Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons SECTION 6 Knee and Lower Leg

Home , Plica syndrome, Prepatellar bursitis

PAIN DIAGRAM Knee and Lower Leg

Osteoarthritis of the hip and thigh Iliotibial band syndrome (see Hip and Patellofemoral instability Thigh section) Osteochondritis dissecans (see Pediatric Orthopaedics section)

Fracture (intercondylar)

Plica syndrome Collateral ligament Collateral ligament tear (LCL) tear (MCL)

Osteonecrosis of the Patellofemoral pain Lateral femoral condyle Patellar fracture

Meniscal tear Medial (lateral) Meniscal tear Patellar tendinitis (medial) Patellar tendon rupture

Fracture Anterior (tibial plateau) Bursitis Lateral (prepatellar) Quadriceps tendon rupture

Quadriceps tendinitis Distal femoral fracture Tibiofemoral fracture (Fractures About the Knee) Collateral ligament tear (MCL) Lateral Medial Popliteal cyst

Meniscal tear (medial) Arthritis Bursitis Medial gastrocnemius (pes anserine bursitis) tear

Medial Posterior

640 Pain Diagram 686 Bursitis of the Knee 715 Home Exercise 739 Patellofemoral Pain 642 Anatomy 690 Procedure: Pes Program for Medial 743 Home Exercise Gastrocnemius Tear Program for 643 Overview of the Knee Anserine Bursa and Lower Leg Injection 717 Meniscal Tear Patellofemoral Pain Plica Syndrome 651 Home Exercise 692 Claudication 722 Home Exercise 746 Program for Knee 694 Collateral Ligament Program for Meniscal 749 Home Exercise Conditioning Tear Tear Program for Plica Syndrome 657 Physical Examination 698 Home Exercise 724 Osteonecrosis of the of the Knee and Program for Collateral Femoral Condyle 751 Popliteal Cyst Lower Leg Ligament Tear 727 Patellar/Quadriceps 754 Posterior Cruciate 668 Anterior Cruciate 701 Compartment Tendinitis Ligament Tear Ligament Tear Syndrome 730 Home Exercise 758 Home Exercise 672 Home Exercise 705 Contusions Program for Patellar/ Program for PCL Injury Quadriceps Tendinitis Program for ACL Tear 707 Fractures About 760 Shin Splints 675 Procedure: Knee Joint the Knee 732 Patellar/Quadriceps Tendon Ruptures 762 Stress Fracture Aspiration/Injection 711 Iliotibial Band 678 Arthritis of the Knee Syndrome 735 Patellofemoral Maltracking 683 Home Exercise 713 Gastrocnemius Tear Program for Arthritis

Section Editor Robert A. Gallo, MD Associate Professor Orthopaedic Surgery Hershey Medical Center Hershey, Pennsylvania

Contributor Mark C. Hubbard, MPT Physical Therapist Bone and Joint Institute Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania

Anterior cruciate ligament Posterior cruciate ligament

Lateral condyle of femur (articular Medial condyle of femur (articular surface) surface)

Popliteus tendon Medial meniscus

Fibular collateral ligament Tibial collateral ligament

Lateral meniscus Medial condyle of tibia Transverse ligament of knee Tibial tuberosity Head of fibula

Gerdy tubercle

Knee: Cruciate and Collateral Ligaments (Anterior View, Right Knee in Flexion) Vastus lateralis muscle Vastus medialis muscle Rectus femoris tendon (becoming Patella quadriceps femoris tendon)

Iliotibial tract

Superior lateral genicular artery Superior medial genicular artery Lateral patellar retinaculum Tibial collateral ligament Biceps femoris tendon Medial patellar retinaculum Inferior lateral genicular artery Inferior medial genicular artery Infrapatellar branch (cut) of Semitendinosus muscle Iliotibial tract Common fibular (peroneal) nerve Saphenous nerve (cut) Semimembranosus muscle Biceps femoris muscle Head of fibula Gracilis muscle Tibial nerve Joint capsule Patellar ligament Popliteal artery and vein Insertion of sartorius muscle Fibularis (peroneus) longus muscle Tibial tuberosity Tibialis anterior muscle Tibia Sartorius muscle Gastrocnemius muscle Common fibular (peroneal) nerve

Superior medial genicular artery Plantaris muscle Soleus muscle

Extensor digitorum longus muscle Superior lateral genicular artery Gastrocnemius muscle (medial head) Gastrocnemius muscle (lateral head) Nerve to soleus muscle Lateral sural cutaneous nerve (cut) Extensor hallucis longus muscle Medial sural cutaneous nerve (cut) Small saphenous vein

Fibularis (peroneus) brevis muscle Gastrocnemius muscle

Fibula Superior extensor retinaculum

Lateral malleolus Medial malleolus Soleus muscle Inferior extensor retinaculum Plantaris tendon Tibialis anterior tendon Extensor digitorum longus tendons Medial branch of deep fibular (peroneal) nerve Fibularis (peroneus) tertius tendon Soleus muscle Extensor hallucis longus tendon Extensor digitorum brevis tendons Flexor digitorum longus tendon Extensor hallucis brevis tendon Tibialis posterior tendon

Fibularis (peroneus) longus tendon Posterior tibial artery and vein

Dorsal digital branches Tibial nerve Fibularis (peroneus) brevis tendon of deep fibular (peroneal) nerve Medial malleolus Calcaneal (Achilles) tendon Dorsal digital nerves Flexor hallucis longus tendon Lateral malleolus Superior fibular (peroneal) retinaculum Flexor retinaculum Muscles of Leg Fibular (peroneal) artery Calcaneal branches of fibular (Superficial Dissection) Calcaneal branch of (peroneal) artery posterior tibial artery Anterior View Calcaneal tuberosity Muscles of Leg (Superficial Dissection): Posterior View

642 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons Overview of the Knee and Lower Leg Knee and lower leg problems are diagnosed by obtaining an appropriate medical history, performing a physical examination, and obtaining appropriate imaging studies. Radiographs are the initial imaging study of choice. Patients with knee problems report pain, instability, stiffness, swelling, locking, or weakness. These ﬁ ndings may occur in or around any aspect of the knee. Careful localization of the pain and tenderness will substantially narrow the differential diagnosis. The examination of patients with knee problems also includes a screening evaluation of the hip, spine, and back; some patients with problems intrinsic to the hip present with distal thigh pain and other symptoms that mimic knee disorders, whereas lumbar radiculopathy can produce thigh, knee, or leg pain. Radiographic examination of the adult knee includes AP, 30° weight-bearing, lateral, and axial patellofemoral (Merchant or sunrise) views (Figure 1). Because of a higher incidence of osteochondritis dissecans and reduced likelihood of osteoarthritis, tunnel views obtained with the knee at 40° of ﬂ exion should replace the 30° weight-bearing views in patients younger than 20 years. If the patient is able to stand, weight-bearing AP radiographs of both knees should be obtained to allow comparison of the injured knee with the opposite, uninjured knee. A 30° weight-bearing view has been shown to demonstrate arthritis and joint space loss more readily than the AP view obtained in full extension. An axial patellofemoral view helps visualize the patellofemoral joint. Radiographs should be inspected

KNEE AND LOWER LEG LOWER AND KNEE Figure 1 A 30° weight-bearing radiograph demonstrates joint space narrowing in the medial compartment of the left knee (black arrows). Note the more subtle joint space narrowing in the medial compartment of the right knee (white arrows) with less obvious degenerative change. (Reproduced from Johnson TR, Steinbach LS, eds: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 532.) 6 SECTION

Overview oftheKneeandLower Leg Essentials ofMusculoskeletal Care 5 Meniscal injuries Meniscal injuries mechanism Extensor injuries Ligamentous syndrome Compartment Dislocations Fractures Musculotendinous strains or PainLeg and Knee Possible Causes ofAcute 1 Table or patellar tendon rupture) quadriceps fracture, (patellar contusions

are other structural causes of acute pain. Patients with ligamentous ligamentous Patients with of pain. causes acute structural other are tears meniscal and tears, and strains musculotendinous disruptions, syndrome. compartment suspected shouldfasciotomies with not bedelayed persons in defi the are measurements pressure compartment diagnosis, clinical isa syndrome compartment Although compartment. fascial tight the within excessive increases and pressure paresthesia the as pain emergency.surgical early Clinically, predominant the a represents and injuries orcrush fractures from results syndrome Compartment knee. the when orhelper apatient scene extends the at reduced often Patellar dislocations are imaging. vascular further 0.9 less than index should prompt ankle-brachial an setting, this In dislocation. aknee of sustaining patient any suspected in determined should be ofextremity index affected the ankle-brachial The injuries. vascular occult with beassociated can and reduce spontaneously dislocations often knee because for injuries should these bereserved of index events. Ahigh suspicion low- from result orhigh-energy and rare are dislocations Knee major trauma. from stem often femur of distal tibia and proximal the fractures whereas falls, during forces, such rapid as deceleration orindirect direct from result can con often can radiographs and diagnosis, differential the narrow can areas the tibio tibiofemoral, the affect dislocations can patellofemoral, orrarely, injury. substantial of presence the a indicate often effusions acute and Deformity loss of function. limb substantial residual sequelae, including prevent to permanent isrequired syndrome compartment or acute ( pain acute with associated of any categories, several Possible be which into can fall diagnoses injury. an to secondary occurs often leg the knee and in Acute pain Acute Pain planning. surgical tool orin diagnostic role advanced workup. an However, as plays often important an MRI diagnostic initial the in indicated israrely MRI fracture, radiographic of patellofemoral the joint. arthritis and trochlea the within alignment baja).patella patellar assess to patellofemoral used are views Axial and alta malposition and (patella patella for the fractures assessing helpful in are radiographs Lateral tibiofemoral and tibia, alignment. proximal and femur of distal the fractures arthritis, compartment 30°extension of and fl of opacities. and radiolucencies areas lesions, other and lesions, blastic lytic including for bony architecture, in changes Although these injuries are not as urgent, isolated ligamentous isolated ligamentous urgent, not as are injuries these Although Fractures can involve any of the periarticular osseous structures; structures; osseous involve can Fractures of any periarticular the dislocations, unreduced fractures, of diagnosis unreduced Prompt noapparent and effusion exceptionWith the traumatic of acute an full in knee the with obtained Weight-bearing radiographs AP nitive method to con nitive to method fi rm the presence of a fracture or dislocation. Patellar fractures ordislocation. Patellar fractures of presence the afracture rm fi bular joint. location of The bular swelling, deformity, tender and exion are used to evaluate medial and lateral lateral and medial evaluate to used exion are © 2016American Surgeons Academy ofOrthopaedic fi rm a diagnosis. To minimize myonecrosis, To adiagnosis. rm minimize Table 1 Table ). fi ndings are ndings further investigation for the presence of a tumor, which can usually investigation usually of for which presence can the atumor, further should prompt that symptoms and signs concerning are pain night Night sweats unrelenting and recognize. to but important uncommon involving joint bone and the are tumors Primary sitting. after walking or rising activity,worsen with and increased with associated bilateral, often are they characteristics; have similar injuries chondral and patellofemoral syndromes, tendinitis, Bursitis, changes. radiographic without pain cause can tears isolated degenerative meniscal changes, loss of with radiographic motion and beassociated can and joint the to line localized by symptoms characterized are both simultaneously. occur often and Although symptoms presenting bone). or (soft-tissue (such infection such as osteomyelitis as orpyomyositis) tumor and conditions less common to besecondary region calf alsocan the in pain chronic section, this in discussed ailments unique the to addition In of disorders. change. etiology The of includes aspectrum pain calf acute an as manifest sometimes can that conditions gout chronic such as are arthropathies In tears. meniscal and injuries, chondral patellofemoral-related and disease), tendinitis, tumors, bursitis, (including syndromes overuse include osteoarthritis, pain knee chronic cause that 2weeks. Conditions for present been morethan defi are leg conditions and pain knee Chronic Chronic Pain considered. be should of débridement joint and the promptirrigation and infection, suggests 50,000 mL cells per than Acell greater count culture. and stain, arthropathy crystalline acute an from distinguished isoften infection similar, is presentation Although patella. the joint to deep knee the within super swelling causes bursa prepatellar the in Infection infection. the palpation of and involved the helpInspection can localize area source. isthe More bursa commonly, adults. in prepatellar the rare joint is knee the within arthritis Septic arthropathy. or crystalline swelling. of and causes pain indirect are strains musculotendinous tenderness; blows and pain localized direct cause and from result Contusions meniscus. the or“unlocks” which reduces manipulation, isrelieved extension and by gentle prevents full that sensation alocking describe tears meniscal joint. with the Somepatients along tenderness and pain localized and foot ground plantedonthe the with sustained injury of atwisting ahistory with persons in should besuspected injury Meniscal knee. actively the straighten to inability collapse an sudden and report rupture) tendon patellar or (such mechanism quadriceps extensor as the to injuries with swelling, instability. Patients and substantial pain, acute with present and of injury time atthe occurred a“pop” that recall often injuries © 2016American Surgeons Academy ofOrthopaedic Osteoarthritis and degenerative meniscal tears have similar have similar tears degenerative and meniscal Osteoarthritis by infection becaused can Acute without obvious pain injury fi cial to the patella; joint sepsis produces a substantial effusion effusion patella; joint the asubstantial cial to produces sepsis fl are using knee aspiration for cell count, crystal, Gram Gram for crystal, cell aspiration count, knee using are fl are with an effusion and minimal radiographic radiographic minimal and effusion an with are fl ammatory or crystalline ned as those that have that those as ned

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ba by iliotibial caused isusually of knee the aspect alongPain lateral the Lateral KneePain suggests in it resembles agoose’s of absence the trauma in area this foot. in Pain such because as isnamed and tendons semitendinosus and gracilis, of sartorius, the of iscomposed insertion the anserinus pes The pathology. anserinus pes with confused often are ligament collateral respectively. medial distal of the to Because itsproximity, injuries joint the to line, distal epicondyle oraregion centimeters several medial the to localized pain with ortibial attachments femoral its near beinjured can ligament Alternatively, collateral medial the should ligament collateral of beconsidered. medial the midsubstance of ortear the swelling injury, recent and asprain localized with isassociated joint line medial the When of knee. the compartment defect orafocal involving chondral medial the arthritis to secondary be region alsocan this However,or locking. in tenderness and pain of asensation catching may report patients ofsegment meniscus, the involves tear the orunstable alarge When meniscus. atorn with fi hallmark isthe joint alongPain medial line the Medial KneePain and patellar tendons, respectively. of quadriceps the insertions of patellar the tear orpartial tendinitis lower and upper atthe poles of indicate patella the focal tenderness and pain contrast, In patella. the to deep achy pain dull, a diffuse, t suggests and symptom presenting isacommon pain knee Anterior Anterior KneePain Location ofPain region isuncommon. knee the in disease Metastatic years. aged 30 20 to persons in occurs which typically cell tumor, giant the is involving knee the tumor benign mostcommon the whereas adults, in chondrosarcoma and adolescents in osteosarcoma are bone tumors be identi neurovascular bundle, abnormalities of the neurovascular system system of neurovascular the abnormalities bundle, neurovascular of location joint of the of popliteal capsule. posterior the Because the distention the may from perceive pain popliteal effusions knee with patients addition, In pain. knee of causes posterior common cyst are t involving isrelatively tears Meniscal pain Posterior knee uncommon. Posterior KneePain joint line. lateral the to localized usually pathology are chondral and tears meniscal tubercle, Gerdy the to epicondyle lateral the from along course its anywhere pain cause can epicondyle, lateral underlying the and tendon the between by friction caused presumably syndrome, iliotibial band plateau.tibial Although condyle femoral or lateral the defector afocal affecting chondral h h e presence of chondromalacia patella. Usually, patella. ofe presence chondromalacia describe patients e meniscal root and those associated with the formation of formation aBaker the with associated those root and e meniscal nd sy ndrome, a lateral meniscal tear, lateral compartment arthritis, arthritis, compartment lateral tear, meniscal alateral ndrome, fi ed on radiographs. The most common malignant primary primary malignant mostcommon The onradiographs. ed fl ammation of the bursa beneath the pes anserine tendons. anserine pes the beneath of bursa the ammation © 2016American Surgeons Academy ofOrthopaedic nd i ng associated ng associated w laterally patellofemoral the manifests joint usually within Instability Patellofemoral ligament eventually tightens. displacement of the patella is attempted. apprehension when lateral exhibits usually patient the case, either locked approximately and 45° deformed in appear will of patient’s the and dislocated Occasionally, remain knee will patella the reduces. spontaneously and ordislocates subluxates transiently patella the of instability, mostcases patellar In patella. the to tether release lateral to divided atheoretical issurgically retinaculum which lateral release” the in have “lateral aprevious undergone exclusively almost ridge. subluxation Medial isseen who patients in beafi will there isintact, ligament if the however, istested; ligament when the laxity may haveknee increased the instances, these In tensioned. fully notof being ligaments the results are of compartment the narrowing the and cartilage articular of knee. the aspects lateral and medial onthe posteriorly tendons hamstring the ofbe gauged by amount the tension within palpated relaxed. patient often Patient the can relaxation with is performed (anterior (medial ligaments posterior) collateral lateral) and and and anterior cruciate ligament–de the in femur onthe anteriorly tibia shifting subluxation orthe patellar during trochlea femoral the within laterally subluxating patella the such as incongruent, are which itscomponents in periods compartment. a as mentioned therefore isnot and commonly symptoms of knee tibia and the between joint, articulation the tibiofemoral, tibiofemoral, patellofemoral. lateral and tibio The medial compartments: three into joint bedivided can knee The Instability unrecognized. ifleft consequences catastrophic in result can and popliteal space the in masses pulsatile painful, as present aneurysms Popliteal artery pain. knee posterior with presenting should patients beconsidered in © 2016American Surgeons Academy ofOrthopaedic l limits by often patient the muscle guarding setting, acute the In Tibiofemoral mechanism. refl causing pain to secondary knee by collapse alsobecaused of can slipping, Buckling the orbuckling. way, of asensation giving describe feelings of others and instability, i gamentous evaluation. An ideal examination of the cruciate of cruciate the examination ideal An evaluation. gamentous Chronic knee instability can occur with severe arthritis; the loss the of severe arthritis; with occur can instability knee Chronic has articulation which refers aphenomenon an to in Instability i th patellar subluxation or dislocation over the lateral trochlear trochlear subluxation ordislocation over patellar lateral th the fi cient knee. Some patients present with with present Somepatients cient knee. ex inhibition of the quadriceps of quadriceps ex the inhibition rm end point end when the rm fi bula, is rarely a source asource israrely bula,

ﬂ exion. In In exion. ﬁ bular bular Overview oftheKneeandLower Leg Essentials ofMusculoskeletal Care 5 647

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patient and provider that intra-articular pathology exists. intra-articular provider that and patient bethe can obesity, with patients in stiffness articularly. An effusion can bedif can effusion articularly. An (as effusion) an orextra- intra-articularly Swelling occur can Swelling full joint capsulepathology of prevents Distention ispresent. knee the (an of accumulation effusion an with associated isoften orsurgery). Stiffness trauma previous (osteoarthritis, causes postoperative) chronic and infection, fractures, (ligamentous injuries, causes acute many has Stiffness refers dif to generally Stiffness Stiffness modi of activity aperiod and protection but without proper functional, may remain mechanism extensor the ruptures, With partial fracture. patellar oradisplaced patella the into tendon orpatellar quadriceps of the insertion at the mechanism of extensor the complete disruption involves mostoften chronically. a weakness Acute catastrophic acutely or occur can knee Weakness of the muscles the around Weakness prolonged sitting. after rising such as immobile, been has knee when the commonly most pseudolocking happens that report Most patients extends. knee the as patella the beneath caught (plica)tissue momentarily becomes synovial thickened the plica syndrome, synovial medial with whereas glide ononeanother, they as stick momentarily surfaces articular when adjacent irregular pseudolocking occurs osteoarthritis, In or, plica less commonly, syndrome. synovial medial osteoarthritis fl of fl typically can knee fully. The extending from knee prevents plateau tibial the and the and condyle femoral the between caught gets meniscus, of atorn a portion aloose bodyor usually when afragment, occurs of knee the Locking Locking fl the extensor mechanism and just inferior to the patella. the to inferior just and mechanism extensor the swollen isfound super The knee. bursa the swelling around of cause extra-articular mostcommon isthe bursitis Prepatellar swelling issuper popliteal fossa. the Conversely, within posteriorly extra-articular pouchmost noticeable and above suprapatellar the in patella the isusually effusion Therefore, an skin. the capsule from the obscure donot structures osseous regions where the in occurs Distention exing, extending, or twisting, or making a “trick” movement. a“trick” ormaking ortwisting, extending, exing, exion may be related to a hamstring strain, orrarely, of the atear strain, exion may ahamstring berelated to “Pseudolocking” is a phenomenon that can present in patients with with patients in present can “Pseudolocking” isaphenomenon that fl exion is also restricted. Patients “unlock” the knee by forcefully knee the Patients “unlock” exion isalsorestricted. fl exion. Although an effusion can beasubtle can effusion an exion. Although fi cation, the tear may become complete. may become of Weakness tear the knee cation, fi cial to the joint capsule and is often more apparent. moreapparent. joint the isoften cial to capsule and ex from the locked the position, range ex but end from the fl uid within the joint) the that indicator within isan uid and © 2016American Surgeons Academy ofOrthopaedic fi culty obtaining full range of range motion. full obtaining culty fi cult to appreciate on examination. onexamination. appreciate cult to fi nding that alerts both both alerts that nding fi nding, especially nding, especially fi cial cial to developing and committing to ahome to exercise developing committing and exercise focus should providedan such the handout as here, beon of only using instead routine aconditioning in provides instruction that program rehabilitation asupervised in participates individual the If berequired. will that of conditioning the intensity the greater engage, to the wishes which aperson in of activity the intensity the greater The activities. recreational and sports in for participation individual the prepare alsowill program conditioning structured a more exercise professional.other or of specialist arehabilitation supervision the under be performed plyometric exercises exercises and should Advanced proprioception exercises. stretching and provided for here strengthening are the and basic strength explosive(high-intensity exercises) for may beadded power after only Plyometric activesession warm-up. exercises an should with begin exercise the agility. addition, and In balance exercises enhance to positionimprove sense) muscle (joint power; proprioception and exercises to exercises improve to of range motion; strengthening basic phases: stretching of consists three program A conditioning of theKnee Musculoskeletal Conditioning inhibition. this cause can of 30 synovial as mL little as with effusion An effusion. a knee are to besecondary can weakness tuberosity. ischial the Alternatively, into insertion hamstring proximal © 2016American Surgeons Academy ofOrthopaedic p be can hamstrings and quadriceps the Exercises strengthen to Strengthening Exercises exercise orother professional.of specialist arehabilitation supervision the under plyometricand exercises should beperformed fl and basic strength would after for competitive beadded athlete the Plyometric exercises training) (power (proprioceptive) training. neuromuscular and stretching, phases: strengthening, focus onthree should of knee the Conditioning of patellofemoral the articulation. help position movements control the the of to and rotators femur the external and internal the and medius, gluteus the maximus, gluteus muscles hip the the such as addition, In knee. the to stability dynamic muscle provides groups hamstrings and quadriceps the Strengthening patellofemoral joint the and articulation. knee the to stability dynamic section. Orthopaedics Stay Fit, and General the found in Prevent Injury Helping Musculoskeletal chapter Conditioning: the Patients in for shoulder, the isdescribed hip, well foot, as spine, knee, and the as for awhole bodyas the includes exercises program that conditioning exibility have exercises achieved. exibility Advanced proprioception been e The goal of a conditioning program is to enable isto people live to goal program ofThe aconditioning The knee has both dynamic and static stabilizers. Muscles provide stabilizers. static and dynamic both has knee The rformed conveniently with progressively heavier ankle weights. conveniently progressively with rformed ankle heavier fi t and healthy lifestyle by being moreactive. by healthy lifestyle being Awell-t and fl exibility have achieved.exibility Patient been handouts fl ex inhibition from knee pain or pain knee from ex inhibition fi

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sport-speci running. and walking such as activities functional during hip and of range knee the motion atthe increase crossover standing exercises leg such as crossovers and stretching of motion. Hamstring range effective increasing bevery in can of immobilization, periods or trauma after especially tissues, soft the Stretching islimited. knee m exercises for quadriceps the effectivenessThe of strengthening Stretching Exercises 8repetitions. 6to to back weightadd drop and agiven weight, with 12 should patient the repetitions reaching After should and work allows 12 upto 8repetitions that 6to repetitions. aweight exercises. with patient should The begin good strengthening extensions hip are and side-lying abductions, curls, hip hamstring grow. to stimulated (for lunges Forward constantly quadriceps), the beprogressive must muscle the sothat is training resistance The physical therapist, athletic trainer, or other trained professional. trained orother trainer, physical athletic therapist, of a supervision the under exercises shouldadvanced beperformed More barrier. side side to from over jumping and rope a6-inch–high muscles. gluteal and Examples of plyometric jumping exercises are development hamstrings, the facilitate of power quadriceps, the in at Explosive power of for lower level the ahigh leg of isnecessary Plyometric Exercises exercise orother specialist. trainer, of aphysical athletic supervision the therapist, under performed should be training Advanced balance for training. proprioceptive available are disks, proprioceptive and tiltboards suchdevices, as commercial Several of knee. ligaments the the protect to ability their improving thereby of proprioceptors, the activity the enhance is to goal The of inputs. afferent proprioceptive training proprioceptive con for orpostural Balance, balance. isimportant training Proprioceptive Proprioceptive Training running. while direction in changes sudden such as maneuvers athletic during of injury risk the reduce to beoptimized to need protective refl and powerful, and bestrong to needs musculature After the patient has achieved normal range of motion and strength, of range strength, motion and achieved normal has patient the After h u letic performance. Plyometrics explosive and letic performance. weight training scle group can be compromised if the range of range ifthe motion of becompromised scle the can group t rol, is the result of the integration of visual, vestibular, of rol, and of result visual, isthe integration the fi c orwork-speci © 2016American Surgeons Academy ofOrthopaedic fi c training should begin. The knee knee should The begin. c training exes exes © 2016American Surgeons Academy ofOrthopaedic on based vary only, will progression program following and of The isintroductory this exercise program • exercising, with your doctor. call pain you If experience • to exercises should beperformed exercises, stretching strengthening the and active warm-up the After • bicycle or astationary muscles upthe by riding warm program, conditioning the Before beginning • Knee Conditioning Home Exercise Program for Strengthening and Stretching Exercises for the Knee Leg crossover Hamstrings 3 to 6 repetitions/3 sets 6repetitions/3 3 to sets 6repetitions/3 3 to sets 6repetitions/3 3 to Hamstrings Hamstrings crossover Standing Hamstrings crossover Leg stretch Hamstring Stretching up working 8repetitions, 6 to slide Wall Quadriceps leg raise Straight sets 10 repetitions/3 leg raise Straight Work of 3sets upto extension Hip Hamstrings hip Side-lying Quadriceps curl Hamstring lunge Forward Strengthening Exercise your speci your avoid to care pain. of taking motion, limit the maintain or increase j physician may recommend evaluation and treatment by aphysical exercise orother professional. therapist treatment and evaluation physician may recommend ogging forogging 10 minutes. (prone) (prone) abduction fi c injury, symptoms, and baseline level baseline and of c injury, symptoms, fl exibility. When performing the stretching exercises, you slowly should stretch stretching the to exibility. performing When Hamstrings up working 8repetitions, 6 to maximus Gluteus progressing 8repetitions, 6to maximus Gluteus progressing 8repetitions, 6to medius Gluteus Quadriceps Muscle Group Muscle Work of 3sets upto 10 repetitions to 12 repetitions to 12 repetitions to 12 repetitions to 12 repetitions 10 repetitions

Repetitions/Sets Number of of Number ﬁ tness. For further progression of this routine, your progression routine, of this Fortness. further Essentials ofMusculoskeletal Care 5 Number of of Number Days per Days per Week Daily Daily Daily 3 3 3 3 3 3 3 Number of of Number Weeks 6 to 8 6 to 6 to 8 6 to 6 to 8 6 to 6 to 8 6 to 6 to 8 6 to 8 6 to 8 6 to 8 6 to 8 6 to 8 6 to 651

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Home Exercise Program for KneeConditioning Essentials ofMusculoskeletal Care 5 Strengthening Exercises • Stand ona • Stand Hamstring Curl • Work of 3sets upto 10 per 3days repetitions, opposite leg. the with • Repeat • Hold for 5seconds. stretch the and knee forward the bending • Lunge forward, feet the approximately 3to upwith • Stand Forward Lunge • Perform 3 sets of 3sets 10 • Perform per 3days repetitions, heel of the oneleg• Raise ceiling. toward the week. Continue forweek. 8weeks. Continue 6to beyond toes. the pass knee Donot let forward-lunging the area. You should left groin feel the in aslight stretch back leg the back and straight. the keeping support. back foot the and provide angled to forward 4 f week. Continue forweek. 8weeks. Continue 6to relax. Hold then position and for this 5seconds forof wall orthe balance. achair over feet. both Hold back distributed the onto e et apart and with the forward foot pointing foot forward pointing the with and et apart ﬂ

at su rface with your weight with evenly rface

© 2016American Surgeons Academy ofOrthopaedic © 2016American Surgeons Academy ofOrthopaedic • Elevate leg the off the apillow your• Lie hips with down under face (Prone)Hip Extension week. exercise Continue the per 3days • Perform opposite leg. onthe • Repeat a with weights starting should beused, • Ankle • Slowly lower leg relax it the and for 2seconds. • Slowly move 45°, leg to top back the upand your in head your • Lie side, on your cradling Side-Lying HipAbduction • Perform the exercise 3 days per week. Continue week. exercise Continue the per 3days • Perform opposite leg. onthe • Repeat a with weights starting should beused, • Ankle a for 8weeks. 6to 8repetitions. 6to to return and weight add 12 Then to progressing repetitions. weight allow to light enough 8repetitions, 6to 5 seconds. Hold position straight. for this knee the keeping a for 8weeks. 6to 8repetitions. 6to to return and weight add 12 Then upto working repetitions. weight allow to light enough 8repetitions, 6to bent. knee the up with leg for the 4 inches straight of acount 5, lifting n r m. Bend the bottom leg for bottom the m. Bend support. d one knee bent 90°.d oneknee ﬂ oor approximately

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Home Exercise Program for KneeConditioning Essentials ofMusculoskeletal Care 5 • Lie onthe Straight (Prone) Leg Raise for week, exercise the per 6to 3days • Perform a with weights starting may beused, • Ankle muscle leg• Tighten thigh of the and straight the • Lie on the Straight Leg Raise • Perform the exercise 3 days per week. Continue week. exercise Continue the per 3days • Perform a with weights starting may beused, • Ankle opposite leg. the with • Repeat hamstrings the tighten leg the • Keeping straight, 8 weeks. 8repetitions. 6to to return and weight add 12 Then upto working repetitions. weight allow to light enough 8repetitions, 6to leg.opposite the position with for Repeat this 5seconds. slowly it 10 6to raise off the inches legother bent. the elbows and oneleg with shown, straight as for 8weeks. 6to 8repetitions. 6to to return and weight add 12 Then upto working repetitions. weight allow to light enough 8repetitions, 6to avoid back. the arching muscles your stomach and Keep tight 6 inches. of leg the oneleg approximately raise and straight. ﬂ ﬂ

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fl oor. Hold © 2016American Surgeons Academy ofOrthopaedic © 2016American Surgeons Academy ofOrthopaedic Stretching Exercises • Perform the exercise 3 days per week, for week, exercise the per 6to 3days • Perform the to • Hold return then for and 5seconds bent 90°. are • Stop when your knees knees The your muscles• Tighten your stomach sothat • Repeat the exercise with each leg 3 to 6 times. leg each 6times. exercise 3to the with • Repeat side side. to from • Alternate • Slowly oneleg pull toward your ear, and lift • Sit onthe Hamstring Stretch your and awall your back against with • Stand Wall Slide 8 weeks. 10 repetitions. position. Work of 3sets upto starting should beyond not pass toes. the fl is back lower Perform 3 sets per day for day 8weeks. per 6to 3sets Perform 5 seconds. Hold for yourkeeping back straight. stretch the leg stretched. not being calves. For you may slightly comfort, the bend of backs your onthe you, place your hands and f e et approximately 1 foot from the wall. the et approximately 1foot from fl

oor w at against the wall. the at against ith your legs straight in front of front in your legsith straight

Home Exercise Program for KneeConditioning Essentials ofMusculoskeletal Care 5 655

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Home Exercise Program for KneeConditioning Essentials ofMusculoskeletal Care 5 • Repeat with the opposite leg crossed in front for front opposite the leg in with crossed • Repeat • Hold for 5seconds. stretch the • K your legs with crossed. • Stand Standing Crossover • Lie on the Leg Crossover • Repeat the exercise with each leg 3 to 6 times. leg each 6times. exercise 3to the with • Repeat side side. to from • Alternate • Hold for 5seconds. stretch the keeping your left to hand, toe your right • Bring 6 to 8weeks. 6 to for day per 3sets Perform 6repetitions. 3 to slowlystraight, toward your toes. forward bend 8 weeks. for day per 6to 3sets Perform stretched. being For you may slightly comfort, leg the bend not legthe straight. sides. out the to arms e eping your feeteping close your legs and together ﬂ

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© 2016American Surgeons Academy ofOrthopaedic © 2016American Surgeons Academy ofOrthopaedic Knee an Physical E and calf musculature, including the hamstrings and calf muscles. calf and hamstrings the including musculature, calf and thigh of posterior the for assess asymmetry standing, With patient the Posterior View ahead. straight pointing feet are the when inward pointed patellae the anteversion), with knees the aligns (femoral shaft femoral onthe forward leaning neck femoral by the caused torsion, usually femoral bowlegged. being as to Internal referred are genu varum with Persons ankles. the between distance the than wider distance by aknee-to-knee ischaracterized malalignment knees). Conversely, (knock knees the between varus distance the than wider distance ankle-to-ankle by an ischaracterized malalignment muscles. Valgus of quadriceps the portion of medial especially the muscle and symmetry, alignment inspect With patient standing, the Anterior View Inspection/Palpation d Lower Leg x amination of t

he Essentials ofMusculoskeletal Care 5 657

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Physical Examination oftheKneeandLower Leg Essentials ofMusculoskeletal Care 5 indicate meniscal or injury patellofemoral arthritis. be able to fl knee assess To Squat ligament. collateral lateral the to injury an with association in beseen injury, which can nerve aperoneal indicate can ankle dorsi to Footdrop orinability ambulation. during ground the foot when the strikes malalignment varus into falls knee the which but in when which standing involves alignment normal thrust, avarus with may walk osteoarthritis, compartment severe medial or trauma from either structures, ligamentous knee of lateral the insuf Patients with for weakness. abductor hip compensate Trendelenburg over leg which leans patient gait to affected the in the pattern). side affected of (antalgic onthe weight duration the gait bearing shorten motion and limit will patient the weight with pain bearing, produce that conditions knee other and With arthritic diagnosis. developing may behelpful in and adifferential on function providesWatch information Gait observation walk. patient the Gait feeling as the patella is pushed down. ispushed patella the feeling as hold to hand the other the using while one hand patella with the to pressure downward maneuver, apply pouch. To milking suprapatellar the the from perform down” joint by “milking bedemonstrated can effusions knee Subtle side oneither beapparent. of will patella dimpling the normal loss region and of of suprapatellar the the fullness ispresent, effusion knee region. alarge If suprapatellar the inspect extended, knee the To and supine patient the with for of effusion, presence assess the an Knee Effusion Persons with primary hip pathology may demonstrate a pathology hip may demonstrate primary with Persons fl ex both knees symmetrically. Pain with squatting may squatting with Pain symmetrically. ex knees both exion, ask the patient to squat. The patient should patient The squat. to patient the exion, ask fl uid waveuid place. in Excess fl

uid will create a “spongy” a“spongy” create will uid fl ex the ex the © 2016American Surgeons Academy ofOrthopaedic fi ciency ciency fl uid © 2016American Surgeons Academy ofOrthopaedic erythema is concerning for bursitis. aseptic isconcerning erythema with associated bursa Swellingof of patella. infrapatellar the the side oneither and to inferior bepalpated can bursa infrapatellar the addition, In side swelling oneither tendon. ofshaped patellar the visible adumbbell- as isusually bursa swollenThe infrapatellar Infrapatellar Bursa tear. of for ameniscal diagnosis test the examination mostsensitive the speci and remains tenderness Joint line meniscus. of atorn diagnosis the supports joint atthe line directly of focal tenderness area sides An of knee. lateral the and medial the both on joint margin along entire joint the the palpate line then tibia, the and femur the softspot between the knee the and supine patient the with tenderness joint line Assess Joint Line Tenderness patellofemoral joint. the within damage cartilage articular suggests maneuver this with of ofa range motion. Asensation crepitus ismoved through knee the patella as onthe place ahand hip the with supine patient the asensitive for place test patellofemoralperform crepitus, of To patella. the palpation undersurface of and edges the allow to medially and patella laterally the displacing and mechanism, of relaxation extensor the ensuring supine, knee. the straighten patient’s actively the to with inability is associated knee increasing with more prominent defect locations. The respective becomes defect at their apalpable creates of tendons these complete rupture poles of respectively; inferior patella, and the superior the and patellarQuadriceps tendinitis produce tenderness at poles of patella. inferior the and superior the palpate To mechanism, extensor the for pathology assess within Patella Patellar tenderness can beelicited can by patient placing the Patellar tenderness fl exed 90°. Identify the joint line within exed 90°. within joint the line Identify fl exed 90°, to then and fi c physical fl exion and exion and

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