The knee
Terms
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- Anterior Cruciate Ligament (ACL) Sprain Treatment
- Unlike collateral ligaments, a torn ACL does not heal. Usually, they are surgically reconstructed. Reconstruction involves patellar (1/3rd), semitendinosus or gracilis autografts, or patellar or Achilles tendon allografts. Autograft = Self pt own tissue. Allograft = donor or cadaver tissue. Two postoperative protocols: Traditional vs. Accelerated.
- Patellar Tendinitis (Jumper's Knee) Pathology
- Chronic inflammation of the patellar tendon that usually develops from repetitive jumping activities (repetitive eccentric contraction). Pt has point tenderness at the inferior pole of the patella. The pain starts as a dull ache with jumping activities, but becomes progressively worse over time.
- Accelerated
- immediate motion with Emphasis on full extension, immediate WBAT, earlier closed chain exercises, return to activity at 2 months and competition at 5-6 months.
- Patellofemoral Stress Syndrome New theory
- Weakeness of the hip abductions and external rotators leads to adduction and internal rotation of the femur during closed chain activity. This leads to excessive forces on the posterior patella as it articulates with the lateral femoral condyle.
- Lateral Collateral Ligament (LCL) Sprain Pathology
- Least common knee ligament injury. Rarely occurs in isolation. Usually caused by impact to the lateral aspect of the knee. May have associated injury to the peroneal nerve.
- Meniscal Repair
- Use of absorbable sutures. Pt wears a brace and uses crutches with partial WB for 6 weeks. Return to full activity at 3 months.
- Medial Collateral Ligament (MCL) Sprain Pathology
- Commonly injured ligament in the knee. Usually caused by a lateral impact to the knee (a valgus force).
- Patellofemoral Stress Syndrome Traditional View
- Poor tracking of the patella causes degeneration on the posterior surface. This is due to a combination of factors: Increased Q angle (angle between the line of pull of the quadriceps muscle and the patellar tendon), weakened VMO, tight ITband, excessive pronation, and patella alta, (sits to high)
- Chondromalacia Patella
- Progressive softening and deterioration of the articular cartilage on the back of the patella. Caused by progression of patellar stress syndrome or from direct impact to the patella. Pt has anterior knee pain with walking, running, squatting and ascending/descending stairs. Pt also has creppitus with knee flexion and extension.
- Postoperative treatment (PCL)
- Knee brace for 4-6 weeks with crutches. Quadriceps isometrics and active hip adduction/abduction done in brace starting at 2-4 weeks. Hamstring strengthening should be avoided initially. Closed chain exercises from 0-45 degrees flexion at 4-6 weeks. No running or jogging for 9 months
- Lateral Collateral Ligament (LCL) Sprain Expected signs/symptoms
- Pt reports hearing or feeling a "pop" and having immediate swelling on the lateral aspect of the knee. Grade 1: No joint laxity. Grade 2: some joint laxity with a varus stress test at 30 degrees flexion. Grade 3: Significant laxity at 30 degrees; some laxity at full extension.
- Posterior Cruciate Ligament (PCL) Sprains Treatment
- There is debate over whether to treat with surgery or not. Pts may not have functional limitations, but altered joint mechanics leads to premature arthritis. Surgery involves reconstruction, similar to ACL reconstruction.
- Anterior Cruciate Ligament (ACL) Sprain Pathology
- Commonly injured ligament in the knee. In open chain, the ACL resists anterior translation on the tibia on the fixed femur. In closed chain, the ACL resists posterior translation of the femur on the fixed tibia. The ACL also resists hyperextension. It is under some tension in all positions of knee motion. The least amount of tension is between 30 degrees - 90 degrees flexion. Usually caused by cutting start/stopping jumping activities during athletics. Female Athletes are more at risk. Reasons: 1 Hormones. 2 Longer Q angle. 3 Biomechanics - Quad:ham strength ratio is higher. - cutting/landing with legs knee flexion.
- Patellofemoral Stress Syndrome Pathology
- Pt complains of nonspecific pain in the anterior knee. Pain increases with ascending or descending stairs, squatting or prolonged sitting. Pt may report that the knee "gives out" even though there is no instability present.
- Traditional
- slow progression to regain ROM, partial WB or NWB postoperatively, closed chain exercises at 3-4 weeks, return to normal activity at 6-9 months
- Lateral Collateral Ligament (LCL) Sprain Treatment
- RICE and E-stim for pain control. Grade 1 & 2: Early AROM and isometric exercises. Crutches initially with WBAT. Progress to open and closed chain strengthening. Return to full activity in 3-5 weeks with a grade 1 sprain. Grade 3: studies have shown that immobilization is sufficient for treating a grade 3 tear. Surgery is not needed unless they have an ACL tear also. Bracing for 4-6 weeks and NWB for 3 weeks. Return to full activity in about 3 months. (same as MCL)
- Iliotibial Band Friction Syndrome Pathology
- AKA- "Runner's Knee." Knee Flexion and extension makes the IT band glide anterior and posterior over the lateral femoral condyle. Repetitive motion with running may cause inflammation of the IT band, periosteum or bursa. Contributing factors include: leg length discrepancies, shortened TFL, and excessive pronation ( increased tibial internal rotation). Poor training habits such as running on uneven surfaces or increasing distances to quicky also contribute.
- Knee Bursitis Treatment
- RICE and AROM Needle aspiration in some cases. Corticosteroid injection or surgical removal of the bursa may be used in chronic or recurrent cases.
- Iliotibial Band Friction Syndrome Treatment
- RICE, Iontophoresis or phonophersis. Stretching, correction of training errors, and orthotics if needed
- Patellar Tendinitis (Jumper's Knee) Treatment
- RICE and anti-inflammatory meds OR transverse friction massage for 5-7 minutes every other day for 1 week with NO anti-inflammatory meds or modalities. Once inflammation resolves, progress strengthening from isometric to isotonic. Eccentric strengthening should be emphasized before returning to sports.
- Meniscal Injury Pathology
- the medial and lateral menisci aid in joint lubrication and stability, distribute weightbearing forces, and act as shock absorbers. The medial meniscus is attached to the MCL and the Joint Capsule. The medial meniscus is injured more often because it transmits greater forces and is relatively immobile. Cause is WB or extending the knee. An example is a cutting motion in athletics
- Meniscal Injury Expected signs/symptoms
- Pt experiences immediate joint line pain. The knee may be "Locked" in partially flexed position due to displaced meniscal tissue
- Acute Patellar Dislocation
- Contact to the medial patella with the foot planted can force the patella to dislocate laterally. This is treated with reduction, followed by immobilization for 3-6 weeks. Physical therapy focuses on ROM and strengthening following immobilization.
- Patellofemoral Stress Syndrome Treatment
- Traditionally - IT band stretching, medial patellar mobilization and taping, strengthening of the VMO. Never theory would focus on hip strengthening and eccentric control of the LE in closed chain
- Posterior Cruciate Ligament (PCL) Sprains Pathology
- Not as common as ACL sprains. Not usually an isolated injury. The PCL resists posterior translation of the tibia on the fixed femur (open chain), and anterior translation of the femur on the fixed tibia (closed chain). This ligament is important for stability while walking down hill. Typically injured in position of knee hyperflexion, or the tibia is forced posteriorly on a fixed femur, or the femur is forced anteriorly on a fixed tibia.
- Knee Bursitis Pathology
- Can be acute, chronic, or recurrent, and can involve various bursae. Housemaid's Knee: the prepatellar bursa is injured with prolonged quadruped position, crawling or falling onto the knee. Clergyman's Knee: the superficial infrapatellar bursa is injured with repetitive kneeling. The deep infrapatellar bursa is irriated from repetitive stress to the patellar tendon.
- Partial Menisectomy (most common)
- RICE and E-stim for pain control. Crutches and WBAT AROM isometrics Open and closed chain exercises as ROM improves and pain decreases. Shortest recovery period of the surgical options (4-6weeks).
- Meniscal Transplant (Least common)
- Allografts or synthetic material. Pt wears a brace and uses crutches with partial WB for 6 weeks. Return to full activity in 9-12 months
- Iliotibial Band Friction Syndrome Expected Signs/Symptoms
- Pt has diffuse pain over the lateral aspect of the knee. Symptoms increase with running or going up/down stairs. Symptoms may decrease after warm-up.
- Anterior Cruciate Ligament (ACL) Sprain Expected signs/symptoms
- Grade 1: No joint laxity. Grade 2: increased anterior translation and pain with anterior drawer test and Lachman's. Grade 3: significant laxity with stress tests; pt reports hearing a "pop" and cannot continue with activity.
- Meniscal Injury Treatment
- Usually a "wait and see" method. Since the meniscus is not innervated, pain comes from inflammation. Allow several days of limited activity for resolution of symptoms. Detached fragments may cause chronic locking or "giving away" of the joint and lead to severe degeneration. Surgical treatment used to mean a totally menisectomy. Now options include a partial menisectomy, meniscal repair or meniscal transplantion. The outer 1/3 of the meniscus may heal with repair.
- Posterior Cruciate Ligament (PCL) Sprains Expected signs/symptoms
- Grade 1: No joint laxity. Grade 2: increased anterior translation and pain with anterior drawer test. Grade 3: significantly increased laxity with posterior drawer and posterior sag tests; pt hears a "pop", but often feels like they can continue activity
- Medial Collateral Ligament (MCL) Sprain Treatment
- RICE and E-stim for pain control. Grade 1 & 2: Early AROM and isometric exercises. Crutches initially with WBAT. Progress to open and closed chain strengthening. Return to full activity in 3-5 weeks with a grade 1 sprain. Grade 3: studies have shown that immobilization is sufficient for treating a grade 3 tear. Surgery is not needed unless they have an ACL tear also. Bracing for 4-6 weeks and NWB for 3 weeks. Return to full activity in about 3 months
- Nonoperative treatment (PCL)
- RICE and E-stim for pain control. May need crutches for a few days. Usually, little functional limitations. AROM and isometrics followed by closed chain exercises. Open chain hamstring strengthening should be avoided because it increases posterior translation of the tibia. Closed chain exercises are good because you get cocontraction of the Quads and Hams.
- Medial Collateral Ligament (MCL) Sprain Expected signs/symptoms
- Swelling and tenderness on the medial aspect of the knee. May have some bruising. Grade 1: No joint laxity. Grade 2: some joint laxity with a valgus stress test at 30 degrees flexion. Grade 3: Significant laxity at 30 degrees; some laxity at full extension.
- Osgood-Schlatter Diease
- Tendinitis of the patellar tendon where it inserts on the tibial tuberosity. Usually occurs in young athletes during the rapid growth years (age 9-13). Pt has swelling over the tibial tuberosity and complains of pain with quadriceps contraction.