wolverine31088@hotmail.it 25 Oct 2014
AN INTRODUCTION TO
INSTRUMENT ASSISTED
SOFT TISSUE
MOBILISATION
OVE INDERGAARD MSC MCSP HCPC
wolverine31088@hotmail.it 25 Oct 2014
TABLE OF CONTENTS
Foreword
4
Introduction
6
What is IASTM?
7
How does IASTM work?
8
- Mechanical effects of IASTM
9
- Neurophysiological effects of IASTM
12
Assessment
15
Treatment
17
Soft Tissue Patterns
18
The EDGE tool
19
Cervical pattern
20
Lateral Cervical pattern
21
Anterior Shoulder Pattern
22
Lateral Upper Arm
23
Medial Upper Arm
24
Lateral Forearm
25
Anterior Forearm
26
wolverine31088@hotmail.it 25 Oct 2014
The Hand
27
Scapula
28
Posterior Trunk
29
Anterior Lower Trunk
30
Anterior Thigh
31
Posterior Thigh
32
Medial Thigh / Knee
33
Lateral Thigh / ITB
34
Posterior Lower Leg
35
Medial Lower Leg
36
Medial Foot
37
Lateral Lower Leg / Foot
38
Anterior Foot
39
Videos
40
References
41
wolverine31088@hotmail.it 25 Oct 2014
Foreword.
It’s my pleasure to write this foreword to Ove’s very well
written and put together Ebook, ‘An Introduction to
IASTM’. I was first exposed to IASTM almost 10 years
ago when I was treating the son of a chiropractor who was
impressed at our use of spinal manipulation and soft tissue
work - for Physiotherapists no less! He brought in these
commercial set of stainless steel tools and we practiced
with them. We all loved the “feel” of them and how they
saved our hands from repetitive strain. Then it went downhill when we asked the cost!
THOUSANDS? I silently told myself, “No matter how successful you become, these
tools are not worth the cost.”
I had treated several metal workers over the years and had them make several iterations
of what would become The EDGE Mobility Tool. The EDGE and it’s baby brother, The
EDGEility are now used worldwide by PTs, OTs, MTs, ATCs, DCs, and by runners and
other fitness minded individuals for self treatment.
The EDGE Mobility System represents what I have always thought, that affordable, high
quality options that save our hands as well as enhance movement and thus outcomes
should be within everyone’s reach. It is also a cornerstone in The Eclectic Approach, my
amalgamation of the art and science of physical therapy.
It is our hope that with this text, you will realize what IASTM is - input to your nervous
system with very little pure mechanical effects, and more importantly what it is not “breaking up” scar tissue or adhesions - which is almost impossible with the force
generated by human hands/tools.
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Ove does an amazing job of teaching the Soft Tissue Patterns I have developed over the
years that stimulate the nervous system through skin and mechanoreceptor stimulation,
increasing pain and movement thresholds by decreasing perceived threat to the CNS.
Read the text, go lighter than you ever have on someone and notice you’ll still make
results, with no soreness or discoloration. After that, go even lighter, you’ll still make
changes. Harness the power of the nervous system and movement with IASTM.
Cheers!
Erson Religioso III, DPT, MS, MTC, CertMDT, CFC, CSCS, FMS, FMT, FAAOMPT
themanualtherapist.com
edgemobilitysystem.com
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Introduction
Instrument Assisted Soft Tissue Mobilization (IASTM) is a relatively new form of
treatment, however similar treatments have been used for centuries with origins as far
back as Hippocrates, the most well-known is Gua Sha which originated in China
centuries ago.
More recently, the modern version of IASTM that we practice today was developed in
the USA as recently as the mid 1990’s, and steel tools were introduced to save the hand
when ‘breaking down’ adhesions and scar tissue following injuries and in the treatment
of soft tissue dysfunction. The treatment approach was initially based on Cyriax's soft
tissue treatments involving frictions.
There has been some development within this area and it has expanded through one
manufacturer of the IASTM tools to many, all with their own designs and thoughts
behind what features the tools should have. Since its inception, more and more therapists
are now looking to this technique to complement the manual work they are doing in
their clinics as they become more familiar with the technique and its benefits.
The tools we use with this course are designed by a Physiotherapist in the USA who was
appalled by the cost of entry for using these excellent soft tissue techniques; training and
tool acquisition that would run into the thousands of dollars. His philosophy and one that
we share is that this technique should be accessible to every therapist and not be
constrained to a monetary issue. The tools have different beveled edges and curves to
enable you to treat the whole body with one tool, something other tools do not offer.
In this manual you will see some reference to the current literature in the area. However,
this is mainly a practical manual and will cover the safe application of the technique and
the soft tissue patterns we use to treat myofascial restrictions and dysfunctions.
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What is IASTM?
“IASTM is a Soft Tissue
Mobilisation technique that
enables the therapist to detect
and
treat
myofascial
restrictions to improve ROM
and decrease pain”
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How does IASTM work?
The mechanisms for how IASTM works are largely being attributed to one thing. That
the treatment causes some therapeutic movement to local lesions, encouraging an
inflammatory process to initiate, pro-inflammatory substances brought in to the area,
which will remove damaged cells and replace these with normal cells thereby improving
healing.
As the technique has evolved and we learn more and more about the possible
mechanisms of this approach. It becomes quite apparent that in clinical practice, the
response from the technique occurs with in a small timeframe of 2-5 minutes depending
on the size of the area. One mechanism that has the potential to cause alteration in tissue
tension within such a timeframe, is the nervous system. The focus on purely a
mechanical effect on breaking down soft tissue dysfunctions has encouraged a far too
aggressive approach and causing unnecessary tissue trauma. With a focus on stimulating
the neurophysiological mechanisms less force is needed, without the trauma to the
tissues. This doesn’t exclude the mechanical effects as these are important as well. The
next few pages will look into these areas in more detail.
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Mechanical Effects of
IASTM
One of the most apparent effects of IASTM is erythema, and indeed an increase in
superficial circulation has been found in Gua Sha (1). Although Gua Sha uses a far more
forceful application than modern IASTM would utilise. Loghmani and Warren (2) have
found that with performing cross frictional IASTM in a rodent MCL, they found that
there was an increased perfusion of the local tissue at both 1 day, and 1 week after the
treatment suggesting that it may have some effect in improving local circulation. This
would cause an increase of nutrients and fibroblasts into the region which results in
collagen deposition and improved healing.
Indeed, studies have shown that IASTM will cause a proliferation of fibroblasts in the
treated areas in acutely injured rodent MCL (3) and in achilles tendinopathy (4,5).
Interestingly, in the study by Loghmani and Warden (3) they surgically injured rodents
MCL bilaterally. They treated the one side with IASTM for 1 min 3 times a week for 4
weeks, whilst the the other side served as the non treated control. What they found was
that the treated side at 4 weeks was 43.1% stronger, 39.7% stiffer, and could absorb
57.1% more energy before failure. They also noted that there was better fibre bundle
alignment and organisation in the treated side compared to the non treated side (fig 1.)
After 12 weeks there was no significant difference between the two sides. This suggests
that IASTM may enable an injury to be therapeutically stressed earlier which may speed
up the return to activity with less risk of re-injury.
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Fig.1 A - uninjured MCL , B-untreated MCL, treated MCL
at 4 weeks (Loghmani and Warden, 2009)
The mechanical compression of IASTM concentrates the application of forces to the
tissues in a way not possible with hands on techniques and the fibrocytic activity may
result in tissue production of ‘mechano-growth factor’ which activates muscle cells, with
change to muscle as well as fascial tissue (6).
There are some theories that IASTM may cause mechanical tension coupled with friction
and the increase in temperature may cause microfailure within collagen cross links,
causing creep in the tissues (7). On a similar note, research by Langevin (8) and Stecco
and Stecco (9) have both found a thickening of fascial tissue in the presence of pain.
Stecco and Stecco (10), have also found that one of the reasons for this thickening is the
excretion of hyaluronic acid between fascial layers causing a reduction in the optimal glide
between these tissue layers. The Fascial ManipulationTM approach uses mechanical
pressure, movement and friction and their research mentions that the treatment is aimed
at increasing the tissue temperature to ‘break down’ the hyaluronic acid chains, thereby
restoring the normal gliding between tissue layers. Manual therapy has also been found to
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be able to alter tissue tone, and to change the consistency of the extra cellular matrix.
Therefore it may alter the viscoelastic, shock absorbing, and energy absorbing properties
(11).
Jean Gimbertau (12), suggests that fascia act like fluid filled tubes that dynamically
change to the stress being put on them. These fluid filled tubes allow for a lengthening of
the tissues as a dynamic weblike structure rather than layers that slide on top of each other.
This offers the possibility that mechanical stress can cause immediate effects on tissue.
We know that both acute trauma and chronic stress on tissues can cause tissue
tightening. Findlay and colleagues (13) mention that acute inflammation causes the
fascia to tighten and loses its pliability. Maintaining postures over longer terms may
therefore prevent the full movement of the fascia. In addition, stretch and compression
of the fascia may cause pain to be felt in structures such as blood vessels and nerves in a
range that was previously pain free.
When releasing the compression by IASTM or other manual therapy techniques,
pressure is relieved on these areas and blood circulation becomes normal (14).
However, the potential mechanical effects do not occur in isolation. The application of the
IASTM tool to both acute and chronic conditions may improve healing, some of the
effects from this would be on a longer timescale, possibly 24-72 hours, and in clinical
practice we observe changes within minutes of starting treatment. Further research into
the mechanical effects of IASTM is necessary.
To further explain the effects of IASTM we need to look to the nervous system.
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Neurophysiological Effects
of IASTM
When a manual treatment is applied to the skin, and potentially the underlying fascia, the
mechanical stimulation will trigger inhibition of pain receptors and the release of the
body’s opioids though descending inhibitory pathways from the CNS and spinal cord.
Treating someone with IASTM will elicit these pathways too. However, you do not need
a steel tool to treat these lesions specifically to get this effect. So, we will not discuss them
in depth, just bear in mind that they do account for some of the analgesic effect that the
tool provides.
Let us instead focus on the direct interaction of the tool with the skin, and the underlyin.
The skin and fascia are highly innervated with sensory nerve fibres, and in contrast, fascia
has been found to contain up to 10 times as many mechanoreceptors as muscle tissue. This
evidence has prompted researchers to change the way we think about the role of the skin
and fascia in proprioception and motor function.
Indeed, the connection with the nervous system is very important as it allows for change
and plasticity of the fascial network. Schleip (15) found that tissues failed to respond
normally once the neural connection was abolished, adding weight to the argument that a
fully functional nervous system is needed for the optimal function of our myofascial
system. Four different types of mechanorecetors have been identified in the fascial system;
these being the Pacini corpuscles, Paciniform corpuscles, Ruffini organs and interstitial
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receptors. (a full view of these and how they respond to stimulus can be found in Fig. 2.)
Out of
Fig. 2 - The four different types of mechanoreceptors found in
fascia (as shown in Schleip 2003)
these 80% of the sensory fibres are the interstitial receptors, with the other three making
up the other 20%. Furthermore, 50% of the interstitial receptors respond to light touch (as
light as a finger stroke), and these receptors are also multimodal and has a role as
nociceptors too. These fibres can be up-regulated due to chemical irritation locally,
causing a chronic firing of the receptors. This up-regulation in firing of the
mechanoreceptors, may be one reason that can cause peripheral sensitization without the
mechanical irritation of any neural structures (i.e. a root compression) (16,17). These
interstitial receptors, along with the rest of the mechanoreceptors, respond to mechanical
pressure and tension. This has an important role to play in both how manual therapy and
IASTM works. A flow chart of how they all work together can be found in fig. 3.
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In summary, the effects we can see in the clinic is as a result of the stimulation of the
nervous system. A slow stroking of the back will inhibit the Gamma motor system,
causing a decrease in muscle tone. The stimulation of the mechanoreceptors also causes
a reflex response that lowers overall muscle tonus and induces a whole body relaxation as
well as an effect on the local area.
Fig. 3 - The neurobiological effect of tissue manipulation (Schliep, 2003)
Fig. 3 - The neurobiological effect of tissue
manipulation (Schliep, 2003)
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Assessment
Using the IASTM tools for assessing soft tissue restrictions and tone gives enhances
what you can feel with your hands through the vibrations and feel from the tool. Here
are a few points on how to get the most out of your assessment:
•
•
•
•
•
•
•
Always apply lubricant to the skin to enable
the tool to slide on the skin and cause
minimal irritation.
Make sure the skin is not broken and that
there are no obvious protrusions on the skin.
i.e. moles
Start scanning superficially with the sharper
side of the tool.
Optimal angle of the tool is 20-30 degrees
Scan longitudinally, in a proximal to distal
or distal to proximal direction.
Some patterns are more restricted in one
direction i.e. upper cervical in a lateral to
medial direction
ST dysfunction usually presents in 2 ways:
- Increased Tone
- Restrictions
Lets have a look at the differences between what we mean by increased tone and
restrictions in assessing and treating soft tissue dysfunctions.
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Restrictions:
•
Often feels like grit and vibrations can be felt through the tool
•
Some patterns are restricted in focal areas
•
Some patterns are restricted throughout the pattern
•
Treated with short quick strokes in one direction until released
•
Progress with depth and may swap to the dull side of the tool
Increased Tone:
•
With increase in tone, a noticeable slowing of the tool when scanning is felt.
•
Treat with the dull side first
• Start with light pressure and slow strokes in one direction
To Help you along with the practical part of assessing and progressing your treatment we have
put together a couple of videos for you to be able to view how we teach it on our practical
courses.
http://toolassistedmassage.co.uk/assessment-and-treatment-progression/
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Treatment
When we do apply the treatment, it important to remember two things. We do not want
to over treat an area and in most cases only light pressure is necessary, however, there
are progressions to the treatment that will be discussed.
For most problems we only need about 1-2 minutes per pattern. Research by the
TherAdvance Group in South America using the Edge tools is due for publication using
diagnostic ultrasound to review tissue changes during treatment. This has shown that the
greatest changes occurs within two minutes of treatment, however, treatments up to 5
minutes may be used for further improvements in pain and range of motion.
When you start treating, make sure that the tissue is in neutral. Only if this is not tolerated
would you regress and treat in tissue slack. Progression of treatment can be done by
adding further tension to the skin/fascia. Discolouration, also know as petachiae, is a
speckled bruising that sometimes occur during IASTM treatment, this is usually minimal
and is normally transient and vanishes within 1-2 days of treatment.
Treatment can be done in a static position such as sitting or in a lying position, or it can
be done more dynamic through functional or dysfunctional painful movements. How
you treat someone is only limited by your own imagination.
For example;
1, Patient is presenting with restricted shoulder internal rotation, you could start treating
the posterior scapula or anterolateral shoulder in neutral, progressing into full internal
rotation.
2. Patient is presenting with limited median neural mobility. You could place the arm on
medium neural load then treat the medial upper arm and anterior forearm patterns
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The Soft Tissue Patterns
When we treat soft tissue dysfunction it is helpful to put it into a system. In this
manual we will present basic patterns to guide your treatment of soft tissue
dysfunctions of the spine, upper and lower limbs. They have been developed through
several years of experience, coupled with research of several myofascial approaches,
including IASTM. These patterns will help you become efficient with the IASTM
tool fast so that you can integrate it into your therapy sessions seamlessly. The
patterns are only a guide, and are not always present, nor are they the only way to
treat soft tissue dysfunction with IASTM. Often the lesions are quite local and it may
not be necessary to treat the full pattern.
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The EDGE tool
The EDGE tool, has been ergonomically designed and offers several different hand holds
which enables you to vary how you use the tool, eliminating operator fatigue. It has 2
main sides, one being a sharper edge, which we use for superficial scanning and
treatment. The flatter, more beveled edge, is much better for doing treatments to decrease
tone and to get into deeper lesions. It has 4 different edges that we use throughout the
body, In terms of aggressiveness of treatment the edges are numbered 1 through 4.
Starting with the edge that give the greatest amount of contact surface and is gentlest on
the patient to number 4 which offers more pin point pressure for isolating specific lesions
and structures. Each of these edges are presented to how suitable they are along with the
soft tissue patterns that follows.
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Cervical Pattern
When we are looking at the upper cervical pattern we are assessing for tone or
restrictions and, we more commonly find the
restrictions in the upper cervical spine to be in the
lateral to medial direction. For the lateral and
anterior neck, including the upper fibres of
Trapezius, we commonly see restrictions in the
proximal to distal direction.
Edge: Upper cervical #3-4
Lateral cervical #2-3
Clinical note: Problems in this region are often in
the upper cervical spine and/or the cervicothoracic
junction
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Improves: Cervical ROM, headaches, posture, Shoulder ROM, prep before
mobilisations or manipulations.
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Lateral Cervical Pattern
In the lateral cervical spine, we can
experience both tone and restrictions, like the
posterolateral pattern the restrictions are more
commonly found in proximal to distal
direction. Due to the underlying structures
and the thickness of the skin in this area, we
only utilise very superficial light strokes here.
Edge #2-3
Improves: Cervical extension, side flexion
and rotation
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Anterior Shoulder Patterns
Anterior chest: Restrictions usually in a medial to
lateral direction, but quite often in the opposite
direction as well; you need to assess both directions.
Follow the bony contours of the clavicle, and also the
lateral edge of the pectoralis major, and follow this
onto the arm where it integrates with the fascia of the
upper arm
Edge #3-4 around the clavicle
#2-3 mid Pec and lateral pec border.
Improves: posture, shoulder ER, abduction and
horizontal abduction
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Lateral Upper Arm
The lateral upper arm pattern is one of the most useful patterns when it comes to shoulder
dysfunction. The pattern runs in the mid line between the biceps and triceps on the lateral
arm, then traces the anterior and posterior border of the deltoid. In this area it is almost
exclusively restrictions. In this area we also
have the radial nerve container.
Edge # 3
Improves: Shoulder IR and ER, flexion and
extension and radial neural mobility.
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Medial Upper Arm
On the medial upper arm we have to be careful, the skin is thin in this area and we have
underlying nerves and blood vessels. We mostly encounter restrictions and this pattern
is very useful for median and ulnar tension.
Edge #2-3
Improves: Median and ulnar neuro mobility
Subscapularis:
For the subscapularis we can assess for restriction
and tone and we can work in both a superior to
inferior pattern or vice versa
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Improves: Shoulder elevation and ER, can help with impingement
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Lateral forearm
In the lateral forearm, it is important to assess the area around the radial bony contours
and the area around the radial head. We usually find restrictions in this area.
Edge #3
Improves:
Radial
neural
mobility,
pronation/supination, lateral epicondylalgia
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Anterior forearm
In the anterior upper arm the main area is the mid line of the anterior forearm, and the
bony contours of the ulna. Restrictions are
more common than increased tone.
Edge #3
Improves: Supination and Pronation, median
and ulnar
neural mobility and medial
epicondylalgia
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The Hand
In the hand the main areas are the thenar and hyopothenar eminence. Most restrictions
are found in the pattern depicted. Treatment strokes are mainly done central to outer
hand.
Edge #4
Improves: Hand mobility, CTS, Median and ulnar
neural mobility.
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Scapular patterns
Around the scapula the main areas are the medial scapular border, the scapular spine,
the lateral border and the upper fibres of trapezius. On the medial edge treatment is
performed either inferior to superior or superior to inferior. On the scapular spine the
direction is usually medial to lateral.
Edge #3-4
Improves: scapular mobility, shoulder mobility,
thoracic mobility, breathing pattern dysfunction
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Posterior Trunk.
In the back, we need to evaluate the thoracic and lumbar paraspinals centrally, both mid
muscle bulk but also in the gutters between the paraspinals, the rib angles, and the
spinous processes. Next, assess the bony contours of the iliac crest, as well as the
thoracolumbar fascia and the Latissimus Dorsi.
Another important area of this pattern is the lower
fibres of Trapezius. Usually restrictions are found
here, however there are often tone issues in the mid
thoracic muscle bulk.
Edge #2-3, #4 between ribs
Improves: trunk mobility, shoulder mobility,
breathing pattern dysfunctions
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Anterior Lower Trunk
For the anterior trunk the main areas are the upper attachments of the Rectus Abdominis
as well as the area over the anterior iliac crest.
Edge #3 and for Anterior ilium #1
Improves: trunk extension, hip extension, lumbar
flexion
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Anterior thigh
For the anterior thigh, there are several areas to consider when assessing and treating.
The lateral quadriceps, mid quadriceps, the area
over the patella and the anteromedial joint line.
Edge #2-3 on the muscle #1 over the patella
Improves: ASLR, hip extension, quad tone, PFPS,
femoral neural mobility
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Posterior thigh
The main area of the posterior thigh to evaluate are the hamstring/gluteal junction, the
hamstring midline then tracing down the line of the tendons.
Edge #2-3
Improves: Hip extension, sciatic neural
mobility, ASLR
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Medial Thigh/Knee
In the medial thigh, the pattern that usually demonstrates restrictions, follows the line
between the medial vastus and Sartorius. Then follows the medial aspect of the thigh
down to the knee, and across the MCL in a superior to inferior direction. Sometimes
there is a need for working transversally
across the medial knee joint
Edge #2-3
Improves: MCL strains, medial knee pain, hip
IR
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Lateral Thigh/ITB
In the lateral thigh and ITB area there are three main areas; the gluteus maximus/ITB
junction, the mid portion of the ITB along the length, and the area between the hamstring
and ITB in the distal portion of the ITB.
Edge #2-3
Improves: Hip IR and ER, ITBS, Tibial
rotation
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Posterior lower leg
For the posterior lower leg, the areas to be assessed are the medial border of the
Gastrocnemius,
the
lateral
Gastrocnemius
and
the
head
of
the
musculotendinous
junction.
Edge #2-3
Improves: Ankle DF, Calf tone, posterior line
tension,Plantar Fasciosis
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Medial lower leg
The main area for the the medial lower leg is the medial tibial border. Most commonly
we find restrictions all along the tibia, however more focal areas can be found.
Edge #3 or inside of #1
Improves: MTSS, improves foot mobility,
lowers calf tone, improves tibial IR on the
femur
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Medial Foot
In the medial foot, we need to follow the medial edge of the 1st ray and around the
medial malleolar bony contours
Edge: #3-4
Improves:
foot
mobility,
pronation, MTSS, plantarfasciosis
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Lateral Lower leg and Foot
In the lateral lower leg and the foot, it is important to trace the bony contours of both the
lateral malleolus and along the 4-5th metatarsals.
Edge: #3-4
Improves: Foot/ankle Inversion, calcaneal rock
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Anterior Foot
For the anterior foot and ankle, the anterior joint line of the foot can get restricted and
also the space between the 1-2 metatarsals.
Edge #3-4
Improves: ankle PF, anterior line tension,
ankle DF
Videos.
wolverine31088@hotmail.it 25 Oct 2014
We have put together 3 videos demonstrating techniques mentioned in this book; one for an upper
cervical release, one for a spinal paraspinal muscle release and one for a hamstring release. They
can be found here.
http://toolassistedmassage.co.uk/videos/
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Notes
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References.
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Tissue: A Pilot Study in Healthy Subjects. EXPLORE: The Journal of Science and Healing. 3(5):456466.
2. Loghmani MT, Warden SJ. Instrument-assisted cross fiber massage increases tissue perfusion and
alters microvascular morphology in the vicinity of healing knee ligaments. BMC Complementary and
Alternative Medicine [2013, 13:240]
3. Loghmani MT, Warden SJ. Instrument-assisted cross-fiber massage accelerates knee ligament
healing. Journal of Orthopaedic & Sports Physical Therapy (JOSPT). 2009 Jul;39(7):506-514.
4. Gehlsen, G.M., et al (1999) fibroblasts response to variation in soft tissue mobilisation pressure.
Med.sci. Sports Exerc 31. 531-535
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6. Hill, M., Wernig, A., Goldspink, G., 2003. Muscle satellite (stem) cell activation during local tissue
injury and repair. Journal Of Anatomy 203 (1), 89e99.
7. Threskeld AS 1992 The eff ects of manual therapy on connective tissue. Physical Therapy 72(12):
893–901
8. Langevin, H., et al., 2009. Ultrasound evidence of altered lumbar connective tissue structure in
human subjects with chronic low back pain. BMC Muscoskeletal Disorders 10, 151e160.
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wolverine31088@hotmail.it 25 Oct 2014
Ove Indergaard MSc MCSP HCPC ACPSM
Ove is a Chartered Physiotherapist working currently in
private practice in Leeds. He holds an MSc in Sports and
Exercise Injury Management and is a Gold accredited
member of the ACPSEM (Association of Chartered
Physiotherapists in Sports and Exercise Medicine). He has
previously worked as a physiotherapist in Elite sport
including British Judo,England Badminton and British
Universities and Colleges Sport.
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