Knee Ligament Injuries Flashcards
Explain knee flexion biomechanics. CKC
femur rolls posteriorly
femur glides anteriorly
ACL guides condyles anteriorly
menisci move posteriorly
Explain knee extension biomechanics. CKC
femur rolls anteriorly
femur glides posteriorly
PCL pulls condyles posteriorly
menisci move anteriorly
Common LE Position for ACL rupture
IR of tibia knee in 10-20 degrees of flexion foot planted deceleration force >valgus collaps
What individuals are more likely to get ACL injuries?
athletes
15-30 years old
60% males/ 40& females (but female athletes more than male)
Why might females be more likely to get ACL injury?
wider pelvis, small femoral notch, hormonal factors.
males athletes tend to be hamstring dominant and females quad dominant
Injury prevention programs?
Sportsmetrics
PEP Program
FIFA F-Mark
ACL History
MOI: ER with foot planted ER with foot planted with valgus force Internal rotation hyperextension cutting or changing direction landing from a jump
Immediate hemarthrosis
popping
feeling of instability
inability to continue playing
In what type of injuries will you see and not see hemarthrosis?
Hemarthrosis: intraarticular injuries like ACL & PCL, patella tendon rupture, patellar dislocation
No hemarthrosis: extra- articular injuries like MCL/LCL
ACL X ray
Segond Fx: almost always indicative of ACL injury
small avulsion fracture of lateral tibial condyle just below joint line
ACL MRI
normal = black injured= gray colored
Will ACL present with a capsular pattern?
YES because of swelling
Who should get ACL reconstruction surgery?
Competative athlete with “best possibe knee” = surgery
Recreational athlete = consideration
non athlete (limit activities/non-op Rx)
influenced by knee instability, secondary injury, reduced activity level, post traumatic OA.
some individuals can return to high demand activities after ACL injury without surgery.
long term functional outcomes may be similar for surgical vs non surgical interventions
ACL deficient knee risk of what?
meniscus tears years later
bone bruises later
most will get signs of OA 10-20 years later
Intensive Rehab Program should include what?
LE Muscle strengthening Cardiovascular endurance training agility training balance perterbation training sport-specific skill training
PreOp training is very improtant!
ACL Injury Interventions
1) CryotherapyElectrical stimulation
2) Strengthening- quads, hamstrings, hip abductors, open chain vs closed chain
3) Joint ROM/ stretching
4) Proprioception Training - progress to balance/perturbation training
5) Gait Training- possible AD– walking to stairs to jogggin to running
6) functional bracing- limited benefit
ACL Rehab
Phase I
Goal
weeks 0-3
- immediate post-injury phase
Goals
- reduce swelling and inflammation (compression wrap, cryotherapy, HVGS)
- normalize knee motion (want full AROM by weeks 2-3)
- voluntary activation of quads (early WB, weight shifting, EMS, quad sets, SLR, 1/4 Squats, develop quand and hamstring co-contraction)
- partial weight bearing with crutches
- immediate stimulation of mechano receptors.
ACL Rehab
Phase II
Goal
weeks 4-6
Dynamic stabilization phase
Goals:
- maintain normal knee ROM
- normalize unilateral muscle ratio
- enhance proximal/distal stabilization
- improve proprioception and neuromuscular control
leg press 0-100 degrees, leg extension 100-40 degrees, wall squats 0-70 degrees , lateral step-ups, front step-downs, hamstring curls, D/C crutches
ACL Rehab
Phase III
Goal
weeks 7-10
Neuromuscular Activity Phase
Goals:
- gradual increase in strength
- promote endurance
- improve core instability
- enhance neuromuscular control
- gradually increase applied loads
*leg extension 100-0 degrees, 20-45 minutes of stationary bicycle, elliptical pool program, perturbation training drills, progression in plyo jumping drills (leg press, foam, floor, boxes), pool running
ACL Rehab
Phase IV
Goal
weeks 11-16
Return to Activity Phase
Goals
- gradual return to sports/activities
- continue strengthening/endurance program
- continue neuromuscular program
- backward>lateral shuffles, lateral shuffles >forward running, jogging>jog/stops>running/stops>suicides, cutting drills, 30-45 minutes of cardio
ACL reconstructions
grafts:
extraarticular: ITB
intraarticular: BPTB autographs and allografts, single/double/quad stranded semitendinosus autographs, semitendinosus/ gracilis autografts
Criteria for return to sport after ACL surgery
Full ROM Quad Strength = 85% of other leg Hamstring strength = 100% Hamstring to quad ratio = >70% Functional Testing >85 of uninvolved side no effusion no pain
PCL MOI
hyperflexoin, direct blow to anterior tibia, hyperextension, rotation
PCL Injury Signs and Symptoms
- pain (posterior when kneeling), may radiate into calf
- mild swelling
- may be ROM limitation
- popping
- infrequent instability
- feelings of giving way
Goals of Non operative PCL Rx
correct neurmuscular deficiences
develop quad-dominant knee
educate pt as to lig deficiency and future signs and symptoms
exercize in safe zone to avoid PF arthritis
modify lifestyle by avoiding high risk activities
brace to protect abnormal motion
Non operative PCL management
grade III: PROM CMP, brace locked into extension
Grades I/II: prom, careful arom, resisted rom limited to 0-60 degrees flexion(brace)
PCL Muscle training
QUAD STRENGTHENING! avoid early hamstring strenghening. 3 way SLR in a brace CKC 0-45 degrees terminal extension only no squats! no downhill walking
Post surgical
protected WB
progressive PROM
Strengthening:
quads
CKC 0-60 degrees
isokinetics 0-60 degrees, full range by month 3, no hi-speed until 5-6 months
Posterolateral Corner MOI
posterolaterally directed blow to the anteromedial proximal tibia
noncontact hyperextension and ER twisting injury
direct blow to a flexed thigh
high energy trauma
return to work/athletics 10-12 months post op
Medial collateral MOI
direct trauma to the lateral knee creating a valgus force
MCL physical exam
tenderness along MCL minimal effusion (extra articular) increased laxity
at 25 degrees flexion, MCL provides 80% of valgus restraint. at full extension, less than 60% of valgus restraint
Differential Diagnosis:
Medial knee contusion
Medial meniscal tear
patellar dislocation
Medial knee contusion:
no laxity noted
Medial meniscal tear:
joint line tenderness, valgus laxity with MCL, difficulty differentiating grade I MCL and MM tear, resolving tenderness with MCL
Patellar Dislocation:
tenderness near the adductor tubercle, (+) patellar apprehension sign
MCL surgical choices
tib anterior allografts
semitendonosis and gracilis autografts
combined rotational injury
ACL/MCL/MM
Follow ACL protocol
protect MCL
consider MM repair
menisectomy
