Anatomy Review of the Medial Knee

BonesTendonsLigamentsMeniscus

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Injury to the Medial KneeSprains and Strains

Assessment make a clinical judgment about the degree of injury

1st degree2nd degree Sprains and Strains

3rd degreeGOALS are based on the degree of injuryMedical referral is based on the degree of injury

Meniscal TearsOther (bursitis, nerve involvement, etc.)

MCL Sprains - Epidemiology

“The MCL is the most commonly injured ligament…”(Ireland, 1999, JAT)

MCL most common knee injury in soccer and basketball (Arendt, 1999, JAT)

The MCL sprain is the most prevalent knee injury in the general population (Add ACL and MCL = 90% of knee injuries). Miyasaka KC, Daniel DM, Stone ML, Hirshman P. The Incidence of Knee Ligament Injuries in the General Population. The American Journal of Knee Surgery. 1991; 4 (1):3-8.

500 knee injuries frequency of knee injuries: ACL, 63% MCL, 44% PCL, 7% LCL, 4%

Combination Injuries Meniscal Tears, etc. Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy of kinematics of the lateral collateral ligament of the knee. AJSM. Nov-Dec 2000; 28 (6):869-878.

Evaluation and Assessment of Medial Knee Injuries

HISTORYINSPECTION – OBSERVATIONPALPATIONSPECIAL TESTS

PROM, AROM, MMTStress TestingEtc.Arthrometry

The LigMaster

The evaluation relies on the expertise of the clinician to assess the MCL sprain given subjective information and performing more objective special (stress) tests.

Evaluation of the Medial KneeHISTORY

What happened/MOI?Direct blow from the side CollateralsTorsion, rotation, “twisting” Cruciates, Collaterals, Menisci

Noises?Sensations?

“Giving way” Tendonitis or Meniscus“Sharp/Knife-like Under Patella” Chondromalacia“Numb” Nerve (burning, tingling, etc.)

UH OH!!UH OH!!

MOI = Blow to the outside of the knee with or without torsion

Arnheim & Prentice, Principles of AT, 9th ed

Evaluation of the Medial KneeHISTORY

When did it happen, onsetPMHSensations felt – PAIN?

Provocation, Quality, Radiating/Referred, Severity (1-10), TimingPin-Point-Pain

Training, surfaces, mileage (10% rule), shoes, etc.

Evaluation of the Medial KneeOBSERVATION

Compare BilaterallyGait

FWB & PWBAntalgic gaitGait deviations

DeformitySwelling, edema, effusion, ecchymosisAtrophy

Evaluation of the Medial KneePALPATION

Palpate bones –compare bilaterally

R/O fx &/or dislocationIF FX or DISLOCATION IS SUSPECTED

splint (ice), MD Referral

Evaluation of the Medial KneePALPATION

Pes anserinus tendons = Sartorius, Gracilis, Semitendinosus

+ Semimembranosus

Evaluation of the Medial KneeRANGE OF MOTION

Can palpate tendons at this timeStabilize legs to isolate jointsCompare bilaterallyAROM PROM GoniometerMMT Make Test or Break Test

Evaluation of the Medial Knee SPECIAL TESTS

Anterior Drawer Test = ACL stabilitySlocum Drawer Test – adds rotation to ADTEx Rot AMRI (ACL + MCL + PMC)

Posterior Drawer Test = PCL Huston’s Test = adds rotation to PDTInternal Rotation PMRI (PCL + MCL + AMC + POL)

ACL decreases ant mvt of femur (86% and medial displacement (30%)

PCL decreases post mvt of femur (90%) and lateral displacement (36%)

Arnheim & Prentice, Principles of AT, 9th ed

15° External Rotation

Evaluation of the Medial Knee - SPECIAL TESTS

Valgus Stress Test

In 0 ° (full extension) = MCL + ACL, PCL, PM capsule, POL, etc.)And somewhere between 5 - 30°flexion = MCL and medial capsule Arnheim & Prentice, Principles of AT, 9th ed

Amount of opening at the joint during valgus stress test compared to the unaffected knee

0-5mm = mild 1+ (very little instability, tenderness, firm end point)5-10mm = mod 2+ (instability in flexion and pain!)>10mm = severe 3+ (instability even in extension, no end point)

Evaluation of the Medial Knee - SPECIAL TESTS

Valgus Stress Test

Special Tests - Meniscal TearsMcMurray’s Test: Ex rotation of tibia + valgus stress extension of the knee click or pain over medial meniscus =+

Apley’s Compression/Distraction Tests

Fox Test

Arnheim & Prentice, Principles of AT, 9th ed

Evaluation of the Medial KneeSPECIAL TESTS

Patellar TestsApprehension Test –Subluxation, DislocationPatellar/Femoral Compression Test (Clark’s Sign) & Crunch TestQ Angle Measurement

Plica Test Functional and Sports Specific Tests

Evaluation of the MCL Summary

The severity of MCL injury is based on point tenderness, swelling over the soft tissue, and findings gained by performing special tests. Evidence Based Practice My Dissertation

Questions

Does Wolff’s law apply to ligaments? “Bone and soft tissue will respond to the physical demands placed on them, causing them to re-model or realign along lines of tensile force”

Prentice, W. (2004). Rehabilitation Techniques, pg. 41.

Is a person’s left leg and right leg the same?Do people have a dominant leg? Do athletes?

More Questions

Do males have stronger bones, tendons, and/or muscles than women?Do males have stiffer ligaments than females? So stronger joints?What if the MCL is the same in males and females? Does that mean the ACL is the same in males and females?

Medial Collateral Ligament

Attachments:Just inferior to the adductor tubercle on the femoral epicondyleMedial tibial flare

2 PortionsSuperficial = Tibial collateral or MCLDeep = medial ligament or capsular ligament attaches to medial meniscus

Medial Collateral Ligament

Deep portion of MCL attaches to medial meniscus.

Posterior aspect of superficial MCL blends into deep PCL and semimembranosus muscle, which also attaches to the medial meniscus

Medial Collateral Ligament

Functions:Valgus stressTibial external rotationTibial anterior translation

Different knee positions matter!

Knee position changes the function of the MCL

In extension: Superficial MCL is taut

In flexion: anterior MCL is taut, posterior is slack

MCL SPRAINThe Valgus Stress Test

The common MOIs for injury to the MCL Direct hit (force) on the outside of the knee (valgus stress)Outward rotational force

Therefore, the position of the knee when performing the Valgus Stress Test is:1. Full Extension2. Flexed 20°

25° How much and why?30°

25° flexion to isolate the MCL

References Norkin and Levangie, 1992.

F.A. Davis2002

Evaluation of Orthopedic and Athletic Injuries (2nd Ed.)

2. Starkey, C., Ryan, J.

Add internal rotation of tibia = ↑ ACL and PCL stress and ↓ stress to MCL

Add external rotation of tibia = ↓ stress on PCL

Flexed = MCL + PCL, Medial Capsule, Post. Oblique Lig.

Full Ext = MCL, PMC + ACL, PCL, POL, medial Quads

20 - 30°flexionNone

Human Kinetics2000

Assessment of Athletic Injuries

1. Shultz, S., Houglum, P., Perrin, D.

DEGREES OF

FLEXIONREFPUBLISHERTEXTBOOKAUTHOR(S)

“…knee flexed just enough so that it unlocks from full extension”

No references

Appleton-Century-Crofts1976

Physical Examination of the Spine and Extremities

5. Hoppenfeld, S.

20 – 30° flexion

References McClure, Rothstein, and Riddle, 1989 & Smith and Green, 1995

Slack Inc.2002

Special Tests for Orthopedic Examination (2nd Ed.)

4. Konin, J., Wiksten, D., Isear, J., Brader, H.

30° flexion in text, 20 - 30° in Table (page 528)

References Lynch and Henning, 1995.

McGraw-Hill 2000

Principles of Athletic Training, (10th Ed.)

3. Arnheim, D., Prentice, W.

DEGREES OF FLEXION

REFPUBLISHERTEXTBOOKAUTHOR(S)

The LigMaster Device and Software

Sport Tech, Inc., Charlottesville, VAJoints: ankle, knee, shoulder, elbowTelos device used in radiology for Graded Stress Radiography (GSR)

The LigMaster Device and Software

Pressure Actuator set at joint lineLinear decoder detects displacementPlots force/strain curve

SLOPEF = Ao EModular elasticity = stiffness laxity

Left Vs. Right

LigMaster Data Summary

Name: PAA 38, Last seen: Thu Jul 01 2004

Test: Right Knee MCL Thu Jul 01 2004 08:32 Title: full ext 1

Test analysis: x-intercept = 0.02 Slope = 19.98

Comparison: Left Knee MCL Thu Jul 01 2004 08:41 Title: full ext 3

Comparison analysis: x-intercept = 0.04 slope = 20.19

Knee MCL analysis: Test ligament slope 1.04% less than comparison

Forc

e, d

N

λ−1/λ2Ligament Strain:

Apparent Ligament Extension, mm

PAA 38,

0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.850

1

2

3

4

5

6

7

8

9

10

11

12

13

14

5 10 15 20 25 30 35 40

TestRight Knee MCLJul 01 2004 08:32

full ext 1

ComparisonLeft Knee MCLJul 01 2004 08:41full ext 3

Same knee, one flexed 20°LigMaster Data Summary

Name: PAA 38, Last seen: Thu Jul 01 2004

Test: Right Knee MCL Thu Jul 01 2004 08:32 Title: full ext 1

Test analysis: x-intercept = 0.02 Slope = 19.98

Comparison: Right Knee MCL Thu Jul 01 2004 08:36 Title: 20 d flex 2

Comparison analysis: x-intercept = 0.01 slope = 16.97

Knee MCL analysis: Test ligament slope 17.72% greater than comparison

Forc

e, d

N

λ−1/λ2Ligament Strain:

Apparent Ligament Extension, mm

PAA 38,

0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.850

1

2

3

4

5

6

7

8

9

10

11

12

13

14

5 10 15 20 25 30 35 40

TestRight Knee MCLJul 01 2004 08:32

full ext 1

ComparisonRight Knee MCLJul 01 2004 08:3620 d flex 2

Position of Knee Study Results

Overall:Overall: FF(4,44)(4,44) = 19.57, = 19.57, PP< .001< .001TT--Tests:Tests: 0 0 --1010°° no differenceno difference0 0 --1010°° & 15& 15°° -- 2020°° differentdifferent1515°° -- 2020°° no differenceno difference* = diff from 0* = diff from 0--1010°°

17.22 17.22 ++ 2.552.552020°° **

18.53 18.53 ++ 2.172.171515°° **

19.83 19.83 ++ 2.222.221010°°

21.00 21.00 ++ 2.172.1755°°

21.51 21.51 ++ 2.882.8800°°

Mean Mean ++ SDSDKnee PositionKnee Position

0

5

1 0

1 5

2 0

0 d5 d1 0 d1 5 d2 0 d

**

Summary

Medial knee injuries are prevalent in athletics, the MCL is the most often sprained ligamentEvaluation and assessment of medial knee injuries includes taking a thorough history, good observation and palpation skills, and being able to perform special testsThe Valgus Stress Test seems to be a valid test and fairly reliable but authors don’t agree on the specifics of itArthrometry may be helpful in gaining more objective information regarding the extent of injury and healing of a ligament after injury Management and rehabilitation should follow an established progression and should be based on the principles of tissue healing. Return to Play should be determined by criterion which includes both subjective and objective information

Workshop Objectives

Review the anatomy of the medial kneeReview assessment techniques for injuries to the medial

kneePick up a tip or two on assessmentPick up a tip or two in teaching this topicIntroduce research that is important to me To get you thinking my wayLeave with the feeling we have not wasted 45 minutes

ResourcesAndrews, J., Harrelson, G., Wilk, K. (2004). Physical Rehabilitation of the Injured Athlete,3rd Ed. , Philadelphia: SaundersArnheim,D., Prentice, W. (1997). Principles of Athletic Training, Ed 9, Boston: McGraw-Hill Company. Photo CD AND 10th Edition (2000) TextBaker, C. Editor (1995).The Hughston Clinic Sports Medicine Book, Baltimore: Williams & WilkinsDenegar, C., Saliba, S., Saliba, E. (2004) Therapeutic Modalities from J. Hertel and C.R. Denegar, 1998, “A rehabilitation paradigm for restoring neuromuscular control following athletic injury,” Athletic Therapy Today 3 (5): 13–14.Konin, J., Wiksten, D., Isear, J., Brader, H. (2002). Special Tests for Orthopedic Examination, 2nd Ed. Thorofare, NJ: SLACK, Inc.Prentice, W. (2004). Rehabilitation Techniques, 4th Ed. Boston: McGraw-Hill CompanyShultz, S., Houglum, P., Perrin, D. (2000). Assessment of Athletic Injuries, Champaign, IL: Human KineticsStarkey, C. Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries, 2nd Ed.Philadelphia: F.A. Davis CompanyVanDeGraaff, KM, Crawley, JL (1999). A Photographic Atlas for the Anatomy &Physiology Laboratory. Englewood, CO: Morton Publishing Company.WWW.Despair.com