Se p te m b e r, 1965 P H Y S I O T H E R A P Y Page 7 to stop completely. There is no pain after a night’s rest but it soon returns after resuming the tasks o f a daily routine which involved a great deal of walking and standing. The patient’s norm al walking pace was very quick. There was a positive arterial zone over both buttocks, more pronounced on the left. Treatment: 1 . Forw ard lying basic section, two thighs as far as the popliteal space, including the two heads o f gastroc- nemeus. A slight cutting reaction over the buttocks could only be obtained after stim ulation o f the trigonum lum borum . First stroke reaction was only “ tickling” . A fter the treatm ent the patient reported that he felt fine and the legs much more alive. 2. Patient reported that he felt fine and had mowed the lawn for 1J hours w ithout ill effects. Treatment: Basic section and both legs including the feet. T he stroke reaction was much sharper except over the feet which only gave a “ tickling” reaction. The lower legs were only treated with short strokes. G eneral relaxation taught. 3. Patient reported he was walking with much greater ease. The sam e areas were treated. A much better erythem a was obtained, the short strokes along the medial and lateral border o f the feet were felt as very sharp. 4. Felt very well after the last treatm ent for two days when some discom fort was felt in the right ilio-tibial tract and the right calf. T reatm ent of back extended to T7 in the forw ard lying position. The two legs were treated in the lying position and treatm ent specially concentrated with short strokes on the ilio-tibial tracts and the popliteal space. These four treatm ents were carried out at 3-4 days interval. A necessary journey caused interruption in the course of treatm ent fo r one m onth. 5. The patient could carry out all necessary walking w ithout having to stop, discom fort in the calves, however, after quick walking necessitated sometimes slowing down o f pace. Treatment: Back to T7, both lower extremities. C utting reaction obtained everywhere. 6. Patient reports th at he can do everything, only slight discom fort in calves on quick walking. Fourteen further treatm ents were given at weekly intervals. The walking pace could gradually be increased. The patient went for a three-week holiday. D uring the holiday he had a slight flareup o f his gastric ulcer. A fter long walks he felt tired but had no acute pain. 26/11/1964. T he treatm ent was resumed. Areas treated were the back to T7, latissimuus dorsi and both legs in­ cluding the feet. A fter the first treatm ent the gastric ulcer gave no further trouble. Seven more treatm ents were given to the same areas at weekly intervals. T he patient only experienced discom fort in the calves on quick uphill walking and the left hallux felt less alive than the rest of the foot. D uring this period the patient had a great deal o f work which involved walking and standing and this could be carried out w ithout discomfort. A fter my return from South Africa I saw the patient again on A pril 21st 1965. D uring the period o f 3 i m onths without treatm ent the patient had no ulcer trouble and no leg discomfort except on quick uphill walking. L iterature: Connective Tissue Massage, Theory and Therapeutic Application. M aria Ebner, 1962. E. and S. Livingstone L td., E dinburgh. SOFT TISSUE INJURIES OF ANKLE AND CALF By M A R IA E B N E R , m .c .s . p . (Teacher’s Certificate). (L ecture-D em onstration given to Physiotherapy Students) These injuries are often considered trivial but may incapacitate the patient fo r a long time. If the treatm ent is not planned on physiological lines, these injuries may recur again at frequent intervals and eventually force the patient to discontinue with athletic activities. I have chosen for illustration of the underlying principles o f treatm ent two frequently-occurring injuries, i.e., “ sprained ankle” and “ partial tear of gastrocnemeus fibres” . The cause o f these injuries is always the use o f tissue beyond physiological limits, resulting in a tear o r stretch o f formed or unformed connective tissue. As a result o f the tear, blood vessels are injured, haem orrhage occurs, exuda­ tion o f tissue fluid takes place and a haem atom a forms. The haem atom a gradually becomes organised into scar tissue which has a tendency to contract and shorten, very often including some nerve fibres into the scar tissue. If the scar tissue is part o f a muscular structure a different coefficient o f expansion is present between the muscle fibres and the scar tissue. Future functional use o f the muscle will often cause pain due to the caught nerve fibres and future tears will often result due to the different coefficient of expansion between the two tissues. A physiological approach to these problem s will have to follow the principles o f tissue rep air and assist them with physiotherapeutic measures as far as possible. The first principle o f treatm ent in these injuries is therefore to limit the am ount o f haem orrhage and exudation and encourage absorption as far as possible in order to limit the am ount o f unavoidable scar tissue. Static hyperaemia as a result of the injury must therefore be changed into active hyperaem ia so that inflam matory products can be carried away in the blood and lym phstream. The second principle o f treatm ent applies to the norm al use o f the p art within physiological limits in order to avoid alienation occuring in the cortical pathway. The two examples chosen may help to illustrate the above- mentioned principles. Sprained Ankle I t is comm only taught that a sprained ankle is a lesion o f the lateral.ligam ent o f the ankle jo in t due to an inversion strain. This explanation assumes th at a ligament is the first line o f defence if unphysiological force is applied to a joint. This is incorrect. Ligaments as well as muscles possess as part o f their structure stretch receptors which record applied stretching strains beyond their physiological stretching ability. As a result of this stretch stimulus muscles reflexly contract to protect structures such as capsules and ligaments which have very little extensibility. If the applied force is too great, inextensible structures such as the periosteal attachm ents o f muscles or fibres at the junction of tendon and muscle o r ligaments passing over a jo in t o r forming part o f the jo in t capsule, will tear. I f the inversion strain is too suddenly o r too forcefully applied and injury occurs, it is therefore reasonable to look for injury in the above-m en­ tioned structures. The muscles affected in an inversion strain which is not strong enough to produce a fracture will be the evertors, i.e., peroneus longus, peroneus brevis and peroneus tertius. I f it is accepted that the weakness and pain after a sprained ankle is due to a muscle lesion rather than a ligamentous lesion the com m on sites of pain and swelling can easily be explained. Pain is often present at the base o f the fifth m etatarsal which represents the insertion o f peroneus brevis which is torn off partially from its insertion. Pain and swelling in front o f the lateral malleolus represents an injury to Dernneus R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 8 P H Y S I O T H E R A P Y September, 1965 tertius. Bruising which is often present approxim ately three inches above the lateral malleolus c