Knee pathologies and impairments

Common Joint Pathologies and Associated Impairments

Osteoarthritis (OA) and rheumatoid arthritis (RA) as well as acute joint trauma can affect knee articulations at the tibiofemoral joint. Decreased flexibility and adhesions develop in the joints and surrounding tissues any time the joint is immobilized for a period of time. Reflex inhibition and resulting weakness of the quadriceps femoris muscle occurs because of joint distention.

Physio Guideline

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis, often referred to as degenerative joint disease (DJD), is the most common disease affecting weightbearing joints. One-third of individuals over the age of 65 have radiographic evidence of OA.  Pain, muscle weakness, and joint limitations affect function and lead to disability. Deformity such as genu varum commonly develops. Factors such as excess weight, joint trauma, developmental deformities, weakness in the quadriceps muscle and abnormal tibial rotation are identified as risk factors for developing OA.

Post-traumatic arthritis in the knee occurs in response to any injury that affects the joint structures but particularly following acute ligament and meniscal tears. Joint swelling (effusion) may be immediate, indicating bleeding within the joint, or progressive (more than 4 hours to develop), indicating serous effusion. Acute symptoms include pain, limited motion, and muscle guarding. Trauma, including repetitive microtrauma, is a common cause of degenerative changes in the knee joint.

Rheumatoid Arthritis

Early-stage RA usually manifests in the hands and feet first. With progression of the disease process, the knees also may become involved. The joints become warm and swollen, and limited motion develops. In addition, a genu valgum deformity commonly develops during the advanced stages of this disease.

Postimmobilization Hypomobility

When the knee has been immobilized for several weeks or longer, such as after healing of a fracture or after surgery, the capsule, muscles, and soft tissue develop contractures, and motion becomes restricted. Adhesions may restrict caudal gliding of the patella, which limits knee flexion, and may cause pain as the patella is compressed against the femur. An extensor lag may occur with active knee extension if the patella does not glide proximally when the quadriceps muscle contracts.183 This usually occurs after operative repairs of some knee ligaments, when the knee is immobilized in flexion for a prolonged period.

Common Impairments

With joint involvement, the pattern of restriction at the knee is usually more loss of flexion than extension. When there is effusion (swelling within the joint), the joint assumes a position near 25_ of flexion, at which there is the greatest capsular distensibility. Little motion is possible because of the swelling Symptoms of joint involvement, such as distention, stiffness, pain, and reflex quadriceps inhibition, may cause extensor (quadriceps) lag in which the active range of knee extension is less than the passive range available. Disturbed balance responses also have been reported in patients with arthritis.

Common Functional Limitations/Disabilities

With acute symptoms and in advanced stages of degeneration, there is pain during motion, weight bearing, and gait that may interfere with work or routine household and community activities. There is limitation of, or difficulty controlling, weightbearing activities that involve knee flexion, such as sitting down and rising from a chair or a commode, descending or ascending stairs, stooping, or squatting.62 With end-stage OA, physical activity is markedly curtailed with less participation in leisure activities (e.g., walking, gardening, swimming, athletic activities) and household activities (e.g., dusting, washing floors, cleaning,shopping).

Physio Guideline

Joint Hypomobility: Management— Protection Phase

Control Pain and Protect the Joint

Patient education

 It is important to teach the patient methods to protect the joint including bed positioning or use of splints in order to avoid deforming contractures, range of motion (ROM) and muscle setting exercisesto maintain mobility, and safe functional activities that reduce stresses on the knee.

Functional adaptation

 To reduce the amount of knee flexion and patellar compression instruct the patient to minimize stair climbing, use elevated seats on commodes, and avoid deep-seated or low chairs. If necessary during an acute flare of arthritis have the patient use crutches, canes, or a walker to distribute forces through the upper extremities while walking.

Maintain Soft Tissue and Joint Mobility

Passive, active-assistive or active ROM

 Use ROM techniques within the limits of pain and available motion. The patient may be able to perform active ROM in the gravityeliminated, side-lying position, or self-assisted ROM.

Grade I or II tractions or glides

Apply gentle techniques, if tolerated, with the joint in resting position (25_ flexion). These techniques are used to inhibit pain as well as maintain joint mobility. Stretching is contraindicated at this stage.

Maintain Muscle Function and Prevent Patellar Adhesions

Setting exercises

 Have the patient perform pain-free quadriceps (“quad sets”) and hamstring muscle-setting exercises with the knee in various pain-free positions, quad sets with leg raising, and submaximal closed-chain muscle setting exercises. Quad sets may help maintain mobility of the patella when the tibiofemoral joint is immobilized and therefore are routinely taught following surgery or when the joint is immobilized in a cast.

Joint Hypomobility: Management—ControlledMotion and Return to Function Phases

As the inflammation decreases and the joint tissues are able to tolerate increased stresses, the goals of treatment change to deal with the impairments that interfere with functional activities. The patient is progressed through controlled motion exercises and activities that focus on safely returning to the desired functional outcome.

Educate the Patient

Inform the patient about his or her condition, what to expect regarding recovery, and how to protect the joints. Teach the patient safe exercises to do at home, how to progress them, and how to modify them if symptoms are exacerbated by the disease or from overuse. Exercises that include specifically designed strengthening, stretching,ROM, and use of a stationary bicycle have been shown to improve funtional outcomes in patients with OA in a home exercise program. It is important to emphasize that maintaining strength in the supporting muscles helps protect and stabilize the joint and that balance exercises help reduce the incidence of falls. Instruct the patient to perform active ROM and musclesetting techniques frequently during the day, especially prior to bearing weight in order to reduce the painful symptoms that occur with initial weight bearing. The patient with OA or RA should be cautioned to alternate activity with rest.

Decrease Pain from Mechanical Stress

Continue use of assistive devices for ambulation, if necessary. The patient may progress to using less assistance or may ambulate for periods without assistance. Continue use of elevated seats on commodes and chairs, if needed, to reduce the mechanical stresses imposed when attempting to stand up.

Increase Joint Play and Range of Motion

Joint mobilization

 When there is loss of joint play and decreased mobility, joint mobilization techniques should be used. Apply grade III sustained or grade IV oscillation techniques to the tibiofemoral and patellofemoral articulations with the joint positioned at the end of its available range before applying the mobilization technique.

Stretching techniques

 Passive and muscle inhibition stretching techniques are used to increase flexibility in the muscles and extracapsular noncontractile soft tissues that restrict knee motion

Mobilization with Movement

 Mobilization with movement (MWM) may be applied to increase ROM and/or decrease the pain associated with movement by improving joint tracking. Mulligan154 stated that MWM is more effective with loss of flexion than extension.

Lateral or Medial Glides

Patient position and procedure: Supine for extension or prone for flexion. Apply a pain-free medial or lateral glide to the tibial plateau by hand or through the use of a mobilization belt. The direction of glide is often in the direction of the pain (i.e., lateral knee pain responds best to a lateral glide of the tibia and medial knee pain to a medial glide).

 

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