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30 m a s s a g e & b o d y wo r k j u l y/a u g u s t 2 0 2 2 are pulling the tibia forward in relation to the femur and putting a high tensile load on the ACL. Another cause of ACL sprain is an extreme hyperextension injury to the knee, such as a direct blow to an extended knee or landing improperly from a jump with the knee hyperextended. Even though the ACL is not palpable due to its location within the knee joint, ACL injury is routinely evaluated with physical examination. Most ACL sprains can be identified with physical examination and an accurate history. First- and second-degree sprains are usually harder to identify because there is not as much excess movement present at the joint. The excessive hypermobility of the knee in severe injuries makes third-degree sprains relatively easy to identify. Keep in mind that some third- degree sprains will have excessive joint mobility but no pain during the evaluation because the ligament is completely detached. Because the ACL lies deep within the knee joint, it is inaccessible to palpation. Consequently, we can't reach this ligament to perform any soft-tissue treatments directly to it. However, that doesn't mean there isn't a role for massage in managing this condition. If the tear is minor, a physician may recommend exercise or movement therapy. Massage can be a beneficial adjunct along with movement therapy to help restore biomechanical balance in the soft tissues of the region. It is also helpful in pain management and reducing reactive muscle splinting after the injury. This is a great example of when working on all the surrounding areas without actually working directly on the primary injured tissue can have great benefit. Shoulder Separation When someone says they separated their shoulder, the image often conveyed is that of a glenohumeral dislocation where the head of the humerus has separated from the glenoid fossa. However, a shoulder separation is actually a ligament sprain at the acromioclavicular (AC) joint where the clavicle meets the acromion process of the scapula. The primary causes of shoulder separation involve the upper shoulder being struck by a heavy or falling object or the individual falling directly on the shoulder. As a result of the impact, the stabilizing ligaments of the AC joint are sprained. The AC ligament stabilizes the AC joint, and the conoid and trapezoid ligaments stabilize the clavicle and the coracoid process of the scapula (Image 3). The conoid soft tissues have been relaxed, rendering a sensation of "ligament release." Let's look at three different ligament sprains to better understand the diversity of what can happen to our ligaments and how we might treat them. ACL Sprain The knee's anterior cruciate ligament (ACL) attaches to the anterior tibia and the posterior femur (Image 2). Inside the knee, the ACL forms a cross with the posterior cruciate ligament (PCL) to provide dynamic stability in the sagittal plane. The ACL's primary function is to prevent forward movement of the tibia in relation to the femur. It also assists in preventing rotation at the knee. Mechanical overload is the primary cause of ACL injury and is common in sporting activities. For example, when an individual is running and suddenly stops, the momentum of the body has a very strong anterior translation force of the tibia in relation to the femur. When the person suddenly stops, the quadriceps also engage in a sudden high-force eccentric contraction to halt movement. Because they attach to the anterior tibia, they Key spinal ligaments. Image courtesy of Complete Anatomy. 4 Iliolumbar ligament Intertransverse ligaments