Ordinarily, people see knee movement in bending (flexion) and straight (extension) that looks like one joint motion. In fact, basic knee complex bone anatomy includes femur, tibia, and patellae. The term knee complex was named due to it combining more than one joint. The knee complex is two articular joints that consists of a tibiofemoral and a patellofemoral joint.
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| Knee motion in daily living (Ref: https://www.crossfit.com/) |
The patellofemoral plays an important role in the tibiofemoral motion. The tibiofemoral provides knee flexion and extension mainly. To complete knee biomechanics, patella or kneecap has to glide during knee flexion and extension that is related to the lever.
Knee injury including intra - articular and extra - articular structure which develop patellae hypomobility or limited kneecap motion can affect knee bending and straight limitation.
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| Knee joint anatomy (Ref: https://www.sportssurgerychicago.com/) |
Patellofemoral joint pain (PFP) is one of the most common conditions presented to the sports physical therapist. Disorders of this articulation are found in a variety of active individuals including runners, tennis players, and military personnel. Females tend to report more patellofemoral pain due to numerous speculations for this reason.
I have always given patellar mobilization in patients with kneecap pain and knee bending and straight limitation that stretching could not achieve motion, to decrease pain and increase knee range of motion.
Basic biomechanically, the kneecap glides upward in knee straight whereas the kneecap seem gliding downward in knee bending.
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| Kneecap gliding related tibiofemoral function (Ref: https://doctorlib.info/) |
I have arranged the mobilization for chronic patellar tendinitis, post ACL reconstruction, post PCL reconstruction, knee OA, Total Knee Replacement, stable lateral patellar dislocation, and ITB syndrome.
The basic kneecap mobilization
Exercise #1: self massage around kneecap.
Exercise #2: Upward gliding (from toe to head direction): for improving knee straight.
Exercise #3: Downward gliding (from head to toe direction): for improving knee bending.
Exercise #4: Lateral gliding (from big toe side to little toe direction): for stretching medial patellofemoral ligament that I hardly glide to this direction.
Exercise #5: Medial gliding (from little toe side to big toe direction): for stretching lateral patellofemoral ligament and insertion of ITB. Because patellar lateral glide is more opportunity than medial glide from muscle imbalance or external force. I often glide to this direction in patients with lateral patellar dislocation and ITB syndrome.
The tibiofemoral joint
This joint is a connection of the tibia and femur that is the biggest of the knee complex. This joint not only provides flexion and extension motion but also allows transmission of body weight from the femur to the tibia while providing hinge-like, sagittal plane joint rotation along with a small degree of tibial axial rotation. To image a hinge joint is like a swing type door or window.
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| Tibiofemoral joint anatomy consists of femur (thigh bone) and tibia (shin bone) (Ref: https://www.lecturio.com/) |
Functionally, the quadriceps muscle group and patellofemoral articulation—along with the tibialis anterior and ankle joint—act to dissipate forward momentum as the body enters the stance phase of the gait cycle. Hamstring group works behind this joint for bending the knee i.e. stepping during walking or running, up - down stairs. Additionally, hamstring provides assisted tibia rotation and prevents tibia forward translation. Tibia forward translation prevention too far can damage an ACL that can say hamstring is ACL knight. ITB is one that involves the knee joint, it provides lateral knee stability and tibia rotation.
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| Hinge joint like (Ref: https://brainly.in/) |
Tibiofemoral joint effusion can be caused by ACL injury, PCL injury, Meniscus injury, cartilage injury, post operative ACL, post operative PCL, post operative meniscus, and knee articular replacement. The effusion can limit joint motion especially slightly knee flexion. Slightly knee flexion is the result of arthrogenic muscle inhibition (AMI) and increased joint space compensation.
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| Gliding related ACL and PCL injury (Ref: https://www.kneeandshouldersurgery.com/) |
Ice compression to control effusion in this joint is one important component to increase range of motion. Sometimes, it needs tibiofemoral joint or patellofemoral joint mobilization to help range of motion improvement.
The patellofemoral joint
The patellofemoral joint consists of femur and patella (kneecap). The patellofemoral articulation is commonly referred to as the extensor mechanism. Although true that the concentric action of this motor unit is extension of the knee, functionally, the quadriceps acts eccentrically during gait, running, or jumping.
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| Patella in trochlea groove of femur (femoral sulcus) (Ref: http://kneereplacements.co.uk/) |
The patella is the largest sesamoid bone in the body. Described in more detail in the section that follows, the patella is invested in the retinacular layer of the extensor mechanism receiving direct insertion of the deeper layer of the patellar tendon distally and the vastus intermedius proximally.
Concave on its superficial surface, the articular surface of the patella contains a vertical central ridge that separates a broader lateral facet from a medial facet and a smaller, more medial odd facet. The patella articulates with the femoral sulcus or anterior articular surface of the distal femur, which is a coalescence of the medial and lateral femoral condyles. Matching the patella, the lateral portion of the femoral sulcus is relatively broader and contains a higher lateral ridge than the medial portion. This topography ascribes some bony stability to the joint when the patella is engaged in the sulcus at an angle of approximately 45 degrees of knee flexion.
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| Patella bone (kneecap) (Ref: https://www.theskeletalsystem.net/) |
The patellar tendon extends from the inferior pole of the patella and inserts on the tibial tubercle. Proximal to the tubercle it is separated from the underlying tibia by the infrapatellar tendon bursa. The patellar tendon comprises a superficial layer, which is contiguous with the retinacular layer, and a deeper layer, which is again the deep layer of the extensor mechanism. In the substance of the patellar tendon, these layers are largely adherent, much as the subscapularis tendon is to the anterior capsule of the shoulder joint.
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| Involved tendon of kneecap: quadriceps tendon (above kneecap) and patellar tendon (below kneecap) (Ref: https://orthoinfo.aaos.org/) |
Some of my patients who got lateral knee pain or medial kneecap border pain from patellar lateral glide. This gliding is able to give shear force to medial patellofemoral ligament which are small connecting ligament between kneecap and femur. Moreover, the patellofemoral cartilage can be degenerated by lateral glide that develop to be patellofemoral pain syndrome afterward. Pushing kneecap toward to little to side direction is a part of lateral knee pain rehabilitation.
If necessary, I have always recommend my patients to do self kneecap mobilization as home base program. cannot achieve full flexion or extension.
Reference:
http://courses.washington.edu/bioen520/notes/Knee_Anatomy_&_Biomechanics_%28Flandry%29.pdf
https://onlinelibrary.wiley.com/doi/pdf/10.1002/jor.24120
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095937/
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