ATMS National Conference October 2001

ATMS Sciaitica presentation was my second national opportunity to present IFR.  Much thanks to Greg Morling, who was instrumental in featuring my work.

ATMS Presentation at School of Integrated Body Therapy

Presenting at the School of Integrated Body Therapy Charmhaven, NSW 2002

Long Lever in Hawaii

Demonstrating proprioceptive straight leg raise with crowding/compression technique applied as a long lever to the hip joint. Joint mechanoreceptors respond to the crowding of the joint & ligamentous structures with inhibiting message.

Perth IFR 1 April 2005

IFR Level 1 Perth Workshop April 2005. Excelllent group of practitioners.

Joint Dysfunction Treatment Protocols

Steven Goldstein explores sacroiliac joint dysfunction & low back pain.

We look at how to create a management plan based on this format, what assessment and special tests to form a working diagnosis, and utilize techniques drawn from direct and indirect myofascial release methods IFR/MFR, positional release technique PRT, muscle energy technique MET, mobilization techniques for the lumbar spine, pelvis and hip, trigger point and deep tissue massage.

To find out more about this DVD, please contact Steven Goldstein on +61 0402 068 658 or you can email at info@fascialrelease.com

Clinical Approaches for Tension Head and Neck Pain

Steven Goldstein will discuss and demonstrate releases that address both a global and local perspectives for the anterior and posterior neck. Assessment includes OA Occipital Atlanto & AA Atlanto-Axial ROM, Special tests for tension headache.

Techniques will specifically address sub-occipital musculature: rectus capitis posterior major & minor, oblique capitis superior & inferior. Releases for the anterior throat region that includes Suprahyoid & Infrahyoid musculature will also be covered.

To find out more about this DVD, please contact Steven Goldstein on +61 0402 068 658 or alternatively you can contact him via email on info@fascialrelease.com

Assessment and Treatment of Fibromyalgia

Fibromyalgia is a chronic syndrome, characterised by widespread body pain and pain at specific tender points. Patients can also exhibit a range of other symptoms including fatigue, sleep disturbance, muscle soreness and headache.

Join Steven Goldstein (ACNM lecturer) to distinguish how best we can manage clients suffering from this debilitating condition in line with the latest evidence-based research supporting the use of massage.

This DVD is available now, to enquire, please contact Steve Goldstein on +61 0402 068 658 or alternatively you can send an email to enquiry about this DVD here

AAMT 5th National Conference Hobart

The AAMT 5th National Conference will be held in Hobart May 22 – 24 2009.

On behalf of the Australian Association of Massage Therapists (AAMT), it gives me great pleasure to invite you to
attend our 5th National Conference, held at the Wrest Point Convention Centre in Hobart Tasmania, 22-24 May 2009.

The theme for 2009 is focusing on core stability, including topics such as structural assessment for and injury due to lack of.

For 2009, the Bowen Therapists Federation of Australia is participating in collaboration with AAMT to present this
event to their membership, which reflects positively on our conference program by increasing the number of
opportunities for delegates to participate in afternoon breakout sessions.

Importantly, I would like to thank those who attended our 2008 national conference in Adelaide and took time to fill
out session feedback forms and rated the overall success of the conference. Once again, we have created a streamed
program, which will result in every delegate having an opportunity to be involved in a hands-on workshop on one of
the afternoons. Needless to say, workshop allocations are done on a first in first served basis so please register early
to avoid disappointment.
With a diversity of interest within the membership comes the challenging task of creating a program that caters
for everyone and I would like to extend my sincere thanks to this year’s Conference Committee and Chief Executive
Officer, Tricia Hughes for the discussion and program input which began soon after our Adelaide conference.
As with all past AAMT conferences, the Gala Dinner ticket is included and I strongly encourage you to attend this
important event, which includes a 3-course dinner and beverages. It is also the time to let your hair down and have
fun with like-minded people in our industry. Please note that there is no discount on conference fees for delegates
unable to attend our Gala Dinner, as we negotiate venue costs based on a variety of expenses and catering makes
up a large part of this.
Finally, I’d like to thank our sponsors and trade exhibitors for their generous support and we look forward to seeing
you at our 5th AAMT National Conference in Hobart.

David Sheehan Conference Organizer

To register your interest please visit the AAMT for a registration form: here

Costings and Policies

As of January 1st, 2010, the local Australian price structure for IFR Foundations, Levels or Advanced classes in Australian Dollars are as follows:

Costing Structure

IFR Foundations 3 Day	$575 Melbourne	$625 Interstate
IFR Intermediate 3 Day	$575 Melbourne	$625 Interstate
IFR Advanced 3 Day	$575 Melbourne	$625 Interstate
IFR Intensive 4 Day	$725 Melbourne	$795 Interstate
IFR Levels One thru Four 2 Day Workshop Fibromyalgia Workshop with DVD	$425 Melbourne $425 Melbourne	$450 Interstate $475 Interstate
IFR Introductory One Day Workshop	$225 Melbourne	$270 Interstate

Discounts are available based on a guaranteed size of group, student or association affiliation.

This would be negotiated with Steven and the organizers.

In Melbourne

USA Prices differ than Australian prices.

Please Contact Steven for details

Shin Pain

anterior tibia

This was article published for the AAMT Australian Association of Massage Therapists March 2006 Journal.

One of the more perplexing areas of the body for a manual therapist to address is the lower leg, ankle and foot. With enormous potential for stress and dysfunction through the body’s handling of weight bearing and exertional activities, the lower leg compartment is often difficult to treat.

Shin pain is an extremely common complaint among any individuals who are active and athletic. Overuse injuries that cause shin pain such as tibial stress fracture, inflammatory shin splints, or compartment syndromes create clinical situations where you have to determine an accurate differential diagnosis, so that your assessment and the treatment choices are critical to your success. Often these overuse conditions co-exist, making diagnosis difficult.

Shin pain can present itself several ways in your practice. Three common varieties we may encounter for treatment are shin splints or medial tibial stress syndrome, tibial stress fracture and compartment syndrome.

“The pathophysiology of overuse injuries is local inflammatory response to stress. The cause are intrinsic (malalignment syndromes-muscle imbalance) or extrinsic (training error)”1 Management of Common Musculoskeletal Disorders 3rd Ed Hertling & Kessler p 419

From a clinical perspective, shin pain involves one or more of three pathological processes; bone stress, inflammation and raised intracompartmental pressure. 2 Clinical Sports Medicine, Bruker & Khan 2nd ed 2001 Chp 26 Shin Pain p508

1. Bone stress is a continuum of increased bone damage due to strain, stress reaction or fracture.
2. Inflammation develops at insertions of muscles, particularly tibialis posterior and soleus and the fascia to the medial border of the tibia.
3. The lower leg has a number of muscle compartments, each enveloped by a thick inelastic fascia. As a result of overuse and/or inflammation, these compartments may become swollen and painful..

Shin splints are a vague term widely used with a variety of definitions. Tibial Stress Syndrome (Shin Splints) is a common lower leg injury that affects many people involved in running sports. It is synonymous with anterior or medial tibial stress syndromes, tendoperiostitis, tibial periostitis, and tibialis tendinitis, all which denote varying degrees of soft tissue and osseous changes1.

It is an over-use injury and inflammatory condition of the tibia or fibula in which micro tears develop in the muscle’s myotendinous origin located along the bone shaft. The repetitive action of dorsiflexion/plantar flexion pulls the muscle away from its attachment on the bone causing periostitis2.

Shin splints are the name given to pain at the front of the lower leg. The most common cause is inflammation of the periostium of the tibia (sheath surrounding the bone). The injury is an overuse injury and can be caused by running on hard surfaces, running on tiptoes and sports where a lot of jumping is involved. If you over pronate then you are also more susceptible to this injury.

Signs and Symptoms for Shin Splint Pain include:

• Tenderness over the inside of the shin
• Lower leg pain
• Occasional edema or swelling.
• Lumps and bumps over the bone.
• Pain when the toes or foot are bent downwards in plantarflexion, and redness over the inside of the shin
• A gradual onset of pain on the inner lower third of the leg, with increased pain with weight bearing activities (running, jumping, etc.).
• Pain with activity that is usually alleviated with rest
• A “dull ache” that may disappear after a warm-up.

Anterolateral shin pain may occur secondary to heel contact on hard surfaces, or to wearing a shoe with a hard heel, or biomechanical abnormalities such as forefoot varus.

Posteromedial shin splints cause symptoms along the posteromedial border of the middle and lower tibia over the posterior compartment, which is appreciated during toe-off. Research has shown a strong positive correlation between excessive pronation and posterolateral shin splints.

Types of tibial stress syndrome

Medial Tibial Stress Syndrome involves the tibialis posterior muscle and often occurs in individuals who are moderately to severely pronated (collapsed medial arch or flat feet), thus placing tension on this posterior muscle and tendon.

Anterior Tibial Stress Syndrome involves the tibialis anterior muscle. This muscle is responsible for 80% of foot dorsi-flexion and acts as a strong decelerator for plantar flexion. Frequently, anterior shin splints arise in runners over-training on hills since both uphill and downhill running requires repetitive firing of the tibialis anterior muscle.

Symptoms are usually worse while running downhill as the tibialis anterior is responsible for slowing down the forefoot after heel strike (eccentric contraction)5. Consequently, a tight Achilles tendon may be found in this syndrome, resisting proper range for the tibialis anterior to function and leading to friction and inflammation.

It is synonymous with anterior or medial tibial stress syndromes, tendoperiostitis, tibial periostitis, and tibialis tendinitis, all of which denote varying degrees of soft tissue and osseous changes1. It is an over-use injury and inflammatory condition of the tibia or fibula in which micro tears develop in the muscle’s myotendinous origin located along the bone shaft. The repetitive action of dorsiflexion/plantar flexion pulls the muscle away from its attachment on the bone causing periostitis.

MTSS or tibial periositis (shin bone) presents exercise-induced pain localized to the distal posteromedial border of the tibia. Clinical distinction with shin splints is hazy, but MTSS is focal and painful. Pathophysiology is controversial, but is most likely periosteal inflammation at the origin of tibialis posterior or soleus

Medial Tibial Stress Syndrome MTSS is an irritation of the tibia (shin bone) at points where the Soleus and Tibialis Posterior muscles attach to it. It is caused by over-use in runners, with those who run on hard surfaces being particularly affected. However, there are a number of factors, such as altered foot, knee and hip posture, which can predispose a person to the syndrome.

Compartment syndrome is a serious, possible life threatening condition whereby trauma or hemorrhage causes swelling within a muscle compartment. It is defined as ‘an elevation of the interstitial pressure in a closed osseofascial compartment that results in micro vascular compromise’ (Mubarak and Hargens 1983).

The most common site of compartment syndrome is the lower leg (Abramowitz and Schepsis 1994), with the anterior compartment being the most frequently affected, followed by the lateral compartment and the deep posterior compartment.

Compartment syndromes arise when a muscle becomes too big for the sheath that surrounds it causing pain. The large superficial muscle on the outside of the shin is called the tibialis anterior and is surrounded by a sheath. This is called the anterior compartment of the lower leg. Compartment syndromes can be acute or chronic.

Acute anterior compartment syndrome can occur as result of an impact which causes bleeding within the compartment and therefore swelling.

A muscle tear which also causes bleeding or an over use injury which also causes swelling.

Symptoms include:
•    Sharp pain in the muscle on the outside of the lower leg, usually the result of a direct blow.
•    Weakness when trying to pull the foot upwards against resistance (dorsiflexing).
•    Swelling and tenderness over the tibialis anterior muscle and pain when the foot and toes are bent downwards

Tibial Stress Fractures

Stress fractures of the lower limbs account for more than 95% of all stress fractures in athletes. One half occurs in the tibia & fibula and is the result in fatigue failure within the bone, although surrounding muscle may fatigue first.
Increased or differing activity result in altered relationship of bone growth & repair. Wolff’s Law.

Factors that influence the development of stress fractures include:
•    Repetitiveness of activities
•    Muscle forces acting across the bone.  Muscle force or torque may stress the bone if imbalances between antagonistic muscles exist.
•    Gradual Onset 2-3 weeks
•    Patient c/o Pain initially with activity
•    Relieves with rest
•    Next stage pain continues for hours, perhaps thru the night or worse at night suggests bone pain

Clinical exam reveals localized tenderness with or without swelling usually over the site of the fracture

Commonly known as ‘crescendo pain’

Stress fracture pain tends to build up gradually during the act of running, beginning as an annoying irritation and becoming a throbbing torment as an athlete continues to run(1).
There is usually little of the numbness, weakness, and swelling associated with compartment syndrome, and pain is usually not present to a significant degree when the athlete is at rest.

Sometimes, there is a specific point of tenderness in the lower leg, which is often felt on the inside of the calf when deep pressure is applied with the fingers.
Often, the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site.

Clinical Heath History and Presenting Symptoms.

It is important to differentiate between symptoms that are presented to make an accurate assessment.

•    If the patient reports the pain improves after warming up and with continued exercise, then periosteal problems are most likely.

•    If the pain worsens with exercise and is accompanied by a feeling of tightness, then compartment syndrome may be present.  A pain that disappears relatively quickly with rest, and the presence of associated symptoms such as numbness, a ‘dead’ feeling in the leg or pins and needles in the foot indicates compartment syndrome

•    If jumping activities increases the pain, or if there is pain at rest or night ache, a stress fracture must be considered.

Treatment and Techniques:

Traditional Treatment for Anterior Shin Splints

With space available for this article we will address treatment of anterior shin splints. The most common treatment for shin splints is at least one week of rest. Ice packs or a light elastic bandage may also help minimize the pain, along with over-the-counter anti-inflammatory pain pills or creams. Shin splints eventually heal, but returning to a stressful activity too soon can cause them to flare up again quickly. This is why many doctors and coaches suggest a two to four week restriction on running after recovering from shin splints. Low impact cross training on bicycles or treadmills may be allowed, however.

Pain from anterior or medial tibial stress syndrome usually comes about with a delayed onset, often 24 hours after the primary bout of physical activity that initiated the problem. If the offending activities can be avoid, this may often be enough to alleviate the problem. 3(Orthopedic Massage, Theory & Technique, Whitney Lowe, Mosby 2003 p82)

With muscular overuse of this nature, massage and direct myofascial release often are modalities of choice. Anterior compartment tightness, the focus is upon tibialis anterior, (TA) which is a long fusiform shaped muscle, covered by strong fascia.  It gains it’s upper attachment from the deep surface of this strong fascia, and the upper two thirds of the lateral tibial surface and adjoining interosseous membrane and inserts through both the superior & inferior extensor retinacula to the medial side of the medial cuneiform bone and the base of the first metatarsal, the insertion reaching under both bones to blend with that of the peroneus longus. (Anatomy & Human Movement: Structure & Function, Palastanga, Field & Soames, Butterworth-Heinemann, 2000, p352)

Traditional massage approaches utilize longitudinal stripping with awareness of how attachment sites affect musculature tension. The amount of depth, force and pressure to be used is within patient tolerance levels. Often a deep tissue approach is ineffective, either due to pain, over or underpressure or myofascial resting tension that does not allow the tibialis anterior to relax. This is usually when the practitioner changes technique to use active engagement of the patient’s dorsiflexion/plantarflexion as the practitioner longitudinal strips the TA from insertion to origin. This tends to be more effective, but again often does not always lower the existing tension of the muscle.

This is when switching modalities using myofascial release is effective. Because the investment of fascia is three-dimensional running superficial to deep, treating the fascial anchoring sites are quite important. For the TA this includes all the superficial crural fascia and awareness of anterior crural intermuscular septum. The crural fascia anchors along the anteromedial tibia and the entire medial border of the fibula from fibular head to fibular malleolus.

Treatment for the superficial crural fascia can be quite straightforward. Many practitioners use direct myofascial release- MFR.

Michael Stansborough, Direct Release Myofascial Technique, p. 52 uses what he calls an Anterior Compartment Interosseous Membrame technique. 5

Patient: Sidelying with upper hip and knee flexed, support with pillow.

Therapist: Stands at foot of the table.

Contact: Use of an elbow with 90º flexion, begin at fibular malleolus. Glide proximally 2-3 inches at a time between tibia & fibula.  Superficial fascia can be treated more quickly-the interosseous membrame will respond to slow steady contact.  Encourage the client verbally to fully allow the weight of the leg into the table.

John Smith, Structural Bodywork, Elsevier Ltd., 2005, p.156 has a MFR Shin technique. 6

Patient: Supine, no bolster

Therapist: Use of a hand with fingers spread, octopus grip, for broad contact superiorly upper to mid anterior crural fascia. You can work on the flat of the tibia, with fingertips on the margins.  Inferior hand anchors reticulum.

Contact & Action: Ask for slow flexion-extension of the ankle

Treatment and Techniques: An Alternative Approach

Steven Goldstein’s Technique. 16

Borrowing from excellent structural integration practitioners such as Peter Schwind, Thomas Myers, Michael Stansborough & John Smith for direct MFR, I attempt to integrate indirect osteopathic technique such as positional release techniques from Lawrence Jones’ strain-counterstrain, joint play techniques from Andrew Noble, indirect two pointing from Michael Mann.

The key is to engage fascial receptor tonus by first stimulating the sensory receptors in the fascia. You achieve this by superficial (very light contact, minimal pressure) contact of the targeted soft-tissue you wish to change.

Patient: Supine with or without bolster

Therapist: Two pointing (Mann 1989) consists of wrapping both hands in a form-oriented approach. (Schwind 2006). Encircle the joint to relax receptor tonus then proceed with more direct MFR. Photos courtesy of Steven Goldstein Integrative Fascial Release Manual 2006

Contact & Action: Usually encasing the joint with both hands for 1-2 minutes with emphasis on static pressure at the hamstring insertions and gastrocnemius origins will also facilitate a golgi tendon organ response.

Apply to ankle joint in the same manner. Relax indirectly the retinaculum with specific focus on the talus bone.

Contact & Action: As tissue soften, engage the superficial fascia around the ankle and employ a superior shear lightly. Sustain with slight crowding of the talus into the tibia.

Because of the strong investment of fascia at the anterior talocrural joint it is important to assess joint play of the talus bone.

talar joint play

Joint Play for the Mortise. 15

The mortise is made up of the lower tibial condyle, tibial and fibular malleolus, which constitutes the superior aspect of the talus.

The joint play movement we are going to assess and treat is anteroposterior glide

Patient lies with hip, knee and ankle at 90º

Therapist:  grasps the patient’s lower leg around the ankle just above the malleoli with left hand, whilst with right hand grasp the dorsum of the foot, this being the stabilizing hand.

Contact & Action:  The mobilizing left hand then pulls forward and pushes back alternatively

The Subtalar 15

The joint play movement for this is called the rock of the talus on the calcaneus

Patient: sitting on the table with legs hanging over the edge.

Therapist: lateral to foot in crouched position. When applying this kind of joint play the ankle must be in long axis extension.

Contact & Action: Left hand pulls and pushes upwards and downwards while the calcaneus is stabilized producing posterior rock of the talus on the calcaneus.

Joint play as Technique

If you can reproduce this assessment then you can crowd or compress the joints into a closed-pack position, sustain light to moderate compression for 30 to 60 seconds, and usually a softening or release of the fibrous capsular tissue will occur. Mobilize as you crowd the joint and usually you will feel as ‘give’ to the hold and a breaking of adhesion. Reassess proximally and usually there is a considerable softening of the crural fascial sleeve.

References

1.    Hertling & Kessler , Management of Common Musculoskeletal Disorders 3rd Ed p 419

2.    Bruker & Khan, Clinical Sports Medicine, 2nd ed 2001 Chap. 26 Shin Pain p508

3.    Whitney Lowe, Orthopedic Massage, Theory & Technique, Mosby 2003 p82)

4.    Palastanga, Field & Soames, Anatomy & Human Movement: Structure & Function, Butterworth-Heinemann, 2000, p352)

5.    Michael Stansborough, Direct Release Myofascial Technique, p 52

6.    John Smith Structural Bodywork, Elsevier Ltd., 2005, p156 has a MFR Shin technique.

7.    Powerpoint:  Foot & Ankle: Researched and Written by Elizabeth Windham and Chris Watts. 2001

8.    Powerpoint: Greg Loomis ‘Compartment Syndrome’ 2003

9.    Powerpoint : Robin Ploeger, Ankle & Lower Leg Anatomy & Injuries, 1998

10.    PDF Download: Sharon Edwards Acute Compartment Syndrome, Emergency Nurse; 12:3, June 2004

11.    PDF Download: Matt Callison , Abstract: Journal of Chinese Medicine #70 October 2002, Article: Acupuncture & Tibial Stress Syndrome, pp54-57

12.    PDF Download: Richard Baxter, Medial Tibial Stress Syndrome: Shin Splints, 2006

13.    Peter Schwind, Fascial & Membrane Technique, Churchill-Livingstone, English Translation 2006

14.    Leon Chaitow & Judith Walker DeLany, Clinical Application of Neuromuscular Technique, Volume 2,The Lower Body, Chp 14, The Leg & Foot, pp501-507

15.    Andrew Noble: Joint Play: A Course in Synovial Joint Mobilization, Version 2.1, 1991

16.    Steven Goldstein: Integrative Fascial Release Course Manual, 2006

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