Although there are many “techniques” in the world of massage and manual therapies, the actual number of fundamental hands-on skill sets that underlie these techniques are few. This is especially true in the world of clinical orthopedic manual therapy (COMT), which is oriented at remedying specific musculoskeletal conditions with which clients present.
Essentially, the fundamental hands-on skill sets of COMT might be listed as soft-tissue manipulation, stretching, and joint mobilization. Most every massage therapist utilizes soft-tissue manipulation; indeed, that is what most people associate with the profession of massage. But when working to remedy a client’s musculoskeletal condition, the effectiveness of a massage therapist’s care is greatly enhanced when stretching is added to the client’s treatment plan.
Stretching
Although there is a lot of debate about stretching, the concept of stretching is actually quite simple and straightforward. Stretching is a mechanical process of lengthening soft tissue. All soft tissues have certain fundamental properties, including the property of creep. Creep describes the gradual change in shape (deformation) of a tissue that occurs when it is subjected to a force that is applied in a slow and sustained manner. Applying the principle of creep to stretching, stretching is simply a tensile force that gradually deforms the soft tissue by lengthening it. So, for all the controversy that surrounds stretching, the essential principle of stretching is valid. If performed well and regularly, stretching succeeds at lengthening tight, taut, and shortened myofascial tissue.
Logistical Challenges to Stretching
As wonderful as stretching can be, however, there are often logistical challenges when applying stretching to the client. For example, if a stretch is applied to a muscle, it is applied to the entire length of the muscle, pulling one or both attachments of the muscle away from the other. This effectively dilutes the effectiveness of the stretching force by spreading it across the entire length of the muscle. But a client’s muscle is not always uniformly tight from one attachment to the other. Sometimes only a small region of the muscle is tight; or perhaps there is a tight myofascial trigger point in one region of the muscle. If the stretch is applied to the entire muscle, it might be so diluted as to not be sufficiently strong enough to stretch the target region or trigger point that is tight. Even more problematic, looser areas of the muscle might compensate for the tighter region, in effect absorbing the stretch and effectively dismissing the tight region from having any stretch force placed on it, as the hypermobile tissue compensates for the hypomobile tissue. In these cases, the application of the stretch force must be modified so as to be focused on the tight region. This can be done by performing the pin and stretch technique.
Pin and Stretch Technique
The pin and stretch technique focuses the force of a stretch to a specific region of the muscle. The therapist uses their hand (or other body part such as an elbow or forearm) to manually place a “pin” into the belly of the muscle and then moves one of the muscle’s attachments away from that pinned point. The pin acts to stop the stretch force from spreading to the rest of the muscle beyond the pin point. Therefore, with the pin and stretch technique, the force of the stretch will be concentrated to the region of the muscle that is between the pinned point and the attachment that is moved.
Images 1A–1C demonstrate the pin and stretch technique using the right upper trapezius as the target muscle and the head and neck (cervicocranial) attachment as the attachment that is moved away from the shoulder girdle (scapuloclavicular) attachment. In Image 1A, the therapist has placed the pin somewhat close to the scapuloclavicular attachment of the muscle; this results in the stretch being focused on the region of the muscle that is indicated by the red Xs. When the pin is moved closer to the cervicocranial attachment, as seen in Image 1B, the focus is narrowed to a more concentrated region of the upper trapezius near the cervicocranial attachment. If the pin is moved even closer to the cervicocranial attachment, as seen in Image 1C, the stretch is even more strongly focused on a narrow region of the muscle closer to the head and neck. In each case, as the pin moves closer to the attachment that is moved, the focus of the stretch narrows to a smaller region of the muscle, and because the stretch force is concentrated over a smaller region, it becomes more powerful. Therefore, the entire reason for the pin and stretch technique is to focus a powerful stretch to a specific region of the target muscle.
Creep: A Definition
All soft tissues have what is termed an elastic range and a plastic range. A tissue’s elasticity describes its ability to return to its normal length after being stretched. If the elastic range of a tissue is exceeded, its plasticity describes the degree to which the tissue will remain altered or deformed.1 Therefore, creep describes when a soft tissue’s elastic ability is exceeded and the tissue enters its plastic range. Differing soft tissues will have differing resistances to being stretched and lengthened. Indeed, fibrous fascial tissue is remarkable for its tensile strength, which is its ability to resist lengthening. But fundamental to all soft tissues is their ability to change their shape and lengthen. Also, the effect of plasticity/creep is not necessarily permanent, so whatever positive effects are gained by stretching must be repeated or the soft tissues will gradually shorten and tighten again. Of course, stretching is not something one can do once or only for a short period of time and then expect to remain loose for the rest of their life. Stretching must be an ongoing part of one’s lifestyle.
Note
1. The term deform usually has a negative connotation, but when a myofascial tissue has become “locked short” (tight), deforming it by lengthening it would be considered a positive change, as it would potentially increase flexibility in the body.
Location of the Pin
The pin and stretch technique is often performed similar to how it is shown in Images 1A–1C, with the therapist starting the position of the pin far away from the attachment that is moved, often at or near the other attachment of the muscle, and then gradually and successively moving the position of the pin to be closer to the attachment that is moved. However, if we critically think through the underlying mechanism of this technique, we will see that not only is it not necessary to carry out the pin and stretch technique in this manner, it does not necessarily make sense. If the point of pin and stretch is to focus the stretch force on a specific taut region of a muscle, say a myofascial trigger point, then it would make sense that the most efficient method to employ this technique would be to place the pin directly next to the trigger point (or other taut tissue), on the “other side” of the trigger point that is “away” from the attachment that will be moved, then perform the stretch.
Again, using the upper trapezius as our example, if the trigger point is located in the upper trapezius, as indicated in Image 2, then the best place to position the pin is as close to the trigger point as possible, but on the “other side”—in this case the scapuloclavicular side of the trigger point, as shown in the image. In this example, if the pin were to be placed anywhere between the trigger point and the cervicocranial attachment, it would be ineffective because the pin would block the stretch force from even making it to the trigger point. The farther the pin is positioned from the trigger point on the scapuloclavicular attachment side, the more diluted the stretch will be. So, when working with pin and stretch technique, the most effective manner in which to perform the technique is to place the pin as close to the trigger point as possible, on the side of the trigger point that is away from the attachment being moved.
Which Attachment Do We Move?
When the target tissue of the pin and stretch technique is in a muscle in which both attachments are easily mobile, it is possible to focus the force of the stretch toward either end of the muscle. Again, let’s use the upper trapezius as our example. In the first example (Images 1A–1C), the cervicocranial attachment was moved, so the stretch force was focused toward the cervicocranial attachment end of the muscle. But if the trigger point that we want to focus the stretch on were toward the scapuloclavicular attachment, then we would need to instead move the scapuloclavicular attachment when performing the pin and stretch technique. So, if the trigger point is toward the scapuloclavicular attachment, we would want to place our pin as close to the trigger point as possible, but on the other side of the point—in this case the cervicocranial side—and then move the scapuloclavicular attachment away from the client’s head and neck, as seen in Image 3.
Unfortunately, for most muscles, only one attachment is easily mobile, and that is usually the distal attachment. For this reason, the pin and stretch technique is usually most effective when the goal is to focus the stretch on a region of the muscle that is closer to the more mobile—usually distal—attachment of the muscle. Two excellent examples of this, one in the upper extremity and one in the lower extremity, are shown in Images 4 and 5. Images 4A–4B show the pin and stretch technique being performed on the right flexor carpi radialis, with two positions of the pin shown. Images 5A–5C show the pin and stretch technique being performed on the right piriformis, with three positions of the pin shown.
Neural Inhibition Stretching Techniques
Essentially, stretching is a mechanical process of applying a physical tensile force to a soft tissue. However, when stretching musculature, mechanical stretching can be enhanced by adding neural inhibition techniques. These techniques take advantage of nervous system spinal cord reflexes that relax/inhibit muscle tone. Classically, it has been stated that there are two nervous system reflexes that can be utilized to relax musculature and, therefore, facilitate a stretch. They are the Golgi tendon organ (GTO) reflex and reciprocal inhibition (RI) reflex.
The GTO reflex occurs when a muscle’s contractile tension increases, thereby pulling on its tendons. This tension at the tendon feeds back into the nervous system to inhibit that muscle (and its synergists) from contracting so hard. This reflex is often interpreted as protecting the tendon from being torn by an excessively forceful muscle contraction. RI reflex occurs when a muscle concentrically contracts and shortens. The nervous system receives this input and reflexively relaxes (inhibits from contracting) the antagonistic musculature so that it can lengthen, thereby allowing the contracting muscle to successfully shorten.
The GTO reflex has been said to be operative in the stretching technique known as contract relax (CR), which is also known as postisometric relaxation (PIR) or proprioceptive neuromuscular facilitation (PNF) stretching. And RI has been stated to be the operative reflex in agonist contract (AC) stretching, the basis of Aaron Mattes’s Active Isolated Stretching (AIS) technique. (Note: AC stretching is also sometimes referred to as PNF stretching, which can create confusion with the GTO-mediated technique.) In recent years, there has been controversy regarding the role of the GTO reflex. It appears that higher nervous system centers in the brain might also be involved, but it still seems likely that the GTO reflex is a part of the inhibition process with CR/PIR/PNF stretching.
Active Pin and Stretch
The pin and stretch technique is often performed with the client passive as the therapist moves the client’s body part into the stretch (as seen in Images 1A–1C). However, pin and stretch can also be performed actively: instead of the client remaining passive as the therapist moves their body part into a stretch, the client actively moves their own body part into the position of stretch. Performing pin and stretch actively does not make a mechanical difference on focusing the stretch to one region of the muscle, but it does make a difference neurologically. When the client actively concentrically contracts musculature on one side of the joint, the antagonist musculature on the other side of the joint is reciprocally inhibited (see “Neural Inhibition Stretching Techniques” on page 54). For example, if the target muscle being stretched is the right upper trapezius, and the client actively moves their shoulder girdle down into depression, then, in addition to the pin and stretch benefit of focusing the stretch force to one region of the target muscle, the stretch will be further facilitated by the target muscle being reciprocally inhibited (relaxed) so it can be better stretched and lengthened (see Image 3).
Joint Mobilization
At the outset of this conversation, I posited that there are three fundamental skill sets in the world of clinical orthopedic manual therapy: soft-tissue manipulation, stretching, and joint mobilization. However, I believe this list can be narrowed to just two fundamental skill sets: soft-tissue manipulation and stretching. I say this because joint mobilization is actually a type of stretching. If we name the two bones at a joint Bone A and Bone B, then the technique of joint mobilization is performed by pinning Bone A and then moving Bone B away from Bone A. Therefore, joint mobilization is actually a form of the pin and stretch technique. But, instead of placing the pin in a muscle belly to focus the stretch toward one end of the muscle or the other, the pin is placed on a bone to focus the stretch on the intrinsic fascial tissue (the joint capsule/ligamentous complex) between that bone and the other bone of the joint. For this reason, I like to refer to joint mobilization as arthrofascial stretching (arthro means “joint”).
Given the tremendous emphasis in recent years placed on treating fascia, it is surprising that more massage therapists do not perform joint mobilization or arthrofascial stretching as part of their treatment. After all, if we recognize that it is important to treat myofascial tissue (as recognized with Thomas Myers’s work), and it is important to treat visceral fascial tissue (as recognized with Jean-Pierre Barral’s work), and it is important to treat subcutaneous fascial tissue (as done with skin rolling and cupping), then why would we want to leave intrinsic fascial tissue untreated? The type of joint mobilization that can be legally and ethically practiced by most massage therapists is Grade IV joint mobilization.* Grade IV joint mobilization is performed with slow oscillations. (It’s important to note that a fast thrust is beyond the scope of practice for massage therapists. Fast-thrust joint mobilization is typically performed only by chiropractic and osteopathic physicians.)
As with any technique, it is extremely important that the skill be learned properly and that the therapist has a proficiency in performing the technique before using it on clients. Even though the technique of joint mobilization/arthrofascial stretching can be learned from an article or video content, given the precision required for this technique, small in-person continuing education classes with one-on-one guidance is recommended.
* Before employing any new technique, including joint mobilization/arthrofascial stretching, please check with your state licensure/certification body to ensure it is legal (within scope of practice) and ethical for you to use.
Pin Contact
When performing a pin and stretch technique, it is possible to use any contact for the pin. Usually, the smaller the point of contact (e.g., a finger pad or thumb pad), the more precise the therapist can be with the technique. However, smaller contacts also tend to be a bit pointed and somewhat uncomfortable for the client. Larger contacts might seem to be more assertive, but as they tend to better spread out the force on the client’s body, they are usually more comfortable for the client when the pressure is appropriately modulated. And, because they are larger, they are more powerful and comfortable for the therapist. Images 6A–6F demonstrate the use of various contacts employed when performing a pin and stretch technique on the right piriformis.
Sometimes, the contour of the client’s body might dictate which contact to use. Images 7A–7B demonstrate pin and stretch for the right pectoralis minor. If the heel of the hand is used, as seen in Image 7A, it might be uncomfortable for the therapist to hold the hand into extension at the wrist joint to avoid contacting the client’s breast tissue. For this reason, using finger-pad contact, as seen in Image 7B, might be preferable.
An Addition to Your Toolbox
When working clinically with orthopedic manual therapy, we have so many options for how to treat our clients. The challenge is to find the therapeutic tools that are the most effective at resolving a client’s condition. An excellent default method is to combine soft-tissue manipulation with stretching of the target myofascial tissue. And, when stretching is included in the treatment plan, depending on the region of the target myofascial tissue that is to be stretched, pin and stretch technique might be the optimal option toward focusing the stretching force. If you have not yet worked with pin and stretch technique, I recommend you begin to include it in your repertoire of treatment tools today.
Joseph E. Muscolino, DC, has been a manual and movement therapy educator for more than 30 years. He is the author of multiple textbooks, including The Muscular System Manual: The Skeletal Muscles of the Human Body (Elsevier, 2017); The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns, and Stretching (Elsevier, 2016); and Kinesiology: The Skeletal System and Muscle Function (Elsevier, 2017). He is also the author of 12 DVDs on manual and movement therapy and teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT), and has created Digital COMT, a video streaming subscription service. Visit www.learnmuscles.com for more information or reach him directly at joseph.e.muscolino@gmail.com.