Knee Seminar

1
Knee Seminar

• Brian Hardy, ATC

2
Anatomy Review

• Bony Anatomy
• Lower Leg
• Tibia
• Fibula
• Upper Leg
• Femur
• Patella

3
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

4
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

5
Anatomy Review

• Ligaments
• Medial Collateral
• Lateral Collateral
• Anterior Cruciate
• Posterior Cruciate

6
Anatomy Review

• Cartilage
• Medial Meniscus
• Lateral Meniscus
• Articular Cartilage

7
Anatomy Review

• Joint Capsule

8
Anatomy Review

• Bursae

9
Anatomy Review

• Nerve Supply
• Blood Supply

10
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?

11
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
• Tibial torsion, femoral anteversion and
  retroversion

12
Knee Evaluation (Observation)

• Tibial torsion
• An angle that measures less than 15 degrees is an
  indication of tibial torsion
• Femoral Anteversion and Retroversion
• Total rotation of the hip equals 100 degrees
• If the hip rotates 70 degrees internally,
  anteversion of the hip may exist

13
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

14
Knee Evaluation (Palpation)

• Palpation Bony
• Medial tibial plateau
• Medial femoral condyle
• Adductor tubercle
• Gerdys 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

15
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

16
Knee Evaluation (Palpation)

• Palpation of Swelling
• Intra vs. extracapsular swelling
• Intracapsular may be referred to as joint
  effusion
• Swelling w/in the joint that is caused by
  synovial fluid and blood is a hemarthrosis
• Sweep maneuver
• Ballotable patella - sign of joint effusion
• Extracapsular swelling tends to localize over the
  injured structure
• May ultimately migrate down to foot and ankle

17
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

18
Knee Evaluation (Special Tests)

• Joint Instability
• Medial Collateral Ligament Instability

19
Knee Evaluation (Special Tests)

• Joint Instability
• Lateral Collateral Ligament Instability

20
Knee Evaluation (Special Tests)

• Joint Instability
• Anterior Cruciate Ligament (Lachmans 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

21
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

22
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
• Flexion-Rotation Drawer Test
• Knee is taken from a position of 15 degrees of
  flexion (tibia is subluxed anteriorly w/ femur
  externally rotated)
• Knee is moved into 30 degrees of flexion where
  tibia rotates posteriorly and femur internally
  rotates

23

• Joint Stability Tests
• Posterior Cruciate Ligament Stability
• Posterior Sag Test (Godfreys test)
• Athlete is supine w/ both knees flexed to 90
  degrees
• Lateral observation is required to determine
  extent of posterior sag while comparing
  bilaterally

24
Knee Evaluation (Special Tests)

• Other Posterior Cruciate Ligament Tests
• Posterior 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
• External Rotation Recurvatum Test
• With the athlete supine, the leg is lifted by the
  great toe
• If the tibia externally rotates and slides
  posteriorly there may be a PCL injury and damage
  to the posterolateral corner of the capsule

25
Knee Evaluation (Special Tests)

• Meniscal Pathology
• McMurrays 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
26
Knee Evaluation (Special Tests)

• McMurray Test Continued

Lateral Meniscus Test
27
Knee Evaluation (Special Tests)

• Meniscal Pathology
• Apleys Compression Test
• Hard downward pressure is applied w/ rotation
• Pain indicates a meniscal injury
• Apleys 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

28
Knee Evaluation

• Girth Measurements
• Changes in girth can occur due to atrophy,
  swelling and conditioning
• Must use circumferential measures to determine
  deficits and gains during the rehabilitation
  process
• Measurements 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 Rating
• Used to determine patients perception of pain,
  stability and functional performance
• Functional Examination
• Must assess walking, running, turning and cutting
• Co-contraction test, vertical jump, single leg
  hop tests and the duck walk
• Resistive strength testing

29
Knee Evaluation

• Q-Angle
• Lines which bisects the patella relative to the
  ASIS and the tibial tubercle
• Normal angle is 10 degrees for males and 15
  degrees for females
• Elevated angles often lead to pathological
  conditions associated w/ improper patella
  tracking
• The A Angle
• Patellar orientation to the tibial tubercle
• Quantitative measure of the patellar realignment
  after rehabilitation
• An angle greater than 35 degrees is often
  correlated w/ patellofemoral pathomechanics
• 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

30
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

31
Knee Rehabilitation

• Three simple keys
• Range of Motion
• Needed to increase motion and return to function
  as quickly as prudent and possible
• Strength
• Needed to deter further problems or protect the
  area of injury from further injury
• Functionality
• Needed to return the student-athlete or patient
  to normal daily activities within reason.

32
Knee Rehabilitation

• Range of Motion Theorys
• Passive ROM is the key to early ROM
• Active ROM starts and progresses as treatments
  continue
• Normal Knee ROM
• Knee Flexion 0o to 130o
• Knee Extension 130o to 0o

33
Knee Rehabilitation

• Passive Range of Motion Exercises
• Flexion Exercises
• Wall Hangs (assisting device is gravity)
• Towel Slides (assisting device is arms)
• Stationary Bike (assisting device is other leg)
• Extension Exercises
• Wall Hangs

34
Knee Rehabilitation

• Strengthening
• Closed Kinetic Chain
• Used early in rehabilitation
• More stable for the knee joint
• Exercise 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

35
Knee Rehabilitation

• Strengthening
• Open Kinetic Chain
• Also used early in rehabilitation
• Exercise include
• Quad Sets
• Hamstring Sets
• Straight Leg Raises in four directions
• Hamstring Curl Machine
• Leg Extension Machine

36
Knee Rehabilitation

• The controversy continues OKC vs. CKC

• CKC Research
• Decrease Tibial Translation 1
• More vastus medialis and lateralis muscle
  activity 2
• Greater patellofemoral compressive forces
• Increased compressive forces and co-contraction 2

• OKC Research
• Increase Tibial Translation 1
• More rectus femoris muscle activity 2
• Less patellofemoral compressive forces
• Increased shear forces and less co-contraction 2

37
Knee Rehabilitation

• Functionality
• Agility Drills / Training
• Ladder
• Dot Drills
• Plyometric Drills / Training