● Cleavage tear : A complete transverse tear that separates the meniscus into superior and inferior fragments. ● Parrot’s beak tear : A combined incomplete radial and longitudinal tear, with a displaceable component that resembles a parrot’s beak. ● Root tear : A tear in the anterior or posterior meniscal roots where the meniscus attaches to the central tibial plateau. ● Degenerative tear : May occur as a result of traumatic or degenerative arthritis. There are many approaches to meniscus tear management ranging from conservative physical therapy to surgery. Non-operative physical therapy goals for meniscal tear include management of joint effusion, range of motion, gait normalization, stretching, education regarding activity modification, and lower-extremity strengthening. If the meniscus does not respond to physical therapy intervention, surgery is typically recommended (Baker, 2018). Surgical procedures include meniscectomy and meniscal repair, though commonly the surgical goal is to spare as much of the meniscus as possible. Procedure type depends on the type of meniscal tear, age and activity level of the patient, and physician preference. Post-op rehabilitation will vary by physician and will include range of motion, gait normalization, lower-extremity strengthening, and functional activity training. Meniscal repair post-op protocols generally call for the patient to be non- weightbearing for 4 to 6 weeks following surgery with restricted ROM (Harput, 2020). Once the patients are cleared for physical therapy, the lower limb muscles tend to be quite atrophied and significant strengthening is required. Aggressive closed-kinetic chain activities are typically avoided (Baker, 2018). end-stage DJD, but are too young to be considered a candidate for a total knee arthroplasty (TKA). This disease can be idiopathic or primary, with symptoms rarely occurring before age 50. Etiology is often unclear, although age- related changes are known to occur to menisci, joint lubrication, and articular cartilage. There is not always a clear association between radiographic evidence of joint disease and magnitude of symptomology. Signs and symptoms include diffuse joint pain that increases with activity, possible joint effusion, radiographic changes including Fairbank’s signs, increased stiffness associated with activity, altered gait, and joint line tenderness (Chen, 2017). Physical therapy management depends on the extent of degeneration and includes patient education to avoid impact activities, manual therapy to improve osteokinematic and arthrokinematic motion of tibiofemoral joint, general conditioning, and specific knee muscle strengthening in a pain- free manner.
depending on the degree of knee flexion (Croutze, 2013). They are thought to play a crucial role in joint stability, proprioception, lubrication, and protection of joint surfaces. The medial meniscus is C-shaped and integrated within the joint capsule, while the lateral menisci is C-shaped and more mobile. The outer third of each meniscus is vascular and composed of fibroblast- like Type I collagen and is best able to heal following injury. Contrarily, the inner two-thirds is avascular by the age of 10, and heavily composed of chondrocyte-like Type II collagen and proteoglycans, and, therefore, does not heal well with injury (Croutze et al., 2013). A likely mechanism of injury is twisting of the leg with the foot planted during weight bearing. Signs and symptoms include locking of the knee, swelling, pain with twisting, and report of pain at the middle and posterior third of the joint line. Physical exam for suspected menisci injury should include McMurray’s test (specificity 94%), Apley’s maneuver (specificity 80%), and palpation of the joint line with reported tenderness (sensitivity 85%; Meserve, 2008). Meniscus injuries are classified by their direction. Vertical tears include the following: ● Longitudinal tear : A tear along the longitudinal axis of the meniscus. ● Radial tear : A tear that is traverse to the circumferential fibers of the meniscus. ● Bucket-handle tear : A complete longitudinal tear resulting in a peripheral and inner fragment. Horizontal tears include the following: ● Transverse tear : A tear at the horizontal axis of the meniscus Articular cartilage Articular cartilage injury is caused by either acute or repetitive trauma to the hyaline cartilage layer of the bone surface. There are typically two types of articular cartilage injuries: isolated cartilage defects and general articular erosion, also known as degenerative joint disease (DJD). The isolated defects are managed according to the area and depth of the damage. Dime-sized or smaller areas tend to demonstrate chondrocyte regeneration, while larger areas require arthroscopic surgical debridement to stimulate fibrocartilage proliferation (Mayo Clinic, n.d.). Degenerative joint disease (DJD) is said to be a natural byproduct of aging and is confirmed on radiographic films and diagnosed according to Fairbank’s signs, which includes joint- space narrowing, presence of osteophytes, and flattening of the femoral condyles. Factors thought to be associated with DJD include activity level, amount of articular cartilage, biomechanical alignment, presence of menisci, level of instability, and obesity. An orthopedic dilemma is presented when patients demonstrate
FRACTURES AFFECTING THE KNEE JOINT
Many lower-extremity fractures are surgically managed with open reduction internal fixation (ORIF), which allows for faster weight bearing. Following the acute phase, rehabilitation for fracture depends upon whether or not surgical intervention was necessary, and which procedure was performed. In general, Patellar, femoral shaft, and condylar fractures Patellar fractures may result from a direct fall onto the knee and usually require surgery to heal. Fractures of the patella are classified based upon fracture type: stable fracture, displaced fracture, comminuted fracture, and open fracture. Stable fractures are a non-displaced form of fracture in which the pieces of bone are correctly matched, and tend to remain this way during healing, thus not usually requiring surgery. Displaced fractures present with separation of bone particles with loss of alignment and tend to require surgery. Comminuted fractures are a very unstable form of fracture in which the patella shatters into three or more pieces. This form of fracture requires surgical
assistive devices may be necessary, and gait training beneficial once the patient is released by their physician to begin physical therapy. Range of motion, progressive resistive strengthening exercises, proprioceptive training, and functional training are all fundamental parts of post-fracture rehabilitation. intervention. Open fractures are fractures in which the bone is exposed through the skin, often causing damage to surrounding muscles, tendons, and ligaments, and requires surgical intervention. These fractures are at higher risk for complications and often take longer to heal (OrthoInfo, n.d.b). Rehabilitation after patella fracture is crucial and relies heavily upon the fracture type and procedure performed. Range of motion, quadriceps and hamstring strengthening, gait training, and functional training should be implemented. Femoral shaft and condylar fractures also significantly affect the knee. Trauma is the most common mechanism of femoral shaft
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