99: Wait, What? Fascial Stiffness & Pain (with Robert Schleip)
Episode Transcript
Summary: Tight tissue is more painful, right? And, helping bodies be less stiff makes them feel better, doesn’t it? Fascial researcher Robert Schleip shares new research that contradicts these commonly held (but rarely examined) assumptions, and helps us think through how we, as body therapy practitioners, can apply this new understanding to our work. Tune in for a nuanced conversation that sheds light on our evolving understanding of fascia, stiffness, and pain.
- Til Luchau’s Advanced-Trainings.com
- Whitney Lowe’s Academy of Clinical Massage
Resources:
- Dr Schleip’s original Facebook post about this study
- The study featured in the episode:
- Also cited by Dr Schleip in this episode:
- Dr Schleip on Instagram
- Dr Schleip on Facebook
Whitney Lowe:
And welcome to The Thinking Practitioner Podcast where Books of Discovery has been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, eTextbooks and digital resources. Books of Discovery likes to say, “Learning adventures start here.” And they see that same spirit here on the Thinking Practitioner Podcast and are proud to support our work, knowing we share the mission to bring the massage and bodywork community enlivening content that advances our profession.
Til Luchau:
Check out their collection of e textbooks and digital learning resources for pathology, kinesiology, anatomy and [email protected], where Thinking Practitioner listeners can save 15% by entering thinking at checkout. How are you, Whitney?
Whitney Lowe:
I’m doing well, sir today. How are you?
Til Luchau:
I’m pretty good. How are you, Robert Schleip? Great to have you with us today.
Robert Schleip:
I’m doing very well and I’m looking forward to a chat with the two of you.
Whitney Lowe:
All right.
Til Luchau:
I am looking forward to it too. You have some interesting ideas as usual to share with us. I’ll introduce you briefly and then we’ll get into those. You have been called, Robert, “One of the founding fathers of modern fascial science as you were instrumental in organizing the Fascial Research Congresses, which started at Harvard School of Medicine in 2007 and the Five Fascial Congresses since then.
You trained both as a certified Rolfer where I met you when you were on the faculty of the Rolfe Institute. You trained both as a certified Rolfer where I met you when you were on the faculty there at the Rolfe Institute, and you trained as a Feldenkrais Practitioner and you’ve been a bridge between clinical practice and science for many decades. You were a co-author. You were listed as a co-author in a very interesting recent study, Myofascial Stiffness of Plantar Fascia and Achilles Tendon in Individuals With Plantar Fasciopathy: an observational cross study. And that’s what we want to talk about today because it’s an interesting one. Welcome, Robert. Anything else people should know about you?
Robert Schleip:
Nope, I love fascia and I love networking and I love the two of you for that reason.
Whitney Lowe:
We love you too.
Til Luchau:
Well, let’s jump right in. Can you tell us a little bit about the paper’s main findings and then maybe we’ll talk about some of the details?
Robert Schleip:
Yes, so this is a nice outcome in my personal development. As you mentioned, for 20,30 years I did most of my work with my hands and my heart connected with my clients. But in the last 10, 15 years, I shifted towards laboratory research and spent more time in scientific research than I do with my clients. And in that field I’ve shifted with my attention that I’m now more, I have to get used to it, a senior scientist now and a mentor to some of the young scientists who are looking for guidance. And that is one of the very rewarding outcomes for me because the laboratory work has been done in Brazil in a laboratory that I have never been. In most of the fascia laboratories I have been, but in this one I have not been. But I connected with them over three years. I gave them not only my smart advice and my critical questions, but I gave them a measurement tool also and gave them advice on to how to use it.
And they used that measurement tool that tries to replicate our finger touching for tighter spots in the tissues as opposed to softer spots. So it measures tissue stiffness and that’s what you often palpate. So we developed a technical touching finger that I’m showing here for those of you who have the monitor to look at it. I’m holding up the IndendoPRO here. That’s a tool that we developed in the last 10 years at Chemnitz University, and they used that on the plantar fascia of people who had pain on the bottom of the foot, and there are different names for it. Plantar fasciitis is the most common name, but now many people call it plantar fasciopathy because they are not so clear whether it’s-
Til Luchau:
Inflammation.
Robert Schleip:
Inflammation. So people with that pain on the bottom of the foot, they selected those who have it more on one side than on the other, and they compared the stiffness of the plantar fascia with that tool and compared it on the painful side with the less painful side. And not only that, they also measured the Achilles tendon.
Til Luchau:
They measured what? I’m sorry.
Robert Schleip:
So I was very intrigued about that study and we can discuss the findings, but basically that’s on the publication.
Til Luchau:
So I’m sorry, Robert, you said they measured the stiffness and something else? I didn’t quite hear what else.
Robert Schleip:
They measured the stiffness on both sides on the painful leg and on the less painful leg on the bottom of the foot on the plantar fascia, but also on the achilles tendon.
Til Luchau:
On the achilles tendon. Got you. Okay. And they found some surprising things. Surprising to us that maybe make us question some of our assumptions, at least it did for me when I saw your post about it. Let’s get into that. But what about the IndentoPRO? The indentometer itself? You said it’s like a finger and you can use it to measure for tight spots or different qualities of the tissue. What exactly does it measure? How’s it work?
Robert Schleip:
You do it similar like if you are touching the body, you press with vertical compression, you finger one millimeter into the tissue, two millimeters, but hardly more than one centimeter. And you measure the resistance or you measure how much force do you need in order to indent the tissue, one millimeter, five millimeter, et cetera. And usually if it’s a homogeneous tissue, it’s a linear increase. So on the first millimeter it gives you, let’s say a hundred grams of resistance on the next one millimeter, 200 millimeters, and then the linear increase of the force needed to indent it or of the tissue resisting you can measure the same weight is called the young modulus or the stiffness of the tissue. And pudding has a softer stiffness than wood. An iron is even stiffer than wood. Ooh, who wonders? So we wanted to know is one of the legs more like a pudding and the other one is more like wood? And that’s what you can quantify here. And when you do it with your hands, it’s sometimes of course easy to do, but often your expectation influences what you feel.
And this is a big problem because we are never free of bias. As a practitioner, you see the color, you see the painful reaction of the client, and your brain cannot ignore that, but this machine can ignore all the other sensory input, so that is one advantage.
Whitney Lowe:
Right. I’ve got a question about that. With the graphing of the pressure that you mentioned, you mentioned it was a linear graph of pressure versus stiffness, and that seems to me a little bit at odds with a lot of what we know, for example, about ligamentous tissue or some of the other connective tissues that have a certain degree of elasticity, and then the curve drops significantly because they have a greater degree of stiffness after that initial pliability is gone. So that wasn’t reflected with what you were finding then, huh?
Robert Schleip:
Do you mean that it changes after a few seconds or after a few millimeters of depth? I didn’t get you?
Whitney Lowe:
Millimeters of pressure.
Robert Schleip:
Okay, yeah.
Whitney Lowe:
So assuming that the pressure is equal to some degree of elastic deformation of the connective tissues.
Robert Schleip:
Yeah, so that’s exactly a big challenge in biomechanics because they love to make simplifications and the stiffness assumes that it’s in a linear increase. So if you have a rubber band and that for each centimeter of elongation it increases in the same degree and then you would define the stiffness as Newton per millimeter or Newton per percentage of elongation and a simplification. So that’s exactly a big challenge.
Whitney Lowe:
Yeah.
Til Luchau:
Well it doesn’t necessarily correlate exactly with what we feel with our touch in that sense, or does it? Does it measure things that are exactly correlated with something you or I might feel with our hands?
Robert Schleip:
That is the other study that we published. I didn’t prepare to share that, but I think it fits very well. Katia Baouche and I published a couple of months ago exactly an exploration of your wonderful question, Whitney. How do we palpate and which machine is good at palpating if you have several layers of tissue lying on top of it with different stiffness? That’s what you have in the human body for example. And that’s a big challenge also, Til, because the skin is really tight tissue, it is a piece of leather. I just returned from a wonderful dissection with Carla Stecco and John Sharkey and many others. Libby Isen was also there in northern Italy, and I think they are still dissecting as we are talking now. And we had fresh frozen cadavers and the skin is a pretty tight insulating rubber seal tissue and we should not underestimate that.
So that’s usually like two, three millimeters. And then underneath you have the subcutaneous connective tissue. If you want, you can subdivide that, but all the subcutaneous connective tissue is a third of the stiffness of the skin. So it is like a sticky syrup, jam, pudding, something like that. And then underneath you have the pretty thin, dense fascia, which is stiffer than the skin. But I was surprised to find out it’s only like 30% stiffer than the skin, not 10 times stiffer.
And so we found out when you palpate four layers of tissue and we took the thickness of the four layers and the relative stiffness in our phantom gel pad model that Katia Baouche and several others than I did out of some silicone similar, phantom material. We took them for the adult human bag in prone position, which is a common palpation. So if you palpate and say, “Let me feel your lumbar muscles or let me feel your lumbar fascia,” you need to go through the skin, you need to go through the second pillow of the subcutaneous connective tissue, which is much softer. And then you are trying to feel the stiffness on the third layer.
And what we found out is that none of our six instruments was able to detect the relative stiffness differences in the fascia because the other layers were too thick and/or too stiff for your hand to palpate the stiffness underneath. So now I question, Whitney, your touch when you say I feel the fascia is tighter on the right side, you probably talking about another tissue, about the subcutaneous connective tissue or about the skin or about the muscle fibers, which are much, much thicker than the fascia as the false layer underneath. So that is really a challenge.
Til Luchau:
So your experiments with models and with your very careful measurements have made you question whether or not we’re feeling deeper fascia or not?
Robert Schleip:
Yeah. In the relaxed position on the plantar fascia, I don’t question it yet because the plantar fascia is really thick and stiff and the subcutaneous connective tissue except for the heel pad, but in the middle of the foot where this study was conducted is relatively thin. So in this study I trust that the stiffness that was measured, this is indentometer, was mainly influenced by the fascia and not by one of the other three layers, but in the human lower back in somebody who lies relaxed in prone position, I question it now.
Til Luchau:
You question our ability to feel that specific deeper layers. But in this case you’re pretty comfortable with what you were measuring?
Robert Schleip:
Yeah.
Til Luchau:
Well, just before we move on to the results, what does this measurement do for us? Does it have direct clinical applications? Would I be using your device in my practice or is it mainly a research tool?
Robert Schleip:
You could use it actually if you work with somebody over several weeks because in one session you don’t need it except as a sales thing to tell the client you have 28-
Til Luchau:
Sell them.
Robert Schleip:
They are impressed and they think Til Luchau how is much better equipped than the guy next door. But honestly you don’t need that. But because your hands should be able to palpate significant differences, this will be finer. But if the difference is so small that only this fine instrument can feel it and not your hands, then you can also question does it really matter if the difference is only half a percent?
But if you are treating somebody or you are watching their self-treatment stretching or jogging or whatever over several weeks, then if the stiffness has become more healthy after six weeks and let’s say a stiffer area in their neck has gotten 15% softer, you wouldn’t be able to tell because you have touched 600 clients in between. And if their stiffness has changed 50% you may be able but a 10% change over six weeks because you don’t have numbers, I would question that you can detect it, before and after. Right-left side, so that’s different. But if both sides of the neck have gotten 10% more healthy or softer as compared before, you can tell them, “Keep doing your exercises. We have a very good chance that in half a year you will be out of pain because already now you are 18% better than you have been.” And that’s the advantage is a tool has numbers and your fingers don’t have numbers.
Til Luchau:
Okay. This actually, I’m glad we’re going here because your study, this one we’re talking about now, had some findings that surprised me and there’s actually been very little research done as far as I know on direct correlations between tissue qualities and pain. Stecco did a couple, Helen Langevin of course did some, but this study that you were co-author on found a correlation. Do you want to tell us about that?
Robert Schleip:
Yeah, because normally I think most practitioners preach it at least three times per week that there is a vicious cycle between tension and pain. That they are chasing each other like a chicken and the egg. And you can start the vicious cycle with an increase of muscular tension that leads to mechanical pressure on the nerve, which by itself could elicit pain or it leads to a lack of circulation, accumulation of waste products, et cetera, and then that leads to pain. And pain by itself would according to that model, increase the muscular tension. That is a very plausible concept and it often fits to our clinical experience. But even before the study and the surprising result found, other studies by Paul Archers and many others have shown in low back pain, it is often the other way around. That the area of the back, let’s say at the lower lumbar spine where you have your pain or if it’s more on the right side than on the left, on this side, the stiffness of the erector spinae myofascial tissue is softer on the painful side.
And you also see in EMG that given the same task, the muscles are less active on the painful side. So that is another pain model where the pain inhibits muscular contraction and that can lead to chronic pain via many mechanisms later on. And then you have to think completely different, how can I activate these silent, inhibited muscle fibers including their modal nerves and the brain regions much more? So that was already an indication that sometimes it goes the other way.
Now here on the plantar fascia, it has been shown to be a similar dynamic as I just described, for back pain. That the side of the foot that has more pain is softer on the plantar fascia, but also on the Achilles tendon even so they often didn’t have pain in the Achilles tendon, but the Achilles tendon seems to be mechanically linked with the plantar fascia.
Til Luchau:
I want to stop for a second and underline that. So the softer side was the more painful side or vice versa, and that extended to the achilles tendon, suggesting a link.
Robert Schleip:
These are the two main outcomes. And there have been in the last two years, other studies pointing in that direction with elastography. That is a very expensive technology that’s very trendy now among medical doctors who have lots of research money, but there are also questions about this method. But now we have a more palpable technique that is more close to how we as physiotherapists, as manual therapists, explore stiffness and it points in the same direction as the elastography studies in the last one or two years have also shown. And they also showed in plantar fasciosis, the fascia on that side is softer than on the healthy side.
Whitney Lowe:
Did you all-
I’m sorry go ahead.
Til Luchau:
Go ahead, Whit.
Whitney Lowe:
Okay, I was just going to say I’m curious if you had any thoughts or ideas about if the softness or the decreased degree of stiffness on the painful side is more cause or effect?
Robert Schleip:
That’s great question. Yeah, so in standing it would make a lot of sense that you stand more often during the week on your non-painful side. That then is a mechanical stimulus for that side to become stronger and for the other one not. Yeah. So that could be one mechanisms. What you measure is not the cause of it, but is the result of it. The same has been described for the inhibition on the back muscles too. So it could go that way.
In walking it’s more complicated because in walking you have your full body weight or almost your full body weight on one leg at a time. So you can shift how many milliseconds you are on it, but the maximum loading should be similar on both sides. You have maybe a longer time, but whether that influences the collagen synthesis more or less, that is more complicated. But in standing I would agree.
Til Luchau:
Okay. So if it is related, if stiffness in this case in the plantar fascia is related to pain, do you have any speculation about the mechanism? How does this relate?
Robert Schleip:
So in another study, not in the Brazilian study the way I participated, they also showed the plantar fascia is thicker and that seems to be often the case in myofascial painful pathologies.
Til Luchau:
That’s what Langevin found on the low back, too.
Robert Schleip:
On the low back so that the painful tissue is thicker but it seems to be softer in many cases. And then it could be a swelling, it could be fibrotic where you have an accumulation of additional collagen fibers or it could be not an increase of collagen type one fibers, but a viscosity change in the ground substance and then it would be like an edema, like a tissue swelling. And I think that is most likely the case in many of these plantar fasciosis examples. That you have a viscosity change and that’s now something that we can explore in the future because if we do five indentations in rapid sequence, we can see how is the dampening versus elastic recoil. And in the healthy tissue, if you bounce it five times, it should bounce back at the fifth time as quickly as on the first time. So just like a perfect elastic rubber band.
But if you have pathology, often the rubber band becomes like a piece of ketchup or honey, so it bounces back with a time delay and that’s called dampening. And that is now something that we are eagerly looking forward to explore because that would confirm that it’s more a water binding change and more like a local water binding, swelling, edema change. And that would be very important. So then I use my hands very different. I’m not trying to make a hard lump softer, I’m trying to push the water in and out of the sponge so that it has a different water bin.
Til Luchau:
Let’s go to applications for a minute. Would this research suggest anything that practitioners could use? Like say in some cases water binding or the swelling effect might be related to pain in other places, maybe densification or fibrosis might be related to pain? Are there ways a practitioner could tell or have you added something to our repertory or ability to sense that?
Robert Schleip:
I would frame my hand whether I have a viscosity change or just a stiffness change included in it. And I would compare vertical compression with diagonal or shearing compression and see if it’s mostly a shearing change between the pathological tissue and a comparable healthy one on the other leg for example, or whether it’s only a stiffness change in a vertical palpation. So that would be a nice teaching thing we could do together in our next pre-training together Til. So we have a palpatory laboratory where you do vertical pressure and then one where the stiffness is the same but the shearing angle is more restricted.
Whitney Lowe:
Can you elaborate on that a little bit of just what would be the difference between those? What would be the cause for the difference in those between the vertical compression and the shearing compression?
Robert Schleip:
Shearing would be how one layer that’s located more superficial to other one, how easy it is to move that in a horizontal displacement in relationship to the lower one.
Til Luchau:
Is it fair to say that the shearing would be seeing what’s happening at the interfaces? Are they able to move and shear against each other while the vertical is more the tissue quality itself?
Robert Schleip:
Yeah. And I would assume, but it’s not black and white that in the vertical one it’s more about the fibrotic resistance and in the shearing it’s more about the lubrication, more whether the ketchup is warm or cold. So it’s more the viscosity of the ground substance, but of course it’s only a gradual difference.
Til Luchau:
Yeah.
Whitney Lowe:
Well I think that-
Robert Schleip:
Interesting. Interesting. I just had a very nice conversation. I’m looking to be in a long train ride with Jan Wilke who is now a professor for Fascia Research in Austria, which is really a celebration for us now. We don’t have amateur researchers who are doing it out of their free pocket. He is running a big department at a university and he said, “I want to make fascia research the number one.” That is part of his contract with them. And he found out that in myofascial pain, he explored it together with me in exercise induced delayed onset muscle soreness, the soreness shows more when you do shearing movements with your thumb than it shows when you do vertical pressure. So in the past we did vertical pressure and asked the client, tell me when the pressure changes into a painful sensation. That’s typical algometry-
Whitney Lowe:
Trigger point work.
Robert Schleip:
… threshold.
But now he uses his thumb and does a circular movement in the skin at a given force and asks the client, “On a pain scale from one to 10, how painful is this?” And that is a more sensitive measurement for delayed onset muscle soreness than the classical algometry. So it’s called Pain Sensitivity Scale. I didn’t know about that.
So that will be also something that a clinician could use that you ask the client how comfortable or uncomfortable is a vertical pressure on the painful limp and a shearing. So where you take your thumb and you make circles in the tissue and you shear the skin two centimeters in a large circle in all four directions. And if the pain is more elicited with the second style, you may have more ground substance change related with inflammatory cytokines than a classical fibrosis. That’s at least our current speculation.
Til Luchau:
And then what really counts from the client’s point of view is our ability to change that or help that or change the pain. So I’m just thinking for myself, there’s such a role in checking in with the client, talking to the client, getting their report. You mentioned the pain scale, but even over time, having them notice or report back. Is what we’re doing, increasing the pain, decreasing the pain? That’s a lot of the information loop I’m using as a practitioner as well.
Robert Schleip:
And I think we should. So when you work on the bottom of the foot, you should not only use vertical pressure, so you use your fingertips or your thumb or whatever and then you ask the client to reach forward to step backwards so that you create diagonal angles in the tissue and then you see how is the pain sensitivity in each of these directions. So I think we have been always doing that, but that also means foam rolling is very limited unless you fix the roll that it doesn’t roll anymore. They are now devices, so you fix the roll that it doesn’t roll and then you do a shear.
Til Luchau:
Do a shear.
Robert Schleip:
But you could do that at any stone on the ground. You don’t need to buy a roller there.
Til Luchau:
Well speaking of fancy rollers, Sue Hitzmann has a lot of shearing kind of things she does with rollers.
Robert Schleip:
Oh nice.
Til Luchau:
Yeah, it makes me think of Greg Lehman’s joke that foam rolling, you can just be like trying to, what did he say? “Trying to filet a chicken with a rolling pin.” You’re not going to filet the chicken, you’re going to mash the chicken. If you just mash that. What you’re saying supports that. It isn’t about just squishing it or mashing it.
Robert Schleip:
But also these metal tools like resin tools, et cetera, they give your hands a better grip. And I just finished a talk with Eric Owens. He is a founder of Delos therapy and he gave me this gumdrop and it’s better than my hand because it has different edges and I can put it on the tissue and then push forward and it has more grip. So I’m now looking at additional tools not to replace my hands, but to make my hands sometimes elongated or more powerful or give my hands more grip in the tissue.
Whitney Lowe:
I’m curious too in terms of-
Til Luchau:
In future episodes you need to talk about instrument assisted work at some point a future episode.
Robert Schleip:
Yeah, that would be hard topic with all the dangers it has.
Til Luchau:
Thank you.
Whitney Lowe:
Yeah. Also, just curious in terms of other ways in which to do this to enhance that shear force application. Do you think that you might actually even get more significant results in some instances when you were applying shear force and then moving the tissues out from underneath that by shortening and elongating them by joint movements simultaneous with that soft tissue manipulation?
Robert Schleip:
Yeah. Also, when you ask them to do the movement rather than you do it, they cannot daydream at the same time. If you tell them keep going, keep going, they are a little bit more, “Yes.” They are, “Now, slower, slower.” Their full engagement is precisely where you are interacting with them. So that’s another important aspect of course, we are not only changing the viscosity of the tissue, but the perceptual connection of your nervous system with whatever sensory stimulation comes from the plantar fascia. And there have been several studies to show that the client attention makes a huge difference to whatever stimulation you give to them. So these client active move participations are a gold mine.
Til Luchau:
There’s the idea that pain’s function is to get our attention and shift our behavior. So why wouldn’t we use our client’s attention when we’re working with pain as well?
Robert Schleip:
That’s a nice one, Til, I like that.
Til Luchau:
I enjoyed seeing your Facebook post about this. We’ll go ahead and put a link to that in the show notes where you talked about some of the clinical applications. When I went and downloaded the paper and read it, I was excited to see that it was about plantar pain as well because that’s a particular place that I had quite a bit of pain for a long time. I would’ve qualified as a subject for this study I think. And then I also just finished like you, Robert, I just finished a dissection with fresh cadavers. This one was with Wojtek Cackowski and Todd Garcia and I was looking especially at plantar layers and the heel pads and I was surprised at how soft they were, even on the harder body styles we had. It was very soft fat there on the heel. I expected something much more fibrous than I found. So to have your study come out with a measurement of stiffness of this was amazing timing and synchronicity.
Robert Schleip:
Yeah. So that’s the other maybe secondary finding of this study that the stiffness change was not only found in the painful tissue itself in the plantar fascia, but it was equally reflected in the Achilles tendon. So there have been many indications, but that is now another robust one that they are functionally like one mechanical unit and that they are not just sometimes influencing. Basically it is like the patellar tendon and its connection with the quadriceps.
So normally the patella is mobile. If it would be fused with the femur, they would be disconnected. But if the patella can slide one centimeter up and down, then whatever tension you have above the patella will be reflected below. And that is now the concept and the dissection that we did in the last two days may be similar to yours, Til, where we see the Achilles tendon has actually two parts and they are linked with each other. They are linked not only via the calcaneus as a bony intersection but also via the heel pad as a soft patella-like plate. And then tension in one end will immediately be reflected in the extension of it. So you could make a cause to call the plantar fascia as distant Achilles aponeurosis. So that would another one.
Til Luchau:
You’re kidding.
Whitney Lowe:
No.
Til Luchau:
I thought you were going to say that calcaneus is like the patella, but saying the heel pad itself?
Robert Schleip:
Oh, yeah. So you have two of these hypomochlion how they are-
Til Luchau:
Hyperbulkion?
Robert Schleip:
Yeah, so that’s a nice name, hypomochlion. It’s like a change of direction in a mechanical pulley system. And for that, so the patella is a hypomochlion in biomechanics, but only if it moves. If it’s fused with the femur, it cannot do that. So both the calcaneus, when it’s free to move, for example in a closed chain with your foot on the ground and the heel in the air, then the calcaneus can be like the patella, a hypomochlion, a shifting piece in between one or two pieces of mechanical tension. But if the calcaneus is fixed, then you can move behind the calcaneus via the heel pad. And we are one of the few animals who have the heel pad so strongly expressed on the ground. And in young people the heel pad can move four or five millimeters in relationship to the calcaneus. And in old people it’s fused with the calcaneus or fused in arendisis. And then we can argue that’s a pathology. So if your heel pad cannot slide in relationship to the calcaneus, not more than one or two millimeters, which is often the case in shoe wearing adults in western concrete cities-
Whitney Lowe:
Right. Yeah.
Robert Schleip:
That’s as pathological as if your patella would be fused with the femur. And then you wonder why the tension transmission doesn’t work anymore and why the rectus femoris cannot influence the knee joint angle anymore. So this is a very nice concept and that study emphasized that it’s one functional unit.
Whitney Lowe:
Something, just thinking about this biomechanically, this is fascinating because we’ve spoken for a long time about the coordinated action between the gastroc and soleus complex and the plantar fascia, but your analogy there about it being similar to the patella is really interesting. But also think about this in terms of it seems, and obviously I’d probably want to read a whole lot more about this, but biomechanically that that’s mostly going to be a factor during the push-off phase because once you’re at heel strike, you don’t really have the opportunity to have that kind of mobility or force transmission because the body weight is pressing the calcaneus into the ground and it’s not really until you get that calcaneus up off the ground and start propelling forward at that point that you’d have a much more significant force transmission from the gastroc-soleus, the tricep-sari group into the plantar fascia. You think that’s relevant there?
Robert Schleip:
Yeah. I think it’s very relevant. Imagine your children would never walk normally, they would always walk with their knees on the ground and then the patella would lose its mobility, maybe. It would fuse to the femur and then the patellar tension may not reflect the tension of the quadriceps anymore. So I think it’s very important that for children and also in puberty you are not just walking. In walking, we land with our heel and then you have the mechanism that you describe, but that you are jogging where you land with your forefoot as a closed chain and your calcaneus in the air and then all that you are jumping, like hopping. So then you land with the forefoot, the plant of fascia gets a lot of tension that pulls the heel pad slightly more forward until it gets resistance from the calves and then it may be pulled in the other way.
So you have that dynamic going forward and backwards of the heel pad but also of the calcaneus. And you have that when you land with your forefoot. You don’t have that when you land on your heel.
Whitney Lowe:
Exactly.
Robert Schleip:
So I think it’s very important that our children do a forefoot landing and you do that by hopping or by jogging and of course more in barefoot. The whole barefoot debate. We don’t need to open that box now, but if you do running with barefoot, you tend to, not all of them, but two-thirds of the people try to land more with the forefoot. And that would have some disadvantages, but it would have that advantage that we are talking about.
Til Luchau:
What you’re describing really affirms the way that I’m working with feet after my own recovery from that injury, the sliding, the connection of the back of the leg, the layering, the shearing, all those things as well as just not trying to soften the tissue, which was your main point, not just about mashing, it’s not about rolling pin on the chicken, it’s about helping things be quiet in the foot.
There’s also what you’re saying about the heel landing, big piece of my recovery was actually barefoot shoes. Not to open that debate, but shifting my weight farther forward. So it wasn’t so much on the heel pad and really looking at when I was wearing those barefoot shoes. For running, it was great because I was forward. For walking around the concrete city, no, that would further injure it for example.
Robert Schleip:
Also, one conclusion of that Brazilian study confirms a clinical observation that many people with a lot of experience have practiced. When you have pain on the bottom of the foot, you treat of course the plantar fascia, but you also treat the non-painful Achilles tendon. And they say you should always do that in the same session. And the other way around too, if the Achilles tendon is painful, you treat that one normally with eccentrical slow motion loading on a step, the eccentric loading protocol is still the gold standard.
Til Luchau:
Heel drops.
Robert Schleip:
Yeah. So the slow heel drops, but in the same session please also treat the non-painful or even if it’s non-painful, the plantar fascia and you get better results than when you only treat the pathological tissue. And now we have one more reason because functionally they are coupled.
Til Luchau:
Talking about treating them as a unit?
Robert Schleip:
Yeah.
Til Luchau:
Well what else do you want to tell us about your interests these days? What else is capturing your interest? What else should we know about?
Robert Schleip:
Well, I want to know about this water binding. So if you have more dampening, I still don’t get it together because we know that in the densification, how the Steccos call it, where you have the hyaluronan in a more sticky form where it binds less water and therefore you have more unbound water. But that tends to go along with more dampening and with an increase in viscosity. And I don’t understand it, because free water would be less viscous. It would be more like a warm honey and not like a cold honey or ketchup. So there is something I’m not understanding. So either it’s not related to the resistance of water molecules that is more the hyaluronan itself or maybe how the hyaluronan interacts with collagen type three. Or there is something about the water binding that I don’t understand.
So if any in the audience has an insight, you can call me in the middle of the night. I’d love to hear that. So that is a challenge. So when you have, for example, an epicondylitis, Antonio Stecco has shown that, then you have a higher viscosity and you have hyaluronan in a less water binding condition. And therefore the water that is in the tissue and that is not less than before should be in an unbound condition and we should call that edema. But unbound water should have less resistance to movement, but it seems to have more viscosity and I don’t understand it.
Til Luchau:
Well, I personally have looked to you for decades now to help me increase my understanding of what’s going on of the mechanisms and possible explanations and then to question my assumptions. So there’s still so much to learn and thank you so much for your continued questions and discoveries and contributions here.
Robert Schleip:
I have another one.
Til Luchau:
Okay.
Robert Schleip:
We’re now doing some stiffness measurement not in prone and relaxed position on the lower back, but in the yoga child’s position. Because the muscles should be as pudding soft as in prone and relaxed position. If you can measure that in this EMG, but the fascia should be three times tighter and then it may be different. It may be possible to feel fascial stiffness on one side as opposed to the other side if there is a stiffness difference. So that’s something one. So we want to explore free stretched positioning, how that influences what you touch and how stiff a tissue is, even if the muscles are relaxed. And I think that’s an important dimension because if you place the client in a pre-stretched position and they are relaxed, the muscle pudding should be as soft as before, but the fascial envelope should be much, much tighter and then you may be able to palpate. So that’s something that we are doing now.
Whitney Lowe:
Fascinating stuff.
Til Luchau:
I’m writing it down.
Whitney Lowe:
Yeah.
Til Luchau:
Still getting clear about it. Well, anything coming up that you want listeners to know about?
Robert Schleip:
Til Luchau is organizing… Dampen me if you don’t need more people to join?
Til Luchau:
Please no, tell us.
Robert Schleip:
Okay. Yeah. So next summer in May, you and Bibiana, a common hero of us,
Til Luchau:
Bibiana Badenes.
Robert Schleip:
… a mindful, walking, spiritual, somatics pilgrimage on the Camino. And I think you are doing it already for the third or fourth time. And now I can join you and I’m looking forward to that.
Til Luchau:
We are so looking forward to that, Robert. Having you along with us, I’m sure we can have some great heel pad discussions and experiments and everything else.
Whitney Lowe:
That’s right. Yeah.
Robert Schleip:
You have to do barefoot, backwards walking with me and then you can ask me to do all kinds of weird stuff with you.
Til Luchau:
Okay. Yeah. You’re joining us on our Walking Workshop on the Camino de Santiago in May, 2024. We’ll put a link into the site. Thank you for mentioning that. Anything else you want listeners to know about, Robert?
Robert Schleip:
No. Yeah.
Til Luchau:
All right, that’s great. And where can people find out more about you and your work?
Robert Schleip:
Somatics PE is a nice website and Oh, my IT guy told me to tell people to follow me on Instagram and Facebook now because I’m shifting not to doing newsletters, but whenever I get excited about something and that’s how you found this article from me, I will do a quick Instagram sharing. That would be a nice way to get connected with new insights and questions and discoveries. So follow me on Instagram and Facebook.
Whitney Lowe:
All right. We’ll do it.
Til Luchau:
Always keeping up, Robert. That’s amazing. That’s great.
Whitney Lowe:
Well thank you so much for sharing your time here with us today. This was a fascinating discussion for sure.
Til Luchau:
Very appreciate it, Robert. Great to see you. Thanks again.
Robert Schleip:
Until next time.
Whitney Lowe:
Okay.
Robert Schleip:
Bye-bye.
Til Luchau:
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Whitney Lowe:
And the Thinking Practitioner Podcast is also supported by ABMP, the Associated Body Work and Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education, and quick reference apps, online scheduling and payments with Pocket Suite and much more.
Til Luchau:
ABMP CE courses podcast, and Massage and Bodywork Magazine, always feature expert voices and new perspectives in the profession, including articles from you, Whitney Lowe, and myself.
Thinking Practitioner listeners can save on joining ABMP at ABMP.com/thinking. Thanks to you, all of our listeners, to our guests today, Robert Schleip, life to our sponsors. Stop by our sites for the video show notes, transcripts and extras, my site is advanced-trainings.com. Yours Whitney?
Whitney Lowe:
And you can find that all on my site at AcademyofClinicalMassage.com. And if you have a story to share with us or a question you’d like us to address, just record a short voice memo on your phone and email it to us and we’ll try to work it in. Our email is [email protected] and we’d love to hear from you there. Or you can look for us on social media. You can find me under my name, Whitney and Til, for you?
Til Luchau:
Til Luchau is my name. Please rate us on Apple Podcast. It really does help people find the show. And you can also hear us, of course, on Spotify, Stitcher, Google Podcasts, wherever else you get your podcasts. Thanks for spreading the word, telling a friend. See you next time.
Whitney Lowe:
Sounds good. See you then.
