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

2. Knee Anatomy

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

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

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

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

7. Inspection
Erythema
Cellulitis?
Septic prepatellar bursitis

8. Range of Motion
Locked knee?

9. Effusion

10. Is it an effusion?
Prepatellar bursitis

11. Effusion Present
ACL tear
Patellar dislocation
Fracture or Bone bruise

12. No Effusion
MCL tear
Meniscus tear
Contusion

13. Stability Exam: Anterior-Posterior
Lachman’s
ACL Tear

14. Stability Exam: Anterior-Posterior
Posterior drawer
PCL tear

15. Stability Exam- Medial and Lateral
Valgus stress
MCL tear

16. Stability Exam- Medial and Lateral
Varus Stress
LCL tear

17. Knee Exam
Joint line tenderness
Meniscal tear?

18. Patellar Exam Palpate medial and lateral patellar facets
Chondromalacia patella

19. Tendon Exam Patellar tendon Quadriceps tendon Iliotibial band
Tibial tubercle

20. Xray
May show fracture
Growth plate status
Often normal

21. Xray
Is it normal?

22. MRI
ACL
Patellar Dislocation
Fracture or Bone bruise

23. MRI
Quality of MRI varies
Radiologists expertise varies

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

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

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

27. ACL tear-Growth Plates Open
Brace
Physeal sparing reconstruction

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

29. Patellar Dislocation Exam
Big effusion
Patellar apprehension
Medial retinacular pain

30. Patellar Dislocation
Xray

31. Patellar Dislocation
MRI

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

33. Fracture or Bone Bruise History
Collision
Fall
Non-contact twist

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

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

36. Fracture
Xray

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

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

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

40. MCL Tear Imaging
Xray-normal
MRI

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

42. Meniscal Tear
History of twisting injury

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

44. Meniscal Tear
Locked knee
Urgent knee arthroscopy

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

46. Meniscus Resection
Sports in 3 weeks

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

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

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

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

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

52. Osgood-Schlatter Disease
Overuse injury
Traction apophysitis

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

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

55. Osgood-Schlatter Disease
Xray

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

57. Osgood-Schlatter Disease
Goes away when apophysis fuses

58. Stress Fracture History
Abrupt increase in activity-must elicit

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

60. Stress Fracture
X-ray

61. Stress Fracture
Bone scan

62. Stress Fractures
MRI

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

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

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

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

67. Osteochondritis Dissecans
X-rays are key

68. Osteochondritis Dissecans
MRI can be helpful

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

70. Osteochondritis Dissecans Treatment
Displaced fragment-surgery

71. Pediatric Knee Injuries
Is it the Hip?