To get some more information about this topic I used following databases: Pubmed, Medline and Pedro. I entered following keywords: friction therapy, friction massage, frictions, cyriax, tendinitis. I went to the library as well and took the book of Cyriax and Goldham with me.
Friction is defined as “an accurately delivered penetrating pressure applied through fingertips” . Cyriax, who is seen as the founder of the friction therapy, believed that deep frictions are appropriate for the treatment of tendinopathy, muscle strains, ligament lesions and scar healing
Clinically Relevant Anatomy
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The role of the therapist is to minimize the scarring that develops perpendicular to the actin and myosin filaments, to facilitate the proliferation of the fibroblasts in the scar and to develop a strong, mobile scar that won’t be a source of recidivate pain when returning to normal activities.
• Traumatic hyperemia, which helps to evacuate pain triggering metabolites.
• Movement of the affected structure which prevents or destroys adhesions and helps optimize the quality of scar tissue and mechanoreceptor stimulation.
• Stimulation of mechanoreceptors, producing a quantity of afferent impulses that stimulate a temporary analgesia.
• Fibroblastic proliferation, responsible for the repair en regeneration of collagen.
• Realignment of collagen fibers, determined by the magnitude of applied pressure.
The 8 rules of deep friction massage are :
• Diagnostic movements and palpation must single out the tissue at fault and the exact location on that tissue.
• The physical therapist’s fingers and patient’s skin must move simultaneously to avoid injury to the skin.
• The massage must be given perpendicular to the tissue’s fiber to smooth the scar down.
• The massage must be given with sufficient sweep to assure that the whole scar is treated.
• The friction must be given deeply, administered within the patient’s pain tolerance. The pain will gradually diminish during the massage.
• The patient must adopt a posture that will adequately expose the tendon.
• If the lesion lies in the belly of the muscle, the muscle must be put on slack. This will aid in separation of the muscle fibers during the massage.
• Tendons with a sheath must be put on stretch to assure maximum success of the massage.
However, there is no scientific evidence supporting such assumptions because massage is unlikely to increase muscle blood flow and studies are lacking on the effects of massage on the realignment of fibers. Nevertheless the inflammatory response to damaged muscle fibers causing a transfer of fluid and cells to damaged tissue is an established fact. The increased fluid produces swelling after injury. Neutrophils and macrophages migrate to the inflammatory sites and play a role in both the damage and repair processes.
Literature about the effects of friction massage in the treatment of tendinitis provides us several insides. In 1997 Davidson et al. created a tendinitis in a rat’s achilles’tendon by injecting the enzyme collagenase. This injection caused a collagen fiber disruption and misalignment. Afterwards they applied longitudinally augmented soft tissue mobilization on the tendon which resulted in fibroblast activation, leading to collagen synthesis. Friction massage is said to stimulate the proliferation of fibroblasts and collagen fiber realignment with cross linkages.They also performed a gait analysis which exposed an improvement in the step length and frequency. A case report demonstrated the potential benefit of a multimodal approach in patients with a shoulder impingement. This conclusion is supported by earlier articles that suggest the multimodal approach is an appropriate method for the successful conservative management of shoulder problems. This approach consisted of following interventions: soft tissue therapy including friction therapy, ultrasound phonophoresis, manipulation and exercise. Longitudinal and transverse frictions were applied to the posterior tenomuscular junction of the infraspinatus muscle, the coracoacromial ligament and the insertion of the supraspinatus on the greater tubercle of the humerus. The transverse motion across the involved tissue and the resultant hyperaemia are said to be the main healing factors of friction massage. The hyperaemia is supposed to release histamine and bradykinins resulting in vasodilation and reduction of oedema. The transverse action is said to prevent the formation of scar tissue while longitudinal friction effects the transportation of blood and lymph. A successful management of a chronic bursitis by using a soft tissue friction massage was also mentioned by Hammer.
But not all articles were in favor of friction therapy; a research report concluded that the manipulation of the wrist was found more effective than ultrasound, friction massage, muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. A reinforcement for this insight can be found in the trail of Brosseau et al. where no benefit was found for patients with extensor carpi radialis tendinitis concerning the control of pain or improvement of grip strength by using deep transverse friction massage. Furthermore this trial showed no significant difference for patients with an iliotibial band friction syndrome in 3 types of pain relief and functional status, measured after 4 consecutive sessions of deep transverse friction massage combined with other physiotherapy modalities. The only clinically important relative percentage difference in pain (22%) was measured while running. An RCT that aimed to compare the effectiveness of an exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy concluded that an exercise programme was more effective than ultrasound and transverse friction at the end of the treatment as well as at the follow-ups. As described by Cyriac the transverse friction was applied for 10 minutes continuously to the patellar tendon.
We can conclude by saying that with the limited evidence, there is still a lot of research to do about friction massage. A lot of RCT’s are lacking a control group, are limited by the small sample size and are only investigating the short-term effects. Therefore it is very difficult to draw conclusions regarding the specific effects of frictions in the treatment of tendinitis and other conditions.
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Clinical Bottom Line
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Recent Related Research (from Pubmed)
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- ↑ Galloway S, Watt J, Sharp C. Massage provision by physiotherapists at major athletics events between 1987 and 1998. Br J Sports Med 2004; 38 (2): 235-7
- ↑ 2.0 2.1 2.2 2.3 Cyriax, Coldham M: Textbook of Orthopaedic Medicine No1 2), pp 9, 10-2 1. London: Bailliere Tindall, 1984
- ↑ 3.0 3.1 Davidson CJ, Ganion LR, Gehlsen GM et al. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine & Science in Sports & Exercise. American College of Sports Md, 1997:313-319
- ↑ Gehlsen GM, Ganion LR, Helfst R. Effects of pressure variations on tendon healing. Muncie, IN: Performance Dynamics, Research Binder, 1998.
- ↑ Tiidus P, Shoemaker J. Effleurage massage, muscle blood flow and long term post-exercise recovery. Int J Sports Med 1995;16 (7): 478-83
- ↑ Shoemaker J, Tiidus P, Mader R. Failure of manual massage to alter limb blood flow: measures by Doppler ultrasound. Med of Sport and Recreation Research (Division of Sport and Sci Sports Exerc 1997; 29 (5): 610-4
- ↑ Clarkson P, Sayers S. Etiology of exercise-induced muscle damage. Can J Appl Physiol 1999; 24 (3): 234-48
- ↑ Smith L. Acute inflammation: the underlying mechanism in delayed onset muscle soreness? Med Sci Sports Exerc 1991;23: 542-51
- ↑ Van der Windt D, Van der Heijden G, Van der Berg S, Gerben ter R, de Winter AF, Bouter LM: Ultrasound therapy for musculoskeletal disorders: a systemic review. Pain 1999, 81:257-271
- ↑ Pribicevic M, Pollard H: A Multi-modal treatment approach for the shoulder: A 4 patient case series, Chiropractic & Osteopathy 2005, 13:20
- ↑ Gimblet PA, Saville J, Ebrall P: A conservative management protocolfor calcific tendinitis of the shoulder. J Manipulative Physiol Ther 1999, 22(9):622-627
- ↑ Pink MM, Tibone JE: The painful shoulder in the swimming athlete. Orthop Clin North Am 2000, 31(2):247-261
- ↑ Shrode LW: Treating shoulder impingement using the supraspinatus synchronization exercise. J Manipulative Physiol Ther 1994, 17(1):43-53
- ↑ Hammer WI: The use of transverse friction massage in the management of chronic bursitis of the hip or shoulder. J Manipulative Physiol Ther 1993, 16:107-111
- ↑ Conroy DE, Hayes KW: The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther 1998, 28(1):3-14
- ↑ Bang MD, Deyle GD: Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000,30(3):126-137
- ↑ 17.0 17.1 Hammer WI: The use of transverse friction massage in the management of chronic bursitis of the hip or shoulder. J Manipulative Physiol Ther 1993, 16:107-111
- ↑ Hammer WI: Friction massage; from Functional soft tissue examination and treatment by manual methods. Gaithersberg: Aspen; 1999:463-478
- ↑ Struijs PAA, Damen PJ, Bakker EWP, Blankevoort L, Assendelft WJJ, Van Dijk CN Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study, Phys Ther. 2003;83:608-616
- ↑ Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, Wells G. Deep transverse friction massage forfckLRtreating tendonitis. Cochrane Database Syst Rev. 2002;(4):CD003528
- ↑ Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clin Rehabil. 2004;18(4):347-52
- ↑ Cyriax HJ, Cyriax JP. Cyriax’s illustrated manual of orthopaedic medicine, second edition. Oxford: Butterworth-Heinemann, 1983
In this month's Members topic we are exploring the foot and ankle with a focus on achilles tendinopathy. This month we have exclusive access to:
- 2 FREE chapters from text books Maitland's Peripheral Manipulation by Hengeveld & Banks 2014 and A Practical Approach to Orthopaedic Medicine by Atkins, Kerr and Goodlad. 2010
- 4 FREE journal articles from The Foot
- An interview with Maitland expert Elly Hengeveld