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ARTICLE IN PRESSJournal of Bodywork and Movement Therapies (2009) 13, 73–80Journal ofBodywork andMovement PILOT STUDYTreating patellar tendinopathy withFascial ManipulationAlessandro Pedrelli, PT a, Carla Stecco, M.D.b, , Julie Ann Day, PT caCorso U. Comandini, 12/B, 47023 Cesena, ItalySection of Anatomy, Department of Human Anatomy and Physiology, University of Padova,Via A Gabelli 65, 35127 Padova, ItalycCentro Socio Sanitario dei Colli, Physiotherapy, Azienda Ulss 16, Padova, ItalybReceived 31 March 2008; received in revised form 20 May 2008; accepted 2 June 2008KEYWORDSFascia;Patellartendinopathy;Fascial Manipulation;Myofascial unit;Centre ofcoordinationSummary According to Fascial Manipulation theory, patellar tendon pain is oftendue to uncoordinated quadriceps contraction caused by anomalous fascial tension inthe thigh. Therefore, the focus of treatment is not the patellar tendon itself, butinvolves localizing the cause of this incoordination, considered to be within themuscular fascia of the thigh region.Eighteen patients suffering from patellar tendon pain were treated with theFascial Manipulation technique. Pain was assessed (in VAS) before (VAS 67.8/100)and after (VAS 26.5/100) treatment, plus a follow-up evaluation at 1 month (VAS17.2/100).Results showed a substantial decrease in pain immediately after treatment(po0.0001) and remained unchanged or improved in the short term.The results show that the patellar tendon may be only the zone of perceived painand that interesting results can be obtained by treating the muscular fascia ofthe quadriceps muscle, whose alteration may cause motor incoordination andsubsequent pathology.& 2008 Elsevier Ltd. All rights reserved.IntroductionPatellar tendinopathy is a very frequent pathologyamong sportspeople, who perform multiple jumps Corresponding author. Tel.: 39 049 8272327;fax: 39 049 8272319.E-mail address: [email protected] (C. Stecco).in sports such as basketball, volleyball, and beachvolley, such that it is also called ‘‘jumper’s knee’’.Patellar tendinopathy is also reported in subjectswho often climb stairs, hike, and squat (EifertMangine et al., 1992; Molnar and Fox, 1993; Morelliand Rowe, 2004). Indeed, the continuous repetitionof certain movements, above all excessive strengthtraining of the extensor compartment (quadriceps),1360-8592/ - see front matter & 2008 Elsevier Ltd. All rights reserved.doi:10.1016/j.jbmt.2008.06.002
ARTICLE IN PRESS74might cause various minor traumas and strainsthat are considered to be at the origin of thisoveruse syndrome. Symptoms, at first characterized by pain during strain, can evolve intoinflammation (tendinitis) (Duri et al., 1999; Wardenand Brukner, 2003) with pain at rest, and eventuallylead to tissue alteration and, in some cases, eventendon rupture. The origin of these symptoms iscommonly attributed to disease of the patellartendon, and so the majority of known treatmentsfocus directly on the tendon itself (Cyriax, 1982;Kountouris and Cook, 2007; Vulpiani et al., 2007;Willberg et al., 2007). In recent years, someauthors (Simons et al., 1999; Stecco and Stecco,2007) have begun to consider alterations of thepatellar tendon as the consequence of chronic,uncoordinated movement of the knee joint dueto incorrect activation of the knee extensormuscles. For this reason, many therapies, includingquadriceps stretching, muscle energy techniquesand tensional release through massage therapy(Chaitow, 2003), focus on the muscles of theextensor compartment. Similar principles can alsobe found in another manual technique, known asFascial Manipulation (Stecco 1996, 2004), however,according to its theoretical model, continuousrepetition of the same movement could cause‘‘densification’’ of the muscular fascia, therebyaltering the efficiency of muscle contraction.Other authors (Pellecchia et al., 1994; Rolf,1997; Schleip, 2003) have also indicated thatfascia is a plastic and malleable tissue, able toadjust to the mechanical, thermal and metabolicstresses, and can possibly be restored to itsphysiological condition through external manipulation treatment. Hence, the aim of this pilot study isto explore the effectiveness of Fascial Manipulationin alleviating the pain component in patellartendinopathy and possible implications are alsodiscussed.In Fascial Manipulation, a map of over onehundred fascial points exists, that, when treatedappropriately, are believed to restore tensionalbalance. In order to select the points to be treatedthe fascial system is first divided into basicelements, or myofascial units (MFUs). Each MFUincludes all of the motor units responsible formoving a joint in a specific direction and theoverlying muscular fascia. Hence, movements ofsingle body segments are considered to be governed by six MFUs, responsible for movements inthe three spatial planes (sagittal, frontal, horizontal). All the forces generated by a MFU areconsidered to converge in one point, called thecentre of coordination (CC); each CC has a preciseanatomical location within the muscular fascia. IfA. Pedrelli et al.the fascia in this specific area is altered, or‘‘densified’’, then the entire MFU contracts in ananomalous manner resulting in non-physiologicalmovement of the corresponding joint, which can bea cause of joint pain. According to the FascialManipulation model, the area where the patientperceives pain is called the centre of perception(CP), thus, for each MFU one CP is described. Inpatellar tendinopathy, the MFU of extension of theknee, called MFU of antemotion genu (AN-GE), isthe more frequently implicated. It is formed by theknee joint, the monoarticular muscular fibres ofvastus medialis, intermedius and lateralis, thebiarticular muscular fibres of rectus femoris andthe relative muscular fascia. The patella and theanterior region of the knee are considered as theCP of this MFU, while the CC is situated overthe vastus intermedius muscle, halfway on thethigh (Figures 1 and 2). The location of this CCoverlaps with the acupuncture point ST32 (Bossyet al., 1980), and with one of the trigger points ofthe quadriceps group, as described by Simons et al.(1999).Figure 1 Deep fascia (fascia lata) of the thigh.
ARTICLE IN PRESSTreating patellar tendinopathy with Fascial Manipulation75Materials and methodsEighteen patients (13 males, 5 females; mean age29.2), with unilateral sub-acute (from 1 to 3months) or chronic (more than 3 months) patellartendon pain (mean duration of symptoms 8.6months) were treated according to the methodology of Fascial Manipulation (Table 1). Subjects withclinical signs of acute joint inflammation (oedema,heat, and rubor) were excluded from this study, aswere subjects with meniscopathy and advanceddegenerative osteoarthritis, as evidenced by MRIand X-rays. A complete physical examination of theknee was carried out, including inspection of thejoint, assessment of the range of motion, musclestrength, and palpation.Prior to commencing treatment, patients wereasked to evaluate the severity of their pain, asexperienced during two specific movement tests,on a VAS scale from 1 to 10 [10 ¼ worst possiblepain, 0 ¼ no pain]. This subjective evaluation wasrepeated after one treatment session and thesessions were then suspended. At a follow-up, 1month after treatment, a third measurement wasrecorded. The mean value of the VAS scalemeasurements was then calculated (Table 2) andthe analysis of the differences in pain wasaccomplished by comparing the results obtainedwith appropriate statistical tests (Kurskal–Wallistest and Dunn’s multiple comparison test as acontrol).Treatment procedure: Movement tests, as indicated by Fascial Manipulation protocol, were performed before treatment to evaluate each MFUinvolved in movement of the knee joint (Figure 3).Results from these movement tests were scoredaccording to Fascial Manipulation protocol, on ascale from 1 to 3 asterisks: pain ¼ *, weakness ¼ *and limited movement ¼ * (Table 3). The CCs of themost dysfunctional MFUs (those with two or threeasterisks) were then subjected to a comparativepalpation assessment prior to selection of the pointsrequiring treatment.Two specific movement tests were also evaluated: going down a 30 cm high step, weight bearingon the suffering limb, and a flat-feet jump, startingfrom a position of total knee bending (squatting)(Figure 4). Subjective pain experienced duringthese two tests was assessed using the Vas scalemeasurement procedure.Figure 2 Schematic representation of the centres ofcoordination (CC) and perception (CP). The CC is over thevastus intermedius muscle, and the CP is located over theanterior part of the knee.
ARTICLE IN PRESS76A. Pedrelli et al.Table 1General characteristics of subjects.PatientGenderAgeDuration of symptoms leyNoneVolleyBody buildVolleyTotal13 M, 5 FMean value 29.2Mean value 8.67 months/Table 2 Results: VAS scale measurement of pain experienced during two specific movement tests (going down a30 cm high step and flat-feet jump test) before treatment, immediately after treatment and 1 month aftertreatment.An operator, other than the therapist whotreated the patients, performed the movementtests and supervised the pain assessments.A single therapist performed all treatments andthe CC of AN-GE was treated in all cases. Thetreatment of this CC is performed with the patientsupine, and the therapist standing to the side of thesuffering limb. The therapist uses their elbow overthe muscular fascia in the area between vastuslateralis and rectus femoris muscles, halfway onthe thigh (Figure 5), applying pressure towards thevastus intermedius. Once the most altered area has
ARTICLE IN PRESSTreating patellar tendinopathy with Fascial Manipulation77Figure 3 The motor tests for the knee segment according to Fascial Manipulation technique: (a) AN-GE test, (b) RE-GEtest, (c) LA-GE test, (e) ME-GE test, (f) IR-GE test, and (g) ER-GE test.Table 3 Evaluation of movements before treatment, according to fascial ******pain. Intermittent friction is maintained for atotal of about 5 min, until the fascia glides freelyand the patient refers that pain has decreasedsignificantly.All patients were asked to suspend sportingactivities for at least 4 days after treatment, toavoid further stress on the treated structures.At a 1-month follow-up, the two specific movement tests were re-assessed and VAS scale measurements were recorded.**********been located, static pressure is initially appliedand, subsequently, a deep friction or mobilizationof the fascial tissues is employed. Verbal feedbackfrom the patient aids in accurate localization ofthe exact point that provokes local and referredResultsAccording to the results of the movement tests,all patients demonstrated a deficit (pain and/orweakness and/or limited movement) in the MFUs onthe sagittal plane, with a specific involvement ofthe MFU of AN-GE. Pain assessments of the entirestudy group during the two specific movement testsbefore treatment (mean VAS 67.8/100) and aftertreatment (mean VAS 25.6/100) indicated a significant decrease of pain immediately after treatment (po0.0001) in all patients.In particular, two cases (nos. 7 and 10) had acomplete regression of pain immediately aftertreatment (mean VAS from 50/100 to 0/100) andthis result was maintained at the 1-month followup. In another four patients (nos. 3, 4, 6, and 18),a good immediate post treatment result was
ARTICLE IN PRESS78A. Pedrelli et al.Figure 4 On the left: going down a 30 cm high step, weight bearing on the suffering limb; on the right: flat-feet jumptest, starting from an angle of total knee bending.follow-up, nine cases (nos. 1, 2, 5, 8, 11, 12, 13, 14,and 16) demonstrated a further reduction in pain ascompared to immediately after treatment (meanVAS from 31.1/100 to 17.8/100). Only threepatients (nos. 9, 15, and 17) referred that whilepain had decreased immediately after treatment(mean VAS from 83.3/100 to 36.7/100) it had thenincreased again (to mean VAS 50/100), although notto the pre-session levels.DiscussionFigure 5 Treatment position of the centre of coordination AN-GE according to the Fascial Manipulation technique.recorded (mean VAS from 57.5/100 to 17.5/100)and, furthermore, at the follow-up, tendon painhad disappeared completely (VAS 0/100). At theAccording to this pilot study, it is evident that afterone session of Fascial Manipulation a certainreduction of pain was recorded in every patientand that these results can be maintained or maypartially regress. The aim of the Fascial Manipulation therapy is to restore gliding between theintrafascial fibres. Raising the temperature ofselected areas of the fascia (corresponding to theCC points), via manual pressure, could allow fortransformation of the ground substance, transforming it from a pathological status of GEL (densefascia) to a physiological status of SOL (fluidfascia). This variation in density probably allowsfor two events. Firstly, during the application ofmanual pressure, the connective tissue adapts andthe intrafascial free nerve endings may slide withinthe fascia more freely, which could explain thesudden decrease in pain during massage in thetreated area. The second event could evolve overthe following days: with enhanced fluidity of theground substance, physiological tensioning of thefibres within the fascia during muscular contraction
ARTICLE IN PRESSTreating patellar tendinopathy with Fascial Manipulationcould allow for correct deposition of new collagenand elastic fibres according to the lines of appliedforce. Subsequent restoration of gliding betweenconnective tissue layers of the fascia would enabletensional adjustments during muscular contraction,resulting in appropriate tensioning of periarticularstructures such as tendons and capsules. Thisrestitution of elasticity to the fascia could alsoexplain the satisfactory results maintained overtime.In the Fascial Manipulation model, the CC isconsidered a point of vectorial convergence formuscular forces or the point of the muscular fasciawhere altered myofascial traction concentrates.Thus, for each segment, we can identify six CCs,one for each direction on the three planes ofmovement. A pathological CC can be pinpointed bya specific clinical exam (movement tests), and notonly by palpation, which differs somewhat from theprocedure for trigger point identification. Hence, aCC could be considered as a type of ‘‘key triggerpoint’’.The myofascial connections within each MFU,and between different MFUs, can provide analternative explanation for referred pain distribution (Stecco et al., 2007, 2008), which often doesnot follow either nerve pathways or the morphology of a single muscle (Hwang et al., 2005). Whenmuscular fascia alters, it is feasible that the variousmotor units of the implicated muscles cannotcoordinate their activity appropriately. Subsequentunaligned joint movement could cause non-physiological stretch of the receptors within the fascia,resulting in a nociceptive signal (Baldissera, 1996).In this way, according to Fascial Manipulationtheory, when the CC is in an altered state it canbe considered as the origin of pain (cause), and thejoint (CP) as the area where pain is referred(consequence).In those cases with partial resolution of symptoms, even though there had been some reductionin pain, indicating a correct interpretation of theproblem, we hypothesize that more treatmentsessions would have been necessary. In fact, themuscular fascia guarantees the anatomical andfunctional continuity of the anterior compartmentmuscles. In particular, the deep fascia of theileopsoas continues with the fascia of the rectusfemoris, and the fascia lata is continuous with thecrural fascia that envelops the tibialis anteriormuscle. Hence, if, for hypothesis, the fascia latais chronically densified, then it is possible thatalterations will occur in contiguous muscularfasciae in an attempt to compensate for thisanomalous tension, with consequent alterations inthe CCs of adjacent segments.79In those cases where we have recorded a reintensification of pain after treatment, it should bepointed out that, as compared with other patients inthe study group, they were far more complicatedclinical cases. In fact, they did not only presenttendinopathy, but case 9 also reported low back pain,case 15 Achilles tendinopathy and subcalcaneal painand case 17 groin pain. Clinical cases such as theselead us to hypothesize a global disorder, or a posturalimbalance involving numerous body segments. Tomake our study as consistent as possible, we decidedto treat the same CC in all patients. In everydaypractice, this CC has proven to be the mostfrequently involved point in this disorder. However,by treating one single CC, responsible for theimbalance of one single MFU, it cannot be enoughto restore balance in similar global disorders.ReferencesBaldissera, F. (Ed.), 1996. Fisiologia e biofisica medica. PolettoMilano.Bossy, J., Lafont, J.L., Maurel, J.C.l., 1980. Sémiologie enAcupuncture. Doin Editeurs, Paris, pp. 157–159.Chaitow, L., 2003. Modern Neuromuscular Techniques, seconded. Churchill Livingstone, Edinburgh.Cyriax, J., 1982. Textbook of Orthopedic Medicine, eighth ed.Balliere Tindall, London.Duri, Z.A., Aichroth, P.M., Wilkins, R., Jones, J., 1999. Patellartendonitis and anterior knee pain. American Journal of KneeSurgery 12, 99–108.Eifert-Mangine, M., Brewster, C., Wong, M., Shields Jr., C.,Noyes, F.R., 1992. Patellar tendinitis in the recreationalathlete. Orthopedics 15, 1359–1367.Hwang, M., Kang, Y.K., King, D.H., 2005. Referred pain patternof the pronator quadratus muscle. Pain 116, 238–242.Kountouris, A., Cook, J., 2007. 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Patellar tendinopathy is a very frequent pathology among sportspeople, who perform multiple jumps in sports such as basketball, volleyball, and beach-volley, such that it is also called ‘‘jumper’s knee’’. Patellar tendinopathy is also reported in
