General Indications
Diagnosis
The reduction in pain achieved after a few minutes localised transverse friction may be very helpful to define the exact location of the lesion.
In muscular, tendinous or ligamentous lesions, a few minutes of massage on the suspected spot results in diminished pain on testing immediately thereafter, so confirming the diagnosis as accurately as an infiltration with local anaesthesia.
Therapy
Muscle bellies.
Friction is given to a healing muscle belly after contusion or in minor muscular tears. In minor muscular tears the friction is often part of a combined treatment as it is usually applied after an infiltration with local anaesthesia.
The aim of treatment in muscular tears is to allow the torn fibres to heal in such a way that normal enlargement during contraction remains possible. A muscle belly normally increases in breadth on contraction, a characteristic that can be disturbed by abnormal adhesion formation. Transverse friction aims to achieve a transverse sweeping movement over the longitudinal muscular fibres without pulling on the tear, so preventing (in the early stage) or breaking down (in the chronic stage) adhesion formation between the individual fibres and between individual fibres and the surrounding connective tissue. It is obvious that, to break down crosslinks in a chronic stage the friction can be given forcefully and for a duration of 15-20 minutes, whereas in more recent lesions the technique will be applied more gently and for a shorter duration.
Friction to a muscle belly is always given with the muscle well relaxed.
To avoid early recurrence, friction is given for one week after all clinical tests have become negative. During the period of treatment all movements or activities that bring on pain should be avoided by the patient.
Theoretically, friction can be used for all muscle belly lesions. However, some lesions respond so well to local anaesthetic infiltration that friction is not used. This is the case in a type IV tennis elbow ( lesion at the muscle belly of the extensor carpi radialis) and . On the other hand, sometimes no alternatives exist for treatment with deep transverse friction. A lesion of the sublavius or intercostal muscles for instance can be treated only by deep transverse friction.
It is a common clinical experience that all musculotendinous junctions (containing both muscular and tendinous fibres) throughout the whole body can be treated only by deep transverse friction. It seems that no alternatives for the friction exist: local anaesthetics, so curative for some muscle belly lesion and steroids, so effective at teno-periosteal lesions, have not the slightest effect on musculotendinous lesions, whereas deep transverse frictions usually have.
Tendons.
All over-use tendinitis can be treated by deep massage except for the tenoperiosteal origin of the extensor carpi radialis brevis (type 2 tennis elbow), which is best treated by an infiltration with steroid, in refractory cases sometimes by manipulations.
Lesions at the tenoperiosteal insertion can be treated either with steroid infiltrations or with deep transverse massage. Sometimes the friction, sometimes the infiltration will be the treatment of choice. Steroid suspension converts quickly an inflamed and painful scar into one free of inflammation. However, the recurrence rate is rather high ( between 20% and 25% ). The aim of the massage is to get rid of the self-perpetuating inflammation by breaking up the disorderly organised scar tissue and adhesion formations by converting it into properly arranged longitudinal connective fibres. This takes longer but once cure is achieved there will be fewer tendency to recurrence.
It may therefore be the policy to start treatment with infiltrations and if the trouble recurs after a few months to substitute with massage.
As a rule however, the friction is always choosen as the treatment of choice in athletes or in case the tendon is weakened (partial rupture). It can not be denied that repeated use of steroids, even in small doses and correctly applied, will temporarily weaken the tendinous structure. Steroids also take away inflammation and pain, so giving the patient the false feeling of being cured. The combination of a weakened tendon and abolition of pain can be disastrous for the tendon.
Lesions in the tendinous body (biceps tendon ?) , either traumatic or resulting from over-use are contra-indications for infiltration with steroids. Ruptures have been reported after intralesional infiltrations with steroids of long tendons and therefore deep frictions are the treatment of choice here.(13, 14)
It is obvious that during the whole period of treatment of tendinitis, tenosynovitis or tenovaginitis, the patient must avoid all activities that provoke the pain, especially loading the affected contractile tissue.
Ligaments.
Transverse massage is an excellent treatment modality in acutely sprained ligaments ( superior and inferior acromioclavicular ligaments) .
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