Recognition and Management of Specific Injuries

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Recognition and Management of Specific Injuries
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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

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• 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

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• 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

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• 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

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• 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

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• 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

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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

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• 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

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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

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• Signs and Symptoms
• Experience pop with severe pain and disability
• Positive anterior drawer and Lachmans
• 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

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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

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• 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

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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

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• 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

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• 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

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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 NSAIDs if the
  result of trauma
• Recurrent conditions may require surgery

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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

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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

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• 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

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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

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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

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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

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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
  Bakers 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 NSAIDs
• Aspiration and steroid injection if chronic

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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

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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

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• 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

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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

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• 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

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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

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• 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, NSAIDs, isometrics, orthotics to correct
  dysfunction
• Surgical possibilities
• Altering muscle attachments
• Shaping and smoothing of surfaces
• Drilling
• Elevating tibial tubercle

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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

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Osgood-Schlatter Disease, Larsen-Johansson Disease

• Osgood Schlatters 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

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• 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

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Patellar Tendinitis (Jumpers or Kickers 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

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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 jumpers knee
  can minimize chances of occurring

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Runners Knee Cyclists Knee

• MOI repetitive/overuse conditions attributed to
  mal-alignment and structural asymmetries
• Signs and Symptoms
• IT Band Friction Syndrome
• Irritation at bands 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

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• Management
• Correction of mal-alignments
• Ice before and after activity
• Utilize proper warm-up and stretching techniques
• Avoidance of aggravating activities
• NSAIDs
• Orthotics

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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

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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

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• 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

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• 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

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• 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

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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

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• 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

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• 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

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• 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

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Summary

• Review anatomy
• Assessment
• History, observation, palpation
• Special Tests
• Injury prevention
• Injury recognition
• Rehabilitation