Chapter 10: The Knee
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Transcript of Chapter 10: The Knee
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Chapter 10:The Knee
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Anatomy
• The bones that comprise the knee joint:
• Tibia• Fibula• Femur• Patella
• There are two joints in the knee:
• Tibiofemoral joint• Patellafemoral joint
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Anatomy
• The medial and lateral meniscus rest between the femur and tibia.
• They are responsible for shock absorption, improved bony correlation, joint lubrication, improved weight distribution, and decreased friction.
• The patella guides the quadriceps, decreases friction during movement, and protects the femoral condyles.
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Anatomy of the Knee• Knee is a hinge joint• Articulation (point of
contact)– Consists of 3 bones
• Stabilized by– Four major ligaments– Cartilage– Strong musculature
• Knee is able to rotate
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Cartilage• Ends of the tibia and femur
– Covered/cushioned by• Pieces of tough cartilage tissue• Called menisci
– Help to stabilize the knee joint– Without bones would rub & wear down quickly
• Top of tibia– Flat like a tabletop
• End of femur– Rounded (called condyles)– Without stabilization, femur would move a lot on the
tibia
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Cartilage-Menisci• Lateral & Medial
– Thicker on sides– Thinner in the middle– Form a dish-shaped
hollow– Attached to the top of
the tibia– Provide a seat for the
femoral condyles to sit in
– Femur moves but will not roll off
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Ligaments• 4 primary knee ligaments
– Medial collateral (MCL)• Helps provide stability to inside of
knee– Lateral collateral (LCL)
• Helps provide stability to outside of knee
– Anterior cruciate ligament (ACL)• Keeps tibia from moving forward on
the femur– Posterior cruciate ligament (PCL)
• Prevents tibia from moving backward on the femur
• ACL & PCL– pass through the middle of the knee
joint– Cross each other (i.e cruciate
means “cross-shaped”)
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Ligaments of the Knee
• Anterior cruciate ligament (ACL)
• Posterior cruciate ligament (PCL)
• Medial collateral ligament (MCL)
• Lateral collateral ligament (LCL)
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Anatomy• Muscles of the Knee
• Quadriceps muscles• Responsible for knee extension
• Hamstring muscles• Responsible for knee flexion
• Calf muscles• Assist in knee flexion
• Other muscles that act at the knee• Sartorius• Popliteus• Plantaris• Gracilis
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Muscles of the Knee• Provide
– Movement– Stability
• Primary muscles spanning the knee– Quadriceps group (perform knee extension)
• Vastus medialis, vastus lateralis, vastus intermedius & rectus femoris
– Hamstring group (perform knee flexion)• Biceps femoris, semimembranosus & semitendinosus• Help prevent forward movement of the tibia on the
femur– By the location of their attachments
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Primary Muscles Spanning the Knee
• Quadriceps group– Vastus medialis, vastus
lateralis, vastus intermedius & rectus femoris
– Perform knee extension
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Primary Muscles Spanning the Knee
• Hamstring group– Biceps femoris,
semimembranosus & semitendinosus
– Perform knee flexion
– Help prevent forward movement of the tibia on the femur• By the location of
their attachments
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Knee Alignment Concerns
• Genu valgum (knock-knees)• Genu varum (bow legs)• Genu recurvatum (hyperextension)• Q-angle
– Greater than 20 increases risk for injury• Leg length discrepancy
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Preventing Knee Injuries• Ligament sprains
– Most common injuries seen at the knee– Muscles provide stability to the knee
• Help resist abnormal bony movement• Athletes should develop strength in the muscles
(quads, hams, gastrocnemius/calf, hip abductors & hip adductors)
– Gastrocnemius-heel raises
– Some trainers & athletes use preventative knee braces• Designed to protect medial collateral ligament
– Tearing can result from a blow to the lateral side
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Treating Knee Injuries & Conditions
• Knee is exposed to many forces• Makes it vulnerable to injuries
– Especially the ligaments• Tendon & bone injuries also occur• Patella & menisci are subject to
unique types of athletics-related injuries
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Ligament Injuries
• Ligament sprains of the knee– Can be
• Mild• Moderate• Severe
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Injuries of the Knee
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Patellar Fracture
• Signs & Symptoms:• Pain directly over bone • Slight to moderate swelling • Pain, especially in the first 30º of
movement• Treatment:
• Immobilize and refer to a physician for x-rays
• Requires lengthy immobilization during recovery
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Patellar Dislocation • Signs & Symptoms:
• Moderate to extreme pain • Moderate swelling • Complete loss of ROM in knee • Obvious deformity laterally
• Treatment:• Refer to physician for reduction• RICE therapy• Progressive strengthening
program
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Patella Dislocation• Patella forced to lateral
aspect of the knee• Often occurs when the knee
is bent and forced to twist inward
• Signs & symptoms– Obvious deformity– Athlete is often in distress
• EMS must be called– Unless team physician is
present• only a physician should
reduce a dislocated patella– Complications may result– Posterior aspect of patella
may be injured further
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OUCH!!!!!!!!!
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Patella-Femoral Stress Syndrome
• Signs & Symptoms: • Pain and tenderness in lateral aspect
of patella • Slight swelling • Crepitus or popping with extension
• Treatment:• RICE therapy• Closed kinetic chain exercises 0-40
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Patellar Femoral Syndrome• Fancy name for a set of
symptoms that include pain/discomfort around patella
• Often caused by patellar tracking problems– Knee bends– Patella is grated across the
femur– Causing cartilage on back of
patella to soften or wear away
– Known as chondromalacia
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Chondromalacia
• Signs & Symptoms:• Pain underneath the patella • Grinding or popping during motion • Slight chronic swelling
• Special Tests: Clarke’s Sign
• Treatment:• RICE Therapy• Quadriceps strengthening
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Patellar Femoral SyndromeChondromalacia
• Characterized by achiness around the patella– Especially with prolonged
sitting in the same position
• Athlete reports a grinding sensation with flexion/extension– Grinding can be felt by
placing hand over knee
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Patella Injuries (Chondromalacia)
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Osgood-Schlatter’s Disease
• Signs & Symptoms:• Pain at insertion of patella tendon• Tenderness to palpation • Enlarged tibial tuberosity • Pain with jumping or running
• Treatment:• RICE therapy• Decrease activity or cross-train
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Osgood-Schlatter Disorder• Irritation at the site of
the patellar tendon attachment– To front of the tibia
• Called tibial turberosity• Repeated stress
causes the patellar tendon to partially pull away from the bone– Called Osgood-
Schlatter’s disorder
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Osgood-Schlatter Disorder• Signs & symptoms
– Discomfort of the knee• Swelling• Tenderness• Pain during activity• Possible bump below knee cap (bony growth at the top of the tibia)
– Can remain even after symptoms have disappeared• Care
– Restrict activity until resolved– Stationary bicycling– Use pain as a guide
• Modify activities based on pain level reported by athlete– Ice before & after activity– Special pad made to fit over front of tibia
• Often improves by age 16 or 17 (but known to last into early 20’s)
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Patellar Tendinitis • Signs & Symptoms:
• Pain in patella tendon or at inferior pole of patella
• Pain increases with activity • Squeaking noise with motion• Slight swelling
• Treatment:• Modality treatment • Ice or ice massage• Ultrasound
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Muscle & Tendon Injuries• Patellar tendinitis
– Overuse disorder• Characterized by quadriceps weakness• Tenderness over the patellar tendon• Minimal swelling
– Condition is also called jumper's knee• Athletes that do lots of jumping often get this condition
(basketball, volleyball)– Early stages
• Athlete typically has pain after activity– Treatment
• Trainer attempts to control inflammation– Apply ice– Modify athlete’s activity level
» Restricting running & jumping– Rehabilitation program
• Address any flexibility problems or weakness of the leg
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Patella Tendon Rupture
• Signs & Symptoms: • Extreme pain with an immediate drop
in pain • Significant swelling • Window shade effect• Complete loss of knee extension • Previous history of chronic tendinitis
• Treatment:• Surgical repair is the only treatment
option• 6-8 months minimum recovery
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Ruptured Patella Tendon
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Knee Dislocation• Signs & Symptoms:
• Immediate pain that may decrease dramatically
• Obvious deformity (usually anteriorly)• Significant swelling• Decreased blood flow and neural
sensation • Treatment:
• Splinted and transported to hospital immediately
• Surgical intervention is often required for neurovascular and ligament repair
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Knee Contusion
• Signs & Symptoms: • Pain at affected site • Moderate swelling and discoloration • Loss of ROM • Decreased weight bearing
• Treatment:• RICE therapy
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Patella Injuries (Bursitis)
Prepatellar bursitis is the inflammation of a small sac of fluid located in front of the kneecap. This inflammation can cause many problems in the knee.
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Causes Bursitis is the
inflammation of a bursa. The prepatellar bursa can become irritated and inflamed in a number of ways.A direct blow or a fall onto the knee can damage the bursa.
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Meniscus Contusion
• Signs & Symptoms: • Pain, especially at full extension• Loss of ROM in extension • Slight swelling
• Treatment:• RICE therapy
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Meniscus Tears
• Signs & Symptoms: • Pain, especially when moved similarly
to the mechanism of injury• Pain with full extension or flexion • Diffuse swelling in the joint (effusion) • Pain along the line of the joint • Sensation of locking or giving out • Clicking or popping sound with
movement
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Meniscal InjuriesMeniscal injuries damage the cushioning tissue between the tibia and the femur, inside the knee joint, on both sides (medial and lateral) of the knee.
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Causes They are highly
vulnerable to injury from abrupt rotations of the knee while it is bearing weight, for example, when you turn to hit a tennis ball, rotating your thigh (femur) while leaving your foot stationary.
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Types of Meniscal Tears
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MRI Torn Medial Meniscus
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Arthroscopic Repair
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Posterior horn tear with multiple flaps
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Meniscus Tears
• Special Tests:• McMurray’s Test• Apley’s Compression Test • Bounce Home Test
• Treatment:• Referral to a physician • Surgery is often required for full
recovery.• RTP depends on surgical option
selected.
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ACL Sprain
• Signs & Symptoms: • Pain in the joint • Athlete hears ‘pop’ at time of injury • Sense of looseness in joint, giving
away, or shifting• Swelling that increases rapidly post-
injury
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Anterior Cruciate Ligament Injuries• Keeps tibia from moving
forward on the femur• If ligament is injured
– Athlete is often disabled– Complaining of the knee
“giving away”, collapsing & popping
• Most serious of all knee ligament injuries
• Most frequently surgically reconstructed
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Anterior Cruciate Ligament Injuries• Often injured as the
athlete is attempting to change directions quickly– Twists the lower leg– May hear a popping
sound during the twisting• Also injured during
excessive hyperextension
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Anterior Cruciate Ligament Injuries• Signs & symptoms
– Rapid swelling– Loss of knee function
• Immediate treatment– PRICE– Knee immobilizer– Crutches
• Follow up with an orthopedist is necessary
• Athlete rarely can continue a high level of function with a torn ACL
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Anterior Cruciate Ligament Injuries
• Often needs to be surgically reconstructed– Determination that must be
made by the athlete, surgeon & athlete’s family
– Depends on the amount of instability that exists
– Level of function desired by the athlete
– Age of the athlete
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Anterior Cruciate Ligament InjuriesKnee Arthroscopy
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Anterior Cruciate Ligament InjuriesKnee Arthroscopy
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ACL has poor healing potentialPCL has intermediate healing potentialMCL heals on its own
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Bone Tendon Bone
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Patella Tendon Graft
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Anterior Cruciate Ligament InjuriesRehabilitation
• Focuses on strengthening the hamstrings– Helps stabilize the tibia– Helps regain full function– Even with aggressive ACL rehab
• May be six months before athlete can return to participation
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ACL Sprain, cont.• Special Tests:
• Anterior Drawer Test• Lachman’s Test• Pivot Shift Test
• Treatment:• Grade 1 or 2 may be treated conservatively.• Grade 3 tear will require surgery.
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PCL Sprain • Signs & Symptoms:
• Pain in posterior aspect of knee • Slight swelling • Joint laxity • Loose feeling with walking
• Special Tests:• Posterior Sag Test• Posterior Drawer Test
• Treatment:• Grade 1 or 2 may be treated
conservatively• Grade 3 tear will require surgery
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Posterior Cruciate Ligament Injuries
• Prevents posterior tibial movement on the femur
• Frequently injured when– athlete falls and a bent
knee bears full weight– Knee is forcefully
hyperflexed– Blow delivered to the
front of the tibia
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Posterior Cruciate Ligament Injuries• Assessment
– Trainer determines mechanism of injury– Athlete reports having heard a pop– Often little swelling with PCL injury
• Initial treatment– PRICE– Referral to a physician
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Posterior Cruciate Ligament Injuries
• Physicians disagree about whether or not surgery should be performed on a severe PCL injury– Even complete PCL tears can be rehabilitated without
surgery• Rehabilitation programs for mild/moderate PCL
sprains– Focus on strengthening the quadriceps– Regaining full function
• Many athletes can become functional again– After initial pain & swelling are controlled– After knee is strengthened
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MCL Sprain
• Signs & Symptoms: • Pain increasing with severity • Joint stiffness • Slight to moderate swelling • Decreased ROM • Joint laxity medially
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Medial CollateralLigament Sprains
• Frequently injured when an athlete receives a blow to the outside of the knee– Causes knee to bend inward
(valgus stress)– Stresses the MCL
• Mild sprain– Medial joint line pain– Little if any swelling– No joint laxity when stressed
by trainer during assessment– Full knee flexion & extension
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Medial Collateral Ligament Sprains• Moderate MCL sprain
– Mild swelling– Discomfort– Some joint laxity when
stressed by the trainer during assessment
• Severe MCL injury– Moderate or severe amount
of swelling– Loss of function– Great deal of joint laxity
when stressed by the trainer during assessment
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Medial Collateral Ligament Sprains• Treated with PRICE• Mild injury
– Elastic wrap for compression/support
• Moderate/severe injury– Knee put in an immobilizer– Trainer should consider
possibility of damage to the menisci or an ACL injury
• Rehabilitation– Focuses on strengthening
the muscles that cross the medial aspect of the knee
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MCL Sprain, Cont.
• Special Tests:• Valgus Stress Test• Apley’s Distraction Test
• Treatment:• RICE Therapy• Immobilization• Progressive strengthening program
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LCL Sprain
• Signs & Symptoms:• Pain over lateral aspect of knee • Slight to moderate swelling • Joint laxity laterally • Joint stiffness • Decreased ROM
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Lateral Collateral Ligament Injuries• Occur less frequently than MCL
injuries• Signs & symptoms are similar to MCL
– Except discomfort is at the lateral aspect of the knee
• Treatment– Same as MCL
• Rehabilitation (regaining joint stability)– Strengthening exercises focus on the
lateral thigh muscles & hamstrings
![Page 79: Chapter 10: The Knee](https://reader036.fdocuments.in/reader036/viewer/2022062501/568166e3550346895ddb19dc/html5/thumbnails/79.jpg)
LCL Sprain, cont.
• Special Tests:• Varus Stress Test• Apley’s Distraction Test
• Treatment:• RICE Therapy• Immobilization• Progressive strengthening program
![Page 80: Chapter 10: The Knee](https://reader036.fdocuments.in/reader036/viewer/2022062501/568166e3550346895ddb19dc/html5/thumbnails/80.jpg)
Discussion Questions
• What would be your response to an athlete who wants to play with an ACL tear?
• How would you react on the field if an athlete dislocated their knee?