1. Copyright 2005 Lippincott Williams & Wilkins Chapter 21 The Knee

2. Copyright 2005 Lippincott Williams & Wilkins Anatomy

3. Copyright 2005 Lippincott Williams & Wilkins Subdivisions of Synovial Cavity

4. Copyright 2005 Lippincott Williams & Wilkins Myology Anterior  Rectus femoris  Vastus lateralis  Vastus intermedius  Vastus medialis Medially  Gracilis  Adductor longus, brevis, magnus Posterior  Biceps femoris  Semitendinosus  Semimembranosus Laterally  TFL/ITB (affected by gluteus maximus, etc.)

5. Copyright 2005 Lippincott Williams & Wilkins Kinematics – Tibiofemoral Joint ROM Flexion/extension 0-140 degrees Extension – Limited by ACL and PCL, posterior capsule, anterior horns of menisci. Flexion – Limited by cruciate ligaments and posterior horns of menisci.

6. Copyright 2005 Lippincott Williams & Wilkins Kinematics – Patellofemoral Joint During Flexion 0–90 degrees – Contact area is more central portion of patella. 135 degrees – Medial facet contacts medial femoral condyle. Ideal static – Patella positioned slightly laterally–Remains in trochlear groove until 90 degrees. Extension – Patella moves superiorly along line of femur if VMO and VL are in balance.

7. Copyright 2005 Lippincott Williams & Wilkins Rolling with Anterior, Anterior/Posterior Glide

8. Copyright 2005 Lippincott Williams & Wilkins Anatomic Impairments Genu Valgum – Femur descends obliquely in a medial direction (normal 5–10 degrees). – Greater load on lateral compartment. – Associated with coxa varum at hip. Genu Varum – Angulation of femur and tibia is 0 or laterally orientated. – Increases load on medial compartment. – Associated with coxa valgum.

9. Copyright 2005 Lippincott Williams & Wilkins Genu Valgum/Varum

10. Copyright 2005 Lippincott Williams & Wilkins Examination and Evaluation Components of Knee Assessment Pelvis/hip – Muscle length, alignment, performance, capsule mobility Knee – ROM, ligament stability, meniscal tests, extension overpressure response, palpation Patella – Orientation, VMO/VL relationship, lateral retinacular tightness Tibia – Torsion, tibial varum/valgum, rotation Foot – Pronation/supination, rear/forefoot alignment

11. Copyright 2005 Lippincott Williams & Wilkins Muscle Performance Muscles commonly tested  Medial and lateral hamstrings  Quadriceps  Gluteal muscles  Iliopsoas  Gastroc-soleus  Hip rotators  Posterior tibialis

12. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Physiologic Impairments Mobility Impairment – Hypomobility  Glide and joint distraction techniques  Patellar mobilization  Quadriceps, hamstring stretches  Abdominal support

13. Copyright 2005 Lippincott Williams & Wilkins Quadriceps Stretch for Hypermobility

14. Copyright 2005 Lippincott Williams & Wilkins Hypermobility  Associated with patellar instability  At risk for ACL injury  Clinical signs – Knee recurvatum and subtalar pronation Treatment  Postural retraining of lower extremity and lumbopelvic region  Co-contraction of lower extremities (high reps-low resistance)

15. Copyright 2005 Lippincott Williams & Wilkins Impaired Muscle Performance Treatment – Strength, endurance, and power training activities. Neurologic Causes:  Lumbar spine injury or disease  MS  Parkinson’s disease

16. Copyright 2005 Lippincott Williams & Wilkins Muscular Strain  Hamstrings and quads most commonly injured. Treatment:  Bleeding control followed by progressive mobility and strengthening.  Plyometrics if within patient’s functional abilities and goals.

17. Copyright 2005 Lippincott Williams & Wilkins Disuse and Deconditioning  Occurs primarily at quadriceps. Treatment:  Strengthening activities for the quadriceps.  Focus on primary cause of disuse.

18. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise for Common Diagnoses – Ligament Injuries ACL  Usually occurs due to hyperextension, deceleration, rotational injury.  Frequently associated with injuries to MCL. Treatment:  Avoid resisted open chain (OC) exercises.  Closed chain (CC) exercises including deceleration, cutting maneuvers, lateral movements, resisted rotational movements, and activities on unstable surfaces.

19. Copyright 2005 Lippincott Williams & Wilkins PCL  Most often a blow to anterior aspect of tibia.  Occasionally, hyperflexion/extension or varus/valgus injury. Treatment:  Avoid open chain exercises.  Closed chain exercises are used.

20. Copyright 2005 Lippincott Williams & Wilkins MCL  Usually torn as a result of valgus stress by a lateral blow or forced abduction of the tibia (skiing). LCL  Much less common than MCL injuries.  Commonly results from hyperextension varus stress. Treatment:  Loading must occur in frontal and transverse planes.

21. Copyright 2005 Lippincott Williams & Wilkins MCL Exercises

22. Copyright 2005 Lippincott Williams & Wilkins Treatment of Ligament Injuries  Pain can be managed with physical agents, mechanical and electrotherapeutic modalities.  Therapeutic exercise (AROM, PROM).  Joint mobilization may be necessary.  Home program may include exercises to increase ROM and neuromuscular re-education.

23. Copyright 2005 Lippincott Williams & Wilkins Treatment of Ligament Injuries (cont.)  Acute  Aquatics is excellent for:  Mobility, gait, initiating balance, walking, physiologic stretching, leg kicks, toe raises, single leg balance, and squats.

24. Copyright 2005 Lippincott Williams & Wilkins Progression  Continuation training and progressing to non-device-assisted exercises.  Land-based CC exercises.

25. Copyright 2005 Lippincott Williams & Wilkins Late Stage  Resisted OC exercises.  Functional specific drills.

26. Copyright 2005 Lippincott Williams & Wilkins Fractures 1.Patellar fracture 2.Distal femur fracture 3.Tibial plateau fracture 4.Treatment  Surgically fixated – AROM/PROM exercises for flexion and extension.  Quadriceps and hamstring setting exercises.  Weight-bearing CC exercises – Based on healing and NM control.

27. Copyright 2005 Lippincott Williams & Wilkins Menisci Injuries  Partial meniscectomy  Most often injured traumatically  Degenerative tears Treatment:  Weight-bearing through large ROM should be avoided.  Partial weight-bearing as tolerated is permitted.  Progression is dictated by procedure.

28. Copyright 2005 Lippincott Williams & Wilkins Self-Management Techniques

29. Copyright 2005 Lippincott Williams & Wilkins Surgical Procedures 1.Osteotomy – Treatment is guided by requirements of a healthy joint. Restoring ROM is crucial to ensure proper distribution of loads. 2.Total knee arthroplasty – Patellar instability can be an issue in 5–30% of TKAs. Limitations at hip and ankle can profoundly affect post-op function.

30. Copyright 2005 Lippincott Williams & Wilkins Tendinopathies Patellar Tendinopathy Treatment  Focuses on patellar tendon’s role in decelerating knee flexion during functional activities.  Stretching exercises are combined with eccentric quadriceps contractions progressing in velocity to match that of daily activities.  OC or CC can be used; however, CC is preferred.

31. Copyright 2005 Lippincott Williams & Wilkins Iliotibial Band Syndrome Treatment:  Postural education  Exercises for underlying impairments (e.g., hip rotator weakness)  Stretching of hip and knee musculature

32. Copyright 2005 Lippincott Williams & Wilkins Patellofemoral Pain Syndrome (PFPS)  Aggravated by knee extension activities.  For example, ascending/descending stairs, squatting, rising from chair, jumping.  Can be caused by frank dislocation, commonly associated with hypermobility of patella, tenderness of patellar borders and femoral condyles, shallow intercondylar groove.

33. Copyright 2005 Lippincott Williams & Wilkins PFPS (cont.)  Overuse.  Poor tracking of patella (shape of osseus surfaces or muscle imbalance).  Q-angle greater in those with PFPS (excessive pronation of foot?)  Greater degree of lateral patellar tilt.  Muscle imbalance (VMO:VL).

34. Copyright 2005 Lippincott Williams & Wilkins PFPS Treatment  General quadriceps strengthening.  All exercises to be performed in pain-free ROM.  Exercises can be CC or OC.  Exercise difficulty is dictated by total target ROM.  Eccentric control exercises are commonly prescribed.  Patellar taping can be helpful.

35. Copyright 2005 Lippincott Williams & Wilkins Summary Relationships among lumbopelvic, hip, knee, ankle, foot requires thorough evaluation and treatment. Anatomic impairments can predispose the patellofemoral joint to poor tracking and excessive loads. Physiologic impairments (mobility, muscle performance, etc.) of neighboring regions can be manifested as symptoms at the knee.

36. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Examination of patellofemoral joint must include muscle length, joint mobility, etc. at neighboring regions and assessment of patellar position and motion. Improvements in impairments and general quadriceps strengthening within the entire lower kinetic chain associated within PFPS may result in positive outcomes.

37. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Major anatomic impairments at the knee are genu valgum/varum. These postures predispose lateral and medial compartments to excessive loads. Physiologic impairments at the knee can be compensated by motion at other joints.