In the previous column, I discussed a complex cascade of biomechanical deviations known as miserable malalignment syndrome (MMS) that leads to numerous complaints of pain and altered movement or function. In this issue, we’ll tackle a few treatment strategies that address the different soft-tissue disorders that can result from this syndrome.
To recap, MMS involves a series of interrelated biomechanical dysfunctions throughout the lower extremity kinetic chain, including: a broad pelvis, a large quadriceps angle (Q angle), femoral anteversion along with a squinting patella, genu valgum (knock-knees), and excessive pronation with internal tibial rotation. Be sure to review the previous article for the condition details (September/October 2015, page 96).
Clearly, some components, such as the broad pelvis or femoral anteversion, are issues of skeletal structure over which we have no control. Yet, structural problems frequently produce soft-tissue compensations or problems. Soft tissues are stressed by the attempt to correct biomechanical dysfunction and, for these concerns, massage can be very helpful.

Hip & Pelvis Region
Let’s start by taking a look at some of the detrimental effects of the broad pelvis and femoral anteversion. As discussed in Part 1, femoral anteversion causes the forward-facing condyles of the femur to angle inward, and the tibia may also rotate internally in order to properly connect with the femur. This postural alteration can increase tension on the iliotibial band (ITB) due to its attachment site on the tibia. A broader pelvis can also increase the distance that the iliotibial band (ITB) must span, and so it, too, can be a factor leading to ITB dysfunction.
In a 2006 article, John Fairclough and his colleagues showed how increased tension on the ITB due to tibial rotation may be a prominent factor in the development of iliotibial band syndrome.1 In fact, the increased tension on the band is likely more important in producing lateral knee pain than friction from repetitive flexion and extension of the knee (the previously believed cause of the pain syndrome).
Helping to reduce tension on the ITB will not reverse the process of femoral anteversion because it is a structural deviation in the femur bone itself. However, it could decrease the likelihood that the altered femoral alignment produces lateral knee pain from ITB irritation.
The most effective way to reduce tension on the ITB is to encourage elongation in the myofascial tissues that insert into the superior portion of the band and pull on it. The primary focus for this treatment is on the gluteus maximus and tensor fasciae latae (TFL).
Because the gluteus maximus is such a thick muscle, reducing tightness in the entire muscle generally requires significant pressure to access the deepest fibers of the muscle. Static compression or very slow gliding techniques are effective for releasing tightness within the muscle. Start with broad surface compression, such as the back of the fist or heel of the hand, so the muscle can begin to initially respond to that level of pressure. After broad contact applications, deeper or more specific areas of tightness can be addressed with small contact pressure applications such as the thumb, fingertip, pressure tool, or elbow (Image 1).
It is easy to overexert yourself when performing this treatment with the thumbs. For that reason, many people use an elbow or pressure tool. Deep and specific longitudinal stripping techniques along the length of the gluteus maximus fibers can be performed slowly and gradually. However, these areas can be highly sensitive. Be particularly conscious of the pressure levels and check in with your client frequently so you don’t put too much pressure in these potentially tender areas (and, of course, use proper draping).
Treating the TFL is important for reducing pull on the ITB around the lateral knee region. The TFL can be treated along with the other hip abductors (gluteus minimus and medius). While these other hip abductors do not necessarily make a direct biomechanical contribution to MMS, they are crucial in maintaining proper gait mechanics.
One of the most effective ways to address these muscles is with an active engagement technique performed with the client in a side-lying position. The abductor group being treated is facing upward. The thigh is hyperextended (extension past 90 degrees) and the client is situated so the lower extremity can be dropped off the back side of the table at the end of each application.
Have the client attempt to lift the entire lower extremity into abduction against slight resistance (your hand). After holding for 3–5 seconds, instruct the client to slowly drop the leg toward the floor (off the back side of the table) as you perform a static compression technique or slow, deep stripping movement on the TFL or hip abductors (Image 2). This is likely to be uncomfortable, so communicate closely with the client about appropriate pressure levels. Repeat this process several times until the entire group has been treated and you can see gains in their length through increased adduction.

Knee & Thigh Region
One of the more common effects from MMS is anterior knee pain resulting from incorrect patellar tracking. A tracking disorder is a problem that occurs when the patella does not move straight up and down between the femoral condyles during flexion and extension movements. In most cases, the patella is being pulled in a lateral direction. This imbalance of forces on the patella can cause anterior knee pain during locomotion and especially when climbing or descending stairs, bending, or stooping.
A large Q angle and femoral anteversion both cause the patella to be pulled more in a lateral direction. Femoral anteversion and overpronation contribute to internal tibial rotation, which is often a contributing factor to lateral patellar tracking dysfunction as well.
The knee pain associated with this tracking dysfunction is often caused by excessive tension forces on the patellar retinaculum. The retinaculum has a high concentration of nerve endings, so it takes little tissue irritation to produce pain. With MMS and lateral tracking disorders, there is greater tensile stress on the lateral extensor tissues than those on the medial side. Treatment will focus on the connective tissues of the quadriceps group and the extensor retinaculum, especially on the lateral side.
Active eccentric lengthening techniques are highly effective for addressing anterior knee pain that results from patellar tracking disorders. This technique is applied to both the quadriceps muscle group and the extensor retinaculum connective tissues. Particular focus is applied to the vastus lateralis, as it is the most lateral of the quadriceps group.
Position the client on the table so the lower leg can be dropped off either the end or side of the table. Instruct the client to move the leg slowly up in extension and back down in flexion. As they drop the leg back into flexion, perform a short stripping technique on the retinacular tissues around the patella (Image 3). The technique can be performed in either a superior or inferior direction.
Cover about 3–4 inches with each application, coordinated with movement of the knee. Repeat several times until the entire area has been thoroughly treated. Give the client a short break after performing about three or four of these, so they are not overwhelmed with excessive sensory input from the simultaneous movement and treatment. Stripping techniques applied during eccentric elongation enhance pliability of the retinacular tissues and decrease excessive pull on the patella.
The quadriceps is a powerful muscle group and sometimes lifting the leg by itself in flexion and extension does not recruit sufficient muscle fibers to generate good tension on the retinacular tissues during movement. You can recruit more muscle fibers by adding additional resistance to the movement at the same time you are performing the stripping technique using a resistance band, ankle weight, or simply offering resistance with your hand. When more fibers are recruited during the eccentric motion, the stripping technique is more effective.
To use a resistance band, simply loop it around the ankle and step on the other end to anchor it to the floor. Keep in mind that as the client moves through extension, the resistance is constantly increasing up to the final point when the knee is straight. Resistance is gradually decreasing as they move the leg down into flexion while you perform the stripping technique, but a significant number of fibers are still being recruited for this action.
Manual resistance may also be used for the eccentric knee extension. Instruct the client to hold the leg in full extension while you offer resistance. Once you establish a level of contraction, instruct the client to slowly let go as you gradually push her leg through the flexion motion, while performing a stripping technique on the retinacular tissues around the knee (Image 4). This process can be repeated several times until all the tissues around the knee are treated.

Foot & Leg Region
Another key factor in MMS is excessive pronation and the corresponding internal tibial rotation. The tibialis posterior is the primary muscle resisting overpronation, and these increased demands can cause overuse problems in the muscle.  
Stretching a muscle through its range of motion is one way to prevent the detrimental effects of overuse. However, there are anatomical limitations that prevent the tibialis posterior from being stretched to its full length, and, therefore, it is susceptible to developing tightness and myofascial trigger points. The tibialis posterior is also challenging to treat because it is difficult to reach in the deep posterior compartment of the leg.
Static compression or active stripping techniques applied during eccentric elongation of the tibialis posterior are very effective to address tightness in this muscle. Static compression techniques can be applied to tight areas of the tibialis posterior by pressing the fingertips right along the medial tibial border. The goal is not to press directly into the tibia, but to press on the soft tissue close to the bone to get at the short fibers of the muscle deep in the posterior compartment.
Active stripping techniques for the tibialis posterior are most effectively performed with the client in a side-lying position with the leg being treated lying flat on the table and the medial side facing up (Image 5). Position the lower leg so the foot is off the end of the table and can move freely. Instruct the client to move the foot back and forth slowly through a full range of dorsiflexion and plantar flexion. During the dorsiflexion movement, perform a short stripping technique along the medial tibial border to encourage lengthening of the tibialis posterior. This will reduce chronic tension or trigger points that may have developed in the muscle.
It may be difficult to get adequate pressure into this muscle group without any resistance. There simply isn’t enough muscular effort required to move the foot through this range of motion while not in a weight-bearing position. Offering additional resistance during stripping or elongation techniques will magnify the effectiveness of this approach.
Begin with the client’s foot in plantar flexion. Place one hand on the plantar surface of the client’s foot near the metatarsal heads while the other hand is used to apply treatment to the tibialis posterior. Instruct the client to hold the position while you attempt to push the foot into dorsiflexion. Once a level of muscle contraction is established, instruct the client to slowly let go of that pressure as you slowly push their foot into dorsiflexion (Image 6) and apply a slow stripping technique along the tibialis posterior, covering about 3–4 inches with each pass. It may take several passes to cover the full length of the muscle. This technique can be painful, so be cautious and check in with your client frequently.

In Sum
MMS is a complex biomechanical pattern with numerous challenging components. As noted, some components, such as the broad pelvis or femoral anteversion, are the result of skeletal structure and can’t be changed. Other facets have significant ramifications that appear as soft-tissue dysfunction. However, it is important not to “pathologize” someone just because some or all of these postural challenges are present. In many cases, people can adapt to certain postural aberrations without having a problem. When soft-tissue dysfunction does result from some of these postural challenges, these massage strategies can help the client manage those conditions and find pain relief.

Note
1. John Fairclough et al., “The Functional Anatomy of the Iliotibial Band During Flexion and Extension of the Knee: Implications for Understanding Iliotibial Band Syndrome,” Journal of Anatomy 208, no. 3 (March 2006): 309–16.

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