1. Chapter 15 Injuries to the Thigh, Leg, and Knee

2. Bony Anatomy Bones of the Region Femur Patella Tibia Fibula

4. Motion The knee is considered a hinge joint The knee only performs two motions: Flexion (0 - 145°) Extension (0 - -5°)

5. Ligaments Major ligaments are: Anterior cruciate. Posterior cruciate. Reduce or prevent anterior/posterior displacement of tibia. Tibial or medial collateral. Fibular or lateral collateral. Protect the knee from valgus/varus (side-to- side) forces.

6. Meniscus There are two semicircular fibrocartilaginous disks in the knee known as the menisci. Medial and Lateral These disks are located in the space between the tibia and femur. Responsible for lubrication and nourishment of the knee joint, weight distribution, and assistance with joint biomechanics.

7. Musculature Muscles of the Region Quadriceps Hamstrings Abductors Adductors Gastrocnemius Major Tendons Quadriceps tendon Patellar tendon

8. Musculature Quadriceps Rectus Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius Create the motion of knee extension Hamstrings Biceps Femoris Semitendinosus Semimembranosus Create the motion of knee flexion

10. Musculature Adductors Adductor Longus Adductor Magnus Adductor Brevis Gracilis Create the motion of hip adduction Abductors Gluteus Medius Gluteus Minimus Create the motion of hip abduction

11. Common Sports Injuries Numerous injuries to the thigh and knee occur in a variety of sports to both male and female participants. Fractures/Dislocations Muscular Strains Tendon/Bursa injuries Ligament Ruptures/Sprains This area is difficult to protect, it can experience repeated trauma in contact and collision sports.

12. Fractures of the Femur and/or Patella Femoral and patellar fractures result from an extremely traumatic event. In the adult, fractures of the femoral neck may result in avascular necrosis of the femoral head. This injury results from disrupted blood supply to the articular cartilage on femoral head. Femoral neck stress fractures are also possible.

16. Fractures of the Femur and/or Patella Signs and symptoms Pain and obvious deformity at the injury site. Swelling and athlete’s report of having suffered a traumatic event. Athlete may report a pop or snap at time of injury. Difficulty walking on the affected leg. The injury needs to be transported and evaluated by a physician. Avascular necrosis is a serious complication of femoral fracture.

17. Fractures of the Femur and/or Patella First Aid Treat for shock. Splint the injured leg, preferably with traction splint. Apply sterile dressings to any open wounds. Monitor vital signs and circulation to lower leg. Courtesy of Kevin G. Shea, MD, Intermountain Orthopaedics, Boise, Idaho]

18. Dislocation of the Tibiofemoral Joint Dislocation of the knee or the tibiofemoral joint can compromise blood flow to the lower leg. Very serious and needs immediate attention. Signs and symptoms Deformity and complete dysfunction of the joint. Extreme pain. First Aid The injury must be splinted. Refer athlete to the nearest medical facility.

19. Soft Tissue Injuries to the Thigh These injuries usually result from direct contact with an opponent (contusion) or from muscle strain. Poorly treated contusions can result in Myositis ossificans traumatica. Signs and symptoms of a muscle contusion History of forceful impact to the area and a feeling of tightness. Swelling and inability to forcibly contract the muscle. Difficulty walking with affected leg.

21. Muscular Strains to the Thigh Hamstrings and adductor muscles are most likely to sustain strains. Strains to adductor muscles are called “groin pulls.” Groin injuries take a long time to heal. Hamstrings usually are weaker and more susceptible to strains than quadriceps. Stretching and strengthening is a part of recovery program.

22. Muscular Strains to the Thigh Signs and symptoms A sharp pain in the affected muscle. Swelling and redness in the immediate area. Bruising to the area. Muscle weakness and inability to contract the muscle forcibly. A defect is visible in severe cases.

23. Muscular Strains and Contusions First Aid Apply ice and compression. Elevate. Athlete should rest and, if necessary, use crutches. If moderate/severe contusion or strain, a medical evaluation of the injury should be obtained. Appropriate strengthening and stretching regimen should be instituted to prevent further injury.

24. Patellofemoral Joint Injuries Acute and chronic injuries can affect patellofemoral joint and may be debilitating. Intervention by the athletic trainer or physician may be necessary. Common Injuries Osteochondritis dissecans (OCD) or “joint mice”. Bursitis Patellar Dislocation/Subluxation Tendonitis Chronic Inflammatory Conditions Patellofemoral Stress Syndrome

26. Osteochondritis Dissecans (OCD) Condition occurs when small pieces of bone are dislodged from joint and float within capsule. A bone fragment can block or lock a joint’s motion and cause damage to joint surface. Signs and symptoms Chronic swelling and knee pain with exertion. Knee may lock; quadriceps may atrophy. Femoral condyles may be tender when palpated. First Aid Application of ice and compression; crutches. Refer athlete to physician.

27. Bursae of the Knee A bursa is a small fluid-filled sac located at strategic points. Numerous bursae are in the knee region; only a few are typically injured.

28. Bursitis of the Knee Inflammation can be caused by: Direct Trauma. Overuse. Infection. The prepatellar bursa is most susceptible to direct trauma.

29. Bursitis of the Knee Signs and symptoms Swelling and tenderness at site. Pain when increased external pressure is applied. Athlete may report direct trauma to knee. First Aid Application of ice and compression. Reduced activity for a short time. In chronic cases, anti-inflammatory agents may be helpful.

30. Patellar Dislocation/Subluxation Injury may be caused by a quick cutting motion that generates a great deal of abnormal force within the knee. Instead of moving normally, the patella moves laterally and may dislocate. Whether the patella remains dislocated or returns to its normal position spontaneously (subluxation) relates to the number of times this type of incident has occurred in the past.

33. Patellar Dislocation/Subluxation Signs and symptoms Severe pain and abnormal movement of the patella when injury occurred. Patella may be obviously out-of-place. Swelling and extreme pain along the medial aspect of the patella. First Aid Apply ice and compression. Elevate. Splint the entire leg (The joint may reduce itself when put back into extension). Transport to a medical facility.

34. Osgood-Schlatter Disease Osgood-Schlatter Disease involves irritation of the patellar tendon complex – chronic inflammatory condition. Osteochondritis of the epiphysis of the tibial tuberosity Common in adolescents who experience excessive muscle activity at growth plate. Constant running and jumping are often causes.

35. Osgood-Schlatter Disease Signs and symptoms Pain and tenderness about the patellar tendon complex. Swelling in the area. Decreased ability to use the quadriceps. If inflammation continues, area over tibial tuberosity may become solid when palpated. First Aid Apply ice and compression. Refer to physician for specific diagnosis. Until inflammation subsides, rest is important.

36. Jumper’s Knee Jumper’s knee is an irritation (tendinitis) of the patellar tendon complex between its attachments on the tibia and the patella. Common to the athlete who must jump a great deal as part of sports participation. Typically, the athlete will experience pain at one of three sites within this complex. Superior or inferior pole of the patella or at the tibial tuberosity.

37. Jumper’s Knee Signs and symptoms Pain and tenderness around the patellar tendon complex that may spread to tibial tuberosity. Decreased ability to use quadriceps for running or jumping. Symptoms that worsen with activity. First Aid Apply ice and compression. Refer to physician for possible anti-inflammatory medications Rest, strengthening, and stretching are helpful.

38. Patellofemoral Conditions Several conditions of the patella involve misalignment of the patella on the femur and result in swelling, cartilage wear and tear, and muscle dysfunction. Patellofemoral Stress Syndrome Chondromalaica Patella

39. Patellofemoral Conditions Misalignment may be related to the Q angle. The Q angle is the difference between a straight line drawn from the anterior superior iliac spine and the center of the patella and a line drawn from the center of the patella through the center of the tibial tuberosity.

40. Patellofemoral Conditions An angle of 15° to 20° is acceptable. Females greater than males. Large Q angle results in patella being pulled too far laterally during extension of the knee Patella rubs on the condyle of the femur, causing pain and irritation.

41. Patellofemoral Conditions If there is abnormal patellofemoral configuration as a result of some skeletal (Q angle), muscular, or mechanical dysfunction pain results. Patellofemoral Stress Syndrome Creates retropatellar (behind the patella) pain of an idiopathic nature. Typically occurs in athletes such as runners or gymnasts who perform a great deal of repetitive movements in their sports activities. Chondromalacia Patella Is a softening and wearing out of the posterior cartilage surface of the patella.

42. Patellofemoral Conditions In the case of patellar pain and discomfort, the athlete will complain of chronic pain and disability. No immediate first aid care to be administered. Rest, ice, compression, elevation, and the use of nonsteroidal anti-inflammatories are helpful. If the athlete has an abnormally large Q angle, muscular imbalances, or other predisposing conditions, he or she should seek the advice of a medical professional to assist in the care.

43. Meniscus Injuries Menisci are typically damaged by quick, sharp, cutting movements. Injury is more likely to occur if the foot is planted firmly on the playing surface. There are many different types of tears, and they affect each athlete differently. In some cases, a torn flap of meniscus will get caught in the joint, causing it to lock.

44. Meniscus Injuries Signs and symptoms Pop or snap when the knee was injured. May not see any significant swelling. May not be painful. Loss of ROM. Athlete may be able to continue participating. A feeling the knee is “giving out” periodically.

45. Meniscus Injuries First Aid Apply ice and compression. Have athlete use crutches. Refer athlete to a physician. Meniscus injuries do not necessarily have to end an athlete’s playing season or career. New methods of surgery enable many athletes to return to participation relatively quickly.

46. Knee Ligament Injuries Injury may occur to the MCL, LCL, ACL, or PCL. Common mechanisms include cutting maneuvers when running and direct blows to the joint.

47. Collateral Ligament Injuries Sprain to MCL is a common sports injury. Occurs as a result of valgus stress. Sprain to LCL is less common sports injury. Varus stress can cause a sprain of the LCL. Both types of sprains render knee unstable in side-to-side movements.

48. Cruciate Ligament Injuries Posterior Cruciate Ligament Injured when the tibia moves forcefully in an posterior direction or when the femur gets pushed forward while the tibia is held in place. Anterior Cruciate Ligament Injured when the tibia moves forcefully in an anterior direction or when the femur gets pushed backward while the tibia is held in place. Quick rotational movements without contact, stops and starts, or awkward landings also injure.

49. Cruciate Ligament Injuries Non-contact Anterior Cruciate Ligament Injury Demonstrated that females encounter more (up to 6X) knee and ACL injuries than their male counterparts. There appear to be many different reasons why female athletes are more prone to ACL injury. The stronger the quadriceps activation during eccentric contraction (changing direction & slowing down), the greater the likelihood of ACL injury, especially in female athletes.

50. Cruciate Ligament Injuries Non-contact Anterior Cruciate Ligament Injury Main causes: Environmental basis including footwear and shoe/surface. Anatomical rational including: Q-angle, posterior tibial slope, notch width and foot pronation. Neuromuscular activity including; strength & recruitment of muscle fibers, joint stiffness and muscular fatigue. Biomechanical rationale with an analysis of the landing techniques.

51. Cruciate Ligament Injuries Signs and symptoms Athlete reports the knee was forced beyond its normal ROM. Pain at the site of the injury. Swelling around the knee. Athlete indicates the knee feels unstable. Athlete reports having a snapping or popping sensation at the time of injury.

52. Cruciate Ligament Injuries First Aid Immediately apply ice and compression. Have athlete walk on crutches. Refer to a physician for medical evaluation.

53. Knee Injury Prevention Research is continuing to outline techniques that will hopefully prevent various injuries. Proper warm-up and stretching is important. Jump and landing training programs may reduce the chance of an ACL tear, especially females. Protective bracing should be the athlete’s choice.

54. Knee Bracing Functional Knee Braces These braces tend to work better than prophylactic braces for assisting athletes after reconstructive knee surgery. Monitor athletes to make sure they wear braces during participation. Athletes should continue wearing braces until released by a physician.