And functional treatment of the LE

Function: Mobility and support for almost all functional activities of the lower limb

ROM norms ◦ Flexion 130-140:

Most ADLs require 115

Increased needs with sport and squatting

◦ Extension 0-10 hyperextension Lack of normal motion will inevitably lead to

dysfunction and pain Increased compressive forces or patella and cartilage

Decreased quad force production (leads to compensation)

How can this affect function up/down the chain?

Gait/Ambulation: 60°

Stairs and Sit - Stand:90° - 120°

Getting up from toilet: 115°

In/out of bathtub: 135°

Knee extension ◦ Quads: RF=2jt Vasti=1jt ◦ TFL/ITB: Can help stabilize terminal knee ext.

Knee Flexion ◦ Semimebranosus, Semitendinosus, Biceps femoris,

Sartorius, Gracilis, Gastroc

◦ Knee is a simple joint: It’s happy when it can flex/extend in the sagittal plane

We need to train stability against forces in frontal/transverse planes

◦ Where does rotational stability come from?

Need to understand what tissues are causing pain ◦ Patient education/expectations/responsibility ◦ Patient specific treatment

Important to help guide treatment ◦ Precautions for specific Dx. ◦ Meniscus – no twisting, focus on rotational stability ◦ Tendinopathy – gradual increase in tendon loading ◦ OA – joint specific treatment, disperse forces

◦ Do you see how “cookie cutter” rehab may not

always be effective?

Diagnosis Patellar Tendonitis

Meniscal Tear

PF Syndrome

Knee OA

Aggravating Factors

Active and passive Rom, eccentric loading, worse with increased load and time.

Twisting and compressive activities, stairs Pop/lock of jt, instability.

Stairs, sitting *with knees bent, typically due to motor control that irritates soft tissue

Stiff/painful, worse in AM and prolonged inactivity. Pain at endranges.

Special Tests Pain with palpation, resisted ext and passive flexion.

Thessely, mcmurray, joint line tenderness Pain at PROM endranges

Correlation of signs/symptom reproduction. Functional tests.

Pain at endrange, ROM limits. Chronic = compensation up/down the chain.

Quad set/SLR ◦ Inhibited by swelling

Literature: less than 20cc can shut down quad

Important for post surgical patients!

◦ Biofeedback and NMES supported by literature ◦ If it’s not done right, it’s not worth doing.

What compensations do you see in the clinic?

Knee extension ROM Functional tests/Special tests ◦ (if indicated/appropriate) to guide where we focus

treatment.

Irritability determines extent of testing day 1

Hip/pelvis ◦ Decreased hip extension leads to weak glutes and

overactive hip flexors

◦ Pelvic drop (trendelenberg vs. reverse tr.)

◦ Adduction/IR likely due to poor lateral hip control

◦ All can translate excessive force to knee joints

Knee ◦ Lack of knee ROM

Decreased knee ext rom may be caused by tonic HS

◦ Quad whip

◦ Varus/valgus

Foot/ankle ◦ Poor push off

Compensated with overactive ant. Tibialis or toe extensors

Weak plantar flexors vs. learned compensation

◦ Lack of DF may cause knee to hyperextend

◦ Normal supination/pronation?

Pronation is NORMAL! Not always a bad thing if controlled

Medial heel whip? Could be result of excessive IR into the LE

Having this info day 1 helps to prioritize impairments.

Need to prioritize impairments to effectively progress through stages of rehabilitation ◦ Always driven by

functional deficits and impairments

◦ What is the goal of exercise/modality/ manual treatment?

Don’t forget about the pyramid!

Strength

Function

AROM

PROM

Edema, Pain Control

Manual RX: ◦ STM: quad/HS/ITB/fat pad/patellar tendon ◦ Joint mobs: patella, tib/fib jt, femoral/tibial

Exercises: ◦ Pain free ROM, Exercises in elevated position ◦ Focus on issues away from irritated tissue (hip/ankle) ◦ Activation exercises: QS, glute ladders, Core breathing ◦ Relaxation techniques: breathing, phasic activation

Taping: ◦ V-tape: fat pad off-loading ◦ Tilt/glide: patellar positioning ◦ X-tape: facilitate glutes, inhibit hyperextension ◦ Pinch/tent taping: off-load tendon/ ligament/ mm belly ◦ Kinesiotaping: web tape to increase lymph flow

Manual Rx: ◦ Knee flexion MWM ◦ Anterior tibial glides (prone) ◦ More than jt and mm limiting ROM

Neural, swelling, pain inhibition/guarding

Exercises ◦ More effective if addressing tissue length AND motor

control: patients need specific instruction Heelslides: focus on hip control as well as stretch Prone hangs: may strengthens HS and shorten muscle Need to focus on multiplanar stability

Poor control will lead to increased tissue irritation Exercises should not reproduce symtpoms

Muslce soreness is NOT a symtpom Pain does NOT always = gain

Exercise must meet life/work demands

Once AROM is pain-free we must incorporate it into functional tasks

Basic skills of LE ◦ SLB ◦ Squat ◦ Step ◦ Lunge

Must master SLB before other single leg exercise ◦ Includes step up, lunge, sidesteps...

One of the most basic functional movements

Basic building block for all single limb activities ◦ Steps, side steps, lunge, throwing, layup, putting on

pants.

Consider using ◦ Mirrors: help increase feedback (initially)

◦ UE assist: help bypass other strength limits

◦ Progress to unstable surfaces, UE/LE movements

◦ Get functional sooner than later!

Most appropriate when patient able to move through functional ROM without pain and normal patterns.

Adding weight/resistance to any abnormal movement pattern will promote abnormal patterns

Many types of strength ◦ Endurance needs vs. maximal force needs ◦ Stability needs vs. mobility needs ◦ Eccentric vs. concentric ◦ Train multiplanar movements when appropriate

It’s common to see faulty mechanics with knee pain ◦ Hip adduction/IR (valgus) with steps/SLB ◦ Femoral IR with knee extension ◦ Quad dominant activation increases stress at knee

joint and to surrounding tissues Squat with increased anterior tibial translation

Quad whip with ambulation

◦ Need to find painful and functional tests (asterisk) The tests help determine what needs to be treated

The tests become the exercises

Function

Dysfuntion?

Restricted?

Weak?

Sit-stand

SLB

Step Up

Squat

Knee treatment is about the hips. ◦ Khayambashi K, et al. and Dolak, KL et al. –

strengthen hip effective for females with pfs

◦ Powers, C 2010 – importance of hip mechanics

Hips role in knee function ◦ Stabilization reduces unnecessary forces at joint

◦ Proper control can decrease muscle imbalances that lead to pain

Focus on control of entire chain ◦ Hip and pelvic control very important (chris powers)

◦ Rehab needs to include proprioceptive/sensorimotor control of the entire chain

SLB, varying surfaces to increase neural control, progressing towards multiplanar/functional movement

◦ Exercises need to be task specific

Bridges increase strength and improve performance of doing a bridge, NOT stairs/sit-stand/walking

If you want to improve something, train it functionally!

Depends on the GOAL of rehab

High MVIC% for strength?

Activation to recruit proper firing of muscle? ◦ Easier exercises for highly irritable patients

◦ To help dampen down compensations

Functional?

Boren et al. 2011 Gluteus Medius ◦ Side plank abd (103% leg down- 88% leg up) ◦ SL squat 82% ◦ Hip clam #4 76% ◦ Sidelying ABD 62%

Gluteus Maximus ◦ Front plank hip ext 106% ◦ Glute squeeze 80% (are you as shocked as I was?) ◦ SL squat 70% ◦ Unilateral wall squat 86% (Ayotte et al.2007)

The good: ◦ we can assume these are great for muscle

strengthening

Rehab concerns: ◦ Is it controlled?

◦ May be too advanced for some patients

◦ Do they have the available ROM?

◦ Does exercise increase pain? (correct recruitment?)

All of these preferentially targets glutes over TFL

Maybe not best choice to turn down TFL, but very functional!

Good ◦ Clam 115

◦ Sidestep 64

◦ Unilateral bridge 59

◦ Quadraped hip ext 50

No dif for knee position

Not so good ◦ Lunge 18

◦ Hip hike 28

◦ Squat 28

◦ Sidelying hip abd 38

Boren et. al 2011 Ekstrom et al. 2007

Glute med ◦ Quad hip ext (non dom)

22%

◦ Glute squeeze 43%

◦ Quad hip ext (dom) 46%

Glute max ◦ Hip clam #2: 12%

◦ Quad hip ext (non dom) 21%

Dom = 59%

◦ Dynamic leg swing 33%

Glute med ◦ Prone bridge 27%

◦ Bridge 28%

◦ Lunge 29%

Glute max ◦ Prone bridge 9%

◦ Bridge 25%