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Recognition and
Management of
Specific Injuries
Medial Collateral
Ligament Sprain
 MOI = severe blow or outward twist
 Grade I: Signs and Symptoms
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Little fiber tearing or stretching
Stable valgus test
Little or no joint effusion
Some joint stiffness and point tenderness on
lateral aspect of the knee
 Relatively normal ROM
 Grade I: Management
 RICE for 24 hours
 Crutches if necessary
 Rehab
 Cryokinetics
 Isometrics
 Progress to SLRs,
bicycle riding, and
isokinetics
 Return to play when all
areas have returned to
normal
 May require 3 weeks to
recover
 Grade II: Signs and Symptoms
 Complete tear of deep capsular ligament and
partial tear of MCL
 No gross instability; laxity at 5-15 degrees of
flexion
 Slight swelling
 Moderate to severe joint tightness
 Decreased ROM
 Pain along medial aspect of knee
 Grade II: Management
 RICE for 48-72 hours
 Crutch use until acute inflammation phase has
resolved
 Possibly a brace or casting prior to the initiation
of ROM activities
 Modalities 2-3 times daily for pain
 Gradual progression from isometrics (quad
exercises) to CKC exercises; functional
progression activities
 Grade III: Signs and Symptoms
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Complete tear of supporting ligaments
Complete loss of medial stability
Minimum to moderate swelling
Immediate pain followed by ache
Loss of motion due to effusion and
hamstring guarding
 Positive valgus stress test
 Grade III: Management
 RICE
 Conservative non-operative versus surgical
approach
 Limited immobilization (with a brace)
 Progressive weight bearing and increased
ROM over 4-6 week period
 Rehab would be similar to Grade I & II
injuries
Lateral Collateral
Ligament Sprain
 MOI = Varus force usually with the tibia
internally rotated
 Direct blow is rare MOI
 If severe enough damage may also
occur to
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Cruciate ligaments
ITB
Meniscus
Bony fragments may result as well
 Signs and Symptoms
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Pain and tenderness over LCL
Swelling and effusion around the LCL
Joint laxity with varus testing
May cause irritation of the peroneal nerve
 Management
 Same as MCL injury management
Anterior Cruciate
Ligament Sprain
 MOI = tibia externally rotated with a valgus force
 Occasionally the result of hyperextension
resulting from a direct blow
 Research is quite extensive in regards to impact
of femoral notch, ACL size and laxity, malalignments (Q-angle), and faulty biomechanics
 Extrinsic factors may include, conditioning, skill
acquisition, playing style, equipment, preparation
time
 May also involve damage to other structures
including meniscus, capsule, and MCL
 Signs and Symptoms
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Experience pop with severe pain and disability
Positive anterior drawer and Lachman’s
Rapid swelling at the joint line
Other ACL tests may also be positive
 Management
 RICE; use of crutches
 Arthroscopy may be necessary to determine
extent of injury
 Surgical repair
 Without surgery, joint degeneration may result
 Surgery may involve joint reconstruction with grafts
(tendon), transplantation of external structures
 Also requires 4-6 months of rehab
Posterior Cruciate
Ligament Sprain
 MOI = fall on bent knee (most common)
 Most at risk during 90 degrees of flexion
 Injury may result due to a rotational force
 Signs and Symptoms
 Feel a pop in the back of the knee
 Tenderness and relatively little swelling in
the popliteal fossa
 Laxity with posterior sag test
 Management
 RICE
 Non-operative rehab
 Appropriate for grade I and II injuries
 Focus on quad strengthening
 Post-operative rehab
 Surgery will require 6 weeks of
immobilization in extension
 Full weight bearing on crutches
 ROM after 6 weeks
 PRE at 4 months
Meniscal Lesions
 Most common MOI is rotary force with
knee flexed or extended
 Tears may be longitudinal, oblique, or
transverse
 Medial meniscus is more commonly
injured due to ligamentous attachments
and decreased mobility
 Also more prone to disruption through
torsional and valgus forces
 Signs and Symptoms
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Effusion developing over 48-72 hours
Pain in joint line
Loss of motion
Intermittent locking and giving way
Pain with squatting
Portions of meniscus may become
detached causing locking, giving way, or
catching within the joint
 If chronic injury, recurrent swelling or
muscle atrophy may occur
 Management
 No locking but indications of a tear are present
 Further diagnostic testing may be required
 If locking occurs, anesthesia may be necessary
to unlock the joint
 Possible arthroscopic surgery
 Healing dependent on location of tear
 Menisectomy
 Partial weight bearing, quick return to activity
 Repaired meniscus
 Requires immobilization, gradual return to activity
over the course of 12 weeks
Knee Plica
 MOI = irritation of the plica
 Often associated with chondromalacia
 Signs and Symptoms
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Possible history of knee pain/injury
Recurrent episodes of painful pseudo-locking
Possible snapping and popping
Pain with stairs and squatting
Little or no swelling
No ligamentous laxity
 Management
 Treat conservatively w/ RICE and NSAID’s if the result of
trauma
 Recurrent conditions may require surgery
Osteochondral Knee
Fractures
 MOI = twisting, sudden cutting, or direct blow
 Signs and Symptoms
 Hear a snap
 Feeling of giving way
 Immediate swelling
 Considerable pain
 Management
 Diagnosis confirmed through arthroscopic exam
 Surgery used to replace fragments in order to avoid
joint degeneration and arthritis
Osteochondritis Dissecans
 MOI = partial or complete separation of
articular cartilage and subchondral bone
 Exact cause is unknown but may include:
 Blunt trauma,
 Possible skeletal or endocrine abnormalities,
 Prominent tibial spine impinging on medial
femoral condyle, or
 Impingement due to patellar facet
 Signs and Symptoms
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Aching pain and point tenderness
Recurrent swelling
Possible locking
Possible quadriceps atrophy
 Management
 Rest and immobilization for children
 Surgery may be necessary in teenagers
and adults
 Drilling to stimulate healing, pinning, or bone
grafts
Loose Bodies
 MOI = repeated trauma
 May result due to osteochondritis dissecans,
meniscal fragments, synovial tissue damage, or
cruciate ligaments injury
 Signs and Symptoms
 May become lodged and cause locking or popping
 Pain
 Sensation of instability
 Management
 If not surgically removed it can lead to conditions
causing joint degeneration
Joint Contusions
 MOI = direct blow
 Signs and Symptoms
 Severe pain
 Acute inflammation
 Loss of movement
 Swelling
 If not resolved within a week then a chronic condition may
exist (synovitis or bursitis)
 Ecchymosis
 Possible capsular damage
 Management
 RICE
 Progress to normal activity following return of ROM
 Padding for protection
Peroneal Nerve Contusion
 MOI = compression due to a direct blow
 Signs and Symptoms
 Local pain and possible shooting nerve pain
 Numbness and paresthesia
 Added pressure may exacerbate condition
 Generally resolves quickly
 In the event it does not resolve, it could result in drop foot
 Management
 RICE
 Return to play once symptoms resolve and no
weakness is present
 Padding for fibular head
Bursitis
 MOI = acute, chronic, or recurrent swelling
 Prepatellar = continued kneeling
 Infrapatellar = overuse of patellar tendon
 Signs and Symptoms
 Localized swelling that results in ballotable patella
 Swelling in popliteal fossa may indicate a Baker’s cyst
 Associated with burse over the semimembranosus or medial
head of gastrocnemius
 Commonly painless and causing little disability
 May progress and should be treated accordingly
 Management
 Eliminate cause
 RICE and NSAID’s
 Aspiration and steroid injection if chronic
Patellar Fracture
 MOI = direct or indirect trauma
 Semi-flexed position with forceful contraction, which
may occur while falling, jumping or running
 Signs and Symptoms
 Hemorrhaging and joint effusion
 Possible capsular tearing, separation of bone
fragments, and possible quadriceps tendon tearing
due to bone fragments
 Management
 X-ray necessary for confirmation
 RICE and splinting if fracture suspected
 Refer
 Possible immobilize for 2-3 months
Patella Subluxation or
Dislocation
 MOI = deceleration with simultaneous cutting in
opposite direction (valgus force)
 Quad pulls the patella out of alignment
 Repetitive subluxation will impose stress to medial
restraints
 Signs and Symptoms
 Subluxation
 Pain, swelling, restricted ROM, and palpable tenderness
over adductor tubercle
 Dislocations
 Total loss of function
 Management
 Reduction
 Performed by flexing hip, moving patella medially, and
slowly extending the knee
 Following reduction, immobilize for at least 4 weeks
 Use crutches
 Isometric exercises
 After immobilization period, horseshoe pad with
elastic wrap should be used to support patella
 Rehab focuses on strengthening the muscles around
the knee, thigh, and hip
 Possible surgery to release tight structures
 Improve postural and biomechanical factors
Infrapatellar Fat Pad
 MOI = becomes wedged between the tibia and
patella
 Irritated by chronic kneeling, pressure, or trauma
 Signs and Symptoms
 Capillary hemorrhaging and swelling
 Chronic irritation may lead to scarring and
calcification
 Pain below the patellar ligament during knee
extension
 May display weakness, mild swelling, and stiffness
during movement
 Management
 Rest
 Avoid irritating activities until inflammation has subsided
 Utilize therapeutic modalities for inflammation
 Heel lift to prevent irritation during extension
 Hyperextension taping to prevent full extension
Chondromalacia patella
 MOI = softening and deterioration of the
articular cartilage
 Three stages:
 Swelling and softening of cartilage
 Fissure of softened cartilage
 Deformation of cartilage surface
 Often associated with abnormal tracking
 Abnormal patellar tracking may be due to genu
valgum, external tibial torsion, foot pronation,
femoral anteversion, patella alta, shallow femoral
groove, increased Q angle, laxity of quad tendon
 Signs and Symptoms
 Pain with walking, running, stairs, and squatting
 Possible recurrent swelling
 Grating sensation with flexion and extension
 Pain at inferior border during palpation
 Management
 Conservative measures
 RICE, NSAID’s, isometrics, orthotics to correct dysfunction
 Surgical possibilities
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Altering muscle attachments
Shaping and smoothing of surfaces
Drilling
Elevating tibial tubercle
Patellofemoral Stress
Syndrome
 MOI = lateral deviation of patella while tracking in
femoral groove
 May result due to tight structures, pronation, increased Q
angle, insufficient medial musculature
 Signs and Symptoms
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Tenderness at lateral facet of patella
Swelling associated with irritation of synovium
Dull ache in center of knee
Patellar compression will elicit pain and crepitus
Apprehension when patella is forced laterally
 Management
 Correct imbalances (strength and flexibility)
 McConnell taping
 Lateral retinacular release if conservative measures fail
Osgood-Schlatter Disease,
Larsen-Johansson Disease
 Osgood Schlatter’s is apophysitis at the tibial
tubercle
 MOI = repeated avulsion of patellar tendon
 Bony callus develops enlarging the tibial tubercle
 Resolves with aging
 Larsen Johansson is the result of excessive
pulling on the inferior pole of the patella
 Signs and Symptoms
 Swelling
 Hemorrhaging
 Gradual degeneration of the apophysis due to
impaired circulation
 Pain with kneeling, jumping, and running
 Point tenderness
 Management
 Conservative
 Reduce stressful activity
 Possible casting
 Ice before and after activity
 Isometerics
Patellar Tendinitis
(Jumper’s or Kicker’s Knee)
 MOI = sudden or repetitive extension
 Jumping or kicking places tremendous strain on patellar or
quadriceps tendon
 Signs and Symptoms
 Pain and tenderness at inferior pole of patella
 3 phases:
 1) pain after activity,
 2) pain during and after activity,
 3) pain during and after activity that may become constant
 Management
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Ice, phonophoresis, iontophoresis, ultrasound, heat
Exercise
Patellar tendon bracing
Transverse friction massage
Patellar Tendon Rupture
 MOI = sudden, powerful quad contraction
 Rare unless a chronic inflammatory condition exists
resulting in tissue degeneration
 Occurs primarily at point of attachment
 Signs and Symptoms
 Palpable defect
 Lack of knee extension
 Considerable swelling and pain (initially)
 Management
 Surgical repair is needed
 Proper conservative treatment of jumper’s knee can
minimize chances of occurring
Runner’s Knee &
Cyclist’s Knee
 MOI = repetitive/overuse conditions attributed to
mal-alignment and structural asymmetries
 Signs and Symptoms
 IT Band Friction Syndrome
 Irritation at band’s insertion
 Commonly seen in individual that have genu varum or
pronated feet
 Pes Anserine Tendinitis or Bursitis
 Result of excessive genu valgum and weak vastus medialis
 Often occurs due to running with one leg higher than the other
 Running on a slope or crowned road
 Management
 Correction of mal-alignments
 Ice before and after activity
 Utilize proper warm-up and stretching techniques
 Avoidance of aggravating activities
 NSAID’s
 Orthotics
The Collapsing Knee
 Giving way of knee
 Result of…
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Weak quadriceps
Chronic instability of ligamentous structures
Torn meniscus
Loose bodies within the knee
Subluxating patella
Chondromalacia
Due to pain
Prevention of Knee
Injuries
 Total body conditioning is required
 Strength, flexibility, cardiovascular and
muscular endurance, agility, speed and
balance
 Muscles around joint must be conditioned
to maximize stability
 Flexibility and strengthening
 Must avoid abnormal muscle action
through flexibility
 ACL Prevention Programs
 Focus on strength, neuromuscular control,
and balance
 Series of different programs which address
balance board training, landing strategies,
plyometric training, and single leg
performance
 Can be implemented in rehabilitation and
preventative training programs
 Shoe Type
 Change in football footwear has drastically
reduced the incidence of knee injuries
 Shoes with more short cleats does not allow
foot to become fixed
 Still allows for control during running and cutting
 Functional and Prophylactic
Knee Braces
 Used to protect MCL
 Used to prevent further
damage to grade 1 and grade
2 ACL sprains
 Used to protect the ACL
following surgery
 Can be custom molded and
designed to control rotational
forces
Knee Joint Rehabilitation
 General Body Conditioning
 Must be maintained with non-weight bearing
activities
 Weight Bearing
 Initial crutch use, non-weight bearing
 Gradual progression to weight bearing while
wearing rehabilitative brace
 Knee Joint Mobilization
 Used to reduce arthrofibrosis
 Patellar mobilization is key following surgery
 CPM units
 Flexibility
 Must be regained, maintained, and improved
 Muscular Strength
 Progression of isometrics, isotonics,
isokinetics, and plyometrics
 Incorporate eccentric muscle action
 Open vs. closed kinetic chain exercises
 Neuromuscular Control
 Loss of control is generally due to pain and
swelling
 Through exercise and balance equipment
proprioception can be enhanced and regained
 Bracing
 Variety of braces
 Some used to control for specific injuries while
others are designed for specific forces, stability,
and providing resistance
 Typically worn for 3-6 weeks after surgery
 Used to limit ROM for a period of time
 Functional Progression
 Gradual return to sports specific skills
 Progress with weight bearing, move into
walking and running, and then onto sprinting
and change of direction
 Return to Activity
 Based on healing process
 Sufficient time for healing must be allowed
 Objective criteria should include…
 Strength assessment
 ROM measures
 Functional performance tests
Summary
 Review anatomy
 Assessment
 History, observation, palpation
 Special Tests
 Injury prevention
 Injury recognition
 Rehabilitation