Chapter 20: The Knee and Related Structures

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Chapter 20 The Knee and Related Structures
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• Complex joint that endures great amounts of
  trauma due to extreme amounts of stress that are
  regularly applied
• Hinge joint w/ a rotational component
• Stability is due primarily to ligaments, joint
  capsule and muscles surrounding the joint
• Designed for stability w/ weight bearing and
  mobility in locomotion

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Functional Anatomy

• Movement of the knee requires flexion, extension,
  rotation and the arthrokinematic motions of
  rolling and gliding
• Rotational component involves the screw home
  mechanism
• As the knee extends it externally rotates because
  the medial femoral condyle is larger than the
  lateral
• Provides increased stability to the knee
• Popliteus unlocks knee allowing knee to flex

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• Capsular ligaments are taut during full extension
  and relaxed w/ flexion
• Allows rotation to occur
• Deeper capsular ligaments remain taut to keep
  rotation in check
• PCL prevents excessive internal rotation, guides
  the knee in flexion, and acts as drag during
  initial glide phase of flexion
• ACL stops excessive internal rotation, stabilizes
  the knee in full extension and prevents
  hyperextension

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• Range of motion includes 140 degrees of motion
• Limited by shortened position of hamstrings, bulk
  of hamstrings and extensibility of quads
• Patella aids knee during extension, providing a
  mechanical advantage
• Distributes compressive stress on the femur by
  increasing contact between patellar tendon and
  femur
• Protects patellar tendon against friction
• When moving from extension to flexion the patella
  glides laterally and further into trochlear groove

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• Kinetic Chain
• Directly affected by motions and forces occurring
  at the foot, ankle, lower leg, thigh, hip,
  pelvis, and spine
• With the kinetic chain forces must be absorbed
  and distributed
• If body is unable to manage forces, breakdown to
  the system occurs
• Knee is very susceptible to injury resulting from
  absorption of forces

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Assessing the Knee Joint

• Determining the mechanism of injury is critical
• History- Current Injury
• Past history
• Mechanism- what position was your body in?
• Did the knee collapse?
• Did you hear or feel anything?
• Could you move your knee immediately after injury
  or was it locked?
• Did swelling occur?
• Where was the pain

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• History - Recurrent or Chronic Injury
• What is your major complaint?
• When did you first notice the condition?
• Is there recurrent swelling?
• Does the knee lock or catch?
• Is there severe pain?
• Grinding or grating?
• Does it ever feel like giving way?
• What does it feel like when ascending and
  descending stairs?
• What past treatment have you undergone?

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• Observation
• Walking, half squatting, going up and down stairs
• Swelling, ecchymosis,
• Leg alignment
• Genu valgum and genu varum
• Hyperextension and hyperflexion
• Patella alta and baja
• Patella rotated inward or outward
• May cause a combination of problems
• Tibial torsion, femoral anteversion and
  retroversion

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• Tibial torsion
• An angle that measures less than 15 degrees is an
  indication of tibial torsion
• Femoral Anteversion and Retroversion
• Total rotation of the hip equals 100 degrees
• If the hip rotates gt70 degrees internally,
  anteversion of the hip may exist
• INSERT 20-9

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• Knee Symmetry or Asymmetry
• Do the knees look symmetrical? Is there obvious
  swelling? Atrophy?
• Leg Length Discrepancy
• Anatomical or functional
• Anatomical differences can potentially cause
  problems in all weight bearing joints
• Functional differences can be caused by pelvic
  rotations or mal-alignment of the spine

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Palpation - Bony

• Medial tibial plateau
• Medial femoral condyle
• Adductor tubercle
• Gerdys tubercle
• Lateral tibial plateau
• Lateral femoral condyle
• Lateral epicondyle
• Head of fibula

• Tibial tuberosity
• Superior and inferior patella borders (base and
  apex)
• Around the periphery of the knee relaxed, in full
  flexion and extension

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Palpation - Soft Tissue

• Medial and lateral collateral ligaments
• Pes anserine
• Medial/lateral joint capsule
• Semitendinosus
• Semimembranosus
• Gastrocnemius
• Popliteus
• Biceps Femoris

• Vastus medialis
• Vastus lateralis
• Vastus intermedius
• Rectus femoris
• Quadriceps and patellar tendon
• Sartorius
• Medial patellar plica
• Anterior joint capsule
• Iliotibial Band
• Arcuate complex

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• Palpation of Swelling
• Intra vs. extracapsular swelling
• Intracapsular may be referred to as joint
  effusion
• Swelling w/in the joint that is caused by
  synovial fluid and blood is a hemarthrosis
• Sweep maneuver
• Ballotable patella - sign of joint effusion
• Extracapsular swelling tends to localize over the
  injured structure
• May ultimately migrate down to foot and ankle

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• Special Tests for Knee Instability
• Use endpoint feel to determine stability
• MRI may also be necessary for assessment
• Classification of Joint Instability
• Knee laxity includes both straight and rotary
  instability
• Translation (tibial translation) refers to the
  glide of tibial plateau relative to the femoral
  condyles
• As the damage to stabilization structures
  increases, laxity and translation also increase
• Valgus and Varus Stress Tests
• Used to assess the integrity of the MCL and LCL
  respectively
• Testing at 0 degrees incorporates capsular
  testing while testing at 30 degrees of flexion
  isolates the ligaments

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• Anterior Cruciate Ligament Tests
• Drawer test at 90 degrees of flexion
• Tibia sliding forward from under the femur is
  considered a positive sign (ACL)
• Should be performed w/ knee internally and
  externally to test integrity of joint capsule

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• Lachman Drawer Test
• Will not force knee into painful flexion
  immediately after injury
• Reduces hamstring involvement
• At 30 degrees of flexion an attempt is made to
  translate the tibia anteriorly on the femur
• A positive test indicates damage to the ACL

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• Pivot Shift Test
• Used to determine anterolateral rotary
  instability
• Position starts w/ knee extended and leg
  internally rotated
• The thigh and knee are then flexed w/ a valgus
  stress applied to the knee
• Reduction of the tibial plateau (producing a
  clunk) is a positive sign

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• Jerk Test
• Reverses direction of the pivot shift
• Moves from position of flexion to extension
• W/out and ACL the tibia will sublux at 20 degrees
  of flexion
• Flexion-Rotation Drawer Test
• Knee is taken from a position of 15 degrees of
  flexion (tibia is subluxed anteriorly w/ femur
  externally rotated)
• Knee is moved into 30 degrees of flexion where
  tibia rotates posteriorly and femur internally
  rotates

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• Posterior Cruciate Ligament Tests
• Posterior Drawer Test
• Knee is flexed at 90 degrees and a posterior
  force is applied to determine translation
  posteriorly
• Positive sign indicates a PCL deficient knee
• External Rotation Recurvatum Test
• With the athlete supine, the leg is lifted by the
  great toe
• If the tibia externally rotates and slides
  posteriorly there may be a PCL injury and damage
  to the posterolateral corner of the capsule

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• Posterior Sag Test (Godfreys test)
• Athlete is supine w/ both knees flexed to 90
  degrees
• Lateral observation is required to determine
  extent of posterior sag while comparing
  bilaterally

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Instrument Assessment of the Cruciate Ligaments

• A number of devices are available to quantify AP
  displacement of the knee
• KT-2000 arthrometer, Stryker knee laxity tester
  and Genucom can be used to assess the knee
• Test can be taken pre post-operatively and
  through rehab

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• Meniscal Tests
• McMurrays Meniscal Test
• Used to determine displaceable meniscal tear
• Leg is moved into flexion and extension while
  knee is internally and externally rotated in
  conjunction w/ valgus and varus stressing
• A positive test is found w/ clicking and popping
  response

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• Apleys Compression Test
• Hard downward pressure is applied w/ rotation
• Pain indicates a meniscal injury
• Apleys Distraction Test
• Traction is applied w/ rotation
• Pain will occur if there is damage to the capsule
  or ligaments
• No pain will occur if it is meniscal

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• Girth Measurements
• Changes in girth can occur due to atrophy,
  swelling and conditioning
• Must use circumferential measures to determine
  deficits and gains during the rehabilitation
  process
• Measurements should be taken at the joint line,
  the level of the tibial tubercle, belly of the
  gastrocnemius, 2 cm above the superior border of
  the patella, and 8-10 cm above the joint line
• Subjective Rating
• Used to determine patients perception of pain,
  stability and functional performance

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• Functional Examination
• Must assess walking, running, turning and cutting
• Co-contraction test, vertical jump, single leg
  hop tests and the duck walk
• Resistive strength testing
• Q-Angle
• Lines which bisects the patella relative to the
  ASIS and the tibial tubercle
• Normal angle is 10 degrees for males and 15
  degrees for females
• Elevated angles often lead to pathological
  conditions associated w/ improper patella tracking

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• The A Angle
• Patellar orientation to the tibial tubercle
• Quantitative measure of the patellar realignment
  after rehabilitation
• An angle greater than 35 degrees is often
  correlated w/ patellofemoral pathomechanics
• Palpation of the Patella
• Must palpate around and under patella to
  determine points of pain
• Patella Grinding, Compression and Apprehension
  Tests
• A series of glides and compressions are performed
  w/ the patella to determine integrity of patellar
  cartilage

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Prevention of Knee Injuries

• Physical Conditioning and Rehabilitation
• Total body conditioning is required
• Strength, flexibility, cardiovascular and
  muscular endurance, agility, speed and balance
• Muscles around joint must be conditioned
  (flexibility and strength) to maximize stability
• Must avoid abnormal muscle action through
  flexibility
• In an effort to prevent injury, extensibility of
  hamstrings, erector spinae, groin, quadriceps and
  gastrocnemius is important

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• ACL Prevention Programs
• Focus on strength, neuromuscular control, balance
• Series of different programs which address
  balance board training, landing strategies,
  plyometric training, and single leg performance
• Can be implemented in rehabilitation and
  preventative training programs
• Shoe Type
• Change in football footwear has drastically
  reduced the incidence of knee injuries
• Shoes w/ more shorter cleats does not allow foot
  to become fixed while still allowing for control
  w/ running and cutting

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• Functional and Prophylactic Knee Braces
• Used to prevent and reduce severity of knee
  injuries
• Used to protect MCL, or prevent further damage to
  grade 1 2 sprains of the ACL or to protect the
  ACL following surgery
• Can be custom molded and designed to control
  rotational forces

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Recognition and Management of Specific Injuries

• Medial Collateral Ligament Sprain
• Etiology
• Result of severe blow or outward twist
• Signs and Symptoms - Grade I
• Little fiber tearing or stretching
• Stable valgus test
• Little or no joint effusion
• Some joint stiffness and point tenderness on
  lateral aspect
• Relatively normal ROM

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• Management
• RICE for at least 24 hours
• Crutches if necessary
• Follow-up care will include cryokinetics w/
  exercise
• Move from isometrics and STLR exercises to
  bicycle riding and isokinetics
• Return to play when all areas have returned to
  normal
• May require 3 weeks to recover

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• Signs and Symptoms (Grade II)
• Complete tear of deep capsular ligament and
  partial tear of superficial layer of MCL
• No gross instability laxity at 5-15 degrees of
  flexion
• Slight swelling
• Moderate to severe joint tightness w/ decreased
  ROM
• Pain along medial aspect of knee
• Management
• RICE for 48-72 hours crutch use until acute
  phase has resolved
• Possibly a brace or casting prior to the
  initiation of ROM activities
• Modalities 2-3 times daily for pain
• Gradual progression from isometrics (quad
  exercises) to CKC exercises functional
  progression activities

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• Signs and Symptoms (Grade III)
• Complete tear of supporting ligaments
• Complete loss of medial stability
• Minimum to moderate swelling
• Immediate pain followed by ache
• Loss of motion due to effusion and hamstring
  guarding
• Positive valgus stress test
• Management
• RICE
• Conservative non-operative versus surgical
  approach
• Limited immobilization (w/ a brace) progressive
  weight bearing for
• Rehab would be similar to Grade I II injuries

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• Lateral Collateral Ligament Sprain
• Etiology
• Result of a varus force, generally w/ the tibia
  internally rotated
• Direct blow is rare
• If severe enough damage can also occur to the
  cruciate ligaments, ITB, and meniscus, producing
  bony fragments as well
• Signs and Symptoms
• Pain and tenderness over LCL
• Swelling and effusion around the LCL
• Joint laxity w/ varus testing
• May cause irritation of the peroneal nerve
• Management
• Following management of MCL injuries depending on
  severity

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• Anterior Cruciate Ligament Sprain
• Etiology
• MOI - tibia externally rotated and valgus force
  at the knee (occasionally the result of
  hyperextension from direct blow)
• May be linked to inability to decelerate valgus
  and rotational stresses - landing strategies
• Male versus female
• Research is quite extensive in regards to impact
  of femoral notch, ACL size and laxity,
  malalignments (Q-angle) faulty biomechanics
• Extrinsic factors may include, conditioning,
  skill acquisition, playing style, equipment,
  preparation time
• Also involves damage to other structures
  including meniscus, capsule, MCL

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• Signs and Symptoms
• Experience pop w/ severe pain and disability
• Rapid swelling at the joint line
• Positive anterior drawer and Lachmans
• Other ACL tests may also be positive
• Management
• RICE use of crutches
• Arthroscopy may be necessary to determine extent
  of injury
• Could lead to major instability in incidence of
  high performance
• W/out surgery joint degeneration may result
• Age and activity may factor into surgical option
• Surgery may involve joint reconstruction w/
  grafts (tendon), transplantation of external
  structures
• Will require brief hospital stay and 3-5 weeks of
  a brace
• Also requires 4-6 months of rehab

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• Posterior Cruciate Ligament Sprain
• Etiology
• Most at risk during 90 degrees of flexion
• Fall on bent knee is most common mechanism
• Can also be damaged as a result of a rotational
  force
• Signs and Symptoms
• Feel a pop in the back of the knee
• Tenderness and relatively little swelling in the
  popliteal fossa
• Laxity w/ posterior sag test
• Management
• RICE
• Non-operative rehab of grade I and II injuries
  should focus on quad strength
• Surgical versus non-operative
• Surgery will require 6 weeks of immobilization in
  extension w/ full weight bearing on crutches
• ROM after 6 weeks and PRE at 4 months

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• Meniscal Lesions
• Etiology
• Medial meniscus is more commonly injured due to
  ligamentous attachments and decreased mobility
• Also more prone to disruption through torsional
  and valgus forces
• Most common MOI is rotary force w/ knee flexed or
  extended
• Can be longitudinal, oblique or transverse tears
• Signs and Symptoms
• Effusion developing over 48-72 hour period
• Joint line pain and loss of motion
• Intermittent locking and giving way
• Pain w/ squatting
• Portions may become detached causing locking,
  giving way or catching w/in the joint
• If chronic, recurrent swelling or muscle atrophy
  may occur

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• Management
• If the knee is not locked, but indications of a
  tear are present further diagnostic testing may
  be required
• If locking occurs, anesthesia may be necessary to
  unlock the joint w/ possible arthroscopic surgery
  follow-up
• W/ surgery all efforts are made to preserve the
  meniscus -- will full healing being dependent on
  location
• Menisectomy rehab allows partial weight bearing
  and quick return to activity
• Repaired meniscus will require immobilization and
  a gradual return to activity over the course of
  12 weeks

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• Knee Plica
• Etiology
• Irritation of the plica (generally, mediopatellar
  plica and often associated w/ chondromalacia
• Signs and Symptoms
• Possible history of knee pain/injury
• Recurrent episodes of painful pseudo-locking
• Possible snapping and popping
• Pain w/ stairs and squatting
• Little or no swelling, and no ligamentous laxity
• Management
• Treat conservatively w/ RICE and NSAIDs if the
  result of trauma
• Recurrent conditions may require surgery

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• Osteochondral Knee Fractures
• Etiology
• Same MOI as collateral/cruciate ligaments or
  meniscal injuries
• Twisting, sudden cutting or direct blow
• Signs and Symptoms
• Hear a snap and feeling of giving way
• Immediate swelling and considerable pain
• Management
• Diagnosis confirmed through arthroscopic exam, w/
  surgery to replace fragment to avoid joint
  degeneration and arthritis

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• Osteochondritis Dissecans
• Etiology
• Partial or complete separation of articular
  cartilage and subchondral bone
• Cause is unknown but may include blunt trauma,
  possible skeletal or endocrine abnormalities,
  prominent tibial spine impinging on medial
  femoral condyle, or impingement due to patellar
  facet
• Signs and Symptoms
• Aching pain with recurrent swelling and possible
  locking
• Possible quadriceps atrophy and point tenderness
• Management
• Rest and immobilization for children
• Surgery may be necessary in teenagers and adults
  (drilling to stimulate healing, pinning or bone
  grafts

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• Loose Bodies w/in the Knee
• Etiology
• Result of repeated trauma
• Possibly stem from osteochondritis dissecans,
  meniscal fragments, synovial tissue or cruciate
  ligaments
• Signs and Symptoms
• May become lodged, causing locking or popping
• Pain and sensation of instability
• Management
• If not surgically removed it can lead to
  conditions causing joint degeneration

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• Joint Contusions
• Etiology
• Blow to the muscles crossing the joint (vastus
  medialis)
• Signs and Symptoms
• Present as knee sprain, severe pain, loss of
  movement and signs of acute inflammation
• Swelling, discoloration
• Possible capsular damage
• Management
• RICE initially and continue if swelling persists
• Gradual progression to normal activity following
  return of ROM and padding for protection
• If swelling does not resolve w/in a week a
  chronic condition (synovitis or bursitis) may
  exist requiring more rest

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• Peroneal Nerve Contusion
• Etiology
• Compression of peroneal nerve due to a direct
  blow
• Signs and Symptoms
• Local pain and possible shooting nerve pain
• Numbness and paresthesia in cutaneous
  distribution of the nerve
• Added pressure may exacerbate condition
• Generally resolves quickly -- in the event it
  does not resolve, it could result in drop foot
• Management
• RICE and return to play once symptoms resolve and
  no weakness is present
• Padding for fibular head is necessary for a few
  weeks

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• Bursitis
• Etiology
• Acute, chronic or recurrent swelling
• Prepatellar continued kneeling
• Infrapatellar overuse of patellar tendon
• Signs and Symptoms
• Prepatellar bursitis may be localized swelling
  above knee that is ballotable
• Swelling in popliteal fossa may indicate a
  Bakers cyst
• Associated w/ semimembranosus bursa or medial
  head of gastrocnemius
• Commonly painless and causing little disability
• May progress and should be treated accordingly
• Management
• Eliminate cause, RICE and NSAIDs
• Aspiration and steroid injection if chronic

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• Patellar Fracture
• Etiology
• Direct or indirect trauma (severe pull of tendon)
• Forcible contraction, falling, jumping or running
• Signs and Symptoms
• Hemorrhaging and joint effusion w/ generalized
  swelling
• Indirect fractures may cause capsular tearing,
  separation of bone fragments and possible
  quadriceps tendon tearing
• Little bone separation w/ direct injury
• Management
• X-ray necessary for confirmation of findings
• RICE and splinting if fracture suspected
• Refer and immobilize for 2-3 months

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• Acute Patella Subluxation or Dislocation
• Etiology
• Deceleration w/ simultaneous cutting in opposite
  direction (valgus force at knee)
• Quad pulls the patella out of alignment
• Some athletes may be predisposed to injury
• Repetitive subluxation will impose stress to
  medial restraints
• Signs and Symptoms
• W/ subluxation, pain and swelling, restricted
  ROM, palpable tenderness over adductor tubercle
• Dislocations result in total loss of function

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• Management
• Reduction is performed by flexing hip, moving
  patella medially and slowly extending the knee
• Following reduction, immobilization for at least
  4 weeks w/ use of crutches and isometric
  exercises during this period
• After immobilization period, horseshoe pad w/
  elastic wrap should be used to support patella
• Muscle rehab focusing on muscle around the knee,
  thigh and hip are key (STLRs are optimal for the
  knee)
• Possible surgery to release tight structures
• Improve postural and biomechanical factors

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• Injury to the Infrapatellar Fat Pad
• Etiology
• May become wedged between the tibia and patella
• Irritated by chronic kneeling, pressure or trauma
• Signs and Symptoms
• Capillary hemorrhaging and swelling
• Chronic irritation may lead to scarring and
  calcification
• Pain below the patellar ligament (especially
  during knee extension)
• May display weakness, mild swelling and stiffness
  during movement
• Management
• Rest from irritating activities until
  inflammation has subsided and therapeutic use of
  cold
• Heel lift to prevent irritation during extension
• Hyperextension taping to prevent full extension

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• Chondromalacia patella
• Etiology
• Softening and deterioration of the articular
  cartilage
• Possible abnormal patellar tracking due to genu
  valgum, external tibial torsion, foot pronation,
  femoral anteversion, patella alta, shallow
  femoral groove, increased Q angle, laxity of quad
  tendon
• Signs and Symptoms
• Pain w/ walking, running, stairs and squatting
• Possible recurrent swelling, grating sensation w/
  flexion and extension
• Pain at inferior border during palpation
• Management
• Conservative measures
• RICE, NSAIDs, isometrics, orthotics to correct
  dysfunction
• Surgical possibilities

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• Patellofemoral Stress Syndrome
• Etiology
• Result of lateral deviation of patella while
  tracking in femoral groove
• Tight structures, pronation, increased Q angle,
  insufficient medial musculature
• Signs and Symptoms
• Tenderness of lateral facet of patella and
  swelling associated w/ irritation of synovium
• Dull ache in center of knee
• Patellar compression will elicit pain and
  crepitus
• Apprehension when patella is forced laterally
• Management
• Correct imbalances (strength and flexibility)
• McConnell taping
• Lateral retinacular release if conservative
  measures fail

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• Osgood-Schlatter Disease and Larsen-Johansson
  Disease
• Etiology
• Osgood Schlatters is an apophysitis occurring at
  the tibial tubercle
• Begins cartilagenous and develops a bony callus,
  enlarging the tubercle
• Resolves w/ aging
• Common cause repeated avulsion of patellar
  tendon
• Larsen Johansson is the result of excessive
  pulling on the inferior pole of the patella
• Signs and Symptoms
• Both elicit swelling, hemorrhaging and gradual
  degeneration of the apophysis due to impaired
  circulation

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• Signs and Symptoms (continued)
• Pain w/ kneeling, jumping and running
• Point tenderness
• Management
• Conservative
• Reduce stressful activity until union occurs
  (6-12 months)
• Possible casting, ice before and after activity
• Isometerics

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• Patellar Tendinitis (Jumpers or Kickers Knee)
• Etiology
• Jumping or kicking - placing tremendous stress
  and strain on patellar or quadriceps tendon
• Sudden or repetitive extension
• Signs and Symptoms
• Pain and tenderness at inferior pole of patella
• 3 phases - 1)pain after activity, 2)pain during
  and after, 3)pain during and after (possibly
  prolonged) and may become constant
• Management
• Ice, phonophoresis, iontophoresis, ultrasound,
  heat
• Exercise
• Patellar tendon bracing
• Transverse friction massage

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• Patellar Tendon Rupture
• Etiology
• Sudden, powerful quad contraction
• Generally does not occur unless a chronic
  inflammatory condition persist resulting in
  tissue degeneration
• Occur primarily at point of attachment
• Signs and Symptoms
• Palpable defect, lack of knee extension
• Considerable swelling and pain (initially)
• Management
• Surgical repair is needed
• Proper conservative care of jumpers knee can
  minimize chances of occurring
• If steroids are being used, intense knee exercise
  should be avoided due to weakening of collagen

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• Runners Knee (Cyclists Knee)
• Etiology
• General expression for repetitive/overuse
  conditions attributed to mal-alignment and
  structural asymmetries
• Signs and Symptoms
• IT Band Friction Syndrome
• Irritation at bands insertion - commonly seen in
  individual that have genu varum or pronated feet
• Pes Anserine Tendinitis or Bursitis
• Result of excessive genu valgum and weak vastus
  medialis
• Due to running w/ one leg higher than the other
• Management
• Correction of mal-alignments
• Ice before and after activity, proper warm-up and
  stretching
• Avoidance of aggravating activities
• NSAIDs and orthotics

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Knee Joint Rehabilitation

• General Body Conditioning
• Must be maintained with non-weight bearing
  activities
• Weight Bearing
• Initial crutch use, non-weight bearing
• Gradual progression to weight bearing while
  wearing rehabilitative brace
• Knee Joint Mobilization
• Used to reduce arthrofibrosis
• Patellar mobilization is key following surgery
• CPM units

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• Flexibility
• Must be regained, maintained and improved
• Muscular Strength
• Progression of isometrics, isotonic training,
  isokinetics and plyometrics
• Incorporate eccentric muscle action
• Open versus closed kinetic chain exercises
• Neuromuscular Control
• Loss of control is generally the result of pain
  and swelling
• Through exercise and balance equipment
  proprioception can be enhanced

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• Bracing
• Variety of braces for a variety of injuries and
  conditions
• Typically worn for 3-6 weeks after surgery --used
  to limit ranges for a period of time
• Some are used to control for specific injuries
  while others are designed for specific forces and
  stability
• Functional Progression
• Gradual return to sports specific skills
• Progress w/ weight bearing, move into walking and
  running, and then onto sprinting and change of
  direction

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• Return to Activity
• Based on healing process - sufficient time for
  healing must be allowed
• Objective criteria include strength and ROM
  measures as well as functional performance tests