A Bad Massage and an Important Clinical Lesson
In this episode of the Unreal Results podcast, I share a personal story about a massage experience that sparked a much bigger conversation about clinical decision-making, practitioner ego, and why the lower leg deserves far more attention than it typically gets. I unpack the anatomy of the calf, the role of fluid congestion, nerve entrapment, and compartmental relationships. I also walk through the exact sequence I use to assess and treat the lower leg in my clients.
In This Episode, You'll Learn:
Why lower leg congestion can influence pain, mobility, and treatment outcomes
The key anatomical regions I assess before doing deep tissue calf work
How I sequence lower leg treatment to improve lymphatic, venous, and neural function
A practical framework for combining patient priorities with assessment findings
This episode is a reminder that assessment should guide treatment, not habit, routine, or practitioner preference, and will challenge you to think differently about both the information your clients give you and the information their bodies are trying to communicate.
Resources & Links Mentioned In This Episode:
Ep. 3: Swelling Reduction Protocol That Works Like Magic
Ep. 8: Unlocking The Fibula
Ep. 14: The Stories We Tell: A Lesson From My Compartment Syndrome
Ep. 18: Lessons From My Back Surgery - Part 1
Ep. 19: Lessons From Back Surgery - Part 2
Ep. 20: Reflexive Core Stability: Lessons From My Back Surgery - Part 3
Ep. 25: The Peripheral Heart
Ep. 37: Swelling Protocol Update
Ep. 47: Always Check The Distal Pulses
Ep. 53: Shin Splints: Beyond Overtraining & Rest - Complete Guide
Ep. 138: The Link Between Potassium and Shin Splints
Ep. 149: Rethinking the Popliteus in Knee Rehab
Check out the Swelling Reduction Protocol Course Here!
Learn the LTAP® In-Person in one of my upcoming courses
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
=================================================
Watch the podcast on YouTube and subscribe!
Join the MovementREV email list to stay up to date on the Unreal Results Podcast and MovementREV education.
Be social and follow me:
Instagram | Facebook | Twitter | YouTube
-
Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in
Well, hello. Welcome back to another episode of the Unreal Results podcast. Um, welcome if you're new here. I had... Well, first of all, last week's podcast with Missy Bunch, which was just a impromptu IG Live, um ki- like posts from that, like social media posts from that recording ki- uh, like, uh, went a little viral, which I wasn't expecting.
Of course, it's that way 'cause it's like something that you, like, you didn't really like ... It was just kinda off the cuff with Missy and I, and shout out Doc Joe O, the old podcast editor and, uh, YouTube editor for, um, the edits of the clips, and like one of the clips just took off Which is great. And then, um, since I had done like a secret sale on the Never Treat the Shoulder First online course and the Nerve Workshop, I posted some more content around basically what we're saying.
Like, literally just like I did another video of... It was an old video of the cross leg lift exercise, which is the exercise I had Missy do on the live, um, which is also clipped in the clip from Joe. Um, so literally like repeated the same thing in a m- more of a tutorial format. Um, and it blew up, which is so funny 'cause I f- it's old.
I shared it in 2024, and it did well, but it didn't like blow up by any means. I put a hook on it, which basically was like, I think I said like, "You can do thousands of reps of serratus punches or scapular pushups, like p- plus pushups, um, or you could do four reps of this exercise, uh, for scapular stability and see results after one set."
So, I mean, obviously it was a good v- I mean, it was a good video however many years ago when I posted it. Still a good video. Um, don't know if it was the hook or just like the algorithm pushing the content since the previous content did so well with Missy or what. But anyways, it did really well, and I gained like 600 new followers from it, which is kinda crazy.
Um, in a perfect world, that would be 600 practitioners, but I doubt it is 'cause it was an exercise post, so, you know, you get a lot of like, um, regular people too, which is fine. I, I'm all for helping regular people. But, um, yeah. So if you are a provider that found me from that post and maybe are listening to the Unreal Results podcast for the first time, like welcome, and then to everybody who is like a diehard listener, thank you for being here, and I hope you enjoyed that podcast too.
And if you haven't seen the tutorial on Instagram, like head on over to Instagram and check it out. Um- So anyways, I'm like, "Why did I talk about that?" It's just my mind's a little blown from it of like, wow, my Instagram's been really busy right now. Um, which is a good thing. Um, so this weekend, I, um, was home, and I, I live in a, like a touristy part of town and, um, there's quite a few, like, little day spas in the area.
Um, I think most of them are, like, um, Asian-style day spas, like re- foot reflexology, those type of, like, more Asian massages, like shiatsu massage, Thai massage, et cetera. Um, and, um, normally when I get a massage... Well, let me tell you a little history with massages. Okay, and also land the plane. The reason why it's, like, I, like, I was like, yes, Saturday I decided to go get a massage at one of these day spas in my neighborhood.
That was the whole story about that. But let me tell you a bit of little history of me and massages. So I've never, like, previously, I've never really loved massages. First, it was like, I didn't love laying on the table. It was hard for me to relax. Um, I had a really hard time relaxing. I just didn't see a purpose of it, and it was pretty painful.
Then I, um- progressed to part of the reason it was hard f- like at first it was just hard for me to relax 'cause I couldn't stop thinking. Then as I got to be a professional, it was hard for me to enjoy massage because I was critiquing people the whole time. And which is a real thing, and not like critiquing them like verbally, like openly critiquing them, but just in my mind being like, "No."
And then if they said anything about anatomy or stretched or tried to tell me something about my body, I was just like a little turned off to it. So, but with that said, like I find a lot of value in manual therapy obviously, and, um, it can be helpful, and eventually I started to get over the being able to relaxing, and I also started a little bit being able to get over the critiquing only because I finally found a good couple massage therapists.
Um, it had people that I trusted, and so like that kind of let go. So, um, then, uh... But it was still pretty painful. Then I started getting regular lymphatic massage, um, for just I was having just a lot of like bloating and general lymphatic congestion. Um, and so I started getting regular lymphatic massage and for that, and a side effect of the regular lymphatic massage was I noticed that then when I would go get a, like deep tissue massage or like even a Swedish massage that was kind of like a little deeper, I w- I didn't have a ton of pain anymore.
And so that was like a really great, um, that was a really great epiphany of like, oh, wow, yeah. When you are just... When your lymphatic system is like overwhelmed, backed up, you're just kind of pretty toxic, and the muscles are ouchie because of that. And so, um Since all, you know, it was like I did regular lymphatic work, and I mean regular of like at first I started out weekly and then I, maybe even more than once a week at the very beginning, but then weekly, and then that went to like every other week, and then every three weeks, and then every month.
And I, and I kept up with it for like two and a half plus years. Um, and like even now, even though I don't get regular lymphatic work, I still am-- I tolerate massage touch much better now. Um, so it can be more enjoyable. Um, I have a regular massage therapist here in San Diego that I love and trust, and who has taken my courses, that does the LTAP on me.
I've talked about her before. She's been on the podcast before, Julie Ariol. Arreola. She's great. She's up in like Carlsbad, Oceanside area. But, um, she can be hard to get into because she's so good and has a regular schedule. And then also that's like 45 minutes to an hour plus away from me given any, you know, given traffic.
And I just on a whim this weekend was like... Well, not a whim. I've been thinking like, "Oh, I need to reach out to Julie to see if I can get in," and then just not doing that, but then also being like, "I really need some just general massage of." And not only general massage of, like I just specifically would really love someone to work on my lower legs because, um, I've been having some Achilles tendonitis-y type symptoms for a couple years now.
I've talked about it on the podcast before I'm sure. Um, and it comes and goes because part of the symptoms of it, part of it is just symptoms of it. I don't think I have... I'm sure I have some sort of tendon pathology, but I don't think it's as bad as it feels because I know part of the pain and the sensitivity is because of the swelling from the lymphatic congestion.
So I've been meaning to do both, like get back into some regular lymphatic, uh, massage with, um, the amazing Linda Ann Cahn, a lymphatic specialist that I'm lucky enough, lucky enough to have here. She lives here in San Diego. Um, but also I just... Also, my, my calves are really tight. Like I've, have com- I, I have exertional compartment syndrome.
I have large calves. Um, I think a little bit of that is genetics. Shante Cofield, you know, the movement maestro, the other day, a co- a few months ago we went to dinner in LA and we were like walking up the stairs and she was behind me. And then like a couple days later she texts me, she's like, "Oh my gosh, I meant to tell you when we went to dinner."
She's like, "No wonder you have compartment syndrome." She's like, "You have the tiniest ankles and the largest calves." And I'm like, "Oh, I've..." It's int- actually, it's very interesting that she said that to me because I see that in my athletes a lot too. They have large calf muscles, but then kind of smaller ankles, and especially have a lot of tension around the extensor retinaculum, which tends to be a entrapment area of some important nerves.
And so, and vascular structures. And so, um, it was cool to hear her say that 'cause I'm like, "Yeah, no wonder." And so also, I've just been wanting someone to just like do spot work on my calves, much like I do for my athletes, um, and just like dig in there because it really helps, not only for the entrapment areas like the extensor retinaculum, but just like the tight, stiff muscles that are there from life.
And then, um, that deep tissue in, in the calf More so than lymphatic work really helps to get the fluid and the congestion out of there. And, um, so it's really needed. And unfortunately, as a whole in the industry, massage therapists and, um, manual therapists, whether they're physios or physical therapists or athletic trainers or chiropractors or whoever, um, they tend to suck at lower leg massage.
And I'm not really sure why that is, um, other than, like, inherently when someone-- w- when athletes, and maybe this is just in athletes, but when athletes, uh, or people with tight calves have tight calves, it's really hard to do deep tissue in there. And it, it's, it's hard on your hands, and it's hard to even feel like you get anywhere, and then it's hard to even sometimes feel the tightness because there's so much pressure.
And I've talked about this before, maybe even in a pod-- past podcast. I'll have Joe link in the show notes about the soleus, um, and, um, probably in the shin splints ep- episodes I've talked about this too. So I'll have Joe link those three episodes, um, talking about how when we have especially some extra fluid in the area, the pressure that it creates in the lower leg, it's like having a full can of soda.
It is really hard to deform that can of soda when it's full of fluid. And first you gotta get the fluid out, and then you can start to kind of deform it. So it's the same thing too is I find in my athletes, like, at first it's v- I'm fighting against this pressure system. And it's like this is also why the sequence to where you touch first and where you treat first is so important.
I'll have Joe link in the show notes the swelling reduction, um, podcasts I've done too. I've done two of them. Because, um, sometimes in order to be able to get good work done in the lower leg, you need to do some other areas in the body. And I'm gonna, I'm gonna relate this back to my experience on Saturday too.
Um, so, um, anyway, so th- this is also, like... I preface all this, this, the whole story about, the whole sat- story about Saturday really is not the podcast. The bulk of the podcast I'm gonna talk more about the lower leg anatomy and, like, my sequence of doing massage in the area to support the lymphatics and the vascular flow, as well as to actually get into the tight muscles and, like, help them not be so tight anymore.
And you all know I hate the word tight, but sometimes that is just the best way to describe it. So, um- Uh, so going back to Saturday. So now you know the reason behind why I was even, like, seeking out, I'm gonna call it general massage, and why even... I actually was like, you know what? These day spas, these Asian day spas in my neighborhood, they might be even better because as a whole, I'd say because the Asian massage day spas usually come with, like, quite a bit of emphasis on the foot and foot reflexology, I was like, at least I know they'll do a good job on the foot and the calf, and maybe a good job is, like, in quotes.
Like, they'll spend time on the foot and calves, more time than if I went to, like, a Massage Envy or a, just a massage therapist in the wild. Because I've been to massage therapists in the wild that are, like, more formalized, um, like therapeutic massage therapists. Maybe they have their own practice or maybe they're in a Massage Envy or whatever the other ones are called, Elements Massage, like all those different massage places.
I've been to massage therapists that work at fancy spas, at resort hotels, and across the board, whenever I've come into them and told them, when they say, "Hey, what brings you in today? What would you like to work on?" I say, "Please don't work on my back at all." You can do a little bit on the shoulders, upper back.
Um, don't touch my neck. Don't touch my back. Please focus on the limbs. I would really like a lot of focus on my lower legs and then my hands and forearms, because as a manual therapist, like, my hands and forearms, like, again, like, I'm like, they're... My, my forearms are so stiff. My thumb muscles are so sore.
I would love for literally, like, an hour massage for 15 minutes on each limb. You don't have to touch my back at all. But yet because of most massage therapists' training and then most of, of the ways they practice, they have this sequence that they go through. It's very hard for them to not spend time on my back, and it infuriates me.
Not for any other reason other than I was like, "You literally just asked me what I wanted. I told you, and then you're not even doing it." And, um, or it's like they'll like start on my limbs and they'll be like, "Oh, these are not too bad," and then c- continue on. And I'm like, "What, what, what does that even mean?"
So anyways, um, so s- so I was feeling like pretty good about this choice to go check out one of the Day Spas on Saturday. And I get there and, um, I had selected the 60-minute foot and body combo massage, foot relax- reflexology and then body. 60 minutes and I was like, "Great," like, "Perfect." Like, I'm thinking it'll be a 30-minute like foot thing and then like a quick rest of the body.
And, um, she has me like start face down and then she starts on my back and then doesn't even ask me what I want. But I'm like, it's okay. Like I signed u- I signed up for a specific package. It's a specific thing, right? And so then she's like going on my back and she's a little deep like many, again, Asian massages are, uh, a little deeper than I would like.
So when she asked how the depth is, I was like, "That's plenty. That's good. Plenty. No more than that." And then she proceeded to go deeper. And I'm like, "What the, what the heck?" And so then she kind of does like a general full back and then she says, pauses and she's like, "Is there something that you want me to focus on today?"
And I said, "Oh, yes. Thank you. I would really love you focus on my calves." And she goes, "What?" And I was like, "My lower legs." And she goes, "Oh, yeah. Okay." And then she does a couple things and then she starts like going to town on my low back and I'm like- I'm like, "Okay, well, like I could see how like if someone asks for their lower legs, I might do a little something at their lumbar spine because I know, you know, like the nerves innervate the legs down there.
Like, that's valid." And then she just is going, like continues to like go lower back, lower back, lower, and like I'm like uncomfortable. Then she gets deeper, so I'm like, "Hey, not that deep please." And she just continues on. Okay, my fault. I should have at that point been like, "Hey, could you stop doing my lower back?
Maybe you misheard me. I'm lower leg, like my legs." Um But she continues on. She, and then she gets to my hips, um, and then, um, finally my legs. And, um, I will say that the side of my Achilles tendonitis pain, my hip was really tight. My hamstring area, like where the nerve, where the tibial nerve comes out of the hamstring, very, very tight too.
And so I'm like, in my brain, I'm like, oh, even though she's not working on my calf, I actually think this is helpful because I'm like, I must have some entrapments a little bit higher up that's causing some of these problems. And so, you know, she does her thing, and then she gets to the calf, and it's tight, and I feel her like getting in there, and then she like switches legs, and I'm like, "Oh, dang it."
And so then she does the other leg, and then she does the arms, and then she has me flip over and does some like face stuff, and then she's like, "Okay, we're done." And I'm like, "Ah." I feel like I was murdered, number one. My back is so sore. And here's the thing. I, the reason, the reason I don't like people touching my back is because I had...
Well, one, I have, um, a lot of segmental instabilities in my lumbar spine. And, um, I tend towards, um, hypermobile. I wouldn't say I am hypermobile, but I'm very mobile. And I'm someone who needs more stiffness in their muscles than mobility, and especially in my trunk, around my spine. And so the reason why I don't like deep tissue or any massage work at all really, in my lumbar spine especially, is because it breaks any of the neurological stiffness my body has created, and also like diminishes a little bit of like the...
I, I'm just gonna say the neural- neurological stiffness that my body has created to provide some stability around those s- segments that I have significant segmental instability and have three extruded discs. I had back surgery, like, you know. I'll have Joe link that, um, podcast in the show notes too, my back surgery podcast.
I, I also believe there are two of them. But that's why I don't have people touch it, because any amount of deep tissue in that area destabilizes me to the point that I get off the table, and then like it takes barely anything, and I feel like disc issues and like start to get back pain. And- The whole thing with the back pain, I don't have back pain anymore.
I've gone so long with, like, minimal back pain or, like, kind of just general back pain here and there with life, but, like, not the back pain I had that led to the surgery for so long that I almost sometimes forget that I had the surgery. And I think that was my thought process during the massage, was like, "Okay, well, I don't normally like it when people do my low back, but you know what?
I've been feeling so good for so long, and, like, maybe a little bit wouldn't hurt." But she did too much. I probably would've been fine with a little bit, but she did too much. So anyways, I leave the, I leave the massage, and I'm like... I can tell. I'm like, "Oh my God, this is not good. I have, like, no stability in my spine."
So then I'm like, "You know what? I'm gonna go for a walk. Maybe, like, some movement and walking will, like, create some- something for me." And I, like, considered even doing some lifts, but I was like, to create some stiffness, but then I was, like, so unstable that I was like, "I don't think a lift's gonna be smart here."
So I ended up... The only bit of comfort I actually ended up finding is I took my sweatshirt and I tied it around my, um, top of my pelvis as tight as I could to provide some stability. You know, almost like an SI joint lock belt. And, um, then I kept that on for, like, three or four hours, basically until I went to bed that night, and I felt so much better when I took it off.
Um, and so that was good. And I, I feel lucky that I understand what happened, and I, and I was able to troubleshoot how to, like, not make it turn into a big thing. I will say on that walk and then my walk the next day, my Achilles does feel a little bit better. Still not great. Still have this feeling of like, "Man, I would've loved some work on my calf."
But it also continues to tell me that, like, a fluid thing is a big part of it, and then, like, I might have some entrapments of the nerves higher up, like I said, in my hip, in my thigh, that might be driving this too. So my biggest thing with that and why I wanted to tell the story around this is because, um, for a couple reasons.
Number one, I don't think this is specific to massage therapy. Um The, in terms of a patient comes in, tells the practitioner want, what they want or what they think they need, and then the practitioner doesn't listen to them. Or they hear them, but they don't listen to them, right? Or they just push the agenda.
And this is a conversation that comes up a lot in the LTAP because the locator test assessment protocol is a way for the body to tell us where to go. But at the same time, a patient comes in and, like, has a desire of why they're coming in. And so we need to make sure we're connecting both of them. So I spend a lot of time while I'm teaching in the classes, like, ig- giving that as an example, okay?
Of how to marry those two things together for the patient and for yourself so that you, the patient feels seen and heard, gets what they want, and then also you as the clinician get to listen to their body and figure out what their body wanted and give them that too. And then here's the spoiler alert.
What you want to do as a practitioner actually doesn't matter. That's your ego driving your practice and, like, that's the no-no. And sometimes ego is a lack of confidence and, like, a reliance upon doing things that are comfortable, um, and habitual. And that's what happens a lot in the massage world is, like, you learn this sequence of, of doing the massage and getting the whole body in the full session, um, and it's hard for you to navigate away from that.
It feels uncomfortable. There's a lot of cognitive dissonance with it. And so you-- it sometimes feels like or, uh, comes across as you're not listening to the patient, when really it's just your ego having a hard time letting go of the normal comfortable pattern it's used to, right? And when you don't have something like the LTAP to help guide you too, it's like, you know, a little harder to just go with what the patient wants sometimes.
Um So there's that. And I, I don't, like I said, I don't think it's, like, specific to the massage therapy in- industry profession, and I'm not, like, dumping on massage therapists here because it happens in every profession. And then also in every profession, there's a lot of crappy practitioners out there.
It's probably not you. You're listening to this podcast, means you like to learn and you like to think outside of the box and you're like, like, literally listening to educational podcasts in your free time. I promise you are not one of those practitioners. But as a consumer, it's hard to pick, it's hard to find the right
It's hard to find good people. Um, and so this, this is part of the frustrating part, right? Um, so I did wanna share that story to highlight those things. And then I also wanted to share a little bit before I dive in on the anatomy of the lower leg part of the podcast, which I'm sorry, I know it's like 30 minutes in and I'm not there yet, but, um, I wanted to also be like I have no i- like, again, I'm not a massage therapist, so I don't know about m- the industry's regulations, licensures, certifications, m- et cetera, when it comes to businesses.
And I can imagine that maybe there are some massage therapists out there that look down upon, like, the Asian massage day spa type places. And, um, I just... Somebody said something in my... I, I had posted on Threads, and somebody had said something in Threads about that, and I was just like, "I have a problem with that."
Uh, because... So I don't have a problem with it if the people are not, like, properly licensed to touch, right? Like, I, I appreciate the, the need for some sort of regulation and protection of the consumers. Okay. So we're gonna say, we're gonna use the assumption that the people that work there are actual licensed massage therapists or have some sort of license to touch.
Whether they are or not, I don't know. Um, but
But the, um, looking down upon them as less than, uh, because of the style of massage they do, um, or the cost it is, right? They get a lot of business because it's low cost, right? Um, is very ironic to me when the industries as a whole, massage, physical therapy, athletic training, chiropractor, when all of these well-educated, you know, I, I say that in quotes for people that are not watching the podcast.
All these well-educated hands-on practitioners are literally using traditional Chinese medicine tools and techniques on the regular, on a regular basis. Kind of whitewashing them, for lack of a better way to think about it. You know, using cupping, using gua sha, which is the Chinese word for tool-assisted soft tissue.
Um, using acupressure, using, I, I mean, I don't know what, uh, what culture reflexology comes from, but, like, using these practices that come from a lot of Asian medicine, whether it's traditional Chinese medicine or Korean medicine or Japanese medicine, whatever it may be ancient medicine. And then sh- like, it's funny to me that all these practitioners use those tools, but then at the same time, like, shit on these businesses as if they're less than.
And I'm like, "Hmm Just I wanted to throw that out there because, um, I think sometimes we do things like that without sort of like taking a second to think about it and think about like the people on the other side of it and also like appreciate that, you know, even on the flip side, if you wanna s- if you wanna go devil's advocate and be like, "Well, they're not licensed.
They're not licensed massage therapists." I'm like, "Okay How did they learn this craft? How, like, I don't know. I just think it's, like, a interesting, it's an interesting, that dynamic that you see in the world. Um, and I'm also like, a lot of it always comes out of, like, jealousy of, like, or, like, a feeling of, like, they're taking your potential patients or, like, you're making your profession look bad.
I got news for you. There's plenty of r- um, non-Asian massage places full of all different types of people providing massage, providing physical therapy, providing athletic training, providing chiropractic services that are shit and licensed. So that has nothing to do with it, right? So it's like... And I'm also like, especially in the state of California, we live in a state with 39 million, billion, who knows how many illions of people.
I promise there's plenty of business for everybody. And that's also like, yeah, your job as a professional is to advertise yourself of why you are different, what makes you unique. So then when I'm Googling who's in my area that I can pick from, I'm more likely to pick you versus somebody else. Okay? So anyways, those are my kind of like, that's my social stand- b- like, sandbox on it.
It's like, a few sandboxes on this. First one, the social sandba- sandbox of that, the cultural appro- appropriation part of that, um, and, like, the just, like, yeah, professionalism on that. But then two, the actual lesson here of, like, are you listening to your patients? Are you meeting what they want with what you think they need?
And is what you think you need, is it being guided by your ego or actually a thorough assessment? And then also, um, there's this lesson of, like, why reaming on someone's low back when they have back pain might not be helpful. And then the final lesson is, which I'm going back to, which is why I went there in the first place, is this lack of real great work around people's calves.
And ironically enough, Instagram, uh, the algorithm, I love it. After I had this experience, I ha- I was served a Um, reel from MoveU people. You know, they're the guys who, like, paint the anatomy on somebody's body and then, like, show you movements or manual therapy. And they had one on the posterior tib, and he was, like, digging in there, and he was like, "Oh, yeah, it's so painful," and digging in there, and I'm like, "Okay, let's talk about this a little bit too."
So, maybe I'll just, just dive right in there, because I will say too, like, most of the techniques I do on people, because I have implemented a lot of the osteopathic therapy, is, is not that painful. Um, but the lower leg work is still very painful. All of my Navy guys, they're like, when they, when I get in there, even my athletes, um, they ha- they, they're like, love to hate it.
Um, that's what I was looking for is some deep tissue in that area. Um, and, you know, these guys, they describe it as the pain cave. Some of them are like, "Okay, we're ready to go to war." Like, um, most of them at one point are like, "Oh my God, you must have the strongest hands I've ever anyone..." Like, there's a lot of comments about, like, how uncomfortable it is.
Okay, there's some reasons for that. First reason it's uncomfortable, um, number one, the lymphatic piece, which I already shared about, right? Like, how... Do you have a fluid congestion problem? Is your lymph pretty, like, gross and toxic? That could be why it hurts. Number two do you have a fluid problem? If there's fluid in the area, it's gonna take a lot of pressure and a lot of work to get that fluid out.
And then oftentimes these deeper muscles are neurologically tight because they're weak, because they haven't been doing their job a lot of times because the nerves have been entrapped and like strangled within the compartments from the fluid or from the, you know, some, some fascial restrictions, much like the superior extensor retinaculum, like I talked about with my skinny ankles.
So, um, those muscles often like are active trigger points basically, and that, that's can be painful. Um Okay. And then, and then the th- ano- another reason why it can be really painful is because, um, when you're doing deep tissue on this area, there's a lot of nerves down there that are fair- some are superficial, some are deep, but either way, um, most of the time when something's really painful in one specific spot, it's like you're compressing a nerve.
And the com- the nerve, when you're compressing a nerve, it's always gonna hurt. It doesn't feel good. Nerves don't like to be compressed, right? So, um, there's a little bit of like h- and why this really remind me of that is he was like, "Oh yeah, this, you gotta get in there and get in there, and it'll be really painful, and like it's, uh, painful for everybody."
I'm like, "Oh yeah, there's a very specific spot which is often called the posterior tibialis", which is, it's not not the posterior tibialis, but it's like very distinct spot there on the posterior tib, in front of the posterior tib actually. Um, that the tibial nerve is right there and the sural nerve is right on top of it, and you're compressing two nerves and it hurts, and it hurts every time.
And so like you do have to kinda keep in your head the anatomy knowledge of the lower leg so you realize like what feels tight. There's a difference between something feeling tight to your hands and needing the manual therapy, and then pressing on something and it hurts and thinking that the reason it hurts is because it's tight and then pressing on it more.
That's not the reason, right? So, um- There's that. And let's talk about it. Let's talk about this. I think it's best if we talk about the
The sequence I do things, the sequence I do things in the lower leg are very specific in order to address entrapment areas first of the neurovascular structures. So if there's any neurological tightness of the muscles in the areas protecting those neurological structures, it decreases. And so the sequence is like this because I found that it often, um, decreases the discomfort.
Even, even though my guys would argue with you because it's still a pain cave, it actually could be a worse pain cave if I didn't start this way. And do I know this for facts? No, I know this from experience in my own body and on my athletes. And so it seems to have worked over time, so I do it that way.
Um, also it seems to be the sequence of which the body often directs me to. And so, um, it's like I've treated enough people now and I'm using my general listening, local listening, and my inhibition tests using posterior tibialis pulse that I'm like f- seeing these patterns as well. So as I go through the sequence, we'll talk about the anatomy as well.
But just to like a real general reminder of the anatomy of the lower leg, it's in compartments, right? So we have, um... I always kind of explain to my patients, we've got like the main hotdog casing around the lower leg, right? That's superficial fascia that goes all the way around it. Then we have those septums that are like similar to the superficial fascia, but like piece make separate containers.
So you have a separate container for the lateral muscles. You have a separate container for the anterior muscles. You have a separate container for the posterior muscles, two of them. You have a deep container, deep posterior compartment, and a superficial posterior compartment. And it's between those compartments that the neurovascular structures run.
Okay? So
I start, most of the time I start in the anterior and lateral compartments. I let the body tell me where first. It's kind of a trade-off of which one's first, the lateral or the anterior, but they usually are together, and they're very similarly together like anatomically. The anterior compartment is a little bit more lateral.
And, um, the thing here, in the anterior compartment, you're going to visualize, feel the pressure quite a bit, um, see it sometimes on the, like, sheeny-ness of the front of the anterior tib there. The f- the key spots for entrapment are going to be around the proximal tib-fib joint, and then about halfway down the shin, um, along the bone, and then about four fingers above the lateral malleolus, maybe even right below that.
That's that superior extensor retinaculum. So those are the three spots. Also correlates with the lateral compartment, those three spots. S- um, the usually more two spots on the lateral compartment, the proximal one and then the inferior one around the retinaculum. In the proximal tib-fib joint area, there's a few things that can get entrapped there.
Basically, posterior and superior to the joint is where the common peroneal nerve has a branch that comes off of it, the lateral sural nerve. The lateral sural nerve goes down the lateral side of the leg, is con- cutaneous. It can get entrapped, um, uh, behind the ligaments of the tib-fib joint, um, on top of the popliteus muscle, so also within, like, the popliteal, like, part of the capsule, which I'm gonna have a lot of links in this episode.
Joe, I'm gonna have Joe link the, um, episode I did all about the popliteus as well. In this area too, when we get to the level of the, um, neck of the fibula, you've got the, um, common peroneal nerves bifurcating into the deep peroneal nerve and the superficial peroneal nerve. The deep peroneal nerve comes more anterior along sort of the tibia, and then the superficial one stays a little bit more lateral.
But up in that proximal area where they split, um, is a common entrapment area, as well as there's a bunch of little branches in that area that start to branch off and then go to the muscles. There's also a vascular entrapment in that spot. The vascular entrapment, as I said, when there's fluid in the lower extremity, it's gonna be really hard to do deep t- tissue on it because it's gonna give you that Coke can effect, and so hitting this spot just from a vascular sh- standpoint is very helpful.
Down that halfway shin area, it's gonna be a combination of saphenous nerve and that deep peroneal nerve spot. And then down, um, or inf- inferior is gonna be around the extensor retinaculum. This is another common entrapment of the anterior tibial artery and the deep peroneal nerve and, um Super common spot that needs to be worked on.
In this, in these areas, my favorite tool to start with is a silicone cup, dynamic cupping in this area. That added emphasis of the skin lift gets, um, some stimulation of the lymphatic structures and just really helps to clear any of that fluid out of there that might be adding to the pressure problem.
Now, here's an additional spot that sometimes I will hit on people, especially if I already notice they have a fluid problem. I will go back up to the thigh and do the area around the adductor hiatus, medial side of the knee. Okay? And then from there, then I will go ahead and flip them over
Well, actually, before I flip them over, I will also take the cup on the dorsum of their foot. The reason I take the cup onto the dorsum of their foot is it gives a skin lift to the deep peroneal nerve. Why do I care about that? Because it is going to affect a lot of the muscles and the joint into dorsiflexion.
And so again, we're just reflexively sort of freeing up the nerves, so they have, um, can glide and slide and do their job. And then this sometimes will get rid of a lot of the reflexive neurological stiffness in the muscles, which it's gonna be easier for me to do deep tissue on them and less painful when there is not a neurological trigger point type thing for me to break.
So then I'll flip them over on their stomach, and my first thing is going to be sometimes I'll use the cup to get the rest of that adductor hiatus sp- space, posterior, um, popliteal space, and then I will start at the popliteus and the soleus. So if their popliteus is tight, I'm going to suspect that the rest of their deep posterior compartment is going to be tight too, because it, they are all part of the same compartment.
So popliteus is part of the deep posterior compartment, along with flexor hallucis longus, um, posterior tibialis, and flexor digitorum longus. Okay? So from this posterior side, after I work on popliteus or while I'm working on popliteus, I'm also taking a flat hand and going down, um, the A lateral side of the posterior calf hitting the soleus and the peroneals.
The soleus is a big, important one, and I'll have Joe link that, um, episode in the show notes too, because the soleus is often called the peripheral heart. The soleus has a huge venous plexus within it. It's also a huge muscle, um, and can have a lot of stiffness in it. But we really want to, like, kind of almost like...
I don't wanna say milk it, because, like, there is a massage term called milking and it's not that. But, like, I wanna do a lot of flat hand work through that, um, soleus, especially where it attaches to the fibula. And on that note, I'll have Joe link the fibula episode too, because I talk a lot about this relationship of the soleus.
But the soleus and then the peroneus brevis attach onto the fibula right there, and that is, like, a key spot that, um, always has a lot of tension, especially in my Navy guys. Um, so then I continue down the leg. I'll do that a few times, and once I feel the fluid kind of have s- moved out of there, the, a lot of the tension on the soleus has changed quite a bit, then I'll orient myself at the base of their feet, and I'll use my thumb in a flat finger technique where I place my thumb, um, like, the thumb pad and the flat part of my thumb in the lateral sulcus to the lateral side of the Achilles tendon there.
And then I'll use my other hand to block it so I can add pressure to it and protect my thumb joint, and then I will strip out that lateral part of the flexor hallucis longus. That is the flexor hallucis longus. And you'll feel, especially if you get the fluid out of there, you'll feel that it's, like, flexor hallucis longus, and then there's a little change in feeling of fiber direction, 'cause that's right where then you feel the peroneals and the flexor digitorum
I'm like making sure I have this right in my brain No, the peroneals. Nope, now I gotta go. See, this is why, this is why you keep pictures around, people. Um, but I'll work up that lateral side, and then eventually, after I clear that lateral side, naturally my thumb gets kinda taken more medial to the middle as it follows the posterior tib.
So I enter the posterior tib, um, and the, in the posterior, uh, first from the flexor, um
the flexor hallucis longus, and then it transitions again. You fall off the flexor hallucis longus medially towards the middle and its posterior tip right there. So, um
Sorry, I'm looking at a picture on the fly
Yep. Yeah, I was right. Okay. Yeah. Um, so when you go up that lateral side, it starts as flexor hallucis longus, and then it's peroneals kind of the whole time. It's peroneals and flexor hallucis longus all the way up to the edge of the soleus attachment. And then as you kinda come up, you can move medial about halfway up the shin, and that gets you posterior tib.
It's also kind of like a split in the muscles, um, and this is where it tends to be really tender because this is also where things kinda drop in a little deeper and you're really compressing the tibial nerve right here. The tibial nerve travels that whole midline but deep, but when you push really hard and can get really hard, it's gonna almost always be tender right there in that middle spot So don't smash it just to smash it because it's painful, I guess is my lesson there.
That because also in this area is there's a superficial nerve, the sural nerve runs right through there too. Okay? So then after you strip out that area, you'll start to feel your thumb kinda c- wanna come on the medial side. So I switch thumbs, come up the medial side. Now, on the medial side, I am now on the tendon, and then the lower down like that, actually, the muscle of the flexor digitorum longus, and as well as it takes me up flexor digitorum longus and posterior tib together.
Um, that medial lower part, again, around the, um, area where the, on the front side, the extensor retinaculum attached, is a real, an area that gets really congested, full of fluid, and, like, has just... Maybe from all the stagnant fluid that gets in that area just is like the flexor digitorum gets kinda glued down.
And so that is an area that you need to spend a lot of time on, both from the posterior side, like I start, and then eventually, after I feel like I've cleared everything on the posterior side, I'll lay them on their lateral side and get in on the medial side. And on the medial side, you really are getting flexor digitorum longus, posterior tib, and the medial soleus.
The medial soleus here can be very tight, um, up a little bit higher in the calf. And then even all the way at the top of the tibia, you're getting the, um, insertion of the popliteus. So this medial side is really good to hit a lot of the deep posterior compartment. Um, the other, um, thing I'd like to point out, and one of the techniques that I think is, um, underutilized for every body part, is what Philip Beach describes as the kabob method.
You wanna make sure you're, you're doing manual therapy on things in, with the body in supine, prone, right sideline, and left sideline. So again too, even when I'm stripping out that medial side, I go flat hand and I use my thumb in that blocking technique quite a bit. But then I also go back to the posterior and get it from that direction.
Okay? And then if there's time, and I, if I felt like I needed it from that first bit of the anterior side when I got the lateral compartment, and then when they laid them on in prone and got the posterior side of the lateral compartment, if I s- feel... If I felt like a lot of peroneal tension there, then I'll flip them and lie them on the other side, stack their legs so I can really get in around the border of the fibula and get the rest of the peroneal muscles that tend to be kinda covered up by the other things when we're on, in prone or, um, supine.
So that's the sequence. Tried and true Tried and true sequence. That whole sequence actually is, um, a video inside the swelling reduction protocol because like I said at the beginning, this deep tissue on the lower leg is a really important piece of our fluid, um, congestion and like need to do. The great thing is, most of the time after you do a few sessions of this, you only have to keep up with it like once a month, maybe every other week, depending on how much the person is on their legs for.
But it's like at first it's gonna be really painful, but a lot of times it's really painful because of the reflexive stiffness, the neurological tightness, and the pressure from the fluid. So, um, hope that's helpful. Lots of things for Joe to link in the show notes. A lot of episodes often link to swelling reduction protocol course as well.
Um, but full circle story why I started telling you about my massage experience on Monday and, um, yeah. There was a, there was another practitioner on Threads too that was like, "Oh yeah, man, I wish you could see me. Like, I can really get in the deep, the calves," like and then they were like, "Why is that not a thing?
Like, why are so many people not very good at getting the calves?" I'm like, "I don't know," because I tell my athletes if the one bit of manual therapy they get during the month, during the week, this, that, this should be it. This should be it. Our lower legs need support, and when we support the lower legs, the rest of the body feels really good.
Anyways, hope you enjoyed that story-ish and hopefully educational piece for you. But, um- That's it for now. We'll see you next week