Thread: Soft Tissue Injuries and Sports Injuries

Injuries to soft tissue, such as muscles, tendons and ligaments oc from a variety of causes and the effects of injury are legion beca people are different. The effects on a sedentary worker will differ fr those on one who is active; housewives will be affected different from their husbands; there are also age differences to be taken in account. The matter is further complicated if those affect, participate in sport and more so if it plays an important part in the lives.

EXAMINATION AND ASSESSMENT

The reader is referred to Problem Orientated Medical Syst¢ (POMR) (Weed, 1968, 1971; Graves, 1971; Cross, 1974; Heath, 19 as a means of keeping medical records and providing a logical forn for patients' notes.

This method of note-keeping organises information re]ating to patient by providing a continued narrative under the headings ofd base, problem list, initial plans and progress notes. The latter written as 'narrative' notes with sub-headings of:

Subjective - what the patient says
Objective - the physiotherapist's observations and evah
tions
Assessment - the physiotherapist's professional opinion
the short- and long-term goals of treatment
Plan - the development of a treatmen.t program

designed to reach those goals.

Examination and assessment of any region should follow the for outlined by Adams, 1981; Cyriax, 1978; Lee, 1978; with emphasis inspection, palpation, range of movement and power. The nature of any pain and its distribution should be noted, as should temperature change, local swelling and joint stability. Sensory testing should not be overlooked. Examination of the upper limb should be conducted with the patient stripped to the waist; for the lower limb, shorts or other appropriate attire should be worn. For examination the padent ideally should be in standing, but may be lying or sitting depending on. his age, height and degree of deformity, and the height of the physiotherapist. It is very difficult for a short physiotherapist to conduct a full examination on a tall patient who is standing. It is tiring and uncomfortable for the elderly or infirm to remain standing for long periods..

The physiotherapist should have at hand a tape measure, scissors, a safety pin, protractor (or goniometer) to aid the examination and should be familiar with the use of a patella hammer.

Once the examination and assessment are completed the physiotherapist is in a position to make a plan of treatment and can then modify and progress the treatment as often as necessary in conducting an 'audit'.

PRINCIPLES OF PHYSIOTHERAPY

SHORT TERM

The objectives should include:

1. Prevention of further damage

2. Limitation of any bleeding

3. Reduction of pain

, Reduction of swelling

S. Prevention of immobility/stiffness in joints and soft tissues

: i. Maintenance of muscle power



LONG TERM

The objectives should include:

1. Restoration of kinaesthetic/proprioceptive mechanisms

2. Reeducation of movement

3. Increase mobility of joint and soft tissue

4. Increase power of muscle

5. Restoration of function and return to daily living

6. Restoration of confidence in affected part

7. Prevention of the return of oedema/swelling

8. Prevention of recurrence of the injury


The modalities of treatment that are used will include ice, compression wtth or without elevation, exercises, ultrasound, interferential, pulsed and unpulsed short wave diathermy.

This type of bandage provides an even pressure and is a well-tried

method of applying compression: It has two main obiectives: 1. To prevent bleeding.

2. To reduceswelling.

APPLICATION

(a) The pressure is applied firmly and evenly over a wide area above and below'the joint even though the pressure is needed locally. (Local pressure is more likely to damage underlying soft tissues and blood vessels and thus preiudice the blood supply.)

(b) The area should be well 13added using cotton wool or gamgee in three layers. The padding should be retained using a flannelette or cr6pe bandage.

1st layer: A thick layer of padding is held on by the bandage which is not taken right to the limit of the padding as this prevents the bandage cutting in. Opportunity is taken at this layer to fill in any hollows, e.g. the coulisses at the ankle.

2rid and 3rd layers: As the first with each layer being covered by the bandage.

(c) The limb should be elevated while the bandaging is applied as this reduces the trapping of blood on the distal part of the limb.

(d) The bandages are applied from distally, working proximally. If possible the limb should be in the neutral or shortened position for the ligaments.



GENERAL RULES FOR APPLYING THE BANDAGE

1. An even pressure should be maintained.

2. Obtain two-thirds to three-quarters overlap of each turn.

3. Keep the edges parallel.

4. Bandage from within out and from below upwards (distal proximal).

5. Support the part being bandaged.

6. Use a bandage of appropriate width, e.g. 7.5-10cm (3--4in) for the ankle region; and 10-15cm (4-6in) for the knee or thigh region.

7. Ensure that the bandage stabilises the chosen area.

8. A back splint can be incorporated.



CLINICAL TYPES OF SOFT TISSUE INJURIES



To simplify the understanding of soft tissue injuries they can be classified as: strains; sprains; ruptures; and contusions.

Although it is accepted that a strain may be a milder form of a sprain and be applied to both joints and muscles, in this chapter it is defined as damage to muscle of less than complete rupture. Sprains are concerned with ligaments and joints. For example, a biceps femoris strain is distinct from a sprained lateral ligament of the knee joint. It is doubtful whether contusion can occur without strains or sprains of some degree; haematoma formation is always associated with strains.



Strain



Muscle and tendon injuries are referred to as strains and are the result of overstretch. They may be sub-divided as follows:

1. Chronic strain: The iniury develops over a long period of time which leads to fatigue, muscle spasm, myositis and ischaemia and varying degrees of damage.

2. Acute strain: The result of a single violent force to a muscle, usually one that is acting over two ioints, which occurs when the contracting muscle is forcibly stretched; for example, the body-weight of a goalkeeper or iumper when landing acts in opposition to the contracting quadriceps.

Ryan (1969) considered strains in four categories; Williams (1979, 1980) describes three, namely, complete, partial intramuscular and partial interstitial. This is not purely an academic exercise, as accurate classification of the extent of the damage (and so by inference the amount of bleeding, muscle spasm and loss of function) will determine the correct line of treatment.



GRADE I: FIRST DEGREE (MILD CONTUSION OR STRAIN)

The initiating trauma is usually crushing and can be the result of a blow from an outside agency, for example the corner of a desk knocking against the thigh on getting up from the chair behind it. There will be tearing of a small number of muscle fibres, the fascia remains intact and bleeding will be minimal. The resulting muscle spasm, pain and tenderness will be locaiised; pain and spasm in the muscle resists stretching. It is usual with these injuries to have limited local muscle endurance but no interference with function.

If the injury is to an active games player treatment should start immediately after injury by the application of ice for 15-20 minutes followed by a compression bandage applied with moderate pressure. After 20-60 minutes the patient is encouraged to stretch the muscle actively but gently; for example, the quadriceps of a sportsman may be stretched by half squats, partial weight-bearing or he may lie prone and carry out non-weight-bearing knee bending. The maxim is 'little activity taken often'. Ultrasound of low power and dosage may be applied immediately. Ideally the patient should be seen four times a day, or at least morning and late afternoon, then reduced progressively after two to three days. Massage may be given around the site of injury but not directly to it.

If the pain is minimal then light work can be resumed on the next day; pain guides the progression but the site of injury should be protected for two to three days to avoid accidental knocks by the application of a sorbo pad and bandaging. A more conservatiw approach will restrict activity for longer, usually until the pain and an! swelling have been resolved for a week.

GRADE 'II: SECOND DEGREE (MODERATE STRAIN)

The trauma is more severe- a greater blow is required. There will be a larger number of muscle cells crushed and torn over a wider area. The fascia is still intact and so the haematoma is confined within the muscle even though the bleeding is considerable. The undamaged muscle and subcutaneous fat will be displaced with the formation of a definite palpable mass which is partially liquid and partially clotted blood. The area of the injury will be very tender with considerable pain. The resulting spasm is more severe than it is with Grade I injuries so there is very little muscle extensibility or contractility. There is a longer time scale for recovery with this level of injury.

Initial treatment starts immediately, or at least within 24 hours, by the application of ice, compression with elevation using a Robert Jones bandage or Tubigrip. No active movement or stretching of affected muscle is allowed for at least 24 hours, although active exercises may be encouraged for unaffected parts in an attempt to maintain basic fitness. If the patient can tolerate the discomfort or pain then'rhythmical static contractions (auto-esisted if possibleI are allowable but no movement of the joints above and below the'injury.

The patient with lower limb muscle damage is allowed to be non-weight-bearing on crutches with a pressure bandage. Dispersal agents containing hyaluronidase can be applied to the injury if there is no wound. Gentle effleurage and kneading proximally is particularly helpful. The patient should be seen at least twice, preferably four times, a day.



After 24 hours: After removal of the pressure bandage, active muscle contraction is encouraged. Extensibility is gained by moving antagonist muscles. Proprioceptive neuromuscular facilitation techniques (PNF) such as slow reversals,, hold-relax and timing for emphasis are of particular benefit. Stretching may be started within the tolerance of the patient. Non-weight-bearing, massage and dythmical static contractions may need to be continued; ultrasound, if of low power output and duration, may be used.



472 hours: All previous treatment is continued with more emphasis .n active unresisted contractions and extensibility, altfiougfi a hbld-relax contract-relax proprioceptive neuromuscular facilitation technique can be adopted, If a good range of movement and full static contraction are obtained then the patient can be progressed to partial .weight-bearing if applicable. Transverse frictions to the affected area • an be added to the massage manoeuvres.


72 hours: Continue the above treatment regime while allowing increasing progression. The pressure bandage can be removed and need not be replaced unless the swelling increases rapidly. Progressive resisted exercises can be instituted with the weight and load commensurate with pain and discomfort. Fowler (1977) outlined a technique for finding the 10-12 Repetition Maximum (RM) which can be useful later. By trial and error, the amount of weight that can just be lifted (the one repetition maximum- 1RM) once by the patient has first to be found; then the 10-12RM is calculated by taking either two-thirds or three-quarters of the IRM which is the amount of weight that will allow maximal power to be developed.

If the lower limb muscle is involved then progress to full weight-bearing should start; when full range of movement .is attained progress from fast walking to jogging to running is allowed.

Assessment and fitness testing is essential before full training is allowed although the return to work may be very much earlier.

If a hard mass is still present in the muscle after four weeks from injury time, myositis ossificans should be suspected; treatment must be stopped and the patient referred back to the doctor.



GRADE III: THIRD DEGREE (SEVERE STRAIN)

This level of injury involves a larger area of muscle. The fascia is torn at least partially, more than one muscle may be involvect and more than one area in the muscle affected. The bleeding, though considerable, is more diffuse due to the fascial tear and an intermuscular haematoma forms.



Treatment: This follows that oudined for Grade II but the patient should be admitted for a period of in-patient care. Progression is much slower; although the patient can mobilise non-weight-bearing in 24-48 hours, partial weight-bearing should not be started too early. Stretching can start five to seven days after injury and active exercises on the second day. Analgesics may be necessary for any pain.



GRADE IV: COMPLETE RUPTURE

The force causing this injury is more than that required to produce Grade III. There is an immediate contraction of muscle ends, with an obvious gap between them. In some instances the sound of rupture may be heard.

Muscle spasm is very severe and widespread with very acute pain.



of the muscle, and inversely proportional to the spasm of the muscle. There is considerable swelling. Active contraction will be absent;


theoretically, there is no limit to extensibility but the acute spasm will prevent it.

Unless joints are involved in the trauma there is no loss of movement produced by the antagonists except the inhibition by the muscle spasm and pain. There is obvious loss of movement produced by agonists in the active range.



Treatment: It is not considered useful to suture the muscle ends together. It is more important to try and secure the fascial sheath, evacuate blood and secure haemostasis. Then a compression bandage is applied and the muscle immobilised for 10-21 days in a shortened position. Physiotherapy may include movement of all free joints; exercises to all unaffected muscles of other groups; and rhythmic static contractions in the area of the injury if possible. If a lower limb muscle is involved the patient may be allowed up non-weight-bearing after 48 hours. Treatment is as outlined for a Grade III injury with slower progression. The use of low frequency current (e.g. faradism) to produce passive contraction, assist mobility of muscle fibres and affect recovery of muscle fibres probably by influencing fast and slow twitch fibres and the distribution of motor units and fusimotor systems, is still under investigation (Pette, 1980). It should be considered as a treatment modality. Physiotherapists will use short wave diathermy, interferential and diapulse as appropriate.



The regime described refers to the muscle belly but there are other sites where the muscle can be damaged:

1. Musculo-periostealjunction: This occurs usually by indirect trauma with pain, little or no swelling and some loss of function. (The degree of swelling will depend upon the extent or degree of damage.)

2. Musculo-tendinousjunction: Shows similar signs and symptoms but a greater loss of function.

3. In the tendon: The tendon is painful and swollen especially if there is a sheath. There is marked loss of function and no high level activity is possible.

4. At the tendon-periosteal junction: There is usually very little tenderness or swelling but considerable loss of function.

General signs and symptoms of soft tissue injury

The level o pain, swelling, tenderness and loss of function are determined by the degree of damage.


There will be increased pain on passive stretch and on active .contraction. To differentiate between the pain caused by moving an inert structure or by contraction of a muscle it is necessary to cause contraction of the muscle against resistance but allow no movement to take place. If this isometric effort produces pain the possibility of there being a damaged ligament is eliminated (Cyriax, 1978). There is varying loss of function and muscle spasm. Tenderness which is local at first will spread later. Swelling may be of very rapid onset and there will be bruising due to tracking under the influence of gravity.



Treatment: The general aims of treatment will be to relieve pain and muscle spasm, restore function and stop- and limit the effects of- the bleeding. Further damage and injury should be prevented by using techniques which are effective and appropriate for the stage of the injury.



Contusions or bruises

These are usually caused by direct blunt violence, crush or direct contact with another person or a hard landing surface. More often than not the skin is unbroken with extravasatJon of blood into the subcutaneous tissue due to capillary damage. The normal blood flow is affected because of occlusion of capillaries and pressure of any swelling. Normal tissue nutrition is impaired. There is stiffness of the part because of pain, swelling and muscle spasm.

The aim of first aid is to limit any bleeding and a hyaluronidase/ heparinoid type of dispersant such as Lasonil, Hirudoid or Movelat cream or gel, is very useful if used within 48 hours and if there is no wound present. Cold compresses and pressure bandages will also be effective in limiting the bleeding and reducing the pain. Depending on the extent of the bruising there may or may not be loss of function. If there is loss of function then it is reasonable to assume that there is at least Grade II/III muscle damage and appropriate action has to be taken.



Haematoma

In addition to the superficial haematoma of a contusion there are two Other types described which are decided by the state of the muscle sheath. Both are caused by damage to blood vessels within the muscle resulting in extravasation.


INTRAMUSCULAR HAEMATOMA

In this category the blood is contained within the immediate area of the muscle by an intact muscle sheath. After an injury producing bleeding, tension within the muscle increases; the bleeding soon stops and haematoma formation is completed within two hours. It remains friable for two to three days during which time there is danger of further bleeding if more trauma occurs.



INTERMUSCULAR HAEMATOMA

If the muscle sheath is torn then the extravasated blood seeps into the space between muscle in the fascial planes. The resulting haematoma is more diffuse and bleeding continues longer as tension does not build up. The extravasated blood tracks under influence of gravity distally and shows a discolouration beneath the skin.

It is difficult to separate inter- and intramuscular haematoma as they show very similar signs in the first 48 hours or so. After this time they can be differentiated. The characteristics of an intermuscular haematoma are:

1. Disappearance, or drastic reduction, of swelling at 48-72 hours; followed by

2. Reappearance of stronger muscular contraction.

3. Evidence of tracking of blood as the bruising shows some distance from the primary lesion.

4. Pain is moderate only.



RESOLUTION OF HAEMATOMA

Organisadon of the haematoma occurs because removal of the blood and exudate is impaired by damage to the blood and lymph vessels, especially the arterioles and the venules. Compression of the veins by congestion, and lack of muscular action in the muscle fascial pump due to pain and spasm, impairs reabsorption and allows organisatiort tO occur.



Recovery and repair



Repair involves two processes, the formation of connective tissue and the regeneration of muscle tissue.

CONNECTIVE TISSUE

The tissue is infiltrated by macrophages which are converted into fibroblasts; together with existing fibroblasts these undergo mitosis because of inactivation of the inhibitory enzymes present in healthy tissues. The fibroblasts secrete procollagen, a precursor of collagen which with the fibrocytes forms scar tissue which, as it matures, strengthens and shortens.

MUSCLE TISSUE (Allbrook, 1980)

Skeletal muscle is able to regenerate and in so doing will close a gap providing it is not too large. Muscle fibres grow at the rate of 1.0-1.Smm per day and need a smooth interface along which to grow. Usually this is impaired by the proliferation offibroblasts and collagen forming too much scar tissue to allow regeneration to occur, and the defect is usually too large. It has been shown that after minor damage


due to pressure there is rapid recovery and within 24 hours after iniury damaged fibres cannot be distinguished from the undamaged.

The cycle of events following severe damage to fibres with associated haematoma is muscle fibre necrosis, phagocytosis and regeneration.

Much of the research work has been performed on animals, and in 1966 Allbrook et al noted that . . . 'it would appear that in clinical cases activity is an important factor in speedy and effective muscle recovery. Active joint and muscle movements provide a suitable environment for muscle and soft tissue regeneration'.

Further work is needed to determine if the repair process can be enhanced and a suitable environment for repair produced by using low frequency electrical stimulation, e.g. fa'radic type currents. There is evidence to show that trophic changes occur when muscles are stimulated electrically (Hudlicka et al, 1980).

Tendon injury

REPAIR

The major problem following laceration and repair of a flexor t6ndon is that functional recovery is hindered by the formation of adhesions which restrict tendon excursion. Potenza (1962) showed that adhesions to repaired tendons occur at each point where the physical integrity of the tendon is disrupted. Excision of the synovial sheath following tendon repair appears to have no adverse effect on the healing process nor on the functional result but if the bony floor of the digital tunnel is damaged through removal of the flexor tendon and disturbing the vincula brevia then extensive adhesions form. Matthews and Richards (1976) demonstrated that adhesions tend to form in the presence of a combination of suturing the tendon, removing the digital theca and immobilisation. (See also Matthews (1979) and Potenza (1980).)

When flexor tendons are divided within the flexor digital sheath there is proliferation of fibroblasts and vascular elements of the surrounding tissues which are damaged at the time of injury. At the same time resting tenocytes are transformed into tenoblasts within the cut ends of the tendon. Repair is then effected by the proliferation of these cells and the synthesis of new collagen fibres (Matthews and Richards, 1974). The initial collagen is laid down at right angles to the long axis of the repaired tendon. In 18-21 days the collagen is re-aligned and in response to tension lies parallel to the long axis. During this time the synovial sheath regenerates. Within 21-25 days there is enough collagen deposited to allow gradual active movement


and unrestricted use can be allowed after five weeks; at 128 days the wound is completely matured and it would be difficult to identify the scar histologically (Potenza, 1980).

The optimum time to commence active mobilisation of a repaired digital tendon is 23-25 days when the scar tissue is sufficiently strong to withstand stress.

JOINT INJURIES

Bass (1969) describes an injury to a joint as having three potential effects; (a) on ligaments only, (b) to the joint producing a synovitis and effusion, and (c) a combination of (a) and (b).

Ligaments

Injuries to ligaments are conventionally described as sprains and are classified in three degrees of severity. These injuries are caused by overstretching at the extreme of the range and are either acute or chronic; most acute lesions will occur in the lower limb or the spine. The medial ligaments of the ankle are damaged during eversion and the lateral ligament by inversion. Damage to the collateral ligaments at the knee occurs during rotary stress on a flexed knee or by a person falling over an outstretched leg, the medial ligament being the one most commonly affected.



GRADE I: FIRST DEGREE (MINOR SPRAIN)

With a Grade I sprain there will be minimal damage with some pain and tenderness at the site of injury. Swelling will be slight and there will be some loss of function. The differential test is to put the ligament at stretch and thus a knowledge of functional anatomy is essential to the physiotherapist.



Treatment: Ice, followed by the application of a Tubigrip bandage, crpe bandage or other type of support, and limitation of use for the first 24 hours. If the injury is to a lower limb ligament then the patient may be allowed to walk but to do little else with the injury during this time. Early commencement of static muscle contractions is desirable gor two reasons: first, the blood flow is maintained and the swelling reduced; second, developing strong muscles will develop strong ligaments (Inglemark, 1957).

GRADE II: SECOND DEGREE (SEVERE SPRAIN)

A greater force is required to produce this level of iniury: many more fibres are involved or a ligament may be partially detached from its attachment. The patient should be assessed medically or (in certain clinics/departments) by an experienced physiotherapist. Swelling is considerable but takes time to develop. Pain and tenderness are more acute. Movement is limited and, if in the lower limb, the patient is unable to bear body-weight even if the knee or ankle is kept stiff and straight. Function is very limited.



Immediate treatment: This involves the use of ice, compression and elevation if appropriate. To reduce pain the doctor may inject a local anaesthetic but activity must be restricted until later when the effects have worn off.



GRADE III: THIRD DEGREE (COMPLETE RUPTURE)

With a Grade III sprain there is rapid onset of effusion, very considerable pain and tenderness, the join, is unstable and there is complete loss of function. This must be assessed medically as the ligament rupture may result in displacement.



Treatment: First aid treatment involves the use of ice and compression with splinting and rest. If the ligament is displaced it is repaired surgically and the limb put in plaster of Paris for six to eight weeks. If it is not displaced plaster of Paris is applied to the limb and retained for six to eight weeks.

Static exercise must be started at once and all non-affected areas must be exercised. After about a week isometric movement can be attempted inside the plaster cast. For a lower limb injury weight- bearing is restricted and the patient is instructed in the use of sticks. When the splint is removed tissue mobility is encouraged and ultrasound, transverse frictions, and hydrotherapy are used. Effusion is controlled by the use of piessure bandaging correctly applied. At the appropriate time the patient joins classwork in the gymnasium.

Synovitis

Cyriax (1978) stated that this term should be abandoned as it is a symptom common to many disorders; it is not a diagnosis. Wiles (1959) said very much the same, especially in the chronic sense. Synovitis is an inflammation of the synovial membrane due for example to trauma, chondromalacia, loose bodies, arthritis, tubercu- Iosis, syphilis or haemophilia. Depending on the site it will mean that there is also damage to ligaments around the joint. The extent of trauma will decide the degree of synovitis; within the knee the menisci, cruciate or collateral ligaments may be involved. If all three are involved the description 'unhappy triad' has been applied O'Donahue, 1970).

Dislocation will damage the synovial membrane, so will 'nipping' of the membrane between the bony ends, even though it is thought that this is not possible. Direct blows will certainly damage. In some patients arthritis may lead to acute synovial rupture. Typically, synovitis is seen in the vigorous person who attempts to carry on despite the effusion.

SIGNS AND SYMPTOMS

There is characteristic swelling which has taken some time to develop. The joint area will be hot and red and the swelling will fluctuate on palpation. Pain may be present over the injured structure but more often there will be a feeling of tension or pressure due to the swelling. "the joint will be held in a relaxed position away from the extremes. Muscle atrophy will occur rapidly especially when the knee joint is involved.

In a synovial rupture of the knee the patient typically describes


getting up from a chair, going upstairs or circuit training, such as step-uPs or stride jumps, and feels a sudden pain at the back of the knee which rapidly swells, spreading into the calf causing an increase in girth of 5-7.5cm (2-3in) after several hours. The synovial fluid is irritating and leads to an inflamed oedematous leg. Homan's sign is positive and the condition is often mis-diagnosed as deep vein thrombosis. The signs of synovids arc similar to those of a haemarthrosis (blood within the joint).



DIFFERENCE BETWEEN HAEMARTHROSIS AND SYNOVITIS

With haemarthrosis the swelling is generalised and occurs rapidly indicating that there is significant intra-articular injury. Less serious injury produces an effusion which is manifest by swelling occurring over a period of hours; the effusion is serous. The classic type of injury to a joint has been described as capsular sprain which can be identified with the Bass classification (Williams, 1964). Thus capsular sprain can involve the whole joint, a specific capsular structure or ligament either as partial or complete sprain.



Signs: Pain on certain movements and extremes associated with local spasm. Clinical instability will only be demonstrable in a complete tear and even then it may be difficult due to muscle spasm. Swelling is usually slight although in some cases gross superficial swelling may be present, e.g. in damage involving the fibular collateral ligament.

TREATMENT

Ligament damage alone: The affected area is rested with a Robert Jones type compression bandage. Ice is useful to help reduce any swelling. Transverse frictions may be given to the site after insonadon with low power ultrasound for 3-5 minutes as the latter will have anaesthedsed the part. Graduated activity is begun at once and isometric action of muscles around the joint is essential.



Synovitis: Ice and compression with elevation as appropriate. Relative rest with specific instructions as to what can and cannot be done. If swelling persists for 48 hours, and if it interferes with mobility, then the joint may be aspirated. After aspiration the joint may be infiltrated with 25-50mg hydrocortisone which may be repeated if necessary. Other anti-inflammatory drugs such as phenylbutazone (Butazolidln) or ibuprofen (Brufen) may be prescribed. After aspiration isometric exercises should be encouraged progressing to a graduated exercise regime when the effusion has cleared. Where necessary weight- bearing must be reduced to a minimum.

HEALING OF LIGAMENTS

When there is a complete tear or a rupture of a ligament the ends. retract and the gap fills wxth blood, not because of bleeding from the ligament but from the damaged subcutaneous tissues. Eventually the clot organises by invasion from fibroblasts, collagen is laid down joining the ends within two weeks. There is insufficient strength to be fully functional until six to eight weeks have passed with restoration of collagenous continuity.

It has been reported that the unstressed length of ligaments is the same if allowed to heal without suturing a it is if the ligament is sutured (Potenza 1980). If, for example, the medial ligament at the right knee is stressed by pushing the thigh medially with the left hand and the leg is pulled laterally with the right hand the sutured ligament will not give or lengthen but the unsutured ligament will do so, the stretch depending on the amount of fibrous tissue between the ends. The suggestion is that for maximum stability of joints, esPecially in the young and in athletes, the damaged ligament should be sutured.



Combined synovitis and ligamentous damage



The synovitis is given priority of treatment.and the injured ligament is protected from further damage.



Bursitis



Bursae are membranous sacs lined with synovial membrane and sited so that they prevent friction or wear and tear of muscle and tendons as they pass over bone. They are of two sorts:

1. Normally occurring (true) bursae are found subitcromially, and at the elbow, knee and heel.

2. Adventitious bursae occur in response to new fnctlon on tendons over bone and can occur anywhere, e.g. hip, ischial tuberosity or at the medial side of the great toe.

The response to injury or disease of both 'types is the same, inflammation, which may be the result of mechanical irritation or bacterial infection.



IRRITATIVE

The inflammation arises because of excessive pressure, friction or gouty deposit. The wall of the bursa becomes mildly inflamed as a result of unaccustomed activity, exercise or ill-fitting shoes. The sacs become filled with clear serous fluid and are not usually painful unless pressured, e.g. a bunion or calcaneal bursitis.

Treatment: Rest, perhaps in a sling for the upper limb and restricted weight-bearing for the lower limb. Short wave diathermy, ice or infra red irradiation as appropriate. Muscle strengthening if necessary (PNF is useful, using slow reversals); mobilising if there is any limitation in joint freedom. The doctor may inject hydrocortisone into the bursa; this requires reduced activity for two to three days afterwards. In intractable cases of chronic pain the bursa may be removed surgically.



INFECTIVE

This may be an acute infection with a pyogenic organism, or a chronic

infection with a low grade Organism such as tuberculosis.



Treatment: Rest; ppropriate antibiotics with surgical drainage or excision. If there is an operation then pre- and postoperative physiotherapy is indicated. Short wave diathermy and massage may be given to the scar but not to the bursa.

Tenosynovitis

This is inflammation of the synovial lining of a tendon sheath but not the fibrous sheath. This condition also presents as an irritative and infective tenosynovitis.



IRRITATIVE

This form is due to excessive overuse and friction There are no adhesions, no limitirg movement but there, is pain and crepitus on palpation. The sheath is mildly inflamed and there is a watery effusion into it. It is likely to occur at the wrist and ankle. Racquet players are particularly prone.



Treatment: Movements must be restricted and he part rested by the use of splints, bandaging or plaster of Paris. If the paratendon of the tendo calcaneus is affected then the heel of the shoe is raised about 2.5cm (lin) fo males, and females are encouraged to wear shoes with a moderate heel. Ultrasound, short wave diathermy, and/or ice may be effective. Cyriax (1978) states that as the cause is longitudinal friction then transverse frictions will cure. Stubborn cases may respond to hydrocortisone injections and for other patients surgical intervention by slitting the sheath may be performed. In this event there will be pre- and postoperative physiotherapy.


BACTERIAL (INFECTIVE)

The acute lesion is caused by a pyogenic organism and produces a purulent exudate. The chronic lesion is caused by a low grade organism or tuberculosis.



Treatment: The appropriate antibiotic is prescribed once the causative organism is known. The part is immobilised for up to two to three months after which physiotherapy may be advocated.



Tenovaginitis



The tendon sheath rather than the synovial sheath is affected. Adams

(1981) states that although the cause is unknown it is not due to

infection. Cyriax (1978) suggests it may, follow repeated strains. Crepitus never occurs but use of the part causes pain.



Treatment is similar to that for tenosynovitis. If the condition affects the extensor pollicis longus or abductor pollicis longus it is referred to as De Quervain's disease.



UPPER LIMB CONDITIONS

Rotator cuff injuries

Whether called rotator cuff injuries or, less commonly, tendinous cuff injuries the muscles involved are supraspinatus, infraspinatus and subscapularis. All of them blend with the capsule distally.

PAINFUL ARC SYNDROME

Adams (1981) gives five causes of the pain caused by abduction at the glenohumeral joint during the middle range of movement. The supraspinatus tendon is usually nipped between the tuberosity of the humerus and the acromion process

ELEVATION NO PAIN

.l. Injury to the greater tubercle (tuberosity) of the humerus, either an undisplaced fracture or contusion to this site.

2. Partial tear of the supraspinatus tendon at the teno-periosteal junction. Cyriax (1978) states that the lesion must lie superficially at this junction for the painful arc to be elicited. If a painful arc occurs during passive elevation then the lesion traverses the distal end of the tendon.

3. Supraspinatus tendinitis.

4. Calcified deposit in the tendon.

5. Subacromial bursitis.

(Cyriax would add infraspinatus and subscapularis tendinitis because involvement of these structures is indistmguishable from that of supraspinatus.)



TREATMENT

Detailed treatment is found in Cyriax (1978) and Adams (1981). Suffice to say that where there is an undisplaced fracture or contusion, it is treated by early mobilising and strengthening exercises. The supraspinatus lesions are treated by rest, transverse frictions, short wave diathermy, ultrasound, exercises, or .injection of hydrocortisone.

A subacromial bursitis is not usually treated by frictions as this form of treatment is ineffectual or tends to make it worse. Muscle spasm may be reduced by effleurage and kneading. Rest in a sling, hydrocortisone injection, ice, short wave diathermy or infra red irradiation may be palliative.



Supraspinatus tendon



A complete tear of this tendon entirely disrupts abduction at the glenohumeral joint. The partial tear elicits a painful arc, i.e. pain around 90 degrees of abduction. The extent of the pain depends on the degree of tearing. If full passive movement is relatively painless, and if there is no painful arc, then the musculo-tendinous junction is probably affected.



CAUSES

The injury may be due to a fall on an outstretched hand or a slippage of a heavy load while lifting. Often the patient is over 60, unless an older sportsman; he experiences pain at the tip of the shoulder which later becomes intolerable; it is usually worse at night. Local tenderness is elicited just below the acromion. The limited abduction possible is produced by scapula rotation and maintained by deltoid.



TREATMENT

In the elderly patient it is usual to avoid an operation because of arthritic changes developing in the shoulder and the poor state of the tendon, but there are no such restrictions on younger patients.

After repair the arm is rested in a plaster of Paris splint with 90 degrees of abduction, 60 degrees of flexion and 45 degrees of lateral rotation for three weeks. Following immobilisation intensive active exercise will be necessary. Massage, heat or ultrasound can be used as adjuncts to mobilisation and restoration of function. The prognosis is fair if repair is carried out immediately, and poor if delayed.



lnfraspinatus

Although this muscle which inserts into the middle of the three impressions on the greater tubercle of the humerus may be ruptured completely, suffer strains or tendinitis, such conditions are rare. The orfly refereA,ce to a rupture is in Cyriax (1978) when he describes it as presenting with painless weakness and a painful arc which is very noticeable at first but then ceases over two to three years. When this occurs 30 degrees of lateral rotation is lost.

Tendinitis and strain of the muscle is more common than a rupture although still rare. The lesion will lie either at the insertion into the greater tubercle or in the body of the tendon. A full range of passive movement will be present at the shoulder; resisted lateral rotation will hurt while all other resisted movements will not. In addition, if the lesion is deep and distal, full passive elevation will be painful because the tendon is nipped between the tubercle and the acromion. If the lesion is superficial there will be a painful arc. If neither of these movements produce pain then a lesion exists in the middle part of the tendon.



TREATMENT

This will consist of rest for the traumatic lesions with ice, ultrasound and, when appropriate, transverse frictions. The treatment of choice for wndinitis is transverse frictions or injection of a steroid suspension at the site of the lesion.



Subscapularis

Damage to the subscapularis muscle, which inserts into the lesser tubercle (tuberosity) of the humerus, will usually be a stress injury caused by over-strain or continued overuse.

There is usually a full range of passive movement but resisted medial rotation is painful and adduction is usually pain-free unless pectoralis major, latissimus or teres major are involved. The site is tender to the touch. There may be a painful arc of movement which suggests that the upper part of the muscle is involved or, if full passive adduction in flexion is painful, the tendon of subscapularis is trapped against the coracoid process (Cyriax, 1978).



TREATMENT

Rest, ice and ultrasound for the recent injury and, when indicated, transverse frictions to the tender site. If tendinitis due to repeated overuse is present then the treatment is transverse frictions or an injection of a steroid suspension by the doctor.



Capsulitis of the shoulder



Other terms for this condition are 'diffuse capsular lesion' (Cyriax, 1978); a manifestation of arthritis or adhesive capsulitis (Neviaser, 1945); and periarthritis or frozen shoulder (Adams, 1981).

The condition is ill-defined and not understood. It is characterised by limitation of passive and active movements. Pain appears as the limit of the range is reached. Resisted movements do not hurt. There is no evidence of infection and injury is not a constant feature. There is loss of capsular resilience with a hardish end-feel like leather being


stretched. The patient complains of severe aching pain in the shoulder and upper arm which comes on gradually. In some instances sleep is disturbed as the patient turns during the night. Abduction, extension, flexion, medial and lateral rotation are all limited by as much as half normal range. Radiography reveals no abnormality and there is no evidence of inflammatory or destructive changes.

There is a tendency to spontaneous recovery within 6-12 months with reduction of pain and shoulder joint stiffness.



TREATMENT

This is relative rest in a sling which should be removed for short periods to allow gentle active-assisted exercises. Antiinflammatory drugs such as aspirin or phenylbutazone may be prescribed.

Provided Cyriax's criteria are matched, and the prescribing consultant agrees, then passive stretching may be commenced, the aim being to stretch the capsule only enough to cause an increase in pain for one to two hours. Steroid injections may be given into the joint and are said to improve movements and reduce pain dramatically, As pain lessens, active exercises are increased and muscles strengthened. In some instances short wave diathermy, ice and ultrasound may be useful.



Long head of biceps brachii



Tendinitis at this site is due to overuse or one severe strain affecting the mid-part of the tendon. Resisted movements at the shoulder are painless and passive movement are full and pain-free. Resisted supination and flexion of the elbow produce pain at the intertubercular sulcus.

Cyriax (1978) suggests treatment by transverse frictions and says that steroid injections are usually unnecessary because massage is frequently effective. Alternatively, ultrasound may be used.



Rupture of the long head of biceps does not occur under normal stress unless the tendon is weak due to age and is aggravated by friction as it runs through the intertubercular sulcus. The patient is usually male and past middle age and complains of moderate pain with the feeling that something is giving way when he pulls or lifts. Later a bulge may be noticed in the front of the arm (Fig. 25/7). There is localised tenderness in the intertubercular sulcus. Resistance to elbow flexion produces bunching of the long head of the muscle. The strength of flexion and supination will not be greatly affected.

TREATMENT

The disability is usually so slight that operation is not required. If repair is needed then it is usual to suture the distal stump into the bicipital groove and ignore the proximal end. Immediate treatment is aimed at encouraging active movements, especially at the shoulder, elbow and radio-ulnar joints. Any pain that is felt will be reduced by analgesics, or by using a sling which can be discarded after two to three days. If, after this time, it is still necessary to rest the limb the patient can carry it in his pocket. Short wave diathermy and resisted muscle work to the antagonists will help overcome spasm and reduce pain. It is essential to strengthen the muscle and to have it restored within two to three weeks.



Tennis elbow (lateral epicondylitis)



This is a common well-defined clinical entity and the term is used to cover all non-specific lesions affecting the wrist extensor group or muscles at their common origin at the elbow

The cause is overuse or strain of the extensor origin,, often caused by a tennis player with a top spin backhand or using a badminton racquet with too small a handle.

A painful scar usually lies at the teno-periosteal junction due to a partial tear of the aponeurotic fibres at the anterior part of the lateral epicondyle. The elbow is unaffected. Pain and tenderness are felt on the outside of the elbow with radiation down to the wrist. Passive and resisted elbow movements are full and painless; resisted extension and radial deviation at the wrist hurt at the elbow, Flexion of the wrist and ulnar deviation are pain-free. A' radiograph will reveal no alteration from the normal.

TREATMENT

In mild cases the limb is rested using a plaster of Paris sling for four to six weeks. Hydrocortisone injection may be given and the part rested for a short time afterwards. Deep transverse frictions may be given. Prior to using a Mills' manipulation (the forced extension of the elbow advocated by Cyriax), short wave diathermy may be of use in mild cases as well as following manipulation. If the injury does not • improve, or fails to respond to conservative methods, then operation is performed when the extensor origin is stripped from its attachment and allowed to fall back.



Other sites where this lesion may occur include:

(a) in the body of the tendon 5-10mm below the epicondyle, or (b) on

the supracondylar ridge in the origin of extensor carpi radialis longus.



The opposite lesion- golfer's elbow (medial epicondylitis)- can occur at the common flexor tendon origin on the medial epicondyle or at the musculo-tendinous junction about 6.25-12.5mm below the epicondyle.

LOWER LIMB CONDITIONS

Hamstrings (biceps femoris)

The signs and symptoms following injury to this muscle will vary h degree and be related to whether the iniury is a Grade I, II or III strain. If the damage is at the fibular insertion then there may be spasm of the muscle and the knee will appear locked, mimickiag the effect of a torn lateral meniscus. There may also be damage to the common peroneal



Resisted flexion of the knee will be painful at the side; there will be spasm in the muscle belly; and the knee will be held in slight flexion to gain the shortened position. Extension of the knee joint will be linted or painful. Weight-bearing will be uncomfortable at Grade I level but will be impossible at Grade III or IV.



TREATMENT

The initial treatment will be ice, rest and compression. For Grade II or III low-powered insonation may be useful with or without faradism. Later, massage using effleurage, kneading and then transverse frictions will be beneficial. Early rhythmical static contractions are advisable in Grade I and II but best delayed for 24-48 hours in Grade III. Progression to free and resisted activity using progressive resisted exercises and PNF, such as slow reversals, hold-relax timing for emphasis as appropriate, follow the normal course.



Quadriceps

The rectus.femoris is the muscle most often damaged, usually at the musculo-tendinous junction, although with, for instance, a more forceful take-off in a sprint start, mis-kick or direct blow, the belly may be affected. Many so-called 'pulled muscles' are the result of haemorrhage from a ruptured vein (Smillie, 1978).

In Grade I minor strain) injuries there is discomfort on extension of the knee and flexion of the hip. This will be disabling in Grade II (moderate strain). In either case performance and function will be affected. In Grade III (severe strain) injuries a definite gap will be felt; and in Grade IV (complete rupture) injuries the gap is clearly visible at about the middle of the thigh. Weight-bearing and function is unaffected in Grade I injuries but is increasingly a problem in Grades II-IV. There will be an area of tenderness at the site of injury, The general signs and symptoms have already been outlined and by applying anatomical knowledge to them it becomes possible to decide which muscle is affected and the degree of damage sustained.

Gross injury to the vastus medialis can occur following trauma relating to the limb having been trapped. Vastus lateralis is seldom injured because it is protected by the ilio-tibial tract but may be involved through herniation of the muscle following inguinal hernia repair by removal of a strip of the ilio-tibial tract. The vastus intermedius is damaged by a direct blow with subsequent haemorrhage which may lead to myositis ossificans.



Quadriceps apparatus



Except as outlined above disruption of the quadriceps apparatus may occur at one of three points:

1. avulsion of the tendon from the upper pole of the patella

2. through the patella

3. at the attachment to the tibial tubercle.

In all of them the applied force is unexpected flexion resisted by contraction of the quadriceps group.



AVULSION OF TENDON FROM THE PATELLA

This injury usually happens to obese, middle-aged or elderly men.

The patient stumbles going down stairs, starts to fall and a strong


reflex contraction of the q.uadriceps occurs. In the middle-aged or the young either the tendon can be avulsed or the patella fractured, in the elderly avulsion usually occurs.

Treatment: This consists of repair with stout non-absorbable sutures or stainless steel wire. A plaster of Paris cylinder is applied and after five days isometric quadriceps exercises are allowed. The patient is usually allowed up non-weight-bearing after 10 days and progressed through partial to full-weight-bearing over a period of four to six weeks. The plaster is removed after two to three weeks and is replaced by a back-slab until 90 degrees flexion and full extension of the knee joint is obtained. Low frequency current stimulation, for example, interrupted direct current (IDC) or faradism, and ultrasound may be . used as and when appropriate.



DISRUPTION THROUGH THE PATELLA

This usually occurs transversely through the mid-patella in middle- aged adults who stumble with a reflex contraction of the quadriceps. The knee is swollen and tender with a tense haemarthrosis. A gap can be felt which fills with blood. The patient is unable to straight leg raise or to move the leg at the knee.



Treatment: This varies widely according to the individual surgeon. It can range from supportive bandaging to surgical interference. The physiotherapist must apprise herself of the surgeon's wishes. In all methods isometric quadriceps muscle drill should be taught.



AVULSION AT THE TIBIAL TUBERCLE

This injury is the least common and occurs in children and young adults. It is very painful and slow to heal. The condition is treated by suture of the patella tendon and a plaster of Paris cylinder applied for six weeks. Gentle quadriceps drill is started five to seven days after operation and gradually increased.

The patient is allowed up non-weight-bearing progressing to partial weight-bearing for a period of four to six weeks finally being allowed full weight-bearing. A back-slab is worn until 90 degrees of flexion is obtained.

PRINCIPLES OF PHYSIOTHERAPY

1. Reduction of pain

2. Reduction of swelling

3. Maintenance of muscle strength

4. To obtain joint stability

5. To obtain joint mobility


6. Avoidance of quadriceps lag
7. Re-education of gait
8. Continuous assessment and testing for fitness

Swelling is usually a problem at the time of injury and following repair. This is controlled by the plaster of Paris or the pressure bandage together with quadriceps ..drill as appropriate and. when allowed. Swelling is likely to occur when the support is removed and when weight-bearing is started; this can be best controlled by quadriceps drill in elevation together with massage such as effleurage, kneading and squeezing-kneading.

The pain will gradually subside but analgesics may be prescribed at first.

Improving muscle strength will also obtain stability of the joint and avoid quadriceps lag. It is achieved by a system of quadriceps drill, progressive resisted exercises, PNF technique of maximal resistance, with slow reversals, timing for emphasis and stabilisations when a weak part of the range is met. To help in the healing process and the correct interplay of muscles it is essential that a normal walking pattern is obtained as soon as possible by emphasis on the equality of weight-bearing, length of stride and the time spent on each. It is also important that the proprioceptors are challenged by using a wobble board, uneven ground, jumping, running and weaving.



Rupture of the tendo calcaneus



This particular injury is very often overlooked as one of the other muscles, such as plantaris, is often suspected of being strained. The rupture is always complete and occurs as a result of forced dorsiflexion when the gastrocnemius is contracting strongly. Many domestic and sporting situations can lead to the damage, e.g. jumping off the bottom step of the stairs, jumping to 'smash' at tennis and landing with full weight on one leg. The injury can occur in all age groups, male or female. It may occur spontaneously in the middle-aged who are taking unaccustomed exercise, probably due to disuse weakness. In the female it may occur while participating in keep fit classes.



CLINICAL SIGNS

A sudden agonising pain rather like a kick is felt and a gap can be palpated some 5cm above the insertion into the calcaneus. There will be some swelling and the patient can walk with a limp or with difficulty. There will be tenderness at the site and some thickening in the area due to the bleeding. The muscle belly will show some spasm. Plantar flexion is possible but is much weaker when performed in long sitting or lying and is produced by the other posterior tibial muscles and the peronei.

Two tests are of use in the diagnosis:

(1) If the tendon is intact, squeezing the relaxed calf will contract gastrocnemius reflexly causing slight plantar flexion.

(2) The patient is asked to raise the heel from the ground while standing on one leg. If the tendon is ruptured this is impossible.



Treatment: This will depend upon the individual surgeon and once again the physiotherapist will need to apprise herself of his wishes. Apart from the variants in treatment techniques, the choice will be further governed by whether the injury is recent or old. In general the post-treatment management may be summarised as follows:

A below-knee plaster of Paris cylinder is applied with the foot plantar flexed, for three to four weeks; during this time the patient is allowed up non-weight-bearing with Crutches. The plaster is then changed and the foot position changed to plantigrade for a further two to three weeks.

At about four to six weeks the plaster is bivalved to allow active non-weight-bearing exercises. Non-weight-bearing walking with crutches continues, and after a further two to six weeks progression to partial weight-bearing is allowed, and then weight-bearing.



OBJECTIVES OF PHYSIOTHERAPY

1. To strengthen the gastrocnemins muscle particularly, and other muscles in general, while the ruptured tendon is healing.

2. To mobilise the ankle joint and foot.

3. To re-educate walking.

4. To develop spring, running and jumping.

5. To limit any swelling.

6. To break down adhesions and overcome their effects.

7. To stimulate the patient's response.

8. To test for fitness- functionally and physiologically if applicable.

Treatment techniques to achieve the objectives of physiotherapy are those of standard orthopaedic practice. Care should be taken not to progress the exercises too soon to avoid breakdown of the repairing tendon. Exercises will progress from non-weight-bearing to partial and then full weight-bearing.

A most important aspect of treatment is that of continuous assessment and fitness testing basing the progression of treatment on the findings. Joint mobility can be aided passively (Maitland, 1977) and actively. Physiological stretching techniques, i.e. reach grasp incline (or lean) support standing; holding with foot in dorsiflexion at the position of discomfort for one to two minutes and then resting for the same period The manoeuvre is repeated two to three Massage such as effleurage, wringing, squeezing-kneading to the calf muscle in elevation helps to limit and reduce swelling. Kneading and transverse friction will be necessary to break down any adhesions and to mobilise the tendo calcaneus and other tendons around the ankle.

The tendon should be well and truly healed within 128 days (4 months) and should be fairly strong at five to six weeks; at the appropriate time exercises and activities can be used to develop spring, running and jumping. Circuits may be incorporated into the regime.



Torn meniscus of the knee

The menisci are semilunar cartilaginous structures attaching centrally to the tibial condyle. They are thicker at the periphery than the central margin. The medial meniscus is broad posteriorly and narrow anteriorly. The lateral meniscus is, by comparison, thicker and has a wider more uniform width than the medial meniscus. The medial meniscus is more fixed than the lateral one. The functions of the menisci can be summarised as weight-bearing, shock absorbing, stabilising and facilitation of rotation.

CLASSIFICATION OF TEARS

Basically there are three types of tear and they

longitudinal split.

all begin as a

Bucket handle tear: The longitudinal tear extends the whole length of the meniscus. This is the commonest type and the central fragment is displaced towards the middle of the joint. It is associated with locking.



Posterior horn tear: The longitudinal tear starts at the concave central border and a tag is produced which displaces centrally but remains attached to the posterior horn.



Anterior horn tear: The tear (which can be either longitudinal or horizontal) appears towards the anterior end of the concave central border. The tag produced remains attached. It is comparatively rare. The tears are usually caused by a twisting, compressional force on a semi-flexed knee and can occur in all age-groups, although the longitudinal injury is more likely in the younger person.



The most common conditions producing abnormal stress and strain on the knee joint are on the football field and, to a lesser extent, in coal mining; any activity involving twisting on a flexed knee will render the menisci liable to damage.



CLINICAL FEATURES

The average age for all meniscectomies between 1940 and 1974 has risen from 27.6 to 43.7 years for males and from 22 to 50 for females and the most common meniscal tear is of degenerative origin (Smillie, 1978). The medial meniscus is affected more often than the lateral.

The twisting injury causes the patient to fall and complain of pain on the antero-medial aspect of the joint and there is inability to continue the activity. There is difficulty in straightening the knee and in walking bearing weight. Overnight the knee becomes swollen; this resolves over two weeks with rest and bandaging. During this period the patient regains the ability to straighten the leg. At some later date the knee gives way during a twisting movement with consequent pain and swelling. These incidents occur repeatedly and eventually the patient will say that the knee 'locks' that is, a sudden interference with extension during rotation occurs. The locking has been shown to be due to interposition of a section of the meniscus between the femur and the tibia at a point anterior to the coronal plane of the joint. It occurs when the longitudinal tear extends to the anterior section and is

dramatically sudden; unlocking is equally sudden, and it is probably this that is the more important sign. True locking occurs about 10-40 degrees short of full extension.

On examination there will be effusion, wasting of the quadriceps and a springy resistance to the last few degrees of extension. Sharp pain is experienced antero-medially.



Lateral meniscus: The features are broadly similar but the history is more vague. Pain is felt laterally but is poorly localised.



TREATMENT

When the diagnosis is confirmed the torn meniscus is excised. If there is doubt about any damage an arthroscopy may be helpful. Smillie (1978) states that 'in practice the menisci injuries present in two forms- acute where the joint is locked, and sub-acute or chronic'. The treatment in the acute form will be to unlock the knee within 24 hours. Operation for removal will be performed within a few days ifpossible In the sub-acute or chronic form an operation to remove the offending meniscus will be performed as soon as possible after diagnosis unless there are any contraindications.

Pre-operative management: A general exercise routine is established to maintain or gain basic fitness. Strong rhythmical quadriceps exercises in a daily class or at least three times a week. A circuit can be devised with a bias to the upper trunk and the arms and the opposite leg. The opportunity can be taken to improve the patient's mobility by exercises of a non-ballistic nature.

If the collateral or coronary ligaments are damaged transverse frictions or ultrasound may be given. Testing for any tendon injury around the joint should be carried out and if any is found it should be treated accordingly. The patient should be taught an effective straight leg raise, measured for crutches (if necessary) and the walking routine practised. A full explanation should be given of the postoperative period including the need for the compression bandage, the absolute importance of practising the quadriceps drill, and the need to move around the bed as much as possible. Consideration must be given to maintain a trained person's basic fitness.

Postoperative management: This depends upon the surgeon. The regime discussed here is a 'middle of the road' approach. (Many surgeons advocate full weight-bearing and greater activity immediately postoperatively.)

Postoperatively the patient is encouraged to practise rhythmical movements of the ankle of the operated leg, and at all joints of the opposite limb to maintain the circulation. Quadriceps drill is encouraged and straight leg raising without lag is attempted. The. patient may be non-weight-bearing until this is achieved. The patient may be confined to bed for 48-72 hours and movement around the bed must be encouraged as muh as possible. Later he will be walking, progressing from non-weight-bearing to partial weight-bearing and then to full weight-bearing in about l0 days with a compression bandage and emphasis on proper gait. If there is any quadriceps inhibition low frequency current stimulation, e.g. faradism, is usually effective. The knee is mobilised to full flexion as soon as possible using ice, heat or ultrasound to supplement the exercise regime.

In the final stages of treatment there is a need to progress exercise for basic fitness by the use Of circuits and weight training, with a bias to activities of the lower limb; use of a wobble board is essential. Massage, such as kneading, transverse frictions and effleurage may be required for the scar, ligaments and the effusion. Full range of mobility of all joints especially the hip, knee and ankle must be maintained. Fitness should be tested using the Harvard step test or other test (De Vries, 1970). In the early stages mobility is measured by using a goniometer, and later by the ability to squat and sit on the heels. Stability is tested early by hopping, and various figured manoeuvres, e.g. weaving, and later progressing to jumping from varying heights, bounding and hurdling. Skills should be tested by dribbling with a football, kicking, jumping, tackling and dancing.



Testing for ligamentous injury

Care must be taken not to test too vigorously otherwise further damage can follow. The patient is supported on a plinth.



MEDIAL (TIBIAL) COLLATERAL LIGAMENT

The lower limb is held at the knee (in extension), the fingers of the holding hand at the back and the palm at the lateral condyle of the femur; the other hand grasps the tibia just above the ankle and while the lower hand pushes laterally the upper pushes medially.



LATERAL (FIBULAR) COLLATERAL LIGAMENT

The viability of this ligament is tested in the same way as the tibial ligament but with the hand positions reversed. The upper hand is on the medial condyle of the femur and the lower hand on the fibular side of the ankle, The upper hand pulls laterally and the lower hand pushes medially.

CRUCIATE LIGAMENTS (DRAWER SIGN)

The knee must be flexed o 90 degrees and the foot fixed on the couch by sitting lightly on it to prevent it sliding. The quadriceps muscle must be relaxed. The fingers are placed on the upper posterior part of

the,tibh and the umbs 0n the anterior femoral condyles. The upper end of the tibia ispushed and pulled.

If the anterior eruciate ligament is damaged then the anterior glide may be in excess of 0.5cm and ff the posterior cruciate ligament is lax then the .posterior glide will be increased by a similar amount.

Noyes et al (1980) discuss the amount of laxity present as being dependent upon the integrity of the secondary restraints on jo/nt movement, e.g. if the medial ligament is torn the amount of laxity present will depend on the damage to th cruciate or the latertl ligaments.



Primary restraint Secondary restraint Clinical test

Torn Laxity --------- Intact Slight laxity
Stretched * Large laxity



Tibial collateral ligament

This ligament is usually damaged as a result of rotary stress on a flexed knee. In football it will occur during a face-to-face tackle is being taken from a player who is or force will be applied to the lateral side of the knee forcing the leg into abduction. As already described, ligaments can sustain minor and major injury including complete rupture. The degree of damage depends on the extent of stress or trauma.

.,In younger patients the damage is nearly always traumatic and with" the older patient chronic strain often complicates an impacted looe body at the knee. There will be effusion which will take time to ,develop. If the joint swells rapidly a haemarthrosis is present and a total rupture should be suspected. There is tenderness at the site of injury. In the younger patient a slipped epiphyseal plate may occur and in damage to the femoral attachment a condition known as Pellegrini-Stieda's disease:may arise due to ossification of the partially avulsed ligament from its upper attachment.


arthritis is present and may prevent the valgus strain test. !.f untreated by physiotherapy the pain and swelling gradually subside over 3-8 weeks and recovery will be effected in 8-12 weeks with movement slowly returning.



COMPLETE RUPTURE

In cases of suspected total rupture the decision, whether it is complete or one of overstretch, must be made as a matter of urgency. If the slightest doubt exists then preparations are made for operative repair. The final diagnosis is not assumed until the presence of abduction in extension is demonstrated (Smillie, 1978). Pain in a complete rupture is usually less than if there is a partial tear. There will be haemarthrosis.

Treatment has already been outlined. Where there is only minor damage the mainstay of it will be quadriceps drill. This may be started at once, but if there is haemarthrosis or ff immobilisation in a plaster cylinder is necessary it will be delayed. Transverse frictions, ultrasound or short wave diathermy may be helpful.



Fibular collateral ligament



This ligament is a strong rounded cord attached to the lateral epicondyle of the femur and to the head of the fibula. It is closely


associated with the biceps femoris attachment and the common peroneal nerve.. It is relaxed in flexion.

Injury is relatively uncommon as it is protected from adduction strain by the opposite limb. Damage may therefore only occur if the likely to happen if the knee is flexed.

Complete rupture seldom occurs as an isolated injury but involves the capsule, the cruciate ligaments and/or the nerve (Smillie, 1978). There may also be lesions of the attachment to biceps femoris and/or the ilio-tibial tract. If damaged, the severity of pain and inflammation will depend upon the grade of strain. The knee will feel warm to hot, with an effusion, yet an almost full range of movement; valgus strain will hurt and palpation will reveal the site of injury.



TREATMENT

1. Ice applications for 15-20 minutes two to four times a day. Rather rh.o have r/e patient trencl fOUl" rimes a day, it is proper to give precise instructions to him so that he may carry it out for himse/f. The application of ice can be quickly reduced to twice daily and then daily. Later still to three times a week.

2. Pressure bandage to control effusion.

3. Transverse frictions when the inflammation has subsided.

4. Isometric quadriceps exercises progressing rapidly to resisted exercises.

5. Non-weight-bearing walking with crutches will be allowed at first, progressing quickly through partial weight-bearing to full weight- bearing with emphasis on correct gait.



Cruciate ligaments

Damage to the cruciate ligaments can cause severe biomechanical disturbance, mainly in an antero-posterior direction They also control lateral mobility, rotation, hyperextension and hyperflexion.



ANTERIOR CRUCIATE LIGAMENT

This ligament is injured as the result of direct violence when:

1. dislocation of the knee occurs;

2. the femur is driven backwards with the knee at right angles and the

tibia fixed;

3. there is a sudden block to rotation; or

4. in abduction it occurs as the medial lignent is damaged,

Ligamentous rupture can occur in four distinct forms: at the inferior and superior attachments within the body of the ligament; and partially antero,medially or postero-laterally. If the injury occurs in isolation the capsule is intact. There is effusion of blood or bloodstained synovial fluid. The haemarthrosis is slight. The risk of injury to the anterior cruciate ligament is increased when there is a torn meniscus present and more violent activity is undertaken.

The clinical picture is usually the slight haemarthrosis in a slightly flexed knee with a possible momentary locking at the time of the injury. Pain and muscle spasm are marked and the joint is tender to touch. The spasm will prevent the drawer sign (see p. 546) being performed though it can be tested after aspiration and anaesthesia.

Established instability will need surgical repair. Much of the instability can be overcome by developing the thigh muscles especially the quadriceps muscles; this can be sufficient in all but the highest levels of sporting activity.


POSTERIOR CRUCIATE LIGAMENT

Rupture of the posterior cruciate ligament together with damage to the posterior part of the capsule is 'of common occurrence' but is very often missed or misdiagnosed (Smillie, 1978). The cause of damage is a force which drives the tibial head backwards when the knee is flexed and most commonly occurs in road traffic accidents when .the knee strikes the dashboard.

The site of injury is at its inferior or superior insertion. Clinically there are contusions, abrasions and lacerations on the anterior aspect of the knee or tibial head (Trickey, 1968). The amount of swelling varies. It will be greater if the capsule is intact. There is tenderness to deep palpation in the popliteal space.

In rupture of the posterior cruciate ligament, the drawer sign occurs spontaneously as the head of the tibia sags backwards when the knees are at right angles and the feet on the couch. Hyperextension will be present if the capsule is ruptured posteriorly.

Conservative treatment will involve strengthening all the thigh muscles to provide stability to the knee. If surgical repair of the ligament is performed a compression bandage is applied postoperatively with the joint in a few degrees of flexion maintained by a plaster of Paris back-slab. When the stitches are removed a plaster cylinder is applied for up to eight weeks, and weight-bearing is allowed.

Physiotherapy will be directed to strengthening all the muscles of the lower limb, especially those of the thigh, and gaining knee flexion and extension. Any effusion which may occur following removal of the plaster cylinder can be treated by massage, ice and elevation and an elastic stocking.