The Acute Knee: A Handbook for Sports Medicine Physicians 3031328434, 9783031328435

Table of contents :
Reviews of This Book
Acknowledgments
Contents
Introduction
1: General Considerations
1.1 The History
1.2 The Physical Examination
1.3 Treatment Considerations
1.3.1 Early Care (First Visit)
1.3.2 Second Visit
2: Acute Patella Injury
2.1 Introduction
2.2 Acute Patella Dislocation
2.2.1 History
2.2.1.1 How Did You Hurt Your Knee?
2.2.1.2 Was It a Fall?
2.2.1.3 Did You Twist Your Knee?
2.2.1.4 Did You Hear a Pop or a Snap?
2.2.1.5 Did Your Kneecap Feel Like It Popped Out of Place?
2.2.1.6 Were You Able to Continue Your Activity?
2.2.1.7 When Did the Knee Swell?
2.2.1.8 Did This Ever Happen to You Before?
2.2.1.9 Did Your Other Knee Ever Pop Out of Socket?
2.2.1.10 Did Anyone Else in Your Family Ever Dislocate Their Patellae?
2.2.2 Physical Examination
2.2.2.1 Examine the Unaffected Knee (See Video 1.3, Chap. 1 and Table 2.1)
2.2.2.2 Examine the Injured Knee
Observation
Palpation
The Apprehension Test (Video 2.1)
2.2.3 Treatment Plan
2.2.3.1 Early Care
2.2.3.2 Second Visit
2.2.4 Factors Influencing Your Decision-Making
2.2.4.1 Predisposing Factors
Age
Activity Level
Occupation
Family History/Bilateral
Associated Injury
Rehability
2.2.5 Differential Diagnosis of an Acute Patella Dislocation
2.2.6 Treatment Recommendation
2.3 Acute Patella Subluxation
2.3.1 History
2.3.2 Physical Examination (See Table 2.2)
2.3.3 Treatment Plan
2.3.3.1 Early Care
2.3.3.2 Second Visit and Treatment Recommendation
3: Medial Collateral Ligament (MCL) Injury
3.1 Introduction
3.2 The History
3.2.1 How Did You Get Hurt?
3.2.2 Did You Hear a Pop?
3.2.3 Were You Able to Continue Your Sport or Activity?
3.2.4 When Did the Knee Swell?
3.2.5 Were You Treated for the Injury?
3.2.6 Did You Ever Hurt This Knee Before?
3.3 Physical Examination
3.3.1 Observation
3.3.2 Palpation
3.3.3 Valgus Stress Testing (Video 3.1)
3.4 Differential Diagnosis
3.5 Treatment
3.5.1 Early Care
3.5.2 Second Visit and Treatment Plan
4: Anterior Cruciate Ligament Injury
4.1 Introduction
4.2 The History
4.2.1 How Did You Hurt Your Knee? Was It a Twist or Direct Fall? Did You Hear a Pop? Could You Continue Your Activity? Did You Need Help Tin Getting Up? Were You Able to Walk On It? If Yes, How Did It Feel? Wobbly?
4.2.2 Did your Knee Swell? When?
4.2.3 Have You Ever Hurt Your Knee Before?
4.2.4 Are You Active in Sports? What Do You Play? How Often?
4.2.5 What Type of Work Do You Do?
4.2.6 Have You Hurt Your Other Knee? Anyone Else in Your Family Hurt Their Knee?
4.2.7 What Level of School Are You In?
4.3 Physical Exam
4.3.1 Observation
4.3.2 Examine the Unaffected Knee
4.3.3 Neurovascular Assessment
4.3.4 Palpation
4.3.5 Apprehension Test
4.3.6 The Lachman Test (Video 4.1)
4.3.7 The Pivot Shift (Video 4.2)
4.3.8 The Dial Test (Video 4.3)
4.3.9 The Anterior Drawer Sign (Video 4.4)
4.3.10 Meniscal Evaluation
4.3.11 Differential Diagnosis
4.4 Treatment Plan
4.4.1 Early Care
4.4.2 The Second Visit
4.5 Factors Influencing Your Decision-Making
4.5.1 Age
4.5.2 Activity Level
4.5.3 Associated Injuries
4.5.4 Rehability
4.5.5 Family History
4.5.6 Gender
4.5.7 Occupation
4.5.8 Body Habitus/Laxity
4.6 Treatment Recommendations
5: Posterior Cruciate Ligament (PCL) Injury
5.1 Introduction
5.2 History
5.2.1 How Did You Get Injured?
5.2.2 Did You Hear a Pop or Snap?
5.2.3 Were You Able to Continue Your Activity?
5.2.4 Did Your Knee Swell? When?
5.2.5 Did You Ever Hurt the Knee Before?
5.2.6 Any Numbness or Pins and Needles in Your Leg?
5.3 Physical Examination
5.3.1 Observation
5.3.2 Neurovascular Assessment
5.3.3 ROM
5.3.4 Joint Line Tenderness
5.3.5 Drop-Back Sign (Video 5.1)
5.3.5.1 Lachman Test and Anterior Drawer Sign
5.4 A Negative Lachman and a Positive Anterior Drawer Sign
5.4.1 Represents a PCL Tear Until Proven Otherwise!
5.4.1.1 Posterior Drawer Sign (Video 5.2)
5.4.2 Differential Diagnosis
5.5 A Negative Lachman and a Positive Anterior Drawer Sign Is a PCL TER Until Proven Otherwise
5.5.1 Treatment
5.5.1.1 Early Care
5.5.2 Second Visit and Treatment Recommendations
6: Multi-Ligamentous Knee Injury
6.1 Introduction
6.2 Posterolateral Ligament Disruption
6.2.1 History
6.2.1.1 How Did the Injury Happen?
6.2.1.2 Did You Hear a Pop?
6.2.1.3 Could You Continue Your Activity?
6.2.1.4 Did Your Knee Swell? When?
6.2.1.5 Did You Ever Hurt Your Knee Before?
6.2.2 Physical Examination
6.2.2.1 Observation
6.2.2.2 Neurovascular Assessment
6.2.2.3 Tenderness
6.2.2.4 Pseudo-Varus Deformity
6.2.2.5 Varus Stress
6.2.3 Treatment
6.2.3.1 Early Care
6.2.4 Treatment Recommendations
6.3 Multi-Ligament Injuries (Dislocated Knee)
6.3.1 History
6.3.1.1 What Happened?
6.3.1.2 Did You Hear a Pop?
6.3.1.3 Could You Continue Your Activity?
6.3.1.4 Did It Swell? When?
6.3.1.5 Neurovascular Questions
6.3.1.6 Can You Feel Your Toes? Do You Have Any Tingling? Where Is the Tingling? Can You Feel the Big Toe? Does Your Entire Foot Feel Sleepy? Can You Move Your Toes?
6.3.1.7 How Would You Grade Your Pain? Is the Pain Getting Worse? Does It Hurt to Move Your Foot, Toes, Ankle? Is the Pain Getting Worse and Worse Despite Being Immobilized?
6.3.1.8 Did You Ever Hurt Your Knee Before?
6.3.2 Physical Examination
6.3.2.1 Observation
6.3.2.2 Neurovascular Assessment
6.3.2.3 Tenderness
6.3.2.4 Ligament Evaluation
6.3.3 Treatment
6.3.3.1 Early Care
6.3.4 Treatment Recommendations
7: Meniscus Tear
7.1 Introduction
7.1.1 History
7.1.1.1 How Did You Get Injured?
7.1.1.2 Did You Hear a Pop or a Snap?
7.1.1.3 Could You Continue Your Activity?
7.1.1.4 Did It Swell? When?
7.1.1.5 Where Does Your Knee Hurt? Point with One Finger!
7.1.1.6 Do You Have Night Pain?
7.1.1.7 Did Your Knee Lock?
7.1.1.8 Did You Ever Hurt Your Knee Before?
7.1.1.9 Family History?
7.1.1.10 Did You Ever Hurt the Other Knee?
7.1.2 Physical Examination
7.1.2.1 Observation
7.1.2.2 Range of Motion
7.1.2.3 Joint Line Tenderness
7.1.2.4 Meniscal Tests
7.1.3 Differential Diagnosis
7.1.4 Treatment
7.1.4.1 Early Care
7.1.4.2 Second Visit
7.1.5 Factors Affecting Your Decision-Making
7.1.5.1 Age
7.1.5.2 Activity Level
7.1.5.3 Alignment
7.1.5.4 The Degree of Arthritis
7.1.6 Treatment
7.1.7 Pearl of Wisdom
8: Extensor Mechanism Disruptions
8.1 Introduction
8.2 TIBIAL Tubercle Injuries
8.2.1 History
8.2.1.1 How Did You Get Hurt?
8.2.1.2 Did You Hear a Pop?
8.2.1.3 Can You Continue Your Activity?
8.2.1.4 Did Your Knee Bother You Before?
8.2.1.5 Did Your Knee Swell?
8.2.1.6 Family History
8.2.2 Physical Examination
8.2.2.1 Observation
8.2.2.2 Neurovascular Assessment
8.2.2.3 Range of Motion
8.2.2.4 Tenderness
8.2.2.5 Ligament/Meniscal Tests
8.2.2.6 Differential Diagnosis
8.2.2.7 Early Care
8.2.3 Treatment Recommendations
8.3 Patella Tendon Ruptures
8.3.1 History
8.3.1.1 How Did You Get Hurt?
8.3.1.2 Did Your Knee Ever Bother You Before?
8.3.1.3 What Sports Do You Play? What Kind of Work Do You Do?
8.3.1.4 Did You Hear a Pop?
8.3.1.5 Were You Able to Continue Your Activity?
8.3.1.6 Did You Need Help to Get Up and Walk Away?
8.3.1.7 Did It Swell? When?
8.3.1.8 Did You Notice a Deformity?
8.3.1.9 Did You Go to the Hospital?
8.3.2 Physical Examination
8.3.2.1 Observation
8.3.2.2 Neurovascular Assessment
8.3.2.3 Range of Motion
8.3.2.4 Tenderness
8.3.2.5 Palpation
8.3.2.6 Ligament/Meniscal Tests
8.3.3 Differential Diagnosis
8.3.4 Treatment
8.3.4.1 Early Care
8.3.5 Treatment Recommendations
8.4 Patella Fractures
8.4.1 History
8.4.1.1 How Did You Get Hurt?
8.4.1.2 Did You Hear a Pop?
8.4.1.3 Could You Continue Your Activity?
8.4.1.4 Did It Swell? When?
8.4.1.5 Did You Notice a Deformity?
8.4.1.6 Did You Ever Hurt Your Knee Before?
8.4.2 Physical Examination
8.4.2.1 Observation
8.4.2.2 Neurovascular Assessment
8.4.2.3 Range of Motion
8.4.2.4 Tenderness
8.4.2.5 Palpation
8.4.2.6 Meniscal/Ligamentous Tests
8.4.3 Differential Diagnoses
8.4.3.1 Early Care
8.4.4 Treatment Recommendations
8.5 Quadriceps Tendon Ruptures
8.5.1 History
8.5.1.1 How Did You Get Hurt?
8.5.1.2 Did You Hear a Pop?
8.5.1.3 Could You Continue Your Activity?
8.5.1.4 Did Your Knee Swell?
8.5.1.5 Did You Notice a Defect?
8.5.1.6 Did You Notice a Deformity?
8.5.1.7 Any Previous Knee Problems?
8.5.1.8 Any Prior Injections to the Knee?
8.5.1.9 What Type of Work Do You Do? Do You Participate in Any Sports or Gym Activities?
8.5.1.10 Past Medical History
8.5.2 Physical Examination
8.5.2.1 Observation
8.5.2.2 Neurovascular Assessment
8.5.2.3 Range of Motion
8.5.2.4 Tenderness
8.5.2.5 Palpation
8.5.2.6 Meniscal/Ligamentous Tests
8.5.3 Differential Diagnosis
8.5.4 Treatment
8.5.4.1 Early Care
8.5.5 Treatment Recommendations
9: Contusions and Chondral Injury
9.1 Introduction
9.2 History
9.2.1 How Did You Get Hurt?
9.2.2 Did You Hear a Pop?
9.2.3 Could You Continue Your Activity?
9.2.4 When Did It Swell?
9.2.5 Did It Get “Black and Blue”?
9.3 Physical Examination
9.3.1 Observation
9.3.2 Neurovascular Assessment
9.3.3 Range of Motion
9.3.4 Tenderness
9.3.5 Associated Ligament Disruption
9.4 Differential Diagnosis
9.5 Treatment
9.5.1 Early Care
9.5.2 Treatment Recommendations
10: The Mimickers
10.1 Introduction
10.2 Gout
10.2.1 History
10.2.1.1 Was There An Injury?
10.2.1.2 Could You Continue Your Activity?
10.2.1.3 When Did the Pain Begin? Did It Swell?
10.2.1.4 Past Medical History?
10.2.2 Physical Examination
10.2.2.1 Observation
10.2.2.2 Tenderness
10.2.2.3 Range of Motion
10.2.3 Treatment
10.2.3.1 Early Care
10.2.4 Treatment Recommendations
10.3 PVNS
10.3.1 History
10.3.1.1 Was There An Injury?
10.3.2 Physical Examination
10.3.2.1 Observation
10.3.2.2 Tenderness
10.3.2.3 Range of Motion
10.3.3 Treatment
10.3.3.1 Early Care
10.3.4 Treatment Recommendations
10.4 Bone Tumors
10.4.1 History
10.4.1.1 Was There An Injury?
10.4.1.2 Did the Knee Swell?
10.4.1.3 Do You Have Night Pain?
10.4.2 Physical Examination
10.4.2.1 Observation
10.4.2.2 Tenderness
10.4.2.3 Range of Motion
10.4.3 Treatment
10.4.3.1 Early Care
10.4.4 Treatment Recommendations
11: The Whole Gestalt (i.e., Conclusion)
Index

Citation preview

The Acute Knee A Handbook for Sports Medicine Physicians Mark F. Sherman Author Seth L. Sherman Editor

123

The Acute Knee

Mark F. Sherman

The Acute Knee A Handbook for Sports Medicine Physicians

With Contributions by Seth L. Sherman

Mark F. Sherman Department of Orthopedics and Sports Medicine Staten Island Orthopedics and Sports Medicine Staten Island, NY, USA

ISBN 978-3-031-32843-5    ISBN 978-3-031-32844-2 (eBook) https://doi.org/10.1007/978-3-031-32844-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my dad, “Doc” Ben Sherman, who epitomized the word Physician. To my mom, the unsung hero, who raised four sons, all of whom are now physicians. She taught us all the meaning of self-sacrifice and love.

Foreword

During residency, dad changed my life by teaching me the “Lachman exam” on an injured high school football athlete. His energy and passion for sharing the love of his craft was contagious. I am so proud to follow in his footsteps as a third-generation team physician and surgeon! Dad’s book is a MUST READ for clinicians interested in a career in sports medicine. Through an easy-to-follow, multimedia, and entertaining format, dad teaches the importance of listening to patients, asking the right questions, and confirming diagnosis through focused physical examination. Dad brings 40+ years of experience to orthopedic sports medicine. He highlights priceless lessons learned the hard way and pearls of wisdom in every chapter and video. As a member of the next generation, I am impressed by his ability to communicate this foundational knowledge through a contemporary lens. I challenge you to master the lost art of history and physical examination in your own practice. Dad’s book is a great way to embrace that worthy mission for your patients. Redwood City, CA, USA

Seth L. Sherman

vii

Reviews of This Book

Dean C. Taylor, MD Mark Sherman’s The Acute Knee is a treasure, and a “must-­ read” for anyone taking care of knee injuries. Mark’s patient-­ centered approach is a breath of fresh air in a world dominated by electronic medical records and a reliance on technology over humanitarian care. Emphasizing concepts like HUMILITY, LISTENING, REHABILITY (a Sherman neologism), and CRU (a new and CRUcial way to think about ACL injuries), The Acute Knee synthesizes Dr. Sherman’s 40  years of experience into a straightforward, readable (and watchable, with complementary videos) manual that emphasizes the essentials of humanely diagnosing and treating knee injuries. This book entertainingly accomplishes its purpose—to get back to the basics and keep it simple—with keen insights for everyone. James Kinderknecht, MD It is well documented that the musculoskeletal exam is poorly done in most medical schools. This handbook on the evaluation of the acutely injured knee by Dr. Sherman is extremely well done and much needed. I feel it is an excellent resource for all sports medicine physicians. Russell Warren, MD Dr. Sherman has created a fine book. He is extremely knowledgeable, having started his career with the late. Dr. John L Marshall at the Hospital for Special Surgery. They carried out numerous studies on the ACL injury. This book clearly defines issues and potential solutions. It nicely explains the options of your care and treatment. It is well worth the read. ix

Acknowledgments

Thank you to Monica Sri Vel for assisting the author and editor with manuscript preparation, video editing, and for helping us keep the project timeline on track.

xi

Contents

1 General Considerations ������������������������������������������������  1 1.1 The History ������������������������������������������������������������  1 1.2 The Physical Examination��������������������������������������  4 1.3 Treatment Considerations ��������������������������������������  7 1.3.1 Early Care (First Visit)��������������������������������  7 1.3.2 Second Visit������������������������������������������������ 10 2 Acute Patella Injury������������������������������������������������������ 13 2.1 Introduction������������������������������������������������������������ 13 2.2 Acute Patella Dislocation���������������������������������������� 14 2.2.1 History�������������������������������������������������������� 14 2.2.2 Physical Examination��������������������������������� 17 2.2.3 Treatment Plan�������������������������������������������� 20 2.2.4 Factors Influencing Your Decision-Making���������������������������������������� 22 2.2.5 Differential Diagnosis of an Acute Patella Dislocation�������������������������������������� 23 2.2.6 Treatment Recommendation ���������������������� 25 2.3 Acute Patella Subluxation�������������������������������������� 26 2.3.1 History�������������������������������������������������������� 26 2.3.2 Physical Examination (See Table 2.2)�������� 27 2.3.3 Treatment Plan�������������������������������������������� 28 3 Medial  Collateral Ligament (MCL) Injury���������������� 31 3.1 Introduction������������������������������������������������������������ 31 3.2 The History ������������������������������������������������������������ 32 3.2.1 How Did You Get Hurt?������������������������������ 32 xiii

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3.2.2 Did You Hear a Pop?���������������������������������� 32 3.2.3 Were You Able to Continue Your Sport or Activity?���������������������������������������� 32 3.2.4 When Did the Knee Swell?������������������������ 33 3.2.5 Were You Treated for the Injury?���������������� 33 3.2.6 Did You Ever Hurt This Knee Before? ������ 33 3.3 Physical Examination���������������������������������������������� 33 3.3.1 Observation ������������������������������������������������ 33 3.3.2 Palpation ���������������������������������������������������� 34 3.3.3 Valgus Stress Testing (Video 3.1) �������������� 35 3.4 Differential Diagnosis �������������������������������������������� 36 3.5 Treatment���������������������������������������������������������������� 37 3.5.1 Early Care �������������������������������������������������� 37 3.5.2 Second Visit and Treatment Plan���������������� 38 4 Anterior  Cruciate Ligament Injury ���������������������������� 41 4.1 Introduction������������������������������������������������������������ 41 4.2 The History ������������������������������������������������������������ 42 4.2.1 How Did You Hurt Your Knee? Was It a Twist or Direct Fall? Did You Hear a Pop? Could You Continue Your Activity? Did You Need Help Tin Getting Up? Were You Able to Walk On It? If Yes, How Did It Feel? Wobbly?�������������� 42 4.2.2 Did your Knee Swell? When?�������������������� 43 4.2.3 Have You Ever Hurt Your Knee Before?���� 44 4.2.4 Are You Active in Sports? What Do You Play? How Often?���������������� 44 4.2.5 What Type of Work Do You Do?���������������� 45 4.2.6 Have You Hurt Your Other Knee? Anyone Else in Your Family Hurt Their Knee?������������������������������������������������ 45 4.2.7 What Level of School Are You In? ������������ 46 4.3 Physical Exam�������������������������������������������������������� 46 4.3.1 Observation ������������������������������������������������ 47 4.3.2 Examine the Unaffected Knee�������������������� 47 4.3.3 Neurovascular Assessment�������������������������� 47

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4.3.4 Palpation ���������������������������������������������������� 47 4.3.5 Apprehension Test�������������������������������������� 48 4.3.6 The Lachman Test (Video 4.1)�������������������� 48 4.3.7 The Pivot Shift (Video 4.2) ������������������������ 49 4.3.8 The Dial Test (Video 4.3)���������������������������� 49 4.3.9 The Anterior Drawer Sign (Video 4.4) ������ 50 4.3.10 Meniscal Evaluation������������������������������������ 50 4.3.11 Differential Diagnosis �������������������������������� 51 4.4 Treatment Plan�������������������������������������������������������� 52 4.4.1 Early Care �������������������������������������������������� 53 4.4.2 The Second Visit ���������������������������������������� 55 4.5 Factors Influencing Your Decision-Making������������ 55 4.5.1 Age�������������������������������������������������������������� 56 4.5.2 Activity Level���������������������������������������������� 56 4.5.3 Associated Injuries�������������������������������������� 57 4.5.4 Rehability���������������������������������������������������� 58 4.5.5 Family History�������������������������������������������� 58 4.5.6 Gender�������������������������������������������������������� 59 4.5.7 Occupation�������������������������������������������������� 59 4.5.8 Body Habitus/Laxity���������������������������������� 59 4.6 Treatment Recommendations �������������������������������� 60 5 Posterior  Cruciate Ligament (PCL) Injury���������������� 63 5.1 Introduction������������������������������������������������������������ 63 5.2 History�������������������������������������������������������������������� 64 5.2.1 How Did You Get Injured?�������������������������� 64 5.2.2 Did You Hear a Pop or Snap?��������������������� 64 5.2.3 Were You Able to Continue Your Activity? �������������������������������������������� 64 5.2.4 Did Your Knee Swell? When?�������������������� 64 5.2.5 Did You Ever Hurt the Knee Before?���������� 65 5.2.6 Any Numbness or Pins and Needles in Your Leg?������������������������������������������������ 65 5.3 Physical Examination���������������������������������������������� 65 5.3.1 Observation ������������������������������������������������ 65 5.3.2 Neurovascular Assessment�������������������������� 66 5.3.3 ROM������������������������������������������������������������ 66

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5.3.4 Joint Line Tenderness��������������������������������� 66 5.3.5 Drop-Back Sign (Video 5.1) ���������������������� 67 5.4 A Negative Lachman and a Positive Anterior Drawer Sign���������������������������������������������� 67 5.4.1 Represents a PCL Tear Until Proven Otherwise!�������������������������������������������������� 67 5.4.2 Differential Diagnosis �������������������������������� 68 5.5 A Negative Lachman and a Positive Anterior Drawer Sign Is a PCL TER Until Proven Otherwise������������������������������������������ 69 5.5.1 Treatment���������������������������������������������������� 69 5.5.2 Second Visit and Treatment Recommendations�������������������������������������� 70 6 Multi-Ligamentous Knee Injury���������������������������������� 73 6.1 Introduction������������������������������������������������������������ 73 6.2 Posterolateral Ligament Disruption������������������������ 73 6.2.1 History�������������������������������������������������������� 74 6.2.2 Physical Examination��������������������������������� 74 6.2.3 Treatment���������������������������������������������������� 75 6.2.4 Treatment Recommendations �������������������� 76 6.3 Multi-Ligament Injuries (Dislocated Knee)������������ 76 6.3.1 History�������������������������������������������������������� 77 6.3.2 Physical Examination��������������������������������� 78 6.3.3 Treatment���������������������������������������������������� 81 6.3.4 Treatment Recommendations �������������������� 81 7 Meniscus Tear���������������������������������������������������������������� 85 7.1 Introduction������������������������������������������������������������ 85 7.1.1 History�������������������������������������������������������� 86 7.1.2 Physical Examination��������������������������������� 88 7.1.3 Differential Diagnosis �������������������������������� 89 7.1.4 Treatment���������������������������������������������������� 91 7.1.5 Factors Affecting Your Decision-Making �� 92 7.1.6 Treatment���������������������������������������������������� 95 7.1.7 Pearl of Wisdom������������������������������������������ 95

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8 Extensor Mechanism Disruptions�������������������������������� 97 8.1 Introduction������������������������������������������������������������ 97 8.2 TIBIAL Tubercle Injuries �������������������������������������� 98 8.2.1 History�������������������������������������������������������� 98 8.2.2 Physical Examination��������������������������������� 99 8.2.3 Treatment Recommendations ��������������������101 8.3 Patella Tendon Ruptures ����������������������������������������101 8.3.1 History��������������������������������������������������������102 8.3.2 Physical Examination���������������������������������103 8.3.3 Differential Diagnosis ��������������������������������105 8.3.4 Treatment����������������������������������������������������105 8.3.5 Treatment Recommendations ��������������������106 8.4 Patella Fractures������������������������������������������������������106 8.4.1 History��������������������������������������������������������106 8.4.2 Physical Examination���������������������������������108 8.4.3 Differential Diagnoses��������������������������������109 8.4.4 Treatment Recommendations ��������������������111 8.5 Quadriceps Tendon Ruptures����������������������������������111 8.5.1 History��������������������������������������������������������112 8.5.2 Physical Examination���������������������������������114 8.5.3 Differential Diagnosis ��������������������������������115 8.5.4 Treatment����������������������������������������������������116 8.5.5 Treatment Recommendations ��������������������116 9 Contusions  and Chondral Injury ��������������������������������119 9.1 Introduction������������������������������������������������������������119 9.2 History��������������������������������������������������������������������119 9.2.1 How Did You Get Hurt?������������������������������119 9.2.2 Did You Hear a Pop?����������������������������������120 9.2.3 Could You Continue Your Activity?������������120 9.2.4 When Did It Swell?������������������������������������120 9.2.5 Did It Get “Black and Blue”? ��������������������120 9.3 Physical Examination����������������������������������������������121 9.3.1 Observation ������������������������������������������������121 9.3.2 Neurovascular Assessment��������������������������121

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9.3.3 Range of Motion ����������������������������������������121 9.3.4 Tenderness��������������������������������������������������121 9.3.5 Associated Ligament Disruption����������������122 9.4 Differential Diagnosis ��������������������������������������������122 9.5 Treatment����������������������������������������������������������������122 9.5.1 Early Care ��������������������������������������������������122 9.5.2 Treatment Recommendations ��������������������123 10 The Mimickers ��������������������������������������������������������������125 10.1 Introduction����������������������������������������������������������125 10.2 Gout����������������������������������������������������������������������125 10.2.1 History����������������������������������������������������125 10.2.2 Physical Examination�����������������������������126 10.2.3 Treatment������������������������������������������������126 10.2.4 Treatment Recommendations ����������������127 10.3 PVNS��������������������������������������������������������������������127 10.3.1 History����������������������������������������������������127 10.3.2 Physical Examination�����������������������������127 10.3.3 Treatment������������������������������������������������128 10.3.4 Treatment Recommendations ����������������128 10.4 Bone Tumors��������������������������������������������������������128 10.4.1 History����������������������������������������������������129 10.4.2 Physical Examination�����������������������������129 10.4.3 Treatment������������������������������������������������130 10.4.4 Treatment Recommendations ����������������130 11 The Whole Gestalt (i.e., Conclusion)����������������������������131 Index����������������������������������������������������������������������������������������135

Introduction

As a third-year medical student, my father, an active general surgeon, gave me a copy of Cope’s The Acute Abdomen. He said that if I read it carefully, I would be a better young physician. As usual, dad was right. Cope’s treatise was a simply written, exciting entry to the world of general surgery. After reading Cope, I knew that I could deal with a patient presenting with acute abdominal pain. To this date, it was one of the most informative and important medical texts that I have read. It is the inspiration to my writing this book. It is not my intention for this book to be an authoritative text. After being in a sports medicine orthopedic practice for the past 40 years, I have accumulated a great deal of practical knowledge. I was also blessed to be trained and associated with some of the great minds in the field of knee surgery. A good portion of my career is involved in teaching younger physicians. I know that it is a long and arduous process to appreciate the “art of medicine.” The goal of this book is to make it easier for a beginning knee practitioner to take an educated history and then perform a thorough physical examination. This will invariably steer them to the course of the correct diagnosis. To keep this book sharply focused, my intent was to deal with the diagnosis of the acutely injured knee. I will also offer my philosophy on the treatment options for these injuries, again emphasizing that these recommendations are far from definitive, but may be helpful in the formulation of your gameplan for the patient.

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Introduction

After completing my residency at Bellevue hospital, I was an arrogant young physician who thought that I knew everything that I needed to know. It took one day of my fellowship at the Hospital for Special Surgery to realize that I had a lot to learn. The fellowship was conducted by the late Dr. John Marshall and Dr. Russell Warren. At my first HSS Monday sports medicine clinic, I walked in to see my patient. He was a high school athlete that twisted his knee at basketball. After my interview and examination, I came out and discussed the case with Drs. Marshall and Warren. I finished the presentation and they simultaneously asked me, “What about the Lachman test?” I responded, “What’s a Lachman?” Incredulously, they both looked at me and were obviously thinking how it was possible that they selected someone like me for the ensuing year. That was not a great moment for me. All of my arrogance instantly converted to humility as I appreciated that there was still a lot for me to learn. Frankly, it took about 3 months before I really began to believe in the powerful accuracy of the history and physical examination. My entire life changed because of that fellowship year. Retrospectively, it was the most important moment of my medical education. I am forever grateful to these mentors who were so far ahead of their time. My year at the Hospital for Special Surgery was an eye opener, paving the way to the oncoming years of my practice. Every day was a learning experience, and thankfully that has not changed. Along the way, I was fortunate enough to meet Dr. John Feagin, a sports medicine physician who epitomized the art of medicine. His tenacity and knowledge concerning the anterior cruciate ligament has been an inspiration. His book, The Crucial Ligaments will forever remain a classic in the field of knee surgery. He has altered my approach to patients, and I am thankful to have had the opportunity to be in his influential presence. His recent death was a great loss to our field, as he truly epitomized the definition of a clinician. Dr. Ron Losee practiced in the tiny town of Ennis, Montana. Who would imagine that this small statured, Santa Claus-like man, from this obscure part of our country, could be such a brilliant thinker and innovator? When Dr. Losee spoke, it was gospel. He has proven that anyone, anywhere, with some intelligence,

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curiosity, and effort can truly revolutionize the medical world. His book entitled Doc should be made mandatory for all young physicians to read. It has been a privilege for me to be an active member of his Jailhouse society. My dad died 20 years ago. He was a practicing physician for more than 60 years. In his last few years, people would often come up to dad and ask him if he was still practicing. Laughingly he would always respond, “I don’t practice anymore, I know what I am doing.” Dad did have the right to say that, for it takes a long time in medicine before we really do know what we are doing. The football field at Lafayette high school in Brooklyn is named after my dad as he was their team physician for 50 years. For years, I was always standing on the sidelines watching dad run onto the field when an athlete went down. In his later years, he didn’t run but he walked. Everything he said was a “pearl” of knowledge. It naturally flowed. He was the consummate teacher, educator, and the last of an amazing breed of generalist that knew an amazing amount about so many aspects of medicine. He had never-ending curiosity and constantly was asking questions. His life in medicine focused on discovering the answers. I vividly remember the day when I taught my 70-year-old father how to do the Lachman test. His enthusiasm for learning this new maneuver was the same as a little boy getting a free ice cream cone. That was a great day for the two of us. He wrote a book at the age of 86, My Patients, My Life. Similar to Doc by Dr. Losee, dad’s book should also be a mandatory reading for every medical student as his passion for medicine and compassion for his patients is self-evident. My purpose of writing this book is to make it a little easier for the younger sports medicine physicians to see the forest through the trees. Too much of modern medicine is based on concrete objective data. Auscultation and palpation are replaced by X-ray, MRI, and CT-scan. The patient with knee pain is invariably and immediately imaged with an MRI before a physical examination is even performed. By no means am I saying that these tests are unnecessary or inaccurate. They are an essential tool in our bag of skills. In the past 40 years, imaging techniques have given us all an amazing awareness of the macro- and micro-pathology of

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acute knee injuries. Many of my colleagues totally rely on these studies to formulate their diagnosis. However, the joy that I have achieved from my years of practice stem from that satisfying moment of being able to listen, examine, and then arrive at an accurate conclusion, which is then confirmed and further dissected by an image such as an MRI. Somewhere in our career, we all should be able to reach that point. Many never do, and I feel sorry that they have missed that opportunity to enjoy one of the great pleasures of being a sports medicine physician. I hope that these chapters give my younger colleagues a fresh and different perspective. I have included my thoughts on the early care and treatment of these injuries. It is not my intent to be precise and definitive as to what is the most appropriate therapeutic regimen. My treatment recommendations are based on my experiences with thousands of patients. I will not go into the details as to the best procedure to perform. Technological advances in surgery change so frequently such that a textbook or manual can never keep up with what is presently the best way to treat the problem. That is way beyond the scope of this manual. My goal is to help you develop a thought process as to what is the best therapeutic path to take for that individual patient. I have often observed attending physicians and residents carefully explain to the patient their options of care. I strongly feel that it is not only our obligation to explain their options, but we should never forget to tell them exactly what we would do if we were sitting in their shoes! Patients want to hear that from their Doctor. I’m hoping that this manual helps you make that decision-making process a little easier. My dad felt that the key to being a fine physician was being able to listen to the patient. Too often we hear our patient’s words but don’t listen. This book attempts to make you a better listener and a better examiner. The rest is up to you.

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General Considerations

1.1 The History In the medical world, orthopedists were long regarded as “carpenters.” The implication being that we are not thinkers and that we are solely craftsman. In the last forty years, this perception has certainly changed. The field of orthopedics is expansive and is now one of the most competitive to enter. I feel that this popularity stems from the great ability of the orthopedist to not only diagnose and treat the patient, but to truly cure them, and allow the patient to return to their prior level of activity. Making the proper diagnosis is the starting point and as in every field of medicine; ascertaining the patient’s history is the key. When the patient presents with the acutely injured knee, your history should reveal an accurate diagnosis 90% of the time. This approaches the accuracy rate of most MRIs. As a fellow at The Hospital for Special Surgery, one of the more interesting studies was undertaken by my mentor’s secretary. She was always overwhelmed by patients calling for appointments concerning their knee injury. It was her job to wean out the less emergent patients. She wanted to see if she could accurately predict those patients who tore their ACL.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­32844-­2_1.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2_1

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1  General Considerations

2

The secretary asked three questions: • Did you hear a pop? • Could you continue your activity? • Did your knee swell in the next 6 h? She accurately diagnosed an ACL tear 92% of the time. Not bad without touching the knee!! I am quite disturbed when I watch a young physician approaching a patient with an acutely injured knee, ask one or two quick questions, and then go right to their physical examination. This is inexcusably poor medicine. As sports medicine physicians and surgeons, we cannot forget that we are still doctors! Surrounding that swollen knee is a very concerned individual who needs compassion, understanding, and most importantly, a physician that listens. The essential core of the history is not only the questions you ask, but more importantly to carefully listen to the patient’s responses. Teaching you to listen is harder than teaching you the right questions. I believe that listening is what separates the real doctors from those that are going through the motions. Your history begins from the instant that you meet the patient. Say hello and introduce yourself. If there are other family members in the room, say hello to them as well, for they are all there for a reason. They are worried. If the patient is a child, immediately speak to the child and not to their parent. Establishing the child’s confidence is as crucial as an adult. Once you have the patient’s confidence, the questioning can begin. Acute knee injuries hurt. These patients are invariably very uncomfortable and often look unhappy. They are also very fearful that you are shortly going to cause them more pain when you examine their knee. No doubt that the average patient looks at the physician as a potential enemy, so it is our job to become someone in whom they have trust. This isn’t easy and it takes time. Time is the key word. In this managed care world, the emphasis is on volume, and doctors want to see how many patients they can see in the shortest period of time. I am fully aware of this problem and

1.1 The History

3

yet your time management cannot sacrifice the consistency and completeness of your history. Your history must dissect the injury. Every detail can be important. It is not good enough to ask the question, “Did your knee lock?,” and be content with a yes or no response. You have to know what the patient meant by locked. Did it truly get stuck where they had to manipulate their knee to get it “unstuck” [one of my favorite words}, or did the knee just catch for a second? Was the knee straight or bent? How bent? Did it swell after it locked? You have suddenly become an attorney asking prodding, pointed questions, and the good news is that you can lead the witness. This careful probing with meaningful questions paints a picture. Listening to the answers focuses your next question, all part of the crystallizing process of coming to the correct diagnosis. Each response will be recorded in your personal computer [your brain], and this will become engrained for future questioning of your next patient. In the acutely injured knee patient, the most forgotten question to ask is, “Did this ever happen to you before?” It never ceases to amaze me how often patients do not offer information unless it is solicited. “Oh yeah Doc, the same thing happened to me two years ago” is always an eye opener and you can’t help but wonder why the patient did not give you that information without you asking? Well, dear colleague, that is the nature of people, and we have to get used to it. If you do not ask the question, you may never know what really happened. Don’t be afraid to make up a questionnaire that has many of the appropriate questions written down. I feel that such a form should be personalized to your specifications, and not pro forma. It is not impersonal to have a questionnaire on your chart. It is actually much more thorough to have the questions written down. This will ensure that you will not forget anything important. However, a form can never delve into the detail of the injury, so leave a margin to scribble in these important facts. I do not love the idea of someone else taking a history for you, but these “high volume “times may demand this method. Such histories are rarely complete, and it is your obligation to fill in the blanks. I have always been able to absorb and digest my own history much more efficiently than one received from a second party.

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1  General Considerations

The histories for each specific diagnosis will be given in greater detail specifically for each condition. The main intent of this chapter was to get you comfortable with this formulation process. Each patient is a mystery, and your history is the major source of clues to unravel the case. The physical exam should confirm your suspicions. The objective tests such as the MRI should prove that you are right. When this all comes together, it is a great feeling of satisfaction, and no doubt the thrill that has kept my interest in sports medicine for all these years.

1.2 The Physical Examination The physical examination in the setting of an acute knee injury is constant. Your examination should vary very little from patient to patient. Your history will have to vary, but the physical examination should be the same. Even though the diagnosis clearly evolves from the history, you must not compromise your physical examination. For example, a patient may come in and tell you that they dislocated their patella. It is tempting to limit your exam to the patella alone and not bother with a complete evaluation. That would be poor medicine! A complete examination must be done with each knee. It is not uncommon to discover associated injuries, and every so often despite a thorough history, your pre-­ examination diagnosis is wrong. Even though I usually formulate a diagnosis after my history, I try to push that out of my head when I do the physical examination. I do not wish to prejudice my own examination. As you get busier and busier in practice, it is only natural to take a shortcut to save time. Unfortunately, that is when diagnoses are missed. An occult malignant tumor about the knee may be discovered at the time of an acute knee injury. It is more common to pick up an associated injury or a second diagnosis by a compulsively complete physical examination (Video 1.1). Your examination table should be in the middle of a room so that you can easily walk around to examine both knees. If a table is against a wall, you have to ask the patient to shift their body around [this is inconvenient for you and the patient]. You always

1.2 The Physical Examination

5

want to examine a knee from the same side as the knee you are examining. Do not try to examine the knee from the opposite side. The patient should be in shorts. Rolling up pants is not acceptable unless they are baggy and so loose that can be rolled up to the proximal thigh. Walk out of the room and have them change if they are not already prepared by your nurse. I cringe when I see physicians examine knees with their patient’s pants on. This is bad medicine, and the patient will be thinking that you did not even take the time to remove their clothing. They are right if you don’t. With women wearing dresses, have them put on a pair of shorts under the dress. Do not leave on stockings for you must observe the skin. The patient must feel comfortable, and your patient’s modesty is an issue that should be respected and not ignored. Go to the side of the table of the unaffected knee (Video 1.2). Observe the alignment in the supine position. My assessment of the unaffected knee is brief and thorough. My goal is to quickly assess their normal range of motion, ligamentous laxity, and patella stability. I say “quickly” for the examination of the unaffected knee is just giving you a baseline assessment. I routinely roll the thigh inward and outward to make sure that the hip freely rotates. I ask the patient to flex and extend their knee as much as they are able. I immediately ask them to do the same on the injured side to assess their injured knee’s motion deficit. Look at both knees from the side. This allows you to visualize the tibial tubercle as well as the relationship of the tibia to the femur. The only way you can appreciate sag of the tibia, as in a PCL injured knee, is to view the knee from the side. Now, look at the patella. The patella is staring you in the face so don’t ignore it. Place the knee in the Fairbank’s position with the hip flexed and externally rotated about 30°, with the ankle crossed over the opposite ankle (Video 1.3). This tightens the retinaculum and seats the patella in the trochlea groove. In this position, move the patella laterally to get an idea of the patella’s “normal” excursion. Bring the knee back to the table and in 20° of flexion, do your Lachman test (Video 1.4). This will give you the magnitude of displacement and quality of the endpoint of the ACL of the unaffected knee. Flex the knee to 90° and do a posterior

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drawer sign (Video 1.5), again feeling for the amount of normal excursion. Now, assess the status of the collateral ligament laxity by stressing the knee in varus and valgus at 0 and 30° of flexion (Video 1.6). That’s enough for now of the unaffected knee. For comparison, you can always go back to this knee . The acutely injured knee will be held fairly rigidly by the patient, typically in a bent position. There is often an associated effusion in the knee that contributes to the patient’s pain and apprehension. They don’t want to move the knee in fear of discomfort. Many will present wearing a knee immobilizer or bandage that was applied at an emergency room. Sit the patient back down and make sure the injured knee is supported by the table or your thigh as you sit in front of them. The immobilizer, if present, should now be removed. Look at the unaffected knee in the seated position with the knee flexed 90° hanging off the side of the table. As you observe, the patient should now actively flex and extend the uninjured knee. DO NOT use your hand to help move either knee. This is active motion and you are looking to see how the patella tracks . Look at the vastus medialis to see if it is well formed or dysplastic. Get an assessment of their active motion. If it is too painful, lie them down and continue the examination. When the patients reclines, have them hold their arms at their side rather than over their heads. This is a more relaxed position. Family members can stay as long as the patient doesn’t mind. Start with observation of the affected knee. Look for ecchymosis and soft tissue swelling. Do your distal neurovascular assessment for pulse, motor, and sensory function. Bulging in the suprapatellar region means that there is a significant effusion. Ask the patient to actively move the knee into flexion and extension. Do not help them! The knee is then allowed to settle back into extension, and the knee is palpated for tenderness. You must be familiar with the knee’s topographical anatomy. First palpate around the patella going toward each epicondyle. Place the knee in the Fairbank’s position and test for patella apprehension and excursion. Ask the patient to flex the knee to 90° and rest the foot on the table. Do not rush them for they will be apprehensive to move their knee. Most acute knees, despite the effusion, with your

1.3  Treatment Considerations

7

encouragement and reassurance, can flex to this position. I always tell the patient that I am going to sit my rear end on their foot. It is good to inform them of this, for otherwise they think you are sitting on them by mistake. They may also think you are a little strange, so give them fair warning. Ninety degrees is the easiest position to feel the joint lines as well as the insertion and origin points of the collateral ligaments. After palpation, I do my anterior and posterior drawer tests, for the knee is already in the appropriate position to do these drawer signs. I then allow the knee to fall back into extension and stress for medial and lateral collateral ligament insufficiency. If the patient cannot go into full extension, just examine the collaterals at 30°. The Lachman test is next. In the acute setting, I never attempt a pivot shift or McMurray maneuver (these knees are quite sore and swollen, and these tests elicit pain and are typically not accurate when performed in this acute setting). From this preliminary review, I hope that you can begin to appreciate the skill of doing an accurate physical examination in the setting of an acute knee injury. Specific details of the physical examination will be given in each chapter as it applies to that diagnosis. I have always found it difficult to learn how to do a physical examination maneuver from the reading of a text. There is nothing like a “hands on” demonstration of a physical examination. I urge you to spend time in the office of an experienced sports physician to observe and learn these skills. The enclosed videos will give you a good start!

1.3 Treatment Considerations 1.3.1 Early Care (First Visit) It is rare for patients to come to your office immediately after the injury. Most patients will be treated at an emergency room or outpatient facility. The sooner you get to see these patients the better. Appropriate treatment from the onset is often a very crucial step in the progression of your care for that individual. Too often have I seen patients arrive several days after their injury, with tight or

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1  General Considerations

inadequate dressings, severely swollen. They are in severe pain, very apprehensive, and afraid to move their knee. As a team ­physician, I understand the advantage of expedient treatment of a knee injury. Your immediate concern and care instills confidence that your patient will appreciate and ease the future care you are going to recommend. The initial treatment plan is to decrease swelling, pain, maintain muscular function, and re-establish motion. The RICE (Rest, Ice, Compression, Elevation) protocol applies to the acutely injured knee. Rest implies limitation of weight-bearing. Crutches are given. The weight-bearing status is dependent on the injury. In the majority of cases, weight-bearing is allowed. Most patients can bear weight as tolerated, using the crutches for extra support. I emphasize a heel-toe gait, to help counteract the tendency to walk with a bent knee. Even with crutches, the amount of walking should be limited. In the presence of a chondral fracture, non-­ weight-­bearing is recommended. For the first few days, I find the compressive dressing to be most important. The ice will not penetrate through the dressing, so I don’t emphasize cold therapy while the compressive dressing is on. I use three or four rolls of six-inch cast padding from ankle to proximal thigh, followed by two to three rolls of sixinch ace bandages. If the patient cannot straight leg raise and has poor quadriceps control, a knee immobilizer is placed on top of the dressing. The patient is told to use the immobilizer for weight-­bearing and is immediately taught to do quadriceps isometrics and leg raises, emphasizing the need to get the leg as straight as possible. Keeping the quadriceps activated is fundamentally the most important part of your initial treatment (this applies to every acute knee injury). The patient is told to remove the immobilizer as often as possible and to move the knee. I always emphasize early range of motion, as the earlier the knee moves the better. After the first 48 h, the patient can remove the dressing. The knee will typically remain swollen, especially if there was an associated chondral injury. Ice packs can now be applied. Large

1.3  Treatment Considerations

9

frozen bags of green peas or corn work very well if more formal medical ice packs are not available. The ice should always be applied over a light towel, not directly on the skin. I have seen some terrible ice burns and blistering from direct ice applied to the skin. Elevation helps to decrease swelling. You must tell the patient that elevation does not mean sitting in a chair, with the affected leg on another chair in front of them. You have to make them understand that the knee must be above the heart!! Never assume that the patient understands what that means, as most patients will not grasp that concept. They should be told to lie down and put their leg up on a box, padded with a pillow- ABOVE THE HEART! For the first week, I do utilize anti-inflammatory medications. A non-steroidal medication will help in the reduction of pain and swelling. Use the drug of which you are most familiar. I usually limit my pain medications. It is rare for me to prescribe opioids. Acetaminophen in association with the NSAID is a good combination. The chondral injuries are more painful and may require a short duration of narcotic therapy. Aspiration of the knee is done for effusions that are tense causing severe pain and likely limiting the patient’s ability to move the knee. Aspiration of a probable hemarthrosis must be done with an 18-gauge needle as the thickness of the blood and possible clots require a larger gauge needle. For effusions, a 20-gauge needle is all that is necessary. The larger the effusion, the easier to aspirate. I like the superolateral approach, about an inch above the patella. A wheal of xylocaine or an ethyl chloride freeze spray takes the edge off the aspiration. I will begin my discussion with the patient concerning their treatment plan, but I tell them that they should concentrate on getting the acute pain and swelling under control. I prefer to save my full discussion to the next visit when they are more comfortable and can concentrate on what is discussed. X-rays are often performed at this initial visit. If indicated, any further testing (i.e., MRI, CT-scan) can be done between the first and second visit.

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1  General Considerations

1.3.2 Second Visit I usually have most patients return after a week. This is the best time to get a more detailed examination and have a thorough discussion with your patient concerning their treatment plan. If you suspect that a surgical procedure will be necessary, I schedule the patient at the end of my office hours. You will have a lot to explain and you DO NOT WANT TO RUSH! At this visit, the patient will be more focused, as their knee pain is under better control. Unlike the “olden days” of acute knee surgery, very few knees need to be repaired within the first few weeks of injury. You will have plenty of time to discuss the treatment options available. The knees are typically still swollen. As the patient’s ROM will be improved, a more thorough examination can now be performed. You will now have time to discuss your “gameplan.” (the specifics will be presented with each chapter). If their insurance allows, I emphasize the need to start a physical therapy program. The earlier they begin to rehabilitate their knee the better. STIFFNESS IS THE ENEMY! Over the years, we have learned that the loss of motion always leads to a compromise in the patient’s final outcome. There are very few acute knee injuries that cannot begin an immediate ROM program. Bracing will depend on the injury incurred and remains specific to the injury. Forty years ago, I came up with the word REHABILITY. This word is not in the dictionary, but I feel it should be. My definition, as the word sounds, is one’s ability to rehabilitate. As a sports medicine physician, I know that this is the most important factor in the outcome of your conservative or operative treatment. Your careful assessment of how the patient reacts to pain, and how they respond to the early stages of rehabilitation, will give you an idea as to how that patient will respond to your treatment protocol. I often have changed my “game plan” as I observe the patient’s early REHABILITY. A good rapport with your physical therapist is very helpful, as they can also help you in determining the patients REHABILITY.  This information aids in your decision-­ making process as to whether or not the patient is a non-operative or operative candidate.

1.3  Treatment Considerations

11

In this manual, I do not want to be too specific as to what is the best treatment for that individual injury. I will give you my personal philosophy and thought process as to what your options are, and what factors I think about before making a treatment recommendation. Experience is not something that you can get by reading an article, textbook, or a manual such as this. However, I do feel that you can develop a philosophy on how to approach each individual, as there is no question that every patient is a little different. That is what makes the whole experience so much fun and so rewarding.

2

Acute Patella Injury

2.1 Introduction The patella is the most overlooked structure in the knee, and ironically it is staring you right in the eye. Certainly, patella injuries are not as glorified nor as exciting as an ACL or meniscal tear. In a private practice, undoubtedly the majority of complaints about the knee stem from the kneecap. Patella pain predominates in all sports and aspects of life. It is not the focus of this chapter to deal with patella pain. This is a treatise on acute knee injuries. My mentor, the late Dr. John Marshall once said to me that the injured patella, like syphilis, is a great “mimicker.” He was trying to tell me that patella injuries often present with stories similar to other common knee conditions. He was right! It is my hope that after reading this chapter that you will never overlook a patella injury. If your index of suspicion is high, the diagnosis will crystallize before your eye.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­32844-­2_2.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2_2

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2.2 Acute Patella Dislocation 2.2.1 History When you walk in the examining room, these patients are usually not very happy. They are in pain and their knee is swollen. They are not in the mood for long conversations and certainly do not want anyone to touch their knee. Hence, you have to be efficient, precise, and gentle. Your first job is to define the mechanism of injury.

2.2.1.1 How Did You Hurt Your Knee? Patella dislocations occur after a twisting motion, with the knee in the mildly flexed position. It is difficult if not impossible to dislocate the patella with the knee in the seated position as in an auto accident. 2.2.1.2 Was It a Fall? Direct blows will usually contuse the patella or cause a fracture, but rarely will cause a dislocation unless there was a twist prior to the fall. Some, but not all patients, can remember the mechanism of the injury. You have to pry the lid open. This is easier in sports such as skiing where the ski serves as a pointer to the direction that their knee went. Many patella dislocations and subluxations occur on descent. Coming off a step or a curb is not an unusual mechanism. The more typical story is that of jumping off a platform, landing from a rebound or after a leap on a volleyball court. 2.2.1.3 Did You Twist Your Knee? There is almost always a twist. A straight hyperextension mechanism, whereby the knee is pushed backwards, can cause a patella contusion in association with other ligamentous injuries, but will rarely be the culprit in acute patella instability. All involve some form of torque so that the patella can slip out of its groove. The force can be mild or severe. Everyone’s patella is different. Most patients with a patella dislocation have predisposing factors (i.e., joint laxity, genu valgus, femoral anteversion, patella alta, and are

2.2  Acute Patella Dislocation

15

more prone to pop out...). The twist will occur with the knee in 20 or 30° of flexion with the leg externally rotated. Few patients remember the exact position, but sometimes they do, making the diagnosis a lot easier.

2.2.1.4 Did You Hear a Pop or a Snap? The patient knows that something bad happened but usually they do not hear a pop. This is more typical of a ligamentous tear. 2.2.1.5 Did Your Kneecap Feel Like It Popped Out of Place? Believe it or not, unless you ask the question, many patients will not report that fact until the question is asked. When the patella goes off the patient know that something is out of position. They often point that the patella went medially because they see a bulge in that part of their knee. They are mistaken for when the patella is off laterally, the medial condyle of the femur is more evident and prominent and they are fooled that the bump is their displaced patella. Many dislocated patellae will spontaneously reduce, and the patient will report that it went out and then right back in place. This reduction often occurs as they straighten their knee. In first time dislocations, I find it rare that the patient will manually push the patella to get it back in place. They are usually too scared and in too much pain to do anything. After multiple dislocations, similar to a shoulder, the patient is more fearless and often reports that he or she proudly did a manipulation and put it back in place by themselves. 2.2.1.6 Were You Able to Continue Your Activity? Most patients cannot continue their sport or activity after a patella dislocation. If the patella remains dislocated, the patient will have to be carried off the field and require transfer to a local hospital. Most patella dislocations spontaneously reduce, and the patient needs help to get up. When they get up, they are reluctant to put weight on their knee. However, if they do try to walk, they usually can manage as long as they keep their knee straight. The knee does not feel as if it will give way despite the recent injury. This helps distinguish their injury from an ACL tear where the patient

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2  Acute Patella Injury

often senses that their knee is “rubbery” or unstable as they try to walk on it. If the patella remains dislocated, these patients will report that they were in severe pain and that the reduction of the patella will probably have required an anesthetic agent at their local emergency room. It is extremely rare that a patella dislocation will present to your office or clinic as unreduced.

2.2.1.7 When Did the Knee Swell? When the patella dislocates, the medial retinaculum of the knee invariably tears, and there is often an associated chondral or osteochondral injury [i.e., avulsion fracture off the patella or a shearing fracture of the lateral femoral condyle]. All of these lead to rapid bleeding, and these patients will report that the knee swelled very quickly, often within the first hour. Within 6 h these knees are tense, swollen, and painful. An associated fracture is associated with even more pain and swelling. 2.2.1.8 Did This Ever Happen to You Before? Do not forget to ask this question! Most patella dislocations will have a prior history of difficulties with their knee. In the past, many will report that “sometimes my knee felt as if it was going out of place.” It is rare that there is not some pre-existing history of patella instability or patella complaints, such as pain with stairs or stiffness after sitting with the knees flexed. They will often report that they have had prior “noises in their knee.” The treatment of recurrent patella instability is quite different than after the initial dislocation. It is not the purpose of this book to define treatment regimens, but accurate diagnosis is crucial to appropriate treatment. A patient that tells you that their kneecap has popped off several other times in the past will be treated completely different than someone with an initial dislocation. I cannot emphasize how often the prior history was missed for the question was never asked! Do not fall into the trap of rushing. Ask your questions and listen to the answers. 2.2.1.9 Did Your Other Knee Ever Pop Out of Socket? It is quite common that the opposite knee has had similar problems in the past. Patella instability is often related to anatomic

2.2  Acute Patella Dislocation

17

malalignment which is typically symmetric. Hence, a majority of patients with patella dislocations will give a history of problems on the opposite side. When a patient state that they are having difficulties with both knees, think patella!

2.2.1.10 Did Anyone Else in Your Family Ever Dislocate Their Patellae? There is a definite genetic predisposition for the patella to dislocate. I have had families where three generations have had members that have patella instability. It is very common to have a sibling with the same problem. As soon as you hear that other family members are involved your antennae should perk up and be suspicious that this is a patella problem.

2.2.2 Physical Examination These patients will typically be sitting on your examination table with the affected knee held out straight or in a knee immobilizer. The knee will look grossly swollen, bulging in the suprapatellar region. Look for ecchymosis. The bruised area will usually be on the medial aspect of the patella extending toward the medial epicondyle. The patient will be reluctant to move the knee depending on the degree of swelling. With your assurance, they will be able to move the knee actively. Do not try to immediately bend the knee. This will incite pain and you will lose your patient’s confidence.

2.2.2.1 Examine the Unaffected Knee (See Video 1.3, Chap. 1 and Table 2.1) After you have looked at the injured knee, take a good look at the opposite knee. Ask the patient to stand and observe the alignment of the extremity. As stated, most patella dislocators will have predisposing anatomic findings that are present on both extremities. Walking may be hard to do, so forget that. They will be limping. Now sit the patient down and observe the normal knee as it moves through an active range of motion. Watch how the “normal” patella tracks. This will give you a good idea about the knee that was

18 Table 2.1  Key points on patella dislocation

2  Acute Patella Injury History  • Patients will tell you it popped out  • There is often a prior history of dislocation  • Family history and bilateralism are frequent Physical Exam  • Hemarthrosis  • Positive apprehension test  • Medial patella, retinacular, and epicondylar tenderness  • Common associated findings:    – Patella alta    – J-sign    – Vastus medialis dysplasia    – Outfacing patella    – Valgus femoral-tibial alignment Treatment  • Multifactorial decision-making process  • Most often non-operative

injured. Patella out tracking as the knee goes from 20° of flexion to full extension [also known as the J-sign] is usually present in the unaffected knee. Sometimes the “normal patella” will actually subluxate and jump off, but the patient feels that this is normal. Now lie the patient down. Again, start with the unaffected knee. Assess the range of motion, looking for the amount of recurvatum. Hyperextension laxity is a predisposing characteristic. Measure the Q-angle with the knee in 20° of flexion, so that the patella is engaged in the groove. This is more accurate than doing the measurement in full extension. Get a feel for the mobility of the unaffected patella. This is best done in the Fairbank’s position whereby the hip is externally rotated, crossing the ankle over the opposite ankle with the knee flexed about 20–30° (Video 2.1). This position will tighten the patella retinaculum. This gives you a better assessment of the patella mobility and normal tightness of the patient’s medial patella restraints [medial patellofemoral ­ligament]. I usually do a quick Lachman on the unaffected knee to give me a baseline for comparison (Video 2.2).

2.2  Acute Patella Dislocation

19

2.2.2.2 Examine the Injured Knee Observation The knee will be held in some flexion secondary to the effusion. Ask the patient to move the knee. Don’t help! See what their active range of motion is. Their motion will be limited secondary to the pain and the effusion. When they lie down, have their arms are at their side, not over their head. This helps the patient relax. Because of the swelling, predisposing visible factors such as the J-sign, patella alta, out tracking, will be difficult to assess, making the examination of the unaffected knee that much more important. Palpation Carefully examine the knee for points of tenderness. The most sensitive areas will be along the medial border of the patella. The tenderness can extend along the medial retinaculum toward the medial epicondyle. Tenderness at the medial epicondyle should make you suspicious for a tear of the medial patellofemoral ligament at its femoral insertion point. Anterolateral tenderness over the femur is also common for as the patella dislocates laterally, the lateral condyle will be bruised or suffer a chondral shearing fracture. Joint line tenderness is typically absent. The Apprehension Test (Video 2.1) Most patients can get their knee in the Fairbanks position. The apprehension test is pathognomonic of a dislocated patella. These patients are extremely nervous about any manipulation of their kneecap. Frankly, they are apprehensive before you even begin to examine them. In the Fairbanks position, you should gently try to push the patella laterally. A truly positive apprehensive sign refers to an immediate contraction of their quadriceps in an attempt to block the displacing maneuver. A painful wince is not truly a positive apprehension sign, but admittedly in an acutely injured knee you may only get that far. These patients will be apprehensive in any position, so if they cannot get their leg into the Fairbanks position, do the test with the knee straight. Even though you are pretty sure of the diagnosis, don’t stop the examination. Associated injuries can occur simultaneously with

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the patella dislocation. An associated ACL tear is rare, but can happen, so you must perform your Lachman test. Examine for joint line tenderness with the knee flexed as much as the patient comfortably tolerates. It is difficult to assess joint line tenderness with the knee in extension. Examine for medial or lateral instability, by gently stressing the knee in valgus or varus. Tests that involve greater degrees of flexion are typically impossible to do and should not be attempted. The patient will be in pain and I avoid these tests. I want the patient to remain my friend. For example, attempting to do a McMurray test [see meniscal exam] will be of no value. PCL tears are very rare in combination with a patella dislocation. I have been fooled by extensor tendon injuries about the knee. Ruptures of the patella tendon in the younger patient or the quadriceps tendon in the middle aged or older patient can present with a similar appearance to a patella dislocation. You should test these patients for their ability to raise the leg off the table. Pain and swelling alone can cause an extensor lag, as will a quadriceps or patella tendon rupture. Palpation in this setting is crucial. These tendon ruptures will be exquisitely tender at the sight of their tear. Direct central tenderness in a patella dislocation is not common, as the tenderness is usually on the sides of the patella. Feel for gaps in the tendons as these are always associated with complete tendon ruptures [see acute extensor tendon disruption]. You do not want to miss a quadriceps or patella tendon rupture, so be suspicious and concentrate on your examination. Don’t rush!

2.2.3 Treatment Plan 2.2.3.1 Early Care The initial treatment plan is to decrease swelling, pain, maintain muscular function, and re-establish motion. The RICE protocol applies. With patella injuries, it is most important to re-establish quadriceps muscle activity. Remember, the quadriceps is the dynamic stabilizer of the patella and is particularly important

2.2  Acute Patella Dislocation

21

when the static stabilizers have been injured. The bulky compressive dressing is helpful to decrease swelling, and I do use a knee immobilizer to support the knee. The knee immobilizer is only utilized until the patient re-establishes quadriceps leg control (able to do leg raises with the knee fully extended). The patient is told to remove the knee immobilizer and actively encouraged to move the knee. This should be done several times a day, with increased frequency as the days pass. The immobilizer is typically needed for a few weeks. Every case is different, as to the amount of swelling and intra-articular damage incurred at injury. I allow full weight-bearing as tolerated with the crutches for support. A three-point gait, heel toe is instructed. The affected leg and the two crutches hit the ground together. Even with an osteochondral fracture of the patella, the patient can weight-bear. Walking amount should be limited! Rest and elevation of the extremity are crucial to get the swelling to decrease. Remember, you have to teach your patient how to elevate the knee ABOVE THE HEART. Cold application can begin after the compressive dressing is removed. This is helpful for pain management and swelling reduction. Please instruct your patient as to how long you want the cold applied and emphasize that the skin has to be protected.

2.2.3.2 Second Visit The patient’s next visit is ideally one week after the initial visit. Ancillary tests (MRI, CT-scan) have been performed during the first week and should be available for your review. The knee should be re-examined, as now the pain and swelling will be somewhat reduced, and the examination can be easier to perform. The usage of the knee immobilizer or hinged knee brace will depend upon the patient’s quadriceps control. A physical therapy prescription is written, which emphasizes the need for active ROM exercises, isometrics, and leg raises, with modalities to help control pain. NSAID are often no longer needed. Cold therapy can be continued for pain. Now is the time where you have to decide upon your treatment recommendations.

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2.2.4 Factors Influencing Your Decision-Making 2.2.4.1 Predisposing Factors There are many anatomic factors that predispose a patient to dislocate their patella. The majority of patients with a patella dislocation will indeed have one or more of these factors. Here is where your objective data from X-ray, MRI, CT scan are needed to develop your treatment rationale. The most common factors are patella alta, dystrophic shallow sulcus, laterally positioned tibial tubercle, femoral-tibial malalignment (rotational or coronal), ligamentous laxity, family history, and others. Predisposing factors will predispose to a recurrent dislocation and may influence a more aggressive primary operative plan. Age The younger the patient, the more likely that there are predisposing factors that made them dislocate. Are their physes open? Younger patients are typically more active, but not always. There are many young “couch potatoes,” who only sit by their computer, and are relatively inactive. This is why your history is so important to your treatment rationale. Activity Level Are they athletic? What sport(s)? Competitive or recreational? How often do they participate (hours per week)? Occupation Student or working person? What kind of employment? Desk job? Climbing, jumping? Civil servant? Do they have to return to their activity at full capacity without restriction? Family History/Bilateral Many first time dislocators will have family members whom they have dislocated, implying underlying predisposing factors. The same is true if their other patella has demonstrated instability.

2.2  Acute Patella Dislocation

23

Associated Injury The X-ray, CT-scan, and/or MRI will reveal whether or not there is an osteochondral injury of the patella or femoral sulcus. How big is the lesion? Is the fracture displaced? How much bone is on the undersurface of the piece that is broken? Rehability This is very subjective but is probably the most important factor as to whether a surgical or non-surgical approach is recommended. You have to get to know the patient and see how they react to their injury. Are they able to tolerate pain? Do they willingly participate in your therapy regimen? This assessment may take several visits. A discussion with the patient’s physical therapist will be helpful.

2.2.5 Differential Diagnosis of an Acute Patella Dislocation The conditions that most commonly confuse the clinician with the proper diagnosis are: • Anterior cruciate ligament tear • Acute patella subluxation • Medial collateral ligament sprain Distinguishing between a patella dislocation and a subluxation can be difficult. Both diagnoses fall under the same spectrum and vary by the degree of force involved. The patella dislocation will have increased swelling and pain related to the more extensive injury needed to dislocate rather than subluxate the patella. The patient will usually be able to inform you that their patella popped out completely and that they put it back in place. The acute subluxation will sense that their knee cap “slipped.” The apprehension sign is the sine quo non of the patella dislocation and is your most helpful discriminator.

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The most common differential diagnosis is that of a torn anterior cruciate ligament [ACL]. A twisting injury followed by immediate swelling should alert you to this possibility. The ACL tear and the patella instability patient can both present with a twist and immediate sense of giving way, the inability to continue their activity, and the feeling that that their knee went out of place. A careful history will help you define the fact that it was the patella that popped out rather than a subluxation of the tibia on the femur. The ACL injured patient will often use their hands to help describe the feeling they had when their knee was injured. This is known as a “two fist sign” {see ACL injury chapter]. Both patients may sense a pop in their knee, but this is rarely reported by the patella dislocation patient. Your physical examination should clearly help you distinguish these two diagnoses. The palpable site of tenderness in the patella patient follows the lines of the medial retinaculum to the medial epicondyle, as well as the anterolateral aspect of the knee, and their apprehension sign will be positive. The ACL patient will have mid to posterior joint line tenderness often on both sides of the knee and a positive Lachman test. The medial collateral ligament sprain also presents with a twist to the knee. There may be a snap but the patient does not sense that something went out of place. These patients can often continue their activity after their injury. The knee can swell, but it is soft tissue extra-articular swelling rather than an acute hemarthrosis. There may be tenderness at the medial epicondyle if the tear of the ligament is proximal, leading to pain on the apprehension maneuver. Remember, the apprehension sign is not positive if the patient only complains of pain. For the apprehension sign to be positive, the patient will contract their quadriceps and “guard” in response to your lateral displacement maneuver. If not, then the apprehension sign is negative. Tenderness at the medial epicondyle can fool you, as patella subluxation, dislocation, and a proximal MCL tear will have tenderness in the same location. Medial opening upon valgus stress will not be present after a patella dislocation unless the MCL is torn as well.

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2.2.6 Treatment Recommendation For the past 40 years of my practice, unless there is an associated significant osteochondral fracture (typically greater than 1 cm in size, or a displaced fragment that is repairable). I have treated the acute patella dislocation non-operatively. Thanks to recent multicenter research studies, treatment philosophy is evolving. The high recurrence rate of a younger active individual, often with predisposing factors, and the permanent damage that can ensue after multiple dislocations, has made primary operative care a rational option. The decision-making process as whether or not to do a primary repair of the ligaments, primary medial patellofemoral ligament reconstruction, tibial tubercle transfer, trochleoplasty, etc. is well beyond the scope of this volume. Prospective research studies, (as have been done with ACL research in the past), will help define a more precise rationale as to whom should be primarily treated surgically, and what is the best operative procedure to perform. Non-operative care is not equivalent to conservative. I firmly feel that a non-surgical approach to any acute knee injury must be aggressive and followed up in the same manner as you would follow a post-operative patient! My non-operative program begins with the early care, as already described. A long period of immobilization is avoided. In the “olden days,” the knee was casted or braced for several weeks to “allow the ligaments to heal.” The majority of patients with an acute patella dislocation have predisposing anatomic factors, which will not change by immobilization. I do not feel that immobilization enhances ligament healing. Quadriceps atrophy is your biggest enemy. A knee immobilizer is utilized until the patient establishes quadriceps control and has confidence that their knee will not buckle. Full weight-bearing crutch walking is allowed until the patient has leg control. I allow range of motion as early as possible, and my primary goal is to have the patient obtain quadriceps control. Formal physical therapy is typically needed for several months. During that time, the patient is doing isometrics, progressing to biking, and beginning a closed chain leg press program. I avoid open chain knee e­ xtensions

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2  Acute Patella Injury

as this is typically painful. Hip abduction exercises are encouraged from the onset of care. By 6 weeks from the acute injury, these patients are ready for the most important phase of the non-operative regimen. Now is the time for the progression to regain total lower extremity strength, and to re-establish normal proprioceptive function. These patients take at least 3 months to regain satisfactory functional activities, but even then, when tested, they are often not ready to return to aggressive sporting activities. You must develop your own “return to play” criteria, as premature return will more than likely lead to a recurrent dislocation. Please don’t rush, and make sure that your patient is ready to return to their prior sport or activity. There is nothing worse than the recurrence of the same type of injury. It is disheartening for the patient as well as yourself.

2.3 Acute Patella Subluxation Acute patella subluxations are more subtle than a frank dislocation. The patella does not dislocate completely, but instead passes off the edge of the trochlea, slipping in and out of its groove. Tearing of the retinaculum does not have to occur, and shear fractures are not as common. The patient will have a transient sensation that the patella went “out of place.”

2.3.1 History Your questioning should be essentially the same as with a patella dislocator. Invariably there will be a prior history of a similar episode in the affected or unaffected knee. There even may be a history of a frank patella dislocation, but this episode is less traumatic and certainly more benign. They sense that their patella quickly went in and out of place. They can usually continue their activity, but eventually the knee will stiffen. Immediate swelling is rare, for there is little acute tearing of the tissues. The patella is contused by the subluxation, and these patients will have some

2.3  Acute Patella Subluxation

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s­ tiffness and mild swelling several days after the injury. A twist is needed to cause the injury, and sporting activities are typically the culprit. Sometimes these patients do not realize that their kneecap slipped, and they will just report a pain in their knee. Unlike the patella dislocator, they are not in that much pain and they will come to your office unbraced, looking fairly comfortable. The family history is often positive for parents or siblings with patella problems.

2.3.2 Physical Examination (See Table 2.2) The patient will typically walk with a mild limp or no limp at all depending on the interval of time from injury to your examination. Look at the patient standing. Almost all subluxations will have malalignment problems including pes planus, femoral anteversion [with its associated “sqinting patellae”], genu varum, or valgus. Check their overall body habitus looking for tissue laxity. Loose-jointedness is associated with patella subluxations. I like Dr. James Nicholas’ tests for laxity which include the ability to touch the palms to the floor, hyperextension of the elbow, the abilTable 2.2  Key points on patella subluxation

History  • Something went out of place  • Knee gives way on level ground  • Knee swells Physical Exam  • Patella alta  • Outfacing patella  • Squinting patella  • Mild j-sign  • Negative apprehension with increased excursion  • Rare effusion Treatment  • Non-operative  • Closed chain strength program  • Bracing

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2  Acute Patella Injury

ity to flex the thumb to touch the forearm, and hyperextension of the second metacarpal-phalangeal joint with the wrist flexed. Sit the patient and look at both patellae. Do they face forward or outward? Do they appear high riding? “Normal” patellae should face straight ahead, not upward or lateral. You can draw a face on the patella, as this is helpful in making the patient understand that they have a funny-looking kneecap. Watch how the patella tracks as the knee actively moves from 90° of flexion to full extension. The patella will typically swerve laterally in the last 10° of extension {a positive J-sign}. The J-sign will usually be positive in both knees. There will be a mild or no effusion. Tenderness will be localized to the medial peripatellar retinaculum, the medial facet of the patella, or the medial epicondyle. The Q-angle is not discriminating as many of these patients will have normal angles. The apprehension sign is negative, and they are not as nervous as the dislocators. If they are apprehensive, I am usually more suspicious that their patella completely popped out of its groove. This can be a tough call, for some subluxations can go pretty far off the edge, but I use the apprehension sign as the best way to distinguish the two entities. Their knee range of motion will be normal as long as there is a minimal effusion. Larger effusions are not typical of subluxations and if this is present other diagnoses should be considered. Joint line tenderness, ligamentous stability, and meniscal tests are all negative.

2.3.3 Treatment Plan 2.3.3.1 Early Care Unlike the patella dislocation, subluxation of the patella patients has minimal swelling. A hemarthrosis is rare, and typically they will develop a mild effusion a day or two after the event. Osteochondral injury is also rare, so the pain will be less. Cold therapy for the first 48–72 h is intermittently applied. The patient is immediately encouraged to start ROM exercises, isometrics, and leg raises. I give crutches and encourage full weight-bearing, heel-toe gait, as pain permits. The patient is told to limit walking

2.3  Acute Patella Subluxation

29

as this will help decrease any swelling that may be present. NSAID medications, such as ibuprofen or naproxen, are recommended for the first few days. A patella knee sleeve is helpful for proprioception and “moral support.” These patients are started on physical therapy immediately, trying to reestablish full ROM and quadriceps control.

2.3.3.2 Second Visit and Treatment Recommendation As with the patella dislocation, most patients with a patella subluxation will have predisposing anatomic factors (i.e., patella alta, trochlea dysplasia, etc.). X-rays, MRI, and CT scan are helpful in defining these parameters. These individuals are at a high risk for a recurrent injury. My initial treatment regimen is always NON-­ OPERATIVE. Patient education is a must! They have to be made aware that they are at a very high risk for this to happen again. The majority of these first time subluxators have never participated in an exercise program. An aggressive rehabilitation program is now indicated. The patient has to be educated as to the importance of muscular control in the prevention of their next injury. You must emphasize that their rehabilitation program is ongoing. The prognosis for the primary patella subluxation is better than the primary patella dislocation, as less anatomic damage has been done to the medial patellofemoral complex. I like to see these patients every 6 weeks for the first 3 months. These visits are usually “coaching pep-talks” that make sure that the patient is continuing in their rehabilitation program. I encourage the usage of a patella sleeve for proprioceptive reasons, especially when they first resume athletic activities. Closed chain leg presses, hip and core strength are encouraged. Biking, swimming, and the elliptical machine are encouraged for aerobic fitness. If the patient suffers recurrent episodes of instability, surgical options are discussed.

3

Medial Collateral Ligament (MCL) Injury

3.1 Introduction In my early years of practice, tremendous emphasis was placed upon the diagnosis of medial collateral ligament injuries. Dr. O’Donoghue’s famous triad of an ACL tear with an MCL and medial meniscal injury had us all thinking about the medial side of the knee. The clipping injury in American football certainly deserved a fifteen-yard penalty for many a knee was severely injured by this mechanism. Classifications and grading systems of these sprains were very important for they dramatically influenced our method of treatment. Since that time much has changed. The MCL no longer carries as devastating a prognosis as we once thought and good prospective studies have demonstrated that few MCL tears necessitate aggressive surgical intervention. This does not mean that we don’t have to be able to diagnose and treat these injuries. In fact, your diagnostic acumen helps to make an earlier treatment plan for the patient which will hasten their recovery.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­32844-­2_3.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2_3

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3.2 The History 3.2.1 How Did You Get Hurt? The MCL injured patient will almost always be able to recall their mechanism of injury. The valgus stress that is required to cause the injury will point their response in the right direction. If there is contact, they will remember that they were hit on the outside of the knee. If they were skiing, they will usually be able to recall the direction of their ski. To suffer an MCL tear, there is always a twist. The patient often falls after the twist confusing you with the possibility of a direct contusion. Probe the details of the mechanism.

3.2.2 Did You Hear a Pop? The patient occasionally will hear an audible pop, but this is an uncommon response. More than likely, they will feel that “something ripped” on the inside of the knee.

3.2.3 Were You Able to Continue Your Sport or Activity? Many of these patients are able to continue their activity, but this does depend on the degree of injury. A grade one or two sprain will have immediate pain, but are often able to get up, walk away, and often attempt MBZ successfully to continue with their prior activity. This is particularly true in the heat of an American football game. Many of these athletes will not tell you about their “twist” until the game is completed and they are in the locker room. The grade 3 injury will typically not be able to continue, for many of these tears will be associated with other knee ligament injuries.

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3.2.4 When Did the Knee Swell? The MCL does not have a very good blood supply. When torn, it will typically take hours for local swelling to appear at the site of the tear. If the swelling is more acute, then an associated injury should be suspected [i.e., ACL, chondral fracture]. Most MCLs take about 24 h to swell as the bleeding is minimal. Ecchymosis often appears several days later. In grade 3 complete tears, the peripheral capsule of the knee is torn, and the swelling can occur more rapidly. A hemarthrosis is NOT typical of an isolated MCL injury. The MCL is an extra-articular ligament and the bleeding that occurs should not fill up the knee.

3.2.5 Were You Treated for the Injury? Most MCL injured patients rarely go to an emergency room. They can typically walk so the need for emergency care is usually not sought. The knee “stiffens” up by the next morning, and they usually seek out an orthopedic consultation.

3.2.6 Did You Ever Hurt This Knee Before? MCL tears are not recurrent problems. It is very rare for me to see someone who has had chronic instability related to an old MCL injury. If the patient states that the knee has been unstable in the past, I am more suspicious of a chronic ACL tear or recurrent patella instability.

3.3 Physical Examination 3.3.1 Observation The MCL injured patient is typically not that “unhappy.” They are in some pain, but this is moderate in nature. As stated, they can usually walk on their injury, but they are limping. Most present

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3  Medial Collateral Ligament (MCL) Injury

with an ACE wrap or a knee immobilizer their trainer, coach, or local physician gave to them. The knee is typically held in a flexed position, as going into extension does cause pain. The knee looks “locked” as the patient is reluctant to straighten it out. Typically, the knee will be held in 10° of flexion. Look at the patient standing to assess the alignment of the unaffected knee. To watch the patella track, sit them down and watch the normal knee actively flex and extend. Now have the patient lie down and quickly but thoroughly examine the unaffected knee. Every individual has different laxity, and this establishes a baseline for your instability exam. ALWAYS reassure the patient that what you are doing on their normal knee will not be as vigorously done on their affected knee. Most people are very nervous that they will be in pain, so this reassurance is crucial to establish a line of confidence. YOU DO NOT WANT TO CAUSE PAIN AT ANY POINT IN YOUR EXAMINATION!!

3.3.2 Palpation Knowing the topographical anatomy of the knee is important in diagnosing the injury. The MCL can tear anywhere along its course. The medial epicondyle, joint line and distally on the tibia can all be the sites of direct tenderness. There is often local swelling that is typically not very extensive. Ecchymosis can appear in the first 24–48 h, but this is usually slight without a gross hematoma. With the knee in a comfortable position of 30° of flexion, and the hip externally rotated, start your palpation along the course of the ligament. Start at least four fingerbreadths below the joint line, as the anatomic attachment of the MCL is quite distal. It is important to distinguish medial joint line tenderness from MCL tenderness. The medial epicondyle must be palpated as this is a common site of injury. Examine the lateral joint line carefully, for lateral plateau injuries and lateral meniscal tears can occur from compression of the lateral side. When a patient is in pain from an MCL tear, determining the extent of instability can be difficult. Have their head flat on the

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35

table with their arms at their side. It is not necessary for them to look at you for this always tenses their muscles. Try to let the knee fall into extension. Always stand on the same side as the affected knee. REMEMBER, do not go directly to examining the MCL.  A complete knee examination is essential for every knee that you see! Palpate for tenderness along the patella and both joint lines.

3.3.3 Valgus Stress Testing (Video 3.1) I like to place my thenar eminence against the lateral epicondyle. This is your post hand [your left hand for the right knee, right hand for a left knee]. Firmly, the stress hand grasps the leg in the mid-shaft of the tibia. REMEMBER, there are two aspects to the assessment of a ligament injury. One is the amount of excursion, and the second is the quality of the endpoint. I have never been that successful at quantifying the number of millimeters that a joint will open. Simply, I usually break it down to none, moderate, or severe, as this is typically consistent with the standards established of a grade 1 through 3 sprains. Upon stress, the quality of the endpoint is essential. If the knee opens, then tightens and springs back, the endpoint is firm. If the knee opens and does not spring back, then the endpoint is soft suggesting a more complete tear. Unlike the ACL, the endpoint of the MCL is never quite as rigidly defined. The valgus stress must be applied with the knee in extension and 30° of flexion. Thirty degrees will isolate the MCL as the posteromedial capsule is relaxed in this position. With vocal encouragement, most patients can get their knees to straighten. Do the best you can to get them to relax! If there is no excursion, with tenderness along the course of the ligament, it is a grade 1 injury. If the knee opens to valgus stress at 30° and does not open in extension, the amount of excursion and quality of the endpoint help define a grade 2 from a grade 3 disruption. At 30°, if there is moderate to severe amount of ­opening with a soft endpoint, I consider it a grade 3 injury. [This may be controversial, but as stated in the preface, this is a personal

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3  Medial Collateral Ligament (MCL) Injury

assessment based on 40  years of examining the acutely injured knee]. If the endpoint is firm, even with moderate opening, I consider it a grade 2. If the knee opens in extension, I consider the injury a grade 3, and I am immediately looking for an associated injury [i.e., ACL, PCL].

3.4 Differential Diagnosis The most common diagnoses confused with MCL injuries are: • Medial meniscal tears. • Patella subluxation. • Lateral tibial plateau compression fracture. The grade 1 MCL tear typically is harder to differentiate from other medial side injuries. Tenderness at the medial joint line without opening on valgus stress can be difficult to distinguish from a medial meniscal tear. Medial meniscal tears will often have an associated effusion, while the MCL injury will have local soft tissue swelling. The topographic anatomy is so important as you must be able to distinguish epicondylar tenderness from joint line tenderness. Medial meniscal injuries are rarely associated with isolated MCL tears. Instability on valgus stress will not be present with a medial meniscal tear, implying that a grade 2 or 3 MCL should be easily distinguishable from meniscal pathology. The acute patella subluxation will often present with medial epicondylar or adductor tubercle tenderness, similar to a proximal MCL injury. In fact, an MCL injury can take place along with a patella subluxation. Patella apprehension and medial patella facet and retinacular tenderness can be distinguishing features. An effusion is more consistent with a subluxation. Valgus instability will not be present in an acute patella subluxation unless there is an associated MCL disruption. The presence of lateral joint line tenderness should make you suspicious of a compression injury to the lateral side. Typically, the patient will have an effusion and be in significant pain. With a compression lateral plateau fracture, the knee will open up in

3.5 Treatment

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extension, and one can be fooled that this is an extensive MCL tear. The endpoint becomes very important in this situation, as the extent of medial instability will be instrumental in determining your treatment plan for a compression plateau fracture.

3.5 Treatment 3.5.1 Early Care Most patients will have already visited an emergency room or other outpatient facility. They will often come to you wearing a knee immobilizer or some other form of support. Hopefully, you will get to see these patients within the first few days of their injury, as the earlier you begin treatment, the faster and better the recovery. The early care follows the RICE protocol. Most MCL injuries have soft tissue swelling without a hemarthrosis, as the ligament is extra-articular. The swelling is rarely excessive unless there is an associated intra-articular fracture or an ACL tear. Despite the pain, the patient is immediately encouraged to begin an ROM program. I emphasize isometrics, so that they immediately work on getting their knees straight. A flexion contracture is the enemy of your rehabilitation and you must fight this from the onset. The MCL injured patient loves to keep the knee flexed for pain relief. A compressive dressing, consisting of 3–4 rolls of 6- inch cast padding and several 6-in. ace warps is applied. I do use an immobilizer, as this prevents valgus motion that incites pain. The immobilizer is used for full weight-bearing ambulation, but frequently removed to begin ROM. Early flexion-extension motion will not affect the outcome of your conservative treatment. The olden days of protracted casting or immobilization to allow the ligament to heal are long gone. As long as the knee is protected from valgus load, motion enhances recovery. The dressing is maintained for a few days and then removed by the patient. They are anxious to normally shower. After bathing, they are told to re-apply the immobilizer for ambulation. Nighttime usage of the immobilizer is also recommended, as twisting and turning in bed cause pain,

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3  Medial Collateral Ligament (MCL) Injury

and put stress on the ligament. Cold therapy is continued along the course of the MCL. This is continued for 5–7 days, and then utilized only for pain management. Though they can full weight-­ bear, I encourage crutches and rest for the first week. If the patient has insurance coverage, I immediately give a prescription to start physical therapy. The prescription gives instructions to start modalities for pain management, active ROM exercises, and isometrics. I typically order a functional double-­ hinged brace which will be applied at the second visit. The patient is instructed to return in 1 week. If my physical examination is consistent with an isolated MCL injury, I do NOT order an MRI.  Intra-articular damage (i.e., meniscal tear, osteochondral fracture) is uncommon with isolated MCL injury and an MRI can be ordered at a later date if necessary.

3.5.2 Second Visit and Treatment Plan The degree of pain which is now present often depends on the site of the MCL tear. The more proximal tears off the medial epicondyle are typically more painful and often cause difficulty for the patient to fully extend their knee. Continuing cool therapy in the region of the epicondyle is very helpful for pain management. The patient is made to understand that the treatment is solely NON-­ OPERATIVE. Again, I emphasize that this is not a “conservative” regimen. An aggressive therapy protocol for the treatment of any grade MCL tear is always indicated. Thanks to the fine work of my friend Dr. Peter Indelicato, the surgical repair of isolated MCL injuries was abandoned. His studies laid the foundation for the present rationale that grade 1, 2, 3 will all heal non-operatively, with excellent functional outcomes. As long as swelling is reduced, a functional double-hinged brace is applied. I do not restrict any motion on the brace. I am very much against setting the brace with a lock that blocks the last 20–30° of extension. This has been proposed to be necessary to help the MCL heal. I feel that this only enhances the development of a flexion contracture which will delay your

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patient’s recovery! The brace should be worn for ambulation and at night, removed for bathing and physical therapy sessions. A stationary bicycle is of great assistance in the rehabilitation of these patients. Biking can be done daily, as the resistance applied is less important than the range of motion that is achieved. Changing seat position is very helpful in regaining flexion and extension. A closed chain strength program is initiated. Leg presses are well tolerated despite the medial pain. I do not encourage knee extensions, as these do incite pain. Hamstring curls and hip strengthening are immediately encouraged. The magic timeframe for most ligament to “heal” is 6 weeks. The degree of the MCL tear is the determining factor as to how quickly the patient can resume full activity. As said, the more proximal tears often take more time to achieve full extension. It is important that you realize that early protected therapy enhances the healing of the MCL and will hasten the patient’s return to sport or other activities. As with every acute knee injury, you have to develop your own criteria as to when it is safe for your patient to return to full functional activities. Running in place, hopping on one leg, duck walking, the distance of a one leg broad jump compared to the unaffected side, are all tests that I personally utilize. In an athlete, the sport and the position they play have a great influence on when I let them return to play (i.e., a point guard on a basketball team will take longer to return than an interior lineman on a football team). On your physical examination, the knee may continue to have increased excursion on valgus stress. This does not affect your functional result, and I urge you not to use that as your criteria as to when the individual can resume full activity. I encourage the use of the functional brace for the resumption of activities. I usually recommend the functional hinged brace for the first 6 weeks. At 12 weeks, I recommend a simple knee sleeve for proprioceptive support. Long-term bracing should not be ­necessary nor encouraged. Long-term workouts in the gym should be encouraged, as the patients dynamic muscular control remains the best preventative medicine!

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3  Medial Collateral Ligament (MCL) Injury

Key Facts History • Valgus stress mechanism. • Rare “pop”. • Often try to resume activity. • Minimal swelling. Physical Examination • Medial soft issue swelling in line with MCL. • Mild effusion. • Instability and/or pain on valgus stress. • Later joint line tenderness may indicate occult plateau fracture. Treatment • Non-operative. • Bracing. • Early range of motion. • Aggressive early physical therapy.

4

Anterior Cruciate Ligament Injury

4.1 Introduction The Anterior CRUciate Ligament(ACL) has inspired more interest than any other sports related injury. Recognition of this injury is CRUcial. The injury can be exCRUciating and is always memorable. (I have had patients describe their injury from 50 years ago as if it just happened.). The ACL is the CRUx of the knee and anatomically crosses with the PCL like a CRUcifix. These words all start with the CRU prefix and will help you describe the significance of the injury to your patient. With the advent of the MRI, the recognition and accurate diagnosis of an ACL disruption have improved. The sweet mystery of being able to perform an accurate Lachman test is a fading memory. As I watch residents examine the knee, I often cringe. The exam is too often scant, quick, and incomplete, as the resident is quickly filling out a MRI requisition which will give them all the answers that they are looking for. The purpose of this book is to get back to basics. Your history and physical exam are more CRUcial than ever when it comes to an ACL disruption. On an MRI, the ligament may have an abnormal signal, and yet on exam its integrity may still be intact. The vice versa may also be true. An accurate history Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­32844-­2_4. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2_4

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often reveals that there was a prior injury, which will not necessarily be recognized by an MRI. Remember, the MRI is a wonderful tool that we now have at our disposal, but it is not a replacement for a proper history and physical examination. In my hands, 95% of the time, the MRI is a confirmatory test to what I believe is going on. It is my greatest pleasure to admit to a patient and their family that “I was wrong,” and that the MRI revealed something that I missed or overcalled (such as a positive Lachman test). I am never embarrassed, as none of us is perfect. By incorporating diagnostic clinical acumen with radiographical support, we can give our patients the most accurate diagnosis and treatment plan.

4.2 The History When you enter your examining room, most ACL injured patients will have already been seen in an outpatient or ER facility. The injury is significant enough to warrant them going for acute care, and most will present to you wearing some sort of splint or immobilizer. They are not happy patients! They are usually swollen and uncomfortable. It is important to have their leg supported as you take your history, so either put them on a table, or have the injured leg on a chair. If the patient is a minor, please talk to the patient and not the parent. The parents can editorialize but try to maintain your conversation with the injured person.

4.2.1 How Did You Hurt Your Knee? Was It a Twist or Direct Fall? Did You Hear a Pop? Could You Continue Your Activity? Did You Need Help Tin Getting Up? Were You Able to Walk On It? If Yes, How Did It Feel? Wobbly? This is a series of questions, which you must ask for every acutely injured knee. In the case of the ACL, almost every injury involves a twist, or the patient will describe a hyperextension mechanism.

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The majority are non-contact and may involve a perpetration, which is the fancy word for someone coming at you and you avoid that person with a twisting maneuver. A direct fall on to the knee goes against an ACL disruption, unless the fall happens after a twist. A pop is heard or felt by many of the patients, and sometimes a nearby athlete will hear the pop. The patient often slides their two clenched hands over each other in a sliding motion, to help them describe the sensation that they felt in their knee. When someone describes a heart attack, they place their fist on their chest to describe the pressure. With an ACL tear, the “Two Fist” maneuver is quite specific and may be observed, as the patient attempts to manually describe their ACL injury. After the twist, the patient often falls to the ground and needs help in arising. When they put their foot on the ground, they sense that it is not normal, making it difficult to walk away. The knee feels insecure, and a helping hand by a bystander is typically required. On a ski slope, the patient may require ski patrol to get down, as they cannot make turns to negotiate the slope. Patients with an acute ACL disruption rarely attempt to go back to what they were doing. Sometimes an athlete will try, but invariably they know that something is wrong, and the knee will not support their activity. If they do go back into the game, the knee will typically give way and they will have to leave the competition.

4.2.2 Did your Knee Swell? When? The ACL does have small blood vessels on its synovial sleeve that are disrupted when the ligament tears. The knee will swell, but it can take a few hours and is not necessarily immediate. If the knee swells immediately, you can bet that there is another associated injury such as an intra-articular fracture, or a capsular disruption. If an athlete is iced up after the injury, the swelling can be minimal. Generally, the knee will swell within the first 6 h, and this is typical of a hemarthrosis. Swelling 24–48 h after an injury is more typically an effusion and can occur with any knee injury.

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4.2.3 Have You Ever Hurt Your Knee Before? This is such a neglected but important question. Unless asked, many patients will forget to volunteer the information. Remember, we are allowed to lead the witness! Many ACL “acute” injuries are second or third injuries. The patient may state that they twisted their knee months ago, that it swelled for a few days, but never saw a doctor. Others may say that they hurt their knees years ago and were told they had a “sprain.” Their knee was “never normal” but they were able to function. Patients with a prior unrecognized ACL tear would have a higher chance of having associated pathology such as articular cartilage damage or meniscus pathology. The acuteness of the injury will affect your judgment. It can definitely change your opinion as to whether or not an operative or non-operative strategy should be followed. It never ceases to amaze me how often this simple question is not asked.

4.2.4 Are You Active in Sports? What Do You Play? How Often? It is not enough to just ask what sports you play. From the history, it is crucial to get a feel for what this patient actually does. It is easy when the patient is an athlete and plays for their high school or college team. That is clear cut, for you know that your patient is a very active individual. The difficulty arises in the recreational athlete. Recreational sports are more a part of a person’s life after they leave college. Twenty-two is my break off year as to the beginning of middle age (this will raise some eyebrows), as many people are now involved in the work force, and do not participate in sports the way they used to. Years ago, Dale Daniel wrote a paper that emphasized that it’s not only the sport one plays but the time spent on that sport that helps decide who will be a “coper” and do well without an ACL. For example, someone who plays racquetball or tennis once a week is far different than the person who plays basketball in a league twice a week. Both individuals feel that they are very ­athletic, but when deciding as to whom needs an ACL reconstruction, they are very different people.

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The jumping sports (basketball, volleyball) are high risk activities. How important are they to the patient? Can they go on with their lives leaving these activities? Football and soccer involve pivoting and contact and are high risks. Many recreational athletes are willing to give up these sports rather than undergo ACL surgery. It is your job to get a feel for what the patient really does and how willing they are to modify their activities. Recent follow-up operative ACL studies reveal that in the recreational athlete, the majority of patients will not return to their prior sport simply because they are afraid of re-tearing their ACL again. If that is true, then most of them may not need an ACL reconstruction to begin with! That is why your assessment of the patient is so important in creating the appropriate game plan of care.

4.2.5 What Type of Work Do You Do? It is important to know what the patient is doing on a daily basis. A sedentary job does not require an ACL to be intact. You do not need an ACL to be a secretary, computer person, or an accountant. Occupations that involve lots of walking do not necessitate the need for an ACL. Jobs where the individual has to climb, jump from a truck, or work on beams, rafters, do need a stable knee. Fireman and police officers need knee stability to protect themselves and others. It is your mission to be formulating a game plan for the patient. In my experience, this game plan is based much more on the personal history, rather than the MRI results or the physical exam. The art of a good history is to have a clear picture of what the patient is all about! Your algorithm of ACL care will be dependent upon this picture.

4.2.6 Have You Hurt Your Other Knee? Anyone Else in Your Family Hurt Their Knee? Remember, the patient rarely volunteers information. You have to ask!

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It is quite common for an athlete to tear one or both ACLs, so don’t forget to ask about the opposite knee. The more you see ACL injuries, the more you realize that there is a genetic predisposition. Find out if any siblings or parents have torn their ACL. This information may help formulate your plan of care. If the ACL on the opposite knee is insufficient, it will definitely affect your thinking process as to the plan of care. If other members of the family have torn their ACL, it is important to make the patient realize that this is not such a simple issue, and their incidence of re-injury may be increased because of this genetic background.

4.2.7 What Level of School Are You In? If the patient is a student, you really want to know about their academic skills, the grade they are in, and when the next time off from school will occur. Most high school and college individuals who tear their ACL will need a surgical reconstruction. Timing is everything in these individuals, as grades can be affected by an ACL surgical procedure. I try not to perform ACL surgery in the middle of an academic semester. It is better to wait for a vacation time (i.e., Christmas, Easter, spring break). The second semester of a senior year in high school is one of the better times to have an operation as the grades are less important. This info is all important for it brings you much closer to the patient and truly helps in your future plan of care.

4.3 Physical Exam Acutely injured ACL patients are typically in pain and not in a smiling mood. Young or old, they are not “happy campers.” Once you’ve taken their history, it is important for you to have the patient lie down and make them comfortable. Shorts are mandatory for a proper examination. Their knee will be in a flexed position, typically because of their hemarthrosis, and they may require a rolled sheet or pillow under their knee.

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4.3.1 Observation As in all exams, this is your first calling. Does the knee look swollen? Is their ecchymosis? What is their active range of motion? Do not push for passive motion, for that will cause the patient pain, and immediately making them apprehensive and tight, making further examination difficult.

4.3.2 Examine the Unaffected Knee What is the normal range of motion? Is there recurvatum? I quickly check for patella mobility in the Fairbanks position. Is the patella hypermobile.? I do a Lachman and Pivot shift tests, as well as an anterior and posterior draw, and then quickly test for medial and lateral laxity. It is best that your examining table is in the middle of your exam room, as then you can easily walk to both sides of the patient without asking them to move. Comparison of the laxity of both knees is very informative. Now go back to the affected knee.

4.3.3 Neurovascular Assessment In the isolated ACL tear, injuries to the vessels and nerves are rare without associated ligamentous disruption.

4.3.4 Palpation Check for an effusion. Usually the swelling is self- evident, but sometimes it is necessary to do the PATELLA TAP TEST. With the one hand push down gently on the suprapatellar pouch, which will push any fluid distally. While doing this, with your other hand, gently play the piano with your second and third finger, tapping on the patella. An effusion will push the patella away from the trochlea and you sense it tap against the trochlea. This is good for subtle effusions, which is not the case in an ACL injured hemarthrosis.

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Palpate for sites of tenderness. What distinguishes the ACL knee from other pathology is JOINT LINE TENDERNESS ON BOTH MEDIAL AND LATERAL JOINT LINES! Your palpation should be done with the knee at as much flexion that the patient can tolerate. Topographic anatomy is crucial (excuse the pun). You must be able to feel the medial and lateral joint lines. Typically, the tenderness will be posteromedial and mid lateral. JOINT LINE TENDERNESS ON BOTH SIDES OF THE KNEE IS AN ACL TEAR TILL PROVEN OTHERWISE!

4.3.5 Apprehension Test Do your patella apprehension test at 30° of flexion. Check for varus and valgus instability at 0 and 30° of flexion. (See Patella Examination).

4.3.6 The Lachman Test (Video 4.1) The Lachman should be performed with the knee at 20–30° of flexion. In a right knee, your left hand firmly grips the femur above the patella, as the right hand grasps the tibia at the level of the tibial tubercle or below. Do not grasp above the tubercle as you want to see the knee as the Lachman test is performed. (vice versa for hand distribution on the opposite knee). Making a stable post on the femur is the essence of the Lachman, as the tibial hand exerts the force to bring the tibia anterior. The fingers grasping the femur also palpate the hamstrings to ensure that they are relaxed, or the exam will be difficult to perform. If you ask sports medicine physicians what defines a positive Lachman test, you will be surprised by the variety of answers. In Dr. Lachman’s original description, the emphasis is solely on the amount of anterior excursion of the tibia on the femur. He described how the concavity in the anterior aspect of the knee disappears, as the tibia comes too far forward. The endpoint palpated was not really discussed. In my opinion, it is the lack of endpoint that truly defines a positive Lachman. IF THE

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ENDPOINT IS NOT PALPATED, IT IS S POSITIVE LACHMAN UNTIL PROVEN OTHERWISE. I feel that this is a key philosophy if you don’t want to miss the diagnosis of an ACL disruption. The very “tight” knee is difficult as the lack of excursion makes it harder to define an endpoint, and hence the excursion becomes more important. The very lax individual can also be difficult as lots of excursion may be present before the endpoint is reached. Practice makes you better but never perfect. Occasionally, I still miss the diagnosis, but if I do, it is almost always a false positive, and the ACL is intact (good news for the patient). The Lachman is graded as an A, solid endpoint, or as a B, no endpoint. A grade 1 Lachman has mild increased excursion whereas a grade 2 has significant excursion. This classification is certainly not a perfect science. I recommend you concentrate on the quality of the endpoint, as this truly defines the functional status of the patient’s ACL.

4.3.7 The Pivot Shift (Video 4.2) In the acute setting, I rarely check the pivot shift test. These patients are typically in pain, and the less manipulation of the knee you do, the better. The pivot shift requires significant maneuvering of the knee, and your patient will not enjoy the flexion rotation that is needed to perform the test. Once the acute pain and swelling of the injury are gone(which usually takes up to 6 weeks), the pivot shift becomes more accurate. There are many articles on technique, position, etc. but in the acute setting, I do not find it to be accurate or beneficial.

4.3.8 The Dial Test (Video 4.3) The Dial Test can be informative and should be done with an acutely injured knee. This helps to give a hint of an associated posterolateral complex injury. It is helpful to have another person support the thigh to help lock the hip from rotating. Support the tibia with both hands 6 inches below the tibial tubercle, and flex

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to 30°. Now, keeping an eye on your tibial tubercle, note the degrees of lateral rotation as the tibia is externally rotated. This should also be done at 45°, and it is crucial (excuse the pun) to compare the amount of external rotation to the opposite knee. In my experience, this test is rarely positive, but should be part of your routine.

4.3.9 The Anterior Drawer Sign (Video 4.4) The Anterior Drawer Sign was originally the sine quo non for the clinical diagnosis of an ACL disruption. This has to be performed with the knee at 90° of flexion, and most ACL injuries are too swollen and in too much pain and spasm to get into that position. When I flex the knee to examine for joint line tenderness, I will typically attempt to do the Anterior Drawer test. I tell the patient that I am going to rest my rear end on their foot, to support the leg. Tell them this before you sit on the foot, otherwise they may think you are a little weird! I gently wrap my hands around the proximal tibia and pull forward, observing excursion, I’m feeling the hamstrings for spasm, as tightness in the hamstrings will negate the test. I have not found an endpoint as helpful with the anterior drawer. Excursion is everything, and this must be compared to the opposite side. End point is important in this position with the posterior drawer, which will be discussed later. Frankly, large anterior excursion should arouse your suspicion for an injured PCL.  ­Unrecognized drop back, secondary to a PCL injury will cause a pseudo positive anterior draw. (See Posterior Cruciate Ligament Chap. 5).

4.3.10 Meniscal Evaluation Meniscal injuries occur in about 50% of acute ACL tears. I do not do any classical meniscal tests (i.e., McMurray, Apley grind) as these maneuvers require flexion and manipulation which are painful and not very accurate. Joint line tenderness should make you more suspicious of a meniscal tear, but as stated earlier, most ACL

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injuries will typically have tenderness at both joint lines, secondary to capsular damage. Hence, clinically, a meniscal tear is definitively hard to diagnose. Do not assume that the knee is “locked,” because the patient has a loss of extension. The effusion and pain will prevent the individual from straightening out the knee. In the acute setting, a bucket handle meniscal tear that displaces and locks the knee is extremely rare. The pattern of meniscal tears in the first time ACL injured knee is typically shorter longitudinal tears or radial tears that do not mechanically lock the knee. If the patient truly has a bucket handle displaced tear, the injury is typically chronic, and the individual probably had a prior ACL disruption.

4.3.11 Differential Diagnosis • Acute patella dislocation. • Chondral fracture (Contusion). • Medial collateral ligament injury. The acute ACL tear is very distinctive. A patella dislocation or a medial collateral ligament tear patient may say they felt a pop. The patella dislocation patient will typically know that the patella was out of socket, which makes life a lot easier for the clinician. The patella dislocation presents with specific sites of tenderness and the apprehension sign is quite definitive. At occurrence, the MCL injured individual may continue their activity and the effusion will be mild (most of the swelling being extra-articular). The sight of tenderness will be very localized to the medial side of the knee. Valgus instability upon stress defines the diagnosis. Chondral fractures are most common after a patella dislocation. A direct blow or fall can cause this type of injury, and the history should help lead you in that direction. The lack of other positive findings may point to this diagnosis. From my younger residents and fellows, I often hear that they can’t do a Lachman test for the knee is too swollen or too painful.

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I must emphasize that with patience and a gentle approach, the Lachman test can be done accurately in almost all patients. It is not a maneuver of force!!! It is one of finesse, experience, and practice. Remember, if the endpoint is not present, it is an ACL disruption until proven otherwise.!! Certainly, the MRI will clarify the diagnosis and is very helpful when it comes to associated injuries, such as meniscal tears, and chondral bruises. Before my patients leave the office for their MRI, they are informed as to what I feel is their diagnosis. They do not hear, “I’m not sure and we will see what the MRI says.” Patients will be more respectful of your clinical knowledge when the MRI confirms your diagnosis and are never upset if you tell them you are wrong (as I said before, it’s usually good news that the ACL looks normal on the MRI, and that your Lachman sign was a false positive). The self-satisfaction of making the correct diagnosis is very rewarding and objective tests such as the MRI should be confirmatory and not diagnostic.

4.4 Treatment Plan Of all the acute knee injuries, no injury can arouse more controversy as to what the best way is to treat an ACL injury. I thank the lord that this manual reflects my personal opinion as to what should be recommended! Thousands of fine papers have been written on this subject. Weekly, hours of conferences take place in our academic institutions, discussing the rationale for treatment. Each patient requires your very personal attention and advice. Your treatment recommendations will affect the patient for life, and you must base your advice on academic knowledge and your own intuition. The intuition comes from experience. Not every patient is a surgical candidate. There are so many factors to consider! In many cases, it is quite clear cut (i.e., the 16-year-old basketball player looking to play college basketball). That’s a “no-brainer”, as surgery is absolutely indicated. It becomes a lot more difficult when the 27-year-old accountant comes to your office. He is a husband and parent, who frequently jogs to keep fit, and likes to play occasional recreational tennis. It’s tax season!

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What do you tell this patient? What would you want done if that was you on the other side of the table? After treating several thousand ACL tears operatively and conservatively, I do have a sense as to what may be the best treatment plan. Because of social media, the average patient feels pressured that if they tear their ACL, they must have a surgical procedure. It’s become a “red badge of courage” to say that I had my ACL fixed! This is certainly not the case. Yes, our technical capabilities have improved, but the successful surgical outcomes depend on many variables. I hope that my thoughts help you create your own game plan. There is a unique story to every patient who tears their ACL. Over these past 40 years, I have treated many individuals with an ACL injury. Many have become dear friends. Many think I’m their hero and still bring me gifts at Christmas. Others have gone to other physicians and have had other surgical procedures. I have performed total knee arthroplasties on the same adolescent that I once treated for an ACL injury. This all leads to the development of the most important character trait that a physician must strive to achieve. HUMILITY! No injury that I have treated has taught me more about humility than the ACL. Through academic research, a treatment rationale has evolved. Ironically, many of the arguments that took place 40  years ago still exist today. Having treated thousands of ACL tears operatively and non-operatively, I do feel that my experience will be of assistance in your development of your own intuition. If that is accomplished, then I will feel that this manual has more than achieved its goal.

4.4.1 Early Care The ACL injured knee presents as an unhappy patient with a swollen, painful, stiff knee. The likelihood of an associated injury intensifies their symptoms. The typical hemarthrosis develops quickly, so that by the time they present to you in your office, they are in trouble. They lack motion and are very reluctant to move their knee. Before they arrive in your office, most ACL injured knees will have been treated elsewhere. They typically arrive in an immobilizer, on

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crutches, with or without a compressive dressing. Your first job is to make them comfortable, usually having the leg supported on a second chair, or having them on the examination table. The RICE protocol starts immediately! Rest involves limited weight-bearing. They are told not to walk very much. I give them crutches and emphasize an immediate 3-point weight-bearing gait. Heel-toe walking is instructed, as the emphasis is on getting the knee into full extension. Limit the walking to the household and restrict stairs. If there is a tense hemarthrosis, I sterilely aspirate the knee and then apply a bulky compressive dressing (I use 4 rolls of 6 in. cast padding wrapped from ankle to proximal thigh, enclosed by two to three 6 inch ace wraps). For moderate swelling, I do not aspirate but I do apply a compression dressing. They are told to leave the dressing on for 48–72 h. Intermittent cold therapy is started after the compressive dressing is removed. This is continued until the swelling diminishes. For the first week, I do use a knee immobilizer. Crutch walking is recommended until the patient re-­ establishes quadriceps control. You do not want them to have another buckling episode. I don’t really emphasize elevation. It is more important that they immediately move their knee. During my examination, I immediately show them how to do an isometric contraction. They are urged to start this despite the pain. I point out to them how quickly the quadriceps will “go down the tubes” unless they start working immediately. “No pain. No gain!” is clearly your motto. Your emphasis on regaining their range of motion is paramount. The patient is instructed to sit on a table to flex and extend their knees. Make them understand that motion and firing the quadriceps reduce swelling in the knee. A flexion contracture is the enemy! Don’t let them use their other leg or hands to lift their affected knee. (This immediately turns off the quadriceps and time is wasted in the process of re-educating a muscle that stops firing). On the first visit, I rarely go over the details of my game plan with the patient or with a minor’s family. I tell the patient/family that further testing is needed and that on the next visit, a treatment plan will be carefully discussed. The next appointment is made in a week, and I always schedule these patients at the end of my office hours where my discussion time is not rushed if not already

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done, an MRI is ordered. The results of the MRI do influence your decision-making process. X-rays are not routinely done unless the patient is over 35 years of age. If the patient has private insurance, I immediately refer them to physical therapy. Your prescription orders focus on active ROM and quadriceps activation. Modalities and stationary cycling are helpful. If a surgical course is obviously indicated (young athlete), I tell the therapist to prepare the patient for surgery. Pre-­ operative therapy is extremely important for excellent post-operative outcomes.

4.4.2 The Second Visit This is usually a good time to re-examine the patient. The pain and swelling are diminished and you can be more accurate in your assessment of joint line tenderness, and the degree of instability. You have hopefully already looked at the MRI pictures NOT JUST THE REPORT!), so that you have already formulated your game plan. With ACL injuries, there are many variables which should be considered before you give the patient your therapeutic recommendations.

4.5 Factors Influencing Your Decision-Making “To operate or not to operate” that is the question? Many factors come into play with the ACL injured individual. You must put the whole gestalt together before you come up with your recommendation. The factors below are all what you must consider. The younger, team athlete is not the issue. Most of the people we all see are the recreational athlete, all of whom think they are super stars! These are the cases that demand your attention to the factors about to be discussed. I will not be discussing the methods of surgical reconstructive or repair techniques. The non-operative regimen consists of persistent strength training, activity modification, and functional bracing for sporting activities. The ACL injured individual will rely on you to choose the appropriate course of treatment.

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4.5.1 Age There is no doubt that as we get older, our activity level changes. However, it has become more and more difficult to define what “older age” means. We live longer, and you can never assume that because one is older that they are less active. When it comes to the ACL injured patient I typically subgroup age into 3 subgroups’ of age: Less than 22 years old, 23–35 years old, 36 plus. The “older age” by this classification is over 35. I’m quite sure that will aggravate a few of the readers. The less than 22-year-old category are typically active individuals. Even if they are not very active in sports, their young age takes precedence. Younger people don’t do well with ACL insufficiency, and the surgical option is the best recommendation. The 23- to 35-year-old category is the hardest group to make a therapeutic plan. At this age, the patient is now employed, and their sports become more recreational, varied, and typically less time is involved with their sport. The other factors about to be discussed take priority over age (see below). Over 35 is now my “older age” group. No matter how athletic the patient thinks they are, they still are “older.” Each case is very individual, and you never want to come off by making the patient think that they are too old to have their ACL reconstructed. If you do, they will find another physician immediately. It is your job to see exactly what they do and to carefully look at all the variables. I tend to think non-operative in this age-group, but certainly there are may “older” people who will require an operative treatment plan to restore their higher functional activity.

4.5.2 Activity Level The patient’s activity level is the most important factor as to whether or not a surgical or non-operative regimen is recommended. Many patients will tell you that they are extremely active. It is your job to precisely define what the patient means by this! In the younger team athlete, a discussion is not needed. Surgery is indicated. “Very active” to a patient may mean that they jog

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6 days a week. Does that patient need an ACL? If that’s the only sport that they do, they more than likely can follow a non-­operative course of treatment. It is not only the sport in which they participate, but more importantly the frequency of their participation. My good friend, the late Dr. Dale Daniel wrote a wonderful paper discussing this issue. The “copers” are those who have good functional ability in the absence of an ACL. The hard task is figuring out who they are! Not every acute ACL needs operative treatment, and the best of ACL surgeons know when not to operate. The participation in vigorous running, jumping, and pivoting sports, done frequently, places the patient in the operative column. Any sport in which there is less jumping, and the knee is kept in the more flexed position, are safer in the face of ACL insufficiency. These lower demand sports such as racquet sports, baseball, jogging, make me lean toward the non-operative category. Again, the frequency of participation is very important in these lower demand sports. None of us has a crystal ball. We can advise the patient, but they must be aware that this predictive process is not a perfect science. All the factors have to be considered.

4.5.3 Associated Injuries This is where your MRI findings come into play, as they do affect your decision-making process. A repairable meniscal tear pushes me to the operative treatment plan. It is crucial (excuse the pun) to save the meniscus, and an intact ACL is the key to the survival of a meniscal repair. The only exception would be in a less active older individual with a posterior peripheral medial or lateral meniscal tear. These lesions can heal without surgery, and you can follow these patients conservatively, carefully watching for meniscal symptoms. An irreparable meniscal injury also pushes me in the operative category. If meniscal function has been compromised by a partial meniscectomy, it is better to have an intact ACL.  ACL insufficiency in combination with meniscal insufficiency progresses rapidly to an osteoarthritic knee. The presence of an ACL may

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delay this process, and yet I don’t have great scientific evidence to support that statement. Try to save the meniscus if you can. The presence of a chondral injury also influences me to recommend ACL surgery. However, as with irreparable meniscal tears, the prognosis for these knees with or without an ACL may not be that much different. Common sense tells us that a more stable knee is more protective against later degenerative changes. This, unfortunately, has not held true. Despite ACL surgery, later arthritic changes have not been prevented, especially if there has been chondral or irreparable meniscal damage. Modern methods of cartilage repair will hopefully change the prognosis for this difficult problem. Time will tell!

4.5.4 Rehability Earlier in the book I talked about rehability, the ability to rehabilitate. This is extremely important in your decision-making process. Getting a “feel” as to whether or not the patient is going to be able to deal with a surgical procedure takes experience. Many of these patients have never had a pain in their life. Predicting pain tolerance is very difficult. I have found pre-operative physical therapy to be very helpful. The therapist will be able to tell you how the patient deals with their pain, and their ability to regain their range of motion. This will give you some idea as to how they will react to a surgical procedure. Immediate surgery is rarely needed, and you do have time to assess the patient’s pain tolerance and rehability. With your ACL patient you are essentially signing a one-year contract together. The surgical path requires dedication, pain tolerance, and the available time to get to therapy. Even a non-operative course requires cooperation. The “copers” are most often the people who dedicate themselves to a long-term strength program, and a willingness to modify their activities.

4.5.5 Family History There certainly is a genetic link to ACL injury. It is quite common for the patient to give a history (If you ask), of a sibling or parent

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that has also torn their ACL. There may be some form of genetic weakness in the ligament itself, or possibly an increased tibial slope. This may change their prognosis and influence the surgical technique you choose, but it does not influence my decision as to whether or not the patient needs an operation.

4.5.6 Gender Undoubtedly the female athlete has a higher risk of an ACL injury. However, gender is not a factor in the decision-making process.

4.5.7 Occupation The patient’s occupation absolutely influences my decision to go operative or non-operative. Any individual that requires absolute knee stability to protect themselves or others needs their ACL to be repaired (the best example would be a fireman or police officer). Vigorous activity that requires a lot of walking, stairs, is not a reason to have an ACL surgery. A very important question is how long can the patient be out of work? Many people cannot economically afford the time off to go through the rehabilitation process, and a non-operative protocol is the more practical choice.

4.5.8 Body Habitus/Laxity Tissue laxity is associated with a higher incidence of ACL disruption and a possible poorer outcome after surgery. However, I do not know of a prospective study that has shown that looseness affects outcome if a non-operative course is followed. I personally feel that the looser individual requires an intact ACL and I tend to recommend surgery for these patients. Be careful about assuming that the overweight individual is inactive. These patients can be extremely active and will require ACL surgery. Many overweight individuals are endomorphic and quite loose jointed, often making their instability more severe. I

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do not hesitate to recommend surgery in these patients. Being overweight in association with ACL insufficiency more than likely increases their risk of earlier degeneration. However, that is not a reason to recommend surgery. There is not enough data to support the fact that an ACL reconstruction will prevent later arthritis.

4.6 Treatment Recommendations Decisions, decisions, decisions!!! There is a lot to think about when an ACL injured patient is sitting in front of you. Your brain has to sort out all the facts and hopefully come to the correct conclusion for that specific patient. Most sports medicine physicians equate an ACL tear as an immediate reason for a surgical procedure. I strongly disagree! A non-operative approach is warranted in many people. Do not equate non-operative with conservative. The non-operative regimen must be as aggressive as what you would do for a post-operative patient. The key to having functional stability, despite ACL insufficiency, is a long-term rehabilitation protocol, and the willingness of your patient to modify their athletic lifestyle. Meniscal preservation is the key to the future of that knee. If a non-operative course is chosen, long-term follow­up visits are needed to ensure that the knee is not deteriorating. Please don’t get the impression that I don’t operate on the ACL.  I have spent my life repairing and reconstructing the ACL. My patients are predominantly quite athletic, and surgery is most often my therapeutic recommendation. As the years have passed, there have been many patients in whom the repair or reconstruction has objectively failed, and yet the patient states that “My knee is great!!” This has made me realize that there is a certain unpredictability of ACL surgery. This continues to intrigue me! There is still a need for long-­ term prospective studies of conservative versus surgery for the ACL injury. I urge you all to participate in such a study as this will better define the best treatment regimen for every individual.

4.6  Treatment Recommendations

Key Facts History • “Pop” • Cannot continue activity. • Swelling within 6 h. • Ask about a prior history? • Family history is important. • Assess activity level (sports, occupational). Physical Examination • Effusion. • Restricted range of motion. • Posterolateral and posteromedial joint line tenderness. • Positive Lachman test. • Don’t attempt pivot shift maneuver (too painful). Treatment • Multifactorial decision-making most dependent upon: • Age. • Activity level. • Associated meniscal damage. • Early rehab to regain range of motion. • Surgery: –– ACL reconstruction: Tissue choices (personal preference). Autograft vs allograft. • Non-operative: –– Aggressive physical therapy. –– Modification of activities. –– Bracing. Case Examples Case Example #1 (See Video 4.5). Case Example #2 (See Video 4.6).

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Case Example #3 (See Video 4.7). Case Example #4 (See Video 4.8). Case Example #5 (See Video 4.9). Case Example #6 (See Video 4.10). Case Example #7 (See Video 4.11). Case Example #8 (See Video 4.12). Case Example #9 (See Video 4.13). Case Example #10 (See Video 4.14).

5

Posterior Cruciate Ligament (PCL) Injury

5.1 Introduction Acute injuries to the Posterior Cruciate Ligament (PCL) are rare. As a younger physician, when I took emergency room calls, motor vehicle accidents accounted for many of these injuries. As my community sports medicine practice developed, it has been rare to see more than 5–10 of these injuries per year. Tertiary sports centers will see more, many of whom are chronically injured. The diagnosis of the acute PCL tear is often missed! This chapter is concerned with the isolated PCL injury. Most PCL injuries occur in combination with other ligaments, capsular, meniscal, and chondral disruption. The diagnosis of the isolated acute PCL injury is subtle. These patients often walk into your examining room with a minimal limp and are not that unhappy. Their benign appearance can fool you, hence the importance of this chapter.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­32844-­2_5.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2_5

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5.2 History 5.2.1 How Did You Get Injured? The patient usually reports a fall on to a flexed knee, or a twist in athletes, most of the isolated PCL tears are non-contact. A fall on the hyper flexed knee is the most common method of injury. A direct blow to the front of the knee, as when seated in a motor vehicle accident is less common. A hyperextension force can be responsible, but in that case combination injuries are more likely.

5.2.2 Did You Hear a Pop or Snap? Most patients do not report an audible sound. They sense that something happened which is difficult to describe. They may feel a sharp pain in the back of their knee, and pain that radiates to the calf.

5.2.3 Were You Able to Continue Your Activity? The majority of patients will continue their activity but know that something is not quite right. An athlete will attempt to run but is unable to do so with any push off ability and typically will discontinue their sport. Patients injured in a motor vehicle or as a pedestrian hit will rarely continue their activity and will seek medical attention. They may be seen in an ER, where the X-rays are normal, and they are told that they have a “sprain.”

5.2.4 Did Your Knee Swell? When? The PCL is intimately associated with the posterior capsule. When injured, the posterior capsule is typically disrupted, and the bleeding from the ligament tear leaks out of the joint into the posterior soft tissues. Like the ACL, there are no major blood vessels, and the blood loss is minimal. The patient reports minimal or no

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swelling and may describe pain in the calf with some posterior soft tissue swelling. This takes place the next day, as there is no immediate effusion. They often complain of a mild ache in their knee.

5.2.5 Did You Ever Hurt the Knee Before? Typically, the answer is no. If there was a prior injury, it too may have been subtle, and the patient may have forgotten that it very happened. Life can go on fairly normally in a PCL insufficient knee, so a prior injury is always a possibility.

5.2.6 Any Numbness or Pins and Needles in Your Leg? A neurovascular assessment is essential to every knee injury. Any numbness or paresthesia may be indicative of a neurovascular injury. Paresthesias should alert you to the possibility of a popliteal artery injury! Fortunately, with isolated PCL disruptions, the neurovascular structures are rarely affected. When the PCL is injured in combination with other ligaments, your index of suspicion must be greatly heightened, so be very direct in you questioning as to the presence of tingling, numbness, loss of power, etc.

5.3 Physical Examination 5.3.1 Observation These patients will walk in with a mild limp, rarely with a cane or crutches. There will not be anything that obvious. Look for ecchymosis at the level of the tibial tubercle, which may reflect a direct ­anterior blow. Varus or valgus alignment is not an associated factor. There can be swelling of the leg.

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5.3.2 Neurovascular Assessment It doesn’t take long to check the pulses and neurological status. Isolated PCL tears are rarely associated with a neurological deficit secondary to a nerve injury. Popliteal artery injuries can be subtle, so make sure you check the pulses and compare them to the opposite side. Carefully assess peroneal nerve and tibial nerve sensory and motor function.

5.3.3 ROM Have the patient sit and assess range of motion. They usually have full extension and may lack some flexion. Soft tissue swelling is usually not obvious. Have the patient lie down and again check ROM. Ask them to push the knee into extension, as this will often cause them posterior pain. An effusion, if present, is typically mild, as the bleeding from the tear will escape into the posterior structures. Because of this, the patient will be able to readily flex their knee to 90° and allow you to get a reasonable examination without the worry of causing too much discomfort.

5.3.4 Joint Line Tenderness Medial/Lateral Joint line tenderness is not a typical finding of an isolated PCL disruption. There will be posterior tenderness, so make sure you put your fingers behind the knee to palpate the joint line. There is often tenderness in the proximal calf, so palpate this area as well. Lie the patient prone, as you see more in this position, and its much easier to palpate the posterior structures. Tenderness, soft tissue swelling, or ecchymosis in the proximal anterior shin, will be present when there is a direct blow to the front of the knee that caused the injury.

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5.3.5 Drop-Back Sign (Video 5.1) Have them flex both knees to 90° and look at the knees from the side. Here is your chance to look for the subtle drop back of the tibia on the femur. Compare the anterior prominence of the tibial tubercles to see if the affected knee has a posterior sag. As my Daddy told me, “If you don’t look for something, you will never find it!” Now have the patient flex the hips to a right angle with the knees staying at the 90° position. The leg is now suspended without the heel on the table. Here, a drop back may be even more dramatic, as gravity is pushing the knee downward. Again, carefully look from the side, comparing the location of the tibial tubercle. Looking from the front will not allow you to see the sag. An isolated PCL tear may have a very minimal sag or none at all. A large sag is indicative of a combined ligamentous injury (i.e., PCL/Posterolateral corner injury).

5.3.5.1 Lachman Test and Anterior Drawer Sign These tests are well recognized as tests for an ACL disruption. In the setting of a PCL tear the Lachman test will reveal a firm endpoint, making it a negative test. You may sense an increased excursion, but that will be more evident when you flex the knee to 90° to do your anterior drawer sign. The anterior drawer will be positive with a definite increased excursion compared to the opposite side. This increased anterior play is secondary to the subtle posterior starting point of the knee. This leads to a “pseudo-­ positive” anterior draw.

5.4 A Negative Lachman and a Positive Anterior Drawer Sign 5.4.1 Represents a PCL Tear Until Proven Otherwise! Don’t be fooled by the increased anterior excursion of the knee, as this is the main reason why the diagnosis is missed!

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5.4.1.1 Posterior Drawer Sign (Video 5.2) In the acute setting, a positive posterior drawer sign can be very subtle. The isolated PCL injury may not have a positive drop back. The absence of the ENDPOINT is the key to the diagnosis. With the knee at 90° of flexion, examine the opposite knee. At the level of the tibial tubercle, using your thenar eminences of both hands to push, a posterior force is applied to the tibia. You will feel a distinct “bang”: of the normal endpoint, which stops you from pushing any further. The more normal knees you examine, the better you will be at appreciating this endpoint. Don’t be afraid to push fairly hard, with some speed, as this will accentuate the endpoint. Now, switch to the affected side and give a similar posterior force. In the acutely injured knee, the absence of the endpoint makes the diagnosis of a PCL disruption. Note: As time passes (a subacute or chronically injured PCL), the knee tends to sag posteriorly. The anterior drawer, as stated, becomes positive, and when you do the posterior drawer, the capsule and scarred PCL will give you the sense of an endpoint. This can fool you! Don’t be surprised by this. Again, in the acute setting, the endpoint will be absent! This is often missed by even the most astute clinicians. As time passes, the sense of an endpoint will reappear, as this is typically associated with the presence of a posterior sag.

5.4.2 Differential Diagnosis • Acute anterior cruciate ligament tear. • Contusion. Because of the increased excursion on the Lachman test, and the positive anterior drawer sign, the acute PCL is typically misdiagnosed as an ACL disruption. (Looking back in the history of sports medicine in the USA, the leaders in the field often fought over this confusion. Some thought the PCL controlled anterior excursion of the knee. Many biomechanical papers have proven that to be wrong). The key is the presence of an endpoint on the Lachman test, and the subtle posterior sag of the knee. Remember.

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5.5 A Negative Lachman and a Positive Anterior Drawer Sign Is a PCL TER Until Proven Otherwise Contusions of the knee from a direct fall or blow can also lead to pain, soft tissue swelling, and occasionally an effusion (In sympathy for the injury the synovium can produce fluid, a “sympathetic effusion”). This diagnosis can be made by your careful history and a negative ligamentous exam.

5.5.1 Treatment 5.5.1.1 Early Care Unless you are a team physician and your athlete is hurt on the field, the acute presentation of an isolated PCL injury is rare. These patients often have mild pain with minimal to moderate swelling. Hence, they often wait to see someone. When they do see their family or outpatient physician, the diagnosis is usually missed. I have found that many of these patients first arrive months after their initial injury. If I do see an acute PCL the immediate treatment is the RICE protocol. The rest involves limitation of walking but allowing full weight-bearing as tolerated. Though rarely needed, crutches are given if the patient senses instability. The swelling is in the soft tissues typically dissecting into the calf musculature. This is where the cold therapy should be applied. Large hemarthroses are rare as any blood will leak out of the associated capsular tear. An associated osteochondral fractured meniscal injury is also rare. A light compressive wrap is helpful proprioceptively, making the patients feel more secure. Leg elevation is helpful if the calf is swollen. If the patient has insurance coverage, they are immediately sent for formal physical therapy, where ROM, modalities to reduce pain, and early biking are prescribed. A strengthening regimen is begun as soon as the patient regains their range of motion.

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On the first visit, I begin the discussion that a non-operative plan is the appropriate course of treatment. I save the more complete discussion for the next visit which is usually in 3  weeks. X-rays and MRI are ordered if not already performed.

5.5.2 Second Visit and Treatment Recommendations The treatment plan for these patients is non-operative. The majority of patients with isolated PCL tears will be able to compensate for this ligamentous insufficiency. This is independent of activity level or age. Quadriceps strength is the essential component of your treatment regimen. You have to educate your patient that quadriceps strength is the counter active force to the tibial drop back of PCL insufficiency. You must emphasize that this is not only the immediate treatment. A long-term commitment to strength training is mandatory. A closed chain leg press regimen is started as soon as the pain has diminished. Biking and the elliptical are well tolerated. For the first 6 weeks, I prefer to stay away from weight-bearing aerobic activities. The athlete who has experience with weight training will respond more rapidly than the non-athlete. These athletes will typically be able to resume their sport in 6 weeks. Open chain knee extensions are encouraged but you must be in the lookout for patella discomfort. If they do have patella pain, try to keep the resistive pad as close to the tibial tubercle as possible or limit the last 10° of extension. It may be necessary to avoid locking out the knee into extension to avoid patella discomfort. I typically tell these patients to wear a knee sleeve for proprioceptive support. This gives these patients a sense of confidence. I do not use a functional knee brace as they have not been successful in restoring anterior tibial positioning. The quadriceps is the best brace they have! It is important to make your patient fully aware that if they start having pain that they should return to see you. Some patients cannot cope with their PCL insufficiency and their knees can deteriorate. I have not been able to predict that group of patients, nor do

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I know of any prospective that predicts who are the “non-copers.” I make every one of these patients aware that this is a possibility and that future surgery may be necessary. A PCL repair or primary reconstruction is rarely needed (see combined instability). Key Facts History • Fall on flexed knee. • Direct blow to front of knee. • Pain and swelling in the calf. • Rare “pop”. • They may be able to continue their activity. Physical Examination • Good range of motion. • Soft endpoint on posterior drawer sign. • Look at them from the side: –– Posterior sag. –– Drop-back sign. • Posteromedial/posterolateral joint line tenderness. • Careful neurovascular assessment. Treatment • Non-operative. • Early aggressive rehab. • Emphasis on quadriceps strength.

6

Multi-Ligamentous Knee Injury

6.1 Introduction These are the most severe of the acute knee injuries. The emphasis of your evaluation must be on ruling out the presence of neurovascular compromise. Any time two or more ligaments in the knee are disrupted, your INDEX OF SUSPICION has to be raised. The force needed to cause these injuries is greater, and the associated damage that can occur to the neurovascular structures is worrisome. In a typical sports medicine private practice, these injuries are relatively rare. I urge you to always be on the lookout, and when these cases do show up, pay close attention to detail.

6.2 Posterolateral Ligament Disruption The posterolateral ligament injury refers to damage to the arcuate “complex.” I always liked the name “complex,” as it essentially tells you that this anatomic area is rather complicated. The popliteus tendon and its fibrous attachments, the fibula collateral ligament, and the posterolateral capsule make up this complicated region of the knee. Numerous anatomic articles have carefully defined the anatomy. Many mechanical studies have helped define the stabilizing function of this region. This injury is rare, subtle, and the diagnosis is often missed.

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6.2.1 History 6.2.1.1 How Did the Injury Happen? A varus external rotational stress mechanism, often with the knee in full extension, will lead to this injury. The patient will rarely remember the awkward position that the knee was in at the time of injury. Their knee will buckle, and they will be on the ground. 6.2.1.2 Did You Hear a Pop? Typically, no, but they may sense a sharp pain on the lateral aspect of their knee. 6.2.1.3 Could You Continue Your Activity? No. This is a major disruption and they will not be able to continue. They will need assistance to get up to walk away, sensing that the knee is “not right” when they put weight on the leg. 6.2.1.4 Did Your Knee Swell? When? These knees have capsular disruption and extra-articular injury, so that the knee rarely has an acute hemarthrosis. To the examiner, this makes the knee look benign. The soft tissue laterally and posteriorly will gradually swell, occurring over the first 24 h. 6.2.1.5 Did You Ever Hurt Your Knee Before? This is typically the first injury.

6.2.2 Physical Examination 6.2.2.1 Observation The knee will look fairly normal. There will be some soft tissue swelling laterally, but hardly noticeable. 6.2.2.2 Neurovascular Assessment As with all major knee injuries you must always check the pulses, sensation, and motor power of the affected extremity. With this injury, the common peroneal nerve is at greatest risk, so make sure your neurological assessment of the distal foot and ankle is thorough.

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6.2.2.3 Tenderness It is usually possible for the patient to flex the knee to 90°, resting their foot on the table. Finding sites of tenderness is best in this position. There will be direct tenderness along the lateral and posterolateral joint line. You should carefully palpate the lateral femoral wall. If the popliteus tendon is avulsed, there may be exquisite tenderness at its femoral insertion. Palpate the fibula head and along the course of the fibula collateral ligament. An effusion may or may not be present. 6.2.2.4 Pseudo-Varus Deformity The key clinical sign to making the diagnosis of this injury is the varus appearance of the knee when it is brought into full extension. The patient relaxes, and you gently raise the ankle and leg, extending the knee. I like to lift the leg by the great toe. When the posterolateral complex is injured, the knee will fall into a position of hyperextension, externally rotate, and now appear as if it is in varus. The external rotation and drop back give this appearance. 6.2.2.5 Varus Stress The fibula collateral ligament is best examined in two ways. With the one hand against the medial condyle, (right hand on right knee, left on left), I varus stress the leg with the other hand at 0 and 30° of flexion. The instability is subtle, and endpoints are difficult to feel. Its more in the degree of opening which you must compare to the opposite side. The knee will not open in extension unless the ACL or PCL is injured. My favorite way to examine for the FCL is to put the knee in the figure of 4 position. In this position, the FCL is normally tense and feels like a tight cord. If the cord is missing, the FCL is torn. This is also a good position to palpate the posterolateral joint line.

6.2.3 Treatment 6.2.3.1 Early Care These knees are typically not that swollen. After the examination, a light compressive dressing and a knee immobilizer are applied. The patient is allowed to full weight-bear with crutches but are

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advised to limit walking. Isometrics and range of motion exercises are encouraged. Ice packs are recommended if there is significant soft tissue swelling. An MRI is ordered.

6.2.4 Treatment Recommendations “To operate or not to operate, that is the question?” I have acutely operated on several knees only where the MRI has demonstrated an avulsed popliteus tendon from the femoral insertion. I have treated the majority of cases non-operatively. I immobilize the knee in a hinged knee brace allowing early unlimited flexion and extension, keeping non-weight-bearing for 6 weeks. This is followed by a 3-month progressive rehabilitation program. Prospective studies are lacking, so it is difficult to say whether early surgical repair is needed. The results of late posterolateral reconstructions have demonstrated excellent results. Because of this, it is reasonable to initially treat these patients non-­operatively. If the patient is unhappy and demonstrates instability, a later reconstructive surgery has demonstrated excellent functional results.

6.3 Multi-Ligament Injuries (Dislocated Knee) A separate volume could be easily written on this subject. If you get to understand the basics of an isolated knee ligament care, it will be a natural sequence for you to be able to accurately examine and diagnose the multi-ligament injury. The priority in all of these patterns of combined ligament injury is your INDEX OF SUSPICION FOR THE POSSIBILITY OF NEUROVASCULAR DAMAGE. Missing a popliteal artery injury can lead to the loss of a limb. Your awareness that a compartment syndrome can develop must be high. The initial and ongoing assessments for a nerve injury are essential. Thus, the correct diagnosis of a severe ligament disruption is secondary to your concern to rule out a much more serious neurovascular event.

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There are many combinations: ACL/MCL, ACL/MCL/PCL, ACL/LCL/PCL, PCL/MCL/, PCL/LCL/ARCUATE, ANTERIOR/ POSTERIOR DISLOCATIONS. They are relatively rare events. Many of these are not sports related. Pedestrian struck injuries and other major traumatic accidents are typically the etiology. Ironically, some of the worst combined injuries that I have seen have been the result of a simple twist and fall. Be on the lookout! When these patients do present themselves, you want to be totally prepared.

6.3.1 History 6.3.1.1 What Happened? If involved in a major traumatic event, the patient will more than likely not know how they injured their knee. The pedestrian struck will often remember the mechanism of injury (i.e., “I was hit on the outside of my knee”). The sports injured patient usually remembers what happened, and this is helpful in your assessment. 6.3.1.2 Did You Hear a Pop? These injuries are more explosive and painful, and most patients do not say they heard a pop but do say that they had severe pain when it happened. 6.3.1.3 Could You Continue Your Activity? NO! It is rare for the individual to be able to even get up. The knees are unstable, and depending on the number of ligaments torn, will not support weight-bearing. Dislocated knees are urgently transported to an emergency room and rarely present in your office. 6.3.1.4 Did It Swell? When? These knees swell immediately, but because of the associated capsular disruption, much of the bleeding with the knee leaks out into the soft tissues. If seen early, these knees can look deceivingly benign. The ecchymosis appears after 24  h, making the serious

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nature of the injury more apparent. REMEMBER, THE WORST KNEE INJURY MAY NOT DEVELOP A HEMARTHROSIS.

6.3.1.5 Neurovascular Questions There are many questions that you must ask for your subjective evaluation of possible nerve damage. 6.3.1.6 Can You Feel Your Toes? Do You Have Any Tingling? Where Is the Tingling? Can You Feel the Big Toe? Does Your Entire Foot Feel Sleepy? Can You Move Your Toes? If the answer is yes to any of these questions, you are now on high alert! 6.3.1.7 How Would You Grade Your Pain? Is the Pain Getting Worse? Does It Hurt to Move Your Foot, Toes, Ankle? Is the Pain Getting Worse and Worse Despite Being Immobilized? Remember, a popliteal artery injury or developing compartment syndrome will present with increasing pain, and stocking glove paresthesias. 6.3.1.8 Did You Ever Hurt Your Knee Before? In a severely traumatized knee, it is natural to forget to ask this question. Don’t assume anything! Sometimes the patient will say that they hurt their knee in the past, which always complicates the picture.

6.3.2 Physical Examination These patients rarely present acutely to your office. As a team physician, you may get to see the injury take place, otherwise, most multi-ligament injured patients will usually go to an emergency room for their acute care. The dislocated knee always goes to an emergency room and will be admitted for observation and treatment. All of these patients are in substantial pain and are typically immobilized in a knee brace. They have already been exam-

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ined by other physicians and are very leery of having someone else examine their knee. It is your task to gain their confidence and assure these patients that you are going to be gentle.

6.3.2.1 Observation Soft tissue ecchymosis and swelling are present in all of these knees. The location of the ecchymosis will give you clues as to which side of the knee is injured. A hemarthrosis may or not be present, depending on the degree of capsular disruption. The range of motion will be limited secondary to pain. 6.3.2.2 Neurovascular Assessment The dislocated knee and the three-ligament injured knee should be assumed to have a popliteal artery or nerve injury until proven otherwise. If you think this way, you will someday save an extremity! In these complicated cases, I don’t waste time and I go directly to the foot. Remember, all the nerves passing through the knee eventually lead to motor function and sensation in the foot. Do a thorough sensory examination of both the dorsum and plantar aspect, focusing on the web spaces and the sole. Next is the patient’s motor function, checking for weakness of any of the foot or ankle musculature. Be systematic and thorough as this initial evaluation may be crucial, as it could change a few days later. Weakness is as important as paralysis. Look for the presence of pallor compared to the opposite extremity. Carefully check for the speed of nailbed capillary filling, again using the opposite side for comparison. All the pulses are assessed. The opposite side is your crucial basis of comparison. Presence of the pulse is not enough, as you must assess the strength of the pulse compared to the unaffected limb. Any sense of a weaker pulse is significant. 6.3.2.3 Tenderness The sites of tenderness are very helpful in distinguishing which ligaments have been disrupted. When two ligaments are injured, the sites will be more specific (i.e., the ACL/MCL will have tenderness along the line of the MCL.  There may be mid-lateral

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joint line tenderness secondary to capsular injury or a lateral bone contusion). If three ligaments are torn, all bets are off as there can be tenderness on all sides of the knee, front and back included. The topographic anatomy of the lateral side is very important to know. Point tenderness at the fibula head, posterolateral corner, or lateral femoral epicondyle gives clues to the nature of the injury. PCL injuries are very often associated with concomitant medial or lateral ligament damage. Palpate the popliteal fossa to feel the posterior joint line.

6.3.2.4 Ligament Evaluation In each chapter concerning the isolated ligament injuries (ACL, MCL, PCL), I have written about the important clinical test that correctly diagnose that specific injury pattern if you practice and perfect those tests, you will be proficient at making the diagnosis of the multi-ligament injured knee. The Lachman test, drop-back sign, anterior and posterior drawer signs, varus–valgus stress testing in extension and flexion, posterolateral pseudo-varus deformity, are all part of your ligamentous examination. If the knee opens up in extension to varus-valgus stress, you should immediately be suspicious of a cruciate ligament disruption (ACL or PCL or both). If your testing reveals that three ligaments are damaged, you should assume that a knee dislocation has occurred, heightening your suspicion for possible neurovascular involvement. The examination must be GENTLY performed. These knees are grossly unstable, often making it difficult to assess the direction in which the instability is most severe. Be sure to look at the knee from the side, as posterior drop back is easily missed looking at the knee from the front. In every direction you stress, it is important to assess the quality of the endpoint. Absence of the endpoint implies a complete ligament disruption. Don’t be very forceful on your varus–valgus testing, as the knee can open up dramatically causing the patient severe pain. Never forget to do the patella apprehension sign, as sometimes the patella will dislocate as part of these complicated injury patterns (particularly in the valgus stress mechanism of an ACL/MCL tear).

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6.3.3 Treatment 6.3.3.1 Early Care As stated, most of these patients will present to an emergency room or outpatient facility. Unfortunately, many present with very poorly applied splint or a knee immobilizer that has been placed without an underlying compressive dressing. Invariably the knee immobilizer is improperly positioned and has slid down the patient’s leg. After you examine the patient, a comfortable compressive dressing should be applied. I recommend 4–6 rolls of six-inch cast padding from ankle to proximal thigh, with several 6-inch ace wraps. The knee immobilizer is applied over the dressing. For the two-ligament injury, this is enough to give stability. If three ligaments are damaged, I will incorporate the foot and ankle using fiberglass tape to make a long leg U-splint up to the proximal thigh. In these very unstable knees, you have to ensure better stabilization while you are making a definitive game plan. I encourage early range of motion in the two-ligament injury, telling them to remove the immobilizer and begin flexion-­ extension exercises. In the three-ligament disruption, I encourage isometrics, leg raises, but wait for further testing before range of motion exercises are begun. If not already performed, MRIs and any necessary vascular tests (i.e., ABI, CT angiogram) are ordered.

6.3.4 Treatment Recommendations Suffice it to say, it would be impossible for me recommend a treatment protocol for the vast combination of injuries that may occur. The purpose of this chapter is to have you make the correct diagnosis and be suspicious for an associated neurovascular injury. Thousands of papers have been written on the timing and technique needed to restore stability to these knees. Most of these knees require operative intervention. Through my lifetime, the pendulum has swung from early surgical repair of the ligaments (within the first 2 weeks) to later reconstructive procedures. Post-­

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operative stiffness and permanent loss of motion are the greatest threat of surgery to the multi-ligament injured knee. The timing of the procedure is crucial. If possible, it is better to wait until the knee has “calmed down,” and the neurovascular situation is stable. The patient must be educated as to the severe nature of their injury, and the prolonged rehabilitation that will be needed to recover. The improved success of modern reconstructive ligament procedures, versus early repair, has given you and the patient more time to properly prepare for what is needed for a successful outcome. Repair of ligaments is very dependent on the quality of the tissue and the demands of the patient. Some ligaments, (i.e., the MCL), will heal conservatively and not require repair or reconstruction. Thus, in the ACL/MCL knee, bracing is often done for the first 6 weeks, allowing the MCL to heal, and then the ACL can be reconstructed. When it came to the combined lateral side injuries, it was originally thought that early repair of the FCL/arcuate complex must be done acutely to restore anatomy and functional stability. Unfortunately, the success of lateral side repairs was unpredictable, and the success of more modern lateral reconstructive procedures has improved the results. Thus, most surgeons now favor reconstructive surgery to the combined lateral side/cruciate ligament disruptions. In my career, I did many primary repairs of ligaments. The best results were always those with avulsion type injuries, where the quality of the ligament was macroscopically good. (Many, however, more than likely had microscopic interstitial injury prior to the disruption, which probably contributed to the failure of many seemingly good repairs). Loss of motion was the major problem, as many of these knees were placed in a cast to protect the repair. There may be a place for a repair of a ligament in some combined injuries, but further prospective studies will be needed to define when and where. The dislocated knee or three-ligament injured knee will require operative intervention. Reconstructive techniques are needed with careful attention to the pre- and post-operative management.

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Key Facts History • This is a major event! • Contact injury most common (i.e., pedestrian hit), but can be non-contact. • Unable to continue activity, needing aid to arise. • May not swell as bleeding leaks out into soft tissues. • Numbness/paresthesias? • Loss of motor power? Physical Examination • Be gentle on your examination! • Neurovascular assessment is crucial. • Loss of motion. • Soft tissue swelling/ecchymosis. • An effusion may not be present as blood can leak out. • Joint line and ligamentous tenderness. • Signs of instability in multiple plains. Treatment • Immediate bracing for support. • Careful evaluation of neurovascular status for the first 2 weeks. • Priority is to regain range of motion and quadriceps control. • To operate or not to operate? –– Multifactorial. –– You have time to make a decision. –– Reconstructive procedures are comparable or better than primary repairs.

7

Meniscus Tear

7.1 Introduction In the 40 years of my orthopedic career, the significant function of the menisci has been clarified. The menisci have become recognized as integral unloaders and stabilizers of the knee. In the early days of open knee surgery, you weren’t a real surgeon unless you were able to remove the entire menisci. In the past, thousands of total meniscectomies were reported, and the long-term consequences predictably led to an arthritic knee. In the 1970s, arthroscopic partial meniscectomy became the standard procedure. The hope was that preservation of as much as possible of the meniscus would save the knee from deterioration. Unfortunately, even the removal of a small portion of the meniscus changes the unloading capability of the meniscus, making the patient at risk for later deterioration. It is ironic that saving the meniscus is now the central theme of caring for the meniscus. However, arthroscopic partial meniscectomy remains the most common meniscal surgery performed, but thanks to modern technological and biological advances, meniscal repair is becoming more commonplace. When feasible, meniscal preservation rather than removal is becoming the new standard of care. As we age, so does the meniscus. Its relatively poor blood supply predisposes it to degeneration, and healing depends on the

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location of the tear. A torn meniscus in the adolescent is typically related to a dystrophic problem (i.e., discoid meniscus), or some other genetic weakness in the tissue. In the younger patient, (15 –35), a meniscal injury requires a more violent force and is typically associated with ligament disruptions. After the age of 40, the meniscus, because of intrinsic degeneration, takes less energy to tear. As I often explain to my patients, “your meniscus is like a shoelace. A new one rarely rips. An old shoelace tears because it’s ready to go, and the simplest force can cause the injury.”

7.1.1 History Most of meniscal injured patients walk into the office without aid. They never look as “unhappy” as the ACL or a patella dislocation; unless of course, the knee is locked! (then, they too are unhappy campers).

7.1.1.1 How Did You Get Injured? Most meniscal tears occur with some form of twist or a squatting maneuver. In the older population, a simple squat is all that is needed. Younger athletes report a forceful twist or fall onto a flexed knee. 7.1.1.2 Did You Hear a Pop or a Snap? A pop is not often reported. The patient often senses a noise or crunch in the back of their knee. An audible noise is rare. 7.1.1.3 Could You Continue Your Activity? Many athletes and workers are able to continue in what they were doing. The knee remains functional. It’s not long before they may be limping. In the heat of a ball game, many athletes report that they could complete the game despite the pain. 7.1.1.4 Did It Swell? When? Swelling usually takes a day to occur. The meniscus is only vascular on its periphery, and those tears that bleed are more commonly associated with an ACL disruption. The meniscus does not

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bleed, and the effusion that takes place is reactive to the injury. The synovium reacts to the meniscal tear by producing fluid, which takes time to develop. The patients typically report a “tightness” in their knee.

7.1.1.5 Where Does Your Knee Hurt? Point with One Finger! I find this to be very helpful. Patients will often put their finger right on the joint line that hurts. When they do, you can bet it is a meniscal tear at that side of the knee. 7.1.1.6 Do You Have Night Pain? This often-forgotten question is very important. Night pain should be clarified to mean pain that wakes you up, not pain that makes it difficult to fall asleep. If you ask, many patients with meniscal tears will report that their knee wakes them up from sleep (more medial than lateral). Not every patient has this symptom, but when they say yes, your index of suspicion will rise. More than likely, the increased load on the underlying bone leads to bone edema, which causes nocturnal discomfort. Night pain should immediately alert you to several possibilities. Malignancy of bone is always first on the list. Fortunately, malignancy is not common in the knee joint, but must be mentioned. In the middle-aged individual, avascular necrosis or a microscopic stress fracture can cause night pain, which is also secondary to the associated bone edema. Most commonly, this condition occurs in middle-aged females, often with associated varus deformity. The onset of pain is spontaneous and sudden, typically without a history of trauma. 7.1.1.7 Did Your Knee Lock? You should ask this question, but you have to clarify what the patient considers locking. True locking means that the knee gets stuck in flexion, and a maneuver is needed to “unstuck the knee” (I like the word unstuck as the patients understand the concept). Many patients state that their knee “locked,” but upon your careful questioning, it turns out that their knee felt hung up in extension.

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That is not meniscal locking and is typically a patellofemoral issue. In the laborer, a squat is the usual culprit as the compression force precipitates the tear. In younger patients, true locking is characteristic of a discoid meniscus (typically the lateral meniscus). These patients will often give a prior history of pain or catching in their knee.

7.1.1.8 Did You Ever Hurt Your Knee Before? Many patients will report that their knee was bothering them prior to the acute injury. It is common to hear that they were having some pains in the back of their knees, but not enough to see a physician. Some patients will report a prior sense of catching in the knee. Many acute tears are the result of a pre-existing tear that may not have been symptomatic. In children, the discoid lateral meniscus will present with a locking of the knee, but upon questioning they will often have a prodrome of lateral symptoms. Always ask about similar symptoms on the opposite side, as bilateral discoid menisci are quite common. 7.1.1.9 Family History? In reference to meniscal tears, I have not found a family association. 7.1.1.10  Did You Ever Hurt the Other Knee? Meniscal tears are often bilateral. This is more than likely related to the patient’s knee alignment, as well as a genetic predisposition to have dystrophic menisci.

7.1.2 Physical Examination 7.1.2.1 Observation These patients may or may not have a limp as this depends on the presence of an effusion. A locked knee will have a limp related to the flexion contracture. Look at the knees standing as the coronal alignment of the knee is crucial. Varus knees are more prone to medial overload

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and medial meniscal tears. The valgus knee is vulnerable to lateral meniscal tears.

7.1.2.2 Range of Motion Loss of extension or flexion is not uncommon from a meniscal tear. This is usually from the associated effusion. The truly locked knee will be more obvious for lateral meniscal tears. The larger bulk of the lateral meniscus will block a greater degree of extension. 7.1.2.3 Joint Line Tenderness This is the most important clinical finding. You must know your topographical anatomy. As stated earlier, the patient will often be able to pinpoint their site of pain. Let them show you where it hurts. You must be able to palpate the joint line, which is best done with knee in greater than 60° of flexion. Be sure to not confuse epicondylar pain from joint line pain! 7.1.2.4 Meniscal Tests In the acute setting, I am not a great fan of classical meniscal tests, such as the McMurray or Apley Grind Test. These flexion rotation maneuvers will cause pain and quickly alienate the patient. I find it best to gently flex the knee. In the presence of meniscal pathology, further flexion will cause them to tighten up and complain of pain. Don’t keep flexing! That’s enough! Stop there. There isn’t a reason to torture someone whom you may have to operate upon! Their pain is more than likely related to pressure caused by an effusion, than the meniscal tear itself. Pain with flexion is sensitive, but not highly specific. I rarely do any further meniscal tests. Keep it simple.

7.1.3 Differential Diagnosis 1. Grade 1 medial collateral ligament tear. 2. Acute patella subluxation. 3. Osteoarthritis. 4. Avascular necrosis. 5. Osteochondritis dissicans.

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The differential diagnosis of a medial meniscal tear must include a grade 1 medial collateral ligament tear and an acute patella subluxation. All can present with a twisting injury and medial sided pain. The mechanism of injury is helpful in the differentiation. The patella and MCL tears will typically occur in less flexion than a medial meniscal tear. Older patients are more prone to meniscal pathology. The site of tenderness is different, but all three diagnoses can be sore on the medial side. Medial epicondylar tenderness must be differentiated from the joint line, for the epicondyle is commonly the point of pathology at the time of a proximal MCL tear, as well as a patella subluxation. Acutely, mild/moderate osteoarthritis can present after an injury. Many of these patients are not symptomatic in their arthritic knee until there is a fall or twist. After an injury, the knee can get inflamed, and they will come to see you. These are difficult cases, as many of these individuals will have an underlying degenerative tear of their menisci that has been present without pain. These are some of the most common cases you will see in your private practice. It takes clinical acumen to define the problem accurately, as the MRI will more than likely say that the patient has both problems. Here is where you have to be a physician! A careful history is most important to define your course of treatment. Night pain and a story of mechanical locking help differentiate the symptoms of degeneration from a clinically significant meniscal tear. Remember, LISTEN to their story. The atraumatic sudden onset of knee pain in a middle or older aged person is avascular necrosis until proven otherwise. Post-­ menopausal females have the highest incidence as do post-­operative partial menisectomized patients. A sudden onset and nocturnal pain is typical and often the major complaints. Many have underlying osteoarthritis and a meniscal tear to confuse the issue, but your clinical story is paramount in making the correct diagnosis. In the younger population, osteochondritis dissecans may present with an acute injury. Upon your history, most will have had a prodrome of mild discomfort. If the necrotic chondral fragment has loosened, they may present with an acute locking episode. The site of tenderness will not be as localized to the joint line as a meniscal tear. X-ray, of course, will help make the diagnosis.

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7.1.4 Treatment 7.1.4.1 Early Care The patient with an isolated meniscus tear rarely presents to your office immediately. Because of the poor vascularity of the meniscus, the swelling is usually secondary to a reactive effusion rather than a hemarthrosis. After a meniscal injury, an effusion can take some time to develop, eventually causing the patient to develop enough pain and stiffness to warrant a doctor visit. Most of these patients will go to the primary doctor before they come to the specialist. Meniscal pain is variable, more dependent on the amount of the effusion rather than the extent of the tear. A bucket handle tear of the meniscus that mechanically locks the knee typically demands immediate attention. Pain and swelling can fool you into thinking that the knee is truly “stuck” (pseudo locking). The pain is more severe when the knee is mechanically locked. The RICE program immediately begins. It is rare that an aspiration is necessary, as the effusions are typically mild or moderate. I emphasize intermittent cold therapy. If there is swelling, I will apply a light compressive dressing (one to two rolls of cast padding and a 6-in. ace wrap). Even if the knee is locked, the patient is immediately instructed to do isometrics. They are taught to activate their quadriceps muscles and attempt to get their knee straight. Active range of motion is encouraged. This is best done by having the patient sitting over the side of the table, attempting to flex and extend their knee. Obviously, if the knee is mechanically locked, the patient will not be a happy camper. They will not want to move their knee. The bulk of a displaced lateral meniscus is greater than the medial, making their extension deficit greater. The patient with a locked lateral meniscus will be more reluctant to move their knee. Your encouragement is valuable as any motion is better than none. Remember, a stiff knee is your enemy! Most often, the “pseudo locked” knee from pain and an effusion will miraculously get “unstuck,” just by your encouragement, rest, and early ROM exercises. I do not use an immobilizer! Crutches are given and full weight-bearing, heel-toe gait is

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encouraged. Rest, meaning limited walking is recommended. Elevation is not necessary. NSAIDs are prescribed for the first 72 h. Tylenol is recommended for analgesia. It is rare that opioids are needed. If not already taken, X-rays and an MRI are ordered. In the over 40-year-old patient, standing X-rays must be done. Four views are ordered; standing AP, 45° standing PA (Rosenberg view), lateral, and a Merchant view. These standing X-rays define the degree of coronal alignment as well as the presence of joint space narrowing. An MRI does not preclude the need for standing X-rays. If the knee is locked, I will delay these tests to make them more comfortable for the patient. If the patient’s insurance allows, I do prescribe physical therapy. This has begun to enhance early symptomatic relief, muscular activation, and range of motion.

7.1.4.2 Second Visit I typically bring the patient back in 1–2 weeks. If they are mechanically locked, they are always told to return in 1 week. This is now the time to discuss your treatment options and plan. At the second visit, a brief physical exam should be done to better define the site of tenderness.

7.1.5 Factors Affecting Your Decision-Making 7.1.5.1 Age What is middle age? That is a very philosophical question. As I age, middle age kept starting later and later! Unfortunately, at 70, I am now in the older age category. Age is important in that after 35, most meniscal tears have a degenerative component. As we age, the meniscus becomes dystrophic and easier to tear. Chances are high that these tears are less repairable. In the middle-aged and older age-group complex patterns of tears are more ­commonplace. There is a good possibility that the meniscus has been torn for a while, and that the acute injury aggravated a pre-existing tear. Age alone makes my initial care conservative. Unless the knee is mechanically locked, there is NO RUSH! Many of these “acute”

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tears just settle down with time. I recommend 6 weeks of rehab. NSAID, and patience. I lose a lot of surgical cases, but these patients often become asymptomatic, and you heroically saved the patient an operation. If the knee is mechanically locked, I recommend surgery. Age is not a factor! To repair or not to repair, the meniscus is then the next difficult decision. Other factors play a roll. Read on...

7.1.5.2 Activity Level The patient’s activity level use to correlate with the patients age. Not anymore! You can’t assume that because the patient is older that they are inactive. You must fully understand their activity level, sporting life, and occupation before you arrive at a treatment plan. I tend to be more aggressive in the more active individual. They are in a bigger hurry to get better, which pushes you in an operative direction. That being said, in very active “older” individuals, not locked, I still try to give them 6  weeks of non-­ operative management. In the younger more active individual, I am more inclined to recommend early arthroscopic treatment. The patient’s activity level is a confusing factor as to whether or not you recommend a repair of the meniscus or a partial meniscectomy. More active patients (i.e., athlete in season) may not want to take the time off to recover from a meniscal repair. Even though you explain the long-term consequences of a meniscectomy, they may stubbornly refuse that option. Non-competitive active patients are much more inclined to undergo a repair despite the longer period of rehabilitation. In the less active patient, a partial meniscectomy is usually the more reasonable option. These patients are wary about the longer and more formidable rehabilitation needed to recover from a meniscal repair! Other factors such as the degree of arthritis in the knee become much more significant. This important conversation concerning partial meniscectomy versus meniscus repair must take place with your patient. Meniscal preservation surely correlates with joint preservation. As of the writing the pendulum has swung toward meniscal repair rather than the old standard of a partial meniscectomy. It is well beyond

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the scope of this manual to define when to perform a meniscal repair. I urge you to evaluate each patient, follow the science, and arrive at your own treatment choice.

7.1.5.3 Alignment Preservation of the meniscus is even more important in the knee with coronal plane malalignment. The varus knee/medial meniscus injury and the valgus knee/ lateral meniscal injury represent serious concerns to the sports medicine physician. The load distribution function of the meniscus is crucial in these patients to avoid rapid deterioration of their articular cartilage. These are patients where meniscal preservation is even more important, and meniscal repair is indicated whenever possible. I am more aggressive in these patients as earlier care may improve the chances of doing a repair. Obviously, the other factors come into play in your decision-making process. 7.1.5.4 The Degree of Arthritis This certainly is a significant factor in your decision-making process. The greater the degree of arthritis, the more conservative I am. The patients with grade 4 changes (subchondral bone exposed) do not benefit from arthroscopic meniscectomy and it is too late for a repair. It is best to treat these individuals conservatively with physical therapy, NSAIDs, injection, etc. The plot thickens when the patient has grade 2 or 3 arthritic changes. These are the most difficult patients. Most of their tears are degenerative and complex and not often repairable. In this group, I am very conservative and try to rehabilitate without a surgical procedure. Arthroscopic partial meniscectomy has variable results as their arthritis is more often the major cause of the patients pain. The exception is the meniscal root lesion that may be repairable. Theoretically, repairing these tears may delay the ­degenerative process from progressing. These tears require long conversations with your patient, as long outcome studies are not yet available to quote. Despite the degree of arthritis, if the patient has true mechanical symptoms and senses a catching, locking, or distinct clunk

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with flexible rotation maneuvers, I will be more aggressive in recommending an arthroscopic procedure. The torn lateral meniscus with mechanical symptoms in the presence of a degenerative lateral compartment often has excellent outcomes. I am not as confident with mechanically symptomatic medial meniscal tears in the presence of medial compartment disease.

7.1.6 Treatment You essentially have three alternatives: (1) an arthroscopic partial meniscectomy, (2) an arthroscopic meniscal repair, or (3) a rehabilitation program with expectant waiting to see how the patient responds. All the factors just discussed must enter your decision-­ making process. Further prospective studies will be needed to assess the long-term outcome of meniscal repair, there is no question that meniscal preservation is the ultimate goal, but unfortunately, this is not always possible. We have come a long way from the good ol’ days of open total meniscectomy. Arthroscopic techniques continue to evolve, making the repairs a more viable alternative. Undoubtedly, arthroscopic partial meniscectomy revolutionized the world of meniscal surgery and remains the most common arthroscopic procedure performed. In the appropriate patient, arthroscopic partial meniscectomy continues to be a rewarding procedure. Biomechanical studies have demonstrated that even partial removal of meniscal tissue will greatly alter the loads on the articular cartilage. Hence, the emphasis on meniscal preservation if possible.

7.1.7 Pearl of Wisdom It is good to remember that in the non-athlete unless the knee is mechanically locked (as confirmed by an MRI), meniscal surgery is never urgent. The outcome will not be affected whether you scope the knee immediately or weeks later. Your patient will always appreciate your patience. It is natural for the average

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patient to be frightened hearing that “immediate surgery” is necessary. They will typically get another opinion and invariably will never come back. It is always better that the patient realizes that they are not getting better and need an operation. My experience has taught me NEVER try to convince a patient that surgery is necessary. Key Facts History • Middle age most common. • Simple squat or twist. • Able to continue activity. • Stiffness and swelling the next day. • Prodromal symptoms often present (“my knee would ache”). • May have night pain. • True locking (the knee gets stuck in flexion). Physical Examination • Joint line tenderness. • Mild effusion. • Pain with flexion rotation. • Loss of extension if locked. Treatment • No rush unless the knee is mechanically locked. • To repair or not to repair, that is the question!! • Multiple factors: –– Age. –– Location of tear. –– Associated ligamentous injury. –– Knee alignment. –– Associated chondral damage/degree of arthritis.

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Extensor Mechanism Disruptions

8.1 Introduction The extensor mechanism includes the tibial tubercle, patella tendon, patella, and the quadriceps tendon. Injuries to any one of these structures readily occur and are part of the spectrum of acute knee injuries. I was taught that the AGE of the patient alone can give you a very good clue as to which site is injured. As you get older, the injury site ascends the extremity. Children and adolescents, with open apophyses, typically disrupt the tibial tubercle. The young adult will often tear the patella tendon. The middle-­ aged person (what is middle age?) will often break the patella. The older age individual will disrupt the quadriceps tendon mechanism. AGE ALONE CAN GIVE YOU A HINT TO THE CORRECT DIAGNOSIS. These patients will usually come in on crutches, as they have typically been seen in an emergency or ambulatory center. They are not happy and are in significant pain. Rarely will they walk in the office, as it is quite difficult for them to bear weight on the affected leg. Often, they will have been placed in some form of knee immobilization. The mechanism of injury is similar in that the knee flexes suddenly, and the quadriceps contracts to prevent the buckling. This creates a force that can injure one of the anatomic sites of the extensor mechanism.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2_8

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8.2 TIBIAL Tubercle Injuries These injuries occur in the adolescent population. The tibial apophysis can avulse, or the tubercle will avulse with the fracture going through the proximal tibia (Salter IV injury).

8.2.1 History These injuries occur in children and are rarely seen after the tibial tubercle apophysis and proximal tibial physis are closed.

8.2.1.1 How Did You Get Hurt? The child will report a fall on a flexed knee or coming off a jumping maneuver (i.e., a rebound at basketball). 8.2.1.2 Did You Hear a Pop? Usually no, but they do have severe pain, and they know something bad happened. 8.2.1.3 Can You Continue Your Activity? No! They will fall and need help to get up. They will not be able to put weight on the leg. 8.2.1.4 Did Your Knee Bother You Before? Most will report a history of prior knee pain in the area of the tibial tubercle. Some will have been treated for Osgood– Schlatter’s, and report having a “bump” on their knee. Typically, these injuries will occur during growth spurts when there is an intrinsic weakness in the tibial tubercle apophysis and proximal tibial physis. 8.2.1.5 Did Your Knee Swell? When the tubercle is completely separated, the swelling will be immediate. It is essentially a displaced fracture and will instantly bleed.

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If its a mild separation of the tuberosity, only the apophysis is injured, and there will be minimal bleeding, as the growth plate cartilage is relatively avascular. In those cases, there will be mild soft tissue swelling localized to the tubercle. In the Salter IV type injury, there is immediate swelling secondary to the intra-articular fracture.

8.2.1.6 Family History It is not uncommon for one of the parents or siblings to have a history of Osgood–Schlatter’s.

8.2.2 Physical Examination 8.2.2.1 Observation The knee is held in a flexed position, and the patient will not want to move the knee. They have significant pain and are not in the mood to talk to you! There will be swelling, at the tubercle and/or the entire knee. You will have to support the leg to get them on the examination table. Look at the knee from the side, as this is the easiest way to see the anterior displacement of the tibial tubercle. In major tibial tubercle avulsions, there will be an effusion as the bleeding enters the knee (hemarthrosis). In the mild separations, an effusion is not common, and there will be localized swelling at the tubercle. 8.2.2.2 Neurovascular Assessment It is highly unlikely for there to be any associated neurovascular damage, but a thorough, as in all knee injuries, check is certainly required. 8.2.2.3 Range of Motion They will not want to move the knee. Do not force the issue. Don’t try to passively move the knee as this will cause severe pain and alienate your patient from further evaluation.

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8.2.2.4 Tenderness They will be exquisitely tender in the anterior tibial tubercle and proximal tibia. Complete separations are obvious and limit your palpation. The more subtle separation will have pinpoint tenderness over the tubercle, and the prominence is more than likely secondary to a pre-existing Osgood–Schlatter’s. 8.2.2.5 Ligament/Meniscal Tests Do not even think about it! These injuries are typically isolated, and because of the pain you will not be able to do an accurate assessment, nor is it necessary. 8.2.2.6 Differential Diagnosis 1. Acute patella dislocation. 2. Contusion. 3. Aggravation of pre-existing Osgood–Schlatter’s. In the young individual, I always think about the patella dislocating. Certainly, a patella dislocation is common in this age-­ group. The mechanism of injury will be different, as the patella dislocation requires a twist, and the tibial tubercle injury is a hyperflexion mechanism. The prodrome of knee symptoms also helps, but both diagnoses can have prior problems with their knee. The physical examination easily differentiates the two diagnoses, as the site of tenderness and possible deformity of the tubercle is self-evident. A direct blow to the front of the knee as from a fall can lead to exquisite bony pain and soft tissue swelling. In the presence of a preexisting Osgood–Schlatter’s, a mild separation will be a difficult clinical diagnosis from a contusion to the tubercle. Even an X-ray can fool you, as you will not know the degree of apophyseal separation that was present before the contusion. In a complete separation, the pain, swelling, and deformity will make the diagnosis. After a mild injury or vigorous activity, a child may report increasing pain and swelling in the region of the tibial tubercle. Even though they may have had Osgood–Schlatter’s, it may not have been recognized. Swelling at the tuberosity can just be an aggravation of their syndrome. This is secondary to microscopic

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separation of the apophysis. The history is extremely helpful, and the magnitude of localized swelling will help differentiate this from a mild/moderate separation of the tubercle.

8.2.2.7 Early Care The patient’s knee should be placed in a compressive dressing from ankle to proximal thigh. I use a knee immobilizer as they have poor quadriceps control and severe pain. The patient, as in all extensor mechanism disruptions, can full weight-bear with crutches, but are advised to rest with the leg elevated. Testing is necessary to confirm your suspicions. X-rays confirm the injury. A CT-scan can be helpful in assessing the degree of displacement. An MRI is rarely indicated for the assessment of these injuries.

8.2.3 Treatment Recommendations The degree of displacement defines the course of treatment. An open reduction and internal fixation is rarely need for the apophyseal separations. I have rarely performed surgery on these injuries, as very few have ever displaced more than a centimeter. If the acute displacement is greater than a centimeter, open fixation may be indicated. Displaced Salter-type injuries, as in any intra-articular fracture, will necessitate open reduction and internal fixation.

8.3 Patella Tendon Ruptures These injuries typically involve the athletic population. The age is commonly from 22 to 40. As with most tendon disruptions, the injury is the result of repetitive use, microscopic tearing (leading to dystrophic changes), and eventual complete rupture. In younger patients, (high school and college) the tendon is still healthy. As time goes on, the tendon will become chronically weakened, and the hyperflexion force will result in the injury. It is rare for a completely healthy tendon to rip. The middle-aged athlete is the most

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vulnerable. Over the years, I consider middle age anywhere from 22 to 65 (as I get older the spread may even increase to 70!). The most common predisposing factor is PATELLA ALTA. The high riding patella increases the mechanical forces on the patella tendon, which leads to microscopic dystrophic changes in the tendon. In children with open growth plates, the distal apophyseal pole of the patella can still be open. This apophysis can separate, mimicking the presentation of a patella tendon rupture. Prior inflammation of this apophysis (Sinding-Larsen Syndrome} can predispose to this injury.

8.3.1 History 8.3.1.1 How Did You Get Hurt? Most commonly, there is a fall or a buckling episode where the knee forcibly flexes. Jumping sports (volleyball, basketball) are the biggest culprits. A slip walking down a stair is a commonly heard story. A twist or contact is not necessary. 8.3.1.2 Did Your Knee Ever Bother You Before? Many of these individuals will have predisposing factors such as a high riding patella (patella Alta), which may contribute to a pre-­ injury source of pain. Patients will report anterior knee pain prior to the injury or say they have been treated for patellar tendinitis. Rarely, some may admit to a prior injection of cortisone in the tendon, (hopefully not by a sports physician who should know better), which weakens the integrity of the tendon. 8.3.1.3 What Sports Do You Play? What Kind of Work Do You Do? Most patella tendon ruptures are a result of overuse. In athletes, it is important to identify the sports in which they participate, but also quantify the amount that they play. For example, someone playing basketball 3–5 times a week is certainly more vulnerable to a once-a-week recreational athlete. People whose occupation involves constant stair climbing and walking certainly put more force across their tendon. Over time this contributes to a weakness of the tendon and higher risk for rupture.

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8.3.1.4 Did You Hear a Pop? Most patients will report a snap or sensation of something ripping. An audible pop is not usually reported. 8.3.1.5 Were You Able to Continue Your Activity? No! 8.3.1.6 Did You Need Help to Get Up and Walk Away? Yes! 8.3.1.7 Did It Swell? When? The knee swells immediately, as the tendon lining (paratenon) does have blood vessels. There will be immediate soft tissue swelling in the anterior soft tissues of the knee. A hemarthrosis is not usually seen as the blood from the extra-articular tendon leaks out of the knee joint. 8.3.1.8 Did You Notice a Deformity? Some patients will report that their knee looked different (the patella is higher riding, making the kneecap more prominent). Some patients will say that they put their finger in the tendon and felt the defect, and make their own diagnosis! 8.3.1.9 Did You Go to the Hospital? Most of these patients seek immediate attention as they cannot walk on their knee. X-rays are typically reported as negative, but every so often the patient will report that the X-ray revealed a “chip” or calcium deposit (representing an avulsion injury). They are treated with an immobilizer, crutches, and sent to your office for definitive treatment.

8.3.2 Physical Examination 8.3.2.1 Observation They will have trouble standing on the affected knee. The knee will be held in moderate flexion. There will be obvious soft tissue swelling in the front of the knee. There may be ecchymosis, but not grossly obvious, for the bleeding is relatively mild. A hemar-

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throsis is not typically present as the tendon is extra-articular, and the blood will escape into the soft tissues. When asked to get up on the exam table, they will need support to raise their leg. They are not happy campers! As the knee flexes, look at where the patella is located. Look from the side as this will allow you to see the height of the patella. Always compare to the opposite knee. With patella tendon ruptures, an immediate PATELLA ALTA will be apparent. As my Dad said, unless you look you will never see anything!

8.3.2.2 Neurovascular Assessment As always, this is mandatory. It is rare that a patella tendon rupture will have any involvement of the nerves or vessels. 8.3.2.3 Range of Motion The patient will reluctantly flex the knee but has pain. They will typically flex to 45°, and then want to stop. They will not be able to do a leg raise. They will not be able to actively extend the knee and will need your passive assistance to do so. BE GENTLE. They are in pain, and this is not a difficult diagnosis to make. 8.3.2.4 Tenderness The maximal point of tenderness will be at the site of the rupture, which can be anywhere along the course of the patella tendon. Proximal tears, off the distal pole of the patella, are the most common. The retinaculum, medial and lateral, are commonly torn with the tendon, so there will be anterior medial and lateral pain to palpation. Distal patella tendon ruptures from the tubercle are rare. The tenderness will go along the course of the entire tendon, as these tears can be in multiple planes up and down the tendon. 8.3.2.5 Palpation When your index of suspicion is high for a tendon rupture, you should gently palpate the tendon for a defect. Your finger will fall into the defect, confirming the diagnosis.

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8.3.2.6 Ligament/Meniscal Tests Associated injuries are rare with patella tendon ruptures. Be gentle in your evaluation. Despite the pain, you should be able to do a Lachman test, as there can be an associated ACL tear. The quadriceps contraction needed to tear the patella tendon, can produce enough of anterior displacement of the tibia to cause an associated ACL tear. I have seen this several times in my career, and you should be on the lookout for this combined injury. Meniscal tears are not commonly seen with patella tendon ruptures, and the tenderness is more retinacular and anterior than that of a meniscal joint line tenderness.

8.3.3 Differential Diagnosis 1. Quadriceps rupture. 2. Patella fracture. 3. Tibial tubercle avulsion. The other extensor mechanism injuries are to be considered with this presentation. They should not be difficult to distinguish! The patella fractures will be exquisitely tender at the patella itself, and most of these patients will have had X-rays that diagnose the injury. The quadriceps ruptures will typically be in the older individual, and their site of tenderness and defect will be more proximal, they will not have a patella alta. Be careful with the tibial tubercle avulsions, as maturity may occur later in age than you think, and I have seen these apophyseal injuries up to the age of 17. It is rare for patella tendon ruptures in that age-group.

8.3.4 Treatment 8.3.4.1 Early Care To reduce swelling, the knee is placed in an ankle to proximal thigh compressive dressing. The patient is advised to start isometrics, even though it is painful to fire their quadriceps. A knee immobi-

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lizer is necessary to support the extremity. With the immobilizer on, the patient can full weight-bear. Sometimes, there is an associated abrasion, which requires local care, as surgery will be needed. It is imperative that the skin is clean before the surgery is performed.

8.3.5 Treatment Recommendations Surgical repair is indicated for all patella tendon ruptures. Continuity of the extensor mechanism is essential for normal functional activity. The patella tendon will not heal without a surgical repair. It is preferable to repair this tendon within the first 2 weeks, as the retraction of the proximal end will be manageable. After 3  weeks, the surgical repairs become technically difficult. The early care is crucial to reduce the swelling and ensure that the skin in good condition for the surgical repair.

8.4 Patella Fractures I will not spend much time on patella fractures, though they can sometimes be subtle, and difficult to diagnose. Obviously, X-rays ultimately help make the initial diagnosis. Diagnostic acumen should point to the diagnosis, and your index of suspicion aids in the appropriate X-ray views to be ordered. For example, a vertical fracture line may be difficult to see on a standard AP and lateral view of the knee. The Merchant view will easily pick up this fracture line, but it is not a routine view in most centers. It would be up to you to order that view, along with obliques, to pick up these more subtle fracture lines. That being said, you should be able to diagnose patella fractures without an X-ray, CT, or an MRI.

8.4.1 History Immediately after the injury, most of these patients will go to an emergency room or outpatient facility. The majority will tell you that they “broke my kneecap,” making the diagnosis self-evident.

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They will typically be in some form of immobilizer and will be in pain. Patella fractures can happen in any age-group, but the middle or older aged individuals are more vulnerable.

8.4.1.1 How Did You Get Hurt? Most will report a direct impact such as a fall onto their flexed knee. A buckling injury going down a stair or a slope is also common. A traumatic direct blow, as from a dashboard hitting the knee in a motor vehicle accident, is another mechanism. A twisting injury can cause a patella fracture, but this is usually in association with a patella dislocation and is typically smaller avulsion type or chondral shear injuries. 8.4.1.2 Did You Hear a Pop? No! Just severe immediate pain. 8.4.1.3 Could You Continue Your Activity? No. It’s too painful, and if the fracture is displaced, they will not be able to walk on their leg. In a non-displaced fracture, individuals may be able to walk by themselves, but are unable to continue in their sport or activity. 8.4.1.4 Did It Swell? When? Yes. Immediately! Fractures bleed and the knee will promptly fill up with blood causing an immediate hemarthrosis (within 6 h). 8.4.1.5 Did You Notice a Deformity? A displaced patella fracture will have a deformity, as the upper half of the patella will be pulled proximally by the intact quadriceps. The patient will notice the deformity and may report a palpable gap in their bone. Without displacement, the deformity will be the significant swelling of the knee, as the hemarthrosis from a patella fracture can be extremely tense and severe. 8.4.1.6 Did You Ever Hurt Your Knee Before? These are typically isolated injuries without a prodrome of symptoms. Anyone can break their patella if enough force is applied. The exception to the rule (there always is an exception in medicine) is the AVULSION fracture of the distal pole of the patella.

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These injuries will present in athletes involved in jumping sports (basketball, volleyball). They will often report mild discomfort in their kneecap prior to the injury. A hyperflexion maneuver and a quadriceps contraction are enough to cause the distal pole injury. The patient may have had an unfused distal patella apophysis, or a possible undetected stress fracture that had been mildly symptomatic. The poorer vascularity of the distal pole of the patella makes it more susceptible to injury. In children, a prodrome of pain at the distal patella is classic for Sinding-Larsen syndrome which weakens the distal apophysis. A mild hyperflexion injury can lead to a complete avulsion of the distal pole of the patella.

8.4.2 Physical Examination 8.4.2.1 Observation These patients are not happy. They are in pain and usually arrive with crutches, wearing an immobilizer. They will need help to get up on the examination table, requiring your manual support to raise the leg. With the immobilizer removed there will be a significant hemarthrosis, with severe swelling of the knee. Anterior ecchymosis will often be present as well as a possible abrasion. In the apophyseal separation, the fracture bleeding will be minimal, as the growth plate is quite avascular. 8.4.2.2 Neurovascular Assessment Fortunately, these injuries do not involve the neurovascular complex of the extremity. 8.4.2.3 Range of Motion Active range of motion is limited. Gravity will help extend the knee on the table. They will not be able to do a leg raise. Active flexion will be severely limited as it is too painful to move. DO NOT TRY TO PASSIVELY MOVE THE KNEE1, unless you want to make an immediate enemy.

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8.4.2.4 Tenderness The tenderness will be directly over the patella and the adjacent medial and lateral retinaculum. Avulsion injuries will have point specific tenderness at the distal pole of the patella. 8.4.2.5 Palpation Displaced fractures will have a palpable defect related to the separation of the fracture fragments. Be gentle when you feel for such defects. 8.4.2.6 Meniscal/Ligamentous Tests It is very rare for there to be an associated ligament or meniscal tear with a patella fracture. These patients are too painful to do any manipulation, so I do not recommend a complete examination. You can gently check the collateral ligaments, as the limited ROM present will allow this exam. The tenderness is anterior and retinacular, not joint line as in meniscal injuries. ACL rupture is rare but can occur with patella fractures. Because of the pain and marked hemarthroses that many patients have, it is difficult to do your Lachman test, but don’t be afraid to try. REMEMBER, the Lachman Test is not a test of force, but one of finesse and experience!

8.4.3 Differential Diagnoses 1. Patella dislocation with chondral shear fracture. 2. ACL tear. 3. Bipartite patella. Anytime you are presented with an acute hemarthrosis, your computer (i.e., brain) has to immediately think of common reasons. As we already know, patella dislocations and ACL disruptions both cause hemorrhage, and immediate swelling, as does a patella fracture. The stories are different as are the physical ­examinations, so these diagnoses should be relatively easy to rule out. A twisting mechanism is classic for the ACL and patella dis-

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location, whereas a buckle hyperflexion is typical for all extensor mechanism injuries. The pain is more severe from a patella fracture, but this is most influenced by the intensity of the effusion. As in a patella fracture, a chondral shear fracture with a patella dislocation will present with a tense hemarthrosis, and retinacular pain. The patella tenderness will be more medial, but apprehension will be present in both situations, as attempts to move the patella will cause severe pain and quadriceps spasm. A palpable gap makes the diagnosis of a patella fracture obvious. The bipartite patella can fool you! Normally, patients may have a bipartite patella that was never recognized. The unfused superolateral patella growth plate will have the appearance of a vertical fracture line. In a direst blow to the patella, the patient will be diagnosed in an emergency facility, that they “broke my kneecap.” These patients will present with pain, but rarely do they have a hemarthrosis. The unfused apophysis is cartilage and does not bleed excessively. They will be directly tender superolaterally. From a fall or direct blow, the apophysis can separate macro or microscopically. However, more often, the injury is that of a contusion with the X-ray finding of what appears to be an acute patella fracture. The severity of pain, lack of swelling, and site of tenderness are all distinguishing features.

8.4.3.1 Early Care These injuries present with significant swelling and often with an associated skin abrasion. A compressive dressing from ankle to proximal thigh is applied. If there is an abrasion, local wound care is given. I like to clean the abrasion and apply Silvadene cream. This is covered by a Xeroform and a sterile gauze. The wound has to be inspected and treated daily until the skin is epithelialized. This is essential if an open reduction and internal fixation procedure is indicated. A knee immobilizer is necessary to support the extremity. Isometric and ankle pumps are encouraged despite the pain. Crutches are necessary as full weight-bearing is allowed. Rest and ­elevation are advised to reduce swelling. An MRI is rarely indicated. A CT scan can be helpful in defining the degree of com-

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minution and amount of displacement. The timing of surgery depends upon the condition of the skin. Technically, surgery is best done within the first 2 weeks.

8.4.4 Treatment Recommendations Non-displaced or minimally displaced fractures can be treated conservatively. An offset of the articular cartilage is less acceptable than mild displacement, and the patient should be made aware of the possibility of later pain. Open reduction and internal fixation are indicated for displaced fractures. Extensor mechanism continuity is essential for lower extremity function. Articular malalignment will lead to post-­ traumatic pain and later arthritis of the patella-femoral joint. Hence, as with any intra-articular fracture, it is important to anatomically align the articular surface, and a surgical approach is indicated.

8.5 Quadriceps Tendon Ruptures Quadriceps tendon ruptures are relatively common and typically affect the “older” aged individual. Most tendon ruptures, in the young or old, are related to dystrophic changes in the tendon. With quadriceps ruptures, the common predisposing factors include obesity, overuse, and dystrophic change in the tendon related to a systemic illness (i.e., renal disease, diabetes, immune diseases). Almost all patients are older than forty, as this is the great age where we seem to start falling apart! The quadriceps is the largest group of muscles in the human body. The forces across the quadriceps tendon are tremendous, especially with activities that include stair ascent and descent, arising from a chair, squatting. The more load applied over time leads to a higher chance of degeneration in the quadriceps insertion. The tendon that ruptures is never healthy. Micro or ­macroscopically dystrophic changes in the tendon weaken its structure, making it vulnerable to injury. A sudden flexion of the

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knee, followed by the quadriceps contraction, leads to forces that exceed the strength of the unhealthy tendon. I always tell my patients that “Tendon ruptures are like ripping your shoelace. A new shoelace never rips. The shoelaces rip in shoes you have been wearing for a while.” Such is the case with quadriceps injuries.

8.5.1 History These patients will come to see you utilizing crutches or a walker. Most often, they will have been seen in an emergency facility and given a knee immobilizer. The rare patient comes in without some form of support. They are in pain and even have difficulty sitting down.

8.5.1.1 How Did You Get Hurt? The classic answer is that their knee just buckled, very often when they are descending a step. They report that their knee bent backwards as they fall to the ground. 8.5.1.2 Did You Hear a Pop? Most patients will report that they felt a distinct snap or ripping sensation in their knee. They know that something bad happened. 8.5.1.3 Could You Continue Your Activity? No! These patients fall and cannot get up without assistance. They are typically older and will not have the strength to get up. If they arise, they will not be able to walk as the knee will buckle. They require assistance to arise, and often an ambulance has to be called as they cannot independently ambulate. They will typically say to you, “I cannot raise my knee.” 8.5.1.4 Did Your Knee Swell? They will report immediate swelling. Like the patella tendon, the quadriceps has a relatively poor blood supply, and the tendon itself will minimally bleed. However, these tears include the medial and lateral retinaculum, which is quite vascular, and will

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immediately bleed when injured. As the bleeding is extra-­articular, the swelling will be extensive and fairly encapsulated in the anterior soft tissues, and a hemarthrosis will not form.

8.5.1.5 Did You Notice a Defect? Only about a third of the patients will say that they felt a hole in the front of their knee. 8.5.1.6 Did You Notice a Deformity? Unlike the patella tendon rupture, there is no major deformity. The patient will report the swelling but will not say that the tendon is higher up than normal. 8.5.1.7 Any Previous Knee Problems? Some patients will report that they have had pains in their knees “for years.” They may report that their knee ached with stairs, or with arising from a chair. Intuitively, you would think that most patients would have a prodrome of knee symptoms related to dystrophic changes, However, in my experience, very few patients give a history of prior treatment for a tendinitis. Many will say that they do have some arthritis in their knee, but do not report specific tendon issues. 8.5.1.8 Any Prior Injections to the Knee? Steroid injections can be a precipitating cause of weight-bearing tendon ruptures. Always ask if there has been any type of prior injection. Where in the knee was it given? 8.5.1.9 What Type of Work Do You Do? Do You Participate in Any Sports or Gym Activities? Many of these patients will give a history of laborious type employment. Their work will involve lots of walking, stairs, or possibly kneeling and squatting activities. (i.e., plumbers, electricians, letter carriers). As they are older patients, they will have been doing these activities for years. The majority of these patients are not athletically inclined. There is a group that has been active in the gym or were former

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athletes. It is not common to see a quadriceps tear from a sporting injury. People who keep fit seem to have less chance of tearing the Quadriceps.

8.5.1.10  Past Medical History Remember, patients will not volunteer information. You have to ask questions to get answers. Are you a diabetic? Any kidney problems? What medications are you taking? If they are obese, ask them about their weight. Have they always been overweight? Recent weight gain?

8.5.2 Physical Examination 8.5.2.1 Observation The patient cannot stand or walk unless they are wearing a knee immobilizer or utilizing crutches or a walker. They cannot raise their leg and will need your support to bring the extremity onto the examination table. There will be substantial anterior superior knee swelling, often with soft tissue ecchymosis in the same area. Because of the swelling, a visible gap is not evident. The patient will not be able to do a leg raise. There will be the sense of a hemarthrosis, as the bleeding is substantial. The blood will leak out into the soft tissues, and the entire knee will appear swollen. 8.5.2.2 Neurovascular Assessment As with the other extensor mechanism injuries, damage to the nerves or vessels is very rare. In this age-group, pulses may be abnormal, but this is probably related to a chronic insufficiency, rather than the injury. 8.5.2.3 Range of Motion The patient will be reluctant to move the knee. They will be able to actively flex to 60°, but pain will usually inhibit further flexion. Gravity will extend the knee, but the patient will not be able to perform any active extension. They cannot do a leg raise.

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8.5.2.4 Tenderness There will be diffuse tenderness over the entire anterior proximal aspect of the knee. Quadriceps ruptures almost always are associated with medial and lateral retinacular tear that extend into the vastus medialis and lateralis. There will be central, medial, and lateral tenderness along the line of the tear. 8.5.2.5 Palpation A palpable defect is usually easy to feel. The gap between the tendon and the patella is typically several centimeters. Gentle finger palpation will allow you to fall into the gap. The patient often tells you that they felt the defect. Most quadriceps ruptures are complete. The rare partial tear will not have a gap and the swelling will be minimal. With some assistance, these patients will be able to do a leg raise, but this depends on the extent of the tear. Partial quadriceps tears are rare. 8.5.2.6 Meniscal/Ligamentous Tests It is very rare for an associated ligament or meniscal tear with a quadriceps rupture. These patients are too painful to do any manipulation, so I do not recommend a vigorous examination. You can gently check the collateral ligaments, as the limited ROM present will allow this exam. The tenderness is anterior and retinacular, not joint line as in meniscal injuries.

8.5.3 Differential Diagnosis 1. Patella fracture. 2. Patella tendon rupture. 3. Patella dislocation. I have not found it difficult to differentiate the quadriceps rupture from patella tendon tears. With quadriceps tendon ruptures, the age-group is older, and these patients will be more likely to be obese and out of shape. Most patella tendon ruptures are a result of overuse in a more athletic population. The clinical appearance is grossly different, as the tendon defects will be in different loca-

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tions. With the patella tendon rupture, the high riding patella is easy to identify. Patella fractures will have direct tenderness over the patella, and if displaced, there will also be a high riding proximal pole that is clinically evident. It is very rare to see a patella dislocation in this older aged group. If it did occur, I am quite sure that the history would have revealed that there was a history of prior dislocations.

8.5.4 Treatment 8.5.4.1 Early Care These patients present with significant pain and swelling. They typically have already been seen at an outpatient facility and arrive wearing a knee immobilizer. To reduce the swelling it is imperative to apply a compressive dressing from the ankle to the proximal thigh. Associated abrasions, though rare with quadriceps injuries, must be appropriately treated (see patella fracture early care). A knee immobilizer must be utilized as these patients do not have any quadriceps control. The patient is allowed to full weight-bear wearing the immobilizer (please emphasize to the patient that the immobilizer must be worn high on the thigh to the mid-calf. Too often they come in with the immobilizer slipped down the leg acting more as a shin guard than a knee protector!). Elevation of the extremity, isometrics, and ankle pumps are instructed and emphasized.

8.5.5 Treatment Recommendations Surgical repair is indicated for all quadriceps ruptures. The quadriceps will retract and will not heal in continuity unless a repair procedure is performed. The repair is best done within the first 2 weeks. After that time, the proximal retraction of the quadriceps will make the repair procedure technically difficult with a lower success rate. The early treatment of reducing swelling greatly reduces the postoperative risks of wound breakdown and infection.

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Key Facts History • Age makes a difference as to location of injury. • Hyperflexion mechanism. • Unable to walk after injury. • Requires help to get up. • Immediate swelling. • Extremely painful. Physical Examination • Unable to do a straight leg raise. • Palpable defect in extensor mechanism. • Marked anterior soft tissue swelling. • Large effusion (Hemarthrosis). • Limited flexion secondary to pain. Treatment • Aspiration of blood for severe pain. • Immediate wound care if there is an associated skin abrasion. • Surgical repair as soon as possible.

9

Contusions and Chondral Injury

9.1 Introduction It is quite common for athletes to fall on their knee or take direct blows to the extremity. Twisting injuries can also precipitate contusions as the knee bones hit against the other. These are often very painful injuries, and the patient can present with what looks like a very severe knee disturbance. Often, the diagnosis of a contusion or a chondral fracture is one of exclusion. Your careful history is the key to making the correct diagnosis. Undoubtedly, it is with these injuries that the MRI is the most enlightening.

9.2 History 9.2.1 How Did You Get Hurt? Most patients will report a direct blow to the knee. Falling forward with the knee flexed is the most common mechanism. Very often the patient does not remember but will say their knee buckled. A twisting injury will usually result in an associated injury such as an ACL tear or a patella subluxation/dislocation which are commonly associated with knee contusions (bone bruise).

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9.2.2 Did You Hear a Pop? Typically, no. They will have immediate pain but rarely will report a noise.

9.2.3 Could You Continue Your Activity? This depends on the severity of the fall or blow. Bony or muscle contusions can hurt like hell. Most of us have taken a knee-on-­ knee injury in our lives, and I’m quite sure you remember the pain. Many athletes will get up and continue their activity with a limp.

9.2.4 When Did It Swell? A fall on the bent knee will result in an anterior injury. The pre-­ patellar bursa is very vascular and will bleed immediately when contused. The swelling will be immediate. A direct blow to the muscle (quadriceps) swells immediately as the muscle has an excellent blood supply. Bony bruises hurt, but edema within the bone takes hours to develop, and there will not be a noticeable effusion until later (12–36 h). A chondral shear fracture, as with any fracture, will swell immediately and cause a hemarthrosis. The hemarthrosis can be intense and cause significant pain. This is particularly true when these injuries occur in association with an ACL tear or a patella dislocation,

9.2.5 Did It Get “Black and Blue”? In the soft tissues, direct blows will develop ecchymosis. This usually takes hours to develop, but eventually the ecchymosis will appear. Intra-articular bony bruises and chondral fractures will not cause external ecchymosis.

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9.3 Physical Examination 9.3.1 Observation Contusions will show obvious soft tissue swelling and /or ecchymosis at the site of the injury. Isolated chondral injuries will not have external signs but will present with an effusion. Chondral injuries in association with other injuries (i.e., patella dislocation, ACL tear) will often have associated soft tissue swelling and possible external bruising.

9.3.2 Neurovascular Assessment Whether the osteochondral injury is in isolation or associated with other injuries, it is rare for there to be a neurovascular injury.

9.3.3 Range of Motion In contusions, there can be loss of motion secondary to pain. For example, a contusion to the quadriceps tendon /muscle unit above the patella can be exceedingly painful, restricting flexion. Chondral injuries cause hemarthrosis, which immediately limits range of motion. These patients will have difficulty with extension and flexion, with significant pain on attempting to move.

9.3.4 Tenderness Contusions will have direct tenderness at the site of the contusion. Isolated chondral injuries may not have obvious specific sites of tenderness. Definitive sights of tenderness, such as joint line tenderness may not be present, but the compartment location of the injury can be tender to the touch. For example, a patella chondral fracture will certainly be tender to patella femoral palpation,

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whereas a posterior medial or lateral chondral injury may not have specific areas of palpable tenderness. Chondral injuries in association with other injuries are not readily apparent. The degree of pain on range of motion is magnified, as fractures are painful. These patients are much more reluctant to move their knee. The location of tenderness will be more typical of the injury, rather than the location of the fracture. The tightness of the hemarthrosis makes the pain significantly greater.

9.3.5 Associated Ligament Disruption Most chondral fractures occur in association with patella dislocations or ACL tears. Thus, your examination must be very specific to rule out these associated injuries. As you know, an acute hemarthrosis can result from these injuries without an intra-articular fracture. The rapidity of the onset of the swelling and the intensity of the acute swelling are clues to the presence of an osteochondral fracture. REMEMBER, fractures, small or large, HURT!!!! The knee will swell rapidly in the presence of chondral fracture.

9.4 Differential Diagnosis 1. Patella dislocation. 2. Acute anterior cruciate ligament tear.

9.5 Treatment 9.5.1 Early Care The early care of a knee bone bruise emphasizes the reduction of swelling and pain. A compressive dressing for several days, followed by cold therapy is indicated. Elevation, isometrics, and active range of motion are encouraged. Crutches are given and limited weight-bearing is advised to help reduce the effusion and

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contact pressure on the area contused. I recommend a 5-day course of anti-inflammatory medication. Chondral injuries are always associated with intra-articular effusions. The early care emphasizes swelling reduction. A compressive dressing, rest, and elevation are encouraged. Isometrics and active range of motion are advised despite the pain. A short course of anti-inflammatory medication is given along with non-­ narcotic pain management. Crutches are always given and depending on the location of the injury, toe touch or non-weight-­ bearing ambulation is advised.

9.5.2 Treatment Recommendations All bone contusions are treated conservatively. The articular cartilage is intact, and the pain of the lesion will subside in several weeks. Weight-bearing progresses as tolerated, along with non-­ weight-­bearing aerobic activities (biking, elliptical), and a progressive muscle strengthening regimen. A return to full activities is allowed when the pain is gone with weight-bearing ambulation. Displaced intra-articular chondral injuries will require an arthroscopic procedure. Excision or repair will depend on the size of the lesion. A non-displaced injury can be followed conservatively with crutches, limited weight-bearing, and range of motion. If the fragment displaces, and the fragment is significantly large, an arthroscopic procedure will be required. Key Facts History • Direct blow is most common. • Twist may be responsible, but then think of associated injury (ACL, patella dislocation). • Immediate swelling.

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Physical Examination • Soft tissue ecchymosis. • Hemarthrosis. • Diagnosis of exclusion (effusion without associated ligamentous or meniscal signs). Treatment • Non-operative for contusions. • Early range of motion. • Chondral fractures may require surgical intervention. • Size and location of the fracture are determining factors.

The Mimickers

10

10.1 Introduction Rarely, you will have a case that throws you a curve ball! The story begins with a knee trauma, but the diagnosis ends up with a surprise ending. The pearl of wisdom that I have, is that you must pay attention to the story. Although these cases are rare, your index of suspicion has to be high. The history gives you the clues. The physical examination may or may not be that helpful. Gout, Pigmented Villonodular Synovitis (PVNS), and bone tumors can present as an acute knee injury and are the “red herrings” that you have to watch out for!

10.2 Gout 10.2.1 History 10.2.1.1  Was There An Injury? Many patients with acute gout of the knee have a mild trauma several days prior to the onset of acute pain. 10.2.1.2  Could You Continue Your Activity? The patients usually state that they were fine after the injury and could continue their activity.

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10.2.1.3  When Did the Pain Begin? Did It Swell? They are often asymptomatic for a few days, hence, the injury more than likely had nothing to do with the onset of their problem (A red herring!). Suddenly, they will report the rapid onset of swelling and severe pain. The onset is often in the middle of the night. 10.2.1.4  Past Medical History? Upon questioning, these patients may have a history of a prior gouty episode, kidney stones, or taking diuretics.

10.2.2 Physical Examination 10.2.2.1  Observation These patients are in acute pain and will not want to move their knee! The knee will be swollen with an obvious effusion. There may be redness about the knee, which can be more apparent if the crystal deposits are in the soft tissues (i.e., pre-patellar bursa, ligament, or tendon insertions.) 10.2.2.2  Tenderness These knees are warm to the touch, and the tenderness will be diffuse. If the surrounding soft tissues are involved, there can be point tenderness that is exquisite to direct palpation. 10.2.2.3  Range of Motion Because of severe pain, motion is typically markedly restricted. The loss of motion in these patients is more dramatic than most knee injuries. Typically, there will be an effusion that contributes to the lack of motion.

10.2.3 Treatment 10.2.3.1  Early Care These patients are in severe pain. Rest with elevation is essential. Ice packs on and off are extremely analgesic. Though the patient

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is reluctant to move the knee, encourage range of motion and isometric exercises. X-rays are ordered to look for the tell-tale signs of periarticular erosions.

10.2.4 Treatment Recommendations As long as there is not a contraindication to non-steroidal medication, I prefer Indomethacin 50 mg po t.i.d. for 2 days, followed by 25 mg for 3 more days. If the patient cannot take this, I prescribe a short 5-day course of tapering prednisone. In my practice, I rarely utilize colchicine. I refer these patients to a rheumatologist for further work-up of this metabolic issue.

10.3 PVNS 10.3.1 History 10.3.1.1  Was There An Injury? What can fool you in the PVNS patient is the occasional history of an acute episode of “my knee locked.” A pedunculated synovial PVNS tumor, often isolated, can catch between the femur and tibia, mechanically locking the knee. This simulates the locking history of a meniscal tear. In the diffuse form of PVNS, the patient often presents with a history of a mild twist. The key to your suspicion is the past history of recurrent effusions. Often these patients give histories of an aspiration of “bloody fluid.”

10.3.2 Physical Examination 10.3.2.1  Observation The effusion is variable. In the pedunculated, isolated PVNS, the effusions, hemosiderin brown in appearance, are typically mild. In the diffuse pattern, the effusions are typically tense, bloody, or hemosiderin brown in color.

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10.3.2.2  Tenderness There is usually no area of joint line tenderness. 10.3.2.3  Range of Motion Loss of motion will be secondary to the extent of the effusion. Though the knee can lock in the isolated case, it is rare for the knee to stay mechanically locked.

10.3.3 Treatment 10.3.3.1  Early Care The chronic effusion requires an aspiration. The nature of the aspirant (a brownish hemosiderin colored fluid) helps confirm the diagnosis. A bulky compressive dressing is applied after the aspiration. An MRI confirms the diagnosis.

10.3.4 Treatment Recommendations If there is mechanical locking, and a pedunculated lesion is found on the MRI, arthroscopy is recommended. If this is the localized PVNS, excision of the lesion and any other suspected area of the disease is arthroscopically removed. The patient must be made fully aware of the high recurrence rate, and that long term follow­up visits will be necessary. In the diffuse pattern of the disease, an arthroscopic synovectomy may be needed. I typically refer these out to an orthopedic oncological specialist.

10.4 Bone Tumors Unfortunately, in a sports medicine physicians’ career, you will come across a knee injured patient that has an underlying malignant bone tumor. These are tragic cases, but your early diagnosis of the condition can make a difference. Osteogenic Sarcomas and Ewing’s tumors of the distal femur are the most common.

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10.4.1 History 10.4.1.1  Was There An Injury? These patients often report a simple twist or fall. These are relatively mild injuries, and yet the patient will not want to bear weight on the knee. They usually do not come to the doctor immediately, unless there is a pathological fracture. When asked, they will have a prior history of discomfort in the knee with activity as well as rest. 10.4.1.2  Did the Knee Swell? This is variable. Distal femoral tumors can cause a sympathetic effusion, which may be more related to the tumor than the injury. 10.4.1.3  Do You Have Night Pain? Tumors typically cause pain at night that will awaken a patient from sleep. Meniscal tears can also cause night pain.

10.4.2 Physical Examination 10.4.2.1  Observation These knees can look very benign. The effusions are typically mild or absent. Atrophy of the quadriceps will be out of proportion to what you would expect. 10.4.2.2  Tenderness There will be direct tenderness to palpation of the bone (distal femur, proximal tibia), the location of the tumor. 10.4.2.3  Range of Motion Most patients will present with full range of motion, unless there is a sympathetic effusion.

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10.4.3 Treatment 10.4.3.1  Early Care The only early care needed is a possible aspiration and compressive dressing applied, if there is a significant tense, painful effusion. I’d rather not do anything invasive to these knees.

10.4.4 Treatment Recommendations These patients are immediately referred to an orthopedic oncological specialist. Key Facts History • You must probe history for prior subtle prior problems with the knee. • Mild mechanism of injury (out of proportion to magnitude of their symptoms). • Night pain. Physical Examination • Limited range secondary to effusions. • Gout: Large effusion, marked tenderness, some redness, onset in middle of night. • PVNS: Large effusion, mild pain. • Tumor: Mild effusion, night pain. Treatment • Gout: Medication, rest, ice. • PVNS: Surgery most often needed. • Tumors: Refer to bone oncology center.

The Whole Gestalt (i.e., Conclusion)

11

Gestalt, by definition, means taking parts and putting them together to produce something of meaning. As a sports medicine clinician, it is our role to do just that. After 40  years of seeing patients, I do feel that I understand the gestalt. Passing it on to you, the reader has been the primary intent of this manual. In closing, I thought it would be worthwhile to remind you of some of my “pearls of wisdom.” I know that it will take time to “get it,” but I am hopeful that this manual will facilitate that tedious process of gaining experience. Here we go……… Make eye contact and say hello to your patient. This even applies to a ball player injured on the playing field! (I always ask their name.) Make the patient as comfortable as possible. Try to assess their level of pain. Reassure the patient that you are not going to cause them any more pain. Your confidence will give your patient confidence in you. When you take a history, remember you are allowed to “lead the witness.” Seek out the clues. For some reason, patients rarely offer information and must be asked questions in order to get answers. BY THE HISTORY ALONE, YOU SHOULD MAKE THE CORRECT DIAGNOSIS 90% of the time. DON’T RUSH your history or physical examination. The physical examination should never change! Even though the history points in the direction of an obvious diagnosis, the complete exam will often reveal the unexpected.

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Your examination table should be in the middle of the room so that you can easily examine both knees without asking the patient to turn around. Keep this in mind when you design your own examination rooms. You must always examine the unaffected knee. This should take less than 30 s, but your comparison to normal is essential. This includes watching the patella actively track from 90 to 0°. Quickly do your apprehension test and then the Lachman. Proceed to the collateral ligaments and then flex the good knee to 90° to do your drawer tests. Quickly test your hip rotation, as hip pathology often conceals itself as knee discomfort. THINK PATELLA! That little bone in the knee is staring you in the face and is the most common source of pathology. Patella issues are the most often overlooked. The patella is the great “mimicker “of the knee. A patella dislocation can look and sound like an ACL tear. A patella subluxation can be hard to differentiate from a grade one MCL tear or a medial meniscal injury. OBSERVE THE KNEE FROM THE SIDE.  The subtlety of posterior drop back is missed unless you look at the knee laterally (as is Osgood-Schlatter’s and many other anterior pathological conditions). The location of joint line tenderness is best examined with the knee in flexion. With encouragement and your patience, even a patient with a painful swollen knee will be able to bend the knee into a flexed position. Don’t push, just encourage. The Fairbanks patella apprehension sign is not based on the patient’s pain. It is the contraction of the quads as you attempt to push the patella laterally, that makes a positive test. This test must be done with the knee in 20 degrees of flexion crossed over the other knee. The Lachman test takes practice. The maneuver requires finesse and patience, not strength. You have to feel the endpoint to appreciate the test. Start with young, thin adolescent knees. This is the best way to practice. Keep doing Lachman’s on everyone! The more you do, the better you will be at the examination. An absent endpoint is a positive Lachman and the ACL is torn until proven otherwise.

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joint line tenderness on both sides of the knee is an ACL tear until proven otherwise. A negative Lachman (endpoint present), and a positive anterior drawer sign is a torn PCL until proven otherwise. If the history points to a meniscal tear, and there is corresponding joint line tenderness, further flexion-rotation maneuvers are not needed to prove the diagnosis. These tests are painful to the patient. Remember, you want to be their friend and always be empathetic. You never want to be the one who aggravates their pain. The most serious knee injury can be deceivingly benign, as there may not be any effusion (The fluid has leaked out as there is significant capsular disruption.) These are the knees where your neurovascular assessment becomes crucial. Mastering a good history and physical examination will give you tremendous self-satisfaction. When further testing confirms your diagnosis, you will have more confidence in yourself, and more significantly, the patient will have more belief in you. We perpetually have to behave as Sherlock Holmes. Solving the mystery of the correct diagnosis is the greatest joy I have as a sports medicine physician. You will develop your own gestalt. I just hope that my advice has pointed you in the right direction. Good Luck.

Index

A Abrasions, 116 Acute knee injury, 2 physical examination, 4–6 treatment consideration, 7–9, 11 Acute patella dislocation history, 14–17 physical examination, 17, 19, 20 predisposing factors, 22, 23 treatment plan, 20, 21 treatment recommendation, 25, 26 Acute patella subluxation history, 26 physical examination, 27 treatment plan, 28 Ancillary tests, 21 Anterior cruciate ligament (ACL), 24 factors, 55, 56, 58, 59 history, 41–43, 45, 46 physical exam, 46, 47, 49–51 recognition and accurate diagnosis, 41 treatment plan, 52, 54 treatment recommendation, 60, 61

Anterior Drawer Sign, 50 Anterolateral tenderness, 19 Apley Grind test, 89 Apprehension test, 19–20 Arthroscopic techniques, 95 B Biking, 39 Bone tumors history, 129 physical examination, 129 treatment, 130 C Cold therapy, 21, 38 Contusion/chondral fracture, 51, 120 differential diagnosis, 122 early care, 122–123 history, 119, 120 physical examination, 121 treatment recommendation, 123–124 Crutches, 122

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. F. Sherman, The Acute Knee, https://doi.org/10.1007/978-3-031-32844-2

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Index

136 D Dial Test, 49 Direct central tenderness, 20 Discoid meniscus, 88 Displaced intra-articular chondral injuries, 123 Displaced Salter-type injuries, 101

J Joint line tenderness, 50

E Ecchymosis, 6, 34 Excursion, 50

M McMurray test, 89 Medial collateral ligament (MCL) differential diagnosis, 36, 37 history, 32, 33 physical examination, 33, 35 sprain, 24 treatment, 37–38 Medial/lateral joint line tenderness, 66 Medial meniscal injuries, 36, 94 Meniscal pain, 91 Meniscal preservation, 93 Meniscus tear, 50, 88 differential diagnosis, 90 factors, 92, 94, 95 history, 86–87 physical examination, 88, 89 treatment, 91, 92, 95 Mild/moderate osteoarthritis, 90 Multi-ligamentous knee injury history, 77–78 physical examination, 78 posterolateral ligament injury, 73 treatment, 81

F Fairbanks patella apprehension sign, 132 Fibula collateral ligament, 75 Flexion-rotation maneuvers, 133 Frank dislocation, 26 G Gentle finger palpation, 115 Gestalt, 131 Gout physical examination, 126 treatment, 126–127 H Hip pathology, 132 Hip rotation, 132 Hospital for Special Surgery, 1 Hyperextension laxity, 18 I Immediate surgery, 58 Intermittent cold therapy, 54 Isolated chondral injuries, 121

L Lachman test, 7, 20, 41, 48–49, 52, 67, 68, 80, 132 Ligament/meniscal tests, 100

N Neurovascular assessment, 47, 65, 79, 99 Night pain, 87 Non-operative care, 25

Index O Open chain knee extensions, 70 Osteochondral injury, 16 Osteochondritis dissecans, 90 P Pain management, 21, 38 Patella apprehension, 6 Patella dislocation, 122, 132 Patella fractures, 116 differential diagnosis, 109, 110 early care, 110 history, 106, 108 physical examination, 108, 109 treatment recommendation, 111 Patella issues, 132 Patella subluxation/dislocation, 119 Patella tendon ruptures differential diagnosis, 105 early care, 105 history, 102, 103 physical examination, 103, 105 treatment recommendation, 106 Patient confidence, 131 Patient’s activity level, 56 Patient’s occupation, 59 Physical examination, 131 Pigmented Villonodular Synovitis (PVNS) physical examination, 127 treatment, 128 Pivot shift, 49 Popliteal artery injuries, 66 Posterior Cruciate Ligament (PCL) differential diagnosis, 68 history, 64, 65 physical examination, 65 ROM, 66 second visit and treatment recommendation, 70 treatment, 69, 70 Posterolateral ligament injury history, 74 physical examination, 74, 75

137 treatment, 75, 76 Post-menopausal females, 90 Pseudo-varus deformity, 75 Q Quadriceps isometrics, 8 Quadriceps tendon ruptures early care, 116 history, 112–114 physical examination, 114 treatment recommendations, 116 R Range of motion, 99 Recreational athlete, 45 Recreational sports, 44 Rehability, 58 Rest, Ice, Compression, Elevation (RICE) protocol, 8, 54, 69, 91 Range of motion (ROM) exercises, 10, 21 S Sherlock Holmes, 133 Soft tissue swelling, 6, 66 Superolateral approach, 9 Suprapatellar pouch, 47 Suprapatellar region, 6 Swelling reduction, 21 T Tenderness, 28, 100, 104, 126 Tibial tubercle injuries differential diagnosis, 100 early care, 101 history, 98, 99 physical examination, 99, 100 treatment recommendation, 101 Tissue laxity, 59

Index

138 U Unaffected knee, 132 V Valgus stress, 35 Varus knee, 88, 94 Varus stress, 75

W Weight-bearing progress, 123