3/1/2017. East Amherst East Aurora Hamburg x2 West Seneca Williamsville Boulevard WHERE ARE WE? THE KNEE JOINT

Transcription

1 WHERE ARE WE? East Amherst East Aurora Hamburg x2 West Seneca Williamsville Boulevard THE KNEE JOINT 1

2 THE KNEE JOINT At the most superficial level, the knee is a simple hinge joint Flexion & Extension The knee has small, less obvious movements, too Rotation Valgus and Varus There are no direct knee muscles that control for the smaller movements, but these movements are often the cause for injury ACTIVITIES OF DAILY LIVING: TIBIA - FEMORAL Activity Going Down Stairs Going Up Stairs Knee Bends Level Walking Peak Force (% of body weight) 346% Body Weight 316% Body Weight 253% Body Weight 150% Body Weight Peak Force Running? 290% Kutznera I, Heinleina, B, Graichena F. Loading of the knee joint during activities of daily living measured in vivo in five subjects. Journal of Biomechanics Aug;43(11): WALKING, WEIGHT LOSS, AND THE KNEE One Pound of Weight Loss Off Loads how much force while walking? 4 Pounds of Pressure Messier S, Gutekunst D, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism July 2005;52(7):

3 FOOD FOR THOUGHT: EXERCISE SUBSTITUTION Lunging Jumping Knee Extensions Running Walking One Legged Squat Squats Elliptical Biking Wall Slides Step Ups SUBSTITUTING EXERCISE: BIKING Peak Compressive Force While Cycling: PF Joint Influencing Factors Work Load (Level) Saddle Height 40% of Body Weight Non-Influencing Factors Pedaling Rate / Foot Position Ericson M, Nisell R. Patellofemoral Joint Forces During Ergometric Cycling. Phys Ther. 1987;67: SUBSTITUTING EXERCISE: ELLIPTICAL Compared to walking: Smaller Reaction Forces Slower Loading Rates Increased Hip Flexor and Knee Extensor Moments 3

4 SUBSTITUING EXERCISE: LEG PRESS Is this functional? Increasing force into extension Last 15 Degrees of Extension vs. Achieving 30 Degrees 2x Quad Force Surface Area Effect of weight 7# Doubles Quad Force Leg Press vs. Standing Extension 0-46 degrees less reaction force Grood ES; Suntay WJ; Noyes FR. Biomechanics of the knee extension exercise. Effect of cutting the anterior cruciate ligament. J Bone Joint Surg Am 1984 Jun;66(5): LUNGES, STAIRS, AND KNEELING Peak axial forces during stepup were nearly 60% greater than during gait Choosing Your Lunges Long vs Short Stride With / Without Stride Multi-Planar Lunges D Lima D, Steklov N, Fregly B. In Vivo Contact Stresses during Activities of Daily Living after Knee Arthroplasty. J Orthop Res : Escamilla R, Zheng N, Macleod T. Patellofemoral Joint Force and Stress Between a Short- and Long-Step Forward Lunge. J of Orth & Sports Phys Ther 2008 Nov;38(11):

5 WHAT S MORE FUNCTIONAL WHAT S MORE FUNCTIONAL? WHAT S YOUR THRESHOLD? Lunging Jumps Knee Extensions Running Walking One Legged Squat Squats Elliptical Biking Wall Slides Step Ups 5

6 FUNCTIONAL EXERCISE PROGRESSION Lunges Single Leg Activities Step Ups Squats Elliptical Walking Biking 6

7 Northtowns Orthopedics Buffalo Rehab Group 2/27/17 Peter L. Gambacorta, DO Orthopedic Surgeon Sports Medicine Peter L. Gambacorta, DO Northtowns Orthopedics General orthopedic surgery Fellowship Trained Sports Medicine Specialist Arthroscopic Surgery Surgery with cameras Knee, Shoulder, Hip, Elbow, Ankle Northtowns Orthopedics Office Locations East Amherst 8750 Transit Road Suite 105 East Amherst, New York Williamsville 36 North Union Road Williamsville, NY Holiday Valley 6133 U.S. Route 219 Suite 1001 Ellicottville, New York

8 After-Hours Orthopedic Service No appointment is necessary! 8750 Transit Road Suite 105 East Amherst, New York After-Hours Urgent Orthopedics Available: Monday through Friday, 4 pm to 8 pm Saturday, 12 pm to 4 pm Sunday, 12 pm to 4 pm Most major insurance carriers are accepted. (716) Agenda Introduction Youth sports Knee Injury prevention Pediatric and Adolescent Sports Medicine Epidemic Problems 2

9 Youth Sports Statistics >30-45 million children and adolescents participate in youth sports in US 2 million high school students sustain injuries yearly More than 3.5 million children ages 14 and under receive medical treatment for sports injuries each year 50%of youth sports injuries are preventable By the age of 13, 70% of kids drop out of youth sports Why are Injuries on the Rise? Title IX - the federal civil rights law that prohibits sex discrimination in education. Enacted in Ratio of HS participation # High School Athletes # College Athletes 1 in 17 1 in 3 300,000 3,000,000 25, ,000 3

10 Increased participation: Increased rates of injury Why are Injuries on the Rise? % Increase! Sports Participation Less free play More sports offered Single sport concentration All star, travel teams Year round participation Higher levels of competition Means to an end Understanding the Difference Child is not a little adult. Child athlete is not a little adult athlete. 4

11 Historic Prospective Kids do not experience major sports related injuries Kids will heal if you put them in a cast or brace Unique Challenges Age Specific Injuries Growth plates Expectations Delayed treatment can lead to other problems Surgical Techniques Limb length Angular deformity Growth arrest Pediatric Sports Medicine Pediatric Orthopedics Adult Sports Medicine Hip Dysplasia Perthes disease Scoliosis Spondylolysis Club foot Congenital deformities Cerebral palsy Spina bifida Hand anomalies Limb length deficiencies Fracture care Ligament injuries (ACL,PCL,UCL) Articular cartilage injuries Tendon injuries Meniscus tear Dislocated shoulder Labral/ SLAP tear Rotator cuff tear Tennis elbow Hip labral tear Snapping hip syndrome Ankle sprains Fracture care 5

12 Scope of Pediatric Sports Medicine Knee: ACL, meniscus, OCD, chondral injuries, patellofemoral dysplasia, tibial spine fractures, patella instability, growth deficiencies, fractures Shoulder: Labral tears, multidirectional instability, SLAP tears, impingement, little leaguer shoulder, rotator cuff tears Elbow: Loose bodies, OCD, UCL injuries, olecranon apophysitis, pediatric elbow fractures Hip: Femoroacetabular Impingement, loose bodies, chondral injuries, dysplasia, SCFE, apophysitis Wrist and Hand: TFCC, fractures, tendon injuries, fractures Ankle and Foot: OCD, instability, os trigonum, anterior/posterior impingment, tarsal coalitions, fractures Spine Back Pain, Spondylolysis, Scoliosis, muscular strains Medical Conditions Concussion, Heart, Psych, Nutrition Agenda Introduction Youth sports Knee Injury Prevention Bone- Skeleton Supports the body Protects organs Allows movement Stores minerals Makes blood cells Anatomy 101 6

13 Anatomy 101 Muscle Engine Produce motion Provide stabilization Generate heat Anatomy 101 Tendon Connector of Muscle to Bone Ligament Connector of Bone to Bone Flexibility versus Laxity Flexibility Stretch of muscle and tendon Laxity Looseness of ligaments 7

14 Common Sports Injuries Hip/ Pelvis Knee Shoulder Elbow Hand/Wrist Leg/ Ankle Foot Spine Why Does My Knee Hurt Bones Knee Anatomy 8

15 Knee Anatomy Cartilage Dynamic layer Muscles and Tendon Knee Anatomy Neural layer Knee Anatomy 9

16 Why Does My Knee Hurt Arthritis Meniscus tears Ligament injuries Knee cap pain Arthritis Osteoarthritis Wear and tear Articular cartilage wears out More common in patients over the age of 50 Develops over time Rheumatoid Chronic autoimmiune disease attacking multiple joints Post Traumatic Develops after an injury Arthritis Symptoms Stiffness and swelling Difficulty bending Increase pain with activity Locks or sticks with movement Weakness and buckling Increased with weather changes 10

17 Arthritis Diagnosis Examination Testing Radiograph MRI Lab Arthritis Treatment Lifestyle modifications Physical therapy Assistive devices Medications Oral, topical Injections Corticosteroid Visco supplementation Surgical Treatment Arthroscopy Arthritis Partial and Total Replacement 11

18 Meniscus Tear Meniscus Fibro cartilage disc Breast bone on a chicken Two meniscus in each knee Medial and Lateral Shaped like a C Function: Shock absorber Stabilize Nourish Etiology Young athlete Traumatic Twist/ Pivot Athletic Activity Deep bend/ squat Mature patient Traumatic Insidious onset Meniscal Tear 12

19 Meniscal Tear Symptoms Pain At the joint line With squatting and bending Locking Click, pop, catching Swelling Often worse after activities Diagnosis Examination Effusion Palpatory tenderness over meniscus Pain with deep knee flexion Mc Murray test Meniscal Tear Radiographs 13

20 MRI Adult patient: MRI of medial meniscus 95.7% sensitivity 81.8% specificity 88.2% positive predictive value(ppv) MRI of lateral meniscus 75% sensitivity 95% specificity 80% PPV MRI of the ACL 100% sensitivity, specificity, accuracy, positive and negative predictive values. Mandelbaum et al. AJSM 1986 Pediatric patient: Meniscal Injury 72% sensitivity 93.5% specificity Under 12 years of age 61.7% sensitivity 91.2% specificity MRI No difference between clinical exam and MRI findings with respect to: Agreement with arthroscopic findings (70%) Sensitivity (70%) Specificity (92%) Conclusion: Selective MRI does NOT provide enhanced diagnostic utility over clinical examination in children. Kocher et al. JSM 2001 Types of Tears Meniscus tear 14

21 Meniscus Healing Blood supply Meniscus Healing Meniscal Tear Conservative Treatment Rest Ice Compression Elevation NSAID S Injections Physical Therapy 15

22 Meniscal Tear Surgical Treatment Arthroscopic surgery Minimally invasive Out patient Light source camera and small instruments Partial Meniscectomy Post operative Meniscectomy Ice, Pain medication Crutches Typically a few days Weight bear as tolerated Begin post operative exercise the day after surgery Begin formal PT days post operative 4-12 weeks Return to full sports and activities without restriction 4-12 weeks 16

23 Meniscal Repair Post Operative Meniscal Repair Ice, Pain medication Crutches Typically 4-6 weeks Weight bearing Toe touch or partial 4-6 weeks Brace Begin post operative exercise the day after surgery Begin formal PT days post operative 4-12 weeks Return to sport and full activities 3-4 months ACL Anatomy Normal ACL Tear 17

24 Who is at risk? Risk- Male : Female ratio Male HS athlete: 1:500 Female HS athlete: 1:70 M: F- 1 : 5-8 > 40,000 HS female ACL injuries/ Year Age years ACL Epidemiology Athletically active Soccer, Basketball, Volleyball Risk comparisons: Male vs Female No known differences in prepubescent children At puberty Males- neuromuscular growth spurt Females- no neuromuscular growth spurt Development of neuromuscular imbalances Yu et al Clin Orth Relat Research

25 Costs of ACL Injury in Adolescent Girls Financial $17,000 per reconstruction with rehab 1 $700,000,000 annually Academic Decreased academic performance 2 Loss of scholarship funding Physical Early OA 3 1. Hewett et al, AJSM 1999, 2. Freedman et al, Clin Orthop 1998, 3. Von Porat et al, 2004 How Do They Happen? Injury Mechanism Non contact Contact 75% 25% 19

26 Injury Mechanism- Pivot Torsional moment Unanticipated deceleration with change in direction Foot firmly planted 57% of non contact injuries Arendt et al, 1999 Risk Factors Environmental ACL Injury Risk Factors Anatomic Hormonal Neuromuscular Neuromuscular Positive Dynamic factors Reaction time Motor muscle recruitment Balance Endurance Strength Peak torque, amplitude and timing Anticipation Maximum co-contraction stiffness 20

27 Injury Prevention Programs Emphasizing proper jump and landing techniques Neuromuscular Control Landing Patterns Strength Power Agility Before After Barber et al AJSM 2006 What does an ACL injury look like? Acute Symptoms Pop Pain Swelling Instability MRI 21

28 Non Operative Complete Tear Natural History Increased rate of meniscal tear Chondral injury and degenerative changes Persistent instability Decreased athletic participation Poor functional outcomes and patient satisfaction ACL Treatment Prepubescent Adolescent Adult 22

29 Age Chronological Age does NOT equate to skeletal/physiologic age Current ACL Reconstruction Recommendations Based on Age ACL Tear Skeletally Immature Patient Partial ACL Tear (<50% Fibers Torn) Skeletally Immature Patient Complete ACL Tear Skeletally Immature Patient Prepubescent Tanner Stage 1 or 2 Males 12 years Females 11 years Adolescents with Growth Remaining Tanner Stage 3 or 4 Males years old Females years old Older adolescents with closing physes Tanner Stage 5 Males 16 years old Females 14 years old Transphyseal reconstruction with autogenous quadrupled hamstring tendons and metaphyseal ixation Adult type Anatomic ACL reconstruction with Hamstrings or Patellar Tendon (Autograft Preferfable) Activity Modi ication Physical Therapy Bracing Physeal-sparing combined extra- and intra-articular reconstruction with autogenous iliotibial band Gambacorta, Frank JAAOS 2013 Future of ACL Surgery Injectable bio enhanced scaffold ACL Repair and Regeneration Suture Eliminate tendon graft Decrease post traumatic OA Murray, MM J Orthop Research

30 Anterior Knee Pain Knee cap pain Swimmers knee Patellofemoral syndrome 15% of all knee pain Females> Males Patellofemoral pain Differential Diagnosis Trauma: Contusion Fracture Dislocation Rupture of Patellar or Quadriceps Tendon Synovial Plica Syndome Osteochondritis Dissecans Post traumatic Chondromalacia Arthritis Hoffa s Disease RSD Patellar or Quadriceps tendinitis Prepatellar/ Peripatellar bursitis Osgood Schlatter or Sinding- Larsen-Johansson disease Lateral Patellar Compression Syndrome Chronic Subluxation of the Patella Recurrent or Chronic Dislocation of the Patella Idiopathic Chondromalicia Patellofemoral Syndrome Symptoms Pain Uni or Bilateral Insidious onset Pop / click Pain with stairs or sitting Swelling +/- 24

31 Patellofemoral Syndrome Treatment Non op successful 80-90% Neuromuscular balance Stretching (flexibility) Strength training Quad Stretch Illioas Psoas Stretch Rectus Stretch Hamstring Stretch Piriformis Stretch ITB Stretch 25

32 Single Knee to Chest Stretch Double Knee to Chest Stretch Achilles tendon stretch Straight Leg Raises Perform 3 sets of 10 repetitions on each leg. Start with no weight and increase ankle weight as appropriate Toe Pointing Up Foot Rotated Out Lying on your side Agenda Introduction Youth sports Knee Injury Prevention 26

33 Injury Prevention According to the CDC, more than half of all sports injuries in children are preventable Sports Trauma and Overuse Prevention STOP Sports Injuries Prevention starts with EDUCATION Information for: Athletes Parents Coaches Healthcare providers Sport specific injury prevention tips 27

34 STOP Sports Injuries General Sports Injury Prevention Tips: Obtain a pre-season physical examination Encourage warm ups and cool downs Encourage proper strength training routines 28

35 Use and maintain proper equipment Encourage athletes to speak to a coach, trainer, parent or physician when they are experiencing PAIN Thank You 29