Screen Knee Issues for Potential Serious Conditions

Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems
Medical Screening for the Knee, Leg, Ankle or Foot Region

Red Flag Red Flag
Condition Data obtained during Data obtained during
Interview/History Physical Exam
Fractures1-4 History of recent trauma: crush Joint effusion and hemarthorsis
injury, MVA, falls from heights, Bruising, swelling, throbbing pain, and point
or sports injuries tenderness over involved tissues
Osteoporosis in the elderly Unwillingness to bear weight on involved leg
Peripheral Arterial Age > 55 years old Unilaterally cool extremity (may be bilateral if
Occlusive Disease5-9 History of type II diabetes aorta is site of occlusion)
History of ischemic heart disease Prolonged capillary refill time (>2 sec)
Smoking history Decreased pulses in arteries below the level of
Sedentary lifestyle the occlusion
Co-occurring intermittent Prolonged vascular filling time
claudication Ankle Brachial index < 0.90
Deep Vein Recent surgery, malignancy, Calf pain, edema, tenderness, warmth
Thrombosis10,11 pregnancy, trauma, or leg Calf pain that is intensified with standing or
immobilization walking and relieved by rest and elevation
Possible pallor and loss of dorsalis pedis pulse
Compartment History of blunt trauma, crush Severe, persistent leg pain that is intensified with
Syndrome12-14 injury - or - stretch applied to involved muscles
Recent participation in a rigorous, Swelling, exquisite tenderness and palpable
unaccustomed exercise or tension/hardness of involved compartment
training activity Paresthesia, paresis, and pulselessness
Septic Arthritis15 History of recent infection, surgery, Constant aching and/or throbbing pain, joint
or injection swelling, tenderness, warmth
Coexisting immunosuppressive May have an elevated body temperature
disorder
Cellulitis16 History of recent skin ulceration or Pain, skin swelling, warmth and an advancing,
abrasion, venous insufficiency, irregular margin of erythema/reddish streaks
CHF, or cirrhosis Fever, chills, malaise and weakness
History of diabetes mellitus
References:
1. Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains. Am Fam Physician. 2002;68:785-794.
2. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2002;68:2413-2418.
3. Hasselman CT, et al. Foot and ankle fractures in elderly white woman. J of Bone Joint Surg. 2003;85:820-824.
4. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments. Injury. 2004;35:443-461.
5. Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients
with diabetes mellitus. Journal of Clinical Epidemiology. 1997;50:659-668.
6. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med.
1998;158:1357-1364.
7. Halperin, JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106:V303-11.
8. Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral
occlusive vascular disease. Scand J Prim Health Care. 1998;16:177-182.
9. Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ.
1996;313:1440-79.
10. Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis in
outpatients. Amer J Med. 2003;115:436-440.
1. Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome. Pain Res Manag.
2001;6:200-203.
2. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989;240:97-104.
3. Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup. Postgraduate Medicine. 1999:105.
4. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder.
Orthop Trauma. 2002;16:572-577.
5. Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30.
6. Stulberg D, Penrod M, Blatny R: Common bacterial skin infections. Am Fam Physician. 2002; 66:119-124.
Joe Godges DPT KP SoCal Ortho PT Residency

KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE
NAME: ________________________________________ DATE: _____________

Medical Record #: _________________________
Yes No
1. Have you recently experienced a trauma, such as a vehicle accident, a

fall from a height, or a sports injury?
2. Have you recently had a fever?
3. Have you recently taken antibiotics or other medicines for an

infection?
4. Have you had a recent surgery?
5. Have you had a recent injection to one or more of your joints?
6. Have you recently had a cut, scrape, or open wound?
7. Do you have diabetes?
8. Have you been diagnosed as having an immunosuppressive disorder?
9. Do you have a history of heart trouble?
10. Do you have a history of cancer?
11. Have you recently taken a long car ride, bus trip, or plane flight?
12. Have you recently been bedridden for any reason?
13. Have you recently begun a vigorous physical training program?
14. Do you have groin, hip, thigh or calf aching or pain that increases with
physical activity, such as walking or running?
15. Have you recently sustained a blow to your shin or any other trauma
to either of your legs?
Joe Godges DPT KP SoCal Ortho PT Residency

1
Knee Capsular Disorder
"Knee Capsulitis"
ICD-9-CM: 719.56 Stiffness in joint of lower leg, not elsewhere classified
Diagnostic Criteria
History: Stiffness
Aching with prolonged weight bearing
Physical Exam: ROM loss - more loss of flexion than extension

Pain at end ranges
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency
2
Knee Capsulitis
ICD-9: 719.56 stiffness in joint of lower leg, not elsewhere classified
Description: This disorder is particularly disabling because of it results in difficulty with rising
from a chair, climbing stairs, kneeling, and walking. The primary complains are pain, stiffness,
instability, and loss of function and sometimes with impaired muscle function.
Etiology: It is considered a sequela of traumatic and age-dependent changes which result in a

loss of cartilage and impairment of function. Capsulitis has been essentially classified as primary
(idiopathic) or secondary, that is a process related to infection, trauma, inflammation,
metabolism, or aging. The portion of the capsule that becomes extended on joint sliding or
rolling may thicken and act to restrict motion in that direction. This capsular thickening
subsequent to synovitis accompanies the destruction of the articular cartilage, and thus the joint
mechanism becomes gradually impaired.
Physical Examination Findings (Key Impairments)
Acute Stage / Severe Condition
• Restricted knee motion

• Pain worse with end-range stretch positions
• Tibiofemoral accessory movements and joint play movements are considerable
limited. Patellofemoral accessory and joint play movements may also be limited
• Quadriceps femoris muscles may be weak and painful due to the tension transmitted
to an inflamed joint capsule by the contracting musculotendinous units that attach to
the capsule
• Palpable tenderness around the joint capsule
Sub Acute Stage / Moderate Condition
As above with the following differences
• Resisted tests of the quadriceps femoris are strong and relatively painless when the
tibio-femoral joint positioned in slight flexion (thus lessening tension on the capsule)
Now (when less acute) examine the patient for common coexisting lower quadrant impairments.
For example:
• Lumbar, hip and ankle movement abnormalities

• Muscle flexibility deficits – especially of the hamstrings, tensor fascia lata, iliotibial
band and sartorius
• Nerve mobility deficits – especially tibial and common peroneal nerves in the knee
area
3
• Weak quadriceps femoris commonly vastus medialis

• Restricted knee extension
Settled Stage / Mild Condition
• Pain with repetitive activities of the knee especially at end range

• Passive movements are painful only with overpressures at end range
4
Intervention Approaches / Strategies
Goals: Prevent movement induced inflammatory reactions.

Avoid muscle guarding
Pain free with daily activities that use knee with low range and amplitude of movements
Pain free sleep
• Physical Agents
Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing
inflammation
Ice and/or TENS for relief of acute pain as well as to reduce muscle guarding
Elevation/compression of knee to assist in reducing inflammation
• External Devices (Taping/Splinting/Orthotics)

Fit patient with knee support if pain relief requires temporary use of an external
device
Use of assistive device for unloading tissue
• Therapeutic Exercises
Pain free active mobility exercises
Pain free walking
Pain free walking and swimming in a pool
• Re-injury Prevention Instruction

Temporarily limit end range of flexion or stretches or activities that aggravate the
patient’s condition.
Goals: Improve tibiofemoral and patellofemoral mobility

Prevent re-injury to the joint capsule
Restore strength of the muscles around knee
• Physical agents
May use ultrasound to the joint capsule prior to active or passive stretching
procedures/exercises.
• Manual Therapy
Soft tissue mobilization to adaptive shortened myofascia around the knee
Joint mobilization to restricted accessory and joint play motions of the
tibiofemoral and patellofemoral articulations
5
Provide stretching exercises to enhance carryover of manual stretching procedures
Provide strengthening exercises to weak knee and hip muscles
• Neuromuscular Reeducation
Provide proprioception exercises to facilitate correct knee position
• Therapeutic Exercise
Initiate lumbar stabilization exercises (i.e., trunk flexor and extensor
strengthening to maintain the lumbar spine in its neutral positions during
performance of daily activities
Initiate stretching exercises to myofascia with flexibility deficits (e.g., hamstrings)
Initiate nerve mobility exercises the nerve with mobility limitations (e.g., sciatic
nerve)
Promote daily performance of low-stress aerobic activity (e.g., walking)
Goals: Normalize tibiofemoral and patellofemoral mobility

Normalize lower quadrant muscle flexibility and muscle strength
Progress activity tolerance
• Approaches / Strategies listed above
• Manual Therapy
Increase intensity and duration of soft tissue mobilization and myofascial
stretching to the maximal tolerable
Increase intensity and duration of joint mobilization procedures to the maximal
tolerable
Progresses intensity and duration of the stretching exercises as tolerated.
Maximize muscle performance of the relevant lower quadrant (hip, knee, ankle
and lumbar) muscles required to perform the desired occupational or recreational
activities
• Ergonomic Instruction
Provide job/sport specific training
6
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities.
Selected References
Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of
manual physical therapy and exercise in osteoarthritis of the knee. Ann Int Med. 2000;132:173-
181.
Puett DW, Griffin MR. Published trials of non medicinal and noninvasive therapies for hip and
knee osteoarthritis. Ann Int Med. 1994;121:133-140.
Rogind H, Bibow-Nielsen B, Jensen B, Moller H, Frimodt-Moller H, Bliddal H. The effects of a

physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil.
1998;79:1421-1427.
7
Impairment: Limited and Painful Knee Flexion
Knee Flexion MWM
Cues: Position the patient supine with the involved knee flexed and a strap around the patient’s
ankle (approximately 80 degrees of knee flexion is required for this procedure)
Place one palm on the anterior aspect of the distal femur and the other on the anterior
aspect of the proximal tibia
Posteriorly glide the tibia
Sustain the posterior glide while the patient actively flexes his/her knee and assists the
active flexion with a pull on the strap
This procedure uses long levers so instruct the patient to apply the force cautiously
The following reference provides additional information regarding this procedure:

Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 101-103, 1995
8
Impairment: Limited Knee Extension

Limited Tibial Anterior Glide
Tibial Anterior Glide
Cues: Position patient with his/her involved thigh supported on the treatment table with the
patella just distal to the end of the table – a strap securing the proximal femur
and/or pelvis to the table adds to the stabilization
A belt holding the involved knee in flexion instead of hanging off the edge of the table is
a nice courtesy
Use a “Chuck Berry” stance - hug the limb like a guitar and generate the force with a
trunk weight shift and a slight knee bend
Stand on the lateral side of the involved limb to do an anterior glide of the medial
condyle – stand on the medial side of the involved limb to do an anterior glide of
the lateral condyle

Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 169, 1989
1
Knee Muscle Power Deficits
“Patellofemoral Pain Syndrome”
ICD-9-CM: 719.46 Pain in joint - lower leg
Diagnostic Criteria
History: Anterior knee pain

Precipitated by trauma (subluxation), unaccustomed weight bearing
activities, or prolonged sitting
Worsens with bent knee sitting and activities – especially squatting,
climbing stairs, or running
Physical Exam: Limited medial patellar glide and/or excessive lateral patellar glide – with
pain at end range of one or both of these glides (may need to vary
the amount of knee flexion to elicit symptoms)
Biomechanical abnormalities (such as pronatory disorders, patella
malalignment, VMO/quadriceps weakness, tight lateral
retinaculum and myofascia excessive lateral tracking excessive Q
angle, hip muscle length and strength imbalances
Patella Lateral Glide Patella Medial Glide
Cues Assess glides at varying degrees of knee flexion - up to about 30°

Determine motion availability
Determine symptom responses at end range - be sure to use a strong force if mild-
moderate forces are asymptomatic
2
"Patellar Tendinitis"
ICD-9-CM: 726.64 Patellar tendinitis
Diagnostic Criteria
History: Anterior knee pain.

Pain associated with repetitive use of extensor mechanism (e.g., jumping,
kicking)
Physical Exam: Symptoms reproduced with palpation to inferior pole of patella, or patella
tendon insertion at the tibial tuberosity
Patellar Tendon Palpation/Provocation
Cues: P= Patella
1= Inferior Pole
2= Superior Pole
3= Tibial Tuberosity
3
Iliotibial Band "ITB Friction Syndrome"
ICD-9-CM: 726.60 Enthesopathy of knee, unspecified
Diagnostic Criteria
History: Lateral knee pain

Pain precipitated by unaccustomed weight bearing activities - such as stair
climbing or running on unlevel surfaces
Physical Exam: Symptom reproduction with palpation and provocation of (1) Gurdy's
tubercle, or (2) lateral femoral condyle with the knee slightly
flexed
Iliotibial Band Palpation
Cues: May need to utilize aggressive palpation to reproduce mild symptoms which develop
after extensive repetitive movement.
1 = Gurdy's Tubercle (insertion of ITB)
2 = Lateral femoral condyle (common site of friction with ITB)
4
"Pes Anserinus Bursitis"
ICD-9-CM: 726.61 Pes anserinus bursitis
Diagnostic Criteria
History: Symptom precipitated by recent repetitive activity (e.g., long distance

running) usually in the presence of some biomechanical
abnormality (e.g., abnormal pronation)
Physical Exam: Medial knee pain

Symptoms reproduced with palpation of pes anserine bursa
Pes Anserine Palpation
Cues: Bursa is located on the medial tibia flare adjacent to the insertion of the semitendinosis
(follow tendon distally to locate bursa)
3 = Pes Anserine Bursa
5
Patellofemoral Pain Syndrome

ICD-9: 719.46 pain in joint - lower leg
Description: Patellofemoral pain syndrome (PFPS) is described as anterior knee pain during
squatting, kneeling, stairs, walking and sitting (especially prolonged sitting) with the knee flexed.
It is typically caused by poor mechanics of the patella as it travels in the femoral groove during
flexion and extension of the knee. This poor tracking which typically causes the patella to
deviate laterally, resulting in excessive stress on the medial patello-femoral compartment due to
stretching and irritation, as well as increased lateral compartment compression.
Etiology: The specific causes of this disorder can vary in individuals and typically lacks a
mechanism of injury. Tight lateral structures including the iliotibial band and the lateral
retinaculum are thought to be the primary causes. There are several biomechanical factors that
contribute to poor tracking of the patella. These include excessive femoral anteversion and
increased midfoot pronation with resultant tibial lateral rotation. **The depth, of the femoral
trochlear groove also has direct bearing on the tracking of the patella. Another factor is the
motor control/strength of the hip abductors and external rotators during weight loading activities.
Intra-articular effusion has been shown to lead to vastus medialis inhibition as well. With
inhibition of this muscle, the oblique fibers of the vastus medialis are not effective in tracking the
patella medially during extension causing the patient to experience PFPS. This disorder is
common in adolescent females due to the biomechanical changes occurring as their bodies
develop, though is not limited to this population.
Physical Examinations Findings (Key Impairments)
• The patient’s reported symptoms are elicited typically with compressive forces about
the involved knee during activities such as squatting and sitting for long periods of
time
• The patella typically has limited medial gliding of the patella secondary to taut
peripatellar structures
• The patient may present with any or all of the following biomechanical abnormalities:
an increased Q-angle, femoral anteversion, lateral tibial torsion, and increased
midfoot pronation, limited external rotation of the hip, limited tibiofemoral extension,
decreased strength in the supinators of the foot during gait, and medial quadriceps
weakness.
6
As Above – except:
• The patient’s reported symptoms are elicited intermittently with the activities noted
above.
• Pain may be elicited only in certain positions of excessive patellofemoral

compression maintained over prolonged periods of time such as sitting, sustained
stair climbing, running or biking with seat too low.
7
Goals: Decrease inflammation

Decrease pain
• Physical Agents
Ice
Ultrasound (in conjunction with mobilization/manipulation)
Acupuncture, acupressure or electroacupuncture for pain control
• Manual Therapy
Soft tissue mobilization to tight lateral peripatellar structures
Joint mobilization to the patella – medial patellar glides, sustained stretch
and high velocity low amplitude manipulation
Joint mobilization to the tibiofemoral joint – restoring normal knee
extension
Sacroiliac evaluation and manipulation

Patellar taping procedures in conjunction with biofeedback and exercise
program to promote proper patellar tracking
Foot orthotics to correct excessive pronation if present
Resistive brace (such as Protonics) to improve hamstring use and restore proper
biomechanics
• Neuromuscular Reeducation
Facilitory techniques to improve the contraction of the hip abductors and lateral
rotators, foot supinators, and, the quadriceps muscle group, focusing, if possible,
on the oblique fibers of the vastus medialis muscle
Stretching exercises for the iliotibial band and hamstrings
Initial exercises should be largely closed kinetic chain activities in the
pain-free range only
• Re-injury Prevention/Instruction:
Temporarily limit any deep squatting, heavy lifting, or through-range resistive
training of the quadriceps
8
Goals: Normalize lower extremity flexibility muscle strength, motor control, and patellofemoral
tracking
Progress exercises to include training for return to a specific work, recreational, or
sport activity
Assess the biomechanics of aggravating activity (e.g. cycling with a seat too low
can increase pain and cause pressure)
Promote painfree, low resistance, repetitive exercises (e.g., cycling) that provide
non-injurious compressive loads to the patellofemoral cartilage
Goal: Return to desired activities
Progress stretching, strengthening and coordination exercises – which includes
training for return to a specific work, recreational, or sport activity
Intervention for High Performance /High

Demand Functioning in Workers or Athletes
Goal: Return to desired occupation or sport

• Further biomechanical assessment during aggravating activity
9
Selected References
Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized
controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33(1):4-19.
Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral
pain syndrome. Phys Ther. 1993;73(2):62-8.
Fulkerson JP. The etiology of patellofemoral pain in young, active patients: a prospective study.
Clin Orthop. 1983;179:129-33.
Lohman E, Harp T. A critical review of patellofemoral pain syndrome in rehabilitation. Crit

Review in Phys Rehab Med. 2002;14(3&4):197-222.
Powers CM. Patellar kinematics, part ii: the influence of the depth of the trochlear groove in
subjects with and without patellofemoral pain. Phys Ther. 2000;80(10):965-78.
Powers CM, Maffucci R, Hampton S. rearfoot posture in subjects with patellofemoral pain. J
Orthop Sports Phys Ther.1995;22(4):155-60.
Salsich GB, Brechter JH, Farwell D, Powers CM. The effects of patellar taping on knee kinetics,
and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral
pain. J Orthop Phys Ther. 2002; 32(1): 3-10.
10
Patellar Tendinitis
ICD-9: 726.64 patellar tendinitis
Description: Repetitive strain injury affecting the patellar tendon, resulting in anterior knee pain.
Etiology: This condition is believed to be the result of repetitive mechanical stresses and is most
commonly found in athletes whose sport involves repetitive, sudden, ballistic movements of the
knee – such as jumping. Intratendinous changes can begin as microtears, which lead to collagen
degeneration, and subsequent fibrosis. The result is usually pain well localized to a small area of
the anterior knee region with specific tenderness at the inferior pole of the patella.
• Severe local tenderness on palpation at either the proximal or distal insertion of the
patellar tendon
• Accessory movement deficits of patella medial/lateral/superior/inferior glide
• Pain with maximum stretching of the quadriceps
• Weak and painful quadriceps muscle when tested isometrically against resistance
• Symptoms can be reproduced 1) using the decline squat test, 2)with eccentric knee
contractions, 3) with deep squats, or 4) with jumping/ sports activities
• Biomechanical abnormalities of the lower quarter may be present – such as excessive
foot pronation; patella alta; femoral anteversion; flexibility deficits in the quadriceps,
hamstrings, and calf muscles, as well as in the iliotibial band; strength deficits of the
gluteal, lower abdominal, quadriceps, and calf muscles
• The patient tolerates more repetitions during functional strength tests before onset of
pain (pain may hinder sport performance, but usually does not limit activities of daily
living)
• Patellar tendon palpation is less tender
• Symptoms may be difficult to illicit unless repeated strenuous movements are

performed
• Mild local tenderness with patellar palpation – note that mild patellar tenderness with
palpation may be a normal finding in active athletes
11
Goals: Alleviate pain

Reduce aggravating and predisposing factors
• Physical Agents
Ice
Phonophoresis
Iontophoresis

Patellar taping procedures may assist with promoting proper patellar tracking
Foot orthotics may be useful to correct excessive pronation
Taping or bracing to unload patellar tendon
• Manual Therapy
Joint mobilization at the patella if hypomobility exists
Initiate non-aggravating, stretching exercises for relevant muscles or fascial tissue
– typically the muscles with trigger points
Initiate non-aggravating, strengthening exercises for relevant weak musculature
• Re-injury Prevention/Instruction:
Temporarily limit any deep squatting, heavy lifting, or resistive training of the
quadriceps
Subacute Stage / Moderate Condition
Goals: Restore function

Prevent future re-injury
• Manual Therapy
Friction massage to the patellar tendon
Progress stretching and strengthening to the relevant myofascia and connective
tissue
Begin sport specific training as tolerated, although still avoiding maximal
concentric and eccentric loads
12
Goals: As above
Progress activity tolerance
Ability to resume sports activity and daily activities without pain
Progress stretching exercises – provide a comprehensive lower quarter stretching
program with emphasis on patient independence and carryover
Progress strengthening exercises with an with eccentric emphasis (e.g., light
jumping activities, progressive resistive exercises, sport specific training)
Begin sport specific training as tolerated, although still avoiding maximal
concentric and eccentric loads
Goal: Full return to sport activity or occupation
Review and correct biomechanics of desired activity, especially landing pattern of
jumps, ankle/foot biomechanics, and hip/pelvic balance and stability
Agility training specific to sports activity
High-velocity ballistic training that is sport specific
Single-leg exercises
Progress with combinations of load (weight), speed, and jumping height
13
Selected References
Bellemans J, Witvrouw, et al. Intrinsic risk factors for the development of patellar tendonitis in
an athletic population. A two-year prospective study. Am J Sports Med. 2001;29:190-5.
Benjamin HJ, Briner WW. Volleyball Injuries. Phys Sportsmed. 1999;27:48-58.
Cook JL, Khan KM, et al. Overuse Tendinosis, Not Tendinitis. Part 1: A New Paradigm for a
Difficult Clinical Problem. Phys Sportsmed. 2000;28:38-48.
Cook JL, Khan KM, et al. Overuse Tendinosis, Not Tendinitis. Part 2: Applying the New
Approach to Patellar Tendinopathy. Phys Sportsmed. 2000; 28:31-46.
Panni AS. Patellar Tendinopathy in Athletes. Am J Sports Med. 2000;28:392-397.
14
Patellar Bursitis
ICD-9: 726.65 prepatellar bursitis
Description: Inflammation and swelling of bursae over the patella.
Etiology: Cause is typically trauma, either due to repetitive extremity movement or to acute
trauma to patella. In active persons, bursitis can be induced by work activity, as seen by carpet
layers, gardeners, and/or roofers. In athletes, patellar bursitis has been reported in football
players, wrestlers, basketball players and dart throwers. Direct injury to the bursae comes from
repetitive contact with the artificial turf, wrestling mat, hardwood floor, or exercise mat.
Physical Therapy Findings (Key Impairments)
• Enlarged bursa, commonly the bordering the patellar surfaces

• The involved bursa are tender, may be slightly warm, and reproduce the reported
symptoms with provocatory palpation
• Resisted knee extension also reproduce the reported symptoms
• Decreased range of motion of knee – pain with passive knee flexion at end range
• Bursa not as tender to palpation – swelling and warmth are also decreased
• The pain is not as intense with active movement of knee
• Improved passive range of motion of knee due to decreased swelling and pain
• Full active and passive range of motion is available with slight pain at end ranges
• Muscles around knee may test to be weak, especially the quadriceps
15
Goals: Decrease swelling and pain
• Physical Agents
Ice
Ultrasound/phonophoresis
• Patient Education/Re-injury Prevention

Avoid activities that aggravate the symptoms
Gentle mobility within painfree ranges
Goals: Restore normal knee and patellar and patellar mobility

Return to moderate activity

Add padding over bursa during kneeling activities
Encourage painfree, low resistance activities such as bicycling or walking
Goal: Return to pain free daily activity
Provide strengthening to weak lower extremity musculature
16
Intervention for High Performance /High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure activities.
Encourage participation in regular low stress aerobic activities to improve fitness,
and strength.
Selected References
McFarland EG, Mamanee P, Queale WS, Cosgarea AJ. Olecranon and Prepatellar Bursitis:
Treating Acute, Chronic, and Inflamed. Phys Sportsmed. 2000; 68(3).
Butcher, JD, Salzman, KL, Lillegard WA. Lower Extremity Bursitis. Am Fam Physician.
1996;53:2317-24.
Almekinders, LC, Temple, JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of
the literature. Med Sci Sports Exerc. 1998;30:1183-90.
17
Iliotibial Band Friction Syndrome

ICD-9: 726.60 enthesopathy of knee, unspecified
Description: The iliotibial band is a thickened strip of fascia lata that extends from the iliac crest
to the lateral tibial tubercle. It serves as a ligament between the lateral femoral condyle and
lateral tibia, stabilizing the knee joint. Iliotibial Band Friction Syndrome (ITBFS) is an overuse
syndrome resulting from friction between the iliotibial band and the lateral knee. It occurs
primarily in runners but is also prominent in cyclists. Characteristic symptoms are sharp pain or
burning on the lateral aspect of the knee proximal to the joint line during exercise. For runners,
the pain is often most intense during the deceleration phase of gait. Walking with the knee fully
extended may lessen the symptoms. Activities start out pain free but symptoms develop after a
reproducible time or distance. Pain subsides shortly after the activity but return with the next
bout of running or cycling.
Etiology: Classified as an over-use injury, Iliotibial Band Friction Syndrome occurs after
continuous, steady long distance runs or cycling. It can also occur after unaccustomed change in
training programs, i.e. cycling or running over hilly terrain, sprint training, increased training
distances, or running on sloped surface (e.g., on the crown of the road always running in the
same direction, such as against traffic). The main symptom is lateral knee pain proximal to the
joint line during exercise. Other predisposing factors are sudden increase in training distances,
cavus foot, genu varum, tibial varum, rearfoot and/or forefoot varus, and leg length discrepancy.
There is also evidence that weak hip abductor musculature is a contributing factor.
Physical Examinations findings (Key Impairments)
• Antalgic gait
• “Stiff legged” walking in order to reduce knee flexion
• Aggravation of symptoms upon climbing or descending stairs or running downhill
• Pain elicited upon thumb pressure over lateral femoral condyle while active flexion-
extension of the knee is performed, with maximum pain at 300 flexion
• Positive Ober’s test – suggesting a “Tight” tensor fascia lata
• Soft tissue restriction along the iliotibial band
• Provocation of pain with palpation over Gurdy’s tubercle
18
• Reduced antalgic gait. Increased knee flexion during walking

• Reduced aggravation of symptoms upon climbing or descending stairs or running
downhill
• Decreased pain upon thumb pressure over lateral femoral condyle while active
flexion-extension of the knee is performed, with maximum pain at 30o flexion
• Reduced pain after start of activity (running, cycling)
Settled stage / Mild Condition
• Mild pain after start of activity (running, cycling)
19
Goals: Control pain and inflammation

Correct poor training habits or any other structural abnormalities
• Physical Agents
Ice packs, ice massage
Ultrasound
Phonophoresis
Electrical stimulation

Temporarily limit any activity that aggravate symptoms
Goals: Avoid continued irritation

Prevent Re-injury
• Manual Therapy
Soft tissue mobilization and manual stretching to the fascial adhesions to the ITB
Stretching intended to elongate the iliotibial band, such as Half-kneeling diagonal stretch,
Ober stretch, modified Ober stretch, Crossover toe touch, Lateral hip drop stretch
The most tension on the ITB is created by having the patient standing and extending and
adducting the leg to be stretched across and behind the other leg. The patient than
sidebends the trunk away from the involved hip/thigh hands clasped overhead

Instruction in proper footwear (including bicycle toe clip options) and orthotics
may be helpful (a lateral sole wedge may be of help)
20
Goals: As Above
Prevent recurrence of resolved symptoms.

Provide stretching exercises to elongate shortened myofascial (e.g., hip flexors,
calf muscles) and strengthening exercises to improve the motor performance in
weak muscles (e.g., gluteus medius and gluteus maximus)

Instruction in proper footwear and orthotics may be necessary
Goal: To return to optimum level of function at work or sports.
Continuation of gradual increase in distance and frequency of activities
21
Selected References
Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med. 1992;14:144-148.
Drogset JO, Rossvoll I, Grontvedt T. Surgical treatment of iliobitial band friction syndrome: A
retrospective study of 45 patients. Scand J Med Sci Sports. 1999;9:296-298.
Fredericson M, Guillet M, DeBenedictis L. Quick solutions for iliotibial band syndrome. Phys
Sports Med. 2000;28.
Fredericson M, White JJ, MacMohon JM, Andriacchi TP. Quantitative analysis of the relative
effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002;83:589-92.
Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band friction syndrome in cyclist. Am J Sports Med.
1993;21:419-424.
Martens M, Libbrecht P, Burssens A. Surgical treatment of the iliotibial band friction syndrome.
Am J Sports Med 1989;17:651-654.
Noble CA. Iliotibial band friction syndrome in runners. Am J of Sports Med. 1980;8:232-234.
Noble HB, Hajek RM, Porter M. Diagnosis and treatment of iliotibial band tightness in runners.
Phys Sports Med. 1982; 10:67-74.
22
Pes Anserine Bursitis

ICD-9: 727.9 unspecified disorder of synovium, tendon, and bursa
Description: An inflammatory condition of the medial knee especially common in certain

patient populations and often coexisting with other knee disorders. The term pes anserinus refers
to the conjoined tendons of the sartorius, semitendinosus, and gracilis muscles as they cross the
proximal aspect of the tibia to insert along its medial surface. The term originates from the Latin
“pes” for foot and “anserinus” for goose and derives from the anatomic observation that the
tendons form a structure reminiscent of a goose’s webbed foot.
Etiology: Inflammation of the pes anserine bursa. This bursa is located 2” inferior to joint line
at the medial tibial flare. Inflammation to this bursa is often a sequela to local trauma, exostosis
and tendon tightness, pes planus (predisposes the patient to problems affecting the medial knee)
or DJD affecting the knee especially in overweight middle-aged to elderly women . A female
patient who is overweight can also experience referred pain to the knee from broad pelvic area
with the resultant angulation at the knee joint putting more stress on the bursa.
• Tenderness over proximal medial tibia

• May have localized swelling at the insertion of medial hamstring muscles
• Negative valgus stress at 30° flexion lessens likelihood of medial collateral ligament
strain
• Negative McMurray’s and painfree knee flexion overpressures lessens the likelihood
of meniscal involvement
• Positive resisted knee flexion in prone position
23
Goal: Decrease swelling and pain.
• Physical Agents
Iontophoresis with dexamethasone
Ultrasound/ phonophoresis
Ice
Gentle stretching in pain free ranges of:
sartorius (hip IR in hip and knee extension)
gracilis (supine hook lying, gently spread knees apart)
hamstrings (long sit, foot turned slightly in, loop towel or sheet around
foot and pull gently while maintaining lumbar lordosis)
triceps surae (standing one with knee extended and one leg flexed)
Quadriceps, hamstring and calf strengthening

Orthotics, where indicated, to correct pes planus

Instruct patient in appropriate exercises, stretches, application of ice and instruct
in the use of orthotics
Patient education for weight management
24
Selected References
Abeles M. Anserine bursitis. Arthritis Rheum. 1986;29:812-3.
Brookler MI, Mongan ES. Anserina bursitis: a treatable cause of knee pain in patients with
degenerative arthritis. California Medicine. 1973;119:8-10.
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician.
1996;53:2317-2324.
Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part II:
Differential Diagnosis. American Family Physician. 2003;68:917.
Forbes JR, Helms CA, Janzen DL.Acute Pes Anserine Bursitis: MR Imaging. Radiology. 1995;
194:525-527
Handy JR. Anserine bursitis: a brief review. South Med J. 1997; 90:376-7.
Hemler DE, Ward WK, Karstetter KW, Bryant, PM. Saphenous Nerve Entrapment caused by
Pes Anserine Bursitis mimicking Stress Fracture of Tibia. ArchPhys Med Rehabil. 1991;72:336-
7.
Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arth Rheum
1985;28:1062-5.
Magee, D. Orthopedic Physical Assessment 3rd ed. WB Saunders Co., Philadelphia, PA, 1997
Stuttle FL: The no-name and no-fame bursa. Clin Orthop. 1959;15:197-99.
White, T. Pes anserine (knee) bursitis rehabilitation exercises. Sports Medicine Adviser 2002.1.
http://www.med.umich.edu/1libr/sma/sma_pesanser_rex.htm
1
Knee – Movement Coordination Deficits
Anterior Cruciate Ligament “ACL Tear”
ICD-9-CM: 844.2 Sprain of cruciate ligament of knee
“ACL Insufficiency”
ICD-9-CM: 717.83 Old disruption of anterior cruciate ligament
Medial Collateral Ligament “MCL Tear”
ICD-9-CM: 844.1 Sprain of medial collateral ligament of knee
Diagnostic Criteria
History: ACL Tear: Trauma or strain - often accompanied by an audible snap or

pop, followed by rapid onset of a large effusion/hemarthrosis
ACL Insufficiency: Episodic giving way, effusion and pain with specific
(usually pivoting) activities
MCL Tear: Trauma involving a valgus stress (e.g., from a fall or a blow to
the lateral knee)
Physical Exam: ACL Tear and Insufficiency: Excessive anterior tibial translation with
Lachman’s Test
MCL Tear: Pain - and possibly laxity - with valgus stress test at 30
degrees of knee flexion
Lachman’s Test
Cues: Stabilize femur, pull tibia anteriorly in a line parallel to the tibial plateau - determine the
amount of tibial anterior translation (0-2 mm is normal)
Other tests (e.g., anterior drawer, pivot shift, KT – 2000) may also be used to assess ACL
integrity
Involuntary, protective muscle guarding by the patient lowers sensitivity of these tests
2
Valgus Stress Test
Cues: Stand facing patient

Allow thigh to rest on table, flex tibia off table
Performing test at 30 degrees of knee flexion is more selective for MCL involvement
Prevent rotational motion of femur and tibia when applying the valgus stress
3
Medial Collateral Ligament Sprain of the Knee

ICD-9: 844.1 sprain of medial collateral ligament of knee
Description: Tension injury to the medial collateral ligament of the knee commonly from a
sudden application of valgus force to the knee. The MCL tenses to the point of micro or
macroscopic injury to its structure.
Etiology: The medial collateral ligament can be injured as the result of contact with a direct
blow to the lateral aspect of the thigh/leg or noncontact with the sudden application of a valgus
torque to the knee. The classic example is a direct blow to the lateral aspect of the athlete’s knee
while the foot is planted to the ground.
Acute Stage/ Severe Condition
• May have the inability to walk or bear weight without pain in more severe cases
• Minimal to moderate effusion and warmth with an isolated MCL injuries; larger
amounts of effusion are associated with ACL and PCL tears which must be ruled out
• Palpation of the MCL produces tenderness
• Knee extension and flexion may be limited due to joint effusion and pain.
• Abnormal laxity and the reproduction of symptoms are identified with valgus stress
testing at 30 degrees of knee flexion.
• May have weakness and pain with knee extension and flexion manual muscle testing
due to the close anatomical proximity of the MCL to vastus medialis, semitendinosis,
and semimembranosis. In a contact injury, lateral structures such as vastus lateralis
and biceps femoris may also be affected.
• Able to walk with minimal pain and without a significant limp

• Strong and painful knee extension and flexion with manual muscle testing
• Minimal to no effusion at the knee
Settled Stage/ Mild Condition
• Knee motion may be limited by stiffness with non-painful spongy end feel or motion
may not be limited at all
• May have difficulty with deep squatting, cutting (Zigzags), and sprinting
4
Goals: Decrease pain, swelling, and inflammation at the knee

Maintain knee mobility
Restore strength to hamstrings and quadriceps
Encourage weight bearing of involved leg
Maintain general conditioning
• Physical Agents:
Ice with compressive wrap or Cryo/Cuff applied to injured knee with elevation
Ultrasound
• Manual Therapy
Friction massage

May use crutches as required to limit pain
May consider a Neoprene sleeve or minimally restrictive lateral hinge brace
Range of motion exercises of the knee (passive→active assisted→active)
Quadriceps setting and straight leg raise exercises (isometric)
Upper body ergometer or swimming to maintain general fitness level while MCL
is healing

Avoiding activities that may stress the MCL
Subacute Stage/ Moderate Condition
Goals: Walk unassisted without a limp

Achieve 90o of knee flexion
Increase knee strength
Begin isotonic progressive resistive for quadriceps and hamstrings
Begin isokinetic exercise if available
Begin closed-chain exercises
Bicycle ergometer, stair climber
Exercises to increase knee flexion to 90o
5
Settled Stage/ Mild Condition
Goals: Achieve full knee ROM

Begin running and functional exercise program
Continue with general conditioning
Full active knee motion exercises
Improve muscle performance required to participate in desired occupational or
recreational activities. For example:
Fast speed walking to gentle straight-line jogging
Jumping
Sprints
Zig-zags
Goals: Return to desired occupational or recreational activities
Maximize muscle performance to relevant leg muscles required to perform the
desired occupational or recreational activities
Progress job/sports specific training to increase mechanical demand. Examples of
activities for athletes:
Sprinting up to full-speed
Zig-zags up to full-speed
Jogging greater than one mile
Figure-eights
Noncontact drills to full-contact drills
Acceleration/deceleration speed play

May utilize standard MCL taping as needed prior to athletic participation
Brace application may be used as needed – may provide psychological benefit
6
Selected References
Dersheid GL, Garrick JG. Medial collateral ligament injuries in football: nonoperative
management of grade I and grade II sprains. Am J Sports Med. 1981;9:365-368.
Holden DL, Eggert AW, Butler JE. The nonoperative treatment of grade I and II medial
collateral ligament injuries to the knee. Am J Sports Med. 1983;11:340-4.
Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996; 21:147-56.
Reider B, Sathy MR, Talkington J. Treatment of isolated medical collateral ligament injuries in
athletes with early functional rehabilitation: a five-year follow-up study. Am J Sports Med.
1994; 22: 470-477.
7
Anterior Cruciate Ligament Sprain/Insufficiency

ICD 9: 844.2 sprain of the cruciate ligament of knee - or -
717.83 old disruption of anterior cruciate ligament
Description: The anterior cruciate ligament (ACL) is the most commonly injured ligament in the
knee. The ACL extends from the anterior aspect of the tibia to the inner aspect of the lateral
femoral condyle and it helps stabilize the knee in the anterior-posterior and rotational planes.
The main blood supply is provided by the synovial membrane and the ACL is innervated by the
tibial nerve.
Etiology: ACL sprains are caused by sudden decelerations, abrupt changes in direction,
hyperextensions, cutting maneuvers on a planted foot, internal tibial rotation, and valgus stresses.
Physical Examinations Finding (Key Impairments)
• Pain
• Swelling
• Decreased range of motion
• Decreased strength
• Abnormal laxity produced with Lachman’s and anterior drawer tests
• Decreased weight bearing on involved lower extremity
Sub Acute Stage/ Moderate Condition
As above with the following differences:
• Minimal to no effusion at the knee

• Minimal limitations in ROM
• Strength testing of knee extension and flexion in mid range are relatively strong and
pain free
• Able to walk with minimal pain and without a significant gait deviations
• Decreased proprioception
As above with the following differences:
• Full ROM
• Minimal to no gait deviations
• Difficulty with sport specific activities (i.e., fast change in directions)
8
Acute Stage/ Severe Condition
Goals: Decrease pain, swelling, and inflammation at the knee

Maintain knee mobility
Restore strength to hamstrings and quadriceps
Encourage weight bearing of involved leg
• Physical Agents
Ice with compression and elevation
Electrical Stimulation
Ultrasound

Assistive device as needed to limit pain
Bracing to provide stability and limit anterior tibial torsion
• Therapeutic Exercise*
Range of motion exercises of the knee (passive→active assisted→active)
Isometric exercises for quadriceps and hamstrings
*Caution: Open chain terminal knee extension exercises (from 60 degrees to 0) with resistance
applied to the distal leg, and closed-chain squatting between 60 and 90 degrees may cause
increased anterior translation of the tibia and excessive stress to the ACL.
• Patient Education
Activity modification, especially avoiding positions that lead to giving way, pain,
and effusion.
Sub Acute Stage/ Moderate Condition

Goals: Walk independently without gait deviations
Increase knee strength
Increase proprioception
• Physical Agents:
Same as those listed above
• External Devices
Functional bracing to increase knee stability
Isotonic progressive resistive for quadriceps and hamstrings
Isokinetic exercise if available
Closed-chain exercises
9
Stationary bicycle
Running on treadmill
Proprioceptive training
Perturbation exercises

Goals: As above
Return to desired recreational activity or sport
Improve muscle performance required to participate in desired occupational or
recreational activities. For example:
Fast speed walking to gentle straight-line jogging
Jumping
Sprints
Zig-zags
Perturbation training
Plyometric and agility training
Selected References
Bagger J, Ravn J, Lavard P, Blyme P, Sorensen C. Effects of functional bracing, quadriceps and
hamstrings on anterior tibial translation in anterior cruciate ligament insufficiency: A preliminary
study. J Rehabil Res Dev. 1992;29(1):9-12.
Colby S, Hintermeister RA, Torry MR, Steadman JR. Lower Limb Stability with ACL
Impairment. J Ortho Sport Phys Ther. 1999;25(8):444-454.
Cooperman JM, Riddle DL, Rothstein JM. Reliability and Validity of Judgments of the Integrity
of the Anterior Cruciate Ligament of the Knee Using the Lachman’s Test. Phys Ther.
1990;70(4):225-232.
Eastlack ME, Axe MJ, Snyder-Mackler L. Laxity, instability, and functional outcome after ACL
injury: copers versus noncopers. Med Sci Sports Exerc. 1999;31(2):210-215.
Fitzgerald K, Axe MJ, Snyder-Mackler L. Proposed Practice Guidelines for Nonoperative

Anterior Cruciate Ligament Rehabilitation of Physically Active Individuals. J Ortho Sport Phys
Ther. 2000;30(4)194-203.
Fitzgerald K, Axe MJ, Snyder-Mackler L. The Efficacy of Perturbation Training in Nonoperative

Anterior Cruciate Ligament Rehabilitation Programs for Physically Active Individuals. Phys
Ther. 2000;80(2):128-139.
Roberts D, et al. Proprioception in People with Anterior Cruciate Ligament –Deficient Knees:
Comparison of Symptomatic and Asymptomatic Patients. J Ortho Sport Phys Ther.
1999;29(10):587-594.
1
Knee Pain
"Medical Meniscus Tear" or "Lateral Meniscus Tear"
ICD-9-CM: 717.3 Unspecified derangement of medial meniscus

717.40 Derangement of lateral meniscus, unspecified
Diagnostic Criteria
History: Joint line or posterior knee pain

Joint locking
Inability to fully bend or straighten the knee
Precipitating twisting/pivoting, hyperflexion, or hyperextension mechanism
Physical Exam: Joint line tenderness (symptoms reproduced)

Guarding, clicking, or pain with hyperflexion, hyperextension or
McMurray’s Test
Hyperflexion Test Hyperextension Test
McMurray's Test
Cues: Begin tests slowly and gently - increase the amount of overpressure force if gentle forces
are easily tolerated
Add tibial rotations and varus/valgus forces in an attempt to elicit symptoms
2
Meniscal Tears of the Knee

ICD-9: 717.3 unspecified derangement of medial meniscus
ICD-9: 717.40 derangement of lateral meniscus, unspecified
Description: Meniscal tears are very common sports injuries. Typical symptoms include pain,
catching, and buckling.
Etiology: The mechanism of injury often describes a twisting injury to the knee, or full flexion
of the knee (as in kneeling) that leads to pain or locking. The twisting can lead to meniscal
tearing through shear forces, whereas loading the knee in full flexion can overload the posterior
horn leading to a meniscal tear.
• Effusion usually accompanies a medial meniscus tear, but not always a lateral tear
• Weight bearing flexion-extension (i.e., squatting) is painful and difficult to perform
• If the knee is locked, a springy- rebound end feel will be noted moving into extension
• McMurray’s test may not able to be performed if considerable effusion restricts
flexion, because it is applicable only from full flexion to 90 degrees. If flexion is
possible, a painful click may elicited on combined external rotation and extension if a
tear exists in the posterior portion of medial meniscus, or on combined internal
rotation and extension if posterior lateral meniscus lesion exists
• Tenderness is present at the joint line where a sprain to the peripheral attachment has
occurred
• Passive overpressure reveals a muscle-guarding end feel at the extremes of flexion

and extension.
As Above-except
• Passive overpressures are reproductive of symptoms only with end range in either
combined external rotation and extension or combined internal rotation and extension
• Rotation opposite the side of the lesion may be painful, especially during Apley’s test
with compression applied. Distraction with rotation should relieve the pain. This
movement should be relatively normal unless a ligamentous injury also exists
3
Goals: Restore painfree active knee movement
• Physical Agents
Ice
Submaximal, controlled, quadriceps and hamstring setting exercises through
available painfree ranges

May use crutches as required to limit pain
Goal: Restore normal, painfree response to overpressure at end ranges flexion or extension.
• Manual Therapy
May attempt manual traction and manual resistance using PNF patterns with an
emphasis on the distraction portion of the facilitation.
Progress knee mobility and strengthening exercises if tolerated
Include exercises that focus on maintaining strength in hip musculature
Goals: Restore normal, painfree response to overpressure to both flexion and extension and
combined movements of external rotation and extension and / or internal rotation and
extension.
Normalize status on weight bearing
Increase strength dynamic control, and endurance of the involved lower extremity
Instruct in stretching exercises to address the patient’s specific muscle flexibility
deficits
4
• Progress strengthening exercises to address the patient’s specific muscle strength

deficits
Goal: Return to desired occupational on leisure time activities.
Progress strengthening with isokinetic exercises using velocity spectrum
rehabilitation
Continue to improve general endurance and conditioning with aerobic activities
such as bicycling, swimming and walking
Progress strengthening, stabilization, and balance activities in functional position
with marching, lunges, step-up and step-down exercises, and plyometric training
or slide board and balance board exercises
Selected References
Bernstein J. Meniscal Tears of the Knee. Diagnosis and Individualized Treatment. Phys
Sportsmed. 2000;28:83-90.
McCarty E. Meniscal Tears in the Athlete: Operative and Non operative Management. Phys
Med Rehabil Clin N Am. 2000;11:867-879.
1
Knee and Leg Radiating Pain
"Peroneal Nerve Entrapment"
ICD-9CM: 355.3 Lesion of lateral popliteal nerve
Diagnostic Criteria
History: Line of pain on lateral side of knee and calf

Paresthesias, potential numbness and weakness
Onset precipitated by trauma or pressure to lateral knee, constrictive
garment, brace, or cast around upper calf
Physical Exam: Symptoms reproduced with peroneal nerve tension test

Symptoms reproduced with palpation/provocation of common peroneal
nerve
Peroneal Nerve Tension Test
Cues: Perform a SLR to the point of first resistance, then plantarflex and invert the ankle and
foot - inquire regarding symptoms with hip extension and flexion while
maintaining plantar flexion and inversion
2
Common Peroneal Nerve Palpation
Cues: 5 = Fibular head/proximal tibiofibular joint

Nerve is located posterior and medial to the superior tibiofibular joint
Assess symptom response to palpation
3
Peroneal Nerve Entrapment

ICD-9: 355.3 lesion of the lateral popliteal nerve
Description: Defined as a state of altered transmission in a peripheral nerve because of

mechanical irritation from related anatomical structures. Entrapment neuropathy of the common
peroneal nerve across the knee can occur in different regions. It can occur as the nerve passes
beneath the biceps femoris tendon in the popliteal fossa or over the bony prominence of the
fibular head and in the fibular tunnel formed by the origin of the peroneus longus muscle and the
inter-muscular septum. The updated name for the peroneal nerve is the fibular nerve.
Etiology: Peroneal nerve entrapment usually is attributed to excessively thick fibrous arch and
narrowing of the tunnel through which the nerve passes. The suspected causes of this disorder
vary, but all causes relate to space occupying disorders of the peroneal nerve as it courses
through the posteriolateral region of the knee and superiolateral region of the leg. Suspected
causes of peroneal nerve entrapment are: trauma or injury to the knee; fracture of the fibula; use
of a tight plaster cast (or other long-term constriction) of the lower leg; habitual leg crossing;
wearing of high boots; pressure to the knee from positions during deep sleep or coma; or injury
during knee surgery. Risk factors for developing this condition are the following: being
extremely thin or emaciated, having diabetes, or having polyarteritis. The diagnosis is
confirmed by a nerve conduction velocity - short segment stimulation technique.
Acute Stage / Severe condition
• Positive Tinel's sign at the neck of the fibula

• Decreased sensations, numbness or tingling on the dorsum of the foot
• Weakness of the ankles or feet
• Pain with provocation of the entrapment site
• Gait abnormalities - such as: "Slapping" gait, foot drop (unable to hold foot
horizontal), or toe drag during swing phases
In this stage you will see symptoms similar to the acute stage except the symptoms might ease up
and will be to a lesser extent.
4
Acute Stage / Severe condition
Goals: Remove or decrease structures causing entrapment

Keep edema or pooling of blood to a minimum
Increase movement of nerve in between tissue
Maintain strength, endurance, and sensations in unaffected sites.
• Manual Therapy
Soft tissue mobilization to restricted fascia or myofascia near entrapment site
Joint mobilization to restricted accessory motions in the superior tibiofibular,
patellofemoral or tibiofemoral joint
• Physical Agents
Electrical stimulation to maintain muscle functioning if a paresis is present
Ultrasound for inflammation reduction
Nerve mobility exercises

An ankle-foot orthosis for the severely impaired with drop foot until return of
function of ankle dorsiflexors
Goal: Remove entrapment structures and increase movement of peroneal nerve through
entrapment sites.
Note that surgery to decompression of peroneal nerve entrapment site may be required in
severe cases or when symptoms persist or recovery remains incomplete for three to four
months
5
Selected References
1. Kanakamedala RV, Hong CZ. Peroneal nerve entrapment at the knee localized by short
segment stimulation. Am J Phys Med Rehabil. 1989;68:116-122.
2. Fabre T, Piton C, Andre D, Lasseur E, Eurandeal A. Peroneal Nerve Entrapment. J Bone

Joint Surg. 1998;1:47-53
3. Vastamaki M. Decompression for peroneal nerve entrapment. Acta Erthop. Scand.

1986;57:551-554
4. Sridhara CR, Izzo KL. Terminal sensory branches of the superficial peroneal nerve: an
entrapment syndrome. Arch Phys Med Rehabil. 1985;66:789-791
5. MEDLINE Plus Medical Encyclopedia Common peroneal nerve dysfunction

http://www.nlm.nih.gov/medlineplus/ency/article/000791.htm
6
Manual Therapy for “Peroneal Nerve Entrapment”
Examination: Superior Tibiofibular Accessory Movements
Treatment: Joint Mobilization: Posterior-Medial Glide (supine w/ wedge)

Anterior-Lateral Glide (tibia on chair - use pisiform)
Soft Tissue Mobilization: Lateral Popliteal or Calf area (p. 57)

Nerve Mobilization: AROM and PROM progression
Impairment: Limited Superior Tibiofibular Posterior/Medial Glide
Fibular Posterior/Medial Glide
Cues: Position the patient with slight knee flexion under a mobilization wedge - with the heel
just off the edge of the table
Stabilize the tibia into internal rotation
The treatment plane runs posterior -medially, thus, the mobilization force is directed
medially, or, it is directed straight posteriorly if the tibia is internally rotated
Use a “soft” thenar eminence as the mobilization contract
7
Impairment: Superior Tibiofibular Anterior/Lateral Glide
Fibular Anterior/Lateral Glide
Cues: Position the patient with the involved knee flexed and with the tibia resting on a low table
or a chair (Provide a stationary table or chair for the patient to hold on to for
balance)
Stabilize the tibia with one hand
Mobilize the fibula anterio-laterally with the hypothenar eminence of the other hand
using a trunk lean
Catch a large portion of the lateral gastrocnemius to cushion the pressure – careful not to
compress the common peroneal nerve

Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 159, 1989
SUMMARY OF KNEE (TIBIOFEMORAL) DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES
DISORDER HISTORY PHYSICAL EXAM PT MANAGEMENT

Knee Mobility Deficit Aching – worse with wt. bearing ROM deficits – esp. loss of flexion PROM/Joint Mobs
“Knee Capsulitis” Stiffness Pain at end ranges Ther Ex’s
Knee Muscle Power Deficit Lateral knee pain SR w/ provocation of Gurdy’s Reduce overuse
Overuse MOI – precipitated by tubercle or Lateral Femoral Physical agents (Ice, US)
“Iliotibial Band Friction Syndrome” unaccustomed wt. bearing – e.g., Condyle STM, C/R, FM, to ITB and Lat thigh
stair climbing or running on PF Taping
unlevel surfaces Rx LE biomechanical impairments
Knee Muscle Power Deficit Medial knee pain SR w/ palpation or provocation of the Reduce overuse and LE biomechanical
Overuse MOI – such as long distance pes anserine bursa impairments
Pes Anserinus Bursitis running in the presence of a LE Physical agents (US/Phono)
biomechanical abnormality (e.g., Gentle FM
abnormal pronation)
Knee Movement Coordination Trauma Excessive anterior tibial translation Physical agents if acute
Deficit Swelling (often acute hemarthrosis) with Lachman’s Test P.R.I.C.E. instructions
“Anterior Cruciate Ligament Giving way Proprioceptive and functional strength
Sprain/Insufficiency” training
Knee Movement Coordination Trauma – involving a valgus stress Pain – and possibly laxity – with Physical agents if acute
Deficit Swelling valgus stress test at 30o of flexion (Ice, US)
P.R.I.C.E. instructions
Medial Collateral Ligament Sprain Proprioceptive and functional strength
training
Friction massage
Knee Pain Twisting/pivoting MOI SR w/: Joint line palpation or Painfree Ther Ex’s
Joint line pain provocation
“Medial or Lateral Meniscal Tear” Locking Hyperflexion, hyperextension,
Cannot fully bend or straighten knee or McMurray’s maneuvers
Knee and Leg Radiating Pain Line of pain on Lat side of knee/calf SR w/: Peroneal Nerve bias LLTT Rx entrapment
Paresthesias, sensory & motor deficits Palpation/provocation of the (STM/JM to Sup. Tib-Fib area)
“Peroneal Nerve Entrapment” Onset MOI – trauma or pressure to lateral Peroneal Nerve Peroneal Nerve Mob
side of knee (e.g., brace) (PROM and AROM Ex’s)
Joe Godges DPT KPSoCal Ortho PT Residency

SUMMARY OF PATELLOFEMORAL DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES
DISORDER HISTORY PHYSICAL EXAM PT MANAGEMENT

Muscle Power Deficits Anterior Knee pain Lateral patella orientation Reduce overuse
Onset related to Limited medial patellar glide STM and stretching of the lateral
“Patellofemoral Pain overuse or trauma SR w/end range of patella glide PF/thigh structures
Syndrome” Sx’s worsen with bent Biomechanical abnormalities of the LE Patellar joint mobs (medial glides)
knee/sitting are common PF taping
positions Normalize LE impairments related
to PF symptomatology
Muscle Power Deficits Anterior knee pain SR w/: Resisted extension Reduce overuse
Onset associated with Palpation/provocation of the Physical agents
Patellar Tendinitis repetitive use of patellar tendon at the superior (Ice, US, Ionto)
Quads – i.e., pole, inferior pole, or Friction massage
jumping insertion on the tibial Taping
tuberosity Progressive reloading/sports training
Muscle Power Deficits Recent blunt trauma to Patellar effusion Reduce weight bearing stress –
the anterior knee SR w/provocation of the suprapatellar, allow healing
“Patellar Bursitis” Repetitive weight prepatellar, or infrapatellar bursa Physical agents
bearing onto knee (Ice, US, Phono)
i.e., kneeling
Joe Godges DPT KPSoCal Ortho PT Residency

1
Patellar Dislocation – Conservative and Operative Rehabilitation
Surgical Indications and Considerations
Anatomical Considerations: Patellar stability is dependent upon two components: bony

(trochlear groove) and soft tissue structures. There are multiple soft tissue layers that surround
the patellofemoral joint. Medially, the superficial layer is consists of the fascia over the sartorius
muscle, the second layer contains the medial patellofemoral ligament (MPFL) and the
retinaculum, and the third layer contains the medial collateral ligament and joint capsule. The
MPFL provides 50-80% of total restraining force medially. Fascial interconnections between
fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps
comprise the lateral retinaculum.
Pathogenesis: Patellar instability can be correlated with one or more of the following
anatomical risk factors: tightness of lateral structures, patella alta, patella or femoral dysplasia,
increased Q-angle, increased sulcus angle, generalized laxity, increased femoral anteversion,
increased external tibial torsion, lateral position of the tibial tuberosity, abnormal foot pronation,
and a vertical vastus medialis oblique (VMO) insertion. Patella dislocation can occur from
indirect, twisting or rapid change of direction with the foot planted, or direct trauma to patella.
Epidemiology: A higher incidence of patellar dislocations occur in females ages 10 to 17 years

of age and the athletically active, with less incidence over age 30. Lateral dislocations are very
common and will be the topic of discussion in this guideline. Medially dislocations are typically
rare and result from direct trauma, an excessive lateral release or overcorrection of a realignment
procedure. Redislocations occur more frequently in patients younger than 20 and tend to
decrease with advancing age.
Diagnosis
• History of dislocation with giving way

• Effusion
• Positive apprehension test (Fairbank sign)
• Medial retinacular tenderness
• Other clinical findings may include:
Patellar mobility (Sage test for lateral retinacular tightness – positive if medial
patellar excursion is less than ¼ of greatest patellar width)
Patellar maltracking
Abnormal Q angle (normal = males – 8-10 degrees, females – 10-20 degrees)
Abnormal sulcus angle (normal = <150 degrees)
• Imaging studies help confirm the diagnosis
2
Nonoperative Versus Operative Management: Conservative treatment includes bracing and

taping to restore proper patellar alignment and physical therapy to regain strength and range of
motion. Conservative treatment is most often attempted first, especially with a first-time
dislocation. Operative treatment is recommended in the presence of anatomical abnormalities or
osteochondral fractures. It is more effective in preventing recurrence of dislocations and is often
only considered after conservative treatment has been unsuccessful.
Surgical Procedure: Many different procedures are performed to correct patellar instability.
Proximal realignment procedures include lateral release, medial reefing, advancement of the
vastus medialis oblique (VMO), and Galleazzi’s procedure. Lateral release involves an incision
of the lateral retinaculum. Medial reefing involves tightening the medial structures and is often
done in conjunction with a lateral release. VMO realignment involves reattaching the VMO
insertion more distally and laterally on the patella. The Galeazzi procedure is seldom performed
however involves attaching the semitendinosus tendon to the medial side of the patella. Distal
realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft tissue
distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial
collateral ligament. Evidence has shown that lateral release is more effective when combined
with another procedure (i.e. proximal or distal realignment) and for many investigators would
only be used it there was a residual patellar tilt after repair/reconstruction of the medial
retinacular structures.
CONSERVATIVE REHABILITATION (Acute)
Note: The following rehabilitation progression after a first-time acute lateral patellar dislocation
is a summary of the guidelines provided by D’Amato and Bach, published in Clinical
Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk.
Phase I
Goals: Decrease pain and swelling

Limit range of motion and weight-bearing to protect healing tissues
Return muscle function
Avoid overaggressive therapy that may lead the patient into a patellofemoral pain
syndrome
Intervention:
• Bracing: set at 0 degrees initially with ambulation, lateral buttress pad in brace
• Ice
• McConnell taping; light compressive bandage
• Instruction in partial weight-bearing with crutches
• Electrical stimulation for activation of the VMO
3
• Supine straight leg raise (SLR) with minimal to no pain

• Ankle pumps if edema is present
• Isometric hamstrings
Phase II
Criteria: no significant joint effusion, no quadriceps extension lag, minimal to no pain with
activities of daily living
Goals: Full ROM – pain-free

Improve quadriceps strength
Low-level functional activities
Initiate conditioning
Avoid patellofemoral symptoms or instability
Intervention:
• Continue patellar bracing or taping

• Weight-bearing as tolerated; discard crutches when extension lag is no longer present
• Continue electrical stimulation and modalities as needed
• Continue supine SLR and add adduction and abduction SLRs
• Toe raises with equal weight bearing
• Closed kinetic chain exercises
• Low-level endurance and pool exercises
Phase III
Criteria: full active ROM, good to normal quadriceps strength, full weight-bearing with normal
gait pattern
Goals: Improve function

Gradual return to high-level activities
Intervention:
• Bracing: wean from bracing and taping as quadriceps function improves

• Four-way hip exercises
• Pool therapy – walking with progression to running
• Sport and skill-specific training
• Proprioceptive training
• Patient education
Criteria for Return to Full Activity (8-12 weeks)
4
• Equal ROM between lower extremities

• No pain or edema
• 85% strength compared with uninvolved limb
• Satisfactory 1-minute single leg hop test, two-legged hop test
• Patellar stability with clinical tests
Preoperative Rehabilitation:
Acute Phase: PRICE - protection, rest, ice, compression, elevation (if acute)
Maintain quadriceps strength and flexibility of the hamstrings
Patellar bracing and taping to restore proper alignment
POSTOPERATIVE REHABILITATION
Distal and/or Proximal Realignment Procedures
Note: The following rehabilitation progression is a summary of the guidelines after a distal
and/or proximal realignment procedure provided by D’Amato and Bach, published in Clinical
Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk. The same rehabilitation
protocol is used for both distal and proximal realignment procedures, with a few exceptions
noted below. For a combined distal and proximal realignment, the protocol for distal
realignment is used.
Phase I for Immediate Postoperative – Weeks 1-6
Goals: Control inflammation

Protect fixation
Activation of quadriceps and VMO
Full knee extension and minimize adverse effects of immobilization
Intervention:
• ROM: 0-2 wks – 0-30 degrees of flexion, 2-4 wks – 0-60 degrees, 4-6 wks – 0-90 degrees
• Brace: 0-4 wks – locked in full extension 24 hours 7 days a week except for therapeutic
exercises and continuous passive motion use, 4-6 wks – unlocked for sleeping, locked for
ambulation
• Weight-bearing: Proximal realignment – as tolerated with two crutches, Distal
realignment – 50% with two crutches
• Quadriceps sets and isometric adduction with electrical stimulation for VMO (* no
electrical stimulation for 6 wks with proximal realignment procedure)
5
• Heel slides 0-60 degrees (proximal), 0-90 degrees (distal)

• Non-weight bearing gastrocnemius/soleus, hamstring stretches
• 4-way SLR with brace locked in full extension
• Resisted ankle ROM
• Patellar mobilization (when tolerable)
• Aquatic therapy at 3-4 wk – gait training
Phase II – Weeks 6-8
Criteria for progression: Good quadriceps set, ~90 degrees of flexion, no signs of active
inflammation
Goals: Increase flexion

Avoid overstressing fixation
Control of quadriceps and VMO for proper patellar tracking
Intervention:
• Brace: discontinue use for sleeping, unlock for ambulation as per physician's orders
• Weight bearing: As tolerated with crutches
• Progress to weight-bearing gastrocnemius/soleus stretching, full flexion with heel slides
• Aquatic therapy
• Balance exercises
• Stationary bike – low-resistance, high seat
• Wall slides 0-45 degrees of flexion progress to mini squats
Phase III Week 8-4 months
Criteria for progression: No quadriceps extensor lag with SLR, nonantalgic gait, no evidence of
lateral patellar tracking or instability
Intervention:
• Discontinue crutches when: no extensor lag with SLR, full extension, nonantalgic gait
pattern
• Step-ups - 2 inches progress to 8 inches
• Stationary bike – moderate resistance
• Endurance – swimming, Stairmaster
• Gait training
• 4-way hip exercise
• Leg press 0-45 degrees of flexion
• Toe raises, hamstring curls
• Continue balance activities
6
• Hamstrings, gastrocnemius/soleus, add quadriceps and iliotibial band stretches
Phase IV 4-6 months
Criteria for progression: Good to normal quadriceps strength, no soft tissue complaints, no
evidence of patellar instability, clearance from physician to progress closed-chain exercises and
resume full or partial activity.
Intervention:
• Progression of closed-kinetic chain exercises

• Jogging/running in pool with resistance
• Functional progression, sport-specific training
Selected References:
Aglietti P, Buzzi R, De Biase P, Giron F. Surgical treatment of recurrent dislocation of the

patella. Clin Orthop. 1994;308:8-17.
Brotzman SB , Wilk KE. Clinical Orthopaedic Rehabilitation. Philadelphia, 2003. Mosby, Inc.
pp 327-342.
Fithian DC, Paxton EW, Stone ML, Silva P, Davis D, Elias D, White LM. Epidemiology and
natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-1121.
Garth WP, Pomphrey M, Merrill K. Functional treatment of patellar dislocation in an athletic

population. Am J Sports Med. 1996;24:785-791.
Maenpaa H, Lehto MUK. Surgery in acute patellar dislocation – evaluation of the effect of
injury mechanism and family occurrence on the outcome of treatment. Br J Sports Med.
1995;29:239-241.
Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue
patellar realignment procedure. Am J Sports Med. 1999;27:575-579.
Scuderi G. Surgical treatment for patellar stability. Orthop Clin N Am. 1992;23:619-630.
Vainionpaa S, Laasonen E, Silvennoinen T, Vasenius J, Rokkanen P. Acute Dislocation of the

patella. J Bone Joint Surg. 1990;72:366-9.
1
Lateral Retinacular Release of the Patella
and its relation with proximal and distal realignment procedures
Anatomical Considerations: Two components of knee extensor mechanism primarily affect the
limits of medial and lateral patellar displacement: bony constraints and ligamentous tethers.
Fulkerson and Gossling described the lateral retinacular structures from superficial to deep as:
the fibrous expansion of the vastus lateralis muscle, the superficial oblique retinaculum (iliotibial
band to lateral border of the patella and patellar tendon), the deep transverse retinaculum (from
iliotibial band to lateral patellar border) bordered superiorly by the epicondylopatellar ligament
and inferiorly by the patellotibial ligament, and the capsulosynovial layer. Fascial
interconnections between fibers of the iliotibial band, lateral hamstrings, lateral collateral
ligament, and lateral quadriceps comprise the lateral retinaculum.
The medial retinacular structures from superficial to deep are the fascia over the sartorius
muscle, the medial patellofemoral ligament (MPFL), the vastus medialis oblique muscle (VMO)
and the retinaculum, and the medial collateral ligament and joint capsule. The primary restraint
to lateral displacement is the medial patellofemoral ligament (MPFL). Slips of the vastus
medialis oblique muscle insert into the MPFL. Contraction of the VMO tensions the MPFL –
providing (approximately) a 60% contribution of this ligament force limiting lateral patellar
dislocation.
Pathogenesis: The most common reasons for anterior knee pain are: overuse, patellofemoral
malalignment, and trauma. Malalignment leads to instabilities (dislocations and subluxations),
and overload of the retinaculum and subchondral bone. Patellar dislocations and subluxations
can be categorized by chronicity (acute vs chronic), direction (medial vs lateral) and cause
(traumatic vs non traumatic). Patellar instability can be predisposed by certain anatomic factors:
patella alta, tightness of lateral structures, increased Q-angle (lateralization of the tibial tubercle),
increased sulcus angle, excessive femoral anteversion, external tibial rotation, genu valgum, pes
planus, hypoplastic lateral trochlear ridge, generalized laxity, weak or hypotrophic vastus
medialis oblique, and hypertrophic vastus lateralis. Another factor is the altered motor
control/strength of the hip abductors and external rotators during weight loading activities. Also,
intra-articular effusion has been shown to lead to vastus medialis inhibition as well. With
inhibition of this muscle, the oblique fibers of the vastus medialis are not effective in tracking
the patella medially during extension predisposing the patient to experience patellofemoral pain.
Chain of events in lateral instability: Patellar tilt resulting from a tight lateral retinaculum can
exert over time lateral retinacular strain and increased pressure on the lateral facet of the patella
leading to lateral patellar compression syndrome or even excessive lateral pressure syndrome,
heralded by arthrosis of the lateral patellofemoral joint. The syndrome is then primarily the
result of chronic lateral tilt, with subsequent lateral retinacular shortening and tightening. This
continues the lateral facet overload, and articular cartilage degeneration results in osteoarthritis
(chronic imbalance of facet loads). In addition, studies have demonstrated MPFL tears at the
adductor tubercle in patients with lateral patellar dislocation.
2
Epidemiology: Historically, it has been considered a primarily female disorder, however some
studies clearly show a male preponderance. Based on the research done, it cannot be said what
the relative risk of patellar dislocation is among males and females. Subluxation and dislocation
occur most frequently laterally, though medial instability can occur as a result of trauma or
overaggressive surgical treatment. There is a higher incidence of acute instability in young
active patients between the ages of 13-20, with less incidence over age 30, reoccurrence is higher
in patients who dislocate at younger than 15. A recurrent rate up to 44% in non-operatively
managed patients has been reported. Fourteen to forty-nine (14%-49%) percent of patients who
sustain a primary acute dislocation will experience recurrent dislocation. Acute dislocation is
seen predominantly in football and basketball players.
Diagnosis
• History of dislocation with giving way

• Anterior knee pain with prolonged knee flexion, ascending or descending stairs.
• Peripatellar retinaculum tenderness
• Effusion
• Crepitus
• Postitive apprehension test (Fairbank sign)
• Positive quadriceps pull test
• Other clinical findings may include:
o Patella alta: most consistent physical examination feature associated with
patellar instability
o Patellar hypomobility (positive on glide if medial patellar excursion is less
than ¼ of greatest patellar width, positive on tilt if decreased)
o Increased Q angle (10° ± 5° for men and 15° ± 5° for women)
o Increased Sulcus angle (normal = <150 degrees)
Imaging studies that help confirm the diagnosis:
o X-rays: Axial view (tilt, patellofemoral incongruence), lateral view
(rotational malalignment, trochlear dysplasia)
o CT: Patellar tilt angles are taken from three midpatellar transverse
tomographic images at 15, 20, 40, and 60 degrees of flexion
o MRI
Arthroscopy also has a role in confirming the preoperative diagnosis of
patellofemoral malalignment
The diagnosis is best made on the basis of the history, physical examination and radiographic
examination (X-rays, CT scan).
Nonoperative Versus Operative Management: Consists of weight reduction, medial quadriceps

and hip external rotator muscles strengthening, hamstrings and quadriceps stretching,
mobilization of the tight lateral retinaculum, kinetic chain balancing, orthotic devices, correction
of foot pronation, low impact loading exercises, taping and bracing and oral anti-inflammatory
medication. It has been reported that 80% of symptomatic patellofemoral disorders respond to
non-operative treatment.
3
Surgical Procedures:
Arthroscopic lateral release is primarily indicated for patients with persistent anterior knee pain
despite of supervised physical therapy with a tight lateral retinaculum clinically and
radiographically documented by lateral patellar tilt, a tender lateral retinaculum, a medial glide of
two or less quadrants, a normal Q-angle, and minimal or nonexistent patellofemoral chondrosis.
The superomedial portal is established 3-6 cm proximal to the superior pole of the patella in line
with the medial edge. Excessive superior extension should be avoided so as not to damage the
vastus lateralis muscle. The entire retinaculum is released, paralleling the lateral edge of the
patella. At the superior aspect of the patella, the release should stay posterior. The patella
should be able to tilt 70 to 90 degrees.
Goal: Allow the patella to seek a central position and prevent lateralization of the patella.
Complications: Hemarthrosis, infection, medial patellar subluxation if excessive lateral release.
An isolated lateral release has poor prognosis in patients with patella alta, an abnormal q-angle
or a hypoplastic trochlea.
Some studies reported better results when this release was combined with another procedure on
the medial retinaculum. Many investigators suggest performing a lateral release if there is a
residual patellar tilt after repair/reconstruction or reefing (tightening the medial structures) of the
medial retinacular structures.
Other proximal realignment procedures include reefing (mentioned above, open or via
arthroscopy) and the advancement of the vastus medialis oblique (VMO), which involves
reattaching the VMO insertion more distally and laterally on the patella.
Goal: Restore patellofemoral alignment in recurrent subluxation or dislocation and to centralize
the patella after a lateral retinacular release.
Complication: Reflex sympathetic dystrophy (possible entrapment of the saphenous nerve).
The lateral retinacular release and the other proximal realignment procedures do not address
bone malalignment. Studies have reported a 86% return to previous level of activity within 3-4
months for individuals having a proximal realignment procedure.
Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft
tissue distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial
collateral ligament. Osteotomy involves reorienting the tibial tubercle medially or antero-
medially to reduce the Q-angle.
Goal: correct patellar tracking on the skeletally mature patient with recurrent
subluxation/dislocation, or an increased Q-angle, and unload damaged articular surfaces.
Indications for surgical procedures are: failure of nonoperative care, osteochondral injury,
patella instability, disruption of MPFL-VMO, high level athletic demands and risk factors.
Surgical Outcomes: 79% obtain good to excellent functional outcome after lateral release with a
combined VMO advancement and tibial tubercle transfer (Palmer 2004).
• Control pain and inflammation: protection, rest, ice, compression, elevation (if acute)
• Maintain or improve strength and flexibility of the quadriceps and the hamstrings
• Improve general lower extremity alignment
• Patellar bracing and taping to prevent more damage
4
Lateral Retinacular Release
The following is a general guideline for the rehabilitation after lateral retinacular release.
Advancement of the patient to the next phase should be considered on an individual basis taking
also into consideration the surgeon’s directives.
The overall goal of rehabilitation is to reestablish appropriate extensor mechanism function and
reduce patellofemoral contact forces.
Phase I: Immediate Postoperative – Weeks 1-2
Goals: Control postoperative pain and swelling

Protect tissues in the process of healing limiting range of motion
Improve muscle function of the lower extremity, specially quadriceps and VMO
Improve range of motion: 0º- 115º knee flexion and full knee extension
Full weight bearing if extension ROM is controlled by muscle
Independent ambulation
Intervention:
• Pain, inflammation and hemarthrosis management: Cryotherapy, compression bandage,
elevation and ankle pumps
• ROM: Early range of motion is needed to ensure that the lateral structures are
maintained in an opened or released position.
* Knee flexion: 0-1 week: 0º- 90º flexion, 75º by day 3, 110º-115º by week 2.
* Knee extension: full.
• Brace: 0-2/4 wks – locked in full extension, removed for rehabilitation
* Some do not recommend the use of immobilizers
• Weight bearing: immediate post-operative ambulation with crutches, weight bearing as
tolerated (WBAT). Full by 2 weeks
• Therapeutic Exercise:
Quadriceps sets at full extension progressing to multi angle isometrics
Electrical stimulation for VMO
Hip external rotators strengthening
Heel slides and wall slides
Non-weight bearing gastrocnemius/soleus, hamstring, ITB, hip flexors stretching
4-way SLR with brace locked in full extension.
* Begin abduction at approximately 3 weeks to minimize lateral pulling of
this muscle group on the patella.
Patellar mobilization (when tolerable)
Aquatic therapy at 2 wks (when wound is healed) with emphasis on gait training
Stationary bike for ROM when sufficient knee flexion is achieved
Phase II – Weeks 3-5
Criteria for progression: Well-controlled swelling and pain

Good quadriceps strength and control
5
ROM: 90º of active knee flexion and full active knee extension
Full weight bearing
Goals: Increase lower extremity strength and flexibility: 70% muscle reconditioning
Control of quadriceps and VMO for proper patellar tracking
Exercise swelling controlled
Improve gait pattern, balance and proprioception.
Establish home exercise program
Independent activities of daily living
Intervention:
• Brace: if brace is used, discontinue use for sleeping, brace at 0º-60º when ambulating
• Weight bearing: WBAT without crutches if:
* Full active knee extension, active 90º- 100º knee flexion, non-antalgic gait
pattern, and no extension lag with SLR.
* Patient can progress from two to one crutches, and then ambulate without them.
• ROM: Knee flexion: Week 2: 100º-115º
Week 3: 115-125º
Knee extension: 60º-0º
45º flexion with heel slides
Complete lower extremity flexibility: Quadriceps, ITB and hip flexors stretching
and progress to weight-bearing gastrocnemius/soleus stretching
Calf raises
4 way hip exercises
Wall slides progression (0-45º) to mini squats
Closed chain kinetic terminal knee extension with resistive tubing or weight
machine, and open chain reconditioning.
Balance and proprioceptive activities
Stationary bike
Treadmill walking with emphasis on normalization of gait pattern
Aquatic therapy
Aerobic reconditioning
Phase III Week 6 weeks return to activity
Criteria for progression: Good to Normal quadriceps strength

Non-antalgic gait
No evidence of lateral patellar tracking or instability
Pain is controlled and associated with activity only
Clearance from physician to progress closed-chain exercises and
resume full or partial activity
Necessary joint range of motion, muscle strength, and endurance to
safely return to athletic participation
Knee extension: 70% of contralateral side.
6
Goals: Restore any residual loss of ROM

Improve functional strength and proprioception
Return to appropriate activity level
Maintenance program development
Intervention:
• Brace: for activity only
Endurance – swimming, stairmaster
Complete lower extremity flexibility
Continue balance activities and gait training
Progression of closed-kinetic chain exercises and proprioception exercises
Step-ups - 2 inches progress to 8 inches: forward and lateral
Stationary bike – moderate resistance
Leg press 0-45 degrees of flexion
0-70º wall squats
Knee extension 90-0º
Toe raises, hamstring curls
Jogging/running in pool with resistance
* Walk/jog progression, Jogging in pool with progression to land
* Forward and backward running, cutting, figure 8’s
Slide Board
Plyometrics
Emphasis on sport/work -specific activity development
Return to sports when the knee is pain free, near full ROM has been obtained, and they have
achieved at least 80% strength as compared with the opposite leg. Most patients are able to go
back to sports by four to six months (Arendt, Fithian and Cohen 2002).
Proximal Realignment Procedures
After a combined proximal and distal realignment, the protocol for distal realignment is suggested.
Phase I: for Immediate Postoperative – Weeks 1-4

Activation of quadriceps and VMO
Full knee extension and reestablish 0º-110º knee flexion
75% weight bearing progression
Reestablish patellar normal glide
Note – with VMO advancement: Early flexion may stretch the advancement
Delay quad strengthening for tissue healing
7
Intervention:
• Pain and swelling management
• ROM: 0-1 wk: 0-30ºof flexion, 2 wks:0-60º, 3 wks: 0-90º, 4 wks:0-110º
(others recommend no more than 90º for 4 weeks)
• Brace: 0-4 wks – locked in full extension and by 6 weeks unlocked for ambulation
* Other studies: in full extension for 1 week then unlocked and by 3 weeks
discontinued.
* Some do not recommend brace locked, but brace as ROM limiting only
• Weight-bearing: with two crutches, from toe touch to 75% WB by end of phase
Muscle reeducation: initiate multi-angle exercises
Heel slides 0-60º
Non-weight bearing gastrocnemius/soleus, hamstring and ITB stretches
4-way SLR with brace locked in full extension
Patellar mobilization (when tolerable)
Aquatic therapy at 3-4 wk – gait training
Phase II: – Weeks 4-10
Criteria for progression: Minimal pain

No signs of active inflammation
0º- 110º of flexion
Muscle control of extension to 0º
75% weight bearing
Goals: Improve ROM and muscle strength (70% of contralateral side)

Exercise swelling controlled
Improve function to full activities of daily living
Intervention:
• Weight bearing: As tolerated with crutches
Complete lower extremity flexibility and progress to weight-bearing
gastrocnemius/soleus stretching,
Balance exercises and gait training
Aquatic therapy
Stationary bike – low-resistance, high seat
Wall slides 0-45º of flexion progress to mini squats
Late phase: close chain/open chain reconditioning
Patella mobilization
Aerobic reconditioning after 6 weeks
Phase III: Week 11 - 4 months
8
Criteria for progression: Full ROM achieved

70% of contralateral side
Pain is associated with activity only
Criteria for activity return must be met
Goals: Resume activity

Maintain program development
Intervention:
Discontinue crutches when: no extensor lag with SLR, full knee extension, non-
antalgic gait pattern
Step-ups - 2 inches progress to 8 inches
Stationary bike – moderate resistance
Endurance – swimming
Jogging/running in pool
Gait training
Progression of closed-kinetic chain exercises
Continue balance activities
Complete lower extremity flexibility: hamstrings, gastrocnemius/soleus,
quadriceps and iliotibial band stretches
Emphasis on sport specific strength
Develop home exercise program
Some studies considered the phase between 4 and 6 months the returning to activity level phase
Phase IV: 4-6 months
Goals: Return to appropriate activity level

Intervention:
• Progress close kinetic chain activities, jogging and running, sport specific activities.
Distal Realignment Procedures
Phase I: 1-2 weeks
Goals: Protect fixation

Control pain and inflammatory process, and minimize effects of immobilization
Re-gain quad and VMO control
ROM: 0º-90º/110º flexion and full knee extension
TTWB, two crutches (50% by end of phase)
Good skin integrity
Independent ambulation
9
Intervention:
• Pain, swelling and hemarthrosis management
• ROM: 0-90°/110º
• Brace: 0-30º 0-4/6 weeks; for ambulation only
* Brace only days 1-4
• Weight Bearing: 0-4 weeks: crutches progressing to 50% weight bearing
Multi angle Quad sets with isometric adduction for VMO recruitment
Full passive knee extension
Passive and active-assisted ROM
Calf, hamstring stretches (non-weight bearing)
4 way SLR (locked brace if extensor lag)
Patellar mobilization
Muscle reeducation, use EMS
Begin aquatic therapy with emphasis on gait at 3-4 weeks
Phase II: 3-4 wks
Criteria for progression: 70% of contralateral side

WB: 50% (X-ray verification of osteometry site healing)
Approximately 90° flexion ROM
No active inflammation
Pain controlled
Muscle control of extension
Goals: Increase flexion ROM: 0-110º

Muscle control of extension
Control inflammation and pain
Wound closure complete
Minimal gait deviation
Intervention:
• Pain and inflammation management
• Brace: for ambulation only Discontinue brace at 4 weeks
• ROM: 0-75º (3rd week), 90º/110º 4th week
Passive and A/A ROM
Discontinue CPM
Mobilize patella
• Weight bearing: 4-6 weeks: wean from crutches
Emphasis on extension exercises
Flexibility: hamstrings and gastrocnemius
Muscle reeducation utilizing EMS
10
SLR and multi angle submaximal isometrics knee extension

Gait and balance training
Phase III: 4 weeks - 8 weeks
Criteria for progression: Approximately 110° flexion ROM

75% WB with 2-1 crutch
Pain control with WB and ROM
Independent in ADL’s
Goals: Increase flexion ROM: 0-135º

Muscle control throughout ROM
Control pain and inflammation
One crutch to none (week 6)
Intervention:
• Continue modalities for pain and swelling
• Weight Bearing: 1 to no crutch, by 6 weeks full WB.
Continue Phase I exercise, progress to full flexion with heel slides
Muscle reeducation using close chain program with 0-30º restriction
Active extension with SLR
Balance exercises and gait training
Stationary bike - week 6 to 8
Pool program
Phase IV: 9 weeks –
Criteria for progression: Swelling controlled

Full range of motion achieved
Normal gait pattern
Good dynamic patellar control with out evidence of lateral
tracking or instability
Criteria for specific activity must be met
Goals: Resume activity

Maintain program development
Intervention:
• Pain is controlled and may be associated with activity only
• Brace: for activity
• Weight Bearing: full weight bearing
Step-ups, begin at 2 inches and progress to 8 inches
Stationary bike with moderate resistance
11
Squats, leg press, forward and lateral lunges

Closed kinetic chain terminal knee extension with resistance
Toe raises
Hamstring curls
Sports specific activity development
Continue proprioceptive exercises
Develop and assess home exercise program
Some recommend a Phase V
Phase V: 4 months - 6 months
Goals: Continue improvements in quadriceps strength, improve functional strength and

proprioception
Intervention:
• Progression of closed chain activities, Jogging in pool with progression to land,
functional progression, sport/work specific training
Late Phase Exercises for Postoperative Patellofemoral Conditions
(Mangine et al proposed late phase exercises for postoperative patellofemoral conditions.)
Criteria for progression: No effusion, painless ROM, joint stability,

Patient performs ADL’s and can complete previous protocol
ROM: minimum of 0-135º, minimal bilateral difference in muscle tone
Goals: Increase function to full activity level

Return to previous activity level
Establish maintenance program
Intervention:
• Warm up: jump rope, stretch, push-ups, sit ups.
• Lifting: leg curls, squats, lunges, toe rises, triceps, bench press
• Agility: plyoball sit-ups, dots, chest bands.
Selected References
Ahmad CS, Lee FY. An all-arthroscopic soft-tissue balancing technique for lateral patellar
instability. Arthroscopy. 2001;17:555-557.
Ahmad CS, Stein BE, Matuz D, Henry JH. Immediate surgical repair of the medial patellar
stabilizers for acute patellar dislocation. A review of eight cases. Am J Sports Med. 2000;28:804-10.
Arendt EA, Fithian DC, Cohen E. Current concepts of patella dislocation. Clin Sports Med.
2002;499-519.
12
Brotzman SB , Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Ed. Philadelphia, Mosby, Inc.; 2003.
Fithian DC, Meier SW. The case for advancement and repair of the medial patello femoral
ligament in patients with recurrent patellar instability. JOTSM. 1999;7:81-89.
Fithian DC, Paxton EW, Stone ML, Silva P, Davis D, Elias D, White LM. Epidemiology and
natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-1121.
Fu FH, Maday MG. Atthorscopic lateral release and the lateral patellar compression syndrome.
Orthop Clin North Am. 1992;24:601-612.
Fulkerson JP, Gossling HR: Anatomy of the knee joint lateral retinaculum. Clin Orthop.
1980;153:183-188.
Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med.
2002;30:447-456.
Halbrecht JL. Arthroscopic patella realignment: an all-inside technique. Arthroscopy.

2001;17:940-945.
Hinton RY, Sharma KM. Acute and recurrent patellar instability in the young athlete. Orthop
Clin North Am. 2003;34:385-96.
Irwin LR, Bagga TK. Quadriceps pull test: an outcome predictor for lateral retinacular release in
recurrent patellar dislocation. J R Coll Surg Edinb. 1998;43:40-42.
Mangine RE, Eifert-Mangine M, Burch D, Becker BL, Farag L. Postoperative management of

the patellofemoral patient. J Orthop Sports Phys Ther. 1998;28:323-335.
Marumoto Jm, Jordan C, Akins R. A biomechanical comparison of lateral retinacular releases.

Am J of Sports Med. 1995;23:151-155.
Nam EK, Karzel RP. Mini open medial reefing and arthroscopic lateral release for the treatment
of recurrent patellar dislocation. a medium-term follow-up. Am J Sports Med [on line
publication].December 2004; volume 32.
Palmer SH, Servant CT, Maguire J, Machan S, Parish EN, Cross MJ. Surgical reconstruction of
severe patellofemoral maltracking. Clin Orthop. 2004;419:144-148.
1
Distal Osteotomy
For Patellar Realignment And Rehabilitation
Anatomical Considerations: Patellar tracking and stability rely on two restraining mechanisms:
a transverse group and a longitudinal group. The longitudinal group consists of the quadriceps
superiorly and the patellar ligament inferiorly. Transversely are the medial and lateral retinacula
from the vastus medialis and vastus lateralis, which include retinacular thickenings acting as
medial and lateral patellofemoral ligaments.
Pathogenesis: Patellofemoral pain, patellar subluxation or dislocation can occur when abnormal
tracking secondary to malalignment of the patella occurs. The origin of malalignment may be a
result of obliquity in the pull of the quadriceps, unilateral tightness, unilateral weakness, trauma
to any of the stabilizing structures, or structural abnormalities, i.e. increased Q-angle.
Epidemiology: There is a higher incidence of acute instability in young active patients between
the ages of 13-20; reoccurrence is higher in patients who dislocate at younger than 15. Female
athletes are at a greater risk for recurrent instability than males, possibly due to anatomic
differences (greater Q-angle). Subluxation and dislocation occur most frequently laterally,
though medial instability can occur as a result of trauma or overaggressive surgical treatment.
The following guidelines discuss lateral instabilities.
Diagnosis: Patellofemoral instability is mainly a clinical diagnosis based on history and clinical
examination. Diagnostic imaging can be utilized to rule out other pathologies. MRI may detect
a disruption in the medial retinaculum, chondral lesions, and determine the angle of congruence.
Non-operative Versus Operative Management: Conservative treatment is generally done

initially which includes physical therapy, taping, and bracing. Surgical intervention is indicated
when conservative treatment fails and recurrent instability and/or pain persists. Distal bony
realignment procedures are indicated for the skeletally mature patient.
Surgical Procedure: Distal realignment involves osteotomy reorienting the tibial tubercle
medially to reduce the Q-angle. Distal osteotomy may be accompanied with proximal soft tissue
procedures including lateral release, reconstruction of the medial patellofemoral ligament, or
advancement of the vastus medialis. Currently, the most frequently used operations include a
flat osteotomy cut with straight medialization of the tibial tubercle (Elmslie-Trillat procedure) or
an oblique cut which uses anteriorization in addition to medialization of the tibial tubercle
(Fulkerson’s procedure). Medialization is recommended for isolated instability, while
anteromedialization is preferred with accompanying patellofemoral pain or chondral lesions to
reduce compressive forces on the patellofemoral joint.
2
• Control pain and inflammation
• Utilize bracing to prevent further subluxation or dislocation
• Maintain ROM and strength without promoting further instability
Note. The following rehabilitation guidelines are compiled from multiple sources (see
references). A comprehensive plan of care should be individualized based on each patient’s
presentation and depending on the operative procedure(s) used. Many surgeons have specific
protocols for use in post-op rehabilitation.
Phase I: Post-op - 6 weeks
Goals Protect fixation

Control inflammatory process
Re-gain quad and VMO control
Minimize effects of immobilization
Full knee extension
Intervention:
• ROM: 0-90°
• Brace: 0-4 weeks; locked in extension except for therapy and CPM use
4-6 weeks; unlocked brace for sleeping
• Weight Bearing: 0-4 weeks; crutches with weight bearing as tolerated
4-6 weeks; wean from crutches, maintain locked brace
Quad sets with isometric adduction for VMO recruitment
Heel-slides 0-90°
Calf, hamstring stretches (non-weight bearing)
4 way SLR (locked brace if extensor lag)
Resisted ankle ROM (non-weight-bearing)
Patellar mobilization
Begin aquatic therapy with emphasis on gait at 3-4 weeks
3
Phase II: 6weeks - 8 weeks
Criteria for advancement to Phase II: Good quad set

Approximately 90° flexion ROM
No active inflammation
Goals: Increase flexion ROM

Increase quadriceps and VMO control
Intervention:
• Brace: Discontinue for sleeping, unlock with ambulation
• Weight Bearing: as tolerated, no crutches
Continue phase I exercise, progress to full flexion with heel slides
Calf stretch in weight bearing
Discontinue CPM
Balance exercises
Stationary bike: low resistance/high seat
Short arc quadriceps extension in pain free ranges
Wall slides 0-45° of flexion
Phase III: 8 weeks - 4 months
Criteria for advancement to Phase III: Good quadriceps tone without extensor lag with
SLR
Non-antalgic gait pattern
Good dynamic patellar control with out evidence of
lateral tracking or instability
Goals: Quad strength good to normal

No patellar instability with exercise
Normalize gait pattern
Intervention:
• Brace: may discontinue
• Weight Bearing: full weight bearing
Step-ups, begin at 2 inches and progress to 8 inches
Stationary bike with moderate resistance
4-way hip for flexion, extension, adduction, abduction
Leg press 0-45°
Closed kinetic chain terminal knee extension with resistance
Toe raises
Hamstring curls
4
Treadmill walking
Continue proprioceptive exercises
Phase IV: 4 months - 6 months
Criteria for advancement to Phase IV: good to normal quad strength

no evidence of patellar instability
no soft-tissue complaints
normal gait pattern
physician clearance for more concentrated closed chain
exercises and resume full or partial activity
Goals: Continue improvements in quad strength

Return to appropriate activity level
Intervention:
• Therapeutic Exercise: Progression of closed chain activities
Jogging in pool with progression to land
Functional progression, sport/work specific
Cosgarea AJ, Browne JA, Kim TK, McFarland EG. Evaluation and management of the unstable
patella. Phys Sportsmee. 2002;30:1-11.
Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med.
2002;30:447-456.
Kisner C, Colby LA. Therapeutic exercise: Foundations and techniques. Philadelphia, 1996,
F.A. Davis Company.
Klimkiewicz JJ. Proximal/distal patellar realignment rehabilitation guidelines. Georgetown

University Hospital Orthopedic Protocols. 2003.
Palmer SH, Servant C, Maguire J, Machan S, Parish E, Cross M. Surgical reconstruction of

severe patellofemoral maltracking. Clin Orthop Relat Res. 2004;419:144-8.
Shelbourne KD, Porter DA. Use of a modified Elmslie-Trillat procedure to improve abnormal
patellar congruence angle. Am J Sports Med. 1994;22:318-323.
1
Patellar Tendon Rupture and Rehabilitation
Anatomical Considerations: Rupture of the patellar tendon most often takes place at the
osteotendinous (tibial tubercle) junction. Rupture of the tendon in this area causes complete
derangement of the extensor mechanism of the knee. Destruction of the extensor mechanism
may lead to an inability to actively obtain and maintain knee extension.
Pathogenesis: Patellar tendon ruptures tend to occur during resisted knee flexion with violent
quadriceps contraction (when landing from a jump). A force greater than 17.5 times body
weight has been reported as the estimated force required to rupture the patellar tendon. The
patellar tendon sustains greater stress than the quadriceps tendon during knee flexion. Since
there is more tensile load on the tendon at its insertion sites than in the middle portion, the
tendon tends to rupture just distal to its attachment to the patella.
Etiology: Intrinsic factors that can lead to rupture of the patellar tendon include repetitive
microtrauma, systemic inflammatory disease, diabetes mellitus, and chronic renal failure.
Extrinsic factors include ruptures that may occur as a result of a corticosteroid injection near the
inferior poll of the patella, sudden eccentric contraction of the quadriceps with the foot planted
and the knee flexed while the person falls (most prevalent mechanism). Surgery to the knee can
also cause rupture of the patellar tendon, these include total knee replacement, using the central
third of the patellar tendon as an autograft (ACL repair) and excision of patellar tendonitis.
Diagnosis: Rupture of the patellar tendon is usually associated with a “pop” or “tearing”
sensation with immediate pain, immediate swelling, and an inability to rise and weight-bear will
also be noted. Upon physical exam the patient will present with tenderness along the anterior
knee and retinacula, patella alta and ecchymosis will also be observed. Lab values may be taken
to rule out systemic disease. Plain film radiographs (AP, axial and lateral views), and/or MRI
provide the confirmation.
Nonoperative versus Operative Management: The type of treatment given to a patient with a
rupture depends on the severity of the rupture. A patellar tendon rupture can be treated
nonoperatively, but only in the case of a partial tear were the patient is able to maintain active
full extension and has normal patellar height. In this case the patient would be immobilized until
the tendon has fully healed and strengthening exercises should be delayed for at least 3 months.
Operative management is typically the approach of choice, especially with a complete rupture.
Surgical intervention is typically initiated as soon as possible to limit the amount of quadriceps
contracture and atrophy.
Surgical Procedure: Surgical repair of a ruptured tendon is usually delayed 4-7 days to allow a
decrease in inflammation and decrease the risk of wound complications. For a patient with an
acutely ruptured tendon the general surgical procedure would include suturing the torn tendon
through bone tunnels in either the patella or tibial tubercle. The location of suturing depends on
the location of the rupture. Debridement of viable tissue may also be performed along the
patellar tendon, tibial tubercle and patella. In patients with chronic patellar tendon ruptures or
2
patients where repair may be impossible the surgeon may choose to do surgery in stages. This
decision depends on the need to replace the patellar tendon with and autograft or allograft, the
degree of patella alta, whether the repair requires augmentation or whether there is peripatellar
scaring.
Preoperative Intervention:
• Discuss with the importance of postoperative rehabilitation
• Identify appropriate patellar height for patient (Surgeon responsibility)
• Identify possible injuries to associated structures: medial/lateral retinacula, menisci,
ACL, PCL, MCL, LCL
Phase I for Immobilization and Rehabilitation: 4-13 days

Maintain patellar mobility
Maintain hamstring strength of the ipsilateral leg and lower extremity strength of the
contralateral leg
Active knee flexion to 45o and passive knee extension to 0o
Intervention:
• Crutch training with toe-touch weight-bearing
• Ice and elevation
• Isometric ipsilateral hamstring exercise, contralateral LE strengthening
• Gentle medial/lateral patellar mobilization (~25%)
• AROM, AAROM and PROM
• Hinged knee brace locked in extension
Phase II for Immobilization and Rehabilitation: 2-4 weeks

Begin weight-bearing
Active flexion to 90o and passive knee extension to 0o
Maintain ipsilateral hamstring and contralateral LE strength
Begin ipsilateral quadriceps retraining
Intervention:
• Crutch training with partial weight-bearing (25-50%)
3
• Ipsilateral quadriceps sets (NO straight leg raises)
Phase III for Immobilization and Rehabilitation: 4-6 weeks

Progress weight-bearing (possibly discontinue crutch use)
Active flexion progressed as tolerated and passive extension to 0o
Continue ipsilateral quadriceps retraining
Intervention:
• Progress to weight-bearing as tolerated, may discontinue crutch use if good quadriceps
control is acquired
• Gait training
• Ipsilateral quadriceps sets (NO straight leg raises)
Phase IV for Immobilization and Rehabilitation: 6-12 weeks

Progress to full active ROM
Continue ipsilateral quadriceps retraining
Intervention:
• Weight-bearing as tolerated
• Gait training
• Hinged knee brace locked in extension until good quadriceps control and normal gait are
obtained
• AROM
• Ipsilateral quadriceps strengthening (straight leg raises without resistance and stationary
cycling at 8 weeks)
4
Phase V for Rehabilitation: 12-16 weeks
Goals: Complete weight-bearing

Progress ipsilateral quadriceps strength
Begin neuromuscular retraining
Intervention:
• Gait Training
• No immobilization
• Ipsilateral quadriceps strengthening
• Proprioception and balance activities (including single leg support)
Phase VI for Rehabilitation: 16-24 weeks
Goals: Begin running

Sport/Job specific training
Intervention:
• Progress program as listed for Phase IV, with sport or job specific training
Phase VII for Rehabilitation: >6 months
• May begin jumping and contact sports when ipsilateral strength is 85-90% of
contralateral extremity
Marder RA, Timmerman LA. Primary repair of patellar tendon rupture without augmentation.
Am J Sports Med. 1999;27:304-307.
Casey MT, Tietjens BR. Neglected ruptures of the patellar tendon. a case series of four patients.
Am J Sports Med. 2001;29:457-460.
Enad JG, Loomis LL. Patellar tendon repair: postoperative treatment. Arch Phys Med Rehabil.
2000;81:786-788.
Matsumoto K, Hukuda S, Ishizawa M, Kawasaki T, Okabe H. Partial rupture of the quadriceps

tendon (jumper's knee) in a ten-year-old boy: a case report. Am J Sports Med. 1999;27: 521-525.
1
Patella – Open Reduction and Internal Fixation
Anatomical Considerations: The patella is a sesamoid bone that is embedded in the quadriceps
tendon. Tensile forces are transmitted from the quadriceps to the tibia via the patella. The
patella is also subjected to compressive forces at the articulation with the femur. At 45° the
patella is under the most force (approximately between 2 and 10 newtons per millimeter
squared). During development the patella most often originates from a single ossification center.
In approximately 23% of patients two to three separate ossification centers exist. Two percent
of the time these centers do not completely merge, the condition is called bipartite patella. Of
these individuals approximately 2% develop symptoms secondary to trauma or chronic stress on
the patella. Traumatic patellar fractures are identified as transverse, vertical, marginal or
osteochondral. Transverse fractures occur horizontally across the patella. Vertical fractures run
from the inferior pole to the superior pole. Marginal fractures occur at the perimeter of the
patella and most often include small fragments. Osteochondral fractures are cracks or
discontinuities of the covering of the patella.
Pathogenesis: Fractures of the patella occur in when the force applied to the patella is stronger
than the bone that constitutes the patella. This can happen when the patella receives a direct
blow or as a result of indirect forces. If the patella is osteoporotic, much less force is required to
fracture the patella. The patella can also be fractured during ACL reconstruction surgery when
autogenous patellar tendon is used. The patella can be fractured while the proximal bone plug is
being removed.
Transverse fractures most often occur with indirect force (for example a forceful quadriceps
contraction). Transverse fractures are the most common fracture to result from a traumatic
patellar dislocation. Vertical and osteochondral fractures are rare and can occur with either
direct or indirect force. Marginal fractures are usually due to a direct force to the side of the
patella.
Epidemiology: Patellar fractures make up approximately 1% of skeletal injuries. Males are more
likely to have bipartite than females, but traumatic patellar fractures do not occur more
commonly in men or women. Osteochondral fractures are more common in children than in
adults.
Diagnosis:
• History of a direct blow to the patella
• There may be a palpable ridge in the patella if the break is complete
• Persistent patellar tenderness
• Decreased function of the extensor mechanism (inability to extend the knee against
resistance)
• Radiographs confirm injury to the bone
• MRI can be helpful to identify or rule out associated ligamentous injuries to the knee
2
Nonoperative Versus Operative Management: Fractures with 2mm or less separation are
indicated for nonoperative treatment. This includes 4-6 weeks of immobilization in a splint or
cast on the conservative side and as little as 2 weeks of immobilization on the aggressive side.
Aggressive nonoperative treatment may include weight bearing as tolerated as early as 1-week
post fracture. Surgical repair is typically recommended for all patellar fractures that demonstrate
3mm or more separation of fragments or a step off of 2mm or more. In the case of comminuted
fractures or fractures of severely osteoporotic bone a synthetic patellar prosthesis can be used.
Surgical Procedure: Surgical techniques include placing two or three wires or canulated screws
perpendicular to the fracture line. In addition, wire can be used around the circumference of the
patella. New procedures include arthroscopic techniques also using screws perpendicular to the
fracture line as well as circumferential wiring. Fixation screws and wiring are not removed post
operatively unless there are complications. Small fragments and loose bodies are removed if
found.
Preoperative Rehabilitation: Goals include gait with the appropriate assistive device, control of
swelling/inflammation, maintaining maximum range of motion, strengthening of surrounding
stabilizing musculature, and patient education. Physical therapy interventions include gait
training, joint mobilizations, strengthening, and modalities.
Phase I: Weeks 1-4
Goals: Pain and edema control

Improvement in muscle contraction
PROM: 0°-30°
Avoid excessive stress on the extensor mechanism
Independent home program
Intervention:
• Cryotherapy
• Electrical stimulation for muscle stimulation (remember to not stress extensor
mechanism)
• Patellar mobilization
• PROM: heel slides
• Isometrics: Quadriceps sets at 20°-30°, hamstring sets
• Straight leg raises
• Immobilization for gait with WBAT (begin WBAT around week 4)
• Weight shifting
3
Phase II: Weeks 5-8

Goals: Pain management
Increase lower extremity strength
PROM: 0°-90°
Intervention:
• Modalities for pain control

• Progress PROM
• AAROM: therapist assisted and stationary bike
• AROM when cleared by physician (6-8weeks)
• Isometrics – continue progress from Phase I
• Open chain hip and ankle strengthening
• Gait training (progress weight bearing)
Phase III: Post Week 8
Goals: Self management of symptoms

Increased ambulation distance
Good sitting and standing tolerance
Good patellar stability and tracking
Intervention:
• AROM: 0°-120°
• Progress lower extremity strengthening: closed chain (squats, steps), continue hip and
ankle strengthening, focus on stability, proprioception, balance, and extensor
strengthening
Phase I for Aggressive Rehabilitation: Weeks 1-2
Goals: Pain and edema control

Improvement in muscle contraction
PROM: 0°-30°
Avoid excessive stress on the extensor mechanism
Independent home program
4
Intervention Week1:
• Cryotherapy
• Electrical stimulation for muscle stimulation
• PROM: heel slides in hinged splint set at 0°-30° to be work constantly except for bathing.
• Isometrics: Quadriceps sets at 20°, hamstring sets
• NWB gait with crutches
• Relative immobilization with hinged splint set at 0°-30°
• Open chain hip strengthening: abduction, adduction, extension
Intervention Week 2:
• Continue interventions from Week 1

• AAROM in hinged splint set at 0°-30°
• Begin WBAT gait with splint and crutches
Phase II for Aggressive Rehabilitation: Weeks 3-4

Increase weight bearing with gait
ROM: 0°-90°
Intervention:

• AAROM: therapist assisted and stationary bike 0°-90°
• AROM: heel slides, short arc quad extension, begin closed chain strengthening
• Isometrics: continue progress from Phase I
• Closed chain hip and ankle strengthening
• Gait training: WBAT with hinged splint and crutches
Phase III for Aggressive Rehabilitation: Weeks 5-6

ROM: 0°-120°
5
Intervention:

• Patellar and tibial/femoral mobilization
• AROM
• Closed chain strengthening: wall squats, supine leg press, stationary bike
• Proprioceptive and balance training
• Gait training: FWB with hinged splint
Phase IV for Aggressive Rehabilitation: Weeks 7-12
Goals: Self management of symptoms

Increased gait distance and speed
Good sitting and standing tolerance
Good patellar stability and tracking
5/5 hip, knee and ankle strength
Intervention:
• AROM: 0°-120°
• Progress lower extremity strengthening: closed chain (squats, steps, increase speed and
force), continue hip and ankle strengthening, focus on stability, proprioception, balance,
and quadriceps strengthening.
Binder AJ. Spoken interview July 28th, 2004.
Diagnosis – Patella ORIF. Medical University of South Carolina, Department of Physical

Therapy. Online. www.muschealth.com/pt May 3, 2004.
Donatelli R. Wooden M. Orthopaedic Physical Therapy. 3rd ed, Churchill Livingstone.

2001:471-473.
Lamoureux C. Patella Fractures. eMedicine Online.

http://www.emedicine.com/radio/topic528.htm May 3, 2004.
Neumann, D. Kinesiology of the Musculoskeletal System. Mosby, Inc. 2002:456-461.
Shabat S, Stern Y, Berner D, Morgenstern D, Mann G, Nyska M. Functional results after patellar
fractures in elderly patients. Arch Gerentol Geriatr. 2003;37:93-98.
1
Anterior Cruciate Ligament Reconstruction
Anatomical Considerations: The anterior cruciate ligament (ACL) lies in the middle of the knee.
It arises from the anterior intercondylar area of the tibia and extends superiorly, posteriorly, and
laterally to attach to the posterior part of the medial side of the lateral condyle of the femur. The
ligament is intra-articular but extrasynovial. The ACL is described as being composed of 3 main
bundles. These bundles include the anteromedial, posterolateral, and intermediate. The ACL
really functions as a continuum, with a portion being tight through all ranges of knee flexion. It
acts as the primary restraint to anterior tibial translation and guides the screw-home mechanism
associated with knee extension. The ACL acts secondarily to prevent varus and valgus,
particularly in the extended knee. Injury leads to abnormal kinematics of the knee. Subluxation
episodes occur, creating abnormal shear forces on the meniscus and articular cartilage.
Subsequent meniscal injury, therefore, is increased significantly.
The major blood supply for the ACL comes from the synovium and fat pads. The vessels
involved are middle geniculate and terminal branches of the inferior medial and lateral
geniculate vessels. Sensory receptors and nerve fibers have been identified in the ligament,
which suggests some sensory role and possible proprioceptive function.
Pathogenesis: Ligaments tear when the mechanical load exceeds the physiological capacity of
the tissue. ACL tears are most commonly due to extrinsic mechanical forces. It may be due to
contact injuries where there is a blow to the side of the knee, such as may occur during a football
tackle. Alternatively, non-contact ACL injuries can occur by coming to a quick stop combined
with a direction change while running, pivoting, landing from a jump, or hyperextension of the
knee joint. ACL injuries are often associated with other injuries. The “unhappy triad” is a
classic example, in which the ACL is torn at the same time as the MCL and the medial meniscus.
Basketball, football, soccer and skiing injuries are common causes of ACL tears.
Epidemiology: Injury of the ACL is the most common ligamentous injury of the knee and
accounts for about 30 injuries per 100,000 of the population, with greater than 100,000 new ACL
injuries occurring each year. Women are more likely to suffer an ACL tear than men are.
Females are at higher risk of ACL injury when considering sports participation numbers. This is
believed to be related to both intrinsic factors (increased Q angle, decreased notch width,
increased joint laxity, hormonal influences) and extrinsic factors (less muscle strength, different
muscle activation patterns, altered cutting and landing patterns). Adults who tear their ACL
usually do so in the middle of the ligament or pull the ligament off the femur bone. These
injuries do not heal by themselves. Children are more likely to pull off their ACL with a piece of
bone still attached, these may heal on their own, or may require the bone to be fixed.
2
Diagnosis
• Mechanism of injury
• Most patients describe a “pop” sound at the time of injury
• Immediate pain and swelling in knee
• Knee joint instability once swelling and pain resolves
• Limited ROM
• Joint line tenderness
• Positive Lachman Test /or Anterior Drawer Test
• Pivot-Shift or Jerk Tests (to assess rotational instability)
• Radiographs to exclude fracture, tumor, and osteoarthrosis
• Arthroscopy
• CT scan for associated fractures or avulsions of the cruciate
• MRI can be helpful in determining the presence, location, and severity of the tear(s) and
to evaluate other injuries to the knee – with 98% accuracy
Nonoperative Versus Operative Management: Surgical repair depends on the extent of

instability and level of activity. It is typically recommended for patients who expect to return to
relatively high functional activities required of recreational athletics. In chronic cases, the major
indication for surgical reconstruction is recurrent instability. Indications for nonoperative
management include patients with active infection, soft-tissue abrasion, and reluctance to
participate in the complex rehabilitation required. Conservative care includes a comprehensive
rehabilitation program, a functional brace for sports, and activity modification.
Relative contraindications are common and include the following: patient is less than 2 weeks
from injury, low activity levels, preexisting osteoarthrosis, skeletal immaturity, and
inflammatory arthropathy. Some people are able to live and function normally with a torn ACL.
However, most people complain that their knee is unstable and may "give out" with attempted
physical activity. Unrepaired ACL tears may also lead to early arthritis in the affected knee.
Surgical Procedure: There are several surgical procedures available including mini-arthrotomy
open technique, two-incision arthroscopically assisted techniques, and one incision endoscopic
technique. Currently, ACL reconstruction is most often performed using an arthroscopically
assisted technique. The most frequently used graft types for ACL reconstruction are the patellar
tendon (PT) and the combined semitendinosis and gracilis tendons (HT). For the past two
decades, the gold standard in ACL reconstructions has been the patellar tendon graft from the
middle third of the tendon, but increasingly the hamstring tendon graft has been used. The shift
in popularity is due to several reasons, including, concerns about damaging the knee extensor
apparatus using the PT and the potential for subsequent anterior knee pain, patella fracture,
ligament rupture, and infrapatella contraction. The HT techniques also have potential
complications including tunnel widening and fixation and concerns of the affects on the muscle
function.
3
Preoperative Rehabilitation
• Patient education on expectation and likely outcomes of rehab

• Patient education on joint protection, to avoid deep squats and low chairs for 12 weeks
• Instructions on post-operative exercises
• Documentation of pre-operative strength and ROM
• Correction on any deficits in flexibility and soft tissue compliance
Note: The following rehabilitation progression is a summary of the guidelines provided by

Bollen, Risberg, Shelbourne. Refer to their publication to obtain further information
regarding criteria to progress from one phase to the next, anticipated impairments and
functional limitations, interventions, goals, and rationales.
Phase I of Rehabilitation: Weeks 0-2
Note: Contact MD immediately if increasing pain, signs of infection, or signs of DVT.
Goals: Control edema and pain

Achieve full extension and 90° of flexion
Weight bearing as tolerated
Begin regaining muscle strength
Quad activation
Intervention:
• Local treatment of swelling with cryotherapy and elevation

• Soft tissue mobilization to hypomobile tissue in superficial fascia near surgery site
• Passive knee extension (heel propped up on pillows and let knee sag)
• Exercise for 5 minutes/hour to stimulate graft ligamentization
• Maintain flexibility with heel slides or prone hamstring curls
• Closed Kinetic chain exercises: hamstrings and quads strengthening, half squats (20-70
degree), cycling with seat high to avoid too much flexion
• Neuromuscular electrical stimulation (NMES), quad activation exercises
• Tibiofemoral mobilization with rotation, patellar mobilizations
• Begin introducing proprioception training with eyes closed
• Crutch training for the first few days
4
Phase II of Rehabilitation: Weeks 2-6
Goals: Control any residual symptoms of edema and pain

Full knee extension ROM to almost full flexion
Progress strength training
Normal gait
Progressive weight-bearing
Return to normal ADL
Intervention:
• Increase load to knee with squats and dips

• Cycling, step machine, leg press 0-90 degrees
• Theraband work to improve knee control and proprioception
• Increase hip adductor and abductor strengthening
• Gait training
Phase III of Rehabilitation: Weeks 6-12
Goals: Full range of motion

Increasing functional activity level
Improve proprioception
Intervention:
• Proprioception training on unstable surfaces

• Wobble board work
• Progressive resistive exercises
• Begin open kinetic chain exercises, beginning range at 40-90° of flexion
• Introduce jogging when muscle strength and control allows
• Progress to jogging in and out of cones from about 10 weeks, changes in directions
should be smooth vs. sudden
Phase IV of Rehabilitation: Weeks 12-26
Goals: Return to pre-injury level sport/occupation at 6 months

Normal strength and speed
Normal agility
Patient fully educated about the future of the knee
Intervention:
5
• Progressive sport specific program

• Sport/work specific strength training
• Progressive sport specific agility and speed work (no sudden twisting/turning until 4
months)
• Plyometrics, quality not quantity
Bollen SR. BASK Instructional lecture 3: Rehabilitation after ACL reconstruction. Knee.
2001;8:75-77.
Bonamo JJ, Fay C, Firestone T. The conservative treatment of the anterior cruciate deficient
knee. Am J Sports Med. 1990;18:618-623.
Chmielewski TL, Stackhouse S, Axe MJ, Synder-Mackler L. A prospective analysis of

incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with
complete acute anterior cruciate ligament rupture. J Orthop Res. 2004;22:925-30 .
Herrington L, Wrapson C, Matthews M, Matthews H. Anterior cruciate ligament reconstruction,

hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome
from surgery. Knee. 2005; 12:41-50.
Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior

cruciate ligament rehabilitation: how much and what type? Physical Therapy Sport.
2004;5:125-145.
Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament

reconstruction. Am J Sports Med. 1990;18:292-299.
1
Posterior Cruciate Ligament Reconstruction and Rehabilitation
Anatomical Considerations: Many authors describe the posterior cruciate ligament (PCL) as the
primary stabilizer of the knee. It is about twice as strong as the anterior cruciate ligament. It is
approximately 38 mm in length and 13mm wide. It runs from the medial femoral condyle to the
posterior tibia. The PCL consists of two bands, the anterolateral and posterolateral. The
anterolateral band is two times as large and is 1.5 times stronger. The anterolateral band is the
band that gets tight on knee flexion, while the posterolateral band is the band that tightens with
knee extension. The PCL as a whole gives the knee 95% restraint to posterior tibial torsion and
is a secondary control to lateral rotation, varus stresses and hyperextension.
Pathogenesis: Tears to the PCL by itself are uncommon. The cause of injury most often is
when some force is applied to the anterior portion of the tibia while the knee is flexed, e.g., the
anterior aspect of the flexed knee striking a dashboard. A fall onto a flexed knee with the foot in
plantar flexion and the tibial tubercle striking the ground first, causing a posterior force to the
proximal tibia, may also result in injury to the PCL. Injury may also occur with forced
hyperextension while the foot is planted in dorsiflexion. A force applied to the anteromedial
aspect of the knee, as during a football tackle, results in a posteriorly directed force and a varus
hyperextension force, may lead to PCL and posterolateral capsular ruptures. When the PCL is
ruptured there is increased posterior translation and this translation increases as knee flexion
increases and has maximum translation between 70-90 degrees, when the anterior cruciate
ligament is fully relaxed.
Epidemiology: Of all the patients seen in the emergency room for ligamentous injuries 37% are
patients with severe knee injuries. Of that 37%, one third are related to sports injuries. The
other two thirds are attributed to other types of injury such as falls and motor vehicle accidents.
PCL injuries account for as many as 20% of all knee ligament injuries. Chronic PCL weakness
can cause or predispose patients to the following pathologies: (1) medial compartmental
osteoarthritis of the knee, (2) meniscal injury, and (3) patellofemoral arthritis.
Diagnosis: The clinical examinations commonly used to assess for PCL instability are the
posterior drawer test, Godfrey or posterior sag test, and the dynamic posterior shift test.
• Positive Posterior Drawer Test with knee at 90° is 90% sensitive and 99% specific. The
posterior drawer test with the knee at 90° is the most sensitive test for detecting PCL
injury. Decreased range of motion may be observed, but may only lack 10-20° of
flexion. Grading the injury upon examination is usually performed by using the
following scale: Grade I injury, step off present but minimal (i.e., 0-5 mm); Grade II
injury, 5-10 mm of posterior translation; and Grade III injury, greater than 10 mm of
posterior translation.
• Positive Godfrey or posterior sag test. 58% sensitive, 97% specificity.
• Positive Dynamic Posterior Shift Test. 95% specific, but only 26% sensitive.
Imaging such as MRI has high sensitivity and specificity in the diagnosis of PCL injury. MRI is
found to be 99% sensitive and specific in the diagnosis of complete PCL tears. Arthroscopy can
2
be performed for further diagnoses of tears in the PCL.

Operative vs. Non-operative Management: The decision to perform surgery or not is primarily
based on the severity of the injury. It is common for non-operative rehabilitation to take place if
the Grade is less than II. The key is to control the swelling, instability, and pain. If the patient,
however, continues to experience pain and instability regardless of rehabilitation and bracing, a
PCL reconstruction may be needed and performed. There are numerous factors that contribute to
which route of treatment will be pursued. It depends on severity of the injury, whether the injury
is to the PCL itself or if it is combined with other injuries to the ligaments or menisci, the
activity level and goals of the patient, and the preference of the physician. Below is outlined the
non-operative and the operative methods of rehabilitation.
Note: the below rehabilitation protocols are derived from guidelines provided by McNeal,
Lintner, Agesen, Ertl, Bhatti, and Kischner. Please refer to their publications for further
information regarding progressions, limitations, expectations, and goals.
Non-operative Rehabilitation: Day 1 to Week 2
Goals: Control the initial inflammation

Regain ROM with muscle function as quickly as possible
Intervention:
• Rest, ice, compression, and elevation (RICE) several times a day, in addition to other
modalities such as electrical stimulation, ice baths.
• Assisted weight bearing. Patients with grade I and grade II injuries can bear as much
weight as they can tolerate immediately. Some may need crutches initially. Crutches and
a long leg brace are recommended only with severe grade III injuries with no other
associated ligamentous laxity or intra-articular damage.
• Electrical stimulation (ES) may be used to stimulate the quadriceps muscle, if the patient
is having difficulty performing quadriceps contractions.
• Exercises for quadriceps and hip strengthening. All open kinetic chain (OKC) hamstring
exercises should be avoided since they promote posterior tibial translation at the knee.
Non-operative Rehabilitation: Weeks 2-12
Intervention:
• Bracing - Only patients with grade III injuries should still be wearing a brace (0-60°)
until at least the third week of therapy. Then, the patient may be fitted for a functional
knee brace.
• Assistive Devices - Crutches can be discontinued and weight bearing as tolerated can be
progressed
• Exercises – At 2-3 weeks, exercises should be progressed with light resistance as
tolerated. The stationary bike may be used for improving ROM. Aquatic exercises can
be used for improving ROM and strengthening. At weeks 3-6, the exercises may be
increased to include closed kinetic chain exercises (CKC) including: leg press, mini
squats, stair stepper, step-ups. Resistance may be increased on the bicycle as tolerated.
At 8-12 weeks, strengthening exercises should be progressed and a light jogging program
3
may be initiated.
Non-operative Rehabilitation: 3 – 9 months
• Exercises – Strengthening and proprioception exercises are progressed as tolerated.

Plyometrics and sport-specific training should also be initiated and accelerated as
tolerated. A running program is developed, and agility drills are integrated.
An isokinetic test and a KT-2000 test should be performed at 3-month, 6-month, 9-
month, and 12-month follow-up visits. The athlete may return to sporting activities when
isokinetic and functional tests are satisfactory according to the PT and the MD. The
patient should not return to competitive sports until full quadriceps strength has been
reestablished.
There are a number of different techniques used to reconstruct the PCL, so the treatment protocol
is determined by the physician, the PT, and the type of graft used in surgery. The types of grafts
used are the patellar tendon, quadriceps tendon, hamstring tendons, and the medial head of
gastrocnemius.
Phase I: Day 1 to Week 2
Goals: Protect the new graft – no active knee flexion.

Gain full knee extension so patient can ambulate with normal gait.
Improve quadriceps control
Intervention:
• Bracing – The patient will be in a post-op brace that is locked at 0 degrees. The brace is
to be worn at all times. The brace will be progressed slowly to 30° depending on how
stiff the patient may be getting. The patient needs to be educated that activities such as
walking down a ramp/hill/incline, sudden deceleration, and squatting activate the
hamstrings and should be avoided and that any weight-bearing exercises should be
performed in brace. The patient can usually weight bear as tolerated on the affected limb
with the use of crutches and a long leg brace.
• Neuromuscular re-education – Improve muscular quadriceps control – consider using
biofeedback or electrical stimulation on the quadriceps – including on vastus medialis
oblique.
• Mobility Exercises: Passive only 0-30°
Seated heel slides using towel
Hamstring stretch
Gastrocnemius/soleus stretch
• Strengthening exercise – Quad sets - if possible “1million/day,” straight leg raises, short
arc quads
• Manual Therapy – Manual patella mobs – especially superior/inferior. Patellar mobility
is also very important, and the patient should be instructed in self-mobilization exercises
4
for the patella, scars, and soft tissues around the knee to prevent fibrosis.
• Physical Agents – Ice can be used following exercise and initially every hour for 20
minutes
Phase II: Week 2 to Week 6
Goals: Protect the graft (note that it is at its weakest point in the healing process)
Ambulate with normal gait
Good quad control
Improve strength and ROM
Minimal to no swelling
Able to ascend/descend stairs
Intervention:
• Exercises: Heel slides – seated and/or supine
Continue quad sets until swelling is gone and quad tone is good
Straight leg raises - add ankle weights when ready
Active knee flexion – PRONE – 0-30/40°
Shuttle/Total gym – 0-60° - bilateral and unilateral; focus on weight
distribution more on heel than toes to avoid overload on patella
tendon
Closed chain terminal knee extension
Leg Press
Step-ups – forward
Step-overs
Wall squats 0-30°
Calf raises
Cycle when 110° of flexion is reached
Continue with HS and calf stretching
Balance/proprioceptive training - weight shifting - med/lat, single leg
stance - even and uneven surface - focus on knee flexion, plyoball
tossing
Aquatic resistance training may be initiated during the later part of this
phase.
• Brace: Continue to wear brace – unlocked to 90° at week 4
Phase III: Week 6 to Week 12
Goal: Perform everyday ADLs without difficulty

Full knee ROM
Intervention:
• Bracing - Post-op brace will is often discontinued at 6 weeks – patient may then be fitted
for functional brace
5
• Exercises: Continue with above exercises, increasing intensity as tolerated.

Active knee flexion – prone – 0-90°
Knee extensions – 0-90°
Step-ups – forward and lateral; add dumbbells to increase intensity; focus
on slow, controlled movement during the ascent and descent
Squats - standing (at week 8)
Lunges – forward and reverse; add dumbbells or medicine ball
Theraband hip flexion
Single leg squats
Single leg wall squats
Cycle – increase intensity; single leg cycle maintaining 80 RPM
Balance/proprioceptive exercise - Plyoball tossing – even and uneven
surfaces, squats on balance board/foam roll,
Cycle – increase intensity
Phase IV: Week 12 to one year
Goal: Perform everyday ADLs without difficulty

Full knee ROM
Increase strength, power, and endurance.
Prepares the athlete for return to competition
Intervention:
• Exercises: Strengthening should continue with focus on high intensity and low
repetitions (6-10) for increased strength.
Hamstring and calf stretches should also continue
Quad stretch should be implemented.
Week 12:
Light resisted hamstring work can be initiated
Initiate lateral movements and sports cord exercises: lunges, forward,
backward, or side-step with sports cord, lat step-ups with sports
cord, step over hurdles.
Jogging/Plyometrics:
When cleared by the physician, the patient can begin light plyos and
jogging at a slow to normal pace. Patient should be focusing on achieving
normal stride length and frequency. Initiate jogging for 2 minutes,
walking for 1 until this is comfortable for the patient and then progress the
time as able. Jogging should first be performed on even surfaces such as a
treadmill or track. Then it can be progressed to mild uneven surfaces such
as grass and then asphalt or concrete. It is normal for the patient to have
increased swelling as well as some soreness, but this should not persist
beyond one day or the patient did too much.
Jump rope and line jumps can be initiated when the patient is cleared to
jog.
6
Jogging and plyos should be performed with brace on.

Advanced Plyos can include squat jumps, tuck jumps, box jumps, depth
jumps, 180 jumps, cone jumps, broad jumps, scissor hops.
Leg circuit: squats, lunges, scissor jumps on step, squat jumps.
Power skipping
Bounding in place and for distance
Quick feet on step – forward and side-to-side – use sports cord
Progress lateral movements – shuffles with sports cord; slide board
Ladder drills
Swimming – all styles
Focus should be on quality, NOT quantity
Landing from jumps is critical – knees should flex to 30° and should be
aligned over second toe. Controlling valgus stress and movements, will be
a challenge at first, and unilateral hops should not be performed until this
is achieved.
Gradually initiate sprints and cutting drills.
Progression: Straight line, figure 8, circles, 45° turns, 90° cuts and
sports specific drills
Agesen T, Ertl J; Kovacs G. Posterior Cruciate Ligament Injury. E-medicine.
http://www.emedicine.com/sports/topic105.htm. Jan. 12, 05.
Bhatti J; Kischner S; Sarmini M. Posterior Cruciate Ligament Injury. E-medicine. 12/19/03.

http://www.emedicine.com/pmr/topic102.htm.
McNeal M; Lintner D. PCL Protocol. http://www.drlintner.com/PCLrehab.htm
Stapelton T. The Posterior Cruciate Ligament. Hughston Health Alert. 1996

http://www.hughston.com/hha/a.pcl.htm.
Sekiya J, Kurtz C, Carr D. Transtibial and tibial inlay double-bundle posterior cruciate ligament
reconstruction: Surgical technique using a bifid bone-patellar tendon-bone allograft.
Arthroscopy. 2004;1095-1100.
Wind W, Bergfeld J, Parker R. Evaluation and treatment of posterior cruciate ligament injuries:
revisited. Am J Sports Med. 2004;32:1765-1775.
1
Medial/Lateral Meniscectomy and Rehabilitation
Anatomical considerations: The meniscus is an important load-bearing structure that supports

70% of the load transmitted through the lateral compartment and 50% medially, thus decreasing
contact pressures on the articular cartilage. It is also an important secondary stabilizer of the
knee, resisting anterior translation. The meniscus has nutritive as well as lubricating properties
in the knee joint as well. The medial meniscus is C shaped and thicker posteriorly. It occupies
50% of the articular contact area of the medial compartment. The lateral meniscus is O shaped
and of equal thickness throughout. It covers 70% of the lateral tibial plateau. The red zone or
fibrous outer portion of the meniscus is vascular and therefore tears there will often heal. The
inner 2/3rds or white cartilaginous zone of the meniscus does not have a good blood supply and
therefore, tears are less likely to heal in this area. The lateral meniscus is not as firmly attached
to the tibia as the medial meniscus and therefore is less prone to injury.
Pathogenesis: The meniscus is most commonly injured by a compressive or weight bearing

force, combined with tibiofemoral rotation in the transverse plane as the knee moves from
flexion to extension. A tear may therefore occur during activities that require rapid cutting or
pivoting.
Epidemiology: The posterior medial meniscus is the most commonly injured portion of the
menisci, secondary to it being less mobile and therefore, greater stresses occurring in this area.
Athletes and younger individuals most often obtain meniscus tears via non-contact activities like
rapid cutting, pivoting or deceleration movements. With increasing age, tears can often occur
with trivial injury due to degeneration of the meniscus.
Diagnosis
• Injury followed by pain in area of medial or lateral joint lines

• Most patients describe pain especially when the knee is straightened.
• Following an injury, the knee may click, lock or feel weak
• Positive McMurray’s or Apley’s tests
• MRI may help to confirm the diagnosis
Nonoperative vs. operative management: The overall treatment goal is to preserve as much
meniscal tissue as possible while addressing the clinical symptoms caused by the meniscal tear.
Nonoperative treatment which consists of anti-inflammatory medications and careful
strengthening exercises may allow for the menisci to heal, especially if the tear lies in the outer
third of the structure. This treatment may take 6-8 weeks in order for meniscal healing to occur.
If the patient continues to complain of symptoms following 6 weeks, arthroscopic
meniscectomy may be considered. Non-operative treatment is usually more appropriate for
patients who are less active or sedentary. Meniscal tears that extend beyond the outer third or
vascular zone will not heal and therefore a partial meniscectomy is recommended. A complete
meniscectomy may be performed especially with significant degenerative tears to the meniscus.
2
Both complete and partial meniscectomies result in a significant increase in the load across the
joint and on the articular cartilage and reduce the shock absorption capacity of the knee. A
partial meniscectomy leaves a rim of tissue in place, which maintains some stress protection for
the articular cartilage, in contrast to a total meniscectomy, which (in the absence of regeneration)
is associated with increased cartilage degeneration, joint narrowing, alterations in bone
geometry, and osteophyte formation. Due to these factors, many surgeons choose to preserve the
meniscus with a meniscal repair or in some cases reconstruction with an allograft. In addition to
the location of the tear, the pattern of the tear may also indicate if surgery may be required.
Longitudinal tears have a favorable healing potential except for a bucket-handle tear (a variant of
a longitudinal tear) in which circumferential fibers are involved. Radial or flap meniscus tears
also involve the circumferential fibers. These tears are more easily managed with debridement/
meniscectomy. Degenerative tears also respond better to meniscectomy than repair.
Surgical procedure: Although meniscectomy was originally performed by open arthrotomy, the
procedure is almost universally done today by arthroscopic means. Partial meniscectomy is
indicated in unstable tears that are not repairable due to location or configuration and serves to
preserve as much of the normal meniscus as possible. In this procedure, the surgeon removes
only the damaged or unstable portion of the meniscus, and balances the residual meniscal rim.
The procedure for a total meniscectomy, the entire meniscus may be removed.
Preoperative rehabilitation: Pre operative rehab for a meniscal injury that is to undergo a
meniscectomy may involve: (1) Swelling and pain control, (2) range of motion exercises, (3)
quadriceps strengthening and (4) aquatic therapy for strengthening if pain is preventing
strengthening with normal weight bearing
Rehab following a partial medial or lateral meniscectomy can usually progress as tolerated, with
no contraindications or limitations due to the fact that there is no anatomic structure that must be
protected. Goals are early control of pain and edema, immediate weight bearing, obtaining and
maintaining full ROM and regaining proper quadriceps strength. The following is a rehab
progression provided by S. Brent Brotzman and Kevin E. Wilk.
Phase 1: Acute phase
Goals: Diminish inflammation and swelling

Restore ROM
Reestablish quadriceps muscle activity
3
Intervention:
Days 1-3
• Cryotherapy
• Light compression wrap
• Electrical muscle stimulation to quadriceps
• Strengthening Exercises: Straight leg raises, hip adduction and abduction, ¼ and/or ½
squats
• Active assisted ROM stretching, emphasizing full knee extension (flexion to tolerance)
• Weight bearing as tolerated (use of axillary crutches as needed)
Days 4-7
• Cryotherapy and continued use of compression wrap
• Electric muscle stimulation to quadriceps
• Strengthening Exercises: Straight leg raises, quadriceps sets, hip adduction and
abduction, knee extension 90-40 degrees, ¼ and/or ½ squats
• Balance/proprioceptive drills
• Active assisted, passive ROM, and stretching exercises (hamstrings, gastrocsoleus,
quadriceps)
• Weight bearing as tolerated
Days 7-10
• Continue all exercises and add: Leg press (light weight), toe raises, and hamstring curls
• Bicycle (when ROM 0-105 degrees with no swelling)
Phase 2: Internal Phase
Goals: Restore and improve muscular strength and endurance

Reestablish full nonpainful ROM
Gradual return to functional activities
Intervention:
Days 10-17
• Bicycle, Stairmaster and/or elliptical trainer for motion and endurance
• Strengthening and coordination exercises: Lateral lunges, front lunges, ½ squats, leg
press, lateral step ups, knee extension (90-40 degrees), hamstring curls, hip adduction and
abduction, hip flexion and extension, toe raises
• Proprioceptive and balance training
• Stretching exercises
Day 17-Week 4
• Continue all exercises
• Pool program (deep water running and leg exercises)
4
• Compression brace may be used during activities
Criteria for progression to Phase 3: Satisfactory clinical examination (minimal effusion)

Full/nonpainful ROM
No pain or tenderness
Satisfactory isokinetic test
Phase 3: Advanced Activity Phase – Weeks 4-7
Goals: Enhance muscular strength and endurance

Maintain full ROM
Return to sport/functional activities
Intervention:
• Therapeutic exercises:Continue to emphasize closed-kinetic chain exercises

May begin plyometrics
Begin running program and agility drills
Brindle T, Nyland J, Johnson D. The meniscus: review of basic principles with application to
surgery and rehabilitation. J Athl Train. 2001;36:160-169.
D’Amato M, Bach B. Knee Injuries. In Brotzman B, Wilk K, eds., Clinical Orthopedic

Rehabilitation. Philadelphia, Mosby,2003.
Poole R, Blackburn T. Dysfunction, Evaluation, and Treatment of the Knee. In Donatelli R,

Wooden M, eds., Orthopedic Physical Therapy. New York,Edinburgh, London, Melbourne,
Tokyo, Churchill Livingstone, 1994.
Rath E, Richmond J. The menisci: basic science and advances in treatment. Br J Sports Med.
2000;34:252-257.
Weinstein S. Arthritis of the Knee. In Weinstein S, Buckwalter J, eds., Turek’s Orthopedics,

Principles and their Applications. Philadelphia, J.B. Lippincott Co., 1994.
1
Meniscal Repair
Anatomical Considerations: The meniscus is a half moon shaped piece of cartilage that acts as
force transmitter between the femur and the tibia. The meniscus has nutritive as well as
lubricating properties in the knee joint as well. In a normal knee, there are two menisci, which
sit on the tibia itself; the lateral and medial menisci. The meniscus itself is largely avascular, and
therefore, cannot repair itself if the tear is in an avascular portion of the meniscus. The only time
a meniscus will repair itself is if the injury is located in the periphery of the meniscus, where it
has a vascular supply. A short (<1cm) stable tear that is limited to the outer 20% of the meniscus
could heal itself with a period of immobilization. Descriptively, the anterior third of the
meniscus is known as the anterior horn, the posterior third as the posterior horn, and the middle
as the body. The complete removal of the meniscus can result in progressive knee arthritis.
Pathogenesis: Traumatic tears are the result of a sudden load being applied to the meniscal
tissue that is severe enough to cause the cartilage to fail. This trauma is usually the result of a
twisting injury on a semi-flexed knee or a blow to the side of the knee that causes the meniscus
to be compressed or levered against. Common examples of this injury are a fall backwards onto
the heel with rotation of the lower leg or a football clipping injury. Degenerative tears are a
result of the failure of the meniscus over time. There is a natural “drying out” of the center of
the meniscus which progresses with age. Therefore, often the mechanism of injury is nothing
out of the ordinary for the patient. An example of a possible mechanism would be a squat to
pick an item up off of the floor. However, other times, there are no memorable injury that
caused the tear.
Epidemiology: A meniscus tear can be located in any location, and in any conceivable pattern.
However, tears that are confined to the anterior horn are unusual. Tears typically begin in the
posterior horn and progress anteriorly. Patients with sports injuries have a mean age of 33 years,
and account for approximately 32% of cases. Patients with non-sporting injuries have a mean
age of 41 years, and account for approximately 39% of cases. Patients with an indefinable injury
have a mean age of 43 years, and account for about 29% of cases. There is a 4:1 male to female
ratio in these tears, and approximately 2/3 of all cases occur in the medial meniscus. It should
also be noted that associated ACL tears were found in 47% of the patients in sports injuries and
in 13% of the non-sporting injuries. In the no-injury group, there were no ACL tears.
Diagnosis
• Pain on the side of the knee at the level of the joint line between femur and tibia
• May observe swelling, but generally low grade, associated with stiffness and limping
• Patient may report a “locking” of the knee in a bent position, associated with pain
• Twisting, squatting or impacting activities cause pain
• Positive McMurray’s, Apley’s grinding test and/or Bounce home test
• Radiographs rule out bony injury
• MRI is helpful in determining the presence, size, location and severity of the tear
2
Nonoperative Versus Operative Management: Surgical repair is typically recommended for

patients who are experiencing pain and/or locking of the joint. Arthroscopic surgery is the
method of choice to treat a tear, as there are currently no medications, braces or physical therapy
treatments that have been shown to promote healing in avascular tears. Arthroscopic surgery is
performed on an outpatient basis, with the surgeon evaluating the tear. Upon this evaluation, the
decision is made to either remove or repair the tear based on the location and size of the tear. If
there is a vertical tear at the rim near the meniscal blood supply, it is desirable to repair the
meniscus by approximating the torn edges of the meniscus to allow for healing and preventing
these edges getting caught in the joint. Note that if the tear is located in an avascular portion of
the joint, a meniscectomy will most likely need to be performed. The main surgical risk is wound
infection and breakdown.
Surgical Procedure: One arthroscopic technique is known as the inside-out method. It uses
cannulas to direct a pair of long needles into the meniscus and out through a small incision in the
back of the knee. The suture ends are then tied together on the outside of the knee capsule to
firmly approximate the tear. This procedure does require a 1 ½” incision to access the area where
the sutures are tied together. Other arthroscopic methods can avoid incisions completely. Some
of these include bioabsorbable arrows and dissolving meniscal staples. T-Fix sutures are another
option that provide a good repair. These sutures have an anchor that acts like a wall anchor and
is deployed after placing the suture through the meniscus, the tear, and the peripheral rim. The
sutures are then tied together from the inside using a knot pusher instrument that secures the
meniscus to the rim.
Phase I: Weeks 1-4
Goals: Decrease swelling and pain

Protect Repair
Increase range of motion and strength
Intervention:
• Physical Agents
Electrical Muscle Stimulation
Cryotherapy
Isometric quadriceps, straight leg raises, active knee extension
Non-weight bearing gait training (weeks 1-2)
Toe touch weight bearing – ¼ body weight gait training (weeks 3-4)
Progressive Strengthening Exercises (hamstrings, quadriceps, gastroc-soleus, ilio-
tibial band)
Closed Chain activities (gait, toe raises, wall squats, mini squats) in weeks 3 and 4
UBE for conditioning (weeks 1-2)
3
Stationary bike < 15 minutes (weeks 3-4)

Post-operative bracing (immobilizer)
Axillary Crutches
• Passive Range of Motion/Manual Therapy
Goal of achieving 0-90 degrees in weeks 1-2; 0-120 degrees in weeks 3-4
Patellar mobilizations
Phase II: Weeks 5-8
Goals: Restore normal, pain free full range of motion

Ability to walk with full weight bearing by weeks 7 and 8, while wearing immobilizing
brace
Intervention:
• Physical Agents
Electrical Muscle Stimulation (stops after week 6)
Cryotherapy
• Passive Range of Motion/Manual Therapy
Goal of achieving 0-135 degrees
Patellar and peri-patellar soft tissue and joint mobilizations
Knee flexion (hamstring curls to 90o)
Knee extension (quad sets 0-30o)
4 way hip exercises
Leg press (70-10o)
Step-Downs
Proprioceptive/balance training (weight shifting, mini trampoline, BAPS board, KAT
board, plyometrics)
Conditioning with stationary bike
Weeks 7/8 and on – stationary bike, aquatic therapy, swimming, walking, stair
climber, elliptical machine, straight running
Axillary Crutches and immobilizing brace as indicated
Phase III: Weeks 9-12
Goal: Allow patient to return to most normal activities including community ambulation,
unlevel surfaces and stairs without pain - and without brace
4
Intervention:
• Approaches / strategies listed above

• Functional training: Introduce running without brace, multi-plane single leg activities,
cutting and full sport activities
Intervention for High Performance / High Demand Functioning in Workers and Athletes
Goal: Return to unrestricted sport or work activity
• Therapeutic exercises
Review desired activity and progress to ballistic activity specific exercises
• Patient education/ergonomics instruction
Educate patient to recognize knee injuries
Instruct in home/gym exercise and stretching program to prevent recurrence.
Selected References
Asik M, Sen C, Taser OF, Sozen YV, Alturfan AK. Arthroscopic meniscal repair with the use of
conventional suturing materials. Acta OrthopedicTraumatol Turc. 2002. Abstract (article is in
Turkish)
Cincinnati Sports Medicine and Orthopaedic Center. Rehabilitation Protocol Summary for
Meniscus Repairs. www.cincinnatisportsmed.com, accessed 7/6/2004
Drosos GI, Pozo JL. The causes and mechanisms of meniscal injuries in the sporting and non-
sporting environment in an unselected population. Knee. 2004;4:143-149.
Greis PE, Bardana DD, Holmstrom MC, Burks RT. Meniscal injury: I. Basic science and
evaluation. J Am Acad Orthop Surg. 2002;10:168-76.
Magee, D. Orthopedic Physical Assessment 4th ed. WB Saunders Co., Philadelphia, PA, 2002
Nevsimal L, Skotak M, Mika P, Behounek J. Clinical examination of menisci in the era of

arthroscopy. Acta Orthopedic Traumatol Cech. 2002. Abstract only as article is in Czech.
Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with
stable knees. Am J of Sports Med. 2004;32:675-680.
1
Knee - Articular Cartilage Procedures
Anatomical Considerations: Articular cartilage covers the articular surfaces of synovial joints
and provides a nearly frictionless surface for kinematics. It lacks blood supply and lymphatic
supply, receiving its nutrients secondary to movement and stresses to the proteoglycans and
collagen. Articular cartilage is composed of type II hyaline cartilage, which does not
spontaneously reproduce and is naturally replaced with fibrocartilage following pathology.
Fibrocartilage lacks the shock absorption and smooth characteristic of hyaline cartilage.
Mechanical motion and loading have been found to increase chondrocyte activity and improve
cartilage generation.
Pathogenesis: Research suggest that it may stem from a variety of causes including: post
traumatic avascular necrosis, idiopathic avascular necrosis, overuse and repeated impact,
blockage of a small artery, unrecognized injury, tiny fracture leading to cartilage damage,
genetic predisposition (if multiple joints involved or family history), abnormal ossification, and
acute trauma or shear force. Osteochondral defects are divided into five stages. Stage 0 - normal,
Stage 1 - softening and/or superficial fissures, Stage 2 - injury extending to less than 50% of
cartilage depth, Stage 3 - injury through 50% of cartilage depth and to subchondral bone, Stage 4
- Subchondral bone exposed, injury to subchondral bone or through to trabecular bone.
Epidemiology: Osteochondral defect is a common disorder of unclear etiology. Predisposing

factors include high impact athletic activities, muscular weakness and instability, malalignment,
and endocrine imbalance. The pathology is historically more common in males (thought to be
secondary to activity level) with prevalence increasing in females, ages 10-40 years, and is
known to occur in the knee, dome of the talus, capitellum, femoral head, and trochlea.
Occurrence is greater in the weight bearing joints and may occur in the upper extremities with
falling onto an outstretched arm.
Diagnosis:
• Patients present with varying pain levels from no complaints to non-relieving pain
following trauma, sudden onset (loose body), gradual onset, or intermittent pain
• Pain is primary complaint, dull ache, poorly localized, rest alleviates, increases with
activity.
• Swelling is often intermittent, increases with activity
• Grating in the joint
• Decreased range of motion, stiffness. Inconsistent range of motion could be indicative of
a loose body
• Locking in the joint and giving way
• Plain film radiographs confirm lesion. MRI, CT, and US are used to diagnose stage of
lesion. Arthroscopy is gold standard evaluation tool
2
Nonoperative Versus Operative Management:

Treatment of osteochondral lesions depends on the size, location, stability of the fragment, and
skeletal maturity (epiphyseal plates). Research and history has shown that articular cartilage will
not spontaneously heal. Stage 1 and 2 lesions are often treated conservatively because the
surgery is invasive and reliability of techniques is indifferent. Surgical intervention is
recommended for stage 3 and 4 lesions and occasional stage 2 lesions depending on level of
activity of patient and physician's choice.
Surgical Procedures: Several surgical intervention options are available and chosen depending
upon the condition of the lesion and goals of the patient. Arthroscopic debridement consists of
removal of loose bodies, spurs, loose cartilage, and the cartilage surface is made smooth.
Arthroscopic abrasion is utilized following debridement to expose bleeding surface of bone in
order to stimulate cartilage healing – however, healing occurs with a less than optimal
fibrocartilage layer. Arthroscopic micro fracture or drilling consists of drilling holes into the
subchondral bone with the intention of stimulating articular cartilage formation from the
subchondral bone. Drilling can be done either retrograde (does not touch the remaining
cartilage) or antegrade (through the remaining cartilage). More invasive options include
osteochondral autograft transfer (OAT) procedure that involves removing a graft and bone plug
from a non weight bearing surface of the knee, usually the patella groove of the medial condyle.
Holes are drilled into the osteochondral lesion and the plugs are then placed in the lesion. The
articular surface is then hyaline cartilage from the plugs, but the space between the plugs is filled
with fibrocartilage. The latest option is Autologous Chondrocyte Transplantation/Implantation
(ACI) that requires a biopsy of healthy articular cartilage from a non weight bearing surface to
be gathered and sent to the lab to culture hyaline cartilage. Cartilage is sent back to the
physician. A periosteal graft is then taken from the tibia and inserted into the lesion with the
new cartilage cells injected below it. The graft is sutured in place with flat sutures.
• Conservative treatment to return patient to highest level of function. If conservative fails

to meet the desired outcomes and/or expectations, then surgery is implicated
• Lower extremity strengthening and arm bike to maintain cardiovascular strength
• Patient education in use of crutches and weight bearing status as appropriate
• A controlled motion brace may be appropriate with symptoms of instability
• Instructions and review post-operative plan and educate on long recovery period
Note: The following rehabilitation protocol is a summary of guidelines for post-operative

articular cartilage procedures provided by Fitzgerald and Irrgang and published in Clinical
Orthopaedic Rehabilitation by Brotzman and Wilk. Please refer to the publication for details on
the progression, potential impairments, and goals of the rehabilitation plan.
3
ARTHROSCOPIC DEBRIDEMENT
Phase I: Early post-operative protection phase: 0-6 weeks
Goals: Protection of healing tissue from shear forces

Restoration of full passive knee extension
Gradual improvement of full knee flexion
Re-establish voluntary quadriceps control
Adhere to weight bearing status
Intervention:
• Full extension at 1 wk
• Full flexion at 3 wks
• Initiate isometric exercises
• Open chain resisted exercises as tolerated
• Closed chain exercise as tolerated in accordance to weight bearing status
• Weight bearing as tolerated crutch training
• Initiate walking program: 3-6 weeks
• Stationary bike: 3-6 weeks
• Swimming program: 3-6 weeks
• Elevate and ice
Phase II: Intermediate Phase: 6-12 weeks
Goals: Full active range of motion should be achieved by this time

Return to full activities.
Intervention:
• Exercises to maintain full active range of motion

• Progress to open and closed chain resisted exercises as tolerated
• Agility and sport specific skill training at 50% effort is initiated, progress to full effort as
tolerated
• Initiate return to full activity as these activities do not induce pain or effusion
• Elevate and ice as needed
4
OSTEOCHONDRAL AUTOGRAFT PROCEDURE

articular cartilage procedures provided by Kevin Wilk and was presented at a Northeast
Seminars symposium in Los Angeles in 2003. Please refer to the publication for details on the
progression, potential impairments, and goals of the rehabilitation plan.
Phase I: Protection Phase: 0-6 weeks
Goals: Protection of healing tissue from shear forces

Gradual improvement of knee flexion
Re-establishment of voluntary quadriceps control
Intervention:
• Brace locked at 0 degrees during ambulation for 4 weeks, sleep in brace 2-4 weeks
• Weight bearing- toe touch for 2 weeks, 25% body weight 3-4 weeks, 50-75% 5-6 weeks
• Immediate motion
• Full passive knee extension
• Passive knee flexion, active assisted range of motion:
0-90o week 1
0-100o week 2
0-110o week 3
0-115o week 4
0-125o week 6
• Isometric quadriceps sets
• Isometrics in multiple angles for quads
• Electrical muscle stimulator to quads if poor recruitment
• Bicycle as range of motion permits
• Active knee extensions: Week 3
• Mini squats 0-50 degrees: Week 3
• Leg press: Week 3
• Gradual return to daily activities as tolerated, reduce if symptoms occur
Phase II: Transition Phase: 6-12 weeks
Goals: Gradual increase range of motion

Gradually improve lower extremity strength and endurance
Gradually increase functional activities
Intervention:
5
• Full weight bearing: Weeks 6-8

• Knee range of motion: 0-125o
• Progress resistive exercises
• Initiate closed chain exercises including step ups and wall squats to 70 degrees
• Stationary bike
• Balance and proprioception drills
• Pool program
• Initiate isotonic strengthening program: Weeks 6-8
• Gradual increase in walking and standing, as swelling and pain allows
Phase III: Maturation Phase: 12-20 weeks
Goals: Improve muscular strength and endurance

Increase functional activities
Intervention:
• Leg press 0-90o

• Bilateral squats 0-60o
• Unilateral step ups and step downs, 2”-8”
• Forward lunges
• Walking program
• Stationary bike
• Balance and proprioceptive drills
• Pool program
• Stairmaster
• Initiate light running program – DETERMINED BY PHYSICIAN
Phase IV: Return to Activity Phase: 20-26 weeks
Goals: Gradual return to full unrestricted functional activities
Intervention:
• Progress exercise program

• Squats 0-65o
• Leg press 0-90o
• Step ups, step downs
• Front lunges
• Bike
• Gradual increase to running and agility drills
• Low impact sports 4 months
• Moderate impact sports 5 months
6
• High impact sports 6-7 months
AUTOLOGOUS CHONDROCYTE IMPLANTATION

articular cartilage procedures provided by Kevin Wilk and was presented at a Northeast
Seminars symposium in Los Angeles in 2003. Please refer to the publication for details on the
progression, potential impairments, and goals of the rehabilitation plan.
Phase I: Protection Phase: 0-6 weeks
Goals: Protection of healing tissue from load and shear forces

Gradual improvement of knee flexion
Regain quad control
Intervention:
• Brace locked at 0 degrees during ambulation for 4 weeks, sleep in brace 2-4 weeks.
• Weight bearing: non weight bearing for 2 weeks, toe touch 3-4 weeks, 25% 5 weeks
• Immediate motion
• CPM first 4-12 hours: 0-40o for 2-3 weeks, increase as tolerated 5-10 degrees per day
• Full passive knee extension
• Passive knee flexion 0-90o at 2 weeks, 0-105o at 4 weeks, 0-120o at 6 weeks
• Stretch hamstrings, calf, quads
• Theraband resisted ankle pumps
• Isometrics for quads
• Active knee extension 90-40 degrees, no resistance
• Stationary bike
• Biofeedback as needed
• Isometric leg press at week 4
• Gradual return to daily activities
• Elevation and ice
Phase II: Transition Phase: 6-12 Weeks
Goals: Gradual increase in range of motion

Gradually improve quad strength and endurance
Gradual increase in functional activities
Intervention:
• Discontinue brace at 4-6 weeks
7
• Progress knee flexion to 125o

• Patella mobilization and soft tissue work
• Continue stretching
• Mini-squats 0-45o
• Closed chain exercises, leg press
• Calf raises
• Open chain resistance, 1#/week
• Stationary bike
• Balance
• Front and lateral step ups
• Increase functional activity as pain and swelling allow
• Walking program
Phase III: Maturation Phase: 12-26 weeks
Goals: Improve muscular strength and endurance

Increase functional activities
Intervention:
• Range of motion to 0-125/135

• Leg press 0-90o
• Squats 0-60o
• Unilateral step ups 2”-8”
• Forward lunges
• Walking program
• Open chain extension 0-90o
• Bike
• Stairmaster
• Swimming
• Nordic track
• Light running at end of phase
Phase IV: Functional Activity Phase: 26-52 weeks
Goals: Gradual return to full unrestricted activities
Intervention:
• Progress resistance as tolerated

• Progress agility and balance drills
• Impact and loading program to build to patients requirements
8
• Progress sport programs as necessary

• Low impact sports at 6 months
• Moderate impact sports at 8-9 months
• High impact sports at 12 months
Barber FA, Chow JCY. New frontiers in articular cartilage injury. Arthroscopy. 2003;19:142-
146.
Bentley G, Biant LC, Carrington RWJ. A prospective, randomized comparison of autologous

chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone
Joint Surg. Br.2003;85:223-230.
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia, Mosby Inc.,.
2003: 350-355.
D’Lima DD, Hashimoto S. Osteoarthritis and cartilage. Journal of the OsteoArthritis Research
Society International. 2001;9:712-719.
Ellenbecker T. Knee Ligament Rehabilitation: New Techniques for Cartilage Repair and
Replacement. Churchill Livingston; 2nd edition. 2000.
Mendicino RW, Catanzariti AR. Mosaicplasty for the treatment of osteochondral defects of the
ankle joint. Clin Podiatr Med Surg. 2001;18:495-511.
Milbrandt T, Berthoux L, Christenson V. Tracing transduced cells in osteochondral defects. J

Pediatr Orthop. 2003;23:430-436.
Nakagawa Y, Matsusue Y. Osteochondral grafting for cartilage defects in the patellar grooves of
bilateral knee joints. Arthroscopy. 2004;20 Suppl 2:32-38.
Wilk K. Surgical treatment options for articular cartilage defects. Northeast Seminars. Los
Angeles 2003.
1
Total Knee Arthroplasty Rehabilitation
Anatomical Considerations: The knee is composed of the distal end of the femur, proximal
portion of the tibia, and the patella. It has a medial and lateral meniscus in between the femur
and tibia to cushion the joint, absorb and transmit weigh-bearing forces. Four ligaments, the
anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament
(MCL) and lateral collateral ligament (LCL) provide anterior-posterior and medial-lateral
support. The knee is an unstable joint, relying on ligaments, menisci, and balanced muscles on
all sides of the joint, particularly the hamstrings and quadriceps, for cushioning and stability. It
is more than a simple hinge joint, as the bone surfaces roll, glide, and rotate on each other.
Pathogenesis: Wear and tear of the knee joint is part of the normal aging process, however,
osteoarthritis (OA) accelerates the degenerative wear of the meniscus. This form of arthritis
usually results from some predisposing factor, such as an injury or deformity. Whether of
unknown origin or secondary to trauma or disease, poor alignment of the leg bones may cause
unequal weight distribution. This leads to excessive wear on one side of the joint surface versus
another, and any irregularity of the knee joint results in wear and tear of the menisci. Over time,
the menisci no longer function as an effective shock absorber/transmitter for the knee. Excessive
localized pressure and damage to the joint result, possibly leading to bone-on-bone contact,
causing symptoms of increased knee stiffness and pain. Remodeling of bone may also occur due
to bone-on-bone contact, causing bony spurs. These spurs contribute to increased pressures
within the joint, leading to pain and decreased function.
Rheumatoid arthritis is an inflammatory joint disease that is destructive to articular cartilage

lining the surfaces of the knee joint. The inflammatory process can cause joint instability and
deformity, muscle atrophy and weakness, swelling, stiffness, and pain.
Epidemiology: Total knee arthroplasty (TKA) is one of the most common orthopedic
procedures: 171,335 primary total knee replacements occurred in 2001. Nearly 90% of patients
who elected to have TKA had OA of the knee, 2/3 were female, and 1/3 were considered obese.
Although patients as young as late-40’s and as old as mid-90’s have received total knee
replacements, the “ideal” knee replacement candidate is between the ages of 65-75, as patients
are healthy enough to recover well from surgery, yet old enough so replacement most likely lasts
the rest of their lives (15-20 years). Obesity is the most modifiable risk factor, but prior knee
injuries/trauma, and extreme physical or repetitive activity can also contribute to increased
incidence of knee OA. Other causes of knee dysfunction leading to TKA include rheumatoid
arthritis, trauma, congenital/acquired joint deformity, and tumors.
2
Diagnosis/Indications For Surgery

• Severe joint pain with weight bearing or motion that compromises functional activities
(severity of pain correlates poorly with radiographic and structural changes in the joint)
• Extensive destruction of articular cartilage of the knee secondary to advanced arthritis
• Gross instability or limitation of motion
• Marked deformity of the knee such as genu varum or valgum
• Knee pain that does not respond to conservative therapy (medication, injections, physical
therapy > six months)
• Previous failed surgical procedure
Nonoperative Versus Operative Management: There are typically four major groups of
nonsurgical treatments:
1) Health and behavior modification, including weight loss and patient education about
behavior changes to reduce impact of disease, physical therapy and exercise to stretch,
strengthen muscles surrounding the knee. Deyle et al concluded that a combination of
manual physical therapy and supervised exercise is more effective than no treatment in
improving walking distance and decreasing pain, dysfunction, and stiffness in patients
with OA of the knee, possibly deferring or decreasing the need for surgical intervention.
Vad et al proposed a progressive five-stage rehabilitation program for managing knee OA
that ranges from protected mobilization to exercises to improve neuromuscular
coordination, timing, and joint protection. Taping and bracing to support and protect the
knee joint, foot orthoses to correct imbalances contributing to unequal weight bearing
forces across the knee joint, and use of TENS for pain control are also included under
this category.
2) Drug treatments, including simple pain relievers, nonsteroidal anti-inflammatory drugs

(NSAIDs), COX-2 inhibitors, opiates, and glucosamine and/or chondroitin sulfate are
several types of drugs used to treat knee OA.
3) Intra-articular treatments involve one or more injections into the knee joint.
Corticosteroid injections, limited to four or less per year, are helpful for significant
swelling causing moderate to severe pain. Typically corticosteroid injections are not
helpful if arthritis affects joint mechanics.
Viscosupplementation with hyaluronic acid, a molecule that is found in joints of the
body, is a way of adding fluid to lubricate the joint and make it easier to move. It can be
helpful for people whose arthritis does not respond to behavior modification or basic
drug treatments. Three to five weekly shots are needed to reduce the pain, but relief is
not permanent.
4) Alternative therapies include the use of acupuncture and magnetic pulse therapy.
Acupuncture is adapted from a Chinese medical practice. It uses fine needles to stimulate
specific body areas to relieve pain or temporarily numb an area. Magnetic pulse therapy
is painless and works by applying a pulsed signal to the knee, which is placed in an
electromagnetic field. Because the body produces electrical signals, proponents think
that magnetic pulse therapy may stimulate the production of new cartilage. Many forms
3
of therapy are unproven but reasonable to try provided they are through a qualified
practitioner and the primary physician is informed of the patient’s decision to try these
therapies.
Elective total knee replacement is, more often than not, the last effort in managing joint pain and
dysfunction caused by arthritis when non-operative treatment of knee pain is not effective.
When erosion of articular joint surfaces becomes severe, TKA is the surgical procedure of choice
to decrease pain, correct deformity, and improve functional movement.
Surgical Procedure: An incision is made down the front of the leg from mid-thigh to several
inches below the knee. The quadriceps muscles are either split down the middle or shifted, along
with the patella, to the side of the thigh. The distal end of the femur and proximal end of the
tibia are sawed off; the menisci and ACL are excised as well. The PCL may also be cut; the pros
and cons of sparing the PCL is currently of debate in knee replacement surgery. The knee
replacement consists of three components that help the surgeon tailor the device to the patient.
A curved femoral component is usually made of shiny chrome alloy; it is attached to the femur
and “replaces” the femoral condyles. The metal tibial component has a flat top with a spike that
goes into a 2” hole that the surgeon drills into the tibia. A disc, made of polyethylene, is
cemented to the top of the tibial component. Depending on its condition, the patella is either left
intact or the inside resurfaced- the patella is never totally replaced. If the patella is resurfaced,
polyethylene is also used to cover the inside.
Total knee arthroplasty components are either held in place with bone cement (cemented
fixation), utilize bone ingrowth via a porous prosthesis (uncemented fixation), or combine
cemented fixation of the tibial component and uncemented fixation of the femoral component
(hybrid). Uncemented fixation has been used primarily for the active patient in whom the risk of
prosthetic loosening over time is most likely, however, the ultimate decision rests with the
attending surgeon.
Preoperative Rehabilitation
• Ensure adequate strength of trunk and upper extremities for support during use of
assistive devices
• Instruction in use of walker/crutches/or cane to maintain desired postoperative weight
bearing status (touchdown weight bearing for uncemented or hybrid replacements, weight
bearing as tolerated for cemented replacements)
• Review of post-operative exercises, bed mobility and transfers, use of continuous passive
motion (CPM) machine as indicated per physician
• General strengthening, flexibility, and aerobic conditioning
While it seems reasonable to believe patients undergoing TKA would benefit from preoperative
strengthening exercises, there is no evidence to support this assumption, either in improving
functional outcome or shortening hospital stay (D’Lima et al., Rodgers et al.).
However, a study by Jones et al showed that patients who have greater preoperative dysfunction
may require more intensive physical therapy intervention after surgery because they are less
likely to achieve similar functional outcomes to those of patients who have less preoperative
4
dysfunction.
Note: The following rehabilitation progression is a summary of the guidelines provided by

Kisner and Colby. Refer to their publication to obtain further information regarding criteria to
progress from one phase to the next, anticipated impairments and functional limitations,
interventions, and goals.
*Use of a CPM device is often initiated by the first day after surgery, per physician protocol. It
has been suggested that CPM decreases postoperative pain, promotes wound healing, decreases
incidence of deep venous thrombosis (DVT), and enables the patient to regain knee flexion more
rapidly during early postoperative days. However, Kumar et al conducted a randomized
prospective study that found no statistically significant difference in range of motion gains using
a CPM device versus active movement. Continuous passive motion units may be recommended
as an adjunct to, not a replacement for, a supervised postoperative rehabilitation program.
Phase I: Maximum Protection: Weeks 1-2
Goals: Control postoperative swelling

Minimize pain
Knee ROM 0-90°
Muscle strength 3/5-4/5
Ambulation with or without use of an assistive device
Establish home exercise program
Intervention:
• Passive range of motion (PROM)-CPM as indicated per physician

• Ankle pumps to decrease risk of DVT
• Bed mobility and transfers usually initiated 24-48 hours post-surgery, depending on
surgical procedure and co-morbidities
• Heel slides in supine or sitting to increase knee flexion
• Muscle-setting exercises of the quadriceps, hamstrings, and hip adductors, possibly
coupled with neuromuscular electrical stimulation
• Assisted progressing to active straight-leg raises in supine, prone, and sidelying positions
• Gravity-assisted knee extension in supine by periodically placing a towel roll under the
ankle and leaving the knee unsupported
• Gentle inferior and superior patellar glides
• Neuromuscular inhibition techniques such as agonist-contraction techniques to decrease
muscle guarding, particularly in the quadriceps, and increase knee flexion
• Gentle stretches for the hamstrings, calf, and iliotibial band
• Pain modulation modalities
• Compressive wrap to control effusion
5
• Gait training
Phase II: Moderate-Minimum Protection: Weeks 3-6
Goals: Diminish swelling and inflammation

Increase ROM 0-115° or more
Increased dynamic joint stability/full weight bearing per implant status
Muscle strength 4/5-5/5
Return to functional activities
Adhere to home exercise program
Intervention:
• Interventions listed in Phase I

• Patellar mobilizations
• Tibiofemoral joint mobilization if appropriate and needed
• Soft tissue mobilization to quadriceps or hamstrings myofascia
• Incision mobilization after suture removal, when incision is clean and dry
• Progressive passive stretches to hamstrings, gastrocnemius, soleus, quadriceps within a
pain-free range
• Stationary bike or peddler without resistance to increase flexion ROM
• Pain-free progressive resisted exercises using ankle weights, theraband/tubing
• Proprioceptive training such as weight shifting, tandem walking, lateral stepping
over/around objects, obstacle courses, lower extremity proprioceptive neuromuscular
facilitation (PNF), front and lateral step-ups, closed-kinetic chain activities
• Closed-kinetic chain strengthening, such as ¼ squats, ¼ front lunges
• Gait training as needed to decrease limp, wean off assistive device
• Protected, progressive aerobic exercise, such as cycling without resistance, walking, or
swimming
Phase III: Return to Activity: Week 6 and beyond
Goals: Progress ROM 0-115° as able, to a functional range for the patient
Enhance strength and endurance and motor control of the involved limb
Increase cardiovascular fitness
Develop a maintenance program and educate patient on the importance of adherence,
including methods of joint protection
Intervention:
• Continue interventions of previous phases; advance as appropriate

• Implement exercises specific to functional tasks, such as transferring from sit-to-stand,
lifting, carrying, push/pulling, squat/crouching, return to work tasks, return to sport tasks
• Improve cardiorespiratory and muscle endurance with activities such as bicycling,
walking, or aquatic programs
6
Avramidis K, Strike P, Taylor P, Swain I. Effects of electrical stimulation of the vastus medialis
muscles in the rehabilitation of patients after total knee arthroplasty. Arch Phys Med Rehab.
2003;84:1850-1853.
D’Lima D, Colwell C, Morris B, Hardwick M, Kozin F. The effect of preoperative exercise on

total knee replacement outcomes. Clin Orthop. 1996;1(326):174-182.
Deyle G, Henderson N, Matekel R, Ryder M, Garber M, Allison S. Effectiveness of manual

physical therapy and exercise in osteoarthritis of the knee: A randomized controlled trial. Ann
Intern Med. 2000;132:173-181.
Fitzgerald G, Oatis C. Role of physical therapy in management of knee osteoarthritis. Curr Opin
Rheumatol. 2004;16:143-147.
Goodman C, Boissonnault W. Pathology: Implications for the Physical Therapist. Philadelphia,

W.B. Saunders Company, 1998.
Jones C, Voaklander DC, Suarez-Almazor ME. Determinants of function after total knee
arthroplasty. Phys Ther. 2003;83:696-706.
Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. Philadelphia, F.A.
Davis Company, 2002.
Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Comparison of clinic- and home-based
rehabilitation programs after total knee arthroplasty. Clin Orthop. 2003;1(410):225-234.
Kumar PJ, McPherson EJ, Dorr L, Wan Z, Baldwin K. Rehabilitation after total knee
arthroplasty: A comparison of 2 rehabilitation techniques. Clin Orthop. 1996;1(331):93-101.
Moore K, Dalley A. Clinically Oriented Anatomy, 4th ed. Baltimore, Lippincott Williams and
Wilkins, 1999.
Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol. What makes
the difference? J Arthroplasty. 2003;18(3):27-30.
Rodgers JA, Garvin KL, Walker CW, Morford D, Urban J, Bedard J. Preoperative physical
therapy in primary total knee arthroplasty. J Arthroplasty. 1998;13:414-421.
Vad V, Hong HM, Zazzali M, Agi N, Basrai D. Exercise recommendations in athletes with early
osteoarthritis of the knee. Sports Med. 2002;32(11):729-739.

Screen Knee Issues for Potential Serious Conditions

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Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems

Medical Screening for the Knee, Leg, Ankle or Foot Region

Joe Godges DPT KP SoCal Ortho PT Residency

NAME: ________________________________________ DATE: _____________

1. Have you recently experienced a trauma, such as a vehicle accident, a

2. Have you recently had a fever?

3. Have you recently taken antibiotics or other medicines for an

4. Have you had a recent surgery?

5. Have you had a recent injection to one or more of your joints?

6. Have you recently had a cut, scrape, or open wound?

7. Do you have diabetes?

8. Have you been diagnosed as having an immunosuppressive disorder?

9. Do you have a history of heart trouble?

10. Do you have a history of cancer?

12. Have you recently been bedridden for any reason?

13. Have you recently begun a vigorous physical training program?

Joe Godges DPT KP SoCal Ortho PT Residency

Knee Capsular Disorder

ICD-9-CM: 719.56 Stiffness in joint of lower leg, not elsewhere classified

Physical Exam: ROM loss - more loss of flexion than extension

ICD-9: 719.56 stiffness in joint of lower leg, not elsewhere classified

Etiology: It is considered a sequela of traumatic and age-dependent changes which result in a

Physical Examination Findings (Key Impairments)

Acute Stage / Severe Condition

• Restricted knee motion

Sub Acute Stage / Moderate Condition

As above with the following differences

• Lumbar, hip and ankle movement abnormalities

• Weak quadriceps femoris commonly vastus medialis

Settled Stage / Mild Condition

As above with the following differences

• Pain with repetitive activities of the knee especially at end range

Intervention Approaches / Strategies

Acute Stage / Severe Condition

Goals: Prevent movement induced inflammatory reactions.

• External Devices (Taping/Splinting/Orthotics)

• Re-injury Prevention Instruction

Sub Acute Stage / Moderate Condition

Goals: Improve tibiofemoral and patellofemoral mobility

Settled Stage / Mild Condition

Goals: Normalize tibiofemoral and patellofemoral mobility

• Approaches / Strategies listed above

Intervention for High Performance / High Demand Functioning in Workers or Athletes

Goal: Return to desired occupational or leisure time activities.

• Approaches / Strategies listed above

Rogind H, Bibow-Nielsen B, Jensen B, Moller H, Frimodt-Moller H, Bliddal H. The effects of a

Impairment: Limited and Painful Knee Flexion

Knee Flexion MWM

The following reference provides additional information regarding this procedure:

Impairment: Limited Knee Extension

Tibial Anterior Glide

The following reference provides additional information regarding this procedure:

Knee Muscle Power Deficits

“Patellofemoral Pain Syndrome”

ICD-9-CM: 719.46 Pain in joint - lower leg

History: Anterior knee pain

Patella Lateral Glide Patella Medial Glide

Cues Assess glides at varying degrees of knee flexion - up to about 30°

ICD-9-CM: 726.64 Patellar tendinitis

History: Anterior knee pain.

Patellar Tendon Palpation/Provocation

Iliotibial Band "ITB Friction Syndrome"

NAME: ____________________________ DATE: _