SPORTS INJURIES REFRESHER KNEE JOINT

cut short) check the insertions onto the patella and the tibia. Tenderness over the quads into the superior aspect of the patella, the patellar tendon into the inferior pole of the patella and the most common – the patella tendon into the tibial tubercule (Osgood-Sclatter’s syndrome). These are all enthesites i.e. where the tendon binds to bone as in tennis elbow. Biomechanical problems such as hyper-pronation and overuse often cause them. I find correction of the biomechanical problem, along with acupuncture, taping or steroid injection helps.

KNEE INJURIES

As with most joint injuries, knee Injuries can be divided into acute and overuse. Acute injuries involve a dysbalance between strength and mobility of the muscle components, ligament strength and the forces put through them. Overuse injuries are caused by repetitive movements, often with underlying biomechanical problems. Learning the aetiology and pathology, then recognising them in the patient, is the key to our diagnosis and treatment. Enquire about sports, extra activities, including increases new sporting goals e.g. half or full marathons, body building/resistance exercises; as this may point to overuse problems.

Mechanism of injury Acute injuries commonly involve excessive force on the knee especially involving twist. A fall with the foot fixed to the ground e.g. with studs on, will often damage the structures of the knee. Rarely the contractile components are injured in acute injury but it is generally much more likely that the damage will occur to the ligaments or menisci. Injuries amongst sports people, especially in contact sports, are often the most clear cut.

+

KEY POINT: A missed ACL tear can end a sports career.

A recent study showed 76% of ACL

injuries were missed by the primary physician (not necessarily a GP!). A careful history that reveals a twisting injury, a caught foot, a pop or crack heard by the patient, immediate pain, the player having to leave the sports ‘arena’ and a knee that swells within 4 hours (usually immediately) EQUALS a

www.sportEX.net online

Video 10: Other menisci tests

cruciate tear UNTIL proved otherwise. YOU can alter people’s sports careers by recognising the injury and referring appropriately. If necessary, ask your local hospital’s orthopaedic registrar for advice on how to refer. Sometimes you may have to argue long and hard, as the patient’s advocate, against doctors who may think they know better. Note that the only other injury that will cause these symptoms is a tibial plateau fracture. This often avoids detection, even by x-ray. It is the other differential diagnosis - and will need hospital investigation.

Older non-sports population tend

to either have osteoarthritic pain or degenerative injuries of the menisci. A common history is repetitive kneeling for example in carpet fitters, leading to a meniscus being caught between the tibial and femoral condyles, then tearing. Acutely injured menisci tend to be more obvious. Peripheral tears especially circumferential tears are more amenable to surgical repair, radial tears may require more radical surgery (partial/total menisectomy).

Collateral ligament injuries do ‘nag on’, with pain limiting return to sport rather than functional loss. Their key is a good history, lack of swelling (or mild) and tenderness on palpation/ stressing the appropriate ligament. Usually exercise including proprioceptive awareness will allow full healing for grade 1 and 2 tears. Full tears usually need surgical repair. Weakness of the VMO is more

likely to present as an overuse problem. This may present with an acute injury initially with pain becoming more persistent. The VMO is very

online Video 12:

demonstration of lateral glide of the patella

important to the patello-femoral mechanism, yet is easily ‘switched off’ by injury and effusion. Specific quads exercises help if applied early. There are numerous methods to treat anterior knee pain/patello-femoral problems, including biomechanical/ podiatric assessment, McConnell taping and VMO specific exercises. These are beyond the scope of this article.

long term (personal observation) so promote them to patients.

+

One muscle injury to note which seems to occur more often to the quads muscle is myositis ossificans. Bone neo-ossification occurs in a deep

11 KEY POINT:

Good quads strength after any injury appears to decrease the speed of disability

online

Video 11: Other menisci tests