In this interview, Jackie discusses the basis for instrument assisted soft tissue mobilization (IASTM), how Graston is unique and effective as a soft tissue modality, the most recent research, as well as describing some very effective techniques at the hip and shoulder. I've also re-posted her article: "Graston Technique Enables Runner With 4 Year History of Hamstring Tendonopathy and Plantar Fasciosis to Train for the 2008 Boston Marathon"
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The following case study is presented to illustrate several important aspects of the Graston Technique (GT):
A comprehensive treatment regimen that includes appropriate soft tissue mobilization utilizing GT, neuromuscular re-education and therapeutic exercise and as in this case an appropriate custom orthotic is necessary to completely alleviate musculoskeletal dysfunction that affects the entire kinetic chain.
Patient Profile: KN is a 35 year old physical therapist who had been unable to consistently return to running since symptoms of hamstring tendonopathy and plantar fasciosis started in the spring of 2003 into 2004 precipitated by her participation in boot camp type exercise classes and interval hill workouts. KN battled bilateral plantar fasciosis which was confirmed to be due to Tarsal Tunnel Syndrome for the next few years but right buttock and hamstring symptoms became disabling from 2006 to 2007. From 2003 to 2007, KN received a total of 4 cortisone injections to her tibial nerve and plantar fascia and 2 injections into her right buttock, all with minimal relief. She also received osteopathic pelvic manipulations and traditional massage therapy with minimal improvements. She attempted to rehabilitate herself via hamstring and gluteal strengthening exercises. When I evaluated KN in the spring of 2007, she was very frustrated and quite fearful that she would never be able to run distance of any length nor be pain free. Her dream of one day running the Boston Marathon in her words seemed "impossible".
Summary of Evaluative Findings: KN presented as a poor shock attenuator due to diminished lower kinetic chain fascial mobility and abnormal foot mechanics. Her severe lack of hip extension ROM effectively eliminated her ability to recruit her gluteal muscles. She opted instead for overuse of the hamstrings as hip extensors which I felt was the etiology of her right buttock and hamstring tendonopathy. (This is a very common pattern that I see in runners and it has been identified by Sahrmann as a cause of persistent buttock and hamstring pain in this population). KN also presented with a "torque foot" which consists of a hypomoble rearfoot varus and in her case a larger forefoot valgus. This foot type as identified by Roberta Nole PT predisposes an individual to plantar fascitis, iliotibial band syndrome, and sacroiliac stress. Individuals with this foot type are typically poor shock attenuators. KN lacked dorsiflexion ROM due to facial restrictions and an equinus calcaneus which further compounded her biomechanics making her a forefoot striker. Examination with the GT 1 and 5 instruments revealed significant fibrosis along her entire right posterior kinetic chain especially proximal hamstrings, lateral thigh, knee and shin and plantar fascia. Muscle strength and recruitment patterns of the lower kinetic chain were inconclusive at the initial evaluation due to fascial restrictions and poor flexibility. I chose to retest strength and motor recruitment patterns later during subsequent treatments as her mobility and ROM improved.
One additional point to ponder considering the etiology of KN's progressive symptoms from its onset in 2003 at her heel to the development of proximal hamstring and buttock symptoms in 2007 concerns the concept of the "Crush/Double Crush" phenomenon documented by David Butler. KN's original pain started in her plantar heel and was later diagnosed via neurodiagnostic testing as "Tarsal Tunnel Syndrome". Could the persistent decrease in nerve conduction and potential for decreased neural and fascial mobility have eventually facilitated the development of proximal symptomatology especially given the fact that her distal symptoms were essentially unresponsive to treatment for such a prolonged period of time? The possibility of distal neuromuscular symptoms developing into proximal dysfunction and vice versa should be considered in all cases. At the time that GT was implemented in 2007, KN's proximal symptoms were far more debilitating that her plantar heel issues. However, treatment of her entire kinetic chain was implemented to take into account the concept of distal neural and fascial restrictions causing similar issues proximally.
Summary of Interventions: KN's total treatment regimen included 10 weekly GT sessions to her entire right lower extremity kinetic chain from spring to mid summer of 2007. Initially, KN's plantar heel and ankle revealed significant fascial restrictions and fibrosis despite the fact that her pain was much more intense in her buttock and hamstring regions. GT with movement was added to her sessions beginning with treatment number 5 in open kinetic chain (Figure 1 and 2).
Figure 1: GT to plantarflexors OKC with movement (plantar and dorsiflexion)
Figure 2: GT to hamstrings OKC with movement (knee extension and flexion)
GT with movement in closed kinetic chain was added for her last 3-4 visits (see Figures 3 and 4).
Figure 3: GT to hamstring/ITB interface during active squat
Figure 4: GT to plantar fascia during active heel raise
KN supplemented her fascial work via GT with daily use of a foam roller; 1-2 minutes per muscle group (see Figure 5).
Figure 5: Self myofascial massage via foam roller to hamstring
KN also wore a nightsplint during sleep. An appropriate semirigid custom orthotic with forefoot and rearfoot posting was prescribed in May. Once hip extension ROM and fascial mobility improved, appropriate gluteal neuromuscular re-education exercises were integrated into her routine (June/July) and progressed from open to closed kinematic chain only as KN was effectively able to recruit target muscle groups (see Figures 6 and 7).
Figure 6: Gluteal activation OKC (patient stabilizes pelvis against pillow)
Figure 7: Gluteal activation CKC
KN resumed a very closely monitored run/walk routine in the summer of 2007 and was able to increase her weekly distance by 10% per week. She continued to receive weekly GT treatments while returning to running. By the end of the summer, KN was running 10-15 miles per week, performing an appropriate exercise routine (combination of strength and flexibility) and was pain free. GT was discontinued as fibrosis was minimal in her right lower extremity by late summer. We scheduled monthly re-evaluations which were held by phone as physical intervention was unnecessary at that point.
Outcome: KN began training for the 2008 Boston Marathon in December of 2007 following a 16 week running program. I reassessed her in January of 2008 and found minimal fibrosis along her entire right posterior kinetic chain. She had maintained her fascial mobility self exercises and was able to demonstrate appropriate gluteal recruitment patterns in open and closed kinetic chain. KN completed long runs of 20 miles on February 29 and March 28. She received her official marathon number as of the writing of this case report and is tapering towards race day on April 21! In her own words
"…honestly, I would not be where I am right now without Graston…"
Summary: This case report highlights the effectiveness of Graston Technique for the alleviation of symptoms associated with chronic fibrosis even after traditional interventions fail. When treating extremity dysfunction, the neural and fascial restrictions in the entire kinetic chain should be considered as potentially contributory. Furthermore, the introduction of GT with movement with progression from open to closed kinetic chain positions greatly enhances its clinical effectiveness and efficiency. Lastly, as effective as GT alone can be, this case illustrates the need for comprehensive evaluation and treatment planning to include all pertinent interventions if full resolution of symptoms is to be achieved.
REFERENCES:
1. Butler, D. The Sensitive Nervous System, 1st édition. Australia: Noigroup Publications, (2000).
2. Course Notes (2007), Graston Technique Module 1.
3. Course Notes (2007), Graston Technique Module 2.
4. Nole, R. Course Notes from 24 Foot Types, Stride Orthotics, Middlbury, CT.
5. Sahrmann, S. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, Missouri: Mosby, Inc. (2002)
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