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Knee Rehab

Knee Rehab. Peter M. Doyle, PT, DPT, MCT Sports Medicine Fellowship USUHS/DeWitt ACH. Outline. Knee Function Rehab progression model Therapeutic exercise Other Interventions. Knee Joint Function. Overview. Knee provides mobility and support during dynamic and static activities

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Knee Rehab

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  1. Knee Rehab Peter M. Doyle, PT, DPT, MCT Sports Medicine Fellowship USUHS/DeWitt ACH

  2. Outline • Knee Function • Rehab progression model • Therapeutic exercise • Other Interventions

  3. Knee Joint Function

  4. Overview • Knee provides mobility and support during dynamic and static activities • Support during weight bearing • Mobility during non-weight bearing • Involved with almost any functional activity of the lower extremity

  5. Knee Joint Motion:Flexion and Extension • Knee flexion - normal ROM is 130-1400 • Routine ADL’s require 115° • Can be as high as 160° in squatting • Extension - 5-100 hyperextension can be normal

  6. ActivitiesKnee Flexion normal gait/level 60° surfaces stair climbing 80° sitting/rising from 90° most chairs sitting/rising from 115º toilet seat advanced function > 115° Functional ROM at the Knee

  7. Arthrokinematics:Femoral Condyles in Flexion • 1st 250 - mainly roll >250 roll and ant glide

  8. Knee Joint Function: Muscle Action

  9. Muscle Action: Flexors • Semimembranosus, Semitendinosus, Biceps femoris, Sartorius, Gracilis, Popliteus, Gastrocs • All are 2 jt. muscles except popliteus & short head of biceps femoris

  10. Muscle Action: Flexors • Gastrocnemius - 2 jt. muscle • Small contribution to flexion • Very susceptible to active insufficiency • During PF with knee flexed, most work done by soleus • At the knee, appears to be more of adynamic stabilizerthan mobility muscle

  11. Muscle Action: Extensors RF 5- 70 VML 15-170 VL 30-400 • Quadriceps • Rectus femoris - 2 jt. • Vastus intermedius, lateralis, medialis • Resultant pull: • Lateralis • Medialis • Rectus femoris VMO 50- 550

  12. Patellofemoral joint

  13. Patellofemoral Joint

  14. Functions of the patella/PFJ • Increase the mechanical advantage of the quadriceps muscle group • Decreases friction - quad tendon & femoral condyles • Helps to distribute the compressive forces that are placed on the femur

  15. Patellofemoral Joint: Patellofemoral Joint Congruence • 1st consistent PF contact is between 10-200 flexion with increased contact as flexion increases • By 900 all aspects of facets have made contact except odd which contacts at >900 • At 1350 - contact is on odd & lat facets

  16. Patellofemoral contact points

  17. Patellofemoral joint stress in weight-bearing and non-weightbearing

  18. Biomechanics: clinical implications(Grelsamer & Klein, 1998) • Quad strengthening can be safely performed in the 0-90 range by varying the mode of exercise if ROM restrictions are in place. • Specifically, open chain (NWB) exercises are most safely carried out from 25-90°, and SLRs with the knee at 0° of extension are equally safe. • Closed chain (NWB) exercises are safest in the 0-45° range.

  19. Rehab Progression

  20. Rehab Model

  21. Tissue Healing

  22. Pain Management • PRICE (Protection, Rest, Ice, Compression, Elevation) • Moist heat (If not in inflammatory) • Physical Agents – ionto, e-stim, TENS • Joint mobilization – Grades I and II

  23. Motion • PROM • Patellar mobs • Tibialfemoral Joint mobilization (accessory and physiologic motions) • Grade III-V • Flex/Ext (some IR and ER) • Stationary bike • Fibular mobs • AAROM • AROM • Heel slides

  24. Motion • Stretching • Quads – prone, standing • Hip flexor – kneeling, supine (Thomas Stretch) • Hamstring – supine, standing, seated (watch lumbar spine) • Gastroc/Soleus – seated towel, standing • ITB / TFL – standing, supine, sidelying

  25. Strengthening • Isometric • Quad sets • Hamstring sets • Glut Sets • ABD ISO • Dynamic • Open chain • Closed chain

  26. Strengthening • Open Chain • SLR • Steamboats • Short arc quads • Knee extensions (avoid last 30 deg) • Hamstring curls

  27. Strengthening • Closed Chain • Terminal knee extension • Squat progression (wall, mini, full) • Lunges / Split squats • Step-ups/Step-downs • Hamstring stool scoots • Eccentric HS in kneeling (difficult can be painful) • Calf raises

  28. Strengthening • Do not forget the Hip • Prior emphasis on quad/VMO activation and deficits missed weakness and imbalance of hip ER, ABD and EXT

  29. Proprioception • SLS • Eyes open / closed • Foam • BOSU Ball • Rebounder • BAPS Board • Body Blade • Clock Drills • Perturbations

  30. Endurance • Bike • Treadmill • Walk, Jog, Run • Elliptical • Stair stepper • Pool • Swim, Jog, Aerobics

  31. Power • Advanced weight lifting • Leg press • Hamstring curl • Squats • Lunges • Dead lifts • Calf raises

  32. Skilled Activity • Figure 8s • Kariokas • Single leg hop • Lateral shuffles • Ladder drills • Form drills • Box jumps/plyometrics

  33. Full Activity • Walk to run progression • Return to sport drills • Return to full practice • Return to competition

  34. Other Interventions

  35. Physical Interventions for PFPS: Crossley et al. 2001

  36. Physical Interventions for PFPS: Crossley et al. 2001

  37. More Support of EccentricsGerber et al. 2009 • Pos op ACL-R • Matched by age, sex, graft type and then randomized • N=40 • Eccentric Quad and Glut max • Progressively post 3 weeks of standard care for 12 weeks with standard strength VS standard strength • Similar finding to previous studies • Re-assed 1 year post op • Increased muscle volume on MR • Increased strength • Increased hop • No difference in ADLS and Lysholm

  38. More Support of EccentricsVisnes, Bahr, 2007

  39. Physical Interventions for PFPS: Crossley et al. 2001

  40. Physical Interventions for PFPS: Crossley et al. 2001

  41. Physical Interventions for PFPS: Crossley et al. 2001

  42. Physical Interventions for PFPS: Crossley et al. 2001

  43. Patients with PFPS who may have success with Lumbopelvic Manipulation: • Clinical Prediction Rule: • Hip IR asymmetry > 14 deg • No patient-reported stiffness sitting > 20 min • Squatting most painful reported activity • Navicular drop > 3mm • Ankle DF > 16 deg with knee flexed Iverson et al, JOSPT, Jun 2008. (Abstract: Iverson 2006)

  44. Physical Interventions for PFPS: Crossley et al. 2001

  45. Running Shoes

  46. Additional Treatment Options

  47. Hip and Core StrengthEarl and Hoch AJSM Oct 2010 • Study Design: Case series; LOE = 4. • Nineteen active women with PFPS • 8-wk strengthen the hip and core • ADM, SL Clam shells, SL SLR, Supine Core, Quadraped, SLS, (LE Stretch) • SLSABD, SLSFLEX, SLSEXT, Showboat, P Plank, S Plank, Mini Sq, (LE Stretch) • Monsterwalks, SLS with Sports Specific UE Movement, Squat Progression to Lunge/Step Down, (LE Stretch)

  48. Hip and Core StrengthEarl and Hoch AJSM Oct 2010

  49. Plyometrics Prevention of ACL InjuryYoo et al. 2010

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