Multi-Ligament Knee Injury With Associated

Fibular Nerve Injury In A Collegiate Football Player

Jill A. Manners, MS, LAT, ATC

Grady J. Hardeman, MEd, LAT, ATC

Richard B. Jones, MD

Western Carolina University, Cullowhee, North Carolina and Southeastern Sports Medicine, Asheville, North Carolina

Objective

To educate certified athletic trainers regarding the recognition, treatment and rehabilitation of an athlete who has sustained a multi-ligament knee injury

To educate certified athletic trainers regarding an unusual common fibular (peroneal) nerve injury

To remind certified athletic trainers of the importance of thorough evaluations

Anatomical Review Soft Tissue Support

Anterior Cruciate Ligament Posterior Cruciate Ligament Medial Collateral Ligament Lateral Collateral Ligament Arcuate Complex Medial and Lateral Meniscii Musculature

Bony Support Medial and Lateral Femoral

Condyles Medial and Lateral Tibial

Condyles

Case Background

20 year-old male collegiate football tailback

MOI: Indirect varus stress placed on the right knee

No previous pertinent medical history of lower extremity injury

Initial Clinical Evaluation

Inspection Palpation Range of Motion Special Tests Initial Treatment?

Follow-up Evaluation (12 hours later)

Swelling had increased dramatically in the ipsilateral foot and knee

Obvious drop foot noted Range of Motion

Knee Ankle

Inability to actively dorsiflex or evert right ankle

Decreased right LE sensation (+) Tinel’s Sign

Physician Evaluation (36 hours post-injury)

Athlete was evaluated by a team physician who confirmed the diagnosis of Grade III ACL and LCL sprains

MRI was immediately ordered due to the patient’s right lower extremity neurological signs and symptoms

Referral to Second Physician

Diagnostic Tests

Plain Radiographs Magnetic Resonance

Imaging EMG / Nerve

Conduction Velocity Study

Differential Diagnosis

Subluxed Tibiofemoral Joint Cryotherapy-Induced Neuropraxia Transected Common Fibular Nerve Fibular Nerve Contusion Fibular Head Fracture Posterior Cruciate Ligament Tear Medial and/or Lateral Meniscal Tear Biceps Femoris Rupture / Strain Acute Anterior Compartment Syndrome?

Diagnosis

Final Diagnosis Grade III Anterior Cruciate Ligament Sprain Grade III Lateral Collateral Ligament Sprain Tear of the Posterior Horn of the Lateral Meniscus Posterior Lateral Complex Disruption Common Fibular Nerve Injury Biceps Femoris Strain Medial Femoral Condyle Contusion Medial Tibial Plateau Microfracture Grade I/II Posterior Cruciate Ligament Sprain

Treatment Initial Treatment

Cryotherapy NWB Gait Straight Leg Immobilizer (locked in 0

degrees) Pre-surgical Rehabilitation

Surgical Fixation ACL Repair using BTB Patellar Tendon

Graft Lateral Collateral Ligament

Reconstruction – Anterior Tibialis Allograft Common Fibular Nerve Debridement Posterior Lateral Complex Repair

Initial Post –Surgical Rehabilitation Placed in a motion-restricting full leg brace which

was locked at 30 degrees of flexion for the first 2 weeks after surgery

Non-weight bearing gait for 6 weeks after surgery Rehabilitation focused on guarded ROM, hamstring

and quadriceps strengthening Biofeedback and Russian Current to promote

anterior tibialis and fibularis tertius strengthening Passive stretch of the posterior lower leg muscles

Physician Follow-up

Athlete was prescribed a non-hinged AFO brace 6 weeks post-surgery

Athlete was prescribed an ACL valgus unloader brace 10 weeks post-surgery

Rehabilitation

Treatment focused on: Knee flexion and extension range of motion Quadriceps and Hamstring Strengthening Lower Extremity Proprioception Training Functional Right Lower Extremity Activities

The athlete was cleared for jogging as tolerated 5 ½ months post-surgery

Complications: Inability of patient to actively dorsiflex right ankle Limitation of functional right ankle range of motion due to

bracing

Current Status

One year post-injury, the athlete demonstrates full function of his right knee

He continues to demonstrate paresthesia over the dorsum of the right foot and foot drop on the right

Recent NCV study demonstrates little to no increase in conduction across the common fibular nerve

Uniqueness of This Case

Mechanism of injury Complexity and number of structures

involved Rare incidence of fibular nerve involvement

during knee ligamentous injury

Relevance to Athletic Training Reinforces the importance of completing

thorough clinical evaluations Requires athletic trainers to think outside the

box in terms of complex structural involvement with a common MOI

Reinforces the importance of athletic trainers being creative during the rehabilitation process

Thank You!Any

Questions?