Editor’s note: Massage therapist and Massage & Bodywork contributor Marybetts Sinclair fell while hiking and shattered her elbow in autumn 2015. This feature details her road to a splendid recovery and how she blended her knowledge with that of her medical team. She now uses her experience to help clients regain full function.
People with recent injuries—cartilage tears, contusions, dislocations, fractures, joint sprains, muscle strains, muscle tears, whiplash injuries, or trauma from falls or car accidents—often seek help through massage therapy. In the early stages, common issues include acute pain, inflammation, joint stiffness, muscle guarding, and muscle tension caused by recruiting uninjured parts to help the body move along. Sadly, however, many people end up with chronic musculoskeletal issues when their injuries don’t completely heal. Fibrotic tissue that is prone to reinjury, painful or restricted movement, postural warps, problems with joints due to uneven wear and tear, long-lasting muscle tightness, and, ultimately, chronic pain can result. According to the American Academy of Orthopedic Surgeons, it is seven times more likely that you will have arthritis in a joint if it has suffered trauma.1
For example, you may have a client with neck pain who comes to see you years after her whiplash injury; or another who presents with frequent knee injuries after a poorly healed knee sprain left him with a limp and an incorrect foot plant; or a young client who is considering a hip replacement, likely as the result of an old running injury that somehow left her hip hurting constantly.
In contrast, I recently suffered a serious injury that healed very well, and I believe my case illustrates not only the importance of intensive rehabilitation, but the level of improvement that can be reached. With my knowledge of bodywork and complementary therapies, and examples of individuals who gave their rehab a lot of energy, my injury healed far beyond my medical team’s expectations. At the same time, I learned a great deal about how to assist my injured clients in their own journeys.
My Rehabilitation
To perform massage, therapists need strength, dexterity, and full range of motion of all the joints of the upper extremities. My injury was severe, and many surgeons believe the elbow is a joint that does not recover well from trauma and has a high tendency to degenerate and become stiff afterward.2 I will never forget the look of dismay on the elbow surgeon’s face when he found out I was a massage therapist! Although he promised to do his best, he told me I might never do massage again. Chances were my arm would be permanently crooked and my ability to extend, flex, and supinate my elbow joint would be severely compromised.
This would also change how I used my shoulder joint, leaving me open to shoulder injury. Strokes performed by most massage therapists would be well-nigh impossible. For example, Swedish effleurage strokes require applying pressure downward with a straight arm and fully extended elbow on the down stroke, followed by elbow flexion and supination of the hand and elbow on the return part of the stroke. Many deep-tissue/myofascial techniques, such as muscle stripping or sinking through superficial tissues to reach deep areas, require a lot of elbow flexion, as well as using the elbow to apply pressure. Others require full elbow extension. To treat trigger points, pressure is applied to the point of the elbow when it is used for ischemic compression, and full flexion is also required. Since my expertise is in Swedish, deep-tissue, and trigger-point massage, elbow problems would have permanently ended my ability to use my arm in my massage work.
It also wasn’t clear I would have normal hand function. The ulnar nerve runs down the back of the elbow (in a groove directly behind the shattered medial epicondyle). The nerve could have been damaged by the fall itself, during surgery, or later, by adhesions developing around the nerve, gluing it down to other structures and compromising its function. Since the ulnar nerve makes it possible for us to type, grip, pinch, make a fist, work buttons, etc., damage to this nerve can have a profound effect on hand function. Numbness or difficulty with coordination of the fingers and pain in the hand, wrist, or elbow were also possibilities.3
During a three-hour surgery, two surgeons worked together to repair my elbow, installing two metal plates, eight screws, and 11 pins to hold the fragments in place. The arm was then placed in a cast, with the elbow bent at 90 degrees. Although after one week I could take the cast off three times a day for a few minutes to exercise, and after three weeks a physical therapist would stretch it during therapy sessions that frequently brought me to tears, the arm remained mostly in the cast for eight weeks after surgery. The day the cast came off, my elbow was very crooked, with 90 degrees of flexion (140 degrees is normal) and 40 degrees of extension (0 degrees is normal).
At this point, I decided to do more than just the standard physical therapy program for a shattered elbow. I was aware that my doctor and physical therapists had low expectations for my ability to return to massage, yet I was buoyed by many cases of wonderful healings I knew about—instances when determination and a willingness to use additional therapies had achieved amazing results.
For example, Meir Schneider, PhD, was born with cataracts, certified permanently blind in his homeland, and did all his schoolwork in Braille; yet, he overcame congenital blindness with diligent practice of the Bates Method of vision improvement.4
Novelist Paul West suffered a massive stroke that did not respond to standard therapies. In One Hundred Names for Love, his wife Diane Ackerman describes her own mix of therapies that healed him—intensive brain workouts, daily swimming, and specially designed speech therapy.5
When he was 48 years old, Catholic priest Mark Neary suffered spinal cord and traumatic brain injuries in a fall. Before beginning alternative therapies, Neary laid in a hospital bed in a fetal position 24 hours a day for two years. Using osteopathy, qigong, acupuncture, Feldenkrais-style physical therapy, chi nei tsang, and Egoscue therapies, Neary began to slowly improve, and made huge progress toward healing. Today, he walks on his own, lives on his own, and enjoys a rich and interesting life.6
Arthur Boorman, an obese veteran with knee and back injuries acquired as a paratrooper, was told by physicians that he would never be able to walk without crutches. However, through diligent practice of yoga, he is now able to not only walk without crutches, but to jog without pain.7
Given these inspirational examples, I felt an intensive, integrated program would give me a much greater chance of success than standard physical therapy alone. I added many other natural techniques, including active isolated stretching, acupuncture, hydrotherapy treatments, massage therapy, pool exercise, and vitamins and herbs. This program, followed diligently, greatly improved my outcome. Improvement came slowly, as I worked on all possible movement at the joint, as well as strengthening and stretching the tissues of my wrist and shoulder joints. Six months after my arm was out of the cast, I had roughly 85 percent range of motion (extension 10 degrees, flexion 120 degrees). Supination, pronation, shoulder range of motion, neck range of motion, and spinal rotation became normal. By 10 months, I had gained 90 percent of full range of motion (extension 5 degrees, flexion 130 degrees). This far exceeded my original prognosis, as my arm was expected to be permanently bent at 30 degrees of extension, with greatly reduced flexion and practically no supination. My physical therapists labeled my progress “amazing,” and six months after my fall, I was back at work doing Swedish and deep-tissue massage. I also had the arm strength to lift heavy objects and do intense garden work like shoveling.
My Program
Here is the program I put together:
1. Standard physical therapy program8
• Twenty percent loss of muscle strength occurs each week in a cast,9 and when my cast was first taken off, my arm was very weak. I was given therapeutic exercises to restore strength, including active flexion and extension of the wrist and elbow, radial deviation, pronation, and supination.
• Immobilizing any joint can cause shrinkage of the joint capsule and actual contracture, so restoring full range of motion began immediately by stretching the joint in all directions. Movements were passive in the early stages, but later, I began including active range of motion of wrist, forearm supination, and pronation, and active elbow flexion and extension.
• Hands-on treatment, such as stretching, joint mobilization, and soft-tissue release, help control edema and scarring and maintain normal joint play. For example, adhesions over the ulnar nerve and between the biceps and brachialis tendons were treated with manual therapy, while twisting or restriction of the brachial nerve near the elbow and compression of the brachial nerve by deep pectoral fascia were treated with neural manipulation.
Several months after my arm came out of the cast, my shoulder extension became very painful because the triceps tendon had become tight and was pressing on the bursae. Manual release of the tendon helped the pain disappear.
2. Massage
In the early stages of injury, massage helped decrease the inflammation and pain in my arm and upper body. It also eased muscle tightness caused by improper movements and relieved emotional stress. Regular self-massage changed a thick, irregular scar to one that is flexible, adhesion-free, and barely discernable. As rehabilitation went on, massage was helpful for releasing muscle tension in the neck and shoulders, arm, chest, and upper back, which was related to my making effort-full movements since my arm was stiff and painful. (Trying to brush your hair or put on an earring with limited elbow flexion can cause all kinds of strange compensatory movements!) Later on in rehab, massage also helped me become more graceful and less tight all over.
3. Supplements and herbal treatments
I took a variety of supplements prescribed by a knowledgeable herbalist to treat inflammation, stimulate healing of the surgical wound and bone, and promote cartilage regrowth on top of the original injury. Every night, using herbal teas and/or anti-inflammatory essential oils, I made an elbow compress and left it on all night.
4. Hydrotherapy treatments
Ice packs were used for swelling and pain in the first few days after surgery, then I switched to heat. Hot packs, hot water bottles, heating pads, heat lamps, and very hot sprays using a shower attachment were used for the whole arm and/or just the elbow to ease pain and reduce inflammation.
5. Pool therapy
Swimming provided excellent exercise for restoring muscle strength and full range of motion, using various resistance tools such as a wrist weight and foam barbells. It also prevented loss of range of motion due to substitution: my shoulder range of motion actually became better than before I broke my elbow.
6. Aaron Mattes’s Active Isolated Stretching
I stretched the muscles of the wrist, elbow, shoulder, and upper back every day to prevent restriction and poor dynamics in the muscles and joints above and below the injury.
7. Acupuncture
To reduce inflammation, increase range of motion, and speed healing, I received acupuncture twice weekly for 10 weeks, then once weekly for 10 weeks, then once every two weeks until the six-month mark.
Rehabilitation for Serious Injuries
Thankfully (hopefully), most of you don't have personal experience with this type of injury to help guide your clients today. So, how can massage therapists help clients going through rehabilitation for a serious injury (including joint replacement surgery)?
We can provide another pair of educated eyes (and hands).
When a health-care team is concentrating on the most serious injury, it is often the case that, due to time or insurance constraints, other musculoskeletal problems can be missed. For example, my emergency room visit focused entirely on my elbow fracture and no physical exam was done. Two days after the fall, a local physical therapist found that rib one on the left side was subluxated posteriorly, and rib two on the left side was subluxated anteriorly, contributing significantly to the pain I was experiencing at that moment, and possibly causing more problems later. Muscle tightness in other areas may not be considered important, but can have effects later.
Massage therapists can not only treat soft tissue, but can also give the client and the other members of the medical team important information.
We can be positive cheerleaders while relieving emotional stress with bodywork.
In his book about the emotional fallout of an illness or injury, psychologist Charles Foster explains that it is natural to be stressed after a serious injury.10 It is normal to feel overwhelmed when faced with events you are not prepared for, particularly ones that hurt and may have scary consequences. (In my case, I was very worried about what never doing massage would mean to my finances and my quality of life. This emotionally vulnerable state was not helped by the accumulation of stresses such as ongoing arm and shoulder pain, poor sleep, undergoing surgery, and discouraging remarks by friends and even some health professionals, giving me little hope for a full recovery.) Foster points out that natural, powerful negative emotional states often get in the way of achieving the fastest, fullest recovery. When our clients feel hopeless and deeply stressed, it is going to interfere with their recovery. First and foremost, we can provide a calm and positive demeanor, show our clients that we have deep faith in the body’s ability to heal, and, wonderfully, we can also provide relief from stress through massage.
We can support the client’s determination to get better and their belief that healing is possible.
Sadly, rates of noncompliance with physical therapy are high. Clients may say they are bored and have lost interest in rehab. Some factors that prevent patients from getting better include stress, depression, and feeling that the therapy is going slowly or not going well.11 A willingness to take on tasks, to tolerate frustration when results are slow to come, and to persevere can all be sapped by emotional stress. Then, unfortunately, the helpless feeling generally leads to a vicious cycle and sabotages the effort the client puts into their rehabilitation program. Poorly healed scar tissue, poor mobility, substitution, and possibly arthritis are common long-term consequences of poorly healed injuries.
One of our strengths as MTs is having a deep faith in the body’s self-healing processes. We can do our clients a huge favor by explaining in a positive way that fully rehabbing an injury can improve their quality of life from that point on. Just look at the difference between a fully rehabbed elbow and a nonrehabbed elbow, and you can see that the client with the poorly healed elbow will suffer for the rest of their life. It’s not just the acute injury; in this case it could also be, in the years ahead, developing a frozen shoulder, hypermobility in a nearby joint, huge amounts of chronic tension that can contribute to problems in other areas, or losing all body awareness in a chronically painful area. We need to communicate to our clients in a positive way that they only have one chance to heal right. We can also show them how much better they can feel each time they receive a massage.
encouraging outcomes
We know massage therapy will help our clients during rehabilitation, but we can be even more effective if we understand how healing occurs, how injuries can be rehabilitated, and the consequences of incompletely healed injuries. We can help and encourage our clients to have the best possible outcomes. I was lucky to have learned this before I was injured and became the client!
Author’s note: this article is gratefully dedicated to all the wonderful people who helped me during my rehabilitation, from doctors and physical therapists, to friends and family who kindly contributed counsel, sympathy, food, rides, money, bodywork, and even washed my hair in the kitchen sink (thanks, Maureen!).
Two similar injuries, one intensively rehabilitated, one with no rehabilitation
Upper extremity after elbow fracture (right). The fall onto the elbow fractured the radial head and shattered the medial epicondyle into seven separate, tiny fragments. The arm is seen after surgery and 10 months of intensive rehabilitation. Elbow extension is 5 degrees, flexion is 130 degrees (90 percent of original elbow range of motion). Supination and pronation are normal; shoulder and wrist range of motion are normal. Biceps and hand flexors are slightly shortened. The elbow joint is pain-free except at extremes of flexion and extension; then, it is a 2 out of 10 on the pain scale.
Upper extremity after elbow fracture (below). The fall onto the elbow fractured the olecranon into eight tiny fragments. The arm is seen after surgery and with no rehabilitation. The image shows her maximum elbow extension and shoulder elevation. Supination is also severely limited. Her elbow is painful and sensitive to the touch, and the olecranon bursa is also swollen and painful. She frequently has tingling in her elbow and hand—a sign of damage to the ulnar nerve. Due to limited extension, both biceps and forearm flexors are very short. When lifting a box or using a shovel, instead of flexing and supinating the elbow to bring the hand under the box or around the shovel handle, this client has to compensate by rotating her humerus externally, contracting the quadratus lumborum and external oblique muscles in order to flex the torso sideways. This substitution pattern could eventually lead to shoulder impingement, subacromial bursitis, or a rotator cuff tear. Limited elbow flexion, over time, may also result in chronic tightness and/or pain in the opposite-side hip flexor muscles, as they counterbalance a changed arm swing.
Positive Communication About Rehabilitation
✗ Avoid saying: “I know these exercises are boring.”
✔ Do say: “You will be much happier with your knee in the future if you can complete these exercises every day.”
✔ Do say: “Perhaps you can make your routine more interesting by doing the exercises at different times of day, or doing the exercises in different places. What about listening to your favorite music at the same time?”
✗ Avoid saying: “If you don’t do your rehab, you will hurt forever!”
✔ Do say: “Let me show you some examples of self-healing that other people managed to pull off. People really can make huge improvements if they stay with their program or add additional therapies such as acupuncture, swimming, or yoga.”
✔ Do say: “I know it can be frustrating, but I am constantly amazed at the ability of the body to heal. This rehab is going to pay off for you!”
The Injured LMT
Rehabilitation of my elbow injury meant I stopped working and needed to spend money for additional therapies. How many MTs have the financial resources today to get by for several months if they have an injury that prevents them from working? How many have disability insurance? How do they afford additional therapies even if they do have good insurance? (Total bill for my surgeries and associated cost was about $40,000. Fortunately, physical therapy was covered by my insurance.) Without insurance, and an emergency fund set aside for just such an accident, a massage therapist could be financially devastated by an injury like mine.
What Steps Can You Take Today?
• Start building an emergency fund reserved for treatment of injuries. Even if you can put just a small amount away each month, begin today! And do not spend it unless you are injured.
• When buying insurance, check into policies that have good coverage for physical therapy after injury.
• Investigate buying disability insurance.
Consequences of Poorly Healed Injuries
Trigger points can develop from trauma to muscles and also from postinjury pain. For example, someone with fractured ribs on one side, for whom it is excruciating to take a deep breath, might splint the area by contracting the external oblique on the same side as the fracture, and thus a trigger point is created. Unfortunately, even when the fracture is mended, the trigger point remains, and the person may continue to splint the area, ending up with a permanently short and tight muscle, which is not only less elastic and can cause pain, but is also more prone to injury.1
Fibrotic tissue. In the body’s heroic, powerful attempt to heal an injury, acute inflammation helps repair the injured tissue by increasing nutrition through greater blood flow and cleaning up debris through more white blood cells to the area.2 Next, scar tissue grows, bringing stability but not elasticity. However, scar tissue grows in a disorganized way and needs normal, healthy motion to help the fibers align properly or remodel. If this does not happen, it can lurk in or around injured structures, forming a kind of glue that holds structures such as muscles, ligaments, fascia, nerves, periosteum, and spaces between bones in poor anatomical positions. For example, if a severe ankle sprain did not heal properly, it could result years later in the ankle and foot being turned in or out slightly due to thick, disorganized scar tissue. When my elbow was finally out of its cast, the fascia between the distal insertion of the left biceps and the brachialis muscle’s insertion underneath it had become extremely tight, adhered to both muscles, and was effectively gluing the two muscles together. This not only limited stretching of the joint capsule (necessary to prevent adhesive capsulitis), but also limited full elbow extension. Scar tissue that had developed between the ends of the proximal left ulna and radius was compressing the artery at the left elbow, which was causing a protective spasm of the biceps, making elbow extension far more difficult.
Painful or restricted movements and postural warps. At the time of injury, pain is helpful because it lets us know that we need to rest the area to prevent us from injuring it further. But many dysfunctional movement patterns can result from high levels of pain during healing. Holding the body in fixed, unchanging positions for long periods of time can happen when there is pain with a movement, or if the area is weak after being immobilized for a long time in a sling, cast, brace, or splint. Reduced strength and alterations in how the joint is moved can predispose one to injury, as muscles, ligaments, and fascia “learn” these new positions, resulting in tense and rigid soft-tissue structures. For example, a hand that was very painful after it was broken may never be used fully again if the person favors it and unconsciously prefers to overwork the other hand. When my elbow cast was removed only five weeks after injury, I had already adopted a kyphotic, slumped-forward position on the injured side, effectively shortening my neck flexor and pectoral muscles while weakening the thoracic and neck extensor muscles. Postural warps caused by patterns of substitution plague many of our clients. Reinjury is more likely, too.
Notes
1. S. Aftimos, “Myofascial Pain in Childhood,” New Zealand Medical Journal 9 (1989): 440–1.
2. G. Trudel, M. Jabi, and H. K. Uhthoff, “Intraarticular Tissue Proliferation After Immobility: Methods of Assessment and Preliminary Results in Rat Knee Joints,” Journal of Rheumatology 25, no. 5 (May 1998): 945–50; “Stop That Cycle of Recurring Injuries: Understanding Your Body’s Healing Cycle,” Go Physio (2014).
Notes
1. M. K. Lotz and V. B. Kraus, “New Developments in Osteoarthritis. Posttraumatic Osteoarthritis: Pathogenesis and Pharmacological Treatment Options,” Arthritis Research & Therapy 12, no. 3 (2010): 211.
2. S. Nandi et al., “The Stiff Elbow,” Hand 4, no. 4 (December 2009): 368–79.
3. J. D. Keener, Ortho Info, “Ulnar Nerve Entrapment at the Elbow,” accessed November 2016, http://orthoinfo.aaos.org/topic.cfm?topic=a00069.
4. M. Schneider, Self-Healing: My Life and Vision (London: Penguin, 1988).
5. D. Ackerman, One Hundred Names for Love: A Memoir (New York: W. W. Norton & Company, 2012).
6. M. Neary, interview with author, first interview April 2007, second interview August 2016.
7. Tara Kelly, “Arthur Boorman, Disabled Veteran, Walks Again After Discovering Yoga,” last updated May 7, 2012, accessed November 2016, www.huffingtonpost.com/2012/05/04/arthur-boorman-veteran-walks-again-yoga_n_1478847.html.
8. J. C. MacDermid et al., “A Survey of Practice Patterns for Rehabilitation Post Elbow Fracture,” The Open Orthopaedics Journal 6 (2012): 429–39.
9. F. W. Booth, “Physiologic and Biochemical Effects of Immobilization on Muscle,” Clinical Orthopaedics and Related Research 219 (June 1987): 15–20.
10. C. Foster, Feel Better Fast: Overcoming the Emotional Fallout of Your Illness or Injury (New York: M. Evans & Company, 2004).
11. D. Millslagel, “Compliance to Physical Therapy,” September 2016, accessed November 2016, www.d.umn.edu/~dmillsla/documents/PTpresentationf09.pdf.
Marybetts Sinclair has been a massage therapist in Corvallis, Oregon, since 1975. She has written three massage therapy textbooks, and has taught across the United States as well as in Canada, Ecuador, Indonesia, Mexico, and South Korea. She can be reached at www.marybettssinclair.com.