1. Multi-Ligament Knee Injury With Associated Fibular Nerve Injury In A Collegiate Football Player Jill A. Manners, MS, LAT, ATC Grady J. Hardeman, MEd, LAT, ATC Richard B. Jones, MD Western Carolina University, Cullowhee, North Carolina and Southeastern Sports Medicine, Asheville, North Carolina

2. Objective To educate certified athletic trainers regarding the recognition, treatment and rehabilitation of an athlete who has sustained a multi-ligament knee injury To educate certified athletic trainers regarding an unusual common fibular (peroneal) nerve injury To remind certified athletic trainers of the importance of thorough evaluations

3. Anatomical Review Soft Tissue Support  Anterior Cruciate Ligament  Posterior Cruciate Ligament  Medial Collateral Ligament  Lateral Collateral Ligament  Arcuate Complex  Medial and Lateral Meniscii  Musculature Bony Support  Medial and Lateral Femoral Condyles  Medial and Lateral Tibial Condyles

4. Case Background 20 year-old male collegiate football tailback MOI: Indirect varus stress placed on the right knee No previous pertinent medical history of lower extremity injury

5. Initial Clinical Evaluation Inspection Palpation Range of Motion Special Tests Initial Treatment?

6. Follow-up Evaluation (12 hours later) Swelling had increased dramatically in the ipsilateral foot and knee Obvious drop foot noted Range of Motion  Knee  Ankle Inability to actively dorsiflex or evert right ankle Decreased right LE sensation (+) Tinel’s Sign

7. Physician Evaluation (36 hours post-injury) Athlete was evaluated by a team physician who confirmed the diagnosis of Grade III ACL and LCL sprains MRI was immediately ordered due to the patient’s right lower extremity neurological signs and symptoms Referral to Second Physician

8. Diagnostic Tests Plain Radiographs Magnetic Resonance Imaging EMG / Nerve Conduction Velocity Study

9. Differential Diagnosis Subluxed Tibiofemoral Joint Cryotherapy-Induced Neuropraxia Transected Common Fibular Nerve Fibular Nerve Contusion Fibular Head Fracture Posterior Cruciate Ligament Tear Medial and/or Lateral Meniscal Tear Biceps Femoris Rupture / Strain Acute Anterior Compartment Syndrome?

10. Diagnosis Final Diagnosis  Grade III Anterior Cruciate Ligament Sprain  Grade III Lateral Collateral Ligament Sprain  Tear of the Posterior Horn of the Lateral Meniscus  Posterior Lateral Complex Disruption  Common Fibular Nerve Injury  Biceps Femoris Strain  Medial Femoral Condyle Contusion  Medial Tibial Plateau Microfracture  Grade I/II Posterior Cruciate Ligament Sprain

11. Treatment Initial Treatment  Cryotherapy  NWB Gait  Straight Leg Immobilizer (locked in 0 degrees)  Pre-surgical Rehabilitation Surgical Fixation  ACL Repair using BTB Patellar Tendon Graft  Lateral Collateral Ligament Reconstruction – Anterior Tibialis Allograft  Common Fibular Nerve Debridement  Posterior Lateral Complex Repair

12. Initial Post –Surgical Rehabilitation Placed in a motion-restricting full leg brace which was locked at 30 degrees of flexion for the first 2 weeks after surgery Non-weight bearing gait for 6 weeks after surgery Rehabilitation focused on guarded ROM, hamstring and quadriceps strengthening Biofeedback and Russian Current to promote anterior tibialis and fibularis tertius strengthening Passive stretch of the posterior lower leg muscles

13. Physician Follow-up Athlete was prescribed a non-hinged AFO brace 6 weeks post- surgery Athlete was prescribed an ACL valgus unloader brace 10 weeks post-surgery

14. Rehabilitation Treatment focused on:  Knee flexion and extension range of motion  Quadriceps and Hamstring Strengthening  Lower Extremity Proprioception Training  Functional Right Lower Extremity Activities The athlete was cleared for jogging as tolerated 5 ½ months post-surgery Complications:  Inability of patient to actively dorsiflex right ankle  Limitation of functional right ankle range of motion due to bracing

15. Current Status One year post-injury, the athlete demonstrates full function of his right knee He continues to demonstrate paresthesia over the dorsum of the right foot and foot drop on the right Recent NCV study demonstrates little to no increase in conduction across the common fibular nerve

16. Uniqueness of This Case Mechanism of injury Complexity and number of structures involved Rare incidence of fibular nerve involvement during knee ligamentous injury

17. Relevance to Athletic Training Reinforces the importance of completing thorough clinical evaluations Requires athletic trainers to think outside the box in terms of complex structural involvement with a common MOI Reinforces the importance of athletic trainers being creative during the rehabilitation process

18. Thank You! Any Questions?