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SOM is the best educational opportunity I've experienced for massage therapy. My first SOM class was a cathartic experience as the pieces of the modality puzzle started to come together. I had already noticed that a combination of modalities worked better than the isolated applications. Patterns were also emerging in terms of optimal order. How wonderful to have found SOM providing a strong theoretical foundation and clinically tested protocols beyond what I could have ever contrived solo!

So my latest adventure in therapeutic massage came when someone complained of knee pain with dx of bursitis. In the past, I would have told her massage cannot help. But since Dr. Ross mentioned massage can help if the bursitis originates with tight muscles aggravating the bursa, I accepted the case. And though the first session provided great results, I sensed I was missing something. So I emailed inquiry to Dr. Ross:
 
" . . . She has medial, lateral, and anterior knee pain. On palpation, she presented trigger points common in three superficial quadriceps. Also, presented with an unusual referral trigger point. Her L Gluteus Medius TrP2 area sent referral pain to R Gluteus Medius area and down the posterior leg and wrapped around to anterior knee! This is the strangest referral pattern I’ve seen. 
 
In her first session the related hypertension decreased from 50 – 80% as discerned by palpation. Post session she described pain as having gone from level 8 to level 3.5. 
 
Given such quick results and the fact that walking aggravates her pain more than squatting on a stool to pull weeds, I wonder whether she was misdiagnosed. Most US physicians don’t acknowledge trpts! Maybe that’s all it is!
 
She works as professional gardener at local farm and nursery. So, there are days when most of the day is pulling weeds. That is no problem. A work day that is mostly walking and standing will cause severe knee pain by the end of her shift. 
 
She is doing therapeutic stretching and strengthening exercise as recommended by her physician for knee bursitis. 
 
She will receive short break massages for 3 sessions total. I couldn’t find any SOM video protocols that match her need. I did use similar principles as SOM recommends for calf muscle tpts except different location. 

While she got excellent results, I wonder whether you have any tx suggestions that will help secure long term results for her.
 
Thank You. This is a client I would have avoided massaging if it were not for your guidance!"

 Here is Dr. Ross suggestion which I will try on second session:
"Bravo!
In regard to protocols. You also have to rule out lumbar erectors or QL on the level of last rib. Unload tissue around the knee (look at knee OA protocol)."

So it was somewhat of a bold move for me to consider treating a client for something which I have no specific training. I simply told her to come into office for evaluation to determine whether her muscles contributed to the condition. I excel in trigger point work. In addition to SOM resources, I rely heavily on trigger point patterns. Here is a great on line resource that is also great to show clients when explaining trigger point therapy. http://www.triggerpoints.net/ 

Prior to the session, I had reviewed trigger points related to her described pain patterns. Once I determined trpts present, it seemed logical to apply the general treatment patterns reflected in many SOM protocols. Though different body parts, the same concepts are repeated.

Per my pre-session instructions, we started the session with patient in comfortable stretchy clothing as one might wear to stretch class. This made for easy palpation of trigger point areas which proved positive for tenderness and HT.  

We started session with prone position with primary goal to calm automatic NS and relax areas stiff as a result of limping gait resulting from the severe knee pain. This allowed me to happen upon the peculiar pain referral pattern mentioned above. Based on the tension patterns, I now suspect the lumbar erectors and QL are involved, as mentioned above by Dr. Ross. 

I look forward to seeing how this case progresses. If anyone else has any input of questions, feel free to chime in. I'm esp interested learning whether anyone else has encountered the unusual trpt referral pattern described above. 

If you've read this far, thank you for your time and consideration.

 

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After viewing the OA protocol, more questions arise. What about the obese client? Lifting the muscles as indicated in several of the techniques is blocked by adipose tissue. Do we go through the motion as best we can or is there an alternative technique for improved effectiveness?

Also, there is no indication that trigger points are specifically addressed. Trpts are present w/ my client. I'm assuming they would also be present w/ OA. So, I'm assuming it's not necessary to address them through the compression holds as we have in the with other protocols such as QL syndrome or trap syndrome. Is that correct? 

Also Dr. Ross wrote, " rule out lumbar erectors or QL on the level of last rib." The OA video does include some treatments related to QL and erectors, is that enough. Or if trigger points are present in erectors and / or QL, is a complete QL protocol necessary? (QL protocol includes release of lumbar erector trpts.) 

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Here is Dr. Ross' reply: 

You include QL if it carries the tension and if not skip this. If the patient obese instead of lifting you use lateral shift of the muscle tissue

Dr. Ross
 

Update: 

Patient reported no pain and no tension after second session Patient reported no pain and no tension after second session when we used OA protocol. Pre-tx she had reported PL4, but until midday, she had held the previous level of release (3.5 from pre-tx of 8). Apparently, a great indicator of perfect timing with the short break sessions!

Thank you Dr. Ross! 

Edited by Carole Jackson

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Update: It turned out this patient had been misdiagnosed. Corrected dx: torn meniscus. This makes the results even more remarkable. And what's more amazing, she has been able to maintain without ongoing MM. 

She is good at self-care. She has a flair-up once in a while but she is able to manage it herself. 

It's been more than 6 months. She was able to meet her number one objective--We ended her short break protocol just in time for her to dance at her daughter's wedding pain-free! 

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Thank you so much. It is your great guidance and teaching resources that made this possible.

She continues to maintain w self care alone. This is even more remarkable in light of her line of work. She works at a local plant nursery and farm doing physical labor! This includes pulling weeds manually!

She is a tribute two the powerful impact of self-care and maintaining of the restorative nature medical massage.

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