ARTICLE IN PRESS

Journal of Bodywork and Movement Therapies (2007) 11, 5460

Journal of
Bodywork and
Movement Therapies
www.intl.elsevierhealth.com/journals/jbmt

SELF-MANAGEMENT: CLINICAL SECTION

Functional problems associated with the

kneePart two: Rehabilitation fundamentals for
common knee conditions$
Craig Liebenson, DC

L.A. Sports and Spine, 10474 Santa Monica Blvd., #202, Los Angeles, CA 90025, USA

Accepted 6 November 2006

Introduction times a direct blow to the knee with the foot

The knee is a commonly painful or injured joint.
Kinetic chain dysfunction is a common factor either
causing or perpetuating such pain or injury (Risberg
et al., 2001, 2004). Part one in this series discussed
typical patterns of functional loss in knee patients.
Biomechanical sparing strategies, stabilization
training and functional exercises were also intro-
duced. In this second part of the series the major
SELF-MANAGEMENT: CLINICAL SECTION
planted.
Dysfunctional kinetic chain: Quadriceps weak-
ness, hamstring over activity, quadriceps avoidance
gait pattern, large strength imbalance between
dominant and non-dominant legs, excessive valgus
shear on landing.
Are there any ways to prevent ACL injury?

distinguishing features of different common clinical
conditions are presented along with the key
rehabilitation goals.
Anterior cruciate ligament (ACL)
reconstruction post-operative
rehabilitation
Clinical symptom complex: Pain, swelling, giving
way with rotation or deceleration.
Tissue injury complex: ACL.
Source of biomechanical overload or mechanism
of injury: Non-contact decelerating or twisting
injury with hyperextension coupled with a varus
or valgus stress on a weight bearing limb. Some-
$
This paper may be photocopied for educational use.
Tel.: +1 310 470 2909; fax: +1 310 470 3286.
E-mail address: cldc@flash.net.
In a prospective, controlled study it has been shown
that soccer players who undergo balance training
can prevent ACL-injuries (Carrafa et al., 1996). The
trained group included 600 players while the
control group consisted of 300 players.
Poor control of valgus loading of the knee predicts
non-traumatic knee injuries in female athletes
(Hewett et al., 2005a, b; McLean et al., 2005).
Female athletes with increased dynamic valgus and
high abduction loads have been shown to be at
increased risk of ACL injury (Hewett et al., 2005a, b).
Females have been shown to utilize different
muscular activation patterns compared to males
(i.e. decreased gluteus maximus and increased
rectus femoris muscle activity) during landing
maneuvers (Zazulak et al., 2005). Decreased hip
muscle activity and increased quadriceps activity
were concluded to be likely contributors to the
increased susceptibility of female athletes to

1360-8592/$ - see front matter & 2006 Published by Elsevier Ltd.

doi:10.1016/j.jbmt.2006.11.002
 ARTICLE IN PRESS
Functional problems associated with the knee
non-contact ACL injuries. Quadriceps dominance
involving preferential activation of the quadriceps
vs. hamstrings (Hewett et al., 1996, 2001) or
strength imbalance between stronger quadriceps
and weaker hamstrings (Baratta et al., 1988) has
been shown to correlated with ACL injury.
Hewett et al. (1999) has shown in female
collegiate athletes that the introduction of supina-
tory training during plyometric squats prospectively
reduced the incidence of injury in the coming
season. The four main components of this training
are plyometric and movement, core strengthening
and balance, resistance training, and speed train-
ing (Hewett et al., 2005b; Myer et al., 2005).
Initial post-operative rehabilitation
Initially after surgery the weakest link is the graft
fixation. This requires fixation for 46 weeks. Bone
to bone fixation heals in 6 weeks, whereas soft
tissue to bone fixation heals in 812 weeks.
Initial goal: obtain full extension
Acute phase post-operative (24 weeks) rehabi-
litation focuses on early joint motion to prevent
capsular contraction (Beynnon et al., 1995). Full
extension and 901 flexion are goals after 1 week
(Cascio et al., 2004). Motion deficits after 2 weeks
should be dealt with aggressively.
Initial exercises: Heel slides
Prone knee curl (leg hangto promote
terminal knee extension)
Progress to range of motion (ROM) on a
bicycle with no resistance after the 1st
week
Key controversy in functional rehabilitation
Protocols differ considerably on the three
main issues of immobilization weight bear-
ing, and return to pivoting sports
Intermediate phase rehabilitation
Are closed kinetic chain (CKC) exercises
dangerous?
Much controversy exists regarding open kinetic
chain (OKC) vs. CKC rehabilitation for the ACL
55
patient. It is often warned that squats are harmful
for the tissues of the knee. It has been found that
there is the same strain on the ACL with CKC
squatting vs. OKC seated knee flexion/extension
exercise (Beynnon et al., 1997; Fleming et al.,
1998). Bynum et al. (1995) randomized 100
subjects to 2 groupsOKC and CKC. The CKC group
had lower mean knee joint laxity and improved
satisfaction with care.
Does this mean there is no role for OKC
exercises?
OKC programs at knee flexion angles between 401
and 901 flexion have been proposed for training
quadriceps. Beginning at 6 weeks post-operatively,
OKC exercise when combined with CKC training led
to better outcomes at 6 months in terms of return
to sport and quadriceps strength than CKC training
alone (Mikkelsen et al., 2000).
What is the role of quadriceps strengthening?
Quadriceps weakness can persist for 2 years after
surgery (Risberg et al., 1999). 71% of the variance
in outcome can be related to quadriceps strength
at 2 years. Quadriceps strengthening should be
started within the 1st week after surgery (Snyder-
Mackler et al., 1995; Lieber et al., 1996).
What is the role of balance or sensory-motor
training?
The addition of perturbation training (unexpected
balance challenges) improved outcomes (Fitzgerald
et al., 2000). Less giving way when returning to
sport was reported. Beard et al. (1994) gave a
SELF-MANAGEMENT: CLINICAL SECTION
sensory-motor program designed to increase ham-
string reflex contraction speed. Both general knee
function and hamstring reaction time improved
over a control group receiving a tradition exercise
approach. A sensory-motor balance training pro-
gram was compared to resistance training in
patients with knee instability (Ihara and Nakayama,
1986). Those who underwent sensory-motor train-
ing improved their hamstring reaction time
whereas those who did resistance training did not.
Poor balance has also been identified as a distin-
guishing marker in ACL deficient knees (OConnell
et al., 1998).
Is training neutral knee posture under load
important?
A program emphasizing control of valgus loads
during squats and landing activities has been shown
to be of value in ACL rehabilitation (Myer et al.,
2006). Such a program emphasized gluteal isolation
preferentially over the quadriceps. Motor control
training of neutral knee postures was trained in
 ARTICLE IN PRESS
56
simple positions and progressed to include plyo-
metrics.
What is the role of the hamstrings in ACL
rehabilitation?
Hamstrings are the main ACL agonist providing a
protective restraint to anterior tibial translation.
CKC hamstring training enhances satisfaction and
earlier return to sports (Bynum).
Return to sport criteria
A literature review showed that 4192% of patients
with patellar tendon autografts return to pre-injury
sports activity levels (Delay, 2001). An international
panel of surgeons and physical therapists reported
that the average time for return for activities is
(Harner et al., 2001).
 Running4.3 months (range 6 weeks12
months).
 Jumping6.5 months (range 312 months).
 Light sports5 months (range 39 months).
 Moderate sports5.8 months (range 49
months).
 Strenuous sports8.1 months (range 418
months).
Most knee surgeons allow return to sport at 67
months with a functional brace (Delay, 2001). Rebe
and Paessler (2001) reported enhanced coordina-
tion in jumping and landing when utilizing a
functional knee brace.
SELF-MANAGEMENT: CLINICAL SECTION
Rehabilitation following meniscus repair
Clinical symptom complex: Point tenderness usual-
ly along medial joint line, mild swelling, clicking or
locking with rotation, and decreased extension
ROM.
Tissue injury complex: Medial or lateral meniscus
tears of the avascular central portion usually early full weight bearing, unrestricted motion, and
require surgery.
Source of biomechanical overload or mechanism
of injury: Twisting injury on a partially flexed knee
with the foot fixed on the ground.
Dysfunctional kinetic chain: Decreased stride,
quadriceps weakness.
Key points (Dehaven and Bronstein, 1997)
 No flexion for first 2 weeks
 After 2 weeks limit flexion to 20701
 Remain partial weight bearing for 46 weeks
C. Liebenson
Return to sport criteria
 According to Shelbourne et al. (1996) 48 weeks
when the quadriceps strength is 75% of the
contralateral side.
 According to Barber (1994) overly restrictive
postoperative restrictions and protocols are
harmful.
 According to Goodwin and Morrissey (2003)
partial mensicotomies are stable immediately.
 According to Bowen et al. (2004) the minimum
time and criteria for return to pivoting sports are
J Standard criteriano effusion or pain; near
normal ROM; symmetric single leg hop,
vertical jump tests; and quadriceps strength
80% of contralateral limb;
J Partial meniscotomyno minimum time;
J Isolated mensical repair3 months;
J Microfracture3 to 6 months;
J Periosteal grafting3 to 6 months;
J Osteochondral Autogenous transfer (OATS)3
to 6 months/MRI confirmation of graft incor-
poration;
J Fresh osteochondral allograft6 months/no
loss of fixation on X-ray;
J Autologenous chondrocyte implantation14
to 18 months/normal X-ray;
J Single leg standing balance eyes closed 20 s;
J Squatting endurance within 15% of age/sex
matched normal.
Combined meniscus repair with ACL
reconstruction
There is no evidence supporting any delays in the
above timelines or protocols for individuals having
combined ACL reconstruction and meniscus repair
(Mariani et al., 1996; Barber and Click, 1997)
Excellent outcomes have been reported utilizing
immediate full ROM and weight bearing (Mariani
et al., 1996). An accelerated program permitting
no limitations on pivoting sports after the resolu-
tion of the postoperative effusion and full motion is
established has been shown to be successful
(Barber and Click, 1997).
Knee osteoarthritis (OA)
What are the physical activity and
performance characteristics in patients with
end-stage knee OA?
Physical activity is 60% lower in OA patients vs.
asymptomatics (Thomas et al., 2003). Patients
 ARTICLE IN PRESS
Functional problems associated with the knee
climbed fewer stairs and shopped less often. Sports
participation was 10% of asymptomatics. They
walked at a 62% slower pace. Sit to stand, stair
performance, and muscular endurance were similar
in males, but 46% weaker in symptomatic vs.
asymptomatic females. Physical activity was more
closely associated with functional performance
than with pain.
McGibbon and Krebs (2002) found that knee OA
patients have a slower walking speed, shorter
stride, reduced ankle power at terminal stance,
and dysfunctional knee kinematics when walking at
a paced speed when compared to asymptomatic
individuals.
Childs et al. (2004) reported increased muscle
activity and muscle co-activation during gait and
stair descent on a 20-cm step. It has been
suggested that this step height may be too high
for the elderly. This is particularly important due to
the high incidence of falls in the elderly. Falls on
stair descent outnumber ascent 3:1 (LaStayo et al.,
2003). Nadeau et al. (2003) has studied the task of
stair climbing. Going up stairs requires concentric
action of hip abductor muscles. Elevation of
contralateral hip is necessary for the swing phase
leg to avoid the step. Decreased knee flexion is also
a problem with stair climbing. Strength of the knee
extensors is needed also to raise the body weight
up. The extension moment in knee is doubled in
stair climbing vs. level walking. About 11 weeks of
eccentric leg muscle training in high risk elderly
individuals improved stair descent performance by
21%, balance by 7%, strength by 60%, and signifi-
cantly decreased the risk of falling (LaStayo et al.,
2003).
Home advice for fall prevention (Liebenson,
2007)
 eliminate loose rugs and wire
 ensure handrails on all stairs
 recommend use of handrail especially when
going down stairs
 practice balance training
 increase cardio-vascular fitness with aero-
bic training
 increase dynamic strength especially of legs
Poor balance has been found in individuals with
bilateral knee OA more so than in an age-matched
control group (Wegener et al., 1997). Pandya et al.
(2005) reported that knee OA reduces obstacle
avoidance strategies and increased the propensity
to trip on an obstacle (the greater the pain the
greater the risk).
57
Should patients with knee OA exercise?
OA often leads to sedentarism, and thus can
increase the risk of CVD, yet historically patients
with OA were advised to avoid activity (Brady
et al., 2003). It is now recognized that exercise
programs for patients with knee or hip OA are
beneficial (Bashaw and Tingstad, 2005; Ettinger
et al., 1997). In a large study of 439 individuals over
the age of 60 with radiologic keee OA either
aerobic or resistance exercise improved function
and reduced pain without increasing any signs of
radiographic arthritis (Ettinger). Petrella and
Bartha (2000) reported that increases in physical
capacity and physical activity are achieved with
exercise. Such rehabilitation may be preventive of
end-stage OA requiring total knee arthroplasty
(TKA). Specific approaches found to be effective
include:
 isometric quadriceps training (Gur et al., 2002;
OReilly et al., 1999; Petrella and Bartha, 2000);
 supervised walking (Toda, 2001);
 general aerobic conditioning (van Baar et al.,
2001).
Patients whose self-efficacy improves with treat-
ment experienced the greatest improvement
(Keefe et al., 1996a, b; van Baar et al., 2001).
The combination of psycho-social approaches with
exercise was superior to either alone. Keefe
recently reported that spouse assisted coping skills
training enhances the effectiveness of the treat-
SELF-MANAGEMENT: CLINICAL SECTION
ment program for knee OA (Keefe et al., 2004).
Total knee arthroplasty (TKA)
Who are the typical candidates for TKA?
Typically performed on individuals between 65 and
80 years old joint replacement surgery is now being
performed on individuals as young as 40 or as old as
90 (Parsons and Sonnabend, 2004). Individuals in
their 40s and 50s have more rapid aseptic loosening
from polyethylene wear. Survivorship of the im-
plants is better in women than men.
Recovery expectations
Pain relief usually begins 1 week post-operatively
(Irens et al., 1996). Rissanen et al. (1995) reported
a 55% reduction in pain intensity at 2 and 5 years.
Noble et al. (2005) recently reported TKA patients
 ARTICLE IN PRESS
58
continue to experience significant disability com-
pared to their age and gender matched peers.
What are key functional problems after
arthroplasty?
Kneeling ability is compromised (Schai et al.,
1999). Those who had difficulty kneeling had scar
pain or back-related problems as major factors
limiting kneeling ability.
Kinematic and electromyographic assessment of
function during the timed up and go test, 6 m walk,
and stair ascent revealed a number of pre-TKA
deficits which all persisted post-surgically (Ouellet
and Moffett, 2002).
Is Rehabilitation Necessary?
Munin et al. (1998) found that early rehabilitation
(day 3) was superior to a usual care group. The
rehabilitation group had a shorter duration hospital
stay, lower total cost of care, more rapid attain-
ment of functional goals. Specific impairments in
pre-TKA patients include decreased knee and ankle
mobility (Ouellet and Moffett, 2002). More inten-
sive post-surgical rehabilitation was recommended
to address these functional deficits.
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 ARTICLE IN PRESS
60 C. Liebenson

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