1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Corrective Strategies for Knee Impairments

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins To provide the health and fitness professional with the knowledge and skills to effectively develop and implement corrective exercise strategies for knee impairments. Purpose

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Understand the basic functional anatomy of the knee complex. Understand the mechanisms for common knee injuries. Determine the common risk factors that can lead to knee injuries. Incorporate a systematic assessment and corrective exercise strategy for knee impairments. Functional Anatomy Knee Injuries Risk Factors Systematic Assessment & Corrective Exercise Strategy Objectives

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The knee is a region that is greatly affected and influenced by joints above and below it. The structures that help form the ankle, and hip joints also make up the knee joint. Over time, this will increase stress and injury risk, ultimately leading to knee impairments. It is important to understand the: anatomy causes exercise strategies for prevention and management Introduction

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The tibia and femur make up the tibiofemoral joint, and the patella and femur make up the patellofemoral joint. The fibula is also noted as it is the attachment site of the biceps femoris which crosses and affects the knee. Functional Anatomy: Bones and Joints Biceps Femoris Tibiofemoral Joint Patellofemoral Joint Tibia Femur Fibula

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Functional Anatomy: Bones and Joints Functional Anatomy: Bones and Joints (cont.) Iliofemoral Joint Sacroiliac Joint Femur Pelvis (Ilium) Sacrum Collectively, these structures anchor the proximal myofascial tissues.

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Functional Anatomy: Bones and Joints Functional Anatomy: Bones and Joints (cont.) Talocrural TibiaFibula Collectively, these structures anchor the distal myofascial tissues of the knee.

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Functional Anatomy: Muscles It is important to restore and maintain normal range of motion and strength, and eliminate any muscle inhibition, to ensure joints are operating optimally. GastrocnemiusSoleusAdductor ComplexHamstrings TFL/IT-BandQuadricepsGluteus MediusGluteus Maximus Muscle imbalances may result in altered force-couple relationships which will lead to altered joint arthrokinematics, increased stresses to the knee, and potential injury.

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Knee Injuries and Associated Movement Deficiencies Patellar Tendinopathy (Jumper’s Knee) Anterior Cruciate Ligament (ACL) Injury Patellofemoral Syndrome Iliotibial Band (IT-Band) Syndrome (Runner’s Knee)

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Systematic Process to Determine Knee Impairments AssessmentObservation Static Posture Pronation distortion syndrome (tibial and femoral adduction and internal rotation) Overhead Squat Knees move inward (adduct and internally rotate) Knees move outward (abduct and externally rotate) Single-Leg Squat Knee moves inward (adduct and internally rotate) Tuck Jump Assessment Knee and thigh deficits (i.e. excessive knee valgus on landing) Foot placement deficits and poor landing technique Identifying faulty movement patterns allows the health and fitness professional to predict possible range of motion restrictions and muscle weakness. Valgus Varus

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Corrective Exercise Strategies for Knee Impairments InhibitActivateIntegrate Inhibitory Techniques Self-Myofascial Release Activation Techniques Isolated Strengthening Integration Techniques Integrated Dynamic Movement Lengthen Lengthening Techniques Static Stretching Once muscle weakness and range of motion deficiencies have been identified, the corrective exercise strategy can be developed utilizing NASM’s Corrective Exercise Continuum.

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 1. Inhibit (Knees Move Inward) CompensationPhaseModalityMuscle(s) ExerciseAcute Variables Knees Move InwardInhibitSelf-Myofascial ReleaseLateral Gastrocnemius Adductors TFL/IT Band Biceps Femoris (short head) Hold on tender area for 30 sec. Biceps Femoris Adductors TFL/IT Band Lateral Gastrocnemius

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 2. Lengthen (Knees Move Inward) CompensationPhaseModalityMuscle(s) ExerciseAcute Variables Knees Move InwardLengthenStatic StretchingLateral Gastrocnemius Adductors TFL Biceps Femoris (short head) Hold stretch for 30 sec. Lateral Gastrocnemius Biceps Femoris AdductorsTFL

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 3. Activate (Knees Move Inward) CompensationPhaseModalityMuscle(s) ExerciseAcute Variables Knees Move Inward ActivateIsolated StrengtheningAnterior Tibialis Posterior Tibialis Gluteus Medius Gluteus Maximus 10-15 repetitions with 2- sec. isometric hold and 4- sec. eccentric contraction Gluteus Maximus Gluteus Medius Posterior Tibialis Anterior Tibialis

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 4. Integrate (Knees Move Inward) PhaseModalityExerciseAcute Variables IntegrateIntegrated Dynamic MovementWall Jumps Tuck Jumps Long Jumps (Two Feet) 180 ○ Jumps Single-Leg Hops Cutting Maneuvers 10-15 repetitions under control Wall Jumps Long Jumps Cutting Maneuvers Single-Leg Hops180 ○ Jumps Tuck Jumps

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 1. Inhibit (Knees Move Outward) CompensationPhaseModalityMuscle(s) ExerciseAcute Variables Knees Move OutwardInhibitSelf-Myofascial ReleasePiriformis TFL Biceps Femoris Hold on tender area for 30 sec. PiriformisBiceps Femoris TFL

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 2. Lengthen (Knees Move Outward) CompensationPhaseModalityMuscle(s) ExerciseAcute Variables Knees Move Outward LengthenStatic StretchingPiriformis TFL Biceps Femoris Hold on tender area for 30 sec. Piriformis TFL Biceps Femoris

18. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Step 3. Activate (Knees Move Outward) CompensationPhaseModalityMuscle(s) ExerciseAcute Variables Knees Move Outward ActivateIsolated StrengtheningAdductors Medial Hamstrings Gluteus Maximus 10-15 repetitions with 2- sec. isometric hold and 4- sec. eccentric contraction Adductors Medial Hamstrings Gluteus Maximus

19. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Integrate (Knees Move Outward) PhaseModalityExerciseAcute Variables IntegrateIntegrated Dynamic MovementJumping Progression Functional Movement Progression Ball Squats with Overhead Press Step-Ups with Overhead Press Lunges with Overhead Press Single-Leg Squat with Overhead Press 10-15 repetitions under control Ball Squats with Overhead Press Step-Ups with Overhead Press Lunges with Overhead Press Single-Leg Squats with Overhead Press

20. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Summary It is important for health and fitness professionals to utilize an integrated assessment process in order to gather the appropriate information needed to develop a specific and systematic corrective exercise strategy.