While studying anatomy in the deserts Arizona (well, really a city in Arizona, but still), I had a number of ah-ha moments, one of the biggest to me was part of my examination of the knee. This is a summary of my examination of the knee and thigh.
The patella essentially floats within the tendons of the quadriceps and has some movement up and down depending on how much the knee flexes or extends. There are numerous connective tissue structures (retinaculum and patellar ligaments) that attach to the patella region that are thought to hold the patella in the correct side-to-side position so that it slides smoothly on the femur underneath. The IT band is a thickening of the tissues that surround the muscles of the thigh, a taut band that spans from the pelvis to just below the outside of the knee. There is a strong attachment of this band onto the outside region of the patella that has been traditionally associated with restricting proper movement of the patella, particularly in the medial direction.
High forces through this joint or abnormal tracking of the patella can lead to compression of the joint and pain. Many therapists attempt to address restricted patellar mobility by pushing and pulling on the kneecap in an attempt to stretch and pull on the retinaculum and ligaments. They also recommend stretching, release, and foam rolling for the IT Band. There is now lots of evidence that the IT Band can’t really be stretched or released, so anyone suggesting this can be done is flat out wrong. Most therapists, even those who believe it can’t be stretched, do believe that IT Band plays a significant role in patellar mobility. It’s what we learn in school, what we see in anatomy books, and what we read online. It’s what I thought until I got the opportunity to examine things closely for myself.
My examination revealed that the primary limitation of patellar mobility comes from the most superficial tissues just beneath the skin. Upon removing this layer, the range of motion of the patella went from normal to excessive, with the other complex layers of connective tissue and fascia including the IT Band remaining intact. The IT Band did attach to the patella, but it played a bigger role in resisting dislocation rather than having any impact on general mobility. It’s more like guard rails on the highway – their utility is only when there is a crash rather than during regular traffic.
This type anatomy knowledge enables me to better understand the factors leading to my patients’ symptoms and tailor treatment to exactly what is going on. In fact, my manual techniques were already addressing these types of issues in ways that many therapists do not.