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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。
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