ASSESSMENT AND MANAGEMENT OF THE ACUTE KNEE AND ANKLE

Cameron Bulluss

newcastle-physio.com.au

Key point

• “correct early diagnosis and correct early management of musculoskeletal injury is crucial, this is particularly true for ligament injuries”

Aim

• Discuss the assessment and management of the following injuries• Ankle

– Lateral ligaments– Tibiofibular ligaments

• Knee– Anterior cruciate ligament tear– Medial collateral ligament tear– Menical tear– Patellofemoral pain

• Discuss some key management options including the use of tape braces and walking aids

• Teach you to competently strap an ankle

The sprained ankle

• 2 possibilities

• Lateral ligament complex anterior talofibular+/- calcaneofibular ligament

• Syndesmosis/tibiofibular ligaments

Lateral Ligament Injuries

Mechanism - weightbearing inversionLigaments involved – anterior talofibular ligament, calcaneofibularligamentImaging – see Ottawa ankle rulesOther structures potentially injured –peroneal muscles, talar dome, fibular, head of fifth metatarsal, midfootPhysical Tests – Inversion stress, anterior drawer of talus on tibiaAcute Managment – tape, or brace or boot or backslab, RICESurgical managment – rarely, taping bracing long term very effective

Anterior and Posterior Tibiofibular LigamentsMechanism – weightbearing external rotationPatient describes – pain, sometimes pop, unable to contine activityLigaments Involved – inferior tibiofibular ligamentsImaging – x-rays, MRIOther structures potentially injured -Medial ligament, joint surface of talus and tibiaPhysical Tests – External rotation of footAcute Management – tape or brace or boot, +/- non or reduced weigtbearingSurgical management – posterior rupture

Strapping vs Bracing vs Boot

• Strapping– Advantages – cheap, effective, allows movement– Disadvantages – requires crutches, skill needed to

apply• Bracing

– Advantages – effective, allows movement, easy to apply

– Disadvantages – cost, requires crutches• Boot

– Advantages – effective, allows early weightbearing– Disadvantages – restricts movement, cost

IMAGING – OTTAWA ANKLE AND FOOT RULES

Imaging - Ottawa Ankle and Foot Rules

• In summary of the guideline, according to the Ottawa Ankle and Foot Rules, x-rays are only required if there is any pain in the malleolar or midfoot area, and any one of the following:

• Bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus

• Bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus

• Bone tenderness at the base of the fifth metatarsal (for foot injuries).

• Bone tenderness at the navicular bone (for foot injuries). • An inability to bear weight both immediately and in the

emergency department for four steps.

Anterior CruciateLigament Tears

Mechanism – rotation in weightbearing, hyperextension

Patient describes – pop, unable to continue activity, rapid swelling

Imaging – MRI (best early)

Other structures potentially injured – other ligaments, menisci, osteochondral surfaces

Physical Tests – lachman’s

Acute managment – crutches +/-brace

Surgical management – yes provided patient can cope with rehab

Medial Collateral Ligament Tears

Mechanism: valgus/rotational

Imaging: MRI

Patient describes pain: usually unable to continue

Other structures potentially injured: ACL, menisci, osteoschondral

Physical tests: valgus at 30 degrees flexion,

Acute Management: Brace, non –weightbearing

Surgical managment: no, unless conservative fails

Meniscal Injuries

Mechanism: twisting, weightbearing, sometimes hyperflexion

Imaging: MRI

Patient describes: pain, sometimes a pop

Other structures potentially involved: other ligaments, osteochondral surfaces

Physical tests: palpation, squat, hyperflexion

Acute management: non weight bearing, protected range of motion

Surgical management: variable

Patellofemoral painPatellar forces – 3-4 times body weight on steps, 7 time body weight squatting, >10 times landing from a jumpCauses – skeletal alignment, biomechanics (overpronation), muscle imbalance, osteochondral damagePatient presents – anterior knee pain, pain with steps, hills, squatting sitting, running, landingPhysical testing – isometric quadriceps at varying degrees of flexion, Management – quadriceps strengthening, biomechanical correction, taping

Practical

• Anterior drawer test – ankle

• Syndesmosis test – ankle

• Medial collateral Ligament test - knee

• Lachman’s test - knee

• Isometric knee extension

• Strapping lateral ligament complex – ankle

• Strapping patellofemoral pain

Resources

• Clinical Sports Medicine – Brukner and Khan

• Atlas of imaging in sports medicine –Anderson

• Handouts – strapping,