The ART Perspective Can Produce Dramatic Results (A Chronic Knee Pain Case)

A patient sought ART treatment for knee pain that had persisted for over a year after a successful knee surgery.  He feels that the surgery was successful because he was pain free up until he received a follow up exam.  During this exam the physician administered an injection that he feels set off is chronic knee pain.  The pain was described as constant.  There was no position that decreased or increased the symptoms.  He described an ache that persisted as he was standing and discussing his symptoms.  As he presented his history he pointed the area of his medial knee as the most significant source of his pain.

When I first found out that I would be treating a post-surgical knee, I had immediately thought that I would be likely dealing with scarring of typical structures like, distal hamstrings, meniscus, popletius. quads etc.., but I now had the first data point of his pain history.  It sounded like nerve pain was a big player here.

This case exemplifies where palpation is key.  I’ve always been told that you cannot treat what you cannot feel.  With this case, blasting away at the wrong structures would have gone nowhere fast.

1. Initial Functional Assessment

Pain was not amplified or diminished with any functional movement or rest.

Significant weakness noted with hip adduction, flexion and extension.

2. Palpation Assessment

· The overall tone of the right flexor group indicated a remarkable global contraction.  Tissue tolerance was sensitive for palpation of the adductor canal. Tissue texture and tension was consistent with entrapment of the saphenous nerve.

3. ART Treatment  Objective to decrease contraction to increase tissue tolerance for further treatment.

· Femoral N. long tract  (Proximal mobilization.)  Femoral sheath entrapment noted at the inguinal canal was noted with palpation was treated as well.

4. Patient Feedback

·Relief, lightness and general strength increase of the left leg is reported.  The patient reported the anterior hip pain was also a chronic pain but he felt it was likely not connected to knee pain.

5. ART Treatment

·ART protocols for saphenous nerve entrapment at the gracillis.

6. Retest for results

· Standing and several minutes of walking was reported to be 80% improved.  He claims to feel the best he has in over a year of chronic pain.

ART Long Tract Nerve Mobilization Paves the Way to Successful Treatment

I recently treated an athlete who sought ART treatment for right forearm pain.   This condition had persisted for approximately three days and was not improving.  This forearm pain has progressed from a simple soreness with lifting dumbbells during workout activity to a pain with lifting light objects such as a cup.

My main point in posting this case is to exemplify the advantage in knowing when to open a window to treatment with ART long tract nerve protocols.   Simply grabbing her forearm and beginning an ART treatment on what was usually identified as “tight” would have been both unproductive and painful for the patient.  Good ART is very often described by the patient as a “hurts good” feeling.   Mobilization of the median nerve in this case paved the way to successful treatment.
 

Treatment Progression

1.       Initial Functional Assessment

·         Pain is replicated with grip and lift of a barbell

·         Weakness noted with squeeze grip

2.       Palpation Assessment

·         The overall tone of the right flexor group indicated a remarkable global contraction.  This tissue tension results in an inability to evaluate tissue for adhesion.

3.       ART Treatment  Objective to decrease contraction to enable further assessment

·         Median N. long tract mobilization of the nerve proximally.  (Distal mobilization seemed unproductive due to contraction.)

4.       Patient Feedback

·         Relief, lightness and strength increase of the forearm is reported

5.       Palpation Assessment

·         The Global contraction has ceased.  Tissue texture and tension consistent of adhesion of the Pronator Teres, Brachioradialis,  FD, FPD, FPL.  Restriction of relative motion of the Brachialis and Biceps.

6.       ART Treatment

·         ART protocols for the structures noted.

7.       Retest for results

·         Lift of barbell indicated significant decrease in pain with strength increase. (2/10)  Some specific “spots” of discomfort were asked to be identified.

8.       ART Treatment

·         A few final passes on identified spots consistent with adhesion.   

Obscure Shoulder Pain with Arm Weakness in the Morning

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A patient presented with left shoulder pain that presented primarily in the morning.  For the past two weeks, he has experienced left anterior neck/shoulder pain and significant left arm weakness in the morning as well as an ache of his left pectoral region.   He was not able to identify any motion that amplified or releived his symptoms.   When asked to identify the most significant region of pain he pointed to the anterior superior border of the scapula.

1.       Visual assessment

·         Hypertrophy of the left levator scapula

2.       Functional Motion Screen

·         Decreased ROM of R cervical rotation with extension (asymmetrical to L motion)

·         Full L shoulder abduction indicated compensation pattern and decreased axis of rotation.

3.       Strength Assessment

·         Infraspinatus and Supraspinatus weakness noted with resistance.  Pain replication of anterior shoulder noted with infraspinatus resistance. 

4.       Palpation Assessment

·         Tissue texture and tension consistent with adhesion of the infraspinatus (superior fibers) and supraspinatus (medial fibers at the levator scapula/supraspinatus junction.

·         Tissue texure and tension consistent with adhesion of the omohyoid with decreased relative motion of the brachial plexus.

5.       Treatment

·         ART protocols to restore relative motion of the brachial plexus with the omohyoid and treatment of noted structures noted in palpation assessment.
The patient reported that this treatment replicated the exact symptoms that were described.

6.       Retest of functional motion

·         Unremarkable motion with R cervical rotation with extension

·         Strength increase with non-painful with resistance of infraspinatus and supraspinatus

·         Increased axis of rotation with full abduction

7.       Impression

It is possible that a rotator cuff dysfunction has resulted in the hypertrophy of the levator scapula with a chronic compensation pattern.    It’s hard to tell whether there was increased load of the omohyoid or this issue is altogether unrelated.    Considering that this issue has only been symptomatic over the last two weeks it’s hard to tell.  What’s most important to me is the symptom reproduction with ART treatment with decreased tension of the brachial plexus with treatment.

I will see this patient in approximately two days.  I look forward to his report of his morning symptoms.

The Active Release Alaska  Blog Objective

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When I first became an Active Release Techniques Provider, and after learning hundreds of ART protocols I was left with the overwhelming feeling of “now what?”.  These protocols gave me the tools of how to treat specific tissues with precision with dramatic results.  Unfortunately, I was left with little else in terms of how to approach a patient case when that specific “spot” treatment either helps for a little while and returns or doesn’t help at all.   As a matter of fact, I don’t often experience a patient case where what hurts is simply a small local region of restriction tissue. 

As a massage therapist, I was thrust into a world where I was overwhelmed with new and challenging cases and a steep learning curve.  I had to dig deep and learn fast.   Over time, I learned from some amazing resources including Michael Leahy’s masters course and his Active Release Techniques extensive library of video case studies.  I have studied Gray Cook, Stewart McGill, Mike Boyle, Craig Leibenson, Brian Abelson, Thomas Meyers and more.  Of course, studying these great minds in physical medicine and strength and conditioning is good stuff, but the rubber meets the road when it comes to case studies and treatment.

With this blog I wish to share case studies of my successes and learning experiences as an Active Release Techniques Provider and NSCA personal trainer.  I want to share case studies with the experienced and the newer ART providers who are now trying to figure out how this ART thing works.  This is for those providers who are trying to figure out how to put it all together.  Hopefully these case studies will be one more piece of information to consider in addition to your other sources of information. 

 I think that my perspective may be unique in that I am not (that I am aware of) married to a specific dogma of thinking.  I did not receive training from a chiropractic or physical therapy school.  Breaking into new ways of thinking by challenging my past training was not a problem for me.  In fact, ART has only helped my former training to make make more sense.  


With patient care what matters is results no matter what it takes to get there.  What matters to me, is thorough logical assessment and measureable results.  To me helping a patient means that an ART provider has helped that patient find the right tool for their problem whether that tool is or a combination of Active Release Techniques, fitness program design, chiropractic, surgery, neurology or physical therapy.

A Case of Thoracic Restriction Resulting in Right Shoulder Pain

I recently treated a case that proved that restriction on thoracic rotation can result in shoulder compensation and pain.   To me this shoulder pain case is a reminder of the importance of evaluating the larger picture in functional motion.  In my practice I rarely treat a patient whose presenting complaints is addressed solely by treating the “spot” that hurts.

1.       Assessment indicated pain replication between the right shoulder is amplified with full shoulder abduction.
 The primary complaint was right shoulder pain between the shoulder blades.  Pain is replicated with full shoulder abduction.   It was clear to me as I palpated this region that the rhomboid, and trapezius region exhibited a quality consisted with contraction. (I don’t like that overused  “tight” word because that doesn’t accurately describe what Is going on.)  The first order of business was to deal with this global contraction by mobilization the dorsal scapular nerve and spinal accessory nerve to eliminate contraction in order to increase tissue tolerance and palpation for adhesion.  With the contraction eliminated I then was able to palpation and treat the restricted tissues at the site of the original symptom complaint.

2.      Retest assessment indicated pain of the thoracic region with full shoulder abduction

Full shoulder abduction resulted in a specific pain just left of the spine at approximately T5-T7.  A seated functional screen of thoracic rotation indicated that there was in fact a significant lack of right thoracic rotation at those segments.  Palpation indicated tissue texture and tension consistent with adhesion of the thoracic multifidi, semispinalis and spinalis.  I applied Active Release Techniques protocols at these structures.

3.        Retest assessment thoracic rotation and shoulder abduction

Thoracic rotation was non-painful unremarkable and ROM increased.

Full shoulder abduction was non-painful and unremarkable.

Ankle Surgury Evaded

A very pleasant patient had been sufferring with a very painful right ankle after a fall that occurred approximately 3 months ago.   An orthopaedic evaluation was conducted and an MRI was taken of the ankle months ago.  The MRI results were inconclusive of structural damage therefore physical therapy was prescribed for this condition.


Physical therapy was then provided for approximently two weeks with no positive results.  The stretching and strengthening strategies only seemed to inflame her ankle pain.  With the lack of success with physical therapy, she returned to the orthpaedic surgeon for further evaluation.  The orthopaedic surgeon suggested surgury to assess and correct her ankle pain.


This woman had decided to try something that was new to her and sought ART treatment for her ankle pain.  Her  collegue had informed her that Active Release Techniques treatments had resolved her case of chronic foot pain that was diagnosed by an Orthopeadic surgeon as plantar fasciitis.


During our first visit I asked her to place her finger on the spot that seemed most painful with weight bearing. At the time of this visit this ankle was even painful with a simple weight bearing load.  She stood on her ankle and placed her finger on a spot posterior and distal the the lateral malleolus.  I then placed my fingers on the same spot and noted that with motion the peroneal tendon was not sliding throught the inferior peroneal retinaculum and then checked to discover there was no slide at the superior peroneal retinaculum.


After several careful passes with Active Release Techniques protocols, I felt a dramatic improvement in the relative motion of the peroneal tendon with the inferior and superior retinaculum.  I felt that this dysfunction was signifigant but needed to check her function to determine the effectiveness of the treatment.


 I asked her to assess the progess with weight bearing load of the ankle.  Her eyes lit up with suprise when she felt the immediate releif of her ankle pain.  She noted a 60% decrease in pain after only a few passes of ART.  After this result, I continued the treatment by noting the tissue, texture and tension of relative structures with palpation.  We planned the next visit two days from this one.


On the second and final visit she reported that weight bearing activity does not result in chronic pain but the ankle was still soar at the end of the work day.  With this feedback I followed that same treatment plan and asked her to call the office with feedback in two days.  That feedback was a report of a pain free ankle.