Chapter 21
The Knee
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Anatomy
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Subdivisions of Synovial Cavity
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Myology
Anterior Posterior
Rectus femoris Biceps femoris
Vastus lateralis Semitendinosus
Vastus intermedius Semimembranosus
Vastus medialis
Medially Laterally
Gracilis TFL/ITB (affected by
Adductor longus, brevis, gluteus maximus, etc.)
magnus
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Kinematics – Tibiofemoral Joint
ROM
Flexion/extension 0-140 degrees
Extension – Limited by ACL and PCL,
posterior capsule, anterior horns of
menisci.
Flexion – Limited by cruciate ligaments
and posterior horns of menisci.
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Kinematics – Patellofemoral Joint
During Flexion
0–90 degrees – Contact area is more central portion of
patella.
135 degrees – Medial facet contacts medial femoral
condyle.
Ideal static – Patella positioned slightly laterally–Remains
in trochlear groove until 90 degrees.
Extension – Patella moves superiorly along line of femur
if VMO and VL are in balance.
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Rolling with Anterior,
Anterior/Posterior Glide
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Anatomic Impairments
Genu Valgum
– Femur descends obliquely in a medial direction (normal 5–10
degrees).
– Greater load on lateral compartment.
– Associated with coxa varum at hip.
Genu Varum
– Angulation of femur and tibia is 0 or laterally orientated.
– Increases load on medial compartment.
– Associated with coxa valgum.
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Genu Valgum/Varum
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Examination and Evaluation
Components of Knee Assessment
Pelvis/hip – Muscle length, alignment, performance,
capsule mobility
Knee – ROM, ligament stability, meniscal tests, extension
overpressure response, palpation
Patella – Orientation, VMO/VL relationship, lateral
retinacular tightness
Tibia – Torsion, tibial varum/valgum, rotation
Foot – Pronation/supination, rear/forefoot
alignment
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Muscle Performance
Muscles commonly tested
Medial and lateral hamstrings
Quadriceps
Gluteal muscles
Iliopsoas
Gastroc-soleus
Hip rotators
Posterior tibialis
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Therapeutic Exercise Intervention for
Physiologic Impairments
Mobility Impairment – Hypomobility
Glide and joint distraction techniques
Patellar mobilization
Quadriceps, hamstring stretches
Abdominal support
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Quadriceps Stretch for Hypermobility
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Hypermobility
Associated with patellar instability
At risk for ACL injury
Clinical signs – Knee recurvatum and subtalar
pronation
Treatment
Postural retraining of lower extremity and
lumbopelvic region
Co-contraction of lower extremities (high reps-low
resistance)
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Impaired Muscle Performance
Treatment – Strength, endurance,
and power training activities.
Neurologic Causes:
Lumbar spine injury or disease
MS
Parkinson’s disease
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Muscular Strain
Hamstrings and quads most commonly
injured.
Treatment:
Bleeding control followed by progressive
mobility and strengthening.
Plyometrics if within patient’s functional
abilities and goals.
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Disuse and Deconditioning
Occurs primarily at
quadriceps.
Treatment:
Strengthening activities for
the quadriceps.
Focus on primary cause of
disuse.
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Therapeutic Exercise for Common
Diagnoses – Ligament Injuries
ACL
Usually occurs due to hyperextension, deceleration, rotational
injury.
Frequently associated with injuries to MCL.
Treatment:
Avoid resisted open chain (OC) exercises.
Closed chain (CC) exercises including deceleration, cutting
maneuvers, lateral movements, resisted rotational movements,
and activities on unstable surfaces.
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PCL
Most often a blow to anterior aspect of
tibia.
Occasionally, hyperflexion/extension
or varus/valgus injury.
Treatment:
Avoid open chain exercises.
Closed chain exercises are used.
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MCL
Usually torn as a result of valgus stress by a lateral blow or
forced abduction of the tibia (skiing).
LCL
Much less common than MCL injuries.
Commonly results from hyperextension varus stress.
Treatment:
Loading must occur in frontal and transverse planes.
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MCL Exercises
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Treatment of Ligament Injuries
Pain can be managed with physical agents,
mechanical and electrotherapeutic modalities.
Therapeutic exercise (AROM, PROM).
Joint mobilization may be necessary.
Home program may include exercises to
increase ROM and neuromuscular re-education.
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Treatment of Ligament Injuries (cont.)
Acute
Aquatics is excellent
for:
Mobility, gait, initiating
balance, walking,
physiologic stretching, leg
kicks, toe raises, single
leg balance, and squats.
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Progression
Continuation training
and progressing to
non-device-assisted
exercises.
Land-based CC
exercises.
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Late Stage
Resisted OC
exercises.
Functional specific
drills.
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Fractures
1. Patellar fracture
2. Distal femur fracture
3. Tibial plateau fracture
4. Treatment
Surgically fixated – AROM/PROM exercises for flexion
and extension.
Quadriceps and hamstring setting exercises.
Weight-bearing CC exercises – Based on healing and
NM control.
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Menisci Injuries
Partial meniscectomy
Most often injured traumatically
Degenerative tears
Treatment:
Weight-bearing through large ROM should be
avoided.
Partial weight-bearing as tolerated is permitted.
Progression is dictated by procedure.
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Self-Management Techniques
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Surgical Procedures
1. Osteotomy – Treatment is guided by requirements of a
healthy joint. Restoring ROM is crucial to ensure
proper distribution of loads.
2. Total knee arthroplasty – Patellar instability can be an
issue in 5–30% of TKAs. Limitations at hip and ankle
can profoundly affect post-op function.
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Tendinopathies
Patellar Tendinopathy Treatment
Focuses on patellar tendon’s role in decelerating knee
flexion during functional activities.
Stretching exercises are combined with eccentric
quadriceps contractions progressing in velocity to match
that of daily activities.
OC or CC can be used; however, CC is preferred.
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Iliotibial Band Syndrome
Treatment:
Postural education
Exercises for underlying impairments
(e.g., hip rotator weakness)
Stretching of hip and knee
musculature
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Patellofemoral Pain Syndrome (PFPS)
Aggravated by knee extension activities.
For example, ascending/descending stairs,
squatting, rising from chair, jumping.
Can be caused by frank dislocation, commonly
associated with hypermobility of patella,
tenderness of patellar borders and femoral
condyles, shallow intercondylar groove.
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PFPS (cont.)
Overuse.
Poor tracking of patella (shape of osseus
surfaces or muscle imbalance).
Q-angle greater in those with PFPS (excessive
pronation of foot?)
Greater degree of lateral patellar tilt.
Muscle imbalance (VMO:VL).
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PFPS Treatment
General quadriceps strengthening.
All exercises to be performed in pain-free ROM.
Exercises can be CC or OC.
Exercise difficulty is dictated by total target
ROM.
Eccentric control exercises are commonly
prescribed.
Patellar taping can be helpful.
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Summary
Relationships among lumbopelvic, hip, knee, ankle,
foot requires thorough evaluation and treatment.
Anatomic impairments can predispose the
patellofemoral joint to poor tracking and excessive
loads.
Physiologic impairments (mobility, muscle
performance, etc.) of neighboring regions can be
manifested as symptoms at the knee.
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Summary (cont.)
Examination of patellofemoral joint must include
muscle length, joint mobility, etc. at neighboring
regions and assessment of patellar position and
motion.
Improvements in impairments and general
quadriceps strengthening within the entire lower
kinetic chain associated within PFPS may result
in positive outcomes.
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Summary (cont.)
Major anatomic impairments at the knee are
genu valgum/varum. These postures predispose
lateral and medial compartments to excessive
loads.
Physiologic impairments at the knee can be
compensated by motion at other joints.
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