Comparison of Compressive Myofascial Release and the Graston Technique for Improving Ankle-Dorsiflexion Range of Motion.
Stanek J, Sullivan T, Davis S. Journal of Athletic Training. 2018, 53(2):000-000.
Full Text Freely Available
Full Text Freely Available
Take Home Message: A single 5-minute compressive myofascial release treatment improved dorsiflexion range of motion more than instrument-assisted soft tissue mobilization.
Insufficient ankle dorsiflexion range of motion predisposes healthy individuals to lower extremity injuries. Clinicians use compressive myofascial release (CMR) or instrument-assisted soft tissue mobilization (IASTM) to target myofascial lesions in the triceps surae that limit ankle flexibility. However, there is little evidence to determine which method may be better at improving ankle dorsiflexion. Therefore, Stanek and colleagues performed a randomized controlled trial to assess the short-term effects of a single 5-minute session of CMR or IASTM (Graston technique) on the triceps surae for improving closed-chain ankle dorsiflexion range of motion among physically active people. The authors measured pre- and post- ankle dorsiflexion range of motion in a standing and kneeling position. They randomized participants with less than 30º dorsiflexion and a Silfverskoild test positive for soft-tissue restriction to 1 of 3 groups: CMR, IASTM, or control group. A single clinician applied all CMR treatments, which began with shaking a muscle belly for 30 seconds, 1 minute focused on lateral and medial sides of Achilles tendon, and 2 minutes focused on the musculotendinous junction. The clinician applied broad strokes, distal to proximal, with knuckles or thumb positioned at 45º to the muscle. A separate examiner administered all IASTM treatments according to the M1 Basic Training course. Treatment began with a 1 minute scanning of the triceps surae, followed by 4 minutes of localized treatment in the areas of restriction. The authors found that CMR produced greater standing dorsiflexion improvements (4.8º) compared with IASTM (1.8º) and control (1.1º) groups. However, the CMR group (4.4º) was only better than the control group (-0.8º) when assessing dorsiflexion improvements with the kneeling assessment (IASTM: 3.1º).
Compressive myofascial release and IASTM are widely used and accepted soft tissue mobilization techniques. The IASTM cultivated a shift in clinical practice by reducing the stress placed on clinicians while performing myofascial release. However, it has eliminated the effect of human touch on mechanical and neurological responses by the patient. The authors acknowledge the CMR treatment took into consideration patient comfort levels when applying pressure. In contrast, the IASTM treatment session focused on appropriate pressure to eliminate an adverse inflammatory response. Perhaps the difference in applied pressure between the two treatment groups could explain the results of this study. Additionally, it is unlikely a clinician will only implement a single treatment session when addressing soft tissue restrictions of the triceps surae group. Clinicians should continually assess ankle range of motion to affirm deficits are present and due to muscular inflexibility and exclude any arthrokinematic restrictions. A discrepancy in dorsiflexion range of motion due to a malpositioned talus or fibula would not benefit from myofascial release therapy. If a clinician confirms that the limited dorsiflexion is attributable to muscular inflexibility, then it may be beneficial to use CMR to elicit immediate effects. Proper evaluation before and after interventions should be used to assure continual improvements are occurring.
Questions for Discussion: When applying CMR or IASTM, do you always take into consideration feedback from your patient or do you rely on your knowledge and experience to apply appropriate pressures? Which technique to you find to be most beneficial to your patients with myofascial restrictions? Do you assess osseous and soft tissue to determine cause of range of motion deficits?
Written by: Danielle M. Torp
Reviewed by: Jeffrey Driban
When applying CMR I rely on both my knowledge and experience along with patient feedback regards to pressure, for IASTM I check in more as my hands are not in direct contact with the skin. It really depends on the athlete and what I am trying to achieve, for IT Band and patellar tendinitis work I use IASTM, for most muscular work I use CMR. If the tightness is a prolong issue I will assess for other causes for the ROM deficiencies.
Thank you for your insight regarding your practices using CMR and IASTM. I think the literature would agree with you on utilizing CMR for myofascial restrictions and the continual re-assessment during treatment application.
There is potential that the prolonged issue for muscle tightness and ROM deficits to be caused by repetitive use and not because of another factor. However, I applaud your commitment to continual re-assessment for other contributing factors. In my clinical experience working with cross country and track athletes, the prolonged triceps surae tightness was simply due to the demands of sport itself. Nevertheless, assessment and re-assessment of chronic injuries is an essential task which should never be overlooked by clinicians.
I am an AT student at a college in Michigan and I prefer CMR over IASTM though I do use both depending on the situation. It is easier to gauge the appropriate pressure during CMR due to the absence of an instrument between yourself and the target tissue. Although, when using IASTM I find myself giving too much pressure and thus have to check in more frequently with the patient on their comfort level. However, it is important with both techniques to get patient feedback. When considering which technique to use for myofascial restriction I typically will pick IASTM for smaller areas or areas of extreme restriction. In athletic populations ROM deficits are typically due to muscle tightness, however it can also be due to structural changes/abnormalities which highlights the need for thorough assessment and rechecks.
Thank you for the comment. I agree with your opinion on being able to gauge pressure better with CMR, however, the IASTM allows you to work on deeper areas of restrictions. In my clinical experience, physically getting in contact with the patient has tremendous benefits. With either treatment option, it is vital to perform a thorough evaluation and determine the goals of the treatment, as you eluded to.