skis for knees - fisiokinesiterapiaacl treatment • grade 3 injuries- surgery • indications –...
TRANSCRIPT
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Skis for Knees
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Anatomy
• ACL• PCL• MCL• LCL• Meniscus
– Medial– Lateral
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Knee Anatomy
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THE KNEE HISTORY• Pain (PQRST)• Contact vs noncontact• Effusions• Mechanical symptoms
– Locking– Instability (falls)
• Initial treatment
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THE KNEE HISTORY• Continue work/play?
• PM/SHx
– Medications
• Occupation/Sport
– Time tables
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ACL: HISTORY• Contact vs noncontact
• Immediate effusion (first 4-12 hr)
• Unable to continue
• Mechanism = pivot, hyperextension
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Physical Exam of the Knee• Inspection
• Palpation
• Range of Motion
• Special tests
• Neurovascular assessment
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INSPECTION
• Effusion
• Erythema
• Ecchymosis
• Edema
• Q angle
• Angular deformities
• Muscular asymmetry
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PALPATIONANTERIOR
• Tibial tubercle
• Infrapatellar tendon
• Quad insertion
• Patellar facets
• Crepitus ?
MEDIAL• MCL
• Meniscus
• Pes anserine insertion
• Tibial plateau
• Femoral condyle
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PALPATIONLATERALLATERAL
• Head of the fibula
• LCL
• Meniscus
• Tibial plateau
• Femoral condyle
• Gerdy’s tubercle
POSTERIORPOSTERIOR• Menisci (posterior horns)
• Popliteal fossa
• Hamstring tendons
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ACL Special Tests• Anterior drawer
• Lachman test
• Pivot shift test
• Valgus stress test at full extension!
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Grading Ligament Injuries
GRADE 1 No instability Good endpoint
GRADE 2 Some instability Fair endpoint
GRADE 3 Opens wide Poor endpoint
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ACL: PHYSICAL EXAM• Decreased ROM• Effusion-hemarthrosis, immediate• + Instability tests
– Lachman: most accurate– Pivot shift– Anterior drawer
• + MCL and meniscus tests
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LIGAMENT EXAMTranslation + ENDPOINTS!
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+ PIVOT SHIFTPalpable clunk as the lateral tibial
condyle reduces on the femur
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LIGAMENT INJURIES:DIAGNOSIS
• Serial Exams
• Plain radiography
• Arthrocentesis ?
• MRI??
• KT-2000???
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LIGAMENT INJURIES: XRAY
• AP– Lateral capsular sign: Segond fx– Tibial spine avulsion fx– Physeal injuries
• Lateral– Lateral condyle divot– Obliques ?
• Tangential (Merchant)
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MRI: If you must…
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The Use of MRI in Evaluation of Knee Injuries
• Sensitivity M. Meniscus 73-100%L. Meniscus 55-90ACL 91-100
• Specificity MM 55-97LM 94-98ACL 99-100
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The Use of MRI in Evaluation of Knee Injuries
• + PV M. Meniscus 81-98%L. Meniscus 90-95ACL 93-100
• - PV MM 86-100LM 70-97ACL 99-100
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The REAL Question-
Is MRI that much better than clinical exam?
• Rose, et al. Arthroscopy, 1996
– Compared accuracy of clinical exam vs MRI
– In 154 pts, clinical exam was as good as MRI
• Many articles comparing MRI to arthroscopy
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“Partial” ACL tear
• > 40% ACL substance
• + Lachman, - pivot shift
• Clinically– Most behave functionally
as full tears
– Continued shifting ↑’s risk of meniscus damage
– Rx as full tear
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The Utility of Arthrocentesis
• Indications
– Diagnosis in question
• ? Infectious/Metabolic process
– Tense effusion
• Indications for surgery
• Timing of surgery
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ACL TREATMENT• Grade 3- Nonsurgical
– ? modify activity
– PRICES
– Hamstrings, gastroc!
– Functional bracing ?
– 100% @ 9-12 months
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ACL TREATMENT• Grade 3 Injuries- Surgery• Indications
– Most active people will require surgery to restore adequate function and decrease instability
– Recurrent instability– Inability to modify activity– Associated injuries: meniscus– Age?
• Wait three weeks due to arthrofibrosis risk• 100% @ 6-12 months
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MCL INJURIESHISTORY
• Mechanism = valgus stress
• Medial joint line pain
• Lack of large effusion
• Difficulty weight-bearing
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MCL INJURIESPHYSICAL EXAM
• Tender to palpation along MCL• Pain + instability with valgus stress
– 30o flexion = MCL– 90o flexion = associated ACL
• Pain with Apley’s distraction test• COMPARE SIDES
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MCL INJURIESTreatment Of Grade 1 &2
• Early mobilization
• Weight-bearing as tolerated
• Hinged knee brace
• PRICES
• Recovery 4-6 weeks
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MCL INJURIESTreatment of Grade 3 (full tears)
• Isolated = nonsurgical management
• Combined = surgery consistent with associated injuries
• Natural Hx = lack of long-term degenerative changes seen with ACL, meniscus
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PCL INJURIES• Mechanism
– Sports = fall on flexed knee with foot plantarflexed, hyperextension, pivot
– MVA = dashboard injury
• Effusion (less than with ACL)
• Shifting/instability (chronic)• Less distinctive
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PCL INJURIESPHYSICAL EXAM
• + Effusion
• + Posterior drawer test
• + Posterior sag sign
• False positive Lachman test
• Common to have isolated injuries
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PCL INJURIESTREATMENT
• PRICES• Functional bracing (early)• Rehab• Surgery if continued instability, effusions• Note- 2% of NFL preseason exam with
incidental isolated PCL tear
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Quad Musculature
• VMO- terminal extension
• VLO• Rectus femoris
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Patellofemoral Arthralgia
Often referred to as chondromalaciapatella. This term should be reserved
for observed articular cartilage damage
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PFA-HISTORY• PQRST of pain
• Pain with:
– Stairs
– Prolonged sitting
– Deep squat activities
• Lack of effusions, locking, instability
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PFA-HISTORY• Theatre sign- pain
with prolonged sitting (as in theatre or planes)
• Pain with stairs
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PFA- PHYSICAL EXAM• Grasshopper eyes• Genu valgus (high Q angle)
– Male < 10o
– Female < 15o
• Pain to palpation peripatellar• + crepitus• + leg length discrepancy
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PHYSICAL EXAM• Patellar compression/grind tests
• No patellar apprehension
• Poor hamstring flexibility
• + “J” sign
• Normal ligaments, meniscus
• Lack of effusion
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XRAYS• AP• Lateral• Tangential
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KNEE- LATERAL XRAYS
• Patella alta/baja
– Insall and Salvati ratio > 1.20
– Blumensaat
• Patellar poles
• Fat pads/ bursae
• Evaluate avulsion fx
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KNEE- TANGENTIAL XRAYS
• Assess patellofemoral joint
• Patellar tilt
• Lateralization
• Depth of trochlear
groove
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Lateralization and Tilt
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PFA- MANAGEMENT
• PRICES• Quad strengthening, hams
flexibility • VMO exercises• Modalities• Patellar taping• Correct leg length discrepancy
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PATELLAR INSTABILITY
• Acute patellar dislocation
• Acute patellar subluxation
• Patellar tracking dysfunction
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PATELLAR DISLOCATION
History• Mechanism = pivot • Immediate effusion• May visualize patella dislocated laterally• + Instability (chronically)
N.B. Patella spontaneously relocates
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PATELLAR DISLOCATION
Physical Exam• Tender peripatellar structures
– Medial retinaculum– Lateral femoral condyle
• Effusion• ? Patella dislocated laterally Xrays- osteochondral fracture, effusion
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XRAYS
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PATELLAR DISLOCATION
Treatment• Knee extension immobilizer x 4 wks• Early quad setting exercises• PRE’s at 4 wks to pain tolerance• Return to sport
– Full, painless ROM– Normal strength– Adequate aerobic fitness
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Biology of the Meniscus• Medial Meniscus
• Semilunar
• Narrow anteriorly
• Adherent to MCL
• Lateral Meniscus
• Circular
• Covers more of tibia
• Uniform size
• Less adherent
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Biology of the Meniscus• Fibrocartilage• Fibrochondrocytes• Extracellular matrix
– Collagens (90% type I)– Elastins– Proteoglycans
• Lateral has more translation on the tibial plateau– Bend but doesn’t break
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Types of Meniscus Tears
• Longitudinal
• Horizontal
• Oblique
• Radial
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MENISCAL INJURIESHistory
• Mechanism = pivot, twist
• + heard a “pop”
• Effusion- 12-36o after injury
• Mechanical Sxs- locking, instability
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MENISCAL INJURIESPhysical Exam
• Joint line tenderness
– IR/ER
• Decreased ROM
• McMurray’s test
• Apley’s compression test
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MENISCAL INJURIESAncillary Studies
• Plain radiographs
– Other causes mechanical Sxs
• MRI
– Higher vascularity in peds patients
• CT-arthrographyoutdated
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Meniscus MRI
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Grading of Meniscal Tears: MRI
• I: globular changes
• II: linear changes not to margin
• III: linear to sup/inf margin
• IV: complex linear changes
• Only grade III and IV visible on arthroscopy
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MENISCAL INJURIESTreatment
• Nonoperative (Aggressive Nonsurgical)
• Acute Rehab– ROM, Quad setting
• Subacute Rehab– ROM, PRE’s
• Bracing (hinged knee brace)
• Continue sport specific drills when tolerable
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MENISCAL INJURIESTreatment
• Operative
– Partial Menisectomy
– Meniscal Repair (peripheral)
– Meniscus Implants
– Total Menisectomy- outdated
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Baker’s Cyst and the Meniscus
• Stone, et al (1996)• Case-control study• Over 1700 MRI’s ⇒ 240 Baker’s cysts• 85% had meniscal tears• Data supported by:
– Miller, et al (1997)– Sansone ,et al (1995)
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Assorted Knee Problems• Osgood-Schlatter Syndrome
• Patellar, Quad Tendinitis
• Plica
• Iliotibial Band Syndrome
• Discoid Meniscus
• Osteoarthritis
• Osteochondritis dessicans (OCD)
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TENDINITISQuadriceps and Patellar
History
• Pain with:
– Jumping
– Stairs
– Prolonged sitting
• Mechanism = overuse
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TENDINITISQuadriceps and Patellar
Physical Exam• Tender superior/inferior pole of
patella
• Tender tibial tubercle
• Tight hams, Achilles, quads
• Pain with resisted action of muscle
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TENDINITISQuadriceps and Patellar
Treatment• P: protection, pain meds• R: rest• I: ice• C: compression• E: elevation• S: support, strength/stretch exercises
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Traction Apophysitis• Osgood-Schlatter “disease”• Sinding- Larsen-Johannson disease
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BURSITIS• Prepatellar bursa• Infrapatellar bursae • Pes anserine bursa
• Mechanism = direct blow, overuse
• Physical exam- point tender, nonintraarticular effusion
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BURSITISTreatment
• NSAID’s
• Ice
• Flexibility exercises
• Steroid injections
• Surgery for chronic cases (prepatellar)
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Discoid Meniscus• Programmed cell death
• More likely to tear
• Often Lateral
• Male > female
• Ages 6-10 yrs
• Xray- wide lateral joint space
• Rx- may require resection if Sx
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Discoid Meniscus
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Discoid Meniscus