Knee Seminar Coach Taylor

Anatomy Review Joint Capsule

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

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

Anatomy Review Ligaments Medial Collateral Lateral Collateral Anterior Cruciate Posterior Cruciate

Anatomy Review Cartilage Medial Meniscus Lateral Meniscus Articular Cartilage

Anatomy Review Joint Capsule

Anatomy Review Bursae

Anatomy Review Nerve Supply Blood Supply

Anatomy Review Nerve Supply Blood Supply

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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+

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

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

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

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

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