MSC MANUAL THERAPYSEPT 2011

JANE ASHBROOK

The Knee

FUNCTIONAL ANATOMY AND CLINICAL PRESENTATIONS

Msc Manual TherapyThe Knee

Anterior Cruiate Ligament

ACL

Normal Partial tear

Treatment

Conservative Management ACL Reconstruction

Indications for ACL reconstruction

Professional athletes must have surgery.Prevents meniscal tears and OA.Recreational athletes will benefit, especially

activities involving twisting and turning eg. Skiing, tennis, squash.

90% of patients achieved normal or nearly normal function following ACLR (Ardern et al, 2011).

Medial Collateral Ligament

MCL

• Indications

Valgus stress test less give in ext suggests ACL/PCL/POL/PMC intact.

DMCL tighten with ER.SMCL primary valgus restraint throughout flex.PMC/POL controls valgus, IR and post drawer

in ext.(Coen et al, 2010)Total ruptures usually occur with associated

injury, including ACL, med or lat meniscus (Nakamyra et al, 2003).

Management

Conservative:Grade 1,2 and acute 3.Protected weight

bearingEarly active

movementHinge brace (gr 3)Progressive strengthFunctional rehabGood outcomes

Surgical: Combined SMCL +/-

DMCL and POL injuries causing severe instability.

Anatomic recontruction of SMCL and POL.

Concurrently with co-existing ACLR.

May require arthroscopy before or after if chondral defect or meniscal tear present.(Cohen et al, 2010)

Posterior Cruciate Ligament

PCL

Indications

Accounts for only 0.65% of all knee injuries (Majewski et al, 2006)

50% MVA (Dandy and Pusey, 1982).Rupture well tolerated ?meniscofemoral

ligaments resist post drawer up to 40% (Malone et al, 2006).

Management

Conservative:?Immobilised in ext

brace 6 weeks.Functional rehab.V little evidence.

Surgical:Avulsion # can be

repaired.Little evidence for

PCLR.No evidence

regarding long term OA.

If instability present then likely to be other ligaments involved and multiple repair required.

Lateral Collateral Ligament

LCL

1.1 % of athletic knee injuries (Majewski et al, 2006)

Common peroneal nerve injured in conjunction in 15% of cases- meta analysis of 139 patients (Malone et al,2006)

If LCL sectioned then small increase in varus is seen on testing.

If large movement detected on varus testing then multiple ligament injury should be suspected.

Postero-Lateral Corner

PLC

Indications

Rarely injured in isolation (Malone et al, 2006).May present with +ve Dial, +ve postlat drawer and

varus opening at 0-30˚ flex.Unstable knee, ?failed ACLR.Post and lat thrust on stance phase of gait.

Management

Conservative:Knee very unstable.Chronic instability or

failed ACL reconstruction.

Surgical:Early repair best:

48hrs-7 days (La Prade et al, 1997).

Larson (sling ITB) or LaPrade (TA allograft) technique.

Correction of lat thrust.

Can’t replace normal PLC function.

Meniscal Injuries

Meniscal tears

Tear posterior horn medial meniscus with meniscal cyst

Radial tear lat meniscus

Indications

Twisting, change of direction on loaded knee.Acceleration/deceleration.Degen tears spontaneous/minor incident.Composite testing most effective.Accuracy difficult in degen tears and

associated lig injuries.Torn discoid lat meniscus: children.Post horn lat meniscus: instability and

detachment, PLC.(McDermott, 2011.)

Tears

Management

Conservative:

Can be asymptomatic.Less mechanical

symptoms in degen tears.

Rehab AROM and functional strength.

(McDermott, 2011)

Surgical:Arthoscopy.Repair: vertical, some

horiz, 25% under 40. Sutures.

Rehab: PWB, 90* brace 6 weeks. Start impact 3 months.

Resect: flap, ragged, complex.

Rehab: very quick.New tech: replacement.

Chondral Surface Injury

Indications

Rotational forces cause stress fracture in subchondral bone, fails to heal, necrosis.

Common in adolescents, usually stable.Unstable in adults, can cause loose body.Classified dependent on extent and depth.Need WB x-ray and MRI.

(Cole and Cohen, 2011)

Management

Conservative:NSAIDsCorticosteroidsChondroprotective

agents.Activity

modification/avoidance.

Brace.Strength and

flexibility.Ineffective.

Surgical:Palliative:

debridement and lavage.

Reparative: marrow stimulating technique.

Restorative: ACI, osteochondral grafting.

Patello femoral Pain Syndrome

Forces

Patellofemoral Joint Reaction Force

Patellofemoral Joint Stress= PJRF ÷ PF contact area.

Unreliable clinical measurement.Increase in angle will increase Lateral patella displacement.

Biomechanics

Angle of knee flexion Event

0-10* No patella contact with femur

10-30* Patella aligns and enters intercondylar notch

0-50* Tension in patella tendon greater than tension in quads

0-90* Contact zone moves proximally

>50* Tension in patella tendon lower than tension in quads

0-60* PJRF and PJS increase

60 ±5* Peak PJS, quads neutral, critical angle

85-90* Quads wrap

(Selfe, 2004)

Indications

Controversy in literature: overloaded with theories.

Subchondral bone deformation(Goodfellow et al, 1998, Naslund et al, 2005)

Intermedullary pressure changes (Arnoldi, 1991) Lateral retinacular neuroma formation (Sanchis-

Alfonso et al, 1998) Vascular dysfunction (Sanchis-Alfonso et al,

2007, Selfe – work ongoing) The tissue homeostasis theory/the biological

inflammatory cascade (Dye et al, 1999

Risk Factors

Lower limb malalignment (Shelton, 1991).VMO:VL muscle imbalance (McConnel, 1986).VM considered single anatomical unit (Hubbard,

1998).Conflicting evidence of delayed onset VMO (Selfe,

2004).VMO onset delay in runners with PFPS (Ng et al,

2011).VMO-VL timing rations vary between healthy

subjects and patients (Selfe, 2004).Effusion inhibits quads: VM (Torry, 2000).

Risk Factors

Reduced quads flexibility, VM reflex response time, explosive strength and vertical jump ability (Witrouw, 2000).

Weakness of hip lateral rotators and abductors (Robinson, 2007 and Ireland, 2003).

PFPS subjects sig difference in ITB length in symptomatic and asymptomatic sides(Hudson and Darthuy, In Press)

ITB tightness increases pressure on lateral patella facet (Merican et al, 2009)

PFPS subjects had significantly shorter hamstrings than asymptomatic controls (White et al, In Press)

Treatment

Poor prediction of recovery if pain persists for 2 years (Price, 2000).

Combination of CKC and OKC exercises required.OKC avoided in 1st 30* flex (Doucette, 1996).Exercises can be performed in controlled pain.Proprioception (Callaghan, 2008, 2010, 2011).Mobilisation and manipulation.Acupuncture.Taping/bracing .Combined (Mason, 2010). Orthotics (Vincenzino, 2010 and Barton, 2009).

Patella Instability

Indications

Functional valgus: if lat force of eccentric quads overcomes VMO and MPFL, patella can dislocate (Greiwe, 2009).

Articular geometry: patella alta-increased translation prior to trochlear engagement (Greiwe, 2009).

Dynamic limb alignment: femoral anteversion, decreased hip abd and IR strength (Ireland, 2003).

Dynamic stability: VMO injury in acute dislocation.

Static stability: MPFL fails at low load, 50% increase lat displacement patella (Greiwe, 2009).

Management

Conservative:Dynamic neuromuscular

control: hip, knee, core.Proprioception.Orhtotics.Rehab remains reduced

in a proportion of patients (Smith, 2010).

VMO activity and onset timing uncertain (Smith, 2010).

Surgical:Tibial tubercle

osteotomy: alter Q-angle.

Distal tubercle osteotomy: decrease patella alta.

Trochleoplasty: Increase trochlear groove.

Quadsplasty: suture VMO to add magnus.

MPFL recon: gracilis aotgraft.

Osteoarthritis

Risk factors

Post menisectomy:Younger patients.Decrease contact

surface area 75% and increase contact pressures 235% (McDermott, 2010)

1400% increased prevalence 21 years after menisectomy (Roos, 1998).

Degenerative:Older patients.Obesity.Repetitive strain,

wear and tear.Genetic

predisposition.

Management

Conservative:Decrease effusion.Increase AROM and

flerxibility. Increase muscle

strength and propriocetion.

Activity modification.NSAIDs.

Surgical:Corticosteroid

injections.Hyaluronic acid

injections.Wash out and

debridement.TKR.