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Hyperextension Knee Injuries Related to Sports

Hyperextension Knee Injuries Related to Sports - El Paso Chiropractor

Hyperextension knee injuries can differ from chronic to acute, depending on their severity, and these are generally considered quite painful. The infrapatellar fat pad, abbreviated as IPFP, is one of the most commonly affected structures due to hyperextension knee injuries. In the presence of an acute knee hyperextension injury, for example, when an athlete is tackled in rugby, the posterior cruciate ligament, or PCL and/or the posterior lateral corner, or PLC, of the knee may become injured.

Infrapatellar Fat Pad


The infrapatellar fat pad is identified as an extrasynovial structure which is located on the anterior of the knee, away from the area of the patella. It’s characterized as a mobile formation and its shape, volume and pressure is altered with the movement of the knee. The infrapatellar fat pad attaches anteriorly to the immediate patellar tendon and inferior pole of the patella, posteriorly attaching to the intercondylar notch of the femur and in some individuals, the ACL. It is a heavily vascularized structure, also innervated by branches of the obturator, saphenous and the well-known peroneal nerve. The fibres which denote pain from the stimulation of the nerve cells are most dense in the central and lateral sections of the infrapatellar fat pad.

Infrapatellar Fat Pad Anatomy Diagram - El Paso Chiropractor

Mechanism of Injury

Injuries or conditions affecting the infrapatellar fat pad may commonly result from a direct blow or as a result of chronic irritation due to hyperextension knee injuries. Both conditions present a series of painful symptoms which can be debilitating. Individuals or athletes with these types of complications experience knees that hyperextend and they may walk with poor quad control and knee hyperextension. The IPFP, or infrapatellar fat pad, can also become injured as a result of direct trauma to the knee, either through a blunt force or through shear injury along with a patellar dislocation or ACL rupture.


Individuals with hyperextension knee injuries originating from infrapatellar fat pad issues often describe a sharp, burning and/or aching deep pain on either side of the patellar tendon. Certain sports or physical activities, including maximal knee extensions or basic activities which require active knee extension, such as going upstairs or prolonged knee flexion, may aggravate the symptoms of hyperextension knee injuries from the IPFP.
Healthcare professionals may perform various clinical tests to diagnose and set apart infrapatellar fat pad complications from other hyperextension knee injuries.  
Upon medical assessments, patients with IPFP disorders frequently present swelling and inflammation along the bottom of the patella, displaying the appearance of puffy knees.

Fluffy Knee Demonstration - El Paso Chiropractor

Objective tests include: Hoffa’s test, performed where the infrapatellar fat pad is palpated on either side of the patella tendon, with the knee in a 30-degree flexion. The knee is then fully and passively extended where increased pain in the IPFP will indicate a positive test; the passive knee extension test is performed by having the patient lie supine, where the knee is passively extended. Pain along the bottom of the patella indicates a positive test result; the differentiation test, as the name pertains, helps to distinguish between infrapatellar fat pad and patellar tendon injuries and/or conditions. Primarily, the location of most tenderness is palpated in 30-degree knee flexion. The patient is then ordered to gently activate their quadriceps muscle while the healthcare professional providing the test resists this movement. The isometric activation of the quadriceps lifts the patellar tendon off the IPFP, decreasing the symptoms on palpation.

Hoffa's Test Demonstration - El Paso Chiropractor


MRI is the most common modality of choice for suspected hyperextension knee injuries to the infrapatellar fat pad. According to the results of an MRI, increased T1 or T2 hypointense signals may conclude the thickening and scarring of the connective tissue of the fat pad, also referred to as fibrosis, usually the result of trauma from an injury. T2 weighted images which display hypointense signals may demonstrate inflammation or acute hemorrhage or edema.


Hyperextension knee injuries caused by disorders of the IPFP effective respond to conservative treatments. The fundamental goal of treatment is to reduce the stress and pressure being placed against the fat pad to decrease the symptoms of pain as well as allow the quadriceps to regain their strength. Infrapatellar fat pad deloading taping procedures should be taught to the affected individuals to prevent continuous compression of the fat pad. Limiting the athlete’s stance and gait must be suggested as early as possible to avoid hyperextension knee injuries during these activities. Helpful exercises which can further benefit throughout the rehabilitation process includes wall squats, splits squats and lunges. Exercises which involve full knee extension should be avoided. To re-train the muscles, quadriceps strengthening drills should specifically be performed in closed kinetic chain positions.

Deloading Tape Demonstration - El Paso Chiropractor

Surgical procedures are rarely required but may include fat pad excision, debridement, synovectomy, infrapatellar plica release and denervation of the inferior pole of the patella.

Posterior Cruciate Ligament Injuries

The posterior cruciate ligament, or PCL, frequently becomes injured when the knee is flexed, although, it can also be injured in hyperextension knee injuries, such as a rugby tackle. Approximately 60 percent of PCL injuries also affect the posterolateral corner, an increased estimate of injuries are primarily involved with knee hyperextension.


The posterior cruciate ligament is also an extrasynovial structure which functions to prevent the posterior shift of the tibia on the femur. It’s made up of an anterolateral bundle which is most rigid during knee flexion and a posteromedial bundle which is most rigid in extension. The posterolateral corner consists of the popliteus muscle, the lateral collateral ligament, bicep femoris tendons and the popliteofibular ligament. Isolated injuries to the posterior cruciate ligament are rare but may be often associated with PCL complications.

Posterolateral Corner Anatomy Diagram - El Paso Chiropractor


Through diagnosis and evaluation of individuals or athletes with posterior cruciate ligament injuries have been recorded with poorly defined knee pain along with minimal swelling. Various assessments are utilized to conclude the presence of injury to the PCL, including: posterior drawer, a test which comprises of having the patient lying supine with the affected knee bent to 90-degrees. The position of the tibia relative to the femur is recognized and recorded by the healthcare professional providing the assessment, where a posterior-positioned tibia indicates the presence of a posterior cruciate ligament injury; with the posterior sag test, the patient lies supine with their hips flexed to 90-degrees and their knees bent to 90-degrees as well. The healthcare professional then supports under the lower calf of both legs, looking for a posterior sag of the tibia; and finally, the quad contraction test is used in the case that a posterior tibial translation is suspected while the patient is supine and their knees are bent to 90-degrees. To perform this test, the medical specialist holds the lower shin and asks the patient to contract their quads. If a posterior sag is present, then, contraction of the quadriceps will lead to an anterior shift of the tibia.

Posterior Sag Test Demonstration - El Paso Chiropractor

Posterior cruciate ligament injuries are classified from 1 to 3 and are preferably measured with the knee in 90-degree flexion where the tibia normally lies 1 cm anterior to the femoral condyles. The grading system is outlined as follows: G1, where the tibia lies anteriorly to the femoral condyles, however, the distance is reduced to 0-5mm; G2, where the tibia lies flush with the condyles; and G3, where the tibia can be pushed beyond the medial femoral condyle.

Recurvatum Test Demonstration - El Paso Chiropractor

As previously mentioned, injuries to the posterolateral corner may also develop with the presence of an injury to the PCL, such as in the case of hyperextension knee injuries. Various evaluation tests are characterized to help determine whether a posterolateral corner injury is present, including: the external rotation recurvatum, or hyperextension, test, performed where the patient lies supine and the healthcare professional stabilizes the distal thigh with one hand while lifting the great toe with the other. If the specialist recognizes more hyperextension in the affected knee, then, a posterolateral corner injury can be concluded; to perform the dial test, the patient must lie prone with the knees flexed to 30-degrees. The healthcare professional then externally rotates the tibia of both legs, making sure the thighs maintain a stabilized position. A greater range of external rotation of more than 10-degrees represents a positive test result. This test can also be performed with the knees flexed at 90-degrees and in the case of increased range, then, a combined injury to the posterior cruciate ligament and PLC injuries are suspected.

Dial Test Demonstration - El Paso Chiropractor

Gait evaluations should also be performed. Patients whom result with instability on the posterolateral corner present varus gait at foot strike when their knee is extended.


Posterior cruciate ligament and posterior lateral corner injuries commonly result due to an acute injury. In the case of a considerable acute injury, X-rays may be requested to exclude the presence of a bony avulsion of the PCL from its tibial insertion. If so, surgical intervention may be necessary to repair this type of injury. MRI scans may also be useful in this instance to help determine the presence of posterior cruciate ligament and posterior lateral corner injuries.


According to various treatment results, individuals and athletes with isolated posterior cruciate ligament tears or ruptures experience an effective functional outcome through a properly designed rehabilitation program, despite of ongoing laxity. However, research studies have concluded that PCL deficiencies do occur during increased pressure within the joints on both the patellofemoral tibiofemoral joints. This may therefore indicate that meniscal tears and articular damage to the medial compartments of the knee, may develop gradually over time. If PCL injuries occur conjointly with the damage of other structures of the knee, including PLC, or whether a considerable instability is found, surgical interventions should be considered. An individual with a grade 3 PCL injury is recommended to participate in immobilized extensions for up to two weeks. An individual with a grade 1 to 2 injury is recommended to participate in a specific rehabilitation program with a focus on strengthening the quadriceps.

Do You Need Surgery for a PCL Injury?

Many healthcare professionals specialize in the diagnosis and rehabilitation of a variety of sports injuries, including hyperextension knee injuries. Chiropractic care is a popular, alternative treatment option which emphasizes on the overall health of the body through the proper alignment of the spine and its surrounding structures, including the muscles, ligaments, tendons, joints and other essential tissues. Chiropractors are also specialized in evaluating many types of sports injuries. Once a doctor of chiropractic, or DC, determines the presence and origin of an individual’s symptoms, they commonly utilize a series of chiropractic adjustments to reduce the stress and pressure around the complex structures of the injury, helping to decrease the athlete’s pain and discomfort. Along with several other types of treatment options, a chiropractor may also recommend a course of rehabilitation stretches and exercises to improve an individual’s original strength, flexibility and mobility as well as speed up the rehabilitation process.
Before engaging in a rehabilitation program, the individual or athlete must primarily seek medical attention from a qualified healthcare professional who will follow up with the most appropriate group of exercises according to each individual’s grade of injury and needs. Advancing with a rehabilitation program will be commonly determined by the patient’s improved symptoms and therefore, should only be modified by the specialist to avoid further injury.

By Dr. Alex Jimenez

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The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to contact us. Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN* email: coach@elpasofunctionalmedicine.com phone: 915-850-0900 Licensed in: Texas & New Mexico*