The knee is both a simple and a very complex joint. Osteopathic thinking embraces the concept of mechanical dysfunction with or without positional displacement. The bones making up the joint can be working in one of several different disturbed positions. This is not so much a positional finding as a lack of function in various possible directions. Techniques are designed to restore function generally, or to mobilize in a particular direction to restore normal relationships. Function is seen to be more necessary than symmetry and position. Nevertheless, in some cases, directions of force are chosen for specific reasons. These usually relate to perceptions of mechanical dysfunction manifesting as apparent malpositioning.
Precautions include the need to avoid excessive force and pain, as in all other areas, but also include the need to avoid excessive pressure over any varicose veins. Some knee syndromes are manifestations of hyper-mobility masked by muscle protection. If this is the case, mobilizing techniques are not indicated, so careful assessment should precede treatment. If a knee is degenerative it will generally tend to have lost some of its normal hyperextension, and excessive attempts to restore this are doomed to failure and will only provoke more pain and problems.
31.1 and 31.2 • Harmonic technique into cir-cumduction sitting The patient sits with her leg over the side of the table. Hold the superior aspect of the tibia with one hand and rock the leg from side to side with the other. At the same time circumduct the foot to induce a rhythmic oscillation in the knee. See earlier section relating to harmonic technique.
Tips: Most useful in cases where rhythm and spring has been lost in normal knee movement. Harmonic technique is particularly useful as a preliminary procedure to structural mobilizing to loosen the tissues and help re-establish circulatory function. Extra considerations: Light patient resistance can be introduced into this movement as a 'muscle re-training' procedure.
31.3 and 31.4 • Harmonic technique into flexion and extension sitting The patient sits with her legs over the side of the table. Instruct her to resist your movements with a light pressure only. Rock the leg forward and back to flex and extend the knee. Vary the start and finish point so that the flexion and extension movement will be through a larger and smaller arc. This has the effect of 'retraining' the proprioceptive feedback from the joint. See earlier section relating to harmonic technique.
31.5 • Articulation patello-femoral joint supine
This hold allows mobilization of the patella through all possible ranges. The accessory ranges of diagonal movement in particular can be addressed as release of these often improves overall function.
Tips: Most useful in the majority of cases of knee dysfunction as the patello-femoral joint may be involved and can often be a neglected element. To avoid discomfort, preliminary work on the surrounding soft tissues is helpful to release the area prior to this technique.
31.6 • Articulation flexion supine Flex the knee over your hand placed in the popliteal space. Use your other hand to monitor the tissue tension to avoid excessive strain. Hold the leg firmly between your forearm and body. Circumduction movements can be added so that the flexion becomes one part of the arc of movement.
Tips: Avoid excessive flexion in the presence of any effusion unless it is very slight.
31.8 • Articulation extension supine Grip the knee firmly and hold it against the table while your other hand braces the foot and lifts the heel. This hold has the advantage over the one shown in photograph 31.7, in that the gastrocnemius is placed on some tension and will be stretched if desired.
Tips: Try varying the amount of dorsiflexion in the foot to assess at what point the limitation of extension manifests. The earlier this occurs, the more the gastrocnemius will be involved in the lack of extension.
31.7 • Articulation extension supine Grip the knee firmly and hold it against the table while your other hand lifts the lower end of the tibia.
Tips: Many knee dysfunctions manifest as a lack of hyperextension, particularly internal derangements. This movement is as much an assessment of successful restoration of function as it is a treatment.
31.9 • Traction supine Hold back on the femur with your fully pronated hand avoiding the patella. The other hand applies the traction and can vary rotation, abduction and adduction of the tibia as necessary.
Tips: Many internal derangements of the knee seem to have some sort of internal entrapment involved. Traction can be very helpful in these instances.
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