COMMON KNEE INURIES IN SPORTS MEDICINELAWRENCE PICCIONI MD

MY BACKROUND

Current team physician for Delaware State University since 1993

Team physician for Wesley College 1992 to 2004

Team physician for Dover High School 1992 to 2004

PURPOSE

Familiarize you with common features of injuries

Reinforce what you already know about diagnosis and treatment

Help decision making as far as treatment or referral

ACCOMPLISH GOAL

Reviewing pertinent anatomy, History and Physical findings

Review differences in adult and pediatric injury patterns

Give some PEARLS

ANATOMY OF KNEE

Bones more pertinent in pediatric group

Tendons – Patellar and Quadriceps

Cartilage – articular and meniscal

Ligaments – ACL, PCL, Medial and lLateral Collateral

LIGAMENT VS CARTILAGE

Cartilage is like a rock in your shoe pain and swelling the more you do the more it hurts

Ligament injuries are like walking on ice

DOES IT HURT AND GIVE OUT OR GIVEOUT AND HURT?

MENSICUS HISTORY AND EXAM

Often minor trauma in adults due to degeneration, sometimes feel a pop

Feel a click plus or minus effusion (popliteal)

Joint line tenderness pain with rotation (McMurray, Appley, etc)

Pain and swelling with activity, low grade

MENISCUS INJURY TREATMENT

Usually surgical or live with it

Meniscus relatively inert and poor healing potential

Outpatient procedure, arthroscopic, 2 to 4 weeks return to many sports if motivated

Not a surgical emergency, difficult to play through

MENISCAL SURGERY

“Repair” usually means taking out torn portion

Only 10% repairable (bucket and vertical tears in outer 1/3)

NFL meniscal injuries more career ending than ACL

ANTERIOR CRUCIATE INJURIES

Most common in sports particularly with acceleration/deceleration

Not always a violent injury many noncontact

Classic is feel a pop followed by intense swelling within 6 hours (hemarthrosis)

Not a surgical emergency Surgery often delayed 3 or more weeks (reconstruction)

ACL TEAR DIAGNOSIS

May have effusion may not some walk in comfortable

Lachman’s test is most classic and STILL most useful

Often missed on MRI (femoral detachment difficult to pick up)

ACL TREATMENT

Not always surgical initial RICE and ROM

PT for quad hamstring strengthening

Brace treatment

Coping and sport modification

Surgery

ACL SURGERY

Reconstruction with multiple graft choices

Who gets it? – under 40, women, buckling with daily activity, competitive level 1 sports

Outpatient surgery mostly arthroscopic return to full sport variable but 6months to one year

PCL & COLLATERAL LIGAMENT

More rare usually in the realm of orthopedist

Not a “Pulled muscle”

Many are not surgical but require detailed diagnosis (combined injuries)

Not emergency but protection with crutches and immobilizer needed

PEDIATRIC KNEE INJURIES

Bones now important

Physeal injuries common (weaker than ligaments and cartilage)

Different age leads to different fractures ie tibial eminence 12yrs tibial tubercal 14yrs

TIBIAL EMINENCE FRACTURE

ACL eqivalent in younger age

Same mechanism of injury

May require surgery usually requires referral

TIBIAL TUBERCULE FRACTURES

Typically occur during adolescence

3 types depending on severity

Only most severe (type 3) require surgery but all require referral

PATELLAR SLEEVE FRACTURE

Common in younger kids

Represents an avulsion of inferior patellar cartilage from bone

Analogous to patellar tendon rupture in adults

Can be difficult to diagnose (pain, fear etc)

TIBIAL TUBERCULE FRACTURES

Usually occur during adolescence

Three types depending on severity

Only type 3 requires surgery but all require referral for treatment

CONCLUSION

History and physical still the key as imaging is confirmatory.

Most injuries not a “pulled muscle”

Relax most are not surgical emergencies

Pediatric injuries tend to be physeal and more emergent