knee injuries

Knee

ACL injury, Cartilage (meniscus) damage, Ligament Sprain, Patellofemoral Joint Dysfunction,Patella pain syndrome, Osgood  s Schlatters Disease, Jumper  s knee, iliotibial band syndrome, Medial Ligament injury, Medial Meniscal Injury, O  Donoghues triad, Housemaids Knee, Articular Cartilage Injury, Quadriceps |Tendon, Baker  s Cyst, post Knee Surgery, Osteoarthritis, Posterior Cruciate Injury, Coronary Ligament Injury

ACL injury:
Whether you are a fan of soccer, rugby, basketball, or any other recreational activity you have at one time or another heard of an ACL injury. Maybe your favourite athlete was sidelined for months with a tear to their ACL, or possibly it was you that had to watch from the sidelines for a few months. The Anterior Cruciate Ligament (ACL) is in fact a common major injury to the knee. Luckily for us with appropriate rehabilitation and or surgery an ACL injury need not be career threatening

The ACL is one of the most important ligaments of the knee, giving it stability. The ACL achieves this role by preventing excessive twisting, straightening of the knee (hyperextension) and forward movement of the tibia on the femur. When these movements are excessive and beyond what the ACL can withstand, tearing to the ACL occurs. This condition is known as an ACL tear and may range from a small partial tear resulting in minimal pain, to a complete rupture of the ACL resulting in significant pain and disability, and, potentially requiring surgery. An ACL tear can be graded as follows:

• Grade 1 tear: a small number of fibres are torn resulting in some pain but allowing full function

• Grade 2 tear: a significant number of fibres are torn with moderate loss of function.

• Grade 3 tear: all fibres are ruptured resulting in knee instability and major loss of function. Often other structures are also injured such as the menisci or collateral ligaments. Surgery is often required.

Causes of an ACL tear
ACL tears typically occur during activities placing excessive strain on the ACL. This generally occurs suddenly due to a specific incident, however, occasionally may occur due to repetitive strain. There are three main movements that place stress on the ACL, these include:

• twisting of the knee
• hyperextension of the knee
• forward movement of the tibia on the femur

When any of these movements (or combinations of these movements) are excessive and beyond what the ACL can withstand, tearing of the ACL may occur. Of these movements, twisting is the most common cause of an ACL tear.

ACL tears are frequently seen in contact sports or sports requiring rapid changes in direction. These may include: football, netball, basketball and downhill skiing. The usual mechanism of injury for an ACL tear is a twisting movement when weight-bearing (especially when landing from a jump) or due to a collision forcing the knee to bend in the wrong direction (such as another player falling across the outside of the knee).

Signs and Symptoms of an ACL tear
Patients with an ACL tear may notice an audible snap or tearing sound at the time of injury. In minor cases of an ACL tear, patients may be able to continue activity only to experience an increase in pain, swelling and stiffness in the knee after activity with rest (particularly first thing in the morning). Often the pain associated with this condition is felt deep within the knee and is poorly localized.
In cases of a complete rupture of the ACL, pain is usually severe at the time of injury, however, may sometimes quickly subside. Patients may also experience a feeling of the knee going out and then going back in as well as a rapid onset of considerable swelling (within the first few hours following injury). Patients with a complete rupture of the ACL generally can not continue activity as the knee may feel unstable, or may collapse during certain movements (particularly twisting). Occasionally, the patient may be unable to weight bear at the time of injury due to pain and may develop bruising and knee stiffness over the coming days (especially an inability to fully straighten the knee). Patients with a complete rupture of the ACL may also experience recurrent episodes of the knee giving way following the injury.

Diagnosis of an ACL tear
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose an ACL tear. Investigations such as an X-ray, MRI scan or CT scan may be required to confirm diagnosis and determine the extent of damage or involvement of other structures within the knee.

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Help! I think I  ve torn my ACL!
Patients with an ACL tear should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities (this may include the use of crutches), regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process in patients with an ACL tear by reducing the pain and swelling

At Wicklow Physiotherapy Clinic we have direct access to a number of reputed surgeons specialised in treating ruptured ACLs. If we suspect a tear we will refer you to a surgeon. The outcome of the MRI and your level of activity will determine whether you have surgery.

Some people are able to manage well after injury without needing surgery. Physiotherapy, by increasing proprioception and building up your quadriceps and hamstring (thigh and leg) muscles, can help to make the knee feel more stable.

If patients opt to be treated conservatively physiotherapy is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of future recurrence. Treatment may comprise:
• soft tissue massage
• joint mobilization
• taping
• bracing
• ice or heat treatment
• electrotherapy (e.g. ultrasound)
• anti-inflammatory advice
• exercises to improve flexibility, strength and balance
• hydrotherapy
• education
• activity modification advice
• crutches prescription
• biomechanical correction
• a gradual return to activity program

Unfortunately, although this stability may be sufficient to cope with careful everyday activities, such a knee rarely stands up to competitive sport. Without surgery the knee may remain unstable on sudden changes of direction, with a feeling of insecurity and slipping of the knee. That is when surgery is recommended. In the past artificial grafts to replace the ACL have not proved to be successful over the years, so now the body  s own tissues either the hamstring muscle or the patella tendon are used.

Physiotherapy and ACL Surgery:
Surgical reconstruction of the ACL is usually required in patients who have both complete and partial rupturse of the ACL and are seeking the highest level of function. The procedure is known as an ACL reconstruction and generally comprises of arthroscopic surgery to reconstruct or repair the ACL with other tissue from your body. The hamstring tendon or patella tendon are most frequently used in this process.

Following ACL reconstruction surgery a lengthy period of rehabilitation of 6  €“ 12 months or longer is required to gain an optimal outcome and return the patient to full activity or sport.

We are skilled in rehabilitating patients post ACL reconstruction surgery and expect you to make a rapid recovery after your operation and to experience no serious problems.

The post-surgery recuperative period and rehabilitation programme can be even more important than the surgery itself. Activities should be arranged to promote healing, upgrade flexibility in the knee, and strengthen surrounding muscles. A range of motion programme following surgery aids in the healing process, promotes better nutrient flow to the cartilage caps at the ends of the femur and tibia, and prevents excess tightness from developing in the knee. Although maintaining adequate range of motion is the primary focus immediately after surgery, strengthening is also initiated without great delay.

The amount of activity a patient is allowed to do and how much they can progress week by week is very individual and depends on the type of surgery performed. We at Wicklow Physiotherapy Clinic see many patients after their ACL surgeries, and have developed an expertise in treating these injuries. We will work closely with your surgeon and help you achieve the best possible outcome from your surgery.

Patellofemoral Pain Syndrome/ Anterior Knee Pain/ Movie-goers Knee/ Chondromalacia Patella
Patellofemoral pain, also referred to as anterior knee pain, is a common musculoskeletal condition in the general and sporting communities. It affects up to 25% of the population, 36% of adolescents and is more prevalent in females.

Patellofemoral Pain Syndrome is characterised by anterior or peri-patellar knee pain in the absence of other knee pathology. This pain can be diffuse or sharp and is usually associated with at least two of the following activities:
• Squatting
• Ascending or descending stairs
• Kneeling
• Sitting for long periods
• Walking/Running

It may be associated with crepitus on knee movements, occasional swelling particularly after exercise, and pseudo locking or giving way.

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Role of physiotherapy
Physiotherapy is the mainstay of conservative treatment for this condition. The most effective treatment for patellofemoral pain is an exercise and taping programme, designed and monitored by a physiotherapist according to the patient’s individual needs. This recognised anterior knee pain management program was first introduced by Jenny McConnell, an Australian physiotherapist (McConnell, 1986). The approach uses a specialised, functional exercise program to improve the muscle control around the knee and taping to reposition the patella.

Benefits of physiotherapy
When treatment is given by a physiotherapist trained in patellofemoral pain, the results are excellent. In the majority of cases, only five to six treatments are required to enable the patient to return to normal and sporting activities. Physiotherapy management, based on that described by McConnell, has been shown to be effective in two large case-series (McConnell 1986, Gerrard 1989) with up to 91% of anterior knee pain patients having an excellent or good response.

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