CONTROVERSIES

in

KNEE INJURIES

David Stock BSc FRCS(Orth.) Dip SEM

Consultant Orthopaedic Surgeon

Lower limb arthroplasty and Sports Medicine

Northampton Sports Medicine and Science, 13th June 2017

Undergraduate

Royal Free Hospital School of Medicine

Post graduate

Royal National Orthopaedic Hospital Stanmore

Fellowship SPORTSMED.SA 2000

Diploma in Sports and Exercise Medicine 2013

2013

Northampton General Hospital 2001

Diploma in Sports and Exercise Medicine (DipSEM)

Rugby

Combined England Students World Cup side 1998

Saracens RFC

Honorary Orthopaedic Surgeon Northampton Saints

Ride London Surrey 100 Bike Ride 2016

London Marathon 2014

Golf, Tennis, Skiing

4 Orthopaedic surgeons General surgeon Psychologists Podiatrists with gait lab Ultrasound Shockwave therapy

BMI Three Shires

The Woodlands

CONTROVERSIES

in

KNEE INJURIES

“Is conservative better than surgical”

David Stock BSc FRCS(Orth.) Dip SEM

Consultant Orthopaedic Surgeon

Lower limb arthroplasty and Sports Medicine

Northampton Sports Medicine and Science, 13th June 2017

Case study 1

MG 49 Male

Winner National Championship for Ironman 9’30’’

Qualified for Kona (14.10.2017)

Last year ↑ discomfort during exercise Rt Knee

(?on/off for years)

Some rest Jan/Feb worked on biomechanics – trunk

control, running mechanics

Extensive shockwave (x15-20)

Examination

Poor alignment in shallow knee bend

No effusion

FROM knee

Meniscal signs -ve

Ligaments stable

Tender over distal pole of patella

FROM hip

Slight tightness of quads and hamstrings

Ober’s test +ve

Differential Diagnosis

Patella tendinopathy

Fat pad impingement

PFJ OA

(all of the above)

Management

Already had extensive physiotherapy

Time scale of Kona (14.10.2017)

MRI

Case study 2

JC 25M Royal Marine

2yo ago manoeuvres in Wales

Pain over front of knee

Rx Painkillers, Physiotherapy

Deployed to Bahrain 18/52

More Physiotherapy

MRI “tiny trace high signal deep to prox part

patella tendon”

Arthroscopy 16.5.2015

MRI July 2016

ESWT discussed “insufficient time for recovery if failed”

August Open surgery – no op. notes available

Awaiting medical discharge

Patella tendinopathy

AKA

• Jumper’s knee

• Patella tendinosis

• Patella tendinitis

Incidence Athletes

13-20%, 35-50% jumping athletes

Jumping, heavy landing

Rapid accel/deceleration

Basketball highest incidence

♂˃♀

22% asymptomatic athletes have U/S changes

Career ending

53% of elite athletes with condition

(cf injury in 20% of athletes)

Aetiology

Extrinsic

Training frequency, intensity, surface, footwear

Intrinsic

Patella height, malalignment, LLD, muscle imbalance,

ankle dorsiflexion, body habitus

Muscular flexibility

Patella morphology – impingement of inferior pole on

dorsal fibres

Risk factors of tendinopathies

Diabetics, ↑ cholesterol, sero –ve arthropathy

Pathology

Traditional

Inflammation and degeneration secondary to tensile

forces

Recent

Impingement and compressive forces causing degeneration

Lesion limited to dorsal fibres of proximal patella insertion

Maximal force 50-70°

?adaptive process secondary to impingement

Continuum Model

Reactive tendinopathy

Tendon dysrepair

Degenerative tendinopathy

All interchangeable

Many differing states at

once

Pain

Structure

Function

No inflammatory cells

High levels neurotransmitter glutamate (?source of pain)

Tendon expanded, increased mucoid degeneration, intra

tendinous calcification, fibrinoid necrosis.

Inflammatory cells not typically seen

Management

Diagnosis

Hx

EX

Ix

Rx

?????

Single leg decline squat test

25˚ decline board

Squat to 90˚

V I C T O R I A N I N S T I T U T E O F S P O R T A S S E S S M E N T (VISA)

1. For how many minutes can you sit pain free?

0 mins 100 mins 0-10

2. Do you have pain walking downstairs with a normal gait cycle?

strong severe no pain 0-10

3. Do you have pain at the knee with full active non-weightbearing knee extension?

strong severe no pain 0-10

4. Do you have pain when doing a full weight bearing lunge?

strong severe no pain 0 -10

5. Do you have problems squatting?

Unable no problems 0-10

6. Do you have pain during or immediately after doing 10 single leg hops?

strong severe no pain 0-10

7. Are you currently undertaking sport or other physical activity? 0 ❒ Not at all 4 ❒ Modified training ± modified competition 7 ❒

Full training ± competition but not at same level as when symptoms began 10 ❒ Competing at the same or higher level as when

symptoms began

8. Please complete EITHER A, B or C in this question.

8a. If you have no pain while undertaking sport, for how long can you train/practise?

NIL 1-5 mins 6-10 mins 7-15 mins >15 mins

8b. If you have some pain while undertaking sport, but it does not stop you from completing your training/practice for how long can you

train/practise?

NIL 1-5 mins 6-10 mins 7-15 mins >15 mins

8c. If you have pain which stops you from completing your training/practice for how long can you train/practise?

NIL 1-5 mins 6-10 mins 7-15 mins >15 mins

TOTAL VISA SCORE ❒

0-100

≤80 equals dysfunction

Minimally clinically significant difference 18

points

Imaging

Plain x-ray

Ultrasound

Areas of hypoechogenic signal

↑ tendon thickness

↑ vascularity and neovascularisation

MRI

↑ tendon thickness

Classification Stage 0 No pain

Stage 1 Pain on intense sports activity

No functional limitation

Stage 2 Pain ant beginning and after sports activity

Able to perform satisfactorily

Stage 3 Pain during sports activity

Difficulty performing at satisfactory level

Stage 4 Pain during sports activity

Unable to perform at satisfactory level

Stage 5 Pain during daily activity

Unable to perform at any level

Roels J. Patellar tendinitis(jumper’s knee). Am J Sports Med.1978;6:362-368

Management

Poor understanding of how the condition develops,

limited knowledge of risk factors.

Paucity of effective and time efficient Rx

Rx protocols derived from of other tendon pathologies

Management Non operative

Activity restriction, Ice, NSAID, Biomechanics, Stretching,

McConnell taping, Patellofemoral brace

• Eccentric strengthening (ECC)

b.d., 3x15 25° incline board, 12/52

• Heavy slow resistance training (HSR)

Squat, leg press, hack squat

x3/52, x4 sets, 15 max rep

Kongsgaard M. Scan Journ.of medical science in Sport 2009

Patella tendinopathy: Clinical Dx, load Mx and advice for

challenging case presentations.

Malliaras P. Cook J. J. Orth. Sports Physical therapy. 2015. 45(11). 887-98

Phase of rehabilitation Aim of treatment Intervention Example exercises

Pain management Reduce pain

Isometric exercises in mid-range as

tolerated. Reduce loading and

activity modification

Sustained holds on leg extension;

45 s, 4 repetitions, 2 times/day.

Strength progression

Improve strength Heavy slow resistance as tolerated

(isotonic)

Leg extension/press, 4 sets of 6-8

repetitions, 3-5 times/wk

Functional strengthening

Progressive resistance exercise

program, functional tasks, address

movement patterns, kinetic chain

and endurance training as required

Walk lunge with body weight or

extra weight, stair walking

Increase power

Increase speed of muscle

contraction, lower the number of

repetitions

Split squats, faster stairs, skipping

exercises

Energy-storage/stretch-shorten

cycle

Develop stretch-shorten cycle Plyometric exercises, graded

gradually

Jumping, deceleration and change

of direction tasks

Training sport-specific Drills specific to sport including

endurance training

Sports specific drills at set intensity

and duration

Maintenance Management of symptoms and

prevention of flare ups

Education, continue strength

training and manage loading as

tolerated

Continue leg extension strength or

Spanish squat exercise while

training and playing

Injections

Steroid only short term relief

Sclerosants

Polidocanol

33pts/42 tendons

VISA 51-62

Hoksrud A. Am J Sports Med 2006;34:1738-38

VISA

≤ 80 dysfunction

Min. Clin. Sign. Change 18 points

Autologous blood

44pts/ 47 knees

x2 injections, 4/52 apart

VISA 39.8→ 74.3

James SL. Br J Sports Med. 2007 Aug 41(8):518-21

PRP

Comparable with ESWT short term?

28 pts. x3 inj. 1/52 apart

MRI 1/12+3/12

Complete return to normal 16 pts

7 no RTS, 3 lower level, 1 change sport, 3→surgery

Significantly improved symptoms and function in athletes with chronic PT and

allowed for recovery to their presymptomic sporting level.

Charousset C. Am J Sports Med. 2014 Ap;42(4) 906-11

Extracorporeal shockwave therapy (ESWT)

No benefit over placebo, jumping athletes with

symptoms 3-12/12

Zwerver J. Am J Sports Med. 2011 Jun.39(6):1191-9

Comparable to surgery

Peers KH. Clin J Sport Med.2003 Mar. 13(2):79-83

Operative

(?stage 4, stage 5)

3/12 eccentric quads prior to surgery

Open

tendon, patella, both

drilling/debriding/excision distal pole of patella

54-100% success

return to elite sport 46-91%

no difference bony vs non bony

RTP 6-10 months

Closed (arthroscopic)

with/without bony procedures

debriding/excision distal pole of patella

RT sport 46-85%

RTP 2-6 months

20 pts. Distal pole resected.

Assessed 6/52, 3+6+12+24/12

Stage 0/1 in 18/20 patients

Lorbach O. Arthroscopy 2008; 24: 167-73

No difference surgical vs conservative (Grade 4)

Success rate (RTS no/mild pain)

45% surgical

55% eccentric

Bahr R Surgical treatment compared with eccentric training for patella

tendinopathy (Jumper’s knee): a randomised, controlled trial. JBJS

(Am) 2006; 88-A:1689-98

BASK Meeting 29th March 2017

Omega 3 1g daily

Ibuprofen 400mg tds

Vit D esp if bone oedema

Physiotherapy

Kongsgaard M. Scan Journ.of medical science in Sport 2009

Cook J. Physiotherapy management of patella tendinopathy (jumper’s

knee). J Physiotherapy Sept 2014. Vol 60 (3) 122-9

Injections

Steroid to fat

Dry needling /PRP

High volume strip

Patella strap, Shockwave

MG 49 Male

Winner National Championship for Ironman 9’30’’

Qualified for Kona (14.10.2017)

Set expectations

Omega 3 1g daily,Vit D

U/S guided injection

Ensure correct physiotherapy

Heavy slow resistance training

Patella tendinopathy: Clinical Dx, load Mx and advice for challenging case presentations.

Malliaras P. J. Orth. Sports Physical therapy. 2015. 45(11). 887-98

Closed surgery with resection of distal patella pole.

Case 3

AH 13 ♀

County hockey

Knee pain and swelling

September 2016

Both knees , mainly left.

Inferolateral aspect patella, sharp

Most of time

Some night pain

Aggravated by bending and exercise

Feels will lock

Recent growth spurt (September)

Ex

Orthotics for pes planus, Normal gait

Poor stability shallow knee bend with pain

Wasted VMO

Effusion – patella tap

No pain on PFJ movements, repetitive resisted led

extension reproduces pain.

Tenderness lateral to patella ligament

ligament and meniscal tests –ve

Poor ankle DF,

Tight hamstrings and quads

Ober’s +ve

Weak gluts

DDX

Fat pad impingement

???PFJ

ITB syndrome

Ix

MRI

B A R F

V O M I T

Brainless Application Of Radiological Findings

Victim Of Modern Imaging Technology

Rx

Wait and see

Scope reattach fragment

Microfracture

Microfracture + (scaffolds)

Osteochondral Autologous Transplantation

Cartilage regeneration (ACI/MACI)

Surgical treatments of cartilage defects of the knee:

Systematic review of RCT’s Devitt, B. Knee Vol 24. Issue 3, June 2017

Age 18-55

1-15cm lesions

10 RCI’s 861pts

4 MFx vs ACI

2 ACI, 2 same

3 MFx vs OAT

2 OAT, 1same

1 MFx vs BST Cargel

Same

All better than nothing

MFx never superior to other Rx’s

Poor long term F/U

Early results favour OATS/Cartilage regeneration

5+ years no difference

Prognosis worse lesions ˃ 2cm

Large lesions ˃ 4.5cm OAT, ACI˃ MFx

No single recommendation

Thank you