As recognition of massage therapy’s importance within health care increases, so does the demand for educated and skilled practitioners. The widespread acceptance of therapeutic massage as a viable pain-relieving option leads many sufferers to see a massage therapist before visiting their physician. Since some orthopedic conditions can be aggravated by therapeutic massage, identification of and referral for these conditions is a testament to a therapist’s competency.

Anterior knee pain presents an ideal opportunity for employing condition differentiation skills. The body’s initial weight-bearing joint is stabilized most by ligaments, making the knee highly susceptible to injury. Using client history, observatory, palpatory and manual resistive testing skills, a therapist can confidently isolate injuries conflicting with massage and avoid manipulating a knee requiring medical attention.

Adding some simple orthopedic tests to a massage therapist’s evaluation can greatly enhance their assessment skills. The descriptions of specialized manual resistive tests for anterior knee pain is not intended to teach diagnosis, but rather, to help a therapist identify possible conditions requiring a referral to another healthcare professional; such as a physician, orthopedist, chiropractor or physical therapist.

A massage therapist increases his/her value exponentially, by knowing when to refer out. According to Benny Vaughn’s video, Functional Assessment Skills for Massage Therapists, “Knowing when NOT TO is just as important as knowing when TO.” Following a knee injury, a foot blue in color and cool to the touch is indicative of a dislocation. Signifying a serious injury to the foot’s blood vessels, this condition should be considered an emergency and professional help must be sought immediately.

When addressing anterior knee pain, the following injured structures mandate additional professional evaluation:

  • Cruciate Ligaments -The cruciate ligaments stabilize the knee by crossing over each other in an X formation, from the upper to lower leg. Located in the center of the knee joint, the anterior cruciate ligament (ACL) is the major stabilizing ligament of the knee, connecting the femur to the tibia. The ACL prevents anterior displacement of the tibia, which would cause a knee to buckle. Of the four major ligaments of the knee, the ACL injury is the most common knee ligament injury.

The posterior cruciate ligament (PCL) also connects the femur to the tibia. The PCL prevents posterior displacement of the tibia. While this ligament is stronger than the ACL, and less frequently injured, it is still important to test for when faced with mysterious knee pain.

  • Collateral Ligaments – The collateral ligaments are the ligaments on either side of the knee joint. On the outer aspect of the knee is the lateral collateral ligament (LCL), and on the inner aspect is the medial collateral ligament (MCL). The LCL stretches from a tubercle on the femur’s lateral condyle to the lateral surface of the head of the fibula, while the MCL connects the femur’s medial epicondyle to the medial tibial condyle. At its midpoint, the fibers of the MCL are firmly attached to the medial meniscus. Damage to the collateral ligaments typically involves significant force, such as a blow to the side of the knee during contact sports or a bad fall.
  • Meniscus – There are two C-shaped pieces of cartilage in the knee joint, the lateral meniscus and the medial meniscus. Knee stabilization, joint lubrication and shock absorption are the three primary functions of the menisci.
  • Chondromalacia patella – Patello-femoral syndrome indicates pain between the femur and patella. The patella is designed to glide smoothly over the femur, however, poor alignment causes inflammation and pain, indicating chondromalacia patella. Chondromalacia patella is the most common source of chronic knee pain, causing pathological changes and possibly leading to deterioration of the articular surface of the patella.

Manual resistive tests can give the massage therapist a substantial amount of information regarding the functioning of these knee components. A painful response from a client indicates a serious injury, necessitating a referral, as does a positive indication for any of the following tests described by Vaughn:

  1. Lachman Test – The Lachman Test stresses the ACL to detect anterior tibial displacement. Performed with the client supine, the therapist grasps the distal portion of the thigh and the proximal portion of the lower leg to create anterior-posterior shifting. This shifting at the knee joint is from pulling the proximal tibia anteriorly, then pushing it posteriorly. Make certain there is a slight bit of flexion in the knee to create some hamstring slack, as hamstring tension can interfere with this test. A positive test is assumed when the movement feels “mushy” (soft endpoint), has a gapping sensation, or when excessive glide is noted. A positive test suggests ACL damage and requires a referral.
  2. The Drawer Tests – The Anterior Drawer Test stresses the ACL and will detect its weakness. Performed with the client supine, the knee is flexed at a 45-degree angle with the foot flat on the table. By sitting on or just past the foot, the therapist stabilizes the leg to prevent its movement. The therapist grasps the proximal portion of the tibia with both hands and yanks towards him/herself.

The Posterior Drawer Test is performed immediately following the Anterior Drawer Test’s forward tibia yank. The Posterior Drawer Test stresses the PCL, and is done by pushing the tibia back towards the client’s thigh. Positive Drawer Tests occur when the movement feels mushy (soft endpoint), has a gapping sensation or when excessive movement (anteriorly or posteriorly) is noted. A positive test suggests ACL or PCL damage and requires a referral.

  1. Valgus Stress Test – The Valgus Stress Test puts pressure on the medial collateral ligament. The client lays supine with extended legs. While supporting the thigh and stabilizing the leg with a firm distal leg grasp, the therapist applies pressure to the lateral aspect of the knee by pushing medially. The knee is slightly flexed to avoid tightened hamstring muscles, which are capable of interfering with the accuracy of this test. The creation of pain or a widened joint space indicates a positive test and requires referral for further evaluation.
  2. Varus Stress Test – The Varus Stress Test puts pressure on the lateral collateral ligament. Positioning is identical to the Valgus Stress Test except pressure is applied to the medial aspect of the knee by pushing laterally. The creation of pain or a widened joint space indicates a positive test and requires referral for further evaluation.
  3. Apley Compression Test – The Apley Compression Test puts pressure on the meniscal cartilage. The client lies prone with the leg at a 90-degree angle to the thigh. The therapist grasps the plantar side of the foot and pushes down into the table. If there is no response, this test can be exaggerated by adding internal and external rotation of the tibia to the downward compression. Because compression traps the meniscus, pain indicates possible meniscal cartilage involvement. When rotation is added to the compression, pain can indicate injury to the meniscus, knee ligaments or both.
  4. Apley Distraction Test – The Apley Distraction Test puts traction on the tibia, decompressing any pressure on the meniscus. The client lies prone with the leg at a 90-degree angle to the thigh. The therapist stabilizes the thigh by using the weight of their leg to prevent movement. Hold the ankle with both hands and pull straight up towards the ceiling, relieving any pressure on the meniscus.

If the Apley Compression Test elicits pain, and the Apley Distraction Test provides pain relief, then the likelihood of meniscal injury is high. If the reverse is true, where pain exists on distraction but not compression, then the collateral ligaments may be injured. In either case, a positive finding suggesting meniscal injury or collateral ligament injury necessitates a referral.

  1. Patellofemoral Compression Test – The Patellofemoral Compression Test puts pressure on the patella. The client sits on the table with the lower legs hanging over the side. The therapist compresses the patella while the client flexes and extends his/her leg within a 35-degree range. The flexion and extension can be done actively (by the client), or passively (by the therapist). A positive test elicits pain or discomfort, indicating patello-femoral syndrome and a subsequent referral.
  2. Clarke’s Sign – Clarke’s Sign is a test designed to identify the presence of chondromalacia patella and can only be done once. A positive test will cause a significant amount of discomfort or pain, and most clients will not allow for its repeat. The patient lies prone. With the web of the hand the therapist presses the patella down towards the feet in an inferior direction. The client is then asked to contract the quadriceps muscle as the therapist continues applying force. The test is positive if the patient cannot complete the contraction without pain, or has a great deal of apprehension about tightening their quads. A positive Clarke’s sign requires a referral; however, quadriceps, hamstring and adductor massage may reduce the pain in the meantime.

Incorporating these manual resistive tests into a massage therapist’s skill set requires practice. It is highly recommended to rehearse new maneuvers on uninjured volunteers before using them in a therapeutic setting. While the descriptions provided act as a guide, live training or repeated video viewing (such as Vaughn’s video) provides complimentary visual support. As a therapist’s comfort level for performing the preceding tests rises, so will his/her confidence in safely working with anterior knee pain.


Functional Assessment Skills for Massage Therapists. Writ. Benny Vaughn. Benny Vaughn Associates. 1997.