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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How to Identify which Massage Techniques are Best for You

I've had many people come in an specifically asking for a modality based on what they read on the website, and yes Trigger Point therapy, or Myofascial Release or Clinical Deep Tissue can help relieve pain.  Client expect these sessions to make them uncomfortable, because If it's a good pain, it's okay right?  Other professionals like Athletic trainers I work with think Active Release Techniques are the best, because, "won't the stretch and movement will be more effective for athletes who need to release the adhesion or contracture," and they can continue training, right?  Of better yet, if Physical Therapy can't address the issues, then it's more serious than a Massage Therapist can resolve - and the next step is surgery?  Finally, my most favorite question was 'will this machine (refers to electrical stimulation)' help my body with cellular renewal, and relieve my pain?

 As I stand there looking at you, I'll be doing a mental assessment. My first impression is that you are here - to see a massage therapist, because you either have no idea where  to start, or at the end of your rope, because no one else has been able to address your concerns.  My review of the situation is 'an assessment or an educated evaluation of a client’s condition and physical basis for his/her symptoms in order to determine a course of treatment” (Clinical Massage Therapy: Rattray and Ludwig). Here's what you'll here me ask:

Do you have a history of pain/injury?

  • If I'm observing structural imbalance, physical differences between right/left side and movement challenges  - is their pain?
  • If there is a postural difference, can you tell me about that 'x?'
  • If you have any reduced ranges of motion/movements that make it more difficult for you to do 'something?'
  • If you have any diagnosis or input from other medical professionals (Chiropractors, Physical Therapists, etc conduct orthopedic or special tests) in order to identify or diagnose you issues?

Why all the questions? Because clinical assessment for massage therapists is usually divided into five areas, which you can remember by the acronym ‘HOPRS’. I am also incredibly interested in why my clients come in asking for specific treatments, and if they self-diagnose through Google or Web MD - call me nosy:)

H – Health history questions (usually known as your case history or medical intake)
O – Observations (i.e.: of posture)
P – Palpation (of soft tissues including muscles and fascia)
R – Range of motion testing (of movements at joints)
S – Special Orthopaedic Tests (specific tests that help us to identify problems more precisely)

There are many misconceptions and misunderstanding of how Massage Therapy can help clients. My job is to make the best use of the time that you pay for...unfortunately there is no 'set recipe, process, protocol' or magic technique. What is missing from questions about best modality, most effective techniques - is the goal for the session, or what they are trying to accomplish. Unless the client communicates what they want to change versus the 'fix' or the 'magic technique,' the story is incomplete. I would never tell my clients they are wrong. They are just misinformed.

Massage can help in all of these situations...you need to be clear about the issues and goals before you select the technique. And to my instructors, I was listening when you said, ' less (pressure) is more (of a benefit)!'

I look at my Massage Techniques much the same way that we saw 'bodymaps' presented in the movie Dr. Strange. They are all slices of the same canvas - the human body. None of the philosophies is exclusively right (or incomplete) when compared to the others: Energy meridians from Traditional Chinese Medicine and Thai Massage can be compared to the energetic understanding from Trigger Point Therapy and Cranial Sacral flows in the body (think Laws of Thermodynamics)...it's all about the energy. It exists, it has to flow, it tends toward equilibrium - and when it doesn't there is a problem. Then there is the whole description of Biopsychosocial Model - people are influenced by their environment. However you want to look at the universe, closed systems of organisms tend to be the exception, not the rule. Once you step into a massage room, there is a partnership that should exist - and effectively address whatever the goal of the session is.

So what does that have to do with massage? Think of energy transfer (or for those who are allergic to the term energy, how about friction and/or heat) between the hands of the massage therapist and their client's body. Think of the messages and signals that the therapists fingers pick up during palpation, because it's all part of what makes ANY massage effective....it is specific to what you body needs, and how I interpret (or anyone else) what will help address the adhesion, trigger point, contracture or block in the flow of 'chi.' Orthopedic assessment helps therapists understand what the body is telling us, and gives us a framework - reducing all the information down to the right path.

If you ask which massage modality is best for me? I'm going to ask, "What do you want to accomplish in the next 30-90 minutes of your life?"