ACL, MCL, LCL, Menisci, Patellar Dislocation Injuries - PDF

Injury to the anterior cruciate ligament; Rehabilitation strategy  Anatomy of ACL  The ACL is a band of dense connective tissue that connects the femur and the tibia.  The ligament originates at the ACL injury medial sid...

Injury to the anterior cruciate ligament; Rehabilitation strategy  Anatomy of ACL  The ACL is a band of dense connective tissue that connects the femur and the tibia.  The ligament originates at the ACL injury medial side of the lateral femoral condyle and runs an oblique course through the intercondylar fossa distal-anterior-medial to the insertion at the medial tibial eminence.  The biomechanical function of the anterior cruciate ligament is complex for it provides both mechanical stability and proprioceptive feedback to the knee. ACL ACL is responsible for stabilizing Biomechan rotational movement at the knee that occur during cutting and ics pivoting activities. ACL is secondary restraint to knee hyperextension. Acts as a secondary stabilizer to stress, reinforcing the MCL. ACL injury Overview The ACL is the most frequent ligament to be injured in the knee joint, accounting for about 50% of all ligament injuries. Complete or partial  Contact injury  Non-contact injury Types of ACL injuries Grade I sprain- some stretching and micro-tearing of the ligament, but the ligament is intact and the joint remains stable Grade II sprain( partial disruption) – some tearing and separation of the ligament fibers and the ligament is partially disrupted. The joint is moderately unstable. Depending on the activity level of the patient and the degree of instability, these tears may or may not require surgery. Grade III sprain (complete disruption) – total rupture of the ligament fibers. The joint is unstable. Surgery is recommended in young or athletic people who engage in sports that involve mostly cutting or pivoting. Evaluation of ACL  MRI- visualize soft tissue, predicting an ACL tear  Diagnostic arthroscopy- to determine an injury Patient is in supine position Patient’s knee is flexed to 90 degree, with feet flat on the table The examiner sits on the patient’s foot to stabilize it, and with the examiner’s hands cupped around the back of the upper culf muscle, the tibia is pulled toward the examiner, If the tibia slides forward from under the femur more than a few degrees, Physical the test shows ACL tear. examination Anterior drawer test Lachman’s test  Takes opposition of hamstrings out of play  Knee flexed 15-30 degrees  Stabilize femur  Apply anterior force to tibia   Surgery  Conservative treatment Physical therapy Treatment Knee brace Medications RICE therapy  Criteria for nonoperative treatment  No concomitant ligament or meniscal damage  Minimal exposure to high- risk activities such as sports and heavy work activity  Willingness to avoid high-risk activity  Age older than 40 years  Advanced arthritis of the involved joint  Inability or unwillingness to comply to postoperative rehabilitation  Once operative reconstruction is chosen, a number of controversial areas must be considered:  Timing of surgery; Operative  Choice of graft; treatment  Fixation method;  Rehabilitation protocol Autografts Achilles tendon Hamstring tendon Patellar ligament (tendon)   Assess and maintain ROM of joint Pre-operative  Minimal swelling- RICE therapy evaluation  Adequate strength and neuromuscular control and  Prevent post-operative complications such treatment as arthrofibrosis Post-operative treatment Rehabilitation protocol spans over a 6 month period and is divided into timelines. Each timeline has goals and exercise suggestions for several domains: range of motion and flexibility, strength and endurance, proprioception, gait, and cardiovascular fitness. General Goals :  Pain control  Maintain patellar mobilization  Edema control  Increase quadriceps/hamstring strength  Wound healing  Balance and neuromuscular re-education  Graft protection  Normal gait pattern  NWB-PWB-FWB progression  Returning to the previous level of activity  Full active range of motion Lack of extension Loss of extension is one of the most common complications. A small degree of knee flexion contracture will restrict the quads ability to regain full strength which is important for functional outcomes. Methods of restoring Extension:  Manual therapy/mobilization  PROM using external devices  Soft tissue massage Sleeping position pillow under the knee- cause limitation of extension in the knee joint Traumatic injury to the medial and lateral collateral ligaments Medial collateral ligament (MCL) Is located on the inner (medial) portion of the knee. It is a big ligament on the medial side of the knee. Functions of MCL: 1.Resist valgus stress force ; 2. Check lateral rotation of tibia; 3. restrain anterior displacement of tibia when ACL is absent   Most isolated MCL injury result from a direct blow to the outer aspect of the upper leg or lower thigh creating a valgus force. Mechanism of  Noncontact external rotation  MCL indirect mechanisms typically also result in associated MCL injury injuries, usually involving the ACL and PCL.  MCL sprains may be isolated or combined with other knee injuries. Classification of medial collateral ligament sprain Grade Damage to ligament Clinical examination 1 Microtrauma with no elongation Tender ligament Normal valgus laxity 2 Elongated but intact Increased valgus laxity with firm endpoint on valgus stress at 20 degrees of knee flexion 3 Complete disruption Increased valgus laxity with soft endpoint on valgus stress at 30 degrees of knee flexion  Visual inspection – identify of swelling Knee palpation – along the entire course of the MCL to locate the area or areas of maximal tenderness. MCL may be Physical associated with tenderness near the adductor tubercle or medial retinaculum adjacent to the patella, but this can also be related to a patellar dislocation or subluxation with a examinatio concomitant VMO avulsion or medial retinacular tear. ns Range of motion Quadriceps/hamstring/ VMO muscles strength  The valgus stress test With the knee in 30 degrees of flexion , injured leg over the side of the examination table, the examiner paces one hand under the heel to support the leg and with the other hand applies a valgus force. Rotation of the thigh should be prevented during this maneuver, and the examination should be compared with the contralateral knee as a control for the amount of joint line opening.  Most MCL injuries are treated nonoperatively Special situations involving a complete ligament disruptions, which may require operative intervention, includes:  A large bony avulsion Treatment  A concomitant tibial plateau fracture  Associated cruciate ligaments injury Surgical fixation of the MCL usually is done within 7 to 10 days after the injury and can be through a primary repair or reconstruction with autograft or allograft augmentation.  In combined ACL and MCL injuries ACL treatment is very important to: Restore the overall stability of the knee Optimize the environment for MCL healing A hinged knee brace and early functional rehabilitation protocol (EFR) are used for combined ACL/MCL injuries  Rehabilitation after MCL injury The EFR program for MCL injury is divided into three phases, with a focus on early return to sport participation. For full return to competitive play, the athlete must fulfill four criteria:  Minimal or no pain  Full ROM  Quadriceps and hamstring strength equal to 90 % of the contralateral limb  Completion of one session of the running program Overall, the average time of return to competitive play varies with both the sport and grade of MCL injury. Lateral collateral ligament injury An injury to the LCL could include:  partially or completely tearing any part of that ligament.  LCL is one of the more commonly injured ligaments in the knee. Mechanism of injury  The main cause of LCL injuries is direct-force trauma to the inside of the knee. This puts pressure on the outside of the knee and causes the LCL to stretch or tear.  Caused by varus stress from direct blow to knee  Foot planted and thigh externally rotates  Less common than MCL or ACL  Can damage the cruciate ligaments, and meniscus. Signs and  swelling of the knee (especially the outer aspect)  stiffness of the knee joint that can cause locking symptoms of the knee  pain or soreness on the outside of the knee  instability of the knee joint (feeling like it’s going to give out)  Physical examination Varus stress test Purpose: The varus stress test shows a lateral joint line gap. Performance: A varus stress test is performed by stabilizing the femur and palpating the lateral joint line. The other hand provides a varus stress to the ankle. The test is performed at 0° and 20- 30°, so the knee joint is in the closed packed position. If the knee joint adducts greater than normal (compared to the unaffected leg), the test is positive. This an indication of a LCL tear.  Treatment The treatment options for LCL injuries will depend on the severity of the injury and the lifestyle. For minor injuries, treatment may include:  applying ice  elevating the knee above the heart  taking a pain reliever  limiting physical activity until the pain and swelling are gone  using a brace (knee immobilizer) or crutches to protect the knee  physical therapy and rehabilitation to strengthen ,regain range of motion, flexibility and stability of joint Physical rehabilitation after injury to the menisci Meniscus tear types  Meniscus plays a vital role in knee health by:  Increasing knee joint space and contact area  Reducing localized stress and buffering against rotational and axial sheer force Injury to this structure may alter normal joint movement, leading to increased contact stress and accelerated osteoarthritis  Mechanisms of injury Causes of Meniscus injuries  An acute twisting injury from impact during a sport activity  Usually the foot stays fixed on the ground and the rest of body rotates  Getting up from a squatting position  Loading the knee from a fixed position Meniscal tears may be associated with anterior cruciate ligament tears - The instability of the knee increases the likelihood of meniscal tear over time Degenerative changes of the knee can contribute to a torn meniscus  The lateral meniscus has been shown to be more mobile than the medial meniscus.  Anterior horn has greater mobility than the posterior horn.  The reduced mobility of the posterior medial meniscus may result in greater stresses in this area, leading to increased vulnerability to injury.  higher rate of meniscal tears that occurs in the posterior medial meniscus. Meniscal healing Blood supply  The outside one-third of the meniscus has a rich blood supply. A tear in this "red" zone may heal on its own, or can often be repaired with surgery.  The inner two-thirds of the meniscus lacks a blood supply. Without nutrients from blood, tears in this "white" zone cannot heal. These complex tears are often in thin, worn cartilage. McMurray Test Meniscus damage  treatment plan depends on:  Type of tear  Size of tear  Location of injury Treatment  Age  Activity level  Any previous or concomitant disease/injury  Rehabilitation goals:  Early control of pain and swelling Rehabilitatio  Maintaining a full ROM n after  Regaining quadriceps strength  WB as tolerated to progress partial meniscectom Combination of weight bearing and increasing knee flexion must be carefully y balanced in the development of a rehabilitation protocol   0-4 wks : In tears with decreased healing potential (white-white tears, radial tears or complex pattern tears) limiting weight bearing(NW) and limiting flexion to 60 degrees  WB starts in about 4-8 wks depends on recovery process  Control pain and swelling Rehabilitatio n after  Regaining quadriceps strength  Generally progress ROM of joint meniscal  Restore and improve muscular strength and endurance  Gradual return to functional activities repair The length of the rehabilitation period depends on the patient’s condition and recovery progress. If a meniscal repair is done, the recovery time and rehabilitation period may be extended – up to six weeks in a knee brace or with crutches. Total recovery time approximately 4-5 months or more Dislocation of patella Introduction  The largest sesamoid bone  It resides within the complex of the quadriceps and patellar tendon  It allows for smooth movement during knee flexion/extension, protects the anterior surface of the knee joint  The most common location of patella dislocation is lateral dislocation.  Patients complain of the knee suddenly giving way, and inability to weight-bear or extend the knee and are often in considerable pain Mechanism of injury  Type I : results when there is powerful contraction of the quadriceps in combination with sudden flexion and external rotation of the tibia on the femur The most common reason for the patellar dislocation  Type II : results from direct trauma to the patella with the knee in flexion, can cause dislocation. Patellar dislocations are common in patients with the following:  Genu valgum  Genu recurvatum (hyperextension)  Excessive femoral neck anteversion or internal femoral torsion  Atrophy of the vastus medialis muscle Types of patellar dislocation Type dislocation Pain Swelling Acute dislocation In response to Present Present trauma Recurrent Isolated episode in Present Present response to trauma Habitual Everytime when Absent Absent knee is flexed Congenital Since birth Absent Absent  Rare condition Habitual Patella dislocates during flexion and relocates during extension dislocation of Without pain and swelling unlike the patella recurrent patellar dislocation Introduction Clinical examination of habitual dislocation of patella Gait Inspection - swelling, dislocation, scar marks - weakness of quadriceps/VMOmuscles - Position of patella: Centrally placed (in extension) and laterally dislocated in flexion - Size of patella: Left appears small than right side Patellar alignment  Q –angle is the angle formed by two intersecting lines Management Surgical realignment is the treatment choice Principle:  Medialization of patella  Maintenance of proximal and distal alignment  Post-operative rehabilitation Goals:  Control inflammation  Brace: 0-4 wks – locked in full extension 24 hours 7 days a week  Protect fixation except for therapeutic exercises  Activation of quadriceps and VMO and continuous passive motion use Rehabilitativ  Full knee extension and minimize adverse effects of immobilization (CPM), 4-6 wks – unlocked for sleeping, locked for ambulation e Precautions for Phase I:  Weight-bearing: NWB-PWB-FWB  Quadriceps sets and isometric management  ROM: 0-2 wks – 0-30 degrees of adduction with electrical flexion, stimulation for VMO 2-4 wks – 0-60 degrees, 4-6 wks – 0- 90 degrees   Increase flexion  Avoid overstressing fixation  Control of quadriceps and VMO for proper patellar tracking Goals for progression: Criteria for progression:  Good to normal quadriceps strength, no soft tissue complaints,  No evidence of patellar instability, clearance from PT to progress closed-chain exercises and resume full or partial activity. Scar formation and its rehabilitative management  Arthrofibro Abnormalsis proliferation of fibrous tissue in and around a joint Arthrofibrosis is defined as a complication of injury or trauma where an excessive scar tissue response leads to painful restriction of joint motion, with scar tissue forming within the joint and surrounding soft tissue spaces and persisting despite rehabilitation exercises and stretches. Scarring adhesions has been described in most major joints, including knees, shoulders, hips, ankles, and wrists. Symptomatic review Loss of ROM/Stiffness Loss of strength Pain Inability to return previous level of activity  Common  Late Rehabilitation cause of  Improper surgery  Intra-articular surgeries Arthrofibro  Injuries sis Common complication of procedures such as ACL reconstruction surgery, total knee arthroplasty. The condition is caused by inflammation and the creation of excess of scar tissue. Excessive scar tissue can cause:  Heat  Pain  swelling  popping  weakness.  making it difficult to walk, drive, or get in and out of a chair Several factors that can lead to limit knee ROM after ACL surgery including: Inapropriate graft placement Acute surgery on a swollen inflamed knee Concomitant medial collateral ligament(MCL) repair Poorly supervised or designed rehabilitation program.   Diagnosis History of injury  History of surgery  Range of motion in the Physical joint  To confirm the diagnosis and get a feel for the examination extent of the problem, an MRI and X-ray are recommended   Surgical treatment  Non-surgical treatment Forcefully stretching under the anesthesia-to break up scar tissue Treatmen Physical therapy: ROM/ flexibility t exercises Cryotherapy , rest and elevation is recommended to control pain and swelling  Prevention: early motion following surgery. Primary goals of treatment Restore ROM -Full passive and active range of motion -In case of knee joint arthrofibrosis o once knee extension is regained and easily maintained, loss of knee flexion can be addressed. Increase joint function  Strengthening exercises -are slowly added when full ROM is restored because the focus procedure and rehabilitation is to address motion and stiffness. Patellar Mobilization  Clinical Orthopedic Rehabilitation Anterior cruciate ligament injury Chapter 47 Pages: 308-318 Medial collateral ligament injury Chapter 54 Pages:367-371 Meniscus injury Chapter 55 Pages: 372-375 Patellofemoral disorder; Patellar instability Chapter 56 Pages: 383-385