Therapeutic Exercise II PDF - The Knee

Therapeutic Exercise II PTA 1010 The Knee  Road Map By the end of this presentation the student should be able to: Identify important aspects of knee structure and function for review Implement a therapeutic exercise program to manage soft tissue and...

Therapeutic Exercise II PTA 1010 The Knee  Road Map By the end of this presentation the student should be able to: Identify important aspects of knee structure and function for review Implement a therapeutic exercise program to manage soft tissue and joint lesions in the knee region related to stages of recovery after and inflammatory insult to the tissues Understand how patellofemoral pain can result from abnormalities at the foot/ankle and hip/pelvis Implement a progressive therapeutic exercise program to manage patients following common surgical procedures for the knee based on the stages of healing Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the knee and adjacent lower extremity regions © Stanbridge University 2023 2  Outline Knee Anatomy Hypo-mobility; and Articular Cartilage Meniscus Tears Arthrokinematics defects and TKA Patellofemoral Exercise Ligament Injuries Pathologies Techniques © Stanbridge University 2023 3 Bones and Joints of the Knee Kisner Fig 21.1 Patellofemoral Joint Tibiofemoral Joint Proximal Tibiofibular Joint © Stanbridge University 2023 4  Screw Home Mechanism of Knee WEIGHT BEARING (CKC) the foot is planted on To unlock the knee: the ground The tibia is fixed The popliteus contracts IR of femur hip extends to lock knee causes femoral ER Knee flexes & hip flexes How does this affect someone lacking full hip extension? © Stanbridge University 2023 5  Screw Home Mechanism of Knee OPEN CHAIN Tibia is free and must externally rotate on the fixed femur Occurs during last 20 degrees of extension in both open and closed chain postures © Stanbridge University 2023 6  Applying Arthrokinematics To increase Knee flexion: Anterior to posterior glide of the tibia on the femur Inferior patellar glide to mimic movement in trochlear groove © Stanbridge University 2023 7  Applying Arthrokinematics To increase Knee extension: posterior to anterior glide of the tibia on the femur superior patellar glide mimic movement in trochlear groove https://sites.google.com © Stanbridge University 2023 8  Common Nerve Sources of Nerve Pain Anterior knee: L3 nerve root Posterior knee: S1 and S2 nerve root © Stanbridge University 2023 9  Outline Knee Anatomy Hypomobility; and Articular Cartilage Meniscus Tears Arthrokinematics defects and TKA Patellofemoral Exercise Ligament Injuries Pathologies Techniques © Stanbridge University 2023 10  Osteoarthritis of the Knee Osteoarthritis = DJD 1/3 of individuals >65 years of age have OA Impairments include pain, muscle weakness, medial joint laxity, and limited joint motion Genu varum is a common deformity © Stanbridge University 2023 11  Osteoarthritis of the Knee Contributing factors include: – Obesity – Previous joint trauma – Developmental deformities – Weakness of the quadriceps – Abnormal tibial rotation © Stanbridge University 2023 12  Knee Hypomobility Post traumatic arthritis- from bleeding in the joint and repetitive microtrauma RA- as the disease advances the knees may become involved Post immobilization hypomobility © Stanbridge University 2023 13  Knee Hypomobility Adhesions and contractures→ causing decreased patellar mobility→ pain and extensor lag Capsular pattern: flexion> extension Joint effusion- the knee assumes a position near 250 of flexion © Stanbridge University 2023 14  Hypomobility of the Knee Signs and Symptoms include: – Distension – Stiffness – Pain – Reflex quadriceps inhibition – Extensor lag – Impaired balance- decreased proprioception © Stanbridge University 2023 15  Hypomobility of the Knee Acute symptoms: – Pain with motion, weight bearing, and gait – Difficulty with weight bearing activities that require knee flexion such as sit to stand and squatting Chronic end stage arthritis: – physical activity is extremely limited with less participation in leisure activities © Stanbridge University 2023 16  Hypomobility of the Knee Acute Phase: 1.Control pain and protect the joint Patient education Functional adaptations 2.Maintain soft tissue and joint mobility PROM Joint mob Grade I and II 3.Maintain muscle function and prevent patellar adhesions Isometric contractions around the joint © Stanbridge University 2023 17  Hypomobility of the Knee Subacute and Chronic phases ✓ Patient education ✓ Decrease pain from mechanical stress (activity modification) and assessment and retraining biomechanics ✓ Assistive devices as needed ✓ Increased Joint Play and ROM -> progress to grades III/IV mobs ✓ Improve muscle performance in supporting (PRE) ✓ Functional training based on the SAID principle ✓ Improve cardiopulmonary endurance © Stanbridge University 2023 18  Hypomobility of the knee Functional training www.oth603competency.weekly.com Step up and Step-down exercises Sit to stand and mini squats to 900 Partial lunges Balance activities Ambulation www.acefitness.org © Stanbridge University 2023 19  Total Knee Arthroplasty Indications for surgery – Severe joint pain with weight bearing – Extensive destruction of the articular cartilage – Marked deformity such as genu varum – Gross instability or limitation of motion – Failure of non-operative treatment © Stanbridge University 2023 20  Total Knee Arthroplasty Post operative management -Table 21.2 Phases of Rehabilitation Immobilization- knee immobilizer CPM- Goals and guidelines pg. 69 Weight bearing is dependent on the type of prosthesis- check operative report and protocol - Box 21.3 Exercise Precautions - Box 21.4 Recommendations for Participation © Stanbridge University 2023 21  Total Knee Arthroplasty Maximum Protection Phase – Prevent vascular and pulmonary complications – Control pain and swelling – Minimize decreased strength in hip and knee – Maintain/improve strength of contralateral limb – Regain knee ROM – Improve trunk stability and balance – Reestablish functional mobility © Stanbridge University 2023 22  Total Knee Arthroplasty Moderate Protection Phase – Increased strength and endurance of knee & hip – Continue to increase knee ROM – Improve standing balance and trunk stability – Continue to improve functional mobility – Improve cardiopulmonary endurance © Stanbridge University 2023 23  Total Knee Arthroplasty Minimum Protection Phase – Task-specific strengthening exercises – Proprioceptive and balance training – Advanced functional training – Cardiopulmonary endurance © Stanbridge University 2023 24  Mobility exercises: Performed as traditional static stretch, AAROM, or LLLD stretching To Increase Extension To Increase Flexion Kisner Fig 21.18 Kisner Fig 21.19 © Stanbridge University 2023 25  Review Describe the screw home mechanism in the knee in both closed and open chain. What is a common deformity with OA of the knee? What compartment of the knee is degenerated with this deformity? What are common impairments associated with knee hypomobility? What are treatment options for each phase of healing with knee hypomobility? © Stanbridge University 2023 26  Articular Cartilage Defects Injuries of ligaments or menisci of the knee are often associated with damage to the articular cartilage of the knee www.boneandspine.org © Stanbridge University 2023 27  Articular Cartilage Defects Successful surgical management of chondral defects is challenging due to their limited capacity to heal Surgical management options include – Microfracture – Osteochondral autograft, mosaicplasty – Autologous chondrocyte implantation – Osteochondral allograft implantation © Stanbridge University 2023 28  Articular Cartilage Defect Microfracture Repair of small defects arthroscopic Penetrates subchondral bone to stimulate marrow-based repair response of fibrocartilage over the defect www.boneandspine.org © Stanbridge University 2023 29  Articular Cartilage Defect Osteochondral Autograft Transplantation/ Mosaicplasty Arthroscopic or mini open procedure Transplantation of intact articular cartilage along with some underlying bone Bone to bone graft Multiple plugs to fill a hole can be used www.intechopen.com © Stanbridge University 2023 30  Articular Cartilage Defect Autologous chondrocyte implantation (Autograft) For full thickness chondral & osteochondral lesions (2-4cm2) 2 stages: 1. Articular cartilage is harvested (arthroscopic), cultured for several weeks 2. implanted (open) and covered with a patch www.researchgate.net 31 © Stanbridge University 2023  Articular Cartilage Defect Osteochondral allograft transplantation – For defects larger than 4cm2 – Intact cartilage from a cadaver – Must be fresh, freezing process ruins the chondrocytes Other procedures: If there is a concomitant pathology then surgical repair must be performed for the cartilage repair to be successful © Stanbridge University 2023 32  Articular Cartilage Defect Postoperative Management Check Operative report & Protocol Confirm weight bearing status Consider each surgery- What tissue was affected? Where is the tissue located? What functions does this affect? Special Considerations Box 21.2 © Stanbridge University 2023 33  Vascularity of the Menisci Peripheral Zone: outer 1/3: highly vascular Central 1/3: relatively avascular Inner 1/3: avascular Kisner Fig 21.17 © Stanbridge University 2023 34  Common Impairments/ Functional Limitations: Meniscus Tears Locking of the knee Catching of the knee Restricted ROM with pain at end range of motion along the tibiofemoral joint line Passive extension: may have springy end feel Swelling Pain and/or giving way during weight bearing © Stanbridge University 2023 35  Meniscus Tears Operative Management: 1. Partial meniscectomy 2. Meniscus repair ROM restricted from 0-90 degrees during first 4 weeks NWB x 4-6 weeks with knee brace locked in extension © Stanbridge University 2023 36  Meniscus Evidence There is no difference between pain and functional outcomes in symptomatic patients who had a meniscal tear and imaging of mild to moderate arthritis who were assigned to surgery with post op physical therapy or physical therapy alone. Katz et al., The New England Journal of Medicine, 2013 © Stanbridge University 2023 37  Meniscectomy vs Repair Meniscectomy Meniscus Repair Maximum and moderate protection Maximum protection phase 4-8 weeks phases 3-4 weeks Check protocol All exercises should be pain free and progressed gradually WB restrictions and ROM limitations built into the protocol based on Cautiously add high impact exercises location of repair and activities © Stanbridge University 2023 38  Meniscal and Articular Cartilage Lesions: Evidence Altman et al, JOSPT, 2010 B Therapeutic exercises B Neuromuscular stimulation (quads) C Progressive knee motion (early motion) C Progressive return to activity (meniscus) D Progressive weight bearing (Conflicting opinions on best approach) D Supervised rehabilitation (vs home exercise) E Progressive return to activity (articular cartilage) © Stanbridge University 2023 39  Review What is an articular defect and the possible surgical methods to treat the pathology? What are the goals of each phase of healing after a total knee replacement? What are the common functional impairments and signs and symptoms associated with a meniscus tear? What activities are last to be added to the rehab post surgically after a meniscus tear? © Stanbridge University 2023 40  Outline Knee Anatomy Hypomobility; and Articular Cartilage Meniscus Tears Arthrokinematics defects and TKA Patellofemoral Exercise Ligament Injuries Pathologies Techniques © Stanbridge University 2023 41  Anterior Cruciate Ligament (ACL) Originates from posteromedial lateral femoral condyle→ inserts on anterior tibia b/w the horns of the M/L menisci Runs through intercondylar notch Two bundles: anteromedial (checks flexion) posterolateral (checks extension) As a whole: -Checks extension, medial rotation & anterior translation of the tibia (0-20, 70-90 degrees) © Stanbridge University 2023 42  ACL www.proactive4pt.com © Stanbridge University 2023 43  ACL Injuries 44 million kids participate in athletics annually Over 200,000 ACL ruptures occur annually Highest reported ACL injury rates in sports involving pivoting, rapid stopping, cutting and directional changes www.excelleport.com © Stanbridge University 2023 44  ACL Injuries MOI: www.youtube.com Contact injury Noncontact injury: higher incidence in females Planting and twisting: excessive dynamic valgus Landing on extended knee Deceleration injury: strong quad contraction, anterior tibial shear forces © Stanbridge University 2023 45  ACL Injuries Post-pubertal adolescent female athletes are 4-6 times more likely to suffer an ACL Injury than their male counterparts Athletes with prior ACL injury are at greater risk for future ACL injury Re-tear trend after return to sport – Women- tear opposite ACL – Men- re-tear same graft © Stanbridge University 2023 46  ACL Management Non-operative: avoid anterior tibial shear -Pros/Cons -Hamstrings strength is important (What affect does the hamstring have on the tibia?) Operative: -Hamstrings Autograft (Box 21.10) -Patellar tendon Bone Autograft (Box 21.9) -Cadaver Allograft © Stanbridge University 2023 47 Which type of graft in better in the long run? © Stanbridge University 2023 48 ACL graft outcomes © Stanbridge University 2023 49 ACL-R Graft Placement © Stanbridge University 2023 50  ACL Management Table 21.6 pg 812 Postoperatively: (for 6+ weeks) -Avoid OKC quad strengthening : 0-45 degrees of flexion -Avoid CKC: 60-900 flexion -Limit prone resisted extension for HS (HS autograft) for ~ 6 weeks Graft remodeling and revascularization © Stanbridge University 2023 51  ACL Management Return to activity takes about 1 year Post op care – Immobilization- Range limiting, locked brace, typically locked in extension for the 1st 6 weeks for ambulation – Greatest stress of graft is between 0-200 extension- decrease ext lag with SLR – Full active knee extension is expected and 90-1100 knee flexion (PROM) by 4-6 weeks © Stanbridge University 2023 52  ACL Management Maximum Protection Phase Early PROM, patellar mobility Modalities for swelling Patient education for graft protection Neuromuscular control, proprioception, stability and balance © Stanbridge University 2023 53  ACL Management Maximum Protection Phase Criteria to progress to the next level – Minimal pain and swelling – Full, active knee extension – At least 1100 knee flexion (PROM) – At least 50-60% quadriceps strength – No evidence of joint laxity – Per PROTOCOL © Stanbridge University 2023 54  ACL Management Moderate Protection/Controlled Motion Phase – ROM and Joint mobility – Grade III for knee FLEXION – No mobilization into extension – Strength and muscle endurance – Neuromuscular control – Gait training – Aerobic conditioning – Activity-specific conditioning © Stanbridge University 2023 55  ACL Management Moderate Protection/Controlled Motion Phase Criteria to progress to the next phase – Absence of pain and joint effusion – Full, active knee ROM – At least 75% knee musculature strength of contralateral side – Hamstring/quadriceps ratio >65% – Functional hop test >70% of contralateral side – No evidence of knee instability © Stanbridge University 2023 56  ACL Management Minimum Protection Phase/Return to Function Phase Return to activity – Box 21.11 Return to Sport Criteria © Stanbridge University 2023 57  “Terrible Triad” = “Unhappy Triad” Kisner Fig. 21.13 Injury involving tears of the medial meniscus, MCL, ACL © Stanbridge University 2023 58 © Stanbridge University 2023 59 © Stanbridge University 2023 60  Posterior Cruciate Ligament Anterior/medial femoral condyle → Posterior/lateral tibia A/L band: taught in flexion P/M band: taught in extension Thicker & stronger cruciate ligament Checks extension, medial rotation, posterior translation of the tibia -M/L stability © Stanbridge University 2023 61  PCL Injuries Method of injury: Posteriorly directed force on anterior proximal tibia i.e. MVA- dashboard Falling on flexed knee with foot plantar flexed Anterior directed force on hyper extended or fully extended knee (multi-directional instability) © Stanbridge University 2023 62  PCL Injury Management Non-operative vs. Operative Care Box 21.13 Avoid exercises and activities that place excessive posterior shear forces on the tibia -Postpone resistance training to the hamstrings Importance of strong quadriceps Initially: place resistance above the knee during open chain hip strengthening exercises © Stanbridge University 2023 63  Collateral Ligaments Medial Collateral Ligament -Medial epicondyle → meniscus, flare of the tibia -Broad, fan shaped -Checks extension, hyperflexion, lateral rotation -Injured with valgus stress to the knee, etc. © Stanbridge University 2023 64  Collateral Ligaments Lateral Collateral Ligament -Lateral femoral epicondyle→ fibular head -Popliteus tendon runs beneath it -Checks hyperextension, lateral rotation -Injured with varus stress to the knee, etc. © Stanbridge University 2023 65  Collateral Ligaments MCL and LCL rehabilitation Treated conservatively by tissue healing phases in chapter 10 MCL Intervention – Table 21.4 © Stanbridge University 2023 66 Knee Ligament Sprain Evidence Logerstedt et al, JOSPT,2010 A Therapeutic exercises B Immediate vs delayed mobilization B Supervised rehabilitation B Neuromuscular electrical stimulation (quadriceps) B Accelerated rehabilitation (ACL reconstruction) B Eccentric strengthening © Stanbridge University 2023 67  Knee Ligament Sprain Evidence Logerstedt et al, JOSPT, 2010 C Cryotherapy C Knee bracing C Early weight bearing C Continuous passive motion © Stanbridge University 2023 68  Review What is the role of each of the 4 major ligaments of the knee? What are mechanisms of injury (MOI) for each of the ligaments? What are the motions of the knee that are protected for each of the ligaments during the acute and subacute phases of healing? What are the post surgical goals for each of the healing phases after PCL and ACL surgery? © Stanbridge University 2023 69  Knee Anatomy Hypomobility; and Articular Cartilage Meniscus Tears Arthrokinematics defects and TKA Patellofemoral Exercise Ligament Injuries Pathologies Techniques © Stanbridge University 2023 70  Patellafemoral Joint Sesmoid bone buried in the quadriceps tendon It is connected to the tibia via the patellar ligament As the knee flexes, the patella enters the intercondylar groove with its inferior margin making contact first www.patellofemoral.org Patellar points of contact on femur through knee flexion ROM 71 © Stanbridge University 2023  Patellofemoral Joint (PFJ) Patella: increases moment arm of the quadriceps Alignment is influenced by: 1. Line of pull of the quadriceps 2. Attachment of the patellar tendon to the tibial tubercle 3. Q angle 4. Dynamic alignment of the limb © Stanbridge University 2023 72  Q- Angle Intersection of the 2 lines represent the bowstringing effect on the patella from the pull of the quadriceps muscle and the patellar tendon Large Q-angle → excessive lateral patellar tracking Normal Q-angle: 10-15 degrees Kisner Fig 21.3 © Stanbridge University 2023 73  Q Angle With an increased Q angle there is increased pressure of the lateral facet against the lateral femoral condyle Structurally occurs with: – Wide pelvis – Femoral anteversion – Coxa vara – Genu valgum – Laterally displaced tibial tuberosity © Stanbridge University 2023 74  Q Angle Lower extremity motions increasing the Q angle include: – External tibial torsion – Internal rotation of the femur – Pronated foot – Dynamic valgus at the knee © Stanbridge University 2023 75  Forces Maintaining Alignment of the Patella In flexion: patella enters the trochlear (intercondylar) groove In extension: poor bony stability Additional restraints: Extensor retinaculum (vastus medialis and vastus lateralis have attachments) Medial and lateral patellofemoral ligaments (attach to adductor tubercle medially & attach to ITB laterally) © Stanbridge University 2023 76 Extensor Retinaculum reinforced by MPFL, Medial Patellotibial ligament www.fadavispt.mhmedical.com © Stanbridge University 2023 77  PFPS Pain Patelofemoral pain syndrome Predominantly in women Incidence rate in athletes: 25% Etiology: repetitive stress on the musculotendinous structures which surround the knee Chang et al, 2015 © Stanbridge University 2023 78  PFPS-Subject Report Common complaints of increased pain with: Ascending and descending stairs Squats Sitting with knee flexed for prolonged time Chang et al, 2015 © Stanbridge University 2023 79  Patellar Mal-alignment & Tracking problems Caused by: 1) Local factors- structures around the knee 2) Distal factors- factors at the foot/ankle 3) Proximal factors- factors at the hip Top factors based on Research: – Quadriceps strength deficits (NOT VMO) Smith et al., Physiotherapy and Practice, 2009 – Dynamic mal-alignment Papadopoulos et al, 2015 © Stanbridge University 2023 80  Patellar Mal-alignment & Tracking Problems Muscle and Fascial tightness: Tight ITB and lateral patellar retinaculum: prevent medial gliding of the patella/pull patella laterally Tight ankle plantar flexors: Excessive pronation of the foot, medial femoral rotation → relative lateral displacement of the patella Tight hamstrings and rectus femoris © Stanbridge University 2023 81  PF Tracking Is the TRAIN moving off the TRACKS or is it the TRACKS moving under the TRAIN ? The femur falls into valgus collapse due to poor hip strength The tibia falls into valgus because of lack of plantar flexion © Stanbridge University 2023 82 Exercise interventions to assist in patellar tracking © Stanbridge University 2023 83  Self MFR to TFL and ITB Foam Roll from iliac crest → greater trochanter (TFL) Foam Roll from inf. greater trochanter → to lateral retinaculum (ITB) Finish with: Pretzel Stretch for ITB and TFL Kisner Fig 21.22 © Stanbridge University 2023 84  Patellofemoral Joint Mobilization Medial Glide Medial Tilt © Stanbridge University 2023 85  PFJ Taping to Improve Patellar Tracking McConnell taping Kinesiotaping www.kinetienda.com © Stanbridge University 2023 86  Taping to Improve PFJ Pain Chang et al, 2015 McConnell Taping Kinesiotaping Used to correct abnormal patellar position Manage VMO and VL muscle imbalance Corrects glide, tilt, and rotation components Origin→ insertion= facilitation of muscle Does not increase proprioception or motor contraction function of a muscle Insertion→ origin- relaxes muscle Stimulates mechanoreceptors- ⇩ pain Can decrease pain but does not change alignment Stimulate mechanoreceptors- ⇩ pain © Stanbridge University 2023 87 Patellar Mal-alignment &Tracking Problems Hip muscle weakness Hip abductors and external rotators leads to excessive hip adduction and IR dynamic knee valgus femur moves medial relative to patella © Stanbridge University 2023 88  Cueing for Hip ER weakness Dynamic valgus: increased Manual cue to lateral patella tracking trigger femoral ER © Stanbridge University 2023 89  Patellar Mal-alignment & Tracking Problems Lax medial capsular retinaculum and/ or medial patellofemoral ligament (MPFL) Insufficient quadriceps firing: neuromuscular electrical stimulation, strengthening exercises Shallow trochlear groove: surgical © Stanbridge University 2023 90  Quadriceps Strengthening ISOMETRIC: quadriceps Sets Supine straight leg raises- quad set plus hip flexion (isometric for vasti, concentric rectus femoris) SLR progressions: Supine→ propped on elbows→ sitting © Stanbridge University 2023 91  Quadriceps Strengthening OCK vs CKC Powers et al, 2014 OKC – Knee extension with variable resistance (VR)- most PFJ at 00 – Knee extension with constant resistance= high PFJ force throughout whole motion CKC – Squat- Most PFJ stress at 900 To reduce PFJ forces OKC Quad loading at 45-90° CKC loading at 0-45° © Stanbridge University 2023 92  Quadriceps Strengthening Range that strengthening should occur depends on the location of the defect: LAQ Inferior patella contacts trochlea at 10-20 degrees of flexion (depends on size of patella and length of patellar tendon) At 300 flexion: inferior facets contact trochlea in an area 2 cm2 At 600: middle facet contacts trochlea At 900: contact area increases up to 6 cm2 © Stanbridge University 2023 93  Additional Sources of Patellofemoral Joint Pain Anterior Knee Pain: Plica syndrome: irritation of remnants of embryological synovial tissue surrounding the patella (usually palpable band medial to the patella) Fat pad syndrome: irritation of patellar fat pad Tendonitis: quadriceps or patellar tendon ITB friction syndrome Pre-patellar bursitis © Stanbridge University 2023 94  Additional Sources of PF Joint Pain Anterior Knee Pain, continued: Osteochondritis dissecans of the patella or trochlear groove (cracks form in the articular cartilage and the underlying subchondral bone) Patellar chondromalacia Patellar OA Apophysitis: Osgood Slater disease (tibial tuberosity), Sinding- Larsen disease (inferior pole of the patella) Symptomatic bipartite patella Trauma: fracture, tendon rupture, etc. © Stanbridge University 2023 95  Common Impairments, Activity Limitations: PFJ Dysfunction Retropatellar pain Anterior knee pain Patellar crepitus, locking, swelling Mal-alignment of the LE in WB: femoral IR, adduction, dynamic valgus, pronation Symptoms with: squatting, jumping, stair negotiation, moving from sit to stand, running, etc. Pes planus (treatment: consider orthotics, calcaneal wedges) © Stanbridge University 2023 96  Common Impairments, Activity Limitations: PFJ Dysfunction Decreased strength: Hip abductors, ER’s, extensors Quadriceps weakness or inhibition Decreased flexibility: ITB/TFL, HS, quadriceps, , hip flexors, calf muscles Overstretched medial patellar retinaculum, MPFL Restricted lateral retinaculum, fascial structures surrounding patella Restricted PFJ mobility: decreased medial glide & tilt primarily © Stanbridge University 2023 97  PFJ Pain Management Acute Phase: Modalities for pain Rest PROM Isometrics Brace or tape © Stanbridge University 2023 98  PFJ Pain Management Subacute and Chronic Phases Correct or modify biomechanical factors Address whole lower extremity Increase strength, dynamic control & pain free mobility Modify abnormal movement strategies © Stanbridge University 2023 99  PFJ Pain Management Subacute and Chronic Phases Improve stability of trunk and pelvis Balance Functional abilities © Stanbridge University 2023 100  Review At various angles of the knee, where is the contact on the posterior aspect of the patella? What are the main causes of pateofemoral pain? What is the most beneficial range to strengthen the quadriceps in OCK? CKC? What are the general rehab goals for each phase of healing? © Stanbridge University 2023 101  Knee Anatomy Hypomobility; and Articular Cartilage Meniscus Tears Arthrokinematics defects and TKA Patellofemoral Exercise Ligament Injuries Pathologies Techniques © Stanbridge University 2023 102  Exercise Techniques Exercise techniques – ROM and Flexibility – OKC – CKC – Plyometrics See Labs © Stanbridge University 2023 103  Plyometrics Stretch-shortening drills Increase – Muscle strength – Power output – Neuromuscular reactions – Coordination Integrated in the advanced phase of rehabilitation (late subacute and chronic) © Stanbridge University 2023 104  Plyometrics Characterized by rapid, resisted, eccentric contraction (stretch) followed by rapid, reversal, concentric (shortening) contraction Amortization phase- time period between the stretch and shortening cycle Keep amortization cycle short by rapid reversal movements © Stanbridge University 2023 105  Plyometrics Teaching loading mechanics Landing should be quiet and soft www.icechamber.com All joints must flex to absorb- hip flexion, knee flexion, ankle DF Should look the same as proper squat form In the deepest squat- align vertically chest, knees and toes (z angle) If landing with buttock below knees- this is too deep Look for trunk and pelvis alignment: no lateral shift or pelvic drop © Stanbridge University 2023 106  Plyometrics Initiating and progressing plyometric Exercises: Begin with DL tasks, jumping or impacting without moving forward, backward or lateral Examples: jump squats, jogging in place, jumping jacks Box jumps: begin with the landing or stepping off the box first with the focus on proper shock absorption and loading mechanics Progress to jumping up onto the surface with the same landing mechanics, with proper squatting for the stretch cycle before leaving the ground © Stanbridge University 2023 107  Plyometric DL progressions Add a movement of the base of support – Jump squats forward and backward – Jump squats with 360-degree turn – Jumping over obstacles © Stanbridge University 2023 108  Plyometrics Moving from DL to SL tasks Lunge jumps- begin on one leg for a period, then transition to alternating the forward leg every rep Running stance to hop High knee skips Use a ladder to add coordination drills © Stanbridge University 2023 109  Plyometrics Progressions For any forward or lateral movement begin with one step loading repetitively Progress to 3 steps focused on form (loading mechanics) rather than speed Then initiate a marked distance, adding the speed component © Stanbridge University 2023 110  Plyometrics Exercise should be designed to address specific functional activities Determinants of Plyometrics – Speed- rapid but safe – Intensity- Gradual increase in resistance to avoid a decrease in activity © Stanbridge University 2023 111  Plyometrics Most common and important sport/ movement tasks: Deceleration Cutting Lateral shuffle Triple hop Jump down/ up from box © Stanbridge University 2023 112  Plyometrics Neurological and biomechanical Influences Eccentric contraction The more rapid the eccentric contraction the more likely stretch Monosynaptic reflex will be activated Reflex Decrease in amortization phase= increased force output Concentric contraction © Stanbridge University 2023 113  Plyometrics Contraindications – Presence of inflammation, pain or significant joint instability Box 23.3- Precautions © Stanbridge University 2023 114  Plyometrics Criteria to implement plyometrics – 80-85% strength of contralateral unaffected limb – 90-95% pain free ROM of moving joints – Sufficient strength and stability of proximal joints © Stanbridge University 2023 115  Plyometrics Determinants of Plyometrics Reps/ better set as a time- count reps completed in the pre-set time (30 sec intervals) – Gradually increase reps within the allotted time – Gradually increase # of activities; max 6/session Frequency: 2x/week Duration: 8-10 weeks (max benefit) © Stanbridge University 2023 116  Road Map By the end of this presentation the student should be able to: Identify important aspects of knee structure and function for review Implement a therapeutic exercise program to manage soft tissue and joint lesions in the knee region related to stages of recovery after and inflammatory insult to the tissues Understand how patellofemoral pain can result from abnormalities at the foot/ankle and hip/pelvis Implement a progressive therapeutic exercise program to manage patients following common surgical procedures for the knee based on the stages of healing Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the knee and adjacent lower extremity regions © Stanbridge University 2023 117