Page 2 P H Y S I O T H E R A P Y June, 1967 A MODERN APPROACH to KNEE INJURIES B y J. A . C . P R I N S L O O , B .S c . (P h y sio .)(R a n d ) T h e treatm en t o f k n ee injuries h as a lw a y s b een m a in ly th e r e s p o n sib ility o f .the p h y sio th e r a p ist, e s p e c ia lly in o r th o p a e d ic and re h a b ilita tio n u n its, o n c e co r r e c tiv e surgery h a s b een d o n e . A lth o u g h m o st o f th e o ld p rin cip les still h o ld , recent a d v a n c e s in th e a ctu a l surgery h a v e b een so g reat, th a t th e c o n s e q u e n t a n d c o n c o m ita n t p h y sio th e r a p y trea tm en t h a s to b e m o d ifie d to m eet d e m a n d s an d en su re la stin g resu lts. T h e trea tm en t sh o u ld be a p p r o a c h e d in te l­ lig en tly a n d d isc r e tio n uspd in e a c h in d iv id u a l c a se in ord er to o b ta in m a x im u m results. W ro n g o r bad trea tm en t can o fte n d o m o r e h arm than n o trea tm en t at all a n d even reverse th e co rr e c tiv e and cu ra tiv e p r o c e sse s. M o v em en ts o f the K nee J o in t F le x io n is p ro d u c e d b y th e h a m strin g s, i.e . b icep s, sem i- te n d in o su s an d se m im e m b r a n o su s, a s w ell a s g a str o c n e m iu s, p o p lite u s, p la n ta ris, sa r to riu s a n d gracilis. P o p lite u s in itia tes flex io n b y la tera lly r o ta tin g th e fem u r o n th e tib ia , w h ich can then a lso be a ssisted b y se m ite n d in o s u s, se m im e m ­ b ra n o su s, sa r to riu s a n d gracilis. E x c essiv e fle x io n is c h e c k e d by th e c o n ta c t o f the le g and th ig h , a s w ell a s th e stru ctu re o f th e tib ia l a n d fem o r a l c o n d y le s; a ls o p a rtly by ten sio n in th e lig a m e n tu m p a te lla e a n d the p o ste r io r cru cia te lig a m e n t. E x ten sio n is p ro d u c e d b y q u a d ricep s a n d te r m in a te d by m ed ia l r o ta tio n o f th e fem u r o n th e tib ia , w h ic h is th e very im p o r ta n t fu n c tio n o f v a stu s m ed ia lis. E x c essiv e e x te n sio n is p reven ted b y th e te n sio n o f the p o ste r io r part o f th e c a p su la r lig a m e n t, th e m ed ia l a n d the lateral c o lla te r a l lig a m e n ts a n d th e p o ste r io r cru cia te lig a m e n t, a s w ell a s th e h a m strin g s a n d g a str o c n e m iu s. R o t a tio n , u n a ss o c ia te d w ith fle x io n o r e x te n s io n , is m o st p r o n o u n c e d w ith th e k n e e flex ed to a rig h t a n g le. M ed ia l rotation is p ro d u ced by p o p lite u s , se m ite n d in o su s a n d p o ss ib ly se m im e m b r a n o su s, gracilis a n d sa r to riu s. It is c h eck ed by th e a n te rio r c ru cia te lig a m e n t. L a tera l ro ta tio n is p ro d u ced b y b icep s a n d c o n tr o lle d by th e m ed ial co lla te r a l lig a m e n t. T h e e x te n d e d p o sitio n o f th e k n ee in th e erec t p o stu r e is m a in ta in ed m a in ly b y gra v ity and a s lo n g a s th e ilio ­ fem o r a l lig a m e n t is ten se, a s this p rev en ts lateral r o ta tio n o f th e fem u r. T h u s flex io n o f th e h ip a n d th e k n ee h a v e to o c c u r c o n c o m ita n tly . Y e t, v a stu s m ed ia lis is th e m o st im p o r ta n t sin g le a n d a c tiv e m u scu la r fa c to r c o n c e r n e d in o b ta in in g “ lo c k in g ” o f th e k n ee. R ou tin e E x a m in a tio n o f th e K nee T h e f o llo w in g p o in ts o f e x a m in a tio n , i f fo llo w e d c o n s is ­ te n tly , w o u ld s h o w u p m o st fa cets o f in te rn a l d era n g em en t o f th e k n e e , w ith a sso c ia te d a n d c o n c o m ita n t in ju ries a n d is su p p lem en ted b y stress ra d io g ra p h y w h ere a n y d o u b t e x is ts or to co n firm a d ia g n o sis. 1. M o v e m e n t. (A c tiv e a n d p a ssiv e ). (a) E x te n sio n to th e fu ll. L o s s o f e x te n s io n is u su a lly p a in fu l and th e site o f p ain is im p o r ta n t. (b ) F le x io n . L o s s o f flex io n is n o t o f t o o m u c h im p o r ­ ta n c e a s this is th e first rea ctio n t o ev en m in o r trau m a. 2. C re p ita tio n . (a) P a te llo -fe m o r a l, fo u n d b y m o v in g th e p a te lla in all th e d ir e c tio n s. (b) J o in t, fo u n d by n o rm a l p a ssiv e m o v e m e n t w h ilst p a lp a tin g th e jo in t at th e sa m e tim e. 3. C o lla te r a l L ig a m e n ts . L a x ity o f b o th th e m ed ia l a n d th e lateral lig a m e n ts ca n be d e m o n str a te d b y p a ssiv e m e d io -la te r a l stress o f th e fu lly e x te n d e d k n ee. 4. C r u c ia te L ig a m e n ts. T h e p a tie n t is su p in e w ith th e k n e e flex ed to a righ t a n g le and fu lly rela x ed . T h e tib ia is m o v e d p a ssiv e ly o n th e fem u r. U n d u e laxity o f th e a n te rio r cr u c ia te lig a m e n t is d e m o n str a te d by “ draw er fo r w a r d s” a n d tra u m a to th e p o ste r io r cru cia te lig a m e n t is sh o w n u p by “ draw er b a ck w a rd s” . 5 . T ib ia l R o ta tio n . (a) M ed ia l r o ta tio n . T h e p a tie n t is in su p in e w ith the hip a n d k n ee fu lly flex ed . U s in g th e f o o t a s a lever, th e tib ia is m e d ia lly r o ta te d by a circu m ­ d u c tio n m o v e m e n t w h ic h e n d s in n e a r ly full e x te n ­ sio n , w h ile th e j o in t is p a lp a te d . T h is is used sp ec ifica lly to in v estig a te th e c o n d itio n o f the p o ste r io r p o r tio n o f th e m ed ia l m en iscu s. (b ) L ateral r o ta tio n . T h is is th e reverse o f the a b o v e p ro ced u re a n d is u sed t o e x a m in e th e p o sterio r p o r tio n o f the lateral m en iscu s. (c) C ir c u m d u c tio n . T h is is d o n e w ith th e k n ee in 2 0 d eg rees flex io n th r o u g h o u t a n d b o th hands p a lp a te th e jo in t w h ile a sm all c ircle is d escribed. T h is te c h n iq u e is u sed to d etect le s io n s in the an te rio r p o r tio n s o f th e m en isci. 6. M a n ip u la tio n U nder A n a esth esia . T h is is se ld o m u sed as p a in is o f great d ia g n o stic value a n d thu s it w o u ld o n ly be a last resort. 7. P ain . T h is is tested by p a tie n t’s sy m p to m s as w ell a s by pressure p a lp a tio n fo r ten d e rn ess o f th e co lla te r a l lig a m e n ts and th e jo in tlin e . E xact lo c a liz a tio n o f th e p a in a n d ten der­ n e ss ca n b e o f d ia g n o stic va lu e. A b d u c tio n and a d d u c tio n o f th e tibia w ill p in ch th e r esp ectiv e m en isci (if ruptured) a n d ca u se p a in . 8 . R e fle x e s . K n e e jerk , a n k le jerk , p lan tar r e sp o n se e tc . are ro u tin e ly tested . 9. Effusion. T h is is e s ta b lish e d by the “ p a te lla ta p ” a n d jo in t flu c tu a tio n . 10. G a it, g e n e r a l a p p e a ra n c e a n d s y s te m a tic re a c tio n s ( if an y, to d eterm in e se p tic fo c u s). T R A U M A T I C C O N D I T I O N S O F T H E K N E E 1. S O F T T I S S U E I N J U R I E S . A . T raum atic S yn o v itis. N o r m a lly s y n o v ia l fluid , ^ c c , is p ro d u c e d by sp ecial cells in th e sy n o v ia l m em b ra n e. It c o n sis ts m a in ly o f m ucin, w h ic h is a lk a lin e , an d fulfils th e fu n c tio n o f p r o te c tio n a g a in st e x c e ssiv e a c id ity . F u r th er it lu b rica te s th e jo in t s , is c o n c e r n e d w ith th e n u tritio n o f th e j o in t stru ctu res a n d the rich b lo o d s u p p ly o f th e sy n o v ia l m em b ra n e d issip a tes e x c e s siv e heat a n d m e ta b o ly te s. T h e p r o d u c tio n o f sy n o v ia l fluid is stim u la ted b y the n o rm a l m o v e m e n t o f th e jo in t. O n trau m a, th e sy n o v ia l m em b ra n e reacts t w o f o l d : 1. T h er e is in creased a c tiv ity o f th e sy n o v ia l c e lls w ith th e resu lta n t in crease in m u c in se c r e tio n a n d even tu al h y p ertro p h y o f th e cells. 2. A gen eral rea ctio n a lso ta k e s p la ce, w h ic h c o n sis ts o f v a so d ila ta tio n w ith e x tr a v a sa tio n o f p la sm a , o b liter a ­ tio n o f ly m p h a tics, in creased a c id ity a n d e v e n p re­ cip ita tio n o f fibrin w ith resu lta n t g ra n u la tio n . T r a u m a tic sy n o v itis o f th e k n ee is in a c tu a l fact a sy m p to m a c c o m p a n y in g all a c u te k n ee injuries a n d c a n n o t be d ia g n o sed as a c o n d itio n a s su ch u ntil all o th e r p o ss ib ilitie s h a v e been elim in a te d . It c o n sis ts o f sw e llin g o f th e k n ee j o in t w ith “ flo a tin g ” o f th e p a te lla w h ich ca n b e d e m o n str a te d b y th e “ p a te lla ta p ” . U s u a lly it ap p ea rs a few h o u rs after injury, offers little r e sista n ce t o p ressure a n d is n o t a c c o m p a n ie d b y a general rea ctio n . T re a tm e n t: O n c e all o th e r p o ss ib ilitie s h a v e b een elim in a te d a s a result o f a c o m p le te in v e stig a tio n , a sim p le trau m atic R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) sy n o v itis is treated w ith a c o m p r e ssio n b a n d a g e and n o n ­ weight b earing e x e r c ise s to th e q u a d ricep s. Ic e a p p lic a tio n s can be u sed to a id c ir c u la tio n , but c o n sc ie n tio u s e x erc ise is o f prim e im p o r ta n c e . I f th e effu sio n is p a rticu la r ly g ro ss, it is aspirated b e fo r e a p p ly in g the b a n d a g e. C h ron ic sy n o v itis is difficu lt to treat a s it is u su a lly a s a result o f n e g le c tin g e x erc ise in th e in itia l sta g e a n d th is can never be c o m p e n sa te d fo r. A t its best it ta k e s several w eek s a n d e v en m o n th s o f c o n c e n tr a te d e x erc ise to clea r up the c o n d itio n a n d r e sto r e th e m uscu lar b a la n ce in a w e a k and unstable k n ee a n d a t its w o rst it ca n lead to p o st-tr a u m a tic o steoarthritis. 3 T raum atic H a em a rth ro sis. It is very se ld o m that a sim p le h a em a rth ro sis w ith o u t a cco m p a n y in g tra u m a t o b o n e, ca p su le , lig a m e n ts o r o th e r soft tissu es, o c c u r s. I f all o th e r p o ss ib ilitie s h a v e been elim in ated , it is treated by im m e d ia te a sp ir a tio n , a p p lic a tio n o f a c o m p ressio n b a n d a g e and im m o b iliz a tio n fo r ten to fourteen d ays t o p rev en t furth er h a em o rrh a g e. A fte r that active k n ee ex e r c ise s are started . U su a lly a h a em a rth ro sis is th e resu lt o f trau m a to the synovial m em b ra n e, lig a m e n ts o r a fracture o f th e tibial spine. In th is c a s e th e re is little d a m a g e a n d h a em o rrh a g e and virtually n o c lo ttin g o f b lo o d . U s u a lly th is ty p e h a s a g o o d prognosis a n d is treated by a sp ir a tio n and rectific a tio n o f causative trau m a. S u b c h o n d r a l fractures m a y n o t b e visib le on rad io g ra p h y , b u t can b e d ia g n o sed b y virtu e o f the ex cessive fat g lo b u le s flo a tin g o n th e su rfa ce o f th e aspirated fluid or by m ea n s o f rep eat ra d io g ra p h y a fter ten to fourteen days. I f it is su sp e c te d , w e ig h tb e a r in g w o u ld be deferred until con firm ation o r o th e r w ise . I f th e so ft tissu e d a m a g e is m uch m o re e x te n siv e , there will be e x c e s siv e h a e m o r r h a g e w ith c lo ttin g . T h is stim u la tes mucin p r o d u c tio n w ith a resu lta n t e ffu sio n a n d o b liter a tio n o f the ly m p h a tic s. O r g a n iz a tio n a n d e v e n tu a l a d h e sio n form ation m ay ta k e p la c e , grea tly im p a irin g fu n c tio n and the progn osis is n o t ro sy . C lin ica lly a h a em a rth ro sis can b e d istin g u ish ed fro m an effusion in th a t it o c c u r s v irtu a lly im m e d ia te ly after injury (o f co u rse there are v a ry in g d eg rees a n d c o m b in a tio n s o f both), there is u su a lly a c u te p ain a n d even sy ste m ic r ea ctio n s like a raised tem p er a tu re an d th e sw e llin g h as a h igh er resistance t o pressu re than a sim p le e ffu sio n . It m ay be o f u se h ere to m e n tio n w h a t th e id ea l c o m p r e s­ sion ban d age s h o u ld b e lik e to fulfil its m a in fu n c tio n , nam ely to c o n tr o l a n d p rev en t e ffu sio n . It is u su a lly a p p lied by the su r g e o n , im m e d ia te ly after c o m p le tio n o f th e o p era ­ tion and b efo re th e to r n iq u e t is re m o v e d o r after a sp ira tio n o f the jo in t. A t lea st a p o u n d o f c o tto n w o o l is used and it is ap p lied in three layers, e a c h secu red by a tig h t d o m e tte bandage a n d str e tc h in g fro m th e a n k le to th e g ro in . T h is ensures fu ll c o n tr o l o f th e s o ft tissu es an d n o k n ee m o v e m e n t will be p o ssib le . T h u s sta tic q u a d ricep s ex e r c is e s ca n be undertaken s a fe ly w ith o u t fear o f k n e e -m o v e m e n t. 2 . L I G A M E N T O U S I N J U R I E S . T h e lig a m e n ts c o n stitu te th e p a ssiv e c o n tr o l a g a in st injury by ex c e ssiv e m o v e m e n t in th e j o in t a n d th e y a ls o d eterm in e the direction in w h ic h m u scle a c tio n w ill be tra n sm itted to the m o v in g su rfa ces. It is a w e ll-k n o w n fa ct th a t in jury to a n y on e iso la te d lig a m e n t w ill c a u se v ery sm a ll in sta b ility in a joint su rr o u n d ed b y n o rm a l m u scu la tu re an d n o t su bjected to excessiv e m u scu la r w o rk . T h u s la x ity and in sta b ility result from tra u m a to m o r e th a n o n e lig a m e n t w ith o r w ith o u t co n co m ita n t m en isca l injury. T h e o n ly e x c e p tio n p o ss ib ly is the m ed ial co lla te r a l lig a m e n t. A . M ed ia l L igam en t. 1. P a r tia l R u p tu re o r S p ra in . T h is u su a lly o c c u r s a s th e resu lt o f a r ela tiv ely m in o r external ro ta ry strain w h ilst th e k n e e is in slig h t flex io n . It can be r e c o g n iz e d b y sw e llin g o v e r th e m ed ia l a sp ec t o f the k n ee w ith v a g u e ten d e rn ess. T h is ten d e rn ess can be localized b y p a lp a tio n , u su a lly n ea r th e fe m o r a l a tta c h m e n t and ca n b e r ep ro d u ced b y lateral r o ta tio n in slig h t flex io n . T he jo in t is sta b le o n p a ss iv e a b d u c tio n and a sy n o v itis or June/ 1967 Page 3 o th e r c o m p lic a tio n s a b se n t in a sim p le tear. W h ere c o m ­ p lic a tio n s are p resen t, a fu ll d ia g n o sis is im p o ssib le an d the le sio n is treated p rim a rily w ith th e p o ss ib ility o f a later in v e stig a tio n . T re a tm e n t A lo c a l in je ctio n o f a n a e sth e tic in to th e area o f m o st ten d e rn ess, fo llo w e d b y a n e la stic a d h e siv e b a n d a g e o fte n a ffo rd s d ra m a tic r e lie f an d q u a d ricep s drill a n d e v e n w e ig h t­ bearin g can b e in stitu ted im m e d ia te ly in th e se sim p le c a s e s. In th e ca se o f e .g . e ffu sio n as a c o m p lic a tio n , th e a b o v e trea tm en t is g iv e n , p lu s a c o m p r e ssio n b a n d a g e and im ­ m e d ia te n o n -w e ig h tb e a r in g q u a d ricep s drill to co n tro l and d ecrea se th e sy n o v itis. O n c e the sw e llin g is d o w n a n d the m u s c le s c a n c o p e , w eig h tb e a rin g is started . A full d ia g n o sis, e .g . m en isca l tear, ca n o n ly be m a d e sh o u ld the jo in t n o t stan d u p to the stra in o f sp o rt e tc . again . P e llig rin i S te id a 's D ise a se . In so m e o f th e se c a se s o f p artial rupture o f th e m ed ia l lig a m e n t th e sy m p to m s (pain and d ecreased R O M ) se em to in crea se, ev en in th e p resen ce o f d iligen t p h y sio th e r a p y trea tm en t. T h is is d u e t o p o st-tr a u m a tic p ara-articu lar o ss ific a tio n o r so -c a lle d P elligrin i S te id a ’s d isea se. T h is c o n ­ d itio n is said t o resu lt fro m ca lc ific a tio n a n d resu lta n t o ssific a tio n at a fertile site , u su a lly an a rea o f o e d e m a or h a e m a to m a a n d is thu s m o r e freq u en tly fo u n d in c a se s o f direct trau m a to the m ed ia l lig a m e n t, lik e a b lo w , rather th a n ind irect tra u m a a s d esc rib ed a b o v e . O n e x a m in a tio n in th e early sta g e s there is gro ss w ea k n ess and lo ss o f flex io n (e v e n p a ssiv e ), severe p a in , lo ca lized ten d e rn ess and a v a g u e th ic k e n in g o f the d eep tissu es. A t a later sta g e th e sy m p to m s are less a cu te, b ut a b o n y p r o ­ m in e n c e ca n be felt m e d ia lly . U ltim a te d ia g n o sis c a n b e m a d e b y m e a n s o f ra d io g ra p h y , u su a lly v isib le o n ly a fte r six w e e k s, but th e a b o v e c a n b e clear cu t e n o u g h . T rea tm en t. 1. M a in ly b y p rev en tin g it by a ccu ra te d ia g n o sis and corre ct treatm en t o r by r e c o g n iz in g it in an early sta g e an d a v o id in g p a ssiv e m o v e m e n t, m a ssa g e o r m a n ip u la ­ tio n , all o f w h ich ten d to e n c o u r a g e th e fo r m a tio n o f h e te r o to p ic b on e. 2. O n c e a d ia g n o sis h a s b een m a d e , all v ig o r o u s exerc ises a re a v o id e d , but g e n tle q u a d ricep s drill and flex io n e x e r c ise s u p to th e lim it o f p a in are d o n e du rin g the a c tiv e p h a se , w h ich m a y la st fro m six to eig h teen m o n th s. S u rgical in te rv en tio n is d ilite r io u s in th e early sta g e . In so m e c a se s th e d ise a se is se lflim itin g and r eso r p tio n m ay e v e n ta k e p la c e . 3. In m o st c a se s su rgical e x c is io n o f th e h e te r o to p ic b on e is n ecessa ry , a s w ell as se v erin g o f all a d h e sio n s, o n c e th e d isea se is n o lo n g e r a c tiv e . A c o m p r e ssio n b an d age is a p p lied a n d a ctiv e k n ee m o v e m e n ts started w ithin 3 -4 days. 2 . C om p lete Rupture. T h is is a v ery d isa b lin g injury a s, a p art fr o m th e in sta b ility cau sed in th e k n e e jo in t, it is u su a lly a c c o m p a n ie d b y trau m a t o th e c ru cia te lig a m e n ts, ru pture o f th e c a p su le , m en isca l injury a n d fracture o f th e lateral c o n d y le o f th e tibia. It is u su a lly ca u se d b y d irect tra u m a an d fo llo w e d b y severe p ain a n d d isa b ility and a se n sa tio n o f “ te a r in g ” in th e jo in t. It m a y a lso be m isle a d in g a s t o se r io u sn e ss , a s a h a em a rth ro sis m a y b e a b se n t in th e c a se o f a to r n o r ruptured c a p su le , w h ich a llo w s th e b lo o d t o e s c a p e fro m th e jo in t. A c o m p le te ru p tu re can o n ly be finally d ia g n o se d after ab d u c tio n “ stress” r a d io g ra p h s. T rea tm en t. (a ) C o n se rv a tiv e . T h is is fo llo w e d in c a se s w h ere th e le s io n is n o t qu ite c o m p le te o r o p e r a tiv e m ea su res are c o n tr a -in d ic a te d , e.g . in th e p r e se n c e o f sk in injury w h ich w ill d e la y o p e r a tio n fo r lo n g er th a n te n days. T h e trea tm en t c o n sis ts o f a sp ir a tio n o f th e jo in t in the ca se o f gro ss sy n o v itis or h a em a rth ro sis a n d th e n th e a p p lica tio n o f a c o m p r e ss io n b a n d a g e, so m e tim e s rein fo rced e .g . by K ra m er w ire o r a p o ste r io r sp lin t. Q u a d ricep s drill is given P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y June, 1967 in th e se c a se s w ith e x trem e ca re and a lw a y s w ith in th e lim it o f p a in , a v o id in g a n y m o v e m e n t w h a tev er a n d sto p p in g if th e re is th e slig h te st in crea se in sy m p to m s. O n c e th e sw ellin g h a s su b s id e d , a sk in tig h t w a lk in g p la ster is a p p lied and e x te n siv e q u a d ricep s drill ca n b e c o m m e n c e d . W eig h tb e a rin g is a llo w e d a fe w d a y s la ter, a lw a y s w ith th e u n d ersta n d in g that the sy m p to m s h a v e su b sid e d su ffic ien tly and th e m u s­ cu la tu r e c a n c o p e a d e q u a te ly . P laster im m o b iliz a tio n is m a in ta in ed fr o m six t o tw e lv e w e e k s a n d m a in te n a n c e and in crea se o f stren g th o f a ll m u scle g r o u p s a ro u n d th e k n ee d u rin g th is tim e is th e o n e sin g le fa c to r w h ic h can d eterm in e c o m p le te r e c o v e r y o r o th e r w ise . O n c e th e p la ste r is r e m o v e d , m o b iliz a tio n o f th e k n e e is c o m m e n c e d a n d correct an d even p r o te c tiv e gait m u st b e ta u g h t. Q u a d ricep s ex e r c ise s sh o u ld b e kep t u p fo r a fe w m o n th s. (b) O p e r a tiv e . T h is is u su a lly reso rted to in th e p resen ce o f o th e r d is­ a b lin g injury, e .g . c ru cia te o r m en isca l d a m a g e , or w h ere th e sin g le injury to th e m e d ia l lig a m e n t is s o e x te n siv e a n d c a u se s su c h in sta b ility , th a t it m a y lea d t o m o r e d a m a g e o f o th e r stru ctu res c o n tr o llin g th e s ta b ility o f th e k n e e jo in t. T h u s in m o st c a se s it w ill b e part o f a gen eral rec o n s tr u c tiv e o p e r a ­ tio n , w h ic h is d iscu ssed later. H e r e th e k n e e w ill be im m o b il­ iz e d fo r fo u r to six w e e k s , d u rin g w h ich tim e q u a d ricep s drill a n d gen eral m a in te n a n c e ex e r c ise s are d o n e fo llo w e d b y m o ­ b iliz a tio n a n d w eig h tb e a rin g . B . L ateral L igam en t. T h is lig a m e n t is o f rela tiv e u n im p o r ta n c e in sta b ilizin g th e k n ee jo in t. It is rein fo rced b y th e ilio tib ia l ban d and b ic e p s an d la x in fle x io n , an d th u s n o t su s c e p tib le t o r o ta tio n - in -flex io n strain s. C o n se q u e n tly an iso la te d c o m p le te rupture o f th e lig a m e n t rarely o c c u r s a n d it is u su a lly part o f gross tra u m a d u e t o great v io le n c e , e .g . p o w e r fu l a d d u c tio n o f the le g o n th e th ig h . In m o st c a se s it is a c c o m p a n ie d b y a tra ctio n injury a n d su b seq u en t g r o ss d a m a g e to th e lateral p o p lite a l n erve o r a v u lsio n o f th e h ead o f th e fib u la , a lth o u g h b o th ca n e sc a p e . T rea tm en t. A s regard s th e lig a m e n t, trea tm en t ca n b e co n se r v a tiv e o r o p e r a tiv e , d ep e n d in g o n th e treatm en t o f th e c o n c o m ita n t trau m a. A s regard s th e n erve le s io n , th e p r o g n o sis is m u c h w o rse. T r a c tio n le s io n s esp e c ia lly sh o w e x te n siv e d a m a g e and v ery little re c o v e r y . T h e b est a p p r o a c h se e m s to b e e x p lo r a ­ tio n an d su tu re w h e r e a n d a s e a r ly a s p o s s ib le as th is afford s t h e b est r eco v e ry p o ssib ilitie s. C . C ruciate L ig a m en ts. T h e s e c o n s titu te th e fa c to r s o f internal sta b ility o f th e k n ee. T h e an te rio r c r u c ia te is o f m o re im p o r ta n c e c lin ic a lly a s it is u su a lly in v o lv e d in to ta l d isr u p tio n o f th e m ed ia l lig a m e n t and ca n b e th e o n ly lig a m e n to u s injury a sso c ia te d w ith tears o f th e m ed ia l m e n isc u s. 1. A nterior C ruciate. In a ca refu l a n a ly sis o f th e an terior c ru cia te, it h as been fo u n d to b e te n se th r o u g h th e w h o le ra n g e o f fle x io n - e x te n sio n . It is tru e that th e greatest te n sio n is in e x te n sio n and a ffects m a in ly th e a n terior fibres; in se m ifle x io n th e lig a m e n t is m o st la x , a lth o u g h th e m id d le fibres are still m ore te n se and in fu ll fle x io n th e p o ste r o -la te r a l fibres are ten se. T h e m e c h a n ism o f in jury is u su a lly r o ta r y and a sso c ia te d w ith m ed ia l m e n isc a l injury, e .g . fo rced fle x io n o r e x te n sio n w ith th e tibia fix ed o r th e a b o v e in th e p resen ce o f p r e v io u s in ternal d era n g em en t (u su a lly m en icsa l tear) w h ic h p rev en ts tib ia l r o ta tio n in th e last b it o f th e R O M . T h e la tter c a n b e a su d d en ru p tu re o r s lo w stretch in g a n d a tte n u a tio n in th e m o r e c h r o n ic c a s e s. A b d u c tio n injuries are less c o m m o n , but m o re im p o r ta n t, a s it o c c u r s o n ly after ru p tu re o f th e m ed ia l lig a m e n t h a s ta k e n p la c e . T h e injury ca n b e c o m p le te , w ith th e lig a m e n t in ta c t, b u t b o n e a v u lse d , (u su a lly fro m th e in ferior a tta c h m e n t t o th e tib ia l sp in e area) or c o m p le te w ith ru pture o f th e lig a m e n t its e lf (u su a lly n ear th e su p erio r a tta ch m en t t o th e fe m o r a l c o n d y le ) o r p artial ru p tu re and a tte n u a tio n d u e to c o n tin u o u s m in o r tra u m a ta . A c u te ru p tu re o f th e a n te rio r cru cia te is u su a lly a sso c ia te d w ith a m ed ia l m e n isc a l tea r (w ith o r w ith o u t recurrent lo c k in g ) o r w ith m e d ia l lig a m e n t ru p tu re w ith o r w ith o u t fra ctu r e o f lateral tib ia l c o n d y le . O fte n th e d ia g n o sis o f a ru p tu re d an te rio r c ru cia te ligam ent is d ifficult as it m a y b e m a sk ed b y c o n c o m ita n t tra u m a or c o m p lic a tio n s, e .g . ru p tu red m e d ia l lig a m e n t, haem arth ro- sis, sy n o v itis, a c u te p a in , ten d e rn ess an d m u scle Spasm. U n le ss th e p a tie n t is se en v ery s o o n after th e injury, it is b est to e x a m in e th e k n e e after a sp ir a tio n a n d e v e n a n a e s­ th e sia . L a x ity ca n be d e m o n str a te d b y th e “ d raw er fo rw a rd s” sig n . It has to be co m p a r e d w ith th e so u n d sid e . T h e “ draw er fo r w a r d s” sig n is u su a lly “ m in im a l” o n iso la te d ru p tu re o f th e an te rio r c r u c ia te a n d “ m a x im a l” w h e n a sso c ia te d w ith ru p tu re o f th e m e d ia l lig a m e n t. U s u a lly ra d io g ra p h y is n e g a tiv e , e x c e p t w h ere an a v u lsio n fracture o f the tib ia l spine is p resen t. 2 . P o ste r io r C ruciate. A s fo r th e an te rio r cru cia te, th e p o ste r io r is sa id t o be ta u t th r o u g h o u t fle x io n -e x te n sio n , th e te n sio n ch a n g in g from th e a n te rio r t o th e p o ste r io r fib r es a s th e jo in t m o v e s from fle x io n t o e x te n sio n . T h u s it w ill p r e v e n t h y p e r e x te n sio n and a lso c o n tr o l m e d ia l r o ta tio n o f th e tib ia in fle x io n . U s u a lly ru p tu re o f th e p o ste r io r c ru cia te is fo u n d a s part o f e x te n siv e trau m a t o th e k n ee a n d rarely a s a n iso la ted injury. T h e m e c h a n ism o f injury is u su a lly th e tib ia being d riven p o ste r io r ly o n th e fe m u r in th e flexed k n e e . T h e type o f ru p tu re fo llo w s th e p a ttern a lr e a d y d esc rib ed fo r the an te rio r c ru cia te lig a m e n t. It c a n be d ia g n o se d b y the “ d raw er b a ck w a rd s” sign . T re a tm e n t. A s h a s b een sta ted p r e v io u sly , ru p tu re o f a n y o n e lig a m e n t o n ly , c a u se s h a r d ly a n y d isa b ility , e sp e c ia lly in th e presen ce o f g o o d m u scu la tu re a ro u n d th e k n e e a n d w h e r e n o stren u ou s d e m a n d s are m a d e o n it, e .g . c o m p e titiv e sp o r t, m in in g , etc. In ca ses w h ere th e re w a s great la x ity a n d d isa b ility , several ty p e s o f s u b s titu tio n s w ere u se d , e .g . H e y G r o v e ’s fa sc ia l— o r S m illie ’s m en isca l su b s titu tio n , b u t th e se se em e d t o have n o la stin g effe ct. In c a se s o f se v e r e la x ity a n d deran gem en t e v e n a r th r o d e sis w a s u sed . T h e n in th e last d e c a d e L in d e m a n n ’s H e id e lb e r g o p eration w a s d e v e lo p e d a n d h a s b e e n u sed in c r e a s in g ly w ith success. B riefly it is as f o l lo w s : F o r A n te r io r C ru c ia te . T h e k n e e is o p e n e d b y a fa ir ly e x te n siv e an te ro -m ed ia l in c isio n a n d th e jo in t e x a m in e d . I f n e c e ssa r y , a m edial m e n ise c to m y is p erfo rm ed . T h e stu m p s o f th e ruptured a n te rio r c ru cia te is e x c is e d . G r a c ilis is d iv id ed n ear its in se r tio n and m o b iliz e d b y blunt d iss e c tio n t o m o re o r less a third w a y u p s o th a t th e lin e o f p u ll w ill b e fro m th e p osterior m id lin e. It is th e n p a sse d th r o u g h th e lateral part o f the p o ste r io r c a p su le , a lo n g th e in te r c o n d y la r n o tc h t o ajjpear in t h e a n te rio r part o f th e jo in t. A h o le is tu n n e le d from 'm ed ial to th e a tta c h m e n t o f lig a m e n tu m p a te lla e o n th e tib ia , to e m e r g e at o r a n te rio r t o th e in fe rio r a tta c h m e n t o f the an te rio r cru cia te, gracilis is p a sse d th r o u g h th e tu n n el and o n e a n d a h a lf in c h e s o f te n d o n is secu red t o th e tibial p e r io ste u m a n d lig a m e n tu m p a te lla e in se r tio n w ith m oderate te n s io n . B o n e c h ip s are p u n ch ed in to th e tu n n e l t o ensure a d e q u a te fix a tio n . T h e w o u n d is c lo s e d in la y ers. A w ell p a d d e d lo n g le g p la ster is a p p lied and su sp e n d e d fro m a B a lk a n fra m e fo r a fe w d a y s b y m e a n s o f w ire lo o p s . I s o m e tr ic c o n tr a c tio n s o f a ll th e leg m u sc le s ca n be started im m e d ia te ly and sh o u ld b e d o n e c o n sc ie n tio u sly , but w ith a d e q u a te rest, d u rin g th e w a k in g h o u r s. N o n -w e ig h t- b ea rin g a m b u la tio n is a llo w e d w ith in 5-7 d a y s. T h e p la ster is r em o v ed after 5 -6 w e e k s an d fu ll str e n g th e n in g a n d m o b iliz a ­ tio n ca n start. H e r e it is o f p rim e im p o r ta n c e t o strengthen a ll th e su p p o r tin g m u scu la tu re o f th e k n e e jo in t. T each corre ct a n d p r o te c tiv e a m b u la tio n , i.e . “ b ra cin g ” th e k n ee on w e ig h tb e a r in g a n d a v o id in g su d d e n tw ists. M e d ia l L ig a m e n t. U s u a lly th is is fo u n d to b e la x a n d repaired at th e sam e tim e . I f there is o n ly slig h t la x ity , it is su tu red , o r i f w ar­ r a n ted a n O ’D o n o g h u e ’s d ista l sh ift o p e r a tio n can be p erfo rm ed . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1967 f o r P o s te r io r C ru c ia te . T he a p p r o a c h is sim ila r a s fo r th e a n te rio r cru cia te. G ra c ilis is severed a n d lo o se n e d and th e n p a sse d th r o u g h a tunnel drilled th r o u g h th e m e d ia l fe m o r a l c o n d y le fro m just distal to th e a d d u c to r tu b er cle to e m erg e in th e an te rio r c o m p a r tm e n t o f th e k n ee jo in t at th e p o in t w h ere th e p o sterio r cruciate a tta c h e s t o th e m e d ia l fem o r a l c o n d y le . T h e te n d o n is passed m ed ia l to th e a n te rio r c ru cia te to en te r th e p o s ­ terior c o m p a r tm e n t o f th e jo in t. It is held there w ith a K och er’s fo r c e p s, th e in c isio n is c lo s e d a n d th e p a tie n t turned o n to h is fa c e . A se c o n d in c isio n is m a d e in th e m idline o f th e p o p lite a l fo ss a a n d th e K o c h e r ’s fo r c e p s w ith the ten d o n , lo c a te d . T h e p o ste r io r c a p su le a n d p erio steu m is cleared o n th e b ack o f th e tib ia fo r o n e in c h a n d th e gracilis te n d o n se c u r e ly su tu red t o th e p e r io ste u m a n d the capsule, w ith th e k n e e in th ir ty d eg rees fle x io n . T h e w o u n d is closed an d th e a fter trea tm en t is th e sa m e a s fo r the anterior cru cia te. C om bined R e p a ir. Should b o th cr u c ia te s be ru p tu re d , gracilis is u sed to substitute th e a n te rio r a n d se m ite n d in o sis th e p o sterio r. Repair o f th e m ed ia l lig a m e n t, i f n ecessa ry , is d o n e b efore the first in c isio n is c lo s e d . A lth o u g h th e r e is still a p p recia b le la x ity in th e jo in t after this o p e r a tio n , it is e x t ie m e ly sta b le d u rin g stren u o u s activity and m o r e a w a ren ess o f te n sio n e x is ts than in fa scia l transplants. 3 . M E N I S C A L I N J U R I E S The m en isci o r se m ilu n a r ca rtila g es fill in th e in co n g ru ity between th e fe m o r a l and tib ia l c o n d y le s t o p r o v id e m o re acceptable a n d fu n c tio n a l jo in t su rfa ces. It is said th a t th e m ovem ents o f r o ta tio n ta k e p la c e b e lo w th e m e n isc i and flexion and e x te n sio n ta k e p la c e a b o v e th e m e n isc i. R e m o v a l o f the m en isci d o e s n o t se em to im p a ir th e fu n c tio n o f the knee jo in t, a g a in p r o v id e d that th e su rr o u n d in g m u scu la tu re is in g o o d c o n d itio n . (a) M e d ia l M e n iscu s. The horn s o f th e m e d ia l m e n isc u s are w id e apart but firmly a tta ch ed to th e tib ia in th e n o n -a rticu la r in te rco n d y la r area. T h e p erip h ery o r a rch is lo o s e ly a tta c h e d to th e tibia by means o f th e c o r o n a r y lig a m e n t (part o f th e c a p su le ) and firmly a tta ch ed to th e fem u r b y m e a n s o f th e d eep fibres o f the m ed ial c o lla te r a l lig a m e n t. T h u s th e m e d ia l m e n isc u s is especially m o b ile o n th e tib ia in r o ta r y m o v e m e n ts and suffers ru p tu re d u rin g r o ta tio n a l stress b eca u se o f this m obility o f its a rch w h ic h la c k s m u scu la r c o n tr o l. D u r in g rotation th e h orn s o f th e m e n isc u s m o v e w ith th e tib ia and the arch w ith th e fem u r, le a d in g t o d isto r tio n a n d ren d erin g it liable to injury. (b) L a te r a l M e n isc u s. It is m o r e circu la r in sh a p e w ith th e an te rio r a n d p o sterio r horns m uch c lo se r to g e th e r and a ls o a tta c h e d to th e in ter­ condylar area o f th e tib ia . T h e a rch is lo o s e ly a tta c h e d to the tibia b y m e a n s o f th e c o r o n a r y lig a m e n t, but th e lig a ­ ments o f H u m p h r e y and W risberg, an d e sp e c ia lly th e posterior sup erficial fibres o f p o p lite u s , a c tiv e ly c o n tr o l the arch o f th e la tera l m e n isc u s d u rin g r o ta tio n . P o p lite u s a cts as an extern al r o ta to r o f th e fem u r fro m e x te n sio n i.e . it initiates fle x io n , but its m a in fu n c tio n is b eliev ed to be control o f th e lateral m e n isc u s b y p rev en tin g it fr o m m o v in g m edially to a p o s itio n w h ere it ca n be cru sh e d , a s th e k nee unlocks fo r fle x io n . T he m e c h a n ism o f injury is sim ila r fo r b o th m en isci, nam ely forced r o ta tio n , but th e lateral m e n isc u s is less liable to th is a n d is injured m o r e o fte n a s a resu lt o f direct violence. M e n isc a l in juries o c c u r m a in ly in y o u n g h e a lth y males w h o p la y a c tiv e sp o r ts lik e fo o tb a ll a n d ru g b y o r w o rk in m ines w h ic h in v o lv e s str e n u o u s w o r k in c o n fin e d sp a ce s on fully flexed k n e e s. U s u a lly th e tearing is a s a resu lt o f forced r o ta tio n o f th e fe m u r o n a fix ed tib ia w ith th e k n ee in flexion. B y ta k in g a d eta ile d h isto r y o f th e m e c h a n ism o f 1 njury, resu ltan t in c a p a c ity , c o u r s e a n d c o m p lic a tio n s or resultant d isa b ility fr o m th e p a tie n t, w ill u su a lly giv e a ■airly clear in d ic a tio n a s t o th e tra u m a . B y a ca refu l clin ica l Page 5 in v e stig a tio n a lo n g the lin es a lr e a d y d esc rib ed , a d ia g n o sis can u su a lly b e m a d e . O n e sh o u ld n ever lo s e sigh t o f th e n a tu ra l p ro cesses o f d e g e n e r a tio n th a t set in in the k n e e jo in t a fte r th e se c o n d d e c a d e a n d a lw a y s ju d g e w h at is th e rela tiv e “ n o r m a lity ” o f th e jo in t b efo re rea ch in g a c o n c lu sio n a n d d e c id in g o n treatm en t. T re a tm e n t. M in o r p e r ip h e ia l tears are s o m e tim e s treated c o n se r v a ­ tiv e ly a lo n g th e lin es o f a m ed ia l c o lla te r a l lig a m e n t rup tu re, but th e se u su a lly giv e rise t o sy m p to m s later, s o that o p e r a ­ tiv e p r o c e d u r e s are fo llo w e d in n early all ca ses. T h is is d e c id e d o n a fte r persistant lo c k in g a n d p ersista n c e o f sy m p to m s, n o tw ith sta n d in g effe ctiv e c o n se r v a tiv e treatm ent. A fte r m e n ise c to m y , a c o m p r e ss io n b a n d a g e is a p p lied a n d th e p a tie n t is nu rsed w ith th e feet e le v a te d . S ta tic qu ad ricep s ex e r c ise s are started im m e d ia te ly a n d p artial w eig h tb e a rin g a llo w e d after 5-7 d ays. T h e stitc h e s are re m o v e d a fter ten d a y s a n d g en tle m o b ilis a tio n o f th e k n ee (a lw a y s u sin g p ain as a c riterio n a n d a v o id in g c a u sa tio n o f a n y Sym p tom s that are p r o lo n g e d after tr ea tm en t) is sta rted . A fte r three w e e k s, str o n g w eig h tb e a rin g ex e r c ise s c a n be started a n d id ea lly th e p a tie n t sh o u ld be a b le to retu rn to w o r k after 6 -8 w eek s and sp o rt a fter th r ee m o n th s. 4 . D I S L O C A T I O N . C o m p le te d is lo c a tio n o f th e k n e e o ccu rs very rarely a n d then a s a result o f e x trem e v io le n c e , d irectly, t o th e low er en d o f th e fe m u r w ith th e tib ia firm ly fix e d , oi t o th e upper en d o f th e tib ia w ith th e fem u r fixed . T h e ty p e o f d islo c a tio n w ill d ep en d o n th e d ir e c tio n o f th e v io le n c e . D is lo c a tio n a s a result o f ro ta ry v io le n c e is ev en m o r e rare. D is lo c a tio n s o f the k n ee are cla ssifie d a c c o r d in g t o th e rela tiv e p o sitio n o r m o v e m e n t o f th e tib ia t o o r o n th e fem u r. F u r th er th e y can vary in d eg ree fr o m in c o m p le te t o c o m ­ p lete (th e latter is o f p u rely a c a d e m ic a l in terest) and b e o f th e c lo s e d o r o p e n v a riety . T h e la tter w ill be c o m p le te w ith e x te n siv e so ft tissu e d a m a g e . ( P le a se s e e n e x t p a g e ) A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS M a n u fa c tu re rs a n d S u p p lie rs o f: O R T H O P A E D I C A P P L I A N C E S , A R T IF IC I A L L I M B S , T R U S S E S , S U R G I C A L C O R S E T S , U R I N A L S , A R C H S U P P O R T S , C O L O S T O M Y B E L T S , E L A S T I C S T O C K I N G S , A N K L E G U A R D S , W R I S T G U A R D S , E L B O W G U A R D S , K N E E G U A R D S , L I G H T D U R A L C R U T C H E S F O R C H I L D R E N , W O O D E N C R U T C H E S , A N D M E T A L E L B O W C R U T C H E S . Phone 2 3 -2 4 9 6 P.O. Box 3412 312 Bree Street, Johannesburg P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y June, 1967 A ll ty p e s w ill in v o lv e th e c o lla tera l lig a m e n ts, c ru cia tes, c a p su le , p o p lite u s , g a stro cn em iu s a n d v a stu s m e d ia lis t o a greater o r lesser e x te n t. T h e la tero -m ed ia l ty p e c a n in v o lv e th e lateral p o p lite a l n erve and th e n e s p e c ia lly th e m e d ia l d islo c a tio n s; o fte n ru pture o f th e sk in a n d u n d erly in g so ft tissu es o c c u r a n d th e n a clo sed re d u c tio n is in c o m p le te d u e to th e o b s tr u s io n o f so ft tissu es in to th e jo in t. A n t e r o ­ p o ste r io r d is lo c a tio n s u su a lly d a m a g e th e p o ste r io r c a p su le and cru cia tes w h ilst th e co lla tera l lig a m e n ts m a y e s c a p e w ith rela tiv ely little d a m a g e and m ore o fte n than n o t th e p o p lite a l artery is in g rave dan ger. D ia g n o sis is e a s y d u e to th e gro ss tra u m a an d d efo rm ity an d fro m th e h isto r y . R a d io g r a p h y is e sse n tia l t o e lim in a te o r e sta b lish c o n c o m ita n t fractures. T rea tm en t. R e d u c tio n u n d er a n a esth esia sh o u ld b e u n d erta k en as s o o n as p o ss ib le , o n c e th e state o f th e cir c u la tio n h a s been fo u n d sa tisfa c to r y . A rterial in su fficien cy d u e t o ru p tu re or th r o m b o s is o r sp a sm o f th e p o p lite a l artery req u ires im ­ m ed ia te e x p lo r a tio n and th is th e n h as p rio rity in treatm en t w ith th e result th a t r ed u ctio n m a y b e deferred u n til th e cir c u la tio n h a s b een restored to sa tisfa c tio n . F a ilu r e o f this w o u ld n e c e s sita te m id th ig h a m p u t a t i o n . P rim ary su tu re o f a to rn p o p lite a l n erv e m a y be u n d ertak en i f an o p e n red u c tio n is n ecessa ry o r in th e c a s e o f an o p e n d islo c a tio n o r it m a y be left till a later d a te . O n ce m o re, tra ctio n le sio n s h a v e th e w o rst p r o g n o sis . A c o m p r e ssio n b a n d a g e w ith b a ck sp lin t or K ra m er w ire rein fo rcem en t is a p p lied (in sligh t fle x io n w h ere th e p o sterio r ca p su le is in v o lv e d ). D u r in g th e first 4 8 h o u rs, e sp e c ia lly , th e cir c u la tio n h as t o be ch eck ed freq u en tly . O n c e th is is sa tisfa c to r y , th e j o in t is aspirated and a n o th e r c o m p r e ssio n b a n d a g e a p p lied . P ro v id e d th e re are n o c o m p lic a tio n s, q u a d ricep s exerc ises c a n be c o m m e n c e d after a w eek o n c e a plaster sp ic a has b een a p p lie d . W eig h tb e a rin g can b e g ra d u a lly started after 6 -8 w e e k s o n a p p lic a tio n o f a sk in tig h t p laster. Im m o b iliz a ­ tio n is u su a lly m a in ta in ed fo r three m o n th s. D u r in g th is tim e c o n s c ie n tio u s e x erc ise o f all th e le g m u scu la tu re is o f p a ra m o u n t im p o r ta n c e and m a y a ctu a lly d eterm in e th e end resu lt. A t th e en d o f three m o n th s m o st so ft tissu es w ill h ave healed an d m o b iliz a tio n m a y b eg in . O ften there w ill b e e x c e ssiv e fib r o u s tissu e a n d ev en h e r e r o to p ic b on e fo r m a tio n , w h ich m u st b e ta k e n in to co n sid er a tio n d u rin g m o b iliz a tio n . In c a se s o f se v ere in tern al d eran gem en t th is m a y a c tu a lly c o n stitu te a d d itio n a l su p p o rt. In m o st ca ses fu n c tio n a l r eco v e ry (w ith o r w ith o u t a id in g ap p a ra tu s, e.g . fo r d rop p ed fo o t) ca n b e a ch iev ed w ith a d e q u a te stren g th en in g o f th e m u scu la tu re , b ut flex io n w ill in variab ly be lim ited. 5 . O S T E O C H O N D R I T I S D I S S E C A N S T h is w ill b e m e n tio n e d very briefly a s so m e a u th o rities h o ld th a t th e c o n d itio n d o e s o ccu r a s th e result o f traum a. T h is is a c o n d itio n w h e r e a fragm ent o f articular ca rtila g e b e c o m e s lo o s e n e d , sc lero sed and e v e n tu a lly separated o f f to fo rm a lo o s e b o d y in th e jo in t. T h e m a in sy m p to m s are va g u e p a in , lo c k in g and w a stin g o f th e quad ricep s. D ia g n o sis in th e ea r ly sta g e s is difficult d u e to th e vagu en ess. T rea tm en t. In y o u n g a d u lts c o n se r v a tiv e treatm en t h as been u sed , m o r e o n a n ex p e r im e n ta l basis. T h e k n e e is im m o b ilised an d n o w e ig h tb e a r in g p erm itted fo r th r ee m o n th s. I f h ea lin g h a s o cc u r r e d , th e j o in t is im m o b ilized fo r a further three m o n th s a n d th e n g rad u al w eig h tb e a rin g and m o b iliz a tio n started . M o s t c a se s are treated op era tiv ely by m ea n s o f a rth ro to m y , w h eth er b e fo r e o r after se p a r a tio n o f th e fragm ent, d ep en d s o n th e se v erity o f th e sy m p to m s a s w e ll a s th e view s o f th e su rg e o n . A fte r trea tm en t is lik e th a t fo r a m en isectom y. T h e resu lts w ill d ep en d grea tly o n th e size o f th e frag­ m e n t s ) and th e a rea affected . I f a large p o rtio n o f th e w e ig h t­ bearin g area is affected at an ea rly a g e , early and gross arth ritic c h a n g e s are t o b e ex p ected . 6 . F R A C T U R E S . In g en era l, th o s e fractures th a t in v o lv e th e k n e e jo in t d irectly , are fra ctu r es o f th e tib ia l sp in e , o f th e tibial p lateau (in v o lv in g th e lateral o n ly or b o th c o n d y le s) o r su b ch o n d ra l fractures o f th e p a te lla and c o n d y le s. A s th e re is su c h a large variant in th e severity o f th e se and th e c o n c o m ita n t and c o m p lic a tin g so ft tissu e inju ries a sso c ia te d w ith th e m , w h ic h in turn g iv e s rise t o very varied s c o p e o f treatm en t th a t c o u ld fill a n o th e r p ap er, t h e y w ill a lso b e m e n tio n e d v ery briefly. T h e te n d e n c y in trea tm en t w h ere fix a tio n a n d n o n - w eig h tb e a rin g are n ecessa ry , to d a y is fo r sk e le ta l tra ctio n b y m e a n s o f p in s a n d th e use o f th e so -c a lle d P erk in s bed w h ich still a llo w s m o v e m e n t o f th e k n e e . I n o ld e r p e o p le e sp e c ia lly , th e te n d e n c y is t o stress m o b ility e v e n i f w e ig h t­ bea rin g is n o t a llo w e d . P H Y S I O T H E R A P Y I N K N E E I N J U R I E S . T h e q u a d ricep s is b y far th e m o st im p o r ta n t m ech a n ism th a t is in v o lv e d in k n e e injuries a n d th e su b se q u e n t return t o fu n c tio n , b ut o n e sh o u ld a lw a y s a im fo r a balan ced a c tio n o f th e su p p o r tin g m u s c le s a n d n o t lo s e sigh t o f the im p o r ta n c e e .g . o f p o p lite u s in in itia tin g fle x io n , o r th a t o f th e h a m strin g s in p r ev en tin g h y p erex ten sio n . T h e o r th o g r a d e p o stu re is u n iq u e to m a n a n d a rela tiv ely rece n t b io lo g ic a l a c q u isitio n . It is a d e lic a te m e c h a n ism that is e a s ily d era n g ed by injury. L o ss o f v o lu m e , t o n e and c o n tr o l in its e lf c o n s titu te s a d isa b ility . Q u a d ricep s in su fficien cy le a d s t o in tra-articu lar tra u m a a s th e j o in t c a n n o t c o p e w ith th e n o rm a l stresses and stra in s and th is in turn le a d s to furth er w e a k e n in g o f q u a d ricep s. T h e o n ly w a y t o c o p e with th is v ic io u s c y c le is t o start n o n -w e ig h tb e a r in g ex e r c ise s that w ill b u ild u p stren g th and to n e su fficien t to c o p e w ith w eig h tb e a rin g . T h e reflex in h ib itio n o f q u a d ricep s after tra u m a ca n re s e m b le a flaccid p a ra ly sis. T h u s after trau m a and o p e r a tio n it is o f p rim e im p o r ta n c e t o in stitu te a ctiv e q u a d ricep s c o n tr a c tio n s (iso m e tr ic o r is o to n ic a s th e ca se m a y b e) im m e d ia te ly , n o t o n ly t o preserve stren g th , b u t a lso to m a in ta in th e k in a e sth e tic se n se . H e a t, ic e and m a ssa g e are o n ly c o m p le m e n ta r y m ea su res to in crea se th e cir c u la tio n . Q u a d ricep s ex e r c ise s c o n tr a -in d ic a te d i n : 1. O p en w o u n d treated b y p rim ary su tu re. 2. H a e m a r th r o sis. 3. A c u te se p sis. T h e s e a ll req u ire a n in itia l p erio d o f rest. F u n c tio n a lly , q u a d ricep s c a n b e d iv id ed in to tw o c o m ­ p o n e n ts , n a m e ly : 1. V a stu s la tera lis, vastu s in te rm ed iu s a n d rectu s fe m o r is w h ich c a u se e x te n sio n o f th e k n ee. 2. V a stu s m e d ia lis , r e s p o n sib le fo r th e last 1 0-15 degrees o f e x te n sio n and th u s th e all im p o r ta n t “ lo c k in g ” o f th e k n e e . E v e n i f th e re is n o in tern al d era n g em en t, m a l-fu n c tio n o f th is w ill c a u se an u n sta b le k n e e . It is a ls o th e site o f first a n d m o st m ark ed w a stin g . T h e f o llo w in g are s o m e p o in ts o f a p p lic a tio n t o rem em b er w h en w o r k in g fo r th e o p tim u m in r eco v e ry o f th e m u s c u la - ' tu r e su r r o u n d in g th e k n ee j o i n t : 1. T h e a ll o r n o n e la w that g o v e r n s c o n tr a c tile u n its. 2. O n e has m a x im a l m e c h a n c ia l e fficien cy w h en th e m u scle fibre starts t o c o n tr a c t fr o m th e fu lly stretch ed p o s itio n . 3. T o in crea se p o w e r ( o f first im p o r ta n c e h ere) e x erc ises o f a h ig h re s ista n c e , lo w re p ititio n rate are best. T o in crea se en d u r a n c e , ex e r c ise s o f lo w resista n ce, h ig h r e p e titio n ra te g iv e th e b est resu lts. 4 . C o -o r d in a tio n . (a ) S p eed o f c o n tr a c tio n t o p rev en t injury. (b) “ T im in g ” , i.e . th e im p o r ta n c e o f a c tio n s o th e r th a n th e p rim e m o v e r , th u s p r o p r io c e p tio n . 5. D o s a g e . (a ) W e ig h tb e a r in g t o o ea rly g iv e s rise to in creased sy m p to m s and m a y e v e n b e d etrim en ta l. ( b) D e v e lo p p o w e r and th e n en d u ra n ce. 6 . R e la x a tio n b etw een in d iv id u a l e x erc ises and se ssio n s is im p o r ta n t e s p e c ia lly in p r o lo n g e d a tr o p h y . 7. P r o g r e ssio n ca n b e in tim e and w o rk d o n e . I f n ecessary, o n e ca n start w ith F a r a d ism t o in itia te c o n tr a c tio n w h ere th e k in a e sth e tic se n se is lo s t , but v o lu n ta r y c o n ir a c tio n is th e m o st im p o r ta n t. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1967 P H Y S I O T H E R A P Y Page 7 g. V ariety. E x e rcises sh o u ld b e sp ec ific fo r th e k n e e , but a lso gen era l, e sp e c ia lly w h e n th e p a tie n t is still co n fin e d to b ed , a n d v aried e n o u g h to h o ld th e in te rest. F rom th e a b o v e it w ill em e r g e th a t o n e h a s t o h a v e at least o n e se ssio n per d a y (a n d m o r e sh o rt se s s io n s in the early sta g es) t o c o n c e n tr a te o n in d iv id u a l ex e r c ise s fo r th e specific c o n d itio n . H e r e o n e h a s to stress th e im p o r ta n c e o f regular e x erc ise th r o u g h o u t th e d a y o f th e p rin cip a l m u scle groups, n a m e ly q u a d ricep s, h a m strin g s, f o o t p u m p in g and gluteal c o n tr a c tio n s as w ell a s iso la tio n o f v a stu s m ed ia lis and p o p lite u s , w h ic h is th e p a tie n t’s r e s p o n sib ility . F r o m th e third d ay o n m o st p a tie n ts ca n p a rticip a te in c la ss w o rk , m ainly a im ed at g en era l m a in te n a n c e , w h ic h is e x trem ely v a lu a b le fro m th e p o in t o f v iew th a t it stim u la te s in terest, en cou rages p a tie n ts t o w o r k o n their o w n , a llo w s for therapeutic g a m e s in th e la ter sta g e s a n d o f c o u r s e e c o n o ­ mises th e u se o f th e p h y sio th e r a p ist’s tim e. p h y sio th e r a p y c a n p la y a v ery im p o r ta n t part in th e reh ab ilitation o f k n e e in ju ries, e s p e c ia lly b y m e a n s o f c o n ­ sc ien tio u s e x e r c ise , p r o v id e d it is a p p lied a c c u r a te ly and with in te llig en ce. Id e a lly o n e w o u ld w a n t t o start train in g the p a tie n t p r e -o p e r a tiv e ly w h ere p o ssib le . F ir stly th is a c­ quaints th e p a tie n t w ith th e ex e r c ise s e x p e c te d p o st-o p e r a - tively and their rela tiv e im p o r ta n c e in th e reh a b ilita tio n program m e. S e c o n d ly it p r o v id e s th e p h y sio th e r a p ist w ith som e n o r m w h e r e b y t o m ea su re p ro g ress. T h ir d ly it can prevent th e e x tr e m e ly rapid lo ss o f k in a e sth e tic se n s e , lo ss o f to n e and a tr o p h y w h ic h is p ecu lia r t o q u a d ricep s. In m o re ch ro n ic c a se s it h as b e c o m e p ra ctice t o treat p a tie n ts o n an o u t-p atient b a sis fo r a w e e k p rior t o o p e r a tio n to tea ch exercises a n d e x p e c te d a m b u la tio n n e cessa ry p o st-o p e r a tiv e - ly- In d iv id u a l e x e r c ise s w ill be left to th e c h o ic e o f ea ch p h ysioth erap ist, as w e ll as a r e h a b ilita tio n p r o g r a m m e , as this d ep en d s la rg ely o n th e se t-u p o f e a c h d ep a rtm en t, personal a b ility a n d su r g e o n s c o n c e r n e d in th e c a se . In co n clu sio n it ca n be m e n tio n e d th a t P .N .F . te c h n iq u e s h a v e been m o st effe ctiv e fo r in d iv id u a l trea tm en t. T h er e is a g o o d variety o f str e n g th e n in g a n d m o b iliz in g te c h n iq u e s w h ich can b e u sed in c o n ju n c tio n w ith ic e t o en su re sp e e d y and op tim u m r e h a b ilita tio n . N ote. T h e a u th o r w ish e s t o th a n k P r o f. G . T . d u T o it and D r . I. S . d e W et o f th e P r e to r ia O r th o p a e d ic H o sp ita l fo r their h elp an d e n c o u r a g e m e n t in th e p r ep a ra tio n o f th is article. ____________________ A P R A Y E R T h e fo llo w in g prayer sh o u ld b e o f great h e lp t o p e o p le as they g r o w o ld e r ; a n d it c o n ta in s m u c h c o n c e n tr a te d w isd om ! L o rd , Thou k n o w e s t b e tte r than I k n o w m y s e l f th a t I a m g ro w in g o ld e r, a n d w ill s o m e d a y b e old. K e e p m e f r o m th e f a t a l h a b it o f th in k in g I m u st s a y so m e ­ thing on e v e r y su b je c t a n d on e v e r y occa sio n . R e le a se m e f r o m cra vin g to s tr a ig h te n o u t e v e r y b o d y 's affairs. M a k e m e th o u g h tfu l b u t n o t m o o d y ; h elp fu l b u t n o t b o ssy . W ith m y v a st s to r e o f w isdom i t s e e m s a p i t y n o t to use it all, b u t Thou k n o w e s t, L o rd , th a t I w a n t a f e w f r ie n d s a t th e end. K e ep m y m in d f r o m r e c ita l o f en d less d e ta ils ; g iv e m e w ings to g e t to th e p o in t. S e a l m y lip s on m y a ch es a n d p a in s ; th e y a r e in cre a sin g a n d love o f reh e a rsin g th em is b eco m in g s w e e te r a s th e y e a r s g o b y . I d a re n o t a s k f o r g r a c e enough to e n jo y th e ta le s o f o th e rs pain s, b u t h elp m e to en d u re th e m with p a tie n c e . / d a re n o t a s k e ith e r f o r im p r o v e d m e m o ry ; b u t f o r a g ro w in g h u m ility , a n d th e lessen in g co c k -su re n e ss when m y m e m o ry se em s to clash w ith th e m e m o rie s o f o th e rs. Teach m e th e g lo r io u s lesson th a t o c c a s io n a lly I m a y b e m ista k en . K e e p m e re a so n a b ly sw e e t; I d o n o t w a n t to b e a sa in t— so m e o f th em a re s o h a r d to live w ith. B u t a so u r o l d p e r s o n is on e o f th e cro w n in g w o r k s o f the devil. G iv e m e the a b ility to se e g o o d th in g s in u n e x p e c te d p la c e s a n d ta le n ts in u n e x p e c te d p e o p le . A n d g iv e m e O L o r d , th e g ra c e to t e ll th em so. A men A STUDENT OUT-PATIENT CLINIC T h e o u t-p a tie n t d ep a rtm en t at th e J o h a n n esb u rg H o sp ita l c o m p r ise s w o m e n s ’ a n d m e n s’ trea tm en t r o o m s, sta ff g y m n a siu m , stu d en ts g y m n a siu m a n d stu d e n ts o u t-p a tie n t clin ic. A t th e c lin ic th e 3rd a n d final y ear stu d e n ts treat a cro ss- se c tio n o f o u t-p a tie n ts u n d er th e su p e r v isio n o f a lectu rer in p h y sio th e r a p y . T h e y g et e x p erien ce in in d iv id u a l trea tm en ts by m a ssa g e , e le c tr o th e r a p y , p a ssiv e m o v e m e n ts, tra ctio n , the a p p lic a tio n o f h e a t and c o ld and in d iv id u a l e x erc ises. G r o u p ex e r c ise s and h e a v y re h a b ilita tio n is d o n e in th e g y m n a siu m . It w a s su g g ested th a t it m ig h t b e o f in te rest to p h y sio ­ th e ra p ists to se e w h at ty p e s o f p a tie n ts are treated here. A n a n a ly sis o f p a tie n ts treated fro m F eb ru a ry , 1965 to F eb ru a ry , 1967 rev ea led th e fo llo w in g : S u rg ica l o u t-p a tie n ts . . . . . . . . 138 M e d ic a l o u t-p a tie n ts . . ............................... 67 P sy c h o lo g ic a l p a tie n ts . . ............................... 22 T O T A L 227 It is o f in terest to n o te th e h ig h in cid en ce o f p sy c h o g e n ic c a s e s se n t fo r p h y sio th e r a p y . O f th e se se v en w ere rece iv in g p sy c h ia tr ic trea tm en t. F u r th er a n a ly sis o f th is gro u p sh o w s th e site o f p a in o r p a ra ly sis t o b e d istrib u ted a s f o l lo w s : T h e n eck — 7, L u m b ar r e g io n — 1, arm s— 3, le g or k n ee— 3, fe e t— 3, H a n d s— 4. O n e h a d “ g en era l p a in s” . T h e “ tr e a tm e n t” re q u e s te d w a s u su a lly so m e fo rm o f heat (w a x , S .W .D .) , m a ssa g e a n d ex e r c is e s. T h e su rgical group w a s th e largest a s it in clu d ed trau m a and o r th o p a e d ic s. F u r th er a n a ly sis o f th is g r o u p in clu d ed : G e n e r a l su rg ic a l (a m p u ta tio n s, p o s t-m a s te c to m y o e d e m a , stress in c o n tin e n c e e tc .)— 13, F ra ctu re s— 2 5 , h a n d s— 19, so ft tissu e le s io n s— 19, feet— 2 5 , sp in a l le sio n s— 37. T h e fracture p a tie n ts w ere u su a lly referred fo r treatm en t o f c o m p lic a tio n s su c h a s stiff j o in t s o r n erv e le sio n s o r r esid u a l p a in and sw e llin g . V e r y few rece n t inju ries are se en . T h e “ h a n d s” w ere th e u su a l cu t te n d o n s, se p tic fingers, p o st-tr a u m a tic stiffn ess. S o ft tissu e le s io n s w ere m a in ly te n d o n itis. T h e fo o t p a tie n ts w ere all w o m e n su fferin g fr o m p a in and w ea k n ess o f th e in tr in sic m u scles. O f th e sp in a l le s io n s 8 w ere cerv ic a l, o n e th o r a cic and 28 lu m b a r. C o n d itio n s in clu d ed o ste o -a r th r itis , d isc le sio n s, se n ile o s te o p o r o s is , a n k y lo sin g s p o n d y litis , trau m a and b a c k a c h e se c o n d a r y to p a th o lo g y at th e h ip . T h e m ed ical group in clu d ed g en era l m e d ic a l (sa lp in g itis, d ia b e tis, p so r ia sis, b ed so re s, e tc .)— 15, n e u r lo g ic a l ( p o ly ­ n eu ritis, p erip h era l n erve le s io n s , trig em in a l h erp es, e tc .)— 2 4 , B e ll’s p a lsy — 7, r h e u m a tio d arthritis— 9 , o ste o -a r th r itis— 8 . O f th e p a tie n ts w ith B e ll’s p a lsy , five r eco v e red c o m p le te ly T h e trea tm en t g iv en w a s u ltr a so u n d (less th a n ■ 5 w a tts/c m a fo r 3-5 m in u te s) d u rin g th e sta g e o f p a in . A s s o o n as v o lu n ­ ta ry m o v e m e n ts retu rn ed , th e trea tm en t u sed w a s ice and ex e r c ise s u sin g stretch , resista n ce a n d irra d ia tio n fro m th e n o r m a l sid e , n eck and a rm s. O n e h ad p a in fo r o n e m o n th an d w a s ad m itted fo r d e c o m p r e ssio n . T h e o th e r h ad had th e a tta ck 2 years p r e v io u sly and w a n ted t o try th e “ n ew te c h n iq u e ” . H e h a d p a rtia lly r eco v e red and sh o w e d n o furth er reco v e ry . T h is gro u p d id n o t in clu d e fa cia l p aralysis d u e to sta b -w o u n d s or c e re b r o -v a scu la r a ccid en ts. T h is is n o t th e o n ly g en era l c lin ic w h ere th e stu d en ts gain p ra ctica l ex p e r ie n c e . T h e y a tten d at o th e r h o sp ita ls and sp e c ia lise d ce n tr e s, an d w o r k in th e g y m n a s iu m an d w ards at th e J o h a n n e sb u r g H o sp ita l. B . W I N T E R , M .C .S .P . T e a ch er o f P h y sio th er a p y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )