Koda Integrative Therapy Group

Therapeutic Massage and Health Partners for Recovery and Performance

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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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Physiotherapy vs. Neuromuscular Massage

Physiotherapy is a health profession concerned with helping to restore physical well-being to people who are suffering from an injury, pain or disability. Using knowledge from our extensive scientific and clinical background (Masters or Doctorate of Physical Therapy), and they are Chartered Physiotherapists or managed by a professional association. They can assess, diagnose and treat conditions and illnesses that affect people of all ages and social groups.

Chartered Physiotherapists, or Physical Therapists, use manual therapy including manipulation, mobilization and myofascial release as well as complementary modalities including electrotherapy and Medical Acupuncture & Dry Needling. In recent years pain management education and counselling techniques have also become integral in most treatment programs. The Chartered Physiotherapist also utilizes prescriptive exercise as a rehabilitative tool to help patients achieve their full potential. While traditionally, Physiotherapy and/or Physical Therapy was regarded as rehabilitative and mainly hospital-based, the profession has expanded greatly into other health care areas. 

Neuromuscular therapy (NMT) is a specialized form of manual therapy that integrates specific massage techniques, flexibility stretching and home care practices to eliminate the causes of neuromuscular pain. NMT theory explains how injury, trauma and other factors can destabilize nerve transmission, making the body vulnerable to pain and dysfunction.

Through neuromuscular therapy training, students learn to manipulate muscles, tendons and connective tissue to restore balance to the central nervous system.

Neuromuscular therapy examines five elements that cause pain: ischemia (lack of blood flow), trigger points (more about trigger point therapy), nerve compression, postural distortion and biomechanical (movement) dysfunction. During an initial session, neuromuscular therapists interview patients about their health history, current physical condition, lifestyle, and stress levels and devise a treatment plan that addresses their pain syndromes.

Using fingers, knuckles or elbows, neuromuscular therapists apply concentrated pressure on areas of pain until they reach a trigger point, usually a spot that’s extra tender or numb. At this point, they’ll begin a stronger, more localized massage to relax the muscle. Relaxing muscles in this way releases lactic acid, increasing blood and oxygen flow, which, in turn, enhances the function of joints, muscles and movement.

Although both are forms of manual therapy, and they deal with the soft tissue of the body - Neuromuscular therapists can be more preventative - since they may see clients with varying degrees of discomfort. The appointments can also be used in conjunction with many other types of treatment including chiropractic visits, acupuncture, physical therapy and orthopedic rehabilitation (post surgery).

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What is Neuromuscular Therapy or NMT

When people ask my ‘what type’ of modalities I specialize in – I usually say I’m a neuromuscular therapist. I prefer to use that title rather than massage therapist, because most people will respond with, ‘Oh, you’re a masseuse.’ Um, no! Because I do a lot more than relaxation massage and helping people de-stress (although I do that too). I am more of a pain management specialist.


What is neuromuscular therapy – it is the most effective type of massage therapy for muscle pain, and it is also called trigger point or myotherapy. The American Academy of Pain Management recognizes this form of massage therapy as an effective treatment for pain caused by soft tissue injury (such as a muscle strain), joint pain throughout the body, muscle tension, spasms and injury and/or surgical recovery or addressing trigger points.

Neuromuscular therapy consists of alternating levels of concentrated pressure on the areas of pain, tightness or muscle spasms. The massage therapy pressure is usually applied with the fingers, knuckles, or elbow at a consistent rate (ischemic pressure) on the spots chosen – until the muscle releases. The pressure may continue from 30 secs to several minutes.

Because Neuromuscular therapy is a specialized form of deep tissue massage digital pressure and friction are used to release areas of strain in the muscle for superficially and deep (think joint pain you can’t get rid of), and these areas of strain are called tender or trigger points and are the cause of muscular pain symptoms.

Trigger points are areas of hypersensitivity in a muscle caused by a continual firing of the signals to the muscle that do not allow it to relax between movement (either contraction or stretch).  These are small areas with the muscle in which there is a contracture of muscular tissue (think of a tiny grain of rice under a sheet).  Blood circulation and nutrients are lacking in that part of the muscle and therefore the muscle spindle is unable to relax.  Trigger points cause pain, fatigue and weakness in the muscle.  Trigger points also create a phenomenon called referral pain.

Referral pain caused by trigger points can exist in areas far from the trigger point – the best example of this Carpal Tunnel – because the source of the issue is generally in the neck, yet clients come in with pain in their wrist. Additional people suffer from sensations of pain, tingling, or numbness.  Examples of referral pain include: sciatica like symptoms (lower leg), lower back pain (from hips and thighs) and headaches (neck).

Neuromuscular therapy is used to treat many different soft tissue problems.  The following list is a small example of issues that may be helped by neuromuscular therapy:
Lower back pain, upper back pain, carpal tunnel like symptoms, sciatica like symptoms, hip pain, headaches, plantar fasciitis, calf cramps, tendonitis, knee pain, iliotibial band friction syndrome, jaw pain, tempomandibular joint pain (TMJ disorders).