POSTERIOR CRUCIATE LIGAMENT

POSTERIOR CRUCIATE LIGAMENT

The posterior cruciate ligament is located in the back of the knee. It is one of several ligaments that connect the femur (thighbone) to the tibia (shinbone). The posterior cruciate ligament keeps the tibia from moving backwards too far.

An injury to the posterior cruciate ligament requires a powerful force. A common cause of injury is a bent knee hitting a dashboard in a car accident or a football player falling on a knee that is bent.

The anterior and posterior cruciate ligaments form an "X" in the center of the knee.

While a posterior cruciate ligament injury generally causes less pain, disability and knee instability than does an ACL tear, it can still sideline you for several weeks or months.

DESCRIPTION

Injuries to the posterior cruciate ligament are not as common as other knee ligament injuries. In fact, they are often subtle and more difficult to evaluate than other ligament injuries in the knee.

Many times a posterior cruciate ligament injury occurs along with injuries to other structures in the knee such as cartilage, other ligaments, and bone.
A complete tear of the posterior cruciate ligament, back view.

Injured ligaments are considered "sprains" and are graded on a severity scale.

Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.

Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.

Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.

Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own.
 People who have injured just their posterior cruciate ligaments are usually able to return to sports without knee stability problems.

CAUSES

An injury to the posterior cruciate ligament can happen many ways. It typically requires a powerful force.

• A direct blow to the front of the knee (such as a bent knee hitting a dashboard in a car crash, or a fall onto a bent knee in sports)
• Pulling or stretching the ligament (such as in a twisting or hyper-extension injury.
• Simple misstep

Sports are a common cause of PCL injury. These injuries are especially common in:

• Football
• Soccer
• Baseball
• Skiing

SYMPTOMS

The typical symptoms of a posterior cruciate ligament injury are:

• Pain with swelling that occurs steadily and quickly after the injury
• Swelling that makes the knee stiff and may cause a limp
• Difficulty walking
• The knee feels unstable, like it may "give out"
• Swelling (mild to severe)
• Knee pain
• Wobbly sensation in the knee
• Trouble walking or bearing weight on the knee

Over time, a PCL tear can lead to osteoarthritis in the knee.

TREATMENT

 RICE. When you are first injured, the RICE method - rest, ice, gentle compression and elevation — can help speed your recovery.

Immobilization. Your doctor may recommend a brace to prevent your knee from moving. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.

Physical therapy. As the swelling goes down, a careful rehabilitation program is started. Specific exercises will restore function to your knee and strengthen the leg muscles that support it. Strengthening the muscles in the front of your thigh (quadriceps muscles) has been shown to be a key factor in a successful recovery.

Surgical Treatment

PCL problems can be acute or chronic. Acute PCL problems are due to a sudden injury. Chronic PCL problems involve an injury that develops over time.

DIAGNOSIS

X-rays and MRIs are also helpful in clarifying the diagnosis and detecting any other structures of the knee that may be injured. It is common to find other ligament injuries or cartilage damage when a PCL tear is found.

PHYSIOTHERAPY AND REHABLITATION MANAGEMENT

The goal of the rehabilitation for individuals undergoing a conservative program is to control the initial inflammatory phase and regain ROM with muscle function as quickly as possible.
PCL TEARS

Apply the rest, ice, compression, and elevation (RICE) method several times a day, in addition to any other modalities incorporated by the physical therapist to control pain and swelling (eg, electrical stimulation, cold whirlpool).

Patients with grade I and grade II injuries can bear weight as tolerated immediately, though some may require axillary crutches initially. Axillary crutches and a long leg brace are recommended for grade III injuries and with other associated ligamentous laxity (ie, posterolateral corner injury) or intra-articular damage.

  FUNCTIONAL ELECTRICAL STIMULATION (FES) may be used to stimulate the quadriceps muscle, but it is probably necessary only if the quadriceps muscle is shut down secondary to pain.

• The physical therapist should instruct the patient in exercises for                                                                                                 
• QUADRICEPS AND HIP STRENGTHENING
• QUADRICEPS SETS
• STRAIGHT LEG RAISES

•  HIP ABDUCTION/ADDUCTION

( multi-angle quadriceps isometrics). At this time, all open kinetic chain (OKC) hamstring exercises should be avoided since they impart posterior tibial translation at the knee.

Initial Exercises

These initial exercises should generally be performed 3 times daily:                     

HEEL-SLIDES OR KNEE BEND TO STRAIGHT                                                                                                                                              
                          
Begin this exercise by lying on your back . Bend and straighten your knee as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 - 20 times.

STATIC QUADRICEPS CONTRACTION
                                                                                Begin this exercise in the position demonstrated  Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel. Put your fingers on your inner quadriceps (VMO) to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible without increasing your symptoms.

RISK FACTORS

Men are more likely than are women to injure their posterior cruciate ligament. Participation in sports such as football and soccer also may increase your risk.

COMPLICATIONS

In many cases, other structures within the knee — including other ligaments or cartilage — also are damaged when you experience a posterior cruciate ligament injury. Depending on how many of these structures were damaged, you may experience some long-term knee pain and instability. You may also be at higher risk of eventually developing arthritis in your affected knee.

CHONDROMALACIA PATELLAE :

Knee Anatomy

Chondromalacia patellae (also known as CMP) is inflammation of the underside of the patella and softening of the cartilage.The cartilage under your knee-cap is a natural shock absorber, and overuse, injury, and many other factors can cause increased deterioration and break down of the cartilage. The cartilage is no longer smooth and therefore movement and use is painful.While it often affects young individuals engaged in active sports it also afflicts older adults who overwork their knees




Physiotherapy Treatment :

In the absence of cartilage damage, pain at the front of the knee due to overuse can be managed with a combination of RICE (rest, ice, compression, elevation), anti-inflammatory medications, and physiotherapy


What Causes Chondromalacia Patellae ?

Your kneecap is normally positioned over the joint of your knee. When you bend your knee, the movement causes the backside of your kneecap to glide over the bones of the knee, specifically the femur or thigh bone. Tendons and ligaments attach your kneecap to your shinbone and your thigh muscle to the kneecap. When any of these components fails to move properly, it can cause your kneecap to rub up against your bone, leading to deterioration in the patella—i.e., chondromalacia or runner’s knee.

Improper knee-cap movement may result from:

•     poor alignment due to a congenital condition
•     weak hamstrings and quadriceps (the muscles in the back and front of your thighs)
•     muscle imbalance between the adductors and abductors (the muscles on the outside and inside of your thighs)
•     repeated stress to your knee joints, such as from running, skiing, or jumping
•     a direct blow or trauma to your kneecap

: Risk Factors :

Who is at Risk for Chondromalacia?

Risk factors for developing runner’s knee include:
Age :

Adolescents and young adults are at high risk for this condition. During growth spurts, the muscles and bones are developing rapidly, which may contribute to short-term muscle imbalances.

Sex :

Females are more likely than males to develop runner’s knee as they typically possess less muscle mass than males. This can cause abnormal knee positioning, as well as more lateral (side) pressure on the kneecap.

Flat Feet :

Flat feet may place more stress on your knee joints than in people who have higher arches in their feet.
Previous Injury

A prior injury to the kneecap, such as a dislocation, can increase your risk of developing runner’s knee.
High-Activity Level

If you have a high-activity level or engage in frequent exercises that place pressure on your knee joints, this can increase the risk for knee problems.


Arthritis :

Runner’s knee can also be a symptom of arthritis, a condition causing inflammation to the joint and tissue. Inflammation can prevent the kneecap from functioning properly.


Symptoms :

The most common symptom of chondromalacia is a dull, aching pain in the front of your knee, behind your kneecap. This pain can get worse when you go up or down stairs. It also can flare up after you have been sitting in one position for a long time. For example, your knee may be painful and stiff when you stand up after watching a movie or after a long trip in a car or plane.

Chondromalacia also can make your knee joint "catch" meaning you suddenly have trouble moving it past a certain point, or "give way" (buckle unexpectedly). These symptoms tend to occur when you bend your knee repeatedly, especially when you go down stairs. In some cases, the painful knee also can appear puffy or swollen.

Chondromalacia can cause a creaky sound or grinding sensation when you move your knee. However, creaking sounds during bending do not always mean that cartilage is damaged.

    Pain around the knee. The pain is usually located at the front of the knee, around or behind the kneecap. The pain is typically worse when going up or down stairs. 
   
 A grating or grinding feeling or noise when the knee moves (crepitus).
    
Rarely, some fluid swelling (effusion) of the knee joint.

1) Front knee pain: tends to be achy rather than sharp
2) Pain going down stairs
3) Pain when you first get up after prolonged sitting
4) A grating/grinding sensation when moving the leg (crepitus)
5) Minor swelling around the patella
6) Tenderness with any pressure through the kneecap 

Diagnosis :

Your doctor will examine your knee looking for areas of swelling or tenderness. Additionally, he or she may look at how your kneecap aligns with your thighbone. A misalignment can be an indicator of chondromalacia. Your doctor may also apply resistive pressure to your extend


    X-rays :  show bone damage or signs of misalignment or arthritis
   MRI : view cartilage wear and tear
   


Grading

There are four grades, ranging from Grade I to IV, that designate the severity of runner’s knee.

 Grade I :  least severe, while Grade IV indicates the greatest severity.

Grade I : severity indicates softening of the cartilage in the knee area.

Grade II d:  a softening of the cartilage along with abnormal surface characteristics. This usually indicates the beginning of tissue erosion.
Grade III  :  thinning of cartilage with active deterioration of the tissue.

Grade IV : the most severe grade, indicates exposure of the bone with a significant portion of cartilage deteriorated. Bone exposure means bone-to-bone rubbing is likely occurring in the knee.


PHYSIOTHERAPY   TREATMENT : 

1)   Exercises: Kneecap exercises and stretches can really help with chondromalacia as well as general strengthening exercises. They all help help to combat any muscle imbalance and improve how the kneecap moves. I have never known anyone with chondromalacia patella who has not had muscle imbalance
Knee straps can help reduce the pain associated with Chondromalacia Patella

2) Knee Brace Straps: Wearing a strap directly under the kneecap helps take pressure off the joint, dramatically reducing pain. They are simple to use and very effective. Visit the knee strap section to find the best brace for you.

Knee Exercise

3) PRICE: Protect, Rest, Ice, Compress, Elevate. This helps reduce pain and swelling and can speed up recovery. Visit the PRICE section to find out how to use it safely and effectively
Medication can help reduce the pain and swelling associated with chondromalacia patella

4) Medication: Non-steroidal anti-inflammatories (NSAID’s) such as ibuprofen will help to relieve inflammation and pain

5) Ice: Using ice regularly, and before and after activity can help reduce swelling and pain

6) Taping: Can help to take the pressure off the kneecap. This is particularly useful for when you are playing sports. A physical therapist can teach you how to do this

7) Modifying your Activity: Limit running, instead try swimming or cycling. If you want to run, ensure you are wearing good shoes with cushioned shoes, and stay off hard surfaces eg concrete

8) Shoe Insoles: Insoles known as orthotics can help to correct flat feet

9) Knee Pads: Gel Pads are an excellent way to reduce pain and irritation when you do have to kneel

10) Surgery: This is only considered if nothing else works and the pain is really affecting you. It is done arthroscopically, where they make 2-3 small holes around the knee and insert a camera. They will then cut any tight ligaments to allow the patella to sit in the right place in the groove and/or shave off any damaged bits of cartilage.

Treatment
he goal of treatment is to reduce the pressure on your kneecap and joint. Resting, stabilizing, and icing the joint may be the first line of treatment. The cartilage damage resulting in runner’s knee can often repair itself with rest.


PhysioTherapy : 



Physical therapy focusing on strengthening the quadriceps, hamstrings, adductors, and abductors can help improve your muscle strength and balance. Muscle balance will help prevent knee misalignment.

Non-weight bearing exercises are typically recommended, such as swimming or riding a stationary bike. Additionally, isometric exercises that involve tightening and releasing your muscles can be used to maintain muscle mass.

Tips to Prevent Chondromalacia : 

You can help reduce your risk of developing “runner’s knee” by following these recommendations.

    Avoid repeated stress to your kneecaps. Wear kneepads if you have to spend time on your knees.
    Create muscle balance by strengthening your quadriceps and hamstrings, as well as your abductors and adductors.
 Wear shoe inserts that correct flat feet by increasing your arch. This will decrease the amount of pressure placed on your knees and may realign the kneecap.

Finally, excess body weight may stress your knees. Maintaining a healthy body weight can help take undue pressure off of knees and other joints. 

You can take steps to lose weight by:

    exercising at least 30 minutes three times a week
    reducing your sugar and fat intake
    eating plenty of water,vegetables, fruits, and whole grains