Glossary

In the acute knee injury consider RICE (rest, ice, compression and elevation). pain and instability can be managed with crutches, the appropriate pain killers and a knee splint like the Super Knee Splint in the first instance. You should have several on the shelf of your practice for the first presentation of the patient. Some of these splints can be purchased in packs of 10.

This is an injury that requires reassessment for the class of ligament injury. Early referral through Accident and Emergency to an Orthopaedic and Trauma Service is mandatory for some grade 2 injuries and all grade 3 ligament injuries.

If you are an iTunes user and want some insight into your knee problem before you see a doctor then try this Knee Arthroscopy App. It is the best App for patients with injured knees and the first of its kind in the iTunes store.

For patients from the USA use this hyperlink: Knee Injury App.

Quadriceps tendon rupture is often difficullt to diagnose and needs a high index of suspicion. There is a new radiological sign to help doctors with this diagnosis. (Hardy JR, Chimutengwende-Gordon M, Bakar I. Rupture of the quadriceps tendon: an association with a patellar spur. J Bone Joint Surg Br. 2005 Oct;87(10):1361-3. Erratum in: J Bone Joint Surg Br. 2006 Jun;88(6):837.)

In the acute injury consider RICE (rest, ice, compression and elevation). pain and instability due to the loss of the extensor mechanism can be managed with crutches and a knee splint like the 3-Panel Knee Splint in the first instance. You should have several on the shelf of your practice for the first presentation of the patient. Some of these splints can be purchased in packs of 10.

This is an injury that requires surgical repair. Early referral through Accident and Emergency to an Orthopaedic and Trauma Service is mandatory.

Patella dislocation is frequently difficult to diagnose. In the history as about the mechanism of injury and previous dislocation. Look for tenderness and bruising along the medial aspect of the patella from rupture of the medial retanaculum. There may or may not be an effusion. Look for Apley's aprehension sign. Look for the predisposing anatomical features for dislocation such as the patients sex, persistent femoral anteversion, the "Q" angle and any patella malalignment, maltracking or dysplasia.

In the acute injury consider RICE (rest, ice, compression and elevation). pain and instability and pain can be managed with crutches and a knee splint like the Three-Panel Knee Splint in the first instance. You should have several on the shelf of your practice for the first presentation of the patient. Some of these splints can be purchased in packs of 10.

This is an injury that frequently requires surgical repair. Five percent of all dislocations are associated with an osteochondral fracture like the one in the radiographs that was repaired with keyhole surgery. Early referral through Accident and Emergency to an Orthopaedic and Trauma Service is mandatory.

OrthopaedicsandTrauma.com asked Mr John Hardy about ACL injury and management. John is a Consultant Orthopaedic Surgeon in London and Bristol in the UK who performed over 105 ACl reconstructions between 1st January 2001 and 1st January 2007. He estimates that he has treated greater than this number of patients conservatively in the same period. John said " The important thing about assessing the patient with an ACL rupture is to undertake it early". "During early assessment, by a Consultant in Orthopaedics and Trauma, the ACL rupture pattern is characterised, complication of the injury such as medial collateral ligament injury and meniscal injury (which needs early intervention) are defined and a treatment plan is instituted with the emphysis on rehabilitation". He said that "The ACL rupture can be characterised into three patterns. These are the partially torn ACL (first image), the torn ACL that heals to the PCL (middle image) and the torn ACL that rolls forward causing permanent intermittent anterior pain and prevention of full extension (final image). When there are no complications of the injury there is no hard and fast rule regarding conservative management of an ACL rupture but it is my experience that the athletes with a partial tear or one which heals to the PCL are likely to get away with conservative management". Where as patients with a symptomatic and demonstrably unstable knee are most likely to have the third type of rupture. (click on the image to see an "active quadriceps sign" of an ACL rupture)

John told OrthopaedicsandTrauma.com " A Cochrane review of published research in 2005 showed there was insufficient evidence from randomised trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice.". Linko E, Harilainen A, Malmivaara A, Seitsalo S. Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev. 2005;Apr 18;(2):CD001356.

"Whether you consider conservative or surgical management is best for your patient I think the most popular off the shelf brace used in my practice for adding some stability to the ACL problem knee is the Donjoy Armor with ForcePoint™ knee brace." said John.

If you are an iTunes user and want some insight into your knee problem before you see a doctor then try this Knee Arthroscopy App. It is the best App for patients with injured knees and the first of its kind in the iTunes store.

For patients from the USA use this hyperlink: Knee Injury App.

"Carpal Tunnel Syndrome is a progressive and slow injury to the median nerve".

Carpal Tunnel Syndrome (CTS) results from the compression of nerve, the median nerve, within the carpal tunnel in the wrist.

Carpal Tunnel Syndrome results in numbness, pain or tingling in your patients arm or hand, especially in the early hours of the morning. Latterly, as the nerve damage progresses, your patient may also experience permanent numbness, clumsiness and weakness in handling objects and sometimes develop pain up the arm to the elbow and rarely as high as the shoulder. If your patient presents with bilateral symptoms then systemic causes of this condition should be sought before considering treatment of the condition itself.

Your patient can try simple treatments for this condition before referring them for surgery to relieve their symptoms. One of the simplest and most effective treatments is the use of Wrist Braces at night to provide a good night sleep without the early waking seen in this condition.

As you are reading this you are likely to be interested in the long term consequences of limb length differences in your patients.

Recent gait analysis demonstrates that the shorter limb sustains a greater proportion of load and loading rates [White SC, Gilchrist LA, Wilk BE. Asymmetric limb loading with true or simulated leg-length differences. Clin Orthop Relat Res. 2004 Apr;(421):287-92.] It is likely that in the long term this leads to earlier degenerate changes in spine, hip knee and ankle.

To measure your patients leg length using a tape measure, measure from the inferior aspect of the anterior superior iliac spine (ASIS) to the inferior aspect of the medial malleolus of the ipsilateral (same) side (upper 2 images). This point beneath the anterior superior iliac spine is found easily by passing the start of the measuring tape up 1cm from the inguinal ligament to its origin at the ASIS. This measures real against apparent leg length. Performing each measurement at least twice is a valid non-invasive clinical measure.[Beattie P, Isaacson K, Riddle DL, Rothstein JM. Validity of derived measurements of leg-length differences obtained by use of a tape measure. Phys Ther. 1990 Mar;70(3):150-7.]

Inequality in leg length can be congenital (from birth or as a result of inequality in growth), acquired (as a result of injury) or iatrogenic (prescription of the wrong insole or surgical shoe). The problem with unequal leg lengths, congenital or acquired, is that it produces a curvature on the spine (scoliosis: lower 2 images). This leads to abnormally high and unequal pressures on the elements of the spine and ultimately over many years abnormal wear due to these unequal pressures. This can contribute to back pain.

So before you prescribe a patient any foot and ankle supports for longer than an arbitary 6 weeks please check your patient's leg lengths and advise them to adjust the unaffected side accordingly. Remember not to assume that your patient was born with equal leg lengths.

With this in mind it should be obvious that some patients need only one insole and other patients need equal thickness insoles and other patients need insoles of differing thickness.

The infrapatella fat pad is otherwise known as Hoffa's fat pad. The infrapatellar fat pad is commonly injured but rarely diagnosed as a cause of pain.

Injury is a frequent cause of anterior knee pain. Anterior knee pain is an umbrella term for many definable conditions.

Abnormalities within the infrapatella fat pad most commonly are the consequences of isolated injury (football) cyclic trauma (running) and degeneration. Inflammatory and neoplastic diseases of the synovium can be confined to the fat pad but are rare. Repetitive trauma can be seen on MRI of the fat pad as intrinsic signal abnormalities. This can occur with both posterior and superior impingement syndromes.[Saddik D, McNally EG, Richardson M. MRI of Hoffa's fat pad. Skeletal Radiol. 2004 Aug;33(8):433-44. Epub 2004 Jun 19.] The image of the MRI scan left is from the above paper on the MRI of Hoffa's fat pad and shows superior impingment as a cause of anterior knee pain. . Hoffa's Disease is frequently associated with meniscal tears.

Click on the image to the left to read on about this condition and its treatments.....

If you are an iTunes user and want some insight into your knee problem before you see a doctor then try this Knee Arthroscopy App. It is the best App for patients with injured knees and the first of its kind in the iTunes store.

For patients from the USA use this hyperlink: Knee Injury App.

The Lateral Collateral Ligament of the knee is the narrow based ligament on the outside of the knee between the femur and the tibia. It is best felt with the patient's foot placed on the contralateral shin in a figure of 4. In this position it can be felt as a cord like structure between the head of the fibula and the lateral femoral condyle. It is injured infrequently. Usually with a force from the inside of the knee. Grade one ligamant injury (pain but no laxity) and grade 2 injury (pain and increased ligamant laxity with an end point) are treated conservatively with RICE (rest, ice, compression and elevation). Early ROM is important. So to enable this any one of the knee braces from the down can be used. Suggest your patient put one in a plastic bag and place it in the fridge over night for the first 72 hours to cool it down for the next day in order to apply ice.

If you are an iTunes user and want some insight into your knee problem before you see a doctor then try this Knee Arthroscopy App. It is the best App for patients with injured knees and the first of its kind in the iTunes store.

For patients from the USA use this hyperlink: Knee Injury App.

The Medial Collateral Ligament of the knee is the broad based ligament on the inside of the knee between the femur and the tibia. It is injured frequently on its own. Usually with a twist or a force from the outside of the knee. Less frequently it is injured with the anterior cruciate ligament and the medial meniscus. This pattern of injury is known as O'Donahue's unhappy triad. Grade one ligamant injury (pain but no laxity) and grade 2 injury (pain and increased ligamant laxity with an end point) are treated conservatively with RICE (rest, ice, compression and elevation). Early ROM is important. So to enable this any one of the knee braces from the Drytex® Playmaker® down can be used. Suggest your patient put one in a plastic bag and place it in the fridge over night for the first 72 hours to cool it down for the next day in order to apply ice.

If you are an iTunes user and want some insight into your knee problem before you see a doctor then try this Knee Arthroscopy App. It is the best App for patients with injured knees and the first of its kind in the iTunes store.

For patients from the USA use this hyperlink: Knee Injury App.

The image left is an arthroscopic view of a neglected meniscal tear in a patient with knee pain more that six weeks. It was unstable. Therefore, it was causing pain when trapping between the condyles of the knee. The high pressure from this small loose fragment of cartilage causes secondary degenerate changes in the hyaline cartilage of the femoral and tibial condyles. This image was before partial menesectomy and chondroplasty. The earlier the intervention for such symptoms the better the outcome.

A missed or neglected meniscal tear is the commonest cause of unicompartmental osteoarthritis in the knee. A meniscal tear like the one in the clip requires partial menesectomy and careful chondroplasty.

How would you as a doctor advise your patient on rehabilitation after keyhole partial menesectomy and chondroplasty (smoothing the surface)? Movement of the joint without excessive load is the best option. Physiotherapists will advise on Continuous Passive Motion once this condition has been treated by day case keyhole surgery. An off loading brace may help your patient with this. Make sure you order the Osteoarthritis knee brace rather than a knee ligament brace because the OA Adjuster or OA Lite type of brace offloads the affected compartment during walking in order to allow as much of the cartilage to recover as possible.

Recommend that your patient uses the brace on the affected and measured knee only knee! Remember to consider the compartment of wear and the side, left or right.

If you are an iTunes user and want some insight into your knee problem before you see a doctor then try this Knee Arthroscopy App. It is the best App for patients with injured knees and the first of its kind in the iTunes store.

For patients from the USA use this hyperlink: Knee Injury App.

When your patient initially wears any orthotic or brace it may feel different or uncomfortable to them. This feeling is quite normal - keep in mind that orthotics and braces are designed to protect or change the way your patient functions. With patience and planning, their braces and orthotics should feel comfortable to the point where some wearers often say they do not notice them. This might take several consultations to achieve but your patience as a doctor should pay off.

The instructions below provide you with advice to help you plan the best program for adapting to your patient's new braces or orthotics. These are guidelines only and apply unless your diagnosis indicates alternative treatments should be considered:

Braces:
Unless the brace was prescribed for immobilisation of an injury rather than prevention of further injury, start by suggesting your patient wear any, spine, shoulder, elbow, wrist, knee or ankle brace for daily activities and walking only. The use of any brace for sport should be gradual beginning in the non-sporting situation, use in training and finally use in sport if appropriate.

Suggest that your patient wear their brace for just an hour on the first day. The following day wear them for two hours, the third day three hours etc. depending on the type and duration of any sporting activity.

If their brace becomes uncomfortable before the prescribed time, suggest they adjust the brace or consider a sleeve, sock or tubigrip. Some patients' find that a change to the padded areas of the brace can help For example a (Floam Cushioned Condyle Pads and Cover) instead of the foam cover can benefit. Occasionally it is necessary to advise they and stop wearing them for a day and try the day after this break from the new brace. If your patient's pain or discomfort persists over time, please ask them to return to yourself to reassess the fitting or refer them on for professional musculoskeletal advice from a Consultant in Orthopaedics and Trauma for further assessment.

Often asking a patient to bring in the prescribed brace will demonstrate they are fitting the brace incorrectly and simple advice on fitting, adjustment or replacement if worn can help.

The fabric of a brace can be cleaned according to the manufacturers advice. Occasionally, the use of baby powder can help the wearer with odour problems and comfort. Patients with sensitive skin might consider wearing an Undergarment or tubigrip beneath the brace.

Patients that want to protect the brace during cooking or sporting activities might consider a washable fabric stocking, old sock or a Sports Cover to achieve this.

Orthotics:
Try to persuade your patient to wear their orthotics for just an hour on the first day. The following day wear them for two hours, the third day three hours etc., until at the end of two weeks they are wearing them all day. If their orthotics become uncomfortable before the prescribed time, suggest they remove them from their shoes and stop wearing them for that day and try the day after this break from the new orthotic. If your patient's pain or discomfort persists over time, please ask them to return to yourself or refer them on for professional musculoskeletal advice from a Consultant in Orthopaedics and Trauma for further assessment.

Some patients report mild discomfort in the legs, knees, hips and/or lower back a when first wearing their orthotics. This discomfort is frequently an indication that the orthotics are working and are being worn (compliance). Small changes in the load pattern and gait will occur throughout the musculoskeletal structure and it may take time for your patient to adjust to these changes. These aches are usually transitory and will disappear in time. Conversely, low back pain is common in the general population and can improve with orthotics.

If the orthotics you prescribed are for one foot only and are temporary suggest to your patient that they try their best to match the orthotic with a shoe that has a similar sole and heel profile such that they are walking with equal (see below). For example some patients order two Podalux Surgical shoes to achieve this. This might help prevent low back ache from leg length inequality.

It is not unusual for orthotics to slip, particularly if they are not full length insoles. If this happens with the silicone heel cups for example suggest your patient try placing them under the insole of their shoe in order to hold the position relative to their heel.

In some cases before placing their orthotics in either new or old shoes, it may be important to take out removable arch supports, rubber or felt additions or other inserts from the inside of the shoes. If despite this the shoe appears tight then occasionally new shoes should be purchased with the insole to hand so as to ensure the correct size is chosen to accommodate the insole.

This advice section is a guideline only. Your patient's specific situation may be different and may require alternative management. Always recommend a consultation two to six weeks after prescribing orthotics.

This is the position in which the knee is flexed to 20° as in the skiing position. This allows the doctor to more acurately measure the affected side for brace fitting. Make a mark on the centre of the patella. Measure 15cm up from the centre of the patella and make and make another mark. Measure the thigh circumference at this point.

Have you have measured a limb in your patient that is wasted due to disuse? If you expect a rapid recovery of the normal muscle bulk of the thigh think about measuring the unaffected side to estimate the best size for your patient over the intervening period of recovery.