Ch 21 knee injuries

MCL

1. Strong superficial component that blends together with the deep component and semimembranosus (also serves to draw meniscus posteriorly during flexion)

2. Deep (weaker) component attaches to medial meniscus as well

   1. Provides static stability to valgus stress and external rotational forces

LCL

1. Fibrous cord that functions with the IT-band, popliteus tendon, arcuate ligament complex, and biceps tendon to support lateral aspect of knee

2. Taut during extension and lax during flexion

Capsular ligaments Ant

connects with extensor mechansim and medial meniscus through cornoary ligaments, tight during flexion

Capsular ligament medial

1. Attaches medial meniscus to femur and allow tibia to move on meniscus inferiorly
   

Capsular ligament psoteior

1. Attaches to meniscus and semimembranosus

   1. Helps to reinforce the posteromedial joint capsul

Capsular ligmaent arcuate ligament

thickening of posterolateral capsule

Cruciate ligametns

ACL, PCL

ACL

1. Prevents the tibia from moving anteriorly during weight bearing

2. Stabilizes the knee in extension and prevents hyperextension

3. Stabilizes against excessive internal rotation and serves as a secondary restraint to valgus/varus stress

   1. Works in conjunction with hamstrings

PCL

1. Taut throughout full ROM

2. Prevents excessive internal rotation

Meniscuis

improve stability of knee, shock absorption and distribute weight

KNee flexion

1. Bicep femoris, semimembranosous, semitendinosous, gracilis, sartorius, gastrocnemius, popliteus, and plantaris
   

Knee extension

1. Rectus femoris, vastus lateralis, intermedius and medialis

ER

biceps femoris

IR

popliteus, semi tend, semi mem, sartorius, gracilis

Dynamic lateral stability

IT band

When should dynamic knee extension exercises be done

1. lower (0-60°) or higher (80-90°) knee ranges when patellofemoral stress is primary concern

MCL sprain

proximal or neare to insertion, damge to medial mensicus, result of laterally applied valgus force to knee and sometimes with rotational forces

rarely a non-contact injury

Concerns for rehab MCL sprain

immbolize very effective

ACL-mCL injury, acl be repaired mcl not

sympotomic treatment with WB as soon as possible

MCl sprain Rehab progression

RICE and modality to treat pain and inflammation

crutch prgoression

no lag in extension and normal gait

immbolize for 1-2 wks with grade 2

Early ROM and quad strengthening begin within first 2 days post injury with grade 1

OKC when pain subsides and ROM improves

CKC toalrted

PNF, ploymetirc exercise and functional activites

Grade 3 MCL sprain

bracing

2-3 weeks at 0-45 degree

2-3 weeks 0-90 degree

Criteria for return mcl sprain

1. Regained full ROM

2. Equal strength bilaterally

3. No tenderness

4. Successful completion of functional performance tests

LCL Sprai

isolated injuries rare b/c secondary stabilizers

result of stress placed on latearl aspect of knee

occur at proximal and distal attachments

Assoicated with injuries to ACL, PCL, posterolatearl joint capsuel, and peroneal nerve

LCL sprain rehab concerns

1. Grade 1 or 2 injuries  treated symptomatically with WB as soon as possible

2. Grade 3 sprain will result in 4-6 weeks non-operative management

3. If rotational instability is associated with grade 3 injury surgical repair will be necessary

Rehab progression for LCL sprain

same as MCL

if sx, braching with PWB will happen for 4-6 weeks

ACl SPrain

cutting and jumping activities

mid substance tear, femur and tibia

tear in meniscus lead to functional disability

exhibits rotational instability lead to functional disability

Injury MOI for ACL

non contact

Risk factors MCL external

type of competion, shoe surface interaction, protective equipment

ACL injury prevention

agility and plyometric

Rehab concerns for ACL

conservative approach, acute pahse to pass and follow up with agressive rehab

Risk factors for MCL internal

femoral intercondylar notch, ACL size, lower extremity aligmnet

Risk Factors for MCL hormonal

Hormonal:

first half of menstrual cycle increased risk of sustaining ACL

Risk factors for MCL biomechanic

Role of foot, ankle, knee, hip, trunk

Changes in direction while running

Deceleration associated with pivots, changes in directions, and landing from jump

Neuromuscular factors (joint stiffness, muscle latencies, muscle recruitment patterns)

Rehab concern with Sx ACL sprain

recurrnet effusion, highly athletic, rotational instability and giving away with daily activites

failure of rheab following

Mid substance repair

suture with splint (direct)

Extra articular

structre that lies outside capsule is moved to mechanically impact ACL function internaly

less expensive, not for high level atheltes

Intra articular reapri

structure inserted that will mimic function of ACL

bone patellar grafts

gracilize and semimberanouss autograft, achilles allograft

quad grast (ess common)

allografts (diseae transmission and tissue regejctio)

Rehab progression for ACL non operative sprain

control pain and swelling through RICE, modalities and NSAIDS

immbolize for protection and comfort, crutches till extension

quad sets, STLR (prevent atrophy and motor control)

Early ROM (heel/wall slides/ stationary bike)

Flexion and extension exersies (restrict for 8-12 weeks to 0-45)

CKC exercise

PNF

functional knee brace

Surgival intervention ACL conservative sprain

slow to flexion and extension

PNWB post op

CKC at 3-4 weeks

RTP 6-9 months

Surgical intervention ACL accelerated sprain

immediate motion and WB to tolerance

early CKC for strength and neuromuscular control

Return to activity 2 months and comp at 4-5

Graft necrosis

6 weeks

Revascularizaiton

8-16 weeks

remodeling

16 wks on

Criteria for return ACL sprain

anywehre for 4-12 months, no joint effusion, Full ROM, isokinetic testing quad and hamstring 85-100

PCL sprains

with ACL, MCL< LCL, or menisucs

controls rolling and gliding of tibia with ACL

prevents postieor translation of tibia on femur

meniscal lesions and chondral defects with PCL deficent knees

INjury MOI for PCL sprain

forced into hyperflexion with foot plantar flexed, posterio driven tibia on fixed femur or anteriorly forced femur on tibia

knee hyperextension with donward force

hyperextension may result in combined PCL/ACL injury

Rehab concerns PCL sprain

altered artrokinematics

sx vs non surgical

surgery is an avulsed

Rehab progression PCL sprain (non operative)

swelling and pain contorlled, immbolize for comfort and protection, quick progression

early ROM and strengthenign initated

focus on qaud, 20-45 degree range, avoid OKC hamstring work due to posterior tibila translation

incorporate CKC exercises to emphase co contractions

avoid repetive stressfull activites

SX intervatnio PCL sprain

maturaiton adn healing process not well documented

limit pain and swelling with RICE and NSAIDS

imbbolization in full extension for 1st week

during second week brae should be unlcoked for ambulation adn PROM exercises

brace worn 4-6 wks 90-100 degree

crutch for 4-6 wk until full WB and achieve full extension

Avoid knee flexion

4-6 CKC

cycling at 6 weeks

progress to joggin 9 months

PCL sprain Criteria for return

no joint effusion

full ROM

isokinetic testing indicates quad and hamstring strength within 85-100

Meniscus injureis

1. transverse, vertical-longitudinal (bucket-handle tear) Aids in stability, acts as a secondary restraint in checking tibiofemoral motion, serves as shock absorber

Medial mensicus

higher incidence injury

due to additiaonl attachments via coronary lig-disrutpion from valgus stress

lcoking at 10-30 degree indicative of medial mensiucs tearing

locking at 90 posteioer meniscal tear

longtindaul or oblique

Injury mechanism MM

weight bearing and rotation while flexing or extending knee

galgus or varus

Rehab concerns MM

wait and see appraoch

minimize pain and inflamatin

may reqruie 3-5 days of limited activity prior to return

Partial menisceimoty

control pain and swelling via modalites and NSAIDS

move to FWB as tolaretaed wihtout limp or extension lag

early pain free ROM with gradual OKC and CKC

functional as ready

Meniscal repair

absorable sutures, vascualr access channels and fibrin clot insertion

compliction minimal if capsualr damage is not present

limit joint motion for healing

lock in full extension for 2 weeks

PWB after 6 wks

range limited to 20-90 degree for weeks 2-4 and 0-90 for 4-6

Patellofemoral Stress syndrome (PFSS)

non spefici anterior knee pain, pian with stair climbing/descending

giving away knee

D

Dynamic alignment of PFSS

stepping and bilateral/unilateral squats

deterermine patellar tracking

static and dynamic stabilizers operate within balance

q angle

a-angle (patella vs tibial tubercle

IT band causes

lateral patella tracking

Vastua medialis casues

active through ROM

lose fatiruge ressitant capacity

Vastus lateralis causes

tightness or muscle imbalance may cause lateral tracking

excessive pronation casues

results in obligatory internal rotation altering mechnias at knee

Tight hamstrings causes

results in creased knee flexion altering foot mechanis and present knee with additional vector forceT

tight gastrocnemius causes

results in incresaed pronation

Patella alta causes

knee flexion occurs ebfore patella is stbailized

latearl subluzation tendency increase

Patella baja causes

restrict knee flexion

Rehab progression MM

strengthening, CKC exercises

reduce compressive forces

mini squats, lateral step ups, statinary bike, slide baord

patella tracking and positiong

VL to VMO ratio

1 to 1

Criteria for return MM

taping continue

maintain VMO activity for 5 minutes during walking gait

can perform step up for 1 min with concomitant VL activity

gradual weaning off tape

tape left off complete when steps up for 5 mins

Chronic subluxation Rehab progression

focus on biomechanical facotrs

restore muscle balance and strength (CKC)

correct postural malalignments

shoe orthotics to correct foot and tibia mehcanis

stretch tight (lateral) structures (patella mobilizations)

Sx intevetnion

ACute dislocaiton rehab progression patella

immbolize for 3-6 weeks with crutch ambulation

work to regain knee extension

quad sets and STLR after dislocaiton (VMO)

CKC initiated for VMO strength after pain

3-6 weeks when no more immbolization a neoprene sleeve with lateral horsehoe pad used

Critera for return Acute dislocaiton

good wuad and VMO strength

perform step downs for 5 minute

sustain half squat for 1 minute without vmo loss

Patella Tenditisn rehba progression

warm up adequate

restrict running adn jumping initally

use eccentrics for quadriceps and ankle DF

tenodeis strap or brace

assessemnt of jump landing technique is critical

Curwin and stanish

5 part plan that incorporates warm-up, stretching, eccentric squatting (goal = 3x10), stretching, and ice

Jensen and Difabio

isokinetic eccentric training (gradual reduction in sets, 5 repetitions, and gradual increase in speed 30-70 degrees per second over 8 week period)

Criteria for Return Patella Tendinitis

1. Return to activity when pain has subsided to point where patient can run and jump without increasing pain and swelling

2. Normal strength bilaterally should also exist for athlete

3. Appropriate mechanics should also be exhibited by the patient to reduce chances of recurrence