Basic Athletic Training Chapter 7 Knee and Thigh Edited by Gurchiek PE 282 Introduction to Athletic Training

Chapter Objectives Identify the anatomy of the knee and thigh Identify the steps in an evaluation format Compare the common injuries to the knee and thigh Demonstrate the principles of rehabilitation to the knee and thigh Describe the preventive/supportive techniques and protective devices for the lower extremity

Anatomy The knee is the largest joint in the body, but structurally weak The instability of the knee is supported by four strong ligaments and 12 muscles The femur (thighbone) is the longest and strongest bone in the body

Knee, Quadriceps, and Hamstring Anatomy Bones Ligaments Cartilage Muscles and tendons and their functions Range of motion

The Knee

Bones of the Knee

THE KNEE JOINT: Structure Modified Hinge joint Two condyles of femur articulate with tibial plateaus Patella articulates with patellar surface of femur

Fibula & Tibia All quads insert here

Pelvic Girdle Hamstrings Originate Here

Patellar Function Protects internal components of knee Increases turning force of quadriceps Decreases friction

Patella Anatomy

Gross Structure of Knee Anterior View

THE KNEE JOINT Structure The Meniscus (Semilunar Cartilage) Menisci are circular rims of fibrocartilage Lateral – “O” shaped Medial – “C” shaped Thick peripheral borders & taper to a thin inner edge

Function of the Menisci Absorb Shock Decrease Friction Deepen the Articular Facet

Ligaments of the Knee Anterior View

Anterior View

Knee Ligament Function Anterior Cruciate Ligament (ACL): Prevents anterior displacement of tibia from femur Posterior Cruciate Ligament (PCL): Prevents posterior displacement of tibia from femur Medial Collateral Ligament (MCL): Prevents excessive medial (valgus) opening of knee Lateral Collateral Ligament (LCL): Prevents excessive lateral (varus) opening of knee

ACL Injury PCL Injury

Blow from Lat Side MCL prevents Med Opening Blow from Medial Side LCL prevents Lat opening

Knee Movements

Varus Valgus

Muscles of the Knee

Knee Extensors - Quadriceps

Knee Flexors - Hamstrings

Other Soft Tissues of the Knee

Evaluation Format History Mechanism of injury (How did it happen?) Location of pain (Where does it hurt?) Sensations experienced (What did you feel?) Previous injury (Have you injured your knee before?) Have you ever injured your other knee? Did you see a Dr. or Have X-ray or Rehab

Observation Compare the uninjured knee to the injured knee Look for Bleeding Deformity Swelling Discoloration Scars, and other signs of trauma

Palpation Palpate the anatomical structures/joints above and below the injured site, then palpate affected area. Using bilateral comparison, these items should be palpated: Neurological (motor and sensory) Circulation (pulse and capillary refill) Anatomical structures (palpate) Fracture test (palpation, compression, and distraction)

Palpation of Anatomical Structures Bones Patella Femur Tibia - Tibial Tuberosity Fibula – Fibular head and shaft Soft Tissues Medial Collateral Lig (med epicondyle of femur to tibia) Lateral Collateral Lig ( lat epicondyle of femur to fib head) Medial & Lateral Meniscus in joint line Patellar ligament & tendon Popliteal space behind knee

Special Tests Look for joint instability, disability, and pain. Assess disability in the following areas: Joint stability Valgus/Varus, Anterior /Posterior Drawer, Patellar Apprehension Muscle/tendon Quads, Hams, Calf, Patellar Tendon and Ligament Accessory anatomical structures Meniscus, Bursa Inflammatory conditions Range of motion (active, assistive, passive, and resistive) Pain or weakness in the affected area

Valgus Stress Varus Stress Test MCL Test LCL

Anterior Drawer Test Reduces hamstring involvement At 90 degrees of flexion an attempt is made to translate the tibia anteriorly on the femur A forward slide or mushy end-feel indicates a positive test A positive test indicates damage to the ACL

Conditions that Indicate an Athlete Should be Referred for Physician Evaluation Gross deformity Significant pain Increased swelling Circulation or neurological impairment Joint instability Suspected fracture or dislocation Abnormal sensations such as clicking, popping, grating, or weakness Locked knee or excessive limited motion Any doubt regarding the severity or nature of the injury

Common Injuries Contusions Ligament sprains Meniscus tears Patellar tendinitis Chondromalacia patellae The female athlete’s knee Osgood-Schlatter condition Muscular strains

Knee Contusions MOI: Direct blow or falling on knee Tx: PRICES, ROM Ex with ice, Pad when return to play May involve bursa Compression pad helps minimize swelling

Thigh Contusions MOI: Direct blow to Quads or Hams Painful and disabling injury S & S: Pain, swelling, spasm, & discoloration Tx: PRICES, Conservative cryokinetics Pad when return to play Football thigh pad works well

Medial Collateral Ligament Sprains MCL damaged by blow to lateral side (Valgus Force) First Degree = MCL Stretched Second Degree – partial tear of MCL Third Degree – Complete tear of MCL Prevent injuries with Proper shoes Quad and Ham strengthening Treat with PRICES Immobilize & Crutches if unstable

Lateral Collateral Ligament Sprains LCL damaged by blow to medial side(Varus Force) Treat as MCL sprain Varus Force

Anterior and Posterior Cruciate Inj When tibia slides forward out from under femur causes ACL injury When tibia slides backward (posterior) out from under femur causes PCL injury Rotation of femur on top of fixed tibia also causes injury to cruciate ligaments. Treat initially with PRICES Refer to physician for further evaluation

ACL Injury PCL Injury

Injuries to the Menisci

Injuries to the Menisci Usually injured by twisting knee while weight bearing Also injured by squatting and landing on stiff knee due to compression of the cartilage MCL has attachment to medial meniscus Do not have good blood supply – usually do not heal Signs & Symptoms = knee may be locked, athlete complains of catching or grinding inside knee with pain, pain in joint line Treatment: PRICES, place on crutches, refer to physician

Patellar Tendinitis Patellar tendon attaches patella to tibia tuberosity Injury caused by excessive stretch and strain to tendon due to running and jumping sports PRICES is treatment, Dr. may prescribe something to reduce inflammation Stretch hamstrings & strengthen quads – emphasize eccentric exercise in later stages of rehab – let pain and swelling be guide for intensity May do well with patellar tendon strap

Chondromalacia Patellae Degeneration and softening of cartilage on underside of patella MOI: Overuse in running, jumping and squatting activities May be predisposed to injury due to improper patellar tracking or size/shape of patella, or excessive lateral pull of quad muscles Strengthen quads with straight leg raises, stretch hams Ice before and after exercise to decrease inflammation Use patellar grind test to check for chondromalacia

The Female Knee May have greater Q angle Tendon dominant as opposed to muscle dominant male Flat feet can lead to greater valgus stress at knee Associated with weak hip abductors

Osgood-Schlatter Syndrome Usually seen in adolescent athletes (growth plate open) Patellar tendon pulls on tibial tuberosity increasing bone growth at tendon insertion causing inflammation Condition can cause chronic knee pain Aggravated by activity – relieved by rest Treatment varies from rest to casting Ice before and after exercise

Muscular Strains – Quads and Hams Stretch or tear of muscles in the quadriceps or hamstrings Common causes include poor strength, repetitive overuse, improper technique During palpation note: Soreness and point tenderness, check for step-off Check AROM, PROM and RROM compare to uninjured side Treat with ROM exercise, progressive resistive strengthening Progressive walking – jogging- running – sprinting program

Rehabilitation Included in any rehabilitation protocol is: Range of motion exercises Resistive exercises Cardiovascular/fitness activities Sport specific activities Return to competition guidelines Full range of motion Strength, power, and endurance are proportional to the athlete’s size and sport No pain during running, jumping, or agility movements No loss of function

Preventive/Supportive Techniques Wrapping techniques for compression Knee compression wrap Wrapping techniques for support Knee joint, hamstrings, quadriceps, hip flexor, and hip adductor wraps Taping techniques for the knee, thigh and hip Collateral knee Hyperextended knee Anterior cruciate Patella tendon Hip pointer

Preventing ACL Injuries in Females Women 4-6 times more likely to tear ACL Common mechanism of injury: non-contact torsion Women—tend to land more straight-legged (ligament dominant) Men—tend to land more with bent knee (muscular dominant) Prevention program—shown to give significant reduction in ACL injuries. Includes: Hamstring strengthening Plyometric/agility drills Proper biomechanics during landing Knee over toes; avoid valgus position

Protective Devices Closed/open patella neoprene sleeve Hinged knee brace Knee brace Lateral patella subluxation braces Patella stabilizing strap Patella tendon tendinitis braces Patella tendon strap Pre-patella bursitis protectors Prophylactics knee brace: rehabilitative and functional Sport-specific pads

Musculoskeletal Disorders Bursitis Dislocation Fracture Iliotibial band friction syndrome Meniscal tear Myositis ossificans Osteochondritis dissecans Popliteal cyst

Questions ?