‘Neurological tightness’ vs. ‘Mechanical tension’: an important distinction for soft tissue management
In the past few weeks we have been focusing on using assessment skills to determine not only the location of the pathology, but also to better define the lesion in order that we are able to select the treatment tool/modality most appropriate to achieve our goal (of course the goal is defined by the aberrant histology present).
The video below show a case of a 23-year old elite hockey player who presented 1.5 months after a second reconstruction surgery for his chronic anterior dislocations (BTW – for those following me on twitter, this is the case that I have been consistently updating you on with video analysis and pictures – @DrAndreoSpina) Due to the condition of the capsule after he tore through the original repair, the surgeon decided to use a cadaveric achilles tendon (allograft) to reinforce the capsule. As the patient was still in the US shortly after surgery, he began ‘standard’ rehabilitation procedures with a therapist for the first 1.5 month which included the standard modalities, soft tissue “release” which, as per the patient, lead to no improvement in ROM. Before starting I had a lengthy discussing with the surgeon who confirmed that ROM had not improved and that at the end of the 2-3 months I have with him (before he goes back to school) he doesn’t expect any significant ROM improvements.
As you can see in the figure which demonstrates 0-5 days of progressive adaptation (in flexion only)…my prognosis is much more ‘inspired’ than the surgeons. What is important to note is NOT simply the improved ROM (which is ACTIVE btw…I care very little for passive/useless ranges), rather that is was done thus far USING ABSOLUTELY NO SOFT TISSUE RELEASE/THERAPY or MOBILIZATION. This progression what via the utilization of PAILs & RAILs rehab only. Why the decision to exclude soft tissue and/or mobilizations to this point…watch the video for the answers.
Take home points:
1. If you cannot achieve an end range of motion, you must decide what the barrier is…nervous system guarding, or actual fibrotic development.
2. Once number one is determined, only then can the appropriate tool be selected for the job.