One would think that the knee, one of anatomy’s most used and abused joints, would have a little better engineering behind it. It doesn’t. And there’s a lot that can go sideways. In this episode of The Rebel MT, Allison details the anatomy of a knee, analyzes why it’s so easily injured, discusses how to best approach it as a bodyworker, and shares the story of her own clunker of a knee, which, it turns out, is why she’s even a massage therapist in the first place.
Rebel Massage Therapist: http://www.rebelmassage.com
Rebel Massage Therapist:
My name is Allison. And I am not your typical massage therapist. After 20 years of experience and thousands of clients, I have learned that massage therapy is SO MUCH more than a relaxing experience at a spa. I see soft tissue as more than merely a physical element but a deeply complex, neurologically driven part of who you are. I use this knowledge to work WITH you—not ON you—to create change that works. This is the basis of my approach. As a massage therapist, I have worked in almost every capacity, including massage clinics, physical therapy clinics, chiropractor offices, spas, private practice, and teaching. I have learned incredible techniques and strategies from each of my experiences. In my 20 years as a massage therapist, I have never stopped growing. I currently have a private practice based out of Long Beach, California, where I also teach continuing education classes and occasionally work on my kids. If they’re good.
AnatomySCAPES—created by and for hands-on professionals.
As therapists, we want more than labeled charts of muscles, nerves, and bones. We crave anatomy education that informs our touch, and we want the know-how for working with the “stuff” in between. We want the whole story.
Led by AnatomySCAPES co-directors, and ABMP Massage & Bodywork magazine columnists, Rachelle Clauson (FRS Fascial Net Plastination Project) and Nicole Trombley (Equilibrio Massage), our in-person lab workshops are in sunny San Diego, not far from the ocean. We teach you what the tissues look like, feel like, how they move, and how they relate to their surroundings.
Your eyes and hands learn to “see” what they could not see before. Come join us in the lab in 2023!
0:00:00.0 Speaker 1: Join AnatomySCAPES in San Diego, California, May 3rd and 4th, for their newest dissection lab experience about the human fascial system, Journey into the Matrix. Find out what's been missing from your muscle charts as you learn what fascia is, where it lives, and how it works. Co-directors, Rachelle Clauson and Nicole Trombley use engaging imagery, 3D model-making and interactive dissection lab experiences all rooted in current scientific research to help you see, feel, and understand what lies beneath the surface. Visit anatomyscapes.com/abmp to learn more.
0:00:47.6 S1: This episode is brought to you by Rebel Massage Deep Tissue Body Butter. Crafted because oil is too slick and lotion absorbs too fast, these organic professional grade body work butters give you the grip you've been looking for. The best techniques in the world can get lost without the right product to support them. Try the Get A Grip version for a more specific, focused work or the Total Meltdown version for that grip with a little extra glide, made by a massage therapist for massage therapists. Head over to rebelmassage.com to get your grip today.
0:01:36.2 S1: Owning a knee is like buying a new car. The second you drive it off the lot, it depreciates in value. Not that we're gonna sell our knees on the black market, no one is making the Forbes 500 list with that venture, but knees fall into that dreaded category of weight-bearing joints, alongside the hips and ankles, that start wearing down the moment we start standing up. True, one could argue that all of our joints are weight-bearing. Technically speaking, though, the more inferior a joint is, the more weight it bears. Ankles and feet clearly win the prize for the most weight-bearing, but knees take the cake for being the most injured joint in the body, which begs the question, why? Before I dive into answering this, spoiler alert, think Ford Pinto, I've got a knee of my own that has a story. It's the reason I'm here, actually. Well, not like here on this earth. That would be funny like Steven King's theory about an ancient turtle vomiting out our universe funny. No, nothing like that.
0:02:32.4 S1: I have an old ACL injury story. Like, 1985 old. I had no idea at the time where that pivotal pop would land me. All I knew is that I was like Sporty Spice as a kid. I played all the sports and never thought for one moment about how awesome my seamlessly fluid anatomy actually was. Now, I contend with a creaky, chronically stiff knee that will never bend all the way. It's a bit of a clunker. I was 15 years old and it was spring, which meant lacrosse season. I was at practice on the field running alongside a teammate trying to check the ball out of her possession. I got a couple of steps ahead, turned to get a better angle, but my cleat got stuck in the mud along with the lower half of my right leg. I heard the pop, saw the immediate swelling and learned pretty quickly what an anterior cruciate ligament is.
0:03:21.7 S1: That's not the story, though. The story is every day that followed that fiasco of struggling with rehab, redefining myself as an athlete, realizing my obliviousness about how the knee works, and the many, many years of then learning the hard way about how a knee heals. Most of us in the industry have similar stories of experiencing pain within ourselves and then wanting to help others with theirs, but the knee stands at the crux of my story. It's the reason I'm here as a body worker and it still vexes me to this day. To be clear, it doesn't vex me in that it stops me from doing what I love to do, but the knee itself is a peculiar piece of anatomy kind of like the Ford Pinto is a funny piece of engineering. I don't know that much about cars, actually, but I do know that the Ford Pinto finds itself among some of the worst cars ever engineered. The knee, not much different. It's design serves a purpose, of course. Locomotion is important to human survival and the Ford Pinto can actually drive. What vexes me is the combination of its simple structure, the complex elements that are required to hold it together, and the lack of muscles supporting it. This, paired with its location, all that weight it's responsible for, makes it ripe for a breakdown like the Ford Pinto. Allow me to explain.
0:04:43.9 S1: The knee is categorized as a synovial joint, which means it is freely moving, not like the stuck joints in the skull. And then sub-categorized as a modified hinge joint, which means it swings like a door hinge with some modification. To be specific, the knee flexes and extends like the opening and closing of a door, but it can rotate a little in either direction like one of those fancy Lamborghini doors that swings out and then pivots up. Fun fact, these are referred to as Lambo doors or scissor doors, and apparently, they cause a lot of problems. Not shocking. What all of this means is that the knee can flex bringing the heel to the glutes, it can extend straightening the leg back out, and it can slightly pivot so that the tibia and fibula rotate internally and externally away from the position of the femur like if you wanna kick a soccer ball with the inside or outside of your foot. But the structure of the knee is a funny thing. It is the largest joint in the human body comprised of three, or four, bones depending on your source.
0:05:42.7 S1: The femur or the thigh bone, the tibia, the shin bone, the patella, the kneecap, and if you like, the fibula or tibia's little helper. The articulation or the joining of these bones is at the core of the problem. You see, the femur rounds out at the knee into two large bumps called condyles. The word condyle, interestingly, stems from the Greek word "condulus", meaning knuckle. The top of the tibia, though, does not support these knuckles very well. It is flat for the most part except for a slight bump in the middle, not quite the stability of, say, a ball and socket joint. And then there is the patella, this floating bone that sits at the front of the knee. The patella is categorized as a sesamoid bone, which means it is embedded in a muscle or tendon. In this case, the quadriceps tendon. It also serves as an attachment site for the patella ligament connecting the quads and the patella down to the tibial tuberosity. The existence of the patella both protects the knee joint and acts as a moment arm that serves to increase the quad's ability to create extension in the knee. There's a lot of physics in there, which we do not have to get into. Just know this, the patella is cool, but problematic.
0:06:54.6 S1: So, essentially, there are these two knuckles that sit atop a relatively flat surface with a floating bone hanging out at the front, which leaves this joint exceptionally unstable and looking a bit like a ballerina in Pointe shoes balanced on top of a free-standing Greek column trying to harness a discus. It is going to need some help. The help, in my opinion, comes in the form of either stitches or supporters. The stitches that weave throughout fastening everything together are the ligaments, of which there are many. The two collateral ligaments, one medial and one lateral, the two cruciate ligaments, the anterior, my personal fave, and the posterior. The word cruciate actually means cross-shaped, which is fitting because the ACL and the PCL cross over each other at the center of the knee, and there are also, bear with me here, the medial and lateral patella femoral ligaments, the left and right oblique popliteal ligaments, the left and right arcuate popliteal ligaments, and the posterior meniscal femoral ligaments. These are lesser well known, but they are right there in the thick of it.
0:08:00.7 S1: Next, there are the supporters or the cushions and lubricators. The medial and lateral menisci are like little pillows for where the femur sits on the tibia. Remove them and you'll see the articular cartilage at the ends of these bones aptly named as they help these articulating surfaces, well, articulate a little better. There is a fat pad hanging out behind the patella sparing it from direct contact. And start meandering through the knee and you will find 11 versa scattered throughout. I will spare you from naming them all, but those pockets of sunshine are like little oil packets easing all of that friction that comes with all that locomotion. Then there is the articular capsule of the knee joint, which falls in both the stitching and the supporting divisions. This heavy player encapsulates most of the parts enclosing at the ends of both the femur and the tibia, it has two layers or membranes, and a lot of responsibility. Its outer layer, or fibrous layer, is pretty thick and holds everything in and it's inner lining or synovial membrane secretes synovial fluid keeping all the parts lubricated. So, yeah, it's both a stitch and a supporter.
0:09:08.7 S1: You may note that all of the anatomy that I've just listed falls under the class of connective tissue. Yep, menisci, ligaments, cartilage, versa, and even the bones themselves are all considered connective tissue. And as you may have guessed, there's more. Most of the muscles that move the knee are not actually on the knee. That would be a funny sight. Wouldn't it? Instead, the majority of the muscles that move the knee are either above it or below it. They all have tendons, though, and those tendons reach across to grab onto the bone they are trying to move. And this means a couple of important things. One, there is even more connective tissue to consider and, two, working on the knee involves understanding how to work with the connective tissue. Before I begin my theories on approaching the knee as a body worker, there are actually a couple of muscles tucked into the popliteal region of the knee and I will address these, but the stockpile of connective tissue at the knee is the basis for so many knee techniques. Like I mentioned before, we are working with a lemon. So we can't treat it like a Ferrari.
0:10:10.2 S1: When a client comes into your office with knee issues, as always, the more detail you get about what they are experiencing, the better, but because there are so many things that can go sideways in a knee, I will pull from my own story and hope that it provides enough inspiration. Almost 40 years later, I've got an old ACL tear repaired with both arthroscopic and reconstructive surgery and not very well rehabilitated immediately after surgery. I was a teenager. Currently a runner and standing most of the day for my work, I have three plus decades of scar tissue buildup and weight-bearing abuse to contend with. So here is my approach. Warming up the muscles that cross the knee comes first. The quads, the hamstrings, and the gastrocs are a good start, but getting into the adductors and even the glutes and the TFL, that IT band is no joke, is a huge help. Once these muscles are nice and warm, position your client supine so that their knee is bent to around 90 degrees and you are sitting on the top of their foot to stabilize it. With broad palms on either side of the knee, begin the friction frenzy.
0:11:14.0 S1: Like you might be rubbing sticks together to start a fire, race your hands back and forth along the medial and lateral ligaments, tendons, and articular capsule to begin the melting process. Disclaimer, no one is melting anything here. There is so much controversy over what myofascial release and friction strokes actually do seeing as research has shown that we can't actually change the make-up of connective tissue, but I will say this, applying friction is applying external movement in ways that tissues may not be capable of moving on their own. Rapidly sliding the tissues over each other creating warmth, accelerating motion, and improving velocity is going to help all the layers begin to glide over and around each other better. And this is a good thing for a stuck knee. Plus, it feels incredible.
0:12:02.9 S1: Moving away from the sides of the knee, use one hand to support under the knee and use the other hand, palm, fingers, thinner, eminence, whatever you choose, and bring that same friction all around the patella, the patella ligament, the quadricep tendon, and all the little spots in between. Holding the knee with both hands and using both thumbs to cross-friction against each other just under the patella can free so much of that stiffness. Then, just play around with friction. Bring the leg out laterally so that the lower leg drops towards the floor off the table and keep that fire going up into the quads through the IT band and even down around the top of the tibia. And throw a little love to the fibula because even though it's used to being left out, that doesn't mean it doesn't like some attention.
0:12:47.5 S1: And lastly for the icing on the cake, with your client prone, gently friction with your palms over the back of the knee. Everything is a little more exposed here. So lighten up on the aggression. Then, lift their foot and flex their knees so that their ankle is resting on your shoulder. With the popliteal area softened, sink into the calf from heel to knee and slide down to where the plantaris peaks out between the two bellies of the gastrocs. With everything nice and warmed up, a moderate compression here should do the trick. Ask your client to dorsiflex their ankle and offer the plantaris a nice stretch. As always, the possibilities here are endless, but if you keep in mind that the knee is a bit of a jalopy held together with a motley crew of stitches and supports, you can keep a knee feeling young again. It may not ever run like a Ferrari, but we gotta love the Ford Pintos we were given.
0:13:39.7 S1: And here we are, the end of the episode. Thank you to the extraordinary crew over at ABMP for helping me get my words into your ears. And if you wanna get any of your words into my ears or, more accurately, into my brain via my eyeballs from a computer screen, drop me a line at firstname.lastname@example.org. That's R-E-B-E-L-M-T at ABMP dot com.
0:14:04.5 S1: I always wanna hear your questions, comments, suggestions or salutations. Also, if you're interested in checking out anything else I'm doing, head over to rebelmassage.com where you will find all sorts of fun things to click on like homemade organic products for your practice, cool links to continuing education classes, thoughts I have typed up and posted here and there, and other Rebel Massage dabblings.
0:14:30.4 S1: Members are loving ABMP 5-minute Muscles and ABMP Pocket Pathology. To quick reference web apps included with ABMP membership, ABMP 5-minute Muscles delivers muscle specific palpation and technique videos plus origins, insertions, and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology created in conjunction with Ruth Werner puts key information for nearly 200 common pathologies at your fingertips and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members, log in at abmp.com and look for the links in the featured benefits section of your member homepage. Not a member, learn about these exciting member benefits at abmp.com/more.