6 P H Y S I O T H E R A P Y JUNE, 1976 T h is policy p roved successful a n d p o p u la r (b o th w ith the p a tie n ts a n d th e p h y sio th era p ists) d u rin g m y fo rty years a t St. T h o m a s ’s) a n d sh o u ld be a d o p te d all over the w orld. The p a tie n t re m a in s u n d e r m edical su pervision th ro u g h o u t a n d is tre a te d by tra in e d e th ic al personnel. A ll th a t need be d o n e no w is fo r d o c to rs to recognise su itable cases a t once a n d fo r p h y sio th era p ists to e q uip them selves to tre a t accordingly. N e ith e r p resents th e slightest difficulty, m erely th e exercise o f a little goodw ill. S U M M A R Y I n m y experience, th e only g oo d re a so n fo r spinal m a n ip u la ­ tio n betw een th e th ird cervical a n d fifth lu m b a r v e rte b ra is an e n d e a v o u r to reduce a displacem ent o f a sm all frag m e n t o f disc. T h is is w h a t lay -m an ip u lato rs, still w ith o u t realising it, have been d o in g fo r th e p a st h u n d re d years a n d h ave gained m uch k u d o s thereby. T h is h a s led th e m o n to unten a b le h y potheses. A n a tte m p t is m ad e to su b stitu te a valid a n a ­ to m ical e x p la n a tio n fo r these successes, in th e h o p e th a t d o c to rs a n d p h y sio th era p ists will n o w accept these logical m easures a n d in c o rp o ra te th em in th e ir daily practice. R E F E R E N C E S C O L D H A M , M . (1975). C h iro p ra c tic . C a n a d .M e d .A ss.J. 929. C Y R IA X , J. (1945). L u m b a g o : T he M e chanism o f D u ra l P a in . L an c et, ii, 427. C Y R IA X , J. (1950). T re a tm e n t o f L u m b a r Disc-L esions. B rit.m ed .J., ii, 1434. C Y R IA X , J. (1954). T e x tb o o k o f O rth o p a e d ic M edicine. Vol. I, P la te s 5-6. C Y R IA X , J. (1975). Ibid. Vol. 1, 6th E d. 462. C Y R IA X , J. (1975). Ib id . Vol. 2, 8th E d . 274. D A N D Y , W. E. (1929). L o o se cartila g e fro m In te rv e rte b ra l D isc sim u la tin g T u m o u r o f Spinal C o rd . A rc h .S u rg ., 19, ii, 660. K E Y , J. A . (1945). In te rv e rte b ra l D isc L esio n s: C o m m o n e st C ause o f L ow B a ck P ain. A n n .S u rg ., 121, 534. The Value of Deep Transverse Frictions in Sports Injuries with particular reference to the knee M A R G A R E T C O L D H A M , M .C .S.P . D e ep tran sv erse frictio n is a n in v alu a b le tre a tm e n t fo r sp o rts injuries. H ow ever, w hen this type o f m assage is being c arried o u t, it m u st be given to th e exact', sp o t a n d in the c o rre c t w a y ; it is o f n o use to look fo r th e ten d e r a rea a nd to m assage there. O ne m u st e xam ine the p a tie n t, find o u t which tissue is a t fa u lt a n d 'th e n look fo r tenderness alo n g that stru c tu re . T h e friction m u st th en be given transversely to the tissue, n o t longitudinally. A IM S O F D E E P T R A N S V E R S E F R IC T IO N S 1. In m u sc u la r lesions th e aim is to m obilise th e m uscle by s e p a ra tin g th e a d h esio n s betw een th e in d ividual m uscle fibres th a t a re re stric tin g its m o bility to w a rd s b ro a d en in g e ac h tim e it c o n tra c ts. T h e m uscle m u st be k ept fully relaxed d u rin g th e friction. 2. In lig a m en to u s lesions, th e objective is to m ove the lig a m en t to a n d fro o ver a d ja c e n t b o n e in im ita tio n o f its n o rm a l b e h a v io u r a n d th u s m ain ta in its m obility. 3. W h en a te n d o n h a s a sh e a th , c re p itu s m ay be present in d ic a tin g ro u g h e n in g o f the te n d o n sh e a th . D e ep transverse frictio n sm o o th e s the gliding surfaces. D u rin g th e transverse fric tio n th e te n d o n m u st be k e p t ta u t. I n te n d o n s w ith o u t a sh e a th , d eep tran sv erse frictio n s b re a k u p sc a r tissue a t the in se rtio n o f th e te n d o n in to b o n e o r sc a r tissue w ithin the te n d o n . T E C H N IQ U E S O F D E E P T R A N S V E R S E F R IC T IO N S 1. A s m en tio n ed e arlier, th e right s p o t m u st be fo u n d . ^ 2. T h e p h y sio th e ra p ist’s fingers a n d th e p a tie n t’s skin m ust m ove as one. I f m ovem ent tak e s place betw een th e p a tie n t’s skin a n d th e p h y sio th e ra p ist’s fingers, th e n th e m assage reach es o nly th e skin a n d n o t th e tissue a t fa u lt, a nd will also give rise to a blister. 3. T h e frictio n m u st be given across th e fibres com posing th e affected stru c tu re s, i.e. transversely. 4. T he frictio n m u st b e given w ith sufficient sweep. 5. T h e frictio n m ust re ac h deeply e n o u g h . It is m ore effective to m assage deeply fo r a few m in u te s th a n to go on indefinitely w ith gentle m assage. 6 . T h e p a tie n t m u st a d o p t a su itab le p o sitio n which ensures th a t the tissue is e ith e r ta u t fo r a te n d o n sh e a th or relaxed fo r a m uscle. I f th e stru c tu re to b e tre a te d is ordinarily o u t o f re ac h o f th e p h y sio th e ra p ist’s fingers, th e n a position m u st be a d o p te d w hereby th e tissue becom es accessible, e.g. the su p ra sp in a tu s te n d o n a t th e sh o u ld e r. T h e a rm is put b eh in d the p a tie n t’s b a ck w hilst th e p a tie n t is in th e half- lying p o sitio n , th ere b y fixing th e a rm in a d d u c tio n a n d m edial ro ta tio n . I n this p o sitio n , th e te n d o n c a n b e easily felt as it passes fro m th e base o f th e c o rac o id process d irectly forw ards over th e h ead o f th e h u m eru s to the g re a te r tu b ero sity . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNIE 1976 F I S I O T E R A P I E 7 R EC EN T i n j u r i e s i n t h e k n e e The knee is a very re w ard in g jo in t fo r th e p h y sio th era p ist to treat, b o th by d eep tran sv erse frictions a n d by m a n ip u la ­ tion. A full h isto ry m u st be ta k e n a n d th e knee exam ined to single o u t the tissue a t fa u lt before sta rtin g trea tm e n t. H istory. T his is m ost helpful a t the knee. T h e follow ing points sh ould be a s c e rta in e d : W hat is the age a n d o c c u p a tio n o f the p a tie n t ? W hat w as he d o in g w hen the p a in first a p p e a re d ? jn w h a t p o sitio n w as his b o d y a n d his leg, a n d w h a t forces were a cting o n his knee a t th e tim e ? A lte rn a tiv e ly , d id th e p a i n c o m e o n f o r n o a p p a r e n t reaso n ? D id the knee give w ay; if so, d id the knee lo ck ; if so, did jt lock in extension o r flexion; if so, h ow did it becom e u n lo ck ed ? On w hich side o f the knee w as th e p a in o r w as it right inside, o r was it all over ? D id th e p a in c h ange from one side o f the knee to the o th e r ? Did it s p r e a d ; if so w here to ? W as the p a tie n t able to w alk ? Did th e jo in t sw ell; if so, h ow q u ick ly ? For how long w as he disabled ? Were th ere re c u rre n c e s; if so, w h a t b ro u g h t th em on ? W hat is th e effect o f going u p a n d d o w n sta irs ; is going down m ore tro u b le so m e th a n up ? Are there su d d e n tw inges ? Does the knee click ? Does it g ra te ? Does it feel as if it m ight give w a y ; if so, does the p a tie n t actually fall ? W hat tre a tm e n t has he h a d , a n d w ith w h a t effect? CLINICAL EX A M IN A T IO N E xam ination re q u ire s ten m ovem ents, eight passive a nd two resisted. P assive M ovem ents. T hese a re e ig h t; fo u r primary a n d fo u r se c o n d ary m ovem ents: The p rim a ry m ovem ents in d ic a te the sta te o f th e jo in t; they a re flexion, e x tension, m edial ro ta tio n , late ra l ro ta tio n . The c ap su la r p a tte rn (in dicating a rth ritis ) is m uch m ore lim itation o f flexion th a n o f extension, e.g. 10° lim ited ex ­ tension c o rre sp o n d in g w ith 90° lim ita tio n o f flexion. Except in gross a rth ritis, ro ta tio n re m a in s o f full range. The se c o n d ary m ovem ents test e ach ligam ent in tu rn ; valgus fo r the m edial colla te ral lig a m en t; varus fo r the lateral lig a m en t; a n te rio r pressure o n th e tibia fo r the anterior cru ciate lig a m e n t; p o ste rio r fo r th e p o ste rio r. If ■ n g e proves excessive, the relevant ligam ent is overstretched. Resisted M ovem ents These are tw o ; resisted flexion fo r th e h a m strin g s and resisted extension fo r the q u a d ric e p s m echanism . P ain indicates a m uscle lesion; w eakness, ru p tu re , o r a nerve lesion. B o th w eakness a n d p a in o n resisted extension characterize a fa ctu red patella. PALPATION O F T H E ST A T IO N A R Y JO IN T Heat W arm th indicates an active lesion; localised w a rm th reveals the site. A ctive lesions a re : re p a ir a fte r a sp ra in , o p e ra tio n , or local fra c tu re ; h a e m a rth ro sis, p ersistent in te rn al d e ran g e ­ ment, rh e u m a to id a rth ritis a n d its v a ria n ts, g o u t, spondylitis or osteitis d e fo rm a n s, R e ite r’s disease, psoriasis, etc. Fluid This m ay be c lear o r b lo o d , o r (b u t n o t in phy sio th era p eu tic cases) pus. T h e p a te lla c a n be ta p p e d a g ain st th e fem u r if a large q u a n tity o f fluid floats th e p a te lla o ff it. A m ore delicate test is flu ctuating th e fluid fro m th e su p ra -p a te lla r p o u c h to the area a t each side o f the p atella. It is well to realise th a t synovitis o f the k n e e ’ m ean s m erely ‘fluid in the knee j o in t’. it is n o t a diag n o sis; fo r in tra -a rtic u la r fluid is c o m m o n to m a n y c o n d itio n s, as d isp a ra te as a sp ra in ed ligam ent, a displaced loose b ody, o r rh e u m a to id a rth ritis . N o tre a tm e n t is possible until the c au se o f the fluid in th e jo in t h as b een ascertained. Capsular Thickening T h e de te ctio n o f c a p s u la r thic k e n in g by p a lp a tio n o f the synovial reflexion at each fe m o ra l c o ndyle in dicates o n e o f the rh e u m a to id g ro u p o f a rth ritid e s, e.g. sp ondylitis, psoriasis, R eiter, o r g o u t, tuberculosis, a n d so on. C a p su la r th ic kening c o n tra -in d ic a te s active phy sio th erap y . Tenderness Since m ost o f the tissues a t th e knee lie superficially, this lends g re at accu racy to diagnosis. T enderness is so u g h t alo n g th e stru c tu re singled o u t by the clinical e x a m in a tio n , alw ays pro v id ed th a t it lies w ith in finger’s reach. L IG A M E N T O U S SP R A IN M edial Collateral Ligament T he knee is forced to w a rd s va lg u s; a su d d e n p a in is felt a t th e in n er side o f th e knee. T he p a tie n t pick s him self up a n d c a n w alk, b u t he becom es increasingly d isabled. A fte r a few h o u rs the knee becom es very sw ollen a n d so p a in fu l th a t he can h a rd ly stand. Signs: In th e a cute stage, lasting som e ten d ays, e x am in atio n is difficult since the a cu te tra u m a tic a rth ritis o v e rsh ad o w s the lig a m en to u s signs. T h e k nee is h o t, full o f fluid, w ith say 10° lim ita tio n o f ex te n sio n , a n d 90° lim ita tio n o f flexion range. B u t th e p a tie n t kno w s he stra in e d th e in n e r side o f his knee, a n d localised tenderness a t som e p o in t alo n g the ligam ent is easily detected. In th e su b a c u te case, w hich lasts a g ood m o n th in the u n tre a te d case, the a m o u n t o f m ovem ent g ra d u a lly in ­ creases, th e h e at a n d fluid a b a te , a n d e x am in atio n becom es p racticable. T h e ligam ent can n o w be tested w ith th e knee s tra ig h t; valgus stra in is fo u n d to h u rt. I f it has ru p tu re d , excessive ra n g e is obvious. In th e c h ro n ic stage, a d h esio n s h a v e fo rm ed , b in d in g the ligam ent a b n o rm a lly to b one. Im p aired lig a m en to u s m o b ility leads to a knee th a t is painless o n o rd in a ry activities, b u t any full use o f the jo in t, e.g. ru n n in g o r at g am es, leads to p a in a t the in n er side o f the knee and som e days h e a t a n d fluid. T h e aim o f tre a tm e n t d u rin g th e a cu te stage is to m ove the ligam ent in im ita tio n o f its n o rm a l b e h a v io u r by deep transverse friction. I n th e c h ro n ic stage, w hen a d h esio n s h ave form ed, m a n ip u la tio n is perfo rm e d in a n e n d e a v o u r to b re ak d o w n the adhesions. Deep Transverse F riction: W h en this is given to the m edial colla te ral ligam ent, it h as to be c a rrie d o u t w ith th e knee held first in extension a n d th e n in flexion, in o rd e r to m a in ta in m o b ility o f the ligam ent a t the a n te rio r a n d p o ste rio r ex­ trem es o f its range. In extension: T he p a tie n t lies su p in e o n the c o u ch w ith the knee in as m uch e x tension as possible. T h e p h y sio th era p ist sits facing the p a tie n t a n d places h e r index finger, rein fo rced by h e r long finger, o n the inner side o f the knee, the th u m b o n th e o u te r side o f the knee a cting as a fulcrum . F le x io n a nd extension o f h e r w rist draw s her in dex finger ov er th e liga­ m ent, w hich is m oved o v e r th e b o n e a t the a n te rio r p a r t o f its ra n g e o f m ovem ent. A large increase in range o f flexion c a n be expected w ith in h o u rs o f this trea tm e n t. In fle x io n : T he p a tie n t lies supine o n the c o u c h w ith his k nee well bent up. T h e p h y sio th era p ist sits facing the p a tie n t a n d places h e r h a n d so th a t h e r index finger, re in fo rc ed by R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 8 P H Y S I O T H E R A P Y JUNE, 1976 h e r long finger, lies a t th e c en tral p o in t o f th e m edial aspect o f th e jo in t line. H e r th u m b acts as a fulcrum o n th e lateral side o f th e knee. F lexion, th e n extension, o f the w rist draw h e r th u m b o ver the ligam ent, w hich is no w m oved to a n d fro over th e b o n e in th e p o s te rio r p a rt o f its range. T h e m assage sh ould be follow ed by passive m o v em en ts in th e early stage a n d by stro n g e r forced m o v em en ts in th e late r stage. F ifteen m in u te s’ m assage th ree tim es a week fo r tw o o r th ree weeks sh ould suffice. M anipulation: T h is is in d icated w hen the ligam ent h as developed ad h esio n s a n d its m o b ility is im paired. F orced extension: T h e p a tie n t lies su p in e on the co u ch a n d the knee is flexed as m uch as possible. T he p h y sio th era p ist sta n d s beside th e p a tie n t, a n d raises th e p a tie n t’s heel off th e c ouch w ith one h a n d w hilst p lacing h e r o th e r h a n d on the p a tie n t’s knee. T he m a n ip u la tio n is c arried o u t by giving a q uick je rk . T h e a d h esio n s p a rt w ith a sm all snap. F orced fle x io n : T h e p a tie n t is placed in th e half-lying p o sitio n w hilst the p h y sio th era p ist s ta n d s facing him . T he h ip is flexed as fa r as it will c o m fo rta b ly go. She th e n places o ne h a n d on his knee in o rd e r to stead y it a n d also to m ain tain flexion at th e hip. F ull flexion is no w forced by th e p h ysio­ th e ra p is t p u sh in g sh a rp ly with h e r o th e r h a n d o n his ankle. F orced rotation in fle x io n : T h e p a tie n t a d o p ts th e half- lying p o sitio n w ith th e h ip flexed. T h e p h y sio th era p ist keeps the knee b e n t by pressing w ith o ne h a n d on his knee. She places th e fingers o f h e r o th e r h a n d ro u n d th e back a n d o u te r side o f the p a tie n t’s heel, a p p ly in g h e r fo rea rm to th e inner b o rd e r o f his fo o t. L atera l ro ta tio n is th en forced. F o r m edial ro ta tio n th e p h y sio th era p ist sta n d s level w ith the p a tie n t’s th ig h , a n d clasps h e r h a n d s tightly ro u n d his heel w hile h o ld in g the h ip a n d knee flexed. B y m oving b o th w rists she tw ists his heel strongly, th u s fo rcin g m edial ro ta tio n a t th e knee jo in t. T hese forced m o v em en ts sh o u ld be follow ed by active m ovem ents to m a in ta in the ra n g e o f m o v em e n t w hich has been achieved. Coronary Ligament T h e k nee is forcibly ro ta te d a n d a su d d e n p a in is felt a t o ne o r o th e r side o f th e p atella. T h e p a in does n o t a t first prevent w alking, b u t th a t evening the knee is w arm , sw ollen a n d p ainful. S igns: T h o u g h a c u te tra u m a tic a rth ritis obscures the lig a m en to u s signs, it is less severe th a n in m edial ligam ent stra in a n d m o re likely to a m o u n t to 5° lim ita tio n o f extension, 45° lim ita tio n o f flexion. B u t th e p a tie n t describes a ro ta tio n stra in a n d th e c o ro n a ry , n o t th e m edial, ligam ent is tender. S p o n ta n e o u s recovery is very slow a n d tak es a t least th ree m o n th s. Treatm ent: M o b ility m u st be m a in tain ed a t the tibio- m eniscal jo in t, b u t m a n ip u la tin g the knee m oves th e fem oro- tibial — th e w ro n g — jo in t. H ence m o b ility is m ain ta in e d or re sto red by d eep tran sv erse friction in th e a cute, su b a c u te o r c h ro n ic stage o f th e sp ra in , a n d cures cases o f a few d a y s’ o r several y e a rs’ sta n d in g in a b o u t a fo rtn ig h t. T h is is a n e xam ple o f a lesion w hich benefits only fro m deep transverse friction. T h e p a tie n t lies su p in e on th e co u ch w ith th e k nee n o t q u ite fully flexed. T h e p h y sio th era p ist sits facing him a n d presses h e r index finger, reinforced by the m iddle finger, d o w n w ard s a n d b a ck w a rd s o n th e shelf fo rm ed by th e su p e rio r a sp e ct o f the tibial condyle. H e re the p h y sio th e ra p ist’s finger com es in to c o n ta c t w ith th e c o ro n a ry ligam ent as it passes b a c k w a rd s to w a rd s the m eniscus. T he frictio n is p e rfo rm e d by a to -a n d -fro m ovem ent o f h e r fo re ­ a rm a n d h a n d . F iftee n m in u te s’ m assage th ree tim es a week fo r tw o o r th re e w eeks is usually sufficient. Cruciate Ligaments T he knee is sprained, th e p a in being felt w ithin th e centre o f the knee. U nless o th e r ligam ents are stra in e d to o , the p a tie n t h as a w arm , p a inful knee c o n ta in in g fluid, b u t ju st a b o u t a full ra n g e o f m ovem ent. S tre tc h in g o ne or o th er cru ciate ligam ent h u rts a n d m ay reveal excessive ra n g e if it is lengthened. T here is n o p a in a t e ith e r side o f th e knee a nd no tenderness o f a n y accessible structure. S p o n ta n e o u s recovery is very slow, six to twelve m o n th s is the m inim um . Id e n tifica tio n o f th e ligam ent a n d asc ertain in g a t which end the lesion lies is difficult, b u t o ne ad eq u a te in filtratio n o f h y d ro c o rtiso n e a t the rig h t sp o t is curative, unless m ark e d len g thening w ith c o n se q u en t instab ility is present. P h y sio th e ra p y is useless a nd m a n ip u la tio n harm ful. Torn Meniscus T h is follow s a ro ta tio n sp ra in th a t first ov er-stretch es the c o ro n a ry lig a m en t; th en co n tin u e d force tea rs th e m eniscus. T h e pa tie n t feels a severe p a in a t one side o f his knee and falls to th e g ro u n d . A tte m p tin g to rise, he finds his knee fixed in flexion, u n a b le to b e a r w eight. T h e knee is m a n i p i i lated, a click is felt a n d h e a rd , a n d full e x tension is restore™ to the knee. H e still h as the c o ro n a ry sprain. T he m edial m eniscus is th e m ore o ften to rn . T h ere fo re, the m a n ip u la tio n described here is fo r a lesion o n th a t side. G en eral anae sth esia m ay be required on the first occasion a p a tie n t displaces p a rt o f th e cartilage. H ow ever, in re cu rre n t d islocation, anae sth esia is seldom necessary. T he p a tie n t lies supine o n the co u ch a n d flexes th e hip a n d knee to a rig h t angle. T h e aim o f tre a tm e n t is to shift the piece o f c artilage m edially, aw ay from w here it lies displaced betw een the fem oral condyles. A s tro n g valgus stra in m ust be place on the jo in t in a n e n d e a v o u r to o p e n its in n e r aspect a n d en co u ra g e re d u ctio n in t h a t d irection. T h e knee m u st be g ra d u ally ex ten d ed while it is ro ta te d ra p id ly to a n d fro. The p h y sio th e ra p ist’s h a n d is, therefore, p laced a t th e o u te r side o f the knee, pressing m edially a nd d o w n w ard s. H e r oth er h a n d grasps the fo o t, ro ta tin g th e leg strongly a nd applying valgus stra in . She also ho ld s the foot up so th a t the pressure o f the first h a n d o n th e k nee increasingly extends the jo in t A sm all click is h e ard as full extension is achieved, indicating th a t re d u ctio n has ta k e n place. A s the m eniscus m oves it strain s th e c o ro n a ry ligam ent. U nless im m ediate m eniscectom y is c o n te m p la te d , this now requires deep friction. Loose Body in Adolescence L oose bodies, o ften m ultiple, freq u e n tly form in th e k n ^ r betw een th e ages o f fo u rtee n a n d tw enty, as th e results o ste o ch o n d ro sis dissecans o r c h o n d ro m a la c ia patellae. M - th e p a tie n t w alks alo n g his k nee su ddenly fixes in extension; he gives th e leg a g o o d sh a k e a n d th en finds he c a n flex it; th ere is n o lasting fixation. T he loose pieces h ave a n osseous nucleus a n d show on th e sk ia g ra m ; th ey sh o u ld be excised. Loose Body in Middle-Age T his is a co m m o n , disabling, a n d un re co g n ise d disorder, usually easy to relieve b u t seldom tre a te d correctly. T h e loose b o d y consists o f c artilage a n d th u s is n o t visible o n the sk ia g ram , w hich instead show s the early o ste o p h y te fo rm atio n th a t com es on in m iddle age a n d causes n o sym ptom s. The diagnosis is th ere fo re o ften ‘o ste o a rth ro sis’, b u t : (a) it com es o n su d d e n ly ; (b) only p a r t o f the knee h u rts ; (c) e x am in atio n show s a sp ra in ed knee w ith o u t previous in ju ry ; (d) it m ay recover a n d th e n re cu r; (e) th e p a tie n t experiences twinges. T h e m iddle-aged p a tie n t states th a t, fo r n o re aso n and w ith o u t a n y stra in , he su ddenly experienced localised pain R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNIE 1976 F I S i O T R e d u ctio n o f lo o s e b od y at the knee, u sually th e in n er side. E v ery step h u rts a n d he walks d o w nstairs o n e step a t a tim e fo r fe ar o f th e tw inge with giving w ay th a t m ig h t to p p le him to th e b o tto m . Signs: T h e signs are th o se o f a sp ra in ed knee. T h ere is fluid in th e jo in t, a n d if the p a in is o n th e in n er side, localised w arm th is usually d e tectable th e re ; full extension h u rts ; 5° or 10° lim ita tio n o f flexion is present. T h e m edial collateral ligament is te n d e r a t th e jo in t line. C learly this ligam ent is strained . . . b u t th e h isto ry in d icates th a t it has n o t been strained. T h e cause c a n n o t th ere fo re be e x ternal fo rc e ; it must be intrinsic. It is; a sm all cartila g in o u s loose b o d y has suddenly shifted to lie a t th e in n er side o f th e jo in t. T h e space- occupying lesion ensures th a t, each tim e the knee is straightened, th e ligam ent is stra in e d . T h e tw inge results from a m om e n tary sub lu x a tio n . T he in te n tio n , w hen m an ip u la tin g a loose frag m e n t w ithin the knee jo in t, is to shift it to the p o ste rio r p a rt o f th e jo in t where it n o lo n g er engages. I n o rd e r to get th e loose piece to m ove, the jo in t space h as to be e n la rg ed ; th ere fo re the m an ipulation is c arried o u t w hilst the jo in t surfaces a re distracted. E R A P I E 9 T h e p a tie n t lies p ro n e o n the co u ch w ith th e knee flexed to a rig h t angle. T he p h y sio th era p ist places one h a n d o n the d o rsu m o f th e p a tie n t’s fo o t a n d th e o th e r o n his ankle. T he w eb o f h e r th u m b c atch e s u n d e r his heel, th u s h o ld in g the fo o t in dorsiflexion w hich en su res good p u rc h ase fo r the o th e r h a n d . She th en lifts th e leg strongly a n d rests his foot on her fa r thigh. A n assista n t places h e r h a n d s o n the th igh ju s t a b o v e the knee-joint, h o ld in g it d o w n . T he tib ia is now distrac ted strongly from th e fem ur. O nce the p h y sio ­ th e ra p is t has felt the p a tie n t relax a n d the b o n e s com e a p a rt, she rem oves h e r thigh from u n d e r th e p a tie n t’s fo o t w hilst still h o lding his knee off th e co u ch a n d re ta in in g h e r tra c tio n d u rin g th e m an ip u lativ e ro ta tio n . T he a ssista n t a n d /o r p a tie n t m ay feel th e click o f re d u ctio n . T h e knee sh o u ld be re-exam ined a fte r each m a n o e u v re a n d th e m an ip u la tio n re p ea te d , o ften several tim es, until m ovem ent is free. Monarticular Rheumatoid Arthritis T he o u tsta n d in g featu res o f th e early case a re : 1. Sw elling a t the k nee com ing o n fo r no re a so n ; 2. T h e d isc re p a n c y betw een the local signs a n d the a rtic u la r ,-signs! T h ere is no in ju ry ; w a rm th , fluid a n d c a p s u la r thickening a p p e a r fo r no a p p a re n t reason. F u rth e r e x am in atio n reveals a full ra n g e o f painless m o v em e n t — a m o st revealing discrepancy. L a te r, o f co u rse, m ovem ent becom es lim ited a nd the c a p s u la r thic k e n in g extrem e. By th e n the diag n o sis is obvious. Treatm ent: In tra -a rtic u la r ste ro id is the o nly effective m easure unless the cause is g out (b u tazolidine), g o n o rrh o e a (penicillin), o r R e ite r’s disease (n o th in g avails). W h en m o n a rtic u la r rh e u m a to id a rth ritis com es o n in m iddle-age, th e sk ia g ram is b o u n d to show a n o ste o p h y te or tw o som ew here, a n d th e se d im e n tatio n ra te is seldom raised. T hese knees a re a p t to be tre a te d in the sam e exercise class as the loose bodies, w ith e q ually in sa tisfa cto ry results. Patellar Tendinitis T h e p a in is felt clearly a t th e fro n t o f th e knee only, a n d w alking som e w ay o r u p sta irs elicits the pain. N o tw inges a re experienced. R e c u rre n t d islo ca tio n o f th e p a te lla causes a tta c k s o f su d d e n d e ran g e m e n t th a t m u st n o t be m ista k e n fo r th o se o f a m eniscal tear. Signs: T h ere is a full a n d painless ra n g e o f m o v em e n t a t the jo in t. R esisted extensions hurts. Treatm ent: I f the sc a r tissue has fo rm e d a t th e teno- periosteal ju n c tio n o f th e su p ra - o r in fra -p a te lla r te n d o n , it m u st be b ro k e n u p by d eep tran sv erse frictio n to th e exact spot. A lternatively, th e a re a can be in filtrated w ith h y d ro ­ co rtiso n e . W hen th e q u a d ric ep s ex p an sio n is affected a t o ne o r o th e r side o f the pa te lla , o nly frictio n avails. I f th e ten d o n s a re n o t affected, a n d th e cause is such e ro sio n o f cartila g e th a t b o n e is grin d in g a g a in st b o n e a t th e pa te lla r-fem o ral jo in t, o nly excision o f the p a tella is effective. Suprapatellar Tendon T h e p a tie n t lies su p in e o n th e co u ch w ith th e knee fully e x te n d ed a n d the q u a d ric e p s relaxed. T he p h y sio th era p ist sits facing him a n d w ith o ne h a n d presses d o w n w ard s o n th e low er p ole o f th e p a te lla w ith th e w eb o f h e r th u m b , h e r fingers to o n e side a n d h e r th u m b to th e o th e r side o f th e knee. T h is resu lts in the u p p e r pole o f th e p atella being tilted fo rw a rd s, th u s b rin g in g th e su p ra -p a te lla r te n d o n in to the m o st accessible p o sitio n fo r m assage. T h e p h y sio ­ th e ra p is t places the rin g finger, reinforced by th e m iddle finger, a gainst the u p p e r p ole o f the p atella. By pressing do w n w ard s a n d b a ck w a rd s, she c atch es th e te n d o n a t its in se rtio n in to bone. T h e frictio n is p e rfo rm e d by a to -an d -fro m ovem ent o f h e r w hole fo rea rm a n d h and. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 1 0 P H Y S I O T H E R A P Y JUNE, 1976 M assage to infrapatellar tendon Infrapatellar Tendon T h e p o sitio n fo r m assa g e o f th e su p ra p a te lla r te n d o n is reversed. T h e u p p e r p ole o f th e p a te lla is pressed b a ck w a rd s, th u s tiltin g th e low er pole o f th e p a te lla a n d b rin g in g the in fra p a te lla r te n d o n in to p ro m in e n ce . T w enty m in u te s’ m assage tw o o r th ree tim es a w eek fo r a m o n th sh o u ld be sufficient. ' v Quadriceps Expansion D e e p fric tio n is th e only effective tre a tm e n t fo r this lesion. T h e p a tie n t lies su p in e w ith th e k nee fully ex ten d ed a n d th e q u a d ric e p s relaxed. T h e p h y sio th era p ist sits facing him , a n d w ith o n e th u m b pushes th e p a te lla fully o ver to the affected side. T h e rin g finger o f th e o th e r h a n d , reinforced by th e m iddle finger, is placed u n d e r th e p ro jec tio n fo rm ed by th e p a te lla , so th a t th e p a lm o f her h a n d faces to w a rd s th e ceiling. T h e fric tio n is p e rfo rm e d by a h o riz o n ta l m ove­ m en t o f h e r fo re a rm a n d h a n d . In recent sp ra in s only tw o o r th ree sessions o f massage lasting tw enty m inutes suffice. L o n g -stan d in g cases may re q u ire six or eig h t sessions. Hamstrings Injury to th e belly o f the ham strin g s is c o m m o n a m ongst sp rin ters a n d fo o tb allers. A t th e tim e o f injury, th e athlete feels the m uscle give way painfully a t th e m iddle o f the p o ste rio r a sp e ct o f the thigh. Som e h o u rs late r he is scarcely a ble to w alk. Signs: P rone-lying, resisted knee flexion h u rts. I f th e m uscle tea r is extensive, th e m uscle belly will n o t stre tc h fully and stra ig h t leg raisin g is n o t o nly painful b u t slightly lim ited for th e first few days. Treatm ent: T h e p a tie n t lies p ro n e , his knee h eld well flexed, his leg su p p o rte d by a c ushion. T he p h y sio th era p ist sits facing th e pa tie n t a n d p u ts b oth h a n d s o n his th ig h . She presses d o w n w ard s until her fingers o n o ne side, a n d her th u m b o n th e o th e r, grasp th e belly o f the m uscle. Shg a lte rn a tely flexes a n d extends her th u m b a n d fingers. Patient* s h o u ld be tre a te d daily fo r th e first w eek a n d o n a lte rn a te days a fte r th a t. A fte r th e m assage, fa ra d ism sh o u ld be given w ith the p a tie n t lying p ro n e a n d the knee k e p t fully flexed. This p e rm its c o n tra c tio n o f th e h a m strin g a n d full b ro a d en in g o u t o f th e belly a t a tim e w hen the m uscle is held in the p o sitio n o f full sh o rte n in g , w hereby all pull on the healing b re ac h is prevented. S U M M A R Y C linical e x am in atio n o f the k nee e n tails eig h t passive a n d tw o resisted m ovem ents. T h e p a tte rn s th a t em erge, ta k e n in c o n ju n c tio n w ith the h istory, e nable a precise diagnosis to be a rriv e d at. M a in te n a n c e o f m obility by transverse fric tio n in som e cases a n d by m an ip u la tio n in o th ers plays a large a n d m ost satisfac to ry p a rt in tre a tm e n t. F o r m any d iso rd e rs th e re is rio-alternative. T h e knee is the jo in t w here c o lla b o ra tio n betw een d o c to r a n d p h y sio th era p ist h a s its h a p p ie st results. N ote T h o u g h , in D r. C y ria x ’s b o o k , he is show n c arry in g o u t th e m a n ip u la tio n s; these a re all c arried o u t e q ually by all his p h ysiotherapists. A C K N O W L E D G E M E N T T h e a u th o r ’s th a n k s a re d u e to M essrs. B a illie re T in d a ll fo r p e rm iss io n to r e p rin t illu s tra tio n s a lre a d y p u b lis h e d in “ O r th o p a e d ic M e d ic in e ” V o lu m e 2, by D r. Ja m e s C y ria x . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )