Dr Ali.Yassaie Orthopaedic surgeon

 OVERUSE KNEE INJURIES  ACUTE KNEE INJURIES

 ILIOTIBIAL BAND FRICTION SYNDROME  POPLITEUS TENDINITIS  PATELLOFEMORAL JOINT PAIN SYNDROME  PATELLOFEMORAL SYNOVIAL PLICA  INFRAPATELLAR FAT PAD SYNDROME  PATELLAR TENDINITIS(JUMPER ’ S KNEE)  PES ANSERINUS BURSITIS

 Caused by tight ITB rubbing over lateral epicondyle of femur when running  Sharp pain over lateral knee when running or cycling  Occassional swelling

 CAUSES: 1- SINGLE LONG HARD RUN 2- RAPID INCREASE IN TRAINING DISTANCES 3- BANKED SURFACES RUN: BEACH OR SHOULDER OF ROAD 4- EXCESSIVE HILL RUNNING

 TREATMENT: 1- REDUCTION OF TRAINING DISTANCE, NSAIDS, DAILY STRETCHING ITB 2- STRENGTHEN IPSILATERAL HIP ABDUCTORS 3- LOCAL INFILTRATION OF CORTICOSTEROID 4- SURGERY

 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

 TREATMENT: 1- REDUCTION TRAINING DISTANCE 2-NSAIDS 3-STRETCHING KNEE FLEXORS 4-ELECTROTHERAPY 5-CORTICOSTEROID INJECTION

 PAIN UNDER “ KNEE CAPS ” WORSEN BY CLIMBING OR DESCENDING HILLS OR STAIRS  PAIN AFTER SITTING DOWN FOR LONG PERIODS  FEMALES MORE THAN MALES  MOST OFTEN SEEN IN ATHLETES PRESENTING IN ADOLESCENCE AND INTO THE 4 th AND 5 th DECADES

 CREPITUS  IRRITABILITY OF PFJ  SMALL SWELLING  QUADRICEPS WEAKNESS AND WASTING (VASTUS MEDIALIS )

 Overuse 1-jogging 2-squatting 3-stairs 4-sudden change(intensity,duration) 5-improper technique or equipment 6-change in footwear or playing surface

 Patellar malalignment 1-malalignment of the legs:(bowleg,knockknee,patella alta) 2-muscular imbalance or weakness

 Activity change(swimming,biking)  Losing weight  Rice method(rest,ice,compression,elevation)  Medication  Physical therapy  surgeory

 Prevention: 1-appropriate shoes 2-warming up 3-streching and flexibility exercises of quadriceps and hamstring 4-increase training gradually 5-reduce any activity that hurt your in the past 6-proper weight

 REMNANTS OF THE SEPTA OF EMBRYONIC JOINT  USUALLY PRESENT BUT ASYMPTOMATIC  MEDIAL PATELLAR PLICA RUNS FROM SUPRAPATELLAR POUCH TO THE INFRAPATELLAR FAT PAD  IMPINGMENT OF THE MEDIAL FEMORAL CONDYLE AND PFJ IN FLEXION

 ACHING ON SITTING DOWN ANTERIORLY  INTENSE THE FIRST WALKING STEPS IN THE MORNING  FELT BANDS MEDIALLY  MILD EFFUSION  PAIN ON RESISTED KNEE EXTENSION MADE WORSE BY GLIDING PATELLA MEDIALLY

 REST  NSAIDS  CORTICOSTEROID INJECTION IF MEDIAL PLICA PALPABLE  ARTHROSCOPIC EXCISION

 REPETITIVE HYPEREXTENTION INJURIES  SURGICAL INTERVENTION  PAIN ON HYPEREXTENTION OVER ANTERIOR KNEE REGION  REST FROM HYPEREXTENTION (MARTIAL ARTS ), NSAIDS, ELECTROTHERAPY

 REPETITIVE EXTENSOR ACTION OF THE KNEE WITH A GENERATION OF LARGE ECCENTRIC FORCES  JUMPING AND LOADING FORCES APPLY THE GREATEST TENSILE FORCES IN THE PATELLAR TENDON WHEN IN LANDING

 GRADUAL ONSET PAIN LOWER POLE OF PATELLA  ASSOCIATED WITH INCREASED TRAINING LOAD  ACUTE EXACERBATIOUS  TENDERNESS  SWELLING  CREPITUS LOCALLY OVER TENDON

 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

 BURSA INFLAMMATION AT MEDIAL ASPECT OF UPPER TIBIA  BURNING LOCALIZED PAIN WHEN RUNNING  TIGHT HAMSTRINGS,INADEQUATE STRETCHING, PREVIOUS HAMSTRING INJURY

 STRETCHING HAMSTRINGS  NSAIDS  REST WHEN ACUTE  LOCAL INFILTRATIONS  ORTHOTICS

 1) ANTERIOR CRUCIATE LIGAMENT RUPTURE (ACL)  2) POSTERIOR CRUCIATE LIGAMENT RUPTURE (PCL)  3) MEDIAL COLLATERAL LIGAMENT TEAR (MCL)  4) LATERAL COLLATERAL LIGAMENT TEAR (LCL)  5) INJURIES TO THE MENISCI  6) OSTEOCHONDRAL PROBLEMS  7) PATELLOFEMORAL INSTABILITY

 30 NEW CASES PER POPULATION PER YEAR  FOOTBALL, BASKETBALL, SKI,...

 Mechanism: 1-Twisting 2-Pivoting 3-Sudden stop

 PAIN  EFFUSION  LACHMAN ’ S TEST  PIVOT SHIFT TEST  ACUTE HAEMARTHOSIS  Giving way

 CONSERVATIVE TREATMENT: RICE BRACE PHYSICAL THERAPY

 SURGICAL TREATMENT: FAILURE>50% CONSERVATIE TREATMENT ARTHROSCOPIC REPAIR

 TWICE STRONGER THAN ACL  RESISTS ANTERIOR SLIDE OF FEMUR WHEN WEIGHT BEARING  RESISTS HYPEREXTENSION  CONTRIBUTES TO MEDIAL STABILITY OF KNEE

 MECHANISMS: 1-DIRECT BLOW OVER UPPER TIBIA WITH KNEE IN FLEXION 2-HYPEREXTENSION OF THE KNEE

 PFJ PAIN  “ GIVING WAY ” RUNNING DOWNHILL  POSTERIOR “ SAG ” INCREASED RECURVATUM OF THE KNEE  PROBLEMS WITH LONG DISTANCE RUNNING, ” STOP-START ” SPORTS,SQUASH

 TREATMENT: 1-CONSERVATIVE WHEN ISOLATED RUPTURE (80% SUCCESS) 2-ARTHROSCOPIC REPAIR

 DIRECT VALGUS FORCE  EXTERNAL TIBIAL ROTATION FORCE  THREE DEGREES OF SEVERITY INJURIES

 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 )

RARE, DIRECT VARUS FORCE PART OF POSTEROLATERAL CORNER STABILITY COMBINED WITH ACL, PCL RUPTURES CONSERVATIVE OR RECONSTRUCTION

 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

 MECHANISM: KNEE FORCED IN FLEXION AND ROTATION WHILE WEIGHT-BEARING  MEDIAL MENISCUS: POSTERIOR THIRD TEARS MORE COMMON  LATERAL MENISCUS: MIDDLE THIRD TEARS MORE COMMON

 JOINT LINE PAIN  LOCKING  GIVING WAY  SMALL SWELLING  - McMURRAY ’ S TEST  APLEY ’ S TEST  MENISCUS CYSTS  ARTHROGRAM  MRI

 ACUTE INJURY: 1-RICE 2-PHYSIOTHERAPY 3-REFER IF NOT SETTLED IN 3 WEEKS

 CHRONIC INJURY 1-INVESTIGATE 2-PARTIAL MENISCECTOMY 3-REPAIR

 OSTEOCHONDRAL FRACTURE ( MIMIC MENISCAL TEARS )  OSTEOCHONDRITIS DISSECANS ( SEPARATED SEGMENT )

Acute trauma Wear and tear Pain Swelling

 Non Surgical: Activity Modification, Pain Medications, Injections  Surgical: Arthroscopic debridement and removal of lose fragments Procedures to restore weight bearing surface

 DISLOCATIONS:  ATHLETE TWISTS ON FIXED TIBIA  IMMEDIATE DEFORMITY AND PAIN  DISLOCATION MAY REDUCE ITSELF

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

DISLOCATION: 3 WEEKS FULL EXTENSION BRACE FOR 6 WEEKS BRACE AT THE FIRST RETURN TO SPORT (PROPRIOCEPTION) SURGERY IF RECURRENT PROBLEM

 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

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