Athletes Treating Athletes

This is part six in the self muscle massage series. In the introduction post, we discussed and demonstrated the the three techniques used below in more depth. If you missed it or would like to review the material you can do so here. If you’d like to see other installments of the series including the calf, hamstrings and hip, you can do so here.

In this installment, we’re going to be moving from the front of the hip down into the front of the thigh where the quadricep muscles are. The primary goal of these muscles is to straighten or extend the knee. This is vital in supporting the body over the knee during full weight bearing, as well as, providing force during propulsion and push off. The quads are one of the most powerful muscle groups in the body and are unique in that they use the patella (also known as the knee cap) as their source of leverage. The patella actually sits in the the common quad tendon and rests over the knee joint as the tendon inserts onto the tibia (or lower leg bone). It is then stabilized by connective tissue that wraps around the knee to minimize side to side movements so that it can track properly through it’s groove. Together these two factors make the quads and front of the knee one of the most common sights of overuse and musculo-tendinous injuries in the body (i.e. quad strain/sprain, contracture (chronic loss of flexibility), tendonitis, and patellofemoral syndrome, aka PFS).

Potential Causes of injury

1) Due to the power of this muscle group, they are capable of overcompensating during gait abnormalities. If you are unable to fully straighten the knee (with calf or hamstring tightness for example) or extend the hip to push off (due to hip flexor tightness), they must work over time to pick up the slack. This makes them very susceptible to overuse injuries as they tighten and become weak under the strain. Think of it as staying in a squat position while walking. If you are unable to fully contract the quad muscle, you are unable to shift the workload to the next muscle group in the chain, and subsequently you are unable to relax it as you do so. The result is a muscle that must work not only to weight bear and push off, but also to pull the leg forward and start the process over.
2) The patella and it’s position over the lower femur (thigh bone) and tibia (lower leg bone) are a common source of pain in the front of the knee, as well as, injury further up into the quad muscles themselves. Part of the reason for this is the dynamic way that the cap is held in place. Unlike other bones in the body that are directly connected to one another, this bone is floating and held in place solely by soft tissue. If any imbalances are present, the cap can be pulled in one direction and become stuck there. This can lead to muscle injury from the resulting muscle imbalance, as well as, inflammation and tendonitis as the bone now rubs on the structures underneath.

Anatomy

Landmarks

There are two important bony landmarks to locate when working on the quadricep muscles. They serve as the two main insertion points.

#1 Tibial Tubercle- this small bony bump on the front of lower leg bone is located just below the patella. It is important because it is where the large tendon of the quads inserts. The patellar tendon refers to the tendon between the bottom of the knee cap and this insertion point.

#2 The ASIS (anterior superior iliac spine). The ASIS is the front part of your hip bone. To find it, start with your hands on your hips and your fingertips pointing towards your stomach. Unlike the other two bony landmarks that are small bumps, the ASIS are larger and easily palpable when you follow the iliac crest forward. Visually, when you lay on your back, they are the two hip bones sticking out towards the ceiling.

The reason for including the ASIS as a landmark is that it is needed to palpate the upper portion of the large quad muscle, the Rectus Femoris. In the last post on the front of the hip, you’ll remember that as we moved down from this spot towards the groin line, there were two muscles that split away towards either side of the thigh to form a “V” at the front of the hip. These two muscles are the TFL (the green line in the picture) and the Sartorious (the purple line in the picture). The Rectus Femoris makes up the floor of the “V” and can be found between these two muscles as it moves towards it’s insertion point (the red upward arrow) further up in the hip.

**Note: To find the “V”, start with your hand on the ASIS and move down towards the groin line. As you rotate the leg in and out, you will be able to feel both muscles moving and sink your thumb right in between them into the “V”. This is where you will find the rectus femoris (RF).

The Muscles

1) Rectus Femoris (RF) - the RF is largest of the four quadriceps muscles and is responsible for extending the knee. Because it is the only quad muscle to cross the hip joint, it also aids in hip flexion. As stated above, to find this muscle, locate the “V” and sink down into that groove between the sartorious and TFL. There you will find the RF as it moves towards its insertion point. If you contract your quad muscles (extend your knee) you will be able to trace it down the middle of the thigh. As you get closer to the patella, there will be a drop off as the muscle becomes tendon.

2)Vastus Intermedius (Middle Quad; VI in the picture)- the VI lays directly underneath to the more superficial RF muscle and is not palpable. However, it is important to note that these two muscles work in opposite directions when they contract. For example, during running, the larger RF works to flex the hip (pulling upward) while the VI works to extend the knee (pulling down towards the patella). Due to this, it is a common sight of soft tissue restrictions as irritation forms between the two muscle layers and they become stuck.

3) Vastus Lateralis (VL)- this is the outermost of the four quad muscles. If you extend your knee, you will be able to see this muscle. As you look down towards your knee, it begins just above the outside of the patella and works it’s way up the thigh. This muscle can be a common sight of soft tissue adhesions and muscle knots in the presence of patellar tracking or lower leg alignment abnormalities.

4) Vastus Medialis Oblique (Inner quad, VMO)- this is the innermost of the quad muscles. It’s function is crucial to maintaining normal patellar tracking. If the muscle becomes weak and stretching out due to imbalances between the VMO and the larger, stronger outer quad muscles, the patella can begin to track abnormally. To find this muscle straighten your knee and roll your whole leg out. Just above the knee cap on the inside you will feel and possibly see the VMO pop out.

(Note: The VL and VMO work together to hold the knee cap in place. In a normal leg the knee cap moves up and down over the front of the knee joint and the VL and VMO fire equally to prevent an side to side movements.)

Self Muscle Massage

What you’ll need: a foam roller and tennis/trigger point ball.

The Techniques:
1) elongation/lengthening with the foam roller
2) cross friction with the tennis ball
3) sustained pressure (trigger point release) with the tennis ball

Key Area’s to work on:

When working on the quads, break it down into three vertical segments.

1) The first segment is as wide as your knee cap and moves straight up the middle of the thigh. This will help you isolate the RF and VI and is pictured in between the red lines in the picture. Keep the leg straight and foot pointed down to the floor when working on this strip. Start with the foam roller and work the whole strip. Then fine tune any problem areas with cross friction and sustained pressure.

2) The second segment is on the outer part of the quad and isolates the VL (between the green and outer red line in the picture above). Rotate your leg in so that your foot is pointing towards your other leg when working on this strip (key: use the hip muscles to rotate the leg, not the quads; you want to keep them relaxed!). Start with the foam roller and work the whole strip. Then fine tune any problem areas with cross friction and sustained pressure.

3) The third segment is on the inner part of the quad and isolates the VMO (between the blue and inner red line). Rotate your leg out so that your foot is pointing away from your other leg when working on this strip. Remember- use the hip and keep the quad relaxed. Start with the foam roller and work the whole strip. Then fine tune any problem areas with cross friction and sustained pressure.

4) The last key area you want to focus on is the upper insertion of the RF (the purple circle up top). Cross friction and sustained pressure work best at this spot.

Video

Below is a video demonstration of the techniques.

References:
1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.