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FahadFahad
zakwanzakwan
MD5MD5
one of the most commonly injuredone of the most commonly injured
jointsjoints
lack of bony and muscular supportlack of b...
1.1. ACUTE KNEEACUTE KNEE
INJURIESINJURIES
2.2. OVERUSE KNEEOVERUSE KNEE
INJURIESINJURIES
ACUTE KNEE INJURIESACUTE KNEE INJURIES
1.1. Anterior cruciate ligament (ACL) injuryAnterior cruciate ligament (ACL) injury...
1. Anterior cruciate ligament (ACL)1. Anterior cruciate ligament (ACL)
injuryinjury
Most are non-contactMost are non-cont...
FemalesFemales playingplaying soccersoccer,, gymnasticsgymnastics andand
basketballbasketball are at highest riskare at h...
HxHx::
Hearing or feeling a “pop” & knee gives wayHearing or feeling a “pop” & knee gives way
Significant swelling quic...
PEPE::
Large effusion,Large effusion, ROM↓ ROM↓
Difficult to bear weightDifficult to bear weight
Positive anterior dra...
Imaging:Imaging:
X-rayX-ray
alwaysalways
MRIMRI
The left ACL has beenThe left ACL has been
torn for over 10 yrs. whilet...
MRI
TreatmentTreatment::
RICERICE
Hinged knee braceHinged knee brace
CrutchesCrutches
Pain medicationPain medication
Reh...
PrognosisPrognosis::
Usually an isolated injuryUsually an isolated injury
Post-op: 8-12 months until full activityPost-...
Posterior cruciate ligamentPosterior cruciate ligament
(PCL)injury(PCL)injury
MxnMxn::
hyperflexionhyperflexion
falling...
TxTx::
RICERICE
ImmobilizationImmobilization
CrutchesCrutches
Physician referralPhysician referral
6-8 weeks rest/re...
Stress testsStress tests
Posterior sagPosterior sag
Strest tests
Sunrise orSunrise or
posterior sagposterior sag
3. Medial Collateral ligament (MCL)3. Medial Collateral ligament (MCL)
InjuryInjury
Important in resistingImportant in re...
HxHx::
Immediate pain over medial kneeImmediate pain over medial knee
Worse with flexion/extension of kneeWorse with fl...
PEPE::
no effusionno effusion
medial swellingmedial swelling
pain with flexionpain with flexion
tender over medialten...
ImagingImaging::
obtain radiographs to r/o fractureobtain radiographs to r/o fracture
MRI if other structures involved ...
 TreatmentTreatment: Grade I: Grade I no laxity @ 0°or 30°→no laxity @ 0°or 30°→
Grade IIGrade II no laxity @ 0°,but→no l...
PrognosisPrognosis::
Grade I -- 10 daysGrade I -- 10 days
Grade II -- 3-4 weeksGrade II -- 3-4 weeks
Grade III -- 6-8 ...
ComplicationsComplications
The terrible triad or unhappy triadThe terrible triad or unhappy triad
Torn ACLTorn ACL
Torn...
4. Lateral collateral ligament4. Lateral collateral ligament
(LCL) injury(LCL) injury
MxnMxn::
Varus force to medial asp...
Tx:Tx:
RICERICE
CrutchesCrutches
Knee immobilizerKnee immobilizer
Physician referral with 2Physician referral with 2n...
5. Meniscal injuries5. Meniscal injuries
Meniscus = ‘little moon’Meniscus = ‘little moon’
in greekin greek
Absorbs shock...
CausesCauses::
Sudden twistingSudden twisting
Young athletesYoung athletes
Simple movementsSimple movements
Older knee...
Hx:Hx:
Clicking, catching or lockingClicking, catching or locking
Worse with activityWorse with activity
Tends to be s...
PEPE::
mild-moderatemild-moderate
effusioneffusion
pain with fullpain with full
flexionflexion
tender at joint lineten...
Imaging:
MRI
TreatmentTreatment::
RICERICE
Surgical repair orSurgical repair or
excision (arthroscopic)excision (arthroscopic)
Crut...
PrognosisPrognosis::
Results of surgical repair/excision areResults of surgical repair/excision are
very goodvery good
...
7. Patellar7. Patellar
dislocation/instabilitydislocation/instability
Patella may dislocate or sublux laterallyPatella ma...
Indirect traumaIndirect trauma
most commonmost common
mechanismmechanism
Strong quadStrong quad
contraction while legcon...
Risk factors:Risk factors:
TraumaTrauma
Pes planusPes planus
Genu valgumGenu valgum
Weak VMOWeak VMO
Hx:Hx:
Feel a ‘pop’ and immediate painFeel a ‘pop’ and immediate pain
Obvious knee deformityObvious knee deformity
Pai...
dislocation
PEPE::
LaterallyLaterally
shifted patellashifted patella
PatellarPatellar
apprehensionapprehension
SwellingSwelling
ImagingImaging::
Standard knee x-Standard knee x-
rays a good startrays a good start
Likely need an MRILikely need an M...
Treatment:Treatment:
NSAIDSNSAIDS
IceIce
Patellofemoral kneePatellofemoral knee
brace/rigid bracebrace/rigid brace
PT...
PrognosisPrognosis
Recurrent instability is common, butRecurrent instability is common, but
rehab is mainstay and very u...
Patella fracturePatella fracture
MxnMxn::
direct impact or trauma to patelladirect impact or trauma to patella
Indirect...
Patella Fracture
Tx:Tx:
RICERICE
ImmobilizeImmobilize
CrutchesCrutches
Possible surgery depending on type ofPossible surgery depending...
OVERUSE KNEEOVERUSE KNEE
INJURIESINJURIES
1. Iliotibial band tendonitis1. Iliotibial band tendonitis
2. Popliteus tendin...
1. Iliotibial band tendonitis1. Iliotibial band tendonitis
Excessive frictionExcessive friction
between iliotibial bandbe...
Iliotibial band tendonitis
Common in runnersCommon in runners
and cyclistsand cyclists
foot pronation, genufoot pronatio...
HxHx::
Pain at lateral kneePain at lateral knee
At first, sxs only after a certainAt first, sxs only after a certain
pe...
PE:PE:
Tender at lateralTender at lateral
femoralfemoral
epicondyle, ~3cmepicondyle, ~3cm
proximal to jointproximal to j...
PE:PE:
Ober’s testOber’s test
Noble’s testNoble’s test
Noble’s test
Iliotibial band tendonitis
Tx:Tx:
Relative restRelative rest
IceIce
NSAIDSNSAIDS
StretchingStretching
CortisoneCorti...
Iliotibial band tendonitis
Prognosis:Prognosis:
Improves with restImproves with rest
Expect long recovery timeExpect lo...
2. Popliteus tendinitis2. Popliteus tendinitis
surrounds posterolateral aspect ofsurrounds posterolateral aspect of
knee,...
discomfort on anterior or superiordiscomfort on anterior or superior
lat.collateral ligament and withlat.collateral ligam...
3. Patellofemoral pain3. Patellofemoral pain
syndromesyndrome
Retropatellar orRetropatellar or
peripatellar painperipatel...
Patellofemoral pain syndrome
Patella not onlyPatella not only
moves up and down,moves up and down,
but rotates and tiltsb...
Patellofemoral pain syndrome
Hx:Hx:
Vague anterior knee pain with insidious onsetVague anterior knee pain with insidious...
Patellofemoral pain syndrome
PE:PE:
Positive compression testPositive compression test
Patellar crepitus with ROMPatell...
Patellofemoral pain syndrome
PE:PE:
CheckCheck
hamstringhamstring
flexibilityflexibility
Patellofemoral pain syndrome
PE:PE:
Check for flat feet (pes planus) or high-arch feet (pesCheck for flat feet (pes plan...
Patellofemoral pain syndrome
PE:PE:
Check heel cord (achilles) flexibilityCheck heel cord (achilles) flexibility
Check ...
Patellofemoral pain syndrome
Tx:Tx:
Physical therapyPhysical therapy
Improve flexibilityImprove flexibility
Quad stren...
Patellofemoral pain syndrome
Tx:Tx:
Relative rest/ModificationRelative rest/Modification
of activitiesof activities
Ici...
4. Patellofemoral synovial4. Patellofemoral synovial
plicaplica
- REMNANTS OF THE SEPTA OF EMBRYONIC JOINT. USUALLY
PRESE...
4) PF SYNOVIAL PLICA
- ACHING ON SITTING DOWN ANTERIORLY, INTENSE THE
FIRST WALKING STEPS IN THE MORNING
O/E: FELT BANDS...
5. Infrapatellar fat pad5. Infrapatellar fat pad
syndromesyndrome
repetitive hyperextention injuries,repetitive hyperexte...
5) INFRAPATELLAR FAT PAD SYNDROME
treatment:treatment:
rest from hyperextention (martial arts )rest from hyperextention ...
6. Patellar tendonitis6. Patellar tendonitis
Also called “jumper’s knee”Also called “jumper’s knee”
Mxn:Mxn:
excessive ...
TXTX::
RestRest
IceIce
HeatHeat
UltrasoundUltrasound
Cross-friction massageCross-friction massage
NSAIDSNSAIDS
Pat...
7. Bursitis7. Bursitis
Can be acute, chronic, orCan be acute, chronic, or
recurrentrecurrent
Numerous bursae involved bu...
Bursitis
Mxn:Mxn:
falling directly on kneefalling directly on knee
Continuous kneelingContinuous kneeling
Overuse of p...
Bursitis
S/S:S/S:
Localized swelling that is similarLocalized swelling that is similar
to a water balloon and is outside...
Bursitis
Bursitis
Bursitis
Tx:Tx:
RestRest
IceIce
CompressionCompression
NSAIDSNSAIDS
Padding for protection when returning toPadding ...
Vascular InjuryVascular Injury
~20% (5-30%) of all~20% (5-30%) of all
dislocationsdislocations
EMERGENCY if NO distalEME...
Neurologic InjuryNeurologic Injury
CommonCommon peroneal nerveperoneal nerve
palsypalsy
Incidence ~20% (10-40%)Incidence...
5. knee injuries
5. knee injuries
5. knee injuries
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5. knee injuries

  1. 1. FahadFahad zakwanzakwan MD5MD5
  2. 2. one of the most commonly injuredone of the most commonly injured jointsjoints lack of bony and muscular supportlack of bony and muscular support positioned between the 2 longestpositioned between the 2 longest bonesbones weight bearing and locomotionweight bearing and locomotion functionsfunctions
  3. 3. 1.1. ACUTE KNEEACUTE KNEE INJURIESINJURIES 2.2. OVERUSE KNEEOVERUSE KNEE INJURIESINJURIES
  4. 4. ACUTE KNEE INJURIESACUTE KNEE INJURIES 1.1. Anterior cruciate ligament (ACL) injuryAnterior cruciate ligament (ACL) injury 2.2. Posterior cruciate ligament (PCL)injuryPosterior cruciate ligament (PCL)injury 3.3. Medial Collateral ligament (MCL) InjuryMedial Collateral ligament (MCL) Injury 4.4. Lateral collateral ligament (LCL) injuryLateral collateral ligament (LCL) injury 5.5. Meniscal injuriesMeniscal injuries 6.6. OSTEOCHONDRAL PROBLEMSOSTEOCHONDRAL PROBLEMS 7.7. Patellar dislocation/instabilityPatellar dislocation/instability
  5. 5. 1. Anterior cruciate ligament (ACL)1. Anterior cruciate ligament (ACL) injuryinjury Most are non-contactMost are non-contact injury, 2injury, 2° to° to deceleration forces ordeceleration forces or hyperextensionhyperextension Planted foot & sharplyPlanted foot & sharply rotatingrotating If 2° to contact, mayIf 2° to contact, may have associated injuryhave associated injury (MCL, meniscus)(MCL, meniscus)
  6. 6. FemalesFemales playingplaying soccersoccer,, gymnasticsgymnastics andand basketballbasketball are at highest riskare at highest risk Risk of injuryRisk of injury 2 – 8 times2 – 8 times in women↑ in women↑ ~250,000 injuries/year in general population~250,000 injuries/year in general population Gender difference not clearGender difference not clear Joint laxity, limb alignmentJoint laxity, limb alignment Neuromuscular activationNeuromuscular activation
  7. 7. HxHx:: Hearing or feeling a “pop” & knee gives wayHearing or feeling a “pop” & knee gives way Significant swelling quickly (< 1 hour)Significant swelling quickly (< 1 hour) UnstableUnstable ↓↓ range of motion (ROM)range of motion (ROM) Achy, sharp pain with movementAchy, sharp pain with movement
  8. 8. PEPE:: Large effusion,Large effusion, ROM↓ ROM↓ Difficult to bear weightDifficult to bear weight Positive anterior drawerPositive anterior drawer Positive Lachman’sPositive Lachman’s
  9. 9. Imaging:Imaging: X-rayX-ray alwaysalways MRIMRI The left ACL has beenThe left ACL has been torn for over 10 yrs. whiletorn for over 10 yrs. while the right knee had an ATLthe right knee had an ATL tear just for one monthtear just for one month
  10. 10. MRI
  11. 11. TreatmentTreatment:: RICERICE Hinged knee braceHinged knee brace CrutchesCrutches Pain medicationPain medication RehabilitationRehabilitation Avoid most activitiesAvoid most activities (stationary bike o.k.)(stationary bike o.k.) Surgery (in most cases)Surgery (in most cases) RICERICE •RESTREST: reduce/stop using injured: reduce/stop using injured area for at least 48hrs. If you havearea for at least 48hrs. If you have leg injury, you may need to stay offleg injury, you may need to stay off of it completely.of it completely. •ICEICE: put an ice pack on the injured: put an ice pack on the injured area for 20 min at a time, 4-8× a day.area for 20 min at a time, 4-8× a day. •COMPRESSIONCOMPRESSION: compression of: compression of an injured ankle may help to reducean injured ankle may help to reduce swelling. These include bandagesswelling. These include bandages such as elastic wraps or splints.such as elastic wraps or splints. •ELEVATIONELEVATION: keep the injured: keep the injured area elevated above the level of thearea elevated above the level of the heart.heart.
  12. 12. PrognosisPrognosis:: Usually an isolated injuryUsually an isolated injury Post-op: 8-12 months until full activityPost-op: 8-12 months until full activity ReferralReferral:: Almost all young, athletic patients will preferAlmost all young, athletic patients will prefer surgical reconstructionsurgical reconstruction ?Increased risk of DJD if not treated?Increased risk of DJD if not treated Can still get DJD if reconstructedCan still get DJD if reconstructed
  13. 13. Posterior cruciate ligamentPosterior cruciate ligament (PCL)injury(PCL)injury MxnMxn:: hyperflexionhyperflexion falling on bent knee with foot plantar flexedfalling on bent knee with foot plantar flexed Hit on fixed anterior tibiaHit on fixed anterior tibia S/S:S/S: ““pop” at the back of kneepop” at the back of knee swelling in popliteal fossaswelling in popliteal fossa + posterior sag test, +sunrise test, + posterior+ posterior sag test, +sunrise test, + posterior drawer testdrawer test
  14. 14. TxTx:: RICERICE ImmobilizationImmobilization CrutchesCrutches Physician referralPhysician referral 6-8 weeks rest/rehab6-8 weeks rest/rehab If surgery is elected, 6 weeks immobilizationIf surgery is elected, 6 weeks immobilization
  15. 15. Stress testsStress tests Posterior sagPosterior sag
  16. 16. Strest tests Sunrise orSunrise or posterior sagposterior sag
  17. 17. 3. Medial Collateral ligament (MCL)3. Medial Collateral ligament (MCL) InjuryInjury Important in resistingImportant in resisting valgus movementvalgus movement Common in contactCommon in contact sports, i.e. football,sports, i.e. football, soccersoccer Hit on outside of kneeHit on outside of knee while foot plantedwhile foot planted Associated injuriesAssociated injuries common, depending oncommon, depending on severityseverity
  18. 18. HxHx:: Immediate pain over medial kneeImmediate pain over medial knee Worse with flexion/extension of kneeWorse with flexion/extension of knee Pain may be constant or present withPain may be constant or present with movement onlymovement only Knee feels ‘unstable’Knee feels ‘unstable’ Soft tissue swelling, bruisingSoft tissue swelling, bruising
  19. 19. PEPE:: no effusionno effusion medial swellingmedial swelling pain with flexionpain with flexion tender over medialtender over medial femoral condyle,femoral condyle, proximal tibiaproximal tibia Valgus stress at 0Valgus stress at 0° &° & 30° PAIN, possible→30° PAIN, possible→ laxitylaxity
  20. 20. ImagingImaging:: obtain radiographs to r/o fractureobtain radiographs to r/o fracture MRI if other structures involved or if unsure ofMRI if other structures involved or if unsure of diagnosisdiagnosis
  21. 21.  TreatmentTreatment: Grade I: Grade I no laxity @ 0°or 30°→no laxity @ 0°or 30°→ Grade IIGrade II no laxity @ 0°,but→no laxity @ 0°,but→ lax @ 30°lax @ 30°  RICERICE  Hinged-knee brace (Grade II)Hinged-knee brace (Grade II)  CrutchesCrutches  Aggressive rehabilitationAggressive rehabilitation  NSAIDsNSAIDs  Treatment:Treatment: Grade IIIGrade III lax @ 0° & 30°→ lax @ 0° & 30°→  Same as aboveSame as above  Consider Orthopedic referralConsider Orthopedic referral
  22. 22. PrognosisPrognosis:: Grade I -- 10 daysGrade I -- 10 days Grade II -- 3-4 weeksGrade II -- 3-4 weeks Grade III -- 6-8 weeksGrade III -- 6-8 weeks When to refer:When to refer: Other ligamentous injuries (surgical)Other ligamentous injuries (surgical) Severe MCL injurySevere MCL injury Not progressing as expectedNot progressing as expected
  23. 23. ComplicationsComplications The terrible triad or unhappy triadThe terrible triad or unhappy triad Torn ACLTorn ACL Torn MCLTorn MCL Torn Medial meniscusTorn Medial meniscus
  24. 24. 4. Lateral collateral ligament4. Lateral collateral ligament (LCL) injury(LCL) injury MxnMxn:: Varus force to medial aspect of kneeVarus force to medial aspect of knee internal rotation of tibiainternal rotation of tibia S/SS/S:: POT over LCL,POT over LCL, pain,pain, swelling,swelling, loss of motion,loss of motion, ““+” varus stress at 30 degrees—solid endpoint with 1+” varus stress at 30 degrees—solid endpoint with 1stst degree, lessdegree, less stability but solid endpoint with 2stability but solid endpoint with 2ndnd degree, no endpoint with 3degree, no endpoint with 3rdrd degreedegree if “+” varus stress at 0 degrees flexion suspect ACL or PCL injury asif “+” varus stress at 0 degrees flexion suspect ACL or PCL injury as wellwell
  25. 25. Tx:Tx: RICERICE CrutchesCrutches Knee immobilizerKnee immobilizer Physician referral with 2Physician referral with 2ndnd or 3or 3rdrd degreedegree
  26. 26. 5. Meniscal injuries5. Meniscal injuries Meniscus = ‘little moon’Meniscus = ‘little moon’ in greekin greek Absorbs shock,Absorbs shock, distributes load,distributes load, stabilizes jointstabilizes joint Thick at peripheryThick at periphery →→ thin centrallythin centrally Lateral Medial
  27. 27. CausesCauses:: Sudden twistingSudden twisting Young athletesYoung athletes Simple movementsSimple movements Older kneeOlder knee
  28. 28. Hx:Hx: Clicking, catching or lockingClicking, catching or locking Worse with activityWorse with activity Tends to be sharp pain at jointTends to be sharp pain at joint lineline EffusionEffusion
  29. 29. PEPE:: mild-moderatemild-moderate effusioneffusion pain with fullpain with full flexionflexion tender at joint linetender at joint line + McMurray’s+ McMurray’s McMurray’s Test
  30. 30. Imaging: MRI
  31. 31. TreatmentTreatment:: RICERICE Surgical repair orSurgical repair or excision (arthroscopic)excision (arthroscopic) CrutchesCrutches NSAIDsNSAIDs Knee sleeveKnee sleeve Asymptomatic tears doAsymptomatic tears do not require treatmentnot require treatment
  32. 32. PrognosisPrognosis:: Results of surgical repair/excision areResults of surgical repair/excision are very goodvery good Return to full activities 2-4 months afterReturn to full activities 2-4 months after surgery; tends to be quicker for athletessurgery; tends to be quicker for athletes When to refer:When to refer: Most symptomatic meniscal injuriesMost symptomatic meniscal injuries require surgeryrequire surgery
  33. 33. 7. Patellar7. Patellar dislocation/instabilitydislocation/instability Patella may dislocate or sublux laterallyPatella may dislocate or sublux laterally Young, active patients at highest risk (~agesYoung, active patients at highest risk (~ages 13-20)13-20) Common in football & basketballCommon in football & basketball ♀♀ > ♂> ♂ Recurrence is common, especially if firstRecurrence is common, especially if first dislocation < 15 yodislocation < 15 yo
  34. 34. Indirect traumaIndirect trauma most commonmost common mechanismmechanism Strong quadStrong quad contraction while legcontraction while leg is in valgus and footis in valgus and foot plantedplanted Other knee ligamentOther knee ligament injuries can occurinjuries can occur
  35. 35. Risk factors:Risk factors: TraumaTrauma Pes planusPes planus Genu valgumGenu valgum Weak VMOWeak VMO
  36. 36. Hx:Hx: Feel a ‘pop’ and immediate painFeel a ‘pop’ and immediate pain Obvious knee deformityObvious knee deformity Painful, difficult to bend kneePainful, difficult to bend knee May spontaneously relocate, leftMay spontaneously relocate, left with feelings of instabilitywith feelings of instability
  37. 37. dislocation
  38. 38. PEPE:: LaterallyLaterally shifted patellashifted patella PatellarPatellar apprehensionapprehension SwellingSwelling
  39. 39. ImagingImaging:: Standard knee x-Standard knee x- rays a good startrays a good start Likely need an MRILikely need an MRI if injury seemsif injury seems significant orsignificant or associated injuriesassociated injuries seem possibleseem possible MRI
  40. 40. Treatment:Treatment: NSAIDSNSAIDS IceIce Patellofemoral kneePatellofemoral knee brace/rigid bracebrace/rigid brace PTPT ROM quickly (~ 2week)ROM quickly (~ 2week) Quad strengtheningQuad strengthening Elec. StimElec. Stim SurgerySurgery Recurrent instabilityRecurrent instability
  41. 41. PrognosisPrognosis Recurrent instability is common, butRecurrent instability is common, but rehab is mainstay and very usefulrehab is mainstay and very useful When to referWhen to refer Associated fractureAssociated fracture Poor response to rehabPoor response to rehab Multiple dislocations (#?) & skill levelMultiple dislocations (#?) & skill level
  42. 42. Patella fracturePatella fracture MxnMxn:: direct impact or trauma to patelladirect impact or trauma to patella Indirect trauma in which a severe pull of the patellar tendon occursIndirect trauma in which a severe pull of the patellar tendon occurs against the femur when the knee if semi-flexedagainst the femur when the knee if semi-flexed S/SS/S:: hemorrhage which results in significant swellinghemorrhage which results in significant swelling painpain POT over PatellaPOT over Patella extreme pain with weight bearing/movementextreme pain with weight bearing/movement
  43. 43. Patella Fracture
  44. 44. Tx:Tx: RICERICE ImmobilizeImmobilize CrutchesCrutches Possible surgery depending on type ofPossible surgery depending on type of fracturefracture
  45. 45. OVERUSE KNEEOVERUSE KNEE INJURIESINJURIES 1. Iliotibial band tendonitis1. Iliotibial band tendonitis 2. Popliteus tendinitis2. Popliteus tendinitis 3. Patellofemoral pain syndrome3. Patellofemoral pain syndrome 4. Patellofemoral synovial plica4. Patellofemoral synovial plica 5. Infrapatellar fat pad syndrome5. Infrapatellar fat pad syndrome 6. Patellar tendonitis6. Patellar tendonitis 7. Bursitis7. Bursitis
  46. 46. 1. Iliotibial band tendonitis1. Iliotibial band tendonitis Excessive frictionExcessive friction between iliotibial bandbetween iliotibial band (ITB) & lateral femoral(ITB) & lateral femoral condylecondyle
  47. 47. Iliotibial band tendonitis Common in runnersCommon in runners and cyclistsand cyclists foot pronation, genufoot pronation, genu varum are riskvarum are risk factorsfactors
  48. 48. HxHx:: Pain at lateral kneePain at lateral knee At first, sxs only after a certainAt first, sxs only after a certain period of activityperiod of activity Progresses to pain immediatelyProgresses to pain immediately with activitywith activity
  49. 49. PE:PE: Tender at lateralTender at lateral femoralfemoral epicondyle, ~3cmepicondyle, ~3cm proximal to jointproximal to joint lineline Soft tissueSoft tissue swelling & crepitusswelling & crepitus No joint effusionNo joint effusion
  50. 50. PE:PE: Ober’s testOber’s test Noble’s testNoble’s test Noble’s test
  51. 51. Iliotibial band tendonitis Tx:Tx: Relative restRelative rest IceIce NSAIDSNSAIDS StretchingStretching CortisoneCortisone Platelet-RichPlatelet-Rich PlasmaPlasma
  52. 52. Iliotibial band tendonitis Prognosis:Prognosis: Improves with restImproves with rest Expect long recovery timeExpect long recovery time When to refer:When to refer: Intractable painIntractable pain Surgery = releaseSurgery = release
  53. 53. 2. Popliteus tendinitis2. Popliteus tendinitis surrounds posterolateral aspect ofsurrounds posterolateral aspect of knee, stabilizer in flexion by resistingknee, stabilizer in flexion by resisting forward displacement of the femur onforward displacement of the femur on the tibiathe tibia less common but same causes as itbless common but same causes as itb (d/d)(d/d)
  54. 54. discomfort on anterior or superiordiscomfort on anterior or superior lat.collateral ligament and withlat.collateral ligament and with resisted knee flexion with tibia held inresisted knee flexion with tibia held in external rotationexternal rotation - treatment: reduction training- treatment: reduction training distance, NSAIDS, stretching kneedistance, NSAIDS, stretching knee flexors, electrotherapy. corticosteroidflexors, electrotherapy. corticosteroid injectioninjection
  55. 55. 3. Patellofemoral pain3. Patellofemoral pain syndromesyndrome Retropatellar orRetropatellar or peripatellar painperipatellar pain resulting from physicalresulting from physical or biomechanicalor biomechanical changes in thechanges in the patellofemoral jointpatellofemoral joint Many forces interact toMany forces interact to keep the patella alignedkeep the patella aligned
  56. 56. Patellofemoral pain syndrome Patella not onlyPatella not only moves up and down,moves up and down, but rotates and tiltsbut rotates and tilts Many points ofMany points of contact betweencontact between patella and femoralpatella and femoral structuresstructures
  57. 57. Patellofemoral pain syndrome Hx:Hx: Vague anterior knee pain with insidious onsetVague anterior knee pain with insidious onset Common cause of anterior knee pain in womenCommon cause of anterior knee pain in women Tend to point to front of knee when asked toTend to point to front of knee when asked to localize painlocalize pain Worse with certain activities, i.e. ascending orWorse with certain activities, i.e. ascending or descending hills & stairsdescending hills & stairs Pain with prolonged sittingPain with prolonged sitting theater sign→ theater sign→ No meniscal or ligamentous sxsNo meniscal or ligamentous sxs
  58. 58. Patellofemoral pain syndrome PE:PE: Positive compression testPositive compression test Patellar crepitus with ROMPatellar crepitus with ROM Mild effusion possibleMild effusion possible May see tenderness withMay see tenderness with patella facet palpationpatella facet palpation →→ medial, lateral, superior,medial, lateral, superior, inferiorinferior Remainder of knee examRemainder of knee exam unremarkableunremarkable
  59. 59. Patellofemoral pain syndrome PE:PE: CheckCheck hamstringhamstring flexibilityflexibility
  60. 60. Patellofemoral pain syndrome PE:PE: Check for flat feet (pes planus) or high-arch feet (pesCheck for flat feet (pes planus) or high-arch feet (pes cavus)cavus) Pes Planus Pes Cavus
  61. 61. Patellofemoral pain syndrome PE:PE: Check heel cord (achilles) flexibilityCheck heel cord (achilles) flexibility Check for a tight iliotibial band (ober’s test)Check for a tight iliotibial band (ober’s test) Ober’s test Achilles stretch
  62. 62. Patellofemoral pain syndrome Tx:Tx: Physical therapyPhysical therapy Improve flexibilityImprove flexibility Quad strengthening,Quad strengthening, especially VMOespecially VMO Other modalities, i.e.Other modalities, i.e. soft tissue release, U/Ssoft tissue release, U/S Patellar tapingPatellar taping
  63. 63. Patellofemoral pain syndrome Tx:Tx: Relative rest/ModificationRelative rest/Modification of activitiesof activities IcingIcing NSAIDSNSAIDS Patellar bracesPatellar braces Addressing foot problemsAddressing foot problems with foot wear andwith foot wear and orthoticsorthotics SurgerySurgery
  64. 64. 4. Patellofemoral synovial4. Patellofemoral synovial plicaplica - 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
  65. 65. 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
  66. 66. 5. Infrapatellar fat pad5. Infrapatellar fat pad syndromesyndrome repetitive hyperextention injuries,repetitive hyperextention injuries, surgical interventionsurgical intervention pain on hyperextention over anteriorpain on hyperextention over anterior knee regionknee region part of patella baja: shorter patellarpart of patella baja: shorter patellar tendon from fibrosis (? previoustendon from fibrosis (? previous surgery) blocking knee flexionsurgery) blocking knee flexion
  67. 67. 5) INFRAPATELLAR FAT PAD SYNDROME treatment:treatment: rest from hyperextention (martial arts )rest from hyperextention (martial arts ) , NSAIDS, electrotherapy., NSAIDS, electrotherapy. significant fibrosis: arthroscopicsignificant fibrosis: arthroscopic excisionexcision
  68. 68. 6. Patellar tendonitis6. Patellar tendonitis Also called “jumper’s knee”Also called “jumper’s knee” Mxn:Mxn: excessive running, jumping or kicking causing extremeexcessive running, jumping or kicking causing extreme tension of the knee extensor muscle complextension of the knee extensor muscle complex S/S:S/S: Pain at the patellar tendonPain at the patellar tendon POT over the distal pole of patellaPOT over the distal pole of patella Pain increases with activityPain increases with activity Thickening of tendonThickening of tendon crepituscrepitus
  69. 69. TXTX:: RestRest IceIce HeatHeat UltrasoundUltrasound Cross-friction massageCross-friction massage NSAIDSNSAIDS Patellar tendon strap/tapingPatellar tendon strap/taping Modify activityModify activity
  70. 70. 7. Bursitis7. Bursitis Can be acute, chronic, orCan be acute, chronic, or recurrentrecurrent Numerous bursae involved butNumerous bursae involved but most commonly injured are themost commonly injured are the prepatellar or the deepprepatellar or the deep infrapatellarinfrapatellar
  71. 71. Bursitis Mxn:Mxn: falling directly on kneefalling directly on knee Continuous kneelingContinuous kneeling Overuse of patellar tendonOveruse of patellar tendon
  72. 72. Bursitis S/S:S/S: Localized swelling that is similarLocalized swelling that is similar to a water balloon and is outsideto a water balloon and is outside the knee jointthe knee joint Pain especially with pressurePain especially with pressure
  73. 73. Bursitis
  74. 74. Bursitis
  75. 75. Bursitis Tx:Tx: RestRest IceIce CompressionCompression NSAIDSNSAIDS Padding for protection when returning toPadding for protection when returning to activityactivity
  76. 76. Vascular InjuryVascular Injury ~20% (5-30%) of all~20% (5-30%) of all dislocationsdislocations EMERGENCY if NO distalEMERGENCY if NO distal perfusionperfusion Patterns of Vascular injuryPatterns of Vascular injury • rupturerupture • incomplete tearincomplete tear • intimal injury (may causeintimal injury (may cause thrombosis)thrombosis)
  77. 77. Neurologic InjuryNeurologic Injury CommonCommon peroneal nerveperoneal nerve palsypalsy Incidence ~20% (10-40%)Incidence ~20% (10-40%) Most Common with varusMost Common with varus injuryinjury PROGNOSIS is POORPROGNOSIS is POOR Complete recovery ~ 20%Complete recovery ~ 20%
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