Manual Techniques for the Knee: A hands on approach to restore function

Katie Cusack, PT, MHS, CMP

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OBJECTIVES
1. Describe manual therapy 2. Brief overview of knee mechanics 3. 3 Describe and demonstrate manual techniques for the patella 4. Describe the Mulligan technique and demonstrate techniques for the knee

Manual Techniques for the Knee

A Hands On Approach to Restoring Function
Katie Cusack, PT, MHS, CMP

Manual Therapy
Considered by many orthopedic physical therapists to be an important component in the evaluation and treatment of musculoskeletal disorders disorders. Benefits have been documented in the literature supporting the use of manual therapy in conjunction with joint mobility and strengthening exercises.

Manual Therapy
A term that encompasses a broad range of techniques. Manual therapeutic techniques are used to relieve pain and to increase joint mobility mobility. Such techniques may include soft tissue mobilization, massage, myofascial release, passive range of motion, joint mobilization, and manipulation.

Considerations
Good understanding of the anatomy of the knee Knowledge of knee joint biomechanics Have already performed a complete evaluation of the knee. Checked for any contra-indications

Anatomy
Tibiofemoral Joint Patellofemoral Joint Superior Tibiofibular Joint

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Osteokinematics
Total range of motion in the healthy knee is from about 5-10 degrees of hyperextension to 140-150 degrees of extension

Tibiofemoral Arthrokinematics
During Knee Extension Open kinetic chain tibia glides anteriorly on the femur Closed kinetic chain femur glides posteriorly on the tibia.

During Knee Flexion Closed kinetic chain Open kinetic chain tibia glides posteriorly on femur glides anteriorly on the tibia. the femur

Screw Home Mechanism

From 20o knee flexion to full extension Open kinetic chain Closed kinetic chain tibia externally rotates femur rotates internally on a stable tibia From full knee extension to 20o flexion Open kinetic chain Closed kinetic chain tibia internally rotates femur rotates externally on a stable tibia

Patellofemoral Arthrokinematics
During flexion at the tibiofemoral joint, the posterior motion of the tibia causes ligamentum patellae to pull the patella posteriorly and distally During extension, the patella is pulled upward along the patellofemoral groove by the quads.

Superior Tib-fib Arthrokinematics

The exact function of this joint is not fully understood and often overlooked. As the knee moves into extension in an open kinetic chain position, the fibular head is p p pulled posterior as the lateral collateral ligament and biceps femoris becomes taut. Knee flexion produces an anterior movement due to the relaxation of the lateral collateral ligament and biceps femoris tendon

Patella mobilizations
Patient position: Supine in slight flexion Technique: Therapist q p stands to the side of the patient and gently mobilizes the patella superiorly/inferiorly direction as well as medially/ laterally

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Sidelying Medial Patella glide

Patient position: Sidelying with knee flexed 200 or less Technique: Place the q heel of your hand over the lateral border of the patella and glide medially

Sidelying Medial Patella Tilt

Patient position: Sidelying with knee flexed Technique: Place the q heel of your hand over the medial of the patella and tilt the medial border posteriorly.

Mulligan Technique
Mobilization with Movement (MWM) was developed by Brian Mulligan Mulligan proposes that minor positional faults occur during injury or strain resulting in movement restrictions and/or pain MWM is almost always performed at right angles to the plane of movement taking place.

Principles
During assessment the therapist will identify one or more objective signs A passive accessory joint mobilization is applied Continuously monitor the patients reaction to ensure no pain is recreated. While sustaining the mobilization, the patient is asked to perform the objective sign

Principles
The application of overpressure at the end of the available range is necessary for lasting improvement. The patient undertakes 3 sets of 10 pain painfree reps of the previously provocative movement. If there is no improvement, the therapist is performing the technique incorrectly or the technique is not indicated.

Knee Flexion MWM

Rotation in the Open Kinetic Chain Mobilization: Internal rotation of the tibia on the femur Movement: Knee flexion

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Knee Flexion MWM

Rotation in Closed Kinetic Chain Mobilization: Internal rotation of the tibia in CKC Movement: Knee flexion

Knee Flexion MWM

Side glide with belt assistance in prone Mobilization: Medial or lateral glide of the tibia through the mobilization belt Movement: Knee flexion

Knee Flexion MWM

Posterior Glide in Supine Mobilization: Posterior glide of the tibia Movement: Knee flexion

Knee Flexion MWM

Superior Tibiofibular Joint in CKC Mobilization: Anterior glide of fibula on stabilized tibia Movement: Knee flexion in partial weight bearing

Knee Extension MWM

Rotation in OKC Mobilization: External rotation of the tibia on stabilized femur Movement: Knee extension

Knee Extension MWM

Side glide in OKC Mobilization: Side glide g of the tibia on a stabilized femur Movement: Knee extension

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Knee Extension MWM

Superior Tibiofibular glide in OKC Mobilization: anterior glide of fibula on a stabilized tibia Movement: Knee extension

Knee extension MWM

Superior Tibiofibular glide in OKC Mobilization: Posterior glide of fibula on a stabilized tibia Movement: Knee extension

Knee Extension MWM

Superior Tibiofibular glide in CKC Mobilization: Anterior or posterior glide of fibula on a stabilized tibia Movement: Knee extension

Conclusion
There are numerous techniques used by physical therapists. Manual therapy can be a beneficial adjunct to the treatment of the knee when attempting to increase range of motion or decrease pain.

Thank you

References
Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD, Hutton JP, Henderson NE, Garber MB. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301-1317. ; Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized controlled trial. Ann Intern Med. 2000;132:173-181. Fitzgerald GK, McClure PW, Beattle P, Riddle DL. Issues in determining treatment effectiveness of manual therapy. Phys Ther. 1994;74(3):227-233.

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References
Hertling D, Kessler RM. Management of common musculoskeletal disorders. J.B. Lippincott, Philadelphia, 1990. Mulligan BR. Manual Therapy. Plane View Services Ltd., Wellington, 2006. Norton C, Levangie P. Joint structure and function. F.A. Davis Company, Philadelphia, 1989. Paulos LE, Rosenberg TD, Drawhurt J, Manning J, Abbott P. Infrapatellar contracture syndrome: an unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med. 1987;15:331-341.

References
Powers CM. Rehabilitation of patellofemoral joint disorders: a critical review. JOSPT. 1998;28(5):345-354. Semonian RH, Denlinger PM, Duggan RJ. Proximal tibiofibular subluxation relation to lateral knee pain: a review of proximal tibiofibular joint pathologies. JOSPT. 1995; 21(5):248-257. Course Notes: The McConnell Patellofemoral Treatment Plan. Chicago, 1995. Course Notes: Follow-up Course for Mulligan Technique. Portland, 2009. Course Notes: Diagnosis and Treatment of the Upper and Lower Quadrant as presented by Brian Mulligan, FNZSP (Hon) Dip MT and Kevin Wilk, DPT, Raleigh, 2010.

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Notes:

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Notes:

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