the knee (week 8)

The Knee and Gait

The Knee and Gait

Muscle Control of the Knee During Gait

• Quadriceps

• Hamstrings

• Soleus

• Gastrocnemius

Hip and Ankle Impairments

• Hip flexion contractures

• Length/strength imbalances

• Foot impairments

Major Nerves Subject to Injury at the Knee

Common fibular nerve - sensory loss and muscle weakness

Saphenous nerve – sensory loss to medial knee and leg

Common Sources of Referred Pain – treat the source of the pain

L3 = ant knee

S1-2 = post knee

L3 = hip joint problems, anterior thigh and knee

Joint Hypomobility:
Nonoperative Management types

Osteoarthritis (degenerative joint disease)

Rheumatoid arthritis

Post-immobilization hypomobility

Common impairments and restrictions

Return to Function Phases

Educate the patient, range of motion, Stretching techniques, improve muscle performance (progressive strengthening, muscular endurance, functional training), improve cardiopulmonary endurance

Protection Phase-

Patient education, Functional adaptations, Passive, active-assistive, or active ROM, Setting exercises

Repair of Articular Cartilage Defects

Procedures

• Autografts

• Allografts

Postoperative Management

• Must be done slowly

• Protected WB over a long time and early movement

Total Knee Arthroplasty indications for surgery

•severe pain

•articular cartilage damage

•deformity

•gross instability

•limited ROM

•failed conservative treatment or previous surgery

TKA procedure

Types of knee arthroplasty

• Unicompartmental

• Bicompartmental

• Tricompartmental

Surgical approach

• Traditional

• Minimally invasive

Fixation

• Cemented

• Uncemented

• Hybrid

TKA operative overview

Computer assisted, image-guided surgery for precise placement and alignment of components

TKA complications

Intraoperative – fracture, peripheral nerve damage

Early/late – infection, joint instability, polyethylene wear, component loosening, delayed wound healing, DVT, decrease knee flex, subluxation and instability or tracking problems

Postoperative Management TKA

Immobilization and early motion

Weight-bearing considerations

• Cemented-WBAT

• Uncemented-TTWB

Exercise

• Initially

  • AP, elevation of leg, deep breathing, ice, compression, isometrics, A/AAROM, PRE

• Progress to:

  • Inc strength and endurance of knee and hip muscles, isometric slow intensity dynamic resistance ex, inc ROM, balance and trunk stability, advanced functional training, aerobic conditioning, strengthening ex, balance training

TKA outcomes

•Pain relief

•ROM

•Strength and endurance

•Physical function and activity level

PF Instability is caused by

Subluxation or dislocation – usually lateral

Multiple dislocations may need surgical repair

Causes: shallow groove in lateral femoral condyle, patella alta, tight lateral retinaculum, inadequate medial stabilizers like VMO, and medial patellofemoral ligament, fracture

Patellofemoral Dysfunction: Nonoperative Management Etiology of Symptoms

Structural and functional impairments

• pain in retro-patellar area and along the patellar tendons

• patellar crepitus(swelling, locking)

• LE alignment

• weakness of hip and VMO

• decreased flexibility of TFL, hamstrings, quads, gastrocsoleus

• restricted lateral retinaculum, IT band or fascial structures

• pronated foot

Activity limitations and participation restrictions Patellofemoral Dysfunction: Nonoperative Management

Limited ADL

Pain related limitations

Inability to maintain prolonged flexed knee postures like sitting or squatting

Patellofemoral Dysfunction management

Initially:

• Modalities for Pain and Joint Effusion

• Rest and Activity Modification

• Splinting or Patellar Taping to Unload the Joint

• Muscle-Setting Exercises in Pain-Free Position

• Gentle ROM in Pain-Free Range

Educate the Patient

Improve Muscle Performance and Neuromuscular Control

Patellar Instability-operative Overview of Surgical Options

If soft tissue problems are causing lateral patellar instability, then repair or reconstruction of the medial patellar femoral ligament or VMO needed

If bone abnormality is the cause of patellar instability, then tibial turbercle osteotomy with patellar tendon transfer is needed

 Surgical Management Indications: Patellofemoral

Acute tear or laxity of the medial patellar structures

Excessive lateral tracking of patella and insufficiency of VMO

Normal boney structures and no evidence of patella alta

Painful, lateral compressive forces at the patellofemoral joint and lateral tilt of patella

Realignment option for immature bone growth with patella instability

Postop Management Patellofemoral

Immobilization and weight-bearing considerations

• range-limiting , hinged orthosis locked in extension or a KI

• WBAT or PWB

Exercise progression

• Goal to restore and improve function of the entire LE and trunk

• Initially-protection

  • Ind gait, control pain and edema, patient education, inc ROM, maintain patellar mobilization, inc muscular control

• Progress to:

  • Normalize gait, inc ROM and joint mob, inc muscle performance, inc control, proprioception and balance, inc aerobic condition

  • Progress to more challenging functional activity without pain, instability or joint effusion

Patellar Tendon With Tibial Tubercle Transfer

Indications for Surgery

Recurrent lateral patellar instability (“giving away”, dislocating)

Painful lateral tracking of patella

Anterior knee pain

Excessive tibial tubercle-trochear groove distance

Patellar Tendon With Tibial Tubercle Transfer Procedures

Purpose: Decreased patellar instability and anterior knee pain by decreasing lateral forces on the patella and improve tracking

operative overview

• Tibial tubercle transfer (Elmslie-Trillat procedure)

• Anteriorization (elevation) of the tibial tubercle

• Distal medialization of the patellar tendon

Patellar Tendon With Tibial Tubercle Transfer procedure

Osteotomy of tibial tubercle then boney prominence is transferred medially and secured with screws

Patellar Tendon With Tibial Tubercle Transfer complications

•Fracture, nerve damage, insufficient skin closure, soft tissue infection, osteomyelitis, nonunion, redislocation, adhesions

Patellar Tendon With Tibial Tubercle Transfer Postoperative Management

Immobilization and weight-bearing considerations – gait with crutches, knee orthosis locked in extenson, TTWB initially

Exercise progression – slow, orthosis set at 0-30 deg or 0-60 deg of flex the first week then to 90 deg by end of 4 wks, etc, closed chain ex in brace as inc weight bearing is permitted

Generally, will be 5-6 months to return to full activity but depends on rate of bone healing and leg strength

Mechanism of Injury MCL

Occurs from valgus force placed across medial joint line of knee

Usually partial or incomplete tear and are graded I, II, III

Mechanism of Injury LCL

Rare

Usually result of traumatic varus force across knee

Mechanism of Injury “Unholy Triad”/“ Terrible Triad”

ACL, MCL, medial meniscus

Most common due to a blow from lateral side of knee

Mechanism of Injury ACL

Most common non-contact mechanism of injury is a rotational force where the tibia is externally rotated on a planted foot

Second most common non-contact is forceful hypertext of knee

If not surgically managed, LCL and posterolateral joint capsule are stressed and become lax

Often a complete tear

Common problems with ligamentous damage

After trauma, knee may not swell for several hours

Instability of the knee might be detected with special testing

If swollen, knee will often go to a position of minimum stress (knee flexed 25 degrees) and the quad muscle is inhibited

During acute phase, if there’s a complete tear, the patient may be unable to bear weight or walk without an AD

Non-operative management Initially

PRICER-first 72 hours

Patient education for gait training with crutches with restricted WB status

Transfer training to avoid pivoting on injured leg

Gait training with crutches until non-antalgic gait is done

QS, SLR, A/AAROM, hip and core strengthening

Non-operative management progression

Improve joint mobility and protection

Improve muscle performance and function

• Strength and endurance

• Neuromuscular control

Improve cardiopulmonary conditioning

Progress to functional training

Ligament Injuries:
Surgical and Postoperative Management General considerations

Which ligament was injured

Location and size of the tear

Degree of instability

Presence of other damaged structures like meniscus

The patient’s goals to return to previous level of function

Ligament Injuries:
Surgical and Postoperative Management

Indications for ligament surgery

Failed to reach functional goals in rehab

Early degeneration changes of joint

surgical approach

Open

Arthroscopically assisted

All arthroscopic

grafts

Autograft (patient’s own) – central third bone-patellar tendon-bone autograft is the “Gold standard” and is the most reliable

Allograft (donor tissue)

Synthetic graft

Surgical and Postoperative Management

General considerations for rehabilitation

Pre-op education – edema control, ex, ROM, protected gait

Rehab – restore functional abilities while protecting the healing graft and preventing post op complications and re-injury

ACL Reconstruction Clinical Signs Indicating Need for Surgery

Disabling instability of the knee

Knee giving way

+ pivot-shift test

Injury to MCL at time of ACL injury

High risk of re-injury

ACL reconstruction complications

Inappropriate placement of graft or bone tunnels

• Inadequate graft length

• Improper graft tension

• Insufficient graft fixation

Fracture

Knee pain

Loss of motion

Persistent weakness and joint instability

Neuroma

Loss of full knee extension*****

Scar tissue

Loss of patellar mob

ACL Reconstruction –
Postoperative Management Immobilization and bracing is used for

Protects the graft from excessive strain and prevents loss of full knee extension

Brace use – after surgery, may or may not be locked in full extension; brace can be unlocked for ROM when permitted, worn all day and night for 1st wk

ACL Reconstruction –
Postoperative Management Weight-bearing considerations

Depends of physician for WB status but with crutches

Brace is locked in full ext with gait using crutches

ACL Reconstruction –
Postoperative Management exercise Initially with brace

Control pain and edema, prevent DVT, inc strength and ROM

Possibly use a CPM

Ankle Pumps, QS, passive knee ext with rolled towel under heel, isometric to hip, A/AAROM, e-stim or biofeedback, 4 position SLRs with brace locked at 0 degrees, HS (with brace on at first), standing hamstring curls no resistance, scooting forward on a seated rolling stool, stabilization ex, self patella mobilizations

Patient educ on donning/doffing knee brace

Gait training with crutches with knee brace locked at 0 degrees

ACL Reconstruction –
Postoperative Management exercise Progression without brace

ROM, closed chain ex, one legged ex, open chain hip ext , abd, and knee ext/flex

Static/dynamic balance activities

Gt training w/o brace when muscle control is evident

Aerobic ex

PRE with eccentric training, advanced closed chain ex like lunges, step ups, advanced balance and agility training

May wear the functional knee brace to decrease risk of reinjury

Mechanism of Injury PCL

Most common as a result of a forceful blow to the ant tibia while the knee is flexed

Usually a complete tear

PCL Reconstruction complications

Popliteal nerve damage, Bleeding, Pain, Decreased knee flexion, Graft failure

PCL Reconstruction Post-op Rehab

Progress more slowly than ACL

Initially, emphasis is on quad strengthening in a brace locked in full extension

After 9-12 weeks of rehab, brace is discontinued and begin slow progression of hamstring strengthening with closed chain exercise

Mechanism of injury medial meniscus

occurs more frequently than lateral

Foot is fixed and femur medially rotates

Ex: Pivoting, getting out of car, clipping injury)

Mechanism of injury lateral meniscus

Foot is fixed and femur laterally rotates

meniscal tear common problems

Pain

Edema

Joint line tenderness

Acute or chronic intermittent locking/catching of the knee

If knee is “locking”, it does not fully extend and there’s a springy end feel with passive extension (bucket hand tear)

if acute, may not be able to bear weight

Meniscal Tears:
Non-operative Management

Usually patient can move the leg to “unlock” it

R.I.C.E. protocol

QS, SLR, AAROM, flexibility exercises, and gait training with crutches and progressive WBAT

When acute symptoms have subsided, try open and closed chain exercises

Meniscectomy

Typically partial

• Complex, fragmented tears

• Tears involving the central (avascular portion)

Surgical Considerations

• Tear is in the outer third

• Tear extends into the central portion on a young or active person

• Future articular cartilage degeneration once removed

Partial Meniscectomy Procedure

Operative overview – day surgery, under anesthesia, usually 3 small incisions, torn meniscus is removed, area irrigated, skin is closed, compression dressing applied

Partial Meniscectomy Postoperative Management

No brace, anti-inflammatories, RICE

WBAT with crutches until the patient has a normal non-antalgic gait pattern

Exercise

• Initially

  • Isometrics, multi plane SLR, A/AAROM, closed chain ex, stationary bike

  • Progress after full ROM and pain free

  • Resistance training bilateral and unilateral, closed chain ex, balance training, simulated high demand functional activity

Meniscus Repair complications

Damage to the saphenous nerve when medial meniscus is repaired

Damage to the peroneal nerve when the lateral meniscus is repaired

Flexion contracture or extensor lag

Failed repair

Meniscus Repair Postoperative Management

Brace locked in full extension worn at all times

Can be unlocked to do exercise and bathing

More conservative approach to rehab than a meniscectomy surgery