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Flashcards in Knee and sport Deck (279):

Mechanism of ACL injury

non-contact pivoting injury


Common associated injury in ACL tear

Lateral meniscus injured in 54%


Concomitant pathology in Chronic ACL tear (3)

1. OCD
2. Complex meniscal tear
3. Arthritis (controversial)


1. gender predisposition

2. Reason / details

1. F:M = 4.5:1

2.a. landing biomechanics and neuromuscular activation patterns (quadriceps dominant) play the biggest role

- females get ACL injury at younger age
- females get more ACL injuries on the supporting leg / males get more ACL injuries on the kicking leg


ACL Function
i. _______% responsible for prevention Ant. Translation of Tibia

ii. Secondary restraint to what other tibial motion

i. 85%

ii. Tibial rotation and varus/valgus rotation


ACL Anatomy
i. Length

ii. Width

i. 32mm

ii. 7-12mm


ACL Anatomy
Anteromedial bundle is:

i.more or less isometric?

ii. Tight throughout ROM but tightest in ____________

iii. Primarily stops _________
and is tested best by ________ test

i. More

ii. Flexion

iii. Primarily stops ANT. TIBIAL TRANSLATION and is tested by ANTERIOR DRAW TEST


ACL Anatomy:
Posterolateral bundle is:

i. more OR less isometric

ii. Tightest in _________ and slack in ___________

iii. Primarily responsible for ___________ stability (test:

i. LESS (ie. greater length changes with ROM)

ii. Tightest in EXTENSION and slack in MID-FLEXION

iii. primarily responsible for ROTATIONAL STABILITY (test: PIVOT SHIFT)


ACL Anatomy

i. Femoral attachment - anterior border ?

ii. Femoral attachment: Bony landmark separating AM/PL bundle

iii. The tibial attachment is anterior tibia between the __(a)___ just medial to anterior horn of __(b)___ meniscus

i. Lateral intercondylar ridge

ii. Bifurcate ridge




ACL Anatomy:
i. Blood supply

ii. Innervation

iii. Composition = 90% Type (a) and 10% Type (b) collagen

iv. Strength: ____ N (anterior)

i. middle geniculate artery

ii. posterior articular nerve (branch of tibial)

iii. a=type 1 ; b=type 3

iv. 2200


ACL Clinical:
i. Most sensitive test (physical exam) for ACL rupture ?

ii. Grading test
(a) A = ____ endpoint / B= ____ endpoint
(b) Grade 1: _____mm translation / Grade 2 ____mm / Grade 3 _____mm

iii. False test may occur with ________

i. Lachman's

ii. (a) A= firm ; B= no

(b) Grd 1 = 3-5mm / Grd 2 =5-10mm / Grd 3 = >10mm

iii. PCL tear


ACL Clinical
i. What is pivot shift ?

ii. Must have an intact ______ for this to work

i. Knee moved from ext to flex and joint reduces/"clunks" at 20-30° of flexion

ii. MCL


Imaging ACL: Segond fracture
i. What is a Segond fracture

ii. Segond represents a bony avulsion of the _____

iii. Assoc. with ACL in ____% of cases

i. Avulsion of prox lateral tibia

ii. Anterolateral ligament

iii. 75-100%


Imaging ACL: XRay

i. Apart from Segond # what other XR sign is assoc with ACL tear ?

ii. What causes this sign?

i. Deep sulcus (terminalis) sign
OR "sulcus sign"

ii. Depression on the lateral femoral condyle at the terminal sulcus
(Represents OCD fracture - OCD>1.5cm reliably associated with ACL injury)


Imaging ACL: MRI

i. sagittal view findings of ACL
(a) ___________

(b) ___________

(c) ___________

(a) discontinuity of fibres on T2

(b) abnormal orientation (flat compared to blumensaat line /intercondylar roof)
** can occur in chronic cases - ACL stick to PCL

(c) no ACL seen


imaging ACL: mri
i. bone bruising seen in > __%

ii. most common locations
(a) , (b) , (c)

i. >50%

(a) middle third of lfc (sulcus terminalis)

(b) Post. third of LTP

(c) Subchondral change persisting years in some cases


imaging : mri
finding on coronal view:
i.what is the "empty notch sign"?

Sign of ACL rupture -> caused by fluid against the lateral wall


Treatment ACL: Non-op

i. non-op treatment: indications

ii. factors linked to cartilage/meniscal damage in ACL deficiency (3)

i. low demand and decreased laxity

(1) Loss meniscal integrity

(2) Frequency of "buckling" episodes/instability

(3) Level I/II activity (jumping, cutting, side-to-side sport, manual labour)


Treatment ACL: Operative
i. indications (4)

- younger, more active

- children (strongly consider operative as activity limitation is not realistic)

- older active patients (age >40 is not a contraindication if high demand athlete)

- prior ACL reconstruction failure


ACL: Treating assoc. injury

i. MCL injury: How to Rx?

ii. Meniscal tear: How to Rx?

iii. posterolateral corner injury: How to Rx?

i. allow MCL to heal (varus/valgus stability) and then perform ACL

*** Note: varus/valgus instability can jeopardize graft***

ii. meniscal repair at the same time as ACL
*** Note: increased meniscal healing rate when repaired at the same time as ACL

iii. recon PLC at the same time as ACL or as 1st stage of 2 stage recon


ACL: Return to sport

i. What determines time to return to sport ? (3)

1) Psychological

2) Functional

3) Demographics


ACL Repair: what is BEAR procedure ?

Arthroscopic Bridge-Enhanced ACL Repair (BEAR) (note: trial with a bridging scaffold is ongoing)

**** addit: repair traditionally high failure rate


ACL Recon Technique: Femoral tunnel

i. Correct placement
(a) Sagittal placement

(b) Coronal placement

i(a). 1-2 mm rim of bone between the tunnel and posterior cortex of the femur

i(b). Lateral wall @ 9-10 o'clock position to create a more horizontal graft


ACL Recon Technique: Tibial tunnel

i. Correct placement
(a) Sagittal placement

(b) Coronal placement

i (a).
center of tunnel should be 10-11mm in front of the anterior border of PCL insertion

i (b). tunnel trajectory of < 75° from horizontal

*** obtain by moving tibial starting point halfway between tibial tubercle and a posterior medial edge of the tibia.


ACL Recon Technique: Graft Placement

i. Graft preconditioning can reduce ____ by up to 50%

ii. Graft tension

iii. position of knee during graft tension ?

i. stress relaxation up to 50%

ii. controversial
- 20N or 40N had no clinical outcome effects in a level 1 study
- DONT overtension

iii. 20-30° of flexion


Principles for revision ACL

i. technique (4)

ii. post-op (1)

i. (1) high-strength grafts (quads , hamstring, allograft)
(2) use dual fixation
(3) bone grafting (tunnel dilation, poor bone stock, staged)
(4) re-harvesting BTB is contraindicated

ii. conservative rehab


ACL Technique: Graft Selection

i. Bone-Tendon-Bone
(a) Pros (4)
(b) Cons (1)
(c) Complications (2)

ia. (1) longest data/Hx "gold-standard"
(2) bone-to-bone healing
(3) can rigidly fix joint line (screws)
(4) Strong @ 2600N

ib. (1) High incidence ant knee pain (up to 10-30%)

ic. (1) patella # (during rehab)
(2) rerupture (assoc w <20yo & graft size <8mm)


ACL Technique: Graft Selection

i. Quadruple hamstring autograft
(a) Pros (4)
(b) Cons (3)
(c) Complications (2)

ia. (1) less perioop pain; (2) less ant knee pain; (3) small incision (4) load to failure 4000N

(1) fixation strength may be < than BTB; (2) decreased peak flexion strength at 3 years vs. BTB; (3) concern re: hamstring weakness in female athletes --> increased risk of re-rupture

ic. (1) "windshield wiper" effect (ie. suspensory fix. causes tunnel abrasion & expansion with rpt knee ROM)
(2) residual hamstring weakness


ACL Allograft
i. pros

ii. cons

iii. processing
(a) Problem with processing allograft with supercritical CO2 and/or radition?

(b) Deep freezing and 4% Chlorhex cause __(1)__ but dont effect __(2)___

i. revision / no donor site morbidity

ii. (1) disease transmission (HIV <1.1 million / Hep even less); (2) slow integration; (3) re-rupture 4.3X higher in pt <20

iiia. both pre-Rx cause decreased strucutral and mech properties

iiib. (1) cell death; (2) strucutral and mech properties


ACL: Paediatric Considerations

Treatment in open physis
i. Non-op
(a) indications

ii. Operative
(a) indications

ia. (1) compliant, low demand pt with no additional intra-articular pathologies
(2) partial ACL tear (60% of adolescents) with near normal Lachman and pivot shift

iia. (1) complete tear


ACL: Paediatric Considerations

i. Technique:
(a) intra-articular (3)

(b) Combined intra-/Extra- articular - what age ?

(c) Adult type - what age ?

ia. (1) Physis sparing (intra-epiphyseal);
(2) Transphyseal (M<13-16; F<12-14);
(3) Partial transphyseal

ib. M<12; F <11

ic. M>16 ; F >14


ACL: Paediatric Considerations

i. (a) what graft? (b) why?

i. (a) soft tissue; (b) rarely cause growth arrest



ACL: Paediatric Considerations

i. Factors found to increase physeal injury include:

a) Tunnel diameter >____mm
b) ________ tunnel position
c) with OR without interference screw ?
d) ________ reaming
e) Others (3)

a) >12mm
(note: 8mm=3% of physis cross-sectional area / 12mm >7-9%)

b) Oblique

c) with = higher risk

d) high speed

e) (1) suturing close to tib tub; (2) lateral extra-art tenodesis; (3) dissection near ring of LaCroix


ACL Rehabilitation
i. immediate
a) Ice Y/N ?
b) Weight-bearing - Y/N?
c) Early passive full extension esp in what group?

a) Yes
b) Yes. Evidence for reductino in PFJ pain
c) Especially in assoc MCL injury OR patella dislocation


ACL Rehabilitation
i. Early
a) Eccentric strength in first __(1)__ weeks has shown __(2)__

b) ________ hamstrings/quads contraction

c) active knee motion ____ to _____ degrees

d) emphasize ______ chain exercise

e) Avoid ? (2)

ia. (1) 3 weeks; (2) incr quads volume and strength

ib. Isometric

ic. 35-90 degrees

id. closed chain (exs with foot planted)

ie. (1) Isokinetic quad strength (15-30°)
(2) open chain quad strength


ACL Surgery: Complications

Tunnel Malposition
i. Causes failure in ____%

ii. Femoral
(a) coronal
(b) Sagital

iii. Tibial
(a) coronal
(b) Sagital

i. 70% (most common cause of failure)

iia. vertical femoral tunnel placement = continued rotational instab

- ant placement = knee too tight in flexion and loose in extension; posterior misplacement (opposite previous)

iiia. ant placement = knee tight in flex + impingement in ext;
iiib. post. placement = ACL will impinge with the PCL


ACL Surgery: Complications

Other causes of failure (14)

1. inadequate graft fixation (graft-screw divergence >30 degrees)
2. missed diagnosis other injuries
3. overaggressive rehab
4. Infection
- coag -ve Staph most common; S. epi > s. aureus
-often can retain graft with multiple I&Ds and antibiotics (6 weeks minimum)
5. Loss of motion & arthrofibrosis (preoperative prevention; regain full ROM during pre-hab; higher risk in acute phase; Rx: <12/52= Rx with aggressive PT and serial splinting / > 12/52 Rx with lysis of adhesions/MUA
6. Infrapatellar contracture syndrome (decreased patellar translation on exam)
7. PT Rupture
8. Patella fracture (most fx occur 8-12/52 postop)
9 Hardware failure
10 Tunnel osteolysis (Rx with observation)
11. Late arthritis (related to meniscal integrity)
12. Local nerve irritation (saph.nerve)
13 Cyclops lesion (fibroproliferative tissue blocks ext; "click" heard at terminal extension)


Hip Labral Tear

1. definition

2. Epidemiology
a) incidence highest in patients with ___________

3. Demographics

4. Location of tear most commonly _________

1. Definition: Traumatic tear of the acetabular labrum that may lead to pain, intra-articular snapping hip

2. Epidemiology
a) incidence highest in patients with acetabular dysplasia

3. Demographics
◾seen in all age groups
◾patients commonly active females

4. Anterosuperior labrum most common location


Hip Labral Tear


1. etiology


1. etiology

i.) femoroacetabular impingement

ii.) hip dysplasia
◾ floppy labrum more susceptible to tearing

iii.) trauma
◾ hip disloc/sublux are a common cause

iv.) capsular laxity
◾incr. translational forces across labrum due to joint hypermobility

v.) joint degeneration
◾causes acetabular edge loading


Hip Labral Tear


1. Structure

2. Has 2 parts:
i. _________
◦ composed of __________
ii. ________
◦ composed of __________

3. Vascularity

4. Innervation

1. Structure : horse-shoe shaped structure continuous with transverse acetabular ligament

2. Has 2 parts:
i. articular
◦ fibrocartilage
ii. capsular
◦ dense connective tissue

3. Vascularity:
◦ capsule and synovium at acetabular margin

4. Innervation
◦branch of nerve to the quadratus femoris
◦obturator nerve


Hip Labral Tear


1. Symptoms

2. Physical examination
a.) provacation test for anterior labral tear?
b.)provacation test for posterior labral tear?

1. Symptoms
◦mechanical hip pain and snapping
◦may have vague groin pain
◦may be associated with a sensation of locking

2. Physical exam

a) provocative tests : anterior labral tear
◾pain if hip is brought from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction

b.) provocative tests : posterior labral tear
◾pain if hip is brought from a flexed, adducted, and internally rotated position to one of abduction, external rotation, and extension.


Hip Labral Tear


1. Gold standard

2. Radiographs


1. Gold Standard = MRI arthrogram
◾92% sensitive for labral tears
◾may be combined with intra-articular injections of lidocaine and steroid for diagnostic and therapeutic purposes

2. Radiographs
◾ useful to exclude other types of hip pathology
◾ may show: ◦ hip dysplasia ◦ arthritis ◦ acetabular cysts


Hip Labral Tear

Treatment : Non-op

1. details

2. Indications

3. Outcomes

1. Rest, NSAIDS, physical therapy, steroid injections

2. Indications
◾initial treatment of choice for all patients with labral tears

3. Outcomes
◾no long-term follow-up data on conservative management


Hip Labral Tear

Treatment : Operative

1. Arthroscopic labral debridement

a. Indications

b. Technique

c. Post-operative care

d. Outcomes
◾__to___% experience short-term relief of symptoms following arthroscopic debridement

2. Arthroscopic labral repair

a. indications

b. outcomes


1. Arthroscopic labral debridement

a.) Indications
◾symptoms that have failed to improve with nonoperative modalities
◾labral tear not amenable to repair

b.) Technique
◾remove any unstable portions of the labrum and associated synovitis
◾underlying hip pathology (e.g. FAI) should also be addressed at time of surgery

c.) Post-operative care
◾limited weight-bearing x4 weeks
◾flexion and abduction are limited for 4 to 6 weeks

d.) Outcomes
◾70-85% experience short-term relief of symptoms following arthroscopic debridement
◾long-term follow-up data not available

2. arthroscopic labral repair
a.) indications
◾symptoms and failed nonoperative modalities
◾full-thickness tears at the labral-chondral junction

b.) outcomes
◾unknown at this time


Hip Labral Tear

An active 23-year-old man has right groin pain that increases with sports activity. Examination reveals decreased internal rotation of the affected hip. He has a positive impingement test and radiographs reveal no crossover sign. An MRI scan is most likely to reveal which of the following?

1. Abnormal alpha angle and a chondrolabral tear
2. Acetabular retroversion
3. Heterotopic ossification
4. Ankylosing spondylitis
5. Coxa varum

A. Abnormal alpha angle and a chondrolabral tear

Young patients with hip pain and a positive impingement test are likely to have femoroacetabular impingement. The triad seen in these patients is a reduced concavity at the femoral head-neck junction, which leads to an increase in alpha angle and a chondrolabral tear. MR-arthrogram is the cross-sectional imaging modality of choice. These patients usually have reduced internal rotation and a positive impingement sign. The other findings, though possible, are not the most likely scenario in this young and active patient.


Hip Labral Tear

Which of the following statements best describes labral tears in the hip?

1. They are unrelated to degenerative joint disease.
2. They lead to increased movement of the femur relative to the acetabulum.
3. They usually result from lesions of the ligamentum teres.
4. They only occur with abnormal bone morphology.
5. They commonly occur in the posteroinferior quadrant of the hip.

A. They lead to increased movement of the femur relative to the acetabulum.

Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability. The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability


Femoroacetabular Impingement

A common cause of :
◦ early onset hip dysfunction
◦ secondary osteoarthritis

1. Epidemiology (3 Types)

1. Epidemiology

a.) Cam impingement
◾refers to FEMORAL disorder is usually in young athletic males and includes
◾decreased head-to-neck ratio
◾aspherical femoral head
◾decreased femoral offset
◾femoral neck retroversion
◾can be due to previous SCFE deformity

b.) Pincer impingement
◾refers to ACETABULAR based disorder usually in active middle-aged women and includes
◾anterosuperior acetabular rim overhang
◾acetabular retroversion
◾acetabular protrusio
◾coxa profunda

c.) Combined Cam/Pincer impingement
◾can include both patient populations
◾refers to combinations of above (up to 80%)


Femoroacetabular Impingement

1. Mechanism

2. Pathoanatomy (ie what is cause of pain/impingement)

3. Associated injuries (3)

1. Mechanism
◦ result of impingement of the femoral neck against anterior edge of acetabulum

2. Pathoanatomy
◾ proximal femur abuts acetabulum with range of motion, especially in flexion:
◦ occurs if femoral head/neck bone is too broad in
Cam impingement
◦ occurs if acetabular bone/labrum overhang is too broad in Pincer impingement

3. Associated injuries
◾ labral degeneration and tears
◾ cartilage damage and flap tears
◾ secondary hip osteoarthritis


Femoroacetabular Impingement


1. Symptoms

2. Examination findings

1. Symptoms
◦activity related groin or hip pain, exacerbated by hip flexion
◦difficulty sitting
◦mechanical hip symptoms
◦can present with gluteal or trochanteric pain (due to aberrant gait mechanics)

2. Exam
◦limited hip flexion (<90 degrees), especially with internal rotation (<5 degrees)
◦anterior impingement test (flexion, adduction, internal rotation) elicits pain
◦externally rotated extremity (can be due to post-SCFE deformity)


Femoroacetabular Impingement


1. Radiographs

2. Characteristic findings on radiographs

1. Radiographs
◾ Radiographic views
◦ false profile view:
- to assess anterior coverage of the femoral head
- standing position at an angle of 65° between the pelvis and the film (end-on to femoral head)

2. Characteristic findings
i.) Asphericity and contour of femoral head and neck ('pistol-grip' deformity)
◾ indicates Cam impingement

ii.) Examine for acetabular protrusio, retroversion, and coxa profunda
◾Crossover sign
◦indicates acetabular retroversion in Pincer impingement


Femoroacetabular Impingement

Imaging : Measurements

1. What is alpha angle ?

2. What is normal alpha angle ?

3. What is the head-neck offset ratio ?

4. What is the head-neck ratio ?

1. Alpha angle:

i.) Method = measured frog-leg lateral radiograph
◾ First line is drawn connecting the center of the femoral head and the center of the femoral neck
◾Second line is drawn from the center of the femoral head to the point on the anterolateral head-neck junction where prominence begins
◾The intersection of these two lines forms the alpha angle

2. Values of >42° are suggestive of a head-neck offset deformity

3. Head-neck offset ratio

i.) Method
◾Measured from lateral radiographs
◾Line #1 is drawn through the center of the long axis of the femoral neck
◾Line #2 is drawn parallel to line 1 through the anteriormost aspect of the femoral neck
◾Line #3 is drawn parallel to line 2 through the anteriormost aspect of the femoral head
◾The head-neck offset ratio is calculated by measuring the distance between lines 2 and 3, and dividing by the diameter of the femoral head

4. Normal values = If the ratio is <0.17, a cam deformity is likely present


Femoroacetabular Impingement

Treatment : Nonoperative

1. Details

2. Indications

1. observation

2. Indications
◾minimally symptomatic patient
◾no mechanical symptoms


Femoroacetabular Impingement

Treatment : Operative

1. Details (4 surgical treatment options)

2. Indications / Contraindications

3. Outcomes

1. Arthroscopic hip surgery

a.) Indications
◾symptomatic patient
◾mechanical symptoms

b.) Outcomes
◾recent literature supports arthroscopy shows equivalent results to open hip surgery

2. Open surgical hip dislocation

a.) Indications
◾gold standard for management of FAI for patients with clinical signs and structural evidence of impingement and...
◾preserved articular cartilage, correctable deformity, reasonable expectations

b.) Contraindications
◾age >55, morbid obesity, advanced joint disease

3. Periacetabular osteotomy

a.) Indications
◾structural deformity of acetabulum with poor coverage of femoral head

b.) technique ◾osteotomy and fixation

4. THR
a.) Indications
◾age >60 years and end-stage hip degeneration


Femoroacetabular Impingement

Operative Technique : Arthroscopic hip surgery

1. Approach

2. Technique

1. Approach
◾arthroscopic approach to the hip

2. Technique
◾trim femoral head/neck in Cam impingement
◾acetabular rim labral debridement vs repair
- isolated labral debridement will not solve problem without treatment of underlying pathology


Femoroacetabular Impingement

Operative Technique : Open surgical hip dislocation

1. Approach

2. Technique

1. Approach
◾anterior (Smith-Peterson) approach
◦ best for isolated femoral head/neck pathology due to limited exposure, although it is possible that acetabular side could be treated
◦ acetabular treatment involves take down of rectus femoris reflected head
◦ femoral osteotomy and fixation

2. Technique
◾uses a "trochanteric flip" for safe access to proximal femur and acetabulum
◦ provides best visualization for hip surgery
◦ preserves all external rotators and blood supply to femoral head (medial circumflex femoral artery)
**nb: no increase in AVN risk**
◦ provides wide exposure of femoral head and acetabulum


Femoroacetabular Impingement

Complications (3)


1. Femoral neck fracture
◦ at risk during open or arthroscopic debridement of Cam lesions
◦ risk is minimized by limiting depth of femoral head-neck osteochondroplasty to <30% of femoral neck diameter

2. Heterotopic Ossification

3. Persistent CAM and pincer lesions following arthroscopic treatment


Trochanteric Bursitis



2. risk factors


3. pathoanatomy

4. Trochanteric bursa is _(a)_ to the hip abductor muscles and _(b)_ to the iliotibial band

1. demographics
◾often occurs in female runners

2. risk factors
◾Is associated with training on banked surfaces

3. pathoanatomy
◾repetitive trauma caused by iliotibial band tracking over trochanteric bursa
◾can irritate the bursa causing inflammation

4. a) superficial ; b) deep


Trochanteric Bursitis


1. Symptoms

2. Physical exam

3. Imaging : Radiographs

4. Imaging: MRI

1. Symptoms
◦lateral sided hip pain, although hip joint is not involved
2. Physical exam
◦pain with palpation over greater trochanter
3. Imaging : Radiographs ◦will be unremarkable
4. Imaging :MRI
◦will show increased signal in bursa due to inflammation on T2 sequence


Trochanteric Bursitis


1. Nonoperative ◦NSAIDS, stretching, PT including modalities, corticosteroid injections
◾indications = first line treatment is always conservative

2. Operative ◦open vs arthroscopic trochanteric bursectomy
◾indications ◾is done only after conservative measures fail


Hip Arthroscopy

indications (10)

contraindications (5)

◦labral tears
◦AVN (diagnosis and staging)
◦loose bodies
◦synovial disease
◦chondral injuries
◦ligamentum teres injuries
◦snapping hip
◦mechanical symptoms
◦impinging osteophytes

•Contraindications ◦advanced DJD
◦hip ankylosis
◦joint contracture
◦severe osteoporotic bone
◦significant protrusio acetabuli


Hip Arthroscopy: Setup

1. Position ?

2. Joint distension

3. Requires traction
◾~__lbs of traction

4 _______ scope placed first. _______ portal placed second ◾then placed under fluoroscopic guidance with the hip flexed and in internal rotation ◦_______ portal placed last

1. Position ◦ supine or in lateral decubitus position

2. Joint distension ◦can load joint with saline to distend joint ◾typically done under flouroscopic guidance

3. requires traction in line with the femoral neck ◾well padded perineal post
◾~50 pounds of traction

4. ANTEROLATERAL scope placed first (arthroscope insertion over guidewire) ANTERIOR portal placed second ◾then placed under fluoroscopic guidance with the hip flexed and in internal rotation; POSTERIOR portal placed last


Hip Arthroscopy

anterolateral portal

1. function
2. location

1. function ◾primary viewing portal ◾anterolateral hip joint access

2. location and technique ◾located 2 cm anterior and 2 cm superior to anterosuperior border of greater trochanter ◾typically established first under fluoroscopic guidance


Hip Arthroscopy

Posterolateral portal

1. function
2. location

◦function ◾posterior hip joint access

◦location and technique ◾located 2 cm posterior to the tip of the greater trochanter


Hip Arthroscopy

Anterior portal

1. function

2. location

1. function ◾anterior hip joint access

2. location and technique ◾ located at intersection between ◾superior ridge of greater trochanter
◾ASIS ◾flexion and internal rotation of hip loosens capsule and assists scope insertion


Hamstring Injuries

Hamstring injuries can occur at any level in hamstring:

1. most common site?
2. avulsion of ischial tuberosity = less common and seen in:

3. Mechanism

4. Pathophysiology

1. myotendinous junction ◾is the most common site of rupture ◾often occurs during sprinting
2. i. seen in skeletally immature; ii. seen in water skiers
3. Mechanism ◦occurs as a result of hip flexion and knee extension
4. Pathophysiology ◦satellite cell plays a role in muscle healing following muscle injury


Hamstring Injuries: Relevant Anatomy

1. "Hamstring" muscles include:
i. / ii. / iii.

2. Common characteristics of hamstring muscles include:
i. originate on ______?
ii. innervated by _____ (____) nerve
iii. blood supply from ______ and ______artery
iv. cross and act upon 2 joints: the hip and knee (except ________)

Relevant Anatomy
1. "Hamstring" muscles
i. semimembranosus topic ◾most lateral attachment
ii. semitendinosus topic ◾semitendinosus and biceps femoris (long head) attach medial to semimembranosus
iii. biceps femoris
◾long head topic ◦ attaches medial to semimembranosus
◾short head topic ◦ origin from linea aspera
2. Common characteristics of hamstring muscles include ◦originate on ischial tuberosity
◦innervated by sciatic (tibial) nerve
◦blood supply from inferior gluteal artery and profunda femoral artery
◦cross and act upon 2 joints: the hip and knee (except short head of biceps femoris)


Hamstring Injuries

1. Physical exam findings

2. XRay may show ____

3. MRI may show _____

1. Physical exam ◦ecchymosis in posterior thigh
◦may have palpable mass in middle 1/3 of posterior thigh (myotendinous rupture)
◦normal hamstring/quadricep ratio is 65%
◦stiff legged gait (avoiding knee and hip flexion)

2 . avulsion off ischial tuberosity

3. avulsion off ischial tuberosity


Hamstring Injuries: Treatment


1. details
2. indications
3. return to play

Treatment :Nonoperative
1. rest, ice, NSAIDS, PWB for 4/52 followed by stretching and strengthening

2. ◾most hamstring injuries
◾single tendon, retraction ≤1-2cm ◾rupture at myotendinous junction

3. Return to play ◾only when strength is 90% of contralateral side to avoid further injury


Hamstring Injuries: Treatment


2. surgical technique

3. results

1. indications:
◾proximal avulsion ruptures ◾partial avulsion that has failed nonop rx for 6/12
◾at least 2 tendons but > 2cm retraction in young, active patients

2. surgical technique
◾TV incision at gluteal crease
◾protect sciatic nerve
◾mobilization of the ruptured tendons
◾repair to the ischial tuberosity with the use of suture anchors

3. results
◾easier to mobilize acute ruptures than chronic ruptures
◾repair of acute ruptures has less sciatic nerve scarring (nb: chronic ruptures may require sciatic neurolysis)


Hamstring Injuries:

1. _______in knee flex, hip ext
2. What is hamstring syndrome ◦posterior buttock and ischial tuberosity pain
3. What is Rx for hamstring syndrome
4. _______scarring and _________

1. Weak in knee flex; hip ext
2. Hamstring syndrome= posterior buttock and ischial tuberosity pain
3. Treatment ◾surgical release and sciatic nerve decompression
4. Sciatic nerve scarring and sciatic neuralgia


Quadriceps Contusion

1. An injury commonly seen in athletes ◦occurs as a result of _______

1. An injury commonly seen in athletes ◦occurs as a result of direct trauma
(common in contact sports)


Quadriceps Contusion

1. Symptoms

2. Physical exam

3. Compartment syndrome rare: test sensory branches of ______ nerve (____, ______, and _______ cutaneous nerves)

1. Symptoms
◦pain at anterior thigh
2. Physical exam ◦tenderness at ant thigh
◦ltd active knee flex due to pain
◦possible knee effusion
◦perform SLR to ensure ext mech intact
3. Femoral nerve (lateral, intermediate, and medial cutaneous nerves) during evaluation for compartment syndrome


Quadriceps Contusion: Imaging

1. Radiographs

2. MRI

1. XRay
◦imaging not necessary if mild contusion and ext mech intact
◦plain radiograph to evaluate for myositis ossificans in chronic injuries
2. MRI ◦ highest sens/spec disorders of the quadriceps
◦MRI helpful in moderate to severe contusions or if quadriceps tendon competency in doubt


Quadriceps Contusion

What is myositis ossificans?

Sustained at any level of play or competition, myositis ossificans is the formation of bone tissue inside muscle tissue after a traumatic injury to the area.


Quadriceps Contusion: Treatment

1. technique
a) acute phase
b) subacute phase

2. indications

3. Angiotensin II receptor blockade (e.g. Losartan
a) indications
b) mecahnism

Treatment : Nonoperative

1a) Immobilize in 120 degrees of knee flexion for 24 hrs followed by therapy
◾cold therapy
◾ACE bandage or hinged knee brace
1b) ◾begin active pain-free quads stretching several times a day thereafter ◾WBAT (crutches often needed initially)
◾close monitoring for compartment syndrome

2. indications: ◾acute injuries

3. ATIIRB (e.g. Losartan)
a) indications: ◾increase muscle regeneration after contusion ◾decrease fibrosis
b) mechanism: ◾blockade of IGF ◾reduces apoptotic cascade of muscle


Quadriceps Contusion: Treatment


Operative: thigh fasciotomies
-> compartment syndrome


Quadriceps Contusion: complications

1. Compartment syndrome ◦usually rupture of deep perforating branches of the _____________

2. Myositits ossificans ◦incidence of __to__% rate with quadriceps contusion

1. Compartment syndrome ◦usually rupture of deep perforating branches of the vastus intermedius

2. Myositits ossificans ◦incidence of 5-9% rate with quadriceps contusion


Meniscal Injury Epidemiology:most common indication for knee surgery
1. higher risk in _____ knees
2. _____ tears = more common EXCEPT in the setting of an acute ACL tear
3. Degenerative tears in older patients usually occur in the _________ horn _____ meniscus

1. Epidemiology:◦higher risk in ACL deficient knees

2. MEDIAL tears = more common than lateral tear EXCEPT in the setting of an acute ACL tear where lateral tears are more common

3. POSTERIOR horn of MEDIAL meniscus


Meniscal Injury

Classification = Descriptive
1. Location
2. size
3. pattern (6)

Descriptive classification
1) Location ◾red zone (outer third, vascularized) ◾red-white zone (middle third) ◾white zone (inner third, avascular)
2. Size
3. pattern
i) vertical/longitudinal ◦ common, esp. with ACL tears ◦ repair when peripheral
ii) bucket handle ◦ vertical tear which may displace into the notch
iii) oblique/flap/parrot beak ◦ may cause locking
iv) radial
v) horizontal ◦ more common in older population ◦ may be assoc with meniscal cysts
vi) complex


Meniscal Injury

Special tests ? (3)

1. Apleys compression

2. Thessaly test

3. McMurray


Meniscal Injury: Special tests ? (3)

1. Thessaly test

2. Apley compression

1. Thessaly test
◾standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking.

2. Apley compression ◾perform prone


Meniscal Injury

1. McMurray's test

1. McMurray's test
◾flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
◾a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.


Meniscal Injury

1. Radiographs - acute vs chronic
2. MRI
a) indications
b) findings
3. _______ indicates the presence of a meniscal tear
4. what does "double PCL" sign indicate ?
5. What does "double anterior horn" sign indicate ?

1. Normal vs. Meniscal calcifications
2. MRI
a) MRI is most sens. but also has a high false positive rate
b)◾MRI grade III signal is indicative of a tear ◾linear high signal that extends to either superior or inferior surface of the meniscus
3. Parameniscal cyst
4. bucket handle tears
5. bucket handle tears


Meniscal Injury

Complications (6)

1. Saph neuropathy (7%)
2. Arthrofibrosis (6%)
3. Sterile effusion (2%)
4. Peroneal neuropathy (1%)
5. Superficial infection (1%)
6. Deep infection (1%)


Meniscal Injury: Treatment

1. Nonop indications

Non-operative ◦rest, NSAIDS, rehabilitation ◾indicated as first line of treatment for degenerative tears


Meniscal Injury: Operative

Partial meniscectomy
1. indications
◾>80% satisfactory function at minimum follow-up
◾50% have Fairbanks radiographic changes (osteophytes, flattening, joint space narrowing)
◾predictors of success ◾age <40yo
◾normal alignment
◾minimal or no arthritis
◾single tear

1. indications: ◾ tears not amenable to repair (complex, degen, radial tear)
◾repair failure >2 times

2. Outcomes:
◾>80% satisfactory function at minimum follow-up
◾50% have Fairbanks radiographic changes (osteophytes, flattening, joint space narrowing)


Meniscal Injury: Operative

Partial meniscectomy

1. predictors of success? (4)

1. predictors of success
a) age <40yo
b) normal alignment
c) minimal or no arthritis
d) single tear


Meniscal Injury: Operative

Meniscal repair

1. indications: best candidate for repair is a tear with the following characteristics:
a.) zone ?
b.) rim width
c.) type of tear ? (2)
d.) ____mm in length

1. indications
a.) peripheral in the red-red zone (vascularized region)
b.) rim width= distance from the tear to the periph meniscocapsular junction (blood supply) ** rim width correlates with the ability of a meniscal repair to heal (lower rim width has better blood supply)
c.) vertical and longitudinal
d.) 1-4 mm in length


Meniscal Injury: Operative

Does ACL reconstruction improve meniscal repair outcomes?

◾traditional literature ?

◾current literature ?

Acute repair combined with ACL reconstruction:

◾traditional literature report higher healing rates with concurrent ACL reconstruction

◾current literature shows no difference in healing for 2nd generation all-inside repairs with/without concomittant ACL reconstruction


Meniscal Injury: Operative

1. __to__% successful
2. highest success when ________
3. poor results with _______(30%)

1. 70-95% successful

2. highest success when done with concomitant ACL recon

3. poor results with untreated ACL-deficiency (30%)


Meniscal Injury: Operative

Meniscal transplantation

1. indications (1)

2. Contraindications (6)

1. Indications:
◾young patients with near-total meniscectomy --> especially lateral

2. Contraindications
◾inflammatory arthritis
◾marked obesity
◾grade IV chondrosis (if not concurrently addressed)
◾malalignment (if not concurrently addressed)
◾diffuse arthritis


Meniscal Injury: Operative

Meniscal transplantation

1 Outcomes
◾requires ____ months for graft to fully heal
◾RTS by ____mths
◾re-tears or extrusion are ________
2. Ten-year follow-up showed: ◾_________ subjective pain and function scores
◾most had radiographic _________________

Meniscal transplantation
1. Outcomes
◾8-12 months
◾RTS @ 6-9 months
◾re-tears or extrusion are COMMON
2. Ten-year follow-up showed:
◾PERSISTENT IMPROVEMENT in subjective pain and function scores


Meniscal Injury: Operative

Total meniscectomy: Technique is of historical interest only

1. outcomes ?

1. Outcomes
◾20% have significant arthritic lesions and 70% have radiographic changes three years after surgery
◾100% have arthrosis at 20 years
◾severity of degenerative changes is proportional to % of the meniscus that was removed


Meniscal Injury: Operative Technique

Partial Meniscectomy

1. Approach

2. Technique

3. Post-op/Rehab

1. approach ◾standard arthroscopic approach
2. Technique ◾minimize resection (DJD proportional to amount removed) ◾do not use thermal (heat probes)
3. Postop ◾early AROM ◾prolonged immob (10/52) is detrimental to healing in a dog model


Meniscal Injury: Operative Technique

Meniscal repair
1.) Gold standard Technique ?

2.) Medial approach to capsule: ◾expose capsule by incising the _(a)_ fascia ◾retract _(b)_tendons/_(c)_ posteriorly
◾developing plane between the _(d)_and _(e)_

3. Lateral approach to capsule ◾develop plane between_(a)_and _(b)_ tendon; ◾then retract _(c)_ posteriorly

1. inside-out technique is 'Gold Standard'

2a. sartorius fascia
2b. retract pes tendons
2c. Semimembranosus
2d. medial gastrocnemius
2e. capsule

3a. IT band
3b. biceps tendon
3c. lateral head of gastrocnemius


Meniscal Injury: Meniscal repair

Inside-out is considered gold standard but other approaches include ? (3)

1. all-inside technique (suture devices with plastic or bioabsorbable anchors) ◾most common
◾many complications (device breakage, iatrogenic chondral injury)

2. outside-in repair ◾useful for anterior horn tears

3. Open repair ◾uncommon except in trauma, knee dislocations


Meniscal Injury: Meniscal Injury: Meniscal repair

1. Technique (general principles)
◾Suture type?
◾Role of rasping?

2. Risks
◾___ nerve (med approach)
◾___ nerve (lat approach)
◾___ vessels

1. Technique
◾vertical mattress sutures are strongest because they capture circumferential fibers
◾healing is enhanced by rasping
2. Risks
◾SAPHENOUS nn. & vv (medial approach)
◾PERONEAL nn. (lateral approach)
◾POPLITEAL vessels


Meniscal Injury: Meniscal Transplantation

1. Technique
a. ____to ____ healing with plugs at each horn or a bridge between horns
b. peripheral _____ sutures
c. correct sizing of the allograft is essential (commonly based on radiographs, within __to__10% error tolerated)

1. Technique
a. BONE-TO-BONE healing with plugs at each horn or a bridge between horns

b. peripheral VERTICAL MATTRESS sutures

c. Correct sizing of the allograft is essential (commonly based on radiographs, within 5-10% error tolerated)


Meniscal Cysts

1. Definition

a. Incidence
b. Demographics

1. A condition characterized by a local collection of synovial fluid within or adjacent to the meniscus

2. Epidemiology
a. incidence=◾no studies of the general population; ◾found in 1-4% of MRIs
b. Demographics= ◾most commonly assoc. with a meniscal tear; ◾no trend to increased age


Meniscal Cysts

1. Location (2)

1. Location
◾perimeniscal cysts◾small lesions of fluid within the meniscus
◾parameniscal cysts (e.g., baker cysts) ◾extruded fluid outside the meniscus (most common)


Meniscal Cysts

1. Perimeniscal cysts:
◾_(a)_ cysts more common than _(b)_ (2:1)
◾_(c)_ cysts = post. horn
◾_(d)_ cysts = ant. horn or mid-portion

2. Parameniscal cysts (e.g., baker cysts):
◾ __a__ common than perimeniscal cysts
◾usually located between _(a)_ and _(b)_ of gastrocnemius

1. Perimeniscal cysts
a) MEDIAL cysts
b) LATERAL (2:1)
c) MEDIAL cysts = post. horn
d) LATERAL cysts = ant. horn or mid-portion

2. Parameniscal cysts (e.g., baker cysts)
a) MORE common
b) SEMIMEMBRANOSUS and c) MEDIAL HEAD of gastrocnemius


Meniscal Cysts: Pathophysiology

1. Mechanism of injury
2a. Horizontal and complex tears usually = ____meniscal cysts
2b. Radial or vertical tears, usually = ____meniscal cysts

3. Associated conditions:
a. _________
b. _________

1. mechanism of injury◾meniscal tear functions as a one-way valve;◾synovial fluid extrudes and then concentrates to form gel-like material

2. Pathoanatomy
a) horizontal and complex tears, usually = PARAmeniscal cysts
b) radial or vertical tears, usually = PERImeniscal cysts

3. Associated conditions:
a) Chondral injury +/- OCD
b) ACL tear


Meniscal Cysts: Anatomy

1. Meniscus composition
2. Meniscus composed of __to__% water
3. Collagen ◾__ % Type I collagen
4. Medial meniscus shape?
5. Lateral meniscus shape?

1. Meniscus composition
◾fibroelastic cartilage
◾interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements
2. 65-75% water
3. 90 % Type I collagen
4. Stretched-out, C-shape with triangular cross section
5. Lateral meniscus:◾more circular in shape◾covers larger area of articular surface


Meniscal Cysts

1. Blood supply
a. Medial meniscus
b. Lateral meniscus

2. Central ___% of meniscus receive nutrition through diffusion through synovial fluid

1. Blood supply
a.) med inf genicular artery
◾supplies peripheral 20-30% of medial meniscus
b.) Lat inf genicular artery
◾supplies peripheral 10-25% of lateral meniscus

2. Central 75% of meniscus' receive nutrition through diffusion


Meniscal Cysts

1. History

2. Symptoms (4)

3. Examination
a.) inspection
b.) palpation
c.) motion

1. May have recent trauma
2. Symptoms
i. asymptomatic
ii. pain ◾localized to medial/lateral joint line or back of knee
iii. mechanical symptoms
iv. delayed or intermittent knee swelling
v. weakness or claudication (NV impingement)

a.) inspection◾popliteal mass (best seen with knee in ext)
b.) palpation◾joint line tenderness◾palpable mass
c.) motion◾crepitus


Meniscal Cysts

1. Radiographs

2. MRI findings:
◾cyst with bright ___ signal
◾ _i_, _ii_ and _iii_ can all resemble cysts on MRI

1. Radiographs should be normal in young pt with acute meniscal injury or cyst

2 MRI findings:
◾cyst with bright T2 signal
◾(i) NECROTIC TISSUE; (ii) NERVE SHEATH tissue and (iii) PUS can all resemble cysts on T2-weighted MRIs
(** IV contrast enhancement may be needed)


Meniscal Cysts: Treatment

1. Rest, NSAIDS, rehabilitation
a) indications:
b) outcomes

2. Aspiration and CSI
a) Indication
b) Outcomes

1a. First-line of Rx for small perimeniscal cysts and parameniscal cysts

1b. Trial of medical therapy to observe patients pain response ◾may be effective in population with degenerative tears

2a. Isolated baker's cysts in young patient

2b. Poor outcomes in older degenerative mensical tears with associated cysts


Meniscal Cysts: Operative

1. Arthroscopic debridement, cyst decompression and meniscal resection
a. indications
b. Outcomes

2. Cyst excision using open posterior approach
a. indications
b. outcomes

1a. perimeniscal cysts with an associated tear that is not amenable to repair (e.g., complex, degenerative, radial tear patterns)
1b. Incomplete meniscal resection may lead to recurrence

2a. Symptomatic parameniscal cysts
2b. Incomplete resection may lead to recurrence


Discoid Meniscus

1. Definition
2. Discoid meniscus is ____ than usual
3. Also referred to as "___-____syndrome"
4. Present in __to__% of population
5. Usually ______ meniscus
6. ___% bilateral

1. Abnormal development of the meniscus leads to a hypertrophic and discoid shaped meniscus
2. Discoid meniscus is LARGER than usual
3. "POPPING-KNEE syndrome"
4. Present in 3-5% of population
5. Usually LATERAL meniscus
6. 25% bilateral


Discoid Meniscus

1. Eponymous name?
2. Types?

1. Watanabe Classification

2. Type I-III
a. Type I: Incomplete
b. Type II: Complete
c. Type III: Wrisberg

** Type III untable as no peripheral attachment other than ligament of Wrisberg**


Discoid Meniscus: Presentation

1. Symptoms

2. Physical exam

1. Symptoms
◦pain, clicking, mechanical locking
◦often becomes symptomatic in adolescence

2. Physical exam
◦mechanical symptoms most pronounced in extension


Discoid Meniscus: Imaging

1. XR - recommended views?

2. XR findings (3)

1. AP and lateral of knee

2. Findings:
a) wide joint space (up to 11mm)
b) squaring of lateral condyle with cupping of lateral tibial plateau
c) hypoplastic lateral intercondylar spine


Discoid Meniscus: Imaging

1. MRI indications

2. Findings

1. MRI = study of choice for suspected symptomatic meniscal pathology

2. Findings (3)
(a) Diagnosis can be made with 3 or more 5mm sagittal images with meniscal continuity ("bow-tie sign")
(b) Sagittal MRI will show abnormally thick and flat meniscus
(c) Coronal MRI will show thick and flat meniscal tissue extending across entire lateral compartment


Discoid Meniscus: Treatment

Nonoperative ◾observation

1. Indications?

Nonoperative ◦observation

1. Indications
◾asymptomatic discoid meniscus without tears


Discoid Meniscus: Operative Treatment

Partial meniscectomy and saucerization

1. Indications

2. Technique

1. Indications
◾pain and mechanical symptoms
◾meniscal tear or meniscal detachment

2. Technique
◾obtain anatomic looking meniscus with debridement
◾repair meniscus if detached (Wrisberg variant)


PCL Injury

1. __to__% of all knee ligamentous injuries

2. Mechanism (3)

1. 5-20% of all knee ligamentous injuries

2. MOI:
(i) Direct blow to proximal tibia with a flexed knee (dashboard injury)
(ii). noncontact hyperflexion with a plantar-flexed foot
(iii). hyperextension injury


PCL Injury

1. Pathoanatomy
a) PCL = primary restraint to ______
b) functions to prevent ________
C) isolated injuries cause the greatest instability at __° of ___

1a. PCL is the primary restraint to POST. TIBIAL TRANSLATION

1b. Functions to prevent HYPERFLEXION/SLIDING

1c. Isolated injuries cause the greatest instability at 90° of FLEXION


PCL Injury

1. Associated conditions

◦ combined PCL and posterolateral corner (PLC) injuries
◦ multiligamentous knee injuries
◦ knee dislocation


PCL Injury

Prognosis with chronic PCL deficiency

◾ PCL def. leads to increased contact pressures in the PFJ & medial compartment due to varus alignment

◾Controversial whether late patellar and MFC chondrosis will develop


PCL Injury: Anatomy
1. Origin
2. Insertion
3. Dimensions
◾__ mm length x __mm diameter
◾PCL is ___% larger than the ACL
4. PCL has two bundles
5. Lies between the meniscofemoral ligaments ◾ligament of _____ (anterior) and ligament of ______ (posterior)

1. posterior tibial sulcus below the articular surface
2. anterolateral medial femoral condyle◾broad, crescent-shaped footprint
3. Dimensions
◾38 mm in length x 13 mm in diameter
◾PCL is 30% larger than the ACL
4a. Anterolateral bundle
◾tight in flexion
◾strongest and most important for posterior stability at 90° of flexion
4b. Posteromedial bundle
◾tight in extension
◾reciprocal function to the anterolateral bundle
5. Lig. of Humphrey (ant) / Lig. of Wrisberg (post) ◾originate from the posterior horn of the lateral meniscus and insert into PCL substance


PCL Injury

1. Blood supply

2 Biomechanics
a. strength is ___to___N (posterior)
b. minimizes posterior tibial displacement (__%)

1. Blood supply ◦supplied by branches of the middle geniculate artery and fat pad

2. Biomechanics
a) strength is 2500 to 3000 N (posterior)

b) minimizes posterior tibial displacement (95%)


PCL Injury: Classification based on posterior subluxation of tibia relative to femoral condyles (with knee in 90° of flexion)

Grades I-III

1. Grade I (partial)

2. Grade II (complete isolated)

3. Grade III (combined PCL and capsuloligamentous)

1. Grade I (partial) ◾1-5 mm PT translation;◾tibia remains anterior to the femoral condyles

2 Grade II (complete isolated); ◾6-10 mm PT translation; ◾complete injury in which the anterior tibia is flush with the femoral condyles

3. Grade III (combined PCL and capsuloligamentous) ◾>10 mm posterior tibial translation; ◾tibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC injury


PCL Injury

Varus/valgus stress
1. Laxity at 0° indicates _____ injury?
2. Laxity at 30° alone indicates _____injury

Posterior sag sign
3. The medial tibial plateau of a normal knee at rest is ___mm ______ to the medial femoral condyle

4. Posterior draw
(*nb: most accurate maneuver for diagnosing PCL injury)

1.. MCL/LCL and PCL injury

2. MCL/LCL injury

3. The medial tibial plateau of a normal knee at rest is 10mm ANTERIOR to the medial femoral condyle

4. (a) Isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in internal rotation; (b) combined ligamentous injuries translate >15 mm in neutral rotation and >10 mm in internal rotation


PCL Injury: Physical examination

1. Quadriceps active test

2. Dial test

1. Quadriceps active test:
◾attempt to extend a knee flexed at 90° = positive if anterior reduction of the tibia occurs relative to the femur

2. Dial test
◾> 10° ER asymmetry at 30° & 90° consistent with PLC and PCL injury
◾> 10° ER asymmetry at 30° only consistent with isolated PLC injury


PCL Injury: Radiographs

1. Recommended views

2. Additional view: Lateral Stress view
a) Technique
b) Significant findings
c) Role in PCL injury

1. AP and supine lateral

2. Lateral stress view
◾apply stress to ant. tibia with knee flexed to 70°
◾asymmetric posterior tibial displacement indicates PCL injury
◾contralateral knee differences >12 mm on stress views suggest a combined PCL and PLC injury
◾becoming the gold standard in diagnosing and quantifying PCL injuries


PCL Injury Treatment: Nonoperative

1. PWB & rehab
(a) Indications
(b) Modalities
(c) Outcomes

2. Relative immobilization in extension for 4 weeks
(a) Indications
(b) Modalities

1a. isolated Grade I (partial) and II (complete isolated) injuries
1b. Quads rehab with focus on knee ext strengthening
1c. RTS in 2-4 weeks

2a. Indications
◾Isolated Grade III injuries
◾surgery may be indicated with bony avulsions or a young athlete
2b.◾extension bracing with limited daily ROM exercises
◾immobilization is followed by quadriceps strengthening


PCL Injury Treatment: Operative

1. ________

2. ________

1. PCL repair of bony avulsion fractures or reconstruction

2. High Tibial Osteotomy


PCL Injury Treatment: Operative

PCL repair of bony avulsion fractures or reconstruction

Indications (3)

1) Combined ligamentous injuries:
◦ PCL + ACL or PLC injuries; ◦ PCL + Grade III MCL or LCL injuries

2) Isolated Grade II or III injuries with bony avulsion

3) Isolated chronic PCL injuries with a functionally unstable knee


PCL Injury Treatment: Operative

PCL repair of bony avulsion fractures or reconstruction

1. Repair
2. Recon
3. Allograft OR autograft most commonly utilised ?

1. Repair: primary repair of bony avulsion fractures with ORIF

2. Reconstruction options include
◾tibial inlay vs. transtibial methods
◾single-bundle vs. double-bundle
◾autograft vs. allograft

3. Allograft is typically utilized with multiple graft choices available:
◾options include - Achilles, B-PT-B, hamstring, and anterior tibialis


PCL Injury Treatment: Operative

1. Primary repair ?
2. Comparison PCL recon compared to ACL recon
3. Successful reconstruction depends on _______?

1. Good results with ORIF of bony avulsions; Poor result with repair of midsubstance ruptures

2. PCL < Successful than ACL recon (*residual posterior laxity often exists)

3. Addressing concomitant ligament injuries

** No outcome studies clearly support one reconstruction technique over the other


PCL Injury Treatment: Operative

High tibial osteotomy
1. indications

2. techniques

1. chronic PCL deficiency

2. techniques:
- consider medial opening wedge osteotomy to treat both varus malalignment and PCL deficiency
- when performing a high tibial osteotomy in a PCL deficient knee, increasing the tibial slope helps reduce the posterior sag of the tibia


PCL Injury Treatment: postop / rehab

1. Post-op

1. Post-operative
- immobilize in extension early and protect against gravity;
- early motion should be in prone position

2. Rehabilitation
- focus on quadriceps rehabilitation
- avoid resisted hamstring strengthening exercises (ex. hamstring curls) in early rehab
(this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft.)


PCL Injury


1. surgery

2. Non-op

1. Popliteal artery injury (at risk when drilling the tibial tunnel
lies just posterior to PCL insertion on the tibia, separated only by posterior capsule)
2. Patellofemoral pain/arthritis
due to chronic PCL deficiency


MCL Knee Injuries

The medial collateral ligament is both a primary and secondary valgus stabilizer of the knee
also known as the tibial collateral ligament


MCL Knee Injuries

Assoc Injuries
1. most common?

2. Others

.3 What is Pellegrini-Stieda Syndrome

1. ACL tears comprise up to 95% of associated injuries
- 20% with grd I MCL injuries
- 52% with grd II MCL injuries
- 78% with grd III injuries

2. Meniscal tears (up to 5% of isolated MCL injuries are associated with meniscal tears)

3. Calcification at the medial femoral insertion site
results from chronic MCL deficiency


MCL Knee Injuries

Classification of MCL Sprains

Grade 1 - mild severity
no loss of ligamentous integrity

Grade 2- moderate severity /
partial tear; increased joint laxity; end point found at 30 deg of flex with valgus stress; fibers remain apposed

Grade 3 - severe /complete tear; gross laxity; no end point with valgus stress at 30 deg of knee flex


MCL Knee Injuries


1. Medial capsulo-ligamentous complex of the knee
(a) function to resist ___ and ____ at the knee

(b) composition

(c) static stabilizers

(d) dynamic stabilizers

(e) Blood supply

1. Medial capsulo-ligamentous (a) valgus and external forces at the knee

(b) Composition
- 3 layers which extend from the ant to post midline
- contains both static and dynamic stabilizers

(c) static stabilizers:
- superficial MCL: primary restraint to valgus stress
- deep MCL and posterior oblique ligaments: secondary restraints to valgus stress

(d) dynamic stabilizers
- semimembranosus complex
(consists of 5 attachments; vastus medialis; medial retinaculum; pes anserine muscle group; sartorius; semitendinosus; gracilis

(e) superior medial and inferior medial geniculate arteries


LCL Injury of the Knee

Epidemiology / incidence

1. incidence:
- isolated injury extremely rare
- 7-16% of all knee ligament injuries when combined with lateral ligamentous complex injuries [particularly PLC injury]


LCL Injury of the Knee: Anatomy


1. LCL characteristics

2. origin

3. insertion

1. LCL characteristics
- tubular, cordlike structure
- dimensions: 3-4mm diameter / 66 mm length

2. origin = lateral femoral epicondyle
- posterior and proximal to insertion of popliteus

3. insertion = anterolateral fibula head
- most anterior structure on proximal fibula
- order of insertion from anterior to posterior - LCL → popliteofibular ligament → biceps femoris


LCL Injury of the Knee: Anatomy

blood supply

Blood supply: superolateral and inferolateral geniculate arteries


LCL Injury of the Knee: Anatomy

layers of lateral knee (layers 1-3)

layer 1: Iliotibial tract, biceps, fascia
*common peroneal nerve lies btwn layers 1 and 2*

layer 2: Patella retinaculum, Patelofemoral ligament

Layer 3:
Superficial: LCL, fabellofibular ligament,

** Inf lat geniculate aa. runs btwn sup/deep

deep: Arcuate lig, coronary lig, popliteus tendon, popliteofibular lig, capsule


LCL Injury of the Knee: Classification

LCL/PLC injury
based on quantification of lateral joint opening as compared with the normal contralateral knee with varus stress
grade 1+: 0-5 mm lateral opening
grade 2+: 6-10 mm lateral opening
grade 3+: >10 mm lateral opening without an endpoint


Rectus Femoris Strain

1. Define

2. Epidemiology

3. Pathophysiology
- mechanism
- pathoanatomy

4. Associated conditions (1)

1. Due to overstretching the muscle which results in tearing of the muscle fibers of the rectus femoris

2. Epidemiology ◦ seen more commonly in soccer and football players

3 Pathophysiology:
◦mechanism= ◾sudden, forceful eccentric contraction of the muscle ◾sprinting from standing position◾kicking soccer ball with great force
◦pathoanatomy ◾acute injuries ◾usually more distal on the thigh◾chronic injuries ◾usually occur closer to the muscle origin

4. Associated conditions ◦avulsion of anterior inferior iliac spine (AIIS) ◾adolescent athletes may have proximal bony avulsion of anterior inferior iliac spine (AIIS) ◾occurs at insertion site of direct head of


Rectus Femoris Strain


1. Osteology
◦ anterior inferior iliac spine (AIIS) [◾origin of direct head of rectus femoris muscle]

2. Muscles
◦rectus femoris
◾crosses hip and knee joint
◾flexes hip and extends knee


Rectus Femoris Strain


Treatment : Nonoperative
◦NSAIDS, rest, ice, stretching/strengthening
◾indications: definitive treatment for vast majority

◦ outcomes
◾usually resolves within 4-6 weeks


Popliteal Artery Entrapment Syndrome

1. Define

2. Epidemiology
◦ ? F / M predominance (about 4:1)
◦ patient age typically __to__ yrs old

1. A condition characterized by constriction of the popliteal artery by either:
◦adjacent muscles
◦fibrous tissues

2. Epidemiology
◦male predominance (about 4:1)
◦patient age typically 25-40 years old


Popliteal Artery Entrapment Syndrome

1. Mechanism

2 Pathophysiology

3. Prognosis
◦__to__% of patients are reported to be asymptomatic after surgery

1. Mechanism
◦typically due to underlying anatomic abnormality

2. Pathophysiology
◦decreased blood flow distal to the popliteal fossa leading to signs and symptoms consistent with compartment syndrome

3. Prognosis
◦70-100% of pts reported to be asymptomatic after surgery


Popliteal Artery Entrapment Syndrome

Classification (Modified Whelan Classification)
Types 1-5

Type I: Medial head of the gastrocnemius is normal but the popliteal artery runs in a aberrant course
Type II: Medial head of the gastrocnemius is located laterally, no deviation of popliteal artery
Type III: There is an abnormal muscle bundle from the medial head of the gastrocnemius that surrounds and constricts the popliteal artery
Type IV: Popliteal artery is entrapped by the popliteus muscle
Type V: Popliteal artery is entrapped by the popliteus muscle


Femoral Neck Stress Fractures


Fracture of the femoral neck secondary to repetitive loading of bone, of which there are two types:
◾compression side (inferior-medial neck)
◾tension side (superior-lateral neck)


Femoral Neck Stress Fractures

1. Epidemiology
2. Mechanism
3. Pathophysiology
4. Associated conditions

1. Epidemiology ◦common in runners
2. Mechanism ◦repetitive loading of femoral neck
3. Pathophysiology
◦ repetitive loading causes microscopic fractures in the femoral neck ◾crack "initiation"
◦ continued repetitive loading does not allow for healing and stress fracture occurs ◾crack "propagation"

4. "female athlete triad"
i. amenorrhea ii.eating disorder iii. osteoporosis
◾must be considered in any female athlete with stress fracture •Prognosis ◦dependent upon patient compliance


Femoral Neck Stress Fractures


Treatment : Non-weight bearing, crutches and activity restriction)
◾indications = compression side stress fractures with fatigue line <50% femoral neck width

Treatment : ORIF with percutaneous screw fixation
◾tension side stress fractures
◾compression side stress fractures with fatigue line >50% femoral neck width
◾progression of compression side stress fractures

** Op technique ◾use three 6.5mm or 7.0mm cannulated screws ◾postop WBAT


Exertional Compartment Syndrome

1. Define
2. Incidence
3. Demographics
4 . Location

1. A condition characterized by reversible ischemia to muscles within a muscular compartment
2. Epidemiology ◦incidence ◾second most common exercise induced leg syndrome ◾behind medial tibial stress syndrome
3. Demographics ◾males >females ◾often seen in 3rd decade of life ◾runners or those who run a lot for their sport
4. location ◾anterior leg compartment most commonly affected (~70%) ◾anterior and lateral leg compartment affected in 10% ◾posterior leg compartment involvement associated with less predictable surgical outcomes


Exertional Compartment Syndrome

Evaluation / Diagnosis

Compartment pressure measurement
◦limb should be in relaxed and consistant position ◦required to establish diagnosis
◦three pressure should be measured
1. resting pressure
2. immediate post-exercise pressure
3. continuous post-exercise pressure for 30 minutes

◦diagnostic criteria
◾resting (pre-exercise) pressure > 15 mmHg
◾immediate (1 minute) post-exercise is >30 mmHg and/or
◾post-exercise pressure >20mmHg at 5 minutes
◾post-exercise pressure >15 mmHg at 15 minutes

* Near-infrared spectroscopy ◦can show deoxygenation of muscle ◾showed return to normal within 25 minutes of exercise cessation


Posterolateral Corner Injury

1. Approximately __to__% knee ligament injuries are to the lateral ligamentous complex

2. Mechanisms (4)

3. Associated injuries

1. Approximately 7-16% knee ligament injuries are to the lateral ligamentous complex
**nb: Missed PLC injury diagnosis is common cause of ACL reconstruction failure**

2. Mechanisms:
◾blow to anteromedial knee
◾varus blow to flexed knee
◾contact and noncontact hyperextension injuries
◾knee dislocation

3. Associated injuries
◾common peroneal nerve (15-29%)
◾vascular injury


Posterolateral Corner Injury

Structures of PLC

1. Static (6)

2. Dynamic (4)

1. static structures
- LCL (most anterior structure inserting on the fibular head)
- popliteus tendon
- popliteofibular ligament
- lateral capsule
- arcuate ligament (variable)
- fabellofibular ligament (variable)

2. dynamic structures
- biceps femoris (inserts on the posterior aspect of the fibula posterior to LCL)
- popliteus muscle
- iliotibial tract
- lateral head of the gastrocnemius


Posterolateral Corner Injury

Function of:

- popliteus ?

- Popliteus and popliteofibular ligament



- Popliteus works synergistically with the PCL to control external rotation, varus, and posterior translation

- Popliteus and popliteofibular ligament function maximally in knee flexion to resist external rotation

- LCL is primary restraint to varus stress at 5° (55%) and 25° (69%) of knee flexion


Posterolateral Corner Injury


Grade I (0-5mm of lateral opening and minimal ligament disruption)

Grade II (5-10mm of lateral opening and moderate ligament disruption)

Grade III (>10mm of lateral opening and severe ligament disruption and no endpoint)


Posterolateral Corner Injury

Physical exam : list (6)

1. gait exam (varus thrust or hyperextension thrust)
2.varus stress
3. dial test
4. external rotation recurvatum
5. posterolateral drawer test
6. reverse pivot shift test

** note: peroneal nerve injury
altered sensation to dorsum of foot and weak ankle dorsiflexion
approximately 25% of patients have peroneal nerve dysfunction


Posterolateral Corner Injury

Physical exam

1. Dial test ?

2. External rotation recurvatum ?

dial test
- > 10° external rotation asymmetry at 30° only consistent with isolated PLC injury
- > 10° external rotation asymmetry at 30° & 90° consistent with PLC and PCL injury q

External rotation recurvatum
- positive when lower leg falls into external rotation and recurvatum when leg suspended by toes in supine patient


Posterolateral Corner Injury

Physical exam

1. posterolateral drawer test

2. reverse pivot shift test

1. Posterolateral drawer test
- performed with the hip flexed 45°, knee flexed 80°, and foot is ER 15°.
- a combined posterior drawer and external rotation force is then applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle)

2. Reverse pivot shift test
- knee positioned at 90° and external rotation and valgus force applied to tibia
as the knee is extended the tibia reduces with a palpable clunk.
-> tibia reduces from a posterior subluxed position at ~20° of flexion to a reduced position in full extension (reduction force from IT band transitioning from a flexor to an extensor of the knee)


Posterolateral Corner Injury


1. XR

2. MRI

1. Radiographs
i. may see avulsion fracture of the fibula (arcuate fracture ) or femoral condyle

2. MRI
i. look for injury to the LCL, popliteus, and biceps tendon
ii. in acute injury may see bone bruising of medial femoral condyle and medial tibial plateau


Posterolateral Corner Injury

Treatment : Non-operative

1. Nonoperative : immobilize knee in full extension with PWB for ~2 weeks
i. indications: in isolated PLC Grade I or II injuries
ii. followed by progressive functional rehabilitation focusing on quad strengthening with return to sports in 8 weeks


Posterolateral Corner Injury

Treatment : Operative

Repair vs Recon

PLC repair : indications
- only in isolated PLC injuries with bony or soft tissue avulsion
- able to operate within 2 weeks of injury

PLC recon: indications
- used for most grade III isolated injuries
- when repair not possible or has poor tissue quality


Patellar Tendinitis


activity-related anterior knee pain associated with focal patellar-tendon tenderness - also known as "jumper's knee"


Patellar Tendinitis

1. Incidence

2. Demographics / risk factors

- up to 20% of jumping athletes

Demographics / risk factors
- males > females
- volleyball most common
- more common in adolescents/young adults
-> quadriceps tendinopathy is more common in older adults
- poor quadriceps and hamstring flexibility


Patellar Tendinitis


Blazina classification system

phase I - pain after activity only

phase II - pain during and after activity

phase III - persistent pain with or without activities / deterioration of performance


Patellar Tendinitis

1. symptoms

2. exam - what is bassett sign?

1. Symptoms: insidious onset of anterior knee pain at inferior border of patella
(pain with prolonged flexion ("movie theater sign")

2. Basset's sign
- tenderness to palpation at distal pole of patella in full extension
- no tenderness to palpation at distal pole of patella in full flexion


Patellar Tendinitis


1. Radiographs: may show inferior traction spur (enthesophyte) in chronic cases

2. Ultrasound: thickening of tendon/hypoechoic areas

3. MRI: tendon thickening /more diagnostic than presence of edema/ increased signal intensity on both T1 and T2 images /
loss of the posterior border of fat pad in chronic cases


Proximal Tib-Fib Dislocation

* Often a missed diagnosis *

1. incidence
2. demographics

3. Pathophysiology = high energy trauma ◾more common with __a.__ and __b.__
◾ (c): fall onto a ____ and A__ducted knee

4. Assoc. conditions (3)

1. incidence =◾rare injury◾even less common as an isolated injury

2. Most common in 2nd to 4th decades

3. (a) horseback riding; (b) parachuting; (c) fall onto a flexed and aDducted knee

4. (i) posterior hip dislocation (flexed knee and hip);
(ii) open tib-fib fx
(iii)other fx about the knee and ankle


Proximal Tib-Fib Dislocation

1. Eponymous name

2. Types (4)

1. Ogden classification

2. Types
Type 1= subluxation Type 2=anterolateral - most common
Type 3= posteromedial
Type 4= superior


Quadriceps Tendonitis

1. Define
2. male-to-female ratio?
3. risk factor
4. Assoc conditions (2)

1. Inflammation of the suprapatellar tendon of the quadriceps muscle

2. 8:1 male-to-female ratio (◾more common in adult athletes)

3. Jumping sports (◾basketball◾volleyball◾athletics (e.g., long jump, high jump, etc)

4. Associated conditions:
◦ Jumper's knee (◾patellar tendonitis)
◦ Quadriceps tendinosis ◾chronic quad tendon degen with no inflamm


Quadriceps Tendonitis

1. Knee extensor mechanism components?

2. Describe the TRIMLAMINAR tendon structure

3. Vascular supply

4. Innervation

1. ◦quadriceps muscles ◾rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
◦quadriceps tendon

2. common trilaminar tendon of quadriceps muscles ◾anterior layer = rectus femoris
◾middle layer = vastus medialis and vastus lateralis
◾deep layer = vastus intermedius

3. medial, lateral and peripatellar arcades

4. Innervated by muscular branches of the femoral nerve (L2, L3, L4)


Patellar Instability

General classification (3 types)

◦acute traumatic ◾occurs equally by gender ◾may occur from a direct blow (ex. helmet to knee collision in football)

◦chronic patholaxity ◾recurrent subluxation episodes ◾occurs more in women ◾associated with malalignment

◦habitual ◾usually painless ◾occurs during each flexion movement ◾pathology is usually proximal (e.g. tight lateral structures - ITB and vastus lateralis)


Patellar Instability

Risk factors include
1. General Factors (3)

2. Anatomical factors
a. Osseous (4)

b. Muscle (2)

1. General factors
◾ligamentous laxity (Ehlers-Danlos syndrome)
◾previous patellar instability event
◾"miserable malalignment syndrome"

2a. Anatomical factors: osseous
◾patella alta (causes patella to not articulate with sulcus, losing its constraint effects)
◾trochlear dysplasia
◾excessive lateral patellar tilt (measured in extension)
◾lateral femoral condyle hypoplasia

2b. Anatomical factors: Muscle ◾dysplastic vastus medialis oblique (VMO) muscle
◾overpull of lateral structures (iliotibial band / vastus lateralis)


Patellar Instability

3. What is 'miserable malalignment'?

"miserable malalignment syndrome"

◾a term named for the 3 anatomic characteristics that lead to an increased Q angle
1. femoral anteversion
2. genu valgum
3. external tibial torsion / pronated feet


Patellar Instability


passive stability and dynamic stability

Passive stability
◾Medial patellofemoral ligament (MPFL)
◦ primary restraint in first 20 degrees of knee flexion
◦ Insertion on femur (between medial epicondyle and adductor tubercle) is usual site of avulsion of MPFL

◾Patellar-femoral bony structures account for stability in deeper knee flexion)
◦trochlear groove morphology, patella height, patellar tracking

Dynamic stability
◾Provided by vastus medialis (attaches to MPFL)


Patellar Instability

What is the Q angle

Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;
- an increased Q angle is a risk factor for patellar subluxation;
- normally Q angle is 14 deg for males and 17 deg for females (Agliettis et. al. Clin. Ortho 1983)


Patellar Instability
Physical Exam

1. increase in passive patellar translation (define)

2. J sign (define)

1. increase in passive patellar translation ◾measured in quadrants of translation (midline of patella is considered "0"), and also should be compared to contralateral side
◾normal motion is <2 quadrants of patellar translation ◾lateral translation of medial border of patella to lateral edge of trochlear groove is considered "2" quadrants and is considered abnormal amount of translation

2. J sign
◾excessive lateral translation in extension which "pops" into groove as the patella engages the trochlea early in flexion
◾associated with patella alta


Patellar Instability

Imaging : Radiographs

1. Which view is best to assess for trochlear dysplasia ?

2. What are the XR signs of tochlear dysplasia ? (3)

1. lateral views
2. XR signs trochlear dysplasia
◾crossing sign (trochlear groove lies in same plane as anterior border of lateral condyle; represents flattened trochlear groove)
◾double contour sign (ant border of lat condyle lies ant to ant border of med condyle - represents convex trochlear groove/hypoplastic medial condyle)
◾supratrochlear spur (arises in proximal aspect of trochlea)


Patellar Instability


1. How do you evaluate patellar height (patella alta vs. baja) ? (5)

2. What are Sunrise/Merchant views used to assess?

3. Patellar height (patella alta vs. baja)

i) Blumensaat's line (should extend to inferior pole of the patella at 30 degrees of knee)

ii) Insall-Salvati method (normal 0.8 to 1.2)

iii) Blackburne-Peel method (normal 0.5-1.0)

iv) Caton Deschamps (normal 0.6 and 1.3)

v) Plateau-patella angle (normal between 20 and 30 degrees)

2. Sunrise/Merchant/Skyline views ◾best to assess for lateral patellar tilt
◾lateral patellofemoral angle (normal is an angle that opens laterally)
◾angle between line along subchondral bone of lateral trochlear facet + posterior femoral condyles
◾normal > 11°
◾congruence angle (normal is -6 degrees)


Patellar Instability

What is the TT-TG distance?

Measured on CT images, the TT-TG (Tib-Tub to Trochlear-groove) distance measures:

The distance between 2 perpendicular lines from the posterior cortex to the tibial tubercle and the trochlear groove

>20mm usually considered abnormal


Patellar Instability : Treatment


Details and indications

NSAIDS, activity modification, and physical therapy

◾mainstay of treatment for first time patellar dislocator (without any loose bodies or intraarticular damage)
◾habitual dislocator

1. short-term immob then 6/52 controlled motion
2. emphasis on strengthening ◾closed chain short arc quads ex's ◾Quad strengthening ◾core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals)
3. Patellar stabilizing sleeve or "J" brace
◾consider knee aspiration for tense effusion ◾positive fat globules indicates fracture


Patellar Instability

Treatment : Operative


** NOTE: Pediatric Treatment : Same principles as adults in general but must preserve the physis - do not do tibial tubercle osteotomy (will harm growth plate of proximal tibia)

◾Arthroscopic debridement (removal of loose body) vs Repair with or without stabilization
ind: OCD/loose body

◾MPFL repair
ind: acute 1st disloc with bony fragment

◾MPFL reconstruction with autograft vs allograft
ind: recurrent instability / no sign. underlying malalignment

◾Fulkerson-type osteotomy (anterior and medial tibial tubercle transfer)
ind: may be used in addition to MPFL or in isolation for significant malalignment / TT-TG >20mm on CT

◾tibial tubercle distalization
ind: patella alta

◾lateral release
ind: isolated release no longer indicated for instability / only indicated if there is excessive lateral tilt or tightness after medialization

ind: rarely addressed (in the USA) even if trochlear dysplasia present / may consider in severe or revision cases


Lateral Patellar Compression Syndrome

1. Define

2. Presents with ?

1. Improper tracking of patella in trochlear groove caused by tight lateral retinaculum
◦leads to excessive lateral tilt without excessive patellar mobility

2. Pain with stair climbing / 'theatre sign' (pain with sitting for long periods of time)

3. Physical exam ◦pain with compression of patella and moderate lateral facet tenderness ◦inability to evert the lateral edge of the patella


Lateral Patellar Compression Syndrome

Radiographs show ?

1. patellar tilt in lateral direction


Idiopathic Chondromalacia Patellae


Condition characterized by idiopathic articular changes of the patella
◦term is now falling out of favor
◦more commonly grouped together with a number of pathological entities known as ◾"anterior knee pain" or
◾"patellofemoral syndrome"


Idiopathic Chondromalacia Patellae

1. Classification

2. Types

1. Outerbridge Classification

2. Type 1: Softening / Type 2: Fissures / Type 3: Crabmet changes / 4: Exposed chondral bone


Prepatellar Bursitis (Housemaid's Knee)

1. Incidence ?

2. Risk factors ?

3. Septic vs aseptic __% vs ___%

1. Most common bursitis of the knee (bursa anterior to patella)

2. ◾excessive kneeling◾common in wrestlers ◾concern for septic bursitis in wrestlers

3. Septic=20% ; Aseptic=80%


Prepatellar Bursitis (Housemaid's Knee)


Nonoperative ◦compressive wrap, NSAIDs, +/-aspiration and immobilization for 1 week ◾indications=most cases; ◾technique: corticosteroid use is controversial

Operative ◦bursal resection
◾indications =rare


Patella Tendon Rupture

1. Incidence

2. Demographics - age and gender ?

3. Location of rupture ?

1. Incidence ◾< 0.5% of the US population per year

2. demographic ◾most commonly in 3rd and 4th decade ◾male > female

3. location: ◾quadriceps tendon rupture > patella tendon rupture


Patella Tendon Rupture

Risk factors

1. Systemic (4)

2. Local (3)

3. Other (1)

Caused by weakening of collagen structure - effected by:

1. Systemic
◾systemic lupus erythematous
◾rheumatoid arthritis
◾chronic renal disease
◾diabetes mellitus

2. Local
◾patellar degeneration (most common)
◾previous injury
◾patellar tendinopathy

3. Other
◾corticosteroid injection


Patella Tendon Rupture

1. Pathoanatomy - 3 patterns of injury

2. Outcome

1. Pathoanatomy : 3 patterns of injury
i. avulsion with or without bone from the proximal insertion/inferior pole of patella (most common)
ii. midsubstance
iii. distal avulsion from the tibial tubercle

** note: rupture is usually the result of end stage or long-standing chronic tendon degeneration **

2. Outcome: most important factor is timing of repair


Articular Cartilage Defects of Knee


Location of OCDs?

◦incidence ◾5-10% of people > 40 years old have high grade chondral lesions

◾chronic ACL tear -> anterior aspect of lateral femoral chondyle and posterolateral tibial plateau
◾osteochondritis dissecans ◾70% of lesions found in posterolateral aspect of medial femoral condyle


Articular Cartilage Defects of Knee


1. Outerbridge (arthroscopic)


1. Outerbridge Arthroscopic Grading System
◾Grade 0=Normal cartilage; 1=Softening and swelling; 2=Superficial fissures; 3=Deep fissures, without exposed bone; 4= Exposed subchondral bone)

2. ICRS (International Cartilage Repair Society) Grading System
◾Grade 0=Normal; 1= Nearly normal (superficial lesions); 2=Abnormal (lesions extend < 50% of cartilage depth); 3=Severely abnormal (>50% of cartilage depth); 4=Severely abnormal (through the subchondral bone)


Articular Cartilage Defects of Knee

MRI imaging

MRI ◾most sensitive for evaluating focal defects

◾Fat-suppressed T2, proton density, T2 fast spin-echo (FSE) offer improved sensitivity and specificity over standard sequences
◾dGEMRIC (delayed gadolinium-enhanced MRI for cartilage) and T2-mapping are evolving techniques to evaluate cartilage defects and repair


Osteonecrosis of the Knee (not SONK)

1. Demographics

2. Location

1. Demographic ◾women:men 3:1
◾more common in women <55 years with risk factors ◾reported to be found after knee arthroscopy in middle-aged women

2. Location ◾typically involves more than one compartment of the knee or even the metaphysis ◾80% are bilateral ◾multifocal lesions are not uncommon


Osteonecrosis of the Knee (not SONK)

1. Risk Factors

2. Prognosis

1. Risk factors
◾dysbaric disorders (decompression sickness, "the bends")
◾marrow-replacing diseases (e.g. Gaucher's disease)
◾sickle cell disease
◾hypercoagulable states
◾steroids (either endogenous or exogenous)
◾inflammatory bowel disease
◾transplant patient
◾virus (CMV, hepatitis, HIV, rubella, rubeola, varicella)
◾protease inhibitors (type of HIV medication)

2. Prognosis = self-limiting condition


Spontaneous Osteonecrosis of the Knee (SONK)

1. Epidemiology - demographics

2. Location

3. Pathophysiology

1. ◾most common in middle age and elderly◾affects females (>55yo) more frequently than males

2. ◾99% of patients have only one joint involved ◾usually epiphysis of medial femoral condyle

3. ◾ may represent a subchondral insufficiency fracture ◾ also believed to be caused by a meniscal root tear


Spontaneous Osteonecrosis of the Knee (SONK)

1. MRI findings ?

2. DDx

1. Lesion is crescent shaped

2. DDx
i. osteochondritis dissecans (more common on lateral aspect of medial femoral condyle in adolescent males)

ii. transient osteoporosis (more common in young to middle age men)

iii. bone bruises and occult fractures (associated trauma, bone fragility or overuse)

iv. idiopathic osteonecrosis of the knee (lesion is not crescent shaped)


Spontaneous Osteonecrosis of the Knee (SONK)


Nonoperative ◦NSAIDs, narcotics, PWB ◾indications=mainstay of treatment as most cases resolve

◦high tibial osteotomy


Osgood Schlatter's Disease (Tibial Tubercle Apophysitis)

Define: Osteochondrosis or traction apophysitis of tibial tubercle

1. Demographics ?
2. Location - bilateral in __to__%
3. Risk factors?
4. Prognosis ?

1. demographics ◾more common in boys◾age bracket = boys 12-15y / girls 8-12y

2. Location: ◾bilateral in 20-30%

3. Risk factors: ◾jumpers (basketball, volleyball) or sprinters

4. Self-limiting but does not resolve until growth has halted



Osgood Schlatter's Disease (Tibial Tubercle Apophysitis)

Tibial tubercle is a secondary ossification center
◦age <11y, ______
◦age 11-14y, _______
◦age 14-18y, _______
◦age >18y, _______

◦age <11y, tubercle is cartilaginous

◦age 11-14y, apophysis forms

◦age 14-18y, apophysis fuses with tibial epiphysis

◦age >18y, epiphysis (and apophysis) is fused to rest of tibia


Osgood Schlatter's Disease (Tibial Tubercle Apophysitis)


◦pain on anterior aspect of knee
◦exacerbated by kneeling

Physical exam
◦inspection ◾enlarged tibial tubercle ◾tenderness over tibial tubercle
◦provocative test ◾pain on resisted knee extension


Osgood Schlatter's Disease (Tibial Tubercle Apophysitis)


1. Sinding-Larsen-Johansson syndrome ◦chronic apophysitis or minor avulsion injury of inferior patella pole
◦occurs in 10-14yr old children, especially children with cerebral palsy

2. Osteochondroma of the proximal tibia

3. Tibial tubercle fracture

4. Jumpers knee


Sinding-Larsen-Johansson Syndrome


Overuse injury causing anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment ◦similar to Osgood-Schlatter's disease which is at the distal attachment of the patella tendon
◦different from Jumper's Knee which is tendonitis of the patella tendon


Sinding-Larsen-Johansson Syndrome

1. Epidemiology ◦demographics
2. Location
3. Pathophysiology

1. Epidemiology ◦demographics ◾more common in adolescence

2 Location ◾patellar tendon insertion at the inferior pole of the patella

3. Pathophysiology ◦chronic injury
◦similar pathogenesis to Osgood-Schlatter
◦overuse causes a traction apophysitis


Osteochondritis Dissecans

1. Epidemiology ◦demographics

2. location

1. ◾juvenile form (open physes) ◾occurs at age 10-15 while the physis is still open
◾adult form (skeletal maturity)

2. ◾knee (most common) ◾posterolateral aspect of medial femoral condyle (70% of lesions in knee) ◾capitellum of humerus


Osteochondritis Dissecans

1. Pathophysiology

2. Pathoanatomic cascade

1. Pathophysiology
mechanism/etiology may be:
- cause of adult form is thought to be vascular

2. Pathoanatomic cascade
◾softening of the overlying articular cartilage with intact articular surface
◾early articular cartilage separation
◾partial detachment of lesion
◾osteochondral separation with loose bodies


Iliac Crest Contusion (Hip Pointer)

1. definition

2. pathoanatomy

1. Mechanism direct trauma or crushing (common in contact sports)

2. Pathoanatomy ◦hematoma occurs into area surrounding iliac wing ◾and can cause bleeding into hip abductor muscles
(** note : rule out avulsion of the iliac apophysis ◾in adolescent patients)


Iliac Crest Contusion (Hip Pointer)

Iliac crest is origin of several muscles any of which can be involved (4)

◦tensor fascia lata
◦gluteus medius
◦abdominal muscles: ◾transverse or oblique muscles


Iliac Crest Contusion (Hip Pointer)

1. Presentation
a. Symptoms
b. Physical exam

2. Imaging
a. Radiographs
b. MRI

1. Presentation

a) Symptoms =pain near iliac crest
b) Physical exam
◦contusion and hematoma near iliac crest
◦affected hip weakness
◦decreased range of motion

2. Imaging
a) Radiographs
◦usually unremarkable
b) MRI
◦usually unremarkable ◦can show large hematoma


Iliac Crest Contusion (Hip Pointer)


Treatment = Nonoperative ◦rest, NSAIDS, steroid injections, and therapy ◾indications =main line of treatment
◾technique = medications / NSAIDs and muscle relaxants may be beneficial
◾therapy= focused on stretching the muscles about the iliac crest ; place affected leg on maximum stretch
◾steroid injections - corticosteroid injection directed near iliac crest
◾return to play --> additional padding during return to play


Anterior Superior Iliac Spine (ASIS) Avulsion

1. ASIS avulsions occur in ______ through the _____

2. Mechanism
◦result from _(a)_ trauma
◦caused by sudden and forceful contraction of __(b)__ and _(c)__
◦occurs during __(d)___(sprinting or swinging a baseball bat)

1. ASIS avulsions occur in young athletes through the physis

2. Mechanism
a) indirect trauma
b) sartorius
c) TFL
d) hip extension


Anterior Superior Iliac Spine (ASIS) Avulsion


Muscles that originate from ASIS and their innervating nerve? (2)

Anatomy : Muscles that originate from ASIS

1. sartorius (femoral n.)

2. tensor fascia lata (superior gluteal n.)


Anterior Superior Iliac Spine (ASIS) Avulsion

Presentation: History
1. athlete will often report a _____ at the time of injury
Presentation: Symptoms
2. may complain of _______ ◾may be confused or misdiagnosed as an acute muscle strain
Presentation: Physical exam
3. may see weakness to ____ and ______ (severe injuries may result in a limp)

4. Imaging: Radiographs

5. CT or MRI

1. athlete will often report a pop or snap at the time of injury

2. may complain of weakness ◾may be confused or misdiagnosed as an acute muscle strain

3. weakness to hip flexion and knee extension

4. Xray: displaced fractures usually can be seen on radiographs ◾may be missed due to location and small size of bony fragment

5. CT or MRI ◦can be obtained to confirm the diagnosis


Anterior Superior Iliac Spine (ASIS) Avulsion


1 Nonoperative

2. Operative

1. Nonoperative ◦rest, protected weight bearing with crutches, and early ROM and stretching
◾indications ◾most cases

2. Operative ◦ORIF of avulsion fracture ◾indications
◾fractures with displacement of > 3 cm
◾painful nonunions


Anterior Inferior Iliac Spine Avulsion (AIIS)

1. Define

2. Most often in adolescent between the ages __to__ years

3. males ____ often than females

4. Mechanism ◾typically occurs due to eccentric contraction of the ______ muscle

1. An apophyseal avulsion injury seen in adolescent athletes (Occurs most often in sports involving kicking)

2. 14-17 years

3. M > F

4. Mechanism ◾typically occurs due to eccentric contraction of the rectus femoris (femoral n.)
◦as hip extends and knee is flexed
◦causes avulsion of its anatomic origin off the pelvis


Anterior Inferior Iliac Spine Avulsion (AIIS)


AIIS is the origin of the ______ muscle

Anterior Inferior Iliac Spine Avulsion (AIIS)

Anterior inferior iliac spine ◦a bony prominence just above acetabulum
◦is the origin of the direct head of the rectus femoris (femoral n.)


Anterior Inferior Iliac Spine Avulsion (AIIS):

1. History
2. Symptoms
3. Physical exam
4. Imaging : Radiographs

Anterior Inferior Iliac Spine Avulsion (AIIS)

1. History ◦sudden "pop" in pelvis

2. Symptoms ◦pain and weakness

3. Physical exam ◦antalgic gait
◦anterior hip pain and hip flexion weakness

4. Imaging: Radiographs ◦show avulsion of AIIS


Anterior Inferior Iliac Spine Avulsion (AIIS)

1. Treatment : Nonoperative

2. Complications (2)

Anterior Inferior Iliac Spine Avulsion (AIIS)

1. Treatment : Nonoperative ◦bed-rest, ice, activity modification
◾indications = almost all treated nonoperatively
◾technique = hip flexed for 2 weeks (position lessens stretch of affected muscle and apophysis) ; follow with guarded weight bearing for 4 week

2. Complications
•Loss of reduction
•Delayed union


Osteitis Pubis

1. define

2. Epidemiology ◦demographics

3. Pathophysiology ◦mechanism

1. Inflammation of the pubic symphysis caused by repetitive trauma

2. Epidemiology ◦demographics ◾common in soccer, hockey, football and running

3. Pathophysiology ◦mechanism ◾repetitive microtrauma to the pubic symphysis by
◾sports involving repetitive kicking
◾sports involving hip repetitive adduction/abduction


Osteitis Pubis: Anatomy

1. Pubic symphysis ◦osteology

2. Muscles : regional attachments

3. Ligaments (4)

Osteitis Pubis: Anatomy

1. Pubic symphysis ◦osteology ◾located at the anterior articulation between each hemipelvis; ◾composed of articular cartilage-covered rami separated by fibrocartilage disc

2. Muscles : regional attachments
◾adductors (adductor magnus; brevis; longus) ◾gracilis ◾rectus abdominis◾pectineus

3. Ligaments
◾superior pubic ligament ◾inferior pubic ligament◾anterior pubic ligament ◾posterior pubic ligament

NOTE: Biomechanics ◾very stable joint
◾strong ligamentous support limits motion


Osteitis Pubis : Presentation

1. Symptoms

2. Physical exam

3. Differential Dx (5)

1. Vague, ill-defined pain is anterior pelvic region ◾worse with activities involving hip adduction/abduction at the anterior pelvis
◾may have spasms with hip adduction

2. Physical exam
◦palpation = localized tenderness directly over the pubic symphysis

3. •Athletic pubalgia ; •Stress fracture of the pubic rami; •Stress fracture of the femoral neck; •Inguinal hernia; •Oncologic disease (rare)


Osteitis Pubis: Imaging

1. Radiographs : recommended views?
2. XR findings?
3. MRI findings
4. Bone scan findings?

1. recommended views ◾AP of pelvis

2. XR findings= ◾osteolytic pubis with bony erosions and often times diastasis of the symphysis ◾degenerative changes within the joint can be seen

3 MRI ◦bone marrow edema found early

4 Bone scan ◦increased activity in area of pubic symphysis


Osteitis Pubis: Treatment

1. Nonoperative
◾ details

2. Nonoperative : outcomes

1. Nonoperative
◾Details=NSAIDS, rest, activity modification
◾indications=treatment for vast majority of cases;
◾modalities=steroid injections are controversial

2. Nonoperative: outcomes
◾self-limiting process which usually resolves with non-operative treatment ◾may take several months to resolve


Athletic Pubalgia & Adductor strain: Introduction

1. define:

2. Epidemiology
◾males vs females incidence ?
◾common in _____ players and ____ players

3. Pathophysiology ◦mechanism of injury ◾may be caused by ______or _____ caused by overuse
◾thought to be a caused by abdominal ______ and thigh ________

1. Clinical entity characterized by anterior pelvic pain or groin pain ◦more commonly referred to as "sports hernia" syndrome
◦condition not fully understood

2 Epidemiology
◾males > females
◾common in hockey players and soccer players
◾location=muscles of abdominal wall or adductor longus

3. Pathophysiology ◦mechanism of injury ◾may be caused by acute trauma or microtrauma caused by overuse
◾thought to be a caused by abdominal hyperextension and thigh abduction


Athletic Pubalgia & Adductor strain:presentation

1. Symptoms

2. Physical exam

3. Provocative tests

4. Imaging

5. Differential Dx

1. lower abdominal pain and inguinal pain at extremes of exertion

2. tenderness to adductor longus

3. pain with valsalva and situps

4. Obtain radiographs, MRI, and bone scan to rule out other cause of symptoms

5. Must be differentiated from subtle true inguinal hernia


Athletic Pubalgia & Adductor strain: treatment

1. Nonoperative

2. Operative (2)

1. Nonoperative ◦rest and physical therapy for 6-8 weeks ◾indications ◾ first line of treatment
2. Operative
(i) pelvic floor repair (hernia operation) vs. adductor / rectus recession
◾indications ◾after extensive nonoperative treatment fails
(ii) decompression of the genital branch of the genitofemoral nerve
◾indications ◾after extensive nonoperative treatment fails


Piriformis Muscles Syndrome
1. Define

2. Sciatic nerve entrapment occurs:
a) _____ to ______ muscle or _____ to ______/______ complex
b) at level of ______ tuberosity

3. Anatomic anomalies may contribute to compression (4)

4. Associated conditions (1)

1. A condition characterized by sciatic symptoms (leg pain) due to extrapelvic sciatic nerve compression at the hip (**sometimes called deep gluteal syndrome**)

2. Sciatic nerve entrapment occurs:
a.) anterior to piriformis muscle or posterior to obturator internus/gemelli complex
b.) at level of ischial tuberosity

3.◾bipartite piriformis◾variations of sciatic nerve path ◾tumors ◾aneurysm of inferior gluteal artery

4. femoroacetabular impingement ◾decreased internal rotation may contribute to contractures of short external rotators and compression on sciatic nerve


Piriformis Muscles Syndrome: Anatomy

Sciatic nerve
1. Exits

2. Muscles [6]: external rotators of the thigh include (superior to inferior)

1. Exits
◾inferior to piriformis
◾superior to superior gemellus

2. Muscles (superior to inferior)
◾superior gemellus
◾obturator internus
◾inferior gemellus
◾obturator externus
◾quadratus femoris


Piriformis Muscles Syndrome:Presentation

1. Symptoms

2. Physical exam (acronym test)

1. Symptoms
◦pain in the posterior gluteal region and migrating down the back of the leg
◦pain may be burning or aching in nature similar to sciatica symptoms

2. FAIR test
◾Flexion, Adduction, and Internal Rotation of hip can reproduce symptoms
◾maneuver places piriformis muscle on tension


Piriformis Muscles Syndrome: Imaging

1. Radiographs - findings?

2. MRI- findings?

3. Electrodiagnostic studies

1. Radiographs = unremarkable

2. MRI = usually unremarkable ; lumbar MRI helpful to rule out spine as cause of compression of sciatic nerve

3. Electrodiagnostic studies ◦can document functional impairment of sciatic nerve


Piriformis Muscles Syndrome: Treatment

1. Nonoperative

2. Operative

1. Nonoperative ◦rest, NSAIDS, muscle relaxants, PT, steroid injections ◾indications=first line of treatment
◾technique= focused on stretching the piriformis muscle and short external rotators
◾corticosteroid injection directed near the piriformis muscles

2. Operative ◦piriformis muscle release and external sciatic neurolysis ◾indications= only indicated in refractory cases after failed conservative measures


Snapping Hip (Coxa Saltans): Intro

1. Define

2. Epidemiology

1. A condition characterized by a snapping sensation in the hip ◦caused by motion of muscles and tendons over bony structures around the hip joint

2. Epidemiology: common in athletes and dancers in their teens or twenties


Snapping Hip (Coxa Saltans)

Three types of snapping hip exist with different causes:

3a. External snapping hip
◾caused by iliotibial tract sliding over greater trochanter

3b. Internal snapping hip ◾most common form
◾caused by iliopsoas tendon sliding over
◦femoral head
◦prominent iliopectineal ridge
◦exostoses of lesser trochanter
◦iliopsoas bursa

3c. Intra-articular snapping hip
◾caused by:
◦loose bodies in the hip (may be seen with synovial chondromatosis)
◦ labral tears


Snapping Hip (Coxa Saltans)

1. Symptoms

1. Symptoms
i. snapping sensation in and around hip joint
◾may be painful or painless
◾patient often able to reproduce snapping
◾aggravated by activity
ii. clicking or locking sensation ◾more indicative of intra-articular pathology


Snapping Hip (Coxa Saltans)

1. Physical exam - internal vs external snapping hip

2. Obers test ?

3. internal snapping hip

4. External snapping hip

1. external snapping hip is often visible while internal snapping is not, but may be audible ("external snapping one can see from across the room, while internal one may hear from across the room")

2. tightness of tensor fascia lata diagnosed with Ober's Test ◾limited hip adduction when hip held in extension

3. Internal snapping hip ◾snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position

4. External snapping hip ◾palpate greater trochanter as hip is actively flexed ◾applying pressure will likely stop snapping, confirming diagnosis


Snapping Hip (Coxa Saltans): Imaging

1. Radiographs
◦recommended views

2. Ultrasound

3. MRI

4. Iliopsoas bursography

1. Radiographs ◦recommended views ◾AP pelvis/hip; ◦findings ◾usually normal◾may be useful to rule-out synovial chondromatosis

2. Ultrasound ◦dynamic study which may demonstrate the snapping band in either internal or external snapping
◦may be used to localize a diagnostic challenge injection into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.

3 MRI ◦useful to rule-out intra-articular pathology; ◦often performed as an arthrogram study; ◦may show inflamed bursa

4. Iliopsoas bursography ◦iliopsoas tendon visualized under fluoroscopy after bursa injected with contrast dye
◦may add therapeutic injection after diagnosis is confirmed


Snapping Hip (Coxa Saltans): Treatment

1. Nonoperative

2. Operative

(a) Excision of greater trochanteric bursa with Z-plasty of iliotibial band

(b) Release of iliopsoas tendon

(c) Hip arthroscopy with removal of loose bodies or labral debridement/repair

1. Nonoperative ◦often internal and external snapping are painless and require no treatment:
◦activity modification ◾indications ◾acute onset (<6 months) of painful internal or external snapping hip
◦physical therapy, injection of corticosteroid ◾indications ◾persistent, painful snapping interfering with activities of daily living

2a. Operative: excision of greater trochanteric bursa with Z-plasty of iliotibial band ◾indications= painful external snapping hip that has failed nonoperative management OR snapping after total hip replacement
2b. Release of iliopsoas tendon ◾indications =painful internal snapping hip that has failed of nonoperative management
2c. Hip arthroscopy with removal of loose bodies or labral debridement/repair ◾indications = intra-articular snapping hip that has failed nonoperative management and has MRI confirmation of i) loose bodies ii) labral tear


Snapping Hip (Coxa Saltans):Surgical Techniques

1. Excision of greater trochanteric bursa with Z-plasty of iliotibial band technique ◾lengthen the iliotibial band by Z-plasty
◾may be done endoscopically

2. Iliopsoas tendon release
a) approach ◾variety of open approaches have been described: [4]
b) post-operative care: avoid ________ for 6 weeks

1. Excision of greater trochanteric bursa with Z-plasty of iliotibial band ◦technique ◾lengthen the iliotibial band by Z-plasty
◾may be done endoscopically

2 Iliopsoas tendon release
a) approach: (i) anterior; (ii) medial; (iii) ilioinguinal; (iv) iliofemoral

b) avoid hip flexion strengthening for 6 weeks


Burners & Stingers: Also known as "dead arm syndrome" or brachial plexopathy


2. Epidemiology

3. Having 1 stinger increases risk of another by ___ times?

4. Pathoanatomy ◦neurapraxias are caused by different mechanisms including ? [3]

1. refers to transient brachial plexus neuropraxia ◦can be serious if they are recurrent or long lasting

2. Epidemiology ◦common in collision sports such as football

3. Having 1 stinger increases risk of another by 3X

4. Pathoanatomy:
i. Traction injury
◾occurs by downward displacement of arm and bending of neck away from side of injury
ii. Compression injury
◾occurs by lateral head turning toward affected side
iii. Direct blow
◾can cause injury with blow at Erb's point superior to the clavicle


Burners & Stingers: Presentation

1. Symptoms : unilateral tingling in arm IS/IS NOT typically isolated to a single dermatome
2. Symptoms usually resolve quickly in __to__
3. Physical exam : cervical ROM
4. Physical exam : tenderness
5. Physical exam: unilateral transient weakness in C__, C__ muscles (____, _____)
6. Can have positive (eponymous) test

1. Symptoms: unilateral tingling in arm IS NOT typically isolated to a single dermatome
2. Usually resolve quickly in 1-2 minutes
3. Physical exam = FULL cervical ROM
4. Physical exam = NO tenderness
5. Physical exam= unilat transient weakness in C5, C6 muscles (deltoid, biceps)
6. Physical exam = can have positive Spurling test


Burners & Stingers: Imaging

1. Radiographs

2. MRI ◦ indicated whenever symptoms are______(inconsistent with stinger)

3 EMG ◦indicated if symptoms persist after ______ . Findings incl _____________

1. Radiographs ◦usually unremarkable
◦C-spine images indicated with recurring symptoms ◾to rule out fx and cervical stenosis

2. MRI ◦indicated whenever symptoms are bilateral (inconsistent with stinger) ◾to rule out cervical spine pathology such as herniated disc or cervical stenosis

3. EMG ◦indicated if symptoms persist after 3 weeks ◾will show abnormalities in roots, cords, trunks, and peripheral nerves


Burners & Stingers: Treatment

1. Nonoperative: return to play
◾ Player may return to play when? [2]

2. Nonoperative: contraindications to return to play incl. [1]

3 Prevention

1. Nonoperative : return to play
a player may return to play when:
(a) complete resolution of symptoms
(b)normal strength and range of motion

2. contraindications to return to play include ◾recurring symptoms (until cervical spine xrays are obtained)

3. Prevention ◦try different neck collars for football players




trauma topics as listed

still to be done


Concussions & Head Injuries : Introduction

1. Definition: Immediate transient impairment of neural function due to a jarring injury to the brain; ◦ LOC is not required and only occurs in ___%

2. Epidemiology
◦ ___K sports-related head injuries/year in USA

3. Associated conditions ◦rule out associated ______ injuries?

1. 10%

2. Approx 330K sports-related head injuries/year
( NOTE : head injuries are the leading cause of sports deaths; ◦helmet use associated with decreased rates of head and neck injuries)

3. Associated conditions ◦rule out associated neck injuries


Concussions & Head Injuries: Anatomy

Layers of the spinal cord and assoc bleeding pattern: [3]

1. dura mater (outside)
◾epidural hematoma
◾subdural hematoma

2. arachnoid (middle)
◾subarachnoid hematoma

3. Pia mater (inside)


Concussions & Head Injuries: Classification

American Academy of Neurology (AAN) guidelines:

1 Describe

Grade I: No LOC and symptoms of confusion last less than 15 minutes

Grade II: No LOC and symptoms of confusion last greater than 15 minutes

Grade IIIa: Brief loss of consciousness (measured in seconds)

Grade IIIb: Brief loss of consciousness (measured in minutes)


Concussions & Head Injuries: Presentation / Imaging

1. Symptoms

2. CT ◦usually normal ◦rule out intracranial hemorrhage
◾_______ hematoma most common
◾_____ , ______ , _______ bleeds also possible
◾CT required if patient is unconscious for _______ ?

1. Symptoms ◦headache and dizziness most common symptoms ◦amnesia (memory loss)

2. CT ◦usually normal ◦rule out intracranial hemorrhage
◾SUBDURAL hematoma most common
◾epidural, subarachnoid, intracerebral bleeds also possible
◾CT required if patient is unconscious for GREATER THAN 5 MINUTES


Concussions & Head Injuries: Evaluation

1. what is the Standard Assessment of Concussion Test (SAC)

2. what is the Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT)

3. Memory testing

4. what is the BESS system ?

1. SAC Test ◦orientation, memory, concentration, exertional delayed recall

◦a computer-based test that assess the users attention, memory, and processing speed
◦comparison is made to baseline scores or historical controls
◦useful tool in guiding treatment and return to play decisions

3. Memory testing ◦antegrade and retrograde must be tested

4 Balance error scoring system (BESS)


Concussions & Head Injuries: Complications

1. Second impact syndrome

2. Epidural bleeding

3. Cumulative effects

4. Postconcussion syndrome

1. Second impact syndrome ◦second minor blow to head before initial symptoms resolve ; ◦due to loss of autoregulation of the brain's blood supply ◦50% mortality rate ◦affects adolescent males

2. Epidural bleeding ◦commonly have a lucid period before neurologic decline
◦neurosurgical decompression and seizure prophylaxis indicated

3. Cumulative effects ◦cumulative effects of repeated concussions is controversial

4. Postconcussion syndrome ◦headache, confusion; ◦RTP contraindicated


Concussions & Head Injuries : Treatment

1. Nonoperatve

2. Graduated return to play: indications

3. Return to play contraindicated until further evaluation when:

4. Prevention

1. Nonoperatve ◦same day return to play is NOT indicated in patients diagnosed with concussion

2. Graduated return to play: indications ◾any athlete <18 years of age
◾elite athletes of any age without team physicians experienced in concussion management

3. return to play contraindicated until further evaluation ◾indications ◾LOC
◾prior Grade 1 concussion in same season
◾symptoms > 15 minutes
◾positive exertional stress test
◾postconcussion syndrome

4. Prevention ◦includes enforcing proper head gear
◦minimizing premature return to play


Tibial Shaft Stress Fractures

1. Define
2. Epidemiology
3. Mechanism
4. Pathophysiology

1. An overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures
2. Commonly seen in runners and military recruits / seen after change in training routine
3. Linear microfractures in trabecular bone from repetitive loading
4. Callus formation->woven bone->endochondral bone formation


Tibial Shaft Stress Fractures: presentation

1. History

2. Symptoms

3. Physical exam

1. Change in exercise routine

2. ◦ Onset of symptoms often insidious ◦ Symptoms initially worse with running, then may develop symptoms with daily activities

3. Pain directly over fracture


Tibial Shaft Stress Fractures

1. recommended views
2. findings

Other imaging
3. Bone scan ?
(note: MRI is replacing bone scan due to high sensitivity)

4. MRI findings?

1. AP and lateral
2. lateral xray may show "dreaded black line" anteriorly indicating tension fracture from posterior muscle force
◾endosteal thickening
◾periosteal reaction with cortical thickening

3. Technetium Tc 99m bone scan ◦findings ◾focal uptake in cortical and/or trabecular region

4. ◾marrow edema
◾earliest findings on T2-weighted images ◾periosteal high signal
◾T1-weighted images show linear zone of low signal


Tibial Shaft Stress Fractures

1. Nonoperative activity restriction with protected weightbearing
- indications
- technique

2. Operative
- indications
- technique

1. Non-op
◾indications=most cases
◾technique = avoids NSAIDs (slows bone healing)
; consider bone stimulator

2. Operative
◾indications = if "dreaded black line" is present, especially if it violates the anterior cortex (nb: fxs of ant cortex of tibia have highest likelihood of delayed healing or non-union)


Tibial Stress Syndrome (Shin Splints)

1. define

2. Incidence = _to_% of running injuries and __% of leg pain syndromes

3. Location

1. Overuse injury or repetitive-load injury of the shin area that includes:
i) medial (posteromedial) tibial stress syndrome ◾most common
ii) anterior (anterolateral) tibial stress syndrome

2. 10-15% running; 60% leg pain syndromes

3. distal and posteromedial tibia


Tibial Stress Syndrome (Shin Splints)

Risk factors (6)

◾runners without enough shock absorption (running on cement or uneven surfaces, improper running shoes)
◾training errors (sudden increase in training intensity and duration)
◾running >20 miles/week
◾hill training early in the season
◾history of previous lower extremity injuries
◾over-pronation or increase internal tibial rotation


Tibial Stress Syndrome (Shin Splints)

1. Pathophysiology =caused by a traction periostitis ◾anterolateral = traction periostitis of ____muscle on tibia and IO membrane
◾posteromedial ◾traction periostitis of which 2 muscles?

2. Associated conditions

1. ◾tibialis anterior
◾tibialis posterior and soleus

2. Associated conditions
i. female athlete triad (critical to diagnose and treat)
ii. tibial stress fractures (females have 1.5-3.5 > risk of progression to stress fractures)


Tibial Stress Syndrome (Shin Splints)

1. Differential Diagnosis for Exertional Leg Pain (8)

(Dx->Tissue Origin->Characteristics)

1. Anterior tibial stress syndrome->Periosteum->Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise, decreases during training

2. Medial tibial stress syndrome->Periosteum->Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, decreases during training

3. Tibial or fibular stress fracture->Bone->Pain with running, point tenderness over fracture site, "dreaded black line" on lateral xray

4. Exertional compartment syndrome->Muscle and fascia->Symptoms begin 10min into exercise and resolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures

5. Leg Tendinopathy->Tendon->May be Achilles tendon, peroneal tendon, or tibialis posterior

6. Sural or SPN entrapment->Nerve->Dermatomal distribution of symptoms

7. Lumbar radiculopathy->Nerve->Worse with lumbar tension position (sitting)

8. Popliteal artery entrapment->Blood Vessel->Diagnosed with vascular studies


Tibial Stress Syndrome (Shin Splints)

Symptoms ?

i. vague, diffuse pain along middle-distal tibia that decreases with running (early stage) ◾differentiate from exertional compartment syndrome, for which pain increases with running

ii. earlier onset of pain with more frequent training (later stages)


Tibial Stress Syndrome (Shin Splints)

Physical exam findings (5)

Physical exam
i. Tenderness along posteromedial border of tibia ◾4cm proximal to medial malleolus, extending proximally up to 12cm
ii. pes planus
iii. tight Achilles tendon
iv. weak core muscles
v. provocative test ◾pain on resisted plantar flexion


Tibial Stress Syndrome (Shin Splints)

Imaging: Radiographs
1. indications
2. findings

1. indications
◾exclude stress fracture

2. findings
◾conventional XRs are normal in first 2-3weeks
◾long-term changes include periosteal exostoses
(note: differentiate from stress fracture, which shows "dreaded black line" )


Tibial Stress Syndrome (Shin Splints)

Imaging: 3-Phase Bone Scan
1. findings (compared to stress fracture)

1. Indications
◾exclude stress fracture

2. Findings
◾diffuse, longitudinal increased uptake along posteromedial border of tibia in delayed phase (Phase 3) but...
◾normal findings on Phase 1 (flow phase) and blood pool phase (Phase 2)
(note: theses findings differentiate from stress fracture, which has focal, intense hyperperfusion and hyperemia in Phase 1 and 2, and focal, fusiform uptake in Phase 3)


Tibial Stress Syndrome (Shin Splints): Nonoperative Rx

Activity modification with nonoperative modalities is 1st line Rx and successful in vast majority

1. techniques

1. Techniques
a) activity modification ◾decreasing running distance, frequency and intensity by 50%
◾use low-impact and cross-training exercises during rehab period
◾regular stretching and strengthening
◾run on synthetic track
◾avoid running on hills, uneven or hard surfaces

b) shoe modifications ◾change running shoes every 250-500miles as shoes lose shock absorbing capacity at this distance
◾orthotics may be helpful in patients with pes planus

c) therapy
◾focus on strengthening of invertors and evertors of the calf

d) other
◾local phonophoresis with corticosteroids may be effective


Tibial Stress Syndrome (Shin Splints): Operative Rx

1. Technique

2. Indication

3. Outcome

1. Deep posterior compartment fasciotomy + release of painful portion of periosteum

2. Indications = failed nonoperative treatment

3. Outcomes = variable results, not likely to cause complete resolution of symptoms


Neck Injuries in Athletes

1. Spectrum of injuries include? (6)

2. What is transient quadriplegia?

3. What is spear tacklers spine ?

1. Spectrum of injuries include
◾ligament sprains
◾burners / stingers
◾spear tackler's spine
◾cervical fxs
◾transient quadriplegia ◾quadriplegia


Neck Injuries in Athletes

What is transient quadriplegia?

Transient quadriplegia:
◾neuropraxia of the cervical cord
◾bilateral upper and lower extremity pain, parasthesias, and weakness
◾symptoms resolve within minutes to hours


Neck Injuries in Athletes

Spear tacklers spine

1. definition

2. treatment

1. definition ◾developmental narrowing (stenosis) of the cervical canal
◾persistent straightening or reversal of the normal cervical lordotic curve
◾concomitant posttraumatic roentgenographic abnormalities of the cervical spine
◾documentation of having employed spear tackling techniques

2. Rx= contraindication to play in contact sports


Neck Injuries in Athletes


1. axial load (compression) with flexion of the spine

2. most injuries in contact sports occur during tackling of another player
◾"spear tackling" = most common mechanism in football
◾can lead to gradual cervical stenosis and loss of cervical lordosis


Neck Injuries in Athletes

Associated conditions include underlying conditions of the cervical spine can increase the severity of neck injuries and be contraindications to play. They include: (5)

1. previous trauma to cervical spine (fractures, ligamentous injuries)

2. cervical stenosis

3. congenital odontoid hypoplasia

4. os odontoideum

5. Klippel-Feil anomalies


Exercise Science : Types of contractions/movements
1. Isotonic
2. Isometric
3. Concentric
4. Eccentric
5. Isokinetic
6. Plyometric
7. Open Chain
8. Closed Chain

1. Force remains constant through range of motion:improves motor performance(eg.Biceps curls using free weights)
2. Constant muscle length and tension that is proportional to the external load; Causes muscle hypertrophy(eg. Pushing against an immovable object)
3. Shortened muscle and tension that is proportional to the external load;(eg.Biceps curl with elbow flexing)
4. Force remains constant as muscle lengthens;Most efficient method of strengthening muscle(eg.Biceps curl extending elbow)
5. Muscle contracts at a constant velocity through varied resistance(eg. requires special equip to test)
6. Rapid eccentric-concentric shortening.
Good training for sports that require power(eg. box jumps)
7. Distal end of extremity moves freely(eg.Seated leg ext)
8. Distal end of extremity fixed (eg. squats)


Exercise Science: Aerobic

1. Energy source
2. Muscle type
3. Exercise duration

2. Type II (A, B) - fast twitch
(note: IIA: aerobic and anaerobic IIB: primarily anaerobic)
3. 10 seconds of high intensity


Exercise Science: Anaerobic

1. Energy source
2. Muscle type
3. Exercise duration
4. Requires (2)

1. Oxidative phosphorylation (Kreb Cycle)
2. Type I muscle - slow twitch
3. endurance
4. High yield ATP and O2


The Female Athlete:Physiologic differences

Women have:
1. ___ body fat %
2. ____ maximal oxygen consumption and Hb
3. ____ cardiac output
4. ____ muscle mass and strength

Woman have increased incidence of: (3)

Women have:
1. a higher body fat %
2. lower maximal oxygen consumption and hemoglobin
3. lower cardiac output
4. decreased muscle mass and strength

Woman have increased incidence of
◾patellofemoral disorders
◾stress fractures
◾ACL injuries


The Female Athlete: ACL injury

1. Risk of injury is ___x greater than males ◦especially with pivoting sports

2. ACL injury is more common in females due to: (6)

1. 2-10x greater

2. (i) landing biomechanics and neuromuscular control differences ◾conditioning and strength play the biggest role ◾females land with their knees in more extension and valgus due to hip internal rotation
(ii) smaller notches
(iii) smaller ACL size
(iv) cyclic hormonal levels ( greater risk during preovulatory phase of the menstrual cycle
(v) leg alignment
(vi) genetic predisposition (underrepresentation of CC genotype of a COL5A1 gene sequence in females with ACL ruptures)


The Female Athlete

Female athlete triad (anorexia athletica) ?

1. amenorrhea

2. disordered eating
◾insufficient caloric intake ◾is the most common cause of amenorrhea in female athletes

3. Osteoporosis
◾obtain a DEXA scan in female athletes with a history of amenorrhea and stress fractures


The Female Athlete
Female athlete triad (anorexia athletica) ?

1. Amenorrhea resulting from: (3)

2. Secondary amenorrhea: definition and cause

3. Incidence in elite runners is nearly ___%

4. leads to? (2)

energy imbalance, low body fat, and hypothalamic-pituitary axis changes

2. Cessation of menses for 6 months after at least one normal cycle) is often caused by hormonal disturbances

3. 50%

4. Bone demineralization and stress fractures


Day 40: Ligaments of the knee

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