HSS Cavanaugh I

PTs, athletic trainers, PAs, massage therapist, orthopedic surgeons, MDs, exercise physiologists, chiropractors

• #1 create a safe env: have a sound understanding of bsic sciences, be aware of physiological heating restraints, etc
• #2 don't hurt the pt: unless it's really necessary for ROM, don't push pt into pain, and instruct the pt to not put self in pain at home
• #3 be aggressive w/o breaking rules 1 and 2

ordered sequence of activities enabling the acquisition or reacquisition of skills required for the safe, effective performance of athletic endeavors

specific adaptations to imposed demands = specificity / replicate in therapy what the pt will be facing in sport or life

use walking as learning and healing, so don't rush to get pt off crutches. Getting off them too early may hurt the wound. Staying on them a little longer can help pt learn better and more safely to walk. (too many MDs will say a pt can get rid of crutche w/o first watching the pt walk)

Don't follow a protocol. Look at guidelines, yes, but then make each treatment personalize to the pt' strength, ROM, prior level of activity, specifics of the surgery, etc.

• don't just treat based on the name of the surgery and the number of days post-op
• don't over-rely on modalities like e-stim

deceleration

2-joint muscles when they're elongated during a quick, powerful stretch

• I, II, III - III is the worst. w II and III you'll feel a  palpable divot at site of injury
• tx is based on grade

rest, ice, compression, elevation

ice can help keep local cells from dying hypoxic deaths

also, work on protection - unload pt, get her on crutches, put a heel lift in both shoes to get her in flexion, etc - whatever will help take pt out of pain

The injury prob happened bc muscle wasn't strong enough to meet the demands placed on it. Got to strengthen it after injury to meet sport's needs

• RICE
• protection
• AROM
• flexibility
• strengthening

• direct blow to thigh
• ice in flexion, w ice held to flexed knee by an ace bandage wrapping around the knee and calf, holding calf in tight
• the flexion, bandage, and ice all provide pressure which limits hematoma and limits ROM loss
• later, put a protective pad on pt's thigh to distribute force of any new blow

old blood from a thigh contusion gets stagnated under a new wound, and the old blood starts turning to heterotopic bone --> permanently reduced ROM --> reduced running speed

process by which bone tissue forms outside of the skeleton

• patella tendonitis
• ITB synderome
• PFPS - patellofemoral pain syndrome
• plantar fascitis

• eval - determine cause
• activity modification - get pt to take some rest, or at least switch to a less harmful activity
• NSAIDS
• therapeutic modalities
• flexibility
• strength
• return to sport progression

• ACL, females (4:1 in basketball, 6:1 in soccer)
• women have wider pelvis, increased flexibility, less developed musculature, narrower femoral notch, more genu valgum

• hyper ext
• varus/valgus force
• rotation
• unhappy triad
• "hanom foot" for skiers
• most ACL injurie are non-contact injuries

ACL, MCL, and med meniscus all go at once

• bone-tendon-bone operation (taking pieces from pt's body)
• hamstrings (spaghetti strings from pt's own)
• allograft - cadaver lig

• prevents foward translation of ibia on femur
• checks IR
• checks hyperext

• age of pt
• activity level(you can do a triathalon w/o an ACL, but if you want to do decellatory or rotational sports you need one)
• laxity (objective finding) / instability (subjective complaint)

• prolonged immobilization/bracing
• limited ROM
• NWB
• "strict protocols" - like a year to recover

• get full ext
• normal gait
• 125 degrees flex
• strength for ascending stairs
• quads firing

• pt edu (what to expect, how to don/doff brace, how to walk w brace)
• KT1000 knee ligament arthrometer
• amb training
• brace management
• therapeutic exercise

• was: ~3 days
• now: ~3 hours

asap, must get knee straight - put a towel under the ankle, not knee

• quad control (SLR w/o knee quivering or pain)
• ROM - full ext and flex
• normal gait pattern w/o crutches
• ascend stairs w normal pattern w/o pain
• descend stairs
• running
• activites for sport - cutting, plyometrics, etc

• full ext
• effusion control (cryocuff)
• quads re-edu (use estim to get them firing -- the body, sensing the knee is hurt, wants to turn off the quads)

• 90-70 degrees flex it's not ACL
• 0-70 it's ACL

never - they hit the PCL

calves off table, contralat leg pushes hurt one into ext, supports it on the way down into flex, then dangle, then try unilat to pus back into flexion. Repeat, and occasionally have contralat leg help push into flexion

PWB - this helps promote ext

loads joint, provides stbility, less shear, less load on ligs, less pattelo-femoral joint reaction force

neuromuscular control mech > joint lax

• Incision site – look for sin quality, infection, etc
• Edema – palpate and measure
• Quad strength – is it firing?
• Strength at hip and ankle joints
• Gait – deviations, how’s the wt bearing Is pt in full extension?

• Work on quad setting (put heel on table, towel under knee to press down against)
• Put pt on short crank bike
• Dangle legs off edge of table w contralat leg helping w flex and ext
• Gait training w crutches
• E-stim on quad to help it fire
• Calf stretch for gastroc

• Full knee ext
• Flex to 120 degrees
• Ascend 6” step w recip pattern
• Normalized gait
• SLR w/o lag (demonstrates quad control)
• Single limb stance eyes closed 10 sec

• Descend 8” step w control
• Treadmill running program
• Accomplishing sport-specific goals
• Perform X jumps over Y distance without apprehension
• 5/5 muscle strength

• Mobilize patella
• Stretch hamstrings
• Bridging – for core strength
• Walking in water
• SLRs in all 4 directions
• Proprioceptive – as soon as 50% wt bearing, get pt on uneven surface, close eyes, reestablish neuro pathways

• Jump up and land softly
• Later, jump both up and down
• Jump rope, jump around a target on the ground or over obstacles

• If it’s an isolated injury à non-op. If it’s combined w MCL, LCL, or PLC, à surgery
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PCL

• Restrain posterior tibial displacement
• Restrain ER
• Restrain varus-valgus rotation

• Average ultimate failure strength < 2x ACL
• Increased forces w hamstring loading 12-100 degrees

• A/P force on a flexed knee w/wo rotary force (ex – knee hitting the dashboard in a car accident)
• Rotary force w varus or valgus force
• Hyperextension

Gliding/sliding btwn tib/fib

• Quads strengthening
• Protect patella
• Restore normal ROM
• Proprioception training
• Functional progression
• Avoid strengthening at deep flexion angles (no deep squats, leg presses, hamstring curls)
• No OKC hamstring strengthening

• Work on motion and wt bearing, but less aggressively than for ACL
• Patella mob
• Quads re-edu
• No OKC hamstring strengthening
• Make sure knee is at 90 degrees flex by 6 weeks

Don’t do it!!

• Primary restraint to valgus force
• Restraint to ER

Taut thru ROMIncreased tautness as knee approaches full ext

• Valgus or valgus/rotation force w leg fixed
• Injury common in football bc players get tackled at knees from the side

• Surgery unlikely for isolated injry (they generally scab down and heal well enough, even grade III)
• Immobilization / Rehab – based on eval
• Consider physiological healing restraints!

• I – pain but no gap – might could return to play next week
• II – hinge w/ an end feel
• III – no end feel – needs a brace, usually season ending
•  

• Increased anterior translation w active knee extension (OKC) esp 60-0 degrees
• Increased stress (ACL) w increased tibial rotation