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What is it?
The knee joint is designed to flex or extend only, with no rotation. It consists of three bones (thigh, leg and knee cap). The cruciate ligaments provide fore-aft stability and the collateral ligaments side-to-side stability. The knee cap is connected to the thigh muscles and helps in the action of straightening a bent knee. The two menisci (medial and lateral) are cartilages which provide padding between the thigh and leg bones.
Cruciate ligament injuries tend to occur with sudden force acceleration or deceleration injuries. Collateral ligament injuries occur with side bending injuries of the knee. Meniscal injuries occur in combined knee flexion and rotation movements. Patella injuries occur as a result of a blow to the point of the knee or with repetitive squatting or climbing. Severe knee injuries can result in a combination of crucial, collateral and meniscal injuries occurring at the same time.
Pre-patella Bursitis (“Housemaids Knee”) occurs in workers who crawl a lot (for example roofers or carpet layers).
Symptoms
Injuries involving either fractures of bones, or rupture of the cruciate ligaments tend to swell rapidly (within minutes of the injury), and medical injuries tend to swell slowly (within hours of the injury).
In addition to pain and swelling other symptoms include instability, locking or giving way.
Incidence
Knee injuries are common. In the aging work-force (particularly the obese) degenerative knee conditions (arthritis) are also common. A prior history of a menisectomy can also lead to knee arthritis.
Key Points
The history is important. Issues to look for include:
Some tears require referral and possible arthroscopies
Early rehabilitation should be mandatory to reduce effusion
Physiotherapy also maximizes range of movement, allows early strengthening and proprioceptive retraining and return to work
Education about re-injury is important from GP or specialist
Lateral tears are rarer than medial tears
History (for meniscal tears) – (ACC recommended treatment profiles)
Swelling usually occurs greater than four hours after injury or the next day
Tears are usually associated with a twisting injury, flexed knee with fixed foot
Determine degree of force associated with injury, amount of mobility and whether there is associated locking or giving away.
History – Collateral ligament
Determine mechanism of injury, whether direct or indirect blow
Determine location of pain or tenderness
Determine whether there is loss of functions
Differential diagnosis
Torn cruciate ligament
Torn medial/collateral ligaments
Osteocondral fracture
Degenerative joint disease
Meniscal injury
Fracture
Recommended investigations (Collateral ligament)
X-rays if swollen for possible fracture
Severe trauma treatment (Collateral ligament)
Analgaesia
Physiotherapy
Tubigrip and crutches
RICE (Rest, Ice, Compression, Elevation)
For meniscal tear as above:
Gradual mobilisation
Passive quadriceps exercises
When to Consider Referral to specialist:
Issues to look for:
The presence of any red flag conditions
The worker has had more than two weeks certified unfit for duties, or more than one month on selected duties
The worker has had more than three weeks off work, or on selected duties and has significant yellow flag conditions
Not back at pre-injury duties within six weeks of the injury.
Red flag conditions:
Immediate onset of significant knee swelling
Significant trauma
Unstable knee
Recurrent locking or giving way
Fever
IV drug use
Steroid use
Severe unremitting night time pain
Patient aged over 50 years
Objective evidence of thigh muscle wasting (quadriceps or VMO)
Yellow flag conditions:
Attitudes and beliefs about pain
Emotions
Behaviour
Family
Compensation issues
Work
Diagnostic and treatment issues
Workplace conflict
Possible alternate duties:
No weight bearing with the affected leg
No overhand gripping with the affected knee
Maximum lift 5 kgs
No squatting or climbing
No prolonged walking or standing