This document outlines various practical issues related to the knee in professional sports. It discusses general issues like assembling a multidisciplinary team and interpreting scans. It then covers non-operative interventions like hyaluronic acid injections and PRP injections. Specific injuries like ACL tears, MCL injuries, meniscal tears, and osteochondral defects are discussed. Treatment options and rehabilitation protocols are provided for each condition.

1. Outline
The Sporting Knee: • General issues in sport
• Diagnosis
Practical Issues • Non operative interventions
• ACL
Dr Mark Gillett • MCL
Head of Medical Services WBA FC
• In season meniscal injury
Head of Science & Medicine British Basketball • OCDs
Consultant Physician HEFT • MRI -ve AKP
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Issues In Professional Sport Generic Issues
• Players • Cohesive MDT essential
• Agents • All opinions have validity- the “specialist’
• Executives cannot always see the whole picture
• Lay perceptions • There are no easy solutions. A jigsaw
• Confounding issues: contracts, team needs to be put together and sound
selection judgment exercised.
• Time scales • Sometimes you will get it wrong
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Non Operative Interventions-
Interpreting Scans
The Sports Physician
• Examine the player • Hyalgans- Ostenil, Durolane
• See the scans yourself • Steroids- short (hydrocortisone) v long
• Discuss the scan with the radiologist (Kenalog, Depo-medrone)
• Only after evaluating all 3 viewpoints can • PRP injections
you make a definitive call • Traumeel
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2. Hyalgans • Hyaluronan is a high molecular weight biopolymer which
is present in many of our tissues as an important
component of the extracellular matrix
• “The oil”
• In the joint cartilage, hyaluronan is the backbone of the
• Most useful in joint with early degeneration proteoglycans, which - together with collagen fibers -
or OCD treated conservatively forms a matrix, in which the chondrocytes are
embedded. Hyaluronan, at the same time, provides
• Don’t expect to much- it’s a few %. viscosity to the synovial fluid for its shock absorbing and
lubricating properties. It furthermore acts as a molecular
• May achieve more if combined with rest
sieve (picture) and coats the pain receptors
and active recovery • Upgrading the concentration and the molecular weight
in the synovial fluid by intra-articular administration of
exogenous hyaluronan (called viscosupplementation).
•
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PRP Injections PRP Science
• Commonly used in MCL injuries • MSK tissue repair begins with formation of
• Now permitted by WADA for injection into a blood clot and platelet degranulation
ligaments but not acute muscle injuries • A variety of growth factors are released
• Status with PMI providers currently under which are beneficial for soft tissue and
review bone healing
• Blood taken and centrifuged to isolate
platelets
• Inject supernatant into injury site
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Traumeel ACL Disruption
• Inflammatory regulatory drug • This is a functional diagnosis- ACL
• Mixture of 14 homeopathic substances deficient v ACL competent
including Arnica and Echinacea • Assessment pitch side often difficult
• Not found it useful for intra-articular • Beware lateral sided pain
disorders • Signs can evolve over 24 hours
• Can be useful in soft tissue disorders
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3. Investigations Reconstruction Options
• MRI usually conclusive • Ipsilateral BPB
• Beware of who reports scans, especially if • Ipsilateral ST
a partial tear is reported • Contralateral BPB
• Beware when scanning in different • Double bundle reconstruction
environment especially overseas • Modified Macintosh repair
• Cadaver graft
• Which is best?
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Bone-Patellar- Bone Autograft Semitendinosis +/- Gracilis Autograft
• Fail at 2900 N (normal ACL fails 1725 N) • Tendon harvested from same incision site
• Stable secure bone plugs at femoral and • Less risk AKP
tibial ends • Long term hamstring weakness not
• Disadvantages- potential AKP and normally an issue
difficulty attaining full extension • Weaker than BPB graft with ST failing at
1200 N and gracilis at 860 N
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Cadaver Allograft Double Bundle Reconstruction
• Out of favour • Aims to replicate native anatomy
• Risk of infection • AM- taut throughout full range knee
motion should control ant translation
• PL- taut towards extension better controls
rotation
• Conflicting results in literature
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4. Trends In Rehab Choosing Your Surgeon
• 6 months • Be aware of their style of consultation
• Highest risk of rupture during initial 4-6 • The polished performers
weeks when the graft necroses, • Always positive
revascularises and remodels. • Sport- nothing different
• Blunt
• Know the style to suit your purpose
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MCL Injuries
• Valgus injury very common • High grade MCL injury- may need surgical
• High grade injuries will need cast bracing reconstruction
at approximately 30 degrees short of full • Lower grade injuries unlikely to create long
extension. term issues if early extension
• Is cast bracing needed to prevent long
term instability?
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• Early stage rehab in sport relatively • High incidence of acute muscle injury in
uncomplicated games immediately following return from
• Notorious for pain in end stage rehab MCL injury
when multi- directional activity is
commenced and progressed
• Early PRP injection
• Early v Late steroid injection
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5. Meniscal Injury In Season Management
• Athletes will have meniscal degeneration • Off load
on MRI • Is there an associated OCD?
• MRI is not as helpful for in the evaluation • Is it the lateral or medial causing the
of meniscal injury as it is in ligamentous issue?
injury • How far in to the season is it?
• Treat the patient not the MRI
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Surgical Options OCDs
• Conservative- higher failure rate but better • Classically on medial femoral condyle or
long term prognosis on trochlear groove of femur
• Aggressive- may relieve symptoms but for • Rotational forces direct trauma
how long • Shearing force between articular cartilage
and subchondral bone
• Repair v Resection
• Weight bearing surfaces- MFC 4x more
common than lateral injuries
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• Biomechanical risk factors femoral • Pain at approx 30 degrees of knee flexion
anteversion and poor gluteal control as patella starts to engage in trochlear
increasing dynamic Q angle thus strain on groove
PFJ
• Single legged squat diagnostic
• Had 2 cases of significant OCDs in
trochlear groove in female international
basketball players in last 2 years.
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6. Treatment Options Microfracture
• Rest and grade rehab • Perforation of subchondral bone to recruit
• Debride mesenchymal stem cells from bone
• Microfracture marrow into lesion
• OATs /ACT • Stem cells develop into cells capable of
producing fibrocartilage
• Important for stable clot to fill defect
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OATs Graft/ Mosaicplasty Anterior Knee Pain
• Take multiple small osteochondral plugs • Fat pad impingement
from the non weight bearing periphery of • Plica
the femoral condyle • Pes anserinus
• Limited by size of donor site • Tendonopathy
• Longer rehabilitation period
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Posterior Knee Pain
• Usually simple diagnoses to make • Distal medial hamstrings- friction
• But often the MRI is -ve intersection
• Difficult situation • Popliteus spasm
• Glutes and single leg stability highlighted • Posterolateral corner injury
• Goal setting and time objectives are • Posterior capsultis
difficult to quantify
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