5/19/2018 The knee complex: understanding the science behind both movement and dysfunction By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS,

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The knee complex: understanding the sciencebehind both movement and dysfunction

By Chris Gellert, PT, MMusc !portsphysio, MPT,C!C!, "M!

#ntroductionThe foot is where movement begins, requiring mobility to performsimple functional movements. The knee however, requires stabilitywith daily movements, but more importantly, dynamic sportmovements such as soccer or football. In this article, we will reviewthe anatomy of the knee, common injuries of the knee, functionalassessments and training strategies to work with clients with previousinjuries.

Figure 1. Dynamic sport of soccer

Basic anatomy of the kneeLet's look at the anatomy of the knee.. The joint is vulnerable when it comes injury,because of the mechanical demands placed upon it and the reliance for soft tsupportthe knee.There aret$o primary joints within the knee, the tibiofemoral joint

patellofemoral joint.

%nee &ointsa' Tibiofemoral (oint Is a hinge joint that permits some rotation between thend of thefemur and pro!imal end of tibia. The joint capsule surrounds the femoral conand tibial

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plateaus and provides stability to the knee by the medial collateral ligament"and thelateral collateral ligament "L$L%.

b' Patellofemoral (oint Is formed by the patella"knee bone% that glides in t

trochleargroove of the femur. The height of the lateral femoral condyle helps prevent lsublu!ation, while soft tissue surrounds the joint to increase stability. This is&gure .

)igure *' !tructures $ithin the knee (oint )igure +' Patellofemo(oint

*' Primary structures $ithin the knee (oint: ligaments and mensici(everal ligaments described below provide stability at the knee joint.a' Collateral ligaments: The two primary supporting ligaments are the medcollateralligament "#$L%, which is along the inside of the knee. The #$L is a thinner aweaker

ligament biomechanically, making it more susceptible to injury more often injperthe research. )hile the lateral collateral ligament"L$L% is along the outside olateral aspectof the knee providing lateral knee stability.

b' "nterior cruciate ligament"C-.:is the most commonly injured kneligamentand

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is taut during knee e!tension. It originates more pro!imally on the femoral sitheposterolateral "*L% bundle. It inserts anteromedially"front and to inner sidetibia.The +$L limits and controls forward translation of tibia on the femur and lim

rotation.

c' Menisci: the menisci are &bro cartilaginous discs located on the articular of thetibia along the medial and lateral tibial plateaus. The outer portion of themeniscus"lateralmeniscus%is oval shaped "% and thick. +ttaching at the anterior and posterioviacoronary ligaments.

/ascularity: The middle third and inner third of both menisci

are relative avascular'The medial meniscus is more $-shaped, and thinner in structure.oth menisci receive nutrition through synovial di/usion and fromblood supply to the horns of the menisci.

)unction of the menisci The menisci provide shock absorption, joint lubricand stabili0ation.

Common in(uries and causes

There are several common injuries that a/ect the knee. The mostcommon are patella femoral syndrome"*1(%, osteoarthritis".+.% andanterior cruciate ligament"+$L% injuries.In this ne!t section, we will review each condition providing a deeperunderstanding of each.

a' Patellofemoral syndromePathophysiology0sign and symptoms: *1( is a condition where the patellanottranslate biomechanically in the trochlear groove between the femoral condy2ere the

patella is positioned in either a tilt, glide or rotation accompanied by di/use,achiness in thefront of the knee.

Contributing )actors1vidence Based 2esearch.: (everal studies have shthatdecreased 3exibility of 4uadricepsand hip 3e!ors"Lankhorst et al. 4564 7et al. 4566%

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contribute to *1(. 8ecreased hip abductor strengthhas been shown a signfactor seenin multiple studies as contributing to *1("9hayambashi, 2., et al. 4564, #eir"4566%,olgla et al. "455:%,$ichanowski et al. "455;%, and

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Pathophysiology0Mechanism of #n(ury The knee is struck while inhyperextension,forcingtibia anterior"forward%on the femur, as seen in &gure F. The +$L can also be withsame mechanism of injury with combined with medial rotation of the lower

e!tremity"L?%.This creates instability and a direct disconnect the nervous system to themusculoskeletal systembecause of the @lack of controlA within the knee joint.

)igure 7' Mechanism of in(ury for "C- tear

Common assessmentsne great test to assess a clientGs movement pattern, is the s4uat'The squat is a classic fundamental primal movement that someonetypically performs almost on a daily basis. )ith this test, you canobserve how the clientGs ankle, knee, hip and back moves compared tonormal movement patterns. This is seen in the &gure below.

)igure 8' !4uat in frontal vie$ !4uat in side vie$

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+nother simple assessment is an in place lunge, which e!amines oneGs contthrough the entirekinematic chain. The lunge is another fundamental primal movement. The lundynamic

movement that is typically performed during daily activities"stooping down tosomething up%or as part of an athletic movement.This test e!amines ankle control, knee control and pelvic movement in the saplane.Lastly, a diagonal traveling forward lunge looks at the ability of the client to cankle,knee, hip, and pelvic movement in both the sagittal and frontal planes.This is not only a functional movement, but very e/ective for sport speci&c cl

)igure 9' #n place lunge )igure ' Traveling for$ard lunge

Training strategies and programming for knee in(uries)ith any injury, the most important thing to remember is the type ofinjury, healing time and prior level of function of the client.

a' Patellofemoral syndrome2ecommendations for training: $ontinued stretching of tighthip 3e!ors, IT, and hamstrings is fundamental. $lient should

be taught initially static core strengthening e!ercises, and thenprogressed to dynamic core strengthening as appropriate.$lient would also bene&t from education on shoes with respectto type that are most e/ective for them, and to cross trainutili0ing, such as hiking, yoga, pilates, and swimming. Lastly, toalter running surfaces"if client runs% and educating the clientabout changing their shoes every F55 miles or B months forma!imum stability and control.

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b' 5steoarthritis of knee5'"'.2ecommendations for training:+qua therapy has been

shown in the research tosigni&cantly reduce pain, improved physical function, strength, and qua

life"2inman,

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It is important to include dynamic training focusing on hamstrings, glutmedius,ma!imus. $losed chain strengthening"$9$%e!ercises, such as diagonal anddiagonal reverse lunges are not only functional, but replicate many com

sportsas soccer, football and basketball accordingly.

)igure ;' ?' Multidirectional

Training Training

Contrainidications/Precautions:+void leg e!tension e!ercises compthis causes ananterior translation"shearing% of the tibia on the femurHstressing the grTherefore,the e!ercise is contraindicated. @Biomechanically, shearing stress o

"C- isgreatest from +? degrees of knee 3exion to full extension'

2ecommendations for training: "merican "cademy of 5rthopedi!urgeons""5!.

Guidelines Post Therapy: $ontinuation of closed kinetic chain e!ercises"ie. reverse lunges, dilunges,

forward lunge with medicine ball trunk rotation%A N months light jogging beginsO > months running beginsO > months introduction of plyometrics

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O (urgical reconstruction typically sidelines athlete for 6-9 monthsonce cleared by

physician can return to sport activities.

!ummary

The knee is a dynamic joint that is comprised of a multitude ofligaments, tendons, connective tissue, muscles thatsynergistically initiate and correct movement, and stabili0ewhen an unstable environment. Dnderstanding the anatomy,biomechanics and weak links of the knee, common injuries andevidenced based training strategies, should provide you with theinsight to better understand and work with clients with thesekind of injuries more con&dently.

$hris is the $? of *innacle Training 7 $onsulting(ystems"*T$(%. + continuing education company, that provides

educational material in the forms of home study courses, liveseminars, 8P8s, webinars, articles and min books teaching in-depth, the foundation science, functional assessments andpractical application behind 2uman #ovement, that isevidenced based. $hris is both a dynamic physical therapist with6> years e!perience, and a personal trainer with 6; yearse!perience, with advanced training, has created over 65courses, is an e!perienced international &tness presenter, writesfor various websites and international publications, consults andteaches seminars on human movement. 1or more information,please visit www.pinnacle-tcs.com.

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21)121C1!ennell, 9.L., et al., 4565, Q2ip strengthening reduces symptoms but not knein people with medial knee osteoarthritis and varus malalignment a randomicontrolled trial,GJournal of Osteoarthritis and Cartilage,vol. 6:, issue

F, pp. B46-B4:.

olgla, L, et al., 455:, Q2ip (trength and hip and knee kinematics during staidescent infemales with and without patellofemoral pain syndrome,GJOSPT,vol. :, pp.

$icanowski, 2 et al., 455;, Q2ip strength in collegiate female athletes withpatellofemoralpain,GMedicine Science Sports Exercise,vol. C, pp. 644;-644.

1robell, ,pp. 6F64-6F4.

2ernnde0-#olina, J., et al., 455:, Q?/ect of therapeutic e!ercise forhip osteoarthritis pain

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Lankhorst, K, et al, 4564, QFFS>BF.

*rins, 455C,G 1emales with patellofemoral pain syndrome have weakhip muscles a systematic review,Australian Journal of Ph"siotherap",vol. FF, issue 6, pp. C-6F.