Tibiofemoral joint

Weight bearing
Structures for mobility & stability
P H YSIC A L T H E R A P Y Most susceptible to traumatic injury

FOR KNEE
DYSF U N C TIO N
yifen shih

Menisci Knee ligaments

 Attachment  The collateral (MCL, LCL), IT tract,
 Transverse, coronary, meniscopatellar ligaments, etc
The cruciate (ACL, PCL), posterior
 Quadriceps, semimembranosus, popliteus
capsular, meniscal ligaments,
Functions

patellar ligament
 Enhance joint congruence
 Assist in gliding motion
 Resisting or controlling movement
 Excessive knee extension (MCL, LCL)
 Varus or valgus stresses at the knee (LCL, MCL)

ACL 的  Anterior or posterior displacement of the tibia

MPL  Medial or lateral rotation of the tibia

 Combined anteroposterior displacements and rotations

PCL
of the tibia
QF
semimembran.su popiiten
The Weight-bearing Axis The Muscles
The
 The mechanical axis of LE anatomical
axis of femur
 Knee flexors:
The hamstrings (Semimembranosus, Semitendinosus, Biceps
 The tibiofemoral angle: 5-10° (b/t 
femoris)
anatomical & mechanical axes of  Sartorius
The
the femur) mechanical  Gracilis
 Physiological genu valgus axis of femur  Popliteus
 Body weight is evenly distributed  Gastrocnemius
between the medial & lateral  Knee extensors:
compartments in standing The  Quadriceps femoris
anatomical
 Genu valgum: the TF angle>15° axis of tibia  Internal rotators:
Popliteus, gracilis, semimembranosus, semitendinosus
 Genu varum: the TF angle<0°


 External rotators:
 Biceps femoris

Knee stability Knee stability: sagittal and frontal plane

 Static stabilizers (SS):  Anteroposterior stabilization

bony structures, capsule &  SS: patella, ACL, PCL, MFL
ligaments (MCL, LCL, ACL,
 DS: Pes anserinus, ITB, popliteus
PCL, ITB, etc)
(major stabilizer in 0-90° knee flexion) & BF

 Mediolateral stabilization
 Dynamic stabilizers (DS):  SS: tibial tubercles, menisci, capsule, MCL,
contractile tissues (QF & LCL in full knee extension
extensor retinaculum, pes  DS: pes anserinus, ITB, popliteus
anserinus, popliteus, BF,
(major stabilizer in 0-90° knee flexion) & BF
SM, gastrocnemius)
Knee stability: transverse plane Knee joint motion

 Sagittal (flex/ext):
 Rotational stabilization 0-140°
 SS: ACL & PCL (esp. in KE), MCL, LCL, posterior
capsule, MFL (restrain excess ER)
 Transverse:
 DS: Pes anserinus, SM, BF, popliteus
ER: 0-45° &
IR: 0-30°

 Frontal (abd/add):
0-3° (maximum at
30° KF)

Screw-home mechanism Knee joint motion during activities

 Terminal KE is coupled with ER of the tibia to

Activity Sagittal Activity Amount of knee
lock the knee joint ROM flexion during stance
 Longer med condyle
Walking 0-67° Walking
 pulled by VL & PCL
 Helfet test: tibial ER during KE Up stairs 0-83° slow 0-6°
Down stairs 0-90° Free 6-12°
Sitting down 0-93°
Fast 12-18°
Tying a shoe 0-106°
Lifting an object Running 18-30°
0-117°
Data from Kettekamp et al (1970), n= 22 Data from Perry et al (1977), n= 7

KF=90° KF=0°
Tibiofemoral joint reaction force

Normal gait: 2-3

Patellofemoral joint

BW
 Running: 6-7 BW
 Important for extensor mechanism
 Easily injured with repetitive knee
 60-70% assumed bending activities
by the menisci

Patella Patellar articulating facets

 Articulating surface moves from the bottom up
 A sesamoid bone when the knee flexes
The odd facet does not come in contact with the
Articulates with the inter-condylar


femoral condyle until at max. knee flexion
(trochlear) groove on the anterior distal
Joint congruency ↓ when extension to 20-30° of KF
femur 

 vertical ridge, medial, lateral facets, & odd

facets
 Function
 Anatomical eccentric pulley for QF
 Reduce friction b/t the QF tendon
& the femoral condyles
 Protect the knee cartilage the odd facet
Patellofemoral joint stability Role of vastus medialis obliquus

 Transverse  RF, VL, VI, & VM: all contracts

 med & lat extensor throughout knee extension
retinaculum (ER), VL &  VL: 12-15° laterally
VM, med & lat PFL, ITB VML: 15-18° medially
 Longitudinal  VMO (50-55° medially):
 the patellar ligament &  alone is unable to extend the knee
quadriceps tendon  keeps the patella on track in gliding on
the femoral condyles (tracking
mechanism), thus prevents lateral
displacement of the patella

Q angle and PFJ Q angle & Bowstring effect

Q
 ASIS - mid-patella - tibial tubercle
 10-15° (with QF relaxed, knee extended) Femur IR

 < 10° with QF contracting

 Net effect of the pull of the quadriceps

Valgus
& the patellar ligament
 Q↑ with wider hips, femoral IR,
genu valgum, tibial ER Tibia ER
 Q> 20°: ↑lateral pull on patella (lateral
tracking disorders, Patellofemoral pain
syndrome)
Force pull on patella Joint reaction force

 Simultaneous pull of the QF and the patellar

tendon

 Least at KE, ↑with KF

 0.5BW at HS during gait,
 1 BW at standing with KF=30°
 3.3 BW at standing with KF=60°, during up
stairs/running
 ~8 BW at squatting or deep knee bending

Ligamentous injuries

Stretching or tearing of non-contractile

Common knee dysfunctions 
tissues, ACL, MCL
The joint: ligaments, menisci, bursa, synovium cavity  Excessive valgus, varus, anterior, posterior,
The bones or rotational forces
The musculotendinous structures  Marked effusion, severe pain & spasm often
mask the underlying instability
 Weakened ligaments take at least 10 months
to return to normal viscoelasticity &
stiffness
Ligamentous injuries-grading Instability of the knee
 Grade I: stretching but no tearing, local tenderness,  Straight instability
minimal edema, no gross instability, firm endfeel, Rx
 Medial, lateral, posterior, anterior
with PRICE

 Grade II: partial tears, moderate local tenderness, mild  Rotatory instability
instability, firm endfeel, Rx with PRICE, brace + rehab  Anteromedial, anterolateral, posterolateral

Grade III: complete tear, variable discomfort and

Combined rotatory instability


edema, clear instability, soft endfeel, Rx with PRICE,
surgery for gross instability

ACL injury 如另 Landing strategies

 ACL deficiency: most common in knee  Valgus landing vs. Straight landing
injuries
 Isolated injury or associated with MCL
& MM damages
 Usually cause anteromedial & anterolateral
instability
 frequent in female athletes
 More in non-contact sports: jumping, cutting
 Landing strategy?
 Multi-directional forces to tibia: anterior,
valgus, rotation
 Forceful contraction of QF
Unhappy triad of O’Donahue ACL+MCL(+PM) Injuries
 MCL tear, ACL tear, damage to the
posterior medial capsule
 Valgus-directed force to the already fully
ER knee

PCL injury Meniscus injuries

 Anteroposteriorly directed force to
tibia or PA directed force to femur  Mostly non-contact in nature
 cutting, decelerating, or landing from a jump
 Commonly occurs in flexed knee  Sudden rotation of the femur on the fixed tibia (pivoting)
 MM tear often accompanied by the ACL tear
Dashboard
 Often associated with degeneration later in life
injury  Mechanical symptoms
 popping, catching, locking, or buckling along with joint line pain
 Often leads to a mild synovitis
 swelling for several days after injury, may be recurrent and
activity related.
 Immediate swelling suggests bleeding instead of reactive joint
fluid
31
31
Meniscal injuries Meniscal injuries
 Physical examination:  Imaging
 Limping gait  X rays: for associated skeletal injury, presence of
 Effusion, joint line tenderness, pain along the joint loose bodies, or degenerative changes.
line, springy end feel  Arthrography: most accurate
 “the locked knee”, pain at the terminal degrees of
 Surgical Management: arthorscopic repair,
flexion (posterior horn) and extension (anterior
horn)
transplantation
 For untreated ACL injuries, meniscal tears rate
 Special tests ↑20% to 5 folds in 5 years
 springy end feel  Favourable outcome for meniscal repair
 The McMurray test  Time from injury (less than 8 weeks)
 Apley’s test  Peripheral location of the tear
 Knee stability should be assessed for concurrent  Patient age less than 30 years
ligamentous injury  Simultaneous ACL reconstruction
 Success rate: 67-92% after 2 years

Strains Thigh muscle strains or rupture

 Stretching or tearing of
contractile tissues
 Quadriceps damage:
 abrupt anterior knee pain, unable or
painful to extend the knee or to bear
weight, passive KF ↑pain, resisted
ext ↑pain
 Hamstring damage:
 posterior thigh pain, unable to flex
the knee, unable to weight bear,
passive KE ↑pain, resisted flex
↑pain
 Rx
 始
Bursitis & tendinitis (tendinopathy) Knee bursitis
 Prolonged or repetitive compressive or
tensile stresses Prepatellar bursitis
IT tract syndrome
 The housemaid’s knee: prepatellar & superficial
infrapatellar bursitis
 The jumper’s knee: patellar tendinitis

 Pes anserinus (knee adductor/IR) tendinitis

 IT tract/band tendinitis

 Rx: Patellar
 acute stage: PRICE, taping tendinitis Pes anserinus
 chronic stage: taping, manual techniques, activity tendinitis/bursitis
modification

突然長⾼n⼈ 骨長太快肌⾁拉扯
The plica syndrome Osgood-Schlatter disease ⽣長
板被拉
 Irritated, inflamed plica  Epiphysitis
 Pain, effusion, and changes in  Pain, enlarged tibial tubercle
joint structure & function (esp.
 Primarily occurs in
medial or superior plicae)
adolescents, pain ceases
 May lead to OA or
after epiphysis closure
chondromalacia
 Rx: PRICE, taping, activity
 Rx: PRICE, Taping, manual
restriction & modification
techniques, activity
modification

40
Anterior knee pain Anterior knee pain

 Patellofemoral pain syndrome (PFPS)  Chondromalacia: ♀>♂

 Prevails in young female (F:M=3:1), knee bending  Softening of the patellar cartilage, med > lat
activities increase pain  Casued by: trauma,↑or↓stress to PFJ
 No bony/cartilage defects  Ant. knee pain & tenderness, ↑with
 Mechanism: knee bending activities, may lead to early
 Patellar mal-tracking (lateral tracking) OA
 Imbalaced muscle activity in VL: VMO  PE:
 Compensation to pronated foot  Crepitus, “+” PF grinding test, skyline (Merchant)
 Compensation to hip ER/ABD weakness view x-rays
 PE: Tightness in TFL/ITB, hamstrings,  ↑Q angle, patellar lateral tracking
gastrocnemius, etc.; weakness in QF, ↑Q angle  QF weakness, extensor retinaculum
tighness/loosening
 Rx: Taping, exercise, activity modification
 Rx: surgical debridement, taping,
exercise, activity modification

Anterior knee pain Degenerated joint disease

lateral

 Patallar dislocation or lateral  DJD, OA (osteoarthritis)

subluxation:  Aging: progressive tear & wear in
 Trochlear defects, extensor lateral cartilage, menisci, & ligaments
retinaculum loosening  pain, morning stiffness < 45min, loss
 excessive lateral pull on patella of mobility or stability, loss of
 Pain, ↑ with sustained KF (e.g. function
prolonged sitting)  PE:
 may
⼀膝後睡 塊
have “Baker’s cysts” in the
 knee “giving way”, exacerbated by
popliteal fossa
repeated contraction of lateral  ROM restriction: KF > KE
quadriceps in KF  Reflex muscle weakness, extensor lag
 Rx: Surgical stabilization, patellar  genu varum more common
brace, QF exercise 㕽䲄
Medial Knee OA
ni
 Degenerated joint disease Degenerated joint disease
 X ray: ↓joint space, spurs,
sclerosis

 Rx: moderate activity,

↓weight, orthorsis (lateral
wedge), mobilization,
exercises & ADL approach

Joint space narrowing, spur (osteophyte) formation, & sclerosis

骨刺和疼痛未必
有關

Genu recurvatum

 Mal-aligned tibia & femur

 leads to prolonged stretch weakness
Evaluation and assessment
of posterior knee joint structures
 Neuromuscular dysfunction
 QF or H weakness?
 H or G tightness?
 LLD
Wedge
 ACL injury? (cause or consequence) correction
 Rx: orthosis, exercise, gait training
Physical therapy evaluation History
 Pain: where? what type? how affected by activities?
S: subjective evaluation & how did it start?
history taking  Aching pain: DJD
Sharp pain: mechanical problem
O: observation &


 Anterior, joint line, posterior, generalized?

objective measurements
 Injury mode: clicking or popping sounds? foot on
A: assessment of the problems, ground? direct or indirect blow? direction of the
establish STGs & LTGs force?
Varus/valgus with or without rotation
 Plan of treatment 

 Non-contact hyperextension/ deceletation

 Forced rotation, rotation with compression or with
varus/valgus
 Dashboard injury

History Observation

 Function: difficulty in running, cutting, pivoting,  Knee flexed during stance

twisting, climbing, or descending stairs?  Not bearing weight? antalgic gait?
 Unable to turn quickly: MCL and LCL?  Intracapsular swelling (resting position: KF~25°)
 Unable to run forward: ACL?
 Unable to descend stairs easily, squat, or run backward: PCL  Intoeing/outtoeing
or posterior capsule  tibial torsion? femoral torsion?
 Knee gives way? swelling? clicking with movements?  Genu recurvatum (back knee)
catches at certain angles? locking?  weak QF or H?
 tight H or G?
 Genu varum or valgum
 bowlegs or knock-knees
Observation Patella alta (camel sign) & baja

 Patella position symmetrical? ⾼

太 雄
 Squinting patella: femur IR or tibia ER
 Frogeye patella: femur ER or tibia IR
 Camel sign: high patella (patella alta)
 Infrapatellar bursitis, fat pad irritation
 Patella baja
 weak quadriceps, tight patellar ligament
 Leg length discrepancy  Patella alta  Patella baja
 Gait disturbance • high patella • Low patella
• infrapatellar bursitis • weak QF
• fat pad irritation • tight patellar ligament

Observation Observation 看有無內外八

 Leg length discrepancy  Gait disturbance

 ASIS-MM; GT-LJL; LJL-LM; MJL-MM  ↑ Knee hyperextension during stance: weak QF
 ↓ KE during stance: joint pain/swelling, meniscus
 Gait disturbance locking, KF spasticity or contracture
 IR (intoeing): anteversion, femur/tibia IR,  ↓ KF during swing: stiff joint, spasticity in KE
metatarsus adductus,  PFPS, ACLI  ↑ KF during swing: drop foot, spasticity in KF or
 ER (outtoeing): retroversion, femur/ tibia ER, congenital PF
femoral hypoplasia  PFPS
 ↓ KF during stance: weak QF, PFPS, OA  instability?

55
Physical examination Examination

 AROM STTT
 AROM
PROM, overpressure & end feel
PROM, overpressure & endfeel


 Resisted isometrics
 Flexion: tissue approximation
 Muscle flexibility
 Extension, IR & ER: tissue stretch
 Functional assessment
 Ligament instability
 Special tests  Capsular pattern: flexion > extension
 Reflexes & dermatome  Patella: tissue stretch (med & lat
shift ~ ½ width in relaxed KE)
 Joint play movement
 Palpation

Examination Resisted isometrics

it  KF: hamstrings (sciatic n. L5, S1-2)
satorius (femoral n. L2-3)
 Muscle flexibility
popliteus (tibial n. L4-5, S1)
 Hip flexors (Thomas’ test) gastroncnemius (tibial n. S1-2)
 Rectus femoris (Kendall’s test or Ely’s test)
 KE: quadriceps (femoral n. L2-4)
 Hamstrings (90-90 test)

 Iliotibial band (ITT) (Ober’s test)

 KF+IR: medial hamstrings, popliteus
 Adductors (hip abd ROM, Phelp’s test)
 KF+ER: lateral hamstrings
 Gastrocnemius (long sitting dorsiflexion ROM)
 H/Q ratio: 50-60% (dynamometer tests)
 at slow speed
 Functional assessment Physical performance test
(Magee, Orthopedic Physical Assessment, chapter 12

ii
 Cincinnati Rating Scale  For hip/knee
 Symptoms (pain, swelling, giving way, etc): 50%  Sit-to-stand time
 Function (overall activity, walking, stairs, running, jumping):  50 FW time or 6 MW distance
50%
 Up & down stair time
 Knee Society Knee Score
 Pain, ROM, stability (deformity): 100%  Squatting repetitions
 Function (walking, stairs, AD): 100%  Running distance or time
 Knee Rating Scale  Jumping/hopping height or repetitions
 Pain, function, contracture, stability, deformity
 WOMAC Pain & Disability Index for hip/knee OA
 Pain, stiffness, function

Ligament instability One-plane medial instability

 Abduction (valgus) stress with KF=0°

 one-plane medial  Test for lesions in medial &
 one-plane lateral posteromedial SS & DS & the cruciates
 one-plane anterior (major disruption of the knee)
 one-plane posterior
 Abduction stress with KF=20-30°
 anteromedial rotary  Test for MCL, OPL, PCL, posteromedial
capsule integrity
anterolateral rotary Grade 1: < 5 mm; Grade 2: 5-10 mm;
在
 
kneejaut
posteromedial rotary Grade 3: >10 mm

 + tibia ER: MCL ⼼⼼雅
 posterolateral rotary

iifnn
 + tibia IR: PCL

Valgus test https://www.youtube.com/watch?v=GSFbttpxCuQ

看疼痛否看是否有 边相比
 One-plane lateral instability One-plane anterior instability

AllA测
Lachman 中準確
n test
试 度 1
(KF=20-30°)
No
 Adduction (varus) stress with KF=0° 

 Test for lesions in lateral (posterolateral)  Modified Lachman, active Lachman

DS & SS, & the cruciates  1°: 3-6 mm; 2°: 6-9 mm;
3°: 10-16 mm; 4°: >20mm
ER
tibia +: ACL (PLB), OPL, APL
Adduction stress with KF=20-30° & ER
Anterior drawer sign (KF=90°)


LCL, posterolateral capsule, APL, ITT, BF

在 时 Modified
chronic  drawer, active drawer
䏈
band
狀 態
anterior
 Gr 1: < 5 mm
Gr 2: 5-8 mm
㵟好 (isometric quadriceps), prone Lachman

+: ACL (AMB), posteromedial & postero-
 Gr 3: >8 mm lateral SS/DS
 + tibia IR: PCL & ACL  May be negative if only ACL is torn

Anterior drawer sign https://www.youtube.com/watch?v=IdnBKv38EEQ

Varus test https://www.youtube.com/watch?v=sg1gk6QKARw Lachman test https://www.youtube.com/watch?v=JFkbKNNa7xQ

傷但不準確只是哩掄
理論上可看出是何band受
Modified Lachman & active anterior
drawer tests One-plane posterior instability
Modified Lachman  Posterior drawer sign
(KF=90°)
 PCL
 Posterior sag sign False positive for ACL
rupture if not reduced!
Active Lachman  PCL, OPL, APL, ACL
Prone Lachman Active anterior drawer  Active drawer (hamstring
isometric contraction)
 Reverse Lachman

Posterior drawer sign

https://www.youtube.com/watch?v=wDIGll5wzZs&list=PLO_peL93VBmkvyIwCU7VcRmpEur148KGh
Active drawer test Posterior sag sign https://www.youtube.com/watch?v=7vgTMnfP4fs
https://www.youtube.com/watch?v=tQCacgQgC-s&list=PLO_peL93VBmkvyIwCU7VcRmpEur148KGh&index=2
Reverse Lachman https://www.youtube.com/watch?v=uBFV1Fdtj4w
 Anteromedial rotary instability Anterolateral rotary instability

 Slocum test with IR=30°

 Slocum test with ER=15°  LCL, APL, PCL, ITB, posterolateral capsule, ACL
 MCL, OPL, posteromedial
capsule, ACL  Lateral pivot shift test (of MacIntosh)
 Anterior subluxation of the tibia (internally
= Lemaire’s T drawer test rotated) during KE, then reduction during KF
(knee giving way during 20-40° of KF)
IR中平昨中秘⼀州
 Primary test for ALRI and ACL ruptures
Tibia is reduced by ITT from KE to KF
Slocum test with ER 15 deg
https://www.youtube.com/watch?v=RGCxkqziHzE Slocum test with IR 30 deg https://www.youtube.com/watch?v=RGCxkqziHzE
Lateral pivot shift test (MacIntosh) https://www.youtube.com/watch?v=qqy5IfkEvfw

Posteromedial rotary instability Posterolateral rotary instability

Hughston’s posterolateral drawer

Hughston’s postero-medial


sign
drawer sign
 Tibia ER + poster drawer
 PCL, LCL
 PCL, OPL, MCL, posteromedial  APL, BF tendon, PL capsule, ACL
capsule, semimembranosus, ACL
 Jacob test (reverse pivot shift)
 Tibia IR (stabilize foot) +
 Supine with KF=80° +ER
posterior drawer
(subluxed), then allow KE +
valgus to reduce the subluxation
Hughston’s posterior drawer sign
https://www.youtube.com/watch?v=lDigNM93GuI
PCL intact PCL torn Reverse Pivot shift
https://www.youtube.com/watch?v=IqGPhYDhLSs
 Posterolateral rotary instability Tests for mensicus injury
 ER recurvatum test  McMurray Test
 Lift both legs (big toes) up in hyperextension, the  fKF + IR for LM, fKF + ER for MM
affected side shows a hyperextension or genu varum (at varying KF angles)
(with ER)  fKF + IR → KE for LM,

 PCL, APL, LCL, BF, PL capsule, ACL 朤fKF + ER → KE for MM

 Bounce Home test

 KF → passive KE (+: springy block)
快速
⼩卡很痛
McMurray
https://www.youtube.com/watch?v=lwDFPAyGGgI
ER recurvatum test
Bounce home test
https://www.youtube.com/watch?v=7thkte5kxY4
https://www.youtube.com/watch?v=P570wBELisU

Tests for mensicus injury Plica Tests 嚇到

Apley’s test  Mediopatellar plica test
掀会
痛

 Prone KF=90° + ER/IR +  KF=30°+ patellar medial shift
distraction (ligaments)
 Prone KF=90° + ER/IR +
compression (meniscus)
毗軫  Hughston’s plica test
tin+ Patellar med shift,

 KF + IR
 Thessaly test forrófux都
可 passively flex/ext the knee to
 One leg standing, rotate the feel for “popping”
femur on the tibia

Apley’s test https://www.youtube.com/watch?v=6Z_9lfX_Pc8 Hughston’s plica test: Hughston's Plica Test - YouTube
Thessaly test: Thessaly Test⎟Meniscus Lesion - YouTube
 Tests for patellofemoral pain Tests for patellofemoral pain
 Clarke’s sign
it
KF=0, 30, 60, 90°, press the patella
 Passive patellar tilt
 KF=0o
瞅 瞅⽤啦 啾
with QF relaxed, lift patella up

base down with the web and ask the
patient to contract the quadriceps
to tilt laterally ~15° lateral
⼩
 Waldron test
 Lateral overpull
 Contract quads in KE, watch
Palpate the patella with deep squats,
patella moves upward (A) &

fell for crepitus (+Pain), catching or lateral
poor patellar tracking laterally (B),
ijc＋ if B > A
A
B
Clarke sign
https://www.youtube.com/watch?v=pRqnODPqxFs

Other special tests Other special tests

在 latdeihle.fiext看痛否
Noble compression test
羅飍 Helfet test: tibial ER

 Q angle  ITT friction on lateral epicondyle
ASIS-midpatella &
熊熊at LLD (leg length discrepancy)
 
往
簽辨
midpatella-tibial tubercle  Screw home during KE
 Q>20°: anterversion,

genu valgum, tibia ER,
ASIS-MM
femoral IR, PFPS, or

GT-LM
subluxed patella, 
 GT-LJL, MTP (MJL)-MM
 KT-1000 , KT-2000
 Apprehension test  Anterior or posterior laxity
(patella dislocation) nigntfux Noble compression test
向外推 https://www.youtube.com/watch?v=PmUGl7ryQOo

嚹
Apprehension test Helfet test
https://www.youtube.com/watch?v=4TnCQppTy1g https://www.youtube.com/watch?v=5_-leVf0neI
KT 1000 https://www.youtube.com/watch?v=pn76MHIHOWc
Reflexes & Dermatomes Joint Play

 Reflexes  Tibia
 patella reflex: L3,4  Traction
 medial hamstring reflex:  Posterior & anterior glides
L5,S1
 Medial & lateral glides
 Dermatomes
 L2: anterior thigh
 L3: medial knee  Patellar
 L4: posterior leg, medial  Medial & lateral shift
malleolus  Patellar depression (caudal glide)
 L5: anterolateral leg, dorsum
 S1: posterlater leg
 S2: heel

Joint play: tibia Joint play: patella

 Swelling Assessment
 Intracapsular  Problems? PT diagnoses
 Brush, wipe, or stroke test 內侧往上外侧往下
knee  Alignment or biomechanical problem?
 Contractile or non-contractile?
wpw  For minimal effusion
此时刚则⿎起米州  Poor mobility or stabilization problem?

i Acute or Chronic?

if


I
 Local or referred?
 Stability or mobility?
 Weakness or tightness?

https://www.youtube.com/watch?v=ySpqA-K5kjo

Assessment

 STGs Treatment approach

 ↓ pain, swelling
 ↑ tissue protection, alignment
 Ligament Injury
 ↑ knee strength, flexibility, ROM, function
 Muscle Injury
 LTGs
 Postural awareness  Joint Injury
 Activity/gait modification & improvement
 Injury prevention
 LE Strength, proprioception, balance, skill
optimization
Treatment: 1-2° ligament injury Collateral ligament taping

 Acute Stage

i
 PRICE
 Protection (immobilize injured tissues)
 Taping
 Bracing
 non-weight bearing (WB) or↓ WB (toe-touch WB,
i
partial WB)
 Assistive devices (AD)
 Crutches or walker

Treatment: 1-2° ligament injury Quad set/Short-arc QS/SLR

 Subacute stage (2-7° day, phase I)

 Protection (immobilize injured tissues)
 Taping
No passive stretching
 Knee sleeves
or resisted exercise!
 Protected WB
 Isometric exercise
 Quadriceps settings (QS), short-arc Quads, SLR
 Hamstrings settings (HS)
 Ankle settings (AS)
 AAROM in hydrotherapy
 Ambulation as tolerated
Assisted KF/KE (right) Treatment: 1-2° ligament injury

 Subacute stage (>7° day, phase II)

 AAROM within pain limits
 Edema reduction
 Progressive eccentric loading
 1/4~1/2 squats
 PRE for KE/KF; synergists strengthening to
enhance stability
 Exercise bike, steppers, jogging if no pain
 WB as tolerated to full WB

mifuxienn 褓为主
斲
puiutn 为主

Resisted KF/KE Treatment: 1-2° ligament injury

single leg squat
 Phase III (chronic)
 Criteria
 No effusion 有腫
沒 脹
 Minimal condyle tenderness
 Full ROM
流
炎
 No sudden increase in laxity

 Aggressive strengthening unstable surfaces

 KE, KF, terminal QF control
 Proprioceptive training
 Close-chain vs. open-chain
 Acceleration-deceleration work
 Agility drills (specific to sports)
 Evaluate for return to training of sport
 P/O ACL rehabilitation
嚇就鐦 以
Continuous passive motion (CPM)
⼀些
教
前就會
⼑ Perioperative stage (1-4 day) Evidence
prefers no brace!
 Brace in 0° or 15° KE block, off at night óm
 KE/KF co-contraction
 CPM optional
• No active QF contraction! 故在⼼会
若定 有eotilg
 ADL, Ambulation with PWB
(unless close-chained) qig
• No passive stretching!

 Early postoperative stage (< 2 week)

 Ambulation with brace or sleeves & WBAT
 Hip muscle PRE
 Isometric knee co-contraction
 Active KF, sitting calf raises Progress KF exercise
 Wall slides 做
cautiously with hamstring 拐杖拿
 Well leg cycling tendon graft!

P/O ACL rehabilitation Carioca crossover drills

 Protected stage (2-6 weeks)
 Brace off PRN during therapy
 Hip PRE (weight machine) • Active assisted QF -
 KF PRE contraction;
 Slow controlled 2-leg squats to 60°
• Progress KF strengthening
 Leg press cautiously with hamstring
 Patellar mobilization tendon graft!
 Walking to FWB
4 6週
 Cycling if KF >110°
- • No passive stretching!

 Well-leg cross-over work

 General aerobic work
 P/O ACL rehabilitation P/O ACL Rehabilitation
 Intermediate postoperative stage (6-12
weeks)  Preparation stage for activity (12-24
 Leg press for strength & endurance
Progress KF exercise weeks)
cautiously with Full range, all speed strength & endurance
 Hamstring strength & endurance 
hamstring tendon graft! works
 2-leg squats to 60°
 1-leg squats to 60°
 Proprioception drills (AP to side/side)
 Balance drills (multidirection, high speed)
 Tube walk, tube run
 Power walk to run
 Stepper
 High speed retrowalking
 Cycle with minimal tension, build up speed
 Cycling
 Run in pool
 Ski, skate with/without brace
 Power walk
• Progressive QF strengthening  No high impact work
 Retrowalking • Large KF (> 30 °) for open-chain exercises
• Small KF (< 60° ) for close-chain exercises
 P/O ACL rehabilitation Plyometrics

 Return to activity (>24 weeks)

 Running drills, straight, figure 8,
circles, shuttle-run
 Hopping, jumping, plyometrics
 Sport specific drills

 Education re:
 long-term exercise program
 Activity selection
 Adverse signs (locking, swelling, giving way)
 Injury prevention (Neuromuscular training)

Landing Strategy

Strategies for managing PCL injuries Strategies for managing PCL injuries
Strategies for managing PCL injuries P/O Meniscus repair
 Progress exercises & WB more gradually after a
central zone repair or meniscus transplantation
Watch out for a
clicking sensation!
 Early rehabilitation (0-2-6 weeks)
 Brace 0-90° day & night for at least 2 weeks or 6
weeks for CZ (central zone) repairs
 ↑flexion gradually, especially after a CZ repair
 Walk with PWB (<50%) until QF control is sufficient
 4-6 weeks for peripheral repair
 6-8 weeks for CZ repairs
 Close-chain exercises with No twisting motion
 KF < 45° for 4 weeks or KF strengthening!
 60-70° for 8 weeks

P/O Meniscus repair P/O Partial meniscectomy

 For symptomatic, older or inactive patients,
 Advanced rehabilitation For tears extending into or localized to the CZ
 No deep squatting, twisting, pivoting until 4-6  No need for maximum protection
months
 No jogging/running until 5-6 months
 Moderate protection (3-4 weeks)
 Exercise & WB under no pain conditions
 90° KF by 4-7 days, FWB by 10 days
Return to Activity (up to 9 months)
Minimum protection & return-to-activity (> 4 wks)


 Refrain from activities involving repetitive, high
joint compression and shear forces  Advanced training (> 4-6 or 6-8 weeks)
 Avoid prolonged squatting in full KF  Plyometics, isokinetic training, jogging, jumping
progress with caution
Knee Braces Treatment for PFPS

 Patellar mobilization & neuromuscular control

 all direction, pain-free gliding of patella with quads sets, add
compression if able
 home program: 5-10 reps x 5-10 times/day
 Stretch:
 tight structures, esp. hamstrings, lateral retinaculum, ITT
 Strengthening: QF, VMO, hip abd/ER
 SLR+Add/IR; squat +Add/IR
 hip Abd & ER
 Heel wedge
 for pronated foot disorders
 Patellar taping

Taping McConnell Taping

 McConnell taping: medial glide taping

 Mulligan taping: ↑tibial IR and femoral ER

Rotation correction:
• Medial rotation:
bring the base
inward and
downward
• Lateral rotation:
bring the apex
inward and upward
Medial glide taping and spiral taping Taping for patellar tendon

Patella strap and sleeve Intervention options

 Physical agents
 Toimprove circulation, tissue flexibility, and to
reduce pain
 Superficial heat, deep heat
 IFC,TENS
 Whirlpool Hydrotherapy
 Tissue & Joint mobilization
Intervention options Intervention options

 Therapeutic exercises  Exercises

 To improve joint mobility, muscle flexibility, muscle
strength, endurance, balance, speed & agility  Resisted KE/KF
 ROM exercises  Short arc quads/long arc quads
 Heel slides  Prone knee bent
 Knee to chest  Squats, double/single, ¼, ½, deep
 Active assisted KF/KE  Wall slides
 Isometrics  Cycles, skiing machine, steppers
 Quadriceps/hamstrings sets  Leg press
 Ankle sets  Knee bench
 SLR

Intervention options Intervention options

 Exercises
 Endurance training  ADL training
 Walking  Transfers
 Jogging, Running  Gait with AD
 Cycles, skiing machine, steppers
 WB status: toe-touch (TTWB), foot-flat (FFWB),
 Swimming
partial (PWB), full (FWB)
 Balance training
 Circle walks, figure 8 walks, cross-over drills
 Taping/bracing
 Retrowalks  Activity modification
 Forward/backward & lateral steps
 Balance bench, boards (BAPS)
 Trampolines
L A B Pr a c tic e I L A B Pr a c ti c e II
 Ligament stability 1. Quads sets
 4 straight tests 2. Short arc/long arc quads sets
 4 rotary tests 3. Hamstrings sets
 Meniscus test 4. SLR with QS
 McMurray, 5. Gluteal sets
 Bounce home,
 O’Donoghue’s,
6. Isometric KE, KF at various angles
 Apply’s tests 7. Resisted KE, KF in sitting or prone
 Muscle strength & flexibility test 8. 1/2 squats, wall slide squats
 Brush/wipe test 9. Retrowalk
10. Step up/down, side steps
11. Tube run

L A B Pr a c ti c e III
 Exercise training for ACL injuries

 Exercise training for PCL injuries

qjhpaddabd也不随青 程是
 Exercise training for patellofemoral pain
syndrome

 Balance training for knee injuries

til