Musculoskeletal pathology knee and hip

ACL tear description

ACL tear Description A traumatic disruption of the fibers of the anterior cruciate ligament (ACL). Commonly seen in contact and noncontact sports. The anterior cruciate ligament can be damaged in several ways: 1. Changing direction rapidly 2. Stopping suddenly 3. Slowing down while running 4. Landing from a jump incorrectly 5. Direct contact or collision, such as a football tackle It has been shown that female athletes have a higher inci- dence of ACL injury than male athletes in certain sports. It has been suggested that this is due to differences in phys- ical conditioning, muscular strength, and neuromuscular control.

ANTERIOR CRUCIATE LIGAMENT

ANTERIOR CRUCIATE LIGAMENT • Runs from ANTERIOR TIBIA to the POSTERIOR FEMUR o Keeps the tibia from being displaced anteriorly on the femur o Frequently injured o It tightens during extension o PREVENTS EXCESSIVE HYPEREXTENSION of the knee

ACL Sprain

Anterior Cruciate Ligament -ACL injuries can occur from both contact and noncontact mechanisms -The most common contact mechanism is a blow to the lateral side of the knee resulting in a valgus force to the knee. -This mechanism can result in injury not only to the ACL but also to the medial collateral ligament (MCL) and the medial meniscus. This injury is termed the "unholy triad" or "terrible triad" injury because of the frequency with which these three structures are injured from a common blow

ACL exam

Exam Large effusion with pain and loss of motion Joint line tenderness associated with lateral femoral, and tibial bone contusion, meniscal tears Weak quadriceps muscle Positive Lachman's test (evaluates anterior tibial translation with the knee between 15° and 30° of flexion, most important test in acute diagnosis) Positive lateral pivot shift test (evaluates and correlates with anterolateral rotatory instability, anterior tibial sub- luxation on the femur as the knee goes into extension) Anterior drawer test Combined injuries, positive valgus stress, and McMurray's tests

treatment

Exercises • Elimination of myofascial restrictions along the lateral hip and thigh • Stretching exercises increasing the length of the • TFL/ITB complex • Strengthening the gluteus medius muscle, especially the posterior fibers that function as abductors and external rotators • strengthening of the hip abductors and extensors and knee flexors along with the extensors • Gradual return to running. Starting with easy sprints on level ground and avoiding any downhill running for the first few weeks • See pg 616 • side lying leg lifts for hip abductor strengthening (37) (Figure 29.2) and prone leg extensions for hip extensor strengthening (39)

Modalities for piriformis syndrome

Modalities Superficial heat and Ultrasound - increase tissue temperature, blood flow, and tissue extensibility and decrease pain Tens - address pain and reduce muscle spasms deep tissue massage - decreased tissue tightness

ACL modalities

Modalities Cryotherapy Lowvoltage electrical stimulation to the quadriceps muscle (to reduce muscle inhibition, to facilitate mus- cle recruitment) High-voltage galvanic stimulation or transcutaneous electrical stimulation to the knee (reduces pain/ arthrogenic muscle inhibition)

POSTERIOR CRUCIATE LIGAMENT

POSTERIOR CRUCIATE LIGAMENT • Runs from the POSTERIOR TIBIA to the ANTERIOR FEMUR o Keeps the tibia from displacing posteriorly on the femur o It tightens during flexion

Patellofemoral syndrome chondromalacia patella (pg 156) https://uhs.berkeley.edu/sites/default/files/patellofemoralpainsyndrome.pdf

Patellofemoral syndrome description • Patellofemoral pain syndrome is pain in the front of the knee and around the patella, or kneecap. • The pain and stiffness it causes can make it difficult to climb stairs, kneel down, squatting, and prolonged sit- ting due to the compressive forces on the joint • This condition is often term chondromalacia patella, which refers to softening and breakdown of the articular cartilage of the patella it can lead to inflammation of the synovium and pain in the underlying bone.

blow to the lateral side of the knee result in what?

blow to the lateral side of the knee resulting in a valgus force to the knee. -This mechanism can result in injury to the ACL and also to the medial collateral ligament (MCL) and the medial meniscus.

short arc quads

knee replacement exercise https://www.youtube.com/watch?v=iDCK-Y1sA84

meniscus tear description

meniscus tear description The menisci are crescent shaped fibrocartilage structures that provide structural integrity to the knee. They have many functions for the knee which include load bearing, shock absorption, joint lubrication, joint stability, and providing proprioceptive feedback. They are subject to stress and strain in sports and activities of daily living and are commonly injured.

ACL pathogenesis

pathogenesis The ACL is a multifilament collagen structure arranged in two bundles: the anteromedial and the posterolateral bundles The ligament is made mainly of Types 1 and 3 collagen fibers, which fail in tension and shear stress Blood supply is through the middle geniculate arteries Nerve supply is through the Ruffini receptors Primary function is to control anterior tibial displacement Secondary function is to control anterolateral tibial rotation Stressed during deceleration in running, cutting, and jumping in noncontact sports Placed under stress with valgus forces in contact sports Females injured when landing with the knee in valgus and hyperextension (position of no return)

Non-surgical Treatment

A torn ACL will not heal without surgery. But non-surgical treatment may be effective for patients who are much older or have a very low movement level. If the overall stability of the knee is intact, the doctor may ad- vise simple, non-surgical options.

Clinical Features

Clinical Features Usually present with gradual onset of pain and swelling in the region of the tibial tuberosity, which is exacerbated with sport activity On physical examination, there is tenderness, local swelling, and prominence in the area of tibial tuberosity Increased pain with knee extension against resistance

knee exercises

Correct squats (knee bends), straight-leg raises, side-leg raises (abduction and adduction), standing hip flexion, lying hip extension, sitting knee extension, standing knee flexion, toe raises, quadriceps setting.

Iliotibial band syndrome description

Iliotibial band syndrome description • is inflammation of the Iliotibial band on the outside of the knee it is being inflames and irrated as it rubs against the outside of the knee joint. • It is the most common cause of lateral knee pain in runners. • The syndrome results from repetitive friction of the iliotibial band (ITB) sliding over the lateral femoral epicondyle, moving anterior to the epicondyle as the knee extends and posterior as the knee flexes, and remaining tense in both positions.

Risk Factors

Risk Factors SIJ dysfunction Lumbar disc disease Hip muscle weakness and inflexibility

Meniscus tear symptoms

Symptoms The most common symptoms of meniscus tear are: • Pain • Stiffness and swelling • Catching or locking of your knee sensation • You are not able to move your knee through its full range of motion

Treatment for piriformis syndrome

Treatment Exercises Stretching of PM muscle with hip flexion, adduction, and intenrrotation (FAIR position) Supine piriformis stretch in the FADIR posi- tion. Strengthening of hip abductors, external rotators, and other core muscles Back stabilization program along with deep tissue massage

Signs and symptoms

clinical presentation includes - Limited abduction of affected hip -Apparent shortening of the femur on the effective side as demonstrated by difference in knee levels . Testing for this condition may include the ortolani test and barlow's test, and diagnostic ultrasound

treatment phases

treatment TABLE 29.1: Phases of Rehabilitation Phase I: Decrease pain and swelling, includes PRICE protocol (ice or ice massage) Phase II: Restore ROM (stretching right after heat or US) eflurage massage on IT band Phase III: Strength training Phase IV: Proprioceptive/balance training Phase V: Functional/sport specific training

ITBFS cause

• ITBFS is caused by excessive rubbing of the band over the lateral epicondyle of the femur during sporting activity, which produces pain and inflammation

Long arc quads

https://www.youtube.com/watch?v=oSV2eCe6ad8 https://www.youtube.com/watch?v=qnm7tuSZmI0

ACL symptoms

-a pop, in the knee, feeling the knee giving away or buckling followed by swelling that decrease after several days, -Loss of full range of motion -Discomfort while walking

treatment

-the focus of treatment is dependent on age, severity and initial attempts to reposition the femoral head within the acetabulum though the constant use of a harness, bracing, splinting or traction. Open reduction with subsequent application of a hip spica cast may be required if conservative treatment fails. Physical therapy may be indicated after cast removal for stretching, strengthening and caregiver education

Cause of patellofemoral syndrome

Cause patellofemoral syndrome is a repetitive overuse disorder resulting from • increased force at the patellofemoral joint It is caused by abnormal tracking of the patella between the femoral condyle's. The tracking problem places increase in misdirected force between the patella and femur. This most commonly occurs when the patella is pulled too far lateral during knee extension factors associated with increased patellofemoral forces include • decreased quadriceps strength, • decreased lower extremity flexibility, • patellar instability • , increased tibial torsion or femoral anti-version and training errors. . Excessive pronation . Tightness in lower extremity muscles (illosas, hamstrings, gastroc, and vastus lateralas) .Patella alta . Patellar Malalignment Patellofemoral pain syndrome can also be caused by abnormal tracking of the kneecap in the trochlear groove. In this condition, the patella is pushed out to one side of the groove when the knee is bent. This abnormality may cause increased pressure between the back of the patella and the trochlea, irritating soft tissues. Factors that contribute to poor tracking of the kneecap include: • Problems with the alignment of the legs between the hips and the ankles. Problems in alignment may result in a kneecap that shifts too far toward the outside or inside of the leg, or one that rides too high in the trochlear groovea condition called patella alta. • Muscular imbalances or weaknesses, especially in the quadriceps muscles at the front of the thigh. When the knee bends and straightens, the quadriceps muscles and quadriceps tendon help to keep the kneecap within the trochlear groove. Weak or imbalanced quadriceps can cause poor tracking of the kneecap within the groove

Clinical Features ITBFS

Clinical Features • Sharp pain or burning in the lateral knee • Patients start running pain-free, but develop symptoms after a reproducible time or distance • Initially, symptoms subside shortly after a run, but return with the next run • Patients often note that running downhill and lengthening their stride aggravate the pain In more severe cases, pain can be present even with walking or when descending stairs exam • Ober's test to assess tightness of the ITB (patient lies on the unaffected side with hip flexed to 90°; the affected hip is abducted, extended, and subsequently adducted; inability to adduct the hip to the examination table is a positive test)

Congenital hip dysplasia

Congenital hip dysplasia also known as developmental dysplasia is a condition characterized by malalignment of the femoral head within the acetabulum. The condition develops during the last trimester in uterus

Effects

Effects Patients with piriformis syndrome typically describe deep aching ipsilateral buttock pain with variable referred pain down the posterolateral thigh and calf. Pain can be aggravated by climbing stairs, prolonged sitting, standing or walking, or placing the affected limb in an internally rotated position. Pain aggravated by hip flexion, adduction, internal rota- tion (FAIR)

Etiology

Etiology tight, tender piriformis muscle irritating or compressing the sciatic nerve it most commonly is a result of direct trauma to the muscle, overuse, or an imbalance between the hip flexors/extensors and external rotators and/or an imbalance between the hip adductors and abductors.

Etiology

Etiology - cultured predisposition, malposition in uterus environmental and genetic influences

ACL tear etiology

Etiology/Type Noncontact injury resulting from deceleration, change of direction, or landing from a jump Contact injury associated with trauma with valgus stress as a common mechanism Isolated injury Combined lesion involving the ACL, medial meniscus, and medial collateral ligament (unhappy triad)

Osgood-Schlatter Etiology/Types

Etiology/Types it is a condition that is caused by repetitive tension to the patellar tendon over the tibia tuberosity in young athletes. This can result in small avulsuion(pulling) of the tuberosity and subsequent swelling extra • The bones of children and adolescents possess a special area where the bone is growing called the growth plate. Growth plates are areas of cartilage located near the ends of bones. When a child is fully grown, the growth plates harden into solid bone. • Some growth plates serve as attachment sites for tendons, the strong tissues that connect muscles to bones. A bony bump called the tibial tubercle covers the growth plate at the end of the tibia. the quadriceps) attaches to the tibial tubercle. o When a child is active, the quadriceps muscles pull on the patellar tendon which in turn, pulls on the tibial tubercle. In some children, this repetitive traction on the tubercle leads to inflammation of the growth plate. The prominence, or bump, of the tibial tubercle may become very pronounced.

Meniscus tear Etiology

Etiology/Types • meniscal injuries are usually associated with twisting on a planted flexed knee Sudden meniscus tears often happen during sports. Players may squat and twist the knee, causing a tear. Direct contact, like a tackle, is sometimes involved. • Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears. • Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

ACL exercises https://www.sportsmednorth.com/sites/sportsmednorthV2/files/ACL-Reconstruction-Protocol.pdf https://www.stoneclinic.com/acl-reconstruction-rehab-protocol https://www.physio-pedia.com/Anterior_Cruciate_Ligament_(ACL)_Rehabilitation

Exercises (pg147) o Nonoperative rehabilitation - Active range of motion - Progress to progressive resisted exercises, in the early postinjury limit resisted terminal knee extension exercises to protect secondary structures precautions ACL when you do close chain exercises with patient that have not have surgery they should only squat between 60 - 90° they should avoid deep squat open chain terminal knee extension with resistance should be avoided o precautions for PCL no isolated open chain knee flexion exercise Postop: articular ACL reconstruction • postop: patient is immobilized in brace , pt have CPM at home, ice,tens and compression, muscle setting, straight leg raise exercise and ambulation moderate protection phase • in the beginning increase range of motion as swelling goes down • muscle setting exercises and straight leg raise, SAQ(short arc quads) • six - 12 weeks: increase strength and progressive stretching ,hip flex, abduction, quad stretching minimal protection phase 12 - 20 weeks- wall squats when pt is 100 degres knee extension, marching in place , step ups, cross over, lateral steps, and single leg balance drills on various surfaces (balance discs, foam half-rolls, BOSU® balls, etc.). Then, add resistance to march outs and low hurdle steps, both forward and sideways • plyometrics, progressive exercise • return to activity 20 - 24 weeks

LATERAL COLLATERAL LIGAMENT of the knee

LATERAL COLLATERAL LIGAMENT of the knee (fibular collateral ligament) • Attaches to the lateral condyle of the femur and attaches to the head of the fibula • Protects the joint from stresses to the medial side of the knee • Very strong and not injured easily

Lateral Collateral Ligament Injuries to the lateral collateral ligament injury

Lateral Collateral Ligament Injuries to the lateral collateral ligament (LCL) are infrequent and are usually the result of a traumatic varus force (medial) across the knee.

MCL ligament

MEDIAL COLLATERAL LIGAMENT of the knee • Broad flat ligament • Attaches to the medial condyles of the femur and tibia o Fibers of the medial meniscus are attached to this ligament which contributes to frequent tearing of the medial meniscus during excessive stress to the media collateral ligament

medial and LATERAL MENISCI

MEDIAL and LATERAL MENISCI • Located on the superior surface of the tibia • Half-moon wedged shaped fibrocartilage disks • Shock absorbers • They deepen the flat surface of the tibia • The medial meniscus is frequently torn lateral force causes medial injury, medial force causes lateral injury

Medial Collateral Ligament injury

Medial Collateral Ligament Isolated injuries to the MCL can occur from valgus forces being placed across the medial joint line of the knee. Whereas most injuries to the ACL and PCL are complete tears of the ligament, injuries to the MCL can be partial or incompleteand

Medical treatment for ACL

Medical The first goal for an ACL injury is to treat the pain and swelling and loss of the normal range of knee motion. There are medications that may be prescribed, along with RICE (rest, ice, compression, elevation of the leg) to help with pain and swelling. The leg should be elevated high above your heart when you are sitting or lying down. An ace ban- dage should be wrapped around your knee to help reduce swelling. Crutches are used to provide support when you walk or go up and down stairs. It is important to do ankle pumps (flexion and extension of the foot) to maintain blood flow of the leg. This decreases the slight chance of a blood clot in the calf.

Medical treatment and exercises for meniscus tear

Medical treatment Price protection brace, assist device, strengthen and mobility ice, and electric stim to decrease swelling and inflammation and pain same exercise as ACL

ITBFS Pathogenesis

Pathogenesis • The ITB is a continuation of the tendinous portion of the tensor fascia lata (TFL) muscle with some contributions from the lateral gluteal muscles(maximus minumus, medius). It originates at the ileum and the anterior superior iliac spine (ASIS).Distally, the ITB spans out and has attachments to the lateral border of the patella and lateral patellar retinaculum before its insertion on Gerdy's tubercle of the tibia • During the running cycle, the posterior edge of the ITB impinges against the lateral femoral epicondyle of the femur just after foot strike. This ''impingement zone'' occurs at, or at slightly less than, 30° of knee flex- ion Repetitive irritation can lead to chronic inflammation, especially beneath the posterior fibers of the ITB, which are thought to be tighter against the lateral femoral epicondyle than the anterior fibers

Piriformis syndrome description

Piriformis syndrome is an uncommon cause of buttock and hip pain. It is a controversial diagnosis that involves pain in the gluteal region, irritation or inflammation of the sciatic nerve, and leg symptoms.

PCL injuries

Posterior Cruciate Ligament Injury to the posterior cruciate ligament occurs when there is a posterior-directed force applied to the proximal tibia when the knee is flexed, as in a dashboard injury or striking the ground landing on the knee, with the foot plantar flexed

Risk Factors

Risk Factors Sport activities that involve jumping (basketball, volley- ball, running) Repetitive direct contact (eg, kneeling)

Meniscus tear test

Tests McMurray test. Your doctor will bend your knee, then straighten and rotate it. This puts tension on a torn meniscus. If you have a meniscus tear, this movement will cause a clicking sound. Your knee will click each time your doctor does the test. Apley's compression Test Bounce Home test

Pes anserine

The Pes anserine ("goose foot") muscle group goose foot • SATORUIS • GRACILLIS • SEMITENINOSUS

Treatment symptoms of Osgood-Schlatter's disease can be acutely ex- acerbated with activity, so there needs to be a period of RICE to reduce pain and swelling at the knee. After inflammation is controlled, a program can begin to increase elasticity in the surrounding musculature (see Figure 1.7). A good quadriceps-strengthening protocol should be included, beginning with muscle-setting exercises done on a table, such as quad sets, and advancing to include closed kinetic chain exercises (in which the limb is in contact with either the ground or another stable surface, such as squats or lunges). Avoiding open kinetic chain activities (when the imb is not in contact with the ground or any other stable surface and is free to move, such as a leg extension) will also help with this injury, since these exercises often increase the symptoms.

Treatment focus on education, reducing pain and swelling with ice. Eliminate activities that place strain on the patella tendon such as squatting, running or jumping. -Flexibility exercises for the hamstrings, quadriceps, gastrocnemius, and soleus muscles - Quadriceps, hamstring, and hip open chain muscle strengthening Closed chain lower extremity exercises Balance and proprioceptive training

Exercise for piriformis syndrome

exercise After ROM and flexibility is improved or even restored with stretching and soft tissue mobilization, hip strength- ening and lumbar stabilization exercises are performed. Tonley et al suggested that weakness of the gluteus medius leads to excessive medial femoral rotation and adduction in weight bearing tasks (11). This places greater strain on the piriformis muscle due to overloading and eccentric demand. Others have suggested L5 radicu- lopathies can cause weakness in the piriformis and other hip external rotators, increasing demand on the muscle. or referred sciatic pain from nerve compression. Strengthening the hip abductors, extensors, and external rotators can help Strength training exercises in a non-weight bearing position, such as the side lying clamshell (Figure 49.2) and supine bridge progression of these exercises focuses on squatting and lunging with emphasis on neu- tral femoral alignment in the transverse plane. Lumbopelvic stabilization exercises that address the transversus abdominus, multifidi, and internal and exter- nal obliques are very important in treating piriformis syn- drome. Plank and side plank exercises (Figures 49.4 and 49.5) are maneuvers that minimize rectus abdominus con- traction while targeting gluteus medius and external oblique muscles (12). Core exercises have recently been described as those involving the lumbopelvic hip complex (13).

exercises

https://www.orthoindy.com/UserFiles/File/IT%20Band%20Program.pdf http://runninginjuryclinic.com/wp-content/uploads/2012/11/IT-Band-Syndrome-Rehab.pdf foam roller, hip abduction, hip adduction, hip flexion, hamstring stretch, the quadricep stretch IT stretch with strap supine or standing and Piriformis Stretch

Treatment for patellofemoral syndrome https://mydoctor.kaiserpermanente.org/ncal/Images/patellofemoral_tips_exercises_tcm75-823272.pdf

treatment treatment should be directed toward pain alleviation and restoration of proper biomechanics. • focus of the treatment dependent on the contributing factor associated with abnormal patellar tracking. Possible treatment options include rice to decrease inflammation and pain, lower extremity flexibility exercises, medial patella glides, biofeedback and patella tapping. Lower extremity strengthening should emphasize the quadricep and in particular the vastus medialis oblique,(VMO) while minimizing patellofemoral compressive forces o extra • Treatment programs should be individualized General recommendations include pain control • with activity modification, correction of patellar malalignment (if appli- cable), and stretching and strengthening exercises for the affected lower limb (14). In general tight structures should be mobilized and the kinetic chain should be balanced (1). o Ex o Therapeutic exercise: stretching exercises focusing on the quadri- ceps, ITB, and hip and core muscles for balance and kinetmatic chain , and plantarflexors. the quadriceps can be stretched in the prone or standing position by pulling the ankle to- ward the buttocks. The ITB can be stretched in the standing position or seated position (Figure 25.3). A supine hamstring stretch is performed by supporting the leg with both hands and slowly straightening the leg (Figure 25.2). The plantarflexors can be stretched by taking a lunge step toward a wall with hands placed on the wall for support. Strengthening exercises focusing on the quadriceps, gluteus maximus and medius, includ- ing but not limited to: seated leg press, small squats, quad sets step up/step down exercises, four-way straight leg raise, single leg knee exten- sion 4. Specialized treatment: Patellar taping, bracing, foot orthoses, if these treatments improve the patient's ability to comply with the strengthening program

sign in symptoms

• anterior knee pain, pain with prolonged sitting, swelling, crepitus, pain when ascending and descending stairs

Osgood-Schlatter

• classification refers to knee pain It is an inflammation of the tibia tuberosity .it becomes inflamed and painful. The patellar tendon pulls on the tibial tuberosity. which causes the bony lump. (It is a self-limiting condition that results from repetitive traction on the tibia tuberosity apophysis)