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). 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.
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 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 end-stage
FRACTURES AFFECTING THE KNEE JOINT
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.
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, assistive devices may be 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 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 fractures, typically involving a direct hit to the thigh or an indirect force transmitted through the knee. Younger patients are often injured in high-energy mechanisms such as automobile accidents (Denisiuk, 2020).
Depending on fracture type, the medical treatment may or may not involve surgery. Assistive devices are recommended as needed, with range of motion, strengthening, and functional training implemented according to prescribing physician protocol. Epiphyseal fractures Epiphyseal fractures of the proximal tibia and distal femur are relatively rare and most commonly seen in the pediatric population. They may result from strains and sprains, and involve disruption in the cartilaginous physis of long bones. They are commonly classified by the five-part Salter-Harris Classification (SH). SH I fractures typically traverse the hypertrophic zone of the physis, splitting it longitudinally, thus separating the epiphysis from the metaphysis. When these fractures are nondisplaced, they may not be apparent on radiograph. Mild to moderate soft tissue swelling may be visible on radiographic film, and clinical signs may evident by swelling at the location of the epiphysis. Generally, closed reduction is necessary for displaced fractures, but open reduction with internal fixation may be required. Outcomes for this fracture are generally good. SH II fractures split partially through the physis and include a triangular bone fragment of the metaphysis. Surgical intervention is required and prognosis is variable. SH III fractures involve both physeal injury and articular discontinuity, involving the physis and extending through the epiphysis joint, with potential to disrupt the joint surface. This injury is less common and often requires open
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