Knee Injuries: Trends & Advances

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Knee Injuries: Trends & Advances

September 23, 2021

1

PAMELA RAST, PHD, LAT, ATC

Dept. of Kinesiology

Athletic Training Program


I am an Athletic Trainer

Athletic trainers are health care professionals who collaborate with physicians to

optimize activity and participation of patients and clients.

Athletic training encompasses the prevention, diagnosis, and intervention of

emergency, acute, and chronic medical conditions involving impairment,

functional limitations, and disabilities.

Why me?

http://members.nata.org/


This lecture will:

• review knee anatomy

• discuss common knee injuries and sources of injury

related knee pain

• identify methods of prevention

• discuss common diagnoses

• review evidence-based assessment/screening and

treatment methods

What we will cover...


At the end of the presentation the participant will:

• be aware of common knee injuries in the WC setting

• understand common knee injury diagnoses

• know work related and non-work-related risk factors for

knee injury

• have knowledge of basic knee anatomy

Content Objectives


At the end of the presentation the participant will:

• have an awareness of the surgical and non-surgical

treatment interventions options for common knee injury

• understand best practice for use of treatment options

• have an appreciation of length of recuperation time

estimates by type of injury

Content Objectives continued


6

Scope of the

Problem:

Workplace

Statistics


Incidence rate -2.5 per 10,000 f-t workers (private industry)

Median days away from work -22 (38% of

cases <30 days)

8.81% of all Natures of Inj. Illness

reported in 2019 (Private Industry)

9.74% of all MSDs reported in 2019(Private Industry)

Source data: BLS Table R13 (2019)

2019 StatisticsBureau of Labor Statistics US Department of Labor (2021)

8


According to the National Safety Council Direct

and indirect costs associated with

knee injuries alone among

workers is estimated at $32,622 per claim.

Using 2019 numbers that’s

Annually

8

$2.5 Billion

Impact


Review of functional anatomy of the

knee and surrounding structures

Knee

Anatomy

9


Ligamentous Arrangement of the KneeAnterior View

10

1. Tibial collateral lig.

2. Medial femoral condyle

3. Posterior cruciate lig.

4. Anterior meniscalfemoral lig.

(Ligament of Wrisberg)

5. Anterior cruciate lig.

6. Lateral femoral condyle

7. Popliteus

8. Fibular collateral lig.

9. Biceps femoris tendon

10. Lateral tibial condyle

11. Lateral meniscus

12. Medial meniscus

13. Medial tibial condyle

Image Source: McMinn & Hutchings (1977)

condyle


Ligamentous Arrangement of the KneePosterior View

11

1. Tibial collateral lig.


3. Posterior cruciate lig.4. ----

5. Anterior cruciate lig.


7. Popliteus

8. Fibular collateral lig.9. Biceps femoris tendon



12. Medial meniscus


14. Ligament of Wrisberg

15. Proximal tibiofibular lig.


condyle

epicondyle


Ligamentous Arrangement of the KneeLateral View

12


7. Popliteus

8. Fibular collateral lig. (LCL)

9. Biceps femoris tendon





Discovered by 2 Belgian orthopedic surgeons)(Dr Steven Claes & Professor Johan Bellemans , 2012)

Located in center of the human knee

Present in 97% of population

may be responsible for injured knees giving way during exercise

New Ligament: Anterolateral Ligament (ALL)

13

Image source: www.terrafemina.com , Par Antoine Lagadec Publié le 7 novembre 2013

http://www.terrafemina.com/


Ligamentous Arrangement of the KneeMedial View

14

1. Tibial collateral lig. (MCL)


12. Medial meniscus




Menisci of the ® Knee

15

Transverse (meniscal) Ligament

Posterior menisco-meniscal Ligament

Medial Meniscus

Lateral Meniscus


A recently identified knee ligament,

thought to be present in 97% of

the human population is the:

A) MCL

B) PCL

C) ACL

D) ALL

REVIEW

QUESTION


A recently identified knee ligament,

thought to be present in 97% of

the human population is the:

A) MCL

B) PCL

C) ACL

D) ALL (Anterolateral Ligament)

REVIEW

QUESTION

ANSWER


Common Knee Injuries in the Work Setting

Common Structures/Conditions

OA

Anterior Knee Pain / Patellar Pain

ACL Tears

MCL tears

Meniscus tears

Extensor Mechanism

Dislocations & Fractures

18

Common MOI

Trauma

Crush

Direct Blow

Fall

Forced movement beyond normal ROM

Overuse (CTD)


Anterior

Knee

Pain

19

Iliotibial band syndrome


Anterior Knee Pain =

• Patellofemoral Pain Syndrome

• Chondromalacia Patella

• Abnormalities in the:

• Forces applied to the Kneecap

• Anatomy of the Knee Cap

Anterior (Front) Knee PainCommon Complaint


Pain in the front of the knee, underneath the knee cap (patella)

Pain going up or down stairs

Difficulty sitting with knees bent for a long period of time

• Movie theater sign

Swelling, catching, locking

Sense of knee cap (patellar) instability

Knee giving out

Anterior (Front) Knee PainSymptoms

21


one of the most common disorders of the knee

25% of knee injuries seen in a sports medicine clinic

insidious onset

ill-defined ache localized to the anterior knee behind the patella

Pain at the inferior pole of the patella

pain aggravated by compressive force

pain on palpation of patellar retinaculum

Patellofemoral Pain Syndrome / Patellofemoral Jt.

22

Image Source: https://www.physionow.ca/blog/knee-pain/patellofemoral-pain-syndrome/


Multifactorial

• abnormal patellofemoral

joint mechanics

• lower kinetic chain

alterations

• overuse

Patellofemoral Pain Syndrome / Patellofemoral Jt. MOI & Risk Factors

bony and structural abnormalities

iliotibial band tightness

abnormal patellar mobility

quadriceps muscle weakness

Q angle

23


No one standard physical exam or imaging

test

Treatment is focused on activity

modification and correction of specific risk

factors.

Nonoperative treatment is successful in the

majority of cases

Patellofemoral Pain Syndrome / Patellofemoral Jt. MOI & Risk Factors

24

Clarke’s Sign / Patellar Grind Test

Patellar Apprehension Test


“Jumper’s knee”

Work involving squatting, jumping from a height

Pain at the inferior pole of the patella

Repetitive microtrauma vs macrotrauma

Chronic/Nagging injury

Osgood Schlatter Disease Association?

Patellar Tendinitis / Patellofemoral Jt.

25


Age - > 30 yo

Gender – more common in men

Weight – more likely in overweight

individuals

Flexibility – tight quads

Conditioning – poor core stability around hip

& knee

Patellar Tendinitis / Patellofemoral Jt. Risk factors

26

Image Source: https://blog.runnics.com/us/uncategorized-us/common-injuries-runners/


The mainstay of Tx for patellofemoral jt. Problems is

REHABILITATION

Surgery indicated for patients with malalignment who

have failed conservative treatment

Patellar Tendinitis / Patellofemoral Jt. Treatment – General Principles

27

Image Source: Floyd E. Hosmer (1999) https://www.aafp.org/afp/1999/1101/p2012.html


Anti-inflammatories (Advil, Aleve)

RICE (Rest, Ice, Compression, Elevation)

Activity modification

Taping (McConnell)

Bracing

Return to work full duty around 6 weeks after PT

Patellar Tendinitis / Patellofemoral Jt. Treatment - Conservative

28


British Journal of Sports Medicine

• Review of 6 trials in favor of stem cell injections in KOA.

• high risk of bias • level-3 or level-4 evidence in favour of stem cell injections in KOA.

• “In the absence of high-level evidence, we do not recommend stem cell therapy for KOA”

Cochrane Review of stem cells for knees

• ongoing without results thus far

(Pas et al. 2017 & Cochrane Database https://doi.org//10.1002/14651858.CD013342)

Stem Cell Injections for Osteoarthritis of the KneeNote on Current Best -Practice

29

https://doi.org/10.1002/14651858.CD013342


Injury to

the ACL

30


>100,000/year

Females: 3-10x risk

Genetic predisposition?

Differences in:

• muscle firing patterns,

• landing

ACL InjuryEpidemiology

31

Image source: Vavken P., Murray M.M. (2013)

mailto:[email protected]


ACL

• prevents tibia from moving anteriorly

• Aids in anterior knee stability

• Aids in twisting, cutting activities

• Without an ACL there is risk of meniscus

and cartilage damage with recurrent

instability

PCL

• prevents tibia from moving posteriorly

ACL/PCLFunction

32


70%-noncontact

Injured by a combination of a sudden

stop with a quick twist

Hx

• Hear a ‘Pop’

• Pain

• Rapid onset swelling

• Unable to play

• Knee feels “unstable”

• Do not trust knee

ACLMechanism of Injury

33


Special Tests

Lachman

• 1+: 1-5mm

• 2+: 6-10mm

• 3+: >10mm

• quality of endpoint:

• ‘A’- firm

• ‘B’- soft

MRI (Gold Standard)

ACL InjuryDx

34

Image source:

https://breddydotorg.files.wordpress.com/2015/04/lachman-test-

lateral-view-can-see-both.jpg?resize=260%2C176


ACL does not heal

Any active person with an ACL tear should consider having it

reconstructed

PREHAB PRIOR TO SURGERY FOR 4-6 weeks

• Get back full ROM

• Decrease swelling

• Improve muscle strength prior to surgery

ACL TearsTx

35


Limited blood supply to ACL - cannot be repaired with stitches

Graft required(tissue to be used as a new ACL)

• Graft options:

• Autograft

• Own Patellar Tendon

• Own Hamstring Tendons

• Allograft

• Cadaver Patellar Tendon or Hamstring Tendons

• All do well, patient choice in many cases

ACL TearsTx

36


Walk on it right away after surgery with Brace

First 6 weeks

• Brace on at all times, including Physical Therapy. Goal : Range of motion

exercises only

6-12 weeks

• No brace, range of motion and add strengthening exercises

3 months – starts running

6 months – RTP / RTW

6 mo-1yr back to competitive sports, knee feels normal

ACL Rehabilitation

37


Patellar tendinitis & patellofemoral

joint dysfunction pain most often

occur in:

A) 18 - 25 yo

B) 30 + yo

C) 50 + yo

D) 60 + yo

REVIEW

QUESTION


Patellar tendinitis & patellofemoral

joint dysfunction pain most often

occur in:

A) 18 - 25 yo

B) 30 + yo

C) 50 + yo

D) 60 + yo

REVIEW

QUESTION

ANSWER


Injury to

Collateral

Ligaments

40

Image Source: Ethos Health - 20 Oct 2016, http://www.ethoshealth.com.au/blog1/medial-lateral-collateral-ligament-injuries-mcl-and-lcl


Primary stabilizer to valgus force.

Secondary stabilizer to Anterior translation.

Resist external rotation.

MCL and ACL have a codependent

relationship.

Medial Collateral / Tibial Collateral Ligament (MCL)Function

41


History

• Classic Mechanism: Isolated Valgus moment to

knee.

PE

• Complete Knee Exam

• Examine MCL with the knee both in full

extension and at 30 degrees of flexion.

• Valgus Stress with knee at 30 degrees of flexion

causes pain or instability of medial knee.

MCLDiagnosis

42


Collateral Ligament InjuryCommon Mechanism

43

Image Source: PHYSIO FIT ADELAIDEhttps://www.google.com/url?sa=i&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjIjLXd1cfcAhVRL6wKHTfdBAcQjRx6BAgBEAU&url=http%3A%2F%2Fwww.physiofitadelaide.com.au%2Fblog%2F3-ways-female-athletes-move-that-puts-them-at-greater-risk-of-sustaining-an-acl-injury-part- &1&psig=AOvVaw1cAS9m03H9aBSbTTJnzoud&ust=1533068900837384

And Amoczky et al. (1977)

External

rotation of

tibia

Medial rotation of femur

Valgus force

Varus force

https://www.physiofitadelaide.com.au/


I - Stretching of fibers. Localized TTP. No instability.

II - Disruption of Fibers. Mild to moderate instability.

III - Complete disruption of ligament. Gross instability.

MCL InjuryGrading System

44


X-Ray

• May demonstrate avulsions.

MRI

• Confirms Diagnosis

• Evals. other ligaments, cartilage.

Collateral LigamentImaging

45

Image Source Jordan Renner, Division of Radiologic Science at UNC-Chapel

MCL Avulsion


The injured MCL heals predictably without repair regardless of its grade.

Non-op management of all MCL tears is considered standard practice.

Grade I and II Injuries

• Non-Surgical Treatment

• Crutches until symptoms improve, WBAT, ROM.

• Edema Control - Ice, Compression, Massage.

• NSAIDS

• Hinged knee brace

• Speeding Recovery

• Good control of swelling can decrease the amount of time for full recovery of motion and

strength.

Treatment of Isolated MCL Injury

46


Grade III MCL

• Non-Surgical Rehab

• Brief period of immobilization

• Start ROM when initial swelling subsides.

• May need a longer period of protected weight bearing.

Persistent valgus instability

• May consider for early surgical reconstruction.

Treatment of Isolated MCL Injury

47


Proximal MCL tears at the femoral insertion

more common than at the distal tibial insertion.

In general, femoral side injuries tend to heal

better than tibial side or midsubstance injuries.

Tibial End vs. Femoral End MCL Injury

48

Femur

Midsubstance

Tibia


Usually do not require MCL reconstruction

Rehab the medial side and achieve full ROM then do ACL

reconstruction.

However, if valgus instability persists after rehab then

reconstruction of ACL and MCL should be considered.

ACL + MCL

49


If significant posterior subluxation is present following

injury, both ligaments should be reconstructed acutely.

If the Joint is well reduced, can treat MCL non-surgically

with bracing. PCL can be reconstructed when full ROM is

achieved, and valgus stability is restored.

If valgus instability persists, reconstruct PCL and MCL.

PCL + MCL

50


Chronic injury results when the MCL complex loses its potential for spontaneous healing.

Usually occurs 3 to 4 months following the initial injury.

Can develop secondary ligamentous instabilities or secondary limb malalignment.

Valgus deformity of limb secondary to chronic MCL

• Osteotomy may be required at time of MCL reconstruction.

Surgical Options

• POL Advancement

• Proximal Capsular Advancement

• Distal Capsular Advancement

• Semimembranosis advancement

• Allograft

Chronic MCL Injury

51


Injuries to

Meniscus

52


Load Bearing

Stability

Lubrication and nutrition

Protects articular cartilage underneath

meniscus

MeniscusFunction

53

Image Source: The Steadman Clinic https://www.thesteadmanclinic.com/patient-

education/knee/meniscus-injuries

https://www.thesteadmanclinic.com/patient-education/knee/meniscus-injuries


Meniscus InjuryCommon Mechanism

54


Twisting/squatting activities

Swelling develops overnight

Associated with ligament injuries 20-60%

Mechanical symptoms of catching, clicking,

locking common

Meniscal InjuriesHistory

5565


Repair to save meniscus function

Meniscus has poor blood supply

Tear has to be in “red zone”

Meniscal injuries:

56


Older patient

• New injury vs degenerative tear over time

Treatment usually with partial meniscectomy

Rehabilitation depends on debridement vs

repair

Partial menisectomy

• 6wk - 3month recovery depending on repair vs

debridement

Meniscal Injuries:Treatment

57


A longitudinal meniscal tear within

the red zone should be repaired via

A) Partial meniscectomy

B) Suture

C) Total meniscectomy

D) Removal of torn flap with burr

REVIEW

QUESTION


A longitudinal meniscal tear within

the red zone should be repaired via

A) Partial meniscectomy

B) Suture

C) Total meniscectomy

D) Removal of torn flap with burr

REVIEW

QUESTION

ANSWER


Knee

Dislocations

and

Fractures

60

Image Source: Gupta, et all., (2007)


High association of injuries

• Ligamentous Injury

• ACL, PCL, Posterolateral Corner

• LCL, MCL

• Vascular Injury

• Intimal tear vs. Disruption

• Obtain ABI’s → (+) → Arteriogram

• Vascular surgery consult with repair within 8hrs

• Peroneal >> Tibial N. injury

Knee Dislocations

61

Image Source: Gopal, S. Knee Dislocations. Slide Share Presentation Aug 2, 2016. Retrieved from: https://www.slideshare.net/shyamgv/knee-dislocation-64627037


History

• MVA, fall onto knee, eccentric loading

Physical Exam

• Ability to perform straight leg raise against gravity (ie,

extensor mechanism still intact?)

• Pain, swelling, contusions, lacerations and/or abrasions

at the site of injury

• Palpable defect

Patella Fractures

62

Image Source: Florian Gebhard, P. & Kregor, C.O.

Oliverhttps://surgeryreference.aofoundation.org/orthopedic-

trauma/adult-trauma/patella/further-reading/patient-

examination


Direct Injury

• (Comminuted Patella fx)

Indirect Injury

• (Transverse Patella Fx)

Patella FracturesMechanism of Injury:

63


Allows prediction of treatment

Transverse

Marginal

Vertical

Stellate

Comminuted

Osteochondral

Patella FracturesTypes

64


Greater than 2mm articular displacement

Greater than 3mm fragment separation

Osteochondral fragment with displacement into joint

Operative TreatmentIndications for Surgery

65


Surgical Treatment

1. Modified tension band wiring

2. Cerclage Wire

3. Patellectomy

Rehab

• 6 weeks in Knee Immobilizer or Cast

• Deskwork only x 6weeks

• PT x 3-4 months

• MMI at 3-4months

Patella FracturesTx & Rx

66

1.

2.

3


Quadriceps Tendon Rupture

67

HX:

• Eccentric Injury to Knee

• usually patient over 40 y.o.

PE:

• Palpable Defect in tendon

• Unable to perform a straight leg raise.

TX:

• Direct repair to bone


Quadriceps Tendon RuptureRehab

68

› Cylinder cast or Knee immobilizer

› Weight bearing as Tolerated

› Isometric exercises start around 6 weeks with

straight leg raises up to 45degrees of flexion

› 8-10 weeks increase ROM to Full

› MMI at 3-4 Months

Post-op Brace w/ ROM Lock

Straight Knee Imobilizer


HX:

• Usually under 40 Y.O.

• Eccentric Contraction to Knee

PE:

• Unable to Perform Straight Leg raise

TX:

• Surgery - Repair Tendon to Bone

69


Isometric Hamstring and Quadriceps exercises begun immediately

TTWB first 2-3 weeks

At 2-3 WEEKS active flexion and passive extension started initiated

6 weeks WBAT, resistance exercises initiated

Delay competitive sports 4-6 months post op

MMI 4 months

Patellar Tendon RupturePost Op Rehab

70


20-30 y/o

female

Valgus Load / Flexed/Externally Rotated Knee

Dislocations occur at 60-70 flexion

Lateral >>> Medial

Patellar Dislocation

71


Non-Operative- 2 schools

• Immobilization and Rehab

• 6 weeks strict Immobilization in cylinder cast/Immobilizer

• Aggressive PT to regain motion/strength

• Recurrent instability--40-50%

• Functional Treatment

• Early ROM with patellar bracing

• Better patient scores, less instability (26%)

Patellar DislocationsTx

72

Image Source: van Gemert, et al. (2012)


Operative Treatment: Rare

Acute

• Repair of the MPFL

• (Repair of the femoral attachment)

Chronic

• Lateral Retinacular Release

• Proximal vs Distal Realignment

• Rehab : 3-4 Months

Patellar DislocationsTx

73


History:

• Age and mechanism extremely important

• Split or wedge fractures in younger patients with stiffer bone

• Depression fractures- older/weaker bone

Associated injuries

• Ipsilateral femoral and tibial fractures

• Cruciate and collateral ligament injuries

• Meniscal tears

• 50% of plateau fractures have meniscus

• Avulsions of intercondylar eminence

Tibial Plateau Fx

74


XRAY

CT SCAN

?MRI

Tibial Plateau FxDx

75


Goals

Restore joint congruity

• Maintain limb alignment

• Allow early stable knee

motion

Tibial Plateau Fx

76

Non-operative treatment

Non-displaced fractures

Minimally displaced lateral plateau fractures

Advanced osteoporosis

Goal not anatomic reduction but restoration of axial alignment and knee motion

No more than 7 degrees malalignment

No varus/valgus instability greater than 5 to 10 degrees

Fractures with less than 3mm articular displacement


Absolute indication for surgery

Open plateau fractures

Fractures associated with

compartment syndrome

Most displaced bicondylar

Fx Displaced medial

condylar Fx

Lateral plateau fractures with

joint instability

Tibial Plateau Fx

77

Post-Op Rehab

Non WB x 6 Weeks

Rehab for ROM – 0-6

weeks

WBAT at 6 weeks

Strengthening at 2-3

Months

MMI at 4-6 Months


Lower extremity injuries most common

Incidence of total knee inj. decreasing. However, % sprains/strains, tears remains

constant

Patellofemoral symptoms treated conservatively if at all possible

Tendon ruptures, grade II ACL/ PCL tears, meniscal tears & patellar fx are

treated surgically

Isolated MCL tears are treated conservatively

Tibial plateau fx conservative or surgical

In Summary

78


Diagnosis

• Orthopedic special tests for initial diagnosis

• X-ray to diagnose associated boney injury

• MRI to confirm diagnosis

MMI

• Fx: 4-6 months

• Ligament: 6-12 months

• Meniscus: 6wks – 3 months

In Summary

79


QUESTIONS ?

80


THANK YOU !THANK YOU !

[email protected]


In the Corporate/Industrial Setting Athletic Trainers:

• possess confidant evaluation skills, and an understanding of orthopedic

protocols for acute, chronic and post surgical rehabilitation.

• perform an ergonomic assessment of both static and dynamic activities, establish

functional capacity exam standards

• fit employees with proper personal protective equipment (PPE),

• develop a line of communication when dealing with an employee incident

• develop and record an accurate assessment of job duties & instruct employees in

proper task performance

• understand established safety issues and OSHA guidelines

• professionally research topics, create a presentation and present material to

pertinent parties

http://members.nata.org/


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Knee Injuries: Trends & Advances

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