KNEE INJURIES PANOS THOMAS TUTOR MSc SPORTS AND EXERCISE MEDICINE UCL

KNEE INJURIES 1) OVERUSE KNEE INJURIES 2) ACUTE KNEE INJURIES

OVERUSE KNEE INJURIES 1) ILIOTIBIAL BAND FRICTION SYNDROME 2) POPLITEUS TENDINITIS 3) PATELLOFEMORAL JOINT PAIN SYNDROME 4) PATELLOFEMORAL SYNOVIAL PLICA 5) INFRAPATELLAR FAT PAD SYNDROME 6) PATELLAR TENDINITIS(JUMPER’S KNEE) 7) PES ANSERINUS BURSITIS

1) ILIOTIBIAL BAND FRICTION SYNDROME (ITB) - TENDON WITHIN FASCIA LATA FROM ILIAC CREST INTO GERDY’S TUBERCLE TIBIA - KNEE FLEXED 30 DEGREES: ITB BEHIND LATERAL FEMORAL CONDYLE KNEE EXTENDED: ITB MOVES ANTERIORLY - ITB SYNDROME: INFLAMMATION DISTALLY IN THE BURSA BETWEEN ITB AND LATERAL FEMORAL CONDYLE

1) ILIOTIBIAL BAND FRICTION SYNDROME CAUSES: A) SINGLE LONG HARD RUN B) RAPID INCREASE IN TRAINING DISTANCES C) BANKED SURFACES RUN: BEACH OR SHOULDER OF ROAD D) EXCESSIVE HILL RUNNING - DISCOMFORT OVER LOWER 3cm ITB, WORSE RUNNING DOWNHILL

1) ILIOTIBIAL BAND FRICTION SYNDROME - O/E: CREPITUS, PAIN ON COMPRESSION OVER LATERAL FEMORAL CONDYLE - “ STRETCHED ITB “: LEG MALALIGNMENT, LEG LENGTH DISCREPANCY, EXCESSIVE FOOT PRONATION, PELVIC CONTRALATERAL DOWNWARD TILT

1) ILIOTIBIAL BAND FRICTION SYNDROME TREATMENT: A) 1st LINE: REDUCTION OF TRAINING DISTANCE, NSAIDS, DAILY STRETCHING ITB, CORRECT ORTHOSIS FOOT PRONATION, STRENGTHEN IPSILATERAL HIP ABDUCTORS ( PELVIC DROP ON GAIT ANALYSIS )

1) ILIOTIBIAL BAND FRICTION SYNDROME TREATMENT: 2nd LINE: LOCAL INFILTRATION OF CORTICOSTEROID 3rd LINE: SURGERY TO DIVIDE ITB 3cm ABOVE LATERAL FEMORAL EPICONDYLE ( V-SHAPED DEFECT ETC )

2) POPLITEUS TENDINITIS - SURROUNDS POSTER.LATERAL ASPECT OF KNEE, STABILIZER IN FLEXION BY RESISTING FORWARD DISPLACEMENT OF THE FEMUR ON THE TIBIA - LESS COMMON BUT SAME CAUSES AS ITB (D/D)

2) POPLITEUS TENDINITIS - DISCOMFORT ANTERIOR OF SUPERIOR LAT.COLLATERAL LIGAMENT AND WITH RESISTED KNEE FLEXION WITH TIBIA HELD IN EXTERNAL ROTATION - TREATMENT: REDUCTION TRAINING DISTANCE, NSAIDS, STRETCHING KNEE FLEXORS, ELECTROTHERAPY. CORTICOSTEROID INJECTION

3) PATELLOFEMORAL JOINT PAIN SYNDROME - FEMALES MORE THAN MALES - MOST OFTEN SEEN IN ATHLETES PRESENTING IN ADOLESCENCE AND INTO THE 4th AND 5th DECADES - PAIN UNDER “KNEE CAPS” WORSE BY CLIMBING OR DESCENDING HILLS OR STAIRS. PAIN SITTING DOWN FOR LONG PERIODS. CREPITUS - ANY SPORT COULD BE ASSOCIATED WITH PFJ PAIN SYNDROME

3) PFJ PAIN SYNDROME - O/E: CREPITUS, IRRITABILITY OF PFJ, SMALL SWELLING, QUADRICEPS WEAKNESS AND WASTING ( VASTUS MEDIALIS ) - BIOMECHANICAL FACTORS: WIDE Q ANGLE (ABOVE 16 DEGREES IN MALES, 18 DEGREES IN FEMALES), SMALL HIGH PATELLA, GENU VALGUS, SHALLOW INTERCONDYLAR NOTCH, PRONATED GAIT WHICH INCREASES IR OF THE TIBIA

3) PFJ PAIN SYNDROME - PAIN IS A COMBINATION OF REPETITIVE INCREASE OF PRESSURE OVER SUBCHONDRAL BONE AND TIGHT RETINACULAR STRUCTURES - PRESSURE OVER ARTICULAR CARTILAGE AFFECTS NUTRITION AND RESULTS IN DEGENERATIVE CHANGES - VASTUS MEDIALIS DYSFUNCTION RESPONSIBLE: FAILURE TO COMPENSATE TENDENCY TO LATERAL SHIFT PATELLA

3) PFJ PAIN SYNDROME - VASTUS MEDIALIS RE-EDUCATION: EXERCISES, McCONNELL’S TAPING, DROP-SQUATS, ECCENTRIC DRILLS FOR 6-8 WEEKS - SURGERY: DEBRIDEMENT AND LATERAL RELEASE PATELLAR TENDON REALIGNMENT ( CORRECT WIDE Q ANGLE )

4) PATELLOFEMORAL SYNOVIAL PLICA - REMNANTS OF THE SEPTA OF EMBRYONIC JOINT. USUALLY PRESENT BUT ASYMPTOMATIC - SYMTOMATIC PLICA: MEDIAL PATELLAR PLICA RUNS FROM SUPRAPATELLAR POUCH TO THE INFRAPATELLAR FAT PAD MAY IMPINGE OF THE MEDIAL FEMORAL CONDYLE AND PFJ IN FLEXION

4) PF SYNOVIAL PLICA - ACHING ON SITTING DOWN ANTERIORLY, INTENSE THE FIRST WALKING STEPS IN THE MORNING O/E: FELT BANDS, MEDIALLY, MILD EFFUSION, PAIN ON RESISTED KNEE EXTENSION MADE WORSE BY GLIDING PATELLA MEDIALLY - TREATMENT: REST, NSAIDS, CORTICOSTEROID INJECTION IF MEDIAL PLICA PALPABLE. ARTHRO. EXCISION

5) INFRAPATELLAR FAT PAD SYNDROME - REPETITIVE HYPEREXTENTION INJURIES, SURGICAL INTERVENTION - PAIN ON HYPEREXTENTION OVER ANTERIOR KNEE REGION - PART OF PATELLA BAJA: SHORTER PATELLAR TENDON FROM FIBROSIS (? PREVIOUS SURGERY) BLOCKING KNEE FLEXION

5) INFRAPATELLAR FAT PAD SYNDROME - TREATMENT: REST FROM HYPEREXTENTION (MARTIAL ARTS ) , NSAIDS, ELECTROTHERAPY. SIGNIFICANT FIBROSIS: ARTHROSCOPIC EXCISION

6) PATELLAR TENDINITIS ( JUMPER’S KNEE ) - REPETITIVE EXTENSOR ACTION OF THE KNEE WITH A GENERATION OF LARGE ECCENTRIC FORCES - BIOMECHANICAL ANALYSIS IN BASKETBALL: JUMPING AND LOADING FORCES APPLY THE GREATEST TENSILE FORCES IN THE PATELLAR TENDON WHEN IN LANDING

6) PATELLAR TENDINITIS ( JUMPER’S KNEE ) - GRADUAL ONSET PAIN LOWER POLE OF PATELLA. ASSOCIATED WITH INCREASED TRAINING LOAD, ACUTE EXACERBATIOUS - O/E: TENDERNESS, SWELLING, CREPITUS LOCALLY OVER TENDON. QUADRICEPS TIGHTNESS (?) INFRAPATELLAR BURSITIS - U/S OR MRI: DEFECT WITHIN THE TENDON

6) PATELLAR TENDINITIS ( JUMPER’S KNEE ) - HISTOLOGY: A) TENOPERIOSTITIS OF LOWER POLE OF THE PATELLA B) GRANULATION OF THE TENDON DEEP IN ITS SHEATH (DEGENERATION )

6) PATELLAR TENDINITIS ( JUMPER’S KNEE ) TREATMENT: - ACUTE EXACERBATION: ACTIVE REST, ICE, NSAIDS, 6 WEEKS RECOVERY - CHRONIC: A) THERMAL (HEAT RETAINING) SLEEVE B) ECCENTRIC EXERCISES, DROP-SQUAT PROGRAMME C) STRENGTHEN SYNERGISTS OF QUADRICEPS

6) PATELLAR TENDINITIS ( JUMPER’S KNEE ) TREATMENT: D) FOOTWEAR, TRACK SURFACE, TAPING PATELLAR TENDON - SURGERY: EXCISION INFERIOR POLE OF PATELLA AND SCARING FROM TENDON (? REPAIR THE TENDON ) 6 MONTHS RECOVERY

7) PES ANSERINUS BURSITIS - BURSA INFLAMMATION AT MEDIAL ASPECT OF UPPER TIBIA - BURNING LOCALIZED PAIN WHEN RUNNING - TIGHT HAMSTRINGS, INADEQUATE STRETCHING, PREVIOUS HAMSTRING INJURY, HAMSTRING ORIENTATION TRAINING PROGRAMME

7) PES ANSERINUS BURSITIS TREATMENT: STRETCHING HAMSTRINGS, NSAIDS, REST WHEN ACUTE, LOCAL INFILTRATIONS, ORTHOTICS

ACUTE KNEE INJURIES 1) ANTERIOR CRUCIATE LIGAMENT RUPTURE (ACL) 2) POSTERIOR CRUCIATE LIGAMENT RUPTURE (PCL) 3) MEDIAL COLLATERAL LIGAMENT TEAR (MCL) 4) LATERAL COLLATERAL LIGAMENT TEAR (LCL)

ACUTE KNEE INJURIES 5) INJURIES TO THE MENISCI 6) OSTEOCHONDRAL PROBLEMS 7) PATELLOFEMORAL INSTABILITY

1) ACL RUPTURE - 30 NEW CASES PER 100.000 POPULATION PER YEAR - FOOTBALL, BASKETBALL, SKI - INTRACAPSULAR STRUCTURE, THREE BANDS OF LIGAMENT: ANTEROMEDIAL, INTERMEDIATE, POSTEROLATERAL - GIVING WAY AFTER TURN, PIVOT, JUMP, AUDIBLE CRACK, HAEMATHROSIS

1) ACL RUPTURE FUNCTIONS – MECHANISM OF INJURY A) “ SCREWING HOME” TIBIA OVER FEMUR BY EXT.ROTATE TIBIA WHEN KNEE EXTENDS B) RESISTING ANTERIOR DISPLACEMENT OF THE TIBIA ON THE FEMUR (SKI) C) EXCESSIVE EXT.ROTATION OF TIBIA (COMBINED MCL AND ACL INJURY )

1) ACL RUPTURE D) VARUS FORCE (LCL AND ACL INJURY ) E) HYPEREXTENSION FORCE ( ACL AND PCL INJURY )

1) ACL RUPTURE - O/E: PAIN, EFFUSION, LACHMAN’S TEST, PIVOT SHIFT TEST - ACUTE HAEMARTHOSIS: 60-80% ACL RUPTURE - X-RAYS: TIBIAL SPINE AVULSION, SEGOND FRACTURE - CONSERVATIVE TREATMENT: 50% OF PATIENTS, HAMSTRINGS EXERCISES, PROPRIOCEPTION, (?) BRACE,(SKI)

1) ACL RUPTURE SURGICAL TREATMENT - FAILED CONSERVATIVE (50% PATIENTS ), AGE (?0A) - PRIMARY REPAIR, INTRARTICULAR GRAFT, EXTRARTICULAR STABILIZATION, ALLOGRAFT, SYNTHETIC LIGAMENT

1) ACL RUPTURE - ARTHROSCOPIC SURGERY VERSUS OPEN SURGERY - UPDATE SURGERY: ARTHROSCOPIC RECONSTRUCION USING PATELLAR OR HAMSTRINGS INTRARTICULAR GRAFT

2) PCL RUPTURE - EXTRASYNOVIAL STRUCTURE, TWICE STRONGER THAN ACL - RESISTS ANTERIOR SLIDE OF FEMUR WHEN WEIGHT BEARING, RESISTS HYPEREXTENSION AND CONTRIBUTES TO MEDIAL STABILITY OF KNEE - MECHANISMS: DIRECT BLOW OVER UPPER TIBIA WITH KNEE IN FLEXION, HYPEREXTENSION OF THE KNEE

2) PCL RUPTURE - PFJ PAIN “GIVING WAY” RUNNING DOWNHILL - O/E: POSTERIOR “SAG”, INCREASED RECURVATUM OF THE KNEE - X-RAYS: AVULSIONS FROM TIBIA - TREATMENT: CONSERVATIVE WHEN ISOLATED RUPTURE (80% SUCCESS) - PROBLEMS WITH LONG DISTANCE RUNNING,”STOP-START” SPORTS,SQUASH

3) MCL INJURY - DIRECT VALGUS FORCE, EXTERNAL TIBIAL ROTATION FORCE - THREE DEGREES OF SEVERITY INJURIES -O/E: 30 DEGREES FLEXION OF THE KNEE VALGUS FORCE TEST TREATMENT: GRADE I: 6 WEEKS RECOVERY, 8 WEEKS TO SPORT GRADE II: 6 WEEKS CRUTCHES, 12 WEEKS TO RECOVER GRADE III: ARTHROSCOPY (OTHER INJURIES ACL ETC )

3) MCL INJURY PELLEGRINI – STIEDA DISEASE - FEMORAL ORIGIN DISRUPTION OF MCL - HETEROTOPIC CALCIFICATION OF PROXIMAL FIBRES - 3-6 WEEKS FROM INJURY, MARKED PAIN ON TWISTING, RESTRICTION OF FLEXION AND EXTENSION - ACTIVE MOBILIZATION (PRESERVE ROM),EXCISION SURGERY

4) LCL INJURY - RARE, DIRECT VARUS FORCE - PART OF POSTEROLATERAL CORNER STABILITY - COMBINED WITH ACL, PCL RUPTURES - CONSERVATIVE OR RECONSTRUCTION (PART OF PLC)

5) MENISCI INJURIES - SHOCK-BEARING STRUCTURES OR “SHOCK ABSORBERS” - REDUCE DISPARITY BETWEEN FEMORAL AND TIBIAL SURFACES, SO INCREASE STABILITY - ASSIST IN ARTICULAR CARTILAGE NUTRITION - CUSHION HYPEREXTENSION AND HYPERFLEXION

MENISCI INJURIES - NUTRITION: PERIPHERY FROM VASCULAR PLEXUS SUPPLY - MED. MENISCUS: POSTERIOR THIRD TEARS MORE COMMON - LAT. MENISCUS: MIDDLE THIRD TEARS MORE COMMON - MECHANISM: KNEE FORCED IN FLEXION AND ROTATION WHILE WEIGHT-BEARING

5) MENISCI INJURIES - PAIN JOINT LINE, LOCKING, GIVING WAY, SMALL SWELLING - McMURRAY’S TEST, APLEY’S TEST, MENISCUS CYSTS - ARTHROGRAM, MRI SCAN - ACUTE INJURY: PHYSIOTHERAPY, REFER IF NOT SETTLED IN 3 WEEKS - CHRONIC INJURY: INVESTIGATE, PARTIAL MENISCECTOMY, REPAIR

6) OSTEOCHONDRAL PROBLEMS - OSTEOCHONDRAL FRACTURE ( MIMIC MENISCAL TEARS ) - OSTEOCHONDRITIS DISSECANS ( SEPARATED SEGMENT )

7) PATELLOFEMORAL INSTABILITY DISLOCATIONS: - SEVERE INJURY: PFJ PAIN SYNDROME, RECURRENT DISLOCATION, LOOSE BODIES FORMATION - ATHLETE TWISTS ON FIXED TIBIA - IMMEDIATE DEFORMITY AND PAIN. DISLOCATION MAY REDUCE ITSELF - RISK FACTORS AS PFJ PAIN SYNDROME

7) PATELLOFEMORAL INSTABILITY DISLOCATION: - REDUCTION: FLEX THE HIP AND GRADUALLY EXTEND THE KNEE - X-RAYS TO EXCLUDE OSTEOCHONDRAL FRACTURES, LOOSE BODIES

7) PATELLOFEMORAL INSTABILITY DISLOCATION: - 3 WEEKS FULL EXTENSION, BRACE FOR 6 WEEKS. BRACE AT THE FIRST RETURN TO SPORT (PROPRIOCEPTION) - SURGERY IF RECURRENT PROBLEM ( INCLUDE MANAGEMENT OF RISK ANATOMICAL FACTORS )

7) PATELLOFEMORAL INSTABILITY SUBLUXATION: - SUSPECTED WITH INSTABILITY – PAIN WHEN TURNING ON THE LEG - ELICIT A POSITIVE APPREHENSION TEST - RISK ANATOMICAL FACTORS TO BE CONSIDERED - CONSERVATIVE TREATMENT OR SURGICAL ANATOMICAL CORRECTION