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Clare Walsh B.App. Sci (Physiotherapy) MA Applied Science (Sports Physiotherapy)
The Sporting Knee – Diagnosis of
Acute Knee Injuries Clare Walsh
APA Sports Physiotherapist Australian Olympic Team Physiotherapist
Introduction
Present commonly to the physiotherapist either on the field or in the clinic.
Being adept at clinical diagnoses is important for ongoing management.
MRI – expensive, claustrophobic, geographically difficult
Introduction
Once our clinical diagnosis (or likely diagnosis) is made we can:
Start the appropriate rehabilitation program for our patient
Refer for imaging x-ray and /or MRI if required
Refer to an Orthopaedic Specialist (via G.P.) if required
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Introduction
Most acute knee injury occur in sports that involve twisting and turning whether contact or non-contact.
There is a higher incidence in contact sport such as football and basketball and very common in women’s sport netball and soccer.
You will also see it in non-contact sports such as surfing or skiing
Structures Structures that will be
discussed in today’s lecture:
ACL
PCL
MCL
LCL
Patella
Mensicus
Articular cartilage
Assessment
History – What happened?
Listening to the history and asking the right questions that are pertinent to the knee is very important
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Important questions
Was the injury contact or non-contact?
Could you play on? If so for how long?
Did you or anyone near you hear a crack or a pop?
Was there swelling? Did the swelling appear immediately?
Have you subsequently had any clicking popping or giving way in the knee -
Giving way
Two types:
1. Twisting or changing direction
2. Straight line
Haemarthrosis
If they say it swelled up very quickly you must suspect a haemarthrosis or bleeding into the joint:
1. ACL
2. Patella dislocation
3. A fracture
Milder swelling that comes on over a day or so is more indicative of other intra-articular pathology
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These questions will give you an idea of:
Severity of the injury
What structures are likely to be damaged
Whether the patient needs an x-ray
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Assessment
Quick tests – gait and squat
Lying supine look and feel
Swipe test
Lachman’s
Reverse Lachman’s, Sag test
MCL valgus stress
LCL varus stress
Patella apprehension test
McMurrays /Thessally test
ACL Injuries
The function of the ACL is:
To stop anterior translation of the tibia on the femur
It is a secondary restraint after the MCL to a valgus force
Controls rotation of the tibia on the femur in the last 30 degrees of extension (the screw home movement)
ACL
ACL injuries are primarily non contact.
It is reported that between 72 and 90 % of all ACL injuries occur without contact
It occurs when the athlete is decelerating pivoting or landing suddenly such as in football e.g. rugby league avoiding a tackle
Decelerating or pivoting such as in a side step.
ACL Injury
The knee gives way suddenly as the
ligament ruptures. It is very painful and the
player will go down suddenly grabbing
the flexed knee
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ACL
Another mechanism is when a skiier falls
backward with the knee fully flexed
ACL
Mechanisms –
One step then stop deceleration such as in netball
ACL Injury in Females
Although the numbers vary a bit in the literature it has been found that females suffer non-contact ACL injury 4 – 6 times more than males.
The mechanism is not entirely clear but the likely explanations are due to:
- smaller intercondylar notch and ac ligament
- differences in mm balance and neuro-muscular control
ACL
In the history the patient will tell you:
they suddenly fell the knee was painful
they heard a pop or crack and thought they had broken something.
They also say it “blew up very quickly” indicative of haemarthrosis
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ACL Clinical test
Lachman’s – draw the tibia forward on the femur
ACL – Clinical tests
Pivot Shift – assess rotary instability
Difficult if – patient has a lot of pain, large patient / small hands.
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Treatment
Immediate – treat swelling with ice and compression
Start quads exercises even if just static
Discuss with patient the need for an x-ray and possible consultation with a knee surgeon
ACL
Discussing Surgery
conservative management may be appropriate for a smaller percentage of patients:
those who don’t play a lot of sport involving change of direction.
Those who are blessed with super neuromuscular co-ordiantion and don’t go on to have instability episodes
ACL
A patient may not have surgery immediately
In this case a good quad, hamstring, glute, proprioceptive and stability program will help the patient pre-op as well as post op.
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ACL - Surgery
Many advances in the last 25 years
Now arthroscopic and various choices:
Autograft – hamstring or patella tendon
Allografts - including achilles and semitendonosis donor tissue or the synthetic LARS (Ligament Augmentation and Recontruction System)
ACL - Surgery
The bonus of the allograft is the reduced rehabilitation time as there is no donor site.
With hamstring and patella tendon grafts hamstring tears and patello-femoral pain are common problems throughout various stages of rehabilitation.
A handful of AFL players have returned to play 3 months after LARS ACL reconstruction
In 2006 Alisa Camplin won a bronze medal in aerial skiing 4 months after her ACL was reconstructed with a donor patella tendon
Lydia Lassila also had an achilles tendon grafted into her knee to be ready for the Olympics in 2006.
ACL - Surgery
However… the general consensus amongst most specialists today would be that Allograft is only appropriate for a small number of patients that may require a shorter return to Elite sport.
The long term success of these grafts is not established and many think inferior to autograft tissue.
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Prevention
I would like to mention briefly prevention
Because of the high incidence in women’s soccer a program that has been trailed in the US and found to be successful is the PEP (Prevent Injury and Enhance Performance)
now been implimented here in Australia. It involves a particular warm up with emphasis on neuromuscular control, proprioception and agility.
It has been reported that it may reduce non- contact ACL injuries by as much as 42%
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MCL - Anatomy
Occur due to a valgus force – skiing, football, basketball
Superficial layer – provides protection from valgus force mostly at 25 -30 degrees flexion
Deep layer – firmly connects to the meniscus and tibial plateau and does not provide significant resistance to valgus force.
MCL
Can occur in isolation or in conjuction with other structures – meniscus, ACL, tibial plateau
Positive testing at 30 degrees flexion – isolation
Positive test at 0 degrees flexion – pm capsule or ACL
Pain is always located medially
Soft tissue swelling sometimes present but little or no effusion if in isolation.
MCL Valgus stress test
MCL - Management
Three grades: 1, 2 & 3
Grades 2 and 3 may be braced in a hinged brace restricting lateral movement – optimum healing occurs when the two ends are in contact
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MCL - Management
Strength and stability exercises important
Straight line activity for 4 – 8 weeks depending on severity
Surgery may be indicated in some cases where the distal attachment is torn and can be re-attached to the tibia.
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PCL
Less common than ACL and MCL
Caused by a blow to the tibia or hyper-extension injury
Patient may not present for a few weeks post injury
Pain is felt deep in the knee or often at the back in the upper calf region
Swelling does not develop at the same rate as for an ACL, usually seen over the next day.
PCL
The clinical test is a reverse Lachman’s or a sag test:
PCL Management
Early treatment should include quads and closed chain co-contraction exercises and Gluteal exercises
Open chain hamstring exercises are avoided due to posterior translation of the tibia
Ongoing problems such as patello-femoral pain often occur and therefore a good stability program is important especially for vastus medialis and glutes.
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PCL
Surgery is rarely needed and only indicated if ongoing problems are experienced such as pain and instability after a decent rehabilitation program is undertaken for about 6 months especially if a high degree of knee function is required for sport.
Surgery may be indicated if other structures are damaged in conjunction with the PCL.
LCL
Lateral collateral ligament injuries are rare in isolation.
In 15 years of football I have only seen 1.
Occur due to a varus force
Differential diagnosis –
Lateral meniscus
biceps femoris tear / rupture
Posterolateral corner which often occurs in conjunction with an ACL injury
Posterolateral corner
Includes:
LCL
PL capsule and arcuate ligament
Popliteus tendon
Can include bicep femoris
Need surgery!
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Meniscus
These injuries are very common
Medial are more common than lateral
Will often result in an effusion especially ones that occur in the periphery
Diagnosis is via the history, palpation and McMurray’s (other tests Ege’s and Thessaly tests in standing)
Diagnosis confirmed on MRI – refer via GP
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Meniscus – clinical tests
McMurray’s test is the most commonly used
Meniscus
Surgery is a successful option especially in acute tears
!
Surgery for repair rather than menisectomy should be considered
For smaller tears or chronic tears such as degenerative then conservative approach is advocated.
Meniscal tears - management
Again treatment centers around treating any swelling and pain.
Followed by a strengthening and dynamic control program orientated towards return to sport.
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Articular Cartilage
These are the difficult ones
Lining of the joint may be degenrative or acutely injured causing a chondral defect.
Often occur in conjunction with another injury espec ACL and Meniscal
Diagnosis – history, +ve effusion, ruling out other structures
MRI
Articular Cartilage
Treatment
Swelling
Strength and stability
Surgery – Haven’t found a successful solution
Chondroplasty has been common but not ideal
Chondral cell implantation - is a prolonged process
PRP and stem cells – still early days and longer term success is unknown
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Patella dislocation
Like ACL’s these result in giving way of the knee and occur in a running and twisting mechanism.
Sometimes the person is not aware of the dislocation if it has reduced quickly
Patella Dislocation
Reduction is by knee extension and helps if you flex the hip
Patella dislocation
They can present similarly to ACL’s due to the pain and disability caused by the injury
Diagnosis is by history, palpation and patella apprehension test
Treatment – Medial glide patella tape
- VMO strengthening
Other Injuries to Consider
Patella fracture
Splint, surgery
Tibial plateau fracture
Occur with ACL’s and meniscal injuries but sometimes not
They may or may not require internal fixation
Require a period of non weight bearing
Patella tendon rupture
surgery
Important points
History ask the right questions
Swelling – if haemarthrosis present must suspect ACL fracture or patella dislocation
Refer on if diagnosis is difficult
Treatment options range from conservative to surgical
Rehab should always include strength, mobility, nueromuscular contol, prorioception and sports specific exercises.
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The End
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References
Barber-Westin et al. Jump –land characteristics and muscle strength development in young athletes; A gender comparison of 1140 athletes 9 -17 years of age. Am J Sports Med. 2006 Mar;34 (3); 375 - 384
Barrett GR et al. Allograft Anterior Cruciate Ligament reconstruction in the young active patient. Arthroscopy 2010 26 (12): 1593 -1601
Brukner P and Khan K. Clinical Sports Medicine. Second Edition 2001. McGraw Hill Companies Inc.
Gagnier J et al. Interventions designed to prevent Anterior Cruciate Ligament injuries in adolescents and adults. A systematic review and meta analysis. Am J Sports Med 2012, 20 (10)
Gichrist J, Mandelbaum B, Melacon H, Ryan G, Sivers H, Griffin L, Watanabe D, Dick R, Dvorak J. A Randomized Controlled Trial to Prevent Noncontact Anterior Cruciate Ligament Injuries in Female Collegiate Soccer Players. The American Journal of Sports Medicine 2008 Vol 36, 8. 1476-1483.
Hing, W. Validity of the McMurray’s test and modified versions of the test: A Systematic literature review. J Man Manip Ther, 2009; 17 (1), 22-35
Swanik C, Covassin T, Stearne D Schatz P. The Relationship between Neurocognitive Function and Noncontact Anterior Cruciate Ligament Injuries. The American Journal of Sports Medicine 2007, Vol 35 6. 943 -947.
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