Download - Knee Injuries: Trends & Advances
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Knee Injuries: Trends & Advances
September 23, 2021
1
PAMELA RAST, PHD, LAT, ATC
Dept. of Kinesiology
Athletic Training Program
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I am an Athletic Trainer
Athletic trainers are health care professionals who collaborate with physicians to
optimize activity and participation of patients and clients.
Athletic training encompasses the prevention, diagnosis, and intervention of
emergency, acute, and chronic medical conditions involving impairment,
functional limitations, and disabilities.
Why me?
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This lecture will:
• review knee anatomy
• discuss common knee injuries and sources of injury
related knee pain
• identify methods of prevention
• discuss common diagnoses
• review evidence-based assessment/screening and
treatment methods
What we will cover...
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At the end of the presentation the participant will:
• be aware of common knee injuries in the WC setting
• understand common knee injury diagnoses
• know work related and non-work-related risk factors for
knee injury
• have knowledge of basic knee anatomy
Content Objectives
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At the end of the presentation the participant will:
• have an awareness of the surgical and non-surgical
treatment interventions options for common knee injury
• understand best practice for use of treatment options
• have an appreciation of length of recuperation time
estimates by type of injury
Content Objectives continued
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6
Scope of the
Problem:
Workplace
Statistics
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Incidence rate -2.5 per 10,000 f-t workers (private industry)
Median days away from work -22 (38% of
cases <30 days)
8.81% of all Natures of Inj. Illness
reported in 2019 (Private Industry)
9.74% of all MSDs reported in 2019(Private Industry)
Source data: BLS Table R13 (2019)
2019 StatisticsBureau of Labor Statistics US Department of Labor (2021)
8
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According to the National Safety Council Direct
and indirect costs associated with
knee injuries alone among
workers is estimated at $32,622 per claim.
Using 2019 numbers that’s
Annually
8
$2.5 Billion
Impact
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Review of functional anatomy of the
knee and surrounding structures
Knee
Anatomy
9
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Ligamentous Arrangement of the KneeAnterior View
10
1. Tibial collateral lig.
2. Medial femoral condyle
3. Posterior cruciate lig.
4. Anterior meniscalfemoral lig.
(Ligament of Wrisberg)
5. Anterior cruciate lig.
6. Lateral femoral condyle
7. Popliteus
8. Fibular collateral lig.
9. Biceps femoris tendon
10. Lateral tibial condyle
11. Lateral meniscus
12. Medial meniscus
13. Medial tibial condyle
Image Source: McMinn & Hutchings (1977)
condyle
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Ligamentous Arrangement of the KneePosterior View
11
1. Tibial collateral lig.
2. Medial femoral condyle
3. Posterior cruciate lig.4. ----
5. Anterior cruciate lig.
6. Lateral femoral condyle
7. Popliteus
8. Fibular collateral lig.9. Biceps femoris tendon
10. Lateral tibial condyle
11. Lateral meniscus
12. Medial meniscus
13. Medial tibial condyle
14. Ligament of Wrisberg
15. Proximal tibiofibular lig.
Image Source: McMinn & Hutchings (1977)
condyle
epicondyle
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Ligamentous Arrangement of the KneeLateral View
12
6. Lateral femoral condyle
7. Popliteus
8. Fibular collateral lig. (LCL)
9. Biceps femoris tendon
10. Lateral tibial condyle
11. Lateral meniscus
Image Source: McMinn & Hutchings (1977)
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Discovered by 2 Belgian orthopedic surgeons)(Dr Steven Claes & Professor Johan Bellemans , 2012)
Located in center of the human knee
Present in 97% of population
may be responsible for injured knees giving way during exercise
New Ligament: Anterolateral Ligament (ALL)
13
Image source: www.terrafemina.com , Par Antoine Lagadec Publié le 7 novembre 2013
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Ligamentous Arrangement of the KneeMedial View
14
1. Tibial collateral lig. (MCL)
2. Medial femoral condyle
12. Medial meniscus
13. Medial tibial condyle
Image Source: McMinn & Hutchings (1977)
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Menisci of the ® Knee
15
Transverse (meniscal) Ligament
Posterior menisco-meniscal Ligament
Medial Meniscus
Lateral Meniscus
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A recently identified knee ligament,
thought to be present in 97% of
the human population is the:
A) MCL
B) PCL
C) ACL
D) ALL
REVIEW
QUESTION
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A recently identified knee ligament,
thought to be present in 97% of
the human population is the:
A) MCL
B) PCL
C) ACL
D) ALL (Anterolateral Ligament)
REVIEW
QUESTION
ANSWER
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Common Knee Injuries in the Work Setting
Common Structures/Conditions
OA
Anterior Knee Pain / Patellar Pain
ACL Tears
MCL tears
Meniscus tears
Extensor Mechanism
Dislocations & Fractures
18
Common MOI
Trauma
Crush
Direct Blow
Fall
Forced movement beyond normal ROM
Overuse (CTD)
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Anterior
Knee
Pain
19
Iliotibial band syndrome
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Anterior Knee Pain =
• Patellofemoral Pain Syndrome
• Chondromalacia Patella
• Abnormalities in the:
• Forces applied to the Kneecap
• Anatomy of the Knee Cap
Anterior (Front) Knee PainCommon Complaint
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Pain in the front of the knee, underneath the knee cap (patella)
Pain going up or down stairs
Difficulty sitting with knees bent for a long period of time
• Movie theater sign
Swelling, catching, locking
Sense of knee cap (patellar) instability
Knee giving out
Anterior (Front) Knee PainSymptoms
21
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one of the most common disorders of the knee
25% of knee injuries seen in a sports medicine clinic
insidious onset
ill-defined ache localized to the anterior knee behind the patella
Pain at the inferior pole of the patella
pain aggravated by compressive force
pain on palpation of patellar retinaculum
Patellofemoral Pain Syndrome / Patellofemoral Jt.
22
Image Source: https://www.physionow.ca/blog/knee-pain/patellofemoral-pain-syndrome/
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Multifactorial
• abnormal patellofemoral
joint mechanics
• lower kinetic chain
alterations
• overuse
Patellofemoral Pain Syndrome / Patellofemoral Jt. MOI & Risk Factors
bony and structural abnormalities
iliotibial band tightness
abnormal patellar mobility
quadriceps muscle weakness
Q angle
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No one standard physical exam or imaging
test
Treatment is focused on activity
modification and correction of specific risk
factors.
Nonoperative treatment is successful in the
majority of cases
Patellofemoral Pain Syndrome / Patellofemoral Jt. MOI & Risk Factors
24
Clarke’s Sign / Patellar Grind Test
Patellar Apprehension Test
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“Jumper’s knee”
Work involving squatting, jumping from a height
Pain at the inferior pole of the patella
Repetitive microtrauma vs macrotrauma
Chronic/Nagging injury
Osgood Schlatter Disease Association?
Patellar Tendinitis / Patellofemoral Jt.
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Age - > 30 yo
Gender – more common in men
Weight – more likely in overweight
individuals
Flexibility – tight quads
Conditioning – poor core stability around hip
& knee
Patellar Tendinitis / Patellofemoral Jt. Risk factors
26
Image Source: https://blog.runnics.com/us/uncategorized-us/common-injuries-runners/
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The mainstay of Tx for patellofemoral jt. Problems is
REHABILITATION
Surgery indicated for patients with malalignment who
have failed conservative treatment
Patellar Tendinitis / Patellofemoral Jt. Treatment – General Principles
27
Image Source: Floyd E. Hosmer (1999) https://www.aafp.org/afp/1999/1101/p2012.html
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Anti-inflammatories (Advil, Aleve)
RICE (Rest, Ice, Compression, Elevation)
Activity modification
Taping (McConnell)
Bracing
Return to work full duty around 6 weeks after PT
Patellar Tendinitis / Patellofemoral Jt. Treatment - Conservative
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British Journal of Sports Medicine
• Review of 6 trials in favor of stem cell injections in KOA.
• high risk of bias • level-3 or level-4 evidence in favour of stem cell injections in KOA.
• “In the absence of high-level evidence, we do not recommend stem cell therapy for KOA”
Cochrane Review of stem cells for knees
• ongoing without results thus far
(Pas et al. 2017 & Cochrane Database https://doi.org//10.1002/14651858.CD013342)
Stem Cell Injections for Osteoarthritis of the KneeNote on Current Best -Practice
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Injury to
the ACL
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>100,000/year
Females: 3-10x risk
Genetic predisposition?
Differences in:
• muscle firing patterns,
• landing
ACL InjuryEpidemiology
31
Image source: Vavken P., Murray M.M. (2013)
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ACL
• prevents tibia from moving anteriorly
• Aids in anterior knee stability
• Aids in twisting, cutting activities
• Without an ACL there is risk of meniscus
and cartilage damage with recurrent
instability
PCL
• prevents tibia from moving posteriorly
ACL/PCLFunction
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70%-noncontact
Injured by a combination of a sudden
stop with a quick twist
Hx
• Hear a ‘Pop’
• Pain
• Rapid onset swelling
• Unable to play
• Knee feels “unstable”
• Do not trust knee
ACLMechanism of Injury
33
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Special Tests
Lachman
• 1+: 1-5mm
• 2+: 6-10mm
• 3+: >10mm
• quality of endpoint:
• ‘A’- firm
• ‘B’- soft
MRI (Gold Standard)
ACL InjuryDx
34
Image source:
https://breddydotorg.files.wordpress.com/2015/04/lachman-test-
lateral-view-can-see-both.jpg?resize=260%2C176
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ACL does not heal
Any active person with an ACL tear should consider having it
reconstructed
PREHAB PRIOR TO SURGERY FOR 4-6 weeks
• Get back full ROM
• Decrease swelling
• Improve muscle strength prior to surgery
ACL TearsTx
35
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Limited blood supply to ACL - cannot be repaired with stitches
Graft required(tissue to be used as a new ACL)
• Graft options:
• Autograft
• Own Patellar Tendon
• Own Hamstring Tendons
• Allograft
• Cadaver Patellar Tendon or Hamstring Tendons
• All do well, patient choice in many cases
ACL TearsTx
36
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Walk on it right away after surgery with Brace
First 6 weeks
• Brace on at all times, including Physical Therapy. Goal : Range of motion
exercises only
6-12 weeks
• No brace, range of motion and add strengthening exercises
3 months – starts running
6 months – RTP / RTW
6 mo-1yr back to competitive sports, knee feels normal
ACL Rehabilitation
37
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Patellar tendinitis & patellofemoral
joint dysfunction pain most often
occur in:
A) 18 - 25 yo
B) 30 + yo
C) 50 + yo
D) 60 + yo
REVIEW
QUESTION
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Patellar tendinitis & patellofemoral
joint dysfunction pain most often
occur in:
A) 18 - 25 yo
B) 30 + yo
C) 50 + yo
D) 60 + yo
REVIEW
QUESTION
ANSWER
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Injury to
Collateral
Ligaments
40
Image Source: Ethos Health - 20 Oct 2016, http://www.ethoshealth.com.au/blog1/medial-lateral-collateral-ligament-injuries-mcl-and-lcl
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Primary stabilizer to valgus force.
Secondary stabilizer to Anterior translation.
Resist external rotation.
MCL and ACL have a codependent
relationship.
Medial Collateral / Tibial Collateral Ligament (MCL)Function
41
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History
• Classic Mechanism: Isolated Valgus moment to
knee.
PE
• Complete Knee Exam
• Examine MCL with the knee both in full
extension and at 30 degrees of flexion.
• Valgus Stress with knee at 30 degrees of flexion
causes pain or instability of medial knee.
MCLDiagnosis
42
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Collateral Ligament InjuryCommon Mechanism
43
Image Source: PHYSIO FIT ADELAIDEhttps://www.google.com/url?sa=i&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjIjLXd1cfcAhVRL6wKHTfdBAcQjRx6BAgBEAU&url=http%3A%2F%2Fwww.physiofitadelaide.com.au%2Fblog%2F3-ways-female-athletes-move-that-puts-them-at-greater-risk-of-sustaining-an-acl-injury-part- &1&psig=AOvVaw1cAS9m03H9aBSbTTJnzoud&ust=1533068900837384
And Amoczky et al. (1977)
External
rotation of
tibia
Medial rotation of femur
Valgus force
Varus force
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I - Stretching of fibers. Localized TTP. No instability.
II - Disruption of Fibers. Mild to moderate instability.
III - Complete disruption of ligament. Gross instability.
MCL InjuryGrading System
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X-Ray
• May demonstrate avulsions.
MRI
• Confirms Diagnosis
• Evals. other ligaments, cartilage.
Collateral LigamentImaging
45
Image Source Jordan Renner, Division of Radiologic Science at UNC-Chapel
MCL Avulsion
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The injured MCL heals predictably without repair regardless of its grade.
Non-op management of all MCL tears is considered standard practice.
Grade I and II Injuries
• Non-Surgical Treatment
• Crutches until symptoms improve, WBAT, ROM.
• Edema Control - Ice, Compression, Massage.
• NSAIDS
• Hinged knee brace
• Speeding Recovery
• Good control of swelling can decrease the amount of time for full recovery of motion and
strength.
Treatment of Isolated MCL Injury
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Grade III MCL
• Non-Surgical Rehab
• Brief period of immobilization
• Start ROM when initial swelling subsides.
• May need a longer period of protected weight bearing.
Persistent valgus instability
• May consider for early surgical reconstruction.
Treatment of Isolated MCL Injury
47
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Proximal MCL tears at the femoral insertion
more common than at the distal tibial insertion.
In general, femoral side injuries tend to heal
better than tibial side or midsubstance injuries.
Tibial End vs. Femoral End MCL Injury
48
Femur
Midsubstance
Tibia
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Usually do not require MCL reconstruction
Rehab the medial side and achieve full ROM then do ACL
reconstruction.
However, if valgus instability persists after rehab then
reconstruction of ACL and MCL should be considered.
ACL + MCL
49
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If significant posterior subluxation is present following
injury, both ligaments should be reconstructed acutely.
If the Joint is well reduced, can treat MCL non-surgically
with bracing. PCL can be reconstructed when full ROM is
achieved, and valgus stability is restored.
If valgus instability persists, reconstruct PCL and MCL.
PCL + MCL
50
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Chronic injury results when the MCL complex loses its potential for spontaneous healing.
Usually occurs 3 to 4 months following the initial injury.
Can develop secondary ligamentous instabilities or secondary limb malalignment.
Valgus deformity of limb secondary to chronic MCL
• Osteotomy may be required at time of MCL reconstruction.
Surgical Options
• POL Advancement
• Proximal Capsular Advancement
• Distal Capsular Advancement
• Semimembranosis advancement
• Allograft
Chronic MCL Injury
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Injuries to
Meniscus
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Load Bearing
Stability
Lubrication and nutrition
Protects articular cartilage underneath
meniscus
MeniscusFunction
53
Image Source: The Steadman Clinic https://www.thesteadmanclinic.com/patient-
education/knee/meniscus-injuries
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Meniscus InjuryCommon Mechanism
54
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Twisting/squatting activities
Swelling develops overnight
Associated with ligament injuries 20-60%
Mechanical symptoms of catching, clicking,
locking common
Meniscal InjuriesHistory
5565
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Repair to save meniscus function
Meniscus has poor blood supply
Tear has to be in “red zone”
Meniscal injuries:
56
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Older patient
• New injury vs degenerative tear over time
Treatment usually with partial meniscectomy
Rehabilitation depends on debridement vs
repair
Partial menisectomy
• 6wk - 3month recovery depending on repair vs
debridement
Meniscal Injuries:Treatment
57
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A longitudinal meniscal tear within
the red zone should be repaired via
A) Partial meniscectomy
B) Suture
C) Total meniscectomy
D) Removal of torn flap with burr
REVIEW
QUESTION
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A longitudinal meniscal tear within
the red zone should be repaired via
A) Partial meniscectomy
B) Suture
C) Total meniscectomy
D) Removal of torn flap with burr
REVIEW
QUESTION
ANSWER
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Knee
Dislocations
and
Fractures
60
Image Source: Gupta, et all., (2007)
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High association of injuries
• Ligamentous Injury
• ACL, PCL, Posterolateral Corner
• LCL, MCL
• Vascular Injury
• Intimal tear vs. Disruption
• Obtain ABI’s → (+) → Arteriogram
• Vascular surgery consult with repair within 8hrs
• Peroneal >> Tibial N. injury
Knee Dislocations
61
Image Source: Gopal, S. Knee Dislocations. Slide Share Presentation Aug 2, 2016. Retrieved from: https://www.slideshare.net/shyamgv/knee-dislocation-64627037
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History
• MVA, fall onto knee, eccentric loading
Physical Exam
• Ability to perform straight leg raise against gravity (ie,
extensor mechanism still intact?)
• Pain, swelling, contusions, lacerations and/or abrasions
at the site of injury
• Palpable defect
Patella Fractures
62
Image Source: Florian Gebhard, P. & Kregor, C.O.
Oliverhttps://surgeryreference.aofoundation.org/orthopedic-
trauma/adult-trauma/patella/further-reading/patient-
examination
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Direct Injury
• (Comminuted Patella fx)
Indirect Injury
• (Transverse Patella Fx)
Patella FracturesMechanism of Injury:
63
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Allows prediction of treatment
Transverse
Marginal
Vertical
Stellate
Comminuted
Osteochondral
Patella FracturesTypes
64
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Greater than 2mm articular displacement
Greater than 3mm fragment separation
Osteochondral fragment with displacement into joint
Operative TreatmentIndications for Surgery
65
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Surgical Treatment
1. Modified tension band wiring
2. Cerclage Wire
3. Patellectomy
Rehab
• 6 weeks in Knee Immobilizer or Cast
• Deskwork only x 6weeks
• PT x 3-4 months
• MMI at 3-4months
Patella FracturesTx & Rx
66
1.
2.
3
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Quadriceps Tendon Rupture
67
HX:
• Eccentric Injury to Knee
• usually patient over 40 y.o.
PE:
• Palpable Defect in tendon
• Unable to perform a straight leg raise.
TX:
• Direct repair to bone
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Quadriceps Tendon RuptureRehab
68
› Cylinder cast or Knee immobilizer
› Weight bearing as Tolerated
› Isometric exercises start around 6 weeks with
straight leg raises up to 45degrees of flexion
› 8-10 weeks increase ROM to Full
› MMI at 3-4 Months
Post-op Brace w/ ROM Lock
Straight Knee Imobilizer
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HX:
• Usually under 40 Y.O.
• Eccentric Contraction to Knee
PE:
• Unable to Perform Straight Leg raise
TX:
• Surgery - Repair Tendon to Bone
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Isometric Hamstring and Quadriceps exercises begun immediately
TTWB first 2-3 weeks
At 2-3 WEEKS active flexion and passive extension started initiated
6 weeks WBAT, resistance exercises initiated
Delay competitive sports 4-6 months post op
MMI 4 months
Patellar Tendon RupturePost Op Rehab
70
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20-30 y/o
female
Valgus Load / Flexed/Externally Rotated Knee
Dislocations occur at 60-70 flexion
Lateral >>> Medial
Patellar Dislocation
71
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Non-Operative- 2 schools
• Immobilization and Rehab
• 6 weeks strict Immobilization in cylinder cast/Immobilizer
• Aggressive PT to regain motion/strength
• Recurrent instability--40-50%
• Functional Treatment
• Early ROM with patellar bracing
• Better patient scores, less instability (26%)
Patellar DislocationsTx
72
Image Source: van Gemert, et al. (2012)
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Operative Treatment: Rare
Acute
• Repair of the MPFL
• (Repair of the femoral attachment)
Chronic
• Lateral Retinacular Release
• Proximal vs Distal Realignment
• Rehab : 3-4 Months
Patellar DislocationsTx
73
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History:
• Age and mechanism extremely important
• Split or wedge fractures in younger patients with stiffer bone
• Depression fractures- older/weaker bone
Associated injuries
• Ipsilateral femoral and tibial fractures
• Cruciate and collateral ligament injuries
• Meniscal tears
• 50% of plateau fractures have meniscus
• Avulsions of intercondylar eminence
Tibial Plateau Fx
74
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XRAY
CT SCAN
?MRI
Tibial Plateau FxDx
75
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Goals
Restore joint congruity
• Maintain limb alignment
• Allow early stable knee
motion
Tibial Plateau Fx
76
Non-operative treatment
Non-displaced fractures
Minimally displaced lateral plateau fractures
Advanced osteoporosis
Goal not anatomic reduction but restoration of axial alignment and knee motion
No more than 7 degrees malalignment
No varus/valgus instability greater than 5 to 10 degrees
Fractures with less than 3mm articular displacement
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Absolute indication for surgery
Open plateau fractures
Fractures associated with
compartment syndrome
Most displaced bicondylar
Fx Displaced medial
condylar Fx
Lateral plateau fractures with
joint instability
Tibial Plateau Fx
77
Post-Op Rehab
Non WB x 6 Weeks
Rehab for ROM – 0-6
weeks
WBAT at 6 weeks
Strengthening at 2-3
Months
MMI at 4-6 Months
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Lower extremity injuries most common
Incidence of total knee inj. decreasing. However, % sprains/strains, tears remains
constant
Patellofemoral symptoms treated conservatively if at all possible
Tendon ruptures, grade II ACL/ PCL tears, meniscal tears & patellar fx are
treated surgically
Isolated MCL tears are treated conservatively
Tibial plateau fx conservative or surgical
In Summary
78
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Diagnosis
• Orthopedic special tests for initial diagnosis
• X-ray to diagnose associated boney injury
• MRI to confirm diagnosis
MMI
• Fx: 4-6 months
• Ligament: 6-12 months
• Meniscus: 6wks – 3 months
In Summary
79
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QUESTIONS ?
80
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In the Corporate/Industrial Setting Athletic Trainers:
• possess confidant evaluation skills, and an understanding of orthopedic
protocols for acute, chronic and post surgical rehabilitation.
• perform an ergonomic assessment of both static and dynamic activities, establish
functional capacity exam standards
• fit employees with proper personal protective equipment (PPE),
• develop a line of communication when dealing with an employee incident
• develop and record an accurate assessment of job duties & instruct employees in
proper task performance
• understand established safety issues and OSHA guidelines
• professionally research topics, create a presentation and present material to
pertinent parties
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Alpert, J.M. (January 13, 2010) Work Related Knee Injury: Evaluation and Treatment Online Presentation
Arnoczky SP, Torzilli PA, Marshall JL. (1977). Evaluation of anterior cruciate ligament repair in the dog: An analysis of the instant center of motion. J Am Anim Hops Assoc
13:553-558
BLS Case and Demographic Characteristics for Work-related Injuries and Illnesses Involving Days Away From Work Calendar Year 2016 Survey Results Retrieved from
https://www.bls.gov/iif/oshcdnew2016.htm
Clancy WG, et al.. (1983). Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. JBJS.;65A:310–322.
Claude T. Moorman, III, Udita Kukreti, David C. Fenton and Stephen M. Belkoff. (1999;) The Early Effect of Ibuprofen on the Mechanical Properties of Healing Medial Collateral
Ligament, Sports Med. 27; 738.
Evans J, Nielson Jl. Anterior Cruciate Ligament Knee Injuries. [Updated 2021 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499848/
Fowler, P. & Williams, D. (1987). The patient with symptomatic chronic anterior cruciate ligament insufficiency: Results of minimal arthroscopic surgery and rehabilitation
AJSM15 321-325;
Gaitonde, DY, Ericksen, A and Robbins RC (2019). Patellofemoral pain syndrome. American Family Physician; 99 (2), 88-94. Retrieved from:
https://www.aafp.org/afp/2019/0115/afp20190115p88.pdf
Geissler, W. & Whipple, T. (1993). Intraarticular abnormalities in association with posterior cruciate ligament injuries, AJSM, 21 846-849;
Gentili, A.., & Chew, F.Tibial Plateau Fracture Imaging . Medscape Reference. Updated: May 25, 2011 Retrieved from http://emedicine.medscape.com/article/396920-overview
Gupta, S. Fazal, MA, Haddad F., (2007). Traumatic anterior knee dislocation and tibial shaft fracture: a case report. Journal of Orthopaedic Surgery;15(1):81-3 Rettrieved from:
https://pdfs.semanticscholar.org/282d/cc6a51be4a4843e859a76b05bfd9c55f88a0.pdf?_ga=2.157939962.1597098169.1533000905-1364711579.1533000905
References
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