Joints: Supports and Anchors in Massage
As a manual therapist, it is important to make sure that the client is comfortable throughout the treatment. This understanding and awareness helps initiative when it comes to taping - both kinesio and stability.
Supports: Supporting the joints whether it be prone, supine, or sideline, with bolsters, towels and/or cushions for example.
Anchors: Support of the joints by the manual therapist to ensure the joint does not compensate during treatment, such as hyperextension or rotation.
Examples of bad support (click on image to find out why they are bad examples):
Example of good support:
What's the difference?
The picture of myself in clinic with Paul "Semtex" Daley (MMA: Bellator, former UFC) shows clear support for the prone position, these being at the head (head not in support due to smiling for the camera), shoulders and feet.
Why are supports important?
Consider why you are treating the client, and what you want to achieve. It is known that movement, especially repetitively, with bad biomechanics and/or posture, can cause the soft tissue to align to the strain, and due to the dysfunction, collagen takes over the elastin capacity causing stiffness. So treating with a lack of support of joints ignores this concept by allowing the client to remain in a dysfunctional posture and thus, reducing impact of the massage. Noting it is important to remain hygienic when using such supports by wiping bolsters down, or using tissue which can be replaced between clients (be environmentally friendly at every opportunity by using recyclable products and ensuring to put them in a recycling bin).
What are the appropriate supports?
- Head: allowing the client to lie face down, with or without a face hole, either a specific head bolster as pictured above, or a towel folded in the shape of a head bolster so that it supports the whole head.
- Shoulders: underneath each shoulder to prevent medial rotation, supporting the relationship between clavicle and scapula. This applies to both males and females, no
- Optional support for lower back: placing a support be it bolster, towel or cushion/pillow, can be placed between navel and hips to reduce lordosis and/or reduce pressure in the lumbar and sacral spine. This is particularly useful when addressing lower back pain.
- Optional support for hip when treating pelvic rotation: if it is found through assessment (ax) that the client has a pelvic rotation, it is important to acknowledge this in treatment, yet to make true impact on realigning tissue matrix, a support is required to create balance between the hips/pelvis.
- Ankles: supporting this structure reduces likelihood of knee hyperextension which strains and sprains the tendons and ligaments, whilst also preventing forced dorsiflexion at the ankle. This is important in general, but especially so when treating the lower limb and back as applying pressure to these areas further increases risk of knee hyperextension and ankle dorsiflexion, thus ignoring the concept of realigning the matrix, reducing impact of treatment, and potentially causing further issue.
- Head: supporting the head in supine is subjective, as the amount of support depends on the spine of the client. A support which is too big could increase strain and sprain on the posterior cervical and thoracic spine, whilst increasing pressure on the anterior head, neck and thoracic cavity which reduces impact of treatment.
- Optional support for lower back: applicable when addressing lordosis, as lying in supine can increase pressure through the lordosis. By using a support be it bolster, folded towel or cushion/pillow, it aids a stretch of the lumbar spine, thus reducing lordodic pressure.
- Knees: lying in supine can cause knee hyperextension which can cause/augment lower back pain. Using a support in the form of bolster, folded towel or cushion/pillow prevents this capacity which increases in risk when treating the lower limbs and lower back.
When working proximal to a joint, is important that the structure remains stable. This can be the elbow when working on the upper limbs in prone, and ankle when working on the anterior lower leg, ankle and foot in supine.
A therapist should be mindful of why they are treating, using initiative when considering what supports and when.
Why are anchors important?
Consider why you are treating the client, and what you want to achieve. To get the best output of treatment, input needs to be the best it can be. When massaging, be it Swedish Massage or Performance Soft Tissue Therapy, the general goal is to reduce tension which increases relaxation and in order to be successful, the therapist needs to take into account the subjective tension lines. This can be initially addressed in assessment (ax), and such notes should be implemented in the treatment - always remember why you are treating and what you want to achieve.
When is an anchor appropriate?
During massage, a variety of pressures are applied and depending on how much tension the client holds subjectively, depends on how their body will react to such pressures. Whether the application is from a pre-competition perspective where pressure remains more superficial, or deep tissue massage, it can cause the body to react in accordance with the subjective tension lines, and thus, compensate. An anchor could be a hand, knee, or forearm, in some extreme cases I've even used my head!!!
- Ankle: Whether you are treating the lower half of the leg or foot with hand or forearm, you can use the other hand to stablise the ankle in a position that aligns the achilles tendon straight, thus the from foot to hip the leg is neither rotated in or out.
- Hip: A technique to release glute tension in prone is to flex the knee and move the lower half of the leg to create soft tissue release (STR) both longitudinally and transversely. However, depending on subjective tension lines, this can cause the knee to move medially or laterally to compensate. This is not condoning the application of deep tissue massage and flexing the knee in a way that is too much for the client, but rather being mindful and respectful to the joints and soft tissue. Watch to see how the body reacts, to which the therapist can then use initiative when deciding if, when and how to counter-act if required. I tend to perform STR in accordance with subjective tension with an elbow, flex and control the leg with the other hand, influence placement of the flexed knee with my knee to reduce compensation, and use the foot on the ground for power.
- Forearm: Working on the forearm can create compensation at both elbow and wrist, noting that treatment of this area can impact fascial tension lines in the upper arm, shoulder and neck. Therefore, it is important to anchor both wrist and elbow to reduce compensation. I find it best to work on the posterior forearm in prone, and anterior forearm in supine as treating in this way works in accordance with Anatomy Trains and makes the most impact. Thus, in prone, I ensure the elbow is supported with a towel, and use my leg as a support for the wrist, treating the forearm with my hand, and reduce compensations through the arm by using my other hand to anchor the wrist and/or hand depending on tension lines. In supine, I support the wrist with my leg, and treat the forearm with my hand and/or forearm, reducing compensations throughout the arm by anchoring the wrist and/or hand depending on tension lines. This technique of anchoring in treatment is extremely beneficial as it complements the aim of creating balance between the anterior and posterior arm by reducing medial rotation tension lines which can begin at the shoulder and travel into the thumb and index finger. This latter note is especially so if assessed (ax) with medial rotation of the shoulder and posturally holding the arm in a medially rotated position also, signified by the palm of the hand facing posteriorly.
Consider anchors and supports subjectively by having an in depth awareness and understanding of reducing tension lines in accordance with improving posture objectively. No two clients are the same so it is paramount that the therapist uses initiative. This helps taping techniques, both kinesio and stability, as it increases understanding of the structures you are taping, whilst raising awareness of the compensations the taping technique is attempting to reduce.
By supporting and anchoring joints, the treatment has much more impact as it enables the tension lines to become more apparent whilst reducing the capacity to compensate. Such techniques are VITAL when treating hypermobile clients as the increased flexibility allows for further compensations, noting that reducing pressure in such treatment is also important to be sympathetic to the extracellular matrix (ECM) composition.