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Module 4: Knee and Lower Leg Injuries, Chronic knee pain: 2 types - Coggle…
Module 4: Knee and Lower Leg Injuries
Intervention Strategies
interventions can be effective in reducing injury rates
but adherence can be poor
Interventions should include
Flexibility
Core Strength
Proprioceptive/neuromuscular training
Feedback
Strengthening
Knee
Injuries
Patellar Tendinopathy
Intro
formally called jumpers knee or patellar tendinitis (but unlikely inflammatory pathology)
results from disruptions to the collagen structure of the patellar tendon
degeneration or separation of fibers
Risk factors
Inflexibility of the posterior chain
Weak lower limbs, including gastroc, quads, and glutes
onset
activities involving jumping and or cutting
volleyball, basketball, high jump, netball, dance, stair climbing
Pain
typically at the inferior patellar pole
reproduced with jumping
Exacerbated in mid-early squat
Inspection
may have deficient quadriceps
signs/symptoms
Swelling
rare but there may be tendon thickening
No Clicks/clunks/crepitus
Tenderness
may be distal to tibial tuberosity
rarely in mid-portion of the tendon
at inferior patellar pole
giving way
only due to quadriceps inhibition
Normal, pain-free ROM
Quad contraction in extension
possibly painful
normal PFJ movement
vastus medialis oblique (general weak quadriceps)
Functional tests
decline squats (reproduce pain)
PFJ taping (less effective)
clinical characteristics
common after ACL reconstructions with patellar tendon grafts
Treatment
Ice only beneficial if athlete feels relief
corticosteroid injections can improve pain
but not a long term solution
cross friction massage no longer indicated
platelet rich plasma (controversial)
surgery may be done if conservative treatment fails
May provide some symptomatic relief
Some research suggests it’s only as effective as an exercise program
Imaging
MRI or ultrasound may show changes to the patellar tendon
Patellar dislocation/subluxation
intro
occurs laterally
patella leaves the trochlear groove
Traumatic or atraumatic
traumatic- direct blow, tackle
atraumatic- doesn't require excessive force
typically in young females or special populations
shallow femoral groove
small patella
ligamnet laxity
after a dislocation, re-dislocation rates are up 44%
the patella may be avulsed during a dislocation, requiring imaging and repair
patella often relocates quickly when knee is extended
signs and symptoms
con be confused with an acl tear
pain and immediate swelling
patient feels something shift or pop out
visible deformity if patella is still dislocated
inability to walk or straighten leg
positive patellar apprehension sign
apply lateral force on patella to try to get it to shift
reproduce the pain and patient will get super apprehensive
Treatment
surgery indicated when:
patient doesn't respond to conservative treatment
medial stabilizers are substantially disrupted
there is an avulsion fracture
post-surgical treatment
similar to other ligament reconstructions
rehab should address underlying issues
core stability
pelvic postioning
Vastus medialis oblique strength
stretching tight lateral structures
Patellofemoral Pain
intro
formerly called chondromalacia patella
pain arises from:
peripatellar synovitis
lateral retinaculum issues
cartilage lesions that trigger synovial irritation
infrapatellar fat pad irritation
self-limiting condition
can predispose a person to early osteoarthritis
Risk factors
Increased tibial rotation
pronated foot
Increased knee valgus
inflexibility
Increased femoral internal rotation
Weak VMO
Signs/symptoms
non-specific, vague pain that is medial, lateral infrapatellar
Inspection
quads may be normal
possible VMO wasting
Onset
running, usually downhill, steps/stairs, hills
weight bear activity with knee flexion
Tenderness
usually medial or lateral patellar facet
May be tender in infrapatellar region
may be unable to pinpoint pain
Swelling
may have small effusion
occasional clicks/clunks/crepitus
Occasional giving way due to subluxation or quad inhibition
normal ROM (may be reduced in severe cases)
quad contraction in extension is not painful but mechanics may be off
PFJ mvmt is restricted medially due to tight lateral structures
VMO
May have wasting, weakness, or subtle deficits in tone/timing
Functional Testing
squats/stairs aggravate pain
PFJ taping should help
Clinical Characteristics
insidious onset
history of recurrent crepitus
feeling of giving way
Treatment
pain reduction
address underlying issues
hip stabilizers
footwear
core
Intrinsic foot strength
glutes
quad bulk
activity reduction
more progressive overload
Taping
Imaging
not required, rely on clinical exam
Meniscal Injury
meniscal tear
acute meniscal tears result from: knee flexion + compression + femoral rotation on the tibial plateau which creates shear forces
types
radial
Progresses to a parrot beak tear
horizontal
progresses to a flap tear
longitudinal
progresses to a bucket handle tear
medial is more likely to be damaged (it is less mobile)
occurs via a plant and twist mechanism with contact
athlete may feel a tearing sensation
small tears may not produce pain/swelling for 24+ post injury
with more significant tears
Pain
Locking sensation
limited ROM
examination reveals
Possible joint effusion
Pain with weighted flexion
joint line tenderness (with knee in flexion)
Limited ROM - typically with displaced tear
positive McMurray's test
positive Thessaly test
Imaging
MRI is best for diagnosis
outer 1/3 of meniscus has best blood supply (best chance for healing)
Treatment
depends on location, severity, and type of tear
smaller tears producing less dysfunction may be treated conservatively
larger, more complex tears may require arthroscopy
additional damage will slow recovery
non surgical treatment indicated
minimal injury or no recall of specific event
able to weight bear
symptoms develop 24-48 hr post injury
minimal swelling
Full ROM with pain only at end ranges
Pain McMurrray's, only in inner flexion range
Previous history of rapid recovery from similar injury
Early degenerative changes on radiograph
surgery indicated
Severe twisting injury, athlete unable to continue play
Locking or several restricted ROM
Positive McMurray’s with clunk
Pain on McMurray’s with minimal knee flexion
Associated ACL tear
little improvement after 3 wks of conservative treatment
best chance of success with surgical repairs when:
the tear happened recently
athlete is younger
knee is stable
tear is peripheral
A graduate rehabilitation program should aim to achieve
normal hip external rotator function
good proprioception
Normal quad/hamstring function
function exercises completed w/o difficulty
Full ROM
no return of symptoms after practice, training or competition
no effusion
MCL Injury
mechanism
valgus stress on a partially flexed knee
contact (tackle, slide)
non contact (skiing, basketball)
Grading
2- more pronounced tenderness, may be swelling, pain with valgus stress test, laxity up to 5mm opening, palpable end point
3- instability tenderness, pain but could be less than other grades, gross laxity with no end point, acl tear may be suspected
1- local tenderness, no swelling, pain but no laxity with valgus stress test
Treatment
recovery can take 4-12 weeks
graduated exercise program to
Maintaining strength of surrounding musculature
Introducing sport-specific activities gradually
Restoring ROM
eliminate swelling
Xray may be indicated to rule out bone injury (MRI is gold standard)
hinged knee brace helps to stabilize knee, while undergoing exercise-based rehab in early rehabilitation
ACL Injury
intro
200 000 surgical reconstructions/year in US
81 per 100 000 adults in Europe
frequency highest in pivoting sports, and those with quick stop/starts
football, basketball, handball, gymnastics, skiing
females 2.5-9.7x more likely to sustain an ACL tear
ACL rupture often occurs with:
MCL tear
Cartilage damage
Meniscal tear
70% are non-contact
primary MOI for non-contact:
rapid deceleration
pivoting (plant and twist)
landing from a jump
a comprehensive history is very important in making the diagnosis
Injury history
Complete ruptures may be painful right away, but fade to a
dull ache
unable to keep competing immediately after injury
feeling of the knee "giving way"
swelling (may be delayed)
audible sounds are common: "pop"
Associated injuries
bone bruises are not uncommon with ACL injury
produce pain and dysfunction
Risk Factors
modifiable
quadriceps dominance
leg dominance
ligament dominanace
trunk dominance
environmental factors
fatigue
non-modifiable
notch stenosis
ligamentous laxity
tibial plateau anatomy
hormonal function
neuromuscular maturation
Examination
lachman test
flex the knee, relax hamstrings, grasp femur just above the proximal tibia, look at the amount of anterior displacement and firmness of end point
a soft end point= acl injury
easier to do in lean athletes
pivot shift test
supine position with hips slightly flexed and knee in full extension, grasp lateral aspect of knee and cup heel of leg with other hand, slowly flex the knee and apply valgus stress while internally rotating tibia
if injured subluxation will occur at 20-30% knee flexion
more complicated assessment
Important considerations for tests
accuracy is dependant on expertise of tester
there can be low sensitivity and specificity
important to take into account whole picture
Special Tests
Exam
Imaging
History
should be performed within the 1st hour of injury
after swelling sets in, palpation and special tests may be difficult
when swelling subsides, exam may be performed again
limited ROM
tender throughout the knee joint
medial joint tenderness
if a meniscal injury is present
lateral joint tenderness
due to impact of tibia and femur with knee in valgus
Anterior drawer test
if acl is deficit you will be able to displace tibia much farther forward
accuracy dependent on how good tester is
subject to low sensitivity and specificity
wide variability
try to displace tibia forward to test integrity
Imaging
xray may be done
looking for segond fracture (anterior lateral capsule avulsion fracture)
MRI may be used pre-operatively to look for associated meniscal or MCL injury
Treatment
immediate care
Decrease swelling
crutches okay for pain management in short term
do not immobilize - start early gentle ROM
but continue non weight bearing ROM
maintain strength of surrounding musculature
graduated exercise program, building up to straight ahead running and then to sport-specific activities
surgery vs non-surgical options
athletes who want to continue cutting/pivoting sports should likely have a reconstruction
typically 8-12 months until full return to sport
decision should consider patient goals, type and extent of injury, associated damage, age, instability
Patellar Tendon rupture
intro
occurs due to rapid eccentric contraction of the quadriceps
preparing for takeoff, falling
previous corticosteroid injections may be a risk factor
signs/symptoms
sudden onset of pain in anterior knee; tearing sensation
inability to stand
visible deformity at the knee
window shade effect
patella retracts proximally
surgical repair required
6-9 month rehab
Intro
The knee joint
includes femur, tibia and patella
Tibiofemoral joint: condyloid joint
Patella glides over femur
Lower Leg
Medial Tibial Stress Syndrome (MTSS)
Intro
Nondescript term for anterior lower leg pain
pain typically along posteromedial border of tibia
Pain is fairly diffuse
more focal pain may indicate a tibial stress fracture
Pain subsides after a warm up, but worsens after activity and first thing in the morning
Known as shin splints
probably not an inflammatory condition
may indicate issues with TA, soleus, FDL
Risk Factors
Footwear
playing surface
Poor technique
fatigue
over pronation
inflexibility
muscle dysfunction
female
obesity
Imaging
Bone scan
may show patchy uptake
unlike stress fracture, which is very concentrated
MRI may show changes
Xrays (negative)
Treatment
cross training for help
examine footwear to treat overpronation
some athletes may be placed in a walking boot
Some people might find heat helps, but could potentially
exacerbate the problem
Symptomatic treatment
cross friction massage
address underlying issues
rest, ice, analgesics
Surgical release may be indicated if conservative treatment fails
Chronic Exertional Compartment Syndrome
Intro
common in distance runners
can occur bilaterally
Increased pressure in the compartment, that results in reduced blood flow and tissues perfusion
ischemic pain and possible damage
ischemia creates pain
patients have lower capillary density
microcirculation is decreased
muscles trying to expand with a confined space
fibrosis of the fascia restricts expansion of the compartment
Symptoms
No pain at rest – increasing pain and tightness with activity
symptoms subside relatively quickly after activity
may have paresthesia or weakness during activity
may be visible changes in lower leg
occurs most often in anterior compartment
Diagnosis
Intracompartmental pressure measurement
non-invasive measurements are also being tested
Treatment
deep massage/cross friction
address underlying issues
reduce activity
dry needling
prolotherapy
surgical release may be indicated
fascietomy
faciotomy
Achilles Injury
types of injuries
Rupture
presentation
Gun shot effect (audible sound)
can feel like being kicked in the tendon
most frequent in the 30s and 40s
10:1 male to female ratio
often occurs after sustained activity (fatigue could play a role)
individual can be asymptomatic prior to rupture
Assessment
Prone inspection
loss of definition in the area
loss of natural unweighted plantarflexion
palpable gap (3-6cm proximal to the insertion)
may be lost due to swelling
Strength testing
plantarflexion is dramtically weakened
positive thompsons test
Treatment
previously, surgery was considered necessary
evidence shows promise in conservative treatment
early ROM & progressive loading is recommended
RTP
jogging 12-16 wks
non contact 16-20 wks
Contact 24-30 wks
all with performance based benchmarks
Potential Rehab issues
Tendon elongation
Gait abnormalities
Calf weakness
Differential
Insertional tendinopathy
Referred pain
Achilles bursitis
Posterior Impingement Syndrome
Tendinopathy (mid tendon pain)
Risk factors
increase in training
post injury return to play
unilateral calf tightness
decreased ROM at the ankle
Haglund's deformity
chronic tendon degradation (tendinopathy) can lead to patial tears
Treatment
follow the flow chart
Alfredson's painful heal drop
do with knee straight and bent to target both SOL and GASTROC
Tibial Stress Fractures
Medial Tibial Stress fracture
common in WB sports
risk factors
running mechanics
bone density issues
pes cavus or planus
acute training increase
leg length discrepancy
hard playing surface
Recognition
gradual onset of pain
aggravated during activity
focal tenderness over the fracture site
pain worsens during activity but may present at rest as well
more focal than in MTSS
bone scan and a good clinical exam is best
Treatment
use of walking boot
relative rest continues until bony tenderness is gone
gradual progression to return to play
Initial non or partial weight bearing (when pain resolves)
If underlying factors not treated, this will happen over and over
Anterior Tibial Stress Fracture
Intro
pain in the area of the fracture
bump is thickening of the periosteum
may be a palpable bump if injury has been present for several weeks/months
high risk fracture site
area of tension in the tibia
poor blood supply
risk of non union
Recognition
similar to a medial tibial stress fracture but location is more anterior
Treatment
bone stimulator
with no success, other options must be considered
some evidence for use of an air brace
surgical options
screw fixation
surgical excision + bone grafting
pulsed electromagnetic stimulation
screen for risk factors
stop all anti-inflammatories
immediately put into a boot
Chronic knee pain: 2 types