Manual Therapy Concepts for Knee Complex: @ 悟理治療部落

Knee 是一個synovial, hinge joint.

Knee的主要功能是mobility and stability. Femur 與tibia 是兩個long lever arms的骨頭, 它們會在knee joint 產生極大的力量且潛在對膝關節之ligament and cartilage有傷害之虞. 但是這樣的compressive forces也提供了weight bearing時的關節穩定度.

這個關節的受傷Mechanisms 通常包括瞬間的trauma 或長期的microtrauma.

通常

瞬間的過多的 torsional和 valgus/varus loads 也常擠壓傷害 meniscus, ligaments, 和造成patella mal-tracking or dislocation.

長期的microtrauma容易產生articular cartilage of the patella, chondral defects, iliotibial band syndrome, tendonitis, 和synovitis等傷害.

Knee Exercise Considerations: Open Kinetic Chain (OKC) versus Closed Kinetic Chain(CKC)

u Open kinetic chain (OKC) 是指末端肢體 free to move. 如踢球

u Closed kinetic chain (CKC) 是指末端肢體fixed。如蹲下.

1. 一般臨床上認為Closed kinetic chain (CKC)比較functional(尤其在下肢而言)所以常是我們knee rehabilitation的首選 (Mann (1980): running的swing phase 70%, and stance phase 30%. sprinting的swing phase 80%, and stance phase 20%. 所以CKC是較functional)

2. 除此之外，也要考慮受傷組織的生物力學特性，

l 例如squat會增加compressive loading和促進joint stability但是若太早給也會對meniscus和chondral bone產生傷害

l 例如 leg presss對ACL受傷缺損是重要的運動但是對PCL反而會產生adverse loads

l 此外研究顯示對patellofemoral dysfunction 而言Leg press比 squat 更能提高VMO to Vastus lateralis ratio. (Simonean, Wilk)

3. Anterior/posterior tibiofemoral shear forces (Wilk):

Open Kinetic Chain (OKC):

Knee flexion時，0-40 degrees ACL會備 loading，而 45-100 degrees則是PCL

Closed Kinetic Chain(CKC):

Squat and leg press (CKC): peak PCL load 發生在 knee flexion 90 degrees,且no load on ACL

MANUAL THERAPY CONSIDERATIONS：

ITB：The ITB tendon glides as the knee flexes and extends. 它作用在knee extension from 30-0 degrees 和knee flexion 40-135 degrees. 當Tibiofemoral screw home mechanism at 30-40 degrees 時ITB 是沒有影響的. 一般，ITB連到fibula後面很容易造成posterior subluxed fibular head with tibial external torsion甚至ankle inversion sprains. (常見proximal posterior tibiofibular restriction 和 anterior subluxed distal tibiofibular restriction，manual therapy對這兩種情形效果很好. )此外在治療的期間善用taping也可以達到很好的效果。"Fibula is the Link to the Foot and Ankle"
Pelvis (iliosacral, sacroiliac, and pubic symphysis)若有mechanical faults 存在也會影響knee joint.可使用manual therapy來restoring the pelvis間接治療knee joint.常見如Anterior rotated ilium會導致leg length discrepancy和vastus medialis看起來是atrophy
Hip Joint: hip capsular tightness會導致increased femoral internal rotation, excessive tibial external rotation, calcaneal eversion and foot supination.且Inhibition of the gluteus medius, hip external rotators.針對tight hip capsule進行mobilization並配合specific muscle strengthening會減少compensatory patterns.
Nerve: 很多anterior knee joint pain其實跟femoral nerve 之cutaneous branch有關，針對femoral nerve執行manual therapy會有不錯的效果。