Veronica Selby, LMT, CMMP, recently graduated from SOMI’s Medical Massage Certification Program. While building her theoretical and clinical skills, Veronica shifted her practice from massage therapy’s preventive, stress-reduction application to a fully operational Medical Massage Practice. Our family medicine office refers her patients, and every time she is able to deliver stable clinical results.
The clinical case you are about to read is an excellent illustration of Veronica’s skills. Still, when we read this submission for the first time, we had the reasonable question: How many patients in the USA, even after successful surgeries, still suffer from pain and dysfunction because no one was able to rehabilitate their soft tissues fully?
Please pay attention to how skillfully Veronica juggled various techniques and modalities she learned from SOMI and her clinical experience. While creating the Medical Massage protocol framework, Veronica brought in additional therapies, made the correct choices, and applied them at the right time. This Medical Massage concept is a perfect clinical application!
Dr. Ross Turchaninov, JMS editor-in-chief
MEDICAL MASSAGE VS. CONSEQUENCES OF SEVERE LEG TRAUMA
Veronica Selby, LMT, CNMT, CMMP
Phoenix, AZ
The patient emailed me on Jan 4, 2024, asking for an evaluation. I sent her a SOMI’s intake form and set up the first appointment several days later. She had been in a car accident five months earlier and spent two months in the hospital. Her treatment was followed up by three months of physical therapy with limited progress. She was looking for an alternative clinical solution to help her with the remaining pain and to restore mobility.
This woman had suffered severe fractures of her left tibia and fibula, and fragments were stabilized by surgery using metal plates and screws. Additionally, she suffered from right-side leg compartment syndrome. As a result of the accident and following surgery, a very thick layer of scar tissue had formed on both legs, triggering stiffness and pain in both ankle joints and the left knee joint at the patellar tendon of the quadriceps muscle. Thus, pain and severe restrictions in the legs and feet mobility were the driving forces for her to seek Medical Massage Therapy in our clinic.
EVALUATION
Severe soft tissue adhesions in both legs are visible. Her right foot is in plantar flexion, which additionally affects her mobility.
Skin
The patient experiences almost constant burning sensations along the lateral surface of the right leg. Mobility of the skin is severely restricted. The intensity of the burning sensation increases with even gentle palpation.
Fascia and Muscles
Due to the immobilization of superficial and deep fascia, mobility of the gastrocnemius, peroneal group, and tibial anterior is severely restricted. Different degrees of muscle spasm and tension are registered in the gastrocnemius, soleus, peroneus longus and brevis, tibialis anterior, and quadriceps muscles.
When I tested her ROM in the left hip joint, the patient exhibited limited extension. I also noticed misalignment in the left hip when she went from sitting to standing. Compression tests ruled out possible irritation of the lumbar and sacral spinal nerves.
TREATMENT
My treatment plan included the layer-by-layer application of proper drainage, lateral shift techniques to increase mobility between layers of the soft tissues and slowly eliminate adhesions, scar management techniques, passive stretching, and Postisometric Muscular Relaxation (PIR) separately for the peroneal group, gastrocnemius and soleus, quadriceps, and hamstring muscles. I added cupping and hot stone massage on the legs to speed up treatment to soften adhesions.
Session 1 – 1/9/2024
I started with Lymph Drainage Massage (LDM), draining the inguinal lymph nodes first and the rest of the leg. I added cupping, skin rolling, and kneading according to the patient’s comfort level to help with cutaneous reflex zones and scar tissue. Next, friction along and across fibers of leg muscles and lateral shift techniques were used. I switched to friction on the anterior, lateral, and medial surfaces of the patellar tendon on the left side and decompressed the quadriceps muscle in an inhibitory regime. I finished the session with PIR and passive stretching for all leg muscle groups.
Session 2 – 1/16/2024
The patient’s mobility had increased somewhat, as had her overall discomfort, which was the expected outcome of her first session. She also mentioned that her sleep quality had significantly improved since the last session. Her primary complaint at this time was pain in her right foot upon walking for an extended period. Active dorsiflexion was painful due to the spasm and scar tissue formation along the peroneal group.
I started with her lower back and hips, hamstrings, and calves. Thirty-five minutes of the session were spent on her anterior legs using LDM, active frictions, and lateral shift techniques. I then used mobile cupping with lift around the scar tissue, initially slowly increasing lift and speed. I finished working on the scar tissue by skin lifting, rolling, and using Connective Tissue Massage strokes.
We ended the session by working on her leg muscles with PIR and passive stretching, concentrating specifically on the peroneal muscles. I told her that she might feel the symptoms flare up in the next couple of days, as I expected that to happen.
Session 3 – 1/23/2024
Mobility continued to improve, but the intensity of the symptoms didn’t change. Symptoms around both ankle joints were still a major issue. I concentrated the entire session on the legs using the same protocol. In the end, I did some Active Release Techniques (ART) for her quadricep at the knee insertion and PIR. She noticed some burning when I applied draining effleurage strokes on her lower legs (likely from the stretched skin).
Session 4 – 1/30/2024
With the same protocol, I started to work more deeply and more intensely to apply greater pressure on the entire system of her leg function. I also used hot stones to soften her scar tissue.
Session 5 – 2/7/2024
The only complaint today was that the left ankle had discomfort and stiffness, but without the pain she experienced before. She also reported pain on the medial surface of the left knee. During examination, I found the medial knee to be swollen and tender. The day before, the patient had gone to an acupuncture clinic where the student extensively used needles. I decided to avoid the area and suggested she use ice at home for 24 hours, switch to heat, and do some knee stretching. The soft tissues on the anterior legs, especially on the left side, were noticeably more mobile when I applied lateral shift techniques.
Session 6 – 2/13/2024
During this session, I wanted to address the excessive plantar flexion in her right foot. I concentrated on her gastrocnemius and soleus and worked on all four surfaces of the Achilles tendon, including its insertion. On the left side, I spent more time on the scar on the lateral knee and near the fibular head. I repeated PIR techniques for all muscle groups.
Session 7 – 2/20/2024
I was thrilled to hear that the patient, for the first time, reported only mild discomfort and stiffness since the last session. She was very optimistic since she had started walking longer distances without pain or dysfunction. Her husband had made a big difference in helping her everyday mobility.
I added work on the left IT band to the protocol and PIR, as well as stretching of the tensor fascia latae muscle and IT band. I continued working on the right soleus, gastrocnemius muscles, and Achilles Tendon with PIR and passive stretching at the end. I spent more time on scar tissue on the right anterior leg.
Session 8 – 2/27/2024
Today, the patient reported that she was completely pain-free and no longer had any issues with mobility. She can walk long distances without any discomfort! I told her that since titanium plates are still there, she may experience stiffness, especially in cold weather. I suggested that in the future, she receive Medical Massage sessions once a month as a preventative measure.
I worked the same protocol as the previous session. In the end, I showed her the before and after pictures of the scar tissue on her legs, suggesting that she return in two weeks when we could keep working on the scar tissue on the right side to see how much more improvement could be made. Pictures before illustrate the patient’s soft tissues and post-surgical scar before and after Medical Massage therapy. Originally, the leg was significantly swollen due to the original injury, postsurgical trauma of the soft tissues and lack of proper somatic rehabilitation.
Unfortunately, the day after Session 8, I suffered a traumatic injury and fractured my clavicle, so I had no way of following up with her treatment for a while. However, I emailed her two weeks later to check on her and was happy to hear that she remained pain-free. She no longer had any burning sensations on her right leg. She went on a hike with no pain for the first time since the injury, noticing mild discomfort in her left ankle when going downhill, but the symptoms subsided the next day.
ABOUT THE AUTHOR
I have wanted to become a Medical Massage Practitioner since I first attended Massage School in 2016. I was very fortunate to have an instructor who had trained under Dr. Ross Turchaninov. I attended my first seminar in October 2017 and was overwhelmed by the information, yet hungry for more. After graduating, I worked mostly for spas such as Elements and Hand & Stone. I even met my wife Heather at Elements Massage, where we both worked as massage therapists. We are now on this Medical Massage journey together, forming our practice as a unit.
I have an intense passion for massage therapy. I very much enjoy educating my clients and other therapists on how much potential is held within our hands. Since I have worked in spas primarily, many therapists have not had the opportunity to learn these concepts. I always encourage them to learn more and take additional education, especially from SOMI if they are drawn to that path. I want to help teach Medical Massage since massage therapists need this information more than ever.
My strongest passion is for my client’s well-being. I am constantly studying and grinding to maximize my efficiency in treating my clients/patients. I have enjoyed assisting my clients in recovering from chronic shoulder pain, chronic neck pain, tendonitis etc. I am overjoyed to be a part of their path to wellness. I see it as an exciting challenge to replicate those same successes, only faster. I am in it for the long game of becoming an efficient medical massage clinician who can deliver quick and stable results. I have also had opportunities to network with local physical therapists, sending my patients there for diagnostics and explaining my role in their healing process in the same medical language they speak.
Category: Case Studies
Tags: 2024 Issue #2