Fascial manipulation.

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Good evening.

Does anyone offer physical therapy as a routine part of their management approach? If so which ones and what kind of results do you get with them?
I've had great success with insoles & exercises following a tissue stress model, SALRE and other common sense concepts with resolving many injuries. There are always stubborn or unusual repeat injuries which did not respond well to what would be deemed the 'correct' intervention.

I did a course recently on fascial manipulation (Stecco method) which answered a lot of my unknowns and I feel is of massive utility. Admittedly I was unconvinced when I attended, but the research presented was compelling and they do have moderate evidence. Fascia was generally forgotten about and dissected from muscle bellies to reveal the muscle for anatomy text books however there are strong links between the fascia and muscle beneath. It was very helpful for me to think of muscles as combined units which affect movement globally and smoothly. For example if we simultaneously abduct extend and externally rotate the hip in standing it is the combined action of many muscles at varying intensities and with some units firing more than others that allows this movement. This energy is translated into buttery seamless motion by the fascia holding the structure and rotating the thigh. The layers of fascia glide over one another to varying extents with the aid of hyaluronic acid.

It explains the palpation of 'trigger points' (that I previously believed to be bollocks) as aggregated hyaluronic acid which is in fact visible with particular MRIs. This prevents the fascia gliding appropriately and causes dysfunctional movement and injury. It certainly doesn't work for everyone however I have had many patients with palpable masses in the fascial areas anatomically corresponding to the problem areas. This can be the size of a pea to a small stone and is really quite incredible to find when you look in the correct anatomical locations. These tend to be the chronic pain patients always bouncing from one injury to the next. Unlike a 'sports massage' you work directly on this palpable mass until it is broken down and the pain can be quite intense. When using this to good effect with patients they can have symptoms radiating proximally or distally following the exact fascial line. It is wild to see an effect in the foot from an intervention at the hip and most excitingly many people have had improvements in neuropathies and very long standing injuries. It is obviously still in its infancy and I am still getting to grips with the basics however myself and a couple of other practitioners have had really quite remarkable results. A colleague has used this to great effect for a number of patients with CRPS, one of which had been offered "counselling or an amputation" as her Rx options. She is now in complete remission of her symptoms.

Interested in hearing anyone else's experiences or opinions on this. I intend to look into manipulations soon as an adjunct. It is my opinion that Podiatric biomechanics ought to one day be taught in a way which allows us to offer manipulations for joints, hands on therapy for myofascial issues, shockwave for tendons & gait analysis, special tests and orthotic interventions based on well reasoned paradigms. I feel we (at least in the UK) get a bad rap as a one trick pony with what Craig calls the Morgans meat pie theory; a 4 degree medial wedge even if the patient walks in with testicular cancer.

I am quite frustrated looking back on my time as a Pod student whereby I was almost taught a history of Podiatry as a profession opposed to the most up to date, sensible and practical tools to tackle pathology. I have had to unlearn and try to put aside as many things as I have had to go and learn. I have a colleague who said something once that stuck with me which seems apt; "you can't have a painful rearfoot varus".