Recognition and Management of Specific Injuries

1. Recognition and Management of Specific Injuries

2. Medial Collateral Ligament Sprain • MOI = severe blow or outward twist • Grade I: Signs and Symptoms • Little fiber tearing or stretching • Stable valgus test • Little or no joint effusion • Some joint stiffness and point tenderness on lateral aspect of the knee • Relatively normal ROM

3. Grade I: Management • RICE for 24 hours • Crutches if necessary • Rehab • Cryokinetics • Isometrics • Progress to SLRs, bicycle riding, and isokinetics • Return to play when all areas have returned to normal • May require 3 weeks to recover

4. Grade II: Signs and Symptoms • Complete tear of deep capsular ligament and partial tear of MCL • No gross instability; laxity at 5-15 degrees of flexion • Slight swelling • Moderate to severe joint tightness • Decreased ROM • Pain along medial aspect of knee

5. Grade II: Management • RICE for 48-72 hours • Crutch use until acute inflammation 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

6. Grade III: Signs and Symptoms • 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

7. Grade III: Management • RICE • Conservative non-operative versus surgical approach • Limited immobilization (with a brace) • Progressive weight bearing and increased ROM over 4-6 week period • Rehab would be similar to Grade I & II injuries

8. Lateral Collateral Ligament Sprain • MOI = Varus force usually with the tibia internally rotated • Direct blow is rare MOI • If severe enough damage may also occur to • Cruciate ligaments • ITB • Meniscus • Bony fragments may result as well

9. Signs and Symptoms • Pain and tenderness over LCL • Swelling and effusion around the LCL • Joint laxity with varus testing • May cause irritation of the peroneal nerve • Management • Same as MCL injury management

10. Anterior Cruciate Ligament Sprain • MOI = tibia externally rotated with a valgus force • Occasionally the result of hyperextension resulting from a direct blow • Research is quite extensive in regards to impact of femoral notch, ACL size and laxity, mal-alignments (Q-angle), and faulty biomechanics • Extrinsic factors may include, conditioning, skill acquisition, playing style, equipment, preparation time • May also involve damage to other structures including meniscus, capsule, and MCL

11. Signs and Symptoms • Experience pop with severe pain and disability • Positive anterior drawer and Lachman’s • Rapid swelling at the joint line • Other ACL tests may also be positive • Management • RICE; use of crutches • Arthroscopy may be necessary to determine extent of injury • Surgical repair • Without surgery, joint degeneration may result • Surgery may involve joint reconstruction with grafts (tendon), transplantation of external structures • Also requires 4-6 months of rehab

12. Posterior Cruciate Ligament Sprain • MOI = fall on bent knee (most common) • Most at risk during 90 degrees of flexion • Injury may result due to a rotational force • Signs and Symptoms • Feel a pop in the back of the knee • Tenderness and relatively little swelling in the popliteal fossa • Laxity with posterior sag test

13. Management • RICE • Non-operative rehab • Appropriate for grade I and II injuries • Focus on quad strengthening • Post-operative rehab • Surgery will require 6 weeks of immobilization in extension • Full weight bearing on crutches • ROM after 6 weeks • PRE at 4 months

14. Meniscal Lesions • Most common MOI is rotary force with knee flexed or extended • Tears may be longitudinal, oblique, or transverse • Medial meniscus is more commonly injured due to ligamentous attachments and decreased mobility • Also more prone to disruption through torsional and valgus forces

16. Signs and Symptoms • Effusion developing over 48-72 hours • Pain in joint line • Loss of motion • Intermittent locking and giving way • Pain with squatting • Portions of meniscus may become detached causing locking, giving way, or catching within the joint • If chronic injury, recurrent swelling or muscle atrophy may occur

17. Management • No locking but indications of a tear are present • Further diagnostic testing may be required • If locking occurs, anesthesia may be necessary to unlock the joint • Possible arthroscopic surgery • Healing dependent on location of tear • Menisectomy • Partial weight bearing, quick return to activity • Repaired meniscus • Requires immobilization, gradual return to activity over the course of 12 weeks

18. Knee Plica • MOI = irritation of the plica • Often associated with chondromalacia • Signs and Symptoms • Possible history of knee pain/injury • Recurrent episodes of painful pseudo-locking • Possible snapping and popping • Pain with stairs and squatting • Little or no swelling • No ligamentous laxity • Management • Treat conservatively w/ RICE and NSAID’s if the result of trauma • Recurrent conditions may require surgery

19. Osteochondral Knee Fractures • MOI = twisting, sudden cutting, or direct blow • Signs and Symptoms • Hear a snap • Feeling of giving way • Immediate swelling • Considerable pain • Management • Diagnosis confirmed through arthroscopic exam • Surgery used to replace fragments in order to avoid joint degeneration and arthritis

20. Osteochondritis Dissecans • MOI = partial or complete separation of articular cartilage and subchondral bone • Exact 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

21. Signs and Symptoms • Aching pain and point tenderness • Recurrent swelling • Possible locking • Possible quadriceps atrophy • Management • Rest and immobilization for children • Surgery may be necessary in teenagers and adults • Drilling to stimulate healing, pinning, or bone grafts

22. Loose Bodies • MOI = repeated trauma • May result due to osteochondritis dissecans, meniscal fragments, synovial tissue damage, or cruciate ligaments injury • Signs and Symptoms • May become lodged and cause locking or popping • Pain • Sensation of instability • Management • If not surgically removed it can lead to conditions causing joint degeneration

23. Joint Contusions • MOI = direct blow • Signs and Symptoms • Severe pain • Acute inflammation • Loss of movement • Swelling • If not resolved within a week then a chronic condition may exist (synovitis or bursitis) • Ecchymosis • Possible capsular damage • Management • RICE • Progress to normal activity following return of ROM • Padding for protection

24. Peroneal Nerve Contusion • MOI = compression due to a direct blow • Signs and Symptoms • Local pain and possible shooting nerve pain • Numbness and paresthesia • Added pressure may exacerbate condition • Generally resolves quickly • In the event it does not resolve, it could result in drop foot • Management • RICE • Return to play once symptoms resolve and no weakness is present • Padding for fibular head

25. Bursitis • MOI = acute, chronic, or recurrent swelling • Prepatellar = continued kneeling • Infrapatellar = overuse of patellar tendon • Signs and Symptoms • Localized swelling that results in ballotable patella • Swelling in popliteal fossa may indicate a Baker’s cyst • Associated with burse over the semimembranosus 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

26. Patellar Fracture • MOI = direct or indirect trauma • Semi-flexed position with forceful contraction, which may occur while falling, jumping or running • Signs and Symptoms • Hemorrhaging and joint effusion • Possible capsular tearing, separation of bone fragments, and possible quadriceps tendon tearing due to bone fragments • Management • X-ray necessary for confirmation • RICE and splinting if fracture suspected • Refer • Possible immobilize for 2-3 months

27. Patella Subluxation or Dislocation • MOI = deceleration with simultaneous cutting in opposite direction (valgus force) • Quad pulls the patella out of alignment • Repetitive subluxation will impose stress to medial restraints • Signs and Symptoms • Subluxation • Pain, swelling, restricted ROM, and palpable tenderness over adductor tubercle • Dislocations • Total loss of function

28. Management • Reduction • Performed by flexing hip, moving patella medially, and slowly extending the knee • Following reduction, immobilize for at least 4 weeks • Use crutches • Isometric exercises • After immobilization period, horseshoe pad with elastic wrap should be used to support patella • Rehab focuses on strengthening the muscles around the knee, thigh, and hip • Possible surgery to release tight structures • Improve postural and biomechanical factors

29. Infrapatellar Fat Pad • MOI = becomes wedged between the tibia and patella • Irritated by chronic kneeling, pressure, or trauma • Signs and Symptoms • Capillary hemorrhaging and swelling • Chronic irritation may lead to scarring and calcification • Pain below the patellar ligament during knee extension • May display weakness, mild swelling, and stiffness during movement

30. Management • Rest • Avoid irritating activities until inflammation has subsided • Utilize therapeutic modalities for inflammation • Heel lift to prevent irritation during extension • Hyperextension taping to prevent full extension

31. Chondromalacia patella • MOI = softening and deterioration of the articular cartilage • Three stages: • Swelling and softening of cartilage • Fissure of softened cartilage • Deformation of cartilage surface • Often associated with abnormal tracking • Abnormal patellar tracking may be due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon

32. Signs and Symptoms • Pain with walking, running, stairs, and squatting • Possible recurrent swelling • Grating sensation with flexion and extension • Pain at inferior border during palpation • Management • Conservative measures • RICE, NSAID’s, isometrics, orthotics to correct dysfunction • Surgical possibilities • Altering muscle attachments • Shaping and smoothing of surfaces • Drilling • Elevating tibial tubercle

33. Patellofemoral Stress Syndrome • MOI = lateral deviation of patella while tracking in femoral groove • May result due to tight structures, pronation, increased Q angle, insufficient medial musculature • Signs and Symptoms • Tenderness at lateral facet of patella • Swelling associated with irritation of synovium • Dull ache in center of knee • Patellar compression will elicit pain and crepitus • Apprehension when patella is forced laterally • Management • Correct imbalances (strength and flexibility) • McConnell taping • Lateral retinacular release if conservative measures fail

34. Osgood-Schlatter Disease, Larsen-Johansson Disease • Osgood Schlatter’s is apophysitis at the tibial tubercle • MOI = repeated avulsion of patellar tendon • Bony callus develops enlarging the tibial tubercle • Resolves with aging • Larsen Johansson is the result of excessive pulling on the inferior pole of the patella

36. Signs and Symptoms • Swelling • Hemorrhaging • Gradual degeneration of the apophysis due to impaired circulation • Pain with kneeling, jumping, and running • Point tenderness • Management • Conservative • Reduce stressful activity • Possible casting • Ice before and after activity • Isometerics

37. Patellar Tendinitis(Jumper’s or Kicker’s Knee) • MOI = sudden or repetitive extension • Jumping or kicking places tremendous strain on patellar or quadriceps tendon • Signs and Symptoms • Pain and tenderness at inferior pole of patella • 3 phases: • 1) pain after activity, • 2) pain during and after activity, • 3) pain during and after activity that may become constant • Management • Ice, phonophoresis, iontophoresis, ultrasound, heat • Exercise • Patellar tendon bracing • Transverse friction massage

39. Patellar Tendon Rupture • MOI = sudden, powerful quad contraction • Rare unless a chronic inflammatory condition exists resulting in tissue degeneration • Occurs primarily at point of attachment • Signs and Symptoms • Palpable defect • Lack of knee extension • Considerable swelling and pain (initially) • Management • Surgical repair is needed • Proper conservative treatment of jumper’s knee can minimize chances of occurring

40. Runner’s Knee & Cyclist’s Knee • MOI = repetitive/overuse conditions attributed to mal-alignment and structural asymmetries • Signs and Symptoms • IT Band Friction Syndrome • Irritation at band’s insertion • Commonly seen in individual that have genu varum or pronated feet • Pes Anserine Tendinitis or Bursitis • Result of excessive genu valgum and weak vastus medialis • Often occurs due to running with one leg higher than the other • Running on a slope or crowned road

41. Management • Correction of mal-alignments • Ice before and after activity • Utilize proper warm-up and stretching techniques • Avoidance of aggravating activities • NSAID’s • Orthotics

42. The Collapsing Knee • Giving way of knee • Result of… • Weak quadriceps • Chronic instability of ligamentous structures • Torn meniscus • Loose bodies within the knee • Subluxating patella • Chondromalacia • Due to pain

43. Prevention of Knee Injuries • Total body conditioning is required • Strength, flexibility, cardiovascular and muscular endurance, agility, speed and balance • Muscles around joint must be conditioned to maximize stability • Flexibility and strengthening • Must avoid abnormal muscle action through flexibility

44. ACL Prevention Programs • Focus on strength, neuromuscular control, and balance • Series of different programs which address balance board training, landing strategies, plyometric training, and single leg performance • Can be implemented in rehabilitation and preventative training programs

45. Shoe Type • Change in football footwear has drastically reduced the incidence of knee injuries • Shoes with more short cleats does not allow foot to become fixed • Still allows for control during running and cutting

46. Functional and Prophylactic Knee Braces • Used to protect MCL • Used to prevent further damage to grade 1 and grade 2 ACL sprains • Used to protect the ACL following surgery • Can be custom molded and designed to control rotational forces

47. 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

48. Flexibility • Must be regained, maintained, and improved • Muscular Strength • Progression of isometrics, isotonics, isokinetics, and plyometrics • Incorporate eccentric muscle action • Open vs. closed kinetic chain exercises • Neuromuscular Control • Loss of control is generally due to pain and swelling • Through exercise and balance equipment proprioception can be enhanced and regained

49. Bracing • Variety of braces • Some used to control for specific injuries while others are designed for specific forces, stability, and providing resistance • Typically worn for 3-6 weeks after surgery • Used to limit ROM for a period of time • Functional Progression • Gradual return to sports specific skills • Progress with weight bearing, move into walking and running, and then onto sprinting and change of direction

50. Return to Activity • Based on healing process • Sufficient time for healing must be allowed • Objective criteria should include… • Strength assessment • ROM measures • Functional performance tests