1	Knee Joint
2	Introduction A look at both the structure and function of the knee joint, from a massage therapist’s point of view & can be used as a teaching tool or as a quick resource for additional information. This requires a look at it’s anatomy, inert structures as well as musculature. With this knowledge can come an understanding of the functional biomechanics. An understanding of functional biomechanics allows a therapist to properly treat a dysfunction within that joint. Though massage therapy is capable of fixing or improving a dysfunction there are also other modalities that can also obtain results in the treatment of some conditions. Therefore a look into other modalities that can compliment massage treatment will be discussed.
3	Agenda This presentation will provide an insight into the anatomy, boney structures as well as musculature followed by a look into the motions available at the joint. Ligature, Nerves, Pathological Testing, Assessment and Treatment of Anterior & Posterior Displacement of the Tibia, Valgus & Varus Conditions of the Tibia. Alternative/complimentary modalities & Exercises.
4	Overview The knee is the largest joint in the body. It is a modified hinge joint. It is very susceptible to trauma because it is a primary weight bearing joint in the body, And because it is not protected by layers of fat or muscle.
5	Vocabulary Anterior Displacement of the Tibia – when the Tibia is pulled forward from it’s natural position. This can be due to tight musculature or structural damage. Posterior Displacement of the Tibia – when the Tibia is pulled back due to tight musculature or structural damage. Valgus Condition of the Tibia – when the distal Tibia is pulled laterally due to tight musculature or structural damage. Varus Condition of the Tibia – when the distal Tibia is pulled medially due to tight musculature or structural damage. Biomechanics – Normal Functioning or movement of the body. Dysfunction – Abnormal or impaired functioning of a body system or joint.
6	Anatomy of the Knee Introduction The anatomy of a joint determines the motions available and the stability in functional biomechanics. Because you must fully understand a joint in order to be able to assess it, our focus will begin with the inert structures & musculature of the knee.
7	Boney Structures around the Knee FEMUR -Medial condyle -Lateral condyle -Intercondylar fossa -Medial epicondyle -Lateral epicondyle -Trochlear groove -Adductor tubercle -Lateral supracondylar ridge -Gluteal line -Linea aspera -Pectineal line TIBIA -Tibial plateau (medial and lateral) -Intercondylar eminence -Medial condyle -Lateral condyle -Tibial tuberosity -Patella
8	Musculature A type of tissue composed of contractile cells or fibers that effects movement of an organ or part of the body. The outstanding characteristic of muscular tissue is its ability to shorten or contract. It also possesses the properties of irritability, conductivity, and elasticity. Muscle tissue possesses little intercellular material; hence, its cells or fibers lie close together.
9	Musculature surrounding the Knee Semimembranosus Semitendinosus Biceps Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris Gracilis Gluteus Maximus Tensor Fascia Lata Muscles that we don’t treat for knee dysfunctions, but are located around the joint. Popliteus Plantaris Gastrocnemius Articularis Genis Sartorius
10	Movements at the Knee The aforementioned muscles create motions at the Knee such as Flexion, Extension, Medial Rotation, Lateral Rotation
11	Semimembranosus Origin: Ischial tuberosity Insertion: Posterior aspect of medial epicondyle of tibia Action: Coxa extension, knee flexion, medial rotation of knee Nerve Innervation: Sciatic
12	Semitendinosus Origin: Ischial tuberosity Insertion: Proximal anteriomedial aspect of tibia (pes anserinus) Action: Coxa extension, knee flexion, medial rotation of tibia Nerve Innervation: Sciatic
13	Biceps Femoris Origin: Ischial tuberosity (long head), lateral supracondylar ridge and lower third of linea aspera (short head) Insertion: Head of fibula Action: Coxa extension, knee flexion, lateral rotation of tibia Nerve Innervation: Sciatic
14	Vastus Lateralis Origin: Greater trochanter and lateral lip of linea aspera Insertion: Tibial tuberosity via patellar tendon Action: Knee extension Nerve Innervation: Femoral
15	Vastus Medialis Origin: Intertrochanteric line and medial lip of linea aspera Insertion: Tibial tuberosity via patellar tendon Action: Knee extension Nerve Innervation: Femoral
16	Vastus Intermedialis Origin: lateral anterior shaft of femur Insertion: Tibial tuberosity via patellar tendon Action: Knee extension Nerve Innervation: Femoral
17	Rectus Femoris Origin: AIIS Insertion: Tibial tuberosity via patellar tendon Action: Coxa flexion and knee extension Nerve Innervation: Femoral
18	Gracilis Origin: Body and inferior pubic ramus Insertion: Pes anserinus Action: Coxa adduction and internal rotation, knee flexion Nerve Innervation: Obturator
19	Gluteus Maximus Origin: Posterior iliac crest, PSIS, lateral sacrum, and sacrotuberous ligament Insertion: Iilotibial Band and gluteal line of femur Action: Coxa extension, external rotation, and abduction Nerve Innervation: Inferior Gluteal nerve
20	Tensor Fascia Lata Origin: Posterior & superior to ASIS on iliac crest Insertion: Lateral condyle of tibia via IT band Action: Coxa abduction, internal rotation, and flexion Nerve Innervation: Superior Gluteal nerve
21	Popliteus Origin: Lateral aspect of lateral epicondyle of femur and lateral meniscus Insertion: Posterior aspect of medial tibia superior to soleal line Action: Medial rotation of tibia, and knee flexion Nerve Innervation: Tibial
22	Plantaris Origin: Lateral epicondyle of femur Insertion: Calcaneus via calcaneal tendon Action: Knee flexion and plantarflexion (weakly) Nerve Innervation: Tibial
23	Gastrocs Origin: Medial and lateral condyles of femur Insertion: Calcaneus via calcaneal tendon Action: Knee flexion and plantarflexion Nerve Innervation: Tibial
24	Articularis Genis Origin: Distal aspect of anterior femur Insertion: Posterior aspect of patella (under it) Action: Pulls the patella out of the intercondylar fossa before quads. contract to allow smooth patellar movement in knee extension Nerve Innervation: Femoral
25	Sartorius Origin: ASIS Insertion: Pes anserinus Action: Coxa flexion, lateral rotation, & abduction, and knee flexion Nerve Innervation: Femoral
26	Musculature Summary There are 15 muscles that affect or are located around the knee. They provide mobility of the joint. If these muscles are injured, & become either tight or weak, they can cause dysfunction of the joint. These dysfunctions will be discussed later on during the presentation.
27	Ligature Two bones of a joint are held together and supported by ligaments, which are bands of fibrous connective tissue. Ligaments also provide attachment for cartilage, fascia, or, in some cases, muscle. Ligaments are flexible but not elastic. This flexibility is needed to allow joint motion, but the nonelasticity is needed to keep the bones in close approximation to each other, and to provide some protection to the joint. When ligaments surround a joint, they are called capsular ligaments.
28	Ligature Surrounding the Knee Coronary Ligaments Transverse Ligament Anterior Cruciate Ligament Posterior Cruciate Ligament Medial Collateral Ligament Lateral Collateral Ligament Oblique Popliteal Ligament Patellar Ligament
29	Coronary Ligaments Located on each the inner and outer rim of the Menisci, they help hold it in place. (as drawn in on the lateral meniscis)
30	Transverse Ligament Attaches or joins the menisci anteriorly as one. This enables the menisci to work together. (shown here in green)
31	Cruciates The Cruciates are intracapsular, they help with mobility, control and stability. They are what create the slide and glide of the femoral condyles on the tibial plateaus. They are named for their origin on the Tibia. (ACL indicated with green line)
32	Anterior Cruciate Ligament Originates on the anterior aspect of the Tibia on the intercondylar eminence and travels superiorly & laterally inserting on the inner aspect of the lateral condyle of the Femur. It resists anterior displacement of the Tibia on the Femur. Posterior Cruciate Ligament Originates on the posterior aspect of the Tibia behind the intercondylar eminence. It runs superiorly & medially and inserts on the medial condyle of the Femur. The PCL is stronger than the ACL, it resists posterior displacement on the Tibia of the Femur.
33	Collateral The Collateral ligaments are located on either side of the Knee. They reinforce the joint and act as guide wires. (LCL indicated with blue, MCL in green)
34	Medial Collateral Ligament Blends with the medial meniscis, it is a strong flat band that runs from the medial epicondyle of the Femur and attaches to the medial condyle of the Tibia. Its lower attachment is slightly anterior to its upper attachment. It stabilizes the joint as well preventing it from gapping open medially. Lateral Collateral Ligament Attaches from the lateral epicondyle of the Femur to the lateral aspect of the head of the Fibula. Its lower attachment is more posterior than its upper attachment. It does not attach to the lateral Meniscis because the tendon of the Popliteus separates them.
35	Oblique Popliteal Ligament This ligament fuses with the Semimembranosus. It also fuses with the posterior joint capsule. It offers support and joint congruency to the posterior joint. Patellar Ligament Is a continuation of the quadriceps tendon. It attaches to the Tibial Tuberosity. In Flexion it will pull codadly while the quadriceps tendon will pull cephalically. It helps with patellar tracking. Tracking is also helped by the Vastus Lateralis & Vastus Medialis. During Extension the quadriceps pulls the patella cephalically.
36	Summary In summary, there are 8 major ligaments in the knee. They provide stability of the joint. If these ligaments are damaged they can cause dysfunction of the joint. Laxity in the Collaterals can allow Valgus or Varus conditions of the knee. In the same way Laxity or damage to the Cruciates can allow Anterior or Posterior Displacement of the Tibia. These conditions will be discussed later on during the presentation.
37	Nerves A fiber made of like neurons that transmit electrical and chemical signals between the central nervous system and body tissues. The four nerves that affect the musculature surrounding the knee are Obturator, Femoral, Sciatic & Tibial.
38	Obturator Nerve Leaves lumbar plexus at L2-L4, it travels through obturator foramen. Pierces through quadratus femoris muscle moving medial down the thigh innervating Adductor Magnus, Adductor Longus, Adductor Brevis, Gracilis, Obtruator externus going through adductor hiatus where it terminates.
39	Femoral Nerve Largest nerve that arises from the lumbar plexus from L2-L4. It runs anterior to the innominates under the inguinal ligament, through the femoral triangle. It runs the length of the anterior thigh & innervates Vastus medialis, Vastus lateralis, Vastus intermedius, Rectus femoris, Pectineus, Iliacus, and Sartorius.
40	Sciatic Nerve Runs through the greater foramen anterior to the Piriformis. The Sciatic nerve runs into the posterior thigh affecting the hamstring muscles. Just above the knee it splits into two nerves called the common Peroneal and the Tibial nerve.
41	Tibial Nerve Runs down posterior aspect of lower leg innervating Gastroc, Plantaris, Soleus, Popliteus, Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallicus Longus.
42	Pathological Testing Is the testing for the integrity of the inert structures of a joint.
43	Figure 8 Test TESTS FOR: laxity of medial collateral ligament (MCL) and lateral collateral ligament (LCL), causing increased mobilization at the knee. Laxity in either of these ligaments could result in Valgus or Varus position of the Tibia respectively. TEST: Have the patient lie supine on the plynth. Abduct their leg off the plynth. Place patient’s ankle between your thighs and hold tight. Place your hands on either side of the patient’s knee. Push knee medially, let it go back to neutral, push knee lateral, go back to neutral. Place traction on the knee by pulling back with your thighs, and then repeat those same motions. Keep motions smooth. Compare movement bilaterally. A positive result is if there is more movement on one side compared to the other (medial to medial & lateral to lateral) In this test if you push laterally on the knee you are testing excessive movement allowed by the LCL, if you push medially on the knee you are testing excessive movement of the MCL.
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45	Valgus/Varus Test TESTS FOR: laxity of MCL and LCL ligaments, causing a Valgus or Varus position of the Tibia respectively. TEST: Have patient lie supine on the plynth. Place rolled up towel or bolster under the patient’s femurs. Place one hand over patient’s knee and grasp patient’s leg just above the ankle. With the inferior hand push tibia medially – checking the LCL, then let it go back to neutral, push tibia laterally – checking the MCL, and let it go back to neutral. Compare movement bilaterally (medial to medial & lateral to lateral). If there is more movement on one side in comparison to the other the test is positive and would indicate laxity of the tested ligament.
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47	Appley’s Decompression (Distraction) TESTS FOR: laxity of MCL and LCL, causing a Valgus or Varus position of the Tibia respectively. TEST: Have the patient lie prone on the plynth. Flex the knee to 90 degrees and place your knee on the back of the patient’s thigh. Be careful not to place too much pressure on them. (It is only there to keep the thigh on the plynth.) Wrap fingers of both hands around patient’s leg just above the ankle. Lift leg and rotate it medially – checking the LCL, let it go back to neutral, rotate tibia laterally – checking the MCL, back to neutral. Compare movement bilaterally. If there is more movement on one side compared to the other test is positive and would indicate laxity of the tested ligament.
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49	Sliding Drawer (Lauchman’s) TESTS FOR: laxity of ACL and PCL ligaments, causing either an anterior or posterior displaced tibia respectively. TEST: Have the patient supine on the plynth, with both coxa and knees flexed to 45 degrees, and feet planted on the plynth. Therapist is seated on feet to stabilize. Use a pistil grip with the thenar eminence of the hands just below the tibial tuberosities. With hands on either side of the knee, draw tibia forward, return to neutral, and then back. Compare the amount of movement to the other leg. Drawing forward on the knee tests the anterior cruciate ligament, and drawing back tests the posterior cruciate ligament.
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51	Thomas Test TESTS FOR: passive test for the elongation of Gluteus Maximus. TEST: Have the patient supine. Therapist has one hand under lumbar spine with hand resting under the iliac crest. The other hand will bring the patient’s leg to their chest, with the knee fully flexed. When you feel the innominate move against your hand, look to see the angle that the leg is at (this is the elastic barrier). Compare bilaterally for asymmetry.
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53	Assessment & Treatment of Dysfunction The purpose of Active, Passive & Resisted Testing is to isolate a dysfunction & to pin point pain.
54	Valgus Condition of the Tibia Visual standing assessment – one foot farther from mid line. (distal tibia more lateral) than other foot. Either it will be there or it won’t. Cause would be either due to tight musculature from a direct trauma pulling the bone out of alignment, or lax ligature allowing the bone to move out of alignment. An excessive Q-angle may place more pressure on the ligaments, creating a bilateral Valgus condition. Obesity may also result in a bilateral Valgus condition of the tibias (plastic deformity of the MCL). Regardless of what initiated the problem, it will result in tight musculature, which needs to be addressed with extrinsic & intrinsic treatment. Ligament testing Valgus/Varus, Applies distraction, Figure 8. If there is laxity in collateral ligaments a valgus condition may be caused by ligature, if not, it is muscle related.
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56	Extrinsic Treatment Position Glute. Max.
57	Extrinsic Treatment Position TFL
58	Extrinsic Treatment Position Biceps Femoris
59	Intrinsic Treatment for a Valgus Condition Intrinsic treatment - patient is supine on the plynth. Bring their leg to the first barrier of adduction, push their knee in slightly from medial to lateral, patient will push out into abduction for 10sec, relax, increase stretch. Repeat 3-5 times. This is best done when therapist is standing on opposite side of the leg that’s being treated.
60	Intrinsic Treatment Position for a Valgus Condition
61	Associated Conditions with a Valgus Condition Laterally Rotated Tibia Medial Rotation Restriction of the knee Adduction Restriction Hip Flexion Restriction Knee Extension Restriction Anterior Fibular Glide restriction
62	Exercise Rehabilitation It is a good idea to have the pt. go for a walk after the treatment to re-educate the joint kinestetic receptors of proper positioning & alignment. Stretches should be assigned for the Biceps Femoris, TFL & Glute. Max. Strengthening exercises should be assigned for the Gracilis & Semi(s).
63	Varus Condition of the Tibia Visual standing assessment, one foot closer to midline (distal tibia more medial) than other foot. Either you see it or you won’t. Cause would be either due to tight musculature (from direct trauma) pulling the bone out of alignment, or lax ligature allowing bone out of alignment. Regardless of what initiated the problem, it will result in tight musculature which needs to be addressed with extrinsic & intrinsic treatment. Ligament testing –Valgus/Varus, Applies Distraction, Figure 8 Testing for laxity in the collateral ligaments. Active, Passive, Resisted tests for musculature that would be involved. Semimembranosus, Semitendinosus, Gracilis. To check the elongation ability of the semis’ test do lateral rotation of the knee. Extrinsic treatment- treat tight musculature toward the dysfunctional joint.
64	Extrinsic Treatment of Semimebranosus & Semitendenosus
65	Extrinsic Treatment Position for Gracilis
66	Intrinsic Treatment for a Varus Condition Intrinsic- Patient is supine on the plynth. Bring them to the first barrier of hip abduction, therapist will push their knee in slightly from lateral to medial. Patient will pull into adduction for 10sec, relax, increase stretch. This is best done with the therapist standing on the same side of the leg being treated.
67	Intrinsic Treatment Positioning for a Varus Condition
68	Associated Conditions with a Varus Condition Medially rotated Tibia Lateral rotation restriction of the knee Abduction restriction Knee Extension Restriction Hip Flexion Restriction Inferior Pubic Subluxation
69	Exercise Rehabilitation It is a good idea to have the pt. go for a walk after the treatment to re-educate the joint kinestetic receptors of proper positioning & alignment. Stretches should be assigned for the Gracilis & Semi(s). Strengthening exercises should be assigned for the Biceps Femoris, TFL & Glute. Max.
70	Posterior Displaced Tibia Visual standing assessment - Fullness in one popliteal space may be indicative of such a condition. Other determining factors could be pain or loss of balance while going downstairs. Or problems going down into a squat. This could be caused by direct trauma to anterior aspect of tibia pushing the bone back, or direct trauma to hamstrings pulling it back. It may also be due to prolonged time spent on one’s knees as a roofer, tile layer etc., driving the tibias posteriorly. This posterior pressure on the tibias results in laxity in the PCL (plastic deformity/creep) creating a posteriorly displaced tibia. Sulcus depth- If the Tibia is posteriorly displaced, the tibial sulcus will be shallow.
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72	Extrinsic Treatment Position for the Hamstrings
73	Intrinsic Treatment for a Posterior Displaced Tibia Intrinsics- Patient prone therapist standing on the same side of patient facing their head. Therapist will grasp foot above malleoli; & place within armpit. They will squeeze the foot into their body with that arm and distract up. The therapist will place their other hand over the tibia and push it anterior. The hand will be free on the arm that is using the armpit to make this easier. The free hand can wrap around the other arm to help brace, stabilizing this treatment. The pt. will contract into knee flexion against your non-yielding resistance. Hold for 7-10 seconds, take up the slack first by increasing pressure anteriorly on the Tibia, and then by increasing knee extension. Repeat 3-5 times ending by taking up the slack.
74	Intrinsic Treatment Position for a Posterior Displaced Tibia
75	Associated Conditions with a Posteriorly Displaced Tibia Posteriorly Rotated Innominate Hip Flexion Restriction Knee Extension Restriction Dropped Metatarsal Arch Bunion on Medial aspect of Great Toe Apparent Short Leg Anterior Fibular Glide Restriction
76	Exercise Rehabilitation It is a good idea to have the pt. go for a walk after the treatment to re-educate the joint kinestetic receptors of proper positioning & alignment. Stretches should be assigned for the Hamstrings. Strengthening exercises should be assigned for the Quadriceps.
77	Anterior Displaced Tibia Visual standing assessment – (Patient will complain of pain going upstairs.) In the Assessment you may find fullness of knee under the patella. Cause will be either due to tight musculature (as in from direct trauma), or lax ligature allowing the displacement. Patient will have difficulty returning from a squat. Ligament testing- Sliding drawer test- testing cruciate ligaments. Sulcus depth- If the Tibia is displaced anteriorly the tibial sulcus will be deep. Active, Passive, Resisted for musculature involved Quads.-can test the elongation ability of quads by doing knee flexion. Extrinsic treatment- treat tight musculature towards the dysfunctional joint.
78	Extrinsic Treatment Position for the Quadriceps
79	Intrinsic Treatment for an Anterior Displaced Tibia Intrinsic- With patient sitting on plynth with knees hanging off the side. Therapist will grasp the patient’s tibia at the ankle and pull it inferiorly. With therapist’s other hand at the proximal end of the tibia, push the tibia back a little and then increase knee flexion. The patient will try and extend for approximately 10 sec; relax push proximal tibia more posteriorly, and then increase knee flexion. Repeat 3-5 times. Make sure that the inferior pull on the tibia remains constant throughout the whole intrinsic treatment.
80	Intrinsic Treatment Position for an Anterior Displaced Tibia
81	Associated Conditions with an Anteriorly Displaced Tibia Anteriorly Rotated Innominate Hip Extension Restriction Knee Flexion Restriction Increased Metatarsal Arch Apparent Short Leg
82	Exercise Rehabilitation It is a good idea to have the pt. go for a walk after the treatment to re-educate the joint kinestetic receptors of proper positioning & alignment. Stretches should be assigned for the Quadriceps. Strengthening exercises should be assigned for the Hamstrings.
83	Other Modalities Because both Valgus/Varus conditions and Anterior/Posterior Displacement of the Tibias is caused by damage to ligaments, there are no real alternative treatments that result in permanent results other than surgical resection of the ligaments. Chiropractors may adjust the position of the bones. But no permanent results will be obtained. Physiotherapists will also provide strengthening exercises for the appropriate musculature.
84	Bibliography Ligature Definition Lippert, Lynn S., Clinical Kinesiology for Physical Therapist Assistants, third edition, F. A. Davis Company, Philadelphia, 1994 Musculature & Nerve Definition Taber’s Cyclopedic Medical Dictionary, Edition 19, F. A Davis company, Philadelphia, 2001 Illustrations Bowden, Bradley, Bowden ,Joan, An Illustrated Atlas of the Skeletal Muscles, Morton Publishing Company, 2002 Netter, Frank H., Atlas of Human Anatomy, Second Edition, Novartis, 1997