Massage and ACL Injuries
- Frank Gioeli
- Feb 13
- 9 min read
As a beginner massage therapist at Rutgers University, I was confident I could perform basic therapeutic and relaxation massages to the average person on my table. About three months in, I had a gentleman who was a hopeful walk-on for their basketball team book a session. About 10 months prior, during tryouts, he tore his ACL in his left knee. I heard of this injury throughout my life but never really was taught what it was, what the hell ACL stood for, and what a massage therapist's role would be in treating the recovery of an ACL surgery or advising on how to prevent it from happening.
So, as a self proclaimed, often called, “nerd”, I researched it. Below, is all my findings as well as the URLs to the websites that allowed me to grow my knowledge of this injury, and advance my career.
This young gentleman has since recovered and is currently playing in France. I am grateful he took a chance on me and am grateful to have been able to compile all this information as a reference point for anyone interested in treating their own clients with ACL injuries, or with learning a bit more about it.
This is a basic, understanding of the ACL and an LMT’s role in treating it. It should not be taken as medical advice or as a replacement of a medical diagnosis of any kind. It is strictly for information purposes only, in a gathered format so you do not have to do it yourself, but can come here as a one stop shop. Please feel free to book an appointment to learn more about my role as a massage therapist, and talk to your doctor about the best treatment plans and when you can be cleared for massage, PT, and strength training.
Here we go!
Anatomy of the ACL in the Knee:
The anterior cruciate ligament is located within the joint capsule of the knee and connects the femur to the tibia. It is responsible for preventing excessive forward movement of the tibia and limiting rotational movement at the knee joint.
The picture below shows the side-on view of the bones and ligaments that make up the knee joint. In the middle of each picture is the ACL.
Together with the posterior cruciate ligament (PCL), it forms an 'X' shape inside the knee joint. The ACL runs from the bottom of the femur at the back of the knee, diagonally through the joint, and attaches to the top of the tibia at the front of the knee. It provides stability to the joint by limiting the rotation and forward movement of the tibia underneath the femur. It is very strong but not very flexible. The ligament fibers can be torn by a sudden change of direction, a sudden transference of weight from one leg to the other, as when landing from a jump, a sudden stop, or by straightening the leg beyond the knee's normal range of motion. An injury of this kind is called an ACL tear.
How can this injury occur?
An ACL injury is the result of excessive stretching or tearing of the anterior cruciate ligament. The severity of the injury can range from a slight stretching to a complete tear or rupture. When it is torn, that is when surgery is necessary. An ACL injury most commonly results from:
A sudden stop or change of direction.
A twisting motion at the knee joint.
A blow or sudden impact to the front of the knee.
Athlete’s involved in sports that require a lot of running and change of direction and speed; (especially contact sports) are most susceptible to ACL injury. Sports that involve the highest risk are soccer, basketball, football, skiing, hockey and gymnastics. Women's gymnastics, basketball and soccer are three of the top four sports with the highest ACL injury rates. ( https://pubmed.ncbi.nlm.nih.gov/17710181)/
Structural issues post surgery include:
It is important to keep a concept of soft tissue continuity in mind when developing a treatment plan. Hamstrings and their antagonist, the quadriceps, function as a good foundation for any treatment plans. Building on that, you can move up the kinetic chain to work on the tensor fascia latae, gluteus maximus, medius and minimus. Progress medially to work on the adductors and their fascial attachments to the hamstrings and quads. Within the adductor group the adductor magnus is a high value muscle, contemporary anatomy texts describe the adductor magnus as having a hamstrings portion (described as the 4th hamstring) and an adductor portion.
Upper body soreness including neck and shoulder discomfort from use of crutches
Saphenous nerve: An often unappreciated contributor to medial knee pain is irritation of the saphenous nerve at the adductor canal (Porr et al. 2013)
Adductor magnus : may be involved in the compression of the femoral artery, due to the interconnection between the adductor magnus and vastus medialis by the vastoadductor membrane (Tubbs et al. 2007). Working the vastoadductor membrane (the adductor magnus tendon & the vastus medialis), may yield good therapeutic results. This band can create a notch with a venous stenosis at the outlet of the Hunter's canal, usually located 12-14 cm above the femoral condyle. Contraction of the adductor longus closes the hiatus, while the adductor magnus opens it.
Vastus lateralis: An expansion from the vastus lateralis tendon blends with the lateral aspect of the capsule of the knee joint and the iliotibial tract, before attaching to the lateral tibial condyle. The vastus lateralis also extends posteriorly and forms a groove with the biceps femoris, the IT band overlies both muscles.
Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction - “The persistence of the increase in extracellular matrix and decrease in satellite cell content despite surgical reconstruction and rehabilitation demonstrate the need to intervene early following an ACL tear to prevent changes at the cellular level that may ultimately limit muscle adaptation during rehabilitation. " (Noehren et al. 2016)
Lower leg and Ankle - Other soft tissue structures that can be included in treatment plans are popliteus, gastrocnemius and the soleus. As for bony articulations; joint mobilizations at the proximal tibiofibular joint and the ankle joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint) will strengthen the therapeutic input.
Questions LMT should ask prior to starting session:
How long ago was the injury & surgery?
Was it a complete tear or a rupture?
Have you been cleared for a massage by your doctor?
Have you been going to physical therapy?
What is your pain level on a 1-10 scale?
What daily activities do you do that causes pain?
Were you on crutches after surgery and for how long?
Any shoulder or back pain or tightness?
What are your goals for recovery? Is it to be able to play again or daily life activities without pain?
Range of motion of the knee (tests listed below) should be checked
Is there any pain in the unaffected leg due to compensation?
ROM tests LMT should check prior to and after session:
Knee Flexion
Patella Movement
Neck rotations, flexions
Shoulder Abduction, Flexion, extensions, internal and external rotations
Session focus:
Your job as the LMT for the client is to stay within your scope of practice and only provide relief if you are trained to do so. An LMT should not be performing stretches if they do not know the stretch nor should they be doing ROM tests if they are not applied correctly. If you do not feel confident, ask for help. A client would respect your decision to ensure you are doing things correctly rather than having you set them back on their road to recovery.
Your main focus is to promote tissue healing and restore normal movement patterns. As part of the assessment process it is important to find out what the patient's goals are. Some athletes may have the goal of returning to their sport after an ACL reconstruction and some may just want to regain daily active living. Our athlete in this scenario is planning on playing this season, so we know his goals.
The main focus early on is to improve range of motion in the knee joint and provide relief to any tension found because of the surgery or the complications of having ACL surgery. Later, therapy shifts towards regaining strength in the weakened muscles around the knee that have atrophied since the surgery from not being used. When the client is in this phase, our job as an LMT is to promote tissue healing and drain any lymph and scar tissue built up.
Post-surgical muscle atrophy is common after ACL surgeries and clients with dedicated physical therapy will generally regain post-surgical quad strength before twelve months.
The client’s back pain can stem from the time post surgery that he was on crutches. For the first four weeks, patients rely on the use of crutches to get around. This may result in clients presenting with the complaint of headaches as well as neck and shoulder discomfort. As a holistic treatment approach it is important to address these complaints as well.
Treatment:
The following techniques are specific to the area around the patella that have an immediate effect on the ACL and muscles proximal that may be overcompensating for the ACL.
It is important to note that working above and below the knee is extremely important in providing relief on the muscles that have been overcompensating and most likely have built up scar tissue, are hypertonic or overworked.
Palpitation Technique
With the client's leg outstretched and parallel to the floor, place the middle and index finger of each hand on either side of the damaged knee approximately 1/2-inch down from your kneecap. Rub the area in a small, steady circular motion for 2 to 3 minutes at a time. This will help loosen the undamaged tendons and ligaments that are over-compensating for the injured ACL. This technique also reduces fluid retention in the knee area.
Cross-Friction on the Patella Technique
This massage technique involves creating mild friction on the frontal ligaments of the knee. Have the client sit comfortably on the floor or another flat surface. Have the client slowly pull the injured knee up toward their chest while keeping their foot flat on the ground. Once the knee is bent in a natural position, the therapist should place all four fingers of each hand on either side of the knee. Place both thumbs just under the front of your kneecap and apply moderate pressure. Begin moving the thumbs from side to side simultaneously for 1 minute.
To Prevent Scar Tissue from forming, this is a great exercise to have the client do. (A therapist can also provide this massage in the same position as the last). To start the roll massage technique, sit in your chair with your knees bent. Slowly and carefully lift your injured leg and place your ankle on your good knee. Take the palms of your hands and put them on each side of your knee with your fingers wrapped around the front of your knee, right above your shin. Slowly take your fingers and slide them across your skin, creating a rolling motion. Repeat this exercise for 2 to 3 minutes a few times
Post session discussion with client:
Educating the client on the benefits of consistent massage therapy is important. Let them know that some of the benefits that hands-on therapy techniques can offer patients with ACL injuries include:
Reducing your levels of pain without pain-relieving medication
Improving your blood circulation
Accelerating the healing process in your injured knee
Reducing swelling and inflammation in and around your injury
Increasing the range of motion of your knee
Lowering the amount of scar tissue that forms at the site of your injury
The client may be concerned about how to ensure this doesn’t happen again. Obviously, we cannot make that promise, but letting them know preventative measures is important.
Preventative measures include:
Warm up properly A good warm up is essential in getting the body ready for any activity.
Rest and recovery Rest is very important in helping the soft tissues of the body recover from strenuous activity. Be sure to allow adequate recovery time between workouts or training sessions.
Stretch and strengthen To prevent ACL injury, it is important that the muscles around the knee be in top condition. Be sure to work on the strength and flexibility of all the muscle groups in the leg.
Balancing Exercises: Any activity that challenges your ability to balance, and keep your balance, will help what is called proprioception – your body’s ability to know where its limbs are at any given time.
Footwear: Be aware of the importance of good footwear. A good pair of shoes will help to keep your knees stable, provide adequate cushioning, and support your knees and lower leg during the running or walking motion.
Strapping: Strapping or taping can provide an added level of support and stability to weak or injured knees.
Avoid activities that cause pain: This is self-explanatory, but try to be aware of activities that cause pain or discomfort, and either avoid them or modify them.
Again, This is a basic, understanding of the ACL and an LMT’s role in treating it. It should not be taken as medical advice or as a replacement of a medical diagnosis of any kind. It is strictly for information purposes only, in a gathered format so you do not have to do it yourself, but can come here as a one stop shop. Please feel free to book an appointment to learn more about my role as a massage therapist, and talk to your doctor about the best treatment plans and when you can be cleared for massage, PT, and strength training.
Frank Gioeli, LMT
Massage Is Therapy For Me
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