resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
TCM Congress in Rothenburg is Largest in Western World
In the medieval town of Rothenburg, deep set within the Bavarian countryside in Southern Germany, the TCM Kongress Rothenburg each year draws around 1.200 participants from more than 40 different countries to attend the biggest TCM conference in the Western world.
Avoid Random Treatment of Trigger Points (Part 2)
We must acknowledge that the fascia, which surrounds literally everything in our bodies, including every muscle fiber, is more than just a covering.
There Really is No Room for Sexism
Recently, Matteo* (a transgender male) approached me during a break in an advanced shiatsu class in Berlin where he was one of two men in a group of 20 women. "Pamela. Don't forget to remind the translator to include male endings."
Help Update the LBP Practice Guideline
The Council on Chiropractic Guidelines and Practice Parameters has announced the release of an updated Clinical Practice Guideline for Chiropractic Management of Low Back Pain for stakeholder review and comment.
Impacting Chiropractic's Future With Technology
When it comes to electronic health records (EHR), Robert Moberg and Dr. Steven Kraus are two of the leading industry experts on the topic.
Expanding Access, Branch by Branch
The big news coming from Capitol Hill isn't merely the recent introduction of a pair of bills designed to expand chiropractic services in the Veterans Affairs and military health care systems; after all, similar legislation has made its way through Congress before, never reaching the Oval Office for presidential signature.
Treating Beyond Pain
More often than not, when a patient presents to the office, it is for a pain complaint. Headache, neck pain, low back pain, sciatica, carpal tunnel... The pain is often the focus of the patient's mindset, and they don't often have any thought of what comes after the pain.
Will You Be an Amplifer or a Mute?
These times are changing, and changing quickly. There have been many challenges to this profession throughout the past few years. The challenge is to talk, then talk and talk some more about this medicine.
B Vitamins Improve Memory, Prevent Brain Atrophy
The 2010 OPTIMA study showed that the accelerated rate of brain atrophy in elderly with mild cognitive impairment could be slowed via supplementation with homocysteine-lowering B vitamins, which included folic acid, vitamin B12 and vitamin B6.
Atypical Femoral Fractures and Bisphosphonate Use: What to Watch For
Bisphosphonates (BP) are popular drugs, with more than 8 billion in sales in 2008; however, profits have declined as patents began expiring. Nonetheless, BP remain the most commonly prescribed drugs for patients at risk of osteoporotic fractures, with several million prescriptions written every year.
Converting More Patients to Your Practice
In 2013 and 2014, the theme was "the money is in the list." This meant that if you had a big email list, you were really making some "cha-ching." Unfortunately, having thousands of emails doesn't equate to thousands of dollars in profit.
The Dietary Supplement Research Dilemma
I do not care what the truth is, one way or another; I just want to know it. And when it comes to dietary supplements, the truth can be hard to find for a number of reasons.
The Need for a New Medical Model: A Challenge for Biopsychosocial and Ecopsychologica Medicine
Chinese medicine speaks of alignment between humans, heaven and earth. It is a complex view with a focus upon relationship. These are comprehensive ideas with no specific terms in contemporary medical practice.
Primary Spine Care: Addressing Concerns & Criticisms
The Dec. 1, 2013 issue of Dynamic Chiropractic included an article describing the implementation of a training program for primary spine practitioners (PSP) within a metropolitan region and supported by a large BC/BS plan.
An Excerpt from TCM Case Studies: Pediatrics
This excerpt is reprinted with permission from Jamie Wu. TCM Case Studies: Pediatrics was released in 2014 by People's Medical Publishing House.
Interpersonal Skills 101: Enhancing the Value of Our Patient Interactions
Recently, I read an interesting article in our local newspaper titled "The Value of Human Interaction." The article presented comments from a senior editor for Fortune magazine who discussed "Civility in the Business World."
Low Back Pain: Posture and Movement Analysis
When performing static and dynamic movement analysis of the lumbopelvic hip area, begin with standing visual posture analysis of the pelvis, and then perform lumbar range of motion and assess what you might see during normal versus abnormal lumbar flexion motion.
A Well-Kept Secret: 5 Element Acupuncture, Part II
Supervising acupuncture interns at a TCM college, it has always struck me how funny it is to hear the clinic manager tell the patients that the Five Element clinic specializes in treating emotions, as if patients with physical pain have no emotions!
The Way We Are Designed: A Conversation with Gil Hedley, PhD
I was first introduced to the work of Gil Hedley by Tom DiFerdinando. He gifted me Gil's DVD series.
Synergy Doesn't Happen in Silos: Acupuncture in Hospitals and Other Healthcare Settings
As acupuncture and traditional East Asian medicine continue to intersect and integrate with biomedical approaches, the conversation about integration expands and becomes richer.
Recreational Cannabis Use and TCM
Many people are drawn to cannabis for its effects physically, mentally and emotionally. Medically, cannabis has some legitimate uses, however the scope of this article is limited to the recreational use of cannabis.
Exploring Elusive Knee Pain
Massage is great for many soft-tissue pathologies. However, sometimes various conditions exist that seem like a common pathology, but then don't respond to the treatment. In some cases, an undiscovered problem may exist. Let's take a look at the synovial plica, a cause of knee pain that can easily mimic other common knee conditions.
What Is a Plica?
During embryologic development tissues gradually change state as they develop into their fully formed structures. Early in fetal development, bands of tissue separate the knee into different compartments. These bands of tissue gradually shrink as the knee joint fully forms and is eventually surrounded by a synovial capsule. However, in some people, these bands of embryonic tissue persist into adulthood and become sleeves or folds of tissue called synovial folds or plica.1
The medial side of the knee is one of the most common locations for a plica to develop. When it develops in this region, it is called medial plica syndrome and may cause pain and discomfort during various movements and is often mistaken for other knee pathologies.
While the plica will have existed for the person's entire life, it may become problematic only later as a result of overuse. The plica becomes swollen and fibrotic for several different reasons. The most common reason for plica irritation is chronic overuse. Repetitive motions of the knee cause friction on the plica and it becomes fibrotic and far less flexible. Depending on its location it can become bowstrung across a bony prominence in the knee.
Other possible factors that can lead to a fibrotic plica, include a direct blow or trauma to the tissue, excessive twisting motions applied to the knee, or intraarticular bleeding or effusion secondary to another injury. Secondary dysfunction, like meniscal damage, may go undetected or misidentified as some other pathology. In rare cases, the plica can become calcified, which causes much greater pain and disrupts tissue mechanics around the knee.2
Once the plica becomes stiff and fibrotic, it can get pinched between the femur and patella during knee extension. The medial side of the knee is the most common site prone to irritation of the plica (Figure 1). The medial patellar plica runs underneath the distal portion of the vastus medialis, called the Vastus Medialis Obliquus (VMO). Pain in the VMO is frequently associated with patellar tracking disorders and tracking disorders are another potential issue that can mask involvement of a synovial plica in the region.1
The fibrotic changes in the joint can eventually lead to softening and degeneration of the cartilage at the patellofemoral complex. As a result, there may be a cause-effect relationship between the synovial plica and development of chondromalacia patella.1
Evaluating the Plica
Identifying the presence of a synovial plica is not easy because it can be so easily ascribed to some other pathology. However, there are key characteristics that show up when a plica is present. The primary complaint is intermittent dull aching pain medial to the patella. The pain is usually increased with activity and tends to be more evident during forceful knee extension, such as standing up from a squatting position.
Sustained flexion usually increases the pain as the plica tissue is pulled taut. Plica pain generally appears during extension motions, but once the knee is static and held in a position of full extension, such as standing, the pain usually decreases. Additional symptoms may include feelings of giving way, snapping, and popping or clicking sounds especially when moving the knee from 90 degrees of flexion into extension (Figure 2).
During palpation, it is common to find general tightness in the knee region, especially within the quadriceps group. The fibers of the quadriceps retinaculum are also likely to be tender. There are deep fascial connections between the distal retinacular quadriceps fibers and the synovial capsule of the knee, so reducing quadriceps tightness is a key treatment goal.
One of the more common findings with many knee injuries is atrophy in the quadriceps group and this is common with plica syndrome as well. The quadriceps, as an anti-gravity muscle group, is prone to rapid atrophy when there is pain or dysfunction at the knee. Evaluate quadriceps atrophy by using a soft tape measure to measure the circumference of the muscle group just superior to the patella and comparing it with the unaffected side.
In some cases there is a distinct taut and palpable band on the medial aspect of the knee that can be rolled under the fingers during palpation of the medial knee. It is not always easily palpable, so this method is not a highly reliant means of determining the presence of a plica.
Another method that may be helpful in identifying the plica is a pain provocation test. This can be performed by holding the knee in about 300 of flexion and pushing the patella in a medial direction. Medial movement of the patella reproduces pain as the plica is pinched between the femur and patella.3 Physical examination of the knee alone is not considered highly reliable to identify the plica, so high-tech diagnostic studies such as MRI may be used.
Treatment of Plica
The synovial plica is usually treated first with conservative treatments such as physical therapy, which will include stretching and strengthening exercises. Stretching helps encourage pliability of all the soft tissues. Strengthening of knee extensor fibers is an initial treatment because they have fascial connections into the capsular tissues, which helps pull the plica tissue out of the way during extension and prevent it from being pinched.4 It is also very important for the person to reduce offending activities, such as repetitive flexion and extension movements of the knee.
Nonsteroidial anti-inflammatory drugs (NSAIDS) are commonly used to address inflammatory activity in the knee. Iontophoresis (anti-inflammatory medication applied with electrical stimulation) and phonophoresis (anti-inflammatory medication applied with ultrasound) can also be used to reduce swelling and manage fibrosis. If these more conservative methods are not effective, intraarticular corticosteroid injections might be used. Surgery is considered the last resort to remove plica tissue.
Role Of the Massage Therapist
There is currently no research regarding massage treatment for plica syndrome. However, a lack of study does not indicate a lack of a role for massage. To determine the effectiveness of massage for any pathology requires considering whether some form of massage would provide a helpful intervention.
We do know that massage is effective in reducing dysfunctional soft-tissue fibrosis in many conditions, and plica syndrome is fibrosis that develops within the synovial fold of the knee joint capsule. It would stand to reason that massage might be helpful in addressing medial plica syndrome by encouraging mobility within the fibrotic or calcified plica. If the plica is caught between the femur and patella, you can push the patella slightly laterally and friction the medial side of the tibiofemoral joint and the area just under the patella.
You might also provide some deep friction along other regions of the medial side of the knee.
Massage would be generally helpful for maintaining proper muscle tone and biomechanical balance of the VMO and distal quadriceps group so that inappropriate tension levels on the knee capsule fiber do not develop.
A critical part of evaluating the appropriateness of massage is to determine if there might be contraindications. In treating plica syndrome, as long as massage is performed within normal pressure levels, there does not seem to be any contraindications to using massage. In fact, massage is more likely beneficial and might reduce the need for surgical intervention.
Conservative treatments like stretching and exercise have some degree of effectiveness. Massage may be a useful adjunct for these treatments. This syndrome offers a good opportunity for further research into a new application for massage.
Author's Note: Receive 1 hour of continuing education credit related to this article by visiting www.academyofclinicalmassage.com. Whitney Lowe is a premier authority on pain and injury treatment with massage therapy. He is the author of Orthopedic Assessment in Massage Therapy and Orthopedic Massage: Theory and Techniques. Lowe's texts and programs have benefited massage professionals for more than 25 years. Learn about Whitney Lowe's innovative and engaging online courses and products by visiting his website, www.academyofclinicalmassage.com.