Koda Integrative Therapy Group

Therapeutic Massage and Health Partners for Recovery and Performance

Filtering by Tag: #ART

Knee Pain, Science and Your Clients

Clients in pain have expectations that their therapist will be able to make the discomfort go away. Over the past years my clients have been talking about the different kinds of overuse injuries that can occur at the knee. With this blog post, I want to give you a better visual of how they are all related to each other, and why knee pain is different -depending on where it is. Let’s break our knee down into three different zones:

1) central and front; 2) outside-lateral edge; 3) inside-medial edge

Think of each zone one as the beginning of problems in the knee - each is related to the different functions of the muscles found most in this area. Zone 1 - includes the front of the knee, and becomes painful when it gets overworked and breaks down (or tightens up) when the other muscles attached into the patellofemoral joint (knee) do not strongly support the movements and actions of the back of the leg. Injuries that occur here are because of mobility restrictions and muscle imbalances in the knee itself.

By comparison, zones two and three are the continuations of problems in the knee from the hip. Instead of the front of the knee breaking down, the body finds a way to compensate around those restrictions and imbalances, either because the hip or the foot is out of balance. This occurs by rotating the the thigh in as shown by the orange arrows - think of compensations and patterns of imbalance - which move the force away from the knee and hip joints. When that rotation is present, new areas become vulnerable to breaking down. When they do, not only do you have to fix the rotation, you also have to go back and fix those underlying problems.

When sports medicine evaluated participants for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters in a 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses identified significant differences between those subjects who developed patellofemoral pain and those who did not: based on quadriceps and gastrocnemius muscle flexibility e,plosive strength -or lack, thumb-forearm mobility, reflex response time of the vastus medialis obliquus and vastus lateralis muscles, and the psychological parameter of seeking social support. Only a shortened quadriceps muscle (1), an altered vastus medialis obliquus muscle (2) reflex response time, a decreased explosive strength capacity (3) and a hypermobile patella (4) had a significant impact on the the incidence of patellofemoral pain.

Let’s take a closer look - Zone 1

(green/front of the leg + knee cap itself)

As you can see in the picture above, zone 1 is the middle strip. It gets top billing for a few reasons. The first is that problems here typically involve less compensation.

Injuries in this area (muscles involved - Rectus Femoris, Vastus Intermedius, ?)

  • Quad muscle strain

  • Quad tendonitis (inflammation in tendon above the knee cap)

  • Patellar tendonitis (inflammation in tendon below the knee cap)

Likely cause:

  • Loss of knee extension (your ability to full straighten your knee out) - this is a musculoskeletal issue!

    • This can be due to tight calf muscles (especially the gastroc), hamstrings/adductors, and glutes.

    • These restrictions can lead to mobility losses in the joints as well (ankle, knee and hip)

  • Strength imbalance between the front and back of the leg resulting in the front of the leg getting overloaded.

  • A combination of both.

Treatment goals:

  • Restore mobility to the joints and muscles. Either through muscle release and stretching.

  • Balance strength out so that the front of the knee is not getting overloaded.

Zone 2 (blue, outside of the leg/knee)

This area of the knee is the outside of the leg and knee where the lateral quads and IT Band are located. These muscles involved are the lateral quads - Vastus Lateralis, TFL. Injuries in this area mean that you are compensating by rotating the upper leg in. This can create friction/inflammation between the IT Band and the lateral quad or down along the outside of the knee cap where the band attaches.

Injuries in this area:

  • IT Band Friction Syndrome (either at lower attachment outside of the knee cap or up higher in thigh between the band and lateral quad muscle beneath it)

Likely cause:

  • Whenever there is compensation, you need to think of the causes in layers that need to be addressed one by one.

    • The first restriction is the rotation. The inner thigh muscles (pes anserine, inner hamstrings/adductors) get stuck in a short position while the IT Band and outer hip get stuck in a stretched out/long position.

    • The second restrictions to consider are what that rotation is trying to make up for. Most likely, this means that the knee has lost its ability to fully extend. Sound familiar? These are the same restrictions we talked about above in the front of the knee.

Treatment goals:

  • Get rid of the rotation so that the leg is straight.

  • Restore mobility to the knee itself.

  • Balance out strength so that the whole leg is working.

Zone 3 (purple, inside of the knee)

This area of the knee is along the inside of the knee where the pes anserine is located - it includes the Adductors, and balances the other muscles of the thigh during movement. Injuries in this area mean that you are compensating by rotating the upper leg in. This can create friction/inflammation between the the muscles stuck in that short/tight position along the inner knee.

Injuries in this area:

  • Patellofemoral Syndrome (PFS)

  • Pes Anserine Bursitis/Tendinopathy

Likely cause:

  • Whenever there is compensation, you need to think of the causes in layers that need to be addressed one by one.

    • The first restriction is the rotation. The inner thigh muscles (pes anserine, inner hamstrings/adductors) get stuck in a short position while the IT Band and outer hip get stuck in a stretched out/long position.

    • The second restrictions to consider are what that rotation is trying to make up for. Most likely, this means that the knee has lost its ability to fully extend. Sound familiar? These are the same restrictions we talked about above in the front of the knee.

Treatment goals:

  • Get rid of the rotation so that the leg is straight.

  • Restore mobility to the knee itself.

  • Balance out strength so that the whole leg is working.

 

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Why Active Release Techniques is Different (from massage)

Most of my friends thought that adding Active Release Techniques to our services was crazy. For one it was developed by Chiropractors...who are not typically as comfortable with soft tissue dysfunction as massage therapists. Fortunately for my clients, they have benefited from my lack of attention to 'background noise.'

When looking at Active Release Techniques (ART) treatment I was immediately drawn to the philosophy - and the ability to sufficiently define and 'diagnose' soft tissue dysfunction. Active Release is a hands-on, touch based and case management process that allows a practitioner to treat soft tissue injuries and provide preventative care. The soft tissue that I deal with primarily refers to muscles, tendons and/or ligaments, fascia and nerves. The specific injuries that it can be addressed through these treatments include repetitive strains, adhesions, tissue hypoxia and/or Delayed Onset Muscle Soreness (DOMS), and finally joint dysfunctions.

ART was initially developed like other forms of Myofascial Release - in fact that was one of the original names. However, the technique has evolved and been redefined due to it's inclusion of peripheral nerve entrapment, and a lot of 'resistant muscular issues' can be treated more effectively when including nerves in the manual treatments.

Although ART gained attention as part of the Ironman Triathalon treatment process for Hawaii athletes (1995) it is now a fundamental treatment process for the preparation for all Ironman events throughout the world, as well as other professional and collegiate sports competitions. Stanford University is one of the current organizations that uses it for all Athletes during season.

Additional applications for ART in work-place injuries started even earlier (1990). Today ART is approved by OSHA (Occupational Safety and Health Agency) as an efficient treatment for preventative care for repetitive motion injuries, and cumulative trauma disorder (CTD) throughout the United States.

Active Release appointments are different at four specific levels:

1) tissue position without tension, passive patient

2) tissue position with tension, passive patient

3) tissue lengthened after contact, passive patient

4) tissue lengthened after contact, passive patient.

Like most massage it is most effective with correct anatomy and kinesiology of the muscles treated. Appointments tend to be shorter (20 min on average), as there are only 3-5 passes required to affect change on the muscle. Over a week there can be as many as 3 appointments, which is strictly based on the tolerance of the patient. Benefits can be seen immediately.

Finally, the use and application of ART as part of training and recovery cycles is remarkable. Better posture and support along with movement retraining and corrective exercise instruction can bring great dividends. Learning to relax musculature after and between repetitions is key to reducing the total insult (breakdown) of issues. Correct movement and postural alignment is fundamental to reducing the re-occurrence of lesions and soft tissue adhesion.

So...now you know the secret, it integrates massage, corrective exercise techniques (PT) and postural alignment in all treatments without creating the core change to the proprioception of the body (ie. body awareness - where Awareness of the body and its relationship with the surrounding environment is mediated by sensation) created by deep tissue massage.

 

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