A 23 year old active male patient presented to the clinic complaining of pain in the anteromedial region of his right knee which commenced 2- 3 weeks ago. The pain could be reproduced with active standing squats felt when going down into the squat position increasing as the patient deepened into greater knee flexion. The pain is only noted when the knee joint is ‘on load’, there is no complaint of pain with passive knee flexion or knee flexion actively produced in single leg stance or in supine. He also complained of stiffness in the thoracic region and subjectively notes that he feels stiff with both seated rotation and supine lumbar rolls though there is no pain elicited with either of these movements. The knee pain was the main concern until 2 days ago when doing power cleans during a CrossFit session he felt a pinch in the right groin/hip flexor during actions where the pelvis was in an anterior tilt.
He attends the gym 4 -5 times per week and focuses on Cross fit style training. The CrossFit prescription is performing “functional movements that are constantly varied at high intensity.” CrossFit is a core strength and conditioning program. The CrossFit program is designed to elicit as broad an adaptational response as possible. CrossFit is not a specialized fitness program but a deliberate attempt to optimize physical competence in each of ten recognized fitness domains. They are as follows: Cardiovascular and Respiratory Endurance, Stamina, Strength, Flexibility, Power, Speed, Coordination, Agility, Balance, Accuracy. The CrossFit Program was developed to enhance an individuals competency at all physical tasks. 
The patient also has occasional bilateral shoulders pain with left greater than the right, this can be provoked with resistance training in varying upper limb movements including shoulder press, incline bench press, and single dumbbell overhead press. This is episodic and abates in 2 to 3 days if left untreated and non-compromised with resistance work to the region. The patient is a working physiotherapist so has a grounding in education for exercise prescription, injury prevention and structural and functional alignment of the body. He could demonstrate both good form and function during his assessment and confirms ‘best posture’ during his functional, active movement patterns.
A study of Injury Rate and Patterns Among CrossFit Athletes was conducted and documented by Sage Journals whereby 486 CrossFit participants completed the survey, and 386 met the inclusion criteria. The overall injury rate was determined to be 19.4% (75/386). Males (53/231) were injured more frequently than females (21/150; P =.03). Across all exercises, injury rates were significantly different (P <.001), with shoulder (21/84), low back (12/84), and knee (11/84) being the most commonly injured overall. The shoulder was most commonly injured in gymnastic movements, and the low back was most commonly injured in power lifting movements. Most participants did not report prior injury (72/89; P <.001) or discomfort in the area (58/88; P <.001). Last, the injury rate was significantly decreased with trainer involvement (P =.028). 
The literature above was valuable because it provides confirmation regarding the injuries described by my patient.
Assessment included full strength testing using of the neurolymphatic reflexes. Results were that the patient was strong in both functional back lines as represented in isometric strength of the latissimus dorsi and strong in hip flexion, knee flexion and ankle dorsiflexion. His ankle range of movement was free though limited to less than 5-7 %. He had poor range of pelvic rotation greater stiffness noted with the bent knees falling passively to the left. He could illicit the notable painful symptom in the knee during testing of a squat, we did not assess for pain, strength or stability in a ‘pistol’ squat or one legged squat due to the fear of pain and aggravation in the region of the knee.
Treatment consisted of stimulation of the various Chapmans Reflex points for the diaphragm and included 10 diaphragmatic breaths, psoas, gluteus maximus at the direct region only, the lateral sling on the ASIS points, the thoracic defense points, his rectus abdominus, internal and external obliques, deep neck flexor and SCM component and concluded with the jaw. On repeat testing we found that the calf ROM was still poor so I added activation of the neurolymphatic points for the calves and tibialis anterior. Other treatment consisted of Lumbar muscle energy technique and fixation of the lower limb into rotation in both directions working into the reduced range first, completing the initial treatment with stretches to the gluteal/hip rotators and quadriceps/hip flexor groups.
Upon reassessment of strength and movement into the squat the client was pain free and noted considerable improved stability and strength. We then added the single pistol squat and managed 99% pain free. The patient also noted that standing body twisting (described by him as lumbar rotation) felt looser and moved with greater freedom.
Advice – daily facilitation of the Chapmans Reflexes including diaphragm (plus breathing), psoas, gluteus maximus, ASIS, thoracic region, SCM, jaw and abdominal regions. Either one can prescribe the Canadian remedies if they recognize the treatment is right for you. The full activations taking no longer than five minutes in duration. He was also to stretch the hips and gluteal region and continue with squats being monitored by pain response.
Follow up 48 hours later found that the ‘pistol’ squats had returned to some pain but the full squats and freedom in the back had remained pain free and loose.
Paula Nutting has over 30 years’ experience in health and massage, specialising in musculoskeletal therapy since 2007. She has lectured on various diploma and degree subjects, as well as coordinated and designed units of study for the vocational and higher education arenas.
A published expert in her field – including her own book series, plus article contributions in various esteemed journals and text books – she has presented courses, seminars and workshops within the local and international massage circuit in areas of musculoskeletal dysfunction, instability of the core, acute and chronic muscle imbalance and many muscle and joint techniques. She also owns and operates a successful massage therapy clinic in the north of Brisbane.
Paula has served on the Australian Association of Massage Therapists (AAMT), Queensland Branch, as Vice President, Director and President. She was also Chair on the Ethics Committee and is currently Chair of the Education Committee. She has been involved in the National Health Practitioners of Canada/AAMT governance and strategic planning, and is a past Director on the Board of the Australian Massage Research Foundation (AMRF).
Details on available books, self-therapy videos, courses and special events can be found at https://www.yourmusculoskeletalspecialist.com/
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