KNEE PAIN & INJURY
YOUR DIAGNOSIS IS: ACL RUPTURE
Tear of (arguably) the most important ligament that provides stability to the knee joint
It presents like this:
· An acute injury that usually involves landing from a jump, pivoting or decelerating suddenly à most are non-contact
· An audible “pop” or “crack” is usually felt à in these instances ACL injury should be suspected until ruled out via MRI
· Often people will return to activity after the initial event and then have to stop due to lack of confidence or buckling in the knee
It feels like this at rest:
· Swelling is usually quite pronounced and can take between 24 and 48 hours to completely develop
· Pain levels are varied and may be compounded by damage to other structures in the knee joint such as the meniscus or lateral ligaments
YOUR DIAGNOSIS IS: PCL RUPTURE
The Posterior cruciate ligament is the primary restrain to posterior movement of the femur on the tibia and secondary restraint to external rotation behind posterolateral corner structures.
PCL tears typically occur as a result of a direct force to the anterior tibia with the knee in a flexed position such as occurs in motor vehicle accidents/ from contact from an opponent during sports or falling on a hyperflexed knee. Hyperextension is another common mechanism of injury resulting in injury to the PCL.
Often the symptoms and pain are poorly defined and vague mostly commonly located to the posterior knee and sometimes involving the calf. As the PCL is an extra synovial structure there is not often a lot of associated swelling that occurs with a PCL tear.
YOUR DIAGNOSIS IS: MCL RUPTURE, or, Medial Collateral Ligament Injury
MCL injuries are commonly the result of a valgus stress to the knee when partially flexed. This can occur during both non-contact and contact incidents. The severity of a MCL injury is determined by 3 grades: grade 1 – mild sprain, grade 2 – moderate sprain/ partial tear, and grade 3 – complete tear. Grade 1 will be characterised by local tenderness over the MCL, with no swelling and or laxity on valgus stress testing. Grade 2 will often be more symptomatic and demonstrate laxity of the MCL on testing, however with a distinct end feel and stable on extension. Grade 3 will be characterised by laxity of the MCL on testing and no end feel, with reported instability. Grade 3 may present swelling if associated capsular tearing is present. MCL injuries may also present in the occurrence of an ACL injury due to the valgus mechanism.
You can expect to feel local tenderness of the MCL and surrounding area depending on the severity of the injury. Ligament laxity and instability may be felt with more severe sprains. Walking up and down stairs may be challenging, in addition to changing directions while walking/ running. A history of poor single leg biomechanics, including strength and control may be predisposing factors to develop an MCL injury.
YOUR DIAGNOSIS IS: ACUTE MENISCAL TEAR
The menisci (medial and lateral) are fibrocartilaginous discs located between your femur and tibia that act as shock absorbers buffering forces placed on the knee joint. By increasing the concavity of the tibia they also help to stabilize the knee and contribute to joint lubrication and nutrition.
Meniscal tears occurring in the younger population most commonly occur as a twisting injury on a slightly flexed knee with the foot planted on the ground often in sporting situations. However meniscal tears can also occur with minimal trauma in the older adult as a result of degenerative change of the meniscus. Meniscal tears are categorised by their type, tear orientation and zone/ location.
The degree of pain associated with an acute meniscal injury can vary considerably based on the type, location and degree of tear. Acute meniscal tears will be characterised by medial or lateral knee pain and swelling that sometimes develops over the course of 24 hours. In severe cases painful restricted ROM in particular flexion is present and intermittent clicking or locking may also occur as the result of a torn flap of the meniscus impinging between the articular surfaces. Some giving way may also occur but often this is a representation of the resultant swelling and quadriceps inhibition rather than a true ligamentous instability that may occur for example in ACL injuries however it is important to note due to the high occurrence of meniscal tears in association with ACL injuries.
YOUR DIAGNOSIS IS: PATELLA DISLOCATION
Patella dislocation occurs when the patella is displaced laterally from within the trochlear groove of the femur. This most often reduces spontaneously however in some cases it may stay out of place for some time causing considerable pain and discomfort. Patella dislocations typically occur with a history of a traumatic force such as that occurs with twisting or jumping or atraumatic which occurs usually with associated ligamentous laxity and without a significant trauma. Patella dislocations are associated with a giving way sensation in the knee, an audible “pop” and the development of severe pain. One often describes a feeling of the knee “going out” or “moving out” of place and is then followed by a relatively immediate onset of intra articular swelling/ hemarthrosis.
During the physical assessment there is often a gross effusion, positive patella apprehension test and tenderness along the medial border of the patella. It is important during initial examination to differentiate from an acute ACL rupture as they both follow similar histories and consequent swelling. During physical examination it is also important to identify the factors which may predispose one to patella dislocation.
We initially manage these with a conservative physiotherapy management plan initially focussing on the resolution of swelling, restoration of knee ROM, in particular extension and quadriceps strength. In some cases such as a second or third dislocation and in the presence of associated injuries such as osteochondral fractures and significant disruption to the medial patellofemoral ligament surgery may be advocated.
Longer term the most important goal of rehabilitation is to prevent and reduce the chances of a recurrence and further patella dislocation. This is achieved through a comprehensive rehab program focussing on the restoration of quadriceps and hamstring strength, lumbopelvic strength and stretching of the lateral structures of the thigh and knee.
As with all injuries an absence of effusion, full ROM, restoration of strength and movement and a full specific return to sport program must be completed before achieving a return to sport clearance.
Long term typically patients will achieve excellent subjective and objective results regardless of the amount of laxity and studies show a good return to sport and full function rates with conservative management.
iii. Tendon rupture – quad/ patella tendon
YOUR DIAGNOSIS IS: PATELLA TENDINOPATHY
The patella tendon is located just below your knee attaching the patella to the tibial tuberosity. It is an important part of the extensor mechanism and transfers the force from the quadriceps muscle to the tibia to extend the leg.
Patella tendinopathy typically occurs as a result of a progressive overload on extensor mechanism typically in the form of a sudden increase in activity and stress on the anterior knee such that occurs in jumping sports like basketball, volleyball and long jumping. The patient will often complain of anterior knee pain aggravated by activities such as jumping, landing, changing direction and decelerating. It is important to distinguish patella tendinopathy from patellofemoral pain and other classic characteristics that define patella tendinopathy include an onset of pain upon rising in the morning and occurring at the start of activity that settles after warm up and returns upon cessation of activity is a classic presentation.
On physical assessment the tendon is typically tender on palpation at the inferior pole of the patella and can be associated with a thickening of the tendon. Pain is characteristically reproduced with squatting and hopping and other possible precipitating factors are also assessed such as quadricep muscle strength and atrophy. A visa-p questionnaire is also another useful tool used to monitor the clinical progress of one with patella tendinopathy.
We initially manage these by appropriate load reduction and management principles first and foremost. This doesn’t mean complete cessation of activity but relative rest and offloading as it is vital for continued load on the tendon to maintain tendon integrity. Strengthening and correcting biomechanical factors to improve the energy absorbing capacity of leg targeting the musculo-tendinous unit and the hip and ankle also forms a very important part of rehab as often one experiencing patella tendinopathy will tend to offload the affected side to avoid pain often leading to weakness and abnormal motor patterns.
Long term a progressive strengthening program is essential beginning with isometric exercise in the load intolerant knee progressing to isotonic strengthening in the form of heavy slow resistance and eccentric training through to plyometric exercise to improve energy storage and release of the patella tendon.
For a 100% return to sport clearance completion of a full and comprehensive strengthening, movement education program, plyometric and return to run program must be completed.
h. Articular cartilage injury
i. Fat pad impingement
j. Fracture of tibial plateau
k. Superior tibiofibular injury
l. Coronary ligament sprain
ii. Patella tendinopathy
iii. Osgood-Schlatter lesion
iv. Sinding-Larsen-Johansson lesion
vi. Synovial plica
i. Pes anserinus tendinopathy/ bursitis
ii. Pellegrini-Stieda Syndrome
ii. Bicep femoris tendinopathy
i. Popliteus tendinopathy
ii. Gastrocnemius tendinopathy
iii. Baker’s cyst