Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
ACSM TPC Part 2 Miami, Florida • February 9, 2013
Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD
Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Acute 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
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
KNEE
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Knee Dislocation • • •
Happens on fields – not often, but: Don’t miss Assess vascular status • • • •
Physical exam Pulse ratios MRI scan Arteriogram
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Marcus Lattimore, running back, MOI: South Carolina vs. Tennessee
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Football: Knee Dislocation
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Knee dislocation ACL/PCL/MCL tears Skin only stabilizing medial side of the knee
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Medial meniscus
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Knee 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.
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Willis McGahee, Univ. of Miami 2003
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
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
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Knee 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
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Vascular Injury Arteriogram Gold Standard Injury ranges from : Thrombus Tear: Intimal Partial Complete Late Vascular compromise from: Thrombus Propagation of Intimal Tear
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
History • 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
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Surgery: Arthroscopy
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Surgery: MCL Repair
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Knee Instabilities
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
AMRI
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Gymnastics
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
ACL Tear
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Basketball
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Basketball
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Basketball: non-contact, unexpected, not thinking
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Knee Knee Instability Instability
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Knee Instabilities
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
ALRI
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
EUA: Correlate mechanism of injury, anatomy, surgical findings to study design in the lab
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Pivot Shift Lateral tibial plateau internally rotating, anteriorly subluxing at 30 to 0 degrees
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Medial compartment: compressive forces posterior medial meniscus, typical tear pattern vertical, posterior
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Injury Mechanisms – Body Positions
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Team Handball 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.
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
ACL Injury occurred, Foot fixed and externally rotated Wide stance, 15° knee flexion, 20 ° valgus, tibia IR 10 °
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
ACL injury occurred Foot fixed and externally rotated, knee 20°, tibia ER 10°, valgus 10°
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
Off-balance, in the air
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Soccer
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Knee Instabilities
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
PLRI
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Normal Knee Exam: PCL Exam
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
PCL – 22 YO Offensive Lineman
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
PCL • 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
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
ACSM TPC Part 2 • February 9, 2013
Mary Lloyd Ireland, MD
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Sideline Assessment of Injuries
To Make the Diagnosis: Use observation of mechanism, physical exam skills, and talk to the athlete
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Non-contact ACL tear, professional football athlete Injuries occur at all levels of talent and experience
ACSM TPC Part 2 • February 9, 2013
Jerry Jerry Rice Rice
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
Who Who is is driving driving the the sideline sideline decision decision and and return return to to play play train? train?
ACSM TPC Part 2 • February 9, 2013
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Acute Knee Ligament Injuries in Athletes
Mary Lloyd Ireland, MD
The End . . .
Thank You!
Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD
Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky
ACSM TPC Part 2 Miami, Florida • February 9, 2013
ACSM TPC Part 2 • February 9, 2013
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ACUTE KNEE LIGAMENT INJURIES IN ATHLETES ACSM TPC II Miami, Florida February 9, 2013
Mary Lloyd Ireland, M.D. UK Healthcare - Orthopaedics & Sports Medicine 601 Perimeter Drive #200 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):4961. 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.
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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.
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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.
