Myofascial Release: DIY PT  (February 2016)

Us vs Them
Oh, to be a natural athlete like a few of our friends: people that break the rules and rarely get injured; the ones that wonder why we and others divert so much time and money into stretching and massage; the lucky individuals that aren’t familiar with a predictable pattern of pain and stiffness with even moderate exertion. I live at the other end of the scale: I have always had a high-maintenance body that demands constant care and counter-action.

I spend 1-2 hours a day, almost every day of the year, tending to the latest dysfunction and hoping to diminish the next one. I’ve just come off of a 3 year period of having one or both knees in pain, or at least highly vulnerable, and am thrilled to again be able to squat as well as tolerate the pressure from kneeling. Happily, I’ve recently wrapped up several years of nagging to show-stopping sacroiliac joint pain that is now reduced to a dull ache. 

In addition to my own self care, I’ve relied on yoga classes and receiving massage for decades to keep me mobile. Together, they’ve kept me active, but I’ve lacked the ease in my body that I’ve longed for, that I know others enjoy. Now I’m wildly excited that, by using the technics in a new book, I’ll be sliding a little bit on the scale towards the natural athletes and their lower maintenance lifestyles. 

My old ankle sprain was targeted for my first ‘mobilization’ & what a success.
Taking It To The Next Level
The book “Becoming a Supple Leopard” (BSL) by Dr Kelly Starrett is worth a look by other non-natural athletes in search of a do-it-yourself (DIY) guide to physical therapy. Marketed to all athletes, it soon becomes clear with reading that the book is targeted to CrossFit junkies and weight lifters. But no matter, both Bill and I quickly found instantly-effective mobilization exercises for our most persistent problems: my ankle and his wrist, as well as the best good-posture cue I’d ever learned. I bought the 2nd edition (2015) from Amazon for about $35 though the list price is $60. 

I would hope that there are other myofascial release books out there that are better than Starrett’s—one’s with less reliance on weight lifting examples—but it’s the first resource I found and it’s doing the job well for us. The pictures in the book tell most of the story and once you get started, the book is easy to use.

I fully expect Starrett’s technics, which are largely myofascial release strategies, to take my tissue health to the next level. The Trigger Point roller that I began using 18 months ago also effects myofascial release but Starrett’s intense technics add a significant new dimension to the process. 

Myofascial Release
What It Is
“Myo-” refers to muscle and “fascial” references fascia, or the mesh of connective tissue that envelopes muscles and bones, among other functions. Injured or overused muscles can develop knots or “trigger points” in them that constrict blood flow to the tissues, resulting in pain or poor function. One can develop a single knot or a patch of knots that will also compromise the normally soft, loose, fascia, compounding the restrictions. And of course, the “release” is about unknotting and smoothing the distorted muscle and fascial tissues.

Bill is delighted to be restoring lost range of motion in his wrist with this ‘distraction’.
Myofascial release is usually achieved by tissue compression or “smashing” as Starrett calls it. Typically you position your troubled muscle over a softball or lacrosse ball resting on the floor and then press as much of your body weight as possible into it. You can maintain the pressure for a count of 20 seconds and then release or slowly drag and stretch the fascia over the ball to force it to tear loose from another structure.

Bill has also benefited from Starrett’s “distraction” technics, which are totally new to us. For one distraction, Bill loops a stretchy exercise band around a post as well as wrapping it around his wrist and then applies steady pressure on the target joints to force them open. Both distraction and smashing are slow, painful, tedious technics but we’ve found them to be highly effective.

What It’s Done For Us
After 2 weeks of use, I declared Starrett’s technics as being on our top 5 list of earth-shattering performance enhancers in the last 30 years, along with yoga, massage, forefoot striking, and the ketogenic diet. Some of Starrett's technics are totally new to us, others are extensions of concepts we know, and each technic we apply to a problem area produces immediate results. Complete cures of a problem may require weeks or more of daily work, but seeing and feeling any progress after 5 minutes of effort on an ancient source of pain or discomfort was highly motivating.

For my body, Starrett’s strategies don’t displace other soft tissue care technics like stretching and massage, but add to them. I’ll continue with my deep yoga practice and receiving sports massage even though they haven’t unraveled all of my imbalances. 

I had hoped for years that mixing in other modalities like Aston Patterning, cranial-sacral, Egoscu, and chiropractic would solve my chronic problems and vulnerabilities, but my old gremlins were escaping detection by these highly skilled hands. Having explored so many approaches made it all the more surprising that Starrett’s technics were, one by one, laying those buried gremlins bare and accessible. We both suspect we are breaking up old scar tissue by using what seems to be cross-frictional massage technics. 

We are dazzled by this book. Bill said “I thought it was a dumb book but now I’m convinced.” I’d been feeding him bits: “This might be good for your wrist; This one sounds like what you do…” Now he goes looking on his own. He had been complaining about his hands/wrists for years and no one had been able to help him much. Recently, he started doing his own massage, with some benefit. But each of the Starrett’s several “mob’s” (mobility exercises) gave him relief the same day. I sprained an ankle in college and presumably that is what has been acting up the last 3-4 years.  The first mobilization I tried from the book gave me near-instantaneous relief.

You do not need to have a command of anatomy to use the BSL book but nonetheless, it is not for the uninitiated. I read about a fourth of the over 400 pages before I jumped ahead to find my first ‘fixes’ that I identified from the author's self-tests. Starrett is a little too slow to define some of his CrossFit terms and a little more clarity on a few of his captions would help, but I like his optimistic, ‘go for it’ attitude and I don’t disagree with anything he has said so far. My only caution about this text is that his target audience is clearly highly durable athletes, which most of us are not, and that his “Level 3 Mobilization Tools” are probably best left to people with dense tissues, which I don’t have. 

Speaking of pain: pain is unfortunately a necessary part of the process with most if not all of Starrett’s mobilization technics. He guides the reader through repair processes or mobilizations to restore dense, stuck tissues to health. If these tissues haven’t yielded to stretching or massage, you are likely in for some serious pain to achieve results. He speaks of passing out or puking—end points I never tolerate in anything I do. I am content to progress more slowly, playing the edge of my pain tolerance well back from such extremes. But I do believe from prior experience with “breaking up scar tissue”—which was my introduction to massage in the mid 1980’s--that pain is unavoidable. The advantage of DIY like this is that you can calibrate the pain but you are also charged with the discipline to do the work.

Partner smashing Bill’s quads in our cramped cabin at Phantom Ranch.
Minimal Equipment Needed
As essentially full-time travelers, we also deeply appreciate “Becoming A Supple Leopard” because its technics don’t require a jungle gym of equipment. We’ve been able to do every mobilization technic that has caught our eye using the self-care toys we already have. We have been using our Trigger Point roller, a softball, a lacrosse ball, a tennis ball, a golf ball-sized ball with a knobby surface, a rolling pin, and a dense but stretchy exercise band. After about 2 months, I added 2 myofascial release balls the size of a tennis ball, but more dense, to our kit. 

I was thrilled that some of Starrett’s technics require no tools at all, only a partner. Granted, a softball is usually easier to come by than 15 minutes of a partner’s hard work, but sometimes a partner is all that we’ve got. We were only days into doing “Leopard” mobilizations when we began our 4 night stay at Phantom Ranch at the Grand Canyon. Taking a softball along on the trek would come at the weight/volume expense of having 2 less avocados in our food stores, so we left the softball at home. We did however use Starrett’s partner ‘smashing’ technics on each others quads: massive, hard-working muscles. It was very empowering to have a way to work, without equipment, on quads, hamstrings, calves, and glutes should we need to in order to hike out comfortably.

An Early Success Story 
I’ve struggled to keep up with Bill on descents since we began hiking in earnest 10 years ago. Switching to forefoot striking in minimalist shoes in 2009 was my first break-through and with each passing year, I closed the gap between Bill and me a little bit more.  However, I’d reached the point that whenever I pushed myself to go faster, I immediately began stumbling and falling. Adding trekking poles on big descents a year ago allowed me to pick-up the pace a bit more because I could usually interrupt a fall with the poles, but I still couldn’t quite keep up with Bill.

The simple tools we use to effect Starrett’s ‘mobilizations.’
My protracted analysis as to what was still holding me back ended with the conclusion that it was a clunky relationship between my eyes not focusing quickly enough on the rapidly changing terrain through massive correction in my progressive-lensed glasses and my aging brain that couldn’t process the information smartly enough for my feet to move faster. That was a frustrating conclusion because I felt powerless to improve my descent speed further.

Lucky for me, it was a soft tissue problem, not a vision or brain problem at all. It was probably a combination of decreased mobility in my knee and ankle joints and disturbed proprioception (spatial awareness information transmitted to my brain) in my ankle that was making me unsteady and therefore slow. Whaling on my first 2 target areas, my lower quads and my old ankle injury, using BSL’s smashing technics, transformed my descending skills in less than a month. I was suddenly gliding down steep, rocky trails without poles and without stumbling.  Not only was I able to reliably stay on Bill’s heels, I could tease him about slacking a little now and then. Talk about feeling transformed!

The Range of Challenges
Simple Fixes
Both Bill and I were lucky: our very first efforts with Starrett’s mobilization technics hit pay dirt. For me, it was a single muscle that was probably glued in place between 2 bones after an ancient ankle sprain. I knew where the greatest source of irritation lived and when I looked at Starrett’s recommendations for mobilizing an ankle, I spotted an exercise that looked like what I needed. I quickly switched from the recommended tennis ball to a small, hard ball with little knobs on it to get deeper between the bones. It was serious pain but I could tell it was going to improve or fix the problem the first day I tried it.

Massage folks had worked on my ankle off and on for years and in what I had hoped would be a final push, I had had 4 different practitioner’s using 4 different modalities tackle my ankle restriction and pain this fall with only slight progress. I was stunned that the first mod I tried had the potential for a cure. After about a month of near daily, painful sessions, I thought it was likely fixed but that perhaps it now needed to heal. I backed off on the prolonged, deep “ripping and tearing” sessions and substituted more maintenance-like tactics, sometimes only using the tennis ball to stimulate the circulation in the tissues. After about 6 weeks, my ankle passed all of my assessment criteria and I declared it healed. I will however continue gentle work on it several times a week to prevent new adhesions from forming while the deeper healing continues. 

Bill had been struggling with a host of thumb and wrist issues for a number of years. He had almost entirely lost the ability to do push-ups because of restrictions in his wrist. Like me, he looked at the pictures of the remedies in BSL and spotted one that seemed like it would improve his wrist range of motion. One session with his top pick from BSL and he knew it had already improved a smidgen. He wasn’t ready to declare a cure at 6 weeks like I was with my ankle, but he was absolutely thrilled to have regained so much functional range of motion and was highly motivated to continue pressing for more.

These are both examples of what I think of as simple fixes—straight-forward, though slow, remedies to address a well isolated problem. I found 1 tactic for my ankle, Bill found 2 for his wrist, and we each hammered away at them and we both made steady progress in improving lost function. After about 2 months of intense effort on other, more complicated problems, we each branched out to new regions of the body and again found more relatively simple problem areas to heal, like my jaw and low back tightness and Bill’s side-torso constrictions.

Complex Fixes
The second major mobilization projects that we each embarked upon while continuing to work with our simple fixes, were our quads, the 4 massive muscles of the front thigh. For both of us, the problem areas and the optimal mobilization technics weren’t at all clear. After about a month of work, what was clear was that we each had a tangled mess that we still didn’t understand. Luckily, a few weeks later, we both were on an accelerating journey towards closure with the irritated muscles.

We began our quadriceps journeys by using a partner technic that Starrett calls “Superfriend Smashing". The recipient lies on the floor on his or her back, the helper stands and ‘saws’ the arch of one foot crosswise on the quads with maximal pressure. It was tiring, tedious work requiring a minimum of 15 minutes per person to do a reasonably thorough job. The results were promising but the progress was so slow that we soon began developing our own technics. We found that the helper could get into the outer, lateral surfaces of the thigh from a seated position and that both sides of the thigh could be worked in standing but by hooking a heel around the muscles. It seemed that it was going to take many months to soften up our quads, but we were determined to keep at it.

Somewhat abruptly, Bill’s quads on his right leg became hypersensitive. Doing little more than touching his thigh with my foot had him writhing in serious distress to the point of no longer being able to receive the work. We had to abandon the partner work on his thighs and he began doing penetrating massage with a wooden baton. After about 10 days, he was convinced that it was a single non-quad leg muscle, an adductor, that was the ring leader. With that clarity came memories of injury to that area years ago. Curiously, even though the adductor was fairly deep, touching distant parts of his quads made him squirm. It took weeks of myofascial release work on the adductor alone before he could resume much work on his other thigh muscles.

I had a similarly circuitous journey with my quads though it didn’t trigger the global reactiveness in my thigh muscles like had happened in Bill’s. Bill religiously smashed my quads almost every night for weeks without as much progress as seemed warranted. I started adding other releases on my own until I was spending equal time on my ITB on the outer surface of the thigh, the thigh muscle attachment in the lower leg near the knee, my lateral glutes (buttock muscles), and the adductors of my inner thighs. 

My time commitment to self-smashing shot up because I was deeply working so much surface area and it was feeling like a 6-month-long project to unravel it all. But one day I felt like I might be reaching the tipping point, that “peeling the onion” or working through the layers on so many muscles of my thighs and hips, was having a synergistic effect and that they were all starting to get better at the same time. 

Both of us immediately had welcome, improved shoulder mobility using this smashing position.
Only then could I confirm a suspicion from months before, which was that much of the painful pull on my knees wasn’t coming from my quads alone, it was from the Sartorious muscle, a long, ribbon-like, superficial muscle that crosses the thigh diagonally and attaches below the knee and at the hip. This had been a very complex fix: it had taken working on about a dozen muscles simultaneously to identify the culprit and only then could I effectively target release for it.

Along with being alert to the fact that your quest for myofascial release in one area may require prior release in other tissues first, know that sometimes the sequencing of your work may reverse from what you have known about your body in the past. 

Charts showing ‘referred pain’ or pain that occurs other than where the source of the irritation resides, indicate that dysfunction in SI joints (sacroiliac) can cause pain in the low back on the same side. The Quadratus lumborum and Erector spinae muscles reside adjacent to the spine and they can hurt solely because the SI joint of the pelvis is irritated. When my SI joint pain was raging, massaging these low back muscles did little to sooth them.  

But almost a year later when my SI joint was nearly healed, I realized that my pain now went in the opposite direction: it was tightness in the low back muscles that was adding to the irritation in my SI joint. This time, since the SI joint was much healthier, working on the low back muscles was actually beneficial to my SI joint, though it wasn’t immediately obvious. Persistently using a myofascial release technic on my low back muscles finally opened the door and I got through the armoring and protecting of the muscles so I could release those tissues. I could immediately feel that the release of the lumbar muscles was going to help my SI pain even though that hadn’t been true in the past.

Other Lessons Learned
Keep At It
The common lesson learned with all of our early myofascial release work was, no matter how frustrating, “Keep at it.” Usually we instantly knew that the release technic we were using would directly deliver the results we were pursuing but at other times, we felt benefit but with no certainty of success. We learned to trust that if we found a hot spot, we might as well go after it even if it seemed like a detour. Best to ‘press on regardless’ in this enormous house cleaning project and clear out the messes as we encountered them. And we became convinced that sometimes what seemed like a circuitous route was probably the best pathway to healing.

"Keep at it” also paid off when going after muscles that seemed fine, like my left low back muscles that were intertwined with my SI joint pain. The same was true with my quads: I’d regularly used a Trigger Point roller on my quads for over a year and thought the tissues were pretty healthy and no massage therapist had suggested otherwise. It took hours of smashing to finally gain the access to the trigger points that I needed to confront and then for the tissues to yield. Patience and persistence are paramount to achieving results with myofascial release work.

Online Help
I found looking online for specific trigger points to be very helpful, especially for the ITB of the lateral thigh and for the Sartorius of the front thigh. Search “sartorius trigger points” and wonderful illustrations will pop-up to guide your smashing. The labeled muscle illustrations at the beginning of many chapters in BSL will aid your searches if you have no anatomy knowledge or need some serious refreshing of your memory.

A Transformative Journey
I’ve armed myself for the aging process with several mantras and the myofascial release technics we are using from BSL are making 2 of them seem wise. One is “Discipline is the key to aging well” and having the discipline to do dozens of hours of painful ’smashing’ is paying huge dividends and should for years to come. My second tenant is that “Aging is largely an accumulation disorder” and that many ‘accumulations’ can be reversed. We believe that that is precisely what is happening with our myofascial release project: that we are clearing out decades-old accumulations in compromised tissues. At the 2 month point in our deep-cleaning project, we could see it and feel the effects when we more smoothly glided down steep hiking trails at ever increasing speeds and felt healthier mobility in our hips, knees, backs, shoulders, ankles, and wrists. We’ll keep smashing in hopes of becoming slightly more like natural athletes.