I need some advice from you more experienced therapists please. I have a case study, an aging triathlete competing at a very high level who has an area of solid scar tissue about two inches long and half an inch thick in his gastroc that he suggests has been there for 10 years plus. I understand that over the years a number of therapists have worked on this area with mixed success.
He still has full RoM but is currently suffering from a mild calf strain, I suspect due to the work the belly of the muscle is having to do to stretch because of this scar tissue build up.
During our first session I spent quite a bit of time frictioning it. I had thought STR could be used perhaps to pull the tissues apart but he has enough stretch to be able to take his ankle through full RoM without putting the force needed through the scar tissue.
I spent time on the latest calf strain and of the surrounding tissues.
What would you do with a case like to this tackle this scar tissue build up? Is deep frictions time and time again the only approach? He is now in the off season so keen to get a resolution if possible.
Any advice very much appreciated.
Best,
Sam (student therapist)
I need some advice from you more experienced therapists please. I have a case study, an aging triathlete competing at a very high level who has an area of solid scar tissue about two inches long and half an inch thick in his gastroc that he suggests has been there for 10 years plus. I understand that over the years a number of therapists have worked on this area with mixed success.
He still has full RoM but is currently suffering from a mild calf strain, I suspect due to the work the belly of the muscle is having to do to stretch because of this scar tissue build up.
During our first session I spent quite a bit of time frictioning it. I had thought STR could be used perhaps to pull the tissues apart but he has enough stretch to be able to take his ankle through full RoM without putting the force needed through the scar tissue.
I spent time on the latest calf strain and of the surrounding tissues.
What would you do with a case like to this tackle this scar tissue build up? Is deep frictions time and time again the only approach? He is now in the off season so keen to get a resolution if possible.
Any advice very much appreciated.
Best,
Sam (student therapist)
hi Sam,
without assessing it, I can only give an idea of how I might treat this:
- 5 mins heat (wheat bag etc) directly on the calf
- superficial MFR, followed by deep MFR.
- deep tissue massage, to the whole calf, include some soft tissue mobilisations directly around the scar tissue.
- DTF directly on scar tissue, for around 5 minutes
- STR directly on the scar tissue - remember, just because someone has full ROM, STR is still effective at stretching the localised muscle fibres that are contracted.
- deep effleurage to flush
- ICE massage for 5 mins
That would be a 30 minute treatment, and I would advise at least 2 treatments per week.
If it has been there for 10 years or so, dont expect to get rid straight away.
Thanks for that! All stuff I am quite capable of. I have him booked in on Friday so will keep this in mind.
IMHO after 10 yrs it just aint gonna happen
"Breakdown of scar tissue" is increasingly a colloquial expression which is used (inaccurately) to describe what frictions and str seek to acheive
Frictions / STR are used to reduce excessive granulation tissue (before it gets chance to mature into scar tissue) or reduce / remove adhesions which form between / within soft tissue structures or between soft tissue and bone
Mature scar tissue is a different beast entirely
Even if it were possible to "break down" fully formed scar tissue with frictions, the resultant damage / trauma would probably be greater than the "injury" itself (aka use of the "common assualt weapons" such jack knobbers / t bars etc)
It could possibly be molded into a different shape but that's about it
My advice is to leave well alone and concentrate on optimising the mobility / flexibility of the uneffected structures
I feel a "debate" coming on 😀
Hi Sam
check with your client that previous treatments have not increased the thickness of the scar tissue. Over enthusiastic frictions and stretching of the effected tissue could re start scar tisue formation.
.
5 mins DTF may be too much, build up to longer durations in proportion to the palpated reductions in following sessions.
Local (thumb pressure) on the scar tissue that follows the release, not forces it, could prove very effective.
To avoid over treating one area be sure you treat the knee and ankle, this will reduce the load on the scar tissue area.
Regards steve
P.S. As DFNU says bring on the debate 🙂
I feel a "debate" coming on 😀
me thinks you are stirring a little:005:
my two pennies worth is; if he has had it for 10+ years and it doesn't affect him in his sports/lifestyle why try and change it, if he has got along fine for 10+ yrs then best just to maintain what he has and prevent it from getting worse. but if you really are intent then the best advice has already been given.
also i see you are a practicing student therapist, so may i ask where your tutor is? and why is he not there guiding you on this subject?????:confused:
a second debate maybe:D:p
I have to disagree, we currently have a client, who is filming/recording his progress with us, basically, he injured his shoulder a decade ago, which lead to scar tissue formation that just went crazy, and lead to permanent disability, he basically couldnt move his arm, his scapula had moved round under his arm.
He has been through every branch of the NHS, and his orthopaedic surgeon even told him that surgery would be inffective. A lifetime of the inability to move his arm was what he could expect.
Yes, my initial thoughts were, no can do, and basically told him as much....however, thankfully my colleague had a bit more faith, and embarked on treatments.
He has combined the treatments with a strong dose of enzymes and MSM, and Im actually staggered at the results he is getting. 12 months on, the guy has got about 90 degree ROM, and he was laughing so much when he showed me something that he can now do, after almost a decade.....putting his hand in his pocket....something that simple he is so thrilled about.
He is being regularly checked by his orthopaedic surgeon, who has told him, whatever he is having done, to keep up with it!
As I said, he is recording his progress and we hope to put this on our website when we have got as far as we can with him.
So, can scar tissue be removed without causing more damage? In my opinion, yes, as long as it is controlled. I have had lots of success with this, especially in retired footballers with chronic scar tissue on ankles.
5 mins DTF after the area has been thoroughly warmed, the fascia worked, and muscles mobilised is perfectly reasonable, and any less may not be as effective.
I agree that sometimes you can cause damage by breaking down scar tissue, however, this is where we 'manage' the injury, and aid the correct healing process, and IMO, what appears to be 2 inches of scar tissue, is probably a couple of centimeters with the rest being extremely thickened fascial protection.
I also agree (sometimes) that if something isnt causing a problem, leave it alone, however, I dont think ive ever come across someone who had a problem that didnt create other problems. even subtle ones.
As for wheres the tutor......well im not Sams tutor...just his training director, but always happy to help 😀
Debate is always good, and we are always going to have different ideas of how to approach treatments, but one thing I have learnt from experience, never say never.
Another possible avenue to look towards to accompany the MFR is to use sports/kinesio taping techniques. I purchased the clinical therapeutic applications of kinesiotaping and it referred to the myofascia as being one part of the systems affected by the use of sports tape.
have a look at various techniques, alternatively I will put it into text what it suggests for the removal of scar tissue if you like.
Hopefully this won't cause a debate.
TT
At last something that Richard and I may "disagree" about (although it is probably about the "wording" than the principle
I totally agree that frictioning scar tissue can / will bring about an increase in ROM however I do not believe it to be (and have seen no studies) to support the concept that it is due to a "breakdown in scar tissue" (scar tissue wouldn't be much cop if someone could break it down with their (re-inforced :)) digits
I believe it to be more due to a combination of factors such as
- alignment of collagen fibres, removal of adhesions (due to localised inactivity not injury)
- increased extensibility / elasticty of surrounding (secondary structures) ie:
"what appears to be 2 inches of scar tissue, is probably a couple of centimeters with the rest being extremely thickened fascial protection" (which can be reduced)
- frictions will also encourage the hydration of localised fascia allowing the to be more compliant
- reduction in pain
- often physiological restrictions such as TP's will also be affected
But does the "theory" really matter? (to the client anyway) if they get an increased ROM who cares what"black magic" was involved 😀
I think we do use laymans terminology for things that arent exactly accurate, such as knots, breaking down etc, and I dont usually comment on treatment protocols because 1) without having the client there, you cant really do more than give an educated guess, and 2) what suits one client may not suit another.
I do agree that theory doesnt matter, when it comes to treatment, in fact, how much have we actually proven with any of the things we do? What matters are results.
TT, I havent yet used fascial taping myself, however, it is something that we use in our clinic, and I believe the benefits are that it does enhance fascial treatments.
Just as another example of 'breaking down scar tissue' (for want of a better term :p)...I had a client with terrible shin splints (for want of another better term:p) and I worked on her for 6 weeks, once per week, pretty similar type of treatment to the one I described above. After about 6 weeks she came in for her treatment, and told me she had a 'lump' in her shin. After feeling it, I decided, nope, its not scar tissue, it feels like bone, and then she told me that 10 years previous, she had been kicked by her horse in the shin, and it had chipped her bone. So all the work had uncovered the said shard of bone, which had been enveloped by fascia (?). My point is, unless we get our clients to have scans, we never really know what we are working, and with any type of treatment, we have to monitor it, especially where there are 'scar tissue' type formations, and if in doubt, refer onwards.
Its my experience that the transformation of scar tissue is dependant on the skill of the practitioner combined with the neurobiochemical potential of conditions present, not the age of the scar tissue.
"Breaking down of scar tissue"
I am only concerned that inexperienced over enthusiasm (DTF) will combine with a client that may be thinking more pain more gain,= a possible recipe for more scar tissue or myogelosis.:(
I used to teach a very vigorous form of healing, which was literally to re-injure, and then to start again, which is what I was taught, and was not only very common in the 90s, was very successful, after all, we arent healers, we are just facilitators, assisting our clients/patients bodies in healing in the correct way. Unfortunately, in this blame and claim culture, I no longer teach this, however with skill, as you quite rightly say, you can greatly assist.
There are some very valid points all round, and certainly back in the day, I would be using DTF for around 15 minutes, combined with mobilisation and ultrasound, but now, I would advise around 5 mins, ensuring that the area is completely prepared.
As I said if it is managed correctly, new scar tissue formation should be greatly reduced.
I would have mentioned ultrasound in my first post, however, I mentioned the heat pad at the start and ICE at the end, however, I have used both, U/S and heat/cold, and both are as effective in both warming the structure at the beginning of the session and helping manage the possible pain and inflammation at the end of the session.
"Breaking down of scar tissue"
I am only concerned that inexperienced over enthusiasm (DTF) will combine with a client that may be thinking more pain more gain,= a possible recipe for more scar tissue or myogelosis.:(
My point entirely !
ie : Rub it hard and make it hurt approach adopted by the "caveman" sports (massage) therapists still rife in the industry)
I'l hold my hand up and agree that I too....
I used to teach (and practice) a very vigorous form of healing, which was literally to re-injure, and then to start again, which is what I was taught, ......
and still believe in certain instances this is still could be considered a valid approach However some so "expert educators" (present company very much excluded) do not seem to have grasped (appreciated?) that there should not be a one size fits all method when utilsing such invasive treatment modalities
Hence my over senstivity when I hear the expression breaking down scar tissue
When I taught (especially beginners) I would never use or show them how to use anything other than the use of thumbs / reinforced digits) for frictions and tp's
I want it to be hard work and uncomfortable for the practitioner to apply frictions because that way they will not be overly "enthusiastc" and overtreat 😮
Rant over, put me back in my box 😀
I see where you are coming from, which is why I stress that it has to not only be treated correctly, but also correctly managed.
Im certainly not in the 'no pain no gain' brigade, however, I do realise that if there is dysfunction, there is also going to be pain/discomfort during the treatment, that can be reduced, by correct preparation.
Stephen, im also a firm believer in the power of pressure, and have got (what some clients have called miraculous) results, just from light thumb pressure. All power to the mighty thumb!! :045::045::045::045:
Im certainly not in the 'no pain no gain' brigade, however, I do realise that if there is dysfunction, there is also going to be pain/discomfort during the treatment, that can be reduced, by correct preparation.
Exactly
Pain / discomfort (may) be the consequence of a treatment but is not the aim of it
(Certain GB physios take note :cool:)
Thanks very much for all the responses!
Thanks Richard for the sound advice. The client likes what I am doing and has already booked another two sessions.
I get plenty of support from the tutors on the course and my peers thanks.
Im now nearing the end of my course (final month) and I am now keen to learn from therapists from all walks of life (including you lot) as I have been well prepared by my course for the outside world of sports therapy (even though I still have a lot to learn).
Thanks again.
My point entirely !
ie : Rub it hard and make it hurt approach adopted by the "caveman" sports (massage) therapists still rife in the industry)I'l hold my hand up and agree that I too....
Yup, am afraid to say I too used to use the caveman approach,:eek: thank god I listened to my intuition and later confirmed by R Shcliep I am now much more a "melter" and not "breaker".:cool:
Now I can keep DTF use to a minimum (to start the theraputic process), but rely on melting to separate the bonding fibers of scar tissue.:)
Yup, am afraid to say I too used to use the caveman approach,:eek: thank god I listened to my intuition and later confirmed by R Shcliep I am now much more a "melter" and not "breaker".:cool:
Now I can keep DTF use to a minimum (to start the theraputic process), but rely on melting to separate the bonding fibers of scar tissue.:)
Whilst I firmly believe that massage is intuitive, and I am a huge fan of MFR (I am proud to say that I was first in the UK to introduce it onto both sports therapy and sport & remedial courses, and got it into the ST NOS), I think you do need a more 'technical' approach to the problem originally posted here.
To 'melt' a decades worth of scar tissue/adhesions/fibrosis would probably take a decade itself, you have to combine with a fairly large set of 'remedial' tools to deal with the problem effectively.
The caveman approach has no place in modern sports therapy, however, im sure there cant be that many of them around anymore, as there are lots of well trained therapists now replacing them.
also i see you are a practicing student therapist, so may i ask where your tutor is? and why is he not there guiding you on this subject?????:confused:
a second debate maybe:D:p
some students are studying on a course spread over one or two years and where they only have direct access to tutors during their weekends of study, they spend the months between doing self directed study and practice hours, during which they may be exposed to a condition or scenario in which they are not fully informed, it is therefore wholly appropriate that they seek advice from "seasoned" therapists on these type of fora, which are a valuable resource for students and therapists alike.
to follow on from your comment, surely we could say that perhaps your tutor didnt guide you sufficiently, given the amount of advice you ask on a wide range of topics surrounding your business , but heyho we are all still learning and therefore all still students of one kind or another
regards
BGFL:cool:
I need some advice from you more experienced therapists please. I have a case study, an aging triathlete competing at a very high level who has an area of solid scar tissue about two inches long and half an inch thick in his gastroc that he suggests has been there for 10 years plus. I understand that over the years a number of therapists have worked on this area with mixed success.
He still has full RoM but is currently suffering from a mild calf strain, I suspect due to the work the belly of the muscle is having to do to stretch because of this scar tissue build up.
During our first session I spent quite a bit of time frictioning it. I had thought STR could be used perhaps to pull the tissues apart but he has enough stretch to be able to take his ankle through full RoM without putting the force needed through the scar tissue.
I spent time on the latest calf strain and of the surrounding tissues.
What would you do with a case like to this tackle this scar tissue build up? Is deep frictions time and time again the only approach? He is now in the off season so keen to get a resolution if possible.
Any advice very much appreciated.
Best,
Sam (student therapist)
IASTM works good