KIN 191AAdvanced Assessment of Lower Extremity Injuries

KNEE/PATELLOFEMORALARTICULATION

INJURIES

INTRODUCTION

• LIGAMENTOUS INJURIES– MCL/LCL/ACL/PCL– ROTATIONAL INSTABILITIES

• MENISCAL INJURIES• OSTEOCHONDRAL DEFECTS• ILIOTIBIAL BAND FRICTION SYNDROME• POPLITEUS TENDINITIS• PATELLOFEMROAL PAIN SYDNEROME• PATELLAR MALTRACKING

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• PATELLAR SUBLUXATION/DISLOCATION• PATELLAR TENDINITIS• PATELLAR TENDON RUPTURE• PATELLAR BURSITIS• SYNOVIAL PLICA• OSGOOD-SCHLATTER DISEASE/ LARSEN-

JOHANSSON DISEASE• CHONDROMALACIA OF PATELLAR• PATELLAR FRACTURE

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LIGAMENTOUS INJURIES

• Single Plane Injuries– MCL– LCL– ACL– PCL

• Rotational Instabilities (Multiplanar)– ALRI, AMRI, PLRI, PMRI

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Medial Collateral Ligament Injuries

• Most common MOI is blow to lateral knee with resulting valgus tension forces

• May also be injured by non-contact and/or rotational stresses

• When knee at 0˚ – MCL, AM/PM joint capsule and pes anserine tendons resist valgus force

• When knee at 20-30˚, MCL is primary restraint to valgus force

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MCL Injury

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• With MCL injury, must also consider medial joint capsule, medial meniscus and if rotational forces, ACL/PCL

• Most MCL injuries managed non-operatively – has good blood supply

• Must be cautious of joint position (ROM) during healing to create optimal environment – bracing/immobilization

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Lateral Collateral Ligament Injuries

• Most common MOI is blow to medial knee with resulting varus tension forces

• Internal rotation of tibia may be secondary contributor to LCL injury

• Must consider lateral joint capsule and cruciate ligament injury pending MOI

• Must rule out peroneal nerve injury• Has poor blood supply – doesn’t heal well and

may need surgical repair

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LCL Injury

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Anterior Cruciate Ligament Injuries

• Most MOI are non-contact rotational forces• Tibia displaced anteriorly on femus (or vice

versa), rotational stress (cutting) or hyperextension

• May be isolated, but typically due to MOI, other structures (joint capsule, menisci) also injured

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ACL Injury

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Predisposing Risk Factors• Extrinsic factors– Sport-specific activities– Muscle strength– Coordination– Athletic skill– Shoe/surface– Medial longitudinal arch

pathologies– Anterior pelvic tilt– Anteverted hip– Menstrual cycle

• Intrinsic factors– Joint laxity– Limb alignment– Small intercondylar

notch– Small ACL– Genu recurvatum

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• Often note an unusual sound (“pop”) or sensation (“knee gave way”) at time of injury

• Immediate swelling typically present and significant – if isolated ACL, intracapsular and if joint capsule involved, extracapsular

• “Partial tears” typically treated as complete tears due to changes in ability of ligament to respond to stresses placed upon it with activity

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• Often treated surgically (ACLR) – somewhat dependent upon activity and/or level of performance

• Can use autografts (patellar tendon, hamstrings) or allografts (cadavers)

• Today’s ACLR rehab vs. initial ACLR rehab - accelerated

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ACL Injuries - Females

• Females with significant numbers of non-contact ACL injuries vs. males

• Predisposing intrinsic risk factors more attributable to females than males

• Females also typically have narrower intercondylar notches than males

• Hormonal changes during menstrual cycle may increase risk of injury – lax ligaments

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Posterior Cruciate Ligament Injuries

• Most common MOI is fall on flexed knee driving tibia posterior on femur

• May also occur with rotational and/or hyperextension MOI

• Often treated non-operatively as quadriceps muscles are able to minimize posterior displacement of tibia on femur

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ROTATIONAL INSTABILITIES

• Involve abnormal internal or external rotation of the tibia on the femur

• Result when multiple stabilizing structures are injured with rotational MOI

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Anterolateral Rotatory Instability (ALRI)

• Involves trauma to ACL and anterolateral joint capsule

• Can be accentuated with associated damage to LCL, IT band, lateral meniscus and/or biceps femoris tendon

• Several special tests – often not clinically reliable and most evaluative under anesthesia

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ALRI Tests

• Slocum Test– Internally rotating tibia during anterior drawer

• Crossover Test– Uninvolved leg steps in front of involved with

involved foot fixed• Pivot Shift Test– Tibia internally rotated and valgus force applied to

knee from extension to flexion – mimics joint subluxation that occurs in ACL deficient knee during functional activities

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Anteromedial Rotatory Instability (AMRI)

• “Triad” injury involving ACL, MCL and medial meniscus contributes to AMRI

• Slocum Test– Externally rotating tibia during anterior drawer

• Crossover Test– Uninvolved leg steps behind involved with

involved foot fixed

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Posterolateral Rotatory Instability (PLRI)

• Posterolateral joint capsule involved, typically associated cruciate injury and/or arcuate ligament complex

• Evaluate with external rotation test for PLRI– Compares external rotation of tibia on femur at 30

and 90˚ of knee flexion – if involved side greater than 10˚ different than uninvolved = + test

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Posteromedial Rotatory Instability (PMRI)

• Combined injury to the PCL, MCL, and medial joint capsule

• MOI – anterior blow to the tibia with the knee partially flexed and under valgus stress and the foot laterally rotated

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MENISCAL INJURIES

• Lateral meniscus tears more common than medial (reversal of initial thinking)

• May be isolated from flexion/hyperflexion with rotation of the knee – “pinched” between tibia and femur

• Often injured in association with cruciate ligament injury

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Meniscus Injury

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• “Classic” symptoms include joint line pain and clicking or locking – helpful but not definitive evaluative tools

• McMurray’s and Apley’s tests indicated, but best tests are MRI/arthroscopy

• Meniscal cysts may develop secondary to meniscal injury especially with peripheral tears – synovial fluid “leak” into damaged meniscus

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OSTEOCHONDRAL DEFECTS

• Fractures of articular cartilage and underlying bone – most common (80%) from medial femoral condyle (males have greater incidence than females)

• Typically accompany other joint injuries – may present with locking or clicking, but may be asymptomatic if isolated

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• If stable and non-displaced, can be treated conservatively

• If conservative management fails or if unstable or displaced OCD, surgical fixation, debridement or transplantation of articular cartilage is indicated

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ILIOTIBIAL (IT) BAND FRICTION SYNDROME

• Results from friction between IT band and lateral femoral condyle during repetitive knee flexion/extension activities

• May present with or as bursitis• Predisposing risk factors include genu varum,

pronated feet and leg length discrepancies

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IT Band Injury

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• Presents with tenderness at IT band crossing point on lateral femoral condyle

• Noble’s Compression Test– Pressure over lateral femoral condyle with passive

knee flexion/extension - + if pain under thumb, esp. at ~30˚ knee flexion

• Ober’s Test– Abducts and extends the hip to allow the tensor

fascia latae to clear the greater trochanter– The hip is then allowed to passively adduct to the

table– Tests for IT band tightness

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Noble’s C. Test and Ober’s Test

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POPLITEUS TENDINITIS

• Similar to the IT band friction syndrome– Exception is the location of the pain• Proximal portion of the tendon (posterior to the LCL)

• Hyperpronated feet (predisposing factor)• Possibly resulting in an increased loading on

the cartilage

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PATELLOFEMORAL PAIN SYNDROME

• Synonomous with patellofemoral joint dysfunction

• Represent PF joint pain without specific MOI• Symptoms worsen with climbing stairs, sitting

with knee flexed for long periods of time (movie sign)

• May be secondary to tracking issues and/or biomechanical abnormalities

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PATELLAR MALTRACKING

• Normal tracking in femoral trochlea dependent upon Q angle, integrity of patellar soft tissue restraints (retinacula), foot/leg mechanics and ham/quad/gastroc flexibility

• Typical onset of symptoms is gradual – chronic changes develop over time as opposed to acutely

• Presents as anterior and/or peri-patellar pain

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PATELLAR SUBLUXATION/DISLOCATION

• Lateral displacement is most common• Commonly occurs with knee in 20-30˚ of

flexion and may also have valgus load at knee• May have associated fracture of patella,

osteochondral fracture of patellar or femur and/or OCD

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• Predisposing risk factors include tight lateral retinaculum, flattened posterior patella, high Q-angle, biomechanical issues

• Usually present with significant swelling and often involve tearing of VMO in addition to medial retinaculum

• Evaluate with apprehension test

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PATELLAR TENDINITIS

• Common in running and jumping activities• Most common site of irritation is inferior pole of

the patella, but may also be at tibial insertion, superior pole of the patella or in tendon mid-substance

• Presents with decreased quad flexibility and occasionally with strength deficits

• Differentiate or associate with fat pad syndrome• Usually treat conservatively

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PATELLAR TENDON RUPTURE• Occurs with excessive tension through tendon

causing failure in mid-substance or at either insertion point

• Present with gross deformity, inability to actively extend the knee and significant swelling immediately

• Surgical intervention is only means of satisfactory outcome

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PATELLAR BURSITIS

• Prepatellar, suprapatellar and infrapatellar• Typically inflamed secondary to acute trauma,

but may be chronic or associated with infection

• Especially prepatellar, presents with significant anterior swelling

• Usually respond well to conservative management – risks with draining

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SYNOVIAL PLICA

• Thickened area of joint capsule – remnant of development

• Most common is medial, but may be lateral• Inflammation from trauma or irritation with

activity are MOI• Typically treat conservatively – occasional

surgical release or debridement

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OSGOOD-SCHALLTER DISEASE

• Inflammatory condition at tibial tuberosity at patellar tendon insertion

• Symptoms similar to patellar tendinitis but tuberosity often enlarged and only site of pain

• Most prominent in adolescents – apophysitis/exostosis

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SINDING-LARSEN-JOHANSSON DISEASE

• Similar to Osgood-Schlatter’s disease, but occurs at either superior or inferior pole of patella

• Traction forces through tendon at bony interfaces causes symptoms

• Can be very debilitating to active adolescents – conservative management can take significant period of time

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CHONDROMALACIA PATELLAR• Softening and deterioration of the articular

cartilage• Possible abnormal patellar tracking due to genu

valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, laxity of quad tendon

• Pain w/ walking, running, stairs and squatting• Possible recurrent swelling, grating sensation

w/ flexion and extension• Pain at inferior border during palpation 44

PATELLAR FRACTURE

• Almost always due to blunt trauma• Obvious difficulties with active and passive

knee ROM activities• Best viewed via sunrise x-ray

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