Recognition of Knee Injuries Evaluation & Treatment Standard 15 I WILL….describe common knee injuries, mechanism of injury, special test, and rehabilitation protocols.

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Knee Injuries

Treatment RICE Crutches Ace Wrap/Compression sleeve Knee immoblizer

EFFUSION means SWELLING

Objective Measurement of Knee Swelling

Boney Anatomy Femur Tibia Fibula Patella Medial Condyle Lateral Condyle Tibia Tibial Plateau Tibial Tuberosity Fibula Fibular Head Patella

Boney Anatomy Patellofemoral Joint Tibiofemoral Joint Where the patella and femur articulate* Tibiofemoral Joint Where the tibia and femur articulate

Soft Tissue Anatomy Ligaments* Attach bone to bone Sprain Ligaments Medial collateral ligament (MCL) Lateral collateral ligament (LCL) Anterior cruciate ligament (ACL) Posterior cruciate ligament (PCL) Sprain Ligaments Cruciate means “cross”

Soft Tissue Anatomy Muscles* Quadriceps Hamstrings Flex the knee Rectus Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius Vastus Medialis Oblique (VMO) Extend the Knee Hamstrings Semitendinosus Semimembranosus Biceps femoris Flex the knee * Strain muscles

Anterior Anatomy Posterior Anatomy

Soft Tissue Anatomy Tendons*: Attach muscle to bone Quadriceps tendon Hamstring tendons Patellar Tendon Illiotibial Band (IT Band)

Soft Tissue Anatomy Articular Cartilage Cartilage covering the articular surfaces of the bones forming a joint Allows the bones of a slide smoothly against one another. * Meniscus A curved, fibrous cartilage that acts as a cushion between the ends of bones Medial is torn most often MOI - twisting motion

What’s wrong with these knees?

Knee Classifications

Ligament Injury Grades Stretching of ligament Little to no laxity Firm end point* Mild swelling Some decreased ROM Crutches if necessary RICE and rehab Continued bracing may be required Grade 2 Partial tear of ligament Slight laxity but no gross instability Firm end point Moderate swelling Moderate to severe joint tightness w/ decreased ROM Positive special test Crutches RICE and rehab Return to play with brace Grade 3 Complete tear of supporting ligaments Complete loss of stability No end point Swelling and joint effusion Loss of motion due to effusion and hamstring guarding Positive special test Crutches RICE and rehab Surgery may be necessary Return to play in brace Increased recovery time

Medial Collateral Ligament (MCL) Sprain MOI: Signs & Symptoms Caused by valgus* stress from direct blow to lateral knee OR Foot planted with toes turned out thigh internally rotates ACL or meniscus damage can also occur Swelling medial knee Pain medial knee Laxity - Grades 1, 2 or 3 Typically scar down and heal well with rehab…non-surgical approach

Lateral Collateral Ligament (LCL) Sprain MOI Signs & Symptoms Caused by varus* stress from direct blow to knee OR Foot planted and thigh externally rotates Less common than MCL or ACL Can damage the cruciate ligaments, IT band, and meniscus Swelling lateral knee Pain lateral knee Can pinpoint LCL with knee in figure 4 Laxity - Grades 1, 2 or 3 Usually heals well with rehab and rest

Posterior Cruciate Ligament (PCL) Sprain MOI Signs & Symptoms Fall on bent knee is most common mechanism Most at risk during 90 degrees of flexion Can also be damaged as a result of a rotational force PCL prevents tibia from moving too far posteriorly Swelling and pain posterior knee Athlete may feel a pop or say their knee gave out Knee effusion Decreased ROM Laxity - Grades 1, 2 or 3

Anterior Cruciate Ligament (ACL) Tear MOI Foot planted with toes turned out (external rotation) and upper leg rotates in (internal rotation) Or contact forcing knee into hyperextension Rotation biggest component 70% non-contact injury Often can be accompanied with other injuries Meniscus, MCL, or both ACL prevents tibia from moving to far forwards

Higher incident in females! Research has indicated that the following factors are contributing to ACL tears in females… Biomechanical…Q-angle Hormonal….menstruation Environmental Anatomical….notch

ACL Tear Signs & Symptoms Joint effusion* Joint instability* Diffuse pain Many times athlete feels a pop or say their knee gave out Loss of range of motion Can have partial tears Most are surgical cases

Meniscus Tears MOI Signs & Symptoms Most common MOI is twisting with knee flexed/extended OR Deep squatting Medial meniscus is more commonly injured Can be longitudinal, oblique or transverse Swelling along joint line or effusion Pain along the joint line Decreased range of motion Catching, popping or locking Pain with twisting or squatting Non-surgical or surgical Repair or removal Has poor blood supply

Iliotial Band (ITB) MOI Signs & Symptoms “Runners Knee” Repetitive/overuse injury Mal-alignment or structural asymmetries Muscles imbalances Weak core a factor Can be the result of running on uneven roads Increase in activities Common in runners & bikers Pain and tightness at the knee or hip

Injury???

Patella Dislocation MOI Signs & Symptoms Patella moves out of patellar grove, usually laterally Contact or non-contact. Non-contact from twisting or quick change of direction. Ligaments, cartilage and bone can be damaged as patella dislocates. Occurs most often in adolescent females due to weak quad muscles and/or increased Q-angle Usually has to be relocated by athletic trainer or doctor. Subluxation* also possible X-ray taken to view articular cartilage Brace Pain that decreases once relocated Visual deformity Swelling, pain and discoloration medially. Positive apprehension test.

Hamstring Tear MOI Signs & Symptoms Acceleration Rapid Deceleration Kicking Over stretching Hyperextension Pain Tenderness Bruising Swelling Spasm Difficulty Contracting

Patellar Tendonitis MOI Overuse: esp. jumping Inadequate conditioning or stretching Obesity Patella Alta: Knee cap sits higher than normal Signs and Symptoms Pain Swelling Warmth Stairs exacerbate

Special Test Anterior Drawer – ACL Posterior Drawer – PCL Apprehension Test – Patella Valgus stress – MCL Varus stress – LCL Deep Squat – meniscus Swelling – objective & documentation

ROM Exercises Heel Slides/Ankle pumps Seated Bike Mini-squats (if FWB)

Strengthening Quad sets…isometric Straight Leg Raise x 4 way…isometric Thera band x 4…isometric (standing) Ankle weights x 4….isotonic Machines x 4…isotonic

Prophylactic Bracing

Knee Immobilizers

MRI Bone Bruising

Knee Injury Exit Ticket What are the 4 stabilizing ligaments of the knee? Define valgus and varus forces? Which side of the knee does the patella dislocate? What are some s/s of a meniscus tear? Which one is most often torn? What is the MOI for an ACL tear? What is the MOI for tearing a meniscus What percentage of ACL tears are non contact? 4 factors that contribute to a higher incident of ACL tears in females?

Knee Injury Do Now…. Which set of muscles flex the knee? What is the spongey material on the end of the bone called? Define subluxation? Which quad muscle controls the patella the last 30%? Contrast sprain & strain Which meniscus is most commonly torn? What is the purpose of prophylactic bracing? What 2 factors are contraindications of rehabilitation program progression? Every rehab bout should end with what modality?

Osteoarthritis & total knee replacement

MRI ACL TEAR

Osteoarthritis

MRI Bone Bruising

MRI Meniscus Tear

MRI Bone Bruising

Tibia Tuberosity fracture & repair

Patella fracture & repair

ACL Tear