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Sports Knee Injury Effusions Sports KneeOrthosports Injury Effusions MRI Orthosports www.orthosports.com.auOrthosports Orthosports Orthosports Orthosports Sporting Knee Effusions and MRI Learning Objectives •Anatomy Orthosports •History Taking • Clinical Examination Orthosports •Imaging Orthosports •Treatment Orthosports • Effusions •WhenOrthosports to refer Orthosports Sporting Knee Effusions and MRI Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Anatomy EffusionsSporting and MRI Knee Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Anterior Patella Removed EffusionsSporting and MRI Knee Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Flexed Lateral EffusionsSporting and MRI Knee Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Posterior EffusionsSporting and MRI Knee Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Chondral Cartilage EffusionsSporting and MRI Knee Cartilage Orthosports •Type II collagen Orthosports •Cross linked type IX collagen • 80% water Orthosports •20Orthosports‐40% dry weight of glycosaminoglycans • Chondrocytes and a composite gel •No Orthosportsblood supply Orthosports Sporting Knee Effusions and MRI Outerbridge Classification •1‐ softening of cartilage •2‐ fibrillation superficial Orthosports •3‐ fibrillation down to subchondral bone •4‐ exposed bone Orthosports Orthosports Orthosports Orthosports Orthosports Sporting Knee Effusions and MRI Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Meniscus EffusionsSporting and MRI Knee Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Meniscus - Anatomy EffusionsSporting and MRI Knee Structural Anatomy • Type I collagen Orthosports – strong in tensile stress – Oriented in a circumferential directionOrthosports –Prevent radial extrusion (Radial,longitudinal & oblique) – Maintain structural integrity during load bearing Orthosports •Orthosports Lateral meniscus more important in weight bearing, more mobile too • MedialOrthosports meniscus contributes to joint stability Orthosports Sporting Knee Effusions and MRI Meniscus ‐ Function Orthosports • Load distribution • Shock absorption Orthosports • Joint stability • Joint lubrication Orthosports Orthosports Orthosports Orthosports Sporting Knee Effusions and MRI Meniscal Function Orthosports • Lateral meniscus covers 76% of the Orthosports articular cartilage Orthosports •Orthosports Medial meniscus covers 60% Orthosports Orthosports Sporting Knee Effusions and MRI Meniscal Function • Load transmission Orthosports –45 – 50% load transmitted to menisci in extension – 85% load transmitted to menisci inOrthosports flexion – Medial side, MM and MTP share load – Lateral side, LM takes 80% load Orthosports Orthosports Orthosports Orthosports Sporting Knee Effusions and MRI Mechanical Function Orthosports –Removing MM decreases contact area MFC by 50 – 70% Orthosports • 100% stress increase on MTP Orthosports Orthosports–Removing LM 45 – 50% decrease in contact area Orthosports• 235 – 335% increase in local contact pressures LTP Orthosports Sporting Knee Effusions and MRI Swelling and Meniscus Tears Orthosports • Isolated meniscal tears do not cause recurrent swelling Orthosports •If the knee is swollen there is almostOrthosports Orthosportscertainly chondral damage Orthosports Orthosports Sporting Knee Effusions and MRI Knee Biomechanics •ACL is primary stabiliser Orthosports • Menisci secondary stabilisers –Medial meniscectomy •ACL‐intact ‐ little effect on AP motion Orthosports •ACL‐deficient ‐Increased AP translation up to 58% at 90° of flexion. Orthosports •HingeOrthosports joint ‐ only slight rotation and translation possible • SynovialOrthosports layer secretes fluid – Lubrication and nutrition for articular cartilage. Orthosports Sporting Knee Effusions and MRI History Taking • Activity level Orthosports • Employment • Pain profile Orthosports • Joint profile Orthosports • Functional profile Orthosports • Remember referred pain Orthosports – Back or Hip Orthosports Sporting Knee Effusions and MRI Pain • Location Orthosports •Rest •Night Orthosports • Stair climbing Orthosports •After sitting PF jt involved Orthosports • Squatting •BarometricOrthosports pressure changes Orthosports Sporting Knee Effusions and MRI Symptoms Orthosports • Swelling •Catching Orthosports • Instability •Onset of symptoms Orthosports Orthosports • ResponseOrthosports to prior treatment Orthosports Sporting Knee Effusions and MRI Giving way Primary Instability SecondaryOrthosports Instability •Joint actually gives way •Pain within the joint. –Ligament deficiency – QuadsOrthosports relax involuntarily –Not painful but knee –Leg buckles hurts afterwards /swells –SensationOrthosports of giving way –Orthosports Repeated giving way –Remove the pain = no leads to arthritis. giving way Orthosports –Meniscal tear, loose body, arthritis, or synovitis. Orthosports Sporting Knee Effusions and MRI Giving way Primary Instability SecondaryOrthosports Instability • Surgery required to fix • Generally not causing the problem furtherOrthosports damage –ACL • Patella subluxing can be –PCL felt as givingOrthosports way –LCLOrthosports • Giving way often non‐ –PLC specific –PFJOrthosports – Loose bodies, patellar chondromalacia, and quads weakness Orthosports Sporting Knee Effusions and MRI Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Patella EffusionsSporting and MRI Knee Patella Stability Orthosports • Bones most important structures • Quads also important Orthosports Orthosports Orthosports Orthosports Orthosports Sporting Knee Effusions and MRI Patella Dislocation Orthosports •Direct blow or twist •Often hear two clicks Orthosports • Notice lump •May require hospital reductionOrthosports •Orthosports Predisposing factors – Shallow trochlear Orthosports –Femoral torsion – Patella Alta Orthosports Sporting Knee Effusions and MRI Patella Dislocation Orthosports •Xrayfor fracture •Rice Orthosports • Splint 1‐2 weeks comfort •Physio Orthosports •Orthosports Quads strengthening •RarelyOrthosports require surgery Orthosports Sporting Knee Effusions and MRI Patella Dislocation ‐ Earlier Referral •Dislocation and large effusion or crepitus implies articular cartilage damage Orthosports •>3 dislocations •Audible crepitus Orthosports • Mechanical symptoms Orthosports • These days surgery more reliable and smaller Orthosports Orthosports Orthosports Sporting Knee Effusions and MRI Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Extensor Mechanism EffusionsSporting and MRI Knee Extensor Mechanism Orthosports • Quadriceps or patella tendon rupture • Unable to straight leg raise Orthosports • Tenderness • Defect Orthosports Orthosports • EarlyOrthosports referral Orthosports Sporting Knee Effusions and MRI Medial & Lateral Jt Line Pain Orthosports • Meniscus • Articular cartilage Orthosports •MCL •Avascular necrosis Orthosports •Orthosports Plica •BursaOrthosports • Tib fib joint • ReferredOrthosports Sporting Knee Effusions and MRI Anterior Knee Pain Orthosports • Chondromalacia • Subluxation Orthosports • Maltracking •Traumatic Orthosports •NonOrthosports specific –(see overuse later) Orthosports Orthosports Sporting Knee Effusions and MRI Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports Anterior Cruciate Ligament EffusionsSporting and MRI Knee ACL Orthosports • Controls 90% of stability to anterior displacement of the tibiaOrthosports • Varus, valgus, rotational restraint • Anteromedial bundle tightens Orthosportsin flexion Orthosportsand the posterolateral becomes lax Orthosports Orthosports Sporting Knee Effusions and MRI ACL ‐ HISTORY Orthosports • Usually twisting injury •Older patients often no trauma Orthosports • Swelling several hours later or next day •Pain Orthosports •ClickingOrthosports •Locking • GivingOrthosports way • Swelling ‐effusions only 50% cases Orthosports Sporting Knee Effusions and MRI ACL •Best time to examine isOrthosports immediate •Worst is 3‐7 days •No need for urgent referralOrthosports •Not everyone needs surgery Orthosports •No harm at all in watching the older Orthosports patients to see if they have instability Orthosports Orthosports Sporting Knee Effusions and MRI Refer Earlier If • Competitive sports Orthosports • Articular surface damage particularly Orthosports patellofemoral and medial compartment •Medial meniscus loss Orthosports •HeavyOrthosports people who are more likely to stretch secondary restraints •VarusOrthosports alignment •Younger Orthosports Sporting Knee Effusions and MRI ACL – Operate if: Orthosports • Giving way with activities of daily living •Want to get back to pivotingOrthosports sports •Meniscal injury Orthosports BestOrthosports to have relatively full painfree ROM prior to surgery Orthosports Orthosports Sporting Knee Effusions and MRI Orthosports Orthosports Orthosports Orthosports Orthosports Orthosports ACL EffusionsSporting and MRI Knee Locked Knee •True locking is lack of 10 –15 degrees of extension Orthosports •Not unable to flex •Try and work out if it is a mechanicalOrthosports block or pain Orthosports • Patella pathology often mimics locked Orthosportsknee Orthosports Orthosports Sporting Knee Effusions and MRI MCL • Common from acute trauma. –Misstep / collision Orthosports –Valgus stress – Immediate pain and swellingOrthosports • Point tenderness medial joint line / mcl Orthosports 0 •Orthosports Valgus stress at 30 reproduces pain • Clearly defined end point = grade 1 or gradeOrthosports
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