Presenting the Medial Knee

Transcription

1 Presenting the Medial Knee

2 7 Workshop Objectives 1. You will get a review of the anatomy of the medial knee 2. You will get a review assessment techniques for injuries to the medial knee 3. You will pick up a tip or two on assessment 4. You will pick up a tip or two in teaching this topic 5. I will introduce research that is important to ME 6. I will get you thinking MY way 7. Leave with the feeling WE have not wasted 45 minutes

3 Anatomy Review of the Medial Knee Bones Tendons Ligaments Meniscus

4 Injury to the Medial Knee Sprains and Strains Assessment make a clinical judgment about the degree of injury 1 st degree 2 nd degree Sprains and Strains 3 rd degree GOALS are based on the degree of injury Medical referral is based on the degree of injury Meniscal Tears Other (bursitis, nerve involvement, etc.)

5 MCL Sprains - Epidemiology The MCL is the most commonly injured ligament (Ireland, 1999, JAT) MCL most common knee injury in soccer and basketball (Arendt, 1999, JAT) The MCL sprain is the most prevalent knee injury in the general population (Add ACL and MCL = 90% of knee injuries). Miyasaka KC, Daniel DM, Stone ML, Hirshman P. The Incidence of Knee Ligament Injuries in the General Population. The American Journal of Knee Surgery. 1991; 4 (1): knee injuries frequency of knee injuries: ACL, 63% MCL, 44% PCL, 7% LCL, 4% Combination Injuries Meniscal Tears, etc. Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy of kinematics of the lateral collateral ligament of the knee. AJSM. Nov-Dec 2000; 28 (6):

6 Evaluation and Assessment of Medial Knee Injuries HISTORY INSPECTION OBSERVATION PALPATION SPECIAL TESTS PROM, AROM, MMT Stress Testing Etc. Arthrometry The LigMaster The evaluation relies on the expertise of the clinician to assess the MCL sprain given subjective information and performing more objective special (stress) tests.

7 Evaluation of the Medial Knee HISTORY What happened/moi? Direct blow from the side Collaterals Torsion, rotation, twisting Cruciates, Collaterals, Menisci Noises? Sensations? Giving way Tendonitis or Meniscus Sharp/Knife-like Under Patella Chondromalacia Numb Nerve (burning, tingling, etc.)

8 UH OH!! MOI = Blow to the outside of the knee with or without torsion Arnheim & Prentice, Principles of AT, 9 th ed

9 Evaluation of the Medial Knee HISTORY When did it happen, onset PMH Sensations felt PAIN? Provocation, Quality, Radiating/Referred, Severity (1-10), Timing Pin-Point-Pain Training, surfaces, mileage (10% rule), shoes, etc.

10 Evaluation of the Medial Knee OBSERVATION Compare Bilaterally Gait FWB & PWB Antalgic gait Gait deviations Deformity Swelling, edema, effusion, ecchymosis Atrophy

11 Evaluation of the Medial Knee PALPATION Palpate bones compare bilaterally R/O fx &/or dislocation IF FX or DISLOCATION IS SUSPECTED splint (ice), MD Referral

12 Evaluation of the Medial Knee PALPATION Pes anserinus tendons = Sartorius, Gracilis, Semitendinosus + Semimembranosus

13 Evaluation of the Medial Knee RANGE OF MOTION Can palpate tendons at this time Stabilize legs to isolate joints Compare bilaterally AROM PROM Goniometer MMT Make Test or Break Test

14 Evaluation of the Medial Knee SPECIAL TESTS Anterior Drawer Test = ACL stability Slocum Drawer Test adds rotation to ADT Ex Rot AMRI (ACL + MCL + PMC) 15 External Rotation Arnheim & Prentice, Principles of AT, 9 th ed ACL decreases ant mvt of femur (86% and medial displacement (30%) PCL decreases post mvt of femur (90%) and lateral displacement (36%) Posterior Drawer Test = PCL Huston s Test = adds rotation to PDT Internal Rotation PMRI (PCL + MCL + AMC + POL)

15 Evaluation of the Medial Knee - SPECIAL TESTS Valgus Stress Test In 0 (full extension) = MCL + ACL, PCL, PM capsule, POL, etc.) And somewhere between 5-30 flexion = MCL and medial capsule Arnheim & Prentice, Principles of AT, 9 th ed

16 Evaluation of the Medial Knee - SPECIAL TESTS Valgus Stress Test Amount of opening at the joint during valgus stress test compared to the unaffected knee 0-5mm = mild 1+ (very little instability, tenderness, firm end point) 5-10mm = mod 2+ (instability in flexion and pain!) >10mm = severe 3+ (instability even in extension, no end point)

17 Special Tests - Meniscal Tears McMurray s Test: Ex rotation of tibia + valgus stress extension of the knee click or pain over medial meniscus =+ Apley s Compression/Distraction Tests Arnheim & Prentice, Principles of AT, 9 th ed Fox Test

18 Evaluation of the Medial Knee SPECIAL TESTS Patellar Tests Apprehension Test Subluxation, Dislocation Patellar/Femoral Compression Test (Clark s Sign) & Crunch Test Q Angle Measurement Plica Test Functional and Sports Specific Tests

19 Evaluation of the MCL Summary The severity of MCL injury is based on point tenderness, swelling over the soft tissue, and findings gained by performing special tests. Evidence Based Practice My Dissertation

20 Questions Does Wolff s law apply to ligaments? Bone and soft tissue will respond to the physical demands placed on them, causing them to re-model or realign along lines of tensile force Prentice, W. (2004). Rehabilitation Techniques, pg. 41. Is a person s left leg and right leg the same? Do people have a dominant leg? Do athletes?

21 More Questions Do males have stronger bones, tendons, and/or muscles than women? Do males have stiffer ligaments than females? So stronger joints? What if the MCL is the same in males and females? Does that mean the ACL is the same in males and females?

22 Medial Collateral Ligament Attachments: Just inferior to the adductor tubercle on the femoral epicondyle Medial tibial flare 2 Portions Superficial = Tibial collateral or MCL Deep = medial ligament or capsular ligament attaches to medial meniscus

23 Medial Collateral Ligament Deep portion of MCL attaches to medial meniscus. Posterior aspect of superficial MCL blends into deep PCL and semimembranosus muscle, which also attaches to the medial meniscus

24 Medial Collateral Ligament Functions: Valgus stress Tibial external rotation Tibial anterior translation Different knee positions matter!

25 Knee position changes the function of the MCL In extension: Superficial MCL is taut In flexion: anterior MCL is taut, posterior is slack

26 MCL SPRAIN The Valgus Stress Test The common MOIs for injury to the MCL Direct hit (force) on the outside of the knee (valgus stress) Outward rotational force Therefore, the position of the knee when performing the Valgus Stress Test is: 1. Full Extension 2. Flexed How much and why? 30

27 AUTHOR(S) TEXTBOOK PUBLISHER REF DEGREES OF FLEXION 1. Shultz, S., Houglum, P., Perrin, D. Assessment of Athletic Injuries Human Kinetics 2000 None flexion Full Ext = MCL, PMC + ACL, PCL, POL, medial Quads Flexed = MCL + PCL, Medial Capsule, Post. Oblique Lig. Add external rotation of tibia = stress on PCL Add internal rotation of tibia = ACL and PCL stress and stress to MCL 2. Starkey, C., Ryan, J. Evaluation of Orthopedic and Athletic Injuries (2nd Ed.) F.A. Davis 2002 References Norkin and Levangie, flexion to isolate the MCL

28 AUTHOR(S) TEXTBOOK PUBLISHER REF DEGREES OF FLEXION 3. Arnheim, D., Prentice, W. Principles of Athletic Training, (10th Ed.) McGraw-Hill 2000 References Lynch and Henning, flexion in text, in Table (page 528) 4. Konin, J., Wiksten, D., Isear, J., Brader, H. Special Tests for Orthopedic Examination (2nd Ed.) Slack Inc References McClure, Rothstein, and Riddle, 1989 & Smith and Green, flexion 5. Hoppenfeld, S. Physical Examination of the Spine and Extremities Appleton- Century-Crofts 1976 No references knee flexed just enough so that it unlocks from full extension

29 The LigMaster Device and Software Sport Tech, Inc., Charlottesville, VA Joints: ankle, knee, shoulder, elbow Telos device used in radiology for Graded Stress Radiography (GSR)

30 The LigMaster Device and Software Pressure Actuator set at joint line Linear decoder detects displacement Plots force/strain curve SLOPE F = A o E Modular elasticity = stiffness laxity

31 Left Vs. Right LigMaster Data Summary Apparent Ligament Extension, mm Name: PAA 38, Last seen: Thu Jul PAA 38, Test: Right Knee MCL Thu Jul :32 Title: full ext Test Right Knee MCL Jul :32 full ext 1 Test analysis: x-intercept = 0.02 Slope = Comparison: Left Knee MCL Thu Jul :41 Title: full ext 3 Force, dn Comparison Left Knee MCL Jul :41 full ext 3 Comparison analysis: x-intercept = 0.04 slope = Ligament Strain: λ 1/λ 2 Knee MCL analysis: Test ligament slope 1.04% less than comparison

32 Same knee, one flexed 20 LigMaster Data Summary Apparent Ligament Extension, mm Name: PAA 38, Last seen: Thu Jul PAA 38, Test: Right Knee MCL Thu Jul :32 Title: full ext Test Right Knee MCL Jul :32 full ext 1 Test analysis: x-intercept = 0.02 Slope = Comparison: Right Knee MCL Thu Jul :36 Title: 20 d flex 2 Force, dn Comparison Right Knee MCL Jul :36 20 d flex 2 Comparison analysis: x-intercept = 0.01 slope = Ligament Strain: λ 1/λ 2 Knee MCL analysis: Test ligament slope 17.72% greater than comparison

33 Position of Knee Study Results Overall: F (4,44) = 19.57, P< <.001 T-Tests: Tests: 0-10 no difference 0-10 & different no difference * = diff from Knee Position Mean + SD * * 0d 5d 10d 15d 20d 15 * 20 *

34 Summary Medial knee injuries are prevalent in athletics, the MCL is the most often sprained ligament Evaluation and assessment of medial knee injuries includes taking a thorough history, good observation and palpation skills, and being able to perform special tests The Valgus Stress Test seems to be a valid test and fairly reliable but authors don t agree on the specifics of it Arthrometry may be helpful in gaining more objective information regarding the extent of injury and healing of a ligament after injury Management and rehabilitation should follow an established progression and should be based on the principles of tissue healing. Return to Play should be determined by criterion which includes both subjective and objective information

35 Workshop Objectives Review the anatomy of the medial knee Review assessment techniques for injuries to the medial knee Pick up a tip or two on assessment Pick up a tip or two in teaching this topic Introduce research that is important to me To get you thinking my way Leave with the feeling we have not wasted 45 minutes

36 Resources Andrews, J., Harrelson, G., Wilk, K. (2004). Physical Rehabilitation of the Injured Athlete, 3 rd Ed., Philadelphia: Saunders Arnheim,D., Prentice, W. (1997). Principles of Athletic Training, Ed 9, Boston: McGraw- Hill Company. Photo CD AND 10 th Edition (2000) Text Baker, C. Editor (1995).The Hughston Clinic Sports Medicine Book, Baltimore: Williams & Wilkins Denegar, C., Saliba, S., Saliba, E. (2004) Therapeutic Modalities from J. Hertel and C.R. Denegar, 1998, A rehabilitation paradigm for restoring neuromuscular control following athletic injury, Athletic Therapy Today 3 (5): Konin, J., Wiksten, D., Isear, J., Brader, H. (2002). Special Tests for Orthopedic Examination, 2 nd Ed. Thorofare, NJ: SLACK, Inc. Prentice, W. (2004). Rehabilitation Techniques, 4 th Ed. Boston: McGraw-Hill Company Shultz, S., Houglum, P., Perrin, D. (2000). Assessment of Athletic Injuries, Champaign, IL: Human Kinetics Starkey, C. Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries, 2 nd Ed. Philadelphia: F.A. Davis Company VanDeGraaff, KM, Crawley, JL (1999). A Photographic Atlas for the Anatomy & Physiology Laboratory. Englewood, CO: Morton Publishing Company.