The client had come in with an injury dating back 18 months. Apparently, the client, an avid surfer, had been out on a wave when injuring his left foot. As his left foot is also his weight bearing foot, the motion of both dorsiflexion and eversion caused something to go awry at the lateral malleolus. This resulted in pain when walking, driving, surfing, and dirt biking. The client drives stick shift, works in steel toe boots on steel decks or concrete flooring, and is maintaining a lifestyle of continuous motion in unforgiving environments. The client had learned to live with the pain and had not even mentioned the injury in prior visits. This was not too unusual as he had only been booking massages for relaxation and wellness, not to treat a specific injury.
Based on the location of the pain, combined with the accompanying movement that exacerbated the injury, I began to suspect there was problems with the client’s peroneal muscles. Were the tendons out of placement at the ankle? Were the extensor muscles of the foot being shortened? Or could it be a trigger point injury?
The muscles I was looking for needed to both be in the correct location and responsible for the correct action along the ankle joint. The location of the pain directed me to research the extensor digitorum longus and brevis, and the fibularis longus, brevis, and tertius. These muscles are also responsible for the actions of plantar flexion and eversion. At the medial edge of the base of the lateral malleolus, there was an area that appeared to be swollen, without any other signs of inflammation. Palpation showed there was definitely a difference between the feeling of the left foot compared to the right. While the client said that lifting the foot in dorsiflexion aggravates the injury, the client was actually trying to put the foot in plantar flexion when the original injury occurred. The movement of the surfboard under his foot actually was the reason for the foot to be in dorsiflexion.
I began the treatment with some basic effleurage while the foot was in plantar flexion, applying pressure on the dorsal surface of the foot and moving proximally to distally along the extensor tendons. This allowed me to begin to warm up the area. From there, I began to do some cross fiber friction work along the extensor retinaculum and muscles surrounding the distal end of the fibula bone. Once the area was sufficiently warmed, it was time to try some other modalities.
Soft tissue release was a practical next step, as it is a great modality for healing injuries. Because of the lock and stretch motion, tiny micro-tears are created along the muscle fibers. This allows for some inflammation to occur, which starts the healing process. Muscle cells have the oldest memory of any cell in the body; by creating these tiny injuries, it allows the are to be flooded with white blood cells.This begins to clear out the damaged tissue and start the building process from the ground up, which is crucial for healing. Red blood cells bring in oxygen and nutrients necessary for healthy rebuilding. I started by locking in at the distal end of the foot on the dorsal surface, and curling the toes into plantar flexion. By twisting the foot into inversion, I was able to slowly stretch the fibularis muscles as well as the extensor muscles. I continued along the path of the fibularis muscles, curling the ankle into plantar flexion and inversion of the ankle. The client reported pain during the stretches, but nothing unbearable. Afterwards, a decrease in pain and increase in mobility was reported by the client. It was recommended that
the client continue to stretch ankle by using plantar flexion and inversion of the left foot to keep the area loose.
The next visit, which took place a week later, showed the pain was back, but the client also admitted to stressing the area by continuing to do long drives using manual transmission, surfing and walking along the wet sand along the water’s edge. Since the previous session had alleviated the pain for a few days, I started there again. After working that area, I found a trigger point located distally to the fibula bone, along the peroneal tertias. In the past, the client had been resistant to trigger point therapy. After the success of the prior treatment, his trust had increased and he was willing to give it a try.
Trigger point therapy is also an effective way to treat injuries. It is common for muscles to get stuck in contraction, and from there adhesions form between the layers of tissue. This stops the natural healthy flow of blood through the muscle fibers. Without the ability for blood to flow through the tissue, everything gets jammed up. None of the damaged cells can be removed from the area, and none of the healthy nutrients or oxygen rich blood can pass through. At this point, the muscle tissue is dying, and the area of adhesion begins to grow. Muscles get stuck in a greater contractive state, with other parts of the body getting pulled out of place, resulting in other injuries in the areas of compensation. By applying intense focused pressure to an area, all of the fluids are pushed out. Once the pressure is released, it allows for a rushing of fluids back into the area. Like before, it is crucial for the oxygen and nutrient rich blood to come flooding into the damaged tissue. Equally important is the ability of lymph fluid to begin clearing out all the damaged dead tissue from the area. By hitting the area hard it allows for a faster healing process. One is also able to slowly and methodically stroke along the muscle fiber to encourage the breaking down of adhesions and healing as well.
I used intense trigger point therapy and felt the tissue break down beneath my thumbs, almost the equivalent of the feeling of a grape bursting beneath the skin. The client asked immediately what I had done, and I responded by asking how he felt. The pain was gone, and mobility was back to normal for the first time in over a year. Client was thrilled with the success of trigger point therapy. I finished with some cross fiber friction and effleurage to keep things moving. Client was advised to continue drinking water, to use ice for pain, and to continue with stretching.
Unfortunately that session happened the night before the client was spending the day on the beach, and after being pain free for 12+ hours, he again triggered the injury walking on the sand. I had the ability to do some research before working with him again, and that led me to believe that perhaps he was experiencing a referred pain from a less localised place. Trigger points along the fibula longus often result in pain in the ankle area. We located the area of pain distal to the lateral knee and hit those areas, as well as the area distal to the fibula as well. This was followed by utilizing British sports medicine along the peroneal longus and brevis, and the extensor longus and brevis as well. All treatments ended with cetripedic effleurage.
After the last treatment utilizing trigger point therapy, I am pleased to say the client currently has no pain and complete mobility in the area. The use of British sports medicine and trigger point therapy, as well as icing, stretching, and increasing water and electrolyte intake were all key components to the client’s healing process. We no longer need to focus any intense therapies to the injured area, and are able to keep the are healthy with basic effleurage and stretching modalities. Client is extremely satisfied with the results.
By Tara Black