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The Knee Joint & Injury


The knee is essentially made up of four bones. The femur, which is the large bone in your thigh, attaches by ligaments and a capsule to your tibia. Just below and next to the tibia is the fibula, which runs parallel to the tibia. The patella, or what we call the knee cap, rides on the knee joint as the knee bends.

When the knee moves, it does not just bend and straighten,there is also a slight rotational component in this motion.  The knee muscles which go across the knee joint are the quadriceps and the hamstrings. The quadriceps muscles are on the front of the knee, and the hamstrings are on the back of the knee. The ligaments are equally important in the knee joint because they hold the joint together. Simply put, the bones support the knee and provide the rigid structure of the joint, the muscles move the joint, and the ligaments stabilize the joint.

The knee joint also has a structure made of cartilage, which is called the meniscus or meniscal cartilage. The meniscus is a C-shaped piece of tissue which fits into the joint between the tibia and the femur. It helps to protect the joint and allows the bones to slide freely on each other. There is also a bursa around the knee joint. A bursa is a little fluid sac that helps the muscles and tendons slide freely as the knee moves.

To function well, a person needs to have strong and flexible muscles. In addition, the meniscal cartilage, articular cartilage and ligaments must be smooth and strong. Problems occur when any of these parts of the knee joint are damaged or irritated.

There are two cruciate ligaments located in the center of the knee joint. The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are the major stabilizing ligaments of the knee. The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the tibia from sliding backwards on the femur). The anterior cruciate liagement prevents the femur from sliding backwards on the tibia (or the tibia sliding forwards on the femur). Most importantly, both of these ligaments stabilize the knee in a rotational fashion. Thus, if one of these ligaments is significantly damaged, the knee will be unstable when planting the foot of the injured extremity and pivoting, causing the knee to buckle and give way.

ACL and PCL Injuries

The ACL (anterior cruciate ligament) and the PCL (posterior cruciate ligament) are the two major ligaments in the knee that work together to provide stability in the knee. They cross each other and form an ‘X’ which allows the knee to flex and extend without side to side movement.

The anterior cruciate ligament (ACL) is one of four major ligaments that provide stability to the knee joint. ACL injuries are most common during sports that require a sudden change of direction, sudden, abrupt stops and starts and lots of jumping. The most common treatment for a torn ACL is arthroscopic surgery and ACL reconstruction.
Injuries to these cruciate ligaments of the knee are typically sprains. The ACL is most often stretched, or torn by a sudden twisting motion while the feet remain planted.

ACL injuries, including partial or complete tears, can occur when an athlete changes direction rapidly, twists without moving the feet, slows down abruptly, or misses a landing from a jump. This type of movement may cause the ACL to stretch to the point of tearing. The degree of ACL injury may determine the type of treatment recommended.

PCL injuries are likely with impacts to the front of the knee, or from hyper-extending the knee. The PCL can also be injured by a direct impact from the outside of the knee joint, such as those that occur during soccer or rugby. Both the ACL and PCL can be injured or torn by a sudden twisting of the knee joint.

Cruciate ligament injuries don’t always cause pain, but typically a loud popping sound can be heard at the time of the injury.

ACL and PCL Injury Treatment

Incomplete ACL and PCL tears are treated conservatively to allow the body to heal on its own.

Rest, ice, compression and elevation are the immediate treatment.

Anti-inflammatory medications and can help reduce pain.

Physical therapy is often recommended to regain and build muscle strength over time.

For a complete tear of the ACL Arthroscopic surgery and ACL Reconstruction is usually performed.

Medial Collateral Ligament Injuries

The medial collateral ligament (MCL) is more easily injured than the lateral collateral ligament (LCL). It is most often caused by a blow to the outer side of the knee (such as occur in contact sports) that stretches and tears the ligament on the inner side of the knee.
The classic sign of this injury is hearing a “pop” and feeling the knee buckle sideways. Pain and swelling are immediate. To diagnose a collateral ligament injury, a medical professional will perform several manual tests (applying pressure on the side of the knee to determine the degree of pain and looseness of the joint) and possibly order an MRI to confirm the diagnosis.

Treatment
Minor sprains of the collateral ligaments will heal with rest and gradual return to activity. R.I.C.E. – rest, ice, compression and elevation help reduce pain and swelling and a knee brace may be used to protect and stabilize the knee. A sprain may take 2 to 4 weeks to heal. A severely sprained or torn collateral ligament may occur along with a torn anterior cruciate ligament, which usually requires repair with Arthroscopic surgery.

Meniscus Tears

A meniscus tear occurs when these pieces of cartilage tear and are injured usually during movements that forcefully rotate the knee while bearing weight. A partial or total tear of a meniscus sometimes occurs if an athlete quickly twists or rotates the upper leg while the foot is firmly planted. This often occurs in field sports such as soccer and rugby.

Symptoms of a Meniscus Tear
An injured or torn meniscus causes mild to severe pain (particularly when the knee is straightened) depending upon the extent of the tear. Severe pain is common when a torn meniscus fragment catches between the femur and tibia. Swelling is common at the time of injury, but can develop hours later as the joint tissues inflame. Frequently, an injury to the meniscus causes an audible click or pop, or the knee may lock, or feel weak. If the meniscus injury is small, these symptoms may resolve over time without treatment, but some meniscus injuries may benefit from a surgical repair.

Diagnosing a Meniscus Tear
To diagnose a meniscus tear or other meniscus injury, a physician takes a complete history and performs a physical exam. It’s often possibly to determine the extent of the injury by manipulating the knee in various ways. Pain, pops, or clicks during this test may suggest a meniscus tear. An MRI may also be done to see the extent of the tear.

Treating a Meniscus Tear
Treatment varies depending upon the extent and location of the meniscus tear. If the tear is minor and the pain and other symptoms resolve quickly, muscle strengthening exercises may be all that’s needed to recover fully. In this case, a patient is usually referred to physical therapy.

Surgical Repair for a Meniscus Tear
A large meniscus tear that causes symptoms or mechanical problems with the function of the knee joint may require arthroscopic surgery for repair. In this procedure, a small camera is inserted into the joint through a small incision, while surgical instruments are inserted into the joint through a second, small incision. With the camera, the surgeon can see the entire joint and remove and repair the torn pieces of meniscus. The goal is to save as much of the original, normal meniscus cartilage as possible.

During meniscus repair surgery the torn section of meniscus is either removed (a partial meniscectomy) or the torn edges are joined back together with suture or tacks.

Knee pain occurs for a variety of reasons, and the best treatment for an injury will often depend on the type of injury, the severity and the individual. Your physician will prescribe specific recommendations for your situation, so always have you knee pain evaluated if it doesn’t resolve within a few days. Delaying treatment can often result in a longer healing process or even a chronic problem, so seek treatment as soon as possible.

The most conservative treatment recommended for all kinds of soft tissue injuries is the R.I.C.E. method (rest, ice, compression, and elevation). Using this method can reduce swelling and pain during acute injuries.

Treatments for Specific Knee Injuries

Chondromalacia

Many doctors recommend that patients with chondromalacia perform low-impact exercises that strengthen muscles, without injuring joints (swimming, cycling, walking). At times a physician may perform arthroscopic surgery to smooth the surface of the articular cartilage and clean and smooth out cartilage fragments that rub on the surface of the femur.

Meniscus Injury

If the tear in the meniscus is minor and the pain and other symptoms go away, the doctor may recommend a visit to a Physical Therapist for a muscle-strengthening program. If the tear to a meniscus is more extensive, arthroscopic surgery may be performed. The meniscus can be repaired in some cases. If the tear is more extensive, a small piece may be removed to even the surface. In some cases, the doctor removes the entire meniscus. However, degenerative changes, such as osteoarthritis, are more likely to develop in the knee if the meniscus is removed. Researchers are developing procedures that may replace a meniscus in the near future.

Cruciate Ligament Injuries – ACL – PCL

For an incomplete tear to a cruciate ligament, a doctor may recommend a visit to a Physical Therapist to strengthen surrounding muscles. A knee brace may also be warranted. If the ACL is completely torn, surgery may be indicated. The torn ends of the ligament may be reattached or completely reconstructed with a graft.

Collateral Ligament Injuries – MCL – LCL

Most sprains of the collateral ligaments will heal if the patient follows a prescribed exercise program, including R.I.C.E. and bracing.

Osteoarthritis

Most often osteoarthritis of the knee is treated with an over-the-counter pain medication or an anti-inflammatory, such as ibuprofen (Motrin, Nuprin, Advil). Exercises may be recommended to strengthen the knee, as well as encourage weight loss.

Tendinitis

Tendinitis is typically treated with R.I.C.E. and ibuprofen to relieve pain and decrease inflammation and swelling. If the tendon is completely ruptured, surgery is necessary to reattach the tendon.

Iliotibial Band Syndrome

Usually, iliotibial band syndrome eases with reduced activity. Strengthening and stretching exercises can also alleviate the IT band pain.
Knee pain occurs for a variety of reasons, but the following tips generally help prevent or reduce pain. Check with you physician for specific recommendations for your situation:
Increase Training Gradually
Doing too much too soon, is one of the major causes of sports injury. Knee pain is particularly common in runners who increase training mileage quickly. The best way to avoid this is to follow the 10 percent rule. This simply means that you should limit your training increases to a maximum of 10 percent each week. That cane be time, load, mileage or any other parameter.

Strengthening Exercises

Muscle weakness or imbalance is one of the first things physical therapists check for when evaluating knee pain. Such an imbalance can be the source of pain. In addition to specific muscle strengthening of the muscles that support the knee (quads, hamstrings, calf), building core strength improves overall stability which may reduce the risk of injury.The balance of quadriceps to hamstring strength is not 1:1; but closer to 3:2. In general healthy hamstrings can lift 60 – 80% of what healthy quads can do.


Flexibility

Athletes who are less flexible than average may benefit from flexibility exercises. This is more critical in athletes involved in stop and go sports or those that require quick cuts and turns. Improving flexibility in the quadriceps, and the hamstrings are helpful.

Skills Training
Coordination drills and proprioceptive training have also been found to be helpful in protecting the knee from injuries.

Appropriate Footwear
Finally, using the correct footwear is helpful to control excess ankle motion (pronation and supination). Prescribed orthotics may also help with this.  Medsport stocks a wide range of protective knee braces. From simple soft support to custom made rigid knee braces, we have them all.

Altered Knee Sleeve (Open Patella) MEDAC 111
Features
3.2mm Breath-O-Prene™ rubber sleeve.
Extra pad for added support and protection.
Unique “Bent Knee ” design..
30cm in length.
Comfortable to wear.
Does not impede circulation.
Indications
•    Chondromalacia patellae.
•    Post Arthroscopy.
•    Other syndromes of Anterior knee pain. (AKP).
•    Patella tracking disorders and instability.
•    Chondral and osteochondral disorders.
•    Traction Apophysitis.
•    Tendonitis, bursitis and synovitis

Stabilizing Knee Brace (Jumpers Knee Brace)     MEDAC 200P
Features
“Donut Patella Disc ” that can be cut to provide lateral, medial, superior or inferior patellar tracking and support.
Medial and lateral stays for stability, which prevents bunching.
Two adjustable velcro pressure straps for individual fit.
Provides comfortable pressure.
32cm in length.

Indications
•    Patella tracking disorders
•    PF (patella-femoral)misalignment
•    Lateral PF compression syndrome.
•    Patella subluxsation/dislocation.
•    Patella instabilities.
•    Chondromalacia Patella.
•    Osteochondritis dissecans.
•    Quads expansion/insertion.


Knee Hinged Stabilizing Brace MEDAC 310
Features
Made from rugged 5mm Breath-O-Prene™ rubber sleeve.
“Donut Patella Disc” that can be cut to provide Lateral, medial, superior or inferior patella tracking and support.
Features a unique “Bent Knee” design.
Covered polycentric-toothed metal hinges.
The hinge features a stop lock at 180∞ to help prevent hyperextension.
4 Velcro straps for individual fit and comfort.
Lightweight.

Indications
•    Moderate to severe (grade II – III) ligament tears.
•    Medial and lateral ligamentous laxity.
•    Torn meniscus.
•    Knee reconstruction. (Cruciate ligament)

Trainer OTS
This cost-effective, single-upright knee brace is the perfect option to treat moderate MCL injuries, or mild combined ligament instabilities. With a diagonal DFS strap that tightens when the knee is extended, Trainer resists valgus forces and minimizes axial rotation. Its carbon steel range-of-motion hinge and injection-molded carbon shells are extremely durable, and an Adjustable Tibial Strap provides tibial capture and improved suspension. The Trainer knee brace is an excellent option for use in activities where a medial hinge may impede performance, or a padded shell covering is required.
Ossur Trainer OTS offers the following benefits:
•    Extremely durable, injection-molded Triax® shells combine strength and flexibility
•    Dynamic Force Strap® eliminates the need for a medial upright
•    Dynamic Force Strap® tightens with extension to resist valgus forces and minimize axial rotation
•    Tempered carbon steel ROM hinge with flex/ext stops
•    Adjustable Tibial Strap (ATS) for improved suspension and fit
•    Coolflex® sleeve provides breathable compression and comfort
Indications for Use
•    Mild to moderate ligament laxity and acute management of Grade I and Grade II MCL sprains
•    Recommended for low to medium contact/impact

Innovator® Post – Operative Knee Immobilizer
Ossur Innovator® Post – Operative Knee Immobilizer offers the following benefits:
•    Simply press, rotate and release flexion/extension settings
•    Low-profile hinge, with no exposed metal
•    Breakaway struts for easy, tool-free length adjustment
•    Locks quickly at 0˚, 10˚, 20˚, 30˚, 45˚, 60˚, 75˚ & 90˚
•    Available in 3 models, 3 lengths, and cool or full foam
Indications for Use
•    Post-op/post-injury ROM control or immobilization

CTi Custom
CTi ligament knee braces provide the ultimate combination of stabilization and protection of the knee joint. This truly custom-made brace uses Accutrac™ hinges with extension stops to glide with the knee and breathable liners coated with bio-inert Ossur Sensil® Silicone to reduce migration and skin irritation. Flexible cuffs and buckles employ SensEdge overmolding to eliminate pressure points.
CTi custom knee braces are available in 3 models — Vapor, Standard and Pro Sport — and can be further customized with a variety of options, colors, designs and/or accessories.
Ossur CTi Custom offers the following benefits:
•    Total Support System™ provides support for ACL, MCL, LCL, PCL, rotary and combined instabilities
•    Hand-laminated, carbon composite frame construction supplies true rigid support
•    Frame shape is low-profile and contours to the leg, making it suitable for a variety of physical activities
•    Anatomically-correct Accutrac™ hinges with extension stops track the natural movement of the knee
•    Proprietary Sensil® padding is comfortable and reduces migration
•    Skin-friendly SensEdge overmolding on buckles and lower cuff improves comfort and eliminates pressure points
•    Flexible lower medial cuff provides increased protection against rotational forces and is breathable for added comfort
•    Constructed from non-corrosive materials, enabling use for water sports
Indications for Use:
•    ACL, MCL, LCL, PCL, rotary and combined instabilities
•    Vapor model for low to medium impact levels
•    Standard model for medium to high impact levels
•    Pro Sport model for highest impact levels