Knee Injuries
Knee injuries are common. Many will heal well with rest, ice, and time.
For sports, a good strong knee is essential for proper play and to prevent injuries. Having a good strength and conditioning program before you are active, is always beneficial as it is easier to be proactive and build up a knee's strength than to try to rehabilitate a painfully
injured knee.
Proper quadracep and hamstring strengths and conditioning make the knee function better. Drills make it less likely to get caught off guard in a game leading to tears to ligaments (ALL) and cartilage (Meniscus). Exercise is medicine.
Many common knee disorders are seen in sports medicine. The following is a brief description of some of the more commonly seen problems.

Knee Problems
1)
Patellofemeral Syndrome
2)
Osgood-Schlatter Syndrome
3)
Pes Anserine Bursitis
4)
Iliotibial Band Syndrome

Many knee injuries arise as a result of overuse or acute trauma. Some may be gradual in onset and be difficult to resolve. An accurate diagnosis is necessary to diagnose them and prescribe the proper treatment for each condition.


Some Common Knee Injuries
Patellofemoral Pain Syndrome (PFP)
- This pain is due to maltracking of the patella (knee cap) as it fails to glide smoothly through the femur groove with knee movement. Pain occurs when the patella and femur are compressed during movement. The patella irritation causes inflammation.

Pain may be worse climbing stairs, during knee bend exercises and with prolonged sitting (the "theatre sign"). People may be predisposed to PFP when their knee is maltracking for any reason, flat feet, overuse of activity, weak inner muscles (the vastus medialis group of the thigh), tight outer knee structures, or trauma.

Treatment involves decreasing the inflammation and restoring the normal glide. The PRICES algorithm (protection, rest, ice, compression, elevation, and support) is always good in new injuries. Anti-inflammatories are useful in control with pain and inflammation.

Physiotherapy may be useful for decreasing inflammation but more importantly to improve the proportion of strength, balance, (usually the vastus medialis group) to restore proper gliding of the patella. Physiotherapy is only just the start and home exercises must be continued. This injury is usually self-limited but can be frustrating for some, as it may rarely take a long time to recover.

Orthotics are sometimes used to correct predisposing foot imbalances. Surgery is rarely used but can be considered in severe cases. Gradual return to activity with emphasis on sports that do not aggravate the condition like swimming, slow jogging, water running, skating, cross country skiing, and roller blading.
Intermediate type sports that do not cause too much patellofemeral strain include: light cycling, soccer, and ice hockey.

The most aggravating sports are those that require lots of lunging or squatting. These are usually dynamic sports such as volleyball, basketball, and racquet sports. They may still be done but it is easier to rest a sore knee completely rather than constantly re-injure it by going back too soon. (which ultimately adds to more time away from that sport)

Supports like tracking braces (Polumbo and Patella Tracking braces) and athletic taping in the McConnell method, helps keep the kneecap in place during rehab.

Osgood Schlatter Disease - is a disease seen in adolescents who still have the growth plate open at the distant pole of the kneecap. Constant overuse will cause traction and pain at insertion of the patella tendon (apophysitis). This causes pain and a local bump.

Treatment usually only involves rest from sport, anti-inflammatories, and possibly a brace and review by a physiotherapist. Usually the problem goes away as the growth plate does.

Pes Anserine Bursitis
- is a specific inflammation of the insertion of the tendons into the inside of the knee, usually caused by overuse
Treatment consists of PRICE, anti-inflammatories, medication, and physiotherapy. Sometimes injection with a corticosteroid is used to treat this.

Iliotibial Band Syndrome - is pain caused by a tight iliotibial band which comes across the outside femur. Often seen in runners. ITB is treated with rest, ice, and anti-inflammatories. Physiotherapy (particularly ultrasound and friction massage) is helpful.
Stretches of the ITB are needed to release the tension. Orthnotics for co-existent foot problems also are helpful.

Important muscle groups to focus on to ensure healthy knees:
1) Quadriceps
2) Hamstring
3) Abductor Group

Rastus Medialis Oblique- This is often a problem area for women. Squats are good for hamstrings and quadriceps, but must be done properly since wrong ones will aggravate knees.

It is essential to have a qualified Phys-ed instructor athletic therapist or physiotherapist assist you in a personalized program (and watching you do your exercises) to ensure you get the maximum rehabilitative and preventative benefit.
Wrong exercises are a waste of time.

Knee Cartilage (Meniscus) and Anterior Cruiate Ligament Injuries
Cartilage injuries to the knee are very common. The 2 menisci of the knee act as shock absorbers and are shaped like crescents. The medial meniscus (inside cartilage) is more frequently injured than the lateral meniscus (outside cartilage). The meniscus acts as shock absorbers of the knee during normal movement

A torn cartilage may be acute, usually from a twisting injury but can also be from chronic injuries. After the knee is injured, players usually notice pain at the inside of the knee and mechanical problems with the knee, often with a "locking or giving way". These are caused by a flap of cartilage jamming the normal joint movement.

Sometimes the knee may have other injuries involving stabilizing ligaments in the knee. The terrible triad of medial meniscus, anterior cruciate ligament (ACL) and medial ligament, is well known after a sports injury. The ACL is a major stabilizer of the knee and when torn leads to instability and pain which can lead to profound decrease in normal activity.

When a ligament or cartilage is suspected of being injured, it is important to exclude other ligamentous injuries. This may not be easily done since swelling and pain can make a good exam difficult. If a knee is still painful after reasonable rest, re-examination is important. Often a meniscus tear is only realized after a "strained" knee has failed to get better.

Diagnosing knee Injuries
Acutely swollen knees should be examined to look for serious injuries. Fractures or instabilities (from torn ligaments) should be treated. If swelling has come up, the physical exam may be difficult.

Immediate treatment should include: PRICES -Protection, Rest, Ice, Compression, Elevation, and Support.
Support refers to crutches. It is important to take weight off no matter what the diagnosis turns out to be. Ice for at least 15-20 minutes several times per day. This is helpful to control pain and swelling.

Elevation of a knee above the level of the heart is also useful. The knee, if very painful, may be splinted (commercial brace or a 'Robert Jones' dressing which swaddles the knee, allowing a limited degree of flexion).
Seeing a sports medicine physician will help determine the extent of the injuries. X-rays are only useful in excluding fractures, but will not show cartilage or ligamentous structures.

Anti-inflammatory medications are useful in blocking the production of the "mediators of inflammation" released by damaged tissue. Reducing swelling is an important goal toward healing since reduction of knee effusion (fluid) makes re-examination easier and the patient more comfortable.

Physiotherapy is useful with knee injuries including meniscus and all tears. Early exercise in controlled movements prevents a atrophy of muscle (which will make the eventual rehabilitation more difficult).

Surgery
Certain injuries like meniscal tears and ACL tears should be assessed for surgery. Not all require it but everyone should be assessed. Meniscul tears, if suitable types, may be repaired. Not all can be repaired and instead are removed.
Surgery is most commonly done with key hole surgery with arthroscopic devices that go into the joint with small instruments. Arthroscopic surgery lends itself to faster healing. All tears are more complicated surgeries and will be discussed by each surgeon with the athletes.

Rehabilitation After Knee Injuries:
Sports that avoid pivoting will be the most difficult. Fast dynamic sports like squash, volleyball, football and basketball are the most difficult. Intermediate sports that may be less difficult include: bicycling, hockey, and baseball. The easiest activities that can also be integrated into a rehab program include: walking, skating, cross country (not downhill) skiing, and swimming (avoid the whip kick).

De-rotational braces, although expensive, are commonly prescribed after knee injuries. They are a poor substitute for proper knee rehabilitation. One study suggested that a cheaper neoprene sleeve gave enough support equal to the more expensive brace.
Preventing Knee Injuries
There are clearly unavoidable situations that lead to serious knee injuries. These injuries often lead to surgery to regain function or pain free status, but there are also preventative measures that may decrease knee injuries.

Preventative Measures
1) Having a strong knee with good hamstring and quadracep strength is important in rehabilitation, but it is also important in preventing an injury from never, or rarely happening. A well organized training program (started pre-season) by a qualified trainer or coach.
2) Proper foot wear. Excessive traction from wearing cleats in some sports may be a cause.
3) Proper training and practice for your sport will make accidents less common. Remember it is easier to prevent some injuries than treat them.
4) A previous knee injury that hasn't healed will increase the risk of injury even in the other knee.

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