Knee Pain - Soft Tissue Injury

What is found during exam of pre-patellar/pes anserine bursitis?

• Observable swelling and local pain

• AROM and PROM knee flexion may be limited

• Resistive testing strong

• Accessory testing normal

• Pain w palpation

Treatment for pre-patellar/pes anserine bursitis?

• Education: avoid kneeling or other painful activities

• Medical management (aspiration)

• Manual therapy

  • Soft tissue mob w/ stretching

• Exercise

  • quad and glute strength

• Correct faulty motions such as quad dominant activity, adduction/IR movements, foot orthotics

• Bike fit/shoe fit, training volumes

  • Peddles narrower than hip causes knee valgus, puts stress on patella or pes

Where is the most common site of patellar tendinopathy?

Inferior pole of patella

What history would you find with patellar tendinopathy?

• Anterior knee pain localized to patella tendon

• Recent increase in intensity or frequency

• Pain worse with activity, reproduced with jumping and asending stairs

What would you find on exam with patellar tendinopathy?

• Palpable tenderness and thickening of tendon with point tenderness

• Pain with passive knee flexion, deep squats, and resisted knee extension

• Possible decrease in quad flexibility

  • Positive thomas and ober’s test

• Typically 3 phases:

  • I: pain after activity

  • II: pain during and after activity

  • III: pain leading to functional disability/constant

What is the treatment for patellar tendinopathy?

• Education: activity modification is crucial

• Manual therapy as needed

• Correct biomechanical factors: foot pronation, patella mobility

• Straps or knee sleeves

• Start eccentric program or slow heavy strength once resistive testing is negative for increased pain

• Progress to functional activities, plyometrics, and activity specific exercises

Difference between contusion and a strain?

• Contusion: direct blow

• Strain: indirect trauma (pulled muscle)

What can contusions lead to?

Compartment syndrome or myositis ossificans

Exam of quad contusion?

• Local tenderness to palpation

• May note swelling, bruising, and palpable hematoma

• Resistive knee extension painful, and stretching for knee extension provokes symptoms

• Limited ROM into flexion (AROM and PROM) with pain (>90° mild, 45-90° moderate, <45 severe)

Treatment of a quad contusion?

• Modalities (NO US OR DEEP MASSAGE)

• Crutches if severe with knee flexed

• Gentle stretching

• Progress to more vigorous stretching after 7-10 days

• Progress to strengthening in subacute stage, begin with isometrics to PREs in pain free range

What should the position of the knee be for a deep thigh contusion to avoid myositis ossificans?

120° flexion for first 24 hours

How to treat myositis ossificans?

gentle AROM and AAROM. Avoid passive stretching and overpressure at end range

What is IT band syndrome better defined as?

Compressive syndrome

Symptoms of IT band syndrome?

• Lateral knee pain with repetitive activity

• Recent increase in intensity or frequency of training or change in equipment

Exam of IT band syndrome?

• Localized pain over outer knee and pain with palpation of lateral femoral condyle

• Usually limited hip and calf flexibility

• Possible glute med/max

• May note adduction w hip IR motion in stance, possible excessive foot pronation

• + Noble compression test

• + Ober’s test

Treatment of IT band syndrome?

• Education

• Modalities for inflammation/pain prn

• Stretching program

• Soft tissue mob for trigger points at glute and TFL

• Strengthening hip abductors, glute max

• Correct muscle imbalances, adduction/IR patterns, squat patterns, and functional movements

• Correct foot mechanics (orthotics) prn

What is Sinding-Larsen-Johansson disease?

Similar to Osgood-Schlatter’s disease, but occurs at inferior pole of patella during 10-14 years old

Complete recovery expected

Treatment of Sinding-Larsen-Johansson disease?

• Rest/activity modification

• Gentle stretching of extensor mechanism/quads

• Correction of muscle imbalances and alignment issues

• Modalities for pain/inflammation

What is the Baker’s cyst?

• Posteriomedial knee

• Most common mass in the popliuteal fossa