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Soft tissue injuries of Knee ORTHODE.ppt
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- 2. Assessing the KneeJoint • Determining the mechanism of injury is critical • History- Current Injury – Past history – Mechanism- what position was your body in? – Did the knee collapse? – Did you hear or feel anything? – Could you move your knee immediately after injury or was it locked? – Did swelling occur? – Where was the pain
- 3. • History -Recurrent or Chronic Injury – What is your major complaint? – When did you first notice the condition? – Is there recurrent swelling? – Does the knee lock or catch? – Is there severe pain? – Grinding or grating? – Does it ever feel like giving way? – What does it feel like when ascending and descending stairs? – What past treatment have you undergone?
- 4. • Observation – Walking,half squatting, going up and down stairs – Swelling, ecchymosis, – Leg alignment • Genu valgum and genu varum • Hyperextension and hyperflexion • Patella alta and baja • Patella rotated inward or outward – May cause a combination of problems • Tibial torsion, femoral anteversion and retroversion
- 5. • Tibial torsion –An angle that measures less than 15 degrees is an indication of tibial torsion • Femoral Anteversion and Retroversion – Total rotation of the hip equals ~100 degrees – If the hip rotates >70 degrees internally, anteversion of the hip may exist
- 7. – Knee Symmetryor Asymmetry • Do the knees look symmetrical? Is there obvious swelling? Atrophy? – Leg Length Discrepancy • Anatomical or functional • Anatomical differences can potentially cause problems in all weight bearing joints • Functional differences can be caused by pelvic rotations or mal-alignment of the spine
- 8. Palpation - Bony •Medial tibial plateau • Medial femoral condyle • Adductor tubercle • Lateral tibial plateau • Lateral femoral condyle • Lateral epicondyle • Head of fibula • Tibial tuberosity • Superior and inferior patella borders (base and apex) • Around the periphery of the knee relaxed, in full flexion and extension
- 9. Palpation - SoftTissue • Vastus medialis • Vastus lateralis • Vastus intermedius • Rectus femoris • Quadriceps and patellar tendon • Sartorius • Medial patellar plica • Anterior joint capsule • Iliotibial Band • Arcuate complex • Medial and lateral collateral ligaments • Pes anserine • Medial/lateral joint capsule • Semitendinosus • Semimembranosus • Gastrocnemius • Popliteus • Biceps Femoris
- 10. • Palpation ofSwelling – Intra vs. extracapsular swelling – Intracapsular may be referred to as joint effusion – Swelling w/in the joint that is caused by synovial fluid and blood is a hemarthrosis – Sweep maneuver – Ballotable patella - sign of joint effusion – Extracapsular swelling tends to localize over the injured structure • May ultimately migrate down to foot and ankle
- 11. • Girth Measurements –Changes in girth can occur due to atrophy, swelling and conditioning – Must use circumferential measures to determine deficits and gains during the rehabilitation process – Measurements should be taken at the joint line, the level of the tibial tubercle, belly of the gastrocnemius, 2 cm above the superior border of the patella, and 8-10 cm above the joint line • Subjective Rating – Used to determine patient’s perception of pain, stability and functional performance
- 12. • Functional Examination –Must assess walking, running, turning and cutting – Co-contraction test, vertical jump, single leg hop tests and the duck walk – Resistive strength testing • Q-Angle – Lines which bisect the patella relative to the ASIS and the tibial tubercle – Normal angle is 10 degrees for males and 15 degrees for females – Elevated angles often lead to pathological conditions associated w/ improper patella tracking
- 13. Special Tests forKnee Instability – Use endpoint feel to determine stability – MRI may also be necessary for assessment – Classification of Joint Instability • Knee laxity includes both straight and rotary instability • Translation (tibial translation) refers to the glide of tibial plateau relative to the femoral condyles • As the damage to stabilization structures increases, laxity and translation also increase
- 14. Valgus and VarusStress Tests • Used to assess the integrity of the MCL and LCL respectively • Testing at 0 degrees incorporates capsular testing while testing at 30 degrees of flexion isolates the ligaments
- 15. Prevention of KneeInjuries Physical Conditioning and Rehabilitation – Total body conditioning is required • Strength, flexibility, muscular endurance, agility, speed and balance – Muscles around joint must be conditioned (flexibility and strength) to maximize stability – Must avoid abnormal muscle action through flexibility – In an effort to prevent injury, extensibility of hamstrings, erector spinae, groin, quadriceps and gastrocnemius is important
- 16. • Functional and ProphylacticKnee Braces – Used to prevent and reduce severity of knee injuries – Used to protect MCL, or prevent further damage to grade 1 & 2 sprains of the ACL or to protect the ACL following surgery – Can be custom molded and designed to control rotational forces
- 17. Recognition and Management ofSpecific Injuries Medial Collateral Ligament Sprain – Etiology • Result of severe blow or outward twist – Signs and Symptoms - Grade I • Little fiber tearing or stretching • Stable valgus test • Little or no joint effusion • Some joint stiffness and point tenderness on lateral aspect • Relatively normal ROM
- 18. Management • RICE forat least 24 hours • Crutches if necessary • Follow-up care will include cryokinetics w/ exercise • Move from isometrics and STLR exercises to bicycle riding and isokinetics • Return to play when all areas have returned to normal • May require 3 weeks to recover
- 19. Signs and Symptoms(Grade II) • Complete tear of deep capsular ligament and partial tear of superficial layer of MCL • No gross instability; laxity at 5-15 degrees of flexion • Slight swelling • Moderate to severe joint tightness w/ decreased ROM • Pain along medial aspect of knee Management • RICE for 48-72 hours; crutch use until acute phase has resolved • Possibly a brace or casting prior to the initiation of ROM activities • Modalities 2-3 times daily for pain • Gradual progression from isometrics (quad exercises) to CKC exercises; functional progression activities
- 20. Signs and Symptoms(Grade III) • Complete tear of supporting ligaments • Complete loss of medial stability • Minimum to moderate swelling • Immediate pain followed by ache • Loss of motion due to effusion and hamstring guarding • Positive valgus stress test Management • RICE • Conservative non-operative versus surgical approach • Limited immobilization (w/ a brace); progressive weight bearing and increased ROM over 4-6 week period • Rehab would be similar to Grade I & II injuries
- 21. Lateral Collateral LigamentSprain Etiology • Result of a varus force, generally w/ the tibia internally rotated • Direct blow is rare • If severe enough damage can also occur to the cruciate ligaments, ITB, and meniscus, producing bony fragments as well Signs and Symptoms • Pain and tenderness over LCL • Swelling and effusion around the LCL • Joint laxity w/ varus testing • May cause irritation of the peroneal nerve Management • Follows management of MCL injuries depending on severity
- 22. Knee Plica Etiology • Irritationof the plica (generally, mediopatellar plica and often associated w/ chondromalacia) Signs and Symptoms • Possible history of knee pain/injury • Recurrent episodes of painful pseudo-locking • Possible snapping and popping • Pain w/ stairs and squatting • Little or no swelling, and no ligamentous laxity Management • Treat conservatively w/ RICE and NSAID’s if the result of trauma • Recurrent conditions may require surgery
- 23. Bursitis Etiology • Acute, chronicor recurrent swelling • Prepatellar = continued kneeling • Infrapatellar = overuse of patellar tendon Signs and Symptoms • Prepatellar bursitis may be localized swelling above knee that is ballotable • Swelling in popliteal fossa may indicate a Baker’s cyst – Associated w/ semimembranosus bursa or medial head of gastrocnemius – Commonly painless and causing little disability – May progress and should be treated accordingly Management • Eliminate cause, RICE and NSAID’s • Aspiration and steroid injection if chronic
- 24. Osgood-Schlatter Disease andLarsen-Johansson Disease Etiology • Osgood Schlatter’s is an apophysitis occurring at the tibial tubercle – Begins cartilagenous and develops a bony callus, enlarging the tubercle – Resolves w/ aging – Common cause = repeated avulsion of patellar tendon • Larsen Johansson is the result of excessive pulling on the inferior pole of the patella Signs and Symptoms • Both elicit swelling, hemorrhaging and gradual degeneration of the apophysis due to impaired circulation
- 26. Signs and Symptoms(continued) • Pain w/ kneeling, jumping and running • Point tenderness Management • Conservative – Reduce stressful activity until union occurs (6-12 months) – Possible casting, ice before and after activity – Isometrics
- 27. Patellar Tendinitis (Jumper’sor Kicker’s Knee) Etiology • Jumping or kicking - placing tremendous stress and strain on patellar or quadriceps tendon • Sudden or repetitive extension Signs and Symptoms • Pain and tenderness at inferior pole of patella – 3 phases - 1)pain after activity, 2)pain during and after, 3)pain during and after (possibly prolonged) and may become constant Management • Ice, phonophoresis, iontophoresis, ultrasound, heat • Exercise • Patellar tendon bracing • Transverse friction massage
- 29. Knee Joint Rehabilitation •General Body Conditioning – Must be maintained with non-weight bearing activities • Weight Bearing – Initial crutch use, non-weight bearing – Gradual progression to weight bearing while wearing rehabilitative brace • Knee Joint Mobilization – Used to reduce arthrofibrosis – Patellar mobilization is key following surgery – CPM units
- 30. • Flexibility – Mustbe regained, maintained and improved • Muscular Strength – Progression of isometrics, isotonic training, isokinetics and plyometrics – Incorporate eccentric muscle action – Open versus closed kinetic chain exercises • Neuromuscular Control – Loss of control is generally the result of pain and swelling – Through exercise and balance equipment proprioception can be enhanced and regained
- 31. • Bracing – Varietyof braces for a variety of injuries and conditions – Typically worn for 3-6 weeks after surgery • Used to limit ranges for a period of time – Some are used to control for specific injuries while others are designed for specific forces, stability, and providing resistance • Functional Progression – Gradual return to sports specific skills – Progress w/ weight bearing, move into walking and running, and then onto sprinting and change of direction
- 32. • Return toActivity – Based on healing process - sufficient time for healing must be allowed – Objective criteria should include strength and ROM measures as well as functional performance tests