Download Knee Conditions

Knee Conditions
Willie McGahee
Shaun Carney
Shaun Livingston
Weightlifter
Anatomy
Ligaments
• ACL
– Prevents:
• PCL
• Anterior translation of tibia on femur
• Rotation of tibia on femur
• Hyperextension
– Resists posterior displacement of tibia on femur
– Knee full extension—posterior fibers are taut; knee full flexion—
anterior fibers are taut
• MCL
– Resist medially directed (valgus) forces
– Complete extension—taut
midrange—posterior fibers most taut
complete flexion—anterior fibers most taut
• LCL
– Resist laterally directed (varus) forces
Anatomy (cont.)
Anatomy (cont.)
Meniscus
• Fibrocartilaginous discs attached to tibial
plateaus
– Medial and lateral
• Functions:
– Stabilize joint by deepening the articulation
– Shock absorption
– Provide lubrication and nourishment
– Improve weight distribution
Joint Capsule and Bursae
• Articular capsule – encompasses both
tibiofemoral and patellofemoral joints
– Suprapatellar bursa
– Subpopliteal bursa
– Semimembranosus bursa
• Bursa outside capsule
– Prepatellar bursa
– Superficial infrapatellar bursa
– Deep infrapatellar bursa
Iliotibial Band
• Extends from tensor fascia latae to
Gerdy’s tubercle on lateral tibial plateau
• Lateral knee stabilizer
• Can have effect on hip and knee
Patellofemoral Joint
• Patella
– Superior, middle, and inferior articular
surfaces
– Functions
• Protect femur
• Increase effective power of quadriceps
Anatomy (Cont’d.)
• Muscles
– Produce movement
– Stabilize the knee
– Quadriceps
– Hamstring
Kinematics
• Knee flexion
•
– Primarily Hamstrings
– Also Popliteus, Gastrocnemius, Gracilis, and
Sartorius
Knee extension
– Quadriceps femoris muscle group
Prevention of Knee Injuries
• Physical conditioning
– Strength
– Flexibility
• Rule changes
• Footwear
– Cleats vs. flat sole
– Position of cleats and size
Contusions
• Knee
– Mechanism: compression
– S&S
• Localized tenderness
• Pain
• Swelling
– Management: standard acute
– Caution: excessive swelling could mask other
injuries
Bursitis
• Prepatellar
– Mechanism
• Acute: direct blow to anterior patella
• Chronic: repetitive blows
– S&S
• Swelling
• Pain with direct pressure
• Pain with passive knee flexion
• Localized swelling
• Baker’s cyst
– Posterior aspect of knee—most often: semimembranosus
 pain with full extension or flexion
• Bursitis management
• Standard acute;  aggravating activities
Ligament Injuries
• Medial Collateral Ligament Sprain
– Most commonly injured ligament
– Cause of Injury
• Result of severe blow or outward twist – valgus force
– Signs of Injury
• Depending upon grade
– Swelling, instability with Valgus testing, stiffness, pt.
tenderness in the medial joint line, decreased ROM
– Care
• RICE, crutches, ROM, isometrics, bracing
Ligament Injuries (contd)
• Lateral Collateral Ligament Sprain
– Cause of Injury
• Result of a varus force, generally w/ the tibia internally
rotated
• Direct blow is rare
– Signs of Injury
• Pain and tenderness over LCL
• Swelling and effusion around the LCL
• Joint laxity w/ varus testing
– Care
• Following management of MCL injuries depending on severity
Ligament Injuries (cont’d.)
• Anterior Cruciate Ligament Sprain
– Cause of Injury
• Foot is on the ground, femur is ER, knee is placed in valgus position
• Hyperextension with a force to the front of the knee with the foot
planted
– Signs
•
•
•
•
Hear or feel a “pop”
Unstable joint
Swelling
Pain
•
•
•
•
RICE
Crutches
Surgery
Usually associated with other injuries
– Care
– Unhappy triad
 ACL, MCL, Medial mensicus
ACL Reconstruction
Ligament Injuries (contd)
• Posterior Cruciate Ligament Sprain
– Cause of Injury
• Fall on bent knee is most common mechanism
• Can also be damaged as a result of a rotational force
– Signs of Injury
• Feel a pop in the back of the knee
• Tenderness and relatively little swelling in the popliteal fossa
• Laxity w/ posterior drawer test
– Care
• RICE
• Non-operative rehab of grade I and II injuries should focus on quad
•
strength
Surgical versus non-operative
– Surgery will require 6 weeks of immobilization in extension w/ full
weight bearing on crutches
– ROM after 6 weeks and PRE at 4 months
Knee Dislocation/Subluxation
• Minimum of 3 ligaments must be torn for knee to
dislocate
– Most often—ACL, PCL, and one collateral ligament
• Concern: damage to other structures; especially
•
neurovascular
S&S
– Individual describes severe injury
– “Pop”
– Deformity (unless spontaneously reduced)
• Management: standard acute
– Spontaneous reduction—physician referral
– Not reduced—activate EMS
Meniscal Conditions
• Classified according to location
• Involve compression, tension, shearing forces
• Longitudinal
– Twisting motion when foot fixed and knee flexed
• Produces compression and torsion on posterior peripheral
attachment
– Bucket-handle tear
•
• Longitudinal segment displaced medially toward center of tibia
Horizontal tear
– Due largely to degeneration
– Shearing from rotational forces
• Tears the inner surface of the meniscus
– Parrot-beak tear
• 2 tears; commonly in middle segment of lateral meniscus
Meniscal Conditions (cont.)
• S&S
– Initial symptoms may be vague or limited
• Limited sensory nerve supply—minimal pain
• Minimal disability
• Minimal swelling
– Understand mechanism
– Delayed swelling
– Joint line pain
– Classic: clicking/locking (not acutely) leads to knee
buckling or giving way
• Management
– Standard acute; treat symptoms
– Physician referral
Patellar Conditions
• Patellofemoral stress syndrome
– Mechanism
• Poor patellar tracking due to weak VMO or tight lateral
structures
– S&S
• Dull, aching pain, ↑ with sitting, squatting, and descending
stairs
• Point tenderness—lateral facet of the patella
• Pain with manual patella compression into trochlear groove
– Management:
• Standard acute; NSAIDs
• Lower extremity assessment
Patellar Conditions
• Chondromalacia
– Degeneration in articular cartilage of patella
– Due to abnormal excursion and compressive forces
– S&S:
• Localized tenderness
• Anterior knee pain
• + Clarke’s test; + Waldron test
– Management
• Standard acute
• Activity modification
Patellar Conditions (contd)
• Patellar instability and dislocation
– Displacement of patella due to internal or external
forces
– Mechanism: deceleration combined with a cutting
motion
– S&S subluxation
• Transient partial displacement; acute or intermittent with
spontaneous reduction
• Feeling of patella slipping when cutting, twisting, or pivoting
• + apprehension test
– S&S dislocation
• “Pop”
• Violent collapse of the knee
• Localized tenderness—medial extensor retinaculum
• Effusion
– Management: standard acute; immediate physician referral
Patellar Conditions (contd)
• Patellar tendinitis
– Due to repetitive or eccentric knee extension activities
– S&S
• Initial—pain after activity on inferior pole of patella
or distal attachment of patellar tendon
• Progression—pain at start of activity, subsides with
warm-up, reappears after activity
• Pain ascending and descending stairs
• Pain with passive knee flexion beyond 120° and
resisted knee extension
– Management: standard acute; NSAIDs
Patellar Conditions (contd)
• Osgood- Schlatter disease
– Inflammation or partial avulsion of tibial apophysis
due to traction forces
– S&S
• Individual points to tibial tubercle as source of pain
• Tubercle appears enlarged
• Pain during activity and relieved with rest
• Pain at extreme knee extension and forced flexion
– Management: treat symptoms; self-limiting
Iliotibial Band Friction Syndrome
• Band drops behind lateral femoral
epicondyle with knee flexion, then snaps
forward over epicondyle during extension
Iliotibial Band Friction Syndrome
(cont.)
• Due to excessive compression and friction
• Associated with overuse, abnormal biomechanics, and poor
flexibility
• S&S
– Pain with exercise progresses from not restrictive to restrictive
even with ADLs
– Extreme point tenderness 2–3 cm proximal to lateral joint line
over epicondyle with leg flexed at 30°
• Management: standard acute; NSAIDs; preventative conditioning
program
Fractures and Associated
Conditions
• Stress fractures
– Common areas
• Femoral supracondylar region
• Medial tibial plateau
• Tibia tubercle
– Occur when:
• Load on the bone is increased
• Number of stresses on the bone increases (e.g.,
changes in training intensity, duration, frequency)
• surface area of the bone receiving load decreases
– S&S: localized pain before and after activity,
relieved with rest and non–weight bearing
Assessment
• History
• Observation/inspection
• Palpation
• Physical examination tests
Patellar Palpation
• Patellar glide
– Hypomobile
– Hypermobile
• Palpation for swelling
– Brush or stroke test (milking)
– Patellar tap test
(“ballotable patella”)
ROM
• AROM
• AAROM
• PROM
• RROM
Stress Tests
• Anterior drawer test
• Lachman’s test
Stress Tests (cont.)
• Modified Lachman’s
• Prone Lachman’s
Stress Tests (cont.)
• Posterior sag (gravity) test
• Posterior drawer test
• Reverse Lachman’s test
Stress Tests (cont.)
• Valgus stress
• Varus stress
Stress Tests (cont.)
• Slocum drawer test
– Anteromedial rotary instability
– Anterolateral rotary instability
Special Tests
• Meniscal tests
– McMurray’s test
– Apley’s compression/
distraction test
– “Bounce home” test
Special Tests (cont.)
• Tests for patellofemoral dysfunction
–
–
–
–
Patella compression or grind
Clarke’s sign
Waldron test
Patellar apprehension
Special Tests (cont.)
• IT band syndrome tests
– Noble compression test
– Ober’s test
Rehabilitation
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
Rehabilitation (cont.)
• Range of motion
Rehabilitation (cont.)
• Closed-chain terminal extension