膝關(guān)節(jié)評(píng)估

1、,膝關(guān)節(jié)評(píng)估,膝部韌帶拉傷,內(nèi)側(cè)副軔帶(MCL)/外側(cè)副軔帶(LCL) 內(nèi)翻壓力測試(Varus Stress test)(圖右)?外側(cè)副軔帶 外翻壓力測試Valgus Stress test(圖左)?內(nèi)側(cè)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(shí)放松(0~30度),伸直時(shí)緊張后十字軔帶: 膝彎屈時(shí)緊張(90度),伸直時(shí)

2、放松,3,PCL,ACL.,4,最常見原因跑動(dòng)中急停改變方向造成一巨大扭轉(zhuǎn)力而損傷高處跳下造成膝扭轉(zhuǎn),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(yàn)/后抽屜試驗(yàn)0~30° :前十字- 緊張

3、 90° : 后十字- 緊張前抽屜試驗(yàn)(+)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(yàn)(+)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(yàn)的盲點(diǎn),腘旁腱(腿后腱)肌(hamstring)太緊會(huì)拉不動(dòng)? 偽陰性當(dāng)后十字軔帶損傷時(shí)會(huì)使脛骨原先就處在后退的位置(sag sign) ?偽陽性

4、,7,Lachman test,對(duì)前十字軔帶損傷最敏感ACL 膝彎屈25~30°然后拉動(dòng)脛骨遠(yuǎn)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(zhuǎn)軸移動(dòng)測試(ACL Pivot shift test),給一拉力將脛骨前拉在膝彎屈0-30°時(shí), 然后給予股骨向內(nèi)側(cè)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(nèi)側(cè)副韌帶、前十字形韌帶和半月軟骨損傷的合并性嚴(yán)重?fù)p傷需碰撞的運(yùn)動(dòng)常見運(yùn)動(dòng)傷害機(jī)轉(zhuǎn): 外側(cè)碰撞力量在膝蓋此時(shí)腳掌還緊貼在地面產(chǎn)生一個(gè)外轉(zhuǎn)的扭力→前十字形韌帶損傷可連帶外側(cè)/內(nèi)側(cè)結(jié)構(gòu)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(guān)? 扭轉(zhuǎn)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(shí)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(yīng)當(dāng)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(guān)節(jié)活動(dòng)時(shí)卡住McMurray test：平躺膝彎屈給與內(nèi)轉(zhuǎn)外轉(zhuǎn)的力?外轉(zhuǎn)的力 ? 外側(cè)半月軟骨(Lat. Meniscus(左圖) ?內(nèi)轉(zhuǎn)的力 ? 內(nèi)側(cè)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(zhuǎn)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(shí)病病人會(huì)有恐慌表情,18,賓骨股骨疼痛綜合征,與造成膝關(guān)節(jié)外側(cè)壓力大的任何因素相關(guān)的生物力學(xué)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(nèi)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(nèi)轉(zhuǎn)?足旋前髖內(nèi)轉(zhuǎn)肌縮短;造成股骨過於內(nèi)轉(zhuǎn)髖外轉(zhuǎn)肌力不足;造成股骨過於內(nèi)轉(zhuǎn): 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(xùn)練: 髁腰肌(Iliopoas) and 股內(nèi)斜肌? 開放/閉鎖鏈運(yùn)動(dòng)伸展內(nèi)側(cè)腘旁腱肌和大腿內(nèi)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(yuǎn)端 : Osgood-Schlatter Dz,23,Infrapatellar bursitisPopliteal bursitis

12、(Baker’s cyst),24,,膝退化性關(guān)節(jié)炎Figure 1 : 正常 Figure 2 : 有骨刺產(chǎn)生, 關(guān)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(biāo): 減輕癥狀I(lǐng)ncrease 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? )