Case Study Marge—Cardiac Rehabilitation Case Study Steven—Repetitive Strain/Overuse Injury: Bursitis Current Assessment and History: Client is 3 weeks post injury and is still in a cast. Surgery was not required. He complains of tension headache and low back pain, and is restless. He is not sleeping well. Client is home recovering. He is not taking any pain medication. Healing progress for the fibula is on schedule. He is obviously overbreathing and is out of sorts. Client seems to be experiencing increased sympathetic dominance in response to reduced activity. He is frustrated about missing tournaments because he is losing opportunities for professional advancement and finances. Overall, he is miserable. Subjective Assessment.: Client reports that he is not sleeping well, and he knows he is breathing with his upper chest and is irritable. He has a recurring headache that he thinks is the result of a combination of sinus pressure and muscle tension. His shoulders, axillary areas, and low back ache from using crutches and the walking cast, and from lying around. The doctor is satisfied with the healing progress and expects the cast to come off next week. Physical therapy will begin immediately and will last 8 to 12 weeks. Objective Assessment.: Objective assessment found the following: • Upper chest and shoulder movement occurs during relaxed breathing. • Client is restless and fidgeting. Left hip is elevated and is anteriorly rotated. • Gait is abnormal. Trunk, hip, knee, and shoulder firing patterns are synergistically dominant. • Psoas and scalenes are short bilaterally; quadratus lumborum is short on the left. Analysis of Assessment and History to Develop Treatment Goals: This client previously has responded to massage, as described in the general protocol in this text. Assessment information is influenced by the fibular fracture and compensation and does not necessarily indicate his post-rehabilitation status. Support rehabilitation and return to competition. Reverse fibrotic changes in left lower leg. Normalize all firing patterns and gait reflexes. Manage preexisting golf-related compensation for areas of tissue shortening, low back pain, plantar fascia pliability, and tendency toward headache. Manage and support final healing phase of fracture for 6 to 8 months. Massage Frequency and Duration: Start with 3 times per week for S—Client reports irritability, restlessness, headache (sinus and tension); low back, neck, and shoulder stiffness; and aching. He also has constipation and intestinal gas. He is doing some upper body activity with light weights but indicates that he does not know how to perform an intense cardiovascular workout with his leg casted. The doctor is not concerned with the cardiovascular deconditioning because it is minor and rehabilitation will begin soon. O—Client is breathing with the upper chest. Neck and chest palpate as tense and restricted. Scalenes, anterior serratus, and quadratus lumborum are short. Left hip is elevated and anteriorly rotated. Edema is present in left leg above the cast. Fullness in large intestine is palpable. Firing patterns and gait reflexes are not assessed. Scalene, sternocleidomastoid, psoas, and quadratus lumborum releases are performed bilaterally. The vascular and tension headache sequence is performed. Abdominal massage addresses constipation. A—Client reports that his headache is almost gone. He feels less stiff and achy. His left foot is itchy. (Note: Massage likely improved circulation.) S—Client reports that he will get the cast off next week. He indicates that after the last massage, he slept better for 2 nights but was restless again last night. He has not had a headache and is not constipated, but his low back is aching. He was tired after the last massage, but in a pleasant way. O—Upper chest breathing is evident through observation and palpation of the shoulders. Firing patterns for the shoulder are displaying synergistic dominance. Edema is evident again in the left leg. Connective tissue bind is palpated in the lumbar and pectoral fascia. A—Breathing assesses as normal with inhale to exhale ratio of 1 : 3. Edema is reduced by 50% in left leg. Connective tissue pliability has improved. Client reports feeling good and less stiff. He is sleepy and plans to take a nap. P—Continue with general protocol. Client will have cast off by next session. He will discuss with the doctor specific recommendations for massage. S—Client had cast removed this morning. He begins rehabilitation in 2 days. The doctor instructed him to move his ankle in pain-free circles. The doctor also requests that massage avoid the area and not perform lymphatic drainage there until after physical therapist evaluates, and then to follow the physical therapist’s directions. O—Moderate lower left leg muscle atrophy is observable. Client is using one crutch as needed. He appears apprehensive about weight bearing on his left leg even though he has been in a walking cast for 3 weeks. A—Client is preoccupied with what is expected at rehabilitation, how long before he can begin to play golf, and his leg muscle atrophy. He talked a lot during the massage and did not seem to relax, even though he reports feeling looser. P—Have client get specific massage instructions from the physical therapist and a copy of the rehabilitation plan, including types of exercises and modalities. S—Client reports that he has begun physical therapy, including cardiovascular work with the stationary bike. The physical therapist indicates that only lymphatic drainage and circulation-focused massage should be done below the left knee. No other recommendations are given. Client forgot to get rehabilitation plan but indicates that the therapist did passive and active range of motion, and he was given homework of drawing the alphabet with his toes. O—Ankle mobility on the left is decreased. Edema is observable. Breathing function is normal for this client. Thigh muscles are bilaterally tense; they are co-contracting. Sacroiliac joint movement on the left is restricted, and the lumbar fascia and the pectoral fascia are binding. Specifically address right forearm and wrist to affect left leg and ankle reflexively. A—Client wants me to work more on left leg, but we discussed importance of following physical therapist’s instructions. Fluid movement improved in left leg. Sacroiliac joint restriction improved 50%. Will continue to monitor. Suggested client point out SI joint restriction to physical therapist. Client reports that his legs still feel tight. Explained that this may be appropriate compensation, and it will be assessed again next massage. P—Continue general massage. Reassess sacroiliac joint. Reduce massage to 2 times per week. S—Client is sore from rehabilitation, especially cardiovascular workout and weight training. Client is beginning proprioceptive training. Physical therapist okays massage in fractured area as long as it does not result in pain or inflammation, with caution given against heavy pressure over fractured area. Client has a tension headache but is sleeping well. He reports that he is anxious to get back to golf. Because the fracture occurred during a nonrelated activity (skiing), the doctor feels that he should be able to begin golf-related activity as long as there is no pain during or after activity in the area of the fracture. Physical therapist manipulated sacroiliac joint. O—Range of motion in left ankle is 90% normal. Atrophy there is beginning to reverse. Tension in both thighs is reduced. Breathing is mildly disrupted. Left calf tissue pliability is reduced. Gait reflex assessment indicates that opposite side function is normal, but unilateral assessment indicates that arm and leg flexors do not inhibit in response to activation of corresponding flexion pattern. Also adductors do not inhibit when abduction is activated. Trunk firing is normal, but hip extension, hip abduction, and knee flexion are synergistically dominant. Knee extension and sacroiliac joint movement are normal. A—Client feels more stable on his feet, especially on the left. Left calf is itchy and prickly (histamine response). P—Continue general massage. Reassess firing patterns and gait reflexes. Monitor sacroiliac joint function and breathing. Begin to introduce golf-specific focus as client begins to practice. S—Client is doing well in rehabilitation. Physical therapist again adjusted left sacroiliac joint. Client went to driving range and hit a bucket of balls yesterday. Body and neck are tight, forearms are stiff, and low back is achy. Client indicates that it feels good to ache like he has played golf. No pain occurs in left ankle. O—Client has a left anteriorly rotated pelvis consistent with golf activity. Firing patterns and gait reflexes returned to same dysfunction as last massage. Eye/neck reflexes do not inhibit as they should in flexion/extension pattern. Wrist flexors and extensors are short; psoas and quadratus lumborum pressure reproduces achy low back symptoms. Used indirect function technique to reduce anterior pelvic rotation. S—Client overdoes it. He is sore and there is mild edema in left ankle. Physical therapy is reduced to every 3 days. Physical therapist discussed the importance of moderation during activity. Client is achy, stiff, and sore. He is irritable, but breathing is normal for this client. O—Client appears frustrated and stiff all over. His adaptive capacity does not appear sufficient for beneficial response to focused massage. General massage protocol is used instead, with focus on relaxation and lymphatic drainage. A—Client fell asleep during massage. I left him sleeping on the massage table and told his wife to make sure he stays hydrated. P—Monitor for adaptive strain, and then determine massage focus. S—Client is 10 weeks post injury and is doing well. Doctor and physical therapist are pleased with his progress despite the setback from overexerting last week. No more cautions are in effect for the fracture area. Client has a sinus headache. O—Client’s firing patterns continue to show synergistic dominance but correct easily. Gait reflexes are normal. Eye reflexes do not inhibit in flexion when eyes are rolled back. Client displays familiar golf pattern: low back pain, pelvic rotation, and high shoulder on the left, with inhibited scapular retraction with attachment tender points and short pectoralis minor and anterior serratus. Client displays co-contraction of wrist flexion and extension, short calves, inhibited gluteus maximus, dominant hamstrings during hip extension, and binding plantar fascia. General massage protocol targets each area as needed. A—Client says he is beginning to feel like himself. He plans to play a round of golf before the next massage. Client is beginning to resume adaptive patterns consistent with his golf style, and compensation in response to the fibular fracture is only mildly evident. P—Return to general maintenance massage with monitoring of tissue pliability in left calf and ankle range of motion. S—Client reports that he played golf and was rusty, but no lingering effects from the time off are apparent. He is frustrated, did not sleep well, and was restless in his sleep. He is going to play 18 holes in a charity golf tournament in 2 weeks and hopes he does not embarrass himself. O—Firing patterns are normal except for the knee flexors. Common pattern of muscle imbalance related to golf persists, as described in previous session. Upper chest breathing is evident. S—Client reports that golf game is improving. He is fatigued. O—Firing patterns are normal except for the knee flexors. Common pattern of muscle imbalance related to golf is found. Upper chest breathing is evident. The Rest of the Story: This client occasionally will experience aching in his left ankle if he is on his feet a lot, especially if the golf course is hilly. He continues to play competitively in the PGA. He still gets headaches, overbreathes, and has forearm tension, low back ache, and golf-related musculoskeletal imbalance. He is a typical professional golfer. He maintains a solid conditioning program and still does not stretch as he should to counterbalance effect of the golf swing. This client will want massage regularly his entire career and beyond. History: No major childhood illnesses. No current illness. Family history of cardiovascular disease. Injuries: Car accident when 12 years old with a broken left wrist that successfully healed. Various contusions from playing baseball since 8 years old. Right ankle deltoid ligament second-degree sprain at 14 years old. Ankle healed but aches occasionally. Current: No injury. Bursitis in right shoulder. Being treated with ice and antiinflammatory drugs. Restless sleep. Excessive caffeine consumption. Posture: Mild rotation of shoulder girdle to the right, pelvic girdle to the left, which is common training and performance adaptation for right-handed pitcher. Externally rotated right leg and mild forward head position. Gait assessment: Arm swing is limited on the left. Left hip flexors do not inhibit when assessed against right shoulder extensors. Range of motion: Right arm internal rotation limited by 20%. Flexion and abduction are normal but painful at end range. Right ankle is hypermobile. Sacroiliac joint is restricted on the left, with medial hip rotation limited with hard end-feel. Muscle testing: Right arm abductors are painful to resistance testing but do not test weak. Hip flexors are weak at maximal pressure bilaterally. Firing patterns: Hamstring dominance is bilateral, and calf is dominant for knee flexion on the right. Trunk firing is rectus abdominis dominant. Shoulder firing on the right is upper trapezius dominant. Hip abductors on the left show quadratus lumborum dominance. Palpation: Right shoulder is warm with reddening and increased sweating during drag palpation. Left and right forearms are taut and binding with increased tension in flexion groups. Pain, point tenderness, and heat are displayed at medial epicondyle on the right. Pain and point tenderness are noted on the medial head of the right gastrocnemius. Calf muscles are adhered on the right. Upper chest breathing pattern is noted. Fascial bind starts from occiput down spine to lumbodorsal fascia to right hip and iliotibial band. Mild edema is felt at bursae in right shoulder. Analysis of History and Assessment: Darrel is highly focused on moving to the major leagues. He loves baseball and seems to overpractice. He has excessive caffeine intake, primarily coffee and soda, which may be contributing to the restless sleep and to the upper chest breathing. Darrell exhibits sympathetic dominance by being fidgety and talking loudly, with a description of a typical day as follows: up early, treatment by the trainer for bursitis and strength and conditioning. Often there is team practice and then more treatment by the trainer. Preseason begins in 4 weeks, with season consisting of around 120 games. Darrel wants to be ready for the season to show off his skills and to be called up to the majors by midseason if luck goes his way. He is healing but is beginning to show signs of reduced recovery. Short-term goals: Reduce sympathetic arousal. Normalize firing patterns. Long-term goals: Support recovery. Normalize connective tissue bind. Maintain normal firing patterns. Increase range of motion of the shoulders by 50%. Reduce pain in shoulder by 50%. Support therapeutic exercise and flexibility. Methods used: Therapeutic massage, muscle energy methods, trigger point methods, connective tissue approaches, and lymphatic drainage. Frequency and duration: 2 times per week, Progress measurement: Firing patterns, gait assessment, range of motion, pain scale, breathing assessment, and feedback from client’s trainer. S—Client reports no change in bursitis pain since assessment. Forearms remain tight. Sleep patterns are the same as previously. Trainer does not want direct work on bursitis area. Client was hit with baseball on right hip. O—No changes in assessment since intake session. Client has bruise on right hip. General massage protocol, including specific breathing pattern sequence. Normalize firing patterns. Perform lymphatic drainage over bruise. A—Breathing pattern is improved as indicated by reduced movement of auxiliary breathing muscles during inhale. Range of motion of right arm has not changed. Bruised area on right hip is less swollen and painful. Firing pattern for right shoulder is normal, but other patterns have not changed. P—Continue with full-body general massage. Reassess breathing and continue to address firing patterns. Add gait reflexes to assessment and treatment. S—Client reports improved sleep for 1 night. Bruise feels better, and calves are tender to the touch 1 day after massage, but feel loose. No change in bursitis. Forearms feel relaxed for 1 day. O—Upper chest breathing is improved slightly. Firing patterns remain synergistically dominant. Gait assessment continues to show right shoulder extension not signaling inhibition to left hip flexors. General full-body protocol performed. Specific attention given to calf/forearm patterns with connective tissue focus. Shear of right gastrocnemius off soleus done. Firing patterns and gait patterns addressed. A—Forearms and calves are more pliable but may be sore to the touch for 24 to 48 hours. Trigger point activity is still present in gastrocnemius. Gait patterns are normalized. Shoulder, hip abduction, and left calf firing patterns are improved. Other patterns would not reset. Client appears to be sleepy and reports that he is sleepy. P—Continue with general massage, targeting firing patterns, connective tissue pliability, and breathing dysfunction. S—Client reports that calves were sore to the touch and during movement. Left forearm is better. Low back is aching around left lumbar area. Sleep is improving. Trainer is concerned about calves being sore during movement. Asks that massage intensity be reduced. O—Upper chest breathing is improved, and auxiliary muscles are not active during relaxed breathing. Firing pattern for shoulder normal, but hip abduction and extension remain in synergistic dominance. Quadratus lumborum active on the left; point tenderness present at left sacroiliac joint. Calves pliable but mildly swollen. Right gastrocnemius beginning to move independently of soleus. Trigger point in gastrocnemius less tender. Forward head improved slightly. Right shoulder less tender to the touch, but right forearm muscle is tense with point tenderness at medial epicondyle. A—Psoas, quadratus lumborum, and rectus abdominis inhibition seems to allow firing patterns to respond to treatment. All but the right calf is normalized. Reassessed gait patterns, and they were normal. Forward head position is improved. Right forearm remains tight and painful. Range of motion of right shoulder increased by 10% before becoming painful. Left sacroiliac joint remains painful to touch, but lumbar aching is improved. P—Next session: Address short muscles in right shoulder. Continue with general massage and firing patterns. Resume connective tissue work. Suggest that client begin scapular retraction exercises and core training. Referred client to trainer for strength exercise program. Also asked client to have trainer evaluate right forearm and elbow tendonitis. S—Client reports that team chiropractor adjusted low back and sacroiliac joint and that they feel better. Trainer increased rotator cuff strengthening exercises and added scapula protraction sequence. Client indicated mild delayed-onset muscle soreness in the area. Calves are no longer sore. Sleep was restless, but client thinks this was the result of upper body aching caused by the increased exercise. Trainer did not increase core strengthening but intends to add exercises next week. Trainer thinks client is throwing too many pitches during practice and this is making his arm sore. He has been icing shoulder when it is sore. O—Forward head position has returned to original assessment position. Shoulder remains rotated right, but pelvis has improved slightly since the chiropractic treatment. All firing patterns again are synergistically dominant. Gait pattern normal. Right forearm and medial epicondyle remain tight and sore to the touch. Bilateral muscle testing of wrist flexors and extensors indicates right side is overly strong—hyperresponsive to resistance pressure and painful at medial elbow. General massage with scalene/quadratus lumborum and psoas/sternocleidomastoid releases bilaterally. Deep lateral hip rotators and shoulder external rotators released (inhibited) and gently lengthened bilaterally. Pectoralis minor inhibited and lengthened bilaterally. All firing patterns addressed. Connective tissue work done on lumbodorsal and anterior thorax fascia. Lymphatic drainage performed on areas of delayed-onset muscle soreness. A—Right shoulder strength and pain are improved according to shoulder abduction assessment. Firing patterns have normalized. Forward head posture is reduced by 90%. Shoulder rotation and pelvic rotation have improved, with shoulder rotation 10% from normal and pelvis asymmetry only slightly dysfunctional, but inflare on the right is identified in postmassage assessment. Wrist flexion on the right painful at normal resistance, but no longer hypersensitive. Point tenderness at medial epicondyle remains. Hip flexor strength is improved. P—Continue with full-body massage with specific focus on normalizing and stabilizing firing patterns and connective tissue bind. Concern is expressed about forearm pain, and client is referred to trainer for reevaluation. S—Client reports that upper pectoralis area and abdomen are sore to the touch but not to movement. Right shoulder does not hurt to sleep on it. Sleep is again better and not as restless. Delayed-onset muscle soreness is better. Client reports that he is a little stiff around his shoulder until he warms up. Client continues to receive chiropractic adjustment for lumbar and sacroiliac joints. O—Firing patterns for hip abduction and shoulder are normal. Hip extension and trunk firing patterns remain synergistically dominant. Hip flexors and shoulder abductors are strong and nonpainful at normal resistance. Right shoulder cannot sustain pressure as long as left. Gastrocnemius adherence and trigger point activity are decreased by 75%. Shoulder rotation has regressed to previous position, but pelvis remains stable. Performed general massage with inhibiting pressure to release scalenes, psoas, sternocleidomastoid, rectus abdominis, infraspinatus, teres minor, triceps, pectoralis minor, and deep lateral hip rotators. Performed passive range of motion of acromioclavicular and sternoclavicular joints bilaterally. Also inhibited hamstrings and biceps while resetting firing patterns. Used positional release on the tender points in the right forearm. Also used positional release on anterior serratus to improve ability to retract scapula. Specifically addressed fascial pliability in anterior and posterior thorax into iliotibial bands bilaterally primarily with kneading (bend and torsion force). Addressed shoulder and elbow through reflexology points on the foot and hand. Applied compression along meridians in arms and legs. Used indirect functional technique on shoulder rotation and right pelvic inflare. A—Positional release effective for anterior serratus and forearm tender points except at right elbow medial epicondyle. Firing patterns are all normalized. Shoulder rotation improved again to within 10% of normal. Inflare improved slightly. Connective tissue bind decreased in thorax but remains in lumbodorsal fascia. P—Continue with current plan. Again refer client to trainer for right elbow pain. Also encourage chiropractic appointments, core strength training, and rotator cuff and scapular retraction strength exercises. S—Client reports that he was restless for the last 2 nights and did not sleep well. He also feels like he is getting a cold. Preseason begins next week. Trainer continues to ice right shoulder and arm and is stretching shoulder, elbow, and wrist muscles. Core training began 2 days ago, and client is sore. He reports that he is in a bad mood. O—Client again displaying an upper chest breathing pattern. Rib cage less mobile than typical for this client. Firing patterns are stable, but gait reflexes are not holding strong in the shoulder flexion/hip flexion diagonal pattern. Client not as cooperative as usual. General massage given to address lymphatic drainage, pain management, mood elevation, and parasympathetic dominance pattern, but no specific work targeted because of the cold. A—Client falls asleep during massage and is groggy when he wakes up. Gave him some hot tea to drink. Also gave him eucalyptus and lavender essential oil to take home to inhale and rub on his chest. Did not perform post assessment. P—Reevaluate: This was last session of 2 times per week schedule. Need to adjust treatment plan for once per week and to accommodate beginning of season. S—Client has a cold, but it is not in his chest, just in his head. He indicates that he has a minor sore throat and sinus headache but feels better than last session. He would like more of the essential oil to take home. His shoulder is better as long as he continues to ice it. The trainer told him that he was pleased with the progress. The right forearm remains sore and tight. He is stiff and slightly sore from the core and rotator cuff and scapular retraction strengthening exercises, but it is better than it was. Client says he is not sleeping well. He believes it is a combination of the cold and muscle aching, and that he is anxious and excited about the season starting. He is frustrated that he does not feel like practicing hard because of the head cold and headache. O—Assessment indicates posture is forward head and shoulder/pelvis rotation stable. Firing patterns are slightly synergistically dominant. Client appears sluggish. Session includes full-body massage with lymphatic drainage focus and headache sequence for sinuses, release of psoas and sternocleidomastoid, and addressing the diaphragm. Performed inhibition by compression on hamstring and biceps and deep lateral hip rotators and lateral shoulder rotators; and deep compression on serratus posterior inferior bilaterally (tender from sniffing). Mobilized facet joints with rhythmic compression and decompression of ribs. Massaged sinus, neck, and head reflex points on feet. Applied rhythmic compression to L1 and L4 acupressure points in hand. Continued to focus on parasympathetic dominance and restorative sleep. A—Client reports headache is better. Firing patterns have improved. Client wants to take a nap. Did not do revision of treatment plan this session. Client is fatigued and wants to relax during massage. S—Client reports that cold is better, but he still has a headache. He is going to be pitching in 2 days and asks for increased focus on his right arm. It has been sore but now is better. Forward head position is nearly normal. Shoulder girdle right rotation is mild, and pelvic girdle left rotation is slight. Right leg external rotation has reduced to slight. Arm swing still reduced on the left, but gait patterns are normal. Internal shoulder rotation is limited by only 10%, which is acceptable. No pain occurs at end range of shoulder movement, but pain remains upon slight overpressure in the right shoulder. Muscle strength testing is normal. Firing patterns continue to assess synergistically dominant but will correct easily, especially when obliques and transverse abdominis fire. Core training should continue to improve this situation. Right shoulder at the area of bursitis is less point tender but continues to redden during drag palpation and remains slightly swollen. Right forearm seems worse during persistent wrist flexion/extension, and there is point tenderness at the medial epicondyle. Gastrocnemius trigger points have resolved, but mild fascial adherence remains in fascial planes. Fascial planes are more pliable but still bind. Upper chest breathing pattern is intermittent. Overall Impression: The client has improved slightly to moderately in all target areas. Posture has improved, and antagonist/agonist patterns have balanced around the shoulder. Irritation on the bursae is reduced, and inflammation is improving and is responding to ice and antiinflammatory medication. Reduced shortening in flexion and rotational patterns is allowing the therapeutic exercise to be increasingly effective. The client has been fairly compliant but does display some symptoms of overtraining. Because the massage application thus far has been moderately successful for the original treatment plan goals, it would be prudent to continue and to add specific treatment for the pitching arm to attempt to reduce muscle tension and pain. A concern is that the arm is this dysfunctional, and the season is just starting. The shoulder is improving, but symptoms at the elbow are not improving. Although symptoms are not yet getting worse, the strain of competitive play may override current adaptive capacity. It would be best to speak with the trainer to coordinate a treatment plan to support performance during the upcoming session. S—Client reports that he is feeling good. His shoulder hurts only a little after practice, and ice takes care of the pain. His forearms are tight, but he can deal with that. He continues to see the chiropractor once a week. He will be pitching in 2 days and is sleeping well. O—Assessment indicates that firing patterns are stable. Hip extension is a bit hamstring dominant, and the rectus abdominis wants to fire during initial trunk flexion but inhibits easily, and firing patterns normalize. Right elbow extension is painful during the last 20 degrees of extension, and the forearm remains tense and binding. Point pain at the epicondyle has improved slightly. General massage protocol given with reflex application at left hamstring to reduce pain in right elbow extension. Also, biceps and triceps are inhibited. Worked on reflexology points in the foot for the shoulder and elbow. A—All firing patterns and gait reflexes normal, with breathing slightly from upper chest. Client excited about season starting. Client reports that forearms feel looser and elbow is less painful. Reports that full elbow extension feels stiff at end range. S—Client reports that he pitched well. Shoulder was only slightly sore the next day. His low back hurts deep, especially when he sits for a while and then stands up. His legs feel heavy but not sore. His elbow hurts when extended, but he can deal with it. He will miss the appointment next week because of road trip. O—Trunk flexion and hip extension firing patterns synergistically dominant, and gluteus maximus inhibited. Slight increase in shoulder/pelvic rotation pattern evident. Right forearm and shoulder slightly swollen. A—Firing patterns normalized, and low back pain resolved. Client slept for half of massage. Muscle stiffness in right arm better, but guarding and flinching remain at medial epicondyle tender points. P—Next massage is in 10 to 14 days. Client will call. Continue with massage as in previous session. Gave client eucalyptus and peppermint essential oil combination for his arm. Also taught him how to use a roller to massage out his forearm and how to do positional release. The Rest of the Story: Darrel became dehydrated from excessive sweating. Potassium/sodium imbalance must have occurred, and his muscles cramped. The muscle pulled away from the medial epicondyle, and he tore his medial collateral ligament. The injury will be corrected with what is called Tommy John surgery. The muscles are reattached, and the palmaris longus tendon is used to reconstruct the medial collateral ligament. There will be a year of rehabilitation before the arm is healed completely. Overview of Client’s Current Condition: Client has had various traumatic injuries since childhood. Both ankles have been sprained, but never a grade 3 injury. She had osteitis pubis in college that was slow to respond to treatment because she would not rest long enough. It eventually cleared up. She had similar symptoms during the last month of each of her two pregnancies and for about a month afterward. Short-term goals: Address lower abdominal groin-type pain. Long-term goals: Enhance sport performance and recovery. Reverse and stabilize pelvic rotation adaptation, and reduce firing pattern dysfunction. Methods: General massage protocol with heavy broad-based pressure for serotonin and endorphin effects; indirect functional technique for pelvis; firing pattern correction. Frequency and duration: Weekly standing appointment for Progress measures: Client-reported pain and satisfaction scale. S—Client reports that she has been functioning well. Sleep, breathing, and soccer performance are satisfactory. She is bothered by tenderness in her symphysis area. She has been using ice but has not been taking any antiinflammatory medication. She requests her typical full-body session with attention to the sacroiliac joints and muscles attaching to the symphysis pubis. O—Client displays typical pattern of pelvic anterior rotation on the right, posterior rotation on the left, slightly longer right leg, symphysis pubis shearing, and point tenderness. Left lumbar muscles are dominant for hip extension on the right, and the gluteus maximus is weak. In addition, there are kinetic chain–related tender points in the left pectoralis major, pectoralis minor, and coracobrachialis. The muscles on the left posterior shoulder are long but asymptomatic. Full application of the general massage protocol included the following: inhibiting pressure on rectus abdominis attachments at ribs and pubis; bilateral psoas release, with bilateral stretching of sternocleidomastoid; and inhibiting left lower lumbar with broad-based compression in shortest area, combined with left hip extension (with knee flexed) active movement.
Case Studies
Case One Tom—Golfer
hours in the client’s home. Reduce frequency to 2 times per week when sleep improves and rehabilitation progresses.
Case Two Darrel—Baseball Player
hours for 6 weeks; then once per week as available during season.
Case Three Tania—Soccer Player
hours.
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Studies
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hours. This is typically too long, but client seemed to respond well.Only gold members can continue reading. Log In or Register to continue
