give some quiz questions(multiple choise) based on this content:Ligament Injuries
Grade-I
● Microscoping tearing of the
ligament
● No joint laxity
Grade-II
● Tearing of some ligament
fibers
● Moderate laxity
Grade-III
● Complete rupture
● Profound joint instability
(15) ACL and PCL - YouTube
Ligament Injuries:
● Anterior cruciate ligament:
○ Function: Prevents anterior translation of tibia on femur -
open chain.
Post of femur on tibia-closed chain
○ Mechanism of Injury:
■ Non-contact mechanism:
● rotational mechanism in which tibia is externally rotated
on a planted foot
● Forced hyperextension of the knee
■ Contact mechanism:
force applied to lateral side of the knee(valgus force)
this force injures : ACL. MCL. Medial meniscus ---- terrible triad
Terrible Triad
▪ ACL
▪ MCL
▪ Medial Meniscus
ACL Tear
ACL Special Tests
● Indicates ACL tear
○ Anterior Drawer Test
■ Pt is supine with knee flexed to 90˚, therapist applies anterior
translation of the tibia
■ (+) test: excessive anterior translation of the tibia on the femur
Video
○ Lachman’s Test
■ Pt has their knee flexed to 30˚, while stabilizing the femur the
therapist applies an anterior translation of the tibia
■ May be a more sensitive test than the Anterior Drawer Test
■ (+) test: excessive anterior translation of the tibia on the femur
Video
The Lateral Pivot-Shift Test for Anterior Cruciate Ligament
Rupture
Valgus force while IR in flexion and ext. +:
Ligament Injuries:
● Posterior cruciate ligament
○ Function: prevent post translation of tiba on femur(open
chain), ant translation of femur on tibia- closed chain
Mechanism of Injury
■ Forceful trauma to the anterior tibia while the knee is flexed
● Dashboard injury
● Falling onto a flexed knee with PF foot
● Sudden, violent knee hyperflexion
PCL Tear
PCL Special Tests
● Indicates PCL tear
○ Posterior Drawer Test
■ Pt is supine with knee flexed to 90˚, therapist applies
posterior translation of the tibia
■ (+) test: excessive posterior translation of the tibia on the
femur
Video
○ Posterior Sag Sign
■ Pt is supine with their knee flexed to 90˚, then the therapist
does a visual inspection of the resting position of the tibia
relative to the femur.
■ (+) test: posterior displacement of the tibia on the femur,
compared to the contralateral side
ACL and PCL Forces
⚫What happens to the tibia when you activate the hamstrings?
IR of tibia rotate the tibia
⚫What happens when you activate the quadriceps?
ER tibia
What does that mean for
precautions after surgery? Femur
Mechanism of Injury
⚪Medial collateral
ligament (MCL):
⚪ Resists valgus stress-
Force on lateral side
⚪ Greatest tension 0-30˚
⚪ Attaches to medial
meniscus
⚪ Rarely treated
surgically
⚪Lateral collateral
ligament (LCL):
⚪ Resists varus stress--
Force on medical side
⚪ Greatest tension 0-30˚
⚪ Less commonly injured
⚪ Typically injured with
other ligamentous
structures
Ligament Injuries:
Valgus Test Varus Test
⚫Medial knee instability
⚪Therapist applies a valgus
force to the knee in full
extension and with 30˚ of
flexion
⚪(+) Test: excessive laxity
at 0˚= major ligamentous
disruption, laxity at 30˚=
MCL tear
⚫Lateral knee
instability
⚪Therapist applies a varus
force to the knee in full
extension and with 30˚ of
flexion
⚪(+) Test: excessive laxity
at 0˚= major ligamentous
disruption, laxity at 30˚=
LCL tear
MCL and LCL Special Tests
Ligament Injuries:Nonoperative Management
▪ Common Structural and Functional
Impairments, Activity Limitations, and
Participation Restrictions
▪ Swelling occurs often after several hours
▪ Pain with stressing the involved ligaments
▪ ROM limitations, knee guarding at 25˚ of flexion-open
pack(minimun stress)
▪ Quad muscle inhibition
▪ Difficulty or inability to bear weight
▪ Knee instability (worse with larger tears)
Ligament Injuries: Nonoperative Management
● Mgmt: Maximum Protection Phase
○ Rest, Ice, WBAT, Avoid pivoting, Quad sets, ROM
● Mgmt: Moderate Protection -> Return to Activity
○ Improve joint mobility and protection
■ Joint mobility through gentle movement
■ Protective bracing
○ Improve muscle performance and function
■ Strength and endurance - OKC and CKC
■ Neuromuscular control - low/single plane -> high/multi plane
intensity
○ Improve cardiopulmonary conditioning
○ Progress to functional training
Anterior Cruciate Ligament Reconstruction
▪ Indications for Surgery:
▪ Disabling Instability, episodes of knee giving way
▪ Multi-ligamentous injury (MCL)
▪ Participates in high-level activities
▪ Procedures
▪ Most common procedure is an arthroscopically assisted or
endoscopic procedure using an Autograft or Allograft
▪ Bone-patellar tendon-bone graft (BPTB)
▪ Semitendinosus-gracilis graft (STG)
ACL Reconstruction
Anterior Cruciate Ligament
Reconstruction
● Postoperative Management
○ Exercise Precautions after ACL Reconstruction
(Box 21.10)
■ Limit HS strengthening with HS graft for 6 weeks
■ Progress knee extension strength cautiously with patellar graft
■ Protected WB for 2 weeks usually with crutches
■ contraction of quads in these position causes greatest ant tibial
translation and stress to the graft during healing:
Avoid resistance at distal tibia during quads strengthening(open
chain)
Avoid open chain knee extension (short- arc quad) 0-45˚ for at least 6-12
weeks
Avoid closed chain strengthening of the quads: knee flexion 60-90˚ initially
– good squat mechanics
Anterior Cruciate Ligament
Reconstruction
● Maximum protection phase
○ Goal: Achieve full extension 1 wk post-op;
○ 90˚ flexion 2 wks. post-op
○ Muscle setting of LE
○ 4 way hip SLRs (resistance prox to knee if used)
SLR in supine, sidelying bottom leg, upper leg, prone
○ ROM in protected range as tolerated, patellar mobs
○ Weight shifting to equal stance single leg stance
○ Mini squats 0-30 deg, stepping, marching; Avoid deep squats
● Moderate protection / controlled motion phase
● Minimum protection / return to function phase
PCL Reconstruction
● Indications for surgery:
■ Complete tear/avulsion of PCL AND instability with chronic pain
■ Failed nonoperative treatment
■ Isolated, symptomatic, grade 3 PCL tear with 8-10 mm posterior tibial
displacement
● Post-op surgical precautions:
■ Immobilized in full ext 4-8 weeks to prevent posterior displacement of tibia
(d/t gravity)
■ WBing may be limited for up to 5 wks, but overall progressed more gradually
● General Precautions:
■ Avoid exercises that put increased posterior shear/forces through
the knee
■ Limit end range knee flexion
Meniscus
Function:
Joint stability
Shock absorption
Increased tibiofemoral contact area
Assists and controls rolling and gliding
Vascularity of the medial and lateral
menisci:
The peripheral zone (outer one-third) is
highly vascular;
the central one-third is relatively
avascular;
the inner one-third is avascular.
Meniscal Tears:
▪ Mechanisms of Injury
▪ Medial Meniscus-connect to MCL
▪ Medial meniscus is injured more frequently than the lateral
meniscus
▪ Foot fixed on ground and femur is internally rotated(closed
chain with WB) (pivoting, squatting and pivoting, getting out
of a car) squat up
▪ ACL injury often accompanies a medial meniscus tear
▪ Lateral Meniscus
▪ Lateral rotation of the femur on a fixed tibia may tear the
lateral meniscus( closed chain with WB)
▪ Simple squatting or trauma . Squat down
Meniscus Special Tests
○ McMurray’s Test
■ Pt is supine. While palpating the joint line, the therapist flexes and extends the knee while internally and externally rotates the foot. (+) test: “pop” or “click” or pt. reports of pain
Video
○ Thessaly Test thsai. Se li
■ Pt standing on test leg flexed to 20˚. Pt can hold onto hands of examiner for balance. Pt rotates knee medially and laterally 3 times each direction.
■ (+) test: joint line discomfort or locking/catching occurs
Video
○ Apley Grind Test. A p li. G rand
■ Pt is prone with the knee flexed to 90˚. The therapist applies a
downward/compressive force at the foot and internally and externally rotates the tibia.
■ (+) test: “pop” or “click” or pt. reports pain
Video
Meniscal Tears:
Nonoperative Management
● Improve motion, strength, endurance, function as needed
● Indications for surgery. Repair vs meniscectomy
○ Repair
■ Lesion in the vascular outer third
■ Tear extending into the central, relatively avascular third of meniscus of young (<40) or physical active older adult (>50)
○ Meniscectomy
■ Displaced tear of meniscus with pain and locking in
older, inactive individual
■ Tear extending into central, avascular third determined not to be repairable
■ Tear localized to avascular inner third
Meniscus Repair Post Op Precautions
● Precautions:
• Meniscus tear effects: End range flexion and extension(home screw
mechanism)
Immobilized in extension initially
range limiting brace for 6 weeks until adequate quad control
■ ROM limited typically to flexion: 0-90˚ for 2 wks
allow: weekly 10˚Increase in knee flexion until achieve full flex
■ May be partial WB for up to 4 wks- MD prescribed
■ If a patient experiences clicking with exercises or WB, report to surgeon
(avoid those activities)
■ no use of leg press machine until about 8 wks (limit motion: 0-60˚)
■ WB ex’s (lunges/ squats) should not be performed knee flex: beyond 45˚
for 4 weeks or beyond 60-70˚ for 8 weeks
■ No hamstring curls until about 8 weeks
■ Avoid deep/prolonged squatting, twisting for at least 4-6 months
■ A central zone will be progressed slower than peripheral zone
(less vascular) (vascular)
Meniscectomy
⚫ Restore ROM and develop strength
⚫ Exercises begin right away after surgery
⚫ Progress as tolerated for patient