R e p rin te d with perm ission o f a nd appreciation to the author a nd “P hysiotherapy” C hartered S o c ie ty o f P hysiotherapy, London. Page 4 P H Y S I O T H E R A P Y December, 1963 SOFT TISSUE LESIONS: LOCALIZATION AND DEEP MASSAGE B y J E N N I F E R H I C K L I N G , m .c .s .p . T h is lec tu re c o n c e rn s th e u se o f d e ep tra n s v e rse frictio n as e la b o ra te d a n d ta u g h t by D r . C y riax , fo r w h o m I have h a d th e p le a su re to w o rk fo r e ig h t years. I t is a m o st a c c u ra te tre a tm e n t fo r m o ving p a r ts : te n d o n s , lig a m en ts a n d m uscles. T h e h a n d m u st d o its w o rk perfectly, a n d this w o rk is d e ep fric tio n a p p lie d to , p e rh a p s , a fin g er’s b re a d th o f tissue. I t follow s t h a t a c c u ra c y o f d iag n o sis is e sse n tia l; h ence th e title th a t I h a v e c h o se n , ‘L o c a liz a tio n a n d d e ep m assa g e.’ T h e s e tw o c a n n o t be s e p a ra te d a n d u n less lo c a liz a tio n c o m e s first, d e ep m a s sa g e is u seless: in fa ct w o rse th a n useless, since th e p a tie n t is p u t to som e d isc o m fo rt to n o p u rp o se . A . L o ca liz atio n T h e m assa g e is to be given to a i - in . , p e rh a p s i - in . , o f tis su e ; it is im p e ra tiv e th a t it s h o u ld be th e rig h t i - in . F o r tw o re a so n s th e p h y s io th e ra p is t s h o u ld be a b le to c a rry o u t su c h lo c a liz a tio n . F irstly , th e d ia g n o s is m a y be s o m e th in g in th e n a tu r e o f ‘p a in fu l s h o u ld e r.’ D e e p m assa g e o f th is s o rt c a n n o t be given to a p a in fu l s h o u ld e r, b u t o n ly to a ‘su p ra s p in a tu s te n d in itis ’ o r ‘b icip ita l te n d in itis ,’ a n d so o n . T h e re fo re su c h a d iag n o sis gives to th e p h y s io th e ra p is t a re sp o n sib ility to find th e p re cise c a u s e o f th e tro u b le . S e condly, k n o w le d g e o f su c h a system o f lo c a liz a tio n e n a b le s th e p h y s io th e ra p is t to assess p ro g re s s objec tiv e ly (a n d th is s h o u ld be d o n e a t e a c h tre a tm e n t) o r to d ecide th a t th e o rig in a l d ia g n o s is w as in c o rre c t o r in co m p lete. I t is n o t u n c o m m o n , fo r in stan c e, fo r a m a jo r in ju ry to m a s k a se c o n d slig h te r o n e , w hich o n ly b eco m es a p p a r e n t w hen th e first h a s c le are d u p . I t c a n th e n p ro p e rly b e d e a lt w ith b y th e p h y s io th e ra p is t w ith o u t re fe rrin g th e p a tie n t b a c k to th e d o c to r, w ith c o n se q u e n t sa v in g o f tim e o n all sides. R e ferre d P a in T h e c h a r a c te r o f re fe rre d p a in , a g a in , m ak e s lo c a liz a tio n e sse n tia l; fo r it is m o re th a n likely th a t w h e re th e p a tie n t feels th e p a in is n o t w h e re th e t r o u b le lies. A lesio n lying de eply in a p a rtic u la r se g m en t c a n be a p p re c ia te d as p a in o r ten d e rn e s s a n y w h e re in th e re le v a n t d e rm a to m e , a n d lesio n a n d p a in a re o fte n w idely s e p a ra te d . T h e m o re severe th e lesion th e m o re d ista l is th e reference o f p a in likely to be. F o r in stan c e, m ild a r th ritis o f th e sh o u ld e r j o in t m ay give rise to p a in o n ly a t th e u p p e r o u te r a sp e ct o f th e a rm , w hereas severe a r th ritis m ay c a u s e p a in as fa r as, a n d p e rh a p s o n ly in, th e lo w e r a rm . T h e m o re d ista l a n d su p e rficial th e lesio n , th e m o re a c c u ra te ly is th e p a in p la c e d , so t h a t if it lies in, fo r in stan c e, a sm all m uscle o f th e h a n d , th e p a tie n t is likely to b e c o rre c t w hen h e p o in ts to w h e re h e th in k s th e tr o u b le is. In v a ria b ly , h o w e v er, th e d ia g n o s is m u s t be m a d e w ith o u t p a lp a tio n . E x a m in a tio n m u s t in clu d e a ll stru c tu re s fro m w hich th e p a in m ig h t a rise (i.e. all th e stru c tu re s o f th e se g m en t in w h ich th e p a in is felt) u n til o n e is fo u n d to be a t fa u lt. O nly th e n m ay p a lp a tio n be u se d , to id en tify th e p a rtic u la r s tru c tu re a n d th e n to find th e p o in t o f m ax im u m te n d e rn e ss in th a t structure. P a in a n d te n d e rn e ss elsew here th a n in th e tissu e fo u n d to be a t fa u lt a re firm ly ig n o red . Selective T ension T h e d ia g n o s is is m a d e b y p u ttin g selective te n s io n o n e a c h s tru c tu re in tu r n , a n d b y a sk in g th e p a tie n t w hich te n s io n b rin g s o n , o r a lte rs, h is p a in . T h e p a tie n t m u st be q u ite c le a r o n th is p o in t, w h ic h is c ru c ia l. T h e q u e stio n is n o t ‘D o e s th is h u r t ? ’, w hich m ay suggest t o h im t h a t it s h o u ld h u r t o r c o n fu se h im w ith his a lre a d y ex istin g pain. H e is a sk e d , ‘D o e s this affect y o u r p a in ? ’, th e p o in t being w h e th e r th e re is a n y a g g ra v a tio n o r a lte ra tio n . F o r p u rp o se s o f e x a m in a tio n , th e tissues m ay be divided in to tw o g ro u p s, in e rt a n d c o n tra c tile . T h e inert group can h a v e te n sio n p u t o n th e m by stre tc h in g a n d so m e tim es by p in c h in g , i.e. by p assive m o v em e n t. I t in cludes capsules, lig a m en ts, b u rs a e a n d nerve sh e a th s. T h e contractile group a ls o c a n h a v e te n s io n p u t o n th e m by p assive m ovem ent b u t it c a n be d o n e m u c h m o re effectively by m ak in g them c o n tra c t, i.e. by resisted m o v em e n t. I t in cludes m uscles,! te n d o n s a n d th e ir a tta c h m e n ts. I t is very im p o rta n t to define w h a t is m e a n t by passive a n d resisted m o v em e n ts in this c o n te x t. T h e passive m o v em en ts a re d o n e th ro u g h th e w hole po ssib le ra n g e , since th e p o in t is to d e te rm in e w hether th ere is lim ita io n o f m o v em e n t (a n d , if so, its p ro p o rtio n ) a n d w h e th e r th e re is p a in . T h e resisted m o v em en t is a s tro n g sta tic c o n tra c tio n . If m o v em e n t is a llow ed a t th e j o in t, it is p e rfe c tly tru e th a t the m uscle is teste d b u t th e in e rt stru c tu re s ro u n d th e jo in t h a v e a lso been involved, a n d if p a in is felt it is n o t clear w hence it arises. T h e jo in t is th e re fo re p u t in to a n eutral p o s itio n so t h a t n o q u e s tio n o f te n s io n o f in ert stru c tu re s arises, a n d th e p a tie n t is a sk e d to c o n tr a c t th e muscle s tro n g ly w hile th e p h y s io th e ra p is t h o ld s h im in such a way as to p re v e n t a n y m o v em e n t o c c u rrin g a n d to m a k e sure th a t he d o e s in d ee d u se th e m uscle h a rd . A m uscle teste d in th is w ay m ay sh o w v a rio u s things. I t m ay b e s tro n g a n d p a in fu l, w h ich suggests a local lesion. I t m ay be w e ak a n d p a in le ss, w hich suggests neurological lesio n o r to ta l ru p tu re . I t m ay be w e ak a n d p a in fu l, which su g g ests p a rtia l r u p tu r e o r a gro ss lesion, su c h as fracture o r n e o p la sm . O r it m ay be s tro n g a n d p a in le ss, in which case it is n orm al an d does not require tre a tm en t, however tender or p a in fu l it m a y be to touch. A c tiv e m o v em en ts h a v e th e ir o w n special v a lu e in th a t they te s t ra n g e, m uscle p o w e r a n d th e p a tie n t’s w illingness to d o th e m o v e m e n t. T h ey th u s p ro v id e a ro u g h g u id e to the s ta te o f a jo in t. I f a n a ctive m o v em e n t is a tte m p te d a t the b eg in n in g o f th e e x a m in a tio n a n d th e p a tie n t c a n n o t d o it, it c a n th e n be b ro k e n d o w n in to its c o m p o n e n t parts. R a n g e c a n be teste d by p assive m o v em e n t, m uscle power by re sisted m o v e m e n t. I f b o th th ese a re fo u n d to be full a n d p a in le ss it suggests th a t th e tro u b le lies in th e p a tie n t’s w illingness to p e rfo rm th e m o v em e n t. P a tte rn s I f m o v em e n ts a re teste d in th is w ay, v a rio u s patterns em erge, o f w hich th e fo llo w in g a re som e o f th e m o st ty p ic a l: 1. A ll passive m o v em e n ts h u r t a n d m ay be lim ited in a p ro p o r tio n a l m a n n e r. R e siste d m o v em e n ts a re s tro n g and p a in le ss. T h is suggests a lesio n o f th e c u ff o f in ert tissue a b o u t th e j o in t, i.e. th e c ap su le , a n d is w h a t is fo u n d in v a rio u s so rts o f a rth ritis . 2. S o m e p assive m o v e m e n ts a re p a in fu l a n d perhaps lim ited. O th e rs a re full a n d pa in le ss. R e siste d m ovem ents a re s tro n g a n d p ainless. T h is suggests lig a m e n to u s strain. T h o se m o v em e n ts w h ich s tre tc h o r m ove th e ligam ent are affected, th e o th e rs a re n o t, n o r a re th e m uscles. T h e sa m e p a tte rn m ay in d ic a te in te rn a l derangem ent, w h en th e re m ay be d is p ro p o rtio n a te lim ita tio n o f movement a n d a h isto ry o f re cu rre n c e . 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. ) December, 1963 P H Y S I O T H E R A P Y Page 5 3. O n e resisted m ov em e n t hur ts, o th er s a r e painless. The passive m o v em e n ts are full and painless. T h is is typical of injury to a muscle o r te n d o n . 4. All m o ve m e n ts hu rt . T hi s suggests a gross lesion outside the scope o f this lecture, or psychogenic d is o rd e r where th e p a tie n t is in ter pr eti ng effort as pain. It is tr ue that with an a cu t e j o i n t lesion all th e resisted m o v e m e n ts may be foun d to h u r t as well as the passive ones, bu t in such cases the passive m o v em e n ts reveal such m a rk e d articular signs th at no mistak es c an be made. 5. Pain ful arc. T hi s suggests t h a t the injur y lies in a position wh er e it can be pi nched between tw o b on y points. An a t o m y show s w he re this is likely to be. 6. Pain on e x tr e m e o f m o ve m e nt . In a d d it i o n to this being c aus ed by an inert s t r u c tu r e on th e str etc h, it m a y also be du e to ni pp ing o f a s t r u c tu r e between tw o b o n y points. Negat iv e responses du r i n g e x a m i n a t io n are as i m p o r t a n t as positive ones, since it is only w he n so m e m o v e m e n ts are found painful a nd others painless t h a t a p a tte rn eme rges at all. T hu s, to find t h a t resisted exte nsi on o f the wrist h u r ts at the elbow tells the e x am i n er n o t h in g a t all. I f resisted extension hu rt s a n d resisted flexion does n o t a nd all m ov e ­ m e n t s a t th e elb ow are full a n d painless, th en only doe s it begin to l oo k like a lesion at the elb ow o f the c o m m o n extensor t e n d o n o f th e wrist, i.e. a ‘tennis el b o w . ’ At this m o m e n t , a n d at this m o m e n t only, when the injury has been localized to a p a r ti cu l a r str uc tu re , is p a l p a ­ tion, confined to t h a t str uc tu re , relevant an d useful. It identifies first the tissue involved an d then the p o i n t of m axi mu m tende rnes s in this tissue. T r e a t m e n t is directed to this spot. B. D eep M a ssag e As has been said, deep friction o f the sor t u n d e r discussion is used in the t r e a tm e n t o f injuries to the mo vi n g pa rts o f the b od y: injuries to t en d on s , muscles a n d ligaments. It would be r eas on ab le to su p p o s e t h a t de ep m as sa ge to the site o f su c h injuries w o u ld a g gr av a te r a th e r t h a n cure. In fact, this is n o t so, a n d we believe this to be be cau se the t r e a tm e n t follows th e o r t h o p a e d i c principle o f m ai nt ai ni ng m o v e m e n t while he aling tak e s place. By m o v e m e n t the pa inful s t r u c tu r e is freed f r o m ad h es io ns e ith e r present or in the process o f f o r m a t i o n , a n d heal in g take s place w i t h o u t the painful scar th at caus es persi ste nt sy m p to m s . T h e friction is given tr ansv ersely to the s t r u c t u r e being m as sa g ed , since this has been fo un d in pract ice to be m o st effective. It a p p e a r s t h a t in this wa y t h e r a p e u t i c m o v e m e n t is best a ch ie ve d ; a t e n d o n s h e a th is s m o o t h e d off agai nst the te n d o n , a liga men t is freed f ro m a d h er e n ce to u n d e r ­ lying b o n e and o n e m u sc le b u n d l e is mobilized u p o n the next. In v a ri a b ly n u m b i n g occu rs, usua lly to su c h a n exte nt th a t th e pa ti e n t will say t h a t he t h in k s the ph y si o t h e r a p i st ’s finger has shifted to a n o t h e r sp o t. T h is p h e n o m e n o n is pr e su m ab l y caus ed by intense local h y p e r a e m i a a n d c o n ­ se q u e n t incre ase in the d e s t r u c t i o n o f Lew is’s P- fa ct o r, whi ch is re sp o ns ib le for pain. I t expla in s w hy this t r e a tm e n t can be given to a cu t e lesions a n d , while u n c o m f o r t a b l e , is by n o m ea n s intolerable. T echnique G eneral rem arks. T h e mas sa ge is given usually for 15-20 m in ut e s an d is rep eat ed as s o o n as in creased tende rnes s has w o r n off. T h is gen erally m e a n s t r e a t m e n t two to th ree times a w e e k ; daily is a lm o s t c ertainly t o o o f t e n ; onc e a week m ay n o t be u n r e a s o n a b l e . It is c o n ti n u e d until the p a ti e n t has full painless f u nc tio n an d th en sto p p e d , howe ver m u c h local t end er nes s t h er e m ay be on p a lp a tio n . I t is explain ed to th e pa ti e n t t h a t this t end er nes s is an a f te r m a t h o f inju ry a n d t r e a t m e n t wh ic h m a y t a k e a week o r tw o to clear u p an d is u n i m p o r t a n t . A b o u t o n e to th ree o r six to eight sessions a r e r eq uir ed , d e p e n d i n g o n the severity o r d u r a t i o n o f t h e t ro ub le. T h e r e sh o u l d be a ste ad y i m p r o v e m e n t f r o m th e beginning, and F ig. 1. F ric tio n to a n te rio r a spect o f trap e zio -first-m e ta c arp a l joint. 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 6 P H Y S I O T H E R A P Y September, 1963 Fig. 3. Friction to upper p a rt of peroneal tendons. 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. ) December, 1963 P H Y S I O T H E R A P Y Page 7 unless th is o c cu rs th e a c c u ra c y o f tre a tm e n t o r o f d iag n o sis com es in to q u e stio n a n d b o th sh o u ld be re assessed. A c uteness is n o c o n tra -in d ic a tio n . F o r in sta n c e , a c u te c rep ita tin g te n o sy n o v itis o f th e th u m b te n d o n s a n d recent sprains a re tw o o f th e c o n d itio n s th a t re s p o n d best. N a tu ra lly in a c u te lesions, w here th e in te n tio n is to p re v e n t a d h e s io n s form ing r a th e r th a n to b re a k th e m u p , m assa g e d o e s n o t have to be given w ith full fo rc e a n d m ig h t c o n sist o f 10-15 m inutes fa irly g entle fric tio n , g ra d u a lly in creased in d e p th until 1 -2 m in u te s o f d e e p e r frictio n c a n be given a t th e e n d . Effleurage is given first, w h e rev e r o e d e m a p re v e n ts th e p h y sio th e ra p ist’s finger fro m re a c h in g th e rig h t sp o t. P h ysio th e ra p ist’s po sitio n . T h is ty p e o f m assa g e is e x ac tin g and it re q u ire s so m e p ra c tic e b e fo re it can be k e p t u p w ith o u t fatigue. T h e p h y s io th e ra p is t sh o u ld sit, a n d be so placed th at her a r m re m a in s as n e a rly as p o ssib le in a restful position. She sh o u ld th e n id entify th e s tru c tu re to be tre a te d by c are fu l p a lp a tio n . T h e m uscles o f fin g er o r th u m b then m aintain p re ssu re on th e lesion w hile th e m uscles o f w rist, forearm o r s h o u ld e r d ra w th e h a n d to a n d fro a n d p ro d u c e friction. In th is w ay e ffo rt is d istrib u te d . T he w hole h a n d sh o u ld m ove. M a ssag e by fin g er m ove- iment a lo n e c a n n o t be s tro n g e n o u g h a n d will qu ick ly produce s tra in , as will m assa g e w ith th e h y p e r-e x te n d e a finger. T h e best p o s itio n is w ith th e finger o r th u m b slightly curved a t every j o in t, o r w ith th e te rm in a l in te rp h a la n g e a l jo int flexed w hile th e p ro x im a l in te rp h a la n g e a l jo in t a n d the m e ta c a rp o -p h a la n g e a l jo in ts re m a in e x te n d e d . E ith e r m ethod e n su re s th a t th e stra in is ta k e n by th e flexor te n d o n s , which a re so o n tra in e d fo r th is, a n d n o t b y th e jo in ts . V a rio u s p o sitio n s m a y b e used d e p e n d in g o n th e e x te n t o r position o f th e in ju ry a n d th e sh a p e o f th e p h y s io th e ra p is t’s h a n d ; the th u m b m a y be laid a lo n g th e s tr u c tu r e ; th e th u m b tip m ay be u s e d ; th e index m a y b e re in fo rc e d b y th e m id d le finger o r vice v e rs a ; th e th u m b a n d fingers m ay b e used in opposition. P hysiotherapist’s fin g e r m oves with the p a tie n t ’s s k in • The p h y sio th e ra p ist’s fin g er m o v es as o n e w ith th e skin and su b cutaneous tissue u p o n th e d a m a g ed s tru c tu re . N o frictio n m ay o ccur betw een fin g er a n d sk in , since th e la tte r th e n very quickly becom es d a m a g e d , a n d o n c e th is h a s o c cu rre d there is n o th in g to b e d o n e b u t w a it fo r it to heal. T h e skin m ust be w atched vig ila n tly a n d im m e d ia te ly th e re is a n y suggestion o f slip, fo r in sta n c e b e c a u se o f sw ea tin g , tr e a t­ m ent sh ould be s to p p e d a n d th e skin w ashed a n d d rie d , o r trea te d w ith su rg ic al sp irit. I f it is v ery sensitive, tr e a t­ m ent m ay h a v e t o be m odified. O c ca sio n a lly a little s u b ­ cu tan eo u s b ru isin g m a y a p p e a r, b u t th is is n o c o n tra -in d ic a - tion and will c le ar u p a s so o n as tre a tm e n t is finished. | Sweep. F ric tio n m u st be given w ith sufficient sw eep. E ach stro k e m u st re a c h rig h t a c ro ss th e site o f th e lesio n in o rd e r to p ro d u c e th e m o b ilizin g effect o f th e tre a tm e n t, and d e p th is n o s u b s titu te fo r th is. A d e ep frictio n w ith o u t sweep has a ‘b o rin g ’ effect w hich is v ery p a in fu l a n d does n o t cure. Depth. A lth o u g h sw eep is its m o st im p o rta n t c o m p o n e n t, the m assage has to be d eep e n o u g h to re a c h th e lesion, a n d in deep-lying stru c tu re s th is re q u ire s a ll th e s tre n g th o f the physio th erap ist’s h a n d . A s h a s been s ta te d , re c e n t in ju rie s may n o t re q u ire th e v ig o u r o f m assa g e t h a t is ne ce ssa ry fo r chronic ones. In v a ria b ly , tre a tm e n t is b e g u n g e ntly, a n d it is only a fte r a few m in u te s, w hen th e n u m b in g effect h a s come in to play, th a t frictio n is given t o th e p ro p e r d e p th . Common Types o f L esion: T h e ir Individual T re a tm e n t Tendons. T hese a re tre a te d by frictio n a lo n e . T h e p a tie n t is told to rest, in t h a t he sh o u ld av o id th e p a in fu l m o v em e n t as fa r as possible. T h e p a r t is n o t im m o b iliz ed . F o r tre a tm e n t te n d o n s w ith a sh e a th a re p u t o n th e stre tc h so th a t the te n d o n fo rm s a firm b a se a ro u n d w hich th e sh e a th is rolled d u rin g frictio n . T h is ty p e o f lesion gives so m e o f th e best a n d sw iftest results. T e n d o n s w ith o u t a s h e a th a re sim ply tre a te d in th e p o sitio n w h e re th ey b e co m e m o st accessible. M u sc les. M in o r m u sc le te a rs a re tre a te d by d e ep frictio n follow ed by a c tiv e off-w eight exercises. T h e m u sc le is p u t in to a re la x ed p o s itio n fo r tre a tm e n t so t h a t th e p h y s io th e ra p is t’s fin g ers c a n get in to it a d e q u a te ly in o rd e r t o m o b ilize it in te rn a lly . L ig a m e n ts. T h e a im in tre a tin g a lig a m e n to u s in ju ry is to m a in ta in o r re g ain fu ll ra n g e o f p a in le ss m o v em e n t a t th e jo in t. W ith a re c e n t sp ra in th e re is u su a lly a tra u m a tic a rth ritis w ith m a rk e d lim ita tio n o f m o v e m e n t a n d o e d e m a . T h e la tte r is d e a lt w ith , if ne ce ssa ry , by effleurage follow ed by fric tio n . T h is d o e s n o t h a v e t o b e v ery fo rc e fu l, b u t m ust be d e ep e n o u g h to m o v e th e lig a m e n t on th e b o n e , a n d this leads to a m a rk e d in cre ase o f ra n g e w ith less p a in . T h is is im m e d ia te ly e n d o rse d by p a ssiv e a n d activ e m o v em e n ts a n d th e p a tie n t sh o u ld leave w ith m o v em e n t a p p re c ia b ly in cre ased a n d u n d e rs ta n d in g t h a t h e s h o u ld try to m a in ta in this. W ith c h ro n ic s tra in s th e p ro b le m is to b re a k a d h e s io n s w hich h a v e b e en p re s e n t fo r so m e tim e. O n ly a m in o r d e g ree o f lim ita tio n is likely to b e p re se n t. F ric tio n is given d eeply, follow ed b y r u p tu r e o f th e a d h e s io n s b y a sh o rt, fo rce d , p a ssiv e m o v em e n t. I t is n o t u su a lly n e ce ssa ry to give exercises to m a in ta in ra n g e , since th e in ju ry is a cold o n e a n d th e a d h e s io n s d o n o t ten d to re -fo rm . F o r tre a tm e n t in b o th cases th e lim b is p u t in to a p o sitio n w h e re th e lig a m en t is accessible. I f tw o e x tre m e s o f ra n g e a re p o ssib le , fric tio n a n d m o v e m e n t a re c a rrie d o u t in b o th ; fo r in sta n c e , a t th e m ed ia l c o lla te ra l lig a m e n t o f th e knee, firstly th e lig a m e n t is m assa g ed in a n d m o v ed to w a rd s flexion, a n d th e n to w a rd s e x te n sio n . A d d itional R e m a rk s T h e tre a tm e n t is u n c o m fo rta b le , b u t m u c h m o re so in th e h a n d s o f a s tu d e n t th a n w h e n th e p h y sio th e ra p ist b e co m es e x p e rt. E x p erien c e lea d s to m u c h sw ifter re su lts, a n d a lth o u g h th e p h y s io th e ra p is t m ay th e n give th e frictio n m u c h m o re d eeply, sh e a lso gives it m u c h m o re c o m fo rta b ly . S om e o f th e w ays in w hich th is is a chieved a re th a t th e fingers le a rn a lively a p p re c ia tio n o f th e stru c tu re s th e y a re o n , use th e p a d r a th e r th a n th e tip , c ling to th e stru c tu re b e in g tre a te d w ith o u t d ra g g in g u n c o m fo rta b ly o n th e sk in , a n d n e v e r ‘b o re ’ o r d ig in. W ith p ra c tic e th e tre a tm e n t b eco m es effortless and re q u ire s n o c o n c e n tra tio n , b u t th e h a n d n e v e r b eco m es ca su a l. C onclusion T h is le c tu re is c o n c e rn e d to say tw o th in g s. F irstly , a p re cise lo c a liz a tio n is e sse n tia l b e fo re th is ty p e o f m assa g e c a n b e effective. A system fo r c a rry in g o u t such lo c a liz a tio n h a s b een evolved a n d it is suggested th a t it m ay well b e used b y p h y s io th e ra p is ts w h e n ev e r th e d o c to r is p re p a re d to p la c e th is co n fid e n ce in th e m . I n effect, such co n fid e n ce w o u ld say, “ I a m satisfied t h a t th is p a tie n t h a s a lesio n su ita b le fo r p h y sio th e ra p y . Y o u a re m o re th a n a tec h n ic ia n . L o c a liz e a n d tr e a t it.” S e condly, it reaffirm s co n fid e n ce in th e u sefulness o f m assa g e, w h ich a t p re se n t lies u n d e r a c lo u d , a n d in th e p h y s io th e ra p is t’s m ain w e a p o n — a stro n g , d isciplined a n d th o u g h tfu l h a n d . R efere n ce , C y riax , J. T e x tb o o k o f O rthopaedic M e d ic in e (1954). T h e P h o to g ra p h s illu stra tin g th is a rtic le a re fro m D r. J . C y ria x ’s T e x tb o o k o f O rthopaedic M edicine. V ol. II. 1955 ed A c k n o w le d g m e n t is m a d e to th e a u th o r a n d to M essrs. C assell a n d C o . L td . fo r p e rm iss io n to re p ro d u c e . 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. )