Kin191 A.Ch.6.Knee.Patellofemoral.Injuries


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Kin191 A.Ch.6.Knee.Patellofemoral.Injuries

  1. 1. KIN 191A Advanced Assessment of Lower Extremity Injuries KNEE /PATELLOFEMORALARTICULATION INJURIES
  2. 2. INTRODUCTION <ul><li>LIGAMENTOUS INJURIES </li></ul><ul><ul><li>MCL/LCL/ACL/PCL </li></ul></ul><ul><ul><li>ROTATIONAL INSTABILITIES </li></ul></ul><ul><li>MENISCAL INJURIES </li></ul><ul><li>OSTEOCHONDRAL DEFECTS </li></ul><ul><li>ILIOTIBIAL BAND FRICTION SYNDROME </li></ul><ul><li>POPLITEUS TENDINITIS </li></ul><ul><li>PATELLOFEMROAL PAIN SYDNEROME </li></ul><ul><li>PATELLAR MALTRACKING </li></ul>
  4. 4. LIGAMENTOUS INJURIES <ul><li>Single Plane Injuries </li></ul><ul><ul><li>MCL </li></ul></ul><ul><ul><li>LCL </li></ul></ul><ul><ul><li>ACL </li></ul></ul><ul><ul><li>PCL </li></ul></ul><ul><li>Rotational Instabilities (Multiplanar) </li></ul><ul><ul><li>ALRI, AMRI, PLRI, PMRI </li></ul></ul>
  5. 5. Medial Collateral Ligament Injuries <ul><li>Most common MOI is blow to lateral knee with resulting valgus tension forces </li></ul><ul><li>May also be injured by non-contact and/or rotational stresses </li></ul><ul><li>When knee at 0˚ – MCL, AM/PM joint capsule and pes anserine tendons resist valgus force </li></ul><ul><li>When knee at 20-30˚, MCL is primary restraint to valgus force </li></ul>
  6. 6. MCL Injury
  7. 7. <ul><li>With MCL injury, must also consider medial joint capsule, medial meniscus and if rotational forces, ACL/PCL </li></ul><ul><li>Most MCL injuries managed non-operatively – has good blood supply </li></ul><ul><li>Must be cautious of joint position (ROM) during healing to create optimal environment – bracing/immobilization </li></ul>
  8. 8. Lateral Collateral Ligament Injuries <ul><li>Most common MOI is blow to medial knee with resulting varus tension forces </li></ul><ul><li>Internal rotation of tibia may be secondary contributor to LCL injury </li></ul><ul><li>Must consider lateral joint capsule and cruciate ligament injury pending MOI </li></ul><ul><li>Must rule out peroneal nerve injury </li></ul><ul><li>Has poor blood supply – doesn’t heal well and may need surgical repair </li></ul>
  9. 9. LCL Injury
  10. 10. Anterior Cruciate Ligament Injuries <ul><li>Most MOI are non-contact rotational forces </li></ul><ul><li>Tibia displaced anteriorly on femus (or vice versa), rotational stress (cutting) or hyperextension </li></ul><ul><li>May be isolated, but typically due to MOI, other structures (joint capsule, menisci) also injured </li></ul>
  11. 11. ACL Injury
  12. 12. Predisposing Risk Factors <ul><li>Extrinsic factors </li></ul><ul><ul><li>Sport-specific activities </li></ul></ul><ul><ul><li>Muscle strength </li></ul></ul><ul><ul><li>Coordination </li></ul></ul><ul><ul><li>Athletic skill </li></ul></ul><ul><ul><li>Shoe/surface </li></ul></ul><ul><ul><li>Medial longitudinal arch pathologies </li></ul></ul><ul><ul><li>Anterior pelvic til t </li></ul></ul><ul><ul><li>Anteverted hip </li></ul></ul><ul><ul><li>Menstrual cycle </li></ul></ul><ul><li>Intrinsic factors </li></ul><ul><ul><li>Joint laxity </li></ul></ul><ul><ul><li>Limb alignment </li></ul></ul><ul><ul><li>Small intercondylar notch </li></ul></ul><ul><ul><li>Small ACL </li></ul></ul><ul><ul><li>Genu recurvatum </li></ul></ul>
  13. 13. <ul><li>Often note an unusual sound (“pop”) or sensation (“knee gave way”) at time of injury </li></ul><ul><li>Immediate swelling typically present and significant – if isolated ACL, intracapsular and if joint capsule involved, extracapsular </li></ul><ul><li>“ Partial tears” typically treated as complete tears due to changes in ability of ligament to respond to stresses placed upon it with activity </li></ul>
  14. 14. <ul><li>Often treated surgically (ACLR) – somewhat dependent upon activity and/or level of performance </li></ul><ul><li>Can use autografts (patellar tendon, hamstrings) or allografts (cadavers) </li></ul><ul><li>Today’s ACLR rehab vs. initial ACLR rehab - accelerated </li></ul>
  15. 15. ACL Injuries - Females <ul><li>Females with significant numbers of non-contact ACL injuries vs. males </li></ul><ul><li>Predisposing intrinsic risk factors more attributable to females than males </li></ul><ul><li>Females also typically have narrower intercondylar notches than males </li></ul><ul><li>Hormonal changes during menstrual cycle may increase risk of injury – lax ligaments </li></ul>
  16. 16. Posterior Cruciate Ligament Injuries <ul><li>Most common MOI is fall on flexed knee driving tibia posterior on femur </li></ul><ul><li>May also occur with rotational and/or hyperextension MOI </li></ul><ul><li>Often treated non-operatively as quadriceps muscles are able to minimize posterior displacement of tibia on femur </li></ul>
  17. 17. R OTATIONAL I NSTABILITIES <ul><li>Involve abnormal internal or external rotation of the tibia on the femur </li></ul><ul><li>Result when multiple stabilizing structures are injured with rotational MOI </li></ul>
  18. 18. Anterolateral Rotatory Instability (ALRI) <ul><li>Involves trauma to ACL and anterolateral joint capsule </li></ul><ul><li>Can be accentuated with associated damage to LCL, IT band, lateral meniscus and/or biceps femoris tendon </li></ul><ul><li>Several special tests – often not clinically reliable and most evaluative under anesthesia </li></ul>
  19. 19. ALRI Tests <ul><li>Slocum T est </li></ul><ul><ul><li>Internall y rotating tibia during anterior drawer </li></ul></ul><ul><li>Crossover T est </li></ul><ul><ul><li>Uninvolved leg steps in front of involved with involved foot fixed </li></ul></ul><ul><li>Pivot S hift T est </li></ul><ul><ul><li>Tibia internally rotated and valgus force applied to knee from extension to flexion – mimics joint subluxation that occurs in ACL deficient knee during functional activities </li></ul></ul>
  20. 20. Anteromedial Rotatory Instability (AMRI) <ul><li>“ T riad” injury involving ACL, MCL and medial meniscus contributes to AMRI </li></ul><ul><li>Slocum T est </li></ul><ul><ul><li>Externally rotating tibia during anterior drawer </li></ul></ul><ul><li>Crossover T est </li></ul><ul><ul><li>Uninvolved leg steps behind involved with involved foot fixed </li></ul></ul>
  21. 21. Posterolateral Rotatory Instability (PLRI) <ul><li>Posterolateral joint capsule involved, typically associated cruciate injury and/or arcuate ligament complex </li></ul><ul><li>Evaluate with external rotation test for PLRI </li></ul><ul><ul><li>Compares external rotation of tibia on femur at 30 and 90˚ of knee flexion – if involved side greater than 10˚ different than uninvolved = + test </li></ul></ul>
  22. 22. Postero medial Rotatory Instability (P M RI) <ul><li>Combined injury to the PCL, MCL, and medial joint capsule </li></ul><ul><li>MOI – anterior blow to the tibia with the knee partially flexed and under valgus stress and the foot laterally rotated </li></ul>
  23. 23. MENISCAL INJURIES <ul><li>Lateral meniscus tears more common than medial (reversal of initial thinking) </li></ul><ul><li>May be isolated from flexion/hyperflexion with rotation of the knee – “pinched” between tibia and femur </li></ul><ul><li>Often injured in association with cruciate ligament injury </li></ul>
  24. 24. Meniscus Injury
  25. 25. <ul><li>“ C lassic” symptoms include joint line pain and clicking or locking – helpful but not definitive evaluative tools </li></ul><ul><li>McMurray’s and Apley’s tests indicated, but best tests are MRI/arthroscopy </li></ul><ul><li>Meniscal cysts may develop secondary to meniscal injury especially with peripheral tears – synovial fluid “leak” into damaged meniscus </li></ul>
  26. 26. O STEOCHONDRAL D EFECTS <ul><li>Fractures of articular cartilage and underlying bone – most common (80%) from medial femoral condyle (males have greater incidence than females) </li></ul><ul><li>Typically accompany other joint injuries – may present with locking or clicking, but may be asymptomatic if isolated </li></ul>
  27. 27. <ul><li>If stable and non-displaced, can be treated conservatively </li></ul><ul><li>If conservative management fails or if unstable or displaced OCD, surgical fixation, debridement or transplantation of articular cartilage is indicated </li></ul>
  28. 28. ILIOTIBIAL (IT) BAND FRICTION SYNDROME <ul><li>Results from friction between IT band and lateral femoral condyle during repetitive knee flexion/extension activities </li></ul><ul><li>May present with or as bursitis </li></ul><ul><li>Predisposing risk factors include genu varum, pronated feet and leg length discrepancies </li></ul>
  29. 29. IT Band Injury
  30. 30. <ul><li>Presents with tenderness at IT band crossing point on lateral femoral condyle </li></ul><ul><li>Noble ’ s C ompression T est </li></ul><ul><ul><li>Pressure over lateral femoral condyle with passive knee flexion/extension - + if pain under thumb, esp. at ~30˚ knee flexion </li></ul></ul><ul><li>Ober’s T est </li></ul><ul><ul><li>Abducts and extends the hip to allow the tensor fascia latae to clear the greater trochanter </li></ul></ul><ul><ul><li>The hip is then allowed to passively adduct to the table </li></ul></ul><ul><ul><li>Tests for IT band tightness </li></ul></ul>
  31. 31. Noble ’ s C. Test and Ober ’ s Test
  32. 32. POPLITEUS TENDINITIS <ul><li>Similar to the IT band friction syndrome </li></ul><ul><ul><li>Exception is the location of the pain </li></ul></ul><ul><ul><ul><li>Proximal portion of the tendon (posterior to the LCL) </li></ul></ul></ul><ul><li>Hyperpronated feet (predisposing factor) </li></ul><ul><li>Possibly resulting in an increased loading on the cartilage </li></ul>
  33. 33. P ATELLOFEMORAL P AIN S YNDROME <ul><li>Synonomous with patellofemoral joint dysfunction </li></ul><ul><li>Represent PF joint pain without specific MOI </li></ul><ul><li>Symptoms worsen with climbing stairs, sitting with knee flexed for long periods of time (movie sign) </li></ul><ul><li>May be secondary to tracking issues and/or biomechanical abnormalities </li></ul>
  34. 34. P ATELLAR MAL T RACKING <ul><li>Normal tracking in femoral trochlea dependent upon Q angle, integrity of patellar soft tissue restraints (retinacula), foot/leg mechanics and ham/quad/gastroc flexibility </li></ul><ul><li>Typical onset of symptoms is gradual – chronic changes develop over time as opposed to acutely </li></ul><ul><li>Presents as anterior and/or peri-patellar pain </li></ul>
  35. 35. PATELLAR SUBLUXATION/DISLOCATION <ul><li>Lateral displacement is most common </li></ul><ul><li>Commonly occurs with knee in 20-30˚ of flexion and may also have valgus load at knee </li></ul><ul><li>May have associated fracture of patella, osteochondral fracture of patellar or femu r and/or OCD </li></ul>
  36. 36. <ul><li>Predisposing risk factors include tight lateral retinaculum, flattened posterior patella, high Q-angle, biomechanical issues </li></ul><ul><li>Usually present with significant swelling and often involve tearing of VMO in addition to medial retinaculum </li></ul><ul><li>Evaluate with apprehension test </li></ul>
  37. 37. PATELLAR TENDINITIS <ul><li>Common in running and jumping activities </li></ul><ul><li>Most common site of irritation is inferior pole of the patella, but may also be at tibial insertion, superior pole of the patella or in tendon mid-substance </li></ul><ul><li>Presents with decreased quad flexibility and occasionally with strength deficits </li></ul><ul><li>Differentiate or associate with fat pad syndrome </li></ul><ul><li>Usually treat conservatively </li></ul>
  38. 38.
  39. 39. PATELLAR TENDON RUPTURE <ul><li>Occurs with excessive tension through tendon causing failure in mid-substance or at either insertion point </li></ul><ul><li>Present with gross deformity, inability to actively extend the knee and significant swelling immediately </li></ul><ul><li>Surgical intervention is only means of satisfactory outcome </li></ul>
  40. 40. PATELLAR BURSITIS <ul><li>Prepatellar, suprapatellar and infrapatellar </li></ul><ul><li>Typically inflamed secondary to acute trauma, but may be chronic or associated with infection </li></ul><ul><li>Especially prepatellar, presents with significant anterior swelling </li></ul><ul><li>Usually respond well to conservative management – risks with draining </li></ul>
  41. 41. SYNOVIAL PLICA <ul><li>Thickened area of joint capsule – remnant of development </li></ul><ul><li>Most common is medial, but may be lateral </li></ul><ul><li>Inflammation from trauma or irritation with activity are MOI </li></ul><ul><li>Typically treat conservatively – occasional surgical release or debridement </li></ul>
  42. 42. O SGOOD -S CHALLTER D ISEASE <ul><li>Inflammatory condition at tibial tuberosity at patellar tendon insertion </li></ul><ul><li>Symptoms similar to patellar tend i nitis but tuberosity often enlarged and only site of pain </li></ul><ul><li>Most prominent in adolescents – apophysitis/exostosis </li></ul>
  43. 43. S INDING -L ARSEN -J OHANSSON D ISEASE <ul><li>Similar to Osgood-Schlatter’s disease, but occurs at either superior or inferior pole of patella </li></ul><ul><li>Traction forces through tendon at bony interfaces causes symptoms </li></ul><ul><li>Can be very debilitating to active adolescents – conservative management can take significant period of time </li></ul>
  44. 44. CHONDROMALACIA PATELLAR <ul><li>Softening and deterioration of the articular cartilage </li></ul><ul><li>Possible abnormal patellar tracking due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon </li></ul><ul><li>Pain w/ walking, running, stairs and squatting </li></ul><ul><li>Possible recurrent swelling, grating sensation w/ flexion and extension </li></ul><ul><li>Pain at inferior border during palpation </li></ul>
  45. 45. PATELLAR FRACTURE <ul><li>Almost always due to blunt trauma </li></ul><ul><li>Obvious difficulties with active and passive knee ROM activities </li></ul><ul><li>Best viewed via sunrise x-ray </li></ul>