Current Issues in Sports Medicine: The Knee Rob Naber, P.T., O.C.S., A.T.,C. Copyright © 2006 Physical Therapy of Los Gato...
The Knee in Sports Medicine
The Knee in Sports Medicine
Current challenges in Sports Medicine <ul><li>Anterior Knee pain </li></ul><ul><li>Anterior cruciate ligament tears in fem...
Etiology <ul><li>Unknown </li></ul><ul><li>Debated Frequently </li></ul><ul><li>Two theories:  </li></ul><ul><ul><ul><li>C...
Optimal Knee Mechanics <ul><li>Patellofemoral articular cartilage thickest in the body </li></ul><ul><li>Allows almost fri...
Chondromalacia <ul><li>Softening and degradation of retropatellar cartilage </li></ul><ul><li>Degraded cartilage results i...
Chondromalacia Evidence <ul><li>Rehabilitation has not been shown to provide long term relief. </li></ul><ul><li>Scott Dye...
Malalignment <ul><li>The patella is somehow skewed or is located too far to one side within the femoral trochlea, causing ...
Treatment for Malalignment <ul><li>Tape applied to the skin to hold the patella in a corrected position. </li></ul><ul><li...
Treatment for Malalignment <ul><li>Specific and selective muscle training exercises aimed at changing the position of the ...
Malalignment Evidence <ul><li>Malalignment does not predict whether an individual will experience anterior knee pain. </li...
Therefore: <ul><li>Neither Chondromalacia nor Malalignment are sufficient to cause anterior knee pain alone. </li></ul><ul...
Quadriceps Function <ul><li>Primary function according to the anatomy texts is extension of the knee. </li></ul><ul><li>In...
Evidence for Eccentric Training <ul><li>Bennet and Stauber 1986. </li></ul><ul><li>Observed the ratio of eccentric quadric...
Eccentric Training <ul><li>KIN-COM Training </li></ul><ul><li>Decreased motor unit recruitment with eccentric contraction....
Eccentric Torque Curve Pre-treatment Post-treatment
Eccentric Training in the Clinic <ul><li>Easily accomplished without expensive computer dynamometers. </li></ul><ul><li>Th...
Eccentric Training in the Clinic
Patellofemoral Contact <ul><li>Patellofemoral contact area changes </li></ul><ul><li>Increases in area with flexion </li><...
Patellofemoral Contact
Patellofemoral Contact Moves Proximal with Flexion
Patellofemoral Compression as Provocation Test
When Compression is Painful <ul><li>Consider the specific location of athletes pain: Patella or Femur </li></ul><ul><li>Pr...
Conclusion <ul><li>Anterior knee pain arises from multiple causes </li></ul><ul><li>Multi-pronged rehabilitation strategie...
Anterior Cruciate Ligament Tears in Female Athletes
Anterior Cruciate Ligament Tears- The Problem <ul><li>One of 10 female athletes will suffer an ACL injury </li></ul><ul><l...
ACL Anatomy <ul><li>One of four of major ligaments in the knee. </li></ul><ul><li>ACL intersects all three planes and prov...
ACL anatomy
Hypotheses to Gender Differences of ACL Tears <ul><li>Hormones cause ligament laxity </li></ul><ul><li>Smaller intercondyl...
Differences in Lower Extremity Strength and Neuromuscular Control <ul><li>Hewett,  et al.  showed female athletes with gre...
Implication for Rehabilitation <ul><li>Muscular strength stabilizes knee </li></ul><ul><li>Muscular attachments to ligamen...
Creating Rehabilitation Program <ul><li>Consider mechanism of injury </li></ul><ul><li>Reactivity of patient’s symptoms </...
Ligament Healing <ul><li>Inflammatory Phase- Day 0-3 hematoma and inflammation seen; macrophages clear necrotic tissue </l...
Jump Strength Training Program <ul><li>Based on Hewett’s successful program. </li></ul><ul><li>Element of ACL reconstructi...
Neuromuscular Training <ul><li>Includes visual, auditory and proprioceptive facilitation to give the athlete the tools to ...
Conclusion <ul><li>ACL tears are significant in all athletes  </li></ul><ul><li>Lack of neuromuscular control is a risk fa...
www.PTofLosGatos.com (408) 358-6505
Upcoming SlideShare
Loading in …5
×

Current Issues in Sports Medicine: The Knee

6,233 views
5,962 views

Published on

Visuals from presentation delivered by Rob Naber, PT, OCS, AT,C at the Spring 2006 West Valley College Sports Medicine Symposium

Published in: Health & Medicine, Sports
1 Comment
17 Likes
Statistics
Notes
No Downloads
Views
Total views
6,233
On SlideShare
0
From Embeds
0
Number of Embeds
152
Actions
Shares
0
Downloads
0
Comments
1
Likes
17
Embeds 0
No embeds

No notes for slide

Current Issues in Sports Medicine: The Knee

  1. 1. Current Issues in Sports Medicine: The Knee Rob Naber, P.T., O.C.S., A.T.,C. Copyright © 2006 Physical Therapy of Los Gatos. All rights reserved.
  2. 2. The Knee in Sports Medicine
  3. 3. The Knee in Sports Medicine
  4. 4. Current challenges in Sports Medicine <ul><li>Anterior Knee pain </li></ul><ul><li>Anterior cruciate ligament tears in female athletes </li></ul>
  5. 5. Etiology <ul><li>Unknown </li></ul><ul><li>Debated Frequently </li></ul><ul><li>Two theories: </li></ul><ul><ul><ul><li>Chondromalacia </li></ul></ul></ul><ul><ul><ul><li>Malalignment of patella and femur </li></ul></ul></ul>
  6. 6. Optimal Knee Mechanics <ul><li>Patellofemoral articular cartilage thickest in the body </li></ul><ul><li>Allows almost friction free motion between patella and femur </li></ul>
  7. 7. Chondromalacia <ul><li>Softening and degradation of retropatellar cartilage </li></ul><ul><li>Degraded cartilage results in increased friction and shear forces </li></ul><ul><li>Physical Therapy is directed at improving strength of the quadriceps in positions that minimize compression of patellofemoral joint </li></ul>
  8. 8. Chondromalacia Evidence <ul><li>Rehabilitation has not been shown to provide long term relief. </li></ul><ul><li>Scott Dye, MD, probed his own knee without anesthesia, and discovered no sensation in the cartilage of his diseased articular cartilage. </li></ul><ul><li>Presence or absence of chondromalacia does not predict knee pain. </li></ul>
  9. 9. Malalignment <ul><li>The patella is somehow skewed or is located too far to one side within the femoral trochlea, causing excessive compression and pain. </li></ul>
  10. 10. Treatment for Malalignment <ul><li>Tape applied to the skin to hold the patella in a corrected position. </li></ul><ul><li>Braces to correct patellar position </li></ul>
  11. 11. Treatment for Malalignment <ul><li>Specific and selective muscle training exercises aimed at changing the position of the patella. </li></ul><ul><li>Specific muscle training exercises aimed at changing the position of the femur. </li></ul><ul><li>The Track and the Train Theory </li></ul>
  12. 12. Malalignment Evidence <ul><li>Malalignment does not predict whether an individual will experience anterior knee pain. </li></ul><ul><li>Evidence to support long-term benefits of non-surgical treatments for patellar alignment is limited and inconclusive. </li></ul>
  13. 13. Therefore: <ul><li>Neither Chondromalacia nor Malalignment are sufficient to cause anterior knee pain alone. </li></ul><ul><li>Suggest a plurality of causes </li></ul><ul><ul><li>Chondromalacia </li></ul></ul><ul><ul><li>Malalignment </li></ul></ul><ul><ul><li>Quadriceps eccentric strength deficits </li></ul></ul>
  14. 14. Quadriceps Function <ul><li>Primary function according to the anatomy texts is extension of the knee. </li></ul><ul><li>In standing and walking, the quadriceps work eccentrically to control knee flexion. </li></ul>
  15. 15. Evidence for Eccentric Training <ul><li>Bennet and Stauber 1986. </li></ul><ul><li>Observed the ratio of eccentric quadriceps torque to concentric torque was not normal in group with anterior knee pain. </li></ul><ul><li>Expected eccentric torque 130%-300% of concentric torque, but those in study were deficient. </li></ul><ul><li>Most patients’ pain was relieved with eccentric training of the quadriceps within 2- 4 weeks. </li></ul>
  16. 16. Eccentric Training <ul><li>KIN-COM Training </li></ul><ul><li>Decreased motor unit recruitment with eccentric contraction. </li></ul>
  17. 17. Eccentric Torque Curve Pre-treatment Post-treatment
  18. 18. Eccentric Training in the Clinic <ul><li>Easily accomplished without expensive computer dynamometers. </li></ul><ul><li>The resistance needed can be generated through the use of gravity and therapist’s resistance. </li></ul>
  19. 19. Eccentric Training in the Clinic
  20. 20. Patellofemoral Contact <ul><li>Patellofemoral contact area changes </li></ul><ul><li>Increases in area with flexion </li></ul><ul><li>Moves from distal to proximal with flexion </li></ul>
  21. 21. Patellofemoral Contact
  22. 22. Patellofemoral Contact Moves Proximal with Flexion
  23. 23. Patellofemoral Compression as Provocation Test
  24. 24. When Compression is Painful <ul><li>Consider the specific location of athletes pain: Patella or Femur </li></ul><ul><li>Protect the patellar contact during strengthening phase </li></ul><ul><li>Use appropriate open vs. closed chain strengthening exercises </li></ul>
  25. 25. Conclusion <ul><li>Anterior knee pain arises from multiple causes </li></ul><ul><li>Multi-pronged rehabilitation strategies offer the greatest likelihood of returning patients and athletes to their pre-symptom state. </li></ul>
  26. 26. Anterior Cruciate Ligament Tears in Female Athletes
  27. 27. Anterior Cruciate Ligament Tears- The Problem <ul><li>One of 10 female athletes will suffer an ACL injury </li></ul><ul><li>10,000 knee injuries per year </li></ul><ul><li>Rate of knee injury in female athletes is 3.7 times greater than males. </li></ul>
  28. 28. ACL Anatomy <ul><li>One of four of major ligaments in the knee. </li></ul><ul><li>ACL intersects all three planes and provides stability in all three planes. </li></ul><ul><li>Controls femoral roll and slide on tibia </li></ul>
  29. 29. ACL anatomy
  30. 30. Hypotheses to Gender Differences of ACL Tears <ul><li>Hormones cause ligament laxity </li></ul><ul><li>Smaller intercondylar notch size </li></ul><ul><li>Differences in lower extremity strength and neuromuscular control </li></ul>
  31. 31. Differences in Lower Extremity Strength and Neuromuscular Control <ul><li>Hewett, et al. showed female athletes with greater valgus alignment during jumping and landing are more likely to suffer an ACL injury. </li></ul><ul><li>Noyes demonstrated male and female athletes had similar excessive valgus alignment. </li></ul><ul><li>Female athletes have weaker hamstrings </li></ul><ul><li>A 6-week training program could correct the valgus alignment. </li></ul>Hewett TE, et al. Am J Sports Medicine 2005;33(4):492-501 Noyes, et al. Am J Sports Medicine 2005; 33(2):197-207
  32. 32. Implication for Rehabilitation <ul><li>Muscular strength stabilizes knee </li></ul><ul><li>Muscular attachments to ligament, tightens ligament upon contraction. </li></ul><ul><li>Include training to avoid valgus loading. </li></ul><ul><li>It is no longer acceptable to reconstruct the ACL but leave neuromuscular control deficient. </li></ul>
  33. 33. Creating Rehabilitation Program <ul><li>Consider mechanism of injury </li></ul><ul><li>Reactivity of patient’s symptoms </li></ul><ul><li>Stage of healing </li></ul><ul><li>Match appropriate treatment and dosage. </li></ul>
  34. 34. Ligament Healing <ul><li>Inflammatory Phase- Day 0-3 hematoma and inflammation seen; macrophages clear necrotic tissue </li></ul><ul><li>Reparative Phase- Day 3 fibroblasts lie down scar tissue; Day 14 fibroblasts predominant and vascular network forming. </li></ul><ul><li>Remodeling Phase- 12 months or more, ligament strength 50-75% of control. </li></ul>
  35. 35. Jump Strength Training Program <ul><li>Based on Hewett’s successful program. </li></ul><ul><li>Element of ACL reconstruction rehabilitation </li></ul><ul><li>Stand alone performance improvement module </li></ul><ul><li>Includes jump analysis, education, strength training and neuromuscular training. </li></ul>
  36. 36. Neuromuscular Training <ul><li>Includes visual, auditory and proprioceptive facilitation to give the athlete the tools to correct faulty lower extremity alignment during jumping, landing and pivoting and use their muscles to absorb impact. </li></ul>
  37. 37. Conclusion <ul><li>ACL tears are significant in all athletes </li></ul><ul><li>Lack of neuromuscular control is a risk factor for injuries to the ACL, especially in female athletes </li></ul><ul><li>Male and Female athletes demonstrate excessive valgus alignment </li></ul><ul><li>Young athletes can learn to gain this control. </li></ul>
  38. 38. www.PTofLosGatos.com (408) 358-6505

×