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Common Injuries to the Knee

ANTERIOR CRUCIATE
INJURIES

ACL injuries also commonly occur with hyperextension of


the knee, deceleration and valgus stress.

INDICATIONS FOR SURGERY:


Complete tear; associated meniscal pathology
Well motivated person who will do the rehab program; physiologically young
Unwilling to change lifestyle; job and sports require twisting, cutting
Minimal evidence of DJD

WHEN TO DO SURGERY : Wait at least 3-4 weeks after injury


Decrease the swelling
Decrease Quad inhibition
Decrease hamstring overfiring
Decrease scarring
Increase ROM; decrease stiffness

SURGERIES PERFORMED
1. Bone-tendon-bone with middle 1/3 of patellar tendon
2. Semitendinosis and gracilis: fold them in so have a 4 tendon bundle
3. Allograph: bone-tendon-bone patellar tendon from cadaver
Key in surgery is correct isometric placement of the graph.

80-90% of patients have a good result with surgery going back to


previous levels of activity. Some complications that may arise and give
a less than favorable result are:

Patellar tendonitis

Patellofemoral pain/chondromalacia

Limited ROM at extremes; loss of even a few degrees of terminal


extension is a problem

Stretching out of graph

COLLATERAL LIGAMENT
INJURIES

MCL tears: most common mechanism is a


blow to the outside of the knee followed by
planting of the foot and twisting of the
knee.

There is a high risk of injury to the medial meniscus with MCL


tears.

KNEE REHAB

PATELLOFEMORAL PAIN
SYNDROME

The patella must have balanced


muscular forces around it to ride
properly in the femoral groove.

The VMO should fire before the VL.

The VMO/VL ratio should be 1:1

Tight ITB, hamstrings and calf can


disrupt muscular balance.

OTHER FACTORS
CAUSING PFPS:
1. Overpronation
2. Anteversion
3. Weak Hip ER & ABD
4. Tibial Varum
5. Increased Q angle

ILIOTIBIAL BAND
SYNDROME

Complains of pain on knee flexion


May complain of snapping
Pain gets worse on ROM from full
flexion to full extension.

Often result of: genu varum; over pronation; femoral


anteversion; spinal problems.

SHIN SPLINTS

Most common area affected is


antereomedial shin.
Starts out as muscle/tendon
injury
Can progress to periosteal
injury
Can end up as a stress fracture

ANKLE SPRAINS

Ottawa ankle rules

JOBST
INTERMITTENT
COMPRESSION
DEVICE

ROM exercises
Strengthening
Proprioception
Agility
Running/jumping

Syndesmotic
Injury

ACHILLES TENDONITIS

ACHILLES TENDON
RUPTURE

LONG REHAB: Average 6-9 months

PLANTAR FASCITIS

Over pronation
Pes cavus foot
Tight calf muscles
Tibial varum
Anteversion
Weak ER of hip

Pharmacology

DRUGS USED FOR


MUSCULOSKELETAL
PATHOLOGY
Analgesics
Drugs that directly affect the healing
process
Drugs that do both

NON STEROIDAL
ANTIINFLAMMATORY
DRUGS (NSAIDS)
Treatment of inflammatory arthritic
diseases
Treatment of the itises

NSAIDS: SIDE EFFECTS


Gastrointestinal Irritation and Ulceration
Decreased Blood Clotting
Kidney Trouble
Other

Common NSAIDs
(OTC)
Bayer

(aspirin)

Tylenol

(acetaminophen)

Aleve

or Naprosyn
(naproxen)
Advil

(ibuprofen)

Common NSAIDS (Rx)

Celebrex (celecoxib)
Voltaren (diclofenac)
Lodine (etodolac)
Nalfon (fenoprofen)
Indocin (indomethacin)
Orudis, Oruvail
(ketoprofen)

Toradol (ketoralac)
Daypro (oxaprozin)
Relafen
(nabumetone)
Clinoril (sulindac)
Tolectin (tolmetin)
Vioxx (rofecoxib

Dosing

Depends
Avoid
Trial

negative drug reactions

and Error

Every
Must

on Goal

patient has a different response

keep blood levels constant for


antiinflammatory response

CORTICOSTEROIDS

Synthetic derivative of cortisol


Mobilizes energy stores
Circulatory changes
Changes in liver and kidney function
Subdue inflammation and immune
response

ACTION
Stabilizes cell membranes which
decreases release of inflammatory
mediators
Inhibits migration of inflammatory cells that
are attracted to the injured area.

INDICATIONS
INFLAMMATORY DISEASES: RA, Lupus,
Ankylosing Spondylitis
NO! Acute musculoskeletal injuries
???? Chronic musculoskeletal injuries

ADMINISTRATION
ORAL: Used in tx of diseases which affect
multiple joints; Dose pack for chronic
musculoskeletal problems
LOCAL INJECTION: Used for tendinitis,
bursitis, fasciitis
TOPICAL USE: Dermatologic effects only

SIDE EFFECTS: ORAL


Osteoporosis: pathologic fractures
Avascular Necrosis
Disturb fat and carbo metabolism: increase risk
of diabetes; increased fat distribution in trunk
and face
Hypertension due to NA and H20 retention
Steroid myopathy
Steroid psychosis

SIDE EFFECTS: LOCAL


INJECTION
No systemic effects
False sense of recovery
Local tendon/muscle atrophy: rupture
Skin changes

ANALGESICS
Allow early initiation of rehab
Improve quality of life for persons with
chronic pain
Allow patients to tolerate surgery

NON-NARCOTIC
Acetaminophen: Has central nervous
system effect through cental inhibition of
prostaglandins
Aspirin: Has peripheral effect through
peripheral inhibition of prostaglandins
NSAIDS: Have analgesic effect on
nervous system as well as decreased
inflammation

NARCOTIC
Common property: bind to opioid
receptors in brain
Results in significant elevation of pain
threshold; can be addictive

INDICATIONS
Mild/moderate musculoskeletal pain: nonnarcotics; acetaminophen first choice;
NSAIDS may be more logical if
inflammation is causing pain, ie acute
injuries and inflammatory arthritis
Osteoarthritis: acetaminophen
Chronic musculoskeletal pain:
acetaminophen

Continued
Acute postoperative pain: narcotics; can
be given IV or IM
Chronic, Severe pain: narcotics
See Table 3 for commonly used analgesic
drugs

SIDE EFFECTS
ACETAMINOPHEN: generally safe; liver
toxicity
ASPIRIN/NSAIDS: as previously covered
NARCOTICS: respiratory suppression;
sedation, nausea and vomiting; urinary
retention; euphoria/dependence

ANTIBIOTICS
Used to treat or prevent bacterial
infections which can occur postoperatively
or post compound fracture
Classified based on chemical structure
and effectiveness against certain bacteria
(Table 4)

INDICATIONS FOR USE


Use drug best suited to fully eradicate the
bacteria causing the infection
Infection must be cultured to determine what
kind it is
Sometimes used prophylactically at time of
surgery; mostly with patients with compromised
immune system
Always used with patients with open fractures

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