Key Points
• Ligaments are dense connective tissue structures composed of elastin that provides a degree of pliability and flexibility, and collagen that gives the tissue tensile strength.
• A sprain is the most common ligament injury and is caused by excess tensile load.
Massage therapists need to understand potential injuries or dysfunctions in the musculoskeletal soft tissues to provide the best treatment possible for their clients. Here, we’ll explore the unique characteristics of ligaments and how those characteristics show up in a number of common ligament problems.
Ligament Structure and Function
The primary function of ligament tissue is to connect adjacent bones and establish skeletal stability. Ligaments are dense connective tissue structures composed of elastin and collagen. Elastin provides a degree of pliability and flexibility, while collagen gives the tissue tensile strength.
Ligaments are designed primarily to withstand tensile loads along the direction of their fiber orientation. Ligament fibers are oriented primarily in a longitudinal direction to provide the greatest resistance to tensile stress. However, forces acting on joints can come from multiple directions, so some ligament fibers are also oriented in other directions. These cross fibers allow the ligament to have some flexibility and strength in other directions. Ligament tissue also makes up a significant amount of the fibrous capsule around synovial joints.
Ligament Sprain
A sprain is the most common ligament injury and is caused by excess tensile (pulling) load on the ligament. Sprains are categorized as first, second, or third degree. Identifying ligament damage relies on understanding the ligament’s location and the motions it is designed to resist. This information, combined with an analysis of the forces the body was subjected to when the potential injury occurred, will help determine the injury degree.
In many cases, it is moderately easy to infer the ligament’s function from the location. For example, the medial collateral ligament of the knee resists force aiming from the lateral to the medial side of the knee (also called a valgus force). With other ligaments, it is not as easy to identify the primary motions they resist.
The severity of ligament damage depends on the size of the ligament and the force it can withstand. Some ligaments, such as the medial collateral ligament of the knee, are large and can withstand high tensile loads. Others are much smaller because they are not resisting such high forces.
If the tensile stress is minor, the ligament can absorb the force with minor elastic deformation (fiber stretching) and is called a first-degree sprain (Image 1). If the force is significant, the ligament fibers stretch past the tissue’s initial ability and undergo plastic deformation, meaning the tissue stretches but does not recoil to its original length. A permanent degree of tissue elongation can occur (Image 1); this plastic deformation represents a second-degree sprain. If the ligament is stretched beyond plastic deformation, it will tear; these are called third-degree sprains.
Ligament sprains frequently occur in sports or traumatic accidents due to high and rapid force loads. However, prolonged stress on the ligaments can also weaken them, making them more susceptible to injury from smaller loads. Ligament sprains are more prevalent in people with systemic disorders such as Ehlers-Danlos or Marfan syndromes because these conditions lead to weakness in connective tissues. In addition, women in the later stages of pregnancy experience a greater number of ligament sprains due to increased ligamentous laxity resulting from elevated levels of the hormone relaxin.
There are various approaches to treating a ligament sprain with massage. If the ligament is accessible, deep friction massage has beneficial results. Originally, the idea behind friction massage was that the transverse movement of the friction helped realign scar tissue and prevent fibrous adhesions between fibers. That specific narrative is being challenged, but the technique still gets beneficial results. We also know that friction massage may aid in fibroblast proliferation, which helps the restoration of damaged tissue.
Other treatments claim to “release” ligaments, though it is unclear what that means. For a tissue to release, it would first have to contract, and because ligaments do not have any contractile properties, there isn’t anything to release. It is possible that in the effort to reach a ligament with manual therapy, other neurologically responsive soft tissues have been relaxed, rendering a sensation of “ligament release.”
Let’s look at three different ligament sprains to better understand the diversity of what can happen to our ligaments and how we might treat them.
ACL Sprain
The knee’s anterior cruciate ligament (ACL) attaches to the anterior tibia and the posterior femur (Image 2). Inside the knee, the ACL forms a cross with the posterior cruciate ligament (PCL) to provide dynamic stability in the sagittal plane. The ACL’s primary function is to prevent forward movement of the tibia in relation to the femur. It also assists in preventing rotation at the knee.
Mechanical overload is the primary cause of ACL injury and is common in sporting activities. For example, when an individual is running and suddenly stops, the momentum of the body has a very strong anterior translation force of the tibia in relation to the femur. When the person suddenly stops, the quadriceps also engage in a sudden high-force eccentric contraction to halt movement. Because they attach to the anterior tibia, they are pulling the tibia forward in relation to the femur and putting a high tensile load on the ACL.
Another cause of ACL sprain is an extreme hyperextension injury to the knee, such as a direct blow to an extended knee or landing improperly from a jump with the knee hyperextended.
Even though the ACL is not palpable due to its location within the knee joint, ACL injury is routinely evaluated with physical examination. Most ACL sprains can be identified with physical examination and an accurate history. First- and second-degree sprains are usually harder to identify because there is not as much excess movement present at the joint. The excessive hypermobility of the knee in severe injuries makes third-degree sprains relatively easy to identify. Keep in mind that some third-degree sprains will have excessive joint mobility but no pain during the evaluation because the ligament is completely detached.
Because the ACL lies deep within the knee joint, it is inaccessible to palpation. Consequently, we can’t reach this ligament to perform any soft-tissue treatments directly to it. However, that doesn’t mean there isn’t a role for massage in managing this condition. If the tear is minor, a physician may recommend exercise or movement therapy. Massage can be a beneficial adjunct along with movement therapy to help restore biomechanical balance in the soft tissues of the region. It is also helpful in pain management and reducing reactive muscle splinting after the injury. This is a great example of when working on all the surrounding areas without actually working directly on the primary injured tissue can have great benefit.
Shoulder Separation
When someone says they separated their shoulder, the image often conveyed is that of a glenohumeral dislocation where the head of the humerus has separated from the glenoid fossa. However, a shoulder separation is actually a ligament sprain at the acromioclavicular (AC) joint where the clavicle meets the acromion process of the scapula.
The primary causes of shoulder separation involve the upper shoulder being struck by a heavy or falling object or the individual falling directly on the shoulder. As a result of the impact, the stabilizing ligaments of the AC joint are sprained. The AC ligament stabilizes the AC joint, and the conoid and trapezoid ligaments stabilize the clavicle and the coracoid process of the scapula (Image 3). The conoid and trapezoid are sometimes referred to as one structure called the coracoclavicular (CC) ligament(s). It is the AC ligament that is usually injured in a shoulder separation, but more severe injuries affect the coracoclavicular ligament complex as well.
In addition to damaging the acromioclavicular and coracoclavicular ligaments, falls or impacts to this region can cause a sprain and/or dislocation to the sternoclavicular joint. Sternoclavicular sprains are not as common but can be serious because a dislocation of the proximal end of the clavicle may cause it to press on or rupture the trachea or jugular vein. Sprains or dislocations at the sternoclavicular joint are considered a separate pathology and are not called shoulder separations.
Physical therapy is a common course of treatment to reestablish stability and proper movement in the acromioclavicular complex. The clavicle should be in the proper position when the ligaments start the rebuilding process and scar tissue develops. An arm sling is generally used to maintain proper alignment of the acromioclavicular complex. In some cases, the clavicle is not positioned ideally and heals in a slightly different position. The altered position rarely causes long-term functional impairment and is primarily a cosmetic issue because it results in an enlarged bump at the AC joint from the protruding distal end of the clavicle.
Deep friction massage is helpful to encourage collagen rebuilding in the damaged ligament fibers. However, if the tear is severe, friction should not be performed until well after the initial inflammatory phase (up to 72 hours post-injury). If the injury is more severe, waiting longer is warranted, and consultation with a physician would be helpful. Massage and stretching applied to the entire shoulder girdle are useful to prevent spasm of the surrounding muscles. Treatment of the entire shoulder complex may also reduce capsular adhesions due to long periods of relative immobility that may be necessary to encourage ligament rebuilding.
Spinal Ligament Sprain
A complex webbing of ligaments runs throughout the spine and is designed to aid in spinal stability. Spinal ligaments have different anatomical characteristics depending on their location and primary function. For example, the intertransverse ligaments run between adjacent transverse processes in the spine (Image 4). However, they are so small that they provide only a minimal amount of stability. The dorsal portion of the supraspinous ligaments from the erector spinae muscles are really more tendinous than ligamentous, as they are primarily composed of tendinous fibers. Consequently, they play a role in transmitting contraction forces from the erector spinae to the spine.
An important supporting ligament in the lumbar region is the iliolumbar ligament. This ligament anchors the L5 vertebra to the pelvic girdle and helps prevent forward sliding and rotational distortions of the lower lumbar vertebrae (Image 4). Due to its position and mechanical vulnerability, the iliolumbar ligament is susceptible to sprain from sudden forces to the lower lumbar or sacral regions.
Identifying spinal ligament sprains through physical examination is difficult due to the depth of the spinal ligaments and the abundance of soft tissues around the spine. A high-tech diagnostic procedure such as MRI is usually required. However, being familiar with the characteristics of ligament sprains and knowing how to do detailed movement testing can help you assess these injuries.
As with other ligament sprains, massage can be helpful mainly by normalizing surrounding soft tissues. Deep friction massage, which is used for other ligament sprains, has very little effectiveness for most spinal ligament sprains because the ligaments are so deep and difficult to access. However, larger and more superficial ligaments, such as the iliolumbar ligament, may respond well to friction massage. Rest from offending activities is crucial, as is preventing spinal motions that further stress the ligaments. Massage can be effective for addressing muscle spasm that develops as a result of pain.
The Limitations of a Muscle-Centric View of the Body
Each professional health-care field has its own lens of bias. As massage therapists, we tend to be muscle-centric in our view of the body. That means when someone comes in with a pain complaint, our tendency might be to assume muscle involvement first. Learning more about other common disorders such as ligament sprains helps us be more accurate clinicians and thus achieve more success with our clients.
Whitney Lowe is the developer and instructor of one of the profession’s most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at academyofclinicalmassage.com.