Chapters Transcript Evaluation and Treatment of Common Knee Injuries in Athletes Dr. Matthew Matava discusses common athletic knee injuries including evaluation, preventions, and intervention. So, Doctor Matthew Matava received his medical degree at the University of Missouri, Kansas City School of Medicine. He then completed his residency in orthopedic surgery at Emory University affiliated hospitals in Atlanta. Georgia and his fellowship in sports medicine and arthroscopic surgery at the Cincinnati Sports Medicine and Orthopedic Center in Cincinnati, Ohio. Doctor Matava is currently professor of orthopedic surgery and physical therapy, as well as the director of the Sports Medicine Fellowship with the Washy Physicians. He sees patients at the was. And BJC Orthopedic Center in Chesterfield and specializes in orthopedics, sports related injuries in adults and children, including ligament injuries of the knee, athletic injuries of the shoulder and elbow, and pediatric orthopedic knee disorders. So, today he's going to talk about evaluation and treatment of common knee injuries in athletes. So thank you so much for being with us today and educating us on this. Right. Well, thanks a lot, Nicole, for the nice introduction and uh welcome to all of you on the line here uh who are tuning in for these talks. Um. So I wanted to kind of, you know, we see a lot of knee injuries and what I do with the surge in sports medicine. But I think also for primary care, um, at least my understanding is you will see a lot of knee injuries as well. Certainly, if you do anything in the emergency room, 30% of all ER visits are related to orthopedics, and a significant number of those are related to the knee. So, um, I have good bit of information here. Um, if you have any questions, you know, feel free to raise your hand virtually or Nicole can stop me and we can kinda talk from there. So I'll just kind of get right at it here. There you go. These are my disclosures. Nothing are relevant for this talk. So if you look at the instance of knee injuries and adolescent and athletes, uh, this is a study published out of the National High School sports related injury surveillance, um, up to between 2005, 2011. They're about 2.9, almost 3 injuries per 10,000 athletic events, um, or exposures. Um, most common sports, as you might imagine, football, girls' soccer, and boys' ice hockey. Um, in terms of the Common injuries, you know, the, uh, if you follow the, you know, the, the sports media, everyone hears about ACL tears and certainly probably meniscus tears. Some of you on this, on this call maybe have had a meniscus tear. I've had both ACLs and meniscus tears myself, but the MCL, the medial cloud ligament, is the most common knee injury we tend to see in athletes. Unfortunately for the athletes, it tends not to require surgery. It tends to be treated with conservative care. So whenever a patient comes in, um, to your office, uh, for a knee history, if you see them on the sideline, if you're covering the game, I'm not sure again if you do that in your practice. Um, in my mind, some of the topics I at least cover with the athletes, first of all, is there any history of trauma? If I'm covering an event, I know what they're doing, but if they come in the office, I don't really know, is this, you know, it came from an acute injury from a practice or a game. Or is this a work related problem that's kind of come about over time? Where the location of the pain is, is very helpful from an anatomic standpoint. Any prior history of pain is consistent with patients with arthritis, perhaps a meniscal tear, a crinicity. Any recent increase in activity would suggest an overuse condition, uh, any change in equipment or playing surface we see a lot in runners. We see a lot of kids who like are off all summer long, then they join the cross country team and they're running 5 miles a day, and all of a sudden now they're having knee pain because they're running in their Nike Air Jordans as opposed to appropriate running shoes, or if they've gone from a relatively soft surface. Uh, for example, you know, asphalt is a softer surface and concrete, and that little bit alone may cause an increase in your pain. Other joint vomit is helpful if there's any concern for some sort of systemic, um, uh, rheumatologic condition. And then obviously night pain, fever, weight loss, those are worrisome signs from an orthopedic standpoint that a tumor might be involved. Um, very uncommon for us to see, um, tumors in any practice, but the knee is the most common kind of anomiclocation, um, for certainly for adolescents who may have, uh, a, uh, osteosarcoma. So it's something to consider in the back of your mind. And athletic-related pain is not gonna be at night, is not gonna be associated with fever or, or with weight loss. So some issues that are relevant to athletes, particularly again location of pain from an anatomic standpoint, the sport and position they played, you can play the same sport, but if you play a different position, for example, with cockey, I take care of the Blues for the past 28 years, um, you know, a goaltender has a lot more different duties than a, than a centerman. Um, and, and that may be manifested as how they present with their symptoms. Whether or not the symptoms are worse than the activity, a huge important uh topic is whether the patient has mechanical symptoms. And when I say mechanical, I mean locking, catching, giving way. In other words, the knee doesn't glide smoothly, it doesn't feel stable, um, and you'll have Types of giving way. The patient, if you ask your knee gives way. If they say their knee gives way like walking down the stairs, um, that's typically functional instability because your quad muscle was not strong enough to hold them up, and that can occur from either fatigue, um, an injury, or just, you know, knee pain that causes the muscle to shut down. But if they have, if they have mechanical instability, um, with cutting and pivoting, then that more implies an anatomic defect either like an ACL tear, a meniscus tear, a loose body, something anatomically that's inside the joint that's causing it not to work properly. A fusion, uh, presence of fusion is very important whether or not they have an. Particular injury, we will tend to see that and I want you to try to distinguish when you, when you are evaluating these patients, swelling from an effusion because 9 times out of 10 we ask the patient if their knee swells, they'll virtually always say yes when from an objective standpoint you're examining them, you're unable to detect any particular effusion. So it's important to sort that out when you're doing your examination. I think it's very important to know whether or not the athlete can play through the injury. Um, some will do that based on their, you know, their perception of pain, based on if you're, if they're a pro athlete, if they're in a contract year, they may try to play through injury. If they have the playoffs or if they're in the playoffs, um, they may treat this injury different than if it's preseason training camp. And so that's something to consider at the kind of the elite level of athlete. Um, any pain with non-play activities is certainly worrisome. And then whether or not the athlete can play with bracing or medication. Again, this is gonna be more of the elite athlete where you have at your disposal medications, you may have injectable medicines we can talk about. You may have bracing that's available, that's not available perhaps for the high school kids. So, um, it really the time of season, the team performance, and the career goals are all gonna affect this, uh, athlete's willingness to play, even though they may have an injury as opposed to just having pain from, from overuse. So, I mentioned this for the effusion, and I think it's really important, I see this a lot. That comes out of the ER and sometimes when they, when they see their pediatrician or a family physician, um, the distinction between an effusion and prepatellar bursitis. On the left is prepatellar bursitis. It's a big baggy ball of fluid that's anterior to the patella. It's not intra-articular, it's extra-articular. And if you palpate the patella, you can see between the you can feel the patella and the femur. There's no fluid there, whereas all the fluids between the skin and the patella. Whereas on the right-hand side, the effusion. If you can kinda take your non-dominant hand and kind of milk the distal thigh, all that fluid in the supra patellar pouch will cause the kneecap to so-called blot where it goes anteriorly, and they'll have very thin tissue between the skin and patella because all the fluids between the patella and the femur inside the joint. So it's very important in terms of prognosis, in terms of diagnosing the problem as to what, which of these two conditions uh they're manifesting. Now, when we talk about infusions, especially for an acute injury, a lot of athletes and now patients will ask me, you know, do I need to have my knee drained? It's a topic we talk about when talk with students and residents and, and that sort of thing. So some of the whens, whys and hows and aspiration. Um, first of all, some of the questions I would think you wanna answer is, is, is the effusion acute or chronic? OK. Chronic may be arthritic, they may have a meniscus tear, they may have, again, rheumatoid arthritis. And acute injury typically probably is a traumatic, uh, situation. Um, was there a traumatic etiology? They'll tell you. I was playing football. I twisted, my knee popped, and 6 hours later, my knee was full of fluid. Was your previous surgery? Are there any joint implants? And that's certainly something relevant if they have a knee replacement in an older patient. Um, I don't think you should be very cavalier and sticking a needle in the joint, um, for the risk of seeding that joint with bacteria from the skin. Um, I would probably call your orthopedic, uh, consultant if they did have a, a known, uh, knee replacement before you inject the joint. Is there any other joint involvement? Um, I've had patients who've had multi multi-joint septic arthritis. Patients with rheumatologic conditions will often have multiple joints involved. And then is there any systemic symptoms? Obviously, with that picture on the right, that's a draining knee after a surgery. That's obviously an infectious process. They may have a fever, they may have chills, night sweats, overall malaises. So these are some of the important things to consider when you consider, when you're thinking, A, am I gonna drain the knee, and B, should I drain the knee? Now, if you look at the normal synovial fluid, as you know from, from your training, the plasma infiltrate, there's very few cells. The ones that are there are monocytes. Albuin is the primary protein. The glucose is comparable to plasma, and you should be able to aspirate fluid. You should be able to see through it, OK? And so if you can't see through it, that implies there's more white cells to imply a sort of a non, um, Non-normal etiology of of, of swelling. The hyaluronic acid, um, that you've probably heard of for various reasons, maintains the joint viscosity. It has a negative charge and that imparts high viscosity to the joint. It enhances joint lubrication. It's a glycosamine glycan which is shown on the right there. And we often will use hyaluronic acid injections to actually treat patients with osteoarthritis. You're familiar with Synvisc, um, Durala, Moovvic, gel one, those are all hyuronic acid analogs that can be very effective in treating patients with osteoarthritis. Now, in terms of joint aspiration principles, again, the indications to me for aspiration, first and foremost is pain relief, OK? Just from the pressure phenomenon that that may occur upon an injury or condition to remove an inflammatory debris. Um, we would not recommend, orthopedically recommend definitive treatment of septo arthritis with an aspiration. Um, there has been, there has been literature out there saying that you can do with repeated aspirations, treat a septic joint. We in the orthopedic world did not advocate this. Um, it can be very helpful for a diagnostic aid, which we'll talk about, and also to improve function just by getting all that pressure out of there. It allows the patient to bend his knee, um, to a greater degree. One of the reasons why we like to get fluid out of the joint, and this is especially postoperatively, is that there's a reflex that is activated with the, um, the neuroreceptors inside the, inside the synovium that goes through the spinal cord that will actually shut down the quad muscle. And so that's why if you're ever see your patients who you know, major reconstructive surgeon like a, like an ACL. They'll often have a lot of quad atrophy. That's that, that's that sort of that uh reflex mechanism that occurs. So again, to try to avoid uh rather overcome that, we try to get the fluid out as much as we can in order to allow them to actually strengthen their quad. Now, some of the contraindications to aspiration, if they're on any anticoagulant therapy, obviously may make them bleed, hemophilia, thrombocytopenia, all because of bleeding issues. The one other caveat I would recommend is to be careful of is to inject your overlying cellulitis for uh patients with bacteremia cause you do that, I want to obviously. Um, it takes an infection that's localized to the skin and actually put it inside the joint. So something to consider. If there's any erythema, I would definitely, you have to aspirate it to rule out a septic joint. I would definitely aspirate away from where the erythema is located. Now, this is the equipment I like to use, obviously sterile gloves. I tend to use a beadine swab. Alcohol pads are not enough. I like to use alpha chloride. I've had my own knee aspirate multiple times for various injuries, and it does, it does hurt to stick the needle in there. I think, I think if you use lidocaine, which a lot of people do, it actually burns more than if you just use ethyl chloride. Um, a 60 cc syringe to, in order to plug the fluid, 18 gauge needle in case the fluid is rather thick. hemostat, in case you need to take off your syringe and then either inject cortisone or if you want, if you, they have a really large um hemorosis to be able to take multiple um um syringes full. And then obviously any specimen tubes or cultures if you're suspicious of infection. Now, ultrasound guide aspiration injections been very has been um very much touted recently. I, I do, I'm not, I have not trained on ultrasound. Guided anything, which tells you how old I am. Um, but again, I feel very comfortable doing this, um, kind of blindly, so to speak. But this, but people who are trained nowadays will be trained in how to do it under ultrasound. If you feel more comfortable to do it that way, then more power to you, whatever you can do more accurately. Um, we've mentioned earlier that patellar ballotment. Here's where you can kind of feel whether or not that patella is sort of rising anteriorly or uh superiorly because of the big fluid wave that you'll get if you sort of milk the thigh down, cause a lot of fluid is in the super patellar pouch that will push the patella up and it makes the aspiration much easier. Now, these are the portals I like to use, the superior portal. At the junction between the femur and the patella. Again, I have to take your hand and kinda melt down that thigh to get all that fluid down there that'll make the patella rise. And so you have a bigger space to go between with your needle between, so you don't hit the femur or hit the patella. Um, if you're going to inject a dry knee with, for example, with cortisone, which I imagine many of you have, um, I don't like to inject via this portal. I like to inject rather on that side on the right, either the anterior auto portal or the anterior medial portal. Those are the arthroscopy portals we tend to use for our nearthroscopy. The reason I like to do that is because if you go on those, those. just off the patellar tendon and you aim at about 45 degree angle from the midline, you'll go right into there and condor notch. There, you're not gonna hit a bone, you're not gonna hit relevant structures that cause pain. It's much easier to get into a dry joint via those portals than if you do in the uh superior auto portal like you normally would when there's a big, uh big hemorosis. So if you look at the classification by leukocyte count, obviously the non-inflammatory conditions, less than 2500 cells, either trauma charcot joint, osteoarthritis, or meniscal tear. When you get between 2500 and 25,000, you're thinking gout, pseudo gout, rheumatoid arthritis. Also, the, the fluid is murkier, you can't read through it, um, like we mentioned earlier. Anything infectious is over, over 50,000, um, acute bacterial infection, tuberculosis less commonly, but something to consider. And then after, obviously, if there's blood, this is typically gonna occur usually from trauma, at least in my patient population. But again, if you have an older patient who's on a, who has a coagulopathy or they're taking um some sort of anticoagulant, um, they will get a bloody fusion. You can get a bloody effusion from pigmented villa nodule or synovitis, which is a common condition of the synovium that produces this hypertrophic synovium that can actually bleed. Um, then you have the rare vascular malformations and the so-called charco arthropathy. Um, where the patient just basically destroys his or her joint because they don't have the nerve receptors to, to prevent them from doing otherwise. But for the most part, most of the blood you see is gonna be from trauma. Now, if you have blood and flat fat, as is shown in that upper right-hand kidney basin there, that implies that there's an intra-articular fracture from the marrow elements coming out that you don't typically see what it's just like an ACL tear that's gonna be pure blood. Um, and then, the clear fluid will either be a rheumatologic process, a subacute meniscus tear, um, osteoarthritis. Um, I actually have a patient recently and you might not believe it because of the timing, but uh actually has uh Lyme ar Lyme disease with an associated synovitis. Um, has had significant recurrent effusions, one hiking. Um, again, this isn't even time this time of the year to get that, but he got it a couple of months ago and is being treated now with doxycycline, but that will give you a recurrent knee effusion that's relatively clear. Now, kind of moving on and the patient um who does present to your office with knee issues, um, this is sort of the plain radiographic assessment that that we recommend. Um, this, the upper left is a weight-bearing PA view with knee at 45 degrees. And what that does is it helps to show the joint space on the back of the, of the joint, and that's where most of the joint wear is gonna be. And so if they have joint space near them, you'll pick it up better with the knee at 45 degrees. We always get weight-bearing views in the PA view, in the PA um um uh plane. Whereas for the lateral view, those are always 30 degrees non-weight bearing, and then we do what's called a merchant and an axial view. I would discourage you from doing um the uh sunrise view, which I'm sure you've heard of. The sunrise view causes the need to be hyperflexed, and what that does is it forces the patella in the trocher groove, which can artificially kind of stabilize the patella. So a merchant view is considered much better for this purpose. This is an example here of the, just the distinction I was trying to make between those two radiographic methods on the, on the X-ray on the left. That's a weight-bearing, uh, view with the knee in full extension, uh, whereas on the right, the patient, same patient, but this time he's flexing his knee to 45 degrees. You see the significant decrease in joint space between the two because most of the joint space wear is gonna be more posterior in the condyle of the femur, and by flexing it to 45 degrees, you will detect that much better than you will with the knee in full extension. So again, And the one on the right is called the Rosenberg view. You may have heard that term. This is what we tend to get in adults where we're trying to rule out any sort of sniff into germ changes. So, but it is, it is a striking difference. You can see if you're not, if you're not looking for it. But at a minimum, please get a weight-bearing view. Never have this be non-weightbearing. Now, an MRI is obviously we've all seen MRI's. It's the, everyone seems to come in nowadays with an MRI in my office. It's very good for ligaments, cartilage, bone, and muscle. Uh, you can imagine multiple planes. It is rear dependent. Um, most MRIs now are between 1.5 and 3 Tesla. Um, you can't have interference from from surgical hardware, depending upon what you're looking for, and the radiologist can kind of account for that in some of the sequences they, they asked for. MRIs can be very expensive. On average, I think around $3500 in Saint Louis for a typical knee exam. So we don't, it's not something we take lightly, although it seems like everybody has an MRI when they come in. So the indications in my mind, we can talk about this after the, after the, the lecture, um, only after plain X-rays. In fact, most insurance companies will not even allow you to do an MRI until you get X-rays to confirm a suspected diagnosis, you're not gonna, you're not getting an MRI just to see what it shows. You should have a diagnosis in mind. Um, and you should also like any test, only get it if it's gonna alter the course of treatment. I have a lot of patients who come in and say, I wanna get an MRI. I just wanna know what's going on. I don't wanna have surgery. I'm doing OK. I just wanna know. Well, that's not an indication for an MRI. OK. And so, I do think there's limited indications for primary care physicians in terms of, at least for the MRI of the knee. And for the reason for that, not to offend anybody on the call, but if a patient has a significant knee injury with their knee, they can't, they can't bend it, it's, it's a large, a large effusion. They probably need referral. Or if they have a condition where you've been treating them appropriately with conservative care, but they're not getting better, probably needs to be referred anyway. So I would, I would discourage you from, from getting a lot of MRIs of the knee. A lot of times there's certain sequences we'll get, we might want to get an MRI with, with ganium injection and arthrogram that you would know to do. And so those are things that, that kind of might play a role as to why you, you may not want to order these routinely. Um, although I do acknowledge that, that you, you and as well as I am often pressured by patients to order them. But again, like anything else we do from a test standpoint, it doesn't really replace a careful history and physical examination. So one of the, one of the first thing I'll talk about is uh meniscal tears because it's just so pervasive. Um, I tore my meniscus, um, I suspect somebody in this call probably has done that as well. Um, there's about a 60% instance in asymptomatic adults, um, very, very common, whereas the symptomatic adults, the annual instance is about 222 out of 100,000 people, still a very, very common injury. Um, the higher the BMI, um, the more associated tears on the lateral side because the lateral meniscus tends to cover more of the top of the lateral ti of plateau, the weight-bearing surface than the medial side does. Patients who have an ACL tear, there's a, there's about a 60% in instance of coexistence of a misscus tear with an ACL tear from an acute injury, it's usually lateralmiscal tears for a chronic injury, medial tears tend to predominate. In terms of age, uh, patients under 30 years of age, they tend to be longitudinal tears. Over 30 years, they tend to be more complex tears, and younger people tend to have more lateral tears. Older people tend to have more medial tears. So, either way, you will tend to see in your office, at least I see more medial tears because again, for the older age population. Um, you know, not, I'm talking about not kids. If you don't see a pediatric population, you're gonna probably see more medial tears. And 60 to 90% of patients, and certainly adult patients with meniscal tears will have some degree of concurrent arthritis. And that often mask, that often will kind of cloud the clinical picture as to how these patients should be treated because you're not, you don't know if they, their pains from the arthritis or is it because of the, uh, the meniscus tear. And so if you look at the structure of the meniscus, you know, the, there's only the peripheral capary plexus only goes to about the peripheral 20% of the meniscus. So the inner 80% is avascular. We call this the white-white area where there's no blood on either side of the tear, whereas the red red area is where there's theoretically blood on both sides of the tear. Um, this is an arbitrary classification, but it helps us to define what treatment might be appropriate. Um, this, this collagen fibers run circumferentially, and this is, this influences a lot how we will surgically treat these because we want to grasp as many fibers as we can if we're going to do a meniscus repair. Um, as you probably remember from days of anatomy, the meniscus does uh load transmission. Like I said, the laterniscus does about 70% of the lateral compartment load, whereas the medialniscus does about 50% of the medial compartment load. It acts as a good shock absorber to distribute the, the the weight-bearing forces over the entire joint, helps with joint fluid, uh, dispersion because again hyaline cartilage is, is receives its nutrition, uh, from the synovial fluid, not from a blood supply. Then the menisci also provide, uh, uh, have a role in this joint stability. So if you have a patient who has an ACL deficient knee, the medial meniscus acts as a secondary restraint to what we call anterior tibial translation or the tibia coming forward, whereas the lateral meniscus is a secondary restraint to the so-called pivot shift where the, where the tibia is rotating around the, around the femur. So good, very important in terms of um a stabilizing role. And this is a slide here that's, that's shown a lot, at least in the orthopedic world, published in 2006, that shows that from 0 to 60 degrees of knee flexion, the more of the meniscus you take out, going from 50%, 75%, a segment of it to the total uh meniscus, there's more to increase uh peak contact stress than the articular cartilage, which basically translates into um wear and tear of the articular cartilage, hence the phenomenon of osteoarthritis. And so if you look at the, what happens from either a near total or total. The evidence goes back to as well as 1948, the so-called Fairbanks changes we see where with a meniscus, you have the body weight dis uh dispersed over a broader area. If the meniscus is taken out, as is shown on the right hand side of that little diagram there, all your body weight is focused on one segment of the articular cartilage, and that's where it breaks down. Hence, osteoarthritis develops. And it's really unknown, you know, what threshold of metastectomy or a meniscus tear is actually needed before you have this cartilage breakdown. There's probably some genetic component to it. Because I osteoarthritis is genetically mediated. Um, it probably has something to do with the, the amount of trauma that the joint sustained to actually to cause the tear. So, but we really don't know how much of your meniscus you need before sort of there's a point of overturn in terms of the, uh, the risk for osteoarthritis. Now we classify menis meniscal tears based on their configuration, pretty simple. A radial tear on the left, complex tear, you can see in the upper, uh, second slide there, just, it's torn in mobile planes, so-called longitudinal tear, horizontal cleavage tear looks on the lower left, looks like a kind of a taco or a hot dog bun on its side, so-called bucket handle tear, which I'm sure you've heard of, looks like the handle of a bucket where the whole piece is displaced and the pair big tear. And really the, how we treat these is pretty much, pretty much based on the configuration. And there's a lot of factors that we consider when influence that will influence the treatment of meniscal tear. First of all, what are their symptoms? If they have just mild pain, they could probably play. If they have mechanical symptoms, like I mentioned earlier, the locking, the catching, probably not gonna be able to do their sport to a significant degree. The, the athlete may not want to play, or if it's a high school kid, he or his parents may not be willing to let him play for fear of further damage. Um, the surgical considerations, that type of tear, the patient's willingness to undergo a repair because of meniscus repair, we're actually suturing the meniscus, the rehab is much longer. It's up to 6 months to return to play as opposed to just having a meniscectomy. Um, the surgeon may have, may or may not have the ability to actually suture a meniscus. There may be associated pathology such as coexisting arthritis, as you can see on the lower right hand X-ray there, or they may have associated ACL tears. So those are all the the surgical considerations. And then there's a team considerations, you know, what time of the season is it? You know, if you're a pro athlete or Uh, Division One power 5 football player, if, you know, if you're hopefully you're gonna make the playoffs or you're in the playoffs, you're probably gonna try to continue to play with this thing, and you probably can do so safely as long as there's no locking or catching. If you're not very relevant in the team and you don't really get into it much and you're playing for high school for fun only, you probably are gonna keep playing with it because you're not gonna have fun doing it. You're probably not gonna be able to play anyway. Um, so this is some of the considerations we have in sports medicine as to how we treat these injuries. Now, if you look at the surgical management of the general meniscal lesions, which you tend to see in, in the older adult, again, very, very common. We always get X-rays, um, weight-bearing views for the reasons I mentioned earlier. We typically try non-operative treatment in these patients, um, typically around at least 3 months. Um, if they have significant and mechanical symptoms, then we will often resort to surgery. Um, if they have advanced osteoarthritis, um, they're very cautious and recommend sort of knee arthroscopy, and insurance companies nowadays. Pretty much uh often we usually not even approve an arthroscopic procedure if there's associated arthritis. If they have minimal OA but they're having mechanical symptoms and persistent pain, that's when we tend to do an arthroscopic partial menostectomy, and it can be a very effective uh treatment and be very helpful in a patient with return to foot too within about 6 weeks. And we do an arthroscopic mastectomy, we just, again, this is for symptomatic patients with mechanical symptoms that cannot be sutured um or the patient doesn't want to follow the post-op regimen for a meniscus repair because there's a lot of, there's, there's a lot of restrictions. We want to take off only the piece of meniscus that's torn back in the 50s and 60s, the surgeons would take out the entire meniscus. Now, we only do the torn fragment. We want to contour the remaining rim as is showing those two lower arthroscopy photos and avoid obviously any articular cartilage damage um that may occur because of the instrumentation. Now, meniscus repair is seen or is needed in about 20% of patients with tears, and these are the tears that occur in that so-called red, red zone where there's good blood supply that theoretically can allow the meniscus to heal. Um, and I, I sort of make the analogy that misscal repair is sort of analogous to fracture fixation. You, you, you need to have Um, when, whenever we repair a fracture or or treat a fracture, you, we have to have, you know, stability. There has to, the fixation has to be, uh, some degree of flexible stability because again, you're walking on this meniscus with your knee motion. Um, you obviously don't wanna cause any damage to the hyaline cartilage. It has to withstand months of healing. There should be favorable biology. In other words, the tear should be in an area where the theoretically can heal, and you obviously wanna reduce any disruptive forces that will, that will cause it not to heal. And so this is the principle here of an inside-out repair. This is the gold standard. This is a, that, that little two-door cannula there is used to pass a needle, and that needle has, there's two needles with a suture between them, and those are passed from inside out, hence the name, and then the, the suture is then tied on the, uh, on the capsule of the joint. And we'll typically put these 3 to 5 millimeters apart. Um, we might typically place them in a vertical fashion, um, because that's again, that's gonna be the strongest repair that you get. Now, there is, what is evolved from the the inside out method is the so-called all inside meniscus repair, and the advantages here is it only takes one surgeon. Um, these are fast. They come in various little darts as you can see on the lower right-hand side there, um, there's no theoretical neurovascular risks because You're doing is you're basically poking a hole through the meniscus. You're deploying the device that gets captured on the other side of the meniscus. You can put multiple anchors in. There is a bit of a cost issue. Um, the sutures that I showed you earlier, they cost about $90 each. These things cost up to upwards of $400. And so, They can sometimes not deploy accurately. They may have a hard time getting to where you want to go anatomically, and there's your, there is the expense. But they have allowed a lot of meniscal, uh, a lot of surgeons who have not been trained on meniscus repair surgery to allow to do these things and save the meniscus, whereas previously they were just taking the meniscus out. And so if you look at the success of meniscus repairs over 5 years, a study that was done in 2022 is a systematic review. Of all the studies over the past 20 years with minimum 5 year follow up, there were 12 studies. The overall failure rate at 86 months was about 20%, 19%. The Inside Out had a much higher, much lower failure rate, 5.5% compared to the all inside methods. There were 22%. There was no difference between medial versus lateral or an isolated tear or those with concurrent ACL surgery. So, in general, we tend to recommend Stabilize the meniscus when possible with the repair, but the patient has to be willing to undergo the rehabilitation. There's about 6 weeks of crutch use, followed by 6 months of um of refrain from sports activities, and a lot of patients don't wanna do that. But again, in the situation where they're having like an ACL or the surgery, then it's, it's part and parcel with the, with the rehabilitation they're doing for that procedure. Now, I sort of been mentioning anterior cruciate ligament here, this is the, the injury that gets the most press in my world. Um, I actually had my ACL torn in 1983 and the surgery I had, there's about an inch, rather a foot-long scar. Um, I was in the hospital 5 days in a cast for 3 months. Nowadays, it takes about an hour and a half to do. You come here for a few hours. There's no cast, there's no brace. You can walk on it that day, and it's a much different animal. Um, There's about 175,000 ACL reconstructions done annually. It's by far and away the most common um topic studied in my world of orthopedic sports medicine research. A brief Google search I did the other day, um, within about 23 seconds, gave 28 million results. And so it's, it's an injury that's known not only to patients, it's known to the media, it's known to everybody. And this used to be something that would be a career ender, um, certainly when I was growing up. But now because there's so many injuries, I've had patients now they are 12 and 13 that have had 2 and 3 ACL tears. I can remember one kid tearing their ACL in all my years of playing sports here in St. Louis. And part of that is because increased, you know, increased participation in sports. We see all these select teams where kids will play 2 and 3 games at a time. They may play in 2 or 3 teams at a time. Um, that's way too much activity for one muscle group and what happens to the theory is that there's muscle fatigue and these type of injuries result. And so we're very much against the whole select. Um, sports, uh, phenomenon that's going on in this country because it's too much for these kids. Um, there's also an increase, uh, in female sports participation that there wasn't previously, and girls are up to 6 times more commonly injured than boys are for ACL tears. There's increased media awareness. Um, if you just Look at the societal cost from a worker who tears his ACL or her ACL. There's about a $40,000 societal cost per injury. And so it's an important topic in this country. Um, I do think we have an excessive emphasis on sports in this country, which only adds, adds to that, uh, to that phenomenon. And so if you look at the instance of ACL tears in children and adolescence, um, over a 20-year period, you can see, there's an increase of 2.3% annually just in the number of tears that have occurred. And so, again, this problem is not going away anytime soon. If you look at the high school ACL injury rate by sports, again, the big, the big ones you might imagine girls soccer, boys football, girls basketball, and girls gymnastics. Again, girls, girls and girls. And so, as I mentioned earlier, girls are up to 6 times more commonly injured than boys are. There's lots of theories as to why that is. There was hormonal receptors of estrogen, progesterone in the ACL that they linked it to their menstrual cycle. Girls have a smaller overall ACL diameter. They have a narrower knee. Um, they have more of an increased angulation of the knee, the so-called Q angle because of a wider hip. But really, the reason that's been accepted now, um, from a research standpoint as to why girls are involved so much more often. is because when, uh, when there's a detrimental force causing the tibia to move forward on a girl, they tend to reflexively fire their quad muscle, which makes the tibia go even further forward, and that tears the ACL. Whereas boys who have a, uh, uh, anterior force or tibia, they will reflexively fire their hamstrings to pull the tibia back to protect the ACL. So it's neuromuscular firing patterns that probably is responsible for this, this, um, big difference between boys and girls. Now, if you look at an argument for a cell reconstruction, if you compare ACL patients who've had surgery with those who have not had surgery, those who've had surgery, there's 3 times lower instance of meniscus tears, 6 times lower incidence of osteoarthritis, and a 17 times lower in instance risk of a total knee replacement over time. So again, protecting the ACL helps to protect the meniscus. The meniscus helps to protect the arterial cartilage, and hence you don't get these, you don't get these downstream effects that you would get if you have recurrent stability. So if you look at the mechanisms of ACL on athletes, 70% of these are non-contact. Typically the so-called valgus external rotation valgus again was when your knee is going towards the medial side, is that, is that, um, is that female basketball players up on the right. Look at the on the far right hand photo there, how much valgus her knee is in. Sometimes you'll also get with hyperflexion and with um internal rotation as well. Now American football, there's a high instance of direct injuries, hyperextension, a varivaous force, or combined forces, um, can cause, can cause the same injury. And we tend to see from a direct mechanism much more damage to the associated structures in the knee like the meniscus and the other ligaments just because of the nature of the injury. And a contact mechanism is pretty much predictive. You're gonna have some sort of, uh, associated damage besides just the ACL. Here's, uh, everyone's favorite quarterback Tom Brady. That was the ACL tear that he's sustained, you remember, typically for a quarterback, it's gonna be their, their front leg as they go to throw. Uh, they're they're unprotected because they're looking away from where the injury is coming from, and they put all their weight on that foot as they lean forward after they throw. So that's the typical mechanism of injury in quarterbacks. Now, the examination of the ACL in your knee, uh, you've probably remember from your, from your, uh, your medical student days, your residency, the Lachman test. Lachman is by far and away the most sensitive test, um, which your knee is held at 30 degrees of flexion. You stabilize the distal femur, you're pulling forward on the tibia to see uh how much translation there is and how firm the endpoint is. There's no correlation with rotational stability, but there is correlation with how much the knee translates anteriorly. The pivot shift, despite the locking being the most sensitive, the pivot shift is the most specific test for an ACL. It's the best predictor of future instability because again, it's documenting rotational instability they shouldn't have um a free cell is intact. And so there's very high correlation between the pivot shift and final function. Um, and you will see some patients who have joint laxy, they'll have what's called a pivot glide where they just, they have a little bit of a jump, but the true pivot shift phenomenon. Um, which is, is kind of hard to teach trainees like residents and students. Um, it is the best predictor for, for, um, how their patients are gonna do, um, post-operatively. Um, OK, the anterior drawer, I don't even tend to do that anymore. Um, this is the one that's your knees at 90 degrees of flexion, as is showing the lower photo there, you're pulling, uh, forward on the tibia. Um, you can get a false positive if they have joint laxity or if they have a PCL tear because in a PCL tear, the tibia is sagged posteriorly and now you're pulling it forward and it's moving much more than you'd expect. Well that cause A cell is torn it's because the PCL is torn and then you're starting out from a more sublux position. You can have a false negative if there's a bigger effusion because there's less motion there. You can also have a false negative because of hamstring spasm. So an acute injury, an anterior drawer, to me, to my mind, is pretty much worthless. Now, I will always recommend examining the other knee, uh, to assess the degree of laxity, especially in kids, and to ease the Also ease them let them know what you're gonna do, but a lot of kids or a lot of females especially, will have a lot of hyperlaxy. You may not detect that if you don't measure their good knee first. You may think that's, you, you may, uh, misdiagnosis as as of being, uh, uh, increased laxity or really at reality, it's just their normal physiology. Now, some of the factors that affect the treatment for an ACL timing factors again, like the meniscus, time of season, duration of playing career, the degree of scale maturity dictates how we do it. Any prior surgery, their occupation, their age. Um, the age is a relative factor that I'll talk about in a second. Any injury factors, how much lacks they're having, whether not they have associated locks meniscal tear. Typically, with an isolated ACL tear, we'll wait about 3 to 4 weeks after the injury to let them get their main motion back, get their swelling down. Um, get their corti muscle function and kind of plan their life, and then you do the surgery. If they have a locked knee, then you don't really have that luxury to wait because the longer you wait, the longer the more risk you have of doing damage to the meniscus. Um, if they have an MCL sprain, which we'll talk about, you may want to wait a little bit only because you wanna let the MCL heal before you do an ACL surgery. Um, the size of the effusion and then the stiffness. And so these are all the factors that go into whether or not we proceed with surgery or we wait with continued therapy. Now, some of the intrinsic risk factors for ACL in uh tears. There's anatomic, I mentioned before with females with ACL width and length, the notch shape. Again, these are of interest but not really cause in terms of the, the, the um sex-based differences. Neuromuscular firing patterns, decreased hamstring strength, decrease abductor strength of the hip, and decreased hip external rotation are all likely contributing factors as to why females are more involved. Um, from physiology standpoint, BMI and weight, higher instance of, of tears. Um, valgus lining patterns and abduction of the hip that has been shown to be, um, predictive. There's also, for those of you who have patients who wanna do some sort of preventive maintenance, there are ACL. Uh, prevention programs out there, they're typically 6 to 8 weeks in length. They basically teach proper landing techniques. Uh, they were, they emphasize strength of the hamstring quad muscature. Um, the one I tend to recommend most is called Sport Metrics. It's out of, uh, Cincinnati. Um, I get, I get nothing for that recommendation, but that was the first one on the market. Um, and they've been very effective in, in reducing the risk of ACL tears, especially in women. And so some of these, so these are all the things we sort of consider that are patients that put the patient at risk for an ACL tear. Now, in terms of non-operative treatment, um, the term copers and adapters have been, have been described for those who have a tear, but they're able to live with it. So in order to be considered a cooper, the athlete must have no pivot shift, OK? They, they may have increased anterior translation, but no pivot shift. They have to accept the limited ability to cut or pivot. They may be, they have to be willing to give up soccer or basketball, things along those lines. They shouldn't have any significant menis or chondral pathology. They have to recognize that they have a 30% chance of having a new meniscus tear that they didn't previously have. Um, they have to be willing to tolerate an ACL brace for at-risk activities like doing yard work or walking on uneven surfaces if they have to do like construction, and they have to be very compliant with physical therapy. And so, I mentioned earlier about age being a, a relative issue. Age is not the primary factor without a person has ACL surgery. Activity level is. And so I've had patients who are 65, 68 years of age who are very active in ni high-level tennis where they're cutting and pivoting with their knee is unstable, that have no associated arthritis, uh, and or do very well with AL reconstruction. Um, if you ever tell a patient they're too old for the surgery, that's the fir first best way to lose a patient. Um, it's what their activity level is. And I'll have patients who are very young relative Speaking, who are very inactive, um, and they, they tend to do very well without surgery. And so, and we talk about that activity level, it doesn't mean I ask them what they do. Well, I have to ride my bike, I walk my dog. Well, that's not really being active in terms of the ACL. Being ACL active is cutting, twisting, pivoting, and jumping. Those are the things you need your ACL for. And so if you're doing more linear type activities, even jogging, you know, in line, you may not, you may not need your ACL. And so there may, there can be discussion there for treating this non-operatively. And so it's sort of the rule of thirds, those who undergo non-operative treatment, a third of them will approve of rehabilitation and can be well compensated. They can be relatively symptom free with ADLs. They may have some symptoms of strenuous activities. 1/3 become worse and actually fail non-operative treatment with pain, swelling, and instability with sports. And then when they're noncompliant, we call these the knee abusers. And they even with rehab and actual modification, they'll have persistent stability and they can do further meniscal and articular cartilage damage. So, hopefully, if you do treat a patient not actually, they're not in that last category of being a knee abuser. So I'm not gonna go into all the technical details of ACL surgery, but just know that in 2025, These are all the options we have to fix the ACL. That's that foot in the middle there, that's an ACL tear, uh, being viewed arthroscopically with a probe kind of pulling on it. Um, the most common graph in this country is the patellar tendon autographed, the upper left uh photo there. The quadriceps tendon is the most, is the second most common, but around the world, the hamstring is very common in Asia. Um, and so the double bundle was a graph we used to do, but never really panned out to be any better than what we're already doing. And then there's a lot of research now going on for primary repair where actually you sew the ACL back together. The jury is still out on whether or not that's really the definitive option for a young athlete, um, but just know that there are, there are very, there are multiple options that uh your surgeon will consider if you do have a tear. Now, one thing I would like just to pass off is that there's been a lot of recent comparisons between autographs and allographs, or, you know, cadaver graphs. Um, and this was a study published by Chris Caden, Sports Health in 2011, and this shows that based on the patient's age, um, the risk of failure, it's 4 times higher. If you use an allograph, compare an autograph, that's irrespective of the type of graph, OK? It's 4 times higher. So I'm 62 years old, so if you go on the, on the X-axis all the way to 62, you know, my risk of failure is gonna be, you know, 4% compared to 1%. Whereas if you have an 18 year old female soccer player, the 4 times higher difference is much more because if her if her Thermal failure rate was about 8%. Well, now it's 32% or around that area with that 4 times higher risk. So again, we never use allographs or cadaver graphs in young athletes, typically under the age of 40 because of this, because of this, uh, risk phenomenon. So, you know, 20 years ago, you've seen a lot of players in the NFL combine that I, I took care of the Rams, you'd see there, they had a lot of all graphs because they're easy to do. Um, they take the surgeon less time to do. They're less painful, so patients think they get over the surgery sooner, but there's a very, very high failure rate. And so we never do allografts anymore for these, this age, uh, patient population. Well unfortunately, despite our best efforts, not all patients do well after surgery. Um, there's only about a 6% chance of retearing your ACL graft. Despite this, though, you know, the graft failure can, can vary up to 30% based on if you have associated meniscal pathology or any of the ligament injuries, um, or if you have graft that's misplaced. The, the biggest cause of failure of an ACL graft is technical error, meaning on the surgeon's side, um, of putting the tunnels in the wrong location. Um, only between 50 and 6.5% of patients actually returned to the level of sport they played. Um, I think most patients, you, we, we actually did a study survey of patients, and they thought that 100% of patients would go back to the same level as they did before surgery. And the reality is many patients go back to the same sport, but significantly less of them go back to the same level of sport. And so, usually the rehabilitation to go back to full sports activities is between 7 and 9 months. Um, that's been a pretty stable number over the past decade or so. There was a Big push to get patients back within 3 months, but that was more of a marketing ploy that surgeons used to try to get them to have patients have them, have them do the surgery. But in reality, they're not really ready to play based on all the metrics we, we follow for at least 6, if not 7 months and sometimes up to 9 to 12 months based on what they wanna do. So it may not be as good as we think we are in terms of getting patients back. Now, this is an associated injury we often see this, the ACL tear with the MCL. You can see that girl number 11, whose knee collapsed into significant valgus, and uh sorry if, if this grosses you out, but um it's usually a crowd favorite talks like this, but significant in out of the ACL but also to the MCL. And so we tend to treat those injuries a little bit differently. And so just to kind of reiterate the rather review the um MCL anatomy, you have the superficial MCL which is sort of the workhorse, and then you have the deep MCL. Which is the mycofemoral muscle tibial ligaments, and it provides valgus stress, uh, to the knee and typically about 30 degrees of knee flexion is where it's most important. Um, and this is a common injury. Like I said before, the MCL is the most common ligament injury of the knee. Um, males are 10 times more commonly injured. Most of these MCL injuries are isolated, unlike the, the video I just showed you. Most of these are isolated. Um, the instance of 3rd degree MCL injuries, that's, in other words, a complete tear, and it can come in injuries about 80%. So if you have a complete MCL sprain, you typically have torn the PCL or the ACL, um, as well. In fact, the instance of 3 degree MCL and ACL is about 95%. Now, typically, these come from certainly football, a dread blow to the lateral aspect of the knee. You can have a non-contact uh valgus mechanism as that girl did who's playing volleyball, and there's usually an external rotation component to it as well. And so the classification is based on the, uh, the kind of AMA um nomenclature that was out in 1966. Um, there is a little confusion here. These have been classified both as in terms of degree, 1st, 2nd, and 3rd degree, based on how many fibers are torn, first degree, the fibers are stretched, but no sniffing laxity. Second degree, this part of the fibers are torn, uh, the rest of them are intact. 3rd degree, it's a complete rupture and you'll have gross lax on examination. And so, Typically, if you just in a in a research standpoint, if you just cut the ice, the MCL completely cut in half. You only have about 4 to 6 millimeters of valgus laxity compared to the contras side. So if you have these grade 2 and grade 3 injuries where you have maybe 10 to 15 millimeters of laxity at 30 degrees and 5 to 10 in full extension and significant rotational um uh asymmetry, then you probably have a coexisting ligament injury again, the, the ACL or the PCL and we'll often see this in patients who stay knee dislocations. So one caveat I would, I guess like to offer is uh how do you examine an MCL. Um, I'm kind of biased in, in talking to the residents about this. I really think you should take the patient's knee, put it over the side of the table, the, the edge of the table is a fulcrum. You can then control their ankle with one hand and then put your index finger and your thumb on the joint line and then apply a vagus stress to the knee at both 30 degrees of flexion and full extension. When you do it in full extension, the crucial ligaments act as secondary restraints. So you may have a complete tear of the MCL, but in full extension, you do vagal stress, the exam is normal. Whereas if you have an ACL and an MCL tear, it'll be loose at both 30 degrees and in full extension, OK? So this, the thing I would suggest is do not do like this commonly shown in, in various books where that you, you use one hand on the thigh and you have the other hand on the foot, lift the patient's leg off the table, and then just crank them into valgus. What happens is you get a little rotation at the hip. You have the femur movement, you have the tibia moving. You can't tell how much laxative there is, if there's an input or not. And so this is a very inaccurate way to, to examine the uh the MCL. Now, if you're not if you're concerned about the degree of laxity, uh, because you're considering, you know, surgical intervention, whatever, we'll often do uh stress X-rays. Here we have on one side, you can see 7.4 millimeter joint space opening. On the other hand, it was twice that much, 14.7. So it's gross difference in, in laxative vagal stress. This is something we will do in the office, um, not frequently, but not infrequently in order to diagnose the degree of laxy from an MCL sprain. An MRI, as you might imagine, the grade 1, the there's fiber disruption, very few fibers are disrupted grossly, but mainly histologically, grade 2, partial gross tear of the of the MCL then uh grade 3 on the far right, complete obliteration of the, of the ligament. Now, the biology of MCL tears, unlike ACL tears, the, the literature would suggest that, and the clinical literature would too. That MCL tears can heal, and the reason for that is because they do have uh intrinsic healing ability, but it's also because they're in an extra-articular location. Unlike the ACL that's in an intra-articular location where the millie is not conducive to biologic healing, the MCL is extra-articular, and so there's a very good abundant blood supply that has a very broad cross-sectional area, and there's a lot of basic science evidence um that shows that these, these ligaments will heal. Um, you do have, if you have a proximal MCL tear where where it tears off the, um, The femoral condyle, there's a marked increased risk for stiffness, and this has been shown in several studies. Whereas if you tear the, the MCL distally off the proximal tibia, you have a marked increase for persistent uh lax or instability. So my sort of my preferred treatment algorithm for MCL tears, it's really based on the, the injury grade. And so, a grade 1 injury where there's, there's pain with valgu stress, but very little laxity. These usually take 2 to 4 weeks to heal. I'll typically we'll put them in a short hinge knee braces is shown on the upper left there. If they have a grade 2, where there's some laxity at 30 degrees, but not in full extension, these usually take about 4 to 6 weeks to heal based on the sport, the position they played, and this is usually a short hinge knee brace. Um, if they have a grade 3 laxity where it's completely torn. Um, this usually takes 6 to 8 weeks to heal. I'll put them in a long leg braces is shown in the upper right, or even a cast for 10 days, and then allow them to start moving. Um, range of motion exercises are recommended several times per day. That, that, um, girl who's doing that test in the middle there, you can see she has a rope around her foot. It's basically allowing her to flex the knee, but it's not put a val of stress on the MCL. It's actually compressed in the medial side of the knee. And so that's, that's a good way to, to, uh, allow, uh, increasing flexion without stressing the ligament. Um, as I mentioned earlier, if there's, uh, the proximal tears tend to lead to persistent stiffness, whereas distal tears tend to lead to persistent laxity. And for those rare cases that do need surgery, MCL reconstruction, Typically, only after 6 to 8 weeks for, of, of non-operative treatment for persistent laxia at both 0 and 30 degrees of flexion, or for those patients you see acutely who have a displaced distal ligament that's slipped up into the joint where you know there's no way that's gonna heal uh in a conservative fashion. So, but a very, very few MCLs actually get treated surgically. So my last topic is gonna be patellothermal pain. Just like 12 more minutes here. I'll try to uh go through relatively quickly. Um, it's most common cause of knee pain in active young individuals. Um, 25% of young athletes will have some degree of patellitheral pain in their careers. If you see any active population, especially adolescents, you'll see a patient with patelophrontal pain. It's the most common overuse condition in young girls. 70% of these cases are between 16 and 25 years of age. There are multiple variants as runner's knee, conomalacia, patellirontal pain syndrome, anterior knee pain, they all mean the same thing. The theories of etiology is chronic overload. They, you, you will get some some kind of bone changes. There's some theoretical injury to the, to the nerves around the knee. Um, the biggest reason as to why you get this is muscle fatigue. And so the, the quadriceps muscle on the medial side, the vascus mediaalis gets overpulled by the vascus lateralis and with weakness with the, with the hip muscuture, the gluteal muscature, cause, causes maltrack of the kneecap, and that causes pain. At least that's, that's the sort of accepted theory. The symptom pattern. It's usually spontaneous or insidious, usually due to overuse of retinacular structures. We see some kids who either do a lot of sports and they're relatively good shape, but they do more than normal because they're trained for a race or a competition, or you'll see another kid who does who's kind of a couch potato, and now they decide that they want to run across the country or play a team, and now they're doing more than they used to do. Either way, it's an obvious condition to what they're used to doing. Um, sometimes we'll see an acute onset. Um, if you typically from an acute injury, usually implies some sort of arterial cartilage damage, uh, to the bone or the cartilage. For the most part, patello frontal pain does not have an acute onset. It's usually more of a chronic, uh, thing that develops over time. In terms of location of pain, if it's on the, on the distal patella, that will typically cause pain and extension. Proximal uh pain is usually worse with the knee 90 degrees of flexion. Uh, these patients, when you ask them, I think I mentioned this earlier, they will often say that these swells. So they'll have the subjective sensation of swelling, but when you examine them, they have no effusion and they have no soft tissue swelling that you can perceive. So I would, I would take their description of swelling kind of with a grain of salt. I would trust more your, your examination before you determine if they're swelling. Cause for the most part, patellofemoral pain does not have an effusion associated with it. There's no, there's simply no anatomic damage. There's no effusion. It's a pain phenomenon only. So the treatment here is to decrease, obviously decreased pain and edema, correcting biomechanical deficiencies, increased strength and endurance. Hence, physical therapy is by far away the primary treatment modality. There's very favorable results. Um, this may be due because of the PT they're doing, it may be because they've altered their activity and rested for 6 weeks. Um, it may be the rehabilitation regimen itself. It's hard to say, but either way, most patients will get better. With this, um, there's an emphasis on closed chain, strengthening of the quadriceps. Closed chain means that the sole of your foot has a resistance of your body weight. So for example, if you go to the gym, you do the leg press, that's a closed chain exercise. That's very good for the patella. Open chain is when the sole of your foot does not have the resistance of your body weight. For example, you go to the gym, you do the leg extension machine where you, the bars in the front. Your, uh, uh, uh, front of your ankle, where you're extended it. There's a lot more sheer stress the patella when you do open chin exercises. So we tend to emphasize the closed chain activities. Um, aerobic conditioning, cross training. Um, one thing I tend not to do is let these kids be out of PE, uh, for any period of time. Oftentimes their moms will want them to be out of PE. Um, the goal is to reduce their activities, not completely eliminate activities. Um, and so, again, quad strengthening is recommended. It's really not known exactly how it improves the pain, but we do know that it does improve the pain based on research and based on, I tell you my clinical experience has been that way as well. Some therapy modalities, treatment options, cryotherapy to reduce pain and edema, ultrasound theoretically causes vasodillitation, to reduce pain, neuromuscular stimulation, out toesis, e stem to reduce pain. Um, biofeedback for selective uh activation of VMO, um, really, there's no consistent improvement when the modality is used alone. These things will be used in a professional training room, like, you know, the Blues, the Cardinals, the Rams, whereas your average high school kid doesn't have access to these sort of modalities. But really, the, the evidence that these modalities, uh, actually work is pretty limited. So, you know, I wouldn't hang my head on them, but again, it is something you can consider doing for patients who tend not to improve with normal rehabilitation. Now Oso Schlaider's disease is a variant of this, and this is a specific activ pain over the tibial tubercle. Typically you see this in the 10 to 13 year old age group, bilaterally involvement is about 20 to 30%. Um, there's equal involvement in males and females because of the increased sports participation in females nowadays. The ideology here, it's felt to be due to repetitive submaximal stress, um, with little minor uh microscopic avulsions at the uh teotypical growth plate, which is where that area is on the lower right here. The patellar tendon associates, uh, inserts on that, on that uh opesis, and with traction, an epophyis is basically a growth plate that's under traction, whereas an epiphysis is one that's under compression. And so with traction from the quad muscle pulling on the patella and pulling the patellar tendon, You get a microvulsion and that causes pain. And what can happen is you get, yeah. Yes, froze for like a couple minutes there, so I just wanna. Oh, OK. That was me. It could have been mine. Well, I've been sort of going on lines of what I've been saying here, so I'm not sure where I left, you can just keep going. I just want to let you know and OK answer right, sorry. OK. Um, the diagnosis here is they often have a problem, especially as an adult, they'll have a prominence with the tibial tubercle. You can see in that in that photo there. They'll have swelling, they'll have pain with the tubercle. Acute cases in kids who are like 12 and 13, usually see this in athletes. They've been, I've never seen this in a non-athlete. They're always playing a lot of sports, they're running around, so they're more prone to have this happen. Um, they'll often have hamstring tightness and the theory is that their knees always in a position of flexion, it puts more attention on the, on the hypothesis. The knee range motion is typically normal. Inarticularly, all the structures is normal. Um, plain radiographs, you may see separation or fragmentation of that apothesis. They may have soft tissue swelling, or even enlargement of the tibial tubercle. And for treatment, it's pretty much dictated by severity. We'll use NSAIDs extra for pain, eccentric quad strengthening, hamstring stretching, um, activity restriction based on the pain severity. That severe pain, it dictates a period of mobilization, full extension, gradual improvement can take actually 12 to 18 months, but eventually outgrow it because eventually the growth plate closes. For those adults who have who have residual pain, it's usually because they have a free fragment of bone that's sitting in the patellar tendon. You can see on that lower right-hand photo of there, there's a little ole, and that will, that, if that's persistently painful and like a carpenter or a plumber or someone who's on their knees all the time, that will virtually always get better by just surgical excision of that piece of, of bone. There's no role for a corticoster injection or PRP or anything that into the tendon itself. Um, and again, the vast majority has never come to surgery. They're, and they're very much treated very successfully with non-operative treatment. So the last topic that is patello from on stability. Um, most patients who take care of an active population will see, uh, patients with this condition. Um, it tends to be more common in girls at the age of 10 to 17. The recurrence rate is anywhere from 15 to 45%. Um. Do 15 showed in 2004, the recurrence rate was highest among female adolescent females. The redislocation rate was about 50% after the second dislocation. So, once it happens the second time, you can bet on it it's gonna happen a third time, and the risk for OA is minimal after less than 5 years, but the risk increases significantly after 5 years. Um, and another study that was in 2015 showed that for every year of age, the risk for recurrence decreases 8%. So the older you get, if you, for an adult who dislocates her knee, their patella when they fall on the stairs, it'll probably never happen again. Whereas if you're a 14-year-old adolescent female with a, with a joint laxity, you can probably count on it happen again reliably. Now, this is the patella ermal instability severity score. I don't need to tell you what that acronym says when you spell it out. But anyway, it does show that the odds of recurrence. For a score greater than 4 is pretty significant. This is based on their age, if they have bile instability, if they have trochal dysplasia, they have, um, if their patellar height is very high compared to the other side, and if they have a significant patellar tilt. So these are all the factors that would predict whether or not someone's gonna have recurrent patellar instability. Now, there's a higher instance in females. The patients, female have an increased pelvic width, knee valgus, hip abduction. Females also have weaker quadriceps. They have a weaker hip external rotation, hip extension, hip abduction. And so these patients will often get the, as I mentioned earlier, so the functional instability because again, their qua strength is just not enough to carry them. On examination, we'll assess your standing and walking gait. Um, Q angle is something we used to measure in the past. We don't measure that any longer because it's, it's quite frankly, very inaccurate. Um, whenever you examine any knee for any condition, you really should document full painless range of hip motion because hip problems can cause knee pain and this perception of instability. Now, for in terms of um um patellar mobility, lateral translation greater than two quadrants would imply laxity of the meal restraints. Meal translation translation less than 1 quadrant would imply a tight later renaculum. You should be able to passively elevate your, your patella about 10 degrees or more. If you, if you can't, that implies that the retinaculum is too tight. And patients who have a uh be score of over 4 out of 9 with generalized laxy are at a higher risk of this. And those, remember the, the so-called Ba score, there's 9 points you can get. Um, for all these things, again, anything over 4 is considered hyperlaxy. Um, patellar mobility, the so-called J sign, looks like the upside down J when the patient goes from flex and extension, and then the lateral squint to the grasshopper side, you can see on the lower, lower foot of there where the kneecap is looking kinda over to the side like a grasshopper would look. Um, we wanna assess them prone and supine in terms of your hip range of motion, assess their gluteal strength, assess their overall limb length. And alignment. This is the imaging we tend to get sort of similar to the uh images I talked about earlier. You see the bilateral merchant view at the top there, marked instability of the patella on the trochleaa. An MRI is very useful to evaluate the patellar trocheal cartilage. It'll tell us if you where your tear the me patello frontal ligament is, which is the main stabilizer, if there's any loose bodies, if there's any concurrent injuries. Again, we typically do MRI's for a larger effusion, patell asymmetry, and loose body on on X-rays. Here's an example of an MRI on the left that's normal on the right trochal dysplasia, where there's deformity. that's, that they were born with of the distal femur that predisposes them to the patellar instability. And so in 200525, there's lots of options for surgical repair. I won't go into all these, but there are lots of options based on how much damage they have, how much coexisting arthritis they have, um, how much stroke or dysplasia they have. And so the most part, in the cases for first-time dislocator, if they have a large uh loose body, if they have an asymmetry patellar alignment, or the patient can't tolerate a recurrence based on their, their job or their advocation. Um, there's a lot of literature against acute repair that shows that patients do very well, um, without having surgery. For the most part, we don't do surgery for the first time unless there's a large loose body floating around. For the surgery that we tend to do is an MPFL reconstruction that stands for the medial patellofemoral ligament. It provides about 60% of the state of the uh of the, of the patella. This is for recurring stability, loss of the retinacular stabilizers, um, and the conflictations that they have advanced patellar arthritis or pain as we showed in the X-ray right there. And when we do an MPFL reconstruction, on the upper slide, X-ray there, you can see the merchant view, you see the patella on the right there that's sort of sitting off and after reconstruction, the lower photograph shows. Uh, what the patella is stabilized with, and that's a semitenosis allograft that we use and we attach to the patella, medial side of the patella, and then attach it to the femur, and that basically reproduces the medial patella from the ligament. Which basically looks like this from a schematic standpoint. So I know I've gone through a lot of stuff. Um, it's 259 by my account. I didn't mean to push it quite that hard, but, uh, again, I, I, I wish we were in person so I can see if you have any questions or not. Nicole, is there anybody with any questions I can answer? I'd be glad to stay as long as you need to. I know you have other, probably have other stuff to do though. I don't see any other, I don't see any questions in the chat or in the Q&A right now. Um, we do have our next speaker on as well, and I know they were asking for a 5 minute bio, but I do a follow up email and if it's OK, can I put your email address on? in case they do have questions that come up. Yeah, go ahead and answer any questions they have about themselves or their patients, whatever, but uh thanks for the opportunity. Again, I hope this was somewhat helpful for you again. I don't know your all your practices know what exactly you do see and not see, but I hope this was helpful. Yes. Thank you so much. Appreciate it. OK, bye bye. Bye. Have a good day. Created by Presenters Matthew Matava, MD Professor, Orthopaedic Surgery and Professor of Physical Therapy Division of Sports Medicine Director, Sports Medicine Fellowship Program View full profile
