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KNEE INJURIES
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ACUTE
INJUIES
POSTERIOR KNEE ANTERIOR
PAIN
KNEE PAIN KNEE PAIN
LATERAL /
MEDIAL
KNEE PAIN
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ACUTE SPORTS
MENISCAL LIGAMENTOUS
INJURIES
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Ligamentous Injuries
HISTORY
– Traumatic Event
ONSET:
– Foot Planted + Knee Flexed
– Event of twisting / turning
– Forces : Valgus stress / Ext Rot of Tib / Anterior
movement of Tib on femur
– UNHAPPY TRIAD: ( TRIAD of Donoghue)
• Medial Capsule MCL ACL ( Medial Meniscus torn)
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Ligamentous Injuries
ONSET:
– Force against anterior thigh + Driving Femur backward
on tibia + last degrees of Knee Extension ACL
– Pure Internal Rotation of Tibia isolated ACL lesion
– Force Driving Tibia posteriorly on femur PCL
( Example : Dashboard injuries)
– HYPEREXTENSION FORCES :
• Posterior Capsule ACL PCL
– HYPERFLEXION FORCES PCL
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Ligamentous Injuries
Continue activities (MCL) /pain
subsides in few minutes / No
COMPLETE RUPTURE
effusion due to capsule rupture /
leaking of fluid out of joint cavity
SEVERE LIGAMENTOUS INJURY
Haemarthrosis Painful Effusion
INTRA-ARTICULAR FRACTURE
Difficulty in Weight Bearing
LESS LIKELY TO CONTINUE Play
PARTIAL INJURY
SLOWER DEVELOPMENT OF
EFFUSION ( CAPSULE IRRITATION)
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SITE & NATUREOF PAIN
• Localized / continuous / deep pain
• Aggravating Factors : any movement that stress the ligament
– Quick Turning MCL / LCL
– RUNNIG FORWARD ACL
– RUNNING Backward / Descending Stairs / squat PCL or posterior Capsule
• Isolated ACL Tear Generalized Discomfort
• Joint Effusion / Haemarth
– Entire knee is painful
– Intense aching , Throbbing pain
– Agg. By weight bearing
• Giving Way
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PHYSICAL EXAMINATION
A. Observation
The patient may hobble into the office, perhaps on crutches. The knee is held slightly flexed with only
toe-touch weight bearing, if any. The shoe, sock, and trousers are removed with difficulty.
B. Inspection
Joint effusion is obvious, especially in the suprapatellar region. The patient stands with the leg held semi
flexed, often unable to place the heel on the floor.
Girth measurements at the suprapatellar region are increased from effusion.
Some redness of the skin over the knee may be noticed. The skin may be somewhat shiny from being
stretched.
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PHYSICAL EXAMINATION
Active movement
a. Weight-bearing flexion–extension is impossible.
b. In the supine position, active movement is limited in a capsular pattern (about
15° loss of extension and 60 to 90° loss of flexion) because of joint effusion, with
pain especially at the extremes of both motions.
c. Passive overpressure is met with a muscle-spasm end feel
Passive joint-play movements
Femorotibial joint may be hypermobile and painful.
a. Anterior glide
b. Posterior glide c. Medial-lateral glide
d. Internal–external tibial rotation
e. Patellar mobility cannot be validly assessed if significant effusion is present.
f. Superior tibiofibular joint. Joint-play movement here may be painful in an LCL sprain. 10
PHYSICAL EXAMINATION
Palpation
1. There is likely to be localized tenderness at the
site of the tear. There may be referred tenderness
in nearby areas as well.
2. Effusion is easily confirmed by the tap test
3. Posterior capsular distension may also be noted
4. The joint is warm and slightly moist
Ligamentous stability and special tests.
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MANAGEMENT
GRADE I & II
Progressive exercises / Functional Activities
Avoidance of Varus / Valgus stresses in MCL / LCL
lesions respectively
Protection to Allow Healing Soft Tissue Release in different degrees of flexion
& extension prevent healing ligament from
adhering to adjacent tissues and help align newly
produced collagen along the normal lines.
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MCL GRADE III
• Conservative Treatment
• Weight Bearing Forces compress the medial side
of the joint thus adding in stability.
• Bracing
– Immobilized in hinge cast to prevent atrophy / valgus
stress ( 1-2 weeks)
• Full Knee Extension without extension lag
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ACL
NON- OPERATIVE
• Controlling REHABILITATION
swelling / pain
• Isometric hams / quads / co-contraction
– 90 of flexion – 45 of extension
• 30-0 Deceleration strain on ACL
• Isometric internal / external rotation exercises
once 90 flexion achieved.
• Electrical Stimulation
• Functional Knee Brace
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ACL
surgical REHABILITATION
• INTRA-ARTICULAR RECONSTRUCTION
– VARIOUS TISSUES Grafts
• PATELLAR TENDON – 168 %
• GRACILLIS – 49%
• SEMITENDINOSUS TENDON – 70%
• QUADS / RETINACULUM – 21 %
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ACL surgical Rehabilitation Rationale
Achieving full ROM and complete reduction of intraarticular inflammation and swelling before surgery to avoid arthro
fibrosis
Early weight bearing and ROM, with early emphasis on obtaining full passive extension
Early initiation of quadriceps and hamstring activity
Efforts to control swelling and pain to limit muscular inhibition and atrophy
Appropriate use of open and closed kinetic chain exercises, avoiding early open chain exercises that may shear or tear the
weak immature ACL graft
Comprehensive lower extremity muscle stretching and strengthening and conditioning
Neuromuscular and proprioception retraining including perturbation training
Stepped progression based on achievement of therapeutic goals (i.e., criteria based sequential progression)
Functional testing and functional sport-specific Training prior to return to play
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PCL REHABILITATION
• No isolated hamstring exercises are performed during the
first 6 to 8 weeks as they may accentuate posterior
subluxation
• Closed chain exercises are emphasized, allowing for
hamstring strengthening but protecting against posterior
tibial translation through the quadriceps–hamstring force–
couple and compressive forces across the joint.
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Meniscal Function
LOAD SECONDARY
TRANSMISSION RESTRAINT TO
JOINT NERVE
ACROSS THE ANTERIOR
LUBRICATION ENDINGS
TIBIOFEMORAL TIBIAL
JOINT TRANSLATION
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Mechanism of Injury
A combination of
torsional and axial loading
appears to underlie many If intrinsic degeneration of the
meniscal injuries. meniscus is present, minimal
trauma may cause tearing.
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TYPES OF TEARS
• Vertical longitudinal tears
normal meniscus.
• Atraumatic horizontal
cleavage, flap, and radial
split tears are more
common in older patients
who have underlying
meniscal degeneration
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HISTORY
• Abnormal stresses ( forced flex+ ER)/(forced ext + IR)
meniscal tear
• Absence of rotation in flexion / extension meniscal tear
• Medial meniscus, being less mobile, is more susceptible to
injury
• Cleated shoes / contact sports
• Associated ligamentous injuries
• Hyperflexion + rotation injury wrestlers
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Site & Nature of Pain
• Sudden onset / deep immediate pain
• “something give” in the joint, often with an accompanying deep, sickening type of pain
• Point to the spot on the joint line if not masked by effusion / other injuries
• Immediate locking of the joint ( 20-30 ext loss)
• Hesitate to resume activity
• Pressure Sensation Effusion
• Complete Restoration of activities
• Intermittent Buckling
• Occasional / persistent clicking of the sound
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PHYSICAL EXAMINATION
• Springy end feel
McMurray’s TEST
• may not be performed if considerable effusion restricts
flexion, because it is applicable only from full flexion to 90°.
• If flexion is possible, a painful click may be elicited on
combined
– External rotation and extension posterior portion of the medial
meniscus
– Internal rotation and extension posterior lateral meniscus
lesion
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PHYSICAL EXAMINATION
• Resisted isometric movements. These should be strong
and painless unless a tendon or muscle has also been
injured
4. Passive joint-play movements
a. Rotation opposite the side of the lesion may be
painful, especially during Apley’s test with compression
applied. Distraction with rotation should relieve the pain.
b. Otherwise, these movements should be relatively
normal unless a ligamentous injury also exists
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Conservative treatment
Symptoms develop over 24–48 hours after injury
Injury minimal or no recall of specific injury
Able to weight-bear
Minimal swelling
Full range of movement with pain only at end of range of
motion
Pain on McMurray’s test only in inner range of flexion
Previous history of rapid recovery from similar injury
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Surgical intervention
Severe twisting injury, athlete is unable to continue playing
Locked knee or severely restricted range of motion
Positive McMurray’s test
Pain on McMurray’s test with minimal knee flexion
Presence of associated ACL tear
Little improvement of clinical features after 3 weeks of conservative treatment
Radial tears are much less likely to heal with conservative intervention
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Rehabilitation program
Phase 1
Phase 2
Phase3
Phase4
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PHASE I (0-1 WEEK)
GOAL
FUNCTIONAL ACTIVITY
Control swelling
Maintain knee extension
Knee flexion to 100°+ Progress to FWB and
4/5 quadriceps strength
normal gait pattern
4+/5 hamstring strength
Gentle ROM
Cryotherapy Quadriceps/VMO setting
Supported (bilateral) calf raises
Electrotherapy
Hip abduction and extension
Compression Hamstring pulleys/rubbers
Manual therapy Gait re-education drills
Light exercise bike
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PHASE 2 (1-2 WEEKS)
FUNCTIONAL ACTIVITY
Swimming (light kick)
Exercise bike
Walking
GOAL
Eliminate swelling ROM drills
Full ROM Quadriceps/VMO setting
4+/5 quadriceps strength Mini squats and lunges
5/5 hamstring strength Leg press (double, then single leg)
Step-ups
Bridges (double, then single leg)
Hip abduction and extension with
rubber tubing
Cryotherapy
Single-leg calf raises
Electrotherapy
Gait re-education drills
Compression Balance and proprioceptive drills
Manual therapy (single leg) 29
PHASE 3 (2-3 WEEKS)
GOAL FUNCTIONAL ACTIVITY
Running
Full ROM Swimming
Full strength As Previous—increase difficulty, Road bike
Full squat repetitions and weight where Sport-specific exercises
(progressively
Dynamic proprioceptive appropriate
sequenced) e.g. running
training Jump and land drills forwards, sideways,
Return to running and Agility drills backwards, sprinting,
jumping, hopping,
restricted sport-specific changing direction,
drills kicking
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PHASE 4 (3-5WEEKS)
FUNCTIONAL ACTIVITY
GOAL
High level sport-specific
Full strength, ROM and strengthening
endurance of affected limb as required
Return to sport-specific drills and restricted Return to sport-specific
training and match play drills, restricted training
and match play
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THANK
YOU
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