KNEE
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Anatomy Review
Bony AnatomyLower Leg
TibiaFibula
Upper LegFemur
Patella
Anatomy Review
Lower Leg MusculatureAnterior
Tibialis AnteriorMedial
Tom, Dick and HarryTibialis PosteriorExtensor Digitorum LongusExtensor Hallicus Longus
LateralPeroneals
PosteriorGastrocnemiusSoleusTibialis Anterior
Anatomy Review
Thigh MusculatureAnterior
Quadriceps FemorisVastus LateralisVastus MedialisVastus IntermediusRectus Femoris
PosteriorBiceps Femoris
Long HeadShort Head
Semi-tendonosisSemi-membranosisGracilis
Anatomy Review
LigamentsMedial Collateral Lateral Collateral Anterior Cruciate Posterior Cruciate
Anatomy Review
CartilageMedial MeniscusLateral MeniscusArticular Cartilage
Anatomy Review
Joint Capsule
Anatomy Review
Bursae
Anatomy Review
Nerve SupplyBlood Supply
Knee Evaluation (History)
Determining the mechanism of injury is criticalHistory- Current Injury
Past historyMechanism- what position was your body in?Did the knee collapse?Did you hear or feel anything?Could you move your knee immediately after injury or was it locked?Did swelling occur?Where was the pain
History - Recurrent or Chronic InjuryWhat is your major complaint?When did you first notice the condition?Is there recurrent swelling?Does the knee lock or catch?Is there severe pain?Grinding or grating?Does it ever feel like giving way?What does it feel like when ascending and descending stairs?What past treatment have you undergone?
Knee Evaluation (Observation)
ObservationWalking, half squatting, going up and down stairsSwelling, ecchymosis,Leg alignment
Genu valgum and genu varumHyperextension and hyperflexionPatella alta and bajaPatella rotated inward or outward
May cause a combination of problemsTibial torsion, femoral anteversion and retroversion
Knee Evaluation (Observation)
Tibial torsionAn angle that measures less than 15 degrees is an indication of tibial torsion
Femoral Anteversion and Retroversion
Total rotation of the hip equals ~100 degreesIf the hip rotates >70 degrees internally, anteversion of the hip may exist
Knee Evaluation (Observation)
Knee Symmetry or Asymmetry
Do the knees look symmetrical? Is there obvious swelling? Atrophy?
Leg Length DiscrepancyAnatomical or functionalAnatomical differences can potentially cause problems in all weight bearing jointsFunctional differences can be caused by pelvic rotations or mal-alignment of the spine
Knee Evaluation (Palpation)
Palpation – BonyMedial tibial plateauMedial femoral condyleAdductor tubercleGerdy’s tubercleLateral tibial plateauLateral femoral condyleLateral epicondyleHead of fibula
Tibial tuberositySuperior and inferior patella borders (base and apex)Around the periphery of the knee relaxed, in full flexion and extension
Knee Evaluation (Palpation)
Palpation - Soft Tissue
Vastus medialisVastus lateralisVastus intermediusRectus femorisQuadriceps and patellar tendonSartoriusMedial patellar plicaAnterior joint capsuleIliotibial BandArcuate complex
Medial and lateral collateral ligamentsPes anserineMedial/lateral joint capsuleSemitendinosusSemimembranosusGastrocnemiusPopliteusBiceps Femoris
Knee Evaluation (Palpation)
Palpation of SwellingIntra vs. extracapsular swellingIntracapsular may be referred to as joint effusionSwelling w/in the joint that is caused by synovial fluid and blood is a hemarthrosisSweep maneuverBallotable patella - sign of joint effusionExtracapsular swelling tends to localize over the injured structure
May ultimately migrate down to foot and ankle
Knee Evaluation (Special Tests)
Active / Passive Range of MotionFlexion – 0o to 135o
Extension – 130o to 0o
Manual Muscle TestingFive Point grading system
5 = Complete ROM against gravity, with full resistance4 = Complete ROM against gravity, with some resistance3 = Complete ROM against gravity, with no resistance2 = Complete ROM, with gravity omitted1 = Some muscle contractility with no joint motion0 = No muscle contractility
Knee Flexion / ExtensionHip Flexion / Extension / Internal Rotation / External RotationDorsiflexion / Plantar Flexion
Knee Evaluation (Special Tests)
Joint InstabilityMedial Collateral Ligament Instability
Knee Evaluation (Special Tests)
Joint InstabilityLateral Collateral Ligament Instability
Knee Evaluation (Special Tests)
Joint InstabilityAnterior Cruciate Ligament (Lachman’s Test)
Will not force knee into painful flexion immediately after injuryReduces hamstring involvementAt 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the femurA positive test indicates damage to the ACL
Knee Evaluation (Special Tests)
Joint InstabilityAnterior Cruciate Ligament (Ant. Drawer)
Drawer test at 90 degrees of flexionTibia sliding forward from under the femur is considered a positive sign (ACL)Should be performed w/ knee internally and externally to test integrity of joint capsule
Knee Evaluation (Special Test)
Other ACL Stability TestsPivot Shift Test
Used to determine anterolateral rotary instabilityPosition starts w/ knee extended and leg internally rotatedThe thigh and knee are then flexed w/ a valgus stress applied to the kneeReduction of the tibial plateau (producing a clunk) is a positive sign
Jerk TestReverses direction of the pivot shiftMoves from position of flexion to extensionW/out and ACL the tibia will sublux at 20 degrees of flexion
Flexion-Rotation Drawer TestKnee is taken from a position of 15 degrees of flexion (tibia issubluxed anteriorly w/ femur externally rotated) Knee is moved into 30 degrees of flexion where tibia rotates posteriorly and femur internally rotates
Joint Stability TestsPosterior Cruciate Ligament Stability
Posterior Sag Test (Godfrey’s test)Athlete is supine w/ both knees flexed to 90 degreesLateral observation is required to determine extent of posterior sag while comparing bilaterally
Knee Evaluation (Special Tests)
Other Posterior Cruciate Ligament TestsPosterior Drawer Test
Knee is flexed at 90 degrees and a posterior force is applied to determine translation posteriorlyPositive sign indicates a PCL deficient knee
External Rotation Recurvatum TestWith the athlete supine, the leg is lifted by the great toeIf the tibia externally rotates and slides posteriorly there may be a PCL injury and damage to the posterolateral corner of the capsule
Knee Evaluation (Special Tests)
Meniscal PathologyMcMurray’s Meniscal Test
Used to determine displaceable meniscal tearLeg is moved into flexion and extension while knee is internally and externally rotated in conjunction w/ valgus and varus stressingA positive test is found w/ clicking and popping response
Medial Meniscus Testing
Knee Evaluation (Special Tests)
McMurray Test Continued
Lateral Meniscus Test
Knee Evaluation (Special Tests)
Meniscal PathologyApley’s Compression Test
Hard downward pressure is applied w/ rotationPain indicates a meniscal injury
Apley’s Distraction TestTraction is applied w/ rotationPain will occur if there is damage to the capsule or ligamentsNo pain will occur if it is meniscal
Knee Evaluation
Girth MeasurementsChanges in girth can occur due to atrophy, swelling and conditioningMust use circumferential measures to determine deficits and gains during the rehabilitation processMeasurements should be taken at the joint line, the level of the tibial tubercle, belly of the gastrocnemius, 2 cm above the superior border of the patella, and 8-10 cm above the joint line
Subjective RatingUsed to determine patient’s perception of pain, stability and functional performance
Functional ExaminationMust assess walking, running, turning and cuttingCo-contraction test, vertical jump, single leg hop tests and the duck walkResistive strength testing
Knee Evaluation
Q-AngleLines which bisects the patella relative to the ASIS and the tibial tubercleNormal angle is 10 degrees for males and 15 degrees for femalesElevated angles often lead to pathological conditions associated w/ improper patella tracking
The A AnglePatellar orientation to the tibial tubercleQuantitative measure of the patellar realignment after rehabilitationAn angle greater than 35 degrees is often correlated w/ patellofemoral pathomechanics
Palpation of the PatellaMust palpate around and under patella to determine points of pain
Patella Grinding, Compression and Apprehension TestsA series of glides and compressions are performed w/ the patella to determine integrity of patellar cartilage
Knee Rehabilitation
Bag of TricksRange of Motion
Joint Mobilization, Soft-Tissue Mobilization
Neuromuscular Control Proprioceptive Neuromuscular Facilitation
Postural Stability Core Stability training
Muscular Strength, Endurance, and Power
Plyometrics, Open KC, Closed KC, Isokinetics, Aquatics
Cardiovascular Endurance
Knee Rehabilitation
Three simple keysRange of Motion
Needed to increase motion and return to function as quickly as prudent and possible
StrengthNeeded to deter further problems or protect the area of injury from further injury
FunctionalityNeeded to return the student-athlete or patient to normal daily activities within reason.
Knee Rehabilitation
Range of Motion Theory’sPassive ROM is the key to early ROMActive ROM starts and progresses as treatments continue“Normal” Knee ROM
Knee Flexion = 0o to 130o+Knee Extension = 130o+ to 0o+
Knee Rehabilitation
Passive Range of Motion ExercisesFlexion Exercises
Wall Hangs (assisting device is gravity)
Towel Slides (assisting device is arms)
Stationary Bike (assisting device is other leg)
Extension ExercisesWall Hangs
Knee Rehabilitation
StrengtheningClosed Kinetic Chain
Used early in rehabilitationMore stable for the knee jointExercise include:
Mini-Squats (or with Swiss ball)Wall SlidesLunges (as ROM permits)Leg Press MachineLateral Step-upsT.K.E (Terminal Knee Extension) with T-Band
Knee Rehabilitation
StrengtheningOpen Kinetic Chain
Also used early in rehabilitationExercise include:
Quad SetsHamstring SetsStraight Leg Raises in four directionsHamstring Curl MachineLeg Extension Machine
Knee Rehabilitation
The controversy continues: OKC vs. CKCCKC Research
Decrease Tibial Translation 1More vastus medialis and lateralis muscle activity 2Greater patellofemoral compressive forces Increased compressive forces and co-contraction 2
OKC ResearchIncrease Tibial Translation 1More rectus femoris muscle activity 2Less patellofemoral compressive forces Increased shear forces and less co-contraction 2
Knee Rehabilitation
Functionality Agility Drills / Training
LadderDot Drills
Plyometric Drills / Training