Knee Therapeutic Exercise For Musculoskeletal Injuries

23
Knee and Thigh
Objectives
After completing this chapter, you should be able to do the following:
1. Discuss the relationship and alignment between the patella and femur.
2. Identify post-injury factors that influence strength output.
3. Define quadriceps extensor lag and AMI and explain their significance.
4. Outline a general progression of rehabilitation for a knee.
5. Identify three soft-tissue mobilization techniques for the knee.
6. Identify three joint mobilization techniques for the knee and the purpose of each of them.
7. Describe three flexibility exercises for the knee, and identify the structures they affect.
8. Describe three proprioception/balance exercises for the knee.
9. Identify three functional activities.
10. Identify three factors that influence PFPS.
917
918 Therapeutic Exercise for Musculoskeletal Injuries
Three mornings a week Steve Turnwell and his friends play a game of basketball at
the university gym before going to work. It is their way of having fun and getting
exercise at the same time. They have been following this routine since they were
in their mid-30s, about 10 years ago. About 2 weeks ago their routine was suddenly
disrupted. Steve jumped to retrieve a rebound and landed in severe pain. He felt as if
someone had shot him in the thigh. Several hours later he underwent a quadriceps
tendon repair and was placed on crutches.
Today he had his first rehabilitation appointment with Joan Runnae, a clinician
who came highly recommended to Steve. After Joan completed his examination,
she explained to Steve what she saw as primary problems and discussed how
she thought they could best resolve those problems. Steve agreed with her and
realized that this was not going to be an easy or short process, but he was willing
to work with Joan to get back onto the basketball court. He liked Joan’s approach
and appreciated the way she was able to explain things better than the physician
did, so he could understand what his injury was and what the surgeon did to repair
it. He knew Joan would work him hard, but he also knew that if he wanted to play
basketball again, he would have to work hard, and he was eager to start.
Although Joan explained to Steve that it would be a lengthy process and would
require Steve to be committed and consistent in his rehabilitation, Joan also knew
that the tissue’s healing process had to be respected. Because it was only 2 weeks
since Steve’s surgery, stress to the newly formed tissue was important, but too
much stress could be detrimental. While using caution with the knee, she could also
start Steve on more aggressive exercises for the hip and ankle without stressing
the patellar tendon. Joan sensed that Steve was the type of person who was eager
and willing to work hard but would also understand precautions if he knew about
them. As she does with all her patients, Joan would keep Steve well informed
throughout his program about what he should and should not be doing and why.
I hate leg exercises. I hate one-legged squats. knee. We still have much to learn, but investigators
I hate the hurdles and the split squats. I hate have given us new insights and information about
all the leg exercises. I know they help me, and knee biomechanics, improved surgical procedures,
I’m able to move around and don’t have knee and updated rehabilitation techniques.
problems, and my hip doesn’t hurt anymore, Although many patients would agree with Mr.
but when my (athletic) trainer tells me I have Strahan’s feelings about therapeutic exercises, these
to do them, I almost feel like my body goes into programs successfully resolve many knee injuries
convulsions. in both athletic and nonathletic populations. This
chapter deals with thigh and knee injuries and their
Michael Strahan, 1971–,
former NFL football player,
rehabilitation. Thigh injuries could just as easily have
media personality been considered along with the hip in the next chapter.
Indeed, I will refer you from one chapter to the other
Over the years, there have been many changes in within each respective chapter, because there is an
approach to rehabilitating knee injuries. The standard intimate relationship between the thigh and knee and
of care changes as we learn more and more about knee the thigh and hip. I have placed several thigh injuries
mechanics and healing. Research findings sometimes in this chapter only because the knee comes before the
determine current approaches to be in error. This rev- hip in the text. Thigh injuries that affect primarily the
elation occurs when we realize that we have “struck hip are presented in chapter 24.
out” with previous treatments and when we have to As with the other chapters in part IV, this one begins
change our techniques to keep up with new discoveries. with general information that affects therapeutic exer-
In recent years there has been a tremendous amount cise programs for knee and thigh injuries. This infor-
of research creating a wealth of knowledge on the mation is vital if the clinician is to design and establish
Knee and Thigh 919
an appropriate therapeutic exercise program for the rare.4 This fact may be so because of the strong static
various injuries of the knee and thigh. This chapter and dynamic structures that surround the joint. The
presents specific therapeutic exercise techniques, ligaments and muscles of the knee give the joint strong
including manual therapy and exercises for flexibility, support, so tremendous forces are needed to produce
strength, and coordination. Recommendations for an injury. The more commonly seen knee injuries are
functional activities before the patient’s return to full discussed later in this chapter. This section deals with
sport or normal-activity participation are also included. unique knee structures that support and protect the
The final section of the chapter discusses rehabilitation joint but are affected when injury occurs.
programs for specific injuries commonly seen in the
knee and thigh.
Controversy continues on the best surgical repair
Knee Structure
technique and the most appropriate postoperative and At first glance, the knee appears to be a relatively
post-injury methods of rehabilitation for the knee. The simple joint, but it is actually quite complex. Within
evolution of surgical and rehabilitation procedures its anatomical structure are several elements that
for knee injuries continues as new evidence comes to influence its function. When balance is deficient, the
light. Some surgeons choose to remain conservative knee becomes susceptible to injury. An understanding
in their postoperative care, while others prefer a more of the knee’s structures and the ways in which they
accelerated approach to their surgical repairs. It is influence one another is basic to the clinician’s abil-
important for rehabilitation clinicians to work with ity to develop a therapeutic exercise program for any
physicians to provide successful rehabilitation out- injury of the knee.
comes for their patients. Both the physician’s and the
rehabilitation clinician’s protocols for rehabilitation Tibiofemoral Joint
of knee and thigh injuries should be based on current The knee joint is actually two joints, the tibiofemoral
best-practice evidence, the severity of the injury, the joint and the patellofemoral joint. The tibiofemo-
structure injured, the specific repair technique used, ral joint has a concave tibia platform attached to a
and the tissue healing timeline. If there is to be an convex femur. This means that when you perform a
error, as with any rehabilitation program, it should be mobilization technique to the joint, the concave tibia
on the side of caution. moves on the convex femur in the same direction as
the physiological movement of the joint. In other
words, a grade III or IV posterior glide of the tibia
on the femur enhances flexion and an anterior glide
CLINICAL TIPS enhances extension.
Specific injuries to the knee and thigh that require
particular types of therapeutic exercise approaches Capsule
include ligament sprains, collateral ligament
sprains, meniscus injuries, patellofemoral injuries,
The knee joint is the largest joint of the body and is
strains and contusions, and bone injuries. Although surrounded by a capsule that aids in joint stability by
treatment guidelines for each of these injuries may merging with the collateral ligaments.5 The capsule
exist, the clinician must always consider the individ- also distributes the synovial fluid around the joint
ual patient’s response and use that as the primary
guideline in treatment progression. during movement and merges with many of the knee’s
bursae. If the joint capsule is restricted, a capsular
pattern becomes apparent. The knee’s capsular pattern
is loss of flexion motion greater than loss of extension
General Rehabilitation motion.6 The joint is in a resting position when it is in
about 20° to 25° of flexion and in a fully close-packed
Considerations position in full extension with lateral tibial rotation.7
The knee is one of the most often injured joints.1-3 The Ligaments
forces applied to it during running, twisting, and lifting The collateral ligaments provide knee protection
activities are complicated by the fact that there are two and stability against medial and lateral stresses.8 The
long lever arms on either end of the joint, making it medial collateral ligament (MCL) attaches to the
susceptible to excessive stress. For as shallow a joint medial meniscus. This arrangement may be one reason
as the knee is, complete dislocation is surprisingly the medial meniscus is often injured with MCL sprains.
In addition to providing protection against valgus joint capsule has mechanoreceptors (Ruffini nerve end-
stresses, the MCL helps to restrict lateral rotation of ings) that are sensitive to pressure and deformation.20
the tibia on the femur. The lateral collateral ligament Injury to the knee’s ligamentous structures can damage
(LCL) does not attach to the lateral meniscus, and it these receptors, impairing proprioception.21,22 Thera-
is taut during medial rotation of the tibia on the femur peutic exercise programs must include techniques to
and when the knee incurs varus stress. Because lateral restore the proprioceptive deficiencies that result from
forces on the knee produce valgus stresses more often knee injuries.23,24
than varus stresses, the MCL is the more frequently Although each ligament has its own responsibility
injured of these two ligaments.9 in supporting and protecting the knee, some ligaments
The anterior and posterior cruciate ligaments also provide assistive support to other ligaments.
(ACL and PCL, respectively) are structures unique These protective designs are known as primary and
to the knee. Their position within the joint enables secondary restraints. For example, the ACL is the
them to provide anterior–posterior stability as well as primary restraint protecting the knee against anterior
rotational stability.10 Some fibers of each ligament are tibial translation, but if it is injured, other structures
taut throughout the knee’s range of motion.11 Injury to such as the capsule, other ligaments, and muscles act
either ligament can cause disabling knee instability. as secondary restraints and are used in nonsurgical
The ACL and PCL are encased within a synovial patients so joint protection continues in spite of the
membrane that provides the ligaments with their pri- injury.25,26 Sometimes the secondary structures can
mary blood supply. If a partial tear of either ligament assume the role of providing normal stability to the
occurs, the synovial membrane may also become dis- joint so surgical repair is not required, but sometimes
rupted, compromising the ligament’s vascular supply. they fall short. Instability caused by ACL or PCL
If this happens, dehiscence, or erosion, of the ligament insufficiencies is often inadequately supported by
eventually results. secondary structures.27
Within the past quarter century, the ACL has
become the most researched structure of the entire Meniscus
musculoskeletal system.12 This may be because of The medial and lateral meniscus serve to cushion the
the frequency with which it is injured, especially joint, deepen the socket, increase joint congruity to
in sports. The ACL protects the knee from anterior better distribute weight-bearing forces, assist in joint
translation of the tibia on the femur. The PCL is not lubrication, and provide stability.28 These structures
injured as often, but there is evidence that injury rates are commonly referred to as cartilage, although this
to the PCL have increased with the growth in sports is a misnomer. These structures are primarily fibro-
participation.13,14 The PCL serves primarily to restrict cartilage (hence the name), but this is certainly not
knee hyperextension and posterior displacement of the their only component. The knee joint also has articular
tibia on the femur.15 cartilage, so the term “cartilage” is not only erroneous
All ligaments of the joint restrain rotational stresses but sometimes confusing, especially to the patient
at the knee. The cruciate ligaments twist and become who has injured articular cartilage, not meniscus. The
taut during medial rotation.16 The collateral liga- medial meniscus is attached to the MCL, the ACL,
ments become taut to provide stability during lateral and the semimembranosus tendon. This arrangement
rotation.16 Rotation is a primary automatic motion is believed to be one cause for the greater frequency
of the knee in both weight bearing and non-weight of injury to the medial meniscus.29 Even though the
bearing.16 In weight bearing, the femur rotates on the lateral meniscus is not attached to the LCL but does
tibia, and in non-weight bearing, the tibia rotates on connect to the popliteus and PCL, it has more freedom
the femur. Since all ligaments restrain rotation, injury of movement and is not affected by collateral ligament
mechanisms that produce excessive rotational forces positioning and stresses. When the knee moves through
can damage more than one ligament and subsequently flexion and extension within the sagittal plane, the
result in joint instability. menisci follow the tibial movements.30 During flexion,
The knee’s joint capsule and intra-articular struc- the menisci are pulled posteriorly by the semimem-
tures, including the anterior and posterior cruciate branosus and popliteus, and during extension they are
ligaments, contain various neuroreceptors that provide pulled anteriorly by the meniscopatellar ligaments.30
the neural system with position information from the During movement from extension into flexion, the
knee.17,18 We know that the ACL contains afferent femur slides posteriorly on the tibia during weight
mechanoreceptors that affect the knee’s stability.19 The bearing so that in a squat position, the weight is borne
Knee and Thigh 921
primarily by the posterior menisci, whereas in exten- Patellofemoral Joint

sion, the femur is primarily on the anterior menisci. The patella, the largest sesamoid bone in the body,
Compressive forces absorbed by the menisci are up to sits within the femoral groove. Its resting position is
50% to 60% of the knee’s loads.29 When the knee is knee extension, and its close-packed position is knee
at 90° flexion and the primary force is applied at the flexion. The patella serves to increase the lever-arm
posterior aspect of the joint as in a squat position, the length of the quadriceps tendon, adds to the cosmetic
meniscal load increases to 85% of the total knee joint appearance of the knee joint, and protects the knee
compressive forces.31 Meniscal posterior horn and from anterior blows.36 It is a common site of knee pain
lateral tears seem to be primarily degenerative tears, and dysfunction.
whereas anterior horn tears are often traumatic events.32 The quadriceps tendon and its medial and lateral
Degenerative tears may be related to the increased expansions surround the patella. The tendon attach-
forces absorbed by the menisci in flexion, as well as ment from the patella to the tibial tubercle is sometimes
to the repetitive activity imposed on the menisci during referred to as the patellar ligament because it travels
squatting, stair climbing, and lifting heavy objects.33 from bone to bone. This structure is also called the
On the other hand, acute tears occur most often during patellar tendon.
a running or cutting maneuver, when the knee is near Patellar stability is the result of static and dynamic
extension.33 A shallower-than-normal joint may also structures. The greatest bony contributor to patellar
lead to either acute or degenerative meniscal injuries.34 stability is the femoral sulcus formed by the medial
The menisci are avascular except for roughly their and higher-ridged lateral epicondyles within which
peripheral 25%. This has a significant impact on con- the patella sits.37 Ligamentous stability comes from
servative and surgical interventions after injury to the the patellofemoral and patellotibial ligaments, which
meniscus. This topic is discussed later in the chapter. help to provide static restraints.37 Active restraints from
the quadriceps provide the greatest dynamic stability.
Screw-Home Mechanism
An examination of patellar alignment occurs in
The knee joint is a modified hinge joint. This means static and dynamic positions. The patella is examined
that although it is similar to a hinge joint, permitting in long sitting for abnormalities in resting. Move-
movement in one plane, the bony segments are not ment of the patella during quadriceps contraction in
entirely congruent throughout. Because the medial long sitting and in weight bearing is also examined
aspect of the joint is larger and extends slightly more because patellar movement in open and closed kinetic
distally than the lateral side, when the knee moves chain conditions may differ. A closed kinetic chain
into extension the lateral joint segments complete their position can change the patellar alignment because
motion before the medial joint segments, so the tibia other factors, such as hip rotation and foot pronation,
rotates laterally as the medial tibial plateau completes alter the way the patella moves when the quadriceps
its motion on the medial femoral condyle in non- contract.38,39
weight-bearing conditions. When the knee extends
during weight bearing, the femur rotates medially on Superior Tibiofibular Joint
the anchored tibia. This mechanism, called the screw- This joint is not actually a joint of the knee because it
home mechanism, occurs in the last 30° of extension is distal to the knee joint, but it can affect the ankle and
and must occur for full extension of the knee. This knee joints. There are no physiological movements in
mechanism is accompanied by anterior cruciate lig- this joint, but it must have full accessory motion for
ament tension, and it gives the joint more stability full ankle range of motion to occur.40 The tibiofibular
than a pure hinge-joint arrangement would because it joint can be a cause of lateral knee pain.41
provides a kind of locking feature.35 The popliteus is
responsible for unlocking the knee during movement Muscles
from full extension into flexion.16 It does this by later- The quadriceps and hamstrings have been the most
ally rotating the femoral condyles with its medial tibial widely addressed muscles because of their promi-
insertion anchored in weight bearing. In non-weight nence in knee control. Both groups also influence the
bearing, the popliteus unlocks the knee as it medially hip, and because they do, positioning of the hip must
rotates the tibia with its proximal insertion stabilized. always be a consideration when one is exercising the
The importance of this mechanism becomes apparent muscles at the knee.
later in the chapter when we discuss full joint motion The quadriceps provides the most dynamic restraint
and joint mobilization. for the knee.42 The rectus femoris is the quadriceps
component that also assists in hip flexion. Hip posi- with the femoral condyles. When contact between
tioning determines where in the motion the rectus the patella and femur occurs as the knee moves into
femoris contributes the most at the knee.43 In a supine flexion, compressive forces develop between the pos-
straight-leg raise, it works throughout the motion, but terior patella and anterior femur and affect primarily
in sitting, the rectus femoris works only in terminal the lateral patella.47 These compressive loads during
knee extension.44 daily functional activities are more than six times
Because of the angle of their pull and tendon inser- body weight.47 Since the patella rests on the fat pad in
tions, the hamstrings produce not only knee flexion full knee extension, it is not in direct contact with the
but also tibial rotation. The biceps femoris produces femur in this position. The area of contact between
lateral tibial rotation, and the semimembranosus and the posterior patella and the femoral groove migrates
semitendinosus produce medial tibial rotation, espe- from the patella’s inferior pole to its superior aspect
cially with the knee flexed. They also act to protect as the knee moves from about 10° to 20° of flexion
against anterior subluxation, dynamically assisting to 90°.48 The area of contact is fairly uniform across
the ACL;42 therefore, they should be trained to become the breadth of the patella.49 Once the knee approaches
more prominent in this role in ACL-deficient knees. the end of flexion, however, the contact is on the odd
Rehabilitation of isolated hamstring muscles should facet medially and the lateral–superior aspect of the
include the additional movements of tibial rotation patella (figure 23.1) until the patella rests on the top
along with hip extension and knee flexion. Eccentric of the lateral condyle in full flexion.50
and concentric activities for all their motions would Of significance with this change in points of contact
most appropriately strengthen the hamstrings through- between the patella and femur is the fact that as the
out all their functions. knee moves into flexion, the amount of contact pres-
sure and the area of contact both increase.51 Contact
Biomechanical pressure is a ratio between the patellofemoral joint
reaction force and the contact area. Joint reaction force
and Physiological Concepts is a compressive force equivalent to the resultant vector
Biomechanical and physiological concepts should help force (of the patellofemoral quadriceps vector force
guide the clinician in choosing therapeutic exercises for and patellar tendon vector force). This vector force is
various knee injuries. They also help us to understand perpendicular to the patella’s contact surface with the
the indications and precautions. These concepts are femur, so the force essentially compresses the patella
briefly reviewed in this section. against the femur. Stress to the patellofemoral joint is
the force per area of contact. In a closed kinetic chain
Patellofemoral and Tibiofemoral activity, the joint reaction forces and the area of con-
Relationship tact both increase as the knee moves from extension
When the knee extends, the patella glides superiorly, to 90°, but the force applied is greater than the area of
and during flexion it glides inferiorly for a total excur- contact, so joint compressive stress increases as the
sion of 5 to 7 cm (2.0–2.8 in.). The patella must glide knee moves into flexion to 90°.52-54 As the knee moves
freely for full knee motion to be possible.
In normal relaxed extension, the patella’s inferior
pole is at the knee joint’s margin and lies on the supra-
trochlear fat pad. A patella that lies superior to this
position is called patella alta, and one that is inferior to 135° 90°
135°
the normal position is called patella baja. Either abnor- Lateral
Medial
mal position restricts full range of motion of the knee.45 45°– 60°
Injuries of the patellar tendon, including ACL recon-
Odd facet 20 °– 30°
structions that use the quadriceps tendon, may develop
patella baja. Injuries such as repaired quadriceps
ruptures have some risk of causing changes in patella
positioning.46 Patella baja or alta requires aggressive
patellar mobilization and soft-tissue-stretching tech-
niques. These techniques are discussed in detail later.
During knee flexion and extension, the patella Figure 23.1 Patellofemoral contact patterns on posterior
glides within the femoral groove and makes contact patella of a right knee.
E6147/Houglum/Fig.23.01/519082/JG/R1
Knee and Thigh 923
from 90° toward 120°, the force decreases and the closed-chain activities occurs in the first 45° of motion,
surface area of contact remains the same, so the stress and the greatest amount of stress occurs in the range of
per surface area decreases. The greatest compressive 45° to 90°.55 The more painful the patellofemoral joint
forces occur in the 60° to 90° positions.51-54 If a patella is, the more limited are the pain-free ranges of motion
is not in good alignment within the femoral groove, the patient has available to exercise to strengthen the
the congruency between the two bones is altered;51 quadriceps without pain. Patients with hyperextended
as a result, compressive forces are distributed over knees may experience pain at and near the range of
a smaller area of contact, increasing the amount of full extension. For each patellofemoral pain patient, it
compression per surface area. This may be one reason is important to find pain-free motion within which to
why malalignment of the patella results in increased strengthen the quadriceps. As strength improves within
pain and irritation of the patellofemoral joint. this available range of motion, the range itself widens,
In an open kinetic chain activity, the joint stress is allowing for progressive strengthening throughout a
lowest at 90° and greatest at 0°.52,53,55 Although there larger range of motion.62
may be some individual variations, open kinetic chain Full squat exercises and full range-of-motion exer-
exercises are least irritating when performed from 45° cises with weight boots or cuff weights attached to the
to 90°, while closed kinetic chain exercises cause the ankle should be avoided by patellofemoral patients
least patellofemoral joint irritation in the ranges of 0° until later in the treatment program when pain is
to 45° and greater than 90°.52,53,56 reduced and strength is improved sufficiently for the
During closed kinetic chain activities such as the patellofemoral joint to tolerate the greater stresses of
weight-bearing phase of gait, patellofemoral com- these activities.53 It is logical to include a slow pro-
pressive forces of about one-half of body weight are gression in range of motion as symptoms decrease
produced, while stair climbing produces about three and strength increases. Shortening the moment-arm
times body weight and squatting produces com- length on weight machines will reduce the compres-
pressive forces of over seven times body weight.57,58 sive forces, but the primary guide to use for program
During open kinetic chain activities the amount of adjustments is the patient’s pain. In summary, your
compressive force changes with the type of activity rule of thumb is this: if patellofemoral pain occurs
and the angle at which it occurs.59 If knee extension with an exercise, reduce either the range of motion or
is performed with a weight attached to the end of the the resistance to create a pain-free exercise to increase
extremity, compressive forces reach their peak at 35° strength.
to 40°, but if the force is applied by a machine arm
at right angles to the ankle such as in an N-K table or Quadriceps Angle
isokinetic machine, the peak compressive forces occur Quadriceps angle (Q-angle) is the angle that is formed
at 90° and decrease as the knee extends.54,58 Based on by a line from the anterior superior iliac spine to the
mathematical formulas, it is estimated that isokinetic middle patella and a line from the middle patella to
exercises reach a peak patellofemoral compressive the tibial tubercle (figure 23.2). The minimum normal
force of about five times body weight.57 Q-angle measurement is 10°. Investigations of Q-angle
Many functional activities are performed in the 0° between males and females are conflicting. Some stud-
to 95° range of motion.60 It is important when you are ies have found differences between the sexes63 while
treating patients with patellofemoral pain to avoid others have not.64 It may be that the major reason for
painful arcs of motion. Generally, closed kinetic this difference in study results is that taller people have
chain exercises from 0° to 40° of flexion provide smaller Q-angles, and the differences found in some
less medial–lateral patellar movement and less patel- studies because of gender may actually be because of
lofemoral stress than open kinetic chain exercises, and height differences.65 The Q-angle can change depend-
open-chain exercises in positions greater than 50° of ing on whether or not the quadriceps is contracted.66
flexion are less stressful.53,61 Clinicians often measure the Q-angle with the patient
These numbers may seem confusing, but you need relaxed in the supine position, and then in the standing
to understand their significance when treating patients weight-bearing position with the quadriceps contracted
with patellofemoral stress injuries. Several points to determine the different measures of the patient’s
are important to remember. The most patellofemoral Q-angle; the angle is usually slightly less when the
stress in open-chain exercises occurs in the first 30° quadriceps contracts.66 If the patient has pronation in
of motion, and the least amount of stress occurs in the weight bearing, the tibia medially rotates and increases
range of 45° to 90°.55 The least patellofemoral stress in the Q-angle.67 If the leg laterally rotates, the Q-angle
entations can increase stress levels on various knee

structures. For example, increased hip medial rotation,
squinting patellae, genu recurvatum, patella alta, tibial
Anterior superior varum, medial tibial rotation, heel height, and compen-
iliac spine satory pronation are malalignments that can contribute
to patellofemoral pain.71-74 Because the lower extremity
is a closed kinetic chain during most of its functions,
we know that malalignment in one segment results in
compensatory changes in another segment. Changes
at the hip or at the foot cause compensatory changes
Q-angle and increase knee stress.75,76 Compensatory pronation
and hip medial rotation with resulting medial tibial
rotation are two malalignment problems that should
be investigated in patients with patellofemoral pain.
CLINICAL TIPS
The quadriceps’ ability to provide optimal muscle
output is significantly decreased in the presence
Patella of either pain or edema. It is important for the clini-
cian to control these secondary effects of injury so
rehabilitation may provide optimal results.
Tibial
tuberosity
Rehabilitation Factors
Figure 23.2 Landmarks for measuring the Q-angle include In addition to the routine rehabilitation concepts that
the anterior superior iliac spine, the mid-patella point, and the guide the development of any therapeutic exercise pro-
E6147/Houglum/Fig.23.02/519083/JG/R2-kh
tibial tubercle. Q-angle measurements should be taken with gram, special factors enter into knee rehabilitation. The
the quadriceps relaxed and contracted. clinician must address them all if a rehabilitation pro-
gram is to be successful. The following sections deal
with the special factors that have the most influence.
decreases. A weak vastus medialis oblique (VMO)
and hip abductors can also increase the Q-angle.51,68 Extensor Lag
In the past, many thought the Q-angle was a key The condition in which full passive motion is present
factor in patellofemoral alignment and symptoms. but active terminal knee extension does not occur is
Because it can change with functional activities, an extensor lag. In other words, the clinician can
unless it is profoundly excessive its significance for move the knee into normal extension, but when the
patellofemoral pain is not considered as great as in the patient contracts the quadriceps, the knee does not
past.69 The Q-angle should be assessed for gross abnor- voluntarily move through the terminal part of its
malities in non-weight bearing and for changes when motion. This extensor lag may occur because of edema,
the quadriceps contracts. Although Q-angle may not pain, stiffness, or weakness.89 We know that pain and
be a primary cause of patellofemoral pain syndrome as edema result in less quadriceps activation, so if these
was once believed, it may contribute to the syndrome factors are present, they may be contributing to active
when other conditions are present. terminal extension loss. If joint or muscle stiffness is
present, then passive motion is also going to be less
Lower-Extremity Alignment than normal; therefore, when an extensor lag exists,
Excessive rearfoot pronation influences the patella’s we know by the definition of extensor lag (full passive
alignment because it increases tibial medial rotation motion but less than normal active motion)90 that joint
and changes the quadriceps tendon pull on the patella.70 or muscle stiffness are not likely contributors.
You should evaluate other lower-extremity alignments On the other hand, if the quadriceps muscle is
during a knee examination because abnormal ori- weak, it may have inadequate strength to fully extend
Knee and Thigh 925
Factors Influencing Post-Injury Strength

Obviously, we know that injury and surgery weaken the knee muscles. Other factors, however, influence knee
strength and function. Some are not often considered, but all affect knee function and are important for that reason.
These factors—edema,77 pain,78 and abnormal ambulation79—lead to impaired muscle function. Reduced func-
tion leads to atrophy and weakness of the muscle.80 Muscle weakness leads to reduced function and control of the
body segment.81 The rehabilitation clinician must pay attention to these factors when examining a patient before
initiating a therapeutic exercise program.
Edema
One of the important goals of first-aid treatment of musculoskeletal injuries is minimization of edema. Once edema
forms, efforts should be made to relieve it as quickly as possible. One reason this is a priority is that studies have
demonstrated that swelling in the knee joint causes a reflex shutdown of the quadriceps.77,82,83 Other researchers
have injected plasma or saline in small quantities (20–30 ml) into normal knees and recorded a profound inhibition
of quadriceps activity to levels 60% below normal.83-85 As fluid quantity increases, quadriceps activity decreases.
Pain
It is commonly understood that pain causes a reflex inhibition of muscle activity.78,85,86 Pain affects both the auto-
nomic and the conscious pathways. The reflex response in the presence of pain is to withdraw. The conscious
response is to refrain from activity that produces pain. If pain persists after an injury, the patient’s ability to perform
active muscle contraction is impaired. The use of electrical stimulation and other modalities to control pain before
therapeutic exercise may result in improved strength-output levels during exercises.87 This can ultimately reduce
the patient’s rehabilitation time by enhancing strength gains.
Ambulation
Normal ambulation uses the right and left lower extremity equally, applying weight-bearing and propulsive forces
equally to and by both extremities. Weakness results when a patient sustains a lower-extremity injury that causes
him or her to favor the injured extremity. An unequal gait produces subnormal stresses on the extremity as the
patient spends less weight-bearing time on it and applies less stress to it. An antalgic gait produces weakness not
only in the injured segment but also throughout that entire lower extremity.88 Therefore, it is important to examine
the total lower extremity after an injury and to correct secondary weaknesses that develop in the extremity’s
non-injured segments.
the knee. Terminal extension to 0° can be difficult length) as the knee approaches its end range means
for a weakened quadriceps to achieve. A long-estab- that a much greater effort is needed from the entire
lished debate continues unresolved between those quadriceps to complete the movement, not just from
who identify the quadriceps as different muscles the VMO.
with different activations and different functions and Some of the often-used open kinetic chain
those who indicate that although the four muscles exercises for strength gains are the quad set, the
have different heads, they activate as one muscle.91 straight-leg raise, and the short-arc quad. Among
Some researchers maintain that because of its fiber these, the quad set is the most effective in producing
alignment, the function of the VMO is to maintain total quadriceps activity.94 The rectus femoris works
medial patellar alignment, providing dynamic restraint more during the straight-leg raise and the short-arc
for the patella.92 Other investigators indicate that the quad exercises.94 Vastus medialis activity is most
VMO does not exert any more effort than any of the apparent during a quad set. As would be expected,
other quadriceps muscles during terminal extension.93 the quadriceps muscles work more during a knee-ex-
It has been demonstrated that the force required of tension exercise than during a straight-leg raise.95
the quadriceps to produce the last 15° of extension Open kinetic chain exercises are an important tool
is twice as great as it is to produce movement in the in restoring isolated quadriceps strength, so these
other ranges of knee motion.90 The quadriceps’ loss exercises are key elements in a therapeutic exercise
of mechanical advantage (decreased moment-arm program for a patient with quadriceps weakness.96
Arthrogenic Muscle Inhibition ground reaction forces imparted to the joint during
In more recent years the term arthrogenic muscle landing activities.104 This result occurred presumably
inhibition (AMI) has been used to identify reduced because those individuals landed with less knee flex-
quadriceps activation after injury.97 It is thought to be ion, so normal shock absorption provided by knee
a protective reflex inhibition the body uses to reduce flexion was lacking. When higher ground reaction
stress that would otherwise be applied to the injured forces are applied to the joint, there is a higher risk
knee joint by the strong quadriceps.98 Quadriceps that the person will develop osteoarthritis.105
AMI contributes to delayed treatment response since Effective treatment of AMI focuses heavily on pre-
it inhibits quadriceps activity and can retard or delay vention. Aggressive treatment of joint effusion in the
effective strengthening efforts because neurogenic early days after injury is important for lasting rehabil-
muscle inhibition prevents the quadriceps from acti- itation outcomes. Since poor rehabilitation outcomes
vating properly.99 If quadriceps weakness persists reflect greater arthrogenic muscle inhibition,106 the
because of AMI, knee stability, function, and optimal contrary may be presumed: if less joint effusion results
performance are impaired, and this increases the risk in less AMI, then minimizing joint swelling is a key
of reinjury if not resolved.99 factor for optimal treatment outcomes. A recent study
Arthrogenic muscle inhibition is most apparent investigated various methods of increasing quadriceps
soon after a joint injury. It has been shown that muscle activation and found that the most effective method
output is diminished by 50% to 70% within the first was transcutaneous electrical nerve stimulation. 107
few hours after surgery and continues to advance to Other studies have identified additional treatments
80% to 90% inhibition within 1 day.100 There is slight that produced increased quadriceps activation. These
recovery to a 70% to 80% loss by the time the injury studies used techniques such as cryotherapy,108 trans-
moves into the proliferation phase of healing, 3 to 4 cutaneous electrical nerve stimulation,107 local muscle
days after surgery.100 Studies have demonstrated that vibration,109,110 and total body vibration.110 When
over the first 6 months after injury there is a plateauing you consider that AMI is thought to result mainly
of AMI that is followed by a very slow reduction in from inhibition of the muscle’s alpha-motoneuron
AMI over the next several months, lasting up to an pool, it makes intuitive sense that correcting AMI
average of 4 years.99 requires facilitation of those receptors being inhibited.
While the main causes of AMI include pain, effu- Although most of these studies demonstrate early but
sion, and joint damage, a very powerful influence promising results, an established, effective intervention
on quadriceps AMI is joint swelling.101 Studies have is yet to emerge.
shown that it does not take much joint swelling to
Open and Closed Kinetic Chain
inhibit normal quadriceps activity. Wood et al.102 found
that only 10 ml (about 1/3 oz) of knee joint effusion Exercises
caused quadriceps inhibition. Additional studies Open and closed kinetic chain exercises each have
have found that swelling of 20 to 60 ml decreased their advocates when it comes to including them in a
quadriceps strength by 30% to 40% of its pre-effusion knee therapeutic exercise program. Some investigators
output.102,103 Although the exact mechanisms are not support the use of closed-chain exercises for ACL
clear, it is evident that neural inhibition at least at the injuries and reconstructions.96,111,112 More recently,
spinal cord levels and perhaps higher cortical levels are research has indicated that a combination of open
a source of this quadriceps response to joint effusion.99 and closed kinetic chain exercises begun early in the
More recent investigations have demonstrated that the therapeutic exercise program is beneficial in ACL
likely source of quadriceps inhibition in the presence rehabilitation.113-115 Results of these studies indicate
of joint effusion is a spinal reflex inhibition of the that better quadriceps strengthening results with earlier
muscle’s alpha motoneuron pool and not higher central use of open-chain exercises for the muscle.
nervous system cortical levels.101 However, the study’s It has been assumed that closed kinetic chain exer-
investigators admit that additional studies are needed cises recruit a co-contraction of hamstrings and quadri-
before such statements may be made with certainty.101 ceps to provide stability; this assumption remains con-
A primary concern of knees with AMI is that troversial and inconclusive. For example, investigators
patients return to normal activity before the quadriceps have demonstrated that the lateral step-up exercise,
has enough strength to provide optimal protection to thought to recruit co-contraction of hamstrings and
the knee joint.104 One study revealed that individuals quadriceps, actually recruits the vastus lateralis and
with AMI secondary to joint effusion had greater vastus medialis components of the quadriceps sig-
Knee and Thigh 927
nificantly but does little to recruit the hamstrings.116 distal to the knee joint to reduce excessive shear-force
On the other hand, it has been demonstrated that a applications. Likewise, exercises using machine
squat exercise generated twice as much hamstring resistance in open-chain exercises should have their
activity as a leg press.117 Additional investigations resistance arms applied close to the knee rather than
are needed to determine how much co-contraction at the ankle.
actually occurs between hamstrings and quadriceps Less stress is applied to the ACL in closed kinetic
during weight-bearing exercises. chain activity during these early degrees of motion,
but stress to the ACL increases during closed kinetic
Shear Stress chain activities when the knee moves beyond about
We know that shear forces are the most destructive 45° of flexion (figure 23.4).118 There is less anterior
forces applied to joints. Both open and closed kinetic shear stress (and less subsequent ACL strain) in
chain exercises can apply shear stresses to the knee weight-bearing activities that are performed in 0° to
joint; however, the range of motion within which 60° of knee motion.121 \
these shear forces are applied is different for open- In summary, the least amount of anterior displace- F
and closed-chain exercises. In an open kinetic chain ment in an anterior cruciate–deficient knee during a
exercise, as indicated in figure 23.3, less anterior closed-chain exercise occurs at 60° and less, while the
shear stress is applied to the ACL in knee extension least displacement in an open-chain exercise occurs at
resistive exercises from 60° to 90° flexion, and more 40° and more.121 Joint compressive forces that occur
is applied in terminal-extension ranges of motion.118 during weight bearing may be responsible for reducing
Although investigators report open kinetic chain the shearing forces and anterior translation that occur
activity’s greatest shear stress on the ACL occurring in open kinetic chain activities.122
at different ranges of motion, either 0° to 40° of flex- Isokinetic exercise is not used until the later phases
ion118 or 15° to 30° of flexion,119 clinicians should be of rehabilitation because it is open chain; its lever
wary of positioning patients in open chain exercises arm can be shortened, but it still applies significant
at less than 40° of flexion after recent ACL injury or shear stresses. When isokinetic exercise is first used,
surgical repair. Resistance added during open-chain the slower speeds should be avoided because slower
activities increases these shear forces.120 speeds produce a greater torque that can increase
Since shear stress increases with greater moment- anterior tibial displacement and ACL strain. Isokinetic
arm lengths, it stands to reason that if manual exercises are usually not added to the therapeutic
resistance is used, especially in the early phases of exercise program until the patient enters the last half
therapeutic exercise, it should be applied immediately of the resistive phase.
Isometric contractions CKC

ROM without boot OKC
ROM with boot
4.4
PF joint stress
ACL strain (%)
2.8
0
–1.5
0 15 20 30 60 90 0 30 60 90
Range of knee motion Degrees
Figure 23.3 ACL strain with open kinetic chain activities. Figure 23.4 Patellofemoral joint stress at different
Comparing this figure with 23.4,
E6147/Houglum/fig we can notice similar declines
23.03/519084/TimB/R2-kh angles. Similarities in stresses during open-chain activities
in the stresses applied in open-chain activities as the knee allow complimentary exercises
E6147/Houglum/fig if an ACL patient also has
23.04/519085/TimB/R1
moves from full extension to 90° of flexion. patellofemoral pain.
Adapted from Beynnon et al. 1995. Based on Steinkamp et al. 1993.
Bracing area involved in new tissue formation will dictate

Perhaps more than any other joint, the knee is a whether these techniques may be more appropriate
frequent site for braces. There are three types of in phase II or in phase III. Early strength and endur-
braces: prophylactic, rehabilitative, and functional. ance exercises begin in phase III (resistive phase) and
The prophylactic brace is used to prevent or reduce encompass a variety of activities that advance from
the severity of an injury,123 the rehabilitative brace static to dynamic and from isometric to isotonic, and
restricts motion of an injured joint, and a functional eventually in later phase III or even phase IV (aggres-
brace improves the stability of an unstable joint.124 sive phase), to isokinetic exercises. The tools used to
A functional brace can also be a prophylactic brace. improve strength depend on the timing of the program,
There are custom-made braces and off-the-shelf the patient’s response, the availability of equipment,
braces. Custom-made braces are more expensive and and the rehabilitation clinician’s preference. Isometric
can cost several hundred dollars or more. Off-the-shelf exercises are used more often in later phase II, when
braces are similar in construction to the custom-made the knee is immobilized, when range-of-motion exer-
braces but come in generic sizes, usually ranging from cises are too painful for the patient, and when the aim
extra small to extra large. is to isolate weak ranges of motion. In most cases, a
The use of braces after ACL injuries is wide- combination of open and closed kinetic chain exercises
spread.125 Braces provide anterior stability during low- is beneficial in phase III and sometimes in later phase
stress loading but have not shown adequate stability II to improve strength.
during more functional athletic load applications.126 Balance and agility exercises begin with dou-
Although several reports indicate there is no difference ble-support weight-bearing activities in phase III or
whether postoperative ACL patients wear braces or late phase II and progress to single-limb static balanc-
not,125,127 other evidence indicates that braces do seem ing on a stable surface. Initial double-support activities
to provide some proprioceptive feedback, so they may might be as simple as gait training with correct weight
be of value for this reason.128 transfer from the right to the left extremity. From there
Patients who have patellofemoral pain often use the activities advance to single-limb stance on a stable
knee sleeves. Once again, the proprioceptive benefit surface then on an unstable surface in phase III. Bal-
as reflected in subjective reports of decreased pain ance activities begin at a low level when the patient
may be the primary advantage. The sleeves do not can bear weight on the extremity in phase II. Once
alter patellar glide or protect the knee from external the patient can place total body weight on the injured
stress, but there is some evidence to indicate a sleeve extremity, single-limb stance activities can begin. For
has some value.129 Even considering the evidence, one these activities, the patient must be able to correctly
cannot dismiss the psychological benefits of increased shift weight without trunk lean onto the involved
confidence and assurance that using a sleeve may give extremity. A trunk lean not only does not permit accu-
the patient.130 rate body-weight transfer onto the extremity, but it also
promotes bad weight-bearing habits during gait and
Program Progression other activities that can become difficult to overcome.
Tissue healing and the injury’s response to exercise are Agility activities advance in later phase III from
primary factors that dictate the rate of progression of a the balance and coordination exercises used in earlier
knee therapeutic exercise program. Range of motion, phase III rehabilitation. Prerequisites for a progres-
strength and endurance, balance and agility, and func- sion to agility exercises are an intact neuromuscular
tional performance are advanced as with therapeutic response system and enough strength and motion to
exercise programs for other body segments. Careful return the body’s center of mass to its base of support
observation by the rehabilitation clinician, as well as when balance is disturbed.131 Agility exercises also
reliance on the patient for accurate feedback about demand appropriate coordination and muscle power,
responses to exercise, is essential for steady progress. so they are the next logical step in the rehabilitation
As with other rehabilitation program progressions, progression before functional and performance-spe-
protecting the injury, reducing pain and edema, and cific exercises. Agility exercises are dynamic; they
maintaining current levels of conditioning are all may begin with no-impact activities and progress
included in phase I (inactive phase) of knee reha- to high-impact activities according to the patient’s
bilitation. Flexibility exercises, joint mobilization, ultimate needs. The lower-level agility exercises are
and soft-tissue mobilization are all techniques that unidirectional, and more advanced agility exercises
usually begin in phase II (active phase); the specific are multidirectional. Agility activities begin at reduced
Knee and Thigh 929
speeds and advance to full speed as the patient pro- inclination to favor the previously injured extremity,
gresses in late phase III. and the ability to perform all motions with confidence.
When adding a new agility exercise to a program,
it is best to include it early in the exercise session
before the patient becomes fatigued; there is evidence Soft-Tissue Mobilization
to demonstrate that fatigue reduces the knee’s pro-
prioceptive function.132 An agility activity requires Pain in the soft tissue surrounding the knee can result
proprioceptive feedback for proper execution. 133 from injury to the local tissue or to distant tissue. The
Therefore, if fatigue reduces proprioceptive function, foot and hip can refer pain into the knee.135 You should
the execution will not be performed as well as it should examine these areas as possible sources of knee pain
be, and the application is undesirable because of the if there has been no frank injury. With injuries to other
risk of engramming an incorrect execution. segments, assessment of the hip and knee segments
Once the patient has mastered the agility exercises, may also be needed to rule out referred pain. You
the final steps—functional, and then performance-spe- must make a differential diagnosis to eliminate other
cific exercises—prepare the person physically and sources of pain to provide appropriate rehabilitative
psychologically for return to full participation. The care for the patient.
program advances to this phase, phase IV, when the Muscles surrounding the knee create their own
injury exhibits no evidence of post-exercise pain or pain-referral patterns. They can refer pain if they suffer
edema and when the injured knee has full range of an injury, if they have associated soft-tissue adhesions
motion and good balance. Strength needs differ for with restrictions of normal tissue mobility, or if they
specific activities; the patient should have 70% to 75% suffer a loss of flexibility and experience increased
normal strength for running, 80% normal strength stress during activity. Trigger points become active
for submaximal agility activities, and 85% normal when subjected to abnormal or excessive stresses.
strength for performance-specific exercises.134 As These issues are discussed in chapter 13.
with other therapeutic exercise programs, functional Soft-tissue mobilization techniques listed in table
activities lead up to specific performance-related 23.1 are discussed in more detail in chapter 13 and
drills that mimic the patient’s normal activities. Per- include the more common pain-referral patterns
formance-specific exercises are designed to come as and trigger point release techniques identified and
close to normal participation demands as possible. advanced by Travell and Simons.135 For additional
They may begin at reduced stress levels, but as the trigger points within other knee muscles, refer to the
patient’s skills and confidence return and goals are Travell and Simons text.135 Other techniques such as
met, the stress of the activity is akin to the stress he or deep-tissue massage for relief of scar tissue adhesions
she will experience on returning to full participation. and cross-friction massage for tendinopathy around the
knee are presented here.
Hip muscles that cross the knee joint or affect
knee movement are included in this chapter. Other
CLINICAL TIPS hip muscles are addressed in chapter 24. For the most
part, soft-tissue referral pain in the anterior aspect of
The knee encompasses two major joints, the tibi-
ofemoral joint and the patellofemoral joint. The knee the knee and thigh originates from the anterior thigh
also contains a joint capsule, ligaments, menisci, and hip muscles.
and muscles. Designing a therapeutic exercise Two areas of the knee and thigh typically require
program must take into account the knee’s unique deep-tissue massage: the quadriceps tendon and the
structure, as well as a number of biomechanical and
physiological characteristics specific to the knee.
TABLE 23.1 Trigger Points Commonly

The final examination to determine the patient’s Seen in the Knee Muscles
readiness for return to full participation should mimic Knee segment Muscles with trigger points
the patient’s activity skills and demands. The reha- Knee flexor Hamstrings
bilitation clinician examines the patient for accurate Popliteus
execution of normal activities, an ability to use both
Lateral stabilizer Tensor fasciae latae
lower extremities equally and without hesitation or any
iliotibial band (ITB). When the quadriceps tendon patient’s lateral thigh from the knee moving toward the
is painful because of excessive stress, irritation, or hip. Soft-tissue restrictions are palpated as “sticking
tendinopathy, cross-friction massage is often used to points” as the hand moves along the lateral thigh.
relieve scar tissue adhesions that can occur secondarily The clinician repeats the deep-tissue massage strokes
to these conditions. The tendon fibers are cross-fric- several times, spending additional time on the more-re-
tioned in the manner described in chapter 13. Because stricted regions. It is important to maintain soft-tissue
the tendon fibers run vertically from the patella to mobility gains by having the patient actively stretch
the tibial tuberosity, the cross-friction technique is the muscles after the manual treatment is completed.
applied horizontally, across the fibers. It is important Several commercial tools are now available to help
that the clinician pull the skin taut with one hand while release soft-tissue adhesions such as those seen in
applying the cross-friction technique with the other large muscles like the quadriceps and hamstrings or
hand to the tendon; otherwise there is a risk that the in tendinous regions like the ITB. These tools include
cross-friction massage just moves the skin against the Graston, the Stick, the Knobble, and several others.
tendon and does not affect the tendon. When used properly, they can be effective on soft-
Cross-friction massage is also used on surgical scars tissue restrictions around the knee and can help reduce
to prevent or reduce adhesions of skin to underlying stress on the clinician’s hands.
adjacent tissues. Even the portal sites of arthroscopy As the restrictive areas release with treatment, tissue
should be examined and treated as needed to prevent mobility improves and the patient reports less tender-
adhesions and promote good tissue mobility after ness with the massage. Range of motion of any joint
surgery. affected by these soft-tissue restrictions also improves.
The tensor fasciae latae and its long, thick tendon In an alternative technique for a home program,
are frequent sites of adhesions, especially after injury the patient applies self-massage using a foam roller
or prolonged pathomechanical stresses such as those or massage roller. If using a foam roller, the patient
seen with genu valgus. These areas along the ITB are lies on the involved side, with the weight on both
relieved by deep-tissue massage. The rehabilitation hands and the thigh on the foam roller (figure 23.5).
clinician flexes his or her hand’s metacarpophalangeal He or she rolls from knee to thigh on the foam roller,
and proximal interphalangeal joints and extends the initially locating those areas that are most tender and
distal interphalangeal joints so the finger pads rest in restricted. Then the patient moves back to those areas
the palm. With the hand in this position, the clinician that are most tender and spends time on each one
uses posterior surfaces of the middle and distal phalanx until the tenderness subsides or reduces. The patient
to apply an even pressure throughout the hand’s contact repeats the process at each tender region until the areas
on the patient’s thigh while guiding the hand along the of tenderness are treated. This technique should not
Figure 23.5 Iliotibial band foam-roller self-massage.

Knee and Thigh 931
produce tenderness in normal tissue, but tenderness

will occur in areas of soft-tissue restriction. If using a Joint Mobilization
massage roller stick, the patient applies firm pressure
with each hand on the ends of the roller as it is moved Injury, surgery, edema, and immobilization can lead
along the restricted soft-tissue region. to reduced joint mobility involving the patellofemoral
The foam roller can also be used to massage the joint,74 tibiofemoral joint,136 and proximal tibiofibular
quadriceps muscle if its fascia is restricted from immo- joint.137 Although the proximal tibiofibular joint is
bilization or injury (figure 23.6). The patient lies prone not actually part of the knee, if it develops reduced
with the body weight on both forearms and with the mobility it can refer pain to the knee and also affect
anterior thighs on the foam roller. He or she uses the ankle mobility. For this reason, you should assess the
arms to move the lower extremities from the hips to tibiofibular joint for restriction during your rehabili-
the knees on the roller, spending more time over the tation examination. The following sections describe
tender sites in a manner similar to that explained for the some of the most commonly used joint mobilization
ITB. The patient makes small back and forth motions techniques for the knee joints. Keep in mind that the
on the roller until one area of pain is relieved, then indications listed for each technique use grade III
moves along the muscle to the next area of tenderness and IV mobilizations, but these techniques can also
and repeats the treatment at that site. This procedure be used to relieve pain when applied using grade I
is used on the entire muscle. and II mobilizations.
Proximal Tibiofibular and

Patellofemoral Mobilizations
CLINICAL TIPS
These joints should be assessed after surgery, edema,
Soft-tissue adhesions are common after immobili- and immobilization. Full knee range of motion
zation and edema formation. These adhesions not
only cause restricted motion but also result in pain requires normal mobility of the tibiofibular and
referred to areas away from the site of injury. Much patellofemoral joints. Knee examinations before
like anchoring a bed sheet and pulling on it, wrin- the start of a therapeutic exercise program should
kles along the sheet occur in areas away from the include assessments of these joints. The resting
anchoring point. Likewise, with tissue adhesions
in one part of the body, other distant parts may be position for the proximal tibiofibular joint is 25° of
affected. To achieve full mobility without pain, the knee flexion with 10° of ankle plantar flexion while
clinician must identify, locate, and treat these areas. its close-packed positions are full dorsiflexion and
weight bearing.
Figure 23.6 Quadriceps foam-roller massage. The application is similar to that for the ITB.
TIBIOFIBULAR JOINT
ANTERIOR AND POSTERIOR
GLIDES
Joint: Proximal tibiofibular joint.
Resting Position: 25° of knee flexion with 10° of ankle
plantar flexion.
Indications: Restricted motion of the knee, ankle, or
both.
Patient Position: Supine with hip and knee flexed and
foot resting on the tabletop.
Clinician and Hand Positions: Clinician stands at Figure 23.7
the side of the treatment table near the knee being
treated and grasps the fibular head with pads of thumb
anteriorly and index and middle fingers posteriorly.
Mobilization Application: Fibular head is moved anteriorly, then posteriorly (figure 23.7).
Notations: The weight of the leg anchored with the foot on the table stabilizes the tibia.
Patellofemoral Joint Mobilization

The patella often suffers restricted mobility after injury, joint effusion, or immobilization. If normal patella
mobility is not restored, full knee range of motion will not be possible. The rehabilitation clinician should
always assess the patella’s mobility in all directions before beginning mobility and stretching exercises for
the tibiofemoral joint.
LATERAL GLIDES
Joint: Patellofemoral.
Resting Position: Knee extension.
Indications: Restricted medial-lateral motion of the patella.
Patient Position: The patient lies supine, and a rolled towel
is placed under the knee for knee comfort and support.
Clinician and Hand Positions: The clinician stands at the
side of the treatment table near the knee being treated,
and the clinician’s thumb pads are on the medial aspect
of the patella. Figure 23.8
Mobilization Application: Thumbs move the patella laterally
(figure 23.8). Care must be taken to apply a lateral force, not a downward or compressive force, on the patella.
Notations: Patellar mobility is necessary for full knee flexion–extension motion and tibial rotation.
Knee and Thigh 933
MEDIAL GLIDES
Indications: Restricted medial-lateral motion of the patella.
is placed under the knee for comfort and support.
side of the treatment table near the knee being treated.
The clinician’s index finger pads are on the lateral aspect
of the patella. Figure 23.9
Mobilization Application: Finger pads move the patella
medially (figure 23.9). Care must be taken to apply a medial force, not a downward or compressive force,
on the patella.
INFERIOR GLIDES
Indications: Restricted inferior motion of the patella.
The clinician’s thumb and index finger are placed around
the superior rim of the patella. Figure 23.10
Mobilization Application: The clinician glides the patella
distally in an inferior direction toward the toes, being careful not to compress the patella on the femur (figure
23.10).
SUPERIOR GLIDES
Indications: Restricted superior motion of the patella.
The clinician’s thumb and index finger are placed around
the inferior rim of the patella.
Figure 23.11
Mobilization Application: The clinician’s thumb and index
finger exert a cephalic force on the patella, avoiding compression of the patella on the femur (figure 23.11).
Tibiofemoral Mobilizations superior tibiofibular joints also can affect total range of
motion, the tibiofemoral joint has the greatest impact.
This is the joint most often mobilized to improve knee Some of the more commonly applied joint mobiliza-
range of motion. Although the patellofemoral and tions for the tibiofemoral joint are included here.
DISTRACTION
Joint: Tibiofemoral joint.
Resting Position: 20° to 25° flexion.
Indications: General restriction or general relaxation.
Patient Position: Supine with knee supported in resting
position.
Clinician and Hand Positions: The femur is stabilized
with one hand proximal to the knee, and the mobilizing
hand is placed proximal to the ankle joint.
Mobilization Application: The tibia is pulled distally by
the mobilizing hand while the stabilizing hand secures
the thigh (figure 23.12). Figure 23.12
Notations: This technique is often used both prior to and

after using grade III and IV mobilizations.
ANTERIOR GLIDES
Indications: To increase knee extension.
Patient Position: Prone. The knee is flexed with the thigh
supported on the table and the patient’s leg resting on
the rehabilitation clinician’s shoulder. A pad under the
distal thigh will make the position more comfortable for
the patient and align the thigh more appropriately for
the glide.
Clinician and Hand Positions: With the clinician at the
foot of the table, the patient’s distal leg is supported Figure 23.13
on the rehabilitation clinician’s shoulder. The clinician
clasps his or her hands around the proximal leg near the posterior knee and glides the tibia anteriorly on the
femur (figure 23.13).
Mobilization Application: The glide force must be parallel to the plane of the joint surface. When the knee is
moved out of the resting position for mobilizations, the angle of force will also change since the force must
always be parallel to the tibia’s joint surface.
Notations: The hamstrings should remain relaxed to produce the most effective results.
An alternative posterior-to-anterior mobilization technique is performed with the patient prone and the
rehabilitation clinician standing along the table’s side at the level of the patient’s knee and rotated to face the
patient’s foot. The clinician supports the distal tibia with the knee at 30° flexion with the stabilizing hand. An
anterior force is applied by the mobilizing hand just distal to the posterior knee joint.
An anterior glide can also be performed with the patient sitting with the thighs on the table and the legs
freely hanging over the side. The clinician sits on a treatment stool facing the patient and secures the patient’s
leg between his or her knees to place the knee in a resting position and places both hands over the posterior
proximal leg just below the knee.
Knee and Thigh 935
POSTERIOR GLIDES
Indications: To increase knee flexion motion.
Patient Position: Patient is supine with a pad under the
thigh to maintain the joint in a resting position.
Clinician and Hand Positions: The rehabilitation clinician
stands near the treated knee and places the heels of his
or her hands on the anterior proximal tibia.
Mobilization Application: Posterior glide parallel to the
tibia’s joint surface (figure 23.14). Figure 23.14
Notations: In an alternative position, the patient is sitting
with the knee over the edge of the table and the thigh supported on the table with a towel roll under the
distal thigh. The clinician sits on a treatment stool facing the patient and secures the patient’s leg between
his or her knees to place the knee in a resting position. The rehabilitation clinician applies a posterior glide
at the tibial condyles.
ROTATIONAL GLIDE: ANTERIOR

GLIDE OF THE MEDIAL TIBIAL
CONDYLE
Resting Position: Resting position is 20° to 25° flexion,
but this technique is often performed in an end-range
position.
Indications: Used to gain lateral tibial rotation in terminal
knee extension.
Patient Position: Prone with a pad under the distal femur
for comfort. Figure 23.15
Clinician and Hand Positions: The heel of one hand is
on the posterior medial tibial plateau.
Mobilization Application: A posterior-to-anterior (PA) glide of the medial posterior tibia on the femur to
produce the screw-home rotation for full knee extension (figure 23.15).
Notations: This technique is used to gain the last few degrees of extension in a knee.
ROTATIONAL GLIDE: POSTERIOR GLIDE

OF THE MEDIAL TIBIAL CONDYLE
Resting Position: Resting position is 20° to 25° flexion, but this technique
is often performed in an end-range position.
Indications: Used to gain medial tibial rotation and knee flexion.
Patient Position: Patient is supine with the knee in flexion.
Clinician and Hand Positions: Clinician places the heel of the hand on
the medial tibial condyle anteriorly.
Mobilization Application: An AP force is applied to the medial tibial
condyle (figure 23.16).
Notations: This technique may be used to acquire the last few degrees
of knee flexion.
Figure 23.16
Flexibility Exercises active motion.140 Although not used as often as they were
a few years ago, CPMs are beneficial in reducing pain
and edema and encouraging the restoration of range of
Flexibility exercises for the knee can be active or motion in the short term;141 however, studies have shown
passive. The techniques used depend on the type of no significant long-term differences between patients
tissue being stretched and how recent the injury is. using and those not using a CPM.142
As a general rule of thumb, healing soft tissue occa- The exercises presented in the following sections
sionally requires time for immobilization to protect are divided into prolonged and active stretches. The
newly forming tissue, but after this immobilization active stretches include some exercises that use assistive
period, movement produces a better result of heal- equipment and some that require only the patient’s active
ing than prolonged immobilization.138 Very new and motion. During active stretches, it is important for the
developing scars of severe muscle, ligament, and patient to contract the opposing muscle whenever pos-
tendon tissue injuries may require up to 3 weeks sible to enhance relaxation of the stretched muscle and
of immobilization, but controlled motion after this achieve a more effective stretch.
period of immobilization will enhance the new tissue’s
strength.138 Mildly injured soft tissue may not require
as long an immobilization and may be able to tolerate
Prolonged Stretches
mild passive stretches, but this activity must be care- These stretches are used when scar tissue that is limiting
fully determined. As scar tissue continues to mature motion is mature or is becoming mature and short-term
in the later proliferation phase and early remodeling stretches would be ineffective in improving tissue flexi-
phase, it may be effectively stretched with active and bility or mobility. Although healing timelines vary from
short-term stretches, but this depends on the injury’s structure to structure, as a general rule, prolonged knee
severity and location. Very adherent scar tissue in its stretches will be more effective than short-term stretches
late remodeling phase or later requires a combination when scar tissue is more than 30 weeks old since this
of scar tissue massage and stretching to loosen adhe- is when levels of type III collagen are comparable to
sions; if it is very mature, long-term stretches may normal ligament tissue.143 We know that healing tissue
be the best way to increase mobility by affecting the continues to mature beyond a year,144 so tissue becomes
tissue’s plastic element.139 more rigid as the healing process continues past 30
After surgical repair of the knee, orthopedic sur- weeks. Therefore, when determining time for prolonged
geons often have the patient’s knee placed in a con- stretching, the clinician must account not only for the
tinuous passive motion (CPM) machine or begin early patient’s tolerance but also for the scar tissue’s age.
Knee and Thigh 937
When using prolonged stretches, the rehabilitation the stretch weight should be decreased or removed to
clinician must tell the patient that the knee will feel stiff make a longer stretch tolerable. As the patient tolerates
once the stretch is released but that the stiffness should the stretch, either a weight can be applied or the stretch
resolve quickly. It may be difficult for the patient to time can be increased. Keep in mind that it would be
take the first few steps after a prolonged stretch. A more beneficial to increase stretch duration than weight.
prolonged stretch is more effective the longer it is If the stretch parameters are appropriate and the patient’s
applied, but it is also more difficult for the patient to tolerance adjusts, the patient may be able to eventually
tolerate. When the force is first applied, the patient may tolerate a 10 to 15 min stretch. These prolonged stretches
not feel that a stretch is occurring, but as time passes may be used as clinical treatments, home exercise pro-
he or she will feel the stretch. A patient may not be grams, or both. If severe restrictions are present, using
able to tolerate a prolonged stretch for more than 5 min prolonged stretches in both the clinic and the home to
initially. If this is the case, and a weight is being used, increase application frequency may be beneficial.
Prolonged Flexibility Exercises for the Knee

Prolonged stretches are indicated if the knee’s end-feel is hard rather than firm. Such an end-feel indicates
that the surrounding scar tissue is of sufficient strength that short-term stretches will not be as effective as
prolonged stretches. It is better to apply a low-level force for a longer time than a more intense stretch force
for a shorter time. If the stretch is of sufficient force, the patient may not feel a stretch when the prolonged
stretch is initially applied, but as the stretch remains, the patient will report feeling the stretch.
PROLONGED KNEE
EXTENSION IN PRONE
Body Segment: Knee.
Stage in Rehab: Resistive phase and beyond with a
recent injury; active phase if it is an older injury.
Purpose: Increase knee extension motion.
Positioning: Patient is prone with a pad under the
distal thigh and the leg hanging off the table (figure
23.17).
Execution: The patient relaxes the leg and maintains
this position for 10 to 15 min.
Figure 23.17
Possible Substitutions: Hip flexion or rotation or pelvis
flexion. If substitution occurs, a strap placed across
the hips and thighs and around the table will secure the extremity in position.
Notations: The prone stretch relaxes the hamstrings at its proximal end, so this position concentrates more
on the joint and its capsule. A weight on the ankle will increase the stretch force, but the weight should
start light and increase only as the patient tolerates. The hip and thigh should be secured as necessary to
prevent pelvis motion or thigh rotation during the stretch.
PROLONGED KNEE
EXTENSION IN LONG SITTING
Go to the online video and watch

video 23.18, which demonstra-
tes a prolonged knee stretch.
Body Segment: Knee.

Stage in Rehab: Resistive phase and beyond with
a recent injury; active phase if it is an older injury.
Positioning: The patient is sitting with the heel of the Figure 23.18
foot placed on another chair seat or table. The calf
is unsupported (figure 23.18).
Execution: The patient relaxes the lower extremity and allows gravity to pull the knee down. A weight may
be applied to the distal and proximal knee to increase gravitational forces.
Possible Substitutions: Hip lateral rotation and knee flexion.
Notations: Applying hot packs before and during the stretch may permit a greater tolerance for the stretch.
Keep in mind that because of the hip position, the hamstrings may be stretched as well as the capsule.
PROLONGED KNEE FLEXION

STRETCH
Body Segment: Knee.
Stage in Rehab: Resistive phase and beyond with a recent injury;
active phase if it is an older injury.
Purpose: Increase knee flexion motion.
Positioning: Patient is sitting in a chair with a pad around the
distal leg and secured with a strap (figure 23.19).
Execution: The strap is anchored to the back chair leg. The
strap is attached around the patient’s ankle and controlled by
the patient’s pulling on the strap. The patient is instructed to
pull the leg back to a point that feels tight but not painful. He
or she holds this position for several minutes before trying to
increase flexion further.
Possible Substitutions: Rotating the leg and thigh; not holding
the stretch long enough—a timer may need to be used.
Notations: An alternative method is for the patient to sit on the
Figure 23.19
floor with the foot against the wall. The patient moves the but-
tocks toward the wall until a stretch is felt in the anterior knee.
This position is maintained for 2 to 3 min before the patient moves the gluteals closer to the wall, then holds
that position for several minutes. The total time for the exercise is 10 to 15 min. With the patient in sitting,
the stretch force is applied to the joint and its capsule, not the muscle crossing it.
Once the knee flexes to 100° but still requires a prolonged stretch, the patient can be positioned prone on a
treatment table with a strap around the pelvis and another one around the mid-thigh. A rolled towel is placed
in the posterior knee and a strap is secured around the ankle. The knee is flexed to its end-flexion position and
secured with the ankle strap to prevent the knee from moving into extension. With the hip in extension, the
quadriceps is being stretched. It is advised to start the patient with a 5 min stretch and slowly increase the time
as the patient’s tolerance improves.
Knee and Thigh 939
Active Stretches stretching the muscle in this position is futile because

the muscle is contracting to maintain balance while
A number of active stretches are available to gain it’s being stretched.
knee flexibility. The important point to remember Active stretches are repeated several times through-
for each stretch is to position the muscle so it is not out the day. As discussed previously, either a 15 s
working during the stretch. A hamstring stretch that hold for about four repetitions or one 30 s stretch is
many athletes use, standing and bending over to touch recommended. When possible, the opposing muscle
the floor, is a good example of what not to do. The should relax the stretched muscle and produce a more
hamstrings hold the body upright in this position to effective stretch on the intended muscle. Common
prevent the person from falling forward; therefore, active stretches are presented in the following sections.
Active Flexibility Exercises for the Knee
WALL SLIDES
Body Segment: Knee (quadriceps).
Stage in Rehab: Active phase.
Purpose: Increase knee flexion motion, especially if the patient is non-
weight bearing (NWB).
Positioning: Patient is supine with buttocks about 60 cm (2 ft) or less
from a wall. A towel is placed under the foot that is resting on the wall.
Execution: The patient slides the foot down the wall, bending the knee
as far as possible (figure 23.20). The uninvolved extremity helps to return
the foot to the starting position. As motion improves, the buttocks are
moved closer to the wall.
Possible Substitutions: Rotating the hip laterally and hip abduction. The
hip, knee, and ankle should remain in good alignment with each other
throughout the exercise.
Notations: If the patient can tolerate more movement, he or she can
encourage more flexion by using the uninvolved extremity to push on
the top of the involved extremity at the ankle.
Figure 23.20
SEATED KNEE FLEXION

Purpose: Increase knee flexion after achieving 50° of flexion.
Positioning: Patient is sitting in a chair with both feet resting on the
floor. The uninvolved foot is placed on top of the involved limb’s ankle.
Execution: The uninvolved extremity pushes the involved knee into
flexion as far as possible (figure 23.21).
Possible Substitutions: Laterally rotating the hip, extending the hip,
abduction of the hip. The knee, hip, and ankle should all remain in the
same plane.
Notations: This exercise is used throughout the day to improve knee
flexion.
Figure 23.21
STANDING KNEE FLEXION

Purpose: Increase knee flexion once near-normal motion is achieved.
Positioning: Patient stands near a wall or table to use as support.
Execution: The patient grasps the foot behind the back and pulls it
toward the buttocks (figure 23.22). The knee should point vertically
downward to the floor during the stretch.
Possible Substitutions: Forward trunk flexion, hip extension or abduc-
tion, and lateral rotation of the tibia. Provide verbal cueing to correct
for improper execution.
Notations: If the patient cannot reach the foot because of insufficient
flexibility, he or she can use a stretch strap in standing. The strap is
wrapped around the ankle and grasped behind the back. The strap is
pulled to move the foot toward the buttock. An erect posture must be
maintained for this exercise.
Figure 23.22
Knee and Thigh 941
STATIONARY BIKE
Purpose: Increase knee flexion motion. This exercise is espe-
cially good once the patient has 90° of flexion and is at least
partial weight bearing (PWB).
Positioning: Feet are secured on foot pedals with straps. The
height of the seat should be such that at the bottom of the crank
position, the knee is near full extension (figure 23.23).
Execution: The patient uses the uninvolved extremity to guide
and control the involved extremity during pedaling.
Possible Substitutions: Ankle plantar flexion, hip hiking, or
shifting body weight to uninvolved side. Provide verbal cueing
to correct technique.
Notations: It is best to begin with a backward motion because
it is easier to achieve a full circle going backward than it is
forward. Once the patient is moving the pedals smoothly in
reverse, he or she can do forward cycling.
Figure 23.23
SUPINE HAMSTRING STRETCH

Body Segment: Knee (hamstrings).
Positioning: The patient lies supine with the unin-
volved extremity extended.
Execution: The involved knee is brought toward the
chest, and the hands are clasped behind the thigh.
The knee is then actively extended as far as possible
so that a stretch is felt behind the knee or in the thigh.
Possible Substitutions: Rotating the pelvis posteri-
orly. To prevent this from occurring, have the patient Figure 23.24
maintain the uninvolved hip and knee in extension
during the stretch.
Notations: A stretch strap can be used around the foot if it is too difficult for the patient to reach the thigh.
Another alternative is to have the patient lie supine in a doorway with the uninvolved extremity extended
into the doorway and the involved foot on the wall (figure 23.24). The stretch is released by bending of the
knee. As the patient’s flexibility increases, the buttocks are moved closer to the doorframe.
STANDING HAMSTRING STRETCH
Go to the online video and watch video 23.25,

which demonstrates a standing hamstring
stretch.
Body Segment: Knee (hamstrings).

Positioning: The standing limb is positioned with the foot facing for-
ward. The involved knee is kept extended during the stretch, with the
foot facing the ceiling.
Execution: The patient bends forward from the hips, not the back, and
tries to reach toward the toes with the opposite hand (figure 23.25). As
patient reaches forward with opposite hand, the motion occurs at the
hips with the chest up and the back straight. The standing foot should
face forward. Both knees should be straight.
Possible Substitutions: Using the same-side arm to reach forward,
flexing from the back rather than the hip, rotating the standing limb,
flexing the standing knee or the stretch knee. Reaching forward with Figure 23.25
the same hand allows trunk rotation. The back should remain straight
by keeping the chest raised and core muscles tense as the patient
leans forward from the hips during the stretch.
Notations: Standing hamstring stretches ensure stabilization of the pelvis because the supporting extremity
remains in extension during the stretch. The height of the surface on which the involved extremity is placed
depends on the patient’s flexibility. With very tight hamstrings, it may be best to begin the stretch with the
foot on a footstool or chair seat. As the patient’s flexibility improves, the height of the supporting object can
be raised. If flexibility is normal, a person should be able to touch the toes of the foot elevated to hip height
with the opposite hand. The patient should not bounce during this exercise. Contraction of the quadriceps
improves the flexibility during the stretch.
Strengthening Exercises stability,147 so exercises for these muscles are included

in knee rehabilitation. Although exercises for the trunk,
hip, and ankle are not discussed here, they should be
Strengthening exercises can begin early in a therapeu- included as part of the total therapeutic exercise pro-
tic exercise program even if the knee is immobilized gram for a knee injury.
or the patient is non-weight bearing. Isometrics help Strengthening exercises should not cause pain or
to increase strength and reduce pain.145 Once active swelling, either during or after the exercise. The cli-
motion is permitted, isotonic activities against grav- nician must solicit routine feedback from the patient
ity can progress to exercises against resistance in the about how the knee responds to exercises throughout
form of free weights, manual resistance, machine the program, especially during the initial treatment
resistance, body weight when weight bearing is per- phase and whenever there are increases in the pro-
mitted, and finally, isokinetic exercises, if available gram. Increased pain and swelling indicate that the
and appropriate. exercises are too severe. In the presence of these signs,
The rehabilitation clinician must bear in mind that the exercise intensity or severity must be reduced. It
some hip muscles and ankle muscles cross the knee is important not to provide too many new exercises
joint and must also be included in the rehabilitation for the same structure at one time; if the patient expe-
process. The hip and lateral thigh muscles act as riences increased edema or pain, you will not know
stabilizers for the knee and are important for knee which new exercise caused the problem. In the early
control.146 Trunk muscles also are important for knee phases of a therapeutic exercise program, it is better to
Knee and Thigh 943
provide a balance of exercises that include perhaps only Isometrics

one or two strengthening exercises for various deficient
areas rather than emphasizing only the quadriceps or Instructions for 10 s isometric exercises should em-
only the hamstrings. For example, the first treatment phasize a 2 s buildup of the muscle contraction to a
session’s strengthening exercises may include short-arc maximum level, a hold at the maximum level for 5 to
quads; manual resistance to hip abduction, adduction, 6 s,148 and then a 2 s decline to full relaxation before the
and extension; and hamstring curls. In this case, if the next repetition. A sudden contraction to maximal levels
patient returns with increased anterior knee pain, it is can cause discomfort and yields a less-than-optimal
likely that the short-arc quads caused the irritation. If result. You should also instruct the patient to repeat the
the patient had received short-arc quad exercises along exercise in sets of at least 10 several times throughout
with full-arc quad and standing squat exercises, it would the day. The following sections provide some sugges-
be difficult to determine the cause of the patient’s pain. tions for common isometric exercises. Other exercises
Once the cause of the knee’s reaction is established, it in these sections progress from non-weight bearing to
is easier to decide what exercises are appropriate. weight-bearing exercises.
Strength Exercises for the Knee

Since normal knee function involves a combination of open- and closed-chain activities, therapeutic exercises
for the knee should also include both types. The clinician, however, must be aware of the different types
of stresses in the various parts of the knee’s range of motion that are applied by open- and closed-chain
activities. As has been discussed, there are some injuries such as anterior and posterior cruciate ligament
injuries and patellofemoral injuries that should avoid resistance in specific ranges of open and closed motion
in the earlier phases of therapeutic exercises.
OPEN KINETIC CHAIN (OKC):

ISOMETRIC QUAD SET
Body Segment: Quadriceps.
Purpose: Strengthen quadriceps during early rehab
when the quadriceps is very weak and the patient
is NWB.
Positioning: Patient is sitting or supine with the knee
extended and the uninvolved knee flexed to relieve
back stress (figure 23.26).
Execution: The patient tightens the quadriceps, trying
to push the posterior knee into the table.
Possible Substitutions: Lateral hip rotation, knee Figure 23.26
flexion, knee abduction. Verbal cueing will correct
these substitutions.
Notations: Placing the hand on the quad to palpate for muscle tightening also helps facilitate a contrac-
tion.149 If the patient cannot feel a contraction, have the person perform the exercise with the uninvolved
quadriceps to feel a normal contraction before performing the isometric with the involved knee. If the
patient is still unable to facilitate a quad contraction, you can lift the heel of the involved limb off the table
about 15 cm (6 in.) and instruct the patient to hold this position as you reduce hand support. You should not
completely remove your hand, though, because the patient will probably not be able to hold the position
independently. A patient who has difficulty producing a quad set in supine can use an alternative position.
The patient lies prone with a rolled towel under the ankle, then tries to push the ankle into the towel roll to
facilitate quadriceps activation. The clinician should palpate the quadriceps to monitor active contractions
during the exercise. Electrical stimulation can also be useful for quadriceps facilitation if the patient cannot
produce a good quad contraction with an active exercise.
OKC: STRAIGHT-LEG RAISE

Purpose: Strengthen the quadriceps.
Positioning: The patient is supine with the unin-
volved knee flexed and the involved knee extended.
Execution: The patient first contracts the quadri-
ceps muscle, then raises the involved extremity off
the table about 20 cm (8 in.) and holds the limb at
that level for about 5 s (figure 23.27). The extremity
is then slowly lowered, and the quadriceps muscle
is not relaxed until the extremity is on the table.
Figure 23.27
Possible Substitutions: Hip rotation, hip abduction,
knee flexion.
Notations: The straight-leg raise is a hip exercise, but because it requires the quadriceps to hold the knee in
extension it is essentially an isometric exercise for the quadriceps, with the exception of the rectus femoris,
which also acts at the hip. The exercise becomes more difficult if the patient is in a long-sitting position
rather than supine. It also is more difficult if the hip is laterally rotated during the lift rather than in a neutral
position. Weights can also be used to increase the difficulty of the exercise, but whether or not weight is
used depends on the specific injury being treated. Positioning the opposite extremity with the foot flat on
the table reduces stress on the lumbar spine. The patient can sit upright to make the exercise more difficult
than in the supine position since the rectus femoris cannot work with the other quadriceps muscles.
OKC: HAMSTRING SETS

Body Segment: Hamstrings.
Purpose: Increase hamstring strength during NWB and immobilization of the knee.
Positioning: Patient is either sitting or supine with the knee in some flexion.
Execution: If in sitting, the patient places the uninvolved foot behind the distal involved extremity at the
ankle and pushes the involved leg against the uninvolved leg, maintaining maximum resistance for 5 s.
If in supine, the patient digs the heel of the involved limb into the tabletop, trying to flex the knee but not
changing the knee position.
Possible Substitutions: Hip rotation or hip extension.
Notations: If the knee is not immobilized, the exercise may be performed at different points within the range
of motion. Whether or not the patient is permitted to perform this isometric at different flexion positions
depends on the specific injury being treated.
Non-Weight-Bearing Isotonic resistive phase (III) of the therapeutic exercise program

even though the patient is non-weight bearing or partial
Exercises weight bearing. Open kinetic chain exercises can be useful
Some of these exercises may sometimes begin late in for strengthening in early resistance activities. The follow-
the active phase and certainly occur during the early ing sections include some suggestions for these exercises.
Knee and Thigh 945
OKC: SHORT-ARC
QUADRICEPS EXERCISE (SAQ)
Stage in Rehab: Late active phase or early resistive
phase.
Purpose: Strengthen the quadriceps in terminal knee
extension.
Positioning: A roll is placed under the knee to position
the knee in partial flexion. The patient is supine to use
the rectus femoris or is sitting to increase the diffi-
culty of the exercise by shortening the rectus femoris.
Execution: With the uninvolved knee flexed, the limb Figure 23.28
of the involved knee is lifted to position the knee in
full extension, and then returned to the starting position (figure 23.28). The patient holds the position in full
extension for about 6 s.
Possible Substitutions: Hip rotation or moving the knee through incomplete extension. Also, moving through
the range of motion too quickly uses momentum rather than muscle force.
Notations: This exercise applies a significant stress to the ACL; therefore, this exercise should not be used
early in rehabilitating an ACL injury or reconstruction. A weight or manual resistance can be applied to the
ankle to increase the difficulty of the exercise provided the injury is not a recent ACL or ACL reconstruction.
The size of the roll can vary, depending on how much of an arc is desired.
OKC: FULL-ARC QUAD EXERCISE

Stage in Rehab: Late resistive phase and into aggressive
phase.
Positioning: The patient sits in a chair or on the edge of a table
with the knees over the edge.
Execution: The foot is lifted slowly upward to fully extend the
knee (figure 23.29). As long as there is no pain and it is not
contraindicated because of the injury, manual resistance,
ankle weights, or rubber-band resistance can be used to
increase the difficulty of the exercise.
Possible Substitutions: Using the hip to move the knee through
its range of motion; moving the extremity through its motion
too quickly so that momentum rather than muscle strength
moves the limb.
Notations: This exercise is used with caution in early phase
III. The patellofemoral joint may be painful during the exercise; Figure 23.29
this is especially the case during the range of motion from
0° to 60° of flexion, because this range places more joint
reaction force on the patellofemoral joint. The ACL is also
stressed during the 0° to 60° arc of motion, so this exercise is
inappropriate for recent ACL injuries.
OKC: HAMSTRING CURLS IN PRONE

Stage in Rehab: Late resistive phase and into aggressive phase.
Purpose: Strengthen hamstrings.
Positioning: The patient lies prone with the foot over the edge of the table and the knee in full extension.
Execution: The knee flexes against gravity, manual resistance, a cuff weight, or a resistance band.
Possible Substitutions: Hip flexion or moving the muscle through a partial range of motion.
Notations: Maximal resistance in this exercise occurs in the beginning of the motion, in which the muscle
is strongest. This exercise is used with caution in early PCL rehabilitation.
OKC: HAMSTRING
CURLS IN STANDING
Stage in Rehab: Resistive phase and
into aggressive phase.
Purpose: Strengthen hamstrings.
Positioning: The patient stands and is
supported by the uninvolved extremity
and by the hands, which grasp a stable
object.
Execution: The knee is flexed against
cuff weights (figure 20.30a), manual
resistance, resistance bands (figure
20.30b), or pulleys, moving through a
full range of motion. a b
Possible Substitutions: Hip flexion Figure 23.30
and moving through a partial range of
motion.
Notations: In this position, maximum resistance occurs at the end of the knee motion, where the hamstring
is at its physiologically weakest position. This exercise is used with caution in early PCL rehabilitation.
Knee and Thigh 947
CLOSED KINETIC CHAIN (CKC):

TERMINAL KNEE EXTENSION
Go to the online video and watch video 23.31,

which demonstrates substitutions for CKC
terminal extension.
Body Segment: Knee.

Stage in Rehab: Resistive phase.
Purpose: Increase weight-bearing strength of the quadriceps in the
final degrees of knee extension.
Positioning: A rubber band is anchored around a stable object such
as an upright bar, doorjamb, or table leg. It is placed around the knee.
A pad or towel roll between the posterior knee and band will enhance
comfort. The patient stands facing the doorjamb or table with the knee
slightly flexed to 30° to 45°. The amount of body weight on the involved
extremity is as much as is required to maintain the foot flat on the floor;
most body weight is on the uninvolved lower extremity. The band is taut
at the start of the exercise.
Execution: The quadriceps muscle is tightened to straighten but not
lock the knee (figure 23.31). The position is held for up to 6 s and then Figure 23.31
slowly released. Patient repeats several times.
Possible Substitutions: Common substitutions for this exercise include lifting the heel off the floor, rotating
the hips, and bending the trunk.
Notations: If a four-way hip machine is available, it can be used for this exercise with the resistance bar
placed behind the distal thigh; the patient’s position is otherwise the same. A pulley system can also be
used in place of the rubber band.
Weight-Bearing Resistive ity.152 This discussion has been expanded by other

investigators, who demonstrate an increase in the
Exercises activity of the entire quadriceps when a ball is placed
Once the patient can bear weight on the injured knee, between the knees to facilitate hip adduction during
weight-transfer activities and gait training may be a squat 153 and leg press.154 Data reveal that it is not
necessary if the person has been on crutches, has possible to isolate VMO activity from that of other
been non-weight bearing or partial weight bearing, or muscles within the quadriceps,155 but if an increase
demonstrates an improper gait pattern. These activi- in quadriceps activity is desirable, then hip adduction
ties, discussed in chapter 22, include weight-transfer activity used simultaneously with squat exercises may
exercises on a scale, gait-training activities, and the increase quadriceps output.153 Controversy on this
use of a mirror to facilitate weight transfer and proper point exists since it has also been shown that activated
gait. Other weight-bearing exercise suggestions are hip muscles do not influence quadriceps activation if
presented in the following sections. analysis is performed using fine-wire electrodes, but
One note must be made of the wall squat exercise changes are observed when surface electrodes are
described later. Some clinicians place a ball between used;156 these results indicate that perhaps changes seen
the knees during this exercise to facilitate an increased with surface electrodes are actually due to cross talk
response from the vastus medialis, a result of this from hip adductors rather than increased quadriceps
exercise that was reported by an early investigation.150 activity.156 In summary, controversy exists within the
Later investigations, however, discount these findings research community about whether activation of hip
and show evidence that hip adduction activity during adductors simultaneously with quadriceps contraction
a squat does not produce an isolated increase in produces greater quadriceps activity150,157,158 or has no
VMO activity151 or any increase in quadriceps activ- impact on quadriceps output when hip adductors are
activated.152,159-162 Since there is disagreement among useful once weight bearing is permitted. The station-
investigators on this point, additional research must be ary bike produces about half as much stress on the
completed before the benefit of hip adduction activity tibiofemoral joint as does walking;163,164 it can also be
during a squat can be considered indisputable. used for strengthening and cardiovascular condition-
ing. Step machines used with controlled degrees of
Reciprocal Training knee motion, and the ski machine, facilitate strength,
A machine such as a stationary bike, a treadmill for motion, reciprocal motion between the right and lower
gait training, a step machine, or a ski machine can be extremities, and cardiovascular conditioning.
CKC: LEG PRESS

Body Segment: Knee and hip; possibly ankle.
Purpose: Strengthen quadriceps and gluteus max-
imus. May also strengthen plantar flexors if plan-
tar-flexion motion is incorporated.
Positioning: Depending on the specific brand of
machine, patient is sitting, semi-reclined, or fully
reclined with feet on a platform; knees and hips begin
in flexed positions.
Execution: Patient pushes the platform with the
lower extremities, extending the hips and knees
(figure 23.32). If also strengthening plantar flexors, Figure 23.32
the patient pushes the platform with the feet to move
the ankles into plantar flexion. If the machine is to be
used only for plantar flexors, the patient begins the exercises with the knees extended.
This machine can be used in a variety of ways:
1. In the supine or seated position, this exercise can provide resistive concentric and increased eccentric
activity if the patient pushes off the platform and catches him- or herself as the feet return to the platform.
The speed of this exercise depends on the force with which the patient pushes off the platform and the
amount of resistance used.
2. If the patient is in a prone tripod position on elbows and knees with the involved foot on the platform
(in a position reverse to the normal position on the machine), the foot is placed high on the platform to
facilitate the quads and hip extensors. In this position, the patient performs a slow and controlled motion
with special attention to gaining full knee extension.
In the prone tripod position, the patient can also perform a rapid push-off and eccentric catch; however, the
faster speed is more difficult and should be used with caution only after the patient has demonstrated proficiency
with the slower exercise.
Possible Substitutions: Collapsing the knee into a valgus position, not moving through a complete range of
motion, rotating the hip, or moving the machine too quickly to use momentum rather than muscle force. The
hip, knee, and ankle should remain in alignment with each other throughout the exercise.
Notations: The patient performs the exercise using both lower extremities or using just the involved limb to
isolate the involved extremity. To reduce patellofemoral stress, the foot should be positioned on the platform
so the knee is flexed no more than 90° in the starting position.
Knee and Thigh 949
CKC: WALL SQUATS

Purpose: Strengthen quadriceps.
Positioning: The patient stands with the back to the wall and the feet
in front of the body.
Execution: Patient squats to bend at the hips and knees, but the knees
should remain behind the ankles so the leg does not go beyond a line
perpendicular to the floor. The patient can hold this position in an iso-
metric hold for several seconds or move up and down without pausing
in the low position. A Swiss ball placed between the wall and the patient
allows the patient to perform a smoother squat motion and prevents dye
in the patient’s shirt from rubbing off on the wall.
Possible Substitutions: Common errors with this exercise include posi-
tioning the feet too closely to the wall so that knee flexion goes beyond
90°, placing more weight on the uninvolved extremity, and hiking the hip
so that the knee does not flex as much.
Notations: If the patient is reluctant to bear weight equally on left and
right extremities, a small platform placed under the uninvolved foot can
facilitate increased weight bearing on the involved extremity. If the knee
flexes to more than 90°, patellofemoral stress increases and pain may Figure 23.33
result. The deeper the squat, the farther away from the wall the feet
are positioned, so the knee is never flexed more than 90° in the maximum squat position. Ways to advance
this exercise are to increase the repetitions or sets; to increase the depth of the squat (as long as the knee
does not move in front of the ankle in the end-squat position); or to have the patient perform the exercise
with only one extremity (figure 23.33), placing the uninvolved extremity on a stool or step. The tibia should
be perpendicular to the floor at the lowest patient position. As the patient squats deeper, the feet must be
moved farther from the wall. The clinician should observe for substitutions and correct as necessary to
ensure correct performance of this exercise.
CKC: PLIÉ
Positioning: The patient stands with the feet in a wide stance with the
hips and feet turned outward about 45°.
Execution: The buttocks are squeezed as the patient slowly bends the
knees, keeping the knees in line with the second toes (figure 23.34).
Possible Substitutions: Not aligning the knees over the second toes;
allowing the knees to move into a valgus position; not keeping the weight
evenly distributed over right and left lower extremities; and not keeping
the back straight.
Notations: The back should remain straight so that as the patient flexes
the knees and hips, the trunk leans forward; the pelvis should not be
allowed to move into a posterior tilt.
Figure 23.34
CKC: LUNGE
Body Segment: Quadriceps and hip extensors.
Purpose: Strengthen quadriceps and gluteals.
Positioning: The patient stands with the feet in a forward–backward
stance with the involved extremity in front.
Execution: The quadriceps and buttocks are tightened, and the weight
is shifted to the front extremity as the patient bends the knee (figure
23.35). This position can be held for several seconds, or the patient can
be instructed to walk across the floor in this manner. As the patient
progresses forward, the body weight is lifted toward the front foot by
the front limb, not pushed forward by the back limb.
Figure 23.35
Possible Substitutions: Common errors are to allow the arch to depress
and the knee to move into a valgus position. The knee should not move
forward ahead of the foot. The leg position with the floor is no more
than perpendicular to the floor. How this exercise is specifically performed (regarding the knee angle) is
determined by the type of injury and where it is in its healing phase.165
Notations: Weights placed in the hands increase the resistance of this exercise. Performing the exercise
on an incline also alters the resistance. The back should remain straight with the patient in a pelvic neutral
position throughout the exercise. Correct execution of this exercise is important to obtain desired results
and prevent excessive stress on injured knee structures.
CKC: MINI-SQUATS
Body Segment: Quadriceps and gluteals.
Purpose: Strengthen the quadriceps and gluteals.
Positioning: The patient stands with feet shoulder-width apart and toes
turned slightly outward.
Execution: Keeping the weight equally distributed, the patient squats to a
comfortable position, maintaining the knees in alignment with the second
toes. The back remains straight as the patient squats, so the hips flex and
move posteriorly and the pelvis remains in neutral throughout the exercise.
Possible Substitutions: Common errors are valgus movement of the knees,
trunk flexion, and hip hiking on the involved side to reduce knee flexion.
If genu valgus is observed, the patient should be instructed to keep the
knees over the second toes and to arch the foot; trunk flexion is corrected
with verbal cueing for a straight back with chest up and instructions to
push the hips back and to keep the chest up; hip hiking is corrected with
instructions to bend the knee more and keep the hips level. Using a mirror
to provide the patient with additional feedback is often beneficial.
Notations: In a progression of this exercise, the patient grasps a band
that is anchored under the feet to increase resistance for home exer- Figure 23.36
cises. Holding weights in the hands increases eccentric and concentric
resistance. Performing the exercise on only one extremity increases the
difficulty (figure 23.36).
Knee and Thigh 951
CKC: SIT-TO-STAND
Body Segment: Quadriceps and gluteals.
Purpose: Strengthen quadriceps in midrange and gluteals.
Positioning: The patient sits in a chair with both feet on the floor under the knees.
Execution: Without using arms for assistance, the patient moves in a slow and controlled manner from the
sit position to standing and then returns to the chair. The knees should remain in line with the second toes;
weight should be equally distributed over right and left extremities; and the back should remain straight
with the chest up and the pelvis in neutral.
Possible Substitutions: Common errors in this exercise include shifting the weight to the uninvolved side,
bending the trunk, jerking up, and dropping down into the chair. Correction techniques are verbal cueing,
using a mirror for visual feedback, or using a higher chair or placing a pad in the chair and later advancing
to a lower seat height as strength improves.
Notations: Once the patient meets the goals of this exercise, he or she can advance to a single-limb exercise.
CKC: GOOD MORNINGS

Body Segment: Hamstrings and gluteals.
Purpose: Strengthen the hamstrings and gluteals.
Positioning: The patient stands with feet shoul-
der-width apart facing a pulley or wall anchor for
rubber tubing. The handle for the pulley rope or rubber
tubing is held by the hand on the unaffected side. The
pulley or wall anchor is in a low position, and the patient
stands with the elbow extended and the arm away from
the side with the tubing taut.
Execution: Keeping the elbow extended, the patient
leans forward by flexing the hip until the trunk is parallel
to the floor as the unaffected lower extremity is raised
in hip extension so the limb remains in the same plane
as the trunk. The chest remains elevated so the back
does not flex as motion occurs from the hip, using the
gluteals and hamstrings eccentrically to flex the hip
(figure 23.37).
Possible Substitutions: Common errors are flexing the
back rather than the hip, not flexing the hip far enough,
laterally rotating the hip, placing the handle in the
same-side hand so the trunk rotates, or not elevating
the uninvolved lower extremity high enough as the
trunk is lowered.
Notations: In a progression of this exercise, the resist-
Figure 23.37
ance or repetitions are increased. The patient may have
difficulty with balance during the early attempts at this
exercise, but as balance and strength improve, stability during this exercise also improves.
Variations of this exercise include other exercises such as picking up cups or cones from the floor. In this
exercise, paper cups or cones or other objects are placed around the patient on the floor. The patient reaches
down to pick them up, flexing from the hip while keeping the back straight and extending the uninvolved lower
extremity posteriorly during the hip flexion motion to make the activity a single-limb stance activity and provide
counterbalance as the patient picks up the object.
Step Exercises
The patient should not try these exercises until he or
she can bear weight on the involved extremity in a
single-limb stance position. Proper weight transfer is
also a prerequisite for these exercises. The step height
may begin at a low level, around 10 cm (4 in.) and
increase to 20 cm (8 in.) as the patient gains strength
and knee control. The rehabilitation clinician watches
the patient perform the exercise and corrects errors as
needed. The patient performs the exercise in a slow
and controlled manner. As with other weight-bearing
resistive exercises, the knee remains in line with the
second toe throughout the motion. The knee should
achieve extension at the top of the exercise, but it
should not lock in extension. During initial perfor-
mance of these exercises, patients often demonstrate
poor knee control, evidenced by wobbling of the knee
as the person raises and lowers body weight. With
strength gains, knee movement becomes steady with
no lateral knee motion.
Common errors for these exercises include several
mistakes for which the clinician observes and corrects,
as indicated. These errors include flexion at the hip
Figure 23.38 Forward step-up.
and trunk to reduce the amount of quadriceps activity
required, locking the knee in the extension position
to reduce the need for muscular control, hip hiking down to the floor, controlling the rate of descent with
to reduce the amount of knee flexion in the lowered the involved extremity.
position, jerking up and dropping down rather than
maintaining a smooth and controlled motion, moving Forward Step-Down This exercise strengthens
the knee into a valgus position and flattening the the quads and gluteal muscles. This exercise em-
foot's longitudinal arch, and pushing off with the phasizes the eccentric portion of the step activity. It
uninvolved limb. Usually, corrections for these errors stresses the knee more than the step-up exercise does
require verbal cueing and placing the patient in front because the patient is moving forward on the extrem-
of a mirror for visual feedback during the exercise. If ity and the knee must move in front of the foot. If the
pushing off with the uninvolved limb, dropping down exercise causes knee pain, the patient should perform
or jerking up, and trunk and hip flexion are not cor- the exercise on a lower step, but if pain also occurs on
rected with these cues, the height of the step may be the lower step, the exercise should be deferred until
too great for the patient’s strength limitations; in this knee control and strength increase. The patient stands
case, it is better to use a lower step. on a step and slowly lowers the uninvolved extremity
These exercise goals are advanced by increasing the to the floor so the heel touches the floor first (figure
numbers of repetitions and sets, increasing the depth 23.39). The patient then returns to the start position,
of the step, and adding weights to the hands. lifting the body up and backward. The patient should
not push off with the uninvolved extremity or use the
Forward Step-Up This exercise strengthens the hands except for balance.
quads. The patient stands facing a step with the in-
volved extremity on the higher step. The patient Lateral Step-Up This exercise strengthens the
shifts the weight to the involved extremity and moves quads and isolates the quads more than the other step
the uninvolved extremity up onto the step, straighten- exercises. The patient stands sideways on a step, with
ing the involved knee to lift up the body onto the step. the involved extremity on the step and the uninvolved
The patient should not push off with the uninvolved extremity on the ground. Only the heel of the unin-
limb (figure 23.38). He or she then reverses motion volved extremity is in contact with the ground; the
to return to the starting position, stepping back and toes remain off the ground throughout the exercise.
Knee and Thigh 953
Figure 23.39 Forward step-down. Figure 23.40 Lateral step-up. Careful observation is
important to ensure proper execution of this exercise.
The patient lifts the body up to the step by tighten-

ing the quads and gluteals (figure 23.40). The patient
Machine Exercises
then slowly returns the uninvolved extremity’s heel A number of machine and weight exercises are avail-
to the floor. If the patient flexes at the trunk, the ham- able for strengthening the knee. Some units vary in
strings are working rather than the quadriceps, so features or style from one brand to another but have
the patient is instructed to maintain an erect trunk or underlying similarities and exercise the same muscles
tighten the gluteals during the exercise. If the patient or muscle groups. Available equipment varies from
feels the exercise more in the lateral hip than in the one facility to another according to budget, space,
quadriceps, the patient is using the gluteus medius and staff preferences. Whatever equipment is used,
muscle to lift the body rather than the quadriceps; in it is imperative for the rehabilitation clinician to be
this case, instruct the patient to flex the knee more familiar with the machine, with the instructions for
and keep the hips level as the uninvolved extremity is use and the indications, and with the precautions and
lowered to the ground. dangers before using it with patients. The following
You can provide additional overload by requiring sections describe exercises with a few of the more
the patient to land the heel of the uninvolved extremity commonly used machines.
away from the step, abducting the involved hips as the
extremity lowers to the floor. Increasing the step height Knee Extension
is another way to increase the difficulty of the exercise. This machine is used with caution. I do not often use
it because of its potential for injury to the patellofem-
oral joint and ACL. It provides an open kinetic chain
exercise that produces patellofemoral compression
forces that progressively increase from lower levels at
video 23.40, which demonstrates
substitutions for lateral step full extension to increasing levels as the knee moves
exercises. to 90° of flexion.166 Open kinetic chain exercises place
the greatest shear stress on the ACL at 15° to 30° of
\I
E
ID
knee flexion.118 It is essential that if an open-chain knee

extension machine is used, it is used cautiously and
in limited degrees of motion. Patients’ pain and your
knowledge of joint stresses are your primary guidelines
when using this machine. As a general rule of thumb,
if pain occurs during a machine exercise, either the
motion through which it is used should be restricted or
the weight should be reduced. If pain still occurs with
these changes, it is not used.
I mention the knee extension unit here, not because I
advocate its use, but because many facilities have such a
unit, so it is important for the rehabilitation clinician to
be aware of it and its potential hazards. It can be effective
if used properly.
The patient sits with the ankle behind a weighted
bar. To facilitate the rectus femoris, the patient inclines
backward with the weight on the hands behind the hips.
Some machines have the backrest positioned so the
patient is naturally reclined. The patient then extends Figure 23.42 Squat exercise can be performed on a variety
the knees (figure 23.41). of equipment types including a bench-press or calf-raise unit if a
squat machine or squat rack is not available.
Squat
This exercise strengthens the quads and hip extensors.
It is an advanced exercise that is not performed until a remain in line with and behind the second toe. The illus-
patient has demonstrated good strength and knee control tration demonstrates the exercise with a barbell, but the
with the step exercises and other closed-chain activities exercise can also be performed with adaptable machines
2, previously outlined. It is commonly placed in the latter such as a bench-press or heel-raise unit.
part of the resistive phase.
With the feet about shoulder-width apart, the weight Hamstring Curl
is placed on the patient’s shoulders. Keeping the back This exercise strengthens the hamstrings. Depending on
straight, the patient squats to no more than a 90° angle the machine, the patient may lay prone, stand, or sit on the
at the hips and knees (figure 23.42). The knees should unit with the machine secured around the posterior ankle.
The knee begins in an extended position, and the patient
flexes the knee (figure 23.43). A common substitution
with this exercise is flexing the hips to gain additional
length for the hamstrings; the clinician should provide
verbal cues if substitution occurs.
Isokinetic Exercises
Isokinetic exercises for the quads and hamstrings usually
begin after the patient has demonstrated control in isotonic
exercises and the injured tissue is strong enough to toler-
ate the stresses applied with isokinetic activities. Ham-
strings and quadriceps can be exercised isokinetically,
isometrically, or eccentrically on isokinetic machines.
If facilitation of the rectus femoris is desired, the seat
back should be reclined to extend the hip (figure 23.44).
The hamstrings can be exercised in a seated position to
maximize output at the knee or in prone. Many clinics do
not have isokinetic equipment; they are not essential to
Figure 23.41 Knee extension machine can be an effective a successful rehabilitation program, but when available,
therapeutic exercise tool if used correctly. they are useful tools for both testing and strengthening.
Knee and Thigh 955
Figure 23.43 Machine hamstring curl.
Proprioception Exercises
Just as with other injured areas, balance, agility, and
coordination must be restored after knee injury or sur-
gery. Proprioception is basic to these parameters. Early
proprioception exercises in phase II before weight Figure 23.44 Isokinetic machine setup for knee exercises.
bearing can include a variety of activities. For example,
with eyes closed the patient can move the involved knee
to mimic the uninvolved knee’s position, or with eyes
Plyometric exercises with boxes develop agility and
closed the patient can position the knee at a designated
power in preparation for functional exercises. These
angle. With the latter activity, the clinician measures the
plyometric exercises are discussed in chapter 22 and
angle to determine the patient’s ability to produce it.
are shown in figure 22.55.
Weight-bearing proprioception exercises are similar
During all of these proprioception activities, the
to those discussed for the ankle in chapter 22. The
clinician monitors and corrects the patient’s perfor-
patient performs stork standing (single-limb stance) on
mance. For example, if the patient does not maintain
the floor with eyes open (figure 23.45a), eyes closed,
the body’s center of mass over its base of support, it is
and with eyes open while rotating the head to left and
indicative of poor core control, so core control must be
right before advancing to stork standing on unstable
addressed before the patient progresses. If the patient
surfaces such as the BAPS board (figure 23.45b),
cannot perform accurate jumping activities on targets,
trampoline (figure 23.45c), or foam rollers.
then the targets should be spaced closer together so
The next progression is to make the balance activ-
that the patient is able to perform the activity cor-
ity more challenging and to facilitate change from a
rectly. If the patient does not maintain balance during
conscious to a subconscious activity. For example, the
a single-limb stance on an unstable surface, then the
patient performs a distracting activity while maintain-
clinician provides the patient with verbal cues that will
ing balance on an unstable surface such as standing on a
improve balance; for example, “tighten your quads and
foam roller while using an upper-extremity device such
your glutes,” or “focus on one object in front of you.”
as a B.O.I.N.G., Body Blade, or other device (figure
23.46). Another example is shown in figure 22.52a.
Other balance and proprioception exercises include
activities on balance boards, the Fitter, and slide Functional and
boards. Activities that develop agility, coordination,
and balance include jumping activities against a
Performance-Specific
resistance band with both lower extremities and then Exercises
with just the involved extremity; treadmill activities
such as retro-walking, side shuffle, and cariocas; and Many of the functional and performance-specific exer-
bilateral and unilateral hopping and jumping activities. cises used for the knee are similar to those discussed
a b c
Figure 23.45 Single-limb stance balance progression: (a) on ground, (b) on BAPS, (c) on trampoline.
direction; backward running with sudden changes to

forward running; sprinting; running circles in clock-
wise and counterclockwise directions; 90° cuts to
the left and to the right; and sport-specific drill and
skill activities. Performance-specific drill and skill
activities are dictated by the patient’s specific sport
or work-activity requirements. Because running, rapid
direction changes, and reliance on both lower extrem-
ities are vital to most sport participation, the running
and hopping activities are universal and should be a
part of most therapeutic exercise programs. These are
discussed in detail in chapters 9 and 22.
Before returning to full participation, the patient
must undergo an examination of performance-specific
activities. This examination uses many of the exercises
and activities the patient has been performing in the
aggressive phase of the therapeutic exercise program.
a b
The patient should be able to perform all of these activ-
Figure 23.46 Beginning- and advanced-level distracting ities without psychological or physical impediment and
balance activities: (a) on 1/2 foam roller, (b) on foam roller.
should demonstrate equal use and performance with
both lower extremities in all tests performed.
in chapter 22 for the ankle. The exercises vary more

according to the patient’s activity demands than the Special Rehabilitation
specific injury because a safe return to full participa-
tion depends on the entire lower extremity’s ability to Applications
withstand stresses and perform properly, regardless of
the segment injured. This section deals with specific injuries to the knee
Functional activities include single, double, and and thigh. The more common knee injuries and their
triple hops; zigzag runs with sudden changes in therapeutic exercise programs are discussed.
Knee and Thigh 957
Ligament Sprains differences between surgically repaired and non–sur-

gically repaired ACL ruptures indicate no differences
Any ligament in the knee can become injured if the in osteoarthritis and functional abilities, but those
stresses applied are sufficient to exceed the ligament’s patients who did not undergo surgical reconstruction
tensile strength limits. Depending on the magnitude developed meniscal damage and instability.180 Until
and direction of the forces applied, a single ligament more definitive and universal criteria are established,
or multiple structures can incur injury. For the sake of these results seem to indicate that active persons would
simplicity, this discussion focuses primarily on injuries benefit from surgical repair of a ruptured ACL.
to individual ligaments. Studies have demonstrated that surgical repair
Anterior Cruciate Ligament Sprain produces the best outcomes when performed after the
inflammation has subsided and full range of motion has
The anterior cruciate ligament (ACL) is the knee lig-
been restored.181,182 Most surgeons perform ACL recon-
ament that is most often sprained.167 Considerations
struction surgery within 3 to 6 weeks after injury.181
unique to this ligament are discussed here, and then a
If a patient elects to have reconstructive surgery, best
case study is presented.
recovery of motion and return to participation results
Although daily activities apply around 454 N (~102
also occur when surgery is delayed.
lb) of stress to the ligament, it can tolerate up to 1,730
Over the years, many types of reconstructive surger-
N (~389 lb) before it ruptures.168,169 It is in a position
ies for the ACL have been tried. Surgical techniques
of maximum stress when the knee is either in about
continue to evolve, but currently the most common
the last 30° of extension or experiencing multiplanar
reconstructive procedures use either an autograft from
loading.170 The ACL is most typically injured during a
noncontact event when the knee is in slight flexion and the patient’s patellar tendon or the medial hamstring
experiences a valgus rotation in a foot-planted position tendons or an allograft.183 There are proponents for
as the athlete decelerates.171 The athlete is often per- each technique, but the evidence indicates there is
forming a cutting maneuver, and the injury can occur essentially no difference in long-term outcomes
with or without contact with another person. Sudden between any of the three techniques.184-186 Surgeon
knee hyperextension with rotation, moving the knee preference may be the primary factor in the choice
into a valgus position is another mechanism of ACL of technique.187 The patellar tendon graft technique,
injury.172 Although it is likely to be a multi-factorial which uses the central third of the patellar tendon with
issue,171 there is evidence to demonstrate that females bone-plug ends from the patella and tibial tuberosity,
have more ACL injuries than males because females is known as the BPTB, or bone–patellar tendon–bone
use different landing strategies during jumping than technique, and is considered the gold standard for
do males.173,174 It has been observed that women use anterior cruciate ligament reconstructions.184 Parts
less knee and hip flexion than men during landing of this technique are performed arthroscopically, and
and stop-jump activities, causing greater activation it involves either one or two surgical incisions. The
of the quadriceps than the hamstrings and increasing semitendinosus and gracilis are used in the hamstring
ACL stress.175 These studies provide interesting if not tendon procedure, which is also a combined open and
compelling evidence for the need to alter women’s arthroscopic procedure. Advocates of the hamstring
conditioning programs and muscle activation strategies tendon graft procedure contend that subjects who
to prevent or reduce ACL injuries. receive hamstring tendon grafts have fewer donor-site
When the ACL is injured, it is often only one of the complications and regain quadriceps strength faster.188
structures injured.176 In these instances, the surgical Of the hamstring grafts, the double-bundle grafts are
repair is usually delayed.177 Additionally, when more better than the single-bundle grafts.189 Allografts may
than one structure is injured, the rehabilitation process be the graft of choice if the reconstruction is on a young
becomes more complicated because it must address patient or is a repeat surgery with the patient reinjuring
considerations other than those related to the ACL. a previously replaced ACL.184 Allografts have been
Once a person sustains an ACL injury, the decision shown to heal more slowly than autografts, but 1 year
about surgery must be made. To date, there is no spe- after surgery, there is no significant difference between
cific system of determining a patient’s candidacy for allografts and autografts.190 More than graft selection,
undergoing ACL reconstruction.178 Most often, factors the choice of anchor systems for the graft appears to
determining a person’s candidacy for ACL reconstruc- be most important.186
tive surgery include age, activity level, desire to return Regardless of the graft and anchor system selected by
to full participation, and knee instability.179 Long-term the surgeon, the rehabilitation clinician is responsible
for returning the patient to optimal performance levels. damage the reconstructed ACL, placing undue stress
Rehabilitation after ACL reconstruction follows two on the structure and advancing osteoarthritis within the
schools of thought, one for delay and the other for joint.180 Therefore, before performing an ACL recon-
acceleration; the better course of action remains struction, the surgeon will repair the meniscus; in these
controversial.191 Some clinicians advocate using the cases, postoperative weight bearing may be limited
accelerated program with competitive and serious or delayed in order to protect the meniscal repair.197
recreational athletes but a more conservative program When you design a specific ACL rehabilitation pro-
with less serious recreational athletes.192 Of these gram for a patient who has undergone reconstructive
camps, members of both groups commonly prefer surgery, key considerations must include the type of
weight bearing to tolerance after surgery.181 Those in graft and fixation used, the type of surgery performed,
the delayed-program camp are concerned about the the surgeon’s rehabilitation preferences, and other
vulnerability of new tissue and believe that stressing injuries present. Although exercise timing is different
the tissue too soon will risk detachment at the graft site, in delayed and accelerated programs, the exercises and
compromise the graft, and render the joint unstable. the progression are essentially the same.
A conservative program restricts running until about Two program timing progressions are provided
the fifth or sixth month, with full return to activities here as examples of an accelerated and a delayed ACL
occurring 6 to 9 months after surgery. program. In actuality, a patient’s program may be
Those advocating the accelerated program for ACL accelerated or delayed or may be a combination of the
reconstructions believe that there are fewer complica- two approaches. Communication with the physician
tions from the surgery when such a program is used.193 about the patient’s progression is crucial to a safe and
In the accelerated program, running activities begin successful rehabilitation outcome. You must assess
after 12 weeks, and the patient can return to full par- the patient at the start of each treatment session and
ticipation in 5 to 6 months. Although the accelerated during the session to determine the appropriateness of
rehabilitation patients are stronger at 3 months postop- the activities. Advancement is based on achieving the
eratively, long-term results demonstrate no differences set goals, so you must assess the patient to determine
overall between the two groups.194 when these goals are achieved.
Histologically, the ACL graft undergoes necrosis If the patient reports pain with any exercise, the
and remodeling once it is transplanted. Initially it is clinician must not only identify where the pain is
avascular, but revascularization occurs at 6 to 8 weeks located but the cause of it. Sometimes patients report
and is completed around 12 weeks postoperatively.195 “pain” when what they describe is the burning sen-
Once the graft is inserted, it goes through a process sation of muscle fatigue. If a patient has pain with a
of necrosis and disintegration followed by tissue specific exercise, the clinician should first inspect the
rebuilding. Because of this process, regardless of the patient’s performance in case incorrect execution is
graft material used, the ACL replacement is weakest causing pain. If the patient performs the exercise cor-
during the first 6 weeks after reconstructive surgery.190 rectly, the next step is to either reduce the intensity of
As part of the healing process, new collagen is formed the exercise or remove the exercise from the program
around the existing matrix of the graft, maturing the until the patient can tolerate the elevated stress of that
graft site and allowing it to manage progressively specific exercise.
greater applied stresses. It may take at least a year for
the graft to appear histologically normal, but it never Accelerated Post-Op ACL Reconstruction
regains normal tensile strength.196 Although the precise Program In an accelerated program, the patient
load-tolerance levels of ACL grafts are not known, it is ambulates with crutches, weight bearing to tolerance
agreed that some mechanical stress is beneficial to the with full knee extension, immediately after surgery.
healing graft.195 For this reason, most surgeons encour- Two days after surgery, passive knee extension to 0°,
age weight bearing, either full or limited, immediately active hip exercises including straight-leg raises, and
after ACL reconstruction. ankle range-of-motion exercises begin. The patient
If the medial meniscus is injured along with the may wear a knee brace, but it is set at 0° extension.
ACL, it must be repaired to ensure a successful out- During the second week, active range-of-motion
come of the ACL reconstruction surgery.180 This repair exercises for the knee begin, as do patellar mobiliza-
is important because the meniscus provides stability tion and soft-tissue mobilization. By the end of the
to the knee; when the meniscus is injured, the knee second week, the patient should be ambulating without
joint’s stability is compromised. An unstable knee will crutches, but he or she continues to use the brace that
Knee and Thigh 959
is now unlocked to allow 0° to 120° of motion.198 Gait uninvolved knee, and proprioception is good in static
training for proper heel-toe ambulation may be nec- and dynamic balance activities.
essary. The brace is worn for about 3 weeks, and then During the fifth to the sixth month, the program con-
discarded.198 In either case, the patient is not allowed tinues into phase IV with strengthening and flexibility
to ambulate without the brace until the patient has full exercises and advances to more functional activities as
active knee extension; allowing the patient to ambulate the patient prepares to return to full sport participation
with a partially flexed knee increases meniscal stress or normal work activities. Because the physician often
and accelerates joint degeneration.199 Closed kinetic relies on the rehabilitation clinician for the information
chain activities such as mini-squats and stationary-bike needed to determine the patient’s readiness to return to
exercises with minimal tension begin during the second full participation, the clinician performs an appropriate
week. Hamstring curls, toe raises, and range of motion examination before consulting with the physician.
to 105° are included at this time. Before returning, the patient must pass all aspects
By the third week, the brace may be removed if of the performance-specific examination; have full
the patient has full knee extension and the physician’s motion, strength, and normal proprioception; and be
protocol indicates it. The patient can exercise in the pain free without edema after exercise. This program
pool; can add other exercise equipment, such as the is condensed into a timeline in figure 23.47.
ski machine and the stepper with no more than a 10
cm (4 in.) step height; and can leg press through a 45° Conservative Post-Op ACL Reconstruction
range of motion. Other exercises include half squats Program A delayed program has the same pro-
to 45° and hamstring curls. The patient can do stork gression of exercises, but they are introduced in the
standing if weight transfer during ambulation is cor- program at a slower rate. Weight bearing progresses
rect. If weight transfer is not correct, then using the from weight bearing as tolerated to full weight bear-
weight scale for weight-transfer training is beneficial. ing with the brace locked in extension for one week.
By the end of the first month, the patient should have The brace is used to perform straight-leg raises. The
115° of flexion and full extension. Tibiofemoral joint brace is unlocked after 1 week, but the patient re-
mobilizations are used at this time if capsular tightness mains on crutches. During the first 2 weeks, hip exer-
and restriction are evident. The patient is now using cises with the brace on, heel raises, and quad sets are
the stepper machine and performing wall squats, heel the strength exercises with which the patient starts.
raises, lunges, lateral step-ups, and forward step-ups. The patient can remove the brace to perform wall
None of the exercises should produce pain or edema or slides to 45°, heel slides, and prone hangs with the
give the patient the sensation of increased knee laxity. foot over the edge of the table for range of motion.
During weeks 6 to 8, if the patient has full active When the patient can perform a quad set with good
extension and flexion to 115° to 120° along with good quadriceps control in full extension, the crutches are
isometric quadriceps strength, he or she should ambu- removed, but the brace wear requirement continues
late without the brace if it has not yet been discontin- throughout the first 6 weeks. Patellar mobilization
ued. Active knee extensions within 100° to 30° and a starts during week 2, and electrical stimulation and
treadmill walking program are implemented during modalities for pain and edema begin during the first
this time. Research has demonstrated that a treadmill week. During the first week, stretching exercises for
set at an incline slightly greater than 12% reduces ACL the hamstrings, gastrocnemius, ITB, and quad sets
strain and patellofemoral strain but recruits greater occur. Cardiovascular activities are limited to an up-
quadriceps activity, and thus may be beneficial for per-body ergometer or unilateral stationary cycling
ACL and patellofemoral rehabilitation programs.200 using only the uninvolved extremity.
During the weeks leading up to the third month, Other exercises are not added until week 6, when
the exercises that the patient has done so far continue, the patient can remove the brace and has good quadri-
progressing in weights, sets, or repetitions as tolerated, ceps control in knee extension. The patient begins
provided they do not produce pain or edema. Plyomet- stationary-bike exercises with both lower extremities,
rics begin by week 12 along with jogging activities. wall squats to 45°, leg press to 45°, lateral step-ups,
By the third to fourth month, the patient progresses forward step-ups, backward step-ups, heel raises, and
to running and sprinting. During this time the patient static balance activities. Pool walking and jogging may
advances to agility drills, more aggressive plyometrics, begin at this time as well.
and performance-specific drills providing full range From 6 to 8 weeks to 5 months, the patient achieves
of motion is present, strength is about 80% that of the normal gait and full range of motion of the knee. Leg
ACL RECONSTRUCTION
Stage I: Passive phase
0–3 weeks Inflammation phase: Passive rehabilitation phase
Goals Relieve pain
Reduce edema, ecchymosis
Relieve spasm
Protect surgical repair
Prevent deconditioning of unaffected body segments
Treatment guidelines Electrical stimulation for pain, muscle spasm
Compression and elevation for edema
If brace is used, maintain locked brace at 0° extension
After day 2: Active hip exercises while wearing knee brace
Ankle ROM exercises
Week 2: Begin active ROM of knee; patellar mobilization; soft-tissue
mobilization
End of second week: ambulate without crutches and brace set at 0°–120°; gait
training PRN
Exercises for unaffected body segments
HEP for pain, edema, and AROM
Precautions Weight bearing status: FWB or WBAT
Encourage proper gait
No resistive exercises to knee
No passive ROM
Stage II: Active phase
3–9 weeks Early proliferation phase: Active rehabilitation phase
Goals No pain, edema, spasm
Weeks 6–8: Full knee range of motion
Increase strength of all deficient muscles and muscle groups
Normal gait
Treatment guidelines End of third week: Discard brace; gait training PRN; aquatic exercises;
stationary bike; ski machine, stepper on short step; leg press 0°–45°; half
squats to 45°; hamstring curls if ACL graft is not hamstrings; single-limb
stance and other balance activities.
End of fourth week: Use joint mobilizations for motion PRN; treadmill
walking at an incline; resisted ankle and hip exercises.
Week 6: Begin hamstring strengthening if hamstring graft was used; otherwise
hamstring strengthening begins after week 3. Initiate early active balance
exercises as precursor to agility exercises.
Week 8: Increase step height for step-up exercises
HEP for strength gains; ROM maintenance
Precautions Use weight-scale exercises if weight transfer is incorrect
Know what type of graft has been used for ACL repair; hamstring stretching
and strengthening exercises will be delayed if hamstring graft has been used.
Correct exercise execution PRN
Do not repeat home exercises during treatment sessions
Stage III: Resistive phase
9–18 weeks Late proliferation phase: Resistive rehabilitation phase
Goals Maintain normal ROM
Achieve 85%–90% normal strength
Normal running gait
(continued)
Figure 23.47 Example of an accelerated ACL reconstruction program. ROM = range of motion; FWB = full weight bearing;
WBAT = weight bearing as tolerated; LE = lower extremity; PRN = as needed; HEP = home exercise program.
960
Knee and Thigh 961

Treatment guidelines Continue with strength progression, all muscle groups
Progressive agility exercises
Include multiplanar exercises
Weeks 8–12: Begin forward jogging
Week 12: Hopping activities and other plyometric exercises
Weeks 12–16: Running/sprinting backward, cutting, cariocas
Precautions Observe and use verbal cues to correct for execution of all exercises
Avoid pain and joint swelling
Stage IV: Aggressive phase
20–36 weeks Remodeling phase: Aggressive rehabilitation phase
Goals Maintain normal strength of all muscles
Maintain normal ROM of all joints
Normal sport and work performance
Treatment guidelines Functional exercise progression
Performance-specific exercises and drills progression
Precautions Correct performance PRN
Figure 23.47 (continued)
press exercises advance to 60° flexion, and the patient These posterior corner structures include an array of
can progress to the stepper and elliptical trainer. At 2 ligamentous and musculotendinous elements such
to 3 months, the patient begins fast walking. as the popliteus complex and the lateral collateral
Running is not permitted until about 4 to 6 months ligament that restrict lateral tibial rotation and varus
postoperatively. Cutting and lateral movements are stress.204 The PCL has two components, an antero-
permitted after the sixth month. A progression of lateral bundle that is the largest portion and becomes
plyometrics, agility exercises, and functional and per- taut with knee flexion, and the posteromedial bundle
formance-specific exercises is gradually incorporated that resists posterior tibial translation and becomes
into the program. taut in knee extension.205 Restoring stability through
During the 6th through the 12th month, once the reconstructive surgery has included using either a
patient has passed the same tests as in the accelerated double-bundle PCL to replace the original PCL ele-
program, return to full sport or work participation is ments or a combination of a double-bundle PCL with
permitted. a posterolateral corner reconstruction.206 Studies have
Recovery from ACL reconstruction can be a slow shown that the latter reconstruction provides preinjury
process whether the patient follows an aggressive or a stability but using only a double-bundle reconstruction
conservative rehabilitation program. In a prospective does not.206
study, patients who underwent ACL reconstruction Posterior cruciate ligament injuries are much
took anywhere from 1 to 2 years to regain full muscle less common than ACL injuries.205,207 The common
function and pain relief.201,202 The clinician must be mechanisms of injury are either hyperextension of the
careful always to consider the tissue healing timeline knee or falling onto a flexed knee.205 Injuries to the
and to coordinate intensity levels of therapeutic exer- PCL occur more often in high-contact sports such as
cises with the timeline. Optimal results are most likely American football, soccer, and rugby and less often
to occur if these factors are respected. in sports such as basketball that require more sudden
cutting and pivoting activities.205 Unlike ACL injuries
Posterior Cruciate Ligament Sprain that may occur without player contact, PCL injuries
Stability provided by the posterior cruciate ligament usually involve player contact or collision. Surgical
(PCL) is actually the combined result of the posterior repair is performed if the knee is unstable, if the
cruciate ligament and the posterior corner structures.203 posterolateral corner is injured, or if other ligaments
Case Study
A 16-year-old male soccer forward suffered a right ACL injury that was repaired last week. His physician required
him to be able to perform a straight-leg raise and quad set before discharging him from the hospital, but now the
physician wants the patient to begin rehabilitation using an accelerated program. The patient is using crutches
and bearing about 50% of his weight on the right lower extremity. He has a rehabilitative brace on the knee, with
the knee joint set at 0° extension and 90° flexion. He is allowed to remove the brace for passive activities only. The
knee has minor edema and some ecchymosis around the knee and into the proximal half of the leg. The surgical
repair used a patellar tendon graft; the patient has two scars, one over the patellar tendon and one over the distal
lateral thigh, in addition to portal scars from the arthroscopy. The surgical scars are healing well but still have
sutures that will be removed next week. There are some soft-tissue adhesions around the knee, especially sur-
rounding the surgical incision sites and the suprapatellar area. The patient reports only minor postoperative pain.
Patellar movement is about 50% normal in all planes, but the patient does not report pain with patellar mobilization
tests. Alignment of the patella is normal, without the presence of patella alta or baja. The patient can perform a
straight-leg raise but cannot lift the limb against any resistance to the motion. Hip adduction is 3+/5, hip abduction
is 4–/5, and hip extension is 4–/5. Knee flexion and extension resistance tests are deferred at this time because
the surgery was less than 7 days ago. He reports some pain with attempts at full weight bearing and admits that
he is very apprehensive about putting full weight on the extremity.
Questions for Analysis
1. What are his problems and your long-term goals? List them in order of priority.
2. What will your first treatment for this patient include today?
3. What will your goals for this first treatment today be?
4. What pre-gait activities will you use to encourage the patient to put more weight on the right lower extremity?
5. What home instructions will you give him before he leaves today?
6. What exercises will you include in his program over the next 2 weeks?
7. Over the next 6 weeks, what exercises will you assign, and what will be your criteria for advancing the
exercises during that time?
8. How long do you expect the patient’s program to take, assuming that he follows a routine course of events
without complications or problems?
9. When will you have him start on a treadmill, and what will be your first exercise on it?
10. Outline a progression from the treadmill to a full running program.
11. List four exercises you will include in the patient’s functional activities program.
12. Describe the performance tests you will use before the patient is allowed back to full sport participation.
have been injured in addition to the PCL.203 Surgical bilitation of posterior cruciate ligament reconstructions
repair of the PCL without these additional elements with non-weight-bearing restrictions ranging from 3
present is controversial, with many surgeons opting weeks to 3 months, postoperative bracing ranging from
for a nonsurgical approach.205 none to up to 12 weeks use, and delayed hamstring
The choice of grafts for PCL reconstruction surgery strengthening beyond isometrics ranging from 6 weeks
is similar to those for ACL reconstruction: single- or to more than 12 weeks.211
double-bundle hamstring grafts, patellar tendon, and It is generally accepted that the PCL experiences a
allografts. Studies demonstrate that the BPTB graft has progressive increase in shear stress in a resisted open
better results than the other options.208-210 kinetic chain flexion exercise as the knee moves from
Rehabilitation considerations for PCL reconstruc- extension to flexion. However, the amount of PCL
tions are different than those for ACL reconstructions shear stress during resisted knee extension is a bit
because stresses to the PCL are different than those of more controversial. Some investigations have found
the ACL. There is a wide range of protocols for reha- high PCL shear stresses in the 85° to 100° ranges of
Knee and Thigh 963
motion (figure 23.48) with less posterior shear as the this time. Hip extension and knee flexion activities are
knee reaches full extension when anterior shear stress avoided during the first 3 weeks, but hip adduction
increases.212 In closed kinetic chain exercises, the pos- and abduction exercises can be used with resistance
terior shear stress becomes progressively greater, going applied on the distal thigh. Range-of-motion exercises
from extension to flexion with the greatest stresses include active knee extension and passive flexion.
occurring in the 70° to 100° range of knee flexion.212 Active and resistive hamstring exercises should be
It is advisable, then, to keep OKC extension exercises avoided because they produce posterior translation
to no more than 60° of flexion, avoid OKC resisted of the tibia on the femur. Strong gastrocnemius con-
exercises in more flexion until the PCL is adequately tractions should also be avoided beyond 30° of knee
healed to withstand those stresses, and to keep CKC flexion because of the translational stress applied to
exercises in a range similar to that for the OKC exten- the joint and stress added to the PCL.214
sion exercises, 0° to 60°.212 Open kinetic chain exercises in the 0° to 30° range
Knees with isolated PCL deficiencies do not gener- of motion can provide good isolated strengthening
ally feel unstable unless the person is walking down an for the quadriceps as long as patellofemoral pain is
incline, because the PCL protects the tibia from pos- avoided since this motion does not create posteriorly
terior displacement on the femur (or anterior femoral directed forces.211 If patellofemoral pain occurs, the
displacement on the tibia). Generally, patients with exercises are modified to avoid pain. Modifications can
isolated PCL injuries without instability can return to include changing the degrees of motion and the angles
full participation after an appropriate rehabilitation of the exercise, reducing the resistance, reducing the
program without surgical reconstruction.213 lever arm of the applied resistance, and using low
The initial goals of a PCL postoperative rehabilita- weights with higher repetitions. These exercises during
tion program in phase I are to resolve pain and edema phase II include quad sets, straight-leg raises, and quad
and restore range of motion. Once signs of inflam- range-of-motion exercises up to 60° of flexion.
mation are managed, important new goals include Posterior shear stress on the knee occurs during
restoration of strength, control, and normal function. hamstring activity in ranges of motion greater than
Modalities to treat pain and edema and electrical stim- 30°;215 on the other hand, quadriceps activity increases
ulation for muscular facilitation are used in phase I. In stress to the PCL during exercises greater than 60° of
the early phase, the knee is supported when the patient flexion.216 Therefore, early rehabilitation exercises
is in long sitting to prevent posterior sag of the tibia on for the hamstrings should stay in the 0° to 30° range
the femur. Patellar mobilization is performed during of motion, and quadriceps exercises should not move
into ranges greater than 60° of flexion.
Weight-bearing allowance immediately after sur-
gery can vary; some physicians allow partial weight
CKC bearing with the knee in extension,217 while most others
OKC insist on non-weight bearing within a range of 6 to
10 weeks postoperatively.218 Most often, crutches are
used initially for non-weight bearing during the first 3
to 6 weeks, then weight bearing advances to tolerance
with gradual progression to full weight bearing without
Stress
assistive devices by 6 to 10 weeks.218-220 During this

time, the patient is encouraged to bear body weight
equally on both lower extremities to facilitate co-con-
traction and thereby reduce the risk of posterior shear
forces on the knee.211
A rehabilitation brace is applied postoperatively
100 85 70 60 0 with the knee locked at 0° extension and worn for 6
Flexion Extension to 10 weeks.218 The brace is removed after the first
Degrees
week for passive exercises only. Around week 5 or 6
Figure 23.48 Composite of flexion and extension shear the brace is unlocked to allow full motion.218 A closed
stresses applied to the posterior cruciate
E6147/Houglum/fig ligament in open kinetic
23.48/544577/KH/R1
kinetic chain exercise in the last 60° of extension with
chain (OKC) and closed kinetic chain (CKC) exercises. a resistance band can be used to strengthen the ham-
Based on Wilk et al. 1996. strings and produce minimal posterior tibial translation
once the patient is partial weight bearing. This exercise agility, plyometrics, functional, and performance-spe-
would be the reverse of the one seen in figure 23.28 and cific exercises about the sixth month. The patient can
would position the patient facing the opposite direction return to full sport participation in an average of 9
and flexing the knee against a band’s resistance. The months, with an average range of 7 to 12 months.221
hamstrings can also be strengthened in an open kinetic Figure 23.49 provides an example of a rehabilitation
chain exercise for hip extension if the patient keeps the progression for a surgically reconstructed posterior
knee extended to reduce posterior tibial shear stress. cruciate ligament.
Once the patient progresses to full weight bearing,
other closed kinetic chain exercises begin in phase III. Collateral Ligament Sprains
Gait training may be necessary if the patient cannot The medial collateral ligament (MCL) can be injured
assume a normal gait. Weight transfer activities may by itself or in combination with other knee structures.
be indicated if the patient is reluctant to bear weight on Collateral ligament injury treatment is different from
the extremity. Proprioception exercises should empha- cruciate ligament treatment.
size recruiting the quadriceps for posterior translation Medial collateral ligaments are more often injured
control, first in static positions and advancing through than lateral collateral ligaments (LCLs).222 An MCL
dynamic activities. Exercises such as wall squats pro- injury occurs as the result of a valgus stress, and an
gressing to standing squats, step-ups, and other CKC LCL injury results from a varus stress to the knee.
exercises are added to the program once the patient is Isolated medial collateral ligament injuries are rarely
full weight bearing. repaired surgically except when instability results
By about the eighth to the tenth week, the patient from a combination of ACL and MCL tears. In those
should have full knee extension without an extensor situations, the MCL may or may not be repaired even
lag and knee flexion to about 90°.211 Once normal gait if the ACL is repaired. One reason for this discrepancy
is achieved, the patient can walk without assistive may be that the MCL can heal on its own, while the
devices after the eighth week. At this time, the pro- ACL cannot.223
gram can progress to aquatic jogging and running, the The rehabilitation programs are similar for MCL
leg press, and increased weights with land exercises. and LCL injuries. Initial treatment includes modali-
Anchoring a weight behind a rolling stool and having ties for pain and swelling. The current philosophy in
the patient sit on the stool, using only the involved treating isolated collateral ligament injuries is to use a
extremity to propel the stool, is a good closed-chain brace in conjunction with an early therapeutic exercise
hamstring exercise. program.224 The patient’s injured knee is placed in a
By the end of the third month, the patient should functional or rehabilitative brace with limits set at 0°
have full knee motion. Treadmill walking begins at this extension and 90° flexion to control ligament stress yet
time. A more advanced closed kinetic chain hamstring still allow motion. The brace is worn for 3 to 6 weeks,
exercise that is performed with the patient kneeling on and crutches, with either non-weight bearing or weight
the table and the clinician anchoring the feet off the bearing to tolerance, are used for 2 to 4 weeks. During
table may begin if the patient has sufficient hamstring this time, active range-of-motion exercises, isometric
strength; as the clinician anchors the legs, the patient exercises to retard quad and hamstring atrophy, and hip
leans the trunk forward as far as possible and then and ankle exercises are used. Patellar mobilization may
returns to the upright kneeling position. The patient be necessary if the joint becomes stiff. Cross-friction
may have sufficient strength for this exercise by the massage to soft tissues can be helpful in promoting
fourth or fifth month. The stepper using small steps or healing and preventing adhesions.225 In 7 to 10 days,
the elliptical trainer is also started at this time. pool exercises are useful for range of motion and
By the sixth month, the patient enters phase IV, strength. After about 2 weeks, the stationary bike can
jogging on a treadmill with progression to running be used if the knee has about 105° of flexion. Before
and then moving into agility exercises, plyometrics that time, the patient can use the bike as a means of
(stressing deceleration activities, pivoting, lateral increasing range of motion.
movements, and jumping), and performance-specific A combination of open and closed kinetic chain
exercises. Knee control for posterior tibial translation exercises is used to increase hamstring and quadri-
should be emphasized throughout the program. ceps strength. These exercises follow the progression
Although the rate is significantly slower, the pro- outlined for cruciate ligament injuries and must not
gression for a surgically reconstructed PCL is the produce patellofemoral pain or increase collateral
same as for an ACL program, with advancement to ligament pain. Once the patient is ambulating in full
POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Goals Relieve pain
Relieve spasm
Brace remains locked at 0° until week 5–6: then unlock for full motion
Progressive WBAT with crutches to FWB by week 6
ROM exercises for hip and ankle muscle groups
PROM of knee in prone, 0°–90°
After PWB: Use rubber bands for hamstrings resistance, last 60° of extension
Patellar mobilization; soft-tissue mobilization PRN
OKC exercises: quad set (isometrics) at various positions within 0° to 60°;
SLR; hip strengthening; ankle strengthening
After week 3: Aquatic exercises and weight shifting, gait training in water
Week 2: Stationary bike without resistance for knee ROM only
Week 4: Unlock brace for sleeping
HEP for pain, edema, and PROM to 90°
Precautions Encourage proper gait once patient begins some weight bearing
Remove brace for exercises, but otherwise brace remains on in full extension
Limit knee motion to 0°–90° for first 2 weeks, then progress as tolerated
Avoid knee hyperextension
No hamstring resistance exercises
When performing soft-tissue or joint mobilizations on the patella, place a
rolled towel under the knee to prevent hyperextension
Week 6: Full weight bearing
Weeks 8–10: Normal knee ROM
Normal gait
Treatment guidelines Week 6: Discontinue brace and crutches; gait training PRN
Week 6: Stepper machine, stationary bike, ski machine, treadmill (walking)
Joint mobilizations, PRN
FWB balance activities
Week 8: Aquatic running, swimming
CKC exercises: Mini-squats to 45°, leg press (0°–60°), wall squats (0°–60°),
heel raises, lunges, hip strengthening
OKC exercises: knee extension and hamstring curls, 60°–0°
HEP for strength gains; ROM
Precautions Avoid knee pain with exercises
Use weight-scale exercises if weight transfer is incorrect
Do not use home exercises during treatment sessions
(continued)
Figure 23.49 Rehabilitation program for posterior cruciate ligament reconstruction. NWB = non-weight bearing; FWB = full
weight bearing; WBAT = weight bearing as tolerated; ROM = range of motion; PROM = passive range of motion; SLR = straight-leg
raise; PRN = as needed; HEP = home exercise program.
965
Normal gait
Treatment guidelines Continue with strength progression, all muscle groups including CKC
hamstrings resistance exercises at hip, step-ups, lateral step-ups
Jogging, advancing to running with increase of strength to 85% normal
Running/sprinting backward, cutting, cariocas
Treatment guidelines Plyometric exercises
Functional exercise progression
Case Study
Last week an 18-year-old female volleyball player injured suffered an isolated injury to the left posterior cruciate
when landing with the knee hyperextended after jumping to block a ball at the net. The physician will not perform
surgery because the knee is stable. He wants you to begin the rehabilitation process with the patient today. Your
examination reveals moderate edema around the knee. The patient has a long-leg brace and can bear partial
weight on the left extremity. Her range of motion out of the brace is 30° to 60°. Her patellar mobility is limited by
about 75%, but her knee is too flexed for you to decide whether the restriction is attributable to the knee position
or inadequate patellar mobility. She has pain at 6/10. The edema and ecchymosis surrounding the knee are causing
the soft tissue to feel tight from the edema pressure, with restricted mobility during palpation. Her strength is 4–/5
in hip flexors and abductors and 3+/5 in hip extensors, adductors, and quads. You have deferred hamstring testing
because of the PCL injury.
1. What will your first treatment with the patient today include?
2. What instructions will you give her to do at home?
3. What exercises will you include in today’s session?
4. Outline your expected timeline for beginning hamstring exercises, walking on a treadmill, and stationary
cycling. Will you use pool exercises with the patient? If you will use the pool, list three exercises.
5. List four functional exercises and performance skill activities you will include in the last phases of her ther-
apeutic exercise program.
6. List the performance tests you will use to determine when the patient is ready to return to full sport partic-
ipation.
966
Knee and Thigh 967
weight bearing, stork standing and other balance has seen the greatest changes over the past several
activities can begin. Walking on the treadmill with pro- years. Current trends in treatment allow for a more
gression to jogging occurs once a normal walking gait rapid return to participation than in the past, with
has been achieved. Jogging then progresses to running reduced deleterious effects.
and sprinting as long as pain and edema are avoided. Surgical treatment of meniscal injuries has evolved
If full motion is not achieved by around week 5 or over the past several years; arthrotomies for complete
6, joint mobilization techniques and prolonged knee removal of a damaged meniscus are now a rarity
stretches may be needed. The patient progresses in and have been replaced by procedures ranging from
strength and agility exercises as long as there are no partial removal of torn segments or repair to allograft
deleterious signs. After achieving motion and strength, replacements (figure 23.50), all of which are performed
the patient advances from agility and plyometrics to through arthroscopes.
functional activities and finally to performance-spe- Isolated injury to the medial meniscus does not
cific exercises. A functional knee brace is often used result in instability to the knee, but if a meniscal tear
before and after return to sport. The collateral ligament is combined with an ACL rupture, the knee becomes
brace does not require the rotational stability that an unstable.226 Isolated meniscal tears tend to be degen-
ACL brace does, but it should have medial and lateral erative tears, whereas meniscal tears that accompany
upright supports to control valgus and varus stress. ACL injuries are more likely to be acute tears.227 A
A person’s tolerance and the severity of the injury stable knee with a meniscal injury may not be a can-
will determine the patient’s rate of progression. Return didate for a meniscal repair, but an unstable knee will
to normal function can occur in as few as 3 to 4 weeks become even more unstable if the meniscus is removed
or can take as long as 2 to 3 months. or partially removed.228 It has been realized for some
time that knees that undergo a meniscal repair with
an ACL repair do better than knees with an isolated
Meniscus Injuries meniscal repair or an isolated ACL repair.229,230
Among all the rehabilitation programs for knee inju- Just as with any tissue repair, meniscal repairs
ries, the rehabilitation program for meniscal injuries must have a viable blood supply to be successful. The
Case Study
A 17-year-old male gymnast suffered an excessive valgus stress with subsequent grade II sprain of his right MCL
during a rings dismount 3 days ago. The physician wants him started on a rehabilitation program. For the past 3
days he has received ice, elevation, compression, and electrical stimulation for edema control. He is on crutches
with a hinged brace set at 0° and 90°. He is bearing about 75% of his body weight on the right extremity when he
ambulates. There is moderate swelling with tenderness to palpation along the MCL. His hip and hamstring strength
is grossly 4/5. He has an extensor lag of 15°. He reports mild pain unless he tries to bend the knee past 60°; then
the pain level becomes moderate. Patellar mobility is normal.
1. List, in order of significance, his problems and your long-term goals for each problem.
2. What will your first treatment for this patient today include? What home program will you give him before
he leaves your facility today?
3. Outline the exercise program you will have the patient perform for the next week. How will you determine
his progression?
4. List three open kinetic chain and three closed kinetic chain exercises you will have him perform within the
next 2 weeks, and list them in the order that you will assign them.
5. What agility exercises will you include in his program?
6. What plyometric exercises will you use?
7. Describe the performance activities you will use in your assessment to determine when the patient is ready
to return to full sport participation.
with immediate postoperative partial to full weight

bearing and motion.
Traditionally, the postoperative care for menis-
cal repairs has been conservative, but accelerated
programs have been used more recently with equal
success.197 There is a wide variation on postoperative
care of meniscal repairs in such areas as amount and
timing of weight bearing, the use of rehabilitation
braces, and the initiation of exercises.197 The more
conservative protocols guard the repair by using
restricted motion and weight bearing to reduce the
shearing and compressive forces that are normally
applied to the menisci during walking, while the more
accelerated programs limit the time on crutches and
use partial weight bearing and active motion in the
early rehabilitation phase to apply appropriate stresses
to healing tissue and prevent unwanted loss of motion
and patellofemoral pain problems.197 The rehabilitation
clinician must communicate with the physician to
Figure 23.50 Meniscal transplant.
create a feasible rehabilitation program for the patient
who has undergone a meniscal repair.
E6147/Houglum/Fig.23.50/519135/JG/R2/HR Because of vascular supply, repaired peripheral
peripheral rim of the meniscus has a blood supply, but tears will heal more quickly than complex tears that
most of its inner substance is avascular.231 Meniscal include the central portions of the meniscus. Factors
blood supply can reach inward as far as 6 mm (about that may determine whether an accelerated or conserv-
0.25 in.).232 Therefore, tears that occur over the outer ative program is followed include not only the location
third of the meniscus have the best healing capabilities. of the repair but also the type and size of the repair.231
Tears that extend inward farther than the structure’s Conservative rehabilitation follows transplants and
blood supply do not do well with meniscal repair complex tear repairs, while more aggressive reha-
procedures. Surgeons’ preferences about the width bilitation may be possible for peripheral tear repairs.
of the meniscal tears that do well with repairs are Rehabilitation using either a conservative or accel-
variable, and range from 2 mm to 6 mm.232,233 Up to erated program involves initially protecting the repair
20% of all meniscal tears are repairable.231 Meniscal or transplant from shear and excessive compression.
repair is advantageous over meniscectomy because Patients must be cautioned that deep squats and piv-
the meniscus remains, and there is consistent evidence oting will risk the surgical site’s integrity. Activities in
that even partial meniscectomy leads to osteoarthritic a rehabilitation program should not produce increased
changes in the joint.231 The rehabilitation process, knee pain or swelling at any point in the program.
however, is significantly longer for a meniscal repair
or replacement than for a meniscectomy. Whereas a Conservative Postoperative Meniscal
rehabilitation program for a meniscectomy generally Repair Rehabilitation Program
requires 4 to 6 weeks, a patient is often restricted from A conservative postoperative meniscal repair rehabili-
sport participation after a meniscal repair for 4 to 6 tation program includes placing the patient on crutches
months.234 with the knee in a brace and non-weight bearing on
The patient who has a medial meniscus and ACL the involved extremity for up to 6 to 8 weeks (figure
injury that both require surgical repair is a difficult 23.51). Toe-touch weight bearing is sometimes allowed
case for the surgeon and rehabilitation clinician. after 2 weeks, with slowly progressive increases in
Meniscal repairs do better if performed as soon after weight bearing to full weight bearing by 6 to 8 weeks.
the injury as possible.235 Following a meniscal repair, A rehabilitative brace is used to keep the knee in an
the postoperative care is conservative, with non-weight extended position at night for the first 3 weeks, but it
bearing and limited motion for up to 6 to 8 weeks. On allows 0° to 90° range of motion during the day for 6
the other hand, the ACL repair is most successful when to 8 weeks after surgery. During this time, the patient
delayed until after the inflammation is resolved and performs hip and ankle exercises and exercises for the
Knee and Thigh 969
uninvolved body segments. Stretching exercises for first 2 weeks. Once the patient demonstrates full active
the hamstrings, gastrocnemius, soleus, and hips occur knee extension, the brace is unlocked for night wear.
during this protective phase. Manual resistance to the Achieving full knee extension motion and active motion
hip should be applied above the knee to prevent stress to 90° is the primary concern during the first 3 weeks
on the knee joint. Quad sets, straight-leg raises, and after surgery. If motion is difficult, it may be necessary
active knee extension without pain are started within the to perform patellar mobilizations in all four directions.
MENISCAL REPAIR
Goals Relieve pain
Relieve spasm
By week 4: 0°–90° ROM
Brace fixed at 0°–90°
Week 1: NWB; Week 2: TTWB (20% BW); increase weight bearing on
involved limb by 20% each week
ROM exercises for knee, hip, ankle muscle groups
OKC exercises: quad set; SLR; knee extension; hip strengthening; ankle
strengthening
After week 3: Aquatic exercises and weight shifting, gait training in water
After week 2: Stationary bike without resistance for knee ROM only
After week 3: Unlock brace for sleeping
HEP for pain, edema, and PROM to 90°
Precautions Encourage proper gait once patient begins some weight bearing
Maintain brace use except for ROM activities
Brace remains locked in extension at night until patient has good quad
contraction in full extension
Week 6: Full weight bearing
Weeks 8–10: Normal knee ROM
Normal gait
(continued)
Figure 23.51 Conservative rehabilitation program for meniscal repair. NWB = non-weight bearing; TTWB = toe-touch weight
bearing; BW = body weight; ROM = range of motion; PROM = passive range of motion; SLR = straight-leg raise; PRN = as needed;
HEP = home exercise program.

Treatment guidelines Week 6: Discontinue brace and crutches; gait training PRN
Joint mobilizations, PRN
Stationary bike
CKC exercises: Mini-squats, leg press (70°–10°), wall squats, heel raises, hip
strengthening
OKC exercises: Limited in flexion to 90° and in extension 30°–90°
Normal gait
hamstrings resistance exercises at hip, step-ups, lateral step-ups
Jogging, advancing to running with increase of strength to 85% normal
Running and sprinting backward, cutting, cariocas
After 6 to 8 weeks when the brace is removed, open kinetic chain knee flexion and extension exercises
stretching of the quadriceps along with tibiofemoral occurs at 6 to 8 weeks. Initial ranges of motion are
joint mobilizations can be used to gain additional knee limited in open-chain knee flexion to 90°, in open-chain
flexion. Crutches are discarded when the patient can knee extension 90° to 30°, and in the leg press to 70° to
walk normally and has adequate quadriceps strength to 10° of extension.235 Pivoting and acceleration–decelera-
control the knee. Balance and proprioception activities tion activities are not allowed for the first 4 to 6 months
in weight bearing begin once the patient is full weight after surgery. From then on, the patient progresses to
bearing. Strengthening the quadriceps and lower functional and performance-specific exercises before
extremity with leg press, mini-squats, wall squats, and returning to sport or normal activities.
Knee and Thigh 971
Accelerated Postoperative Meniscal Treatment includes the use of crutches with weight
Repair Program bearing to tolerance. An immobilizer brace may be
initially used but eventually progresses to a functional
As mentioned, accelerated rehabilitation programs are
brace to stabilize the patella. Therapeutic exercises pro-
usually possible after repairs of peripheral meniscal
gress to the patient’s tolerance. Electrical stimulation
lesions. In an accelerated program, weight bearing is
to the quadriceps and modalities for pain and edema
allowed as the patient tolerates it, but the patient uses
control are applied during phase I, usually during the
crutches until he or she can walk normally. Range-of-
first 2 weeks. Increases in pain and edema are avoided
motion exercises are used during the first postoperative
throughout the entire program. Patellofemoral pain
week. Quad sets and straight-leg raises also begin during
can be produced at any time, but especially in the
the first week. The goal during the first few weeks is to
early phases of rehabilitation when the tissues are still
achieve full range of motion without increased edema in
inflamed from the initial insult. All exercises should
the knee. By the end of week 2 or 3, the patient who has
be pain free. If an exercise produces pain, it is delayed
good control of knee extension can ambulate normally
until the patient can perform it without pain.
without crutches.
It is important to work on hip stability exercises
In weeks 2 to 4, the patient can use pool exercises
during phase I. These exercises include strengthening
and closed kinetic chain exercises including stationary
hip extensors and abductors especially. Additionally,
biking, mini-squats, and a walking treadmill program.
core muscle strengthening should be included in any
By weeks 6 to 9, isokinetic exercises are suitable. Jog-
program for the patellofemoral joint, whether it is to
ging, progressing to running, is added before lateral and
manage a dislocation or patellofemoral stress syn-
pivoting movements are added. By that time, the patient
drome. As was previously mentioned, hip and core
has at least 85% quad strength. The patient progresses
to phase IV of rehabilitation when quadriceps strength muscles all play important roles in patellofemoral
is 90% and the knee has full motion. Within this phase, joint stability. See chapters 24 and 17 for hip and core
multiplanar activities such as cutting, cariocas, and exercises, respectively.
agility activities begin in months 4 to 5. These activities Initial strength exercises in the late active phase
progress to performance-specific exercises, then to full and early resistive phase include straight-leg raises
return to normal function by months 5 to 6. and pain-free short-arc exercises with progression
into a greater arc of motion as strength gains and pain
permit. Rehabilitation exercises are a combination
Patellofemoral Injuries of open and closed kinetic chain activities. Program
Patellofemoral injuries can be complex injuries and emphasis should be on quadriceps strength and patellar
frustratingly slow to respond to treatment. Several fac- control during all activities. As strength and knee con-
tors may contribute to patellofemoral injuries, especially trol improve, exercises in the later program progress
the nontraumatic injuries. This section deals with the to more rapid activities until functional speeds are
most frequently seen patellofemoral injuries. possible with good patellar control.
Lower-extremity alignment is examined in standing
Patellar Dislocations and Subluxation and walking because pronation occurs during ambu-
Patellar instability is more often seen in women than lation and can increase the risk of patellar instability;
in men. This is thought to be the result of an increased feet with excessive pronation may require correction
Q-angle secondary to a wider pelvis, which increases with orthotics.
the lateral vector force on the patella.236 It is surprising The rehabilitation program duration depends on
to realize that the other strongest predictive factors whether the dislocation or subluxation is a first-time
include age (under 20 years old) and activity level.237 event or a recurring injury. Recovery from an acute
The mechanism for patellar dislocation and sublux- subluxation or dislocation can take more time than
ation is lateral rotation of the thigh with knee flexion from a recurring injury. An average expected recovery
on a planted foot. If the patella subluxes rather than period is 4 to 12 weeks; recurrent injuries are on the
dislocates, it often relocates independently or sponta- shorter side and first-time injuries require the longer
neously. A frank dislocation may or may not relocate on recovery time.
its own. First-time dislocations may not relocate unless
they occur in skeletally immature females,238 but recur- Patellofemoral Pain Syndrome
rent ones often do relocate without assistance. Pain and Syndromes of the patellofemoral joint can be caused
edema are severe, especially in first-time dislocations. by many factors, individually or in combination. The
Case Study
A 20-year-old male ice hockey forward experienced a left knee meniscal tear. He underwent an arthroscopic repair
of the meniscus yesterday and comes to you today to begin his rehabilitation program. He is walking PWB with
crutches. He reports mild pain and a sensation of tightness around the knee. Your examination reveals swelling of
2.5 cm (1 in.) around the knee’s joint margin. The patient’s active range of motion is –15° extension and 90° flexion.
Passive range of motion is 0° extension and 100° flexion. He can perform a straight-leg raise but cannot tolerate
resistance in the motion. Other hip motions are 4/5. Hamstring strength is 4–/5. The patella is slightly restricted
about 30% in its mobility.
1. What will your first treatment with the patient include today?
2. What will you give him as home exercises and instructions before he leaves today?
3. What are your goals with him for the first week of treatment?
4. Preseason hockey practice begins in 2 months. What will you tell the patient when he asks you whether he
will be ready by then?
5. When do you expect him to be able to begin full weight bearing? When do you expect him to begin squats
with weights?
6. What will you say when the patient asks you why he cannot straighten the knee when he could before the
surgery?
7. Present a progression of proprioceptive exercises that you will have in this program. Discuss the progres-
sion of agility exercises you will use. List the performance activities you will include in the final phase of the
patient’s program.
term for this frustrating injury, “syndrome,” demon- pain, especially on stairs or ramps. Swelling is usu-
strates that the medical community has been unable ally mild, but the posterior surface of the patella is
to identify one specific etiology. tender to palpation.
Mechanism Patellofemoral pain is a common Underlying Factors PFPS is anterior knee pain
complaint among athletes as well as among the gen- and irritation caused by abnormal stresses applied to
eral population. It is often referred to by its generic the knee’s extensor mechanism. Patellofemoral pain
title, anterior knee pain, but it has also been identified syndrome is a multifactorial condition. Although it
as chondromalacia, patellofemoral pain syndrome, can result from direct trauma to the patella, it is more
patellofemoral stress syndrome, and patellofemoral often the result of cumulative stresses in the pres-
joint dysfunction.38,239-241 Chondromalacia is a term ence of additional contributing factors, both extrinsic
that was used in the past to describe anterior knee and intrinsic to the joint. These factors are thought
pain; however, chondromalacia refers to a specific to include tightness in the ITB, hamstrings, and gas-
injury that involves softening and degeneration of trocnemius; weakness in the VMO or imbalance of
the patella’s posterior articular cartilage and is not an strength between the VMO and vastus lateralis; ex-
accurate diagnosis for most anterior knee pain con- cessive pronation; increased Q-angle; knee hyperex-
ditions. The most commonly used term today to de- tension; and patellar alignment.242 More recently, it
scribe anterior knee pain is patellofemoral pain syn- has been demonstrated that people with PFPS have
drome (PFPS).73 weak hip muscles compared to persons without the
condition.71,243 Since PFPS is a multifactorial con-
Signs and Symptoms Typical signs and symp- dition, it is likely that a patient has more than one
toms of PFPS include stiffness after prolonged sit- of these factors contributing to PFPS. Each element
ting, pain with activities such as stair climbing and should be evaluated when examining the patient with
running, and pain after activity.73 Crepitus is usually PFPS because correction of or compensation for
present. The patient may experience a giving way of these malalignments must occur if the PFPS is to be
the knee because of reflex inhibition secondary to resolved.
Knee and Thigh 973
Normal function of all body segments relies on a Any one of these factors by itself may create
balance of the surrounding structures. This balance patellofemoral pain. When more than one of these
includes adequate flexibility and proper strength so factors is present, the problem becomes more difficult
that forces are adequately and appropriately directed to to resolve.
produce the desired motion and applications of force.
If hamstring, gastrocnemius, ITB, or lateral connective
Patellar Orientation Patellar orientation and
alignment are examined in a relaxed long sitting or
tissue structures are tight, they apply imbalanced forces
supine position, and in closed-chain positions in both
on the knee.244,245 Tight hamstrings prevent full exten-
static and dynamic conditions. Patellar alignment
sion, so the knee is in flexion during activities when
varies from one patient to another; it can also be dif-
it should be extended, increasing compressive forces
ferent from left to right knee in the same person. In
on the patellofemoral joint. If knee flexion is less
a relaxed open-chain position with the knee resting
than 60°, the need for increased knee flexion during
near full extension on a rolled towel and the femur
ambulation is compensated by increased dorsiflexion
in parallel alignment with the examination table-
to clear the toe. Normally 10° of dorsiflexion is needed
top, the rehabilitation clinician assesses the patellar
for ambulation, but if gastrocnemius tightness does not
alignment in various planes. The clinician examines
permit this motion, or if the hamstrings create a need
for the presence of any of these abnormal positions:
for more dorsiflexion and it is not available, the foot
lateral glide, lateral tilt, inferior tilt, and rotation. In
pronates in an attempt to achieve the necessary dor-
the relaxed, extended position, the patella should rest
siflexion. Excessive pronation requires tibial medial
slightly lateral to the center of the knee with the in-
rotation, which increases valgus stress on the knee. A
ferior pole at the knee’s joint margin. If the patella’s
tight ITB pulls the patella laterally as the ITB moves
position is more than a few millimeters to the later-
posteriorly during knee flexion. In cases of severe
al aspect, it sits in a lateral glide position. A medial
distal ITB tightness, the patella is in a lateral tilt posi-
glide position is rare. When a finger is placed on top
tion because of the ITB’s lateral pull on it.
of the medial and lateral poles of the patella, they
If the hip muscles, especially the hip extensors and
should be level with each other when observed from
hip abductors, are not strong, there is no hip stability
eye level; if the lateral finger is lower than the medial
from which the knee can function. A weak base at the
finger, the patella is in a lateral tilt. A medial tilt is
hip for the knee creates an unstable situation for knee
rare. When a finger is placed on top of the mid-su-
function. An unstable condition at the knee makes it
perior patellar surface and another is placed on top
difficult to maintain the patella in proper alignment
of the inferior patellar pole, the fingertips should be
during lower-extremity activities. Weak hip muscles
level with each other when observed from eye level;
have been linked to patellofemoral pain syndrome.246
if the distal finger sits lower than the proximal finger,
If either the VMO is weak or an imbalance exists
the patella sits in an inferior tilt, or posterior tilt. This
between the VMO and the vastus lateralis, the patella
tilt is also referred to as an AP tilt and is referenced
moves laterally during quadriceps contractions.162
from the location of the patella’s inferior pole. Look-
This permits the patella’s lateral rim to ride more on
ing from directly above the patella, the superior me-
the lateral femoral condyle than in the intercondylar
dial and lateral poles should be in the same plane; if
groove, where it normally glides during knee motion.
the lateral pole lies more proximally on the knee and
If the vastus lateralis is tight, the lateral pull during
the medial pole lies more distally, the patella is later-
quadriceps contractions is exaggerated. Repetitive
ally rotated. If the medial pole lies more proximally,
gliding against the condyle leads to inflammation of
the patella is medially rotated. A lateral rotation is
the patella’s articular surface.
more common than a medial rotation. These patellar
If the knee is in hyperextension, the inferior pole of
positions are demonstrated in figure 23.52.
the patella is often tilted inward. This causes the patella
to push into the fat pad during full extension, and to
glide with an inferior tilt during knee motion, changing
the relationship between the patella and the femoral
groove. The patella has increased contact inferiorly
video 23.52, which demonstrates
as it glides in the groove, increasing stresses at the patellofemoral dysfunction during
inferior pole. Swimmers with hyperextended knees weight bearing.
have reported complaints of PFPS.247
Lateral Medial Lateral Medial Lateral Medial
Normal orientation Lateral glide Lateral tilt
Inferior tilt
Normal orientation Lateral rotation Medial rotation
Figure 23.52 Patellar orientation.
The patella’s tracking pattern is examined in non- eral retinaculum was cut, or an advancement of the
tibial tubercle medially to allow a better patella align-
weight bearing. As the patient contracts theE6147/Houglum/Fig.23.52/519137/JG/R2/HR
quadriceps
while in full knee extension, the clinician observes the ment. It has been demonstrated, however, that many
patella for its movement. Normal patella movement PFPS patients have better results with nonsurgical
occurs similar to an inverted J-figure, so patellar management that consists primarily of exercise.251
tracking ends with some lateral motion. If lateral
248
Determination of the underlying causes dictates
structures are tight or the VMO is weak, the patella what is included in the treatment program. Orthotics
will move upward in a lateral path from the start may be needed if excessive pronation is present;252
of patellar movement. During knee movement into flexibility exercises and soft-tissue mobilization tech-
flexion, the patella migrates medially as the Q-angle niques are necessary if tightness and adhesions exist;253
decreases and the patella becomes centered in the strengthening and improving hip and core control
trochlea. Maltracking of the patella is commonly seen will reduce patellofemoral stresses;254 and muscle
in patients with PFPS.249 reeducation and strengthening exercises, especially
Alignment is also observed in standing, and move- for the VMO, are needed with all patellofemoral pain
ment of the patella is observed while the patient per- regardless of cause242 because pain causes an inhibition
forms an activity such as a lunge or step-down. During reflex and weakens the quadriceps.86
initial flexion, the patella sometimes moves and tilts
laterally but then moves medially by the time the knee Patellar Taping Technique A technique devel-
reaches flexion at 30°. Changes in patellar alignment
250 oped by Jenny McConnell, an Australian physio-
and glide during weight bearing can indicate various therapist, uses a combination of taping to the patella
factors that should be corrected, such as pronation, and exercises. Her initial theory stated that the tape
weakness, incorrect firing patterns, and tightness. corrected patellar alignment to relieve pain and al-
low the patient to exercise to regain strength.255 More
Corrections Common surgical procedures to treat recent studies, however, have shown conflicting re-
patellofemoral pain and patellofemoral malalignment sults on the efficacy of patellar taping. Some have
in the past included a lateral release in which the lat- demonstrated that no change in patellar position oc-
Knee and Thigh 975
curs;256-259 others have demonstrated that a reduction the patient is instructed in tape application, removal,
in pain or minimal short-term changes in alignment and skin care so that he or she can reapply the tape
do occur with the tape.260,261 These studies, however, daily until symptoms subside. As quadriceps strength
consistently point out that the effects of taping on pa- improves and pain decreases, the patient is weaned
tellar position were limited. Patellar position changed from the tape.
only at 10° of knee flexion,262 and no change occurred The cloth undertape is applied smoothly but without
in the open-chain position.261 Changes that did occur tension to the skin over the patella, medial knee area,
lasted less than 15 min after activity began. Empirical and into the popliteal region. The correction tape is
evidence persists to support the theory that McCon- applied with force over the undertape to move the
nell taping reduces pain in spite of the now accepted patella. The tape is applied with quadriceps relaxed,
fact that the tape does not change functional patellar the knee in extension, and a rolled towel under the
alignment. It has been speculated that the tape may knee for comfort and to prevent the knee from being
provide neural inhibition through neurosensory affer- locked.266 If pain occurs during the middle range of a
ent stimulation of the large A-beta fibers.263,264 squat, the tape may be applied with the knee positioned
Research has shown that patellar taping facilitates in the painful range of flexion. The quadriceps must
a quicker response of the VMO during step-up activ- remain relaxed during any McConnell tape application.
ities and delays the onset of vastus lateralis response For patients whose patella sits in a lateral glide, the
while increasing the onset of VMO response during correction tape is applied from lateral to the lateral
a step-down exercise.265 It has yet to be determined border of the patella with a medial pull on the tape
whether this change in muscle response results from over the medial femoral condyle (figure 23.53). The
improved muscle response secondary to pain reduction soft tissue over the medial femoral condyle is lifted
or neurosensory facilitation. toward the patella manually to create a fold in the skin
on the medial side and ultimately provide a better pull
Patellar Tape Application Although it has been of the tape.266 A couple of strips of treatment tape may
demonstrated that patellar taping does not change be necessary. Each strip should create a subsequently
the position of the patella, tape applications advo- larger soft-tissue crease.
cated by McConnell are presented here because the For patients whose patella sits in a lateral tilt, a strip
tape has been shown to consistently reduce pain, al- of tape is firmly anchored at the middle of the patella
though the reason remains elusive. When more than and pulled firmly toward the medial femoral condyle so
one malalignment is present and one of them is a that the lateral patellar border is lifted to move the patella
posterior tilt, the posterior tilt is corrected first; oth- level with the anterior femoral plane266 (figure 23.54).
erwise, the greatest malalignment is corrected first.
The tapes used for patellar taping are Cover-Roll,
used as a hypoallergenic cloth undertape to protect
the skin, and Leukotape, used as the “treatment” tape.
The tape should reduce the patient’s pain symptoms
immediately. To evaluate its effectiveness, the patient
performs an activity that reproduces the pain such as
a step-down, and the pain level is assessed. Although
the pain may or may not completely resolve, studies
have demonstrated reduced pain after the tape appli-
cation in 50%264 to 94%160 of anterior knee pain cases.
If your patient perceives no change in pain, the treat-
ment tape should be reapplied or the patient should
be reassessed for other issues. The tape can be worn
for extended periods of time to effect a low-load,
long-term stretch on soft tissues. It is worn 23 h a day
with an hour off, usually after a shower, to relieve
skin stress. With a reduction in pain, an increase in
quadriceps strengthening can occur. The tape can get
wet without any effect on its adhesion, but over time,
it loses its effectiveness. The treatment tape strip may
be readjusted if it loosens. If taping proves effective, Figure 23.53 Lateral glide correction.
the superior half of the patella to lift the inferior pole

up and away from the fat pad (figure 23.56).
Skin irritation may occur with the use of tape. To
minimize this risk, the tape is removed carefully;
an adhesive remover should be used after the tape
has been taken off, and the skin should be carefully
cleansed and conditioned with a moisturizer when the
tape is not in use. If a small area of skin breakdown
occurs, the area is covered with a protective dressing,
and the tape should not be applied to that area. If the
skin breakdown area is too large, the tape is discontin-
ued until the skin heals. If an allergic reaction occurs,
the tape cannot be used.
Soft-Tissue Mobility Soft-tissue adhesions and
tightness along the distal ITB and into the lateral reti-
naculum often play a role in patellar malalignment.267
Figure 23.54 Lateral tilt correction. These structures should be treated with deep-tissue
massage, myofascial release, and prolonged stretch-
ing in the case of a tight ITB. Deep-tissue massage
The soft tissue is lifted on the medial aspect to provide can be applied by the rehabilitation clinician with the
a better result. dorsal side of a flat fist (flexed MPs and PIPs, ex-
For patients whose patella sits in a lateral rotation tended DIPs), with pressure delivered over the pos-
alignment, the tape is anchored on the inferior patel- terior middle and distal phalanges, as was discussed
lar pole. The patella is manually rotated into correct earlier in this chapter in the section “Deep-Tissue
alignment and then the tape is pulled upward and Massage.” Other myofascial techniques using tools
medially266 (figure 23.55). If an inferior tilt is present, such as Graston or The Roller are also effective on
it is taped first to reduce infrapatellar fat-pad irritation. these structures. The patient can use a foam roller to
A posterior tilt is usually taped in combination with a perform self-massage techniques (see figure 23.5).
lateral tilt or lateral glide.266 The tape is applied over The patient can perform manual massage techniques
Figure 23.55 Lateral rotation correction. Figure 23.56 Inferior tilt correction.
Knee and Thigh 977
over the distal lateral thigh throughout the day while Lower-limb alignment and mechanics have a direct
sitting (figure 23.57). impact on the patellofemoral joint.73,271 Muscles in
The patient is instructed to perform stretching exer- distal and proximal segments must be corrected for
cises for all tight muscle groups and should perform imbalances along with the knee muscles if patellofem-
them throughout the day. The muscle groups com- oral pain is to be resolved. Muscles that control foot
monly included are the hamstrings, gastrocnemius, pronation, including the posterior tibialis, anterior
and tensor fasciae latae. tibialis, and peroneals, should be strengthened and
reeducated for pronation control and foot stability
Additional Therapeutic Exercises Therapeu- during closed-chain activities.
tic exercise is a vital part of the total rehabilitation Quadriceps strength is primary to a successful
program for patellofemoral pain. Stretching and rehabilitation program.272 Electrical stimulation and
strengthening exercises can alter patellar tracking to biofeedback can be used to facilitate quadriceps activa-
establish a more correct alignment.39,61,254,268 Because tion. These electrical modalities are used in open-chain
muscle imbalance can play a role in PFPS, it is log- exercises such as the straight-leg raise and SAQ and
ical to assume that improvement in muscle balances in closed-chain exercises for concentric and eccentric
can improve this condition. activity such as walking, step-downs, and lunges.
As for all extremity programs, exercises for core, A combination of open- and closed-chain activities
pelvic, and hip stabilization should be included in the within a pain-free range of motion is part of a total
therapeutic exercise program.71,254,269,270 Deficits in therapeutic exercise program. Patellofemoral taping
the strength of these areas are seen in patients with might be needed, especially in the early phases of
PFPS.39,147,243 The results of these studies indicate therapeutic exercise when patellofemoral pain prevents
that hip muscles and abdominals, especially lower adequate quadriceps activation.
abdominals, play a key role in providing adequate knee When the patient can perform closed-chain activi-
control during closed-chain activities. Trunk and core ties in a slow and controlled manner and without pain
exercises were presented in chapters 17 18 and include and the patient can achieve the goals that have been
strengthening exercises for the abdominal obliques, set, the speed of the activities increases to challenge
lower abdominals, and spine extensors. In addition, lat- muscle recruitment patterns and prepare the patient for
eral and posterior hip muscles should be strengthened agility, functional, and performance-specific exercises.
to provide hip stability during knee activities. Many of As the patient achieves the set goals through gains in
these hip exercises are seen in chapter 24. strength, control, and flexibility, he or she follows a
Figure 23.57 Iliotibial band massage.

progression of exercises similar to that for other knee cause patellar tendon pain: Pressure over the tendon,
injuries, advancing to increased stress and forces, more quadriceps tightening (especially eccentric activity),
challenging coordination and agility activities, func- and stair climbing (especially going down). There may
tional activities, and finally performance-specific exer- be slight edema in the tendon.
cises. Return to full participation is possible once the Initial rehabilitation goals are to identify and correct
patient is pain free; correction of etiological factors has the etiological factors and reduce pain. Modalities such
occurred; the patient has normal flexibility, strength, as phonophoresis, iontophoresis, ice, and electrical
agility, and power; and the patient demonstrates normal stimulation may be effective. Cross-friction massage
execution of performance-specific activities. across the tendon can be useful in promoting heal-
ing by improving mobility and reducing soft-tissue
Patellar Tendinopathy adhesions.273,274 The rehabilitation clinician applies
Patellar tendinopathy can be related to patellofemoral cross-friction to one tender location on the tendon until
alignment, so the same factors presented for PFPS the pain is reduced or relieved; he or she then moves
should be examined and assessed when the patient has to another site on the tendon and repeats the procedure
patellar tendinopathy. Patellar tendinopathy is often until all tender sites are treated.
called jumper’s knee because jumping activities are the Therapeutic exercises include a combination of
primary precipitating factor. With the energy absorp- flexibility and strength. Stretching exercises for the
tion that occurs when landing from a jump, jumping hamstrings, quadriceps, lateral thigh, and calf muscles
on hard surfaces and excessive repetitions can overload are taught to the patient and are easily incorporated
the tendon beyond its stress-absorbing capabilities. into a home exercise program. Initial strengthening
Tissue breakdown then occurs. This stress becomes exercises include primarily eccentric exercises275 that
exaggerated with the presence of muscle imbalances are discussed in chapter 15. Eccentric exercises begin
such as weakness or tightness or mechanical malalign- slowly and through a relatively pain-free range of
ments such as foot pronation. motion. Some pain may occur with these exercises, but
Pain occurs in the patellar tendon between the the pain resolves before the next treatment. Additional
patella and the tibial tuberosity. Classic activities exercises include open-chain exercises to isolate the
Case Study
A 16-year-old female cross-country runner has had left knee pain for the past month. The pain has progressed so
that it now interferes with her workouts and occurs even during walking. The physician has diagnosed her with PFPS
and wants her to begin rehabilitation. Your examination reveals genu valgus and recurvatum with foot pronation
in standing. The patient’s running shoes have excessive wear on the lateral posterior heel so that the midsole is
showing through the outsole. The shoes have a sewn curved last. The patient’s rearfoot and forefoot have excessive
mobility. Straight-leg raise is to 70°; ankle dorsiflexion in rearfoot neutral is 0°. She has a positive Ober’s test, and
deep palpation reveals tenderness along the distal ITB. Her quadriceps strength is 4/5, lower abdominal strength
is 3/5, and hip extension strength is 4/5. Patellar alignment assessment reveals a posterior and lateral tilt. Patellar
tracking in long sitting primarily occurs laterally. In standing, lateral patellar tracking is less than in non-weight
bearing but continues throughout knee flexion. When the patient performs a step-down exercise, pain occurs, and
the knee wobbles. Palpation of the posterior patellar surface reveals tenderness medially and laterally, especially
over the inferior aspect.
1. Create a list of her potential etiological factors that have led to her current problem.
2. List her problems in order of priority. Correlate each problem with a long-term goal.
3. What will your treatment for the patient include today? What instructions will you send her home with today?
4. What will you tell her when she asks what she should do about her workouts?
5. Given her signs, in what part of the range of motion would you expect the patient to have the most pain?
6. List two elements you will use to strengthen the VMO during the first week.
7. What are your short-term goals for the next two weeks for the patient?
Knee and Thigh 979
quadriceps and closed-chain exercises for functional necessitates a longer recovery time than a strain that
stresses. The rate of the program’s progression is does not produce bleeding. Ecchymosis is often distal
purely dependent on the patient’s response to the to the site of a muscle tear because gravity pulls the
exercises. Patients who can do performance-specific blood caudally.
exercises without pain or hesitation can return to Lack of normal flexibility, fatigue, incoordination,
normal activities. and a sudden violent contraction or stretch of a con-
tracting muscle can all be frequent precipitating factors
Quadriceps Tendon Rupture in muscle strains.
Quadriceps tendon ruptures occur most commonly Remember that rehabilitation progression must
in people 30 to 50 years old as a result of a sudden coincide with tissue healing. Initial treatment goals in
quadriceps contraction; the cause is probably a gradual phase I include relieving pain, swelling, and spasm.
degeneration, although prior complaints of tendinopa- Pulsed ultrasound is effective in promoting the absorp-
thy are not usual.276 Tendon ruptures occur more often tion of ecchymosis. Electrical stimulation is useful in
in males than in females. As with Achilles tendon relieving pain and spasm. Stretches with activation of
ruptures, the patient feels as though he has been shot the antagonists help to relieve muscle spasm and regain
or kicked in the knee. The patient cannot bear weight range of motion beginning in phase II.
on the extremity. The rupture can occur from either If the patient cannot ambulate normally, assistive
the tendon attachment between the patella and tibial devices are used with weight bearing to tolerance.
tuberosity (patellar tendon rupture) or the tendon Strength exercises are incorporated into the program
between the patella and quadriceps (quadriceps tendon during late phase II or early phase III as the patient
rupture). Complete ruptures are surgically repaired, tolerates them. Active range of motion against gravity
with the knee kept either locked in extension with a may be all that is tolerated initially, but progression
brace or on a CPM machine for the first few weeks. to resisted open- and closed-chain exercises occurs
There are two general approaches to rehabilitation: within a few days. A variety of activities, including
the conservative approach, which includes a long-leg proprioceptive neuromuscular facilitation, manual
cast or brace with limited weight bearing and motion resistance, aquatic exercises and gait training, sta-
restricted to 40° of knee flexion for 6 weeks, and an tionary-bike exercises, co-contraction exercises, and
approach that favors early functional activities, which unilateral weight bearing can begin within 1 to 3 days
include full weight bearing postoperatively with a once spasm and pain have subsided.
gradual progression of increasing knee flexion.277 In The program advances as tolerated to eccentric
either case, weight bearing is restricted initially and and isokinetic exercises. Eccentric exercises are
then advanced to weight bearing as tolerated in the important for muscle strains because athletic activity
brace. One recent study permitted full weight bearing places high eccentric demands on lower-extremity
in an extension-locked brace 1 week after surgery with muscle groups.279 Agility activities requiring more
removal of the brace to allow ROM to 55° of knee rapid muscle responses are introduced into the pro-
flexion.278 At 6 weeks, the patients were allowed to gram late in phase III as the patient gains strength,
discard the brace and push for full knee motion.278 It is coordination, and balance control. After the patient
interesting to note that none of their patients suffered moves into phase IV and can perform functional and
re-ruptures, and in long-term follow-up, the patients performance-specific exercises, he or she is ready to
were satisfied with their results.278 be tested functionally for return to full work or sport
In terms of strength progression after patellar participation.
tendon repairs, straight-leg raises, quad sets, and hip
exercises are used during the first 10 days to 2 weeks. Hamstrings
Patellar mobilizations are used to maintain patellar Hamstring strains most commonly occur at the mus-
mobility. After about 3 to 6 weeks, exercises begin out culotendinous junction, either near the ischial tuberos-
of the brace and follow a progression similar to that ity involving the semimembranosis280 or more toward
for other surgical repair programs. The period until the mid-lateral or distal aspect of the muscle where
return to full activity is 4 to 9 months. the biceps femoris tendon inserts more distally.281
Hamstring strains often occur during high-speed
activities such as sprinting or during sudden changes
Strains and Contusions in muscle activity.
The severity of a strain determines the length of recov- A proper rehabilitation program is important after
ery. Ecchymosis indicates at least a grade II strain and hamstring strains. Stretching exercises begin within 2
to 4 days after an injury in phase II. Also during this can include activities such as bridging, hamstring
time, the patient can perform exercises for core mus- curls within a pain-free range, lunges, deadlifts, good
cles and other muscles and body segments not affected mornings, step-ups, leg presses, slide board, resisted
by the injury. Single-leg balance activities can also be hip exercises in all directions, and heel raises.
added during this time. Home exercises will assist in Once the patient’s strength is 90% of normal and
the patient’s progression. The clinician should con- full motion is present, the patient enters phase IV
tinue with the usual assessment before each treatment where plyometrics and multiplanar exercises advance
session and each activity to ensure optimal progress. to functional and then performance-specific exercises.
Passive hamstring stiffness is often a predisposing Before the return to normal activities, the clinician has
factor in strains.282 After an injury, additional loss the patient complete a number of sport- or work-spe-
of flexibility occurs. Appropriately timed deep and cific tests. When he or she successfully passes these
cross-friction massage to the injury site will promote tests and has been released by the physician, the patient
healing and reduce scar tissue adhesions that will oth- can return to normal activities.
erwise restrict hamstring mobility. Hamstring strains
often recur.283 Scar tissue that was not adequately Quadriceps
treated during the rehabilitation of a hamstring strain Two-joint muscles involved in jumping or sudden
may lead to reinjury once the patient returns to normal changes in direction during eccentric activities are
activities.284,285 Therefore, the first time a patient suffers susceptible to strain injuries;288 for this reason, the
a hamstring strain, the rehabilitation clinician must rectus femoris is the most often strained muscle of the
locate the area of injury and use these deep-tissue quadriceps muscle group. The treatment course for this
techniques to create sufficient scar tissue mobility to injury follows the same routine and phases as for ham-
reduce the chances that the patient will suffer injury string strains. Phase I includes treatment techniques to
after returning to normal activities. These techniques relieve pain, swelling, and spasm. Stretching activities
may be initiated about 3 to 6 weeks after injury, in begin on days 2 to 4 in phase II and are accompanied
phase III, once the tissue’s collagen develops. initially by isometric exercises as tolerated. Aquatic
In addition to regaining muscle flexibility and soft exercises and gait training, proprioceptive neuro-
tissue mobility, strength must also be restored. As with muscular facilitation, passive stretching, and station-
other injuries, strength exercises begin in phase III. ary-bike exercises are used early in the program. In the
Eccentric exercises have proven to be beneficial for resistive phase (III), isometric exercises are replaced
hamstring strain injuries.286 Other strength exercises with eccentric activities and progress to other resistive
Evidence in Rehabilitation
A hamstring strain remains a common injury in many sports. Perhaps one reason for its persistence is that the
causes of hamstring strains are multifactorial. As with other injuries that have so many varied combinations of
causes, preventing hamstring injuries remains an elusive feat. A recent investigation focused on potential causes
and interventions.287 Based on evidence in the literature, the authors indicated that hamstring strains occurred
during eccentric contraction of the muscle. It is interesting to note that sports in which eccentric hamstring activity
is not apparent, such as swimming and cycling, do not see hamstring injuries. Another contributing factor may be
an excessively anteriorly tilted pelvis since such a design stretches the hamstrings so they are stressed before they
are activated. A history of previous hamstring strains places the person at increased risk for another hamstring
strain; the authors theorize that the scar tissue formation may reduce both hamstring strength and flexibility. They
also point out that other investigators have identified a proliferation of scar tissue adhesions to adjacent muscle
fibers, which further restricts mobility and increases the muscle’s susceptibility to damage during eccentric activity.
Weakness in the hamstrings after injury creates an imbalance between quadriceps and hamstrings on the ipsi-
lateral limb and an imbalance between left and right hamstrings; both factors increase the risk of reinjury. Finally,
muscle fatigue creates incoordination and weakness, further increasing the person’s risk of reinjury. Since most
hamstring injuries occur during eccentric activity, the authors advocated the use of eccentric exercises as part of
the rehabilitation program. Flexibility exercises, neuromuscular coordination activities, and scar tissue management
techniques are all recommended to reduce reinjury of hamstring strains.
Knee and Thigh 981
exercises as tolerated. In phase IV, isokinetic, agility, pression loads. A patellar fracture usually occurs as
plyometric, and functional and performance-specific the result of a direct blow, but a tibial fracture occurs
exercises progress as previously mentioned for other most often because of torsional or compression forces.
knee rehabilitation programs. Epiphyseal plate injuries of the proximal tibia or distal
femur occur in adolescent patients whose growth
Iliotibial Band Syndrome plates have not yet matured. Damage to these sites
Iliotibial band syndrome is an overuse syndrome that can alter bone growth.295 Displaced fractures require
results from friction between the ITB and the lateral open reduction and internal fixation (ORIF). Frac-
femoral epicondyle. It is seen most often in middle- tures repaired with ORIF procedures become more
and long-distance runners. Friction is thought to take stable more quickly and can sometimes undergo a
place at 30° of knee flexion when the ITB is pulled over more accelerated therapeutic exercise program. Tibial
the lateral femoral epicondyle, and it occurs during plateau fractures require non-weight bearing after sur-
running when the tensor fasciae latae and gluteus gery. Rehabilitation of these fractures follows courses
maximus, the muscles attaching to the ITB, are active similar to those of other lower extremity fractures. As
and are pulling on the band during the initial stance with any fracture of any segment, therapeutic exercises
phase.289,290 During downhill running, more time is follow closely with the tissue’s healing progression,
spent in flexion, increasing ITB stress. using the patient’s pain and other responses to exer-
Predisposing factors may include leg-length dis- cises as a guide to specific exercise application.
crepancy, increased Q-angle, genu valgus, and foot
pronation. Running hills and increased running dis- Osteochondral Injuries
tances can also lead to ITB syndrome.291 Articular cartilage covering joint surfaces is a very
The patient complains of pain along the ITB (espe- unique type of cartilage, unlike most other types in the
cially over the lateral femoral epicondyle), increased body. Its characteristics along with unique concerns
pain with walking or running (especially down hills), about healing and treatment options after injury are
edema, and crepitus. Snapping can sometimes be felt presented in chapter 2.
over the lateral femoral epicondyle.
Treatment must involve correction of predisposing Repair Options Osteochondral injuries are artic-
factors, stretching, and strengthening. Modalities to ular cartilage defects that occur as a result of trauma
relieve the inflammation and a workout modification to the articular surface, often a direct impact, includ-
are useful in phase I. Running at a faster speed may ing bone bruises.294 These lesions occur most often in
reduce ITB pain, because during faster running the knee young adults.294 The lesions often develop into local-
is at more than 30° flexion in the early weight-bearing ized areas of degeneration. Several treatment options
phase.292 When pain is relieved, strengthening exercises are available for these isolated degenerative changes
for deficiencies should proceed in phase III with the in the knee. As was mentioned in chapter 2, there are
inclusion of open and closed kinetic chain exercises, three main surgical options: debriding the chondral
concentric and eccentric closed-chain activities, and a surface, resurfacing the chondral defect, and a more
progression as previously presented for return to full recent technique called the osteochondral autologous
sport participation. transfer system (OATS). An abrasion arthroplasty is
a debridement technique, while subchondral drilling
and creation of microfractures stimulate bleeding to
Osteochondral Injuries introduce stem cells into the area and are examples
Fractures of the knee bones can be traumatic or of resurfacing techniques. Subchondral drilling uses
stress related. Femur fractures are not common multiple drill holes to expose subchondral bone, al-
occurrences, but tibial fractures are seen more often. lowing bone marrow blood to move into the injured
Unfortunately, osteochondral injuries are common in site.296 The microfracture technique also accesses the
young athletes,293 and if managed poorly, they can be subchondral blood supply but uses a small pick rather
a source of pathology for years.294 Before delving into than a drill bit to create small microfractures around
osteochondral injuries, we’ll briefly address fracture the articular cartilage defect.297 The debriding, drill-
rehabilitation. ing, and microfracture techniques all introduce stem
cells into the area via introduction of the marrow
Bone Fractures blood supply.298 The initial tissue produced through
Fractures of the knee result from direct blows and these techniques is hyaline-like cartilage.299 Unfor-
impact forces, torsional and traction stresses, or com- tunately, the hyaline-like cartilage is replaced by
fibrocartilage within 2 to 3 years.298 The OATS pro- is determined by the number of plugs used to repair
cedure consists of obtaining a small fragment of bone the lesion; for three or fewer plugs, the time of partial
along with its articular cartilage from a portion of the weight bearing is 2 weeks, but with each additional
non-weight bearing joint surface and inserting it into plug inserted, one more week of partial weight bearing
the articular defect site.299 Although the OATS proce- is required up to a maximum of 8 weeks.305
dure is the newest surgical technique for articular car- For either the patellar or femoral condylar pro-
tilage, it also shows the most promise in initial study cedure, a brace locked in extension is used during
results. It has been reported that 93% of patients un- ambulation to reduce shear stress on the lesion site.
dergoing the OATS procedure were able to return to Shear stress is among the most damaging of all stresses
sports activities, while only 52% of microfracture pa- applied to the joints.306 Normal ambulation places shear
tients returned to sports activities.300 stresses on the knee.307 Therefore, using a straight-leg
brace with no weight bearing for the first 2 weeks pro-
Osteochondral Postoperative Rehabilitation A tects the surgical site from stresses it would otherwise
successful postoperative outcome after osteochon- experience. The brace is often worn at night for the
dral surgery depends on a good rehabilitation pro- first 2 to 4 weeks, locked in extension.
gram.301 The rehabilitation clinician must be aware Early range of motion occurs using either a CPM
of the precautions for postoperative care. Issues of machine several hours a day, passive ROM activities,
concern include providing an environment that is or a combination of both. Recall that the goal during
optimal for graft protection and healing. This means this initial period is to stimulate chondral formation
providing some stress to allow tissue to heal with without applying excessive loads to the lesion site.
optimal strength but not overstressing it to damage Electrical stimulation, isometric exercises, and other
the graft. Early controlled loading and motion have nonresistive open-chain exercises occur after the first
been shown to be beneficial.302 Studies have also week in femoral condylar repairs. Hip, ankle, and core
demonstrated that cyclic loading increases chondro- exercises are also used at this time. Biofeedback for
cyte synthetic activity, 302 so periodic weight bearing muscle reeducation is useful for quadriceps facilitation
and range of motion may actually stimulate articular and control. It is appropriate to add aquatic exercises
cartilage repair. On the other hand, there is a limit in deep water for range of motion after the operative
to how much weight should be applied since bearing wounds are well healed. Patellar mobilization and
too much weight or bearing it too soon may hinder soft-tissue mobilization are begun in the second
articular cartilage repair.303 Therefore, the clinician’s post-op week. By the end of the second week, the
goal must be to provide enough stress to create strong patient should have 90° of flexion with full extension.
tissue but not to overstress the healing tissue. It is im- By the end of the second week, the brace is unlocked
portant for the clinician to know where the chondral to 20° with increases in motion as the quadriceps
repair is within the joint and to realize where with- gains strength. A stationary bike without resistance
in the range of motion the patella and femur are in for range-of-motion gains is used after the third week.
contact to stress that repair. A knowledge of patel- Active–assistive range-of-motion exercises, progress-
lofemoral contact areas throughout the knee’s range ing to active range-of-motion exercises are also used
of motion is vital to understanding range-of-motion then. By week 3 or 4, the patient should be able to
restrictions placed on the patient, especially during demonstrate good quad control without an extensor lag
the first several weeks of rehabilitation when contact and should have near-normal knee range of motion.
pressure and stress should be minimized. After the third week, mild resistive aquatic exercises
Osteochondral rehabilitation is slightly differ- in deep water are suitable.
ent for repairs of the patella than for repairs of the By 6 to 8 weeks, the knee should have full range
femoral condyles. Rehabilitation of a patellar graft of motion. Also at this time, full weight bearing with
allows weight bearing immediately after surgery, but crutches begins. Crutches are not removed until the
motion is limited to the 0° to 30° range, and no open- patient can ambulate normally, has no extensor lag,
chain exercises are permitted for the first 3 weeks.304 and has full motion in knee extension. The brace can
Rehabilitation for femoral condylar repairs allows also be discontinued by this time. Aquatic exercises
partial weight bearing only after the second week, can progress from the deep to the shallow end in chest-
but open-chain range-of-motion exercises can begin to waist-high water with progressive weight bearing.
immediately to enhance lubrication and nutrition at the Progressive resistive exercises in the open and closed
surgical site.304 The duration of partial weight bearing kinetic chain, using small arcs of motion initially and
Knee and Thigh 983
advancing to larger arcs of motion, start after 6 weeks. Bone-fracture rehabilitation programs follow the
Exercises such as mini-squats, wall sits, heel raises, same basic progression, but the timing for return to
and leg presses begin once the patient is full weight full sport participation is more rapid. A general range
bearing. Exercises should remain pain free in all arcs of time for return to sport after a fracture is 4 to 8
of motion. A ski machine or stepper can also be started. months. The time range varies according to whether the
Once the patient can ambulate without crutches, tread- fracture is treated surgically or immobilized without
mill walking begins. Static balance exercises progress surgery, the location and type of fracture, the age of
to dynamic balance exercises as tolerated. the patient, and the physician’s preference. See figure
A gradual progression from balance exercises to 23.58 for an outline of progression for rehabilitation.
coordination exercises to agility exercises takes place
as the patient gains strength and improves proprio- Osteochondritis Dissecans Osteochondritis
ceptive functions. Jogging, then running is allowed dissecans (OCD) is a multifactorial condition that oc-
at 4 to 6 months postoperatively. Full return to sport curs more often in children and adolescents than in
participation occurs at 7 to 12 months. adults.308,309 A bone flake in juvenile OCD or a bone
CHONDRAL MICROFRACTURE
Goals Relieve pain
Reduce edema, ecchymosis, effusion
Relieve spasm
End of week 2: 0°–90° knee ROM
Brace locked at 0°
CPM 6–8 h/day
Weeks 1–2: NWB; Week 3: TTWB (20% BW); increase weight bearing
on involved leg as quad strength improves
ROM exercises for hip and ankle muscle groups
PROM for knee
Biofeedback/electrical stimulation for quadriceps facilitation
OKC exercises: quad set; SLR; hip strengthening; ankle strengthening in
knee brace
After week 3: Aquatic exercises for ROM
Week 3: Stationary bike without resistance for knee ROM only
HEP for PROM for the knee often throughout the day
Precautions Maintain brace use except for ROM activities
Brace remains locked in extension at night first 2 to 4 weeks and until
patient has good quad contraction in full extension
(continued)
Figure 23.58 Rehabilitation progression after a chondral microfracture. ROM = range of motion; CPM = continuous passive
motion machine; NWB = non-weight bearing; TTWB = toe-touch weight bearing; FWB = full weight bearing; BW = body weight;
SAQ = short-arc quadriceps; CKC = closed kinetic chain; OKC = open kinetic chain; SLR = straight-leg raise; PRN = as needed; HEP
= home exercise program.
Weeks 6–8: Full weight bearing with crutches
Wean from crutches as quad control is achieved
Treadmill ambulation without crutches
Week 8: Normal knee ROM
Balance activities once FWB
Normal gait
Treatment guidelines Weeks 6–8: FWB gait training with crutches as needed
Joint mobilization, soft-tissue mobilization PRN
Stationary bike
CKC exercises: mini-squats, leg press, wall squats, heel raises, hip
strengthening
OKC exercises: SAQ, hamstring curls
Aquatic: cardiovascular conditioning, resistive exercises and gait training
PRN
Normal gait
hamstring resistance exercises at hip: Step-ups, lateral step-ups, squats,
leg press, lunges
Week 16: Jogging, advancing to running with increase of strength to
85% normal
Week 20: Running or sprinting backward, cutting, cariocas
Avoid pain and joint effusion
984
Knee and Thigh 985
fragment in adult OCD occurs at various sites of the with progressive weight bearing can be used, starting
femoral condyle. Juvenile OCD occurs in youths in shoulder-high water and moving progressively
aged 10 to 20 years.310 Symptoms include nonspecific into shallower water as tolerated. Activities to restore
knee pain, point tenderness over the site, and quadri- proprioception using a BAPS board and a balance
ceps atrophy. There is minimal effusion, and the pa- board, as well as single-limb stance balance activities,
tient may experience catching, locking, or giving way are helpful.
during ambulation. Rehabilitation after surgical treatment includes
Treatment for adult OCD includes arthroscopic immediate weight bearing unless the lesion is large;
debridement of loose bodies. If the lesion is small, in this case, weight bearing may be restricted. A grad-
an abrasion arthroplasty or autogenous grafting can ual progression of exercises that do not produce pain
also be performed. Arthroscopy is the gold-standard takes place as with other knee lesions. An expected
treatment for removing loose bodies in adults with recovery to full sport participation usually takes about
OCD.310 However, juvenile OCD is more conservative 4 to 6 months.
with prolonged rest and immobilization.311 Non-weight
bearing restrictions may extend for 6 to 8 weeks.308
Studies have shown that juvenile patients do better Summary
with nonoperative care using these non-weight bearing
and activity restriction strategies as long as the lesion The knee is positioned between two long lever arms, so
is stable and has an intact cartilage surface.312 it is often the site of injury in any number of activities
Rehabilitation for juvenile OCD must try to reverse and sports. The patellofemoral joint is susceptible to
the deleterious effects of immobilization and inactivity. pain and dysfunction. Patellofemoral pain syndrome is
Cardiovascular exercise using the upper extremities usually a multifactorial condition, and it is important
and lower-extremity exercises for the uninvolved for the clinician to identify the underlying problems
segments help to maintain conditioning levels during that lead to a specific patient’s condition. Stresses for
immobilization. Quad sets, straight-leg raises, and knee structures change in both open- and closed-chain
electrical stimulation can assist in retarding atrophy activities; it is important for the clinician to understand
during immobilization as well. Range-of-motion when stresses are high or low so appropriate rehabilita-
exercises are often permitted during the prolonged tion exercises are used in a patient’s program. Trigger
time of non-weight bearing. Patellar and soft-tissue point treatment, joint mobilization techniques, and
mobilizations may also assist in maintaining knee progressive exercises from flexibility to functional
range of motion. activities and performance exercises were included
Active exercises are used once knee motion is in this chapter. Some of the more common injuries of
permitted. Weight-bearing exercises include weight- the knee and thigh were presented along with rehabil-
transfer activities and gait training. Aquatic exercises itation programs for them.
LEARNING AIDS
Key Concepts and Review
1. Discuss the relationship and alignment between the patella and femur.
Patellar stability is produced by both static and dynamic structures. The bony configuration,
with the patella seated within the femoral sulcus formed by the medial and higher-ridged lateral
epicondyles, is the greatest bony contributor to patellar stability. Patellofemoral and patellotibial
ligaments help provide static restraints and patellar stability. Active restraints come primarily
from the quadriceps. The patella is in various degrees of contact within its groove in the femur
during any specific point within the knee’s range of motion. A combination of compressive forces
and the amount of area of contact determines the stress on the patellofemoral joint.
2. Identify post-injury factors that influence strength output.
Edema and pain both cause automatic withdrawal of quadriceps activity. An abnormal gait, using
the injured extremity less than normal, also results in reduced muscle activity. These factors in
combination contribute to a further reduction of strength in the injured extremity.
3. Define quadriceps extensor lag and AMI and explain their significance.
An extensor lag occurs when full passive motion of knee extension is present but the patient
cannot actively achieve full extension. It is an indication of quadriceps weakness. AMI, or arthro-
genic muscle inhibition, occurs as a result of joint swelling, pain, or injury. An inhibition of the
muscle’s normal motoneuron pool functions inhibits normal activity of the muscle. Quadriceps
AMI contributes to delayed response to treatment because it inhibits quadriceps activity and
can retard effective strengthening efforts since the neurogenic inhibition prevents the quadriceps
from activating properly. This is a condition that may persist for long after the initial injury and
can interfere with normal lower extremity function.
4. Outline a general progression of rehabilitation for a knee.
As with other body segments, specific applications depend on specific deficiencies. Modalities
are used to relieve pain and edema and effusion and to encourage the healing process in phase
I. Soft-tissue and joint mobilization techniques may be necessary. Range of motion, active and
passive, is used to increase motion in phase II. Easy strengthening exercises can be started late
in phase II or early in phase III within a pain-free range of motion or with isometric exercises.
In phase III, manual resistance can progress to machine and body-weight resistances, resistance
bands, and isokinetics. A combination of open- and closed-chain exercises are a part of the pro-
gram once the patient is weight bearing. Weight-bearing proprioception and balance activities
begin with something simple like a stork stand and progress to balance activities on unstable
surfaces. Once flexibility, balance, and strength have reached appropriate levels, either late in
phase III or early in phase IV, plyometric exercises, such as target jumping, lateral jumps, box
activities, and depth jumps, can be used. In phase IV, functional activities progress to perfor-
mance-specific exercises that mimic the patient’s sport or work demands before full participation
in the patient’s sport or work is permitted.
5. Identify three soft-tissue mobilization techniques for the knee.
Three such techniques include foam roller myofascial release to the ITB, trigger point release
to the popliteus, and cross-friction massage to the patellar tendon.
6. Identify three joint mobilization techniques for the knee and the purpose of each of them.
Lateral glides of the patella are used for full flexion–extension range of motion of the knee;
posterior glides of the tibia on the femur increase flexion; and rotational glides increase terminal
flexion and extension of the knee.
7. Describe three flexibility exercises for the knee, and identify the structures they affect.
Flexibility exercises include standing knee flexion stretch for the quadriceps with the heel behind
the buttocks, standing hamstring stretch with the involved extremity on an elevated surface, and
the gastrocnemius stretch with the knee straight.
8. Describe three proprioception/balance exercises for the knee.
Exercises for proprioception/balance include stork standing with eyes open, eyes closed, and eyes
open with head rotations to the left and right, stork standing on a 1/2 foam roller, and standing
on a foam roller while catching a ball.
9. Identify three functional activities.
Three functional activities include running and cutting while dribbling a basketball, sprinting
forward and then backward with rapid changes in direction, and lateral glides with pivots to
left and right.
10. Identify three factors that influence PFPS.
Three such factors are weak quadriceps, weak hip and trunk control, and tight hamstrings.
Critical Thinking Questions

1. In this chapter’s opening scenario, how much knee flexion motion would you expect Steve
to have after 2 weeks of immobilization? What would be the most effective kind of motion
exercise he should be able to start on his first day of rehabilitation? What strengthening
Knee and Thigh 987
exercises would you give him for his hip and ankle on his first day of rehabilitation? When
you would expect him to have full knee motion? When would you start him on passive
stretching exercises for his quads? Justify your timetable.
2. When would you begin patellar mobilization on Steve? When would you begin soft-tissue
mobilization to the quadriceps repair site? Give your rationale for these timetables.
3. If you had two patients with knee injuries, one with an ACL sprain and the other with an
MCL sprain, which one (if either) would you be more cautious with and why? How would
their rehabilitation programs differ?
4. If a patient complains of patellar tendinopathy, what structures would you investigate for
possible causes? What key items would you include in your history questions? Would you
use primarily open- or closed-chain exercises at first, and why?
5. A teenaged patient you have been rehabilitating for weakness after a contusion on the
anterior knee near the lateral femoral condyle continues to complain of pain in the knee
even though his strength is improving. How would you approach the problem and what
would you suspect?
Lab Activities
1. Perform soft-tissue mobilization on your lab partner’s ITB. First examine the area for any
restrictions, and then apply mobilization to relieve the main restrictive areas. Examine the
area after your treatment. What changes do you and your partner (objectively and subjec-
tively, respectively) observe? What do you think has occurred with the treatment? Use a
foam roller to perform a soft-tissue mobilization technique on the same area for the same
amount of time. Compare the sensory changes between the two techniques. Based on the
differences, what would be the advantages and disadvantages of each technique?
2. Locate the trigger points on your lab partner for the muscles listed. As you perform each
one, indicate what the pain pattern would be if the trigger point was active.
a. Popliteus
b. Medial hamstrings
Which one was your partner’s most sensitive trigger point? Perform a treatment tech-
nique on it, and provide your partner with a home exercise for the tender trigger point.
3. Perform grade II and IV joint mobilizations on your lab partner and identify what restriction
would be best treated with each mobilization for the following joints:
a. Patellofemoral glides
•• Medial glide
•• Lateral glide
•• Superior glide
•• Inferior glide
b. Tibiofemoral glides
•• Distraction
•• Anterior
•• Posterior glide
•• Anterior glide of the medial condyle
Are the medial and lateral patellofemoral glide excursions the same? Perform the tibi-
ofemoral glides first in the resting position, and then in other open-packed positions. How
does the amount of motion change with the different positions? What implications does
this outcome have on treatment?
4. Have your partner perform two different prolonged stretch exercises to increase knee
flexion. Is there an advantage to one over the other?
5. Identify short-term stretches you would give a patient to perform at home to improve knee
flexion and extension. Identify the position in which you would place a patient to stretch
a knee with extension limited to 15° of flexion and the position for another stretch that
could be used on a knee with extension limited to 90° of flexion. What factors do you
have to consider that are unique to each condition when coming up with an exercise for
each situation?
6. Have your partner perform two different exercises (same level of difficulty) to strengthen
the quadriceps. How are they different? Why might you use one over the other? Explain
your rationale.
7. Have your partner perform a lateral step-up exercise for 20 repetitions on an 8 in. step.
What substitution patterns must you watch for, and how would you correct them?
8. Have your partner perform a wall squat using three different ways of doing it so each
exercise is a progression of the previous one. Have your partner perform 20 repetitions of
each exercise. Does your partner agree that the sequence you created is a progression, or
is a later exercise easier than a previous one? What are the substitution patterns for which
you should watch, and what verbal cues would you give to correct each substitution?
9. Have your partner perform three proprioceptive exercises, each one a progression of the
previous exercise. What have you used to determine when your partner can progress to
the next exercise (what are your goals for each exercise)?
10. Evaluate your partner’s patellar alignment for lateral tilt, lateral shift or glide, inferior tilt,
and rotation. What malalignments do you see? Are they bilateral? If there are malalign-
ments, why might your partner have them? What exercises might correct the alignment
deficiencies?
11. Have your partner perform a quad set in supine and a lunge in standing or go up and down
a step. What differences in patellar tracking do you see between the two positions? How
would you correct any deficiencies you noted?
12. You are seeing a patient (a high school basketball forward) for the first time today. She is
2 weeks postoperative with an ACL reconstruction (patellar tendon graft). List in proper
sequence all the exercises you would include in the rehabilitation program. You do not
need to identify timing, only the sequence in which you would add the exercises. Also,
indicate when you might consider discontinuing an exercise in the program and your
rationale for doing so.

Knee Therapeutic Exercise For Musculoskeletal Injuries

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23

Knee and Thigh

primarily by the posterior menisci, whereas in exten- Patellofemoral Joint

entations can increase stress levels on various knee

Factors Influencing Post-Injury Strength

Isometric contractions CKC

Bracing area involved in new tissue formation will dictate

TABLE 23.1 Trigger Points Commonly

Figure 23.5 Iliotibial band foam-roller self-massage.

produce tenderness in normal tissue, but tenderness

Proximal Tibiofibular and

Patellofemoral Joint Mobilization

Notations: This technique is often used both prior to and

ROTATIONAL GLIDE: ANTERIOR

ROTATIONAL GLIDE: POSTERIOR GLIDE

Prolonged Flexibility Exercises for the Knee

Go to the online video and watch

Body Segment: Knee.

PROLONGED KNEE FLEXION

Active Stretches stretching the muscle in this position is futile because

Active Flexibility Exercises for the Knee

SEATED KNEE FLEXION

STANDING KNEE FLEXION

SUPINE HAMSTRING STRETCH

STANDING HAMSTRING STRETCH

Go to the online video and watch video 23.25,

Body Segment: Knee (hamstrings).

Strengthening Exercises stability,147 so exercises for these muscles are included

provide a balance of exercises that include perhaps only Isometrics

Strength Exercises for the Knee

OPEN KINETIC CHAIN (OKC):

OKC: STRAIGHT-LEG RAISE

OKC: HAMSTRING SETS

Non-Weight-Bearing Isotonic resistive phase (III) of the therapeutic exercise program

OKC: FULL-ARC QUAD EXERCISE

OKC: HAMSTRING CURLS IN PRONE

CLOSED KINETIC CHAIN (CKC):

Go to the online video and watch video 23.31,

Body Segment: Knee.

Weight-Bearing Resistive ity.152 This discussion has been expanded by other

CKC: LEG PRESS

CKC: WALL SQUATS

CKC: GOOD MORNINGS

The patient lifts the body up to the step by tighten-

knee flexion.118 It is essential that if an open-chain knee

Figure 23.43 Machine hamstring curl.

direction; backward running with sudden changes to

in chapter 22 for the ankle. The exercises vary more

Ligament Sprains differences between surgically repaired and non–sur-

Stage III: Resistive phase

Figure 23.47 (continued)

assistive devices by 6 to 10 weeks.218-220 During this

Figure 23.49 (continued)

with immediate postoperative partial to full weight

Stage II: Active phase

Figure 23.51 (continued)

Lateral Medial Lateral Medial Lateral Medial

Normal orientation Lateral glide Lateral tilt

Normal orientation Lateral rotation Medial rotation

Figure 23.52 Patellar orientation.

the superior half of the patella to lift the inferior pole

Figure 23.57 Iliotibial band massage.