Presentation by Clare Walsh, Sports Physiotherapist for Clinical Edge (www.clinicaledge.com.au)
SUBJECTIVE EXAMINATION
1. Was the injury contact or non-contact?
2. Did you play on? If so, how long could you play on for?
3. Did you or anyone around you, hear a pop or a crack, or did you feel a pop?
4. Was there immediate swelling or did it take a couple of days to develop?
5. Is there any clicking, popping or giving way at the knee joint?
Giving way associated with twisting or turning which usually means that rotational instability is caused by the ACL, and also buckling in a straight line due to quads insufficiency if knee is weak or there is swelling.
If there is immediate swelling, this indicates a haemarthrosis and this can really only mean three things:
1. An ACL rupture, because of the rich blood supply to the ligament
2. Patella dislocation
3. Fracture
If milder swelling, more indicative of intra-articular pathology
OBJECTIVE EXAMINATION
Gait assessment
Squat - assess if they are able to compress the knee joint and whether WB is equal
In supine, assess the swelling with the swipe test, sweeping the fluid from the medial pocket to the lateral - a positive test will produce a pocket of fluid on the medial side
72-90% of ACL injuries are non-contact injuries
ACL rupture occurs when the athlete is decelerating and pivoting, or landing suddenly (maybe avoiding a tackle in rugby league) - the tibia moves forwards on the femur and ruptures the ACL. This is very painful and will usually result in the athlete grabbing the flexed knee.
Lachman's - looking for an end feel with anterior drawer
Reverse Lachman's - looking for an end feel with posterior drawer (assessing integrity of PCL)
Surgery is recommended for complete ACL ruptures. Recent studies have shown that at 8 years post injury with conservative management only, those with partial ACL tears did very well but those with compete ruptures did not have good outcomes.
Surgery is done arthroscopically, either with a hamstring tendon or patella tendon graft from the same knee, or more recently through a LARS procedure (ligament augmentation and reconstruction system) using a synthetic allograph. The LARS procedure has a reduced recovery time as there is no donor site and therefore no specific hamstring or patella tendon healing time required
Prevention Injury and Enhanced Performance is a programme that was started in the USA and is being rolled out in Australia. This is a warm up that has been proven to reduce ACL injury by 42% and involved neuromuscular control and proprioception exercises.
MCL sprain occurs with a valgus force to the knee, commonly in skiing and basketball. This can occur in isolation, or along with a medial meniscal injury. There can be some swelling localised to the ligament itself but there will not be any effusion inside the knee joint.
Grade I: Painful but no laxity
Grade II: Painful++ and some laxity
Grade III: Obvious laxity and no end feel
Test the MCL with a valgus stress at 30 degrees flexion. Grade II and III tears should be supported with a hinged knee brace to allow the ligament to tighten. Knee strengthening is essential to provide some stability to the knee joint. Straight line activity only for 4-6 weeks with grade II, possibly 8 weeks with grade III.
PCL tears usually occur with a hyperextension injury. PCL reconstruction was the preferred choice a number of years ago, but recent research suggests that the patient can get just as good recovery, if not better, from conservative management.
To test the PCL, first assess tibial sag in crook lying.
PCL injuries requires lots of VMO and control work to prevent patellofemoral problems from occurring.
LCL injuries are rare but occur with a varus stress to the knee joint. The LCL is part of the postero-lateral corner of the knee, including the biceps femurs and the postero-lateral capsule and the arcuate ligament.
If there is a complete rupture of the postero-lateral corner of the knee, this will require surgery as the knee will be very unstable. There could also be a lateral meniscus tear or a B Femoris tear in isolation.
Meniscal injuries are very common and result in an effusion that presents over a day or so, usually around the periphery/joint line, especially with a bucket handle tear. Medial are more common than lateral, and can be diagnosed by subjective questioning, palpation and McMurray's test. MRI can also be used to confirm diagnosis.
The McMurray's test can only be done in full flexion. If the knee is too painful to achieve full flexion, then a diagnosis cannot be made. The McMurray's test is done by taking the knee into full flexion then applying a varus and valgus stress to the knee. If locking, arthroscopy will be effective. For smaller tears in the posterior horn, a conservative approach will be tried in the first instance. If continual swelling and pain, best to refer on to an orthopaedic surgeon for a surgical opinion.
The articular cartilage can be damaged through knee injury, especially with impact which can cause a chondral pathology. in some cases, there may already be damage to the articular cartilage which becomes worse with impact. Chondral injuries commonly occur with ACL injuries and meniscal injuries. To diagnose a chondral injury, it is likely that you have ruled out any other meniscal or ligamentous damage but there is still effusion present. MRI can diagnose this injury.
To treat the articular cartilage injuries, you can't treat the cartilage itself so treat the symptoms.
Chondroplasty is the most common form of surgery (debridement through arthroscope) which lets the area bleed and scar over, providing a little more shock absorption at the joint. Chondral cell implantations are being carried out but it is a drawn out process. Chondral cells are grown in a petri dish then implanted back into the injured site. Unfortunately, there is a long period of NWB which brings other issues. Stem cells (greater than 10 years away before using as a regular form of treatment).
Patella dislocations present similarly to ACL ruptures. To relocate the knee, extend the knee with hip flexed. The patella dislocation causes a haemarthrosis and tenderness on the medial side where the retinaculum is likely to have been torn when the patella has dislocated laterally. The patella apprehension test (passive lateral glide) will be positive for apprehension. Usually tape the knee and allows a more normal gait pattern.
Patella fracture can be treated in an extension zimmer brace for 6-8 weeks and may require K-wiring.
Tibial plateau fracture can occur with ACL tears and meniscal injuries but can also occur in isolation. They may or may not occur internal fixation but requires a period of non-weightbearing.
Patella tendon rupture results in the distal end of the patella tendon coming way. Surgery is essential.
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