On Field Assessment and Management of Acute Knee Injuries: A Physiotherapist s Perspective Jessica Condliffe Physiotherapist / Clinic Manager TBI Health Wellington
Presentation Outline Knee anatomy review Key acute findings with particular acute injuries ACL/MCL/Meniscus/PCL/Posterolateral corner Acute management Onward referral Imaging
Acute on the Field Injuries Cruciate ligament injury (ACL/PCL) Collateral ligament injury (MCL/LCL) Meniscal injury Tendon injury (quadriceps/patella) Fractured patella Dislocated patella Image taken from: https://www.humankinetics.com
Key Acute Findings Significant History Mechanism of injury Inability to weight bear at time of injury Onset of swelling (extent and time frame) Sense of disruption / audible pop Locking, catching, instability Previous episodes, management and results General health / other illnesses Significant Clinical Examination Swelling, bruising, abrasions, scars Inability to extend knee or flex knee >90 Appropriate clinical tests Multidirectional instability
Diagnosis ACL Mechanism of injury Non-contact resulting from sudden deceleration and change of direction with a fixed foot, often with an audible pop or sensation of dislocating Clinical presentation and tests Significant swelling within a few hours Lachmans test (most sensitive 10 days following) Anterior Drawer test Pivot Shift test 70% accuracy Early diagnosis of ACL tear is important because of the risk of further injury to other intra-articular structures if the person returns to sport unaware of the severity of the initial injury.
Diagnosis - MCL Mechanism of injury A direct blow to the lateral aspect of the knee applying a valgus stress to the joint Clinical presentation and tests Abduction stress test 0 medial capsule, posterior capsule,?acl/pcl 30 partial or complete MCL tear Tenderness along MCL Often less swelling (extra capsular)
Diagnosis Medial and Lateral Meniscus Mechanism of injury Acceleration or deceleration typically associated with flexion, tibial rotation and compression (twisting, squatting or cutting) Clinical presentation and tests Locking, catching - be wary of acute locking Joint line tenderness Effusion Loss of end of range of motion McMurrays and Apleys Grind Tests
Diagnosis - PCL Mechanism of injury Posterior force to proximal tibia Ie: fall onto ground onto flexed knee or hyperextension Add rotation component: posterolateral complex Clinical presentation and tests Vague symptoms, mild to moderate effusion Posterior Drawer test Posterior Sag sign
Diagnosis Posterolateral complex iliotibial tract, lateral ligament, popliteus complex, popliteofibular ligament, middle third of the lateral capsular ligament, fabellofibular ligament, arcuate ligament, posterior horn of the lateral meniscus, lateral coronary ligament, posterior lateral part of the joint capsule Mechanism of injury Blow to the anteromedial tibia in an extended knee or fall on a flexed knee or hyperextension Clinical presentation and tests Posterior knee pain, mild to moderate effusion Instability into extension Posterolateral Drawer test Reverse Pivot Shift Varus Stress test
Algorithm Internal derangement suspected? Assess for likely diagnosis Provide initial treatment MCL tear Meniscal tear Yes Isolated ACL/PCL tear Locked knee d/t meniscal tear Injury to posterolateral complex Early treatment at the primary presentation is vital in order to offer the best chance of maximal functional recovery and to minimize long-term disability. Refer for rehabilitation Refer for rehabilitation Initiate referral to specialist Initiate referral to specialist
Onward Referral? People with no evidence of ligament laxity or meniscal damage should be treated with R.I.C.E., paracetamol if required and advised to resume usual activities when pain and swelling have settled, and return for follow-up if symptoms persist after seven days. Referral for rehabilitation is recommended for people with: suspected meniscal tears injuries to the MCL other ligament injuries to manage symptoms until seen by a specialist. Early referral to a specialist is recommended for people with: injury to the ACL, PCL or posterolateral complex a locked knee due to suspected meniscal entrapment Subsequent referral to a specialist for people with: with a suspected meniscal tear if symptoms persist after a trial of rehabilitation for six to eight weeks at any stage of the rehabilitation process where symptoms persist and clinical milestones are not being achieved. Bracing is generally not required, but is appropriate for an acute rupture of the medial collateral ligament tear (MCL) until knee stability has been achieved in four to six weeks.
Imaging X-ray The routine use of X-rays has been questioned and the cost effectiveness should be evaluated. Ottawa Knee Rules - > 55, tender head of fibula, tender patella, unable to flex > 90, unable to WB four steps MRI ACL: MRI is valid for diagnosis but the advantage of MRI over clinical evaluation remains unclear. Appropriate to evaluate other structures that could be damaged. MCL: sensitive in detecting tears but difficult to differentiate between the different grades of injury. Generally non-operative management therefore MRI is of little practical value unless clinical examination suggests multiple structures are involved Meniscus: common indications for MRI of the knee. Accurate in identifying the size and location of most meniscal tears and its ability to identify the presence of associated damage to ligaments and articular cartilage
Summary Comprehensive history taking combined with physical exam should guide diagnosis Know the anatomy If you re suspicious of something more then get a second opinion!