Adolescent Sports Injury

General Information
Case no.	1.A Adolescent Sports Injury
Authors	Christopher Tumminello, PT, DPT, EP-C Brian Eckenrode, PT, DPT, Board Certified Clinical Specialist in Orthopaedic Physical Therapy Ari Kaplan, PT, DPT, CSCS, COMT, Cert MDT, Board Certified Clinical Specialist in Sports Physical Therapy
Diagnosis	Knee dislocation with multiligamentous knee injury (KD III-MC)
Setting	On-field assessment and emergency room management
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Describe the management of an acute on-field knee injury. Determine the need for immediate medical attention of a patient with an acute on-field knee injury. Describe the appropriate tests and measures considered for this patient in the acute phase of injury.

Pre-case clarification
Physical therapy scope of practice	It should be noted that all physical therapists are not qualified to provide coverage of athletic events. The highest qualification physical therapists can obtain in order to be able to provide athletic venue coverage is through becoming a board-certified sports clinical specialist (SCS) offered through the American Board of Physical Therapy Specialties (ABPTS). Additional credentials for physical therapists to be able to provide on-field coverage include the certified athletic trainer (ATC) or emergency medical responder (EMR) certification.

Pre-case clarification

Physical therapy scope of practice

It should be noted that all physical therapists are not qualified to provide coverage of athletic events. The highest qualification physical therapists can obtain in order to be able to provide athletic venue coverage is through becoming a board-certified sports clinical specialist (SCS) offered through the American Board of Physical Therapy Specialties (ABPTS). Additional credentials for physical therapists to be able to provide on-field coverage include the certified athletic trainer (ATC) or emergency medical responder (EMR) certification.

Medical
Chief complaint	Instability and pain in left knee
History of present illness	While assisting with on-field coverage of a high school football game with an athletic trainer and sports medicine physician, a 16-year-old, right-handed male, who plays quarterback, sustained a traumatic left knee injury. The quarterback was dropping back to attempt a pass, when he transitioned his weight to his front leg (left leg) and sustained a hit from an opposing player to the anterolateral aspect of his left knee.
Past medical history	Asthma
Past surgical history	None
Allergies	Peanuts
Medications	Albuterol inhaler as needed
Precautions/Orders	N/A—on-field assessment

Social history
Home setup	Lives with his parents, younger sister, and dog in a two-story home. Four steps to enter, with right handrail when ascending. Bedroom is on the second floor. Half bathroom on the first floor, and full bathroom on the second floor. Indoor stairs have handrails on both sides.
Occupation	Full-time high school student. Busses tables at a local restaurant on the weekends.
Prior level of function	Independent with all activities of daily living.
Recreational activities	Starting high school quarterback in the fall. Starting shortstop for baseball in the spring.

Physical Examination: On-Field Assessment
Subjective
“My knee bent backward, and I definitely heard a pop. Pretty sure everyone heard it.”
Objective
Observation	No head or neck trauma noted with injury. Player is alert and oriented to person, place, and time. No blood or open wound present. No obvious deformity to the left lower extremity. Effusion absent to the left lower extremity.
Neurovascular assessment	Unable to detect a left popliteal artery, posterior tibial artery, or dorsalis pedis pulse. (Fig. 1.1). No temperature change noted to the distal left lower extremity. No complaints of numbness or tingling at this time to the left leg.
Musculoskeletal assessment	Knee special testing was deferred due to acuity of injury, combined with the loss of pulses to the left lower extremity.
Treatment	Given the current presentation and inability to bear weight through the left leg, and undetectable pulses, the left knee was immobilized on field. An ambulance was called for immediate transportation to the hospital.

Fig. 1.1 Areas of auscultation and palpation of the peripheral arterial pulses. (a) Auscultation areas. (b) Palpation points. (c) Palpation techniques. (Source: Vascular diagnosis. In: Steffers G, Credner S, eds. General Pathology and Internal Medicine for Physical Therapists. 1st ed. Thieme; 2012.)

Pause points
Based on the above information, what is the priority Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what is the priority

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Vital signs	Hospital day 0: emergency department
Blood pressure (mmHg)	132/80
Heart rate (beats/min)	92
Respiratory rate (breaths/min)	16
Pulse oximetry on room air (SpO₂)	98%
Temperature (°F)	98.6

Hospital Day 0, Emergency Room: Physical Examination
Subjective
“I got hit, and my left knee got bent backward and popped. It’s really hurting now.”
Objective
General	Observation	Well-nourished fit high school male. Appears to have left knee pain, cognitively intact and answering questions appropriately. Left lower extremity pallor, right lower extremity was unremarkable.
	Pain (left knee)	8/10 currently
	Palpation	Left lower extremity slightly colder to touch compared to the right lower extremity.
Head, ears, eyes, nose, and throat (HEENT)	(–) Congestion, sore throat or otalgia, denies head injury with hit during the game.
Cardiovascular and pulmonary	(–) Chest pain, palpitations, dyspnea on exertion, edema, syncope, aspiration, shortness of breath, orthopnea (–) Cough, congestion, wheezing, or sputum production Lower extremity pulses: Right: 2 + throughout Left: femoral artery, 4 + ; popliteal artery, 0; posterior tibial, 0; dorsalis pedis, 0
Gastrointestinal	(–) Abdominal pain, hematemesis, melena, nausea, vomiting, diarrhea
Genitourinary	(–) Dysuria, frequency, urgency, blood in urine
Musculoskeletal	Range of motion	Right	Left
	Range of motion	Unremarkable	Limited knee flexion and extension due to pain/acuteness of injury.
	Strength (manual muscle testing)	5/5 ankle dorsiflexion 5/5 ankle plantar flexion 5/5 ankle inversion 5/5 ankle eversion	1/5 ankle dorsiflexion 1/5 ankle plantar flexion 1/5 ankle inversion 1/5 ankle eversion
	Other	Special tests (including ligamentous testing) of the left lower extremity were deferred due to loss of pulses and findings from diagnostic imaging.
Neurological	Balance	Not assessed due to lower extremity injury.
	Cognition	Alert and oriented x four.
	Coordination	Not assessed at this time.
	Cranial nerves	II–XII: intact
	Reflexes	Not assessed at this time.
	Sensation	Right lower extremity: unremarkable Left lower extremity: diminished below the knee

Imaging/Diagnostic tests	Hospital Day 1, Emergency Room: Emergency Department
Radiographs	Trauma series (AP and lateral views): negative for fractures on left lower extremity. No signs of growth plate injury or disruption.
Magnetic resonance	Magnetic resonance angiography (MRA): presence of popliteal arterial occlusion in left leg.

Medical management	Hospital Day 1, Postoperative Day 0: Medical Ward
Surgical intervention	Under general anesthesia, the patient underwent exploration of the popliteal artery via a medial approach. An intimal flap disruption was discovered in the popliteal artery, leading to a thrombectomy via catheter with suturing of the intimal flap. To avoid restenosis, the repair utilized a saphenous vein patch from the contralateral leg.
Postoperative	Restoration of normal popliteal, posterior tibialis, and dorsalis pedis pulses.
Additional imaging	Magnetic resonance imaging (MRI): tear of the left posterior cruciate ligament (PCL), anterior cruciate ligament (ACL), medial collateral ligament (MCL), and lateral meniscus. These findings meet the diagnostic criteria of a KD III-MC via anatomic (Schenck) classification of knee dislocations.

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“To play football again.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☐ Physician’s ☑ Physical therapist’s ☐ Other’s	Provide single visit for crutch training along with written instructions for home exercise program and wound management for safe discharge home with supervision from parents.

Plan

☐ Physician’s

☑ Physical therapist’s

☐ Other’s

Provide single visit for crutch training along with written instructions for home exercise program and wound management for safe discharge home with supervision from parents.

Bloom’s Taxonomy Level	Case 1.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. Which findings decrease suspicion for a catastrophic spine injury?
Analyze	5. After an artery injury, how many hours can pass before there is an increased risk of limb amputation? 6. If a vascular injury is present with a knee dislocation, how often is surgery indicated? 7. What is the hierarchy of an on-field assessment?
Apply	8. What are the proper procedures for applying a splint to the patient on the field prior to transportation to the hospital? 9. In the initial plan of care as the treating physical therapist in the acute care hospital, what exercises could safely be implemented upon discharge from the hospital?
Understand	10. What are the common nerve and artery injuries associated with a knee dislocation? 11. What knee structures are involved in the diagnosis of KD III—MC, and what knee structures are involved in the other KD classifications? 12. What are the 6 Ps of acute ischemia?
Remember	13. What must be ruled out when there is a complaint of extremity numbness following a traumatic on-field injury?

Bloom’s Taxonomy Level	Case 1.A Answers
Create	1. The patient is a 16-year-old male who underwent surgery after sustaining a traumatic left knee dislocation, involving tears of his ACL, PCL, and MCL (KD III—MC). Upon his in-hospital postoperative physical therapy evaluation, pulses and capillary refill were intact in his left lower extremity. He demonstrates the physical ability to ambulate with axillary crutches independently and understands importance of utilizing a locked knee brace or immobilizer with mobility activities. Poor quadriceps muscle activation was observed by having the patient attempt an isometric quadriceps contraction. His home exercise program should focus on frequent application of ice, compression, and elevation, in addition to beginning quadriceps isometrics, gluteal isometrics, ankle pumps, and knee range of motion (ROM) ahead of a consult with an orthopaedic surgeon. 2. Short-term goals: The patient will ambulate 150 feet using bilateral axillary crutches independently while maintaining non–weight-bearing status within 3 days to be independent at home. The patient will ascend/descend a flight of steps using bilateral axillary crutches while maintaining a non–weight-bearing status independently within 3 days to be independent at home. The patient will demonstrate the ability to properly don and doff his knee immobilizer brace independently within 3 days to be independent at home. 3. Long-term goals: The patient will perform a left straight leg raise without a quadriceps lag to improve LLE strength and allow for safe functional transfers and bed mobility within 4 weeks. The patient will demonstrate left knee active ROM from 0 to at least 90 degrees of flexion within 4 weeks, prior to his scheduled knee reconstruction, in order to maximize a favorable postoperative outcome. (It should be noted that patients may be immobilized in 20 degrees of flexion to prevent posterior subluxation of the tibia, which could endanger the popliteal artery after popliteal artery repair.)
Evaluate	4. Possible findings of catastrophic spine injury would include unconsciousness or altered level of consciousness, bilateral neurologic findings or complaints, significant midline spine pain with or without palpation, and obvious spinal column deformity.
Analyze	5. Without an early diagnosis of vascular changes (within 8 hours), the risk of required amputation increases. 6. Of patients who sustained a vascular injury with a knee dislocation, 80% required vascular surgery and 12% resulted in amputation. 7. Prevent further injury, minimize the zone of injury, decrease pain, promote healing, and allow a safe return to athletic competition if appropriate is the hierarchy of an on-field assessment.
Apply	8. A splint for a knee dislocation should be applied so that it adequately supports the joint at, above, and below the injury. In this case, splinting of the hip and ankle may be excessive, but a posterior knee splint or long leg immobilizer should be applied to prevent additional injuries. 9. Straight leg raises, side lying hip abduction, and prone hip extension can be initiated with the knee in an immobilizer or locked brace. Additionally, ankle and knee passive/active assist ROM should be included for this patient. The patient should avoid active hip adduction, to minimize stress to the healing MCL. Knee flexion beyond 90 degrees of flexion and 0 degrees of extension should be avoided at this stage to minimize tension on the vascular repair.
Understand	10. The popliteal artery and common peroneal nerve are the most commonly associated injuries with knee dislocations, occurring in 19 and 20% of knee dislocations, respectively. 11. See Table 1.15. 12. Pain, pallor, paralysis, pulse deficit, paresthesia, and poikilothermia
Remember	13. Cervical and lumbar spine injuries must be cleared prior to transporting or moving a patient with complaints of numbness, tingling, or weakness after sustaining a traumatic on-field injury.

Table 1.15 Anatomic classification of knee dislocations
Class^a	Injury
KD I	PCL or ACL intact knee dislocation Variable collateral involvement
KD II	Both cruciate ligaments torn, collaterals intact
KD III	Both cruciate ligaments torn, one collateral torn. Subset M (medial) or L (lateral)
KD IV	All four ligaments torn.
KD V	Knee fracture dislocation
KD V.1	Fracture dislocation with a single cruciate injury.
KD V.2	Fracture dislocation with both cruciate ligaments torn, collaterals/corners intact.
KD V.3	Fracture dislocation with both cruciate ligaments and one collateral/corner torn. Subset M (medial) or L (lateral)
KD V.4	Fracture dislocation with both cruciate ligaments and both collaterals/corners torn.
Abbreviations: ACL, anterior cruciate ligament; KD, knee dislocation; PCL, posterior cruciate ligament. ^aSubtypes may include: C, arterial injury; N, neurologic injury.