Fahad Fahad zakwanzakwanMD5MD5

one of the most commonly injured one of the most commonly injured jointsjointslack of bony and muscular supportlack of bony and muscular supportpositioned between the 2 longest positioned between the 2 longest bonesbones

weight bearing and locomotion weight bearing and locomotion functionsfunctions

1.1. ACUTE KNEE ACUTE KNEE INJURIESINJURIES

2.2. OVERUSE KNEE OVERUSE KNEE INJURIESINJURIES

ACUTE KNEE INJURIESACUTE KNEE INJURIES1.1. Anterior cruciate ligament (ACL) injuryAnterior cruciate ligament (ACL) injury2.2. Posterior cruciate ligament (PCL)injuryPosterior cruciate ligament (PCL)injury3.3. Medial Collateral ligament (MCL) InjuryMedial Collateral ligament (MCL) Injury4.4. Lateral collateral ligament (LCL) injuryLateral collateral ligament (LCL) injury5.5. Meniscal injuriesMeniscal injuries6.6. OSTEOCHONDRAL PROBLEMSOSTEOCHONDRAL PROBLEMS7.7. Patellar dislocation/instabilityPatellar dislocation/instability

1. Anterior cruciate ligament (ACL) 1. Anterior cruciate ligament (ACL) injuryinjuryMost are non-contact Most are non-contact

injury, 2injury, 2° to deceleration ° to deceleration forces or hyperextensionforces or hyperextension

Planted foot & sharply Planted foot & sharply rotating rotating

If 2° to contact, may If 2° to contact, may have associated injury have associated injury (MCL, meniscus)(MCL, meniscus)

FemalesFemales playing playing soccersoccer, , gymnasticsgymnastics and and basketballbasketball are at highest risk are at highest risk

Risk of injury Risk of injury 2 – 8 times 2 – 8 times ↑ in women↑ in women~250,000 injuries/year in general population~250,000 injuries/year in general populationGender difference not clearGender difference not clear

Joint laxity, limb alignmentJoint laxity, limb alignmentNeuromuscular activationNeuromuscular activation

HxHx::Hearing or feeling a “pop” & knee gives Hearing or feeling a “pop” & knee gives wayway

Significant swelling quickly (< 1 hour)Significant swelling quickly (< 1 hour)UnstableUnstable↓ ↓ range of motion (ROM)range of motion (ROM)Achy, sharp pain with movementAchy, sharp pain with movement

PEPE::Large effusion, Large effusion, ↓ ROM↓ ROMDifficult to bear weightDifficult to bear weightPositive anterior Positive anterior

drawerdrawerPositive Lachman’s Positive Lachman’s

Imaging:Imaging:X-ray alwaysX-ray alwaysMRIMRI

The left ACL has been The left ACL has been torn for over 10 yrs. torn for over 10 yrs.

while the right knee had while the right knee had an ATL tear just for one an ATL tear just for one

monthmonth

MRI

TreatmentTreatment::RICERICEHinged knee braceHinged knee braceCrutchesCrutchesPain medicationPain medicationRehabilitationRehabilitationAvoid most activities Avoid most activities

(stationary bike o.k.)(stationary bike o.k.)Surgery (in most cases)Surgery (in most cases)

RICERICE•RESTREST: reduce/stop using injured : reduce/stop using injured area for at least 48hrs. If you have area for at least 48hrs. If you have leg injury, you may need to stay leg injury, you may need to stay off of it completely.off of it completely.•ICEICE: put an ice pack on the : put an ice pack on the injured area for 20 min at a time, injured area for 20 min at a time, 4-8× a day.4-8× a day.•COMPRESSIONCOMPRESSION: compression of : compression of an injured ankle may help to an injured ankle may help to reduce swelling. These include reduce swelling. These include bandages such as elastic wraps or bandages such as elastic wraps or splints.splints.•ELEVATIONELEVATION: keep the injured : keep the injured area elevated above the level of area elevated above the level of the heart.the heart.

PrognosisPrognosis::Usually an isolated injuryUsually an isolated injuryPost-op: 8-12 months until full activityPost-op: 8-12 months until full activity

ReferralReferral::Almost all young, athletic patients will prefer Almost all young, athletic patients will prefer

surgical reconstructionsurgical reconstruction?Increased risk of DJD if not treated?Increased risk of DJD if not treatedCan still get DJD if reconstructedCan still get DJD if reconstructed

Posterior cruciate ligament Posterior cruciate ligament (PCL)injury(PCL)injuryMxnMxn: :

hyperflexionhyperflexionfalling on bent knee with foot plantar flexedfalling on bent knee with foot plantar flexedHit on fixed anterior tibiaHit on fixed anterior tibia

S/S: S/S: ““pop” at the back of kneepop” at the back of kneeswelling in popliteal fossaswelling in popliteal fossa+ posterior sag test, +sunrise test, + posterior + posterior sag test, +sunrise test, + posterior

drawer testdrawer test

TxTx::RICERICEImmobilizationImmobilizationCrutchesCrutchesPhysician referralPhysician referral6-8 weeks rest/rehab6-8 weeks rest/rehabIf surgery is elected, 6 weeks If surgery is elected, 6 weeks immobilizationimmobilization

Stress testsStress testsPosterior sagPosterior sag

Strest testsSunrise or Sunrise or posterior sagposterior sag

3. Medial Collateral ligament (MCL) 3. Medial Collateral ligament (MCL) InjuryInjuryImportant in resisting Important in resisting

valgus movementvalgus movementCommon in contact Common in contact

sports, i.e. football, soccersports, i.e. football, soccerHit on outside of knee Hit on outside of knee

while foot plantedwhile foot plantedAssociated injuries Associated injuries

common, depending on common, depending on severityseverity

HxHx::Immediate pain over medial kneeImmediate pain over medial kneeWorse with flexion/extension of kneeWorse with flexion/extension of kneePain may be constant or present with Pain may be constant or present with movement onlymovement only

Knee feels ‘unstable’Knee feels ‘unstable’Soft tissue swelling, bruisingSoft tissue swelling, bruising

PEPE::no effusionno effusionmedial swellingmedial swellingpain with flexionpain with flexiontender over medial femoral tender over medial femoral

condyle, proximal tibiacondyle, proximal tibiaValgus stress at 0Valgus stress at 0° & 30° → ° & 30° →

PAIN, possible laxityPAIN, possible laxity

ImagingImaging::obtain radiographs to r/o fractureobtain radiographs to r/o fractureMRI if other structures involved or if unsure of diagnosisMRI if other structures involved or if unsure of diagnosis

TreatmentTreatment: Grade I: Grade I→no laxity @ 0°or →no laxity @ 0°or 30°30°

Grade IIGrade II→no laxity @ →no laxity @ 0°,but 0°,but lax @ 30° lax @ 30° RICERICE Hinged-knee brace (Grade II)Hinged-knee brace (Grade II) CrutchesCrutches Aggressive rehabilitationAggressive rehabilitation NSAIDsNSAIDs

Treatment:Treatment: Grade III Grade III → lax @ 0° & 30°→ lax @ 0° & 30° Same as aboveSame as above Consider Orthopedic referralConsider Orthopedic referral

PrognosisPrognosis::Grade I -- 10 daysGrade I -- 10 daysGrade II -- 3-4 weeksGrade II -- 3-4 weeksGrade III -- 6-8 weeksGrade III -- 6-8 weeks

When to refer:When to refer:Other ligamentous injuries (surgical)Other ligamentous injuries (surgical)Severe MCL injurySevere MCL injuryNot progressing as expectedNot progressing as expected

ComplicationsComplicationsThe terrible triad or unhappy The terrible triad or unhappy triadtriadTorn ACLTorn ACLTorn MCLTorn MCLTorn Medial meniscusTorn Medial meniscus

4. Lateral collateral ligament 4. Lateral collateral ligament (LCL) injury(LCL) injuryMxnMxn: :

Varus force to medial aspect of knee Varus force to medial aspect of knee internal rotation of tibiainternal rotation of tibia

S/SS/S: : POT over LCL, POT over LCL, pain, pain, swelling, swelling, loss of motion, loss of motion, ““+” varus stress at 30 degrees—solid endpoint with 1+” varus stress at 30 degrees—solid endpoint with 1stst degree, less degree, less

stability but solid endpoint with 2stability but solid endpoint with 2ndnd degree, no endpoint with 3 degree, no endpoint with 3rdrd degree degreeif “+” varus stress at 0 degrees flexion suspect ACL or PCL injury as wellif “+” varus stress at 0 degrees flexion suspect ACL or PCL injury as well

Tx:Tx:RICERICECrutchesCrutchesKnee immobilizerKnee immobilizerPhysician referral with 2Physician referral with 2ndnd or 3 or 3rdrd degreedegree

5. Meniscal injuries5. Meniscal injuriesMeniscus = ‘little Meniscus = ‘little

moon’ in greekmoon’ in greekAbsorbs shock, Absorbs shock,

distributes load, distributes load, stabilizes jointstabilizes joint

Thick at periphery Thick at periphery → → thin centrallythin centrally

Lateral Medial

CausesCauses::Sudden twisting Sudden twisting Young athletesYoung athletes

Simple movements Simple movements Older kneeOlder knee

Hx:Hx:Clicking, catching or lockingClicking, catching or lockingWorse with activityWorse with activityTends to be sharp pain at joint Tends to be sharp pain at joint lineline

EffusionEffusion

PEPE::mild-moderate mild-moderate effusioneffusion

pain with full pain with full flexionflexion

tender at joint linetender at joint line+ McMurray’s+ McMurray’s

McMurray’s Test

Imaging:MRI

TreatmentTreatment::RICERICESurgical repair or Surgical repair or

excision (arthroscopic)excision (arthroscopic)CrutchesCrutchesNSAIDsNSAIDsKnee sleeveKnee sleeveAsymptomatic tears do Asymptomatic tears do

not require treatmentnot require treatment

PrognosisPrognosis::Results of surgical repair/excision are Results of surgical repair/excision are very goodvery good

Return to full activities 2-4 months after Return to full activities 2-4 months after surgery; tends to be quicker for athletessurgery; tends to be quicker for athletes

When to refer:When to refer:Most symptomatic meniscal injuries Most symptomatic meniscal injuries require surgeryrequire surgery

7. Patellar 7. Patellar dislocation/instabilitydislocation/instabilityPatella may dislocate or sublux laterallyPatella may dislocate or sublux laterallyYoung, active patients at highest risk Young, active patients at highest risk

(~ages 13-20)(~ages 13-20)Common in football & basketballCommon in football & basketball♀ ♀ > ♂> ♂Recurrence is common, especially if first Recurrence is common, especially if first

dislocation < 15 yodislocation < 15 yo

Indirect trauma most Indirect trauma most common mechanismcommon mechanismStrong quad contraction Strong quad contraction while leg is in valgus while leg is in valgus and foot plantedand foot planted

Other knee ligament Other knee ligament injuries can occurinjuries can occur

Risk factors:Risk factors:TraumaTraumaPes planusPes planusGenu valgumGenu valgumWeak VMOWeak VMO

Hx:Hx:Feel a ‘pop’ and immediate painFeel a ‘pop’ and immediate painObvious knee deformityObvious knee deformityPainful, difficult to bend kneePainful, difficult to bend kneeMay spontaneously relocate, left May spontaneously relocate, left with feelings of instabilitywith feelings of instability

dislocation

PEPE::Laterally Laterally shifted patellashifted patella

Patellar Patellar apprehensionapprehension

SwellingSwelling

ImagingImaging::Standard knee x-Standard knee x-rays a good startrays a good start

Likely need an MRI Likely need an MRI if injury seems if injury seems significant or significant or associated injuries associated injuries seem possibleseem possible

MRI

Treatment:Treatment:NSAIDSNSAIDSIceIcePatellofemoral knee Patellofemoral knee

brace/rigid bracebrace/rigid bracePTPT

ROM quickly (~ 2week)ROM quickly (~ 2week)Quad strengtheningQuad strengtheningElec. StimElec. Stim

SurgerySurgeryRecurrent instabilityRecurrent instability

PrognosisPrognosisRecurrent instability is common, but Recurrent instability is common, but rehab is mainstay and very usefulrehab is mainstay and very useful

When to referWhen to referAssociated fractureAssociated fracturePoor response to rehabPoor response to rehabMultiple dislocations (#?) & skill levelMultiple dislocations (#?) & skill level

Patella fracturePatella fractureMxnMxn: :

direct impact or trauma to patelladirect impact or trauma to patellaIndirect trauma in which a severe pull of the patellar tendon occurs Indirect trauma in which a severe pull of the patellar tendon occurs

against the femur when the knee if semi-flexedagainst the femur when the knee if semi-flexedS/SS/S: :

hemorrhage which results in significant swelling hemorrhage which results in significant swelling pain pain POT over PatellaPOT over Patellaextreme pain with weight bearing/movementextreme pain with weight bearing/movement

Patella Fracture

Tx: Tx: RICERICEImmobilizeImmobilizeCrutchesCrutchesPossible surgery depending on type of Possible surgery depending on type of fracturefracture

OVERUSE KNEE OVERUSE KNEE INJURIESINJURIES1. Iliotibial band tendonitis1. Iliotibial band tendonitis2. Popliteus tendinitis2. Popliteus tendinitis3. Patellofemoral pain syndrome3. Patellofemoral pain syndrome4. Patellofemoral synovial plica4. Patellofemoral synovial plica5. Infrapatellar fat pad syndrome5. Infrapatellar fat pad syndrome6. Patellar tendonitis6. Patellar tendonitis7. Bursitis7. Bursitis

1. Iliotibial band tendonitis1. Iliotibial band tendonitisExcessive friction Excessive friction

between iliotibial band between iliotibial band (ITB) & lateral femoral (ITB) & lateral femoral condylecondyle

Iliotibial band tendonitis

Common in Common in runners and cyclistsrunners and cyclists

foot pronation, foot pronation, genu varum are risk genu varum are risk factorsfactors

HxHx::Pain at lateral kneePain at lateral kneeAt first, sxs only after a certain At first, sxs only after a certain period of activityperiod of activity

Progresses to pain immediately Progresses to pain immediately with activitywith activity

PE:PE:Tender at lateral Tender at lateral femoral epicondyle, femoral epicondyle, ~3cm proximal to ~3cm proximal to joint linejoint line

Soft tissue swelling Soft tissue swelling & crepitus& crepitus

No joint effusionNo joint effusion

PE:PE:Ober’s testOber’s test

Noble’s testNoble’s test

Noble’s test

Iliotibial band tendonitisTx:Tx:

Relative restRelative restIceIceNSAIDSNSAIDSStretchingStretchingCortisoneCortisonePlatelet-Rich PlasmaPlatelet-Rich Plasma

Iliotibial band tendonitisPrognosis:Prognosis:

Improves with restImproves with restExpect long recovery timeExpect long recovery time

When to refer:When to refer:Intractable painIntractable painSurgery = releaseSurgery = release

2. Popliteus tendinitis2. Popliteus tendinitissurrounds posterolateral aspect of surrounds posterolateral aspect of knee, stabilizer in flexion by resisting knee, stabilizer in flexion by resisting forward displacement of the femur forward displacement of the femur on the tibiaon the tibia

less common but same causes as less common but same causes as itb (d/d)itb (d/d)

discomfort on anterior or superior discomfort on anterior or superior lat.collateral ligament and with resisted lat.collateral ligament and with resisted knee flexion with tibia held in external knee flexion with tibia held in external rotationrotation

- treatment: reduction training - treatment: reduction training distance, NSAIDS, stretching knee distance, NSAIDS, stretching knee flexors, electrotherapy. corticosteroid flexors, electrotherapy. corticosteroid injectioninjection

3. Patellofemoral pain 3. Patellofemoral pain syndromesyndrome

Retropatellar or Retropatellar or peripatellar pain resulting peripatellar pain resulting from physical or from physical or biomechanical changes in biomechanical changes in the patellofemoral jointthe patellofemoral joint

Many forces interact to Many forces interact to keep the patella alignedkeep the patella aligned

Patellofemoral pain syndromePatella not only Patella not only

moves up and down, moves up and down, but rotates and tiltsbut rotates and tilts

Many points of Many points of contact between contact between patella and femoral patella and femoral structures structures

Patellofemoral pain syndromeHx:Hx:

Vague anterior knee pain with insidious onset Vague anterior knee pain with insidious onset Common cause of anterior knee pain in womenCommon cause of anterior knee pain in womenTend to point to front of knee when asked to localize Tend to point to front of knee when asked to localize

painpainWorse with certain activities, i.e. ascending or Worse with certain activities, i.e. ascending or

descending hills & stairsdescending hills & stairsPain with prolonged sitting Pain with prolonged sitting → theater sign→ theater signNo meniscal or ligamentous sxsNo meniscal or ligamentous sxs

Patellofemoral pain syndromePE:PE:

Positive compression testPositive compression testPatellar crepitus with ROMPatellar crepitus with ROMMild effusion possibleMild effusion possibleMay see tenderness with May see tenderness with

patella facet palpation patella facet palpation → → medial, lateral, superior, medial, lateral, superior, inferiorinferior

Remainder of knee exam Remainder of knee exam unremarkableunremarkable

Patellofemoral pain syndrome

PE:PE:Check Check hamstring hamstring flexibility flexibility

Patellofemoral pain syndromePE:PE:

Check for flat feet (pes planus) or high-arch feet (pes Check for flat feet (pes planus) or high-arch feet (pes cavus)cavus)

Pes Planus Pes Cavus

Patellofemoral pain syndromePE:PE:

Check heel cord (achilles) flexibilityCheck heel cord (achilles) flexibilityCheck for a tight iliotibial band (ober’s test)Check for a tight iliotibial band (ober’s test)

Ober’s test Achilles stretch

Patellofemoral pain syndromeTx:Tx:

Physical therapyPhysical therapyImprove flexibilityImprove flexibilityQuad strengthening, Quad strengthening,

especially VMOespecially VMOOther modalities, i.e. soft Other modalities, i.e. soft

tissue release, U/Stissue release, U/SPatellar tapingPatellar taping

Patellofemoral pain syndromeTx:Tx:

Relative rest/Modification Relative rest/Modification of activitiesof activities

IcingIcingNSAIDSNSAIDSPatellar bracesPatellar bracesAddressing foot problems Addressing foot problems

with foot wear and with foot wear and orthoticsorthotics

SurgerySurgery

4. Patellofemoral synovial 4. Patellofemoral synovial plicaplica- REMNANTS OF THE SEPTA OF EMBRYONIC JOINT.

USUALLY PRESENT BUT ASYMPTOMATIC- SYMTOMATIC PLICA: MEDIAL PATELLAR PLICA

RUNS FROM SUPRAPATELLAR POUCH TO THE INFRAPATELLAR FAT PAD MAY IMPINGE OF THE MEDIAL FEMORAL CONDYLE AND PFJ IN FLEXION

4) PF SYNOVIAL PLICA- ACHING ON SITTING DOWN ANTERIORLY, INTENSE

THE FIRST WALKING STEPS IN THE MORNINGO/E: FELT BANDS, MEDIALLY, MILD EFFUSION, PAIN

ON RESISTED KNEE EXTENSION MADE WORSE BY GLIDING PATELLA MEDIALLY

- TREATMENT: REST, NSAIDS, CORTICOSTEROID INJECTION IF MEDIAL PLICA PALPABLE. ARTHRO. EXCISION

5. Infrapatellar fat pad 5. Infrapatellar fat pad syndromesyndromerepetitive hyperextention injuries, repetitive hyperextention injuries, surgical interventionsurgical intervention

pain on hyperextention over anterior pain on hyperextention over anterior knee regionknee region

part of patella baja: shorter patellar part of patella baja: shorter patellar tendon from fibrosis (? previous tendon from fibrosis (? previous surgery) blocking knee flexionsurgery) blocking knee flexion

5) INFRAPATELLAR FAT PAD SYNDROMEtreatment:treatment:rest from hyperextention (martial rest from hyperextention (martial arts ) , NSAIDS, electrotherapy. arts ) , NSAIDS, electrotherapy.

significant fibrosis: arthroscopic significant fibrosis: arthroscopic excisionexcision

6. Patellar tendonitis6. Patellar tendonitisAlso called “jumper’s knee”Also called “jumper’s knee”Mxn: Mxn:

excessive running, jumping or kicking causing extreme tension excessive running, jumping or kicking causing extreme tension of the knee extensor muscle complexof the knee extensor muscle complex

S/S: S/S: Pain at the patellar tendonPain at the patellar tendonPOT over the distal pole of patellaPOT over the distal pole of patellaPain increases with activityPain increases with activityThickening of tendon Thickening of tendon crepituscrepitus

TXTX: : RestRestIce Ice HeatHeatUltrasoundUltrasoundCross-friction massageCross-friction massageNSAIDSNSAIDSPatellar tendon strap/tapingPatellar tendon strap/tapingModify activityModify activity

7. Bursitis7. BursitisCan be acute, chronic, or recurrentCan be acute, chronic, or recurrentNumerous bursae involved but Numerous bursae involved but most commonly injured are the most commonly injured are the prepatellar or the deep infrapatellarprepatellar or the deep infrapatellar

BursitisMxn: Mxn: falling directly on kneefalling directly on kneeContinuous kneeling Continuous kneeling Overuse of patellar tendonOveruse of patellar tendon

BursitisS/S: S/S:

Localized swelling that is similar Localized swelling that is similar to a water balloon and is outside to a water balloon and is outside the knee jointthe knee joint

Pain especially with pressurePain especially with pressure

Bursitis

Bursitis

BursitisTx: Tx:

Rest Rest Ice Ice Compression Compression NSAIDSNSAIDSPadding for protection when returning to Padding for protection when returning to activityactivity

Vascular InjuryVascular Injury~20% (5-30%) of all ~20% (5-30%) of all

dislocationsdislocationsEMERGENCY if NO distal EMERGENCY if NO distal

perfusionperfusionPatterns of Vascular injuryPatterns of Vascular injury

• rupturerupture• incomplete tearincomplete tear• intimal injury (may cause intimal injury (may cause

thrombosis)thrombosis)

Neurologic InjuryNeurologic InjuryCommon Common peroneal nerve peroneal nerve palsypalsy

Incidence ~20% (10-40%)Incidence ~20% (10-40%)Most Common with varus Most Common with varus injuryinjury

PROGNOSIS is POORPROGNOSIS is POORComplete recovery ~ 20%Complete recovery ~ 20%