Sport Injury

 ACL
 PCL
 Medial/Lateral collateral ligament
 Medial/Lateral Meniscus
 ACL & PCL common in exam

Aims:
I. To determine which structures is involved
II. Perform special test to confirm diagnosis

How to differentiate Knee OA and sport injury?

 Knee OA= elderly (>50years old)
 Sport injury= younger

Chief complain:
I. Instability(no need D/D of pain)
II. Instability + Knee Pain(D/D of pain such as trauma,inflammatory joint disease,
Tumor,Infection,Degenerative)
 D/D of pain:
a. Trauma: ask about history of MVA and history of fall
b. Infection: Bacterial such as knee septic arthritis (fever, recurrent admission for
lung infection(pneumonia)(usually immunocompromised), history of long
antibiotic treatment in ward) and TB (hemotypsis, night sweat, fever, loss of
weight and appetite, history of TB contact)
c. Degenerative Disease: pain is mechanical and related to movement such as in
OA, start up pain (in the morning)
d. Tumor: Pain is Nocturnal (at night), severe type of pain, not relief by simple
analgesic, not related to movement (resting pain), loss of weight and appetite
e. Inflammatory joint disease:
- Rheumatoid Arthritis: mostly female patient, morning stiffness of the small
joint of hand and fingers lasted >1hour & >2weeks, symmetrical pattern on
both side, associated with Bouchard’s nodule (in proximal interphalangeal and
metacarpophalangeal joint)
 Heberden’s nodule in distal interphalangeal joint and seen in primary OA
- Ankylosing Spondylitis: mostly male patient, lower back pain which aggravated
by resting and relief by movement, shortness of breath, anterior
uveitis(blurring of vision)
- Gouty arthritis: ask about any history of medication taken for gouty arthritis
and any history of acute inflammation(pain or swelling) in first
metatarsophalangeal joint
- Reiter’s Syndrome: conjunctivitis(redness or inflammation of eyeball),
urethritis(painful micturition), arthritis(multiple joint pain)
-Psoriatic arthritis: scaly skin lesion
Analysis of chief complain: To know which structure is involved
I. Mechanism of injury
 MVA= PCL usually injured
 Sport injury= ACL usually injured

II. History of ‘POP’ sound

 Commonly in ACL injury, don’t have in PCL

III. Onset of swelling

 Immediate swelling after sport injury (within same day)= ACL injury
 Immediate swelling after MVA (within same day)= PCL injury

IV. What happened after swelling ?

 Swelling fluctuating (on & off)= Meniscus injury
 Because most of the tear at middle zone(red white zone), when patient not
walking, no bleeding, so no swelling, if walk, there is bleeding and swelling (on &
off swelling)
 Swelling regressed (no recurrent)(only 1 episode)= ACL & PCL injury

V. What happened when climbing up and down stairs?

 Pain on climbing up stairs= ACL injury
 Because femur move backwards and tibia move forward when climbing up stairs
to support (Normally ACL stable the tibia)
 Pain on going down stairs= PCL injury

VI. What happened when walking on even and uneven floor?

 Patient complain of instability and cannot walk on even floor= ACL& PCL injury
 Knee is in extended position when walk on even floor and normally it support by
ACL & PCL together.
 If only one of the ligament either ACL or PCL is injured, patient still can walk on
even floor.
 Patient complain of pain when walking on uneven floor= collateral ligament
injury
 Knee in flexion when walking on uneven floor and normally support by collateral
ligament

VII. Locking episode(sudden inability to extend knee)(tak boleh gerak kaki)

 In meniscus injury
 Patient need to rotate the tibia only can continue to extend knee

VIII. History of medication and hospitalization?

ACL injury:
I. Sport injury
II. Pop sound
III. Immediate swelling
IV. 1 episode of swelling
V. Difficulty climbing up stair
VI. Instability walk on even floor

Examination

1. Exposure: umbilicus and below

2. Ask patient to walk with shoe off to observe gait

 Antalgic gait due to pain (short stance phase)
 Lateral thrust gait in complete rupture of collateral ligament (knee move
outward when walking)

3. NO NEED squat and NO NEED inspect from front,back and side

4. Local Inspection:
a. Thigh:
 Look for Vastus Medialis Oblique
 Atrophy of VMO in ACL & PCL injury (thigh look smaller)
 Can measure if got time
b. Knee:
 Deformity: Go to foot end then bring foot together to see varus or valgus, NO
varus or valgus deformity in sport injury
 Scar: surgical and open wound scar
 Swelling
c. Leg:
 Inspect gastrocnemius and peroneus muscle for any atrophy
 Atrophy present usually

5. Palpation
a. Superficial
 Temperature of knee: not raise
 Soft tissue: Palpate VMO, gastrocnemius, peroneus for any atrophy
b. Deep
 Knee flex 90degree and examiner sit on patient foot.
 Then palapte from distal to proximal (mid shaft/shin) and using both thumb to
hook and press
1. First, palpate from mid shaft/shin of tibia then slowly go up to tibial tuberosity.
2. Then both thumb in tibial tuberosity in the middle.
3. Then one thumb move laterally towards the fibular head then go back to middle
4. Then another thumb move medially towards the pes anserinus then go back to
middle. (pes anserinus is the insertion for tendon of sartorius, gracilis and
semitendinosus, if pain= indicate patient either have rheumatoid arthritis or
anykylosing spondylitis)
5. Then slightly go up until feel a soft area, patella tendon and stop here.
6. Then one thumb move to lateral side along joint line(abit 斜上去), will feel
soft,soft then hard which is the lateral collateral ligament, then go back to middle
which is patellar tendon again.
7. Then another thumb move to medial side along joint line(abit 斜上去), will feel
soft,soft then hard which is the medial collateral ligament, then go back to middle
which is patellar tendon again.
8. Then go up along the border of patella.
 In sport injury, tenderness around joint line (especially medial joint line)

 Then, palpate hamstring, Achilles tendon, patella tendon after deep palpation

6. Movement

 Extension and flexion of knee

 Usually full ROM

7. Special Test

 Supine with knee extended

I. Knee in extension
II. Knee flex 30degree
III. Knee flex 90degree
IV. Knee flex fully
I. Lachmann Test (Knee in Extension) - For ACL injury
 Left hand, 4 fingers at back of calf muscle (insert from medial), thumb at tibial
tuberosity
 Right hand on thigh push femur down or posteriorly
 Left hand pull tibia up or anteriorly
 If patient bigger size, put our knee underneath patient knee then translate tibial
anteriorly
 Positive test= translation= ACL injury(2 bundle of ACL tear, if only 1 bundle=-
ve)

II. Valgus and Varus stress test (Knee flex 30 degree)- For Collateral ligament injury
 Left hand underneath the knee, with thumb palpate lateral joint line and middle
finger palpate medial joint line
 Maintain the knee in slightly flex at 30degree
 Right hand on patient ankle then do varus and valgus stress, if got injury or tear,
will feel widening of space
 Valgus stress(推进去): middle finger feel for opening of of medial joint line
 Varus stress(推出来): thumb feel for opening of lateral joint line
 If patient bigger size, put patient ankle under our armpit, then use both thumb
to feel medial and lateral joint line .

III. Knee flex 90 degree

a. Sagging Sign
 Flex both knee at 90 degree
 Go to side of patient to check for any posterior sagging by looking at tibial
tuberosity (curving backwards) and compare both side to see the level are equal
or not
 2nd method, we sit at patient foot, put thumb on medial side of patella and slide
thumb from medial side of patella to tibial tuberosity (both hand simultaneously
together), can feel a step off normally (medial step off)
 If no step off is felt= posterior sagging (tibial translate posteriorly)
 Then must correct the posterior sagging by put right thumb on medial joint line
and palm at back, and left thumb on tibial tuberosity.
 Then pull tibia anteriorly, after pulling out, then feel for the step off again from
the initially position then finally both thumb together at tibial tuberosity
 If can feel the step off= sagging is corrected then proceed to drawer test.

b.Anterior and Posterior Drawer Test(+ve even 1 bundle is tear)

 Knee flex 90 degree and sit on patient foot
 Make sure hamstring muscle completely relax
 Put both thumb on tibial tuberosity
 Our elbow in extended position and use our body weight to pull tibia anteriorly
(anterior drawer test) then push posteriorly (posterior drawer test)
 Positive test can see tibia translated

IV. Mc Murray’s Test (Knee in full flexion)- For Meniscus Injury

 Fully flex the knee( leg in contact with thigh)
 Put left hand on top of knee with thumb at lateral joint line and middle finger at
medial joint line
 Rotate the tibia medially and laterally(external and internal rotate) and hold
ankle with right hand
 Then extend slightly apply valgus or varus
 For lateral meniscus= Fully flex knee then internal rotate ankle, then extend
then varus
 For medial meniscus= fully flex knee then external rotate ankle, then extend
then valgus
 Positive test= Clicking sensation or painful facial grimase
Extra: Apley grinding test- Meniscus injury
 Prone position, knee flex 90degree, palm on patient heel and press down then
rotate internally and externally
 Lateral meniscus= pain on internal rotate
 Medial meniscus= pain on external rotate

Pivot shift test for ACL (not important)

Investigation
I. Laboratoy
 FBC
 ESR & CRP if pain
 No tumor marker
 No nerve conduction study

II. Radiological
 X-ray (not important)
 No ultrasound
 No CT scan
 MRI
 Colour of ACL PCL and meniscus= black
 Colour of synovial fluid= white/bright
 If whitish area seen between black area= ligament disconnected or torn part at
ligament or meniscus, so synovial fluid fill the space.

Treatment
I. Non operative
 Medication: pain killer
 Physiotherapy: quadriceps and hamstring muscle strengthening exercise, TENS,
heat therapy, shock wave diathermy, Ultrasound
 Injection: No need
 Immobilization: Knee brace/ guard

II. Operative
a. ACL reconstruction- from patellar tendon, achilles tendon, semitendinosus
tendon
b. PCL reconstruction- from patellar tendon, achilles tendon, semitendinosus
tendon
c. Meniscus repair or Menisectomy
 Indication for menisectomy= torn at white zone, locking episode

d. Collateral ligament reconstruction