Treatment of a patient with post-natal chronic

calf pain utilizing instrument-assisted soft

tissue mobilization

Amy J Bayliss DPT

Frank J Klene, SPT, CSCS

Evelina L Gundeck, SPT

M Terry Loghmani PhD

Objectives

Hypothesize the potential mechanisms for the

development of postnatal chronic calf pain

Explain the innovative treatment of GISTM

Detail the case description and outcomes

Explore other potential applications of the

technique in women’s health

Why present this case?

Musculoskeletal pain is common in prenatal

and postnatal women

Most common site of recognized pain is low

back or pelvic pain

Leg and foot pain is also relatively common Incidence of 56%

82% of those with leg pain reported onset during the

second and third trimester

Vullo et al, 1996

What we know

Leg pain is common during pregnancy

What are the likely causes? Hormonal, edema, biomechanical

Shouldn’t all these causes disappear after

delivery? In fact most people do have symptom resolution of leg

pain 3-4 months after delivery

So why should I keep listening?

Our case study did not

gain relief

Symptoms continued

for 2 years

Potential Mechanism #1 (hormonal)

Relaxin

Activation of collagenolytic system

Alteration of ground substance of CT by

increasing water content

Regulation of new collagen formation by

activating fibroblasts

Overall effect is remodeling of connective tissue

What if that remodeling is imperfect?

myofascial dysfunction

Vullo et al, 1996

Potential Mechanism #1 (hormonal)

Progesterone

Increases cause relaxation of the muscular walls

of the blood vessels

Decreasing venous return

Leading to dependent edema

Bamigboye et al, 2009

Potential Mechanism #2 (edema)

Leg edema can affect up to 80% of pregnant

women

The edema can be due to:

Increase in fluid volume

An alteration in venous smooth muscle tone

Increased pressure within the veins due to

reduced venous return

Decreased colloid osmotic pressure

Cordts et al, 1996

Potential Mechanism #2 (edema)

So how could the edema cause pain?

Localized inflammation

Exerts pressure on local nerves

Lack of adequate nutrition to the cells

Why does pain remain after the edema has

resolved?

Localized inflammation chronic inflammation

myofascial restriction due to increased

collagen cross-linkingAmiel et al, 1982

Potential Mechanism #3 (biomechanical)

Lower extremity musculoskeletal dysfunction

could be affected by: Changes in gait pattern

Center of gravity changes

Weight gain

Increased overall lower extremity demand

Could these biomechanical changes result in

unresolved impairments, scar tissue or

myofascial dysfunction?

Purpose of the Case Study

To describe a patient with a 2-year history of

post-natal chronic calf pain

Explain her regimen of treatment utilizing

instrument assisted soft tissue mobilization

Present the outcomes

Case description

A 35-year-old female who developed calf

pain during the last trimester of her pregnancy

Following the onset of severe lower leg edema

(+) gestational diabetes

(-) high blood pressure or pre-eclampsia

Case description

Symptom description

Right mid-calf pain

Present for 2 years

Described as a dull ache

Varies between constant and intermittent

Frequently present at rest

2/10 now, 5/10 worst, 0/10 best

Case description

Symptoms aggravated by:

Direct pressure on the calf

Prolonged standing

Stair walking

Case description

Symptoms relieved by:

No relieving activities

Case description

Systems review/previous medical testing

X-ray

MRI with contrast

US Doppler study

Lab work ruled out any clotting/blood disorders

No vascular, blood or skeletal abnormalities

No benefit/effect from anti-inflammatories or

a steroid dose pack

Case description

Impairments were minimal:

Rearfoot to leg orientation, 6º valgus

Mild genu recurvatum with hip internal rotation

Decreased PF strength [(L) 5/5, (R) 4+/5]

Joints above and below cleared.

No ROM or muscle length deficits. (In fact the

right calf complex had greater muscle length than the left.)

Vascular tests all WNL’s.

Circumferential calf measurements were equal.

Case description

Impairments:

Multiple soft tissue restrictions on palpation

(manual & IASTM) in the right calf

significant tenderness reported by the patient (8/10)

large nodular restrictions in right mid-calf in lateral

and medial gastrocnemius

Case description

Functional limitations

74/80 on the Lower Extremity Functional Scale

(LEFS)

Disability

Difficulty with stairs

Unable to lift her son and walk up or down stairs

due to pain

Binkley et al, 1999

Treatment

Treatment consisted of a form of IASTM, the

Graston technique®

Utilizes specifically designed patented stainless

steel instruments

Targeted stretching and strengthening program

Treatment

9 treatment sessions over 8 weeks

Treatment consisted of

Warm-up

Instrument soft tissue mobilization

Manual and self stretches for gastrocnemius &

soleus

Eccentric calf strengthening (started at visit 3)

Ice for control of inflammation

Treatment Day 1: 1/29/09

Warm-up Stair running

IASTM 6 minutes right

posterior calf

Manual stretches Gastrocnemius and

soleus

30 second hold x 3

Ice 10 minutes

Treatment: IASTM

Application of the IASTM

Treatment: Targeted exercise

Soleus and gastrocnemius stretches

Eccentric calf strengthening

Outcomes

Tissue quality of the right calf was normalized

upon palpation manually and with tools

no soft tissue restrictions or pain

Right calf strength 5/5

Pain rating at 0/10

LEFS 80/80

Follow-up

At 1 month

At 4 months

No return of soft tissue abnormalities

No pain with soft tissue palpation

The non-treated calf was tender to a scan with the

Graston instruments but not the treated calf at both

follow-ups.

Conclusions

The patient’s symptoms were likely due to myofascial

dysfunction

contributory causes may have been hormonal, edema related, or

biomechanical

Unable to conclude if the soft tissue restriction was

present in the muscle or surrounding connective tissue

Focused mobilization of the soft tissue resolved the

patient’s symptoms

Conclusions

We cannot rule out manual techniques could have had

similar outcomes

However IASTM gives a mechanical advantage and

minimizes the clinician’s joint stress

Cost efficient and effective

Non-invasive, non-pharmaceutical

Our patient was pleased with her outcome

Other Applications in Women’s Health

Post-mastectomy scar release

Post C-section scar release

SI joint dysfunction

Edema

Questions?

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