Integrated Manual Therapy & Orthopedic Massage
For Complicated Lower Extremity Conditions
Assessment Protocols Treatment Protocols
Treatment Protocols Corrective Exercises
Artwork and slides taken from the book Clinical Massage Therapy: A Structural
Approach to Pain Management Published by Pearson Education
By
Author & International Lecturer
James Waslaski LMT, CPT
Integrated Manual Therapy & Orthopedic Massage
For Complicated Lower Extremity Conditions Today’s manual therapist needs to have multiple skills in order to address a wide variety
of complicated musculoskeletal pain conditions. Specialization in just one modality is
becoming a thing of the past because of limited patient outcomes. This unique total
system consists of orthopedic assessment, clinical reasoning, multidisciplinary and multi-
modality therapies, and precise corrective stretching and strengthening exercises.
Participants will learn to integrate the skills of leading practitioners from the fields of
massage therapy, physical therapy, athletic training, personal training, osteopathic and
chiropractic to restore balance, posture, function and pain free living. Recent clinical
studies will forever change the way manual therapists look at musculoskeletal pain,
muscle-tendon strain pain, and adhesive capsular pain. This seminar will teach manual
therapists to address clinical conditions of the lower extremity such as hyperpronation,
excessive supination, Achilles tendinosis, plantar fascial pain, tarsal tunnel syndrome,
posterior tibial stress syndrome, anterior lateral compartment syndrome, fixated ankle
joints, joint arthritis, morton’s neuroma, bunions, hammer toes, flat feet, and ankle
sprains and strains. Corrective stretching and strengthening techniques will be also taught
to keep the muscles balanced, and joints aligned for pain free living.
Twelve Steps: 1. Client History 2. Assess Active Range of Motion 3. Assess Passive Range of Motion 4. Assess Resisted Range of Motion 5. Area Preparation 6. Myofascial Release/ Compression Broadening 7. Cross Fiber Gliding/Trigger Point Therapy 8. Multidirectional Friction 9. Pain Free Movement 10. Eccentric Scar Tissue Alignment 11. Stretching 12. Strengthening James Waslaski is an Author & International Lecturer who teaches approximately
40 seminars per year around the globe. He’s served as AMTA Sports massage Chair
and FSMTA Professional Relations Chair. He’s developed 8 Orthopedic Massage and
Sports Injury DVDs, and authored manuals on Advanced Orthopedic Massage and
Client Self Care. His new book, Clinical Massage Therapy: A Structural Approach to
Pain Management was published by Pearson Education in 2011. James presents at
state, national and international massage, chiropractic, and osteopathic
conventions including keynote addresses at the FSMTA, World of Wellness, New
England Regional Conference, the World Massage Festival, and Australian National
Massage Conventions. His audience includes massage and physical therapists as
well as athletic trainers, chiropractors, osteopaths, nurses and physicians. He is a
certified personal trainer with NASM. James received the 1999 FSMTA International
Achievement Award and was inducted into the 2008 Massage Therapy Hall of
Fame. www.orthomassage.net
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CLINICAL MASSAGE THERAPYA Structural Approach to Pain Management
CHAPTER
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Lower Leg, Ankle, and Foot Conditions
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Chapter Outline
• Twelve-Step Approach to Lower Leg, Ankle, and Foot Conditions
• Achilles Tendinosis• Gastrocnemius Protocol to Address
Achilles Tendon Pain• Soleus Protocol• Posteromedial Shin Splints
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Chapter Outline
• Flat Feet and Fallen Arches and Hyperpronation
• Plantar Fasciitis• Anterior Compartment Syndrome (ACS)• Anterolateral Shin Splints• Inversion Ankle Sprain and Strain• Stress Fracture
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Learning Objectives
• Choose the appropriate massage modality or treatment protocol for each specific clinical condition of the lower leg; Based on restoring normal range of motion throughout the body, and normal muscle resting lengths
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Learning Objectives
• The focus is to work on the contracted muscle groups typically short and —gastrocnemius, soleus, and tiblialis posterior—before working on the weak, inhibited antagonists—tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneals
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Learning Objectives
• This will ensure–Structural integration—balance of the
opposing muscle groups–That the therapist eliminates the
underlying soft-tissue cause of the lower leg conditions before addressing the clinical symptoms
• Restore pain-free ankle joint normal range of motion
• Create ankle stability
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Learning Objectives
• Differentiate between soft-tissue problems caused by–Myofascial restrictions–Muscle–tendon tension–Trigger point tension–Strained muscle fibers–Sprained ligaments–Nerve compression–Bony fixations
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Learning Objectives
• Teach the client self-care stretching and strengthening exercises (if needed) to perform at home to maintain musculoskeletal balance and pain-free movement following therapy
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-1 Lower Leg Muscles
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-2 Ankle Plantar Flexion, 30–50 Degrees.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-3 Ankle Dorsiflexion, 20–30 Degrees.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-5 Ankle Eversion at Subtalar Joint 15–20 Degrees.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-5 Ankle Eversion at Subtalar Joint15–20 Degrees.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-16A Muscle Resistance Test, Soleus.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-6 Myofascial Spreading, Gastrocnemius.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-7 Compression, Gastrocnemius.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-8 Cross-Fiber Gliding Strokes and Trigger Point Work, Gastrocnemius.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-9A Arthrokinetics, Compression.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-9B Arthrokinetics, Decompression.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-10 Gastrocnemius Stretch.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-13 Myofascial Release of Soleus.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-14 Ankle Distraction and Traction.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-15 Soleus Stretch.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-16A Muscle Resistance Test, Soleus.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-16B Multidirectional Friction, Soleus.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-17 Eccentric Muscle Contraction, Soleus.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-18B Myofascial Release, Right Achilles Tendon.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-19 Tibialias Posterior Review.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-21 Myofascial Release, Tibialis Posterior.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Precautionary Note
• There is an accupressure point approximately four fingers above the medial malleolus and a reflexology point between the malleolus and calcaneus. Avoid direct pressure on these areas on pregnant women.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-22 Posterior Tibialis Stretch.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-25 Compression and Myofascial Spreading, Foot Muscles.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-26 Massage Intereoseus Membrane Using Long Bones of Foot.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-29 Bunion.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-28A Arthrokinetics, Gentle Compression.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-28B Arthrokinetics, Traction.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-23 Plantar Fascial Pain is not usually red, swollen and inflamed.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-27 Stretch Muscles and Plantar Fascia of the Foot by Extending the Toes.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-24 Muscle Resistance Test for Plantar Fascial Strain.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-32 Multidirectional Friction, Plantar Fascia Strain.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-33 Eccentric Muscle Contraction,Plantar Fascia Strain.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Precautionary Note
• When you take a client’s ankle out of inversion and plantar flexion, this may lower the arch and change the foot strike. For clients who wear hard orthotics in their shoes, this can create increased pressure on the plantar fascia. Make sure they are aware of this and consult their podiatrist.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-35 Muscle Resistance Test on Anterior Compartment Muscles.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-34 Anterior Compartment Muscles.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-36 Retinaculum Release.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-38 Compression Broadening.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-39 Release Intermuscular Septums.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-42A Ankle Decompression.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-42B Traction Hip, Knee, and Ankle.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-44 Ankle Ligaments.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-53 Lateral Leg Muscles.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-45 Muscle Resistance Test, Ankle Strain.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-46 Myofascial Release, Lateral Lower Leg.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-47 Compression Broadening, Lateral Lower Leg.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-49 Muscle Resistance Test, Ankle Strain.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-50 Multidirectional Friction.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-51 Eccentric Muscle Contraction.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-44 Ankle Ligaments.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-52 Eccentric Ligament Technique.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Stretching (Client Self-Care)
• Goal: for the client to perform stretches suggested by you to create normal muscle resting lengths in shortened or contracted muscle groups, and restore normal range of motion to the joint.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-54 Gastrocnemius Stretch.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-55 Soleus Stretch.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-56 Stretch posterior tibialis to correct supination. Stretch Peroneals to correct hyper-pronation!
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Strengthening (Client Self-Care)
• Goal: to strengthen weak, inhibited muscle groups around a joint creating muscle balance throughout the —structural integration.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Precautionary Note
• To prevent reinjury after treating a strain, have the client refrain from beginning a strengthening program for 7 to 10 days, or until he or she is pain-free. To facilitate healing, have the client stretch the tight antagonist muscles, taking the tension off the injured muscles until pain-free strengthening can begin.
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-57 Strengthen Peroneals to stabilize lateral ankle.
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Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-58 Strengthen Posterior Tibialisto correct hyper-pronation problems..
Clinical Massage Therapy: A Structural Approach to Pain ManagementJames Waslaski
Figure 4-59 Strengthen Tibialis Anterior for anterior compartment syndrome clients.
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