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1、膝关节康复膝关节康复第1页，共45页，编辑于2022年，星期二Objectives1、to identify the structures of the knee complex,including joint type,articular shape,and the surrounding tissues 2、to describe joint motions occurring at the knee complex,including physiological and accessory movements,muscle actions,and factors checking kne
2、e motions 第2页，共45页，编辑于2022年，星期二3、to understand the stability mechanism of the knee complex and the possible mechanisms of injury 4、to understand functions of the meniscus and the ligaments surrounding the knee complex 5、to explicate functions of the sesamoid bone such as the patella as well as its s
3、ignificance in biomechanics第3页，共45页，编辑于2022年，星期二第一节、第一节、Functions of the Knee1、To provide stability for weight bearing 2、To allow mobility of the leg in space 3、To transmit the loads from the upper body and thigh to the lower leg 第4页，共45页，编辑于2022年，星期二第二节、第二节、Joint Structure of the Knee Complexn nJoi
4、nts at the knee complex n nPatella n nmeniscus n nQ-angle 第5页，共45页，编辑于2022年，星期二Joints at the knee complex1.1.tibiofemoral joint(knee joint)：principal joint at the knee complex2.2.patellofemoral joint NOTE：In Neumanns book,the tibiofemoral joint was divided into medial and lateral tibiofemoral joints
5、 第6页，共45页，编辑于2022年，星期二第7页，共45页，编辑于2022年，星期二Tibiofemoral joint(TF joint)proximal componentsproximal components：femur femur convex femoral condyles convex femoral condyles distal componentsdistal components：tibia tibia concave superior surface of the tibial plateau concave superior surface of the tibi
6、al plateau C-shaped medial C-shaped medial meniscusmeniscus and O-shaped lateral and O-shaped lateral meniscusmeniscusjoint typejoint type：hinged jointhinged jointDOF=2 DOF=2 because of the because of the meniscimenisci between the articular surfaces between the articular surfaces 第8页，共45页，编辑于2022年，
7、星期二n nmotions：concave on convex knee flexion/extension with posterior/anterior glide of the tibial plateau on the femoral condyles tibia inward/outward rotation：only occurs at the knee flexed position n nresting position：slight knee flexion(10)n nclosed-packed position：full knee extension 第9页，共45页，编
8、辑于2022年，星期二第10页，共45页，编辑于2022年，星期二Patellofemoral joint(PF joint)proximal componentsproximal components：femur femur convex femoral condyles convex femoral condyles distal componentsdistal components：patella patella 3 concave facets of the patella 3 concave facets of the patella joint typejoint type：sa
9、ddle joint saddle joint DOF=2 DOF=2 motions motions superior/inferior glide associated with knee extension/flexion superior/inferior glide associated with knee extension/flexion medial-lateral shift medial-lateral shift：c-curve movement c-curve movement 第11页，共45页，编辑于2022年，星期二Patella1.1.largest sesam
10、oid bone in largest sesamoid bone in the body the body 2.2.locationlocation：embedded in embedded in quadriceps tendon quadriceps tendon 3.3.functionfunction：to increase to increase mechanical leverage of mechanical leverage of the quadriceps the quadriceps 第12页，共45页，编辑于2022年，星期二patellar compression
11、force：1.1.to pull the patella against to pull the patella against the anterior surface of the anterior surface of the femur the femur 2.2.increased with knee increased with knee flexion flexion 第13页，共45页，编辑于2022年，星期二patella contact area1.1.At full extension,the distal At full extension,the distal po
12、rtion of the patella is in portion of the patella is in contact with the superior contact with the superior portion of the trochlea portion of the trochlea 2.2.As knee flexion,the contact As knee flexion,the contact area moves proximately area moves proximately 3.3.Contact area increases from 0.8 Co
13、ntact area increases from 0.8 cm2 at knee full extension to 4 cm2 at knee full extension to 4 cm2 at 90 of flexion(Hehne,cm2 at 90 of flexion(Hehne,1990)1990)第14页，共45页，编辑于2022年，星期二Meniscus1.1.medial meniscusmedial meniscus：C-shaped C-shaped 2.2.lateral meniscuslateral meniscus：O-shaped O-shaped 3.3.
14、functions functions to deepen the tibial plateau for to deepen the tibial plateau for knee stability knee stability to absorb the ground reaction to absorb the ground reaction forcesforces：carrying 40-70%of carrying 40-70%of loads across the knee joint loads across the knee joint 第15页，共45页，编辑于2022年，
15、星期二Meniscus4.removal of menisci increases the magnitude of stresses on the cartilage of the tibia plateau changes the size and location of tibiofemoral contact area 第16页，共45页，编辑于2022年，星期二Meniscus 5.movements of meniscus Both menisci distorted and moved posteriorly during knee flexion and anteriorly
16、during knee extension In rotation,both menisci follow the motions of the femoral condyles Movements significantly greater in weight-bearing conditions 第17页，共45页，编辑于2022年，星期二Q anglefull name：quadriceps angle the angle formed by the line of pull of the quadriceps and the line representing patellar ten
17、donmale：12 female：15 第18页，共45页，编辑于2022年，星期二n nThe Q angle is an estimate of the effective The Q angle is an estimate of the effective angle at which the quadriceps averages its angle at which the quadriceps averages its pull.pull.defined as the angle formed by defined as the angle formed by the line
18、 of pull of the quadriceps the line of pull of the quadriceps and the line representing the and the line representing the patellar tendon.patellar tendon.n n It is determined by drawing It is determined by drawing a line from a line from the Anterior Superior Iliac Spine to the the Anterior Superior
19、 Iliac Spine to the center of your knee capcenter of your knee cap and a second and a second line from the center of your knee line from the center of your knee cap to the insertion of the patellar cap to the insertion of the patellar tendontendon.Normal is below 12 degrees,.Normal is below 12 degre
20、es,abnormal is usually considered to be above abnormal is usually considered to be above 15 degrees.15 degrees.第19页，共45页，编辑于2022年，星期二第三节第三节 Kinematics of the Kneen nknee flexion/extension n ntibia inward and outward rotation 第20页，共45页，编辑于2022年，星期二Knee flexion and extension1.joint involved tibiofemor
21、al joint patellofemoral joint 2.plane of motion：sagittal plane(not really)第21页，共45页，编辑于2022年，星期二3.axis of rotation a frontal axis passing through the center of the medial and lateral epicondyles of the femur instant center of rotation(IAR)：axis of rotation changes through the range of motion(not a f
22、ixed point)path of IAR forms a semi-circle from lateral view 第22页，共45页，编辑于2022年，星期二4.osteokinematic movements range of motion(ROM)0-140 for knee flexion 0-140 for knee flexion some for knee hyperextension some for knee hyperextension closed kinematic chain motions deep squatting deep squatting stand
23、ing up from sitting standing up from sitting stance phase of the gait cycle stance phase of the gait cycle supine lying with the leg pushing supine lying with the leg pushing against the wall against the wall 第23页，共45页，编辑于2022年，星期二functional range walking:0-67 climbing stairs:0-83 descending stairs:
24、0-90 sitting in a chair:0-93 tying a shoe:0-106 lifting an object from the floor:0-117 第24页，共45页，编辑于2022年，星期二5.5.arthrokinematic movements tibiofemoral joint：concave on convex Tibia on Tibia on FemurFemurPatella on Patella on FemurFemurMenisci relative Menisci relative to tibiato tibiaKnee Knee Flex
25、ionFlexionposterior posterior glide glide inferior glideinferior glideposterior posterior displacementdisplacementKnee Knee ExtensionExtensionanterior anterior glideglidesuperior glidesuperior glideanterior anterior displacementdisplacement第25页，共45页，编辑于2022年，星期二6.screw-home mechanism synonym：knee lo
26、cking mechanism continuous inward rotation of the femur that accompanies the completion of knee extension during the closed kinematic chain motions 第26页，共45页，编辑于2022年，星期二7.patellar tracking movement：dictated by quadriceps contraction medial/lateral shift：c-curve pattern from knee flexion to extensio
27、n medial/lateral tilt：The patella tilts medially from knee flexion to extension,but the patella is still in the laterally tilt position even the knee is in the fully extended position.第27页，共45页，编辑于2022年，星期二8.factors checking knee flexion mass of the hamstrings passive tension of the quadriceps tensi
28、on of the posterior cruciate ligament 第28页，共45页，编辑于2022年，星期二9.factors checking knee extension bony contact passive tension of the hamstrings tension of the anterior cruciate ligament 第29页，共45页，编辑于2022年，星期二Tibia inward and outward rotation1.1.only occurs in the knee flexed position and not indicate s
29、crew home mechanism2.2.joint involved：tibiofemoral joint3.3.plane of motion：transverse plane4.4.axis of rotation：vertical axis through or close to medial tibial intercondylar tublercle 第30页，共45页，编辑于2022年，星期二5.osteokinematic movements total range=70-80 at 90 of knee flexion outward inward rotation no
30、 rotation at full extension 6.arthrokinematic movements：spin of the tibia on the femoral condyles menisci movements follow the motions of the femoral condyles 7.outward rotation is limited by the passive tension of the popliteus muscle 第31页，共45页，编辑于2022年，星期二第四节第四节 Muscles Actions Around the Knee n n
31、knee extensors n nknee flexors n ntibia inward rotators n ntibia outward rotators 第32页，共45页，编辑于2022年，星期二Knee extensors1.quadriceps femoris 1.quadriceps femoris n nrectus femorisrectus femoris：two-joint two-joint muscle muscle knee extensor knee extensor hip flexor hip flexor n nvastus medialis vastu
32、s medialis vastus medialis longus vastus medialis longus vastus medialis obliquus vastus medialis obliquus n nvastus lateralis vastus lateralis n nvastus intermedialis vastus intermedialis 第33页，共45页，编辑于2022年，星期二Knee extensors2.Efficiency of quadriceps depends on the patella 3.Maximum isometric force
33、 occurs at 60 of knee flexion 4.No quadriceps activity required to keep knee extension at erect stance 5.isokinetic strength：H/Q ratio=0.7:1 第34页，共45页，编辑于2022年，星期二Knee flexors hamstrings：two-joint muslce biceps femoris semitendinosus semimembranosus sartorius（缝匠肌）Gracilis（股薄肌）Popliteus（腘肌）gastrocnem
34、ius：two-joint muslce 第35页，共45页，编辑于2022年，星期二Tibia inward rotation at 90 of knee flexionpopliteuspopliteus：knee flexion knee flexion+inward rotation+inward rotationSemitendinosusSemitendinosussemimembranosus semimembranosus 第36页，共45页，编辑于2022年，星期二 Tibia outward rotation at 90 of knee flexion biceps fem
35、oris 第37页，共45页，编辑于2022年，星期二第五节第五节 Knee Stability n nfactors affecting stability of the tibiofemoral joint n nFactors affecting stability of the patella 第38页，共45页，编辑于2022年，星期二Factors affecting stability of the tibiofemoral joint 1.bony configuration1.bony configuration：the least important the least i
36、mportant 2.tension of ligaments or other connective tissues 2.tension of ligaments or other connective tissues n nanterior cruciate ligament(ACL)anterior cruciate ligament(ACL)：anteromedial stability anteromedial stability prevent anterior displacement of the tibia prevent anterior displacement of t
37、he tibia n nposterior cruciate ligament(PCL)posterior cruciate ligament(PCL)：anterolateral stability anterolateral stability prevent posterior displacement of the tibia prevent posterior displacement of the tibia n nlateral collateral ligaments(LCL)lateral collateral ligaments(LCL)：prevent varus str
38、ess prevent varus stress n nmedial collateral ligament(MCL)medial collateral ligament(MCL)：prevent valgus stress prevent valgus stress n nmedial and lateral retinaculum medial and lateral retinaculum n niliotibial bandiliotibial band第39页，共45页，编辑于2022年，星期二3.passive tension of muscles：quadriceps femor
39、is hamstrings pes anserinus第40页，共45页，编辑于2022年，星期二Factors affecting patella stability1.bony configuration 1.bony configuration Prominent anterolateral aspect of the femoral condyle Prominent anterolateral aspect of the femoral condyle 2.ligaments or connective tissue 2.ligaments or connective tissue
40、patellar ligament patellar ligament medial and lateral retinaculum medial and lateral retinaculum iliotibial band iliotibial band 3.muscles 3.muscles tensor fascia lata muscle tensor fascia lata muscle vastus medialis vastus medialis：contraversial contraversial 第41页，共45页，编辑于2022年，星期二第六节第六节 Mechanism
41、 of Injury at the Knee n ndirect stressn n n nrepeated stresses第42页，共45页，编辑于2022年，星期二direct stressvarus stress lateral collateral ligament injurysuddenly turning around with knee flexion unhappy triad：MCL+ACL+medial meniscus injury 第43页，共45页，编辑于2022年，星期二Repeated stressesrepeated knee flexion and extension stresses iliotibial band friction syndrome jogging on the curved road（在弯道上慢跑）jogging on the court（在球场上慢跑）repeated jumping and landing patellar tendinitis(jumpers knee)repeated anterior shear stress popliteal tendinitis jogging downhill（下坡慢跑）第44页，共45页，编辑于2022年，星期二第45页，共45页，编辑于2022年，星期二