Final Untested Content

What is the Achilles make up of?

The independent tendons of the gastrocnemius and soleus fuse to become one tendon, approximately 5 to 6 cm proximal to the calcaneal insertion.

Where is the retrocalcaneal bursa located?

Proximal to the insertion, between the tendon and the calcaneus

What is the thickest and strongest tendon in the body?

the achilles

What does the achilles tendon not have?

NO synovial sheath but is surrounded by paratenon

-Only vascular tendons are surrounded by paratenon

If there is posterior heel pain what could it be?

• Achilles Tendonitis, Achilles Bursitis or Retrocalcaneal Bursitis • Need to decide exactly where the pain is!

• True tendon pain is usually confined to the tendon itself

What is Retrocalcaneal Bursitis?

• Bursa in the recess between the anterior inferior side of the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess)

• Sometimes seen with insertional tendinopathy

• Structural irritants (tight/pokey)

• Pain just above the insertion of the Achilles Tendon

• Pain with squeeze from side

What is Achilles Bursitis (Superficial calcaneal bursitis)?

• Bursa located between calcaneal prominence or the Achilles tendon and the skin

• Pain posterior aspect of heel with solid swelling

• Often due to excessive friction or by wearing shoes that are too tight or too large

What is the inflammation stage management of achillies itis?

POLICE/PEACE & LOVE

-Address training and equipment issues

• Heel lift- shorten achilles

• Pad- donut

• Achilles Stretch

• New Shoes/popped out

What are external factors from Tendinitis/Paratenonitis?

Rub from shoe/equipment

Running down hill- Tibialis anterior

Rub from laces- Tibialis anterior

Hyper dorsiflexion- Achilles

What are the internal factors of Tendinitis/Paratenonitis?

foot malalignment

Rub over bone

Cavus or flat/pronating feet

What are the symptoms and signs for Tendinitis/Paratenonitis?

• Pain and/or Crepitation (of Paratenon) of acute onset

• Red and hot over involved structure

• Usually precipitated by movement around the ankle joint - Remember too much , too soon!

What is the diagnosis of Tendinitis/Paratenonitis?

• Made on the basis of local swelling

• STTT- what will that look like?

• Palpation over structures

Paratenonitis Inflammatory/Destructive plan

Police/PEACE &LOVE

Heel lift/pad/support

Ankle Paratenonitis Repair plan

Heat

- Idealize ROM- Stretch gastrocs/ soleous

- Start strength and proprioception ex. as able

-Address training issues

Achilles Tendinosis predisposing factors?

• Years of running

• Excessive pronation (increased load on Gastrocs/soleus to resupinate)

• Poor flexibility

• Training in cold climate

• Improper footwear

Diagnoses of achiles tendonosis

• History FITT, Pain

• Pain usually 2-7 cm from the insertion onto the calcaneus

Observation achiles tendonosis

• More thickening over large portion of tendon

• Faulty biomechanics

• On STTT, both plantar and dorsiflexion cause pain and crepitus (if paratenon involved), particularly with loading

• Nodules /bumps may be palpable

What is the treatment of tendinosis?

• Goals- idealize ROM and start strengthening

• Eccentric strengthening programs

• Rehabilitative exercises

• NO the use of NSAIDS

What is the most common tendon that is ruptured?

The Achilles tendon is the most commonly ruptured tendon

What are the risk factors of an achilles rupture?

male sex (10:1)

• use of steroids

• prior rupture on the contralateral side.

What is the subjective report (symptoms) of an achilles rupture?

- Patient reports pop or snap like someone kicked them

• Pain may be immediate then rapidly subsides.

• Usually pain only at site of tear.

• Usually occurs 1-2 inches above the insertion

What are the clinical signs of an achilles rupture?

• Palpable gap

• Positive Thompson test

• Dorsiflexed when relaxed

What is the Inspection/palpation of an achilles tendon rupture?

• Foot hangs straight down - No plantar flexion

• Palpable divot 1-2"above insertion

• Unable to plantar flex. Relatively loose on stretch

• May have bruising/redness, if seeing the patient the following day

What the the thompson's test?

Repture achilles

Positive test is no movement

What is the tibiofemoral joint?

• Articulation of the medial and lateral condyle of the femur and tibia (Tibiofemoral joint)

• Allows transmission of body weight from the femur to the tibia while providing hinge-like, sagittal plane joint rotation along with a small degree of tibial axial rotation

What is Patellofemoral joint?

• articulation- patella and femur

• The patella is the largest sesamoid bone in the body.

• Referred to as the extensor mechanism

• Also works eccentricelly during gait

When is the knee most stable?

• More stable in extension

• Help from dynamic stabilizers

• Poor bony fit when flexed

•Strong fibrous joint capsule

What structure does the knee rely on?

• MCL

• LCL

• ACL

• PCL

• Dynamic stabilizers

What is the capsule of the knee?

• Anteriorly to suprapatellar pouch

• Inferior to infra patellar fat pad and bursa

• Medially it communicates with the deep fibers of the MCL

• Posteriorly covers femoral condyles

• Lined by synovial membranes, except posteriorly where it passes in front of the cruciates

What is the Superficial Lateral Support Complex of the knee?

• Iliotibial band and biceps Femoris

What is the middle Lateral Support Complex?

Patellofemoral ligaments and retinaculum

What is the deep Lateral Support Complex?

• Lateral (Tibial) Collateral Ligament (LCL)

• Popliteus tendon

• Capsule

• Other ligaments (Arcuate, Fabelofibular, etc.)

Lateral aspect of the knee is significantly supported by?

Muscles

- Biceps Femoris

- IT band

- Popliteus tendon

- Capsular ligaments (lateral capsule)

- Lateral Collateral Ligament

What are lateral knee injuries?

• less common than injuries of the medial

• Injured with varus directed force

• High-grade injuries = higher forces = injures multiple structures

• Isolated high grade LCL tears are uncommon

What is the lateral collateral ligament?

• Round fibrous cord about the size of a pencil.

• Extends from the lateral epicondyle of the femur to lateral fibular head

• Extra capsular (generally less swelling)

• Primary static restraint to varus

When is there the greatest load on the knee?

Load at 25-30 degrees greater than at 90

What is the Superficial of the medal support complex of the knee?

Sartorius and fascia

What is the middle of the medial support complex of the knee?

Contains superficial MCL and Semimembranosus

What is the deep of the medial support complex of the knee?

Contains Deep fibers of MCL and capsule

What is Medial Support Complex stability?

• MCL primary stabilizer -25-20 degrees

• ACL/PCL secondary vs. valgus

• Muscles help in full extension

• Medial hamstrings (Sartorius, semimembranosus + semitendinosus)

• Medial head of gastrocs.

• Quad muscles (vastus med.)

• Bony structure is tertiary support

What is the medial collateral ligament?

•A capsular ligament (swelling)

•Has superficial and deep components

• Deep portions connect directly to the medial meniscus

• Superficial portions run from medial femoral epicondyle to superomedial surface of tibia

What is medial view of the knee flexion and extension?

most active resisting valgus loading when knee is 25-30 degrees of flexion

MCL- Superfical support in the majority

What is the Anatomy of the Anterior Cruciate Ligament (ACL)?

Runs from anterior tibial plateau to the posterior medial aspect of the lateral femoral condyle.

• 2 major bundles named for their attachment on the tibia:

• Anteromedial- Tighter in flexion

• Posterolateral- Tighter in extension

• Primary restraint to anterior tibial translation

• Greatest translation occurs at 20-30

What are the ACL attachments?

• From anterior aspect of tibial plateau to posterior medial aspect of lateral femoral condyle.

• 2 major bands:

• Anteriomedial

• Posterolateral

What is the stabilizing role of the ACL?

Weaker of the two cruciate ligaments

• Functions to restrict posterior translation of the femur relative to the tibia during weight-bearing

• Restricts anterior translation of the tibia during non-weight bearing

• Also limits excessive rotation of the tibia

• Secondary support for VALGUS and VARUS with collateral ligament damage

What is the Anatomy of the Posterior Cruciate Ligament (PCL)?

• The PCL originates on the lateral aspect of the medial femoral condyle and inserts posteriorly to intercondylar area of tibia

• 2 major bundles named for their attachment on the tibia:

• Anterolateral- Tight in Flexion (larger)

• Posteromedial- Tight in Extension (smaller)

• Larger and stronger than the ACL

• Primary restraint to posterior tibial translation

• Greatest translation occurs at 20-30

What are the PCL attachments?

• From lateral aspect of medial femoral condyle

• Passes medial to ACL

• inserts posteriorly to intercondylar area of tibia

2 bundles

• Larger anterolateral

• Smaller posteriomedial

What is the Stabilizing role of the PCL?

• Stronger of the two cruciate ligaments

• Functions to restrict anterior translation of the femur relative to the tibia during weight bearing

• Restricts posterior translation of the tibia during non-weight bearing

• Also limits hyper- internal rotation

• Secondary support for valgus and varus with collateral ligament damage

What is the meniscus?

• Once believed to be a useless remnant of intra-articular attachments

• Serve essential roles in maintaining knee function

• Stabilize knee by increasing concavity of tibia

• Shock absorption

• Compression facilitates distribution of nutrients

What is the medial meniscus?

• C- Shaped

• Larger radius of curvature

• Tight connection with capsule and MCL

• Poor mobility

What is the lateral meniscus?

• O Shape

• Smaller (tighter) radius of curvature

• Attached loosely to capsule and popliteal tendon

• Increased mobility

What is the meniscal Fixation?

• The menisci are fixed in place and prevented from extruding by coronary ligaments and anterior and posterior transverse meniscal ligaments

• Deep portion of capsule attached to periphery of meniscus

• Medial is thicker/tighter than the lateral.

What are the zones of the meniscal and there bloodflow?

• Red zone has good blood supply- outer 1/3

• Red-white zone- minimal blood supply- middle 1/3

• White -white zone is avasular

Subjective Knee Assessment - Overview

• Area of pain

• Medial, lateral, internal?

• Mechanism of Injury

• Varus or Valgus

• Contact or non-contact

• if contact, from where?

• if non-contact, decelerating, cutting, landing, etc?

• Sounds (i.e. " pop " or "crack")

• Continue to play/ able to WB ?

• Locking, giving way since?

Subjective Knee Assessment - Swelling

• Nature of any swelling - hemarthrosis?

• Bleeding into the joint

• Typically occurs more quickly than synovial effusion/capsular swelling

• Noticeable swelling 2-6 hours post-injury

• >75% were ACL tears in adults

• Patellar dislocation next most common (young) followed by fracture and meniscal tears

• In pediatrics, suspect patellar dislocation

• Past history of trauma, surgeries

What are the Ottawa Knee Rules?

-Are age 55 or older

-Have tenderness at head of fibula

-Have isolated tenderness of patella

-Have inability to flex knee to 90 degrees

- inability to walk 4 steps

What is a patellar dislocation?

occurs when the patella moves out of its groove laterally onto/over the femoral condyle

What is the MOI of an Acute Patellar Dislocation?

• Forceful knee rotation (tibia ER/femur IR) +/- forceful quadriceps contraction

•Knee usually near full ext. (out of trochlea)

•+/- laterally directed force

Patellar Dislocation - Symptoms

• May report feeling knee "shift", "move" or "pop out"

• Pain++ until reduced

• Fast swelling

Patellar Dislocation - Signs

• "Loss of knee function (if still dislocated)

• Tenderness over medial border of patella

• Positive lateral apprehension test

• Need to R/O ACL...Why??

If the patella is dislocated, you should?

slightly flex the hip and slowly extend the knee. Usually the patella relocates. If it does not, do not force the patella medial.

There may be some associated fractures (back of the patella, lateral femoral condyle).

Lateral Collateral Ligament - The Facts

• Less common yet complicated = number of structures

• Usually varus loading + hyperextension

• Most contribution at 20-30 of knee flexion

• May include ITB, lateral hamstrings and/or popliteus

Medial Collateral Ligament - The Facts

• Most frequently injured knee structure

•Valgus force with or without rotation

• Often occur in isolation

Signs and Symptoms of Collateral Ligament Sprains

• Reports of pain over structure

• minimal swelling LCL only- More if soft tissue injury

• Slow localized swelling medial side (grade 2+)

• Capsular effusion >8 hrs.

• Stress testing: In the same direction of MOI!

ACL Injuries - The Facts

• OContact or non-contact mechanism

• Usually during cutting or single leg landing

• May occur in isolation or in combination with other injury

• 75% sustain meniscal injuries

• 80% have a bone bruise on lateral joint line or (Segond Fracture)

• 2-8 x higher injury rate in females

What are the MOIs of ACL Injuries?

1. Valgus after MCL- usually with contact

2. Deceleration/ internal rotation – non-contact

3. Hyperextension- Not in isolation

4. Quads Active – anterior tibial translation

ACL Injury: Quads Active Mechanism

• Main mechanism: -rapid deceleration -untoward landing

• Shoe - surface interface friction

• Anterior tibial dislocation by quads

ACL symptoms

• Audible "pop" or "crack"

• very painful to minimal pain

• Usually unable to continue activity

• Hemarthrosis - 1-6 hours

• May report instability or giving way

ACL signs

• Restricted movement

• especially extension

• Lateral joint tenderness- often mistaken for LCL

• 80% Lateral bone bruise or Segond fracture

• Positive Anterior Drawer & Lachman's Positive

• Graded like other ligaments

What are Posterior Cruciate Ligament Injuries?

• Strongest of the knee ligaments

• Only 1 in 10 cruciate injuries involve the PCL

• ~60% include injuries to other structures

• Meniscal tears

• Usually sports injuries- but also common in MVAs

PCL Etiology/MOI

• Most common is a direct blow to upper portion of the tibia

• Fall on a flexed knee

• MVA-Dashboard injury or pre-tibial trauma

• Hyper-flexion

• Increased tension in anterior segment

• impinged between posterior tibia + intracondylar notch roof

• Hyperextension

PCL Signs

• Minimal swelling

• Posterior drawer test is most sensitive

• Graded like other ligaments

• Sag test will be positive

• Need to assess medial and lateral structures too!

What is Patellofemoral Pain?

PFP is characterized by pain in the peripatellar/retropatellar area that is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee

What activities can aggravate patellofemoral pain?

• Pain walking down stairs

• Pain with squatting

• Pain following sitting for long periods

• Running, jumping, hopping

What is the % of physiotherapy (PT) visits for Patients with patellofemoral pain syndrome (PFPS)?

10-25%

What is the primary focus of evaluating overuse injuries?

• Primary focus of evaluating overuse injuries of the knee is to identify factors that may contribute to the condition

What is hypo and hyper pressure?

We strive for equal pressure distribution across the back of the patellae to ensure proper nutrition.

• If medial aspect of Patellofemoral Joint has hypo-pressure.

• If lateral aspect has hyper-pressure

- Results in cartilage rub and fibrillation

What are the Proposed Contributing INTRINSIC Factors for Patellofemoral Pain?

1. Lower chain alignment

2. Excessive pronation

3. Poor multi-plane lumbo-pelvic / Pelvo femoral control (core, gluteus medius)

4. Shortened muscles: hamstrings, ITB, calves and rectus femoris

5. Pull of quads

What is excessive pronation?

• Over pronation at the subtalar joint causes internal rotation of the tibia and delayed re-supination

• This affects screw-home mechanism as tibia doesn't externally rotate

• As such the femur must internally rotate more to get to extension

• Results in lateral pull on the patella

Tight muscles (quads, hamstrings, iliotibial lateral and triceps surae) crossing the knee may cause altered function and/or pain...

- Quadriceps: Increased compression of the PF joint during physical activities

- Hamstrings: Antagonist to quadriceps- Will require increased quadriceps force production to overcome length issue

- Iliotibial Lateral: influence on patella = Increased pressure over the lateral Band surface of the trochlear groove. Must move over the femoral condyle at 25-30 flexion

- Triceps Surae: Limit ankle dorsiflexion, which is often compensated for by excessive rotation of the lower leg, altered Q-angle

What is Vastus Medialis Dysfunction?

• Sum of all 4 quads and tibial tendon are offset into valgus

• Theory that weak VMO will not be able to maintain alignment

• Slow

• Weak

• Altered line of pull

- Will cause abnormal pull on the patella... Overloading lateral side

Patellofemoral Pain Treatments

• Follow the general rehabilitation protocol

• Rehabilitation = identification and "correction" of intrinsic and extrinsic issues

• One of the most difficult musculoskeletal (to be managed by professionals)

• May be slightly different for each individual

Patellofemoral Pain Treatment- Initial Phase

POLICE/PEACE&LOVE

Relative rest

Palliate pain

decrease swelling

identify training issues

Patellofemoral Pain Treatment-Repair Phase

Correct biomechanical issues as able.

• Look at muscle length, muscle strength and function

Patellofemoral Pain Treatment- Remodeling Phase

Slowly increase training frequency and intensity

Evidence Based Practice Tips for PFP Rehabilitation

• Daily exercises of two to four sets of ≥10 reps ≥6 weeks.

• Higher reps of sets, patients involved in sports (including significant running and jumping)

• Knee braces and patellar taping (Conflicting research)

• Prefabricated foot orthoses = reduced short term pain

What are the 13 Rs of concussions?

Recognize - What is a concussion Remove –Player from competition Refer – to those with specialized knowledge

Re-evaluate– Follow-up Assessment

Rest & Exercise -Strict rest not better Rehabilitate – Neck pain and headaches Recover – Symptoms and signs

Return to Learn/Play Reconsider – Long-term Effects

Residual Effects- Second Impact Retire – Education and Alternatives Refine – Parasport/Pediatrics Reduce – Rules/Training

What is a concussion?

Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities.*

What does a concussion initiate?

Initiates a neurotransmitter and metabolic cascade

- possible axonal injury, blood flow change and inflammation affecting the brain.

When may signs and symptoms present with a concussion?

Symptoms and signs may present immediately, or evolve over minutes or hours

- MOI is your first sign

- commonly resolve within days, but may be prolonged.

What is the use of CT or MRI and Concussions?

No abnormality is seen on standard structural neuroimaging studies such as CT or MRI

What are the physiological changes with a concussion?

• ↓cerebral blood flow and ↑ glucose demand lead to a cellular energy crisis (mismatch between glucose availability and demand)

• This can lead to neuronal injury/death

• Dysregulation may persist for up to 10 days

What is second Impact Syndrome?

• Occurs primarily in young athletes and there are uncertainties about its pathophysiology

• Many clinicians never encounter a case, with some experts doubting its existence.

• Usually after previous, recent brain injury(s) (concussion) followed by a second brain injury

What is there to know about swelling and second impact syndrome?

• The second injury is usually more severe and can lead to brain swelling

• It is not known why the brain swelling occurs so rapidly and profoundly.

• Hypothesized to be of acute loss of autoregulation and alteration of the blood-brain barrier.

• This causes major neurological decline.

• May be fatal

For second impact syndrome what can you do

Most cases die, but some survive because of emergency neurosurgical decompression providing extra space for the swollen brain

• SIS is preventable by preventing the second blow to the brain.

What are sports related concussion caused by?

SRC is caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain

"60% from head impacts"

What is the threshold for concussions?

- No agreed-on Biomechanical threshold for injury (60-168g)

- Force does NOT factor in on symptom severity

What is the inherent design of helmets?

• Ideal for preventing high-energy impact forces associated with catastrophic head injuries

• Less ideal for reducing the lower impact/rotational related to concussions

What is the evidence of SRC and Helmets?

The evidence examining the protective effect of helmets in reducing the risk of SRC is limited in many sports.

- There is sufficient evidence in terms of reduction of overall head injury in skiing/snowboarding to support strong recommendations and policy to mandate helmet use in skiing/snowboarding

- 28% reduction in concussion rate with mouthguard use in ice hockey across all age groups

• mouthguards should be mandated in child and adolescent ice hockey and supported at all levels

- We need to continue to evaluate headgear in non-helmeted contact and collision sport to help inform headgear recommendations in the future

Are concussions getting worse?

• Over 30 concussion severity scales have been presented

• None have been scientifically validated

• No such thing as a minor, severe, Grade 1,2 or 3

• Reason time missed is getting longer is because we are getting smarter with how we deal with them