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Knee

The knee joint joins the thigh (femur) with the lower leg (Tibia) and consists of two articulations: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body and is very complicated. The knee is a mobile pivotal hinge joint), which permits flexion and extension as well as a slight medial and lateral rotation. In humans the knee supports nearly the whole weight of the body, it is the joint most vulnerable to both acute injury and the development of osteoarthritis. It is often grouped into tibiofemoral and patellofemoral regions.

Anterior Cruciate Ligament

Where is the ACL?

The word "cruciate" loosely defined, means "crossed", referring to the fact that there are two cruciate ligaments, the ACL (a broad ligament) crosses from front to back and the PCL (Posterior Cruciate Ligament) crossing from the back to the front. The ACL begins from the anterior portion of the intercondylar area of the tibia (shin bone), just behind the attachment of the medial mensicus. The ACL courses upwardly and backwards and attaches to the lateral condyle of the femur (thigh bone). The ACL is slack when the knee is flexed (bent as it is at your desk) and taut when fully extended (knee is straight as in standing).

What is the function of the ACL?

The main function of the ACL is to stabilize the joint. It prevents displacement (movement) and rotation of the femur on the tibia. The easiest application of this phenomenon is when going down the stairs or playing sports with a torn ACL. This is noticeably more difficult as a descent down stairs feels unstable to the lower leg.

Causes of ACL Injury?

Injuries to the ACL are among the most common of all sports-related knee injuries. It's estimated that each year in the United States between 95,000 and 250,000 people sustain a torn or ruptured ACL. The most common cause of ACL rupture is a traumatic force being applied to the knee in a twisting movement. This can occur with either a direct or an indirect force. Typically ACL tears happen when you slow down suddenly or cut or pivot with your foot firmly planted, twisting or overextending the knee. This type of stress in the knee can stretch the ACL beyond its normal elastic range for it's fibers and subsequently tear. Once the ligament tears, it doesn't heal — it remains loose. In our practice, about half of the cases of ACL rupture occur without contact, i.e., while side-stepping, pivoting or landing from a jump. The other half are associated with some type of contact, whether it be on the football field, on the snow fields or in a motor vehicle accident. Skiing injuries usually occur during a fall in the inexperienced skier, on rented skis when the bindings do not release. Women have ACL injuries more often than men do. The exact reason for this isn't clear. It is likely due to differences in anatomy, hormones, strength or conditioning.

What are the symptoms of an ACL tear?

When you tear your ACL, you may feel or hear a pop in the knee, experience significant pain in the knee, and have immediate swelling. When you try to stand and put weight on the injured leg, the knee may give way and feel unstable. In most cases, you must stop physical activity due to pain or because the knee is no longer able to support your weight.

 

Treatment Options:

There are both conservative (Non-Operative) and operative options. Some patients are able to rehabilitate their knee with a comprehensive physical therapy program and utilization of a brace for activities at risk. Patients involved in a sport that includes a jump, cut, or pivot; often opt for a surgery to reconstruct the torn ACL. The goal of the surgery is to restore the stability of the joint. This is accomplished by placing a graft in the knee to replace the native ACL.

 

After Surgery:

Your surgeon will instruct you on your allowed activities during the post-operative period. It is important that the surgeon understands your goals and when you would like to return to sport/activities. A supervised physical therapy is often prescribed after surgery. The goal of PT is to restore normal function in your knee and strengthen the surrounding and biomechanically important muscle groups.

 

Authors:

The Sports Medicine Clinic

Chris Peterson, DO

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

 

Knee Anatomy

 

ACL Anatomy

 

ACL Tear

 

ACL tear

 

Tom Bracy ACL Tear

 

Knee Anatomy

ITB

 

 

Iliotibial Band Syndrome

IT Band Syndrome (ITBS) is another condition often causing knee pain. This syndrome involves non-contractile soft tissue located on the outside of the leg running from the hip to below the knee known as the Iliotibial Band. ITBS is one of the most common causes of lateral knee pain in runners and cyclists. Dysfunction of this band of soft tissue often causes friction and irritation to various structures on the outside of the knee such as the lateral epicondyle of the femur, or the fat pad and bursa in between. Symptoms of ITBS include lateral knee pain when running (worse downhill), palpable pain on the outside of the knee joint, or pain when climbing stairs.
Possible Treatments:

IT Band Strap: to reduce friction and irritation at the lateral aspect of the knee.
Orthotics: improve biomechanical alignment of the lower extremities and allow for improved gait mechanics.
Stretching and Soft Tissue Massage: of IT Band and hamstrings
Strengthening: hip abductor, hip internal/external rotators, and quadriceps strengthening
Ice and other modalities: to reduce pain and inflammation

 

Authors:

The Sports Medicine Clinic

Chris Peterson, DO

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT

 

Foam Roll Link:

Foam Roll

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

 

Knee Anatomy

LCL Anatomy

 

Lateral Collateral Ligament

Where is the LCL?

The lateral collateral ligament (LCL) is a strong flat band of fibrous tissue that extends from the lateral epicondyle of the femur (thigh bone) to the top of the fibula bone. It is part of a larger group of complex structures referred to as the LCL and posterolateral corner that provide stability to the outside of the knee. Other important structures in the posterolateral corner are the iliotibial band (IT band), popliteus tendon, and popliteofibular ligament. What does the LCL do?

The LCL and structures of the posterolateral corner provide stability to the outside (lateral) part of the knee. These structures prevent the outside of the knee from opening up with walking or other movements.

Causes of LCL Injury?

The LCL and posterolateral corner structures are typically injured when the inside of the knee is struck or with high energy mechanisms, such as car accidents, that lead to other ligament tears in the knee. Injuries to the LCL and posterolateral corner rarely occur in isolation and are usually associated with tears of other knee ligaments, in particular the anterior and posterior cruciate ligaments (ACL and PCL).

What are the symptoms of an LCL tear?

The most common symptom following an injury to the LCL and posterolateral corner is pain over the outside (lateral side) of the knee. Pain, swelling, decreased motion, and instability are common with this injury. Because injuries to the lateral side of the knee usually involve injuries to other structures of the knee, it may be difficult to place weight on the knee.

What is the treatment? Partial tears of the LCL and posterolateral corner structures can sometimes be treated without surgery but complete tears require surgical treatment. The torn ligaments can sometimes be repaired, or sewn back together, but oftentimes require reconstruction by placing a graft to replace the injured structures. Since other ligaments are usually also injured in the knee, these other injuries would also need to be surgically addressed at that time.

 

Authors:

Proliance Surgeons

Ron Gregush, MD

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

Knee Anatomy

MCL Anatomy
MCL Tear
Carson Palmer

 

Medial Collateral Ligament

Where is the MCL?

The medial collateral ligament (MCL) is a strong flat band of fibrous tissue that extends from the medial epicondyle of the femur (thigh bone) to the medial plateau and superior part of the medial surface of the tibia (shin bone). The MCL is a thickening of the fibrous joint capsule and has an attachment to the medial meniscus.

What does the MCL do?

The MCL is one of four ligaments that are critical to the stability of the knee joint. A ligament is made of tough fibrous material and functions to control excessive motion by limiting joint. The four major stablizing ligaments of the knee are the anterior and posterior cruciate ligaments (ACL and PCL, respectively), and the medial and lateral collateral ligaments (MCL and LCL, respectively). The MCL functions to limit how much the outside of the knee opens during movement.

Causes of MCL Injury?

The MCL is typically injured when the outside of the knee is struck. This type of stress in the knee can stretch the MCL beyond its normal elastic range and lead to a tear. Once the ligament tears, it heals very slowly. In comparison to muscles, ligaments and tendons have less blood flow, thus producing slower healing time. An MCL tear can occur as an isolated injury or it can be associated with other knee injuries, in particular tears of the ACL and medial meniscus. The combination of an ACL tear, MCL tear, and medial meniscus tear is referred to as the “unhappy triad.”

What are the symptoms of an MCL tear?

The most common symptom following an MCL injury is pain directly over the ligament on the inside (medial side) of the knee. Knee pain, swelling, and decreased motion are common with this injury. Swelling directly over the torn ligament may and bruising are common 24 to 48 hours after the injury. Generalized joint swelling (joint effusion) may or may not be present with this injury. Symptoms of a medial collateral ligament injury tend to correlate with the extent of the injury. MCL injuries are graded on a scale of I to III. A grade I injury is a small tear within the ligament. A grade II injury is a medium sized tear. A grade III injury is a complete tear of the MCL, which is usually associated with tears of other knee ligaments. If only the MCL is truly injured, walking is usually not a problem, and athletes are often able to return to competition after being cleared by their doctor.

What is the treatment?

Most MCL tears heal own their own without the need for surgery. A brace is often prescribed to protect the ligament while it heals. Grade I and grade II injuries usually resolve within 4-6 weeks, though full recovery may sometimes take longer than this. During this time, it is important to work on strengthening the surrounding muscle groups and physical therapy is often prescribed. Grade III injuries are more severe injuries that are usually associated with tears of other ligaments in the knee and may require surgery.

 

Authors:

Proliance Surgeons

Ron Gregush, MD

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

Knee Anatomy

PFS GrooveLateral Tracking

 

 

 

 

 

 

 

 

 

 

PFS

 


 

Patella Femoral Syndrome

Patellofemoral Syndrome involves dysfunction of the patellofemoral joint consisting of the patella (knee cap) and how it articulates with the end of the femur (upper leg). During normal mechanics the patella tracks in a specific groove controlled medially and laterally by quadriceps muscles (VMO and Vastus Lateralis) and the IT Band, as well as intrinsic ligaments inside the knee joint.

Dysfunction in this joint is often due to improper tracking of the patella caused by various factors such as biomechanical misalignment of the lower extremities, muscle imbalances, or improper gait mechanics. Symptoms vary but may include increased knee pain with repetitive bending of the knee during weight bearing activities such as running, climbing, squatting or prolonged sitting.

Possible Treatments:

Orthotics: improve biomechanical alignment of the lower extremities and allow for improved gait mechanics.
Strengthening: quadriceps muscle strengthening, specifically emphasizing the VMO for proper patellar tracking.
Stretching and Soft Tissue Massage: due to inflexibility at the quadriceps, hamstrings, iliotibial band, calf, and lateral retinaculum.
Ice and other modalities: to reduce pain and inflammation at the knee joint.

 

Authors:

The Sports Medicine Clinic

Chris Peterson, DO

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

 

Hamstring

Hamstring MRI

Proximal Hamstring Tear

What are the hamstrings?

The hamstrings are a group of muscles located at the back of the thigh. They consist of the semimembranosus, semitendinosus, and biceps femoris. The majority of hamstring injuries occur within the muscle belly and heal readily with time and physical therapy. In some cases, the hamstrings can be injured right where they attach to the pelvis, the ischial tuberosity. These are known as proximal hamstring injuries. Proximal hamstring injuries can be subdivided into two types: Tendon injury with full detachment from the ischium (tendon rupture), and partial tears and overuse microtraumatic tendon injuries.

What are the symptoms?

The symptoms of an acute proximal hamstring tear are severe pain in the buttock, in particular with sitting. Significant bruising and swelling are very common and weakness with knee flexion may be present. Proximal hamstring tears often occur in sports when the hamstring is forcefully contracting while being stretched at a high speed (eccentric contraction). Examples of these activities include sprinting, track and field events, running contact sports (football and soccer), and waterskiing. Predisposing factors which can lead to a hamstring injury include lack of warm-up, poor flexibility, and poor running mechanics (over striding). The symptoms of a chronic partial tear include a deep chronic pain with exertion, such as kicking or sprinting, and it is often painful to sit for long periods of time or bend forward with the knees extended.

What are the treatments?

For patients with acute complete tendon ruptures, surgery is often needed to reattach the proximal hamstring tendon to its origin on the ischium. The partial tear and overuse injury is one of the more frustrating hamstring injuries, as they usually do not require surgical treatment but the rehabilitation is often lengthy. Physical therapy is a mainstay of treatment and involves:

• Manual Treatment: to reduce tissue tension and muscle guarding at the hamstrings, restore full range of motion, and work through any scar tissue that may be present.

• Strengthening/Stretching: emphasizing static stretching with gradual progression to dynamic stretching program. Strengthening program progressing isometric, concentric, and eccentric exercises to return to sport specific activity.

• Modalities: as indicated to reduce pain and inflammation.

 

Authors:

Proliance Surgeons

Ron Gregush, MD

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006.

Knee Anatomy

Meniscus
Meniscus MRIMeniscus Arthrocopic

Meniscus Injuries

What is the Meniscus:

The knee has two semicircular fibrocartilagenous structures that act as a cushion. These rings are the main shock absorbers and help redistribute the forces applied to the knee, especially during high impact activities. They also provide passive joint stabilization and contribute to joint proprioceptive input. The Menisci are located on the medial and lateral platform of the tibia. The medial meniscus inserts anteriorly onto the intercondylar area of the tibia and courses posteriorly to attach to the area just in front of the posterior cruciate ligament. On the periphery the medial meniscus has attachments to the joint capsule and the medial collateral ligament and is connected to the tibia via the coronary ligaments. The lateral meniscus has two horns that insert just anteriorly and posteriorly to the intercondylar eminence. On the periphery the lateral meniscus attaches to the joint capsule, tibia via coronary ligaments, and to the popliteus tendon that assists with movement of the lateral menisus during knee flexion.

 

Cause of Meniscus Tears:

Athletes are most susceptible to meniscus injuries due to the cutting and pivoting nature of their activity. Twisting of the knee in a semiflexed position is the most common mechanism of injury. Meniscus tears occur primarily if the normal arthokinematics of the knee joint are altered. For example, during knee flexion the tibia should slightly internally rotate, but if the tibia is forced into external rotation instead then abnormal shearing forces are applied to the menisci resulting in a possible tear. The same goes for extending the knee. If the knee is forced into internal rotation during extension instead of external rotation then a tear is likely to occur. Tears may also occur during hyperflexion in weight-bearing. There are many different classifications of meniscal tears. The most common tears are oblique or vertical longitudinal. Oblique tears can cause a loose flap that may cause a catching sensation in your knee or excess pain. The vertical longitudinal tear (or bucket-handle) is more common in young patients. As you age the incidence of more complex tears goes up.

Symptoms:

Symptoms of a meniscus tear generally involve a sudden onset of deep pain around the joint line that may also be paired with giving way of the joint and swelling. A catching or locking sensation in your knee is also indicative of a meniscal tear.

Treatment:

Treatment for a meniscal tear varies depending on the severity of the injury. Generally conservative treatment and activity modification are attempted prior to surgical intervention. Some tears may remain asymptomatic. Indications for meniscal surgery include symptoms that limit daily activities, work, or sports, and if conservative treatment has not eliminated symptoms. Menicus surgeries include a meniscal resection (or partial menisectomy) in which all mobile fragments are removed, a meniscal repair where the surgeon attempts to aide the meniscus in the healing process, or a meniscal transplant that uses donor tissue to replace the meniscus. A meniscal repair requires a longer rehabilitation, but can help preserve the cartilage. Meniscal transplants are a relatively new treatment option that is still lacking evidence to support its success.

 

Authors:

Lake Washington Physical Therapy

Benjamin Wobker, PT, DPT
University of Montana

Jenna Kokes

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods 3rd Edition. Darlene Hertling, Randolph M. Kessler

Pathology and Intervention in Musculoskeletal Rehabiliatation. David J. magee, James E. Zachazewski, William S. Quillen.

Knee OA

Knee OA

Knee OA MRI

Osteoarthritis (OA)

What is Osteoarthritis?
Osteoarthritis (OA) is caused by the mechanical breakdown of cartilage within a joint. Cartilage is a made from 60-80% water, proteins (collagen and proteoglycans), and cells that produce collagen (chondrocytes) and serves to provide shock absorption and allow bones to glide smoothly over each other. With repetitive or abnormal forces, cartilage can break down and eventually lead to bone rubbing on bone. Changes in structures around the joint (muscles, tendons, ligaments), fluid accumulation, and bony overgrowth (bone spurs) can develop leading to chronic pain and painful functioning. Who does it affect? Knee Osteoarthritis or Degenerative Joint Disease (DJD) is the most common type of Osteoarthritis effecting more than 7 million people in the U.S. Though the etiology of OA is not entirely clear, incidence of knee OA increases with age (generally effecting individuals >38 years old) and effects women more commonly than men. It is hypothesized that women are more affected than men due to larger Q Angle (Q angle is formed from a line drawn from the pelvis to the knee cap).

Causes:

Risk factors for development and progression of knee OA include obesity, underlying biomechanical abnormalities (genu varum/valgum), and weak hip musculature. However in a study done by Hunter et al, it is reported that knee alignment did not predicte development of OA but was a marker of the disease severity.
What are the symptoms of knee OA?
Knee pain and crepitus with active range of motion, morning stiffness in the knee joint that lasts for >/=30 minutes, and bony enlargements of the knee joint. What are the treatments for knee OA? There are multiple treatment options for knee OA. A growing body of evidence has shown that a physical therapy interventions to include manual therapy, strengthening exercises, Stretching, and joint mobilization is effective for improving joint functioning, mobility, and decreasing pain. Along with decreasing pain, physical therapy intervention has been shown to slow the progression of the arthritis therefore decrease the need for joint arthroplasty. Other treatment options that are commonly used in conjunction with physical therapy include topical lotions, Non-Steroidal Anti Inflammatory drugs, cryotherapy, TENS units, and Glucosamine supplements.

 

Authors:

Lake Washington Physical Therapy

Christina Bosik, PT, DPT

Benjamin Wobker, PT, MSPT

 

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

Deyle, G., et al. 2005. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Physical Therapy (85). 1201-1218. Brigham and Womens Hospital.

 

Total Knee Replacement

What is a Total Knee Replacement:

Total Knee Replacement (TKR) or Total Knee Arthroplasty (TKA) is the most common joint replacement surgery performed. In 2009, 620,000 TKR’s were performed in the United States alone. This surgery is performed for end-stage (or “bone on bone”) osteoarthritis of the knee. This condition results from “wear and tear” of knee cartilage, the smooth tissue that lines the ends of the bone and normally allows for painless motion. The primary goals of this surgery are to restore knee function and motion, decrease pain, and enable patients to return to previous or improved levels of function. During this surgery, small wafers of bone are removed from the end of the femur bone in the thigh, the beginning part of the tibia bone in the lower leg, and the back side of the knee cap. These ends are resurfaced with metal and plastic pieces that are cemented in place. This allows for immediate weight-bearing and initiation of physical therapy for the replaced knee.

Physical Therapy Treatment:

Initial treatment includes safety instruction, ambulation and gait training, emphasis on early range of motion exercises, and instructions in activities of daily living. Once an adequate level of function and motion is achieved, a more aggressive strengthening program is established which is important for long-term outcomes and return to previous levels of activity.

 

Authors:

Bellevue Bone & Joint
Dr. Jonah Hulst, MD

Lake Washington Physical Therapy

Benjamin Wobker, PT, MSPT

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006

Deyle, G., et al. 2005. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Physical Therapy (85). 1201-1218. Brigham and Womens Hospital.


 

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