Knee Ligament Injuries

1. Knee Ligament Injuries

2. The ligaments around the knee are strong. However, • sometimes they can become injured. Ligaments injury Sprained Ruptured Majority tend to stretched and quickly settle down Partial Complete Knee injuries by LakeeshaPerera

3. There are a number of different things that can cause • injury to the ligaments in your knee: • You may have a direct blow to your knee or knock • into something with your knee. • Your knee may be moved outside of its usual range of • movement. For example, this can happen during a • fall, if you land awkwardly during sport, or after a • sudden movement. Knee injuries by LakeeshaPerera

4. Sprains and partial tears • Intact fibers splint the torn ones and so spontaneous healing will occur • Adhesions may result, so active exercise is prescribed • Aspirating the haemarthrosis and applying ice packs intermittently relieves pain • Weight-bearing is allowed • Knee is protected from rotation or angulation strains by a heavily padded bandage or a functional brace Knee injuries by LakeeshaPerera

5. Complete tears • Isolated MCL or LCL treated as above • Isolated tears of ACL may be treated by early operative reconstruction if the individual is a professional sportsman • Cast-brace is worn until symptoms subside, thereafter movement and muscle-strengthening exercise. This is sufficient in about half of the patients as they regain good function and need no further treatment. • Remainder will have varying instability, late assessment will identify those who will benefit from ligament reconstruction. • Isolated tears of the PCL are usually treated conservatively Knee injuries by LakeeshaPerera

6. Combined injuries • In ACL and collateral ligament injury treatment starts with joint bracing and physiotherapy to restore a good range of movements before ACL reconstruction • Combined injuries involving the PCL the same approach is used however all damaged structures need to be repaired Knee injuries by LakeeshaPerera

7. Complications • Adhesions • If the knee with a partial ligament tear is not actively exercised, torn fibers will stick to intact fibers and bone. • The knee gives way with catches of pain, localized tenderness and pain on lateral or medial rotation occur • Confusion with a torn meniscus can be resolved by the grinding test or arthroscopy • Instability • The knee continues to give way and tends to get worse predisposing to osteoarthritis. Reconstruction before degeneration is wise. Knee injuries by LakeeshaPerera

8. Grading Ligament Injuries Knee injuries by LakeeshaPerera

9. Anterior cruciate ligament injury • ACL injury most often occurs during sports such as • football, basketball, skiing and tennis. • The injury often happens if you land on your leg and • then quickly pivot or twist your knee in the opposite • direction. • About half of people with an ACL injury also have injury • to their meniscus or another ligament in the same knee. • Woman > men Knee injuries by LakeeshaPerera

10. Types of ACL Tears Knee injuries by LakeeshaPerera

11. Physical Exam of the Knee • Inspection • Palpation • Range of Motion • Special tests • Neurovascular assessment Knee injuries by LakeeshaPerera

12. ACL: HISTORY • Contact vs noncontact • Immediate effusion (first 4-12 hr) • Unable to continue • Mechanism = pivot, hyperextension Knee injuries by LakeeshaPerera

13. ACL Special Tests • Anterior drawer • Lachman test • Pivot shift test • Valgus stress test at full extension! Knee injuries by LakeeshaPerera

14. ACL: PHYSICAL EXAM • Decreased ROM • Effusion-hemarthrosis, immediate • + Instability tests • Lachman: most accurate • Pivot shift • Anterior drawer • + MCL and meniscus tests Knee injuries by LakeeshaPerera

15. “Partial” ACL tear • > 40% ACL substance • + Lachman, - pivot shift • Clinically • Most behave functionally as full tears • Continued shifting ↑’s risk of meniscus damage • Rx as full tear Knee injuries by LakeeshaPerera

16. ACL TREATMENT • Grade 3- Nonsurgical • modify activity • splint & crutches, Closed chain WB to strengthen • PRICES • Hamstrings, gastroc! • Functional bracing • 100% @ 9-12 months Knee injuries by LakeeshaPerera

17. ACL TREATMENT • Grade 3 Injuries- Surgery • Indications • Most active people will require surgery to restore adequate function and decrease instability • Recurrent instability • Inability to modify activity • Associated injuries: meniscus • Age • Wait three weeks due to arthrofibrosis risk • 100% @ 6-12 months Knee injuries by LakeeshaPerera

18. Posterior cruciate ligament injury • Not as common as an ACL injury. • Because the PCL is wider and stronger than the ACL. • PCL sprains usually occur because the ligament was • pulled or stretched too far, anterior force to the knee, or a • simple misstep. • PCL injuries disrupt knee joint stability because the tibia • can sag posteriorly. Knee injuries by LakeeshaPerera

19. The ends of the femur and tibia rub directly against • each other, causing wear and tear to the thin, smooth • articular cartilage. • This abrasion may lead to arthritis in the knee • There are a number of ways that the PCL can become • injured. • For example, • It may be injured during a car accident if the front of • your bent knee hits the dashboard. Knee injuries by LakeeshaPerera

20. It may also be injured from falling on to your bent knee. • Your PCL can also be injured if your knee is hit from the • front whilst your leg is stretched out in front of you with your • foot on the ground - for example, during a game of football. Knee injuries by LakeeshaPerera

21. At first, some people with a PCL injury may not have • much in the way of symptoms . • It may take a while for you to realize that there is a • problem. • For example, you may later notice pain that comes on • when going up and down stairs or when starting a run; or, • your knee may feel unstable when walking on uneven • ground. Knee injuries by LakeeshaPerera

22. PCL INJURIES PHYSICALEXAM • + Effusion • + Posterior drawer test • + Posterior sag sign • False positive Lachman test • Common to have isolated injuries Knee injuries by LakeeshaPerera

23. PCL INJURIES TREATMENT • PRICES • Functional bracing (early) • Rehab • Surgery if continued instability, effusions Non-operative • Aggressive rehab • Focus quadriceps • No support for bracing • closed kinetic chain • Open kinetic chain extension avoided • 90% quads strength prior to normal athletics Knee injuries by LakeeshaPerera

24. Medial collateral ligament injury • Injuries to the MCL can happen in almost any sport and • can affect people of all age groups. • They often happen when your leg is stretched out in front • of you and the outer side of your knee is knocked at the • same time - for example, during a rugby or football tackle. Knee injuries by LakeeshaPerera

25. MCL INJURIES PHYSICAL EXAM • Tender to palpation along MCL • Pain + instability with valgus stress • 30o flexion = MCL • 90o flexion = associated ACL • Pain with Apley’s distraction test • COMPARE SIDES

26. MCL INJURIES Treatment Of Grade 1 &2 • Early mobilization • Weight-bearing as tolerated • Hinged knee brace • PRICES • Recovery 4-6 weeks Knee injuries by LakeeshaPerera

27. MCL INJURIES Treatment of Grade 3 (full tears) • Isolated = nonsurgical management • Combined = surgery consistent with associated injuries • Natural Hx = lack of long-term degenerative changes seen with ACL, meniscus Knee injuries by LakeeshaPerera

28. Lateral collateral ligament injury • Injury to the LCL is less common than injury to the MCL. This • is because your other leg usually protects against injury to the • inner side of your knee. • (It is usually a direct blow to the inner side of your knee that • causes an LCL injury.) • But, this ligament injury can sometimes happen if one leg is • stretched out in front of you and doesn't have the other leg for • protection - for example , during a rugby or football tackle. Knee injuries by LakeeshaPerera

29. What are the symptoms of a knee ligament injury? If you have injured one or more of the ligaments in your knee, the symptoms are likely to be similar regardless of the ligament that is injured. The severity of the symptoms depends on the degree of the injury to the ligament. For example, a ligament that is completely torn may produce more in the way of symptoms than a ligament that is just sprained (stretched).  Knee injuries by LakeeshaPerera

30. Symptoms can include: 1.A popping sound, or a popping or snapping feeling 2. Swelling of your knee. Can hear at the time of injury if ligament completely torn Bleeding inside from the damaged ligament It leads to swelling Completely torn ligament Minor ligament sprains Knee injuries by LakeeshaPerera

31. 3. Pain in your knee. depend on the severity of the knee injury. 4.Tenderness around your knee on touching. This may be minor sprains ----mild tenderness over the actual ligament ligament torn -----more generalised and severe tenderness 5. Not being able to use or move your knee normally. complete ligament tears--- severely reduce minor sprains----relatively good Knee injuries by LakeeshaPerera

32. 6. A feeling that your knee is unstable or perhaps giving way if you try to stand on it. This may cause you to limp. Again, this depends on how severe the ligament injury is. You may be able to stand if you only have a minor sprain. 7. Bruising around your knee can sometimes appear, although not always. It may take some time for bruising to develop. Knee injuries by LakeeshaPerera

33. Historical Clues to Knee Injury Diagnoses Knee injuries by LakeeshaPerera

34. Special tests for ligaments Posterior Cruciate Anterior Cruciate • Assess stability of 4 knee ligaments via applied stresses* Medial Collateral Lateral Collateral Knee injuries by LakeeshaPerera

35. The stabilizing roles of each ligament include: • prevents the knee from buckling inwards (valgus injury) • prevents the knee from buckling outwards (varus injury) • prevents the tibia from sliding forward under the femur • prevents the tibial from sliding backward under the femur MCL LCL ACL PCL Knee injuries by LakeeshaPerera

36. Stress Testing of Ligaments • Use a standard exam routine • Direct, gentle pressure • No sudden forces • Abnormal test • Excessive motion = laxity • Soft/mushy end point** Knee injuries by LakeeshaPerera

37. Normal Stability • Normal test is no motion with varus and/or valgus stress • with knee in neutral and 30 degrees of flexion • Lachman’s test assesses Anterior Cruciate Ligament: • Normal test is <5mm of forward movement of tibia on • femur with knee at 30 degrees of flexion • With knee in 90 degrees of flexion and foot stabilized, normal test will have <5mm of anterior motion (assessing ACL) or <5mm of posterior motion (assessing PCL) Medial and Lateral collateral ligaments • Anterior and Posterior Cruciate Ligaments' control anterior/posterior motion • Anterior and posterior drawer testing assesses ACL and PCL Knee injuries by LakeeshaPerera

38. Normal end point of ligament that examiner feels with applied stress is FIRM. A soft or mushy end point implies ligament damage (stretching or complete tear). Knee injuries by LakeeshaPerera

39. Collateral Ligament Assessment Patient and Examiner Position* Knee injuries by LakeeshaPerera

40. *Position patient supine on table with thigh resting on edge of exam table and foot supported by examiner • Knee in 30 degrees of flexion – • WHY? Increased laxity of medial side of knee in extension may indicate additional damage to posterior structures (posterior joint capsule & PCL) Knee injuries by LakeeshaPerera

41. Valgus Stress Test for MCL* Note Direction Of Forces Knee injuries by LakeeshaPerera

42. *VALGUS (MCL) stress • Proximal hand on lateral aspect of knee holds and stabilizes thigh • Distal hand directs ankle laterally • Attempt to open knee joint on medial side • Estimate the medial joint space and evaluate the stiffness of motion. • Positive test = Significant gap in medial aspect of knee with valgus stress = MCL injury. Knee injuries by LakeeshaPerera

43. Varus Stress Test for LCL* Note direction of forces Knee injuries by LakeeshaPerera

44. *VARUS (LCL) Stress • Supine position, with knee at 20 to 30 degrees of flexion and thigh supported. • Stabilize medial aspect of knee and push ankle medially, trying to open knee joint on lateral side • Disruption of LCL is indicated by difference in degree of lateral knee tautness with varus stress. Compare affected knee to uninjured side Knee injuries by LakeeshaPerera

45. Lachman Test* • Patient Position • Physician hand placement Knee injuries by LakeeshaPerera

46. *Lachman Maneuver more sensitive and specific for ligamentous tears than drawer sign. • Patient is supine • Knee flexed to 20-30 degrees • Hand placement: • Grasp and stabilize patient’s thigh just proximal to patella • With opposite hand, try to move proximal tibia forward on femur • POSITIVE TEST = Excessive forward motion of tibia (>5mm) without firm endpoint indicates ACL damage Knee injuries by LakeeshaPerera

47. Modification for patient with large thighs: • Thigh placed over knee of examiner • Push downward on femur with hand while other hand grasps proximal tibia, attempting to move it anteriorly Knee injuries by LakeeshaPerera

48. Lachman Test • View from lateral aspect* Note direction of forces Knee injuries by LakeeshaPerera

49. Anterior Drawer Test for ACL • Physician Position & Movements* • Patient Position Note direction of forces Knee injuries by LakeeshaPerera

50. *Patient Position • Supine • Flex hip of affected knee to 45 degrees • Bend knee to 90 degrees • Patient's foot planted firmly on examination table • Physician position: • Sitting on dorsum of foot, place both hands behind knee • Once hamstrings relaxed, try to displace proximal leg anteriorly • Anterior drawer test is LESS SENSITIVE for ACL damage than Lachman’s Maneuver Knee injuries by LakeeshaPerera