3. • Knee joint is the largest and most complex joint.
• The upper bone is the femur and the lower bone is the tibia. The small
bone at the lateral side is the fibula. The knee cap (patella) is in front of
the knee.
• There are large muscles in the front of the thigh (the quadriceps) and back
of the thigh (the hamstrings).
• Ligaments join the knee bones and provide stability to the knee:
-The anterior cruciate ligament prevents the femur from sliding backward
on the tibia (or the tibia sliding forward on the femur).
-The posterior cruciate ligament prevents the femur from sliding forward
on the tibia (or the tibia from sliding backward on the femur).
-The medial and lateral collateral ligaments prevent the femur from sliding
side to side.
• Two C-shaped pieces of cartilage called the medial and lateral menisci act
as shock absorbers between the femur and tibia.
• Numerous bursa, or fluid-filled sacs, help the knee move smoothly.
(G. J Tortora, 2009)
4. PATHOPHYSIOLOGY
• Osteoarthritis is a deterioration and changes happened mostly at the knee
where articular cartilage that cushions the bones breaks down, and causes
the bones to rub together.
• Articular cartilage is living tissue. The growth and repair will decreases
with age.
• Elasticity and viscosity of synovial fluid changes as hyaluronic acid
concentration decrease.
• This results in the formation of ulcers that extend deep into the bones.
• The surfaces of the knee gradually "wear out“ and creates pain, swelling,
and stiffness.
• Weight-bearing activity becomes painful, often limiting physical activity.
• After a while bone spurs may form and ligaments and muscles around the
joint become weaker.
(OA health Center, 2009)
5.
6. Total Knee Replacement
• Osteoarthritic of the knee is the commonest reason which
necessitates knee replacement.
• Total knee replacement (TKR) is a surgery where only the worn-out
cartilage surfaces of the joint are replaced.
• The operation (also called knee arthroplasty) is basically a "re-
surfacing“ of the knee joint because only the surface of the bones
are actually replaced.
• When the patient having a TKR, the surgeon removes damaged
cartilage and bone from the surface of the knee joint and replaces
them with a man-made surface of metal and plastics.
• A small amount of bone is removed, the collateral ligaments are left
intact, and the muscles and tendons are left intact.
(AAOS, 2011)
7.
8.
9.
10. Clinical Presentation
• Pain is felt around the knee join
• Joint stiffness usually lasts less than 20 minutes
• Limitation of movement
• Loss of function
• Affected joints may have tenderness and firm swellings at the joint
• Decreased range of motion (ROM).
• Worse with weight bearing and ambulation.
• May be cartilaginous crepitus or a crackling feeling on palpation. There
may be coarse.
• Malalignment of the leg with a varus deformity or bow-legged positioning
of the leg d/t loss of cartilage.
(OA health Center, 2009)
11. Dr Management
• Other treatment options before surgery :
i) Medications : NSAIDs
ii) Medications injected into the joint : Corticosteroid injections fight
inflammation
iii) Creams or ointments to rub onto the skin
iv) Exercise and physical therapy : Exercise strengthens the muscles that
support the knee
v) Weight loss : Every pound a person gain puts an extra 3 pounds of pressure
on the knees
vi) Nutritional supplements
• If these treatment options don't relieve the pain well, less effective, not tolerable,
the doctor may suggest surgery.
i) arthroscopic surgery : involves small incisions to remove pieces of
cartilage and trimmed the damage tissue to
smoothen the joint surfaces
ii) knee replacement surgery : replacing the damaged parts with an
artificial joint. These are made of metals and plastics
(OA health Center, 2009)
12. PT Management
• Exercise to improve strength, flexibility balance and maintain joint motion
• Electrotherapy
• Taping
• Use of a knee brace or compression bandage
• Ice or heat treatment
• Hydrotherapy
• Education
• Anti-inflammatory and supplement advice (e.g. glucosamine and
chondroitin)
• Weight loss
( Leonard Ong Yao Jian, 2011)
14. Subjective Assessment
Name : Mrs. J
Age : 60 years old
Gender : Female
R/N : AS00******
Location : Outpatient ( Gymnasium)
D.O.A : 28/04/2013
D.O.R : 04/02/2013
Race : Indian
Dr. Diagnose : Bilateral knee OA
Dr. Mx : TKR Rt knee. Planned for Lt knee 6 months after.
15. Patient’s Problem :
1. Pt c/o mild uncomfort at both knee during walking
2. Pt c/o need mild assisstance during sitting to standing
3. Pt c/o need assisstance to climb up stairs
16. BODY CHART
VAS : (Rt) 0/10- rest
3/10- on movement
(Lt) 0/10- rest
4/10- walking
Agg : bend Rt knee towards
90°
Ease : rest/sitting
Nature : pulling pain on both
side posterior thigh
Irritability : low
24 h : intermittent pain
(depends on movt) TKR incision site
17. Current History : Pt done post TKR for Rt knee on 29/01/2013. Having
complicated patella tendon medial 30% tear on Rt knee
during manipulation, repaired with prolene 2/0. After 3
months, pt able to walk without walking aids. She is having
good improvement. Pt is not allowed to do Rt knee flexion
more than 90° yet. Doctor planned for Lt knee TKR, 6
months after the Rt side which is on Aug 2013.
Past History : Having bilateral knee OA since 2011. Intraarticular injection
hyaluronic acid was given 1x on 31/10/2011 but was not
helpful. No history of fall or accident.
PM History : Rt breast carcinoma. Done mastectomy and axillary clearance
on 2009. on follow-up every 6 months
- on T.tamoxifen 20mg OD
18. Special Question
General health: healthy
Weight loss : nil
Smoking : nil
Social History
Occupation : Retired officer
Status : Married. Having 2 daughters and a son.
House Environment : single storey house – staying with husband and a
daughter
Activities : Indoor activities. Not involved any vigorous activities.
19. Observation
General : A medium sized old Indian lady came to department
independently. Walking without aids. Walking with
slight limping gait towards Lt side, slow and careful.
Looks healthy and cooperative.
Local : No swelling, no redness, no dry skin on both knee.
Palpation : No warmness, no tenderness, no muscle spasm on
both knee
20. Objective Assessment
Range of Motion (ROM)
Joint Movement Rt active Rt passive Lt active Lt passive Normal
Hip Flexion AFROM - AFROM - 0-120°
Extension “ - “ - 0-20°
Abduction “ - “ - 0-45°
Adduction “ - “ - 0°
Knee Flexion -10°-75° -10°-75° -40°-90° -40°-90° 0-120°
Extension Ext lag
10°
- Ext lag
40°
- 0°
Ankle Dorsiflexion AFROM - AFROM - 0-20°
Plantarflexion “ - “ - 0-50°
Int : Reduce joint ROM both knee d/t pain and muscle tightness
22. Muscle Bulk
From base of
patella
Rt (cm) Lt (cm) Differences
5 cm (VMO) 51.0 51.5 0.5
10 cm
(Quadriceps)
53.0 53.0 0
15 cm
(Hamstrings)
55.0 55.0 0
From apex of
patella
13 cm
(Gastrocnemius)
41.5 40.5 1.0
Int : Normal muscle bulk for both LL
23. Patella mobility
Movement Rt Lt
Superior glide Less mobile Crepitus
Inferior glide Less mobile Crepitus
Medial glide Less mobile Crepitus
Lateral glide Less mobile Crepitus
Int : Crepitus found on Lt knee d/t degenerative changes
Less mobile of patella on Rt knee d/t lack of activities
24. Sensation test : Hot and Cold
Special test
Lt Knee
Patella Grinding Test : +ve
Dermatome Rt Lt
L1 Intact Intact
L2 “ “
L3 “ “
L4 “ “
L5 “ “
S1 “ “
S2 “ “
S3 “ “
Int: Skin sensation intact on both LL
25. Analysis Problem
Impairment Functional limitations Participation restrictions
Pain at Lt knee d/t
degenerative changes
Unable to sit on the floor Unable to join family
gathering
Reduce patella mobility on
both Lt knee d/t
degenerative changes
Difficult to perform sitting
to standing from the chair
Difficult to meet friends
and attend event
Reduce Rt and Lt joint ROM
knee flexion and extension
d/t prolonged immobilize
Difficult to perform sitting
to standing from the chair
Difficult to meet friends
and attend events
Reduce muscle strength for
Rt and Lt knee flexor and
extensor d/t muscle
weakness
Difficult to climb up stairs Feel uncomfortable to go
shopping
Limping gait d/t uneven
weight bearing caused by
pain
Unable to walk fast Feel tired to walk far and
involved in any activities
26. Short Term Goal
1. To reduce pain on Lt knee from 2/10 to 0/10 within 1/7
2. To improve joint ROM for Rt and Lt knee flexion and extension within
1/12
3. To reduce hamstring tightness on both knee within 1/12
4. To improve muscle strength for Rt and Lt knee flexor and extensor within
3/12
5. To improve walking pattern within 6/52
6. To maintain balance and weight bearing within 2/12
Long Term Goal
1. To optimize maximum functional activity and improve ADL such walking
and sitting to standing.
27. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
Pain Management
- Heat modalities
i) Hot pack
To reduce pain & improve
blood circulation of Lt knee
-Pt. in long sit.,apply hot
pack on skin of Lt knee, 20
mins.
The effects of
thermotherapy are used
clinically to control
pain,increase soft tissue
extensibility and accelerate
healing.
(Cameron M. ,2009)
Therapeutic Exs
- Active exs
i) Knee flexion and
extension
- pt sitting on chair,
perform knee flexion and
extension actively; 20x;
3reps, 2x/day
‘Exercise to improve or
eliminate impairments in
thigh muscle flexibility and
strength,
and improve performance
of endurance activities with
repetitions.’ (James
Rainville, MD,2004)
28. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
- Stretching exs i) Hamstring stretch
To reduce hamstring
muscle tightness
-Pt in long sit., towel at
sole with both end hold by
both hand, elevate leg till
feel stretch at hamstrings,
perform both LL, hold 15
secs, 15 mins
ii) TA stretch
to maintain ankle joint
ROM
-Pt in long sit., towel at
sole with both end hold by
both hand, pull the end
towel to stretch the TA,
perform both LL, hold 15
secs, 15 mins
Holding stretches for 15
seconds, as opposed to five
seconds, may result in
greater improvements in
active ROM. ( Roberts J M,
1999)
29. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
- Strengthening exs i) IRQ
To improve quadriceps
muscle strength
-Pt. in long sit., both
below knee supported
with tumble foam, do
alternate IRQ, 10 secs,
hold, 15 mins
ii) VMO with ball
To maintain VMO
strength
-Pt. in high sitt., put a
soft ball between thigh,
ask pt. to squeeze the
ball, lift up both leg, hold
10 secs, 15 mins
For most tears, some
simple exercises can help
maintain muscle strength
in the front of the thigh
(quadriceps), back of the
thigh (hamstrings), calf,
and hip.
( Freddie H. Fu, 2010)
30. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
Pt Education - Avoid to put more stress
on Lt knee that may trigger
the pain
- Advice on wearing knee
guard
HEP Continue exs as taught at
home
31. Evaluation
1. Pt able to follow command and understands the treatment
2. Pt not complained any uncomfortable during exercise
3. Pt can tolerate with the exercise given and willing to continue exercise at
home
32. Review
Planned to have next follow- up on 21/05/2013
• KIV for posture analysis
• Reassess on pt. both knee pain
• Reassess on pt. ROM and muscle power for both knee
• Reassess on pt. walking pattern for both LL
• Continue all treatment done on next visit within pt toleration.
33. Follow Up
21/05/2013
S : i) Pt told that pain had reduced on Rt knee when walking from 2/10
to 0/10
ii) Pt c/o slight unstable during walking towards Lt side
ii) Pt c/o pain at Lt knee had worsen with vas 4/10 when walking
iv) Pt still claims of pulling pain at posterior thigh especially when get up from
sitt.
O : Pt came to department independently w/o walking aids. Able to drive
auto car alone. Her limping gait obviously seen d/t Lt knee had worsen the
pain. Looks healthy and cooperative. She brought along referral letter from Dr
to allow Rt knee flexion towards 90°.
Palpation : no swelling, tenderness, redness, dry skin on both knee
34. Posture
Anterior view : Left sh. is slight lower than right sh.
Lt ASIS is lower than Rt ASIS
Lt knee is not align with Rt knee
Lt knee not fully extended
Posterior : Lt scapula is slight lower than right side
Lt sh is lower than Rt sh.
Lt popliteal lower than Rt popliteal
Weight bearing more on Rt LL
Lateral : Both knee not fully extended – Lt side more flexed than Rt side
35. ROM
MMT
Joint Action Rt active Rt passive Lt active Lt passive
Knee Flexion -5°-80° -5°-80° -35°-90° -35°-90°
Extension -5° -5° -35° -35°
Int : Reduce joint ROM for both knee flexion and
extension d/t pain and muscle tightness
Muscle Rt Lt
Knee flexor 4/5 4/5
extensor 4/5 4/5
Int : Reduce muscle power knee flexor and
extensor both knee d/t muscle weakness
36. Patella mobility
Muscle Bulk same as previous AX
A :
I. Pain at Lt knee d/t degenerative changes
II. Reduce joint ROM for Rt and Lt knee flexion d/t pain and muscle
tightness but has improves from last visit
III. Reduce muscle power for Rt and Lt knee flexor and extensor d/t muscle
weakness
IV. Abnormal posture d/t muscle tightness and pain of Lt LL
37. Short Term Goal
1. To reduce pain on Lt knee from 3/10 to 1/10 within 1/7
2. To improve joint ROM for Rt and Lt knee flexion and extension
within 1/12
3. To reduce hamstring tightness on both knee within 1/12
4. To improve muscle strength for Rt and Lt knee flexor and extensor
within 2/12
5. To improve walking pattern within 6/52
6. To maintain balance and weight bearing within 2/12
7. To correct posture within 6/52
Long Term Goal
1. To optimize maximum functional activity and improve ADL such
walking and sitting to standing.
38. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
Pain Management
- Heat modalities
i) Hot pack
To reduce pain & improve
blood circulation of Lt knee
-Pt. in long sit., apply hot
pack on skin of Lt knee, 20
mins.
The effects of
thermotherapy are used
clinically to control pain,
increase soft tissue
extensibility and accelerate
healing.
(Cameron M. ,2009)
Therapeutic Exs
- Stretching exs
i) Hamstring stretch
To reduce hamstring
muscle tightness
-Pt in long sit., towel at
sole with both end hold by
both hand, elevate leg till
feel stretch at hamstrings,
perform both LL, hold 15
secs, 15 mins
‘Exercise to improve or
eliminate impairments in
thigh muscle flexibility and
strength,
and improve performance
of endurance activities.’
(James Rainville, MD,2004
39. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
- Active exs i) Knee flexion
To improve knee ROM
- Pt side ly on Lt side,
perform Rt knee flexion
actively, 20x; 3 reps/day
ii) Bean ball for knee flexion
- pt sup ly, bean ball under
both popliteal, actively
perform knee flex and ext;
20x
Active range-of-motion
exercises for the knee may
reinforcing, with repeated
gentle challenges to the
end ranges of movement in
Osteoarthritis of the Knee.
( Deyle, G D, 2000)
- Strengthening Exs i) Quad bench
To strengthen the quad
muscles
- pt sitt on quad bench,
weight 1kg, hold for 8 secs,
perform for both LL, 15mins
After acute symptoms
subsided, exercises should
be performed in open chain
and closed chain positions
to improve strength and
endurance in isolated
muscle groups and to
prepare the patient for
functional activities. (Kisner
C. & Colby L. A.,2007)
40. PLAN OF TREATMENT INTERVENTION EVIDENCE BASED
ii) Hamstring bench
To improve ROM of knee
flexion.
pt sitt on hamstring bench,
weight 1kg, hold for 8 secs,
perform for both LL,
15mins
Pt Education Avoid to put more stress
on Lt knee that may trigger
the pain
- Advice on wearing knee
guard
HEP Continue exs as taught at
home
Evaluation
1. Pt able to follow command and understands the treatment
2. Pt not complained any uncomfortable during exercise
3. Pt can tolerate with the exercise given and willing to continue exercise
at home
41. Review
1. Reassess on pt ROM and muscle power for both knee
2. Reassess on Lt knee pain
3. Reassess on pt. walking pattern for both LL
4. Continue all treatment done on next visit with pt toleration.
42. Conclusion
Total knee replacement has proven to be successful and beneficial to
modern surgery. Even not all patients with osteoarthritis get back their
normal knee actions as normal person, but most patients enjoy many
years of painless knee function with no limits on their ability to stand,
walk and perform other activities of normal daily living.
The rehabilitation programme may takes time but the effectiveness of
TKR more or less will depends on the patients compliance itself. The
most important thing is the physicians have to let the patients know
that TKR is a life-enhancing surgery, not life-saving surgery.
43. References
• Anonymous (n.d). Total knee replacement, Joint Replacement Institute, St Vincent
Medical Center. Retrieved May 1, 2013 http://www.jri-
docs.com/knee/KneeReplace ment/Resources /Pages/TheGoalsofTotalKnee
Replacement.aspx
• Anonymous, (2011). Total knee replacement, American Academy of Orthopedic
Surgeon. Retrieved May 2, 2013,
http://orthoinfo.aaos.org/topic.cfm?topic=a00389
• Anonymous, (2012). Total knee replacement, Southern California Orthopedic
Institute. Retrieved May 10, 2013, http://www. scoi .com /total-knee-
replacement.php
• Carolyn Kisner and Lynn Allen Colby (2002). Therapeutic Exercise, Foundations and
Techniques. 5th Ed. Davis Company, Philadelphia.
• G. J. Tortora and B. H. Derrickson (2009).Principles of anatomy and physiology. 12th
Ed. John Wiley and Sons, Inc.
• Palmer S.H. (n.d). Total knee replacement. Retrieved May 12, 2013,
http://www.kneeclinic.com.au/papers/TKR/tkrchapter.htm
• Zelman, D. (2013). Knee Osteoarthritis: When to Consider Surgery. Retrieved April
30, 2013, Webhttp://www.webmd.com/osteoarthritis/osteoarthritis-knee-
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