PresentingPresenting thethe MedialMedial KneeKnee 7 Workshop Objectives

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

„ Bones „ Tendons „ „ Meniscus to the Medial Knee

„ 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 …” (Ireland, 1999, JAT) „ MCL most common knee injury in soccer and basketball (Arendt, 1999, JAT)

„ The MCL 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 . 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

„ HISTORY „ INSPECTION – OBSERVATION

„ The evaluation relies „ SPECIAL TESTS on the expertise of the clinician to assess „ PROM, AROM, MMT the MCL sprain given „ Stress Testing subjective information and „ Etc. performing more „ Arthrometry objective special „ The LigMaster (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 ” Æ Chondromalacia „ “Numb” Æ Nerve (burning, tingling, etc.) UHUH OH!!OH!!

Arnheim & Prentice, Principles of AT, 9th ed MOI = Blow to the outside of the knee with or without torsion Evaluation of the Medial Knee 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. Evaluation of the Medial Knee OBSERVATION

„ Compare Bilaterally „ Gait „ FWB & PWB „ Antalgic gait „ Gait deviations „ Deformity „ Swelling, edema, effusion, ecchymosis „ Atrophy Evaluation of the Medial Knee PALPATION

„ Palpate bones – compare bilaterally Æ R/O fx &/or dislocation „ IF FX or DISLOCATION IS SUSPECTED Æ splint (ice), MD Referral Evaluation of the Medial Knee PALPATION

Pes anserinus tendons = Sartorius, Gracilis, Semitendinosus + Semimembranosus Evaluation of the Medial Knee RANGE OF MOTION

„ Can palpate tendons at this time „ Stabilize legs to isolate „ Compare bilaterally „ AROM Æ PROM Æ Goniometer „ MMT Æ Make Test or Break Test Evaluation of the Medial Knee SPECIAL TESTS „ Anterior Drawer Test = ACL stability „ Slocum Drawer Test – adds rotation to ADT „ Ex Rot Æ AMRI (ACL + MCL + PMC)

Arnheim & Prentice, Principles of AT, 9th ed ACL decreases ant mvt of (86% and medial 15° External displacement (30%) Rotation 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 Arnheim & Prentice, Principles of AT, 9th ed Evaluation of the Medial Knee - SPECIAL TESTS Valgus Stress Test

„ Amount of opening at the 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 + valgus stress Æ extension of the knee Æ click or pain over =+

Arnheim & Prentice, Principles of AT, 9th ed „ Apley’s Compression/Distraction Tests

„ Fox Test Evaluation of the Medial Knee 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 , 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 Medial Collateral Ligament

Deep portion of MCL attaches to medial meniscus. Posterior aspect of superficial MCL blends into deep PCL and , which also attaches to the medial meniscus Medial Collateral Ligament

„ Functions: „ Valgus stress „ Tibial external rotation „ Tibial anterior translation „ Different knee positions matter! Knee position changes the function of the MCL

In extension: In flexion: anterior MCL is Superficial MCL is taut 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° How much and why? 30° DEGREES AUTHOR(S) TEXTBOOK PUBLISHER REF OF FLEXION 20 - 30° 1. Shultz, S., Assessment of Human Kinetics Houglum, P., Athletic None flexion Perrin, D. Injuries 2000 Add internal Full Ext = Flexed = MCL Add external rotation of MCL, PMC + PCL, Medial rotation of tibia tibia = ↑ ACL + ACL, Capsule, Post. = ↓ stress on and PCL stress PCL, POL, Oblique Lig. PCL and ↓ stress to medial MCL Quads

References Evaluation of 25° flexion to 2. Starkey, C., F.A. Davis Norkin and Orthopedic isolate the Ryan, J. Levangie, and Athletic 2002 MCL Injuries (2nd 1992. Ed.) DEGREES OF AUTHOR(S) TEXTBOOK PUBLISHER REF FLEXION

Principles of References Athletic McGraw-Hill 30° flexion in 3. Arnheim, D., Lynch and Training, (10th text, 20 - 30° in Prentice, W. 2000 Henning, 1995. Ed.) Table (page 528)

Special Tests References 4. Konin, J., for Slack Inc. McClure, 20 – 30° flexion Wiksten, D., Orthopedic Rothstein, and 2002 Isear, J., Examination Riddle, 1989 & Brader, H. (2nd Ed.) Smith and Green, 1995 Physical Appleton- “…knee flexed Examination Century-Crofts of the Spine just enough so 1976 5. Hoppenfeld, S. and No references that it unlocks Extremities 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 (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

LigMaster Data Summary Apparent Ligament Extension, mm 5 10 15 20 25 30 35 40

Name: PAA 38, PAA 38, Last seen: Thu Jul 01 2004 14 13 Test: Right 12 Test Knee MCL Right Knee MCL 11 Jul 01 2004 08:32 Thu Jul 01 2004 08:32 full ext 1 Title: full ext 1 10

9 Test analysis: x-intercept = 0.02 8 Slope = 19.98 7 Force, dN 6 Comparison: Left 5 Compari son Knee MCL Left Knee MCL Thu Jul 01 2004 08:41 4 Jul 01 2004 08:41 full ext 3 Title: full ext 3 3

2 Comparison analysis: x-intercept = 0.04 1 slope = 20.19 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 Ligament Strain: λ−1/λ2

Knee MCL analysis: Test ligament slope 1.04% less than comparison Same knee, one flexed 20°

LigMaster Data Summary Apparent Ligament Extension, mm 5 10 15 20 25 30 35 40

Name: PAA 38, PAA 38, Last seen: Thu Jul 01 2004 14 13 Test: Right 12 Test Knee MCL Right Knee MCL 11 Jul 01 2004 08:32 Thu Jul 01 2004 08:32 full ext 1 Title: full ext 1 10

9 Test analysis: x-intercept = 0.02 8 Slope = 19.98 7 Force, dN 6 Comparison: Right 5 Comparison Knee MCL Right Knee MCL Thu Jul 01 2004 08:36 4 Jul 01 2004 08:36 20 d flex 2 Title: 20 d flex 2 3

2 Comparison analysis: x-intercept = 0.01 1 slope = 16.97 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 Ligament Strain: λ−1/λ2

Knee MCL analysis: Test ligament slope 17.72% greater than comparison Position of Knee Study Results

Overall: F = 19.57, P< .001 (4,44) 20 * T-Tests: 0 -10° no difference * 0 -10° & 15° - 20° different 15° - 20° no difference 15 * = diff from 0-10° 0d 10 5d Knee Position Mean + SD 10d 0° 21.51 + 2.88 15d 20d 5° 21.00 + 2.17 5 10° 19.83 + 2.22

15° * 18.53 + 2.17

20° * 17.22 + 2.55 0 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: McGraw- Hill 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