Guiding Principle VII: Feel – Macro and Micro

Tactile skill is the hallmark of Myotherapy. So what do you feel for?

I dread the question.

Invariably, nearly every new patient somewhere during the course of treatment asks, ‘So what do you feel for?’ For me this is a hard question to answer. It is not hard to answer because I am uncertain about what I feel for, but it is hard to answer because the sensation that I search for makes me sound like a quack.

But, I will endeavour to explain it to you here.

What I don’t feel for.

For the sake of this article I will assume that you are good with your surface anatomy, bony landmarks, muscular borders, origins and insertions and can palpate these effectively.

Commonly as therapists we use our tactile assessment skills to feel tightness, lumps, firmness and so on as a way of assessing skeletal muscle. I will describe these, for the sake of this article as macro observations. I have found these macro observations to be entirely inconsistent with restriction of movement, muscular health and function.

Macro observations (the physical!)

In other words, one person will have muscles that feel very firm, but have no restriction in range of movement and no tenderness. Another person will have very soft muscles and have terrible flexibility.

Several muscles are ‘ropy’ by nature, such as iliocostalis thoracis or levator scapula, easily construed as ‘ropy and tight’ yet a perfectly healthy iliocostalis feels exactly the same.

Another person will have subcutaneous fascial lumps around their lumbosacral area that feels terrible yet is in no way symptomatic or unhealthy.

These macro observations such as tightness on tactile assessment are just so inconsistent that they are unhelpful as means of assessment when searching for myofascial restrictions or myofascial trigger points. If they have any value, it is only that of comparison. For example, does the right iliocostalis feel as ropy as the left?

Micro observations (sensations!)

I am using the terminology micro observations to describe the subtle sensations that can be felt overlying muscle, tendon and bone and often between muscular borders. These sensations would best be described as inhabiting that space between the skin and the muscle below. In a very unscientific sense, on the surface of the muscle.

The primary sensation that I search for, I can only describe as a buzz. Perhaps tingling or a fuzzy sensation are better words. I describe this tactile observation as a micro observation because it can be felt and assessed irrespective of the macro shape and/or tightness of the underlying muscle.

In other words, if a patient’s muscle feels firm or soft, ropy or relaxed, lumpy or smooth it is the presence or absence of the micro sensations that matters. The macro feel of the muscle is far less significant.

My experience has found that the resolution of these micro observations consistently resolves myofascial referred pain and restores range of movement.

The sensation.

The micro observation, I would describe as a buzz or tingling sensation. Other therapists have described it as ‘popping bubbles’. If you could feel the carbonated bubbles like beer or soft drink under your fingers, this would resemble the sensation.

I am not talking about some imagined energy. This sensation is subtle but very real.

Note that I am literally talking about a sensation, as opposed to the texture of a surface felt on a physical object. In the same way that you can physically feel the prickling sensation of a low grade electrical current when you touch a certain thing, you know that the prickling sensation is not the texture of the surface of the physical object you are touching. Nonetheless you are feeling both. You are feeling the macro (the physical shape and surface texture of the object) and you are also feeling the micro (the prickling sensation that is not the physical shape, nor the physical surface texture of the object).

So it is that you feel this sensation under the skin.

On tactile assessment of erector spinae for example, one could move the skin perpendicular to the muscle fibre direction and feel the macro (physical). The distinct rope like shape of the erector spinae muscle. Or one could do the same thing, once again feeling the macro, the distinct rope like shape of the muscle, but at the same time, feel the micro (sensation). Again, a subtle fuzzy sensation that is quite separate from the physical shape of the muscle itself.

I believe that in some complementary health fields, people approach therapy with a preconceived philosophy of energy pathways, for example. As such they treat with the anticipation of finding these energy pathways and describe whatever they feel, in alignment with their preconceived philosophy. What I am trying to explain in this article is the opposite.

What I feel and work by, every day, is a very consistent and real observation that is difficult to verbalise and align with our current scientific understanding of muscle and fascia. There are some plausible scientific possibilities but more of that later.

Invariably, nearly every new patient somewhere during the course of treatment asks ‘so what do you feel for.’ For me this is a hard question to answer. It is not hard to answer because I am uncertain about what I feel for, but it is hard to answer because the sensation that I search for makes me sound like a quack.

Now as Myotherapists, many of you reading will know exactly what I am talking about and some of you will not be able to relate. I have found over the years as I have sought to teach others what to feel for, that some feel it clearly while others not at all.

These observations are closely related to the physiology of myofascial trigger points.

The tactile observations I have described above occur in the vicinity of myofascial trigger points as charted by Travell and Simons. They are almost certainly a component of the myofascial trigger point physiology. Being that this is a young area of science, it is hard to explain exactly what is going on here. Even conventional trigger point theories are being refined at present.

Typically the sensation can be felt overlying active or latent trigger point locations. It is most intense immediately overlying the trigger point location and fades in intensity as you palpate away from the trigger point. For example an active trigger point in a long muscle like iliocostalis thoracis will exhibit the sensation most clearly on the trigger point location and palpation 1, 2 or 3 centimetres moving superiorly or inferiorly along the same muscle. The same sensation can be felt but in diminishing measure.

Micro feel is less localised than the traditional notion of trigger points.

Myotherapists are used to searching for areas of localised tenderness. A taut band, a pressure point, a trigger point. This micro feel that I am describing here does not always subscribe to localised trigger point locations. In fact sometimes the sensation or surface tension can be observed regionally. For example, palpating around the superior angle of the scapula, these sensations may be observed throughout this entire region. As such the micro feel can be observed under the skin overlying rhomboids, levator scapulae and the upper fibres of trapezius.

This designates an area much bigger than a localised trigger point, yet if one overlays the charted trigger points in levator scapula, rhomboids and trapezius together at once they will clearly demarcate this whole region. To the enquiring mind this observation opens the idea that perhaps the trigger point mechanism is mediated regionally by the overlying fascia, rather than trigger points being isolated muscular injuries.

Micro feel is often found in fascial spaces.

What I mean by this is: often the sensation is most apparent between muscles or even overlying bone.

As stated already, it does occur in trigger point locations – but – while we are used to conceiving of trigger points existing in the muscle fibres, in the belly of the muscle per se, this micro feel is often prominent on the borders of muscles or in the spaces between muscles. Start in the trigger point locations but palpate the muscles as three dimensionally as you can. Palpate all the borders that are accessible to search for this sensation.

Micro feel dissipates.

If you can identify the sensation in a trigger point location that is consistent with your patient’s symptoms then cross-fibre manipulation will see the sensation dissipate. Manipulate the location briefly, then leave it alone for a few minutes. When you manipulate it a second time, if you have been effective the sensation will be less intense. Repeat manipulations until the sensation is resolved completely and test range of movement.

Some more objectively measurable observations.

Some more objective measurable observations are consistently seen when micro feel is resolved.

• ROM is restored: Once the sensation has dissipated, full pain-free range of movement is restored. If it isn’t then search more diligently the trigger point locations that can cause pain or stiffness in the patient’s area of discomfort.
• Tenderness is resolved: Once the sensation has been resolved tenderness to touch disappears. Often I will remind people that I am using the same pressure as I used at first and they are surprised to find the tenderness is less or gone altogether.
• Pain patterns are resolved: Once the micro feel has been resolved the myofascial pain pattern will disappear.

Surface tension.

If the buzz sensation is simply not apparent to you then this second observation may be helpful.

This second kind of micro feel is a subtle sense of tension under the skin, between the skin and the muscle, if you like. For want of better terminology, a kind of surface tension. This sensation is only objectively measurable between right and left on the same individual, not from individual to individual. This sensation can be felt and assessed irrespective of the macro shape of the underlying muscle.

In other words, if a patient’s muscle feels firm or soft, ropy or relaxed, lumpy or smooth, all of this is irrelevant. I explain surface tension as means of micro feel here because it is an adjacent observation that occurs in concert with the fuzzy sensation. If you can’t feel the fuzzy sensation, you will be able to learn this.

I have observed that regions that harbour myofascial trigger points will exhibit some additional tension between the skin and underlying muscle. A slightly firmer feel to a flat hand and a subtle feeling of adhesion between the skin and muscle, such that the skin does not glide as well over the underlying muscle. An elite athlete with no myofascial dysfunction will exhibit a clear distinction between muscle and skin. Such that the skin will move effortlessly over the underlying muscle. Almost like the presence of an oily lubricant between the skin and muscle.

What I am trying to describe here is a concept. I am not trying to categorise body types. Every individual will be different and the concept of surface tension is only useful when comparing right and left on one individual. With every new individual you need to recalibrate your feel so that you can compare right and left with a new set of lenses for each person.

Finally if tactile sensation is not your strength then a strong knowledge of myofascial pain patterns and trigger point locations will enable you to work the right areas with the right form of manipulation and still get great results. You just don’t get the subjective evaluation.

My application.

After I have taken a history and determined which of the patient’s symptoms are likely to be myofascial pain patterns, I will commence tactile survey of the trigger point sites that can refer to those pain locations. I have found that locking onto the skin and moving it over the underlying muscle is the best way to search for the sensation and assess any sense of adhesion (surface tension).