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Chapter 20: The Knee and Related Structures

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Title: Chapter 20: The Knee and Related Structures


1
Chapter 20 The Knee and Related Structures
2
  • Complex joint that endures great amounts of
    trauma due to extreme amounts of stress that are
    regularly applied
  • Hinge joint w/ a rotational component
  • Stability is due primarily to ligaments, joint
    capsule and muscles surrounding the joint
  • Designed for stability w/ weight bearing and
    mobility in locomotion

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Functional Anatomy
  • Movement of the knee requires flexion, extension,
    rotation and the arthrokinematic motions of
    rolling and gliding
  • Rotational component involves the screw home
    mechanism
  • As the knee extends it externally rotates because
    the medial femoral condyle is larger than the
    lateral
  • Provides increased stability to the knee
  • Popliteus unlocks knee allowing knee to flex

13
  • Capsular ligaments are taut during full extension
    and relaxed w/ flexion
  • Allows rotation to occur
  • Deeper capsular ligaments remain taut to keep
    rotation in check
  • PCL prevents excessive internal rotation, guides
    the knee in flexion, and acts as drag during
    initial glide phase of flexion
  • ACL stops excessive internal rotation, stabilizes
    the knee in full extension and prevents
    hyperextension

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  • Range of motion includes 140 degrees of motion
  • Limited by shortened position of hamstrings, bulk
    of hamstrings and extensibility of quads
  • Patella aids knee during extension, providing a
    mechanical advantage
  • Distributes compressive stress on the femur by
    increasing contact between patellar tendon and
    femur
  • Protects patellar tendon against friction
  • When moving from extension to flexion the patella
    glides laterally and further into trochlear groove

15
  • Kinetic Chain
  • Directly affected by motions and forces occurring
    at the foot, ankle, lower leg, thigh, hip,
    pelvis, and spine
  • With the kinetic chain forces must be absorbed
    and distributed
  • If body is unable to manage forces, breakdown to
    the system occurs
  • Knee is very susceptible to injury resulting from
    absorption of forces

16
Assessing the Knee Joint
  • 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

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  • 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?

18
  • 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

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  • 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 gt70 degrees internally,
    anteversion of the hip may exist
  • INSERT 20-9

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  • 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

22
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

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Palpation - Soft Tissue
  • Medial and lateral collateral ligaments
  • Pes anserine
  • Medial/lateral joint capsule
  • Semitendinosus
  • Semimembranosus
  • Gastrocnemius
  • Popliteus
  • Biceps Femoris
  • Vastus medialis
  • Vastus lateralis
  • Vastus intermedius
  • Rectus femoris
  • Quadriceps and patellar tendon
  • Sartorius
  • Medial patellar plica
  • Anterior joint capsule
  • Iliotibial Band
  • Arcuate complex

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  • 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

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  • Special Tests for Knee Instability
  • Use endpoint feel to determine stability
  • MRI may also be necessary for assessment
  • Classification of Joint Instability
  • Knee laxity includes both straight and rotary
    instability
  • Translation (tibial translation) refers to the
    glide of tibial plateau relative to the femoral
    condyles
  • As the damage to stabilization structures
    increases, laxity and translation also increase
  • Valgus and Varus Stress Tests
  • Used to assess the integrity of the MCL and LCL
    respectively
  • Testing at 0 degrees incorporates capsular
    testing while testing at 30 degrees of flexion
    isolates the ligaments

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  • Anterior Cruciate Ligament Tests
  • 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

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  • Lachman Drawer 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

29
  • 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

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  • 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

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  • 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

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  • 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

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Instrument Assessment of the Cruciate Ligaments
  • A number of devices are available to quantify AP
    displacement of the knee
  • KT-2000 arthrometer, Stryker knee laxity tester
    and Genucom can be used to assess the knee
  • Test can be taken pre post-operatively and
    through rehab

34
  • Meniscal Tests
  • 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

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  • 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

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  • 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

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  • 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
  • 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

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  • 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

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Prevention of Knee Injuries
  • Physical Conditioning and Rehabilitation
  • Total body conditioning is required
  • Strength, flexibility, cardiovascular and
    muscular endurance, agility, speed and balance
  • Muscles around joint must be conditioned
    (flexibility and strength) to maximize stability
  • Must avoid abnormal muscle action through
    flexibility
  • In an effort to prevent injury, extensibility of
    hamstrings, erector spinae, groin, quadriceps and
    gastrocnemius is important

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  • ACL Prevention Programs
  • Focus on strength, neuromuscular control, balance
  • Series of different programs which address
    balance board training, landing strategies,
    plyometric training, and single leg performance
  • Can be implemented in rehabilitation and
    preventative training programs
  • Shoe Type
  • Change in football footwear has drastically
    reduced the incidence of knee injuries
  • Shoes w/ more shorter cleats does not allow foot
    to become fixed while still allowing for control
    w/ running and cutting

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  • Functional and Prophylactic Knee Braces
  • Used to prevent and reduce severity of knee
    injuries
  • Used to protect MCL, or prevent further damage to
    grade 1 2 sprains of the ACL or to protect the
    ACL following surgery
  • Can be custom molded and designed to control
    rotational forces

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Recognition and Management of Specific Injuries
  • Medial Collateral Ligament Sprain
  • Etiology
  • Result of severe blow or outward twist
  • Signs and Symptoms - Grade I
  • Little fiber tearing or stretching
  • Stable valgus test
  • Little or no joint effusion
  • Some joint stiffness and point tenderness on
    lateral aspect
  • Relatively normal ROM

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  • Management
  • RICE for at least 24 hours
  • Crutches if necessary
  • Follow-up care will include cryokinetics w/
    exercise
  • Move from isometrics and STLR exercises to
    bicycle riding and isokinetics
  • Return to play when all areas have returned to
    normal
  • May require 3 weeks to recover

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  • Signs and Symptoms (Grade II)
  • Complete tear of deep capsular ligament and
    partial tear of superficial layer of MCL
  • No gross instability laxity at 5-15 degrees of
    flexion
  • Slight swelling
  • Moderate to severe joint tightness w/ decreased
    ROM
  • Pain along medial aspect of knee
  • Management
  • RICE for 48-72 hours crutch use until acute
    phase has resolved
  • Possibly a brace or casting prior to the
    initiation of ROM activities
  • Modalities 2-3 times daily for pain
  • Gradual progression from isometrics (quad
    exercises) to CKC exercises functional
    progression activities

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  • Signs and Symptoms (Grade III)
  • Complete tear of supporting ligaments
  • Complete loss of medial stability
  • Minimum to moderate swelling
  • Immediate pain followed by ache
  • Loss of motion due to effusion and hamstring
    guarding
  • Positive valgus stress test
  • Management
  • RICE
  • Conservative non-operative versus surgical
    approach
  • Limited immobilization (w/ a brace) progressive
    weight bearing for
  • Rehab would be similar to Grade I II injuries

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  • Lateral Collateral Ligament Sprain
  • Etiology
  • Result of a varus force, generally w/ the tibia
    internally rotated
  • Direct blow is rare
  • If severe enough damage can also occur to the
    cruciate ligaments, ITB, and meniscus, producing
    bony fragments as well
  • Signs and Symptoms
  • Pain and tenderness over LCL
  • Swelling and effusion around the LCL
  • Joint laxity w/ varus testing
  • May cause irritation of the peroneal nerve
  • Management
  • Following management of MCL injuries depending on
    severity

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  • Anterior Cruciate Ligament Sprain
  • Etiology
  • MOI - tibia externally rotated and valgus force
    at the knee (occasionally the result of
    hyperextension from direct blow)
  • May be linked to inability to decelerate valgus
    and rotational stresses - landing strategies
  • Male versus female
  • Research is quite extensive in regards to impact
    of femoral notch, ACL size and laxity,
    malalignments (Q-angle) faulty biomechanics
  • Extrinsic factors may include, conditioning,
    skill acquisition, playing style, equipment,
    preparation time
  • Also involves damage to other structures
    including meniscus, capsule, MCL

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  • Signs and Symptoms
  • Experience pop w/ severe pain and disability
  • Rapid swelling at the joint line
  • Positive anterior drawer and Lachmans
  • Other ACL tests may also be positive
  • Management
  • RICE use of crutches
  • Arthroscopy may be necessary to determine extent
    of injury
  • Could lead to major instability in incidence of
    high performance
  • W/out surgery joint degeneration may result
  • Age and activity may factor into surgical option
  • Surgery may involve joint reconstruction w/
    grafts (tendon), transplantation of external
    structures
  • Will require brief hospital stay and 3-5 weeks of
    a brace
  • Also requires 4-6 months of rehab

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  • Posterior Cruciate Ligament Sprain
  • Etiology
  • Most at risk during 90 degrees of flexion
  • Fall on bent knee is most common mechanism
  • Can also be damaged as a result of a rotational
    force
  • Signs and Symptoms
  • Feel a pop in the back of the knee
  • Tenderness and relatively little swelling in the
    popliteal fossa
  • Laxity w/ posterior sag test
  • Management
  • RICE
  • Non-operative rehab of grade I and II injuries
    should focus on quad strength
  • Surgical versus non-operative
  • Surgery will require 6 weeks of immobilization in
    extension w/ full weight bearing on crutches
  • ROM after 6 weeks and PRE at 4 months

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  • Meniscal Lesions
  • Etiology
  • Medial meniscus is more commonly injured due to
    ligamentous attachments and decreased mobility
  • Also more prone to disruption through torsional
    and valgus forces
  • Most common MOI is rotary force w/ knee flexed or
    extended
  • Can be longitudinal, oblique or transverse tears
  • Signs and Symptoms
  • Effusion developing over 48-72 hour period
  • Joint line pain and loss of motion
  • Intermittent locking and giving way
  • Pain w/ squatting
  • Portions may become detached causing locking,
    giving way or catching w/in the joint
  • If chronic, recurrent swelling or muscle atrophy
    may occur

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  • Management
  • If the knee is not locked, but indications of a
    tear are present further diagnostic testing may
    be required
  • If locking occurs, anesthesia may be necessary to
    unlock the joint w/ possible arthroscopic surgery
    follow-up
  • W/ surgery all efforts are made to preserve the
    meniscus -- will full healing being dependent on
    location
  • Menisectomy rehab allows partial weight bearing
    and quick return to activity
  • Repaired meniscus will require immobilization and
    a gradual return to activity over the course of
    12 weeks

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  • Knee Plica
  • Etiology
  • Irritation of the plica (generally, mediopatellar
    plica and often associated w/ chondromalacia
  • Signs and Symptoms
  • Possible history of knee pain/injury
  • Recurrent episodes of painful pseudo-locking
  • Possible snapping and popping
  • Pain w/ stairs and squatting
  • Little or no swelling, and no ligamentous laxity
  • Management
  • Treat conservatively w/ RICE and NSAIDs if the
    result of trauma
  • Recurrent conditions may require surgery

55
  • Osteochondral Knee Fractures
  • Etiology
  • Same MOI as collateral/cruciate ligaments or
    meniscal injuries
  • Twisting, sudden cutting or direct blow
  • Signs and Symptoms
  • Hear a snap and feeling of giving way
  • Immediate swelling and considerable pain
  • Management
  • Diagnosis confirmed through arthroscopic exam, w/
    surgery to replace fragment to avoid joint
    degeneration and arthritis

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  • Osteochondritis Dissecans
  • Etiology
  • Partial or complete separation of articular
    cartilage and subchondral bone
  • Cause is unknown but may include blunt trauma,
    possible skeletal or endocrine abnormalities,
    prominent tibial spine impinging on medial
    femoral condyle, or impingement due to patellar
    facet
  • Signs and Symptoms
  • Aching pain with recurrent swelling and possible
    locking
  • Possible quadriceps atrophy and point tenderness
  • Management
  • Rest and immobilization for children
  • Surgery may be necessary in teenagers and adults
    (drilling to stimulate healing, pinning or bone
    grafts

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  • Loose Bodies w/in the Knee
  • Etiology
  • Result of repeated trauma
  • Possibly stem from osteochondritis dissecans,
    meniscal fragments, synovial tissue or cruciate
    ligaments
  • Signs and Symptoms
  • May become lodged, causing locking or popping
  • Pain and sensation of instability
  • Management
  • If not surgically removed it can lead to
    conditions causing joint degeneration

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  • Joint Contusions
  • Etiology
  • Blow to the muscles crossing the joint (vastus
    medialis)
  • Signs and Symptoms
  • Present as knee sprain, severe pain, loss of
    movement and signs of acute inflammation
  • Swelling, discoloration
  • Possible capsular damage
  • Management
  • RICE initially and continue if swelling persists
  • Gradual progression to normal activity following
    return of ROM and padding for protection
  • If swelling does not resolve w/in a week a
    chronic condition (synovitis or bursitis) may
    exist requiring more rest

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  • Peroneal Nerve Contusion
  • Etiology
  • Compression of peroneal nerve due to a direct
    blow
  • Signs and Symptoms
  • Local pain and possible shooting nerve pain
  • Numbness and paresthesia in cutaneous
    distribution of the nerve
  • Added pressure may exacerbate condition
  • Generally resolves quickly -- in the event it
    does not resolve, it could result in drop foot
  • Management
  • RICE and return to play once symptoms resolve and
    no weakness is present
  • Padding for fibular head is necessary for a few
    weeks

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  • Bursitis
  • Etiology
  • Acute, chronic or recurrent swelling
  • Prepatellar continued kneeling
  • Infrapatellar overuse of patellar tendon
  • Signs and Symptoms
  • Prepatellar bursitis may be localized swelling
    above knee that is ballotable
  • Swelling in popliteal fossa may indicate a
    Bakers cyst
  • Associated w/ semimembranosus bursa or medial
    head of gastrocnemius
  • Commonly painless and causing little disability
  • May progress and should be treated accordingly
  • Management
  • Eliminate cause, RICE and NSAIDs
  • Aspiration and steroid injection if chronic

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  • Patellar Fracture
  • Etiology
  • Direct or indirect trauma (severe pull of tendon)
  • Forcible contraction, falling, jumping or running
  • Signs and Symptoms
  • Hemorrhaging and joint effusion w/ generalized
    swelling
  • Indirect fractures may cause capsular tearing,
    separation of bone fragments and possible
    quadriceps tendon tearing
  • Little bone separation w/ direct injury
  • Management
  • X-ray necessary for confirmation of findings
  • RICE and splinting if fracture suspected
  • Refer and immobilize for 2-3 months

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  • Acute Patella Subluxation or Dislocation
  • Etiology
  • Deceleration w/ simultaneous cutting in opposite
    direction (valgus force at knee)
  • Quad pulls the patella out of alignment
  • Some athletes may be predisposed to injury
  • Repetitive subluxation will impose stress to
    medial restraints
  • Signs and Symptoms
  • W/ subluxation, pain and swelling, restricted
    ROM, palpable tenderness over adductor tubercle
  • Dislocations result in total loss of function

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  • Management
  • Reduction is performed by flexing hip, moving
    patella medially and slowly extending the knee
  • Following reduction, immobilization for at least
    4 weeks w/ use of crutches and isometric
    exercises during this period
  • After immobilization period, horseshoe pad w/
    elastic wrap should be used to support patella
  • Muscle rehab focusing on muscle around the knee,
    thigh and hip are key (STLRs are optimal for the
    knee)
  • Possible surgery to release tight structures
  • Improve postural and biomechanical factors

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  • Injury to the Infrapatellar Fat Pad
  • Etiology
  • May become wedged between the tibia and patella
  • Irritated by chronic kneeling, pressure or trauma
  • Signs and Symptoms
  • Capillary hemorrhaging and swelling
  • Chronic irritation may lead to scarring and
    calcification
  • Pain below the patellar ligament (especially
    during knee extension)
  • May display weakness, mild swelling and stiffness
    during movement
  • Management
  • Rest from irritating activities until
    inflammation has subsided and therapeutic use of
    cold
  • Heel lift to prevent irritation during extension
  • Hyperextension taping to prevent full extension

65
  • Chondromalacia patella
  • Etiology
  • Softening and deterioration of the articular
    cartilage
  • Possible abnormal patellar tracking due to genu
    valgum, external tibial torsion, foot pronation,
    femoral anteversion, patella alta, shallow
    femoral groove, increased Q angle, laxity of quad
    tendon
  • Signs and Symptoms
  • Pain w/ walking, running, stairs and squatting
  • Possible recurrent swelling, grating sensation w/
    flexion and extension
  • Pain at inferior border during palpation
  • Management
  • Conservative measures
  • RICE, NSAIDs, isometrics, orthotics to correct
    dysfunction
  • Surgical possibilities

66
  • Patellofemoral Stress Syndrome
  • Etiology
  • Result of lateral deviation of patella while
    tracking in femoral groove
  • Tight structures, pronation, increased Q angle,
    insufficient medial musculature
  • Signs and Symptoms
  • Tenderness of lateral facet of patella and
    swelling associated w/ irritation of synovium
  • Dull ache in center of knee
  • Patellar compression will elicit pain and
    crepitus
  • Apprehension when patella is forced laterally
  • Management
  • Correct imbalances (strength and flexibility)
  • McConnell taping
  • Lateral retinacular release if conservative
    measures fail

67
  • Osgood-Schlatter Disease and Larsen-Johansson
    Disease
  • Etiology
  • Osgood Schlatters is an apophysitis occurring at
    the tibial tubercle
  • Begins cartilagenous and develops a bony callus,
    enlarging the tubercle
  • Resolves w/ aging
  • Common cause repeated avulsion of patellar
    tendon
  • Larsen Johansson is the result of excessive
    pulling on the inferior pole of the patella
  • Signs and Symptoms
  • Both elicit swelling, hemorrhaging and gradual
    degeneration of the apophysis due to impaired
    circulation

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  • Signs and Symptoms (continued)
  • Pain w/ kneeling, jumping and running
  • Point tenderness
  • Management
  • Conservative
  • Reduce stressful activity until union occurs
    (6-12 months)
  • Possible casting, ice before and after activity
  • Isometerics

70
  • Patellar Tendinitis (Jumpers or Kickers Knee)
  • Etiology
  • Jumping or kicking - placing tremendous stress
    and strain on patellar or quadriceps tendon
  • Sudden or repetitive extension
  • Signs and Symptoms
  • Pain and tenderness at inferior pole of patella
  • 3 phases - 1)pain after activity, 2)pain during
    and after, 3)pain during and after (possibly
    prolonged) and may become constant
  • Management
  • Ice, phonophoresis, iontophoresis, ultrasound,
    heat
  • Exercise
  • Patellar tendon bracing
  • Transverse friction massage

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  • Patellar Tendon Rupture
  • Etiology
  • Sudden, powerful quad contraction
  • Generally does not occur unless a chronic
    inflammatory condition persist resulting in
    tissue degeneration
  • Occur primarily at point of attachment
  • Signs and Symptoms
  • Palpable defect, lack of knee extension
  • Considerable swelling and pain (initially)
  • Management
  • Surgical repair is needed
  • Proper conservative care of jumpers knee can
    minimize chances of occurring
  • If steroids are being used, intense knee exercise
    should be avoided due to weakening of collagen

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  • Runners Knee (Cyclists Knee)
  • Etiology
  • General expression for repetitive/overuse
    conditions attributed to mal-alignment and
    structural asymmetries
  • Signs and Symptoms
  • IT Band Friction Syndrome
  • Irritation at bands insertion - commonly seen in
    individual that have genu varum or pronated feet
  • Pes Anserine Tendinitis or Bursitis
  • Result of excessive genu valgum and weak vastus
    medialis
  • Due to running w/ one leg higher than the other
  • Management
  • Correction of mal-alignments
  • Ice before and after activity, proper warm-up and
    stretching
  • Avoidance of aggravating activities
  • NSAIDs and orthotics

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Knee Joint Rehabilitation
  • General Body Conditioning
  • Must be maintained with non-weight bearing
    activities
  • Weight Bearing
  • Initial crutch use, non-weight bearing
  • Gradual progression to weight bearing while
    wearing rehabilitative brace
  • Knee Joint Mobilization
  • Used to reduce arthrofibrosis
  • Patellar mobilization is key following surgery
  • CPM units

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  • Flexibility
  • Must be regained, maintained and improved
  • Muscular Strength
  • Progression of isometrics, isotonic training,
    isokinetics and plyometrics
  • Incorporate eccentric muscle action
  • Open versus closed kinetic chain exercises
  • Neuromuscular Control
  • Loss of control is generally the result of pain
    and swelling
  • Through exercise and balance equipment
    proprioception can be enhanced

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  • Bracing
  • Variety of braces for a variety of injuries and
    conditions
  • Typically worn for 3-6 weeks after surgery --used
    to limit ranges for a period of time
  • Some are used to control for specific injuries
    while others are designed for specific forces and
    stability
  • Functional Progression
  • Gradual return to sports specific skills
  • Progress w/ weight bearing, move into walking and
    running, and then onto sprinting and change of
    direction

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  • Return to Activity
  • Based on healing process - sufficient time for
    healing must be allowed
  • Objective criteria include strength and ROM
    measures as well as functional performance tests
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