A bum knee can be a real drag, especially for someone who is extremely active. Knee problems can hinder participation in your favorite sport, prevent you from enjoying that night on the town, or inhibit healthy mobility when performing everyday activities. It can be frustrating when you have tried just about everything and you feel there is no relief in sight. Invasive procedures are often a person’s last-ditch effort that many prefer to avoid whenever possible. Massage can help!
Massage therapy techniques can often help knee pain. It will depend on the underlying cause. For lasting results, it will likely take more than one treatment. The best results are usually found when massage is combined with therapeutic exercise and other recommended pain management methods.
Let’s discuss how massage therapy can help improve the pain and discomfort associated with knee pain. We will also discuss some other helpful tips to help get you back on your feet.
Important Anatomy of the Knee
The knee is a synovial joint consisting of a joint cavity filled with synovial fluid. Synovial fluid helps to lubricate the joints and produce smooth movement, and also provides nutrition to surrounding cartilage. To help encourage the circulation of this synovial fluid through the joints, regular joint movement is necessary. As the saying goes “motion is lotion.”
In conditions such as osteoarthritis, excess amounts of synovial fluid can enter the joints to compensate. This increase can cause distention of the joints and lead to increased pain and discomfort in the area.
The Bones and Ligaments
The knee joint is comprised of three bones and four major ligaments. Unlike tendons, which connect muscle to bones; ligaments connect bone to bone and are there to hold the bones together and provide joint stability.
The bones that compose the knee joint are the femur (thigh bone), tibia (shin bone), and patella (knee cap). The major ligaments of the knee are the famous anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), the lateral collateral ligament (LCL) and the capsular ligament.
Ligaments are pretty tough cookies. It takes quite a bit of force to injure these durable structures. When an injury occurs to a ligament it is called a sprain. Sprains can occur due to a sudden shift in direction in sports like soccer; a bad landing in sports like gymnastics and the high jump; and in blunt force situations that can occur on hockey and football fields.
Unlike tendon injuries that can heal in 3-8 weeks; ligament injuries can take anywhere from a few weeks up to several months to recover, depending on the grade of the sprain.
Sprains and the Collateral Ligaments
An excessive blow to the side of the knee, a sudden shift of direction, or a twist of the knee can cause a ligament sprain. The most common type of sprain occurs with the anterior collateral ligament. It is important to understand the stages of healing when considering treatment strategies for a ligament sprain.
Stages of Sprain Healing
- Acute Inflammatory Stage:
This stage occurs during the first few days following an injury. Pain, swelling, and redness are present as the body puts into action its mechanisms to protect the injured area. At this stage, P.R.I.C.E. should be implemented.
- Protection – Support devices such as splints or braces may be used to help protect the joint as it heals. Crutches may also be used to help reduce pressure on the area during ambulation.
- Rest – During the first few days following injury, the rest of the area is advised. However, it is very important to gradually resume activities as soon as possible within the pain tolerance threshold to facilitate a healthy recovery.
- Ice – An ice pack should be applied to the injured area for 15-20 minutes every 2-3 hours. Make sure to cover the ice application with a piece of absorbent fabric to help prevent frostbite.
- Compression – Wrap a bandage around the area to help support the area, and manage any swelling.
- Elevation – Prop the leg up on a plush pillow so that it is above your heart. This will help reduce swelling and encourage excess fluid in the area to drain.
Massage therapy modalities during this phase are contraindicated, as massage can increase edema and risk of hemorrhage during the acute stage of an injury. However, a massage therapist certified in Manual Lymphatic Drainage (MLD) or Complete Decongestive Therapy (CDT) can incorporate this technique alongside PRICE, which can help reduce pain and swelling and help increase comfort during this stage of the healing process. .
Lymphatic massage is an extremely gentle massage technique that promotes lymph to drain out of the affected area. Lymphatic massage uses very light and gentle contact, is superficial, and DOES NOT reach the muscular layers. It is imperative that the therapist performing this technique be certified in manual lymphatic drainage (MLD), or complete decongestive therapy (CDT) to assure proper application of this delicate method of treatment
- Subacute Stage: The sub-acute stage of injury occurs after the swelling has subsided, usually between three to seven days following an injury. During this stage, the body continues to lay down new scar tissue and this tissue begins to strengthen. This stage can usually last three to four weeks and is where massage therapy begins to gain importance.
At this stage, it is important to take into consideration the grade of the sprain, as it may impact the treatment strategies and timeline. There are three grades of knee sprains:
- Grade 1 Sprain (Mild) – This level involves an overstretched ligament, and can occur with simple instances such as misjudging a step or walking over an unanticipated crack in the pavement, and results with microscopic tears to the tissue. This grade of injury doesn’t prevent load-bearing activities, and walking aids are not necessary. It can take a few weeks to return to normal activities.
- Grade 2 Sprain (Moderate) – A grade two sprain involves significant injury to the ligament; however, the tissue is not fully severed. The area of sprain is tender to the touch, and movement/weight-bearing of the leg can induce pain. A grade 2 sprain can take between 2-4 weeks to heal.
- Grade 3 Sprain (Severe) – A grade 3 sprain involves a complete tear of the ligament. Swelling and bleeding underneath the skin are common, and weight-bearing is unstable and can cause significant pain in the area.
Sprains react well to massage therapy, once the sub-acute stage has been reached. During this stage, the massage therapist will begin to manage scar tissue formation, continue to help reduce lingering edema and swelling, and encourage a healthy range of motion throughout the area. Also, the massage therapist will likely begin to assess musculoskeletal imbalances. Areas that run along the fascial network will be explored, from the bottom of the feet to the top of the body.
Your therapist may work on areas of your body that you had no idea were connected to the injured area. To better understand this concept, we can explore the concept of tensegrity (the interconnected relationship between the connective tissues, the muscles, and the skeleton), and begin to think of the body more like a sailboat than a lighthouse, as described by Thomas Myers of Anatomy Trains.
In addition to massage treatments, your massage therapist will likely recommend therapeutic exercises and self-care techniques to do at home to ensure effective and efficient use of time away from the clinic.
- Remodeling/Maturation Stage:
During this final stage of healing, more aggressive techniques will be utilized by the massage therapist. The focus will shift from a focus on inflammation and realignment of scar tissue to the breakdown of excessive scar tissue and adhesions. More aggressive techniques will be utilized to restore a functional range of motion, and a shift of emphasis will be placed on finding and addressing faulty compensatory movement patterns.
Tips to Help Prevent Sprains
Some effective ways to help prevent a knee ligament sprain include the following:
- strengthen the muscles that surround the area
- perform a proper warm-up before recreational activities
- make sure to slow down during your activity when fatigue starts to set in
- maintain a healthy weight
- avoid kneeling on hard surfaces without the use of a cushion or knee pads
Side Note: No matter how hard we try, life happens and circumstances that lead to ankle sprains are often unavoidable. However, when navigation life, we should do our best to bring awareness to our surroundings and take care to avoid ligament sprains. Up to 40-50% of minor ankle sprains can lead to chronic ankle instability.
The Knee Joint Capsule and Meniscus
The knee joint capsule consists of two layers. The outer layer contains fibrous connective tissues to help hold the joint in place, and the deeper layer contains the synovial membrane that helps keep the joint lubricated.
This area can become painful when the hamstrings and gastrocnemius muscles are not functioning optimally, causing excessive and prolonged tension around the area. Massage therapy techniques such as circular friction around the knee joint and cross-fiber friction across the patella tendon and the tendons of surrounding muscles. These techniques can help significantly reduce chronic inflammation, reduce fascial adhesions, and help restore range of motion.
The medial and lateral meniscus can often be involved in knee pain following an injury. When performing their job optimally they provide slide between the condyles of the femur (thigh bone) and the tibia (shin). The meniscus is most vulnerable to a tear when this slide is not present, Pain along this area, or “clicking and popping” can signal disharmony in this area.
A massage therapist with additional training in medical massage modalities such as Active Release Techniques® can assess and utilize advanced manual therapy techniques to effectively treat these issues.
The Muscles Surrounding the Knee
To stabilize the knee joint, we depend on bones, muscles, and ligaments. With muscles being one of the major stabilizers of the knee. We will now discuss the muscles and the role they play.
Anterior and Lateral Knee Pain – Meet The Muscles
The Quadriceps and Lateral Knee pain
The quadriceps group of muscles’ main action is to extend the knee to perform actions like kicking a football. This muscle group is a major player in knee stabilization. If certain portions of this muscle group become weakened or atrophied due to long periods of bed rest, knee functionality can become compromised.
The quadriceps consists of four muscles that work together to extend the knee (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius). These four muscles come together and attach at the knee cap to form the quadriceps tendon.
The vastus lateralis muscle takes up the majority of the lateral region of the quadriceps group, is the strongest of the quadriceps muscles, and has a tremendous amount of real estate on the outside region of the leg. This muscle is important to address with lateral knee pain, especially around the area where the IT lies on top.
The IT band lies directly on top of the vastus lateralis muscle. During sports such as running, the VL and IT band will move in opposite directions of one another. If any adhesions are located between these two structures, it can limit effective movement and can cause a feeling of tightness and/or pain in the lateral thigh, and often down to the knee.
To encourage proper slide between these two structures the massage therapist will utilize techniques to pin the IT band as the VL moves distally over it. This technique will help to break down any fascial adhesions and encourage a healthier movement pattern between structures. A massage therapist with advanced training in modalities such as Active Release Techniques® will have the skills necessary to perform this protocol effectively.
Iliotibial Band / Tensor Fascia Latae:
Iliotibial Band (ITB) – Facts and Fallacies
There is much confusion when it comes to the iliotibial band/tract. This Latin derived term refers to the areas of attachment ilio- (iliac crest of the hip) and -tibial (shin bone).
IT Band Syndrome is often referred to as Runner’s Knee, which is a condition that can cause pain and discomfort where the IT band meets the lateral epicondyle (outside of the knee). This condition is also found in long-distance cyclists and tennis players.
When the leg is outstretched in extension, the lower portion of the IT band is positioned in front of the condyle of the knee. However, when the knee is bent in flexion, this band travels to the back of the knee.
ITB syndrome can develop for a multitude of reasons: Repetitive flexion/extension of the knee; poor quadriceps flexibility; weak or atrophied quadriceps; the excessive anterior tilt of the pelvis; leg length discrepancies and bow-legs [genu varum (knee bent outwards)].
Many fitness trainers and massage therapists continue to practice foam rolling and forearm massaging the H.E. double toothpicks out of the IT band and hope for great results. While a great idea, in theory, this band is extremely resilient. Trying to loosen this tough band is analogous to trying to loosen up a truck tire with a massage or a foam roller.
While there is no arguing that the ITB is a major factor contributing to lateral knee pain because of its attachment to the tibia; efforts to obtain results by placing compressive forces on the band directly are futile.
Tensor Fasciae Latae (TFL) and Vastus Lateralis
The tensor fasciae latae is the muscular portion of the IT band, and the most superficial muscle at the top of the anterior hip. This muscle is responsible for stabilizing the knee joint and is a muscle worth considering when addressing an unstable knee or pain on the outside of the knee.
The TFL is a flexor and abductor of the hip, so it moves the leg toward your chest and out to the side of the body. This muscle is difficult to address when lying on your back on a massage table because the other leg gets in the way.
Your massage therapist will likely have you lying on your side and utilize myofascial massage techniques to address the muscle through its range of motion.
The peroneus longus is one of three peroneal muscles, and their main action is to bring the foot outward at the ankle joint (eversion). The only one of these three muscles to attach near the knee joint is the peroneus longus.
This muscle can become fibrotic and contain trigger points near the knee that can translate to lateral knee pain. This pain occurs mostly in runners, especially those who tend to run on uneven surfaces.
Sports massage and trigger point therapy can help reduce the pain and discomfort of lateral knee pain associated with this muscle.
The genu articularis is a muscle worth noting. This small muscle is deep to the rectus femoris and vastus lateralis. When the symptoms involve a sharp pain just above the knee, this muscle should be considered.
This muscle is very short, deep, and well hidden. It functions to keep the suprapatellar bursa in place. If sharp pain is experienced deep and at the top of the knee cap, this little bugger may be the culprit. The genu articularis is difficult to find and treat effectively. The massage therapist must have a soft touch, yet be able to go deep through the rectus femoris and vastus lateralis muscles that are more superficial.
While traditional massage methods will not be possible due to the location of this small muscle, a massage therapist with training in advanced manual therapy techniques like Active Release Techniques® will be prepared to successfully treat this important little muscle.
Posterior and Medial Knee Pain – Meet The Muscles
Hamstrings and Gastrocnemius
We will focus on the hamstrings and gastrocnemius as a unit because they intersect at the back of the knee, specifically the upper heads of the gastrocnemius and the tendons of the biceps femoris and semimembranosus. During movement of the knee, these structures move in opposite directions of one another. It is important that they move freely against each other. If there is any lack of slide due to adhesions, there will likely be discomfort in this area.
The goal for the massage therapist is to reduce the friction around this area by working between the head of the gastrocnemius and the hamstring tendons to encourage slide between these structures as they move the leg through its range of motion.
When experiencing knee pain at the back outside of the knee, popliteus may be a player. This muscle assists in knee flexion, helps to rotate the shin bone inward when in flexion, and stabilizes the knee in rotation. This muscle – with the additional help of gastrocnemius, soleus, biceps femoris, and the collateral ligament – also helps with the positioning of the lateral meniscus in place because of its fascial connection.
When this muscle is tight it can have a tremendous impact on foot placement during gait by causing excessive pronation , causing problems throughout the entire kinetic chain.
This sneaky little bugger hides under the calf and hamstrings, so it takes precision and a little TLC to get to this muscle effectively.
Adductor Muscle Group
There are three main muscles responsible for bringing the legs together (adduction) the adductor magnus, adductor longus, and adductor brevis. The adductors are especially important when pain is experienced on the medial side of the knee, and if the knees cave inward. These are signs that there may be an imbalance.
When massaging this strong and massive muscle group, it is important for the therapist to address the entire group throughout the entire length of the muscle – from the pubic ramus, ischial ramus, and ischial tuberosity, all the way to the linea aspera, to the tendinous insertion at the adductor tubercle of the femur.
The gracilis is a long muscle that attaches to the pubic area and travels down the inside of the leg to just below the knee cap, attaching at the shin bone. This muscle helps bring the leg towards the midline of the body (adduction), as well as helps to flex (bend) the knee. Excessive tightness or trigger points along this muscle can lead to medial knee pain. The massage therapist will usually address trigger points along the length of this muscle, as well as assess adductor flexibility.
The sartorius muscle is the longest in the body, and it gets its name from the Latin word sartor, meaning tailor because of the muscles three actions. In early times tailors sat with their legs crossed, which represents the three actions of this muscle. The sartorius muscle flexes at the hip, bends the knee, and turns the thigh bone outwards. These three actions are necessary to cross one leg over the other.
This muscle attaches at the inside of the shin bone and can often cause pain local to this area.
This muscle holds a great deal of importance, and if it is not working at its optimum it can cause a cascade of problems: low back pain; anterior pelvic tilt, forward shoulder posture(kyphosis), over-stretched abdominals, digestive issues, and medial knee pain.
The Efficacy of Massage and Knee Pain
According to a study published in the 2006 Archives of Internal Medicine, people who received massage therapy for knee osteoarthritis reported seeing improvements in their pain and stiffness.
A follow-up study was published in 2012. PLoS One, found that to obtain optimal results from massage, Swedish massage treatments should occur weekly and the best session length is 60-minutes.
A study in the August 2015 Journal of Traditional Chinese Medicine also found that Chinese massage therapy can bring short-term relief from osteoarthritis knee pain.
“Osteoarthritis is a leading cause of disability and affects more than 30 million people in America,” said lead author Adam Perlman, M.D., program director of the Leadership Program in Integrative Healthcare at Duke University School of Medicine. “Medications are available, but many patients experience adverse side effects, raising the need for alternatives. This study demonstrates that massage has the potential to be one such option.”
Richard A. Lehman, LMT, CSCS
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