CHRONIC LATERAL KNEE PAIN AND EHLERS … Place Delange... · muscles crossing the knee joint. ......

Running head: CHRONIC LATERAL KNEE PAIN AND EHLERS-DANLOS 1

The Effects of Massage Therapy on Chronic Lateral

Knee Pain in a Patient with Ehlers-Danlos Syndrome:

A Case Study

Natalie A. Delange

Tel. (250) 303-0218 email. [email protected]

Address. 8869 Driftwood Road, Black Creek, BC. V9J1A9

West Coast College of Massage Therapy - Victoria

CHRONIC LATERAL KNEE PAIN AND EHLERS-DANLOS 2

Acknowledgements

I would like to express my sincere gratitude to the case study subject for his

participation in this project. Volunteering his time to this study has enabled me to

learn and grow as a therapist. The staff, administration and fellow students at

WCCMT Victoria gave insight and shared their knowledge through my studies

for which I’m very appreciative.

Conflict of Interest and Consent

Therapist and patient were acquainted through a mutual friend prior to this study.

In accordance with the College of Massage Therapists of British Columbia’s code

of ethics, proper measures were taken to ensure that this relationship did not affect

or influence the therapist’s clinical treatment of this patient. Informed consent was

obtained from the patient prior to and throughout this study. All identifiable

information has been removed from this study to protect the privacy of the

patient.


Abstract

This case study explored the effect of massage therapy on chronic knee pain in an

Ehlers-Danlos Syndrome (EDS) patient. The patient was a 25-year-old male with

a history of chronic pain and “clicking” of the left knee during standing flexion. A

sequence of ten treatments was administered over eight weeks. The lower

extremity was assessed through various orthopedic testing, including hip range of

motion with a goniometer. A variety of general Swedish massage (GSM)

techniques were used throughout this study. Trigger point pressure release

(TPPR), muscle stimulation, myofascial holds and contract-relax stretches were

also included. For homecare, exercises were given to stretch and strengthen the

muscles crossing the knee joint. Lastly, various changes to activities of daily

living (ADLs) were recommended. The effectiveness of the treatments was

measured using a 0-to-10 patient pain scale, orthopedic testing, and knee girth

measurements. The goals of this study were to alleviate lateral knee pain, reduce

lateral patellar pull and increase joint awareness. The results of this study show

that massage therapy proved to be beneficial for this particular patient. Chronic

lateral knee pain was eliminated, tension in the vastus lateralis muscle was

decreased allowing for proper patellar alignment at rest and patient awareness in

joint proprioception was increased. These findings support the use of massage

therapy as a means to alleviate pain and discomfort associated with EDS.

Key words: Ehlers-Danlos Syndrome, Patellar tracking, Massage Therapy


Table of Contents

Title Page………………….………………………………………………1

Acknowledgements and Conflict of interest……………...……………….2

Abstract……………………….…………………………………………...3

Table of Contents……………….…………………………………………4

Introduction…………………….………………………………………….5

Methods……………………….…………………………………………..9

Results………………………………….………………………………...18

Discussion/Conclusion………………………………………..………….20

References…………………………………….………………………….23

Appendix A: Progression Photos……………………….………………..28

Appendix B: Letter From The Patient…………………………………...30

Appendix C: Patient Consent Form……………..…………………...…..31


Introduction

Ehlers-Danlos Syndrome (EDS) refers to a group of inherited disorders caused by

a genetic mutation in collagen that disrupts the synthesis of connective tissues

(Childs, 2010). The variation of these genes appears to be one of the main reasons

that EDS has such a vast impact on the body’s supporting structures and their

functional ability. This inherited syndrome occurs from 1 in 5,000 to 1 in 10,000

depending on which type of EDS is present (Rombaut, Malfait, Cools,

De Paepe & Calders, 2010). There are 6 main subtypes of the 13 recognized types

of EDS (The Ehlers-Danlos Society, 2017). Research by Malfait and De Paepe

(2014) states that the three most common subtypes of EDS are hypermobility,

classic, and vascular types while kyphoscoliosis, arthrochalasis, and

dermatosparaxis are infrequent. This syndrome presents with a multitude of

clinical manifestations including joint hypermobility, velvety hyperextensible

skin, musculoskeletal pain, easy bruising, and generalized weakness and fragility

of the soft connective tissues (Malfait & De Paepe 2014). Massage cannot

“reprogram defective genes,” however, it could potentially help relieve pain

associated with the hypertonia that is caused by the increased muscular effort

required to support unsteady joints (Werner, 2008).

Massage therapy has yet to be fully researched as a treatment to alleviate pain

associated with EDS, however there are a few alternative options available. A


systematic review of pain control methods in patients with EDS was conducted in

2015: The pain solutions perceived as the most beneficial were opioids, surgical

interventions, splints and braces, avoidance of potentially dangerous activities,

heat therapy, as well as massage therapy; opioids were identified to be the

treatment of most success for pain management (Arthur, Caldwell, Forehand &

Keith, 2015).

Patients with EDS can use opioids to control pain, but unwanted complications

and side affects may occur. Symptoms of constipation, drowsiness, and apathy

have been reported, and abuse of medications has also been found to occur

(Prokop, Adamczyk & Krajnik, 2010). The risks and inconvenience

accompanying medications are weighed against the positive results of patients

being able to function with limited pain. Prokop, Adamczyk & Krajnik (2010)

state that opioids should be the patient’s last resource after other methods have

failed.

Another option includes the use of local anesthetic trigger points to help with

chronic myofascial pain with EDS patients. In a 2016 study, a numbing serum

was injected into trigger points of a patient with EDS and paired with hot

hydrotherapy, deep tissue massage, stretches, and use of oral non-steroidal anti-

inflammatory drugs (NSAIDS) (Tewari, Madabushi, Agarwal, Gautam & Khuba,

2017). This study showed 60-80% pain relief within the first week. This method,


however, is very invasive. Comparable results were shown in a less invasive

manual trigger point pressure release technique used by massage therapists (Hains

& Hains, 2010).

Physiotherapy is another field that uses manual therapies, which are used to help

mediate pain in EDS patients. Physiotherapy can provide the patient with physical

rehabilitation techniques for unsteady, hypermobile joints and their associated

pain. Physiotherapy uses non-invasive, self-motivated methods, and can be

considered the most successful traditional strategy when dealing with pain

(Keer & Simmonds, 2011). However, while physiotherapy has been shown to

increase proprioception and strengthen unstable joints, EDS patients have

reported the use of physiotherapy alone is not enough (Tewari et al., 2017).

The patient chosen for this study was a healthy 25-year-old male with EDS

suffering from chronic left knee pain. The exact type of EDS the patient has was

undetermined, however, he presented with hyperextensible skin (Figure 1) and

unstable joints of the lower extremity. Skin abnormalities are common in most

EDS subtypes and can include fragility, hyperextensibility, bruising, cigarette

paper appearance, and atrophic scaring (Hauser & Phillips, 2011). Hauser and

Phillips (2011) claim that other than skin abnormalities, the most recurrent

complaints are musculoskeletal pain. The patient’s major complaint was muscle

and knee pains as well as joint instability of the left lower extremity. At rest, the


patient’s left patella faced laterally. A weak vastus medialis muscle can have this

affect on the patella (Sakai, Luo, Rand, An, 2000). Myofascial contractures may

develop in the imbalanced muscles supporting unstable joints, which can lead to

pain and discomfort (Tewari et al., 2017). Prior to this study the patient had no

exposure to massage therapy and had yet to find a way to control his pain.

An appropriate non-invasive therapy has yet to be found as a solution for

managing pain experienced by EDS patients. It seems health care providers need

to gain more experience treating the syndrome to be able to provide appropriate

and practicable therapy. The primary goal of this case study was to determine if a

course of massage therapy treatments could alleviate lateral knee pain, reduce

lateral patellar pull at rest, and increase joint awareness and proprioception for a

patient with Ehlers-Danlos Syndrome.

Figure 1: Patient’s knee

presentation


Methods

Patient profile

The patient was a 25-year-old male presenting with chronic left knee pain for the

last two years. He had been working as a carpenter, so his job was extremely

physical, requiring a lot of heavy lifting and long standing squats. At the age of

14, he was diagnosed with EDS and has suffered from many injuries with extreme

outcomes for the past twelve years. The patient has no familial history of EDS

that he is aware of. At least twice a year he experiences an injury that requires

medical attention. These injuries are usually from trauma to a bony prominence

leading to excess fluid that exceeds the skins capacity, requiring surgical

drainage. He has no history of dislocations or breaks; however, he has suffered

from chronic muscle and joint pain his whole life. Pain medications tried were

acetaminophen and ibuprofen, but did not provide relief for the patient. Other than

emergency visits to the doctor, the patient has never sought out medical attention

or alternative therapy for his condition. The client’s goals and desired outcomes

were to find a non-invasive way to alleviate his chronic pain.

Assessment

The baseline for the subject’s assessment was established during the initial intake

of the first treatment. Beighton score testing, a method used to diagnose

hypermobility associated with EDS, was performed during the first assessment


(The Ehlers-Danlos Society, 2017). The following subjective and objective

measures were used to evaluate the treatments’ effectiveness: (1) The patient was

asked to evaluate his progress in terms of pain and subjective disability

(Figure 2); and (2) The examiner used active range of motion, manual muscle

tests, special orthopedic tests, knee girth measurements, and active modalities to

assess knee function (Table 1, 2, and 3). The muscles crossing the knee joint were

the focus of the study based on the research of lateral knee pain referral as well as

the stabilizing muscles of the knee (Rattray & Ludwig, 2000).

Girth measurement was taken by using a tape measure at the supracondylar ridge,

mid patella, and tibial tuberosity bilaterally pre and post treatment to assess knee

effusion. These measurements were taken every treatment to assess knee effusion

and joint irritation.

Pictures were taken of the patient’s knee alignment, active squatting, and sensory

changes during treatments one, five, and ten. These pictures were taken as a

means of visual measurement of the patient’s progress of positioning throughout

the duration of the study (Appendix A).


Orthopedic Tests Treatments

Beighton Score Testing 1

Stork 1,8,9

Trendelenburg All

Gillet’s All

Adductor Contractor All

Hamstring 90-90 All

Thomas All

Ober’s All

Apley’s Distraction 1

Apley’s Compression 1, 9

Table 1: Schedule of Orthopedic Testing (Magee, 2014).

Range Of Motion Treatments

Hip ROM 1,2,3,5,6,7,8,9,10

Knee ROM 1, 10

Table 2: Schedule of Range of Motion Measurements

Manual Muscle Tests Treatments

Gluteus Maximus 1,5,6,9,10

Gluteus Medius 1,7,10

Gluteus Minimus 1,7

Piriformis 1

Adductor Group 1,2,3,10

Beceps Femoris 1,6

Vastus Lateralis 1,5

Vastus Medialis Oblique 1,2,3,5,6,7,9,10

Gastrocnemius 1

Table 3: Schedule of Manual Muscle Tests (Kendall, F., McCreary, E., Provance,

P., Rodgers, M., & Romani, W., 2005)


Figure 2: Left Lateral Knee Pain Presentation Pre and Post Treatment.

Treatment Plan

This study focused on reducing chronic lateral knee pain, stabilizing the left knee

joint, and reducing lateral pull on the patella at rest. The patient was treated in the

student clinic at the West Coast College of Massage Therapy, Victoria, BC. Each

appointment was 70 minutes in length, which included 10 minutes at the

beginning for interview and assessment, 10 minutes at the end for reassessment

and homecare instructions, and a total of 50 minutes for hands-on treatment. The

Sharp Sharp

Ache

Ache

Tight

Dull

Dull Ache

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6 7 8 9 10

Pa

in

Treatment

Pre Treatment

Post Treatment


patient received 10 treatments over the course of 8 weeks. Each treatment focused

on the chronic lateral knee pain and vastus lateralis muscle hypertonicity,

however, modifications were made in various treatments to accommodate for

variations in patient’s presenting symptoms (Table 4). During the first half of the

study, treatments were once a week; in the second half, the treatment frequency

was increased to twice a week, as the therapist judged that this could potentially

improve outcomes.

Rattray (2000) explains that general Swedish massage (GSM) has various effects

on the musculoskeletal system, which include increased circulation, improved

lymphatic and venous return, as well as decreased pain perception and

sympathetic nervous system firing. Hypertonic muscles have the ability to restrict

blood flow to the musculature and, therefore, create a domino effect on joints and

circulatory structures around the effected muscle (Stewart, 2014). Based on this,

the therapist chose GSM to improve circulation and decrease the pain and

restrictions caused by the hypertonicity of the patient’s muscles.

Myofascial contractures may develop in the muscles supporting hypermobile

joints causing myofascial pain (Tewari et al., 2017). Shah and Bhalara (2012)

state that fascial restrictions may form due to inflammation, tissue injury, postural

stress, or lack of active range of motion. The two main techniques used to release

fascial adhesions are direct trigger point pressure release and prolonged fascial


holds (Paolini, 2009). As defined by Rattray, “a trigger point (TrP) is a

hyperirritable spot, usually within a taught band of skeletal muscle or it’s fascia”

(Rattray & Ludwig, 2000). Myofascial pain is a common presentation of pain

with EDS patients (Castori et al., 2012) and TrP in the vastus lateralis muscle can

refer pain into the lateral thigh and knee (Rattray & Ludwig, 2000), therefore,

MFR was chosen as an appropriate technique to use during treatments.

Contract-relax stretching was chosen to further assist in relaxing the hypertonic

muscles attaching around the knee joint. A thermaphore (deep moist heating pad)

was used to warm the muscles before being stretched (Rattray & Ludwig, 2000).

Tapotement is one of the most useful stimulatory strokes in massage (Rattray &

Ludwig, 2000). Rattray and Ludwig (2000) state that tapotement for less then

three minutes helps stimulate fatigued muscles by increasing sympathetic nervous

system firing. To strengthen the fatigued and hypotoned muscles around unstable

joints, the therapist used a fingertip tapotement technique while the patient

actively engaged the muscle.

Treatment Details

Treatments one to five were designed to be exactly the same, with modifications

depending on daily presentation of the patient (Table 4). Each treatment focused

on relieving the myofascial adhesions of the vastus lateralis muscle in addition to


stimulating the fatigued vastus medialis oblique muscle in order to reduce lateral

patellar displacement. The patient was positioned in prone for 20 minutes; a

thermaphore placed under the anterior thighs for the first 5 minutes to warm the

quadriceps muscles, and then GSM was applied to the whole posterior leg by

techniques including effleurage, palmer stroking, picking up, wringing, and

knuckle kneading (Rattray & Ludwig, 2000). Muscle stripping was applied to the

hamstring muscles and the gastrocnemius muscle. Attachment release was applied

to the vastus lateralis and vastus medialis muscles along the linea aspera. A

contract relax stretch was performed on the quadriceps once they had been

warmed up by the thermaphore. Stimulation was then done to the gluteus

maximus muscle by rapid fingertip tapotement while the patient actively extended

his hip up and down for one minute. This stimulatory technique was used to

encourage proper muscle firing with hip extension. Treatment was bilateral,

however, less time was spent on the unaffected leg. The patient was positioned in

the supine position for 30 minutes. GSM including longitudinal stroking, picking

up, wringing and knuckle kneading was administered to the anterior thigh. Focus

was given to the lateral thigh muscles of the left leg. Muscle stripping along the

vastus lateralis muscle and iliotibial band C-bending was administered.

C-Bending is used to target golgi tendon organs, proprioception nerve receptors

near musculotendonous junctions, as a means to ease spasm and tone of a muscle

(Rattray & Ludwig, 2000). Trigger point therapy was conducted to the vastus


lateralis and vastus medialis an inch above the insertion point at the patella. The

therapist first palpated the trigger point, pressed down toward the belly of the

muscle until the patient reached a seven on the pain scale, and then held the

compression until the pain subsided to a one or zero. Therapist repeated TPPR

three times on each muscle followed by active ROM by the patient to restore

motion and muscle length (Rattray & Ludwig, 2000). Finally, stimulation to the

vastus medialis oblique muscle was done for one minute as the patient actively

extended the knee. The goal of this modality was to encourage proper muscle

firing with knee extension and increase tonicity of the vastus medialis oblique

muscle.

Treatments 5-10 were identical to the first five treatments; however, instead of

trigger point therapy a fascial hold was done. The trigger points that were

palpable in the first half of treatments became impalpable, yet the fascial

restrictions were still present. Three fascial holds were conducted by grasping the

thigh and applying a superior glide with hands on either side and held for one

minute. The fascial holds were the last technique used in each of the last five

treatments.


Treatment # Modification Reasoning

2 Contract relax applied to

hamstrings before treatment

Patient presented with a

posterior hip rotation in the

assessment and the therapist

used a contract relax technique

to help adjust the hip angle.

3 No stimulation to VMO Patient had a constant ache in

his left knee during the

treatment and therapist did not

want to aggravate it.

5, 6, 7 Contract relax to hamstring

muscles in supine

Patient presented with very

hypertoned hamstring muscles.

9 No thermaphore used in prone Swelling present in the left

knee.

Table 4: Treatment Modifications

Home care:

Patient was given homecare after each treatment. The focus of homecare was

stretching, strengthening, and patient awareness and education on biomechanics

of proper squatting techniques. Stretching exercises addressed the hypertoned

muscles of the lower extremity. Strengthening exercises of vastus medialis

oblique muscle and gluteal muscles were used to increase stability of the knee and

hip joint.


Results

Throughout the course of this case study the patient continued to make positive

gains. To start, patient awareness increased rapidly throughout the study. Partway

through the study, the patient reported “I am continuously thinking about how I

am squatting and the forces on my knee.” Additionally, lateral thigh tension was

reduced significantly when measured with Ober’s orthopedic testing protocol,

progressing from positive to negative throughout the study (Table 5); this

improvement was also evident in the pictures (Appendix A), which showcase the

patella shifting from lateral to a more neutral position by the end of the study. By

evaluating lateral knee pain in every treatment using Rattray’s (2000) pain scale, a

decrease was apparent from the initial treatment to the final treatment. The

patient’s pain started at an eight out of ten at the beginning and progressed to a

zero out of ten in the last couple of treatments where pain was non existent

(Figure 2). During the intake of the fifth treatment the patient reported a “numb”

sensation in his left medial knee. The “numbness” gradually diminished as

treatments progressed (Appendix A). By the end of the study all measures of

effectiveness showed improved results.


Orthopedic Test Treatment # Pre Treatment Post Treatment

Beighton Score 1 4/9 ---

Stork Test

1 (+) Bilaterally (+) Bilaterally

8 (-) Bilaterally (-) Bilaterally

9 (+) Left (-) Bilaterally


Trendelenburg

Test


2-10 (-) Bilaterally (-) Bilaterally

Gillet’s Test


2 (+) Right (-) Bilaterally


Adductor

Contracture Test





Thomas Test


2 (+) Bilaterally (-) Bilaterally




Ober’s Test

1 (+) Left (+) Left





Eli’s Test

2,3,4 (+) Bilaterally (+) Bilaterally




Apley’s

Compression Test



Table 5: Orthopedic Test Results Pre & Post Treatment


Discussion/ Conclusion

Musculoskeletal and joint pain is a common issue within the average population

and the EDS community. There are many treatments that attempt to alleviate the

discomfort associated with joint pain. There are no studies, to the therapist’s

knowledge, that specifically document the effects of massage therapy on the EDS

population.

This case study explored the effect of massage therapy on chronic knee pain in an

EDS patient. This patient was able to experience the benefit of massage for the

first time. He communicated throughout the study the positive impact the sessions

had on his knee and how much relief it had brought to his body. He expressed his

gratitude for being chosen for this study as he had finally found a way to relieve

his pain (Appendix B). Apart from finding pain relief, the study taught him a great

deal about himself and how his daily movements relate to his overall health.

The primary goal of this case study was to determine if a course of massage

therapy treatments could alleviate lateral knee pain, reduce lateral patellar pull at

rest, and increase joint awareness and proprioception. The treatment outcomes in

this study were extremely positive. A quote from one of the treatments, “I feel

like I have a new knee,” showcases this positive outcome. The stability in the

knee joint was improved through dedication to homecare. Trendelenberg and

Stork orthopedic tests began to show negative by the middle of the study and


continued to do so throughout the remainder of the study (Table 5). The negative

results of these orthopedic tests prove stability of the lower extremity improved

throughout the study. Dedication to homecare strengthening exercises of the

vastus medialis oblique muscle and patient education on proper squat techniques

allowed the patient to eventually squat without “clicking” (Appendix A), which

further seems to prove that stability of the knee was increased. Lateral knee pain

diminished throughout the study and by the end was non-existent (Figure 2).

Through negative Thomas and Ober’s orthopedic tests it is clear that lateral thigh

tonicity was decreased which allowed for the patella to rest in a more neutral

position. Progression pictures in Appendix A illustrate the patella gradually

shifting from lateral to a more neutral position by the end of the study.

One deviation from the positive results occurred after treatment 5. The patient

began to feel a “numb and tingling” sensation in the left medial knee. The reason

for this is idiopathic, however, the therapist predicts this was due to the increase

in weight applied during vastus medialis oblique muscle strengthening. Over

exertion of the vastus medialis muscle can lead to hypertrophy of the muscle and

cause irritation of the branch of the femoral nerve that runs through vastus

medialis oblique muscle (Detterline, A., Babb, J., & Noyes, F. R., 2016).

This study contained cost efficient homecare and positive treatment results,

leading to client compliance. Massage therapy showed to be helpful for this


specific patient; however, further studies need to be conducted to further

consolidate the affects of massage therapy on chronic musculoskeletal pain

experienced by EDS patients.


References

Arthur, K., Caldwell, K., Forehand, S., & Keith, D. (2015). Pain control methods

in use and perceived effectiveness by patients with Ehler-Danlos

syndrome: a descriptive study. Disability and Rehabilitation, 38(11),

1063-1074.

doi: 10.2109/09638288.2015.1092175

Beighton, P., De Paepe, A., Steinmann, B., Tsipouras, P., & Wenstrup, R. J.

(1998). Ehlers danlos syndromes: revised nosology. American Journal of

Medical Genetics, 77(1), 31-7.

Castori, M., Morlino, S., Celletti, C., Celli, M., Morrone, A., Colombi, M.,

Camerota, F., & Grammatico, P. (2012). Management of pain and fatigue

in the joint hypermobility syndrome (aka ehlers-danlos syndrome,

hypermobility type): principles and proposal for a multidisciplinary

approach. American Journal of Medical Genetics Part A, 158(8), 2055-

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De Paepe, A., & Malfait, F. (2012). The Ehlers–Danlos syndrome, a disorder with

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APPENDIX A: Progression Photos

Treatment 1 Treatment 5 Treatment 10

Left Knee Presentation: one mark made on center of patella and another on the

tibial tuberosity to showcase lateral patellar pull at rest.

Treatment 1 Treatment 5 Treatment 10

Squat Performed Without “Clicking”


Treatment 5 Treatment 6 Treatment 7 Treatment 8

Sensory Changes of the Left Medial Knee

**All photos are of patient involved in this study and consent from the patient

was given for documentation.


APPENDIX B: Letter From The Patient

“I just wanted to send a very warm thank you for all of our massage therapy

sessions. To be honest I had no idea massage could be of benefit to me until a few

weeks prior to treatments when you reached out to me. As soon as we started it

was clear that this was the right treatment for me. It was relaxing, therapeutic,

and gave instant results! I have found a noticeable change in the way I perform

sports, work, and even carry myself. It wasn’t until I missed on of our sessions

when I realized how much I needed it. My left knee pain was a bizarre pain that I

wrote off to be normal. My knee feels great now and I really appreciate you for

all the help and care you have provided me with through our sessions.”


APPENDIX C: Patient Consent Form

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