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Injuries and medical problems in sport > Knee injuries > Flashcards

Knee injuries Flashcards

1
Q

What is the pes anserinus?

A

The conjoined tendons of three muscles that insert onto the anteromedial surface of the proximal tibia:

  • sartorius
  • gracilis
  • semitendinosus
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2
Q

What is used as a graft for ACL repair?

A

Patella tendon (can use hamstring for younger athletes)

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3
Q

What is the name of the point of insertion for the IT band on the lateral thigh?

A

Gerdy’s tubercle
Smooth facet on the lateral aspect of the tibia
adjacent to tibio-fibular joint and just below knee

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4
Q

Name the main lateral structures of the knee from superficial to deep layers

A
  1. LAYER 1: IT tract, biceps femoris
  2. LAYER 2: Patellar retinaculum
  3. LAYER 3:
    - SUPERFICIAL: Anterolateral ligament, LCL + fabellofibular ligament
    - DEEP: Arcuate ligament, coronary ligment, popliteus tendon, popliteofibular ligament, capsule
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5
Q

Superficial lateral structures of the knee

A

IT tract, biceps femoris

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6
Q

Layer 2 of lateral structure of knee

A

Patellar retinaculum

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7
Q

Layer 3 of lateral structure of knee

A

SUPERFICIAL:

  • LCL
  • Fabellofibular ligament
  • Anterolateral ligament

DEEP:

  • arcuate ligament
  • coronary ligament
  • popliteus tendon
  • popliteofibular ligament
  • capsule
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8
Q

Layer 1 of medial knee structures

A

LAYER 1
- sartorius and fascia (patellar retinaculum)

LAYER 2

  • semimembranosus
  • superficial MCL
  • posterior oblique ligament

LAYER 3

  • Deep MCL
  • capsule
  • coronary ligament
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9
Q

Origin and insertion of the MCL

A

Originates posterior to the medial epicondyle

Inserts 1-6cm along medial aspect of tibia

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10
Q

ACL rupture is likely to be associated with which other injury?

A

lateral meniscus tear

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11
Q

Ddx traumatic/atraumatic knee pain

A
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12
Q

What questions do you ask about the knee symptoms? (and common ddx)

A
  • Pain (VAS, upstairs PFP, twisting menisci)
  • Instability (ACL, PCL)
  • Mechanical Sx (meniscus bucket handle – goes into the notch in the middle/loose body)
  • Stiffness
  • Swelling
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13
Q

How can different types of instability suggest different ddx?

A
  • Pivoting, twisting, cutting = ACL
  • Linear instability - quad weakness
  • Side-to-side = PCL
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14
Q

Mechanical knee symptoms and common ddx

A

locking, clicking, snapping

  • menisci
  • loose body
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15
Q

relevant questions to ask in Hx

A
  • Treatment received pitch-side –> date
  • Benefits of previous Tx
  • Athletic Hx, level of play/hours, skill level, goals
  • Type of sport
  • PMHx/review of Sx
  • Occupational Hx
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16
Q

Sequence of knee examination

A

1- inspection
2- palpation
3- ROM, strength
4- Patella- tilt, apprehension, translation, crepitus, J-sign, Q-angle
5- Meniscal tests
6- Ligamentous stability- drawer, lachman’s, varus/valgus
7- Gait

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17
Q

Causes of anterior knee pain

A
  • PFP
  • Hypertrophic fat pad syndrome
  • Patellar instability
  • Quadriceps tendonitis
  • Patellar tendonitis
  • Arthritis
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18
Q

Causes of medial knee pain

A
  • Meniscus tear
  • MCL injury
  • Pes anserinus bursitis
  • medial plica syndrome
  • hypertrophic fat pad syndrome
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19
Q

Causes of lateral knee pain

A
  • Meniscus tear
  • Biceps tendonitis
  • hypertrophic fat pad syndrome
  • ITB syndrome
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20
Q

Causes of diffuse knee pain

A
  • Osteoarthritis
  • Inflammatory arthritis
  • Septic arthritis
  • trauma –> haemarthrosis
  • PVNS
  • neoplastic
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21
Q

which meniscal tear is more common

A

medial (lateral more common in ACL tear)

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22
Q

common meniscal tear in older patients

A

degenerative- posterior horn of medial meniscus

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23
Q

describe the meniscal zones and their management

A

Red zone (outer third, vascularized therefore try to repair as increased chance of healing)

Red white (middle third)

White zone (inner third, avascular – will not heal, need debridement)

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24
Q

Sx meniscus tear

A
  • pain (joint line tenderness)- can be intermittent
  • locking/clicking (mech Sx)
  • delayed or intermittent swelling/effusion
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25
Indications for non-operative Mx meniscal tear
- <5mm stable peripheral tear - Stable vertical longitudinal tears (peripheral) - Infrequent and minimal mechanical Sx - Associated ligamentous instabilities - Medically unfit
26
O/E meniscus tear
joint line tenderness, effusion, McMurray’s
27
Ix for meniscal tears + what you would see
- Radiographs, MRI | - Double PCL sign = bucket handle tear (vertical tear which may displace into the notch), fluid where meniscus should be
28
Mx meniscal tears
Operative = partial meniscectomy or arthroscopic meniscal repair (FasT-Fix) Non-operative = if <5mm, in red (peripheral) zone, no Sx, unfit
29
What is the common Hx/Sx of an articular cartilage lesion?
- usually follows trauma - joint line tenderness/localised pain - catching sensation - incidental/accompanies another injury - effusion
30
partial vs full thickness chondral lesions
``` partial = avascular full = potential to fill with fibrocartilage (type 1 collagen) ```
31
problem with articular cartilage defects?
gives rise to loose bodies, painful and accelerates OA
32
Grading of cartilage defects
33
Imaging for articular cartilage tears
- x-ray - CT- tibial tubercle to trochlear groove distance, Q angle - MRI with gadolinium
34
Surgical Tx for AC lesions- indications/contraindications
- Surgery grade 3/4 lesions | - Avoid in: obesity, inflammatory, degeneration
35
What is OAT?
OAT replaces chondral defects with normal hyaline articular cartilage, a distinct advantage over microfracture. A plug of the patient's own healthy cartilage and bone is harvested from a non-weight bearing portion of the joint. One or multiple strategically arranged plugs can be transferred to fill the defect.
36
Surgical Tx of chondral lesions
- microfracture - OATS - ACI and osteochondral allografft The last 2 work best
37
What is ACI?
Autologous chondrocyte implantation (ACI) | Effective for treating small areas of cartilage damage
38
Describe the proces of microfracture for chondral lesions
Multiple small holes in the surface of the joint, which stimulates a healing response
39
Microfracture for AC lesions- benefits
- immediate post-op ROM on passive movement - Weight bearing 6-8 weeks - RTP after 4-9 months
40
OATS- recovery period
NWBing 3 weeks immediate full ROM 4 months return to sport
41
ACI- recovery period
- Immediate CP - NWBing till ROM/quads strength fully restored - FWB 10-12 weeks - offloading brace may be used - 12-18 months before high impact
42
Classic Hx ACL tear
- 'pop', collapse - immediate swelling - couldn't continue to WB - Lack of confidence - episodes of giving way
43
ACL tear O/E
- positive anterior drawer - positive Lachman's - effusion - quadricep avoidance gait (don’t fully extend knee)
44
O/E, what severity ACL tear requires surgery
Grade II/III pivot shift
45
classic injury that causes and ACL tear
non-contact pivoting
46
Epidemiology of ACL tears
F5>M1 – landing biomechanics and NM activation patterns (quad dominant)
47
Ix ACL tear
radiograph | MRI
48
Preferred Mx ACL injury for jumpers vs footballers and the negatives of both
JUMPING ATHLETES - hamstring graft - RTP delayed 6 months FOOTBALLERS - bone patellar tendon bone (BTB) autograft - bone-on-bone healing - reduced laxity in graft - 30% incidence anterior knee pain
49
Post-op ACL
- early ROM emphasized - extension + flexion - Closed chain exercises emphasised early - running 3-4 months - RTP 6-9 months
50
Causes of PCL injuries
Dashboard injury | Hyperflexion of the knee with plantar-flexed foot
51
Sx PCL injury
``` Posterior knee pain but often subtle Swelling. Stiffness. Difficulty bearing weight. Knee instability. ```
52
O/E for PCL injury
- positive posterior drawer - posterior sag - quadriceps active test - positive dial at 90deg +/- 30
53
Mx isolated PCL tears
Brace for 4 weeks & rehab No surgery RTP 4-6 months when quads strength equal both sides
54
Mx combined PCL and MCL/ACL/knee dislocation
Surgical reconstruction < 2 weeks
55
non- operative Tx PCL injury first 6/52 Rehab
- PWB - Hamstring/gastroc stretching - quad strengthening - Use of PCL that provides dynamic anterior drawer
56
non- operative Tx PCL injury first 6-12/52
- Increasing quad/gastroc strength + ROM
57
non- operative Tx PCL injury 13-18/52
- Running and sport-specific exercise | - RTP 4-6 month when quad strength equal
58
post-op management ACL injury
2-3/52- Brace locked in full extension, passive ROM on2-3, quads isometric 6/52- WB as tolerated, quads isometric, closed chain, open kinetic chain extension (60-0) >6/52- WB as tolerated, 0-125 ROM, isotonic quads, leg press, rowing Functional activity phase 6-9/12
59
MCL injuries grade 1+2 rehab
- grade 1+2 = hinged brace, NSAIDs - closed chain exercises - jogging once quad strength 80% contralateral - RTP once 80% max speed achieved Grade 1 & 2 will heal – good blood supply (sup medial & inf medial geniculate arteries)
60
Grde 1 vs grade 2/3 MCL injury RTP time
grade 1: 10-14 days grade 2/3: 3-4 months grade 3- operative – repair or reconstruction
61
Grade 3 MCL Mx/rehab
- 80% are combined injuries - Tibial sided tears require acute surgical repairs - PWB 4-6 weeks - Closed chain 6 weeks Squatting, jogging, light agility, slow RTP
62
MCL Sx
- mostly combo with ACL - pop - pain medially - bruising and effusion
63
Sx of LCL injuries
- instability near full extension - Difficulty pivoting/climbing stairs - Lateral joint line pain and swelling - often with PCL/ACL may be accompanies with common peroneal nerve injury
64
LCL Mx/rehab
65
Patellar tendonitis- who is affected
- jumping athletes | - repetitive, forceful eccentric contraction of extensor mechanism
66
Sx patellar tendinitis
insidious onset of anterior knee pain at inferior border of patella – pain after or during activity
67
O/E patellar tendinitis
- Swelling over tendon - tenderness inf border of patella - Basset’s sign (tenderness to palpation at distal pole of patella in full extension but none in full flexion)
68
Ix for patellar tendonitis- what would you see?
X-ray - enthesophyte in chronic cases USS - thickening of tendon - hypoechoic areas MRI - tendon thickening - increased signal - loss of posterior border of fat pad
69
Mx of patellar tendinitis
- Eccentric exercise programme and stretching of quadriceps and hamstrings - US therapy - Chopat’s strap or taping - NO cortisone injections ⇒ risk of rupture
70
Indications non-operative knee dislocation Mx
- first time | - no fracture/habitual dislocator
71
Indications operative knee dislocation Mx
- displaced osteochondral fragments/loose bodies - MPFL repair - recurrent instability - malalignment (osteotomy)
72
Non-operative Mx knee dislocation
- 6/52 controlled motion - closed chain, short arc, quads strengthening - core/hip strengthening - j-brace
73
Method of narrowing TG and TT distance (reducing chance of knee displacement)
Tibial tubercle osteotomy
74
Most common knee ligament injury
MCL – excessive valgus stress e.g. skiing, rugby, football
75
MCL Mx
76
Posterolateral corner injury
LCL, popliteus tendon, popliteofibular ligament

Injuries and medical problems in sport (17 decks)

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