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March 8 - knee.doc

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Physical Education and Sport
Brad Kern

March 8 – Knees Recognition and Management of Specific Injuries Medial Collateral Ligament Sprain Cause of injury: result of severe blow or outward twist – valgus force Signs of Injury – grade 1 • Little fiber tearing or stretching • Stable valgus test but there will be some pain • Little or no joint effusion • Some joint stiffness and point tenderness on medial joint line aspect of the knee • Relatively normal ROM with a grade 1 MCL sprain Signs of Injury – Grade 2 • Complete tear of deep capsular ligament and partial tear of superficial layer of MCL • No gross instability; slight laxity • There will be little or no joint effusion • Slight swelling • Depending on swelling, there will be Moderate to severe joint tightness with decreased ROM • Joint effusion inside the knee will affect the ability to extend that leg more than the ability to flex the leg. When you have that joint effusion, you will see the capsular pattern and extension will be limited. • Pain along medial aspect of knee Signs of Injury – grade 3 • Complete tear or supporting ligaments • Complete loss of medial stability, meniscus disruption • Minimum to moderate swelling • Immediate pain followed by ache • Loss of motion due to effusion and hamstring guarding • Positive valgus stress test. There will be no pain because the ligament is torn. Care • RICE or PRICE (P stands for protection) for at least 24 hours • If there is a grade 2 sprain, you will be pulling on those already ripped fibers. In hockey when you are striding, you are creating a valgus force and you will feel a sharp pain if the MCL is injured • We want to progress from isometric exercises to straight leg raise exercises • After straight leg raises, you can go into bike riding and isokinetics (where ROM is controlled an resistance is set) • Crutches if necessary • Knee immobilizer may be applied • Move from isometrics and STLR exercise to bicycle riding and isokinetics • Return to play when all areas have returns to normal (continued bracing may be required) • Conservative non-operative approach for isolated grade 2 and 3 injuries • Limited immobilization (with a brace); progressive weight bearing for 2 weeks • Follow with 2-3 week period of protection with functional hinge brace • When normal range, strength, power, flexibility, endurance and coordination are regained athlete can return (some additional bracing and taping may be required) Lateral Collateral Ligament Sprain Cause of Injury • Result of a varus force, generally with the tibia internally rotated • Direct blow is rare Signs of Injury • Pain and tenderness over LCL • Swelling and effusion around the LCL • Joint laxity with varus testing Care • Following management of MCL injuries depending on severity Anterior Cruciate Ligament Sprain Cause of Injury • MOI – athlete decelerates with foot planted and turns in the direction of the planted foot forcing tibia into internal rotation • May be linked to inability to decelerate valgus and rotational stresses – landing strategies • Male vs. Female injury rates • Research is quite extensive in regards to impact of femoral notch, ACL size and laxity, malalignments (Q-angle) faulty biomechanics • Extrinsic factors may include conditioning, skill acquisition, playing style, equipment, preparation time • Most common MOI is deceleration in direction to the planted foot • Also involves damages to other structures including meniscus, capsule, MCL Signs of Injury • Experience pop with severe pain and disability • The pain will eventually subside • Rapid swelling at the joint line. We want to assess this injury within 10 minutes • Will present a Positive anterior drawer and Lachman’s tests • Other ACL tests may also be positive Care • RICE; use of crutches, if there are stability issues • Arthroscopy may be necessary to determine extent of injury • Could lead to major instability in incidence of high performance • Without surgery, joint degeneration may result • Age and activity may factor into surgical option • We need an ACL for a young kid to effectively play sports • An older person who tears their ACL may just do rehab • Surgery may involve joint reconstruction with grafts (taken from the tendons of the hamstring), transplantation of external structures • This will require brief hospital stay and 3-5 weeks of a brace • Also requires 4-6 months of rehab Posterior Cruciate Ligament Sprain Cause of Injury • Most at risk during 90 degrees of flexion • Fall on bent knee is most common MOI • Can also be damaged as a result of rotational force • Most common injury of ligaments is PCL injury • The quads assist the PCL. There are athletes who don't have a PCL Signs of Injury • Feel a pop in the back of the knee • Tenderness and swelling in the popliteal fossa • Laxity with posterior sag test. Posterior sag is where someone lies on the back make them do 90 degree knee flexion. If the tibial tuberosity sags, that is a positive sign of a PCL injury Care • RICE • Non-operative rehab of grade 1 and 2 injuries should focus on quad strength • Surgical versus non-operative care Meniscus Injuries
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