By Sue Rochman

Training & Conditioning, 10.2, March 2000, http://www.momentummedia.com

Treating the Athlete

Beyond Stretching

Myofascial release combines stretching and massage to relieve tight fibers that result from injury that other modalities may not be addressing.

Sue Rochman is a freelance writer based in San Francisco. She is a regular contributor to Training & Conditioning.


“The missing link.” These are the words therapists use again and again to describe the role of myofascial release (MFR) in healing acute and chronic soft-tissue injuries. Is it possible that the oft-overlooked fascial system is the key to such injury treatment? Although there is virtually no research to support this claim, those who have studied the fascial system and developed the current MFR techniques are convinced that the answers to chronic pain problems reside inside the fascia’s tangled web.

The fascial system is made up of thin, three-dimensional tissue that runs throughout the entire body. Fascial tissue surrounds all of the body’s organs and bones as well as every muscle and muscle fiber. In its normal state, the fascia should be relaxed and smooth, and its layers should glide fluidly against one another without restriction or restraint. Inflammation, injuries, and the cumulative effects of poor or uneven posture, however, can cause the fascia to become shortened, tight, and hard, and cause the fascial layers to stick together. It is believed that these fascial restrictions can contribute to chronic pain, negatively affect performance, and potentially lengthen an injured athlete’s recovery time.

“When an injury occurs, the layers of the fascia become hard and glued together, as if they had been covered with hairspray,” explains Jill Cohen, CMT, an instructor and practitioner of MFR, in Santa Cruz, Calif. “With myofascial release, we can take the glue-like substance—these adhesions—and expand and stretch it so that the fascia glides as it once did.”

“The fascia isn’t separate from the muscle,” adds John Barnes, PT, President and Owner of the Myofascial Institute and one of the primary originators of MFR. “It interpenetrates the muscle down to the cellular level. And when the fascia, which is very powerful tissue, tightens down, it’s like an internal body-stocking that has shrunk. When that occurs, the muscle cannot elongate properly, and a shortened muscle can’t accelerate properly, no matter how much you work out.

“The problem is that the typical tests used to diagnose injuries don’t detect damage to, or restrictions in, the fascia,” he continues. “But the fact is that all injuries go through an inflammatory process that causes the fascial system to tighten. And a lot of recurring injuries athletes endure are actually old, unrecognized fascial restrictions, which is why they never really get better.”

Osteopaths first began addressing the role of the fascia in treating soft-tissue injuries in the 1950s. Since then, the principles that form the basis of MFR have become better understood, resulting in an expansion of specific stretches and styles for treating fascial tightness.

In some ways, modalities such as connective tissue massage, Rolfing, and soft-tissue mobilization are similar to MFR. Unlike Rolfing, however, which is often painful and rough, MFR is gentle and relaxing. And, while at first glance MFR may look like massage, the goal of myofascial release is to return injured, tight, hard fascia to its original smooth, soft state. This is accomplished through the use of stretches designed to equalize the muscles and to remove restrictions, thereby improving muscle and nerve function.

Not everyone is convinced that MFR is the holy grail of sportsmedicine some tout it to be, however. Most practitioners of MFR stress that the techniques are most effective when they’re combined with other modalities, and some believe that the fascia is just one small component that must be addressed following an injury. And, of course, there are those in the general medical community who scoff at it altogether.

How it Works
One of the reasons MFR has had trouble catching on in mainstream sportsmedicine is that it requires an intuitive, subjective approach. “Myofascial release,” explains Carol Manheim, author of The Myofascial Release Manual, “is a highly interactive stretching technique that requires feedback from the patient’s body to determine the direction, force, and duration of the stretch and to facilitate maximum relaxation of the tight or restricted tissues.”

By “listening” to the body’s physical reactions and to the patient’s verbal feedback, the therapist determines in which order fascia and muscles will be stretched, how much force should be used, and how long the stretches should be held. The stretches are not released until the therapist begins to elicit a process referred to as “unwinding.”

“Unwinding,” explains Barnes, “is when the body starts to move spontaneously to the position it was in before it was injured or traumatized. When it hits those positions, the holding patterns that were in the subconscious come forward to the conscious level, which is nature’s way of letting the body learn and let go.”

Of course, athletic trainers teach athletes stretches all the time. But experts in MFR say their stretches differ in significant ways. “Unlike traditional stretching techniques,” says Barnes, “with myofascial release you feel for the restriction and then, instead of sliding through it, you wait there. After you get through the first barrier, you get to the second barrier, which is what has been missed in traditional therapy. And you have to wait there a minimum of 90 to 120 seconds, pressing into the restriction with a gentle, sustained pressure without sliding. And when you feel the release, it feels like taffy stretching, and then you don’t slide, but instead, you just take the slack out of the system and move to the next barrier. The fascial system is like concentric layers of an onion—there’s barrier after barrier, and you have to be patient, take your time, and go through each barrier.”

In effect, over the course of several sessions, the stretches that comprise MFR are believed to initiate a process of neuromuscular reeducation of the fascial fibers. “What happens is that the person’s body is used to being stuck and restricted in that position,” explains Michael Schwahn, CMT, Administrative Director of, and massage therapist at, Midwest Myofascial Therapy Center, in Minnetonka, Minn. “During the first treatment, we will release the area, but then over the next few days, the tissue will tighten up and go back into that restricted position, because that’s how it’s used to being. On the second visit, we do the releases again, and this time, when the tissue tightens back up, it’s not going to be as tight as it was the first time. This process occurs after each session, and each session builds on the last one to make the area gradually become less tight.”

A Whole-Body Approach
There are many ways in which an assessment that MFR practitioners do is similar to what athletic trainers do. For example, if a swimmer had shoulder pain, a myofascial release therapist, like an athletic trainer, would begin with range-of-motion and other traditional tests to determine the type of injury and the location and extent of the pain. But then the techniques would diverge.

For most MFR practitioners, a large component of any assessment and treatment is a postural evaluation. Based on the information received, the therapist uses specific types of releases designed to reduce or eliminate pain, tightness, or a lack of range of motion and to address postural imbalances.

“If someone came in with a rotator cuff injury, for example,” says Schwahn, “we’d first do a history and then look at the posture to see if one shoulder is lower or more rounded than the other, if one scapula is higher, and then look at the alignment of other areas of the body as well. Then we’d put the athlete on the table and palpate the area to see if and where we can feel restrictions and tenderness. After that, we’d use gentle techniques to warm up the area and then use compressions and a cross-hand stretching technique to induce unwinding in all areas that might be affected, such as the interior thoracic area, the pectoral muscles, and the rhomboids.”

This is a key tenet of MFR—that restrictions and adhesions in the fascia in one part of the body can affect and cause pain and reduced range of motion in other areas. “While we, of course, look for the symptom, we also look elsewhere for the cause,” says John Sundquist, CMT, Program Director of, and massage therapist at, Midwest Myofascial Therapy Center. “So, for example, if an athlete had a hamstring injury, we’d address the injured area of the leg, but we’d also look elsewhere to see if the hips are torqued or rotated and at what else is happening with the body. It’s a whole-body approach.”

“I don’t look at the body as separate muscles,” agrees Cohen, who worked with MFR for a number of years on swimmers with chronic injuries at the University of California, Santa Cruz. “I think of it as one big piece of cloth or fascia. And where there is a snag that is pulling the garment—the body—off, I’ll work in those areas, so that the opposing muscles have equal strength and the body isn’t fighting just to be erect.”

This whole-body approach, based on identifying and treating restricted tissue, has led many athletes to MFR treatments when injuries are not present—to improve performance by addressing problem areas that may not yet have caused injuries but are impeding optimal body movement. And there are few limitations to when MFR can be used. “As with other techniques,” says Barnes, “you would follow normal precautions and not do myofascial release on a recent fracture or in an area where there is an open wound. But once that is ruled out, it’s completely safe.”

Combining Benefits
MFR is a technique that can be easily incorporated into the work that physical therapists, massage therapists, and athletic trainers do. Think of it as another modality—one that works particularly well when combined with other whole-body approaches. A common scenario is using chiropractic adjustments within an MFR framework of assessment and treatment.

“By combining the myofascial release with chiropractic approaches, I’ve found that I can shorten treatment time and improve treatment outcome,” says William Charschan, DC, CCSP, head of Charschan Chiropractic and Sports Injury Center, in N. Brunswick, N.J., and former Medical Director for USA Track and Field. “Most of the pain syndromes that individuals experience have a lot to do with shortened fascia, even though the fascia itself doesn’t really cause pain. With this combination, I’ve been able to take athletes whose muscles are functioning at 20 to 30 percent capacity and bring it up to 80 to 90 percent or even 100 percent.”

It was frustration with not seeing their clients get better when treated solely with traditional massage techniques that led both Schwahn and Sundquist to seek training in myofascial release. “I’d see patients hit this plateau,” says Schwahn, “and they wouldn’t move beyond that. I kept thinking, ‘There’s got to be something else out there.’ And after the training I had in myofascial release, I had better results in one month than I’d had in the previous seven or eight months on some of the patients I’d been working on.”

Schwahn and Sundquist say they have found that the focus that MFR puts on posture is especially important for athletes. “The role that posture plays in performance is often not addressed,” says Schwahn, “so we often discuss with athletes how bad posture can cause the fascia to bunch up in certain places. This creates a pull or drag throughout the whole body, which can cause pain and negatively affect their performance by reducing strength and flexibility. Also, chronic conditions can worsen if the body isn’t aligned.”

Not a Panacea
Not all of those familiar with MFR sing its praises quite so loudly, however. John Woolf, ATC, PT, Head Athletic Trainer at the University of Arizona, has been incorporating MFR into his work with athletes since 1991. While he finds it helpful, he is less enthusiastic about its potential than many of those who specialize solely in this area, and he particularly questions the connection MFR practitioners make between posture and pain.

“To suggest that someone’s posture is causing the pain is inaccurate,” he says. “There’s no reliable research at all to suggest that somebody’s posture may be contributing to the mechanical stress on the tissue that is causing the pain.”

That, he says, underscores the main problem he sees with attributing too much credit to MFR. “I think those who see it as an end, although they do have results, you don’t know if those results can be attributed to this. There’s very little research in the literature, in part, because it’s a very ‘feeling’ modality, which means there isn’t the reliability that what one person trained in myofascial release will do is the same as what another person will do on the same individual.”

“I use it as a tool to decrease pain, to improve range of motion, and to restore function,” Woolf says. “And that’s important to point out, because sometimes people start to diagnose the problem based on this paradigm of a fascial constriction. I’m not firmly a believer that there is a diagnosis of myofascial dysfunction.

“This is an extraordinarily important differentiation,” he continues, “because I feel that people—athletic trainers, physical therapists, and massage therapists—may feel as if they are making an accurate assessment of the problem based on the myofascial status. It’s a tool athletic trainers can use. But I don’t feel that if an athlete came in and said he had back pain, that I would say he had a myofascial problem and start doing myofascial release on him. I would do an evaluation and use the releases as a tool to help create the environment somewhere in the system for that tissue to heal.”

Which is to say that he does believe the techniques that comprise MFR can be valuable, if understood and used in the right framework. “I think that the fascia is an integral part of the body, no question,” he says. “And I know that the research does support that the fascia is innervated. And if you have innervation, and you have an opportunity where you are stretching something and have input to the system, you can hope to get some output, which may be a response from the nervous system to relax that area. I anticipate that’s the foundation behind this. I don’t think people are actually changing the structure of the fascia. But there appears to be some benefit, which may be a neuroreflexive response. And there is little research to say it’s anything but that.”

Ready for More?
Whether, and to what extent, MFR becomes a routine part of athletic training room programs remains to be seen. Without research studies to turn to, it is likely that controversy over how MFR contributes to healing will continue. Meanwhile, those who have found it to be successful will continue to tout its benefits.

Athletic trainers interested in this approach for athletic injuries can either obtain training themselves or seek out someone skilled in this technique. To obtain training in MFR, an individual must first have licensing in another bodywork field.

Carol Manheim, PT, and other instructors agree that in a weekend course an athletic trainer could learn the basic skills and assessments of MFR and be able to begin incorporating the modality into their work with athletes. “I teach my whole book in a three-day weekend,” says Manheim. “And it would be incredibly beneficial for athletic trainers. It’s probably the only technique I know of that can fine-tune the muscles this well. It can take [athletic trainers] beyond any kind of stretching technique they have been using. And the athlete doesn’t need to be injured to benefit from the fine-tuning that myofascial release provides.”

“I think that if athletic trainers learned this technique, it would enhance their practice 10-fold,” says Cohen. “It would take the frustation out of what they are doing when they find that they just can’t get their athletes better.”

In addition, if an athletic trainer is looking for a therapist who can bring the MFR modality to the training room, specialists in this field generally agree that such a person need not specialize in treating athletes. “Whether people are old or young, we look at them the same,” says Sundquist. “Of course, we need to know their history, and an athlete will have quite a history, but having a background in treating athletes isn’t necessary.”


Resources
The Myofascial Release Manual by Carol Manheim is available through bookstores. Manheim regularly teaches courses throughout the United States. For more information, call (843) 556-6363, or go to .

John Barnes’ Myofascial Institute has extensive training and treatment programs. Call (800) 327-2425, or go to . His son, Brian, is seminar leader for the nationwide Myofascial Mobilization Workshops and founder of the Myofascial Treatment Center of San Francisco, which can be reached at (415) 863-3433.

For training in your area, many chiropractic and massage therapy schools offer courses in MFR.