3/1/2017

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WHERE ARE WE?

East Amherst

East Aurora

Hamburg x2

West Seneca

Williamsville

Boulevard

THE KNEE JOINT

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THE KNEE JOINT

• At the most superficial level, the knee is a simple hinge joint

• Flexion & Extension

• The knee has small, less obvious movements, too

• Rotation

• Valgus and Varus

• There are no direct knee muscles that control for the smaller movements, but these movements are often the cause for injury

ACTIVITIES OF DAILY LIVING: TIBIA - FEMORAL

Kutznera I, Heinleina, B, Graichena F. Loading of the knee joint

during activities of daily living measured in vivo in five subjects.

Journal of Biomechanics. 2010 Aug;43(11):2164–2173.

Activity Peak Force (% of body weight)

Going Down Stairs 346% Body Weight

Going Up Stairs 316% Body Weight

Knee Bends 253% Body Weight

Level Walking 150% Body Weight

Peak Force Running?

290%

WALKING, WEIGHT LOSS, AND THE KNEE

Messier S, Gutekunst D, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism July 2005;52(7):2026-2032.

• One Pound of Weight Loss Off

Loads how much force while

walking?

4 Pounds of Pressure

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FOOD FOR THOUGHT: EXERCISE SUBSTITUTION

Walking

Elliptical

Biking

Running

Lunging

Squats

Step Ups

Knee Extensions

Jumping

Wall Slides

One Legged Squat

SUBSTITUTING EXERCISE: BIKING

• Peak Compressive Force While

Cycling: PF Joint

40% of Body Weight

Ericson M, Nisell R. Patellofemoral Joint Forces During

Ergometric Cycling. Phys Ther. 1987;67:1365-1369.

• Influencing Factors

• Work Load (Level)

• Saddle Height

• Non-Influencing Factors

• Pedaling Rate / Foot Position

SUBSTITUTING EXERCISE: ELLIPTICAL

• Compared to walking:

•Smaller Reaction Forces

•Slower Loading Rates

•Increased Hip Flexor and Knee

Extensor Moments

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SUBSTITUING EXERCISE: LEG PRESS

• Is this functional?

• Increasing force into extension

• Last 15 Degrees of Extension vs. Achieving

30 Degrees

• 2x Quad Force

• Surface Area

• Effect of weight

• 7# Doubles Quad Force

• Leg Press vs. Standing Extension

• 0-46 degrees less reaction force

Grood ES; Suntay WJ; Noyes FR. Biomechanics of the

knee extension exercise. Effect of cutting the anterior

cruciate ligament. J Bone Joint Surg Am 1984

Jun;66(5):725-734.

LUNGES, STAIRS, AND KNEELING

• Peak axial forces during step-

up were nearly 60% greater

than during gait

• Choosing Your Lunges

• Long vs Short Stride

• With / Without Stride

• Multi-Planar Lunges

D’Lima D, Steklov N, Fregly B. In Vivo Contact Stresses during Activities of

Daily Living after Knee Arthroplasty. J Orthop Res26 2008:1549-1555

Escamilla R, Zheng N, Macleod T. Patellofemoral Joint Force and Stress

Between a Short- and Long-Step Forward Lunge. J of Orth & Sports Phys

Ther 2008 Nov;38(11):681-690.

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WHAT’S MORE FUNCTIONAL

WHAT’S MORE FUNCTIONAL?

WHAT’S YOUR THRESHOLD?

Walking

Elliptical

Biking

Running

Lunging

Squats

Step Ups

Knee Extensions

Jumps

Wall Slides

One Legged Squat

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FUNCTIONALEXERCISE PROGRESSION

Biking

Walking

Elliptical

Squats

Step Ups

Lunges

Single Leg Activities

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Northtowns OrthopedicsBuffalo Rehab Group

2/27/17

Peter L. Gambacorta, DO

Orthopedic Surgeon

Sports Medicine

Peter L. Gambacorta, DO

Northtowns Orthopedics

– General orthopedic surgery

Fellowship Trained Sports Medicine Specialist

Arthroscopic Surgery

– Surgery with cameras• Knee, Shoulder, Hip, Elbow, Ankle

Northtowns Orthopedics

Office LocationsEast Amherst

8750 Transit Road Suite 105East Amherst, New York 14051

Williamsville

36 North Union RoadWilliamsville, NY 14221

Holiday Valley

6133 U.S. Route 219 Suite 1001 Ellicottville, New York 14731

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After-Hours Orthopedic ServiceNo appointment is necessary!

8750 Transit Road Suite 105 East Amherst, New York 14051

After-Hours Urgent Orthopedics Available:Monday through Friday, 4 pm to 8 pm

Saturday, 12 pm to 4 pmSunday, 12 pm to 4 pm

Most major insurance carriers are accepted.

(716) 839-2230

Agenda

• Introduction

• Youth sports

• Knee

• Injury prevention

Pediatric and Adolescent

Sports Medicine

Epidemic Problems

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Youth Sports Statistics >30 -45 million children and

adolescents participate in youth sports in US

2 million high school students sustain injuries yearly

More than 3.5 million children ages 14 and under receive medical treatment for sports injuries each year

50%of youth sports injuries are preventable

By the age of 13, 70% of kids drop out of youth sports

Why are Injuries on the Rise?

• Title IX - the federal civil rights law that prohibits sex discrimination in education.

• Enacted in 1972

1972 2012

Ratio of HS

participation

1 in 17 1 in 3

# High School

Athletes

300,000 3,000,000

# College

Athletes

25,000 180,000

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Increased participation: Increased rates of injury

Why are Injuries on the Rise?

• Less free play

• More sports offered

• Single sport concentration

• All star, travel teams

• Year round participation

• Higher levels of competition

• Means to an end0

2000000

4000000

6000000

8000000

1972 2006

80 % Increase!

Sports

Participation

“Child is not a

little adult.”

“Child athlete is

not a little adult

athlete.”

Understanding the Difference

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Historic Prospective

Kids do not experience

major sports related injuries

Kids will heal if you put

them in a cast or brace

Unique Challenges

• Age Specific Injuries

– Growth plates

• Expectations

• Delayed treatment can

lead to other problems

• Surgical Techniques

– Limb length

– Angular deformity

– Growth arrest

Pediatric Sports Medicine

Pediatric Orthopedics

• Hip Dysplasia

• Perthes disease

• Scoliosis

• Spondylolysis

• Club foot

• Congenital deformities

• Cerebral palsy

• Spina bifida

• Hand anomalies

• Limb length deficiencies

• Fracture care

Adult Sports Medicine

• Ligament injuries (ACL,PCL,UCL)

• Articular cartilage injuries

• Tendon injuries

• Meniscus tear

• Dislocated shoulder

• Labral/ SLAP tear

• Rotator cuff tear

• Tennis elbow

• Hip labral tear

• Snapping hip syndrome

• Ankle sprains

• Fracture care

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• Knee: • ACL, meniscus, OCD, chondral injuries, patellofemoral

dysplasia, tibial spine fractures, patella instability, growth deficiencies, fractures

• Shoulder: • Labral tears, multidirectional instability, SLAP tears,

impingement, little leaguer shoulder, rotator cuff tears

• Elbow: • Loose bodies, OCD, UCL injuries, olecranon

apophysitis, pediatric elbow fractures

• Hip: • Femoroacetabular Impingement, loose bodies, chondral

injuries, dysplasia, SCFE, apophysitis

• Wrist and Hand: • TFCC, fractures, tendon injuries, fractures

• Ankle and Foot: • OCD, instability, os trigonum, anterior/posterior

impingment, tarsal coalitions, fractures

• Spine• Back Pain, Spondylolysis, Scoliosis, muscular strains

• Medical Conditions• Concussion, Heart, Psych, Nutrition

Scope of Pediatric Sports Medicine

Agenda

• Introduction

• Youth sports

• Knee

• Injury Prevention

Anatomy 101

• Bone-

– Skeleton

– Supports the body

– Protects organs

– Allows movement

– Stores minerals

– Makes blood cells

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Anatomy 101

• Muscle

– “Engine”

– Produce motion

– Provide stabilization

– Generate heat

Anatomy 101

• Tendon

– Connector of Muscle to Bone

• Ligament

– Connector of Bone to Bone

Flexibility versus Laxity

• Flexibility

– Stretch of muscle and tendon

• Laxity

– Looseness of ligaments

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Common Sports Injuries

• Hip/ Pelvis

• Knee

• Shoulder

• Elbow

• Hand/Wrist

• Leg/ Ankle

• Foot

• Spine

Why Does My Knee Hurt

Knee Anatomy

• Bones

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Knee Anatomy

• Cartilage

Knee Anatomy

• Dynamic layer

– Muscles and Tendon

Knee Anatomy

• Neural layer

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Why Does My Knee Hurt

• Arthritis

• Meniscus tears

• Ligament injuries

• Knee cap pain

Arthritis

• Osteoarthritis– “Wear and tear”

• Articular cartilage wears out

– More common in patients over the age of 50

– Develops over time

• Rheumatoid– Chronic autoimmiune disease

attacking multiple joints

• Post Traumatic– Develops after an injury

Arthritis

• Symptoms– Stiffness and swelling

– Difficulty bending

– Increase pain with activity

– “Locks or sticks” with movement

– Weakness and buckling

– Increased with weather changes

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Arthritis

• Diagnosis

– Examination

– Testing

• Radiograph

• MRI

• Lab

Arthritis

• Treatment– Lifestyle modifications

– Physical therapy

– Assistive devices

– Medications• Oral, topical

– Injections• Corticosteroid

• Visco supplementation

Arthritis

• Surgical Treatment

– Arthroscopy

– Partial and Total Replacement

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Meniscus Tear

Meniscus

• Fibro cartilage disc– Breast bone on a chicken

• Two meniscus in each knee– Medial and Lateral

• Shaped like a “C”

• Function:– “Shock absorber”

– Stabilize

– Nourish

Meniscal Tear

• Etiology

– Young athlete

• Traumatic Twist/ Pivot

• Athletic Activity– Deep bend/ squat

– Mature patient

• Traumatic

• Insidious onset

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Meniscal Tear

• Symptoms

– Pain

• At the joint line

• With squatting and bending

– Locking

• Click, pop, catching

– Swelling

• Often worse after activities

Meniscal Tear

• Diagnosis

– Examination

• Effusion

• Palpatory tenderness over meniscus

• Pain with deep knee flexion

• Mc Murray test

Radiographs

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MRI

Adult patient:

MRI of medial meniscus

95.7% sensitivity

81.8% specificity

88.2% positive predictive value(PPV)

MRI of lateral meniscus

75% sensitivity

95% specificity

80% PPV

MRI of the ACL

100% sensitivity, specificity, accuracy, positive and negative predictive values.

Mandelbaum et al. AJSM 1986

MRI

Pediatric patient:

– Meniscal Injury

72% sensitivity

93.5% specificity

Under 12 years of age

61.7% sensitivity

91.2% specificity

– No difference between clinical exam and MRI findings with respect to:• Agreement with arthroscopic findings (70%)• Sensitivity (70%)• Specificity (92%)

Conclusion:Selective MRI does NOT provide enhanced diagnostic utility over clinical examination in children.

Kocher et al. JSM 2001

Types of Tears

Meniscus tear

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Meniscus Healing

• Blood supply

Meniscus Healing

Meniscal Tear

• Conservative Treatment

– Rest

– Ice

– Compression

– Elevation

– NSAID’S

– Injections

– Physical Therapy

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Meniscal Tear

• Surgical Treatment

– Arthroscopic surgery

• “Minimally invasive”

• Out patient

• Light source camera and small instruments

Partial Meniscectomy

Post operative Meniscectomy

• Ice, Pain medication• Crutches

– Typically a few days

• Weight bear as tolerated• Begin post operative exercise the day after

surgery• Begin formal PT 10-14 days post operative

– 4-12 weeks

• Return to full sports and activities without restriction 4-12 weeks

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Meniscal Repair

Post Operative Meniscal Repair

• Ice, Pain medication• Crutches

– Typically 4-6 weeks

• Weight bearing Toe touch or partial– 4-6 weeks

• Brace• Begin post operative exercise the day after surgery• Begin formal PT 10-14 days post operative

– 4-12 weeks

• Return to sport and full activities 3-4 months

ACL Anatomy

Normal ACL Tear

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Who is at risk?

ACL Epidemiology

• Risk- Male : Female ratio– Male HS athlete: 1:500

– Female HS athlete: 1:70

– M: F- 1 : 5-8

• > 40,000 HS female

ACL injuries/ Year

• Age– 15-25 years

• Athletically active– Soccer, Basketball, Volleyball

Risk comparisons: Male vs Female

• No known differences in prepubescent children

• At puberty– Males- neuromuscular growth

spurt

– Females- no neuromuscular growth spurt

• Development of neuromuscular imbalances

Yu et al Clin Orth Relat Research 2001

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Costs of ACL Injury in Adolescent Girls

• Financial– $17,000 per reconstruction with rehab1

– $700,000,000 annually

• Academic– Decreased academic performance2

– Loss of scholarship funding

• Physical– Early OA3

1. Hewett et al, AJSM 1999, 2. Freedman et al, Clin Orthop 1998,

3. Von Porat et al, 2004

How Do They Happen?

Injury Mechanism

Non contact Contact

75% 25%

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Injury Mechanism- Pivot

• Torsional moment

• Unanticipated deceleration with change in direction

• Foot firmly planted

• 57% of non contact injuries

Arendt et al, 1999

ACL Injury Risk Factors

• Risk Factors

– Environmental

– Anatomic

– Hormonal

– Neuromuscular

Neuromuscular

• Positive Dynamic factors– Reaction time

– Motor muscle recruitment

– Balance

– Endurance

– Strength

• Peak torque, amplitude and timing

– Anticipation

– Maximum co-contraction → ↑ stiffness

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Injury Prevention Programs

• Emphasizing proper jump and landing techniques

• Neuromuscular Control

– Landing Patterns

– Strength

– Power

– Agility

Before After

Barber et al AJSM 2006

What does an ACL injury look like?

• Acute Symptoms

– “Pop”

– Pain

– Swelling

– Instability

MRI

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Non Operative Complete Tear

Natural History– Increased rate of meniscal tear

– Chondral injury and degenerative changes

– Persistent instability

– Decreased athletic participation

– Poor functional outcomes and patient satisfaction

ACL Treatment

Prepubescent Adolescent Adult

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Chronological Age does NOT equate to skeletal/physiologic age

Age

Current ACL Reconstruction Recommendations Based on Age

PartialACLTear(<50%FibersTorn)

SkeletallyImmaturePatient

CompleteACLTearSkeletallyImmature

Patient

ActivityModi icationPhysicalTherapy

Bracing

Prepubescent

TannerStage1or2

Males≤12yearsFemales≤11years

AdolescentswithGrowth

Remaining

TannerStage3or4

Males13–16yearsoldFemales12–14yearsold

Olderadolescentswith

closingphyses

TannerStage5

Males≥16yearsoldFemales≥14yearsold

AdulttypeAnatomicACLreconstructionwithHamstringsorPatellar

Tendon(AutograftPreferfable)

Transphysealreconstructionwith

autogenousquadrupled

hamstringtendonsandmetaphyseal ixation

Physeal-sparingcombinedextra-andintra-articular

reconstructionwith

autogenousiliotibialband

ACLTearSkeletallyImmature

Patient

Gambacorta, Frank JAAOS 2013

Future of ACL SurgeryInjectable bio enhanced scaffold

Suture

ACL Repair and Regeneration

Eliminate tendon graft Decrease post traumatic OA

Murray, MM J Orthop Research 2013

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Anterior Knee Pain

• “Knee cap pain”

• “Swimmers knee”

• Patellofemoral syndrome

• 15% of all knee pain

• Females> Males

Patellofemoral pain

• Trauma:– Contusion– Fracture– Dislocation– Rupture of Patellar or

Quadriceps Tendon• Synovial Plica Syndome• Osteochondritis Dissecans• Post traumatic Chondromalacia• Arthritis• Hoffa’s Disease• RSD

• Patellar or Quadriceps tendinitis• Prepatellar/ Peripatellar bursitis• Osgood Schlatter or Sinding-

Larsen-Johansson disease• Lateral Patellar Compression

Syndrome• Chronic Subluxation of the

Patella• Recurrent or Chronic Dislocation

of the Patella• Idiopathic Chondromalicia

Differential Diagnosis

Patellofemoral Syndrome

• Symptoms

– Pain

• Uni or Bilateral

– Insidious onset

– Pop / click

– Pain with stairs or sitting

– Swelling +/-

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Patellofemoral Syndrome

• Treatment

– Non op successful 80-90%

– Neuromuscular balance

• Stretching (flexibility)

• Strength training

Quad Stretch

Illioas Psoas Stretch

Rectus Stretch

Hamstring Stretch

Piriformis Stretch

ITB Stretch

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Single Knee to Chest Stretch

Double Knee to Chest Stretch

Achilles tendon stretch

Straight Leg Raises

Perform 3 sets of 10 repetitions on each leg.

Start with no weight and increase ankle weight as appropriate

Foot Rotated OutToe Pointing Up Lying on your side

Agenda

• Introduction

• Youth sports

• Knee

• Injury Prevention

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Injury Prevention

According to the CDC, more than half of all sports injuries in children are preventable

Sports Trauma and Overuse

Prevention

STOP Sports Injuries

• Prevention starts with EDUCATION

• Information for:– Athletes – Parents – Coaches – Healthcare providers

Sport specific injury prevention tips

www.stopsportsinjuries.org

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STOP Sports Injuries

• General Sports Injury Prevention Tips:

– Obtain a pre-season physical examination

– Encourage warm ups and cool downs

– Encourage proper strength training routines

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– Use and maintain proper equipment

– Encourage athletes to speak to a coach, trainer, parent or physician when they are experiencing PAIN

Thank You