The knee complex: understanding the science

behind both movement and dysfunction

By Chris Gellert, PT, MMusc !portsphysio, MPT,
C!C!, "M!
#ntroduction
The foot is where movement begins, requiring mobility to perform
simple functional movements. The knee however, requires stability
with daily movements, but more importantly, dynamic sport
movements such as soccer or football. In this article, we will review
the anatomy of the knee, common injuries of the knee, functional
assessments and training strategies to work with clients with previous
injuries.
Figure 1. Dynamic sport of soccer
Basic anatomy of the knee
Let's look at the anatomy of the knee.. The joint is vulnerable when it comes to
injury,
because of the mechanical demands placed upon it and the reliance for soft tissue to
support
the knee.

There are t$o primary joints within the knee, the tibiofemoral joint and the
patellofemoral joint.
%nee &oints
a' Tibiofemoral (oint Is a hinge joint that permits some rotation between the distal
end of the
femur and pro!imal end of tibia. The joint capsule surrounds the femoral condyles
and tibial
plateaus and provides stability to the knee by the medial collateral ligament"#$L%
and the
lateral collateral ligament "L$L%.
b' Patellofemoral (oint Is formed by the patella"knee bone% that glides in the
trochlear
groove of the femur. The height of the lateral femoral condyle helps prevent lateral
sublu!ation, while soft tissue surrounds the joint to increase stability.

This is seen in
&gure '.
)igure *' !tructures $ithin the knee (oint )igure +' Patellofemoral
(oint
*' Primary structures $ithin the knee (oint: ligaments and mensici
(everal ligaments described below provide stability at the knee joint.
a' Collateral ligaments: The two primary supporting ligaments are the medial
collateral
ligament "#$L%, which is along the inside of the knee. The #$L is a thinner and
weaker
ligament biomechanically, making it more susceptible to injury more often injured
per
the research. )hile the lateral collateral ligament"L$L% is along the outside or
lateral aspect
of the knee providing lateral knee stability.
b' "nterior cruciate ligament,"C-.: is the most commonly injured knee
ligament and
2
is taut during knee e!tension. It originates more pro!imally on the femoral side than
the
posterolateral "*L% bundle. It inserts anteromedially"front and to inner side% on the
tibia.
The +$L limits and controls forward translation of tibia on the femur and limits tibial
rotation.
c' Menisci: the menisci are &bro cartilaginous discs located on the articular surface
of the
tibia along the medial and lateral tibial plateaus. The outer portion of the
meniscus"lateral
meniscus%is oval shaped ",% and thick. +ttaching at the anterior and posterior horns
via
coronary ligaments.
/ascularity: The middle third and inner third of both menisci
are relative avascular'
The medial meniscus is more $-shaped, and thinner in structure.
.oth menisci receive nutrition through synovial di/usion and from
blood supply to the horns of the menisci.
)unction of the menisci The menisci provide shock absorption, joint lubrication
and stabili0ation.
Common in(uries and causes
There are several common injuries that a/ect the knee. The most
common are patella femoral syndrome"*1(%, osteoarthritis",.+.% and
anterior cruciate ligament"+$L% injuries.
In this ne!t section, we will review each condition providing a deeper
understanding of each.
a' Patellofemoral syndrome
Pathophysiology0sign and symptoms: *1( is a condition where the patella does
not
translate biomechanically in the trochlear groove between the femoral condyles.
2ere the
patella is positioned in either a tilt, glide or rotation accompanied by di/use,
achiness in the
front of the knee.
Contributing )actors,1vidence Based 2esearch.: (everal studies have shown
that
decreased 3exibility of 4uadriceps and hip 3e!ors"Lankhorst et al. 4564 7 #eira
et al. 4566%
3
contribute to *1(. 8ecreased hip abductor strength has been shown a signi&cant
factor seen
in multiple studies as contributing to *1("9hayambashi, 2., et al. 4564, #eira et al,
"4566%,
.olgla et al. "455:%,$ichanowski et al. "455;%, and <obinson et al. "455;%. ,ther
factors include
prolonged wearing of high heels, muscle imbalances"quadriceps=hamstrings%.
b' 5steoarthritis,5". of the knee
Pathophysiology0sign and symptoms: + degenerative process of varied etiology,
which
includes mechanical changes within the joint as seen in &gure >.
2isk )actors: ?!cessive weight born on hip joint, muscle imbalance, repetitive
stressors.
!ign and symptoms *ain in the a.m. described as @achyA that decreases as the day
progresses,
pain with weight bearing or walking, di/iculty squatting, and lateral thigh
discomfort.
)igure 6' 5steoarthritis of knee
c' "nterior cruciate ligament in(uries
In the last several years, there has been more news about the
incidence of +$L injuries. The
incidence rate is greatest between the ages of 6B and 6: years'
1emale athletes are '-C! more
likely to sustain an +$L injury then male athletes. This results in at
least 455,555 +$L
reconstructions are performed each year in the Dnited (tates, with
estimated direct costs of
E' billion "in D.(. dollars% annually"1robell, <., et al 4565%.
4
Pathophysiology0Mechanism of #n(ury The knee is struck while in
hyperextension, forcing
tibia anterior"forward%on the femur, as seen in &gure F. The +$L can also be injured
with
same mechanism of injury with combined with medial rotation of the lower
e!tremity"L?%.
This creates instability and a direct disconnect the nervous system to the
musculoskeletal system
because of the @lack of controlA within the knee joint.
)igure 7' Mechanism of in(ury for "C- tear
Common assessments
,ne great test to assess a clientGs movement pattern, is the s4uat'
The squat is a classic fundamental primal movement that someone
typically performs almost on a daily basis. )ith this test, you can
observe how the clientGs ankle, knee, hip and back moves compared to
normal movement patterns. This is seen in the &gure below.

)igure 8' !4uat in frontal vie$ !4uat in side vie$
5
+nother simple assessment is an in place lunge, which e!amines oneGs control
through the entire
kinematic chain. The lunge is another fundamental primal movement. The lunge is a
dynamic
movement that is typically performed during daily activities"stooping down to pick
something up%
or as part of an athletic movement.
This test e!amines ankle control, knee control and pelvic movement in the sagittal
plane.
Lastly, a diagonal traveling forward lunge looks at the ability of the client to control
ankle,
knee, hip, and pelvic movement in both the sagittal and frontal planes.
This is not only a functional movement, but very e/ective for sport speci&c clients.

)igure 9' #n place lunge )igure :' Traveling for$ard lunge
Training strategies and programming for knee in(uries
)ith any injury, the most important thing to remember is the type of
injury, healing time and prior level of function of the client.
a' Patellofemoral syndrome
2ecommendations for training: $ontinued stretching of tight
hip 3e!ors, IT., and hamstrings is fundamental. $lient should
be taught initially static core strengthening e!ercises, and then
progressed to dynamic core strengthening as appropriate.
$lient would also bene&t from education on shoes with respect
to type that are most e/ective for them, and to cross train
utili0ing, such as hiking, yoga, pilates, and swimming. Lastly, to
alter running surfaces"if client runs% and educating the client
about changing their shoes every F55 miles or B months for
ma!imum stability and control.
6
b' 5steoarthritis of knee,5'"'.
2ecommendations for training: +qua therapy has been
shown in the research to
signi&cantly reduce pain, improved physical function, strength, and quality of
life
"2inman, <ana (., et al 455;%, stretching IT., hip 3e!ors, quadriceps and
hamstrings,
strengthening $eaker hip abductors"glute mediasHminimus%. (trengthening
speci&cally
hip abductors in various studies when compared to general strengthening
resulted in s
signi&cant reduction in knee pain, objective change in functional outcome
tests, physical
function and daily activities".ennell,9.L., et al. 4565 7 2ernInde0-#olina, J et
al. 455:%.
$ore strengthening shoulder also is an integral part of the training program.
c' "C- in(ury,"nterior cruciate ligament in(ury.
2ecommendations for training: should focus on hamstring strengthening.
(trengthening
the hamstrings biomechancally transfers the load from the front of the knee to
the
back, thereby decreasing the stress to the +$L. Keuromuscular training as
seen in
&gure C, is very e/ective. It challenges the connection between the nervous
and
musculoskeletal system requiring the client to stabili0e the entire kinematic
chain.
<esearch has shown neuromuscular training reduces +$L injuries
"2D L .($2?<, #. 4565 7 Jri/in LM, et al., 455B%.
$ore strengthening should be multidirectional in nature as seen in &gure 65. In
the picture
on the left, left trunk rotation involves the internalHe!ternal obliques, atissimus
dorsi,
and right glute medius and minimus muscles to stabili0e, as the left glute
medius and
minimus to stabili0e. )ith the yellow cord applied from the back, this
engages the abs
primarily to stabili0e"from the front% accompanied by the obliques to stabili0e,
which
the low back e!tensor muscles contract to prevent being pulled backwards.
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It is important to include dynamic training focusing on hamstrings, glute
medius,
ma!imus. $losed chain strengthening"$9$%e!ercises, such as diagonal forward
and
diagonal reverse lunges are not only functional, but replicate many common
sports
as soccer, football and basketball accordingly.

)igure ;' <ynamic stabili=ation )igure >?' Multidirectional
Training Training
Contrainidications/Precautions: +void leg e!tension e!ercises completely
this causes an
anterior translation"shearing% of the tibia on the femurHstressing the graft.
Therefore,
the e!ercise is contraindicated. @Biomechanically, shearing stress on the
"C- is
greatest from +? degrees of knee 3exion to full extension'
2ecommendations for training: "merican "cademy of 5rthopedic
!urgeons,""5!.
Guidelines Post Therapy:
$ontinuation of closed kinetic chain e!ercises"ie. reverse lunges, diagonal
lunges,
forward lunge with medicine ball trunk rotation%
A ' N months light jogging begins
O > months running begins
O > months introduction of plyometrics
8
O (urgical reconstruction typically sidelines athlete for 6-9 months and
once cleared by
physician can return to sport activities.
!ummary
The knee is a dynamic joint that is comprised of a multitude of
ligaments, tendons, connective tissue, muscles that
synergistically initiate and correct movement, and stabili0e
when an unstable environment. Dnderstanding the anatomy,
biomechanics and weak links of the knee, common injuries and
evidenced based training strategies, should provide you with the
insight to better understand and work with clients with these
kind of injuries more con&dently.
$hris is the $?, of *innacle Training 7 $onsulting
(ystems"*T$(%. + continuing education company, that provides
educational material in the forms of home study courses, live
seminars, 8P8s, webinars, articles and min books teaching in-
depth, the foundation science, functional assessments and
practical application behind 2uman #ovement, that is
evidenced based. $hris is both a dynamic physical therapist with
6> years e!perience, and a personal trainer with 6; years
e!perience, with advanced training, has created over 65
courses, is an e!perienced international &tness presenter, writes
for various websites and international publications, consults and
teaches seminars on human movement. 1or more information,
please visit www.pinnacle-tcs.com.
9
21)121BC1!
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