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The Common Knee Injuries Experience by Professional Sportsmen
- 2. Why is this topic important? The common knee injuries and management Some anatomy Epidemiology Meniscal injuries ACL injuries PCL injuries Medial Collateral Conclusions (Visual!) Quiz
- 3. To the group: Sports injuries 10-20% of ED acute injuries Most commonly knee and ankle Impact on health, life, economy Chance to consider knee anatomy & examination To me: Personal interest
- 5. Few studies BUT UK professional rugby players: Part of knee injured Prevalence (%) Meniscal 18.5 ACL 4.3 PCL 3 Medial collateral 28.9 Patellofemoral 12.3 Other (minor) 33 Adapted from Dallana et al 2007
- 6. Presentation: Immediate vs. longer duration Symptoms: Pain, locking, clicking O/E: locking (McMurray’s test), effusion, joint line tenderness, palpable meniscal cyst Diagnosis: clinical, (MRI, arthroscopy)
- 7. Mechanism of injury: Landing/twisting with knee flexed (associated with ACL tear) Management : Conservative – RICE & early physio Surgical – Arthroscopic repair, resection
- 8. Presentation: Acute traumatic vs. present long after with unstable knee Symptoms: ‘pop’, ‘something goes’, pain, instability O/E: swelling (hours), tense effusion, +ve anterior drawer, Lachmann’s, pivot shift Diagnosis: clinical, (MRI, EUA, arthoscopy)
- 9. Mechanism of injury: twisting/valgus strain with foot fixed (medial collateral, meniscal association) Management: Conservative - RICE and physio Surgical – unstable knee/sportsmen – arthroscopic hamstring tendon graft
- 10. Usually rare & less common than ACL Symptoms: ‘pop’, ‘something goes’, pain, less instability O/E: swelling (less than ACL), posterior sag, +ve posterior drawer Diagnosis: clinical, (MRI, arthoscopy)
- 11. Mechanism of injury – front on impact forcing tibia backwards/hyperextension Management: Conservative – RICE and physio – almost all Surgical – if combined injuries/knee unstable
- 12. Common – isolation or with ACL Symptoms – ‘something goes’, pain, instability O/E – NO effusion (extra-articular), tender over MCL, joint opening on valgus stress
- 13. Mechanism of injury – valgus strain (hence commonly with ACL) Management: Conservative – brace and physio 6/52 Surgical - other injuries or chronic unstable MCL
- 14. Knee injuries common in sportsmen and ED injury admissions Diagnosis predominantly clinical – history (mechanism of injury) and examination More than one ligament often injured Treatment – surgery usually required for sportsmen
- 15. Valgus Twist
- 18. Gray’s Anatomy for students Dallalana, R.J., Brooks, J.H., Kemp, S.P., and Williams, A.M. The epidemiology of knee injuries in English professional rugby union. American Journal of Sports Medicine 2007. 35(5) :p818-830. http://www.orthopedicsurgerybook.com/Images/knee-menisucus-tear-surgery.jpg http://www.empowher.com/condition/anterior-cruciate-ligament-injury ACL pic http://www.kneejointsurgery.com/html/ligament/acl.html http://bestpractice.bmj.com/best-practice/monograph/575.html http://www.sportsdoc.umn.edu/Patients_Folder/Knee/pcl%20recon/PCLreconstruction http://www.wheelessonline.com/image6/pcl2.jpg http://www.easyfizzy.co.il/image/users/46789/ftp/my_files/medollig.gif http://blog.oregonlive.com/pac10/2007/10/large_Patcowan.jpg http://seanlaceystrengthandconditioning.wordpress.com/ http://www.kneejointsurgery.com/html/ligament/acl.html http://www.mountsinai.org/patient-care/service-areas/bone-joint-and- spine/areas-of-care/orthopaedic-knee
Editor's Notes
- Look at epi, consider some of these common knee injuries and a bit about their management”
- Health – current state and future – studies show 50% have OA radiographic changes at 10 years. Extrapolate – almost all have at 15-20 (seen studies where rate is certainly 80%). And no one has shown surgical patients do better (but no RCT). Economy - Home and leisure, sport, and occupational accidents combined make a major contribution (86%) of the total hospital costs of injury in Europe. Personal interest – sports and careers which may deal with them (A+E, orthopod, sports medicine) “This includes clearly pointing out that ACL surgery can only be expected to improve knee stability, but that ACL surgery does little or nothing to secure a future healthy knee.”
- Left knee ACL – attaches to a facet on ant part of intercondylar area of the tibia and asscends posteriorly to attach to facet at the back of the lateral wall on intercondylar fossa of femur. Prevents anterior displacement of tibia relative to the femur PCL - attaches to a post aspect of intercondylar area of the tibia and asscends anteriroly to attach to medial wall of the intercondylar fossa of femur. Prevents posterior displacement of tibia relative to the femur Collaterals - one on each side and they stabilise the hinge like motion of the knee Lateral – cord like – lateral femoral epicondlye to the lateral surface of the fibular head Medial – broad and flat – attached to underlying fibrous membrane (lateral separated by a bursa) – anchored to medial femoral epiocondly superiorly and medial margin and medial surface of tibia inferiorly Menisci – 2 – lateral and medial fibrocartilaginous c shaped cartilages – med and lat. Both attached at each end to facets in intercondylar region of the tibial plateau. Medial also attached around its margin to joint capsule, lateral isnt and therfore more mobile. Often said to act as ‘schock absorbers’ they improve the coming together between fem/tib condyles during joint movements as the fem condyles change from small curved surfasces in flexion to large flat surfaces in extension. (disperse body wt and reduce friction)
- Several injury surveillance systems collect data on the epidemiology of injuries in a number of sports across the world7,24,26; however, only the Australian Football League (AFL)40-42 and the National Collegiate Athletic Association (NCAA)4 injury surveillance systems have published detailed information on knee injuries. In rugby union, several studies have reported that injuries to the knee, in particular anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries, represent a disproportionate number of severe injuries and subsequent absence in collegiate women30 and in amateur48 and professional5,9-11,49 male players; however, the reviews of knee injuries in male rugby players have not been comprehensive.
- Function – “shock absorbers” Immediately after injury (painful & locked) vs months/years chronic nag (minor) – diff types/positions of tears manifest diff sx Large effusion v. Periph tear with lots of bleeding, small chronic MRI – confirm, partic if dubious Hx. Arthroscopy most accurate
- Medial meniscus attached around margain to capsule of joint and to tib collat lig. Lat menisc unattached to capsule – more mobile. Medial therfore more commonly injured. http://www.youtube.com/watch?v=oHgu5e9K3Ww – owen Peripheprahl bucket handle – retains meniscus (peripheral=vasc and can heal, further in cannot) Resection – reduces mechanical pain from unstable frag in ST and dull ache inflamm changes from reaction to loose fibrocart, increases OA in long term – increased load on artic surface
- Gives way – particularly when trying to turn rapidly – classically can run in straight line, but cant twist or turn. Swells almost immediately as ACL more vascular than menisci which swells over 24 hours Ant drawer – standard one we have been taught Lachmann’s – best for ACL deficiency – brings tibia forward on fixed femur. Flex knee to 30, thumbs pointing toward hip, one hand over prox tib and stabilse femur with other – lift tib to see if abnormal forward movement Pivot shift test – hard to perform – flexed knee held in int rotation with valgus force applied. As knee comes from flexion to extension at about 15degrees tibia jumps forward to subluxed posit – shows how ACL deficient knee gives way MRI or EUA to confirm if diff to elicit positive examination findings.
- Conservative – some can mod activities and manage with hamstring rehab alone. NOT professional sportsman Women increased risk compared to men ACL size; knee joint laxity; standing posture, foot pronation (�dropped arch�), misalignment of the lower extremity, and pelvic position; and hormonal variations. Furthermore, they have explored shoe-surface interaction; playing surface; skill level; level of conditioning, muscle strength, and altered neuromuscular controls. With regard to environmental, anatomical and hormonal risk factors, there is no conclusive evidence that any one single risk factor correlates directly with an increase in ACL injury in female athletes. Therefore, the emphasis has turned to biomechanical risk factors and the use of neuromuscular and proprioceptive intervention programs to address potential biomechanical deficits. Surgical (wiki) If the tear is severe, surgery may be necessary because the ACL can not heal independently because there is a lack of blood supply going to this ligament. Surgery is usually required among athletes because the ACL is needed in order to perform sharp movements safely and with stability. The surgery of the ACL is usually done several weeks after the injury in order to allow the swelling and inflammation to go down. During surgery the ACL is not repaired instead, it is reconstructed using other ligaments in the body. There are three different types of ACL surgery. Patella tendon-bone auto graft and hamstring auto graft are the most common and preferred and tend to produce the best results. For the Patella tendon-bone auto graft, the central 1/3 of the patella tendon is removed along with a piece of bone at the attachment sites on the kneecap and tibia. The advantages of using this method is that the patella tendon and ACL are relatively the same length and it uses a bone to bone attachment which most surgeons agree is much stronger than other healing methods. Disadvantages of this method is common anterior knee pain due to the removal of bone from the kneecap. For the hamstring auto graft, two tendons are taken from the hamstring muscles and wrapped together forming the new ACL. Advantages of this method are less pain associated with post surgery healing than that of the patella tendon-bone graft due to the fact no bone was removed and the incision is small. Disadvantages of this method is that it takes longer to heal since there is no bone to bone healing and the tendon to bone takes awhile to become rigid.[14] After the surgery, rehabilitation is required in order to strengthen the surrounding muscles and stabilize the joint.
- PCL is stronger/thicker Perhaps more common here due to nature of rugby – potential for direct impact to front of the tibia in a tackle Posterior drawer – same as ant but push backwards
- Goalkeeper’s injury, knee hit dashboard and tibia forced posteriorly Not uncommon to have pro rugby players who are PCL deficient
- Surgical – often focused on other injury repair – ACL etc For higher grade tears of the MCL with ongoing instability, the MCL can be sutured or replaced. Other non-surgical approaches for more severe MCL injuries may include prolotherapy (Prolotherapy is also known as "proliferation therapy" or "regenerative injection therapy." ("Proliferative Injection Therapy") involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain. E.g. Dextrose solution), which has been shown by Reeves in a small RCT to reduce translation on KT-1000 arthrometer versus placebo Best Px out of them all as extrarticular so assuming it is sole injury and good recovery – shouldnt cause OA
- Mechanism of injury? Valgus stress and twisting of knee with fixed foot Likely injury? ACL (and MCL damage) Examination findings? ACL - swelling (hours), tense effusion, +ve anterior drawer, Lachmann’s, pivot shift MCL - NO effusion (extra-articular), tender over MCL, joint opening on valgus stress
- Mechanism of injury? Front on impact, forcing tibia backwards against (forward moving) femur Likely injury? PCL Examination findings? swelling (less than ACL), posterior sag, +ve posterior drawer