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Treatment Tools

By Debbie Roberts, LMT

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The 4-Faced Troublemaker: Treating the Quadriceps Femoris

The famous quadriceps femoris group, which I refer to as the four-faced troublemaker, will be the topic of my next couple of articles—with step-by-step examples of my treatment protocols. Clients from my case studies encountered unique injuries with a different overload or deceleration, thus creating familiar trigger point (TrP) referral patterns.

For a deeper study of this quadriceps group, please see chapter 14 of “Myofascial Pain and Dysfunction: The Trigger Point Manual (Vol. 2)” by Janet G. Travell, M.D. and David G. Simons, M.D.

The Deceleration Injury

There are multiple reasons that have been given for forming trigger points—one explanation comes from understanding the mechanism of a deceleration injury. A deceleration injury is a result of momentum in which the body is forcibly stopped and the tissues are overstretched to help stop the body-part it is attached to. The onset or activation of a TrP is usually associated with some degree of mechanical abuse of the muscle in the form of muscle overload, which may be acute, sustained, and/or repetitive.1

In addition, leaving the muscle in shortened position can convert a latent TrP to an active TrP, and this process is greatly aggravated if the muscle is contracted while in the shortened position. In paraspinal muscles (and very likely others), a degree of nerve compression that causes identifiable neuropathic electromyographic changes are associated with an increase in the number of active TrPs. These TrPs may be activated by disturbed microtubule communication between the neuron and the endplate since the motor endplate is the peripheral core TrP pathophysiology.

An example of a deceleration injury that you may have already treated is the tissues of sternocleidomastoid (SCM). During a whiplash injury the cervical spine goes through a forced acceleration to a quick deceleration by the SCM and anterior cervical muscles. These tissues have sustained an overload injury, which when left shortened can convert a latent TrP to an active TrP along with the pain and stiffness.

Another example you may have encountered, common in baseball pitchers, is trigger points formed in the infraspinatus—due to the muscle performing as the “brakes.” The body goes through a quick acceleration and then a forceful deceleration by the rotator cuff to stop the momentum.

The 4-Faced Troublemaker: Treating the Quadriceps Femoris - Copyright – Stock Photo / Register Mark Prevention is Best

In personal training we have methods to help train the deceleration action of a muscle for the prevention of sports injuries. Deceleration training creates the ability to slow down and control force production. Too often people just jump right into exercise or run a 5K with very little preparation. In simple terms it is too much for the tissues to handle so quickly—there needs to be enough training time to allow for adaptation.

This is how the amateur athletes start the formation of the nodules—by micro-tearing of the tissues. Over time these micro-tears become knots in the tissue and cause either pain or dysfunction. Just a reminder of how our muscles work through three actions, concentrically to create acceleration and force production, isometrically to stabilize or balance and eccentrically to decelerate and decrease force production. Amateurs usually work on the first one, just get out there and run which is the concentric acceleration phase.

Case OF The Killer 5K

The first case I would like to share with you is a client who signed up for a 5k as a way to lose weight. Although she had not been doing any regular training she decided to just start running. Her knee became so problematic that she went to a rheumatologist thinking she must have a terrible case of arthritis.

After several tests the doctor didn’t discover anything that was obviously causing her pain. When she came to see me I asked how many miles she was running per week, when the pain started, and if she had changed shoes. She was only running a few miles per week, but was trying to increase each week. The pain came on gradually, and yes she had bought new running shoes for her training and event.

As a side bar to all of you, she wasn’t warming up; she hadn’t studied how to gradually increase her mileage; and she wasn’t stretching much after her runs because of time constraints. Along with that she didn’t follow the recommended - 10 percent use for new shoes for at least four weeks to gradually allow her feet, ankle, knees and hips adapt.

I had her point to the source of pain which was right over the knee cap. I performed a Thomas test looking at the quadriceps length and found that her right side (the area if pain) was much more restricted than her left. My goal was to increase the length in the quadriceps and decrease the knee pain.

This was the typical rectus femorisTrP which is found high on the thigh just below the anterior inferior iliac spine. Her posture also played a part due to her anterior pelvic tilt. The most important piece of treatment is to have a reference point or goal during the session to see if your treatment choice or modality is working. In this case my reference point came from the Thomas test and referred-knee pain.

The Rectus Femoris  TrP Treatment Plan

  1. I began the treatment with manual therapy and focused on stripping the rectus femoris muscle, and surrounding fascia.
  2. I followed this with light massage cupping to the same line.
  3. Then I used heat by utilizing a hydroculator pack until the thigh was warmed through.
  4. Next, I performed prioceptive neuromuscular facilitation (PNF) stretching to the rectus femoris.

I repeated this pattern for 45 minutes, re-testing my reference point after each round of the therapy. She was 90 percent better after first session and 100 percent after the second session. The muscle stabilization portion was her homework—this would help correct the things that got her there in the first place. Additionally, this would train the rectus femoris to handle the deceleration required for running.

The Case of Backswing & Follow Through

The second case was a client of mine who loved to play golf. He had complaints of sudden onset of medial knee pain, and a buckling knee. He was cleared by an orthopedic doctor with no real obvious cause for the pain. I tested the length of the quadriceps group using the Thomas test, along with looking at the adductor group’s length by using the FABER test. I also manually took the leg out into abduction with the leg medially rotated to isolate the adductor group. I found the side of the complaint (his left side) to be relatively shorter than his right in all three tests.

This prompted me to ask if he had recently changed golf shoes—which affect the way the ankle transfers energy from the right side (backswing) to the left side (follow through). If the shoe is too stiff it may not allow the ankle to go through ankle inversion and eversion appropriately, thus putting stress above the knee joint. This would have happened every time he performed his follow through. During palpation he was point tender at the proximal TrP of the vastus medialis, which refers over the anteromedial aspect of the knee and lower thigh.

The TrPs in this muscle are easily overlooked because the taut muscle fibers only minimally restrict the range of motion of the knee and because the TrP may not produce pain, but only dysfunction. The vastus medialis is often a “quitter.” After several weeks or months, the initial pain phase of its TrPs changes to an inhibition phase. The pain is then replaced by unexpected episodes of quadriceps weakness that produce buckling of the knee.1

Treatment of the Vastus Medialis TrP

Note—it’s important to use your reference points, point of pain, the Thomas test, FABER test and length of the adductors.

  1. I treated the client in both a supine and side lying posture—starting with the client supine and focusing the line of therapy through its entire length to the posterior aspect of the femur along the length of its shaft.
  2. Next, I had the client lay in a side posture with the treatment leg ext-ended and the adductor exposed. The other leg was bent to a 90 degree angle resting comfortably on a pillow.
  3. I then manually lengthened the tis-sues of vastus medialis and the facial connection with the adductor group.
  4. This was followed with light massage cupping and then with PNF stretching of the quadriceps group, and the adductor group.
  5. Last, I utilized heat with a hydro-culator pack.

You may need to repeat each step until the length and pain are changed. I am happy to report this client was 100 percent better after one treatment.

Editor's Note: Debbie’s next two articles will focus on the last two muscles of the quadriceps femoris group, vastus intermedius and vastus lateralis.


  1. Travell J, Simmons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2. Philadelphia: LWW, 1998.
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