Anatomy

MCL is composed of three-layered sleeve of

static and dynamic stabilizers
Static stabilizers
o Superficial MCL
o Posterior oblique ligament
o Deep MCL
Dynamic stabilizer

Function of MCL
Main function is to resist valgus and external
rotation loads
Superficial MCL is primary restraint to valgus
loads
Posterior oblique, deep MCL and cruciate
ligaments are secondary restraints to valgus
loads

Evaluation
Knee should be inspected for ecchymosis,
localized tenderness, presence of effusion
Abduction stress testing should be
performed with knee at 0
o
and 30
o
(a.k.a.
valgus stress test)
Pathologic laxity is indicated by amount of
increased medial joint space separation
compare to opposite normal knee
Pathologic laxity (medial joint space grade)
o Grade I: 1-4mm
o Grade II: 5-9mm
o Grade III: >10mm
Evaluation of other associated injuries


Abduction Stress Test (Valgus Stress Test of the Knee)




Imaging
Plain radiograph
MRI
o Imaging modality of choice to diagnose
o Advantage it identifies the location
and extent of injury

Treatment
Non surgical
o Indicated in all grade I and grade II
injuries
o Grade III that are stable in extension
without associated cruciate injury
o RICE, rehabilitation and strengthening
exercises
Surgical
- Indicated in isolated grade III injuries with
persistent instability despite
rehabilitation
- Acute repair

LATERAL COLLATERAL LIGAMENT INJURY

Epidemiology
LCL injuries are less common than the MCL
7-16% of all knee ligament injuries

Anatomy
Lateral compartment of the knee is
supported by dynamic and static stabilizers
Dynamic stabilizers consist of :
o biceps femoris
o iliotibial band
o popliteus muscle
o lateral head of gastrocnemius
Static stabilizer consist of:
o fibular collateral ligament
o popliteus tendon
o arcuate ligament



Function of LCL
Is the primary restraint to varus stress at 5
o

and 25
o
knee flexion
The popliteus restricts posterior tibial
translation, external tibial rotation, varus
rotation

Evaluation
Adduction stress (a.k.a. varus stress test) is
performed at both 0 and 30
o

Isolated laxity at 30
o
consistent with LCL
injury
Laxity at both 0 and 30
o
is seen with
additional injury to ACL, PCL


Varus stress test of knee

Classification of LCL injury
Grade I: 1-5mm lateral joint space opening
Grade II: 6-10mm
Grade III:>10mm

Imaging
Plain radiograph
MRI

Treatment
Non surgical
o Indicated for grade I and grade II
isolated injuries of LCL
o Limited immobilization with protected
weight bearing
Surgical
o Complete injuries or avulsion of LCL
o Primary repair of LCL

SOFT TISSUE OVERUSE

Pathophysiology
o Tendinosis
an overuse injury with
recalcitrant symptoms of pain
with activity
Histologically: a chronic
intratendinous degenerative
lesion of tendon
Instead of normal constructive
adaptive response of repeated
loading, the tendon no longer
respond in positive fashion but
starts to accumulate increasing
amount of poorly organized
and dysfunctional matrix
(Hallmark of tendinosis)
Occurs most commonly in
rotator cuff, patellar tendon,
achilles tendon, posterior
tibialis tendon

Classification of Tendinosis
Blazina Grading
o Grade I- pain that occurs only after activity
o Grade II- pain occurs during activity but
does not affect performance
o Grade III- pain occurs during the activity
and affects performance such that athlete
cannot train and perform at desired level

Treatment
o Mostly managed conservatively.

Non surgical
o Consist of rest and physical therapy
Surgical
o If nonsurgical management fails
o Excise and stimulate healing response
o Stimulate bone healing between
attachment of tendon and bone

SHOULDER IMPINGEMENT
Rotator Cuff Tendinitis
Tendinitis/ bursitis/ impingement
Young and middle aged athletes
Overhead injury
Compromised of the space bet the humeral
head and acromial arch
Primary
o Usually due to degenerative changes
and spurring
Secondary
o Problem with keeping the humeral
head centered in the glenoid fossa
o Caused by the weakness of the
Rotator Cuff muscles
o Symptoms usually activity specific

Classification of Impingement
External
o Pathology is outside the GH joint and
confined to the subacromial space
o Compression of the rotator cuff,
usually the supraspinatus by the
acromion
o Slow insidious onset, no history of
trauma
Secondary
o Problem with keeping the humeral
head centered in the glenoid fossa
during arm movement
o Weakness of the Rotator Cuff
Subcoracoid/ Stenosis
o Ant shoulder pain
Internal (Glenoid) Impingement
o Posterior shoulder pain in the
throwing or overhead athlete
o Stiffness, slow to warm up

Etiology
Poor posture
Increasing age
Poor muscle tone
Instability of the glenohumeral joint which
allows increased translation of the humeral
head
Degenerative arthritis
Osteopenia/ osteroporosis
Acromion morphologies
o Type I- Flat
o Type II- Curved
o Type III- Hooked

Manifestations
Shoulder pain with shoulder level or overhead
activity
Pain when reaching behind the back
Pain in the deltoid region or lateral arm
Shoulder tenderness
Decreased strength if prolonged
Loss of range of motion due to pain and disuse
Pain at night and inability to lie on the affected
arm
Locking sensation with abduction
Active palm down abduction is painful


Neers Sign

Neer's impingement sign is elicited when the
patient's rotator cuff tendons are pinched
under the coracoacromial arch. The test

is
performed by placing the arm in forced
flexion with the arm fully pronated.
The scapula should be stabilized during the
maneuver to prevent scapulothoracic motion.
Pain with this maneuver is a sign of
subacromial impingement.


Empty can Sign
Shoulder elevated to 90 in the scapular plane
Forearms fully pronated (thumb down)
Examiner instructs the patient to resist
downward pressureon the elbow.
Pain, weakness in shoulder = Supraspinatus
tendinitis/tear


Full Can sign
Shoulder elevated to 90 in the scapular plane
Forearms fully pronated (thumb UP)
Examiner instructs the patient to resist
downward pressure on the elbow.
Pain, weakness in shoulder = Supraspinatus
tendinitis/tear
The supraspinatus is best isolated with the
thumb UP (full can test).
The empty can test is more likely to cause
pain, and therefore may not show true
weakness of the supraspinatus (due to a tear).


Hawkins Sign (aka. Hawkins-Kennedy test)
Examiner stands in front of, or to the side of
the patient.
Involved shoulder is forward flexed to 90, and
the elbow is flexed to 90
Examiner supports the forward flexed arm
with one hand, while internally rotating the
shoulder (humerus).
Shoulder pain = Supraspinatus tendinitis/
impingement

Diagnostics
Xray
MRI
Ultrasound

Treatment principles
Restore ROM with proper stretching
Strengthening of the shoulder-stabilizing
musculature
Pectoral stretches
Pain relief
Improve mechanics
Improve shoulder stability
Patient education to minimize further trauma
Patient education on correct posture
Surgery when all else fails


Cute oh!