Acute Ankle and Knee Lecture to Gps
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Transcript of Acute Ankle and Knee Lecture to Gps
ASSESSMENT AND MANAGEMENT OF THE ACUTE KNEE AND ANKLE
Cameron Bulluss
newcastle-physio.com.au
Key point
• “correct early diagnosis and correct early management of musculoskeletal injury is crucial, this is particularly true for ligament injuries”
Aim
• Discuss the assessment and management of the following injuries• Ankle
– Lateral ligaments– Tibiofibular ligaments
• Knee– Anterior cruciate ligament tear– Medial collateral ligament tear– Menical tear– Patellofemoral pain
• Discuss some key management options including the use of tape braces and walking aids
• Teach you to competently strap an ankle
The sprained ankle
• 2 possibilities
• Lateral ligament complex anterior talofibular+/- calcaneofibular ligament
• Syndesmosis/tibiofibular ligaments
Lateral Ligament Injuries
Mechanism - weightbearing inversionLigaments involved – anterior talofibular ligament, calcaneofibularligamentImaging – see Ottawa ankle rulesOther structures potentially injured –peroneal muscles, talar dome, fibular, head of fifth metatarsal, midfootPhysical Tests – Inversion stress, anterior drawer of talus on tibiaAcute Managment – tape, or brace or boot or backslab, RICESurgical managment – rarely, taping bracing long term very effective
Anterior and Posterior Tibiofibular LigamentsMechanism – weightbearing external rotationPatient describes – pain, sometimes pop, unable to contine activityLigaments Involved – inferior tibiofibular ligamentsImaging – x-rays, MRIOther structures potentially injured -Medial ligament, joint surface of talus and tibiaPhysical Tests – External rotation of footAcute Management – tape or brace or boot, +/- non or reduced weigtbearingSurgical management – posterior rupture
Strapping vs Bracing vs Boot
• Strapping– Advantages – cheap, effective, allows movement– Disadvantages – requires crutches, skill needed to
apply• Bracing
– Advantages – effective, allows movement, easy to apply
– Disadvantages – cost, requires crutches• Boot
– Advantages – effective, allows early weightbearing– Disadvantages – restricts movement, cost
IMAGING – OTTAWA ANKLE AND FOOT RULES
Imaging - Ottawa Ankle and Foot Rules
• In summary of the guideline, according to the Ottawa Ankle and Foot Rules, x-rays are only required if there is any pain in the malleolar or midfoot area, and any one of the following:
• Bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus
• Bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus
• Bone tenderness at the base of the fifth metatarsal (for foot injuries).
• Bone tenderness at the navicular bone (for foot injuries). • An inability to bear weight both immediately and in the
emergency department for four steps.
Anterior CruciateLigament Tears
Mechanism – rotation in weightbearing, hyperextension
Patient describes – pop, unable to continue activity, rapid swelling
Imaging – MRI (best early)
Other structures potentially injured – other ligaments, menisci, osteochondral surfaces
Physical Tests – lachman’s
Acute managment – crutches +/-brace
Surgical management – yes provided patient can cope with rehab
Medial Collateral Ligament Tears
Mechanism: valgus/rotational
Imaging: MRI
Patient describes pain: usually unable to continue
Other structures potentially injured: ACL, menisci, osteoschondral
Physical tests: valgus at 30 degrees flexion,
Acute Management: Brace, non –weightbearing
Surgical managment: no, unless conservative fails
Meniscal Injuries
Mechanism: twisting, weightbearing, sometimes hyperflexion
Imaging: MRI
Patient describes: pain, sometimes a pop
Other structures potentially involved: other ligaments, osteochondral surfaces
Physical tests: palpation, squat, hyperflexion
Acute management: non weight bearing, protected range of motion
Surgical management: variable
Patellofemoral painPatellar forces – 3-4 times body weight on steps, 7 time body weight squatting, >10 times landing from a jumpCauses – skeletal alignment, biomechanics (overpronation), muscle imbalance, osteochondral damagePatient presents – anterior knee pain, pain with steps, hills, squatting sitting, running, landingPhysical testing – isometric quadriceps at varying degrees of flexion, Management – quadriceps strengthening, biomechanical correction, taping
Practical
• Anterior drawer test – ankle
• Syndesmosis test – ankle
• Medial collateral Ligament test - knee
• Lachman’s test - knee
• Isometric knee extension
• Strapping lateral ligament complex – ankle
• Strapping patellofemoral pain
Resources
• Clinical Sports Medicine – Brukner and Khan
• Atlas of imaging in sports medicine –Anderson
• Handouts – strapping,