Sport Injuries of the Knee

Objectives Revise anatomy Common injuries: Basic management Menisci ACL, PCL Collaterals Basic management

Anatomy Compound joint Femoral condyles and Tibial articular surfaces Patello-femoral joint Menisci: Medial / Lateral Ligaments: ACL, PCL MCL, LCL

Anatomy (Menisci) Medial Meniscus Lateral Meciscus C- shaped Peripheral 20-30% is vascular Lateral Meciscus Round shaped Peripheral 10-25% vascular

Function of Menisci Deepen the articular surfaces of tibial plateau Have role in: Stability Lubrication Nutrition

Anterior Cruciate Ligament Tibial attachment: Between intercondylar eminence Femoral attachment: Posteromedial aspect of lateral femoral condyle 33mm long and 11mm wide Consists of two bundles Anteromedial: tight in flexion Posterolateral: tight in extension

Posterior Cruciate Ligament Tibial attachment: Tbial sulcus below articular surface Femoral attachement: Anterolaterally on medial femoral condyle 38mm long and 13mm wide 2 bundles Anterolateral: tight in flexion Poseromedial: tight in extension

Medial Collateral Ligament Two parts: Superficial: Originates from medial femoral condyle Inserts at periosteum of proximal tibia deep to pes anserinus Deep: A capsular thickening and is blended with the medial meniscus

Lateral Collateral Ligament Origin: Lateral femoral epicondyle Insertion: At the fibular head

Statistics

Statistics

Mechanism of Injury

Mechanism of Injury

History

Examination Look, Feel, Move Special Test Anterior Drawer Test Posterior Drawer Test Valgus Stress Test Varus Stress Test McMurray Test

Special Tests Anterior Drawer Test Posterior Drawer Test

Special Tests Varus Stress Valgus Stress

Special Tests (Menisci) McMurray

Special Tests (Menisci) Apley’s Grinding

Investigations X-rays AP, Lateral AP standing Skyline

Investigations X-rays AP, Lateral AP standing Skyline

Investigations X-rays AP, Lateral AP standing Skyline

X-rays Tibial eminence fracture signifying ACL bony avulsion

MCL Injury Avulsion Stress Film

MRI- Meniscal Tear

MRI- ACL Tear

MRI- PCL Tear

MRI- Collateral Ligaments

Management of Acute Injury Rest Splint Ice Packs Analgesia Quadriseps Rom

Management of Acute Injury Rest Splint Ice Packs Analgesia Quadriseps Rom

Management of Acute Injury Rest Splint Ice Packs Analgesia Quadriseps Rom

Management of Acute Injury Rest Splint Ice Packs Analgesia Quadriseps Rom

Management of Acute Injury Rest Splint Ice Packs Analgesia Quadriseps Rom

Management of Specific Injuries

Meniscal Tears Tears causing mechanical symptoms and those who fail conservative management requires operative treatment

Meniscal Tears

Meniscal Tears Partial Menisectomy Meniscal Repair Tears in white zone Radial tears Longitudinal tears Bucket handle tears Meniscal Repair Peripheral, longitudinal tears in red zone

Meniscal Tears

Treatment for Meniscal Tears Partial Menisectomy Meniscal Repair

ACL Tears Non-contact pivoting injuries associated with an audible pop and haemarthroses Treatment is individualized depending on Age Level of activity Instability Associated injuries Associated injuries: Lateral Meniscal tears are more common than Medial Meniscal tears

ACL Tears Conservative Reconstruction Isloated tears with no instability Partial tears Recreational activities Light sport only Sedentary Quadriceps and Hamstring strengthening exercises Associated injuries Full thickness tears with instability Competitive sports Reconstruction with Bone-Patella tendon Hamstring Tendon

PCL Tears Direct blow to anterior tibia with knee flexed Dashboard injury Hyperextension or Hyperflexion

PCL Tears Conservative Reconstruction Tendon Allograft Grade I- PCL stretched (<5mm laxity) Grade II- PCL Torn (5-9mm laxity) Physiotherapy Grade III- PCL torn (>10mm laxity) Grade IV-A - PCL + LCL Grade IV-B - PCL + MCL Grade IV-C – PCL + ACL Tendon Allograft

MCL Tears Valgus stress to the knee Most commonly occurs at medial femoral attachment Grade I- strain Grade II- Partial Tear Grade III- Complete Tear

MCL Tears Hinged Knee Brace for isolated injuries Combined injuries will require reconstruction of the respective ligaments (ACL, PCL, posteromedial corner)

LCL tears Isolated LCL injuries are uncommon and can be treated conservatively with brace if grade II Complete tears with associated ACL/PCL requires reconstruction

Miscellaneous Injuries Quadriceps and Patellar Tendon rupture Patellar Tendinitis Quadriceps Tendinitis

Quadriceps Tendon Rupture

Patellar Tendon Rupture

Quadriceps Tendinitis Patellar Tendinitis Quadriceps Tendinitis Jumper’s Knee Basketball and Volley ball Pain and tenderness at inferior border of patella Rest NSAIDS Physiotherapy Pain at superior border of patella Rest NSAIDS Physiotherapy

Patellar Tendinitis

Quadriceps Tendinitis

Pediatric knee Osgood Schlatter's Disease Osteochondrosis or traction apophysitis of tibial tubercle Most commonly seen in boys 12-15 years Increased in jumpers (basketball, volleyball) or sprinters and football Pathophysiology stress from extensor mechanism Prognosis self-limiting but does not resolve until growth has ended

Osgood Schlatter's Disease Presentation Symptoms pain on anterior aspect of knee exacerbated by kneeling Physical exam enlarged tibial tubercle tenderness over tibial tubercle provocative test pain on resisted knee extension

Osgood Schlatter's Disease Imaging Radiographs recommended views lateral radiograph of the knee findings irregularity and fragmentation of the tibial tubercle MRI not essential for diagnosis

Osgood Schlatter's Disease Treatment Nonoperative NSAIDS, RICE (rest, ice, compression and elevation ) , activity modification, strapping/sleeves to decrease tension on the apophysitis and quadriceps stretching indications first line of treatment outcomes 90% of patients have complete resolution cast immobilization x 6 weeks severe symptoms not responding to simple conservative management above Operative ossicle excision indications  refractory cases 

Summary Acute Injuries: splint, ice packs, NSAIDS & Physiotherapy Specific Management: Menisci: repair v/s menisectomy ACL: depends upon the age and activity level PCL: according to grades MCL and LCL: depends upon isloated injuries or in combination