The Value of Deep Transverse Frictions in Sports Injuries with particular reference to the knee

This policy proved successful and popular (both with the patients and the physiotherapists) during my forty years a t St. Thom as’s) and should be adopted all over the world. The patient remains under medical supervision throughout and is treated by trained ethical personnel. All that need be done now is for doctors to recognise suitable cases at once and for physiotherapists to equip themselves to treat accordingly. N either presents the slightest difficulty, merely the exercise o f a little goodwill.


The Value of Deep Transverse Frictions in Sports Injuries with particular reference to the knee M A R G A R E T C O L D H A M , M .C.S.P.
D eep transverse friction is an invaluable treatm ent for sports injuries. How ever, when this type o f m assage is being carried out, it m ust be given to the exact', spot and in the correct w ay; it is o f no use to look for the tender area and to m assage there. O ne m ust exam ine the patient, find out which tissue is at fault a n d 'th e n look for tenderness along that structure. T he friction m ust then be given transversely to the tissue, n o t longitudinally.

A IM S O F D E E P T R A N SV E R SE F R IC T IO N S
1. In m uscular lesions the aim is to mobilise the muscle by separating the adhesions between the individual muscle fibres th a t are restricting its m obility tow ards broadening each tim e it contracts. T he muscle m ust be kept fully relaxed during the friction.
2. In ligam entous lesions, the objective is to m ove the ligam ent to and fro over adjacent bone in im itation o f its norm al behaviour and thus m aintain its m obility.
3. W hen a tendon has a sheath, crepitus m ay be present indicating roughening o f the tendon sheath. D eep transverse friction sm oothes the gliding surfaces. D uring the transverse friction the tendon m ust be kept tau t. In tendons w ithout a sheath, deep transverse frictions break up scar tissue at the insertion o f the tendon into bone o r scar tissue w ithin the tendon.

T E C H N IQ U E S O F D E E P T R A N SV E R SE F R IC T IO N S
1. A s m entioned earlier, the right spot m ust be found. 2 . T he physiotherapist's fingers and the patien t's skin must m ove as one. If m ovem ent takes place betw een the patien t's skin and the physiotherapist's fingers, then the massage reaches only the skin and n o t the tissue at fault, and will also give rise to a blister.
3. T he friction m ust be given across the fibres com posing the affected structures, i.e. transversely.
4. The friction m ust be given with sufficient sweep. 5. T he friction m ust reach deeply enough. It is more effective to m assage deeply for a few m inutes th an to go on indefinitely with gentle m assage.
6 . T he patient m ust a dopt a suitable position which ensures th a t the tissue is either tau t fo r a tendon sheath or relaxed for a muscle. I f the structure to be treated is ordinarily out o f reach o f the physiotherapist's fingers, then a position m ust be adopted w hereby the tissue becom es accessible, e.g. the supraspinatus tendon at the shoulder. T he arm is put behind the p a tie n t's back whilst the patient is in the halflying position, thereby fixing the arm in adduction and medial rotation. In this position, the tendon can be easily felt as it passes from the base o f the coracoid process directly forwards over the head o f the hum erus to the greater tuberosity.

RECENT i n j u r i e s i n t h e k n e e
The knee is a very rew arding jo in t for the physiotherapist to treat, both by deep transverse frictions and by m anipula tion. A full history m ust be taken and the knee exam ined to single out the tissue a t fault before starting treatm ent.
History. This is m ost helpful at the knee. T he following points should be ascertain ed : W hat is the age and occupation o f the patient ? W hat was he doing w hen the pain first appeared ? jn w hat position was his body and his leg, and w hat forces were acting on his knee at the tim e ?
A ltern ativ ely , d id th e p a in co m e o n fo r n o a p p a re n t reason ?
Did the knee give w ay; if so, did the knee lock; if so, did jt lock in extension o r flexion; if so, how did it becom e unlocked ?
On which side o f the knee was the pain o r was it right inside, o r was it all over ?
Did  The secondary m ovem ents test each ligam ent in tu rn ; valgus for the m edial collateral ligam ent; varus for the lateral ligam ent; anterior pressure on the tibia for the anterior cruciate ligam ent; posterior for the posterior. If ■nge proves excessive, the relevant ligam ent is overstretched.

Resisted M ovem ents
These are tw o; resisted flexion for the ham strings and resisted extension for the quadriceps m echanism . Pain indicates a muscle lesion; weakness, rupture, or a nerve lesion. B oth weakness and pain on resisted extension characterize a factured patella.

PALPATION O F THE STATIONARY JO IN T
Heat W arm th indicates an active lesion; localised w arm th reveals the site. Active lesions are: repair after a sprain, operation, or local fracture; haem arthrosis, persistent internal derange ment, rheum atoid arthritis and its variants, gout, spondylitis or osteitis deform ans, R eiter's disease, psoriasis, etc.

Fluid
This m ay be clear o r blood, or (but n o t in physiotherapeutic cases) pus. T he patella can be tapped against the fem ur if a large quantity of fluid floats the patella off it. A m ore delicate test is fluctuating the fluid from the supra-patellar pouch to the area at each side o f the patella. It is well to realise that synovitis o f the knee' m eans m erely 'fluid in the knee jo in t'.
it is not a diagnosis; for intra-articular fluid is com m on to m any conditions, as disparate as a sprained ligam ent, a displaced loose body, o r rheum atoid arthritis. N o treatm ent is possible until the cause of the fluid in the joint has been ascertained.

Capsular Thickening
T he detection o f capsular thickening by palp atio n o f the synovial reflexion at each fem oral condyle indicates one o f the rheum atoid group o f arthritides, e.g. spondylitis, psoriasis, Reiter, o r gout, tuberculosis, and so on. C apsular thickening contra-indicates active physiotherapy.

Tenderness
Since m ost o f the tissues at the knee lie superficially, this lends great accuracy to diagnosis. T enderness is sought along the structure singled o u t by the clinical exam ination, always provided th a t it lies w ithin finger's reach.

Medial Collateral Ligament
The knee is forced tow ards valgus; a sudden pain is felt at the inner side of the knee. The patient picks him self up and can walk, but he becom es increasingly disabled. A fter a few hours the knee becom es very swollen and so painful th at he can hardly stand.
Signs: In the acute stage, lasting som e ten days, exam ination is difficult since the acute traum atic arthritis overshadow s the ligam entous signs. T he knee is hot, full of fluid, with say 10° lim itation o f extension, and 90° lim itation of flexion range. B ut the patient know s he strained the inner side o f his knee, and localised tenderness at som e point along the ligam ent is easily detected.
In the subacute case, which lasts a good m onth in the untreated case, the am ount o f m ovem ent gradually in creases, the heat and fluid abate, and exam ination becom es practicable. T he ligam ent can now be tested w ith the knee straight; valgus strain is found to hurt. I f it has ruptured, excessive range is obvious.
In the chronic stage, adhesions have form ed, binding the ligam ent abnorm ally to bone. Im paired ligam entous m obility leads to a knee th at is painless on o rdinary activities, but any full use o f the joint, e.g. running o r at gam es, leads to pain at the inner side o f the knee and som e days heat and fluid.
T he aim o f treatm ent during the acute stage is to m ove the ligam ent in im itation o f its norm al behaviour by deep transverse friction. In the chronic stage, w hen adhesions have form ed, m anipulation is perform ed in a n endeavour to break dow n the adhesions.
Deep Transverse Friction: W hen this is given to the m edial collateral ligam ent, it has to be carried out with the knee held first in extension and th en in flexion, in order to m aintain m obility o f the ligam ent at the anterior and posterior ex trem es o f its range. M anipulation: T his is indicated w hen the ligam ent has developed adhesions and its m obility is im paired.
Forced extension: T he patient lies supine on the couch and the knee is flexed as m uch as possible. The physiotherapist stands beside the patient, and raises the patien t's heel off the couch w ith one hand whilst placing her other hand on the patien t's knee. The m anipulation is carried out by giving a quick jerk. T he adhesions p art with a small snap.
Forced flexion: T he patient is placed in the half-lying position whilst the physiotherapist stands facing him . The hip is flexed as far as it will com fortably go. She then places one hand on his knee in order to steady it and also to m aintain flexion at the hip. Full flexion is now forced by the physio therapist pushing sharply with her o ther hand on his ankle.
Forced rotation in flexion: T he patient adopts the halflying position with the hip flexed. T he physiotherapist keeps the knee bent by pressing with one hand on his knee. She places the fingers o f her other hand ro u n d the back and outer side o f the patien t's heel, applying her forearm to the inner border o f his foot. L ateral ro tatio n is then forced. F o r m edial ro tatio n the physiotherapist stands level w ith the patien t's thigh, and clasps her hands tightly ro und his heel while holding the hip and knee flexed. By m oving b oth wrists she twists his heel strongly, thus forcing m edial ro tation at the knee joint.
These forced m ovem ents should be followed by active m ovem ents to m aintain the range o f m ovem ent which has been achieved.

Coronary Ligament
T he knee is forcibly rotated and a sudden pain is felt at one or o th er side of the patella. T he pain does n o t a t first prevent walking, but th a t evening the knee is warm , swollen and painful.
Signs: T hough acute traum atic arthritis obscures the ligam entous signs, it is less severe th an in m edial ligam ent strain and m ore likely to am o u n t to 5° lim itation o f extension, 45° lim itation o f flexion. B ut the p atient describes a rotation strain and the coronary, n o t the m edial, ligam ent is tender.
Spontaneous recovery is very slow and takes a t least three m onths.
Treatm ent: M obility m ust be m aintained at the tibiom eniscal jo in t, but m anipulating the knee m oves the fem orotibial -the w rong -jo in t. Hence m obility is m aintained or restored by deep transverse friction in the acute, subacute or chronic stage o f the sprain, and cures cases o f a few days' or several years' standing in a bout a fortnight. This is a n exam ple o f a lesion w hich benefits only from deep transverse friction. T he patient lies supine on the couch with the knee not quite fully flexed. T he physiotherapist sits facing him and presses her index finger, reinforced by the m iddle finger, dow nw ards and backw ards on the shelf form ed by the superior aspect o f the tibial condyle. H ere the phy siotherapist's finger comes into contact with the coronary ligam ent as it passes backw ards tow ards the m eniscus. The friction is perform ed by a to-and-fro m ovem ent o f her fore arm and hand. Fifteen m inutes' m assage three tim es a week fo r tw o or three weeks is usually sufficient.

Cruciate Ligaments
The knee is sprained, the pain being felt w ithin the centre o f the knee. Unless o ther ligam ents are strained too, the patient has a warm , painful knee containing fluid, but just a bout a full range of m ovem ent. Stretching one or other cruciate ligam ent hurts and m ay reveal excessive range if it is lengthened. There is no pain at either side o f the knee and no tenderness o f any accessible structure.
Spontaneous recovery is very slow, six to twelve m onths is the m inim um . Identification of the ligam ent and ascertaining a t which end the lesion lies is difficult, but one adequate infiltration o f hydrocortisone at the right spot is curative, unless m arked lengthening with consequent instability is present. Physiotherapy is useless and m anipulation harm ful.

Torn Meniscus
This follows a ro tation sprain th at first over-stretches the coronary ligam ent; then continued force tears the meniscus. T he patient feels a severe pain at one side o f his knee and falls to the ground. A ttem pting to rise, he finds his knee fixed in flexion, unable to b ear weight. T he knee is m a n i p i i lated, a click is felt and heard, and full extension is restore™ to the knee. H e still has the coronary sprain.
The m edial m eniscus is the m ore often torn. T herefore, the m anipulation described here is for a lesion on th a t side.
G eneral anaesthesia m ay be required on the first occasion a patient displaces p art of the cartilage. However, in recurrent dislocation, anaesthesia is seldom necessary.
The patient lies supine on the couch and flexes the hip and knee to a right angle. T he aim o f treatm ent is to shift the piece of cartilage m edially, away from w here it lies displaced between the fem oral condyles. A strong valgus strain m ust be place on the jo in t in an endeavour to open its inner aspect and encourage reduction in th a t direction. T he knee m ust be gradually extended while it is rotated rapidly to a n d fro. The physiotherapist's hand is, therefore, placed at the o uter side o f the knee, pressing m edially and dow nw ards. H er other hand grasps the foot, rotating the leg strongly and applying valgus strain. She also holds the foot up so that the pressure o f the first hand on the knee increasingly extends the joint A small click is heard as full extension is achieved, indicating th at reduction has taken place.
A s the m eniscus m oves it strains the coronary ligament. Unless im m ediate m eniscectom y is contem plated, this now requires deep friction.

Loose Body in Adolescence
Loose bodies, often m ultiple, frequently form in the k n^r betw een the ages o f fourteen and twenty, as the results osteochondrosis dissecans o r chondrom alacia patellae. Mthe patient walks along his knee suddenly fixes in extension; he gives the leg a good shake and then finds he can flex it; there is no lasting fixation.
The loose pieces have an osseous nucleus and show on the skiagram ; they should be excised.

Loose Body in Middle-Age
This is a com m on, disabling, and unrecognised disorder, usually easy to relieve but seldom treated correctly. T he loose body consists o f cartilage and thus is not visible on the skiagram , which instead shows the early osteophyte form ation th at comes on in m iddle age and causes no sym ptom s. The diagnosis is therefore often 'osteoarthrosis', b u t : (a) it com es on suddenly; (b) only p a rt o f the knee hu rts; (c) exam ination shows a sprained knee w ithout previous injury; (d) it m ay recover and then recur; (e) the patient experiences twinges. T he m iddle-aged patient states that, for no reason and w ithout any strain, he suddenly experienced localised pain

JUNIE 1976
FISiOT R eduction o f loose body at the knee, usually the inner side. Every step hurts and he walks dow nstairs one step a t a tim e fo r fear o f the twinge with giving way th a t m ight topple him to the bottom .
Signs: T he signs are those o f a sprained knee. T here is fluid in the jo in t, and if the pain is on the inner side, localised warmth is usually detectable there; full extension hu rts; 5° or 10° lim itation o f flexion is present. T he m edial collateral ligament is tender at the jo in t line. Clearly this ligam ent is strained . . . but the history indicates th at it has not been strained. T he cause cannot therefore be external force; it must be intrinsic. It is; a small cartilaginous loose body has suddenly shifted to lie a t the inner side o f the joint. T he spaceoccupying lesion ensures that, each tim e the knee is straightened, the ligam ent is strained. T he twinge results from a m om entary subluxation.
T he intention, w hen m anipulating a loose fragm ent within the knee jo in t, is to shift it to the posterior p art o f the jo in t where it no longer engages. In ord er to get the loose piece to move, the jo in t space has to be enlarged; therefore the m anipulation is carried out whilst the jo in t surfaces are distracted.
T he patient lies prone on the couch with the knee flexed to a right angle. The physiotherapist places one hand on the dorsum o f the p atient's foot and the other on his ankle. The web of her thum b catches under his heel, thus holding the foot in dorsiflexion w hich ensures good purchase fo r the other hand. She then lifts the leg strongly and rests his foot on her far thigh. A n assistant places her hands on the thigh ju st above the knee-joint, holding it dow n. The tibia is now distracted strongly from the femur. O nce the physio therapist has felt the patient relax a n d the bones com e a p art, she rem oves her thigh from under the p a tie n t's foot whilst still holding his knee off the couch and retaining her traction during the m anipulative rotation. The assistant a n d /o r patient m ay feel the click of reduction. T he knee should be re-exam ined after each m anoeuvre and the m anipulation repeated, often several tim es, until m ovem ent is free.

Monarticular Rheumatoid Arthritis
The outstanding features of the early case are: 1. Swelling at the knee com ing on for no reason; 2. T hediscrepancy betw een the local signs a n d the articular ,-signs! T here is no injury; w arm th, fluid and capsular thickening appear for no apparent reason. F u rth e r exam ination reveals a full range of painless m ovem ent -a m ost revealing discrepancy. L ater, o f course, m ovem ent becom es lim ited and the capsular thickening extrem e. By then the diagnosis is obvious.
W hen m onarticular rheum atoid arthritis com es on in middle-age, the skiagram is bound to show an osteophyte or two som ewhere, and the sedim entation ra te is seldom raised. These knees are apt to be treated in the sam e exercise class as the loose bodies, with equally insatisfactory results.

Patellar Tendinitis
T he pain is felt clearly a t the fro n t o f the knee only, and walking som e way o r upstairs elicits the pain. N o twinges are experienced. R ecurrent dislocation o f the patella causes attacks o f sudden derangem ent th a t m ust n o t be m istaken for those of a m eniscal tear.
Signs: T here is a full and painless range o f m ovem ent at the joint. Resisted extensions hurts.
Treatm ent: I f the scar tissue has form ed at the tenoperiosteal junction o f the supra-o r infra-patellar tendon, it m ust be broken up by deep transverse friction to the exact spot. Alternatively, the area can be infiltrated with hy d ro cortisone. W hen the quadriceps expansion is affected at one o r o th er side o f the patella, only friction avails. I f the tendons are n o t affected, and the cause is such erosion o f cartilage th at bone is grinding against bone a t the patellar-fem oral joint, only excision of the patella is effective.

Suprapatellar Tendon
T he patient lies supine on the couch with the knee fully extended and the quadriceps relaxed. The physiotherapist sits facing him a n d with one hand presses dow nw ards on the lower pole o f the patella w ith the web o f her thum b, her fingers to one side a n d her thum b to the o th er side o f the knee. T his results in the upper pole o f the patella being tilted forw ards, thus bringing the supra-patellar tendon into the m ost accessible position for m assage. T he physio therapist places the ring finger, reinforced by the m iddle finger, against the upper pole o f the patella. By pressing dow nw ards a n d backw ards, she catches the tendon a t its insertion into bone. T he friction is perform ed by a to-and-fro m ovem ent o f her w hole forearm a n d hand.