Management

MANAGEMENT

Overview

  • Always follow general principles:
    • Rest, Ice, Compression, Elevation (first 48-72 hours)
    • Avoid Heat, Alcohol, Reinjury and Massage (for first 48-72 hours)
    • Most injuries allow weight bearing as tolerated (consider crutches)
    • Arrange followup for reassessment once the acute symptoms have subsided
  • Consider more significant injury if:
    • Noise / feeling = “pop” or “crack” – likely to be ligament rupture – often ACL; may also be meniscal
    • Haemarthrosis = boggy, bloody swelling with rapid onset as opposed to effusion = watery swelling with gradual onset. Haemarthrosis = usually one of ACL/PCL rupture, intraarticular fracture, PFJ dislocation, meniscal tear. LIPOhaemarthrosis (presence of fat on x-ray) indicates fracture
    • High force injury (pedestrian struck by car; patient kicked by horse)
      Giving way – likely to be ACL (usually collapses into flexion +/-valgus with feeling of bones moving on each other) or posterolateral corner (usually collapses into extension +/- varus) or PFJ instability
    • Locking
      • True locking = inability to flex or extend the knee (meniscal or loose body)
      • Pseudo locking = inability to actively or passively extend through the last 30 degrees (not just because of pain = meniscal or other intraarticular pathology)

Superior Tibiofibular Joint

Injury

  • Can sublux anteriorly or posteriorly.
  • Anterior subluxations can be caused by an inversion injury of the ankle (or direct contact)
  • Posterior subluxation is often cumulative due to over-flattening of the foot (or direct contact)
  • Often injured in association with other ligaments
  • Often posttraumatic subluxations of this joint mimic lateral ligament injuries of the knee or lateral meniscus tears.
  • Sometimes the varus stress test will be painful as the lateral ligament attaches to the fibular head.

Management

  • If subluxed, may need to reduce
  • Usually managed with taping to minimise movement of joint (direction dependent on mechanism of injury)
  • If chronic subluxation / dislocation occurs, surgical reconstruction may be necessary
  • As usually occurs in conjunction with other injuries, these must also be managed.

Medial Collateral Ligament

Injury

  • Commonly injured (up to 70% of knee injuries involve the MCL)
  • Mechanism of injury is usually an abduction or rotary force on a semi-flexed knee
  • Can often occur in conjunction with ACL (similar mechanism) and Medial Meniscus (has attachment to MCL) – “Torn Triad”

Findings

  • On range of motion, usually painful in terminal (last 30 degrees) of extension and flexion past 60-70 degrees
  • Tenderness located over the medial ligament (!)Effusion if no other significant injury
  • Pain along medial knee +/- gapping on valgus stress testing

Grading

  • Grade I = pain but no laxity, firm end feel
  • Grade II = pain with some laxity, firm end feel
  • Grade III = +/- pain with significant laxity; minimal or no end feel
  • Complete Rupture may mean no pain after initial injury = no nerve fibres to hurt!
  • All ligaments are taut at full extension – therefore if laxity exists, it is likely there is damage to more than just the MCL (Capsule, ACL, PCL)
  • If pain / laxity is only at 30 degrees, more likely to be isolated MCL sprain

Management

  • Grade I (ie pain with no laxity)
    • Mx conservatively – brace not needed
  • Grade II (pain with mild laxity)
    • Usually Mx conservatively +/- brace
  • Grade III (significant laxity +/- pain)
    • Usually Mx conservatively in hinged knee brace or splint (backslab or other) away from full extension
    • Sometimes repaired surgically (more so if in conjunction with other structures and knee unstable)

Lateral Collateral Ligament

Injury

  • Less commonly injured than MCL
  • Mechanism of injury is usually an adduction or rotary force on a semi-flexed knee
  • Can often occur in conjunction with other structures (superior tib/fib joint – LCL attaches to fibular head, popliteus, Posterolateral corner)

Findings

  • On range of motion, usually painful in terminal (last 30 degrees) of extension and flexion past 60-70 degrees
  • Tenderness located over the lateral ligament (!)
  • Effusion if no other significant injury
  • Pain along lateral knee +/- gapping on varus stress testing

Grading

  • Grade I = pain but no laxity, firm end feel
  • Grade II = pain with some laxity, firm end feel
  • Grade III = +/- pain with significant laxity; minimal or no end feel
  • *Complete Rupture may mean no pain after initial injury = no nerve fibres to hurt!
  • All ligaments are taut at full extension – therefore if laxity exists, it is likely there is damage to more than just the LCL (Capsule, PCL, ACL)
  • If pain / laxity is only at 30 degrees, more likely to be isolated LCL sprain

Management

  • Grade I (ie pain with no laxity)
    • Mx conservatively – brace not needed
  • Grade II (pain with mild laxity)
    • Usually Mx conservatively +/- brace
  • Grade III (significant laxity +/- pain)
    • Usually Mx conservatively in hinged knee brace or splint (backslab or other) away from full extension
    • Sometimes repaired surgically (more so if in conjunction with other structures and knee unstable)

Anterior Cruciate Ligament

Injury

  • Usually injured on a semiflexed knee with some combination of rotation / valgus; other common mechanisms are hyperextension or direct blow to posterior tibia
  • Often injured in association with other structures, especially the MCL and medial meniscus = “torn triad”

Findings

  • Variable findings as usually injured in conjunction with other structures
  • Isolated ACL tear may have near full AROM / PROM, restricted by swelling
  • Swelling – usually extensive and reasonably quick – haemarthrosis
  • May have hyperextension
  • Probably minimal tenderness anteriorly
  • Increased laxity of anterior movement of the tibia on the femur
  • Need to check for PCL disruption as this might give false positives to tests
  • Meniscal tear can give a false negative (blocks anterior movement of the tibia)
  • Look for avulsion fracture of the tibial spine, particularly in the paediatric population

Grading

  • Grading for cruciate ligament injuries can be difficult due to pain with testing and the challenge of quantifying laxity in the AP direction,however a similiar grading system could be used.
  • Cruciate ligament rupture would be more common than collateral ligament rupture

Management

  • If isolated ACL injury, probably allow full AROM
  • If other concurrent injuries, need to factor these in to management
  • Zimmer Splint only if necessary
  • WBAT
  • Refer on for followup – confirm Diagnosis – if unsure get another opinion – physiotherapist or sports physician or consider MRI if will change Mx
  • For athletic and younger population, surgical reconstruction is almost essential (but not needed immediately)
  • Few people are able to participate in twisting sports without an ACL
  • Most people are able to complete everyday activities without problems if they are ACL deficient, however there is an increased incidence of OA
  • If ACL deficient and surgery is not an option, a comprehensive rehabilitation program should be undertaken.
  • If the knee gives way, even in a sedentary patient, this is another indication for surgery as this will also lead to degenerative changes or meniscal damage

Posterior Cruciate Ligament

Injury

  • Mechanisms include fall or direct blow onto anterior tibia or hyperflexion
  • Often injured in association with other structures, especially the LCL and posterolateral corner

Findings

  • Variable findings as usually injured in conjunction with other structures
  • Isolated PCL tear may have near full AROM / PROM, restricted by swelling
  • Swelling – usually extensive and reasonably quick – haemarthrosis
  • May have hyperextension
  • Probably minimal tenderness posteriorly
  • Increased laxity of posterior movement of the tibia on the femur; may have posterior “sagging” of the tibia at rest
  • Need to check for ACL disruption as this might give false positives to tests
  • Meniscal tear can give a false negative (blocks posterior movement of the tibia)
  • Look for avulsion fracture of the tibial spine, particularly in the paediatric population

Grading

  • Grading for cruciate ligament injuries can be difficult due to pain with testing and the challenge of quantifying laxity in the AP direction,however a similiar grading system could be used.
  • Cruciate ligament rupture would be more common than collateral ligament rupture

Management

  • If isolated PCL injury, newer research suggests management in an extension splint (avoiding flexion) with a high density foam pad sitting behind the superior portion of the posterior tibia to prevent posterior subluxation
  • If other concurrent injuries, need to factor these in to management
  • WBAT
  • Refer on for followup – confirm Diagnosis – if unsure get another opinion – physiotherapist or sports physician or consider MRI if will change Mx
  • Surgery for PCL rupture is not anywhere as common as that for ACL rupture.
  • Following successful rehabilitation, most people are able to participate in twisting sports without a PCL
  • If the knee gives way, even in a sedentary patient, this is an indication for surgery as this will also lead to degenerative changes or meniscal damage

Posterolateral Corner

Injury

  • Mechanism is usually hyperextension with a varus force
  • The patient may complain of (or demonstrate) giving way into extension / varus which differs from an ACL deficient knee which tends to give way into flexion

Findings

  • Aside from tenderness over the involved structures (ie posterolaterally), severe posterolateral corner injuries usually present with laxity into extension +/- instability in extension (varus)
  • It is important to differentiate between a PCL injury and a PLC injury. On posterior draw test:
    • Knee is flexed to 90 and the amount of posterior tibial translation is assessed.
    • Reassess at 30. If increased here as well then the patient has an associated PLC injury.
  • Patients with significant laxity into extension / varus or those who are not resolving with time would benefit from MRI

Management

  • Posterolateral corner injuries with demonstrable laxity generally require surgical intervention or otherwise tend to be unstable

Meniscal Injury

Injury

  • Mechanism is usually rotation on a semiflexed knee
  • Can happen acutely or as a result of degenerative changes

Findings

  • Often injured on a semi-flexed knee with a rotary, medially or laterally directed force.
  • Can often occur in conjunction with other structures (MM – MCL and ACL)
  • Consider that tests for meniscal damage would also be +ve if there is other intraarticular pathology such as an osteochondral fragment or  loose body
  • Variable findings as usually injured in conjunction with other structures
  • May be restricted extension – last 30 degrees, if meniscal fragment blocking movement = “Pseudolocking”, not to be confused with pain at end of range (due to ligamentous injury)
  • May get stuck – unable to flex or extend – usually caused by a fragment lodged within the knee = “True Locking”
  • Swelling – may be extensive and reasonably quick – haemarthrosis
  • May have joint line tenderness

Management

  • The menisci have a poor blood supply and once outside the teenage years generally have a poor propensity to heal without surgical intervention
  • Nonetheless, as with most knee injuries, conservative management should be trialled.
  • There is no particular reason to limit weightbearing or ROM but deep squatting, twisting and sitting on low chairs should be avoided
  • For the non-athletic population, conservative management may be trialled, but if locking or pain persists, surgery may be inevitable.
  • If clinically unclear but still highly suspicious and adequate healing time has been given without success, MRI / specialist referral is advisable

Patello-Femoral Joint

  • PFJ problems are common in patients who:
    • Are young and female
    • Are overweight
    • Have a shallow trochlear groove
    • Have an increased Q angle (ie knock knees)
    • Have generalised ligamentous laxity

PFJ Dislocation

Injury

  • Usually a sporting or twisting mechanism
  • Usually feeling or visualisation of patella moving out of place
  • The patella may spontaneously reduce (don’t assume that it can’t be dislocated because if didn’t stay out)

Findings

  • Swelling may be substantial and relatively quick
  • Will usually have peripatellar tenderness
  • Positive apprehension test
  • Usually plain film to exclude fracture
  • The medial retinaculum is almost always ruptured, however this does not change management so US / MRI not indicated

Management

  • Zimmer Splint necessary – avoid knee flexion for 2/52 or until stability improves (may be a bit longer)
  • WBAT
  • Refer on for Physio followup – needs quads strengthening and taping / bracing
  • No sport for 6/52 or longer (needs at least 6/52 for adequate healing, but sometimes pain dictates a longer rehabiliation period).
  • Generally, if 3 or more dislocations, some sort of surgical intervention is required.
  • Surgical management of patellofemoral instability is largely not as successful as for other injuries (eg ACL reconstruction) and in the author’s opinion should be avoided where possible by a comprehensive rehabilitation program and PFJ taping / bracing
  • Obviously if conservative management fails, surgery or activity alteration is required.

PatelloFemoral Joint Pain

Injury

  • Also known as anterior knee pain / PFJ syndrome
  • Vague pain behind or around the patella generally without specific incident
  • Caused by poor tracking of the patella in the trochlear groove
  • Worse if has been sitting for long periods, down>up stairs

Findings

  • Generally only mild (if any) swelling
  • Pain on loading the quadriceps with the knee flexed (squat / stairs)
  • May have increased pain with knee flexion
  • May or may not have localised tenderness
  • May have involvement of the infrapatellar fat pad

Management

  • A comprehensive rehabilitation program, including quadriceps and VMO strengthening is required
  • Taping is quite effective in unloading painful structures


Tendinopathy

Injury

  • Tendinopathy involves a process of mucoid degeneration with neovessels (presence of neurovascular structures within the tendon) which is also known as “tendinosis” (tendon degeneration without inflammation).
  • Tendinopathy is usually the result of an inability to recover adequately from the load placed on the structure, which may be caused by or excessive activity (especially if a sudden increased in load) or biomechanical error such as:
    • Inappropriate footwear (poor shock attenuation)
    • Unforgiving running surfaces
    • Poor lower limb mechanics (eg increased force  required to supinate the foot)
    • Tight quadriceps / ITB
    • Poorly tracking patella
  • Patellar tendinopathy is more common than quadriceps tendinopathy and is especially common in athletes who jump frequently, such as basketballers, volleyballers and netballers (often called “jumper’s knee”)

Findings

  • Clinically, the patient usually has tenderness over the inferior pole of the patella however tendinopathy can also occur mid substance or at the site of insertion into the tibial tubercle
  • Generally only mild (if any) swelling
  • Pain on loading the quadriceps with the knee flexed (squat / stairs)
  • May have increased pain with knee flexion
  • May or may not have localised tenderness
  • May have involvement of the infrapatellar fat pad
  • Ultrasound can show extent of damage, however does not really change management

Grading

  • Tendinopathy is categorised into stages:
  • Stage 1 – Pain only after activity
  • Stage 2 – Mild symptoms until warmed up, then  pain after activity
  • Stage 3 – Pain that doesn’t warm up –  continually sore

Management

  • Correction of biomechanical irregularities
  • Eccentric exercise program
  • Relative rest
  • Recalcitrant cases may need additional Mx options – NO patches, sclerosing agents, autologous blood have all been used with additional effect; surgery is reserved for cases not responding to conservative Mx

Paediatric Overuse

Injury

  • The paediatric equivalent of patellar tendinopathy is  overuse at the bony interface.
  • Aside from the factors listed under tendinopathy, the child might have recently had a growth spurt and be particularly tight in the lower limb musculature, in particular the quadriceps

Findings

  • Clinically, the patient usually has tenderness over the inferior pole of the patella (Sinding Larsen Johannsen’s) or the tibial tubercle (Osgood Schlatter’s)
  • Generally only mild (if any) swelling
  • Pain on loading the quadriceps with the knee flexed (squat / stairs)
  • May have increased pain with knee flexion
  • X-ray may show fragmentation of the inferior pole or tibial tubercle

Grading

  • Grading is as per tendinopathy:
    • Stage 1 – Pain only after activity
    • Stage 2 – Mild symptoms until warmed up, then  pain after activity
    • Stage 3 – Pain that doesn’t warm up –  continually sore

Management

  • Correction of biomechanical irregularities
  • Eccentric exercise program
  • Relative rest and cautioning regarding potential for avulsion fracture if does not manage

Tendon Tears / Rupture

  • Failure can occur in the quadriceps tendon (above the patella) or the patella tendon (below the patella)
  • There is often a history of tendinopathy or the patient is in middle age

Findings

  • As with muscle strains, pain will be on stretch (knee flexion) and contraction of the quadriceps
  • There will be localised tenderness over the quadriceps or patellar tendons and in substantial tears, a palpable defect
  • If the patient cannot straight leg raise or initiate quadriceps and has tenderness over the quadriceps tendon or patellar tendon, they likely have a significant tear or rupture.
  • Confirmation may be required on ultrasound if clinical examination is not conclusive

Management

  • Substantial tears require surgical repair
  • Small tears may be managed conservatively in a Zimmer Splint and as per tendinopathy