KNEE INJURIES DR. ANDREW POTTER SPORT & EXERCISE MEDICINE PHYSICIAN

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1 KNEE INJURIES DR. ANDREW POTTER SPORT & EXERCISE MEDICINE PHYSICIAN

2 CLASSIFICATION MENISCUS ACUTE CRUCIATE LIGAMENT (ACL/PCL) MEDIAL COLLATERAL LIGAMENT PATELLAR INSTABILITY LOOSE BODY CHRONIC PATELLOFEMORAL PAIN OSTEOARTHRITIS OSTEOCHONDRAL DEFECT TENDONOPATHIES APOPHYSITIS ITB FRICTION SYNDROME FRACTURE

3 ASSESSMENT MECHANISM OF INJURY SYMPTOMS EXAMINATION INVESTIGATIONS MANAGEMENT

4 ACUTE INJURIES MECHANISM Direct blow falling onto patella = bursitis patellar bruising, osteochondral defect lateral valgus force = lateral contusion + MCL stress fracture head of fibula + peroneal nerve damage (paraesthesia + foot drop) medial varus force = lateral collateral ligament Hyperflexion posterior horn of meniscus Hyperextension ACL, PCL Rotation + flexion = meniscus Rotation + flexion + change of direction = ACL Landing from jump

5 DEEP ACL, fracture ACUTE INJURIES SITE of PAIN Often diffuse, non-specific but can provide clues ANTERIOR patellofemoral MEDIAL Medial CL Medial meniscus LATERAL Lateral CL Lateral meniscus Fibula POSTERIOR PCL

6 SITE - joint effusion contusion haematoma prepatellar bursa ACUTE INJURIES SWELLING ONSET - rapid effusion = haemarthrosis ACL, fracture, patellar dislocation later = serous meniscus, MCL, chondral defect May be affected by ice, compression CONTUSION, HAEMATOMA - direct blow distal quads

7 ACUTE INJURIES NOISE MOVEMENT POP = ACL CLICK = MENISCUS TEAR = LIGAMENT whole knee shift = ACL patella shift laterally usually return to position CHANGE SHAPE medial or lateral mass = patellar dislocation

8 ACUTE INJURIES RETURN TO PLAY - indication of severity REDUCED MOVEMENT - effusion locked knee in flexion = meniscus reduced flexion-extension = effusion, obstruction locked in extension = quads spasm WEIGHT BEARING - severity

9 CHRONIC INJURIES SITE of PAIN MEDIAL medial compartment degeneration medial meniscus pes anserinus bursitis, tendonitis LATERAL - lateral compartment degeneration lateral meniscus ANTERIOR - patellofemoral patellar tendon tendonosis, SLJ, OSD prepatellar bursitis POSTERIOR - patellofemoral Baker s cyst

10 CHRONIC INJURIES INSTABILITY True ligamentous Patellofemoral subluxation, dislocation Reflex quads inhibition CATCHING Meniscal Loose body osteochondral defect (OA, OCD) Patellofemoral SWELLING Baker s cyst (Popliteal Cyst) usually intra-articular pathology CREPITUS Patellofemoral chondral damage

11 CHRONIC INJURIES EXACERBATIONS Pain, swelling, catching ACTIVITIES - walking, running, jumping, kicking time of onset TWISTING - twisting with weight bearing = meniscal, chondral car, bed, rolling over = meniscal SQUATTING - squatting = meniscal, PFJ rising = PFJ SITTING - movie sign = PFJ STAIRS - down = PFJ

12 KNEE EXAMINATION GENERAL weight bearing shape - knee / quadriceps angle leg swelling - effusion localised bruising muscle function & wasting - general quads/vmo gluteals active movement - restriction SPECIFIC specific conditions compare sides

13 KNEE INJURIES INVESTIGATIONS ASPIRATION aseptic technique diagnostic aid - haemarthrosis, serous effusion, lipohaemarthrosis comfort PLAIN X-RAY 3 views - AP, PA, lateral skyline views at 20/40/60 or 45/90 degrees flexion for PFJ ULTRASOUND SCAN cystic swellings collateral ligaments

14 CT (ARTHROGRAM) meniscal tears chondral defects fractures KNEE INJURIES INVESTIGATIONS MRI soft tissues around knee meniscus ligaments - cruciate, collateral chondral defects bone bruising NUCLEAR BONE SCAN OCD, tumours

15 TREATMENT ACUTE GENERAL Rest Ice Compression Support Analgaesics NSAID s -? probably in short term Diagnosis SURGERY post-op rehab return to activity ACUTE REHAB graded return to activity

16 TREATMENT CHRONIC GENERAL Remove stress Treat pain Address aetiological factors Ongoing maintenance programs physical pharmacological

17 CASE SCENARIOS