Total knee arthroplasty When conservative measures have been exhausted, a patient may be a candidate for total knee arthroplasty (TKA). Surgical techniques for TKA vary by surgeon. Most techniques involve complete removal of the femoral and tibial joint surfaces and resurfacing of the patella using cemented fixation. Immediate rehabilitation depends on surgical procedure and physician protocol, however most patients are administered a front wheel walker and given orders to weight bear as tolerated (OrthoInfo, n.d.d). Rehabilitation efforts should focus on achieving 0 to 90° of knee range of motion within the first few weeks. Aggressive stretching and joint mobilization may be used if range of Hamstring strain Hamstring strains are four times more likely to occur than quadriceps strains, with a rate of 12% to 16% of all athletic injuries (Schmitt, 2012). The most common mechanisms of injury are sprinting in track and field, football, baseball, and waterskiing. Risk factors for sustaining hamstring injury include decreased flexibility, muscle fatigue, decreased strength, poor core stability, poor warm-up, poor lumbar posture, and previous history of hamstring injury, with the latter being the most prevalent risk factor. The actual mechanism of injury is thought to be due to weakness of the muscle in its eccentric state. Biomechanically, high-speed running requires the hamstring to contract eccentrically when the hip is flexion, thus placing the hamstring in an elongated position, while the lower leg moves into flexion of the knee (Schmitt et al., 2012). Hamstring strains are graded on a scale of I to III, where Grade I is the least involved with micro damage, Grade II is a partial tear, and Grade III is a complete tear of the muscle. Grade III lesions may require surgery, and the patient often presents with a significant limp. Swelling, ecchymosis, poor tolerance of knee motion, and pain are also common presentations (Schmitt et al., 2012; Medline Plus, n.d.). There is evidence suggesting that incorporating lengthened state eccentric hamstring training may reduce the rate of re-injury. Other intervention strategies include avoiding stretches that cause pain and proceeding cautiously with progressive resistance exercises. Very light resistance isometrics should be the initial exercise program, with high repetition rate. Spica wrapping or splinting of the knee may be required for Grades II and III injuries initially to reduce inflammation and protect the joint. Extended phases of hamstring strain rehabilitation around 6 weeks post- injury may consist of more dynamic exercises and higher- 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 resistance, lower-repetition exercises. Quadriceps strain and contusion injury
motion is progressing too slowly. Ultimately, if the patient does not achieve this range of motion, the surgeon may recommend surgical manipulation under anesthesia. Open kinetic chain exercises such as quadriceps isometrics, heel slides, straight leg raises, and hip adductor squeezes into a pillow should be taught initially, with progression to standing closed kinetic chain exercises as tolerated by the patient. These may include standing partial squats, step- ups, and step-downs. Gait and functional activity training, as well as activity modification and instruction to avoid kneeling, should also be included in the rehabilitation program.
SOFT-TISSUE INJURIES OF THE KNEE
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, 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).
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