Soft Tissue Issues
FEATURE
Brian Jensen
DC
As I have looked for ways to improve my patients’ responses to care, I learned to look for the things that stand in the way of improvement. It can be a long list that includes past trauma, lifestyle choices, diet, medications, genetics, attitudes, laziness — the list goes on. Experience is a wonderful teacher, and as our practices evolve over time, we benefit from the sheer repetition of thousands of patient encounters. Those experiences show us patterns, and gradually, things become more predictable.
When I began my practice, my limited experience often led to frustration if a patient didn’t improve quickly or relapsed over a period of time. This was in contrast to the many patients who responded very quickly and seemed to get along without any complications. I often wondered what I was doing wrong, but as time went on, I realized that I needed to develop some additional skills, and my patients needed to be more accountable for their own results. Hippocrates is credited with saying, “The patient must combat the disease along with the physician. Results are not guaranteed; they are earned by patients who are willing to work alongside of the doctor.” I found that to be applicable to my patients, but I had to develop some tools to help them.
My early years of patient care consisted of instrument adjustments, some electrical muscle stimulation, and moist heat for tight and sore muscles. I quickly added custom flexible orthotics that supported all three arches of the foot to my protocols and saw even better results. As I learned more about improving posture, I started having more “complications” with care. Patients occasionally complained that they were developing additional symptoms with something that hadn’t previously bothered them. The common denominator of these complaints seemed to be that they were soft tissue issues. I wasn’t creating soft tissue problems; I was revealing them by helping the patient move through greater ranges of motion. I had to learn how to help my patients adapt to this new level of function.
Paralyzed limbs, facial paralysis, and loss of speech can all be restored because of the neuroplastic nature of the brain and nervous system.
As our knowledge of the brain and functional neurology has expanded over the past several decades, we have developed skills and methods to utilize the neurological capabilities our patients possess. One of the most profound examples of these capabilities is in the recovery of stroke patients. Paralyzed limbs, facial paralysis, and loss of speech can all be restored because of the neuroplastic nature of the brain and nervous system.
Neuroplasticity is the principle that says the brain can change. New neural networks can be developed, and that can change function. This principle allows us to help patients develop better, more efficient posture and functional movement. It’s what helps a patient go from inefficient, painful gait patterns that stress knees, hips, pelvis, and spine to walking with a smooth, efficient gait with strong posture. It’s an amazing transformation to witness, but sometimes there are bumps in the road, and that’s where we need to consider the role of soft tissue structures.
Poor posture, gait, and movement disorders are essentially a repetitive-use injury in progress. We are familiar with the assembly-line worker that does the same movement day after day and develops carpal tunnel syndrome or tendonitis in the wrist or elbow. Traditional treatment is provided on the inflamed or strained tissue, and when it heals or feels better, the person can return to the activity.
For the typical chiropractic patient, repetitive-use injuries show up in the form of low back, sacroiliac joint, neck, hip, knee, ankle, shoulder, elbow, and wrist pain. Trigger points or myofascial dysfunction can occur in the trapezius muscle, levator scapula, supraspinatus, infraspinatus, teres minor, erector spinae, iliocostalis, iliotibial band, quadriceps, tibialis anterior, gastrocnemius, and soleus.
Using a digital postural assessment app to quantify posture is a good start for identifying the basic pattern that the patient has developed. Simple range of motion assessments, both active and passive, as well as a functional squat test will quickly show asymmetrical limitations of movement. Since the human body is immensely complex, it is sometimes challenging to identify specifically which tissue is the culprit. Considering that the neuroplastic nature of the body creates posture and movement patterns based on repetition, some of the patterns and soft tissue dysfunction have been around for a long time and are the result of old injuries. Those injuries resulted in recruitment of neighboring muscle groups while the injured tissue healed, and the result was loss of fine motor control, which resulted in aberrant gait and movement patterns. Those patterns can persist after the injury is healed, and the pain has resolved, creating a variety of extremity and spinal joint stress.
The Role of the Pedal Foundation
One of the most consistent sources of postural and movement pattern dysfunction is the pedal foundation. Our feet become our interface with the earth somewhere around age one. They feed information into our cerebral cortex, where motor responses are generated and sent back into the body to keep us upright, able to ambulate, and seek food, shelter, and community. This proprioceptive feedback does a masterful job of adapting to changes in our environment and to actual physical differences or asymmetries in the feet. Custom three-arch orthotics, along with adjusting, soft tissue work, and posture-specific therapeutic exercise, have been a successful combination for creating new efficient movement patterns.
Those distortions create tension in the myofascial system, which can be a source of soft tissue pain and functional disorders.
Identifying the quality of the foundation is key to identifying if the feet are a contributing source of joint and soft tissue dysfunction. 3D laser imaging of the feet will tell you in about a minute if the feet have been feeding the brain clean, efficient proprioceptive input. If one foot pronates more than the other one, which can be measured with a navicular drop test, a cascade of biomechanical distortions begins to work their way up the kinetic chain, creating rotational changes in the ankles, knees, hips, pelvis, and spine. Those distortions create tension in the myofascial system, which can be a source of soft tissue pain and functional disorders. This sets the stage for more significant injuries, including sprains, strains, pulled muscles, tendonitis, and tendinopathy. Then Wolfe’s law of bone modeling and Davis’s law of soft tissue modeling kick in, and you have the ingredients for bone spurs and joint degeneration.
Addressing the myofascial system in practice can seem a little daunting because chiropractors are busy adjusting patients, and it’s not unusual to have a limited amount of time with them. I have found that it isn’t prohibitive from a time perspective, and the procedure isn’t needed every visit. Best of all, the results can be felt immediately.
Instrument Assisted Soft Tissue Mobilization (IASTM) Is a Popular Method for Addressing Myofascial Restrictions
Numerous devices are available, from handheld scraping tools to mechanical percussive tools with myofascial attachments, as well as functional taping systems. I personally prefer the mechanical advantage of a percussive tool purely for the time savings it gives me. The textbook Anatomy Trains is a great resource that explains the superficial myofascial system and how to address it clinically.
Older injuries from muscle strains that created scar tissue, myofascial dysfunction, and trigger points can also be addressed with low-tech mechanical devices. Compressing and lengthening the tissue with roller devices for muscle management improves the compliance of the muscle tissue and immediately creates an improvement in flexibility. Low-level laser therapy or cold laser has also been used successfully to address some of these soft tissue problems. Once the muscle and myofascia have regained their compliance, or the ability to contract and relax, joint function begins to improve, and the physiology of the joint returns to a healthier state.
The aging process is an example of entropy, a gradual decline in posture, balance, mobility, endurance, and the ability to repair and recover. When patients present with the common pain syndromes that drive them into our office, I try to connect their condition with the process of decline they may be experiencing. One of the simple messages I relay to them is that “tight muscles (and fascia) hold bones tightly.” Our ability to detect and treat these nuances improves our patients’ chances of having a successful resolution of their condition and increases their chances of aging with better posture, balance, mobility, endurance, and quality of life.
^ Dr. Brian Jensen is a graduate of Palmer Chiropractic College and owner of Cave Spring Chiropractic in Roanoke, VA He has been in practice for over 35 years. As a member of the Foot Levelers Speakers Bureau, he travels the country sharing his knowledge and insights. See continuing education seminars with Dr. Jensen and other Foot Levelers Speakers at too tie velers.com/continuing-education-seminars.
