MultiLigament Knee Injury With Associated Fibular Nerve Injury
Multi-Ligament Knee Injury With Associated Fibular Nerve Injury In A Collegiate Football Player Jill A. Manners, MS, LAT, ATC Grady J. Hardeman, MEd, LAT, ATC Richard B. Jones, MD Western Carolina University, Cullowhee, North Carolina and Southeastern Sports Medicine, Asheville, North Carolina
Objective n n n To educate certified athletic trainers regarding the recognition, treatment and rehabilitation of an athlete who has sustained a multi-ligament knee injury To educate certified athletic trainers regarding an unusual common fibular (peroneal) nerve injury To remind certified athletic trainers of the importance of thorough evaluations
Anatomical Review n Soft Tissue Support q q q q n Anterior Cruciate Ligament Posterior Cruciate Ligament Medial Collateral Ligament Lateral Collateral Ligament Arcuate Complex Medial and Lateral Meniscii Musculature Bony Support q q Medial and Lateral Femoral Condyles Medial and Lateral Tibial Condyles
Case Background n n n 20 year-old male collegiate football tailback MOI: Indirect varus stress placed on the right knee No previous pertinent medical history of lower extremity injury
Initial Clinical Evaluation n n Inspection Palpation Range of Motion Special Tests Initial Treatment?
Follow-up Evaluation (12 hours later) n n n Swelling had increased dramatically in the ipsilateral foot and knee Obvious drop foot noted Range of Motion q q n n n Knee Ankle Inability to actively dorsiflex or evert right ankle Decreased right LE sensation (+) Tinel’s Sign
Physician Evaluation (36 hours post-injury) n n n Athlete was evaluated by a team physician who confirmed the diagnosis of Grade III ACL and LCL sprains MRI was immediately ordered due to the patient’s right lower extremity neurological signs and symptoms Referral to Second Physician
Diagnostic Tests n n n Plain Radiographs Magnetic Resonance Imaging EMG / Nerve Conduction Velocity Study
Differential Diagnosis n n n n n Subluxed Tibiofemoral Joint Cryotherapy-Induced Neuropraxia Transected Common Fibular Nerve Contusion Fibular Head Fracture Posterior Cruciate Ligament Tear Medial and/or Lateral Meniscal Tear Biceps Femoris Rupture / Strain Acute Anterior Compartment Syndrome?
Diagnosis n Final Diagnosis q q q q q Grade III Anterior Cruciate Ligament Sprain Grade III Lateral Collateral Ligament Sprain Tear of the Posterior Horn of the Lateral Meniscus Posterior Lateral Complex Disruption Common Fibular Nerve Injury Biceps Femoris Strain Medial Femoral Condyle Contusion Medial Tibial Plateau Microfracture Grade I/II Posterior Cruciate Ligament Sprain
Treatment n Initial Treatment q q n Cryotherapy NWB Gait Straight Leg Immobilizer (locked in 0 degrees) Pre-surgical Rehabilitation Surgical Fixation q q ACL Repair using BTB Patellar Tendon Graft Lateral Collateral Ligament Reconstruction – Anterior Tibialis Allograft Common Fibular Nerve Debridement Posterior Lateral Complex Repair
Initial Post –Surgical Rehabilitation n n Placed in a motion-restricting full leg brace which was locked at 30 degrees of flexion for the first 2 weeks after surgery Non-weight bearing gait for 6 weeks after surgery Rehabilitation focused on guarded ROM, hamstring and quadriceps strengthening Biofeedback and Russian Current to promote anterior tibialis and fibularis tertius strengthening Passive stretch of the posterior lower leg muscles
Physician Follow-up n n Athlete was prescribed a non-hinged AFO brace 6 weeks postsurgery Athlete was prescribed an ACL valgus unloader brace 10 weeks postsurgery
Rehabilitation n Treatment focused on: q q n n Knee flexion and extension range of motion Quadriceps and Hamstring Strengthening Lower Extremity Proprioception Training Functional Right Lower Extremity Activities The athlete was cleared for jogging as tolerated 5 ½ months post-surgery Complications: q q Inability of patient to actively dorsiflex right ankle Limitation of functional right ankle range of motion due to bracing
Current Status n n n One year post-injury, the athlete demonstrates full function of his right knee He continues to demonstrate paresthesia over the dorsum of the right foot and foot drop on the right Recent NCV study demonstrates little to no increase in conduction across the common fibular nerve
Uniqueness of This Case n n n Mechanism of injury Complexity and number of structures involved Rare incidence of fibular nerve involvement during knee ligamentous injury
Relevance to Athletic Training n n n Reinforces the importance of completing thorough clinical evaluations Requires athletic trainers to think outside the box in terms of complex structural involvement with a common MOI Reinforces the importance of athletic trainers being creative during the rehabilitation process
Thank You! Any Questions?
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