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Exercise Science
ES 300

ES 300 Exam 2 Knee Pathology and Management The Knee Joint:  The knee joint connects the femur to the tibia.  There are two joints in the knee  the tibiofemoral joint  The patellofemoral  modified hinge joint that allows the knee to bend and straighten and rotate slightly and from side to side.  The knee is part of a chain that includes the pelvis/ hip/ and upper leg/ lower leg/ankle and foot  Alignment test: Ant + Posterior drawer test Knee Alignment: There are three translations at the knee:  Compression – Distraction  Medial – Lateral Translation  Anterior – Posterior Translation The knee is a hinge with three different rotations around an axis  Flexion – Extension  Abduction – Adduction  Internal – External Rotation The Q Angle:intersection of a line down through tibial tubercle to the midline of patella and from ASIS to midline Avg. Male 10-15 degrees Avg. Female 15-20 degrees (womens hips are wider) Cartilage and Ligaments of the knee:  Meniscal Injuries. Cartilage supporting ligaments (fibrocartilage = shock absorber)  The medial meniscus bears majority of the weight up to 90%.= weight bearing injury  The menisci function knee stabilization, shock absorption, lubrication, mobile buffering, load bearing  Pivot Point for internal and external rotation of normal gait  Anchored to capsule predisposing greater tearing Vasuclarity of Meniscus: Red-Red zone outside most vascular & easier to heal Red-white zone middle white-white zone- inside, least likely to heal Leg Length Discrepancy: True: anatomical (ASIS to medial Malleoli) Apparent: functional (navel to medial malleoli. Assess glute function on short leg. Medial collateral Ligament Sprain: • Etiology: Severe blow or outward twist, Possible Medial Meniscus damage Stress inside leg hit from a lateral aspect. Grade 1: MCL Extent of Injury Little fiber tearing or stretching (no permanent change) Little or no joint effusion (swelling) Little to no laxity with endpoint Some stiffness and point tenderness Relatively normal ROM Management RICE at least 24 hours Crutches prn Isometrics & Straight leg raises to bicycle riding and isokinectics RTP when all areas have returned to normal Recovery Time: 3 weeks to recover Grade 2: MCL Extent of Injury Tears in MCL and Medial Capsule Slight Laxity with endpoint Slight swelling Moderate to severe joint tightness w/ decreased ROM Pain along medial knee Management RICE 48‐72 hours; crutch use Brace prior to ROM activities Modalities 2‐3x daily for painGradual exercise progression Grade 3: MCL Extent of Injury Complete tear Loss of stability Minimum to moderate swelling Immediate pain ache and guarding Loss of motion due to effusion and hamstring Management: RICE Conservative vs. Surgical Aproach Limited immobilization with a brace. Progressive weight bearing Rehab would be similar to I and II Lateral Collateral Ligament Sprain:  Etiology Varus force, generally w/ tibia IR Direct blow is rare  Signs and Symptoms Pain and tenderness over LCL Swelling and effusion and Joint laxity  Management Following management of MCL injuries depending on severity Anterior Cruciate Ligament Sprain:  Etiology Tibia ER & valgus force at knee Hyperextension Direct blow Inability to decelerate  Weak Hamstrings = Main Function of the Hamstrings is to decelerate Male versus female Extrinsic factors Unhappy Triad  Signs and Symptoms  Experience “POP”  Severe pain and disability  Rapid swelling at joint line  Management RICE; crutches Major instability in high performance W/out surgery joint degeneration may result Age & activity may factor into surgery Posterior Cruciate Ligament Sprain: Etiology 90 degrees of flexion Fall on bent knee Rotational force– Signs and Symptoms Pop in back of knee Tenderness & relatively little swelling Management RICE Non‐operative rehab of grade I and II Surgical versus non‐operative– Surgery will require 6 weeks of immobilization in extension w/ WB on crutches– ROM after 6 weeks and PRE at 4 months Progressive Resistance Exercise Meniscal Lesions: • Etiology • Medial more than lateral • Rotary force w/ knee flexed or extended • Signs and Symptoms • Effusion over 48‐72 hr. period • Joint line pain & loss of motion • Intermittent locking & giving way Meniscus Injury Rehab  Management  MRI- soft tissues  If locking, anesthesia to unlock  Possible arthroscopic surgery  Menisectomy rehab  Repaired meniscus (snipping ends)  Manual Meniscal Release  (McMurray’s) Joint Contusions:  Etiology Blow to muscles crossing joint  Signs and Symptoms Present as knee sprain Swelling, discoloration Possible capsular damage  Management RICE initially ‐ continue if swelling persists Gradual progression to activity following return of ROM and padding for protection Bursitis: (use knee pads)  Etiology Acute, chronic or recurrent swelling Prepatellar = continued kneeling Infrapatellar = overuse  Signs and Symptoms Prepatellar may be localized above knee In popliteal fossa ‐ Baker’s cyst (back of the knee)  Management Eliminate cause, RICE and NSAID’s Aspiration & steroid injection if chronic (needs to be pulled out) Patellar Fracture:  Etiology Direct or indirect trauma Forcible contraction, falling, jumping or running  Signs and Symptoms Hemorrhaging and joint effusion w/ generalized swelling  Management X‐ray Note: 3% population has Bipartate / Tripartate (doesn’t attach anyways) – RICE and splinting – Refer and immobilize for 2‐3 months Patella Subluxation/Dislocation:  Etiology Deceleration & simultaneous cutting in opposite direction (valgus force at knee) Slowing down and cutting. LARGE Q angle= HIGH RISK Quad pulls patella out of alignment May be predisposed  Signs and Symptoms Subluxation – pain & swelling, restricted ROM, palpable tenderness adductor tubercle Dislocations ‐ total loss of function Management Reduction by flexing hip, moving patella medially &slowly extending the knee X‐ray Immobilization 4 weeks w/ use of crutches and isometrics After immobilization, horseshoe pad w/ elastic wrap Muscle Rehabilitation (Glutes, hamstrings, vastas medialis) Possible surgery (lateral release) Improve postural and biomechanical factors Patellar Tendonitis:  Jumper’s or Kicker’s Knee Etiology Stress & strain on patellar or quad tendon Sudden or repetitive extension  Signs and Symptoms Pain & tenderness at inferior pole of patella  Management Ice, phonophoresis, iontophoresis, ultrasound, heat Exercise Patellar tendon bracing Transverse friction massage Patellar Tendon Rupture:  Etiology Sudden, powerful quad contraction w/ bodyweight Chronic inflammation Point of attachment  Signs and Symptoms Palpable defect, lack of extension Considerable swelling & pain (initially)  Management Surgical repair Proper jumper’s knee can minimize Disuse of steroids Runner’s Knee or Cyclists Knee:  Etiology Repetitive/overuse  Signs and Symptoms IT Band Friction Syndrome Pes Anserine Tendinitis or Bursitis  Management Correction of mal‐alignments Ice before & after activity Proper warm‐up & stretching Avoidance of aggravating activities NSAID’s and orthotics Chondromalacia Patella (Patella Femoral Syndrome)  Etiology Softening & deterioration of articular cartilage Abnormal patellar track, shallow femoral groove, large Q angle, laxity of quad tendon  Signs and Symptoms  Pain w/ walking, running, stairs and squatting Possible recurrent swelling, grating sensation w/ flexion and extension Pain at inferior border during palpation  Management Conservative measures RICE, NSAID’s, isometrics, orthotics to correct dysfunction Surgical possibilities FEMALE ATHLETE TRIAD: osteoporosis: bone loss/ Amenorrhea (menstrual)/ low energy (eating disorder) Discontinue activity 14 days, crutches, WB when pain gone, cycling, biomechanics must be addressed MUST HAVE COMPLETE ROM 80-90% of pre injury strength. ……………………………………………………………………………………… ……………………………………… Category 1 Movements three category movement hierarchy serves to provide you a model for -Rehabbing an athlete after surgery or injury -Layering movements and skill progressions -Understanding movement complexity - Separate good from the bad movement errors and mobility restrictions Can you brace spine? Do you understand how to load and create torque through primary engines (hips and shoulders) Need to work on your weakness to become stronger. Technique: Always address motor-control first. Mobility: targeting the areas that are restricting your movement. Mechanics- motor control, consistency, intensity Category 1: (air squat) Position of high stability (PHS) with connection Position of high stability (PHS) PHS- braced organized position that allows you to maintain maximum stability through hips and shoulders. Connection- Maintaining a torsion force through the entire range-of-motion Category 2: (jumping and landing) Start in a PHS Remove connection with speed Finish in a PHS Instead of maintaining torque throughout the entire range of the movement, you insert a speed element. Harder to hide weaknesses in this movement Category 3 movements (the snatch) Start in one position, remove the connection, and arrive in a completely different position. The athlete needs to be able to spontaneously generate stability while changing position or direction. Position of transition remove connection with speed Position of high stability (PHS) Upright the torso= more motor-control, ROM, and stabilization required to carry out the movement Squatting Keeping shins vertical Load your hips and hamstrings (initiate with hamstrings) through a “hip hinge” Chest up, butt back will cue an overextension fault Instead cueing the athlete to sit your hamstrings back. Distributing weight through the center of the foot Create a stable shoulder Air: thumbs turned inside body Barball: screw hands into the bar rotate pinky out bend bar over back Back Squat Faults: Grip Fault (Broken at wrist) Find the Shelf Press head back to create neutral spine If ROM is a problem then slide hands out to an appropriate position Mobilize Thoracic spine/Anterior Shoulders and Chest/Posterior Shoulders and Lats/Downstream Arm (Elbow and wrist) Grip Fault (Elbows High) Same as above Head fault Walk back by trying not to look down Walk back by using the same sequence every single time!!! Good Morning Squat This is very common in athletes who squat with feet turned out. Make sure feet are straight ahead Create and maintain torque through ROM, screw feet into ground. Breathing out before squatting= unstable. Breath, Squeeze glutes, knees out, ribcage down, maintain stability Squat Faults: Knee Forward Fault Isolate the first 6 inches of the squat Create ER by screwing feet in and knees out Create the hip hinge Mobilization of Glutes/Hips/Quads Overextension Spinal Fault First 6” of squat Create ER Create Hip hinge Mobilization of Hips/Quads/Glutes/Hamstrings/Trunk Valgus Knee Faults Extra ER of the feet will increase likelihood of this problem occurring Iso first 6” of squat Create ER Create Hip hinge Mobilize Hips/Quads/Hamstrings/Glutes/Calf Heel Cord Shoulder Fault Wind up into a stable, extrenally rotated position Mobilize Thoracic Spine/Anterior Shoulders and Chest/Posterior Shoulders and Lats Open Foot Fault Distribute weight evenly through the foot between the heel and the ball of your foot. Mobilize ankle and plantar surface/calf and heel cord/Hips and Quads/Adductors/Glutes Ankle Wall Test and the Pistol Test The Butt Wink Squeeze your butt and stabilize your spine in the top position Initiate your squat by driving hamstrings back Knees out/Screw feet into ground Mobilize Hips/Quads/Glutes/Hamstrings/Calf/Heel Cord/Trunk Knee Forward fault in bottom position Initiate Hip hinge Knees go forward-push them back and go up thr right way. Mobilize Hips/Quads/Adductors/Hamstrings/Glutes Head fault Do not throw head back maintain a neutral spine DEADLIFT: BRACE-CREATE TORQUE-LOAD HIPS & HAMSTRINGS- KEEP SHINS VERTICAL-DISTRIBUTE WEIGHT IN THE CENTER OF THE FOOT MOST COMMON MISTAKE IS TO BEND OVER AND THEN ATTEMPT TO BECOME ORGANIZED Take all of the slack out of the system: create as much tension as possible prior to lifting object TENSION FAULT: RAISE YOUR BUTT AND BRING YOUR KNEES BACK Push Up: upper body squat LOAD YOUR PECS/TRICEPS KEEP YOUR FOREARMS VERTICAL DISTRIBUTE WEIGHT OVER THE CENTER OF YOUR HAND SHOULDER WIDTH HAND POSITION HANDS POINTED AHEAD FEET TOGETHER GLUTES SQUEEZED LEVER FORWARD AND POSITION SHOULDERS OVER HANDS (ELBOW PITS FORWARD) ELBOW BACK FAULT: THINK OF KNEES FORWARD ON THE SQUAT MOTOR CONTROL FIX PULL SHOULDERS BACK AND CREATE TORQUE BY SCREWING HANDS INTO THE GROUND POSITION ELBOW PITS FORWARD FOREARMS AS VERTICALAS POSSIBLE AS YOU INTIATE MOVEMENT The Thigh, Hip, Groin, and Pelvis The Hip • Must withstand the forces of weight bearing (3-22x bw) Stress of standing on the hip is 1/3 of BW Stress of standing on one leg is 2.5x BW Use of a cane reduces stress on the hip up to 40% (proper use & height) • Must withstand the force of muscular contraction In sprinting the quad moves 0mph – 100mph – 0mph 2.25x per second • The hip is one of the largest joints in the body • The hip is more prone to bone/joint damage while the shoulder is more prone to soft tissue injury • Disorders of the hip are more age related than any other joint • Infant – Congenital (Hip Dysplasia) socket isn’t deep enough • Adolescent – Growth plate injury (Slipped Capital Femoral Epiphysis) • Young Adult – Trauma (accidents, sports) • Geriatric – Osteoarthritis, fracture • The Hip is a relatively rigid ball and socket joint larger labrum fibrocartilage (STABILITY) • Functional Anatomy • Acetabulum is the fusion of three bones lium, Ischium, Pubic • The head of the femur is 2/3 of a sphere • The rim of the acetabulum is protected by fibrocartilage (labrum) • Protects the acetabulum Deepens acetabulum making dislocation more difficult • Stretch of the Gluteus medius may be painful in geriatric clients with DJD (degenerative joint disease) - Superior and Lateral pain • Hyaline Cartilage and fatty tissue surround the acetabulum (female athlete triad= loss) • Aging, corticosteroid use and bone demineralization lead to re-absorption of tension trabeculae predisposing the femoral neck to pathologic fracture due to the shearing forces of daily activities • Epiphyseal plates at right angles to the tension trabeculae predisposing the plates to ground reaction forces/ epiphyseal plate fractures (Salter Harris Fractures) or Slipped Capital Femoral Epiphysis • 10-20% of people who suffer hip fractures die within one year. (mortality rate 5 yrs = 90%) -Fracture exposes bone marrow into blood stream= pulmonary embolism Trabeculea breakdown causes falls in geriatric patients Closed Kinetic Chain: - Drop arch L. foot -Int Rot. Tibia -buckle knee - int rot. Femur Hip drops L - compensatory R upper - Lumbarthorasic paraspinals spasm -depressed R shoulder - lead to wrist and elbow problems Trabecular Patterns: Tension Trabeculae are medial to lateral Compression Trabeculae inferior to superior Quadriceps Contusion: #1 Thigh Injury • Etiology: Traumatic blunt blow • Signs and Symptoms- Graded 1-4 Pain, transitory paralysis, immediate effusion with palpable swollen area • Management Conservative!!! RICE, NSAID’s and analgesics Crutches for 3 &4 Aspiration of hematoma Follow-up care consists of ROM, and PRE w/in pain free range KT TAPING Myositis Ossificans (Traumatica): • Etiology Ectopic bonerepeated blunt trauma Gradual deposit of calcium and bone formation (in muscle belly) • Signs and Symptoms X-ray shows calcium deposit after 2-6 weeks Pain, weakness, swelling, decreased ROM • Management Treatment must be conservative May require surgical removal if too painful and restricts motion (extreamly large 1 time force or repetitive small forces) Quadriceps Muscle Strain: • Etiology Sudden stretch, Falls on bent knee, Sudden contraction , Weakened constricted muscle • Signs and Symptoms: Pain, point tenderness, spasm, loss of function and little discoloration • Management RICE, NSAID’s and analgesics Manage swelling, compression, crutches Isometrics and stretching as healing progresses Neoprene sleeve: compression in area and gives false security Hamstring Muscle Strains: #2 most common thigh injury • Etiology Exact unknown (closed kinetic chain, leg discrepancy) • Signs and Symptoms • Grade 1 – after cool down, soreness during movement and point tenderness • Grade 2 - partial tear, “snap”, severe pain, and loss of function • Grade 3 - Rupturing of tendinous or muscular tissue, severe edema, severe ecchymosis, palpable mass • Management RICE, NSAID’s and analgesics Grade I - don’t resume full activity until complete function restored Grade 2 and 3 conservatively, gradual return to stretching / strengthening later • Soreness eliminated = isotonic leg curls (eccentrics) • Recovery may require months to a full year • Greater scaring = greater recurrence Acute Femoral Fractures: • Etiology Shaft – Middle Third Fall or direct blow • Signs and Symptoms Pain, swelling, major deformity • Management Treat for shock , Splint, X-ray Groin Strain: • Etiology Difficult to diagnose Running , jumping, twisting w/ hip external rotation or severe stretch Imbalance • Signs and Symptoms Sudden twinge or tearing Produce pain, weakness • Management • RICE, NSAID’s and analgesics for 48-72 hours • Determine exact muscle involved • Rest is critical • Delay exercise until pain free • Restore normal ROM and strength, support w/ wrap Dislocated Hip: • Etiology • Result of traumatic force directed along the long axis of the femur • Signs and Symptoms • Flexed, adducted and internally rotated hip • Serious pathology • Management • Immediate medical care • Contractures may further complicate • 2 weeks immobilization and crutch use for at least one month • Careful of Avascular Necrosis: head of the femur dies and collapses lack of BF Snapping Hip Phenomenon: • Etiology Common in young female dancers, gymnasts, hurdlers Muscles around hip become imbalanced Structurally narrow pelvis, increased hip abduction and limited lateral rotation Hip stability compromised • Signs and Symptoms Pain w/ balancing on one leg, possible inflammation • Management Cryotherapy and ultrasound to stretch musculature and strengthen weak musculature Hip Contusion- Hip Pointer: Bruise at the top of the pelvic bone (iliac crest) • Etiology Contusion of iliac crest / abdominal musculature • Signs and Symptoms • Pain, spasm, and transitory paralysis Decreased rotation of trunk or thigh/hip flexion • Management • RICE at least 48 hours, NSAID’s, • X-ray , Ice massage, ultrasound, Injection • Recovery 1-3 weeks Iliotibial Band Syndrome: • Etiology Running, Cycling, Squatting Leading cause in knee pain in runners Chronic Unidirectional movements w/o other directional movements • Signs and Symptoms Pain is usually above the knee on lateral aspect Intensifies during foot strike Pain persists after activity Pain may also be present Below knee where it attaches Proximal at the TFL or thigh • Management Old Treatments: Avoid activities that aggravate the condition, RICE, Stretching • McConnell’s Taping, VMO Strengthening IT band compression wrap, IASTT, ART, Foam Roller Hip Bursitis: • Etiology Local Soft Tissue Trauma Repetitive stress injury Strain injury Infection • Signs and Symptoms Ca
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