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Scar tissue, knots, adhesions oh my… What is YOUR outcome measure when performing soft tissue treatments….and more importantly, is it palpable??

December 6, 2011

Last week I posed the question on facebook… “What is your outcome measure when performing soft tissue work?”  For reasons unknown to me, most people decided to message their answers as opposed to posting them??

The answers that I received were not unexpected and mirrored those that I have heard over the years during our seminars.  Here are some of the more common ones that are offered (and please note, these answers come just as commonly from students as they do from seasoned therapists who have practiced for a number of years):

–       Scar tissue or ‘adhesions’

–       Range of motion

–       Tightness

–       Tissue quality – changes in the “feeling of the tissue.”  (This is often accompanied with some adjectives like “gritty,” or “leathery.”

–       “Knots” or “popcorn” in the tissue

–       Pain

And the surprisingly common…

–       “I don’t know”

The array of answers should not surprise us when thinking of the instruction that each of the manual professions has received on this topic.  I personally do not recall any time spent on discussing this topic in school.  It was often dismissed by the instructors saying “when you feel it, you will know” ….or my favorite explanation offered when students practice on each other, “you are all healthy….when you have ‘real’ patients you will feel problems in the tissue” (I guess that students are impervious to soft tissue problems??).

The closely associated question that I often ask following “what is your outcome measure” is “how do you know when your soft tissue treatment is done.”  Obviously if one does not have a clear concept/answer for the first question, the second surly cannot be ascertained, as one clearly wouldn’t know when to stop treating if they have no clear goal in mind.

As I often note at our F.A.P. seminars, palpation is a skill that needs to be practiced and honed.  Not only in terms of learning how to find structures (although I might add, the F.A.P. system is great for this), but also in terms of assessing the status of the tissue once it is found (a concept that is introduced during F.A.P. seminars, and is highly expanded upon during F.R. seminars).  It is only when the practitioner has a clear understanding of these two answers that they will be able to confidently trust their palpatory assessment.

Here is a good example to demonstrate this point.  Lets take the condition ‘Lateral epicondylosis.’  We have all be taught in school, or have read in texts that this condition is caused by increased ‘tightness’ in the extensor muscles leading to an increased ‘tug’ on the common tendon inserting into the lateral epicondyle (first off, this explanation of anatomy is highly flawed and inaccurate even though it continues to be described as such ….but that is another discussion).  This ‘tug’ then leads to tendon breakdown, and subsequent pain.  The underlying cause is frequently noted to be participation in racquet sports, or repetitive strain caused by actions such as typing, or jobs requiring manipulation of small objects.  Well….here is the monkey wrench….not all patients with lateral epicondylosis fit this description.  Further, not all patients with lateral epicondylosis have any ‘tightness,’ ‘adhesions’,  ‘knots’, ‘popcorn’, or changes in the ‘tissue quality’ of their extensor group…yet they have lateral epicondylosis just the same.  In this scenario, if the therapist doesn’t have a clear outcome measure by which he/she measures the status of the tissue, they will proceed to stretch, strip, scrape, or release perfectly normal tissues for no other reason other than that they were taught that it is the correct way to treat the condition.  In so doing, they may have overlooked the fact that the patient had a direct injury to the lateral epicondyle that may have been the original factor leading to the tendon decay; or that they had previously suffered from this condition on the contra-lateral side (perhaps suggesting a genetic predisposition to the condition); or that the patient chronically maintains a position that stresses the lateral joint capsule…and that their diagnosis is incorrect to begin with!

Scar tissue, knots, and ‘adhesions’ oh my!

–       Adhesion?  What exactly is an ‘adhesion’?  Well, it is a piece of collagen that is laid down in a haphazard fashion.  Further, it is nanometers’ in size and is UN-PALPABLE.

–       ‘Scar-tissue’ then is several pieces of collagen (adhesions) laid down in a haphazard fashion.  However, as is noted with lesions to the skin, the original injury has to be significant enough to create an actual scar (as is seen with the healing of an external cut) in order for it to be palpable to our touch.  However we as therapists claim to be treating ‘micro-scarring’ left behind by repetitive strain.  Thus, outside of healed overt muscle tearing (>2nd degree) we once again cannot palpate it.

–       “Knots”….well, I don’t even understand what that term means…..I thought that was just something that we told our patients…but apparently, many therapists look for them.

–       “Popcorn” I suppose is a way of describing what is felt under a Graston (or other) tool when it is sliding over the skin.  However, as was discussed in my blog

Subcutaneous fat tissue ...."Popcorn"?????

post entitled “Is your soft tissue technique doing what you think its doing?” this ‘popcorn’ is more likely representative of subcutaneous fat deposits then it is of microscopic scar tissue (see figure)

–       Range of motion – this outcome measure puzzles me most of all.  Do gymnasts not require soft tissue treatment because they are flexible?  Does soft tissue work actually cause long lasting improvements in flexibility? No.

–       Pain – please refer to this blog post entitled “Pain on palpation is not a finding”

–       “Tissue Quality” – As I noted in ONE OF MY PREVIOUS BLOG POSTS, we cannot palpate abnormalities in tissue without the use of movement.  It is only in this way that one can determine there to be aberrant tissue mechanics or properties.

–       That leaves us with “I don’t know”….which might very well be the most honest answer (as well as the most common).

I believe that there is a consensus as to the target of our soft tissue therapies….fibrosis/scarring.  This fibrosis develops in the fascia (SEE THIS BLOG POST)  But if we cannot actually feel it, how can we use it as our outcome?  Quite simply, scar tissue/fibrosis/adhesion is palpated as abnormal tissue tension between layers of tissues (this can be between muscles, tensons, or ligaments….or between bundles of muscles….or even between muscle cells)….and this tension can only be palpated during tissue movement.

The next obvious question is “what would be considered abnormal tension?”  During Functional Range Release seminars as we are teaching the ‘Tissue Tension Technique’ (which is the palpation technique F.R. practitioners use to assess tissues) we describe it as such….

“Abnormal tension is tension felt in tissue during motion WITHIN the

 normal range of motion of a particular articulation”

With this clear concept in mind, while using the ‘Tissue Tension Technique,’ I can confidently rely on my palpation findings.  Further, when abnormalities are found, I have a precise, consistent outcome measure that can guide the application of my soft tissue treatments, and subsequently that can guide the prescription of rehabilitation exercises.  When you consider the un-reliablility of our other assessment techniques….ROM, orthopaedic tests, etc….confidence in palpation proves very important.


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