5/14/2013. Acute vs Chronic Mechanism of Injury:

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1 Third Annual Young Athlete Conference: The Lower Extremity February 22, 2013 Audrey Lewis, DPT Acute vs Chronic Mechanism of Injury: I. Direct: blow to the patella II. Indirect: planted foot with a valgus force applied edand det either e internal rotation otato of the femur or external rotation of the tibia; twisting movement about the knee Report a sensation of giving away at the knee Recurrence rate: 15-44% after conservative treatment Generalized joint laxity Femoral anteversion Genu valgus/genu recurvatum Foot pronation Patella alta Tibial external rotation Trochlear groove dysplasia Lateral femoral condyle dysplasia Dysplastic VMO 1

2 Periods of rapid growth in the adolescent athlete often present as musculotendinous tightness in setting of ligamentous laxity Peak muscle mass and strength lag several years behind peak height velocity Medial Patellofemoral Ligament (MPFL) Medial Retinaculum Dynamic stabilizers: VMO Be aware of the possibility of osteochondral fractures, articular cartilage injuries i General ligamentous laxity Patellar positioning and mobility (Q angle, J sign, patellar translation/glide test, passive patellar tilt test, apprehension sign) Standing lower extremity alignment (genu valgum, femoral or tibial rotation, squinting or inward facing patellae, excessive pronation) Gait and dynamic movement (previously discussed) 2

3 Initial: knee immobilizer, crutches if needed to assist with ambulation, NSAIDs for pain control, RICE Short period of immobilization (3-6 weeks) Flexibility/ROM and patellar stabilization if hypermobile (taping techniques: KT, McConnell) Quad strengthening focusing on VMO recruitment (alter motor control of VMO relative to VL by functional training) emphasis on eccentric strengthening Bracing options, orthotics Significant weakness in hip external rotation, abduction and extension with concurrent increases in hip adduction, internal rotation and subsequent knee abduction are noted when comparing patients with patellofemoral pain to pain free individuals Thus increased focus on strengthening of the gluteal musculature/posterior chain as part of rehab protocols Gluteus medius (abduction), Gluteus maximus (extension, external rotation, superior portion hip abductor during gait) gluteus medius using % maximum volitional (MVIC) 70% MVIC were deemed acceptable in this study for enhancement of strength Side plank with dominant leg down (103% MVIC) Side plank with dominant leg on top (89% MVIC) Single leg squat (82% MVIC) Clamshell progression (position 4) (77% MVIC) Front plank with hip extension (75% MVIC) 3

4 gluteus medius using % maximum volitional Sidelying hip abduction (81% MVIC) Single limb squat (64% MVIC) Single leg deadlift (58% MVIC) Standardized lowering height for single limb activities cm =height of step Wall squat (unilateral) (52% MVIC) Front step up (44% MVIC) Lateral step up (38% MVIC) Electrodes placed on the stance limb Pelvic drop (57% MVIC) Weight bearing with hip flexion (20 d) and contralateral hip abduction (25 d) (46% MVIC) Weight bearing with hip abduction (25 d) (42% MVIC) 4

5 gluteus medius using % maximum volitional 70% MVIC were deemed acceptable in this study for enhancement of strength Front plank with hip extension (106% MVIC) Gluteal squeeze (81% MVIC) Side plank abduction with dominant leg on top (73% MVIC) Side plank abduction with dominant leg on bottom (71% MVIC) Single limb squat (71% MVIC) gluteus maximus using % maximum volitional Single limb squat (59% MVIC) Single limb deadlift (59% MVIC) Sidelying hip abduction (39% MVIC) gluteus maximus using % maximum volitional Single leg squat (86% MVIC) Forwardstepup(74%MVIC) Lateral step up (56% MVIC) 5

6 Single leg squat best exercise for gluteus medius and gluteus maximus Double leg squat with applied load (resistance band) may be more beneficial than the same exercise without band when goal is to activate the gluteus maximus Tensor Fascia Lata (TFL) acts as a hip abductor as well as hip internal rotator Can cause excessive lateral force on the patella and lateral patellar retinaculum via connections with ITB What exercises can isolate gluteus maximus (superior) and gluteus medius, minimizing TFL activation? 1. Clamshell 2. Single leg bridge 3. Hip extension exercises on all fours (knee extended, knee flexed) 4. Side steps 6