Quadriceps strain and contusion injury Acute quadriceps strains most commonly occur in athletes including rugby, soccer, and football players due to the action of sudden, high-velocity running that requires eccentric contraction of the quadriceps muscle while regulating hip and knee extension. High forces placed across the muscle or passive stretching of the muscle during eccentric contraction results in strain. Factors placing the quadriceps at risk for injury include its inherent role as a predominantly Type II pennate muscle, its architecture across two joints, and muscular fatigue (Kary, 2010). A pennate muscle is one in which the fascicles attach obliquely (in a slanting position) to its tendon. This type of muscle generally allows higher force production. Similar to the hamstring, quadriceps strains are classified into three grades. Grade I includes minor muscle tearing, limited loss of muscle function, and mild pain. Grade II includes more significant muscle damage and loss of muscle function with higher levels of pain reported by the patient. Grade III tears are complete, and include significant pain and complete loss of strength. Quadriceps strain can be difficult to distinguish from iliopsoas or adductor strain. This injury most commonly involves the rectus femoris. Physical exam should include observation of swelling, ecchymosis, bulging or disruption of the muscle (as observed with more severe disruption), and mobility impairment. Palpation of the muscles are necessary along the entire length of the muscle, noting areas of disruption and maximal tenderness. Muscle testing of the rectus femoris should include knee extension, hip flexion, and testing of knee extension with the hip both flexed and extended (Kary, 2010). As with any soft tissue injury, acute treatment should include rest, ice, compression, and elevation if possible. Patients may be directed to take NSAIDs by their physician. After 3 to 5 days, Anterior cruciate ligament The anterior cruciate ligament (ACL) is a primary stabilizer of the knee. Approximately 60% of knee ligament injuries include the ACL, and occurs nine times more in women than men (Cimino, 2010). The most commonly reported mechanism of injury is twisting of the body with a planted foot, producing an audible “pop.” It may occur with or without deceleration of the body in motion and produces a sudden onset of pain and instability of the knee. Tears of the ACL are frequently accompanied by medial collateral ligament (MCL) tears and meniscus tears in an injury referred to as “the unhappy triad” (Cimino et al., 2010). Diagnosis of ACL tears include subjective history of mechanism of injury as described above. Objective examination includes performance of Lachman’s test, which holds a sensitivity value of 60% to 100%, (mean 84%; Decary, 2017). Other objective tests specific to the ACL are the anterior drawer test (mean sensitivity 62%), and pivot-shift test (mean sensitivity also 62%; Makhmalbaf, 2013). The use of MRI is the gold standard in identifying ACL tears, with 95% specificity as confirmed by an arthroscopic procedure. After identification of an ACL tear, initial management often includes immediate referral to physical therapy to address inflammation and of motion impairments. The decision must then be made by the patient and physician to manage the injury conservatively (often with physical therapy alone), or to surgically reconstruct the ACL. The decision to reconstruct the ACL is most often made when the patient anticipates continuing physical activities in which rapid acceleration and deceleration are required. Surgery may also be recommended for patients who experience recurrent episodes of the injured knee giving way, as well as patients with impaired collateral ligaments or meniscus damage. Postoperative rehabilitation will vary by surgeon. Many protocols require the patient to begin physical therapy within 3 to 5 days of surgery. The patient often presents with significant amounts of
gentle stretching, pain-free progressive resistive strengthening, and range of motion can begin. Gentle warm-up, proprioceptive training, and functional exercises should also be implemented. At approximately 6 weeks, more dynamic activity can progress and, if applicable, a return to sport training may be acceptable. Quadriceps contusion is the second most common injury reported to the quadriceps muscle. This injury is sustained by a direct blow to the quadriceps muscle resulting in significant pain to the anterior thigh. As with the quadriceps strain, the muscle should be observed for ecchymosis and obvious deformity, as well as palpated for areas of maximum pain. Gait should be assessed for aberrant movements and muscle strength should be tested, including knee extension and hip flexion. Measurement of knee range of motion should also be recorded. Treatment for quadriceps contusion should begin with the knee braced into 120° of flexion immediately for the first 24 hours to prevent hematoma formation. Ice and NSAIDs may also be used. There is evidence suggesting that NSAIDs may prevent the formation of myositis ossificans (MO; consisting of ossification of muscle fibers) after severe contusions. After the acute phase, treatment will mirror that of quadriceps strain. Progression of a severe quadriceps contusion to MO is evident on radiographic images in 9% to 17% of cases (Kary, 2010). Clinical indications of MO include continued pain for 2 to 3 weeks following injury, loss of knee flexion, and persistent swelling. In these cases, radiograph images commonly are taken within 3 weeks of injury, and reveal non-neoplastic bone formation in the area of the contusion (Kary, 2010). Treatment for MO consists of stretching, knee mobilization and range of motion, and quadriceps strengthening. A case of MO may cause flare- ups in pain and swelling, and in severe cases require surgical removal (Kary, 2010).
LIGAMENT INJURIES
pain, with a brace and crutches with weight-bearing status orders created by the physician and enforced by the physical therapist. Early achievement of terminal knee extension is critical. Perhaps the most debilitating complication of ACL reconstruction is arthrofibrosis with knee flexion contracture due to lack of early and consistent knee extension stretching. Low load, long- duration stretching and patella mobilization is recommended to achieve early knee terminal extension. Muscular activation of the knee extensors is also important. This may be achieved by using neuromuscular electric stimulation (NMES), or electromyographic (EMG) biofeedback. Systematic review of the literature favors the use of NMES for patients post-ACL reconstruction, with improved muscle scores by approximately 6 weeks post-op (Kim et al., 2010). Interestingly, the ACL graft is most often at its weakest at 6 weeks post-op. Special considerations and patient education should be made at that time to prevent graft rupture. Patients should be gradually progressed through the physician- determined rehabilitation protocol, with dynamic activities introduced generally around 6 months post-op. For athletes, a return to sport training often takes 1 year. Posterior cruciate ligament The posterior cruciate ligament (PCL) serves as stabilizing ligament to prevent excessive posterior translation of the tibia on the femur. Complete tear of this ligament is far less common than in the ACL, constituting 3.5% to 20% of knee ligament tear injuries (Peterson, 2017). The reported mechanism of injury is often falling on a flexed knee or a motor vehicle accident in which the knee struck the dashboard. The posterior drawer test assesses the intact nature of the PCL. Posterior translation during the test indicates impairment to the PCL. Many athletes return to sports with a PCL-deficient knee and isolated PCL reconstruction is rare.
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