Can Swedish massage, cryotherapy, and straight-leg raises assist in reducing the discomfort resulting from patellar tracking disorder?
Richard Decker
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Richard Decker

Abstract
Aim: To undertake a study to determine the effects of massage in treating a subject with patellar tracking disorder.
Design: A case report involving a report on the intervention and outcome for a single subject.
Setting: A private clinical setting at a local community college.
Participant: Subject is a 42-year old Caucasian female, who engages regularly in moderate physical activity and works in a clerical environment as an administrative assistant.
Outcome measures: The perceived level of activity of the subject to perform moderate physical activity. A goniometer is used to measure range of motion of the subject’s knee flexion.
Intervention: Subject attended a treatment session once a week for 6 weeks. Each session was 50 minutes in length. Exercises were also completed at the subject’s home.
Results: Range of motion measured with a goniometer to the subject’s affected and non-affected knee showed improved angular measurements, specifically, an increase of 20 degrees in knee flexion to the affected knee was observed.
Conclusion: This study demonstrated that the use of massage therapy, cryotherapy, and straight-leg raises could indeed aid in the treatment of patellar tracking disorder. Further studies are needed to determine which components of the treatment are the most effective with a wider sampling size and different groups.
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Keywords: Massage, Massage therapy, Knee dislocation, Cold therapy, Cryocup
Acknowledgements
The author would like to thank Ami Wilson Kalisek, LMT, Lurana Bain, LMT, and CJ Decker, MHRM, ABD for their guidance and support during this study.
Introduction
With patellar tracking disorder, the kneecap (patella) shifts out of place as the leg bends or straightens. In some cases, the kneecap can shift to the outside of the leg, while in others, it shifts toward the inside. The knee joint is a complex hinge that joins the two bones of the lower leg with the thighbone. The kneecap sits in a groove at the end of the thighbone and is held in place by tendons at the top and bottom by ligaments on the sides. A layer of cartilage lines the underside of the kneecap, and helps it glide along the groove in the thighbone. A problem with any of these parts in or around the knee can lead to patellar tracking disorder.
(WebMD, 2013)
Several patellar tracking disorders usually result from an one or combination of several issues: 1) the knee may be mal-formed 2) muscles in the front of the thigh
(quadriceps) may be weak or out of balance 3) ligaments, tendons, or muscles may be too loose or too tight, and cause damage to the cartilage in your kneecap. 4) being are overweight 5) over use from being a runner 6) wear and tear from sports that require repeated jumping, knee bending, or squatting. (WebMD, 2013)
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Various symptoms with the disorder include pain in the front of the knee when squatting, jumping, kneeling, or when going down stairs; popping, grinding, slipping or catching in the kneecap when one bend or straightens the leg; a buckling or giving way of the knee if it suddenly cannot support one’s weight.
(WebMD, 2013)
Patellar tracking disorder affects women more than men and is more frequent in adolescents and young athletes. (Titicula,M., n.d.)
With this information individuals are looking for alternative forms of treatment to surgery. With more individuals utilizing exercise and putting more strain on their knees more emphasis is be placed on the treatment and care of individuals with patellar tracking disorder. This is especially important in adolescent athletes as they are still developing and the effects of drugs & surgery may impact their daily activities in the future.
Given previous studies have reflected the treatment of patellar tracking disorder, this study focused on massage therapy, cryotherapy, and straight-leg raises could indeed aid in the treatment of patellar tracking disorder?
Methods
Client Profile
Subject was a 42-year-old Caucasian female, diagnosed with dislocation of her patella. The dislocation first occurred when subject was in high school and had since had multiple reoccurrences. Mostly occurs when she sidesteps and will
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relocate itself upon flexion of the knee. A brace was worn to help subject keep the knee straight during the day and slept with it on at night. The brace was worn when the subject in the Navy.
The subject’s daily activities are those of an administrative assistant, including sitting for long periods of time, and rising to stand and walk as needed. The subject reported she intentionally rises from her chair after 1 ½ to 2 hours of sitting to do some walking to stretch out her legs and her knee. She also reported that she likes to do walking as part of her daily exercise routine.
Subject saw a doctor about her knee and, after an x-ray, it was determined that the ligaments connecting her patella are more lateral than the general population. She was told that this positioning along with a rounding of the patella bone, makes it easier for her knee to dislocate. As such, the doctor recommended surgery to the knee.
During this initial interview of the case study, the subject displayed signs of antalgic gait when walking and as pressure was placed on the right knee. Using a goniometer, the subject’s range of motion for knee flexion was 140 degrees on left knee and 127 degrees on her right knee. Subject was not on any medication at that time and she has received permission from her doctors for the case study treatments. During the initial interview, a 60-minute massage treatment was also performed. Review of SOAP notes showed that right IT band was tight on the lateral side and the muscles around patella were tighter on the lateral side, as
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opposed to the medial side. The bursa behind the right patella was more inflamed than the left side. Subject’s right hip was medially rotated more than the left side.
Treatment Plan
A treatment plan was implemented for a 50-minute massage therapy session once a week for six weeks. After the initial interview and assessment the following treatment plan was developed. The subject was asked to lie supine on the massage table and instructed to flex her knees to her comfort level. Each leg was measured using a goniometer to measure the angle of the knee flexion. After these measurements were taken, the subject was then asked to extend at the hip and knee, and the angle of the knee was again then measured with the goniometer.
After the assessment measurements were taken, the subject was positioned prone for the massage treatment.
To help the subject relax and prepare for the main component of the treatment, compressions were done on the upper and lower posterior extremities. After the compressions, gliding strokes with light pressure were used on posterior upper extremities for 10 minutes. This included upper back, neck, arms and hands.
Transitioning from the upper extremities to the lower extremities a combination of open palm and loose knuckle strokes with firm pressure were applied to the greater trochanter and IT band on both lower extremities starting with the subject’s right extremity and then moving to the left. Light circular motions were used on the posterior lateral and medial sides of the knee. The plantaris and popliteus were
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also treated with the same light circular motions. Each lower extremity was treated for 5 minutes each.
After the massage was done with the subject in the prone position the subject was turned supine. A long axis distraction was then performed on each lower extremity for 1 minute each. The subject was then asked to lift their leg up 5 inches from the table flexing from the hip joint for 5 seconds with the therapist applying downward resistance with both of the therapist’s hands on the distal shaft of the subject’s tibia. The straight-leg raises were repeated 5 times. Illustrations of the straight-leg raises are shown in figure 1.
Figure 1
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Long gliding strokes with firm pressure were applied to each lower extremity starting from the greater trochanter and working caudal to the ankle. Firm circular strokes and loose knuckles were used on the greater trochanter, IT band, and quadriceps. After these strokes, light circular motions were used along each side of the knee cap (patella) and the top of the patella too. This application was used on the other non-affected extremity as well. Each lower extremity was worked on for 5-minutes each.
To focus on the subject’s pathology a cryocup was used on the subject’s right knee for 5 minutes using a gentle pressure with circular motions. A cryocup is a massage tool that utilizes ice formed in the bottom cup for application to the area treated while top ringed half is insulated and provides a gripping surface for the therapist.
After working the anterior upper extremities the subject’s upper extremities were working on for 10 minutes. This included a combination of gentle gliding strokes and firm circular motions with loose knuckles on the upper neck, arms and hands.
To promote a relaxing healing state after the extremities were worked on the subject’s head was massaged next. The strokes included light gentle circular motions with the therapist’s fingertips on the subject’s face. An occipital release was applied to the subject for 2-minutes. The overall massage to the subject’s head was for 5-minutes.
The subject was asked to preform the straight-leg raises as illustrated in figure 1 as their in-home treatment. The treatment consisted of 8 – 12 repetitions, 3 times per
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day. A chart was provided to the subject every week for them to check off that they performed the treatment in the morning, mid-day, and evening each day for the week. The chart was turned in each week to the therapist for review and a new chart provided to the subject for the following week.
Results
A subject with patellar tracking disorder gave informed consent to participate in the study. The subject completed the study and attended all treatment sessions with no withdrawals. A range of motion of knee flexion and extension using a goniometer was used track quantitative results of the study as shown in charts 1 and 2.
Range of motion measurement with knee flexion in the affected right knee had shown an increase of 20 degrees in the subject’s ability to flex her right knee.
Chart 1 shows that during the subject assessment, but before treatment, the measurement was 127 degrees with and increased to 145 by the second week. A decrease of 3 degrees was observed at the week 3 session in which the subject had treatment 5 days after her previous treatment instead of 7 days.
Measurements of the unaffected knee were also taken during the study. The initial measurement was 140 and ended with 146, an increase of 6 degrees of angular flexion of her unaffected knee. A decrease of 3 degrees was also observed during the week 3 session.
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150
145
140
135
140
145
142
143
146 146 145
139 140
147
140
Left Knee Range
Flexion
Right Knee Range
Flexion
130
127
125
120
115
Week 1 10/3/14
Week 2 10/10/14
Week 3 10/15/14
Week 4 10/24/14
Week 5 10/31/14
Week 6 11/7/14
Week
1
Week
2
Week
3
Week
4
Week
5
Week
6
Chart 1
Range of motion measurement with knee extension were not taken during the initial assessment during week 1, this was introduced at the beginning of her week
2 session. The therapist believed this additional measurement might assist in the tracking of results to the study. An increase of 1 degree was observed at the end of the study of the affected knee. The unaffected knee remained constant, with the exception of a drop of 3 degrees during the week 5 session.
In between sessions 5 and 6, the subject had experienced a mild accident. The subject’s car door had closed suddenly and hit her in the back, around L4 and L5.
The client had seen her medical doctor and was released for massage therapy. The at home straight-leg raises were discontinued by direction of the doctor after the week 5 session. The measurements taken with the goniometer did not reflect a change in the range of motion.
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16
14
15 15 15
12
14
Left Knee Range
Extension
12
12 12
Right Knee Range
Extention
10
11
10 10
8
Week 1 10/3/14
6
4
2
Week 2 10/10/14
Week 3 10/15/14
Week 4 10/24/14
Week 5 10/31/14
Week 6 11/7/14
0
0
0
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
Chart 2
Discussion
Although this was a pilot study and therefore aimed to test design feasibility, the results suggest that the addition of massage therapy may indeed aid in the treatment of patellar tracking disorder. The increase in the range of motion to the subject’s affected and non-affected knee supports this statement. The results prove to be beneficial not only to the subject but to the massage therapy field as well. An increase in range of motion provides reassurance to the subject that they can perform daily activities without fear of patellar dislocation.
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In the analysis of the data an anomaly was observed with a decrease in the range of motion of the subject’s knee. The subject was unable to attend their normally scheduled session during week 3 and met with the therapist 2 days prior to their regular treatment date. This change in the regularly scheduled treatments also meant that the subject’s treatment for week 4 of the study would be extended by 9 days. During the prolonged time between the treatments the subject still completed the in-home treatments that were provided by the therapist. However, due to the accident after the week 5 session the subject discontinued the in-home straight-leg raises. Since these exercises were discontinued the range of motion was not affected by this one inactivity. It may be concluded that this component of the treatment plan was not a crucial part of the reducing the discomfort of the subject.
It was discovered by the therapist during the study that the subject had also been losing weight as part of her life goals. It is unknown how this much this impacted the results of the study since the lower extremities play an important role in the support of body weight during daily activities.
While the study proceeded with minimal disruption, this could be attributed with the small sample size. Additional studies may be needed to determine which components of the treatment were the most effective to the outcome of the subject’s overall improvement. Components of the treatment included Swedish massage, straight-leg raises, and cryocup therapy. However, in light of the small sample size and additional components, this study has created a platform from which future studies may develop a more definite trial.
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References
WedMD.com. (2013) Retrieved from http://www.webmd.com/painmanagement/knee-pain/tc/patellar-tracking-disorder-topic-overview
Titicula, M. (n.d.). Patellofemorial tracking and McConnell taping. Retrieved from http://www.mccc.edu/~behrensb/documents/PatellartrackingdisorderandMcConnel lTaping.pdf
Pateller dislocation. (n.d.) Retrieved October 1, 2014, from http://www.physioadvisor.com.au/10276750/patellar-dislocation-dislocated-kneecap-physi.htm
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