KNEE
Home screw mechanism:
Extension – locking Flexion – unlocking
Patella movement Superolateral in groove Inferomedial out of groove
Open chain – tibia moves ER in last 20 IR in first 20
Close chain – femur moves IR in last 20 ER in first 20
Supporting structures Biceps femoris, TFL, vastus lat. Pes anserine
Patellar motion:
- Close chain: Squatting Maximum joint reaction force between 30-60
- Open chain: Weight training maximum force around 30 flex (peak stress=60; compression=75)
- Knee extension: patella is not in contact with superior groove of femur minimum compression force
- Knee flexion 15-60: Patella is in contact
Patellar tracking:
- Joint reaction force is highest between 30-60
- Increased Q-angle: wide pelvis, fem anteversion, coxa vara, genu valgum
- Muscle tightness: IT band, TF, PF tight, hams, RF
- Muscle weakness: hip abductors, external rotators
- Laxity: medial capsular retinaculum, weak VMO
Genu valgum – knock knees Genu varum – bowlegs
Increased Q-angle Decrease Q-angle
Femoral IR – Femoral ER –
1) tight hip adductors and IR 1) Tight hip ER and abductors
2) Weak hip abductors and ER 2) Weak hip adductors and IR
Tibial ER – Tibial IR –
1) Tight IT band, TFL, VL 1) Tight pes anserine
2) Weak VMO
Foot – Foot –
1) Pronation 1) Supinated
2) DF 2) PF
Ligament injuries:
ACL PCL MCL LCL
Anatomy - LAMP Lateral femoral Medial femoral Medial femoral Lateral femoral
condyle to condyle to condyle to med tibial condyle to lat
intercondylar intercondylar tibial
eminence eminence
Function Prevent anterior Posterior translation Prevents medial Prevents
tibial translation of tibia and external translation lateral
and internal tibial rotation translation
rotation of tibia Prevents hyperflexion
Prevents of knee
hyperextension of
knee
Cause of injury Non-contact, Dashboard injury, Valgus force Varus force
sudden stopping direct blow to flexed
and inward rotation knee
of knee.
Symptoms Pain, AUDIBLE POP Pain Pain, effusion on Lateral knee
medial side, symptoms
sometimes
associated with
medial meniscus
injury (includes pop)
Special tests Anterior drawer Posterior drawer Valgus stress test Varus stress
Lachman Posterior sag test test
Pivot shift
Support Hams Quads - -
Intervention: Open chain resistance exercise increase quads strength more than close chain exercise- partial
squats, leg press and heel raises
ACL injury:
Maximum stress on graft= 0-20 flexion and full extension
Immobilization and bracing WB considerations
Rehab brace (0-6weeks) protect joint, limited Initial WB is allowed with the grafts
motion, locking mechanism
Increase by 2-3 weeks
Lock brace in full extension during ambulation
4 weeks FWB after achieving full knee extension
Remove brace after full extension is achieved
Functional brace high demand sports
Knee conditions:
OA RA Posttraumatic arthritis Post immobilization
hypomobility
Genu varum develops Genu valgum develops eventually After injury- ligament/meniscal Majorly in knee extension
eventually injury
Large weight bearing Starts with hand and wrist Joint effusion Adhesions restricting patella
joints mobility
Impairments Intervention- phase 1 Phase 2 and 3
- Restriction flexion>extension - Avoid Stretching - Do not increase ROM if patient cant control the motion
- Swelling position 25 flexion - PROM, AROM - Grade 3 and 4 mobz
- Ms setting exc - lateral knee pain lateral tibial glide and vice versa
- Close chain exc - flexion and IR mobz
- Grade 1 and 2 mobz - extension and ER mobz
- assistive devices if pain present - PRE- light resistance and high speed
- All basic quad strengthening exc can be done
Patellofemoral joint dysfunction:
PF instability Malalignment
- abnormal Q angle - increased Q angle
- patella Alta (high) - genu valgum
- patella Baja (low) restrict knee extension - tibial ext torsion
- tight lateral retinaculum - femoral anteversion
- inadequate med stabilizers- VMO, med PF lig - foot hyper pronation
PFPS
Common impairments Interventions
- Ant knee pain - Stretching tight structure
- Lateral tracking of patella - Strengthening weak structure
- Tight quads, hip adductors, IR, IT band, TFL, - Patellar mobz – medial glide
hams, PF - Open chain exercises (quad sets, SLR, PRE)
- Weak ER, abductors, VMO, extensors - Close chain exc- major component
- Medial tipping of patella
- Activity: painful descend stairs, jump, sit-to-
stand, squatting
Soft tissue lesion CMP Osteochondritis dissecans Apophysitis
1) Jumper’s knee (15-30yrs) - degeneration of articular - children and adolescents Cause: tight quads
- patellar tendonitis cartilage - active sports 1) Osgood-Schlatter:
- repetitive jumping activities - pain in kneeling - decreased blood supply to traction tibial tuberosity
- tight quads - movie theatre patella knee joint loose bodies in apophysitis
- pain in prolonged sitting, - active extension is painful the knee joint 2) Sinding Larsen
squatting, descending stairs - retro patellar pain in Johansson syndrome:
descending stairs, squatting - inferior pole of patella
2) Runner’s knee - locking and buckling of knee
- IT band friction
- tight IT band
3) Housemaid’s knee
- prepatellar bursitis
- prolonged kneeling or
recurrent trauma to anterior
knee
TKA:
Immobilization: bulky compression, posterior knee splint
WB: 25% 50% 75% 100% from 6 weeks 8 weeks 10 weeks 12 weeks respectively
Exercises Maximum Moderate
ROM - Ms setting exc - stretching, hold & relax to increase knee
- AA and active SLR in supine flexion and extension
- Terminal Knee Ext (TKE) - grade 3 inf or sup patellar mobz for flex or ext
- wall slides, partial squats respectively
- partial lunges to develop knee extensor control
and reduce extensor lag
- heel slides
- gravity assisted knee flexion in high sitting
- gravity assisted knee extension in supine or long
sitting with towel under heel
- gentle inf and sup patellar glides
Strength PRE in non-operated leg- hip ext, abd, quads - multiple angle isometrics
- low density resist exc for quads, hams and hip
ms
- resisted SLR
- WB closed chain exc: resisted TKE in standing
- forward/backward/lateral step ups and step
downs
- stationary cycling as high as possible to
emphasize knee extension
