KNEE VOCAB: USING YOUR BOOKS (CHP. 16 PG. 252) DEFINE THE FOLLOWING • Patella: largest sesamoid in the • Fat pads: cushion the front of body the knee • Menisci: • Genu valgum: • Avascular necrosis: death of • Genu varum: bone tissue due to lack of blood supply. • Hemarthrosis: blood in the • Anterior Cruciate Ligament: joint • Posterior Cruciate Ligament: • MRI: soft tissue diagnostic tool • Medial Collateral Ligament: • Translation: anterior gliding of • Lateral Collateral Ligament: the tibia KNEE STATIONS KEY 12.False 1. Lateral Collateral Ligament (LCL) 13.True 2. Tibia 14.True 3. Anterior Cruciate Ligament (ACL) 15.True 4. Rectus Femoris 16.Flexion, extension 5. Hip flexion, knee extension 17.Femur, tibia, fibula, patella 6. Vastus lateralis 18.MCL 7. Knee extension 19.Femur 8. Semimembranosus 20.Medial meniscus 9. Knee flexion, hip extension 21.Posterior cruciate ligament (PCL) 10.Biceps Femoris 11.Knee flexion, hip extension KNEE LABELING Femur Posterior View

Tibia Posterior View

Medial Lateral Condyle Condyle

Fibula Posterior View

Lateral Collateral Medial Ligament Collateral Ligament Posterior View

Medial Lateral Meniscus Meniscus Posterior View

Anterior Humphrey’s Cruciate Ligament Ligament

Posterior Cruciate Ligament Medial Lateral Epicondyle Epicondyle

Anterior View Posterior Cruciate Ligament

Anterior Cruciate Ligament

Tibial Tuberosity Gluteus Gluteus Medius Maximus

Iliotibial Band

Semimembranosus Biceps Femoris

Semitendinosus Iliopsoas

Pectineus

Adductor Vastus Longus Lateralis Gracilis Vastus Intermedius Sartorius Vastus Medials Rectus Femoris Knee PRACTICE 1 1.

2. 4.

3. 5. Knee PRACTICE 1 KEY 1. Medial condyle

2. Medial 4. Lateral collateral meniscus ligament

3. Posterior cruciate 5. Fibula ligament Popliteus

Flexor digitorum Tibialis longus posterior Gastrocnemius

Plantaris

Soleus

Flexor hallucis longus Gastrocnemius

Achilles Tendon Knee Palpations, practice w/video KNEE COMPLEX THE KNEE IS DESIGNED TO

• PROVIDE STABILITY • PROVIDE MOBILITY KNEE FACTS • MOST COMPLEX JOINT IN THE BODY. • CONSIDERED A HINGE JOINT. • STABILITY DEPENDS ON THE LIGAMENTS, JOINT CAPSULE, MUSCLES. • PROVIDE STABILITY DURING WEIGHT BEARING. • UNSTABLE LATERALLY AND MEDIALLY. KNEE JOINT • SURROUNDED BY JOINT CAPSULE • LARGEST IN BODY • BURSAE: • 2 DOZEN AROUND THE KNEE • FAT PADS: • INFRAPATELLAR IS THE LARGEST. • CUSHIONS ANTERIORLY AND SEPARATES THE PATELLAR TENDON FROM THE JOINT CAPSULE NERVE AND BLOOD SUPPLY  NERVE SUPPLY  TIBIAL  SEMITENDINOSUS, SEMIMEMBRANOSUS, GASTROCNEMIUS  PERONEAL NERVE  BICEPS FEMORIS  FEMORAL NERVE  QUADRICEPS

 BLOOD SUPPLY:

 POPLITEAL ARTERY STEMMING FROM THE FEMORAL ARTERY. LEG ALIGNMENT

• DEVIATIONS MAY BE A FACTOR IN KNEE INJURY, ALWAYS DIFFER FROM PERSON TO PERSON • ARE THE PATELLAS LEVEL? • ARE THE PATELLAS FACING FORWARD? • CAN THE ATHLETE TOUCH THE MEDIAL FEMORAL CONDYLES AND MEDIAL MALLEOLI TOGETHER? • ARE THE KNEES FULLY EXTENDED? • ARE BOTH KNEES EQUALLY EXTENDED? LEG ALIGNMENT GENU VALGUM: KNOCK KNEES

• PRONATED FEET • TENSION ON LIGAMENTOUS STRUCTURES OF MEDIAL PART OF KNEE • COMPRESSION OF LATERAL ASPECTS • ABNORMAL TIGHTNESS OF IT BAND GENU VARUM: BOW LEGS

• TENSION ON LIGAMENTS ON THE LATERAL SURFACE OF THE KNEE/IT BAND • SUPINATED FOOT LEG ALIGNMENT: GENU RECURVATUM: HYPEREXTENDED KNEES • COMPENSATION FOR LORDOSIS • STRETCHING OF HAMSTRING MUSCLES • PRODUCE ANTERIOR PRESSURE ON KNEE, POSTERIOR LIGAMENTS AND POSTERIOR TENDONS Q ANGLE

• CREATED WHEN LINES ARE DRAWN FROM THE MIDDLE OF THE PATELLA TO THE ASIS AND FROM TIBIAL TUBEROSITY THROUGH THE CENTER OF THE PATELLA • SHOULD BE MEASURED WITH THE KNEE FULLY EXTENDED, AND FLEXED AT 30 DEGREES • NORMAL ANGLE = 10 DEGREES FOR MALES, 15 FOR FEMALES • GREATER THAN 20 ARE CONSIDERED EXCESSIVE AND COULD LEAD TO KNEE PAIN AND INJURIES. KNEE LABELING QUIZ EVERYTHING MUST BE SPELLED OUT. INCLUDE DIRECTIONAL TERMS

VERSION A

VERSION A KEY MUST HAVE DIRECTIONAL TERMS. ALL OR NOTHING CREDIT. 1 PT EACH

1. FEMUR 12. LATERAL CONDYLE/EPICONDYLE 2. MEDIAL CONDYLE 13. LATERAL MENISCUS 3. MEDIAL MENISCUS 14. LATERAL COLLATERAL LIGAMENT 4. POSTERIOR CRUCIATE LIGAMENT 15. MEDIAL COLLATERAL LIGAMENT 5. MEDIAL COLLATERAL LIGAMENT 16. MEDIAL MENISCUS 6. TIBIA 17. ANTERIOR CRUCIATE LIGAMENT 7. LATERAL CONDYLE 18. POSTERIOR CRUCIATE LIGAMENT 8. ANTERIOR CRUCIATE LIGAMENT 19. MEDIAL CONDYLE/EPICONDYLE 9. LATERAL MENISCUS 10. LATERAL COLLATERAL LIGAMENT 11. FIBULA • • • • FIBULA TIBIA PATELLA FEMUR • • • • • GIVES STABILITYGIVES TOANKLE MUSCLES BEARS NO WEIGHT,ATTACHMENT SITE FOR LEG PRIMARY INLOWER BONE BEARING WEIGHT ABSORPTION WITHINTENDON, SHOCK =BONE SESAMOID LONGEST ANDTHESTRONGEST

BONES LIGAMENTS • MEDIAL COLLATERAL LIGAMENT (MCL) • PROTECTS FROM VALGUS ( MEDIAL) DISPLACEMENT • LATERAL COLLATERAL LIGAMENT (LCL) • PROTECTS FROM VARUS (LATERAL) DISPLACEMENT, TAUT DURING KNEE EXTENSION • ANTERIOR CRUCIATE LIGAMENT (ACL) • MOST FREQUENTLY RUPTURED, PROTECTS FROM ANTERIOR TIBIA MOTION • ORIGINATES ON ANTERIOR TIBIAL PLATEAU, AND ON POSTERIOR FEMUR, MADE OF 3 TWISTING BANDS • POSTERIOR CRUCIATE LIGAMENT (PCL) • PROTECTS FROM POSTERIOR DISPLACEMENT, STRONGER THAN ACL MCL SPRAIN MCL

MOST COMMON INJURED LIGAMENT IN KNEE MOI: VALGUS STRESS LATERAL BLOW W/ FOOT FIXATION, SEVERE TWIST. S/S: SWELLING, LIMITED ROM, PN., LOF, INSTABILITY TX: PRICE, STRENGTHENING/ROM EXERCISES, FUNCTIONAL ACTIVITIES. MCL GRADE 1 SPRAIN MOI: VALGUS FORCE GRADE 1: - MILD LIGAMENT FIBERS TORN OR STRETCHED S/S: JOINT IS STABLE, MILD OR NO SWELLING, MILD PN., STIFFNESS, JOINT TENDERNESS TX: PRICE, STRENGTHENING MCL GRADE 2 SPRAIN MOI: VALGUS FORCE • GRADE 2: • TEARING OF THE CAPSULE, PARTIAL TEAR OF MCL • S/S: MODERATE INSTABILITY (MORE DURING FLEXION) SWELLING, JOINT STIFFNESS, AROM (FLEXION AND EXTENSION) & PROM = PN AND LOF • TX: PRICE, CRUTCHES, STRENGTHENING, POSSIBLE BRACE MCL GRADE 3 SPRAIN MOI: VALGUS FORCE • GRADE 3: • COMPLETE TEAR OF MCL AND SUPPORTING LIGAMENTS • S/S: +VALGUS TEST, COMPLETE LOSS OF MEDIAL STABILITY, SEVERE PN, HEAR A “POP” SEVERE SWELLING, LOF, • CHECK ACL, PCL AND MENISCUS • TX: PRICE, CRUTCHES, MCL BRACE, ROM AND STRENGTHENING, USUALLY NON- OPERATIVE MCL SPRAIN SPECIAL TESTS: VALGUS STRESS TEST Procedure: Place one hand on the lateral aspect of knee and the other on the medial aspect of the ankle

Apply a valgus force to the knee at 0 and 30 degrees

Positive Test: pn and laxity at the MCL LCL SPRAIN

• MOI: VARUS STRESS • MEDIAL BLOW • S/S: PAIN, INFLAMMATION, INSTABILITY, LOSS OF FUNCTION AND ROM • TX: PRICE, STRENGTHENING AND ROM EXERCISES, FUNCTIONAL ACTIVITIES. LCL SPRAIN SPECIAL TEST: VARUS STRESS TEST Procedure: Place one hand on the medial aspect of the knee and the other on the lateral ankle

Apply a varus force to the knee at 0 and 30 degrees

Positive Test: pn and laxity at the LCL KNEE PRACTICE 2 1. WHAT TYPE OF JOINT IS THE KNEE? • HINGE 2. WHAT IS THE MAIN BURSA IN THE KNEE? • INFRAPATELLAR 3. THE PERONEAL NERVE WORKS WHAT ONE MUSCLE? • BICEPS FEMORIS 4. THIS MALALIGNMENT OF THE KNEES COULD BE FROM PRONATED FEET AND PUTS COMPRESSION ON THE MEDIAL ASPECT AND TENSION ON THE LATERAL ASPECT? • GENU VALGUM 5. WHAT IS THE FORCE CALLED THAT CAUSES AN MCL SPRAIN? • VALGUS

ACL SPRAIN • MOI: TORSION (FOOT FIXATION W/TWISTING), OR A BLOW. (EX: ATHLETE RUNNING THEN TURNS SUDDENLY.) • HIGHEST INCIDENCE OF TEAR = FEMALE SOCCER PLAYERS, THEN FEMALE BASKETBALL PLAYERS ACL SPRAIN

• S/S: POP, FOLLOWED BY DISABILITY, “FEELS LIKE MY KNEE IS COMING APART” RAPID SWELLING, PAIN. • TX: PRICE, SURGERY…THEN STRENGTHENING, ROM EXERCISES, FUNCTIONAL ACTIVITIES. • PREVENTION: NO SINGLE EXERCISE CAN PREVENT ACL TEARS, BUT CAN BE LOWERED BY PERFORMING TRAINING DRILLS EMPHASIZING POWER AND AGILITY AND BY IMPROVING MUSCULAR REACTIONS WITH JUMPING AND BALANCE DRILLS • HTTP://WWW.YOUTUBE.COM/WATCH?V =FYDUU93DRBM ACL SPRAIN SPECIAL TEST: ANTERIOR DRAWER Procedure: Put the athlete in knee flexion. Place hands on the superior aspect of the gastrocnemius and pull anteriorly

Positive test: pn and tibia moves forward ACL SPRAIN SPECIAL TEST: LACHMANS

Procedure: Firmly grasp the distal femur and the proximal tibia. With the knee in slight flexion pull the tibia anteriorly

Positive Test: Laxity compared to uninjured side

BUDDY TAPE, WATCH AND PRACTICE ON PARTNER

• HTTPS://SPARK.ADOBE.COM/VIDEO/ZMELXDJWHVRFA PCL SPRAIN

• MOI: SEVERE HYPEREXTENSION, OR A FALL W/KNEE FLEXED TO 90 DEGREES. • S/S: FEELING A POP IN BACK OF KNEE, TENDERNESS, LITTLE SWELLING, INSTABILITY, PAIN. • TX: PRICE, NON-OPERATIVE, STRENGTHENING QUADS, ROM EXERCISES. PCL SPRAIN SPECIAL TEST: POSTERIOR DRAWER POSTERIOR SAG

Procedure: athlete lies supine with knees and Procedure: W/athlete in knee flexion push hips flexed to 90. hold the tibias at 90 and look posteriorly on tibia for sagging of the proximal tibia Positive test: laxity compared bilaterally Positive Test: sagging of proximal tibia

CARTILAGE

• MENISCUS: TWO OVAL FIBROCARTILAGES THAT DEEPEN THE ARTICULATION AND CUSHION ANY STRESSES PLACED ON THE KNEE JOINT • MEDIAL MENISCUS • C SHAPED, ATTACHED TO MEDIAL FACET OF TIBIA • LATERAL MENISCUS • O SHAPED, ATTACHED TO LATERAL ASPECT OF TIBIA CARTILAGE

 RED ZONE: OUTER ONE THIRD, GOOD VASCULAR SUPPLY  RED-WHITE ZONE: MIDDLE ONE THIRD AND HAS MINIMAL BLOOD SUPPLY  WHITE-WHITE ZONE: INNER ONE THIRD IS AVASCULAR. MENISCUS INJURY

• HIGHER INCIDENT OF INJURY BECAUSE IT ATTACHES TO THE TIBIA AND THE CAPSULAR LIGAMENT. • MOI: FIRM FOOT FIXATION WITH ROTARY FORCE (TORSION) WHILE THE KNEE IS EXTENDED OF FLEXED, CUTTING MOTION, SQUATTING MENISCUS INJURY CONT’D

• S/S: SWELLING, DISCOLORATION, PAIN ALONG THE JOINT LINE, LOSS OF ROM, LOCKING, CLICKING, BUCKLING, PAIN WITH SQUATTING AND STAIRS.

• TX: MRI, IF LOCKED MAY HAVE TO BE PUT UNDER ANESTHESIA TO UNLOCK IT, SURGERY, STRENGTHENING AND ROM EXERCISES, ICE. DIFFERENT TYPES OF MENISCUS INJURY Bucket Parrot beak Handle (laceration) Loose body • Cutting • torsion • Forced w/foot flexion fixation • Younger athletes s/s: Joint effusion, joint line pain, giving away, pain with squats or stairs, locking, clicking, popping MENISCUS INJURY SPECIAL TEST: MCMURRAY’S CLICK Procedure: with one hand on the joint line and the other on the foot internally rotate the tibia and apply a valgus force while moving into extension and flexion. Repeat the same procedure with the tibia externally rotated and with a varus force.

Positive Test: Clicking sensation at the joint line, pain MENISCUS INJURY SPECIAL TEST: APLEY COMPRESSION & DISTRACTION

Procedure: athlete lies prone with knee in extension. Place one hand on the distal hamstring and pull up on the tibia with the other hand. Then push down on the tibia while rotating.

Positive Test: Pain w/ distraction = joint capsule Pain w/compression = meniscus injury

SWEEP TEST

• PROCEDURE: SWEEP THE MEDIAL ASPECT OF THE KNEE FROM DISTAL TO PROXIMAL 3-4 TIMES. SWEEP THE LATERAL ASPECT OF THE KNEE ONCE. LOOK FOR SWELLING BUBBLE TO APPEAR ON THE MEDIAL ASPECT. • (+) TEST = APPEARANCE OF SWELLING MUSCLES

• ANTERIOR THIGH • QUADRICEPS • KNEE EXTENSORS (4) LIST THEM • POSTERIOR THIGH • HAMSTRINGS • KNEE FLEXORS (3) LIST THEM MUSCLES • MEDIAL THIGH • GROIN • LEG ADDUCTORS (3) LIST • LATERAL THIGH • TENSOR FASCIA LATAE, GLUT.MEDIUS • LEG ABDUCTORS • LOWER LEG • GASTROCNEMIUS • KNEE FLEXORS

KNEE PRACTICE 3 1. WHAT IS THE MOI FOR AN ACL SPRAIN? • FOOT FIXED WITH TORSION 2. NAME ONE OF THE TWO SPECIAL TESTS FOR AN ACL SPRAIN? • ANTERIOR DRAWER OR LACHMAN’S 3. NAME ONE OF THE TWO SPECIAL TESTS FOR A PCL SPRAIN? • POSTERIOR DRAWER OR POSTERIOR SAG/GODFREY’S 90-90 4. WHICH MENISCUS IS ‘O’ SHAPED? • LATERAL 5. LIST A MUSCLE THAT DOES KNEE FLEXION? • SEMITENDINOSUS, SEMIMEMBRANOSUS, BICEPS FEMORIS, GASTROCNEMIUS QUAD CONTUSION

• MOI: COMPRESSION FORCE, BLOW TO THE SOFT TISSUE OF THIGH • S/S: INFLAMMATION, DISCOLORATION. LOSS OF ROM, PAIN • TX: CONSERVATIVELY, ICE W/LEG IN FLEXED POSITION, PRICE, PROTECTIVE PADDING. • FOLLOW UP CARE: ROM EXERCISES, HEAT, PULSED US, ELASTIC ACE WRAP, PRE’S, BEWARE OF MYOSITIS OSSIFICANS QUAD STRAIN • MOI: SUDDEN STRETCH/CONTRACTION EX; JUMPING, KICKING • S/S: PAIN, SPASM, LOSS OF FUNCTION, • TX: PRICE, ANALGESICS, PAIN FREE ROM, PRE’S, CRUTCHES, NEOPRENE SLEEVE HAMSTRING STRAIN • MOI: MUSCLE FATIGUE, FAULTY POSTURE, LEG LENGTH DISCREPANCY, TIGHT HAMSTRINGS, IMPROPER FORM • S/S: DISCOLORATION, PAIN, LOSS OF FUNCTION, SWELLING. • TX: EXTREMELY CONSERVATIVE, PRICE, ANALGESICS, REDUCED ACTIVITY. MOVE TOWARDS, PAIN FREE STRETCHING, PAIN FREE EXERCISES, JOGGING, STATIONARY BIKE. MMT’S QUAD KNEE MMT’S HAMSTRINGS QUESTIONS? OTHER INJURIES:

• BURSITIS • PATELLAR TENDONITIS (JUMPERS KNEE) • PATELLA DISLOCATION • OSGOOD-SCHLATTER DISEASE • IT BAND TENDONITIS (RUNNERS KNEE) OTHER INJURIES Bursitis Patellar Tendonitis Patella dislocation Osgood-Schlatter IT band tendonitis

MOI Acute, chronic, recurrent; jumping, kicking or running thigh rotates internally apophysitis with pain overuse condition KEY prepatellar bursa becomes places tension on patella & with lower leg rotates at attachment of commonly in genu inflamed from placing pressure on quad tendons; sudden & externally forces knee patellar tendon to varum & pronated front of knee while kneeling & repetitive forceful valgus-patella goes tibial tuberosity; bony feet; irritation at deep infrapatellar bursa becomes extension of knee laterally; R/O ACL & callus forms; repeated bands insertion & irritated from overuse of tendon PCL avulsion of patella over lateral femoral tendon epicondyle S/S swelling above knee is ballatable; pain; tenderness at inferior pain; swelling; swelling; hemorrhage; PTT over insertion and redness; increased temp.; painful pole of patella; pain after complete LOF; degeneration of lateral femoral & disabling from swelling activity; pain during & deformity apophysis leads to epicondyle after activity; pain during impaired circulation; activity & prolonged after severe pain when kneeling, jumping and running; PTT over anterior proximal tibial tuberosity

Tx eliminating cause; rest; anti- ice; phonophoresis; relocate; immobilized decrease activities; correction of inflammatory meds; compression iontophoresis; US; heat; in extension; crutches; cast; ice; isometric malalignments; ice; wraps; aspiration; steroid injection brace or strap; transverse brace; SLR; rehab for strengthening of thigh proper warm-up, friction massage; anti- knee, thigh, & hip; muscles stretching; avoid inflammatory meds surgery inclines; anti- inflammatory meds; orthotic KNEE SPECIAL TESTS QUIZ VERSION A NOT MATCHING SPELL EVERYTHING OUT VERSION A

1. NAME THE 4 BONES OF THE KNEE. 2. WHAT IS THE SPECIAL TEST TO TEST LAXITY IN THE MEDIAL COLLATERAL LIGAMENT? 3. NAME THE 2 SPECIAL TESTS THAT TEST THE ACL 4. WHAT IS THE ATHLETES POSITION FOR THE POSTERIOR SAG TEST? WHAT LIGAMENT ARE YOU TESTING? 5. WHAT LIGAMENT DOES THE VARUS TEST ASSESS? 6. WHAT IS THE BIGGEST FAT PAD IN THE KNEE? VERSION A KEY 11PTS

1. FEMUR, TIBIA, FIBULA, PATELLA (4 PTS) 2. VALGUS STRESS TEST (1 PT) 3. LACHMANS, ANTERIOR DRAWER (2 PTS) 4. LYING SUPINE HIP FLEXION AT 90, PASSIVE KNEE FLEXION AT 90. PCL (2 PTS) 5. LATERAL COLLATERAL LIGAMENT (1PT) 6. INFRAPATELLAR FAT PAD (1 PT) Knee Rehab • When injuries occur, the focus of the athletic shifts from injury prevention to injury treatment and rehabilitation

Treatment and rehabilitation (for that athlete!)

KneeInjury Rehab prevention Overall Goals of Knee Rehab

• To prevent de-conditioning • To restore the injured part to a pre-injury state Short Term Goals

• Controlling pain – NSAIDS, Cryotherapy, thermotherapy • Maintaining or improving flexibility • Restoring or increasing strength • Reestablishing neuromuscular control • Maintain level of CV fitness Long Term goals

• To return the injured athlete to practice or competition as quickly and safely as possible Functional Activities (progression)

• Walking – Forward, backward, straight line, curve • Jogging – Straight, curve, uphill, downhill • Running – Forward, backward • Sprinting – Straight, curve, large & small figure eight, zigzag, carioca Return to Play Criteria

• Full ROM • Full Strength • Pain Free Designing a rehab Program

• Heel slides (why?) • Quadriceps contractions (why?) • Knee ext. no weight (SAQ) (why?) • 4 way Hip exercises(add, abd, flxn, ext) (why?) Phase 1 • Pilates: clams/90/90 (why?) • Theraball: adductor squeezes, reverse planks, hamstring curls no bridge (why?) • Balancing (why?) • Bike workout (why?) • Stretching (why?) Designing a rehab Program

• Wall Slides (why?) • Knee Extension PRE’s (why?) • hamstring curls w/bridge PRE’s (therball, weight, bands) (why?) • Theraball squats (why?) Phase • Calf raises (why?) • ½ lunges, chops, chicken foot (grid) (why?) • 4 way Hip exercises tubing (Pilates, add, 2 abd, flxn, ext) (why?) • Balancing eyes open, Floor to BOSU or trampoline (why?) • Monster walk….. (why?) • Teetter-totters (why?)

Designing a Rehab Program Con’t • BOSU ball work (why?) • 2 foot jumping (front back and lateral) (why?) Phase • Full lunges (matrix) (why?) • Balancing eyes closed, OR catching a ball… (why?) • Versa loop/monsters PRE w/lateral movement (why?) 3 • Quick leg curls with manual resistance (why?) • Bike workout (why?)

• Be creative! (why?) • Running • Jumping Sports • Drills Specific Knee PRACTICE 4 1. List one specific exercise that decreases swelling in the knee? – Heel slides, bike, wall slides 2. List one specific exercise that increases ROM in the knee? – Heel slides, bike, wall slides 3. List one specific exercise that increases strength in the knee? – Quad set/contraction, knee ext., 4 way hip, clams, 90/90, reverse clams, hamstring curls, squats, calf raises, lunges, chops, chicken foot, monster walk, teeter-totter, jumping, leg curls* 4. List one specific exercise that increases PNF in the knee? – Balance, reverse plank, monster walk, teeter-totter, jumping, leg curls 5. List one functional activity for the knee? – Running, jumping, SS drills, jogging, sprinting 1. What rehab exercise are they working on? 2. How could you make this sports specific? 3. What is this exercise? 4. What muscle(s) is she working? 5. How could you make this into a phase 1 exercise? 6. How could you make lunges into a Phase 1,2,3 exercise? 7. Which phase would this fall into? 8. How could you make it a different phase? Kraack’s Knee Review Options

• Termrrhage • Jeopardy • Pictionary • Practice practical • Head of the Class Knee Unit Test

Out of 37 points. Spelling counts You CAN abbreviate Each slide is timed so will automatically advance. Vocabulary Mega Matching: 1 pt each

1. Cushions the front of the knee. A. Patella 2. Adds cushion AND deepens the knee. B. Menisci 3. Supports the medial aspect of the knee. C. Avascular 4. Most frequently hurt landing on the knee D. ACL with it flexed at 90 degrees. E. PCL 5. Supports the lateral aspect of the knee. F. MCL 6. A diagnostic tool for soft tissue injuries. G. LCL H. Fat pads I. Genu valgum J. Genu varum K. Hemarthrosis L. MRI M. Translation Special Tests Mega Matching: 1 pt each

7. Valgus A. ACL 8. Manual Muscle Testing B. PCL 9. Posterior sag C. MCL 10. McMurray’s test D. LCL E. Meniscus F. Hamstrings Injuries Mega Matching: 1 pt each

11. Happens at the tibial tuberosity A. MCL sprain in younger athletes. B. ACL sprain 12. Happens from landing on an C. Bursitis extended knee. D. Traumatic patellar 13. Happens from continued subluxation/dislocation kneeling or direct blow. E. Knee hyperextension 14. Happens to joggers and cyclists. F. Osgood-Schlatter disease G. Patellar tendinitis H. Runner’s knee Outline Multiple Choice: 1 pt each

15. Strongest ligament and main 17. Lachman’s is used to test what? stabilizer of the knee? A. ACL B. LCL C. MCL D. PCL A. ACL B. LCL C. MCL D. PCL 18. Most often injured ligament in the 16. Which muscles does abduction knee? A. Biceps femoris A. ACL B. LCL C. MCL D. PCL B. Gastrocnemius C. Tensor fascia latae D. Vastus medialis Outline True/False: 1 pt each

19. The medial meniscus is prone to disruption by valgus and torsional forces.

20.One of the most important aspects of a good evaluation is to understand the MOI by taking a good history.

21.The infrapatellar fat pad is the largest in the knee. Misc. Short Answer: varied points 22. Describe the ligament damage in a Grade 1 MCL sprain? (1) 23.List 2 s/s of a Grade 1 MCL sprain? (2) 24.The tibia is (directional term) to the fibula. (1) 25.A football athlete is hit on the lateral surface of his knee. He has significant pain and some immediate swelling on medial surface. What do you suspect is the injury? (1) 26.A football athlete is hit on the lateral surface of his knee. He has significant pain and some immediate swelling on medial surface. What are the 3 most appropriate special tests to r/o or r/i an injury? (3) 27. List one of the muscles in the hip adductor group? (1) Labeling: 1 pt each 28

31

29 32

30 Labeling: 1 pt each

34.Knee Movement 33. Muscle Name Vocabulary Mega Matching: 1 pt each KEY

1. Cushions the front of the knee. (H, Fat pads) A. Patella 2. Adds cushion AND deepens the knee. (B, Menisci) B. Menisci 3. Supports the medial aspect of the knee. (F, MCL) C. Avascular 4. Most frequently hurt landing on the knee with it flexed at 90 D. ACL degrees. (E, PCL) E. PCL 5. Supports the lateral aspect of the knee. (G, LCL) F. MCL 6. A diagnostic tool for soft tissue injuries. (L, MRI) G. LCL H. Fat pads I. Genu valgum J. Genu varum K. Hemarthrosis L. MRI M. Translation Special Tests Mega Matching: 1 pt each KEY

7. Valgus (C, MCL) A. ACL 8. Manual Muscle Testing (F, Hamstrings) B. PCL 9. Posterior sag (B, PCL) C. MCL 10. McMurray’s test (E, Meniscus) D. LCL E. Meniscus F. Hamstrings Injuries Mega Matching: 1 pt each KEY

11. Happens at the tibial tuberosity in younger athletes. A. MCL sprain (F, Osgood-Schlatter disease) B. ACL sprain 12. Happens from landing on an extended knee. (E, Knee C. Bursitis hyperextension) D. Traumatic patellar 13. Happens from continued kneeling or direct blow. (C, subluxation/dislocation Bursitis) E. Knee hyperextension 14. Happens to joggers and cyclists. (H, Runner’s knee) F. Osgood-Schlatter disease G. Patellar tendinitis H. Runner’s knee Outline Multiple Choice: 1 pt each KEY

15. Strongest ligament and main 17. Lachman’s is used to test what? stabilizer of the knee? A. ACL B. LCL C. MCL D. PCL A. ACL B. LCL C. MCL D. PCL 18. Most often injured ligament in the 16. Which muscles does abduction? knee? A. Biceps femoris A. ACL B. LCL C. MCL D. PCL B. Gastrocnemius C. Tensor fascia latae D. Vastus medialis Outline True/False: 1 pt each KEY

19. The medial meniscus is prone to disruption by valgus and torsional forces. True

20.One of the most important aspects of a good evaluation is to understand the MOI by taking a good history. True

21.The infrapatellar fat pad is the largest in the knee. True Misc. Short Answer: varied points KEY 22. Describe the ligament damage in a Grade 1 MCL sprain? (1) – Slight stretch of MCL 23. List 2 s/s of a Grade 1 MCL sprain? (2) – Stable, mild or no swelling, mild pn, stiffness, joint tenderness 24. The tibia is (directional term) to the fibula. (1) – medial 25. A football athlete is hit on the lateral surface of his knee. He has significant pain and some immediate swelling on medial surface. What do you suspect is the injury? (1) – MCL sprain 26. A football athlete is hit on the lateral surface of his knee. He has significant pain and some immediate swelling on medial surface. What are the 3 most appropriate special tests to r/o or r/i an injury? (3) – Valgus, an ACL test, a meniscus test 27. List one of the muscles in the hip adductor group? (1) – Adductor longus, adductor brevis, adductor magnus, pectineus, gracilis Labeling: 1 pt each KEY 28. Femur

31. ACL

29. L. 32.M. Meniscus Meniscus

30. Fibula Labeling: 1 pt each KEY

34. Knee extension 33. Semimembranosus Hip Labeling

Sports med 2 Iliac Ilium Crest

Femur Base of the Sacrum

Acetabulum

Neck of the Femur Sacrum

Greater Trochanter

Lesser Trochanter Anterior Superior Iliac Spine (ASIS)

Head of the Femur Coccyx Anterior Inferior Iliac Spine (AIIS)

Pubis

Ischium Pubic Symphysis ilium

Ischium

Pubis iliac crest

AIIS

Acetabulum Posterior Superior iliac Spine (PSIS)

ASIS

Posterior Inferior iliac Spine (PIIS) AIIS Pectineus Adductor Brevis

Adductor Gracilis Longus

Adductor Magnus Gluteus Medius Gluteus Maximus Tensor Fascia Latae

iliotibial Band iliopsoas

TFL

Adductor Rectus Longus Femoris Sartorius Pectineus

Gracilis

Vastus Vastus Medialis Lateralis Gluteus Maximus iliotibial Band

Biceps Femoris

Semimembranosus Gluteus Medius

Semitendinosus Gluteus Medius

Gluteus Maximus Glutues Minimus

Piriformis The Hip

Sports Med 2 The Hip

• A ball and socket joint • Hip transmits the load from the foot to the spine and vice versa Blood & Nerve Supply

• Femoral artery • Common Iliac Vein • Femoral Nerve • Sciatic Nerve – Largest nerve in the body – Innervates thigh and lower leg Bursae

• Iliopsoas and deep trochanteric bursae – Most important ones Injury

• Trochanteric Bursitis – MOI: • Common at the greater trochanter, high in women w/ increased Q angle, or leg length discrepancy • Inflammation of bursa, or insertion of gluteus medius, or IT band – S/S: • c/o pain on lateral hip • Radiating pain down to the knee • Tenderness over greater trochanter – TX: • PRICE, NSAIDS, ROM, PREs, no inclined running – Special Tests: Obers, Ober’s Test -Athlete lays on unaffected side -Knee flexed at 90 degrees -Lift top leg into abduction, slight hip extension -Allow the affected leg to drop into adduction

-If leg does NOT drop = + tight IT band Bones • Sacrum, Coccyx – Innominate bones: ossify and fuse early in life • Pelvis – Support the spine and trunk – Transfer their weight to the lower limbs – Placement for bony attachment • Ilium, Ischium, Pubis – Make up pelvis Injuries • Hip Pointer (contusion) – MOI • blow to inadequately protected iliac crest • Most handicapping injury in sports, difficult to manage – S/S • Immediate pain, spasms, transitory paralysis of soft structures • Unable to rotate the trunk or to flex the thigh with out pn – TX • RICE, referral, x-ray, ice massage, ultrasound, injection • Doughnut pad for return to play Hip dislocation Injuries

• Hip Dislocation pg 727 fig. 21-30 – MOI • Rarely occur during sports, major trauma • Femur is adducted and flexed – S/S • Flexed, adducted, and internally rotated thigh • Deformity, nerve damage – TX • Immobilization, ice, analgesics Injury • Avulsion Fracture – MOI: • Most common: 1) ischial tuberosity (hamstrings), 2)AIIS(rectus femoris), ASIS (sartorius) • Sudden acceleration/deceleration – S/S: • Sudden local pain • Limited movement – TX: • X ray, PRICE, crutches, ROM, Progressive Resistance Exercises (PREs) – Special Tests: Hip MMTs Injury • Osteitis Pubis – MOI: • running sports (XC, football, soccer, wrestling) • Repetitive stress on pubis symphysis by surrounding muscles – S/S: • Groin pain while running, squats, sit ups – TX: rest, NSAIDS, gradual return to play – Special Tests: running, sit up, squats Articulations • Sacroiliac Joint – Supported by ligaments – Connects sacrum to ilium • Joint Capsule – The acetabulum is cushioned by the labrum • Hip Joint – Made of femur head and acetabulum – Padded at the center by a mass of fatty tissue, ligaments and capsule Ligaments

• Iliofemoral – Y ligament of Bigelow – Strongest ligament of body – Prevents hyperextension

• Pubofemoral – Prevents excessive abduction Ligaments

• Ischiofemoral – Prevents internal rotation and adduction – On posterior aspect • Ligamentum Teres – Ligament to the head of the femur – A bridge to allow blood vessels and nerves to enter the head of the femur Injuries • Hip Sprain – MOI • Strong = best protected, seldom injured • Violent twisting produced by opponent, foot firmly planted and trunk forced in opposing direction – S/S • Athlete is unable to circumduct the thigh • pain – TX • X-rays to rule out fx • RICE, analgesics, limit wt. bearing, pain free ROM – Special Tests: active circumduction of thigh, IR, ER IR/ER Injuries • Sacroiliac Joint Sprain (S.I. Joint) – MOI • Twists with both feet on the ground • Stumbles forward, falls backward, steps in hole – S/S • Pain over joint, muscle guarding, radiating pain down back of gluteus and hamstring • Asymmetrical ASIS/PSIS or leg length difference – TX • Modalities, brace, stability exercises – Special Test: FABERS/Patricks FABERs /Patrick Test

• Procedure: Place foot on the opposite extended knee of the painful SI joint

• Apply pressure downward on the bent knee.

• Positive test: Pain felt in hip or SI jt. = SI joint dysfunction Muscles • Anterior – Iliacus • Triangular shaped, flexes the hip – Psoas (major and minor) • Flexes the hip – Sartorius • Crosses medially across anterior thigh • Hip flexion, and external rotation – Rectus Femoris • Hip flexion and knee extension Muscles • Lateral – Tensor fascia latae • Hip abduction • Posterior – Piriformis- ext. rotation – 3 gluteal muscles • Gluteus Maximus: extension, adduction, helps us get up from a sitting position • Gluteus Medius: abduction • Gluteus Minimus: abduction – Hamstrings: hip extension, knee flexion • Biceps Femoris, Semitendinosis, Semimembranosus Piriformis stretch Hip Abduction

• Practice Hip MMTs for abduction adduction, and flexion • Practice the piriformis stretch Muscles • Medial – adductors and rotators of the hip – Gracilis • Adduction, external rotation – Pectineus • Adduction, external rotation – Adductor longus, brevis and magnus • Adduction, external rotation Injuries • Groin Strain (adductor/Hip flexor strain) – MOI • Torn during twist or pull while running or jumping – S/S • Feel twinge or tearing during an AROM • may feel worse the next day • Pain, weakness, bruising – TX • PRICE, analgesics, ROM and PREs • Rest is the best treatment, protective spica – Special Tests: MMTs Thomas Test

• Procedure: Athletes lies supine legs together

• ATC places on hand under athletes lumbar curve

• One thigh is brought to the chest flattening the spine.

• Return bent leg to extended position, lumbar curve should return.

• Positive Test: Extended thigh should be flat on the table, if not = tight hip flexor Kendall test Procedure: Athlete lies supine with knees off table

Athlete brings one leg to their chest

Positive Test: If thigh comes off the table = tight hip flexor • Quad Contusion Injury – MOI • Direct blow to the thigh

•Superficial •deeper •Moderate bruise •Pain, swelling pain and •Disability, may split the •Mild •cannot flex swelling,

limping, fasciae

Grade 2 Grade 3 Grade Grade 1 Grade hemorrhage, knee more pain, no than 90 cannot flex •Severe pain, swelling, pt degrees knee limited ROM, tenderness limp

•Full ROM 4 Severe/Grade

– TX: flx w/ice pack ,PRICE,NSAIDS, PREscrutches Injury

• Myositis Ossificans Traumatica – MOI: • Severe blow or repeated blows to thigh, usually the quadriceps • Can lead to ectopic bone production (myosositis ossificans) – S/S: • Pain, swelling, decreased function – TX: • Conservative, surgery one year later – Special Tests: • AROM knee flexion/ext Injury • Hamstring Strain – MOI • Most common injury to thigh, exact cause not known • Possible MOI: muscle fatigue, faulty posture, leg length discrepancy, tight hamstrings – S/S • Hemorrhage, pain, loss of function. • 3 grades of strain – TX • PRICE, NSAIDS, very conservative, PREs – Special test: MMTs Hamstring MMT Injury • Snapping Hip: ➢ Excessive repetitive movement in dancers, gymnasts, hurdlers, sprinters – MOI: • Imbalance in muscle • IT band moves over the greater trochanter – S/S: • c/o of snapping with pain – TX: • Ice, NSAIDS, ultrasound, then stretching and strengthening Trendelenburg’s test

Procedure: Athlete stands, foot on the unaffected side is lifted

Look at the iliac crest to see if it stays level

Positive test: if unaffected side lowers OR If standing on leg and affected hip moves into abduction

= Weak abductors Injury

• Femoroacetabular impingement (FAI) • Hip Impingement • MOI – abutment of the acetabular rim and the proximal femur – Bone abnormalities, congenital or developed • S/S – Anterolateral hip pain – aggravating activities: prolonged sitting, leaning forward, getting in or out of a car, and pivoting in sports. • TX – Analgesics, ROM, PREs – Refer to Ortho • FADIR Special Test • Flexion adduction internal rotation • Procedure: Flex, adduct, and internally rotate the leg • Positive test: anterolateral hip pain Measuring for Leg length

• 2 main ways: – Anatomical discrepancy – Functional discrepancy Anatomical discrepancy (true method)

(actual bone is shortened)

Athlete lies supine with legs straight

Measurement is taken between the medial malleoli and ASIS

Bilaterally compare Functional discrepancy Due to pelvic tilt or deformity

Athlete lies supine, legs straight

Measurement is taken from umbilicus to the medial malleoli

Bilaterally compare Hip Assessment

Sports Med 2 History

• What are your symptoms – Weakness, disability, pain – Can they move their leg in a circle? • Describe pain – felt mainly in groin and medial frontal part of the thigh, can also refer to the knee – Is it radiating, tingly, dull, achy? • When does the activity occur? • How old is the athlete? Observation

• Should observe while standing in all directions, standing on one leg, and walking • Front view – Are the hips even? – lateral tilted hip could = a leg length discrepancy or muscle contraction on one side • Side view – Abnormal tilt of the pelvis, anterior/posterior – indicate lordosis or flat back Observation • Lower limb alignment – Genu valgum (knocked knees) – Genu varum (bow legged) – Genu recurvatum (hyper-extended) – Patellar alignment • Even PSIS – indicate a lateral shift of the pelvis • Standing on one leg could produce hip pain, indicate pain in pubic symphysis, or abductor weakness • Ambulation: observe while walking and sitting • Walking will cause distortion Bony Palpation • Posterior • Anterior – Posterior superior iliac spine (PSIS) – Anterior Superior iliac spine (ASIS) – Ischial tuberosity (we won’t do this one!) – Iliac crest – Sacroiliac joint – Greater trochanter – Pubic tubercle (we wont do this one!) Palpation

• Soft tissue: we won’t be doing these either! – Groin region – Femoral triangle – Sciatic nerve – Major muscles Palpation

• Groin palpitations – Could be caused by • Swollen lymph nodes, indicating infection • Adductor muscle strain Palpation

• Muscle Palpation: for pain swelling or fiber disruption – Iliopsoas – Sartorius – Rectus femoris at the hip joint – Gracilis – Pectineus – Adductors – Gluteals – Hamstrings Hip Rehab

Sports Med 2 • Athlete must maintain cardiorespiratory fitness – Bike – swimming • Total body strengthening • Muscle endurance • Proper stretching • Proprioception • PNF • Important to remember that initial rehab must be pain free Phase 1

• Isometric contractions • ROM – PNF stretching • Pool Rehab (non-wt. bearing) – running – Kicking – ROM Phase 2

• Passive Stretching • Balancing • Isotonic contractions – Squatting – Hamstring curls – Pilates – High knees – Ball squeezes Phase3 • Static and Dynamic Stretching • Lunges • MMTs w/band resistance • Squatting – On bosu ball or with weight • Hamstring curls – With weight • Pilates – Increase difficulty • High knees – Sprint with resistance band on waist Muscle Energy Techniques

• Uses muscle contraction to help re-align bones/joints • “shotgun” adduction/abduction – For pubic symphysis • Flexion/Extension – For anterior/posterior rotation Functional testing (phase 3) • Squatting • Going up and down stairs one/two at a time • Crossing the leg • Running straight ahead • Running and decelerating • Running and twisting • One legged hop • Jumping • Zig zag running Return to play criteria

• Full ROM in all movements • Pain free • Bilateral strength • stability Rules of the Game • Rules of the Game • What signal will the ref give for blood in wrestling? • Draw and list the items to set up for a wrestling match. • How many innings are played in a high school baseball game? Softball? • In baseball and softball, what does “top of the inning” mean?