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 PERFORMED1. 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 on Goal

Avoid negative drug reactions

Trial and Error

Every patient has a different response

Must 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: non-narcotics; 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