HEMME Approach To Knee Pain

HEMME APPROACH
TO
KNEE PAIN
HEMME APPROACH TO KNEE PAIN

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INSTRUCTIONS FOR THE ANSWER SHEET
Thank you for investing in our HEMME APPROACH TO KNEE PAIN course.
We’ve tried to make this course interesting and informative.
Now that you're ready to start the course, these instructions will make it
easier to complete the quiz on pages 42-45. First, there are no trick
questions. The answers are clearly stated in the book. Second, the questions
are not taken at random, they follow the same sequence as the text. Third,
the questions cover the major points. Reading the table of contents, chapter
headings, section headings, and tables may be helpful.
This course requires work. Since 2 hours of continuing education credit

are given for completing the course, you are not expected to read the manual
and complete the quiz in less than 2 hours.
Feel free to use the manual as you take the quiz. It may be helpful to
look over the questions before reading the manual. Even though passing is a
score of 75% or above (five points per question), this should not be a
problem for most people. If needed, retakes will be allowed.
Above all else, please follow these three instructions:
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p RETURN THE ANSWER SHEET IN THE ENVELOPE PROVIDED.
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The spelling of your name for certificates will be taken directly from the
answer sheet. Please be patient. Quizzes are normally graded the same day
they arrive. Most state boards recommend holding certificates at least four
years unless otherwise instructed. Good luck with the quiz and thank you
again for taking the course.

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EVALUATION FORM
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v
HEMME APPROACH
TO KNEE PAIN
Copyright, David H. Leflet, 2001

All rights reserved
Published by HEMME APPROACH PUBLICATIONS

3334 Spring Valley Lane
Bonifay, FL 32425
(850) 547-9320
The author grants permission to photocopy limited portions of this manual for personal
use. Beyond this consent, no portion of this manual may be copied or reproduced in any
form without written permission from the author.
Even though the author has made every effort to ensure the accuracy of the information
herein, science is progressive and theories change with time. Practitioners are advised to
consult appropriate information sources if they have any questions concerning the
information or principles presented in this manual. Neither the author nor the publisher
can warrant that the information contained in this course is accurate or complete in every
respect, and they are not responsible for how this information is used.
It is also the responsibility of the practitioner to determine the appropriateness of any

principle or technique in terms of personal competency and scope of practice. Written
medical opinions are the best way to resolve any questions concerning conditions that
indicate or contraindicate soft-tissue therapy, and the advice from a licensed attorney or
written legal opinions are the best way to resolve any questions concerning the law.
Since the laws regarding the practice of massage therapy may vary from state to state, the
standards appropriate for one state may not be appropriate for other states.

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PREFACE
This course was written to give soft-tissue practitioners a brief overview

of the various conditions that cause knee pain and then focus on the main
conditions that are treatable by soft-tissue therapy. Even though conditions
such as runner’s knee or chondromalacia can be treated by conservative
measures, torn menisci or ruptured ligaments often require surgery and soft-
tissue therapy is most effective during postoperative rehabilitation.
Though torn menisci or ruptured ligaments will sometimes heal without
surgery, patients who are treated by surgical methods such as arthroscopic
surgery are more likely to regain full use of the injured knee than patients
who are treated by conservative measures. While this may not be a problem
for people who are not physically active, most younger patients and most
athletes are not willing to accept a loss of function and will opt for surgery.
Because of the difficulty evaluating a knee injury without imaging
equipment such as an x-ray machine—other than minor strains or sprains—
most knee injuries should be diagnosed by a physician before they are
treated by conservative measures. If damage to a meniscus or ligament is
minor, most physicians will recommend conservative measures and take a
watch-and-wait approach. In most cases, the same methods that are used for
treating a torn meniscus or ruptured ligament after surgery can also be used
for treating minor tears. The indications that conservative measures are not
adequate and surgery may be required include: persistent swelling; atrophy;
a knee that locks, buckles, or gives way; and progressive joint degeneration.
Following the same tradition as other courses, this course is built on the
HEMME APPROACH foundation. The course materials are based on physical
medicine, osteopathy, chiropractic, and massage therapy, and the entire
course is built around the same steps that are used in all HEMME APPROACH
courses—history, evaluation, modalities, manipulation, and exercise.
Practitioners who complete this course should be able to identify and
treat many of the common soft-tissue impairments—such as pain, limited
range of motion (ROM), and weakness—that affect the knee. Because of the
knee’s complex nature, rehabilitation of a knee injury often requires a team
approach, with a qualified physician supervising the team.
There will be situations, however, where the patient’s condition has been
diagnosed by a physician and the patient is free to pursue whatever
conservative measures offer the best results. The principles and techniques
presented in this course can also be applied to this type of situation.

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TABLE OF CONTENTS
INTRODUCTION ....................................................................................... 1
KNEE JOINT............................................................................................... 2
Bony Anatomy of the Knee ......................................................................... 2
Major Muscles that Affect the Knee............................................................ 2
Quadriceps Femoris........................................................................... 2
Rectus Femoris .............................................................................. 2
Vastus Lateralis ............................................................................. 2
Vastus Medialis ............................................................................. 3
Vastus Intermedius ........................................................................ 3
Hamstrings......................................................................................... 3
Semimembranosus......................................................................... 3
Semitendinosus .............................................................................. 3
Biceps Femoris .............................................................................. 4
Tensor Fasciae Latae (TFL) .......................................................... 4
Major Ligaments of the Knee............................................................ 4
Meniscus............................................................................................ 4
ANATOMY (illustration).................................................................. 5
Loose Bodies ..................................................................................... 5
SOFT-TISSUE THERAPY ......................................................................... 6
HEMME APPROACH ................................................................................ 7

HEMMEGON (model) ...................................................................... 9
HISTORY .................................................................................................... 10
Contraindications............................................................................... 10
Popliteal Arterial Aneurysm.............................................................. 10
Interview............................................................................................ 11
EVALUATION............................................................................................ 12
Observation........................................................................................ 12
Palpation ............................................................................................ 12
Muscle Testing .................................................................................. 13
Q (Quadriceps) Angle........................................................................ 14
Distraction and Compression ............................................................ 15

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Apley Compression Test ................................................................... 15
McMurray’s Test ............................................................................... 15
Patellofemoral Grind Test ................................................................. 15
Treatable Conditions ......................................................................... 15
Patellofemoral Stress Syndrome................................................ 16
Indications and Treatment ......................................................... 16
Corticosteroid Injections................................................................ 18
Torn Menisci.................................................................................. 19
Ruptured Ligaments ...................................................................... 20
MODALITIES ............................................................................................. 21
Wound Healing and Therapeutic Cold.............................................. 23
Ice Packs ............................................................................................ 24
Trigger Points and Ice ....................................................................... 25
Contraindications for Cold ................................................................ 25
Indications for Therapeutic Cold....................................................... 25
Thermotherapy................................................................................... 25
MANIPULATION....................................................................................... 26
Laws and Principles of Soft-Tissue Therapy .................................... 26
General Laws and Principles ............................................................. 27
TRIGGER POINT THERAPY ................................................................. 28
NEUROMUSCULAR THERAPY ............................................................. 30
Inhibition........................................................................................ 31
Proprioceptive Inhibition ............................................................ 31
Post-Isometric Relaxation (Inhibition) ....................................... 32
Reciprocal Inhibition................................................................... 33
Stretching to Reset Proprioceptors .................................................... 33
Facilitation ......................................................................................... 34
Activation of Stretch Reflex .......................................................... 34
Muscle Spindle Facilitation ........................................................... 34
Repeated Contractions ................................................................... 34
CONNECTIVE TISSUE THERAPY .......................................................... 35
Thixotropy ..................................................................................... 35
Hysteresis....................................................................................... 35
Creep.............................................................................................. 35
RANGE OF MOTION STRETCHING ..................................................... 36

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EXERCISE .................................................................................................. 37
Exercise Principles ............................................................................ 37
Chronic Overuse Injuries................................................................... 38
Prevention.......................................................................................... 38
Glucosamine Sulfate.......................................................................... 38
CONCLUSION............................................................................................ 39
BIBLIOGRAPHY........................................................................................ 40
HEMME APPROACH QUIZ...................................................................... 42

INTRODUCTION
The knee is a simple synovial hinge joint that is formed by the distal end
of the femur, the proximal end of the tibia, and a sesamoid bone called the
patella. Other structures that are related to the knee include:
• joint capsule A two-layered sac that encloses a synovial joint.

• fibrous tissue The outer surface of a joint capsule.
• synovial membrane The inner surface of a joint capsule.
• plica A fold in synovial membrane of a joint capsule.
• bursa A closed sac or envelope lined with synovial membrane.
• meniscus A crescent-shaped fibrocartilaginous structure in the knee.
• articular cartilage A cartilage that covers the articular ends of a joint.
• ligament A band of fibrous connective tissue that connects to bone.
• muscle An organ with muscle tissue, nerve tissue, and connective tissue.
• quadriceps femoris tendon The insertion that imbeds the patella.
• trochlear groove A groove that lies between the femoral condyles.
Partially because it connects the two longest bones in the human body—
femur and tibia—the knee joint has a tendency to be unstable. Ligaments
are the non-contractile structures that stabilize the knee and muscles are the
contractile structures that stabilize the knee.
The four major ligaments that support the knee joint are the anterior and
posterior cruciate ligaments and two collateral ligaments. The seven main
muscles or muscle groups that affect the knee are the (1) quadriceps group,
(2) hamstring group, (3) tensor fascia latae, (4) popliteus, (5) gastrocnemius,
(6) soleus, and (7) sartorius. The knee joint is the largest articulation in the
body, and because of the linkage between the hip, knee, and ankle joint, any
muscles that affect the hip or ankle joint may also affect the knee joint.
Despite the large number of soft-tissue components in the knee, there are
many knee problems, such as torn menisci or ruptured ligaments, that are not
responsive to conservative care and often require surgery. Rather than focus
on these problems, this course will concentrate on conditions that are
treatable by soft-tissue therapy such as patellofemoral stress syndrome,
which includes runner’s knee and chondromalacia. There will also be a brief
discussion of postoperative rehabilitation protocols following a torn
meniscus or ruptured ligament. These protocols are usually supervised by a
physician, and the protocols for the same operation are not always the same.

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KNEE JOINT
Bony Anatomy of the Knee
The knee is made up of three bones—femur, tibia, and patella—and two

major articulations: the tibiofemoral joint and the patellofemoral joint.
Motion within the tibiofemoral joint results from gliding and rolling of the
femur on the tibia, and motion within the patellofemoral joint results from
the patella—a sesamoid bone—articulating with the distal end of the femur.
Besides protecting the anterior surface of the femur, the patella increases the
efficiency of the quadriceps muscles. The knee has two ranges of motion:
• Range of motion (ROM) for flexion: 0 degrees to 135 degrees.

• Range of motion (ROM) for hyperextension: 0 degrees to 10 degrees.
Knee flexion can be as high as 160 degrees, and hyperextension may or

may not be present. The passive range of motion (ROM) for both flexion
and hyperextension is often slightly greater than the active range of motion.
Major Muscles That Affect the Knee
QUADRICEPS FEMORIS To stretch the quadriceps from a prone

position with the patient’s knee flexed,
lift the patient’s thigh into extension.
RECTUS FEMORIS
Action: extends leg and flexes thigh.

Origin: iliac spine and rim of acetabulum.
Insertion: base of patella and tuberosity of tibia.
Innervation: femoral nerve.
The lateral patellar retinaculum is
VASTUS LATERALIS a fibrous band that runs from the
vastus lateralis tendon to the
lateral margin of the patella.
Action: extends leg.
Origin: lateral aspects of femur.
Insertion: patella and common tendon of quadriceps femoris.
Innervation: branches of femoral nerve.

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VASTUS MEDIALIS
Action: extends leg and draws in patella.

Origin: medial aspect of femur.
The medial patellar retinaculum is
a fibrous band that runs from the
VASTUS INTERMEDIUS vastus medialis tendon to the
medial margin of the patella.
Action: extends leg.
Origin: anterior and lateral surfaces of femur.
The hamstrings and the opposing quadriceps play a major role in rehabilitation of
the knee. Tight hamstrings increase the pressure between the patella and femur and
limit the knee’s ROM, whereas weak quadriceps cause instability and incoordination. To
relieve patellar pressure and restore ROM, lengthen the hamstrings by using connective
tissue therapy and ROM stretching. To increase stability and improve coordination,
strengthen the quadriceps by using (1) trigger point therapy to reduce pain inhibition and
(2) neuromuscular therapy to increase neurologic efficiency and muscle recruitment.
If one muscle group is tight and the opposing muscle group is weak: lengthen the
tight muscles before you strengthen the weak muscles. This will help to maintain muscle
balance and prevent tight muscles from limiting the ROM of weak muscles.
To stretch the hamstrings from a supine

HAMSTRINGS position with the patient’s knee fully
extended and foot dorsiflexed, push on
SEMIMEMBRANOSUS the patient’s ankle to flex the thigh.
Action: flexes and rotates leg medially and extends thigh.

Origin: ischial tuberosity.
Insertion: medial condyle of tibia and lateral condyle of femur.
Innervation: tibial portion of sciatic nerve.
SEMITENDINOSUS
Action: flexes and rotates leg medially, extends thigh.

Origin: ischial tuberosity.
Insertion: upper part of medial surface of tibia.
Innervation: tibial portion of sciatic nerve.

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BICEPS FEMORIS
Action: flexes and rotates leg laterally and extends thigh.

Origin: long headischial tuberosity and short headlinea aspera.
Insertion: head of fibula and lateral condyle of tibia.
Innervation: tibial and peroneal portions of sciatic nerve.
TENSOR FASCIAE LATAE (TFL) To stretch the TFL and

ITB from a side-lying
position with the tight
Action: flexes and rotates thigh medially. muscle and band on top,
Origin: iliac crest and iliac spine. push the patient’s thigh
Insertion: iliotibial band (ITB) of fascia lata. into extension and then
into lateral rotation and
Innervation: branch of superior gluteal nerve. adduction.
Major Ligaments That Affect the Knee

The ACL is a major stabilizer of
• Anterior cruciate ligament (ACL) the knee, and rupture of the ACL
• Posterior cruciate ligament (PCL) is a frequent athletic injury. If an
• Tibial (medial) collateral ligament (TCL) ACL ruptures, there may be an
audible pop followed by pain.
• Fibular (lateral) collateral ligament (FCL)
The ACL limits anterior movement of the tibia on the femur, the PCL
limits posterior movement of the tibia on the femur, the TCL supports the
knee against inward stress, and the FCL supports the knee against outward
stress. Support for the knee is also provided by iliotibial band (ITB), lateral
capsular ligament (LCL), and medial capsular ligament (MCL).
Meniscus
The knee has two menisci and both are composed of fibrocartilage.
When viewed from the top, each meniscus resembles the letter “⊂” and the
open parts face each other “⊂⊃” without touching. The menisci perform
four major functions: (1) act as shock absorbers (2) improve joint stability,
(3) distribute weight, and (4) help to lubricate the joint. Since they are not
firmly attached to either the femur or tibia, menisci are free to move when
the knee is flexed, extended, or rotated. Because the outer borders are more
vascularized than the inner borders, injuries to the outer borders of menisci
receive more blood and heal faster than injuries to the inner borders.

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ANATOMY
Loose Bodies
Besides the normal structures, the knee joint may also have abnormal
structures such as small pieces of bone or torn meniscus called loose bodies
that float around inside the synovial joint capsule and may cause the knee to
give way or lock (catch) if they get trapped between the femur and tibia. As
used here, locking implies an inability to fully extend the knee.
Many patients discover on their own that they can release a locked knee
by fully flexing and then fully extending the hip and knee joint. Some
patients will also internally or externally rotate the leg during extension. An
audible clunk may be heard when the knee is flexed, and the loose body is
normally displaced when the knee is extended. Also called joint mice, loose
bodies can be removed by arthroscopic surgery if they cause persistent joint
locking. Meniscal tears may also cause the knee joint to lock or give way.

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SOFT-TISSUE THERAPY
Soft-tissue therapy is medically defined as manipulation of soft tissue for

therapeutic purposes, with or without modalities and with or without active
or passive movement. Since the late 1800s, soft-tissue therapy has been
recognized as being curative, palliative, and hygienic.
By definition, soft-tissue impairments are soft-tissue lesions, defects, or
dysfunctions that cause pain, abnormal changes in range of motion (ROM),
or weakness. Disability results when soft-tissue impairments severely limit a
person’s ability to function normally and perform useful activities.
In soft-tissue therapy, rehabilitation is the process of restoring normal
function by correcting soft-tissue impairments and allowing the body to heal
itself. When viewed as a problem-solving process, the first part of soft-
tissue therapy involves identifying the problem (history and evaluation), and
the second part involves solving or treating the problem (modalities,
manipulation, and exercise).
Soft-tissue therapy can produce local changes that affect limited parts of
the body or global changes that affect large parts of the body. Manipulation
of superficial tissue can also produce psychological effects such as general
relaxation and a sense of well-being.
The medical-history and physical-evaluation processes are used to
determine if soft-tissue therapy is indicated or contraindicated. Treating a
patient when soft-tissue therapy is not indicated serves no useful purpose.
Treating a patient when soft-tissue therapy is contraindicated can be harmful
to the patient and may result in being charged with malpractice.
Beyond the classical benefits of massage such as improved circulation,
removal of waste products, and general sedation or relaxation, soft-tissue
therapy specifically addresses pain, limited range of motion, and weakness.
The typical targets of soft-tissue therapy are trigger points, tender points,
spasms, contractures, adhesions, and restricted scar tissue or fascia. By
focusing on these targets, soft-tissue therapy can improve muscular balance,
symmetry, posture, proprioception, and biomechanical efficiency.
More than simply treating symptoms or signs, soft-tissue therapy also
addresses the underlying causes. If the symptoms or signs of a soft-tissue
impairment are pain, limited range of motion, or weakness, soft-tissue
therapy will treat the underlying causes such as trigger points, tender points,
spasm, adhesions, contractures, or proprioceptive deficits. In other words,
soft-tissue therapy treats the causes for disability as well as the symptoms.

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HEMME APPROACH
The HEMME APPROACH is a logical, conservative, and comprehensive

method for treating patients with soft-tissue impairments when soft-tissue
therapy is indicated. The principles and techniques in this approach are
based on scientific research, empirical observation, and clinical experience.
Like most conservative methods, the HEMME APPROACH emphasizes
modalities and manipulation over medication and surgery. The HEMME
APPROACH method—pronounced HEM as in hem and ME as in me—is named
after the acronym HEMME that stands for:
HEMME
H HISTORY
E EVALUATION
M MODALITIES
M MANIPULATION
E EXERCISE
More than just a series of steps, the HEMME APPROACH is based on what
system theory refers to as a language model. Language models are used
when complex ideas cannot be formulated mathematically. The purpose of a
language model is to simplify the process of converting knowledge into
action and measuring the results. Language models can be used to (1)
identify problems, (2) collect information, (3) formulate theories, and (4) test
possible solutions by using feedback.
The six connecting steps that hold the model together are:
CONNECTING STEPS
1. ENTER PATIENT 4. OBJECTIVES SATISFIED
2. ALTERNATIVES 5. OBJECTIVES NOT SATISFIED
3. FEEDBACK 6. OUTSIDE INFORMATION
In the HEMME APPROACH model (HEMMEGON), the five basic steps—

HISTORY, EVALUATION, MODALITIES, MANIPULATION, and EXERCISE—are
in bold letters and the other six steps are in outline letters. The starting point,
the step titled ENTER PATIENT, is boxed.

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Lines and arrows show which directions of movement are possible
within the model. Therapy begins when the patient enters the system. Step
one is titled ENTER PATIENT. The first two basic steps in the model titled
HISTORY and EVALUATION define the patient's problem. History refers to
medical history and evaluation refers to physical evaluation.
The next step in the model is titled ALTERNATIVES. This step is a link
between the problem as defined by HISTORY and EVALUATION and possible
solutions as defined by MODALITIES, MANIPULATION, and EXERCISE.
Alternatives should be specifically defined. If modalities, manipulation,
or exercise are needed, practitioners should know specifically which
modalities, manipulations, and exercises are needed. Workable plans for
therapy should include goals, timetables, and measurable results.
The steps MODALITIES, MANIPULATION, and EXERCISE are situated on
one line to emphasize that therapy may include one or more of these three
steps. If modalities, manipulation, and exercise are used, a normal sequence
would be (1) modalities, (2) manipulation, and (3) exercise.
The next step is FEEDBACK. Like homeostatic mechanisms that regulate
blood pressure, the HEMME APPROACH uses positive and negative feedback
to regulate the course of therapy. Positive feedback validates the course of
therapy being followed and negative feedback indicates a need for change.
If feedback is positive, it is normally best to continue the same treatment
until all improvements cease. Changes can be made in five basic ways: (1)
change the activities that occur during a step, (2) repeat one or more steps,
(3) change the sequence for using steps, (4) obtain outside information and
reenter the system, or (5) exit the system.
The step for entering new information in the upper left-hand corner of
the HEMMEGON is titled OUTSIDE INFORMATION. Like any living system, the
HEMME APPROACH is capable of receiving and processing input from the
outside. This step can be used to enter outside information from sources
such as consultations, research, or laboratory testing. After new information
is received and processed, that knowledge can be entered at four points: (1)
HISTORY, (2) EVALUATION, (3) ALTERNATIVES, or (4) FEEDBACK.
Practitioners can exit the system by using FEEDBACK to reach the steps
titled OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED. If the objectives
of therapy are not satisfied, you can either exit the system completely or
reenter it by using the steps titled HISTORY, EVALUATION, or ALTERNATIVES.
If the objectives of therapy are satisfied, the sequence would go from
FEEDBACK to OBJECTIVES SATISFIED and you would exit the system.

9

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HISTORY
Contraindications
The conditions listed below are general contraindications to soft-tissue

therapy and normally should not be treated without a physician’s approval:
• Acute inflammation or infection Acute or active inflammation is

• Anatomically weak or delicate areas indicated by redness, heat,
swelling, pain, and loss of
• Calcification of a tendon or muscle function, such as the inability to
• Carotid sinus syndrome bear weight, walking with a
• Complete insensitivity to pain or touch limp, or the inability to walk.
• Complete tearing or avulsion of a muscle
• Conditions requiring surgery or psychiatry
• Constant, progressive pain or sharp stabbing pain
• Constant, pulsating axillary pain or referred cardiac pain
• Degeneration that weakens tendons, cartilage, or bone
• Dislocations, subluxations, or severe skeletal deformity
• Fever, chills, or poor general health A history of popping, clicking or
• Hemorrhage or circulatory dysfunction crepitus within a knee can be
• Highly contagious or debilitating diseases normal or pathologic and may
not cause pain, whereas a
• Hypermobile ligaments or joints history of swelling indicates a
• Open fractures, wounds, or lesions pathological condition.
• Painful, hot, or swollen joints
• Patients with organic or functional psychosis
In addition to pain or
• Ruptured or avulsed tendons or ligaments swelling, a ruptured
• Unexplained weakness, numbness, or paresthesia ligament may be
indicated by abnormal
laxity or instability in
Popliteal Arterial Aneurysm the knee joint.
Since aneurysms can be aggravated by tension or compression and the

popliteal artery is a common site for aneurysms, caution must be used when
applying pressure to the diamond-shaped popliteal fossa (depression) that
lies on the posterior aspect of the knee. Patients with a popliteal arterial
aneurysm could have a lump in the popliteal region that resembles a cyst,
pulsating hematoma, or thrombus. To avoid injury, do not apply pressure to
any mass found in the popliteal fossa, and refer the patient to a physician.

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Interview
When conducting an interview, separate the patient from the problem and
then focus on the problem. Always remember that histories are taken to
evaluate the patient's condition and not the patient. Three basic questions to
start a medical history interview are:
Feeling or hearing a “pop”
during a knee injury may
• What can you tell me about the problem? indicate a torn tendon,
• Are you under a doctor’s care? ligament, or meniscus.
• What was the quality of any past treatment?
The acronym PDQ summarizes these first three questions above:
Because of the difficulty evaluating a knee

PDQ problem without extensive testing and
P Problem instrumentation—except for emergency
D Doctor's care situations—most knee problems should be
diagnosed by a physician prior to treatment.
Q Quality of past treatment
When taking a medical history relating to a knee problem, there are five
basic types of dysfunction that are frequently reported by patients:
• Pain: an unpleasant sensation often associated with tissue damage.

• Swelling: an increase in size because of fluid accumulation.
• Locking: a sudden and painful limitation of movement in one direction.
• Giving way: sudden weakness and instability with or without pain.
• Crepitus: a grinding, crackling, or grating sound during joint movement.
In addition to asking about these five types of dysfunction, ask the

patient to explain how the knee joint is different now than it was before the
injury. If one knee joint is dysfunctional and the other is normal, ask the
patient to compare the involved joint with the uninvolved opposite joint.
Besides the first three signs of inflammation—pain, swelling, and a loss
of function—the patient may also report heat and redness, which indicates
the inflammation is acute rather than chronic. If pain or swelling is reported
on only one side of the joint, the problem is often caused by either a tendon,
ligament, or bursa. If a patient reports knee pain when running down stairs
or doing deep-knee bends, the cause is probably related to the patella.

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EVALUATION
After taking a medical history, conducting a physical evaluation is the

next step in formulating a treatment plan. Physical evaluations are normally
considered more objective and less subjective than medical histories.
Swelling is indicated by a loss of the patellar groove on
Observation either side of the patella when the patient is supine.
Observation can be used to evaluate shape, contour, posture, symmetry,

scars, swelling, atrophy, perspiration, skin color, tonus, calluses, abrasions,
blisters, injuries, and twitching (fasciculations). Observation may reveal
protective positioning, compensatory movements, guarding, or limping.
To aid observation, a tape measure can be used to measure the girth of
both knees and thighs, which may indicate that a knee injury has caused
swelling or atrophy. A goniometer can be used to measure the knee’s active
or passive ROM, and it can also be used to measure the angle between the
femur and tibia. Since the quadriceps run parallel to the femur, the distal
tendons for the quadriceps pull on the patella at the same angle (Q angle).
If a knee is swollen, pressing on the lateral side may
Palpation cause a perceptible bulge on the medial side.
Palpation is probably the most useful method of physical evaluation used

in soft-tissue therapy. When soft-tissue impairments occur because of
changes in structure or function, palpation can isolate the offending tissues
by finding pain, tenderness, abnormal tonus, swelling, atrophy, abnormal
shapes or contours, and changes in temperature. Crepitus, popping joints, or
snapping tendons can be found by using either palpation or auscultation
(listening for abnormal body sounds with or without a stethoscope).
Skin can be palpated for texture, consistency, mobility, moisture, and
thickness. Palpation combined with observation can be used to locate
landmarks and topographic anatomy (regional or surface anatomy).
When evaluating the knee, palpation can be used to identify atrophy of
the quadriceps or hamstring muscles, popliteal cysts, or joint fluids. Joint
instability is easier to recognize by having the patient stand or walk than by
palpating the knee joint. Even though tight tissue can often be detected by
palpation, extending the knee to 180 degrees is a better way to check for
flexion contractions. When palpating for joint fluid, extending the knee will
often reveal joint fluid that was not apparent when the knee was flexed.

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Muscle Testing
Manual muscle testing is a clinical method for measuring muscular

strength and range of motion (ROM). It evaluates the function of muscles,
tendons, and associated tissue. Strength measures the patient's ability to hold
steady or move against resistance. When patients hold against resistance,
muscles contract isometrically without changing in length. When patients
move against resistance, muscles contract isotonically and shorten.
The four main factors affecting strength are (1) neurologic efficiency, (2)
the contractile force exerted by muscle fibers, (3) the integrity of tendons and
aponeuroses, and (4) the ability of opposing muscles to reach normal length.
Even though joints are not part of a muscle, the integrity of joints can also
affect strength and weakness. If a joint is irritated, locked, or unstable, a
muscle crossing the joint may test weak when the muscle itself is normal. Any
condition that changes joint space above or below physiologic limits will
adversely affect the ability of joints to produce movement.
Range-of-motion testing measures joint movement by degrees of arc in a
circle. The starting position is zero (neutral position) and degrees are added in
the direction the joint moves from starting position. Except for rotation,
starting position is normally the same as anatomical position.
Active range of motion (AROM): the force for movement is provided by the
patient without assistance or resistance from the examiner.
Passive range of motion (PROM): the force for the movement is provided by
the examiner without assistance or resistance from the patient.
Active-assisted range of motion: the force for the movement is provided by
the patient with some assistance from the examiner.
Resisted range of motion: the force for the movement is provided by the
patient and works against resistance from the examiner.
For the safety of the patient, active, passive, and active-assisted range-of-
motion testing should always be done first, and resisted range-of-motion
testing last. Active range-of-motion testing gives the examiner a chance to
observe the patient's ROM with gravity as the only outside force.
If a patient fails the active ROM test, the next step is passive ROM testing.
If the patient's passive ROM is limited, the probable causes are joint
dysfunction, spasm, or contracture. If the patient's passive ROM is normal,
active-assisted ROM testing can be used to locate weaknesses that interfered

14
with the patient's active ROM. Possible causes for weakness are neurologic
dysfunction, lack of motivation, pain inhibition, disuse atrophy, or fatigue.
The six grades used in muscle testing range from 5 to 0.
MUSCLE TESTING BY GRADE

NORMAL 5 Hold against gravity and full resistance (N).
GOOD 4 Hold against gravity and some resistance (G).
FAIR 3 Complete range of motion against gravity (F).
POOR 2 Complete ROM with gravity eliminated (P).
TRACE 1 Evidence of contraction only (T).
ZERO 0 No evidence of contraction (0).
Note: Normal is a higher grade than Good.
Three points that relate to safety are (1) do not apply excessive force or
break the patient's contraction, (2) apply resistance slowly and progressively
(easy on), and (3) remove resistance slowly and progressively (easy off).
Since flexion or extension of the knee depend on the quadriceps and
hamstrings working together, these muscles can be tested as a group. When
these two muscle groups are tested, bilateral comparison can be used to
cross-check the results from muscle testing. If only one knee is thought to
be affected, the results from testing the impaired side should be compared
with the results from testing the normal side. If the muscles on the impaired
side are the weakest, a grade of 5 may be too high. If muscles on both sides
of the body test the same, a grade of 4 for the impaired side may be too low.
Q (Quadriceps) Angle
The Q angle is formed by the intersection of two lines: the top line goes
from the anterior superior iliac spine to the center of the patella and the
bottom line goes from the tibial tubercle to the center of the patella. If the Q
angle is normal, the angle as measured from the center of the patella should
be about 10 degrees for males and 15 degrees for females when the knee is
fully extended. Values greater than 20 degrees are considered abnormal and
may be associated with patellofemoral stress syndrome.

15
Distraction and Compression
Distraction (pulling apart joint surfaces) and compression (pushing

together joint surfaces) can be used to help identify injured structures. If
ligaments are damaged, using distraction may cause pain. If the articular
cartilage or menisci are damaged, using compression may cause pain.
Apley Compression Test
With the patient prone and the knee flexed to 90 degrees, (1) press down
on the patient’s foot to compress the knee and (2) rotate the foot medially
and laterally. A painful response may indicate a torn meniscus.
McMurray’s Test
With the patient supine, move the hip and knee into maximum flexion
and then gently extend the hip and knee by pulling on the ankle with one
hand while supporting the knee with the opposite hand. An audible click or
thump during extension may indicate a torn meniscus. Some examiners
internally or externally rotate the leg prior to extending the hip and knee.
Patellofemoral Grind Test
With the patient supine and the hip and knee fully extended, place one
hand on the patella to resist upward (cephalad) movement toward the head
and tell the patient to gently contract the quadriceps. A pain response may
indicate chondromalacia. To eliminate the possibility that compressing the
synovial lining (synovium) is causing the pain, flex the patient’s knee to
about 45 degrees with the foot flat on the table and repeat the same test. If
both tests are positive, the probability of chondromalacia is even higher.
Treatable Conditions
The three conditions covered below are patellofemoral stress syndrome,

torn menisci, and ruptured ligaments. Unlike patellofemoral stress
syndrome, torn menisci and ruptured tendons often require surgery, and soft-
tissue therapy produces the best results when used during postoperative
rehabilitation to accelerate healing or restore normal usage.

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PATELLOFEMORAL STRESS SYNDROME
Runner’s knee and chondromalacia have been placed under one heading
because the signs, symptoms, causes, and treatments for these conditions are
similar. The term chondromalacia implies that the articular cartilage has
undergone swelling, softening, and possibly fissuring (cracking), and these
pathologic changes are characteristic of several different conditions
including runner’s knee, osteoarthritis, and degenerative arthritis.
Rather than draw a line between runner’s knee and chondromalacia,
which is practically impossible, the two will be discussed as one condition:
patellofemoral stress syndrome—which is less severe than osteoarthritis,
where the fissures reach the bone below the articular cartilage (subchondral
bone), or degenerative arthritis, where subchondral bone is visibly eroded.
Both of these conditions produce pain around the front of the knee—
especially when running downhill—and are usually caused by abnormal
pressure between the patella and femur. In many cases, the abnormal
pressure occurs because the patella does not stay between the femoral
condyles when the knee is flexed. The reasons for the patella not tracking
properly between the femoral condyles include:
• excessive pronation of the foot Indications that the patella is not tracking
• weak vastus medialis properly between the femoral condyles are
pain, swelling, and a grinding or crackling
• tight hamstring muscles sound called crepitation—which may be
• tight iliotibial band (ITB) caused by erosion of the articular cartilage.
• Q angle greater than 20 degrees
Indications and Treatment
Indications for runner’s knee and chondromalacia include pain behind

the patella, especially when running downhill. During the advanced stages,
pain behind the patella may be felt during all running and also when walking
or running down steps. Although running should be stopped until the
condition improves, riding a stationary bicycle should not be a problem and
is also a good way to maintain muscular strength and aerobic fitness.
The common treatments for both runner’s knee and chondromalacia
include using an orthotic to reduce pronation of the foot, strengthening the
vastus medialis (quadriceps), stretching the hamstrings, tensor fasciae latae,
or iliotibial band (tract), and surgical release of the lateral retinaculum.

17
Even though some doctors prefer to use arthroscopic surgery for treating
chondromalacia, conservative treatments that use orthotics and exercise are
often more effective. Since a runner’s foot that turns in (pronates) as the
foot leaves the ground will have a tendency to cause chondromalacia,
orthotics are used to reduce pronation as the runner’s foot moves from heel-
strike to toe-off. Once the problem with pronation has been corrected, the
second step is using exercise to strengthen the quadriceps muscles.
There are two important principles regarding rehabilitation of knee
injuries that apply to almost every situation. The first applies to protective
spasm and the second applies to exercise.
First principle: Protective spasm is a protective reaction that occurs
after a soft-tissue structure such as a ligament is damaged. The muscles that
control the knee joint go into spasm and prevent or restrict movement. This
process is also called guarding or splinting. While this reaction may be
useful during the acute stage of an injury when protecting or resting the
injured part is necessary, during the subacute stage, protective spasm can
retard healing and delay the patient’s return to normal activity by causing
limited ROM, pain inhibition, muscular weakness, and muscle atrophy.
During the subacute stage, soft-tissue therapy should be used to reduce
protective spasm, increase ROM, and help the patient regain normal usage of
the injured knee. This includes neutralizing pain inhibition that normally
accompanies protective spasm. To accomplish this goal: the first step is
using cryotherapy to reduce pain, spasm, and swelling; the second step is to
use trigger point therapy, neuromuscular therapy, connective tissue therapy,
and ROM stretching to reduce pain, restore ROM, increase strength, and
promote tissue growth; and the third step is to use exercise to increase
flexibility, strength, muscular endurance, and cardiovascular fitness.
Second principle: During the early stages of rehabilitation when
exercise is needed to avoid atrophy, start with isometric exercises and then
progress to isotonic exercises. Isometric exercises strengthen a muscle
without moving the joint, whereas isotonic exercises strengthen a muscle
and move the joint at the same time. Until the knee is fairly well healed, it is
safer to strengthen a muscle without moving the joint. If tissues are not
given enough time to heal, contractile and noncontractile tissues that are
stretched or compressed because of moving the knee joint may be damaged.
Regrettably, there is no absolute rule for determining exactly when
tissues are strong enough to tolerate movement. As a general rule, if pain,
swelling, and heat are present, the injury is still in the acute stage and the

18
knee should be protected and rested. If pain, swelling, and heat are not
present when you start manipulation or exercise and they suddenly appear,
this may indicate that more time is needed for healing. Because therapy is
not an exact science, you must constantly monitor the patient’s condition,
use feedback from the patient, and make whatever adjustments are needed.
While there is no universal formula that applies to every situation, the
rule of 10 can be used for isometrically strengthening the quadriceps during
the subacute stages of a knee injury. According to the rule of 10, perform 10
isometric contractions 10 times per day and hold each contraction about 10
seconds. This exercise should be done with the patient supine and the knee
extended. One advantage of having patients on their back is that they can
place the palm of their hand on top of the thigh to feel the contraction.
If the knee is capable of more exertion than isometrically contracting the
quadriceps for 10 seconds while the knee is fully extended, the best general
exercise for runner’s knee or chondromalacia is to sit on a desk with the
knee fully extended—0 degrees—and (1) slowly flex the knee from 0
degrees to about 30 degrees, (2) hold the position for 3 seconds, and (3)
slowly extend the knee back to 0 degrees. If the knee is flexed to more than
30 degrees, this will increase the risk of injury because it pulls the patella
back into the trochlear groove. The difference between 0 degrees and 30
degrees is about 6 inches. As long as the patient can still fully extend the
knee, you can increase resistance by hanging a weight over the ankle.
The 30 degrees of movement between 0 degrees and 30 degrees should
be relatively pain-free because the patella does not seat itself in the trochlear
groove until flexion reaches about 30 degrees. Exercises that require the
knee to flex more than 30 degrees—such as climbing stairs or doing deep
knee bends—are not recommended for people with chondromalacia.
Athletes with chondromalacia will often feel the most knee pain at the
deepest part of a deep squat where flexion is the greatest.
Corticosteroid Injections
Even though local corticosteroid injections can relieve pain and reduce
swelling, they can also delay healing by inhibiting fibroblast function,
disrupting collagen formation, and reducing blood supply to a tendon—
which may cause necrosis and increase the risk of rupture. Because of these
problems, injections should be close to the tendon but not into the tendon,
and strenuous exercise should not be resumed without a doctor’s approval.

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TORN MENISCI
Menisci act as spacers between the femoral and tibial condyles. The
superior surfaces are in contact with the femur, the inferior surfaces are in
contact with the tibia, and the lateral surfaces adhere to the synovial
membrane of the joint capsule. While some meniscal tears may resolve
themselves without surgery—persistent swelling; atrophy; having the knee
lock, buckle, or give way; and progressive joint degeneration indicate that
surgery is needed. Postoperative rehabilitation, which is usually supervised
by a physician, may include using a brace to protect the injured knee,
strengthening the quadriceps, stretching the hamstrings or the iliotibial band,
and prescribing antiinflammatory medication or analgesics.
Two factors that may limit a patient’s ROM are spasm in the hamstrings
or contractures in the patellar tendon or joint capsule. Spasm can be treated
by using trigger point therapy, neuromuscular therapy, and ROM stretching,
whereas contractures are treated by using connective tissue therapy or ROM
stretching. Although heat can be used to increase tissue extensibility and
facilitate stretching, the risk that heat may increase effusion, subcutaneous
bleeding, or swelling explains why heat is rarely used in knee therapy.
When recovery from a torn menisci operation is fairly complete, pain,
swelling, and stiffness should be largely resolved, and the knee should not
lock, give way, or produce pain when the patient walks up or down stairs.
Once a patient regains normal usage of the knee, the final step is trying to
maintain the knee’s integrity and prevent future injuries.
The best approach for most patients is to follow a fitness program that
includes exercises for flexibility, strength, muscular endurance, aerobic
fitness, proprioception, and coordination. Two exercises that are usually
considered safe are (1) riding a stationary bicycle and (2) swimming.
While most protocols for postoperative rehabilitation follow a sequence
that starts with protecting the injured part and ends with exercise, some
protocols call for weight bearing early in the program and others postpone
weight bearing until later in the program. Part of this variation depends on
the doctor’s preference and part depends on the nature of the surgical repair.
Minor repairs that involve highly vascular tissue heal faster than major
repairs that involve less vascular tissue. The temperament of the patient can
also be a factor. Athletes have a tendency to reinjure tissues because of
overexertion, whereas sedentary patients have a tendency to suffer from
atrophy or contractures because of their unwillingness to exercise.

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RUPTURED LIGAMENTS
Torn ligaments are often caused by the foot remaining stationary while
the knee is forcefully rotated. The indications that a ligament has ruptured
include a snapping noise, pain, immediate instability or disability, and rapid
swelling. Locking of the knee may occur if a meniscus is torn.
If a ligamentous injury is severe, several ligaments may be ruptured, the
knee may be subluxed or dislocated, the peroneal nerve or popliteal artery
may be damaged, stability may decrease, and the victim may go into shock.
The probability that conservative measures will be adequate for treating
a ruptured ligament are extremely small, and failure to have a ligament
surgically repaired in a timely manner may cause degeneration (arthrosis)
that would not have occurred if surgery was performed sooner. Where soft-
tissue therapy can play a major role is during the postoperative stage. If
used correctly, it can reduce pain or spasm, restore ROM, increase muscular
strength or endurance, and help the patient regain normal use of the knee.
Like postoperative rehabilitation following surgical repair of a torn
meniscus, therapy should be done under the direct supervision of a doctor
who is familiar with the patient’s condition. In most cases, medication will
be needed to help control inflammation, infection, or pain.
While the four stages of rehabilitation that a patient goes through when
recovering from either a torn meniscus or a ruptured ligament are similar—
acute, subacute, return to normal usage, and maintenance—restoring ROM
and having the patient put weight on the injured knee are often done earlier
when a ligament is repaired than when a meniscus is repaired.
Unlike postoperative management for a torn meniscus where the focus is
mainly on strengthening the quadriceps and lengthening the hamstrings,
following the surgical repair of a ruptured ligament it may be necessary to
stretch or strengthen other muscles to avoid weakness, tightness, pain,
atrophy, or contractures. Which muscles need to be treated will depend on
which ligaments were ruptured and how much time passed since the repair.
Besides strengthening the quadriceps and stretching or strengthening the
hamstrings, gluteus maximus, tensor fasciae latae (TFL), and gastrocnemius
or soleus (calf muscles), the iliotibial band (ITB) may need to be stretched.
Because of the large number of variables when dealing with ruptured
ligaments, extensive knowledge, continuous evaluation of the patient’s
condition, and constant feedback from the patient are needed in order to
know if the present course of therapy is increasing muscular control.

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MODALITIES
Cryotherapy is a broad term that refers to therapeutic use of cold, and

cooling is the process of removing heat from an object. Cold can be applied
by using ice packs, immersing body parts in ice water, using blocks of ice to
stroke or press body parts (ice massage), or using a vapocoolant spray.
The average temperature range for cold modalities is 32°F to 65°F, and
most of the cold modalities used in soft-tissue therapy involve water. In
addition to local effects such as decreases in local metabolism, blood flow,
and pain, the application of ice to large parts of the body produces global
effects such as decreases in body temperature, pulse, and respiration.
Different parts of the body behave differently when exposed to cold.
Since the face and hands have more cold receptors than the thighs and feet,
the face and hands are more sensitive to cold than thighs and feet.
Cooling occurs at different rates. Surface tissues cool much more
rapidly than deep tissues, and total immersion in ice water cools a body part
faster than ice packs or ice massage. Once a body part has been cooled,
rewarming takes about twice as long as cooling. For example, a body part
cooled for 20 minutes takes about 40 minutes to rewarm.
If the amount of change between the starting temperatures and the final
temperatures is the same, cooled areas take longer to rewarm and reach the
precooled starting temperature than warmed areas take to cool and reach the
prewarmed starting temperature. Rewarming takes longer than cooling
because cold decreases blood flow faster than heat increases blood flow.
Blood vessel diameter is the most important single factor that regulates
blood flow. When smooth muscles contract because of cold and reduce the
diameter of blood vessels (vasoconstriction), blood flow decreases. When
smooth muscles relax because of heat and increase the diameter of blood
vessels (vasodilation), blood flow increases. Cold and heat seem to affect
the tonus of smooth muscle by combining direct action with reflex effects.
When body parts are cooled, vasoconstriction reduces blood flow and
prevents warm arterial blood from entering the cooled area. When body parts
are warmed, vasodilation increases blood flow and allows cooler blood to
enter the warmed area and lower the temperature by removing heat.
In addition to lowering blood flow by causing vasoconstriction, cold
reduces blood flow by increasing blood viscosity and decreasing production
of pain-producing substances that cause vasodilation. Increasing blood
viscosity reduces blood flow by increasing intravascular resistance to blood

22
flow, and decreasing production of pain-producing substances prevents
vasoactive chemicals from causing vasodilation.
During the acute stage of a knee injury when stabilization and rest of the
injured body part are advisable, ice packs should be applied for 10 to 30
minutes, removed for 2 hours, and reapplied for 10 to 30 minutes—3 to 5
times a day. Injuries can be stabilized by using tape or a brace.
When treating a knee sprain, ice should be applied within 36 hours.
Waiting more than 36 hours can increase the time needed for recovery as
much as five days. When cold is compared with heat, people treated within
36 hours by cold normally recovered faster than people treated within 36
hours by heat. For best results, ice and compression should be applied to a
sprained knee within minutes after the injury occurs.
Post-traumatic edema also responds better to cold than heat. When the
application of a 50°F to 60°F cold bath for 20 minutes on the third day after
the injury was compared to the application of a 102°F to 106°F whirlpool
bath for 20 minutes on the third day after the injury, the cold bath reduced
edema and the hot whirlpool bath had no effect.
Effusion is the escape of fluids from blood vessels or lymphatics into a
tissue or cavity because of seepage or rupture, and it may cause swelling in
the joint capsule of the knee or weakness in the quadriceps—especially the
vastus medialis. While the following sequence for a contrast bath may help
to reduce pain and minor swelling, it should not be used during the acute
stage of an injury when subcutaneous bleeding may be present or during the
subacute stage of an injury if it appears to cause pain or swelling.
1. submersion in a 102°F to 106°F whirlpool bath for 4 minutes

2. submersion in a 50°F to 60°F cold bath for 2 minutes
This sequence—4 minutes hot followed by 2 minutes cold—is repeated

three times. Stopping after the knee is cooled may help to reduce pain.
Frostbite is defined as local tissue damage that results from exposure to
extreme cold and skin temperatures below freezing. In mild cases, the skin
becomes red (erythema), swollen, and slightly painful. In severe cases, the
skin becomes pale, cold to the touch, and painless or numb. Because of ice
crystals, ischemia, dehydration, and necrosis, severe frostbite can damage
soft tissues down to the bone and cause gangrene. Unlike frozen gel-packs
that produce temperatures below 32°F, there is no danger of frostbite when
ice packs are placed directly on the skin for 30 minutes or less.

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Wound Healing and Therapeutic Cold
Cold induces analgesia by (1) decreasing production of pain-producing

chemicals such as bradykinin, (2) slowing nerve conduction velocities to a
point where pain receptors (nociceptors) can no longer transmit painful
stimuli, and (3) reducing protective spasm by decreasing muscle spindle
activity. When acting as a counterirritant, cold raises the pain threshold by
blocking out painful stimuli and causing the release of endorphins.
On the positive side, cold-induced analgesia facilitates exercise by
controlling pain and reducing muscle spasm. Spasticity, a state of increased
muscle tone with exaggeration of the tendon reflexes, can be temporarily
reduced by using cold to decrease the sensitivity of muscle spindles.
On the negative side, cold decreases tissue extensibility and flexibility
by increasing tissue viscosity. Even though cold can be used effectively to
facilitate exercise when pain is the limiting factor, heat can be used more
effectively when the ability to exercise is limited by a decrease in tissue
extensibility and flexibility. Even if heat is used before exercise to reduce
stiffness, cold can still be used after exercise to control pain or edema.
Cold counteracts edema by decreasing tissue metabolism, decreasing
production of inflammatory chemicals such as histamine, and slowing
vascular changes such as vasodilation that cause microscopic bleeding or
edema. Once swelling has occurred, compression and elevation reduce
swelling more effectively than cold by reducing capillary filtration pressure.
If cold is used to prepare body parts for exercise, exposure to cold
should not be longer than needed to induce analgesia. While short-duration
cold appears to facilitate muscles and produce a slight increase in strength,
long-duration cold decreases strength. Long-term exposure to cold may
cause a decrease in strength because (1) blood flow decreases, (2) viscosity
increases, and (3) proprioceptive (muscle-spindle-cell) efficiency decreases.
The acronym RICE emphasizes the four basic steps for using ice:
• Rest To emphasize the need to protect the injured part,

• Ice the acronym PRICE can be used: Protect, Rest,
Ice, Compress, and Elevate.
• Compression
• Elevation
In the acronym RICE, rest implies the injured body part is stabilized, as
well as rested, and elevation implies the injured body part is elevated above

24
the level of the heart if possible. RICE is recommended as immediate first
aid for most acute musculoskeletal injuries. As suggested by the acronym
PRICE, healing will not be possible unless the injured part is protected.
In sports medicine, ice packs are normally applied to stabilized body
parts for about 20 or 30 minutes every 2 hours with compression and
elevation if possible. Ice treatments are continued for about two days.
While ice and compression reduce edema more effectively than cold
alone, combining ice with compression increases the risk of causing
neurapraxia. By definition, neurapraxia is the failure of a nerve to conduct
nerve impulses because of local compression or ischemia. Even moderate
pressure on a nerve may stop nerve conduction, such as a leg falling asleep.
After swelling because of edema or subcutaneous bleeding stops,
switching to heat during the subacute stage of an injury may accelerate
wound healing by increasing (1) local circulation, (2) tissue metabolism, and
(3) phagocytosis. Subcutaneous bleeding is much less likely to cause
swelling than edema, and it may occur with or without visible swelling.
Most edema related to trauma (inflammatory edema) is caused by chemical
changes that occur during the inflammation process. The prolonged use of
cold during the subacute stage of an injury may retard wound healing by
decreasing local circulation, tissue metabolism, and phagocytosis.
Cold does not always produce the anticipated responses. Even though
cold has a tendency to decrease flexibility by increasing viscosity or
decreasing tissue extensibility, it may also increase flexibility. If muscles
are in spasm and cold relieves the spasm, the increase in flexibility caused
by reduction of spasm may be more than enough to offset the decrease in
flexibility caused by increasing viscosity or decreasing tissue extensibility.
Ice Packs
The easiest way to make an ice pack is to fill a plastic bag with 2 pounds
of crushed or shaved ice, squeeze or suck out the excess air, and tie the end
in a knot. A properly constructed plastic ice pack should not leak. Elastic
wraps can be used to hold ice packs in place and generate moderate pressure.
Ice packs can be placed directly on the skin or wrapped in a towel and then
placed on the skin. Since water is a better conductor of heat than air, moist
towels allow faster cooling than dry towels. Ice packs can also be made by
placing ice in a terry cloth towel. When properly used, ice packs are less
likely to cause frostbite than cold-gel packs or ethyl chloride spray.

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Trigger Points and Ice
When ice is used to neutralize trigger points, most patients perceive four
stages: cold, burning, aching, and numbness. In most cases, a trigger point
is neutralized by the time the patient feels numbness, and the affected
muscle should be warmed and then stretched. When dealing with knee pain,
this method is useful for treating quadriceps tendinitis, which is often caused
by trigger points in the quadriceps—especially the vastus lateralis. The
opposing hamstring muscles should also be checked for trigger points.
Contraindications for Cold
Contraindications for cold include compromised local circulation, heart

disease, hypertension, cold hypersensitivity, acrocyanosis, open lesions or
rashes, Raynaud’s disease, cryoglobulinemia, or areas affected by frostbite.
If cold is used, explain that even though some patients experience minor
discomfort, the benefits will far outweigh the pain. To make cryotherapy
more acceptable, keep body parts that are not being treated warm and dry.
Indications for Therapeutic Cold
Even though long-term cold can help to reduce

Indications for Cold spasm, brief cold may increase tonus. Even so,
1 Muscle spasm neuromuscular therapy is a more effective way to
2 Pain increase tonus than brief cold, and when treating a
knee injury, therapeutic cold is used to reduce
3 Edema pain, spasm, effusion, and swelling.
4 Trauma
Thermotherapy
When treating knee pain, thermotherapy is used to a lesser extent than

cryotherapy for two reasons: (1) knee problems often involve swelling and
heat has a tendency to increase edema and (2) knee problems often involve
abnormal laxity and heat has a tendency to increase tissue extensibility.
Except for situations where contractures or fascia are limiting ROM or
heat gives the patient relief from pain—as may occur if a knee is arthritic—
cold is the modality of choice when treating knee pain. It should also be
remembered that cold, like heat, can reduce pain or spasm, and superficial
cold has much greater penetration than superficial heat.

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MANIPULATION
Manipulation implies skilled and dexterous treatment by using the

hands. The manipulations used in the HEMME APPROACH are low-velocity
pushing or pulling movements that correct soft-tissue impairments by
repositioning soft tissue. The four types of manipulation used in HEMME
APPROACH are (1) trigger point therapy, (2) neuromuscular therapy, (3)
connective tissue therapy, and (4) range-of-motion stretching.
The main goals of soft-tissue manipulation are (1) correct soft-tissue
impairment and (2) restore normal function in terms of strength, endurance,
flexibility, pain-free movement, coordination, and mobility. These goals
should be accomplished by using the least amount of force possible.
The normal sequence for treating soft-tissue impairments is (1) trigger
point therapy to reduce pain, (2) neuromuscular therapy to inhibit spasm or
facilitate weak muscles, (3) connective tissue therapy to lengthen adaptively-
shortened tissues or break adhesions, and (4) range-of-motion stretching to
reset proprioceptors, improve tonus, and normalize ROM. This sequence
can be used with or without the use of modalities.
Laws and Principles of Soft-Tissue Therapy
Soft-tissue therapy is based on scientific laws and principles. Pflüger's

Laws of Unilaterality, Symmetry, Intensity, and Radiation and the Arndt-
Schultz law—weak stimulus causes activity, moderate stimulus increases
activity, strong stimulus retards activity, and very strong stimulus stops
activity—have not been included because they are now considered obsolete.
HEMME APPROACH LAWS
X HEMME’s 1st law: Most conditions treatable by soft-tissue therapy are

characterized by pain, limited range of motion, or weakness.
Y HEMME’s 2nd law: Most conditions treatable by soft-tissue therapy can

be identified and treated by using five basic steps: History, Evaluation,
Modalities, Manipulation, and Exercise.
Z HEMME’s 3rd law: Always be ready, willing, and able to disregard any
law, principle, axiom, or belief that proves to be incorrect.

27
GENERAL LAWS AND PRINCIPLES
The following laws and principles can be found in medical dictionaries

and textbooks, and they are still considered valid.
1. Beevor's axiom: The brain knows nothing of individual muscles, but

thinks only in terms of movement.
2. Creep: Deformation of viscoelastic materials when exposed to a
slow, constant, low-level force for long periods of time.
3. Facilitation-Inhibition:
A. When a nerve impulse passes once through a set of neurons to the
exclusion of other neurons, it usually takes the same path in the
future and resistance to the impulse becomes less.
B. As opposites, facilitation encourages a process and inhibition
restrains a process.
4. Hooke’s Law: The stress applied to stretch or compress a body is
proportional to the strain or changes in length thus produced, provided
that the elastic limit of the body has not been exceeded.
5. Hilton's law: The nerve trunk that supplies a joint also supplies the
muscles that move the joint and the skin that covers the insertions of the
muscles that move the joint.
6. Hysteresis: Energy loss in viscoelastic materials subjected to stress or
to cycles of loading and unloading.
7. Sherrington's laws:
A. Every posterior spinal root nerve supplies one particular region on
the skin, although fibers from segments above and below can invade
this region.
B. Reciprocal Inhibition: when the agonist receives an impulse to
contract, the antagonist relaxes.
C. Irradiation: nerve impulses spread from a common center and
disperse beyond the normal path of conduction. Dispersion tends to
increase as the intensity of stimulus becomes greater.
8. Stretch reflex: A muscle contracts in response to passive longitudinal
stretch. (also called myotatic reflex or Liddell-Sherrington reflex)
9. Thixotropy: Certain gels liquefy when agitated and revert to gel
upon standing.
10. Wolff's law: Bone and collagen fibers develop a structure most suited
to resist the forces acting upon them.

28
TRIGGER POINT THERAPY
Trigger points are hyperirritable spots or zones that produce pain when
stimulated by pressure. The cause for trigger points seems to be mechanical
stress and microscopic or macroscopic trauma. Once connective tissues or
muscle tissues have been disrupted by trauma, the three things that normally
follow are inflammation, abnormal metabolic activity, and hypertonia.
Besides appearing as spots or zones, trigger points can appear as hard
nodules or palpable bands of indurated tissue. Even though trigger points
can be found in tendons, ligaments, skin, or periosteum, the ones found in
muscles or fascia (myofascial trigger points) seem to be the most common.
Trigger point therapy is the process of going from one trigger point to
the next until all trigger points have been neutralized. Any trigger point that
is left untreated may generate new trigger points.
The following signs indicate the presence of trigger points:
• points or zones that are tender when pressure is properly applied

• distinct patterns of referred pain or radiated pain
• the presence of taut, indurated, or ropy bands within a muscle
• tremors or fasciculations when pressure is properly applied
• jump signs or local twitch responses when pressure is properly applied
• abnormal weakness, shortness, tightness, or spasm within a muscle
Locating trigger points depends on the identification of certain

characteristic signs. The most common signs are (1) pain when pressure is
correctly applied, (2) referred pain, (3) a jump response, (4) a local twitch
response, and (5) hardness or ropiness within a muscle.
The simplest test for a trigger point is the appearance of pain when
pressure is correctly applied to sensitive tissues. Light pressure is normally
more discriminating than heavy pressure. Light pressure can be applied by
using the fingers or thumb to compress or pinch suspect tissues.
Stretching a muscle can sometimes be used to locate trigger points. If
stretching produces a dull pain, palpate the muscle for trigger points. If
trigger points are not found, the pain may be joint pain. Whereas trigger
points often produce intermittent pain, joints often produce continuous pain.
If trigger points are treated while a muscle is held in a stretched position, the
muscle may lengthen even more as the trigger points are neutralized.
If a patient recoils while pressure is being applied, the jump sign is
positive. If the trigger point is in a muscle, slight pressure will sometimes
29
cause spontaneous contraction of the entire muscle. A positive jump sign
combined with simultaneous radiation of pain to other parts of the body is
strong evidence of trigger point involvement.
Cutaneous tissue responses and a positive twitch response can be used
for additional verification. If skin that is pinched and pulled away from the
body feels coarse, granular, and inelastic, the cutaneous tissue response is
positive. If taut bands of indurated tissue within the muscle respond
elastically by snapping back into place after plucking the tissues like a guitar
string, the twitch response is positive.
Satellite trigger points are trigger points activated by another trigger
point in the same reference zone. When left untreated, satellite trigger points
often become primary trigger points and develop their own satellite trigger
points. They may also reactivate primary trigger points.
Secondary trigger points develop in synergistic or antagonistic muscles
because of compensatory overload. When active trigger points weaken a
muscle or make it more difficult to stretch, synergistic muscles compensate
for the weakness by substitution while antagonistic muscles compensate for
the added resistance to stretch by working harder.
Three factors seem to explain why trigger point therapy reduces pain:
X Digital pressure disperses pain-producing chemicals.

Y Digital pressure stimulates production of endogenous opioids.
Z Trigger points stimulated by pressure act as a counterirritant.
The best method for gauging treatment time is continuing pressure until
the tissues change in consistency and soften or melt down. The normal
sequence is a sharp increase in pain followed by a gradual decrease in pain.
If the patient reports no reduction in pain after one minute, stop the pressure
because the trigger point being treated may not be the main cause of pain.
If acute inflammation or infection are present, trigger point therapy is
contraindicated. If trigger point therapy is successful, relief will occur in
several minutes and patients may report that they feel pressure but no pain.
The final step after trigger point therapy is ROM stretching. If tissues
are not stretched to a normal length, trigger points may recur. Low-velocity
stretching helps to restore normal length without causing tissue damage.

30
NEUROMUSCULAR THERAPY
The key to understanding medical neuromuscular therapy is realizing

that muscles contract or relax because of the complex relationship between
inhibition and facilitation. Muscles contract when (1) facilitation is strong
enough to cause contraction, and (2) facilitation is stronger than inhibition.
Muscles relax when (1) there is no facilitation, or (2) inhibition is stronger
than facilitation. Facilitation is the sum of all facilitatory synaptic events
and inhibition is the sum of all inhibitory synaptic events.
Neuromuscular therapy is characterized by techniques that inhibit or
facilitate muscles. The primary tissues acted upon are nerve and muscle
tissue. Inhibition encourages elongation; facilitation encourages shortening.
Neuromuscular techniques can strengthen a muscle by eliminating
factors that cause weakness. This allows the patient to attain the greatest
amount of strength possible without using exercise to increase strength.
Inhibition and facilitation have the following uses:
X Inhibition:
• Lengthen hypertonic muscles (decrease hypertonia and muscle tension)

• Strengthen weak muscles (decrease the rate of abnormal contractions)
Y Facilitation:
• Shorten stretched muscles (increase hypertonia and muscle tension)

• Strengthen weak muscles (increase the rate of normal contractions)
When treating the knee, the protocol for using neuromuscular therapy to
balance muscles or muscle groups has seven steps:
1. Evaluate muscle and tendon length by testing ROM.

2. Use inhibition to relax and lengthen restricted muscle tissue.
3. Use ROM stretching to lengthen restricted connective tissue.
4. Evaluate strength by muscle testing.
5. Use facilitation to strengthen weak muscles.
6. Reevaluate muscle and connective tissue for length and strength.
7. If needed, treat again by using stretching, inhibition, or facilitation.

31
An underlying principle that applies to most methods of soft-tissue
therapy is (1) lengthen first, and (2) strengthen second. If one muscle is
too short, the opposing muscle is too long, and both muscles are weak,
lengthen the short muscle first. This will decrease tension on the longer
muscle and help it assume its normal length. After the short muscle is
lengthened, strengthen the long muscle to increase tension on the short
muscle. If two opposing muscles test long and weak, which is unlikely
unless a joint is hypermobile, strengthen both muscles and then monitor
length to ensure that both muscles shorten to their normal length.
Inhibition
The three main ways to inhibit a muscle are (1) proprioceptive

inhibition, (2) post-isometric relaxation, and (3) reciprocal inhibition.
Proprioceptive Inhibition
Soft-tissue therapy uses two methods of proprioceptive inhibition: (1)

compression of muscle spindles, and (2) activation of Golgi tendon organs.
While compressing muscle spindles is often easier and more effective than
stretching GTOs, both techniques are useful.
To use the first method, compress the belly of a muscle toward the center
until the intrafusal fibers in the muscle spindle become slack and cause
reflex inhibition. This can be done by grasping the muscle near the
musculotendinous junctures and using convergent force to compress the
belly of the muscle until both hands meet near the center.
The direction of push is parallel to the muscle and the rate of push is
slow enough for tissues to thin out, melt down or dissolve as the fingers
move toward the center of the belly. The need for anything more than
moderate force indicates that movements are too fast. Hypertonic muscles
will normally relax and test weak after muscle-spindle inhibition.
To use the second method of proprioceptive inhibition, apply tension to
GTOs by using ROM stretching to increase the distance between the distal
and proximal insertion of a muscle. This activates the GTOs, which protect
a muscle from overstretching, by increasing tension on the tendons. Stretch
weakness may occur if a muscle is overstretched for a long time, and heavy
digital pressure—also called inhibitory pressure—may cause a decrease in
tonus if the pressure is applied to the junction between a tendon and muscle.

32
Post-Isometric Relaxation (Inhibition)
Fatigue can be used to inhibit contraction. If hypertonic muscles

contract isometrically for about 10 seconds and then relax, the refractory
period that follows contraction decreases neurologic efficiency. According
to the rebound phenomena, muscles should have a tendency to relax after
being strongly contracted. During the refractory period, muscles become
hypotonic and easier to stretch. Isometric contractions may also cause
autogenic inhibition because of tension on the Golgi tendon organs. The
technique of stretching a muscle after an isometric contraction is called post-
isometric relaxation. The sequence is contract–relax–passive stretch.
If isometric contractions are too strong, accessory muscles may contract
or irritate the muscles that need to be stretched. Moderate contractions will
discourage other muscles from being recruited. Contractions can still be
effective at 10% maximal effort with a 5-second hold. Muscles should be
held in a slightly stretched position during contraction. Cycles of contract-
relax-stretch can be repeated up to 5 times with stretches 30 seconds long.
If post-isometric relaxation is used, breathing cycles should correspond
with periods of contraction against isometric resistance and relaxation. The
best method is having the patient (1) exhale during contraction, (2) inhale
during the first stage of relaxation, and (3) exhale during the second stage of
relaxation as muscles are being slowly stretched by low levels of force.
1. Patient exhales and contracts (practitioner applies counterforce).

2. Patient inhales and relaxes (practitioner stops counterforce).
3. Patient exhales and deepens relaxation (practitioner stretches muscle).
After the basic three-part sequence of contract–relax–passive stretch, the

patient should be encouraged to actively stretch the target muscle. The
sequence would then become contract–relax–passive stretch–active stretch.
While most advocates of post-isometric relaxation recommend using
moderate contractions before stretching, a few recommend using maximal
contractions. After placing a muscle about midway between full contraction
and full extension, the patient is told to contract with maximum effort for
about 10 seconds and then relax. After the patient relaxes, the slack is
quickly taken up and the muscle is stretched for about 30 seconds. This
sequence can be repeated 5 times. Normally used for chronically shortened
muscles, maximal contractions increase the risk of tissue damage and pain.

33
Reciprocal Inhibition
When muscles work in pairs, facilitation of the agonist causes reciprocal

inhibition of the antagonist. As the agonist contracts, the antagonist relaxes
to allow stretching by the agonist. Relaxation of the agonist is apparently
caused by a reflex activity that allows proprioceptors in the agonist to
interact with proprioceptors in the antagonist.
If the antagonist fails to relax, the agonist may test weak despite normal
strength. Coordinated movement is possible because one muscle relaxes
when the opposing muscle contracts. Anything less than total relaxation of
the antagonist restricts shortening of the agonist.
If a flexor muscle is hypertonic, contracting the opposing extensor
muscle should cause the flexor muscle to relax. If a flexor muscle such as
the biceps brachii is in spasm, contracting the triceps brachii should cause
the biceps brachii to relax. If contracting the triceps brachii stretches the
biceps brachii, the stretching may help to relax spasm in the biceps brachii.
Stretching to Reset Proprioceptors
After relaxing a muscle that is abnormally short because of spasm or

hypertonia, the final step is stretching the muscle to reset proprioceptors and
prolong the effects of therapy. Once reset, a proprioceptor’s old memory is
replaced by a new memory. If the old memory represents hypertonia and
limited length, range-of-motion stretching can be used to establish a new
memory that represents normal tonicity and length.
The mechanism that muscles use to store memory is poorly understood.
Unlike viscoelastic materials, such as connective tissue, that have an elastic
memory based on physical properties, proprioceptive memory seems to
involve a complex interaction between proprioceptors, muscle tissue, spinal
nerves, and the brain. Whereas elastic memories respond to physical force,
proprioceptive memories respond to physical force and psychological stress.
In soft-tissue therapy, the normal sequence for using inhibition with
ROM stretching is (1) relax muscles by using inhibition, and (2) lengthen
tissues by using ROM stretching. If ROM stretching is used to reset
proprioceptors, using inhibition techniques before ROM stretching reduces
the risk of tissue damage. Although ROM stretching itself is not considered
a method of inhibition, when used slowly and progressively, it does produce
some degree of inhibition and can be used to reduce hypertonicity or spasm.

34
Facilitation
Most facilitation techniques are based on activation of muscle spindles.

Forces that reduce the tension on muscle spindles have a tendency to inhibit
contraction, while forces that increase tension on muscle spindles have a
tendency to facilitate contraction. Facilitation can be used without inhibition
if muscles test weak but are able to achieve full range of motion when tested
passively. The three main ways to facilitate a muscle are (1) activation of
the stretch reflex, (2) muscle spindle facilitation, and (3) repeated
contractions.
Activation of Stretch Reflex
Muscle spindles react to sudden stretching by a reflex contraction called

a stretch reflex, myotatic reflex, or Liddell-Sherrington reflex. What is often
called a tendon reflex is actually caused by activating a stretch reflex.
Sharply striking the patellar tendon rapidly stretches the quadriceps and
should cause a “knee jerk.” The stretch reflex is a protective mechanism that
guards muscles from being actively or passively stretched too quickly.
Muscle Spindle Facilitation
The highest concentration of muscle spindles is found in the belly of the

muscle. The safest way to facilitate a skeletal muscle is by grasping the
belly of a muscle near the center and using divergent force to stretch the
muscle in opposite directions away from the belly. The direction of pull is
parallel to the muscle and the rate of pull is faster than pulling to lengthen a
muscle, but not fast enough to cause pain. Weak muscles will normally test
stronger after facilitation. Other ways to facilitate a muscle are plucking,
tapping, rapidly shaking, and briefly applying ice to the belly of the muscle.
Repeated Contractions
If a muscle is capable of reaching its full range of motion, repeated isometric

or isotonic contractions will facilitate and strengthen the muscle. While
facilitation reverses the effects of inhibition, improves neurologic efficiency,
and helps a muscle achieve its normal strength, only progressive-resistance
exercises can strengthen a muscle beyond its normal limit.

35
CONNECTIVE TISSUE THERAPY
Connective tissues support or connect other tissues. Examples of dense

fibrous connective tissue are tendons, ligaments, aponeuroses, deep fascia,
and dermis. Other types of connective tissue are bone, adipose tissue,
cartilage, mucous membrane, lymphoid tissue, blood, and lymph.
There are three basic principles that help to explain and predict the
behavior of viscoelastic materials such as fibrous connective tissue:
Connective-Tissue Principles
Thixotropy: gels liquefy when agitated.
Hysteresis: energy is lost because of stress.
Creep: deformation because of a constant force.
Thixotropy
Because of thixotropy, connective tissue manipulation is thought to

increase tissue mobility by (1) liquefying viscous gels, (2) decreasing tissue
viscosity, and (3) reducing tissue tension. Because of thixotropy, tissues may
feel like they thin out or melt down when digital pressure is applied.
Hysteresis
As a result of hysteresis, pulling and releasing soft tissue causes the

tissue to soften and change shape because energy is lost in the form of
friction and heat. Because of hysteresis, a slow stretch, 5-second hold, and
slow release repeated 10 times should cause a permanent increase in length.
Creep
Creep is the deformation of a viscoelastic material when exposed to a

slow, constant, low-level force for a long time. To use creep, small degrees
of constant tension are applied until a soft tissue starts to relax and lengthen.
The point at which a soft tissue starts to lengthen is often referred to as a
meltdown or release. Constant tension is continued until the soft tissue is
fully elongated or no further stretching is needed. The keys to using creep
effectively are (1) minimize force and (2) maximize time. When creep is
used, the application of heat tends to accelerate the rate of lengthening.

36
RANGE-OF-MOTION STRETCHING
The soft tissues affected by ROM stretching include muscles, tendons,

fascia, ligaments, and joint capsules. Most ROM stretching lengthens
muscles and tendons by increasing the distance between the origin and
insertion, and the direction of pull is opposite that of the muscle's action.
One exception is stretching the patellar tendon to restore mobility. Here the
patient’s knee is fully extended to release tension on the tendon and you use
your thumbs to move the patella back and forth perpendicular to the tendon.
A muscle is an organ composed of (1) muscle tissue, (2) nerve tissue,
and (3) connective tissue. If a muscle’s ROM is limited, connective tissue is
more likely to be the cause than muscle tissue. Unlike the length of muscle
tissue, which is controlled largely by proprioceptors, the length of
connective tissue is controlled largely by thixotropy, hysteresis, and creep.
The reason for therapeutic ROM stretching is to help joints achieve or
maintain a normal ROM. A joint that is neither too stable nor too mobile is
biomechanically most efficient. Decreasing a joint's ROM to less than
normal may increase stability, but cause rigidity and stiffness. Increasing a
joint's ROM beyond normal may increase mobility, but cause instability.
If trigger point therapy is used to reduce pain or neuromuscular therapy
is used to lengthen a muscle by reducing tonus (inhibition), range-of-motion
stretching should be used afterward to reset proprioceptors–gamma motor
neurons—and help the muscle spindles readjust to the muscle’s new length.
Since tightness in the calf muscles is a problem that often accompanies
knee pain, a wall stretch can be used as a supplement to passive stretching:
• Stand and face a wall at arm’s length with feet perpendicular to wall.
• Place palms on wall at shoulder level with fingers pointing up.
• Keep heels on ground and lean slowly forward toward the wall.
• Stop leaning forward when stretching starts to cause pain.
• Hold position until there is no pain and the body relaxes.
• Return to starting position and repeat stretch as many times as needed.
If placing your chest on the wall does not produce enough stretch, you
can increase the distance between your feet and the wall. Performing this
stretch with the knees flexed will stretch the soleus, whereas performing this
stretch with the knees extended will stretch the gastrocnemius and soleus.

37
EXERCISE
When dealing with a knee problem, most exercises are done in the pain-
free and crepitus-free ROM. Since muscle atrophy may start within 7 to 14
days after a knee operation, exercise should be started as early as possible.
Failing to start exercise early may also encourage synovial adhesions.
The basic principle behind exercise is defined by the acronym SAID:
Specific Adaptation to Imposed Demands. When demands for strength,
endurance, or flexibility are imposed on the body, the body responds by
trying to make specific adaptations. If a demand for strength, endurance, or
flexibility is imposed on a muscle, the muscle responds by trying to increase
strength, endurance, or flexibility.
If demands placed on the body are too great, the body may not respond
in a beneficial way and the overload may cause overload (overuse) injuries.
The three factors that contribute to overload injuries are (1) intensity, (2)
duration, and (3) frequency. While any of these three factors may cause
macrotrauma or microtrauma, high-intensity injuries are often associated
with macrotrauma such as muscle tears or ruptured tendons, whereas high-
frequency injuries are often associated with microtrauma such as chronic
inflammation of muscles or tendons because of repetitive-strain injuries.
Exercise Principles
Even though the reasons for developing an exercise program may vary,
the same principles that apply when conditioning an athlete for competition
will also apply when helping a patient recover from a knee injury.
(1) The Overload Principle: The intensity, frequency, or duration of training

must be increased periodically for improvement to continue.
(2) The Intensity Principle: Increasing intensity is the first way to increase
overload.
(3) The Frequency and Duration Principle: Frequency and duration are the
second and third ways to increase overload.
(4) The Specificity Principle: Specific exercises produce specific biophysical
adaptations that affect specific parts of the body.
(5) The Training Principle: Percentages of gains are normally greatest during
the early stages of an exercise program and diminish as the program
continues.

38
Chronic Overuse Injuries
One characteristic of a chronic overuse knee injury is that pain and

swelling have a tendency to decrease when activities that affect the knee are
stopped and a tendency to increase when activities that affect the knee are
resumed. The most common treatments for a chronic overuse injury are (1)
use better training methods, (2) eliminate movements that are known to
cause overuse injuries, (3) decrease the intensity or duration of the activity
that causes overuse injuries, and (4) get more rest. Since a poor diet can be a
contributing factor, people with overuse injuries should make certain that
their level of nutrition, including vitamins, minerals, and fluids, is adequate.
Whenever possible, athletes as well as other active people should follow
the heavy-easy principle: heavy workouts on one day should alternate with
light workouts—or no workouts—on one or more of the following days.
This gives the body time to recover and microtrauma time to heal.
Prevention
Taking the following measures may help to prevent knee injures:
• Avoid activities, surfaces, or shoes that cause abnormal stress.

• Do stretching, strengthening, and endurance exercises.
• Do not force the knee beyond its normal range of motion.
• Take frequent breaks to relax and stretch tight muscles.
• Avoid working while fatigued or under severe mental stress.
• Develop good health habits such as adequate rest and good nutrition.
• Warm-up before strenuous activity and cool down slowly afterward.
• If needed, use orthotics, tape, or braces to reduce the risk of injury.
• Avoid activities that place abnormal stress on a weak or injured knee.
• Do not allow old knee injuries to go untreated.
Glucosamine Sulfate
Some studies indicate that glucosamine sulfate reduces inflammation and

promotes healing. Unlike corticosteroid injections, which may weaken
connective tissue, glucosamine sulfate encourages connective tissue growth.
For people with osteoarthritis, this supplement seems to improve knee
function by reducing pain and stiffness and stopping cartilage deterioration.

39
CONCLUSION
The goal for rehabilitation is to restore normal function as quickly and

safely as possible, and one of the most difficult parts of knee therapy is to
find the right balance between protecting the knee and rest on one hand and
manipulation or exercise on the other. If the timing is wrong, the patient’s
condition may worsen rather than improve. Without constantly monitoring
the patient’s condition and getting feedback from the patient, there is no way
to know if the selected course of therapy is working or is not working.
Differences between patients such as age, illness, physical condition
prior to the injury, nutrition, smoking, psychological stress, and motivation
can have a major effect on timing. Patients who are not willing to take an
active part in their own rehabilitation will not progress. Because of the need
for active participation by the patient, a good therapist must also be a good
communicator. This means being a good listener as well as a good speaker.
Take the time to answer questions, and use words that patients understand.
The ten-step sequence for treating almost all knee problems is:
• protection: decrease the possibility of further injury.

• rest: increase the time available for healing.
• cryotherapy: reduce pain, spasm, and edema.
• trigger point therapy: reduce pain and spasm.
• neuromuscular therapy: reduce pain and spasm and increase strength.
• connective tissue therapy: lengthen restricted connective tissue.
• range-of-motion stretching: restore normal range of motion.
• stretching exercises: increase range of motion and flexibility.
• isometric exercises: prevent atrophy and increase strength.
• isotonic exercises: increase strength, endurance, and coordination.
If these ten steps are effective: the quadriceps should be strong enough
to move the knee joint and stabilize the knee, the hamstrings should be long
enough to allow full extension of the knee, it should be possible to use the
knee without having it lock or give way, and using the knee should not cause
pain, swelling, or heat. Even if there is still some degree of crepitus,
clicking, or damage to the cartilage after rehabilitation is completed, therapy
is still considered successful if the patient has regained normal usage of the
knee and any problems that still remain are asymptomatic.

40
BIBLIOGRAPHY
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42
HEMME APPROACH QUIZ
1. The knee joint is a synovial:
a. pivot joint
b. gliding joint
c. hinge joint
d. condyloid joint
2. Which muscle originates from the lateral aspects of the femur and
extends the leg?
a. rectus femoris
b. vastus lateralis
c. vastus medialis
d. tensor fasciae latae (TFL)
3. If the quadriceps are weak and the hamstrings are tight:
a. strengthen the quadriceps first

b. lengthen the hamstrings first
c. strengthen the hamstrings first
d. lengthen the quadriceps first
4. The anterior cruciate ligament (ACL):
a. is a major stabilizer of the knee

b. is frequently injured by athletes
c. may give an audible pop if ruptured
d. all of the above
5. Small pieces of torn meniscus that may cause the knee to give way or
lock are called:
a. foreign bodies
b. loose bodies
c. joint lice
d. floaters

43
6. Soft-tissue impairments may cause:
a. pain
b. abnormal changes in ROM
c. weakness
d. all of the above
7. The acronym HEMME stands for:
a. health, evaluation, modalities, manipulation, and exercise

b. history, estimation, modalities, manipulation, and exercise
c. history, evaluation, modalities, manipulation, and exercise
d. history, evaluation, modalities, manipulation, and energy
8. A common site for aneurysms, the diamond-shaped popliteal fossa is

located:
a. on the lateral aspect of the knee

b. on the medial aspect of the knee
c. on the posterior aspect of the knee
d. on the anterior aspect of the knee
9. What type of sound does crepitus produce?
a. popping
b. snapping
c. grinding
d. clunking
10. An instrument for measuring joint angles is called a:
a. refractometer The disk with a pivot point in the center has

numbers from 0 degrees to 360 degrees
b. dynamometer equally spaced around the circumference.
c. tonometer The reading for the instrument shown here
d. goniometer to the left would be about 90 degrees.

44
11. Q (Quadriceps) angles greater than 20 degrees are:
a. normal for males

b. normal for females
c. normal for either males or females
d. abnormal for either males or females
12. The patella not tracking properly between femoral condyles may be
caused by:
a. weak vastus medialis

b. tight hamstring muscles
c. tight iliotibial band
d. all of the above
13. Which type of exercise is safer during the early stages of rehabilitation?
a. isometric
b. isotonic
c. plyometric
d. aerobic
14. Which factor increases the probability that arthroscopic surgery will be
needed to repair a torn meniscus?
a. persistent swelling
b. muscle atrophy
c. locking or giving way
d. all of the above
15. When using a contrast bath to treat a knee injury, the sequence is:
a. 2 minutes of hot followed by 4 minutes of cold

b. 4 minutes of hot followed by 2 minutes of cold
c. 2 minutes of hot and 2 minutes of cold
d. 4 minutes of hot and 4 minutes of cold

45
16. The acronym PRICE stands for:
a. protect, restrict, ice, compress, and exercise

b. protect, restrict, ice, compress, and elevate
c. protect, rest, ice, compress, and exercise
d. protect, rest, ice, compress, and elevate
17. When dealing with knee pain, quadriceps tendinitis is often caused by
trigger points in the:
a. tensor fasciae latae (TFL)

b. iliotibial band (ITB)
c. quadriceps
d. hamstrings
18. When using neuromuscular therapy to balance muscles or muscle

groups, the first step is:
a. Evaluate muscle and tendon length by testing ROM.

b. Use inhibition to relax and lengthen restricted muscle tissue.
c. Use ROM stretching to lengthen restricted connective tissue.
d. Evaluate strength by muscle testing.
19. The purpose for the wall stretch is to lengthen the:
a. calf muscles
b. quadriceps
c. hamstrings
d. TFL and ITB
20. Which measures may help to prevent knee injuries?
a. Avoid activities, surfaces, or shoes that cause abnormal stress.

b. Do not force the knee beyond its normal range of motion.
c. If needed, use orthotics, tape, or braces to reduce the risk of injury.
d. all of the above

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HEMME APPROACH

This course requires work. Since 2 hours of continuing education credit

Above all else, please follow these three instructions:

n COMPLETE THE TOP OF THE ANSWER SHEET.

o ANSWER QUESTIONS 1 THROUGH 20.

p RETURN THE ANSWER SHEET IN THE ENVELOPE PROVIDED.

HEMME APPROACH TO KNEE PAIN

HEMME APPROACH TO KNEE PAIN ANSWER SHEET

PLEASE CIRCLE THE BEST ANSWER.

7. A B C D 14. A B C D Our fax number

Please use the return envelope included with this course.

HEMME APPROACH PUBLICATIONS

HEMME APPROACH TO KNEE PAIN

If we have permission to use your comments, please sign below.

HEMME APPROACH TO KNEE PAIN

Copyright, David H. Leflet, 2001

Published by HEMME APPROACH PUBLICATIONS

It is also the responsibility of the practitioner to determine the appropriateness of any

HEMME APPROACH TO KNEE PAIN

This course was written to give soft-tissue practitioners a brief overview

HEMME APPROACH TO KNEE PAIN

SOFT-TISSUE THERAPY ......................................................................... 6

HEMME APPROACH ................................................................................ 7

HEMME APPROACH TO KNEE PAIN

HEMME APPROACH TO KNEE PAIN

HEMME APPROACH QUIZ...................................................................... 42

HEMME APPROACH TO KNEE PAIN

• joint capsule A two-layered sac that encloses a synovial joint.

HEMME APPROACH TO KNEE PAIN

Bony Anatomy of the Knee

The knee is made up of three bones—femur, tibia, and patella—and two

• Range of motion (ROM) for flexion: 0 degrees to 135 degrees.

Knee flexion can be as high as 160 degrees, and hyperextension may or

Major Muscles That Affect the Knee

QUADRICEPS FEMORIS To stretch the quadriceps from a prone

Action: extends leg and flexes thigh.

HEMME APPROACH TO KNEE PAIN

Action: extends leg and draws in patella.

To stretch the hamstrings from a supine

Action: flexes and rotates leg medially and extends thigh.

Action: flexes and rotates leg medially, extends thigh.

HEMME APPROACH TO KNEE PAIN

Action: flexes and rotates leg laterally and extends thigh.

TENSOR FASCIAE LATAE (TFL) To stretch the TFL and

Major Ligaments That Affect the Knee

HEMME APPROACH TO KNEE PAIN

HEMME APPROACH TO KNEE PAIN

Soft-tissue therapy is medically defined as manipulation of soft tissue for

HEMME APPROACH TO KNEE PAIN

The HEMME APPROACH is a logical, conservative, and comprehensive

In the HEMME APPROACH model (HEMMEGON), the five basic steps—

HEMME APPROACH TO KNEE PAIN

HEMME APPROACH TO KNEE PAIN

HEMME APPROACH TO KNEE PAIN

The conditions listed below are general contraindications to soft-tissue

• Acute inflammation or infection Acute or active inflammation is

Since aneurysms can be aggravated by tension or compression and the