Crural Fascia Instrument Assisted Soft Tissue Mobilization (IASTM)

IASTM Instructions

• Pressure: Pressure should be sufficient to feel resistance from the target tissue; that is, pressure should be applied to the "first resistance barrier".
  • Tissue Tension: It may be beneficial to increase tissue tension by lengthening the target tissue. Pressing a tool into tissue that is in a passively shortened position can result in a lack of tissue resistance, which will result in little if any shear force to the target tissue.
• Angle: The tool angle to the skin should be approximately 30° - 45°.
• Scanning Strokes: Start with long, slow strokes over the full length of the target tissue to note irregularities in tissue consistency.
• Treatment Strokes: Treatment strokes should be shorter, performed at a moderate tempo, in multiple directions, and over tissue assessed as irregular. The goal is to disrupt connective tissue that may be impeding optimal extensibility.
• Total Strokes: 10 - 30 strokes per region is likely sufficient, with the total dose dependent on the size of the area and the individual's tissue tolerance. Note, that scanning strokes should be included in total strokes.
• Treatment Direction: Perform 2-5 strokes in each direction. It can be helpful to visualize a clock or compass face and perform strokes in line with each number or direction (e.g. N, NW, W, SW, S, SE, E, NE).
  • Redness and Patechiae: The development of petechiae or excessive redness is an indication to stop treatment in that area. Initially, this dosage may feel inadequate; however, petechiae and redness are often signs that bruising and significant soreness may follow (Note, bruising may take 24 - 72 hours to become visible). Although Traditional Chinese Medicine (TCM) and the practice of "Gua Sha" considered petechiae the goal of treatment, IASTM as taught by the Brookbush Institute, is performed with the intent to increase mobility and potentially decrease tissue sensitivity. Patechaie and some bruising are not abnormal, but it is likely an indicator that either pressure or dose (total strokes) should be reduced if IASTM is performed in subsequent sessions.
• Addressing Trigger Points: Addressing active and latent trigger points with IASTM, which are often areas of assessed irregularity in tissue consistency, may improve carry-over from session to session. That is, the addition of IASTM to an integrated treatment plan may aid in maintaining the reduction in trigger point over-activity and sensitivity that results from a session.
• Advanced Technique - IASTM with Pin and Stretch: This technique is "more aggressive" and should likely be used in small doses to address "stubborn" mobility issues, with patients/clients who have already exhibited good tolerance to IASTM techniques (tissue tolerance and pain tolerance). Following the identification of an area of altered tissue consistency, the IASTM tool is used to "pin" the tissue in the opposite direction of lengthening (generally, pressure has a distal to proximal vector). This technique may be progressed in intensity with the following additions:
  1. Static IASTM tool with passive lengthening (manual lengthening by the practitioner)
  2. Dynamic IASTM tool (strokes in the opposing direction) with passive lengthening
  3. Static IASTM tool with active or active-assisted lengthening (lengthening by the client or patient)
  4. Dynamic IASTM tool with active or active-assisted lengthening
  5. Static IASTM tool with active-assisted lengthening and over-pressure (client/patient and practitioner force)
  6. Dynamic IASTM tool with active-assisted lengthening and over-pressure
• Assess, Address, and Reassess: As with all techniques, IASTM should only be recommended when indicated by a reliable objective assessment (e.g. goniometry), and continued use should be based on a significant improvement on that assessment (> 5° improvement in ROM). Note, "feelings are not facts".

Anatomy:

• Crural Fascia: The crural fascia is the deep fascia of the lower leg, between the knee joint and ankle joint. This fascial sheath envelops and invests in the fascia of the muscles of the lower leg, the intermuscular septa, and the periosteum of the tibia and fibula. Proximal to the knee the crural fascia continues as the fascia latae, and distal to the ankle the crural fascia continues into the retinacula of the ankle, and the plantar and dorsal fascia of the foot.
  • Increasing Tension/Lengthening: Terminal knee extension may increase tension in the posterior and lateral aspects of the crural fascia, and knee flexion may result in some increase in tension in the anterior aspect of the crural fascia. Ankle motion tends to have a larger influence on crural fascia tension, including dorsiflexion increasing tension over the gastrocnemius and soleus, inversion increasing tension over the fibularis (peroneal) muscles, and eversion increasing tension of the medial crural fascia.

Clothing and Covering:

• IASTM cannot be done over clothing. It is advised that the client/patient is informed prior to the session that they will be asked to remove shoes, socks, and/or stockings covering the ankle and/or lower leg. Although it is never our intent to make a client uncomfortable, we also do not want embarrassment to impede great therapy. Often authentic communication, a little empathy, and some planning can reduce or eliminate potentially embarrassing moments.

Patient Position

• It may be possible to address the crural fascia with the practitioner sitting at the patient's feet, the feet off the end of the treatment table, and the patient in supine. However, it is likely most comfortable for the practitioner to stand or sit with the patient in prone, and the knee flexed to 30° - 45°.

Potentially Sensitive Tissue

• No Sensitive Tissues: Assuming that these techniques are directed at the superficial layers of fascia, it is unlikely they will compress or abrade any sensitive or delicate structures. However, responsible application of this technique is still expected. Two potential exceptions may be the common fibular nerve and the Achilles tendon. The common fibular nerve is relatively superficial in the area just posterior to the fibular head, and although this is a relatively uncommon area to treat with IASTM, it may be addressed because it is a common soleus trigger point site. It is advised that the depth or location of IASTM is adjusted if any burning, tingling, or numbness is experienced by the patient. Additionally, the Achilles tendon may not be especially susceptible to damage from IASTM; however, IASTM over the Achilles tendon can be quite uncomfortable. It is advised that IASTM over this area starts with less pressure than commonly applied and gradually increases to the desired treatment pressure.

Trigger Points

• Gastrocnemius: Common gastrocnemius trigger points are in the middle of the muscle bellies of the medial and lateral head.
• Soleus: Common soleus trigger points occur just medial the fibular head, and in the middle of the muscle belly - between the distal ends of the heads of the gastrocnemius.
• Fibularis Muscles: Common fibularis muscle trigger points are in the center of the muscle bellies of the fibularis longus and fibularis brevis. However, the muscles themselves are relatively short, with long tendons making up a large portion of their length. The trigger point for the fibularis longus can generally be located approximately 2" distal of the fibular head, and the fibularis brevis trigger point can be located near the mid-length of the fibula.