Nancy McNamara, CMMP, LMT is one of newest graduates form our Medical Massage Certification Program. For more than 2 years we’ve worked with Nancy and we gradually built her professional expertise and clinical thinking. The results are exceptional and therapists may observe them firsthand while reading Nancy’s submission to JMS’s Case of the Month Contest.
Please pay attention to the depth of Nancy’s evaluation skills and how carefully but with clinical precision she was able to peel off layers of soft tissue dysfunctions and years of pain and suffering. Seeing such profound impact our former students are able to make in patients’ lives makes us proud of the effectiveness of SOMI’s program.
Dr. Ross Turchaninov, Editor in Chief
MEDICAL MASSAGE VS 30 YEARS OF PAIN AND MISERY
by Nancy McNamara, CMMP, LMT
A gentleman in his mid-60s (Mr. J) came to my office on 7/01//19 with Right Side Lower Back Pain (Lumbalgia). Periodically he also experienced pain radiation to the dorsal surface of both feet along the 3rd and 4th phalanges and bi-lateral pain and numbness in his feet. All his life he worked in a sitting position as a CPA.
His pain and numbness in his feet, which is mostly centered around both greater toes, has a 30 year-old history after he had a Laminectomy to relieve pressure of bulging discs L4 and L5 while he was in his 30s. Later on, the patient had two more surgeries to remove debris from the original back surgery and a third surgery to clean up scar tissue.
His recent symptoms were diagnosed by a neurologist as not being associated with impingement of the spinal nerve on the level of the spine, but rather from peripheral nerve compression by muscles. The patient was prescribed Zoloft as a muscle relaxant. He complained that medication did nothing to resolve his pain and cramping but made him “feel sick and psychotic.”
Originally his symptoms began in the right leg and foot and after 10 years of on and off “moved to the left.” He clearly remembers that symptoms on the right foot manifest themselves approximately three years after his laminectomy for L4 and L5.
Over the years the patient was treated by number of physicians and physical therapists but didn’t get any stable clinical results. For the last 8 months the patient had been confined to his recliner and could not even walk around a grocery store without severe cramping in both legs, pain and sensory deficit in his feet.
His current complaints are: pain on the dorsal surface of his feet more prominent on the right; bi-lateral lower back pain especially prominent on the right; right gluteal pain (the patient said ‘right here in a circle” as he pointed to the area over the right posterior superior iliac spine and gluteal area).
Evaluation of the Soft Tissues in Lumbar Area
First of all, I wanted to rule out acute compression of the spinal nerves in the last lumbar segments. A Vertical Compression Test on spinous processes of L4 and L5 didn’t trigger any new sensory abnormalities (pain, burning, tingling, numbness) down to the leg and foot.
My next step was to examine fascial tension in his lower back. Both parts of Kibler’s Technique pointed to severe tension accumulation in the first level of Connective Tissue Zones (dermis of the skin) and the second level of connective tissue zones (superficial fascia which cover lumbar erectors) on the level L4-L5. I was unable to even barely pinch fold skin in these areas.
Examination of the third level of connective tissue zone (i.e., deep fascia) using Lateral Shift Technique indicated the presence of great tension in the deep fascia which separates lumbar erectors from the quadratus lumborum muscle. In other words, the patient developed heavy scarification of deep fascia with severe adhesions formed between two muscle layers which replaced the normal network of fibrotic bridges with high elasticity.
The Sensory Test to examine the presence of cutaneous reflex zones didn’t show significant differences between right and left sides, but this finding was uninformative since the patient had already exhibited profound sensory abnormalities and simply couldn’t differentiate intensity of his sensation during the test application.
What was obvious is the Dermographism Test. It pointed to severe parasympathetic tone predominance in the lumbar area which was an additional indicator of long presence of chronic pain which actively disturbed balance within autonomic the nervous system.
c. Skeletal muscles
Next, I detected the presence of active trigger points and great tension in lumbar erectors and quadratus lumborum muscles.
Examination of the periosteum indicated very active periostal trigger points along the right iliac crest, especially at the insertion of erectors and QL muscles.
However, these local findings in the patient’s lower back can be also the results of spinal surgery done more than 30 years ago.
Examination of the Soft Tissues in Lower Extremities
Examination of the gluteal area indicated the presence of active trigger points in gluteal muscles. An especially active trigger point was detected in the right piriformis muscle.
Also the patient exhibited so significant tension is hamstrings and posterior leg muscles that Compression Test as well as Tinnel’s Test for both soleus canal (for tibial nerve) and tarsal canal (for common peroneal nerve) were very positive.
Thus, it was almost impossible to determine if either the Tibial nerve or Peroneal nerve are compromised or both. So according to Peroneal Nerve Neuralgia and Tibial Nerve Neuralgia protocols recommended by Science Of Massage Institute I need to start with the Piriformis Protocol as I previously ruled out acute disc compression of L4 and L5 spinal nerves.
MEDICAL MASSAGE THERAPY
For the first 5 sessions I used Piriformis Syndrome Protocol suggested by SOMI. However, I started with addressing the lumbar area concentrating on paravertebrals and QL giving more attention to the right side. During these sessions I also worked on hamstrings, adductors and posterior leg muscles following pathways of sciatic as well tibial and common peroneal nerves. I finished each session with PIR for the QL and piriformis muscles. I used twice a week sessions.
Even after the 2nd session the patient began to feel less pain and discomfort in his lumbar erectors, QL and gluteal muscles. As soon as tension in the QL muscle started to diminish I noticed lesser tension in his entire gluteal muscles, especially piriformis. It gave me additional confidence that the initial cause of his symptoms was in the lumbar area and it was responsible for reflex zones formation down to the leg. As a result of 30 years history of chronic pain the initial reflex reactions on his lower extremity developed in independent clinical problems which masked the initial trigger.
By the 3rd session much of tension in the muscles of his lower legs was dissipated and I was now able to clearly determine that it was the Common Peroneal nerve part of the Sciatic nerve being compressed by peroneal muscles and tibialis anterior bilaterally. The tension in the soleus canal and consequent tibial nerve irritation was just reflex reaction to the years of chronic pain and tension.
I based my assumption on the fact that Tinnel’s Test was still very positive under the fibular head (for common peroneal nerve) while it was now negative over the soleus canal (for tibial nerve). Also, application of electric vibration below the fibular head sent a clear shock wave all way into the toes of the right foot. Finally, there were very painful periosteal reflex zones formed along the pathway of common peroneal nerve from lateral calcaneus, talofibular ligament and all way along the 5th metatarsal bilaterally, but more prominent on the right.
Another encouraging factor was that during the 3rd session the patient complained of circular pain” in right QL and gluteal muscles becoming “much duller.” I encouraged him to continue homecare stretches for piriformis and right QL.
During following sessions, I began to focus on bilateral application of Peroneal Nerve Neuralgia protocol while continuing to treat tibialis anterior and posterior leg muscles. Tibialis proved to be very tight and almost heavily fibrotic. I included therapy of cutaneous reflex zones with skin friction, pinching, skin rolling along the lateral leg all way down dorsal aspect and toes on both feet.
Mr. “J” has been faithfully seeing me for treatments 2x a week, 3-5 days apart since 7-01-19. He does all his suggested homework exercises with enthusiasm. The following is a list of his many “little victories” he has experienced:
1. By his 6th session Mr. J reports ROM and mobility of ankles “feels more loose” and felt more improvement in walking after 4th treatment.
2. By the 7th session he reported a 50 % decrease of tingling in the feet and toes after I started to engage his periosteal reflex zones with Cyriax’s friction over lateral calcaneus, lateral ankle, talofibular ligament to 5th metatarsal bones in both feet.
3. By the 8th session Mr. “J” reported his feet get sore but rubbing them brought relief from painful burning. He also notices numbness in both toes starting to resolve.
4. By the 9th session lesser discomfort and numbness moved from the 4th toe to middle toes bilaterally. Walking feels less like “walking on pebbles.”
5. By the 10th session Mr. “J” was able to walk better and “even my wife noticed improvement in my gait and walk”. He also noticed that “feet feel more like flesh.” I observed that once tough fibrotic firmness along peroneal group and tibialis anterior became more pliable. He also reported that during PIR therapy the passive stretching of peroneals and Tibialis Anterior his muscles “has more bounce to it.”
We started to see each other once on a weekly basis:
1. August 13th: Mr. “J” was able to cross an entire store without employing a slow, cautious gate in which he usually curls his toes with each step. Pain is resolved but still has tingles and numbness.
2. August 23rd: Mr. “J” begins stretching 3 times a day after reviewing proper techniques for homework exercises. His “new favorite hobby is to rub my feet because it feels so good!” I observed that now Trigger Point Therapy requires a small fraction of the time to control tension and residual discomfort!
3. September 19th: Mr. J played pool for 6 hours! “rubbed my sore feet and went to dinner!” Some minor flare up was controlled by work on lower back and gluteal muscles bilaterally. Quickly provided TM and passive stretching before resuming PNN protocol.
4. September 23rd: Mr. J begins planning for a more active lifestyle. “I’d like to do something all day” he again requests attention to lower back and gluteal muscles before application of Peroneal Nerve Neurlagia’s protocol.
5. September 30th: Mr. J had an active 3-day weekend of “doing too much” yardwork that included landscaping and the next day 6 hours of a billiard contest. As a result, he had two days of relapse. We were able to quickly control it. Lately Mr. J reported one last remarkable victory: “Ankles feel much better! Feet feel really good!” He now rubs his feet with a gua sha stone, does his exercises and rolls his ankles in circles, “Feels like walking in slippers!”
After consulting with Dr. Ross Turchaninov he suggested adding TENS unit application at home along the strategic points of common peroneal nerve and lumbar decompression by inversion table. Mr. J has accepted these two amendments and had additional improvements!
So how did this all happen? It is my theory that years of sitting at a desk working as a CPA and his various hobbies resulted in compression and bulging of disc L4 and L5 which led to the laminectomy while in his 30s. Lack of correct soft tissue rehabilitation in combination with consequent spinal surgeries triggered common peroneal and later tibial nerve irritation and adhesions formed between layers of the soft tissues in his lower back, legs and feet. As a result, normal mobility between layers was greatly affected, additionally contributing to the nerve irritation and ROM restriction. Eventually his symptoms progressed to almost complete disability in both feet. I am sure that it was his right QL which at one point threw off lumbar balance affecting erectors and right piriformis. With time it led to entrapments of sciatic and later its common peroneal branch.
Medical Massage saved my patient from disability and brought him back to the active productive life!
In January 2011 I graduated from the National Massage Therapy Institute with Honors. During the 8 months of education I quickly realized that my interests leaned more toward rehabilitation than spa massage. Ironically, for five years I worked in Tranquil Touch Day Spa, quickly becoming Lead Therapist within just a few months. My skills were deemed as “being more medical” by the owner. However, I still felt I had much more to learn and felt hindered. I wanted to be able to help my clients more to prevent many unnecessary surgeries I witnessed my clients going through to avoid pain and dysfunctions. I felt that I could help many of them, but I didn’t have enough skills yet. So, I decided to pursue Orthopedic Massage seminars hoping that it would lead me to my desired path and give me the skills I needed to help my clients even more!
In 2012 I began taking Orthopedic Massage seminars. My first one was with Dr. Jeff Cullers with Premier Education. I thoroughly enjoyed his instruction, his humor and his enthusiasm for interacting with students. He is an excellent teacher.
In 2016 I received an invitation to attend a Trigger Point Therapy seminar that was highlighted as strictly scientifically based. It intrigued me and I was very excited to learn that Dr. Jeff Cullers would be the instructor.
I was astounded at the flood of data, clinical cases, evaluation skills I learned during the class. I also was shocked by the number of cases presented in medical literature of the damage and even life-threatening injuries caused by improperly trained therapists who tried to do their best helping clients, but were missing proper clinical training. That seminar completely changed the way I started to practice clinical massage and work with tensed muscles. Immediately my clinical results dramatically improved.
This two-day seminar opened my door to the exciting and vast field of Medical Massage which is superior to any of my previous trainings. It would also lead me to the Science Of Massage Institute and Dr. Ross Turchaninov. From then on I decided that I would reach my goals to be a Medical Massage Practitioner through SOMI. I immediately signed up for further training with Dr. Jeff Cullers and later work with Dr. Ross Turchaninov.
Today, I am happy to say I have reached my initial goal! I still have a lot of learning to do, but I finished my training with SOMI and became a Medical Massage Practitioner. SOMI equipped me with understanding and clinical skills to help my now “patients” regain mobility, avoid unnecessary surgeries, and resolve complex pain syndromes. One of my patients told me, “You gave me my life back!” and now my days are filled with many similar victories.
If it were not for Dr. Ross and SOMI none of this would have been possible! Thank you Dr. Ross for bringing science based Medical Massage to the USA. In my practice I have always lived and worked by the words of Jesus in the scripture: ”There is more happiness in giving than there is in receiving.” I deem it an inestimable privilege to help my patients in extremely complex clinical cases, keeping them from opioids and unnecessary surgeries and giving them their lives back. It has been an honor to become a student of Dr. Ross Turchaninov, Dr. Jeff Cullers and SOMI.
Nancy McNamara, CMMP, LMT
Category: Case Studies
Tags: 2019 Issue #4