KNEE INJURIES

 PANOS THOMAS

 TUTOR MSc SPORTS AND EXERCISE

MEDICINE
 UCL
 KNEE INJURIES
 1) OVERUSE KNEE INJURIES

 2) ACUTE KNEE INJURIES

 OVERUSE KNEE INJURIES
 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)
 - 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
 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
 - 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
 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
 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
 - 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
 - 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
 - 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
 - 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
 - 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
 - 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
 - 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
 - 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
 - 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
 - TREATMENT:
 REST FROM HYPEREXTENTION
(MARTIAL ARTS ) , NSAIDS,
ELECTROTHERAPY.
 SIGNIFICANT FIBROSIS:
ARTHROSCOPIC EXCISION
 6) PATELLAR TENDINITIS
( JUMPER’S KNEE )
 - 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 )
 - 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 )
 - 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 )
 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 )
 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
 - 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
 TREATMENT: STRETCHING
HAMSTRINGS, NSAIDS, REST WHEN
ACUTE, LOCAL INFILTRATIONS,
ORTHOTICS
 ACUTE KNEE INJURIES
 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
 5) INJURIES TO THE MENISCI
 6) OSTEOCHONDRAL PROBLEMS
 7) PATELLOFEMORAL INSTABILITY
 1) ACL RUPTURE
 - 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 )
 1) ACL RUPTURE
 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)
 1) ACL RUPTURE
 SURGICAL TREATMENT
 - FAILED CONSERVATIVE (50%
PATIENTS ), AGE (?0A)
 - PRIMARY REPAIR, INTRARTICULAR
GRAFT, EXTRARTICULAR
STABILIZATION, ALLOGRAFT,
SYNTHETIC LIGAMENT
 1) ACL RUPTURE
 - ARTHROSCOPIC SURGERY VERSUS
OPEN SURGERY
 - UPDATE SURGERY: ARTHROSCOPIC
RECONSTRUCION USING PATELLAR
OR HAMSTRINGS INTRARTICULAR
GRAFT
 2) PCL RUPTURE
 - 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
 - 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
 - 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
 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
 - RARE, DIRECT VARUS FORCE
 - PART OF POSTEROLATERAL
CORNER STABILITY
 - COMBINED WITH ACL, PCL
RUPTURES
 - CONSERVATIVE OR
RECONSTRUCTION (PART OF PLC)
 5) MENISCI INJURIES
 - 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
 - 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
 - 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
 - OSTEOCHONDRAL FRACTURE
( MIMIC MENISCAL TEARS )
 - OSTEOCHONDRITIS DISSECANS
( SEPARATED SEGMENT )
 7) PATELLOFEMORAL
INSTABILITY
 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
 DISLOCATION:
 - REDUCTION: FLEX THE HIP AND
GRADUALLY EXTEND THE KNEE
 - X-RAYS TO EXCLUDE
OSTEOCHONDRAL FRACTURES,
LOOSE BODIES
 7) PATELLOFEMORAL
INSTABILITY
 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
 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