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lengthening by grabbing tissue and pulling it in that direction. To allow both hands to work, you may instruct the client to flex her knee by using her hands to pull the knee toward her chest, or use your own body to apply flexion pressure to the lower leg. Seated Quadriceps Work Good old-fashioned softening of the quadriceps with the forearm is always helpful. Of course working with your client in a supine position is also acceptable, but does not stretch the tissue or joint. Having the client sitting and actively flexing the knee as you apply force in a distal direction to TREATMENT 3: FREEING THE PATELLA Even with deep joint injury or surgery, the patella often becomes restricted and can cause tendinitis and secondary pain. It is unfortunate that many early massage trainings instill fear of working in this important area. Be careful to not compress the patella against the femur when working, but do work for more ease in proximal/distal and lateral/medial movement. Tight tissue and tension in the iliotibial (IT) band and vastus lateralis most often will cause the patella to deviate laterally, so although not shown in this example, any work to lengthen and soften the IT band is very helpful. Don't try to accomplish too much in one session. A little work each time will be helpful. Patellar Mobilization The patella will only glide freely when the knee is fully extended (another reason to return full extension to the knee joint as soon as possible). Palpate the difference on yourself by attempting to slide your patella back and forth with the knee just slightly With the soft, flat border of your thumb, gently lift the patella and slowly mobilize in all directions, waiting at end range of restriction for a softening of resistance. In this case, I am actually lifting and tilting the patella with my thumbs slightly below the anterior surface so it is not compressed against the femur. You can even rotate the patella clockwise and counterclockwise. Soft-Tissue Patellar Work In addition to mobilizing the patella by working directly with the bone as a lever, it is very important to soften tissue around the perimeter of the patella that can interfere with tracking. Work slowly in all directions with fingers or knuckles and wait for the melt of tissue. expedite lengthening is more efficient for biomechanical use of your weight and also assists with joint tracking and other neurological movement patterns. Anchor and stretch strokes applying force proximally while stretching the tissue by increasing flexion are also very effective for freeing more superficial adhesions around the knee joint. bent, as it would be if supported by a bolster in supine position. Now let your knee rest in full extension (without contracting the quadriceps) and notice how much more easily the patella moves. To mobilize the patella, the knee should be extended as straight as is comfortable without a bolster. TREATMENT 4: FREEING THE ILIOTIBIAL BAND With virtually every knee injury, the IT band will become tight and hard. Not only is this uncomfortable or painful for the client, but the tightness causes strain on the knee, pulls the patella laterally, and prevents smooth flexion and extension. The biggest complaint that some clients express for work in this area is that the therapist moves too fast and exerts pressure directly into the femur rather than obliquely. Although not shown here, work to release the tensor fascia latae and all of the gluteals is always helpful visit massageandbodywork.com to access your digital magazine 59