Knee Injuries

ACL Tear Involved Structures: ACL MOI: Changing direction rapidly Stopping suddenly Slowing down while running Landing from a jump incorrectly Direct contact or collision, such as a football tackle

ACL Injury

ACL Tear Predisposing factors = HUGE area for current research! More likely to occur in females than males Hormonal? Anatomical factors? Level of conditioning? Jump landing Landing with knees more extended

ACL Tear S/S: Observation: Palpation: Tender along joint line Feel and hear a “pop” Severe pain and disability Initial pain may subside in a few minutes Observation: Rapid joint line swelling Palpation: Tender along joint line Special Tests: Decreased ROM Positive Lachman’s test MRI Confirmation

MRI of ACL Normal ACL in RED Torn ACL

ACL Tear Care RICE Crutches No surgery = increased risk of knee joint degeneration Surgery = ACL Reconstruction using graft 4-6 months of rehab following surgery Use of knee brace = little evidence exists but still recommended by many physicians

Surgery = Arthroscopy Intact ACL Torn ACL

ACL Reconstruction Graft may be made of patellar tendon or hamstring tendon

PCL Sprain Involved Structures: PCL MOI: Fall with full weight on front of a bent knee Also could be a rotational force S/S: Feel a pop in the back of the knee

PCL Sprain MOI = Fall on a bent knee

PCL Sprain Observation: Palpation: Special Tests: Minimal swelling in back of knee Palpation: Tenderness in back of knee Special Tests: Positive posterior sag test MRI Confirmation

MRI of PCL Normal PCL Torn PCL

Posterior Sag from PCL rupture

PCL Sprain Care: RICE Grade 1-2= Non-operative rehabilitation focusing on quadriceps and hamstrings Grade 3= May require surgery

MCL Sprain Involved Structures: MCL Can also involved medial joint capsule and medial meniscus because of attachment MOI: Result of direct blow to outside of knee or a twisting force of knee VALGUS force

MCL Sprain MOI twisting or direct blow = VALGUS force

MCL Sprain S/S: Observation: Pain along medial aspect of knee Observation: Swelling around MCL Palpation: Tender along medial aspect of knee Special Tests: Positive valgus stress test

MCL Sprain Care RICE Crutches Rehabilitation Progression Focus on quadriceps strengthening Heals well  Surgery usually not necessary

LCL Sprain Involved Structures: LCL MOI: Result of a varus force Direct blow is rare

LCL Sprain MOI  Direct blow to inside of knee or twisting = VARUS force

LCL Sprain S/S: Observation: Palpation: Care: Pain over lateral aspect of knee Observation: Swelling around LCL Palpation: Pain and tenderness over LCL Special Tests: Positive varus stress test Care: RICE Crutches Rehabilitation Progression Focus on quadriceps strengthening

Meniscus Injuries Involved Structures: Medial meniscus more common because it attaches to MCL Lateral meniscus not attached and therefore can “move out of the way” MOI: Rotational force while weight bearing

Meniscus Injuries S/S: Observation: Palpation: Special Tests: Intermittent locking, clicking, and giving way Pain- increase with squatting Observation: Swelling may be present Palpation: Point tender along joint line Special Tests: Loss of ROM Positive McMurray Test MRI Confirmation

Meniscus Injuries Care: Location/size of tear determines need for surgery Disability, pain, and locking may mean surgery is required 2 Surgery Options: 1.) Menisectomy = remove part of meniscus Quick recovery! 2.) Meniscus Repair = suture to repair torn portion Long recovery!

Meniscal Tears

Surgical Treatment of Meniscal Tears Menisectomy Suture/ Repair

Tibiofemoral Dislocation Involved Structures: Tibia Femur Poplietal Artery Knee Ligaments MOI: High velocity impact Car accident Direct blow during contact sport Up to 40 percent of patients with knee dislocations sustain an associated vascular injury

Tibiofemoral Dislocation S/S: Pain, instability, and deformity Observation: Obvious deformity Special Tests: X-Ray and MRI Nerve and Vascular tests to assess damage

Tibiofemoral Dislocation Care: Immobilization- splint on field to prevent further damage Surgical emergencies Without rapid identification and repair, associated vascular injuries may jeopardize the leg. Immediate reduction followed by careful neurovascular assessment is necessary. Eventual repair of ligaments

Tibial Plateau Fracture Involved Structures: Tibial plateau Femoral condyles MOI: Fall with knee extended Axial load Twisting

Tibial Plateau Fracture S/S: Pain with weight bearing Observation: Swelling Palpation: Point tender near joint line Special Tests: X-ray and MRI to confirm Care: Non-displaced = brace and rehabilitation Displaced = surgery

Patellar Dislocation Involved Structures: MOI: Patella Patellofemoral Groove Medial Retinaculum Lateral dislocation is most common! MOI: Direct blow Rapid change of direction Twisting of knee

Patellar Dislocation S/S: Observation Palpation Special Tests: Total loss of function Pain Unstable Observation Obvious Deformity Rapid Swelling Palpation Obvious deformity Pain along medial aspect of knee Special Tests: Limited ROM Positive Apprehension Test X-ray

Patellar Dislocation Care: Immobilize RICE Rehabilitation program focusing on quadriceps Surgery may be required for repeated dislocations Taping/Bracing McConnell Tape Knee Brace

Patellar Fracture Involved Structures: Quadriceps tendon Patellar tendon MOI: Direct or indirect trauma (severe pull of tendon) Forcible contraction, falling, jumping or running

Patellar Fracture S/S: Pain, swelling Observation: Swelling, possible deformity Palpation: Tender over patella Palpable deformity may be present Special Tests: Limited ROM X-ray necessary for confirmation of findings

Patellar Fracture Care: Splint- prevent further injury RICE Immobilize for 2-3 months for bone healing

Cartilage Defect Involved Structures: MOI: Articular cartilage Behind patella Femoral Condyle Tibial Plateau MOI: Acute= rotational force Chronic= Degeneration of cartilage S/S: Pain with weight bearing

Cartilage Defect Observation: Swelling may be present Palpation: May or may not be tender depending on location of defect Special Tests: X-ray and MRI to confirm ROM may be limited Care: May or may not need surgery depending on location and size of defect

Patellar Tendonitis Involved Structures: Patella Patellar tendon Tibial Tuberosity MOI: Jumping or kicking - placing tremendous stress and strain on patellar or quadriceps tendon Sudden or repetitive extension may lead to inflammatory process S/S: Pain and tenderness at inferior pole of patella, along tendon, or at tibial tuberosity

Patellar Tendonitis Observation: Special Tests: May affect gait Redness/bruising could occur Palpation: Pain and tenderness at inferior pole of patella patellar tendon tibial tuberosity Special Tests: ROM and strength testing (flexion and extension) Increased pain with extension MRI possibly

Patellar Tendonitis Care: Avoid aggravating activities Ice cup massage Anti-inflammatory medicine Flexibility of quads and hamstrings Patellar tendon bracing: off load the patellar tendon to decrease stress Cho Pat Brace/Strap Pre-wrap roll

IT Band Syndrome Involved Structures: IT band insertion over lateral femoral condyle MOI: Overuse: increased friction during flexion and extension IT band slides over lateral femoral condyle Leads to irritation of bursa Common in runners and cyclists Malalignments and structural asymmetries of foot and lower leg

IT Band Syndrome S/S: Tenderness, warmth, swelling, and redness over lateral femoral condyle Pain with activity Observation: Could be mild swelling, redness but typically observation is normal Palpation: Tender over IT band insertion; Increased warmth Special Tests: ROM: increased pain with flexion and extension Positive Noble’s Compression Test

IT Band Syndrome Care: Correction of mal-alignments ICE and NSAIDs Stretching and light foam rolling of IT band Avoidance of aggravating activities Taping/Bracing Compression sleeve Cho Pat / Pre-wrap rolled over insertion

Pes Anserine Bursitis Involved Structures: MOI: Pes Anserine Gracilis Sartorius Semitendinosus Bursa Anterior medial aspect of tibia MOI: Overuse Common in runners Improper training/technique Knee malalignments Could also be caused by a direct blow to the anterior medial aspect of tibia

Pes Anserine S/S: Pain at bursa Observation: Mild swelling/redness could occur Palpation: Point tender over pes anserine Special Tests: Flexibility testing  Hamstring tightness Care: Rest / avoid activities that increase pain Ice cup massage Anti-inflammatory medicine Increase flexibility of hamstrings with stretching and foam rolling

Patellofemoral Pain Syndrome Involved Structures: Patella Patellofemoral Groove Quadriceps muscles MOI: Overuse patella tracking wrong within the patellofemoral groove Muscle imbalances Knee malalignments

Patellofemoral Pain Syndrome S/S: Feel like patella is “slipping” Pain around edges or underneath patella May report “clicking” or “crunching” sensation Crepitus! Symptoms increase going up and down stairs Observation: Knee malalignments Patella malalignments Palpation: May or may not be point tender around patellofemoral joint

Patellofemoral Pain Syndrome Special Tests: X-rays can help determine alignment problems Flexibility testing ROM and strength testing Positive Patellar Grind Test Patella Mal-tracking

Patellofemoral Pain Syndrome Care: Rest  Avoid aggravating activity Ice and anti-inflammatory medicine Correct malalignments, if possible Rehab exercises to correct muscle imbalances Bracing: Knee Brace to correct lateral glide of patella