Alejandra is a 38-year-old massage therapist student who six years ago suffered a knee injury that has affected her daily physical activities ever since. She also states that unfortunately her body has not been the same since she got injured. She states that she has always been an active person and one day while working out at the gym doing a jumping exercise, she landed on the wrong side and dislocated her kneecap, (misplacement of the patella). The doctors told her that tears also occurred on her anterior cruciate ligament (ACL).
A jumping box is a type of exercise in which an athlete projects himself or herself from the ground and lands with two feet on an elevated box. The high box jump is a plyometric exercise that increases explosive power throughout the lower body, specifically the quads, glutes, and hamstrings. Unfortunately, this is a type of exercise in which a lot of people suffer injuries to their lower body due to the physical degree involved.
Alejandra states that the pain she felt that day was excruciating, and she was taken to the hospital and was prescribed pain medication and to rest completely for three months. She then started taking physical therapy for about six months twice a week. Unfortunately, she was also told she was not going to be able to perform any intense workouts (such as squats, lunges, etc.) and this made her very upset. As a result of that injury, Alejandra has been battling chronic Patellar Tendonitis (aka ‘Jumper’s knee) for over five years now and has explored different type of treatment option for her ailment without any indefinitely relief.
Chronic Patellar Tendonitis (aka ‘Jumper’s knee) is an inflammation of the patellar ligament/tendon that attaches the patella (kneecap) to the tibia bone. The patellar ligament/tendon refers to the portion inferior to the patella whit its insertion at the tibial tuberosity. The patellar ligament/tendon is the shared tendon of the Quadriceps Femoris Group (rectus femoris, vastus medialis, vastus lateralis, vastus intermedius).
During the interview intake to Alejandra she states that some of her symptoms are pain, aching and tenderness below the patella whenever she climbs stairs, hills or kneels on her knees. She also states that she feels pain sometimes when she arises from a chair or squatting positions and that her knee also feels inflamed some days. Alejandra states she uses a knee strap whenever she performs physical activities, she applies ice whenever she feels pain or inflammation and does home stretches.
Alejandra started medical massage therapy nine months ago and she started getting massages on her knee a few months ago. She has learned that massage will help her in the healing process by increasing circulation, decrease tightness in adjacent muscles and increasing flexibility and strength.
The following is a treatment plan that I have created for Alejandra:
After reviewing the interview intake filled out by Alejandra, and carefully reviewing the above throughout case history, I decided that the best approach will be to perform the following knee assessments to look for meniscal and ligamentous injuries to locate Alejandra’s knee pain:
- Anterior Drawer Test — to assess the Anterior Cruciate Ligament ACL (have client supine with knee bent; pull the client’s tibia away while the client pulls their femur towards their chest)
- Posterior Drawer Test — for PCL (have client supine with knee bent; push the client’s tibia while client pushes their femur towards you)
- Lachman Test — to assess the ACL & Posterior Cruciate Ligament PCL (have client supine with legs straight on the table; compress the tibia while lifting the femur to test the ACL; compress the femur while lifting the tibia to test the PCL)
- Patellofemoral Compression Test — (have client supine; cup hand around client’s patella, have client medially rotate their hip/laterally rotate their hip/push knee up while inverting foot/push knee up while everting foot)
Then, having completed the above assessments I will follow with massaging the client in a supine position to access the following muscles that act on the knee found on the anterior side:
- Rectus femoris –hip flexion, knee extension
- Vastus lateralis – knee extension, pulls patella laterally
- Vastus intermedius – knee extension
- Vastus medialis – knee extension, pulls patella medially
- Sartorius, Gracilis and Semitendonosus – these help to give stability to the medial side of the knee (muscles located on the medial side of the knee and attach at the pes anserinus area of the tibia bone).
Once I massage both knees for 15-20 min each in a supine position, I will position the client on a prone position to access the following muscles that are located on the posterior side and that could be tight and/or weakened:
- Hamstrings (3) (upper side):
- Semimembranosus – hip extension, knee flexion, internal tibial torsion
- Semitendinosus – hip extension, knee flexion, internal tibial torsion
- Biceps femoris – hip extension, knee flexion, external tibial torsion
The following muscles will also be accessed on the prone position (lower side):
- Gastrocnemius – knee flexion
- Popliteus – helps with knee flexion, rotates tibia internally (this small muscle inserts on the posterior surface of the tibia).
- Plantaris – helps with knee flexion, rotates tibia internally (this slim muscle has a long tendon that goes down the medial side of the soleus and merges into the achilles tendon).
- Tensor Fascial Lata , Gluteus Maximus – through IT Band help to perform lateral torsion
I will finish the session by letting the client know I will like to see her in 7-10 days and continue seeing her for three to five sessions of 30-40 minutes and after that we will revaluate her condition and decide if I will need seeing her every 7-10 days or once a month. I will also advise client to drink plenty of water, apply ice to sore areas for a maximum of twenty minutes if she experiences inflammation. I will also strictly advise the client to AVOID HEAT as this increases inflammation. In addition, I will advise client to follow the following self care tips: rest from painful activities, stretch quadriceps, hamstrings, and calves prior activities, and adjust her body mechanics (e.g. learn proper take off and landing techniques).
By Jess Mendoza