CLINICAL PRACTICE GUIDELINES DOCUMENT CODE:

INSTITUTE / DEPARTMENT: SECTION:

Institute of Orthopedics and Sports Medicine Sport Medicine

TITLE: EFFECTIVITY DATE:

Clinical Practice Guidelines / Clinical Pathways for Sports Medicine

Page 1 of 2

Disease / Condition:

ANTERIOR CRUCIATE LIGAMENT (ACL) DEFICENT KNEES

Intended Users:

· Orthopedic Surgeons
· Rehabilitation Medicine/ Emergency Room Doctors
· Physical Therapists
· Nursing Services

Target Population:

· Patients with ACL Deficient Knees

Objectives:

· To identify, recognize and manage knee instability due to ACL injuries

Interventions and Practices:

· An injury to the ACL ligaments is most often a non-contact injury. A history of a popping
sensation in acute twisting of a hyperextended knee, associated with knee effusion, is highly
predictive of an ACL tear. Patients usually have difficulty bearing weight and ambulating.

· Physical examination may often reveal a swollen, tender knee in acute setting. The most
sensitive test for ACL tears is the Lachmann test. Other tests to check for ACL injuries include
the anterior drawer and pivot-shift test. It is also important to evaluate other associated injuries
by checking the neurovascular status, varus and valgus laxity, and joint line tenderness.

· AP and lateral knee xrays are requested in the setting of acute knee injuries to rule out
fracture/dislocation. However, ACL injuries are rarely diagnosed via radiographs, although
some clues may point towards an ACL tear diagnosis (i.e., condyle depressions, Segund
fractures). Magnetic resonance imaging (MRI) is the imaging modality of choice in confirming
ACL tears, as well as other concomittant injuries (ligaments, meniscal, or articular cartilage
injuries). It should be used in conjunction with history and physical examination.

· ACL reconstructive surgery is recommended for young active adults (18-25 years old), as it
decreases pathologic laxity, instability, and associated injuries (i.e., meniscal tears). (Moderate
recommendation). The recommended timing of surgery is within 5 months after injury to protect
articular cartilage and menisci. (Moderate). Use of either bone-patellar-bone graft and
hamstrings graft for reconstruction were recommended. There is also a strong
recommendation for early post-operative rehabilitation. There is limited evidence supporting
non-surgical management for low activity patients, as 25% of these patients will ultimately
require surgery (ACL reconstruction and/or meniscal surgery).
 CLINICAL PRACTICE GUIDELINES DOCUMENT CODE:

INSTITUTE / DEPARTMENT: SECTION:

Institute of Orthopedics and Sports Medicine Sport Medicine

TITLE: EFFECTIVITY DATE:

Clinical Practice Guidelines / Clinical Pathways for Sports Medicine

Page 1 of 2

Working Committee: Approved by:

JOSE RAUL C. CANLAS

Dept/Inst Head
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

SECTION:
INSTITUTE / DEPARTMENT: Sports Medicine
Institute of Orthopedics and Sports Medicine

EFFECTIVITY DATE:
TITLE:
Clinical Practice Guidelines / Clinical Pathways for Sports Medicine
Page 1 of 2

Disease / Condition:

MENISCAL TEARS

Intended Users:

· Orthopedic Surgeons
· Rehabilitation Medicine/ Emergency Room Doctors
· Physical Therapists
· Nursing Services

Target Population:

· Patients with meniscal tears

Objectives:

· To identify, recognize and manage joint line symptomatology due to meniscal tears

Interventions and Practices:

· Meniscal tears are defined as defects or splint in the meniscocapsular complex, and may be classified as
degenerative or non-degenerative. Physical examination is not as sensitive. Tests used are the Apley’s grind
test, McMurray’s test and direct joint line tenderness palpation. MRI evaluation can help in clinching the
diagnosis and helps classify lesions according to appearance: target, possible target, or no target. A target is
defined as any lesion for which surgery is indicated.

· It may also be classified according to clinical manifestations: locked knee, acute injury with a target meniscal
lesion, target meniscal lesion with symptoms and signs, possible target meniscal lesions with symptoms and
signs, and advanced structural osteoarthritis (OA).

· Urgent arthroscopic meniscectomy was recommended for patients with locked knee, with MRI-confirmed
findings. In patients with acute injury and a concomitant target lesion, meniscal preservation via repair is
recommended, depending if the location, configuration of tear and age is applicable. For symptomatic patients
with target meniscal lesions or possible target lesions, non-operative management may be tried for 3 months.
These include patient education, physical therapy, and intra-articular steroid injection. If still without
improvement after 3 months, arthroscopic surgery may be considered.
·
· Meniscal repair may be considered in acute meniscal tears located at the red-red up to red-white zones,
specifically located < 2 mm from the periphery. Longitudinal tears have the best capacity for healing. For other
meniscal tears not satisfying this criteria, with associated mechanical symptoms not responsive to
conservative therapy, partial meniscectomy is recommended. The goal is to remove only the torn area, while
retaining as much normal meniscus as possible, especially the peripheral rim.

· Patients with meniscal tears in the setting of advanced OA are not suitable candidates for arthroscopic
surgery.
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

SECTION:
INSTITUTE / DEPARTMENT: Sports Medicine
Institute of Orthopedics and Sports Medicine

EFFECTIVITY DATE:
TITLE:
Clinical Practice Guidelines / Clinical Pathways for Sports Medicine
Page 1 of 2

Outcomes Considered:

· Relief of pain, locking and functional disability

· Return to play / activities

Major Recommendations:

· Regular follow-ups with the orthopedic surgeon

· Compliance with rehabilitation protocols

Clinical Algorithms:

· Clinical Practice Guidelines Flow Chart

Review Method:

· Every 2 years

Guideline Availability:

· Institute of Orthopedics and Sports Medicine

References:

· Orthopedic Knowledge Update 9. American Academy of Orthopedic Surgeons, 2008.

Working Committee: Approved by:

JOSE RAUL C. CANLAS

Dept/Inst Head
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

INSTITUTE / DEPARTMENT: SECTION:

Institute of Orthopedics and Sports Medicine Sport Medicine

TITLE: EFFECTIVITY DATE:

Clinical Practice Guidelines / Clinical Pathways for Sports Medicine

Page 1 of 2

Disease / Condition:

PATELLAR DISLOCATION

Intended Users:

· Orthopedic Surgeons
· Rehabilitation Medicine Doctors
· Physical Therapists
· Nursing Services

Target Population:

· Patients with patellar dislocation

Objectives:

· To identify, recognize and manage patellar instabilities

Interventions and Practices:

· The history usually shows that the patient experienced buckling of the knee after twisting it.
Occasionally, a direct blow on the medial surface of the knee can result in a patellar
dislocation. The patient may narrate that a deformity was noted over the anterior knee and that
the knee was held in slight flexion. If the deformity was spontaneously reduced, straightening
the knee might have done it. Patients with recurrent patellar dislocation will give a history of a
previously similar injury.

· Physical examination of an unreduced patellar dislocation will reveal a knee that is partially
flexed with the patella lying laterally. The patient has tenderness along the lateral aspect of the
femur and medial patella or medial femoral epicondyle. The patellar apprehension test is
positive. In the physical examination, predisposing factors such as genu valgum, increased Q
angles, excessive foot pronation, patella alta, and generalized ligamentous laxity should also
be looked for. In addition, the knee should be examined for concomitant injuries.

· Radiographs include an AP and lateral view of the knee and a Merchant’s view for the patella.
Before requesting these, gently reduce the dislocation. One may instill a local anesthetic agent
intra-articularly prior to reducing the patella. Radiographs should be examined for abnormal
patellar tilt or lateral displacement and the presence of osteochondral fractures.

· For a first time patellar dislocation in which no malalignment is present and in which
radiographs are normal, after the patella has been reduced, further treatment consists of rest,
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

INSTITUTE / DEPARTMENT: SECTION:

Institute of Orthopedics and Sports Medicine Sport Medicine

TITLE: EFFECTIVITY DATE:

Clinical Practice Guidelines / Clinical Pathways for Sports Medicine

Page 1 of 2

cold compress over the area, immobilization in full extension for 6 weeks, and elevation to
reduced swelling. Thereafter, an aggressive quadriceps rehabilitation program is begun.
Rehabilitation of the patella-femoral joint emphasizes hamstring flexibility, gravity and active
assisted flexion, quadriceps control in the last 20 degrees of extension, and progressive
resistive exercises at low torque to decrease the potential for articular cartilage damage and
pain.

· For acute dislocation associated with recurrent instability, extremity malalignment, or abnormal
radiographs, examination under anesthesia and arthroscopic evaluation of the knee, particular
the patello-femoral articulation is recommended. Examination under anesthesia and
arthroscopy are helpful to identify osteochondral fractures, retinacular tears, and vastus
medialis obliquus (VMO) avulsions. Osteochondral loose bodies are removed from the joint
during arthroscopy. Surgical options to correct residual instability or tracking abnormalities
include medial capsulorrhaphy, lateral release, distal realignment, proximal realignment, and
surgical repair of the medial soft tissue restraints.

Outcomes Considered:

· Relief of pain and functional stability

· Return to play / activities

Major Recommendations:

· Regular follow-ups with the orthopedic surgeon

· Compliance with rehabilitation protocols

Clinical Algorithms: Flow chart

Review Method:

· Every 2 years

Guideline Availability:

· Institute of Orthopedics and Sports Medicine

References:

· Orthoped
ic Knowledge Update 9. American Academy of Orthopedic Surgeons, 2008.
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

INSTITUTE / DEPARTMENT: SECTION:

Institute of Orthopedics and Sports Medicine Sport Medicine

TITLE: EFFECTIVITY DATE:

Clinical Practice Guidelines / Clinical Pathways for Sports Medicine

Page 1 of 2

Working Committee: Approved by:

JOSE RAUL C. CANLAS

Dept/Inst Head
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

SECTION:
INSTITUTE / DEPARTMENT: Sports Medicine
Institute of Orthopedics and Sports Medicine

EFFECTIVITY DATE:
TITLE:
Clinical Practice Guidelines / Clinical Pathways for Sports Medicine
Page 1 of 2

Disease / Condition:

ACUTE LATERAL ANKLE SPRAINS

Intended Users:

· Orthopedic Surgeons
· Rehabilitation Medicine Doctors
· Physical Therapists
· Nursing Services

Target Population:

· Patients with patellar dislocation

Objectives:

· To identify, recognize and manage ankle inversion and eversion injuries

Interventions and Practices:

· Through the history, one can determine the mechanism of injury, gauge the severity of injury (could the patient
walk after the injury?), and whether there is an underlying chronic ankle instability.

· Through the physical examination, one can determine the most likely structures involved in the injury. In
addition, one should look for associated injuries.

· Radiographs of the ankle include the AP, mortise and lateral views to rule out fractures or syndesmotic
injuries. Stress radiographs are requested if a severe sprain or syndesmotic injury is suspected.

· Acute treatment consists of rest, ice, compression and elevation. Crutches are used until weight bearing is
possible without pain. Conservative treatment involves use of an ankle support for 3 – 6 months, range of
motion exercises, resistive exercises for the ankle evertors and dorsiflexors, and proprioception exercises.

· Grade I and II sprains involve a partial tear of the ligaments. Grade III tears are complete tears. Grade IIIa is a
complete tear of the ATFL, Grade IIIb is a complete tear of the ATFL and CFL, Grade IIIc is a complete tear of
the ATFL and CFL with involvement of the peroneal tendon (tear or subluxation), and Grade IV tears are
associated with a fracture.

· Surgical treatment for acute lateral ankle sprains involves non-anatomic or anatomic ligament reconstruction.
In addition, additional injuries such as osteochondral fractures and peroneal tendons tears or subluxation
should be addressed.
 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

SECTION:
INSTITUTE / DEPARTMENT: Sports Medicine
Institute of Orthopedics and Sports Medicine

EFFECTIVITY DATE:
TITLE:
Clinical Practice Guidelines / Clinical Pathways for Sports Medicine
Page 1 of 2

· The
conservative management of ankle fractures involves the use of a non-weight bearing long leg circular cast
(for some undisplaced fractures, a short leg circular cast may be used) for 6 weeks, followed by a short leg
walking cast for another 3 weeks. Radiographic control of the reduction should be done regularly.

· Surgical
management of ankle fracture pattern. In general, the fibula serves as the key to reduction. It should be
remembered, however, that the aim of surgery is to have a congruous articular surface, and this should
always be strived for.

· For chronic
instability, physical therapy with orthosis use is the initial form of treatment. If these fail, anatomic or
nonanatomic ligament reconstruction should be considered.

· ATFL –
anterior tralobular ligament

· CFL -
calcaneofibular ligament

Outcomes Considered:

· Relief of pain and functional disability

· Ankle stability
· Return to play / activities

Major Recommendations:

· Regular follow-ups with the orthopedic surgeon

· Compliance with rehabilitation protocols

Clinical Algorithms:

· Clinical Practice Guidelines Flow Chart

Review Method:

· Every 2 years
· Foot and Ankle Scoring Systems

Guideline Availability:

· Institute of Orthopedics and Sports Medicine

 DOCUMENT CODE:
CLINICAL PRACTICE GUIDELINES

SECTION:
INSTITUTE / DEPARTMENT: Sports Medicine
Institute of Orthopedics and Sports Medicine

EFFECTIVITY DATE:
TITLE:
Clinical Practice Guidelines / Clinical Pathways for Sports Medicine
Page 1 of 2

References:

· Orthopedic Knowledge Update 9. American Academy of Orthopedic Surgeons, 2008.

Working Committee: Approved by:

JOSE RAUL C. CANLAS

Dept/Inst Head