Chapter 21 The Knee
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Transcript of Chapter 21 The Knee
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Copyright 2005 Lippincott Williams & Wilkins
Chapter 21The Knee
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Anatomy
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Subdivisions of Synovial Cavity
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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.)
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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 Flexion0–90 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 EvaluationComponents 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 techniquesPatellar mobilizationQuadriceps, hamstring stretchesAbdominal 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 diseaseMSParkinson’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.