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Presenting the Medial Knee PresentingPresenting thethe MedialMedial KneeKnee 7 Workshop Objectives 1. You will get a review of the anatomy of the medial knee 2. You will get a review assessment techniques for injuries to the medial knee 3. You will pick up a tip or two on assessment 4. You will pick up a tip or two in teaching this topic 5. I will introduce research that is important to ME 6. I will get you thinking MY way 7. Leave with the feeling WE have not wasted 45 minutes Anatomy Review of the Medial Knee Bones Tendons Ligaments Meniscus Injury to the Medial Knee Sprains and Strains Assessment Æ make a clinical judgment about the degree of injury 1st degree 2nd degree Sprains and Strains 3rd degree GOALS are based on the degree of injury Medical referral is based on the degree of injury Meniscal Tears Other (bursitis, nerve involvement, etc.) MCL Sprains - Epidemiology “The MCL is the most commonly injured ligament…” (Ireland, 1999, JAT) MCL most common knee injury in soccer and basketball (Arendt, 1999, JAT) The MCL sprain is the most prevalent knee injury in the general population (Add ACL and MCL = 90% of knee injuries). Miyasaka KC, Daniel DM, Stone ML, Hirshman P. The Incidence of Knee Ligament Injuries in the General Population. The American Journal of Knee Surgery. 1991; 4 (1):3-8. 500 knee injuries Æ frequency of knee injuries: ACL, 63% MCL, 44% PCL, 7% LCL, 4% Combination Injuries Æ Meniscal Tears, etc. Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy of kinematics of the lateral collateral ligament of the knee. AJSM. Nov-Dec 2000; 28 (6):869-878. Evaluation and Assessment of Medial Knee Injuries HISTORY INSPECTION – OBSERVATION PALPATION The evaluation relies SPECIAL TESTS on the expertise of the clinician to assess PROM, AROM, MMT the MCL sprain given Stress Testing subjective information and Etc. performing more Arthrometry objective special The LigMaster (stress) tests. Evaluation of the Medial Knee HISTORY What happened/MOI? Direct blow from the side Æ Collaterals Torsion, rotation, “twisting” Æ Cruciates, Collaterals, Menisci Noises? Sensations? “Giving way” Æ Tendonitis or Meniscus “Sharp/Knife-like Under Patella” Æ Chondromalacia “Numb” Æ Nerve (burning, tingling, etc.) UHUH OH!!OH!! Arnheim & Prentice, Principles of AT, 9th ed MOI = Blow to the outside of the knee with or without torsion Evaluation of the Medial Knee HISTORY When did it happen, onset PMH Sensations felt – PAIN? Provocation, Quality, Radiating/Referred, Severity (1-10), Timing Pin-Point-Pain Training, surfaces, mileage (10% rule), shoes, etc. Evaluation of the Medial Knee OBSERVATION Compare Bilaterally Gait FWB & PWB Antalgic gait Gait deviations Deformity Swelling, edema, effusion, ecchymosis Atrophy Evaluation of the Medial Knee PALPATION Palpate bones – compare bilaterally Æ R/O fx &/or dislocation IF FX or DISLOCATION IS SUSPECTED Æ splint (ice), MD Referral Evaluation of the Medial Knee PALPATION Pes anserinus tendons = Sartorius, Gracilis, Semitendinosus + Semimembranosus Evaluation of the Medial Knee RANGE OF MOTION Can palpate tendons at this time Stabilize legs to isolate joints Compare bilaterally AROM Æ PROM Æ Goniometer MMT Æ Make Test or Break Test Evaluation of the Medial Knee SPECIAL TESTS Anterior Drawer Test = ACL stability Slocum Drawer Test – adds rotation to ADT Ex Rot Æ AMRI (ACL + MCL + PMC) Arnheim & Prentice, Principles of AT, 9th ed ACL decreases ant mvt of femur (86% and medial 15° External displacement (30%) Rotation PCL decreases post mvt of femur (90%) and lateral displacement (36%) Posterior Drawer Test = PCL Huston’s Test = adds rotation to PDT Internal Rotation Æ PMRI (PCL + MCL + AMC + POL) Evaluation of the Medial Knee - SPECIAL TESTS Valgus Stress Test In 0 ° (full extension) = MCL + ACL, PCL, PM capsule, POL, etc.) And somewhere between 5 - 30° flexion = MCL and medial capsule Arnheim & Prentice, Principles of AT, 9th ed Evaluation of the Medial Knee - SPECIAL TESTS Valgus Stress Test Amount of opening at the joint during valgus stress test compared to the unaffected knee 0-5mm = mild 1+ (very little instability, tenderness, firm end point) 5-10mm = mod 2+ (instability in flexion and pain!) >10mm = severe 3+ (instability even in extension, no end point) Special Tests - Meniscal Tears McMurray’s Test: Ex rotation of tibia + valgus stress Æ extension of the knee Æ click or pain over medial meniscus =+ Arnheim & Prentice, Principles of AT, 9th ed Apley’s Compression/Distraction Tests Fox Test Evaluation of the Medial Knee SPECIAL TESTS Patellar Tests Apprehension Test – Subluxation, Dislocation Patellar/Femoral Compression Test (Clark’s Sign) & Crunch Test Q Angle Measurement Plica Test Functional and Sports Specific Tests Evaluation of the MCL Summary The severity of MCL injury is based on point tenderness, swelling over the soft tissue, and findings gained by performing special tests. Evidence Based Practice Æ My Dissertation Questions Does Wolff’s law apply to ligaments? “Bone and soft tissue will respond to the physical demands placed on them, causing them to re-model or realign along lines of tensile force” Prentice, W. (2004). Rehabilitation Techniques, pg. 41. Is a person’s left leg and right leg the same? Do people have a dominant leg? Do athletes? More Questions Do males have stronger bones, tendons, and/or muscles than women? Do males have stiffer ligaments than females? So stronger joints? What if the MCL is the same in males and females? Does that mean the ACL is the same in males and females? Medial Collateral Ligament Attachments: Just inferior to the adductor tubercle on the femoral epicondyle Medial tibial flare 2 Portions Superficial = Tibial collateral or MCL Deep = medial ligament or capsular ligament Æ attaches to medial meniscus Medial Collateral Ligament Deep portion of MCL attaches to medial meniscus. Posterior aspect of superficial MCL blends into deep PCL and semimembranosus muscle, which also attaches to the medial meniscus Medial Collateral Ligament Functions: Valgus stress Tibial external rotation Tibial anterior translation Different knee positions matter! Knee position changes the function of the MCL In extension: In flexion: anterior MCL is Superficial MCL is taut taut, posterior is slack MCL SPRAIN The Valgus Stress Test The common MOIs for injury to the MCL Direct hit (force) on the outside of the knee (valgus stress) Outward rotational force Therefore, the position of the knee when performing the Valgus Stress Test is: 1. Full Extension 2. Flexed 20° 25° How much and why? 30° DEGREES AUTHOR(S) TEXTBOOK PUBLISHER REF OF FLEXION 20 - 30° 1. Shultz, S., Assessment of Human Kinetics Houglum, P., Athletic None flexion Perrin, D. Injuries 2000 Add internal Full Ext = Flexed = MCL Add external rotation of MCL, PMC + PCL, Medial rotation of tibia tibia = ↑ ACL + ACL, Capsule, Post. = ↓ stress on and PCL stress PCL, POL, Oblique Lig. PCL and ↓ stress to medial MCL Quads References Evaluation of 25° flexion to 2. Starkey, C., F.A. Davis Norkin and Orthopedic isolate the Ryan, J. Levangie, and Athletic 2002 MCL Injuries (2nd 1992. Ed.) DEGREES OF AUTHOR(S) TEXTBOOK PUBLISHER REF FLEXION Principles of References Athletic McGraw-Hill 30° flexion in 3. Arnheim, D., Lynch and Training, (10th text, 20 - 30° in Prentice, W. 2000 Henning, 1995. Ed.) Table (page 528) Special Tests References 4. Konin, J., for Slack Inc. McClure, 20 – 30° flexion Wiksten, D., Orthopedic Rothstein, and 2002 Isear, J., Examination Riddle, 1989 & Brader, H. (2nd Ed.) Smith and Green, 1995 Physical Appleton- “…knee flexed Examination Century-Crofts of the Spine just enough so 1976 5. Hoppenfeld, S. and No references that it unlocks Extremities from full extension” The LigMaster Device and Software Sport Tech, Inc., Charlottesville, VA Joints: ankle, knee, shoulder, elbow Telos device used in radiology for Graded Stress Radiography (GSR) The LigMaster Device and Software Pressure Actuator set at joint line Linear decoder detects displacement Plots force/strain curve Æ SLOPE F = Ao E Modular elasticity = stiffness Æ laxity Left Vs. Right LigMaster Data Summary Apparent Ligament Extension, mm 5 10 15 20 25 30 35 40 Name: PAA 38, PAA 38, Last seen: Thu Jul 01 2004 14 13 Test: Right 12 Test Knee MCL Right Knee MCL 11 Jul 01 2004 08:32 Thu Jul 01 2004 08:32 full ext 1 Title: full ext 1 10 9 Test analysis: x-intercept = 0.02 8 Slope = 19.98 7 Force, dN 6 Comparison: Left 5 Compari son Knee MCL Left Knee MCL Thu Jul 01 2004 08:41 4 Jul 01 2004 08:41 full ext 3 Title: full ext 3 3 2 Comparison analysis: x-intercept = 0.04 1 slope = 20.19 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 Ligament Strain: λ−1/λ2 Knee MCL analysis: Test ligament slope 1.04% less than comparison Same knee, one flexed 20° LigMaster Data Summary Apparent Ligament Extension, mm 5 10 15 20 25 30 35 40 Name: PAA 38, PAA 38, Last seen: Thu Jul 01 2004 14 13 Test: Right 12 Test Knee MCL Right Knee MCL 11 Jul 01 2004 08:32 Thu Jul 01 2004 08:32 full ext 1 Title: full ext 1 10 9 Test analysis: x-intercept = 0.02 8 Slope = 19.98 7 Force, dN 6 Comparison: Right 5 Comparison Knee MCL Right Knee MCL Thu Jul 01 2004 08:36 4 Jul 01 2004 08:36 20 d flex 2 Title: 20 d flex 2 3 2 Comparison analysis: x-intercept = 0.01 1 slope = 16.97 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 Ligament Strain: λ−1/λ2 Knee MCL analysis: Test ligament slope 17.72% greater than comparison Position of Knee Study
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