1. The knee is dependent on the rest of the body, particularly the foot and hip.

2. We can determine whether our efforts are functional or nonfunctional through

examining concepts on the Functional Spectrum.
3. We view the knee and the rest of the body in all three planes of motion: sagittal,
frontal, and transverse.
4. Many of the muscles that control the knee dont actually cross the knee.
5. An important functional strategy for the knee is the concept of Integrated Isolation.
6. As we analyze the knee, are the foot and hip helping or inhibiting the function of the
knee?
7. There are many functional specialized tests for the knee, such a single leg balances
and excursion tests, that will help us to look at components of the foot and hip in
the different planes of motion.
8. Any rehabilitation strategy needs to treat the cause of the problem, as well as the
compensations and the symptoms.
9. Manual functional techniques help to integrate the body and create the Chain
Reaction desired.
10. The strategies for functional training of the knee and body are similar to those for
rehabilitation.
11. Different drivers and different tweaks (through various exercises) are used to help
or feed into the knee, then gradually taken away so the knee can stand on its own.
12. The magic behind what we do is not in the medicine or exercises but in the
patients body.
13. The essence of Chain Reaction is that all parts of the body depend on each
other, and no one part is more important than the other.
14. Golf is a great activity to show various parts of the body and how they contribute to
2002 Functional Design Systems

each other.
15. It will be exciting to see how continued research will help us further understand
function and its impact on how we view the body.
 v1.1 THE KNEE
From Bottom to Top / From Top to Bottom
From Inside Out/ From Outside In
By: Gary Gray, PT

OBJECTIVES FOR THE KNEE FUNCTIONAL GUIDE

To assimilate up-to-date information and knowledge about the
knee and its dependencies on the rest of the body

To learn how to apply effective functional techniques when

testing, training, and rehabilitating the knee

To understand and appreciate the tri-plane Chain Reaction

principles as they apply to the knee.

HOW TO USE THIS FUNCTIONAL GUIDE

This functional guide can be used as a convenient summary
of the programs contents to take with you after viewing.
You can also use this guide as a notebook; space has been
provided so that you can make notes on relevant tracts as
you watch them.
One of the most important strategies overall, and certainly with the knee, is the concept
of INTEGRATED ISOLATION.

INTEGRATION - The primary purpose of the knee is to absorb shock and propel us to
another place in space. It does this in the frontal, sagittal, and transverse planes and,
as we have seen, gets its input from the foot and hip. Both the foot and hip keep saying,
knee, we can help you!

As the foot walks or runs, it reacts to the body, gravity, ground

reaction, and momentum immediately feeds information to the
knee. The knee will then flex, go through the abduction
component, and internally rotate. These three motions make
up the one tri-plane loading motion of the knee, thus facilitating
the reaction of the proprioceptors and muscles.

The hip likewise is a great asset to the knee during Chain

Reaction loading as the hip flexes, internally rotates, and
adducts, lengthening and stimulating the powerful hip muscles
in all three planes of motion and integrating with the knee.

As we evaluate the knee, it is critical to create an environment where we gradually integrate

and then gradually isolate out planes of motion, other joints, other muscles groups in
order to determine the cause, compensations, and symptoms.

ISOLATION: WHAT IT IS NOT!

NONFUNCTIONAL ISOLATION - putting the knee in places its never been before,
stabilizing as its never been before, applying force foreign to it, asking, for example,
the quadriceps to extend the knee (which they really dont do) and the hamstrings to
flex the knee (which they really dont do). The knee get confused.
ISOLATION: WHAT IT IS!
FUNCTIONAL ISOLATION - allowing the motions at the hip and foot to occur which will
help the knee be successful. Then we gradually isolate the knee and gradually tweak
some of those motions, some of the mechanical advantages, some of the proprioceptive
facilitators to where the knee is not being helped as much.

EXAMPLES: USING THE HANDS AS A DRIVER

SAGITTA L . . . instead of facilitating forward flexion of the hip which will make it easier
for me to squat, if I put my hands over my head and create hip extension and take the
powerful hip muscles out of the picture, my squat is now less successful.

FRONTA L . . . using the same strategy in the frontal plane, if I drive my hands overhead
in the opposite direction to facilitate more hip adduction, I facilitate the system. If I move
my hands overhead in the frontal plane to decrease hip adduction, the system is being
inhibited.

TRANSVERSE . . . driving my arms to create more internal rotation facilitates the system.
Driving my arms the opposite way to position the hip in an externally rotated posture,
creates more isolation.

SUMMARY - As we take the friends of the knee away, the knee will begin to feel the
isolation but still sense the integration. So, there are a number of options: different
drivers, different body parts, even different equipment pieces that we can work with to
tell the knee we will either feed things good to you that will make you more successful,
or we will gradually take your friends away to make it more challenging yet still functional.
THE KNEE - One of the most fascinating joints in the body

FINDINGS - Traditionally, the knee has been looked at in an isolated manner

when testing, training, and rehabilitating for increased effectiveness. What we
are finding now is just how dependent the knee is on the rest of the body . . .
particularly the foot and hip.

The question becomes is the knee doing what we want it to during testing,
training, and rehabilitation? Is what the knee is doing functional, less functional,
or nonfunctional?

We are able to articulate whether our efforts are functional or nonfunctional by

examining a list of concepts, or litmus tests: the Functional Spectrum

FUNCTIONAL SPECTRUM
NON FUNCTIONAL FUNCTIONAL
Lab-like Life-like
Rigid Flexible
Isolated Integrated
Artificial Physiological
Gravity Confused Gravity User
Fake Real
Deceptive Proprioceptive
Mechanical Biomechanical
Limited Unlimited
Link Action Chain Reaction

Those exercises/tests that reproduce what we want our patients to do, as

demonstrated along the functional end of the spectrum, are what we want to utilize.
CHAIN REACTION - Understanding

The knee does not live by itself . . . it has to react between different parts of
the body.
Three dimensional: we view the knee and the rest of the body in the sagittal,
frontal, and transverse planes of motion.
The knee is caught in the middle with few places to go and no place to hide.
As the hip and foot move, the knee has to go along.
An injury may not be the knees fault; we have to know how the knee feeds
information to the rest of the body, and how the rest of the body feeds
information to the knee in all three planes of motion.

MUSCLES - As we look at the muscles around the knee, one of the fascinating
things is many of the muscles that control the knee itself dont actually cross the
knee. An example is th soleus muscle (as part of achilles tendon) that doesnt
even cross the knee but is important to knee extension during walking or running
as it decelerates the lower leg during that motion.

CONCLUSION - We have to understand why the knee does what it does! Only
then can we approach the knee from a very functional approach. We will begin
to ignore some of our nonfunctional concepts because there is a huge gap
between traditional knee exercises that have nothing to do with function and
functional exercises that we can objectively quantify, appreciate, and take
advantage of to benefit those who entrust themselves to us.
GENERAL APPROACH - In order to gain an understanding, besides doing the traditional
tests, we want to take a look at the global function of the patient in all three planes initially.
That might consist of:
a gait exam, and tweaking that exam to give us some information on how the knee
is doing, then
bringing the patient closer and observing what the knee does in all three planes,
possibly with an excursion test asking the knee to bend and extend, internally and
externally rotate, and go through the frontal plane motion of abduction and adduction.

ARE THE FOOT AND HIP HELPING OR INHIBITING THE KNEE?

LEFT LEG BALANCE; ANTERIOR REACH TEST WITH RIGHT LEG

Objective: to force the knee to flex; check how much ankle dorsiflexion exists. It is
adequate to load the calf to make the knee successful? (hip relatively neutral)

LEFT LEG BALANCE; ANTERIOR LATERAL REACH WITH RIGHT LEG

Objective: to invert and lock foot up to see if adequate dorsiflexion and good motion
through the ankle, and a bit through the subtalar joint. Does this help the knee to be
successful?

LEFT LEG BALANCE; MEDIAL REACH TEST WITH RIGHT LEG

Objective: how much eversion of foot and how well can knee be driven medially to
accept stresses imposed upon it by opposite leg.

LEFT LEG BALANCE; MEDIAL ROTATION REACH TEST WITH RIGHT LEG
Objective: to open hips up and put them at a mechanical disadvantage; and driving
medially to the left foot to see if there is good eversion and good dorsiflexion to
control that motion.

Recalling integrated isolation, the hip has been facilitated out and the foot facilitated in
with above tests.
FUNCTIONAL SPECIALIZED TESTS FOR THE KNEE - CONTINUED

LEFT LEG BALANCE; OVERHEAD POSTERIOR REACH WITH BILATERAL

UPPER EXTREMITY
Objective: is the person able to load his hip and get good hip extension?

To isolate more, keep the right foot next to the left foot but not touching. This will limit
the amount of counterbalancing. Is the ankle dorsiflexed, is the knee flexing, is the hip
getting good extension, am I adding to or subtracting from the knee?

LEFT LEG BALANCE; ANTERIOR REACH WITH BILATERAL UPPER EXTREMITY

AT SHOULDER HEIGHT
Objective: to facilitate sagittal plane flexion of the hip and dorsiflexion of the ankle and
assist in determining how well the body can decelerate forward sagittal plane motion.

TRANSVERSE PLANE EXCURSION TESTS (LEFT HIP INTERNAL ROTATION

AND EXTERNAL ROTATION)
Objective: to close (internally rotate) and open (externally rotate) the hip and then
asking how the knee and the foot respond to the loading (closed) and the unloading
(open) of the hip. How well does the entire chain tolerate transverse plane stress?

SUMMARY - There are lots of tests, but for the knee, we want to know what the hip is
doing for or against it and what the foot is doing for or against it. We want to incorporate
tests that look at components of the foot in the sagittal and frontal planes, and components
of the hip in the sagittal and transverse planes, as well as the frontal.
INITIAL THINKING - Any rehabilitation strategy, based on the complete analysis,
needs to treat the cause of the problem and, also, take away the compensations
and symptoms. Functional manual techniques will be helpful to integrate the
body and create the Chain Reaction desired.
CASE STUDY - Patellar Femoral Dysfunction
Explanation: the patella femoral joint is one of the most common problems
associated with the knee. Often the cause has nothing to do with the patella
itself. One of the common reasons is the inability of the foot to appropriately
roll-in or pronate to allow lengthening of muscles and allow the femur to
internally rotate when it should.
If internal rotation does not occur because of limitations at the subtalar joint or
ankle joint, then we get the patella smashed against the femur without the good
internal rotation of the femur. Then the butt does not get turned on which
results in an ineffective hip and out of sync patella femoral joint.
So, for our case, symptoms are in the knee, the cause is at the foot, and there
is a primary compensation at the hip. So, the strategies below treat an individual
with limited calcaneus eversion and limited dorsiflexion of the ankle when the
foot is inverted with abnormal compensation at the hip.

TREATMENT/EXERCISES: STRETCHES, STRENGTH AND STRETCHES,

AND BALANCE REACHES
1. Using the TrueStretch, the patient put their effected left leg foot forward on the everted surface
of the TrueStretch, loads, and takes their left hand and reaches across in front of them. At the
same time, functional manual techniques are used on the lower leg to facilitate internal rotation,
subtalar joint eversion and midtarsal joint inversion.

RESULT: Functional mobilization to help the knee and the hip get properly loaded in all three
planes with good internal rotation, abduction and flexion.
2. In the TrueStretch, assume a position consistent with gait. With the left foot back on the
inverted surface of the TrueStretch, the patient will position the right foot forward and to the
left on the TrueStretch angle platform while performing a sagittal plane arm reach.
Functional manual facilitation is done with external rotation of the left lower leg, inversion of
the subtalar joint, and dorsiflexion of the ankle.

RESULT: Facilitating external rotation of the tibia and the femur with inversion of the heel
and dorsiflexion of the ankle, along with the actual internal rotation of the left hip joint itself,
facilitates appropriate patella femoral reaction.

3. Home exercise . . . Full weight bearing on left foot, use right leg as a driver by swinging it out
over the posterior medial vector while stabilizing hands high.

RESULT: Left femur internally rotates with foot everting and dorsiflexing to facilitate knee
flexion, internal rotation and abduction.

4. Left leg full weight bearing, driving right knee up and across along the anterior lateral vector.

RESULT: As right leg drives pelvis, dorsiflexion in the ankle along with inversion of the
subtalar joint, along with internal rotation of the left hip facilitates knee extension with external
rotation with adduction.

5. Balance reach . . . left leg balance with right leg anterior lateral reach to a cone.

RESULT: Ankle dorsiflexion with inversion of subtalar joint with external rotation of femur and
tibia and facilitating appropriate patellar femoral reaction.

6. Balance reach . . . with two cones as targets, second cone along posterior medial vector.
Right leg reach to posterior medial cone.

RESULT: Left subtalar joint eversion with internal rotation of tibia and femur to facilitate
loading patellar femoral joint in transverse and sagittal planes.

REVIEW - Through functional manual therapy, stretching, and balance reaction exercises, the
subtalar joint and ankle were addressed as the cause to facilitate more effective hip reaction
(which was the compensation) to facilitate appropriate patella femoral reaction through a Chain
Reaction approach.
PHILOSOPHY - The strategies for training are similar to those for rehabilitation.
All three planes of motion are in use during Chain Reaction . Different drivers
and different tweaks are used to help the knee, and then gradually taken away
so the knee can stand on its own. The knee has to react to what the body
above it is doing and what the body below it is doing.

STRATEGIES - In the many exercises on the video, the main emphasis is to

feed into the knee with the help of the hip, for instance, and then go the other
way and feed it out. All the exercises are done in all three planes. And when
the hip is taken out, the calf and foot are often taken out and the trunk becomes
the primary help to the knee.
EXERCISES (AND TWEAKS) FROM VIDEO
3D Lunge Matrix Forward Reach (matrix means done in all 3 planes; anterior, lateral and rotational)

3D Lunge Matrix Overhead Reach

3D Lunge Matrix Overhead Reach (as far back with arms overhead as possible)

3D Lunge Matrix Rotational Reach (arms to same side)

3D Lunge Matrix Rotational Reach (arms to opposite side)

SIngle Leg Balance Squat (SLBS) Rotational Reach

SLBS Rotational Reach (without counterbalance left foot next to right foot but not touching)

SLBS Overhead Rotational Reach

Two Footed Matrix Jumps

Two Footed Matrix Jumps Overhead Reach

Two Footed Matrix Hop 360 Rotation (clockwise and counterclockwise)

Two Footed Matrix Hop 360 Rotation Overhead Reach

Two Footed Matrix Hop 360 Rotation Hands Behind Head

3D Matrix Hop 360 Rotation (one foot)

Two Footed Matrix Hop 360 Rotation Hands Back and Forth Rotation

One Footed 3D Matrix Hop 360 Rotation Overhead Reach

Two Footed 3D Matrix Hop 360 Rotation Cervical Rotation

One Footed 3D Matrix Hop 360 Rotation Hands Behind Head Cervical Rotation Eyes Closed

LOWER EXTREMITY PERFORMANCE AND PREVENTION VIDEO

(By Vern Gambetta and Gary Gray, PT - 866-230-8300)

CLOSE - There are hundreds of variations and exercises that can be used for
training the knee, along with the other body parts above and below it, to be as
functionally strong as possible.
THE PREMISE - It is an amazing thing how the body can be rehabilitated and
trained to function appropriately. The body will move in one motion, but all three
planes or dimensions together make up that motion. It is the same with human
nature . . . we are all body, mind and spirit and that cannot be separated; so as
we work with patients, we need to have an appreciation for the impact we have
on their whole being.

THE MAGIC - The magic is not in the medicine but in the patients body - in the
vis medicatrix naturae, the recuperative or self corrective energy of nature.
What the treatment does is to stimulate natural functions or what hinders them.
C.S. Lewis, Miracles

All we are about is using what we have to design the best environment for
healing to take place. We are not going to create healing. We have to under-
stand Chain Reaction and how the body functions. All parts of the body are
important, and no one more important than the other. They each depend on
each other . . . the essence of Chain Reaction, and certainly the knee.

THE GOLF ANALOGY

Golf is a great activity to show members of the body how they contribute to
each other . . . a great Chain Reaction transformation.

Golf is a pure Chain Reaction from the ground up and from the top down.

The important part in golf is the loading, or the backswing.

The knee will be evidence biomechanically of whats going on.

The right knee performs differently from the left knee during the backswing.
THE GOLF ANALOG - C o n t i n u e d

The right knee flexes, stays internally rotated and minimally abducted during a
proper backswing (the foot has to say everted at the subtalar joint putting pres-
sure on the inside of the right heel).

The left knee significantly abducts, flexes, internally rotates, as revealed by

moving towards a target almost in front of the right foot (this requires significant
internal rotation and adduction of the hip on the left side).

The right side loads in all three planes primarily from the top down: foot stable,
pressure on inside of right heel, knee in good loaded position, pelvis moves
over the right femur, creating eccentric load of all hip muscles, with hip flexion,
hip adduction and hip internal rotation.

The left side happens predominantly from the bottom up: the foot everts and
dorsiflexes with the knee abducting significantly, internally rotating and flexing,
allowing the femur to internally rotate faster than the pelvis, creating internal
rotation of the left hip, along with left hip flexion, and left hip adduction. (left hip
is now loaded).

THE RESULT - In golf, a Chain Reaction is created in the swing that allows
many members of the body to contribute. A tri-plane eccentric load occurs
through the hips and trunk by taking advantage of the knees. The knees, as
good members of the body, are evidence of what goes on in the swing, and are
indicators of the rest of the bodys effectiveness.
As the wrap-up, it;s fun to see what is happening in the field and what the future
holds for our patients, clients, and athletes!

THE CHALLENGE - To understand the research, but also how to apply the
information, and then to clinically apply the information functionally. We need to
understand how the results should influence our day-to-day evaluation, treat-
ment, and training of our clients.

RECENT RESEARCH FOR THE KNEE -

WITH DR. DAVID TIBERIO AS FRIEND AND RESEARCH SPECIALIST

1. A sturdy looked at the result of external loads on the knee during a lot of
functional activity.

KEY FINDINGS: The knee flexion or the sagittal plane motion during all of
these different maneuvers didnt change very much. The big change based
on the different maneuvers was the motions of the knee in the frontal and
transverse planes in the external torques.

COMMENTS: This seems to indicate that as we torque or change direction,

were going to decelerate, and as we thus load in the transverse and frontal
planes, it means the hip and foot have to decelerate/accelerate what is
happening at the knee also.
2. A study looked at the same external load effect during functional activity.

KEY FINDINGS: During these external functional events, a lot of the energy is
not only driven bottom up from the ground but a lot is driven from the top
down.

This study points out the importance of the hip. This study also drew the
conclusion that it was the transverse and frontal plane motion forces that
create the greatest danger for ligament. (thus, do we now try to avoid those
motions in those planes, or do we recognize the importance of them and train
through a program based on function?)

COMMENT: It is not a good strategy to try to train the knee to stay there
when its been proven throughout function that the knee will go in all these
planes and motions and can be safe and productive.

3. Another study looked at a patient that was ACL deficient and in testing were
able to objectively quantify what happened.

KEY FINDINGS: Abnormal complications occurred in the frontal and transverse

plane motion.

COMMENT: In looking at the data carefully, it would suggest that it was the
failure of motion in one plane, primarily frontal, to load the hip. One has to
assume, if the knee fails to load, that the hip or foot is not doing its job. Failure
to load in one plane leaves the knee susceptible in other planes.

Again, what we do with any of this information to further benefit our clients
is what is important!