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									                                     AN INTEGRATED APPROACH
                                       TO REHABILITATION OF
                                                                            Part II
                                                                     with Art Riggs
 After introducing the importance of a holistic view of knee rehabilitation in order to restore proper gait, the
 previous article ended with our fingers deep in the IT band. The techniques that were demonstrated began
 with more superficial work that is appropriate soon after injury or surgery, and progressed to tools for re-
 turning flexion mobility. We now turn our attention to treatment strategies to improve full extension to the
 knee and to a more detailed explanation of the complexities of gait, including techniques to deal with the
 compensatory reactions in the feet and hips that occur after injury.

Treatment #5 Returning                     deter you; just use the usual pre-         tory reflexes to the quadriceps
Normal Extension                           cautionary techniques to distin-           inhibiting them from contracting
                                           guish the muscle tissue from the           to straighten the knee. They also
Because of the impossibility of
                                           artery and be precise in your              recruit their allies (agonists?),
normal gait without full knee
                                           work.                                      the hamstrings, to strongly con-
extension, I feel that this is the
                                                                                      tract and prevent the knee from
major goal for proper rehabilita-          Since these are relatively weak
                                                                                      straightening. Reducing irrita-
tion after injury or surgery. Of           flexors of the knee compared to
                                                                                      tion to and lengthening these
course tight fascia and muscles,           the hamstrings, popliteus and
                                                                                      small muscles is a first step in
particularly the hamstrings, will          plantaris are often neglected in
                                                                                      proper functioning of the larger
prevent full extension, but the            conventional therapy. Their role
                                                                                      muscle groups.
therapist should also be skilled           in preventing full knee extension
in working with the deeper re-             is less one of strong muscular
strictions in the joint itself by          resistance than of being
using mobilization techniques              “agitators” delegating re-
(shown later) to work with the             sponsibility to stronger mus-
knee joint. Let’s begin with               cles that do the dirty work of
some of the major muscles that             preventing knee extension.
contract after trauma and pre-             The body always reacts to
vent the knee from straightening.          pain as a strong dictate of
                                           movement, and both these
Working with Popliteus and
                                           muscles can be sensitive or
                                           painful when stretched if
One area of caution: You may               they shorten after injury. At
                                                                                      Photo # 10-- Popliteus and Plan-
feel a fairly strong pulse from the        the first sign of pain in popliteus
popliteal artery, but don’t let this       and plantaris, they send inhibi-
Note: This article will use the more common usage of the term “leg” to refer to the entire lower extremity as opposed to
strict medical terminology where “leg” specifically refers to the portion of the lower extremity between the knee and ankle.

                                                                                                      Bodywork e-News 11
                            Treatment for the Legs
Although most of the examples         Working with the Ham-
in this article will recommend        strings
working with muscles in a
                                      These are the most important
stretched position to effect a re-
                                      muscles to relax and stretch to
lease, working in a very sensitive
                                      allow extension. The hamstrings
area like the posterior knee is
                                      will have learned to contract
best done with enough flexion to
                                      anytime the knee approaches the
allow easy entry through superfi-
                                      painful angle of straightening.
cial layers and have popliteus
                                      You must not only release any
and plantaris relaxed so they are
                                      fibrous restrictions, but must
not irritable. As they relax and
                                      also train these muscles (and to
lengthen with your work, then
                                      a much lesser extent, the gas-
slowly extend the knee by using
                                      trocnemius which also crosses
a smaller bolster to retrain their
                                      the joint and is a minor flexor) to
stretch receptors to feel safe with
                                      relax into a lengthened position.
more extension. Once these
                                      In the prone position refrain
muscles relax, the primary flex-
                                      from using a bolster under the
ors and extensors of the knee can                                            Photos #11 & 12 --Facilitated
                                      ankle so the leg can straighten.
begin to work properly without                                               Lengthening Strokes for the
neurological interference from        Hamstring work is almost always        Hamstrings
popliteus and plantaris.              beneficial for injured knees, but
                                                                             Although this may be the most
                                      remember that if the knee is still
Usually popliteus and plantaris                                              important muscular work you do
                                      inflamed and extension is pain-
are shortened as a protective                                                to return normal function to the
                                      ful in the joint, then it is a natu-
mechanism rather than from ad-                                               knee, luckily, it is relatively sim-
                                      ral reflex for these muscles to be
hesions. Therefore, strokes in a                                             ple work without fancy tricks.
                                      short and tight. If the joint is
distal direction are most effec-                                             Notice that if you have your cli-
                                      painful in movement or struc-
tive to train them to relax and                                              ent slide down so that both feet
                                      tural barriers such as adhesions
lengthen. Use very soft fingers to                                           are hanging off the table; com-
                                      are present, then the hamstrings
sink through superficial tissue to                                           paring the injured knee with the
                                      will naturally contract to protect
find the tight muscles and very                                              healthy knee is an easy measure-
                                      the knee. Extensive work with
slowly stroke distally, with an                                              ment to determine normal ex-
                                      the hamstrings will always be
intention of simply relaxing and                                             tension. In this case, the right
                                      helpful, but permanent length-
stretching an irritable muscle.                                              knee doesn’t allow full extension,
                                      ening will only take place after
The texture and depth of pop-                                                so the right heel is about an inch
                                      the joint heals. This will some-
liteus and plantaris is very simi-                                           higher than the left. Use your
                                      times take several weeks or even
lar to what it feels like to work                                            fingers, knuckles or forearms to
                                      months, so follow-up visits over
on the scalenes in the anterior                                              slowly stroke distally while visu-
                                      an extended period of time are
neck, so use the same principles.                                            alizing grabbing and stretching
                                      helpful to incrementally
While working on these muscles,                                              the hamstrings. You should con-
                                      lengthen the muscles. Joint mo-
it is also a perfect time to begin                                           tinue your intention of lengthen-
                                      bilization will be very helpful in
stretching the more superficial                                              ing below the knee to the gas-
                                      freeing the joint so the ham-
fascia in the posterior knee.                                                trocnemius and soleus. Note the
                                      strings will not contract for pro-
                                                                             dorsiflexion of the ankle to pro-
                                                                             vide stretch.

                                                                                           Bodywork e-News 12
                            Treatment for the Legs
                                     The largest paradigm shift in my      Straightening the knee to full
                                     bodywork occurred after I had         extension requires that there is
                                     been practicing for almost 10         freedom for the tibia to glide
                                     years when I took a spinal me-        back and forth on the femur
                                     chanics class and began working       (shear) rather than just straight-
                                     with joints, not only in the spine,   ening like a simple hinge. Soon
                                     but virtually anywhere on the         after injury, adhesions begin to
                                     body. I hope that new therapists      form, and even the slightest limi-
                                     won’t wait as long as I did.          tation can impact gait. Most
Photo #13 --Anchor and Stretch                                             therapists are trained to work on
                                     With the knee, we are primarily
Techniques for the Hamstrings                                              the knee supported by a bolster,
                                     working to improve extension,
                                                                           but this practice prevents ex-
Not all your work with the ham-      flexion, and a bit of rotation be-
                                                                           tending the joint into its struc-
strings will be to educate them to   tween the femur and the tibia.
                                                                           tural barriers to release them.
lengthen. There may be signifi-      Anatomists agree that the knee
                                                                           Early in the recovery process,
cant thickening and adhesions in     joint is the most complicated in
                                                                           you may work in supine position
different depths of the muscles      the body, but some relatively
                                                                           with the leg just resting extended
or surrounding fascia that need      simple joint mobilization tech-
                                                                           on the table as you gain your cli-
detailed release. Anchor and         niques can be practiced safely
                                                                           ent’s confidence, but as you be-
stretch strokes using precise        and effectively even if you are
                                                                           gin making progress, place a bol-
pressure at fibrosed areas are       new to this concept. Although it
                                                                           ster under the ankle or calf so
effective. Visualize that you are    is tempting to look at the joint as
                                                                           the knee is suspended in space
placing all of your intention on a   a simple hinge, in reality, when
                                                                           (“bridging”) as demonstrated in
knot in a rubber band. Anchor        moving from extension to flexion
                                                                           the photo.
with proximal oblique pressure       and back, the tibia must slide
at adhesions when the knee is        anterior and posterior and rotate
flexed and then slowly lower the     relative to the femur. After knee
ankle to extend the knee and fo-     injury or surgery, tightening
cus the stretch at your anchor.      muscles that surround the knee
                                     can contract and compress the
Cautionary note: If your client is
                                     joint from all sides impeding the
recovering from anterior cruciate
                                     articulation of the bones. If nor-
repair, the surgeon may prefer
                                     mal movement between the tibia
that the knee does not reach full
                                     and femur is not returned within
extension. It is advisable to
                                     a reasonable period of time, then
check with the doctor for guide-
                                     adhesions form deep in the joint
lines about the limits of exten-
                                     and can permanently restrict
sion to work for. This caution
                                     joint mobility. Since most thera-
should also apply to the use of
                                     pists are apprised of ways to
joint mobilization techniques
                                     stretch the knee into flexion, we
shown in the next section.
                                     will concentrate on extension
                                     and rotation.

Treatment #5--Joint Mobili-          Anterior and Posterior
zation Techniques for the            Shear of the Tibia and Fe-            Photos # 14 & 15--Anterior/
Knee                                 mur                                   Posterior Sheer

                                                                                        Bodywork e-News 13
                            Treatment for the Legs
Remember to place your inten-         mobilization techniques is to ap-     Reverse the process as you pull
tion deep in the joint, and that      ply enough force to mobilize the      the leg back into full extension
unlike simply stretching the knee     joint, but not so much force that     by rotating the tibia externally
into extension as you would if        your client has pain or is fighting   through the range of motion. Of
the client is prone, you are ap-      against you.                          course it can even be more help-
plying posterior pressure directly                                          ful to perform this technique
                                      Mobilizing Rotation of the
down towards the table and visu-                                            while also stretching tight fascia
                                      Tibia and the Femur
alizing sliding the tibia and fe-                                           or muscles, but your primary
mur in opposite directions. Mo-       When the knee moves, the tibia        intention is to be rotating the
bilization can be applied in two      actually rotates upon the femur,      tibia around the femur.
ways. First, you can use rela-        rotating externally as the knee
                                                                            As you flex the knee by helping
tively quick pulsations of pres-      extends and internally as the
                                                                            your client bring her knee to her
sure with about two pounds of         knee flexes. If rotation is im-
                                                                            chest, place steady pressure to
force, repeating the pulsations       paired, then flexion and exten-
                                                                            rotate the tibia internally. When
for a minute or more. It is crucial   sion are impaired. The rotation
                                                                            you reach the end range of com-
to move the joint all the way un-     is subtle, but important to work
                                                                            fortable flexion, stay in this posi-
til end range resistance is felt.     with.
                                                                            tion and continue to exert gentle
This is helpful in over-riding
                                      Cautionary note: Rotational joint     internal rotational force while
conscious soft tissue holding
                                      mobilizations should not be per-      waiting for softening of resis-
patterns and begins to free up
                                      formed if there is any question of    tance
the joint as the bones slide back
and forth. Secondly, you can ap-      a torn meniscus or ligaments
ply a steady pressure downwards       after injury, but are very helpful
with a bit more pressure, but be-     after surgical repair of such inju-
ing careful that your client is not   ries.
too uncomfortable. Sustain the
pressure for a minute or two,
waiting for a feeling of softening
in the joint and a sense that the
bones are sliding past each other.

In the first photo I am putting
pressure on the femur so that it
is sliding posterior relative to
the tibia. Conversely, by placing
your hands below the knee on
the tibia, you are now sliding
the tibia posterior relative to
the femur. As you become
adept at these procedures you
can expand your effectiveness                                               Photos # 18 & 19 —Seated Rota-
by experimenting to either                                                  tional Mobilization
compress or traction the joint as
you apply anterior/posterior          Photos # 16 & 17 —Supine Rota-        This technique works well if your
shearing pressure. The key to the     tional Mobilization.                  client has large or heavy legs or
success with this and most joint                                            you feel unstable on the table. It

                                                                                          Bodywork e-News 14
                            Treatment for the Legs
has the added advantage of sta-       Toe off: This is the important                steps of very elderly people (I
bilizing the femur during move-       stage of walking that propels the             find that working for better knee
ment and of the natural gravity       body forward. With limited knee               extension is greatly appreciated
of the lower leg placing traction     extension, the stride is shortened,           by my older clients). If the foot is
the joint while you work. As you      approximating the “mincing”                   not far enough behind the body,
have your client flex her knee,
rotate the tibia medially and
then reverse the rotational direc-
tion to external as the knee is
extended. Remember that the
most release will happen at the
end range of movement so hold a
sustained pressure at this range
of motion for up to a minute.


The treatment suggestions that
we have covered so far should
provide considerable benefit for
your clients who have knee prob-
lems and anyone looking for bet-
ter movement and freedom of
the entire leg. As mentioned ear-
lier, a great many people have
sustained injuries that persist in
compensatory patterns of move-
ment that have been ingrained
for decades. A holistic treatment
plan that deals with the compli-
cated relationship between the
feet, ankles, knees, and hips will
be a great boon to your practice
and will provide better move-
ment for all your clients, not just   Box 1: In varying degrees, limited knee extension will have the following results in gait,
with injuries.                        including a short stride. If you can return normal extension to the knee (the primary
                                      restriction), then most of the secondary compensations in the foot and hip will improve
Now, let’s revisit the chart in Box   with minimal intervention. Muscles that are inhibited will need to be strengthened, and
1, more detail to discuss the ba-     any good sports medicine book will have suggestions. These images confine themselves
sic kinesiology of walking gait at    to the pelvis and below, but notice how pelvic tilt is also affected and will have effects up
toe off and heel strike with more     the spine and beyond. If you consider how a tight psoas on the affected side will present
                                      side-bending and rotational strain on the lower back, it becomes clear how the effects of
attention to the feet, ankle, and
                                      injury radiate globally.
                                                                                                     Bodywork e-News 15
                             Treatment for the Legs
it loses its power to propel the       straighten, then the leg is unable    Although one can understand
body forward and energy is ex-         to swing forward in front of the      these kinesiological principles at
pended in lifting the body up in-      body with ease. Instead of land-      a cerebral level, by far the best
stead of forward. The foot ceases      ing on the rear of the heel with      way to understand what is hap-
to flex at the toe joints              the ankle slightly dorsiflexed, the   pening in your client’s body is to
(transverse arch) and become           foot lands flat at a more vertical    feel the sensations in your own
immobile causing the plantar           angle, preventing the normal          deep experience by mimicking
fascia to shorten. The ankle re-       rolling motion from heel to toe       the limping pattern. What joints
mains in a neutral position            that dissipates shock. Gastrocne-     aren’t moving? What muscles
rather than plantarflexing to          mius and soleus remain short          are contracting improperly? If
push off, so tibialis anterior be-     and will need lengthening so the      you simply concentrate to pre-
comes short and gastrocnemius          foot can dorsiflex. The ankle will    vent your knee from straighten-
and soleus become weakened.            need to be mobilized in both          ing, you will experience the pro-
                                       plantar and dorsiflexion be begin     found compensations from the
As previously covered, since the
                                       working like a smooth hinge.          toes up through the hips as you
knee won’t extend, the ham-
                                                                             walk. In classes, I actually have
strings, upper gastrocnemius,          In addition to being short in the
                                                                             students tape their knees to pre-
plantaris, and popliteus become        distal portion to prevent knee
                                                                             vent full knee extension, and
shortened and will all need            extension, the hamstrings will
                                                                             also have them experiment with
lengthening work, but don’t for-       also remain tight near the ischial
                                                                             placing a pebble in the forefoot
get to work with the superficial       tuberosity as they prevent a full
                                                                             or heel of their shoes. This is an
fascia, especially behind the knee     leg swing forward. It is easy to
                                                                             excellent way to feel both the
to stretch this tissue. Perform        see how working with the ham-
                                                                             joint and muscular adaptations
joint mobilization to return nor-      strings is the key to rehabilita-
                                                                             to pain or discomfort, and will
mal flexion, extension and rota-       tion.
                                                                             enable a strategy for treatment.
tion of the joint itself.
                                       All of these complex feedback
                                                                             Treatment #6 Balancing
Many therapists neglect the hip        loops occur from the simple re-
                                                                             Secondary Compensations
in rehabilitation of the leg. If the   striction to knee extension. Re-
leg cannot extend freely to the        member the chicken/egg rela-          Now we can move to some tech-
rear, then rectus femoris and          tionship with the joint and the       niques to return proper function
psoas will become short because        muscles. The lack of proper joint     to secondary areas that respond
they don’t need to release to al-      movement will cause the mus-          to knee dysfunction. Work to
low the hip to extend for a long       cles to shorten, but these short-     satellite areas is extremely im-
stride. They also will become          ened muscles will solidify im-        portant because of their ten-
fibrous from overwork, since the       proper joint movement if the          dency to reinforce limping pat-
leg is not propelled by the foot       walking pattern becomes in-           terns, but until proper function
and ankle to swing forward, rec-       grained. Be sure to become            is returned to the primary site of
tus femoris and psoas will have        skilled in joint mobilization tech-   injury, the secondary compensa-
to use more energy to lift the leg     niques on the joint itself to help    tory patterns will persist. It is
to overcome inertia. Instead of        restore proper mechanics. The         perfectly appropriate to work on
swinging freely forward, the           best news is that these tech-         secondary compensations
knee will be lifted at a more ver-     niques work equally well for re-      throughout your treatments be-
tical angle by the pull of these       storing proper movement pat-          cause they often cause discom-
muscles.                               terns after injury to the feet, an-   fort as they adapt. However,
                                       kles, and hips.                       your primary goal should be to
Heel Strike: If the knee cannot

                                                                                           Bodywork e-News 16
                            Treatment for the Legs
return the primary injury site to                                         the ankle. Use your knuckles or
health as soon as possible, and                                           the ulnar surface of your forearm
then focus on the feet and hips.                                          to soften and free this tissue.
                                                                          Anchor in one direction and then
                                                                          mobilize the ankle in any oppos-
Freeing the Toes, Trans-                                                  ing direction to improve freedom.
verse Arch, and Plantar Fas-                                              This is an excellent technique
cia                                                                       after ankle sprains or on virtu-
                                                                          ally anyone who wishes easier
With a limping gait, the feet be-                                         ankle movement.
come stiff and inflexible as they    Photo #21 Softening the Plantar
land similar to wearing a very                                            Improving Hip Mobility
                                     Fascia and Freeing Dorsiflexion.
stiff-soled shoe that prevents the
toes from flexing and providing
power on toe off.
                                     can be difficult when the leg is
                                     straight. This technique offers
                                     the advantage of using your body
                                     weight, being able to exert strong
                                     pressure to dorsiflex the ankle,
                                     and the use of the broad and
                                     comfortable tool of your forearm.
                                     This technique is also useful to     Photo #23 Freeing the Proximal
                                     treat plantar fasciitis.             Hamstring for Easier Leg Swing

Photo # 20 Restoring Toe Exten-
                                     Improving Ankle Movement             By flexing the leg with the knee
                                                                          relatively straight, you can place
Working in the end range of mo-                                           the hamstrings on a nice stretch
tion is the key to this technique.                                        while releasing any areas with
With soft fingers, bend the toes                                          anchor and stretch strokes
as far as possible into an upward                                         against the stretch. Don’t strain
dorsiflexed extension. With                                               yourself by holding the leg with
knuckles or fingers patiently                                             your arm if your client is large.
work the area of the metatarsal                                           You can be inventive and use
heads, with both cross-fiber                                              your shoulder and body to apply
                                     Photo #22 ---Freeing the Ankle
strokes and in the direction of                                           stretch to the leg or even have
lengthening of tissue. This is                                            your client apply the stretch by
also and excellent way work on                                            using a strap over the bottom of
the plantar fascia for the length                                         her foot.
                                     The front of the ankle is sur-
of the foot.
                                     rounded by a fibrous retinacu-
                                     lum that can stiffen the ankle
                                     joint like an Ace Bandage, limit-
The biomechanics of stretching
                                     ing both plantarflexion and dor-
the foot into dorsiflexion in ei-
                                     siflexion and causing torsion on
ther the prone or supine position

                                                                                        Bodywork e-News 17
                           Treatment for the Legs
                                      Apply pressure with you other          will present his or her own
                                      hand to extend the hip and work        unique adaptive mechanisms to
                                      in the direction of stretch work-      injury and that the solutions to
                                      ing with your fingers for superfi-     solving limping problems rarely
                                      cial tissue and with you forearm       are simple or lie in only one area.
                                      for deep muscular work on the          These considerations are what
                                      quadriceps.                            make our work so interesting
                                                                             and rewarding.
                                      This technique is also useful for
                                      working with the psoas in a            Remember that a holistic treat-
                                      stretch, but do not over-extend        ment not only includes a broad
Photo #24 Releasing the Rectus
                                      the hip. If the hip is too ex-         view of distant joints and com-
                                      tended, it becomes difficult to        pensations, but should consider
The rectus femoris and front of       sink through the superficial tis-      the whole person you are work-
the pelvis will become short and      sue in the anterior pelvis to con-     ing with, including the causative
tight if your client has been         tact the psoas.                        factors of their injury (especially
walking with a limp that pre-                                                with overuse injuries), their ap-
vents the leg from freely swing-                                             proach to self-help though home
ing back into extension. Work-        I hope that this article have          programs of stretching and
ing in the neutral supine position    given you insight into the inter-      strengthening, and their emo-
will soften tissue but not stretch    esting interrelationship of the        tional feelings. Fear, anger, de-
enough to open the area. This         joints of the legs as well as some     pression, and self-judgment are
position allows you to work eas-      specific tools to successfully treat   often associated with injuries.
ily using your own body weight        problems, not only to the knees,       We always treat more than mus-
as you stretch the leg into exten-    but to the other joints of the         cle, tendon, and bone. The best
sion. Support your client’s head      lower extremity. All joints of the     therapists’ skills are more of an
and neck, and possibly low back       leg are inextricably linked to-        art than a craft as they provide a
with pillows, and have your cli-      gether in a complex feedback           hopeful healing environment for
ent pull her opposite leg to her      loop that must be treated in a         their clients with their humanity
chest to keep the pelvis in a neu-    holistic manner for the best re-       and contact with the person be-
tral position.                        sults. Remember that each client       hind the injury.

                                                           Art Riggs
                    Deep Tissue Massage & Myofascial Release
                     Best Selling 7 Volume, 11 Hour
                     encyclopedia of advanced massage DVD
                     and a visual guide manual
                                     Available from:

                        Art Riggs is planning to travel to Australia in Oct 2010,
                        to register interest for workshop:

                                                                                           Bodywork e-News 18

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