Академический Документы
Профессиональный Документы
Культура Документы
Complex joint that endures great amounts of trauma due to extreme amounts of stress that are regularly applied Hinge joint w/ a rotational component Stability is due primarily to ligaments, joint capsule and muscles surrounding the joint Designed for stability w/ weight bearing and mobility in locomotion
Functional Anatomy
Movement of the knee requires flexion, extension, rotation and the arthrokinematic motions of rolling and gliding Rotational component involves the screw home mechanism
As the knee extends it externally rotates because the medial femoral condyle is larger than the lateral Provides increased stability to the knee Popliteus unlocks knee allowing knee to flex
Capsular ligaments are taut during full extension and relaxed w/ flexion
Allows rotation to occur Deeper capsular ligaments remain taut to keep rotation in check
PCL prevents excessive internal rotation, guides the knee in flexion, and acts as drag during initial glide phase of flexion ACL stops excessive internal rotation, stabilizes the knee in full extension and prevents hyperextension
Kinetic Chain
Directly affected by motions and forces occurring at the foot, ankle, lower leg, thigh, hip, pelvis, and spine With the kinetic chain forces must be absorbed and distributed If body is unable to manage forces, breakdown to the system occurs Knee is very susceptible to injury resulting from absorption of forces
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
An angle that measures less than 15 degrees is an indication of tibial torsion
Palpation - Bony
Medial tibial plateau Medial femoral condyle Adductor tubercle Gerdys 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
Palpation of Swelling
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
Jerk Test
Reverses direction of the pivot shift Moves from position of flexion to extension W/out and ACL the tibia will sublux at 20 degrees of flexion
Meniscal Tests
McMurrays Meniscal Test
Used to determine displaceable meniscal tear Leg is moved into flexion and extension while knee is internally and externally rotated in conjunction w/ valgus and varus stressing A positive test is found w/ clicking and popping response
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 patients perception of pain, stability and functional performance
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 bisects 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
The A Angle
Patellar orientation to the tibial tubercle Quantitative measure of the patellar realignment after rehabilitation An angle greater than 35 degrees is often correlated w/ patellofemoral pathomechanics
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
Shoe Type
Change in football footwear has drastically reduced the incidence of knee injuries Shoes w/ more shorter cleats does not allow foot to become fixed while still allowing for control w/ running and cutting
Management
RICE for at 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
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
Management
RICE Conservative non-operative versus surgical approach Limited immobilization (w/ a brace); progressive weight bearing for Rehab would be similar to Grade I & II injuries
Management
Following management of MCL injuries depending on severity
Management
RICE; use of crutches Arthroscopy may be necessary to determine extent of injury Could lead to major instability in incidence of high performance W/out surgery joint degeneration may result Age and activity may factor into surgical option Surgery may involve joint reconstruction w/ grafts (tendon), transplantation of external structures
Will require brief hospital stay and 3-5 weeks of a brace Also requires 4-6 months of rehab
Management
RICE Non-operative rehab of grade I and II injuries should focus on quad strength Surgical versus non-operative
Surgery will require 6 weeks of immobilization in extension w/ full weight bearing on crutches ROM after 6 weeks and PRE at 4 months
Meniscal Lesions
Etiology
Medial meniscus is more commonly injured due to ligamentous attachments and decreased mobility
Also more prone to disruption through torsional and valgus forces
Most common MOI is rotary force w/ knee flexed or extended Can be longitudinal, oblique or transverse tears
Management
If the knee is not locked, but indications of a tear are present further diagnostic testing may be required If locking occurs, anesthesia may be necessary to unlock the joint w/ possible arthroscopic surgery follow-up W/ surgery all efforts are made to preserve the meniscus -- will full healing being dependent on location Menisectomy rehab allows partial weight bearing and quick return to activity Repaired meniscus will require immobilization and a gradual return to activity over the course of 12 weeks
Knee Plica
Etiology
Irritation of the plica (generally, mediopatellar plica and often associated w/ chondromalacia
Management
Treat conservatively w/ RICE and NSAIDs if the result of trauma Recurrent conditions may require surgery
Management
Diagnosis confirmed through arthroscopic exam, w/ surgery to replace fragment to avoid joint degeneration and arthritis
Osteochondritis Dissecans
Etiology
Partial or complete separation of articular cartilage and subchondral bone Cause is unknown but may include blunt trauma, possible skeletal or endocrine abnormalities, prominent tibial spine impinging on medial femoral condyle, or impingement due to patellar facet
Management
Rest and immobilization for children Surgery may be necessary in teenagers and adults (drilling to stimulate healing, pinning or bone grafts
Management
If not surgically removed it can lead to conditions causing joint degeneration
Joint Contusions
Etiology
Blow to the muscles crossing the joint (vastus medialis)
Management
RICE initially and continue if swelling persists Gradual progression to normal activity following return of ROM and padding for protection If swelling does not resolve w/in a week a chronic condition (synovitis or bursitis) may exist requiring more rest
Management
RICE and return to play once symptoms resolve and no weakness is present Padding for fibular head is necessary for a few weeks
Bursitis
Etiology
Acute, chronic or recurrent swelling Prepatellar = continued kneeling Infrapatellar = overuse of patellar tendon
Management
Eliminate cause, RICE and NSAIDs
Patellar Fracture
Etiology
Direct or indirect trauma (severe pull of tendon) Forcible contraction, falling, jumping or running
Management
X-ray necessary for confirmation of findings RICE and splinting if fracture suspected Refer and immobilize for 2-3 months
Management
Reduction is performed by flexing hip, moving patella medially and slowly extending the knee Following reduction, immobilization for at least 4 weeks w/ use of crutches and isometric exercises during this period After immobilization period, horseshoe pad w/ elastic wrap should be used to support patella Muscle rehab focusing on muscle around the knee, thigh and hip are key (STLRs are optimal for the knee) Possible surgery to release tight structures Improve postural and biomechanical factors
Management
Rest from irritating activities until inflammation has subsided and therapeutic use of cold Heel lift to prevent irritation during extension Hyperextension taping to prevent full extension
Chondromalacia patella
Etiology
Softening and deterioration of the articular cartilage Possible abnormal patellar tracking due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon
Management
Conservative measures
RICE, NSAIDs, isometrics, orthotics to correct dysfunction
Surgical possibilities
Management
Correct imbalances (strength and flexibility) McConnell taping Lateral retinacular release if conservative measures fail
Larsen Johansson is the result of excessive pulling on the inferior pole of the patella
Management
Conservative
Reduce stressful activity until union occurs (6-12 months) Possible casting, ice before and after activity Isometerics
Management
Ice, phonophoresis, iontophoresis, ultrasound, heat Exercise Patellar tendon bracing Transverse friction massage
Management
Surgical repair is needed Proper conservative care of jumpers knee can minimize chances of occurring If steroids are being used, intense knee exercise should be avoided due to weakening of collagen
Management
Correction of mal-alignments Ice before and after activity, proper warm-up and stretching Avoidance of aggravating activities NSAIDs and orthotics
Weight Bearing
Initial crutch use, non-weight bearing Gradual progression to weight bearing while wearing rehabilitative brace
Flexibility
Must be 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
Bracing
Variety of 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 and stability
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
Return to Activity
Based on healing process - sufficient time for healing must be allowed Objective criteria include strength and ROM measures as well as functional performance tests