chapter 23 knee and thigh. the knee the knee is one of the most frequently injured joints in...
TRANSCRIPT
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chapter
23
Knee and Thigh
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The Knee
• The knee is one of the most frequently injured joints in athletics.
• The forces applied to it during sport activities are complicated by the fact that there are two long lever arms on either end of the joint, making it a joint that is susceptible to injury.
• Stability comes from ligaments and muscles.
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Knee Structure
• Two joints: tibiofemoral joint and patellofemoral (PF) joint
• Capsule: resting = 20°-25° flexion; closed = full extension, external rotation (ER)
• Ligaments: medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL), posterior cruciate (PCL)
– MCL: restricts valgus stresses, ER
– LCL: restricts varus stresses, internal rotation (IR)
– ACL, PCL: restrict AP stresses; taut during IR(continued)
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Knee Structure (continued)
• Neuroreceptors: in capsule, ligaments• 1° stability: ligaments; 2°= capsule, muscles• Medial/lateral meniscus: fibrocartilage screw
home mechanism: flexion extension WB: IR femur
NWB: ER tibia
• Muscles: quadriceps and hamstring groups, popliteus
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Patellofemoral Joint
• Resting position: full extension• Closed position: knee flexion• Patella must glide freely for full knee motion to
occur• Patella excursion is 5-7 cm• Inferior pole of patella lies at tibiofemoral joint
margin• Contact between femur and patella changes
through range of motion (ROM)(continued)
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Patellofemoral Joint (continued)
• Joint reaction force: compressive force = PF quadriceps muscle and tendon resultant vector force
• Contact pressure: ratio between PF joint reaction force and contact area
• In closed kinetic chain, as knee flexes, contact area and compressive force increase
• Force is greater than surface , so compression increases in WB with ROM increases
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Figure 23.1
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PF Compressive Forces
• Greatest patellofemoral compressive forces occur in 60°-90° positions.
• Closed kinetic chain (CKC): 0° to 30° produces minimal PF stress.
• Open kinetic chain (OKC): <20° (without weights) produces minimal PF stress.
(continued)
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PF Compressive Forces (continued)
• Distally attached cuff weights produce maximum patellofemoral compressive forces at 35°-45°.
• Greatest tibiofemoral shear force: 15°-30°.
• Machine resistance applied at the ankle reaches maximum patellofemoral compressive forces at 90°.
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Figure 23.4
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Patellar Malalignments
• Patella alta: patella higher than its normal position in the patellofemoral groove
• Patella baja: patella lower than its normal position in the patellofemoral groove
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Q-Angle
• = The angle that is formed by a line from the anterior superior iliac spine (ASIS) to the middle patella and a line from the middle patella to the tibial tubercle
• Normal Q-angle 10°-15°• Can change from weight bearing to non-weight
bearing• Disputable evidence that it is larger in women
because of pelvic structure• Pronation or a weak vastus medialis oblique
(VMO) can increase the Q-angle
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Figure 23.2
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Leg Alignment
• Excessive rearfoot pronation influences the patella’s alignment.
• Since the lower extremity works as a CKC during most functions, malalignment in one segment affects or causes compensatory changes in another segment.
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Factors Affecting Postinjury Strength
• Edema: inhibits quadriceps function• Pain: causes reflex withdrawal inhibition• Antalgic gait: causes weakness throughout
lower extremity
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Rehabilitation Concepts
• Extensor lag: in presence of full passive knee extension, incomplete active knee extension is secondary to quadriceps weakness.
• Quadriceps force required for last 15° of extension is twice as great as for other ranges of motion because of the muscle’s reduced mechanical and physiological advantage.
(continued)
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Rehabilitation Concepts (continued)
• ACL stress in weight bearing is at least 0°-60°
• ACL stress in non-weight bearing is greatest at 30°-60° and least at 60°-90°
0-60°
60-90°
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Figure 23.3
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Knee Bracing
• ACL braces provide stability during low-stress loads but not during functional loads.
• Knee braces may provide proprioceptive feedback.
• Types: prophylactic for prevention, rehabilitative for protection, functional for stability
• Custom and off-the-shelf
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Therex Progression
• Dictated by tissue healing and response to exercise stress
• Range of motion via exercise, joint mobilization, soft-tissue mobilization
• Strength exercises with low-level resistance initially
(continued)
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Therex Progression (continued)
• Balance with bilateral support, progressing to unilateral static and then dynamic activities
• Agility activities• Functional activities• Sport- and activity-specific exercises
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Soft-Tissue Mobilizations
• Massage for edema, spasm
• Deep-tissue releases for adhesions• Foam roller on tensor fascia latae (TFL),
quadriceps or deep-tissue massage• Trigger point releases:
– Quadriceps: patella from rectus femoris or vastus medialis
– Popliteus: posterior knee pain – TFL: lateral thigh
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Figure 23.5a1
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Figure 23.5a2
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Figure 23.5a3
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Figure 23.5a4
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Figure 23.5b1
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Figure 23.5b2
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Figure 23.5b3
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Figure 23.7a
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Figure 23.7b1
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Figure 23.7b2
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Figure 23.7c
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Figure 23.10
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Figure 23.11
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Figure 23.12
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Figure 23.13a
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Figure 23.13b
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Figure 23.13c
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Figure 23.13d
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Figure 23.14
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Figure 23.15
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Figure 23.16
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Figure 23.17
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Figure 23.18
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Flexibility
• Short-term: active versus passive• Prolonged• Age of scar tissue• Continuous passive motion (CPM) machines
immediately following surgical repair
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Figure 23.19
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Figure 23.20
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Figure 23.22
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Figure 23.23
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Figure 23.25
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Figure 23.26
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Figure 23.27
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Strength
• Can begin early even if knee is immobilized and non-weight bearing.
• Exercises for trunk, hip, and ankle should be included.
• Pain or swelling should not occur during or after exercise.
• Add exercises judiciously so can identify cause of inflammatory response.
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Figure 23.28
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Figure 23.33
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Figure 23.35
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Figure 23.39
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Figure 23.40
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Figure 23.41
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Figure 23.43
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Figure 23.44
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Proprioception and Functional Activities
• Program includes proprioceptive exercises aimed at restoring balance, agility, and coordination.– See figure 23.46a-c.
• Functional exercises for the knee, which are similar to those for the hip and ankle, use hopping, running, and cutting as well as sport-specific drill and skill activities.
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Figure 23.46a
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Figure 23.46b
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Figure 23.46c
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Figure 23.47a
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Figure 23.47b
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Injury: Sprain
• Swelling occurs in 2-24 h• ACL reconstruction: patellar tendon or
hamstring graft• Delayed versus accelerated rehab• Strong gastrocnemius contraction avoided
beyond 30° flexion in PCL sprains• MCL injuries rarely surgically repaired• Avoid patellofemoral pain
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ACL Reconstruction
• Rehabilitation considerations– Patient age– Weight-bearing status– Source of graft
• Must always keep in mind healing and maturity of graft
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Meniscal Injuries
• Isolated meniscal tears are more likely to be degenerative.
• Lateral meniscal repairs have a better success rate than medial repairs.
• In the long run, meniscal repair is more beneficial than meniscectomy.
• Conservative versus accelerated rehab
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Figure 23.49
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Meniscal Repair
• Arthroscopic procedure• Weight bearing is partial initially• Avoid stressing meniscus in area of repair.• Communication with surgeon is vital.
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Patellar Injuries
• Patellar dislocations and subluxation • Patella plica syndrome• Osgood-Schlatter disease• Patellar tendinitis patellofemoral stress
syndrome = PFSS (PFPS)• Tendon rupture
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Patellar Dislocation
• Extreme pain, edema• Disability prolonged if swelling is excessive• Quadriceps strengthening important• Inability to walk without assistive devices until
full active knee extension is possible and patient ambulates without limping
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PFPS
• Must identify and correct causative factors• Must relieve muscle imbalances• Effects of foot, hip, trunk• Evaluate patellar alignment and tracking in
weight bearing and non-weight bearing • McConnell taping effective in relieving pain
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Figure 23.50a
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Figure 23.50b
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Figure 23.50c
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Figure 23.50d
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Figure 23.50e
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Figure 23.50f
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Figure 23.51
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Figure 23.52
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Figure 23.53
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Figure 23.54
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Strains and Contusions
• Hamstring strains—hamstring tightness often a predisposing factor
• Quadriceps strains—often due to jumping or sudden changes in direction
• Quadriceps contusions—first goal is to resolve pain and spasm and maintain flexibility
(continued)
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Strains and Contusions (continued)
• Myositis ossificans: causes non-neoplastic bone formation in the muscle
• Iliotibial band (ITB) syndrome: – Overuse syndrome in middle- and long-distance
runners– Pain at 30° knee flexion when ITB is pulled over the
lateral femoral epicondyle
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Fractures
• Patella fracture: often result of a direct blow• Tibial fracture: often due to torsion or
compression forces
• Epiphyseal plate injuries of the proximal tibia or distal femur
−Occur in adolescents whose growth plates have not yet matured
−Can alter bone growth
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Osteochondritis Dissecans
• Unknown etiology• Affects femoral epiphysis in juveniles, femoral
condyle in adults• Bone flake in juvenile osteochondritis dissecans
(OD), bone fragment in adult OD• Knee pain, tenderness, quadriceps atrophy;
catching, locking, or giving way• Treatment and rehabilitation