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Therapeutic Kinesiology:Musculoskeletal Systems, Palpation, and Body Mechanics
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Description
Chapter 12 Notes
Transcript
Therapeutic Kinesiology Instructor Manual: Ch12 p.7
TK INSTRUCTOR MANUAL: CHAPTER 12
The Knee
Chapter manuals include:
Objectives
Lecture Notes
Suggested Classroom and Student Development Activities
For other chapter-by-chapter resources, see:
Key Term Quizzes
Muscle Origin and Insertion Worksheets
Muscle OIAs List by Chapter
MyTest Test Bank
For additional resources see “Teaching Tips and Tools”:
7 research-based learning principles for kinesiology courses in massage
5-step self-directed learning cycle for body mechanics courses
Tools that build metacognitive skills: e.g., concept (mind) maps, grading rubrics, and self-assessments inventories
OBJECTIVES
Name the three bones of the knee.
List and demonstrate the palpation of 10 bony landmarks of the knee.
Describe the menisci and bursae in the knee.
Name and describe the two joints of the knee and seven supporting ligaments.
Describe patellar movement and problems that occur with poor patellar tracking.
Define the mechanical axis of the lower limb and the Q angle.
Describe the range of motion and joint mechanics of the tibiofemoral joint.
Name types of misalignments in the knee and describe the structural problems they cause.
Define and contrast axial rotation and terminal rotation of the knee.
Demonstrate the palpation of the menisci and prepatellar bursa of the knee.
Identify the origins, insertions, and actions of the knee flexors and extensors.
Identify the trigger points and pain referral patterns of the knee flexors and extensors.
Demonstrate the active movement and palpation of the knee flexors and extensors.
LECTURE NOTES
BONES OF THE KNEE
Largest and most complex joint in body
Functional link between feet and hips
Allows us to move torso closer to ground
Paradox of knee
Balancing vertical stability with extreme mobility
Knees work under extreme compression stress
Functions as a major shock absorber
Most minimally congruent joint
Result: most commonly injured joint
Three bones of the knee
Femur
Longest bone in the body
Bowed for flexibility
Shaft and neck shaped like the number 7
Distal end flares into triangular shape
Two large epicondyles on distal end
Lateral condyle two times the size of medial condyle
Tibia
Massive, thick vertical shaft
Transfers weight from knee to foot
Tibial plateau on proximal end
Horizontal surface for axial weight loading
Patella
Triangular-shaped sesamoid bone, kneecap
Menisci: Fibrocartilage disks in knee
Absorb shock
Distribute load circumferentially across joint
Reduce friction during motion
Stabilize by improving joint congruency
Guide pathway of motion
Bursae: Fluid-filled synovial sacs around knee
Approximately 14 bursae padding knee
Functions: Reduce friction
Located under tendons, between sliding structures
Two types
Free bursae
Envaginations of synovial lining
JOINTS AND LIGAMENTS OF THE KNEE
Patellofemoral joint: Between patella and femoral intercondylar groove
Serves as anatomical pulley
Increases mechanical advantage of extensor muscles
Protects tibiofemoral joint from tendinous friction
Deflects pull of quadriceps away from femur
Tibiofemoral joint: Between tibia and femur
Both joints share large, fibrous joint capsule
Both joints stabilized by multiple ligaments/tendons
Ligaments are taut in knee
Ligaments are slack in flexion to allow rotation
Muscular tendons around knee provide backup support
Lateral ligaments of knee
Lateral collateral ligament (LCL): fibular collateral ligament
Lateral epicondyle to head of fibula
Prevents excessive abduction, genu varum (bowlegs)
Medial collateral ligament (MCL): tibial collateral ligament
Medial epicondyle to proximal tibia
Prevents excessive aduction, genu valgus (knock-knees)
Anterior cruciate ligament (ACL)
Anterior tibia to posterior lateral femoral condyle
Prevents anterior displacement of tibia
Twists around PCL during flexion/extension
Posterior cruciate ligament (PCL)
Posterior tibia to medial femoral condyle
Short, thicker, twice as strong as ACL
Prevents posterior displacement of tibia
Patellar ligament
Blends into quadriceps tendon
Short, flat ligaments over patella
Secures front of knee
Iliotibial band (ITB), also called iliotibial tract (ITT)
Flat, broad tendon of tensor fascia latae
Stabilizes lateral side of knee
Oblique popliteal ligament
Broad, flat posterior ligament covering capsule
Tendinous expansion of semimembranosus muscle
Common knee injuries
Cruciate ligament rupture or tear
Causes drawer sign: Excessive tibial displacement
With ACL injury tibia will displace anteriorly
With PCL injury tibia will displace posteriorly
"Terrible triad"
Common knee injury in contact sports.
From posterior lateral blow to knee.
Damages ACL, medial meniscus, and MCL
Patellar motion and tracking
Patella glides up/down intercondylar groove
Patella tracks along curvilinear path
Thick hyaline cartilage covers/protects posterior patella
Patellar dysfunctions
Patellofemoral pain syndrome
From poor tracking from imbalanced muscle pulls
Causes arthritis, inflammation, recurring dislocation
Chondromalacia
Reoccurring inflammation to hyaline cartilage
Causes premature deterioration of patellar cartilage
Restricts gliding motion, causes stiffness and pain
Iliotibial band syndrome
Inflammatory condition, common cause of knee pain
Tight, fibrotic ITB rubs lateral femoral epicondyle
Knee alignment
Knee is highly calibrated joint
Optimal knee alignment minimizes shock and wear
Measures of knee alignment
Mechanical axis of lower limb
Q angle: average 15 degrees
Normal genu valgum: 510 degrees
Knee misalignment
Genu varum
A bow-legged alignment
Increases compression on medial meniscus
5 degrees of genu varum increases disk compression by 50%
Genu valgum
A knock-kneed alignment
Increases compression on lateral meniscus
Range of motion in knee
Flexion: soft end-feel
120 degrees with hip straight
140 degrees with hip flexed
Extension: 5 degrees
Hyperextension in knee
Genu recurvatum
Hyperextension of knee beyond normal range
Occurs when stabilizing muscles fail
Common in lordotickyphotic postures
Rotation of knee
Axial rotation: tibia rotates with knee in flexion
30 degrees medially
40 degrees laterally
Rotation only occurs during flexion
Terminal rotation: screw home mechanism
Occurs at end of extension to stabilize knee
Tibia and femur counterrotate, twist, and lock
Movement of the menisci
Femoral condyles press menisci across tibial plateau
Lateral meniscus moves 12 millimeters, twice the distance of medial meniscus
During flexion menisci move posteriorly
During extension menisci move anteriorly
During rotation menisci move opposite each other
If disk shifts too slowly, tears can occur
MUSCLES OF THE KNEE
Overview of muscles of the knee
Extensors: quadriceps
Flexors: hamstrings
Rotators: hamstrings, popliteus, gracilis, sartorius
Dynamic stabilizer: gastrocnemius
Flexors of knee: Quadriceps (Figure 12.40)
Rectus femoris: Only two joint muscles in group
O: Anterior inferior ischial spine (AIIS)
I: Tibial tuberosity via patellar ligament
A: Flexes hip and extends knee
Vastus medialis: Distal oblique fibers stabilize patella
Vastus intermedius: Lies deep to rectus femoris
Vastus lateralis: Largest, most lateral vasti
O: Lateralis – Lateral edge of linea aspera, gluteal tuberosity, greater trochanter
Medialis – Medial edge of linea aspera
Intermedius – Upper two-thirds of anterior and lateral femoral shaft
I: Patellar ligament and tibial tuberosity
A: Extends knee; vastus medialis oblique stabilizes the knee
Extensors of knee: Hamstrings
Biceps femoris: Only two joint muscles in group
Semimembranosus: Attaches to medial meniscus via capsule
O: Ischial tuberosity
I: Posterior and medial aspect of medial tibial condyle
A: Flexes knee and assists medial rotation, extends hip and assists medial rotation
Semitendinosus: Tendon inserts on pes anserinus
O: Ischial tuberosity
I: Proximal part of medial tibia
A: Flexes knee and assists medial rotation, extends hip and assists medial rotation
Other muscles acting on knee
Gastrocnemius: Dynamic stabilizer in knee extension
Sartorius: "Tailor's muscle," assists knee flexion and medial rotation
Gracilis: Assists flexion when hip is flexed
Popliteus: Medial rotator of knee
Unlocks knee from terminal rotation
Tendon attaches to lateral meniscus
SUGGESTED CLASSROOM STUDENT DEVELOPMENT ACTIVITIES
PROVIDE AN OVERVIEW OF THE CLASS
Before class, write a short schematic overview of the class on the board, then go over it at the beginning of class. For example:
Today's class covers:
Bones of knee
Joints and ligaments
Muscles of knee
Activities: Review, lecture and assessments, palpation exercises, recap
STRUCTURAL OBSERVATION EXERCISE: The knee
Have three students volunteers stand next to each other so that the other students can observe their knees. Have the volunteers remove their shoes and socks and roll their pants up past their knees. Ask the students the following questions:
Standing front view
Look at knees in relation to neutral. Do you see genu valgum (knock-kneed) or genu varum (bow-legged) stresses? If so, how does this affect the alignment of the hips and ankles?
Is VMO working? (If so, the kneecap will be lifted.)
Is tibia relatively vertical or twisted?
Which direction does the kneecap point? If it does not point straight ahead, what is causing it to point in another direction? (Could be coming from rotation in the hips, could be from torsion in the knee, could be from overpronation or supination in the foot or ankle.)
What is the position of knee in neutral (chronic flexion or HE)? How does this affect muscles around the knee?
How do torsions in knee affect chain of joints and muscles in LL? Look down to overpronation and oversupination.
Standing side view
Have the students turn sideways and look at the knee alignment.
Are the knees straight, bent, or hypextended?
Is the heel under or behind the ankle (the calcaneus should extend behind the ankle)?
Check the relationship of the knees to the position of the pelvis (is it level or tilted?) and the spinal alignment.
Have the students slightly bend the knees and notice what happens to the position of the pelvis and spinal alignment.
Have the students hyperextend the knee and notice what happens to the position of the pelvis and the spinal alignment.
Sitting
Have the students sit on a massage table with the lower legs hanging off the sides.
Look at how the tibia hangs. Is it vertical? Rotated? Abducted or adducted?
Check rotations (3040 degrees in flexion).
Movement observation*
Have the students do a small knee bend and extension.
Do the knees stay aligned with the hips and ankles in the sagittal plane during the knee bend?
Is the knee moving over second toe?
Check angle of inclination in femur (57 degrees is normal).
Rotations/counterrotations of tibia and femur at joint.
Flex: Tibia medially rotates, femur laterally rotates. Reverse on extension.
What excessive rotations do you observe?
With rotations, what muscle would be short and which stretch-weakened?
*Note: See knee video segment for demonstration of tibiofemoral rotations in flexion and extension.
PALPATION EXERCISES
Bony landmarks of the knee (p. 336)
Menisci and bursae in the knee (p. 339)
Ligaments of the knee (p. 343)
EXPLORING TECHNIQUE EXERCISES
Passive range of motion for the knee (p. 352)
Tibiofemoral rotations (p. 353)
SELF-CARE EXERCISES
Correcting genu recurvatum (hyperextended knees) (p. 350)
Tracking and guiding menisci motion (p. 356)
© 2013 by Education, Inc. Foster, Instructor Resources for Therapeutic Kinesiology
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