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Studies have shown that some of the most commonly encountered injuries in wilderness medicine are musculoskeletal (MSK) or soft tissue. According to one study in the Western Journal of Medicine, lower limbs (38%) and head and neck (25%) injuries account for over half of soft tissue injuries in wilderness settings. As a provider participating in wilderness medicine, it is crucial to have multiple options for treating these common injuries. Osteopathic Manipulative Medicine (OMM) is a long-studied set of hands-on diagnostic and treatment techniques that offer many simple solutions to provide relief from MSK and soft tissue injuries. These manipulations aim to restore normal body mechanics and facilitate a return to activity by relieving pain, alleviating muscle spasms, and improving blood flow and mobility. Since many of the techniques can be done anywhere and require little more than two hands, they are a great addition to the treatment strategy in an austere environment. Here, we discuss a few common backcountry injuries and their indicated osteopathic treatments. Any time a patient is treated with OMM, they should also be encouraged to hydrate well and use NSAIDs as an adjunct as needed. It is important to note that these techniques should not be performed for life-threatening or severe injuries such as fractures and should never delay definitive treatment for severe injuries.

Plantar fasciitis

Plantar fasciitis is one of the most common causes of foot pain in adults. It is a common, chronic affliction in the backcountry and can cause considerable discomfort and may even result in gait alterations, decreased mobility, and difficulties with evacuations. Counterstrain is a technique within OMM performed to provide slack to the fascia to promote relaxation and spontaneous tissue release. To perform counterstrain for plantar fasciitis, first have your patient lay face-down (prone). Bend the knee on the affected side to 90° and allow the foot to relax. On the plantar surface of the foot, palpate the anterior aspect of the calcaneus. Find the most tender area and monitor this point with a finger throughout the entire treatment (Figure A). Establish with the patient that this starting point is a 10/10 pain. (The patient does not need to be in 10/10 pain, this is only a reference point for treatment). Grasp the heel in one hand while monitoring the point. Hold the forefoot in the other hand and fold the toes and forefoot toward the heel (Figure B). Press on the tender point again and ask the patient to rate the pain. Adjust the amount of flexion until the pain has decreased to 3/10 or less and hold the position for 90 seconds while monitoring the point. After 90 seconds, release the foot back to neutral and reassess the point for improvement. This technique can be repeated several times until the patient reports adequate pain relief. Absolute contraindications to this treatment include patient inability to tolerate appropriate positioning or recent severe injury or sprain that would be aggravated or worsened by the position.

A. Left thumb marks the forefoot position of the tenderpoint for the duration of treatment.

B. Hands grasp and fold the heel and forefoot towards each other to alleviate pain while monitoring the tenderpoint. Hold for 90 seconds.

Trapezius Spasm and Suboccipital Release

Head and neck injuries account for over 25% of all wilderness morbidity and headaches make up 19% of nonfatal injury complaints. Both are associated with many outdoor sports. Neck pain and headaches can often be attributed to muscle hypertonicity or spasm. Treating hypertonic muscles and muscular spasms can be achieved through inhibitory pressure. In this technique, steady pressure is applied to tight or painful tissue to promote relaxation and decrease pain levels. To apply this technique to a spastic trapezius, begin with the patient on their back (supine). Grasp the trapezius just lateral to the base of the neck (Figure C) in the area that feels most like a “rope” structure in the muscle. Hold the muscle between the thumb and fingers (Figure D). Apply pressure, asking the patient what he or she can tolerate (Figure E). The treatment may be uncomfortable but should not be unbearable. Hold pressure and wait to feel changes to the tissue such as warmth or softening; this can take several minutes. Contraindications to this treatment would be inability to tolerate or recent trauma resulting in bony instability near the trapezius

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C. Hand positioning used to grasp the trapezius.

D. The hand position is lateral to the neck and can be anywhere along the trapezius.

E. Apply steady pressure with the patient relaxed.

Inhibitory pressure can also be applied to treat upper neck spasms and tension headaches using a technique known as suboccipital release. Indications for this include neck or head muscle tension, spasms, or restriction of passive rotation at the joint between the head and neck. To perform the technique, have the patient lay supine and instruct them to relax the head and neck. Find the space between the base of the head and the neck. This space is called the occipito-atlantal joint (OA). Curve your hands into a cup-shape and place your fingertips in this space (Figure F). Keep your hands there while applying pressure upwards (anterior) and towards the top of the head (superior) (Figure G). Allow the patient’s head to rest into your fingertips as you feel the muscles begin to relax (sometimes described as a “melting sensation”). You can have the patient take deep breaths to facilitate the relaxation as you are performing the technique. You can either keep your hands in this position statically or you can dynamically apply the forces in a repetitive rhythmic motion depending on patient preference. Subjective improvement after the treatment includes a decrease in pain. Objective improvements include decreased muscle tension and increased passive and active motion at the joint. Contraindications to this technique include localized severe trauma, infection over the OA joint, or inability of the patient to cooperate with proper positioning.

 

F. Curve hands and place fingertips in the space just below the base of the skull.

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G. Apply gentle pressure upwards and back towards you (anterior and superior).

 

Lumbar Myofascial Release (Kneading)

Low back pain is common in backcountry enthusiasts and can be detrimental to finishing a trek, climb, ski day, or just make outdoor experiences generally less enjoyable. With the use of a simple OMM technique for the appropriate indications, you or your patient can get back to activity with improved functionality. Myofascial release alleviates tension between the muscles and the connective tissue of the lower back. To use this technique, have the patient lie prone on a comfortable surface. Position yourself on the opposite side of the body part you are treating, so you are reaching across the patient’s back. Locate the spine and position the hand closest to the patient’s head just lateral to the spine. To get leverage and to shorten and relax the tissues of the low back, grasp the patient’s pelvis at the ASIS (anterior superior iliac spine) with the hand closest to the patient’s feet (Figure H). As if kneading dough, push the heel of your hand from the paraspinal muscles laterally and towards the mat while pulling your other hand in the opposite directions (Figure I). Continue this until the paraspinal muscles of the lower back relax and the patient begins to feel less tense. Attempt to perform the kneading during patient exhalation while they are taking deep breaths to facilitate better muscle relaxation. Do not use this technique if there is any concern for fracture, local wound, or inability of the patient to tolerate

H. From the beginning position shown here, knead laterally with the palm of your hand while gently pulling the pelvis towards you with the other hand. Repeat motion.

I. Ending position

Inhibitory pressure can also be applied to treat upper neck spasms and tension headaches using a technique known as suboccipital release. Indications for this include neck or head muscle tension, spasms, or restriction of passive rotation at the joint between the head and neck. To perform the technique, have the patient lay supine and instruct them to relax the head and neck. Find the space between the base of the head and the neck. This space is called the occipito-atlantal joint (OA). Curve your hands into a cup-shape and place your fingertips in this space (Figure F). Keep your hands there while applying pressure upwards (anterior) and towards the top of the head (superior) (Figure G). Allow the patient’s head to rest into your fingertips as you feel the muscles begin to relax (sometimes described as a “melting sensation”). You can have the patient take deep breaths to facilitate the relaxation as you are performing the technique. You can either keep your hands in this position statically or you can dynamically apply the forces in a repetitive rhythmic motion depending on patient preference. Subjective improvement after the treatment includes a decrease in pain. Objective improvements include decreased muscle tension and increased passive and active motion at the joint. Contraindications to this technique include localized severe trauma, infection over the OA joint, or inability of the patient to cooperate with proper positioning.

 

F. Curve hands and place fingertips in the space just below the base of the skull.

Conclusion

This is a very brief overview of some common techniques that can be used to enhance treatment of MSK and soft tissue injuries in the wilderness. OMT provides an alternative, simple, non-resource intensive (just your hands and a mat!) treatment option with few contraindications for some of the most common ailments in wilderness settings. Successful treatment with these techniques takes practice so we encourage you become comfortable with the techniques prior to use. There exist multiple online resources for osteopathic- and non-osteopathic providers alike to become more familiar with the subtleties, research, and pathophysiology behind these techniques and more.

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