Module 2 - MCL, LCL, ACL

(MCL injury) Grade II is opening at the _____ knee and a _____ endpoint

(MCL injury) Grade II is opening at the medial knee and a soft endpoint

Precautions for MCL or LCL injury 'Precautions (Phase I and II): Avoid _____ stress (MCL), _____ stress (LCL) and Avoid _____ in a weight bearing position

Avoid Valgus stress (MCL), Varus stress (LCL) and Avoid rotation in a weight bearing position

(MCL injury) Grade III presents with significant opening at the _____ knee and no discernable _____

Grade III presents with significant opening at the medial knee and no discernable endpoint

Injury to the ACL may also result from ___ ________ injuries such as occurs with rapid ________ where the ________ may contract forcefully and excessively translate the tibia _______ while the foot is planted

Injury to the ACL may also result from non- contact injuries such as occurs with rapid deceleration where the quadriceps may contract forcefully and excessively translate the tibia anteriorly while the foot is planted

Injury to the ACL may result from a ______ injury and particularly following a direct blow to the knee which results in knee ______ or _____

Injury to the ACL may result from a contact injury and particularly following a direct blow to the knee which results in knee hyperextension or valgus

Ligament injuries result from trauma ______ the capability of the ligament to restrain a specific direction of force

exceeding

The ______ has attachments from the MCL and needs to be considered anytime there is medial pain

meniscus

T/F MCL injuries can usually be managed non

operatively due to the good blood supply and ability to heal-true

For the anterior drawer test, the knee is positioned in __ to __ degrees of flexion and you pull the tibia _______. A positive test occurs if increased _____ is observed in comparison to the contralateral side and a "___" endpoint is felt. Care should be taken when performing this test to ensure the tibial tubercle sits _____ to the patella. A ______ position of the tibial tuberosity may be due to tear of the _ _ _ resulting in a posterior "sag". The anterior drawer test may also be limited by the posterior horns of the ______ restricting ____ translation or from active guarding using the ______. Subsequently, other tests and specifically the Lachman's may be ____ informative for ruling in or out an ACL injury. The anterior drawer test can also be modified using tibial _____ or ____ rotation starting positions to test _____ stability

For the anterior drawer test, the knee is positioned in 80 to 90 degrees of flexion and you pull the tibia anteriorly. A positive test occurs if increased laxity is observed in comparison to the contralateral side and a "soft" endpoint is felt. Care should be taken when performing this test to ensure the tibial tubercle sits anteriorly to the patella. A posteriorly position of the tibial tuberosity may be due to tear of the PCL resulting in a posterior "sag"(we will cover this in the PCL tests). The anterior drawer test may also be limited by the posterior horns of the meniscus restricting anterior translation or from active guarding using the hamstrings. Subsequently, other tests and specifically the Lachman's may be more informative for ruling in or out an ACL injury. The anterior drawer test can also be modified using tibial internal or external rotation starting positions to test rotational stability

Grade I injuries are _____ with only a _____ fibers torn but the integrity of the ligament (is or is not?) maintained. Endfeel is _____ without laxity in comparison to the non involved side

Grade I injuries are minor with only a few fibers torn but the integrity of the ligament is maintained. Endfeel is firm without laxity in comparison to the non involved side

(LCL injury) Grade I is defined as ____ but ___ appreciable laxity

Grade I is defined as pain but no appreciable laxity

(MCL injury) Grade I is defined as _____ but no appreciable ______

Grade I is defined as pain but no appreciable laxity

Grade II injuries occur when ____ fibers are torn with some _____. End feel is ____ or late there is some ______ or(increased or decreased?) joint motion compared to the opposite side. _____ is also present

Grade II injuries occur when more fibers are torn with some laxity. End feel is soft or late there is some gapping or increased joint motion compared to the opposite side. Laxity is also present

(LCL injury) Grade II is opening at the ____ knee and a ___ endpoint

Grade II is opening at the lateral knee and a soft endpoint

Grade III injuries or a ______ tear results in extreme ______ and end feel is______ with increased joint ______ with ligament tests

Grade III injuries or a complete tear results in extreme laxity and end feel is absent with increased joint translation with ligament tests

(LCL injury) Grade III presents with significant _____ at the _____ knee and ___ discernable endpoint

Grade III presents with significant opening at the lateral knee and no discernable endpoint

It is important to remember, trauma often results in damage to (one or multiple?) structures. There are ______ restraints which are the first structures stopping translation, glide or angulation of the tibia or femur. If the______ structure is injured, the forces are then _______ to the secondary restraints which assist with keeping the joint segments linked. An initial injury may result in damage to ______ the primary and secondary restraints depending on the severity. An initial injury may also damage only the _______ restraints; however, if the person is subjected to ______ forces at another time, _____ the intact primary restraint, the secondary restraints may be subsequently _____ as well

It is important to remember, trauma often results in damage to multiple structures. There are primary restraints which are the first structures stopping translation, glide or angulation of the tibia or femur. If the primary structure is injured, the forces are then transferred to the secondary restraints which assist with keeping the joint segments linked. An initial injury may result in damage to both the primary and secondary restraints depending on the severity. An initial injury may also damage only the primary restraints; however, if the person is subjected to similar forces at another time, without the intact primary restraint, the secondary restraints may be subsequently damaged as well

Landing from a jump resulting in a ______ position of the knee is also a common mechanism of injury to the ACL, as is ______ with the knee planted and with _____. A "pop" or _____ ____ of the knee is common and immediate ______ frequently accompanies these injuries

Landing from a jump resulting in a valgus position of the knee is also a common mechanism of injury to the ACL, as is twisting with the knee planted and with valgus. A "pop" or giving way of the knee is common and immediate swelling frequently accompanies these injuries

Presentation for Ligament Injury History:_______ trauma. Effusion: _____ the presentation, greater the damage. Difficulty weight bearing: Dependent on extent of _____, _____ and pain. Decreased _____ ____ _____: Dependent on effusion, pain. Pain reproduction: _____, ______. Strength: Possibly weaker _____ or ______due to pain inhibition

Presentation for Ligament Injury History: Immediate trauma Effusion: Earlier the presentation, greater the damage. Difficulty weight bearing: Dependent on extent of damage, effusion and pain. Decreased range of motion: Dependent on effusion, pain. Pain reproduction: Angulation, rotation. Strength: Possibly weaker quadriceps or hamstrings due to pain inhibition

Regaining knee ______ early is an important consideration following any knee injury so the protective phase should prioritize not losing any knee ______ range of motion and gradually regaining knee _____ range of motion

Regaining knee extension early is an important consideration following any knee injury so the protective phase should prioritize not losing any knee extension range of motion and gradually regaining knee extension range of motion

Similar to the MCL, surgery for LCL injuries is reserved to _______ rupture or knee ________. Repair of the LCL often results in persistent ______ so technically, this may be a ______ difficult surgery than MCL reconstruction or repair and reconstruction may be the ______ approach as compared to a repair

Similar to the MCL, surgery for LCL injuries is reserved to complete rupture or knee dislocation. Repair of the LCL often results in persistent laxity so technically, this may be a more difficult surgery than MCL reconstruction or repair and reconstruction may be the preferred approach as compared to a repair

Special tests for an ACL injury include use of the _ _ 1000 or 2000 which are available in some clinics, the ______ test, the _____ _____ test, and the ____ ____ test

Special tests for an ACL injury include use of the KT 1000 or 2000 which are available in some clinics, the Lachman's test, the anterior drawer test, and the pivot shift test

(MCL injury) The patient will complain of pain on the (medial or lateral?) aspect of the knee and the ligament will be painful on _____. ______ is often present; however, this is generally ___ present immediately following injury

The patient will complain of pain on the medial aspect of the knee and the ligament will be painful on palpation. Swelling is often present; however, this is generally not present immediately following injury

The KT 1000 or 2000 are primarily used to assess ________ displacement of the tibia relative to the patella; however, may be used to assess _______ displacement. This may be used pre operatively, but surgeons will also request the use of this device post operatively later in the rehabilitation process to assess the _____ of the _____ . The device is positioned with the proximal pad against the ____ and the distal part of the machine stabilized against the _____. Pulling on the handle ______ provides a measure of the ____ displacement of the ____ relative to the _____. A side to side difference of >= __ mm is indicative of a ____ rupture of the ACL

The KT-1000 or 2000 are primarily used to assess anterior displacement of the tibia relative to the patella; however, may be used to assess posterior displacement. This may be used pre- operatively, but surgeons will also request the use of this device post- operatively later in the rehabilitation process to assess the stability of the graft. The device is positioned with the proximal pad against the patella and the distal part of the machine stabilized against the tibia. Pulling on the handle anteriorly provides a measure of the anterior displacement of the tibia relative to the patella. A side to side difference of >= 3 mm is indicative of a complete rupture of the ACL

The Lachman's test is generally considered the _____ sensitive and specific special test for the _____ ______ ligament. The knee is positioned in __ to __ degrees of flexion. The tibia should be pulled ______ and this should be done in a relatively_____ fashion to allow you to appreciate the end feel. This allows the ligament to _____ and you can feel for a hard stop. A positive test is increased _____ laxity compared to the uninvolved side and a ____ endpoint. You should be aware of guarding of the _____ as this can prevent the ______ translation. The test is also more difficult if there is major _____.

The Lachman's test is generally considered the most sensitive and specific special test for the anterior cruciate ligament. The knee is positioned in 20 to 30 degrees of flexion. The tibia should be pulled anteriorly and this should be done in a relatively rapid fashion to allow you to appreciate the end feel. This allows the ligament to tighten and you can feel for a hard stop. A positive test is increased anterior laxity compared to the uninvolved side and a soft endpoint. You should be aware of guarding of the hamstring as this can prevent the anterior translation. The test is also more difficult if there is major effusion.

The anterior cruciate ligament runs from _____ on the tibia to _____ on the femur and in the closed chain also limits ______ rotation of the tibia on the femur.

The anterior cruciate ligament runs from anterior on the tibia to posterior on the femur and in the closed chain also limits external rotation of the tibia on the femur.

The clinical presentation of an LCL injury is pain on the ______ side of the knee. Because of the proximity of the _____ nerve to the LCL, signs and symptoms of _____ nerve involvement may accompany an LCL injury. The special test for LCL injuries is the _____ stress test at ___ degrees and ___ degrees of knee flexion

The clinical presentation of an LCL injury is pain on the lateral side of the knee. Because of the proximity of the peroneal nerve to the LCL, signs and symptoms of peroneal nerve involvement may accompany an LCL injury. The special test for LCL injuries is the varus stress test at 0 degrees and 30 degrees of knee flexion

The common mechanism of injury to the lateral collateral ligament is being hit on the _____ of the leg with the foot planted or landing in a (varus or valgus?) position

The common mechanism of injury to the lateral collateral ligament is being hit on the inside of the leg with the foot planted or landing in a varus position

The _____ attachment of the ligament takes longer to heal and a brace may be used to prevent _____ or ______ stress to the knee and allow healing to occur. The brace may be locked in the _____ packed position of the knee at __ degrees of flexion or may be open to allow movement from _ to __ degrees of flexion, but protect the joint from ______. Once in the controlled motion phase, range of motion and strength may be progressed

The distal attachment of the ligament takes longer to heal and a brace may be used to prevent valgus or varus stress to the knee and allow healing to occur. The brace may be locked in the loose packed position of the knee at 30 degrees of flexion or may be open to allow movement from 0 to 90 degrees of flexion, but protect the joint from angulation. Once in the controlled motion phase, range of motion and strength may be progressed

The mechanism of injury for a medial collateral ligament injury is a (valgus or varus?) injury such as may occur with being hit on the (inside or outside?) of the knee with the foot planted or if the person lands from a jump with the knee in a (varus or valgus?) position.

The mechanism of injury for a medial collateral ligament injury is a valgus injury such as may occur with being hit on the outside of the knee with the foot planted or if the person lands from a jump with the knee in a valgus position.

The pivot shift assesses the ability of the _ _ _ but it is a difficult test to perform. False ______ results are common as patients will often ______ and actively prevent the motion. The patient's leg is held with the tibia either in slight _____ rotation or ______. The therapist's hand on the _____ controls the rotation of the tibia while the hand on the ______ portion of the knee provides a _____ stress. The knee is moved from full extension to approximately __ degrees of flexion. A positive pivot shift test is relocation of the tibia at approximately __ degrees of knee flexion. The pivot shift results from a _____ subluxation of the tibial ______ with the application of a _____ stress in extension and ______ rotation of the tibia. With the knee extended, the iliotibial band is _____ to the femoral condyle and the ______ of the knee joint. When the iliotibal band ______, and is ______ to, the midline of the knee joint around ___ degrees the tibia moves with gravity without the support of the ITB. This results in the positive "relocation" finding.

The pivot shift assesses the ability of the ACL but it is a difficult test to perform. False negative results are common as patients will often guard and actively prevent the motion. The patient's leg is held with the tibia either in slight internal rotation or neutral. The therapist's hand on the foot controls the rotation of the tibia while the hand on the lateral portion of the knee provides a valgus stress. The knee is moved from full extension to approximately 30 degrees of flexion. A positive pivot shift test is relocation of the tibia at approximately 30 degrees of knee flexion. The pivot shift results from a rotary subluxation of the tibial plateau with the application of a valgus stress in extension and internal rotation of the tibia. With the knee extended, the iliotibial band is anterior to the femoral condyle and the midline of the knee joint. When the iliotibal band crosses, and is posterior to, the midline of the knee joint around 30 degrees the tibia moves with gravity without the support of the ITB. This results in the positive "relocation" finding.

The special test to assist in ruling in an MCL injury is the ______ _____ test performed at __ and __ degrees of knee flexion. The MCL has ___ bands, one which is more taut in ______ and one in _____ and for minor injuries, palpation in both _____ and _____ may be needed if the symptoms are not obvious

The special test to assist in ruling in an MCL injury is the valgus stress test performed at 0 and 30 degrees of knee flexion. The MCL has two bands, one which is more taut in extension and one in flexion and for minor injuries, palpation in both flexion and extension may be needed if the symptoms are not obvious

The valgus stress test at __ degrees of knee flexion tests the MCL along with the secondary restraints. The valgus stress test at __ degrees of knee flexion isolates the MCL, ______ and/or _____ is a positive test. _____ and____ at __ degrees also indicates possible damage to the ___ and/or __

The valgus stress test at 0 degrees of knee flexion tests the MCL along with the secondary restraints. The valgus stress test at 30 degrees of knee flexion isolates the MCL, gapping and/or pain is a positive test. Gapping and pain at 0 degrees also indicates possible damage to the PCL and/or ACL

The varus stress test at __ degrees of knee flexion tests the LCL along with the secondary restraints. Gapping and pain at __ degrees also indicates possible damage to the ___ and/or ___ and these ligaments need to be kept in mind for your hypothesis testing. The varus stress test at __ degrees of knee flexion isolates the LCL.

The varus stress test at 0 degrees of knee flexion tests the LCL along with the secondary restraints. Gapping and pain at 0 degrees also indicates possible damage to the PCL and/or ACL and these ligaments need to be kept in mind for your hypothesis testing. The varus stress test at 30 degrees of knee flexion isolates the LCL.

T/F Ligaments injures are graded on a scale from grade I to IV

false I-III

T/F LCL injuries occur as commonly as MCL injuries

false do not

T/F LCL injuries can also be managed non operatively due to the good blood supply and ability to heal

true