Bone immobilization—how it is affected by the surrounding muscles and how it affects those muscles—should be a consideration in any massage work.
Once, a woman working for the Tennessee Board of Massage Therapy told me that as a massage therapist I was not legally allowed to touch bones. I asked her how I was supposed to give a massage without touching bones, and she replied, “I don’t know, but you have to find a way.”
Bones are an integral part of what we do as massage therapists. Muscle mass and bone health are interconnected, according to research. As the old anatomy equation indicates, muscles move bones at joints.
If one part of this equation is immobile, misaligned, hypertonic, hypotonic or inflamed, all parts of the equation are affected.
While any of these descriptors can cause imbalance and pain, immobilization of a bone is a multilayered accomplishment.
Generally, a hypertonic muscle that moves a bone out of alignment and into an unnatural position will not cause the bone to become immobile; however, a few hypertonic muscles that move the distal end of the bone one direction and the proximal end of the bone a different direction can absolutely create immobilization of a bone.
For example, “Mary,” a client, presented with osteoarthritis in the metatarsophalangeal joints of her big toes.
Six years after first noticing the pain, she had a surgical resection of the first metatarsal in her right foot.
She now has one screw in the right metatarsal.
While she has no cartilage in her right first metatarsophalangeal joint, the resection created space in the joint, which led to natural movement and little pain.
Two years later, she had a partial joint replacement in the first metatarsophalangeal joint of her left foot. The prosthetic was placed into the proximal phalanx.
Six years after the partial joint replacement, the prosthetic failed, the left big toe’s motion was extremely limited and the pain was severe.
The diagnosis was hallux rigidus, a form of degenerative arthritis.
The only solution was to have the first metatarsophalangeal joint of her left foot fused.
Mary waited six months after the original doctor’s appointment to get the surgery.
In that time, the compensation patterns in her body multiplied. Her right foot preferred oversupination and her right leg had been in a laterally rotated position for a long time.
In compensation, the left foot had been mildly overly pronated and the left leg had been mildly medially rotated.
The pain in her left big toe caused Mary to oversupinate her left foot with every step. In compensation, her left lower leg began to move lateral, and within a few weeks, her left leg became laterally rotated.
The right leg was unable to compensate for this. At first, Mary’s pain was in her left hip, then in both sacroiliac joints. Finally, a month before the fusion surgery, the pain landed in her right femur.
Her right femur had become immobile. Her right tibia was pulled lateral from the position of her right foot. This means gastrocnemius, popliteus and plantaris were pulling the lower femur into a lateral position.
In order to compensate for the left-leg position and remove pain from the sacroiliac joints, the body needed the right hip to rotate medial.
Iliacus, tensor fasciae latae, gracilis and adductor magnus were pulling the hip into medial rotation.
The proximal femur attempted to follow the hip bone, but the distal femur needed to move into a lateral position. The femur became stuck between the warring muscle factions.
As the femur immobilized, other muscles became involved, namely the deep-six lateral hip rotators tightened and then became motionless.
Two of the deep-six lateral hip rotators are also muscles of the pelvic floor; specifically, piriformis and obturator internus.
Because Mary’s right hip was hypertonic, motionless and inflamed, the right side of her pelvic floor reacted and she began to have a pelvic-floor imbalance.
Symptoms included intense burning along the femur, an inability to move in any direction without extreme pain, and severe pain that moved based on Mary’s activity.
If she sat for a period of time, the pain would be in the pelvic floor, or deep inside the sacrum. After sleeping, the pain would be in the right hip joint. Walking for any period of time would cause the pain to move to the right knee.
Several sessions of work revealed Mary’s right femur was immobilized and was the cause of the tremendous pain she was experiencing.
I used specific range-of-motion work on Mary’s thighs, hips and lower legs to ascertain whether normal movement of the bones was present and which muscles and ligaments needed to be released to restore normal movement.
These few sessions also revealed to me working on the right femur or even the right hip had little to no effect.
Mary’s right gastrocnemius, soleus and popliteus were exceptionally hypertonic, adhered and inflamed on the lateral side of her lower leg.
When these muscles were released, the tibia was able to move into a more neutral position and the femur immobilization was alleviated. This considerably lessened Mary’s pain.
Additionally, when the left adductor magnus, tensor fasciae latae, piriformis, gluteal muscles and hamstrings were released, the left thigh and hip were no longer in a laterally rotated position and the proximal right femur was able to move again. This also significantly decreased Mary’s pain.
Now, for Mary, the pattern was going to repeat itself until the surgery.
As long as she pulled her left foot into supination with every step, the compensation would continue. This example does let us see, however, an immobilized bone can cause muscle tension, pain and rigidity, such as that in the deep-six lateral hip rotators.
On the other hand, muscle tension, rigidity and imbalance, such as that in gastrocnemius and soleus, contributed to the immobilization of the femur.
Without understanding the relationship of the talus to the tibia and the tibia to the femur, the immobilization of the femur and, therefore, the pain created by said immobilization would have been impossible to alleviate.
Further, without an understanding of how the calf muscles impact the tibia and femur, it would have been difficult to help with Mary’s complaint.
Let’s look at another example.
Temporal bone immobilization is common and can cause a variety of symptoms, including tension in one side of the jaw, which can lead to clenching of the teeth on that side; an imbalance of both anterior and posterior neck muscles; temporal headaches, occipital headaches; and misalignment of the sphenoid bone.
Recently, one of my clients, “Barbara,” presented with frequent, excruciating occipital headaches and posterior muscle tension. The most common place to begin working, of course, would be the suboccipital area.
However, I find most occipital headaches are caused by an imbalance in the longus colli and longus capitis muscles in the anterior neck; specifically, longus capitis, which inserts on the basilar aspect of the occiput, the area just anterior to the foramen magnum.
This means if one longus capitis muscle is hypertonic, it will pull the occiput to that side, immediately creating an occipital imbalance. In Barbara’s case, it was not possible to assuage her occipital headaches by simply correcting this muscle imbalance.
In her case, the imbalance in longus capitis was only one component in a temporal bone immobilization.
Generally, if the right side longus capitis is hypertonic, then the right jaw muscles are hypertonic.
However, for Barbara, the right longus capitis and the right lower jaw muscles, including geniohyoid, mylohyoid, digastric and stylohyoid, were hypertonic, but her mandible was shifted to the left and the left mastoid and temporalis muscles were tight.
Within the first session, I understood that her sphenobasilar joint, the joint inside the cranial base between the occiput and the sphenoid, was misaligned.
The occiput was being pulled to the right, while the sphenoid was being pulled to the left
With further assessment, I began to understand her maxillae and palatine bones were also shifted to the left. Both the maxillae and the palatine bones articulate with the sphenoid.
It was hard to say whether they were pulling the sphenoid to the left or the sphenoid was moving them to the left. However, it was obvious the temporal bones were caught between the position of the occiput and the position of the sphenoid.
Through the sphenosquamosal sutures and the occipitomastoid and lambdoid sutures, the temporal bones articulate with both the occiput and the sphenoid.
To mobilize the temporal bones, I would have to release the muscles in the anterior neck, including the hyoid muscles, along with the suboccipital muscles.
Additionally, the sphenobasilar joint needed to be realigned, and the sphenoid could not be released until the maxillae and palatine bones were released.
Although I knew early on a temporal bone immobilization was the cause of Barbara’s agonizing headaches, the only way to mobilize the temporal bones was with an understanding of what effected the temporal bones’ immobilization and what was affected by the immobilization.
For example, temporal bone immobilization could cause tension in both the anterior and posterior muscles of Barbara’s neck.
Splenius capitis and longissimus capitis both attach to the mastoid process of the temporal bone, as does sternocleidomastoid, digastric and stylohyoid muscles.
But it is just as possible the temporal bone was affected by the muscle imbalance in longus capitis, which pulled the occiput to the right and tightened all the posterior muscle tissue attaching to the occiput.
This imbalance coupled with the maxillae and palatine bones moving left would have shifted the position of the temporal bones and affected all musculature attaching to the temporal bones.
Either way, mobilization of the temporal bone meant working in more than one area, releasing muscles, mobilizing bones and having an understanding of the compensation pattern.
In Tennessee, the law states any issue to do with bones has to be referred to a chiropractor.
I agree chiropractors are invaluable, and working with one can be beneficial to clients.
However, in both of the examples provided in this article, my clients’ chiropractors were unable to help the pain because of the muscular involvement.
Whether you work in private practice or with a chiropractor (as an independent contractor), you should possess a liability insurance policy that covers many modalities and protects your in case of client accident or injury.
As massage therapists, we are not trained to manipulate bones—but by understanding the relationship between muscle and bone, and which muscles and ligaments to release, we can help alleviate bone immobilization.
About the Author
Dawn Lewis, LMT, has been a massage therapist since 1995, and a massage and anatomy instructor since 1997. Spontaneous Muscle Release Technique (SMRT) is a modality she created in 1996 and began teaching in 1997. Through Full Circle, Lewis teaches SMRT throughout the country and via DVDs.
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