Issue link: https://www.massageandbodyworkdigital.com/i/68008
CONNECTIONS Injury to any joint of the leg will necessarily impact the joints above and below. In addition to offering specific treatment strategies for the knee, this article will also discuss the complex interplay and feedback loops between muscles and all major joints in the legs and how to work with compensatory limping patterns that occur after injury. Today, with current health insurance restrictions, many patients rarely see their doctors for follow up or for more than perfunctory physical therapy after acute knee injuries or after the scars from surgery have healed. After my third knee arthroscopy and in spite of extensive conventional physical therapy treatment of strengthening, stretching, ultrasound, electrical stimulation, and various anti-inflammatory modalities, I still experienced considerable pain and limping patterns. I had essentially started to believe that my surgeries just didn't work well and that I must accept my fate, when a friend twisted my arm to see a physical therapist who eschewed many of the conventional physical therapy modalities and concentrated upon soft tissue manual therapy. I had never before experienced bodywork, but after one treatment of manual work to free restrictions in the muscles and fascia around the knee and some attention to compensatory holding in my hip and ankle, I felt that I had a new knee. So I suppose that I was actually lucky to have experienced my knee problems because my astonishment at the effectiveness is what led me into the bodywork field. The benefits I continue to receive from hands-on treatment are not the proprietary domain of sophisticated physical therapy. With good manual skills and an understanding of the complex interplay of the joints from the foot to the hip, any massage therapist can really help clients recovering from injury. Unfortunately, many massage therapists are hesitant to work with injuries because they are given little instruction on dealing with post-injury or surgery cases except for caveats that instill trepidation. We will focus on the knees, but since injuries to the foot, ankle, and hip often present the same compensatory movement patterns as knees, the strategies in this article will be just as helpful for treating these injuries to return normal gait in a holistic manner. These techniques are not magic bullets to be arbitrarily followed. Clients must be treated as unique individuals based upon their particular injury or surgery, their experience of pain or dysfunction, and their adaptive compensations in gait. As tempting as it is to move into specific techniques, it is essential to develop an understanding of the complex relationship between all the joints of the leg and how they influence recovery from injury so that therapists can have a logical plan for treatment, rather than just trying to work where it hurts or using some technique that looked good in a class or book. NEUROLOGICAL FACTORS When manual therapy and conventional western medical methods prove to be less than satisfactory, the success of Pilates and somatic therapies such as Feldenkrais Method demonstrates the importance of treating more than the specific injury site. The benefits of movement therapies are due to their understanding of the kinesiology and neurological patterns of how limping becomes established and hampers healing. It is short-changing your client to focus your attention on just the muscular issues at the injury site without considering joint compensations above and below the site of dysfunction and working to mobilize them. The movement of the knee through extension and flexion is a sophisticated combination of spinal cord reflexes and conscious higher order brain function. To greatly simplify: When the quadriceps (the agonists in this case) contract, they extend the knee (The rectus femoris, along with the psoas, can also flex the hip, and will need to be addressed to return normal hip If the joint does not quickly return to normal pain-free movement, there is a likelihood of limping patterns being established that disrupt function above and below the knee. 54 massage & bodywork november/december 2008