2. Tenderness indicates injury to anterior portion of the internal semilunar cartilage.

3. Usual point of tenderness after strain of the internal lateral ligament. Lig. indicates the position of the longest fibres of the internal lateral ligament.

If the internal lateral ligament has been torn, or if, in addition, the internal semilunar cartilage has slipped, treatment should follow on usual lines; but it should be noted that the internal lateral ligament has broad attachment both above and below, the deep fibres being comparatively short and the superficial longer (see Fig. 91, Lig.). Local treatment should therefore be directed to a wide area, extending from a considerable distance above the lower end of the condyle of the femur to the shaft of the tibia. The third exercise mentioned above must be omitted.

After massage for reflex effect, to remove spasm, to assist the circulation, and for hastening the absorption of local effusion, relaxed movement should be administered with the usual precautions; but particular care should be taken not to allow any tendency of the tibia to separate from the inner condyle of the femur. In other words, no "gaping" must be allowed on the inner side. The safest position to conduct treatment is to rest the limb on the masseur's lap (see Figs. 32 and 33). The one test of successful treatment is the progressive absorption of fluid. If it is noticed to have increased one day, or even if it is found not to have decreased, then treatment has been excessive. As soon as relaxed movement to a right angle has been reached, exercises without weight may be prescribed (see Chapter XX (Re-Education In Walking).). Whether the sole and heel of the boot are built up on the inner side or not, the patient must be instructed to walk correctly, fair heel and toe, to keep the toes straight, and to throw all weight on the outer side of the foot.

In all recent knee injuries special care must be taken that relaxed movements are absolutely painless, are very minute in amplitude at the outset, and that the leg is never treated as a pump-handle. From the outset the patient should be taught to exercise the quadriceps, even though the limb is fixed on a back-splint and no movement is allowed.

A common cause of "water on the knee" is the nipping of the retro-patellar pad of fat. In this case only complete extension must be avoided, as pain over the position shown in Fig. 91 (1), on extension, is the sign by which we recognise the condition. It is due to the "nipping," and every care must be taken to avoid repetition of the accident. This injunction should be unnecessary if the laws for administering relaxed mobilisation are adhered to, as any movement administered must be painless. Some, however, seem to think that because extension is painful it is therefore their duty to work away at it. It is in reality the ideal way to prolong and augment the evil they are trying to cure.

When treating any case of synovitis of the knee we have, perhaps, one of the best examples in the whole body of the difference between prescribing movement and function. There is all the difference in the world between allowing a patient to swing his leg and to use it for walking. It is the weight-bearing function of the lower limb that is the last thing we can restore after injury. Everything else may be perfect long before use is possible; but the day when use can be permitted will arrive far more quickly, if the other functions and activities are maintained intact than if they are neglected.

Dislocations of the ankle are almost always fracture-dislocations. As regards their treatment, nothing further need be added to what has been said on the subject of fractures near the ankle-joint (see p. 170). The great dread that should always be present in the mind of anyone treating these injuries is the subsequent development of flat-foot. Exercises for the muscles that help support the arch should therefore be given and prescribed from the outset, and particularly the short muscles of the foot. Re-education in walking should always occupy a prominent position in the treatment of these cases.

The same applies when treating all sprains of the foot, and treatment should follow exactly the course mapped out for a sprained ankle. Massage should include at least the whole of the leg, and also of the thigh if the injury is severe. The subsequent re-education in walking is, of course, all-important.