Soft Tissue Injuries Knee

Andy Higgins

Clinical Specialist Physiotherapist

Derriford Hospital

Introduction

• The aim of today is to review the acute soft tissue injury patient group and

improve our ability in our management of them. • The ED is the starting point . • Development of a working diagnosis.

• Anatomy/Physiology.

• History taking.

• Clinical examination. A good thorough history taking with a basic examination can benefit the patient dramatically.

Aim to Cover

• To briefly review relevant anatomy

• Salient points of subjective assessment of knee injuries

• Review the patho-biomechanics of common knee injuries

• To apply this information with the practical sessions and enable us all to leave with refined and/or developed skills

Knee Examination – Subjective History

• Mechanism/onset is a key piece of information – if available! Think of the amount of force involved?

Also attention to : • Onset of swelling? • Ability to weight bear • “Pop” sensations

Is there any history of: • Locking • Clicking → All might suggest internal • True giving Way / instability derangement

Knee Examination

Observation (look): • Deformity • Muscle wasting • Swelling - effusion • Structural alignment

Palpation (feel): • Heat • Swelling – sweep tests • Pulses • Apply the OTTAWA RULE

OTTAWA Knee Rules

For knee injuries – not insidious onset

• Age 55 years or older

• Tenderness at head of fibula

• Isolated tenderness of patella

• Inability to flex knee to 90 degrees

• Inability to walk 4 weight-bearing steps immediately after the injury and in the emergency department

Knee Examination cont…

• Palpation for site of pain – relate to anatomy.

• Active range of motion.

• Passive range of motion.

• Straight leg raise.

• Special tests – Ligamentous tests

• Gait Analysis

Special Tests / Ligament Integrity Tests

• We have a range of tests at our disposal to be able to test the integrity of the ligaments of the knee.

• We are looking for the presence of pain upon selectively stressing each ligament.

• Or - We are looking for the evidence of laxity and a presence/lack of an END FEEL .

Grading of Ligamentous Injuries

Can be applied to most ligament injuries throughout the extremities.

• Grade 1 – Pain No laxity

• Grade 2 – pain with laxity/deformity – with end feel on stress testing

• Grade 3 – Pain – severe laxity/deformity –little or no end feel on stress testing - RUPTURE

Knee – Special Test / Integrity Tests

• Posterior Cruciate → Posterior Sag Ligament Pencil Test

• Anterior Cruciate → Anterior Ligament Drawer / Lachman’s Test

• Medial Collateral Lig → Valgus Stress

• Lateral Collateral Lig → Varus Stress

• Menisci → McMurray’s / Apley’s…

Anterior Cruciate Ligament (ACL) Injuries

Mechanism of Injury: •Pure Hyperextension, or •Combination of valgus force and external rotation of the tibia relative to the femur •Or Varus stress and internal rotation of the lower leg. •Does not have to be a CONTACT injury Leads to: •Rapid onset haemarthrosis •Often describe a “pop” sensation •Feeling of instability •Inability to bear weight •Exam may show – laxity on stress testing http://www.youtube.com/watch?v=HjyRZXO10D4

ACL

Good

Bad!

Posterior Cruciate Ligament (PCL) Injuries

• In isolation, very rare.

• Hard impact to anterior tibia

• RTC / contact sport

• Not typically unstable on rotation

• Examination may show

posterior laxity / sag

Medial Collateral Ligament (MCL) Injuries

• Can be produced by:

Valgus force

With or without rotation

• Proximal origin most effected

• Can be combination injury due to multiple attachments – “O’donoghue’s Unhappy Triad”

• Examination may show pain and or laxity on stress testing

• http://www.youtube.com/watch?v=_fxKCDkOiJs

Lateral Collateral Ligament Injuries

• Can be produced by:

Varus forces

• Much less common than MCL injuries

• Rarely isolated injuries

• Examination may find pain or laxity on stress testing

• http://www.youtube.com/watch?v=l_HVKZnlDCc

Postero-lateral Corner Injuries

• Significant injury

• Typically forced varus and extension injury.

• Beware of instability but with little swelling.

• Posterior calf bruising

• Rare – but NOT to be

missed!

Mechanisms of Injury – Meniscal Lesions

• Common in activities involving forced rotation on a weight-bearing leg.

• Can be slow onset of effusion.

• Localised anterior/medial knee joint pain - commonly.

• If age>50yrs then consider

degenerative meniscus if no

history of trauma – commonly

resolve without intervention.

• Acute Locked Knee – if true

– urgent orthopaedic opinion

Patella Dislocation

• Common injury – mostly ?Medial or Lateral?

• Not to be underestimated/overlooked

• Other injury/pathology can occur

• A recurrent dislocator can also injury additional structures – ACL +

• X-ray not just to check that

the patella is relocated.

• The subluxing patella!?

Quadriceps Tendon / Infrapatellar Tendon Rupture

• History is key

• Typically minor trauma

• Beware the middle

aged male!

• Ability to SLR?

• Palpation - ?Dip

Overuse Injuries

• Patellar Tendinopathy

• Ilio-tibial Band Syndrome

• Osgood Schlatter’s Disease

Often will describe a history of overuse (MOI) and the location of symptoms is fairly descriptive.

Use of Imaging For Knee Injuries

• OTTAWA Rule – is a good guide.

• ABC’s

• What else are you looking for?

Subtle radiographic findings can indicate significant pathology:

Practical Session

Treatment of Acute Soft Tissue Knee Pathology

• Any patient with apparent or highly suspected significant internal derangement must be followed up.

• If gross instability – Grade II/III MCL / LCL or PLC – urgent orthopaedic assessment same day.

• ACL/PCL injuries are important – but not Urgent (except in paeds)

• Acute knee clinic/Physio ED Clinic

• Minor grade 1 injuries need simple soft tissue injury advice

• Cricket pad splint can be used for any significant knee ligament injury.

• Physiotherapy Referral

• Send home with advice to begin static quads contractions .

• Ice regime – with appropriate placement and duration.