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Manual Techniques for the Knee: A hands on approach to restore function

Katie Cusack, PT, MHS, CMP

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OBJECTIVES

1. Describe manual therapy 2. Brief overview of knee mechanics 3. 3 Describe and demonstrate manual techniques for the patella 4. Describe the Mulligan technique and demonstrate techniques for the knee

Manual Techniques for the Knee

A "Hands On" Approach to Restoring Function

Katie Cusack, PT, MHS, CMP

Manual Therapy

· Considered by many orthopedic physical therapists to be an important component in the evaluation and treatment of musculoskeletal disorders disorders. · Benefits have been documented in the literature supporting the use of manual therapy in conjunction with joint mobility and strengthening exercises.

Manual Therapy

· A term that encompasses a broad range of techniques. · Manual therapeutic techniques are used to relieve pain and to increase joint mobility mobility. · Such techniques may include soft tissue mobilization, massage, myofascial release, passive range of motion, joint mobilization, and manipulation.

Considerations

· Good understanding of the anatomy of the knee · Knowledge of knee joint biomechanics · Have already performed a complete evaluation of the knee. · Checked for any contra-indications

Anatomy

· Tibiofemoral Joint · Patellofemoral Joint · Superior Tibiofibular Joint

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Osteokinematics

· Total range of motion in the healthy knee is from about 5-10 degrees of hyperextension to 140-150 degrees of extension

Tibiofemoral Arthrokinematics

During Knee Extension Open kinetic chain ­ tibia glides anteriorly on the femur Closed kinetic chain ­ femur glides posteriorly on the tibia.

During Knee Flexion Closed kinetic chain ­ Open kinetic chain ­ tibia glides posteriorly on femur glides anteriorly on the tibia. the femur

Screw Home Mechanism

From 20o knee flexion to full extension Open kinetic chain ­ Closed kinetic chain ­ tibia externally rotates femur rotates internally on a stable tibia From full knee extension to 20o flexion Open kinetic chain ­ Closed kinetic chain ­ tibia internally rotates femur rotates externally on a stable tibia

Patellofemoral Arthrokinematics

· During flexion at the tibiofemoral joint, the posterior motion of the tibia causes ligamentum patellae to pull the patella posteriorly and distally · During extension, the patella is pulled upward along the patellofemoral groove by the quads.

Superior Tib-fib Arthrokinematics

· The exact function of this joint is not fully understood and often overlooked. · As the knee moves into extension in an open kinetic chain position, the fibular head is p p pulled posterior as the lateral collateral ligament and biceps femoris becomes taut. · Knee flexion produces an anterior movement due to the relaxation of the lateral collateral ligament and biceps femoris tendon

Patella mobilizations

· Patient position: Supine in slight flexion · Technique: Therapist q p stands to the side of the patient and gently mobilizes the patella superiorly/inferiorly direction as well as medially/ laterally

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Sidelying Medial Patella glide

· Patient position: Sidelying with knee flexed 200 or less · Technique: Place the q heel of your hand over the lateral border of the patella and glide medially

Sidelying Medial Patella Tilt

· Patient position: Sidelying with knee flexed · Technique: Place the q heel of your hand over the medial ½ of the patella and tilt the medial border posteriorly.

Mulligan Technique

· Mobilization with Movement (MWM) was developed by Brian Mulligan · Mulligan proposes that minor positional faults occur during injury or strain resulting in movement restrictions and/or pain · MWM is almost always performed at right angles to the plane of movement taking place.

Principles

· During assessment the therapist will identify one or more objective signs · A passive accessory joint mobilization is applied · Continuously monitor the patient's reaction to ensure no pain is recreated. · While sustaining the mobilization, the patient is asked to perform the objective sign

Principles

· The application of overpressure at the end of the available range is necessary for lasting improvement. · The patient undertakes 3 sets of 10 pain painfree reps of the previously provocative movement. · If there is no improvement, the therapist is performing the technique incorrectly or the technique is not indicated.

Knee Flexion MWM

Rotation in the Open Kinetic Chain Mobilization: Internal rotation of the tibia on the femur Movement: Knee flexion

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Knee Flexion MWM

Rotation in Closed Kinetic Chain Mobilization: Internal rotation of the tibia in CKC Movement: Knee flexion

Knee Flexion MWM

Side glide with belt assistance in prone Mobilization: Medial or lateral glide of the tibia through the mobilization belt Movement: Knee flexion

Knee Flexion MWM

Posterior Glide in Supine Mobilization: Posterior glide of the tibia Movement: Knee flexion

Knee Flexion MWM

Superior Tibiofibular Joint in CKC Mobilization: Anterior glide of fibula on stabilized tibia Movement: Knee flexion in partial weight bearing

Knee Extension MWM

Rotation in OKC Mobilization: External rotation of the tibia on stabilized femur Movement: Knee extension

Knee Extension MWM

Side glide in OKC Mobilization: Side glide g of the tibia on a stabilized femur Movement: Knee extension

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Knee Extension MWM

Superior Tibiofibular glide in OKC Mobilization: anterior glide of fibula on a stabilized tibia Movement: Knee extension

Knee extension MWM

Superior Tibiofibular glide in OKC Mobilization: Posterior glide of fibula on a stabilized tibia Movement: Knee extension

Knee Extension MWM

Superior Tibiofibular glide in CKC Mobilization: Anterior or posterior glide of fibula on a stabilized tibia Movement: Knee extension

Conclusion

· There are numerous techniques used by physical therapists. · Manual therapy can be a beneficial adjunct to the treatment of the knee when attempting to increase range of motion or decrease pain.

Thank you

References

· Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD, Hutton JP, Henderson NE, Garber MB. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301-1317. ; · Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized controlled trial. Ann Intern Med. 2000;132:173-181. · Fitzgerald GK, McClure PW, Beattle P, Riddle DL. Issues in determining treatment effectiveness of manual therapy. Phys Ther. 1994;74(3):227-233.

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References

· Hertling D, Kessler RM. Management of common musculoskeletal disorders. J.B. Lippincott, Philadelphia, 1990. · Mulligan BR. Manual Therapy. Plane View Services Ltd., Wellington, 2006. · Norton C, Levangie P. Joint structure and function. F.A. Davis Company, Philadelphia, 1989. · Paulos LE, Rosenberg TD, Drawhurt J, Manning J, Abbott P. Infrapatellar contracture syndrome: an unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med. 1987;15:331-341.

References

· Powers CM. Rehabilitation of patellofemoral joint disorders: a critical review. JOSPT. 1998;28(5):345-354. · Semonian RH, Denlinger PM, Duggan RJ. Proximal tibiofibular subluxation relation to lateral knee pain: a review of proximal tibiofibular joint pathologies. JOSPT. 1995; 21(5):248-257. · Course Notes: The McConnell Patellofemoral Treatment Plan. Chicago, 1995. · Course Notes: Follow-up Course for Mulligan Technique. Portland, 2009. · Course Notes: Diagnosis and Treatment of the Upper and Lower Quadrant as presented by Brian Mulligan, FNZSP (Hon) Dip MT and Kevin Wilk, DPT, Raleigh, 2010.

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Notes:

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Notes:

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