This excellent clinical case was submitted to the News from the Clinic section of JMS by one of our former students, Carole Suzanne Jackson, and it illustrates a very important aspect of Medical Massage practice: correctly formulated treatment strategy must be used even if time has past and other modalities failed to deliver stable clinical results.
Carole also presented a great example of out of box clinical reasoning which SOMI cultivates in our students. Any recommended treatment from any educational source forms only the foundation, but only personal treatment experiences and eventually developed clinical intuition allow the therapist to deliver stable results in a relatively short time.
Dr. Ross Turchaninov
MEDICAL MASSAGE VS CHRONIC PAIN ONE YEAR POST ANKLE REPLACEMENT SURGERY
by Carole Suzanne Jackson, BS, MA, LMT, CMMP, BCTMB,
A female client in her mid-forties presented with severe pain with one-year post-op of a total ankle replacement surgery. She appeared very fit. She stays active primarily through horse riding. When she completed the prescribed physical therapy, it had been excruciating and failed to rehab as intended. She was still limping with pain a year later. Even with that much time passed, I knew Medical Massage would help, but I could only guess as to how much.
Prior to her treatment, I watched a video animation of the surgery to help me understand stresses that occurred during surgery.
Observation of the posterior scar. It formed a deep dimple during plantar flexion of the foot. Having reviewed the surgical procedure for that prosthetic, it seemed obvious that a dimple represented a scar from a puncture wound that went to the bone. Trigger Point Test was positive for the gastrocnemius TrP1 and soleus TrP1 and TrP3. Periosteal trigger points were present on palpation of the anterior fibula and tibia just proximal to the prosthesis. No pain was evident when the anterior scar was palpated, frictioned and stretched. The patient reported that the physical therapist had done extensive work on the scar.
The plantar fascia was moderately tender and hypertonic on palpation. With the greater toe passively extended the plantar fascia was under such tension that it was mostly exposed as a cord directly under the skin. The pressure in this string was so high that one could snap it back and forth like on a string. Using the tip of the index finger, I accessed the inner surface of the plantar fascia and applied very moderate pressure vertically. This simple examination triggered a painful scream from the patient.
Medical Massage every other day for 6 sessions. Treatment plan consisted of:
1. Decompression all leg compartments
2. Work on plantar fascia with the Medical Massage protocol for Plantar Fasciitis
3. Mobilization of post-op scar
4. Elimination of periostal trigger points
The treatment addressed the gastrocnemius and soleus through a layered approach targeting skin, superficial fascia, gastrocnemius so as to release superior, medial and inferior medial trigger points. Once the leg was decompressed, then I treated the posterior scar tissue according to instruction in Medical Massage textbook, Volume II, pg. 324. Due to the tightness of the calf’s skin and fascia, I modified the treatment by substituting skin lifting and skin rolling for active mobile cupping.
Next, I treated the plantar fascia. I followed protocol from the Medical Massage textbook, Volume I (2nd Edition), pg. 500-506. I also watched it demonstrated in the Science of Massage Institute’s Video Library.
Given the extreme hypertension in the plantar fascia, I also applied the technique described in News from the Clinic section of the Journal of Massage Science: Medical Massage VS Plantar Fasciitis. This clinical case presented almost identical pictures of the string-like plantar fascia identical to my patient. My treatment targeted in the inner layer of the plantar fascia. I again exposed the string-like fascia through passive toe extension. Using the tip of the index finger I penetrated as far as possible under the fascia from the medial edge of the foot along its inner arch and applied intense friction along it. At the beginning it was very painful.
In later stages of the therapy I applied Periostal Massage in the periosteal trigger points on anterior fibula and tibia. It was important to avoid frictions and compressions of the tendons located on the anterior surface of the ankle joint to avoid tendonitis. I worked medially and laterally to those tendons.
Positive changes of decreased pain and sensitivity were evident by day 3 and continued to progress until the 6th day where we achieved complete elimination of pain.
NINE MONTHS FOLLOW UP
I am happy to report remarkably stable results. The patient stated that her ankle feels more mobile and she rarely has pain. “You did a great job with me and my post prosthetic surgical issues. Pain reduction, edema reduction, and improvement to my gait. I’ve walked miles this summer in Europe, and could not have imagined that before.”
1. Even when the patient has completed physical therapy and time has lapsed since the surgery, it’s worth trying Medical Massage to resolve pain and restricted tissue including scars.
2. Though skin rolling and lifting was the suggested treatment, active mobile cupping over the scar and surrounding area made a good alternative treatment.
3. Take time to examine the affected area and tissues. Researching the trauma applied during surgery may give some insight into where to assess traumatized tissues.
Carole Suzanne Jackson, BS, MA, LMT, CMMP, BCTMB graduated from our Science of Massage Institute in August 2017. She has practiced as an independent massage therapist since 2008 in Greater Orlando, Florida. Her website is www.restoredbytouch.com.
Carole specializes in spine health—including scoliosis. She is strong on empowering her patients in self-care and prevention. Thus, their high compliance rate. She developed a women’s online support group called Muscle Health Matters: Aging Gracefully with Pain-Free Vitality https://bit.ly/2LW2hcI This helps educate her clients and provides a community service.
Carole Suzanne Jackson
P.O. Box 300383
Fern Park, FL 32730