Lecture 8. The Common Sport Injuries of the Knee Part 2 PDF

The common sport injuries of the knee and related structures BY Ass. Prof. Walid Abouelnaga PhD, MSc, PT Aqaba University of Technology  Recognition and management of specific injuries: Ligament Injuries: The major ligaments of th...

The common sport injuries of the knee and related structures BY Ass. Prof. Walid Abouelnaga PhD, MSc, PT Aqaba University of Technology  Recognition and management of specific injuries: Ligament Injuries: The major ligaments of the knee can be torn in isolation or in combination. Depending on the application of forces, injury can occur from a direct straight-line or single-plane force, from a rotary force, or from a combination of the two.  Recognition and management of specific injuries: Medial Collateral Ligament Sprain: Etiology : Caused by either a direct blow from the lateral side in a medial direction (valgus force) or from lateral tibial rotation , and it results most often from adduction and internal rotation( femur ). It has greater risk of injury compared to lateral sprains because of its more direct relation to the articular capsule and the medial meniscus. Any position of the knee, from full extension to full flexion, can result in injury if there is sufficient force. Recognition and management of specific injuries: Medial Collateral Ligament Sprain: Grade 1 medial collateral ligament sprain: ❑ A few ligamentous fibers are torn and stretched. ❑ The joint is stable during valgus stress tests. ❑ There is little or no joint effusion. ❑ There may be some joint stiffness and point tenderness just below the medial joint line. ❑ Even with minor stiffness, there is almost full passive and active range of motion. Recognition and management of specific injuries Medial Collateral Ligament Sprain: Grade 1 medial collateral ligament sprain: Management: Immediate care consists of POLICE for at least 24 hours Crutches are used if the patient is unable to walk without a limp. Follow-up care may involve ice application for 20 minutes before exercise or a combination of cold and compression or pulsed ultrasound. Isometrics and straight-leg exercises are important until the knee can be moved without pain. The patient then progresses to stationary bicycle riding or a high speed isokinetic program. Exercises for regaining neuromuscular function should also be incorporated. The patient is allowed to return to full participation when the knee has regained normal strength, power, flexibility, endurance, and neuromuscular control. Usually, a period of 1 to 3 weeks is necessary for recovery When returning to activity, the patient may require tape or brace support for a short period. Recognition and management of specific injuries Medial Collateral Ligament Sprain: Grade 2 medial collateral ligament sprain: Indicates both microscopic and gross disruption of ligamentous fibers. The only structures involved are the medial collateral ligament and the medial capsular ligament. No gross instability but minimum or slight laxity during full extension; however, at 30 degrees of flexion when the valgus stress test is performed, laxity may be greater. Moderate swelling unless other structures are involved i.e. meniscus, ACL, subluxated or dislocated patella, or a fracture. Moderate to severe joint tightness with an inability to fully, actively extend the knee. The patient is unable to place the heel flat on the ground. Definite loss of passive range of motion. Pain in the medial aspect, with general weakness and Recognition and management of specific injuries Medial Collateral Ligament Sprain: Grade 2 medial collateral ligament sprain: Management: POLICE should be applied for 48 to 72 hours. The patient should use crutches until the acute phase of injury is over and he or she can walk without a limp. A posterior splint or postoperative knee-immobilizing splint may be used for 2 to 5 days, after which range of motion exercises are begun. Modalities should be used two or three times daily to modulate pain and to control inflammation. Isometric exercise emphasizing quadriceps strengthening (quad sets, straight-leg lifts) should progress to active resisted full-range exercise as soon as possible. Recognition and management of specific injuries Medial Collateral Ligament Sprain: Grade 2 medial collateral ligament sprain: Management: Closed kinetic chain exercises, such as cycling on a stationary bike, stair climbing, and resisted flexion and extension, should be used as early as possible. Functional progression activities should be incorporated early in the rehabilitation program. The patient should be encouraged to use a brace and taping when he or she tries to return to running activities Conservative care of the grade 2 medial collateral ligament sprain has been successful. Recognition and management of specific injuries: Medial Collateral Ligament Sprain: Grade 3 medial collateral ligament sprain: A complete tear of the supporting ligaments. Complete loss of medial stability. Gross swelling. Immediate, severe pain followed by a dull ache. Loss of motion because of effusion and hamstring guarding. A valgus stress test that reveals some joint opening in full extension and significant opening at 30 degrees of flexion. Recognition and management of specific injuries: Medial Collateral Ligament Sprain: Grade 3 medial collateral ligament sprain: Management: POLICE should be used for at least 72 hours. Conservative nonoperative treatment is recommended for isolated grade 3 MCL sprains. In combined injuries = recovery times and long-term results regarding knee function and stability appear to be better than with surgical repair. Conservative treatment usually involves limited immobilization in a hinged rehabilitation brace set to allow 30 to 90 degrees of motion and progressive weight bearing for 2 to 3 weeks, with motion increased to 0 to 90 degrees for another 2 to 3 weeks.  Recognition and management of specific injuries: Medial Collateral Ligament Sprain: Grade 3 medial collateral ligament sprain: The rehabilitation program would be similar to that for grade 1 and 2 sprains, although recovery time would be longer. Recognition and management of specific injuries: Lateral Collateral Ligament Sprain: Etiology: The force required to tear this ligament is varus, often with the tibia internally rotated. If the force or blow is severe enough, both cruciate ligaments, the attachments of the iliotibial band, and the biceps muscle may be torn. The same mechanism could also disrupt the lateral and even the medial meniscus. If the force is great enough, bony fragments can be avulsed from the femur or tibia. Less prevalent than sprain of the medial collateral ligament. Recognition and management of specific injuries: Lateral Collateral Ligament Sprain: Symptoms and signs (with the respect to the grade of injury): Pain and tenderness over the LCL; with the knee flexed and internally rotated, the defect may be palpated. Swelling and effusion over the LCL. Some joint laxity with a varus stress test at 30 degrees ( depends on the grade of injury) ; if laxity exists in full extension, ACL and possibly PCL injury should be evaluated. The greatest pain with grade 1 and grade 2 sprains; in grade 3 sprains, pain may be intense initially and then will become a dull ache. Management: Management of the lateral collateral ligamentous injury should follow procedures similar to those for medial collateral ligamentous injuries. Recognition and management of specific injuries: Anterior Cruciate Ligament Sprain: Etiology: The anterior cruciate ligament sprain is generally considered to be the most serious ligament injury in the knee. Injury to the ACL can occur from contact or non-contact causes. As with the medial collateral ligament, a blow to the lateral knee can be a contact cause. Situations that place a loaded knee joint in a combined position of flexion, valgus, and rotation of the tibia on the femur can rupture the ACL in a non- contact manner. Noncontact mechanisms are approximately 80% more likely to cause an ACL injury. Typically, the athlete is decelerating from a jump or forward running. The position of the hips has a substantial impact on the incidence of ACL injury, if the hip is adducted relative to the pelvis the chances of ACL injury are significantly increased. Recognition and management of specific injuries Anterior Cruciate Ligament Sprain: Etiology: Recognition and management of specific injuries Anterior Cruciate Ligament Sprain: Symptoms and signs: The athlete will often experience a pop followed by immediate disability and will complain that the knee feels like it is shifting. Rapid swelling at the joint line. Positive anterior drawer sign and a positive Lachman’s sign. Proprioception is also decreased in the anterior cruciate– deficient knee. Management: Fitzgerald et al. (2000) developed guidelines for selecting appropriate candidates for non-operative ACL deficiency management. The primary criteria were no concomitant ligament or meniscal damage and a unilateral ACL injury. Recognition and management of specific injuries Anterior Cruciate Ligament Sprain: ❑ Other criteria include the following: Timed hop test score of 80% of the uninjured limb. Knee Outcome Survey Activities of Daily Living Scale score of 80% or more. Global rating of knee function of 60% or more. No more than one episode of giving way in the time from injury to testing.  Other possible criteria for non-operative ACL treatment include the following: Minimal exposure to high-risk activities such as sports and heavy work activities. Willingness to avoid high-risk activity. Age older than 40 years. Success in prolonged coping with or adaptation to ACL deficiency. Recognition and management of specific injuries Advanced arthritis of the involved joint. Inability or unwillingness to comply to postoperative rehabilitation. Surgery may involve joint reconstruction, which uses a graft from either the patellar tendon, hamstring tendon, or less commonly the quadriceps tendon that will roughly follow the course of the ACL and will functionally replace the ACL. This type of surgery involves a brief hospital stay, a week of protection for healing wounds, 3 to 5 weeks in braces, and 4 to 6 months of rehabilitation. Recognition and management of specific injuries: Anterior Cruciate Ligament Sprain: Preoperative Phase (3 to 6 Weeks after Injury): The goal during this phase is resolution of post injury swelling and pain and restoration of full range of motion. The patient should begin strengthening exercises through a full pain-free range of motion as soon as she can tolerate them. The patient should be psychologically prepared for surgery during this phase. Phase 1: Acute phase: GOALS: To minimize swelling, pain, and hemorrhage after surgery; establish and maintain full knee extension; achieve good quadriceps control; begin working on regaining knee flexion; and regain neuromuscular control. ESTIMATED LENGTH OF TIME (ELT): 1 week.  Recognition and management of specific injuries: Anterior Cruciate Ligament Sprain: POLICE during the entire first week 3 or 4 times per day to control swelling + Electrical muscle stimulation to control pain and elicit muscle contraction + Constant passive motion. Achieve full extension by end of first week. Weight shifting on crutches. Early quadriceps activity is important = perform straight-leg raises and multi angle submaximal isometrics at 90, 60, and 40 degrees. Hip exercises, especially adduction. Active isotonic hamstring contractions to achieve 90 degrees of flexion by end of second week. Mobilize patella. Weight bearing as tolerated with brace locked in full extension. Recognition and management of specific injuries: Anterior Cruciate Ligament Sprain: Phase 2 :Repair: GOALS: To achieve a normal gait pattern; maintain full extension, strengthen quadriceps and hamstrings, increase knee flexion, maintain cardiorespriratory endurance, improve neuromuscular control, and begin light functional activities. ELT: 1 to 6 weeks. Electrical muscle stimulation; POLICE to control swelling initially and after each treatment session. The amount of swelling will determine the athlete’s ability to contract the quadriceps. Electrical muscle stimulation to facilitate muscle contraction and for reeducation. Ultrasound to increase blood flow. Ambulation with brace locked in full extension initially (surgeon dependent). Patient should progressively increase range of motion in brace as tolerated. Recognition and management of specific injuries: Anterior Cruciate Ligament Sprain: Remove brace by week 3 or 4. Full weight bearing without a limp at the end of 4 weeks. Patient should attain full range of motion before she engages in intense strength training. Patient should concentrate on hamstring strengthening and should use closed kinetic chain activities and co- contractions as much as possible as well as strengthening exercises, such as minisquats, step-ups, hamstring and hip leg presses, and standing knee flexion and extension. Multidirection patellar mobilization should be used to mobilize the tibia. A stationary bike should be used as soon as range of motion permits, as well as proprioceptive activities.  Recognition and management of specific injuries: Anterior Cruciate Ligament Sprain: Phase 3: Remodeling GOALS: To concentrate on functional progressions and return to high-demand activity. ELT: 7 weeks to 6 months. Electrical muscle stimulation to facilitate contraction. Ultrasound to facilitate blood flow. Massage to decrease scar. Mobilization techniques as needed. Isokinetic testing. High-speed training using rubber tubing. Patient should begin hop training and work on balance, always emphasizing the quality of movement with each activity. Functional activities should be incorporated. Patient should begin returning to running program at about 4 months.  RECOGNITION AND MANAGEMENT OF SPECIFIC INJURIES Posterior Cruciate Ligament Sprain : The PCL has been called the most important ligament in the knee, providing a central axis for rotation. The PCL provides about 95 percent of the total restraining force to straight posterior displacement of the tibia. Etiology :The PCL is most at risk when the knee is flexed to 90 degrees. A fall with full weight on the anterior aspect of the bent knee with the foot in plantar flexion or receipt of a hard blow to the front of the bent knee can tear the PCL. A PCL has also been referred to as a “dashboard injury,” relating to a motor vehicle accident in which the driver’s or passenger’s knee hits the dashboard, forcing the tibia posteriorly and injuring the PCL. In addition, it can be injured by a rotational force, which also affects the medial or lateral side of the knee. RECOGNITION AND MANAGEMENT OF SPECIFIC INJURIES Posterior Cruciate Ligament Sprain:  RECOGNITION AND MANAGEMENT OF SPECIFIC INJURIES Posterior Cruciate Ligament Sprain : Symptoms and signs: The patient will report feeling a pop in the back of the knee. Tenderness and relatively little swelling will be evident in the popliteal fossa. Laxity will be demonstrated in a posterior sag test. The posterior drawer test is positive. Management: POLICE should be initiated immediately. Nonoperative rehabilitation of grade 1 and grade 2 injurie should focus on quadriceps strengthening.  Recognition and management of specific ` injuries Posterior Cruciate Ligament Sprain : As with isolated tears of the ACL, there is controversy over whether tears to the PCL should be treated nonoperatively or with surgical intervention. But - Surgery is occasionally recommended. Rehabilitation after surgery generally involves 6 weeks of immobilization in extension with full weight bearing on crutches. Range of motion exercises are begun at 6 weeks, progressing to the use of PRE at 4 months.  Recognition and management of specific injuries Meniscal Lesions: The medial meniscus is higher incidence of injury than the lateral meniscus because of the attachment to the medial structures, the medial meniscus is prone to disruption from valgus and torsional forces. Etiology : Tearing can occur as the result of excessive forces being placed on healthy tissues or otherwise normal forces being exerted on a degenerating meniscus. A valgus force can adduct the knee, often tearing and stretching the medial collateral ligament; meanwhile, its fibers twist the medial meniscus outward.  Recognition and management of specific injuries The most common mechanism is weight bearing combined with a rotary force while the knee is extended or flexed. If an individual makes a cutting motion while running, it can distort the meniscus. If the knee is forcefully extended from a flexed position while the femur is internally rotated = tear to medial meniscus. A forceful knee extension with the femur externally rotated = tear to the lateral meniscus. Meniscal lesions can be longitudinal, oblique, or transverse. Because of the blood supply of a meniscus, tears in the outer one-third of the meniscus may heal over time if stress in the area is a minimized. Tears that occur within the mid-substance of the meniscus often fail to heal because of lack of adequate blood supply. Recognition and management of specific injuries Meniscal Lesions: Symptoms and signs: Effusion developing gradually over 48-72 hours. Joint-line pain and loss of motion. Intermittent locking and giving way of the knee. Pain when the patient squats or change direction quickly. Management: Surgical management of meniscal tears should make every effort to minimize loss of any portion of the meniscus. Healing of the torn meniscus depends on where the tear has occurred.  Recognition and management of specific injuries Meniscal Lesions: Resection, or a partial menisectomy, involves removing as little as possible of the meniscus through an arthroscopy. Partial menisectomy of a torn meniscus is much more common than meniscal repair. Postsurgical management for a partial menisectomy does not require bracing and allows partial to full weight bearing on crutches as quickly as can be tolerated for about 2 weeks. A repaired meniscus requires immobilization in a rehabilitative brace for 5 to 6 weeks. The patient should be on crutches, progressing from partial to full weight bearing at 6 weeks. During immobilization, the patient can perform active ROM exercises between 0 and 90 degrees. At 6 weeks, full ROM resistive exercises can begin. Recognition and management of specific injuries Bursitis : Bursitis in the knee can be acute, chronic or recurrent. Although any one of the numerous knee bursae can become inflamed, anteriorly the prepatellar, deep infrapatellar, and suprapatellar bursae have the highest incidence of irritation. Etiology : The prepatellar bursa often becomes inflamed from placing pressure on the front of the knee while kneeling, and the deep infrapatellar bursa becomes irritated from overuse of the patellar tendon. Recognition and management of specific injuries Bursitis : Symptoms and signs: Localized swelling above the knee that is ballotable ( prepatellar bursa). Swelling is not intra-articular. There may be some redness and increased temperature. Some inflamed bursae may be painful and disabling because of the swelling and should be treated accordingly. Management: Management usually follows a pattern of eliminating the cause, prescribing rest, and reducing inflammation. To control bursitis elastic compression wraps and anti-inflammatory medication can be used. With chronic bursitis (thickened synovium) aspiration and steroid injection are needed.  Recognition and management of specific injuries Patellar instability: Acute Patellar Subluxation or Dislocation: Etiology: When an individual plants his or her foot, decelerates, and simultaneously cuts in an opposite direction from the weight bearing foot, the thigh rotates internally while the lower leg rotates externally, causing a forced knee valgus. The quadriceps muscle attempts to pull in a straight line and, as a result, pulls the patella laterally, a force that may dislocate the patella laterally. The patella most easily dislocates or subluxates when the knee is in 20° to 30° of knee flexion or after a valgus blow to the knee. The mechanism for patellar dislocations and subluxations is similar to that of an MCL sprain.  Recognition and management of specific injuries Patellar instability: Acute` Patellar Subluxation or Dislocation: Symptoms and signs: Pain. Swelling. Giving way. Knee ROM is restricted in flexion and extension because of swelling. Palpation of the medial patellar retinaculum, and/or the VMO at either its origin or insertion produces pain. The patella rests in an abnormal position. ✓ +ve Apprehension Test for Patellar Instability.  Recognition and management of specific injuries Patellar instability: Acute Patellar Subluxation or Dislocation: Management: To reduce a dislocation, the hip is flexed and the patella is gently moved medially as the knee is slowly extended. With a large hemarthrosis, joint aspiration may be indicated to reduce quadriceps inhibition and pain. After reduction, the knee is immobilized in extension for 4 weeks or longer, and the patient is instructed to use crutches. During immobilization, the patient should perform isometric exercises. After immobilization, the patient should wear a horseshoe- shaped felt pad that is held in place around the patella by an elastic wrap or sewn into an elastic sleeve that is worn while the patient runs or performs an activity. Commercial braces are also available. Muscle rehabilitation should focus on strengthening all the musculature of the knee, thigh, and hip. Recognition and management of specific injuries Patellar Tendinopathy (Jumper’s Knee): Etiology: Jumper’s knee occurs when chronic inflammation develops in the patellar tendon either at the superior patellar pole (usually referred to as quadriceps tendinitis), the tibial tubercle, or most commonly at the distal pole of the patella (patellar tendinitis), often the result of overuse. It usually develops in athletes from mechanical overloading of the tendon with activities that require rapid acceleration and deceleration, as in repetitive jumping and landing; hence the name. Recognition and management of specific injuries Patellar Tendinopathy (Jumper’s Knee): Symptoms and signs : Point tenderness on the inferior pole of the patella. Little or no effusion. Dull aching pain after jumping or running following repetitive jumping activities. Pain usually disappears with rest but returns with activity. Pain becomes progressively worse until the patient is unable to continue. There are also reports of difficulty in stair climbing and squatting, and an occasional feeling of giving way. Recognition and management of specific injuries Patellar Tendinopathy (Jumper’s Knee): Management: Ice, phonophoresis, iontophoresis, ultrasound. Superficial heat modalities, such as whirlpool. A patellar tendon tenodesis brace or strap may also be used. Deep transverse friction massage. Exercise: eccentric exercise using squats on a 25-degree decline board.