Archive for knee cartilage

Chondromalacia Patella

Photo Credit: http://www.houstonmethodist.org/

Chondromalacia patella refers to cartilage damage to the underneath side of the patella (the part that contacts the femur). It is often due to wear and tear over time, but can occasionally be caused by trauma, as well. Symptoms include pain with stair climbing (especially underneath the kneecap), getting stiff after sitting for long periods of time, and grinding in the knee known as crepitus. Muscle imbalances can also put you at a greater risk for this condition, the most notable being a difference between the strength of the VMO versus the strength of the more lateral muscles.

The VMO, or vastus medialis oblique, is a part of the quadriceps group of muscles.  This particular muscle sits just above and medial to the kneecap, and runs on an oblique, or diagonal orientation from the adductor magnus tendon to the tibial tuberosity.  This muscle plays a vital role in proper patella tracking.  If it is weaker than the muscle more lateral to it, like to vastus lateralis, the patella may not track properly (may be pulled more tot he outside of the leg). The patellar groove (also known as the intercondylar fossa of the femur) allows the patella to move along the femur without much friction or interference.  Should the patella be pulled out of this groove, the underneath side may encounter more friction as it tracks.  This can results in more wear and tear to the underneath side of the kneecap, resulting in chondromalacia patella.

Another thing that can lead to poor patellar tracking here is something called a poor Q patella between the quadriceps muscle (from its attachment at the AIIS) and the patellar tendon/ligament (and its attachment on the tibial tuberosity).  A normal Q angle is approximately 10-12 degrees for men and around 15-18 degrees for women.  A higher number can indicate poor patellar tracking, which may result in degeneration to the underneath side of the patella.  Those who hyperpronate at the ankle (or roll in) are at a higher risk for an increased Q angle.  Muscle imbalances, such as those mentioned above, may also affect your Q angle.

Photo credit: http://www.lbgmedical.com

Rehab

While no one (therapist or doctor) can fully reverse damage that has already been done to the cartilage underneath your patella, you can take actions to reduce pain, restore muscle balance, and keep it from progressing.  Your therapist will check the biomechanics of your knee, hip, and ankle as you move and walk, climb stairs, etc., to ensure proper patella tracking. Bracing and taping can be helpful in these cases.  Making sure the muscles surrounding your knee are strong and balanced is key.  This will often target strengthening the VMO while ensuring muscles like vastus lateralis, your IT Band, hamstrings, and calves are not too short (ie, need stretching to improve flexibility).

Some ways to target your VMO include quad sets with your foot turned our slightly, short arc quads (SAQ’s) in parallel or turned-out, SAQ’s or long arc quads (LAQ’s) with a ball or pillow between your knees, mini squats against a wall or ball squats, single leg mini squats or heel drops off a step, stationary lunges, step-ups or step-downs.  Exercises should be done in pain-free range and only done as long as you can control the movement and maintain proper alignment.

Photo credit: http://patellofemoral.completesportscare.com.au

Your therapist may also include neuromuscular re-education in your plan of care.  This involves re-teaching your muscles in which ones should fire and which ones shouldn’t (or perhaps, shouldn’t fire as much) when performing certain functional tasks.  This can often be very simple in concept, but difficult to master and frustrating at times, as you’ll be focusing on breaking bad habits and replacing them with good ones. When working to re-educate your muscles on the “right way” to do things, awareness and attention to detail are paramount.

Another part of your rehab regime may be agility training, which will include things like running, jumping, and landing training.  The Bosu Ball can again be helpful here, as I’ve often employed doing lunges with the front leg on the Bosu Ball once a certain amount of strength and control has been met, but more challenge is needed before the patient or dancer is released from physical therapy to resume his/her normal level of activity.

This concludes our look into chondromalacia patella.  Stay tuned next week as we look into patellar tendinopathy and jumper’s knee.

Sources

http://www.sportsinjuryclinic.net/rehabilitation-exercises/knee-hamstring-thigh-exercises/vmo-rehab

https://en.wikipedia.org/wiki/Intercondylar_fossa_of_femur

http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/q-angle

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AFFILIATE DISCLOSURE

This website contains affiliate links, which means Tricia may receive a percentage of any product or service you purchase using the links in the articles or advertisements. You will pay the same price for all products and services, and your purchase helps support Tricia’s ongoing research and work. Thank you for your support!

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Meniscus Tears

Common Knee Injuries- Meniscus Tears

Last week, we looked at the structure and function of the knee.  This week, we begin our examination of common knee injuries.  First up: meniscus tears.

As stated in last week’s blog post, the meniscus serves as a shock absorber between the femur and the tibia. The medial is more commonly injured, especially with MCL injuries. The lateral is less commonly injured, but is more often injured with ACL tears versus the medial meniscus. Mechanisms of injury include twisting or turning, trauma, and sometimes even squatting. Degenerative tears can also occur with aging. Tears are typically confirmed via MRI, but can be inferred from history (what happened when the symptoms started), symptoms, and special tests your physical therapist can perform. Symptoms of a meniscus tear involve pain, stiffness, swelling, catching or locking, giving way or buckling, limited range of motion (ROM), and subsequent weakness.

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The four most common tears are bucket handle, radial, flap, and horizontal. Bucket handle tears describe a rip down the middle of the meniscus (form front to back). The meniscus remains attached as a whole, but torn part floats towards the center of the knee like the handle of a bucket (still attached at the sides). While there is good blood flow in this area, it often needs to be repaired surgically. The good news is that is can often be reattached versus shaved off, and you can retain all of your shock absorber. Because tears here cause a portion of the meniscus to float towards the center of the knee, it gets in the way of the knee fully extending, causing what is known as locked knee (unable to fully extend). This type of tear is often a result of a twisting injury. Radial tears run perpendicularly from the inner rim of the meniscus out towards the edges. Radial tears tend to be in areas of poor blood flow, and often require surgery to shave and trim the affected area. Flap tears are a type of horizontal tear that result in the a piece of the meniscus being able to peel away from the rest, which can result in it getting caught places where it ought not to. This, too, usually requires surgical intervention. Other horizontal tears can result in the meniscus almost being torn in half (horizontally), resulting in one meniscus almost looking like two lying on top of each other. This is a common type of tear that often also requires arthroscopic surgery. If tears occur on the outer 15% of either meniscus, they have a better chance of healing on their own, as this area of the menisci is more vascularized. Tears in the remaining menisci may require surgery if symptomatic. Degenerative tears, which appear more like fraying at the inner edges of the menisci, are often not symptomatic, and may not require surgery.

Rehab

Initially, your doctor will most likely advise you to follow the RICE protocol:

  • Rest
  • Ice
  • Compression (with brace, kinesiotape, or an ace bandage)
  • Elevation (keeping the foot above the height of the heart when reclined)

After the acute phase (whether form injury or after surgery), you’ll begin to gently reintroduce movement and function again by focusing on increasing active range of motion (AROM) and strength. Your physical therapist will guide you in what’s appropriate to do and when. Some examples include quad sets to work on straightening the knee and heel slides (with a strap and without) to work on bending the knee. It’s best to keep these motions in what physical therapists often refer to as relatively “pain-free” range. If you’ve had surgery, you will most likely have pain, so this won’t be entirely pain-free. If you already have pain at rest, then it’s best to do these movements in a range that will not make your pain levels spike. Once your able to do these without increased pain, you’re physical therapist will usually tell you you’re ready to move onto strengthening exercises. Here, you may introduce things like mini squats, step-ups, and leg raises (standing or lying down), terminal knee extension, leg press, and hamstring curls. You’ll be able to progress these exercises by increasing weight, Theraband resistance (latex free version here) and/or repetitions. You may also begin to incorporate some balance exercises here: shifting from two feet to one foot, then standing on a softer surface, then on elevé. You may even do balance exercises on a Bosu Ball, which is a great way to increase proprioception.  You’ll eventually progress to things like jumping and hopping again, or running, but these are final steps in your rehab. Again, your therapist will be able to guide you through your recovery.

That’s it for meniscus tears.  Stay tuned next week as we dive into ligament sprains and tears.

Sources

https://en.wikipedia.org/wiki/Patella

https://en.wikipedia.org/wiki/Popliteus_muscle

http://orthoinfo.aaos.org/topic.cfm?topic=a00358

http://www.miamisportsmedicine.com/MeniscalInjury.html

http://www.howardluksmd.com/types-meniscus-tears/

http://radsource.us/meniscal-tear-patterns/

http://emedicine.medscape.com/article/1252011-overview

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AFFILIATE DISCLOSURE

This website contains affiliate links, which means Tricia may receive a percentage of any product or service you purchase using the links in the articles or advertisements. You will pay the same price for all products and services, and your purchase helps support Tricia’s ongoing research and work. Thank you for your support!

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