A Manual Therapists Guide To Bodywork Utilizing The Ligament System

Created by Arik Gohl Written by Arik Gohl & JoAnn Kovaly

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The material in this manual may not be copied, reproduced or used without the written permission of Arik Gohl at Progressive Manual Therapies and JoAnn Kovaly at Body Shoppe Pilates & Massage

Arrows are used on many of the pictures to depict direction of movement ( ) or isometric contraction ( ).

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Table of Contents

Foundation Module - Most Used Releases

! Ligaments 101A ! ! ! The Muscles!! ! ! The Physiology of MLT! ! Releases At a Glance! ! Pectorals! ! ! ! Levator / Trapezius! ! ! Psoas!! ! ! ! Erector Spinae Group ! ! Forearm Extensors / Supinators! Forearm Flexors / Pronators! ! ! ! ! ! ! ! ! ! ! 6 14 22 ! ! 28 29 - 30 31 32 33 34 - 35 35 - 36

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! ! ! ! ! !

Module One - Feet & Legs !

! ! ! ! ! ! ! ! Releases At a Glance! The Feet! ! ! Anterior Compartment! Quadriceps! ! ! Adductors! ! ! IT Band! ! ! Hamstrings! ! ! Calves! ! ! Ilio-lumbar! ! ! Pelvic Misalignment!! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 39 - 40 ! 40 - 44 45 46 47 48 49 50 52 ! ! 54 ! ! ! ! !

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Module Two - Hips, Spine & Neck

! ! ! ! ! ! ! ! ! ! ! ! ! Releases At a Glance! ! ! Cervical Rebalancing - A First Priority! Quadratus Lumborum! ! ! Spinal Rotators! ! ! ! Side-lying Erector Spinae Group ! ! Abdominals! ! ! ! ! Hip Rotators! ! ! ! ! Hip Extensors! ! ! ! Ligamentum Nuchae! ! ! Cervical Facet Capsuls! ! ! Sternocleoidmastoid - SCM ! ! Scalenes - Anterior & Medial! ! Scalenes - Posterior! ! ! Occipitals & Mandibular! ! ! 57 - 58 59 60 61 62 63 64 65 66 67 68 69 70 71

Module Three - Shoulders & Arms

! ! Releases At a Glance! Rib Mobilization! ! Triceps! ! ! Biceps ! ! ! Serratus Anterior! ! Deltoid - Anterior! ! Supraspinatus! ! Deltoid - Medial ! ! Glenohumoral Release! Subscapularis! ! Infraspinatus!! ! Latisimus Dorsi! ! Rhomboids! ! ! Teres Major & Minor!! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 73 - 74 75 76 77 ! ! 78 79 80 ! ! 81 ! 82 ! ! 83 84 85 ! ! 86 87 ! !

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! ! ! ! ! ! ! ! ! !

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Integration - The MLT Approach to Pathologies

! ! ! ! ! ! ! ! ! ! ! Session Overview! ! ! ! Typical First Session Releases! ! Cervical Pain / TMJD / Whiplash! ! Thoracic Outlet Syndrome !! ! Epicondylitis! ! ! ! ! Carpal Tunnel Syndrome! ! ! Adhesive Capsulitis - Frozen Shoulder! Low Back / Sciatica / SI Joint ! ! Plantar Fascitis ! ! ! ! Which Ligament Do I Use?! ! Index - Find that Release!! ! ! 88 89 90 91 91 91 92 93 94 ! 95 96

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Foundation Module
Ligaments 101A The Background & Physiology of Manual Ligament Therapy Protocol Steps Applications of Manual Ligament Therapy Considerations & Contraindications Foundation Releases At a Glance The Pectorals - Minor & Major The Trapezius & Levator The Psoas The Erector Spinae Group The Forearm Extensors & Supinators The Forearm Flexors & Pronators

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Ligaments 101A
Ligament: From Latin, means strong band or tie of white brous connective tissue that joins bones to other bones or to cartilage in the joint areas. The bundles of collagenous bers that form ligaments tend to be pliable but not elastic. They permit freedom of movement within a certain range while holding the attached bones rmly in place. Ligaments have very little blood / oxygen supply.

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Ligament fun facts... There are 900 ligaments in the human body Including the retinaculum there are 107 ligaments in the human foot There are 123 ligaments in the human hand Ligaments support many internal organs including the liver, kidneys and spleen Ligament hysteresis in the Facet Joint Capsule a major factor in whiplash pain

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The Muscles

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Muscle Fun Facts:

There are over 600 voluntary / skeletal muscles in the human body Muscles are made of microscopic laments which contract and slide over each other causing the muscles to shorten and therefore contract. Muscles can only contract, they do not lengthen unless an opposing muscle contracts and causes the rst muscle to lengthen. There are over 30 facial muscles Eye muscles are the busiest muscles - scientists estimate they move more than 100,000 times a day The largest muscle is the Gluteus Maximus Some of the strongest muscles are the Soleus, the Masseter and the tongue. The tongue only has one origin / insertion point Muscle with the longest name: Levatorlabiisuperiorisalaequenasi (connects the upper lip and the wing of the nose)

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The Background and Origination of Manual Ligament Therapy

Manual Ligament Therapy was inspired from the Logan Basic T e c h n i q u e , discovered by Dr. Hugh B. Logan in the early 1900s. Dr. Logan is considered to be one of the forefathers of modern chiropractic medicine and the technique is still taught today. The Logan Basic Technique utilizes directional pressure to the Sacrotuberous ligament, reducing the tone in surrounding muscle tissues that are not directly connected to the ligament, specically the lumbar and thoracic para-spinal muscles. This technique is still used by the chiropractic community and is very useful for patients suffering from Scoliosis. No documentation existed, until now, of using a similar technique with ligaments to release hypertonic muscles. Arik Gohl, the creator of the MLT technique, expanded the unexplored use of ligaments for releasing hypertonic muscles and in doing so created an entire new bodywork modality. Manual Ligament Therapy is Federally Trademarked and is Patent Pending.

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Ligaments Redefined
For the past several hundred years, medical science has regarded ligaments primary role in the body as being tissue attachments between the bones and little else. Proprioceptive information in the body was attributed to muscles, tendons and skin. In the last twenty ve years, federally funded studies have uncovered a vital element in the cause of musculo-skeletal dysfunction. Ligaments not only contribute proprioceptively to how the body moves, but actually may have more mechanoreceptor feedback to the brain via the CNS than the muscles, tendons and skin. They contain Runi Corpuscles (similar to Golgi) and free nerve endings all of which supply the CNS and Thalamus with a signicant amount of proprioceptive information. The CNS uses the ligaments to monitor and deliver not only proprioceptive data, but also to inuence muscular tonicity based on ligament perceived inuences such as injury and weight stress.

The ligaments were considered, over several centuries, as the major restraints of the joints, keeping the associated bones in position and preventing instability, e.g. their separation from each other and / or malalignment. This project, conducted over 25 years, presents the following hypothesis: 1. Ligaments are also major sensory organs, capable of monitoring relevant kinesthetic and proprioceptive data. 2. Excitatory and inhibitory reex arcs from sensory organs with the ligaments recruit / de-recruit the musculature to participate in maintaining joint stability as needed by he movement type performed. 3. The synergy of the ligament and associated musculature allocates prominent role for muscles in maintaining joint stability. M. Solomonow, PhD. MD, (hon)Professor, Orthopedic Surgery Director, Bioengineering Division & Musculoskeletal Disorders Research Lab, University of Colorado, Denver

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Ligament afferents may contribute to joint stability, muscle coordination and proprioception through direct polysynaptic reex effects onto ascending pathways and skeletomotoneurones, and / or indirectly via reex actions on the gamma-muscle spindle system. Theoretical and experimental evidence indicate that ligament afferents, together with afferents from other joint structures, muscles and the skin, provide the CNS with information on movements and posture through ensemble coding mechanisms, rather than via modality specic private pathways. Sjolander, 2002

Afferent is the information of the sensory source / structure to the CNS. Efferent is the information sent back to the structure via the CNS. Gamma muscle-spindle system is the system encompassing the interaction between the Gamma motor-neurons and the muscle spindles in which the Gamma motor-neurons supply information on degree of stretch to the intrafusal bers within the muscle spindles.

In ligament terminology, the word creep is used in a deconstructive nature and in a constructive nature. When used in a deconstructive nature, it is an expression of micro-damage within the collagen ber structures of the tissue, triggering an inammatory response. Used in a constructive nature or as an expression of therapeutic value, it describes the traction of ligament tissue.

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Injury - The Chain of Events

1. 2. 3. Occurrence of injury - injury can be either sudden acute or repetitive stress induced. There is ligament creep caused by hysteresis (micro tearing of the tissue). Mechanoreceptors (Runi Corpuscles) within the ligaments send afferent signals to the CNS instigating muscle splinting to protect the joint. This is done by direct and indirect ligamentous inuence on intrafusal bers via the gamma muscle spindle system. The intrafusal bers are then signaled to increase the level of muscle hypertonicity, shortening of the muscles, to protect the joint. Due to the lack of general nutritional circulation in ligaments, both active and latent trigger-points form. Latent trigger-points cause the joint dysfunction. Once the injury has abated and / or resolved, the latent trigger-points continue to thrive in the nutrient scarce tissues of the ligaments. These latent trigger-points continue to cause ligament mechanoreceptors to send incorrect information to the CNS, falsely signaling that the injury still exists. This, in turn, continues to signal to the intrafusal bers to continue ongoing muscle hypertonicity in otherwise healthy muscle tissue.

4. 5. 6.

What Causes Ligaments to Respond This Way?

Hypothesis:

When a ligament is damaged, the muscles surrounding the compromised area become hypertonic in a guarding pattern.

Hypothesis Test:
Case subjects performed knee exion / extension before and after static loads were applied to the proximal tibia for ten minutes. Using electromyography (measurements of muscular tone taken with electronic sensors placed on specic muscular structures) to measure tonicity, it was found that in extension, quadriceps electromyography increased signicantly after anterior cruciate ligament creep. Chu, 2003

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How Does Manual Ligament Therapy Work?

(Just like pressing control / alt / deleteon your computer)

A. Damaged and dysfunctional ligaments have trigger-points caused by creep and hysteresis. B. Direct pressure to the ligament trigger point utilizes a neurological feedback effect to reduce muscular tone as well as to increase ligament tissue quality. C. If ligaments are treated along with muscle and tendon tissues, most musculo-skeletal pathologies will resolve quicker and with a higher quality of function. When a patient continues to re-injure or a slow response to conventional therapies is observed, Manual Ligament Therapy will provide dramatic results. Until now, there have been no documented manual therapies utilizing the treatment of ligaments in this manner. MLT is the rst manual therapy technique of its kind.

MLT Protocol Steps

Step One: The practitioner palpates and / or tests the muscle groups for hypertonicity and range of motion. Step Two: Upon locating hypertonic muscles, the limb is positioned in a manner that shortens (as much as possible) the muscle or muscle group to be treated with MLT. Step Three: Locate the ligament that has been determined, within the protocol, to provide the most inuence for the muscle group to be released. Step Four: Apply light to mild static pressure (2-3 pounds per square inch) to the ligament, usually in a cross ber direction. Using a kitchen food scale will help to understand how much 2-3 pounds of pressure per square inch is. While applying ligament pressure, the practitioner provides a point of resistance for the patient to perform an isometric contraction of the antagonist muscle for 4-6 seconds, about the length of one long breath. The limb is them re-positioned followed by more antagonist contractions. Each repositioning of the limb affects different bers within the targeted muscle. Step Five: Lengthen the muscle and retest for hypertonicity and ROM.
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Patients should experience an 85-90% reduction of tension, tenderness and dysfunction. If this is not the case, the process should be repeated along with a change in angle of pressure. If a release of 80-95% is not seen within two to three attempts, check to verify that the ligaments were properly located. Manual Ligament Therapy results will be less if there are other pathologies involving the central nervous system or there are psychological issues involved. MLT should not be attempted again with that muscle until further testing has been carried out.

Applications of Manual Ligament Therapy

For Chronic and Subacute conditions of increased muscle hypertonicity. A useful tool for any clinician who has a patient presenting unresolved muscle tone. This includes Fibromyalgia and other Chronic Pain Disorders. Can be used at onset of grade-1 and grade-2 muscle strain. MLT has been shown to provide marked improvement in healing time compared to rest, ice and elevation alone.

Considerations & Contraindications

In the event of a partial or full tear of the ligament, treatment should not take place until the patient has clearance from a physician. Splinting of the joint by the surrounding musculature is productive and needed to prevent further damage to the ligament. For acute ligament sprain and swelling, treatment should be reserved for the surrounding tissues. For pregnant patients, when treating areas such as the heel, ankle region and the low back region, reduced pressure and application times should be observed due to correlation with labor inducing trigger points. Due to the prolic involvement of ligaments in supporting internal organs, the potential for utilizing Manual Ligament Therapy to treat organ dysfunction exists.

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Releases at a Glance - The Foundation Releases

Muscle: Pectorial Minor Ligament: Coracoacromial ! / Sternoclavicular Isometric: Scapular Retraction

Muscle: Ligament: Isometric:

Pectoral Major Coracoacromail Scapular Retraction

Muscle: Ligament: Isometric:

Levator / Trapezius Sternoclavicular Scapular Depression

Muscle: Ligament: Isometric:

Psoas SI Hip Extension

Muscles: Ligament: Isometric:

ESGs SI Spinal Flexion

Muscle: Ligament: Isometric:

Forearm Extensors Ulnar Collateral Forearm Flexion

Muscle: Supinator Ligament: Ulnar Collateral Isometric: Pronation

Muscle: Forearm Flexors Ligament: Radial Collateral for student use only - not for reprint or sale~ Isometric:~Intended Forearm Extension

Muscle: Pronators Ligament: Radial Collateral page 28 Isometric: Supination

Muscle: Pectorals

Ligament: Coracoacromial & Sternoclavicular

Isometric: Scapula Retraction

Protocol: Test muscle for hypertonicity / ROM Patient supine with shoulder passively rolled forward and their elbow at their side Therapist stands on opposite side of the patients Pectorals to be released Therapist superior hand on Coracoacromial Ligament Therapists inferior hand on patients elbow Apply light lateral pressure to CA Ligament Isometric contraction for Pectoral Minor: Shoulder abduction Shoulder extension Continue onto the Pectoral Major Release

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Pectorals: Continued

Protocol: Passively bring patients exed elbow across the lower torso to end range isometric contraction for Pectoral Major Shoulder Abduction in Three Positions: Lower Torso - affects upper Pectoral bers Mid Torso - affects mid Pectoral bers Chin Height - affects lower Pectoral bers Finish with medial pressure to the Sternoclavicular ligament Recheck muscle for hypertonicity / ROM

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Muscle: Levator & Trapezius

Ligament: Sternoclavicular

Isometric: Scapular depression

Protocol: Test muscle hypertonicity with palpation or ROM Patient is side-lying with neck in extension Therapist stands either in front or in back of patient with their inferior hand under the patients arm Passively shorten muscle by elevating their shoulder to their ear. Bring shoulder as posterior as possible. Apply light superior directional pressure to the Sternoclavicular Ligament Isometric contraction: patient to lightly depress their arm to their feet Repeat one to two times each time passively elevating the shoulder more Protocol - Upper Trapezius Protocol same as above with patient applying two to three times the amount of pressure Retest muscle hypertonicity / ROM

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Muscle: Psoas

Ligament: SI

Isometric: Hip Extension

Protocol: Check patients ROM by testing hip extension Patient supine with leg in frog position Therapist stands on same side as muscle being released - with their thigh placed to secure the patients knee Locate the SI Ligament - apply light superior / medial pressure Have patient engage pelvic oor Isometric contraction: Patient presses leg into hip extension from three positions Hip Abduction / Flexion - 90 degrees - affects inferior bers Hip Abduction / Flexion - 45 degrees - affects low back bers Hip / knee almost fully extended - affects thoracic bers Repeat protocol on other side Recheck patient ROM

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Muscle: Erector Spinae Group

Ligament: SI Ligament

Isometric: Spinal Flexion

Protocol: Palpate for muscle hypertonicity. Alway perform MLT release for Psoas before releasing the ESGs. Patient supine with their head in the cradle and arms at their side Locate the base of the SI Ligament with inferior hand Therapists superior hand is on patients upper ESG on the same side as muscle releasing Locate the SI Ligament apply superior / medial pressure Isometric contraction: Three positions Neck Flexion - ngers inferior on ligament Thoracic Flexion - rolling shoulders into the table move ngers a little superior on ligament therapist superior hand on ESGs to be released Lumbar Flexion - have patient lift abdominals and pelvic oor up into therapist hand - again, therapist moves ngers a little superior and lateral on the SI Ligament Retest for muscle hypertonicity

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Muscles: Forearm Extensors

Ligament: Ulnar Collateral

Isometric: Wrist Flexion

Protocol: Palpate muscles for hypertonicity - check ROM in pronation / supination Therapist stands on same side of patient as muscle being released Therapist superior hand on patients hand - therapist inferior hand on ligament Extend wrist to end range - ngers pointing toward patients chin - therapist hand on patient nger tips for isometric Locate the Ulnar Collateral Ligament just barely off the Olecranon Process medial pressure Isometric Contraction - Wrist Flexion in Three Positions to affect all bers of the Extensors Note: If patient suffers from misalignment of the cervical vertebrae, a noticeable trigger-point will often exist at the radial epicondyle. This misalignment can cause the re-occurrence of this trigger-point within a short time after MLT treatment due to cervicogenic neuropathy of the radial nerve.

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Muscle to Release: Forearm Supinator

Ligament: Ulnar Collateral

Isometric: Pronation

Protocol: This follows seamlessly after the forearm extensor release Patients arm rotated into full supination Therapist superior ngers on the palm - hand supporting the wrist Therapist inferior hand on the Ulnar Collateral Ligament Isometric Contraction: Forearm Pronation Chase the stretch two to three times Retest muscle hypertonicity / ROM

Muscle to Release: Forearm Pronators

Ligament: Radial Collateral

Isometric: Supination

Protocol: This release is to follow the forearm exor protocol Patients arm rotated into full pronation Therapists inferior hand holding the palm / wrist - (be sure to support the wrist so there is no joint movement during isometric contraction) Therapists superior hand on the Radial Collateral Ligament - lateral pressure Isometric Contraction: Forearm Supination Chase the stretch two to three times Retest for muscle hypertonicity / ROM
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Muscles: Forearm Flexors

Ligament: Radial Collateral

Isometric: Wrist Extension

Protocol: Test for muscle hypertonicity / ROM Therapist inferior hand on patients hand - their ngers and thumb curled into a tight st - thumb tucked in Their knuckles pointed toward their chin Therapist superior ngers on Radial Collateral Ligament - pressure is lateral Isometric Contraction: Wrist Extension in Three Positions to Affect all Fibers of the Forearm Flexors Knuckle to chin Knuckle to chest Knuckle to heel Retest for muscle hypertonicity / ROM

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