(Published in Massage Magazine April, 2013)
I once had a women in the Tennessee government tell me that as a massage therapist I was not legally allowed to touch bones. I asked her how I was supposed to give a massage without touching bones, and she replied, "I don't know, but you have to find a way." Bones are an integral part of what we do as massage therapists. As the old anatomy equation says, "muscles move bones at joints." if one part of this equation is immobile, misaligned, hypertonic, hypotonic, inflamed, etc., all parts of this equation are affected.
While any of these descriptors can cause imbalance and pain, immobilization of a bone is a multi-layered accomplishment. Generally a hypertonic muscle that is moving a bone out of alignment and into an unnatural position will not cause the bone to become immobile. However, a few hypertonic muscles moving the distal end of the bone one direction and the proximal end of the bone a different direction can absolutely create immobilization of a bone.
For example, Mary presented with osteoarthritis in the metatarsophalangeal (MP) joints of her big toes. Six years after first noticing the pain, she had a surgical resection of the first metatarsal in her right foot done. She now has one screw in the right metatarsal, and while she has no cartilage in her right first MP joint, the resection created space in the joint, which has led to natural movement and very little pain. Two years later, she had a partial joint replacement in the first MP joint of her left foot. The prosthetic was placed into the proximal phalanx.
Six years after the partial joint replacement, the prosthetic failed, the left big toe's motion was extremely limited and the pain was severe. The diagnosis was Hallux Rigidus. The only solution was to have the first MP joint of her left foot fused. Mary waited six months after the original doctor's appointment to get the surgery.
In that time, the compensation patterns in her body multiplied. Her right foot preferred over-supination and her right leg had for a very long time been in a laterally rotated position. In compensation, the left foot had been mildly over-pronated and the left leg had been mildly medially rotated. The pain in her left big toe caused Mary to over-supinate her left foot with every step. In compensation, her left lower leg began to move lateral, and, within a few weeks, her left leg became laterally rotated.
The right leg was unable to compensate for this. At first, Mary's pain was in her left hip, then in both SI joints. Finally, a month before the fusion surgery, the pain landed in her right femur. Her right femur had become immobile. Her right tibia was pulled lateral from the position of her right foot. This means that gastrocnemius, popliteus, and plantaris were pulling the lower femur into a lateral position.
But, in order to compensate for the left leg position and remove pain from the SI joints, the body needed the right hip to rotate medial. Iliacus, TFL, gracilis, and adductor magnus were pulling the hip into medial rotation. The proximal femur attempted to follow the hip bone, but the distal femur needed to move into a lateral position. The femur became stuck between the warring muscle factions.
As the femur immobilized, other muscles became involved, namely the deep 6 lateral hip rotators tightened and then became motionless. Two of the deep 6 lateral hip rotators are also muscles of the pelvic floor, namely piriformis and obturator internus. Because Mary's right hip was hypertonic, motionless, and inflammed, the right side of her pelvic floor reacted and she began to have a pelvic floor imbalance.
Symptoms included intense burning along the femur, an inability to move in any direction without extreme pain, and severe pain that moved based on Mary's activity. If she sat for a period of time, the pain would be in the pelvic floor, or deep inside the sacrum. After sleeping, the pain would be in the right hip joint. Walking for any period of time would cause the pain to move to the right knee.
Several sessions of work revealed that Mary's right femur being immobilized was the cause of the tremendous pain she was experiencing. However, these sessions also revealed that working on the right femur or even the right hip had little to no effect. Mary's right gastrocnemius, soleus, and popliteus were exceptionally hypertonic, adhered, and inflammed on the lateral side of her lower leg.
When these muscles were released, the tibia was able to move into a more neutral position and the femur immobilization was alleviated. This considerably lessened Mary's pain. Additionally, when the left thigh and hip were released and were no longer in a laterally rotated position, the proximal right femur was able to move again and the pain significantly decreased.
Now, for Mary, the pattern was going to continue repeating itself until the surgery. As long as she pulled her left foot into supination with every step, the compensation would continue. This example does let us see however that an immobilized bone can cause muscle tension, pain, and rigidity, such as that in the deep 6 lateral hip rotators. On the other hand, muscle tension, rigidity, and imbalance, such as that in gastrocnemius and soleus, contributed to the immobilization of the femur.
Without understanding the relationship of the talus to the tibia and the tibia to the femur, the immobilization of the femur, and therefore the pain created by said immobilization, would have been impossible to alleviate. Further, without an understanding of how the calf muscles impact the tibia and femur, it would have been difficult to help with Mary's complaint.
Bone immobilization should be a consideration in any specific massage work. Let's look at another example. Temporal bone immobilization is common and can cause many different symptoms, including tension in one side of the jaw (this can lead to clenching of the teeth on that side), an imbalance of the neck muscles (both anterior and posterior), temporal headaches, occipital headaches, and a misalignment of the sphenoid bone.
Recently one of my clients, Barbara, presented with frequent, excruciating occipital headaches and posterior muscle tension. The most common place to begin working, of course, would be the sub-occipital area. However, I find that most occipital headaches are caused by an imbalance in the longus colli and longus capitis muscles in the anterior neck. Specifically, longus capitis which inserts on the basilar aspect of the occiput (the area just anterior to the foramen magnum). This means that if one longus capitis muscle is hypertonic, it will pull the occiput to that side, immediately creating an occipital imbalance.
In Barbara's case it was not possible to assuage her occipital headaches by simply correcting this muscle imbalance. In her case, the imbalance in longus capitis was only one component in a temporal bone immobilization. Generally, if the right side longus capitis is hypertonic then the right jaw muscles are hypertonic. But, for Barbara, the right longus capitis and the right lower jaw muscles (i.e. geniohyoid, mylohyoid, digastric, and stylohyoid) were hypertonic, but her mandible was shifted to the left and the left mastoid and temporalis muscles were tight.
Within the first session I understood that her sphenobasilar joint (the joint inside the cranial base between the occiput and the sphenoid) was misaligned. The occiput was being pulled to the right, while the sphenoid was being pulled to the left. With further assessment, I began to understand that her maxillae and palatine bones were also shifted to the left. Both the maxillae and the palatine bones articulate with the sphenoid. It was hard to say whether they were pulling the sphenoid to the left or the sphenoid was moving them to the left.
But it was obvious that the temporal bones were caught between the position of the occiput and the position of the sphenoid. Through the sphenosquamosal sutures and the occipitomastoid and lambdoid sutures, the temporal bones articulate with both the occiput and the sphenoid.
To mobilize the temporal bones, I would have to release the muscles in the anterior neck, including the hyoid muscles, along with the sub-occipital muscles. Additionally, the sphenobasilar joint needed to be realigned, and the sphenoid could not be released until the maxillae and palatine bones were released.
Although I knew early on that a temporal bone immobilization was the cause of Barbara's agonizing headaches, the only way to mobilize the temporal bones was with an understanding of what effected the temporal bones and what was affected by the temporal bones. For example, temporal bone immobilization could cause the tension in both the anterior and posterior muscles of Barbara's neck. Splenius capitis and longissimus capitis both attach to the mastoid process of the temporal bone, as does SCM, digastric, and stylohyoid. But it is just as possible that the temporal bone was affected by the muscle imbalance in longus capitis, which pulled the occiput to the right and tightened all the posterior muscle tissue attaching to the occiput. This imbalance coupled with the maxillae and palatine bones moving left would have shifted the position of the temporal bones and affected all musculature attaching to the temporal bones.
Either way, mobilization of the temporal bone meant working in more than one area, releasing muscles, mobilizing bones, and having an understanding of the compensation pattern. As with Mary, mobilization of the femur meant working in more than one area, releasing muscles, mobilizing bones, and having an understanding of the compensation pattern.
In Tennessee the law states that any issue to do with bones has to be referred to a chiropractor. I agree that chiropractors are invaluable and working with one is highly beneficial to clients. But, in both of the examples I gave you in this article, the chiropractor was unable to help the pain because of the muscular involvement. Understanding how the muscles affect the bones and how the bones affect the muscles can help us to better help our clients.