Category Archives: Soft Tissue Therapy and Recovery

Massage & Muscle Stiffness

One of the main reasons that athletes seek out massage is to decrease the muscle stiffness they feel due to intense training and competing. A recent paper by Crommert and colleagues (Scand J Med Sci Sport, 2014) evaluated the effects of massage on muscle stiffness in the medial gastrocnemius of eighteen healthy volunteers.


Seven minutes of massage was performed on the gastrocnemius of one leg for each subject – 2min of effleurage, 2min of petrissage, 2min of deep circular friction, and 1min of effluerage – while the non-massaged lower leg served as the control. Immediately following massage, the subjects rated their level of pain experienced during the massage on a 0 to 10 scale (0 = no pain, 10 = worst imaginable pain).

Muscle stiffness was measured using shear wave elastography to quantify the shear elastic modulus (stiffness) at the midpoint of the medial gastrocnemius muscle belly at three time points: before massage (baseline), immediately following massage (follow-up 1), and after 3min of rest following follow-up 1 (follow-2), in both the massaged and non-massaged legs.


  • Medial gastrocnemius stiffness was significantly lower immediately following massage (follow-up 1) compared with baseline and following rest (follow-up 2).
  • There were no significant differences found between baseline and follow-up 2 in the massaged leg, indicating a return to normal muscle stiffness.
  • Average level of pain rating was 1.3 +/- 1.6 and there was no correlation found between perceived pain level and a reduction in muscle stiffness in the massaged leg at follow-up 1.


Massage appears to reduce muscle stiffness; however the results are short lived with a rapid return back to baseline levels.

Practical Applications

The authors suggested four potential mechanisms that may lead to a decrease in muscle stiffness from massage:

  1. A decrease in motoneuron excitability due to general relaxation.
  2. Manual pressure and stretching leading to a breaking apart of stable cross-bridges between actin and myosin filaments, which are spontaneously formed while the muscle is at rest.
  3. Increased intramuscular temperature from the massage.
  4. The possibility that all of these mechanisms are working together, rather than any one of them working in isolation.

These theoretical mechanisms for why manual/touch therapy works are interesting and most likely not the only mechanisms at play. I’d be inclined to think that #4 above is the most likely scenario, along with other potential influences.

The fact that massages influence on muscle stiffness was short lived is interesting. From a practical standpoint, when applying this stuff to athletes for specific purposes of addressing muscle tone and stiffness, there are a few things I think about with regard to the outcome in this study:

  • The length of treatment may have been too short to produce a more longer lasting effect. Maybe seven minutes isn’t enough? One proposed mechanisms that led to a decrease in muscle stiffness was general relaxation from massage. While not measuring stiffness, Arroyo-Morales have done some studies looking at massage therapy and autonomic changes – a shift towards a more parasympathetic state – leading to greater relaxation. The two studies they performed used 40min massages following intense cycling exercise in order to achieve this result.
  • Maybe the techniques used are to passive in order to produce longer lasting changes? As I discussed a few weeks ago, there might be different massage techniques for different recovery purposes. If the goal is to improve some sort of functional outcome (E.g., decrease muscle stiffness and/or improved ROM) maybe passive techniques, like the ones used in this study, need to be coupled with more active techniques which force the client to be an active participant in the treatment. This puts the client in the driver seat and might allow their brain to be more receptive to the changes taking place and cause them to be more longer lasting.
  • Finally, maybe the treatment needed to be followed up with active movement in order to “make it stick”? In the past, I have written about the idea that massage might be useful to “open the window”, to help decrease threat or increase awareness for the client, and then should be followed up by movement therapies in order to teach the brain to move and be strong through the new ROM on its own. Perhaps the reduction in muscle stiffness, found in this paper, would have been longer lasting with movement therapy? Certainly a short treatment time can be beneficial in certain situations, depending on your goal. Grieve and colleagues found that a 10min treatment consisting of trigger point therapy and light stretching was adequate enough to produce a significant increase in ankle dorsiflexion in recreational runners. In a situation where the goal of treatment is some sort of functional outcome, rather than more recovery based, these short bouts of massage therapy may be enough to produce a result and then should be followed up with some sort of movement based therapy.

Massage therapy appears to impact the body on different levels via different mechanisms. This study evaluated muscle stiffness and found that seven minutes of massage was effective at decreasing muscle stiffness, however, the results were short lived. From a practical standpoint, the fact that massage decreased muscle stiffness is promising and there might be other factors that could enhance the effect of the positive change in muscle stiffness seen in this study. In an actual treatment setting we rarely (or never) rely solely on one single modality or approach and usually a variety of different approaches are stacked on top of each other, depending on the intended goal of the treatment. When used in conjunction with other modalities, the findings from this study may potentially be augmented.

Soft Tissue Techniques For Athletic Recovery

In my last article I discussed a new paper looking at Massage and Exercise Induced Muscle Damage. At the end of the article I discussed some of the ways massage can be thought of as a modality to use within the recovery process from competition or during intense training phases. I thought it would be good to put together some more formal thoughts on the topic as recovery is different for everyone and athletes often have individual complaints or needs that have to be met. By altering your treatment approach you may have a better chance of meeting these needs and helping to play a more significant role in the recovery process.

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In the left hand column we see a variety of different complaints that an athlete may have and reasons that they may be seeking out massage. In the right hand column there are a few different options for treatment. This is by no means and absolute list. It is just a few ideas to get the therapist thinking of potential treatment effects. Unfortunately, most therapists have a one-size-fits-all approach to therapy and, no matter what your complaint or need is, you are going to come in, lie on the table and get a deep tissue massage (oftentimes leaving the individual more sore the next day). By trying to vary our treatment approach and be aware of the athlete’s complaint, we can (a) meet the athlete’s needs and (b) alter our soft tissue inputs from treatment to treatment, preventing the body from adapting to the exact same thing every time.

Briefly looking at the different types of complaints:

  • In the first group, we are dealing with athletes who have a high level of fatigue and exhaustion. This may come from a period of overreaching or overtraining. Additionally, within this bucket are athletes that have a high level of anxiety (and perhaps may show a higher amount of sympathetic dominance). For the athletes with these complaints our treatment options are to help them attain a more relaxed state. For this, I favor longer massage sessions (60-90min) with a lot of slow compression and long holds of skin stretching. These techniques tend to be very relaxing and provide a therapeutic effect. The suggestion of placing the athlete prone is to decrease the amount of visual input (as well as the urge to talk or speak) and to attempt to get them to shut down for a moment and maybe even fall asleep on the table. Additionally, working on the neck and paraspinals in this prone position seems to evoke a sense of relaxation and have a calming effect on the system. The therapist should resist the urge of trying to go too deep with their compressions, to a point where the athlete becomes very engaged in the session and is trying to fight against your pressure. Work to the athlete’s tolerance level. Much of the ideas in this section came from some of the research I have discussed a few years ago on Massage and HRV and Massage and Stress as well as some of the concepts I took from Robert Schleip’s text, Fascia: The Tensional Network of the Human Body, which I discussed in THIS article.
  • In the second group we see one of the most common reasons why athletes seek out massage – soreness. The massage technique suggestions for this complaint come from some of the research discussed on my last article as well as the research I discussed in an article two years ago from Crane et al. Both articles explained a massage approach for muscle damage dealing with 5-10min of gliding strokes to the affected muscle region. I also put into this section things like contract relax stretching or pin and stretch modalities as method to engage the athlete, get them to move around a little bit, and, in the process of creating movement with human touch, allow them to perceive themselves as “less sore”.
  • The final group is one of mobility or “tightness” as well as treatments geared towards maintenance of mobility and tissue quality. The aim of dealing with the athletes in this group is to have a good understanding of where their movement system is currently (what is their baseline) and then determining when they are below their norm (oftentimes, following intense competition or training, the individual may tighten up or stiffen up and lose some of their normal movement). Also, knowing what is normal for the athlete in the sense of tissue quality (tone) and what is abnormal, for that individual, can be extremely important and helpful in guiding your treatment approach. Within this group the modalities selected are more active, engaging the athlete to move and be a participant in the treatment. Thus, things like pin and stretch techniques or active stretching/mobility techniques can be very valuable. Additionally, Dr. Andreo Spina’s work, Functional Range Release, can be extremely helpful for engaging the resistance barrier, applying tension to the tissue, and using things such as PAILs and RAILs to actively engage the athlete with movements into and out of their limited range (Dr. Spina also has an approach called Functional Range Conditioning, which is a nice follow up to the hands on treatment as it is a movement based approach to re-teach the system how to move into certain ranges of motion). Other ideas for the treatment approaches in this group came from articles and sources on Foam Rolling and increases in joint ROM, muscle stripping with eccentric contraction (gliding techniques with active movement), ischemic compression (trigger point compression) and increases in joint ROM, the work for Travell and Simons, as well as others discussing trigger point theories, and the fascial manipulation work of Stecco.

Wrapping Up

As I stated earlier, the treatment approach/modalities in the right column are by no means an exhaustive list. The goal of this article was to provide a framework for therapists to begin to think about and consider how their treatment techniques impact the athlete/client and perhaps can (and should) be modulated based on what the athlete’s symptoms/complaints are. In this way, the therapist can approach treatment with the athlete and hopefully better meet their needs and facilitate a positive recovery outcome.

Massage and Exercise Induced Muscle Damage

A number of studies over the years have evaluated the potential role massage plays in recovery following exercise or competition, looking at factors such as lactate clearance and delayed onset muscle soreness (DOMS). Commonly, the studies looking at massage and DOMS base their outcome on the subjects’ perception of how the muscle feels following the exercise protocol and then how it feels following massage at different time points (immediately following, +12hrs, +24hrs, +48hrs, etc) in comparison to a control group. A recent paper by Shin and Sung took the investigation a step further in order to try and understand how massage affects recovery with regard to muscle strength and proprioception.


Twenty one subjects, who did not regularly perform strength training exercises for the lower extremities, were randomly divided into two groups. Eleven subjects were in the massage-treatment group, while 10 subjects were in the control group.

Exercise Protocol

The EIMD protocol consisted of the subjects going up and down a five-story building 20 times. Following the 20 reps, the subjects rested for 5min and then had their lactate levels measured. Lactate levels were measured pre- and post-exercise in order to confirm that the subjects sustained an adequate level of muscle fatigue.

Measurements of Proprioception & Strength

Strength was measured using surface EMG over the gastrocnemius during resting and isometric contractions (pushing against a wall without ankle movement for 5sec while in a prone position). Ultrasonography of the gastrocnemius during the same 5sec isometric contraction was also assessed. Proprioception was evaluated using a dual inclinometer, which measured knee and ankle proprioception via passive-to-active angle reproduction. The subjects completed three trials, lying prone, and proprioception was measured as the difference between the targeted angle and the reproduced angle in the ankle and knee joints.


The experimental group in this study received a 15 minute massage to the gastrocnemius, which consisted of light stroking, milking, friction, and skin rolling – all commonly used massage techniques. The control group received sham transcutaneous electrical nerve stimulation (TENS) to the gastrocnemius for 15min.


> EIMD was confirmed in both subject groups via a significant increase in pre- to post-lactate levels.

> Massage to the gastrocnemius increased activation of the medial gastrocnemius head during isometric contraction following the EIMD protocol.

> Massage appeared to have a positive effect on pennation angle of the superficial layer of the gastrocnemius.

> The massage treatment group increased proprioception at the ankle joint, following EIMD, however the changes in the knee joint were not found to be significant.

My Comments

Massage and soft tissue therapy continue to be recovery modalities sought out by athletes, sports physios, and coaches. While a large part of the result an individual gets from massage following intense exercise may come in the way of psychological relaxation or perception that the treatment is doing something favorable (IE, placebo – which is not a bad thing!), this paper does appear to suggest that there may be other benefits at play. The tests used in the paper are not dynamic in nature, so it would be hard to suggest that perhaps those in the massage group could get off the table and go for another run up and down the stairs; however, it would be interesting to evaluate their ability to repeat their performance, following the protocol, 24hrs later, as this would be similar to what an athlete may be asked to do during a competitive season or during the rigors of a training camp.

As mentioned above, the psychological aspects of any form of touch therapy cannot be understated. The idea of placing your hands on an individual and them producing a response of overall relaxation and them believing in the overall effect is a massive win in terms of shifting that athlete to a more recovered state. That being said, from a more physiological perspective, this is not the first study to look at massage and potential improvements in joint range of motion following treatment. MacDonald and colleagues (J Strength Cond Res, 2013) looked at self-myofascial release massage, using a foam roller, and increases in knee joint range of motion and Forman and colleages (J Body Work Mov Thera, 2014) showed an increase in hamstring range of motion following deep stripping massage with eccentric contraction. Additionally, using trigger point pressure to the gastrocnemius and soleus, Grieve and colleagues (J Body Work Mov Thera, 2013) showed improved ankle joint dorsiflexion in recreational runners.

Finally, looking at the massage intervention in this study – 15min of treatment to the gastrocnemius is a long time to spend on one single muscle. A 2012 study by Crane and colleagues, evaluated the attenuation of inflammation following EIMD using massage therapy. They found that a 10min massage, using effleurage (gliding strokes), petrissage (kneading strokes), and slow stripping strokes to the quadriceps muscle were effective for mitigating the inflammatory response following an intense bike protocol. Perhaps the duration of time spent on one single muscle is a key aspect to attaining certain results when there is excessive soreness or exercise induced muscle damage.

In my next article I will lay out a few ideas surrounding common athlete symptoms, when it comes to high amounts of training, and different massage modalities that may be effective in order to positively influence those symptoms.

Trigger Points Revisited: Implications For Sport

It has been over 5 years since I wrote my Trigger Point 101 article, which offered a basic explanation of trigger points for strength and conditioning coaches. The article is still one of the most popular on the site and in a recent discussion with Dr. Phil Snell, regarding Trigger Points, I figured I’d circle back around and revisit the topic.

Questions About Trigger Points

Trigger points are still a hotly debated topic and my aim is not to get into a name convention about what we should call them (I’ll let the researchers sort that one out). What we do know is that there are two main kinds of trigger points we may be dealing with:

  • Active Trigger Points – These are trigger points that are currently referring their characteristic pain response. For example, you have some pain in the anterior shoulder and when I push on your infraspinatus it refers the pain you are currently feeling and after some time that pain dissipates and goes away.
  • Latent Trigger Points – These are the trigger points that only produce pain when they are provoked. Using the above example, you would not be experiencing any anterior shoulder irritation, however, if I started to massage your infraspinatus you end up feeling a referral pain in your anterior shoulder, which dissipates after treatment.

One thought that Dr. Snell raised in our discussion was centered around the idea that maybe trigger points don’t ever go away. Perhaps they just modulate between being latent and being active based on activities that we perform in our daily lives.

This is certainly an interesting hypothesis and it has been shown in a number of studies that latent trigger points are very common in asymptomatic subjects (Fernandez-de-Las-Penas C, Dommerholt J. 2014.). The more that I think about it, the more I think that maybe trigger points are a potential ramification of being upright. After all, we do tend to see a lot of the same muscles develop trigger points and these are often the same muscles that we need to hold us up against gravity (Upper Traps, Gastroc, Erectors, etc). Additionally, many of the muscles that commonly develop trigger points are those that Janda suggested had the tendency for hypertonicity:


Thinking more about Dr. Snell’s assumption and the idea that trigger points may be related to us being upright I believe there are some important applications regarding sport and sports preparation.

Implications For Sport

Training for sport is brutal. Athlete’s log long hours in the gym and long hours on the field/court/track, day after day, month after month, and year after year. On top of that the movements tend to be rather repetitive in nature, in order to develop specific skills and technique, leading to overuse injuries and unique strain patterns.

The Integrated Hypothesis of Trigger Points (McPartland JM, Simons DG. 2006.) encompasses multiple physiological components:

“The ‘integrated hypothesis’ regarding the etiology of myofascial trigger points states that each trigger point has a sensory component, a motor component, and an autonomic component.  The hypothesis encompasses local myofascial tissue, the CNS, and systemic biomechanical factors.”

This hypothesis allows us a to paint a very broad picture of how an athlete’s soft tissue may react to the stresses that we place upon them in training and competition as well as how their daily lives may impact soft tissue structures. If trigger points don’t ever go away but rather just modulate from latent to active based on activity, as Dr. Snell suggested, and if they are a product of being upright, perhaps the goal of soft tissue therapy in sport should be to aid in supporting the physiological system to prevent increased trigger point activity (Note: Of course this is not just specific to soft tissue therapy but the program as a whole. Because trigger points can be influenced by multiple factors – nutrition, hydration, overuse, repetitive strain, psycho-emotional stress, etc – it is important to manage all stressors within the training program.).

The concept of latent trigger points is an interesting one. While trigger points may not actively be referring a pain pattern it has been suggested that their presence may disturb motor function leading to issues such as muscle weakness, inhibition, increased motor irritability, muscle cramps, or altered muscle recruitment patterns (Fernandez-de-Las-Penas C, Dommerholt J. 2014.Shah, 2008.,Ibarra, 2011). Recently, it has been suggested that trigger points may play a roll in central sensitization (Fernandez-de-Las-Penas C, Dommerholt J. 2014.) due to their ability to activate and maintain sensitization of central pathways. This may happen through ongoing sensitization of previously silent dorsal horn neurons brought about by various neuropeptides and inflammatory compounds, such as, bradykinin, CGRP, substance P, TNF-a, IL-6, etc. (Shah, 2008.). Thus, because everyone posses latent trigger points, because latent trigger points can become active trigger points, and because latent trigger points may negatively influence motor function and increase inflammatory compounds that can make an athlete more adverse to changes in their dorsal horn neurons, managing soft tissue health and treating latent trigger points to help manage their activity and prevent them, as best as possible, from becoming active may be a good strategy.

Treatment of Latent Trigger Points in Healthy Subjects

A recent study by Grieve and colleagues (2013) set out to evaluate the immediate effect of restricted ankle joint dorsiflexion ROM after a single treatment of latent trigger points in recreational runners. The twenty-two runners in the study were tested to have restricted ankle dorsiflexion with both a straight knee (gastroc) and knee bent to 90 degrees (soleus). The presence of trigger points were confirmed with a palpatory assessment. The subjects served as their own control and were randomly assigned to either an intervention or control session, 1 week apart.

Intervention Session

  • Lewit’s barrier release concept was applied to trigger points in the gastroc and/or soleus (which were marked on the client during the palpatory assessment to ensure accuracy). The Lewit barrier release concept is performed by applying increased thumb pressure over the marked trigger point until the first barrier of tissue resistance is felt. This barrier was perceived to be ‘tender’ but not ‘painful’ to the subject. The pressure is maintained until the therapist felt a release in muscle tension.
  • Following the release of muscle tension a 10sec passive stretch was applied to the treated muscle.
  • This sequence of treatment and stretch were performed for a 10min treatment period.

Control Session

  • During the control session, subjects performed a 10min supervised rest period.


  • Ankle dorsiflexion was measured at baseline and post 10min treatment/rest period for both groups.

Findings & Relevance

Post treatment measurements of dorsiflexion revealed a 4 degree and 3 degree increase in soleus and gastroc dorsiflexion, respectively. Both findings were clinically and statistically significant.

This paper confirms a few of the concepts discussed above:

  • First, latent trigger points, while not referring pain, may negatively influence motor function and range of motion.
  • Second, a small amount of time (10min) was required in order to see clinically relevant improvements in ankle dorsiflexion in asymptomatic recreational runners.

Treatment of soft tissue structures as part of the training process may be beneficial for keeping tissue healthy and keeping the athlete training. Perhaps some of the ROM benefits in this study can be had with the FOAM ROLLING that athletes perform prior to warm up and training.

Wrapping Up

Soft tissue treatment has an important place within a structured training program and the idea that we should be treating latent trigger points in athletes as a means of preventing them from becoming active, enhancing joint function, and decreasing tissue tension is an interesting one. Latent trigger points may be a product of being upright as well as the tasks the athlete commonly performs. Understanding the sport and the soft tissue structures which are stressed in that sport may be helpful when planning a treatment session. Treatment can be performed via hands on therapy, dry needling techniques, or foam rolling. As indicated in the paper above by Grieve and colleagues, treatment does not need to be overly painful or aggressive. The Lewit barrier concept takes the tissue to the first barrier of resistance and works within the individual’s level of discomfort. I typically use a 1-10 scale and ask the client to not let me get over a 7 >> Some may refer to this as a “good hurt” and treatment of trigger points has been shown to bring about a favorable shift in the autonomic nervous system (Delany JP, 2002.). Many of the trigger points line up with the Stecco centers of coordination and treatment to those regions, with either compression (as in the Lewit barrier concept) or friction (as in the Stecco treatment approach) may be beneficial. It is common to follow treatment of a trigger point, once there has been a decrease in tissue tension and a decrease in client sensation, with some form of stretch, as used in the study by Grieve and colleagues above. The types of stretches I commonly apply are Muscle Energy Techniques, some form of active isolated stretch, a low grade passive stretch (as indicated in the Grieve study), or some type of pin and stretch technique. Finally, it is important to educate the athlete on self-care strategies and remember that trigger points are multifaceted and things such as nutrition, hydration, sleep, stress, etc, all play a roll in their expression.

Interview with Dr. Andreo Spina

I am extremely excited to have Dr. Andreo Spina coming to Portland in March to present his Lower Extremity Functional Anatomic Palpation & Treatment Course. For registration information CLICK HERE (NOTE: Early Bird Discount ends January 1!). This is a course you wont want to miss and it isn’t often that Dr. Spina comes up to the Northwest.

I truly believe this is one of the best con ed courses out there for chiropractors, physical therapists, and massage therapists. You can read my review of the course HERE.

Despite Dr. Spina’s crazy schedule of traveling, teaching, studying, and, lets not forget, being a clinician, I was fortunate enough to snag a bit of his time so that we could do a short interview for the site discussing some of his thoughts on soft tissue treatment.


1) Thanks for taking the time out of your busy clinical and teaching schedule to do this interview, Dr. Spina. Can you please give the readers a short overview of your background??

Sure thing…

I studied Kinesiology at McMaster University in Hamilton, Ontario, Canada.  I later graduated with summa cum laude and clinic honors from the Canadian Memorial Chiropractic College as a Doctor of Chiropractic and subsequently completed the two-year post-graduate fellowship in sports sciences. During my time studying Chiropractic, I became the first pre-graduate student to tutor in the cadaver laboratory in the department of Human Anatomy, a position that continued throughout my post-graduate fellowship program.

Stemming from my passion of studying and teaching anatomy, in 2006 I created Functional Anatomic Palpation Systems (F.A.P.)™ which is a systematic approach to soft tissue assessment and palpation.  Following the success of F.A.P. seminars, I later created a follow up system of soft tissue release and rehabilitation called Functional Range Release (F.R.)® technique which is now being utilized by manual practitioners around the world including the medical staffs of various professional sports organizations.  I then combined the scientific knowledge gained during my studies with my 29 years of martial arts training in various disciplines to create the third installment of my curriculum, Functional Range Conditioning (FRC)™, which is a system of mobility conditioning and joint strengthening.

Aside from my work teaching seminars, I also own a sports centre in Toronto, Ontario where I practice and train clients.  I am a published researcher, and I have authored chapters in various sports medicine textbooks.

2) You approach to soft tissue therapy is extremely comprehensive and, after having attending one of your courses before, it is obvious that you have spent a lot of time reading research in order to develop your thought processes and theories about what may be taking place when we apply contact to another person’s body. The fascial system is a big part of your approach and the concept of the fascial system and how the body is connected has gained a lot of popularity in recent years. Can you please explain your approach and this concept you refer to as “Bioflow Anatomy”?

To say that the Functional Range Release system has a sole focus on fascia is not entirely accurate actually, although it might have been in the not so distant past.  Further examination of literature has led/forced me to be more inclusive of other tissues, which together constitute the most abundant type of tissue in the human body, namely Connective Tissue (CT).  Examples of other tissues inclusive in CT other than fascia include bone, cartilage, tendons, ligaments, blood vessels, lymphatic tissues…and even 80% of nerve structure.  When contemplating the effects of manual therapy ‘inputs,’ or even training inputs for that matter, we must be inclusive of all of these tissue types as each of them will equally adapt to applied inputs.  To say that with a particular soft tissue technique application I am affecting one tissue vs. another is as inaccurate as claiming that any particular exercise targets a single tissue, which is in fact impossible.  This line of thought stems from literature examining the effects of load inputs on cellular/subcellular processes…a topic that we dive into deeply in the FR Release curriculum.

There has indeed been an increased focus on the ‘body is connected’ concept mostly stemming from a renewed interest in fascia.  This has led to the concept of myofascial slings/trains for example which speaks to the idea that tissues of the body blend into one another rather than existing/acting as independent structures.  This concept has progressed our view of live anatomy immensely at a gross tissue level.  However in my opinion it also contradicts its own premise.  Namely, that all tissues are connected.  If all tissues are indeed connected, then to distinguish specific lines in the body is to fall into the original trap of structure individualization.

I believe that the next ‘evolution’ of how we think about the anatomic continuum must occur not at the gross tissue level, but at the microscopic level, as this is where its true nature is observed.  The fact of the matter is that all of the tissues listed above under the broader label of connective tissue represent a continuum whose boarders are difficult to delineate even with the help of a microscope.  In other words, it is difficult, and unrealistic to distinctly separate these tissue forms as they simply represent changes in composition of identical elements – namely cells, fibers, and ground substance.

If I were to show you a magnified tissue slide of a tendon ‘inserting’ into a bone and asked you to draw a line distinguishing where the change occurs you would not be able to do so.  You would simply be able to say that on one side of the slide the composition of cells, fibers, and ground substance looks more “tendon-like,” while on the other side it looks more “bone-like.”  Thus the distinction between the two exists as a gradual progression/change in composition.  In this light, ALL body tissues are not only connected…they are actually all different expressions of the same substances.

We get into much more detail in the FR curriculum regarding this topic as I feel that we must consider the affects of our assessments, treatments, and even training applications at a histological level, vs. the gross tissue level, which is the norm.
Getting back to your original question regarding BioFlow anatomy, it can be generally defined as a term used to describe, and conceptualize the extent of continuity found in human tissue at the microscopic level.  Part of the FR curriculum is dedicated to creating a detailed understanding of how tissue exists in the living body.  Specifically how tissues seemingly ‘flows’ from one form to another.  This concept vastly alters not only ones perception of anatomy, but also their understanding of tissue assessment, treatment, rehabilitation, and training.

3) Your courses all start with a very comprehensive palpation class. I feel this is not only important but also incredibly helpful. A lot of therapists or clinicians say, “I don’t need to start with the palpation course. I already know how to palpation”. Can you please tell us why you feel the need to start there and why specific palpation is so important? I feel like your course does one of the best jobs in teaching this than any I have ever taken.?

It’s a common occurrence that some practitioners enter the seminars with the belief that the palpation portion will serve simply as a review, as it is there belief that their palpation skills are adequate.  I enjoy seeing the ‘ah-ha’ moments when they realize that they are palpating many of the structures that they have been ‘treating’ for years…for the very first time.  In fact, I had many, many of these moments during the creation of the palpation system that is taught at FR seminars – Functional Anatomic Palpation Systems.

In my opinion palpation forms the backbone of manual therapy practice…or at least it should. Although many of us are taught to rely on orthopedic testing, such tests can only provide general information regarding the location of an injury.  The reason is that orthopedic tests are developed (and for that matter are only useful for) is for the localization and diagnosis of what I refer to as ‘macro’ tissue injury, which can be defined as damage on a gross tissue level.  Examples of this type of injury include osseous fractures, overt muscle or ligament tears, neural tissue damage, etc.  As manual therapists however, the majority of the cases that we deal with are ‘micro’ tissue injuries such as feelings of ‘tightness,’ poorly defined aches/pains, movement errors, etc.  For such conditions, ‘macro’ tissue diagnostic procedures help very little in generating a useful manual medical diagnosis, and even less in guiding the creation of a subsequent manual therapeutic treatment plan.

As an example, tests confirming a diagnosis of “Sub-acromial impingement” only serve to inform us of the area of pain; namely the sub-acromial space.  However this diagnosis can represent pathology in several different structures and can comprise of several different histological processes – Supraspinatus Insertional tendonopathy, Biceps tendonitis/opathy/osis/tenosynovitis, Internal impingement (Posterior superior Glenohumeral joint impingement), sub-acromial bursitis, etc., are all possible under this ‘umbrella’ diagnosis.  While this diagnosis may be suitable for a medical doctor, for a manual therapist it is of very little use, as it does not allow us to select the appropriate treatment intervention(s).  Say for example this diagnosis represents a bursitis and the therapist decides to try Graston for example.  Being an inflammatory condition, this would lead to a worsening of symptoms.  Or say the diagnosis represents a tendonosis of the Supraspinatus muscle and the therapist decides to apply ultrasound & ice.  In this case the literature dictates that the selected treatments will have little to no effect.

The reality of manual practice is that aside from a good clinical history, which is by far the most important aspect of assessment, it is the palpatory findings that are ultimately used to both define pathologic tissue, and subsequently to guide decision making when selecting a treatment approach.  This is a concept that I learned very early in my career by shadowing various manual medical practitioners.  Following any and all diagnostic procedures, it always came down to the therapist actually palpating the area….and subsequently, during the application of manual care, it is ones ability to palpate that guides our decisions moment by moment.

In light of this, I always found it odd that so little effort was dedicated to perfecting the art of palpation, and as I began to teach practitioners of several disciplines all around the world I soon learned that this problem was not solely found in my profession, nor was it localized to North America.

With any skill, be it in sport, art, etc., the perfection of the skill cannot simply be obtained via brief introduction…it requires training.  No martial artist has ever had confidence in using a technique in competition simply by observing it on a few occasions.  They require hours and hours of mindful, repetitive practice before they can demonstrate proficiency.  Contrary to how it is taught, I believe palpation requires the same dedicated practice.  Thus, in Functional Range Release curriculum, a large percentage of time is dedicated to learning a systematic approach to the palpation of soft tissue structures.

This includes not only instruction regarding the localization of structure (which by it self is insufficient) but also in the interpretation of palpatory findings.  When I confront a group of practitioners with the simple question of “what are we palpating for,” I am always surprised by the large variety of conflicting answers.  I am even more surprised to hear that almost all of the offered answers represent on scientific ‘analogies.’  Some common examples include:

  • “Knots” – which obviously do not occur in any literal sense.
  • “Scar” tissue/“adhesions” – which simply represents disorganization of connective tissue amounting to fibers being laid down in the wrong direction…fibers which are nanometers in size and are thus un-palpable.
  • “Rope-y-ness” – which is inevitable as all muscles are encased and are thus shaped like ropes.
  • “Tightness” – This can refer to ‘mechanical’ tightness caused by an area of aberrant fibrosis…OR it can refer to ‘neruologically-induced” tightness/spasm.  Thus it does not defined the pathology enough to decide on clinical interventions.
  • “Range of motion” – which is generally not a good clinicical outcome measure as per the literature.  Further, soft tissue application is not intended to induce permanent improvements to range of motion as that is generally known to require progressive stretching/strengthening procedures over a period of time.
  • “Pain” – which can normally be found in various areas of everyone’s body during palpation.
  • “Bumps” – which likely represent the small pockets of adipose tissue which sit in the sub-dermal fibrous scaffolding known as the fascia Superficialis.
  • …and the most common, “I don’t know…but I know it when I feel it,” which can be loosely translated as “I don’t really know.”

If a practitioner cannot define what they are feeling for in any realistic, scientific manner, then what is the outcome measures guiding their treatment?  By this I don’t mean the outcome measure used to define success in the eyes of patients such as pain or range of motion.  I mean what is the tactile finding that, on a moment-by-moment basis, guidance the practitioners treatment?  How does one know when soft tissue ‘release’ procedures are appropriate vs. passive modalities?  How does one know the needed amplitude and direction of force to apply?  How does one know when the treatment is over?  These and many other questions require that the practitioner is able to palpably distinguish between normal and abnormal anatomic structure, and further that they have a working definition/understanding of what they are looking for.

Of course at this point I expect many readers to be thinking that they did indeed have instruction in palpation during their education…to them I encourage them to find a certified FR practitioner and ask them to describe the level of palpation specificity that was taught to them at the certification seminar….its far more powerful to hear it from them then from the person teaching the courses.

4) There are many systems of soft tissue release or fascial release out there. One question that always comes up is, “How is your course different than the others?” Can you please address that for the readers??

I think the best way to answer that question is to describe both why, and how I developed the FR Release system.  When I was a student studying manual therapy, I made it a point to both exposed myself to, and understand the premise of as many approaches as I could.  By doing so I soon realized the following:

  1. The development of most soft tissue treatment systems have historically been done in a trial and error fashion.  Supporting scientific evidence was then sought out retrospectively to justify the various approaches.  If none was to be found, it seldom led to any significant changes.  Further, it would be commonly claimed that there is no literature available to guide manual care in an evidence-based manner.
  2. Many ‘new’ systems simply represented a re-packaging of older systems approach.
  3. None of the currently available systems gave any focus to either assessment, or rehabilitative procedures.
  4. Most systems, when given enough time, began to lag behind in terms of current scientific knowledge.

The development of the FR system came out of a desire to create an approach to soft tissue injury management OUT OF the most current scientific literature.  As I read more and more I soon realized that there is indeed ample scientific knowledge available that can be used to develop a ‘best-approach’ to the management of soft tissue injury and/or dysfunction.  The key was that I had to dive more deeply into topics seldom studied in the context of manual therapy such as cellular/sub-cellular biology, tissue morphogenesis, and cellular biophysics.  In this literature one can learn of tissue responses to load application at the cellular level.  Because the application of manual care at the base level is concerned with controlled load application (be it via externally applied load such as soft tissue ‘release’ procedures, or internal loading via rehabilitative procedures) a logical, evidence-guided approach can be made for both soft tissue treatment application and rehabilitative procedures utilizing this knowledge, which forms the basis for the FR Release system.  I believe this to be a major way that the system sets itself apart from others.  We not only take a logical, evidence-guided approach, but we insist that each participant be thoroughly exposed to these concepts.  To do so we provide several mandatory online lectures, to be studied prior to the seminar that walk participants through the through process and supporting evidence for its creation and utilization.  These lectures cover topics ranging from how to interpret palpatory findings, to BioFlow Anatomy (described earlier), to progressive tissue adaptation mechanisms.

Further, as is noted above, much of the seminar is dedicated to learning our specific system of soft tissue palpation and assessment.  We are not concerned with simply teaching treatment “protocols.” Rather we teach a complete system of assessment, treatment, and rehabilitation, thus preparing participants to apply FR to any and all potential musculoskeletal diagnosis’.  We are less concerned with changing what one thinks than we are with how one thinks.

5) You mentioned in your bio that various professional sports organizations medical teams have begun using the FR Release system.  Can you tell us more about that?  

Sure.  Thus far we have certified the staffs of the Arizona Diamondbacks (MLB), and Houston Rockets (NBA).  We also currently have seminars lined up with the staffs from the Chicago Cubs, Seattle Mariners, San Diego Padres, and the Philadelphia Phillies MLB teams.  We are also working with the NCAA staff of Texas A&M University.

Our feedback thus far has been outstanding with regards to the effectiveness of the system on their players for injury treatment, rehabilitation, and prevention.

6)  What would one expect if they choose to attend a certification seminar?

The FR curriculum is divided into 3 sections – Upper Limb, Lower Limb, & Spine.  Each section consists of a 3-day practical seminar along with a significant preparatory online lecture component (9 lectures in total).

Each seminar begins with training in the Functional Anatomic Palpation Systems (FAP) for the body region.  FAP is a systematic approach to soft tissue palpation and assessment looking to improve the practitioner’s ability to both locate tissue, as well as interpret their palpatory findings for assessment purposes.

Following that we teach the FR Release component, which includes manual treatment/release procedures as well as an original rehabilitative approach including the PAILs & RAILs systems (Progressive & Regressive Angular Isometric Loading).

Once successfully completed, participants receive certification for the particular body region (FR  is a registered trademarked system).  This automatically includes them in our websites find a provider function, and allows them access to our social media groups, as well as our members only online site where we are constantly providing new ideas, techniques, concepts, cases, etc, related to the FR system.  This allows us to omit the need for “recertification’s.”

7)  You also teach a mobility conditioning seminar called Functional Range Conditioning, or FRC.   Perhaps you can give us a brief overview of that system?

FRC is a system of mobility training based in scientific principals and research. Mobility, defined as flexibility plus strength, refers to the amount of USABLE motion that one possesses across a particular articulation (joint). The more mobile a person is, the more they are able to maximize their movement potential safely, efficiently, and effectively. FRC Seminars teach participants, ranging from manual therapists, to personal trainers and strength and conditioning specialists, how to improve mobility in both their clients, as well as themselves.  In the process, the system also builds articular strength and neurological control, which translates into injury prevention. More importantly, workshops explain the scientific basis behind this new and invaluable system. Participants come away not with a simple list of exercises, but a greater understanding of the musculoskeletal system, and the tools needed to implement FRC methodology in the training/ rehabilitation programs of patients, clients, or themselves.

8) Thank you for your time today, Dr. Spina. Can you please tell the readers where they can find more information about your courses as you have several coming to the United States in the upcoming months and through 2014, including one that we will be hosting in Portland.

For more information regarding seminars including dates and locations you can visit  I am also one who shares lots of information on social media including a frequently updated blog –, Twitter feed – @DrAndreoSpina, and Facebook page – FunctionalAnatomySeminars.