Soccer Knee Injuries and Exam Ben Kittredge, MD Commonwealth Orthopaedics

Knee Anatomy

Pediatric Knee Injuries Acute (event occurs) Chronic (no event)

Acute Injuries What happened? Non-contact twist? Did the knee swell up right away? Hear or feel a “pop” ? Able to continue playing?

Acute Knee Injuries Ligament injury (ACL, MCL) Meniscus tear Fracture/Bone bruise Patellar dislocation

Knee Exam Inspection Range of motion Is there an effusion? Joint line tenderness Stability

Inspection Erythema Cellulitis? Septic prepatellar bursitis

Range of Motion Locked knee?

Effusion

Is it an effusion? Prepatellar bursitis

Effusion Present ACL tear Patellar dislocation Fracture or Bone bruise

No Effusion MCL tear Meniscus tear Contusion

Stability Exam: Anterior-Posterior Lachman’s ACL Tear

Stability Exam: Anterior-Posterior Posterior drawer PCL tear

Stability Exam- Medial and Lateral Valgus stress MCL tear

Stability Exam- Medial and Lateral Varus Stress LCL tear

Knee Exam Joint line tenderness Meniscal tear?

Patellar Exam Palpate medial and lateral patellar facets Chondromalacia patella

Tendon Exam Patellar tendon Quadriceps tendon Iliotibial band Tibial tubercle

Xray May show fracture Growth plate status Often normal

Xray Is it normal?

MRI ACL Patellar Dislocation Fracture or Bone bruise

MRI Quality of MRI varies Radiologists expertise varies

ACL Injuries 400,000 reconstructions per year in the US Females 4 times more likely to tear ACL with non-contact injury

ACL Tears-Prevention High intensity plyometrics, balance training, and strengthening Neuromuscular Feedback

Treatment-ACL Tear-Growth Plates Closed Patellar tendon Hamstring Allograft

ACL tear-Growth Plates Open Brace Physeal sparing reconstruction

Patellar Dislocation History Twisting injury Collision May not know patella dislocated Immediate swelling Can’t play

Patellar Dislocation Exam Big effusion Patellar apprehension Medial retinacular pain

Patellar Dislocation Xray

Patellar Dislocation MRI

Patellar Dislocation Loose Body – Arthroscopy Brace? Rehab Return to play when comfortable

Fracture or Bone Bruise History Collision Fall Non-contact twist

Fracture or Bone Bruise Exam Effusion May or may not be able to localize pain Inability to bear weight

Bone Bruise Xray normal Diagnose by MRI Usually back to sports in 4-6 weeks

Fracture Xray

Fracture Treatment 6-12 weeks to heal Brace? Cast Surgery

MCL Tear History Valgus injury May or may not have contact Pop? May keep playing May not swell right away

MCL Tear Exam Medial joint line pain Opening with valgus stress No effusion

MCL Tear Imaging Xray-normal MRI

MCL Tear Treatment Brace for 2-6 weeks Pass functional test to play Surgery if off tibia

Meniscal Tear History of twisting injury

Meniscus Tear Exam Swelling may or may not be present Joint line pain Locked knee?

Meniscal Tear Locked knee Urgent knee arthroscopy

Meniscus Repair Non-weight bearing 6 weeks Sports in 4 months

Meniscus Resection Sports in 3 weeks

Chronic Injuries Chondromalacia patella Osgood-Schlatter Disease Stress Fracture Osteochondritis Dissecans

Chondromalacia Patella Poorly localized anterior knee pain Dull, aching pain Worse with jumping, climbing, squatting

Exam Point tender at medial patellar facet View patellar tracking Normal exam-think about hip

Chondromalacia Diagnosis Xray- usually normal MRI- usually normal Xray pelvis?

Chondromalacia Patella Treatment Sports menu? Brace NSAIDS Rest Physical Therapy MRI?

Osgood-Schlatter Disease Overuse injury Traction apophysitis

Osgood-Schlatter Disease Jumping sports-basketball, volleyball Dull, aching pain Boys 13-14 Girls 11-12

Osgood-Schlatter Disease-Exam Inspection Point tender over tibial tubercle

Osgood-Schlatter Disease Xray

Osgood-Schlatters Treatment NSAIDS Brace Relative rest Full rest Physical therapy Knee immobilizer Cast

Osgood-Schlatter Disease Goes away when apophysis fuses

Stress Fracture History Abrupt increase in activity-must elicit

Stress Fracture Exam May be point tender May be difficult to localize

Stress Fracture X-ray

Stress Fracture Bone scan

Stress Fractures MRI

Stress Fracture Treatment Rest for 3 months Crutches? Non-weight bearing?

Stress Fracture Healed Pain free 2 weeks Run 2 miles (30 min) twice per week 10% increase per week

Osteochondritis Dissecans Subchondral bone disorder Softening of overlying cartilage May fragment Occasional cause of knee pain

Osteochondritis Dissecans Overuse injury Repetitive micro-trauma Poorly defined aching pain Stress fracture

Osteochondritis Dissecans X-rays are key

Osteochondritis Dissecans MRI can be helpful

Osteochondritis Dissecans Treatment Non-weight bearing at least 3 months Prognosis depends on growth plate status

Osteochondritis Dissecans Treatment Displaced fragment-surgery

Pediatric Knee Injuries Is it the Hip?