Knee Rehabilitation. Anatomy Review Bony Anatomy Lower Leg Tibia Fibula Upper Leg Femur Patella.
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Transcript of Knee Rehabilitation. Anatomy Review Bony Anatomy Lower Leg Tibia Fibula Upper Leg Femur Patella.
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