Case of the Month

In every issue of our journal you will find Case of the Month which we will select among submitted ones. Everyone who is using Medical Massage protocols in their practice may submit their cases for the review and we will share with our readers the best one in every new issue. In the beginning of the 2010 our readers will vote for the Best Case of the Year and we will give prize to the winner!

If you would like to share with our readers your account of professional success and participate in Case of the Month program click here.

CASE TO SAVE THE RUNNER

We chose this case, submitted by Mr. B. Hemphill LMT, because it reflects three major advantages of a correctly formulated medical massage protocol: simplicity, high effectiveness, and ability to produce quick and stable clinical results. Also, we would like to emphasize that Mr. B. Hemphill's client already exhausted all conservative options of the traditional medicine before he started the medical massage treatment.

The client was 53-year-old male. Runner, who was training for the PF Chang Marathon for 6 months before he got injured.

Initial complaints

Client had pain in left Achilles' tendon and in the muscles of the left lower leg, left hamstring and left gluteal area. The client feels mild to moderate pain on the posterior surface of the calcaneus while walking, pain which greatly increases in intensity while running. Also, the pain was of greater intensity in the morning; for the first 10-15 minutes after waking, the client was unable to put any pressure on his left foot.

Clinical History

The client was training for the PF Chang Marathon for 6 months before he got injured. He had the above described clinical symptoms for over 4 weeks prior to the initial visit. Initially, he visited his doctor who prescribed anti-inflammatory and pain medication, and was told to stay off running. The client also tried physical therapy, without success.

Clinical Symptoms

Examination of the client during the initial visit revealed signs of inflammation in left Achilles' tendon:
1. The tendon was swollen and was thicker compared to the right side;
2. The skin over the left Achilles' tendon was reddish and exhibited signs of local edema;
3. The soft tissue in the area of the left Achilles' tendon felt hotter compared to right Achilles' tendon;
4. Application of even mild pressure on the Achilles tendon induced pain and triggered the withdrawal sign;
5. Active dorsal flexion was 10 degrees before the onset of pain;
6. Passive stretching of the Achilles' tendon and the posterior lower leg muscles, using dorsal flexion of the foot, was very painful.

The client exhibited active trigger points in the gastrocnemius, soleus, biceps femoris, gluteus maximus and piriformis muscles. These active trigger points are considered the secondary body reaction to prolonged constant limping.

Medical Massage Protocol

I used Medical Massage Protocol for the tendinitis of Achilles' tendon published in Medical Massage textbook, Volume I, 2nd Edition.

First session

First visit was an hour-and-a-half long. It included initial evaluation of the client, as well as treatment itself.

The medical massage protocol employed included the following modalities:
1. Work on the Achilles' tendon with the foot in plantar flexion. Lymph-drainage massage and gentle effleurage strokes along, and later across, the tendon were used;
2. Very gentle local stretching of the Achilles' tendon;
3. Work on gastrocnemius, soleus, hamstring and gluteus maximus muscles using effleurage along the pathway of drainage, friction along and across fibers, kneading in the inhibitory regime, and passive stretching.

Second session

Session was conducted 3 days later, and lasted 45 minutes. The same protocol as in the first session was used, with the addition of trigger point therapy in the areas of active trigger points in the muscles of the lower leg, the posterior thigh and the gluteal area.

Third session

This session was conducted a week later, and lasted 45 minutes. An evaluation at the beginning of the session revealed that the client now had a larger ROM in the left ankle joint, especially in the direction of dorsal flexion (up to 15 degrees), and he reported no longer limping during regular walking.

The session was conducted after the application of ice and passive stretching of the Achilles' tendon. The same protocol was used as previously, but this time friction was conducted more intensively, especially the cross-fiber friction, and the passive stretching was more productive because client did not have intense pain.

Fourth session

The session was conducted 3 days later, and lasted 30 minutes. It concentrated on the lower leg, the left posterior thigh and the left gluteal area, so as to give the Achilles' tendon time to recover. Therapeutic massage in combination with trigger point therapy and post-isometric muscle relaxation were used.

Fifth session

There remained residual symptoms of inflammation in the Achilles' tendon. This session was conducted 3 days after the previous one and the protocol employed was similar to that of the third session; the only difference was more intensive work on the Achilles' tendon and application of PIR to the gastrocnemius and soleus muscles.

Sixth session

There was no pain and the left ankle joint had full ROM. This session was conducted 6 days later, on day of the event. I went to the site of the event, and before the start of the marathon stretched the client. His time was the best he had had in 10 years.

Currently the patient does not have any symptoms of inflammation in the Achilles' tendon and is training for the next marathon. I work on this client monthly to maintain him generally, and his left Achilles' tendon in particular, in good shape.

Brad Hemphill, LMT

Graduated from Utah College of Massage Therapy in 1999. Has worked with the Junior National Speed Skating Team in Utah. Moved to Arizona in 2000 and worked at Arizona Biltmore and Westin Kierland Spas. Currently works with a chiropractor and has a mobile massage business. He specializes in medical massage and sports therapy.
Mr. B.Hemphill can be contacted through this website.

table of contents
	Case of the Month In every issue of our journal you will find Case of the Month which we will select among submitted ones. Everyone who is using Medical Massage protocols in their practice may submit their cases for the review and we will share with our readers the best one in every new issue. In the beginning of the 2010 our readers will vote for the Best Case of the Year and we will give prize to the winner! If you would like to share with our readers your account of professional success and participate in Case of the Month program click here. CASE TO SAVE THE RUNNER We chose this case, submitted by Mr. B. Hemphill LMT, because it reflects three major advantages of a correctly formulated medical massage protocol: simplicity, high effectiveness, and ability to produce quick and stable clinical results. Also, we would like to emphasize that Mr. B. Hemphill's client already exhausted all conservative options of the traditional medicine before he started the medical massage treatment. The client was 53-year-old male. Runner, who was training for the PF Chang Marathon for 6 months before he got injured. Initial complaints Client had pain in left Achilles' tendon and in the muscles of the left lower leg, left hamstring and left gluteal area. The client feels mild to moderate pain on the posterior surface of the calcaneus while walking, pain which greatly increases in intensity while running. Also, the pain was of greater intensity in the morning; for the first 10-15 minutes after waking, the client was unable to put any pressure on his left foot. Clinical History The client was training for the PF Chang Marathon for 6 months before he got injured. He had the above described clinical symptoms for over 4 weeks prior to the initial visit. Initially, he visited his doctor who prescribed anti-inflammatory and pain medication, and was told to stay off running. The client also tried physical therapy, without success. Clinical Symptoms Examination of the client during the initial visit revealed signs of inflammation in left Achilles' tendon: 1. The tendon was swollen and was thicker compared to the right side; 2. The skin over the left Achilles' tendon was reddish and exhibited signs of local edema; 3. The soft tissue in the area of the left Achilles' tendon felt hotter compared to right Achilles' tendon; 4. Application of even mild pressure on the Achilles tendon induced pain and triggered the withdrawal sign; 5. Active dorsal flexion was 10 degrees before the onset of pain; 6. Passive stretching of the Achilles' tendon and the posterior lower leg muscles, using dorsal flexion of the foot, was very painful. The client exhibited active trigger points in the gastrocnemius, soleus, biceps femoris, gluteus maximus and piriformis muscles. These active trigger points are considered the secondary body reaction to prolonged constant limping. Medical Massage Protocol I used Medical Massage Protocol for the tendinitis of Achilles' tendon published in Medical Massage textbook, Volume I, 2nd Edition. First session First visit was an hour-and-a-half long. It included initial evaluation of the client, as well as treatment itself. The medical massage protocol employed included the following modalities: 1. Work on the Achilles' tendon with the foot in plantar flexion. Lymph-drainage massage and gentle effleurage strokes along, and later across, the tendon were used; 2. Very gentle local stretching of the Achilles' tendon; 3. Work on gastrocnemius, soleus, hamstring and gluteus maximus muscles using effleurage along the pathway of drainage, friction along and across fibers, kneading in the inhibitory regime, and passive stretching. Second session Session was conducted 3 days later, and lasted 45 minutes. The same protocol as in the first session was used, with the addition of trigger point therapy in the areas of active trigger points in the muscles of the lower leg, the posterior thigh and the gluteal area. Third session This session was conducted a week later, and lasted 45 minutes. An evaluation at the beginning of the session revealed that the client now had a larger ROM in the left ankle joint, especially in the direction of dorsal flexion (up to 15 degrees), and he reported no longer limping during regular walking. The session was conducted after the application of ice and passive stretching of the Achilles' tendon. The same protocol was used as previously, but this time friction was conducted more intensively, especially the cross-fiber friction, and the passive stretching was more productive because client did not have intense pain. Fourth session The session was conducted 3 days later, and lasted 30 minutes. It concentrated on the lower leg, the left posterior thigh and the left gluteal area, so as to give the Achilles' tendon time to recover. Therapeutic massage in combination with trigger point therapy and post-isometric muscle relaxation were used. Fifth session There remained residual symptoms of inflammation in the Achilles' tendon. This session was conducted 3 days after the previous one and the protocol employed was similar to that of the third session; the only difference was more intensive work on the Achilles' tendon and application of PIR to the gastrocnemius and soleus muscles. Sixth session There was no pain and the left ankle joint had full ROM. This session was conducted 6 days later, on day of the event. I went to the site of the event, and before the start of the marathon stretched the client. His time was the best he had had in 10 years. Currently the patient does not have any symptoms of inflammation in the Achilles' tendon and is training for the next marathon. I work on this client monthly to maintain him generally, and his left Achilles' tendon in particular, in good shape. Brad Hemphill, LMT Graduated from Utah College of Massage Therapy in 1999. Has worked with the Junior National Speed Skating Team in Utah. Moved to Arizona in 2000 and worked at Arizona Biltmore and Westin Kierland Spas. Currently works with a chiropractor and has a mobile massage business. He specializes in medical massage and sports therapy. Mr. B.Hemphill can be contacted through this website.