Stanbridge - T4 - TE2 - W4 - The Knee

Therapeutic Exercise II: The Knee

• This course covers therapeutic exercises for the knee, focusing on common knee pathologies.

Road Map

• Students will be able to identify key aspects of knee structure and function.
• Students will be able to implement therapeutic exercise programs for soft tissue and joint lesions.
• Students will understand how patellofemoral pain relates to abnormalities in the foot/ankle and hip/pelvis.
• Students will implement progressive therapeutic exercises for knee surgery patients based on healing stages.
• Students will demonstrate exercise progressions to improve range of motion (ROM), muscle performance, and lower extremity function.

Outline

• Knee Anatomy and Arthrokinematics: Focuses on knee joint structure and movement.
• Hypomobility; Articular Cartilage defects and TKA: Covers restricted movement and cartilage damage, including total knee arthroplasty (TKA).
• Meniscus Tears: Discusses meniscus injuries, including types of tears and treatment approaches.
• Ligament Injuries: Details various ligament injuries, with emphasis on the ACL and PCL.
• Patellofemoral Pathologies: Explores patellar tracking and pain syndromes..
• Exercise Techniques: Describes various exercise techniques, including ROM, flexibility, strengthening exercises, and plyometrics.

Bones and Joints of the Knee

• The knee is composed of the femur (thighbone), tibia (shinbone), patella (kneecap), and fibula (smaller lower leg bone).
• Key joints include the patellofemoral joint, tibiofemoral joint, and proximal tibiofibular joint.
• The meniscus is a C-shaped cartilage that cushions the joint.
• Ligaments support the knee joint, providing stability.

Screw Home Mechanism of Knee

• The knee's screw-home mechanism describes the slight rotation of the tibia on the femur during extension.
• Internal rotation of the femur in weight-bearing.
• This rotation helps the knee lock into extension to keep it stable when standing or walking.

Applying Arthrokinematics

• To improve knee flexion, anterior-posterior glide of the tibia is needed on the femur.
• Inferior glide of the patella needed to mimic motion in the trochlear groove.
• Posterior-anterior glide of the tibia over femur for extension.
• Superior gliding of the patella is associated with extension.

Common Nerve Sources of Nerve Pain

• Anterior knee pain – L3 nerve root
• Posterior knee pain – S1 and/or S2 nerve root

Osteoarthritis of the Knee

• Osteoarthritis (OA) is a degenerative condition causing pain, muscle weakness, and restricted joint motion
• Individuals over 65 have a 1/3 chance of developing OA
• Genu varum (bowlegs) is a common deformity in people with knee OA.
• Obesity, prior joint trauma, and developmental deformities may increase risk of OA

Knee Hypomobility

• This describes reduced knee mobility.
• Contributing factors include adhesions/contractures, reduced patellar mobility (extensor lag), and swelling.
• Symptoms include pain, reduced ROM, and impaired balance.

Acute Phase of Knee Hypomobility

• The management focus is pain control, protecting the joint, maintaining soft tissue and joint mobility using PROM and Grades I and II joint mobilization techniques and maintaining muscle function to prevent patellar adhesions.

Subacute and Chronic Phases of Knee Hypomobility

• Managing pain from mechanical stressors
• Adjusting biomechanics and training
• Improving ROM
• Strengthening supporting muscles
• Functional training and cardiopulmonary endurance using methods based on SAID principle.
• Implementing assistive devices as needed.

Total Knee Arthroplasty

• Indications for surgery include severe joint pain, significant cartilage destruction, gross instability or motion limitation, and treatment failure after non-surgical interventions.
• Post-operative management involves immobilization, controlled weight-bearing, and progressive CPM and exercises as tolerated according to the rehabilitation protocol.
• Rehabilitation phases include a maximum protection phase, a moderate protection phase, and a minimum protection phase leading to return to activity.

Maximum Protection Phase

• Manage vascular/pulmonary complications
• Control joint pain and swelling
• Maintain/improve strength of the contralateral limb
• Regain ROM in the knee
• Improve trunk stability/balance
• Establish functional mobility

Moderate Protection Phase

• Strength & endurance of knee and hip.
• Maintaining and increasing knee ROM.
• Improve stability in standing postures
• Improve function
• Improve cardiopulmonary endurance

Minimum Protection Phase

• Improving task specific strengthening exercises for functional activities
• Proprioceptive & balance training
• Advance functional training
• Improving cardiopulmonary endurance

Mobility Exercises

• Traditional/static stretching
• AAROM (active assisted range of motion)
• LLLD (lying-leg-lowering) stretches

Review Questions

• Questions cover the screw-home mechanism, common knee deformities (genu varum), impairments associated with knee hypomobility, and treatment options for various knee conditions.

Articular Cartilage Defects

• Cartilage damage frequently associates with ligament or meniscus injuries.
• Surgical options include microfractures, osteochondral autograft/mosaicplasty, autologous chondrocyte implantation, or osteochondral allograft implantation,.

Microfracture

• Arthroscopic repair method to treat minor cartilage defects.
• Improves fibrocartilage over the damaged area by stimulating bone marrow-based repair processes.

Osteochondral Autograft Transplantation/ Mosaicplasty

• An arthroscopic or mini-open procedure, transplanting intact articular cartilage with underlying bone.
• Utilizes plugs to fill gaps in cartilage.

Autologous Chondrocyte Implantation

• Two-stage procedure: harvest and culture cartilage cells, followed by implantation and patch covering damaged area.

Osteochondral Allograft Transplantation

• Used for larger defects transferring intact cartilage from a cadaver.
• Critical to use fresh grafts ,as freezing processes damage the chondrocytes.

Postoperative Management (Articular Cartilage Defects)

• Check operative report & protocol to know treatment plans and activities that are contraindicated.
• Confirm weight-bearing status
• Determine treatment based on tissue affected, location of tissue, function of tissue affected

Vascularity of the Menisci

• Peripheral meniscus outer third is highly vascularized, while the center and inner portions are relatively avascular.

Common Impairments/Functional Limitations: Meniscus Tears

• Locking, catching, restricted range of motion, springy end feel on passive extension, swelling, and/or pain and giving way during weight bearing.

Operative Management: Meniscus Tears

• Partial meniscectomy
• Meniscus repair
• ROM is restricted in the first 4 weeks from 0 to 90 degrees
• NWB (non weight bearing) x 4-6 weeks, with a knee brace in extension,.

Meniscectomy vs. Repair

• Meniscectomy patients have a maximum protection phase of 3-4 weeks.
• Meniscus repair involves a maximum protection phase for 4-8 weeks. Weight bearing protocol is altered based on the location of the meniscus repair.

Meniscal and Articular Cartilage Lesions: Evidence-Based Treatment

• Key components of successful rehabilitation include therapeutic exercises that target neuromuscular stimulation of quadriceps, progressive knee motion, and progressive return to activity exercises.

Review (general)

• Review questions cover articular defects, total knee replacement rehabilitation, meniscus tear diagnoses, and activity modifications post meniscus repair or surgery, providing a complete look at all knee rehabilitation phases.

Knee Anatomy and Arthrokinematics

• Covers the structure and biomechanics of the knee, detailed knee anatomy, and arthrokinematics of the knee joint.

Ligament Injuries

• Overview of various ligament injuries in the knee, focusing on the ACL, PCL, MCL, LCL.
• Origin, insertion, roles, and common mechanisms of injuries (MOI) for each ligament are discussed.
• Key motions are considered for each ligament for acute and subacute phases.
• The rehabilitation goals for surgical interventions (PCL, ACL) in healing phases are described .

Anterior Cruciate Ligament (ACL)

• Key characteristics/ functions—originates on the medial aspect of the lateral femoral condyle.
• It runs through the intercondylar notch, connecting to the anterior aspect of the tibial.
• The ACL has 2 bundles with specific functions (Anteromedial- checks flexion. Posterolateral—checks extension.)
• The ACL is critically important for maintaining stability
• The ACL plays key roles in checking extension, medial rotation and anterior tibial translation of the tibia (ranges in degrees).
• Epidemiology- Frequency and high rates associated with pivoting, quick cuts, pivots, rapid stopping and directional changes affecting mostly female athletes. -Mechanism of Injury (MOI): Contact (high incidence in females) and non-contact injuries (more common in females), with excessive valgus(knock-knees) are major factors
• Females have 4-6 times greater risk to suffer ACL injury than male athletes.
• Treatment options include non-operative methods to avoid anterior tibial shear or operative methods (including hamstring autograft, patellar tendon autograft, and cadaver allograft).
• The study highlights that there are no significant differences among various graft types after 5 years

Posterior Cruciate Ligament (PCL)

• Functionally checks extension, medial rotation, and posterior tibial translation -Epidemiology, MOI, and Treatment (non-surgical versus surgical; importance of resistance exercises; and initial resistance placement are highlighted)

Collateral Ligaments (MCL & LCL)

• Knee stability: MCL and LCL stabilizes medial rotation, hyperextension, etc and valgus (knee stress) ( MCL and varus (knee stress) (LCL).
• Management: Conservative treatment protocols related to tissue healing phases (Chapter 10) including Table 21.4.

Knee Ligament Sprain Evidence

• Evidence-based treatment approaches, including the use of therapeutic exercises, immediate versus delayed mobilization, supervised rehabilitation, neuromuscular electrical stimulation, accelerated rehabilitation (ACL reconstruction), and eccentric strengthening.

PFJ Pain

• Common causes for PFJS (Patellofemoral Joint Syndrome).
• Structures affected/ involved in PFJS (Q Angle—patellar position—muscle and fascia weakness and tightness).
• Symptoms and treatment options covered by the lectures.

PFJ Pain Management

• Acute phase—modalities to address pain.
• Sub acute and Chronic phase—modifying biomechanical factors, exercises that increase endurance, strength, and dynamic control, as well as addressing pain-free mobility and altering movement strategies or patterns.
• Focus on improving stability of trunk, pelvis, and balance abilities.

Review (PFJ) Questions

• Comprehensive review questions regarding PFJS—including the mechanics of pain, identifying contact areas, and determining most beneficial strength training angles.

Exercise Techniques

• ROM, Flexibility, OKC (open kinetic chain), CKC (closed kinetic chain), Plyometrics drills.

Plyometrics

• Stretch shortening drills
• Increasing muscle strength and power output, through improving neuromuscular reactions; and coordinating movement patterns.

Plyometrics Progressions

• Begin with movements (DL-dominant leg) and progress to more complex movements (SL-single leg) by adding step counts, while maintaining proper form and mechanics.
• Training can begin by adding movement to the base of support, such as jumping squats and/or jumping over obstacles.
• Exercises can progress by beginning bilateral movements (DL) then moving to unilateral (SL) by alternating legs, and adding more reps within a set time.
• The key is to maintain proper form, and progressing to include more distance/speed over time (by adding distance within a step progression.

Plyometric Determinants

• Speed and intensity—important factors requiring gradual increases in resistance and/or speed to help avoiding decreased activity.

Plyometric Contraindications

• Contraindications—presence of pain or inflammation or significant joint instability.
• Precaution—the use of proper precautions and protocols must be taken to avoid injuries

Criteria to Implement Plyometrics

• 80-85% strength of contralateral limb
• 90-95% pain-free ROM in joints
• Adequate strength and stability of proximal joints

Plyometrics Determinants

• Number of reps that should be completed within a specified time; increasing reps gradually and number of activities.
• Frequency—2x/week
• Duration—8-10 weeks (maximum benefit)

Review (General)

• Comprehensive review questions encompassing general topics in knee rehabilitation, including the function, mechanisms of injury, healing phases and treatment strategies for each condition and related surgeries.