Knee soft tissue injuries Flashcards
what are examples of traumatic knee injuries?
- ACL
- PCL
- MCL
- PLC (post lateral corner)
- meniscus
what are the roles or functions of the ACL?
- primary stabiliser of the knee
- controls medial rotation of the tibia on the femur
- resists anterior movement of the tibia on the femur
- aids to restrict hyperextension of the knee
- guides the knee locking mechanism
what is an ACL injury classified into?
- partial or complete tear
- the ACL is designed to withstand a certain level of force - if the threshold is met the ligament can rupture
what is epidemiology?
how often diseases or conditions occur in different groups of people and why
what are 5 variables that predict return to sport after an acl injury?
- age at injury
- competitive athlete status
- time of surgery
- cartilage surgery
- cartilage lesion - damage to cartilage tissue
how do ACL injuries happen?
1.** non contact-** changiung direction rapidly, landing after a jump, deceleration
2. contact - tackles, collisions, direct blow to the knee
what other structures can an ACL tear occur in association with & what term describes this?
- medial collateral ligament
- medial meniscus
- called the uphappy triad
what are the** intrinsic risk factors** for acl injury?
intrinsic - factors about us
- age
- high BMI
- gender - female more likely
- ethnicity- white more likely
- anatomy - variation?
- previous acl injury
what are examples of modifiable risk factors for ACL injury?
- high BMI
- poor fitness ;level
- reduced hip strength
- neuromuscular control
- biomechanics - faulty
what are the signs & symptoms of ACL injury?
- patient describes a pop or crack at the time of injury
- unable to continue playing on
- able to walk after - if complete tear- nociceptors have been disrupted and person cant feel pain as much
- larger amount of swelling within hours
- haemarthrosis - bleeding in the joint
what would be signs of ACL injury during subjective exam?
- if patient says they are in pain and knee is swollen
- if patient has difficulty moving knee
- if the patient has a event or MOI in patients medical history
- if the patient describes the knee as a feeling of ‘giving way’
what might you notice in a physical examination of someone with an ACL injury?
- haemarthrosis - bleeding in a joint
- reduced ROM of knee
- antalgic gait (abnormal shortened stance phase as they dont want to place weight on injured leg)
- positive stability tests eg anterior drawer test and lachman’s test
what stability test is the most sensitive and specific test for ACL & what signifies a positive test?
Lachmans test
* positive - lack of end feel and anterior movement of tibia on femur
on physical examination of a patient with a suspected ACL injury, should you do a posterior or anterior drawer test first?
- posterior drawer test first always !
- As we want the knee to be in neutral
why are females more likely to tear their ACLs?
- different biomechanics
- anatomical hormonal differences
- difference in neuromuscular control
how do the greatest ACL strains occur?
- combined loading pattern - frontal and transverse plane movements with anterior tibial shear (force)
what are the options for reconstruction of the ACL (surgical options)?
- allograft - donor tissue from cadaver
- autograft- graft from the injured patients body - either from** hamstring or patella tendon **
compare bone patella tendon bone vs hamstring grafts as a surgical method
-
PBTB- most commonly used, **good healing **as bone is stronger and heals fast, lower re-rupture rate, strongest graft
2. hamstring - second most commonly used, semitendinous muscle used, used in younger patients, not as strong as BPTB graft, smaller graft scar
what are the goals for post-operative rehab for ACL tear?
months 4-5 and months 5-6
- months 4-5 - normalise knee ROM, optimise strength and focus on basic foundational movement patterns
- months 5-6- progress strength, flexibility, neuromuscular control, endurance, running on level surfaces
what are the most effective components in warm up to focus on to prevent ACL injury & how long should you do this for?
- balance work
- biomechanical training - focusing on hip, knee and ankle
- strength training - hamstrings, quads and glutes
- pylometrics
- 10-15 mins - 2-3 times a week
is the PCL often injured with other ligaments?
- yes - often injured with other ligaments
what is the MOI of a PCL injury?
- direct blow to anterior tibia with flexed knee
- hyperextension injury
- fall onto flexed knee
- tibia falls back on femur
what are the signs and symptoms of a PCL injury during a subjective exam?
- posterior knee pain going into calf
- feeling of instability of the knee
- unable to play or peform
- difficulty walking
- descent on stairs - pain and difficulty (as knee is partially flexed)
what are the signs and sympotoms of a PCL injury during a physical exam?
- swelling
- posterior sag sign- tibia sagging in relation to the femur
what does a positive sag test look like?
- tibia subluxes posteriorly when the PCL is ruptured
what is the active quadriceps test for pcl injury?
- Patient lying in supine with knee and hip flexed
- patient contracts quads with the physio stabilising the ankle and providing reisstance
- contraction draws the tibia anteriorly in a PCL deficient knee
what is the posterior drawer test?
- patient lying in supine with knee flexed
- physio sits on patients foot
- physio places hand on tibial tuberosity and pushes tibia back after picking up soft tissue slack
- positive test - if there is excessive posterior translation or movement
in what cases might surgery be recommended for PCL injury?
- if other structures involved
- grade III tear detected
- significant rotatory instability of knee
what are the roles of the medial collateral ligament?
- stabilises the medial aspect of the knee
- restricts rotation and valgus (knees pointing inward) stresses
- note the MCL merges with the medial meniscus
describe the signs and symptoms of a MCL tear grade I
- pain and tenderness on palpation +
- valgus stress testing is painful
- minimal swelling
- minimal loss of rom
- reduced strength
- patient may or may not have difficulty weight bearing
Describe MCL tear grade II
- pain and tenderness on palpation ++
- valgus stress painful but lax (loose) but definite end point
- effusion - fluid in capsule
- loss of ROM
- reduced strength
- difficulty weightbearing
- will feel unstable
- brace is indicated
what does the management (conservative) of MCK grade I-II involve?
- POLICE
- modified rest
- protected weightbearing
- brace
- taping
- progressive, outcome based rehab
- proprioception and sport specific training
describe a grade III MCL tear
- usually torn from femoral attachment
- patient will report floppy or wobbly knee
- immediate pain at the time of injury but may settle as the fibres are torn
- may have initial swelling - can settle quickly as fluid escapes through torn capsule
- gross laxity (looseness) on testing
what is the management for MCL grade III
- POLICE
- modified rest
- protected WB
- locked brace for 6 weeks
- surgeons discretion to increase range of motion
what is a good test for MCL injury?
valgus stress test
* knee in flexion - physio holding it - applyoing medial force from the lateral part of knee
* positive test - increased laxity and pain
Describe an LCL injury and the roles of the lcl
- roles - stabilises lateral aspect of knee
- injuries - less common than ACL and MCL, injury is due to excessive or direct varus stress on kne
what is the varus stress test?
- test used to detect LCL injury
- patient in supine with knee flexed to 20-30 degrees and physio holds leg
- physio applies force on the medial side of knee
- pain and laxity - potential positive
what is a PLC injury?
- traumatic inury with lateral instability, PCL and ACL injury
- surgery generally indicated
- many are missed - always assess
what does the MOI of a PLC injury involve?
- blow to anteromedial knee
- **varus blow to flexed knee **
- contact or non contact hyperextension
- external rotation twisting injury
- knee dislocation
how can meniscal injuries occur?
- forceful rotation or twisting of knee on a planted foot
- often associated with ligament injury eg MCL and medial meniscus
what are the main tests for meniscus tear?
- mcmurrays test
- apleys test
- palpation of medial or lateral joint line
what does the mc murray test involve - lateral vs medial menisci and what does a posiitve test signify??
- patient lying supine
- put patient knee into flexion and tibia in internal rotation (lateral meniscus0
- then put patient knee into full flexion and externally rotate the knee for medial mensicus
- ensure physios hand is on the joint capsule to palpate any cracks or pops
- positive test - audible clicks with pain
