Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh.pdf

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 9 Functional Anatomy and Rehabilitation of the Knee and Thigh Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Functional Anatomy and Rehabilitation of the Knee and Thigh FUNCTIONAL ANATOMY AND REHABILITATION OF THE KNEE AND THIGH Introduction Main knee & thigh injuries Ligament sprains Meniscus injuries Patellofemoral pain Muscle strains and contusions Bone injuries Knee is one of the most frequently injured joints in the body causing significant functional limitations CKC activities rely on a sound knee joint e.g. walking, standing, sit to stand Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 4 Introduction Need to examine the entire kinetic chain Knee injury may be affecting loading though proximal & distal segments/joints Restrictions or weakness in surrounding joints may be contributing to knee pain Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 5 Knee Structure Tibiofemoral joint: Concave tibial platform & convex femur Knee joint capsule: Surrounds joint & merges with collateral ligaments Collateral ligaments provide medial, lateral & rotational stability MCL attaches to medial meniscus & resists valgus forces LCL resists varus forces Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 6 Knee Structure Cruciate ligaments provide anterior-posterior & rotational stability ACL resists forward displacement of the tibia on the femur PCL resists knee hyperextension & posterior displacement of the tibia on the femur Medial & lateral meniscus Cushion the joint Deepen the socket (stability) Joint congruity (distribute WB forces evenly) Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 7 Knee Structure Screw-home mechanism (last 30° of ext.) “Locks” knee into extension Tibia rotates laterally – OKC Femur rotates medially – CKC Quads & hamstrings provide muscular stability for knee Also affect the hip therefore hip/pelvic position important Quads: rectus femoris, vastus lateralis, vastus intermedius, vastus medialis – extend the knee and stabilise the patella Biceps femoris rotates tibia laterally Semimembranosus & semitendinosus rotate tibia medially Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 8 Patellofemoral Joint Patella sits in the femoral groove Glides superiorly during knee extension Glides inferiorly during knee flexion Glides a total of approx. 5-7cm CKC: Greatest PF stress between 60-90° flexion; least stress at 0-45° and >90° flexion OKC: Greatest PF stress at 0° extension, least stress at 90° flexion Patella stability: Static (femoral groove, PF & PT ligaments) & active (quads) structures Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 9 Quadriceps Angle (Q-Angle) Angle that is formed by a line from the ASIS to the middle patella and a line from the middle patella to the tibial tuberosity Minimum normal Q-angle is 10° Can change from WB to non-WB Pronation or weak VMO can increase Q-angle Considered less significant now than in the past Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 10 Factors Affecting Post-Injury Strength Oedema Shuts down functioning of the quadriceps Proportional to quantity of fluid Pain Reflex inhibition (autonomic & conscious pathways) Reduced muscle output Ambulation Weakness occurs with antalgic gait Bad habits develop & are difficult to correct Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 11 Extensor Lag Normal passive knee extension is present but client cannot actively extend knee to full terminal extension Causes Pain Oedema Stiffness Weakness Must identify cause and treat appropriately Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 12 Ligament Sprains Most knee ligament injuries result from an external force Some can result from Stopping suddenly Jumping – take-off/landing Knee ligaments can be torn in isolation or in combination Force can be direct, single plane, rotary or combination Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 13 Anterior Cruciate Ligament (ACL) Sprain Mechanisms Usually non-contact with knee in slight flexion, foot on the ground, valgus knee force, tibia externally rotated – For example, performing a cutting manoeuvre/dodging an opponent Sometimes a hyperextension mechanism of injury Females > males Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 14 Anterior Cruciate Ligament (ACL) Sprain Signs & symptoms of a grade 3 rupture Athlete feels a “pop” Immediate disability Knee feels “loose” Rapid swelling Positive anterior drawer (unstable) Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 15 Anterior Cruciate Ligament (ACL) Sprain Treatment PRICER Definitive diagnosis (imaging) Arthroscopic examination Full reconstructive surgery 6 - 8 weeks in limited motion brace 6 – 12 months rehabilitation Routine use of braces/taping in sport Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 16 ACL Reconstruction Options ACL reconstruction surgery https://www.youtube.com/watch?v=Xsq0sQp6DwU ACL reconstruction surgery https://www.youtube.com/watch?v=W86Zd1ni5xw A range of surgical options Autologous hamstring (semitendinosus and sometimes gracilis) or patellar tendon graft Cadaveric donor grafts Synthetic graft (LARS) Graft from a relative (repeat procedures) Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 17 ACL Reconstruction – Conservative Rehab Protocol Brace used to lock knee into full extension for first week Progress from WB as tolerated to full WB SLR Brace unlocked after first week – remain on crutches Hip extension, heel slides, quad sets with brace on for strength Wall slides to 45°, heel slides, prone hangs with foot over edge of table for ROM Week 6 – Patient should have good quad control in knee extension & can remove brace Stationary cycling, wall squats to 45°, leg press to 45°, lateral/forward/backwards step-ups, heel raises, static balance Pool walking & jogging Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 18 ACL Reconstruction – Conservative Rehab Protocol 6/8 weeks – 5 months Normal gait Full ROM of the knee Leg press to 60° flexion Stepper & elliptical trainer 2-3 months Begin fast walking 4-6 months Begin running 6 months+ Cutting & lateral movements Plyometrics, agility, functional/performance Full return to activity usually 12 months Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 19 Posterior Cruciate Ligament (PCL) Sprain Mechanisms External force most common Hyperextension or landing on flexed knee – tibia driven backwards Signs & symptoms of a grade 3 rupture May feel “pop” Tenderness in popliteal area Laxity in posterior “sag” drawer Treatment PRICER Definitive diagnosis (imaging) Arthroscopic examination Grade 1 & 2 – non-operative care Grade 3 - surgery Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 20 Collateral Ligament Sprains (MCL and LCL) MCL sprains more common than LCL MCL mechanism either direct blow to lateral knee (valgus) or severe rotation LCL mechanism blow to medial knee (varus) Non-surgical treatment if injury isolated to single ligament Knee brace 3-6 weeks (limited to 90° flexion) & crutches 2-4 weeks Active ROM exercises & isometric strength exercises initially Aquatic exercises after 7-10 days Stationary cycling after 2 weeks Combination of OKC & CKC exercises Agility, plyometrics & functional exercises once adequate ROM & strength May return to play with knee brace for medial & lateral stability Full return 1-3 months Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 21 Meniscal Injuries Mechanisms MM > LM due to MCL & jt. capsule attachment Rotation while WB on leg with knee extending Femur IR = MM; Femur ER = LM Signs & symptoms Severe pain & loss of movement Sudden locking of knee Pain at joint line (usually one sided) Pain increased with squatting or twisting Swelling (especially peripheral tears) Treatment Conservative vs. surgical repair / meniscectomy Peripheral tear has vascular supply = faster healing Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 22 Patellofemoral Pain Syndrome (PFPS) Mechanisms Single or multiple factors – lateral tracking of patella Tight hamstrings, gastrocnemius, lateral retinaculum, increased Q-angle, tight ITB, excessive foot pronation, patella alta, weak VMO & hip abductors Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 23 Patellofemoral Pain Syndrome (PFPS) Signs & Symptoms Tenderness over lateral facet of patella especially after activity or up/down stairs Swelling, stiffness in knee after prolonged sitting Dull ache in centre of knee Crepitus felt with patella compression examination Treatment Strengthening VMO, adductors & abductors Improving core strength & limb control Stretching hamstrings, gastrocnemius & ITB OKC & CKC exercises should be performed 0-30° flexion Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 24 Iliotibial Band (ITB) Syndrome Mechanisms Postural problems: Anterior pelvic tilt, knee hyperextension and poor mechanics – decreased gluteus medius or VMO activity Increased compression between ITB and underlying tissues (lateral epicondyle) Tight quads & hip flexors (Thomas test), weak/underactive glutes (prone hip extension test), positive Trendelenburg sign Signs & Symptoms Sharp stabbing pain over lateral knee area that worsens with continued running or cycling (worse running downhill) Palpation of lateral epicondyle will be painful Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 25 Iliotibial Band (ITB) Syndrome Treatment Address all predisposing factors identified during assessment Consider training volume – recent changes Posture education, flexibility and strength – particularly around the hips for knee control, balance training Ice to control inflammation & self-massage hips & quads Corticosteroid and/or PRP injection Surgical intervention as a last resort Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 26 Patellar Tendinopathy (Jumper’s Knee) Mechanisms Sudden or forceful repetitive knee extension Repetitive eccentric loading – Patellar mal-alignment – Excessive foot pronation Breakdown & degeneration of the tendon – may lead to rupture Signs & Symptoms Pain & tenderness at inferior pole of patella Stage 1: Pain after sport/activity Stage 2: Pain during and after activity Stage 3: Pain during and prolonged after activity – performance hampered Thickening of tendon Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 27 Patellar Tendinopathy (Jumper’s Knee) Treatment Ice Correcting muscle strength/flexibility imbalances Stretching quads, hamstrings, ITB & gastrocnemius Gradual progression of eccentric strength OKC & CKC exercises Corticosteroid and/or PRP injection Surgical intervention as a last resort Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 28 Quadriceps Contusion “Corky” Mechanism Direct blow to the thigh Blood vessels are damaged Muscle fibres crushed against femur Signs & Symptoms Pain Loss of function Thigh becomes progressively stiff with increasing effusion Decrease in quad function/weakness Pain on knee flexion Pain on knee extension Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 29 Quadriceps Contusion “Corky” Treatment Mild, moderate, severe Surgical intervention can be necessary in extreme cases Intra-muscular haematoma Inter-muscular haematoma PRICER Gentle passive stretching while ice applied – Maintains flexibility of quads – Decreases stiffness Use of crutches (moderate & severe) Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 30 Knee Osteoarthritis Similar to hip OA, characterised by A breakdown of articular cartilage Inflammation within the joint A narrowing of the joint space Osteophyte (bone spur) formation Ligamentous laxity about the joint Pain, swelling and joint stiffness are the hallmark signs and symptoms Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 31 Knee Osteoarthritis Treatment should be administered similar to that of hip OA Normalise biomechanics Increase physical activity levels Reduce body mass if overweight or obese Treatment can include Pain medication (paracetamol and NSAIDs) Corticosteroid injection Viscous fluid injection (Synvisc) Exercise and dietary intervention (supported by better evidence than any of the above) Total (or unicompartmental) joint replacement Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 32 Knee Osteoarthritis – Total Joint Replacement Total joint replacement is used as an ‘end of the road’ treatment option for knee OA Generally favourable outcomes, but not for all patients Usual surgical risks apply (including risk of infection and complications of general anaesthesia) Total knee replacement https://www.youtube.com/watch?v=8YAgrv9dkhc&has_verified=1 Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 33 Knee – Special Tests Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 34 Knee – Special Tests Patellar Grinding Test https://www.youtube.com/watch?v=pRqnODPqxFs Anterior Draw Test https://www.youtube.com/watch?v=IdnBKv38EEQ Posterior Draw Test https://www.youtube.com/watch?v=AiHpMqqLgkI Valgus Stress Test https://www.youtube.com/watch?v=GSFbttpxCuQ Varus Stress Test https://www.youtube.com/watch?v=sg1gk6QKARw Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 35 Knee – Special Tests Apley’s Test https://www.youtube.com/watch?v=6Z_9lfX_Pc8 McMurray’s Test https://www.youtube.com/watch?v=lwDFPAyGGgI Week 9 - Functional Anatomy and Rehabilitation of the Knee and Thigh 36