The Sporting Knee:Practical Issues

Dr Mark GillettHead of Medical Services WBA FC

Head of Science & Medicine British BasketballConsultant Physician HEFT

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Outline• General issues in sport• Diagnosis• Non operative interventions• ACL• MCL• In season meniscal injury• OCDs• MRI -ve AKP

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Issues In Professional Sport

• Players• Agents• Executives• Lay perceptions• Confounding issues: contracts, team

selection• Time scales

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Generic Issues

• Cohesive MDT essential• All opinions have validity- the “specialist’

cannot always see the whole picture• There are no easy solutions. A jigsaw

needs to be put together and soundjudgment exercised.

• Sometimes you will get it wrong

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Interpreting Scans

• Examine the player• See the scans yourself• Discuss the scan with the radiologist• Only after evaluating all 3 viewpoints can

you make a definitive call

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Non Operative Interventions-The Sports Physician• Hyalgans- Ostenil, Durolane• Steroids- short (hydrocortisone) v long

(Kenalog, Depo-medrone)• PRP injections• Traumeel

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Hyalgans

• “The oil”• Most useful in joint with early degeneration

or OCD treated conservatively• Don’t expect to much- it’s a few %.• May achieve more if combined with rest

and active recovery

• Hyaluronan is a high molecular weight biopolymer whichis present in many of our tissues as an importantcomponent of the extracellular matrix

• In the joint cartilage, hyaluronan is the backbone of theproteoglycans, which - together with collagen fibers -forms a matrix, in which the chondrocytes areembedded. Hyaluronan, at the same time, providesviscosity to the synovial fluid for its shock absorbing andlubricating properties. It furthermore acts as a molecularsieve (picture) and coats the pain receptors

• Upgrading the concentration and the molecular weightin the synovial fluid by intra-articular administration ofexogenous hyaluronan (called viscosupplementation).

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PRP Injections

• Commonly used in MCL injuries• Now permitted by WADA for injection into

ligaments but not acute muscle injuries• Status with PMI providers currently under

review

PRP Science

• MSK tissue repair begins with formation ofa blood clot and platelet degranulation

• A variety of growth factors are releasedwhich are beneficial for soft tissue andbone healing

• Blood taken and centrifuged to isolateplatelets

• Inject supernatant into injury site

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Traumeel

• Inflammatory regulatory drug• Mixture of 14 homeopathic substances

including Arnica and Echinacea• Not found it useful for intra-articular

disorders• Can be useful in soft tissue disorders

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ACL Disruption

• This is a functional diagnosis- ACLdeficient v ACL competent

• Assessment pitch side often difficult• Beware lateral sided pain• Signs can evolve over 24 hours

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Investigations

• MRI usually conclusive• Beware of who reports scans, especially if

a partial tear is reported• Beware when scanning in different

environment especially overseas

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Reconstruction Options

• Ipsilateral BPB• Ipsilateral ST• Contralateral BPB• Double bundle reconstruction• Modified Macintosh repair• Cadaver graft• Which is best?

Bone-Patellar- Bone Autograft

• Fail at 2900 N (normal ACL fails 1725 N)• Stable secure bone plugs at femoral and

tibial ends• Disadvantages- potential AKP and

difficulty attaining full extension

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Semitendinosis +/- Gracilis Autograft

• Tendon harvested from same incision site• Less risk AKP• Long term hamstring weakness not

normally an issue• Weaker than BPB graft with ST failing at

1200 N and gracilis at 860 N

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Cadaver Allograft

• Out of favour• Risk of infection

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Double Bundle Reconstruction

• Aims to replicate native anatomy• AM- taut throughout full range knee

motion should control ant translation• PL- taut towards extension better controls

rotation• Conflicting results in literature

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Trends In Rehab

• 6 months• Highest risk of rupture during initial 4-6

weeks when the graft necroses,revascularises and remodels.

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Choosing Your Surgeon

• Be aware of their style of consultation• The polished performers• Always positive• Sport- nothing different• Blunt• Know the style to suit your purpose

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MCL Injuries

• Valgus injury very common• High grade injuries will need cast bracing

at approximately 30 degrees short of fullextension.

• Is cast bracing needed to prevent longterm instability?

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• High grade MCL injury- may need surgicalreconstruction

• Lower grade injuries unlikely to create longterm issues if early extension

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• Early stage rehab in sport relativelyuncomplicated

• Notorious for pain in end stage rehabwhen multi- directional activity iscommenced and progressed

• Early PRP injection• Early v Late steroid injection

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• High incidence of acute muscle injury ingames immediately following return fromMCL injury

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Meniscal Injury

• Athletes will have meniscal degenerationon MRI

• MRI is not as helpful for in the evaluationof meniscal injury as it is in ligamentousinjury

• Treat the patient not the MRI

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In Season Management

• Off load• Is there an associated OCD?• Is it the lateral or medial causing the

issue?• How far in to the season is it?

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Surgical Options

• Conservative- higher failure rate but betterlong term prognosis

• Aggressive- may relieve symptoms but forhow long

• Repair v Resection

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OCDs• Classically on medial femoral condyle or

on trochlear groove of femur• Rotational forces direct trauma• Shearing force between articular cartilage

and subchondral bone• Weight bearing surfaces- MFC 4x more

common than lateral injuries

• Biomechanical risk factors femoralanteversion and poor gluteal controlincreasing dynamic Q angle thus strain onPFJ

• Had 2 cases of significant OCDs introchlear groove in female internationalbasketball players in last 2 years.

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• Pain at approx 30 degrees of knee flexionas patella starts to engage in trochleargroove

• Single legged squat diagnostic

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Treatment Options

• Rest and grade rehab• Debride• Microfracture• OATs /ACT

Microfracture

• Perforation of subchondral bone to recruitmesenchymal stem cells from bonemarrow into lesion

• Stem cells develop into cells capable ofproducing fibrocartilage

• Important for stable clot to fill defect

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OATs Graft/ Mosaicplasty

• Take multiple small osteochondral plugsfrom the non weight bearing periphery ofthe femoral condyle

• Limited by size of donor site• Longer rehabilitation period

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Anterior Knee Pain

• Fat pad impingement• Plica• Pes anserinus• Tendonopathy

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• Usually simple diagnoses to make• But often the MRI is -ve• Difficult situation• Glutes and single leg stability highlighted• Goal setting and time objectives are

difficult to quantify

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Posterior Knee Pain

• Distal medial hamstrings- frictionintersection

• Popliteus spasm• Posterolateral corner injury• Posterior capsultis