2. Mohsen Mardani-Kivi, M.D. Orthopedic Department, Guilan University Of Medical Sciences

3. Anatomy Bones: Femur Tibia patella

4.  ligaments  MCL  LCL  ACL  PCL Anatomy

5. Extensor muscles : Muscles: Quadriceps:  Vastus medialis  Vastus lateralis  Rectus femoris  Vastus intermedius

6. Flexor muscles :  Semimembranosus  Semitendinosus  Biceps femoris  gastrocnemius

7. Biomechanics :  Tibiofemoral Joint  Patello-femoral joint

8. Patella :  largest sesamoid bone  The primary functional role: knee Extension

9. Femoral condyles The medial condyle is larger and lower than the lateral condyle.

10. Valgus and Varus Genu

11.  Flexion : 120-150°  Extension : 5-10°  Internal rotation : 10°  External rotation : 30-40° Major Movements

12.  Inspection :  Baker's cyst  genu recurvatum  Valgus deformity (knock-kneed)  Varus deformity (bowlegged) Physical Examination

13.  Palpation :  Temperature change  Joint line tenderness Physical Examination

14.  Motion :  The patient should be asked to move their knee  Full ROM is 0-135 degrees  Examination of crepitus : clicking of the joint with motion Physical Examination

15. Valgus or varus stress test: One hand at the lateral aspect of the knee joint and the other hand at the medial aspect of the distal tibia. Valgus or varus stress is applied to the knee at both zero degrees (full extension) and 30 degrees of flexion.

16. 1-Anterior Drawer Test Anterior force applied at 90 degrees of flexion Examination

17. 2-Posterior Drawer Test Most accurate test for PCL tear. Patient in supine position with knee flexed 90°. Apply a posteriorly directed force to proximal tibia. Examination

18. 3-Lachman Test: best test for ACL laxity. Knee placed in 20-30 degrees of flexion, the femur is stabilized, and an anteriorly directed force applied to proximal calf. Examination

19. 4-Pivot-Shift Test Confirms complete ACL tear. Based on very early flexion causing anterior subluxation of the tibia that is reduced with further flexion (20-40 degrees) due to the posterior pull of the iliotibial tract. Examination

20. Mc. Murray’s Test Examination

21. ACL

22. Etiogenesis: Sports-related injury Sports-related injury (80% non- contact!) Motor-vehicle collisions Falls Work-related injuries. occur when pivoting or landing from a jump. The knee gives-out from under the athlete when the ACL is torn. ACL injury

23. How is the ACL injured

24. ACL injuries in Female athletes: competitive sports higher risk while participating in competitive sports. ACL injury

25. Noncontact Audible pop (usually a hyper-Ext.+ pivot combination Hemarthrosis Unable to return to play. Contact and high-energy trauma Often associated with other ligamentous and meniscal injuries. terrible triad A valgus stress to the knee  The classic "terrible triad": ACL, MCL, and medial meniscus tears Clinical feature

26. Signs and Symptoms Acute Marked pain and pop Swelling Difficulty at bearing weight on the affected knee Chronic loose The knee feels loose giving way “buckling”, “giving way” or instability Pain and swelling

27. Radiography

28. Diagnosis History Physical exam X-rays  normal (only to R/O fracture) (Gold Standard) MRI  (Gold Standard) excellent for evaluating not only the ACL but also the meniscus, articular cartilage and other knee ligaments

29. In adult with bone fracture With other lesion Just ligament tearing : General Population Athlete Chronic tearing

30. Treatment acute What is the treatment for an acute ACL tear? Rest Ice Elevation Compression Protected Weight Bearing Brace

31. Treatment

32. Surgery Reconstruction of the ACL by drilling tunnels in your femur and tibia Tunnel in thigh bone for graft passage ↑

33. Meniscal Tear

34. Functions of the menisci Lubrication and nutrition of the joint Shock absorbers Evenly distribute weight throughout the knee Allows for smoother motions between the femur and tibia

35. The inner 2/3 of the menisci are avascular Only! outer 1/3 is vascular (with blood supply) Anatomy

36. Mechanisms of injury Sport injury: Usually the foot stays fixed on the ground and the rest of body rotates Getting up from a squatting or crouching position Loading the knee from a fixed position

37. Types of Meniscal Tear Types: Vertical Radial Horizontal Degenerate Complex Horn A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of the knee

38. Torn meniscusSuture repair of meniscus Treatment

39. MCL SPRAIN

40. MCL Sprain Usual cause: Contact sports Contact sports Force applied to the outside of the knee, which pushes the knee inwards and beyond its normal range of motion.

41. Inside knee Pain Swelling Instability Perhaps a popping sound heard at the moment of injury Sprained MCL Symptoms

42.  Medical history  Ph/Ex.  X-ray imaging  R/O fractures  MRI MCL Sprain Diagnosis

43. Usually respond to conservative treatment, Ice pack Resting the knee joint Bandage and Bracing NSAIDs Surgery is rarely required. MCL Sprain Treatment

44. MCL Tear

45. May occur: isolated or complex injury (most commonly: ACL and/or Meniscal tear).

46.  Pain  Swelling  Limitated ROM  positive valgus stress test Symptoms

47.  Simple Radiography  Stress Film  Ant. Graphy in Abd Diagnosis

48.  Cast  Brace  Surgery Treatment

49. LCL Tear

50. Etiogenesis: direct blow to the inside of the knee

51.  Pain  Swelling  Limited ROM  positive varus stress test  Drop foot: Weakness in the foot, if the peroneal nerve is stretched during the injury or is pressed by swelling in surrounding tissues Symptoms

52.  Rest  NSAIDs  Ice  Knee Exercises Treatment

53. Rehab

54. physical therapy The first few sessions of PT  more modalities / fewer manual techniques: Heat/ice Ultrasound Electrical stimulation Manual stretching Passive ROM for full knee flexion and extension

55. Once pain and swelling are reduced  mainly focus on increasing the strength and flexibility Vary depending on the individual physical therapy

56. Stretching Hamstrings Quadriceps Calf muscles

57. Stretching continued Hip flexors Hip adductors

58. Strengthening Focusing on strengthening the muscles around the knee is essential in rehabilitation Quad sets Straight leg raises (in all planes) Heel raises Leg Curl Leg extension

59. Balance Balance can sometimes be compromised after an injury or surgery Here are some balance exercises that can help

60. Dynamic exercises Progression to more dynamic sports specific exercises helps with the transition back into sports