I and II injuries, quadriceps strengthening is imperative throughout recovery. Hamstring strengthening should be avoided for at least 4 months to prevent damage to the reconstruction. Sport-specific therapy may commence four months postoperatively (Yaras, 2020). In 2013, a new lateral knee ligament was discovered: the anterolateral ligament (ALL). There had been controversy surrounding its true anatomical parameters and existence until the cadaveric study conducted by Claes et al. (2013) identified its true anatomic nature. The ALL bony attachments are the femur and tibia, and it is distinguished from the anterolateral joint capsule. The origination is the lateral aspect of the femoral epicondyle, anterior to the origin of the LCL. It takes an oblique course and inserts onto the anterolateral aspect of the proximal tibia and the lateral meniscus (Claes et al., 2013). Meniscal tears Menisci are critical for maintaining stability and force- absorption capabilities of the knee. It is estimated that menisci are responsible for 60% to 90% of loads transmitted across the joint space between the femoral condyles and tibial plateau, 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 ● 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
functional activity training. When operative intervention is deemed necessary, anatomical medial knee reconstruction may be recommended (Logan, 2016). Post-operative rehabilitation focuses on early motion and the return of normal neuromuscular control and coordination with progression based on attainment of specific phase criteria and goals that may vary according to the surgeon. Lateral collateral ligament The lateral collateral ligament (LCL), also known as the f ibular ligament serves as one of the key stabilizers of the knee joint. Originating on the lateral epicondyle of the femur and inserting on the fibular head, the lateral collateral ligament’s primary purpose is to prevent varus stress and posterior-lateral rotation of the knee. Lateral collateral ligament injury is less common than other ligamentous injury due to mechanism of injury required to impair the ligament—a varus force occurring from inside the medial aspect of the leg is required to sustain this injury. The most common mechanism of injury is seen via a high impact blow to the anteromedial knee, combining hyperextension and extreme varus force. Noncontact hyperextension and noncontact varus stressors have also been reported to cause LCL injuries, though they are rare (Yaras, 2020). LCL injury commonly occurs in tandem with injury to other structures including the PCL, ACL, or the knee capsule. Lateral capsular ligaments and fibular collateral ligaments may also be injured. More severe injury to the lateral aspect of the knee may involve the biceps femoris tendon and iliotibial band disruption at the attachment at the head of the fibula and Gerdy’s tubercle. Due to proximity anatomically, the peroneal nerve and popliteal tendon may also be involved, as well as the knee menisci. Signs and symptoms include a report of varus knee contact in a sport, with acute lateral knee pain and knee point swelling. Evaluation should include varus knee joint testing, and assessment of knee swelling. A comprehensive full range of motion knee exam is imperative for all patients. Palpation of the lateral knee should be performed with the most common exam finding being pain at palpation. This may also be evident along the infrapatellar bursa, Gerdy’s tubercle, and the patellar tendon attachment (Yaras, 2020). As it is rare for injury to occur to the LCL in isolation, treatment is heavily dependent upon what other structures were damaged. In more mild cases, the patient may be placed in a hinged brace and prescribed crutches with orders to weight bear as tolerated. Rest, ice, and compression are warranted in the acute phases. Physical therapy 3 to 5 days after injury to promote range of motion, decrease pain, and slowly implement progressive resistive training is beneficial. If the patient undergoes surgery, rehabilitation will be dependent on procedures provided and post-op protocol, which will vary by surgeon. Rehabilitation for Grade I and II strains generally may include passive and active prone knee flexion, initiated in the immediate weeks following injury to help prevent stiffness or contracture. Around 6 weeks post-injury, a hinged knee brace is removed, and the patient may begin physical therapy with focus on quadriceps strengthening, proprioceptive capabilities, and strengthening of the muscles of knee and hip. Patients may return to sports only when meeting the following criteria: full, painless knee motion, complete reduction of lateral knee tenderness, and complete resolution of ligamentous laxity. In general, return to sports is approximately 4 weeks for Grade I injuries, and 10 weeks for Grade II (Yaras, 2020). For Grade III injury rehabilitation, patients should be non- weight bearing in a knee immobilizer for 6 weeks after surgical interventions if they are performed. As in Grades
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