Remedial Massage for Ligament and Joint Sprains

While a very recent or serious strain may need a special approach, a ligament strain which is not very serious can be one of the easiest injuries to resolve.1

Photo of a sprained foot with a bruise
Yeowch!
We are learning more about how the body responds to strains and sprains during the last 5 to 10 years, and this new research is changing the way we treat these tear injuries for the better – much better.

First of all, before we describe the treatment, let’s quickly cover off some terminology…

What is a sprain?

“Sprain” is the term given to a tear of the fibres of ligaments or joint capsules, different to muscles.

A tear injury to a muscle or muscle tendon, however, is called a “strain.”

In summary:

  • Tendons attach muscles to bones, and a tear injury is called a strain (or rupture).
  • Ligaments attach bones to other bones, and a tear injury is called a sprain (or rupture).
    • Joint capsules hold a joint together, and a tear injury is also called a sprain, since it makes up the capsular ligament.
  • A similar tissue is a meniscus, such as those found in the knee or jaw. This can also be torn, and is called simply a tear or rupture.

Ligaments and joint capsules are made up of pretty much the same stuff: a very firm collagen based cord-like structure.

Ligaments change shape very little as you move, since they stabilise your joints and hold the bones in place, stopping them from going too far. They do not contract, and would only shorten by going slack.

Henry Vandyke Carter [Public domain]
The shoulder joint showing ligaments holding the bones together, and the joint capsule holding the joint together.
When you sprain a ligament or capsule your body responds with its immune system. Inflammation usually happens, and the injured area becomes red, swollen, hot, and painful.

The suffix “~itis” is added to the name of the inflamed tissue, making the technical term for an inflamed ligament injury “ligamentitis.”

If it’s a capsular ligament that is inflamed, it’s called “capsulitis.” In some cases there might be an adhesive capsulitis, sometimes called a “frozen” joint like frozen shoulder or frozen hip.

Scar Tissue: Your friend now, your foe later.

Your body responds to inflammation in ligaments and capsules by laying down scar tissue in a disorganised, patch-work, cross-thatched fashion. This stabilises the site of injury to reduce the potential for re-injury. Then it sends all the nourishment and building blocks to rebuild the injured tissue.

At the same time, gentle movement of the injured area is necessary for the disorganised scar tissue to re-orient itself in the correct direction, so that when the injury heals there is free and easy movement.

If the scar tissue does not re-orient itself, the restricted movement can cause pain. This pain may last for years after the initial injury has healed.

If there is no remaining heat, redness and swelling, and pain only sometimes (that is, only painful when irritated), then it cannot be called ligamentitis or capsulitis. Instead it is more properly called ligamentosis or capsulosis, with the suffix “~osis” telling us that there is degeneration or damage to the tissues without inflammation.

This can still be a debilitating condition, making it hard to perform in sports and exercise or to do normal everyday activities without painful irritation.

Treatment

The treatment for such an injury is a relatively simple four-step protocol.2

  1. Unload the muscles surrounding the injured joint so that they are not pulling on it and stressing the scarred fibres.
  2. Apply multi-directional friction with the pads of fingers or thumbs with no more than a moderate pressure for a maximum of 30 seconds. This softens the disorganised scar tissue.
  3. Compress and then suddenly release the joint tissues to reorganise the softened scar tissue.
  4. Re-test for any pain on movement. If pain still occurs, repeat the process up to three times.

This process turns dysfunctional scar tissue into functional, pain-free scar tissue.3

From dysfunctional…
…to functional.

If the injury was particularly serious, it is important not to over-treat the area and risk inflaming or irritating it further. While most sprain injuries can be completely resolved in just one treatment (especially if it is more than six weeks old) some may need two or three treatments.

It often amazes my clients when they find that the pain they had been living with for weeks, months or even years, having had old-fashioned or out-of-date treatments from other, often very skilled therapists, simply goes away.

Sometimes it looks like magic. But I assure you, it’s just biology.

The problem with old-school treatment for sprains

One final word on the use of painful, aggressive traditional methods of treating sprains and strains.

Back when I was at massage college in 2007 we were taught that to re-organised the scar tissue we should apply cross-fibre frictioning to a deep level for up to six minutes, and that this frictioning would realign the disorganised fibres.

What we now know from solid clinical research4 is that this approach actually further irritates and inflames the tissues, in some cases making it worse.

It is my opinion that this outdated method is barbaric and its teaching should be replaced in the curriculum of manual therapy training centres immediately.

If any therapist is making you tap-out on the table due to the pain of treating a strain or sprain injury, seek another therapist who knows about these new methods.


Sources:

  1. Mally J, “Multidirectional Friction”, downloaded on 27 Jun 2016 from Massage Technique Library.
  2. Waslaski J, 2012 “Pelvic Stabilization And Complicated Knee Conditions” p18, The Institute for Pain Management, Dallas, TX
  3. Waslaski J, 2012 “Integrated Manual Therapy & Orthopedic Massage For Complicated Knee Conditions – Workshop Notes” pp11–12, The Institute for Pain Management, Dallas, TX
  4. Cook and Kahn, 1998 “Patellar tendinopathy: some aspects of basic science and clinical management”, Br J Sports Med 1998;32:346–355