膝關節(jié)評估

1、,膝關節(jié)評估,膝部韌帶拉傷,內側副軔帶(MCL)/外側副軔帶(LCL) 內翻壓力測試(Varus Stress test)(圖右)?外側副軔帶 外翻壓力測試Valgus Stress test(圖左)?內側副軔帶Grade 0: 無松弛Grade 1: 1cm,2,膝部韌帶拉傷前十字軔帶(ACL), 后十字軔帶(PCL),前十字軔帶: 膝彎屈時放松(0~30度),伸直時緊張后十字軔帶: 膝彎屈時緊張(90度),伸直時

2、放松,3,PCL,ACL.,4,最常見原因跑動中急停改變方向造成一巨大扭轉力而損傷高處跳下造成膝扭轉,前十字軔帶 -- 非碰撞接觸損傷,后十字軔帶損傷,脛骨下陷(sag sign) 常見騎摩托車撞擊前檔板后損傷,5,前十字軔帶(ACL) ; 后十字軔帶(PCL),90°-前抽屜試驗/后抽屜試驗0~30° :前十字- 緊張

3、 90° : 后十字- 緊張前抽屜試驗(+)表示脛骨被拉向前超過0.5cm，?前十字軔帶可能斷裂后抽屜試驗(+)表示脛骨被向後推離股骨超過0.5cm?后十字軔帶可能斷裂,,6,抽屜試驗的盲點,腘旁腱(腿后腱)肌(hamstring)太緊會拉不動? 偽陰性當后十字軔帶損傷時會使脛骨原先就處在后退的位置(sag sign) ?偽陽性

4、,7,Lachman test,對前十字軔帶損傷最敏感ACL 膝彎屈25~30°然后拉動脛骨遠離股骨若輕易被拉開表示前十字軔帶斷裂,8,前十字軔帶旋轉軸移動測試(ACL Pivot shift test),給一拉力將脛骨前拉在膝彎屈0-30°時, 然后給予股骨向內側的壓迫?前十字軔帶穩(wěn)定度如果出現(xiàn)卡住 – 突然半脫位 → pivot shift test(+),9,膝部 Knee Unhappy Triad,膝蓋扭傷合

5、并內側副韌帶、前十字形韌帶和半月軟骨損傷的合并性嚴重損傷需碰撞的運動常見運動傷害機轉: 外側碰撞力量在膝蓋此時腳掌還緊貼在地面產生一個外轉的扭力→前十字形韌帶損傷可連帶外側/內側結構的破壞,10,小的撕脫性骨哲折 在脛骨近端和前十字軔帶有關? 扭轉傷害? Segond Fx,11,前十字軔帶損傷在X線表現(xiàn),A Fat-Suppressed Proton-Density weighted Sagittal image,實心條狀,1

6、2,MRI下正常前十字軔帶,T1-weighted MRI,T1-weighted MRI,13,MRI appearances in ACL,在應當出現(xiàn)前十字軔帶的位置卻看不到代表就是有損傷 Sagittal image shows complete (or near-complete) nonvisualization of the ACL with ill-defined edema and hemorrhage in the

7、 usual location of the ACL in the intercondylar notch.,14,MRI appearances in ACL tear,T1-weighted MRI,Proton-density weighted fat-suppressed sagittal image 軔帶邊緣不規(guī)則?部份斷裂,15,Diagnosis : Partial tear of the proximal ant

8、eromedial band of the ACL,,半月軟骨損傷,關節(jié)活動時卡住McMurray test：平躺膝彎屈給與內轉外轉的力?外轉的力 ? 外側半月軟骨(Lat. Meniscus(左圖) ?內轉的力 ? 內側半月軟骨(Med. meniscus(右圖 ) 檢查有無雜音(click sign),16,meniscus 半月軟骨,Apley’s test：下壓且旋轉若有明顯疼痛在膝蓋處表示陽性,

9、17,臏骨痛(Patellofemeral Pain),賓骨碾磨測試(patellofemoral grind test)Apprehension test（恐懼） 賓骨被向外推時病病人會有恐慌表情,18,賓骨股骨疼痛綜合征,與造成膝關節(jié)外側壓力大的任何因素相關的生物力學缺損都可能造成疼痛Q angle 角度過大足部過度pronation （flatfoot）髕骨過度外移髕骨過高或過低(Patell

10、a alta(高位) or baja(低位),19,Hamsting strain Quadriceps strain,20,賓骨股骨疼痛綜合征,股內斜肌(VMO vastus medialis oblique muscle) 肌力不足: 最重要的穩(wěn)定肌肉股骨前傾造成股骨過於內轉?足旋前髖內轉肌縮短;造成股骨過於內轉髖外轉肌力不足;造成股骨過於內轉: Iliopsoas, Gluteal muscles,21,

11、賓骨股骨疼痛綜合征,治療足弓使用特殊鞋墊支撐肌力訓練: 髁腰肌(Iliopoas) and 股內斜肌? 開放/閉鎖鏈運動伸展內側腘旁腱肌和大腿內收肌群避免 W坐姿,22,賓骨肌腱炎(Patellar tendonitis)近端 : 跳躍膝(Jumper’s knee) 遠端 : Osgood-Schlatter Dz,23,Infrapatellar bursitisPopliteal bursitis

12、(Baker’s cyst),24,,膝退化性關節(jié)炎Figure 1 : 正常 Figure 2 : 有骨刺產生, 關節(jié)腔變窄,Osteoarthritis: gradingDepartment of Rheumatology and Medical Illustration,University of Manchester,Grade 0 : No featuresGrade 1 : Doubtful narrowi

13、ng of joint space and possible osteophytic lippingGrade 2 : Definite osteophytes and possible narrowing of joint space Grade 3 : Moderate multiple osteophytes, definite na

14、rrowing of joint space, and some sclerosis and possible deformity of bone endsGrade 4 : Large osteophytes, marked narrowing of joint space, severe sclerosis , and definite deformity of bone ends,髂脛束綜合癥 (Iliotibial

15、band syndrome ),Ober test,27,Open and Closed-kinetic Chain Exercise,Closed-kinetic chain exercise provide a more significant compression force across the knee while activating cocontraction of the quad

16、riceps and hamstring muscles.Open-chain exercise at low flexion angles may produce an increase in anterior shear forces, that may cause laxity in the ACL.,28,Open and Closed-kinetic Chain Exercise,Open-ch

17、ain exercise generate more isolated muscle activities and allow for more specific strengthening training. ? Closed-chain better than Open-chain exercise in ACL reconstruction? Avoid early open-chain exercise,2

18、9,反覆賓骨不穩(wěn)定的治療,目標: 減輕癥狀Increase quadriceps strength a d endurance (VMO > lateral structures).Use of passive restraints (Palumo-type bracing, McConnell taping) to augment stability during transition. Patella

19、r TapingCreate a mechanical medial shift of the patella ? centralizing it with in the trochlea groove and improving patellar tracking.,30,Therapeutic ExercisesHeel slides / Wall slides(?)Patellar mobi

20、lization,31,Therapeutic ExercisesQuadriceps sets Straight leg raises(SLR) all planes with brace in full extension until quadriceps strength is sufficient to prevent extension lag. Slowly raise it 6 to 10 inches o

21、ff the floor. Hold this position for 5 seconds and then relax. Perform 3 sets of 20 repetitions, 4 to 5 days a week.,32,Nonioerative treatment of Recurrent Patellar Instability (Lateral),High EMG activity of the VMOLe

22、g press. Lateral step-up.Isometric quadriceps setting.Hip adduction exercise.,33,General Guidelines for Nonioerative treatment of Recurrent Patellar Instability (Lateral),Gradual restoration of flexibility (stretching

23、) for noted deficits.Iliotibial band Quadriceps,34,Two-person Ober stretch,Cross-over lateral fascial stretch,Self ober stretch,Leaning lateral fascial stretch,Quadriceps self-stretch,General Guidelines for Nonioerativ

24、e treatment of Recurrent Patellar Instability (Lateral),Gradual restoration of flexibility (stretching) for noted deficits.3. Hamstring4. Gastrocnemius,35,Therapeutic ExercisesHamstring CurlsHold this position fo

25、r 5 seconds and then relax. Perform 3 sets of 20 repetitions, 4 to 5 days a week, continuing for 3 to 4 weeks.Straight –Leg Raises(Prone) Tighten the hamstrings of the injured leg and raise the leg toward the ceil

26、ing as far as you can. Hold the position for 5 seconds. Perform 3 sets of 20 repetitions, 4 to 5 days a week.,36,Therapeutic ExercisesNon-weight bearing gastrosoleus, Hamstring stretchesProne extension hangs fo

27、r gravity – assisted knee extensionSupine and leg elevation with resistance,37,Therapeutic ExercisesMini squats 0~30? Stationary bike (begin with high seat, low tension)Closed-chain extension (leg press 0~30? )