Knee Rehabilitation

Anatomy Review

Bony Anatomy Lower Leg

Tibia Fibula

Upper Leg Femur

Patella

Anatomy Review

Lower Leg Musculature Anterior

Tibialis Anterior Medial

Tom, Dick and Harry Tibialis Posterior Extensor Digitorum

Longus Extensor Hallicus Longus

Lateral Peroneals

Posterior Gastrocnemius Soleus Tibialis Anterior

Anatomy Review

Thigh Musculature Anterior

Quadriceps Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris

Posterior Biceps Femoris

Long Head Short Head

Semi-tendonosis Semi-membranosis Gracilis

Anatomy Review

Ligaments Medial Collateral Lateral Collateral Anterior Cruciate Posterior Cruciate

Anatomy Review

Cartilage Medial Meniscus Lateral Meniscus Articular Cartilage

Anatomy Review

Joint Capsule

Anatomy Review

Bursae

Knee Evaluation (History)

Determining the mechanism of injury is critical History- Current Injury

Past history Mechanism- 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 Injury What 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)

Observation Walking, half squatting, going up and down stairs Swelling, ecchymosis, Leg alignment

Genu valgum and genu varum Hyperextension and hyperflexion Patella alta and baja Patella rotated inward or outward

May cause a combination of problems

Knee Evaluation (Observation)

Knee Symmetry or Asymmetry

Do the knees look symmetrical? Is there obvious swelling? Atrophy?

Leg Length Discrepancy Anatomical or functional Anatomical differences

can potentially cause problems in all weight bearing joints

Functional differences can be caused by pelvic rotations or mal-alignment of the spine

Knee Evaluation (Palpation)

Palpation – Bony Medial tibial plateau Medial femoral condyle Adductor tubercle Gerdy’s tubercle Lateral tibial plateau Lateral femoral condyle Lateral epicondyle Head of fibula

Tibial tuberosity Superior 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 medialis Vastus lateralis Vastus intermedius Rectus femoris Quadriceps and patellar

tendon Sartorius Medial patellar plica Anterior joint capsule Iliotibial Band Arcuate complex

Medial and lateral collateral ligaments

Pes anserine Medial/lateral joint capsule Semitendinosus Semimembranosus Gastrocnemius Popliteus Biceps Femoris

Knee Evaluation (Special Tests)

Active / Passive Range of Motion Flexion – 0o to 135o

Extension – 130o to 0o

Manual Muscle Testing Five Point grading system

5 = Complete ROM against gravity, with full resistance 4 = Complete ROM against gravity, with some resistance 3 = Complete ROM against gravity, with no resistance 2 = Complete ROM, with gravity omitted 1 = Some muscle contractility with no joint motion 0 = No muscle contractility

Knee Flexion / Extension Hip Flexion / Extension / Internal Rotation / External Rotation Dorsiflexion / Plantar Flexion

Knee Evaluation (Special Tests)

Joint Instability Medial Collateral Ligament Instability

Knee Evaluation (Special Tests)

Joint Instability Lateral Collateral Ligament Instability

Knee Evaluation (Special Tests)

Joint Instability Anterior Cruciate Ligament (Lachman’s Test)

Will not force knee into painful flexion immediately after injury Reduces hamstring involvement At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the

femur A positive test indicates damage to the ACL

Knee Evaluation (Special Tests)

Joint Instability Anterior Cruciate Ligament (Ant. Drawer)

Drawer test at 90 degrees of flexion Tibia 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 Tests Pivot Shift Test

Used to determine anterolateral rotary instability Position starts w/ knee extended and leg internally rotated The thigh and knee are then flexed w/ a valgus stress applied to the

knee Reduction of the tibial plateau (producing a clunk) is a positive sign

Jerk Test Reverses direction of the pivot shift Moves from position of flexion to extension W/out and ACL the tibia will sublux at 20 degrees of flexion

Joint Stability Tests Posterior Cruciate Ligament Stability

Posterior Sag Test (Godfrey’s test) Athlete is supine w/ both knees flexed to 90 degrees Lateral 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 posteriorly

Positive sign indicates a PCL deficient knee

Knee Evaluation (Special Tests)

Meniscal Pathology McMurray’s Meniscal Test

Used to determine displaceable meniscal tear Leg is moved into flexion and extension while knee is internally and

externally rotated in conjunction w/ valgus and varus stressing A 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 Pathology Apley’s Compression Test

Hard downward pressure is applied w/ rotation

Pain indicates a meniscal injury

Apley’s Distraction Test Traction is applied w/

rotation Pain will occur if there is

damage to the capsule or ligaments

No pain will occur if it is meniscal

Knee Evaluation

Palpation of the Patella Must palpate around and under patella to determine points of pain

Patella Grinding, Compression and Apprehension Tests A series of glides and compressions are performed w/ the patella to

determine integrity of patellar cartilage

Knee Rehabilitation

Bag of Tricks Range 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 injuryFunctionality

Needed 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 Exercises Table Hangs

Knee Rehabilitation

StrengtheningClosed Kinetic Chain

Used early in rehabilitationMore stable for the knee jointExercise include:

Mini-Squats (or with Swiss ball) Wall Slides Lunges (as ROM permits) Leg Press Machine Lateral Step-ups T.K.E (Terminal Knee Extension) with T-Band

Knee Rehabilitation

StrengtheningOpen Kinetic Chain

Also used early in rehabilitationExercise include:

Quad Sets Hamstring Sets Straight Leg Raises in four directions Hamstring Curl Machine Leg Extension Machine

Knee Rehabilitation

Functionality Agility Drills / Training

LadderDot Drills

Plyometric Drills / Training