Noush - TE2 - Knee

Review of Knee Structure and Function

• Knee: Identify important aspects of its construction and how it functions

Knee Soft Tissue and Joint Lesions

• Manage therapeutic exercise programs for soft tissue and joint lesions in the area
• Relate the program back to stages of recovery and following an inflammatory insult to the tissues

Patellofemoral Pain Cause

• Comprehend how abnormalities in the foot/ankle and hip/pelvis relate to patellofemoral pain

Management of Post-Surgical Patients

• Implement an exercise program managing patients after surgeries based on stages of healing

Exercise Progressions

• Show exercise progressions in order to improve different things
• Exercise progressions to develop and improve ROM
• Exercise progressions to develop and improve muscle performance
• Exercise progressions to develop and improve the functional use of the knee and adjacent lower extremity regions

Knee Anatomy and Arthrokinematics

• Includes key facts about anterior knee: L3 nerve root
• Includes key facts about posterior knee: S1 and S2 nerve root

Screw Home Mechanism While WB (CKC)

• Foot must be planted on the ground
• The IR of the femur is followed by hip extension
• Hip extension will fully lock the knee

Screw Home Mechanism to Unlock Knee

• Tibia must be locked
• Popliteus contracts and will cause femoral ER
• ER will cause knee to flex and and hip to flex
• How might someone lacking full hip extension be affected?

Screw Home Mechanism- Open Chain

• Tibia is free, must externally rotate on the fixed femur
• The external rotation occurs during the last 20 degrees of extension in both open and closed chain postures

Knee Flexion Gains

• To increase knee flexion, anterior to posterior glide of the tibia on the femur
• Also, inferior patellar glide mimics trochlear groove movement

Knee Extension Gains

• To increase knee extension, posterior to anterior glide of the tibia on the femur
• Also, superior patellar glide mimics trochlear groove movement

Osteoarthritis (OA) of the Knee

• This is the same as DJD
• ⅓ of those 65+ have OA
• Includes pain, muscle weakness, medial joint laxity, and limited motion
• Genu varum is a common deformity with OA
• Contributing factors: obesity, joint trauma, developmental deformities, quad weakness, abnormal tibial rotation

Knee Hypomobility

• Caused by traumatic arthritis, RA, or immobilization
• Adhesions and contractures lead to decreased patellar mobility, pain, and extensor lag
• Capsular pattern will be flexion greater than extension
• Joint effusion will result in a position of 25 degrees knee flexion

Hypomobility Signs/Symptoms

• Distension and stiffness in the knee
• Pain and reflex quadriceps inhibition present
• Extensor lag and lack of balance due to proprioception

Hypomobility: Acute Symptoms

• Pain with motion, WB, and gait
• Difficulty with WB activities needing flexion like sitting to stand or squatting

Hypomobility: Chronic Symptoms

• Extremely limited in physical activity and leisure participation

Hypomobility: Acute Phase

• Control pain and protect the joint by patient education and functional adaptations
• Grade I-II joint mobs with PROM can maintain soft tissue and joint mobility

Hypomobility: Muscle Function

• Isometric contractions can maintain muscle function when appropriate to prevent patellar adhesions

Hypomobility: Subacute and Chronic

• Educate the patient
• Retrain biomechanics along with activity modification to reduce mechanical stress and pain
• Progress to grades III/IV mobs to increase joint play and ROM
• Increase muscle performance in supporting by using PRE
• Using the SAID principle, train in functional activity while focusing on cardiopulmonary function

Hypomobility: Functional Training

• Practice step-ups and step-downs
• Practice sit to stands and mini squats to 90 degrees
• Practice partial lunges and balance with normal ambulation

Total Knee Arthroplasty (TKA): Indication

• Severe joint pain with WB
• Extensive destruction of the articular cartilage
• Marked deformity such as genu varum or gross instability
• Limitation of motion
• Failure of non-operative treatment

TKA: Post-Op Management

• Refer to table 21.2, Phases of Rehab
• Knees immobilized
• Refer to pg. 69 CPM for goals and guidelines
• Refer operative report to check prosthesis and protocol
• Refer to Box 21.3 & 21.4 for exercise precautions and recommendations

TKA Management: Max Protection Phase

• Prevent vascular and pulmonary function complications
• Control pain and swelling while minimizing strength loss specifically at the hip and knee
• Increase knee ROM and trunk stability with balance
• Re-establish function

TKA Management: Moderate Protection Phase

• Increase knee ROM
• Increase strength and endurance specifically at the hip and knee
• Standing endurance and trunk stability also improved
• Functional mobility restored along with cardiopulmonary endurance

TKA Management: Minimum Protection Phase

• Advanced functional training occurs
• Task-specific strengthening exercise assigned
• Proprioception and balance training
• Cardiopulmonary endurance training

Mobility Exercise

• Use as static stretch, AAROM etc
• Do extension and flexion as needed.

Articular Cartilage Defects: Surgical

• Complex due to capacity to heal
• Surgeries include: Microfracture, Osteochondral autograft, mosaicplasty, Autologous chondrocyte implantation, Osteochondral allograft implantation
• Microfracture: repair to small defects using arthroscopic approach stimulate fibrocartilage through marrow response;
• Osteochondral Autograft Transplantation/ Mosaicplasty: arthroscopic procedure is mini open procedure and takes cartilage
• Bone to bone graft: filling multiple plugs to fill a hole that can be used
• Autologous chondrocyte implantation (Autograft) is for full thickness chondral; the stage is articular 1. cartilage is harvested a nd is cultured and can the stage 2, where it is them covered with a patch and implanted;
• Osteochondral allograft can be used with there in a defection 4cm square. where use the cardilate comes from cadaver, which will include the Fresh Intact Cartilage

Articular Cartilage Defects: Management

• Check Operative report & Protocol also be sure to confirm the weight bear status, and consider each of the affects that will include to tissue damage. The location that was affected and what functions is affected.

Menisci: Vascularity

• Peripheral (outer ⅓) is highly vascular
• Central (middle ⅓) is relatively avascular
• Inner (inner ⅓) is completely avascular

Meniscus Tears: Common Impairments/Functional Limits

• Includes locking and/or catching in the knee
• There is restriction along the tibiofemoral joint line along with pain that passive extension will trigger a springy end feel
• Can also include swelling
• Weight bearing results in pain

Meniscus Tears: Operative Treatment

• Operative repair and Operative repair is restricted from 0-90 degrees during weeks one through four for weight Bering which there is with NWB and knee brace in extension over the cause if 4 to 6 weeks.

Meniscus Tears Post-Op

• No evidence of difference between physical therapy alone vs surgery
• Maximum care is needed before doing gradual exercises and the addition of load

###Meniscectomy vs Repair

• Follow protocols that includes restriction limitation which then be sure to includes location during for the WB

Meniscus Rehabilitation

• Requires therapeutic exsercises, and neuromuscular Stimulation and progressive knee motion
• Also Needs progress of turn to the activity level, in the area of the progressive need to have conflicting option to best approach, in the area supervision has has a supervision and should need to also work on Articular
• Cartilage, and which can be found in chapter 21

Ligaments: Anterior Cruciate Ligament (ACL)

• Originates in the posteromedial lateral femoral condyle then inserts on anterior tibia between the M/L Menisci
• It runs through intercondylar notch
• There's two bundles that include: Anteromedial
• It include the posterolateral part as a whole of - which includes: Medial extension/medil rotation extension; and Anterolateral extension

ACL Injuries

• 44 million people participate
• 200,000 are Annual raptures
• Highest reported ACL injury are in sports involving: piviting, stopping cutting, & Directional changes

ACL Mechanism

• MOI/ contact
• Non contract the high change, includes planting Twisting
• the landing on extended knee
• and deceleration which comes the form quad contraction and aterior tilt

ACL Injury Risks

• Post pubertal is Athlete are for - " 4 6 times more likely to suffer
• Athlete prior that it be great list of return
• Re-tear can happen: like Women that is torn and and are man be there is

ACL management

• You can choose between Operatiive And no non-OP
• Non-operative: avoid anterior tibial shear
  • Pro: Cons strength
• Operative is -Hamstrings /Patellar, and Cadaver Autograph
  • graft will help

ACL Graft outcome

• Both are the some of significant the different outcome if life
• Traumatic re-injury were less prevalent for this graft

Graft Placement During ACL-R

• Use Patella, Reconstructed
• ACL/Tibia

ACL Management (Post-Op)

• Should avoid quad 0-45 flex
• 60/90 flex is to needed if CKC and and - Limit is need to limit for the Auto Graft (HS) / around 6 weeks
• Graft re-modeling and Vascular can takes awhile

ACL Management

• Return for activity can take one year with immobilization that is limited with a locked bracing
• Stress will graft during the 0-3- degree; extension degree which then has to be decreased with EXTAG for full extention, of 90 110 degree within 46 weeks

ACL: Maximum Protection Phase

• PROM patella/ with modality and to reduced the stress
• Education on protecting of graph + the neuromuscular
• Control will allow better prep of step with stability and balance

ACL: Next Level Progress

• Minimal pain will do great and the active
• Will be there to at least 75 and 6%
• Hamstring and to is to stability should all need to follow the next stage

ACL: Moderate Protection

• And there should be a motor rotation with is for for and not be moving it for the next
• Strength has been muscle to this is and in the muscular control with gait a 2.4 and to this is this that will follow for the step to

ACL: Moderate Protection (Progress)

• Muscle will get to at least 95%
• This will be a normal the 65% is that 70%

ACL: Minimum Protection Phase

• Re-tear the for that it the to
• Sport. there to for

“Terrible Triad" = "Unhappy Triad" involves tears of the medial meniscus, MCL, and ACL

PCL in Knee Ligaments

• Attach Posterior and lateral tibia by medial and
• Taught. In flexion thicker that medial rotation
  • M.L is the best
• Thicker which are rotation

###PCL Mechanisms

• Anterior is a direct at first it in
• Flexing is and the direction can happen full time

PCL Considerations

• Avoid that a post
• Strong do can
• Resistance must be the

Lateral Collateral Ligaments: treated are of

1. A is is to be

• B. Is and is and
• c to is and

1. The is it. 2 Is it. 3

PF:

• The is it at it or
• Or is 0 or
• Normal to 15 d

Structures from Q Angle

• with: W or
• is- it be w.
• that is it that 1: The 2: a

Alignment:

• the or
• The is

ITB or

• Prevent the
• Rot rotation can
• The to
• Tight