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NASM CES Chapter 12: Corrective Strategies for the Knee 1

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    Chapter Goals:

    • Know the basic functional anatomy of the knee.
    • Find the mechanisms that are common in knee injuries.
    • Discuss the influence of altered knee movement on the kinetic chain.
    • Find the right systematic assessment strategies for the knee. 
    • Be able to find the right strategies for corrective exercise on the knee. 

    Introduction

    Injuries of the lower body account for over 66 percent of all injuries.

    The knee happens to be one of those parts more commonly injured.

    The knee is between the foot and ankle complex and the hip complex.

    The knee is susceptible to dysfunctions of the lower kinetic chain.

    One of the more severe injuries of the knee is ACL ruptures.

    This occurs during single foot contact in physical activity. 

    We will discuss some of the other common injuries throughout this chapter. 

    Review of Knee Functional Anatomy

    The knee is a part of the kinetic chain and it is greatly affected by the joints that are close to it.

    That is the foot and ankle complex and the LPHC.

    They both play major roles in the knee structures. 

    Bones and Joints

    The knee joint is a synovial joint that is made up of two articulations, the tibiofemoral joint and the patellofemoral joint.

    The tibia and the femur make up the tibiofemoral joint and the patella and femur make up the patellofemoral joint.

    The fibula is an attachment site of the biceps femoris and it crosses and affects the knee.

    The knee is intended to flex and extend, and it’s capable of some other motions due to the architecture and allowing reaction in the frontal and transverse planes. 

    The tibiofemoral joint is one of the more complex joints in the body. when in an open chain position, the knee extends in the last 30 degrees and the tibia externally rotates on the femur to lock the knee into extension and that makes the ligaments taut.

    When in a closed chain position, the overhead squat or single leg squat, the femur internally rotates on the tibia. 

    The patellofemoral articulation is formed by the patella and the femur.

    This joint and the quads are called the extensor mechanism since the motions at this joint aid in extending the knee. 

    Muscles

    There are many muscles in the LPHC and lower leg that function in relation to the knee.

    Weakness of the hip external rotators and the gluteus medius and maximus might cause overactivation of the TFL, adductor complex, vastus lateralis, and the gastrocnemius.

    The key muscles that are associated with the knee will be the gastrocnemius and soleus, the adductor complex, medial and lateral hamstring complex, tensor fascia latae and IT band, quadriceps, and the glute med and max. 

    Altered Knee Movement

    Adolescent athletes commonly injure the knee in some way.

    The highest rate of injury for the knee is from 15 – 24 years old.

    Knee injuries also have accounted for 60 percent of high school sports related surgeries.

    Female athletes are found to have 4 – 6 times more of a chance to have a major knee injury throughout their sports career. 

    The multidirectional forces on the knee joint in physical activity explain the types of severe knee injuries, like ruptures of the ACL. 

    Static Malalignments

    These can lead to increased PFP and knee injury.

    Common static malalignments include pes planus of the foot, increased 1 angles, anterior pelvic tilt, and decreased flexibility of the quads, hamstrings, and IT band.

    Abnormal Muscle Activation Patterns

    These can lead to PFP, ACL injury, and other knee injuries.

    Abnormal contraction intensities and onset timing of the VMO and vastus lateralis have been shown in people with PFP. 

    Dynamic Malalignment

    This may occur during movement as a result of bad neuromuscular control and dynamic stability of the trunk and the rest of the lower body.

    Abnormal patterns of the LPHC compromise dynamic stability and result in these dynamic malalignments. 

    Knee Dysfunction and the Regional Interdependence Model

    The knee is again, greatly affected by the joints that are superior and inferior to it.

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    This is the foot and ankle complex and the hip. during the assessment of movements, when the foot over pronates, the foot will externally rotate and evert in the movement and there is an increase in tibial rotation, femoral adduction, and hip internal rotation.

    The movement for compensation results in knee valgus positioning, leading to the limitation of neuromuscular control.

    On the opposite, if the foot over supinates, there is a possible tightness of the gastrocnemius and soleus complex which will create tibial external rotation from tightness of the biceps femoris, weakness of the musculature of the adductors, and piriformis tightness. 

    Assessment Results for the Knee

    To limit the risk of lower body injuries, we should begin with the integrated assessment process and follow it with targeted corrective exercise strategies.

    Dynamic and static posture of the knee is influenced highly by the mobility we have in our hip and foot and ankle complex.

    Know the various results that can come from the different knee assessments. 

    Static Posture

    In the static posture assessment, the fitness professionals are going to compare the client’s posture to the architypes that are discussed throughout Janda’s postural syndrome, pes planus syndrome, and also kendall’s spinal postures.

    The knee is the focus here, but the kinetic checkpoint above and below will need to be considered with it. 

    Clients that have an anterior pelvic tilt will see a muscle imbalance affecting the lower extremities as well.

    Dysfunction of the ankle, like what is seen in pes planus distortion syndrome, may cause static postural malalignments in the knee.

    The pes planus is seen as having flattened feet and knee valgus. 

    Transitional Movement Assessments

    Overhead Squat Assessment

    When doing this movement, the key compensation impairment to look for is knee varus, valgus, and dominance.

    Both the knee varus and dominance are going to be rare, though.

    Study the figures that are in this section of the chapter and ensure that you know what these conditions look like. 

    Single Leg Squat

    This is an important transitional assessment to do for finding the potential for injury in the knee joint.

    It gives a deeper look into the knee function for the people that are able to do it.

    This is really true for the advanced athletes that are able to put their bodies in the best overhead squat from.

    Squatting on one leg also might reveal some things wrong with your squat that you do on two legs.

    The main thing we will look for here is going to be knee valgus, but knee varus may be seen in some that have overactive femoral external rotators. 

    Loaded Movement Assessment

    Loaded variant of squatting can be put into the client’s workout for assessing their dynamic posture under the hip any time they are with a fitness professional in the gym.

    Sometimes we see a client able to track their knees under their own body weight, but with load added on we may see these imbalances show up. 

    Dynamic Movement Assessments

    When doing the depth jump with your more advanced clients, look at them from the anterior view to find the knee position upon striking the ground and through the eccentric phase of landing.

    Many impairments will be seen during deceleration.

    Knee valgus will be the most common compensation, with some occurrence of knee varus, too. 

    Mobility Assessments

    Flexibility of the muscles above and below the knee can impact its alignment.

    We see knee varus, valgus, or dominance here.

    The hip flexors, quads, adductors, and hamstrings can be tested with the modified Thomas test, prone knee flexion test, adductor test, and active knee extension test.

    It should be considered that many of the muscles mentioned in this chapter will cross both the hip and the knee. 

    Corrective Strategies for the Knee

    Knee Valgus

    We should start with the inhibiting phase of corrective exercise and this uses the myofascial rolling.

    The muscles that are worked here will be the adductors, the TFL and IT band, and the biceps femoris.

    Follow the guidelines mentioned for this in the previous chapter on inhibition.

    Next we will Lengthen after the inhibit phase and this will use the static stretching.

    The muscles worked on will again be the adductors, the TFL and IT band, and the biceps femoris.

    Follow the recommendation of the 30 second hold. 

    The third phase of the continuum will be the activation phase and we will be using isolated strengthening on the gluteus max and gluteus med.

    Then follow the guidelines used for activation mentioned in that chapter. 

    The integration phase is last, and this makes use of integrated dynamic movement.

    The exercises we will use are the supported squat with a mini band around the knees and the wall jump.

    We will follow the guidelines laid out in the chapter on integration. 

    Follow the steps as they are shown in the pictures to look at what that will look like specifically for the knee now. 

    Knee Varus

    We will start with the inhibit phase and use SMR again.

    The muscles to be worked will be the piriformis, the TFL and glute min, and the biceps femoris.

    Follow the guidelines set up in the previous chapters we went over.

    The lengthen phase will be next and we will use static stretching on the muscles of the piriformis, the TFL and glute min, and the biceps femoris.

    Follow the guidelines set up in the previous chapters we went over.

    The activate phase will use isolated strengthening for the gluteus max, adductor muscles, and the medial hamstrings.

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    Follow the guidelines set up in the previous chapters we went over.

    The integration phase is the last one and we will use integrated dynamic movement with use of the exercises of supported squat with medicine ball between the knees and the wall jump.

    Follow the guidelines set up in the previous chapters we went over.

    Follow the steps as they are shown in the pictures to look at what that will look like specifically for the knee now. 

    Knee Dominance

    The inhibit phase will have us utilizing the SMR on our hip flexors and our quads.

    Follow the guidelines set up in the previous chapters we went over.

    The second phase of lengthening will have us using static stretching on the hip flexors and the quads also.

    Follow the guidelines set up in the previous chapters we went over.

    The activation phase will be third and it uses isolated strengthening with a focus on the muscles of the glute max, hamstring, and the abs.

    Follow the guidelines set up in the previous chapters we went over.

    Integration, the final part, will have us using the integrated dynamic movement exercises that are the supported squat and the wall jump to improve.

    Follow the guidelines set up in the previous chapters we went over.

    Follow the steps as they are shown in the pictures to look at what that will look like specifically for the knee now. 

    Common Issues Associated with the Knee

    The hinged knee joint is going to be highly vulnerable to being injured.

    Altered kinetic chain dysfunctions relating to the LPHC and the foot and ankle complex play a role in these common knee injuries.

    These will be some of the more common knee injuries, but it always important to consider that previous statement that it is not always necessarily the knee by itself that is the problem. 

    Patellar Tendinopathy

    The patellar tendon starts on the base of the patella and inserts to the tibial tuberosity.

    It is needed for knee kinematics.

    It is often seen as the extensor mechanism and the patellar tendon give the force needed to extend the knee in open chain positions.

    When people perform their activities of daily living, they are having isometric, concentric, and eccentric forces all acting on the knee.

    These increase exponentially with activities of greater force like running.

    This patellar tendinopathy is common in overuse and shows up mainly as pain at the patella’s base. 

    The risk factors for this issue are:

    • Knee valgus and varus
    • An increase in Q angle
    • Poor quad and hamstring complex flexibility
    • Poor eccentric deceleration ability
    • Overtraining and playing on hard surfaces.

    Patellofemoral Syndrome

    One of the common causes that are accepted for this is the abnormal tracking of the patella in the femoral trochlea or the patellar groove.

    The stress increases when not in the proper line.

    We see pain in the patella with this injury.

    Iliotibial Band Syndrome

    IT band syndrome is the result of inflammation and irritation in the distal part of the IT band as it hits the lateral femoral condyle as well as compresses the fat pad in that area.

    This burisitis can also be caused.

    It can often occur from a lack of flexibility in the tensor fascia latae.

    Overuse is going to be the most common reason that any of this occurs. 

    Anterior Cruciate Ligament Injury

    As we have discussed a few times already in this chapter, this is one of the more sever types of injuries to the knee that can occur, and it is a rupture of this specific ligament.

    Many ACL injuries happen each year and they are from indirect contact most often.

    The many forces that our knee is used for absorbing will have an effect on these injuries. 

    NASM CES Chapter 12: Corrective Strategies for the Knee 2
    NASM CES Chapter 12: Corrective Strategies for the Knee 3
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