8 – 13 March,2010

Page 1
IDK and role Of Sports Physician

Lt Col (Dr) S DasSarma

 The most frequent
Orthopedic arthoscopic
procedure
1. Knee arthroscopy and
meniscectomy
2. Shoulder arthroscopy and
decompression
3. Carpal tunnel release
4. Knee arthroscopy and
chondroplasty
5. Removal of support implant
6. Knee arthroscopy and
anterior cruciate ligament
reconstruction
?
Poor biomechanics
causing injury
Prevention

Emergency management

Proper diagnosis

Plan treatment modality

Prehabilitation

Rehabilitation
Role of meniscus
JOINT MOTIONS:

3 rotations
3 translation

3 Accessory
movements
TYPICAL ACL INJURY

Non-contact injury occurs in 70%

of cases.
Running or jumping with
sudden deceleration and
direction change, or pivoting
while rotating or lateral
bending (valgus stress).

Contact injury
Lateral blow leading to
hyperextension or lateral
stress while foot is planted.
Theories to Explain Increased Incidence in
female

Structural Training
• Wider pelvis Differences
• Q-angle – Strength
• Joint laxity – Technique
• Narrow intercondylar notch

Hormonal – Estrogen

• Collagen Strength
• Joint Laxity
What are the Differences?
 Time to Peak Torque
Hamstrings
Females have a longer
Male athletes vs male non-
electromechanical delay then
athletes 328-443 msec
males
Males hamstring muscles fire Female athletes vs male
faster non- athletes 430-443
msec
(Huston & Wojlys AJSM
1996)
 Recruitment Order

Male athletes:
Hamstrings Quads Gastroc

Female athletes:
Quads Hamstrings Gastroc
(Huston & Wojlys AJSM 1996)
 Muscle Strength

 Female athletes = female controls

(Huston & Wojlys AJSM 1996)

 Quad/hamstring ratio 47% in females

 Quad/hamstring ratio 67% in males
 Technique

Males Females
 Flex knee 20-30°  Straight-legged to 10°
when landing flexed posture when
 Hamstrings control landing
landing  Attempt to use quads
 Proper force to control landing
attenuation  Causes valgus knee
position
 Use hamstrings and
hip extensors less
 Move through
deceleration faster
Drop Vertical Jump
Single Leg Squat

• The SLS simulates a common

athletic position, requires control
for the body over a planted leg, and
is used to screen for poor hip
strength and trunk control.
• Female subjects have a tendency to
have a decreased hip control when
going down and coming up in a
squat which can cause knee valgus
movement (Zeller, 2003).
• Knee valgus is thought to be a
possible factor for noncontact ACL
injury (Hewett, 2004).
 Risk Factors

Footwear
Longer cleats at edge of sole
with fewer, smaller cleats in
the middle of the sole
’s torsional resistance

Lambson 1996 AJSM

Risk Factor

Uneven playing surface

Unexpected foot position
may change muscle
activation patterns
Balance thrown off

Boden, Orthopedics
 Shoes with lower ACL injury
risk:
•Cleats flat, all the same size
on forefoot
•Screw in cleats with 0.5in
ht/diameter cleats
•Pivot disk: 10-cm circular
edge on sole of forefoot
•Flat shoes on turf

Lambson 1996 AJSM

Bracing
 Knee Braces

Prophylactic –DO not prevent rotation injures

Functional – provide stability to unstable knee

No great studies
No studies showing custom fit better than pre-sized
More limitation than prophylactic braces ( do prevent
rotation injuries as well)
Limiting extension to 10-20 degress may prevent
hyperextension injuries

Rehabilitative – allow protected and controlled motion during

knee rehabilitation

Patellofemoral Braces – improve patellar tracking

Studies mixed on effectiveness
Typically made of neoprene with butresses that support
the patella – relatively inexpensive
Prophyla PatelloFemoral Brace
Functional Brace
ctic
Brace
ROLE OF KINETIC CHAIN

• Hip extensor weakness

• Ankle stabilizer weakness
• Poor core stability
Components of ACL Prevention

•Flexibility

•Strengthening
•core strength

•Plyometric training
Flexibility
• Check - clinically, functionally
• Improve
• Proper technique
Essentials of Plyometric
Training • Bod y po si t i o ni ng
• Bod y po si t i o ni ng
CC
oror r rect
ect post
post ururee
• Jum p s t r ai g ht up
• Jum p s t r ai g ht up
Sof
Sof t t l laandi
nding
ng
• Bal ance
Bal ance
 Plyometrics
• A n ef f ect i v e pl yom e t r i c pr ogr a m sh oul d:
A n ef f ect i v e pl yom e t r i c pr ogr a m sh oul d:

ppeak
eakl laandi ndinnggf foor rces
ces
 m agni t ude of m om en t s at t he knee
 m agni t ude of m om en t s at t he knee
kknee
neef fl l exiexioonnan anglglee
 l ow er ext r em i t y st r engt h
 l ow er ext r em i t y st r engt h
vverert ti ica
cal l j juummpp hei
height
ght
 I m pr ov e l a ndi n g m ec hani c s
I m pr ov e l a ndi n g m ec hani c s
 CKC

Squats Lunges
More Quadriceps Exercises

Leg Extension

Leg Press
 More Quadriceps Exercises

Plyometric or Jump Training Uphill Running

Hamstring Exercises

?? RESP
CORE
RESP
CORE
Hamstring Exercises
Exam Settings

1. Sideline Exam (on the field

triage)
2. Training room (post game
eval)
3. Office/clinic Exam (delayed
+ detailed)
Sideline Exam Routine

1. Determine mechanism
2. Point of maximum
tenderness
3. Maneuver producing
most pain
4. Determine severity of
damage
 Knee Hemarthrosis
Differential Diagnosis

ACL
70%
Meniscus
50%
Fracture
20%
Patellar dislocation
PCL
• Types of Instability
• Single plane instability –
• Dual plane….
• Antero-lateral - ACL and LCL/ITB
• Antero-medial - ACL and MCL
• Postero-lateral - PCL and posterior capsule/ LCL
• Postero-medial - PCL and posterior capsule

• Mechanical instability may be graded….

• Grade 0 - Normal (left = right)
• Grade 1+ - less than 5mm laxity
• Grade 2+ - 5 to 10mm laxity
• Grade 3+ - more than 10 to 15mm laxity….

• Functional instability may also be graded….

• Grade 0 - Normal
• Grade 1 - Gives way during change of direction at
speed
• Grade 2 - Gives way during running straight
• Grade 3 - Gives way when changing direction at
walking pace or uneven ground
• Grade 4 - Gives way when walking forward on level
ground
Rotatory Instability
 LachmanTest ,Anterior/post
Drawer Test ,pivot shift test

Lachman Test Sens 87% Spec 93%

Anterior Drawer Sens 48% Spec 87%
Pivot Shift Test Sens 61% Spec 97%
 (Jackson JL, et al.)

Joint Line Tenderness Sens 76% Spec 29%

McMurray Test Sens 52% Spec 97%
 Knee X-Rays

Ottawa Knee rules: determines the need

for x-rays, proven sensitive for
fracture.

1. Age > 55
2. Tenderness head of fibula
3. Isolated patellar tenderness
4. Inability to flex knee 90 degrees
5. Inability to bear weight
Segond Fracture:
avulsion fracture
of anterolateral
tibial plateau at the
site of attachment
of the lateral
capsular ligament.

Avulsion fractures
from femoral or
tibial ACL
attachments.
MRI – T1
MRI – T2
A
Indication of opt in ACL
C
L

r Knee instability
Young ; athlete
e
c No or a little DJD
o
n
s
t
Graft Choices

• Autografts
• Bone-patellar tendon-bone
• hamstrings (Grac & Semi-T)
Patella Tendon Graft
Interference screw

Biodegradable

Metalic
Examples of post-op regimes…..

Early (0 to 6 weeks)
Protect ligament - braces…
CPM to achieve mobility
Teach safe transfers….
Muscle re-education - hamstrings and
CKC…
Progressive WB - usually PWB to FWB…
Sample Rehabilitation Program
• WEEKS 0-2:
• Non weight bearing
• Quadriceps and Hamstring isometrics
• Electrical muscle stimulation
• Ankle ROM and strengthening
• Heel slides
• Patellar mobilization
• WEEK 4:
• Non weight bearing
• Quadriceps and Hamstring isometrics
• Straight leg raises
• Electrical muscle stimulation Straight leg raises
• Pool exercises (hip and ankle)
• Stationary bike
• Stairmaster
• WEEK 6:
• Non weight bearing
• Quadriceps and Hamstring isometrics
• Straight leg raises with weight (see diagram)
• Hamstring curls (see diagram)
• Hip progressive resistance exercises
• Pool ROM Hamstring Curl
• Cycling for ROM
 • Sample plan (continued)
• WEEK 8:
• Begin weight bearing
• ROM should be 0 and 110 degrees
• Cycling
• Hamstring curls 
• Jump rope
• Swimming
• 3 MONTHS:
• ROM 0 and 125 degrees
• Treadmill walking
• Cycling
• Quarter squats
• Sport specific skills
• 4 - 6 MONTHS:
• ROM 0 and l40 degrees
• Treadmill walking
• Isotonic knee extensions
• Isokinetics when 10% of body weight can be done isotonically (120-240degrees/second)
• Step-ups
• 6 MONTHS:
• Test isokinetically
• Begin terminal knee extension
• Running (straight ahead)
e
a
lii
n
Fixation to bone in tunnel
g

PT 8 weeks
Ham 12 weeks
e
a Graft strength
lii
0 – 2 weeks Normal
n 2 – 6 weeks Decreasing
g 6 – 12 weeks Weakest
12 weeks on Increasing
9 months Normal
Revascularisation !
s Prehabilitation
t
r Education( bio feed back)
Muscle strengthening
u Quads vs Hamstring ratios
c ROM
t Proprioception
Core stability
i
o
n
s
t
r
u
c
t When To go for Opt
i
o Full RoM
Locked knee ?
n
No effusion

No pain
Meniscus MRI
 Mechanical Causes

Meniscus Unstable Injuries

Locking and catching symptoms

Must be differentiated from

“popping and clicking”
Sometimes cannot extend knee

Surgery is indicated sooner

because possible damage to knee
from unstable meniscus
 Meniscal Injuries - mechanism
• Movements of the menisci during flexion,
extension and rotation (posterior during flexion,
anterior during extension)

• Mechanism of injury normally involves extension

and rotation as loads applied to each meniscus
may be in opposite direction….
• Extension/internal rotation - medial meniscus
• Extension/external rotation - lateral meniscus
(less common due to less firmly bound down
to the tibia)
• Usually in a non-contact situation - during
cutting manoeuvres

• May also occur in occupations which involve

sustained squatting or kneeling
Types of Meniscal Tear

Depends on
degree of
degeneration and
mode of injury

Presentation is
dependent on
type of tear
 Clinical Presentation

Specific history in most cases

Pain - usually from coronary and
menisco-femoral ligaments

Torn fragment may become displaced

leading to locking of joint - limited
extension - close packed position
‘Giving way’ – instability

Effusion
Positive meniscal tests - McMurray’s,
Apley’s, Shear tests (medial and lateral)
etc.

MRI may reveal tear

 Management

Small peripheral tears

may be treated
conservatively if injury
within vascular zone

Repair - if tear within

vascular zone.

Excision - partial or
complete resection of
torn meniscus via
arthroscopy or
arthrotomy
 Knee Rehabilitation

CKC Research • OKC Research

Decrease Tibial Translation – Increase Tibial
More vastus medialis and lateralis Translation 1
muscle activity – More rectus femoris
Greater patellofemoral muscle activity 2
compressive forces – Less patellofemoral
Increased compressive forces and compressive forces
co-contraction – Increased shear forces
and less co-contraction
2
E
x Reduction of swelling - R.I.C.E.
e Re-education of quads activity - high incidence of post op.
inhibition…
r WB a.s.a.p. - +/- walking aids as necessary….
Pain control as necessary….
c Restoration of mobility and strength
i Functional re-educate as necessary - include proprioceptive re-
education…
s Use pain and effusion as guide….
Concept of cycling,
e
Following repair
This will require a similar pattern of rehabilitation but more
? conservatively….
Site of repair will determine how conservative - peripheral vs,
more central…
NWB to PWB immobilisation for 3 to 6 weeks….(note different
regimes….)
Return to running and sport 3 to 4 months post-operatively…
r
u
i
s
Up to 80% of ACL injuries
e
97% Lateral
s Not caused by arthroscopies
↓ PGs in overlying cartilage
↓ GAGs in overlying cartilage
↓ GAG + ↑ risk OA
Takes 2 years to
normalise

Management- RR M Ar
RO
LE
O FS
PO
RT
SP
HY
SIC
IAN
I SP
AR
A MO
U NT
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THANK YOU