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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 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 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 Cruciate ligaments ITB Meniscus Bony fragments may result as well Signs and Symptoms 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 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 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 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 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 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 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 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… 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