1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 15 Knee Conditions

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Anatomy Structure of the knee. A. Anterior view. B. Posterior view

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Anatomy (cont’d) Structures of the knee. C. Lateral view. D. Medial view

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Anatomy (cont’d) Structures of the knee. E. Superior surface of the tibia. F. Bursa of the knee

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Anatomy (cont’d) Tibiofemoral Joint –Condyles of femur with plateaus of tibia –Hinge joint—flexion/extension –Tibia does rotate laterally on femur during last few degrees of extension –“Screwing-home mechanism” Produces a locking of the knee in final degrees during extension

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Anatomy (cont’d) Meniscus –Fibrocartilaginous discs attached to tibial plateaus –Medial and lateral E. Superior surface of the tibia

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Anatomy (cont’d) Meniscus (cont’d) Functions: –Stabilize joint by deepening the articulation –Shock absorption –Provide lubrication and nourishment –Improve weight distribution Medial meniscus has an attachment to the MCL and semimembranosus

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Joint Capsule and Bursae Articular capsule – encompasses both tibiofemoral and patellofemoral joints Bursa inside the capsule –Suprapatellar bursa –Subpopliteal bursa –Semimembranosus bursa

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Joint Capsule and Bursae Bursa outside capsule –Prepatellar bursa –Superficial infrapatellar bursa –Deep infrapatellar bursa F. Bursa at the knee

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligaments ACL –Prevents: Anterior translation of tibia on femur Rotation of tibia on femur Hyperextension PCL –Resists posterior displacement of tibia on femur

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligaments (cont’d) MCL –Resist medially directed (valgus) forces LCL –Resist laterally directed (varus) forces A. Anterior view. B. Posterior view

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellofemoral Joint Patella –Superior, middle, and inferior articular surfaces –Functions Protect femur Increase effective power of quadriceps

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellofemoral Joint (cont’d) Patella. A. Anterior view. B. Posterior view

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Q-Angle Q-angle –Angle between line of resultant force produced by quadriceps and line of patellar tendon – Males 13°; females 18° – Q-angle— lateral patellofemoral contact  Q-angle— medial tibiofemoral contact

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Q-Angle (cont’d)

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerves Tibial nerve –Hamstrings except short head of biceps Common peroneal –Short head of biceps Femoral –Quadriceps

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerves (cont’d) Innervation of the knee. A. Anterior view. B. Posterior view

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Supply Femoral artery Popliteal artery Genicular arteries Collateral circulation around the knee. A. Anterior. B. Posterior. C. Circulation to meniscus

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions Knee flexion –Hamstrings –Assisted by: Popliteus Gastrocnemius Gracilis Sartorius Motions at the knee. A. Flexion and extension

20. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Knee extension –Quadriceps femoris muscle group Rectus femoris Vastus lateralis Vastus intermedius Vastus medialis Vastus medialis oblique (VMO)

21. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Knee extension (cont’d) –Screw-home motion Rotation and passive abduction and adduction –Capability maximal at approximately 90° of knee flexion

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Patellofemoral joint motion –During knee flexion and extension, patella glides in the trochlear groove –Tracking is dependent on the direction of the net force produced by the attached quadriceps

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Knee Injuries Physical conditioning –Strength –Flexibility Rule changes Footwear –Cleats vs. flat sole –Position of cleats and size

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions Knee –MOI: compression –S&S Localized tenderness Pain Swelling –Management: standard acute; extreme point tenderness physician referral –Caution: excessive swelling could mask other injuries

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Infrapatellar fat pad – Entrapped between the femur and tibia –S&S Locking, catching, giving way Palpable pain on either side of patellar tendon Extreme pain on forced extension

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Infrapatellar fat pad (cont’d) –Management Standard acute If symptoms persist > 2-3 days, physician referral Protect the area during activity

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Peroneal nerve –MOI: blow to the posterolateral aspect of the knee –S&S Radiating pain down lateral aspect of leg and foot

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Peroneal nerve (cont’d) –S&S (cont’d) Severe cases Initial pain—not immediately followed by tingling or numbness As swelling ↑ within nerve sheath Weakness in dorsiflexion or eversion

29. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Peroneal nerve (cont’d) –S&S (cont’d) Severe cases As swelling ↑ within nerve sheath Loss of sensation in dorsum of foot, especially between 1st and 2nd toes May progressively occur days or weeks later

30. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Peroneal nerve (cont’d) –Management: Standard acute, but caution with compression Severe S&S—immediate physician referral

31. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis Prepatellar –MOI Acute: direct blow to anterior patella Chronic: repetitive blows –S&S Swelling Pain with direct pressure Pain with passive knee flexion Localized swelling

32. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Pes anserine –MOI: Friction between tendon and MCL Direct trauma –S&S Pain with knee flexion

33. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Infrapatellar –Mechanism: Friction between patellar tendon and fat pad/tibia May be associated with patellar tendinitis

34. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Infrapatellar (cont’d) –S&S Point tender with possible swelling posterior to patellar tendon  pain at end range of resisted knee extension and passive flexion Prolonged knee flexion may  symptoms

35. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Bursitis management –Standard acute;  aggravating activities or total rest –Protect area during activity

36. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions AAOS classifies ligamentous knee injuries according to: –Functional disruption of a specific ligament –Amount of laxity –Direction of laxity Direction divides laxity into 4 straight and 4 rotatory laxities Knowing knee position at impact and direction the tibia displaces or rotates indicates the damaged structures

37. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Knee instability

38. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Knee instability

39. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight medial laxity (valgus laxity) –Involves MCL; posterior medial capsule— possibly PCL –Lateral forces cause tension on medial aspect of knee

40. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight medial laxity (valgus laxity) (cont’d) –1 st degree Mild pain medial joint line Little or no joint effusion/mild swelling at site Full ROM with minor discomfort Valgus @ 0°—stable; @ 30º—+

41. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight medial laxity (valgus laxity) (cont’d) –2 nd or 3 rd degree Unable to fully extend the leg; often walk on the ball of foot; unable to keep heel flat on the ground

42. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight lateral laxity (varus laxity) –Involves LCL, lateral capsular ligaments, PCL –Medial forces produce tension on lateral aspect of knee Not usually isolated—presence of IT band, biceps femoris, popliteus

43. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight lateral laxity (varus laxity) (cont’d) –S&S Similar to MCL Swelling minimal—no attachment to capsule Instability may not be obvious if other stabilizers are intact

44. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight anterior laxity (anterior instability) –Anterior displacement of tibia on femur –Involves ACL—rarely isolated –MOI: cutting or turning maneuver, landing, or sudden deceleration

45. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight anterior laxity (anterior instability) (cont’d) –S&S Pain Minimal and transient to severe and lasting Deep in knee difficult to pinpoint “Pop” Effusion within 3 hours; reports knee giving way—does not feel right

46. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight posterior laxity –Tibia displaced posteriorly –Involves PCL –MOI Hyperextension force Fall on flexed knee (initial contact at tibial tuberosity)

47. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Straight posterior laxity (cont’d) –S&S Sense of stretching to posterior knee “Pop” Rapid joint effusion ↓ knee flexion due to effusion

48. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligamentous Conditions (cont’d) Management –Standard acute –Unable to walk normally – crutches should be used –Physician referral Not typically an ER, but seen by physician 1-2 post-injury

49. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Dislocation/Subluxation Minimum of 3 ligaments torn for knee to dislocate –Most often—ACL, PCL, and one collateral ligament Concern: damage to other structures; especially neurovascular MOI: cutting, twisting, or pivoting maneuver

50. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee Dislocation/Subluxation (cont’d) S&S –Individual describes severe injury –“Pop” –Deformity (unless spontaneously reduced) Management: standard acute –Spontaneous reduction—physician referral –Not reduced—activate emergency plan, including summoning EMS

51. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Meniscal Conditions Classified according to location Involve compression, tension, shearing forces Longitudinal –Twisting motion when foot fixed and knee flexed Produces compression and torsion on posterior peripheral attachment –Bucket-handle tear Longitudinal segment displaced medially toward center of tibia

52. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Meniscal Conditions (cont’d) Meniscal tears

53. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Meniscal Conditions (cont’d) Horizontal tear –Due largely to degeneration –Shearing from rotational forces Tears the inner surface of the meniscus –Parrot-beak tear 2 tears; commonly in middle segment of lateral meniscus

54. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Meniscal Conditions (cont’d) Meniscal tears

55. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Meniscal Conditions (cont’d) S&S –Initial symptoms may be vague or limited Limited sensory nerve supply—minimal pain Minimal disability Minimal swelling –Understand mechanism

56. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Meniscal Conditions (cont’d) S&S (cont’d) –Delayed swelling –Joint line pain –Classic: clicking/locking (not acutely) leads to knee buckling or giving way Management –Standard acute; treat symptoms –Physician referral

57. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions Patellofemoral pain –Causes Mechanical (e.g., patellar subluxation or dislocation) Inflammatory (e.g., prepatellar bursitis, patellar tendinitis) Other causes (e.g., reflex sympathetic dystrophy, tumors) –Dynamic stabilizer—extensor mechanism

58. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Extensor mechanism

59. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellofemoral stress syndrome –Mechanism Poor patellar tracking due to weak VMO or tight lateral structures

60. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellofemoral stress syndrome (cont’d) –S&S Dull, aching pain, ↑ with sitting, squatting, and descending stairs Point tenderness—lateral facet of the patella Pain with manual patella compression into trochlear groove

61. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellofemoral stress syndrome (cont’d) –Management: Standard acute; NSAIDs Physician referral

62. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Chondromalacia –Degeneration in articular cartilage of patella –Due to abnormal excursion & compressive forces

63. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Chondromalacia (cont’d) –S&S: Anterior knee pain and crepitus w/ walking stairs or deep knee bends Pain and crepitus increase w/ active & resisted knee extension. Localized pain and tenderness on the medial and lateral patellar borders.

64. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Chondromalacia (cont’d) –Management Standard acute Physician referral

65. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar instability and dislocation –Displacement of patella due to internal or external forces –MOI: deceleration combined with a cutting motion

66. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar instability and dislocation (cont’d) –S&S subluxation Transient partial displacement; acute or intermittent with spontaneous reduction Feeling of patella slipping when cutting, twisting, or pivoting

67. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar instability and dislocation (cont’d) –S&S dislocation “Pop” Violent collapse of the knee Localized tenderness—medial extensor retinaculum Loss of limb function Effusion

68. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar instability and dislocation (cont’d) –Management: Standard acute Immediate physician referral Coach should not attempt to reduce

69. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar tendinitis –Due to repetitive or eccentric knee extension activities –S&S Initial—pain after activity on inferior pole of patella or distal attachment of patellar tendon Progression—pain at start of activity, subsides with warm-up, reappears after activity; eventually pain both during and after activity

70. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar tendinitis (cont’d) –S&S (cont’d) Pain ascending and descending stairs; pain after prolonged sitting –Management: standard acute; physician referral

71. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Osgood- Schlatter disease –Inflammation or partial avulsion of tibial apophysis due to traction forces –S&S Individual points to tibial tubercle as source of pain Tubercle appears enlarged Pain during activity and relieved with rest Pain at extreme knee extension and forced flexion

72. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Patellar tendon traction-type injuries

73. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Osgood- Schlatter disease (cont’d) –Grade 1 – Pain after activity that resolves within 24 hours 2 – Pain during and after activity that does not hinder performance and resolves within 24 hours 3 – Continuous pain that limits sport performance and daily activities –Management: do not permit to continue activity until seen by a physician

74. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Sinding-Larsen-Johansson disease –Inflammation or partial avulsion of apex of patella due to traction forces –Usually seen in children 8 to 13 years old involved in running and jumping sports.

75. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Sinding-Larsen-Johansson disease (cont’d) –S&S Gradual onset of pain Pain with palpation of inferior patellar pole with knee extended and patellar tendon relaxed –Management: do not permit to continue activity until seen by a physician

76. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Extensor tendon rupture –Due to powerful eccentric muscle contractions –S&S Partial rupture—pain and weakness in knee extension

77. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Extensor tendon rupture (cont’d) –S&S (cont’d) Total rupture distal to patella High-riding patella Palpable defect over the tendon Inability to extend knee extension or perform a straight leg raise

78. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patellar Conditions (cont’d) Extensor tendon rupture (cont’d) –S&S (cont’d) Total rupture from superior pole with extensor retinaculum still intact Knee extension is possible, but weak and painful –Management: standard acute; crutches; immediate referral to a physician

79. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Iliotibial Band Friction Syndrome Band drops behind lateral femoral epicondyle with knee flexion, then snaps forward over epicondyle during extension Due to excessive compression and friction Associated with overuse, abnormal biomechanics, and poor flexibility

80. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Iliotibial Band Friction Syndrome (cont’d) Iliotibial band

81. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Iliotibial Band Friction Syndrome (cont’d) S&S –Pain with running progresses from not restrictive to restrictive even with ADLs –initial lateral ache progresses into a more painful, sharp, and localized discomfort over the lateral femoral condyle just above the lateral joint line –Flexion and extension of the knee may produce a creaking sound

82. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Iliotibial Band Friction Syndrome (cont’d) Management: –Acute –NSAIDs –Do not permit to continue activity until seen by a physician

83. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions Avulsion fracture –Due to direct trauma, excessive tensile forces, overuse –S&S: localized pain and tenderness over the bony site

84. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Epiphyseal and apophyseal fracture –Tibial tubercle fracture MOI Forced flexion of knee against a straining quadriceps contraction Violent quadriceps contraction against a fixed foot

85. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Epiphyseal and apophyseal fracture S&S Pain, ecchymosis, swelling, and tenderness Difficulty going up and down stairs knee extension painful and weak Larger fractures involving extensive retinacular damage Patella rides high Knee extension is impossible

86. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Epiphyseal and apophyseal fracture (cont’d) –Distal femoral epiphyseal fracture MOI: varus or valgus stress applied on a fixed, weight-bearing foot –S&S: Pain around knee Unable to bear weight

87. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Stress fractures –Common areas Femoral supracondylar region Medial tibial plateau Tibia tubercle

88. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Stress fractures (cont’d) –Occur when: Load on the bone is increased Number of stresses on the bone increases (e.g., changes in training intensity, duration, frequency) Surface area of the bone receiving load decreases

89. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Stress fractures (cont’d) –S&S: Localized pain before and after activity Relieved with rest and non–weight bearing

90. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Chondral fracture (involves articular cartilage) Osteochondral fracture (involves articular cartilage and underlying bone) –Due to compression from direct blow to knee causing shearing or forceful rotation Osteochondral fracture

91. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Osteochondral fracture (cont’d) –S&S Painful “snap” Considerable pain & rapid swelling Displaced fracture: locking; crepitus

92. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures and Associated Conditions (cont’d) Fracture management –Standard acute –Use of crutches –Immediate physician referral Stress fracture management –Physician referral

93. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment S &S that require immediate physician referral –Obvious deformity suggesting a dislocation or fracture –Significant loss of motion or locking of the knee –Excessive joint swelling –Gross joint instability –Reported sounds, such as popping, snapping, or clicking, or giving way of the knee

94. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment (cont’d) S &S that require immediate physician referral (cont’d) –Possible epiphyseal injuries –Abnormal sensations in the leg or foot –Any unexplained or chronic pain that disrupts an individual’s play or performance Refer to Application Strategy 15.2