Transcript Derbyshire Sports Injuries Clinic presents

The Knee
Anatomy- 1st layer
The knee joint
 Made up of two
joints:
 Tibiofemoral joint:
 Hinge joint
 Collateral ligaments
 Cruciate ligaments
 Menisci
 Patellofemoral joint:
 Medial retinaculum
 Patellar tendon
Anatomy-ligaments
 ACL
 PCL
 MCL
 LCL
 Popliteal ligaments
 Meniscofemoral
ligament
 Transverse ligament
Anatomy-medial view
Anatomy- lateral view
Anatomy-posterior view
Anatomy- bursae
Movements of the knee
 Flexion
 Extension
 Accessory movements in certain positions can
take place with external forces:
 Valgus
 Varus
 External rotation
 Internal rotation
Patient walks in c/o knee pain
 What is the mechanism of
injury?
 A planted foot with a valgus
force and/ or twisting
movement is a serious position
of danger for the knee
 Was there a noise?
 Did the knee swell up
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immediately?
Is there any bruising?
Was the patient able to play
on?
Is the patient able to
weightbear?
Is there any clicking/ giving
way/ locking now?
Patient walks in c/o knee pain
 Acute, chronic or sub-acute?
 Does pain increase or decrease with activity?
 Patient’s job and leisure activities and any
possible contributing factors?
 Gait? Limping or normal walking? Able to cope
with stairs?
 Does the patient have any hip pain?
 Any back pain? Leg pain? Could this be an L3
Nerve root compression?
Where is the pain?
Causes of haemarthrosis
 ACL tear
 PCL tear
 Patella dislocation
 Osteochondral fracture
 Peripheral tear of the meniscus (more
commonly medial)
 Hoffa’s syndrome (acute fat pad
impingement)
More clinical pearls
 There is little effusion with collateral ligament
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tears
An effusion that develops after a few hours or the
next day is a feature of meniscal and chondral
injuries
Assume everything with a pop or a snap is an ACL
tear
Assume all clicking and locking is meniscal...
Especially loss of extension
If the knee locks in extension and flexion is
difficult it is likely to be patellofemoral pain
Giving way can be indicative of ACL or meniscal
injury, but if this is longstanding with no injury, it
may be muscle weakness
Ottawa Knee rules
 Age 55> or <18
 Tenderness at head of
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fibula
Isolated patella
tenderness
Inability to flex to 90°
Inability to bear weight
both immediately and in
the emergency
department (4 steps)
High suspicion are:
 High speed injuries
 Children or adolescents
 Clinical suspicion of loose
bodies
90% of knee X-rays are normal.
Assessment
 Observe active range:
ability to squat if
appropriate, control
through the knee.
 Observe position of
patella in standing
 Passive range of
movement in supine:
loss of particularly
extension will cause
long term problems
 Palpate the patella for
differences from side
to side
ACL assessment
 Anterior Drawer test:
 Knee at 90° flexion, foot kept stable
 Tibia drawn anteriorly
 Assess for degree of movement and end point
 Lachman’s Test
 Knee at 15° flexion
 Draw tibia forward
 Assess for degree of movement and end point
ACL assessment
 Pivot Shift Test:
 Tibia internally rotated
 Knee in full extension
 Apply a valgus force
 In a knee with ACL deficiency the condyles will sublux.
The knee is then flexed, looking for the clunk of a
reduction, a positive Pivot shift. Extending the knee
again, if the knee clicks, this is a positive ‘jerk test’.
 Loss of ROM, especially extension
 Lateral joint line tenderness due to lateral joint
capsule stretching due to subluxation
 Medial joint line tenderness if associated meniscal
injury
ACL injury
 Relatively common in sport
 Over 10 000 ACL reconstructions performed in
the USA every year
 Generally sports that involve pivoting...
Football, netball, rugby, gymnastics, downhill
skiing etc.
 2-10 x higher risk in females
 Can occur in isolation or with meniscal,
articular cartilage and MCL injury
ACL injury
 75% rupture chance if there was a twist, a pop and a
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click!
Extremely painful, particularly at first
Athletes are initially unable to continue their activity,
and further activity is limited by significant
haemarthrosis. Very occasionally this can be delayed.
Some athletes ‘try’ to play again when knee has
settled and report incidences of acute instability
Examination of the knee when swollen is very difficult.
Diagnosis should be based on subjective report, and
appropriate referral made.
MRI is the imaging of choice, but X-ray is needed to
check for an avulsion fracture (‘Segond’).
80% of ACL tears have a bone bruise over the lateral
femoral condyle.
PCL assessment
 Posterior sag:
 Both knees flexed to 90° and patient relaxed
 Observe tibia position relative to femur
 Reverse Lachman’s Test
 Lachman’s prone!
 Posterior drawer test
 Knee at 90°, push tibia posteriorly
 Also assess in internal and external rotation
 Assess range and quality of end point
 X-ray to ensure no bony avulsion
 MRI is the gold standard for PCL tear
assessment
PCL injury
 PCL is a primary restraint to posterior drawer
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and secondary restraint to external rotation.
Less common than ACL (thicker ligament),
usually associated with meniscal and chondral
injury as well as lateral meniscus injury.
Usually results from a blow to the anterior
tibia with the knee flexed.
Hyperextension may also result in injury to
the PCL and posterior capsule.
Pain is poorly defined, posterior pain,
sometimes in the calf.
Collaterals
MCL: Valgus force
LCL: Varus force
Test at full extension and also 30° flexion
Grade 1: hurts on testing with no laxity visible
Grade 2: hurts and gaps with laxity but with end
point
 Grade 3 isn’t that painful on testing, LARGE
amount of movement. Feels ‘wobbly’. Frequently
associated with ACL injuries, often capsular
tearing with this grade, swelling therefore present
 Always local tenderness at insertion point
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Collateral ligament injury
 MCL is a result of a
valgus force
 LCL tear is less
common and due to a
high-energy direct
varus stress on the
knee and often
associated with PCL
tear
 Treatment is generally
conservative, although
bracing is required for
more severe injuries.
Menisci
 Pain on palpation of the joint line
 Positive McMurray’s test:
 The knee is flexed and at various stages of
flexion the tibia is internally and externally
rotated
 Pain and a ‘clunk’ make this test positive
 Joint effusion
 Pain on squatting (especially if posterior horn is
involved)
 Restricted ROM
 MRI is investigation of choice
Meniscal injury
 Generally a twisting injury
 Doesn’t have to be a quick injury
 Degree of pain associated with an acute injury can
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vary dramatically.
Sometimes a tearing sensation will be felt
Sometimes pain is of late onset... Up to 24 hours later
Small tears may also occur with minimal trauma in the
older athlete as a result of degenerative changes
Surgical indications include:
 Inability to continue playing
 Locked knee or severe lack of ROM, particularly EOR
flexion
 Palpable clunk on McMurray’s Test
 Associated ACL tear
 No change after 3 weeks post-injury
Patella and tendon
 Assess the patella in 30° knee flexion, push
the patella laterally, if the patient has
apprehension, consider a dislocating patella
 Pain infrapatella is usually the tendon (or can
be bursal)
 Fractured patella can occur due to direct
trauma or through quadriceps avulsion.
 In adolescents consider Osgood Schlatter’s
Disease, particularly if a prominent tibial
tubercle. This is a growth plate
osteochondritis
Articular cartilage damage
 Chondral damage can
be a major cause of
symptoms in the knee
 Can be primary or
secondary
(ligamentous
instability... ACL has
high incidence of
medial & lateral
femoral condyle and
tibial plateau chondral
damage)
Anterior knee pain
 20-40% of all MSK
consultations in general
practice
 Generally AKP is due to:
 Patellofemoral pain
 Patella tendinopathy
 Other causes can include:
 Synovial plica
 Pre-patella/ infrapatella
bursitis
 Fat pad impingement
 Quadriceps tendinopathy
 Patellofemoral instability
Patellofemoral pain
 Generally insidious onset, vague pain
 Often secondary to an acute incidence
 A diffuse ache exacerbated by loading eg stairs or
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running... Doesnt tend to have to be eccentric loading
only.
Prolonged sitting can be painful
Worsening pain while exercising tends to be PFPS,
while pain at start of exercise, and ceasing of exercise
tends to be Patella tendinopathy
Previous injury to the knee predisposes one to PFPS
Any effusion around the knee >15ml of fluid will
switch off VMO (major stabiliser of the knee)
increasing the risk of adverse knee mechanics and
therefore PFPS
Assess the patella position relative to the painfree side
Patella tendinopathy
 Mostly involves jumping/ multidirectional sports
 Significantly more painful with eccentric loading
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rather than any other type of loading
Pain is inferior pole of the patella, or the tendon
Pain is always bad in the morning
Chronic tendinopathy can take 3-6 months to
settle
Surgery is only indicated after a considered and
lengthy conservative programme has failed
Lateral knee pain
 Mostly due to Ilitobial band
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friction syndrome (ITBFS)
Repeated flexion/ extension at
the knee causes ITB to rub on
the lateral epicondyle
Training errors and
biomechanical problems are the
major causes of ITBFS
Occasionally biceps femoris
tendon can become inflamed and
tender
Superior tib-fib joint can also
give lateral knee pain
OA of the lateral compartment
Nerve root irritation/ entrapment
Medial knee pain
 PFPS
 Medial meniscal
injury
 OA of the medial
compartment
 Pes anserinus
bursitis
 Referred pain
Posterior knee pain
 Biceps femoris,
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gastrocnemius or
popliteus
tendinopathy
Referred pain
Baker’s cyst
Posterolateral corner
injury
DVT
Claudication
Advice to you as GPs
 If it’s swollen, refer to orthopaedics
 If it’s anterior knee pain, always refer to physio
 If it’s giving way, refer to orthopaedics
 A painless click is not a problem, as long as no
locking or giving way is associated.
 Kids with Osgood’s should rest when sore, and try
to get strong when condition is stable
 Rest will NEVER fix an injury.
 Cycling (not standing on the pedals) is generally a
knee friendly sport. Running is not.