ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the MEDICAL MASSAGE PROTOCOLs that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy.

This video is a presentation of the MEDICAL MASSAGE PROTOCOL in cases of Knee Osteoarthritis. It is based on scientific publications reviewed in Medical Massage, Volume I. Please refer to pp. 462-476 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of Knee Osteoarthritis.

In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.

MEDICAL MASSAGE IN CASES OF KNEE OSTEOARTHRITIS

Duration: 45 to 60 min

Step 1. Work on the lower back
a. Effleurage and relaxation of the paravertebral muscles

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Duration: 2 min
Pressure: below the pain threshold

Begin with superficial effleurage in the direction of drainage, and later switch to the deep effleurage.

Apply the technique for the relaxation of the paravertebral muscles. The “big fold” technique and general techniques are shown in the video.

b. Friction on the lateral surface of the spinous processes

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Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Apply friction on the lateral surface of the spinous processes of the lumbar vertebrae. Concentrate on the spinous process of the L4 and L5 vertebrae.

The video shows the one-handed and bi-manual variants of this technique. To review it step by step, click here.

At the end of this part, employ intense superficial friction in the areas where the cutaneous branches of the L4 and L5 spinal nerves emerge under the skin. To review this technique, click here.

c. Traction-rotation technique

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Duration: 1 min
Pressure: below the pain threshold

Apply the traction-rotation technique on the lower back (to review it step by step, click here). The white arrow indicates the application of the vertical pressure to stabilize the pelvis.

Step 2. Work on the posterior surface of the lower extremity
a. Effleurage in the direction of drainage

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Duration: 2 min
Pressure: below the pain threshold

Begin with the application of superficial effleurage in the direction of drainage, and later switch to deep effleurage.

At the end, employ effleurage with unequally distributed pressure. To review this technique step by step, click here.

b. Kneading in the inhibitory regime

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Duration: 3 min
Pressure: below the pain threshold

Apply kneading in the inhibitory regime on the muscles of the posterior thigh and lower leg (to review Protocol #1 click here).

c. Friction on the tendons of the posterior thigh muscles

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Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Begin with the application of friction along, and later across, the tendon of the biceps femoris muscle. At the beginning of the video, the location of the tendons of the biceps femoris muscle is shown.

Next, apply the same combination of techniques along the tendons of the semimembranosus and semitendinosus muscles. In the video, the location of the both tendons is shown.

At the end of this step, inhibit the H-reflex in the biceps femoris, semimembranosus and semitendinosus muscles by applying repetitive compressions on the tendons during the patient’s prolonged exhalation. Fit 3 to 5 compressions into each exhalation.

Step 3. Work on the adductor muscles
a. Kneading

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Duration: 2 min
Pressure: below the pain threshold

Apply kneading of the adductor muscles in the inhibitory regime (to review the Protocol #1 click here).

b. Friction

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Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Apply friction along, and later across, the tendons of the adductors at their insertion into the medial condyle of the femur, pubic and ischial bones. The practitioner should discuss this treatment with the patient beforehand, as it is applied very close to the private parts.

Step 4. Work along the medial collateral ligament

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Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

1. Deep effleurage on the medial surface of the knee joint along the medial collateral ligament. The index finger applies most of the pressure.

2. Circular friction on the medial surface of the knee joint along the medial collateral ligament.

3. Friction along the fibers of the medial collateral ligament.

4. Friction across the fibers of the medial collateral ligament.

5. Application of intensive circular friction at the point of insertion of the medial collateral ligament into the medial condyle of the tibia.

6. Application of intensive circular friction at the origin of the medial collateral ligament from the medial condyle of the femur.

7. Bi-manual stretching effleurage along the medial collateral ligament.

8. Finally, application of the manual or electric vibration permanent, mobile mode along the medial collateral ligament.

Step 5. Work on the anterior thigh and knee
a. Kneading of the quadriceps muscle

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Duration: 2 min
Pressure: below the pain threshold

Apply kneading of the quadriceps muscle in the inhibitory regime (to review the Protocol #1 click here).

b. Work on the tendon of the quadriceps muscle

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Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Begin with stretching effleurage along the tendon. Notice that the left thumb is placed just above the upper pole of the patella and stabilizes the patella during the strokes.

Apply effleurage along the edges of the tendon. While pushing the left hand forward, slightly squeeze the tendon between your fingers. The left thumb is in the same position and provides counterresistance.

Inhibit the H-reflex in the quadriceps muscle by applying 4 to 5 compressions on the tendon during the patient’s prolonged exhalation.

Apply intensive friction along, and after this across, the tendon of the quadriceps muscle. Notice that the left hand stabilizes the patella during the strokes.

Passively stretch the tendon of the quadriceps muscle along its fibers during the patient’s exhalation. Grasp the patella with the right hand and the quadriceps muscle with the left hand, and pull them apart during the patient’s prolonged exhalation.

Passively stretch the tendon of the quadriceps muscle across its fibers during the patient’s exhalation. Grasp the patella with the left hand and the tendon of the quadriceps muscle with the right hand. The main tools for this stretch are the right thumb placed flatly in front of the medial edge of the tendon and the left index placed on the lateral edge of the patella. During the patient’s prolonged exhalation, push the right thumb and the left index against each other, thus effecting passive stretching of the tendon of the quadriceps muscle.

Change fingers and now place your left thumb and right index on opposite sides of the tendon and the patella, laterally stretching the tendon during the patient’s exhalation.

Step 6. Work on the lateral surface of the thigh
a. Effleurage

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Duration: 1 min
Pressure: below the pain threshold

Anatomical landmark in the video: the dashed line indicates the greater trochanter

The patient is on the unaffected side. Begin with deep effleurage on the lateral surface of the thigh in the direction of drainage.

Next is the application of stretching effleurage along the iliotibial tract. The left hand stabilizes the pelvis while the base of the right hand slides forward first along the anterior edge of the iliotibial tract, then along the iliotibial tract itself, and finally along the posterior edge of the iliotibial tract. Use a very small amount of lubricant for these strokes.

b. Tissue displacement technique

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Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Apply the tissue displacement technique on the iliotibial tract. Place both thumbs and the base of the hands in front of the anterior edge of the iliotibial tract, tighten the wrist joints and, using the weight of your body, push your hands forward to move the iliotibial tract posteriorly.

c. Friction

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Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Anatomic landmark in the video: the dashed line indicates the head of the fibula

Apply friction at the insertions of the iliotibial tract into the lateral condyle of the tibia and the head of the fibula. Begin with friction along the fibers of the iliotibial tract, and later switch to cross-fiber friction.

Step 7. Intra-articular therapy
a. Friction on the condyles of the tibia and femur

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Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Anatomic landmarks in the video: the dashed line indicates the patella; the upper solid lines indicate the condyles of the femur; the lower solid lines indicate the condyles of the tibia; the dotted lines indicate the lateral and medial edges of the patellar ligament.

Place the tip of your thumb into the joint between the lateral condyles of the femur and tibia and direct pressure downward against the tibia (the white arrow) while applying friction.

Change position and now employ the index to apply friction on the femur. The white arrow indicates the direction of the pressure during the strokes.

Repeat the same sequence on the medial condyles (one each) of the tibia and femur.

b. Electric vibration

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Duration: 1 min
Pressure: below the pain threshold

Apply electric vibration in the permanent, mobile mode along the knee joint. Try to fit the massager into the tight space between the condyles of the femur and tibia on both sides (see video).

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Step 8. Passive stretching of the lower extremity

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Duration: 1 min
Pressure: below the pain threshold

Grasp the lower leg above the ankle joint and pull it along the axis of the lower extremity during the patient’s prolonged exhalation. Be sure not to bend the knee during the stretch. The white arrows indicate the direction of the stretch.

Connective Tissue Zones

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Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Use connective tissue massage technique to work in the connective tissue zones of the first and second levels.

At the end of the video, the tissue displacement technique is shown which addresses the connective tissue zones of the third level. Apply CTM at the beginning of Step 5.

Postisometric Muscular Relaxation

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Duration: 4 min
Pressure: below the pain threshold

Place the leg in the starting position of 90-degrees flexion. Ask the patient to extend the knee while you resist this movement. The white arrows indicate the direction of the contraction.

For the second level, increase the initial knee flexion before asking the patient to once again extend the knee against your resistance.

Apply three passive stretches during the patient’s prolonged exhalation after each level of the PIR.

Full Protocol:

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