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Knee Injuries
• Anterior Cruciate Ligament Sprain
– Mechanism of Injury
• MOI - tibia externally rotated and valgus force
at the knee (occasionally the result of
hyperextension from direct blow)
• May be linked to inability to decelerate valgus
and rotational stresses - landing strategies
• Female versus Male
• Research is quite extensive in regards to
impact of femoral notch, ACL size and laxity,
malalignments (Q-angle) faulty biomechanics
• Extrinsic factors may include, conditioning, skill
acquisition, playing style, equipment,
preparation time
• Also involves damage to other structures
including meniscus, capsule, MCL
– Signs and Symptoms• Experience pop w/ severe pain and disability
• Rapid swelling at the joint line
• Positive anterior drawer and Lachman’s
• Other ACL tests may also be positive
– Management• RICE; use of crutches
• Arthroscopy may be necessary to determine extent of injury
• Could lead to major instability in incidence of high performance
• W/out surgery joint degeneration may result
• Age and activity may factor into surgical option
• Surgery may involve joint reconstruction w/ grafts (tendon), transplantation of external structures
– Will require brief hospital stay and 3-5 weeks of a brace
– Also requires 4-6 months of rehab
MCL – Medial Collateral Lig.
• Medial Collateral Ligament Sprain
– Etiology
• Result of severe lateral (Valgus) blow or outward twist
– Signs and Symptoms - Grade I
• Little fiber tearing or stretching
• Stable valgus test
• Little or no joint effusion
• Some joint stiffness and point tenderness on Medial
aspect over ligament and lateral aspect over contusion
from direct blow
• Relatively normal ROM
– Management
• RICE for at least 24 hours
• Crutches if necessary
• Follow-up care will include
cryokinetics w/ exercise
• Move from isometrics and
STLR exercises to bicycle
riding and isokinetics
• Return to play when all
areas have returned to
normal
• May require 3 weeks to
recover
– Signs and Symptoms (Grade II)
• Complete tear of deep capsular ligament and partial tear
of superficial layer of MCL
• No gross instability; laxity at 5-15 degrees of flexion
• Slight swelling
• Moderate to severe joint tightness w/ decreased ROM
• Pain along medial aspect of knee
– Management
• RICE for 48-72 hours; crutch use until acute phase has
resolved
• Possibly a brace or casting prior to the initiation of ROM
activities
• Modalities 2-3 times daily for pain
• Gradual progression from isometrics (quad exercises) to
functional progression activities
– Signs and Symptoms (Grade III)
• Complete tear of supporting ligaments
• Complete loss of medial stability
• Minimum to moderate swelling
• Immediate pain followed by ache
• Loss of motion due to effusion and hamstring guarding
• Positive valgus stress test
– Management
• RICE
• Conservative non-operative versus surgical approach
• Limited immobilization (w/ a brace); progressive weight
bearing for
• Rehab would be similar to Grade I & II injuries
• Lateral Collateral Ligament Sprain
– Etiology• Result of a varus force, generally w/ the tibia internally
rotated
• Direct blow is rare
• If severe enough damage can also occur to the cruciate ligaments, ITB, and meniscus, producing bony fragments as well
– Signs and Symptoms• Pain and tenderness over LCL
• Swelling and effusion around the LCL
• Joint laxity w/ varus testing
• May cause irritation of the peroneal nerve
– Management• Following management of MCL injuries depending on
severity
• Posterior Cruciate Ligament Sprain– Etiology
• Most at risk during 90 degrees of flexion
• Fall on bent knee is most common mechanism
• Can also be damaged as a result of a rotational force
– Signs and Symptoms• Feel a pop in the back of the knee
• Tenderness and relatively little swelling in the popliteal fossa
• Laxity w/ posterior sag test
– Management• RICE
• Non-operative rehab of grade I and II injuries should focus on quad strength
• Surgical versus non-operative– Surgery will require 6 weeks of immobilization in extension w/
full weight bearing on crutches
– ROM after 6 weeks and PRE at 4 months
• Meniscal Lesions– Etiology
• Medial meniscus is more commonly injured due to ligamentous attachments and decreased mobility
– Also more prone to disruption through torsional and valgus forces
• Most common MOI is rotary force w/ knee flexed or extended
• Can be longitudinal, oblique or transverse tears
– Signs and Symptoms• Effusion developing over 48-72 hour period
• Joint line pain and loss of motion
• Intermittent locking and giving way
• Pain w/ squatting
• Portions may become detached causing locking, giving way or catching w/in the joint
• If chronic, recurrent swelling or muscle atrophy may occur
Patellar Tendinitis / Rupture• Inflammation of Patellar Tendon
• Squeek…
• Chronic – excessive knee flexion
• RICE / NSAIDS
• Rupture
– Patella will slip superior. Quads will pull patella up
in the groove. Sits about a ½ patella high
– Surgical repair
– Sudden and explosive Quad Contraction
Prevention of Knee Injuries• Physical Conditioning and Rehabilitation
– Total body conditioning is required
• Strength, flexibility, cardiovascular and
muscular endurance, agility, speed and
balance
– Muscles around joint must be conditioned
(flexibility and strength) to maximize
stability
– Must avoid abnormal muscle action
through flexibility
– In an effort to prevent injury, extensibility of
hamstrings, erector spinae, groin,
quadriceps and gastrocnemius is important
• ACL Prevention Programs
– Focus on strength, neuromuscular control,
balance
– Series of different programs which address
balance board training, landing strategies,
plyometric training, and single leg performance
– Can be implemented in rehabilitation and
preventative training programs
• Shoe Type
– Change in football footwear has drastically
reduced the incidence of knee injuries
– Shoes w/ more shorter cleats does not allow foot
to become fixed while still allowing for control w/
running and cutting
• Functional and
Prophylactic Knee
Braces
– Used to prevent and
reduce severity of
knee injuries
– Used to protect MCL,
or prevent further
damage to grade 1 &
2 sprains of the ACL
or to protect the ACL
following surgery
– Can be custom
molded and
designed to control
rotational forces
Knee Plica
• Fetus has three synovial cavities – internal wall is not fully absorbed
• Most common – infrapatellar plica
• MOI – Direct Blow / trauma
• S&S – false painful locking, snap, pain while going up and down stairs and squatting
• No Swelling or laxity
• Treatment – Rest, NSAID, possible surgery
Osteochondral Issues• Knee Fracture –
– MOI – Same mechanism that produce collateral, cruciate or meniscal tears.
– Can shear off either a piece of bone attached to articular cartilage or the cartilage alone
– Twisting, cutting, direct blow
– S&S – Snap, knee gives way, immediate and extensive hemarthrosis, pain
– Treatment – Surgery, repair, replace, avoid degeneration and arthritits
– Can be on condyles or patella
Osteochondritis Dissecans
• Partial or complete separation of a piece of articular cartilage and subcondral bone
• Lateral portion of the medial femoral condyle
• MOI – Unknown – Trauma?, Genetics?
• S&S – Locking, ache, swelling, Quad atrophy
• Treatment – Rest and Immobilization
Loose Bodies
• AKA – Joint Mice
• MOI – Osteocondritis Dissecans, Meniscus tears, synovial tissue, cruciate tears
• S&S – Locking, popping, pain, instability –comes and goes
• Treatment – Surgical removal
Infrapatellar Fat Pad
• MOI – Becomes wedged between tibia and patella, irritated by chronic kneeling, direct blows
• S&S – Capillary bleeding, swelling of fatty tissue, scarring and calcification.
– Pain below patellar tendon, during extension
– Weakness, mild swelling, stiffness
Treatment – Rest, avoid irritating activities
Bursitis / Ruptures• Acute, Chronic or Recurrent
• Typically the Prepatellar, Deep Infrapatellar and the suprapatellar bursae have highest rate
• MOI – Becomes inflammed due to a number of issues
• S&S – localized swelling above the knee, which is extracapsular
• Treatment – Rest, NSAID’s, compression
• Ruptures – Act like Jello in the Knee, will scar and refill. Massive amounts of swelling
Baker’s Cyst
• Bursitis – Popliteal fossa
• Commonly painless, causing no discomfort or disability
Patellar Fractures
• MOI – Direct blow or indirect trauma– Indirect – severe pull of the patellar tendon occurs
against the femur when the knee is semiflexed
– Direct injury – produces fragments with no displacement
• S&S – Bleeding, joint effusion, generalized swelling
• Treatment – X-ray, ICE, Compression, immobilized for 2 -3 months
Patellar Subluxation / Dislocation
• Quad contraction with a valgus force, causing the patella to dislocate.
• Most often to the lateral side of the knee.
• Often found above and next to the Quads
Chondromalacia
• Roughening of the bottom of the patellar and the articular cartilage.
• Snap, pop, crunch, grind
• (60 grit sand paper)
Osgood Schlatter’s Syndrome
• Avulsion fracture of the Tibial Tuberosity, due to the Patellar tendon trying to rip it off.
• Excessive growth / rapid growth, bones grow too fast, muscles don’t stretch and tries to rip off bone
• More common in teenagers and in male
ACL Special Tests
• Lachmans video
• Anterior Drawer Video
• Pivot Shift
• ENDPOINT – Firm vs Soft
• LAXITY – excessive joint movement
PCL Special Test
• Posterior Drawer Video
• Posterior Sag
MCL Tests
• Valgus Stress
• Valgus Stress at 30 degrees (Isolates MCL)
• Video
LCL Tests
• Varus Stress
• Varus Stress at 30 degrees (Isolates LCL)
• Video
Capsular Swelling
• Float Test
• Cruciates
• Articular Cartilage
• Meniscus
• Plica
Patellar Dislocation / Subluxation
• Apprehension Test
• Video
