Addressing Degenerative Joint Disease of the Right Knee through Integrative Therapeutic Massage while Treatment Planning Efficiently

with a Deaf Patient; a Case Study

Frank Leonard Mazzella II

Acknowledgements

I would like to thank my wife for supporting me throughout my studies here at CNS and being

there for me while created this paper. I would like to thank the Center for Neurosomatic Studies

for providing me with the supervision, the knowledge and the wherewithal to create this report. I

would also like to thank Randall Clark for the supervision and his innate ability to teach anatomy

with diligence and precision, Kevin Wade for the advance technique know how and Paul St.

John for being so devoted into the evolution of this integrative therapeutic approach that allows

us to handle so many delicate cases.

Abstract

Background

Knee pain can result from injuries to the knee or hip. The knee joint is composed of three

articulating bones – the femur (thigh bone), tibia (shin bone) and patella (knee cap). These bones

are held together by ligaments and the quadriceps muscle helps with stability. The joint, like

other joints in the body is lined with cartilage, but in addition, it also has menisci which help to

mould the surfaces of the knee joint so they can articulate more favorably and help to provide

some lubrication. Knee pain can result due to injury to any of the above structures. The objective

of this case report was to document the changes that were made to the case study participant who

is deaf and suffers from knee pain especially around the medial aspect of the right knee. The case

study was performed over a 5 week period and was supervised by the authors massage therapy

school. Each massage session lasted anywhere from 60 -150 minutes. Multiple modalities were

combined in this soft tissue approach to resolving medial knee pain.

Case Presentation

The client is a retired 70 year old divorced woman who is 5 feet 2 inches tall and weighs 150

pounds. The client is fully deaf in both ears and was diagnosed with prelingual hearing loss at the

age of two. She is affluent in sign language, she does not read lips very well and her main form

of communication is through written communications to those that do not sign. It appears that the

onset of this condition may have been a gradual one but 2 weeks prior to massage therapy

superiorly to the gluteal region and inferiorly to the posterior leg compartment. The client’s

Chiropractor gave a diagnosis of degenerative joint disease to both knees, with by bilateral

lateral patella displacement.

Therapist Assessment

The client has multiple postural asymmetries that were documented in a postural charting

assessment prior to the first treatment. The inferior aspect of the medial knee appears to have

excess adipose tissue with fascial restrictions that were examined during pre-treatment

palpations. Upon palpation of the medial aspect of the knee the client reported an intense burning

sensation. It was observed that both patella’s were laterally displaced and this was confirmed

with an anterior/posterior bilateral radiograph of the knees. The client’s gait cycle contains a

limp when the client puts pressure on the right leg. Standing for a short duration during the initial

postural charting assessment only exacerbated the knee pain.

Outcomes

The therapist is a massage therapy student and participated in this case study through the

supervision of a clinical supervisor. He is in his 18th month of school and will be a graduate one

week from the end of this report. The client’s overall level of pain decreased significantly and

this was documented through three separate assessment measures that were later graphed. The

client states that although she is not 100 percent pain free, the overall knee condition is greatly

improved. Her ability to return to her regular routines and hobbies has been restored.

Keywords

Pre-lingual deafness, Osteoarthritis, Patella, Vastus Lateralis, Fascia, Table Tennis, Treatment

Plan, Massage Therapy

Introduction

Knee pain can result from injuries to the knee or hip. The knee joint is composed of three

articulating bones – the femur (thigh bone), tibia (shin bone) and patella (knee cap). These bones

are held together by ligaments and the quadriceps muscle helps with stability. The joint, like

other joints in the body is lined with cartilage, but in addition, it also has menisci which help to

mould the surfaces of the knee joint so they can articulate more favorably and help to provide

some lubrication. Knee pain can result due to injury to any of the above structures. Pain due to

structural knee problems is commonly felt at the front of the joint. Knee pain can also result from

hip problems which may provide a diagnostic challenge(1).

According to the report: Relieving Pain in America: A Blueprint for Transforming

Prevention, Care, Education, and Research, pain is a significant public health problem that costs

society at least $560-$635 billion annually, an amount equal to about $2,000.00 for everyone

living in the U.S. This includes the total incremental cost of health care due to pain from ranging

between $261 to $300 billion and $297-$336 billion due to lost productivity (based on days of

work missed, hours of work lost, and lower wages)(2).  Symptomatic radiographic knee

osteoarthritis (OA) has a functional impact on 12% of adults aged 60 or older—4.3 million

people—in the United States. The knee is one of the joints most commonly affected by OA.

Given projected increases in the aging and obese populations, the incidence of OA of the knee is

predicted to rise. Moreover, despite earlier research indicating joint cartilage degeneration as a

possible primary cause of knee OA—initiating internal joint inflammation, edema, and pain—

recent research has investigated the causative role of the quadriceps muscle, which is located on

the anterior thigh. In this muscle, weakness, impairments in function, influence on knee joint

loading, and proprioceptive deficits seem to contribute to the development or progression of knee

OA (3). The only reputable study published in regards to table tennis injuries states that there are

more than 100 million table tennis players worldwide and that the incidence of knee injuries is

13.4 percent compared to (lumbago) of the waist injuries were more prevalent at 23.5 percent(4).

A study was published in the International Journal of Therapeutic Masssage and

Bodywork that did show that the use of self massage decreased the severity of pain in patients

that were diagnosed osteoarthritis of the knee(3). Previous research has not definitively identified

the cause of knee OA. Therefore, the focus of treatment for knee OA is the management of its

symptoms with emphasis on self-management therapies such as exercise and complementary and

alternative medicine (CAM) therapies, such as massage. Evidence suggests, as noted above, that

the quadriceps may play a role in the disease—hence, the emphasis on massage on that muscle in

the present study. Following this further, the Perlman et al. 2006 research study on massage for

knee, OA suggested “massage therapy is efficacious in the treatment of OA of the knee, with

beneficial effects persisting for weeks following treatment cessation.”(3)

According to the Americans with Disabilities Act (ADA), providers are required to

engage in "effective communication" with their hearing impaired patients. The type of

accommodation for "effective communication" varies based on several factors. These include the

nature of the patient’s impairment, patient’s ability to communicate as well as the complexity of

the medical matter. It is not a necessity to provide a deaf patient with an interpreter if the patient

and therapist have other means of effectively communicating (4).

Methods

Client Profile

The client is a retired 70 year old divorced woman who is 5 feet 2 inches tall and weighs

150 pounds. The client is fully deaf in both ears and was diagnosed with prelingual hearing loss

at the age of two(5). She is affluent in sign language, she does not read lips very well and her

main form of communication is through written communication to those that do not sign. The

client participates in a general exercise regimen where she only does upper body workouts,

usually a pushup type upper body exercise. The regular activities that the client participates in

are going for walks and the client regularly plays table tennis for multiple hours at times.

Previous medical diagnoses for client includes: cancer to the right breast, gastroesophageal

reflux, and the patient had two C-section operations while giving birth to her two children due to

a small pelvis, as stated by the client. The cancer of the right breast was diagnosed by her

Oncologist and the gastroesophagel diagnosis was performed by her general medical practitioner

in Indiana. As for her current knee condition, she has not sought and form of body work for this

condition but upon arrival of the first treatment session the client was wearing a patella knee

brace that was wrapped around her right tibial tuberosity. A knee diagnosis was initiated by a

local chiropractor and the chiropractor stated that the client has mild degenerative changes to

several regions of both knees as noted. No evidence of acute fractures, dislocations or active

destructive processes. It is apparent from an A/P lateral x-ray there is obvious displacement of

both patellas laterally and it is more pronounced on the right.

The client states that her diet is a mixed food diet in which she states that she eats meats,

fruits, and vegetables. The client is currently taking 28mg’s of Aspirin daily and is currently

taking EPA, Magnesium, Curcumin, Digestive enzymes, and CoQ10 in supplemental form.

The client’s chief complaint is that she experiencing right knee pain medially just inferior

to the medial tibial condyle and lateral to the tibial tuberosity. At times the knee pain radiates

superiorly towards her gluteus maximus region and inferiorly towards her anterior lower leg

compartment. The knee condition is her greatest source of pain and at times the pain got up to a 9

on pain scale of 1 to 10. Subjectively, the pain is deep, sharp, and feels like there is a stinging

sensation. The client also states that she experiences a limited amount of right humeral

abduction, and this is more noticeable while playing table tennis. Walking for long periods of

time and playing long matches of table tennis exacerbates her knee pain. The client is willing to

put in 100 percent of her effort to achieve the maximal goals per this case study. She would

ultimately like to be as pain free as possible and is willing to do whatever it takes outsides of the

clinic to maintain the gains that were made throughout this case study.

Diagnostic Assessment

After the first massage intervention, the client was able to go in for her initial diagnostic

appointment which was to rule out a lower leg length inequality and another diagnostic

appointment was scheduled to X-ray both knees. The lower leg length inequality X-ray was

performed by the chiropractor who followed the Friberg and the Janet Travell MD protocol(6)

The Chiropractor states that there is degenerative joint disease of the right and left knee and there

is displacement of the patella bilaterally. Bone density is adequate. Mild degenerative changes

are noted at several regions of the bilateral knees. There is no evidence of acute fractures present,

dislocations or active destructive processes. There is significantly more soft tissue present

medially than laterally where the patellas are displaced. The joint space is significantly

compromised bilaterally.

Clinical Findings

The initial clinical assessment was performed by doing a full postural workup in which

the practitioner took an extensive series of objective measurements. There were 84

measurements charted in total. The measurements that were taken in three positions: standing,

supine and in a sitting position. The initial assessment was documented with the use of a postural

chart and many postural asymmetries were noted. In a standing position, it was observed that the

patient had a right torso tilt from the cranium down to her ilium.

When observing the patient along her midsagital plane it was documented that the

patient’s left Acromioclavicular joint was superior compared to the right, the left clavicle

followed the AC joint superiorly, the left temporal bone and the occiput were left superior, the

right Anterior Superior Illiac Spine was superior, the left glenohumeral joint was superior, and

the clients’ illiums were flared medially and laterally to the clients’ right. There was evidence of

a torso tilt to the patients’ right as the client’s cranium and torso were both off of the midsagittal

plane.

Along the coronal plane, it was documented that the client has a forward head posture

bilaterally and the clients’ right ear was more anterior than the left according to their relationship

to the AC joint. The right AC joint is more anterior than the left but the glenohumeral joint, the

lateral epicondyle of the femur, and the lateral malleolus all remained in line with each other

along this often time called, frontal plane.

Many of the supine measurements remained the same as the standing measurements but

there were some remarkable changes. Along the midsagittal plane, it was charted that the right

temporal bone was sheared anteriorly, but in the supine position this distortion balanced out. The

left AC joint switched from the right joint AC being more anterior to the left and switching to a

more anterior position. The clavicles balanced out from the left clavicular head being more

superior than the right clavicular head resting into both the left and the right clavicular heads

becoming more horizontally oriented in their relationships. Three of four of the anterior torso

markers became more balanced horizontally in their nature limiting the amount of torso tilt in the

supine position. All, but one of the seated measurements remained the same when compared to

the standing measurements that were performed at the beginning of this postural assessment.

The last assessment was to document the way that the cranial bones were situated

inferiorly and superiorly to one another or anteriorly or posteriorly to one other along the

midsagittal plane. In both standing and in a supine position, the superior orbital ridge, the

external meatus, the maxillary arch, and the occipital ridge were more superiorly situated than

were the same bones on the left aspect of the client. When assessing the cranial distortions in an

anterior to posterior fashion it was noted that that these distortions existed: the external auditory

meatus, the mastoid process, the external angular process, the maxillary arch and the posterior

ramus of the mandible were all sheared anteriorly to the right. In a supine position, three of the

five measurements remained the same while the posterior ramus of the mandible and the

maxillary arch balanced out horizontally.

Assessment Measures

Prior to any massage treatment protocols being initiated, a full postural assessment was

performed along with gathering subjective data from the patient while qualifying the subjective

data to the objective data. The postural charting was performed to the exact specifications and

reduplicated as taught by Neurosomatic Educators Course, Posturology 101 and 202 (7). There

were a series of nine treatments in total and at the beginning of each session; a full postural

analysis was performed. The measurements were performed with both visual analyses comparing

distortions with the use of the therapists’ index fingers and also with the use of a goniometer to

measure the degree of anterior pelvic tilt. A plum bob was used to qualify if there was a lateral

torso shear present. When measuring the individuals’ posture, the therapist used repeatable

boney landmarks were used assess bilateral superior/inferior and anterior/posterior symmetry. In

all, 84 different measurements were taken in the four positions available: the coronal plane, the

midsagittal standing plane, the supine midsagittal plane, and the seated midsagittal plan at the

beginning of each session. To ensure accuracy, a blue felt tip pen was used to mark the physical

postural chart. When the measurements were level, the blue marker was used to show a

horizontally level line and when the distortion was off, an oblique line would be present. Each

session has a full chart to represent the client’s progress, similarities, and their changes. All of

which can be seen in the blue marker. The AC joint is an easy measurement to show the patient,

most individuals can see the slant and the therapist can reinforce the asymmetry, visually.

Therapeutic Intervention

The author/student performed this case report under the supervision of the clinical supervisor and

under the criteria that was outlined by the Massage Therapy Foundation. Throughout the course

of this study, there were many body work techniques were performed on the client.

The majority of the bodywork techniques that were applied to the client consisted of general

massage strokes, neuromuscular techniques, myofascial release, cranial bone and suture

mobilizations, and joint circumduction including thorough mobilizations of the pelvis and

sacroiliac joint.

The client’s progress was monitored with the use of three assessment measures: the

Bournemouth MSK questionnaire, a Numeric Pain Intensity Scale, and a Numeric Pain Distress

Scale. These were given to the patient prior to starting each massage intervention along with a

three question form that allowed the author to get subjective data from the patient. Getting this

subjective data from the client was due to the fact the client was deaf and ultimately this saved

the practitioner time and got the client on the table in a more timely fashion.

When the author initiated the start of a treatment session, a thorough evaluation of the right knee

was performed to check the mobility of the patella along with the patellar ligament, the pes

anserine region on the medial aspect, the muscles and tendons on lateral aspect, and the posterior

compartment as well. Fascial stretching of the medial aspect of the knee was performed in the

initial part of every therapeutic session to potentially break up any restrictions or adhesions

around the knee joint. According to the book Clinical Appilcations of Neuromuscular

Techniques, if the pain is acute and is localized to the medial or lateral regions of the knee,

ligamentous and or menical damage may be suspected.(9) The muscles attachments of the pes

anserine were treated with deep friction strokes and compressions. The author was able to

analyze each posturolgy chart prior to starting treatment and these findings were discussed with

the client. The distortions that were analyzed lead the practitioner to the areas of the body that

may be attributing to the clients knee condition. For example, the patient had in inflared left

illium and an outflared right illium which appeared to create an external rotation of the right

femur. (10) The author chose to work on this condition by addressing what was pulling the left

illium medially and treating the muscles were contributing to the lateral outflare of the right

illium. The left deep lateral rotators of the hip were treated with deep frictions, cross fiber

frictions, tractions, and compression strokes while the medial rotators of the hip were treated

with longitudinal glides, compressions, frictions, and skin rolling.(11) All regions of the body

were addressed especially the concentric muscle groups that were delineating the patient from

the sagittal, midsagittal, and coronal planes that were charted during the pre- treatment postural

assessment.(12) The gluteal group was treated with deep compressions and frictions, whereas,

the adductor group, the quadriceps group, and the erector spinae group were treated with deep

longitudinal glides releasing any areas that were taut or there were palpable nodules. Multifidus

and rotatores were treated in the concave areas of the scoliotic curve that was present with a

massage star lateral to the spinous processes once the erector group was released.(13) Because of

the ability to pull on the patella and shift the knee cap laterally,(14) the Vastus Lateralis was

treated with longitudinal stroke in a supine and in side lying while the attachments on the knee

were treated with deep compressions, cross fiber frictions and with the fiber frictions.

No two therapeutic interventions were the same. There was a total of 9 sessions performed in

total and each session lasted anywhere from 1 hour to 2 ½ hours. Postural charting and

assessment took 10-15 minutes in the beginning of each session along with the client intake

which could last in excess of 10 minutes. Methods were changed throughout this case study

allowing the postural charting to be the guide to the regions that were being treated. As the

postural distortions changed so did the regions of the body that were addressed. The knee was

always treated in the beginning of each treatment session to get client feedback and to address

the client’s chief complaint. Atlas (C-1) and Axis (C-2) corrections were made in the first two

treatments to level out the cranial base and open up the space that surrounds the brainstem.(15)

No further Atlas/Axis treatments were required as the initial distortions did not return.(16) This

was documented in the remaining 7 postural charts.

Informed Consent

The first consent that was derived was laid out in such a way that the client understood what was

expected of them, what therapist goals were in depth, and exactly how many treatment sessions

would be prior to starting treatment for this case study. There were many factors laid out in the

informed consent write up but another document needed to exist. In order to maintain full

communication with the deaf participant, the Author felt that it was necessary to have any

documents that needed to be given to the client written up prior to the treatment session. The

initial informed consent form did neglect to ask the participant if they would allow or consent to

full publication. After reviewing the initial document, it was pretty clear that if the assignment

were to be published, then a signed document of this release needs to exist. A second consent

form was created and signed by the participant to allow for future publications in the event this

publication was selected.

Timeline

1966 2007 12/07/2014 12/27/2014 1/06/15

Right knee

injury

sustained while

skiing

Client felt a

“pop” in her

knee when it

was

hyperextended

Right knee

became

remarkably sore

after playing

table tennis for

multiple hours

The pain

progression of the

right knee is

getting worse

First maasage

intervention took

place at 7:00 PM

(Student Clinic)

Results

The client reported that there was a significant change to the type of pain that she was

experiencing prior to starting soft tissue treatment. Initially the pain was a radiating type of pain

that went from the medial aspect of her knee and traveled superiorly to the lateral gluteal region.

Subjectively the initial type of pain was a deep, sharp, and the sensation of stinging. After the

last treatment session, the client stated that her knee condition was drastically improved. The

pain subjectively was more of a dull ache around the medial epicondyle of the tibia. The client

was not given a Bournemouth Questionnaire or any one of the two Visual Analog Scales prior to

her first appointment. The client did, however; fill out her intake form and the severity of her

pain was around an 8 on a scale where 10 is of highest intensity.

(Figure 1)

Figure 1 is chart that shows the total sum of the collected points from the Bournemouth

Musculoskeletal Questionnaire over the span of the case study

(Figure 2)

0  10  20  30  40  50  60  

1/9/2015  

1/11/2015  

1/13/2015  

1/15/2015  

1/17/2015  

1/19/2015  

1/21/2015  

1/23/2015  

1/25/2015  

1/27/2015  

1/29/2015  

1/31/2015  

2/2/2015  

2/4/2015  

2/6/2015  

2/8/2015  

Total  Sum  of  points  on  Bournemouth  MSK  Ques6onnaire  

5  

2   1.5   1.5  0.75   0.5  

1.5   2  0  

2  

4  

6  

Point  S

um  

Total  sum  of  points  added  up  on  Numeric  Pain  Intensity  Scale  

 

Series1  

Figure 2, the graph above is the daily point sum of the Visual Analog Scale that was used to

show the overall intensity of the pain the client was experiencing prior to starting any treatment.

This VAS was given to the patient right before the daily postural assessment at the beginning of

each session.

(Figure 3)

Figure 3 was another VAS scale given to the patient daily prior to treatment as well to show how

distressful the pain was from the time of the last treatment to starting the next massage session.

There were significant postural changes that were charted in the postural charts. Many of these

changes appeared to be from the waist down. There was a significant reduction in the amount of

pelvic obliquity, or the amount of inflare or outflare of the ileums bilaterally. The degree to

which the pelvis was anteriorly tilted slightly improved. When measuring the client to rule out a

4  3  

3.5  

1.5  0.75   0.75  

1.75   1.75  0  1  2  3  4  5  

Point  S

um  

Total  sum  of  points  added  up  on  Numeric  Pain  Distress  Scale  

 

Series1  

potential leg length discrepancy, it was charted that the client possibly had a shorter right leg. At

the last treatment sessions postural assessment, the clients measurements had leveled out at the

greater trochanter, the tibial tuberosity, and at the heel pads bilaterally. This lead the author to

believe that there was a functional leg length discrepancy not an anatomical one in nature.(17)

The most remarkable visual change was how the medial aspect of the right knee responded to the

myofascial work that was performed. The initial palpation and assessment showed a remarkable

amount of fascia pitting and adipose congestion around the pes anserine region of the right knee.

By the end of the ninth treatment session, the fascia and the musculature appeared smooth and

the initial redness was gone.

The client tolerated treatment very well and gave the therapist feedback through written

communications, through pre-established hand signals, body language, and through eye contact

letting the practitioner know when the amount of pressure was to intense. The client was

receptive to starting a home care regiment which including stretches aimed at site specific

muscle groups along with a home care treatment program that used a six inch foam roller to

target areas that were contributing to her postural distortions. Foam rollers are used to mimic

myofascial release techniques and have been used by therapists, athletes, and the general public

alike to increase range of motion (ROM) and alleviate pressure points.(18)  The monitoring of

the treatment was done through handouts given to the patient, through email, through texts ,

visual aids, and other forms of written communications.

The author speculates that the treatments that were given had a desirable outcome due to the fact

that the VAS scales and the Bournemouth MSK Questionnaire all showed a decrease in the total

sum throughout the case study.

Discussion

The author was confident about the outcome and the effectiveness of the treatment due to the fact

that the training that he has had over the last 17 months was so rigorous and demanding. The

author was not confident at first about the way that he would effectively be able to lay a clear,

concise, and understandable line of communication to the client while achieving the goals of

being as pain free as possible that the client wanted so badly. The findings that were obtained

were obtained through postural chartings, written forms of communications, and these findings

were used to try and take the extra stressors off of the medial aspect of the knee as this was the

client’s chief complaint. The author understood that when the patella was displaced laterally and

this dysfunction could place concentric tightness around the lateral aspect of the knee but was

unsure if there was an eccentric strain at the medial aspect of the knee.(14) Neither of the two

was ruled out and the treatment progressed with this variable being taken into consideration.

Upon assessing the client’s postural charts, it was evident that there were many areas or regions

of distortions that could be putting additional stressors on the clients’ knee. Initially it was

thought that the client may have an anatomical abnormality that contributed to a shorter right leg.

This was ruled out by a radiograph that was taken in such a way that it can be duplicated

repeatedly, accurately, and has published authenticity.(7) There appears to be not very many

reviewable scientific literature on massage therapy to clients that are diagnosed with OA of the

knee and the only reputable publication that was found was from the IJTMB, but this study was

done on a self care basis.(3)

The results that were obtained appeared to be due to the fact that there was a lot of pre-treatment

planning done ahead of time and a lot of research was done into how to communicate thoroughly

to a client that is deaf and cannot hear directions but instead can understand written and other

forms of non-verbal communications.(19) Other therapists may not experience the same results

because one must be patient and have multiple sources of communication lines established prior

to starting therapeutic interventions. It is the author’s opinion that communication may supersede

clinical application when dealing with clients that are deaf or hearing impaired. The outcome of

the treatment that was performed far exceeded the therapist’s expectations. The therapist looked

at the body as a whole unit and anything that could break down the kinetic chain needed to be

addressed. The client stated that not all of the discomfort was resolved but the fact that client was

able to walk again normally and now has the ability to play long matches of table tennis, she is

very happy. This brought on hope to the client and a sense of relief that was easily recognizable

in the form of body language and through written communications.

While there was an overall decline in the pain score in all three questionnaires that were graphed,

there was a sharp increase in the total score in the second week of the massage intervention

according to the Bournemouth MSK Graph. The total some of accumulated points jumped from

a total of 25 to a total sum of 48.The author believes that this was due to two circumstances.

1. The pain increased due to fact that many of the muscular groups that were treated

experienced techniques that placed initial stresses or strains to the tissue that was being

released. The client did state that her knee “popped” and this generated more discomfort

and uneasiness.

2. The client marked on the Bournemouth MSK Questionnaire opposite to the way that the

Bournemouth was established. 0 is the least amount of pain experienced and 10 is the

highest extent of pain perceived. This could easily be rearranged by the way the patient

skimmed over the initial instructions where 10 was the lowest score and 0 was the highest

score.

Massage therapy programs should incorporate into their curriculum the means of proficiently

communicating and treatment planning with their clients that may be hearing impaired, the

author believes this would result in a more positive and trustworthy therapeutic relationship.

More education and research needs to be done between communities, the massage industry, and

the hearing impaired community to ensure that similar outcomes are achieved regularly.

Patient Client Perspective

The client was asked to provide the practitioner a detailed account of their experience. The client

had this to say about her experience: “I thanked Frank Maella of CNS for selecting me to

participate in this 5 week study”. ”After seeing the radiographs of my pelvis and knee bones, it

makes sense to me that there are many contributing factors to my knee pain”. There is no more

limp to my gait, and I can walk slowly, cautiously, and happily”. “There is no more limping”.

“Although my right knee, is not 100 percent pain-free, I m happy that I can walk more on a daily

basis”.

References:

1. "Knee Pain." My Virtual Medical Centre. 26 Sept. 2013. Web. 1 Feb. 2015. <http://www.myvmc.com/diseases/knee-pain/>.

2. "AAPM Facts and Figures on Pain." The American Academy of Pain and Medicine. Web. 1 Feb. 2015. <http://www.painmed.org/patientcenter/facts_on_pain.aspx>.

3. Atkins ThD, RN, Dorothea V, and David A Eichler PhD. "The Effects of Self-Massage on Osteoarthritis of the Knee: A Randomized, Controlled Trial." International Journal of Therapeutic Massage & Bodywork 6.1 (2013): 4. International Journal of Therapeutic Massage & Bodywork. International Journal of Therapeutic Massage & Bodywork. Web. 1 Feb. 2015. <http://ijtmb.org/index.php/ijtmb/article/view/119/243>.

4. Shida, Yukisha, Seiko Shida, Shiro Suzuki, Hiromi Murakami, and Nobuo Yuza. "Injuries and Systemic Disorders of Table Tennis Players: Results of a Survey." International Journal of Table Tennis Sciences 1 (1992): 111-16. Web. 13 Feb. 2015. <http://www.ittf.com/ittf_science/SSCenter/docs/199208019 - Yukihisa - Table tennis.pdf>.

5. "Guidelines for Hearing Impaired Patients." Medical Group Management Association. Web. 15 Feb. 2015. <http://www.mgma.com/government-affairs/issues-overview/compliance/guidelines-for-hearing-impaired-patients>.

6. JH Smith MD, R., Shearer, A., S Hildebrand, PhD, M., & Van Camp, PhD, G. (2014). Deafness and Hereditary Hearing Loss Overview. GeneReviews®. Retrieved January 31, 2015, from http://www.ncbi.nlm.nih.gov/books/NBK1434/

7. Knutson, G. (2005, July 20). Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: Prevalence, magnitude, effects and clinical significance. Retrieved January 31, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232860/

8. Clark, R, and Jones, T. The Posturology Handbook. Vol. 1. Clearwater: Neurosomatic Educators, 203. 23-173. Print.

9. Delaney, Judith, and Leon Chaitow. "The Knee." Clinical Applications of Neuromuscular Techniques: The Lower Body. 2nd ed. Vol. 2. New York: Churchill Livingstone Elsevier, 2011. 468. Print.

10. Delaney, Judith, and Leon Chaitow. "The Pelvis." Clinical Applications of Neuromuscular Techniques: The Lower Body. 2nd ed. Vol. 2. New York: Churchill Livingstone Elsevier, 2011. 338. Print.

11. Salvo, Susan. "Massage Techniques, Joint Mobilizations, and Stretches." Massage Therapy: Principles and Practice. 4th ed. Vol. 1. St. Louis: Elsevier Sunders, 2012. 140-157. Print.

12. Delaney, Judith, and Leon Chaitow. "Posture, acture, and Balance." Clinical Applications of Neuromuscular Techniques: The Lower Body. 2nd ed. Vol. 2. New York: Churchill Livingstone Elsevier, 2011. 27-40. Print.

13. Delaney, Judith, and Leon Chaitow. "The Thorax." Clinical Applications of Neuromuscular Techniques: The Upper Body. 2nd ed. Vol. 1. New York: Churchill Livingstone Elsevier, 2011. 559-566. Print.

14. "PATELLAR DISLOCATION (DISLOCATED KNEE CAP) AND PATELLAR INSTABILITY." Knee Pain Info. Web. 14 Feb. 2015. <http://www.kneepaininfo.com/kneepatellardislocation.html>.

15. Schuenke, Michael, Erik Schulte, and Udo Schumacher. "Trunk Wall: Bones, Ligaments, and Joints." Thieme Atlas of Anatomy: General Anatomy and Musculoskeletal System. 1st ed. Vol. 1. Stuttgart, New York: Everbest, 2010. 102. Print.

16. Clark, Randall, Tracy Jones, and Paul St. John. Neurosomatic Approaches to the Axial System. 3rd ed. Vol. 1. Clearwater: Neurosomatic Educators, 2014. 127-138. Print.

17. Kennedy BEng (Mech), CPed, Séamus. "Leg-Length Discrepancies: Diagnosis and Treatment." Oanp.com The O&P Edge. 1 Jan. 2005. Web. 14 Feb. 2015. <http://www.oandp.com/articles/2005-08_07.asp>.

18. Sullivan, KM, DB Silvey, DC Button, and DG Behm. "Roller-massager Application to the Hamstrings Increases Sit-and-reach Range of Motion within Five to Ten Seconds without Performance Impairments." International Journal of Sports Physical Therapy 8.3 (2013): 228-36. Print.

19. "Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings."Americans with Disabilities Act. US Department of Justice, 1 Jan. 2003. Web. 14 Feb. 2015. <http://www.ada.gov/hospcombrprt.pdf>.