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  • Case Study – Beth’s Knee

    Beth’s right knee hurts so bad she can hardly walk, she told me when she arrived for her appointment. Thankfully, Beth had scheduled a 2-hour session. I begin by assessing the alignment and mobility of Beth’s right femur. The femur was fairly immobile and out of its natural placement. It was anterior at the hip and posterior at the knee, while being lateral at the hip and medial at the knee.

    This position would have created conflict in several muscles. First, let’s look at piriformis. Although Beth’s right femur was lateral at the iliofemoral joint, it was not laterally rotated. The lateral movement of the femur created an unnatural stretch on piriformis, as did the anterior shift of the femur head in the acetabulum.

    In Beth’s case, the right piriformis, at its origin on the second through fourth sacral vertebrae, had pulled S2-S4 to the right. Complicating matters in Beth’s hips was the position of the left femur head. The left femur, while mobile, was compensating for the right by moving posterior and slightly medial at the iliofemoral joint.

    The movement in the left femur head had created a situation for gluteus maximus. While the upper fibers of Beth’s left gluteus maximus were being pulled to the right, the lower fibers were engaged and contracting due to the posterior and medial position of the left proximal femur. In its tension, gluteus maximus had pulled the coccyx, upon which it has origins, to the left. Gluteus maximus on the right was hypertonic as well, but it was pulling the coccyx inferior on the right.

    So, to recap, Beth’s second through fourth sacral vertebrae were moving to the right, creating a mild right side movement of the first and fifth sacral vertebrae, and her coccyx was moving to the left, while moving inferior on the right. This created a misalignment of the sacrococcygeal joint that caused muscle weakness and pain.

    Next, let’s look at iliopsoas. As Beth’s right femur moved anterior, her iliopsoas muscle was moved toward extension. But, the lateral movement of the femur was engaging iliopsoas. This created conflict within Beth’s right iliopsoas muscle, leaving it inflamed, and, I would guess, exhausted.

    Along the length of Beth’s right femur, muscle tension shifted from lateral to medial. At the proximal end, vastus lateralis and TFL were hypertonic, while vastus medialis and the adductor muscles needed more tone. However, toward the distal end of the femur, vastus medialis and the adductors were incredibly tight, while vastus lateralis needed more tone. Rectus femoris was hypertonic all the way down.

    Beth’s quadricep tendon was extremely tight and her patella was pulled into the femur, with very little movement in any direction. Thinking about the difference in position from the lateral shift of the proximal femur to the medial shift of the distal femur, I suspected Beth was weighting to the right side while standing most of the time. I asked, Beth confirmed this was the case. I asked if she hyperextended her right knee, she thought, and said yes, most of the time.

    All of this made sense to the position of Beth’s femur, and the fact that it was lateral at the hip and medial at the knee. The proximal fibers of rectus femoris were tight because the femur had moved anterior into the space that rectus femoris normally occupied, while the distal fibers were tight because Beth was hyperextending her knee.

    Additionally, the hyperextension of her right knee was causing a posterior pelvic tilt on the right, moving her proximal femur anterior and her distal femur posterior. Or, it is possible, that the posterior pelvic tilt led to the hyperextension of the knee. Since I intended to work both, I figured the answer to what had come first might present itself through the session.

    I moved further down Beth’s leg. Her medial gastrocnemius was adhered and hypertonic, pulling the proximal tibia medial, while her foot was oversupinated, moving the talus and the distal tibia in a lateral direction.

    Of course there was more to see. This was a systemic compensation pattern. The posterior pelvic tilt could have been caused by a twist in her diaphragm, a shift in her ribcage, or a shoulder issue. Every structure was effected or was affecting other structures.

    But, for this 2-hour session, I had a lot to do. I began at with her foot and lower leg. Beth was extremely tender and had some low level lymphedema. I combined Spontaneous Muscle Release Technique or SMRT with the mildest deep tissue, MLD, and myofascial unwinding. Working through one adhesion at a time; releasing the ligaments in the intertarsal joints and the talocrural joint; working with the position of the tibia to release the twist in the periosteum. Slowly but surely, Beth’s leg began to unwind and straighten out.

    I worked all the way into her hips. By the time I got to piriformis, the femur was mobile and had mostly moved back into its natural space. The piriformis release was huge. I mildly duplicated the original position of the proximal femur, moving the femur lateral and anterior with my right hand, while engaging piriformis by creating a direct line of lateral compression and mild abduction with my left hand. Piriformis visibly spasmed once and then released completely. Beth said, “both my hips just moved to the left.”

    Time had run out. The rest would have to wait for another day!