Lecture 7 - The Common Sport Injuries of the Knee Part 1 PDF

The common sport injuries of the knee and related structures BY Ass. Prof. Walid Abouelnaga PhD, MSc, PT Aqaba University of Technology  INTRODUCTION Because so many activities place extreme stress on the knee, it is one of the mo...

The common sport injuries of the knee and related structures BY Ass. Prof. Walid Abouelnaga PhD, MSc, PT Aqaba University of Technology  INTRODUCTION Because so many activities place extreme stress on the knee, it is one of the most traumatized joints in the physically active population. The knee is commonly considered a hinge joint because its two principal movements are flexion and extension. However, because rotation of the tibia is an essential component of knee movement, the knee is not a true hinge joint. The stability of the knee joint depends primarily on the ligaments, the joint capsule, and the muscles that surround the joint. The knee is designed primarily to provide stability in weight bearing and mobility in locomotion; however, it is especially unstable laterally and medially.  KNEE ANATOMY Bones: The knee joint complex consists of the femur, the tibia, the fibula, and the patella.  KNEE ANATOMY Articulations: The knee joint complex consists of four articulations between the femur and the tibia, the femur and the patella, the femur and the fibula, and the tibia and the fibula. Menisci: The menisci are two oval (semilunar) fibrocartilages that deepen the articular facets of the tibia, cushion any stresses placed on the knee joint, and maintain spacing between the femoral condyles and tibial plateau.  Knee Anatomy ✓ Stabilizing ligament: ` Cruciate Ligaments: The cruciate ligaments account for a considerable amount of knee stability. They are two ligamentous bands that cross one another within the joint capsule of the knee. The anterior cruciate ligament (ACL) attaches below and in front of the tibia; then, passing posteriorly, it attaches laterally to the inner surface of the lateral condyle. The posterior cruciate ligament (PCL), the stronger of the two, crosses from the back of the tibia in an upward, forward, and medial direction and attaches to then anterior portion of the lateral surface of the medial condyle of the femur. Capsular and Collateral Ligaments: Additional stabilization of the knee in provided by the capsular a collateral ligaments. Besides providing stability, they also dire movement in a correct path. Although they move in synchrony, they a divided into the medial and lateral complexes.  Knee Anatomy ✓ Stabilizing ligament:  Knee Anatomy Joint capsule: The articular surfaces of the knee joint are completely enveloped by the largest joint capsule in the body. The joint capsule is divided into four regions: the posterolateral, posteromedial, anterolateral, and anteromedial. Each of these four “corners” of the capsule is reinforced by other anatomical structures. Knee Musculature: For the knee to function properly, a number of muscles must work together in a complex manner.  Knee Anatomy ✓ Muscles:  Knee Anatomy ✓ Muscles :  Knee Anatomy ✓Muscles :  Knee Bursae: A bursa is composed of pieces of synovial tissue separated by a ` thin film of fluid. The function of a bursa is to reduce the friction between anatomical structures.  The physiotherapist / sport therapist is usually the first person to observe the injury; therefore, he or she is charged with clinical diagnosis and immediate care. The most important aspect of understanding what pathological process has taken place is to become familiar with the traumatic sequence and mechanisms of injury, either through having seen the injury occur or through learning its history. History: To determine the history and major complaints involved in acute knee injury, the athletic trainer should ask the following questions: Current Injury What were you doing when the knee was hurt? What position was your body in? Did the knee collapse? Did you hear a noise or feel any sensation at the time of injury, such as a pop or crunch? Could you move the knee immediately after the injury? If not, was it locked in a bent or extended position? (Locking could mean a meniscal tear.)  Knee Assessment History: After being locked, how did it become unlocked? Did swelling occur? If yes, was it immediate, or did it occur later (Immediate swelling could indicate a cruciate injury or tibial fracture, whereas later swelling could indicate a capsular, synovial, or meniscal tear). Where was the pain? Was it local, all over, or did it move from one side of the knee to the other? Have you hurt the knee before? (Refer to “Recurrent or Chronic Injury,” which follows). What does it feel like to go up and down stairs? (Pain could indicate a patellofemoral pain syndrome or meniscal tear, for example.) What past treatment (past surgery, physical therapy, etc.), if any, have you received for this or any other previous lower extremity injury or condition?  Knee Assessment Observation: A visual examination should be performed after the major complaints have been determined. The patient should be observed in a number of situations: walking, half-squatting, and going up and down stairs. The leg also should be observed for alignment and symmetry or asymmetry. Patellar alignment should be observed ( patella alta , patella paja). Note : we have to make the observation that is related to area : skin texture, color , swelling , deformity, abnormal sounds, range of motion , gait , etc…  Knee Assessment Palpation: The area of injury should be palpated to determine obvious structural deformities, areas of swelling, and points of tenderness. Bony Palpation: The following bony landmarks should be palpated:  Knee Assessment ❑ Palpation: Soft tissue Palpation: The following bony landmarks should be palpated:  Knee Assessment ` Special Tests for Assessment of joint stability: Collateral Ligament Stress Tests Valgus and varus: Stress tests are intended to reveal laxity of the medial and lateral stabilizing complexes, especially the collateral ligaments. The patient lies supine with the leg extended. Valgus Stress Test: To test the medial side, the therapist holds the ankle firmly with one hand while placing the other hand over the head of the fibula. The therapist then places a force inward in an attempt to open the side of the knee. This valgus stress is applied with the knee fully extended, or at 0 degrees, and at 30 degrees of flexion. The examination in full extension tests the MCL, posteromedial capsule, and cruciates. At 30 degrees of flexion, the MCL is isolated. Varus Stress Test: The therapist reverses hand positions and tests the lateral side with a varus force on the fully extended knee and then with 30 degrees of flexion the knee extended, the LCL and posterolateral capsule are examined. At 30 degrees of flexion, the LCL is isolated. note: The lower limb should be in a neutral position with no internal or external rotation.  Knee Assessment Special Tests for Assessment of joint stability : Collateral Ligament Stress Tests Valgus and varus:  Knee Assessment Special Tests for Assessment of joint stability : Collateral Ligament : Apley Distraction Test: With the patient in the same position as for the Apley compression test, the examiner applies traction to the lower leg while rotating it back and forth. This maneuver distinguishes collateral ligamentous tears from capsular and meniscal tears. If the capsule or ligaments are affected, pain will occur; if the meniscus is torn, no pain will occur from the traction and rotation.  Knee Assessment Special Tests for Assessment of joint stability : Anterior Cruciate Ligament Tests: Drawer Test at 90 Degrees of Flexion: The patient lies on the treatment table with the injured leg flexed. The examiner stands facing the anterior aspect of the patient’s leg, with both hands encircling the upper portion of the leg immediately below the knee joint. The examiner positions his or her fingers in the popliteal space of the affected leg, with the thumbs on the medial and lateral joint lines. If the tibia slides forward from under the femur, this is considered a positive anterior. Special Tests for Assessment of joint stability : Lachman Drawer Test: The Lachman drawer test is administered by positioning the knee in approximately 30 degrees of flexion. The examiner uses one hand to stabilize the leg by grasping the distal end of the thigh and the other hand to grasp the proximal aspect of the tibia and attempts to move it anteriorly. One problem with the Lachman test is that, if the patient is very large or if the examiner has small hands, it is difficult to perform this test efficiently. Several alternative methods may be used. First, a tightly rolled towel or other support can be placed under the femur and the examiner can use one hand to stabilize the femur and the other to anteriorly translate the tibia. A second alternative is to slide the lower leg off the edge of the examining table with the knee and femur supported by the edge of the table. Again, one hand should be used to stabilize the femur and the other to anteriorly translate the tibia. Finally, the patient may be placed prone with the knee and lower leg just off the edge of the table. Using the table to stabilize the femur, the examiner can anteriorly translate the. A positive Lachman test indicates damage to the anterior cruciate.  Knee Assessment Lachman Drawer Test :The Lachman drawer test is considered to be a better test than the drawer test at 90 degrees of flexion.  Knee Assessment Special Tests for Assessment of ` joint stability : posterior Cruciate Ligament Tests: 1. Posterior Drawer Test: The posterior drawer test is performed with the knee flexed at 90 degrees and the foot in neutral. Force is exerted in a posterior direction at the proximal tibial plateau. A positive posterior drawer test indicates damage to the posterior cruciate ligament. 2. Posterior Sag Test (Godfrey’s Test): With the patient supine, both knees are flexed to 90 degrees. Observing laterally on the injured side, the tibia will appear to sag posteriorly when compared with the opposite extremity if the posterior cruciate ligament is damaged.  Knee Assessment Special Tests for Assessment of joint stability: posterior Cruciate Ligament Tests:  Knee Assessment Special Tests for Assessment of joint stability : Meniscus tear: 1. McMurray’s Meniscal Test : McMurray’s meniscal test is used to determine the presence of meniscal tear. The patient is positioned face up on the table with the injured leg fully flexed. The examiner places one hand on the foot and one hand over the top of the knee, fingers touching the medial joint line. The ankle hand scribes a small circle and pulls the leg into extension. As this occurs, the hand on the knee feels for a clicking response. Medial meniscal tears can be detected when the lower leg is externally rotated, and internal rotation allows the detection of lateral tears.  Knee Assessment Special Tests for Assessment of joint stability : Meniscus tear: 2. Apley Compression Test: The Apley compression test is performed with the patient lying facedown and the affected leg flexed to 90 degrees. While stabilizing the thigh, the examiner applies a hard, downward pressure to the leg and rotates the leg back and forth. If pain results, a meniscal injury has occurred. A medial meniscal tear is noted by external rotation, and a lateral meniscal tear is noted by internal rotation of the lower leg.  Knee Assessment Special Tests for Assessment of joint stability : Meniscus tear: 2. Thessaly Test: In the Thessaly test, the patient stands flatfooted on the floor.The clinician stands in front of and supports the patient by holding his or her outstretched hands. The patient then rotates his or her knee and body, internally and externally, three times, keeping the knee in 5 degrees f flexion. This procedure is repeated with the knee flexed at 20 degrees. In a positive test, the patient reports medial or lateral joint-line discomfort and may have a sense of locking or catching. With this maneuver, the knee with a meniscal tear is subjected to excessive loading conditions. The test is always performed first on the normal knee, so that the patient can compare the Normal with the injured knee.  Knee Assessment Functional examination: It is important that the patient’s knee also be tested for function. It must be added that not only do patients need to be able to do these functional tests, but do them correctly without altered movements/compensations. The patient must be able to bear weight prior to attempting functional testing. The patient should be observed walking and, if possible, running, turning, performing figure eights backing up, and stopping. The co- contraction test, vertical jump, and single-leg hop test are also useful functional tests. The resistive strength of the hamstring and quadriceps muscles should be compared with the strength of the uninjured knee. The patient should be able to perform these tests at full speed, without limping or favoring the injured knee. If baseline testing was done prior to injury, the baseline results should be used to compare with post-injury test results to determine if the patient is able to perform at pre-injury levels.  Knee Assessment Patellar examination: Any knee evaluation should include inspection of the patella. Numerous evaluation procedures are associated with the patella and its associated structures. The following evaluation procedures can provide valuable information about possible reasons for knee discomfort and problems in functioning. Patellar Compression/ Grinding test: With the knee held to create approximately 20 degrees of flexion, the patellar compression test forces the patella downward into the femoral groove. A positive test causes pain and/or crepitus. If the patient feels pain or if a grinding sound is heard during the patellar grind test, a pathological condition is probably present. Patellar examination: With the knee still flexed, the patella is forced downward and is held in this position as the athlete contracts the quadriceps. A positive Clarke’s sign is present when the patient experiences pain and grinding.  Knee Assessment Patellar examination:  Knee Assessment Patellar examination: Fairbank’s patellar apprehension test: Test that indicates whether the patella can easily be subluxated or dislocated.With the knee and patella in a relaxed position, the examiner pushes the patella laterally. The patient will express sudden apprehension at the point at which the patella begins to dislocate.