Knee

Post syndromes related to the knee joint here.


 * Iliotibial Band Syndrome**

The iliotibial band could be considered as an independent lateral stabilizer of the knee joint. It is a thickening of the deep fascia that surrounds the musculature of the thigh, the fascia lata. Proximally, it is anchored at the iliac crest, and serves as the insertion for both the tensor fascia latae and the gluteus maximus (receiving most of the tendon). It is continuous with the intermuscular septum that separates the vastus lateralis and the biceps femoris, and it also attaches to the femur. Distally, it has attachments to the lateral femoral epicondyle, the lateral patellar retinaculum, the patella, the patella tendon, and the Gerdy tubercle on the tibia. There are conflicting theories about what iliotibial band syndrome is. What it’s not: What it might be: Because the actual etiology of the disorder isn’t known, the method of injury isn’t known either. It presents as an overuse injury. Patients who complain of ITBS will have a history of a recent increase in activities that involve load bearing with the knee flexed. For runners, this might be an increase in mileage, adding hills, a change in shoes, running terrain, or running mechanics (increasing stride). For cyclists, this might be a change in mileage or adding hills. Other activities in which ITBS complaints have been reported are rowing, skiing, triathlons, soccer, basketball, and field hockey. Some research indicates that patients with ITBS demonstrate increased hip adduction and knee internal rotation. Other researches have found that runners with ITBS have weaker hip abductors when comparing their affected with their unaffected side and when compared with controls.
 * Definition:**
 * It is not “iliotibial band friction syndrome,” a theory based on the location of the common complaint – irritation at the lateral femoral condyle – and the mistaken belief that the ITB translates anteriorly and posteriorly as the knee flexes. The ITB doesn’t translate.
 * It is not bursitis. There are no bursa between the ITB and the lateral femoral condyle.
 * It might be irritation of a highly vascularized and innervated fat pad that does lie between the ITB and the LFC. In flexion, the ITB is pulled medially into the LFC, and this may irritate the fat pad that lies between the two.
 * It might be enthesitis (tendonitis) – an inflammation of a ligamentous or muscular attachment to a bone – that results from unusual and/or increased stress on the structure.
 * Method of Injury:**
 * Signs**
 * A positive Ober test (indicates a stiff TFL)
 * A positive Noble compression test: Patient is positioned supine, with the affected knee flexed to 90 degrees. Pressure is applied over the proximal, prominent part of the lateral femoral condyle as the knee is gradually extended. A positive test is indicated when pain is reproduced at 30-40 degrees.
 * A positive Renne’s test: The patient stands on the affected leg and flexes the knee to 30-40 degrees. A positive is indicated when a palpable “creak” is produced where the ITB passes over the LFC.
 * A positive Creak test: The patient stands on the affected leg and flexes the knee to 30-40 degrees. A positive is indicated when an audible “creak” is produced where the ITB passes over the LFC.
 * Symptoms**
 * Complaints of pain between the lateral femoral condyle and Gerdy’s tubercle on the tibia, secondary to activity.
 * Grades of ITB tendonitis:
 * Grade I: Pain occurs after activity. Activity is not limited.
 * Grade II: Pain occurs during activity. Activity is not limited.
 * Grade III: Pain occurs during activity. Activity is limited.
 * Grade IV: Pain prevents activity.

Baker, R. L. et al. (2011). Iliotibial band syndrome: Soft tissue and biomechanical factors in evaluation and treatment. //PM&R//, //3//, 550-561. doi: 10.1016/j.pmrj.2011.01.002 Cleland, J. A., & Koppenhaver, S. (2011). //Netter's Orthopaedic Clinical Examination: An Evidence-Based Approach//. (2nd ed.). Philadelphia: Saunders Elsevier. Dutton, M. (2008). //Orthopaedic Examination, Evaluation, and Intervention//. (2nd ed.). New York: McGraw Hill Medical. Fairclough, J. et al. (2006). The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. //Journal of Anatomy//, //208//(3), 309-316. doi: 10.1111/j.1469-7580.2006.00531.x Falvey, E. C. et al. (2010). Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. //Scandinavian Journal of Medicine & Science in Sports//, //20//, 580-587. doi: 10.111/j.1600-0838.2009.00968.x
 * Treatment Strategy** – There is no standard of care
 * Therapeutic Exercise – strengthen the glutes
 * Sub-acute:
 * Isometric clamshells with theraband
 * Isometric fire hydrants (hip ext, abd, and ER) with theraband
 * Isometric squats with theraband
 * Remodeling
 * Squats with weight and theraband
 * Power firehydrants (isometric) with theraband
 * Bridges
 * Maturation
 * Single leg bridges
 * Single leg squats
 * Power firehydrants (isotonic) with theraband
 * Patient Education -- rest then return gradually with proper form
 * Acute:
 * All irritating activity must cease
 * Sub-acute
 * Patient should be pain-free for two weeks before resuming any activity
 * Proper form for activity. Consider providing biofeedback in clinic.
 * Proper exercise progression
 * Remodeling/Maturation
 * Activities should remain pain-free
 * Assistive Devices – don’t seem to apply
 * There have been suggestions in the literature to consider foot orthoses, although there is no specific evidence to support their use.
 * Manual Therapy – little evidence of any contribution
 * In the sub-acute and remodeling phases, soft tissue manipulation may provide palliative comfort, free adhesions, stimulate healing
 * Home Exercise Program – stretch the TFL, strengthen the glutes
 * See Ther Ex above for glute strengthening
 * Sub-Acute and Remodeling
 * TFL stretching – Do the Ober. Do it again. And again. Repeat.
 * Pain control/Modalities – treating symptoms
 * In the acute stage: ice, oral NSAIDs, corticosteroid injections (for patients experiencing severe pain that is unresponsive to ice and NSAIDs)
 * In the sub-acute stage: Ultrasound (consider phonophoresis or iontophoresis)
 * References:**

** Kline **, C.M. (2011). The Suprising Iliotibial Band. //Journal of the American Chiropractic Association//, 48 (7): 2-6
Langford C.A., Gilliland B.C. (2012). Chapter 337. Periarticular Disorders of the Extremities. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), //Harrison's Principles of Internal Medicine//, 18e. Retrieved February 4, 2012 from []. Lininger, M. R., & Miller, M. G. (2009). Iliotibial band syndrome in the athletic population: Strengthening and rehabilitation exercises. //Strength and Conditioning Journal//, //31//(3), 43-46. doi: 10.1519/SSC.0b013e3181a100a3 Moore, K. L. (2010). //Clinically Oriented Anatomy//. (6th ed.). Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins. Strauss, E. J. et al. (2011). Iliotibial band syndrome: Evaluation and management. //Journal of the American Academy of Orthopaedic Surgeons//, //19//(12), 728-736. Wilson P.E., Pengel K. (2011). Chapter 25. Sports Medicine. In W.W. Hay, M.J. Levin, J.M. Sondheimer, R.R. Deterding (Eds), //CURRENT Diagnosis & Treatment: Pediatrics//, 20e. Retrieved February 4, 2012 from [].


 * __ Patellar Tendinosis __**

Patellar tendinosis is also known as jumper’s knee because it is commonly seen in those that participate in lots of jumping activities or sports. (3) It causes pain in the proximal patellar tendon, which is what connects the patella to the tibia (not the quadriceps tendon). It is often referred to as the patella ligament so it can be confusing. The pain is caused by constant stress to the tendon, which causes minor tears in that tendon; having too many tears for the body to keep up with often leads to patellar tendinitis. Reoccurring tendinitis can turn into tendinosis which is often characterized by increased degeneration of the tendon. (6) Basically, it’s a chronic injury of failed healing and degeneration of collagen that does not involve inflammation. [|Picture] (2)
 * Definition**

It is often caused by over use or strain of the patellar ligament which is often from too much jumping, especially on harder surfaces. It could be directly due to a sudden increase in the intensity or frequency of one’s physical activity. This is not always the case though; even people that don’t jump often can get patellar tendinosis. There are many other things that can cause strain to the patellar tendon. These include: being overweight, tight quadriceps and hamstrings, poor leg bone alignment, muscle imbalance, an increased Q angle (knock knees) or a raised patella (known as patella alta). (6)
 * Mechanism of Injury**

Symptoms can begin with pain in the proximal patellar ligament after exercise, so just below the kneecap. Then it may progress to pain during exercise which can be debilitating. (2) Exercise can be anywhere from walking all the way up to HIT like jumping and sprinting. Tendinosis often starts out as tendinitis so you may experience some swelling at the beginning but if the pain still persists for weeks later and there is no swelling then most likely it has become tendinosis. It sometimes can result in on and off again pain so sometimes athletes tend to ignore it which makes it worse over time. It may get to where it is painful with ADLS or even with rest.
 * Signs/Symptoms**

//Modalities/Pain Control// Since this is a chronic condition, thermotherapy is more beneficial and is often more comfortable for the patient. Thermotherapy increases circulation, promotes healing, and eases pain. Therefore continuous ultrasound on the affected area would be good. Ultrasound has been found to increase collagen synthesis and increase the tensile strength of the ligament. (4)
 * Treatment Strategy**

//Manual Therapy// There is not a lot of research treating patellar tendinosis using manual therapy but one article did say you could perform a massage to the tendon for treatment but it didn’t specify which type. (4) Another article suggested friction massage and stretching may help to stimulate blood flow but that they may not be more effective than other therapeutic options. (1) David mentioned that friction massage to the proximal portion of the tendon would be good to do. You want to make sure the inferior edge of the patella is sticking out (so push on the superior edge) so that you can really get in there nice and deep, right on the tendon.

//Assistive Devices// There are many different types of knee brace options that patients can wear. These are more commonly used for those patients that want to continue being active in sports. There are patella straps that they can wrap just below their patella to help keep the ligament nice and tight and to prevent extra movement and pain in the knee. Those are the most common because they are small and more comfortable. There are also larger knee braces they can wear that are thicker or just go around more of the knee. They are most likely more expensive as well. The main point is just to apply pressure to the patellar ligament to keep it nice and tight, which will help decrease the stress on it. (5) David mentioned that the patellar knee strap will increase the patellar-patellar tendon angle and therefore decreases the load on the tendon because it shortens the tendon. [|Picture] (5)

//Education// Educate the patient on some of the possible causes of their condition and on what exactly tendinosis is and how it’s different from tendinitis. Tell them that rest from high impact activities like jumping is best. Inform them of the benefits of physical therapy and how applying tensile forces to ligaments help them to heal better and allow better blood flow to them.

//Therapeutic Exercises// Tendons have slow healing rates and high re-rupture rates due to poor blood supply so physical therapy is very beneficial in treating and containing patellar tendinosis. (2) The idea is to create strengthening exercises for the tendon but also to allow rest from high frequency activity and from plyometrics. (4) One of the exercises the patient could do in the clinic is single leg squats on an incline surface, facing downhill. (2) Any exercises that increase the quadriceps and calf muscles are good too because those muscle bodies often atrophy in chronic conditions like this because the body begins to adapt to the knee injury and you may begin to use these muscles less. If the injury was due to jumping stress then another option would be to teach the patient better jumping and landing body mechanics. (4) Eccentric exercises are good to do for any kind of tendinosis issue. It's good to do eccentric exercises for about five days and cross friction as well each about three times a day, that way you are irritating the tendon and the body will see it as a new injury (acute instead of chronic). To heal tendons it is best to do lots of repetitions, with low load.

//Home Exercise Program// Initially the patient would want to rest their leg when they can and only do their exercises once a day maybe three times a week and then slowly increase the frequency to once every day and then up to 2-3 times a day if possible. It would be good to ice their tendon after exercising and they could apply heat packs a couple times a day (maybe morning and night) to relieve pain if wanted. Then exercises to strengthen their quads and calves like squats, lunges, and calf raises would be good options.

//References:// 1.Cook, J. L. (2001). What is the most appropriate treatment for patellar tendinopathy? //British Journal of Sports Medicine//, //35//(5), 291-294. doi:10.1136/bjsm.35.5.291 2. Davies, Malcolm, and Fares Haddad. "How Science Is Catching up with Chronic Front-of-knee Pain." //Sports Training | Sport Fitness//. Web. 11 Feb. 2012. . 3. Hamilton, B., & Purdam, C. (2004). Patellar tendinosis as an adaptive process: a new hypothesis. //British journal of sports medicine//, //38//(6), 758-61. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine. doi:10.1136/bjsm.2003.005157 4. Jill L. Cook, B. A. S., PT; Karim M. Khan, MD, PhD; Nicola Maffulli, MS, MD, PhD; Craig, & Purdam, D. P., PT. (2000). Overuse Tendinosis, Not Tendinitis Part 2: Applying the New Approach to Patellar Tendinopath. Retrieved February 11, 2012, from http://www.cornerstoneptc.com/pdf/overuse-tendinosis.pdf 5."Knee Bands." //The Knee Shop//. The Braceshop, Inc., 2008. Web. 11 Feb. 2012. . 6. Mayo Clinic Staff. "Patellar Tendinitis: Causes - MayoClinic.com." //Mayo Clinic//. 8 Jan. 2010. Web. 11 Feb. 2012. [].

__**MENISCAL INJ**____**URY**__

 * __Definition__:** A rupture or tearing of the fibrocartilage cushion (meniscus) of the knee. Three types of meniscal tears are:
 * Longitudial à may progress to Bucket Handle tear
 * Radial à may progress to Parrot Beak tear
 * Horizontal à may progress to Flap tear


 * __Mechanism of Injury__:** Injury is most common in young athletes, however injury can also result from degeneration of the cartilage with age. Sudden tears in young athletes are from a forceful twist/rotation of the knee joint in a flexed position, in particular with pressure or full body weight on that limb. In the elderly with degenerative issues, they may simply twist when standing and injure the meniscus because it has weakened with age.


 * __Signs & Symptoms:__**
 * A “pop” may be felt upon injury with gradual stiffness over the next 2-3 days
 * Joint line tenderness and effusion
 * Worsened symptoms by flexing and loading the joint – ex: squatting
 * c/o clicking, locking, or giving way
 * feelings of an unstable knee
 * decreased knee ROM
 * __Diagnostic Tests__**
 * **McMurray’s test –**Patient is supine in full knee flexion. Palpate the joint line and apply medial rotation and a varus force through the tibia while moving into extension (testing lateral meniscus). To test injury to the medial meniscus, apply lateral rotation and a valgus force.
 * [|**http://www.youtube.com/watch?v=IwBW-X4n1fU**]
 * **Apley’s test –**Patient is prone with the knee flexed to 90 degrees. Apply compressive or distracting force through tibia and rotate the tibia. Compression will aggravate symptoms, distraction will alleviate symptoms.
 * [|**http://www.youtube.com/watch?v=9sz8joKYpqs**]
 * **Grind test –** Patient is supine. Flex the knee to varying degrees and apply compressive and rotation force through the tibia.
 * **Ege’s Test –** performed with the patient squatting, can hear or feel a click in the area of the meniscus tear. Patient’s feet are turned outward to detect a medial tear and turned inward to detect a lateral tear.
 * **MRI**


 * __Treatment__**
 * Treatment may be surgical or non-surgical depending on how severe the tear/injury to the meniscus was. Interventions will be relatively the same, however progression and intensity will vary.
 * **Education:** The patient should be educated on how the injury can occur to prevent re-injuring the cartilage. Depending on the location of the tear, the cartilage may not be higher vascularized and can be at risk for further injury. The patient will also be educated on pain management and a home exercise program which may follow a physician protocols.
 * **Therapeutic Exercise:**
 * Gentle ROM ex’s (ROM may be limited per the physician’s orders)
 * Gentle stretching
 * quad and hamstring strengthening
 * Proprioception and Balance training
 * Continue to progress weight bearing per physician orders
 * weight bearing activities with limited knee flexion (ex: mini squat, leg press, total gym)
 * Running, swimming, plyometric exercises at late stages of therapy
 * Example of Meniscus Tear Protocol
 * **Assistive Equipment**
 * Crutches, walker, or cane may be used to maintain weight bearing precautions
 * A knee brace may be issued to help prevent tibial rotation and to maintain ROM guidelines
 * **Manual Therapy**
 * Patellar mobilization for knee ROM
 * Tibiofemoral distraction for pain management
 * **Home Exercise Program**
 * HEP will include exercises to increase ROM, flexibility, and strength as discussed in the previous Ther. Ex. Section
 * **Modalities/Pain Control**
 * Electrical Stimulation- indicated for pain control and to assist in quad muscle facilitation
 * NSAIDS
 * Ice, elevation, compression


 * REFERENCES**

Hall, C. M., & Brody, L. T. (2005). //Therapeutic exercise moving toward function//. (2nd ed., pp. 508-509). Philadephia, PA: Lippincott Williams & Wilkins. Hoppenfeld, S. (1976). //Physical examination of the spine & extremities//. (pp. 191-194). Norwalk, CT: Appleton & Lange. Loudon, J., Swift, M., & Bell, S. (2008). //The clinical orthopedic assessment guide//. (2nd ed., pp. 307-308). Lowe, W.R. (2011). Meniscus Repair Rehabilitation. http://www.drwaltlowe.com/attachments/wysiwyg/File/MeniscusRepairProtocol.pdf Lowe, R., Decoen, M., & Vankeerberghen, C. (2011). Meniscal repair. Retrieved from http://www.physio-pedia.com/index.php/Meniscal_Repair Lowe, R. & Uytterhaegen. (2011). Arthroscopic Meniscectomy. Retrieved from http://www.physio-pedia.com/index.php/Arthroscopic_Meniscectomy Orthoinfo.(2009).Meniscal tears. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00358 Types of meniscal tears. (2011). Retrieved from http://www.netterimages.com/image/10892.htm

= **__Knee Instability__** =

Instability of the knee is usually due to an acute or chronic injury of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL) and/or posterolateral complex of the knee.
 * Definition:**

True instability is a condition that occurs when the joint translates out of its ligamentous and muscular boundaries and the articular surfaces partially or totally disengage.


 * Signs and Symptoms:**

__ACL Signs__

-//Lachman Test//, a positive test would show excessive anterior translation of the tibia on the femur as compared to the opposite side (sensitivity = .63, specificity = .90).

-//Anterior Drawer Sign//, a positive test would show excessive anterior translation of the tibia on the femur as compared to the opposite side (sensitivity = .76, specificity = .86).

-//Pivot Shift Test//, a positive test would result if at approximately 30-40 o the tibia reduces with a clunk (sensitivity = .93, specificity = .89).

__Symptoms__
 * 1) Hearing a “pop”.
 * 2) Pain (moderate to severe).
 * 3) Swelling.
 * 4) Feeling of knee instability.

__PCL Signs__

-//Posterior Drawer Sign//, a positive test would show excessive posterior translation of the tibia as compared to the opposite side (sensitivity = .90, specificity = .99).

-//Posterior Sag Test//, a positive test would show the tibia dropping back or “sagging” back when the patient’s hip and knee are flexed to 90 o with their foot being supported by the clinician.

__Symptoms__
 * 1) Pain (mild to moderate).
 * 2) Pain when kneeling and squatting.
 * 3) Pain with running, slowing down, walking up or down stairs, or ramps.
 * 4) Rapid onset of knee swelling and tenderness.
 * 5) Feeling of instability.

__MCL Signs__

-//Valgus Stress Test//, a positive sign would show excessive gapping of the medial joint line with or without pain.

__Symptoms__
 * 1) Pain directly over the ligament.
 * 2) Swelling.
 * 3) Bruising.
 * 4) Knee instability.

__Grades of MCL Injuries__

-//Grade I//: Mild tenderness on medial side of knee usually over the ligament. When a valgus force is applied to the knee pain is felt, but no laxity is felt in the joint.

-//Grade II//: There is significant tenderness on the medial side of knee and over the ligament. Swelling is now seen over the ligament. When a valgus force is applied to the knee, pain is felt and there is laxity in the joint.

-//Grade III//: This is a complete tear of the ligament; there is significant joint laxity, and the patient may complain of a very unstable knee.

__LCL Signs__

-//Varus Stress Test//, a positive sign would show excessive gapping of the lateral joint line with or without pain.

__Symptoms__
 * 1) Pain (mild to moderate).
 * 2) Stiffness.
 * 3) Swelling.
 * 4) Locking or catching when the joint is moved.
 * 5) Numbness or weakness in the foot could occur if the peroneal nerve is stretched during the injury or compressed because of swelling.

__Grades of LCL Injuries__

-//Grade I//: Mild tenderness on lateral side of knee usually over the ligament. When a varus force is applied to the knee pain is felt, but no laxity is felt in the joint.

-//Grade II//: There is significant tenderness on the lateral side of knee and over the ligament. Swelling is now seen over the ligament. When a varus force is applied to the knee, pain is felt and there is laxity in the joint.

-//Grade III//: This is a complete tear of the ligament; there is significant joint laxity, and the patient may complain of a very unstable knee.


 * Mechanism of Injury:**

__ACL__
 * 1) Large valgus-producing force with the foot firmly planted.
 * 2) Large axial rotation torque applied to the knee, with the foot firmly planted.
 * 3) Any combination of the previous two, especially involving a strong quadriceps contraction with the knee in full or near-full extension.
 * 4) Severe hyperextension of the knee.

__PCL__
 * 1) Falling on a fully flexed knee (with ankle fully plantar flexed), so that the proximal tibia strikes the ground first.
 * 2) Any event that causes forceful posterior translation of the tibia or anterior translation of the femur, especially while the knee is flexed.
 * 3) Large axial rotation or valgus-varus applied torque to the knee with the foot firmly planted, especially with the knee flexed.
 * 4) Severe hyperextension of the knee causing a large gapping of the posterior side of the joint.

__MCL__
 * 1) Valgus-producing force with the foot planted (e.g., “clip” in football.)
 * 2) Severe hyperextension of the knee.

__LCL__
 * 1) Varus-producing force with the foot planted.
 * 2) Severe hyperextension of the knee.

__Posterolateral Complex__ (arcuate ligament, LCL, popliteus tendon, lateral head of gastrocnemius, oblique popliteal liagament)


 * 1) Hyperextension or combined hyperextension with external rotation of the knee.


 * Treatment Strategy:**

__Surgical/Non-surgical Indications__

__ACL__ The goal of ACL treatment is to prevent re-injury. It can either be fixed operatively or non-operatively, and this decision is based on factors (patient’s age, activity level, future expectations, and willingness to participate in PT) that are different for every person.

Non-operative management of ACL tears are most successful in patients that do not have any other associated injuries and are willing to give up highly demanding sports. Rehabilitation for this non-operative method would be big in proprioceptive training along with education about high-risk activities and strategies to prevent re-injury

Operative management of ACL tears usually involves the use of an autograft, allograft or synthetic graft to repair the torn ACL. Physical therapy is a very important aspect for patients that decide to have ACL surgery. Recently, there has been a big push for these patients to be WBAT as soon as possible with a major objective being early and long term maintenance of full knee extension.

__PCL__ Injuries to the PCL account for 15-20% of knee ligament injuries. Reconstruction is not usually required for the treatment of acute isolated PCL injuries (degree of posterior translation is less than 10 mm) instead a non-operative aggressive rehabilitation program should be created.

Reconstruction would be advised if the posterior translation is greater than 10 mm and no firm end feel is felt. If posterior translation is greater than 10 mm reconstruction is recommended because there is a good chance that a secondary restraint has been compromised. Rehabilitation after PCL reconstruction is designed to regain ROM without putting stress on the graft.

__MCL__ The treatment for an acute isolated MCL injury (incomplete tear) is a conservative one. RICE should be implored during the first 48 hours and should be followed with knee immobilization and the use of crutches for pain control. Weight-bearing as tolerated is suggested as pain allows, for the best results.

Chronic MCL insufficiency is rare and happens usually in combination with an ACL or PCL injury; surgery could be warranted if this is the case.

__LCL__ An LCL injury by itself is not very common; it usually happens in conjunction with an injury to the posterolateral complex, PCL, or ACL. If the LCL is injured along with part of the posterolateral complex a surgical intervention within two weeks would be ideal.

__Patient Education__ Patient should be educated via models/pictures and clinician expertise about their specific injury, what options they have (RICE, rehab, surgery), and what type of recovery time they are looking at. The patient should be educated on the plan of care including the importance of and proper use of any assistive devices (possibly), the use of modalities, and exercises that could possibly be used.

__Assistive Devices__ The use of crutches, walkers, possibly canes, braces, and knee immobilizers could all potentially be used depending on which ligament(s) the patient has injured. Crutches would more often be used for younger more active people with ACL/PCL injuries that are just out of surgery. Walkers would more often be used for older patients that would not be able to safely get around with crutches. The use of a cane could be used as an intermediary when weening from a walker to independent ambulation. Braces and knee immobilizers will most likely be used for all patients especially in the early stages of the injury and post-surgery.

__Pain Control/Modalities__ //RICE// can be used for the acute phases and post-surgery. //NSAIDS// these can be used to help reduce pain and possibly prescribed pain medication (post-surgery). //Cryotherapy// (Ice massage, ice packs, cold packs, or cyro-cuff) can be used for the acute phases, post-surgically, and after rehabilitation sessions to reduce swelling and pain. //Thermotherapy// can be used in the fibroblastic stages to increase circulation, increase tissue extensibility, and has also been shown to have an analgesic effect. //Ultrasound// could be used in the acute stages on the non-thermal setting in order to stimulate fibroblast activity to increase protein synthesis and help with tissue regeneration. After the acute stages ultrasound can be used on the thermal settings to increase the extensibility of collagen fibers, decrease joint stiffness, reduce muscle spasms, increase blood flow and help control inflammation. //Electrical stimulation//.

__Manual Therapy__ //Massage// could be warranted depending on the injury. //Friction massage// could help depending on the injury in order to help loosen any scar tissue, aid in the absorption of local edema and reduce any muscle spasm.

__Therapeutic Exercises__

__ACL__

Phase 1 (Weeks 0-3): PROM, AAROM, AROM, and strengthening, weight shifts, aqua-therapy (all incisions need to healed to initiate this)

Phase 2 (weeks 4-6): Increasing knee ROM 0-135, gait training, beginning functional strengthening, PROM, AAROM, AROM and strengthening, discontinue crutch use (no limp should be present), wall slides, step-up progression, balance and proprioceptive exercises, continue aqua-therapy (increase intensity).

Phase 3 (weeks 7-12): Working to attain full ROM, continue functional strengthening, continue balance and proprioceptive exercises, initiation of gym strengthening exercises as tolerated (leg press, total gym, hamstring curls, abduction/adduction strengthening),

Phase 4 (weeks 13-24): Advancing previously exercises, sport and work specific drills performed, working toward returning back to normal functioning.

__PCL__ (See ACL) No active hamstring work for the first 3-4 months in order to protect the PCL graft.

__MCL__ (Depending on the grade you will have different phase lengths)

Phase 1: Rest from activities that cause pain, pain-free stretching exercises, quad sets, hamstring holds, straight leg raises.

Phase 2: Rest from activities that cause pain, stretching, quad-sets, hamstring holds, straight leg raises, introduce dynamic strengthening (knee extension, knee flexion, step-ups, calf-raises), Initiate balance exercises (airex pad)

Phase 3: Continue stretching, advance dynamic strengthening, cycling, weighted walking forward/backwards and side-to-side, continue balance exercises.

Phase 4: Continue stretching, continue strengthening, initiate hopping exercises, working to get back to normal functioning.

__LCL__ (See MCL)


 * References:**
 * 1) Loudon, J., Swift, M., Bell, S. (2008). The Clinical Orthopedic Assessment Guide.
 * 2) Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.
 * 3) Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY:McGraw
 * 4) Neumann, D. A. (2010). //Kinesiology of the Musculoskeletal System//. (2nd ed.). St. Louis, MO: Mosby Elsevier.
 * 5) Moore, K. L. (2010). //Clinically Oriented Anatomy//. (6th ed.). Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins.
 * 6) Kakarlapudi, T. K., & Bickerstaff, D. R. (2001). Knee instability: isolated and complex. //The Western journal of medicine//, //174//(4), 266-72. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1071355&tool=pmcentrez&rendertype=abstract
 * 7) Jacobson, W., & Lewandoski, T. (2009). The Knee Ligament Injury and Rehabilitation. //Spring//, //5//(4).
 * 8) Millett, P. J. (n.d.). ACL Reconstruction Rehabilitation Protocol. //Sports Medicine//.


 * Osteoarthritis of the Knee **

Degenerative changes affecting the articular cartilage of the knee, including progressive destruction of the articular cartilage, formation of osteophytes, or bone spurs, at the joint margins, and narrowing of the joint space over time. OA of the knee is present in one or more of the following compartments: 1. medial tibiofemoral 2. lateral tibiofemoral 3. patellofemoral
 * Definition**

Osteoarthritis may be //idiopathic//, when there is no known etiology, or //secondary// when a known etiology such as trauma exists. __Risk Factors__
 * Mechanism of Injury**
 * Advancing age
 * Obesity
 * Physically demanding occupation
 * Repetitive stress to knee complex
 * Trauma
 * OA in other joints
 * Abnormal knee alignment
 * Genu varum may lead to medial tibiofemoral OA
 * Genu valgum may lead to lateral tibiofemoral OA


 * Signs / Symptoms**
 * Morning stiffness
 * General knee pain: intermittent or constant
 * Swelling / tightness of the posterior knee, may be minimal to severe
 * Deep knee ache
 * Pain with weight bearing activities
 * Pain at rest (during later stages of OA)
 * Decreased ROM in capsular pattern (loss of flexion greater than extension)
 * Muscle weakness
 * Crepitus
 * Bony enlargement/ tenderness


 * Treatment Strategy**

__Modalities-Pain Control__ Modalities may be used for the treatment of osteoarthritis of the knee with the goals of pain management and increased comfort during physical activity. The use of superficial heat will increase local circulation and decrease pain. For these reasons moist hot packs, dry heating pads, paraffin, and hydrotherapy are all treatment options. Another option is cryotherapy, which may be used to control joint swelling and reduce pain. Studies have also shown that TENS and laser treatment are helpful to decrease pain. NSAIDS and cortisone injections can also be used to decrease knee pain.

__Manual Therapy__ A study by Deyle et al found that manual mobilization, manual muscle stretching, and soft tissue mobilization proved beneficial in decreasing knee pain and stiffness in patients with OA. It was found that mobilization for loss of knee extension in grades III and IV decreased symptoms of knee pain and stiffness almost immediately, mobilization for loss of knee flexion in grades III and IV should be utilized carefully at end range to avoid pain, and grade IV patellar glides may used with caution not to compress the patella. Muscle stretching included the quadriceps femoris, hamstrings, gastrocnemius, adductors, illiopsoas, tensor fasciae latae and IT band. Soft tissue mobilization was performed on the suprapatellar and peripatellar regions, the medial and lateral joint capsule and the popliteal fossa.

__Assistive Device__ Assistive devices, such as a cane used on the contralateral side of the affected knee, or use of a walker can help improve mobility by decreasing forces on the knee.

__Orthotics and Bracing__ For patients with medial tibiofemoral OA as a result of genu varum, foot orthoses and valgus knee bracing have been shown to reduce medial knee stress. A laterally wedged insole produces valgus torque on the knee which counteracts medial knee stress and reduces compression on the medial knee compartment.

__Education__ Patients should be educated to wear shoes with well cushioned soles and arch support. They should find alternatives to standing, kneeling, and squatting for long periods of time and take frequent rest periods throughout the day. If obesity is a cause of OA the patient should be educated on the benefits of weight loss in reducing forces on the knees.

__Exercise__ Therapeutic exercise is important to strengthen the quadriceps femoris along with the entire extremity and improve range of motion. Initial exercises should be isometric, such as quad sets, to avoid compressive forces at the knee while still improving muscle tone and preparing the joints for additional activity. The clinician can then incorporate additional exercises such as step ups and partial squats. When prescribing these exercises the clinician should be careful not to apply to many exercises that cause compressive forces at the knee. Exercises should be performed in the pain free range and progressed gradually. Aquatic exercises would be an option to reduce these forces at the knee. Range of motion exercises such as knee flexion and extension stretches and Nu-Step would also prove beneficial. Additionally, aerobic exercise such as walking and balance exercise including tilt and roller boards may prove beneficial.

__Home Exercise Program__ Parts of the therapeutic exercise program can be incorporated into a home exercise program such as knee flexion / extension stretches, quad sets, walking, cycling, or aquatic exercise for the patient to perform on days with no therapy.

__Surgical Intervention__ If the condition is severe surgical intervention may be necessary. Examples of possible interventions include: arthroscopy, debridement, hemiarthroplasty, and total knee replacement.

Deyle, G. D., Allison, S. C., Matekel, R. L., Ryder, M. G., Stang, J. M., Gohdes, D. D., Hutton, J. P., et al. (2005). Research Report Effectiveness for Osteoarthritis of the Knee : A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a. //Physical Therapy//. Dutton, M. (2004). The knee joint complex. //Orthopaedic: Examination, evaluation, & intervention//. (pp. 790-791). New York, NY:McGraw-Hill. Fitzgerald, G. K., & Oatis, C. (2004). Role of physical therapy in management of knee osteoarthritis. //Current opinion in rheumatology//, //16//(2), 143-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14770101 Gould, B. E., Dyer, R. M. (2011). Muskuloskeletal Disorders. //Pathophysiology for the health professions.// (4th ed., pp. 587-588). Saunders. Loudon, J., Swift, M., Bell, S. (2008). Knee. //The clinical orthopedic assessment guide.// (2nd ed., pp. 295-329). Champaign, IL: Human Kinetics. Neumann, D. A. (2010). Lower Extremity. //Kinesiology of the musculoskeletal system: Foundations for rehabilitation.// (2nd ed., pp. 552-554). Mosby, Inc. O'Sullivan, S. B., & Schmitz, T. J. (2007). Arthritis. //Physical rehabilitation// (5th ed., pp. 1057-1081). Philadelphia, PA: F.A. Davis.
 * References**


 * Patellofemoral Pain Syndrome **


 * __ Definition __**
 * The patellofemoral joint is made up of the femur and the patella. The patella is the largest sesamoid bone in the body and is contained within the patellar tendon and covers the anterior portion of the knee.
 * Patellofemoral pain syndrome is broadly defined as pain originating from the front of the knee and the patellofemoral joint or its supporting structures.
 * It has also been called Runner’s Knee, Chondromalacia Patella (can result from this syndrome but they are independent), Retropatellar Pain, and Anterior Knee Pain (1)
 * Can be acute or chronic
 * It can be seen in both athletes and non-athletes and is responsible for 30% of injuries presenting to sports medicine clinics. (2)
 * This syndrome is most commonly seen in women (33% in female athletes with knee injuries and 17% in male athletes) (2)
 * Since this is such a broad definition, it is important to rule out a number of other pathologies including: patellofemoral arthrosis, patellar subluxation/dislocation, prepatellar bursitis, ligamentous tears or sprains, meniscal pathologies, patellar or quadriceps tendinitis, and tumors. (1)


 * __ Mechanism of Injury __**
 * Anatomical Factors
 * General tightness, weakness, or imbalance of the thigh/hip muscles
 * Tight or Weak Quadriceps
 * Tight Hamstrings
 * Posterior force on the knee, increasing patellofemoral pressure
 * Tight IT band
 * Lateral force on the patella and can ER the tibia
 * Weak VMO and tight lateral retinaculum
 * Permits a lateral tracking of the patella
 * Tight gastrocnemius
 * Can cause compensation in the foot and increase the force on the knee
 * Femoral anteversion
 * Tibial torsion
 * Genu Valgum (knock-knees)
 * Genu Recurvatum (hyperextension of the knees)
 * Pes Planus (flat feet)
 * Excessive pronation (eversion, DF, abduction)
 * Causes IR of femur and tibia which changes the mechanics of the patella
 * Pes Cavus (high arches)
 * Excessive supination (inversion, PF, adduction)
 * Less cushion at heel strike
 * Large ‘Q’ Angle
 * Larger in women
 * Malalignment of the patella
 * Generally in the lateral direction. This can lead to overloading and wear on the cartilage of the bony surface which can then cause early signs of arthritis.
 * Trauma to the patella or leg
 * Car accident, sports injury, fall, dislocation
 * Chronic overuse
 * Repeated weight bearing
 * Steps, hills, and uneven surfaces


 * __ Signs and Symptoms __**
 * Pain under or around the patella where it articulates with the femur
 * May be unilateral or bilateral
 * Pain is usually dull and aching but can become sharp or burning
 * Pain with stairs, squatting, kneeling or sitting for an extended period of time may cause pain (“movie goers sign”)
 * Patient may state that it feels like their knee is “giving out”
 * Possible swelling after activity
 * Clicking or cracking sound with knee flexion
 * Symptoms tend to present when a new activity is initiated or the intensity of a current activity is increased

It is initially important for the patient to rest, especially if the cause was overuse. If athletes want to continue to exercise, they may switch to non-weight bearing activities such as swimming. Ice can be applied to reduce pain and any swelling after activity. Compression can be applied alone or with ice. Elevating the leg can help reduce swelling if present. NSAIDs have not been shown to be very effective but some patients may benefit from them. Modalities such as electric stimulation and biofeedback have shown some effectiveness. Phonophoresis, iontophoresis, ultrasound, and cold laser are frequently used to treat patellofemoral pain syndrome but there is not enough evidence to prove that they work. Surgery is a last resort for a patient with patellofemoral pain syndrome. The surgeon may perform a lateral release of the retinaculum or resurface the patella, depending what is causing the problem.
 * __ Modalities/Pain Control __**


 * __ Therapeutic Exercise __**
 * Therapeutic exercise depends on the muscular or biomechanical causes of the syndrome.
 * The goal is to balance muscle strength and the forces on the patella
 * Research has shown that progressive programs of 2-4 sets of ten or more repetitions shows the most benefit (4)
 * Biomechanical studies show that stress on the patellofemoral joint is least during weight bearing and closed chain activities. (2)
 * Quadriceps Strengthening (including the VMO) is important because this muscle group is paramount in patellar movement.
 * Quad Sets
 * SLR
 * SAQ and LAQ
 * Squats
 * Step Ups/Step Downs
 * Monster Walks
 * Gluteal Strengthening
 * Glut Sets
 * Prone SLR
 * Prone opposite arm opposite leg
 * Stretching of the IT band
 * Seated with one leg crossed over, turn the body to the side of the bent leg
 * Foam Roll
 * Standing, cross one leg over the other and allow the supporting hip to “fall” out to the side
 * Stretching of the Hamstrings
 * While supine, keep the unaffected leg straight while bringing the opposite knee toward the body. Slowly straighten the affected bent knee toward the ceiling.
 * While standing, bend at the waist and try to touch the floor with the hands.
 * Stretching of the Gastrocnemius

It is necessary to thoroughly discuss the syndrome with the patient as well as the mechanism of injury. The patient should be instructed on proper body mechanics and appropriate low to no impact exercises to do while the knee is healing. Aggravating factors such as sitting for a long time, stairs, and running should be discussed with the patient so that they can be avoided as much as possible. It is also very important to talk with the patient about their footwear. Shoes that do not fit properly or are worn out will not provide the necessary support and could be contributing to the problem. Usually running shoes are changed every 300 to 500 miles. (3)
 * __ Patient Education __**


 * __ Assistive Devices __**
 * Knee Sleeves and Braces
 * Effectiveness is controversial
 * A brace with C-Shaped padding can be used to help keep the patella from drifting
 * Elastic sleeve may provide some relief but will not prevent patella deviation
 * Arch Supports and Orthotics
 * May improve biomechanics in the LE
 * Can help alleviate symptoms caused by pes planus or pes cavus
 * Crutches can be used if the patient is in extreme pain, but they are generally not needed


 * __ Manual Therapy __**
 * Depends on the mechanism of injury
 * Medial-Lateral Patellar Mobilization (most common)
 * Can be done to test for tightness of the lateral retinaculum as well as help to loosen tightness found (2)
 * Mobilizations can also be done for the hip or knee joint depending on what is causing the problem
 * Taping
 * Can aide in temporarily correcting patellar malalignment
 * Massage
 * Loosen tight musculature
 * Deep friction massage to soft tissue around the lateral patella

The patient should be given some exercises to do at home that will help with stretching and strengthening. Home exercises should be selected based on the mechanism of injury and what structures may be causing the problems. Quadriceps strengthening and stretching of tight musculature are two components that need to be included since these are a major factors in Patellofemoral Pain Syndrome. (5) Exercises should serve their purpose without being too confusing time consuming. Compliance with the HEP may affect patient recovery time and what can be accomplished during physical therapy.
 * __ Home Exercise Program __**


 * __ References __**

1. "Johns Hopkins Sports Medicine Patient Guide to What is Patellofemoral Pain Syndrome?." //The Department of Orthopaedic Surgery//. Johns Hopkins Medicine, n.d. Web. 08 Feb 2012. .

2. LaBella, Cynthia. "Patellofemoral pain syndrome:evaluation and treatment." //Primary Care: Clinics in Office Practice//. 31. (2004): 977-1003. Web. 08 Feb. 2012. .

3. Juhn, Mark. "Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment." //American Family Physician: a peer-reviewed journal of the American Academy of Family Physicians//. 60.7 (1999): 2012-2018. Web. 09 Feb. 2012. <http://www.aafp.org/afp/1999/1101/p2012.html

4. Harvie, Daniel, Timothy O'Leary, and Kumar Saravana. "A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works?." //Journal of Multidisciplinary Healthcare//. (2011): 383-392. Web. 11 Feb. 2012.

5. LaBotz, Michele. "Patellofemoral Syndrome." //Physician and Sportsmedicine//. 32.7 (2004): n. page. Web. 11 Feb. 2012. [Syndrome.PDF]

6."Runner's Knee (Patellofemoral Pain)." //OrthoInfo//. American Academy of Orthopaedic Surgeons, Aug 2007. Web. 08 Feb 2012. .