Anda di halaman 1dari 65

Terra Rosa

Open information for Bodyworkers
No. 18, May 2016

Photo by Patty Kousaleos

Iliotibial band syndrome, Isometrics for tendinopathy, Trochanteric Bursitis, Overpronation,

Peak performance with CORE Myofascial Therapy, Interview with Dr. Jean-Claude Guimberteau


Clinical internship program for advanced certification training in CORE Sports & Performance Bodywork at
XPE Sports in Boca Raton, FL. See page 54. Photos by Patty Kousaleos

Terra Rosa E-magazine, Issue No. 18, May 2016.

Photo by Patty Kousaleos

To subscribe to this e-magazine and bodywork news, visit and

send a message from the Contact Us page.

Iliotibial Band Sydnrome

Be flexible in our theoriesWhitney Lowe

Our methods still get results; its our explanations

that need updating Til Luchau

Extrapolating results from research to hands-on

manual therapy should be done with cautionJoe


Empirical evidence is the realityRobert Baker


Dont let one study deter you from work on this

areaArt Riggs


More on ITB research


Isometrics for Tendon Pain Practical implementation

and considerations Ebonie Rio, Craig Purdam, Sean
Docking & Jill Cook


An interview with Dr. Jean-Claude Guimberteau


How I treat Trochanteric Bursitis Tom Ockler, PT


Overpronation Joe Muscolino


Overselling Overpronation Jeff Tan


The Hand-L Massage Tool: From Dream to Reality

Bob McAtee, LMT


A working experience with CORE Myofascial Therapy

Taso Lambridis, MSc


Research Highlights


6 Questions to David Steven


6 Questions to Bob McAtee



Terra Rosa E-mag 1

Iliotibial Band
There is a view that ITB cannot be stretched and current treatment strategies
are outdated, we asked experts on their opinions and treatment options.
Contributions from:
Whitney Lowe, Joe Muscolino, Til Luchau, Robert Baker & Art Riggs

2 Terra Rosa E-mag

Photo by Patty Kousaleos

Iliotibial Band Syndrome (ITBS) is a common

overuse injury common with runners and cyclists,
especially when their training levels have recently
intensified. It was reported as the second most common running injury and most common reason for
lateral knee pain in runners. ITBS can also be associated with court sports, strength training
(especially from weight-bearing squats), and even
pregnancy. Other contributing factors can be leg
length differences. ITBS produces burning pain on
the lateral aspect of the knee, and exacerbated by
running, especially downhill.

2007, they stressed that there are several basic

anatomy of the ITB that had been overlooked:

It is conventionally believed that the pain is caused

by the repetitive movement of the cabled iliotibial
band (ITB) sliding back and forth across the outer
surface of the lateral epicondyle. This mainly occurs
in 25 to 30 of knee flexion, irritating the ITB or its
associated bursa during repetitive activities such as
running. Conventional treatment often locates the
sore spots around the condyle and performs crossfibre friction with the aim to break down the adhesions, which will enhance fibroblast generation and
encourage tissue remodelling.

As ITB is a whole structure, the authors believed

that ITB cannot create frictional forces by sliding
back and forth over the epicondyle during flexion
and extension of the knee. This illusion of motion
was created by the reciprocal tightening of the anterior and posterior portions of the ITB during knee
flexion-extension. They proposed that ITBS is
caused by increased compression of the highly vascularized and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. The pain can be related to a chronic increased tension of the ITB caused by increased tension of the TFL or gluteus maximus muscles.

Fairclough et al. questioned this notion that the ITB

moves with respect to the lateral epicondyle during
knee flexion-extension. In a study published in
the Journal of Science and Medicine in Sport in

(1) The ITB is not a discrete structure but a thickened part of the fascia lata which envelopes the entire thigh;
(2) It is connected to the linea aspera by an intermuscular septum and to the supracondylar region
of the femur (including the epicondyle) by coarse,
fibrous bands which are not pathological adhesions;
and a bursa is rarely present but can be mistaken
for the lateral recess of the knee.

Terra Rosa E-mag 3

The authors concluded that ITB

syndrome is related to impaired
function of the hip musculature
and that its resolution can only be
properly achieved when the biomechanics of hip muscle function
are properly addressed.

Another study by Falvey et al.

(2012) conducted an anatomical
examination of the ITB on cadavers. They tested stretching routines for ITB, and measuring the
actual lengthening of the ITB by
implanting strain gauges in the
cadavers ITB. They concluded

that ITB is very resistant to

stretch since it lengthened less
than 0.2 percent with a maximum
voluntary contraction. Thus, they
challenged the idea of stretching
the ITB as a treatment for ITBS.
They suggested treatment of ITBS
should treat the muscular components of ITB and TFL complex.
Many sceptics and internet gurus
hailed this study as the definite,
claimed that IT Band Stretching
Does Not Work, Stop abusing
your IT band, You cant stretch
the ITB, It can not lengthen and
it is NOT tight, there is no scientific or anatomical reason to believe that any kind of IT band
stretch is even possible, let alone
an effective treatment

The conventional view of the iliotibial band friction syndrome. (Illustration based
on: Nicholas & Hershman. The Spine and Extremity in Sports Medicine. Mosby,

We asked experienced teachers

and manual therapists on the implications of these studies, and
treatment strategies for ITBS.

Falvey, E. C., R. A. Clark, A. Franklyn
Miller, A. L. Bryant, C. Briggs, and P.
R. McCrory. "Iliotibial band syndrome: an examination of the evidence behind a number of treatment
options." Scandinavian Journal of
Medicine & Science in Sports 20, 4
(2010): 580-587.

A diagram of compartment-like space around the ITB. Based on Muhle et al.

(Radiology, July 1999).

4 Terra Rosa E-mag

Fairclough, John, Koji Hayashi,

Hechmi Toumi, Kathleen Lyons,
Graeme Bydder, Nicola Phillips, Thomas M. Best, and Mike Benjamin. "Is
iliotibial band syndrome really a friction syndrome?." Journal of Science
and Medicine in Sport 10, 2 (2007):

ITB: Be flexible in our theoriesWhitney Lowe

One of the key hallmarks of practice in musculoskeletal healthcare is the necessity of being flexible in our theories. We must admit that our understanding of biomechanics and pathology may
change as research emerges. This concept has been
illustrated very well with emerging research about
the structure and function of the iliotibial band.
It has become quite popular to treat the iliotibial
band with all sorts of the pressure applications,
tools, or the latest craze which appears to be foam
rolling of the iliotibial band. These concepts have all
been built upon the premise of tightness in the
iliotibial band contributing to knee or hip pain. Unfortunately, research has demonstrated that these
treatments are based on a flawed model of iliotibial
band function and pathology.
The most common error that seems to be continually perpetuated by many in the massage and manual therapy communities is the idea of tightness in
the iliotibial band which is relieved by extensive
pressure applications. These soft-tissue treatments
run the gamut from small focused stripping techniques with a thumb, elbow, or pressure tool, to the
broad pressure applications applied during foam
rolling. Yet in all of these approaches the idea is that
deep pressure applied to the iliotibial band will help
relax tightness in the iliotibial band, reduce pain,
and improve function.
Yet this philosophy ignores key components of anatomy and biomechanics. The iliotibial band functions
predominantly as a tendon. Also, the connective tissue that composes this dense band, has very little
elasticity. Consequently, the iliotibial band is not
designed to stretch and elongate like many people
propose. Because the iliotibial band acts as the tendon for two primary muscles, the gluteus maximus
and tensor fasciae latae, its primary function is to
transmit the tensile forces generated by those muscles. Attempting to get the iliotibial band to feel

loose like muscle tissue is like trying to get the patellar tendon to feel loose like the muscle tissue
comprising the quadriceps or hamstring muscles.
Recent biomechanical studies such as the one by
Fairclough have also shed new light on pathological
conditions which have formerly been blamed on the
iliotibial band. For many years the orthopaedic literature has suggested that iliotibial band friction
syndrome is a pathology caused by repeated rubbing of the iliotibial band across the lateral femoral
condyle during flexion and extension of the knee.
These recent biomechanical studies have shown
that the iliotibial band is not as mobile across the
epicondyle as once described. The result suggests
that the lateral knee pain associated with iliotibial
band tightness may have more to do with other motions such as internal tibial rotation than the once
described friction from rubbing back and forth
across the condyles during flexion and extension.
Our fields of massage and manual therapy are constantly subjected to new fad treatments for addressing a plethora of musculoskeletal pain complaints.
In many of these cases there is some initial excitement and success reported with these treatments,
which may often be attributed to the treatment as a
novel experience and early placebo effects. When
time has passed and demonstrated that anatomical
or biomechanical models may be flawed, its time to
re-evaluate and possibly abandon them in favour of
more accurate explanations for what we are attempting to do.

Whitney Lowe has been a massage educator for over

20 years. He researches and authors articles on pain
and injury assessment techniques in numerous publications.. See his website for more information

Terra Rosa E-mag 5

Our methods still get results; its our explanations that need
updating Til Luchau
Thanks for the opportunity to comment on the ITB
studies and controversy. Ive been watching this
debate from a distance since the shrill social media
posts about it began to appear a few years ago, and
now that youve called me out, I enter the fray with
a bit of caution, since I am a practitioner and trainer
of practitioners, and not a researcher or academic
per se. But heres what stands out to me in reading
over the studies, posts, and comments:
1. Its interesting (though not exactly revolutionary)
that the Falvey study described the ITB as a thickening of the legs surrounding fascia latae, "rather than
a discrete entity. (Of course fascial anatomists have
been saying this about all fascial structures for quite
some time now, but great to see it in a non-manual
therapy study).
Figure 1. Cross section of the human leg (from Grays Anat2. Similarly, its interesting that the ITB was found
to attach to the femur along its entire length. This is omy).
different from the impression gained from convening that the ITB was found to be impossible to
tional 2-dimensional anatomy illustrations, but is
lengthen much by stretching. The ITB is a tendon,
consistent with what can be seen in 3D imagery,
its thus its function is probably to transmit or to
such as the Visible Human Projects data set (Figure
2, used in our trainings as well as in Tom Myers and store tension, rather than modulate tension by
lengthening as a muscle belly would. (Interestingly,
others), and with cross-sectional images going back
here is a small study that suggests foam rolling deto Greys 1918 anatomy atlas (Figure 1). In crosscreases jump performance, at least in the short
section, the ITB is barely visible, and is seen as the
surfacing of a deep inter muscular septum, rather
masterstheses/2/, though it does conclude that ITB
than a discreet band on the side of the leg.
rolling can be beneficial in injury recovery.)
3. Its fascinating that no ITB bursas were found in
5. It makes sense to me that rolling would not
any of the cadaveric specimen. If this holds true for
stretch the ITB (even if it was stretchable), or dif
living bodies (and in those younger than the studys
ferentiate it from its surrounding tissues (which is
average age of 76 years old), then it suggests that
one of the things we think were doing in our Ad
explaining lateral knee pain as bursal irritation
vanced Myofascial Techniques approach). Greg Lehneeds re-thinking.
man (whos iconoclastic perspectives I do enjoy,
4. Like Joe Muscolino says in his comments, Im not
even though he probably throws a lot of babies out
uncertain if results from tissue-stretching and strain with his bathwater) says about this issue "I cant
experiments on elderly cadavers can be directly apfillet a chicken breast with a rolling pin. In other
plied to living bodies of all ages. But it is not surpris- words, mashing the ITB may or may not have some

6 Terra Rosa E-mag

Figure 2. Cross-section of the human leg, mid thigh, arrows indicate the location of the ITB which extends deep within the leg
via an intermuscular septum that attaches it to the femur along its entire length. Image from the Visible Human Project.

benefits, but stretching or separating it from its surroundings probably arent the explanations for why
ITB rolling helps (or hurts).
6. This issue aside, in my reading over the abstract
and the debates, I dont find any logic that supports
NOT rolling the ITB, unless youre 1) overdoing it,
or 2) doing it right before a performance event involving jumping. In fact, many authors sceptical of
the stretching theory allow that there may be addition benefits not explained by stretching. So instead
of one of the studies authors blog post title, "Iliotibial Band: Please do not use a foam roller! , a more
logical conclusion might be Rolling (probably) does
NOT stretch the ITB, but dont over-do it!
7. In my hands-on practice, I dont feel much if any
stretch when I work with the ITB, though I often
think I feel a change in ITB tissue resilience, density,
and differentiation. And of course, clients report a
change in movement, lateral leg proprioception, and
pain as a result of hands- on work, and often, from
rolling their ITBs themselves. There are several
possible explanations for what I feel, and for the
improvements my clients report, with influences on
the nervous system being the primary suspects, and

any actual change in the tissues physical properties

being secondary.
8. After reading the different views on ITB work, I
went and wrote more about my own views as an
article for the May-June 2016 issue of the Massage &
Bodywork magazine here. (See also the video here
So in conclusion, heres more evidence to suggest
that our tissue-based models of manual therapys
effects might be less accurate than we thought. But,
that doesnt mean that the old ways dont get re
sults; it just means we need to stay open-minded
about our explanations about how they do their
good. And once we get clearer about the new models, theyll doubtless inspire new ways of working
that we might not have imagined under the old
Til Luchau,, is a Certified
Advanced Rolfer and the originator of the Advanced
Myofascial Techniques series.

Terra Rosa E-mag 7

ITB: Extrapolating results from research to hands-on manual

therapy should be done with cautionJoe Muscolino
I always enjoy research and the conclusions that are
reached from the studies, but extrapolating to hands
-on manual therapy should be done with caution. As I read the Falvey et al.s study, it purports
to show that:
1. The ITB has little or no ability to stretch, and
2. there is no bursa located between the lateral
femoral condyle and the ITB.
Therefore, it is unlikely that an ITB friction syndrome exists; and that trying to stretch the ITB, specifically by foam rolling, is not only not a valuable
clinical manual/movement therapy technique, but a
deleterious one.
My specialty is more macro-kinesiology than microkinesiology as discussed here. But here are my general thoughts and concerns regarding the study's
findings and conclusions:
1. The tissue used had an age of 76 +/- 10 years.
This means that all subjects were elderly, the tissue
was not representative of younger or even middleaged individuals. Soft tissues in elderly people tend
to be less plastic and elastic.
2. Perhaps the presence or lack thereof of a bursa
may be influenced by the age of the cadaver subjects.
3. Beyond all this, I never like to make conclusions
based on research alone. I love research, but it
should not allow us to ignore well-known principles
of anatomy/physiology/kinesiology/histology. To
wit, all soft tissue is to some degree elastic and plastic. Fascia is more so plastic than elastic, meaning it
can be deformed, meaning it can adapt to forces
placed upon it. Indeed, the principle of creep
states that soft tissue is deformable when a sustained force is placed upon it. To state that
the ITB cannot be stretched at all is to throw this
8 Terra Rosa E-mag

well-accepted principle away. Certainly, much of the

purpose of dense fibrous fascial tissue such as tendons and ligaments (and the ITB is effectively a tendon for the TFL and gluteus maximus) is to have
great tensile strength, meaning that it does resist
stretch. Otherwise, tendons would stretch every
time that a muscle contracted, meaning that the
muscles contraction force would never be exerted
on its attachments. But, having said this, even dense
fascial tissue must be somewhat plastic and therefore deformable/stretchable.
4. Given that all soft tissue is somewhat amendable
to manual therapy, foam rolling, or massage for that
matter, should be somewhat effective. However,
given the dense nature of the ITB, I would believe
that the manual therapy would have to be performed in a very disciplined manner over a long period of time (months or years) to be effective.
5. In some ways, the conclusion of this study reminds me of the controversy over stretching in general. There are still many people out there who
claim in some manner that stretching does not
work. Yet, every study I have read shows that IF
stretching is done in a disciplined manner over a
long period of time, it is effective at increasing flexibility. If the act of placing a tensile (stretching) force
can have absolutely no effect upon mechanically
deforming fascial soft tissue, then it would seem
that we are doomed to becoming ever increasingly
tighter and rigid as we age. In a larger picture, this
makes no sense to me. I cannot see how movement,
whether it is formal stretching or non-formal
stretching that occurs as a result of the normal
movement of an active lifestyle can have no effect
on fascial tissue. Fascial tissue is a mechanical structure that should be able to respond to mechanical
forces. To ignore this is to ignore the entire realm of

6. I am actually the last person who should be countering this article's principle tenet because I believe
that ITB syndrome does not occur anywhere near as
often as it is purported to exist. When ITB friction
syndrome does exist, it should be located directly at
the lateral femoral condyle (or perhaps at the
greater trochanter), but not anywhere along the
middle of the ITB, as it is so often claimed to be present. In my opinion, the vast majority of pain anywhere along the ITB (other than the lateral femoral
condyle or the greater trochanter) that is blamed on
the ITB is actually due to tightness in the underlying
vastus lateralis or vastus intermedius. And if this is
true, then I would find that foam rolling (or massage) would compress the vastus musculature,
which would be a good thing. After all, massage/
manual therapy does work the vast majority of the
time by compressing soft tissue. So to claim that
foam rolling is deleterious is to effectively negate
the entire field of manual therapy. (One can think of
the wonderful Gil Hedley Fuzz Speech in which he
describes the benefit of movement and manual therapy toward decreasing the build-up of fascial tis-

sue.) I realize that the author of the study might not

intend to make this claim, but it seems the inescapable conclusion of claiming that pressure from foam
rolling should be avoided (unless he is simply ignoring the possible role of the underlying vastus lateralis and vastus intermedius tissue).
All in all, I find that using the results of this study as
a basis for the conclusions that
1) ITB friction syndrome does not exist, and
2) manual compression therapy (read: foam rolling)
is absolutely ineffective, or worse, deleterious,
would be an unsubstantiated reach.
Joseph E. Muscolino, DC, is a chiropractor in private
practice in Stamford, CT who employs extensive soft
tissue manipulation in his practice. He has been a
massage educator for more than 25 years . He is the
author of multiple textbooks including The Muscle
and Bone Palpation Manual, and the author of multiple DVDs on Manual Therapy. His website is

Terra Rosa E-mag 9

ITB: Empirical evidence is the realityRobert Baker

First, I want to say great questions and comments.

It really is confusing when you have such well-done
studies like Falvey et al. that present good information that the ITB stretches minimally in cadavers.
My response is that the clinician gets to choose
what works and what does not work. The empirical
evidence is the reality. If you use a foam roller and
use soft tissue techniques, both the patient and you
will know what works. Perhaps the first challenge is
helping clients discriminate change in the short and
medium term, with a long term strategy. Both the
foam roller and hands on techniques will likely
move Substance P and other neuro-modulators so a
short term pain reduction may be present. Now if
pain is a factor in increased tone in soft tissue, then
perhaps the overall tone of the entire region may
reduce. It may also be true that kinematics improve,
and muscle activation changes as pain is reduced.
So, the treatment session includes questions about
pain reduction, and perhaps observations of gait,
step down at 6 inches (15 cm) and maybe other
functional tasks. So this clinical assessment of pain
and function and duration of change are key areas
to understand empirical outcome.
From the research perspective, there is evidence
that ITB length does occur with stretching1.
10 Terra Rosa E-mag

I have never seen a research project that tested

foam roller. However the physiological concept is
moving neuro-modulators, and traditional tack and
stretch soft tissue methods that we use with our
hands and instruments. In the literature, I think expert opinion favours hands-on techniques2. Conceptually, one soft tissue deficit is the bow string effect
of the vastus lateral and biceps femoris that I referenced in my review paper. In this case you are trying to normalize the interface between the adjacent
soft tissues to reduce that stress among those structures. Another conceptual approach is to look at the
overall tone of the soft tissue including the gluteus
maximus and TFL to ITB connects. This is based in
part on the recent work of Carolyn Eng and colleagues3 looking at the ITB as an energy absorbing
structure in swing phase and delivers energy back
in stance phase. So in effect, you are normalizing the
tone of the ITB as a musculoskeletal structure interacting with the biceps femoris, vastus lateralis, and
perhaps other muscles that affect running stride.
The point that I am suggesting is that the ITB functions as more than a physical constraint to the lateral knee and femur. It likely has a proprioceptive
role, and may even contribute energy to help running economy. The role of soft tissue mobilization
may be to promote better tone among the related

muscles, and reduce pain caused by neuromodulators, trigger points and perhaps adhesions to
nearby muscles. If you are looking at improved
kinematics by better muscle performance, then the
issue of a length change in the ITB is more an academic debate than a primary focus. The soft tissue
work readies the muscles to work within their capacity in a pain reduced and overall healthier environment.
Muscle contractions and joint kinematics are the
factors to treat. So your body work is trying to assist
in muscle performance: well timed, appropriate duration and well balanced. The soft tissue work aims
at normalizing muscle tone to improve muscle performance: eccentric and isometric muscle activation
from lumbar core through the hip. Reducing pain,
trigger points, tension, all normalize muscle tone
and muscle readiness. Promoting the lumbar core
length tension relationships may be a factor as well,
but this is not fully researched.
Your empirical assessment should consider more
than simply pain or ITB length, as an improvement
is better lowering of the body with fewer trunk, pelvic and knee deviations. Unfortunately, the root factor may be non-visible strain rate issues. So we
have to use kinematic and muscle activation to
gauge strain rate. Hamill et al. 4 found significant
strain rate issues but not significant strain issues. So
you can have a kinetic factor (strain rate) without
necessarily a change in length factor. So the question of whether or not the ITB lengthens is not the
only consideration, and may be a secondary consideration.
I will close by suggesting that a person cannot be at
their best if stressed and irritated, and pulled and
pushed while trying to perform. The same is likely
true for the ITB. My suggestion is that the ITB works
with muscles that cannot perform well in a painful,
irritated, push and pull environments. Our techniques should aim to create relaxed muscle tone
and hospitable environments where muscle performance is easier for the entire run and entire day.

The foam roller can be gentle or aggressive, so the

actual method for the foam roller is based on your
goal. If you simply want to move neuromodulators
and ease tone, tweak that method so the ITB is nurtured at its own pace. If you want to separate adhesions between neighbouring muscles, perhaps you
modify the technique to stretch and isolate those
structures as appropriate to any other stretching
technique. Creative use of therapeutic balls may be
even better. Your clinical empirical evidence seems
appropriate to use when assessing these approaches.
1. Fredericson M, White JJ, Macmahon JM, et al.
Quantitative analysis of the relative effectiveness of
3 iliotibial band stretches. Arch Phys Med Rehabil
2. Fredericson M, Guillet M, Debenedictis L. Innovative solutions for iliotibial band syndrome. Phys
Sports Med 2000;2:53-68. doi: 10.3810/
3. Eng CM, Arnold AS, Lieberman DE, et al. The capacity of the human iliotibial band to store elastic
energy during running. J Biomech 2015;12:3341-8.
doi: 10.1016/j.jbiomech.2015.06.017.
4. Hamill J, Miller R, Noehren B, et al. A prospective
study of iliotibial band strain in runners. Clin Biomech (Bristol, Avon) 2008;8:1018-25.
Robert Baker is a Doctoral
Candidate in Orthopedic and
Sports Science at Rocky
Mountain University of
Health Professions, Provo, UT.
His dissertation is on: Comparison of hip muscle electromyography and 3D kinematics in runners with iliotibial band syndrome. He is the
President of Emeryville Sports Physical Therapy in
Emeryville, CA. He specialised in sports and orthopedic practice with a blended manual therapy and exercise approach.

Terra Rosa E-mag 11

ITB: Dont let one study deter you from work on this area
Art Riggs
What an interesting subject! I appreciate and agree
with most all the comments of your experts, but after reinforcing some of their statements, Id like to
take a more informal approach to some of the
broader issues that we therapists must deal with in
interpreting and implementing research studies
into our practices and offer a few strategies for
Of course I agree with the comments questioning
the validity of conclusions about the stretching ability of the ITB from embalmed cadaver studies, and
that even if it does not stretch appreciably, that
benefits from manual therapy to the ITB can still be
achieved and may be due to many other factors
such as neuromodulators, trigger points, or release
of adhesions. I particularly liked Joe Muscolinos
caveat against extrapolating manual therapy strategies from isolated studies, along with his pointing
out that fibrous tissue has different qualities besides just ability to stretch. Ill add my skepticism of
jumping to conclusions from purported evidencebased research implying that manual therapy to
the band is ineffective and that treating ITBS, can
only (my emphasis) be properly achieved when the
biomechanics of hip muscle function are properly addressed. Such exclusionary and simplistic implications that stretching and manual work on the ITB is
not productive would short-change creative analysis and treatment of a complex situation that our
clients desire. I would also suggest a more complex
chicken/egg feedback loop, where the increased
tension and especially pain of ITBS can cause dysfunction of muscles and joints rather than just being
a result of their dysfunction.
The narrow conclusions and implications of treatment of the article remind me of other controlled
cadaver studies stating that the SI joint is immovable, and quibbling over distinctions between true
sciatica and apparent false sciatica that seems to
12 Terra Rosa E-mag

discount overlap in symptoms and effective treatment.

Of necessity, careful evidence-based research must
isolate factors, both of anatomy, symptoms, and
treatments. But inference from the study that defines and limits ITBS symptoms as lateral knee pain
and implies that since the ITB cant be stretched,
attempts to lengthen are useless, is an example of
the pitfalls of improper inference from isolated
facts, especially in brief summaries or abstracts.
Abstracts and capsulized summaries often neglect
many important descriptions of the methods and
conclusions of the studies. A famous comic quipped,
I used speed-reading for Tolstoys War and Peace
and it only took 45 minutes!!!.....It was about Russia. More studied reading of the studies and com
ments from other researchers exemplify the importance of more careful reading and consideration of
experiments and data. As a brief example, the
measure of stretch was performed only with tension devices placed 8 cm proximal to the lateral
condyle of the kneequestionably an accurate
measure of the complex activity of movement of the
ITB during activity.
What is the ITB? It is valuable that the authors point
out that it is not a discrete anatomical entity but a
thickening of the iliotibial tract or fascia latae. So
extrapolating causes and treatment from isolated
measurement of the ITB seems a stretch of throw
ing the baby out with the bathwater. ITBS would
seem to be much broader in scope and this exemplifies the importance of semantics when anatomy
makes its way into everyday speech by laymen. We
see this in many other popularizations and simplifications of anatomy. For many people the glutes
seem only to refer to gluteus maximus rather than
the complicated weave of all the posterior pelvic
muscles. To the public, the term abs refer only to

rectus abdominus rather than the complex relationship between the internal and external obliques,
and transversus abdominus, as well as deeper abdominal muscles.
Attempting to isolate the ITB from the more accurate complex of the iliotibial tract and muscular and
fascial connections that go both distal to the knee
and ascend past the pelvis seems misleading. I
think the more functional term lateral line (Figure
1) used Ida Rolf, Tom Myers, James Earls and many
other structural integrators is much more useful
and helpful for planning strategy, and henceforth I
will speak to the issues of the term ITB with this
broader definition.
Pain along the lateral line also seems much more
extensive than just lateral knee pain caused from
running and other athletic endeavours mentioned
in the article; albeit the information that a bursa
often does not even exist was very interesting. Many
people, including non-athletes report considerable
pain on the entire length of the lateral line. I would
suggest that a tight and misaligned lateral line may
be associated as both a cause and effect of strain
patterns descending to foot balance and plantar fasciitis, and ascending upwards to hip and low back
pain and stress patterns.
Also, although the lateral line does indeed act like a
tendon in contraction of the TFL and gluteus maximus, it is not a tendon and has different cellular
composition with properties of collagen and fascia
with a capacity to alter its texture in response to
manual therapy. Its role is not simply to exert force
on the knee joint like a Newtonian physics pulley. In
many ways it acts like a postural muscle to enable
standing without muscular contraction, providing
lateral stability, and has the important role of dissipating and distributing shock from foot plant.
When stress is applied to the lateral line it actually
recoils like a spring to augment muscular contraction from above and increase spring in walking and

Figure 1. The Lateral line.

Terra Rosa E-mag 13

Moving Beyond the Study to Applications

Since ITBS is so common, Id like to move beyond
the science of an isolated study to discuss some
issues for treatment. Lets face it it is very com
mon for clients to come to us seeking manual work
with complaints about pain in the lateral line and
reporting benefit from manual therapy that go well
beyond what would be expected from a placebo effect. We need to be able to work with this issue
with understanding and skill.
Alignment of stress through joints and tissue by
minimizing torsional strain is at least as important
as simple stretching. Effective therapy should consider global issues of joints, fascia, transmission of
shock, and the differences in the structure of individuals. A good structural integration approach
should consider among others: varus/valgus knee
patterns, internal/external femur rotation, anterior/posterior pelvic tilt and stress from factors in
feet in pronation/supination and inversion/
Addressing ITBS causes and treatments
Manual therapy along the entire lateral line in combination with frequent and consistent home programs is an excellent plan, but it is crucial to recognize that alignment of torsional forces is equally important. A tight and painful lateral line can be reacting to very different body structures and activities
since tissue and structure thicken according to
strain patterns. Assessment of these patterns is crucial for treatment instead of one-size-fits-all unimaginative strokes.
Shock transmission: A varus (bowlegged) knee and
a high arched foot in impact related activities will
send shock up the lateral aspect of the leg causing
thickening of the entire area including vastus lateralus. Working with the feet for more balanced foot
plant by mobilizing the lateral and medial arches to
dissipate shock is often helpful along with attention
to the adductors and medial leg for lateral/medial
leg balance.
Strain and overwork of the lateral leg due to valgus
knees (knock knees) or over-pronation presents a
14 Terra Rosa E-mag

different problem. This is often a hyper-mobility

issue, and soft tissue work would be considerably
different from the previous example. The lateral
compartments may be compensating in a productive attempt to provide stability, so stretching the
ITB may be counter-productive. This is not to imply
that thoughtful work on the area should be skipped,
but the goals would be to increase circulation, free
adhesions, work with trigger points and to work
with alignment of the knee and hip. Rather than
working to lengthen the ITB, cross-fibre work to
break down adhesions and promote tissue health
and decrease inflammation would be more effective.
Proximal strain patterns: As the authors note, strain
on the ITB is often created from above the knee.
Working with gluteus and TFL as described later
can be very beneficial. In addition to lengthening
and softening these tight muscles, enabling them to
glide over deeper tissues by freeing their anterior
and posterior borders with precise compartment
separation strokes so they may exert force in a direct line depending upon hip flexion or extension.
Visualize rolling the muscles from side to side in
different positions of hip flexion, paying attention to
any possible bias for restrictions on each side.
More global issues: Dont be too muscle specific in
treatment; consider broader factors that may influence strain and torsion upon the hip, knee, and feet,
including looking at broad fascial strain patterns
that may transmit over several body segments.
Shoulder carriage, tight lumbar fascia, quadratus
lumborum, or hamstrings that are associated with
pelvic tilt can significantly improve distribution of
Clarity in intention with touch
The key to softening, lengthening, and aligning fibrous tissues is to grab and stretch the tissue rather
than just sliding over it and compressing it. Use lubrication sparingly to enable a good grip and stretch
on whatever layer you are working on. The biggest
complaint I hear is from too aggressive and painful
work. Almost always it is a result of two factors:
First, working too fast so tissue does not have
enough time to melt and cooperate; this actually can

Figure 2. Stretching the lateral line by adducting leg past


result in a rebound that counters your attempt to

promote lasting release.
Second, working too vertically and painfully compresses the ITB and other fibrosed tissue against
the femur. This is the same drawback with foam
rollers that several others mention. We are trying to
elongate and align tissue, not squeeze and compress. The only force necessary is to slowly sink
into whatever level you wish to free, then to grab
without sliding and then apply force distally (rather
than proximally since compression from activities
jams the tissue upwards) at a very oblique angle
while also working for alignment.
It is crucial to have clarity on your intention and
techniques rather than just performing rote strokes
without consideration of the depths of restriction.
Different layers should be able to slide over each
other. I teach the following examples in detail in
classes, but limitations on space prevent that now.
They are not intended as specific directions but as a
conceptual way of working.
Free, align, and lengthen superficial fascia before
addressing deeper layers , so it can slide over the
fascia lata and consider fascial restrictions above
and below the area of lateral pain. Work with broad
and soft touch using fingers or palms of the hand to
feel the superficial fascia glide over the facia latae.
This can be done in neutral positioning, but adding
stretch to the entire complex can be accomplished
by adducting the leg across the midline. Examples
here demonstrate the supine position (Figure 2)
and a more aggressive stretch having the client in

Figure 3. Working on the ITB in side-lying position, putting

the ITB on a stretch .

side-lying assisted by gravity with the leg extended

and hanging off the table (Figure 3).

After working superficial fascia, sink to the next

layer and very slowly iron the entire fascia
latae by grabbing and sliding with it for length and
direction, feeling for wrinkles and thickening and
waiting for the tissue to melt. Pin and stretch
strokes are an effective strategy using a soft forearm or fists. Rather than just working in a neutral
position, lengthening the lateral line by body positioning when working is also very helpful add
stretch (Figures 2 & 3).

Terra Rosa E-mag 15

Figure 4. Softening the lateral line.

Free and clarify anterior and

posterior borders of the ITB by
compartment separation
strokes. Notice if the band seems
restricted on one side more than

the other and clarify the boundaries with precise strokes (Figure

Figure 5. Compartment separation strokes along the anterior or posterior border

of the ITB.

16 Terra Rosa E-mag

Free large groups of muscles

and fascia to slide over deep
layers, including the femur. Free
the lateral line to slide over the
deeper vastus lateralus and then
roll the whole quadriceps group
and lateral compartment around
the femur, paying attention to
whether if presents a bias to
move medially or laterally and
working to help it pull in a
straight line from the hip to the
knee. Grab the entire complex to
slide and rotate over deeper tissues and, in turn, visualize sliding
all layers to roll around the femur
where they seem stuck to the
bone. (Figure 6).

Figure 6. Grabbing, rolling, and mobilizing the ITB from both deep restrictions
and from adjacent, parallel muscles.

aggressive treatment that can

increase symptoms. A home program is essential. As others mention, Im not a big fan of the foam
roller although it certainly seems
to be popular. So it may be a
worthwhile approach for some
people, although I think other
options are more effective and
humane. One limitation with the
foam roller is that it is difficult to
work in tangential directions (the
ball that Bob Baker mentions can
solve this and also allows for different levels of inflation to not be
painful.) Foam rollers present an
all-or-none situation by having all

Soften and elongate the muscles

that attach to the ITB, but pay
particular attention to freeing
them from adjacent or deeper
restrictions. Perform muscle
separation strokes along anterior
and posterior border of the TFL
which may be exerting torsion
from adhesions along the anterior or posterior border. Roll
the muscle using precise pressure
with a fist or knuckles so it can
work freely in different degrees
of hip flexion and extension. Also
work along the borders of the
gluteus maximus, especially at
fibrous build up at its lower attachment and to free it to slide
easily from adhesion to the
deeper rotators (Figure 7).
Home Exercise
ITBS needs frequent incremental
work; it seems unrealistic to create beneficial change by treating
every week or two. Trying to
make up for lost time between
treatments can result in over-

Figure 7. Soften and elongate the muscles that attach to the ITB.

Terra Rosa E-mag 17

Figure 8. Using a Theracane to "iron" dense tissue in different directions down the entire leg.

of ones weight on the roller which is often too in

tense for a painful ITB, and can also require a fair
amount of strength in the shoulder girdle to move
the body and maintain a side-plank yoga posture
and create back strain. Too aggressive and perpendicular manual work using excess lubrication that
prevents grabbing tissue has the same drawback.
The biggest drawback to the roller is that it only
compresses tissue (picture a tire rolling over soft
ground and leaving an imprint) rather than the allimportant stretching and alignment that are beneficial. For this reason I recommend using a stick of
some sort that allows for different directional vectors, variation in pressure, access to adjacent tissue
such as lateral hamstrings or quadriceps, and especially, the ability to grab and stretch tissue approximating manual work rather than just compressing.
In the following example (Figure 8), the client is using a Theracane which allows for pinpoint pressure
to trigger points from the hip down the entire leg
and of course anywhere else on the body. It is also
useful to create balance with the adductors while
comfortably sitting in a chair. Almost all clients I
show this technique to feel it is far more effective
and easy to tolerate than foam rollers.

18 Terra Rosa E-mag

Good luck! And dont let one study deter you from
work on this area. Clients want and appreciate
work whether for ITBS or just to ease strain and
tension. Properly performed manual work on the
lateral line not only is helpful for treatment of ITBS,
but feels worthwhile and actually pleasant to most

Art Riggs is a certified advanced Rolfer who has been

practicing and teaching in the
San Francisco Bay area and
internationally for over more
than 20 years. His graduate
studies were in exercise physiology at the University
of California in Berkeley. He is the author of Deep Tissue Massage: A Visual Guide to Techniques, now in a
second edition and translated into five languages,
and the seven volume companion DVD set. He just
released a new "Deep Tissue Massage-A Full Body
Integrated Approach" DVD set. His website is at

More on ITB Research

Iliotibial band stores and releases
elastic energy during running
ITB can only found in homo sapiens, and it has been hypothesised that ITB allows us to stand upright. A study from Harvard
published in May 2015, examined how the ITB stores and releases elastic energy to make walking and running more efficient. The researchers developed a computer model to estimate
how much it stretched and by extension, how much energy it
stored during walking and running. They found that ITBs
energy-storage capacity is substantially greater during running
than walking, and thats partly because running is a much
springier gait.

We asked Dr. Eng on how she measured the strains of ITB and
the difference with the study by Falvey et al.
In their study, Falvey et al. measured strains in the ITB when
the subject's joint angles are static and not changing. I am not
surprised that their results suggest small strains in the ITB because they do not account for the muscle/ITB strains occurring
when the joints move (e.g., hip and knee flexes for the posterior
ITB). These joint angle changes play an important role in determining ITB strains in my study.

The ITB is undoubtedly integrated with other muscles and con

nective tissues in the limb and this determines the large forces
being transmitted through the structure. While some of the
forces generated by the muscles at the hip (i.e., gluteus maximus
Lead author Carolyn Eng explained the role the ITB plays in locoand tensor fascia lata) may be lost with their connections to
motion: One part of the IT band stretches as the limb swings
other structures/tendons at the hip, a large portion will still be
backward, Eng explained, storing elastic energy. That stored
transmitted to the knee via the ITB. Using cadaveric dissections,
energy is then released as the leg swings forward during a stride,
I determined the percentage of the hip muscles' cross-sectional
potentially resulting in energy savings. Its like recycling energy,
area (and hence, force) that inserts on and is transmitted to the
replacing muscles with these passive rubber bands makes movITB and my calculations did not include the portions of these
ing more economical. There are a lot of unique features in humuscles that insert on bone or other tendinous structures at the
man limbs like long legs and large joints that are adaptahip.
tions for bipedal locomotion, and the ITB just stood out as something that could potentially play a role in making running and
Eng, C. M., Arnold, A. S., Biewener, A. A., & Lieberman, D. E. (2015).
possibly even walking more economical. Their calculation
The human iliotibial band is specialized for elastic energy storage
showed that largest strains in the anterior part of ITB occur in
compared with the chimp fascia lata. The Journal of Experimental
early swing with ITB stretching 0.91.7 cm beyond slack length. Biology, 218(15), 2382-2393.
Meanwhile peak strains in posterior part of ITB occur in late
swing, stretching 1.43.0 cm beyond slack length.

Questioning the Ober Test

Does the Iliotibial Band Move?

The Ober test is the most commonly recommended physical

examination tool for assessment of ITB tightness. Willet et al.
(2016) questioned the validity of the Ober test. They conducted
an experiment using embalmed cadavers. They refute the hypothesis that the ITB plays a role in limiting hip adduction during the Ober test and question the validity of these tests for determining ITB tightness. The study suggests that the Ober test
assesses tightness of structures proximal to the hip joint, such
as the gluteus medius and minimus muscles and the hip joint
capsule, rather than the ITB.

A study by Elsing et al. (2013) examined whether the ITB

moves relative to the lateral femoral epicondyle (LFE) as a function of knee flexion in both nonweight-bearing and weightbearing positions in asymptomatic recreational runners. Evaluation using ultrasound on the ITBs of 20 male and
female asymptomatic recreational runners clearly showed an
anteroposterior motion of the ITB relative to the LFE during
knee flexion-extension. The ITB does, in fact, move relative to
the femur during the functional ranges of knee motion.

Willett, G. M., Keim, S. A., Shostrom, V. K., & Lomneth, C. S. (2016).

An Anatomic Investigation of the Ober Test. The American Journal
of Sports Medicine, January 11, 2016.

Jelsing, E. J., Finnoff, J. T., Cheville, A. L., Levy, B. A., & Smith, J. (2013). Sonographic Evaluation of the Iliotibial Band at the Lateral Femoral Epicondyle Does the Iliotibial Band Move?. Journal of Ultrasound in Medicine,32(7), 1199-1206.

Terra Rosa E-mag 19

New Books & DVDs

Advanced Myofascial Techniques, Volume 2 by Til Luchau is
the second of two beautiful, information-packed guides to highly
effective manual therapy techniques. Focusing on conditions of the
neck, head, spine and ribs Volume 2 provides a variety of tools for
addressing some of the most commonly encountered complaints.
With clear step-by-step instructions and spectacular illustrations,
each volume is a valuable collection of hands-on approaches for
restoring function, refining proprioception, and decreasing pain.
Invaluable for practitioners, teachers, and students of hands-on
manual therapies.

Deep Tissue Massage : An Integrated Full Body Approach Coordinating Deep Tissue and Myofascial Release into a Fluid Bodywork
Session by Art Riggs. This extensive new set (seven DVDs, over 9 hours)
was created after countless requests from therapists who loved the first
set, Deep Tissue Massage and Myofascial Release but were having trou
ble working the therapeutic philosophy and techniques into a fluid deep
tissue massage, especially in a spa setting. Rather than discrete sections
like the previous set, we move from A to Z, covering the whole body in a
common sequence of beginning in prone, moving to supine with a whole
segment devoted to the important side-lying position. Since the focus is
upon smooth massage, we spend less time on biomechanics, the great detail on strategies and techniques and anatomy offered in the first set, but
still provide a huge number of specific nuts and bolts techniques.

Traumatic Scar Tissue Management, Therapeutic massage principles, practice and protocols by Nancy Keeney Smith and Cathy Ryan.
The management of scar tissue is a huge and growing problem for massage and other manual therapists. Many are afraid to deal with it but research has showed that appropriate massage treatment can have significant results both physically and psychologically. Existing books have
chapters on the problem but there is no practical manual available on the
subject at the present time which tells the therapist what to do (and what
not to do). This book fills that gap, explaining the physiologic and pathophysiologic background, and providing practical guidance about how to
help patients.

20 Terra Rosa E-mag

A N A T O M Y F O R T H E 2 1 S T C E N T U RY

with John Sharkey
Sydney, June 2016
Myofascial Trigger Points (MtPs) Versus
A unique integrated neuromuscular approach for the
treatment of unresolved pain due to MtPs or nerve

2-3 June 2016 This is that one stop workshop that

covers everything you need to know about identifying
and treating Myofascial Trigger Points and nerve injury.
David G Simons (Travel and Simons), the father of Myofascial Trigger Points was mentor to John Sharkey and
wrote the forward to Johns first book (a trigger point
manual). Differentiating between neural generated pain
and Myofascial Trigger Point pain is essential in providing the correct soft tissue interventions for successful
therapeutic outcomes.

The Final Frontier

Working within Endangerment sites, providing
Manual and Movement Techniques to stay mobile
and pain free.

4-5 June 2016 This informative workshop provides

therapists with the necessary anatomical and palpatory
excellence to expertly navigate the holy grails of the human body (endangerment sites). Providing safe neuromuscular techniques using digital applications guarantees effective therapeutic interventions for soft tissue
based chronic pain conditions. Through your newfound
anatomical knowledge and unique hands-on clinical
pearls each learner will develop a greater appreciation
of local and global anatomical connections.

The Theory of EverythingBioTensegrity, anatomy for the 21st century

11-12 June 2016 This workshop is ideally suited to the advanced manual and movement therapist with appropriate clinical experience and a desire to take on fresh new ideas, new models and a new way of thinking. Therapists
are warmly encouraged to demonstrate their current screening, assessments and therapeutic applications with John
while he will provide feedback and suggestions offering a new vision supported by connective tissue techniques for
successful manual and movement interventions for all participants. This workshop provides you, the chronic pain soldier the effective full body kinetic chain ammunition you need in the war on pain.
John Sharkey MSc is a world renowned presenter and authority in the areas of bodywork and movement therapies. He is a Clinical Anatomist (BACA), Accredited Exercise Physiologist (BASES) and Founder of European Neuromuscular Therapy with more than 30 years of experience gained throughout his
career working alongside his mentors and colleagues Leon Chaitow, David G. Simons, Stephen Levin
MD, Prof. Kevin Sykes. John is recognised as a leading protagonist of BioTensegrity (providing new
models and paradigm shifts concerning living movement and anatomy promoting therapeutic interventions for the reduction of chronic pain.

Terra Rosa E-mag 21

Isometrics for Tendon Pain

Practical implementation and
By Ebonie Rio, Craig Purdam,
Sean Docking & Jill Cook
A recent research has demonstrated a positive effect in patellar tendinopathy following isometric exercise.
This articles shares a number of practical considerations in implementing it.

Tendinopathy, pain and dysfunction in the tendon,

can be difficult to treat. Traditionally eccentric exercise has been used in the rehabilitation of tendinopathy and has been shown to be superior to concentric only and passive treatments. However,
there are many instances where the use of eccentric
exercise is unhelpful or in fact detrimental, for example the in-season athlete where adherence is
poor or pain may increase. Even those who work
with the non-athletic population know that adherence is a challenge as eccentrics are painful to complete 1.
Recent research has demonstrated a positive effect
(reduced tendon pain, reduced motor inhibition and
improved muscle performance) following isometric
exercise in patellar tendinopathy 2,3, supporting the
pioneering clinical use by Jill Cook and Craig Purdam4. However, this isnt quads over fulcrum.
Clinicians need to understand a number of concepts
around the use of isometric exercise in tendinopathy. The research has been conducted in the patellar tendon, however clinically we are using with
other lower limb tendons. Key considerations in22 Terra Rosa E-mag

Fig. 1. Patellar tendon pain commonly felt localised at the

inferior pole.

clude; differential diagnosis (how to pick if the tendon is the source of symptoms), how to remove
abusive loading and use loading for analgesia and
how / when to progress.
Differential diagnosis
Patellar tendinopathy (pain in the tendon at the
front of the knee) occurs in jumping athletes or
those that change direction quickly5. It has two hallmark features:

(1) pain remains very localised to the inferior pole (people can point with one finger and it doesnt move or spread) (Fig.
1), and
(2) dose dependent pain with increasing
energy storage tendon load.
A good way of remembering this is that
people with patellar tendinopathy can
ride a bike without pain because it isnt
energy storage of the patellar tendon but
jumping is painful, even though both activities use their quadriceps muscles.
We found differences in the motor responses (termed corticospinal excitability) of people with localized pain compared to people with more diffuse anteFig. 2. Mid-range knee extension.
rior knee pain6. Clinically, we also see
that the use of heavy isometrics is better in those
ments after you address and any changes. Of course
that fit the above description of patellar tendinopathere is a bit more to it that cannot be covered here!
thy. Those with diffuse anterior knee pain, for exIsometrics for patellar tendinopathy
ample patellofemoral pain, often do not tolerate
heavy leg extension holds! This clinical consideraWe conducted pilot testing to see what factors were
tion is so important. Remember it is a clinical diagimportant in using isometrics. It seems for tendons,
nosis and not an imaging based diagnosis. People
it needs to be heavy and time under tension is imwith imaging changes in their patellar tendon can
portant. We tested lots of combinations and found
have pain driven from another source (such as pa5 x 45 seconds (with 2 minutes rest for muscle and
tellofemoral pain) we see this often.
central recovery) was effective. It was heavy 70%
of their maximal voluntary quadriceps contraction.
Using brain imaging techniques, we were also able
How to remove abusive loading
to see that isometrics reduced motor inhibition so
not only were people in less pain (a lot less pain)
Anything that asks the patellar tendon to store enthey had less inhibition and therefore were 19%
ergy and release it is difficult, for example quick
stronger! The exercise was conducted on a leg exlunging and change of direction and jumping.
tension machine (Fig. 2). We also completed an inTherefore, athletes may need to reduce these types
season trial to show that they can be used in-season
of activities if their tendon is showing signs of not
to reduce pain and allow participation. We have
coping. Signs of not coping can be seen in the realso completed an isometric research using the
sponse to tendon load 24 hours later. For example
Spanish squat belt (see Spanish Squat Exercise) that
if someone plays volleyball and the next day they
is currently being prepared for journal submission.
are no more sore, we would consider this load to be
within their capacity7. Whereas, if their pain spiked
we would consider the load to be greater than their
capacity. This concept is important as is understanding how to improve capacity find the level of
loading that they tolerate and make small incre-

Isometric exercise can be used to reduce tendon
pain immediately and without decline in muscle
performance when used as tested. The research is
Terra Rosa E-mag 23

Spanish Squat Exercise

3. Squat back as deep as possible keeping your spine upright

dont lean forward. These two pictures show different
ranges but both have a straight spine.

This exercise is designed to reduce patellar tendon pain and

should be done daily as shown below.
1. Position belt around a sturdy pillar. The belt is long so any
size pillar/pole may be used. Just wrap the belt as many
times around pillar as needed so that when you step one
leg inside each loop, the belt is around upper calf and
your toes against pillar as shown. Make sure loops are
2. Place legs inside loop (one in each) with toes positioned
against the pillar to stop you sliding.

Aim for thighs parallel to ground (e.g. picture on the right)

but it is more important that your spine is straight, not how
deep you are. Go as deep as you can hold.
Hold this position for 45 seconds five times. Have a two
minute rest in between each squat. Dont come down &
up stay squatting down for the whole 45 seconds!
It is possible that the tendon may be slightly uncomfortable,
usually early in the first squat, but this improves.
Dont lean your trunk forward.

currently in patellar tendinopathy with more to follow. It is important to determine whether the tendon is the source of symptoms or at least determine
whether they are likely to respond positively to that


Ebonie Rio has a PhD and a Masters in Sports Physiotherapy,

Bachelor Physiotherapy (Hons) and Bachelor of Applied Science. She is currently a post doctoral fellow at La Trobe University and also work at the Victorian Institute of Sport.

3. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia

and reduces inhibition in patellar tendinopathy. Br J Sports Med

Craig Purdam is the Deputy Director of Athlete Services and the

Head of Physical Therapies at the Australian Institute of Sport. He
has worked as a clinician in elite sport for over 30 years and has
been a physiotherapist to five Olympic Games (1984-2000) .
Sean Docking has a PhD and a Bachelor Health Sciences (Hons)
and is currently a Post doctoral fellow at La Trobe University. His
research interest is in tendon injury.
Jill Cook is a Professor at La Trobe University Sport and Exercise
Medicine Centre. Her research interests are in tendon injury,
tendon pathology, sports injuries, and musculoskeletal injuries.

24 Terra Rosa E-mag

1. Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports
Med 1998;26(3):360-6.
2. Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training:
changing the way we think about tendon rehabilitation: a narrative
review. Br J Sports Med 2015.

4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology

model to explain the clinical presentation of load-induced tendinopathy.
Br J Sports Med 2009;43(6):409-16.
5. Malliaras P, Cook J, Purdam C, et al. Patellar Tendinopathy: Clinical
Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther 2015:1-33.
6. Rio E, Kidgell D, Moseley GL, et al. Elevated corticospinal excitability
in patellar tendinopathy compared with other anterior knee pain or no
pain. Scand J Med Sci Sports 2015.
7. Cook JL, Docking SI. "Rehabilitation will increase the 'capacity' of
your ...insert musculoskeletal tissue here...." Defining 'tissue capacity': a
core concept for clinicians. Br J Sports Med 2015;49(23):1484-5.

Functional Fascial Taping

with Ron Alexander

Evidence-Based Pain Relief

This workshop teaches a fast and simple way for clinicians to reduce
pain, improve function, encourage normal movement patterns and
rehabilitation of musculoskeletal pathologies in a pain-free environment.
FFT has been shown to have a significant effect on Non-Specific
Low Back Pain in a randomised double-blind PhD study. FFT is a
non-invasive, immediate, functional and an objective way to decrease musculoskeletal pain.

Ron Alexander
STT [Musculoskeletal],
FFT Founder and Teacher

A great way to encourage

to hold longer

Brisbane 16-17 July 2016

Melbourne 23-24 July 2016
Sydney 30-31 July 2016
Register Now at:

Terra Rosa E-mag 25

An interview with
Dr. Jean-Claude Guimberteau
Dr. Jean-Claude Guimberteau is a hand surgeon renowned for his live fascia
film Strolling under the Skin. We recently talked with him about his new book.

In Architecture of the Living Fascia, The extracellular

matrix and cells revealed though endoscopy, Dr.
Guimberteau, a hand surgeon, gives us a direct view
from the surface on the skin deep to the bone. Dr
Guimberteau is the first person to film living human
tissue through an endoscope in an attempt to understand the organisation of living matter.
He discovered that within the extracellular matrix
(ECM) there is a continuous, bodywide, multifbrillar
network of fibres and fibrils, extending from the surface of the skin to the periosteum. In addition, there
are no distinct separate layers within this continuum
of living matter.

26 Terra Rosa E-mag

What led you to the discovery and study of the

architecture of the connective tissue.
I was seeking a technical procedure to reconstruct
flexor tendons, when I came upon the sliding system that I termed the MVCAS (Multimicrovacuolar
Collagenic Absorbing System). I first used a microscope to understand how it was working. This tissue, which neatly ensures the efficacy of gliding
structures and their independence, is composed of a
network of collagen fibrils whose distribution
seems to be totally disorganized and apparently illogical at a first sight. This impressed me because
my Cartesian mind could not come to terms with
the idea of chaos and efficiency co-exists perfectly.
This was the starting point for an intellectual voyage that took me far from the beaten track and off

The mobility, flexibility, and elasticity of the fibrillar structures create a gigantic firework display of fibrillar movement.
(From Guimberteau, 2016, Handspring Publishing).

into the largely unknown world of fractals and chaos. an addition of organs linked by a connective tissue
but contrary, constituted by a structured fibrillar
Dr Guimberteau, you described the "fibrillar" net- mesh in which the organs have developed. The conwork that can be found from the superfical to the nective tissues role is far more important than sim
ply connecting, it is in fact the constitutive tissue.
Just take an endoscope and descend slowly from the
skin surface until the depth of the bone and you will
realize that there is a continuum of fibrillar of variable diameter, irregular, fractal but formed within an
uninterrupted continuum. We know now that there
is also a microfibrils cytoskeleton framing the cell
which is linked to the ECM. The body thus can be described with a real architecture fibrillar at all levels.
We can visualise our body as a global structure with
a specific, three-dimensional architecture made up
of elements that, while fragile, have a persistent capacity for adaptation.

Through our observations, we see how this elaborate microfbrillar construction, composed of microvacuoles filled with collagen and glycosaminoglycans or with cells, is capable of adapting to all types
of constraint in three dimensions, thanks to its mobility and other inherent properties.
You also mentioned that a living form has to be
structured, as well as mobile, supple, adaptable
and self-sufficient.

Indeed, finding a global fibrillar structure framing

the body and structuring the form, already provides
an architectural explanation. But when you observe
Is this the same as the superficial and deep fascia? that these fibres have an ability to stretch, split, slip,
a capacity of adaptability , to absorb stresses, you
It is completely different from the superficialis or
deep fascia which are only local and functional den- understand that this fibrillar system provides the
movement, flexibility, resistance to the force of gravsifications of this fibrillar network.
ity and allows morphogenesis.
This opens towards another body concept , a new
structure ontology that living human matter is not
Terra Rosa E-mag 27

A microvacuole can change shape (adapt) by stretching, widening, or shortening, and still be able to return to its initial
shape. These changes occur simultaneously and in synchrony with the movements of the fibrillar system to return to
its initial shape. (60 magnifications). From Guimberteau, 2016, Handspring Publishing).

You made an observation on the effect of manual

therapy under the skin. Can you tell us what happened?

But in addition, looking more closely, you can see the

vessels with red blood cells in movements and especially the cells changing of shape and having small
movements between them. The influence on cytoskeleton is obvious.

We filmed several times, in association with a manual therapist, during surgeries the effects of massage
on the skin.
Massage undoubtedly has a mechanical and visible
effect on all the structural elements and at least 10
When you move the skin, all the components move
cm around the massaged area.
together, you can observe the hypodermis and lobules twirling, the underlying sliding system adopting You can see these video sequences on the DVD from
all the postures, the fibres intersecting, intertwining, my book Architecture of Human Living Fascia, The
without breaking. There is a harmony in motion.
extracellular matrix and cells revealed though endoscopy, Handspring Publishing, 2015.

This beautifully illustrated book and DVD introduce Dr Guimberteau's groundbreaking work. He is the first person to publish "movies" showing the structure of
the fascia and how the fascia responds to. The book and accompanying DVD provide, for the first time, an explanatory introduction and explanation of these theories and link them to the visual evidence shown in the video.
Available at

28 Terra Rosa E-mag

New Books & DVDs

Healing with Yoga by Jeanine Orbuchay & Dr. Joe Muscolino. This video is designed to allow anyone to practice yoga, either by simply focusing on key parts of the body, or by doing a fullbody practice from start to finish. Additionally, viewers can learn
about each part of the body they are interested in, including the location and function of each muscle group, how to palpate it, and how
to stretch and strengthen it.
Choose to go straight through an all-levels yoga practice focusing on
one muscle group at a time, or watch each anatomy, functionality
and palpation description of the muscle groups before each group of
yoga poses. Either way you choose to view it, start expanding your
experiential understanding of the anatomy of the human body.

The Concise Book of Muscles, 3rd Edition by Chris Jarmey and John
Sharkey is designed in quick-reference format to offer useful information about the
main skeletal muscles that are central to anatomy, physical therapy, massage, chiropractic, physiotherapy, osteopathy, or any other health-related field. Each muscle section is
colour-coded for ease of reference. Enough detail is included regarding each muscles origin, insertion, action, and nerve innervation (including the nerves common course or
path) to meet the requirements of the student and practitioner.
The book also highlights those muscles that are heavily used and therefore subject to injury in a variety of sports and activities, as well as offering a range of exercises that can be
used to stretch or strengthen a specific muscle or muscle group.
The Original Body, Primal movement for yoga teachers by John Stirk addresses the physiological experience of yoga. The soft tissue, skeletal, fluid and spatial
sensations experienced in practice are considered in sequence and collectively as the
reader becomes drawn into a depth of feeling and understanding that lies beyond practice. Yoga teachers are shown how to use a deeper feeling to unveil an innate powerful
physical wisdom. This includes bringing together anatomical visualisation and imagination, the development of awareness as a movement, and the management of sensation.
This book focuses on honing and harnessing the practitioners essential experience in
order reveal a more profound style of teaching from within. Teachers are invited to consider the impediments to a deeper practice and will be taken through the common factors
inhibiting sensory pathways. These include conditioning, habit, trauma, anxiety, nonessential thought and the effect of technique and methodology in teaching.

Advanced Myofascial Techniques: Migraines & Headaches by Til Luchau.

This DVD shows the complete instructor demonstrations from the popular Advanced Myofascial Techniques: MIGRAINES & HEADACHES course. Includes supplemental techniques not shown in live courses.
Learn Advanced Myofascial Techniques that can dramatically improve your ability to work
with all types of headaches and migraines, plus ear and sinus issues, vertigo, and more.

Terra Rosa E-mag 29

How I treat Trochanteric Bursitis

Tom Ockler, PT

30 Terra Rosa E-mag

A diagnosis of trochanteric bursitis can be tricky for

several reasons. The US healthcare (sick care)
system encourages high volume so accuracy is low
on the importance scale. The diagnosis may just be
hip pain, or it may actually be trochanteric bursitis.
Regardless, over the years I have found that most
times there is no evidence of bursitis. Its just
faster to give it an important sounding diagnosis.
No matter what the diagnosis, the hip requires a
thorough investigation to narrow down the actual
To me, its quite obvious the trochanteric bursa
does not become inflamed for no good reason. To
simply calm down the bursa ( treat the symptom) is
helpful but if you do not correct the underlying
causes for the issue, it will be a lengthy course of
treatment at best and at worst, a repeating problem
that can effect gait and therefore impart imbalanced
forces on the entire lower extremity. A cascade of
orthopedic and musculoskeletal sequelae can lead
to a chronic pain syndrome.
The most common complaint is that the patient
cant lie on the painful side at night. Sometimes even
lying on the non-painful side hurts too, due to the
stretching of the ITB and lateral hip muscles over
the tender trochanter. It can be aggravated by a fall
onto a hard surface like ice, cycling, walking,
running, lying on it or nothing that they can think of.

If youve ever seen or had an olecranon bursitis,

they can be spotted a mile away. This is not the case
with a trochanteric bursitis. The trochanteric bursa
may not be swollen to the naked eye and even
palpation doesnt give a clue to swelling that you
might expect to accompany this diagnosis.
If you have taken my MET 1 course, you know that I
start the session assessing for a hypomobile S.I.J.,
looking for S.I. or I.S. dysfunction and functional leg
length issue. In theory, if one leg is behaving longer
(functional leg length discrepancy) that alone can
put extra tension / pressure on the trochanter by
the gluteus medius and minimus as well as the
iliotibial band.
I use MET to get a level and symmetrical platform
from which to work off of. After the correction and
stabilization exercises, I then start poking around.
Literally poking around for tender pointsin the
gluteus medius, minimus, piriformis, TFL, as well as
the trochanter itself. In addition, although they are
on the medial aspect of the hip joint, I check out the
adductor tendon and the pectineus muscle for
tender points. Long term dysfunction of lateral
muscles can create a domino effect of the medial
muscles and vice versa.
Any and all of these muscles can cause pain and
usually indicate tightness and sensitivity to stretch
which makes them prime candidates for causing hip
pain or actual trochanteric bursitis.
Once a balanced and symmetrical pelvis and sacrum
has been achieved with Muscle Energy, I use
counterstrain technique. The technique called
counterstrain, commonly called strain counterstrain
or positional release, is a prime choice for getting
rid of these trigger / tender points and returning
the muscle spindles and thus the corresponding
muscles to normal resting tone. Its important to
check all of these muscle trigger points as any one of
them could be causing the pain.
If not already familiar with the strain counterstrain
techniques, a great resource is Positional Release
Therapy by Kerry J. DAmbrogio and George B. Roth.
Leon Chaitow ND DO also has an excellent book on
Terra Rosa E-mag 31

Positional Release Techniques. Lastly, you could

probably type in the particular counterstrain
technique you want to see on the YouTube website.
Example below is a Strain counterstrain for the
Piriformis muscle.

I will then use Cold laser and / or microcurrent

directly over the trochanter to help with the
soreness and reduce swelling. Patients can use mild
cool packs or NSAIDs to help in the initial few days.
I also recommend a pillow between the knees to
keep the femur level with the pelvis while sleeping.
If the patient does a considerable amount of driving
and this aggravates the condition, I recommend
cutting out a 3 (or 7.5 cm) piece of foam that just
fits the lower dimensions of the bucket seat.
Carefully cut the foam as to avoid contacting the
slanted sides of the bucket seat. This helps to
minimize trochanteric contact with the slanted side
of the bucket seat and thus assist in the healing
For males, getting the wallet out of the back pocket
is a must. Cargo pants are useful here.
On the second visit, provided that the symptoms are
way down, I will also teach ITB stretching (the old
hooker stretch) to help lengthen out the tissues
that cross the lateral hip.
The above protocol is so effective that usually by the
second session, they can lie on the hip with much
less pain and may even be sleeping the night on that
side. Two or three visits spread out over a week to
10 days is my norm with these issues.
32 Terra Rosa E-mag

If there is no improvement in a few visits, you might

want to consider the possibility of a stress fracture
or degenerative joint disease. Labral tears may also
cause enough dysfunction in the sequential firing of
hip muscles that a bursitis can come about as a
sequelae of the labral disease. The scour test would
be performed at the initial evaluation. Also the
FABER test would indicate a more serious hip joint
Although out of the scope of most bodyworkers,
custom, corrective orthotics my be the final piece of
the puzzle for persistent repetitive hip pain. A
forefoot or rear foot varus deformity for example,
can set off a plethora of lower extremity muscle
misfiring and contribute to the pain and dysfunction
that so often accompanies painful hip syndrome.
Corrective orthotics, ( as opposed to
accommodative orthotics which are all too often
issued to the trusting patient) can set the subtalar
joint to a more neutral position and give a more
balanced role to the muscles of the entire lower
Have a troubling patient? Drop me an email and let
me know. I am always happy to shed light or offer a
different perspective.

Tom Ockler P.T. has extensive

teaching experience throughout
the United States, Canada,
England and Australia. As a
teacher, Tom has earned the
nickname "The Patch Adams of
Physical Therapy" due to his
unique style of injecting
humour into complicated
subjects. He has developed teaching methods that
explain very complicated subjects in easily
understandable formats. His two books and DVDs
Muscle Energy Technique for Lower Extremities,
Pelvis, Sacrum, and Lumbar Spine and Muscle Energy
Techniques for the Thoracic Spine, Ribs, Shoulder and
Cervical Spine have been hailed by students as the
most user friendly and useful Muscle Energy manuals

Dr. Joe Muscolino

Pronation and supination are normal healthy motions of the foot that occur between
the tarsal bones. The problem is when our arch structure excessively pronates, in other
words, overpronates.

Figure 1 The subtalar joint of the foot. The transverse tarsal joint is also seen. (Muscolino, JE. Kinesiology: The Skeletal System and
Muscle Function. 2ed. Elsevier.)


triplanar motions.

Pronation and supination are normal healthy motions of the foot that occur between the tarsal bones.
These motions occur primarily at the subtalar joint
between the talus and calcaneus; however, they also
occur at the transverse tarsal joint (the transverse
tarsal joint is actually composed of two joints: the
talonavicular joint medially between the talus and
navicular; and the calcaneocuboid joint laterally between the calcaneus and cuboid) (Figure 1).

The principle cardinal plane component motion of

pronation is frontal plane eversion. For this reason,
it is common to hear pronation described as eversion. However, eversion is only one component of
pronation, albeit the largest. Pronation also involves
subtalar abduction (effectively lateral rotation) of
the foot in the transverse plane, and subtalar dorsiflexion of the foot in the sagittal plane. Similarly, the
largest component motion of supination is inversion.
However, supination also involves subtalar adduction (effectively medial rotation) of the foot in the
transverse plane, and subtalar plantarflexion of the
foot in the sagittal plane.

Pronation and supination each occur in one oblique

plane around one oblique axis, therefore they are
uniaxial motions; however, because these oblique
plane motions occur across all three cardinal planes,
pronation and supination are often described as

Terra Rosa E-mag 33

Figure 2 The Arch structure of the foot is composed of the medial longitudinal arch, the lateral longitudinal arch, and the
transverse arch. (Muscolino, JE. Kinesiology: The Skeletal System
and Muscle Function. 2ed. Elsevier.)

Foot pronation causes the arch structure of the foot

to drop. The arch structure consists of three arches:
the medial longitudinal arch on the big toe side,
which is the largest and best known of the arches;
the lateral longitudinal arch on the little toe side; and
the transverse arch across the metatarsal heads
(Figure 2). Whenever any one of these arches collapses, as a rule, the entire arch structure collapses.
Overpronation/Flat Foot
Dropping the arch structure of the foot is a natural
and healthy posture. It occurs during the gait cycle
during midstance when our body weight is directly
above the foot. Before much of our world was paved
and flat, the ground was often uneven. From a position of full supination, varying the degree of pronation would therefore allow the arch to drop and flatten the necessary amount to mold to the contour of
the ground upon which we are standing (Figure 3).
Pronating to drop the arch also allows for shock absorption when striking the ground during walking,
running, and jumping. The problem is when our arch
structure excessively pronates, in other words, overpronates.
Because overpronation causes the arch structure to
drop, it is known in lay terms as flat foot. In scientific
terms, it is known as pes planus, which is Latin for
foot flat (pes cavus is the term for an overly supi
nated foot, in other words, an excessively high arch).
There are two types of overpronation/flat foot: rigid
flat foot and supple flat foot. With supple flat foot,
34 Terra Rosa E-mag

Figure 3 Varying the degree of supination/pronation allows the

foot to mold to the contour of the ground. (Modelled from a
figure in Neumann, DA: Kinesiology of the musculoskeletal system: foundations for physical rehabilitation, ed 2, Elsevier.)

which is the more common of the two types, the clients arch is perfectly healthy when not weightbearing, but upon weight-bearing, the foot pronates
excessively and the arch structure collapses. By contrast, a rigid flat foot is always flat/overly pronated,
regardless of whether the client is weight-bearing or
not (Figure 4).

There are many causes of supple flat foot. Given that
the arch structure of the foot is determined by soft
tissue pulls of musculature and ligaments, a supple
flat foot is caused by either lax ligaments and/or
weak musculature that cannot support the arch
when the weight of the body passes through the subtalar (and transverse tarsal) joint. Muscles that act to
support the arch can be divided into the following
groups (Table 1):
Supinators (invertors) of the foot These muscles have their bellies located in the leg. They
are the tibialis anterior and the extensor hallucis longus in the anterior compartment;
and the Tom, Dick and Harry group: tibialis
posterior, flexor digitorum longus, and flexor
hallucis longus muscles of the posterior deep
compartment (Figures 5A and 5B).
Stirrup Muscles The stirrup muscles, whose
bellies are also located in the leg, are named


Figure 4 Overpronation of the foot, also known as flat foot. A, Supple flat foot when not weight-bearing. B, The same supple flat foot
when weight-bearing. C, Rigid flat foot. Note: The contour of the medial longitudinal arch is highlighted in each figure. Courtesy Joseph E. Muscolino DC.

because they support the arch/underside of

the foot like a stirrup. They are the tibialis
anterior of the anterior compartment
(already mentioned above) and the fibularis
longus of the lateral compartment (see Figure 5A).
Intrinsic plantar musculature Muscles of Plantar Layer I group of the intrinsic plantar
musculature have attachments into the
plantar fascia. By supporting the plantar fascia, they help to support the arch (see Figure
5C). They are the flexor digitorum brevis,
abductor hallucis, and abductor digiti
minimi pedis.
Lateral rotators of the thigh at the hip joint
This group indirectly supports the arch because it acts to prevent the thigh from medially rotating. When the weight-bearing foot
pronates, because the foot is planted on the
ground, the calcaneus of the subtalar joint is
not fully free to move, therefore the talus

moves as well. This is a closed-chain reverse

action of the proximal talus upon the distal
calcaneus, and results in medial rotation of
the talus. Because the ankle (talocrural)
joint does not allow rotation, the tibia medially rotates with the talus; and because the
extended knee joint also does not allow rotation, the femur medially rotates with the
tibia. Therefore, hip joint lateral rotation
musculature can support the arch by acting
to brake/prevent medial rotation of the femur/tibia/talus (Figure 5D). Hip joint lateral rotation musculature includes the posterior gluteal musculature, the deep lateral
rotator group (piriformis, quadratus femoris, superior and inferior gemellus, and obturator internus and externus), and the sartorius.
It should be mentioned that hip joint abductor
musculature can also be important for maintaining the arch of the foot. If this musculature is weak, the thigh can fall into adducTerra Rosa E-mag 35

Table 1 Musculature that supports the arch

Leg/Subtalar joint

Foot/Plantar fascia

Thigh/Hip joint

- Tibialis anterior

- Flexor digitorum brevis

- Gluteus maximus

- Extensor hallucis longus

- Abductor hallucis

- Gluteus medius and minimus

- Tibialis posterior

- Abductor digiti minimi pedis

- Piriformis

- Flexor digitorum longus

- Quadratus femoris

- Flexor hallucis longus

- Superior and inferior gemellus

- Fibularis longus

- Obturator internus and externus

- Sartorius
- Tensor fasciae latae (TFL)

tion, this causes a genu valgus force

(abduction of the leg at the knee joint),
which tends to result in medial rotation of
the thigh, and therefore the leg and talus,
promoting arch collapse. Abductors of the
hip joint are the gluteal muscles, tensor fasciae latae (TFL), and the sartorius.
Another contributor to overpronation is tight pronator (evertor) musculature (fibularis musculature
and extensor digitorum longus), which can pull the
foot into pronation on that side, making it more difficult for the supinator musculature to support the
arch structure.
Most all fascial ligamentous tissue that is located on
the plantar side of the foot helps to support the
arch. Most notable are the long and short plantar
ligaments, the spring ligament, the intertransverse
metatarsal ligaments, and the plantar fascia (Figure
6). If this fascial ligamentous tissue is excessively
lax, perhaps due to genetic factors or to forces
placed upon it during life, it will not be able to hold
the bones in their proper posture, especially during
weight-bearing postures, and the arch will collapse.
As stated, the collapsed arch of overpronation essentially occurs because of the inability of the musculature and ligament complex to support the arch
structure, especially when bearing weight. Therefore, any factor that increases downward force
through the arches will tend to exacerbate this condition. First among these factors is being overweight, which increases the weight that is borne
through the arches. Carrying heavy loads/objects
acts in a similar manner because the weight of
whatever is being carried must ultimately pass
through the arches of the feet.

36 Terra Rosa E-mag

Another factor is a turned out posture of the foot.

This usually occurs because of excessively tight
baseline tone of deep lateral rotation musculature
of the thigh at the hip joint (e.g., piriformis). When
walking with a turned out posture, the persons
weight passes more directly over the medial longitudinal arch, increasing the likelihood that it will
collapse (Figure 7). Ironically, the baseline tone of
the lateral rotation musculature of the hip joint
might be tight enough to cause the unhealthy
turned out posture of the foot, but not strong
enough to prevent the weight-bearing foot from
overly pronating as a result of this altered posture.
It is important for the lateral rotation musculature
to have a healthy and loose baseline tone, but to be
strong enough to contract to prevent overpronation
when needed during the gait cycle.
Proper footwear can be another factor. If a person
does overly pronate, then wearing shoes that have
little or no arch support can allow the excessive
pronation to occur. Wearing high-heeled shoes can
also exacerbate this problem because they shift
body weight to be borne more anteriorly in the foot,
increasing force through the transverse arch, causing it to collapse. This will result in weakness of the
entire arch structure of the foot, including the medial and lateral longitudinal arches, thereby resulting in overpronation.
Finally, the longer that a client has had an overly
pronated foot, the more likely it is that fascial adhesions accumulate that exacerbate the condition by
holding the foot in a posture of excessive pronation.
This is especially true for rigid flat foot, but might
also become a factor that causes a supple flat foot to
gradually transition toward becoming a rigid flat

Figure 5 Muscles that support the arch. A, Superficial view of the anterior leg. B, Deep view of the posterior leg. C, Superficial view
of the plantar foot. D, Deep view of the posterior pelvis. (Muscolino, JE. Kinesiology: The Muscular System Manual: The Skeletal Muscles of the Human Body, 2ed. Elsevier.)

Signs and symptoms

The first and most obvious sign of overpronation is
a flat foot/dropped arch (See Figure 4). The supple
flat foot will have an arch when not weight-bearing
but will be seen to lose the arch upon weightbearing. A rigid flat foot will be flat whether the person is bearing weight through the foot or not. Because overpronation results in medial rotation of
the talus, leg, and thigh, the clients lower extremity
will usually excessively medially rotate when standing (Figure 8A).
Pain does not necessarily accompany this condition,
but it often does. A supple flat foot results in the
arch excessively dropping each time the foot strikes
the ground. This causes the soft tissues on the underside of the foot to be forcefully stretched each
time the foot contacts the ground, tugging at their
attachments and likely causing either spasms in the
plantar intrinsic musculature (due to the muscle
spindle reflex) and/or inflammation of the plantar
fascia (known as plantar fasciitis). Either of these
conditions can cause pain, especially upon weightbearing. Because these tissues attach to the underside of the calcaneus, the stretching forces placed
upon them will be transmitted to the calcaneus, possibly leading to a heel spur (due to Wolffs Law: the
deposition of calcium in response to physical
stress). Therefore, overpronation is often accompanied by plantar intrinsic musculature spasm, plantar fasciitis, and/or heel spur.

Overpronation can also cause ramifications farther

up the clients body. Dropping the arch tends to in
crease genu valgus (knock-kneed) posture, which
places increased tension stress to the medial knee
and increased compression stress to the lateral
knee. Further, if the overpronation is present on
only one side, or if it is present to a greater degree
on one side than the other, then the pelvis on that
side will drop. This places an asymmetrical force on
the clients sacroiliac joints and also often results in
a compensatory scoliosis to bring the head back to
level (Figure 8B).
Assessment of overpronation follows from the signs
and symptoms of the condition. The most important
assessment tools are static and dynamic postural
assessment, which will reveal the characteristic
dropped arch.
For static postural assessment, have the client stand
facing you, a few feet away, and note the height of
the arches, including the relative symmetry of the
arches of the left and right feet (Figure 9A). Note
also the orientation of the patella on each side. Patellar orientation will follow the rotation of the femur/thigh; with overpronation, the patella on that
side will be oriented more medially (See Figure 8A).
If a dropped arch is found, postural examination
should also look to correlate the presence of genu
Terra Rosa E-mag 37

Figure 6 Fascial ligamentous tissues on the plantar surface of the

foot that help to support the arch. Medial view. Note: The intertransverse metatarsal ligaments are not seen.

Static postural assessment can also be done from

the posterior perspective. In this case, instead of
viewing the arches directly, look at the Achilles (calcaneal) tendons; each tendon should be ver
tical. With a collapsed arch, the Achilles tendon will
bow inward instead (Figure 9B). The medial malleolus will also usually be seen to jut inward. If the
dropped arch is unilateral or greater on one side
than the other, postural examination should include
evaluation of a dropped iliac crest and possible
compensatory scoliosis as well (See Figure 8B).
Dynamic postural assessment can be even more effective than static postural assessment. With the
client facing you, ask the client to march in place. It
is important that the client moves slowly and lifts
each foot high enough (close to the height of the
other knee) so that you have time to observe how
much the weight-bearing arch drops each time the
foot strikes the ground. If you have enough space,
for example a long hallway, the client can be asked
to walk while you observe their lower extremities.
As the client walks toward you, assess how much
the medial longitudinal arch drops and the patella
medially rotates when the foot hits the ground. As
the client walks away from you, assess the degree of
bowing in the Achilles tendons and the excursion of
the medial malleolus as the foot hits the ground.
When evaluating pronation motion, keep in mind
that when standing, marching, or walking (in other
words, upon weight-bearing), the foot should pronate to some degree, and therefore the arch structure should drop somewhat. Because there is not
universal consensus on exactly what subtalar joint
neutral posture is, and exactly how much pronation
is healthy versus unhealthy, it is best to eyeball this
38 Terra Rosa E-mag

Figure 7 Walking with the foot turned out increases weightbearing force directly over the arch of the foot, increasing the
likelihood that it will overly pronate. Courtesy Joseph E. Muscolino DC

motion, using your judgment. It is also helpful to

compare left and right sides; symmetry should be
Passive range of motion assessment of the foot at
the subtalar and ankle joints can also be done, with
particular attention to the clients inversion and
eversion ranges, Inversion is often limited in clients
who overly pronate; eversion is often excessive.
Hands-on palpatory examination should then be
done. Check for the presence of tightness and/or
myofascial trigger points (TrPs) in the associated
musculature. It is important to check all muscles
that help to support the arch of the foot (i.e., foot
supinators and hip joint lateral rotators and their
synergists) because they might develop TrPs as they
attempt to control the excessive pronation (see Table 1). Similarly, palpate the antagonists to these
muscles (i.e., foot pronators and hip joint medial
rotators and their synergists) to see if their baseline
tone is contributing directly to the overpronation; if
they are tight/overly facilitated, they might be creating forces that pull the foot into excessive pronation. Palpatory examination should also be performed to assess for fascial adhesions within the
plantar surface of the foot. Generally speaking, the
more fascial adhesions, the more rigid the foot is.
Finally, it is important to assess for joint play/
mobilization of the joints of the foot. Because overpronation usually results in dropping of the tarsal
bones (as the arch structure drops, the tarsal bones
drop), it is especially important to assess the motion
of the bones to move from plantar to dorsal in direction (Figure 10). Mobilization of the tarsals from
plantar to dorsal will usually be restricted in an
overpronating foot, especially a rigid flat foot or a

chronic supple flat foot.

In addition to physical examination, it is also important to conduct a verbal history to determine

whether the client has any habitual postures that
might contribute to overpronation. For example,
sitting cross-legged with the ankle of one leg placed
on the thigh of the other, or driving with the heel of
the right foot placed in front of the brake and the
thigh turned out so that the toes of the foot are on
the gas pedal; these postures tend to promote a
turned-out posture of the foot. A habitual pattern of
standing on one leg with body weight shifted to that
side will tend to increase weight-bearing and therefore physical stress to the foot on that side. Checking the clients shoes for excessive wear on the lat
eral side of the heel can also be helpful.
Medical Diagnosis
Overpronation is a dysfunctional postural condition
of the musculoskeletal system, so no further medical diagnosis/assessment is usually needed. However, if X-Rays are done, they can support the assessment by showing the dropped posture of the
bones of the foot. Both weight-bearing and nonweight-bearing films should be done. A rigid flat
foot will demonstrate the dropped arch on both
weight-bearing and nonweight-bearing films,
whereas a supple flat foot will demonstrate the
dropped arch only on the weight-bearing film.

Differential assessment
When a client presents with overpronation, it is important to differentially assess whether it is due to a
rigid or supple flat foot. It is also important, as mentioned, to assess the possible presence of the postural affects of overpronation higher up in the body.
Look especially for genu valgus, medially rotated
femur/thigh, and dropped iliac crest on the side of
overpronation, as well as a possible compensatory
Manual treatment
Because overpronation, whether it is a supple or
rigid flat foot, usually does not directly cause pain,
and even its effects farther up the body will probably not cause pain for many years or decades, it is
likely that the clients condition will be chronic by
the time that it is addressed. For this reason, there
is a good chance that it will be stubborn and resistant to treatment. Chronicity, not severity, is usually
the biggest determinant to how easily a clients con
dition responds to treatment. With chronicity
comes increased fascial adhesions as well as entrenchment of the neural patterning of muscle

Figure 8 Effects higher in the body of overpronation of the

right foot. A, Medial rotation of the entire lower extremity;
note the orientation of the right patella compared to the left. B,
Overpronation often results in a dropped pelvis (iliac crest) on
that side as well as a compensatory scoliosis. Courtesy Joseph
E. Muscolino DC

Terra Rosa E-mag 39

Figure 9 Static postural examination of overpronation. A, Anterior view. B, Posterior view. Courtesy Joseph E. Muscolino DC

memory tone. For this reason, treatment of an

overly pronating foot must be consistent.
A good guideline for all rehabilitative manual therapy care is to treat the client two times per week
until the desired outcomes have been met. Treatment frequency of twice-a-week is not common in
the world of massage, but is the norm in all other
musculoskeletal rehabilitative fields, and should be
adopted if clinical orthopedic massage is being done
to remedy a musculoskeletal pathologic condition.
Treating a client once per week might feel good
temporarily, but is often ineffective at creating true
and lasting improvement.
For a supple flat foot, manual therapys role is indi
rect. By employing both soft tissue manipulation
and stretching, the goal is to loosen tight musculature and eliminate TrPs. This can both relax the
baseline tone of muscles that are pulling toward
pronation as well as strengthen muscles that support the arch by increasing the efficiency of their
contraction. Manual therapy should also be directed
to any sequelae of overpronation, such as tight lateral rotation hip joint musculature or tight paraspinal musculature as a result of scoliosis, if present.
For the rigid flat foot, as well as the supple flat foot
that is becoming more rigid, manual therapys role
is more direct. It is performed to loosen fascial adhesions that are locking the bones in a position of
pronation. In these cases, deeper soft tissue ma-

Arch Imprint Assessment

A fun and instructive assessment for the arch structure of the foot can be done with a little oil and construction
paper. Place a film of oil on the plantar surface of the clients foot and then ask the client to step on colored con
struction paper. When the client lifts the foot, an imprint of their arch will be visible on the paper. This can then be
repeated for the other foot. These imprints can be shown to the client to demonstrate the posture of their arches
(see accompanying figures). When performing this assessment, be sure to instruct the client to place their weight
evenly on both feet as they place the oiled-foot down.

40 Terra Rosa E-mag

Summary of Manual Treatment Protocol for

1. Heat, soft tissue manipulation, and stretching of
the muscles of the leg/foot (especially the supinators)
2. Heat, soft tissue manipulation, and stretching of
the plantar musculature
3. Arthrofascial stretching (joint mobilization) of the
foot from plantar to dorsal in direction, especially for
a rigid flat foot

4. Soft tissue manipulation and stretching of the hip

joint musculature (especially lateral rotators, medial
rotators, adductors, and abductors)
5. Assess and treat the spine if appropriate
(especially for compensatory scoliosis)
6. Strengthen (or refer out to strengthen) the weakened/inhibited musculature

Figure 10 Joint motion palpation (joint mobilization) of the foot

with force being directed from plantar to dorsal in direction. A,
Reinforced thumb pad contact. B, Pisiform contact. Courtesy Joseph E. Muscolino DC

nipulation into the plantar side of the foot, stretching of the tight muscles, and arthrofascial stretching
(Grade IV soft tissue joint mobilization) is called for.
And because stretching is always more effective if
the soft tissues are warmed up first, moist heat is
also valuable as a modality. Depth of pressure
should always begin as light to moderate, but will
usually have to transition to being deeper to access
long-standing fascial adhesions and deeper tight
musculature that are likely with a rigid flat foot or
even a chronic supple flat foot.

As important as manual therapy can be for overpronation, it can never fully and permanently resolve
the condition. The primary objective of manual
therapy is to loosen the tight musculature and other
taut soft tissues. However, this only addresses one
part of the problem, and usually the lesser part. The
other aspect of this condition is the weakness of the
musculature that must support the arch structure
against the forces that cause overpronation. These
muscles must be strengthened. Therefore, referral
to a fitness trainer, physical therapist, yoga or Pilates instructor, or the recommendation of specific
exercises to strengthen the muscles that support the
arch (see Table 1) is imperative (for more on the
strengthening of these muscles, see the Self-care for
the client section below).
There are a few precautions when working on a client with overpronation. Care must be exercised if
working near the fibular head because of the presence of the common fibular nerve; and care must be
taken if working the medial ankle region because of
the presence of the tibial nerve and artery. If work
is being done in the gluteal region for the deep lateral rotators of the hip, be aware of the location of
the sciatic nerve near the piriformis and lying superficial to the quadratus femoris.
One precaution and possible contraindication is to
be careful when attempting to make any structural
change to a middle-aged or elderly persons foot.
Terra Rosa E-mag 41

Their tissues are less elastic than a younger persons; and if they have been overpronating for dec
ades, it is likely that all the tissues throughout their
body have adapted to this structure. A good guideline is to exercise caution if the client is over 50
years of age. The older the client, the more slowly
and carefully the treatment regimen should be introduced. Changing something as fundamental as
the foots foundational posture for the body might
cause unwelcome compensatory adaptations above.
Beyond these precautions, be sure to gradually transition from light to deep pressure for all clients
when working the plantar side of the foot because
many people are tender in this region.
Self-care for the client

When working with a client for the treatment of

overpronation of the foot, client self-care is extremely important. Supple flat foot is essentially a
condition of weakness of the ligament complex and
musculature that support the arch structure of the
foot. Therefore, strengthening the weak musculature is imperative if the condition is to be resolved.
The specific musculature that should be assessed
and strengthened if weak is given in Table 1. The
challenge is that this musculature must be strengthened to the point that it can not only do its originally intended job, but also be strong enough to
compensate for the weakened fascial ligament complex. If this is possible, it will require dedication on
the part of the client. The major muscle groups to
strengthen are the supinators (invertors) of the
foot, and the lateral rotators and abductors of the
thigh at the hip joint.
One very easy, inexpensive, and low-tech way to
accomplish home-care strengthening is to use elastic tubing or bands to provide resistance when performing the exercise (Figure 11). One end of the
elastic tube can be stabilized by being placed in a
closed door (or by being tied to a stable structure).
The resistance of the exercise is determined by the
length of the tube, which is easily altered by changing the distance that the client sits from the door.

As a general rule, these exercises should be performed in four phases. Phase one involves performing the exercises slowly through a short range of
motion; phase two is done by moving through the
same short range of motion, but quickly. Phase
three is performed slowly through a large range of
Figure 11 Resistance exercise for overpronation using elastic
motion; and phase four is performed by moving
tubing. A and B, Performing inversion of the foot at the subtalar
quickly through a large range of motion. Begin by
joint against resistance. A, Starting position. B, Inversion of the
performing each exercise for approximately 15-30
foot. C and D, Performing lateral rotation of the thigh at the hip
joint against resistance. C, Starting position. D, Lateral rotation of seconds, gradually working toward 60 seconds.
Once each phase can be comfortably and profithe thigh. Courtesy Joseph E. Muscolino DC
42 Terra Rosa E-mag

ciently performed, direct the client to transition to

the next phase. As a general guideline, each phase
should be performed approximately 2-4 weeks before the client is ready to graduate to the next
phase. Once all four phases have been mastered,
your client can begin again, this time with greater
One excellent self-care exercise for the intrinsic
plantar musculature of the foot can be performed
with a towel. Instruct the client to be seated, barefooted, with a towel placed in front of them on a
hardwood, tile, or linoleum floor. Ask the client to
flex their toes, scrunching up and drawing the towel
toward them; then relax the toes and release the
towel. Have the client repeat this until the entire
towel has been drawn toward them (Figure 12).
This exercise can be repeated as desired.
Another excellent exercise for the intrinsic plantar
musculature can be performed using marbles or
small balls. Instruct the client to be seated, barefooted, with marbles/balls on the floor in front of
them. Ask the client to pick up a marble, one at a
time, and then place it back down (Figure 13). This
can be repeated as long as desired.
Finally, it is important to discuss with the client postures to be avoided, proper shoes or orthotics to
wear (for more on orthotics, see the next section,
Medical Approach), and if the client is obese, the
possibility of losing weight. If you are schooled in
orthopedic taping, this modality can also be valuable. The importance of taping is not to temporarily
support the arch, but rather to help the clients
nervous system receive proper proprioceptive feedback so that it can begin to re-learn the proper
static posture and dynamic acture between pronation and supination.
Medical treatment
Overpronation is a postural dysfunction pattern,
therefore there really is no medical approach. If a
podiatrist is consulted, it is likely that orthotics to
support the clients arches and control excessive
pronation will be recommended. Generally, orthotics can be divided into two categories: soft and rigid.
Rigid orthotics better control the clients foot mo
tion, but do not provide shock absorption for the
joints of the lower extremity and spine; whereas
soft orthotics provide excellent shock absorption
but do not control the clients pronation as well. The
best orthotic to use will vary from client to client.
There is also the choice of custom made/fitted orthotics that can be quite expensive, versus premade
store-bought orthotics that cost far less. Custom fit-

Figure 12 Towel scrunching exercise for the plantar intrinsic

musculature. A, Starting position. B, Flex toes and draw towel
toward you. C, Relax toes. D, Flex toes and draw towel toward
you again. Courtesy Joseph E. Muscolino DC

Terra Rosa E-mag 43

Figure 13 Marble pick-up exercise. A, Gripping the marble. B, Picking up the marble. Courtesy Joseph E. Muscolino DC

ted orthotics are superior, but their cost may be

prohibitive for the client. Often, store-bought orthotics will work perfectly fine. Again, the decision
must be made on a client-by-client basis.
It should be stated that the decision to wear orthotics is a controversial one. Orthotics are a passive
brace that do little or nothing to retrain the clients
body to stop overpronating. In fact, it could be argued that they do harm in that they remove the
need for the clients arch support musculature to
contract, thereby causing it to further weaken. The
same argument could be made for shoes with
sturdy arch support. There is merit to this argument. However, if the clients musculature cannot
be retrained, or the client is simply not interested in
attempting the retraining program, then a passive
support is likely better than the effects of chronically overpronating. If the client is interested in
strengthening the arch structure of the foot, then as
this goal is being reached, gradually transitioning
the client toward minimalist shoes can aid in the
demand upon the musculature to strengthen.
Case study
Kerrati is a 36 year-old manager who works at a
retail store. She came in for wellness massage, but
during the postural examination, the therapist noticed that Kerratis right arch drops markedly upon
weight-bearing. Further, her right iliac crest is low
and she has a mild lumbar scoliosis (convexity to
the right). Kerrati does not report experiencing pain
in her right foot or elsewhere in her body.
After finding the overpronation, the therapist performed a palpatory exam and found tightness in
Kerratis plantar foot as well as myofascial TrPs in
Kerratis right-sided tibialis anterior, fibularis
longus, gluteus medius, upper gluteus maximus, and
piriformis. Tightness was also found in the musculature (erector spinae, transversospinalis, and quad44 Terra Rosa E-mag

ratus lumborum) located in the concavity of the scoliosis, in the left low back. With palpation into these
areas, Kerrati experienced tenderness and mild
pain. Range of motion examination showed slightly
decreased inversion of the right foot. The therapist
also performed motion palpation assessment of the
tarsal and metatarsal bones on the plantar side of
the foot, and found restricted motion generally for
the right foot compared to the left, especially when
assessing mobilization of the tarsals from plantar to
dorsal in direction.
Given the assessment of overpronation of the Kerratis right foot, along with the dropped iliac crest
and compensatory scoliosis, the therapist recommended two one-hour massages per week for four
weeks and one one-hour massage per week for the
following four weeks. The therapist also referred
Kerrati out to a fitness trainer with the request that
the fitness trainer specifically focus on strengthening all the musculature that supports the arch structure of the foot.
With Kerrati lying supine, soft tissue manipulation
was performed for the anterior and lateral compartments of the leg for approximately 5-10 minutes,
gradually transitioning from mild to deeper pressure. Kerrati was then turned prone and soft tissue
manipulation was performed for the posterior compartment of the leg and plantar foot for approximately 5-10 minutes, again gradually transitioning
from mild to deeper pressure to access the deep
musculature on the posterior side. This was followed by moist heat to the plantar foot and posterior leg for an additional 10-15 minutes while the
therapist worked Kerratis hip joint lateral rotation,
abduction, and adduction musculature, as well as
the lumbar spine musculature.
The therapist then stretched Kerratis foot into supi
nation and pronation, as well as plantarflexion and
dorsiflexion. After stretching was done, the thera-

pist performed arthrofascial stretching (Grade IV

soft tissue joint mobilization) to Kerratis foot, with
emphasis placed on mobilizing the tarsal bones
from the plantar to dorsal direction. With the remaining time, the therapist worked the clients
other-side lower extremity.
Each session was carried out in a similar manner. As
Kerrati gradually improved, increasing depth of
pressure and assertiveness of stretching and joint
mobilization was employed. Kerrati was given selfcare stretches for her low back and her hip joint
deep lateral rotators; and she was told to perform
these stretches two to three times per day after a
hot shower or other form of moist heat application.
She was also recommended to perform the towel
scrunching and marble pick-up exercises for her
feet. Finally, proper posture at work and home was
discussed, including the recommendation to find
shoes with better arch support, with the long-term
goal to transition toward minimalist shoes.
At the end of eight weeks, Kerratis tarsal and meta
tarsal bones were much more mobile, and many of
the TrPs in her leg, buttock, and low back were improved. Further, her tenderness to palpation in
these regions was diminished approximately 80%.
Kerrati is still working with her trainer, who is reporting that the strength of the targeted muscles is

improving nicely.
For proactive self-care with the goal of continuing
to improve the overpronation dysfunction of her
right foot, Kerrati continues to receive clinical orthopedic massage once or twice each month and
continues to work out with her trainer twice per
week. Whether this plan will be successful toward
entirely resolving her overpronation will take many
months or longer to determine. However, catching
this condition relatively early bodes well for improvement and was critically important to correct
the compensatory postural changes above.
Joseph E. Muscolino, DC, is a chiropractor in private
practice in Stamford, CT who employs extensive soft
tissue manipulation in his practice. He has been a
massage educator for more than 25 years . He is the
author of multiple textbooks including The Muscle
and Bone Palpation Manual, The Muscular System
Manual, and Kinesiology (Elsevier) and Advanced
Treatment Techniques for the Manual Therapist:
Neck and Manual Therapy for the Low Back and PelvisA Clinical Orthopedic Approach (LWW) and the
author of multiple DVDs on Manual Therapy. Joe
teaches Continuing Education Clinical Orthopedic
Manual Therapy (COMT) Certification workshops
around the world and in Australia.
Terra Rosa E-mag 45

Clinical Orthopedic
Massage Therapy
with Dr. Joe Muscolino
Sydney, July 2016

This workshop covers the major clinical orthopedic assessment and treatment techniques
(soft tissues & Joint mobilization) for the neck.

This workshop covers major clinical orthopedic

assessment and treatment techniques for the
lower extremity

15-16 July 2016, Sydney

17-18 July 2016, Sydney


Dont miss this unique experience to
train with Dr. Joe Muscolino.


No. 11

"Joe Muscolino is a master of his profession! His broad

knowledge on the human body and extensive experience
made the workshops interesting and engaging. I would
recommend his workshops to any body-worker. I,
myself, can't wait for the next one!" Zuzana G, North Sydney.

By Jeff Tan
Overpronation can be used as an excuse for selling food orthosis.
Matt Wallden argued that there is no such thing as a flat foot, only
a lazy or deconditioned foot. He further suggested a credit card
test and a simple exercise to correct for it.

Recently I was alerted by the

internet fact that 90% of the
general population's feet are over
-pronated. Pronation is the motion of the foot as it roles inward
after the foot makes contact with
causes the arch of the foot to flatten excessively placing stress and
pressure on tissues and ligaments of the foot. Overpronation , flat foot, pes planus,
fallen arches has been worried to
lead to many foot problems including plantar fasciitis, ankle
pain, lower back pain etc.

study published in 1993 evaluated foot morphology and injury

risk in 246 male army recruits
followed during 12 weeks of intensive training. They found that
20% of trainees with the flattest
feet had the lowest injury risk. In
contrast, the 20% with the highest arches had a 6-fold greater

injury risk than the flat-footed

group. The middle 60% of trainees had an intermediate risk.
This study dispel the notion that
flat-footed people are prone to
injury during exercise. But people with high arches should be
advised to pursue non - weight-

Various websites mainly selling

foot orthoses or related products
claim 60% and even up to 90% of
the population suffered from
this condition, and should be corrected. However, a medical review on its prevalence found
mostly on children, with quite a
high variation estimates from
less than 1% to as much as 78%.
A Cochrane review concluded
that Flat foot is often unneces
sarily treated, being ill-defined
and of uncertain prognosis.

Figure 1 Pronation and supination of the subtalarjoint,

Not all people with overpronation have problems. A

Image By Ducky2315 [CC BY-SA 3.0 (], via

Wikimedia Commons

Terra Rosa E-mag 47

bearing exercise, particularly if they have a rigid

Matt Wallden, an osteopath from the UK, in a publication published in Journal of Bodywork and Movement Therapies, suggested that theres no such
thing as a flat foot, only a lazy or deconditioned
foot. He challenged the idea that the necessity on
the use of foot support, as to support a biological
structure, in the long term, is to weaken it.
Matt Wallden proposed using a credit or business
card test, which was designed to screen for subtalar
joint neutral by podiatrist Michel Joubert. The client
in a normal standing posture, place a credit or business card alongside the lateral border of the foot in
alignment the lateral malleolus. When the talus is
palpated to be in subtalar neutral, this means that
the lateral malleolus is in direct vertical alignment
above the lateral border of the foot. The distance
between the vertical border of the credit card and
the lateral malleolus is a measure of the degree of
static pronation, which usually ranges from between 5 to 15 mm. The credit card test is an easy
and objective test for static subtalar pronation, the
distance from lateral malleolus to vertical border of
the credit card can be measured in millimetres.
To remedy this condition, Matt proposed the use of
a foam roller longitudinal exercise, which trains
the nervous system not doing the job it should do;
in combination with a likely concomitant deconditioning of the muscles.
He described the exercise balancing on an unstable
surface as follows:
The client lies down on a foam roller in a longitudinal position with knees flexed to support the body
and feet flat against the floor. This condition may
already create an instantaneous change in the foot
posture because the foot needs to balance the body
and bears less weight. The next challenge is to ask
the client to place her hands across the chest and to
lift one foot off the floor. This creates another level
of balance challenge and simultaneously unloading
the foot. As the foot on the ground needs to establish stability, it automatically attempts neutralize its
subtalar position by switching on the intrinsic
muscles of that foot, leading to the reformation of
the arch. The credit card test can be re-evaluated
after the exercise.
Note that there various causes of overpronation,
and the above exercise is only for training weak
muscles. When a client has an indication of overpronation that needs to be addressed, the cause
48 Terra Rosa E-mag

Credit Card Test: The distance of lateral malleolus to the

vertical border of the credit card card can be a measure of
the degree of subtalar pronation.

needs to be tackled first before pursuing with treatments.

Burns J, Crosbie, J., Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot. Australasia
J Podiatric Med, 2006; 40 (3): 61-6.
Cowan DN et al. Foot morphologic characteristics
and risk of exercise-related injury. Arch Fam Med
1993 Jul 2 773-777.
Evans, A.M., and Keith R. A Cochrane review of the
evidence for non-surgical interventions for flexible
pediatric flat feet. Eur J Phys Rehabil Med 47
(2011): 69-89.
Matt Wallden. Don't get caught flat footed How
over-pronation may just be a dysfunctional model.
J Bodyw Mov Ther. 2015 Apr;19(2):357-61.


Advanced Myofascial Techniques

With Til Luchau,
Sydney: Whiplash (25 26 Sept 2016)
Canberra: Spine, Ribs, & Low Back (28-29 Oct), Advanced Ribs (30 Oct)
Tweed Heads: Spine, Ribs, & Low Back (8-9 Oct), Advanced Ribs (10 Oct)
Learn cutting-edge techniques that you can use immediately to start solving some of your most difficult client
challenges. Entertaining as well as informative, the classes combine experiential learning, 3D anatomy
visuals, technique-specific demonstrations, and hours of hands-on supervised table practice.
Til Luchau is the Director of A legend around the USA for
his thorough, student-focused approach to trainings, Til brings more than 25 years of knowledge, talent and enthusiasm to these programs. He has trained thousands of practitioners in
over a dozen countries on five continents. He is the author of the Advanced Myofascial techniques book (Handspring Publishing).
Terra Rosa E-mag 49

More Info at:

The Hand-L Massage Tool:

From Dream to Reality
By Bob McAtee, LMT
Bob McAtee, the inventor of Hand-L, tells the history behind the famous massage tool.

Massage Tools: Overview

A recent blog post on the the Terra Rosa website
noted that massage tools can help enhance the
therapeutic effects of a treatment, and tools can also
help therapists, preventing them from fatigue and
injury. The highest risk for a massage therapist is
mainly wrist, fingers, and thumbs injuries. A survey
conducted by Terra Rosa a few years ago indicated
that 60% of the surveyed massage therapists in Australia have a prevalence of wrist and thumb injuries.
Enter the Hand-L Massage Tool
As we celebrate the 20th anniversary of Hand-L Massage Tool, we thought it would be interesting to have
look back. First, by way of introduction to those of
you unfamiliar with it, the Hand-L is a patented ceramic pressure tool, ergonomically designed to reduce stress on thumbs, fingers, and wrists. Its unique
shape contributes to its comfort and effectiveness.
50 Terra Rosa E-mag

The Hand-L was first introduced to the massage

therapy community in 1996, and the updated HandL 2.0 became available in 2014.
The Hand-L 2.0 is made of hand-finished stoneware
clay in an attractive earthtone colour, glazed at cli
ent contact areas for comfort, unglazed on the gripping surface to provide safe, slip-free control even if
using oil/lotion/cream. The updated glaze finish on
the client contact surfaces has slightly more drag
than the original to provide better control when
working with lubricant on the skin.
The Hand-L works well in many applications, including trigger point work, cross-fibre work, and deep
stripping. Its effective with lubricant on the skin, or
through clothing, so its ideal for use during chair
massage. Many manual therapists use the Hand-L
successfully in the application of the scraping tech
niques of IASTM (Instrument Assisted Soft Tissue

for a massage tool to use in my sports massage

practice and for my own self-massage. I had already
been a full-time massage therapist for 11 years by
then and was noticing the wear-and-tear on my
thumbs, fingers, and hands. In those days, there
were only a few massage tools on the market (the
Knobble, the Theracane, and a variety of T-bar
tools) and none of them fit my hand properly or
were too large to do the detailed work I needed
them for.

Figure 1 One of the original, hand-built prototypes for the

Hand-L, 1992.


The Story of the Hand-L: Bringing an Idea to

Throughout the summer of 1992, I had been looking


In September of 1992, I woke from a restless dream

in the middle of the night with an image fully
formed of the perfect shape for a massage tool. I
rarely remember my dreams, but this was an image
so vivid I could not forget it. When morning finally
came, I grabbed some clay and proceeded to handbuild several prototypes of what I had "seen" in my
dream. Figure 1 shows of the original pieces.
Over the next few months, my friend Greg, a local
ceramic artist, gave me access to his studio and his
clay to hand-build another 50 or so pieces, all of
them slightly different, trying to refine the design.
Each of these pieces had to air-dry, be glazed, and
then fired in the kiln, a somewhat time-consuming
process. These pictures show the evolution from a
one-ended to a two-ended tool, then the addition of
non-slip elements, as well as an attempt to make

Figure 2 (a) This is another version of the shape I was trying to recreate from a dream. (b) This version shows the evolution to the two-ended shape, with color added for aesthetics. (c) a different view, to show the added texture (yellow
dots) to help provide a non-slip gripping.

Terra Rosa E-mag 51

them visually appealing.

Once I got to the end of my own design capabilities, I
enlisted another friend (a sculptor and toy-maker)
who helped refine the final design. We finally went
into production and started selling the Hand-L in
1996 (4 years after "the" dream).
Start-Up Challenges
The greatest challenge for a start-up business is
funding, and my situation was no different. I could
not afford to go into mass-production of the Hand-L,
so had to find a small production studio that could
make the tool in batches of 50-100 at a time. I maintained that level of production for several years.
We also had to come up with a design for a retail
box, a belt holster, organize an instructional brochure, and solve a million other little issues that go
into producing and selling a product. The learning
curve was steep!
I applied for a patent on the Hand-L in 1997 and it
was awarded January 4, 2000. This allowed me to
take the Hand-L to the next level of production and

Figure 3. Here is the original Hand-L, made of white porcelain clay with the logo stamped into the non-slip grip.

I hope you find the Hand-L as useful in your practice

as the tens of thousands of other therapists worldwide who have adopted it.
Features that make the Hand-L unique:

The original ceramic massage tool.

Ergonomically designed for comfort.

Unique shape maximizes leverage, not strength.

Relieves pressure on thumbs, fingers, and wrists.

Helps prevent overuse injuries.

In 2014, we brought the manufacturing back home

The Hand-L tool is now available at:
to Colorado. Due to a major change in the manufac-
turing process, we've made some small design and
color changes to the Hand-L that make it even more Read 6 Questions to Bob on page 63.
visually appealing, without changing its ergonomics
or functionality. We are once again crafting the Hand
-L in small batches to help us better control their

52 Terra Rosa E-mag

Register at

Sydney, 15-16 October 2016

Sydney, 17-18 October 2016

Fascia of the Pelvic Floor

Fascial Toning

Terra Rosa E-mag 53

Sydney, 21 October 2016

Sydney, 22-23 October 2016

A working experience with

CORE Myofascial Therapy
By Taso Lambridis, MSc
Photo by Patty Kousaleos

CORE Myofascial Therapy was developed by George

Kousaleos, a highly experienced Structural Integration Therapist based in Florida, USA who also has a
major role with the Athletic Program at Florida
State University. George developed the Sports Massage team for the British Olympic Association in
preparation for the 1996 Atlanta Games and helped
established the Olympic massage therapy standards
for the Athens 2004 Olympics.
54 Terra Rosa E-mag

Those who have attended any of his course in Australia over the past 2 years can attest to the fact that
George is probably one of the most engaging teachers and has an in-depth knowledge of the myofascial method gained from over 40 years of work in
the field of Structural Integration. I recently had the
opportunity to be part of a team of soft-tissue therapists who attended a 1 week long training internship run by George in Florida, USA with the added

Photo by Patty Kousaleos

opportunity of working on elite-level college American Football athletes undergoing an 8-week speed
training and conditioning program.
As a physiotherapist, I already received my certification in CORE Myofascial Therapy having attended
Georges courses in Sydney but the opportunity of
working closely with him was too great not to be
missed. I was invited due my particular interest in
the SIJ and pelvis and for what further knowledge I
could provide to the rest of the therapy team. My
week-long experience gave me the perfect opportunity to apply the CORE Myofascial Therapy to these
professional athletes as well to provide me with
some insight into the world of Pro-American Football, better known as the NFL.
George had teamed up with Toni Villani, the Director of XPE Sports in Boca Raton, who is considered a
speed guru and sports trainer, known for getting
excellent results and helping a wide range of athletes to achieve a professional status in their chosen
sport. George was to provide CORE Myofascial Ther-

apy with the help of a group of 8-10 therapists each

week who would receive instruction on structural
bodywork. The aim of the CORE Myofascial Therapy
was to enhance the athletes training performance
and recovery but also very importantly to prevent
30 elite-level, college American Football players
would attend an 8-week conditioning program under the guide of Toni Villani and his trainers. These
college athletes were hoping to turn professional
and would train at XPE Sports in the hope of performing well at the upcoming trials and securing a
professional NFL contract.

Just to give you some background. The NFL is big
business and dwarfs any of the Australian footy
codes generating billions of dollars with many players earning salaries in excess of the combined salaries of entire NRL teams. For example the current
Terra Rosa E-mag 55

Photo by Patty Kousaleos

quarterback at the San Francisco 49s is on a con

tract worth annually $US 11.5 million. In Australia
recent interest in the NFL has been generated by an
ex-rugby NRL player Jarryd Hayne who switched
codes in 2015 aiming to secure a long-term player
contract and a spot on the 53-man roster of the 49s.
Some sobering facts of what it takes to be a professional NFL player will give you some idea of the
challenge that Jarryd Hayne faces in order to secure
that permanent spot with the San Francisco 49s
since most rookies wont make it beyond the first 3
years in order to make a decent living out of the
Consider this:

The Combine
This is the NFLs official trial for new recruits where
college football players perform physical and mental tests in front of NFL coaches, general managers
and scouts; this also includes a series of gruelling
medical examination and player interviews to assess their mental aptitude. About 300 athletes are
invited each year and their performance at the combine can affect their draft status, salary contract and
future careers.
The combine tests include:

The 40-yard dash,

Bench press repetitions of 225 pounds,

1,093,234 high school players.

Vertical & Horizontal jump,

6.5% will play in college.

Several shuttle & cone drills,

Only 1.6% of college players get drafted by

the NFL.

Position specific drills.

Of the 300 rookies making a team, only 150

players make into Year 4.

56 Terra Rosa E-mag

Although there are critics of the combine who question whether these tests reliably measure or predict
a players success as a pro-NFL player, this has become a major sporting event of its own and is

Photo by Patty Kousaleos

screened on the NFLs own subscriber TV channel. It

covers over 30 hours of coverage over the 4 days
and receives between 5-6 million viewers; the 40
yard dash has become the Olympics of the NFL.
Myofascial Therapy
The structural bodywork was performed according
to the CORE Myofascial Therapy protocol developed
by George Kousaleos. Georges approach has main
tained much of the basic form and method developed by Dr. Ida Rolf and has remained pure by promoting her ideals of Structural Integration. There is
a distinct focus on spreading the superficial layer
of fascia and works in a systematic manner from
superficial to deeper layers. This work has to be experienced to fully appreciate its profound effects on
an individuals postural awareness and ease of
movement. On a regular basis you could see the
look of amazement and the sincere appreciation
from the players immediately after the sessions and
they would often comment on how the work we
gave allowed them to consistently train at the intense levels expected by Toni Villani.
The training in myofascial therapy and learning
about structural integration strategies was done in
the morning while the athletes were put through
their training sessions and then in the afternoon, we
conducted the therapy sessions for about 3 hours
each day. We had 45 minutes sessions for each athlete which might seem like a luxury but given the
size of these athletes and the numbers of athletes
attending XPE Sports, we were kept very busy. In
order to ensure a uniformity of treatment throughout the 8 weeks, it was explained to us from the
start that we were only to use CORE Myofascial
Therapy even though we all had extensive clinical
experience in treating athletes. In this way, the athletes would receive the same treatment from any of
the therapists who happened to be working on
them in any given week.

a key role with the Athletic Department) sustain

much lower injury rates than other college athletes.
For me personally, myofascial therapy has had profound effects on how I treat patients. Having integrated myofascial release method into my clinical
practice for over 10 years, I have found that CORE
Myofascial Therapy has given me further insight
into the amazing world of fascia and the tools to
provide long-lasting beneficial effects to my patients.

Taso Lambridis is a Physiotherapist working

in Sydney and is the Director of Spinal Synergy Physiotherapy. He has a BSc in Physiotherapy and MSc in Sports Medicine.
Taso has over 20 years of clinical experience
and has a particular interest in treating
complex spine problems. He has extensive knowledge on
the SIJ and teaches courses to physiotherapists and other
manual therapist on an evidence based approach to SIJ
Dysfunction. He has been using myofascial release for over
10 years in his own practice and this has greatly enhanced
his clinical practice.

I was impressed that given the intensity of training

the athletes been put through, for the whole 8
weeks there was not a single injury. It is also worth
mentioning that athletes who regularly receive this
work at Florida State University (where George has
Terra Rosa E-mag 57

Photo by Patty Kousaleos

Maximise Oxygenation


with George Kousaleos
Sydney, November 2016
"George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing
CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy - James Waslaski LMT;
Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage

CORE Myofascial Therapy Certification

CORE Sports and Performance Bodywork


Sydney 19,20,21 November 2016

CORE Myofascial Therapy 1: 11,12,13 November 2016

CORE Myofascial Therapy 2: 14,15,16 November 2016

This 3-day seminar will examine the basic styles of performance

inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are
appropriate for each style of performance, we will focus on developing training and event protocols for endurance, sprint,
power, and multi-skilled athletes.

An intermediate to advanced, six-day workshop designed to

give practicing massage therapists in-depth knowledge and
hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve
your clients structural body alignment and increase their physi
cal performance.

Getting the basic Myofascial Spreading done on my

first day resulted in a dramatic improvement of my
body alignment Mic, Townsville

George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy
and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced
and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years.
George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the
International Sports Massage Team for the 2004 Athens Olympics.

58 Terra Rosa E-mag
Your Source for Massage Information
AMT , ATMS, IRMA, MAA Approved CEs.

For more information & Registration


Recent Research Highlights

What is bad for your heart is bad for
your tendons
Individuals with unhealthy blood cholesterol levels
are more likely to have tendon pain or altered tendon structure, according to a new study.
Australian authors Ben Tilley, Jillian Cook and colleagues from Monash University and University of
Canberra published Is higher serum cholesterol
associated with altered tendon structure or tendon
pain? A systematic review in the British Journal of
Sports Medicine
The authors noted that tendon pain occurs in individuals with extreme cholesterol levels (familial hypercholesterolaemia, an established risk factor for
coronary heart disease.). Cholesterol also accumulates in tendons. They conducted this review is to
investigate whether the association with tendon
pain is strong with less extreme elevations of cholesterol.
The review included 17 tendon studies with data
from more than 2000 people, and results indicated
that there is a relationship between an individuals
lipid profile and tendon health.
The most interesting finding was that the pattern
of cholesterol changes seen with tendinopathy was
similar to that which increases cardiovascular disease risk. It seems that what is bad for your heart is
bad for your tendons. The researchers theorize
that cholesterol deposits lead to inflammation of the
tendons, and this leads to structural changes that
make the area vulnerable to injury and pain.
However, the more important benefit of identify
ing a link between cholesterol and tendinopathy is
the potential for early detection of high cholesterol,
and management of cardiovascular disease risk, in
those presenting with tendon pain.

A New Muscle "Discovered":

The tensor vastus intermedius
How many muscles are there in the Human body?
From the Biotensegrity viewpoint there is only one.
However from the clinical anatomy perspective a
muscle can achieve autonomy once it can be shown
to meet specific criteria. An article published in the
journal Clinical Anatomy (March 2016) by a group
of researchers in Switzerland claimed that they
have "discovered" a "new" muscle in the Quads!
The quadriceps femoris is traditionally described as
a muscle group composed of the rectus femoris and
the three vasti. However, clinical experience and
investigations of anatomical specimens are not consistent with the textbook description. The researchers have found a second tensor-like muscle between
the vastus lateralis (VL) and the vastus intermedius
(VI), hereafter named the tensor VI (TVI).
A TVI was found in all dissections of 26 cadavers. It
was supplied by independent muscular and vascular branches of the femoral nerve and lateral circumflex femoral artery. Further distally, the TVI
combined with an aponeurosis merging separately
into the quadriceps tendon and inserting on the medial aspect of the patella.
The authors suggest a couple of likely functions of
the TVI:
By way of its basic orientation travelling down
the outside of the thigh from the hip, crossing the
quadriceps tendon on a diagonal to reach the inside
aspect of the kneecap it is probable the TVI plays
a role in patellar control.
As the TVI aponeurosis is often fused or closely related to the VI muscle, it may exert tension on this
muscle contributing to the VI function as well.
Hence the name: tensor of the vastus intermedius

Terra Rosa E-mag 59

Research Highlights
To Roll or Not to Roll
Selfmyofascial release (SMR) using either a foam
roll or roller massager becomes quite popular in
Sports and Bodywork. These tools are promoted to
enhance recovery and performance. A recent review
published in International Journal of Sports Physical
Therapy attempt to evaluate the efficacy of these
rollers on joint range of motion, muscle recovery,
and performance.
The authors searched for peer reviewed publications that measured the effects of SMR using a foam
roll or roller massager on joint ROM, acute muscle
soreness, DOMS, and muscle performance. A total of
14 research articles were evaluated.
Does selfmyofascial release with a foam roll or roller
massager improve joint range of motion with
out effecting muscle performance?
Both foam rolling and the roller massage may offer
shortterm benefits for joint ROM at the hip, knee,
and ankle without affecting muscle performance.
Also, that SMR may have better effects when combined with static stretching after exercise
After an intense bout of exercise, does self
myofascial release with a foam roller or roller
massager enhance post exercise muscle recovery and
reduce DOMS?
Foam rolling and roller massage after high-intensity
exercise does attenuate decrements in lower extremity muscle performance and reduces perceived
pain in subjects with a post exercise intervention
period ranging from 10 to 20 minutes. Continued
foam rolling (20 minutes per day) over 3 days may
further decrease a patient's pain level.
Does selfmyofascial release with a foam roll or roller
massager prior to activity affect muscle perform
Short bouts of foam rolling (1 session for 30 seconds) or roller massage (1 session for 2 minutes) to
the lower extremity prior to activity does not enhance or negatively affect muscle performance but
may change the perception of fatigue.
The authors concluded that the current literature
measuring the effects of SMR is still emerging. The
results of this analysis suggests that foam rolling
and roller massage may be effective interventions
for enhancing joint ROM and pre and post exercise
muscle performance. However, due to the heterogeneity of methods among studies, there currently is
no consensus on the optimal SMR program.

60 Terra Rosa E-mag

Scalp Massage Can Increase Hair

A new study from Japan evaluated the effect of scalp
massage on hair in Japanese males and the effect of
stretching forces on human dermal papilla cells in
Nine healthy men received 4 minutes of standardized scalp massage per day for 24 weeks using a
scalp massage device. Total hair number, hair thickness, and hair growth rate were evaluated. The results showed that standardized scalp massage resulted in increased hair thickness 24 weeks after
initiation of massage (0.085 0.003 mm vs 0.092
0.001 mm). In vitro, DNA microarray showed gene
expression change significantly compared with nonstretching human dermal papilla cells. A total of
2655 genes were upregulated and 2823 genes were
downregulated. The analyses also showed increased
expression of hair cycle-related genes and decrease
in hair loss-related genes. The authors concluded
that stretching forces result in changes in gene expression in human dermal papilla cells, and scalp
massage transmits mechanical stress to human dermal papilla cells in subcutaneous tissue.

Manual therapy as an effective

treatment for fibrosis in a rat model
Key clinical features of carpal tunnel syndrome and
other types of cumulative trauma disorders of the
hand and wrist include pain and functional disabilities which may involve tissue inflammation and/or
fibrosis. To understand how massage therapy affects the cellular level, authors Geoff Bove and colleagues examined the effectiveness of modelled
manual therapy (MMT) as a treatment in forearm
tissues of rats which were induced with repetitive
stress injuries. The study was published in Journal
of Neurological Science
Young adult, female rats were examined: food restricted control rats were trained for 6 weeks before performing the performing a high repetition
high force (HRHF) reaching and grasping task for 12
weeks. A group of 11 rats has no treatment (n=11),
while another group received modelled manual
therapy (n=5) for 5 days per week for the duration
of the 12-week of task.
The results showed that rats receiving the manual
therapy expressed less discomfort-related behaviour and performed progressively better in the
HRHF task. Grip strength, while decreased after
training, improved following thereof. Fibrotic nerve
and connective tissue changes (increased collagen
and TGF-1 deposition) present in 12-week control

Research Highlights
rats were significantly decreased in 12-week after
The authors concluded that these observations support the investigation of manual therapy as a preventative for repetitive motion disorders.

The benefits of coffee on skeletal

Australian loves their coffee and epidemiological
studies have revealed an association of coffee consumption with reduced incidence of a variety of
chronic diseases as well as all-cause mortality. However there is little attention on its effect on skeletal
muscle. A recent review published in Life Science
Journal suggesting that coffee has beneficial effects
on skeletal muscle.
Coffee has been shown to induce autophagy, improve insulin sensitivity, stimulate glucose uptake,
slow the progression of sarcopenia, and promote the
regeneration of injured muscle. Coffee consumption
has also been shown to attenuate the progression of
sarcopenia, the progressive loss of muscle mass and
strength with age. Mice who consumed caffeinated
coffee in their drinking water over a 4-week treatment period showed greater muscle weight and grip

cross-sectional area of the paraspinal compartment

were quantitatively measured from axial images at
the level of the transverse processes and the Chronic
Pain Grade Scale was used to assess low back pain
intensity and disability.
The results of observations showed a shorter length
of fascia around the parapsinal compartment was
significantly associated with high intensity low back
pain and/or disability, after adjusting for age, gender, and body mass index.
The authors concluded that a shorter lumbar
paraspinal fascia is associated with high intensity
low back pain and/or disability among communitybased adults. Although cohort studies are needed,
these results suggest that structural features of the
fascia may play a role in high levels of low back pain
and disability.

Massage therapy decreases pain and

fatigue after Ironman triathlon
A study from Brazil published in Journal of Physiotherapy asked the question Can massage therapy
reduce pain and perceived fatigue in the quadriceps
of athletes after a long-distance triathlon race

The author concluded that current studies investigating the effects of coffee on skeletal muscle have
only utilized animal and in vitro models. No studies
have utilized human subjects, any volunteer?

The study recruited 74 triathlon athletes who completed an entire Ironman triathlon race and whose
main complaint was pain in the anterior portion of
the thigh. The study was a Randomised, controlled
trial with concealed allocation, intention-to-treat
analysis and blinded outcome assessors. The experiShorter lumbar paraspinal fascia is
mental group received massage to the quadriceps,
associated with high-intensity lower which was aimed at recovery after competition, and
the control group rested in sitting. The outcomes
back pain
were pain and perceived fatigue, which were reThe thoracolumbar fascia plays a role in stabilization ported using a visual analogue scale, and pressure
of the spine by transmitting tension from the spinal pain threshold at three points over the quadriceps
and abdominal musculature to the vertebrae. It has muscle, which was assessed using digital pressure
been hypothesized that the fascia is associated with algometry.
low back pain through the development of increased
The trial showed that the experimental group had
pressure in the paraspinal compartment, which
leads to muscle ischemia. A study from Monash Uni- significantly lower scores than the control group on
the visual analogue scale for pain and for perceived
versity and colleagues from Australia, published in
fatigue. There were no significant between-group
the Journal Spine, investigated the relationship between structural features of the thoracolumbar fas- differences for the pressure pain threshold at any of
the assessment points.
cia and low back pain and disability.
Seventy-two participants from a community-based
study of musculoskeletal health underwent Magnetic
Resonance Imaging from the T12 vertebral body to
the sacrum. The length of the paraspinal fascia and

The authors concluded that massage therapy was

more effective than no intervention on the post-race
recovery from pain and perceived fatigue in longdistance triathlon athletes.
Terra Rosa E-mag 61

1. When and how did you decide to become a

My first visit to a Chiropractor as a 19 year old. I
was in first Mining Engineering at UNSW and I was
so impressed with the speed I was fixed (1 treatment) that I wanted to be a Chiropractor immediately, especially as I was quite a sceptic going into
my first appointment. So I dropped out of Mining
Engineering and started Chiropractic the next year.

2. What do you find most exciting about bodywork

The ability to fix a long term issue and quite often
very quickly, especially on a patient who has been
unable to use their body properly for some time either an athlete or older person.

3. What are your favourite bodywork books?

My favourite body work books are anything by Donatelli, some great ones on specific sports rehab,
any of Stollers imaging books and Carla Steccos
Functional Atlas of the Human Fascial System.

4. What is the most challenging part of your work?

The most challenging part of my work is dealing
with with severely degenerative spinal conditions.

5. What advice you can give to fresh manual therapists who wish to make a career out of it?
Advise to new manual therapists is get into good
habits with your own body positioning at the start
of your career and also be careful not to put exces62 Terra Rosa E-mag

sive load or pressure through your own joints at

their end range of movement. Your future longevity
depends on getting this right.

6. How do you see the future of manual therapy?

The future of manual therapy will be very strong as
more and more patients are looking to minimise
prescription medication usage due to their often
adverse effects. The keys will be, correct diagnosis,
specific treatment, good communication with the
patient and good results.

David Steven has been in private practice as a Chiropractor for 21 years in both Balgowlah and Neutral
Bay, Sydney. He has the skills and ability to diagnose,
treat and fix both spinal and peripheral conditions
involving both the bony structures and the connective
tissues. He has extensive experience using various modalities including Chiropractic, Acupuncture, Dry
Needling, various soft tissue techniques including Active Release Technique, Kinesiotaping and Sports
He Developed, a stretch/ strength
video database for use by practitioners worldwide.
David has years of experience treating elite athletes
including numerous Olympic and Commonwealth
athletes from various sports, national rugby league
and rugby union. Recently he was appointed Chiropractor at the Polyclinic for the Rio Olympic games

1. When and how did you decide to become a bodyworker?

I came to massage and bodywork via my degree in
psychology. I got interested in the work of Willhelm
Reich and his theories that body armoring blocks
emotional energy flow. This led me to study and
receive body therapy with Neo-Reichian practitioners. As I saw the benefits of this work in my own
life, I decided to pursue the work. One of the prerequisites for the program I was interested in
studying was to take a basic massage course. As it
turned out, I did not pursue the training in NeoReichian work, but decide to pursue massage and
bodywork more generally. My next level massage
training was through a school that focused on
bodywork (structural integration and emotional
release) than just massage.
2. What do you find most exciting about bodywork
Im often amazed that after 35 years, I never get
bored with the work. Every day brings new challenges, new ways to work with the same clients,
and new opportunities to keep learning.
3. What are your favourite bodywork books?
My publisher would be unhappy if I didnt refer to
my own book first ;-):
1. Facilitated Stretching, 4th edition with online
video, Robert E. McAtee and Jeff Charland
2. Functional Atlas of the Human Fascial System,
Carla Stecco
3. The Muscle and Bone Palpation Manual, Joe Muscolino (one of several of Joes titles that I use regu
4. Therapeutic Massage in Athletics, Pat Archer
5. Sport and Remedial Massage Therapy, Mel Cash

4. What is the most challenging part of your work?

I wear many hats (massage therapist, writer, educator, inventor, business owner) and my biggest
challenge is carving out the time to keep current in
each of these endeavors. I hope to begin work on a
new book soon, one that Ive been thinking about
for years, but have not been able to pursue due to
other demands on my time. Wish me luck!
5. What advice can you give to fresh manual therapists who wish to make a career out of it?
1. Its important to realize that it takes time to build
the physical and emotional stamina to have a fulltime manual therapy practice. Its better to go slow,
and let the business build organically.
2. Practice good self-care, pay yourself first, dont
let clients control your schedule (this is a hard one),
never stop learning, be willing to adapt your work
to stay healthy and to stay current.
6. How do you see the future of manual therapy?
I believe we will always have a need for professional practitioners skilled in the art of touchingon-purpose to provide relief from pain, to promote
physical performance (whether sport or work related), and to provide nurturing contact that humans need to thrive.
Bob McAtee, LMT, CSCS, has been a massage therapist
since 1981, specializing in sports massage and soft tissue
therapy. Since 1988, Bob has maintained an active, international private practice in Colorado Springs, CO. His clientele includes Olympic and professional athletes, dancers,
performers, and recreational athletes, active older adults,
stressed office workers, and those suffering soft-tissue injuries. He is the author of Facilitated Stretching, a how-to
book about PNF stretching, used by health and fitness professionals worldwide.
Bob invented the patented Hand-L Massage Tool, used by
manual therapists worldwide to save their thumbs. For
more information, please visit

Terra Rosa E-mag 63