needs of the patient based on objective findings and may include passive physiological and accessory movements, muscle stretching, and soft-tissue mobilization. Specifically, mobilization Grades III and IV performed for 2 to 6 rounds of 30 seconds per technique may be performed for loss of knee extension or flexion. Grade IV patellar glides performed with the knee in 5 to 10° of flexion may be performed in the direction of determined restriction to promote knee flexion and extension, including medial, lateral, caudal, and cephalad. Graded joint mobilizations to the hip, lumbar spine, and ankle, depending on limitation in passive or active movement, should be provided as well (Deyle et al., 2005). Cliborne et al. (2004) investigated the role of the hip in treatment of patients with knee OA. The investigators found that some patients benefit from mobilization of the hip joint to provide relief of knee OA pain and mechanical dysfunctions, while others did not. Further investigation was carried out by another research group, and a clinical prediction rule was created to identify patients with knee OA who would benefit from mobilization of the hip. Five variables were identified as indicators of patients likely to benefit from hip mobilization including: ● Hip or groin pain or paresthesia. ● Anterior thigh pain. ● Passive knee flexion <122°. ● Passive hip internal rotation <17°. ● Pain with hip distraction. (Currier et al., 2007) If two variables are present the likelihood ratio is 12.9 with a 97% probability of success with hip mobilization. Exercises should consist of active range of motion stretches, muscle strengthening, stretching, and lower-extremity aerobic exercise such as working out on a stationary bicycle or elliptical machine. Home exercises may be prescribed by the supervising physical therapist to support progression of functional ability. Prescribed strengthening exercises may include the quadriceps, hamstrings, gluteals, hip rotators, hip abductors, hip adductors, Total knee arthroplasty When conservative measures have been exhausted, a patient may be a candidate for total knee arthroplasty (TKA). Surgical techniques for TKA vary by surgeon. Most techniques involve complete removal of the femoral and tibial joint surfaces and resurfacing of the patella using cemented fixation. Immediate rehabilitation depends on surgical procedure and physician protocol, however most patients are administered a front wheel walker and given orders to weight bear as tolerated (OrthoInfo, n.d.d). Rehabilitation efforts should focus on achieving 0 to 90° of knee range of motion within the first few weeks. Aggressive stretching and joint mobilization may be used if range of motion is Hamstring strain Hamstring strains are four times more likely to occur than quadriceps strains, with a rate of 12% to 16% of all athletic injuries (Schmitt, 2012). The most common mechanisms of injury are sprinting in track and field, football, baseball, and waterskiing. Risk factors for sustaining hamstring injury include decreased flexibility, muscle fatigue, decreased strength, poor core stability, poor warm-up, poor lumbar posture, and previous history of hamstring injury, with the latter being the most prevalent risk factor. The actual mechanism of injury is thought to be due to weakness of the muscle in its eccentric state. Biomechanically, high-speed running requires the hamstring to contract eccentrically when the hip is flexion, thus placing the hamstring in an elongated position, while the lower leg moves into flexion of the knee (Schmitt et al., 2012). Hamstring strains are graded on a scale of I to III, where Grade I is the least involved with micro damage, Grade II is a partial
and core- stabilizing muscles. Quadriceps strengthening should include (at a minimum) static quad sets and standing terminal knee extensions performed with a resistance band. Progression of closed-chain exercises should be performed to enhance functional activity tolerance. These may include partial squats, using upper-extremity support if needed, and step-ups with verbal and visual cuing to maintain proper knee alignment. Lower- extremity stretches may include the gastrocnemius, soleus, hamstrings, and quadriceps muscles. A systematic review of the scientific literature reveals high- level evidence for exercise and patient education to reduce body weight, reduce pain, and improve functional abilities in patients with knee OA. There is mid-level quality evidence that acupuncture and transcutaneous electric stimulation is beneficial for pain reduction in patients with this impairment. Furthermore, there is moderate-level evidence that low-level laser and psycho- educational interventions are helpful in lowering pain levels (Jamtvedt et al., 2008). A randomized trial of arthroscopic surgery for the treatment of knee OA revealed no additional benefit over physical or medical therapies. In this study, participants were randomized into either the surgical group, or an “optimized physical therapy and medical therapy group” in which they received one hour of physical therapy once per week for 12 weeks. These participants each received a home exercise program focusing on areas of impairment unique to them. Instruction was provided for activity modification including activities of daily living, stair use, and modalities for pain modulation. Surgical participants received synovectomy, debridement, excision of degenerative tears of menisci, fragments of articular cartilage, or osteophytes, depending on impairments unique to the patient. The surgical participants also received physical therapy and medication following their procedure. Post-treatment WOMAC scores were not significantly different between the two groups, demonstrating equal effectiveness of conservative management for the treatment of moderate knee OA (Kirkley et al., 2011). progressing too slowly. Ultimately, if the patient does not achieve this range of motion, the surgeon may recommend surgical manipulation under anesthesia. Open kinetic chain exercises such as quadriceps isometrics, heel slides, straight leg raises, and hip adductor squeezes into a pillow should be taught initially, with progression to standing closed kinetic chain exercises as tolerated by the patient. These may include standing partial squats, step-ups, and step- downs. Gait and functional activity training, as well as activity modification and instruction to avoid kneeling, should also be included in the rehabilitation program.
SOFT-TISSUE INJURIES OF THE KNEE
tear, and Grade III is a complete tear of the muscle. Grade III lesions may require surgery, and the patient often presents with a significant limp. Swelling, ecchymosis, poor tolerance of knee motion, and pain are also common presentations (Schmitt et al., 2012; Medline Plus, n.d.). There is evidence suggesting that incorporating lengthened state eccentric hamstring training may reduce the rate of re- injury. Other intervention strategies include avoiding stretches that cause pain and proceeding cautiously with progressive resistance exercises. Very light resistance isometrics should be the initial exercise program, with high repetition rate. Spica wrapping or splinting of the knee may be required for Grades II and III injuries initially to reduce inflammation and protect the joint. Extended phases of hamstring strain rehabilitation around 6 weeks post-injury may consist of more dynamic exercises and higher-resistance, lower-repetition exercises.
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