1. Knee Seminar
Coach Taylor

2. Anatomy Review
Joint Capsule

3. Anatomy Review Lower Leg Musculature Anterior Medial Lateral Posterior
Tibialis Anterior
Medial
Tom, Dick and Harry
Tibialis Posterior
Extensor Digitorum Longus
Extensor Hallicus Longus
Lateral
Peroneals
Posterior
Gastrocnemius
Soleus

4. Anatomy Review Thigh Musculature Anterior Posterior Quadriceps Femoris
Vastus Lateralis
Vastus Medialis
Vastus Intermedius
Rectus Femoris
Posterior
Biceps Femoris
Long Head
Short Head
Semi-tendonosis
Semi-membranosis
Gracilis

5. Anatomy Review Ligaments Medial Collateral Lateral Collateral
Anterior Cruciate
Posterior Cruciate

6. Anatomy Review Cartilage Medial Meniscus Lateral Meniscus
Articular Cartilage

7. Anatomy Review
Joint Capsule

8. Anatomy Review
Bursae

9. Anatomy Review
Nerve Supply
Blood Supply

10. Anatomy Review
Nerve Supply
Blood Supply

11. Knee Evaluation (History)
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
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?

12. Knee Evaluation (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

13. Knee Evaluation (Observation)
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 >70 degrees internally, anteversion of the hip may exist

14. Knee Evaluation (Observation)
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

15. Knee Evaluation (Palpation)
Palpation – Bony
Medial tibial plateau
Medial femoral condyle
Adductor tubercle
Gerdy’s 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

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

17. Knee Evaluation (Palpation)
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

18. Knee Evaluation (Special Tests)
Active / Passive Range of Motion
Flexion – 0o to 135o
Extension – 130o to 0o
Manual Muscle Testing
Five Point grading system
5 = Complete ROM against gravity, with full resistance
4 = Complete ROM against gravity, with some resistance
3 = Complete ROM against gravity, with no resistance
2 = Complete ROM, with gravity omitted
1 = Some muscle contractility with no joint motion
0 = No muscle contractility
Knee Flexion / Extension
Hip Flexion / Extension / Internal Rotation / External Rotation
Dorsiflexion / Plantar Flexion

19. Knee Evaluation (Special Tests)
Joint Instability
Medial Collateral Ligament Instability

20. Knee Evaluation (Special Tests)
Joint Instability
Lateral Collateral Ligament Instability

21. Knee Evaluation (Special Tests)
Joint Instability
Anterior Cruciate Ligament (Lachman’s 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

22. Knee Evaluation (Special Tests)
Joint Instability
Anterior Cruciate Ligament (Ant. Drawer)
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

23. Knee Evaluation (Special Test)
Other ACL Stability Tests
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
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

24. Joint Stability Tests Posterior Cruciate Ligament Stability
Posterior Sag Test (Godfrey’s test)
Athlete is supine w/ both knees flexed to 90 degrees
Lateral observation is required to determine extent of posterior sag while comparing bilaterally

25. Knee Evaluation (Special Tests)
Other 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

26. Knee Evaluation (Special Tests)
Meniscal Pathology
McMurray’s 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
Medial Meniscus Testing

27. Knee Evaluation (Special Tests)
McMurray Test Continued
Lateral Meniscus Test

28. Knee Evaluation (Special Tests)
Meniscal Pathology
Apley’s Compression Test
Hard downward pressure is applied w/ rotation
Pain indicates a meniscal injury
Apley’s 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

29. Knee Evaluation Girth Measurements Subjective Rating
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 patient’s perception of pain, stability and functional performance
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

30. Knee Evaluation Q-Angle The A Angle Palpation of the Patella
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
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

31. Knee Rehabilitation Bag of Tricks Range of Motion
Joint Mobilization, Soft-Tissue Mobilization
Neuromuscular Control
Proprioceptive Neuromuscular Facilitation
Postural Stability
Core Stability training
Muscular Strength, Endurance, and Power
Plyometrics, Open KC, Closed KC, Isokinetics, Aquatics
Cardiovascular Endurance

32. Knee Rehabilitation Three simple keys Range of Motion Strength
Needed to increase motion and return to function as quickly as prudent and possible
Strength
Needed to deter further problems or protect the area of injury from further injury
Functionality
Needed to return the student-athlete or patient to normal daily activities within reason.

33. Knee Rehabilitation Range of Motion Theory’s
Passive ROM is the key to early ROM
Active ROM starts and progresses as treatments continue
“Normal” Knee ROM
Knee Flexion = 0o to 130o+
Knee Extension = 130o+ to 0o+

34. Knee Rehabilitation Passive Range of Motion Exercises
Flexion Exercises
Wall Hangs (assisting device is gravity)
Towel Slides (assisting device is arms)
Stationary Bike (assisting device is other leg)
Extension Exercises
Wall Hangs

35. Knee Rehabilitation Strengthening Closed Kinetic Chain
Used early in rehabilitation
More stable for the knee joint
Exercise include:
Mini-Squats (or with Swiss ball)
Wall Slides
Lunges (as ROM permits)
Leg Press Machine
Lateral Step-ups
T.K.E (Terminal Knee Extension) with T-Band

36. Knee Rehabilitation Strengthening Open Kinetic Chain
Also used early in rehabilitation
Exercise include:
Quad Sets
Hamstring Sets
Straight Leg Raises in four directions
Hamstring Curl Machine
Leg Extension Machine

37. The controversy continues: OKC vs. CKC
Knee Rehabilitation
The controversy continues: OKC vs. CKC
CKC Research
Decrease Tibial Translation 1
More vastus medialis and lateralis muscle activity 2
Greater patellofemoral compressive forces
Increased compressive forces and co-contraction 2
OKC Research
Increase Tibial Translation 1
More rectus femoris muscle activity 2
Less patellofemoral compressive forces
Increased shear forces and less co-contraction 2

38. Knee Rehabilitation Functionality Agility Drills / Training
Ladder
Dot Drills
Plyometric Drills / Training