Knee o 2 interposed menisci supported by ligaments +

muscles
o For mobility + stability
o Anteroposterior stability: cruciate ligaments
o Raises + lower body; move foot in space
o Mediolateral stability: medial (tibial) + lateral
o Supports body when standing
(fibular) collateral ligaments
o 1o fxnal unit in walking, climbing, running + sitting
o Convex: condyles of femur; medial condyle is
activities
longer than lateral (locking mechanism)
STX + FXN o Concave: tibial plateaus + fibrocartilaginous
meninsci. Medial plateau is larger
o Distal femur (2 condyles) + proximal tibia (2 tibial o Meniscus = improve congruency.
plateaus) + large sesamoid bone in qauds tendon
Tibial condyles via coronary ligaments
(patella).
patella via patellomeniscal ligaments
o Proximal tibiofibular jt -> separate jt capsule fxns c
Anterior + Posterior meniscofemoral
ankle
ligaments = lateral meniscus to femur
Medial meniscus = jt capsule + medial
collateral ligament + ant & post cruciate
ligs + semimembranosus ms.
Lateral meniscus = PCL + tendon of
popliteus
**medial meniscus = greater chance of
tear c lat F to knee
o NWB OKC
Concave plateaus same slide
Terminal extension = tibia ER, femur IR
Flexion = tibia IR, femur ER
o FWB CKC
Convex condyle opposite slide
o Screw-home mechanism
JOINTS
Passive stabilizing fxn
o Lax jt capsule Final degrees of ext. = locking
o Tibiofemoral jt Tibia is fixed c foot weight bearing
o Patellofemoral jt Terminal ext = femur IR, tibia ER
o Bursae: Suprapatellar, subpopliteal + Medial condyle slides more post than lat
gastrocnemius bursae condyle
Tibiofemoral Jt.

o Biaxial, modified hinge

 Hip ext; taut iliofemoral lig (supports
femur IR)
When unlocked: femur ER, hip flex.
Popliteus ms.
**hip flexion contracture: no locking mech
(cannot stand upright)
Patellofemoral Jt.
o Sesamoid bone in quadriceps tendon
o Intercondylar groove on ant aspect of distal
portion of femur
o Art surface covered in smooth hyaline cartridge
o Embedded in ant of joint capsule
o Tibia via ligamentum patellae
o Surrounded by bursae
o Knee flex: patella enters intercondylar groove.
Inferior margin making first contact then slides
caudally along the groove
o Knee ext: patella slides superiorly
o **if motion is restricted: interferes with flex + ext =
extensor lag c active knee ext.
Patellar Fxn
o Inc moment arm of quads in ext.
o Redirects F of quads
Patellar Alignment
o Dependent on pull of quads + tibial tubercle via
patellar tendon = bowstring effect; lateral tracking
o Q-angle = anterior superior iliac spine -> midpatella
+ tibial tubercle -> midpatella
o (N) Q-angle = 10-15 (F>M)
Forces Maintaining Alignment
o Boney restraint of trochlear groove (femoral
sulcus)
o Superficial portion of extensor retinaculum:
dyamic stability at transverse plane
Vastus medialis
Vastus lateralis
o Medial + lateral patellofemoral ligament: passive
stab at transverse plane
Adductor tubercle (medially)
Iliotibial band (laterally)
o Medial & lateral patellotibial ligament + pattelar
tendon: (longitudinal) fixate patella inferiorly
against active pull of quads sup
Patellar Malalignment and Tracking Problems
o Increased Q-angle
Inc pressure of lat facet against lat fem
condyle during knee flex
Wider pelvis, fem anteversion, coxa vara,
genu valgum, lat displaced tibial
tuberosity.
Inc Tibial ER, Femoral IR, pronated subtalar
jt
Dynamic knee valgus (knee jt center moves
medially) = inc Q-angle
Muscle + fascial tightness: tight ITB + lat
retinaculum = no medial gliding.
o Muscle and fascial tightness
Tight ITB + lat retinaculum = no medial
glide
Tight plantarflexors = pronation of foot
during dorsiflexion -> medial torsion of
tibia -> lateral displacement of tibial
tuberosity
Tight rectus femoris + hamstring =
compensation
o Hip muscle weakness
Weak hip abd + ER = add of fem + knee
valgus; inc femur IR
Patellofemoral pain syndrome
o Lax medial capsular retinaculum/insufficient VMO
Weal vastus medialis obliquus d/t disuse, jt
swelling, pain = poor medial stability
Lateral drift of patella
Patellar Compression
o Patellar contact
 Knee ext, patella sup to trochlear groove.
Knee 15flex, inf border of patella
articulates c sup aspect of groove
Knee flex = patella slides distally
o Compression forces
Full ext = no contact of patella on troch
groove, no compression on articular
surfaces
Quads + patellar tendon pull patella, taut
when flexed
30-60 higher force
Squatting = less force
OKC NWB greatest force at 30 flex; with
variable resistance peak stress at 60 +
peak compression at 75
Inc Q-angle = inc lat facet pressure during
knee flex
KNEE EXT. MUSCLE FXN
o Quads = prime mover for knee ext. (CKC: soleus +
hams)
o CKC: quads controls flex
o Patella: moment arm of extension. Greatest 30-60
diminishes at 15-0
o Torque: for quads occurs at 70-50 dec at 15
(requires most cxn
KNEE FLEX. MUSCLE FXN
o Hams = prime knee flex; rot of tibia
o More efficient cxn during hip flex
o Popliteus = supports post capsule
o Pes anserinus (Sartorius, gracilis, semitendinosus)
= med stab, affects CKC rot
Gait MS control
o Quads = compensation lurch trunk ant during
initial contact (for stab + locking); excessive heel
rise during fast walking
o Hams = knee snapping into ext during terminal
swing. Progressive genu recurvatum
o Soleus = hypertext of knee during preswing; loss of
heel rise; lag/slight drop of pelvis
o Gastroc = hypertext during loading response, loss
of PF during preswing + push off
HIP + ANKLE IMPAIRMENTS
o Hip flexion contracture: knee cannot ext during
terminal stance
o Length/ strength imbalances: pain during walking
or running
o Foot impairments
Major nn subject to injury
*branches of sciatic nn proximal to popliteal fossa
o Common fibular (peroneal) nn (L2-L4): fibular
head. Sensory loss + ms weakness
o Saphenous nn (L2-L4): skin along medial side of
knee + leg = chronic pain syndrome
Referred Pain
o L3 ant knee
o S1-S2 post knee
o L3 ant thigh + knee
MANAGEMENT OF KNEE DISORDERS + SURGERIES
A. JT. HYPOMOBILITY
1. Joint Hypomob: Nonop
OA + RA + acute jt trauma. Dec flexibility, adhesion
o OA = genu varum, knee instability
o RA = genu valgum
o Loss of flexion (more common)
o Walking, gardening, swimming, athletic +
household activities
Jt Hypomob: Protection Phase
o Control pain + protect jt
Pt educ
PROM + ms setting
Minimize stair climbing
Elevated seats on commodes
Avoid deep-seated/low chairs
Use of crutches, cane, walker
o Maintain soft tissue + jt mobility
PROM, AAROM, AROM
Grade I/II jt distraction ant + post
o Maintain muscle fxn + prevent patellar adhesion
Setting exercises: pain free quads + hams
ms setting
Jt. Hypomob: CM + RTF
o Progression (stretching, strengthening, stretching)
Stationary bicycle
AROM + Ms setting
Alternate activity with rest
 o Decrease pain from mechanical stress MC site: weight bearing portion of med +
Assistive devices lat fem condyle, trochlear groove,
Avoid low chairs articulating facets of patella
o Increase joint play + ROM o Size of chondral lesion (greater than 1-2cm2 <4cm2)
Grade III/IV sustained/oscillatory 2. Total knee arthroplasty
techniques to tibiofemoral + o Usually for 70yrs old c arthritis
patellofemoral jt posn at end range. (flex : o Goal: relieve pain + improve pt physical fxn &
IR + post ; ext : ER + ant ; lat glide) quality of life
Stretching (Passive + PNF): low intensity,
Indications
long duration within pt tolerance
MWM o Severe jt pain c weight bearing or motion
o Improve ms performance in supporting ms compromises fxnal abilities
Multiple angle isomets o Extensive destruction of articular cartilage of the
AROM in OKC + CKC knee 2 to advanced arthritis
Ms endurance o Marked deformity of the knee (genu valgum, genu
Fxnal training varus)
Step-up + step-down exercise (forward, o Gross instability or limitation of motion
backward, lateral) o Failure of nonoperative mx or a previous surgical
Wall slides + minisquats to 90 procedure
Partial lunges
Balance activities
Ambulation
o Improve cardiopulmonary endurance
Swimming, water aerobics, aquatic
exercises
Bicycling
High impact activities

Jt. Surgery + Postop Mx

o Arthroscopic debridement + lavage = remove loose

bodies
o Abrasion arthroplasty = stimulate growth +
replacement of articular cartilage
o Osteochondral autograft
transplantation/mosaicplasty
o Autologous chondrocyte implantation
o Synovectomy = jt effusion, synovial proliferation,
pain from RA/JRA
o Osteotomy of distal femur/prox tibia
o Total knee arthroplasty
o Arthrodesis
o Goal: Reduce pain, correct deformity/instability,
restore lower ex fxn Complications

Indications for surgery o Intraoperative

Intercondylar fx
o Symptomatic knee caused by a small to relatively
Damage to peripheral nn
large focal lesion of tibiofemoral/patellofemoral jt.
Malpositioning of implant
o Posoperative Postop Mx
Infection
o Cementless fixation: weight bearing touch down
Jt. Instab
only for 4-8wks while using crutches or walker
Polyethylene wear
o Cemented fixation: weight bearing c crutches or
Component loosening
walker immediately after surgery, FWB at 6wks
DVT
Criteria to progress
Max protection phase
o Minimal swelling + pain
o Well-healed incision c no signs of infection
Etiology
o Independent basic ADL & amb c appropriate assist
device
o AROM approaching full/nearly full, active knee ext.
+ 90 flex
Mod protection/CM
o AROM: full knee ext, 110 flex
o Quads/hams/hips mmt 4/5
o Minimal pain during exercises + amb s cane
B. Patellofemoral dysfxn
o PF instab
Ab(N) Q-angle, dysplastic trochlea, patella
alta, tight lateral retinaculum, inadequate
med stab. Fx. MC lat.
o PF pain c malalignment/biomechanical dysfxn
Inc Q-angle, fem anteversion, external
tibial torsion, genu valgum, foot
hyperpronation
Tigh lat retinaculum, weak VMO,
incompetent MPFL, patella alta, patella
baja, laxity, dyplastic fem trochlea
o PF pain s malalignment
Soft tissue lesion: plica syndrome, fat pad
syndrome, tendonitis (jumpers knee), ITB
friction syndrome, prepatellar bursitis
(housemaids knee)
o Tight medial and lateral retinacula/patellar
pressure syndrome
Inc contact pressure at patella + troch
groove
o Osteochondritis dissecans of patella/femoral
trochlea
Pain on retrosurface of patella
Squatting, stooping, ambulating,
descending steps
o Traumatic patellar chondromalacia
Softening/fissuring of cartilaginous surface
of patella (arthroscopy or arthrography)
Degeneration
o PF osteoarthritis
Idiopathic/post traumatic
o Apophysitis
Osgood-schlatter dse + sinding-larsen
Johansson syndrome
Overuse during rapid growth
Self-limiting
o Symptomatic biparlite patella
o Trauma
o Ant knee pain: trauma, overuse, faulty patellar
alignment
o Local factors = surrounding stx (PFPS): infrapatellar
fat pad, ligaments, quads tendon, medial & lateral
retinaculum, subchondral bone. Walking/squatting
o Distal factors = ER during relaxed stance, rearfoot
eversion, delayed/prolonged rearfoot eversion
during walking/running, inc midfoot mob
o Proximal factors = inc hip add + IR during running,
single-limb act of squatting, jumping, drop landing.
Hip ABER weakness
Impairments
o Pain in retropatellar region
o Pain along patellar tendon or subpatellar fat pads
d/t irritation
o Patellar crepitus; swelling or locking of knees
o Altered lowerex alignment; inc hip abd, IR,
dynamic knee valgus( valgus collapse) during FWB
o Weak hip AbEr + extensors
o Weak VMO
o Dec flexibility of Tensor fasciae latae, hams, quads,
gastric, soleus
o Overstretched medial retinaculum
o Restricted lateral retinaculum, ITB, fascial stx
around patella
o Dec medial gliding/medial tipping of patella
o Pronated foot
Activity Limitations
o Limited ADL d/t pain
o Reduced ability to get in or out a chair/car
o Ascend descend stairs, walk, jump, run
o Inability to maintain prolonged flex knee postures:
sitting, squatting
1. Patellofemoral Symptoms Mx: Nonop
Protection Phase
o Modality, rest, gentle motion, muscle-setting
exercises in pain-free motions.
o Splint patella/tape
CM + RTF
 o Pt educ o An appropriate realignment option for the
o Increase flexibility of restricting tissues skeletally immature patient with patellar instability
Stretching/self-stretching
C/I
Gastroc, quads, hams, TFL
Patellar mobilization: medial glide o Proximal realignment procedures are not
Medial tipping of patella appropriate for patients with articular
Patellar taping degeneration of the medial patella, patella alta, or
o Improve muscle performance and neuromuscular trochlear dysplasia, because they may exacerbate
control or have no impact on symptoms
NWB OKC exercise:
Quads setting in pain free posn
quads set c straight-leg raise
progression of resisted isomets (multiple
angle c tibial IR)
Short-arc terminal extension
WB CKC exercise:
PWB
High reps
Terminal knee extension c light
resistance in standing
Bilateral -> unilateral minisquats
Double-leg, single-leg standing wall
slides, short step, long step lunges,
forward backward lateral step-ups, step-
down. Elastic resistance
Balance + agility training c strengthening
Exercises in weight bearing posn
Plyometric
o Fxnal activities
o Modify mechanical stresses
2. Patellar Instab: Surgical + Postop Mx

Proximal Extensor Mechanism

Realignment: Medial Patellofemoral
Ligament Repair or Reconstruction Procedure
and Related Procedures
o Open surgical approach, medial parapatellar
Indication incision
o MPFL repair/tightening
o Deficiency (acute tear, chronic laxity) of the medial
o MPFL reconstruction
patellar support structures (MPFL)
o VMO imbrication/advancement
o Excessive (or abnormal) lateral tracking of the
o Lateral retinaculat release + other concomitant
patella + insufficiency of the VMO
procedures (LRR)
o Normal boney architecture (normal tibial tubercle-
trochlear groove distance) and no evidence of Complications
patella alta trochlear dysplasia
o Painful, lateral compressive forces at the o Postop
patellofemoral joint + persistent lateral tilt of the Superficial infection
patella despite a previous LRR DVT
 o Intraop
Inaccurate graft placement
Excessive imbrication of VMO

POST OP MX
Criteria to Progress develop with premature closure of this epiphyseal
plate
Maximum protection

o Minimal pain and swelling C. Ligamentous Injury

o Incision healing well; no signs of infection 1. Non Op
o Full, active knee extension (no evidence of
extensor lag) and at least 90 of knee flexion MOI:

Moderate Protection ACL

o No swelling or extensor lag o F to lat knee/valgus F to knee

o Knee ROM: 0 to 135 o C medial collateral ligament + med meniscus
o Sufficient strength of knee and hip musculature (at o Terrible Triad (ACL, MCL, med meniscus)
least 75% compared to nonoperated side) to o Knee ER/forceful hyperextension
initiate lower extremity functional activities o **more common in women

Distal Realignment Procedures: PCL

Patellar Tendon with Tibial Tubercle o F to ant tibia while knee flex
Transfer and Related Procedures o Falling on flexed knee
o Sudden, violent hyperflexion of knee
Indications
MCL
o Painful lateral tracking of the patella with no
instability o Valgus F on medial jt lin of knee
o Anterior knee pain associated with patellar o Can be partial/incomplete
maltracking and patellofemoral arthrosis (chondral
LCL
or osteochondraldefects) of the lateral and distal
retropatellar surfaces o Traumatic varus force across knee
o Abnormally increased Q-angle
o Excessive tibial tubercle-trochlear groove distance Impairments
(> 15 mm) o If tested when the joint is not swollen, the patient
CONTRAINDICATION: feels pain when the injured ligament is stressed.
o If there is a complete tear, instability is detected
o Boney procedures are not recommended for the when the torn ligament is tested.
skeletally immature patient whose tibial o When effused, motion is restricted, the joint
tubercle growth plate is open. Recurvatum of the assumes a position of minimum stress (usually
knee can
 flexed 25), and the quadriceps muscles are
inhibited (shut down)
o When acute, the knee cannot bear weight, and the
person cannot ambulate without an assistive
device.
o With a complete tear, there is instability, and the
knee may give way during weight bearing, which
would prevent the individual from returning to
specific work or sport and recreation activities that
require dynamic knee stability.
2. Ligamentous Injury: surgical of the knee, such as the MCL, resulting in rotatory
instability of the joint
Types
o Injury of the MCL at the time of ACL injury to
o Intra-articular prevent lax healing of the MCL
o Extra-articular o High risk of reinjury because of participation in
highdemand, high joint-load activities related to
Grafts work, sports, or recreational activities
o Autograft
o Allograft
o Synthetic graft

Indications

o Frequent episodes of the knee giving way

(buckling) during routine ADL as the result of
significantly impaired dynamic knee stability
despite a course of nonoperative management
o A positive pivot-shift test because an ACL deficit is
often associated with a lesion of other structures
 Meniscal Postop
Phase Goal Intervention
1. Knee ROM 1. AAROM + AROM of knee flexion
Gravity assisted knee flexion (sitting)
Active heel slides in supine posn
Maximum Protection

2. Patellar mobility 2. Gr I/II glide

3. Activation of knee ms 3. Quads control in full ext + setting
Assisted SLR in supine
Phase

Active OKC knee ext + flex in sitting posn

Hams setting ex + multiple angle isomets
4. Neuromuscular 4. Balance training in standing posn (ext brace)
control/responses, Trunk + LE stab
proprioception, balance Minisquats <45
5. Flexibility + strength of hip + 5. Stretch hams + PF
ankle Gluts + adductor setting ex (SLR)
1. Restore full knee ROM 1. Low load, long duration stretching ( knee flexion)
2. Ms strength + endurance 2. Elastic resistance low intensity, OKC + CKC
Hip + ankle strengthening (Hip abd + ext)
3. Neuromuscular 3. Balance CKC: standing on unstable surface + perturbation
Phase
Mod

control/responses, + minitrampoline
proprioception, balance FWB: unilat balance = partial lunges, step ups/downs
Low intensity agility drilles
4. Flexibility of hip + ankle 4. Stretch ITB + rectus fem

** Plyometrics
Phase
Min

Partial Meniscus Post Op

Control Inflam + pain + Muscle setting
Max +

independent amb + knee SLR

Mod

control + ROM AROM knee

**FWB: 4-7 days CKC
Full Pain free ROM, N Gait Strengthening
Endurance
Min

Bilat. + Unilat. CKC

Proprioceptive + balance
Plyometrics