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\pgncont\pgndec\pgnstarts1\pgnrestart Sports Knee Injuries Part 3 Dr. J. Michael
Bennett The Caduceus Society Grand Rounds Houston, TX\par \par [Video Disclaimer: This
information is for educational purposes only.
It's not intended as a substitute for professional medical advice, diagnosis or treatment.
You should not act upon any information provided here without first seeking medical advice
from a physician.]\par \par Bursitis and cysts, you can pretty much get these anywhere in
the joint.
They can be chronic, they can be acute.
Prepatellar bursitis, like I mentioned before, you have swelling over the interior aspect
of the knee cap.\par \par Usually you see these in patients that work on their knees,
or you have patients that are laborers or patients that get on their knees while laying
down floor or tile.
They'll have a lot of Prepatellar bursitis.
Prepatellar bursitis is over use of the patella tendon.
It's a little bit lower than the knee cap where they have some swelling and pain.\par
\par Swelling of the popliteal fossa, which is posteriorly.
You could have a Baker's Cyst, all that is, is just swelling.
When patients get swelling in the joints, in some patients it's pretty obvious, you
see swelling in the front of the knee.
It's severely swollen, it looks like a cantaloupe.\par \par Other patients you look at their knees,
not very swollen, but you feel the back of their knee and you feel a balloon in the back
of their knee.
That's a Baker's cyst, it's a benign cyst that goes up and down with the amount of fluid
and inflammation that you have in the joint.
When patients hear that they have a Baker's cyst they get really worried and upset and
they think it's something serious.\par \par A lot of times it will just go away once the
inflammation is addressed.
I've only had to take out one Baker's cyst in my entire career and it was large enough
that it compressed the neurovascular bundle in the back of the leg.
I'll show you a picture of it, but it is very rare that you have to take any of these out.\par
\par You always want to eliminate the cause of the bursitis or the cyst formation.
Ice, compression, elevation, anti-inflammatory, sometimes injection, aspiration can also be
helpful.
Very, very rarely a cyst incision.\par \par This here is the Baker's cyst I was talking
about.
It's the MRI here, looking at the posterior aspect of the knee, this is the calf region,
this is the cyst here.
The neurovascular structures were back here so it started compressing on them.
Patient started developing neurologic symptoms, vascular symptoms.\par \par This is the cyst
after we took it out, so that was a pretty good size cyst.
Patella injuries, things like a patellar fracture.
It can occur direct or indirect, sometimes they can get it from the patella actually
avulsing.\par \par The patella tendon avulsing off the patella itself.
The quad tendon avulsing off the patella itself.
Or they can have a direct impact type of injury with patella fractures.
Usually patient will have a lot of swelling in the joint, a hemorrhage in the joint.
Indirect fractures can cause capsular tearing or separation of bone fragments, possible
quad tendon tearing as well.
Little bone separation, if it's a direct injury.
If they fell on their knee, sometimes it's just a little mild crack, they won't have
displacement.\par \par If it's a pretty good, traumatic injury sometimes they'll have significant
displacement.
X-rays are always necessary to confirm the finding.
Ice and splinting if fracture is suspected and always refer out just to determine if
surgery is indicated at the time.\par \par This is just an example of a patient I had
here.
This patient had, you can have two types, or a couple types, of fracture of the patella.
You can have a transverse fracture which is very unstable because you have the quad tendon
pulling up top and the patella tendon pulling down below and that patella is basically going
to pull apart.\par \par They don't have a quad, they don't have an extensive mechanism,
they can't lift their leg up, because they don't have the leverage to do that because
there is a detachment or break in the patella.
Those need surgery, pretty much all of them, if it's are transverse.\par \par Now these
longitudinal fractures are a little less likely to need surgery.
If it's non-displaced you can actually get by with treating them in a splinter cast as
long as it doesn't move.
But if you do have some step off, such as here.
To minimize their risk of arthritis sometimes we have to fix them.\par \par I fixed this
patient arthroscopically.
Just go in there and look at the joint, there's the fracture there in the kneecap.
I basically put some screws across it, percutaneously, and compressed that fracture.
This is after reducing it.
That really minimizes their chance of arthritis if you can do that.\par \par Patella subluxations
or dislocations is usually secondary to a cutting, twisting movement at the knee.
Quadriceps pull the patella out of the alignment.
Some athletes are predisposed of the injury, like I talked to you before.
High Q angles, patients that have any abnormal retroversion or torsion in their legs.
Maybe at a higher predisposition for kneecap dislocations.
Repetitive subluxations and imposes stress to the remedial restraints.\par \par I mean,
if you keep having dislocations to the structures that hold that knee cap in place remedially
in the inside of the knee, the medial patellofemoral ligament becomes stretched out and sometimes
it can heal like that and then they end up recurrently, dislocating constantly.\par \par
Signs and symptoms.
The subluxation, pain and swelling.
A lot of times they'll have pain with subluxation, restrictived range of motions, palpated or
tenderness over the medial aspect of the knee, and dislocation usually result in a total
loss of function.\par \par Management.
If the kneecap is dislocated, you have to pop it back in the joint.
A lot of patients know how to do this but if you don't know how to do this, then you've
got to get it to a doctor that can pop it back into the joint.\par \par Reduction is
performed by flexing the hip and moving the patella medially while slowly extending the
knee, because they are going to be bending that knee with a kneecap out of joint.
You have to slowly extend the knee while flexing the hip.\par \par Following reduction, if
you can get it back in place, you put it in an immobilizer for about four weeks.
Sometimes, they can scar into place and stabilize that kneecap, especially if this is a first
time dislocator.\par \par If this patient has been dislocating seven, eight times a
month, they are not going to get a good result with just a bracing.
At that point, you probably want to get an MRI.
Look to see if they have any loose bodies in the joint, see if there are ligaments detached.
An MRI would be indicated.\par \par After a immobilization period, if you do have that
primary or acute dislocation you can put them in a horsehoe pad brace with elastic wrap.
Horseshoe brace, all it is a kind of U-shaped brace that is called a lateral J-brace also,
kind of holds that kneecap in position.\par \par Rehab focuses on the muscles around the
knee, helps stabilize the knee cap.
Sometimes you have to do possible surgery to release tight structures on the lateral
aspect, on the outside of the knee.
Then tighten up the medial aspect but that is something we would have to evaluate the
patient for.\par \par Fat pad injuries; a lot of times this is a diagnosis of exclusion.
We've ruled everything out, we don't know where the pain is coming from.
A lot of times they can have pain secondary to some scarring within the fat pad itself,
inferior to the patella.\par \par Usually you see this in patient that are doing a lot
of kneeling.
They can get some inflammation in that area, get some hemorrhaging and swelling in the
fat pad region.\par \par Like I mentioned before, scaring and calcification can occur.
Usually it occurs below the patella ligament during the extension.
Stiffness, swelling, weakness is usually what the patient presents with.\par \par The way
to treat this is generally just conservative.
Rest from irritating activities until the inflammation has subsided, using cooling or
cryokinetic therapy, hyperextension taping to prevent full extension, or occasionally
injections.\par \par You've got to be careful with injections, because you don't want to
inject anything near tendons.
You have a high risk of tendon rupture, if you put any kind of steroid or lidocaine marking
near tendons.
You have to be very careful if the patient needs an injection.\par \par Chondromalacia
Patella, we see a lot of this.
All that this means is that there is a little bit of softening or deterioration underneath
the knee cap.
A patient as they come in say, "My knee cap pops, clicks, and crunches."
"Well do you have any pain?"
"No."
"Well, if it doesn't hurt you, then it just mean you have a little softening of the cartilage
underneath there."\par \par Now if they have pain, then it could be an abnormal or weakening
of the quadriceps and so it's good to get them into some sort of therapy session to
build the quadriceps up, particularly the VMO.\par \par Sometimes it can just be due
to, you see more patients that have flat feet because their feet end up actually pronating,
bringing their knees together and creating more irritation across the knee cap as well.
You can actually evaluate the patients feet, see if they need something like an orthotic,
give them some arch support.
As well as look at their quadriceps to see if they need some sort of rehabilitation for
the quadriceps to help that knee cap track in a better position.\par \par The treatment
typically, anti-inflammatories, isometrics, quad strengthening, and orthotics.\par \par
Surgery is very rarely indicated but occasionally we go in there to smooth the cartilage down
like we showed you in that video.
Sometimes a lateral release is indicated where I actually release the tight structures on
the lateral aspect of the knee.\par \par That is only if the knee cap is tilted or it's
impinging on the lateral trochlear.
That is what this is describing here.
If you have a knee cap that is tilted on X-ray, rubbing up against this lateral femoral condyle.\par
\par It's called Patellofemoral Stress Syndrome and that just means the knee cap is rubbing
up against that condyle surface causing pain and inflammation, tenderness in the lateral
facet of the knee cap, swelling as well, dull ache in the center of the knee.\par \par Patella
compression lessens the pain, sometimes we can correct the imbalances with strength and
flexibility, or condyle taping.
We actually use these taping techniques to track in a better position, or we can do the
lateral release like we mentioned before, to help balance the knee out in a better position.\par
\par Apophysitis, these are in kids, you can see this in pain patients that don't have
closed growth plates yet.
They are still doing a lot of activities but they come in, they can't bend their knee,
can't extend their knee, they've got severe pain, they don't have a history of injury,
their parents just bring them in saying "Johnny can't run like he did yesterday, he has a
lot of pain and swelling."\par \par They think the worst.
They think some ligament injury or what have you.
Actually, it's just, you know maybe he hit a growth spurt and he's got an apophysitis,
which is an inflammation of his growth plate.
Usually what happens is the bone structures are basically outgrowing the muscular tendon
structures.\par \par The muscular tendon structures are playing catch up and sometimes they put
a lot of overdue stress at their insertion sight.
This is basically Osgood- Schlatter's which occurs right at the tibial tubercle.
This is Larsen- Johansson's disease, which occurs at the inferior aspect of the patella.
These are the most common places you are going to see it.\par \par If they have them chronically,
sometimes, very rarely, you can have an avulsion or a fracture through that growth plate but
it's very rare.
You treat this conservatively.\par \par You actually just modify the patients activities,
treat with anti- inflammatories, make sure they are doing adequate stretching activities,
because a lot of these kids are growing so fast they have tight hamstrings.
That changes their running mechanism a little bit, so they are overloading the front of
the knee.\par \par All you have to do is really rest them and stretch out those hamstrings.
Really make sure they've got a good stretching program.\par \par But this is what it looks
like here.
Osgood-Schlatter's, there is where the patella tendon inserts right here, this is the open
growth plate and this can start getting fragmented or look very abnormal.
That means they have an apophysitis, like I mentioned before.\par \par These are the
signs and symptoms, point tenderness, pain when kneeling, jumping, running.
Management reduces stressful activity until the union occurs.
Unfortunately, these kids keep on getting these problems as they play their sports until
their growth plates shut down.\par \par Just make sure the parents understand that if they
are hurting, take a break.
Let the pain go away, let the swelling go away then they can get back to their sports
and activities.
Possible casting, if you have a patient that is non-compliant, sometimes we have to break
out the casts but that is very rare.\par \par Isometrics, like I said before, strengthening
as well as stretching is key.
Patellar Tendon, Patellar Tendonitis, is jumper or kickers knee.
Usually see this is in a lot of martial arts patients that come through, or basketball
players.
Jumping and kicking places a tremendous amount of strain on the quadriceps and patella tendon.
Usually they get point tenderness along either of these tendons.\par \par There are three
phases that it can occur; it can occur after activity, during and after activity, or during
and after and may become constant or chronic.
You really want to treat it before it becomes chronic and constant.\par \par Ice, phonophoresis,
iontophoresis, ultra sound, heat, exercise, patella tendon bracing, and transverse friction
massage.
This is the most common patella tendon brace we use to kind of unload that tendon and let
it heal.\par \par As well as saying on an MRI there is normal tendon fibers here inserting
with the inferior pull of the patella.
You can see that white area.
This is actually the degenerative tearing of that central third of the patella tendon.
It can actually be very painful for those patients.
Sometimes we have to go in there and remove that portion.
Most patients get better with conservative treatment.\par \par Patella tendon rupture,
you are going to know this patient when they come in.
It is a pretty obvious finding.
Usually occurs when a sudden powerful quadriceps contraction.
Usually the patient will have an undergoing, underlying tendonitis that weakens the tendon
and that is why they rupture.
It usually occurs at the point of attachment.
These patients will not be able to lift their leg up because they will have a detached extensor
mechanism, they'll have a palpable defect.\par \par You'll push on the patella tendon, it's
mushy and you feel a defect.
They have significant pain and swelling.
At this point surgery is indeed indicated.
You can usually avoid this by taking care of these patients who have the tendonitis's
early.
Making sure they are doing their stretches, treating the jumpers knee, using the anti-inflammatories,
try to minimize any kind of tendon degeneration from occurring in the first place.\par \par
This is what I mentioned before, steroids you want to avoid them at all cost regarding
tendons.
Runners knee, cyclist knee usually due to repetitive overuse conditions, usually from
malalignment in the knees, occasionally.
IT band syndrome is very, very common particularly in runners and cyclists.\par \par Usually
irritation at the IT band insertion, it can occur approximately up in the hip region or
distally.
It can occur at the iliac wing where it starts or down distally where it inserts at the tibia.
You can also have pes anserinus tendinitis or bursitis.
That's on the medial side of the knee right rather than the ducks foot area, you have
a little bursa there that can get irritated.\par \par A lot of times this can be corrected
by correcting the malalignment with correct orthotics, bracing, ice, anti-inflammatories,
and stretching.
A lot of these are just treated non-operatively across the board.\par \par In conclusion,
the goals of managing sports injuries, I want to make sure you do a thorough history and
physical exam.
I want to make sure you do a prompt treatment, recognize the mechanism of injury, make sure
you get an adequate history, do a good physical exam, and determine if further test are necessary.
Such as an MRI, and X-ray, or an EMG.\par \par Then determine if something needs to
be done, patient needs to be referred out, or is it something that you can rehabilitate
on your own and just let it heal up.\par \par Early return to activity without a risk a
of injury is the goal.
We always want to make sure that your patients understand everything.
Every little point of intervention, you need to make sure they understand why you are doing
it, and what the outcome is.\par \par That's going to be key with prevention, maintenance,
and compliance with your patients.
That is basically it.
I know it's been long but I wanted to try and cover everything regarding the knee.
Make sure you guys are comfortable with it.}