Knee Joint -Orthopedic 475

Learning Objectives Identify essential parts of knee anatomy Recognize different knee pathology Describe abnormal alignment of the knee and its relation to knee injuries Evaluate knee abnormalities using specific tests Recognize indication for total knee replacement surgery Practice PT treatment for miniscus tear Practice ACL and PCL PT treatment Practice Total knee PT treatment

THE KNEE one of the largest joints in the body especially important in the function of human bipedal locomotion supporting the body during static and dynamic activities. Statically Statically, in the closed kinematics chain, the knee works with the ankle and hip to support the body weight in the erect position

Dynamically the knee must act in concert with the lower kinetic chain structures to efficiently direct motor forces through to the ground. Lastly the knee also performs the role of positioning the foot in space during open kinetic chain activities (walking).

Consist of two joints within same capsule 1. Tibial-femoral articulation and the 2. Patellar-Femoral articulation. Two additional joints superior and inferior tibial-fibular articulation.

menisci Two asymmetrical fibrocartilaginous joint discs called menisci are located on the tibial condyle Two asymmetrical fibrocartilaginous joint discs called menisci are located on the tibial condyle Medial meniscus is a semicircle, lateral meniscus is four-fifths of a ring Medial meniscus is a semicircle, lateral meniscus is four-fifths of a ring The wedge shaped menisci increase the radius of the curvature of the tibial condyles and therefore Joint congruity The wedge shaped menisci increase the radius of the curvature of the tibial condyles and therefore Joint congruity The medial meniscus is more firmly attached to the tibia The medial meniscus is more firmly attached to the tibia

LIGAMENTOUS COMPONENTS Medial collateral (tibial collateral) Medial collateral (tibial collateral) Lateral collateral (Fibular collateral) Lateral collateral (Fibular collateral) Anterior Cruciate (ACL) Anterior Cruciate (ACL) Posterior Cruciate (PCL) Posterior Cruciate (PCL)

Dr. salameh al dajah Ortho KNEE INJURY AND PATHOLOGY Ligamentous Ligamentous

. Meniscus

Fracture Tibial plateau fracture Tibial plateau fracture Intera-articular fracture Intera-articular fracture Patella fracture Patella fracture Distal femur fracture Distal femur fracture

. Pathology Osteochondritis dissecans - partial or complete detachment of a fragment of cartilage and subchondral bone Osteochondritis dissecans - partial or complete detachment of a fragment of cartilage and subchondral bone Chondromalicia patella Chondromalicia patella Osgood-Schlatter - partial separation of the tibial tuberosity Osgood-Schlatter - partial separation of the tibial tuberosity Geno varus/Valgus Geno varus/Valgus

DJD or RA DJD or RA Recurrent dislocation of the patella Recurrent dislocation of the patella Baker’s Cyst Baker’s Cyst SWELLING: SWELLING: 1. Immediate (1 - 2 hours post injury) consists of blood, indicates ligament tear, osteochondral fracture, or peripheral meniscus tear (doughy, taut) 1. Immediate (1 - 2 hours post injury) consists of blood, indicates ligament tear, osteochondral fracture, or peripheral meniscus tear (doughy, taut) 2.Synovial swelling ( hours) indicates joint irritation (boggy feeling) 2.Synovial swelling ( hours) indicates joint irritation (boggy feeling) 3. Infections: Purulent (pus) red, hot, infection 3. Infections: Purulent (pus) red, hot, infection

SPECIAL TESTS Tests for Ligamentous Integrity Tests for Ligamentous Integrity Valgus Stress Test (Lateral ligament tear) Valgus Stress Test (Lateral ligament tear) Varus Stress Test (medial ligament tear) Varus Stress Test (medial ligament tear) Lachman Test (Anterior Cruciate ligament) Lachman Test (Anterior Cruciate ligament)

Dr. salameh al dajah Ortho 2014

Chondromalecia Patella Weakness of vastus medialis Clark’s sign test (pull the patella down ward toward the foot and then ask patient to tighten the quadreceps) Treated by vastus medialis strengthening exercise

Drawer Sign Test (anterior draw for anterior cruciate stability) Drawer Sign Test (anterior draw for anterior cruciate stability) Posterior Sign test (for posterior cruciate stability) Posterior Sign test (for posterior cruciate stability)

Dr. salameh al dajah Ortho 2014

Meniscal Pathology Tests for Meniscal Pathology (Notice pain or tenderness on the lateral surfaces of the knee, popping, snapping with movement, and inability to fully extend the knee (locking)) Tests for Meniscal Pathology (Notice pain or tenderness on the lateral surfaces of the knee, popping, snapping with movement, and inability to fully extend the knee (locking))

Apley's Compression Test Apley's Compression Test Apley's Distraction Test Apley's Distraction Test McMurray test McMurray test

Dr. salameh al dajah Ortho 2014 Aply’s Test

Dr. salameh al dajah Ortho 2014 McMurray Test: Tibial IR and Tibial ER

Dr. salameh al dajah Ortho 2014 Tests for Patellofemoral Pathology Apprehension test for the patella to assess for recurrent dislocation Apprehension test for the patella to assess for recurrent dislocation

Dr. salameh al dajah Ortho 2014 Q Angle or Patellar Femoral Angle

Total knee Replacement (TKR) Knee replacement usually done for main reason which is to relieve pain related to Knee OA

Dr. salameh al dajah Ortho 2014 Total knee replacement

Dr. salameh al dajah Ortho 2014 CPM machine

Total knee physical therapy procedure 1. MD order to start PT, the order should include the weight bearing status, the rate of the advancement for ROM when CPM machine used, and the need to use knee brace when patient standing. 1. MD order to start PT, the order should include the weight bearing status, the rate of the advancement for ROM when CPM machine used, and the need to use knee brace when patient standing. 2. Isometric strengthening exercise for all the lower extremity muscles 2. Isometric strengthening exercise for all the lower extremity muscles 3. Active assistive ROM to the knee joint 3. Active assistive ROM to the knee joint 4. Active ROM to the ankle joint 4. Active ROM to the ankle joint 5. SLR exercise after the full weight bearing order received from the MD 5. SLR exercise after the full weight bearing order received from the MD 6. Bed mobility and bed side sitting and standing on FWW or Parallel bars 6. Bed mobility and bed side sitting and standing on FWW or Parallel bars

7. Gait training and ambulation with FWW 7. Gait training and ambulation with FWW 8. The goal for ROM is to reach 0-90 degree for functional purposes 8. The goal for ROM is to reach 0-90 degree for functional purposes 9. Rehabilitation course to include more aggressive ROM and all of the knee muscles strengthening exercises 9. Rehabilitation course to include more aggressive ROM and all of the knee muscles strengthening exercises 10. Advance to ambulate with a cane or one elbow crutch 10. Advance to ambulate with a cane or one elbow crutch 11. In the acute case patient may required to apply ice pack to control post surgery swelling 11. In the acute case patient may required to apply ice pack to control post surgery swelling 12. Home exercise and family education 12. Home exercise and family education

Special strengthening exercise Special quadriceps exercises Special quadriceps exercises Each muscle of the quad has its own strengthening exercise Each muscle of the quad has its own strengthening exercise Special hamstring exercises Special hamstring exercises You need to separate between hamstring and gluteal maximums strengthening exercise You need to separate between hamstring and gluteal maximums strengthening exercise