Presenting the Medial Knee

Transcription

Presenting the Medial Knee
7 Workshop Objectives
1.
2.
3.
4.
5.
6.
7.
You will get a review of the anatomy of the medial
knee
You will get a review assessment techniques for
injuries to the medial knee
You will pick up a tip or two on assessment
You will pick up a tip or two in teaching this topic
I will introduce research that is important to ME
I will get you thinking MY way
Leave with the feeling WE have not wasted 45
minutes
Anatomy Review of the Medial Knee

Bones
Tendons
Ligaments
Meniscus
Injury to the Medial Knee
Sprains and Strains

Assessment Æ make a clinical judgment about
the degree of injury

1st degree
2nd degree Sprains and Strains
3rd degree
GOALS are based on the degree of injury
Medical referral is based on the degree of injury
Meniscal Tears
Other (bursitis,
nerve involvement, etc.)
MCL Sprains - Epidemiology

“The MCL is the most commonly injured ligament…”
(Ireland, 1999, JAT)

MCL most common knee injury in soccer and
basketball (Arendt, 1999, JAT)

The MCL sprain is the most prevalent knee injury in
the general population (Add ACL and MCL = 90% of knee
injuries). Miyasaka KC, Daniel DM, Stone ML, Hirshman P. The Incidence of Knee Ligament Injuries
in the General Population. The American Journal of Knee Surgery. 1991; 4 (1):3-8.

500 knee injuries Æ frequency of knee injuries:
ACL, 63% MCL, 44% PCL, 7% LCL, 4%
Combination Injuries Æ Meniscal Tears, etc.
Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy of kinematics of the lateral
collateral ligament of the knee. AJSM. Nov-Dec 2000; 28 (6):869-878.
Evaluation and Assessment of
Medial Knee Injuries

HISTORY
INSPECTION – OBSERVATION
PALPATION
The evaluation relies
on the expertise of
SPECIAL TESTS
PROM, AROM, MMT
Stress Testing
Etc.
Arthrometry

The LigMaster
the clinician to assess
the MCL sprain given
subjective
information and
performing more
objective special
(stress) tests.
Evaluation of the Medial Knee
HISTORY

What happened/MOI?
Direct blow from the side Æ Collaterals
Torsion, rotation, “twisting” Æ Cruciates,
Collaterals, Menisci
Noises?
Sensations?

“Giving way” Æ Tendonitis or Meniscus
“Sharp/Knife-like Under Patella” Æ Chondromalacia
“Numb” Æ Nerve (burning, tingling, etc.)

UH OH!!
Arnheim & Prentice, Principles of AT, 9th ed
MOI = Blow to the
outside of the knee with
or without torsion
HISTORY

When did it happen, onset
PMH
Sensations felt – PAIN?
Provocation, Quality, Radiating/Referred, Severity
(1-10), Timing
Pin-Point-Pain

Training, surfaces, mileage (10% rule), shoes,
etc.
OBSERVATION

Compare Bilaterally
Gait
FWB & PWB
Antalgic gait
Gait deviations

Deformity
Swelling, edema, effusion, ecchymosis
Atrophy
PALPATION

Palpate bones –
compare bilaterally
Æ R/O fx &/or
dislocation
IF FX or
DISLOCATION
IS SUSPECTED
Æ splint (ice), MD
Referral
PALPATION
Pes anserinus tendons =
Sartorius, Gracilis,
Semitendinosus
+ Semimembranosus
RANGE OF MOTION

Can palpate tendons at this time
Stabilize legs to isolate joints
Compare bilaterally
AROM Æ PROM Æ Goniometer
MMT Æ Make Test or Break Test
SPECIAL TESTS

Anterior Drawer Test = ACL stability

Slocum Drawer Test – adds rotation to ADT
Ex Rot Æ AMRI (ACL + MCL + PMC)
15° External
Rotation

ACL decreases ant mvt of
femur (86% and medial
displacement (30%)
PCL decreases post mvt of
femur (90%) and lateral
displacement (36%)
Posterior Drawer Test = PCL

Huston’s Test = adds rotation to PDT
Internal Rotation Æ PMRI (PCL + MCL + AMC + POL)
Evaluation of the Medial Knee - SPECIAL TESTS
Valgus Stress Test

In 0 ° (full extension)
= MCL + ACL,
PCL, PM capsule,
POL, etc.)
And somewhere
between 5 - 30°
flexion = MCL and
medial capsule
Evaluation of the Medial Knee - SPECIAL TESTS
Valgus Stress Test

Amount of opening at the joint during valgus
stress test compared to the unaffected knee
0-5mm = mild 1+ (very little instability,
tenderness, firm end point)
5-10mm = mod 2+ (instability in flexion and
pain!)
>10mm = severe 3+ (instability even in
extension, no end point)
Special Tests - Meniscal Tears

McMurray’s Test: Ex rotation of tibia + valgus stress Æ
extension of the knee Æ click or pain over medial meniscus =+

Apley’s Compression/Distraction Tests

Fox Test
SPECIAL TESTS

Patellar Tests

Apprehension Test –
Subluxation, Dislocation
Patellar/Femoral
Compression Test (Clark’s
Sign) & Crunch Test
Q Angle Measurement
Plica Test
Functional and Sports
Specific Tests
Evaluation of the MCL
Summary

The severity of MCL injury is based on point
tenderness, swelling over the soft tissue, and
findings gained by performing special tests.
Evidence Based Practice Æ My Dissertation
Questions

Does Wolff’s law apply to ligaments?
“Bone
and soft tissue will respond to the
physical demands placed on them, causing
them to re-model or realign along lines of
tensile force”

Prentice, W. (2004). Rehabilitation Techniques,
pg. 41.
Is a person’s left leg and right leg the same?
Do people have a dominant leg? Do athletes?
More Questions

Do males have stronger bones, tendons, and/or
muscles than women?
Do males have stiffer ligaments than females? So
stronger joints?
What if the MCL is the same in males and females?
Does that mean the ACL is the same in males and
females?
Medial Collateral Ligament

Attachments:

Just inferior to the
adductor tubercle on the
femoral epicondyle
Medial tibial flare
2 Portions

Superficial = Tibial
collateral or MCL
Deep = medial ligament
or capsular ligament Æ
attaches to medial
meniscus
Deep portion of MCL
attaches to medial meniscus.
Posterior aspect of superficial
MCL blends into deep PCL
and semimembranosus
muscle, which also attaches to
the medial meniscus
Functions:
Valgus
stress
Tibial external
rotation
Tibial anterior
translation

Different knee
positions matter!
Knee position changes the function
of the MCL
In extension:
Superficial MCL is taut
In flexion: anterior MCL is
taut, posterior is slack
MCL SPRAIN
The Valgus Stress Test

The common MOIs for injury to the MCL
Direct hit (force) on the outside of the knee (valgus
stress)
Outward rotational force

Therefore, the position of the knee when performing the
Valgus Stress Test is:
1. Full Extension
2. Flexed 20°
25°
30°
How much and why?
AUTHOR(S)
1. Shultz, S.,
Houglum, P.,
Perrin, D.
Full Ext =
MCL, PMC
+ ACL,
PCL, POL,
medial
Quads
2. Starkey, C.,
Ryan, J.
TEXTBOOK
PUBLISHER
REF
Assessment of Human Kinetics
Athletic
None
2000
Injuries
Flexed = MCL
+ PCL, Medial
Capsule, Post.
Oblique Lig.
Evaluation of
Orthopedic
and Athletic
Injuries (2nd
Ed.)
Add external
rotation of tibia
= ↓ stress on
PCL
Add internal
rotation of
tibia = ↑ ACL
and PCL stress
and ↓ stress to
MCL
F.A. Davis
2002
References
Norkin and
Levangie,
1992.
DEGREES
OF
FLEXION
20 - 30°
flexion
25° flexion to
isolate the
MCL
AUTHOR(S)
3. Arnheim, D.,
Prentice, W.
4. Konin, J.,
Wiksten, D.,
Isear, J.,
Brader, H.
5. Hoppenfeld, S.
TEXTBOOK
PUBLISHER
Principles of
McGraw-Hill
Athletic
Training, (10th 2000
Ed.)
Special Tests
for
Orthopedic
Examination
(2nd Ed.)
Physical
Examination
of the Spine
and
Extremities
Slack Inc.
2002
AppletonCentury-Crofts
1976
REF
References
Lynch and
Henning, 1995.
DEGREES OF
FLEXION
30° flexion in
text, 20 - 30° in
Table (page
528)
References
McClure,
20 – 30° flexion
Rothstein, and
Riddle, 1989 &
Smith and Green,
1995
No references
“…knee flexed
just enough so
that it unlocks
from full
extension”
The LigMaster Device and Software

Sport Tech, Inc.,
Charlottesville, VA
Joints: ankle, knee,
shoulder, elbow
Telos device used in
radiology for Graded
Stress Radiography
(GSR)
The LigMaster Device and Software

Pressure Actuator set at
joint line
Linear decoder detects
displacement
Plots force/strain curve
Æ SLOPE

F = Ao E

Modular elasticity =
stiffness Æ laxity
Left Vs. Right
Apparent Ligament Extension, mm
LigMaster Data Summary
5
Name: PAA 38,
Last seen: Thu Jul 01 2004
14
10
15
20
25
30
35
40
PAA 38,
13
Test: Right
Knee MCL
Thu Jul 01 2004 08:32
Title: full ext 1
Test
Right Knee MCL
Jul 01 2004 08:32
full ext 1
11
10
Force, dN
Test analysis:
x-intercept = 0.02
Slope = 19.98
12
9
8
7
6
Comparison: Left
Knee MCL
Thu Jul 01 2004 08:41
Title: full ext 3
Comparison analysis:
x-intercept = 0.04
slope = 20.19
5
Comparison
Left Knee MCL
Jul 01 2004 08:41
full ext 3
4
3
2
1
0
0.05
0.1
Knee MCL analysis:
Test ligament slope 1.04% less than comparison
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0.55
Ligament Strain: λ−1/λ2
0.6
0.65
0.7
0.75
0.8
0.85
Same knee, one flexed 20°
Apparent Ligament Extension, mm
LigMaster Data Summary
5
Name: PAA 38,
Last seen: Thu Jul 01 2004
14
10
15
20
25
30
35
40
PAA 38,
13
Test: Right
Knee MCL
Thu Jul 01 2004 08:32
Title: full ext 1
Test
Right Knee MCL
Jul 01 2004 08:32
full ext 1
11
10
Force, dN
Test analysis:
x-intercept = 0.02
Slope = 19.98
12
9
8
7
6
Comparison: Right
Knee MCL
Thu Jul 01 2004 08:36
Title: 20 d flex 2
Comparison analysis:
x-intercept = 0.01
slope = 16.97
5
Comparison
Right Knee MCL
Jul 01 2004 08:36
20 d flex2
4
3
2
1
0
0.05
0.1
0.15
Knee MCL analysis:
Test ligament slope 17.72% greater than comparison
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0.55
Ligament Strain: λ−1/λ2
0.6
0.65
0.7
0.75
0.8
0.85
Position of Knee Study Results
Overall: F(4,44) = 19.57, P< .001
T-Tests: 0 -10° no difference
0 -10° & 15° - 20° different
15° - 20° no difference
* = diff from 0-10°
Knee Position
Mean + SD
0°
21.51 + 2.88
5°
21.00 + 2.17
10°
19.83 + 2.22
15° *
18.53 + 2.17
20° *
17.22 + 2.55
20
*
*
15
10
5
0
0
5
1
1
2
d
d
0d
5d
0d
Summary

Medial knee injuries are prevalent in athletics, the MCL is the
most often sprained ligament
Evaluation and assessment of medial knee injuries includes
taking a thorough history, good observation and palpation
skills, and being able to perform special tests
The Valgus Stress Test seems to be a valid test and fairly
reliable but authors don’t agree on the specifics of it
Arthrometry may be helpful in gaining more objective
information regarding the extent of injury and healing of a
ligament after injury
Management and rehabilitation should follow an established
progression and should be based on the principles of tissue
healing. Return to Play should be determined by criterion
which includes both subjective and objective information
Workshop Objectives
Review the anatomy of the medial knee
Review assessment techniques for injuries to the medial
knee
Pick up a tip or two on assessment
Pick up a tip or two in teaching this topic
Introduce research that is important to me
To get you thinking my way
Leave with the feeling we have not wasted 45 minutes
Resources

Andrews, J., Harrelson, G., Wilk, K. (2004). Physical Rehabilitation of the Injured Athlete,
3rd Ed. , Philadelphia: Saunders
Arnheim,D., Prentice, W. (1997). Principles of Athletic Training, Ed 9, Boston: McGrawHill Company. Photo CD
AND 10th Edition (2000) Text
Baker, C. Editor (1995).The Hughston Clinic Sports Medicine Book, Baltimore: Williams &
Wilkins
Denegar, C., Saliba, S., Saliba, E. (2004) Therapeutic Modalities from J. Hertel and
C.R. Denegar, 1998, “A rehabilitation paradigm for restoring neuromuscular control
following athletic injury,” Athletic Therapy Today 3 (5): 13–14.
Konin, J., Wiksten, D., Isear, J., Brader, H. (2002). Special Tests for Orthopedic
Examination, 2nd Ed. Thorofare, NJ: SLACK, Inc.
Prentice, W. (2004). Rehabilitation Techniques, 4th Ed. Boston: McGraw-Hill Company
Shultz, S., Houglum, P., Perrin, D. (2000). Assessment of Athletic Injuries, Champaign, IL:
Human Kinetics
Starkey, C. Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries, 2nd Ed.
Philadelphia: F.A. Davis Company
VanDeGraaff, KM, Crawley, JL (1999). A Photographic Atlas for the Anatomy &
Physiology Laboratory. Englewood, CO: Morton Publishing Company.
WWW.Despair.com