Knee

Knee

1. injuries

   • meniscus
     • patella femoral pain syndrome
       • Gastroc muscle strain
         • ACL
           • MCL
     • ITB friction syndrome

2. PFPS

   • biomechanics
     • muscle tightness/weakness
       • pain/steps, hills, uneven surfaces
         • knee valgus
           • femoral internal rotation
             • if neglected - patellofemoral osteoarthritis
               • increased loads to PFJ
   • treatment
     • relative rest, stop aggrevating activities
       • keep CV work, swimming, pain free
         • ice for pan
           • quad strength for pattella tracking
             • look at hips and ankles
               • glute med
                 • footwear, pronate
               • quads, hams, hip abd/add, gastroc stretching
                 • soft tissue reduce pattella friction
                 • non flexible

3. ITB Friction syndrome

   • occurs knee flexion
     • ITB passes over Lateral epicondyle
       • some think inflammation of itb as result of friction
         • some results in bursitis
           • seen athletes run down hill
             • change knee angle, foot strike reduced
   • features
     • pain lateral side aggrev. knee running
       • downhill/stairs
         • tenderness over lateral epicondyle of femur 1-2 cm above joint line
           • repeated flexion/extension may reproduce symptoms
             • obers
               • hug opposite knee
     • treatments
       • rest aggrevating activitys
         • reduce inflammation - ice, nsaids, electro
           • increase fexibility: massage - stretch
             • increase lateral hip stabilizers
               • correct predisposing factors
                 • heat before exercise

4. ·

   • meniscal tears
     • mechanism
       • foot anchored to ground
         • weight bearing
           • twisting action
       • more common in acl deficient knees
     • features
       • small tear no immediate symptoms
         • over 24 hours pain and swelling appear
         • larger tears
           • pain on joint line
             • immediate reduced ROM
               • intermittent locking
                 • pain on squatting
                   • clicking
           • feels a tearing sensation
             • joint effusion
               • pain hyperflexion
                 • 90% healling rates in peripheral meniscus
       • treatment
         • gradual rehab, control pain, swelling, ice, compression, electro
           • NWB until effusion has decreased and flexion 100
             • bucket handle require surgery - mri
               • increase full rom and strength
                 • gentle rom
                   • increase surrounding muscle strength
                     • re- ed gait
                       • rehab on ipad
               • knee brace up to 6 weeks
   • ACL
     • contact/non contact
       • sudden change direction
         • twisting /cutting
           • landing
             • knee slight flexion, valgus, IR/ER of tibia
               • contact - impact with varus force
     • features
       • often hears pop
         • sudden pain
           • repetitive giving way
             • swelling
               • in first few hours
                 • haemarthrosis
               • best asses time of injury prior to swelling
                 • painful and decreased extension
                   • lachmans
                     • anterior draw test
                       • feels poppin out then in
                         • instability
                           • widespread tenderness
                             • restricted ROM
                               • joint line tenderness
                                 • if medial possible meniscus also
       • restore hyperextension
         • reduce swelling and pain
           • restore flexion
             • strengtheing
               • quads, hams, hip ext, hip abd, calves
                 • NWB - CKC - PWB - FWB
                   • sport specific
                     • return to sport
         • conservative + pre opp
         • before surgery
           • knee has hyperextension
             • minimal/no swelling
               • almost full flexion
                 • good control of quads
                   • inflammation resolved (4 weeks)
           • post surgery
             • restore hyperextension
               • reduce swelling and pain
                 • restore flexion
                   • same as
                     • <
                     • return 6-9 months post surgery
   • • MCL
       • force applied to lateral side of knee
         • valgus
         • high manouvvre, foot on floor with valgus stress
           • falling valgus force
             • grade 1
               • localised tenderness on femoral condyle
                 • no swelling
               • grade 2
                 • marked tenderness - local swelling
                   • valgus test produces pain
                     • laxity with definate end point
                 • grade 3
                   • complete tear
                     • feeling of instability
                       • present pain but not much
                         • ligament tenderness
                           • no distinct endpoint
       • features
         • feeling loose/ giving way
           • instant pain medially
             • knee ext/flex painful and limited
               • walk impaired
                 • swelling of joint
                   • tender over insertion on medial femoral condyle/joint line
         • grade 1
           • protect ligament - brace
             • decrease pain/inflammation
               • isometrics not done between 0-20 of flexion
                 • avoid stress healing
                 • hamstring, hip abd/add after 48 hours
                   • after 1 week progress to full extension and functional exercise
           • grade 2
             • brace in 20-60 degrees
               • 4-6 weeks
                 • ligament heal
               • treat same grade one with brace
                 • after brace incr. ROM - heat, massage, mobes
                   • jogging after 6 weeks if quads strong
             • Grade 3
               • brace for 6 weeks
                 • 2 weeks - 30-60
                   • 2 weeks - 10 - 90
                     • 2 weeks - 0 - 130
                       • strengthen quads, abd, hams same grade 1-2
                         • full quad strength must be returned before back to sport
                           • usually 12 weeks
     • early rehab
       • unilateral isometric control
         • after iso control able - static quads
           • chopping
             • flex/ext
               • add/abd
                 • on side/ on back
         • compare billaterally, alternate
       • intermediate
         • 25/50/75 - squat, stand
           • 2 hand, 1 hand, no hands
           • 2 foot calf raise
             • ""^
             • squat against wall
               • can add calf raises
               • on bench
                 • stand and sit
                   • holding onto bench
                     • weight on hands
                 • wall squat
                   • 25, 50, full squat
                     • can progress onto balance board
         • late
           • knee extension with theraband
             • chair sits
               • can add weight
               • walk on spot
                 • high knees
                 • step ups - down bench
                   • step ups, down, bench lateral
                     • progress to chair
                       • forward lunge
                         • progress to bench
                           • dumbells
                         • reverse lunge
                           • increase lunge distances
                             • multidrectional lunges
                             • plyometrics
                               • proprio
                   • progress with dumbells
                     • entire foot on bench
                       • step down toes first