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2 Use active engagement techniques on the hip abductors from a side-lying position. 3 Use active eccentric lengthening techniques to address anterior knee pain. small contact pressure applications such as the thumb, fingertip, pressure tool, or elbow (Image 1). It is easy to overexert yourself when performing this treatment with the thumbs. For that reason, many people use an elbow or pressure tool. Deep and specific longitudinal stripping techniques along the length of the gluteus maximus fibers can be performed slowly and gradually. However, these areas can be highly sensitive. Be particularly conscious of the pressure levels and check in with your client frequently so you don't put too much pressure in these potentially tender areas (and, of course, use proper draping). Treating the TFL is important for reducing pull on the ITB around the lateral knee region. The TFL can be treated along with the other hip abductors (gluteus minimus and medius). While these other hip abductors do not necessarily make a direct biomechanical contribution to MMS, they are crucial in maintaining proper gait mechanics. One of the most effective ways to address these muscles is with an active engagement technique performed with the client in a side-lying position. The abductor group being treated is facing upward. The thigh is hyperextended (extension past 90 degrees) and the client is situated so the lower extremity can be dropped off the back side of the table at the end of each application. Have the client attempt to lift the entire lower extremity into abduction against slight resistance (your hand). After holding for 3–5 seconds, instruct the client to slowly drop the leg toward the floor (off the back side of the table) as you perform a static compression technique or slow, deep stripping movement on the TFL or hip abductors (Image 2). This is likely to be uncomfortable, so communicate closely with the client about appropriate pressure levels. Repeat this process several times until the entire group has been treated and you can see gains in their length through increased adduction. KNEE & THIGH REGION One of the more common effects from MMS is anterior knee pain resulting from incorrect patellar tracking. A tracking disorder is a problem that occurs when the patella does not move straight up and down between the femoral condyles during flexion and extension movements. In most cases, the patella is being pulled in a lateral direction. This imbalance of forces on the patella can cause anterior knee pain during locomotion and especially when climbing or descending stairs, bending, or stooping. A large Q angle and femoral anteversion both cause the patella to be pulled more in a lateral direction. Femoral anteversion and overpronation contribute to internal tibial rotation, which is often a contributing factor to lateral patellar tracking dysfunction as well. The knee pain associated with this tracking dysfunction is often caused by excessive tension forces on the patellar retinaculum. The retinaculum has a high concentration of nerve endings, so it takes little tissue irritation to produce pain. With MMS and lateral tracking disorders, there is greater tensile stress on the lateral extensor tissues than those on the medial side. Treatment will focus on the connective tissues of the quadriceps group and the extensor retinaculum, especially on the lateral side. Active eccentric lengthening techniques are highly effective for addressing anterior knee pain that results from patellar tracking disorders. This technique is applied to both the quadriceps muscle group and the extensor retinaculum connective tissues. Particular focus is applied to the vastus lateralis, as it is the most lateral of the quadriceps group. Position the client on the table so the lower leg can be dropped off either the end or side of the table. Instruct the client to move the leg slowly up in extension and back down in flexion. As they drop the leg back into flexion, perform a short stripping technique on the retinacular tissues around the patella (Image 3). The technique can be performed in either a superior or inferior direction. F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 99

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