1. Copyright © 2013. F.A. Davis Company Part IV: Exercise Interventions by Body Region Chapter 21 The Knee

2. Copyright © 2013. F.A. Davis Company STRUCTURE AND FUNCTION OF THE KNEE

3. Copyright © 2013. F.A. Davis Company  Tibiofemoral Joint – Characteristics – Arthrokinematics – Screw-home mechanism  Patellofemoral Joint – Characteristics – Mechanics Joints of the Knee Complex

4. Copyright © 2013. F.A. Davis Company  Patellar Alignment – Forces maintaining alignment – Patellar malalignment and tracking problems Increased Q-angle Muscle and fascial tightness Hip muscle weakness Lax medial capsular retinaculum or an insufficient VMO muscle  Patellar Compression – Patellar contact – Compression forces Patellar Function

5. Copyright © 2013. F.A. Davis Company  Knee Extensor Muscle Function – Closed-chain function – Patella – Torque  Knee Flexor Muscle Function  Dynamic Stability of the Knee Muscle Function

6. Copyright © 2013. F.A. Davis Company  Muscle Control of the Knee During Gait – Quadriceps – Hamstrings – Soleus – Gastrocnemius  Hip and Ankle Impairments – Hip flexion contractures – Length/strength imbalances – Foot impairments The Knee and Gait

7. Copyright © 2013. F.A. Davis Company  Major Nerves Subject to Injury at the Knee – Common fibular (peroneal) nerve – Saphenous nerve  Common Sources of Referred Pain Referred Pain and Nerve Injuries

8. Copyright © 2013. F.A. Davis Company MANAGEMENT OF KNEE DISORDERS AND SURGERIES

9. Copyright © 2013. F.A. Davis Company  Common Joint Pathologies and Associated Impairments – Osteoarthritis (degenerative joint disease) – Rheumatoid arthritis – Postimmobilization hypomobility – Common impairments – Common activity limitations and participation restrictions Joint Hypomobility: Nonoperative Management

10. Copyright © 2013. F.A. Davis Company  Management: Protection Phase – Control pain and protect the joint Patient education Functional adaptations – Maintain soft tissue and joint mobility Passive, active-assistive, or active ROM Grade I or II tractions or glides – Maintain muscle function and prevent patellar adhesions Setting exercises Joint Hypomobility: Nonoperative Management (cont'd)

11. Copyright © 2013. F.A. Davis Company  Management: Controlled Motion and Return to Function Phases – Educate the patient – Decrease pain from mechanical stress – Increase joint play and range of motion Joint mobilization Stretching techniques Mobilization with movement Joint Hypomobility: Nonoperative Management (cont'd)

12. Copyright © 2013. F.A. Davis Company  Management: Controlled Motion and Return to Function Phases (cont’d) – Improve muscle performance in supporting muscles Progressive strengthening Muscular endurance Functional training – Improve cardiopulmonary endurance  Outcomes Joint Hypomobility: Nonoperative Management (cont'd)

13. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedures – Microfracture – Osteochondral autograft transplantation/mosaicplasty – Autologous chondrocyte implantation – Osteochondral allograft transplantation – Other procedures  Postoperative Management Repair of Articular Cartilage Defects

14. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedure – Background Types of knee arthroplasty Surgical approach Fixation – Operative overview – Complications Total Knee Arthroplasty

15. Copyright © 2013. F.A. Davis Company  Postoperative Management – Immobilization and early motion – Weight-bearing considerations – Exercise progression Total Knee Arthroplasty (cont'd)

16. Copyright © 2013. F.A. Davis Company  Postoperative Management (cont’d) – Exercise Maximum protection phase – Goals and interventions – Criteria to progress Moderate protection phase – Goals and interventions – Criteria to progress Minimum protection/return to function phases Total Knee Arthroplasty (cont'd)

17. Copyright © 2013. F.A. Davis Company  Outcomes – Pain relief – ROM – Strength and endurance – Physical function and activity level Total Knee Arthroplasty (cont'd)

18. Copyright © 2013. F.A. Davis Company  PF Instability  PF Pain With Malalignment or Biomechanical Dysfunction Related Patellofemoral Pathologies

19. Copyright © 2013. F.A. Davis Company  PF Pain Without Malalignment – Soft tissue lesions – Tight medial and lateral retinacula or patellar pressure syndrome – Osteochondritis dissecans of the patella or femoral trochlea – Traumatic patellar chondromalacia – PF osteoarthritis – Apophysitis – Symptomatic bipartite patella – Trauma Related Patellofemoral Pathologies (cont'd)

20. Copyright © 2013. F.A. Davis Company  Etiology of Symptoms – Consensus on factors leading to PF symptoms Local factors Distal factors Proximal factors  Common Impairments, Activity Limitations, and Participation Restrictions Structural and functional impairments Activity limitations and participation restrictions Patellofemoral Dysfunction: Nonoperative Management

21. Copyright © 2013. F.A. Davis Company  Modalities for Pain and Joint Effusion  Rest and Activity Modification  Splinting or Patellar Taping to Unload the Joint  Muscle-Setting Exercises in Pain-Free Position  Gentle ROM in Pain-Free Range Patellofemoral Symptoms: Management—Protection Phase

22. Copyright © 2013. F.A. Davis Company  Educate the Patient – Instruction – Home exercise program  Increase Flexibility of Restricting Tissues – Patellar mobilization: medial glide – Medial tipping of the patella – Patellar taping Patellofemoral Symptoms: Management — Controlled Motion and Return to Function Phases

23. Copyright © 2013. F.A. Davis Company  Improve Muscle Performance and Neuromuscular Control – VMO: A closer look – Non-weight-bearing (open-chain) exercises Quad sets in pain-free positions Quad sets with straight-leg raising Progression of resisted isometrics Short-arc terminal extension – Weight-bearing (closed-chain) exercises – Functional activities Patellofemoral Symptoms: Management — Controlled Motion and Return to Function Phases (cont'd)

24. Copyright © 2013. F.A. Davis Company  Modify Biomechanical Stresses  Outcomes Patellofemoral Symptoms: Management — Controlled Motion and Return to Function Phases (cont'd)

25. Copyright © 2013. F.A. Davis Company  Overview of Surgical Options Patellar Instability: Surgical and Postoperative Management

26. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedures – Background and operative overview MPFL repair or tightening MPFL reconstruction VMO imbrication (advancement) Lateral retinacular release and other concomitant procedures – Complications Proximal Extensor Mechanism Re-alignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures

27. Copyright © 2013. F.A. Davis Company  Postoperative Management – Immobilization and weight-bearing considerations – Exercise progression Proximal Extensor Mechanism Re-alignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures (cont'd)

28. Copyright © 2013. F.A. Davis Company  Postoperative Management (cont’d) – Exercise Maximum protection phase – Goals and interventions – Criteria to progress Moderate protection/controlled motion phase Minimum protection/return to function phase  Outcomes Proximal Extensor Mechanism Re-alignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures (cont'd)

29. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedures – Background and operative overview Tibial tubercle transfer (Elmslie-Trillat procedure) Anteriorization (elevation) of the tibial tubercle Distal medialization of the patellar tendon Distal Realignment Procedures: Patellar Tendon With Tibial Tubercle Transfer and Related Procedures

30. Copyright © 2013. F.A. Davis Company  Complications  Postoperative Management – Immobilization and weight-bearing considerations – Exercise progression  Outcomes Distal Realignment Procedures: Patellar Tendon With Tibial Tubercle Transfer and Related Procedures (cont'd)

31. Copyright © 2013. F.A. Davis Company  “Unholy Triad”/“ Terrible Triad”  Mechanisms of Injury – Anterior cruciate ligament – Posterior cruciate ligament – Medial collateral ligament – Lateral collateral ligament Ligament Injuries: Nonoperative Management

32. Copyright © 2013. F.A. Davis Company  Ligament Injuries in the Female Athlete – Biomechanical risk factors – Neuromuscular risk factors – Structural risk factors – Hormonal differences  Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (functional limitations/disabilities) Ligament Injuries: Nonoperative Management (cont'd)

33. Copyright © 2013. F.A. Davis Company  Management: Maximum Protection Phase  Management: Moderate Protection (Controlled Motion) Through Return to Activity Phases – Improve joint mobility and protection Protective bracing – Improve muscle performance and function Strength and endurance Neuromuscular control – Improve cardiopulmonary conditioning – Progress to functional training Ligament Injuries: Nonoperative Management (cont'd)

34. Copyright © 2013. F.A. Davis Company  Background – General considerations and indications for ligament surgery – Types of ligament surgery – Grafts: types, healing characteristics, and fixation – General considerations for rehabilitation Ligament Injuries: Surgical and Postoperative Management

35. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedures – Operative overview Surgical approach, graft selection, and harvesting Graft placement and fixation – Complications Anterior Cruciate Ligament Reconstruction

36. Copyright © 2013. F.A. Davis Company  Postoperative Management – Immobilization and bracing Types of postoperative bracing Brace use and initiation and progression of knee ROM – Weight-bearing considerations – Exercise progression Preoperative exercises Postoperative exercise progression Anterior Cruciate Ligament Reconstruction (cont'd)

37. Copyright © 2013. F.A. Davis Company  Postoperative Management (cont’d) – Exercise Maximum protection phase Moderate protection and controlled motion phase Minimum protection and return to function phase  Outcomes – Graft selection and outcomes – Approaches to rehabilitation – Functional bracing Anterior Cruciate Ligament Reconstruction (cont'd)

38. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedures – Operative overview – Complications Posterior Cruciate Ligament Reconstruction

39. Copyright © 2013. F.A. Davis Company  Postoperative Management – Immobilization, protective bracing, and weight bearing – Exercise progression – Exercise Maximum protection phase Moderate and minimum protection phases Posterior Cruciate Ligament Reconstruction (cont'd)

40. Copyright © 2013. F.A. Davis Company  Mechanisms of Injury  Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions  Management Meniscal Tears: Nonoperative Management

41. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedure – Operative overview – Complications Meniscus Repair

42. Copyright © 2013. F.A. Davis Company  Postoperative Management – Immobilization, protective bracing, and weight bearing – Exercise Maximum protection phase Moderate protection/controlled motion phase Minimum protection/return-to-function phase  Outcomes Meniscus Repair (cont'd)

43. Copyright © 2013. F.A. Davis Company  Indications for Surgery  Procedure – Operative overview – Complications  Postoperative Management – Immobilization and weight bearing – Exercise Maximum and moderate protection phases Minimum protection and return to function phases Partial Meniscectomy

44. Copyright © 2013. F.A. Davis Company EXERCISE INTERVENTIONS FOR THE KNEE

45. Copyright © 2013. F.A. Davis Company  PNF Stretching  Gravity-Assisted Passive Stretching Techniques – Prone hang – Supine heel prop  Self-Stretching Technique To Increase Knee Extension

46. Copyright © 2013. F.A. Davis Company  PNF Stretching Techniques  Gravity-Assisted Passive Stretching Techniques  Self-Stretching Techniques – Gravity-assisted supine wall slides – Self-stretching with the uninvolved leg – Rocking forward on a step – Sitting To Increase Knee Flexion

47. Copyright © 2013. F.A. Davis Company  Foam Roller Stretch To Increase Mobility of the IT Band at the Knee

48. Copyright © 2013. F.A. Davis Company  To Develop Control and Strength of Knee Extension (Quadriceps Femoris) – Quadriceps setting (quad sets) – Straight-leg raise (SLR) – Straight-leg lowering – Multiple-angle isometric exercises – Short-arc terminal knee extension – Full arc extension Open-Chain (Non-Weight-Bearing) Exercises

49. Copyright © 2013. F.A. Davis Company  To Develop Control and Strength of Knee Flexion (Hamstrings) – Hamstring-setting (hamstring sets) – Multiple-angle isometric exercises – Hamstring curls Open-Chain (Non-Weight-Bearing) Exercises (cont'd)

50. Copyright © 2013. F.A. Davis Company  Initiation of Closed-Chain Exercises  Partial Weight-Bearing and Support Techniques  Closed-Chain Isometric Exercises – Setting exercises for co-contraction – Alternating isometrics with rhythmic stabilization – Closed-chain isometrics against elastic resistance Closed-Chain Exercises

51. Copyright © 2013. F.A. Davis Company  Closed-Chain Dynamic Exercises – Scooting on a wheeled stool – Unilateral closed-chain terminal knee extension – Partial squats, mini-squats, and short-arc training – Standing wall slides – Forward, backward, and lateral step-ups and step- downs – Partial and full lunges Closed-Chain Exercises (cont'd)

52. Copyright © 2013. F.A. Davis Company  Strength and Muscle Endurance Training  Cardiopulmonary Endurance Training  Balance and Proprioceptive Activities (Perturbation Training)  Plyometric and Agility Drills  Simulated Work-Related Activities and Sport- Specific Drills Functional Progression for the Knee

53. Copyright © 2013. F.A. Davis Company  Critical Thinking and Discussion  Laboratory Practice  Case Studies Independent Learning Activities