Question from a Reader: ART vs. Graston Technique?

Hey Aleck

Well I just had confirmation of a partial (Grade II) hamstring tear with an MRI ordered by my orthopedic doc. It happened 3 months ago during my 11 mile long run. I didn’t hear/feel anything pop or snap. I felt a slight tight/stiffness in the belly of the hamstring at the 7th mile mark and tighten-up even more as I finished the rest of the 11 miles. I was able to finish my run, but the following short runs; I just didn’t have a full stride. I did my hamstring stretches. I have also been to physical therapy for past month (3x a week) that my orthopedic doc referred me. PT had me do a lot of balancing and strengthening exercises. Don’t get me wrong, overall my legs feel stronger. But I haven’t been able to run more than 5 miles before I feel the “tightness” in the belly of the hamstring. My marathon pace used to be a 7:30 pace. I can’t even do an 8 min pace on a 5 mile run.

Question for you – Do you think Graston or ART would help my hamstring? I’ve been told ART works well with Ironman ~ to encourage recovery or something like that? How many sessions of ART would you recommend to have? Does it deal with the inflammation as well?

Cheers,
Mike

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Hi Mike -

I'm sorry to hear of your injury. Good news is that you have a great chance of recovery and getting back to running full speed again. Better news is that the journey back to the land of running and competing in races doesn’t have to be as long and bumpy as you might think. We’ve all heard of the tragic stories of months of rest and out for a whole season with repeated hamstring pull and never getting back to the pre-injured status. But it doesn’t have to be like that.

The basic principle behind both A.R.T. (Active Release Technique®) and Graston Technique® is addressing and breaking up the scar tissues that have formed around a soft tissue injury. I've certainly worked on many hamstring "pulls" and tears successfully with both A.R.T and Graston Technique.

The body naturally produces scar tissues (collagen fibers) to “patch” up the tear. However, these collagen fibers are layered in a random fashion and they tend to be very sticky ~ resulting in limited flexibility within the muscle and adhesion formation to surround tissue, further limiting flexibility. This explains the tightness you described. Some could even feel a “knot” in the area of the scarred muscle.

Graston Technique tends to be more aggressive and is a better technique for thick/matted tissue, post-operative scar tissue and tendinopathy. This instrument-based soft tissue technique is a cut above other hands-on techniques for degenerative tendon (tendinosis) and post-surgical cases of all types. It’s designed to cause an inflammatory reaction in the tissue which stimulates the production of new collagen fiber – the basic building block of muscle and tendon fibers. The instruments allow the practitioner to gain a “vibration” sensation of the scar tissue with the instruments. The patient typically simultaneously experiences a noticeable tenderness while the tool goes over the injured area. The technique is designed to break cross-fiber links, splay fibers and increase fascial mobility. I prefer Graston Technique for chronic cases, where conventional forms of treatment have failed.

A.R.T. is not only an exceptional technique/treatment with the detailed oriented nature. Every soft tissue in the body (muscles, ligamnets, tendons & nerves) has at least one protocol to address it if it's involved in the injury. Its concept is to re-establish motion between fascial planes thus reducing fibrous adhesion and glide between layers of tissue. The technique is useful for acute, chronic, overuse; repetitive strain injuries and post-op cases . It’s a quite a dynamic technique ~ When A.R.T. is applied appropriately, it is far more forgiving to the patient and the injured tissues. The experience of the A.R.T. practitioner always plays a big part ~ understanding the nature of the injuries, experience working with athletes with similar condition. Beware of imitations ~ there are some practitioners who are familiar with A.R.T. and suggest they do a certain type of myofascial release technique that's similar to A.R.T. I do not doubt they treat soft tissue injuries. They just simply do not do A.R.T. (I digress.)

Given that both techniques work directly on the injured tissue, it is only right that the recipient would “feel” it. Sometimes a little; sometimes a lot. But it shouldn’t be painful (this is where it gets a bit subjective with differentiating good pain vs. bad pain.) If the patient is tensing up tremendously and biting down , most definitely, either technique is not applied appropriately.

I use A.R.T. on 99.9% of my patients and approximately 40% with Graston Technique. Depending on the patient and their condition on the day of the treatment, I may choose to add Graston with the treatment. So, it's hard for me to say if you should go with one or the other. I certainly have not shied away from using Graston on hamstring tears because of the bulk of the muscle, and the tenacious nature of hamstring tears.

I wouldn’t suggest you to take any anti-inflammatory medication for at least 48 hrs after either treatment since the techniques are meant to introduce the healing properties of the inflammatory cascade. You can take pain medication if needed though.

As for how many treatments you'll need, quite frankly ~ I don't know. For some injuries, the turn around time could be as quick as 2-3 treatments in a matter of 2 to 3 weeks. Some may take longer. It depends on the extensiveness of the tear, how much healing has taken place and how symptomatic you are during the treatment.

Thanks for sending in your questions and I hope this was helpful to you. Best of luck in your recovery.

Heel Pain ~ Plantar Fasciitis & Heel Spur... more than meets the eye

Let's not bore you with numbers/stats about the percentage or frequencies of heel pain or how much it cost the health-care system to treat heel pain sufferers. It’s a prevalent complaint that frustrates a lot of the sufferers and the professionals that encounter them.

Myths about Heel Pain:

• Myth ~ Heel spurs cause heel pain and need to be surgically removed.
  
  • Fact - there's a poor correlation with x-ray findings of heel spurs with heel pain (ie. incidental findings of heel spur without pain or tremendous pain with no heel spur ~ go figure?!) It is not recommended to have the spur surgically removed because it leads unnecessary tissue damage... prolonging the resolution of the pain.
    

• Myth ~ Inflammation is the cause heel pain.
  
  • Fact - inflammation is the natural healing process of the body. It's a 'signal' of tissue damage and that the body is trying to isolate and heal the damaged tissue. It's the result of repetitive stress onto the heel that prevents incomplete healing.
  
  
• Myth ~ Plantar fasciitis is the cause of the heel pain.
  
  • Fact - it is unlikely that the Plantar Fascia is the only tissue involved. There are a lot of tissues at the heel area. Many of them run very deep and oftentimes, are not addressed/treated properly. The pain is due to the scarring of the layers of tissue, inhibiting circulation and flexibility of the area.
  
  
• Myth ~ Rest is the best thing for the heel pain.
  
  • Fact - rest will only minimize the irritation of the irritated tissues. The scarred tissues will not go away on its own. It's best addressed with a pro-active attitude with ice, manual therapy (e.g. Active Release Technique, Graston Technique, Shock Therapy etc.), proper stretching and strengthening exercises.
  
  
• Myth ~ Night splint will make the heel pain go away.
  
  • Fact - it's a very passive and awkward means of addressing it. The thought behind this tool is to keep the ankle/foot in a dorsiflexed position overnight to minimize tightening of the Achilles & Plantar Fascia. I've heard of people sleeping with it every night for months with unimpressive results. Night should be used temporary rather than long term solution.

Typical Pain Pattern...

• gradual onset, without any association with trauma
  
• stabbing-like pain at the heel, commonly at bottom front edge of the heel bone where the Plantar Fascia & other muscles are attached
  
• first-step pain ~ most noticeable in the morning as the foot strikes the floor or after a prolonged period of rest
• pain tends to reduce to a dull ache as the day progresses
  
• with pressure, the arch is very tender
  
• with pressure, the rim of the heel pad is very sensitive
  
• unable to heel walk due to sensitivity of the heel bone
  

Contributing factors...

• history of wearing high heels ~ shortened Achilles Tendon, which leads to greater tension onto the bottom side of the heel bone
  
• history of wearing non-supportive footwear ($10 flip flops without arch support ~ engages faulty windlass motion & creating excessive lateral motion of the calcaneus)
• excessive elliptical machines usage
• faulty running mechanics
  
• after pregnancy
• tight Achilles Tendon

Anatomy of the foot & ankle…Let’s discuss a bit about the anatomy of the foot & ankle, and the makeup of heel pain.

(This section is more than you need to know, but as always, knowing is half the battle. The take home message in the section is to make sure when you seek medical attention, the physician addresses the anatomy with you and identifies the source of pain.)

Feel free to skip past this section and scroll down to the Home Regimen and Professional Help section.)

Bones ~ 27+ bones in the foot (Talus, Calcaneus, Navicular,Cuboid, Cuneiform [3], Metatarsals [5], Phalanges [14], Sesamoid bone [1+]). The ‘+’ is the non-uniformity of the formation of the seamoid bones underneath the big toe. Some people have 1, some heave 2… the seamoid bone functions to better the bio-mechanical configuration of the muscles & tendons attached to the clumsy big toe.

Muscle, Tendons, Ligaments & Joints ~ what can be said about the muscles, tendons, ligaments & joints ~ there are a lot of them.

Muscularly, there are multiple layers of tissue on the bottom of our feet. The first layer deep to the skin is the infamous yet unusual suspect, the Plantar Fascia. The next 3 layers of muscles, 14 out of 18 are found in the foot, where the other 4 muscles originate somewhere in the leg and extend themselves down into the foot via tendons. Keep in mind; this is just the bottom part of the foot. Significant to heel pain, there are 4 muscles attached to the heel bone. Also there's the Achilles tendon that attaches itself to the back of the heel bone (aka calcaneous), with the Gastronemius & Soleus at the other end of the tendon.

Ligaments-wise, counting them simply undermines their functional importance. There are at least one gazillion ligaments between 2 bones. Each ligament acts to counteract the forces between the bones.

Joints ~ the first one that comes to mind is the “ankle joint”, aka the Mortise joint, aka the Talocrural joint, is formed by the Tibia, Fibula, & Talus. It’s labeled as a hinge-type of synovial joint. But most anatomists negate the complexity of the joint and all that it does, and all that happens to/with it. The other joints, the transverse tarsal joint, and the tarsometatarsal joints are crucial to the formation and functionality of arch .

FYI ~ the Talocalcaneonavicular joint is the third ball-and-socket joint of the body.

Biomechanics of the Arch of the Foot ~ Windlass Mechanism
Windlass Effect is an engineering concept that describes movements of heavy loads. In the foot, windlass mechanism is essential for correct foot/ankle function – and the principle remains simple, and true to its engineering origin.

The Windlass Mechanism is coordinated by the layers of muscle, tendon, ligament and the bony architecture, to maintain arch height, foot rigidity and arch flexibility.

The windlass motion involves the toes extending upward, drawing tension to the muscles and ligaments at the bottom of the foot. This tension pulls all the bones together tightly to maintain height of the arch, converts the foot to a rigid structure, and transfer the forces to propel the body off the ground.

Without correct windlass function, the arch of the foot collapses and fails to act as an efficient lever, thus limiting the push-off power. Faulty or absence of the windlass mechanism will result in additional tension generated onto the structures of the foot. The repetitiveness of the usage of the foot/ankle will result in tissue insult/failure --> PAIN!

Home Regimen (anecdotal success)

• persistent stretching of the Achilles tendon.
• rolling the arch with a golf ball rolling ~ find the sore spot and just gently attend to it (roll in all different directions). If you push too hard onto the ball, your heel wouldn't like it very much. The weight of your leg onto the ball is much enough to loosen things up a bit
• Repeatedly picking up marbles (or wine-corks) with your toes ~ actively strengthening your muscles. Do it until the foot & toes get a tad bit tired, or until you're bored ~ several minutes everyday is a good start.
  
• Ice ~ ice the entire foot with a ice water. 10-15 minutes in the evening
• Heat ~ warm up the foot ASAP in the morning to loosen up the heel

Professional Help ~ If the heel is not feeling better after a week or 2 with some self TLC, seek professional assistance to help address the problem.

• Imagining study ~ a plain film x-ray may be a good start to determine that there isn't a more serious problem, e.g. stress fractures, bone contusion, cysts etc...
  
• Manual Therapy ~ address proper joint biomechanics with mobilization/adjustment of the foot/ankle bones combined with Active Release Technique, Graston Technique to the injured soft tissues (muscles, ligaments, and tendons)... this is a formula I've used to help a lot of amateur and professional athletes.
  
• Orthotics ~ this is a tricky one. The insole is meant to position the foot/arch in its most bio-mechanical advantageous position. It won't necessarily resolve the problem but least the foot/arch has some support. It's your preference if they are custom made at the podiatrist/chiropractor or store bought ones ~ whichever works for you. My favorite in-store insoles are the Superfeet