An orthopedic surgeon referred Patrick for massage treatment for a very painful and debilitating knee injury, in hopes of avoiding an invasive surgery. Patrick’s injury would usually fall outside the scope of massage treatment but demonstrates how massage can be used for advanced injuries in a cooperative health-care relationship with a physician. In addition, this case illuminates the role of clinical reasoning.
The problem began several weeks earlier when Patrick slipped on his apartment stairs. He used his right leg to catch himself, placing a sudden, intense load of his whole body weight on one lower extremity. He felt a sudden and excruciating pain around his right knee as he fell to the ground. Knowing he had injured it badly, he immediately iced the area.
The next day there was significant bruising in his distal anterior thigh, a great deal of pain and swelling around his knee, and very limited motion. He went to the doctor and was diagnosed with a distal quadriceps tear. Further investigation showed the exact site of the tear was the musculotendinous junction between the distal quadriceps and the patellar retinaculum.
Patrick was advised to rest the leg for several days until the acute inflammatory stage had subsided, then to begin gentle movement and stretching. He continued to have considerable range-of-motion restriction and serious pain.
Three to four weeks postinjury, a significant mass of scar tissue had developed in his distal thigh around the site of the tear. Patrick’s orthopedist was concerned that if this scar tissue was not reduced, regaining range of motion in the knee would be extremely difficult. At this point, Patrick was referred to massage treatment to see if it was possible to avoid surgery.
In Patrick’s history, he shared that he had been a competitive bodybuilder who had previously used anabolic steroids. One of the known side effects of anabolic steroid use is gradual weakening of connective tissue. Thus, it is likely that steroid use weakened his quadriceps muscles and retinacular tissues so that when they were overwhelmed by this accident, the tissues tore.

Anatomical Considerations
A key step in considering appropriate treatment for a quadriceps tear is to consider the role of the knee extensor tissues. The quadriceps muscle group must generate a tremendous amount of power for forward propulsion and shock absorption in the knee. However, the anatomical design of the lower extremity has serious challenges for producing the high force loads required for knee extension.
In a lever system like the knee, one link (the tibia) moves around an axis of rotation in relation to the other link (the femur). In general, when a pulling force is applied to the moving link from a position close to the axis of rotation, it is not able to generate powerful movements. When the pulling force is farther away from the axis of rotation, much more power can be generated.
The body meets this biomechanical challenge in two ways. The first is by aligning the quadriceps muscle-tendon unit farther away from the axis of rotation. The patella is embedded within the quadriceps tendon, and as a result, acts as a fulcrum to pull the tendon farther away from the axis of rotation. This allows the tendon to produce a greater force during muscle contractions. This is the primary biomechanical function of the patella.
The second way the quadriceps gain more pulling power is to spread their attachment points over a broader area than just into the patellar tendon alone. Most anatomy texts show all of the quadriceps’ fibers blending into the patellar tendon, but in reality, many of them are connected to the patellar retinaculum. The pulling force of the quadriceps is then transmitted through the retinacular tissues to the tibia. It is this factor that is of key importance in Patrick’s case.
Patrick’s quadriceps tear extended through a significant amount of the retinacular tissues. These tissues are richly innervated so the injury was very painful. The retinacular tissues are not as highly vascularized as muscle tissue, which poses some interesting challenges for the healing process because decreased vascularity can impair the speed of tissue healing. It’s likely that some of the torn muscular fibers healed faster than the retinacular fibers.
Because the tear occurred through muscle and retinacular tissue, it caused a massive amount of scar tissue. The added tissue and binding of the scarring impede the stretching movements necessary to regain proper motion. If surgery is necessary, the likely surgical approach would involve scraping the scar tissue loose—a fairly invasive procedure. This would also cause further scarring in the area, which would be detrimental to the overall treatment goal of increased tissue pliability.
Consequently, the primary goals of the massage treatment will be to reduce the excessive scar tissue fibrosity and help regain range of motion in order to avoid surgery.

Assessment and Evaluation
At the time of Patrick’s first visit, knee flexion was limited to about 15 or 20 degrees. There was no limitation to knee extension.
Initial assessment indicates very dense and fibrous tissue in the area around the distal quadriceps just superior to the patella. Fibrous thickening is very palpable throughout this region as well. Patrick also reports intense pain with palpation using moderate pressure. There is binding restriction at the limit of passive knee flexion, and end range of flexion causes pain.
Resisted knee extension produces anterior knee pain. Patrick also senses weakness in the knee and feels he cannot put weight on the knee without it failing. This sensation is caused by a neurological process called reflex muscular inhibition, in which the brain, in an effort to avoid intense pain and further injury, shuts off contraction signals to the affected muscles when they are heavily engaged.

Treatment Strategies
The primary treatment technique for tissue tearing and fibrous scar tissue development is generally deep friction massage. However, in Patrick’s case, it is unclear whether that type of treatment will be effective given the amount of scar tissue over such a wide area. It appears unlikely that deep friction alone will be sufficient to achieve the range of motion gains we need, and a number of other treatment procedures will likely need to be included as well.
Another factor is that massage is likely to be quite painful and will only work if Patrick is very compliant with all treatment suggestions inside and outside the treatment room. Because of the relatively recent nature of the injury (several weeks old when we started treatment, and considered subacute at this point), it is also clear that the greatest benefits will come from frequent treatments.
Patrick came in twice a week for 30-minute massage sessions. Each session began with extensive work on the quadriceps muscle group using gliding techniques to reduce overall tightness and encourage tissue elasticity and optimal tissue health. Following this work, longitudinal stripping was performed throughout the entire anterior thigh region. Because Patrick’s quadriceps were large and muscular, it was important to get as much tissue relaxation as possible throughout the entire muscle.
Deep transverse friction was then applied to the scar tissue region in the distal quadriceps and retinaculum. Friction techniques were performed over the entire area with moderately deep pressure for several minutes. The pressure level used was enough to produce tissue quality change, but not enough to produce reactive muscle splinting. For Patrick, the work was uncomfortable but tolerable, and he was instructed to speak out if it became more than he could tolerate. Client-practitioner communication is very important in this type of treatment.
Immediately after the friction techniques were performed, static knee flexion stretches were used to help encourage further stretching of the involved tissues. This series of extensive friction treatments followed by stretching was repeated three to four times in each treatment session.
After the first two treatment sessions, pin and stretch techniques to the distal quadriceps were introduced. The pressure was applied to the injured region while the knee was in extension and maintained as the knee was slowly brought as far into flexion as possible. The amount of knee flexion possible was documented in each treatment session so we could measure improvement in successive treatments.
The first four sessions (two per week) showed promising initial results. Patrick tolerated treatment well and complied with a home-care plan his physical therapist gave him to interface effectively with the massage approach. At this point, active engagement lengthening methods were added to the treatment. These techniques involved deep stripping performed during eccentric action (flexion) of the quadriceps muscles and were aimed mainly at the distal quadriceps fibers and retinaculum, but also applied throughout the length of the muscle.  Although this technique was more painful for Patrick, it helped him make significant gains in tissue elasticity.
After each treatment session, heat was applied to the tissues to enhance connective tissue pliability. Immediately after the heat treatment, we stretched him in flexion as far as possible. The stretch position was held for about 20 to 30 seconds and repeated three to four times. Holding stretches for this length of time helps encourage elasticity and creep (tissue elongation) in the connective tissues much better than a short duration stretch.
For treatment support, I taught Patrick to perform many of the friction techniques and encouraged him to use them prior to the daily stretching routine he was doing at home. Regular application of the massage technique prior to the stretching helped increase his range of motion even more.
After four weeks of twice-weekly therapy, there was marked improvement in range of motion (about 60 degrees of knee flexion) and a reduction in associated pain. At this point, Patrick had a follow-up appointment with the orthopedist who was very excited about our results and encouraged us to continue the same treatment process.
At six weeks, Patrick was getting close to 110 degrees of knee flexion and there was a clear reduction in the amount of fibrous tissue that was palpable in the injury area. It was determined that he could space the treatments out, but continue his vigorous home treatment regimen.

Conclusion
This case was successful for a number of reasons. First, the injury was addressed early in the healing process when the tissue was still pliable. In many cases, you don’t have the opportunity to intervene until an injury is much older. The older the scar tissue is when treatment begins, the more challenging it is to make significant tissue consistency changes.
The fact that Patrick was a former athlete, highly motivated, and willing to endure significant pain during treatment helped achieve these results. Many soft-tissue treatments can be performed without inducing pain, but there are certain conditions in which the intended results are difficult to achieve without some degree of discomfort. It takes skillful evaluation by the therapist to determine what pain levels are acceptable and when it is too much.
This case highlights the importance of having a high degree of knowledge about several contributing elements of advanced massage: anatomy, assessment protocols, biomechanics, and the soft-tissue rehabilitation process. Proper massage technique was clearly necessary, but technique knowledge alone would not have been sufficient to create this treatment plan. Patrick’s case emphasizes that effective treatment is a compendium of cognitive and functional knowledge and physical skills.
It is valuable when we have clinical references in textbooks or resource material that give us guidelines about how to address certain pain or injury complaints. However, nothing can replace good clinical reasoning based on substantive knowledge and understanding, because the majority of the time we are presented with unique individuals and presentations that may differ significantly from common pain or injury condition descriptions.

Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe’s free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com.

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