Soccer Knee Injuries and Exam Ben Kittredge, MD Ben Kittredge, MD Commonwealth Orthopaedics...

Soccer Knee Injuries and Soccer Knee Injuries and ExamExam

Ben Ben Kittredge, Kittredge, MDMD

CommonwealCommonwealth th OrthopaedicsOrthopaedics

Knee AnatomyKnee Anatomy

Pediatric Knee InjuriesPediatric Knee Injuries

Acute (event Acute (event occurs)occurs)

Chronic (no event)Chronic (no event)

Acute InjuriesAcute Injuries

What happened?What happened? Non-contact twist?Non-contact twist? Did the knee swell Did the knee swell

up right away?up right away? Hear or feel a Hear or feel a

“pop” ?“pop” ? Able to continue Able to continue

playing?playing?

Acute Knee InjuriesAcute Knee Injuries

Ligament injury Ligament injury (ACL, MCL)(ACL, MCL)

Meniscus tearMeniscus tear Fracture/Bone Fracture/Bone

bruisebruise Patellar dislocationPatellar dislocation

Knee ExamKnee Exam

InspectionInspection Range of motionRange of motion Is there an Is there an

effusion?effusion? Joint line Joint line

tendernesstenderness StabilityStability

InspectionInspection

ErythemaErythema Cellulitis?Cellulitis? Septic prepatellar Septic prepatellar

bursitisbursitis

Range of MotionRange of Motion

Locked knee?Locked knee?

EffusionEffusion

Is it an effusion?Is it an effusion?

Prepatellar bursitis Prepatellar bursitis

Effusion PresentEffusion Present

ACL tearACL tear Patellar dislocationPatellar dislocation Fracture or Bone Fracture or Bone

bruisebruise

No EffusionNo Effusion

MCL tearMCL tear Meniscus tearMeniscus tear ContusionContusion

Stability Exam: Anterior-Stability Exam: Anterior-PosteriorPosterior

Lachman’s Lachman’s ACL TearACL Tear

Stability Exam: Anterior-Stability Exam: Anterior-PosteriorPosterior

Posterior drawerPosterior drawer PCL tearPCL tear

Stability Exam- Medial and Stability Exam- Medial and LateralLateral

Valgus stressValgus stress MCL tearMCL tear

Stability Exam- Medial and Stability Exam- Medial and LateralLateral

Varus StressVarus Stress LCL tearLCL tear

Knee ExamKnee Exam

Joint line Joint line tendernesstenderness

Meniscal tear?Meniscal tear?

Patellar ExamPatellar Exam

Palpate medial and Palpate medial and lateral patellar lateral patellar facetsfacets

Chondromalacia Chondromalacia patellapatella

Tendon ExamTendon Exam

Patellar tendonPatellar tendon Quadriceps tendonQuadriceps tendon Iliotibial bandIliotibial band Tibial tubercleTibial tubercle

XrayXray

May show fractureMay show fracture Growth plate Growth plate

statusstatus Often normalOften normal

XrayXray

Is it normal?Is it normal?

MRIMRI

ACLACL Patellar Patellar

DislocationDislocation Fracture or Bone Fracture or Bone

bruisebruise

MRIMRI

Quality of MRI Quality of MRI variesvaries

Radiologists Radiologists expertise variesexpertise varies

ACL InjuriesACL Injuries

400,000 400,000 reconstructions reconstructions per year in the USper year in the US

Females 4 times Females 4 times more likely to tear more likely to tear ACL with non-ACL with non-contact injurycontact injury

ACL Tears-PreventionACL Tears-Prevention

High intensity High intensity plyometrics, plyometrics, balance training, balance training, and strengtheningand strengthening

Neuromuscular Neuromuscular FeedbackFeedback

Treatment-ACL Tear-Treatment-ACL Tear-Growth Plates ClosedGrowth Plates Closed

Patellar tendonPatellar tendon HamstringHamstring AllograftAllograft

ACL tear-Growth Plates ACL tear-Growth Plates OpenOpen

BraceBrace Physeal sparing Physeal sparing

reconstructionreconstruction

Patellar Dislocation Patellar Dislocation HistoryHistory

Twisting injuryTwisting injury CollisionCollision May not know May not know

patella dislocatedpatella dislocated Immediate Immediate

swellingswelling Can’t playCan’t play

Patellar Dislocation Patellar Dislocation ExamExam

Big effusionBig effusion Patellar Patellar

apprehensionapprehension Medial retinacular Medial retinacular

painpain

Patellar DislocationPatellar Dislocation

XrayXray


MRIMRI


Loose Body – Loose Body – ArthroscopyArthroscopy

Brace?Brace? RehabRehab Return to play Return to play

when comfortablewhen comfortable

Fracture or Bone Bruise Fracture or Bone Bruise HistoryHistory

CollisionCollision FallFall Non-contact twistNon-contact twist

Fracture or Bone Bruise Fracture or Bone Bruise ExamExam

EffusionEffusion May or may not be May or may not be

able to localize able to localize painpain

Inability to bear Inability to bear weightweight

Bone BruiseBone Bruise

Xray normalXray normal Diagnose by MRIDiagnose by MRI Usually back to Usually back to

sports in 4-6 weekssports in 4-6 weeks

FractureFracture

XrayXray

Fracture TreatmentFracture Treatment

6-12 weeks to heal 6-12 weeks to heal Brace?Brace? Cast Cast SurgerySurgery

MCL Tear HistoryMCL Tear History

Valgus injuryValgus injury May or may not May or may not

have contacthave contact Pop?Pop? May keep playingMay keep playing May not swell right May not swell right

awayaway

MCL Tear ExamMCL Tear Exam

Medial joint line Medial joint line painpain

Opening with Opening with valgus stressvalgus stress

No effusionNo effusion

MCL Tear ImagingMCL Tear Imaging

Xray-normalXray-normal MRIMRI

MCL Tear TreatmentMCL Tear Treatment

Brace for 2-6 Brace for 2-6 weeksweeks

Pass functional Pass functional test to playtest to play

Surgery if off tibiaSurgery if off tibia

Meniscal TearMeniscal Tear

History of twisting History of twisting injuryinjury

Meniscus Tear ExamMeniscus Tear Exam

Swelling may or Swelling may or may not be presentmay not be present

Joint line painJoint line pain Locked knee?Locked knee?

Meniscal TearMeniscal Tear

Locked kneeLocked knee Urgent knee Urgent knee

arthroscopyarthroscopy

Meniscus RepairMeniscus Repair

Non-weight Non-weight bearing 6 weeksbearing 6 weeks

Sports in 4 monthsSports in 4 months

Meniscus ResectionMeniscus Resection

Sports in 3 weeksSports in 3 weeks

Chronic InjuriesChronic Injuries

Chondromalacia Chondromalacia patellapatella

Osgood-Schlatter Osgood-Schlatter DiseaseDisease

Stress FractureStress Fracture Osteochondritis Osteochondritis

Dissecans Dissecans

Chondromalacia PatellaChondromalacia Patella

Poorly localized Poorly localized anterior knee painanterior knee pain

Dull, aching painDull, aching pain Worse with Worse with

jumping, climbing, jumping, climbing, squattingsquatting

ExamExam

Point tender at Point tender at medial patellar medial patellar facetfacet

View patellar View patellar trackingtracking

Normal exam-think Normal exam-think about hipabout hip

Chondromalacia DiagnosisChondromalacia Diagnosis

Xray- usually Xray- usually normalnormal

MRI- usually MRI- usually normalnormal

Xray pelvis?Xray pelvis?

Chondromalacia Patella Chondromalacia Patella TreatmentTreatment

Sports menu?Sports menu? BraceBrace NSAIDSNSAIDS RestRest Physical TherapyPhysical Therapy MRI?MRI?


Overuse injuryOveruse injury Traction Traction

apophysitisapophysitis


Jumping sports-Jumping sports-basketball, basketball, volleyballvolleyball

Dull, aching painDull, aching pain Boys 13-14Boys 13-14 Girls 11-12Girls 11-12

Osgood-Schlatter Disease-Osgood-Schlatter Disease-ExamExam

InspectionInspection Point tender over Point tender over

tibial tubercletibial tubercle


XrayXray

Osgood-Schlatters Osgood-Schlatters TreatmentTreatment

NSAIDSNSAIDS BraceBrace Relative restRelative rest Full restFull rest Physical therapyPhysical therapy Knee immobilizerKnee immobilizer CastCast


Goes away when Goes away when apophysis fusesapophysis fuses

Stress Fracture HistoryStress Fracture History

Abrupt increase in Abrupt increase in activity-must elicitactivity-must elicit

Stress Fracture ExamStress Fracture Exam

May be point May be point tendertender

May be difficult to May be difficult to localizelocalize

Stress FractureStress Fracture

X-rayX-ray

Stress FractureStress Fracture

Bone scanBone scan

Stress FracturesStress Fractures

MRIMRI

Stress Fracture Stress Fracture TreatmentTreatment

Rest for 3 monthsRest for 3 months Crutches?Crutches? Non-weight Non-weight

bearing?bearing?

Stress Fracture HealedStress Fracture Healed

Pain free 2 weeksPain free 2 weeks Run 2 miles (30 Run 2 miles (30

min) twice per min) twice per weekweek

10% increase per 10% increase per weekweek

Osteochondritis Osteochondritis DissecansDissecans

Subchondral bone Subchondral bone disorderdisorder

Softening of Softening of overlying cartilageoverlying cartilage

May fragmentMay fragment Occasional cause Occasional cause

of knee painof knee pain


Overuse injuryOveruse injury Repetitive micro-Repetitive micro-

traumatrauma Poorly defined Poorly defined

aching painaching pain Stress fractureStress fracture


X-rays are keyX-rays are key


MRI can be helpfulMRI can be helpful

Osteochondritis Dissecans Osteochondritis Dissecans TreatmentTreatment

Non-weight Non-weight bearing at least 3 bearing at least 3 monthsmonths

Prognosis depends Prognosis depends on growth plate on growth plate statusstatus

Osteochondritis Dissecans Osteochondritis Dissecans TreatmentTreatment

Displaced Displaced fragment-surgeryfragment-surgery

Pediatric Knee InjuriesPediatric Knee Injuries

Is it the Hip?Is it the Hip?

Soccer Knee Injuries and Exam Ben Kittredge, MD Ben Kittredge, MD Commonwealth Orthopaedics...

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