Download Common Sports Injuries

Common Sports Injuries
Meniscus Tears
BY NEIL BARRY
USI 10098422
By Neil Barry. USI 1009842
• Introduction: based on the mechanism of meniscus tear
injuries, common sports these injuries are associated
with, and their rehabilitative and medical management
options.
Anatomy
• The Knee
Above and Below
• The Hip: good structural interity of
the knee helps maintain a healthy
Q angle at the hip. Poor stability
at the kneecan lead toincreased
Q angle, causing knee valgus.
This can lead to weakness in the
abductor group.
• The hamstring and quadriceps
group can also be affeted by knee
dysfunction overtime.
• Notably, the vastus medialis
oblique (VMO) tends to lose bulk
rapidly with decreases in knee
Above and Below
Meniscus• The word "meniscus" refers to
a crescent-shaped structure.
The medial meniscus of the
knee is a thickened crescentshaped cartilage pad between
the two joints formed by the
femur (the thigh bone) and the
tibia (the shin bone). The
meniscus acts as a smooth
surface for the joint to move
on.
• - Head of right tibia seen from
above, showing menisci and
attachments of ligaments->
Medial Meniscus
• The medial meniscus is a
C shaped fibrocartilage,
the circumference of which
is attached firmly to the
medial articular facet of
the tibia and to tthe joint
capsule by the coronary
ligaments. Posteriorly, it is
also attached to fibers of
the semimembrinosus
muscle
Lateral Meniscus
• This is more O shaped
• The ligament of Wrisberg
and is attached to the
is the part of the lateral
lateral articular facet on
meniscus that projects
the superior aspect of the
upward, close to the
tibia. The lateral meniscus
attachment of the posterior
also attaches loosely to
cruciate ligament.
the lateral articular capsule • The transverse ligament
and to the popliteal
joins the anterior portions
tendon.
of the lateral and medial
mensici.
The Meniscus
•
•
•
•
•
•
•
Anterior and posterior meniscal horns attach to the intercondylar eminence of the tibial plateau.
The coronary ligaments provide peripheral attachments between the tibial plateau and the
perimeter of both menisci.
The medial meniscus is also attached to the medial collateral ligament, which limits its mobility.
The lateral meniscus is connected to the femur via the anterior (ligament of Humphrey) and
posterior (ligament of Wrisberg) meniscofemoral ligaments, which can tension its posterior horn
anteriorly and medially with increasing knee flexion.
The transverse ligament provides a connection between the anterior aspects of both menisci. The
increased stability provided by the ligamentous attachments prevents the menisci from being
extruded out of the joint during compression.
The meniscus is typically an avascular structure with the primary blood supply limited to the
periphery. Only the peripheral 10% to 25% of the meniscus is vascularized.
For that reason, when meniscus is damaged in the central portion it is usually unable to undergo
a normal healing process. The most peripheral portion of the meniscus which has a blood supply
and is more likely to heal.
Meniscal Blood Supply
• Blood is supplied to each
meniscus by the medial
genicular artery. Each
meniscus can be divided int
three circumferential zones:
the red-red zone is the outer,
one third and has a good
vascular supply;
• the red-white zone is the
middle one third and has
minimal blood supply;
• the white-white zone on the
Clinical Presentation, Assessment and Diagnosis
• Joint line tenderness and effusion, either medially or laterally,
however it is of note that because the inner portion of the
meniscus is avascular and without nerve supply, an injury to the
meniscus can result in no pain or swelling.
• Symptoms are frequently worsened by flexing and loading the
knee, activities such as squatting and kneeling are poorly
tolerated.
• Complaints of 'clicking', 'locking' and 'giving way' are common
• Joint line tenderness has been reported to be the best common
test for meniscal injury.
• Arthroscopy and Imaging
Meniscal Lesions
• The medial meniscus has a much higher incidence of
injury than does the lateral because the coronary ligament
attaches the medial meniscus peripherally to the tibia and
also to the capsular ligament. The lateral meniscus does
not attach to the capsular ligament and is more mobile
during knee movement.
• Because of the attachment to the medial structures, the
medial meniscus is prone to disruption from valgus and
torsional forces.
Special Tests
• McMurray's test positive if a pop or a snap at the joint line
occurs while flexing and rotating the patient's knee.
• Apley's test performed with the patient prone, and with the
examiner hyperflexing the knee and rotating the tibial
plateau on the condyles.
• Steinman's test performed on a supine patient by bringing
the knee into flexion and rotating.
• Ege's Test is performed with the patient squatting, an
audible and palpable click is heard/felt over the area of
the meniscus tear. The patient's feet are turned outwards
to detect a medial meniscus tear, and turned inwards to
detect a lateral meniscus tear.
Common Mechanism of Injury in Sports
• a valgus force can adduct the knee, often tearing and
stretching the medialcollateral ligament; meanwhile its
fibers twist the medial meniscus outward.
• repeated mild strains reduce the strength of the knee to a
favorable one for catilaginous tear through lessoning its
noral ligamentous stability.
• the most common mechanism is weight bearing with a
rotational force while the knee is extended or flexed.
• cutting motions made while running can also distort the
medial meniscus.
Mechanism continued
• another way a longitudinal tear can occur is when the
knee is forcefully extended from a flexed positionwhile the
femur is internally rotated.
• during extension the medial meniscus is suddenly pulled
back, causing the tear.
• The lateral meniscus can sustain an oblique tear, when
the knee is forcefully extended while externally rotated.
• as a result of the force of this action, the meniscus is
pulled out of its normal bed and pinched between the
femoral condyles.
Evidence Based Guidelines
• Symptoms and signs
• Dx of these injuries should be made as early as possible,
to avoid muscle spasm and swelling obscuring the normal
shape of the knee.
• A meniscal tear may or may not result in the following:
• effusion developing gradually over 48-72 hurs
• joint-line pain and loss of motion
• intermittent locking and giving way of the knee
• pain during a squat
Signs cont'd
• After meniscal tears the rutured edges harden, and may
eventually atrophy.
• Portions of the meniscus MAY become detached and wedge
between the articulating surfaces of the tibia and femur, thus
imposing a locking, catching or giving way of the joint.
• Chronic lesions may result in recurrent swelling and atrophy
around knee.
• The patient may complain of a sense of the knee collapsing, of a
popping sensation.
• May be an inability to squat or change direction quickly without
pain when running. such symtoms may prompt surgical
intervention.
Treatment Options
• Tears in the mid substance of the meniscus often fails to
heal because of its inadequate blood supply.
• The knee that is locked by a displaced meniscus may
require unlocking with the patient under anesthesia so
that a detailed examination can be done.
• If locking continues, arthroscopic surgery may be required
to remove a portion of the meniscus.
• Surgery should attempt to save as much of the menisci as
possible as it plays a critical role in preventing
degenerative joint disease.
Rehabilitation
• Post surgical management for a partial menisectomy does not
require bracing and allows partial to full weight bearing on
crutches as quickly as can be tolerated for about 2 weeks, even
sooner for the active athletic population in some cases.
• A repaired meniscus requires immobilization in a brace for 5-6
weeks.
• The patient should be on crutches, progressing from partial to full
weigh bearing at 6 weeks.
• During immobilization, active ROM exercises btwn 0-90 degrees
should be done.
• At 6 weeks, full ROM resistive exercises can begin. Rehab should
thereafter concentrate on endurance.
Prehab for Meniscus Tears
• Ensuring the knee joint is both strong and flexible
• Address muscle imbalances early
• Ensure good functional symmetry of the adductors and
abductors
• Stretching of the knee musculature
• Manage the extensibility of the hamstrings, erector
spinae, groin, quadriceps and gastrocnemius.
• Injured knees must be properly rehabilitated.
References
• http://physicaltherapyweb.com/mcmurray-test-orthopedicexamination-knee/
• http://www.pthaven.com/page/show/102042-apleydistraction-and-compression
• http://www.physio-pedia.com/Steinman_Test
• http://www.physio-pedia.com/Ege's_Test
• Prentice, William. Principles of Athletics Training, 11th
edit: 591-622. 2003