Acute Knee Injuries - World Health Webinars€¦ · Knee – Diagnosis of Acute Knee Injuries Clare Walsh ... discussed in today’s lecture: ACL PCL MCL LCL Patella Mensicus

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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

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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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Acute Knee Injuries - World Health Webinars€¦ · Knee – Diagnosis of Acute Knee Injuries Clare Walsh ... discussed in today’s lecture: ACL PCL MCL LCL Patella Mensicus