The Knee
Chapter 21
Part IV: Exercise Interventions by Body
Region
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STRUCTURE AND FUNCTION OF
THE KNEE
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Joints of the Knee Complex
 Tibiofemoral Joint
– Characteristics
– Arthrokinematics
– Screw-home mechanism
 Patellofemoral Joint
– Characteristics
– Mechanics
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Patellar Function
 Patellar Alignment
– Forces maintaining alignment
– Patellar malalignment and tracking problems
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Increased Q-angle
Muscle and fascial tightness
Hip muscle weakness
Lax medial capsular retinaculum or an insufficient VMO muscle
 Patellar Compression
– Patellar contact
– Compression forces
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Muscle Function
 Knee Extensor Muscle Function
– Closed-chain function
– Patella
– Torque
 Knee Flexor Muscle Function
 Dynamic Stability of the Knee
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The Knee and Gait
 Muscle Control of the Knee During Gait
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Quadriceps
Hamstrings
Soleus
Gastrocnemius
 Hip and Ankle Impairments
– Hip flexion contractures
– Length/strength imbalances
– Foot impairments
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Referred Pain and Nerve Injuries
 Major Nerves Subject to Injury at the Knee
– Common fibular (peroneal) nerve
– Saphenous nerve
 Common Sources of Referred Pain
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MANAGEMENT OF KNEE
DISORDERS AND SURGERIES
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Joint Hypomobility:
Nonoperative Management
 Common Joint Pathologies and Associated
Impairments
– Osteoarthritis (degenerative joint disease)
– Rheumatoid arthritis
– Postimmobilization hypomobility
– Common impairments
– Common activity limitations and participation
restrictions
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Management: Protection Phase
– Control pain and protect the joint
• Patient education
• Functional adaptations
– Maintain soft tissue and joint mobility
• Passive, active-assistive, or active ROM
• Grade I or II tractions or glides
– Maintain muscle function and prevent patellar adhesions
• Setting exercises
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Management: Controlled Motion and Return
to Function Phases
– Educate the patient
– Decrease pain from mechanical stress
– Increase joint play and range of motion
• Joint mobilization
• Stretching techniques
• Mobilization with movement
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Management: Controlled Motion and Return
to Function Phases (cont’d)
– Improve muscle performance in supporting
muscles
• Progressive strengthening
• Muscular endurance
• Functional training
– Improve cardiopulmonary endurance
 Outcomes
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Repair of Articular Cartilage
Defects
 Indications for Surgery
 Procedures
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Microfracture
Osteochondral autograft transplantation/mosaicplasty
Autologous chondrocyte implantation
Osteochondral allograft transplantation
Other procedures
 Postoperative Management
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Total Knee Arthroplasty
 Indications for Surgery
 Procedure
– Background
• Types of knee arthroplasty
• Surgical approach
• Fixation
– Operative overview
– Complications
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Total Knee Arthroplasty (cont'd)
 Postoperative Management
– Immobilization and early motion
– Weight-bearing considerations
– Exercise progression
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Total Knee Arthroplasty (cont'd)
 Postoperative Management (cont’d)
– Exercise
• Maximum protection phase
– Goals and interventions
– Criteria to progress
• Moderate protection phase
– Goals and interventions
– Criteria to progress
• Minimum protection/return to function phases
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Total Knee Arthroplasty (cont'd)
 Outcomes
– Pain relief
– ROM
– Strength and endurance
– Physical function and activity level
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Related Patellofemoral Pathologies
 PF Instability
 PF Pain With Malalignment or Biomechanical
Dysfunction
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Related Patellofemoral Pathologies
(cont'd)
 PF Pain Without Malalignment
– Soft tissue lesions
– Tight medial and lateral retinacula or patellar pressure
syndrome
– Osteochondritis dissecans of the patella or femoral
trochlea
– Traumatic patellar chondromalacia
– PF osteoarthritis
– Apophysitis
– Symptomatic bipartite patella
– Trauma
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Patellofemoral Dysfunction:
Nonoperative Management
 Etiology of Symptoms
– Consensus on factors leading to PF symptoms
• Local factors
• Distal factors
• Proximal factors
 Common Impairments, Activity Limitations,
and Participation Restrictions
• Structural and functional impairments
• Activity limitations and participation restrictions
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Patellofemoral Symptoms:
Management—Protection Phase
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Modalities for Pain and Joint Effusion
Rest and Activity Modification
Splinting or Patellar Taping to Unload the Joint
Muscle-Setting Exercises in Pain-Free Position
Gentle ROM in Pain-Free Range
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Patellofemoral Symptoms: Management—
Controlled Motion and Return to Function
Phases
 Educate the Patient
– Instruction
– Home exercise program
 Increase Flexibility of Restricting Tissues
– Patellar mobilization: medial glide
– Medial tipping of the patella
– Patellar taping
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Patellofemoral Symptoms: Management—
Controlled Motion and Return to Function
Phases (cont'd)
 Improve Muscle Performance and Neuromuscular
Control
– VMO: A closer look
– Non-weight-bearing (open-chain) exercises
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Quad sets in pain-free positions
Quad sets with straight-leg raising
Progression of resisted isometrics
Short-arc terminal extension
– Weight-bearing (closed-chain) exercises
– Functional activities
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Patellofemoral Symptoms: Management—
Controlled Motion and Return to Function
Phases (cont'd)
 Modify Biomechanical Stresses
 Outcomes
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Patellar Instability: Surgical and
Postoperative Management
 Overview of Surgical Options
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Proximal Extensor Mechanism Re-alignment:
Medial Patellofemoral Ligament Repair or
Reconstruction and Related Procedures
 Indications for Surgery
 Procedures
– Background and operative overview
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MPFL repair or tightening
MPFL reconstruction
VMO imbrication (advancement)
Lateral retinacular release and other concomitant
procedures
– Complications
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Proximal Extensor Mechanism Re-alignment:
Medial Patellofemoral Ligament Repair or
Reconstruction and Related Procedures (cont'd)
 Postoperative Management
– Immobilization and weight-bearing considerations
– Exercise progression
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Proximal Extensor Mechanism Re-alignment:
Medial Patellofemoral Ligament Repair or
Reconstruction and Related Procedures (cont'd)
 Postoperative Management (cont’d)
– Exercise
• Maximum protection phase
– Goals and interventions
– Criteria to progress
• Moderate protection/controlled motion phase
• Minimum protection/return to function phase
 Outcomes
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Distal Realignment Procedures: Patellar
Tendon With Tibial Tubercle Transfer and
Related Procedures
 Indications for Surgery
 Procedures
– Background and operative overview
• Tibial tubercle transfer (Elmslie-Trillat procedure)
• Anteriorization (elevation) of the tibial tubercle
• Distal medialization of the patellar tendon
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Distal Realignment Procedures: Patellar
Tendon With Tibial Tubercle Transfer and
Related Procedures (cont'd)
 Complications
 Postoperative Management
– Immobilization and weight-bearing considerations
– Exercise progression
 Outcomes
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Ligament Injuries:
Nonoperative Management
 “Unholy Triad”/“ Terrible Triad”
 Mechanisms of Injury
– Anterior cruciate ligament
– Posterior cruciate ligament
– Medial collateral ligament
– Lateral collateral ligament
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Ligament Injuries:
Nonoperative Management (cont'd)
 Ligament Injuries in the Female Athlete
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Biomechanical risk factors
Neuromuscular risk factors
Structural risk factors
Hormonal differences
 Common Structural and Functional Impairments,
Activity Limitations, and Participation Restrictions
(functional limitations/disabilities)
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Ligament Injuries:
Nonoperative Management (cont'd)
 Management: Maximum Protection Phase
 Management: Moderate Protection (Controlled
Motion) Through Return to Activity Phases
– Improve joint mobility and protection
• Protective bracing
– Improve muscle performance and function
• Strength and endurance
• Neuromuscular control
– Improve cardiopulmonary conditioning
– Progress to functional training
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Ligament Injuries: Surgical and
Postoperative Management
 Background
– General considerations and indications for
ligament surgery
– Types of ligament surgery
– Grafts: types, healing characteristics, and fixation
– General considerations for rehabilitation
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Anterior Cruciate Ligament
Reconstruction
 Indications for Surgery
 Procedures
– Operative overview
• Surgical approach, graft selection, and harvesting
• Graft placement and fixation
– Complications
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Anterior Cruciate Ligament
Reconstruction (cont'd)
 Postoperative Management
– Immobilization and bracing
• Types of postoperative bracing
• Brace use and initiation and progression of knee ROM
– Weight-bearing considerations
– Exercise progression
• Preoperative exercises
• Postoperative exercise progression
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Anterior Cruciate Ligament
Reconstruction (cont'd)
 Postoperative Management (cont’d)
– Exercise
• Maximum protection phase
• Moderate protection and controlled motion phase
• Minimum protection and return to function phase
 Outcomes
– Graft selection and outcomes
– Approaches to rehabilitation
– Functional bracing
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Posterior Cruciate Ligament
Reconstruction
 Indications for Surgery
 Procedures
– Operative overview
– Complications
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Posterior Cruciate Ligament
Reconstruction (cont'd)
 Postoperative Management
– Immobilization, protective bracing, and weight
bearing
– Exercise progression
– Exercise
• Maximum protection phase
• Moderate and minimum protection phases
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Meniscal Tears:
Nonoperative Management
 Mechanisms of Injury
 Common Structural and Functional
Impairments, Activity Limitations, and
Participation Restrictions
 Management
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Meniscus Repair
 Indications for Surgery
 Procedure
– Operative overview
– Complications
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Meniscus Repair (cont'd)
 Postoperative Management
– Immobilization, protective bracing, and weight
bearing
– Exercise
• Maximum protection phase
• Moderate protection/controlled motion phase
• Minimum protection/return-to-function phase
 Outcomes
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Partial Meniscectomy
 Indications for Surgery
 Procedure
– Operative overview
– Complications
 Postoperative Management
– Immobilization and weight bearing
– Exercise
• Maximum and moderate protection phases
• Minimum protection and return to function phases
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EXERCISE INTERVENTIONS FOR
THE KNEE
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To Increase Knee Extension
 PNF Stretching
 Gravity-Assisted Passive Stretching Techniques
– Prone hang
– Supine heel prop
 Self-Stretching Technique
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To Increase Knee Flexion
 PNF Stretching Techniques
 Gravity-Assisted Passive Stretching Techniques
 Self-Stretching Techniques
– Gravity-assisted supine wall slides
– Self-stretching with the uninvolved leg
– Rocking forward on a step
– Sitting
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To Increase Mobility of the IT Band
at the Knee
 Foam Roller Stretch
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Open-Chain (Non-Weight-Bearing)
Exercises
 To Develop Control and Strength of Knee
Extension (Quadriceps Femoris)
– Quadriceps setting (quad sets)
– Straight-leg raise (SLR)
– Straight-leg lowering
– Multiple-angle isometric exercises
– Short-arc terminal knee extension
– Full arc extension
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Open-Chain (Non-Weight-Bearing)
Exercises (cont'd)
 To Develop Control and Strength of Knee
Flexion (Hamstrings)
– Hamstring-setting (hamstring sets)
– Multiple-angle isometric exercises
– Hamstring curls
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Closed-Chain Exercises
 Initiation of Closed-Chain Exercises
 Partial Weight-Bearing and Support
Techniques
 Closed-Chain Isometric Exercises
– Setting exercises for co-contraction
– Alternating isometrics with rhythmic stabilization
– Closed-chain isometrics against elastic resistance
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Closed-Chain Exercises (cont'd)
 Closed-Chain Dynamic Exercises
– Scooting on a wheeled stool
– Unilateral closed-chain terminal knee extension
– Partial squats, mini-squats, and short-arc training
– Standing wall slides
– Forward, backward, and lateral step-ups and stepdowns
– Partial and full lunges
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Functional Progression for the
Knee
 Strength and Muscle Endurance Training
 Cardiopulmonary Endurance Training
 Balance and Proprioceptive Activities
(Perturbation Training)
 Plyometric and Agility Drills
 Simulated Work-Related Activities and SportSpecific Drills
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Independent Learning Activities
 Critical Thinking and Discussion
 Laboratory Practice
 Case Studies
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