Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 1

Mary Lloyd Ireland, MDAssociate Professor Dept. of Orthopaedic Surgery &

Sports MedicineUniversity of KentuckyLexington, Kentucky

Mary Lloyd Ireland, MDAssociate Professor Dept. of Orthopaedic Surgery &

Sports MedicineUniversity of KentuckyLexington, Kentucky

ACSM TPC Part 2Miami, Florida • February 9, 2013

ACSM TPC Part 2Miami, Florida • February 9, 2013

Acute Knee LigamentInjuries in Athletes

Acute Knee LigamentInjuries in Athletes

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 2

Acute Knee DislocationsAcute Knee Dislocations

• Uncommon, but . . .May be underdiagnosed

• If knee opens up to varus/valgus stress testing in extension, assume a knee dislocation

• Direction of dislocation• Anterior: hyperextension

mechanism• Posterior: direct blow anterior

proximal tibia

• Uncommon, but . . .May be underdiagnosed

• If knee opens up to varus/valgus stress testing in extension, assume a knee dislocation

• Direction of dislocation• Anterior: hyperextension

mechanism• Posterior: direct blow anterior

proximal tibia

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 3

KNEEKNEE

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 4

Knee DislocationKnee Dislocation

• Happens on fields – not often, but:• Don’t miss• Assess vascular status

• Physical exam• Pulse ratios• MRI scan• Arteriogram

• Happens on fields – not often, but:• Don’t miss• Assess vascular status

• Physical exam• Pulse ratios• MRI scan• Arteriogram

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 5

Marcus Lattimore, running back, MOI:South Carolina vs. Tennessee

Marcus Lattimore, running back, MOI:South Carolina vs. Tennessee

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 6

Football: Knee DislocationFootball: Knee Dislocation

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 7

Knee dislocation ACL/PCL/MCL tearsSkin only stabilizing medial side of the knee

Knee dislocation ACL/PCL/MCL tearsSkin only stabilizing medial side of the knee

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 8

Medial meniscusMedial meniscus

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 9

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 10

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 11

Knee Dislocation AlgorithmKnee Dislocation Algorithm

Algorithm for treatment of the Multiple Ligament Injured Knee, from Harner, CD, “Complex Knee Injuries including dislocation: Preoperative planning, evaluation and pitfalls,” AAOS, Phoenix AZ, Feb. 3-6, 2000.

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 12

Willis McGahee, Univ. of Miami 2003Willis McGahee, Univ. of Miami 2003

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 13

InstabilitiesInstabilities

• Anteromedial rotatory instabilities (AMRI)• Combined AMRI and ALRI• Anterolateral rotatory instabilities (ALRI)• Straight posterior• Posterolateral rotatory instabilities (PLRI)• Combined ALRI and PLRI• Straight instabilities

• Anteromedial rotatory instabilities (AMRI)• Combined AMRI and ALRI• Anterolateral rotatory instabilities (ALRI)• Straight posterior• Posterolateral rotatory instabilities (PLRI)• Combined ALRI and PLRI• Straight instabilities

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 14

Knee DislocationsKnee Dislocations

• Most knee dislocations reduce spontaneously

• Refer to center with vascular surgeon• Communicate with ER

• Use your cell phone to call the ER• Put a note on the patient• Transfer to facility with angiography suite and

vascular surgeon on call• If high suspicion, do arteriogram

• Most knee dislocations reduce spontaneously

• Refer to center with vascular surgeon• Communicate with ER

• Use your cell phone to call the ER• Put a note on the patient• Transfer to facility with angiography suite and

vascular surgeon on call• If high suspicion, do arteriogram

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 15

Vascular InjuryVascular Injury

Late Vascular compromise from:ThrombusPropagation of Intimal Tear

Late Vascular compromise from:ThrombusPropagation of Intimal Tear

Arteriogram Gold Standard

Injury ranges from :ThrombusTear:

IntimalPartial Complete

Arteriogram Gold Standard

Injury ranges from :ThrombusTear:

IntimalPartial Complete

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 16

HistoryHistory

• 16YO white male, high school football player• Football game, valgus twisting blow to body

injury• Unable to keep playing• Evaluated on sideline, seen in ER• Seen in office 3 days later

• 16YO white male, high school football player• Football game, valgus twisting blow to body

injury• Unable to keep playing• Evaluated on sideline, seen in ER• Seen in office 3 days later

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 17

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 18

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 19

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 20

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 21

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 22

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 23

Surgery: ArthroscopySurgery: Arthroscopy

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 24

Surgery: MCL RepairSurgery: MCL Repair

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 25

Knee InstabilitiesKnee Instabilities AMRI

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 26

GymnasticsGymnastics

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 27

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 28

ACL TearACL Tear

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 29

BasketballBasketball

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 30

BasketballBasketball

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 31

Basketball: non-contact, unexpected, not thinkingBasketball: non-contact, unexpected, not thinking

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 32

Knee InstabilityKnee Instability

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 33

Knee InstabilitiesKnee Instabilities

ALRI

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 34

EUA:Correlate mechanism of injury, anatomy, surgical findings to study design in the lab

EUA:Correlate mechanism of injury, anatomy, surgical findings to study design in the lab

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 35

Pivot ShiftLateral tibial plateau internally rotating, anteriorly subluxing at 30 to 0 degrees

Pivot ShiftLateral tibial plateau internally rotating, anteriorly subluxing at 30 to 0 degrees

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 36

Medial compartment: compressive forces posterior medial meniscus, typical tear pattern vertical, posterior

Medial compartment: compressive forces posterior medial meniscus, typical tear pattern vertical, posterior

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 37

Injury Mechanisms – Body PositionsInjury Mechanisms – Body Positions

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 38

Olsen OE, Myklebust G, Engebretsen L, and Bahr R, “Injury Mechanisms for Anterior Cruciate Ligament Injuries in Team Handball: A Systematic Video Analysis,”in Am J Sports Med 32(4);June 2004, 1002-1012.

Olsen OE, Myklebust G, Engebretsen L, and Bahr R, “Injury Mechanisms for Anterior Cruciate Ligament Injuries in Team Handball: A Systematic Video Analysis,”in Am J Sports Med 32(4);June 2004, 1002-1012.

Team HandballTeam Handball

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 39

ACL Injury occurred, Foot fixed and externally rotatedWide stance, 15° knee flexion, 20 ° valgus, tibia IR 10 °

ACL Injury occurred, Foot fixed and externally rotatedWide stance, 15° knee flexion, 20 ° valgus, tibia IR 10 °

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 40

Off-balance, in the airOff-balance, in the air

ACL injury occurredFoot fixed and externally rotated, knee 20°, tibia ER 10°, valgus 10°

ACL injury occurredFoot fixed and externally rotated, knee 20°, tibia ER 10°, valgus 10°

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 41

SoccerSoccer

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 42

Knee InstabilitiesKnee Instabilities PLRI

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 43

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 44

Normal Knee Exam: PCL ExamNormal Knee Exam: PCL Exam

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 45

PCL – 22 YO Offensive LinemanPCL – 22 YO Offensive Lineman

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 46

PCLPCL• Mechanism

• Low velocity – sports blow to anterior tibia, foot plantarflexed

• Exam• Grades I-II-III based on relation to medial femoral

condyle• Assess collateral ligaments

• Most commonly posterolateral instability• Greater tibial external rotation

• Acute reconstruction• Knee dislocation• Grade III collateral ligament injuries

• Mechanism• Low velocity – sports blow to anterior tibia, foot

plantarflexed• Exam

• Grades I-II-III based on relation to medial femoral condyle

• Assess collateral ligaments• Most commonly posterolateral instability• Greater tibial external rotation

• Acute reconstruction• Knee dislocation• Grade III collateral ligament injuries

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 47

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 48

Sideline Assessment of InjuriesSideline Assessment of Injuries

To Make the Diagnosis:To Make the Diagnosis:Use observation of mechanism, physical exam

skills, and talk to the athlete Use observation of mechanism, physical exam

skills, and talk to the athlete

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 49

Non-contact ACL tear, professional football athlete

Injuries occur at all levels of talent and experience

Non-contact ACL tear, professional football athlete

Injuries occur at all levels of talent and experience Jerry RiceJerry Rice

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 50

Who is driving the sideline decision and return to play train?Who is driving the sideline decision and return to play train?

Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD

ACSM TPC Part 2 • February 9, 2013 51

Mary Lloyd Ireland, MDAssociate Professor Dept. of Orthopaedic Surgery &

Sports MedicineUniversity of KentuckyLexington, Kentucky

Mary Lloyd Ireland, MDAssociate Professor Dept. of Orthopaedic Surgery &

Sports MedicineUniversity of KentuckyLexington, Kentucky

ACSM TPC Part 2Miami, Florida • February 9, 2013

ACSM TPC Part 2Miami, Florida • February 9, 2013

Acute Knee LigamentInjuries in Athletes

Acute Knee LigamentInjuries in Athletes

The End . . . Thank You!The End . . . Thank You!

ACUTE KNEE LIGAMENT INJURIES Mary Lloyd Ireland, M.D. IN ATHLETES UK Healthcare - Orthopaedics ACSM TPC II & Sports Medicine Miami, Florida 601 Perimeter Drive #200 February 9, 2013 Lexington, KY 40517 (859) 218-3131 Fax: (859) 323-2255

_________________________________________________________________________

BIBLIOGRAPHY

American Medical Association: Standard Nomenclature of Athletic Injuries. Chicago, American Medial Association, 1966. Arendt e, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports Med 1995;23(6):694-701. Barber-Westin SD et al. Reducing the risk of noncontact anterior cruciate ligament injuries in the female athlete. Phys Sportsmed 2009;37(3):49-61. Carson F, Polman RC. The facilitative nature of avoidance coping within sports injury rehabilitation. Scand J Med Sci Sports 2010;20(2):235-240. Colvin AC, Meislin RJ. Posterior cruciate ligament injuries in the athlete: diagnosis and treatment. Bull NYU Hosp Jt Dis 2009;67(1):45-51. Fanelli GC. Treatment of combined anterior cruciate ligament-posterior cruciate ligament-lateral side injuries of the knee. Clinics in Sports Medicine 2000;19(3):493-502. Fanelli GC. Surgical treatment of ACL-PCL –medial side-lateral side injuries of the knee. Operative Techniques in Sports Medicine 2003;11(4):263-274. Fanelli GC. Systematic approach to the multiple ligaments injured knee. Arthroscopy 2003;19 (Dec. Suppl 1). Garrick JG (Ed). Orthopaedic Knowledge Update: Sports Medicine. American Orthopaedic Society for Sports Medicine. AAOS, Rosemont, 2004. Harner CD. Complex knee injuries including dislocation: Preoperative planning, evaluation and pitfalls. AAOS, Phoenix AZ, Feb 3-6, 2000. Hefti F, Muller W. Current state of evaluation of knee ligament lesions. The new IKDC knee evaluation form. Orthopade 1993;22:351-362.

ACUTE KNEE LIGAMENT INJURIES IN ATHLETES 2 Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg 1976;58A:159. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part II. The lateral compartment. J Bone Joint Surg 1976;58A:173. Hutchinson MR, Williams RI, Ireland ML. Knee Injuries. In: Ireland ML, Nattiv A. The female athlete. Philadelphia: W. B. Saunders, 2002, pp387-419. Ireland, M.L., Hutchinson, M.R., Gaudette, M., Williams R.I. The knee. In The Injured Athlete, 3rd ed. Perrin, D. (ed.) Philadelphia: Lippincott-Raven,1999, 353-419. Kurtz CA, Sekiya JK. Treatment of acute and chronic anterior cruciate ligament-posterior cruciate ligament-lateral side knee injuries. J Knee Surg 2005;18(3):228-239. Lim BO et al. Effects of sports injury prevention training on the biomechanical risk factors of anterior cruciate ligament injury in high school female basketball players. Am J Sports Med 2009;37(9):1728-1734. Maffulli N et al. Long-term health outcomes of youth sports injuries. Br J Sports Med 2010;44(1):21-25. Myer GD et al. Longitudinal assessment of noncontact anterior cruciate ligament injury risk factors during maturation in a female athlete: a case report. J Athl Train 2009;44(1):101-109. Mohtadi N. Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency. Am J Sports Med 1998;26(3):350-359. Moller M, Atterman J, Myklebust G, Wedderkopp N. Injury risk in Danish youth and senior elite handball using a new SMS text messages approach. Br J Sports Med 2012;46(7):531-553. Mueller W. The knee: Form, function, and ligament reconstruction. New York, Springer-Verlag, 1983, pp 80-84. Myklebust G, Steffen K,. Prevention of ACL injuries: how, when and who? Knee Surg Sports Traumatol Arthrosc 2009;17:857-848. Nicholas JA. Injuries to knee ligaments. JAMA 1970;212(13):2236-2239.

ACUTE KNEE LIGAMENT INJURIES IN ATHLETES 3 O’Brien WR, Friederich NF, Muller W, Henning CE. Functional anatomy of the cruciate ligaments. American Academy of Orthopaedic Surgeons Instructional Videotape. Park Ridge, Illinois, AAOS, 1991. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury Mechanisms for anterior cruciate ligament injuries in team handball: A systematic video analysis. Am J Sports Med 2004;32(4):1002-1012. Rotterud JH et al. Effect of gender and sports on the risk of full-thickness articular cartilage lesions in anterior cruciate ligament-injured knees: a nationwide cohort study from Sweden and Norway of 15783 patients. Am J Sports Med 2011;39(7):1387-1394. Spindler KP et al. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. Am J Sports Med 2011;39(2):348-359. Stijak L et al. Predicting ACL rupture in the population actively engaged in sports activities based on anatomical risk factors. Orthopedics 2011;34(6):431. Thomee R et al. Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2011;19(11):1798-1805. Zhang Y et al. Biomechanical simulation of anterior cruciate ligament strain for sports injury prevention. Comput Biol Med 2011;41(3):159-162.