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Chapter 15
Knee Conditions
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Knee Anatomy
Structure of the knee. A. Anterior view. B. Posterior view
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Knee Anatomy (cont’d)
Structures of the knee. C. Lateral view. D. Medial view
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Knee Anatomy (cont’d)
Structures of the knee. E. Superior surface of the tibia. F. Bursa of the knee
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Knee Anatomy (cont’d)
• Tibiofemoral Joint
– Condyles of femur with plateaus of tibia
– Hinge joint—flexion/extension
– Tibia does rotate laterally on femur during last
few degrees of extension
– “Screwing-home mechanism”
• Produces a locking of the knee in final degrees
during extension
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Knee Anatomy (cont’d)
E. Superior surface of the tibia
• Meniscus
– Fibrocartilaginous
discs attached to
tibial plateaus
– Medial and lateral
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Knee Anatomy (cont’d)
• Meniscus (cont’d)
• Functions:
– Stabilize joint by deepening the articulation
– Shock absorption
– Provide lubrication and nourishment
– Improve weight distribution
• Medial meniscus has an attachment to the MCL and
semimembranosus
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Joint Capsule and Bursae
• Articular capsule – encompasses both tibiofemoral
and patellofemoral joints
• Bursa inside the capsule
– Suprapatellar bursa
– Subpopliteal bursa
– Semimembranosus bursa
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Joint Capsule and Bursae
F. Bursa at the knee
• Bursa outside capsule
– Prepatellar bursa
– Superficial
infrapatellar bursa
– Deep infrapatellar
bursa
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Ligaments
• ACL
– Prevents:
• Anterior translation of tibia on femur
• Rotation of tibia on femur
• Hyperextension
• PCL
– Resists posterior displacement of tibia on femur
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• MCL
Ligaments (cont’d)
– Resist medially directed (valgus) forces
• LCL
– Resist laterally directed (varus) forces
A. Anterior view. B. Posterior view
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Patellofemoral Joint
• Patella
– Superior, middle, and inferior articular surfaces
– Functions
• Protect femur
• Increase effective power of quadriceps
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Patellofemoral Joint (cont’d)
Patella. A. Anterior view. B. Posterior view
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Q-Angle
• Q-angle
– Angle between line of resultant force produced
by
quadriceps and line of patellar tendon
–
Males 13°; females 18°
–  Q-angle— lateral patellofemoral contact
 Q-angle— medial tibiofemoral contact
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Q-Angle (cont’d)
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Nerves
• Tibial nerve
– Hamstrings except short head of biceps
• Common peroneal
– Short head of biceps
• Femoral
– Quadriceps
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Nerves (cont’d)
Innervation of the knee.
A. Anterior view. B. Posterior view
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Blood Supply
• Femoral artery
Collateral circulation around the knee. A. Anterior.
B. Posterior. C. Circulation to meniscus
• Popliteal artery
• Genicular arteries
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Kinematics and Major Muscle Actions
• Knee flexion
Motions at the knee.
A. Flexion and extension
– Hamstrings
– Assisted by:
• Popliteus
• Gastrocnemius
• Gracilis
• Sartorius
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Kinematics and Major Muscle Actions
(cont’d)
• Knee extension
– Quadriceps femoris muscle group
• Rectus femoris
• Vastus lateralis
• Vastus intermedius
• Vastus medialis
• Vastus medialis oblique (VMO)
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Kinematics and Major Muscle Actions
(cont’d)
• Knee extension (cont’d)
– Screw-home motion
• Rotation and passive abduction and adduction
– Capability maximal at approximately 90° of knee
flexion
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Kinematics and Major Muscle Actions
(cont’d)
• Patellofemoral joint motion
– During knee flexion and extension, patella glides
in the trochlear groove
– Tracking is dependent on the direction of the net
force produced by the attached quadriceps
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Prevention of Knee Injuries
• Physical conditioning
– Strength
– Flexibility
• Rule changes
• Footwear
– Cleats vs. flat sole
– Position of cleats and size
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Contusions
• Knee
– MOI: compression
– S&S
• Localized tenderness
• Pain
• Swelling
– Management: standard acute; extreme point
tenderness physician referral
– Caution: excessive swelling could mask other injuries
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Contusions (cont’d)
• Infrapatellar fat pad
–
Entrapped between the femur and tibia
– S&S
• Locking, catching, giving way
• Palpable pain on either side of patellar tendon
• Extreme pain on forced extension
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Contusions (cont’d)
• Infrapatellar fat pad (cont’d)
– Management
• Standard acute
• If symptoms persist > 2-3 days, physician
referral
• Protect the area during activity
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Contusions (cont’d)
• Peroneal nerve
– MOI: blow to the posterolateral aspect of the
knee
– S&S
• Radiating pain down lateral aspect of leg and
foot
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Contusions (cont’d)
• Peroneal nerve (cont’d)
– S&S (cont’d)
• Severe cases
• Initial pain—not immediately followed by
tingling or numbness
• As swelling ↑ within nerve sheath
• Weakness in dorsiflexion or eversion
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Contusions (cont’d)
• Peroneal nerve (cont’d)
– S&S (cont’d)
• Severe cases
• As swelling ↑ within nerve sheath
• Loss of sensation in dorsum of foot,
especially between 1st and 2nd toes
• May progressively occur days or weeks
later
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Contusions (cont’d)
• Peroneal nerve (cont’d)
– Management:
• Standard acute, but caution with compression
• Severe S&S—immediate physician referral
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Bursitis
• Prepatellar
– MOI
• Acute: direct blow to anterior patella
• Chronic: repetitive blows
– S&S
• Swelling
• Pain with direct pressure
• Pain with passive knee flexion
• Localized swelling
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Bursitis (cont’d)
• Pes anserine
– MOI:
• Friction between tendon and MCL
• Direct trauma
– S&S
• Pain with knee flexion
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Bursitis (cont’d)
• Infrapatellar
– Mechanism:
• Friction between patellar tendon and fat
pad/tibia
• May be associated with patellar tendinitis
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Bursitis (cont’d)
• Infrapatellar (cont’d)
– S&S
• Point tender with possible swelling posterior to
patellar tendon
•  pain at end range of resisted knee extension
and passive flexion
• Prolonged knee flexion may  symptoms
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Bursitis (cont’d)
• Bursitis management
– Standard acute;  aggravating activities or total
rest
– Protect area during activity
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Ligamentous Conditions
• AAOS classifies ligamentous knee injuries according to:
– Functional disruption of a specific ligament
– Amount of laxity
– Direction of laxity
• Direction divides laxity into 4 straight and 4
rotatory laxities
• Knowing knee position at impact and direction the
tibia displaces or rotates indicates the damaged
structures
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Ligamentous Conditions (cont’d)
Knee instability
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Ligamentous Conditions (cont’d)
Knee instability
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Ligamentous Conditions (cont’d)
• Straight medial laxity (valgus laxity)
– Involves MCL; posterior medial capsule—
possibly PCL
– Lateral forces cause tension on medial aspect of
knee
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Ligamentous Conditions (cont’d)
• Straight medial laxity (valgus laxity) (cont’d)
– 1st degree
• Mild pain medial joint line
• Little or no joint effusion/mild swelling at site
• Full ROM with minor discomfort
• Valgus @ 0°—stable; @ 30º—+
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Ligamentous Conditions (cont’d)
• Straight medial laxity (valgus laxity) (cont’d)
– 2nd or 3rd degree
• Unable to fully extend the leg; often walk on
the ball of foot; unable to keep heel flat on the
ground
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Ligamentous Conditions (cont’d)
• Straight lateral laxity (varus laxity)
– Involves LCL, lateral capsular ligaments, PCL
– Medial forces produce tension on lateral aspect
of knee
• Not usually isolated—presence of IT band,
biceps femoris, popliteus
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Ligamentous Conditions (cont’d)
• Straight lateral laxity (varus laxity) (cont’d)
– S&S
• Similar to MCL
• Swelling minimal—no attachment to capsule
• Instability may not be obvious if other
stabilizers are intact
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Ligamentous Conditions (cont’d)
• Straight anterior laxity (anterior instability)
– Anterior displacement of tibia on femur
– Involves ACL—rarely isolated
– MOI: cutting or turning maneuver, landing, or
sudden deceleration
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Ligamentous Conditions (cont’d)
• Straight anterior laxity (anterior instability) (cont’d)
– S&S
• Pain
• Minimal and transient to severe and lasting
• Deep in knee difficult to pinpoint
• “Pop”
• Effusion within 3 hours; reports knee giving
way—does not feel right
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Ligamentous Conditions (cont’d)
• Straight posterior laxity
– Tibia displaced posteriorly
– Involves PCL
– MOI
• Hyperextension force
• Fall on flexed knee (initial contact at tibial
tuberosity)
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Ligamentous Conditions (cont’d)
• Straight posterior laxity (cont’d)
– S&S
• Sense of stretching to posterior knee
• “Pop”
• Rapid joint effusion
• ↓ knee flexion due to effusion
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Ligamentous Conditions (cont’d)
• Management
– Standard acute
– Unable to walk normally – crutches should be
used
– Physician referral
• Not typically an ER, but seen by physician 1-2
post-injury
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Knee Dislocation/Subluxation
• Minimum of 3 ligaments torn for knee to dislocate
– Most often—ACL, PCL, and one collateral
ligament
• Concern: damage to other structures; especially
neurovascular
• MOI: cutting, twisting, or pivoting maneuver
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Knee Dislocation/Subluxation (cont’d)
• S&S
– Individual describes severe injury
– “Pop”
– Deformity (unless spontaneously reduced)
• Management: standard acute
– Spontaneous reduction—physician referral
– Not reduced—activate emergency plan, including
summoning EMS
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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
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Meniscal Conditions (cont’d)
Meniscal tears
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Meniscal Conditions (cont’d)
• 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
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Meniscal Conditions (cont’d)
Meniscal tears
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Meniscal Conditions (cont’d)
• S&S
– Initial symptoms may be vague or limited
• Limited sensory nerve supply—minimal pain
• Minimal disability
• Minimal swelling
– Understand mechanism
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Meniscal Conditions (cont’d)
• S&S (cont’d)
– Delayed swelling
– Joint line pain
– Classic: clicking/locking (not acutely) leads to
knee buckling or giving way
• Management
– Standard acute; treat symptoms
– Physician referral
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Patellar Conditions
• Patellofemoral pain
– Causes
• Mechanical (e.g., patellar subluxation or
dislocation)
• Inflammatory (e.g., prepatellar bursitis, patellar
tendinitis)
• Other causes (e.g., reflex sympathetic dystrophy,
tumors)
– Dynamic stabilizer—extensor mechanism
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Patellar Conditions (cont’d)
Extensor mechanism
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Patellar Conditions (cont’d)
• Patellofemoral stress syndrome
– Mechanism
• Poor patellar tracking due to weak VMO or
tight lateral structures
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Patellar Conditions (cont’d)
• Patellofemoral stress syndrome (cont’d)
– 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
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Patellar Conditions (cont’d)
• Patellofemoral stress syndrome (cont’d)
– Management:
• Standard acute; NSAIDs
• Physician referral
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Patellar Conditions (cont’d)
• Chondromalacia
– Degeneration in articular cartilage of patella
– Due to abnormal excursion & compressive
forces
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Patellar Conditions (cont’d)
• Chondromalacia (cont’d)
– S&S:
• Anterior knee pain and crepitus w/
walking stairs or deep knee bends
• Pain and crepitus increase w/ active &
resisted knee extension.
• Localized pain and tenderness on the
medial and lateral patellar borders.
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Patellar Conditions (cont’d)
• Chondromalacia (cont’d)
– Management
• Standard acute
• Physician referral
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Patellar Conditions (cont’d)
• Patellar instability and dislocation
– Displacement of patella due to internal or
external forces
– MOI: deceleration combined with a cutting
motion
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Patellar Conditions (cont’d)
• Patellar instability and dislocation (cont’d)
– S&S subluxation
• Transient partial displacement; acute or
intermittent with spontaneous reduction
• Feeling of patella slipping when cutting,
twisting, or pivoting
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Patellar Conditions (cont’d)
• Patellar instability and dislocation (cont’d)
– S&S dislocation
• “Pop”
• Violent collapse of the knee
• Localized tenderness—medial
extensor retinaculum
• Loss of limb function
• Effusion
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Patellar Conditions (cont’d)
• Patellar instability and dislocation (cont’d)
– Management:
• Standard acute
• Immediate physician referral
• Coach should not attempt to reduce
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Patellar Conditions (cont’d)
• 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;
eventually pain both during and after activity
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Patellar Conditions (cont’d)
• Patellar tendinitis (cont’d)
– S&S (cont’d)
• Pain ascending and descending stairs; pain
after prolonged sitting
– Management: standard acute; physician referral
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Patellar Conditions (cont’d)
• 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
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Patellar Conditions (cont’d)
Patellar tendon
traction-type injuries
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Patellar Conditions (cont’d)
• Osgood- Schlatter disease (cont’d)
– Grade
• 1 – Pain after activity that resolves within 24
hours
• 2 – Pain during and after activity that does not
hinder performance and resolves within 24 hours
• 3 – Continuous pain that limits sport performance
and daily activities
– Management: do not permit to continue activity until
seen by a physician
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Patellar Conditions (cont’d)
• Sinding-Larsen-Johansson disease
– Inflammation or partial avulsion of apex of
patella due to traction forces
– Usually seen in children 8 to 13 years old
involved in running and jumping sports.
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Patellar Conditions (cont’d)
• Sinding-Larsen-Johansson disease (cont’d)
– S&S
• Gradual onset of pain
• Pain with palpation of inferior patellar pole
with knee extended and patellar tendon
relaxed
– Management: do not permit to continue activity
until seen by a physician
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Patellar Conditions (cont’d)
• Extensor tendon rupture
– Due to powerful eccentric muscle contractions
– S&S
• Partial rupture—pain and weakness in knee
extension
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Patellar Conditions (cont’d)
• Extensor tendon rupture (cont’d)
– S&S (cont’d)
• Total rupture distal to patella
• High-riding patella
• Palpable defect over the tendon
• Inability to extend knee extension or
perform a straight leg raise
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Patellar Conditions (cont’d)
• Extensor tendon rupture (cont’d)
– S&S (cont’d)
• Total rupture from superior pole with extensor
retinaculum still intact
• Knee extension is possible, but weak and
painful
– Management: standard acute; crutches;
immediate referral to a physician
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Iliotibial Band Friction Syndrome
• Band drops behind lateral femoral epicondyle with
knee flexion, then snaps forward over epicondyle
during extension
• Due to excessive compression and friction
• Associated with overuse, abnormal biomechanics,
and poor flexibility
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Iliotibial Band Friction Syndrome (cont’d)
Iliotibial band
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Iliotibial Band Friction Syndrome (cont’d)
• S&S
– Pain with running progresses from not restrictive
to restrictive even with ADLs
– initial lateral ache progresses into a more
painful, sharp, and localized discomfort over the
lateral femoral condyle just above the lateral
joint line
– Flexion and extension of the knee may produce
a creaking sound
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Iliotibial Band Friction Syndrome (cont’d)
• Management:
– Acute
– NSAIDs
– Do not permit to continue activity until seen by
a physician
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Fractures and Associated Conditions
• Avulsion fracture
– Due to direct trauma, excessive tensile forces,
overuse
– S&S: localized pain and tenderness over the
bony site
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Fractures and Associated Conditions
(cont’d)
• Epiphyseal and apophyseal fracture
– Tibial tubercle fracture
• MOI
• Forced flexion of knee against a straining
quadriceps contraction
• Violent quadriceps contraction against a
fixed foot
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Fractures and Associated Conditions
(cont’d)
• Epiphyseal and apophyseal fracture
• S&S
• Pain, ecchymosis, swelling, and tenderness
• Difficulty going up and down stairs
• knee extension painful and weak
• Larger fractures involving extensive retinacular
damage
• Patella rides high
• Knee extension is impossible
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Fractures and Associated Conditions
(cont’d)
• Epiphyseal and apophyseal fracture (cont’d)
– Distal femoral epiphyseal fracture
• MOI: varus or valgus stress applied on a fixed,
weight-bearing foot
– S&S:
• Pain around knee
• Unable to bear weight
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Fractures and Associated Conditions
(cont’d)
• Stress fractures
– Common areas
• Femoral supracondylar region
• Medial tibial plateau
• Tibia tubercle
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Fractures and Associated Conditions
(cont’d)
• Stress fractures (cont’d)
– 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
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Fractures and Associated Conditions
(cont’d)
• Stress fractures (cont’d)
– S&S:
• Localized pain before and after activity
• Relieved with rest and non–weight bearing
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Fractures and Associated Conditions
(cont’d)
• Chondral fracture (involves
articular cartilage)
Osteochondral fracture
• Osteochondral fracture (involves
articular cartilage and
underlying bone)
– Due to compression from
direct blow to knee causing
shearing or forceful rotation
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Fractures and Associated Conditions
(cont’d)
• Osteochondral fracture (cont’d)
– S&S
• Painful “snap”
• Considerable pain & rapid swelling
• Displaced fracture: locking; crepitus
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Fractures and Associated Conditions
(cont’d)
• Fracture management
– Standard acute
– Use of crutches
– Immediate physician referral
• Stress fracture management
– Physician referral
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Coach and Onsite Assessment
• S &S that require immediate physician referral
– Obvious deformity suggesting a dislocation or
fracture
– Significant loss of motion or locking of the knee
– Excessive joint swelling
– Gross joint instability
– Reported sounds, such as popping, snapping, or
clicking, or giving way of the knee
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Coach and Onsite Assessment (cont’d)
• S &S that require immediate physician referral
(cont’d)
– Possible epiphyseal injuries
– Abnormal sensations in the leg or foot
– Any unexplained or chronic pain that disrupts an
individual’s play or performance
• Refer to Application Strategy 15.2
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