INSTITUTE- UIAHS

DEPARTMENT- PHYSIOTHERAPY
MASTER OF PHYSIOTHERAPY (MPT)
Advanced Sports injury Management Strategies-II
20MPB-752
Dr. Kamran Ali
Assistant Professor

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BIOCHEMISTRY- CARBOHYDRATE
 E. Special tests
2. stability tests
(a) MCL
(b) LCL
(c) ACL
(i) Lachman’s test
(ii) anterior drawer
test
(iii) pivot shift test 7. Neural
(d) PCL
6. Functional Tension
(i) posterior sag
3. Tests Tests
1.presence (ii) reverse
flexion/rotation 4. Patellar 5.
Lachman’s test Apprehension Patellofemoral a. Squat Test a. Prone
of effusion (iii) posterior
(McMurray’s) Test joint
drawer test test b. Hop test knee bend
(iv) external c. Jumping
rotation test—
active and b. slump
passive
(e) patella
(i) medial and
lateral patella
translation (or
mobility)
 FIG: Presence of eff usion. Manually drain
the medial subpatellar pouch by stroking the fluid
in a superior direction. Then ‘milk’ the fluid back
into the knee from above on the lateral side while
observing the pouch for evidence that fl uid is
reaccumulating. This test is more sensitive than
the ‘patellar tap’. It is important to diff erentiate
between an intra-articular effusion and an extra-
articular hemorrhagic bursitis

FIG: Passive movement—extension. Hold

both legs by the toes looking for fixed fl
exion deformity or hyperextension in the
ACL, or PCL rupture. Overpressure may be
applied to assess end range. This procedure
may provoke pain in meniscal injuries
FIG: Stability test—MCL. This is tested with the knee
in full extension and also at 30° of fl exion (illustrated).
The examiner applies a valgus force, being careful to
eliminate any femoral rotation. Assess for onset of
any pain, extent of valgus movement and feel for end
point. If the knee ‘gaps’ at full extension, there must be
associated posterior cruciate injury

FIG: Stability test—LCL. The LCL is tested in a

similar manner to the MCL except with varus
stress applied
 Stability test—anterior drawer test. This is
performed with the knee in 90° of fl exion and the
patient’s foot kept stable. Ensure the hamstrings are
relaxed with the index finger on the femoral
condyles. The tibia is drawn anteriorly and assessed
for degree of movement and quality of end point.

Stability test—Lachman’s test. Lachman’s test is

performed with the knee in 15° of fl exion, ensuring the
hamstrings are relaxed. The examiner draws the tibia
forward, feeling for laxity and assessing the quality of
the end point. Compare with the uninjured side Stability test—posterior drawer
test. With the knee
as for the anterior drawer test,
the examiner grips the
tibia fi rmly as shown and
pushes it posteriorly. Feel
for the extent of the posterior
movement and quality
of end point.

Stability test—posterior sag. With both knees

fl exed at 90° and the patient relaxed, the position of
the tibia relative to the femur is observed. This will
be relatively posterior in the knee with PCL deficiency
Special test—pivot shift test. With the tibia
internally rotated and the knee in full extension, a
valgus force is applied to the knee. In a knee with ACL
defi ciency, the condyles will be subluxated. The knee
is then fl exed, looking for a ‘clunk’ of reduction, which
renders the pivot shift test positive. Maintaining this Flexion/rotation (McMurray’s) test. The
Special tests—patellar
position, the knee is extended, looking for a click into knee is flexed and, at various stages of fl
apprehension test. The
subluxation, which is called a positive jerk test exion, internal and external rotation of knee may be placed on a
the tibia are performed. The presence of pillow to maintain 20–30°
pain and a palpable ‘clunk’ is a positive of fl exion. Gently push the
McMurray’s test and is consistent with patella laterally. The test is
meniscal injury. If there is no ‘clunk’ but positive if the patient
the patient’s pain is reproduced, then
develops apprehension with a
the meniscus may be damaged or there
sensation of impending
may be a patellofemoral joint
dislocation
abnormality
 INVESTIGATIONS
• The main aim of performing an X-ray in cases of moderately severe acute knee
injuries is to detect an avulsion fracture associated with an ACL injury or a tibial
X-RAY plateau fracture following a high-speed injury.

• In cases of uncertain diagnosis and suspected meniscal abnormality

MRI
• To determine the extent of ACL injury, articular damage and patellar tendon injury.

• Partial tear of patellar tendon.

• Can detect the size and location of bursal swelling, and identify intra versus extra
ULTRASOUND articular swelling.

• Can be used as an investigation and treatment both.

ARTHROSCOPY
 Ottawa knee rule
• A set of decision criteria known as the Ottawa knee rule was developed in an adult emergency medicine setting in the
mid 1990s
• Criteria for Ottawa Knee Rule
• A knee radiograph is indicated after trauma only when at least one of the following is present:
• patient age more than 55 or less than 18 years
• tenderness at the fibular head
• tenderness over the patella
• inability to fl ex the knee to 90° (this captures most hemarthrosis, fractures)
• inability to weight-bear for four steps at the time of the injury and when examined.
To these, we suggest a high index of suspicion for:
• high-speed injuries
• children or adolescents (who may avulse a bony fragment instead of tearing a cruciate ligament)
• if there is clinical suspicion of loose bodies.
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 Patellofemoral pain syndrome
The patellofemoral pain syndrome (PFPS) is a common cause for “anterior
knee pain” and mainly affects young women without any structural changes
such as increased Q-angle or significant pathological changes in articular
cartilage . Therefore, PFPS is a diagnosis of exclusion.
Static or dynamic malalignment
• The role of the Q-angle (static measure) as predictor for PFPS
is discussed controversially .
• Rauh et al. [2007] found that cross-country runners with
increased Q-angle (>20°) are more prone to knee injury than
athletes with normal Q-angle.
• In contrast, Park et al. [2011] have shown that the Q-angle is
not increased in PFPS patients. Other reports also do not show
strong correlations between static measures such as the Q-
angle to the onset of PFPS.
• That means that the cause for maltracking of the patella and
the imbalance of the vastus medialis and lateralis in some
patients with a PFPS may not be part of a structural fault.
Role of vastus lateralis and vastus medialis muscle

• Pal et al. [2011] have demonstrated that “patella maltracking” in patients

with PFPS correlates with a delayed activation of the M. vastus medialis.
An imbalance in the activation of the M. vastus medialis obliquus and M.
vastus lateralis was also shown by Cowan et al. [2001]. In patients with a
PFPS, the M. vastus lateralis was earlier activated than the M. vastus
medialis obliquus when patients climbed downstairs and upstairs. In the
control group that imbalance did not exist. These findings were
supported by several other studies . Patients with patellofemoral
problems exhibited atrophy of the vastus medialis obliquus [2011].
• Despite these results, however, it is not clear whether the M. vastus
lateralis and medialis imbalance are the primary cause for patellar
maltracking.
• Myer et al. [2010] studied female middle and high school
basketball players. In this study, athletes who developed a new
PFPS demonstrated increased knee abduction moments of the
symptomatic limb. That means there is a dynamic valgus position
of the knee joint, which might be reinforced by an internal
rotation of the femur and tibia .
• A dynamic valgus alignment is more frequently observed in female
athletes compared to males. These biomechanical and
neuromuscular mechanisms may be links to the pathogenesis of
PFPS in young female athletes. The functional or dynamic valgus
may influence patella tracking leading to lateralization of the
patella (Macintyre, 2006].
 • Joint Mobilization
PFPS Rehabilitation Protocol •Medial Patellar Glide most important
•Phase 1: 2-4 weeks •Perform with the knee in multiple positions (except
•Phase 2: 2-4 weeks full flexion)
•Phase 3: 2-4 weeks •Progress from 0o
•Stretching the Lateral retinaculum
•Phase 4: Functional testing
•Begin with Grade 1 and 2 and progress to grades 3
Phase 1 and 4
•Phase 1 of this rehabilitation program is •Grades I and II- pain reduction and relaxation (2-3
primarily gauged at increasing ROM and oscillations 1-2 min)
general strengthening Should focus on the •Grades III and IV- increase mobility (2-3 oscillations
areas of concern brought upon evaluation fro 20-60 sec)
•Dependent on severity athlete may continue •Repeat 3-5 times
limited participation while rehabilitating. NMC training
Phase 1: stretching •Basics; begin shoes on eyes open on stable surface
•ITB** •Progress to shoes off
•Hamstrings •Then eyes closed
•30 seconds; record errors
•Quadriceps/hip flexors •T-band kicks
•Groin musculature •All should be performed with 30o flexion
Phase 1: Strengthening
Open Kinetic Chain Exercises- all 3sets 12 repetitions Phase 1: Cardiovascular training
•Quad sets Aquatics
•Manual resisted knee extension
•Straight leg raises
•Running in water
•Hip flexion •Swimming; freestyle
•Extension •Elliptical
•Abd/add •Bicycle
•Movements dependent on areas of weakness •Be aware of ROMs that cause pain
•Towel squeeze
•Isometric abd
•Sprint programs on bike
•Use light weights and gravity •Phase 2
Phase 1: Strengthening •Progressing to phase 2 when…
Closed kinetic chain exercises- 3x12 •Inflammation significantly reduced
•Terminal knee extension with theraband •Pain only occurs past 90 degrees of CKC
•Use biofeedback if available. •Significant strength gains in VMO and other
•Leg presses- 45o
quad musculature
•Squats- 45o
•Sustained contraction (biofeedback)
•Front/lateral step ups
•Wall squats •Increased ROM in hamstrings, quads,
•Isometric Wall sits 30 sec hold adductors
•Progress to 2 min •Dependent on where tightness is present
Phase 2 Phase 2: strengthening
•Continue stretching (specifically ITB) • Closed kinetic chain exercises- 3x15
•Continue Patellar mobilizations
•Continue NMC- progress • Wall squats to 90oIncorporate adduction squeeze with
medicine ball
•Continue strengthening
•Emphasize CKCE • Wall sits @ 90o
•Increase weight • Leg Press
•Increase ROM of exercises
Phase 2: Neuromuscular control
• Deeper ROMs
•Progress to unstable surface with no shoes • Barbell squats
•Progress to unstable surface with eyes closed • Front lunges
•Sport specific activities while performing • Reverse lunges
•Quadrant hops Phase 2: Isokinetic strengthening
•Progression • Concentric/eccentric protocol of quad muscle
•Add resistance with theraband
• Begin at lower velocities work up to more functional velocities.
•Can incorporate 180o rotations with hop.
• Studies have shown that isokinetic strengthening of quad musculature for 8
•Lunges on an unstable surface- 3x12 weeks relieved the symptoms in 70% of patients with PFPS.
•Straddled position; one leg on unstable surface • Typical progressions:
•Hands on hips
• 90o per sec
•90degrees bend
•Can do forward or backward lunges • 150o per sec
• 225o per sec
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 Second level
 Third level
 Fourth level
 Fifth level
Phase 3
Phase 3: functional activities  As they become better and times improve progress to more
dynamic forms of plyometrics
 Sprinting
 Side to side ankle hops (over barrier): 2x 16
 Smaller Figure 8’s
 Squat with overhead medicine ball toss: 2x 25
 T-Drill (sprint)
 Single leg side to side ankle hops(over barrier): 2x 16
 Four Corner Drill
 Lateral step ups: 2x 20
 Agility ladder drills
 Squat jumps
 Use more dynamic drills
 Lunge jump (beginner)
 Modified Four Corner Drill
 4-3-2-1
 1-2-4-3-1
 Sport Specific
 Shuffle, back peddle, carioca

Phase 3:  Plyometrics

 Begin with the basics
 As they become better and times improve progress to more
Reference

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