Chapter 21

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Chapter 21

The Knee

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Anatomy

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Subdivisions of Synovial Cavity

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Myology

Anterior Posterior
 Rectus femoris  Biceps femoris
 Vastus lateralis  Semitendinosus
 Vastus intermedius  Semimembranosus
 Vastus medialis
Medially Laterally
 Gracilis  TFL/ITB (affected by
 Adductor longus, brevis, gluteus maximus, etc.)
magnus

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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.

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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.

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Rolling with Anterior,
Anterior/Posterior Glide

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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.

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Genu Valgum/Varum

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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

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Muscle Performance

Muscles commonly tested

 Medial and lateral hamstrings


 Quadriceps
 Gluteal muscles
 Iliopsoas
 Gastroc-soleus
 Hip rotators
 Posterior tibialis

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Therapeutic Exercise Intervention for
Physiologic Impairments
Mobility Impairment – Hypomobility

 Glide and joint distraction techniques


 Patellar mobilization
 Quadriceps, hamstring stretches
 Abdominal support

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Quadriceps Stretch for Hypermobility

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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)

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Impaired Muscle Performance
Treatment – Strength, endurance,
and power training activities.

Neurologic Causes:
 Lumbar spine injury or disease
 MS
 Parkinson’s disease

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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.

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Disuse and Deconditioning

 Occurs primarily at
quadriceps.

Treatment:
 Strengthening activities for
the quadriceps.
 Focus on primary cause of
disuse.

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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.

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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.

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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.

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MCL Exercises

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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.

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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.

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Progression

 Continuation training
and progressing to
non-device-assisted
exercises.
 Land-based CC
exercises.

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Late Stage

 Resisted OC
exercises.
 Functional specific
drills.

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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.

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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.

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Self-Management Techniques

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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.

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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.

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Iliotibial Band Syndrome

Treatment:

 Postural education
 Exercises for underlying impairments
(e.g., hip rotator weakness)
 Stretching of hip and knee
musculature

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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.

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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).

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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.

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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.

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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.

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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.

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