Atlas of knee MRI anatomy

A beautiful navigation through a complete knee MRI in all three planes. Thanx to http://w-radiology.com.

NEMEX-TJR neuromuscular training program

Neuromuscular training seems to gain ground in the therapeutic interventions for almost all the musculoskeletal disorders. It gradually becomes clear to everyone that the neuromuscular adaptations are much more profound and important for our body and its effort to heal itself. Recently, one more study showed the immediate efficacy of neuromuscular exercise in patients with severe osteoarthritis of the hip or knee - See more at Physiospot.

A very nice guideline for the NEMEX-TJR training program presented in this study can be found here.

Total Knee Replacement exercise booklet

Regular exercise to restore your knee mobility and strength and a gradual return to everyday activities are important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you exercise approximately 20 to 30 minutes two or three times a day and walk 30 minutes, two or three times a day during your early recovery.

A beautiful booklet with simple and important exercises published by Thunder Bay Regional Health Science Center.

Meniscal tears

A physical therapists will face these situations quite often in his daily practise. It is useful to know the main types of a meniscal tear and base his treatment plan accordingly.

Kevin Stone: The bio-future of joint replacement

Arthritis and injury grind down millions of joints, but few get the best remedy -- real biological tissue. Kevin Stone shows a treatment that could sidestep the high costs and donor shortfall of human-to-human transplants with a novel use of animal tissue.

Inspired by www.thestudentphysicaltherapist.com.

Proximal tibiofibular ligament instability

A nice and simple article by Dr. Robert F. LaPrade on this very rare pathology.

Injury to the proximal tibiofibular joint is rather rare, but it can be debilitating in patients who have symptoms.  The usual mechanism is having a patient fall on a plantar-flexed ankle, with the stress being brought through the fibula, such that the proximal fibula will sublux out of place over the lateral aspect of the knee joint.  In other circumstances, there may be a more obvious injury where one has a significant trauma or motor vehicle accident where the proximal tibiofibular joint is disrupted. 

In most circumstances, it is the posterior proximal tibiofibular joint ligament which is disrupted.  This results in the fibula rotating away from the tibia during deep squatting.  This can result in a feeling of instability, a visible bony deformity, and concurrent irritation of the common peroneal nerve.  This is because the common peroneal neve crosses the lateral aspect of the fibular neck within 2-3 cm of the lateral aspect of the fibular head. 

Read more.

Selected as "one of the Best Doctors in America", Dr. Robert F. LaPrade is a complex orthopaedic (orthopedic) knee surgeon at The Steadman Clinic in Vail, CO specializing in complex knee injuries.  He also serves as Chief Medical Officer, Deputy Director of the Sports Medicine Fellowship Program and Director of the International Research Scholar Program at the Steadman Philippon Research Institute.

Hoffa's syndrome | Fat pad impingement

A very nice article on the fat pad impingement syndrome (Hoffa's syndrome) by Dr Chang Haw Chong :

What is Fat Pad Impingement?

Sometimes after a forceful direct impact to the kneecap, the fat pad can become impinged (pinched) between the distal thigh bone ( femoral condyle) and the kneecap (patella).

As the fat pad is one of the most sensitive structures in the knee, this condition is known to be extremely painful. The knee pain is  situated anteriorly on either side of the lower kneecap and is worsened by straightening (extension) of the knee joint. Hence the fat pad comes under constant irritation and may become significantly inflamed.

It is also termed Hoffa’s Syndrome.

What Are the Symptoms of Fat Pad Impingement?

• Pain and/or swelling around the bottom and under the kneecap
• Patients may have a history of knee hyper-extension (called genu recurvatum)
• Positive Hoffa’s test (with the patient in lying with their knee bent, the examiner presses both thumbs along either side of the patellar tendon, just below the patella. The patient is then asked to straighten their leg. Pain and/or apprehension of the patient is considered a positive sign for fat pad impingement)

Treatment of Fat Pad Impingement

Treatment of this condition is normally by conservative methods such as:

• Rest and avoiding aggravating activities – stop running.
• Ice or cryotherapy to reduce pain and inflammation.
• Physiotherapy modalities such as ultrasound and TENS.
• Muscle strengthening exercises to maintain the strength and fitness of the surrounding muscle groups
• Taping the patella may help. One method involves taping the upper surface of the patella to allow more space for the structures beneath the lower surfaces i.e. the fat pad.  This leads to less stress and impingement on the fat pad.

If conservative treatment does not work then surgery may be advised. This may involve the complete or partial removal of the fat pad itself.

Read more.

You can also read a nice article here.

Iliotibial band syndrome

Tensor fasciae latae muscle

Origin: Spina iliaca anterior superior

Insertion: iliotibial band

Actions: Hip > ABD, FLEX, INT ROT

Gluteus maximus muscle

Origin: Dorsal surface of the sacrum and facies glutea of the ilium

Insertion: Upper fibers > iliotibial band, lower fibers > tuberositas glutea of the femur

Actions: Hip > EXT, EXT ROT, upper fibers > ABD, lower fibers > ADD

Iliotibial band insertion: lateral tubercle of the tibia (tuberculum of Gerdy, after French surgeon Pierre Nicolas Gerdy [1797–1856]).

Iliotibial band syndrome is a common overuse syndrome especially in long distance athletes. There are a lot of factors that can cause this syndrome, both biomechanical and training, but the exact cause is not completely understood.

When an athlete is running his foot touches the ground about 3000 times per mile. After running for 10 times he has touched the ground 30000 times. The force required to lift his body weight while running is about 3 times this weight. So, if someone weight 70 kg he will need to exert force to lift 210 kg. This means that his leg joints and muscles are loaded with extreme forces during exercise.

Biomechanics

The iliotibial band (ITB) provides the knee with stability. When the knee is in flexion over 30 degrees, the ITB is moving dorsally behind the lateral epicondyle of the femur. When the knee is extended, the ITB is moving ventrally in frond of the lateral epicondyle of the femur. This movement irritates the ITB and the bursa that lies under the insertion of it and attaching on the periosteum of the lateral epicondyle of the femur (Running News, Margaritis, 2008).

       

Research has shown that the joint capsule of the knee is folding at the point of attachment of the ITB and it is this structure that is inflamed in the ITB syndrome and not the ITB itself (Running News, Margaritis, 2008).

Causes

The ITB syndrome is an overuse syndrome which appears when the body's natural healing mechanism do not have enought time to heal the micro-damages at the point. However, there are a lot of risk factors that can increase the chances of it to appear. Here are some major causes (Running News, Margaritis, 2008):

1. Uneven leg lenght > causes variations in the function and position of the hip abductors and the pelvis bone increasing tension on the ITB

2. Genu varum > increases tension on the ITB

3. Foot overpronation > causes tibial internal rotation and hip adduction increasing tension on the ITB

4. Week hip abductors > causes increased hip adduction and internal rotation increasing tension on the ITB

5. Myofascial limitations > tight hip flexors and/or extensors and rotators increase tension on the ITB

Assessment

The pain is located at the lateral side of the knee, but it may also appear in the hip. Pain increases with running, hip and knee active flexion, hip active or passive adduction. Palpating the region can also reproduce the symptoms.

Special tests to reproduce the symptom:

Ober test > positive if the hip remains abducted.

Thomas test > positive if the knee off the bed is not flexed more than 70 degrees or hip cannot be adducted more than 15 degrees.

During assessment, the iliopsoas, the rectus femoris, the gastrocnemius and the soleus muscles should be also assessed for tightness or weakness.

How to protect yourself against the ITB syndrome

• Avoid running on hard surfaces
• Avoid running in descending surfaces
• Avoid extreme increases in your training session
• Have proper running shoes and buy new ones every 300-400 miles of training
• Stretch your legs during and after your training
• Increase knee, hip and pelvis muscle strength

Physical therapy for ITB syndrome

Acute phase - inflammation (2-5 days):

- reduce inflammation putting ice at the region for 10-15 minutes, 2 times per day

- avoid movements that reproduce the symptoms and take some rest

- add light stretching of the ITB to avoid contractures during the healing process

Later phase - proliferation (up to 6 weeks):

- facilitate fibers' normal alignemnt and prevent abnormal activation to become habitual

- increase blood flow to the region through passive activation, static stretching, gentle isometric activation with very minimum or no loading and open chain exercises, massage, and electrotherapy

- strengthen the hip abductors and external rotators, the quadriceps and the cuff muscles

- stretch the ITB and the hip adductors, extensors and internal rotators

Remodelling phase (up to 1 year):

- rebuild all locomotive properties and put the patient back to his/her daily life as functionally as possible

- use passive, active and isometric activation

- work with coordination, proprioception and functional activation

- suggested methods: ballistic stretching, PNF, dynamic stretching, weights in closed chain

- strengthen the hip abductors and external rotators, the quadriceps and the cuff muscles

- stretch the ITB and the hip adductors, extensors and internal rotators

References:

• Brody TL, Carrie MH. Therapeutic Exercise: Moving Toward, Function. 3rd ed. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2011.
• Running News. The iliotibial band syndrome. Anastasios Margaritis. c2008 [cited 2008 November 28]. URL: http://www.runningnews.gr/item.php?id=4930.
• Schuenke M, Schutle E, Schumacher U. Thieme Atlas of Anatomy: General Anatomy of the Musculoskeletal System. New York: Thieme Medical Publishers, Inc.; 2006.

Always visit your personal GP, Orthopedic MD or PT before trying anything yourself that may worsen the situation.

Meniscal tears risk factors

Source: Anatomy and Physiotherapy

Musculoskeletal Monday by Gökmen Yapali, MSc: 

Meniscal tears are an important cause of disability and a risk factor for other conditions such as osteoarthritis. There are a lot of contributing risk factors for meniscal tears, both occupational and personal. Understanding risk factors allows practitioners and researchers to diagnose, treat and develop prevention strategies for the knee. 

A meta-analysis was performed for 17 risk factors. 11 studies, with a total of 7358 participants, were selected for a systematic review. Data of 10 of the 11 studies was available for meta-analysis. Qualitative analysis was conducted using data from 3 of the 11 studies. 

Results showed strong evidence that age (older than 60 years), gender (male), work-related kneeling and squatting, and climbing stairs (greater than 30 flights) were risk factors for degenerative meniscal tears. Strong evidence was also found that playing soccer and playing rugby were strong risk factors for acute meniscal tears. Waiting longer than 12 months between the anterior cruciate ligament injury and reconstructive surgery was a strong risk factor for a medial meniscal tear but not for a lateral meniscal tear.

> From: Snoeker et al., J Orthop Sports Phys Ther 43 (2013) 352-367. All rights reserved to the Journal of Sports & Orthopaedic Physical Therapy.

Nordic walking and osteoarthritis

For the aftercare stage of patients with osteoarthritis operation in the hip or the knee, the physical therapist should advise the patient on maintaining the targets they have achieved, for instance by giving them tips on engaging in healthy physical activity behavior in their everyday life or, if useful, by helping patients enter regular community exercise or sports programs, or supervised group exercise programs, such as tai chi, Nordic walking or other exercise programs (KNGF Guidelines for osteoarthritis of the hip and knee).

Assessment & treatment guidelines_1

Physiotherapy assessment and treatment in Physical Therapy education is something that you will start doing from day 1.

I believe that there is only one way to be good in that - by organizing all this information in nice documents and have them in your portfolio to access them anytime.

Here is a small file I have created with assessment and treatment guidelines for the following cases:

Osteoarthritis of the hip

Knee trauma

Acute ankle sprain

Thoracic outlet syndrome

Olecranon fracture

Carpal tunnel syndrome

Low back pain (non-specific, sub-acute phase)

Shoulder pain

Tennis elbow

Colles fracture