chapter 20

1. 1 Chapter 20 Injuries to the Thigh, Leg, and Knee

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3. 3 Anatomy Review Knee articulations

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5. 5 Anatomy Review

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7. 7 Common Sports Injuries - Bursitis Soft tissue injuries: bursa small fluid-filled sac located at strategic points numerous bursa around the knee region -- only a few are typically injured inflammation can be caused by trauma, chronic irritation or infection the prepatellar bursa is often irritated by trauma

8. 8 Common Sports Injuries - Bursitis Signs/symptoms: swelling/tenderness increased pain caused by manual pressure history of trauma or chronic injury First Aid: apply ice and compression reduction of activity if chronic -- anti-inflammatory agents with a physician�s approval

9. 9 Common Sports Injuries � Patella Patellofemoral conditions Some conditions of the patella may be directly or indirectly related to Q-angle. As shown in the illustration, Q-angle is computed as the difference between a line drawn from the center of the patella compared with one drawn from the center of the patella through the center of the tibia. Excessive Q-angle may be related to problems such as patellar chondromalcia or ACL tearing.

10. Proper Patellar Tracking 10

11. 11 Common Sports Injuries � Femur FX Signs & Symptoms pain at the injury site difficulty in walking swelling and/or deformity athlete may report having suffered a traumatic event athlete may report a pop or snap at time of injury First Aid: splint the injured leg apply sterile dressings to any related wounds monitor vital signs and circulation of the lower leg refer to a physician via ambulance History results from an extremely traumatic event may also be in the form of a stress fracture, especially the femoral neck region In the adult, fractures of the femoral neck may result in avascular necrosis of the femoral head. This injury results from disrupted blood supply to the articular cartilage on the femoral head.

12. 12 Common Injuries - Muscle Strains History Sudden acceleration or deceleration (acute) Fatigue induced (chronic) May report feeling/hearing pop or snap Sign/symptoms A sharp pain in the affected muscle Swelling weakness & inability to contract the muscle forcefully discoloration (2nd degree) visible deformity (3rd degree) First aid I.C.E. rest anti-inflammatory refer to a physician (3rd degree)

13. 13 Common Sports InjuriesPatellar Dislocation/Subluxation History Onset: Acute or chronic Location of Pain: Medial jt capsule as well as pain under the patella. Mechanism: forceful extension with femoral ext rotation while knee is in flex Observation: Unreduced patellar show an obvious deformity Swelling within 24 hrs after onset of injury Palpation Pain over the lateral & medial side of the patella Origin of the VMO Along the Patella Tendon Functional AROM: Pain during the 1st 300 of flexion or terminal extension RROM: decrease isometric str. During extension when knee is flexed 00 & 300. Special Test (+) Apprehension Test [subluxation]

14. 14 Common Sports InjuriesPatellar Dislocation/subluxation Treatment: slowly extend leg (reduce) I.C.E immobilize the injury with knee immobilizer for 4 weeks treat any open wounds with sterile dressings monitor vital signs and circulation of the lower leg Refer to MD

15. 15 Patellar Tendonitis �Jumpers Knee� History Onset: Chronic Location of Pain: Inferior pole and/or insertion site at the tibial tuberosity or tendon itself. Mechanism: Repetative movement involving resisted knee extension Observation Swelling around the patellar tendon & inferior pole of the patella or tibial tuberosity (Osgood-Schlatter) Palpation Tenderness on the patellar tendon & inferior patella pole or tibial tuberosity Functional AROM: Pain during knee extension PROM: Pain during end of knee flexion RROM: Pain throughout knee flx ROM First Aid: Ice NSAIDs Rest Patella strap

16. 16 Common Sports InjuriesMyositis Ossificans Soft tissue injuries contusions -- can occur anywhere but are common in the anterior thigh -- sports such as football and ice hockey require padding of the region for prevention if force of injury is sufficient a deep bruise may result -- including damage to the underlying periosteum if not cared for properly, myositis ossificans may develop Signs/symptoms: history of forceful impact muscle spasm and swelling loss of function & pain difficulties in walking First Aid: apply ice and compression if severe, put on crutches rest avoid further irritation until the acute phase has passed protective doughnut padding with a thermoplastic dome required when athlete returns to play

17. 17 Common Sports InjuriesMeniscus tears History Onset: Acute Location of pain:Along the medial or lateral jt line Mechanism: Tibal rotation w/ flexion & valgus or varus force. Observation Jt effusion may develop over 24 to 48 hrs. In the JT line or popliteal fossa Palpation Pain along the JT line and b/w the joint line when knee is flexed to 90� Functional AROM: ROM is decreased PROM: Pain at extreme of flexion/extension RROM: Pain or locking is revealed Special Test (+) McMurray�s test (+) Apley�s Compression Note: Test ACL & MCL First Aid: ice and compression put athlete on crutches refer to a physician

18. 18 Common Sports Injuries-MCL/LCL Sprain History Onset: Acute Location of pain: Medial side of the knee (MCL), Lateral side of the knee & fibula head (LCL) Mechanism: Valgus force or excess external rotation (MCL), Varus force or excess interal rotation (LCL) Observation Swelling medial side (MCL), lateral side (LCL)

19. 19 Common Sports Injuries-MCL/LCL Sprains Palpation Tenderness along the length of the MCL or LCL Functional AROM: pain on terminal ranges of flexion & extension (MCL/LCL) PROM: pain on terminal ranges of flexion & extension (MCL/LCL) RROM: decreased strength & pain during flexion/extension Special test Valgus stress test (MCL) Varus stress test (LCL) First Aid: ice and compression Immobilize PRN put athlete on crutches PRN Note: 3o refer to doctor

20. 20 Common Sports Injuries-ACL/PCL History Onset: Acute Location of pain: within the knee joint radiating anteriorly (ACL) or posteriorly (PCL) Mechanism: (ACL) tibia moves anterior on the femur or femur moves posterior to tibia. Hyperextension of the knee. Rotation also tears ACL . Most are noncontact. (PCL) tibia moves posterior to femur when @ 90� angle. Requires some sort of force . Aka Dashboard injury Observation Rapid swelling Tibia sagging (PCL) Palpation (ACL) cannot palpate (PCL) tenderness in the poplital fossa Functional (ACL) AROM: swelling may prohibit full ROM PROM: pain throughout the ROM RROM: if pain on AROM & PROM, do not perform RROM (PCL) AROM: pain when fully flexed PROM: pain when nears full flexion RROM: pain near terminal flexion

21. 21 Common Sports Injuries-ACL/PCL Special Test (ACL) Anterior Drawer test (ACL) Lachman�s test (PCL) Godfrey�s sign (PCL) Posterior Drawer test

22. 22 ACL � Surgical Options ACL Repair Suturing of torn ACL to itself Highly unsuccessful; outdated ACL Reconstruction Patellar tendon or Hamstring (Semitendinosus) Patellar used to be favored, but slightly longer rehab intially & pain b/c of tendon Semitendinosus causes less pain but hamstring can bother later Cadaver � ACL or Achilles

23. 23 ACL Rehab Rehab lasts anywhere from 4-6 mons ROM is most important along with protection of graft No open chain resisted knee ext til at least 4 mons Mechanical issues must be addressed; particularly take-off and landing Hamstrings must also be strengthened

24. ACL Prevention Women are 5x more likely to tear their ACL Hormones? Higher Q-angle Lack of hamstring recruitment Improper take-off/landing technique Prevention Programs Developed SportsMetrics � �knees under the hips and over the ankles� 6 week program Incorporates flexibility, strength, and plyometric training Reinforces proper take-off and landing techniques Not only reduces likelihood of ACL tear but also improves athletic performance. 24