Common Knee Injuries in Distance Runners

Introduction

• Runners that average > 25 miles/wk have injury rate > 30% per year

• Production of better shoes ---> decreased number of foot injuries, but not as effective in protecting knees

Introduction

• Knee has become most common site of injury in long distance runners

Biomechanics

• Rule of “too’s” common in runners

• Runners court disaster if they exercise too often, too hard, too soon and too much after injury, and attempt treatment too late

Biomechanics

• 67% of running injuries are result of training errors

• Body needs time to accommodate new stress levels

• Injury often due to sudden increase in frequency, duration, or intensity of training

Biomechanics

• Running -----> great forces across knee, especially during push off

• During running, force across kneecap is 7 x body wt.

Knee Problems: History

• High % of runner’s injuries are reaggravation of old injuries

• High % due to change in running style to compensate for prior injury

Physical Exam

• Thorough exam of knee

• Limb alignment

• Heel alignment

• Examine shoes’ patterns of wear

Anterior Knee Pain

• Termed “runner’s knee” in 1970’s

• Pain in front aspect of knee

• Several causes

Lateral Pressure Syndrome

• c/o “pain under kneecap”

• Increased pain running downhill, or sitting prolonged period in one position

• Due to poor tracking of kneecap

Lateral Pressure Syndrome

• Tight band on outer portion of kneecap - lateral retinaculum

• Treatment = conservative (6 mos. VMO strengthening)

• If fails, lateral release w/ arthroscope

• Outpatient surg.- 8 wk before running

Patellar Instability

• Maltracking or slight dislocation of kneecap

• Changes joint compression forces

• Symptoms of “pain in front of knee” or “knee giving way”

Patellar Instability

• If maltracking is subtle, treatment conservative -VMO strengthening

• If strengthening fails, lateral release for subtle maltracking

• If major maltracking, realign kneecap

Patellar Tendinitis

• Inflammation of patellar tendon

• “Jumper’s knee” but common in runners

• Symptoms = pain in front of knee just below kneecap

Patellar Tendinitis

• Excess stress on tendon ---> “microtears”

• Pain comes on gradually during run

• Runners often “run through it”, but as tendinitis worsens, often cannot run

Patellar Tendinitis

• Easily diagnosed by physical exam

• Treatment = REST, Iontophoresis in therapy

• DO NOT allow M.D. to inject cortisone in this region (may lead to rupture!)

Patellar Tendinitis

• If no relief w/ 3-6 mo of rest, get MRI

• Depending on severity of findings on MRI, may surgically excise area of pathology

Meniscal Tears

• Meniscus = “shock absorber” of knee

• Torn meniscus uncommon in young runners, but very common in middle age runners

Meniscal Tears

• Young runner - torn meniscus usually secondary to inciting incident (twisting injury)

• Middle aged runner - gradual onset of pain/clicking

Meniscal Tears

• Recurrent swelling

• “Catching” in knee

• “Giving way” or “locking” in younger runner

• Great difficulty squatting

Meniscal Tears

• Easily dx by exam

• Definitive dx = MRI

• Treatment = arthroscopic repair vs resection

• Back to running in 4-6 wk

Stress Fractures

• common in runners

• usually in mid to lower tibia (shin)

• less commonly, just below knee

Stress Fractures

• local tenderness, pain, swelling (+ bone scan)

• Rx = REST until symptoms abate

Degenerative Arthritis

• Significant rise in runners age 60-70

• No direct evidence citing running as a cause of arthritis

• With older runners, arthritis more commonly seen

Degenerative Arthritis

• Will running accelerate arthritis?

• Answer: YES

Degenerative Arthritis

• Must modify running program once Dx made

• Begin cross-training w/ biking, swimming, non-impact activities

• Arthroscopic “clean up” effective in only 65 %

Iliotibial Band Syndrome

• Pain = outer portion of knee

• Aggravated by running downhill

• Pain starts at 1-2 miles, progresses, and ceases after run

• Usually no pain w/ other sports

Iliotibial Band Syndrome

• “Bow-legged” alignment ?

• “Turning in” of forefoot

• Weak hip abductors ---> pelvic sag---> ITB

• Wear on outer sole of shoe

ITB: Treatment

• Stretch ITB

• Strengthen hip abductors

• Steroid injection vs iontophoresis

• Surgery = LAST RESORT !!

– Partial release of ITB

– Out for 4 wk

Summary

• Most injuries will resolve w/ modification of training program

• May need change in running surface, style, shoe, or mileage

Training Program

• May not need to stop running

• May need to reduce mileage, intensity

• Cross-train !!

• Aqua-jogging ---> non wt.bearing aerobic workout - maintains strength, endurance, mobility

Shoe Types

• Motion Control Shoe - prevents pronation

• Cushion Shoe - for rigid arches; provides more flexibility

• Support Shoe

Muscle Reconditioning

• Must restore muscle strength, endurance after all injuries

• If deficits persist - runner modifies running style ------> different injury !

Conclusions

• Knee remains most common site of injury in runners

• Most injuries are due to training errors

• Remember “Rule of Too’s”

Conclusions• Avoid surgery at all costs!!

• Most injuries can be treated w/ modification of training program, NSAIDS, P.T., time!!!

• Remember: HAVE PATIENCE

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Graft Selection in ACL Reconstruction

Introduction

• Complex issue

• Must consider material properties of graft (graft strength)

• Consider needs of patient

Introduction

• Patient weight, size, sex

• Patient’s activity level

• Type of sport

• Job requirements

Graft Types

• Bone-patellar tendon-bone

• Allograft (cadaveric achilles, b-pt-b)• Quadruple Hamstring

Bone-Patellar Tendon-Bone

• Central 1/3 of patellar tendon w/ bone plugs

• Most common graft in USA

• “Gold Standard”

Bone-Patellar Tendon-Bone

• Convenient - 1 incision ; readily available

• Bone block allows excellent fixation w/ screws

• Bone block allows bone to bone healing

Bone-Patellar Tendon-Bone

• Animal studies - graft shows faster incorporation than allograft

• Ultimate strength initially greater than native ACL

Bone-Patellar Tendon-Bone

• Loses 50% strength over time ---> strength approaches native ACL

• Among graft choices, shown to have greatest strength in most biomechanical studies

Disadvantages

• Anterior knee pain (16% in some reports)

• Patellar tendinitis

• Patellar tendon rupture, patellar fracture

Disadvantages

• Don’t recover motion as quickly

• ? increase in Quadriceps weakness

• May not be available in revision cases

• Increased operative time

Bone-Patellar Tendon-Bone

• Ideal candidate = high performance athlete who requires intense rehab / future performance

• Prefer no hx of patellofemoral Sx

• Larger athletes

Hamstring Graft

• Harvest semitendinosus and gracilis - 2 cm incision

• Quadruple loop ---> size and strength approaches bone-p.t.- bone graft

Hamstrings: Advantages

• Smaller, more cosmetic incision

• Lower complications from harvest

• Earlier return of motion; less pain

• ? Less anterior knee pain later

Hamstrings: Disadvantages

• No bone to bone fixation - weaker initial strength?

• Some feel rehab should be less aggressive due to decreased initial strength

Hamstring Graft

• Ideal candidate - smaller female athletes

• Any athlete with hx of patellofemoral pain

• Athletes who do a lot of kneeling (baseball catcher, volleyball players)

Allograft

• Harvested from cadaver

• Achilles tendon & patellar tendon most common

• Risk HIV transmission = 1 in 1.7 million

Allograft

• Controversial evidence that immune response occurs

• Controversial evidence - graft incorporates more slowly

Allograft

• Some studies show lower knee scores at f/u

• Slightly more inconsistent results

• ? increased laxity at 2-5 yrs

Allograft: Advantages

• No harvest site morbidity

• No size deficits

• Faster surgery

• Smaller incision

Allograft: Disadvantages

• Infection risk (but negligible)

• Possible immune response (effusion, tunnel enlargement)

• Increased $$

Allograft: Disadvantages

• Slower healing rate

• Less predictable results

• ? increased laxity at 2-5 yrs

Allograft

• Ideal candidate = older athletes who put less stress on knee and may tolerate slightly looser knee in return for decreased stiffness/patellofem. pain