Knee

Knee

1. ACL Tear/Sprain

   • Failure at 1725-2195 N
     • hear a 'POP"
       • Swelling, Giving Way,Loss of Extension
     • can be caused by trauma or non-contact
       • non-contact-deceleration/acceleration with valgus near full extension
   • Semitendinosus/gracilis Graft 200% stronger.STRONGEST
   • Modifiable Risk Factors
     • Narrow Femoral notch
     • joint hyper laxity (Beighton scale)
     • Combined loading(flexion or extension with varus or valgus)
     • muscular strength /firing
   • Shear forces at the knee
     • ACL: avoid OKC extension 45 degrees to 0 degrees
     • PCL: avoid OKC extension 90-75 degrees and OKC flexion
   • 25% suffer 2nd ACL injury within 10 years
     • Reasons why...
       • Delayed force development
       • Poor Postural control
       • poor control of hip IR moment
       • Landing asymmetry
         • to counteract these impairments
           • core strengthening
           • proprioceptive training
           • Neuro Approach
   • Non-Modifiable RF
     • Hormones (Pre-ovulatory phase)
     • shoe-surface interface (Traction)

2. PCL Tear/Sprain

   • Traumatic
     • Ant to Post or sudden HyperEXT
       • hear "pop"
         • posterior knee pain
           • loss of Extension during exam
   • No active hamstring for 6 weeks.
     • extension to 0 Degrees ASAP
       • Quad control ASAP

3. MCL/LCL Tear/Sprian

   • Trauma
     • MCL: lateral to medial trauma (Valgus)
       • Point tenderness and swelling
         • No Active Varus/ Valgus Stress 0-6 weeks
     • LCL: medial to lateral trauma (Varus)

4. Meniscal Tear

   • Medial Meniscus
     • Bigger "C" shaped
   • Lateral Meniscus
     • Smaller but wider
     • Popliteus muscle attaches to the Lateral meniscus
   • Trauma
     • Rotational injuries
       • Fixed distal extremity with rotation: compression with rotation.
         • joint line pain
           • springy end feel with extension
             • Loss of extension
               • complaints of giving away
       • distal 1/3 tears are repairable due to greater blood supply
         • Repairing the meniscus is preferred rather than a meniscectomy

5. Patellar Femoral Pain Syndrome/ Chondromalacia

   • Key components of History
     • Female> Male
       • Overuse
         • poor biomechanics
           • Pain with stairs and jumping
             • pain with prolonged positions (especially sitting)
   • Key components of Physical Examination
     • Pain with resisted extension
       • Pain with palpation
         • Patellar tendon
         • supra patellar bursa
         • Medial and lateral retinaculum
         • ITB
     • Poor Quad control: VMO Eccentric Control
       • Poor patellar mobility (medial and superior glides)
         • Tight musculature: ITB has connections into the Lateral Retinaculum
           • Poor LE probation control: Hip weakness and foot structures
           • <-------
   • 3 Contributing factors to PFPS/Chondromalacia
     • 1-Plica
       • Connective tissue on MEDIAL side of the knee that should absorb as you develop
     • 2-Forces on the Patella
       • PFJ is predisposed for lateral movement
         • due to bony structure and stronger/bigger muscles on the lateral side
           • Contraction of the patella is typically superior and lateral
     • 3-Structural alignment
       • Q- angle predisposes patella to lateral glide due to quad advantage.
         • the bigger the Q angle the greater the likelihood for lateral glide.
   • These individuals have weak hip abductors and ER's.
   • SERF Strap

6. Bursitis

7. Patellofemoral Instability

   • Acute-Traumatic
     • Distinct event
   • Chronic
     • Recurrent subluxation...Malalignment
   • Habitual
     • Occurs during flexion movement due to proximal pathology
   • Passive stability
     • Medial patellofemoral ligament
     • Bony structures
   • Dynamic stability
     • VMO
   • History
     • MOI: Non contact twisting with knee extended and foot Externally rotated
       • Complaints of instability
         • Anterior knee pain
   • Risk factors
     • Ligamentous laxity
     • Previous instability event
     • Miserable Malalignment syndrome
     • Osseous: patella alta, trochlear dysplasia, excessive patellar tilt, lateral femoral condyle hypoplasia.
     • Muscle: weak VMO, overall of lateral structures
   • Physical exam
     • Medial sided tenderness
     • increase in passive patellar translation
     • Patellar apprehension
   • Surgery is last resort
     • LATERAL RELEASE
     • Realignment of the Quadriceps
     • Medial Retianaculm tightening

8. Articular cartilage defects

   • Acute trauma
   • Chronic repetitive overload
   • 5 Surgical procedures
     • Lavage/Debridement
     • Microfracture
     • Autologous Chondrocyte Implantation
     • Osteochondral Autograft Transfer (OATS)
       • From less important area
     • Osteochondral Allograft Transfer (OATS)
       • From cadaver

9. Knee Replacements

   • Unicompartmental/ Unicondylar
   • TKR
     • Most Common
   • Bicompartmental
     • Rare
       • Unicondylar with a patellar component
   • If NON- Cemented PWB to let bone grow in.
   • If PCL is left will give more stability if taken out will give more mobility.
   • Drop and dangle

10. Special Tests

    • ACL
      • Anterior Drawer
      • Lachman's Test
      • Pivot Shift
    • PCL
      • Posterior Drawer
      • Posterior Sag
    • Collateral Ligaments
      • Valgus Test: MCL
      • Varus Test: LCL
    • Meniscal Tears
      • McMurray Test
      • Apley's Test
      • Thessaly's Test
    • Patellofemoral Syndrome
      • Clarke's Sign
      • McConnell's Test
      • Step Up/Step Down Test
      • Patellar Apprehension Test
      • Noble compression test?

11. General info

    • Pes Anserinus
      • Sartorius
      • Semitendinosus
      • Gracilis
    • Common knee fractures/ ruptures
      • Patellar Fracture
        • Quadriceps/patellar tendon rupture
    • Less common fractures /ruptures of the knee
      • Femoral Fractures
        • Distal Hamstring Rupture
          • ITB rupture

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