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The Knee

The Knee. Chapter 21. Structure and Function of the Knee. Joints of the Knee Complex. Tibiofemoral Joint Characteristics Arthrokinematics Screw-home mechanism Patellofemoral Joint Characteristics Mechanics. Patellar Function. Patellar Alignment Forces maintaining alignment

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The Knee

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  1. The Knee Chapter 21

  2. Structure and Function of the Knee

  3. Joints of the Knee Complex • Tibiofemoral Joint • Characteristics • Arthrokinematics • Screw-home mechanism • Patellofemoral Joint • Characteristics • Mechanics

  4. Patellar Function • 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

  5. Muscle Function • Knee Extensor Muscle Function • Closed-chain function • Patella • Torque • Knee Flexor Muscle Function • Dynamic Stability of the Knee

  6. The Knee and Gait • Muscle Control of the Knee During Gait • Quadriceps • Hamstrings • Soleus • Gastrocnemius • Hip and Ankle Impairments • Hip flexion contractures • Length/strength imbalances • Foot impairments

  7. Referred Pain and Nerve Injuries • Major Nerves Subject to Injury at the Knee • Common fibular (peroneal) nerve • Saphenous nerve • Common Sources of Referred Pain

  8. management of Knee disorders and surgeries

  9. Joint Hypomobility: Nonoperative Management • Common Joint Pathologies and Associated Impairments • Osteoarthritis (degenerative joint disease) • Rheumatoid arthritis • Postimmobilization hypomobility • Common impairments • Common activity limitations and participation restrictions

  10. Joint Hypomobility: Nonoperative Management (cont'd) • 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

  11. Joint Hypomobility: Nonoperative Management (cont'd) • 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

  12. Joint Hypomobility: Nonoperative Management (cont'd) • 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

  13. Repair of Articular Cartilage Defects • Indications for Surgery • Procedures • Microfracture • Osteochondral autograft transplantation/mosaicplasty • Autologous chondrocyte implantation • Osteochondral allograft transplantation • Other procedures • Postoperative Management

  14. Total Knee Arthroplasty • Indications for Surgery • Procedure • Background • Types of knee arthroplasty • Surgical approach • Fixation • Operative overview • Complications

  15. Total Knee Arthroplasty (cont'd) • Postoperative Management • Immobilization and early motion • Weight-bearing considerations • Exercise progression

  16. Total Knee Arthroplasty (cont'd) • 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

  17. Total Knee Arthroplasty (cont'd) • Outcomes • Pain relief • ROM • Strength and endurance • Physical function and activity level

  18. Related Patellofemoral Pathologies • PF Instability • PF Pain With Malalignment or Biomechanical Dysfunction

  19. Related Patellofemoral Pathologies (cont'd) • 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

  20. Patellofemoral Dysfunction: Nonoperative Management • 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

  21. Patellofemoral Symptoms: Management—Protection Phase • 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

  22. Patellofemoral Symptoms: Management—Controlled Motion and Return to Function Phases • Educate the Patient • Instruction • Home exercise program • Increase Flexibility of Restricting Tissues • Patellar mobilization: medial glide • Medial tipping of the patella • Patellar taping

  23. Patellofemoral Symptoms: Management—Controlled Motion and Return to Function Phases (cont'd) • 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

  24. Patellofemoral Symptoms: Management—Controlled Motion and Return to Function Phases (cont'd) • Modify Biomechanical Stresses • Outcomes

  25. Patellar Instability: Surgical and Postoperative Management • Overview of Surgical Options

  26. Proximal Extensor Mechanism Re-alignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures • 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

  27. Proximal Extensor Mechanism Re-alignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures (cont'd) • Postoperative Management • Immobilization and weight-bearing considerations • Exercise progression

  28. Proximal Extensor Mechanism Re-alignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures (cont'd) • 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

  29. Distal Realignment Procedures: Patellar Tendon With Tibial Tubercle Transfer and Related Procedures • 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

  30. Distal Realignment Procedures: Patellar Tendon With Tibial Tubercle Transfer and Related Procedures (cont'd) • Complications • Postoperative Management • Immobilization and weight-bearing considerations • Exercise progression • Outcomes

  31. Ligament Injuries: Nonoperative Management • “Unholy Triad”/“ Terrible Triad” • Mechanisms of Injury • Anterior cruciate ligament • Posterior cruciate ligament • Medial collateral ligament • Lateral collateral ligament

  32. Ligament Injuries: Nonoperative Management (cont'd) • 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)

  33. Ligament Injuries: Nonoperative Management (cont'd) • 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

  34. Ligament Injuries: Surgical and Postoperative Management • Background • General considerations and indications for ligament surgery • Types of ligament surgery • Grafts: types, healing characteristics, and fixation • General considerations for rehabilitation

  35. Anterior Cruciate Ligament Reconstruction • Indications for Surgery • Procedures • Operative overview • Surgical approach, graft selection, and harvesting • Graft placement and fixation • Complications

  36. Anterior Cruciate Ligament Reconstruction (cont'd) • 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

  37. Anterior Cruciate Ligament Reconstruction (cont'd) • 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

  38. Posterior Cruciate Ligament Reconstruction • Indications for Surgery • Procedures • Operative overview • Complications

  39. Posterior Cruciate Ligament Reconstruction (cont'd) • Postoperative Management • Immobilization, protective bracing, and weight bearing • Exercise progression • Exercise • Maximum protection phase • Moderate and minimum protection phases

  40. Meniscal Tears: Nonoperative Management • Mechanisms of Injury • Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions • Management

  41. Meniscus Repair • Indications for Surgery • Procedure • Operative overview • Complications

  42. Meniscus Repair (cont'd) • Postoperative Management • Immobilization, protective bracing, and weight bearing • Exercise • Maximum protection phase • Moderate protection/controlled motion phase • Minimum protection/return-to-function phase • Outcomes

  43. Partial Meniscectomy • 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

  44. Exercise interventions for the knee

  45. To Increase Knee Extension • PNF Stretching • Gravity-Assisted Passive Stretching Techniques • Prone hang • Supine heel prop • Self-Stretching Technique

  46. To Increase Knee Flexion • 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

  47. To Increase Mobility of the IT Band at the Knee • Foam Roller Stretch

  48. Open-Chain (Non-Weight-Bearing) Exercises • 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

  49. Open-Chain (Non-Weight-Bearing) Exercises (cont'd) • To Develop Control and Strength of Knee Flexion (Hamstrings) • Hamstring-setting (hamstring sets) • Multiple-angle isometric exercises • Hamstring curls

  50. Closed-Chain Exercises • 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

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