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3/1/2017
1
WHERE ARE WE?
East Amherst
East Aurora
Hamburg x2
West Seneca
Williamsville
Boulevard
THE KNEE JOINT
3/1/2017
2
THE KNEE JOINT
• At the most superficial level, the knee is a simple hinge joint
• Flexion & Extension
• The knee has small, less obvious movements, too
• Rotation
• Valgus and Varus
• There are no direct knee muscles that control for the smaller movements, but these movements are often the cause for injury
ACTIVITIES OF DAILY LIVING: TIBIA - FEMORAL
Kutznera I, Heinleina, B, Graichena F. Loading of the knee joint
during activities of daily living measured in vivo in five subjects.
Journal of Biomechanics. 2010 Aug;43(11):2164–2173.
Activity Peak Force (% of body weight)
Going Down Stairs 346% Body Weight
Going Up Stairs 316% Body Weight
Knee Bends 253% Body Weight
Level Walking 150% Body Weight
Peak Force Running?
290%
WALKING, WEIGHT LOSS, AND THE KNEE
Messier S, Gutekunst D, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism July 2005;52(7):2026-2032.
• One Pound of Weight Loss Off
Loads how much force while
walking?
4 Pounds of Pressure
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3
FOOD FOR THOUGHT: EXERCISE SUBSTITUTION
Walking
Elliptical
Biking
Running
Lunging
Squats
Step Ups
Knee Extensions
Jumping
Wall Slides
One Legged Squat
SUBSTITUTING EXERCISE: BIKING
• Peak Compressive Force While
Cycling: PF Joint
40% of Body Weight
Ericson M, Nisell R. Patellofemoral Joint Forces During
Ergometric Cycling. Phys Ther. 1987;67:1365-1369.
• Influencing Factors
• Work Load (Level)
• Saddle Height
• Non-Influencing Factors
• Pedaling Rate / Foot Position
SUBSTITUTING EXERCISE: ELLIPTICAL
• Compared to walking:
•Smaller Reaction Forces
•Slower Loading Rates
•Increased Hip Flexor and Knee
Extensor Moments
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SUBSTITUING EXERCISE: LEG PRESS
• Is this functional?
• Increasing force into extension
• Last 15 Degrees of Extension vs. Achieving
30 Degrees
• 2x Quad Force
• Surface Area
• Effect of weight
• 7# Doubles Quad Force
• Leg Press vs. Standing Extension
• 0-46 degrees less reaction force
Grood ES; Suntay WJ; Noyes FR. Biomechanics of the
knee extension exercise. Effect of cutting the anterior
cruciate ligament. J Bone Joint Surg Am 1984
Jun;66(5):725-734.
LUNGES, STAIRS, AND KNEELING
• Peak axial forces during step-
up were nearly 60% greater
than during gait
• Choosing Your Lunges
• Long vs Short Stride
• With / Without Stride
• Multi-Planar Lunges
D’Lima D, Steklov N, Fregly B. In Vivo Contact Stresses during Activities of
Daily Living after Knee Arthroplasty. J Orthop Res26 2008:1549-1555
Escamilla R, Zheng N, Macleod T. Patellofemoral Joint Force and Stress
Between a Short- and Long-Step Forward Lunge. J of Orth & Sports Phys
Ther 2008 Nov;38(11):681-690.
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WHAT’S MORE FUNCTIONAL
WHAT’S MORE FUNCTIONAL?
WHAT’S YOUR THRESHOLD?
Walking
Elliptical
Biking
Running
Lunging
Squats
Step Ups
Knee Extensions
Jumps
Wall Slides
One Legged Squat
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FUNCTIONALEXERCISE PROGRESSION
Biking
Walking
Elliptical
Squats
Step Ups
Lunges
Single Leg Activities
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1
Northtowns OrthopedicsBuffalo Rehab Group
2/27/17
Peter L. Gambacorta, DO
Orthopedic Surgeon
Sports Medicine
Peter L. Gambacorta, DO
Northtowns Orthopedics
– General orthopedic surgery
Fellowship Trained Sports Medicine Specialist
Arthroscopic Surgery
– Surgery with cameras• Knee, Shoulder, Hip, Elbow, Ankle
Northtowns Orthopedics
Office LocationsEast Amherst
8750 Transit Road Suite 105East Amherst, New York 14051
Williamsville
36 North Union RoadWilliamsville, NY 14221
Holiday Valley
6133 U.S. Route 219 Suite 1001 Ellicottville, New York 14731
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After-Hours Orthopedic ServiceNo appointment is necessary!
8750 Transit Road Suite 105 East Amherst, New York 14051
After-Hours Urgent Orthopedics Available:Monday through Friday, 4 pm to 8 pm
Saturday, 12 pm to 4 pmSunday, 12 pm to 4 pm
Most major insurance carriers are accepted.
(716) 839-2230
Agenda
• Introduction
• Youth sports
• Knee
• Injury prevention
Pediatric and Adolescent
Sports Medicine
Epidemic Problems
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Youth Sports Statistics >30 -45 million children and
adolescents participate in youth sports in US
2 million high school students sustain injuries yearly
More than 3.5 million children ages 14 and under receive medical treatment for sports injuries each year
50%of youth sports injuries are preventable
By the age of 13, 70% of kids drop out of youth sports
Why are Injuries on the Rise?
• Title IX - the federal civil rights law that prohibits sex discrimination in education.
• Enacted in 1972
1972 2012
Ratio of HS
participation
1 in 17 1 in 3
# High School
Athletes
300,000 3,000,000
# College
Athletes
25,000 180,000
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Increased participation: Increased rates of injury
Why are Injuries on the Rise?
• Less free play
• More sports offered
• Single sport concentration
• All star, travel teams
• Year round participation
• Higher levels of competition
• Means to an end0
2000000
4000000
6000000
8000000
1972 2006
80 % Increase!
Sports
Participation
“Child is not a
little adult.”
“Child athlete is
not a little adult
athlete.”
Understanding the Difference
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Historic Prospective
Kids do not experience
major sports related injuries
Kids will heal if you put
them in a cast or brace
Unique Challenges
• Age Specific Injuries
– Growth plates
• Expectations
• Delayed treatment can
lead to other problems
• Surgical Techniques
– Limb length
– Angular deformity
– Growth arrest
Pediatric Sports Medicine
Pediatric Orthopedics
• Hip Dysplasia
• Perthes disease
• Scoliosis
• Spondylolysis
• Club foot
• Congenital deformities
• Cerebral palsy
• Spina bifida
• Hand anomalies
• Limb length deficiencies
• Fracture care
Adult Sports Medicine
• Ligament injuries (ACL,PCL,UCL)
• Articular cartilage injuries
• Tendon injuries
• Meniscus tear
• Dislocated shoulder
• Labral/ SLAP tear
• Rotator cuff tear
• Tennis elbow
• Hip labral tear
• Snapping hip syndrome
• Ankle sprains
• Fracture care
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• Knee: • ACL, meniscus, OCD, chondral injuries, patellofemoral
dysplasia, tibial spine fractures, patella instability, growth deficiencies, fractures
• Shoulder: • Labral tears, multidirectional instability, SLAP tears,
impingement, little leaguer shoulder, rotator cuff tears
• Elbow: • Loose bodies, OCD, UCL injuries, olecranon
apophysitis, pediatric elbow fractures
• Hip: • Femoroacetabular Impingement, loose bodies, chondral
injuries, dysplasia, SCFE, apophysitis
• Wrist and Hand: • TFCC, fractures, tendon injuries, fractures
• Ankle and Foot: • OCD, instability, os trigonum, anterior/posterior
impingment, tarsal coalitions, fractures
• Spine• Back Pain, Spondylolysis, Scoliosis, muscular strains
• Medical Conditions• Concussion, Heart, Psych, Nutrition
Scope of Pediatric Sports Medicine
Agenda
• Introduction
• Youth sports
• Knee
• Injury Prevention
Anatomy 101
• Bone-
– Skeleton
– Supports the body
– Protects organs
– Allows movement
– Stores minerals
– Makes blood cells
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Anatomy 101
• Muscle
– “Engine”
– Produce motion
– Provide stabilization
– Generate heat
Anatomy 101
• Tendon
– Connector of Muscle to Bone
• Ligament
– Connector of Bone to Bone
Flexibility versus Laxity
• Flexibility
– Stretch of muscle and tendon
• Laxity
– Looseness of ligaments
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Common Sports Injuries
• Hip/ Pelvis
• Knee
• Shoulder
• Elbow
• Hand/Wrist
• Leg/ Ankle
• Foot
• Spine
Why Does My Knee Hurt
Knee Anatomy
• Bones
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Knee Anatomy
• Cartilage
Knee Anatomy
• Dynamic layer
– Muscles and Tendon
Knee Anatomy
• Neural layer
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Why Does My Knee Hurt
• Arthritis
• Meniscus tears
• Ligament injuries
• Knee cap pain
Arthritis
• Osteoarthritis– “Wear and tear”
• Articular cartilage wears out
– More common in patients over the age of 50
– Develops over time
• Rheumatoid– Chronic autoimmiune disease
attacking multiple joints
• Post Traumatic– Develops after an injury
Arthritis
• Symptoms– Stiffness and swelling
– Difficulty bending
– Increase pain with activity
– “Locks or sticks” with movement
– Weakness and buckling
– Increased with weather changes
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Arthritis
• Diagnosis
– Examination
– Testing
• Radiograph
• MRI
• Lab
Arthritis
• Treatment– Lifestyle modifications
– Physical therapy
– Assistive devices
– Medications• Oral, topical
– Injections• Corticosteroid
• Visco supplementation
Arthritis
• Surgical Treatment
– Arthroscopy
– Partial and Total Replacement
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Meniscus Tear
Meniscus
• Fibro cartilage disc– Breast bone on a chicken
• Two meniscus in each knee– Medial and Lateral
• Shaped like a “C”
• Function:– “Shock absorber”
– Stabilize
– Nourish
Meniscal Tear
• Etiology
– Young athlete
• Traumatic Twist/ Pivot
• Athletic Activity– Deep bend/ squat
– Mature patient
• Traumatic
• Insidious onset
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Meniscal Tear
• Symptoms
– Pain
• At the joint line
• With squatting and bending
– Locking
• Click, pop, catching
– Swelling
• Often worse after activities
Meniscal Tear
• Diagnosis
– Examination
• Effusion
• Palpatory tenderness over meniscus
• Pain with deep knee flexion
• Mc Murray test
Radiographs
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MRI
Adult patient:
MRI of medial meniscus
95.7% sensitivity
81.8% specificity
88.2% positive predictive value(PPV)
MRI of lateral meniscus
75% sensitivity
95% specificity
80% PPV
MRI of the ACL
100% sensitivity, specificity, accuracy, positive and negative predictive values.
Mandelbaum et al. AJSM 1986
MRI
Pediatric patient:
– Meniscal Injury
72% sensitivity
93.5% specificity
Under 12 years of age
61.7% sensitivity
91.2% specificity
– No difference between clinical exam and MRI findings with respect to:• Agreement with arthroscopic findings (70%)• Sensitivity (70%)• Specificity (92%)
Conclusion:Selective MRI does NOT provide enhanced diagnostic utility over clinical examination in children.
Kocher et al. JSM 2001
Types of Tears
Meniscus tear
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Meniscus Healing
• Blood supply
Meniscus Healing
Meniscal Tear
• Conservative Treatment
– Rest
– Ice
– Compression
– Elevation
– NSAID’S
– Injections
– Physical Therapy
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Meniscal Tear
• Surgical Treatment
– Arthroscopic surgery
• “Minimally invasive”
• Out patient
• Light source camera and small instruments
Partial Meniscectomy
Post operative Meniscectomy
• Ice, Pain medication• Crutches
– Typically a few days
• Weight bear as tolerated• Begin post operative exercise the day after
surgery• Begin formal PT 10-14 days post operative
– 4-12 weeks
• Return to full sports and activities without restriction 4-12 weeks
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Meniscal Repair
Post Operative Meniscal Repair
• Ice, Pain medication• Crutches
– Typically 4-6 weeks
• Weight bearing Toe touch or partial– 4-6 weeks
• Brace• Begin post operative exercise the day after surgery• Begin formal PT 10-14 days post operative
– 4-12 weeks
• Return to sport and full activities 3-4 months
ACL Anatomy
Normal ACL Tear
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Who is at risk?
ACL Epidemiology
• Risk- Male : Female ratio– Male HS athlete: 1:500
– Female HS athlete: 1:70
– M: F- 1 : 5-8
• > 40,000 HS female
ACL injuries/ Year
• Age– 15-25 years
• Athletically active– Soccer, Basketball, Volleyball
Risk comparisons: Male vs Female
• No known differences in prepubescent children
• At puberty– Males- neuromuscular growth
spurt
– Females- no neuromuscular growth spurt
• Development of neuromuscular imbalances
Yu et al Clin Orth Relat Research 2001
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Costs of ACL Injury in Adolescent Girls
• Financial– $17,000 per reconstruction with rehab1
– $700,000,000 annually
• Academic– Decreased academic performance2
– Loss of scholarship funding
• Physical– Early OA3
1. Hewett et al, AJSM 1999, 2. Freedman et al, Clin Orthop 1998,
3. Von Porat et al, 2004
How Do They Happen?
Injury Mechanism
Non contact Contact
75% 25%
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Injury Mechanism- Pivot
• Torsional moment
• Unanticipated deceleration with change in direction
• Foot firmly planted
• 57% of non contact injuries
Arendt et al, 1999
ACL Injury Risk Factors
• Risk Factors
– Environmental
– Anatomic
– Hormonal
– Neuromuscular
Neuromuscular
• Positive Dynamic factors– Reaction time
– Motor muscle recruitment
– Balance
– Endurance
– Strength
• Peak torque, amplitude and timing
– Anticipation
– Maximum co-contraction → ↑ stiffness
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Injury Prevention Programs
• Emphasizing proper jump and landing techniques
• Neuromuscular Control
– Landing Patterns
– Strength
– Power
– Agility
Before After
Barber et al AJSM 2006
What does an ACL injury look like?
• Acute Symptoms
– “Pop”
– Pain
– Swelling
– Instability
MRI
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Non Operative Complete Tear
Natural History– Increased rate of meniscal tear
– Chondral injury and degenerative changes
– Persistent instability
– Decreased athletic participation
– Poor functional outcomes and patient satisfaction
ACL Treatment
Prepubescent Adolescent Adult
3/1/2017
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Chronological Age does NOT equate to skeletal/physiologic age
Age
Current ACL Reconstruction Recommendations Based on Age
PartialACLTear(<50%FibersTorn)
SkeletallyImmaturePatient
CompleteACLTearSkeletallyImmature
Patient
ActivityModi icationPhysicalTherapy
Bracing
Prepubescent
TannerStage1or2
Males≤12yearsFemales≤11years
AdolescentswithGrowth
Remaining
TannerStage3or4
Males13–16yearsoldFemales12–14yearsold
Olderadolescentswith
closingphyses
TannerStage5
Males≥16yearsoldFemales≥14yearsold
AdulttypeAnatomicACLreconstructionwithHamstringsorPatellar
Tendon(AutograftPreferfable)
Transphysealreconstructionwith
autogenousquadrupled
hamstringtendonsandmetaphyseal ixation
Physeal-sparingcombinedextra-andintra-articular
reconstructionwith
autogenousiliotibialband
ACLTearSkeletallyImmature
Patient
Gambacorta, Frank JAAOS 2013
Future of ACL SurgeryInjectable bio enhanced scaffold
Suture
ACL Repair and Regeneration
Eliminate tendon graft Decrease post traumatic OA
Murray, MM J Orthop Research 2013
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Anterior Knee Pain
• “Knee cap pain”
• “Swimmers knee”
• Patellofemoral syndrome
• 15% of all knee pain
• Females> Males
Patellofemoral pain
• Trauma:– Contusion– Fracture– Dislocation– Rupture of Patellar or
Quadriceps Tendon• Synovial Plica Syndome• Osteochondritis Dissecans• Post traumatic Chondromalacia• Arthritis• Hoffa’s Disease• RSD
• Patellar or Quadriceps tendinitis• Prepatellar/ Peripatellar bursitis• Osgood Schlatter or Sinding-
Larsen-Johansson disease• Lateral Patellar Compression
Syndrome• Chronic Subluxation of the
Patella• Recurrent or Chronic Dislocation
of the Patella• Idiopathic Chondromalicia
Differential Diagnosis
Patellofemoral Syndrome
• Symptoms
– Pain
• Uni or Bilateral
– Insidious onset
– Pop / click
– Pain with stairs or sitting
– Swelling +/-
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Patellofemoral Syndrome
• Treatment
– Non op successful 80-90%
– Neuromuscular balance
• Stretching (flexibility)
• Strength training
Quad Stretch
Illioas Psoas Stretch
Rectus Stretch
Hamstring Stretch
Piriformis Stretch
ITB Stretch
3/1/2017
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Single Knee to Chest Stretch
Double Knee to Chest Stretch
Achilles tendon stretch
Straight Leg Raises
Perform 3 sets of 10 repetitions on each leg.
Start with no weight and increase ankle weight as appropriate
Foot Rotated OutToe Pointing Up Lying on your side
Agenda
• Introduction
• Youth sports
• Knee
• Injury Prevention
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Injury Prevention
According to the CDC, more than half of all sports injuries in children are preventable
Sports Trauma and Overuse
Prevention
STOP Sports Injuries
• Prevention starts with EDUCATION
• Information for:– Athletes – Parents – Coaches – Healthcare providers
Sport specific injury prevention tips
www.stopsportsinjuries.org
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STOP Sports Injuries
• General Sports Injury Prevention Tips:
– Obtain a pre-season physical examination
– Encourage warm ups and cool downs
– Encourage proper strength training routines
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– Use and maintain proper equipment
– Encourage athletes to speak to a coach, trainer, parent or physician when they are experiencing PAIN
Thank You