Knee Problems

Have you considered the control over the knee occurring from ball & socket joints? Traditionally, anatomical constructs of reasoning suggest that the lateral & medial stability of the knee is precariously maintained by collateral ligaments. However, what controls the tibia and femur? Since, the hip and talo-navicular joints are ball & socket joints they serve the function of providing ROM. The motor control conundrum that such large ROM presents is it's balance with stability not only in the hip and talonavicular joint but also those regions abilities to contribute to the protection of the ligaments of the knee.

link to explanation in Shoulder section

Motor learning theory devised by Bernstein suggests that the body will use the momentum of the limbs to optimize the degrees of freedom in the system.  Similar to a mass-spring analogy where the perturbations of the mass will be dependent on the damping characteristics of the spring,  the brain will introduce muscle tone to dampen the angular velocity and hence acceleration of the system.  Therefore, instead of the muscles of the leg lifting the limb, the antagonistic muscles are decelerating the limb towards the end of trajectory.  Moreover, by using eccentric (muscle lengthening and contracting) muscle contractions the system becomes efficient through these decelerating movements through enhanced visco-elastic rebound as well as the conservation of momentum. 

see Motor Learning section for further explanations

As such, the muscles around the hip and talo-navicular joints perform the function of multidimensional stability. Clearly, the femur affects knee positioning and the position of the ilium/hip will affect timing of the muscles around the hip-thigh. Any anterior ilial rotation generally makes it difficult for the gluteus maximus to fire before or simultaneously with the hamstring muscles. Tightness of the adductor muscle can cause an 'inflare' of the ilium, potentially placing adverse tension on the ischiococcygeal and sacrotuberal ligaments. Moreover, this adverse tension of the adductors could affect the nutrition to the knee through the phylogenetic link of these muscles with the medial collateral ligament and hence medial meniscus. Any adverse function of the iliopsoas can affect femoral blood flow which is likely to affect slow twitch, stabilising, endurance muscles more than fast twitch, glycolitic, ballistic muscles. Hence, as the duration of activity increases, movement stability may break down, leading to 'poor form' and potential injury.

The subjective examination should include aspects of the stage, stability, irritability and severity of the disorder.

link to further explanation

Hence the physical examination should include analysis of

• gait
• squat

• pelvc symmetry
• lumbo-pelvic dynamics
• femoral pulse
• inferior lateral movements of the T/S and lateral diaphragm control over Psoas Major function

• foot dynamics (esp. pronation <-> supination)

go to foot - orthotics section for further details

• muscle timing and duration of contribution between Vastus Medialis and Vastus Lateralis, Gluteus Maximus and Hamstrings, Gluteus Medius and Adductor synergy, deep hip rotator endurance and strength.

• Relationship between the deep and superficial abdominal muscles and their affect on pelvic symmetry and lumbopelvic rhythm.
• ROM's of the hip, knee, foot and L/S
• Muscle energy techniques
• Cycling Kinematics
• Bike Seat Position

- anterior (front) knee pain : raise seat slightly (unless grossly malpositioned generally the changes are in the order of 2-3mm)

- posterior (back) knee pain : lower the seat slightly and/or move it forwards for butt tightness

- lateral (outside) knee pain : lower the seat and/or move it backwards

- inside knee pain : cleat and ankle position, symphasis pubis and adductor strain - seat may be too high, forefoot varus may require the insertion of a pedal wedge (Lemond LeWedges)

• Pedal Position

- moving the foot forward on the pedaal creates increases in quadriceps power, however it also increases the loading of the patello-femoral joint

- moving the foot back on the pedal engages the hamstrings and gluteal muscles to provide synergistic extensor power to the quadriceps

• Stability

- fit for skiing?

• Abdominal and Gluteal Strengthening

• Motor learning using Quadriceps VMO training

additionally, EMG can be used in combination with transverse abdominis, gluteus medius, medial calf muscles and VMO

• Gluteal lengthening, combined quads/abdominal strengthening

• Lumbo-pelvic dynamic stretching a la Krause

• Taping of the patella

Taping or other aids can also be used around the hip/buttocks to prevent femur internal rotation thereby reducing the relative lateral alignment of the patella w.r.t the femur.

In conclusion, the examination and treatment of the knee should include assessment of all the structures which can affect knee function. Prior to the physical examination, a thorough subjective examination should be conduct to enable the client and the therapist to engage in the clinical reasoning process. Interested readers should look at the Instructional Design section of this website.

knee paper summaries

Last update : 28 November 2009