Positional Release In-Service

Alyssa Morley, SPT

I. Principles1
a. Indirect approach: moving joint or muscle away from the direction of resistance until
the resistance has released, thereby allowing the muscle to joint or muscle to return to
its original state
b. Reassessment
i. Continually reassessing is key: you need objective findings to monitor the
effectiveness of the release and to determine if further releases or approaches
are necessary
c. Treatment principles1
i. Follow the direction of ease of motion
ii. Move away from pain
iii. If performing a muscular release, approximate the origin and insertion points
iv. Go away from the barrier in the joint
v. Recreate injury position
vi. Adapt release to the unique patient
vii. Soft tissue palpation to monitor tissue changes
viii. Find optimal position where tissues are balanced and relaxed
ix. When returning to resting position, do so slowly and while supporting the body
region/extremity
x. When needed, perform isometrics following releases
1. Perform isometric contraction of the antagonist muscle to further
release tension of the agonist through reciprocal inhibition
1
II. Theories
a. Injury through nociceptors and proprioceptive feedback
i. When a muscle is strained, muscle spindles activate to attempt to prevent
muscle damage
ii. The quick activation of the antagonist increases afferent input more than what
the central nervous system (CNS) predicted
iii. The maximal afferent input to the counterstrained muscle overrides nociceptor
input, which is perceived by the CNS as a strain even though this muscle is in its
shortened position
iv. Bringing the muscle out of the release position slowly is thought to reduce
afferent input to remove the impact of the panic induced response that caused
the shortening of tissues
1. The release position is often that of the original injury
b. Somatomotor System
i. Somatic dysfunction is the result of a high gamma gain
1. An increase in activity in the gamma motoneuron, causing increased
muscle contraction due to increased afferent input and muscle spindle
firing
 ii. Gamma gain results in a disparity between intrafusal and extrafusal fibers due
to contraction, which increases the disparity further and creates more afferent
input into the loop
1. This increases the disparity further, causing contraction past the normal
resting length as the extrafusal fibers contract to quiet the muscle
spindle
iii. Approximating the origin and insertion of the muscle decreases the disparity
between the extra- and intrafusal fibers, decreasing the afferent input into the
gamma loop
III. Deig Positional Release Technique1
a. Dynamic approach
i. Treat what restrictions are found in your patient
ii. Monitor the patient response
iii. Use patient feedback and palpation to guide the release
iv. Often uses approximation of origin and insertion of muscles
1. Positions are often held for 60-90 seconds
2. Can follow-up with isometrics of antagonist to further release tension
through reciprocal inhibition
b. Evaluation Process
i. Through palpation, range of motion, patient history, and functional movements
determine the area of severe impairment and treat first
1. This may clear up secondary areas without individual intervention
2. If secondary areas present, treat the next severe and so on
ii. Both tonic and dynamic muscles will respond and can be treated with positional
release
1. Tonic muscles (upper and middle trapezius, pectoralis major and minor,
and levator scapulae) due to chronicity of maintained postures
a. These muscles also have increased numbers of muscle spindles
which can lead to more dysfunction
2. Dynamic muscles present often with muscle weakness during
examination and require less shortening typically in the positioning
iii. Evaluation and reevaluation are constant
1. Choose 1-2 tests (ROM measure, functional movement, etc) to easily
perform both before and after a release to monitor effectiveness
2. If multiple attempts yield little to no results, reevaluate tissues
a. May not have identified correct target area
b. If patient isn’t relaxed, it may inhibit the process
3. If the restriction is clearing but not abolished, perform the release again,
but no more than 2-3 times
a. You can also adjust the position to greater determine the target
area
b. Perform isometrics to elicit relaxation via reciprocal inhibition
iv. Breaking patterns
1. Highly patterned movements can lead to tissue shortening
 2. Using positional release can reset the system, and allow this pattern of
chronic shortening through repeated motions to be broken
3. Releasing the pattern can also allow for new movement patterns to be
practiced to create more optimal movement patterns
c. Hand placement
i. Palpation hand
1. Monitoring muscle tension in target area
a. A softening of muscle tension, or a reduction in tension
b. May also feel a warming, or the therapeutic pulse that is
bringing blood flow to the area (often faster than patient’s
vascular pulse)
i. Disappearance of this may indicate release is finished
2. Maintain constant pressure throughout positioning
3. Try to keep this hand on the patient at all times
ii. Positioning hand
1. Use this hand to alter positioning of body segments
d. Body positioning
i. Position treatment area in a shortened position
1. Not end range as this can increase afferent input and inhibit the
relaxation response
2. Active contraction by the patient will also inhibit this response
3. Address the anterior-posterior and medial-lateral components of the
position before adding in a rotational component
4. Support the patient’s body with pillows, towel rolls, or your own body
to allow full relaxation of the patient
a. Must also be a position of comfort for the PT as the positions
are held for 60-90 sec typically, usually closer to 90 sec (5- 20
min total is typical)
5. If tension is the result of an injury, positioning reflects position of injury
6. Always bring the patient out of the position slowly and with support
e. Patient Responses
i. While palpating tender points and positioning patient, ask “better, worse, no
different” to help determine target area and involve patient in treatment
1. If they have a tender point, they may state if feels that you have moved
your palpation hand off this point as it releases in this position
ii. Feelings of comfort or relief in position of release
iii. Immediate change in pain level
iv. May feel warmth or tingling
IV. Indications for Positional Release1
a. Patient does not tolerate soft tissue massage or trigger point release
b. Shortened tissue in tonic muscles
c. If using in conjunction with other techniques, perform positional release first
i. Follow this with static stretching and strengthening
ii. Beginning with isometric strengthening can enforce new movement patterns
V. Contraindications for Positional Release3
a. Fracture in the region of application
b. Open wounds
c. Infection
d. Pain during positioning for treatment
VI. Use for Self-Treatment or HEP1
a. Relatively low risk treatment and can be taught to family members
i. Have them perform 3-4 treatments while you observe and provide feedback
b. Difficult to perform to self, due to difficulty positioning without any active movements
i. Prone quadratus lumborum, hand, wrist, or finger releases can be performed by
the patient themselves
VII. Evidence and Research
a. Study with 6 subjects, all with cervicobrachialgia (1 male, 5 female)2
i. Positional release performed to bilateral upper trapezius for 10 session, 30 min
sessions
ii. EMG taken at rest before treatment and after treatment of the initial and final
sessions
iii. All experienced decreased pain, decreased tension shown by EMG, decreased
scores on the McGill Pain Questionnaire
b. Acute torticollis in 3 student athletes, 1 staff member (athletic trainer)4
i. One clinician gathered AROM measurements, another performed the positional
release intervention
1. Subjects completed the Disablement of the Physically Active (DPA) scale
ii. Each subject one 90 second positional release treatment per session until
symptoms resolved
1. Treated most severe tender point first, progressed to next severe
iii. All subjects experienced a minimally clinically important difference in the DPA
after the first treatment
1. ¾ returned to normal AROM following one treatment session
2. After 2 sessions, all subjects had reached their AROM goal
3. Average AROM gain in flexion was 30.5 deg, rotation away from the
tender point by 39 deg, and toward the tender point by 28.5 deg
iv. Pain during movement and palpation abolished in 2 treatments for 3 of the
subjects, those
1. 3 subjects discharged on day 3
2. 1 subject discharged on day 4
c. Positional Release for Tension Headache: Case Report5
i. 47 y/o patient with dull headache for 9 months with cervical trigger points
ii. Psychological, pharmacological, interventions were ineffective and imaging and
nerve conduction testing were both normal
iii. Pain originated in shoulder and neck and radiated into the head; worsened with
static positions
iv. Multiple trigger points found in cervical muscles and upper trapezius bilaterally
 v. Positional releases to these muscles were performed until tension released (5-
20 min)
vi. In two sessions, pain went from 10/10 to 8/10 on the Numeric Pain Index, no
pain after 3rd session
1. No headaches during 8 month follow-up
Resources

1. Deig D. Positional Release Technique: from a Dynamic Systems Perspective. Woburn, MA:
Butterworth-Heinemann; 2001.

2. Kelencz CA, Tarini VA, Amorim CF. Trapezius upper portion trigger points treatment purpose in
positional release therapy with electromyographic analysis. N AM J Med Sci. 2011;3(10):451-
455. doi:10.4297/najms.2011.3451.

3. Baker RR, Nasypany A, Seegmiller JG, Baker JG. Treatment of Acute Torticollis Using Positional Release
Therapy: Part 1. Int J Athl Ther Train. 2013;18(2):34-37. doi:10.1123/ijatt.18.2.34.

4. Baker RR, Nasypany AG, Seegmiller JG, Baker Jundefined. Treatment of acute torticollis using
positional release therapy: Part 2. Int J Athl Ther Train. 2013;18(2):38-43.
doi:10.1123/ijatt.18.2.38.

6. Mohamadi M, Ghanbari A, Jaberi AR. Tension–type–headache treated by positional release therapy: A

case report. Man Therap. 2012;17(5):456-458. doi:10.1016/j.math.2012.04.005.
 l 02 Positional Release Technique

The common flexor tendon arises

Common Flexor Tendon
Flexor Carpi Ulnaris
Palmaris Longus
Flexor Carpi Radialis
from the medial epicondyle of th
humerus. This gives rise to the thre:
superficial flexor muscles of the
forearm shown: flexor carpi radi-
alis, palmaris longus, and flexor
carpi ulnaris. The deeper wrist flex-
ors include flexor digitorum super-
ficialis and profundus and flexor
pollicus longus. The pronator teres
should be considered in the release·
however, it does not flex the wrist.;

Figure 9-17 A: Wrist flexor muscle (anterior view, palmar surface).

The patient is supine. The therapist

sits on the involved side. A general
release of the superficial wrist
flexor group is with 90° or more of
elbow flexion and wrist and finger
flexion. Pronation of the elbow is
included in the release because of
the pronator teres association at the
origin. The deeper wrist and finger
flexors (flexor digitorurn profundus
and flexor pollicis longus-not
shown) can be released with a more
neutral position of the elbow ~d a
focus on wrist and finger flexi~n-
Adjust pronation, supination, radial
and ulnar deviation, and the degree
of flexion to fine tune the release.

Figure 9-17B: Wrist flexor release.

 Trunk and Upper Extremity Muscular Appllcatton
Common Extensor Tendon
Extensor Carpi Radialis Longus
Extensor Carpi Radialis Brevis
Figure 9-18A: Wrist extensor muscle (posterior view).
Figure 9-18B: Wrist extensor release.
103
The common extensor tendon
arises from the lateral epicondyle of
the humerus. This gives rise to the
four wrist extensors shown: exten-
sor carpi radialis brevis, extensor
digitorum, extensor digiti minimi,
and extensor carpi ulnaris. The
extensor carpi radialis longus mus-
cle (also shown) arises from the
humerus just above the common
extensor tendon. The supinator
muscle (not shown) also arises from
a broad origin on the lateral epi-
condyle of the humerus and should
be considered in the release but
does not extend the wrist. 1
The patient is supine. The therapist
sits on the involved side. A general
release of the wrist extensor group
is with elbow supination and wrist
and finger extension. Regarding
flexion and extension, the elbow is
in a neutral position. Adjust supina-
tion, pronation, radial, and ulnar
deviation and the amount of exten-
sion in wrist and fingers to fine tune
the release.
64 Positional Release Technique

The quadratus lumborum ar·

from the iliolumbar ligament ISes
th e ·1· t d . . and
I iac cres an 1s inserted int
the inferior border of the twelft~
rib and to the transverse processes
Quadratus - - - - # I f
Lumborum
of L1 through L4 by four small
tendons. 1

II

Figure 8-2A: Quadratus lumborum (anterior view).

The patient is prone. The therapist

stands on the involved side. The hip
and knee are positioned in flexion,
abduction, and side bending toward
the involved side with the arm slid
under the space between the hip and
table. One hand palpates as the other
hand takes the lower ribs inferior,
the iliac crest superior, or both. You
may need to sacrifice your palpating
hand to address both components at
once. Follow the rotational pattern
through the ribs and pelvis to fine
tune the release. Patients often
report sleeping in a variation of this
release position, which chronicallr
shortens the muscle. Use this posi-
tion for a self-release (see Chapter 5).

Figure 8-2B: Prone quadratus lumborum release.

-
Pelvis and Lower Extrernffles Muscular Appllcaflon 65

The patient lies on the uninvolved

side. The therapist stands either in
front of or behind the patient, sup-
porting the patient's head with a
pillow. Bring the lower ribs inferior
while taking iliac crest superior. The
side bending component happens
automatically in side-lying position
and the rotational pattern is easier
to follow in this position as well.

Figure 8-2C: Side-lying quadratus lumborum release.

80 Positional Release Technique

The gastrocnemius arises by tw

heads, medial and lateral, from th~
respective condyles of the fem
. f Ur,
the postenor emur, and the kn
joint capsule. The tendon joins th:
of the soleus muscle to form the
tendo calcaneus, which inserts int
the middle posterior aspect of th~
Gastrocnemius calcaneus. The soleus arises deep to
IUIA-- Medial Head
r1Ju1111--- Lateral Head the gastrocnemius from the poste-
rior fibula and fibular head and the
medial tibia. The tendon joins that
of the gastrocnemius muscle to
form the tendo calcaneus, which
inserts into the medial posterior
aspect of the calcaneus.1

- -- Calcaneal
Tendon

Calcaneal -------t■._i\
Tendon

Figure 8-13A: Gastrocnemius (left) and soleus (right) (posterior view).

The patient is prone. The therapist

stands on the involved side. The
knee is flexed to about 90". One hand
plantarflexes the ankle through a
hold on the calcaneous, as the other
hand palpates·the muscle. Use layer
palpation for the soleus fibers. Use
rotation of calcaneus with inversion
and eversion to fine tune the release.
Release the calcaneal insertion with
inversion or eversion of the calca·
neous by approximation between
the lower muscle fibers and calca·
neous. Release for the soleus muscle
is the same except that the knee flex·
ion is not always required for the
release.

Figure 8-13B: Gastrocnemlus and soleus release.

 Head and Neck Muscular Application 109

The sternocleidomastoid arises

from two heads: the medial head
originates from the superior ante-
rior surface of the manubrium of
the sternum while the lateral head
originates from the superior and
anterior surfaces of the middle third
of the clavicle. The insertion is into
the lateral surface of the mastoid
process of the temporal bone with a
thin aponeurosis inserting into the
superior nuchal line of the occiput. 1

-~~- Sternocleidomastoid

figure I0-4A: sternocleidomastoid muscle (lateral view).

The patient is supine. The therapist

sits at the head of the table. Take the
neck into flexion with rotation to
~I the opposite side and side bending
to same side. One hand can support
the head in this position while the
other hand palpates. If necessary,
sacrifice the palpating hand to ele-
vate the clavicle.

liau,11 II\_.
-a•s,
1/
· ernocleldomastold release.
r
I
Head and Neck Muscular Application 107
I
I
The trapezius muscle was dis-
cussed in Chapter 9. Its origination
and insertion points are shown in
Figure 9-7A.

~ t - - - Occipital Insertion

Upper Trapezius

Lower Trapezius
.
1
)

Figure 10-3A: Trapezius muscle (posterior view).

The patient is supine. The therapist

sits at the head of the table. Elevate
the scapula by taking the shoulder
or scapula superior and medial
toward the ear. Rotate the neck to
the opposite side, extend and side
bend the neck to the same side. The
hand that supports the neck can
also palpate the involved fibers or
position the arm for scapular eleva-
tion and have a free hand for pal-
pation. The therapist can fine tune
the release through either the neck
or shoulder. If necessary, take the
head off the table to increase the
extension component of the release
(shown). Have the patient slide up
the table while the therapist sup-
ports the neck in the release posi-
tion. After the release, support the
neck as the patient slowly slides
back down on the table.
Figure 10-39.
· Upper trapezlus release.
 Pelvis and Lower ExtremitleS Muscular Appllccrflon
73

The three hamstring muscles are the

lateral biceps femoris and two
medial muscles, semitendinosus and
semimembranosus. The long head
of the biceps femoris arises from the
ischial tuberosity and sacrotuberous
ligament, while the short head arises
from the linea aspera posterior to
the adductor magnus. The biceps
femoris inserts into the fibular head
and the lateral condyle of the tibia.
The semitendinosus arises from the
ischial tuberosity in common with
the biceps femoris and inserts into
Biceps Fernoris the medial aspect of the body of the
Semitendinosus Long Head
tibia and the deep fascia of the leg.
The semimembranosus also arises
semimembranosus Short Head from the proximal aspect of the
ischial tuberosity (separate from the
other two hamstrings) and inserts
into the lateral condyle of the femur,
the fascia of the popliteus muscle, !' ◄
the medial collateral ligament, and
fascia of the leg.1

Figure 8-8A: Hamstring muscles (posterior view).

The patient is prone. The therapist

stands on the involved side. Position
the hip in extension with a pillow, if
tolerated. Keep the hip in neutral
regarding extension, if not tolerated.
Take the hip into external rotation
with knee flexion and external rota-
tion of tibia. Fine tune the release
through the entire kinetic chain via
the ankle.

Figure 8-8
B: Biceps femorls release.
 74 Positional Release Technique

The patient is prone. The therapist

stands on the involved side. Position
the hip in extension with a pillow, if
tolerated. Take the hip into internal
rotation with knee flexion and inter-
nal rotation of tibia. Fine tune the
release through the ankle.

Figure 8-8C: Semitendinosus and semimembranosus release.

The hamstrings also can be treated

effectively with the patient posi-
tioned supine. The therapist sits on
the involved side on a low stool (or
the table is raised). The involved leg
is dropped off the table, below the
knee. From this position, the thera·
pist can palpate the involved area of
the hamstrings with one hand and
adjust the position of the hip, .knee,
and ankle with the other hand. As
previously, external rotation of the
hip is generally used for the lateral
hamstrings and internal rotation for
medial hamstrings. The release
position often is the same for bo~h
medial and lateral hamstrings, in
regard to internal or external rota·
tion of the hip, if the patient has a
significant strain pattern. Then,
only slight variations in a~le
movements will be required to fine
Figure 8-8D: Hamstring releases with the patient In a supine position. tune the release.