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Knee

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Knee

Ligament Tears/ Sprains
- ACL
  - MOI
    - Non- contact
      - Deceleration/ Acceleration & Valgus nearing full Ext
      - "LE Pronation"
        Genu valgus, Hip IR, & Ankle inversion
      - Can prevent to some degree- train to keep knee out of valgus!
    - Trauma AKA Contact
      - Fixed distal Extremity
      - Blow Occurs from Posterior to Anterior & Lateral to Medial
      - Tackled PA & ML
  - Risk Factors
    - Shoe- Surface interface: Traction! Slippery or foot sticks
    - Females:
      - Narrow femoral Notch
        ACL  gets stuck in the notch and can cause tears 
      - 3-5x more likely in females
    - Joint Laxity
      - Beightons Scale:
        >4 = higher likelihood
    - Hormones
      - Preovulatory phase however research has shown that there is no correlation 
    - Combined Loading
      - Flex/ Ext WITH Var/ Val
        Due to the Multiimensional stress, we are at risk!
    - Muscular Strength/ Firing
      - Strong Eccentric Quads
        Occurs more in females than males Due to females different landing mechanisms, they get a stronger quad contraction with more EXT This Causes an anterior shearing force that increases the likelihood of ACL damage 
      - NEUROMUSCULAR TRAINING & EDUCATION
        Program focuses on deficits of the individual. Works on Combined loading, jump landing mechanisms, and muscular strength 
        Reduce ACL tears by up to 50%
    - Sports
      - Common in Soccer Players
  - Medical Tests
    - MRI = Gold Standard
  - Special Tests
    - Lachmans/ Anterior Drawer
      - Test for Anterior Translation of ACL
    - Pivot Shift
      - Incorporates the rotational component of the ACL
  - Physical Exam
    - Edema/ Effusion w/in 2 hours
    - "Giving Way"
      - Think of the Olympic runner video!  http://www.nbcolympics.com/video/us-runner-finishes-race-after-falling-hard
    - Reports hearing a "Pop"
    - Loss of Exension
      - This is due to the protective mechanism or the gross edema 
  - Loads Placed on ACL
    - ACL Failure occurs @
      - No significant difference between gaft types (patellar, Hamstrings, or cadaver) has been shown over long term. 
      - Normal= 1725 to 2195 N
      - Patellar Graft = 138-170% Stronger
      - Semiteninosous/ Gracilis Graft = 200% stronger
  - Surgical Repair Interventions
    - 3 Main Graft Types
      - Allograft
        Cadaver Tissue 
      - Autograft
        One' sown tissue  Tissue or organ that is transplanted from one part to another part of the same body. The tissue chosen is really based off of comfort... both have same long term outcomes.  Earlier research found that some individuals experienced patellofemoral pain with the knee graft 
        Patellar Tendon
        Bone, tendon, bone graft
        drill a tunnel in the alignement of where ACL was before. Reproduce anatomical position of ACL and string graft through there. Put a dissolvable screw to anchor bone to bone. Bone heals quickly and well because it has lots of blood flow. PRP probably isn’t necessary because the surgery opens the bone allowing plasma to come out anyways. 
        Medial Hamstring
        Part of semitendinosis and gracilis tendons removed  Portion of bone is not removed with this graft 
    - ACL TX Protocol
      - 0-6:  -Lose brace at around 3 weeks and then lose crutches when you can walk without a limp 6-12: ** 6 weeks is a critical time during healing. This is when the repair is at its weakest- it is starting to revascularize and pt is beginning to feel really good however, we need to focus on balance in order to prepare for next steps 
      - Eccentric Strengthening
        Most injuries occur as we are decelerating AKA Eccentrics so its important to strengthen
      - OCK
        Allows for Ms ISOLATION
      - CKC
        Functional for Multijoint Movements
      - NMES
        Help Improve gait
      - Accelerated Rehab
        Early Extension
        Early WB
      - Cryotherapy
        Early for Pain Control
    - ROM Timeline
    - Knee Extension is more important than Flexion
      - Need Extension early on so we can walk!!!
        Unless we have full extension, we will walk with limp
  - Poor Oucomes of ACL Reconstruction
    - 25% suffer a 2nd ACL surgery within 10 years
    - Delayed Force development
      - Ex: Quads, It is not about Strength... its about timing!!!
    - Poor Postural Control
      - Need Stability
    - Poor Control of Hip IR Moment
    - Landing Asymmetry
    - Can fix the Outcomes with:
      - Better Testing
        LESS: Landing Error Scoring System
        Single hop for distance
        Cross-over hop for distance
        Triple hop for distance
        Six meter Timed hop
      - Core Strengthening
      - Proprioceptive Training
      - "Neuro" Approach
        Whole vs. Part Environmental Context (clinic vs on the field)Visual Feedback: laser pointer attached to knee so you can see where knee is pointed during exerciseFaded Feedback: The intensity of feedback decreases over time (becomes less frequent) Random Practice: Intermix practice of various tasks during session; contextual interference b/c gives time to forget!External Focus
  - Function of ACL
    - Prevent anterior translation of h tibia
    - Tight when knee is extended and lose when knee flexed
    - Provides rotary stability for Medial an Lateral rotation
    - Helps to prevent Valgus
- PCL
  - History
    - Trauma
      - Anterior to Posterior force
    - Non Contact
      - Sudden Hyperextension
    - Hear a POP
  - Physical Exam
    - Localized Posterior Pain
    - Loss of Extension
      - In gait or on exam
  - Medical Tests
    - MRI
  - Special Tests
    - Posterior Drawer
    - Posterior Sag
  - Healing
    - PCL's are not usually reconstructed
      - Have a better ability to heal versus ACL
    - General Time Frames
  - Function
    - Tight during Knee Flexion
    - Prevents Hyperflexion of the knee
    - Prevents Posterior translation of the tibia on the femur
Greastest Shear Forces at the Knee
- ACL
  - 45 deg to 0 deg (terminal Extension)
    - Sheer forces on tibia on the femur causing ACL strain.  Only important in the ACL deficient knee. Won’t damage graft because the reconstructed ACL can take about 3x more than the shear force of a Short Arc Quad
  - OKC & CKC stresses are similar
- PCL
  - Knee Flexion
  - 90-75 deg Extension
  - OKC & CKC stresses are similar
    - Quad control required for control of knee in OKC & CKC
- Neutral Position = 75 deg