Common Injuries to the Knee
ANTERIOR CRUCIATE
INJURIES
ACL injuries also commonly occur with hyperextension of
the knee, deceleration and valgus stress.
INDICATIONS FOR SURGERY:
Complete tear; associated meniscal pathology
Well motivated person who will do the rehab program; physiologically young
Unwilling to change lifestyle; job and sports require twisting, cutting
Minimal evidence of DJD
WHEN TO DO SURGERY : Wait at least 3-4 weeks after injury
•Decrease the swelling
•Decrease Quad inhibition
•Decrease hamstring overfiring
•Decrease scarring
•Increase ROM; decrease stiffness
SURGERIES PERFORMED
1. Bone-tendon-bone with middle 1/3 of patellar tendon
2. Semitendinosis and gracilis: fold them in ½ so have a 4 tendon bundle
3. Allograph: bone-tendon-bone patellar tendon from cadaver
Key in surgery is correct isometric placement of the graph.
80-90% of patients have a good result with surgery going back to
previous levels of activity. Some complications that may arise and give
a less than favorable result are:
• Patellar tendonitis
• Patellofemoral pain/chondromalacia
• Limited ROM at extremes; loss of even a few degrees of terminal
extension is a problem
• Stretching out of graph
COLLATERAL LIGAMENT
INJURIES
MCL tears: most common mechanism is a
blow to the outside of the knee followed by
planting of the foot and twisting of the
knee.
There is a high risk of injury to the medial meniscus with MCL
tears.
KNEE REHAB
PATELLOFEMORAL PAIN
SYNDROME
The patella must have balanced
muscular forces around it to ride
properly in the femoral groove.
The VMO should fire before the VL.
The VMO/VL ratio should be 1:1
Tight ITB, hamstrings and calf can
disrupt muscular balance.
OTHER FACTORS
CAUSING PFPS:
1. Overpronation
2. Anteversion
3. Weak Hip ER & ABD
4. Tibial Varum
5. Increased Q angle
ILIOTIBIAL BAND
SYNDROME
Complains of pain on knee flexion
May complain of snapping
Pain gets worse on ROM from full
flexion to full extension.
Often result of: genu varum; over pronation; femoral
anteversion; spinal problems.
SHIN SPLINTS
Most common area affected is
antereomedial shin.
Starts out as muscle/tendon
injury
Can progress to periosteal
injury
Can end up as a stress fracture
ANKLE SPRAINS
Ottawa ankle rules
JOBST
INTERMITTENT
COMPRESSION
DEVICE
ROM exercises
Strengthening
Proprioception
Agility
Running/jumping
Syndesmotic
Injury
ACHILLES TENDONITIS
ACHILLES TENDON
RUPTURE
LONG REHAB: Average 6-9 months
PLANTAR FASCITIS
Over pronation
Pes cavus foot
Tight calf muscles
Tibial varum
Anteversion
Weak ER of hip
Pharmacology
DRUGS USED FOR
MUSCULOSKELETAL
PATHOLOGY
• Analgesics
• Drugs that directly affect the healing
process
• Drugs that do both
NON STEROIDAL
ANTIINFLAMMATORY
DRUGS (NSAIDS)
• Treatment of inflammatory arthritic
diseases
• Treatment of the “itises”
NSAIDS: SIDE EFFECTS
• Gastrointestinal Irritation and Ulceration
• Decreased Blood Clotting
• Kidney Trouble
• Other
Common NSAIDs
(OTC)
Bayer
(aspirin)
Tylenol
(acetaminophen)
Aleve
or Naprosyn
(naproxen)
Advil
(ibuprofen)
Common NSAIDS (Rx)
•
•
•
•
•
•
Celebrex (celecoxib)
Voltaren (diclofenac)
Lodine (etodolac)
Nalfon (fenoprofen)
Indocin (indomethacin)
Orudis, Oruvail
(ketoprofen)
• Toradol (ketoralac)
• Daypro (oxaprozin)
• Relafen
(nabumetone)
• Clinoril (sulindac)
• Tolectin (tolmetin)
• Vioxx (rofecoxib
Dosing
Depends
Avoid
Trial
negative drug reactions
and Error
Every
Must
on Goal
patient has a different response
keep blood levels constant for
antiinflammatory response
CORTICOSTEROIDS
•
•
•
•
•
Synthetic derivative of cortisol
Mobilizes energy stores
Circulatory changes
Changes in liver and kidney function
Subdue inflammation and immune
response
ACTION
• Stabilizes cell membranes which
decreases release of inflammatory
mediators
• Inhibits migration of inflammatory cells that
are attracted to the injured area.
INDICATIONS
• INFLAMMATORY DISEASES: RA, Lupus,
Ankylosing Spondylitis
• NO! Acute musculoskeletal injuries
• ???? Chronic musculoskeletal injuries
ADMINISTRATION
• ORAL: Used in tx of diseases which affect
multiple joints; Dose pack for chronic
musculoskeletal problems
• LOCAL INJECTION: Used for tendinitis,
bursitis, fasciitis
• TOPICAL USE: Dermatologic effects only
SIDE EFFECTS: ORAL
• Osteoporosis: pathologic fractures
• Avascular Necrosis
• Disturb fat and carbo metabolism: increase risk
of diabetes; increased fat distribution in trunk
and face
• Hypertension due to NA and H20 retention
• Steroid myopathy
• Steroid psychosis
SIDE EFFECTS: LOCAL
INJECTION
• No systemic effects
• False sense of recovery
• Local tendon/muscle atrophy: rupture
• Skin changes
ANALGESICS
• Allow early initiation of rehab
• Improve quality of life for persons with
chronic pain
• Allow patients to tolerate surgery
NON-NARCOTIC
• Acetaminophen: Has central nervous
system effect through cental inhibition of
prostaglandins
• Aspirin: Has peripheral effect through
peripheral inhibition of prostaglandins
• NSAIDS: Have analgesic effect on
nervous system as well as decreased
inflammation
NARCOTIC
• Common property: bind to opioid
receptors in brain
• Results in significant elevation of pain
threshold; can be addictive
INDICATIONS
• Mild/moderate musculoskeletal pain: nonnarcotics; acetaminophen first choice;
NSAIDS may be more logical if
inflammation is causing pain, ie acute
injuries and inflammatory arthritis
• Osteoarthritis: acetaminophen
• Chronic musculoskeletal pain:
acetaminophen
Continued……
• Acute postoperative pain: narcotics; can
be given IV or IM
• Chronic, Severe pain: narcotics
See Table 3 for commonly used analgesic
drugs
SIDE EFFECTS
• ACETAMINOPHEN: generally safe; liver
toxicity
• ASPIRIN/NSAIDS: as previously covered
• NARCOTICS: respiratory suppression;
sedation, nausea and vomiting; urinary
retention; euphoria/dependence
ANTIBIOTICS
• Used to treat or prevent bacterial
infections which can occur postoperatively
or post compound fracture
• Classified based on chemical structure
and effectiveness against certain bacteria
(Table 4)
INDICATIONS FOR USE
• Use drug best suited to fully eradicate the
bacteria causing the infection
• Infection must be cultured to determine what
kind it is
• Sometimes used prophylactically at time of
surgery; mostly with patients with compromised
immune system
• Always used with patients with open fractures