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52 massage & bodywork november/december 2008

Treating the Knee and Lower Extremities, Part I

s a veteran of seven knee surgeries resulting from my genetic

roots of extremely bowlegged peasant ancestry, combined with

excessive and, some might say, obsessive athletic overindulgence,

I have a virtual PhD of personal research in acute and chronic

injuries to the legs and recovery from surgeries. Through my

own experience and the treatment of fellow sufferers, I’ve learned

that the best treatment should include a wide range of approaches

from soft-tissue muscular and fascial work, joint mobilization,

stretching, strengthening, and neuromuscular reeducation.

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Injury to any joint of the leg will or surgery cases except for caveats NEUROLOGICAL FACTORS
necessarily impact the joints above and that instill trepidation. We will focus When manual therapy and conventional
below. In addition to offering specific on the knees, but since injuries to western medical methods prove to
treatment strategies for the knee, this the foot, ankle, and hip often present be less than satisfactory, the success
article will also discuss the complex the same compensatory movement of Pilates and somatic therapies such
interplay and feedback loops between patterns as knees, the strategies in as Feldenkrais Method demonstrates
muscles and all major joints in the legs this article will be just as helpful the importance of treating more
and how to work with compensatory for treating these injuries to return than the specific injury site. The
limping patterns that occur after injury. normal gait in a holistic manner. benefits of movement therapies
Today, with current health insurance These techniques are not magic are due to their understanding of
restrictions, many patients rarely see bullets to be arbitrarily followed. the kinesiology and neurological
their doctors for follow up or for more Clients must be treated as unique patterns of how limping becomes
than perfunctory physical therapy after individuals based upon their particular established and hampers healing. It is
acute knee injuries or after the scars injury or surgery, their experience of short-changing your client to focus
from surgery have healed. After my pain or dysfunction, and their adaptive your attention on just the muscular
third knee arthroscopy and in spite of compensations in gait. As tempting as it issues at the injury site without
extensive conventional physical therapy is to move into specific techniques, it is considering joint compensations above
treatment of strengthening, stretching, essential to develop an understanding of and below the site of dysfunction
ultrasound, electrical stimulation, and the complex relationship between all the and working to mobilize them.
various anti-inflammatory modalities, joints of the leg and how they influence The movement of the knee through
I still experienced considerable pain recovery from injury so that therapists extension and flexion is a sophisticated
and limping patterns. I had essentially can have a logical plan for treatment, combination of spinal cord reflexes
started to believe that my surgeries rather than just trying to work where and conscious higher order brain
just didn’t work well and that I must it hurts or using some technique that function. To greatly simplify: When
accept my fate, when a friend twisted looked good in a class or book. the quadriceps (the agonists in this case)
my arm to see a physical therapist who contract, they extend the knee (The
eschewed many of the conventional rectus femoris, along with the psoas,
physical therapy modalities and can also flex the hip, and will need
concentrated upon soft tissue manual to be addressed to return normal hip
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
If the joint does not quickly
my astonishment at the effectiveness is
what led me into the bodywork field.
return to normal pain-free
The benefits I continue to receive
from hands-on treatment are not the movement, there is a likelihood
proprietary domain of sophisticated
physical therapy. With good manual
skills and an understanding of the
of limping patterns being
complex interplay of the joints from the
foot to the hip, any massage therapist
established that disrupt function
can really help clients recovering from
injury. Unfortunately, many massage above and below the knee.
therapists are hesitant to work with
injuries because they are given little
instruction on dealing with post-injury

54 massage & bodywork november/december 2008

function in the later stages of recovery).
In order to facilitate this action, the
Limited Knee Extension
hamstrings (antagonists) must relax so In varying degrees, limited knee extension will have the
the two muscle groups aren’t competing
with each other. Conversely, in knee following results in gait, including a short stride. If you
flexion the hamstrings contract to can return normal extension to the knee (the primary
flex the knee (or extend the hip if restriction), then most of the secondary compensations in
the knee is fi xated) while at the same
time, the quadriceps must relax. This the foot and hip will improve with minimal intervention.
process of contraction/relaxation of Muscles that are inhibited will need to be strengthened, and
opposing muscles is called reciprocal any good sports medicine book will have suggestions. These
inhibition and occurs at an unconscious
reflex level in all parts of the body. images confine themselves to the pelvis and below, but
If there is pain or soft tissue notice how pelvic tilt is also affected and will have effects up
restriction in the knee joint, a complex the spine and beyond. If you consider how a tight psoas on
series of protective reflexes occurs
that overrides the smooth function of the affected side will present side-bending and rotational
reciprocal inhibition to compensate strain on the lower back, it becomes clear how the effects of
for the restriction or prevent the joint injury radiate globally.
from moving into painful positions.
This reaction may be useful in the early
stage of recovery to prevent pain or
protect the joint, but if the joint does
not quickly return to normal pain-
free movement, there is a likelihood TOE OFF
of limping patterns being established
that disrupt function above and below LIMITED HIP

the knee. These global feedback loops SHORT RECTUS

tend to exacerbate and fi xate the HAMSTRINGS &

original injury. Understanding how

the foot, ankle, and hip at fi rst respond HAMSTRINGS

to and later continue to affect the SHORT PLANTARIS

knee is often the key to rehabilitation,
not only of acute problems but INHIBITED GASTROC
long-standing chronic ones. LIMITED
Although there are many different PROPULSION PROPULSION

patterns for compensation in walking,

limited knee extension demonstrates
the most common limping patterns
for knee pain. In part two of this HEEL STRIKE
article we will go into a deeper
analysis of gait, techniques for joint
mobilization, and some strategies for INHIBITED

returning normal function to the feet

and hips. For now, this illustration
will give you a map of short muscles HAMSTRINGS
that you can begin working with to SHORT PLANTARIS
directly improve knee function.



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TREATMENT STRATEGIES the amazing ability of the human tissue will most likely be very warm
FOR THE KNEE body to direct its own healing. Often, from natural inflammation processes; it
Even ideal techniques or soft tissue clients are hoping be quickly fi xed is strongly recommended that whenever
strategies may prove less than effective by outside intervention or magic working on injuries, you apply ice packs
or possibly counterproductive if bullets. I prefer to look at my work as for 10 minutes after the session and
performed without considering clients’ returning balance, thereby opening have your client apply ice later in the
progress in their healing process. We the door for their bodies to heal day. Hot or very red, irritated tissue,
all walk a fi ne line between providing themselves. Giving clients confidence especially if the client has a fever, is a
effective work or occasionally and trust in their body’s recuperative serious problem after surgery, and the
working too hard or too early, thereby powers is another gift that you can client should immediately contact his
increasing inflammation. Never provide, in addition to your work. or her surgeon to rule out an infection
attempt to force inflamed tissue to After surgery, most orthopedists in the joint. That said, what do you
release. The real skill in rehabilitation and physical therapists feel that if the do when you fi rst see a client after
is gained through experience of incision is healing properly, it is safe surgery or an acute knee problem?
determining what is constructive to perform superficial work to reduce Although clients may be concerned
pain versus too aggressive intent. swelling, prevent adhesions from with the lack of knee flexion, the
It is understandable that both forming, and improve mobility after primary culprit in limping is a lack
therapists and clients are anxious to approximately seven days. To play it of knee extension, even if it is just a
progress as quickly as possible with safe, I recommend waiting for at least matter of a few degrees. Certainly
recovery, but I feel that too early or 10 days, and always proceeding with you should work to improve flexion,
aggressive intervention may disrupt authorization from the surgeon. The

56 massage & bodywork november/december 2008

but in most normal, relatively level injured or surgically repaired knee will hands. Your intention should be very
walking and running conditions, it is usually lack the resilience and mobility superficial, no more than a half inch
possible to navigate without limping, of normal tissue and feel leathery. deep, as you visualize very slowly
even with restricted flexion. Once This is a different quality from softer beginning to fi rst soften tissue and then
you understand how the ankle, knee, puffi ness of deeper joint swelling which unwind and separate this outer sleeve
and hip are related, you can begin to may also be present, but will give more from deeper tissue and the joint. If
work with a rational strategy to return easily because of the additional fluid performed properly, the client usually
normal movement to the whole leg. in the joint capsule. It is almost as if a comments that it feels quite enjoyable
tight sleeve has been wrapped around (in an intense way) and freeing. The
TREATMENT 1: FREEING THE the joint. This is the body’s attempt softening of tissue might feel like you
SUPERFICIAL SLEEVE to stabilize after trauma—either are slowly letting your fi ngers test the
This is really quite easy and gratifying surgical or accidental—and should be ripeness of an apple while being careful
work once you have a feeling for it, the fi rst issue addressed. The client to not bruise it. Gently grabbing the
but it is quite different from typical will probably have some residual pain incision, lifting it and slowly moving
kneading, effleurage, or deep muscular and fear, so it is crucial to move slowly back and forth (in a motion similar
work of conventional massage. This and within the pain threshold. to skin rolling) is very helpful; again,
work will facilitate improvement in With your fi ngers softly curved, the doctor’s permission is needed for
both flexion and extension and the take hold of as broad an area of treatment soon after surgery. After
feeling of tightness surrounding the tissue as you can with the soft pads softening the tissue, visualize that you
knee. The superficial tissue around an of your fi ngers and the palms of your are sliding this superficial layer around

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Flexion is rarely a lasting tissue has sufficiently healed and is

not inflamed, take the joint to the end
range of comfortable flexion and work
problem, and returning to extend that end range either passively
or by having your client actively flex
full extension should be a the knee while you work on any soft
tissue areas that are resisting. Your
higher priority. However, most client can tell you where the tissue
is tight and resisting movement.

clients seem quite concerned Prone Knee Flexion Technique

To ensure that you are not stressing
with flexion and it is relatively the knee capsule, be sure to have your
client inform you if the restriction feels
easy to improve. like it is deep in the joint rather than
in the soft tissue you are addressing.
Also make sure that the patella is not
compressed against the table. Slowly
flex the knee with your other hand and

You want that leathery superficial

the joint in whatever direction it wants
tissue to slide over the joint in all
to stretch, unwind, and release—almost
directions so it does not disrupt joint
like very slowly wringing out a wet
function. An effective technique is
towel—being careful that you are
to rotate the outer sleeve of tissue
grabbing and stretching tissue rather
as far as it will go and then ask your
than sliding over it. There is little or
client to very slowly flex and extend
no need for lubrication, which makes
the knee so that the joint moves under
the skin slippery and requires more
the sleeve that you are stabilizing.
pressure to grab the sensitive tissue.
address any areas distal to the knee
that are restricting movement. The
fist, fi ngers, or even the forearm are
The release happens at the end range of FLEXION
effective tools. In addition to freeing
restricted motion and at a very oblique As mentioned earlier, flexion is rarely
localized tissue where you are working,
angle (not from jostling tissue back and a lasting problem, and returning
this will also stretch the quadriceps.
forth or working on deeper tissue). It full extension should be a higher
This is the perfect time to offer your
is almost as if you are trying to free priority. However, most clients seem
client suggestions about a home
the lid from a jar, slowly applying steady quite concerned with flexion and it is
stretching program for rehabilitation.
pressure and waiting (hoping) that it relatively easy to improve. Your goal is
will eventually release and move. to increase joint range of motion and
Supine Knee Flexion
mobility at the end range restriction of
Address any soft tissue restrictions
tissue. Working in the neutral position
around the joint. This approach affords
is of minimal benefit. If superficial
more contact with the anterior knee
and patella as well as the quadriceps.
Stretch the knee into flexion and ask
where any restrictions are felt. You
can use anchor and stretch strokes
applying pressure proximally as you
flex the knee against adhesions, or
you can work in the direction of
Photos and illustration courtesy of Art Riggs
with thanks to model Joanne King.

58 massage & bodywork november/december 2008

TREATMENT 3: FREEING With the soft, flat border of your
THE PATELLA thumb, gently lift the patella and slowly
Even with deep joint injury or surgery, mobilize in all directions, waiting at
the patella often becomes restricted end range of restriction for a softening
and can cause tendinitis and secondary of resistance. In this case, I am actually
pain. It is unfortunate that many early lifting and tilting the patella with my
massage trainings instill fear of working thumbs slightly below the anterior
in this important area. Be careful to surface so it is not compressed against
not compress the patella against the the femur. You can even rotate the
femur when working, but do work patella clockwise and counterclockwise.
for more ease in proximal/distal and
lengthening by grabbing tissue and
lateral/medial movement. Tight tissue Soft-Tissue Patellar Work
pulling it in that direction. To allow
and tension in the iliotibial (IT) band In addition to mobilizing the patella
both hands to work, you may instruct
and vastus lateralis most often will by working directly with the bone
the client to flex her knee by using
cause the patella to deviate laterally, so as a lever, it is very important to
her hands to pull the knee toward her
although not shown in this example, soften tissue around the perimeter
chest, or use your own body to apply
any work to lengthen and soften the of the patella that can interfere
flexion pressure to the lower leg.
IT band is very helpful. Don’t try to
accomplish too much in one session. A
Seated Quadriceps Work
little work each time will be helpful.
Good old-fashioned softening of the
quadriceps with the forearm is always
Patellar Mobilization
helpful. Of course working with your
The patella will only glide freely when
client in a supine position is also
the knee is fully extended (another
acceptable, but does not stretch the
reason to return full extension to
tissue or joint. Having the client sitting
the knee joint as soon as possible).
and actively flexing the knee as you
Palpate the difference on yourself by
apply force in a distal direction to
attempting to slide your patella back
and forth with the knee just slightly
with tracking. Work slowly in all
directions with fi ngers or knuckles
and wait for the melt of tissue.

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
expedite lengthening is more efficient
patella laterally, and prevents smooth
for biomechanical use of your weight
bent, as it would be if supported by a flexion and extension. The biggest
and also assists with joint tracking and
bolster in supine position. Now let your complaint that some clients express for
other neurological movement patterns.
knee rest in full extension (without work in this area is that the therapist
Anchor and stretch strokes applying
contracting the quadriceps) and notice moves too fast and exerts pressure
force proximally while stretching the
how much more easily the patella directly into the femur rather than
tissue by increasing flexion are also very
moves. To mobilize the patella, the obliquely. Although not shown here,
effective for freeing more superficial
knee should be extended as straight work to release the tensor fascia latae
adhesions around the knee joint.
as is comfortable without a bolster. and all of the gluteals is always helpful

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With immobility (remember that the gluteus maximus

attaches directly to the IT band).
either border with fi ngers is very
effective to allow the band to stretch
in a straight line and also to allow
after injury Working with the Iliotibial the patella to track correctly instead
Band in Side-Lying Position of being pulled too far laterally.
or surgery, Just softening the tissue will be of
substantial benefit, but putting the CONNECTEDNESS
adhesions may IT band on as much as a stretch as
possible by having the leg extended
I hope that this fi rst of two articles
provides some helpful strategies for
in the side-lying position will add to working with knee injuries, and more
form along the benefit of this work. In addition to important, stimulates some thought
stretching in a distal direction with about the interconnectedness and global
the anterior issues involved in treating not only
injuries to the legs, but in treating any
or posterior other injuries. The forthcoming article
in the January/February issue will offer
specific tools for returning full range
border of the of motion to the knee in extension
and in working with joints.
IT band. Art Riggs is a certified advanced Rolfer
who has been practicing and teaching in the
San Francisco Bay area and internationally for
over more than 20 years. His graduate studies
were in exercise physiology at the University of
California in Berkeley. He is the author of
Deep Tissue Massage: A Visual Guide to
Techniques, now in a second edition and
translated into five languages, and the seven-
volume companion DVD set. Visit his website
at www.deeptissuemassagemanual.com.

the soft underside of your forearm, 1. This article uses the more common use of the
grabbing the IT band and rotating it word leg to refer to the entire lower extremity,
around the leg to free it from deeper as opposed to strict medical terminology where
adhesions is also very helpful. leg specifically refers to the portion of the lower
extremity between the knee and ankle.

Compartment Separation
With immobility after injury or Editor’s Note: Massage & Bodywork magazine
surgery, adhesions may form along is dedicated to educating readers within the
the anterior or posterior border of scope of practice for massage therapy. This
the IT band. Precise work along feature was written based on author Art
Riggs’ years of experience and education. It
is meant to add to readers’ knowledge, not
to dictate their treatment protocols.

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