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1 © 2011 McGraw-Hill Higher Education. All rights reserved. Chapter 20: The Knee and Related Structures

2 One of the most traumatized joint in the physically active population 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

3 Anatomy- Bones Femur- aka the thigh bone, articulates with the tibia Tibia- shin bone, groves in which femur condyles articulate with Fibula- rotational movement Patella- largest sesmoid bine, located in the tendon of the quadricep

4 Figure 20-1 © 2011 McGraw-Hill Higher Education. All rights reserved.

5 Menisci Two oval fibrocartilages –Deepens the articular facets –Cushions any stresses –Maintains spaces between the femoral condyles and the tibial plateau –Stabilizes the knee at 90 degrees (medial)

6 Medial Meniscus: C-shaped Lateral Meniscus: O-shaped Meniscal Blood Supply: three zones –Red- Red: outer zone and good vascular supply –Red-White: middle third, minimal blood supply –White- White: inner third, avascular

7 Figure 20-2 © 2011 McGraw-Hill Higher Education. All rights reserved.

8 Stabilizing Ligaments Anterior Cruciate Ligament: (ACL) starts in the anterior portion of the tibia back to the lateral condyle of the femur –Three twitsted bands –Prevents femur from moving posteriorly in weight bearing and tibia moving anteriorly in non weight bearing –Stabilizes tibia from internal rotation –Works with the hamstrings

9 Posterior Cruciate Ligament: (PCL) stronger of two, back of the tibia to the front of the medial femoral condyle –Resists internal rotation of tibia –Prevents hyperextenstion of the knee –Limits anterior movement of femur in weight bearing and posterior movement of tibia in non weight bearing

10 Medial Collateral Ligaments: (MCL) includes both superficial and deep –Attaches above the joint line on the medial epicondyle of the femur and below on the tibia –Keeps knee from Valgus and external roation

11 Lateral Collateral Ligament (LCL) – fibrous cord about the size of a pencil –Attaches to the lateral epicondyle of the femur and the head of the fibula –Keeps knee from Varus movement

12 Figure 20-3 A-B © 2011 McGraw-Hill Higher Education. All rights reserved.

13 Figure 20-3 Capsule Ligaments © 2011 McGraw-Hill Higher Education. All rights reserved.

14 Joint Capsule Knee joint is enveloped by a the largest joint capsule Reinforced by collateral ligaments and muscle

15 Figure 20-4 © 2011 McGraw-Hill Higher Education. All rights reserved.

16 Knee Musculature Knee Flexion: bicep femoris, semitendinosus, semimembranosus, gracilis, sartorius, gastrocnemius, popliteus, and plantaris Knee Extension: (Quad) vastus medialis oblique, vastus lateralis, vastus intermedius and rectus femoris

17 External Rotation: bicep femoris (knee moves into extension) Internal Rotation: popliteal, semitendinosus, semimembranosus, sartorius and gracilis (knee moves into flexed) Iliotibial Band (IT Band): dynamic lateral stabilizer

18 Figure 20-5 A & B © 2011 McGraw-Hill Higher Education. All rights reserved.

19 Figure 20-5C © 2011 McGraw-Hill Higher Education. All rights reserved.

20 Bursae Synovial tissue sac to reduce the friction between structures Over 2 dozen in the knee joint

21 Fat Pads Several around the knee Infrapatellar in largest in the knee

22 Nerve Supply Tibial Nerve: innervates the hamstring and gastocnemius Common Peroneal Nerve: Innervates the short headof the bicep femoris, wraps around fibula head (prone to injury) Femoral Nerve: innervates the quadriceps and sartorius

23 Figure 20-6 © 2011 McGraw-Hill Higher Education. All rights reserved.

24 Blood Supply Popliteal fossa which stems from the femoral artery –Breaks into four brances

25 Figure 20-7 © 2011 McGraw-Hill Higher Education. All rights reserved.

26 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

27 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, limits anterior translation and posterior translation when tibia is fixed and non-weight bearing, respectively ACL stops excessive internal rotation, stabilizes the knee in full extension and prevents hyperextension © 2011 McGraw-Hill Higher Education. All rights reserved.

28 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

29 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

30 Assessing the Knee Joint Determining the mechanism of injury is critical History- Current Injury pg 563 –Past history –Mechanism- what position was your body in? –Did the knee collapse? –Did you hear or feel anything? (pop) –Could you move your knee immediately after injury or was it locked? –Did swelling occur? (sudden or gradual) –Where was the pain (local or diffuse) © 2011 McGraw-Hill Higher Education. All rights reserved.

31 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? © 2011 McGraw-Hill Higher Education. All rights reserved.

32 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

33 Leg Alignment Genu Valgum: knocked knee –Pronated feet –Increase tension on medial ligaments, compression on lateral surface Genu Varum: bowlegs –Structural: Deviation of the femur and tibia –Functional: Associated with hyperextended knees Genu Recurvatum: Hyperextended knees –Compensation of lordosis or swayback –Weakness of the hamstring

34

35 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

36 Genu Recurvatum

37 Patella Malalignment Patella Alta: patella in a more superior position when standing –The patella tendon to patella ratio is greater than 1:1; usually greater than 20% Patella Baja: sets in a more inferior position –Less than a 1:1 ratio

38 Measuring Alignment Tibial Torsion: Have the patient kneel on a stool with the foot relaxed –Dissect center of the thigh and the lower leg –Another line between the heel and the foot

39 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 >70 degrees internally, anteversion of the hip may exist Figure 20-9 © 2011 McGraw-Hill Higher Education. All rights reserved.

40 Patella Orientation Position of the patella relative to the tibia with the patient supine Glide: deviated laterally or medially Patellar Tilt: height of the medial to the lateral border of the patella Patellar Rotation: Line of the inferior pole of patella to the femur Anteroposterior Tilt: Laterally

41 Glide Component & Tilt Component

42 Figure & 13 © 2011 McGraw-Hill Higher Education. All rights reserved.

43 Knee Symmetry or Asymmetry Do the knees look symmetrical? Is there obvious swelling? Atrophy? © 2011 McGraw-Hill Higher Education. All rights reserved.

44 Leg Length Anatomical: Measured from the ASIS to the lateral malleolus –Anatomical differences can potentially cause problems in all weight bearing joints Functional: Measured from Umbilicus to medial malleolus –Functional differences can be caused by pelvic rotations or mal-alignment of the spine

45 Observation Lab Leg Alignment Patella Malalignment Tibial Alignment Patella Orientation Leg Length

46 Palpation - Bony Medial tibial plateau Medial femoral condyle Adductor tubercle Gerdys tubercle Lateral tibial plateau Lateral femoral condyle Lateral epicondyle Medial epicondyle Head of fibula Tibial tuberosity Patella Superior and inferior patella borders (base and apex) Around the periphery of the knee relaxed, in full flexion and extension © 2011 McGraw-Hill Higher Education. All rights reserved.

47 Palpation - Soft Tissue Vastus medialis Vastus lateralis Rectus femoris Quadriceps and patellar tendon Sartorius Medial patellar plica Anterior joint capsule Iliotibial Band Arcuate complex Medial and lateral collateral ligaments Pes anserine Medial/lateral joint capsule Semitendinosus Semimembranosus Gastrocnemius Popliteus Biceps Femoris © 2011 McGraw-Hill Higher Education. All rights reserved.

48 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- moving swelling from one side to another –Ballotable patella - sign of joint effusion Extracapsular swelling tends to localize over the injured structure –May ultimately migrate down to foot and ankle

49 Special Tests 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

50 –Collateral Ligament Stress Tests (Valgus and Varus) 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 Hands at ankle and head joint line © 2011 McGraw-Hill Higher Education. All rights reserved.

51 –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 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

52 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 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

53 A series of variations are also available for the Lachman Drawer Test –May be necessary if athlete is large or examiners hands are small –Variations include Rolled towel under the femur Leg off the table approach with athlete supine Athlete prone on table with knee and lower leg just off table © 2011 McGraw-Hill Higher Education. All rights reserved.

54 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 –Slocums test is variation on the pivot shift © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-20

55 Jerk Test –Reverses direction of the pivot shift –Moves from position of flexion to extension –W/out an ACL the tibia will sublux at 20 degrees of flexion © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-21

56 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-22

57 Losees Test –Similar to flexion- reduction drawer test –Performed side-lying –Begins with knee at 45 degrees of flexion and external tibial rotation –Knee is subluxed anteriorly –As the knee is extended it reduces © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-22

58 KNEE SPECIAL TEST LAB PART I VALGUS VARUS DRAWER TEST LACHMAN DRAWER PIVOT-SHIFT

59 Posterior Cruciate Ligament Tests Page 572 and 573

60 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

61 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 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

62 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 throughout rehabilitation Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

63 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 when clicking and popping are felt © 2011 McGraw-Hill Higher Education. All rights reserved.

64 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

65 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

66 Thessaly Test –Patient stands on one leg –Tested with knee flexed to 5 degrees and 20 degrees –Patient then rotates trunk and knee into internal and external rotation, with clinician supporting patient –Positive test results in pain along medial or lateral joint line –Perform test on healthy side first for comparison © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-29

67 KNEE SPECIAL TEST LAB PART II POSTERIOR DRAWER EXTERNAL ROTATION RECURVATUM POSTERIOR SAG (GODFREYS) MCMURRAYS MENISCAL APLEY COMPRESSION

68 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

69 Patellar Examination 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

70 Q-Angle –Lines which bisect 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 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

71 FIGURE A, Measuring the Q angle of the knee. B, Determining the A angle.

72 Patellar Compression, Patellar Grinding, & Apprehension Grind: knee at 20 degrees flexion- patella moved forward and back Grind: knee flexed, patella forced forward, patient contracts and extends knee Apprehension: for subluxed or dislocated, patella forced laterally

73 © 2011 McGraw-Hill Higher Education. All rights reserved. Patella Grinding, Compression and Apprehension Tests

74 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 –Tests should be performed at speed w/out limping or favoring injured limb –Use baseline for comparison if available © 2011 McGraw-Hill Higher Education. All rights reserved.

75 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 –Hamstring strength approx 60-70% of quad © 2011 McGraw-Hill Higher Education. All rights reserved.

76 Decreasing the Risk for ACL Injury –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 short cleats does not allow foot to become fixed - still allows for control w/ running and cutting © 2011 McGraw-Hill Higher Education. All rights reserved.

77 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-37

78 The Knee and Related Structures Part II

79 Recognition and Management of Specific Injuries Medial Collateral Ligament Sprain –Etiology Result of severe blow from lateral side (valgus force) – 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

80 –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 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

81 –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 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

82 Grade 1Grade 2 Grade 3

83 –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 and increased ROM over 4-6 week period Rehab would be similar to Grade I & II injuries © 2011 McGraw-Hill Higher Education. All rights reserved.

84 Lateral Collateral Ligament Sprain Page 581

85 Lateral Collateral Ligament Sprain –Etiology Result of a varus force, generally w/ the tibia internally rotated If severe enough damage can also occur to the cruciate ligaments, ITB, and meniscus, producing bony fragments as well © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-41

86 Lateral Collateral Ligament Sprain –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 –Follows management of MCL injuries depending on severity © 2011 McGraw-Hill Higher Education. All rights reserved.

87 Anterior Cruciate Ligament Sprain –Etiology MOI - tibia externally rotated and valgus force at the knee (occasionally the result of hyperextension from direct blow) plant and twist 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 May also involve damage to other structures including meniscus, capsule, and MCL © 2011 McGraw-Hill Higher Education. All rights reserved.

88 Signs and Symptoms –Experience pop w/ severe pain and disability –Positive anterior drawer and Lachmans –Rapid swelling at the joint line –Other ACL tests may also be positive © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-42

89 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

90 Posterior Cruciate Ligament Sprain Page 584

91 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 Sometimes referred to as a dashboard injury –May result when flexed knee of car driver or passenger hits the dashboard © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-43

92 –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

93 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 Tears may be longitudinal, oblique or transverse © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-44

94 –Signs and Symptoms Effusion developing over 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

95 –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 -- with full healing being dependent on location Meniscectomy 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

96 Knee Plica Page 586

97 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

98 Management –Treat conservatively w/ RICE and NSAIDs if the result of trauma –Recurrent conditions may require surgery © 2011 McGraw-Hill Higher Education. All rights reserved. Figure Medial Patellar Plica

99 Osteochondral Knee Fractures –Etiology Same MOI as collateral/cruciate ligaments or meniscal injuries Twisting, sudden cutting or direct blow Fractures of cartilage and underlying bone varying in size and depth –Signs and Symptoms Hear a snap and feeling of giving way Immediate swelling and considerable pain Diffuse, pain along joint line © 2011 McGraw-Hill Higher Education. All rights reserved.

100 –Management Diagnosed through use of CT and MRI Treatment dependent on stability of fracture If stable the patient will be casted If fragment is loose surgical reattachment will occur or removal via arthroscopic Microfracture procedures used to repair defects in underlying bone –Generates small amounts of bleeding to stimulate bone growth and healing Rehabilitation is dependent on location of fracture ROM is typically initiated early after surgery with active strengthening beginning after 6 weeks Return to activity at 3-6 months © 2011 McGraw-Hill Higher Education. All rights reserved.

101 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

102 –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) © 2011 McGraw-Hill Higher Education. All rights reserved.

103 Joint Contusion Page 588

104 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

105 Peroneal Nerve Contusion –Etiology Compression of peroneal nerve due to a direct blow by the neck of the fibula –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

106 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

107 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

108 Patellar Fracture –Etiology Direct or indirect trauma (severe pull of tendon) Semi-flexed position with 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 © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-47

109 Acute Patella Subluxation or Dislocation Page 589 © 2011 McGraw-Hill Higher Education. All rights reserved.

110 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 individuals may be predisposed Repetitive subluxation will stress medial restraints –Signs and Symptoms W/ subluxation, pain and swelling, restricted ROM, palpable tenderness over adductor tubercle Results in total loss of function © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-49

111 –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

112 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

113 Injury to the Infrapatellar Fat Pad (continued) –Management Rest from irritating activities until inflammation has subsided Utilize therapeutic modalities for inflammation Heel lift to prevent irritation during extension Hyperextension taping to prevent full extension © 2011 McGraw-Hill Higher Education. All rights reserved.

114 Chondromalacia patella –Etiology Softening and deterioration of the articular cartilage Undergoes three stages –1. Swelling and softening of cartilage –2. Fissure of softened cartilage –3. Deformation of cartilage surface Often associated with abnormal tracking Abnormal patellar tracking may be due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon © 2011 McGraw-Hill Higher Education. All rights reserved.

115 Figure © 2011 McGraw-Hill Higher Education. All rights reserved. Chondromalacia

116 –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 –Altering muscle attachments –Shaping and smoothing of surfaces –Drilling –Elevating tibial tubercle © 2011 McGraw-Hill Higher Education. All rights reserved.

117 Patellofemoral Stress Syndrome Page 592 © 2011 McGraw-Hill Higher Education. All rights reserved.

118 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

119 Osgood-Schlatter Disease and Larsen- Johansson Disease –Etiology Osgood Schlatters is an apophysitis occurring at the tibial tubercle –Begins cartilaginous 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

120 Figure 20-53

121 –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 –Isometrics for quadriceps and hamstrings © 2011 McGraw-Hill Higher Education. All rights reserved.

122 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

123 Figure © 2011 McGraw-Hill Higher Education. All rights reserved.

124 Patellar Tendon Rupture –Etiology Sudden, powerful quad contraction Generally does not occur unless a chronic inflammatory condition persists 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

125 Iliotibial Band Friction Syndrome (Runners Knee or Cyclists Knee) Page 595 © 2011 McGraw-Hill Higher Education. All rights reserved.

126 Iliotibial Band Friction Syndrome (Runners Knee or 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 –Positive Obers test Pes Anserine Tendinitis or Bursitis –Result of excessive genu valgum and weak vastus medialis –Often occurs due to running w/ one leg higher than the other (running on a slope or crowned road) © 2011 McGraw-Hill Higher Education. All rights reserved.

127 –Management Correction of mal- alignments Ice before and after activity Utilize proper warm- up and stretching techniques Avoidance of aggravating activities NSAIDs and orthotics © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 20-5

128 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

129 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 and regained –The patient must be challenged © 2011 McGraw-Hill Higher Education. All rights reserved.

130 Figure 20-59

131 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, stability, and providing resistance 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

132 Return to Activity –Based on healing process - sufficient time for healing must be allowed –Objective criteria should include strength and ROM measures as well as functional performance tests © 2011 McGraw-Hill Higher Education. All rights reserved.


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