Lab 9 Knee (Long Answer)

Rehabilitation Priorities

Objectives:

• Reduce or cease aggravating activities: Focus on avoiding movements that trigger pain or discomfort in the knee joint. This includes modifying daily activities and avoiding high-impact exercises that may worsen the condition.

• Maintain non-stressful joint motion and condition of other muscles: Engage in gentle movements to promote circulation and maintain muscle condition without stressing the affected area, ensuring other muscle groups remain active to support overall functionality.

Initial Management (Acute Phase, 48 hrs):

• Ice, elevation, NSAIDs or corticosteroids, and pain medications: Apply ice packs to reduce swelling; elevate the leg to decrease fluid accumulation; consider non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids to alleviate inflammation and pain, and utilize prescribed pain medications as necessary. Incorporate electrotherapy modalities as an adjunct treatment to support healing.

Symptoms Resolution:

• Optimize patella position and improve lower limb biomechanics: Focus on adjusting the alignment of the patella to ensure proper tracking during movement, which can prevent further injury and pain, while also enhancing the overall biomechanics of the lower limb to promote efficient movement.

Patello-femoral Joint Syndrome

• Recognition of the common joint pain syndrome affecting the knee: Understand that this syndrome is often caused by mechanical issues, muscle imbalances, or structural problems, leading to pain around the patella during activities such as squatting or climbing stairs.

Exercise Rehabilitation

Initial Phase

• Gentle hip/knee flexion Range of Motion (ROM): Initiate gradual, non-painful movements to restore flexibility and begin healing. Begin with passive range of motion exercises and progress to active assisted and independent movements.

• Condition the other body parts: Engage in exercises for the unaffected leg, such as stationary biking with the uninvolved leg or upper body ergometers, allowing for cardiovascular conditioning while minimizing stress to the injured knee.

First Progression

• Flexibility: Assess and address tight muscles needing intervention as follows:

  • TFL & ITB: Their tightness can lead to lateral patella deviation, which exacerbates pain.

  • Rectus Femoris: Tightness causes patella alta, increasing the risk of injury.

  • Gastroc/Soleus: Can lead to compensatory foot pronation, increasing the quadriceps workload and patellofemoral joint reaction force (PFJRF).

  • Hamstrings: Their tightness can increase workload on the quadriceps and PFJRF.

• Flexibility Exercises: Include stretches for:

  • Adductor stretch

  • Gastrocnemius stretch

  • Soleus stretch

  • Iliotibial Band (ITB) stretches

  • Hip extensor stretches (ITB, Glute Max, Trunk Rotators)

  • Hamstring stretches

  • Hip flexors stretches

  • Quadriceps stretch

Second Progression

• Isometric Exercises: Conduct isometric exercises at multiple angles while avoiding painful ranges.

  • Emphasize VMO (Vastus Medialis Oblique) with isolated contractions at safe angles to avoid exacerbation of symptoms.

  • 90° flexion is beneficial as it maximizes compression while minimizing shear forces on the joint, essential for tissue healing.

  • Engage in full extension exercises to nourish the joint and improve strength without high impact.

• Strengthening Exercises: Focus on strengthening key muscle groups crucial for knee stability:

  • VMO Isolation Training: Isometric contractions should be performed at varying angles to strengthen the VMO.

  • Strengthening of key muscles involves reinforcing:

    • Gluteus Medius associated with hip external rotators and abductors to stabilize the pelvis and knee.

    • Hip Adductors due to their anatomical relevance to VMO functioning.

    • Quadriceps through isometric exercises at multiple pain-free angles, partial squats (in ranges < 45°), and closed kinetic chain (CKC) exercises preferred due to their lower PFJRS compared to open kinetic chain (OKC) exercises.

    • Leg extensions at 60 - 90° flexion to promote quadricep strength without risking the patellofemoral joint.

Maintenance (Return to Sport)

• Gradual and Systematic Return: As strength and flexibility improve, ensure appropriate patella alignment and tracking during movement.

  • Engagement in functional progressions: Incorporate running, kicking, cutting/agility drills, plyometrics, and taping if necessary to support joint function and recover fitness levels prior to injury.

Advanced Rehabilitation

• Balance Training: Introduce both bilateral and unilateral balance exercises (e.g., wobble boards) to enhance proprioception and stability in the knee.

  • Step Up and Step Down exercises (forwards + laterally): Aim to improve coordination and strength in functional patterns.

• Plyometrics: Focus on exercises such as forward/lateral jumping, depth jumps, and slow weaving for agility to prepare for sport-specific demands while minimizing injury risk.

Concluding Comments

• Seek professional medical advice to tailor the rehabilitation program to individual needs and monitor progress effectively.

• Use pain as a guide; recognize that pushing through pain is not a viable approach. Instead, address underlying issues and aim to progress gradually.

  • Remember to always consider proximal or distal biomechanical causes that may contribute to knee issues.

• Be aware of the need for referral for medical review if no improvement is observed within an expected timeframe.

• Be mindful of upcoming assignments and presentations to be completed and submitted as per established deadlines.