Cross friction massage

 The purpose of deep friction massage is to maintain the mobility within the soft tissue structures of ligament, tendon, and muscle and prevent adherent scars from forming. The massage is deep and must be applied transversely to the specific tissue involved unlike the superficial massage given in the longitudinal direction parallel to the vessels which enhances circulation and return of fluids.
Before friction massage can be performed successfully, the correct structure must be found through proper evaluation procedures. The distinction must be made between contractile structures such as the muscle belly, musculotendinous junction, tendon, and tendon-periosteal junction and noncontractile structures such as the joint capsule, bursae, fascia, dura mater, and ligament (Table In addition to finding the right spot, the massage must also be given the most effective way by following these basic principles.

1) The proper location must be found through proper evaluation procedures and palpation of the specific tendon, ligament, or muscle.
2) Friction massage must be given across the affected fibers. The thicker and stronger a normal structure, the more important friction is given strictly across the grain.
3) The therapist's fingers and patient's skin must move as one, otherwise moving subcutaneous fascia against muscle or ligament could lead to blister formation or subcutaneous bruising.
4) The friction massage must have sufficient sweep and be deep enough.
5) The patient must be in a comfortable position.

The frequency and duration of treatment varies
with the severity and type of the injury. In a recent injury, i.e., ligament sprain, start daily with gentle massage to keep mobility. It is important for the therapist to distinguish between tenderness and pain. Tenderness can be due to deep friction and can persist long after the pain disappears. Pain is elicited by clinical assessment and reassessment. Deep friction massage may be given every other day or when the excess tenderness has worn off. The duration of the treatment varies; for example, with an acute ligamentous injury, the gentle massage performed may last only 1-2 minutes. However, it may well take several minutes to be able to get your fingers on the structure depending on the severity of pain. With deep friction massage, the treatment will last 10-15 minutes.

The goals are two-fold: to provide movement to the tissue itself and to produce traumatic hyperemia. In the acute injury, the massage consists of gentle passive movements which move the structure but do not detach the healing fibrils from proper formation. The transverse movement is an imitation of the structure's normal mobility by broadening but not stretching or tearing the healing fibers. The movement encourages realignment and lengthening of these fibers.
The second goal, traumatic hyperemia, results in the enhancement of blood supply to the area. The hyperemia appears to diminish pain by increasing the speed of destruction of Lewis' P substance, probably due to the release of histamine. Lewis' P factor is an irritative metabolite which produces ischemia when it accumulates.

The use of movement in the treatment of soft tissue injuries to muscle, ligament, and tendon is based upon the work of Stearn. She observed the fibroblasticactivity in the healing of connective tissue as well as possible scar formation, as related to the effect of movement. Her conclusions were that fibrils form almost immediately and that external
factors were responsible for the development of an orderly arrangement of the fibrils. 

Although there is presently no definitive research relative to friction massage and connective tissue, there certainly have been many cases of patients treated by therapists with positive results. Additional rationale for using friction
massage could well be the expansion of Stearn's connective tissue theory through understanding of the anatomy, physiology, and repair process which exist. A discussion of relevant literature is presented so that a physical therapist can achieve an understanding of connective tissue in order to effectively and appropriately use friction massage.