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98 M A S S A G E & B O DY WO R K • D E C E M B E R / J A N U A RY 2 0 0 5
I
n the past several issues, I’ve described how the field and thickest tendons of the body, and it can usually
of orthopedic massage offers a unique and valuable handle a great deal of stress.
approach to the assessment and treatment of specific Although it is often referred to as one tendon, the
soft tissue injuries. My goal has been to impart some of patella tendon mechanism consists of six distinct parts
the Essential Principles of working with those in pain that function together as a single unit. The patella ten-
and to teach the application of these principles to the don proper (A) attaches the quadriceps muscles to the
kinds of injuries people generally bring to a bodywork- patella. As the tendon approaches the patella it flattens
er’s office. Previously, I addressed collateral ligament into an aponeurotic sheet and envelops the tendon. The
injuries in the knee and several ankle and shoulder edges of this structure called the medial quadriceps
injuries. In this article, I return to the knee to discuss expansion and the lateral quadriceps expansion (C),
additional Essential Principles that help to assess and wrap under the medial and lateral portions of the patel-
treat another commonly injured structure, the patella la for about an eighth of an inch. Beyond the quadriceps
tendon. expansion, flanking the patella, lie the most medial and
most lateral parts of the mechanism: the medial patella
Introduction retinaculum and lateral
njuries to the patella ten- patella retinaculum (D).
I don, sometimes called the
quadriceps tendon, are the
In most people there is
about a half-inch of
most frequently misunder- space between the patel-
stood knee injuries. A strain A la tendon and the reti-
and/or partial tearing of an nacula, as seen in the
aspect of the patella tendon illustration. Finally, the
mechanism is a common C most distal part of the
cause of anterior knee pain. B1 mechanism, called the
The injury can occur above, patella ligament (B),
below, and/or on the inside attaches the patella to
or outside aspects of the the tibia (E) of the lower
patella, and usually causes a B leg at the tibial tuberosi-
D
generalized ache in the front ty. This last part of
of the knee just below or the structure, though
around the kneecap. Because technically a ligament
D
the pain can be felt in several because it connects bone
different places, pinpointing to bone (patella to tibia),
its cause is often difficult. functions as a tendon
E
Often called “runner’s connecting the patella
knee,” “hiker’s knee,” or tendon proper over the
“biker’s knee,” patella tendon patella to the tibia.
injury usually develops gradu- There are two cate-
ally. The pain often comes and gories of patella tendon
goes according to the amount injuries: chronic and
of activity performed, and may start several hours after a acute. In an acute injury, some of the fibers are
strenuous activity or even on the following day. People strained, swollen, and — in some cases — partially torn
with this injury frequently feel pain while walking — apart. In a chronic case, the fibers that were strained
especially when climbing stairs or hills, but sometimes and torn have healed poorly, forming a matted scar that
when walking down stairs as well. Deep knee bends are is painful and tends to re-tear with each new strenuous
often painful, particularly when straightening up. If the exertion. A severe acute case, if left unattended and
injury is recent and somewhat acute, the knee may ache untreated, may become chronic.
all the time.
The patella protects the anterior knee joint and pro- Principle: Make a Thorough Assessment
vides a fulcrum to increase the functional strength of
the quadriceps muscles. When the quadriceps muscles Orthopedic massage brings a certain mind-set to mas-
contract, they pull on the patella tendon mechanism, sage and bodywork, emphasizing clear assessment and
which attaches to the tibial tuberosity below the knee, specific treatment rather than a hit-or-miss approach.
which in turn straightens the knee. Most tendons serve We begin assessing an injury long before the client gets
only one muscle, but the patella tendon serves all four on the table. Here are four elements of a thorough
of the strong muscles that form the quadriceps. This is assessment, incorporating some Essential Principles
quite a load. The patella tendon is one of the strongest related to working with soft tissue injury.
D E C E M B E R / J A N U A RY 2 0 0 5 • M A S S A G E & B O DY WO R K 99
essential principles
Application:Thorough Assessment of
Possible Patella Tendon Injury
100 M A S S A G E & B O DY WO R K • D E C E M B E R / J A N U A RY 2 0 0 5
important question to ask is: Does Application:Verifying
the pain appear while climbing stairs Patella Tendon Injury
or hills? As mentioned earlier, it’s
important to ask about warm-up pro- Verifying injury to the patella ten-
cedures. Also ask about the levels of don mechanism can be problematic
stress and tension in the person’s life because the pain is often absent
and what level of exertion is needed when the client comes to your office.
in the exercises they normally engage For best results, you might try testing
in. Excess muscle tension in the thigh for this injury soon after an activity
is a possible cause of patella tendon that makes the client’s knee feel sore.
strain, because a tense muscle
fatigues more quickly, placing more Injury Verification Test
stress on the tendon. Other causes of Have the client sit on a table with
strain may include poor form in a her legs hanging off the side, so
particular athletic activity or running there’s a 90 degree angle between
and jumping on cement surfaces. her thigh and her shin. Kneel in
Learning about the types and loca- front of the injured knee and place
tions of your client’s athletic activi- both of your hands in front of the
ties can give you insight into these ankle. Ask your client to forcefully
contributing factors. try to straighten her leg as you
resist, not allowing it to move. This
Body Alignment will cause pain if the patella tendon
The knee joint is particularly sus- is injured. If the test fails to produce
ceptible to injuries resulting from pain, increase the bend at the knee
misalignments in other areas of the and try it again.
body. For example, if the foot turns If the injury is not too severe, this
out more than five degrees while test will not elicit pain unless the
the knee moves straight ahead dur- patella tendon has been stressed
ing athletic activity, inordinate beforehand. For instance, runners types of therapies, ranging from self-
stress is placed on a small portion of often have to run five miles before treatment to treatments that require
the patella tendon (usually the the tendon begins to hurt. In such specialized training. It’s important to
medial aspect) and can cause strain. cases, ask the client to run five know the range of therapies available
Unless the alignment is corrected, miles before coming to your office, to clients and to have them choose a
the tendon will probably strain and and then test the knee. Having treatment regimen that makes sense
tear repeatedly. If you suspect mis- clients climb a lot of stairs often to them. At the same time, certain
alignment as a cause of your client’s works well, too. injuries respond better to one type of
patella tendon injury, consider In addition to testing for patella treatment than to others. Orthopedic
referring him to a professional who tendon injury, you may also have to massage provides very specific infor-
specializes in movement retraining perform additional assessments. mation to help a therapist guide a
(see Alignment Correction, page This injury is often mistaken for client toward choosing effective
109, for more details). chondromalacia or bursitis of the treatment for a particular injury.
knee, which cause a similar aching
Principle: Injury Verification pain, though in different locations Application:Treatment
Through Testing in the (under the kneecap or deep inside Choices for Patella Tendon
Stretched Position the knee). Sometimes a person has Injury
more than one of these injuries at
An Essential Principle of testing the same time. To figure out what’s A number of treatment approaches
tendons and muscles is that testing going on, it’s often necessary to are effective in working with patella
from a stretch position places greater assess each injury separately. tendon injuries. These include fric-
stress on the structure. The greater the tion therapy, myofascial therapy,
stretch, the more fibers are recruited Principle: Effective deep massage, exercise therapy, align-
to produce the movement. Therefore, Treatment Choices ment correction, and injection thera-
you’ll elicit more information from py. Rest is often recommended as a
verification tests when the tendons As I’ve discussed in each article in treatment, but it is frequently inef-
and muscles are stretched than when this series, healing of injured tissues fective, particularly in long-standing
these structures are relaxed. can be supported by several different cases.
104 M A S S A G E & B O DY WO R K • D E C E M B E R / J A N U A RY 2 0 0 5
essential principles
D E C E M B E R / J A N U A RY 2 0 0 5 • M A S S A G E & B O DY WO R K 105
attaches to the upper portion of the patella and apply weight-calibrated exercises systematically increase the
horizontal friction. When the tendon strain is above the strength of the tendon. This procedure must be performed
patella, it is usually at the top inner or outer corner. Use every single day for 6 to 8 weeks for it to be effective. If a
your finger to reach under the patella as much as you client will not be able to do it consistently for any reason,
can when you friction. this program is not a good choice. Try something different.
There are five steps to the program: warm up, stretch,
Friction of the quadriceps expansion exercise, stretch, and use of ice or heat. Give the client
To work on the inner (medial) portion of the quadri- the following instructions:
ceps expansion, sit at the side of the knee and, with one 1. First, warm up the tendon for a few minutes by walk-
thumb at the lateral side of the patella, push the kneecap ing around or by swinging the leg back and forth at
firmly in the medial direction. While holding it there, the knee while sitting on a table or other high surface.
place the index finger of your other hand underneath the 2. Stretch the tendon five times, for 30 seconds each
medial edge of the patella, with the pad of the finger fac- time, by lying prone and pulling your foot to your
ing the ceiling. As you friction in a head-to-toe direction, buttock. If you feel no pull, either in the knee or in
press upward (anteriorly), compressing the thin, sheet-like the front thigh, place a towel or pillow under the
piece of tendon just under the lip of the patella. This can lower thigh just above the knee. This will elevate the
be painful, so go easy at first. thigh, increasing the angle and therefore the stretch.
When working on the lateral quadriceps expansion, If your injury is fairly serious, take care getting into
sit on the side of the table opposite the knee you will be the stretching position. The following instructions will
working on — frictioning is much easier from that side. guide you safely into position to stretch your left knee.
Reach across the table to the knee and, from the medial Reverse the directions if your right knee is injured.
side, push the patella laterally with your thumb. Hold it Begin sitting on your right hip, with both legs bent.
there with one hand and use the index finger of your Take hold of the top of your left foot with your left
other hand to work the lateral quadriceps expansion, hand. Now twist to your right and slide down so that
just as you did with the medial portion. Press up under you’re lying face down with your head turned to the
the lateral edge of the patella, compressing the piece of left. Bring the bent leg in line with the straight one. It
tendon that wraps around the side of the kneecap. will tend to remain out to the side. Now draw your
left heel gently toward the center of your left buttock,
Friction of the retinaculum as far as it will go easily, resisting the temptation to
Injury to this part of the tendon mechanism is much less bounce the foot. Rest a moment between stretches. Be
common. The client points to an area of pain a half inch to sure to hold each stretch for 30 seconds and repeat it
an inch to the right or left of the patella when performing five times. Use a watch to track the time.
resisted extension of the quadriceps. Cross-fiber friction is 3. There are many quadriceps exercises you could use,
easily applied to this area once you locate the exact spot. but I’ve found the one described here to be the easi-
est. While wearing an ankle weight, sit on a table
Myofascial Therapy with your legs dangling. Slowly straighten your leg,
In a certain percentage of cases, there is adhesive hold it a moment, then lower it again. Repeat this
scarring in the myofascial layer covering the various 10 times before resting and starting again. Complete
structures described above. If you are trained and skilled three sets of 10. If the exercise is too stressful on
in myofascial work, you may add this to your treatment your knee, try lying down and supporting your leg
protocol. To test whether there’s a myofascial compo- by placing pillows of varying thickness under the
nent, do a myofascial stroke over each structure. If knee. Begin at a 30 degree angle and later progress
working at this level of the tissue causes discomfort, to a 60 degree angle.
perform myofascial therapy on these tissues before mov- Do this exercise slowly on the first and second
ing to friction therapy, which addresses the level of days. On the third, fourth, and fifth days, increase
injury to the tendon, and then massage therapy. your speed to a moderate tempo. On the sixth and
seventh days, do the exercise a little faster. Always
Exercise Therapy stick to three repetitions of 10.
Exercise therapy may be an effective treatment by For the exercise program to be effective, only the
itself if done correctly and regularly as outlined below, third set of 10 should cause some tiredness. This
but it is far more effective when combined with mas- challenges the tendon structure and causes it to
sage and friction therapy. strengthen. Begin with one to three pounds. If you
feel no stress or fatigue, you’re not using enough
Patella tendon exercise program1 weight. Try again the next day with a little more
The exercise program that follows is the most effective weight. If you feel stress or fatigue during the first
one I’ve ever come across. The stretching realigns the 10 or 20 repetitions, you’re using too much weight.
scar tissue fibers so that they can heal correctly, and the Stop and begin the next day with less weight.
108 M A S S A G E & B O DY WO R K • D E C E M B E R / J A N U A RY 2 0 0 5
essential principles
Alignment Correction
At the beginning of treatment, check to see whether
there is a knee/ankle alignment problem that needs to
be corrected. Misalignment is a frequent cause of patella
tendon strain, and it will also hamper the tendon’s heal-
ing capacity. If a person’s alignment is poor, the arch
will be dropped in an excessively pronated position and
the feet will be turned outward as the knees point for-
ward. Two types of approaches are useful for alignment
problems. Well-fitted orthotic devices often correct the Conclusion
alignment and help redistribute weight evenly through- t least one of these treatment modalities will work
out the knee. Alignment retraining is also useful to help
lessen the stress on the tendon while it’s healing and to
A in most cases of patella tendon injury. The longer
the person has had the injury and the less cooperative
prevent further injury. Consider referring your client to the client is, the more lengthy the treatment will be.
a professional who is skilled in movement retraining. Once the client begins to get better, he or she will feel
This may be a dance teacher, exercise instructor, the urge to do more and more activity. It’s like a starv-
Feldenkrais practitioner, Alexander teacher, yoga practi- ing person seeing food for the first time in weeks —
tioner, or massage therapist with exercise training. the person will lunge for it and do too much. I always
tell my clients that this is the time of greatest danger
Injection Therapy for re-injury. Encourage and educate your clients to
Injections should be used only when all other treat- return to full activity very slowly so they will remain
ments have failed. This will occur in some long-standing injury-free. Pain is ephemeral; once it’s gone, people
and severe cases in which the scar tissue is too tough to seem to forget it. Teaching clients to warm up
break down manually. Xilocane and corticosteroids are properly,2 correcting existing alignment problems, using
injected to deinflame the scarring. When there are many equipment properly, as well as helping clients approach
stubborn adhesions, the point of the needle can be used activities in a more relaxed manner, are essential to a
to actually puncture the scars. I once worked with a med- responsible and well-rounded massage and bodywork
ical student who had extremely severe patella tendon practice. M B &
strain for two years. She had pain constantly when walk-
ing or even sitting with her knees bent at a 90 degree
References
angle. Climbing stairs was impossible. The pain made her 1 This program is adapted from Curwin, Sandra, and Stanish,William D. Tendinitis: Its Etiology and
so weak that I could keep her leg from straightening with Treatment.Toronto:The Collamore Press, D.C. Heath and Company, 1984.
2 Benjamin, Benjamin. Exercise Without Injury. Chapter Four. New York: Summit Books, 1979.
just one finger during the test. She couldn’t lift three
pounds without pain. Deep massage, friction therapy, and Ben Benjamin, Ph.D., holds a doctorate in education and sports
medicine. He is the founder and president of the Muscular Therapy
exercise therapy were all ineffective. One injection made Institute in Cambridge, Mass., and has been in private practice for 40
her 80 percent better and finally got her started on a years. He is the author of Listen to Your Pain, Are You Tense? and
recovery program that I could help her with. Exercise Without Injury. He can be contacted at bb@mtti.com.
D E C E M B E R / J A N U A RY 2 0 0 5 • M A S S A G E & B O DY WO R K 109