Strengthening the Knee After a Partial Meniscal Tear & Subluxation of the Patella

Hailey Bisschoff

May 30, 2019 Global Comprehensive Program 2018-2019

Tsawwassen Wellness Center, 5133 Springs Blvd #120, Vancouver, BC

2

Abstract

The menisci are two very critical components of the knee joint, as they help to mobilize

and stabilize the knee during load-bearing, load transmission and shock absorption, by

spreading the weight of the body equally throughout the knee. Both the medial and lateral

menisci are thin pieces of cartilage which are found between the femur (thighbone) and tibia

(shinbone). The menisci also help to prevent deterioration of the articular cartilage by

lubricating the joints in the knee – ultimately working to prevent osteoarthritis. Movements

such as cutting, twisting, or hyperextension are often the cause of meniscal tears and are often

accompanied by Anterior Cruciate Ligament Tears. In this case, the meniscal tear was caused by

a sudden rotation of the femur on a fixed tibia while the knee was in flexion.

The patella (kneecap) is a small bone that sits in between two grooves called the

femoral condyles, in the front of the knee joint. It serves as a connection point for the muscles

in the front of the thigh and the tibia, allowing for flexion and extension of the knee. It also

helps to protect the knee. A subluxation of the patella is a temporary dislocation of the kneecap

from its anatomically correct position – meaning the bone has slipped out from between the

two grooves, in this case, towards the lateral side of the knee.

3

Table of Contents

2) Abstract

3) Table of Contents

4) Anatomical Description of the Knee

9) Case Study

11) BASI Conditioning Program

15) Conclusion

16) Bibliography

4

Anatomical Description of the Knee

The image below portrays an anterior view of the knee with the knee cap removed,

showing that the knee is the connection point between the upper leg (femur) and lower leg

(tibia and fibula). The menisci (medial and lateral) are two pieces of cartilage found in between

the femur and tibia.

The Medial Collateral Ligament (MCL), found on the inside of the knee, helps support

the connection of the femur and tibia. The Lateral Collateral Ligament (LCL), found on the

outside of the knee, helps support the connection of the femur and fibula. The Posterior

5

Cruciate Ligament (PCL) is the ligament located in the inner backside of the knee that helps

connect the femur and tibia, and it prevents the tibia from moving too far backwards. The

Anterior Cruciate Ligament (ACL) is the ligament found in the inner front of the knee that helps

to connect the femur and tibia, preventing the tibia from sliding out in front of the femur and

providing rotational stability of the knee. The PCL and ACL cross each other diagonally, creating

an “X” shape within the knee joint.

The image below shows the knee from a lateral view. Here we see the location of the

patella (knee cap), sitting in front of the femur and above the tibia.

6

The image below shows the lateral femoral condyle, which is found on the outside of

the knee, and the Medial Femoral Condyle, which is found on the inside of the knee. The knee

is a synovial hinge joint – allowing the movement of two or more bones along one axis to flex

and extend. One of the purposes of the Femoral condyles is to create a divot for the patella to

sit in, allowing for the hinge movement to occur. The femoral condyles also connect to both the

lateral and medial menisci in the knee.

7

The image shown below portrays a subluxation of the patella. In the top diagram, we

can see that the patella (knee cap) has moved from its normal position between the femoral

condyles towards the outside of the knee. The bottom image shows the patella in its

anatomically correct position.

8

There are several different types of meniscal tears. The image below shows the type

that my client experienced, a radial meniscal tear, which is a single slit in the meniscal cartilage.

9

Case Study

My client, Jon Bear, is a 28-year-old male who suffered a knee injury three years ago.

The injury arose while he was up to bat at baseball. As he swung, his leg rotated, but the knee

didn’t follow. Jon went directly to the hospital and was sent for x-rays, where they found a

partial radial tear of the lateral meniscus and subluxation of the patella. He was not referred for

any surgical procedures, as the tear was partial. He was however, referred to a physio therapist,

who he saw for several months and was told to wear a knee brace as well. Since the incident,

Jon has experienced great weakness in his knee and pain when engaging in activities like

climbing stairs, running and squatting. He is a moderately active person who has recently

realized the importance in restoring the strength of his knee in order to prevent further injury

and deterioration of the knee joint. Jon is now a university student, which requires him to be

sitting for many hours of the day. He is also a father to his 1.5-year-old son, which requires him

to be on the floor, chasing after his son and moving from a squat-to-stand position frequently.

After my first few sessions with Jon, we discovered where some of his weaknesses are

and built goals to strengthen them through the Pilates practice. We will be working to

strengthen the muscles surrounding and supporting the knee joint in hopes to support proper

alignment of the knee. A key component in achieving this is to strengthen the abdominals and

back muscles, as they support stability and mobility of the body as a whole. During Jon’s

postural and gait assessment, I noticed slight Genu Valgum (knock knees) – a lateral deviation

10

of the distal tibia relative to the knee. Therefore, will be working on strengthening the internal

rotators and stretching the external rotators. The primary movers of knee flexion are the

hamstrings (semimembranosus, semitendinosus, biceps femoris) and we will therefore work to

strengthen and stretch these muscles. The primary movers of knee extension are the

guadriceps femoris (rectus femoris, vastus medialis, vastus intermedius, vastus lateralis), so we

will be working to strengthen and stretch these muscles as well. Jon is a new client who is not

very familiar with Pilates and does not engage in physical activity very often. Therefore, I am

starting his program with more foundational BASI exercises in hopes to improve strength and

stability that will benefit his body on a daily basis. Advanced and master exercises will be

omitted from his program until a later date when he has built enough strength and body

awareness.

11

BASI Conditioning Program

BLOCK EXERCISE MUSCLE

FOCUS

OBJECTIVE NOTES

Warm Up - Pelvic Curl - Spine Twist Supine - Chest Lift - Chest Lift w/ Rotation

- Abdominals - Hamstrings - Abdominal obliques

- Spinal articulation - Hamstring control - Pelvic lumbar stabilization - Spinal rotation - Abdominal control w/ oblique emphasis - Abdominal strength - Pelvic stability - Abdominal strength w/ oblique emphasis

* strengthening the hamstrings to support knee function and mobility * teaching the core stabilizer muscles to engage and support the body when in rotation – hoping

Foot Work - Parallel Heels - Parallel Toes - V Position Toes - Open V Heels - Open V Toes - Calf Raises - Prances - Prehensile - Single Leg Heel - Single Leg Toes

- Hamstrings - Quadriceps - Foot plantar flexors

- Hip extensor strength - Knee extensor strength - Warm Up - Ankle plantar flexor strength - Foot stretch

* strengthening the hamstrings, quads & calves to support movement of the knee * working the knee extensors to support knee movement * Working to improve range of motion of the knee

12

Abdominal Work

- Hundred Prep - Coordination

- Abdominals - Abdominal strength - Shoulder extensor control - Pelvic lumbar stabilization

* Training the body to stabilize through the core while the legs are moving

Hip Work - Frog - Circles (down, up) - Openings

- Hip adductors - Hamstrings

- Hip adductor strength - Knee extensor control - Pelvic lumbar stabilization - Hip extensor control - Hip adductor stretch

* Strengthening the hamstrings to support movement of the knee * Training the body to stabilize through the core while the legs are moving

Spinal Articulation

- Bottom Lift - Bottom Lift w/ Extension

- Abdominals - Hamstrings

- Spinal Articulation - Hip extensor strength - Hip extensor control

* Strengthening the hamstrings and glutes to support movement of the knee * Stabilizing the hips by engaging the deep core muscles

Stretches - Standing Lunge - Hamstrings - Hip flexors

- Hip flexor stretch - Hamstring stretch

* Stretching the hamstrings, quadriceps and hip flexors to support optimal knee function

Full Body Integration (F/I)

- Scooter - Up Stretch 1

- Abdominals - Back Extensors

- Trunk stabilization - Shoulder stabilization - Hip extensor control/strength - Knee extensor control/strength

* Strengthening the knee extensors to support knee movement * Strengthening balance

13

- Hamstring stretch - Shoulder stretch

*Stretching the hamstrings to support optimal knee movement

Arm Work * Arms Standing Series - Chest Expansion - Hug-A-Tree - Circles (Up, down) -Punches - Biceps - Butterfly Arms

- Latissimus dorsi - Pectorals - Shoulder extensors - Shoulder horizontal adductors - Triceps - Biceps - Abdominal Obliques

- Strengthen shoulder extensors - Trunk stabilization - Shoulder horizontal adductor strength/stretch - Scapulae control - Increase range of motion in shoulder joint - Elbow extensor strength - Elbow flexor strength - Stretch anterior aspect of the shoulder - Abdominal oblique stretch/control

* Stabilizing through the core muscles while the arms move * Strengthening balance

Full Body Integration

(A/M)

OMIT UNTIL SESSION 21+

OMIT UNTIL SESSION 21+

OMIT UNTIL SESSION 21+

OMIT UNTIL SESSION 21+

Leg Work * Single Leg Side Lying Series - Changes - Scissors - Circles (Forward, backward)

- Hip Adductors - Hip Extensors - Hip Flexors

- Hip adductor strength - Pelvic lumbar stabilization - Hip joint range of motion - Hip extensor stretch - Hip flexor stretch

* Strengthening the hips and improving range of motion of hips * Stretching the hip flexors/extensors to support movement in the leg

14

* Training the body to stabilize through the core while the legs are moving

Lateral Flexion/ Rotation

- Mermaid - Abdominal obliques

- Spinal mobility - Scapulae stabilization

* Stretching through the side body * Strengthening the obliques to support rotational movement

Back Extension - Pulling Straps 1 - Pulling Straps 2

- Back Extensors - Back extensor strength - Shoulder extensor strength - Shoulder adductor strength

* Strengthening through the co-contraction of the back extensors and abdominals

15

Conclusion

After applying the above BASI conditioning program twice a week for 20 weeks (with

variations), we can confidently say that Jon has more strength and stability in his knee. Jon says

that he feels his knee is able to support him in his daily movement much more than it could

before. He plans to continue his journey with Pilates to advance the progress he has already

seen with his meniscal and patellar injury. Jon plans to implement a Pilates conditioning class

into his schedule weekly, along with other forms of exercise. This goes to show that it’s never

too late to start rehabbing a past injury through the Pilates practice, as we have seen great

results with Jon from his injury that took place three years ago. Without going through any

surgical procedure, Jon now has a better range of motion in the knee joint, with much less pain

during activities that used to cause him discomfort. He feels a deeper strength within his body

as a whole because we made effort to improve his overall strength in hopes to better support

his knee. His back and abdominal muscles have been strengthened, which are helping to carry

his body in a more functional way. All of the muscles in the leg have been trained to help

support the movement of the knee, and hopefully prevent any movement outside of the proper

range of motion of the knee joint. It is great to see Jon making a steady recovery and I look

forward to continue working with him to support his knee and bring further improvement to his

body strength and mobility.

16

Bibliography

1. Cox, Chandler F., and John B Hubbard. “Anatomy, Bony Pelvis and Lower Limb, Knee Patella.” StatPearls [Internet]., U.S. National Library of Medicine, 6 Dec. 2018, www.ncbi.nlm.nih.gov/books/NBK519534/.

2. Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, 2013.

3. ISACOWITZ, RAEL. CLIPPINGER, KAREN SUE. CLIPPINGER, KAREN. Pilates Anatomy: Your Illustrated Guide to Mat Work for Core Stability and Balance. HUMAN KINETICS, 2019.

4. “Knee Dislocation and Instability in Children - OrthoInfo - AAOS.” OrthoInfo, Pediatric Orthopaedic Society of North America, Feb. 2019, orthoinfo.aaos.org/en/diseases--conditions/patellar-dislocation-and-instability-in-children-unstable-kneecap/.

5. Summit Medical Group. “Kneecap (Patellar) Subluxation.” Summit Medical Group, RelayHealth, 2014, www.summitmedicalgroup.com/library/adult_health/sma_subluxing_kneecap/.

6. Makris, Eleftherios A, et al. “The Knee Meniscus: Structure-Function, Pathophysiology, Current Repair Techniques, and Prospects for Regeneration.” Biomaterials, U.S. National Library of Medicine, Oct. 2011, www.ncbi.nlm.nih.gov/pmc/articles/PMC3161498/.

7. “Posterior Cruciate Ligament Injuries - OrthoInfo - AAOS.” OrthoInfo, American Academy of Orthopaedic Surgeons, 2009, orthoinfo.aaos.org/en/diseases--conditions/posterior-cruciate-ligament-injuries/.

8. Wood, Samantha. Pilates for Rehabilitation: Recover From Injury and Optimize Function. Human Kinetics, 2019.