By Curt Lezanic, LMT, CMMP
As one continues to learn and practice Medical Massage, we are periodically challenged by unusual clinical cases—and by unusual patients. In my own practice, I developed a reputation for working with individuals who had undergone knee replacement surgery but were not making progress in physical therapy. The following is the story of one such case.
I received a call from a 55-year-old construction worker who had undergone knee replacement surgery and was unable to either extend or flex his knee. We scheduled an evaluation.
When he arrived, two things immediately caught my attention. First, the length of his surgical scar was highly unusual for a knee replacement—almost twice the typical length. Second, there was a complete lack of knee joint mobility (Fig. 1).
Fig. 1. Patient’s knee following surgery and lack of rehabilitation
We sat down and discussed his history. Several months earlier, he had fallen from a ladder and fractured his femur. X-rays revealed not only the fracture but also a tumor in the femur above the knee joint. The fracture was therefore pathological, caused by bone weakened by the tumor. The femur fracture was externally stabilized, and the patient was referred to an oncologist. A biopsy performed one week later confirmed that the tumor was malignant.
As part of his cancer treatment, the tumor was surgically removed. Because the fracture occurred at the tumor site, a section of bone above the knee, along with the knee joint itself, was removed and replaced with an endoprosthesis.
The surgery was successful, and the patient was referred to physical therapy for rehabilitation. This is where the story becomes particularly interesting.
The patient was completely non-compliant. He told me that he constantly argued with the physical therapists and refused to perform the prescribed exercises. This behavior continued for approximately one month, after which the physical therapy clinic discharged him. He was then referred to a second physical therapy group, where the same scenario occurred.
By the time he came to my office, more than two months had passed since surgery, with essentially no rehabilitation. He sat in front of me, explaining what he would and would not do. He spoke to me in the most hostile manner possible. I immediately understood why two different physical therapy groups had dismissed him. To say that our initial conversation was “interesting” would be a gross understatement.
I am a former SOMI student and a regular reader of the Journal of Massage Science. After reading JMS articles on Brain Self-Defense Mechanisms, I came to understand the critical importance of addressing the psychological component in patients under extreme health stress.
For therapists seeking to support patients in complex and severe health situations, I strongly recommend reading the two-part JMS article on brain self-defense mechanisms.
The patient’s brain employs various psychological self-defense reactions to cope with stress triggered by pain, trauma, and uncertainty. The individual sitting in front of me was not inherently unpleasant; he was psychologically traumatized by a fracture, a cancer diagnosis, a major surgery with an uncertain future, and failed rehabilitation—partially due to his own behavior. His brain had chosen anger as a defense mechanism. Without addressing this reaction, no therapeutic intervention could succeed.
To change the direction of our interaction, I first explained his current condition in straightforward terms. I then firmly told him that what I was offering was his last opportunity for recovery. If he wasted another week or two, he would permanently lose knee function. I ended by looking directly into his eyes and saying:
“You can leave my clinic right now, but never try to contact me again expecting my help. What is your decision?”
At that moment, I could see a clear shift in his mental state. After a brief silence, he said that he would work with me. From that point forward, I was entirely in charge of his rehabilitation—with his complete cooperation.
TREATMENT
We began with lymphatic drainage. The patient had significant edema in the affected leg, and I treated him several times per week for the first couple of weeks to bring the swelling under control.
As the edema decreased, we gradually began addressing the knee joint itself. Session by session, the range of motion slowly improved. Knee flexion increased to approximately 90 degrees, while extension progressed more slowly.
As the patient observed clear improvements in both range of motion and pain reduction, he began taking responsibility for his recovery. He joined a gym and consistently performed the home exercises I prescribed.
Once the edema was largely resolved, I shifted focus to the soft tissues of the leg and thigh. As expected, the skin and fascia no longer presented significant restrictions. However, the muscles—particularly above the knee—were a different matter.
Examination revealed dysfunction in the lumbar erector spinae and quadratus lumborum due to compensatory gait patterns. The quadriceps, adductors, hamstrings, and posterior leg muscles were extremely tight and contained multiple active trigger points that severely restricted the knee range of motion.
From this point forward, each session followed a structured protocol:
- Effleurage of the lumbar region, gluteal area, thigh, and leg, directed toward lymphatic drainage
- Layer-by-layer decompression of the lumbar musculature, followed by Trigger Point Therapy applied to the erector spinae and quadratus lumborum
- Lower extremity drainage
- Application of friction and kneading techniques to superficial and deep skeletal muscles of the thigh and posterior leg
- Trigger Point Therapy applied to active points
- Post-isometric muscular relaxation techniques
- Passive stretching and rhythmic flexion and extension of the knee and ankle joints
The patient responded exceptionally well to the treatment.
I also assigned detailed home exercises, including muscle stretching and appropriate use of gym equipment. I gave the patients proper homework from SOMI’s YouTube Channel: Dr. Ross | Medical Massage – YouTube
TREATMENT OUTCOMES
After approximately six weeks of consistent work together, I informed the patient that he no longer required treatment. The edema had fully resolved. He could flex the knee to 70 degrees without pain, and knee extension was fully restored.
Let us consider the alternative scenario: if the patient had not contacted me, and I had not been familiar with JMS‘s publications on brain self-defense mechanisms. Most likely, he would have lost functional use of the knee and lower extremity, lost his ability to work, and become permanently disabled.
This case illustrates why therapists must treat not only pain and somatic dysfunction, but also understand how to address a patient’s psychological state from a somatic perspective. While treating the body, we must simultaneously influence the patient’s perception of their condition—because without that shift, proper rehabilitation is impossible.
ABOUT THE AUTHOR
Of all the things I have learned in my twenty-plus years in massage therapy, let me repeat: all of it pales in comparison to what I have learned through SOMI’s training in Medical Massage.
Medical Massage provides me with the education and experience to address the void often experienced by patients in pain. These patients’ conditions are not severe enough for a surgical intervention, and at best, are offered only minimal relief through various painkillers and muscle relaxants. This is the area between pain medications, muscle relaxants, and surgery in which I work. Medical Massages provides me with the tools to achieve clinically stable, highly effective relief. I cannot understate the effectiveness of the MEDICAL MASSAGE PROTOCOLs.
I am very excited that Dr. Ross Turchaninov, through the Science of Massage Institute, is offering a certification in Medical Massage Therapy. Our industry needs this, and our patients deserve it. I want to encourage more massage therapists to learn and adopt Medical Massage. I should not be the only massage therapist in San Antonio, Texas, practicing this modality. To those considering learning this, I can assure you that the financial and personal rewards are well worth the effort.
Category: Medical Massage
Tags: 2025 Issue #3