Knee Injuries

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Knee injuries are very common, in particular in contact sports. A majority of the injuries that halt professional careers affect the knee. Before going into detail about these injuries I must emphasise the vital importance of the neuro-muscular control of the kinetic chain. Any weakness in that chain, such as poor ankles or poor core stability, can predispose to knee injuries.

The figures below show the anatomical appearances of the knee from different angles with arrows indicating the locations of symptoms from the injuries.

MCL tear

MCL tear

ITB friction syndrome

ITB friction syndrome

Osgood-Schlatter's disease

Fig. 79

Prepatellar bursitis

Osgood-Schlatter's disease

Fig. 78

Fig. 79

Quadriceps rupture
hamstring rupture

Fig. 80

Fig. 81

Fig. 82 Leg extension manoeuvres are closed chain exercises for the quadriceps muscles

TRAINING OF MUSCLES SUPPORTING THE KNEE

All strength exercises that aim to develop muscle power and volume should be performed slowly and in a controlled manner in concentric mode for one to two seconds and in eccentric mode for three to four seconds. The exercise should be performed with 8 RM for three sets to achieve muscle hypertrophy and increased strength. The injured leg must initially be trained separately from the non-injured.

Quadriceps muscle strength can be trained with leg press, squats or leg extension manoeuvres. The vastus medialis muscles require special attention after patella (kneecap) dislocation or in mal-tracking conditions that cause anterior knee pain. If the patella is subluxated or out of place and knee extensions cause pain, a soft knee brace can be useful and give very good results. The quadriceps muscles are essential for knee stability in activities such as jumping, sprinting, twisting and turning. The rectus femoris muscle, the most

Fig. 83 Flexibility test for the quadriceps muscles Fig. 84 Flexibility test for the rectus femoris muscle

powerful of the quadriceps, also controls hip flexion, together with the iliopsoas muscle. The flexibility of the quadriceps muscles is improved with stretching and can be performed in different ways.

Hamstring muscle strength is trained with knee flexion and hip extension exercises, standing or sitting, using wires with weights or specific machines allowing a hamstring curl. The hamstring muscles are particularly important in activities such as sprinting and turning and work against and with the quadriceps to stabilise the knee. The hamstring, despite being a hip extensor and knee flexor, extends the knee joint during the last 15 degrees of extension.

The endurance of the thigh muscles can be trained with 15-50 RM resistance for three sets, using a bicycle with the pedal under the heel or forefoot in either a forward-leaning or straight-up position or with running, if allowed. Flexibility is trained with stretching.

Good proprioceptive muscle function is vital to prevent further injuries. Co-ordination training can be done on wobble boards, initially in the static mode, followed by dynamic one-leg hops and controlled landings. A one-leg hop is a good test of the proprioceptive function of the leg.

Fig. 85 Flexibility test for the hamstring muscles Fig. 86 Stretching of the hamstring muscles

Fig. 85 Flexibility test for the hamstring muscles Fig. 86 Stretching of the hamstring muscles

Fig. 87 Plyometric exercises are effective, but put the Lower extremities under high-impact forces

Functional training depends on the patient's needs and may include running in a straight line, side-stepping, twisting, turning, jumping, landing and various forms of plyometric exercises. Knee function is dependent on the entire kinetic chain and posture; unstable or weak ankles or poor core stability will hamper knee function and may predispose to knee injuries. Core stability exercises should be included in all rehabilitation of injuries discussed in this book.

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Fig. 89 Anterior drawer test is another sensitive test for revealing an ACL tear. Sit gently on the patient's foot. Knee should be flexed around 90 degrees. Move tibia anteriorly. If there is increased laxity and no firm endpoint the test is positive

Fig. 88 Lachman's test is very effective for revealing an ACL rupture. Hold the thigh firmly with one hand. Knee should be slightly flexed. Move tibia anteriorly. If there is increased laxity and no firm endpoint the test is positive

SYMPTOMS The symptoms are pain and immediate haemarthrosis, caused by bleeding from the ruptured ligament. This is an injury common in contact sports such as football, rugby and other high-intensity sports such as downhill skiing. There is often a 'pop' sound from the knee and an inability to continue.

AETIOLOGY The typical athlete suffers a hyperextension or valgus rotation sprain. In many cases it is a non-contact injury, where the player loses balance and twists the knee. The ligament can rupture partially or completely. In growing athletes the bone insertion can be avulsed (tibia spine fracture). This injury is often associated with other injuries to cartilage, menisci, capsule or other ligaments.

CLINICAL FINDINGS There is intra-articular bleeding (haemarthrosis) in most cases. If there is a capsule rupture as well, blood can penetrate from the joint and cause bruising along the lower leg, so the

Fig. 89 Anterior drawer test is another sensitive test for revealing an ACL tear. Sit gently on the patient's foot. Knee should be flexed around 90 degrees. Move tibia anteriorly. If there is increased laxity and no firm endpoint the test is positive

Fig. 90 The pivot shift test is difficult to do but, if positive, an ACL tear is confirmed

joint effusion does not look too severe. In rare cases, there is no haemarthrosis. The Lachman test is positive if the rupture is complete. This is the most sensitive test and can verify an anterior cruciate ligament rupture in more than 90 per cent of cases. Anterior drawer tests and pivot shift tests are complementary tests for the same purpose. Note! Since there are often associated injuries, the examination must include tests for collateral ligaments, menisci, cartilage and the capsular structures.

INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is valuable to rule out fractures, in particular in growing or elderly athletes. MRI can verify a complete ACL tear in most cases but is more important for evaluating associated injuries.

TREATMENT An athlete with haemarthrosis and a suspected ACL tear should be seen by an orthopaedic surgeon to consider an early arthroscopy. This procedure can verify the diagnosis and also deal with associated injuries that are often missed. Reconstruction of the ligament is recommended for active athletes in pivoting sports. Sedentary people and participants in non-pivoting sports may recover through rehabilitation only. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon.

EXERCISE PRESCRIPTION Cycling and swimming (not breast stroke) are good alternatives to keep up general fitness. Rehabilitation back to full sport usually takes around six months with or without surgery.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows the return to full sport.

DIFFERENTIAL DIAGNOSES Posterior cruciate ligament rupture. Initial posterior sagging will give a sense of anterior translation of the tibia during a Lachman or anterior drawer test and mislead the examiner but the posterior drawer test is positive. Associated injuries, such as a bucket handle menis-cal tear, can cause the knee to lock, and mask a positive Lachman test.

PROGNOSIS Surgery (ACL reconstruction) will allow return to professional sports in around six to nine months. The risk of re-rupture is about 5 per cent within five years. The reconstruction will protect the knee from further meniscus or cartilage injuries. However, reconstruction or not, the knee will be more vulnerable to stress and in the long term, 10 to 20 years, the risk of developing osteoarthritis is significant, compared to a non-injured knee.

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Fig. 91 Arthroscopic view of new patellar bone graft in an ACL reconstruction

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