The Knee

The knee is one of the most common joints injured during sports activity (Fig. 1). Common sports knee injuries are listed in Table 1. Careful evaluation of the hip is required in anyone presenting with knee pain as hip pain is frequently referred to the knee in children and adolescents. Signs of a more serious knee injury include a knee effusion, knee catching or locking, instability, inability to bear weight, and a concerning history. Knee radiographs should include an anteroposterior (AP), lateral, tunnel, and sunrise view for all acute injuries (Fig. 2). Oblique radiographs can be useful to visualize fractures but are not a standard view. Secondary imaging should not be ordered without initial plain films. Immobilization is necessary for fractures, patellar tendon ruptures, and medial collateral ligament (MCL) injuries with most other injuries responding to early range of motion. Rest, ice for 20 minutes at a time, compression, and elevation of the joint above the heart (RICE) should be implemented after an acute injury.

IT band Fat pad

Tibia

Lateral collateral ligament

Lateral condyle Posterior cruciate ligament Anterior cruciate ligament

Femur

Fibula

Quadriceps muscles

Medial collateral ligament

Meniscus

Pateiiar tendon (ligament)

Patella {normally in centre of knee)

Inferior pole of patella tibial tuberosity

Figure 1 Knee diagram.

Table 1 Common Sports Knee Injuries

Injury

Acute/ chronic

Mechanism of injury/symptoms

Physical examination

Anterior cruciate Acute ligament

Fat pad impingement Chronic

IT band syndrome Chronic

Medial collateral Acute ligament

Meniscus Acute

Osgood Schlatter Chronic

Osteochondritis Chronic dessicans

Patellofemoral stress Chronic syndrome

Usually noncontact; the planted leg is twisted; hear or feel a pop; instability; swelling within a few hours Pain with running/jumping; pain under or next to the patellar tendon Lateral knee pain with running; clicking sensation of lateral knee Valgus stress to the knee; swelling, instability

Twisting mechanism; may have catching or locking; may lack full extension

Pain with running, jumping, kneeling Intermittent pain and/or swelling with running, jumping, walking Retropatellar or peripatellar tenderness with running, stair climbing, prolonged sitting, giving way sensation

Large effusion; positive Lachman's; may have concomitant ligament or meniscus injury

Pain medial or lateral to patellar tendon; no effusion; pain with repetitive knee extension Lateral knee pain over IT band; positive

Ober's test Moderate effusion; pain along MCL; pain or instability noted with valgus stress test at 0° or 30°

Small effusion; posterior-medial, or posterior-lateral jointline tenderness; pain with full flexion of the knee Pain over tibial tuberosity; tight hamstrings +/— effusion; +/— pain at medial femoral condyle

+/— medial or lateral facet tenderness, positive compression and apprehension test, no effusion

(Continued)

Table 1 Common Sports Knee Injuries (Continued)

Injury

Acute/ chronic

Mechanism of injury/symptoms

Physical examination

Patellar dislocation

Acute or

Twisting mechanism or fall; pain and

Large effusion; pain around patella and facets,

chronic

immediate swelling around patella

medial retinacular pain, positive compression

and apprehension test

Patellar tendonitis

Chronic

Pain with running and jumping

Pain over patellar tendon; tight hamstrings

Posterior cruciate

Acute

Fall or hit with knee in flexed position;

Effusion; positive sag sign and posterior drawer

ligament

swelling

test

Salter Harris I fracture of

Acute

Valgus stress to the knee with swelling;

Effusion; pain at distal femoral or proximal

distal tibia or proximal

may have decreased range of motion

tibial physis, pain with valgus stress

femur

Sinding Larsen-

Chronic

Pain with running, jumping, kneeling

Pain at inferior pole of patella; tight hamstrings

Johansson syndrome

Abbreviations'. IT, iliotibial; MCL, medical collateral ligament.

Abbreviations'. IT, iliotibial; MCL, medical collateral ligament.

Figure 2 Knee radiographs: (A) anteroposterior; (B) lateral; (C) tunnel; (D) sunrise.

Case 1: A 16-year-old field hockey player has had four months of bilateral knee pain that worsened in the last week since field hockey started. She denies any injury or trauma that began her symptoms. She says the pain began during lacrosse season last spring and is worse with running, stair climbing, and prolonged sitting. She denies swelling but says the knee does occasionally buckle on her. She has used pain medications and some occasional ice along with an over the counter knee brace without much relief. She took most of the summer off from sports and noticed pain when she began running three miles a day for lacrosse tryouts last week.

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