Transcript KNEE INJURIES - University of Tehran

KNEE INJURIES
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PANOS THOMAS
TUTOR MSc SPORTS AND EXERCISE
MEDICINE
 UCL
KNEE INJURIES
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1) OVERUSE KNEE INJURIES
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2) ACUTE KNEE INJURIES
OVERUSE KNEE INJURIES
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1) ILIOTIBIAL BAND FRICTION SYNDROME
2) POPLITEUS TENDINITIS
3) PATELLOFEMORAL JOINT PAIN
SYNDROME
4) PATELLOFEMORAL SYNOVIAL PLICA
5) INFRAPATELLAR FAT PAD SYNDROME
6) PATELLAR TENDINITIS(JUMPER’S KNEE)
7) PES ANSERINUS BURSITIS
1) ILIOTIBIAL BAND
FRICTION SYNDROME (ITB)
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- TENDON WITHIN FASCIA LATA FROM
ILIAC CREST INTO GERDY’S TUBERCLE
TIBIA
 - KNEE FLEXED 30 DEGREES: ITB BEHIND
LATERAL FEMORAL CONDYLE
 KNEE EXTENDED: ITB MOVES
ANTERIORLY
 - ITB SYNDROME: INFLAMMATION
DISTALLY IN THE BURSA BETWEEN ITB
AND LATERAL FEMORAL CONDYLE
1) ILIOTIBIAL BAND
FRICTION SYNDROME
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CAUSES:
A) SINGLE LONG HARD RUN
B) RAPID INCREASE IN TRAINING
DISTANCES
C) BANKED SURFACES RUN: BEACH OR
SHOULDER OF ROAD
D) EXCESSIVE HILL RUNNING
- DISCOMFORT OVER LOWER 3cm ITB,
WORSE RUNNING DOWNHILL
1) ILIOTIBIAL BAND
FRICTION SYNDROME
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- O/E: CREPITUS, PAIN ON
COMPRESSION OVER LATERAL
FEMORAL CONDYLE
 - “ STRETCHED ITB “: LEG
MALALIGNMENT, LEG LENGTH
DISCREPANCY, EXCESSIVE FOOT
PRONATION, PELVIC
CONTRALATERAL DOWNWARD TILT
1) ILIOTIBIAL BAND
FRICTION SYNDROME
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TREATMENT:
 A) 1st LINE: REDUCTION OF TRAINING
DISTANCE, NSAIDS, DAILY
STRETCHING ITB, CORRECT
ORTHOSIS FOOT PRONATION,
STRENGTHEN IPSILATERAL HIP
ABDUCTORS ( PELVIC DROP ON GAIT
ANALYSIS )
1) ILIOTIBIAL BAND
FRICTION SYNDROME
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TREATMENT:
 2nd LINE: LOCAL INFILTRATION OF
CORTICOSTEROID
 3rd
LINE: SURGERY TO DIVIDE ITB 3cm
ABOVE LATERAL FEMORAL
EPICONDYLE ( V-SHAPED DEFECT
ETC )
2) POPLITEUS TENDINITIS
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- SURROUNDS POSTER.LATERAL
ASPECT OF KNEE, STABILIZER IN
FLEXION BY RESISTING FORWARD
DISPLACEMENT OF THE FEMUR ON
THE TIBIA
 - LESS COMMON BUT SAME CAUSES
AS ITB (D/D)
2) POPLITEUS TENDINITIS
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- DISCOMFORT ANTERIOR OF SUPERIOR
LAT.COLLATERAL LIGAMENT AND WITH
RESISTED KNEE FLEXION WITH TIBIA
HELD IN EXTERNAL ROTATION
 - TREATMENT: REDUCTION TRAINING
DISTANCE, NSAIDS, STRETCHING KNEE
FLEXORS, ELECTROTHERAPY.
CORTICOSTEROID INJECTION
3) PATELLOFEMORAL JOINT
PAIN SYNDROME
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- FEMALES MORE THAN MALES
 - MOST OFTEN SEEN IN ATHLETES
PRESENTING IN ADOLESCENCE AND INTO
THE 4th AND 5th DECADES
 - PAIN UNDER “KNEE CAPS” WORSE BY
CLIMBING OR DESCENDING HILLS OR
STAIRS. PAIN SITTING DOWN FOR LONG
PERIODS. CREPITUS
 - ANY SPORT COULD BE ASSOCIATED WITH
PFJ PAIN SYNDROME
3) PFJ PAIN SYNDROME
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- O/E: CREPITUS, IRRITABILITY OF PFJ,
SMALL SWELLING, QUADRICEPS
WEAKNESS AND WASTING ( VASTUS
MEDIALIS )
 - BIOMECHANICAL FACTORS: WIDE Q
ANGLE (ABOVE 16 DEGREES IN MALES, 18
DEGREES IN FEMALES), SMALL HIGH
PATELLA, GENU VALGUS, SHALLOW
INTERCONDYLAR NOTCH, PRONATED
GAIT WHICH INCREASES IR OF THE TIBIA
3) PFJ PAIN SYNDROME
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- PAIN IS A COMBINATION OF REPETITIVE
INCREASE OF PRESSURE OVER
SUBCHONDRAL BONE AND TIGHT
RETINACULAR STRUCTURES
 - PRESSURE OVER ARTICULAR CARTILAGE
AFFECTS NUTRITION AND RESULTS IN
DEGENERATIVE CHANGES
 - VASTUS MEDIALIS DYSFUNCTION
RESPONSIBLE: FAILURE TO COMPENSATE
TENDENCY TO LATERAL SHIFT PATELLA
3) PFJ PAIN SYNDROME
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- VASTUS MEDIALIS RE-EDUCATION:
EXERCISES, McCONNELL’S TAPING,
DROP-SQUATS, ECCENTRIC DRILLS
FOR 6-8 WEEKS
 - SURGERY: DEBRIDEMENT AND
LATERAL RELEASE
 PATELLAR TENDON REALIGNMENT
 ( CORRECT WIDE Q ANGLE )
4) PATELLOFEMORAL
SYNOVIAL PLICA
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- REMNANTS OF THE SEPTA OF
EMBRYONIC JOINT. USUALLY PRESENT
BUT ASYMPTOMATIC
 - SYMTOMATIC PLICA: MEDIAL PATELLAR
PLICA RUNS FROM SUPRAPATELLAR
POUCH TO THE INFRAPATELLAR FAT PAD
MAY IMPINGE OF THE MEDIAL FEMORAL
CONDYLE AND PFJ IN FLEXION
4) PF SYNOVIAL PLICA
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- ACHING ON SITTING DOWN ANTERIORLY,
INTENSE THE FIRST WALKING STEPS IN
THE MORNING
 O/E: FELT BANDS, MEDIALLY, MILD
EFFUSION, PAIN ON RESISTED KNEE
EXTENSION MADE WORSE BY GLIDING
PATELLA MEDIALLY
 - TREATMENT: REST, NSAIDS,
CORTICOSTEROID INJECTION IF MEDIAL
PLICA PALPABLE. ARTHRO. EXCISION
5) INFRAPATELLAR FAT PAD
SYNDROME
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- REPETITIVE HYPEREXTENTION
INJURIES, SURGICAL INTERVENTION
 - PAIN ON HYPEREXTENTION OVER
ANTERIOR KNEE REGION
 - PART OF PATELLA BAJA: SHORTER
PATELLAR TENDON FROM FIBROSIS
(? PREVIOUS SURGERY) BLOCKING
KNEE FLEXION
5) INFRAPATELLAR FAT PAD
SYNDROME
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- TREATMENT:
 REST FROM HYPEREXTENTION
(MARTIAL ARTS ) , NSAIDS,
ELECTROTHERAPY.
 SIGNIFICANT FIBROSIS:
ARTHROSCOPIC EXCISION
6) PATELLAR TENDINITIS
( JUMPER’S KNEE )
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- REPETITIVE EXTENSOR ACTION OF THE
KNEE WITH A GENERATION OF LARGE
ECCENTRIC FORCES
 - BIOMECHANICAL ANALYSIS IN
BASKETBALL: JUMPING AND LOADING
FORCES APPLY THE GREATEST TENSILE
FORCES IN THE PATELLAR TENDON WHEN
IN LANDING
6) PATELLAR TENDINITIS
( JUMPER’S KNEE )
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- GRADUAL ONSET PAIN LOWER POLE OF
PATELLA. ASSOCIATED WITH INCREASED
TRAINING LOAD, ACUTE EXACERBATIOUS
 - O/E: TENDERNESS, SWELLING, CREPITUS
LOCALLY OVER TENDON. QUADRICEPS
TIGHTNESS (?) INFRAPATELLAR BURSITIS
 - U/S OR MRI: DEFECT WITHIN THE
TENDON
6) PATELLAR TENDINITIS
( JUMPER’S KNEE )
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- HISTOLOGY: A) TENOPERIOSTITIS
OF LOWER POLE OF THE PATELLA
 B) GRANULATION OF THE TENDON
DEEP IN ITS SHEATH
(DEGENERATION )
6) PATELLAR TENDINITIS
( JUMPER’S KNEE )
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TREATMENT:
- ACUTE EXACERBATION: ACTIVE REST,
ICE, NSAIDS, 6 WEEKS RECOVERY
- CHRONIC: A) THERMAL (HEAT
RETAINING) SLEEVE
B) ECCENTRIC EXERCISES, DROP-SQUAT
PROGRAMME
C) STRENGTHEN SYNERGISTS OF
QUADRICEPS
6) PATELLAR TENDINITIS
( JUMPER’S KNEE )
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TREATMENT:
 D) FOOTWEAR, TRACK SURFACE,
TAPING PATELLAR TENDON
 - SURGERY: EXCISION INFERIOR
POLE OF PATELLA AND SCARING
FROM TENDON (? REPAIR THE
TENDON ) 6 MONTHS RECOVERY
7) PES ANSERINUS
BURSITIS
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- BURSA INFLAMMATION AT MEDIAL
ASPECT OF UPPER TIBIA
 - BURNING LOCALIZED PAIN WHEN
RUNNING
 - TIGHT HAMSTRINGS, INADEQUATE
STRETCHING, PREVIOUS HAMSTRING
INJURY, HAMSTRING ORIENTATION
TRAINING PROGRAMME
7) PES ANSERINUS
BURSITIS
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TREATMENT: STRETCHING
HAMSTRINGS, NSAIDS, REST WHEN
ACUTE, LOCAL INFILTRATIONS,
ORTHOTICS
ACUTE KNEE INJURIES
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1) ANTERIOR CRUCIATE LIGAMENT
RUPTURE (ACL)
 2) POSTERIOR CRUCIATE LIGAMENT
RUPTURE (PCL)
 3) MEDIAL COLLATERAL LIGAMENT
TEAR (MCL)
 4) LATERAL COLLATERAL LIGAMENT
TEAR (LCL)
ACUTE KNEE INJURIES
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5) INJURIES TO THE MENISCI
 6) OSTEOCHONDRAL PROBLEMS
 7) PATELLOFEMORAL INSTABILITY
1) ACL RUPTURE
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- 30 NEW CASES PER 100.000 POPULATION
PER YEAR
 - FOOTBALL, BASKETBALL, SKI
 - INTRACAPSULAR STRUCTURE, THREE
BANDS OF LIGAMENT: ANTEROMEDIAL,
INTERMEDIATE, POSTEROLATERAL
 - GIVING WAY AFTER TURN, PIVOT, JUMP,
AUDIBLE CRACK, HAEMATHROSIS
1) ACL RUPTURE
FUNCTIONS – MECHANISM OF INJURY
 A) “ SCREWING HOME” TIBIA OVER
FEMUR BY EXT.ROTATE TIBIA WHEN KNEE
EXTENDS
 B) RESISTING ANTERIOR DISPLACEMENT
OF THE TIBIA ON THE FEMUR (SKI)
 C) EXCESSIVE EXT.ROTATION OF TIBIA
(COMBINED MCL AND ACL INJURY )
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1) ACL RUPTURE
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D) VARUS FORCE (LCL AND ACL
INJURY )
 E) HYPEREXTENSION FORCE ( ACL
AND PCL INJURY )
1) ACL RUPTURE
- O/E: PAIN, EFFUSION, LACHMAN’S TEST,
PIVOT SHIFT TEST
 - ACUTE HAEMARTHOSIS: 60-80% ACL
RUPTURE
 - X-RAYS: TIBIAL SPINE AVULSION,
SEGOND FRACTURE
 - CONSERVATIVE TREATMENT: 50% OF
PATIENTS, HAMSTRINGS EXERCISES,
PROPRIOCEPTION, (?) BRACE,(SKI)
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1) ACL RUPTURE
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SURGICAL TREATMENT
 - FAILED CONSERVATIVE (50%
PATIENTS ), AGE (?0A)
 - PRIMARY REPAIR, INTRARTICULAR
GRAFT, EXTRARTICULAR
STABILIZATION, ALLOGRAFT,
SYNTHETIC LIGAMENT
1) ACL RUPTURE
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- ARTHROSCOPIC SURGERY VERSUS
OPEN SURGERY
 - UPDATE SURGERY: ARTHROSCOPIC
RECONSTRUCION USING PATELLAR
OR HAMSTRINGS INTRARTICULAR
GRAFT
2) PCL RUPTURE
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- EXTRASYNOVIAL STRUCTURE, TWICE
STRONGER THAN ACL
 - RESISTS ANTERIOR SLIDE OF FEMUR
WHEN WEIGHT BEARING, RESISTS
HYPEREXTENSION AND CONTRIBUTES TO
MEDIAL STABILITY OF KNEE
 - MECHANISMS: DIRECT BLOW OVER
UPPER TIBIA WITH KNEE IN FLEXION,
HYPEREXTENSION OF THE KNEE
2) PCL RUPTURE
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- PFJ PAIN “GIVING WAY” RUNNING
DOWNHILL
- O/E: POSTERIOR “SAG”, INCREASED
RECURVATUM OF THE KNEE
- X-RAYS: AVULSIONS FROM TIBIA
- TREATMENT: CONSERVATIVE WHEN
ISOLATED RUPTURE (80% SUCCESS)
- PROBLEMS WITH LONG DISTANCE
RUNNING,”STOP-START” SPORTS,SQUASH
3) MCL INJURY
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- DIRECT VALGUS FORCE, EXTERNAL
TIBIAL ROTATION FORCE
 - THREE DEGREES OF SEVERITY INJURIES
 -O/E: 30 DEGREES FLEXION OF THE KNEE
VALGUS FORCE TEST
 TREATMENT: GRADE I: 6 WEEKS
RECOVERY, 8 WEEKS TO SPORT GRADE II:
6 WEEKS CRUTCHES, 12 WEEKS TO
RECOVER GRADE III: ARTHROSCOPY
(OTHER INJURIES ACL ETC )
3) MCL INJURY
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PELLEGRINI – STIEDA DISEASE
- FEMORAL ORIGIN DISRUPTION OF MCL
- HETEROTOPIC CALCIFICATION OF
PROXIMAL FIBRES
- 3-6 WEEKS FROM INJURY, MARKED PAIN
ON TWISTING, RESTRICTION OF FLEXION
AND EXTENSION
- ACTIVE MOBILIZATION (PRESERVE
ROM),EXCISION SURGERY
4) LCL INJURY
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- RARE, DIRECT VARUS FORCE
 - PART OF POSTEROLATERAL
CORNER STABILITY
 - COMBINED WITH ACL, PCL
RUPTURES
 - CONSERVATIVE OR
RECONSTRUCTION (PART OF PLC)
5) MENISCI INJURIES
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- SHOCK-BEARING STRUCTURES OR
“SHOCK ABSORBERS”
 - REDUCE DISPARITY BETWEEN FEMORAL
AND TIBIAL SURFACES, SO INCREASE
STABILITY
 - ASSIST IN ARTICULAR CARTILAGE
NUTRITION
 - CUSHION HYPEREXTENSION AND
HYPERFLEXION
MENISCI INJURIES
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- NUTRITION: PERIPHERY FROM
VASCULAR PLEXUS SUPPLY
 - MED. MENISCUS: POSTERIOR THIRD
TEARS MORE COMMON
 - LAT. MENISCUS: MIDDLE THIRD TEARS
MORE COMMON
 - MECHANISM: KNEE FORCED IN FLEXION
AND ROTATION WHILE WEIGHT-BEARING
5) MENISCI INJURIES
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- PAIN JOINT LINE, LOCKING, GIVING WAY,
SMALL SWELLING
- McMURRAY’S TEST, APLEY’S TEST,
MENISCUS CYSTS
- ARTHROGRAM, MRI SCAN
- ACUTE INJURY: PHYSIOTHERAPY, REFER
IF NOT SETTLED IN 3 WEEKS
- CHRONIC INJURY: INVESTIGATE, PARTIAL
MENISCECTOMY, REPAIR
6) OSTEOCHONDRAL
PROBLEMS
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- OSTEOCHONDRAL FRACTURE (
MIMIC MENISCAL TEARS )
 - OSTEOCHONDRITIS DISSECANS (
SEPARATED SEGMENT )
7) PATELLOFEMORAL
INSTABILITY
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DISLOCATIONS:
- SEVERE INJURY: PFJ PAIN SYNDROME,
RECURRENT DISLOCATION, LOOSE
BODIES FORMATION
- ATHLETE TWISTS ON FIXED TIBIA
- IMMEDIATE DEFORMITY AND PAIN.
DISLOCATION MAY REDUCE ITSELF
- RISK FACTORS AS PFJ PAIN SYNDROME
7) PATELLOFEMORAL
INSTABILITY
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DISLOCATION:
 - REDUCTION: FLEX THE HIP AND
GRADUALLY EXTEND THE KNEE
 - X-RAYS TO EXCLUDE
OSTEOCHONDRAL FRACTURES,
LOOSE BODIES
7) PATELLOFEMORAL
INSTABILITY
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DISLOCATION:
 - 3 WEEKS FULL EXTENSION, BRACE
FOR 6 WEEKS. BRACE AT THE FIRST
RETURN TO SPORT
(PROPRIOCEPTION)
 - SURGERY IF RECURRENT PROBLEM
( INCLUDE MANAGEMENT OF RISK
ANATOMICAL FACTORS )
7) PATELLOFEMORAL
INSTABILITY
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SUBLUXATION:
- SUSPECTED WITH INSTABILITY – PAIN
WHEN TURNING ON THE LEG
- ELICIT A POSITIVE APPREHENSION TEST
- RISK ANATOMICAL FACTORS TO BE
CONSIDERED
- CONSERVATIVE TREATMENT OR
SURGICAL ANATOMICAL CORRECTION