Repair and remodelling of healing tissues respond to cyclic loading and motion.¹ Early motion and loading of injured tissues is not without risk, however, and excessive loading can inhibit or stop healing. Deep transverse friction imposes cyclic loading without bringing too much tension on the healing longitudinal structures of tendon or ligament and can therefore be considered as beneficial.

Deep transverse friction

Deep transverse friction (although the word friction is technically incorrect and would be better replaced by ‘massage’) is a specific type of connective tissue massage ² developed in an empirical way by Cyriax.³

Transverse massage is applied by the finger(s) directly to the lesion and transverse to the direction of the fibres. It can be used after an injury and for mechanical overuse in muscular, tendinous and ligamentous structures.4–6 In many instances the friction massage is an alternative to infiltrations with steroids. Friction is usually slower in effect than injections but leads to a physically more fundamental resolution, resulting in more permanent cure and less recurrence. Whereas steroid injection is usually successful in 1–2 weeks, deep friction may require up to 6 weeks to have its full effect.

The technique is often used before and in conjunction with mobilization techniques. In minor muscular tears, friction is usually followed by active movement, in ligamentous tears by passive movement and in tendinous lesions by active unloaded movements until full resolution has been achieved.

It is vital that transverse massage is performed only at the site of the lesion. The effect is so local that, unless the finger is applied to the exact site and friction given in the right direction, relief cannot be expected.

Over the years, and unfortunately enough, the technique has developed a reputation for being very painful for the patient. However, pain during friction massage is usually the result of a wrong indication, a wrong technique or an unaccustomed amount of pressure. Friction massage applied correctly will quickly result in an analgesic effect over the treated area and is seldom a painful experience for the patient.

Mode of action

Transverse massage should be used empirically for what it is and what it achieves; there is no scientific proof for any postulates about the underlying mechanism of action.

Only a few studies exist,7,8,9 and more research is urgently needed. However, experienced therapists know in what kind of soft tissues they can expect good results with transverse massage and where the technique does not work. Transverse massage either is effective quickly (after 6–10 sessions) or not at all. Advice on indications, contraindications and modalities of the technique that are given in this book rely solely on the experiences of the authors and not on scientific research.

However, although the exact mode of action is not known, some theoretical explanations have been put forward. It has been hypothesized that friction has a local pain-diminishing effect and results in better alignment of connective tissue fibrils.

Relief of pain

It is a common clinical observation that application of local transverse friction leads to immediate pain relief – the patient experiences a numbing effect during the friction and reassessment immediately after the session shows reduction in pain and increase in strength and mobility. The time to produce analgesia during the application of transverse friction is a few minutes and the post-massage analgesic effect may last more than 24 hours.¹⁰ The temporary relief at the end of a session may prepare the patient for treatment with mobilization not otherwise possible, such as selective rupture of unwanted adhesions.

A number of hypotheses to explain the pain-relieving effect of transverse massage have been put forward:

• Pain relief during and after friction massage may be the result of modulation of the nociceptive impulses at spinal cord level: the gate control theory (see Ch. 1). The centripetal projection into the dorsal horn of the spinal cord from the nociceptive receptor system is inhibited by the concurrent activity of the mechanoreceptors located in the same tissues. Selective stimulation of the mechanoreceptors by rhythmical movements over the affected area thus ‘closes the gate for pain afference’.

• According to Cyriax, friction also leads to increased destruction of pain-provoking metabolites, such as Lewis’s substances. This metabolite, if present in too high a concentration, provokes ischaemia and pain.³

• It has also been suggested that prolonged deep friction of a localized area may give rise to a lasting peripheral disturbance of nerve tissue, with local anaesthetic effect.

• Another mechanism through which reduction in pain may be achieved is through diffuse noxious inhibitory controls, a pain-suppression mechanism that releases endogenous opiates. The latter are inhibitory neurotransmitters that diminish the intensity of the pain transmitted to higher centres.11–13

It is now generally recognized that internal and external mechanical stress applied to the repair tissue is the main stimulus for remodelling immature and weak scar tissue – with fibres that are oriented in all directions and through several planes – into linearly rearranged bundles of connective tissues.¹⁶ Therefore, during the healing period, the affected structures should be kept mobile by normal use. However, because of pain, the tissues cannot be moved to their full extent. This problem can be solved by friction. Transverse friction massage imposes rhythmical stress transversely to the remodelling collagenous structures of the connective tissue and thus reorients the collagen in a longitudinal fashion. Friction is thus a useful treatment to apply early in the repair cycle (granulation and beginning of remodelling stage): the cyclic loading on and motion of the healing connective tissues stimulates formation and remodelling of the collagen.¹⁷

Friction prevents adhesion formation and ruptures unwanted adhesions (Fig. 5.1)

In that transverse friction aims to achieve transverse movement of the collagen structure of the connective tissue, crosslinks and adhesion formation are prevented. In the early stages of proliferation when crosslinks are absent or still weak, friction must be very light so as to cause only minimal discomfort. Therefore, in the first day or two following an injury, friction is given with slight pressure only and over a short duration, e.g. 1 minute.

Fig 5.1 Friction achieves a transverse movement between longitudinally arranged collagenous fibres.

At a later stage when strong crosslinks or adhesions have formed, more intense friction is needed to break these down.18–21 The technique is then used to soften the scar tissue and to mobilize the crosslinks between the collagen fibres and the adhesions between healing connective tissue and surrounding tissues. This, together with the local anaesthesia produced, prepares the structures for mobilizations that apply longitudinal stress to the structures and rupture the larger adhesions.

Friction induces traumatic hyperaemia

Forceful deep friction produces vasodilatation and increased blood flow to the area. It may be hypothesized that this facilitates the removal of chemical irritants and increases the transportation of endogenous opiates, so causing a decrease in pain. Such a forceful friction, resulting in hyperaemia is only desirable in chronic, self-perpetuating lesions.

Indications

Diagnosis

The reduction in pain achieved after a few minutes of localized transverse friction may be very helpful to define the exact location of the lesion. In muscular, tendinous or ligamentous lesions, a few minutes of massage on the suspected area results in diminished pain on testing immediately thereafter, so confirming the diagnosis as accurately as an infiltration with local anaesthesia.

Preparation for mobilizations and manipulation

Transverse massage is often applied before and in conjunction with other mobilizing techniques. In muscular lesions, friction is given before active or electrical contractions on an unloaded muscle. The purpose is to allow broadening of the muscle and so the prevention of adhesion formation between adjacent muscle fibres and/or bundles.

For reasons of pain relief, transverse massage is usually required before manipulative breakage of ligamentous adhesions is performed. This may be indicated in chronic ligamentous lesions at knee and ankle.

Deep and thorough friction also precedes manipulation of the elbow in type II tennis elbow. The technique is used for its desensitizing and softening effect which makes the manipulation more tolerable.

Therapy

Muscle bellies

Friction is given to a healing muscle belly after contusion, in minor muscular tears and in so-called ‘myosynovitis’. In minor muscular tears the friction is often part of combined treatment because it is usually applied after an infiltration with local anaesthesia and is followed by active contractions.

The aim of treatment in muscular tears is to allow the torn fibres to heal in such a way that normal increase in breadth on contraction remains possible, a characteristic that can be disturbed by abnormal adhesion formation. Transverse friction aims to achieve a transverse sweeping movement over the longitudinal muscular fibres without pulling on the tear, so to prevent (in the early stage) or to break down (in the chronic stage) adhesion formation between the individual fibres and between individual fibres and the surrounding connective tissue. It is obvious that to break down crosslinks in a chronic stage, the friction can be given forcefully and for a duration of 15–20 minutes, whereas in more recent lesions the technique must be applied more gently and for a shorter duration. Friction to a muscle belly is always given with the muscle well relaxed.

In recent tears, especially in the large muscles of the lower limb, friction is followed by active or electrical contractions with the muscle in a position of maximal relaxation and without weight bearing, so that tension does not fall on the healing breach.

To avoid early recurrence, friction is given for 1 week after all clinical tests have become negative. During the period of treatment, all movements or activities that bring on pain should be avoided by the patient.

Theoretically, friction can be used for all muscle belly lesions. However, some lesions respond so well to local anaesthetic infiltration that friction is not used. This is the case in type IV tennis elbow (lesion at the muscle belly of the extensor carpi radialis). On the other hand, sometimes no alternatives exist to treatment with deep transverse friction (Box 5.1). A lesion of the subclavius or intercostal muscles for instance can be treated only by deep transverse friction.

Box 5.1 Muscle belly disorders that can be treated only by deep transverse friction

Subclavius

Brachialis

Supinator

Adductors of the thumb

Interosseus muscles of the hand

Intercostal muscles

Oblique muscles of the abdomen

Interosseus muscles of the foot

Musculotendinous junctions

It is a common clinical experience that all musculotendinous junctions (containing both muscular and tendinous fibres) throughout the whole body can be treated only by deep transverse friction. It would seem that no alternatives exist: local anaesthetics, so curative for some lesions of muscle bellies, and steroids, so effective for tenoperiosteal lesions, have not the slightest effect on musculotendinous lesions, whereas deep transverse friction usually has.

Tendons

All overuse tendinitis can be treated by deep massage except for the tenoperiosteal origin of the extensor carpi radialis brevis (type II tennis elbow), which is best treated by an infiltration with corticosteroid or, in refractory circumstances, sometimes by manipulations.

Tenosynovitis also usually responds well to deep transverse massage. In this condition, occurring in long tendons with a sheath, inflammation and roughening of the gliding surfaces of both tendon and sheath give rise to pain and sometimes to crepitus. Friction rolls the sheath around the stretched tendon, so facilitating functional movement between the tendon and its sheath. The technique is useful in both acute and chronic lesions.

Lesions at the tenoperiosteal insertion can be treated either with corticosteroid infiltrations or with deep transverse massage. Corticosteroid suspension quickly converts an inflamed and painful scar into one free of inflammation. However, the recurrence rate is rather high, between 20% and 25%.³ The aim of the massage is to get rid of the self-perpetuating inflammation by breaking up the disorderly scar tissue and adhesion formation by converting it into properly arranged longitudinal connective fibres. This takes longer but once cure is achieved there will be less of a tendency towards recurrence. It may therefore be a policy to start treatment with infiltrations but if the trouble recurs after a few months to substitute with massage.

As a rule, however, friction is always selected as the treatment of choice in athletes or when the tendon is weakened (partial rupture). It cannot be denied that repeated use of corticosteroids, even in small doses and correctly applied, temporarily weakens a tendinous structure. Steroids also take away inflammation and pain, so giving the patient the false impression of being cured. The combination of a weakened tendon and abolition of pain can be disastrous – rupture may ensue.

There exist also a few conditions that seem to respond only to deep transverse friction. Steroid infiltrations are useless here. This is so in tendinous lesions of the interosseus in the hand and at the quadriceps expansion at the patella.

Lesions in the tendinous body, either traumatic or resulting from overuse, are contraindications for infiltration with corticosteroids. Ruptures have been reported after intralesional steroid infiltrations of long tendons and therefore deep frictions are the treatment of choice here.22,23

It is obvious that during the whole period of treatment of tendinitis, tenosynovitis or tenovaginitis, the patient must avoid all activities that provoke the pain, especially the loading of the affected contractile tissue.

Ligaments

Transverse massage is an excellent treatment in acutely sprained ligaments, especially in ligaments of the knee and ankle. The background, mode of action and technique differ considerably and depend on the stage of the lesion.

It has been explained (see Ch. 3) that early mobilization is extremely important for swift and full recovery of ligamentous sprains. However, in advocating this, one main difficulty is encountered: the intensity of the initial inflammatory reaction. The slightest movement causes pain which forces the patient to immobilize the joint and the ligaments. However, during immobilization, regenerating fibrils quickly start to form randomly organized scar tissue, leading to crosslinks and adhesion formation. This problem can be solved by gentle transverse frictions. Rhythmic movement across the inflamed ligament eases the pain and the tissue can be moved to and fro in an imitation of its normal behaviour.

In recent cases the friction need not last long nor be very vigorous – 1 or 2 minutes of daily gentle transverse sweeping movement over the regenerating fibrils is enough. As pain diminishes over subsequent days friction is progressively increased to about 4–5 minutes for 2 or 3 days and finally to a full duration of 15–20 minutes. From the third day, friction is followed by passive and active movements within the limits of pain to maintain normal gliding of the ligament over adjacent bones. When the lower limb is involved, the patient should be instructed to walk as normally as possible but without provoking too much pain.

In chronic ligamentous lesions, frictions are also used but in a totally different way. Here adherent scar tissue has formed abnormal attachments as the result of healing during a period of insufficient movement. As a result of the reduced mobility of the ligament, vigorous use of the joint re-sprains the ligament and in due course leads to recurrent sprains.

Treatment will consist of rupturing the adhesions by manipulation, for which vigorous deep friction to the site of the adhesions prepares the ligaments. The massage weakens and desensitizes the structure, making the forced movement practicable and painless.

Experience has shown that particular ligamentous lesions can be treated only by friction. This is the case for the posterior carpal ligaments at the wrist and the tibiotalar ligaments.

Joint capsules

Deep transverse friction can be applied to the capsules of the trapezium–first metacarpal joint, the temporomandibular joint and the cervical facet joints. The indication is traumatic arthritis or osteoarthrosis. Results are fair, provided the arthrosis is not too advanced. Indications and contraindications to friction are outlined in Table 5.1.

Table 5.1

Indications and contraindications to friction

Contraindications

Ossification and calcification of soft tissues

Extensive ossification in muscles, tendons, ligaments or capsules is a bar to all active treatment. However the minor calcifications that may occur after a sprain can be managed by friction. In supraspinatus tendinitis, calcification is regarded as responsible for complaints when the insertion is very tender to touch and a radiograph shows calcification. These findings are a contraindication to friction. In contrast, when calcification is present in the absence of severe tenderness, transverse massage can be given.

First, the therapeutic movement should be applied to the exact site of the lesion which may occupy only a very small volume of tissue. In other words, an identification of the site to within 1 cm must be achieved which relies entirely on clinical diagnosis and palpation of the lesion, based in turn on anatomical knowledge. In some instances it will be necessary to palpate carefully the entire structure at fault so as to find the point that reproduces the patient’s pain.

Secondly, friction should be applied transversely across the longitudinally orientated fibres, with sufficient sweep to reach all the affected tissue and firmly enough to produce movement between the individual connective tissue fibres of the affected structure.

Third, the movement can only reach deeply seated structures if the deep friction technique of Cyriax is used; that implies attention must be paid to different elements such as the position of the patient and of the therapist’s hand, which fingers are used, the amount of pressure, the duration and frequency of the sessions. The patient’s skin and the therapist’s finger must move as one, so that the deep layers of the skin move over the affected fibres. Therefore all cream, ointments, powder or any other procedure, such as previous heat, that makes the skin sweat, must be avoided. Six to 12 treatments are normally necessary. Except in acute ligamentous disorders they are not given more often than every other day because otherwise the site of the lesion may still be too tender from the previous treatment to permit adequate massage.

Position of the patient

The patient’s position must be comfortable because it must be maintained for up to 15–20 minutes. Sitting or lying is preferable.

The lesion must be brought within finger’s reach. In some structures this can be easily attained but others such as the supraspinatus insertion and the anterior aspect of Achilles tendon, require more specific positioning of the patient.

In addition, positioning must place the affected structure under the required amount of tension. Full relaxation is necessary for a muscle belly in order not only to treat its surface but also to access a deeply seated lesion. Tendons with a sheath must be kept taut otherwise friction will be ineffective between tendon and sheath. The same applies in ligamentous lesions, which are also placed in tension but within the limits of pain.

Position of the therapist and the hands

The bodily position of the patient should be the most comfortable and least tiring for the therapist. Working height is of chief importance, so an adjustable high–low couch is ideal. To have some economy of effort the therapist should adopt a position that utilizes body weight to a maximum. Usually this is standing and with the patient on a slightly lower plane. The therapist should avoid flexed positions. The shoulder should also not be in abduction because this quickly leads to pain and cramp in the neck and shoulder girdle.

Massage is performed by the whole arm and is not just an activity of hand and digits. Movement is generated in the shoulder and conducted via elbow and forearm to the digits. One set of muscles is used to apply force and another to provide movement, for example pressure with the fingers, movement with the arms. Digits, hand and forearm should generally form a straight line and are kept parallel to the direction of movement.

The majority of friction techniques are performed in two phases: an active movement, usually as a result of flexor muscular activity and a passive movement, when the arm and hand are returned to the starting position. At the end of the passive phase there should also be a moment of rest during which the therapist fully relaxes the muscles.

The hands can be used in a variety of ways depending on the tissues to be treated and the surface worked on. The wrist and metacarpophalangeal joints should be kept in an almost neutral position. The interphalangeal joints are slightly flexed to avoid traumatic arthritis.

Three main techniques can be distinguished.

To-and-fro movements

These are used in the treatment of dense, round or flat collagenous bundles (tendons or ligaments) and in the treatment of tenosynovitis. The active phase is a sweep with the tip(s) of one or two digits across the tendinous structure. During the passive relaxation phase the finger is returned to the starting position, without losing contact between finger and skin. Movement is with the arm; friction is given by use of the pulpy part of the finger (Fig. 5.2). In large lesions, as in peroneal tendinitis, two or three adjacent fingers are used together. In deep-seated lesions as in tendinitis of the long head of biceps in the bicipital groove or at its insertion on the radius or in infraspinatus tendinitis, the thumb performs friction.

Fig 5.2 Friction to the supraspinatus tendon: counterpressure is by the thumb.

Counterpressure is usually provided to enable a good sweep. The finger(s) applying counterpressure and stabilization are most important in bringing those applying friction into the right position and also determining the direction of the friction. The thumb is used (to give counterpressure) when the sweep is performed by a movement of the index reinforced by the middle finger or the middle finger aided by the index finger. When the thumb does the massage, counterpressure is from the fingers (Fig. 5.3). The most common way of applying friction around a round edge on a flat surface is to use the index reinforced by the middle finger. Sometimes the opposite is done: the middle finger is reinforced by the index. Sometimes counterpressure is not given, for example in friction to the quadriceps expansion or intercostal muscles.

Fig 5.3 Friction to the infraspinatus tendon: counterpressure is by the fingers.

Pronation–supination

This technique is often used where the lesion is difficult to reach: the anterior aspect of the Achilles tendon, popliteus tendon and the dorsal interossei of the metacarpals. Massage is performed with the pulpy part of the third finger (long finger), reinforced by the index finger. The long finger is used because its long axis is the prolongation of the axis of pronation–supination rotation of the forearm (Fig. 5.4).

Fig 5.4 Active phase of pronation–supination friction technique to the anterior aspect of the Achilles tendon. a, starting position; b, end of supination (active) movement.

The active phase is usually on supination. No counterpressure is given. Caution is taken not to move the finger on the skin but rather to move the skin and the fingertip as a whole. The passive phase is the pronation movement that brings the frictioning finger back to the starting position without losing contact with the skin.

Pinch grip

This is the normal technique for a muscle belly. The pinch is between the thumb and the other fingers. The muscle is fully relaxed. The fingers are placed at one side of the affected area and the thumb at the opposite side (Fig. 5.5). By drawing the fingers upwards over the affected area, the therapist feels the muscle fibres escape from the grip until only skin and subcutaneous tissue remain.

Fig 5.5 Pinch grip friction to the Achilles tendon. a, starting position; b, end of active phase.

During the passive phase the fingers are slightly relaxed and moved downwards into the previous deep position where the same movement starts again.

Sometimes the same technique is used in tendinous lesions, for example, at the sides of the Achilles tendon.

No movement between finger and skin is allowed

Deep friction can only be effective when skin and subcutaneous fascia are moved over tendon ligaments or muscles. No movement is allowed between the therapist’s finger and the patient’s skin. If movement occurs between finger and skin, blistering soon takes place and usually indicates faulty technique. Sometimes it can be avoided by keeping the skin dry by the use of 95% alcohol in water and/or by placing a piece of cotton in between the finger and the skin.

In the obese, subcutaneous soreness and/or ecchymosis may occasionally occur and sometimes a nodule may form. For this reason the finger should not be in continuous contact with the same area but should displace the skin slightly to one or other side, before pressure is applied.

Direction of friction must be transverse to the tissue fibres

Longitudinal massage improves the circulation of blood and lymph but has no effect on musculoskeletal lesions. On the contrary, because lesions of tendons, muscles and ligaments are normally caused by a longitudinal force, longitudinal massage can possibly be harmful in that it may separate the ruptured ends further. To restore and/or maintain full mobility of a lesion, massage must be given across the fibres, so moving all fibres in relation to each other. To achieve this, the therapist must have a good anatomical knowledge of the direction of the fibres.

Sweep

The main goal of friction is to move fibres in relation to each other and adjacent structures. Enough sweep must be given to the friction for this purpose, so the frictioning finger starts at the far side of the lesion, glides over it and ends at the near edge. Pressure alone, however hard and painful it may be, is totally ineffective. Adequate sweep is sometimes limited by the amount and elasticity of the overlying skin. Initial displacement of skin over the lesion from the near to the far side may help increase sweep and reduce the risk of blistering.

Amount of pressure

Over recent decades, friction has been held in some disrepute in that it was perceived by some as synonymous with very painful treatment. Though it cannot be claimed as wholly pain-free, the pain should not be unbearable. When excessive pain is provoked, this is usually the result of a failure to understand the meaning of the term ‘deep’, which means ‘as deep as needed to reach the lesion’. Many therapists misinterpret this in such a way that they feel that they always have to work hard physically, which obviously leads to pain and may do more harm than good.

The amount of pressure applied depends on three elements:

• The depth of the lesion: that friction must always reach sufficient depth to move the affected fibres in relation to their neighbours and sometimes the underlying bone or capsule, increased pressure must be applied to deeper structures.

• The ‘age’ of the lesion: recent sprains and injuries require only preventive friction because crosslinks or adhesions have not had time to form. In long-standing cases more pressure is needed to get rid of these. However, pressure should always be associated with movement and should not replace it because pressure alone is both painful and ineffective.

• The tenderness of the lesion: in severely inflamed lesions that are very tender to touch, friction with the usual amount of force may be very painful. Pain can be avoided by starting with a minimal amount of pressure – just enough to reach the lesion – and progressively increasing the force as treatment proceeds.

In order to avoid painful sessions of deep transverse friction it is good practice to grade its application. Begin with a sweep that is gentle and continue this for a few minutes; some numbness of the treated area follows which allows slight intensification of the amount of pressure, which in turn leads to more numbness. Finally, it will be possible to give effective massage that is practically painless to the patient.

Duration and frequency

Friction is usually given for about 10–20 minutes and, because of tenderness, on every second day. The ideal timing of the next treatment is when local tenderness caused by the previous session has resolved. If tenderness persists after 2 days, the pressure used during friction should not be diminished but the interval between sessions must be increased.

Massage immediately after a ligamentous sprain or a minor muscular rupture may be applied daily for the first week but should be of very low intensity and short duration.

Treatment is stopped once the patient is pain-free during daily activities and functional tests are totally negative. Local tenderness may persist longer but disappears spontaneously because it is the outcome of repetitive hard pressure. However, in a minor lesion of a muscle belly, massage is continued for 1 week after full clinical recovery to prevent recurrence (see Table 5.2; see also Box 5.2).

Box 5.2 Summary of deep friction technique

1. Position of the patient must:

be comfortable

bring lesion within finger’s reach

be appropriate for the type of structure at fault:

• tendon/ligament under tension

• muscle belly: relaxed

2. Position of the therapist must:

be comfortable

facilitate economy of effort:

• alternating active and passive phases

• using large muscles

4. Use of the fingers:

Counterpressure

Friction using the fingers

5. Other points:

Fingers and skin move as one unit

Direction of friction must be transverse

Sufficient sweep must be used

The pressure must be appropriate

Duration and frequency must be appropriate

Table 5.2

Transverse massages/modalities

Passive movements

Treatment by passive movement is otherwise known as mobilization. It cannot be performed by the patient and requires the intervention of a therapist. Depending on its velocity and the range of movement that is aimed for, it can be graded as A, B and C mobilization:

• Grade A mobilization is a passive movement performed within the pain-free range.

• Grade B mobilizations are passive movements performed to the end of the possible range. The latter is indicated by an end-feel. All stretching and traction techniques are grade B mobilizations.

• Grade C mobilization is a minimal thrust with a high velocity and over a small amplitude. It is performed at the end of the possible range, i.e. the moment the therapist has reached the end-feel. Another word for grade C mobilization is manipulation.

Passive movements within the pain-free range are usually called for in the treatment of injured connective tissue. A comprehensive literature evaluation and meta-analysis of experimental studies of the past several decades have demonstrated that regeneration of injured connective tissue is significantly better with the application of continuous passive motion. If the healing tissues are not loaded, regeneration results in unstructured scar tissue. Under functional load, the collagen fibres are oriented in a longitudinal direction and the mechanical properties are optimized.²⁴

Grade A mobilizations are therefore applied early in the treatment of sprained ligaments to promote orientation of the regenerating fibres. They are given in conjunction with gentle transverse massage and within the pain-free range. Care should be taken not to bring the fibres under longitudinal stress in order not to disrupt the healing breach. The movements are of short duration but repeated often.

Distractions at the shoulder

Grade A mobilizations are also used on the capsule of the shoulder in stage III arthritis when stretching and intra-articular steroids are contraindicated (see Ch. 14). In this condition, long-standing stimulation of the nociceptors has increased neuro-sympathetic activity, giving rise to vasoconstriction, muscle spasm and pain.

Gentle and rhythmical grade A movements are performed in such a way that the fibres are stretched longitudinally, stimulating the mechanosensor mechanisms in the joint and so inhibiting somatosympathetic reflexes that are co-responsible for the increased inflammation of the joint.

Deformity correction

Some cases of lumbago show persistent spinal deviation even after the pain has ceased. A quick thrust manipulation so effective in relief of pain is not effective in correcting the remaining deformity, but sustained translatory gliding in the opposite direction is most helpful. The movement is performed slowly and care is taken to keep the gliding within the pain-free range (see Ch. 40).

Reduction of an intra-articular displacement in a peripheral joint

When a meniscus or some other piece of intra-articular cartilage (with or without an osseous nucleus) becomes displaced and locks a joint, the logical treatment is either to remove it or manœuvre it into such a position that the joint can again move freely over a normal range. The technique needed for the latter is usually a series of manipulative movements which normally contain elements of traction combined with movements of rotation and flexion or extension. In general, these are first performed in the less painful direction of movement and repeated several times with progressively increasing force.

Unlike manipulations in the spine, the manœuvre to reduce an intra-articular loose body is not a grade C mobilization because the movement is not performed at the end of range nor does it contain a ‘thrust’ element. The flexion–extension movement is over a wide range and stops before the end-feel is reached. The rotation movements are performed to the end of range where end-feel is sensed by the therapist. The ‘manipulation of an intra-articular displacement in a peripheral joint’ is therefore a combination of grade A and grade B mobilizations.

Grade B mobilizations

To maintain a normal range at the joint

Paralysed muscles may lead to a loss of normal range of motion of the corresponding joint. This can be avoided by gently stretching the capsule, starting as soon as possible after the onset of paralysis. The approach should also be considered for joints that have been injured or subjected to surgery. In such circumstances, there may be the paradox that immobilization is needed for a fracture to heal but that movement is required to prevent loss of capsular elasticity. Often the problem can be solved by adapting the technique of capsular stretching so that it does not influence the site of the fracture.

To stretch the capsule of a joint

Grade B mobilizations may be required to stretch the joint capsule in non-acute arthritis and in early osteoarthrosis. The technique will be further referred to as capsular stretching. Capsular stretching is particularly useful in shoulder and hip joints but is applicable in all ‘non-irritable’ capsulitis. The condition is characterized by:

• a limitation in the capsular pattern (see Ch. 4)

• demonstration of a hard-elastic end-feel to restricted movements (see Ch. 4).

In the very beginning of arthritis, muscle spasm forces the joint to be held in a position of ease, so restricting movement in some directions more than in others (see Capsular pattern, Ch. 4). Immobilization and inflammation cause disordered deposition of collagen fibres in the joint capsule and lead to the formation of capsular adhesions, which in turn are responsible for more restriction of movement and pain. Stretching aims at restoring mobility and function by breaking micro-adhesions and producing elongation of the shortened capsule. To be applicable, however, the ligamentous end-feel must be reached before the protective muscle spasm begins. To be successful, the therapist should therefore be able to differentiate between an elastic and a spastic end-feel.

The technique is a slow and steady pressure, performed at the end of range over about 30 seconds to 1 minute with as much force as is reasonable for the patient to bear. Tension is slightly diminished for a few seconds, so affording the patient some respite, and then again increased. From time to time the procedure is completely interrupted. If tension is released too quickly, some pain may be felt and it is therefore wise to bring the limb back into neutral position under traction. The technique is not painless. The stretching causes some micro-ruptures, which result in an inflammatory response and after-pain that lasts for a few hours.

Normally, capsular stretching is given for 15–20 minutes, three times a week. The therapeutic effect is slow.

Capsular stretching can be preceded by application of heat, either through short-wave diathermy or ultrasound. This can relieve some pain and seems to lower the viscosity of the collagenous tissue, allowing more movement for less force. In vivo studies on the effects of heat on ligament extensibility have shown that sustained force applied after elevating tissue temperature produced significantly greater residual elongation.25,26

Manipulation of a joint capsule under anaesthesia is a grade C mobilization and is only considered for postoperative intra-articular adhesions. A joint that has been manipulated under anaesthesia requires daily intensive mobilization immediately afterwards in order to prevent the formation of new intra-articular adhesions.

To stretch a muscle

Children with short calf muscles can be helped by sustained stretching. The procedure consists of a series of alternating passive stretchings and active contractions. Stretching is maintained for about 8–10 seconds and is followed by full relaxation and active contraction of the muscle. These alternating movements are performed six to eight times per session, preferably daily but at a minimum of three times a week. The earlier the stretching is started, the better the result. Above the age of 15 not much improvement can be expected.

Traction

Traction is used to separate articular surfaces from each other and can be employed in two ways: as an accessory to manipulation or as the sole treatment. Reducing a displaced fragment is obviously easier when the bone ends between which it lies are pulled apart. If the fragment projects beyond the articular edge, tautening of the ligaments and capsule also provides a centripetal force. In that traction diminishes the pressure on the fragment, pain decreases, which allows the patient to relax the muscles more.¹⁸ In the cervical and thoracic spines, traction is a built-in safety measure for protecting the spinal cord during manipulation (see below) although the use of traction for this purpose and at these sites does not imply that manipulation can be performed on a basis of ‘try and see what happens’ without a proper diagnosis.²⁷

In the spine, traction is used as the sole treatment only in nuclear disc protrusions, which are rare at the cervical and thoracic levels but are more common in the lumbar area. Spinal traction is always mechanical and is performed with the help of a harness (lumbar or low thoracic) or a sling (cervical or upper thoracic). Spinal traction distracts the intervertebral disc spaces. It also pulls the apophysial joints apart and slightly widens the intervertebral foramina.27–31 At the same time, negative intradiscal pressure is produced with centripetal ‘suction’ on any protrusion. The posterior longitudinal ligament is tightened, which may help reduce a displaced fragment. All these elements are helpful in the progressive reduction of a nuclear disc protrusion. Reduction of herniated bulges has been demonstrated on epidurography^31–33 and on CT scan³⁴ during and after traction. The effect of traction depends on the amount of force applied, the length of time per session, the interval between each session and the total number of sessions.³⁵

Grade C mobilizations

Grade C mobilizations or manipulations are forceful passive movements, performed at the end of range. Spinal manipulations are mainly to interrupt discodural or discoradicular contact. At the peripheral joints the purpose of a manipulation is to rupture unwanted adhesions between bone and ligament or bone and tendon or to reduce small bony subluxations in the wrist or foot.

Rupture of ligamentous adhesions

Small ligamentous adhesions sometimes develop between a healing ligament and bone. They usually result from a sprained ligament that has been immobilized during the healing process. The usual presentation is at the lateral ligaments of the ankle and at the medial collateral ligament of the knee. The clinical features are local pain during exertion and a small limitation of movement in one direction only. The adhesions can be ruptured by a high-velocity, small-amplitude thrust manipulation, after preparation of the affected ligament with intensive deep transverse friction.

The joint is stretched as far as possible in the limited direction and manipulated with a single firm thrust, during which a typical ‘snap’ is often heard. Harm is not caused to the ligament nor to the other parts of the joint because the adhesions bear the brunt of the force. The manipulation is almost painless and after-pain is not to be expected. A successful manipulation should achieve an immediate result. Active movements during the following days to maintain function should be highly encouraged.

Rupture of tenoperiosteal adhesions

In type II tennis elbow (tendinitis of the attachment of the extensor carpi radialis brevis), adherent and disorganized scar tissue causes a self-perpetuating inflammation. The manipulation aims to rupture the adhesions and produce a permanent elongation of the tendon. The high-velocity manœuvre is preceded by thorough deep transverse friction in order to numb and to weaken the spot. The manipulation is performed only once per session; 10–15 sessions may be required to achieve a result.

Forced movements should not be performed when signs and symptoms of capsular inflammatory activity are present. These are spontaneous pain, pain especially at night, wide reference of pain, inability to lie on the affected side at night or to bear weight on the affected side. Local warmth and effusion are other pointers of a highly inflamed joint. However, if these symptoms and signs are present but the rest of the clinical examination demonstrates internal derangement (e.g. knee, hip, ankle), manipulation is indicated and can safely be performed.

Spinal manipulative therapy includes all procedures of mobilizing or adjusting the spine by means of the hands. As in the peripheral joints, grade A and B mobilizations are movements of low velocity with varying amplitude but remaining within physiological limits and within the patient’s tolerance and control.

A manipulation or grade C mobilization usually implies a single thrust of high velocity performed at the end of a passive movement after the ‘slack’ has been taken up, and over a small amplitude. It goes beyond the physiological limit but remains within the anatomical range. Precision of the movement and control of the applied force are required.³⁶ Spinal manipulative therapy is a valuable method in the treatment of mechanical spinal disorders. Although it has not been scientifically validated, some studies have shown beneficial effect.^37–40 However, its potential benefit should not be overestimated and the indications must be well defined and based on a sound clinical diagnosis. It must never be done as a test to see if it is effective. Therefore it should not be used on all those with back and neck pain although it may well cure a proportion who actually require it. To use McKenzie’s words:

Even if you have a hammer in your hand not everything you see is a nail. Therefore indiscriminate use of spinal manipulative therapy must not be made if the criticisms that have been justifiably levelled at chiropractice and osteopathy are to be avoided. The development of postgraduate courses in manipulation is welcome, although some have overvalued the benefits of manipulative therapy. All who undertake manipulation have experienced the feeling of pride and joy in producing cure. It is the duty of those who have more experience of the benefits and limitations of manipulative therapy to moderate the understandable enthusiasm of those entering the field – a few successes may quickly lead to the temptation to manipulate every patient for any disorder.⁴¹

Manipulation either helps quickly or not at all. Therefore if improvement does not occur after one or two sessions, manipulation is not likely to be successful and it is pointless to continue with it.