Self Muscle Massage pt 11- Mid Back

This is part eleven in the Self Muscle Massage Series. In the introduction post to this series we introduced and demonstrated the three muscle release techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In this post we’ll be working on the mid back or thoracic region. It is home to the rib cage and as such is the most stable part of the spine. While this feature is required as a means of protecting vital organs and the spinal cord itself, it also means that the area can be difficult to work on when trying to loosen up muscles and other soft tissue structures. This area is also home to the shoulder blades or scapula. While technically part of the shoulder itself, the shoulder blade relies on both the muscles of the thoracic region and the shoulder joint to function properly. Imbalances or muscle restrictions here will affect shoulder function and can lead to more serious injuries.

Anatomy

Bony Landmarks

#1 The Thoracic Spine (aka T1-12). You may have heard of the spine being described by letters and numbers. Traditionally, the spinal column is broken down into four regions (the neck/cervical – C, thoracic/midback – T, lumbar/low back – L, and sacrum/tailbone- S) and then given a number based on it’s level. The number refers to each specific vertebrae (they are stacked up one on top of the other). The easiest way to visualize the the level is to count the little bumps down the middle of your back. These are the spinous processes ( the little circles in the middle of the picture above). There are twelve vertebrae in the thoracic spine, numbered one thru twelve. Of all the regions of the spine, the thoracic or mid back region is the easiest to visualize. For each vertebrae or level, there is a rib that connects to each side. Both ribs wrap around the outside of the body to connect in the front at the breast bone (or sternum). This forms the actual rib cage itself.

#2 Upper Border- T1/first rib. The thoracic/midback spine are the easiest to identify because each level in this region has a rib coming off it’s side. To find the first level (aka T1), place both hands around your neck (thumbs in the front and fingers wrapping around to the back). Where your fingertips meet in the back, you will feel a big bony bump. This is the first thoracic vertebrae and marks the start of the rib cage. For the sake of this post, it will also mark the upper border. If you find yourself working above this level, you’ve gone to far and are now working on the neck or cervical region.

#3 Lower Border- T12/last rib. To find the lower border you will need to find T12 where the last rib connects to it. Start with your hands on your rib cage and work your way down till you find the last one (note: not all of the lower ribs reach around to the front; the lower two in particular do not. For this reason, keep your thumbs on your back and your hands on your side to make sure you feel them). When you find the last one, follow it to the spine and find the little bump (spinous process). This is T12 (or vertebrae #12 of the thoracic spine). The key here is that when working on the muscles of the mid back you need to work all the way up the rib cage! Consider this the lower border for the area when trying to loosen up the muscles. If you find yourself working below it, you’re actually working on the low back.

Muscles

 

Like the low back, the muscles in this region are arranged in layers. To better identify where they begin and end, we’ve broken them down into these layers.

Layer One (the innermost layer closest to the bone)

#1 The Transversospinalis Group. This group is actually composed of several smaller muscles, including the rotatores, semispinalis and multifidus muscles. The key take away from identifying this group as a whole is that these are all very small muscles that connect one spinal segment to the next. They all start on the transverse processes (where the ribs attach) and differ only in how many levels they move  up the spine. The main part of the muscles sits between the spinous processes (bumps down the middle of your back) and where the ribs start (think 1-2 finger widths depending on your size).  Since these muscles are the closest to the bone, simply leaning backwards will contract the larger and more superficial muscles. To contract this group, slide your fingers just to the side of the spinous process, dig them in, and lean back. From here rotate your upper body to the opposite side (i.e. if feeling the right side, twist left while leaning back). You will feel the muscles push into your fingertips.

Layer Two

#1 The Erector Spinae Group. This group is also composed of multiple muscles and lays directly over the TS group. There are three muscles in this group. From closest to the spine to furthest away they are: spinalis, longissimus and iliocostalis. Due to the size of these muscles, they are very easy to locate. All three muscles run vertically along the spine from the bottom of the rib cage up to the top. Most of the fibers are between the spine and the shoulder blade. It is difficult to isolate each of the three muscles. Typically, these are the muscles you spasm/injure while performing lifts/carries or twisting motions.

 

 

 

Layer Three


#1 Rhomboids. The rhomboids lay just above the ES muscle group and attach the shoulder blade to the spinous processes. The easiest way to find them on yourself is to reach your hand behind to the small of your back. With your opposite hand (depending on your flexibility/mobility; if you can’t have a friend help you) you will feel the muscle push into your fingertips along the edge of the shoulder blade. If you are having difficulty looking for your shoulder blade, the easiest way is to lay your hand on top of your shoulder with your fingertips pointing towards the back. When you do so you will feel bone under your fingertips; this is the spine of your shoulder blade. From here, work your way in towards the spine till you find the inside edge. In the space between this edge and your spine are the rhomboids. The muscle itself angles up slightly so when working on this muscle, remember up + in.

Layer 4 (the most superficial)

#1 The trapezius muscles. On top of the previous three layers of muscles is the trapezius muscle. It is typically broken down into three parts- upper (which will be covered in the next post on the neck or cervical region), middle and lower. Together this muscle works to rotate and move the shoulder blade to better accommodate the shoulder joint as it moves. The middle fibers pull the shoulder blades together and the lower portion rotates the scapula up while pulling the shoulder blade down. The muscle forms a big diamond on your back with the upper fibers inserting near the base of your skull, running out to the ends of your shoulder blades and then down to T12 (the end of your rib cage).

Soft Tissue Release

What you’ll need: stick/foam roller and tennis ball

The techniques: click here for an introduction to the techniques and a video demonstration

1) Lengthening/elongation with the foam roller or stick.

2) Cross friction with your hand or tennis ball.

3) Sustained pressure or trigger point release with the tennis ball.

Key Areas

When working on the muscles of the thoracic region, try to visualize the muscles moving in two main directions.

#1 The muscles either move up and down parallel to the spine or between the shoulder blade and the spine. When using the foam roller, you will want to position it in two ways: perpendicular to the spine and parallel to the spine. This will allow you to hit all of the muscles described above.

a) When the foam roller is positioned horizontally you will be able to work on the TS and ES muscle groups.

b) When the foam roller is positioned vertically you will be able to work on the rhomboids and trapezius muscles.

#2 Always start with the foam roller as a way to loosen up the muscles and to increase blood flow to the area before moving to the deeper cross friction and trigger point techniques.

#3 Cross friction works best on the ES muscles, rhomboids and traps. Remember- let the tennis ball sink into the muscle and work PERPENDICULAR to the way the muscle fibers run. There should be minimal movement of the tennis ball (approx 1 inch) when performing this technique. Here are some pictures to help visualize the direction you will be working in:

 

 

 

 

 

#4 Here are some popular trigger points in the low back (trigger points = yellow x’s).

 

#5 Thoracic Mobilization. Due to the fact that the tiny little muscles interconnecting all of the vertebral levels are difficult to find and work on, you may find it easier to work on stretching them out by mobilizing the spine itself. For this you will need the foam roller. Technique is demonstrated in the video. The goal here is to stretch out all of the little connections that exist between each level. By doing so you will be effectively working on the smaller muscles. remember- this should never hurt. If you are working your way down the spine and get to a level that is uncomfortable, do NOT try to push through it. You can go safely to the point of discomfort, but moving past that will likely do more harm than good. This isn’t one of those no pain, no gains examples.

 

goal here is to stretch out all of the little connections that exist between each level. By doing so you will be effectively working on the smaller muscles. remember- this should never hurt. If you are working your way down the spine and get to a level that is uncomfortable, do NOT try to push through it. You can go safely to the point of discomfort, but moving past that will likely do more harm than good. This isn’t one of those no pain, no gains examples.

Video

Here is a video demonstration of the mid-back.

References

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

4) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.

Self Muscle Massage - pt 13 Posterior Shoulder

This is part thirteen in the Self Muscle Massage Series. In the introduction post to this series we introduced and demonstrated the three muscle release techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In this post we’ll be moving on from the neck and back to the shoulder. Traditionally, the shoulder is considered the least stable joint in the body. Like the hip, the shoulder joint is a ball and socket joint. However, unlike the hip which is supported by the large gluteal and hip muscles, the shoulder has only the small rotator cuff muscles, deltoid, and inter-scapular muscles. This means two things: 1) that the shoulder is a very mobile joint (it can move in six different directions) and 2) it is a very common site of injury.

Due to the volume of material, we will discuss the shoulder in two posts- one on the posterior (back) and one on the anterior (front). In this post we will start with the back of the shoulder.

Anatomy

Bony Landmarks

In your reading, you may have heard of something called the “shoulder girdle”. This is composed of three bones: the scapula, the clavicle, and the humerus. The scapula lays on the back of the rib cage (it is held in place by muscle) and connects to the clavicle/collar bone which wraps around from the top of your chest. These two bones meet on the outside of the shoulder at the acromion process (this is the bony bump on the outside of your shoulder). Just beneath the acromion is where the humerus (upper arm bone) attaches to the shoulder blade (the ball or head of the humerus connects to a socket in the scapula known as the glenohumerual joint). Part of the reason it is referred to as the shoulder girdle versus simply the shoulder joint is because there are actually two joints- 1) where the scapula and the clavicle/collar bone meet at the acromion (this is your AC joint) and 2) the glenohumeral joint where the humerus connects to the scapula.

#1 The Scapula (aka the Shoulder Blade). Think of the shoulder blade like a bony triangle that sits on the back of the rib cage and is held in place by muscle. The most prominent feature of the shoulder blade is the large bony ridge that runs across it. This is known as the spine of the scapula. If you reach over your shoulder with your fingers, this bony ridge will be easy to feel.

#2 The Acromion Process. The acromion process is technically the outermost edge of the scapula. It is an important bony landmark because where the acromion and the clavicle (collar bone) meet is your AC joint. While the AC joint is small, it is commonly injured when the clavicle is pulled away from the acromion (there are only ligaments holding the joint together and they can be torn). This is commonly referred to as a seperated shoulder and is graded in three levels of severity. A grade three is the worst and can be visually seen (the clavicle actually pops up in relation to rest of the shoulder). The easiest way to find the acromion is to start with your fingers on your collar bone and to follow it towards the outside of the shoulder. The outermost edge is the acromion.

#3 The Humerus. The humerus is the large bone of the upper arm. It travels from the elbow up to the shoulder where it connects to the scapula at the glenohumeral fossa (the humerus is the ball and the scapula is the socket). A unique feature of the humerus is the ball portion (also known as the head of the humerus). It is lined with grooves and tunnels where the rotator cuff and bicep/tricep muscle tendons travel through and attach. It is important to note that as your lift your arm, the head of the humerus rotates down to allow the longer shaft of the bone to travel without hitting the acromion process. In the event of injury or swelling, it is possible for this space to be decreased (a common injury referred to as Impingement).

Muscles

The muscles in the back of the shoulder joint originate in one of two places. They either begin on the scapula itself and move to the humerus or they begin on the humerus and attach to the scapula. There are two layers of muscles.

Layer One: the deeper layer.

#1 Supraspinatus/Infraspinatus. Both of these muscles are part of your rotator cuff (there are actually four: these two, the teres minor and the subscapularis which is not pictured). They are the easiest to visualize and locate because they sit on either side of the spine of the scapula. The supraspinatus sits above the spine and the infraspinatus sits below it. Both muscles then travel to insert onto the back of the head of the humerus. These muscle are responsible for externally rotating the arm (external rotation would be if you tried to reach behind your head).  To palpate them, reach your opposite hand over your shoulder. As you rotate your arm (reach behind your head and then behind your back), you will feel the supraspinatus above the spine and then the infraspinatus below it (you may need to change your hand position to feel the back of the shoulder under your arm pit for this).

#2 Teres Minor/Major. Like the two muscles above, the teres muscles also start on the scapula and move to the humerus. The teres minor is the smaller of the two and runs along the inner border of the shoulder blade just below the infraspinatus. The teres major on the other hand starts on just the bottom edge of the scapula and then travels over to the humerus. The biggest difference between the two is WHERE they insert on the humerus. The minor inserts onto the back part while the major inserts onto the front of the humerus. This change in insertion allows the major to internally rotate the arm (this would be if you tried to reach behind your back to tuck in your shirt) and extend/adduct the shoulder (pull the arm back and in towards the body). The teres minor on the other hand is only responsible for externally rotating the arm along with the two rotator cuff muscles above. To palpate these muscles, reach your hand under your armpit to the back of your shoulder and rotate your arm. You will feel them moving beneath your fingers.

Layer two: the more superficial muscles.

#1 The deltoid. This muscle is the large tear drop muscle that drapes over the entire shoulder. Due to it’s size it is traditionally broken up into three parts (anterior, middle and posterior). All three originate on the humerus. The posterior portion of the muscle then moves to insert along the spine of the scapula. This muscle works to lift the arm out to the side (abduct), into external rotation (reaching behind the head), and into extension (pulling the arm straight back). Palpation of this muscle is easy. Just place your hand on your other shoulder and lift the arm out to the side. The deltoid will be the large muscle beneath your hand.

#2 The Tricep. This muscle is important to mention when talking about the back of the shoulder because it has two parts (a short head which works strictly at the elbow and a long head that works to extend the shoulder and pull the arm in against the side (adduction). The long head of the tricep works its way up from the back of the elbow joint to insert onto the scapula (just below the glenohumeral fossa (socket). In the event of inflammation or injury at the back of the shoulder, it is important to remember and work on this muscle to fully release the area. To find the tricep start with your hand on the back of your upper arm and straighten your elbow. You will feel the muscle moving beneath your fingers.

#3 The Latissimus Dorsi. Like the long head of the triceps, the Lat muscle is also important to mention in this discussion because it assists with shoulder movement but also because it travels through this busy intersection. The Lat muscle originates down in the lower back/ribcage and then wraps around the ribs up to the shoulder where it sneaks through to insert on the front part of the humerus (like the teres major). This attachment allows the lat to extend, internally rotate and adduct the arm.

Soft Tissue Release

What you’ll need: stick/foam roller and tennis ball

The techniques: click here for an introduction to the techniques and a video demonstration

1) Lengthening/elongation with the foam roller or stick.

2) Cross friction with your hand or tennis ball.

3) Sustained pressure or trigger point release with the tennis ball.

Key Areas to work on

 

#1 Foam Roller.

When working on the back of the shoulder, start by loosening up the larger and more superficial muscles. Position the roller horizontally and start by working on the trapezius muscle as a whole. To better lengthen the muscle fibers, you will need to change the position of your arms as you do so. While on the lower fibers, you will want to keep your arms down by your sides. While on the middle fibers, cross your arms behind your head. And lastly, while on the upper fibers, straighten your arms up over your head. These arms positions will help move the shoulder blade. From here, position the roller vertically (in the same direction of your spine) and lay on top of it. This will allow you to work on the muscles between the two shoulder blades as you roll side to side with your arms out at your sides. Next, position the roller diagonally and work the latissimus dorsi muscle. You will be able to work the muscle all the way from the rib cage up into the back of the shoulder. These three techniques are great way to start and warm up the general area. From here you can roll onto your side and position the roller in your arm pit to better target the smaller, deeper muscles where they sneak through from the shoulder blade to the humerus (you will want your arm position up over head with palm facing up towards the ceiling). Start by rotating or rolling forward and back in this position and work your way up to actually rolling from shoulder to rib cage (this will be very tender and may take some time to work up to!).

#2 Tennis ball- cross friction.

The key with cross friction is to remember that you are working perpendicular to the muscle fibers. This means that you will be working in an up and down direction. The movement itself is very small (maybe 1-2 inches). Sink the tennis ball in deep, relax and then maintain that depth as you work. If you feel like the ball is rolling or sliding, you’re moving too much. When working on the posterior shoulder, the primary location for trigger point work will be at that intersection at the back of the shoulder. You can start by laying flat on your back and progress to laying on your shoulder. Both ways are demonstrated in the video. If you’re still unsure of the cross friction technique and how to properly do it, click here for a review.

#3 Tennis Ball- Trigger point.

When moving onto trigger point areas, stick to the intersection spots. There is a LOT of overlap in the back of the shoulder. Remember, let the tennis ball sink in nice and deep and just sit on it. If after 2-3 minutes it hasn’t released, move onto the next spot!

1) Start just below the outer part of the spine of scapula and work your way down through the infraspinatus and the teres minor/major. Think three tennis ball widths and you will have all of them covered. If you don’t feel like you can get enough pressure laying flat on your back, roll over onto your side. From here you should be able to lean in for plenty of pressure. If that still isn’t enough, try rotating your arm to find the spot.

2) The Latissimus Dorsi. Once you’ve covered the back of the shoulder, slide the ball down over your ribs. The Lats usually have some fun trigger point spots. The meatiest part of the muscle is along the ribcage just below the shoulder blade.

3) The Tricep/Deltoid intersection. The triceps can be a sneaky source of tension. Try sliding the tennis ball over to just below the delt and roll onto your side for this one.

4) Lastly, if the back of your shoulder is full of knots/tension, always check the main muscle belly’s of the infra and supraspinatus muscles.

Video

Here is a video demonstration of the muscle release techniques for the shoulder.

References

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

4) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.

Self Muscle Massage- pt 7 Adductors

This is part seven in our self muscle massage series. In the introduction to this series we introduced and demonstrated the three techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In the next part of our series, we’re going to be talking about the inside of the thigh. This area is home to your adductor muscles and includes the gracilis and the adductor trio (more specifically the adductor magnus, longus, and brevis muscles). Together these muscles work primarily to pull the leg in towards the midline of the body. Their secondary function is to rotate or roll the thigh/leg in towards the body (aka internal rotation). Lastly and most important of all, they assist in extending the hip which is key during endurance sports. Due to their multiple functions and location, this area is a common source of both acute and overuse injuries- the most popular of which is the groin strain/sprain or tear.

Potential causes of injury:

1) On a muscular level, tension is increased in the adductor muscles any time that the knee is pulled in towards the mid-line of the body. This can happen in the presence of weak outer hip muscles (gluteus medius and minimus). If the glutes are unable to hold the pelvis level, the adductors will remain in their shortened position and can develop contractures (chronic shortening of the muscle fibers). This can lead to muscle breakdown and a repetitive overuse injury or an acute “groin” injury in which the muscle is unable to respond to a rapid lengthening movement (aka a sprint, jump, or sudden side-to-side movement). The adductor muscles are also prone to injury due to their role in hip extension. If an athlete is unable to push off normally through the toes and knee, the hamstrings and adductors must work harder to assist with propulsion.

2) On a structural level (meaning bones and joints), the entire leg can be pulled in towards mid-line when there is over-pronation at the foot and ankle (aka the foot is allowed to roll in and flatten out the arch). If this occurs, the adductor muscles are kept in their shortened position. Over time, the outer hip muscles will be unable to compensate and the adductors will develop contractures.

Anatomy:

Landmarks

#1 Upper insertion point (on the pubic bone):

The first key landmark you will need to know when working on the adductors is their upper insertion point on the pubic bone. To do so, start by locating your ASIS (the front part of your hip bone). If you recall from the earlier posts on the hip, start with your lands flat on the top of your hip bones. Then follow them forward towards your stomach. Where they flatten out and end are the ASIS. From here, the rest is easy. Follow the groin line (the crease between hip and thigh) down and towards your pubic bone. As you do so, move your leg in and out from mid-line. You will feel the large common tendon as you move your leg in. On the picture above, the purple X represents the pubic bone and the common adductor insertion point.

#2 Femoral Triangle:

The second key landmark you will need to know when working on the adductor muscles is the femoral triangle. This will help you locate the Adductor Longus (AL) muscle which is the most frequently injured of this muscle group. The triangle is starts at the ASIS and sartorious insertion, runs down the groin line to the pubic bone, and follows the AL in to where it crosses paths with the sartorious muscle. To find the triangle, start at the ASIS and work your way down towards the pubic bone. At the pubic bone, locate the common tendon and follow the upper most muscle in and towards the upper part of the thigh until it meets the quad muscle. Then trace from the ASIS down and you will have your triangle. Note: the triangle is small. If you find yourself halfway down the thigh, you missed it. The outer part of the triangle (the sartorious) is unimportant when working on this muscle group. The primary goal is to locate the AL muscle and trace it all the way to the overlying quad muscles. From there you can use the AL to move up and down through the remaining adductor muscles (the brevis is located above and inside the triangle and the magnus is located below and outside of the triangle).

#3 lower insertion points @ the knee (adductor tubercle + pes anserine):

The last key land marks that you will need to know when working on the adductors are the lower insertion points. The first is the adductor tubercle. This bony landmark is located on the lower femur and lies deep to and between the quad and hamstring muscles. While specifically locating it is not necessary, it is important to note that the adductor trio all insert into the lower femur. It is also important to note that one of the adductor muscles actually crosses the knee joint which brings us to the second landmark, known as the pes anserine. Due to it’s importance in stabilizing the inner knee, we are going to focus on this landmark versus the deeper adductor tubercle. The pes anserine involves three separate muscles that cross the inner knee joint to insert on the tibia (lower leg bone). They are the sartorious (blue line), gracilis (red line) and the semitendinosus (purple line and part of the inner hamstring muscles). This is a common area for inflammation and tendonitis. It is also easy to palpate and find. See the video below for more detailed instructions on how to differentiate between the three tendons.

Muscles

#1 Gracilis.

Of all the inner thigh muscles, the gracilis is the easiest to find. Start at the common tendon insertion at the pubic bone. Unlike the other adductor muscles which work their way in towards the femur (long thigh bone), the gracilis remains on the outside and works it’s way straight down towards the knee and it’s insertion into the pes anserine. It is a very common area for soft tissue adhesions and tension due to it’s role in stabilizing the knee joint. It is also a key area to work on due to it’s overlapping with the deeper adductors and hamstrings.

#2 Adductor Longus (AL).

This muscle is the most commonly affected in sprains/strains or “groin pulls”. To find this muscle start by finding the common origin at the pubic bone. There are two major muscle paths originating from it. The gracilis muscle will move down towards the knee while the second muscle, the AL, will move in towards the quad and femur.

#3 Adductor Brevis (AB).

This is the smallest and uppermost adductor muscle. It is located just above the AL and inside the femoral triangle.

#4 Adductor Magnus (AM).

This muscle is deep to it’s surrounding muscles. To specifically find it, you will need to find the gracilis first and then the hamstrings beneath it. To differentiate between the two, start with your fingers on the gracilis and bend/straighten your knee. You will be able to feel the hamstring contracting as you do so. From there you want to sneak your fingers in between the gracilis and hamstring muscle. Deep to the bone and between them is the AM muscle.

Soft Tissue Release

What you’ll need: stick/foam roller and tennis ball

The techniques:

1) Lengthening/elongation with the foam roller or stick.

2) Cross friction with your hand or tennis ball.

3) Sustained pressure or trigger point release with the tennis ball.

Key Areas to work on:

1) Common insertion point on pubic bone-

This area, while hard to work on, is important to think about, especially in the presence of acute sprain/strain symptoms. It will be difficult to work on with the foam roller and tennis ball due to it’s location and the surrounding bones/muscles. Cross friction using your hands will be the best technique for helping to improve soft tissue mobility and decrease tenderness over the area. Start as close to the bone as you can and work your way down the thigh. This will allow you to work on the common tendon, as well as, the muscle-tendon junction. Depending on your flexibility, you can use the tennis ball to work on the back side of this insertion point using the trigger point technique. Start in a long sit position with both knees straight in front of you. Then slide forward and spread your legs out into a V-position (maintain straight knees). Find your sit bone and position the tennis ball just below and inside of it. Then lean forward to try and touch the toes of that leg. As stated earlier, it’s a tough area to get to so you may not feel much when doing this technique depending on your flexibility. If you’re having nagging troubles near the upper insertion, you can always schedule some time with your favorite sports massage therapist or bodywork specialist.

2) Hamstring/Adductor Intersection-

This intersection is important to note because it is a common source of muscle tension and overuse injury due to the muscles role in hip extension. To find this area, start halfway between the knee and upper adductor insertion point. Palpate the rope like gracilis muscle. Then bend/straighten your knee. Directly beneath it, you will feel the hamstring muscle moving (especially as you bend your knee). This is the area you are looking for. The best way to work on it is to use the foam roller first and then move onto the deeper techniques of cross friction and trigger point (sustained pressure).

3) Common insertion point on the knee (pes anserine)-

This area should be a key area to work on regardless of symptoms. The pes anserine is home to three muscles that help stabilize the inner knee joint. Together they form a common tendon that inserts into the lower leg bone (tibia). Foam roll/stick the area first to loosen up the muscles and to decrease tenderness over the area. Cross friction with your hand works best, although, you will be able to use the tennis ball. Position the ball on the back and inside of the knee where the three tendons join together to wrap around the front. From here you will be be able to perform both the cross friction and trigger point techniques. Be careful! This area is usually very sensitive. When using the foam roller/stick, be sure to try and work deeper into the inside of the knee just above the joint line. This will allow you to work on the deeper adductor muscles where they insert onto the adductor tubercle.

Video

Here is a video demonstration of the techniques.

References

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

Self Muscle Massage pt 8- Shin/Outer Ankle

This is part eight in our Self Muscle Massage Series. In the first part of the series we introduced and discussed the three release techniques that will be used below. If you would like to review them, click here. If you would like to see any other part of the series, click here.

In this installment of the series, we’ll be talking about the front and outside of the lower leg. This area includes your shin, the top of your foot and the outside of your ankle up to your knee. It is home to the anterior tibialis (AT), extensor digitorum (ED), and the peroneal muscles. It is also a very common area for overuse injuries in the form of tendonitis, muscle strains/sprains and spasms, the most popular of which is “shin splints”.

Potential Causes of Injury

In normal gait, these muscles are responsible for lowering the foot all the way to the ground. The front muscles or dorsiflexors (their primary function is to pull the toes and ankle up) slowly lower the foot to the ground from heel to toe. The outer muscles (their primary function is to evert the foot or tilt the foot out to the side away from the body) slowly lower the foot to the ground from the outside of the heel, over the arch and onto the big toe. As you move through push off, these muscles rely on elastic recoil to pull the toes and ankle up for clearance through the swing phase. This reduces a large amount of the stress on these muscles and allows them to use their full strength for shock absorption at heel strike. However, if push off is decreased in any way (over pronation, high arches, tight calves for example), these muscles must then work overtime to not only pull the toes/ankle up so that you don’t trip over them and but also to slowly lower the foot to the ground upon heel strike. Over time, the muscles will become overworked and can break down.

Anatomy:

Landmarks

There are three landmarks used to navigate the muscles in the shin area and outer part of the lower leg. Remember, there are two bones in the lower leg that run parallel to each other from the knee to the ankle. The inner most and larger bone is the tibia and the smaller, outer bone is the fibula.
#1 The fibular head- The fibula head is actually located slightly below the knee. To find it, while sitting with your knee bent, wrap your hand around the upper part of your calf so that the space between your thumb and index finger are directly behind the knee and your fingers are wrapped around towards the front of your knee. The fibular head will be the large, bony bump under your index finger.

#2 The lateral malleolus (outer ankle bone)- The lateral malleolus is the lower end of the fibula bone and makes up the outer portion of the ankle joint (the tibia makes up the other half and makes up the medial malleolus). Very easy landmark to find. As you move up the lower leg from the ankle to the knee towards the fibular head, this line will be your outer border. As you work on the muscles in this region if you find yourself behind the fibula, you’re working on the muscles in the back of your leg and need to come forward towards the shin.

#3 The Tibia- The tibia is your large lower leg bone. It joins with the femur to create the knee joint and runs down the leg to make up the inner portion of the ankle joint. Use the tibia as your inner border when working on this region. Always stay to the outside  of it when working on these muscles.

Muscles:

When working on the muscles in this area, think of them in three strips. You have one strip directly off the tibia, a strip next to it, and then an outer strip that starts on the fibular head.

#1 Anterior Tibialis (AT)- The first muscle in the lower leg and the easiest to find is the anterior tibialis or AT. It starts just below the knee on the tibia, runs down the front of the leg and then wraps across to the inside of the ankle. It is responsible for pulling the ankle up (dorsiflexion) and in (inversion). It is also the most common location for “shin splints”.

#2 Extensor Digitorum Longus (EDL)- The second muscle in the lower leg lies between the AT and the fibular head. It starts on the upper tibia, runs down the front of the leg and then splits into four tendons (one to each of your smaller toes). It is responsible for pulling your toes and ankle up (toe extension and dorsiflexion).

#3 Extensor Hallicus Longus (EHL)- This muscle lies deep to the AT and EDL muscles on the front of the lower leg. It starts on the tibia, runs down the front of the leg and then becomes a tendon to the big toe. It is responsible for extending the big toe and dorsiflexing the foot. While the larger muscle may be hidden, the lower tendon is visible and can be traced up to where it meets the other muscles.

#4 Peroneals (Longus and Brevis)-

I’m going to bunch these two muscles together since they are both responsible for the same motion and follow the same pathway; the brevis is just shorter. Both muscles are responsible for everting the foot (tilting the foot out away from the body; just the foot moves, not the entire leg). The long muscle runs from the fibular head, down the outside of the leg, behind the lateral malleolus and wraps under the foot just before heel. The short muscle starts midway down the fibula and follows the same path.

Soft Tissue Release Techniques

What you’ll need: foam roller and tennis ball

The techniques:

1) Lengthen/elongate the muscle with the foam roller.

2) Cross friction (works perpendicular to the muscle fibers) with the tennis ball.

3) Sustained pressure or trigger point release with the tennis ball.

Key Area’s to Work On:

#1 The first key area to target when working on this area of the lower leg is at or just below the fibular head. This area is also where the IT Band comes in from the outer thigh as well as where the gastroc and soleus muscles come in from the calf. Be sure to foam roll this area first as a warm up. Start on the side of the leg and then rotate forward to get just in front of it and backwards to get just behind it. This will help loosen up the intersection areas for the different muscle groups coming together. Cross friction and sustained pressure also work very well at this area.

#2 The second key area to target is the muscle bellies of these muscles. A “muscle belly” refers to the thickest part of the muscle and is a common area for tension, as well as, muscle knots/spasms. Start by warming up the area with the foam roller and look for tender sports or knots. Then get to work with the tennis ball. Start with cross friction and then sink deeper with sustained pressure/trigger point release.

#3 The third key area to target is the front of the ankle where the tendons all come together. Draw a line between the top of the two ankle bones and the bottom, and you’ll be on the right spot. If you pull your toes/ankle up you should be able to see a thick band pop up. This contains the AT, EHL, and EDL tendons. The tennis ball will work best in this area with the cross friction technique. see the video below for more specifics.

#4 The last key area (not pictured above) is in regards to any pain/tenderness you may be having along the top of your foot. When working on the tendons here it is best to use your thumb for the cross friction technique. Start light and work deeper as the tenderness allows. Remember- cross friction moves perpendicular to the direction of the tendon.

Video

Here is a video demonstrating the soft tissue release techniques for this area.

References

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

Self Muscle Massage pt 14- Anterior Shoulder

This is part fourteen in the Self Muscle Massage Series. In the introduction post to this series we introduced and demonstrated the three muscle release techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In this installment of the series we’re going to be moving from the back of the shoulder around to the front and side. Traditionally, the shoulder is considered the least stable joint in the body. Like the hip, the shoulder is a ball and socket joint. However, unlike the hip which is supported by the large muscles of the hip and thigh, the shoulder has only the small rotator cuff muscles, deltoid, and inter-scapular muscles. This means two things: 1) that the shoulder is a very mobile joint (it can move in six different directions) and 2) it is a very common site of injury.

Anatomy

Bony Landmarks

In your reading, you may have heard of something called the “shoulder girdle”. This is composed of three bones: the scapula, the clavicle, and the humerus. The scapula lays on the back of the rib cage (it is held in place by muscle) and connects to the clavicle/collar bone which wraps around from your breast bone/sternum. These two bones meet on the outside of the shoulder at the acromion (this is the bony bump on the outside of your shoulder). Just beneath the acromion is where the humerus (upper arm bone) attaches to the shoulder blade (the ball or head of the humerus connects to a socket in the scapula known as the glenohumeral fossa). Part of the reason it is referred to as the shoulder girdle versus simply the shoulder joint is because there are actually three joints- 1) where the scapula and the clavicle/collar bone meet at the acromion (this is your AC joint), 2) the glenohumeral joint where the humerus connects to the scapula, and 3) the sternoclavicular or SC Joint where the clavicle attaches to front of the rib cage at the sternum.

When working on the front of the shoulder, there are four major landmarks you should know:

#1 The sternum (commonly called the breast bone). The sternum is the innermost border when you are working on this area. This is where the ribs connect in the front of your chest before wrapping around to connect to your spine in the back. In addition to being the inner border, the sternum is also where the clavicle starts.

#2 The clavicle (aka the collar bone). The clavicle is one of the most frequently fractured ones in the body. This is because it is the only bone that directly connects the shoulder and arm to the rest of the skeleton. Large impacts to the arm secondary to falls can easily overload this small bone resulting in fractures. The clavicle is part of two separate joints, one at either end. When working on the front of the shoulder, consider this your upper border.

#3 Humerus. The humerus is the large bone of the upper arm. It travels from the elbow up to the shoulder where it connects to the scapula at the glenohumeral fossa (the humerus is the ball and the scapula is the socket). A unique feature of the humerus is the ball portion (also known as the head of the humerus). It is lined with grooves and tunnels where the rotator cuff and bicep/tricep muscle tendons travel through and attach. It is important to note that as your lift your arm, the head of the humerus rotates down to allow the longer shaft of the bone to travel without hitting the acromion process. In the event of injury or swelling, it is possible for this space to be decreased (a common injury referred to as Impingement).

#4 Scapula. Think of the shoulder blade like a bony triangle that sits on the back of the rib cage and is held in place by muscle. The most prominent feature of the shoulder blade is the large bony ridge that runs across the back of it. This is known as the spine of the scapula. If you reach over your shoulder with your fingers, this bony ridge will be easy to feel. The most prominent feature on the front is the coracoid process which is bony bump that the pec muscles attach to. To find this process, trace your fingers along your clavicle until you feel it curve back just before it gets to the outside of the shoulder. From here drop your fingers down approx 1 inch and press in. Pull your shoulder blades back together and then round your shoulder forward. You will feel a bony bump push forward. This is the coracoid.

Muscles
Deep Layer

#1 Pec Minor. This is the smaller of the two pectoral muscles. It originates on the ribs and angles up to attach to the coracoid process.

#2 Biceps (Long Head) Tendon. The bicep muscle has two tendons, one for the long head and one for the short head. The long head is unique in that it allows the bicep to move not only the elbow but also the shoulder joint. The short head can only move the elbow joint. The long tendon has its own groove in the head of the humerus and is a common site for tendonitis and inflammation. It is frequently confused with rotator cuff tendonitis, but is actually closer to the chest while the rotator cuff (supraspinatus in particular) is closer to the outside of the shoulder. To find this tendon, place your hand over the front of your shoulder. With your elbow against your side, bend and straighten your elbow. As you do so, you will be able to feel the bicep tendon move beneath your fingers.

#3 Supraspinatus (part of the rotator cuff). Like the Bicep described above, in the front of the shoulder the rotator cuff tendons sneak through from where they originate on the back of the shoulder blade. The most commonly injured tendon is the supraspinatus (see the post on the back of the shoulder for pictures and more info). As it sneaks through to the front you can find it. Start by finding the bicep tendon that move your fingers just past it towards the outside of the shoulder. With your elbow at your side, rotate your arm in/out. You will feel the supraspinatus tendon move beneath your fingers as your do so.

#4 Subscapularis (part of the rotator cuff). The subscap muscle is the only part of the rotator cuff that starts on the inside of the shoulder blade. From there it inserts onto the front of the humerus and assists in rotating the arm in (like you’re trying to reach behind your back). This muscle is deep in the arm pit.

#5 Serratus Anterior. Like the subscap muscle, the serratus originates on the inner surface of the shoulder blade and wraps around to attach to ribs 1-9 underneath the arm/armpit. These attachments allow the serratus to lift the scapula, pull it tight against the rib cage (known as protraction- this motion would occur if you were trying to punch your arm forward with the arm out straight in front of you) and rotate it upwards. To find this muscle, lift your arm up to shoulder height and reach around underneath your arm with your other hand. From here, punch that arm forward. The lower part of the muscle will be easier to feel.

Superficial Layer

#1 Pectoralis Major. This muscle is easily identified by most people. It covers the entire chest as two muscles, one on each side. It starts on the clavicle and sternum and inserts on the upper humerus. This muscle pulls the humerus in to the body, helps lift the shoulder up into flexion (over head with the arm in front of you), and protracts the shoulder blade (pulls it against the ribcage).

#2 Anterior Deltoid. This muscle is the large tear drop muscle that drapes over the entire shoulder. Due to it’s size it is traditionally broken up into three parts (anterior, middle and posterior). All three originate on the humerus. The anterior portion of the muscle then moves to insert along the clavicle. This muscle works to lift the arm out to the side (abduct), into internal rotation (reaching behind the back), and into flexion (pulling the arm straight up in front of you). Palpation of this muscle is easy. Just place your hand on your other shoulder and lift the arm out to the side. The deltoid will be the large muscle beneath your hand. You will be able to trace the front part forward to the clavicle.

Soft Tissue Release

What you’ll need: stick/foam roller and tennis ball

The techniques: click here for an introduction to the techniques and a video demonstration

1) Lengthening/elongation with the foam roller or stick.

2) Cross friction with your hand or tennis ball.

3) Sustained pressure or trigger point release with the tennis ball.

Key Areas to Work On

 

#1 Foam Roller. When working on the front of the shoulder, start by loosening up the larger and more superficial muscles. Position the roller vertically at the front of your shoulder and start by working on the pectoralis muscles as a whole. You may find that this area is very tender. If so, try using a raised surface versus actually laying on the roller itself. A bed or table works best. This way you can directly control the pressure you are using and can work your way up to laying on the roller. From here position the roller in your arm pit to better target the smaller, deeper muscles where they sneak through from the shoulder blade to the humerus (you will want your arm position up over head with palm facing up towards the ceiling). Start by rotating or rolling forward and back in this position and work your way up to actually rolling from shoulder to rib cage (this will be very tender and may take some time to work up to!). Rotating forward over the roller will target the front of the shoulder best.

#2 Tennis Ball- Cross Friction. The key with cross friction is to remember that you are working perpendicular to the muscle fibers. This means that you will be working either up/down or horizontally (front/back) depending on where you are in front of the shoulder. The movement itself is very small (maybe 1-2 inches). Sink the tennis ball in deep, relax and then maintain that depth as you work. If you feel like the ball is rolling or sliding, you’re moving too much. When working on the front of the shoulder, the primary location for trigger point work will be along the pec muscles or along the anterior deltoid. Standing will be the easiest for this area and both techniques are demonstrated in the video. If you’re still unsure of the cross friction technique and how to properly do it, click here for a review.

Key areas for cross friction will be:

1) The biceps tendon itself. Start high and work your way down.

2) The supraspinatus tendon.

3) The strip in between the two tendons.

4) The intersection spot in the middle (white line). See video for how to find the intersection.

5) The pec muscles. For these muscles you will want to work to the inside of the intersection and in an up/down direction versus the yellow forward/back pictured above.

#3 Tennis Ball- Trigger Point. When moving onto trigger point areas, remember, let the tennis ball sink in nice and deep and just sit on it. If after 2-3 minutes it hasn’t released, move onto the next spot!

Key trigger point areas include:

1) The upper pec below the clavicle

2) Just below the coracoid process

3) The intersection at the front of the shoulder (see video for a description on how to find this area)

4) The space in between the biceps and supraspinatus tendons.

Video

Here is a video demonstration for using these techniques on the front of the shoulder.

 

References

 

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

4) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.

Self Muscle Massage- pt 4 Lateral Hip

This is part four in the self muscle massage series. In the introduction post, we discussed and demonstrated the three soft tissue release techniques that will be used below. If you missed it or would like to review, click here. If you would like to catch up on the other muscle groups we’ve covered so far, you can do so here.

In the next part of our series, we’re going to be talking about the outside or lateral aspect of the hip. This area includes your ITB or Iliotibial Band, your Gluteus Medius/Minimus muscles and your TFL (tensor fascia latae) muscle. The outside of the hip is unique in that it provides stability when standing on one leg. For example, when you step onto your left foot, these structures pull down on your left hip to keep both hips level with each other. If there is injury or weakness, the right side will drop and gait will be compromised as the body then needs to compensate for leg clearance and propulsion. Due to this role in normal gait and trunk stability, the outside of the hip is prone to overuse injuries. In particular, this area is is affected by any alignment abnormalities that move the leg in or out from the vertical mid-line of the body.

Potential causes of injury:

1) On a muscular level, tension is increased on the outside of the hip any time that the knee is pulled in towards the mid-line of the body (sometimes called knock knee or genu valgum). This can happen with chronic tightness (or contracture) of the adductors and internal rotators. When this occurs, the gluteus medius and minimus muscles are held in a lengthened position and subsequently weakened.

2) On a structural level (meaning bones and joints), the knee joint can be pulled in towards the mid-line when there is over-pronation at the foot and ankle. Indirectly, the outside of the hip can also be affected by the presence of an anterior pelvic tilt (when the front of the pelvis rotates down towards the ground). This results in tight hip flexors and weak hamstrings/glutes which alters normal propulsion during gait. The result is commonly that the inner hamstrings and adductors work harder to extend the hip and over time shorten due to the repetitive stress; the knee is pulled in towards the mid-line due to the resulting muscle contracture and the lateral hip muscles overloaded.

Anatomy:

Bony structures

Like the posterior aspect of the hip, working on the outside will require you to know and find a few bony landmarks. There are four: 1) the greater trochanter, 2) the PSIS, 3) the ASIS, and 4) the head of the fibula.


#1 The Greater Trochanter- the GT is a common muscle insertion point on the outside of the hip. To find it, start with your thumb on top of your hip bone at the highest point of the iliac crest. From there, simply lay your hand down over the outside of your hip with your fingers pointed down towards the floor. The GT can be found under or close by where your middle finger is (it will be a small bump).

#2 PSIS (posterior superior iliac spine)- To find this one, you’re going to start with your hands on your hip bones (iliac crest) so that your thumb is pointing towards your back and your fingers are pointing forwards towards your stomach. As you reach behind with your thumbs, you’re looking for two small bumps on either side of your spine. Visually, you can see them. They are the two “dimples” at the small of your back.

#3 The ASIS (anterior superior iliac spine)- while the PSIS is at one end point of the iliac crest towards the back, the ASIS is the end point towards the front. To find it, start with your hands on your hips and your fingertips pointing towards your stomach. Unlike the other two bony landmarks that are small bumps, the ASIS are larger and easily palpable when you follow the iliac crest forward. Visually, when you lay on your back, they are the two hip bones sticking out towards the ceiling.

# 4 Gerdy’s Tubercle/Fibular Head- I’m including this landmark to point out that your ITB runs all the way down the outside of your leg and inserts BELOW the level of your knee cap. While sitting with your knee bent, wrap your hand around the upper part of your calf so that the space between your thumb and index finger are directly behind the knee and your fingers are wrapped around towards the front of your knee. The fibular head will be the large, bony bump under your index finger. Slide forward just in front of this towards the front of your knee and you will have the insertion point of the ITB, also known as Gerdy’s Tubercle. As long as you are working in this area between the knee cap and the fibular head, you’re on the right spot.

Soft Tissue Structures

1) GM (gluteus medius + minimus). These two muscles lay one on top of the other and are two fan shaped muscles that originate on the outside of the ilium (hip bone) and insert onto the greater trochanter. The larger medius muscle is the more superficial of the two. Together these muscles abduct the hip (move the leg out to the side and away from vertical midline). They also contribute to rotation of the hip. With the hip in flexion they rotate the knee out (external rotation) and with the hip in extension, they rotate the knee in (internal rotation).

2) TFL (tensor fascia latae). The TFL is a small muscle that originates from the ASIS and inserts into the ITB itself. To find this muscle, lay on your back with your hand on the ASIS. With your knee bent, flex your hip (bring your knee towards your chest like you were sitting in a chair) and rotate your whole leg IN (think opposite motion of crossing your ankle over your knee). As you rotate the leg, the knee will move in slightly and the outside of your ankle will come up. You will feel the TFL move under your hand.

3) ITB (iliotibial band). The ITB starts at the greater trochanter and runs all the way down the outside of the leg to tibia (just in front of the fibular head).

Soft Tissue Techniques

What you’ll need: a foam roller and a tennis/trigger point ball.

Techniques:

1) Elongation/lengthening with the foam roller

2) Cross friction with the tennis ball

3) Sustained pressure/trigger point release with the tennis ball.

Key Areas to Work On:

1) The Gluteus Medius and Minimus take up the whole “fan” on the outside of the hip. Be sure to work the whole fan to get a full release of the muscles. Cross friction and trigger point (sustained pressure) work best on the is area.

2) The TFL is slighly in front of the GM “fan” and below the ASIS. Use the foam roller to release general tension and trigger point any muscle knots or spasms.

3) The ITB is best worked with the foam roller. Use the elongation technique to warm up the area and then cross friction with the roller. Be sure to work from the greater trochanter all the way down below the knee.

Video

Here’s a video to help demonstrate the techniques specific to the lateral hip.

References

1) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

Self Muscle Massage pt 9- The Foot

This is part nine in our self muscle massage series. In the introduction to this series we introduced and demonstrated the three techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In the next part of our series, we’re going to be talking about the muscles of the foot. This area is home to four unique layers of muscles that work together to provide movement and shock absorption as they support the joints and arches of the foot during weight bearing and walking. During normal gait, the foot lands on the outside of the heel and must then absorb and transmit that force to the inside of the foot to allow for push off from the big toe. If there is any disruption in this process (due to tight muscles for example), it is very common for the small structures of the foot to break down under the load of the body. Some examples of injuries that can occur include plantar fasciitis, heel spurs, sesamoiditis, neuromas and bunions.

Potential causes of injury:

#1 Abnormal rotation of the foot. If the foot is twisted too much or too little during the weight bearing process (i.e. overpronation or underpronation/supination), the smaller structures of the foot can be injured. This can be caused by lax joints in the midfoot and arches or due to soft tissue restrictions in the long tendons of the lower leg (peroneals/post tib).

#2 Bunion/loss of 1rst MTP extension. In the event that motion becomes restricted in the this area, the foot will become unable to fully load the big toe in preparation for push off. Over time this will lead to compensation and rotation of the lower leg and ankle to allow the foot to fully flatten to the ground during full weight bearing. As the rotation occurs, the gastroc and soleus become less efficient and the smaller muscles of the lower leg must assist with forward propulsion.

#3 Ankle restrictions. These can be the result of sprain/strain injuries where the ligaments, bones, and joints have been affected or from the larger muscles of the lower leg (gastroc, soleus, achilles). If the ankle is restricted, particularly in dorsiflexion (bringing the toes/ankle up towards your nose), the larger muscles will be unable to fully help while walking. This will shift increased work to the foot and big toe to provide push off.

Anatomy

Landmarks

Basic bony landmarks for the foot are easy. You have the inner and outer ankle bone (medial and lateral malleolus) and the heel bone (the calcaneous). Instead of focusing on the million little bones, ligaments and joints in between, we’re going to focus on the structures important to the muscles and key areas we’ll be working on.#1 Peroneal Tendon. As you may remember from the last blog post on the outer ankle and shin, the long peroneal tendon runs down the outside of the lower leg, runs behind the ankle bone and to the base of your little toe (5th metatarsal). From there it wraps under the outside of the foot into the arch. To find where that tendon moves beneath the arch start at your little toe. Trace the bone backwards towards your ankle bone. As you get to the middle of the foot you should feel a small bump and the bone will drop off (become less superficial). This is the base of the 5th met. and directly behind it is where the peroneal tendon passes through. If you can find this bump, you’ll be to work on the tendon as it moves towards the arch.

#2 Post Tib Tendon. On the inside of the ankle, you will find the second long tendon that we’ll talking about- the posterior tib. This tendon runs from deep in the calf, down behind the inner ankle bone (medial malleoulus) and behind the navicular bone before it also wraps underneath the arch of the foot. To find the navicular bone start on the inside of the big toe and trace your finger backwards along the bone (NOT the soft tissue of the arch; it’s above the arch). As you get towards the midfoot area you will find a big bump (it may be visible depending on your feet). You can’t miss it. This is the navicular tuberosity and the posterior tibialis tendon passes behind it and below it to wrap around the arch. If you can find this bump, you’ll be on the right area to work on the tendon.

Muscles

The foot is actually home to four different layers of muscles. On top of those is your planar fascia (sometimes called the plantar aponeurosis).

#1 The Plantar Fascia. The PF starts on the heel bone (calcaneous) and then moves up to the ball of the foot and toes (also known as the heads of the metatarsals, one for each toe). It is a thick connective tissue that supports the arch of the foot to provide support during weight bearing.

#2 Post Tib + Peroneal Tendons. On either side of the plantar fascia, you will see the two long tendons of the post tib and long peroneal where they wrap around into the arch. The posterior tib is responsible for pulling the foot in towards midline while the peroneal tendon pulls the foot out away from the body. These are important in determining how the foot functions. If one muscle develops a contracture (chronic shortening of the muscle fibers) it will maintain the foot in a tilted position. This will disrupt how the foot accepts weight and pushes off.

#3 The deeper muscles. Directly underneath the plantar fascia you will find the smaller muscles of the foot. An easy way to visualize these muscles is to start on the heel. There are three main muscles that branch off of the calcaneus. The outermost is your Abductor Digiti Minimi (AbDM). This small muscle controls the little toe and provides support to the outside of the foot during heel strike. Directly next to this muscle is the Flexor Digitorum Brevis (FDB). This small muscle is what pulls the toes down into flexion (curls them). There are four tendons, one each to the smaller toes. Directly next to the FDB is the Abductor Hallicus (AbH). This muscle is the innermost along the arch and is responsible for pulling the big toe out away from the other toes. It wraps around from the inner heel to the outside of the base of the big toe. Once you have found these three muscles, you can move up the foot towards the big toe. In between the tendons of the FDB and the AbH lies the next muscle on our list- the Flexor Hallicus Brevis (FHB). This muscle is responsible for pulling the base of the big toe down into flexion and is unique from the others in that it is home to the two sesamoid bones (the little circles in the purple muscle). The sesamoids are like mini-knee caps for the big toe. They help generate power for propulsion. This muscle runs from deep in the foot to the base of the first metatarsal. It is important to note that this muscle does not go above the 1rst MTP. However, the tendon of the Flexor Hallicus Longus (FHL) does. This muscle is deep in the calf of the lower leg and runs down along the inner ankle before running the length of the foot to the tip of the big toe. This tendon runs between the two sesamoids and is responsible for flexing the full toe.

Soft Tissue Release

What you’ll need: small foam roller or frozen water bottle and a tennis ball.

The techniques:

1) Lengthening/elongation with the foam roller or stick.

2) Cross friction with tennis ball.

3) Sustained pressure or trigger point release with tennis ball.

Key Areas to work on:

#1 Plantar fascia/FDB + AbDM + AbH. When using the foam roller or frozen water bottle on the bottom of the foot, break the area down into three vertical sections- 1) one from the bottom of the little toe to the heel, 2) one from the bottom of the big toe to the heel, and 3) everything in between to the heel. As you use the roller, be sure to rotate foot to get all three sections. Start with the middle portion in the seated position and progress to standing to increase the pressure. Then roll your foot to the inside to the get that strip. Lastly, roll the foot to the outside to get that strip. This will allow you to get the three main muscle coming off of the heel and lengthen them all the way to where they insert at the ball of the foot under the toes.

#2 The Tendons. Once you have warmed up the foot with the foam roller you are ready to move onto the deeper techniques of cross friction and trigger point. Remember: the key is to work perpendicular to the tendons when using the cross friction technique. Sink in deep first and then start the movement. It should be very small (approx 1 inch). Key areas that you will want to hit will be along the heel bone (calcaneous). You will want to work all the way around the heel to get the three muscles that originate there. Moving up the foot you will then want to work on the peroneal tendon (#2) and the posterior tib tendon (#3). These come in horizontal so be sure to work in an up and down direction. Lastly, you will want to work just below the big toe. This will get the FHB muscle, as well as, the tendon of the FHL. If you have pain tenderness into the big toe, you can use your fingers to perform cross friction on the tendon. Once you have performed the cross friction technique, you can move onto the sustained pressure/trigger point release. The above 4 areas are common places to hit as well as directly in the middle of the foot for the plantar fascia.

Video

Here is a video demonstration of the soft tissue release techniques of the foot.

References:

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

Self Muscle Massage- Pt 1 The Calf

In the introduction to the Self Muscle Massage series, we discussed and demonstrated the three different techniques that will be used. Click here if you missed them or would like to review them.

In this part of the series, we’re going to start with the calf muscles. They play a major role in shock absorption as you step onto your foot, provide control and balance as you move over your foot/ankle from double to single leg stance, and assist in propulsion as you push off of your toes at the end of the gait cycle. With that in mind, they are a common source of problems in the lower extremities. Tight calf muscles can lead to problems both in the foot and shin, as well as, up the chain into the knee, hip, and back.

There are three primary muscles in the calf region. To make it easier to locate them, let’s break them up into two layers of muscles.

1) Superficial Muscles

There are two muscles in the top (superficial) layer- the gastroc and the soleus. The gastroc is the easiest and most visible of all the calf muscles- it’s the two bumps that pop out when you step up on your toes. The soleus muscle is underneath the gastroc and lower down the leg (think just below the two muscle bellies (bumps) of the gastroc on either side of the achilles tendon/ or mid-way between the knee and heel). Both of these muscles become the Achilles Tendon which inserts into the back of your heel. The main difference between the two muscles is in how they work. The larger gastroc muscle helps you push off of your toes when the knee is straight versus the soleus muscle which does the same thing while the knee is bent. For example- it is very common for runners to have sore and stiff soleus muscles following a hilly run when they are unable to fully extend the knee and push off going uphill and when the knees are bent and shock absorption is increased coming downhill.

2) Deep Muscles

In the second layer of muscles is your posterior tibialis. This muscle is located deep to both the soleus and gastroc. It runs down the middle of the back of your lower leg before moving towards the inside of the leg and down the tibia. It’s tendon can be felt as it wraps around the inside ankle bone (medial malleolus) and inserts into the arch of your foot. The reason that I want to involve this muscle is that it is frequently involved in plantar fasciitis/heel injuries and is a sight of tendonitis behind the ankle. The post tib helps support the arch and maintain heel position as you step onto your foot. From a muscle action perspective, the post tib plantar flexes the ankle (points the toes down) and inverts the calcaneous (points the toes in towards the midline of the body). As the larger calf muscles fatigue/stiffen, it is very common for the posterior tib to help compensate by helping with push off and toe clearance. The result is frequently the foot swinging through with the arch positioned up towards the sky instead of down towards the ground. The post tib can also be a source of “shin splints” because of this.

Soft Tissue Techniques

What you’ll need: a foam roller and a tennis/trigger point ball.

The techniques:

1) Elongation/lengthening with the foam roller.

2) Cross friction with the tennis ball

3) Sustained pressure/trigger point release with the tennis ball.

Key area’s to work on:

#1)  The lateral (outer) head of the gastroc. This is a busy area in the lower leg and always good for some “fun” knots. Both the gastroc and soleus have origins in this area near the fibular head (the skinny outer leg bone that runs parallel to the tibia).

#2) The musculo-tendinous juncture (where gastroc and soleus become the achilles tendon). Intersection points are always a prime area to work on because as muscles fatigue they can start to work against each other instead of in that smooth and fluid movement.

#3) Posterior tibialis. This muscle is often overlooked! It’s a major source of shin splints and plantar fasciitis. The key to working on this muscle is to find it. In the picture below it is the red muscle. While it’s deep to the larger gastroc/soleus muscles, it can be easily found on the inside part of your leg where it comes out near the bone, becomes a tendon and then runs down the leg, behind your ankle bone and wraps into the arch of your foot. Start by sitting cross legged (on the floor or in a chair) with the inner ankle bone up towards the sky. With your thumbs on the tibia bone in the middle of the calf between knee and ankle, slide backwards an inch or so into the muscle. Using just your ankle, try to supinate your foot (lift your arch up towards the ceiling). You will feel the muscle move under your thumbs. This is a great position to use cross friction on the post tib! Remember, sink your thumbs in deep. You want the skin and muscle to move together. It’s a very small movement (1-2 inches). Go easy! If you’ve never worked this muscle before, it can be VERY tender.


Here’s a video demonstrating the techniques for the calf:

References:

1) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

Self Muscle Massage- pt 5 Anterior Hip

This is the fifth part of the Self Muscle Massage series. In the introduction post to this series, we discussed and demonstrated the three soft tissue release techniques that will be used below. If you missed it or would like to review them, click here. If you would review the other muscle groups covered so far, click here.

In this installment of the series we’re going to be finishing up with the hip by covering the front or anterior portion. This area includes your hip flexors (psoas and iliacus), sartorious, TFL, rectus femoris (large quad muscle), and pectineus/obturator externus. The front of the hip is important in pulling the leg forward and lifting the femur to allow for clearance of the entire lower extremity (i.e. up stairs, inclines, etc). Like the other sections of the hip, the anterior aspect is also prone to injury. It is a common site of muscle contractures (chronic loss of flexibility) and musculotendinous injuries (i.e. tendonitis and “snapping hip” syndrome).

Potential Causes of Injury

1) During normal ambulation, the hip flexors are active during the swing phase (meaning they pull the leg through to start the stance phase all over). With normal push off at the big toe, knee, and hip, part of this motion is passive (meaning the hip flexor can use that momentum to lesson the load on itself). If the push off is incomplete ( as is the case with chronically tight gastrocs and hamstrings for example), the hip flexors must pick up the slack and actively pull the leg through. This can result in a tendon/muscle overuse injury or an acute injury due to a forceful contraction.

2) Due to their location, the muscles in the front of the hip are prone to contractures due to prolonged sitting. As the muscles adapt to that shortened position, they limit hip extension and subsequently push off. This can result in tendon/muscle injuries.

3) In the presence of an anterior pelvic tilt (when the front of the pelvis tips down towards the ground), the anterior muscles are kept in a shortened position and can lead to contracture over time. The hamstring muscles in the back of the thigh are then weakened by being kept in a lengthened position. As the back of the hip is unable to extend, the hamstrings are also unable to compensate, and the hip flexors are left to do all of the work.

4) Combine any of the above scenarios with a deviation from mid-line (when the the whole leg is pulled in towards mid-line) and it is not uncommon for the tight and overworked anterior muscles to get pulled out of their grooves and begin sliding/snapping over the hip bones. This is commonly referred to as snapping hip syndrome.

Anatomy:

Landmarks

In the front of the hip there are two landmarks used to navigate the muscles. One is bony and the other is soft tissue.

#1 The ASIS (anterior superior iliac spine)- while the PSIS is at one end point of the iliac crest towards the back, the ASIS is the end point towards the front. To find it, start with your hands on your hips and your fingertips pointing towards your stomach. Unlike the other two bony landmarks that are small bumps, the ASIS are larger and easily palpable when you follow the iliac crest forward. Visually, when you lay on your back, they are the two hip bones sticking out towards the ceiling.

#2 The groin line- this is a visible soft tissue landmark. When you flex  your hip (lift your knee up towards the ceiling), it is the line/crease between your thigh and pelvis.

Muscles

#1) The TFL- the TFL is a small muscle that originates from the ASIS and inserts into the ITB itself. To find this muscle, lay on your back with your hand on the ASIS. With your knee bent, flex your hip (bring your knee towards your chest like you were sitting in a chair) and rotate your whole leg IN (think opposite motion of crossing your ankle over your knee). As you rotate the leg, the knee will move in slightly and the outside of your ankle will come up. You will feel the TFL move under your hand.

#2) The Sartorious- this muscle is a s small rope like muscle that originates on the ASIS and wraps across the thigh to insert just below the inside of the knee. Like the TFL, to find this muscle, bend your knee and flex your hip (bring the knee up towards the ceiling). Rotate your whole leg OUT (like you’re trying to prop your ankle up on your other knee). You will feel the Sartorious move under your hand.

**Note: the TFL and Sartorious form a “V” at the front of the hip. Start with your hand on the ASIS and move down towards the groin line. As you rotate the leg in and out, you will be able to feel both muscles moving and sink your thumb right in between them into the “V”. The floor of the V is where the next muscle is, your rectus femoris (RF).

#3) Rectus Femoris (RF) - the RF is one of the four quadriceps muscles and is responsible for extending the knee. Because it is the only quad muscle to cross the hip joint, it also aids in hip flexion. As stated above, to find this muscle, locate the V and sink down into that groove between the sartorious and TFL. There you will find the RF as it moves towards its insertion point.

#4) Psoas/Illiacus - The Psoas and Illiacus muscles are the large hip flexor muscles. They insert into the front of the femur and then move up into the abdominal cavity. The Illiacus muscle inserts into the inside of the pelvic bone and the psoas move up to insert into the lumbar spine. Due to the deeper location, working on the upper portions of the muscles is difficult, specific due to the presence of internal organs, and should be left to professionals. There are a few ways you can work on them however. First, you can work on them at their distal insertion onto the femur. To do so you will need to work your way down the groin line.

In the picture above, the blue lines represent your two landmarks. The one at midline is your belly button and the other is your ASIS. The red lines represent your abdominal muscles. To find the distal portion of the psoas and illiacus, start on the blue lines and work your fingers in until you find the outer edge of your abs. Move just outside of them (towards the hip) and follow that down to the groin line (this is the green line in the picture).

The other area that you can access the psoas is to work on it’s upper insertion into the lumbar spine. To locate the lumbar spine, palpate your last rib and trace it around to your back. This is the level of the last thoracic (midspine) level (T12). Each subsequent bump is the lumbar spine. In the case of the psoas muscle it inserts into levels two through four.

To work on the upper levels, you then want to target just to the side of the lumbar spine. The further away from the spine you move, the less likely your are to be on the right spot.

#5 Pectineus and Obterator Externus- these muscles are furthest down the groin line towards mid-line of the body. Due to their location they work with the adductors to move the leg in to the body. As you find the psoas and iliacus muscles, move medial (towards the mid-line) and feel for a pulse. The femoral artery moves through this area. The muscles are medial (towards mid-line) to the the artery and insert right into the pubic bone. The pectineus is the more superficial and lays directly over the obterator. Note: if you ever feel any numbness/tingling while trying to locate these muscles, move closer to the pubic bone. You’re hitting the femoral nerve.

Soft Tissue Techniques

What you’ll need: foam roller and tennis/trigger point ball.

Techniques:

1) Elongation/lengthening with foam roller.

2) Cross friction with the tennis ball.

3) Sustained pressure/trigger point release with the tennis ball.

Key Area’s to Work On:

1) The trick with the front of the hip is to work the entire groin line from the ASIS to the pubic bone.

2) Due to the deeper nature of the muscles, cross friction and trigger point works best on this area. However, the foam roller can still be used to loosen things up and desensitize the area prior to using the tennis ball.

Video

Here’s a video demonstrating the different techniques for the anterior hip:

References

1) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

 

 

Self Muscle Massage- pt 6 Quads

This is part six in the self muscle massage series. In the introduction post, we discussed and demonstrated the the three techniques used below in more depth. If you missed it or would like to review the material you can do so here. If you’d like to see other installments of the series including the calf, hamstrings and hip, you can do so here.

In this installment, we’re going to be moving from the front of the hip down into the front of the thigh where the quadricep muscles are. The primary goal of these muscles is to straighten or extend the knee. This is vital in supporting the body over the knee during full weight bearing, as well as, providing force during propulsion and push off. The quads are one of the most powerful muscle groups in the body and are unique in that they use the patella (also known as the knee cap) as their source of leverage. The patella actually sits in the the common quad tendon and rests over the knee joint as the tendon inserts onto the tibia (or lower leg bone). It is then stabilized by connective tissue that wraps around the knee to minimize side to side movements so that it can track properly through it’s groove. Together these two factors make the quads and front of the knee one of the most common sights of overuse and musculo-tendinous injuries in the body (i.e. quad strain/sprain, contracture (chronic loss of flexibility), tendonitis, and patellofemoral syndrome, aka PFS).

Potential Causes of injury

1) Due to the power of this muscle group, they are capable of overcompensating during gait abnormalities. If you are unable to fully straighten the knee (with calf or hamstring tightness for example) or extend the hip to push off (due to hip flexor tightness), they must work over time to pick up the slack. This makes them very susceptible to overuse injuries as they tighten and become weak under the strain. Think of it as staying in a squat position while walking. If you are unable to fully contract the quad muscle, you are unable to shift the workload to the next muscle group in the chain, and subsequently you are unable to relax it as you do so. The result is a muscle that must work not only to weight bear and push off, but also to pull the leg forward and start the process over.

2) The patella and it’s position over the lower femur (thigh bone) and tibia (lower leg bone) are a common source of pain in the front of the knee, as well as, injury further up into the quad muscles themselves. Part of the reason for this is the dynamic way that the cap is held in place. Unlike other bones in the body that are directly connected to one another, this bone is floating and held in place solely by soft tissue. If any imbalances are present, the cap can be pulled in one direction and become stuck there. This can lead to muscle injury from the resulting muscle imbalance, as well as, inflammation and tendonitis as the bone now rubs on the structures underneath.

Anatomy

Landmarks

There are two important bony landmarks to locate when working on the quadricep muscles. They serve as the two main insertion points.

#1 Tibial Tubercle- this small bony bump on the front of lower leg bone is located just below the patella. It is important because it is where the large tendon of the quads inserts. The patellar tendon refers to the tendon between the bottom of the knee cap and this insertion point.

#2 The ASIS (anterior superior iliac spine). The ASIS is the front part of your hip bone. To find it, start with your hands on your hips and your fingertips pointing towards your stomach. Unlike the other two bony landmarks that are small bumps, the ASIS are larger and easily palpable when you follow the iliac crest forward. Visually, when you lay on your back, they are the two hip bones sticking out towards the ceiling.

The reason for including the ASIS as a landmark is that it is needed to palpate the upper portion of the large quad muscle, the Rectus Femoris. In the last post on the front of the hip, you’ll remember that as we moved down from this spot towards the groin line, there were two muscles that split away towards either side of the thigh to form a “V” at the front of the hip. These two muscles are the TFL (the green line in the picture) and the Sartorious (the purple line in the picture). The Rectus Femoris makes up the floor of the “V” and can be found between these two muscles as it moves towards it’s insertion point (the red upward arrow) further up in the hip.

**Note: To find the “V”, start with your hand on the ASIS and move down towards the groin line. As you rotate the leg in and out, you will be able to feel both muscles moving and sink your thumb right in between them into the “V”. This is where you will find the rectus femoris (RF).

The Muscles

1) Rectus Femoris (RF) - the RF is largest of the four quadriceps muscles and is responsible for extending the knee. Because it is the only quad muscle to cross the hip joint, it also aids in hip flexion. As stated above, to find this muscle, locate the “V” and sink down into that groove between the sartorious and TFL. There you will find the RF as it moves towards its insertion point. If you contract your quad muscles (extend your knee) you will be able to trace it down the middle of the thigh. As you get closer to the patella, there will be a drop off as the muscle becomes tendon.

2)Vastus Intermedius (Middle Quad; VI in the picture)- the VI lays directly underneath to the more superficial RF muscle and is not palpable. However, it is important to note that these two muscles work in opposite directions when they contract. For example, during running, the larger RF works to flex the hip (pulling upward) while the VI works to extend the knee (pulling down towards the patella). Due to this, it is a common sight of soft tissue restrictions as irritation forms between the two muscle layers and they become stuck.

3) Vastus Lateralis (VL)- this is the outermost of the four quad muscles. If you extend your knee, you will be able to see this muscle. As you look down towards your knee, it begins just above the outside of the patella and works it’s way up the thigh. This muscle can be a common sight of soft tissue adhesions and muscle knots in the presence of patellar tracking or lower leg alignment abnormalities.

4) Vastus Medialis Oblique (Inner quad, VMO)- this is the innermost of the quad muscles. It’s function is crucial to maintaining normal patellar tracking. If the muscle becomes weak and stretching out due to imbalances between the VMO and the larger, stronger outer quad muscles, the patella can begin to track abnormally. To find this muscle straighten your knee and roll your whole leg out. Just above the knee cap on the inside you will feel and possibly see the VMO pop out.

(Note: The VL and VMO work together to hold the knee cap in place. In a normal leg the knee cap moves up and down over the front of the knee joint and the VL and VMO fire equally to prevent an side to side movements.)

Self Muscle Massage

What you’ll need: a foam roller and tennis/trigger point ball.

The Techniques:

1) elongation/lengthening with the foam roller

2) cross friction with the tennis ball

3) sustained pressure (trigger point release) with the tennis ball

Key Area’s to work on:

When working on the quads, break it down into three vertical segments.

1) The first segment is as wide as your knee cap and moves straight up the middle of the thigh. This will help you isolate the RF and VI and is pictured in between the red lines in the picture. Keep the leg straight and foot pointed down to the floor when working on this strip. Start with the foam roller and work the whole strip. Then fine tune any problem areas with cross friction and sustained pressure.

2) The second segment is on the outer part of the quad and isolates the VL (between the green and outer red line in the picture above). Rotate your leg in so that your foot is pointing towards your other leg when working on this strip (key: use the hip muscles to rotate the leg, not the quads; you want to keep them relaxed!). Start with the foam roller and work the whole strip. Then fine tune any problem areas with cross friction and sustained pressure.

3) The third segment is on the inner part of the quad and isolates the VMO (between the blue and inner red line). Rotate your leg out so that your foot is pointing away from your other leg when working on this strip. Remember- use the hip and keep the quad relaxed. Start with the foam roller and work the whole strip. Then fine tune any problem areas with cross friction and sustained pressure.

4) The last key area you want to focus on is the upper insertion of the RF (the purple circle up top). Cross friction and sustained pressure work best at this spot.

Video

Below is a video demonstration of the techniques.

References

1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.