*2.1.9 Massage application to reduce swelling/hematoma (aggressive massage techniques)*

The massage that aims to mobilise fluid elements (edema/hematoma) in athletes has a clearly accelerated-aggressive form, and its execution (pressure, direction, massaging point) can lead to high pain (VAS scale 7–8) during application. This aggressive massage technique uses straight manipulations and mainly deep slips and special massaging techniques (stripping massage) because circular strokes are not allowed in the acute stage of injuries and in the phase when the fibres of the injured tissue are immature or, even worse, have not been restored yet.

The basic manipulations (effleurage-kneading) begin more centrally than the site of the injury. Through the mobilisation-increase of the venous return of large vessels, the massage techniques are meant to "empty" the injured areas and to create and environment (negative pressure) suitable for the mobilisation of the edemahematoma located in the periphery of the injured area. Immediately afterwards, massage techniques are once again applied directly to the injury using straight manipulations from the periphery towards the centre. Through direct mechanical effect, swelling and hematomas are directed towards the trunk or from deeper to more superficial layers, which ultimately facilitates hematomas removal. These manipulations have been described in a study by the Laboratory of Therapeutic Exercise and Sports Rehabilitation at the University of Patras, Greece, in which aggressive massage techniques were performed to speed up the recovery of a professional football player after a 1st degree hamstring strain. The results of the study were encouraging as recovery time was reduced to almost half of the usual time and the footballer resumed full training and participation in games in 15 days. The soft tissue techniques used to remove the edema were stripping massage, cupping therapy, and IASTM techniques [79].

The application of the manipulations described above leads to significant pain due to pressure on the injured tissues and increased hydrostatic pressure, which, in turn, increases the irritation of the sensory receptors of pain. However, the aggressive approach drastically accelerates the reduction of the accumulation of metabolic substances and blood-hematoma and enables the process of fibre re-adhesion to begin sooner. The application time ranges between 5 and 10 minutes, and the pressure/intensity of the techniques must be alternated (mild to intense/deep-surface) to be more tolerable for the athlete. Immediately after the mobilisation of the edema-hematoma, cryotherapy should be applied to reduce (via vasoconstriction) the amount of the mobile fluids that will return to the massaged-injured area.

#### *2.1.10 Massage for aligned fibre re-adhesion and reduction of scar tissue*

In the subacute phase of the injury, when the swelling-hematoma has been removed and tissue re-adhesion and scar tissue deposition begins, massage also plays a critical role in facilitating the proper repair of the injured area. The application of straight manipulations (deep kneading, soothing rolling, tapping linear strokes) in the direction that the fibres of the injured anatomical area are normally arranged in creates a tendency for linear re-adhesion as well as reduction of adhesive deposition and scarring.

Proper alignment and reduction of the amount of hard connective tissue in the injured area reduces the loss of elasticity and strength experienced in the presence of adhesions [1, 2, 80], thus reducing the risk of the recurrence of injury [2]. In addition, massage can "dissolve" fibrous deposits that can impede the flow of interstitial fluid by clogging tiny pores of the fascia, which restores the circulation of interstitial fluid [3].

These significant effects of massage on tissue repair have been supported by research on animals that have technically suffered muscle strain and received massage as basic treatment in randomised studies. The massaged muscles had normal microscopic illustrations in contrast to the non-massaged muscles, which showed histological adaptations such as (a) dislocation of the myofibrils, (b) significant deposition of connective tissue, (c) persistent hematomas, (d) increased number of fibroids in the connective tissue, and (e) enlargement of the blood vessels accompanied by the thickening of their walls [63].

#### *2.1.11 Massage application in delayed-onset muscle soreness (DOMS)*

DOMS generally describes the tenderness and pain of muscles that develop hours or even days (24–72 hours) after specialised and demanding sports training (eccentric-plyometric) [81].

This negative adaptation after intense exercise leads to decreased elasticity of the anatomical structures involved (upper and lower extremities) and to clearly reduced muscular strength [5, 65]. Several theories for DOMS have been proposed, including the activation of free nerve endings by (a) lactic acid accumulations, (b) muscle and ligament injuries, (c) exit to the intracellular space of intramuscular enzymes, and (d) prostaglandins [81]. Histological examinations of muscle cells after eccentric loadings have revealed structural cellular adaptations (migration of cellular elements) that cause local edema and inflammation [65, 82].

In addition, connective tissue injury is evidenced by the high concentration of hydroline and hydroxylysine in athletes' urine after eccentric exercise [81]. Theoretically, and based on the previous chapters, the fact that massage can move fluids from the intercellular and interstitial spaces and reduce the accumulation of metabolic products [48, 51, 54–56] may have a positive effect on reducing DOMS. This is confirmed by several studies that have shown that massage can significantly reduce muscle sensitivity because of eccentric-plyometric muscle activity and contribute to improving the rate of tissue healing and the reduction of cellular inflammation by improving the supply of nutrients and oxygen to the tissues [34, 56, 65, 83–85].

Moreover, massage can lead to faster recovery of muscle strength, which is significantly reduced after eccentric exercise [20, 81, 86, 87].

Finally, several studies have recorded reduced muscle soreness, lower perception of fatigue, and improved perceived recovery [16, 20, 45, 88] at variable intervals after the massage, ranging from 24 to 96 hours.

#### *2.1.12 Effects of massage on the inactivation of trigger points*

The creation of painful trigger points is one of the painful syndromes and injuries of the musculoskeletal system that have been observed after intense exercise. These points refer to localised areas of high sensitivity that are usually located within a stretched muscle bundle. The clinical feature of these myofascial trigger

#### *Soft-Tissue Techniques in Sports Injuries Prevention and Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.96480*

points is that they cause intense focused pain during compression as well as other symptoms, such as reported pain, muscle dysfunction, and autonomic phenomena.

The causes of such pain triggers include biomechanical body abnormalities, injuries, chronic inflammation, and psychological factors but may also be the result of tissue overuse during exercise [89, 90]. Beyond focused pain, the negative adaptations caused by the existence of areas of excessive tension and ischemia include reduced elasticity and deficient strength production and muscle function in general [89]. In addition, pain triggers have been blamed for causing painful muscle spasms (cramps) during exercise [91].

The treatment of such pathological signs of pain includes, among others, techniques that combine cryotherapy and stretching (stretch and spray), electrotherapy (tens, ultrasound), and massages of various kinds [90, 92].

The treatment of painful trigger points has been part of classic massage techniques and therapy techniques that rely on ischemic compression of trigger points, leading to the deactivation of said points and to the reduction of pain symptoms. In particular, the application of massage in the form of either classic-Swedish massage [93, 94] or ischemic pressure [95] significantly reduced the intensity of pain in patients with painful trigger points in the trunk (lumbar and cervical region) [96] and the thigh muscles (hind thighs) [97].

#### *2.1.13 Application of ischemic pressure to deactivate painful trigger points*

Ischemic pressure deactivates painful trigger points via two main mechanisms: ischemia and the following hyperaemia as well as local and focused tissue stretching. Ischemic pressure initially creates a reduction in local perfusion; once the pressure is removed, hyperaemia occurs in the area, which can help clear the muscle of inflammatory derivatives and pain metabolites, thus desensitising the nerve endings. In addition, constant local pressure on the trigger points will lead to continuous stretching that can potentially "solve" painful adhesions and reduce muscle spasms [89].

In a study by Fousekis et al. at the University of Patras, ischemic pressure techniques were applied to amateur soccer athletes on painful lower-back trigger points to evaluate the effectiveness of these techniques in pain. From the very first week of application, the participants reported a decrease in pressure sensitivity according to VAS and a pain reduction as ischemic pressure was effective for treating trigger points [98].

### **2.2 Instrument-assisted soft tissue mobilisation (IASTM): the ERGON IASTM technique**

Mobilisation techniques using special tools made of stainless steel are a form of aggressive mobilisation of soft tissues. There are several variations of such tools (Myobar, Fibroblaster, Smart Tools, Rockblade, Hawkgrip), but the Graston and ERGON tools are the most prevalent ones in research.

Soft tissue techniques using special equipment require tools designed to adapt to the various tissues, shapes, and curves of the body. These tools are used for the following purposes: (a) to detect and release scar tissue, adhesions, and fascial sclerosis; (b) to increase blood circulation; and (c) to reduce muscle tone and pain [99–101].

Significant advantages have been reported in using such tools rather than one's hands when evaluating the abnormalities of tissues, although a stainless-steel tool is inferior to the human hand in the first stage of the standard evaluation, which

involves tissue palpation for the assessment of temperature, humidity, edema, and muscle spasms in the superficial tissues of the body [102].

Massaging the tissues with special tools enhances a therapist's sense and information about the condition of the tissues as the fatty areas of the therapist's fingers that come in contact with the patient's body compress the tissues, while the tools have a narrower edge to separate them [102, 103].

According to the manufacturers, the tools act as percussion instruments: when in contact with hard fibrous tissue, they transmit an echo (vibration sensation) to the therapist's hand, improving their ability to recognise and evaluate adhesions and fibrous deposits [101, 102]. In addition, the use of such tools allows the mobilisation of deep and hard structures without overloading the therapist's fingers.

In particular, IASTM techniques in conjunction with cross-friction massage can reduce scar tissue deposition after an injury, reduce the hardness of preformed connective tissue deposits, and facilitate the healing of chronic overuse injuries by re-damaging tissues and linearly re-connecting them [96, 101, 104–107].

IASTM techniques also appear to lead to changes in microvascular morphology and hyperaemia [108] and to increased fibroblastic mobilisation and activation, an adaptation that leads to regeneration and repair of the injured collagen [101, 104, 107]. These adaptations have been supported by studies with animals and individual case studies with humans [100, 101, 103–106, 108, 109].

For example, a study of mice that underwent controlled rupture of the medial lateral ligament in their knee and were treated with an IASTM treatment showed that the ligaments that received the Graston massage were stronger (43.1%), harder (39.7%), and could absorb up to 57.1% and more load until break point compared to untreated ligaments. In addition, specific ligaments during the microscopic analysis showed better arrangement and alignment of the newly formed collagen [108].

Such findings were attributed by the same researchers to increased perfusion and the change in the microvascular morphology observed after the application of IASTM techniques to the inner lateral ligaments of mice [109].

#### *2.2.1 IASTM technique applications*

There are several IASTM techniques, the most well-documented being the Graston and ERGON techniques. ERGON IASTM TECHNIQUE is an innovative therapeutic approach that combines static and dynamic manipulations of the body's soft tissues with special clinical equipment meant for the treatment of pathological conditions. The technique takes its name from the Greek word "ergon," which etymologically means "what a person produces with their work, manual or mental, scientific or artistic."

With the ERGON IASTM TECHNIQUE, the therapist can induce short-term and long-term adaptations to the soft tissues of the human body. The techniques follow specific application rules and parameters. Poor application of techniques and non-compliance with the correct parameters may lead to the opposite result and cause injuries to the treated area.

#### *2.2.2 IASTM diagnostic applications*

The general evaluation of the patient is followed by the evaluation of the injured anatomical area using the ERGON TOOLS. A scan of the soft tissue is performed with a special diagnostic application technique, namely the Ergon Technique Scanning Procedure (ETSP). ETSP is based on a specific use of the ERGON TOOLS that allows detecting scar tissue, adhesions, and fascial hardening/shortening.
