seminar.pdfzgenu valgum and genu varum zhyperextension and hyperflexion zpatella alta and baja...

KNEE

www.fisiokinesiterapia.biz

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