**KNEE SPRAINS & INSTABILITY

ICD 9

LATERAL COLLATERAL SPRAIN 844.0

MEDIAL COLLATERAL SPRAIN 844.1

CRUCIATE SPRAIN 844.2

UNSPECIFIED SPRAIN 844.9

KNEE INSTABILITY 818.86

HEMARTHROSIS 719.1

CAPSULAR LIGAMENTS

•  Posterior compartment MCL , LCL, OBLIQUE POPLITEAL

•  LAT. COMPLEX -- Popliteus tendon, LCL, Arcuate lig.

•  MED. COMPLEX—MCL, Semimenbranousis Tendon, Oblique Popliteal ligament

•  ANTERIOR COMPARTMENT-- ARCUATE

INTRA-CAPSULAR LIGAMENTS

•  ACL

•  PCL

•  POSTERIOR MENISCOFEMORAL

•  LIG. OF WRISBERG posterior meniscofemoral ligament

•  LIG OF HUMPHREY anterior meniscofemoral ligament

•  TRANSVERSE (MENISCOMENISCAL)

DEFINITION & DISCUSSION

•  TRAUMATIC OVER STRETCHING OR TEARING OF LIGAMENTS

•  MOST COMMON GARDEN VARIETY SPRAIN—MCL, Valgus or hyperextension

•  MOST COMMON SEVERE SPRAIN-- ACL

•  KNOW THE 3 GRADES OF SEVERITY

•  UNHAPPY TRIAD OF O'DONAHUE- MCL, ACL, Medial Meniscus

MECHANISM / ETIOLOGY (DETAILS IN NOTES)

•  VALGUS – MCL & ACL MOST LIKELY

•  VARUS – LCL & ACL MOST LIKELY

•  A ® P FORCE – PCL MOST LIKELY (MVA?)

•  P ® A FORCE – ACL MOST LIKELY

•  HYPEREXTENSION – ALL LIGS. AT RISK; POST CAPSULE, ACL, & MCL MOST LIKELY

•  INTERNAL ROTATION – ACL & LAT. COMPL.

•  EXTERNAL ROTATION – ACL & MEDIAL COMPLEX

HISTORY

•  AGE—May play a role in the weak link in the joint

•  MECHANISM EXTREMELY IMPORTANT

•  LOCATION OT PAIN

•  HOW LOCALIZED IS THE PAIN

•  HOW MUCH PAIN

•  IS IT GETTING BETTER OR WORSE

•  HOW MUCH SWELLING

•  SIGNIFICANCE

•  “POP” – 7 THINGS IT COULD BE?

•  1) ACL

•  2) PCL

•  3) LCL

•  4) MCL

•  5) Fracture

•  6) Knee dislocation

7) Meniscus

•  WHAT IS MOST COMMON INJURY WHEN PAIN & SWELLING ALSO OCCURS?

•  WHEN DID SWELLING BEGIN? (if it began today and swelled up it may be a hemarthoses)

•  FEELING OF INSTABILITY (ie GIVING AWAY)?

EXAMINATION

•  DEGREE OF ANTALGIA (4 step test)

•  LOCATION OF TENDERNESS?

•  LOCATION & EXTENT OF SWELLING?

•  LOCATION & EXTENT OF ECCHYMOSIS?

•  HEMARTHROSIS? SIGNIFICANCE—most common cause is an ACL tear, a fracture may also be present

•  ORTHOPEDIC TESTS (see lab notes)

•  SINGLE PLANE / DIRECTIONAL

•  MULTIDIRECTIONAL Slocum or pivot shift

•  XRAYS? MRI?

ORTHOPEDIC TESTS – SEE LAB NOTES

•  “GOLDEN PERIOD” starts about 5 min after injury and lasts for 30-60 min

•  SAG SIGN

•  A. – P. DRAWER & SLOCUMS

•  PIVOT SHIFT

•  VALGUS STRESS (0 & 30 °)

•  VARUS STRESS (0 & 30° )

•  MAY HAVE TO WAIT WEEKS OR MONTHS AFTER GOLDEN PERIOD TO ACCURATELY EVALUATE STABILITY

HEMARTHROSIS

•  RAPID, EXTENSIVE SWELLING

•  DISCOLORATION

•  MOST COMMON CAUSE—ACL tear

•  OTHER CAUSES

•  PATELLA DISLOCATION

•  OSTEOCHONDRAL FX

•  SEVERE MENISCAL TEAR (RARE)

•  PCL TEAR

•  UNHAPPY TRIAD

•  BLEEDING DYSCRASIA – DRUGS? I.e. Aspirin

•  WHAT TO DO? Refer for aspiration

XRAY DECISION MAKING

•  OTTOWA GUIDELINES ( 18 YRS & OLDER )

•  55 YRS OR OLDER

•  ISOLATED BONY TENDERNESS (ESPECIALLY FIBULAR HEAD OR PATELLA)

•  INABILITY TO FLEX 90 DEGREES

•  + 4 STEP TEST

•  LATER – FAILURE TO RESPOND, WORSENING, INSTABILITY, OR ABILITY TO BEAR WT DOESN'T IMPROVE

•  RULES DON'T APPLY WHEN INTOXICATION, HEAD INJURY, PARAPLEGIA, ¯ SENSATION, & MULTIPLE INJURIES ARE INVOLVED, if injury is > 10 days old

SEVERITY

•  GRADE 1 – TREAT CONSERVATIVELY!

•  LOCALIZED PAIN & SWELLING

•  NO LAXITY ON STRESS TESTS

•  NO HEMARTHROSIS

•  GRADE 2 – TREAT MCL & LCL ; REFER ACL & PCL FOR 2 ND OPINION

•  MORE PAIN & SWELLING (LESS LOCALIZED)

•  SLIGHT LAXITY ON STRESS TESTS

•  FIRM LIGAMENTOUS END POINT

•  MORE SWELLING / HEMARTHROSIS RARELY

•  GRADE 3 – BEST TO REFER

•  SIGNIFICANT LAXITY ON STRESS TESTS

•  SOFT OR EMPTY END POINT

•  END POINT PAIN?

•  HEMARTHROSIS COMMON

•  DISLOCATED KNEE – MEDICAL EMERGENCY!

ACUTE TREATMENT

•  SAME PRINCIPLES AS ANKLE

•  P.R.I.C.E.S.

•  ELASTIC WRAP/SLEEVE

•  UNIVERSAL IMMOBILIZER

•  LOCK-OUT BRACE

•  CRUTCHES 1-2 weeks

•  TAPE?

POST ACUTE TREATMENT

•  SAME PRINCIPLES AS ANKLE

•  LET PAIN, SWELLING, LAXITY & WT BEARING GUIDE THE PROGRESSION

•  EARLY PAINFREE ACTIVE NON-RESISTIVE ROM EXERCISES / POOL EXERCISES / CRYO-KINETICS

•  ISOMETRIC SLR & OTHER SETTING EXERCISES EARLY AS TOLERATED

•  PROGRESS TO QUAD & HAM ISOTONICS AS TOLERATED

•  WALK – JOG – RUN PROGRESSION (LATER)

POST ACUTE TREATMENT

•  CLOSED VS OPEN CHAIN RESISTED EXERCISES

•  OPEN - NO SIGNIFICANT CO-CONTRACTION OF ANTAGONISTS & STABILIZERS; MORE STRESS ON LIGAMENTS; better latter to isolate

•  CLOSED – CO-CONTRACTION REDUCES LIGAMENTOUS STRESS (especially on cruciates) – THUS ARE PREFERRED TO OPEN CHAIN UNTIL LATER IN REHABILITATION WHEN LIGAMENTS ARE HEALED

HINGED BRACES

•  OTC – USES? COST?

•  CUSTOM OTC – USES? COST?

•  CUSTOM CAST – USES? COST?

PROPHYLACTIC KNEE BRACING (REID, 1992)

•  CONTROVERSIAL

•  MOST AGREE TO ONLY BRACE THE UNSTABLE KNEE

•  LITTLE EVIDENCE TO SUPPORT PROPHYLACTIC BRACING THE STABLE KNEE

RUNNING PROGRESSION (REID, 1992)

•  SAME AS ANKLE

•  START W/ WALKING OR AQUAJOGGER

•  JOGGING AFTER 1 WK WALKING

•  STRAIGHT AHEAD RUNNING NEXT

•  DIRECTION CHANGES LATER

•  DECELERATION LAST

•  BRACE OR TAPE DURING

•  ICE AFTER

ROTATIONAL INSTABILITY (Review Biomech. 4 notes)

•  KNOW ANTEROLATERAL & ANTEROMEDIAL

n REFER MULTIDIRECTIONAL / ROTATIONAL INSTABILITIES

u Anterolateral – ACL & lateral capsule damage (+ Slocum's/interally rotated)

u Anteromedial – ACL & medial capsule damage (+ Slocum/externally rotated)

u Posteromedial – PCL & medial capsule (+ Posterior drawer / internal rotation)

u Posterolateral – PCL & lateral capsule damage (+ Posterior drawer / external rotation)

 

INSTABILITY TX

•  BEST TO GET 2 ND OPINION

•  HYPERMOBILITY & MILD INSTABILITY BEST TX'D CONSERVATIVELY (focus on 2° stabilizers)

•  MAY PREDISPOSE TO PATELLAR, MENISCUS TEARS, ITB & PES ANSERINE PROBLEMS

•  STRENGTHENING KEY MUSCLE GROUPS & BRACING ARE KEYS TO TX (review 2ndary stabilizers)

•  SIGNIFICANT ACL, MCL, LCL, MULTI- DIRECTIONAL, & ROTATIONAL INSTABILITY – ORTHOPEDIC REFERRAL

•  PCL TEARS BEST TX'D CONSERVATIVELY (closed chain Quadriceps exercises are key to rehab. program)

•  KEY TO ACL REHABILITATION ARE HAMSTRING STRENGTHENING, BUT CLOSED CHAIN SQUATS ARE ALSO IMPORTANT

 

**Disclaimer The information in this medical library is intended for informational and educational purposes only and in no way should be taken to be the provision or practice of chiropractic, medical, or professional healthcare advice or services. This information is from third parties such as: NIH, American Medical Journal, AMA, Dr. Carnes, & WSSC. The information should not be considered complete or exhaustive and should not be used for diagnostic or treatment purposes without first consulting with your chiropractor, physician or other healthcare provider. The owners of this website accept no responsibility for the misuse of information contained within this website. BIG does not review or endorse accuracy or effectiveness of materials and treatments in this library.

 

 

Chiropractic & Physical therapy to the Portland metro area: West Linn, Oregon City, Lake Oswego, and Tualatin. Owner & Chiropractor. Ryan Lambert Bellacov will give professional service to bring you pain relief. www.bigsportsmed.com; Dr. Ryan Lambert Bellacov with years of experience working with athletics.