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loads on the knee extensor structures make them susceptible to injury. The patella functions to increase the power of the quadriceps, acting as a fulcrum during extension, and is embedded within the tendon of the quadriceps muscles (Image 4). Consequently, there is a great deal of tensile (pulling) force on the patellar tendon with knee extension during lifting. As the knee extends, the patella moves in a superior direction. Sometimes the forces on the tendon are not equal; most commonly there is a greater pull on the lateral side compared to the medial side of the patella. The imbalanced pull can produce a patellar tracking disorder, a primary cause of anterior knee pain. Delivery workers also sustain chronic overuse tendon pathologies such as patellar tendinosis, which is chronic overload on the tendon but not necessarily a tracking disorder. Patellar tendinosis involves chronic degeneration of the collagen matrix within the patellar tendon. Unfortunately, tendinosis heals slowly, and people often go back to activities long before they are at optimum function, thereby aggravating and prolonging the existing injury. ACL and meniscus pathology are also common. Powerful contractions of the quadriceps, as during lifting and bending, produce a high tensile force on the ACL, which can, with repetition, cause gradual breakdown and sprain injury to the ACL. The ACL can be injured with simultaneous bending and twisting movements, which are common for delivery drivers. Rotational stress to the knee puts the ACL in a compromised position, a common mechanism of injury, and can seriously stress the medial collateral ligament (MCL) and the medial meniscus. In fact, these three structures are so frequently injured together that they are known as the "terrible triad." The ACL and medial meniscus are structures deep within the knee and inaccessible to massage treatment. Conditions involving these two structures should be treated by an orthopedist. The MCL, however, is accessible for massage treatment and responds well to deep-friction massage, along with other movement methods used in physical therapy. EVALUATION AND TREATMENT CONSIDERATIONS Low Back A variety of treatment techniques are valuable for both injury prevention and treating existing conditions in delivery workers. Appropriate treatment is dictated by which structures are responsible for producing the pain. Consequently, assessment and evaluation are of key importance. Low-back pain assessment can be challenging, but there are some simple key principles to help clarify your client's condition. Reports of sharp, shooting pain sensations, especially down the lower extremity, are likely if there is a disc pressing on lumbar nerve roots. Suspicion of neurological involvement can be further examined with special orthopedic tests, such as the straight leg raise test. This is one of the most commonly used evaluation procedures for identifying neurological involvement of the lumbar nerve roots. Palpation will clarify muscular injury, such as myofascial trigger points, Patellar retinaculum hypertonicity, or muscle strain. Developed palpation skills combined with knowledge of anatomy and relevant structures help determine which tissues might be the cause of pain (if palpation reproduces the pain). Note that pain referred to other regions from palpation of lumbar muscles is frequently an indication of myofascial trigger points. Pain that mimics the exact sensation the client reports strongly suggests involvement of local muscles as the primary cause. Further validation of which soft tissues are injured can be aided by combining information from active, passive, and manual resistive tests. Myofascial techniques gently pull and elongate the connective 4 The patellar retinaculum is a frequent cause of anterior knee pain. 3D anatomy images. Copyright Primal Pictures Ltd. www.primalpictures.com. tissues of the superficial fascia, decreasing tightness in the deeper muscles. Initial relaxation allows these deeper muscles to be treated with more specific techniques. Myofascial methods also reveal the areas of greater resistance and muscle tightness that need attention. 108 massage & bodywork november/december 2012