CHAPTER 5 KNEE GENU VALGUM The alignment pattern

CHAPTER 5 KNEE

GENU VALGUM (외반슬) The alignment pattern of genu valgum commonly demonstrates: 1. Excessive Internal Rotation of the femur (external rotation restriction) 2. Excessive External Rotation of the tibia (Internal Rotation restriction) 3. Medial Patella deviation due to femur rotation

DYSKINETIC MUSCLES Knee: 1. Gracilis 2. Semitendinosus 3. Sartorius Hip 1. Psoas 2. lliacus 3. Piriformis 4. Semimembranosus 5. Popliteus 6. Vastus Medialis and Lateralis 4. Gluteus Maximus ＆ Medius 5. Obturator Externus ＆ Internus 6. Quadratus Femoris

관련근육 • VASTUS MEDIALIS – O: intertrochanteric line(medial) – I: medial condyle of tibia – N: 대퇴 신경 – A: Extends leg at knee joint

관련근육 • VASTUS LATERALIS – O: intertrochanteric line(lateral) – I: lateral margin of patella( 경골조면 ) – N: 대퇴신경 – A: Extends leg at knee joint

관련근육 • PIRIFORMIS – O: internal surface of sacrum, sacrotuberous ligament – I: greater trochanter 의 상연 – N: S 1, S 2 – A: 대퇴외회전, 외전운 동(abd. )

관련근육 • GLUTEUS MAXIMUS – O: 천골후방, sacrotuberous lig. – I: 대퇴근막장근, 대퇴의 gluteal tuberosity – N: inf. Gluteal n. – A: 대퇴 abd. 외회전운동. 몸체 신전

관련근육 • Obturator externus – O: pubic bone, 폐쇄 공 주변 좌골부 – I: trochanteric fossa of femur – N: Obturator nerve – A: 대퇴 외회전

관련근육 • Obturator internus – O: pelvic surface of obturator membrane – I: greater trochanter 의 내측면 – N: 천신경총 분지 – A: hip joint에서 대퇴 외회전

관련근육 • Quadratus femoris – O: ischial tuberosity 의 lateral border – I: below intertrochanteric crest – N: 천신경총 분지 – A: hip joint에서 대퇴 외회전

GENU VARUM (내반슬) The alignment pattern of genu varum commonly demonstrates: 1. Excessive External Rotation of the femur (Internal rotation restriction) 2. Excessive Internal Rotation of the tibia (External Rotation restriction) 3. Lateral Patella deviation due to femur rotation

DYSKINETIC MUSCLES Knee: 1. Biceps Femoris 2. Tensor Fascia Lata Hip 1. Tensor Fascia Lata 2. Gluteus Minimus 4. Vastus Lateralis 5. Vastus Medialis 4. Adductor Brevis 5. Adductor longus

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 • Tensor fascia lata – O: 장골능외측 – I: 대퇴상부의 iliotibial tract – N: superior gluteal n. – A: 대퇴 내회전, 굴곡

관련근육 • VASTUS LATERALIS – O: intertrochanteric line(lateral) – I: lateral margin of patella( 경골조면 ) – N: 대퇴신경 – A: Extends leg at knee joint

관련근육 • VASTUS MEDIALIS – O: intertrochanteric line(medial) – I: medial condyle of tibia – N: 대퇴 신경 – A: Extends leg at knee joint

관련근육 • Gluteus minimus – O: middle and inferior gluteal line – I: greater trochanter 의 anterior surface – N: superior gluteal n. – A: hip joint에서 대퇴 외전, 대퇴 내측회전

관련근육 • Adductor brevis – O: pubis의 inf. Ramus. – I: linea aspera의 근위 부 – N: Obturator n. – A: hip joint에서 대퇴 내전

관련근육 • Adductor longus – O: pubic bone의 ant. – I: linea aspera의 중간 부위 – N: Obturator n. – A: Adduct thigh, 내회 전보조

EXTERNALLY ROTATED TIBIA ① IND: Medial capsular ligament pain, genu valgum, prominent medial tibial condyle and plateau, tightness of the pes anserine tendons, chondromalacia patellae, restricted internal tibia rotation. ② PP: Prone with involved knee flexed 50˚ to 70˚. ③ DP: End of table with involved knee resting on the Dr. s shoulder. ④ CH: Thenar contact behind tibial condyles. ⑤ IH: Interlocked with CH.

LOC: Internally rotate with caudad thrust (toward the Dr. ). MOD: Internally rotate, traction and thrust. DM: 1. Semitendinosus 2. Gracilis 3. Sartorius 4. Semimembranosus 5. Popliteus

교정법 • EXTERNALLY ROTATED TIBIA

교정법 2 • EXTERNALLY ROTATED TIBIA

교정법 3 • EXTERNALLY ROTATED TIBIA

교정법 4 -1 • EXTERNALLY ROTATED TIBIA

교정법 4 -2 • EXTERNALLY ROTATED TIBIA

INTERNALLY ROTATED TIBIA ① IND: Lateral capsular ligament pain, genu varum, prominent lateral tibial condyle and plateau, tightness of the ilio-tibial and lateral hamstring endons, chondromalacia patellae, restricted external tibia rotation. ② PP: Prone with involved knee flexed 50˚ to 70˚. ③ DP: End of table with involved knee resting on the Dr. 's shoulder. ④ CH: Thenar contact behind tibial condyles. ⑤ IH: Interlocked with CH. ⑥ LOC: Externally rotate with caudad thrust (toward the Dr. ). ⑦ MOD: Externally rotate, traction and thrust.

DM: 1. Biceps Femoreis (long head) 2. Biceps Femoris (short head) 3. Tensor Fascia Lata

교정법 • INTERNALLY ROTATED TIBIA

교정법 2 • INTERNALLY ROTATED TIBIA

교정법 3 • EXTERNALLY ROTATED TIBIA

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 • Tensor fascia lata – O: 장골능외측 – I: 대퇴상부의 iliotibial tract – N: superior gluteal n. – A: 대퇴 내회전, 굴곡

POSTERIOR TIBIA ① IND: Popliteal fossa tenderness, anterior tivial trauma, posterior cruciate ligament damage, posterior drawer sign, patellar tendon hypotonicity and depression, restricted anterior tibia motion. ② PP: Prone, involved knee flexed 70˚. ③ DP: End of table with involved tibial condyles. ④ POC: Both hands interlock on the posterior aspect of the tibial condyles. ⑤ LOC: Toward the Dr. (posterior to anterior).

MOD: Traction and thrust toward the Dr. DM: 1. Vastus Intermedius 2. Rectus Femoris 3. Hamstrings

교정법 • POSTERIOR TIBIA

관련근육 • Rectus femoris – O: ASIS, ilium above acetabulum – I: patella tendon을 통 한 경골조면 – N: femoral n. – A: knee joint에서 leg 신전, hip joint에서 대퇴굴곡

관련근육 • Hamstring muscles – – – – 1. 2. 3. 4. 5. 6. 7. Sciatic nerve. Quadratus femoris Biceps femoris Semimebranosus Semitendinosus Tibial n. Common peroneal n.

관련근육 • Quadratus femoris – O: ischial tuberosity 의 lateral border – I: below intertrochanteric crest – N: 천신경총 분지 – A: hip joint에서 대퇴 외회전

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

ANTERIOR TIBIA ① IND: Patellar tendon tenderness, Anterior Drawer Sign, Anterior Cruciate Ligament damage, patellar tendon hypertonicity or tendonitis, restricted posterior tibia motion. ② PP: Supine with involved leg extended. ③ DP: Side of involvement. ④ CH: Proximal anterior tibia. ⑤ IH: Supporting distal tibia and ankle. ⑥ LOC: Anterior to posterior. ⑦ MOD: Dr. traction leg distally and thrusts anterior to posterior.

DM: 1. Semimembranosus 2. Semitendinosus 3. Biceps Femoris 4. Quadriceps

교정법 • ANTERIOR TIBIA

관련근육 • Quadratus femoris – O: ischial tuberosity 의 lateral border – I: below intertrochanteric crest – N: 천신경총 분지 – A: hip joint에서 대퇴 외회전

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

MEDIAL TIBIA ① IND: Trauma to lateral tibia, valgus trauma, medial collateral ligament damage, restricted lateral motion. ② PP: Supine, involved hip flexed approximately 45˚. The knee is slightly flexed. ③ DP: Side of involvement standing laterally with leg in Dr. 's axilla. ④ CH: Pisiform at proximal medial tibial condyle. ⑤ IH: Wrist of the CH. ⑥ LOC: Medial to lateral. ⑦ MOD: Traction toward the Dr. then thrust with the pisiform contact at the medial tibial condyle.

DM: 1. Tensor Fascia Lata 2. Biceps Femoris 3. Gracilis 4. Semitendinosus 5. Sartorius 6. Semimembranosus

교정법 • MEDIAL TIBIA

관련근육 • Tensor fascia lata – O: 장골능외측 – I: 대퇴상부의 iliotibial tract – N: superior gluteal n. – A: 대퇴 내회전, 굴곡

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

LATERAL TIBIA ① IND: Trauma to medial tibia, valgus trauma, medial collateral ligament damage, restricted lateral motion. ② PP: Supine, involved hip flexed approximately 45˚. The knee is slightly flexed. ③ DP: Side of involvement standing laterally with leg in Dr. 's axilla. ④ CH: Pisiform at proximal lateral tibial condyle. ⑤ IH: Wrist of the CH. ⑥ LOC: Lateral to medial. ⑦ MOD: Traction toward the Dr. then thrust with the pisiform contact at the lateral tibial condyle.

DM: 1. Gracilis 2. Semitendinosus 3. Sartorius 4. Semimembranosus 5. Tensor Fascia Lata 6. Biceps Femoris

교정법 • LATERAL TIBIA

관련근육 • Tensor fascia lata – O: 장골능외측 – I: 대퇴상부의 iliotibial tract – N: superior gluteal n. – A: 대퇴 내회전, 굴곡

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

SUPERIOR PATELLA ① IND: Patellar tendonitis, quadricep spasm, chondromalcia patellae, restricted inferior patella motion. ② PP: Supine, leg extended. ③ DP: Side of involvement. ④ CH: Superior hand takes a web contact over superior aspect of the patella. ⑤ IH: Stabilizes tibia below the knee. ⑥ LOC: Superior to inferior. ⑦ MOD: Traction inferior and thrust.

DM: 1. Vastus Intetmedius 2. Rectus Femoris 3. Hamstrings

교정법 • Superior Patella

관련근육 • Rectus femoris – O: ASIS, ilium above acetabulum – I: patella tendon을 통 한 경골조면 – N: femoral n. – A: knee joint에서 leg 신전, hip joint에서 대퇴굴곡

관련근육 • Quadratus femoris – O: ischial tuberosity 의 lateral border – I: below intertrochanteric crest – N: 천신경총 분지 – A: hip joint에서 대퇴 외회전

SUPERIOR-LATERAL PATELLA ① IND: Patellar tendonitis, quadricep spasm, chrondromalacia patellae, genu valgum, restricted inferior-medial motion. ② PP: Supine, leg extended. ③ DP: Side of involvement. ④ CH: Superior hand takes a web contact over superior-lateral aspect of the patella. ⑤ IH: Stabilizes tibia below the knee. ⑥ LOC: Superior to inferior and lateral to medial. ⑦ MOD: Traction according to the LOC and thrust.

DM: 1. Vastus Medialls 2. Vastus Intermedijus 3. Rectus Femoris 4. Hamstrings.

교정법 • Superior Lateral Patella

관련근육 • VASTUS MEDIALIS – O: intertrochanteric line(medial) – I: medial condyle of tibia – N: 대퇴 신경 – A: Extends leg at knee joint

관련근육 • Rectus femoris – O: ASIS, ilium above acetabulum – I: patella tendon을 통 한 경골조면 – N: femoral n. – A: knee joint에서 leg 신전, hip joint에서 대퇴굴곡

SUPERIOR-MEDIAL PATELLA ① IND: Patellar tendonitis, quadricep spasm, chrondromalacia patellae, genu valgum, restricted inferior-lateral patella motion. ② PP: Supine, leg extended. ③ DP: Side of involvement. ④ CH: Superior hand takes a web contact over superior-medial aspect of the patella. ⑤ IH: Stabilizes tibia below the knee. ⑥ LOC: Superior to inferior and lateral to medial. ⑦ MOD: Traction according to the LOC and thrust.

DM: 1. Vastus Lateralis 2. Vastus Intermedius 3. Rectus Femoris 4. Hamstrings.

교정법 • Superior Medial Patella

관련근육 • VASTUS LATERALIS – O: intertrochanteric line(lateral) – I: lateral margin of patella( 경골조면 ) – N: 대퇴신경 – A: Extends leg at knee joint

관련근육 • Rectus femoris – O: ASIS, ilium above acetabulum – I: patella tendon을 통 한 경골조면 – N: femoral n. – A: knee joint에서 leg 신전, hip joint에서 대퇴굴곡

INFERIOR FIBULA ① IND: Inversion sprain, tender fibular collateral ligament due to injury, restricted superior fibula motion. ② PP: Lateral recumbant position. ③ DP: End of table in plane with distal fibula malleolus. ④ CH: Lateral malleolus between thenar pads. ⑤ IH: Placed on wrist of CH. ⑥ LOC: Inferior to superior. ⑦ MOD: Traction cephalad, thrust is made with the CH at the lateral malleolus.

DM: 1. Biceps Femoris (long head) 2. Biceps Femoris (short head) 3. peroneus Longus 4. Peroneus Brevis 5. Peroneus Tertius 6. Extensor Hallucis Longus 7. Extensor Digitorum Longus

교정법 • Inferior fibula

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 • Peroneus longus – O: 비골의 측면 상 2/3 – I: medial cuneiform bone의 측면, 제 1중족 골의 base – N: 천비골신경 – A: plantar FLEXES, EVERTS FOOT.

관련근육 • Peroneus tertius – O: 비골전방 하 1/3, interosseous membrane – I: 제 5중족골 base의 dorsal surface – N: 심비골신경 – A: dorsiflexes and everts foot.

관련근육 Extensor hallucis longus – O: 비골의 전면 중간 부 – I: great toe 의 base – N: 심비골신경 – A: extends great toe, dorsiflexes and inverts foot.

관련근육 Extensor digitorum longus – O: 비골의 전면 상 2/3 – I: 4개의 측방 toe 발 등부위 – N: 심비골신경 – A: extends toes, dorsiflexes and inverts foot.

POSTERIOR INFERIOR FIBULA ① IND: Pain at fibular head, inversion sproin, lateral collateral ligament pain at the ankle, lateral hamstring complaints, restricted anterior-superior fibula motion. ② PP: Supine, knee flexed. ③ DP: Stand lateral to involved leg with superior hand placed in popliteal fossa. ④ CH: In popliteal fossa with thenar pad contacting the fibular head. ⑤ IH: Distal tibia and fiblua. ⑥ LOC: Inferior to superior and posterior to anterior. ⑦ MOD: Dr. flexes leg with inferior hand contacting at the ankle area and thrusting in a lifting motion with superior hand at the head of the fibula.

DM: 1. Biceps Femoris (long head) 2. Biceps Femoris (short head) 3. Peroneus Longus 4. Peroneus Brevis 5. Peroneus Tertius 6. Extensor Hallucis Longus 7. Extensor Digitorum Longus

교정법 1 -1 • Posterior Inferior fibula

교정법 1 -2 • Posterior Inferior fibula

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 • Peroneus longus – O: 비골의 측면 상 2/3 – I: medial cuneiform bone의 측면, 제 1중족 골의 base – N: 천비골신경 – A: plantar FLEXES, EVERTS FOOT.

관련근육 • Peroneus tertius – O: 비골전방 하 1/3, interosseous membrane – I: 제 5중족골 base의 dorsal surface – N: 심비골신경 – A: dorsiflexes and everts foot.

관련근육 Extensor hallucis longus – O: 비골의 전면 중간 부 – I: great toe 의 base – N: 심비골신경 – A: extends great toe, dorsiflexes and inverts foot.

관련근육 Extensor digitorum longus – O: 비골의 전면 상 2/3 – I: 4개의 측방 toe 발 등부위 – N: 심비골신경 – A: extends toes, dorsiflexes and inverts foot.

SUPERIOR FIBULA ① IND: Eversion sprain, tender fibular collateral ligament due to jamming injury, may result in a slight foot drop, restricted inferior fibula motion. ② PP: Supine, leg extended and hip flexed approximately 45˚. ③ DP: End of table with Pt. 's foot placed on anterior thigh. ④ CH: Proximal portion of lateral malleolus between thenar pads. ⑤ IH: Wrapped over CH to stabilize. ⑥ LOC: Superior to inferior. ⑦ MOD: Traction caudad, thrust is made with the CH at the lateral malleolus.

DM: 1. Biceps Femoris (long head) 2. Biceps Femoris (short head) 3. Tibialis Anterior 4. Peroneus Longus 5. Peroneus Brevis 6. Peroneus Tertius 7. Extensor Digitorum Longus

교정법 • SUPERIOR FIBULA

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 Tibialis anterior – O: 경골의 상 ½, 경골 의 lateral condyle – I: 제 1중족골 base , medial cuneiform bone 의 발바닥, 내 측 – N: 심비골신경 – A: dorsiflexes at ankle joint and inverts foot.

관련근육 • Peroneus longus – O: 비골의 측면 상 2/3 – I: medial cuneiform bone의 측면, 제 1중족 골의 base – N: 천비골신경 – A: plantar FLEXES, EVERTS FOOT.

관련근육 • Peroneus tertius – O: 비골전방 하 1/3, interosseous membrane – I: 제 5중족골 base의 dorsal surface – N: 심비골신경 – A: dorsiflexes and everts foot.

관련근육 Extensor digitorum longus – O: 비골의 전면 상 2/3 – I: 4개의 측방 toe 발 등부위 – N: 심비골신경 – A: extends toes, dorsiflexes and inverts foot.

POSTERIOR-MEDIAL FIBULA ① IND: Inversion sprain, hamstring pull, trauma to anterior-lateral knee, genu valgum. restricted anteriorlateral fibula motion. ② PP: Prone, leg flexed 70˚ to 90˚. ③ DP: End of table kneeling with invloved ankle resting on Dr. 's shoulder. ④ CH: Pisiform contact at the medial aspect of the fibular head. ⑤ IH: Interlaced with the CH. ⑥ LOC: Posterior to anterior and medial to lateral. ⑦ MOD: Traction in the direction of the LOC then thrust.

DM: 1. Biceps Femoris (long head) 2. Biceps Femoris (short head) 3. Tibialis Anterior 4. Peroneus Longus 5. Peroneus Brevis 6. Peroneus Tertius 7. Extensor Digitorum Longus

교정법 • POSTERIORMEDIAL FIBULA

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 Tibialis anterior – O: 경골의 상 ½, 경골 의 lateral condyle – I: 제 1중족골 base , medial cuneiform bone 의 발바닥, 내 측 – N: 심비골신경 – A: dorsiflexes at ankle joint and inverts foot.

관련근육 • Peroneus longus – O: 비골의 측면 상 2/3 – I: medial cuneiform bone의 측면, 제 1중족 골의 base – N: 천비골신경 – A: plantar FLEXES, EVERTS FOOT.

관련근육 • Peroneus tertius – O: 비골전방 하 1/3, interosseous membrane – I: 제 5중족골 base의 dorsal surface – N: 심비골신경 – A: dorsiflexes and everts foot.

관련근육 Extensor hallucis longus – O: 비골의 전면 중간 부 – I: great toe 의 base – N: 심비골신경 – A: extends great toe, dorsiflexes and inverts foot.

관련근육 Extensor digitorum longus – O: 비골의 전면 상 2/3 – I: 4개의 측방 toe 발 등부위 – N: 심비골신경 – A: extends toes, dorsiflexes and inverts foot.

ANTERIOR-LATERAL FIBULA ① IND: Lateral hamstring tendon pain, genu varum, hamstring pull, excessive pronation, eversion sprain, trauma to posterior-lateral knee, restricted posterior medial fibula motion. ② PP: Prone, leg fixed 70˚. ③ DP: End of table kneeling with involved ankle resting on Dr. 's shoulder. ④ CH: Pisiform contact at the anterior-lateral aspect of the fibula head. ⑤ IH: Interlaced with the CH. ⑥ LOC: Anterior to posterior and lateral to medial. ⑦ MOD: Traction in the direction of the LOC then thrust.

DM: 1. Biceps Femoris (long head) 2. Biceps Femoris (short head) 3. Peroneus Longus 4. Peroneus Brevis 5. Peroneus Tertius 6. Extensor Hallucis Longus 7. Extensor Digitorum Longus

교정법 • ANTERIORLATERAL FIBULA

관련근육 • Biceps femoris – O: 장두-ischial tuberosity , 단두linea aspera – I: 비골두 측면, 경골측 방condyle. – N: 좌골신경분지 – A: hip joint에서 대퇴 신전, knee joint에서 leg 굴곡

관련근육 • Peroneus longus – O: 비골의 측면 상 2/3 – I: medial cuneiform bone의 측면, 제 1중족 골의 base – N: 천비골신경 – A: plantar FLEXES, EVERTS FOOT.

관련근육 • Peroneus tertius – O: 비골전방 하 1/3, interosseous membrane – I: 제 5중족골 base의 dorsal surface – N: 심비골신경 – A: dorsiflexes and everts foot.

관련근육 Extensor hallucis longus – O: 비골의 전면 중간 부 – I: great toe 의 base – N: 심비골신경 – A: extends great toe, dorsiflexes and inverts foot.

관련근육 Extensor digitorum longus – O: 비골의 전면 상 2/3 – I: 4개의 측방 toe 발등부위 – N: 심비골신경 – A: extends toes, dorsiflexes and inverts foot.