is strong evidence of the facial connection through the SBL, functional back line, (FBL) and functional front line (FFL); as well as moderate evidence in the spiral line (SL) above the pelvis and lateral line (LL) in the leg and pelvis.
Taking this fascial line theory of interconnected postural movement patterns further, it’s hypothesized that by applying FST to the hip, a release of facial restriction could occur in neighboring regions, resulting in a cross-communication response.
In a 2018 clinical study at the Institute of Technology Tralee; a total of 23 active male and female participants aged 18-57 were selected to take part in a study on the application of FST and its effectiveness in increasing unilateral active and passive hip flexion. All participants presented with minor to moderate lower back pain (0-4/10 on the pain scale) and chronic hamstring tension. Bilateral measurements of active and passive straight leg hip flexion were collected, and participants received a 20 minute FST treatment on the right leg and hip only.
Post-therapy results showed not only an increase in hip flexion in the treated leg; greatest being in active measurements at 8.220, but also in the untreated (left) leg at a 5.080 increase. Furthermore, participants reported feeling of lightness and more fluid movement within both hips, as well as a significant decrease in overall lower back pain.
FST is unique as the therapy focus is on releasing restrictions not only along the length of a muscle but more importantly at the point where movement occurs; within the joint capsule. This study demonstrated that FST applied to the right hip produces a relatable response in the left hip through cross-communication along the body’s facial lines. It’s encouraging to say that FST can be used early on in a client’s rehabilitation as an indirect treatment method. Incorporating this therapy into a treatment plan; fascial pliability can be more globally managed and reduce further restrictions along the facial lines to encourage the healing process.
PUT INTO PRACTICE
Fascial tissue is highly responsive to movement; so when assessing a client’s ROM, it’s important to concentrate on how the body responds to different ranges and angles. Warming up the joint with a gentle circumduction motion is a great place to start. Gradually increasing in range will give the therapist and client a sense of how that joint likes to move, and allow you to feel for any clicking, popping, and sticking within that joint. It’s a lot like going through your various running drills before a race. You want to be sure your muscles are warm, ROM is fluid, and your feeling energized and ready for the event.
As FST is about feel and maintaining a loose and relaxed body, coaching your client through deep, slow diaphragmatic breaths allows you to work without any unwanted resistance, and improves your ability to feel for the points of restriction. Finding the first point of resistance, also known as the R1, is key in producing the best results, as it will be well within the clients stretch tolerance and decreases the risk of any pain or discomfort with each technique. It’s important that the clients experience is as pain-free as possible, and with each increase in range the limb is taken into a slightly different angle of approach, so to address different fibers of the facial tissue and points of the joint capsule. The tissues should release without much effort from the therapist and respond to the therapy gradually. Taking your time to bring the limb into new ranges allows the body to process the change and release for further ranges without any kickback from the client.
FST not only applies a stretch to the tissue but also incorporates constant traction and subtle glides in the joint when reaching new ranges. The deeper and further you take a client into these new ranges the more resistant they can become. Often times clients will hold their breath, tense up, or wiggle away to “get through the pain,” creating unwanted stress on the client as well as the therapist, which can potentially lead to injury. All of these signs of pain and discomfort can easily be adjusted by reducing the depth and angle of a stretch, or simply syncing your clients breathing with each technique; remembering to exhale slowly as you take them into new ranges. Feedback throughout the therapy from your client allows the therapist to focus on releasing the restrictions from the tissue itself – not the client resisting.
Key points to take away from the study and how to approach it in practice:
1. Assess movement patterns (gait, squat, or specific athletic movement) and repeat with manual ROM tests (active, passive, resisted) on the table.
2. Always start on the unaffected side to see what the client’s normal ranges are
3. Feel how the joint moves in a relaxed state (checking for popping, clicking, and sticky spots)
4. Find the barriers of resistance in various angles
5. Sync breathing (clients and yours) with each stretch movement
6. Take your time, use your body weight, and remember less is more
7. Re-test and adjust accordingly
FST can be described as a way to release and “melt away” restriction in the fascial tissue to improve resting patterns and movement. In a clinical setting, adding fascial stretch therapy to your services can help broaden your approach to injury rehabilitation. Treating the body as a vast interconnected unit is a growing trend in manual therapy and offers new perspectives as to how rehabilitation for an injury can be planned out. As fascial tissue interpenetrates and surrounds all organs, muscles, and bones to create a functional structure; treating the bodies fascial lines as a system of its own allows the opportunity for the body to heal as a whole.
• Adstrum, S., Hedley, G., Schleip, R., Stecco, C., Yucesoy, C.A., 2017. Defining the Fascial System. Journal of Bodywork & Movement Therapies, 21, pp. 173 – 177
• Myers, T.W. 2008. Anatomy Trains 2nd Edition: Myofascial Meridians for Manual and Movement Therapists. Churchill Livingstone
• Schleip, R. 2017. Fascia as a Sensory Organ: A Target of Myofascial Manipulation. [pdf] Available at: < http://axissyllabus.org/assets/pdf/Schleip_Fascia_as_a_sensory_organ.pdf.
• Stecco, A., Macchi, V., Masiero, S., Porzionato, A., Tiengo, C., Stecco, C., 2008. Pectoral and Femoral Fascia: Common Aspects and Regional Specializations. Surgical and Radiologic Anatomy. 31(1), pp. 35 – 42
• Weisman, M.H.S., Haddad, M., Lavi, N., Vulfsons, S., 2013. Surface Electromyographic Recordings after Passive and Active Motion along the Posterior Myofascial Kinetic Chain in Healthy Male Subjects. Journal of Bodywork & Movement Therapies, 18, pp. 452 – 461