Should We Crush Tissue?

by Mitch Hauschildt, MA, ATC, CSCS

Recently, I have found myself reflecting back on some techniques and approaches that I have significantly changed my thought process and approach on.  While it frustrates me that in the past I have made decisions and used techniques that are sub-optimal, I also believe that this evolution is an indication of improved treatment and training techniques over time and it also shows a personal commitment to finding the best solution to every problem, given what you know at the time.  So, I do believe that it is a sign of a commitment to excellence, even though I wish I knew then what I know now.

One item that I have significantly changed my approach on over recent years is the idea of “crushing tissue” in an effort to improve movement quality.  Not very long ago, I fell victim to the notion that “more is better” and that if I was going to change how people move, I needed to mechanically change and deform tissue with aggressive interventions with a ton of pressure.  This includes deep massage, trigger point therapy, watching people sweat while they lie on a foam roll, bruising patients with IASTM, and dropping elbows whenever and wherever I saw fit.  While I didn’t go to some of the extremes of other clinicians, I do know that many people “smash” tissue by doing things like walking on their patients or using very heavy weighted objects to “release tissue.”

I believe that these ideas stem from the following thought processes:

The belief that more is better

Its interesting to me that the world of manual therapy has fallen victim to this idea.  In the pharmaceutical world, we understand the idea of a “minimal effective dose,” but for some reason that doesn’t seem to get translated to our physical rehabilitation.  Just because we know that a little bit of a cholesterol lowering medicine makes a patient feel better doesn’t mean that they will feel twice as good if we double the dosage of the medication.  We wouldn’t even think about using more medication unless absolutely necessary, but we don’t think twice about placing more pressure on tissue, even though we can’t show that more really is better.

The belief that we are mechanically releasing and deforming fascia

It has been believed for many years that part of the reason that we don’t move well is because our fascia is “tight” or we need to mechanically break up adhesions in the tissue by putting large amounts of pressure and crushing said tissue.  The problem with this mechanical approach is that if you look at Dr Travell’s work, it states that it takes somewhere around 2000 lbs per square inch of pressure to deform fascia by 1%.  So, if we understand that it takes literally a ton of pressure to change fascia, we then understand that you can’t crush tissue hard enough to actually make a change.

We do, however, know that manual interventions make a difference in tissue gliding and movement quality.  So, if it isn’t because of a mechanical deformation, it must be coming from somewhere else.

The belief that if it works for elite athletes, it must work for everyone

Many interventions that we use with the general population originated in the sports medicine world with elite athletes.  Elite athletes have special needs and also have a more aggressive approach to therapy and treatment in general.  I’m not saying that it is necessary for elite athletes to always have aggressive treatment, but if there is a population that needs it, they are it.  They also tend to desire aggressive treatment because they are usually Type A personalities that enjoy this type of approach.

We need to keep in mind that just because it works well for elite athletes (and I’m not saying that it is actually important to crush their tissue), doesn’t mean that it is the right thing to do for the general population.  Unfortunately, health and fitness programs have evolved into extreme sports that are being marketed as fitness programs.  This is dangerous at best.

Do we need to crush tissue?

The simple answer is no.

Minimal effective dose works really well with soft tissue work.  To understand why it works, it is important to first understand what is really going on with soft tissue work.

I believe that the term “myofascial release” is rather misleading.  We think of using something like a foam roll as “releasing tissue”.  But, if the layers of our tissue is mechanically bound together, how does direct pressure break up these adhesions?  The reality is that the majority of soft tissue work that we as clinicians do is creating a nervous system response.  Robert Schleip’s model demonstrates that by stimulating the mechanoreceptors in the fascia, a signal is sent to the brain, which in turn introduces more fluid into the area in need which improves tissue gliding via improved viscosity.  It is by enlarge a neuromuscular response.

To further the explanation that soft tissue work is a nervous system response, we can also look at trigger points in a muscle belly.  We know they exist because we see, touch and feel them in our patients and clients every day.  But, for anyone who has spent any time in a cadaver lab, they can attest that trigger points don’t exist in dead people.  I think we can have a good conversation as to what actually triggers the development of a trigger point, but the evidence is clear that they are a nervous system response.  So, reducing them by stimulating the receptors in the skin is simply telling the brain to change neurological tone in the area.  It doesn’t take a lot of pressure to stimulate those receptors.

The final note on the neurological topic is related to some research that I recently came across from the British Journal of Sports Medicine.  In the study, they looked at 13 patients who had chronic pain in both of their Achilles tendons.  They surgically went in and scraped the Achilles tendon under anesthetic with the guidance of ultrasound and doppler technology.  They then followed the patients and found that 11 out of the 13 people had a resolution of their symptoms on both limbs and did not require surgery on the opposing leg.  The researchers concluded that the pain and symptoms are controlled much more centrally than previously thought.  In other words, they performed the ultimate mechanical “release” on one leg, which resulted in reduced pain on both limbs indicating that the brain is what is ultimately controlling their pain and symptoms.  An intervention that stimulates the autonomic nervous system can be powerful enough to modulate pain and dysfunction throughout the human body.

Also understand that if you are causing a bruise with your treatment approach (with the except of cupping), you are likely increasing the inflammatory response, thus slowing tissue healing.  IASTM has gotten a bad name in a lot of circles because historically people have been bruised by the treatment.  Newer research debunks the idea that bruising is necessary.

Take Home:

• Many soft tissue dysfunctions are not due to mechanical adhesions or tissue restrictions.  Rather, they are a response by the brain.
• Improving these dysfunctions occurs when by stimulating the mechanoreceptors in the fascia, which triggers a sequence of events that improving tissue gliding and/or moderates muscle tone.
• If you suspect that tissue layers are actually mechanically bound together, releasing it will only occur by decompressing or providing a shear force to the tissue in the area.
• Minimal effective dose should be the gold standard for soft tissue work.  There is no need to crush tissue.
• There are a variety of tools and techniques that can be used to improve tissue quality including IASTM, Foam Rollers, Dry Needling, and massage.
• Depending upon your desired outcome, consider changing the variables of depth of pressure, rate, medium, and so on to change tone and ultimately improve movement patterns.
• Pain and bruising are not necessary and likely counterproductive to tissue healing.

I am a huge fan of manual therapy and soft tissue work.  It is the first thing that I do in almost all of my treatments every day.  But, we need to take a logical approach to manual therapy and understand that there is very little, if any reason to crush tissue.

Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery  Br J Sports Med 2014;48:19 1421-1424 Published Online First: 28 November 2012

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