Common Work Related

Injuries to the Knee

James Dettling, MD, FAAOS, FACS

1
 Introduction

• Knee injuries are one of the most common

orthopedic injuries in our society

• Knee injuries occur in people of all age groups,

lifestyles and activity levels

• Gender, race non-specific

2
 Introduction

• The knee is the largest and arguably one of the

most complex joints in the human body

• Knee injuries are the most frequent cause of

disability related to sports activity and one of the
most common causes of impairment in our
country’s workforce

3
 Introduction

The knee flexes and extends, allowing the body to

perform many activities, from walking and running
to climbing and squatting.
The
There are a variety of structures that surround the knee
and allow it to bend and that protect the knee joint from
injury.

4
 Introduction

• Whether a knee injury occurs on a playing field

or at a work site, traumatic disorders of the knee
occur because of external forces placed across/
through the knee

5
 Introduction

• Majority of knee injuries are minor and self-

limiting

• Devastating knee injuries do occur frequently

and can lead to significant morbidity, loss of
function and permanent impairment

6
 Introduction

• In the 1980’s the orthopedic community became

focused on injuries to the knee as a major cause
of disability in the athletic community

7
 Introduction

• In the past three decades major advances have

been made in all specialties in orthopedics,
particularly in regards to the knee

8
 Introduction

• Research in anatomy, biomechanics,

epidemiology, surgical techniques, non-surgical
treatments and rehabilitation protocols have led
to an explosive understanding of the knee joint.

9
 Introduction

• Over the past few decades the Anterior Cruciate

Ligament (ACL) has been studied as much as if
not more than any other orthopedic structure *

• Almost 5000 articles published in past 20 years

on this structure alone *

10
 Introduction

• With the advent of the arthroscope orthopedic

sports medicine physicians saw an opportunity to
utilize arthroscopy to identify, study and treat
knee injuries in athletes in a minimally invasive
manner to maximize functional outcomes and
minimize morbidity

11
Epidemiology

12
 Epidemiology

Knee injuries in the adult general population:

• 4/1000 community adults

• 46% women (older); Likely non-sports

related

• 54% men (younger); Likely sports related

13
 Epidemiology

Knee injuries in the adult general population:

• 37% knee injuries required orthopedic surgeon’s

care

• 12% required surgical care

14
 Classification of Knee Injuries:

Ligament injuries to the knee are the more common than any
other type of major knee pathology

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 Classification of Ligament Injuries:

ACL injuries are the most common ligament injured in the

knee.

> 200,000 ACL ruptures occur in the U.S. annually **

16
 Epidemiology
• The knee is the most commonly injured joint by adolescent
athletes with an estimated 2.5 million sports-related
injuries presenting to EDs annually.

• The most common diagnoses:

• strains and sprains (42.1%)

• contusions and abrasions (27.1%)
• lacerations and punctures (10.5%).

Acad Emerg Med. 2012 Apr;19(4):378-85

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Anatomy

18
 Anatomy

The knee is made up

of 4 main structures:

Bones
Ligaments
Tendons Diff

Cartilage

19
 Anatomy Femur

Patella

Bones
Tibia
Femur
Tibia
Patella (knee cap)

20
 Anatomy
ACL PCL

4 Major Ligaments MCL

LCL

Anterior Cruciate Ligament (ACL)

Posterior Cruciate Ligament (PCL)
Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)

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Anatomy
Quadricep

Tendons
Patellar
Quadricep
Patellar

22
 Anatomy
Hyaline

Meniscal
Cartilage

Articular (Hyaline)
Meniscal
Medial
Lateral

23
 Definitions
• Strain- muscle or tendon is overstretched or torn.

• Sprain- a stretching or tearing of a ligament

• Contusion- a region of injured tissue or skin in which blood capillaries have

been ruptured; a bruise

• Laceration- a deep cut or tear in skin or flesh

• Acute- injuries less than 3 months old

• Chronic- injuries more than 3 months old

• Ligament- structure that attaches a bone to a bone

• Tendon- structure that attaches a muscle to a bone

24
 Mechanism of Injury

Closely evaluating the mechanism of a reported

injury can often times delineate between industrial
and non-industrial disorders identified in the knee.

25
Mechanism of
Injury

Causation
An identifiable factor (ie;
accident) that results in a
medically identifiable
condition

26
Mechanism of Injury
Evaluating Causation:

• C4 Form (report of injury)

• Patient History

• 3rd party witnesses/Video

27
 Mechanism of
Injury

Causation

C4 Form

• Not a holy grail

• Often filled out while patient
under duress
• Patient not educated on
medical terminology
• Filled out by other party
present with patient
28
 Mechanism of
Injury

Causation
Patient history: critical to
identifying mech of injury
and determining causation

Witnesses/Video: when
available often play an
important role when an injury
is disputed

29
 Common Work
Related Knee Injuries

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 Common Knee Injuries
• Strains/Contusions

• Ligament injuries

• ACL, PCL, MCL, LCL

• Cartilage injuries

• Articular cartilage disorders

• Meniscal injuries

• Tendon injuries

• Quadricep & Patellar Tendons

• Fractures/Dislocations

31
Orthopedic Surgical Emergencies

Involving the Knee

These injuries require immediate surgical
intervention often within a finite time frame (ie; 4-6
hours after the injury) to prevent limb/life
threatening complications or sequelae

32
Orthopedic Surgical Emergencies
Involving the Knee

• Knee dislocation (tibio-femoral)

• Open knee joint (Penetrating trauma or

laceration into the joint itself)

• Open fracture

• Neuro-vascular injury

• Septic joint (infection within the joint space)

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Common Work Related Knee
Injuries

Typical Mechanism of Injury

Signs & Symptoms

Radiographic Evaluation

Treatment

34
 Ligament Injuries

Anterior Cruciate Ligament

Deficiency

Tear or loss of function of the ACL

35
 Anterior Cruciate Ligament
Deficiency
Mechanism of injury

• Caused by a deceleration/rotational force placed

through a knee

• Caused by an extreme hyperextension force

placed through a knee

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 Anterior Cruciate Ligament
Deficiency
Common Examples of Mechanism of Injury

• Twisting Knee Injury (High energy)

• Fall from a ladder or into a trench

• MVA

• High energy direct blow ( i.e.: clipping injury)

• Stepping into a hole

• Knee dislocation

• Penetrating trauma

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 Anterior Cruciate Ligament
Deficiency
Symptoms
• Pain

• Immediate Effusion

• Instability

• Mechanical Symptoms (popping, clicking, locking)

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 Anterior Cruciate Ligament
Deficiency
Clinical Signs
• Large effusion

• Limited range of motion, severe involuntary guarding

• Anterior Drawer, Lachman test, Pivot shift

**Immediate exam is best to diagnose an ACL injury. Delayed

exam may give equivocal findings.

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 Anterior
Cruciate
Ligament
Deficiency
Radiographic
Evaluation

• X-ray series
• MRI
• KT-1000 (objectively
evaluates laxity)
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Anterior Cruciate
Ligament
Deficiency
Treatment
• “RICE” (rest, ice,
compression, elevation)
• Rehabilitation
• Bracing
• Modification of
Activity
• Surgical Stabilization

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 Anterior Cruciate Ligament
Deficiency

Surgical Treatment

Numerous techniques for reconstruction

Numerous tissue choices for reconstruction

Surgical repair is not an option at this time

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43
 Anterior Cruciate Ligament
Deficiency
Surgical Treatment
Different patients require different methods of ACL
reconstruction (patient’s knee = patient’s
choice……w/guidance)

Various surgical techniques, methods of fixation, and

tissue/graft selection are within the standards of care

Surgeon must be ready, willing and able to utilize a

number of methods, tissues or fixation devices to
obtain best possible outcome

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 Ligament Injuries

Posterior Cruciate Ligament

Deficiency

Tear or loss of function of the PCL

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 Posterior Cruciate Ligament
Deficiency
Mechanism of Injury

• Caused by a significant posteriorly directed

force upon the front (anterior) aspect of the
knee (proximal tibia)

• Caused by a significant rotational force placed

upon the knee
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 Posterior Cruciate Ligament
Deficiency
Common examples of Mechanism of Injury

• MVA (dashboard injury)

• Fall from heights onto anterior aspect of knee

• SEVERE twisting knee injury

• High energy direct blow to knee (clipping injury)

• Knee dislocation

• Penetrating trauma
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 Posterior Cruciate Ligament
Deficiency
Symptoms
• Pain

• Immediate Effusion

• +/- Instability

• Mechanical Symptoms (popping, clicking,

locking)

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 Posterior Cruciate Ligament
Deficiency
Clinical Signs
• Large effusion

• Limited range of motion, involuntary guarding

• Posterior Drawer, Reverse Pivot shift

**Immediate exam is best to diagnose an ACL injury.

Delayed exam may give equivocal findings.
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 Posterior Cruciate
Ligament
Deficiency

Radiographic
Evaluation

• X-ray series
• MRI

50
 Posterior Cruciate Ligament
Deficiency
Treatment

** CONSERVATIVE**

• Rehabilitation

• Bracing

• Modification of Activity

Surgical Reconstruction
(rarely required)

51
Ligament Injuries

Medial Collateral Ligament

Deficiency

Tear or loss of function of the MCL

52
 Medial Collateral Ligament
Deficiency

Mechanism of Injury

Caused by a laterally directed force/load cross

the knee (from the outside of the knee).

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 Medial Collateral Ligament
Deficiency
Common Examples of Mechanism of Injury

• Direct blow to the knee from outside (lateral side)

…….clipping injury

• Fall from height

• MVA

• Knee dislocation

• Penetrating trauma

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 Medial Collateral Ligament
Deficiency
Symptoms

• Pain (localized to the medial aspect of knee)

• Instability

• Loss of range of motion, involuntary guarding

• Soft tissue Swelling ( not effusion)

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 Medial Collateral Ligament
Deficiency

Clinical Signs

• focal tenderness along medial femoral condyle

and/or joint line

• focal soft tissue swelling medially

• + valgus laxity of the knee

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 Medial
Collateral
Ligament
Deficiency
Radiographic
evaluation

• X-Ray series
• MRI

57
 Medial Collateral Ligament
Deficiency
Treatment
• Conservative , conservative,
conserative………
• Bracing full time 6-8 weeks

• Rehabilitation

• Surgical repair RARELY required!

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Ligament Injuries

Lateral Collateral Ligament

Deficiency

Tear or loss of function of the LCL

59
 Lateral Collateral Ligament
Deficiency

Mechanism of Injury

Caused by a medially directed force/load cross

the knee (from the inside of the knee)

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 Lateral Collateral Ligament
Deficiency
Common Examples of Mechanism of Injury

• Direct blow to the knee from inside (medial side) …….clipping

injury

• Fall from height

• MVA

• Knee dislocation

• Penetrating trauma

61
 Lateral Collateral Ligament
Deficiency
Symptoms

• Pain (localized to the lateral aspect of knee)

• Instability

• Loss of range of motion, involuntary guarding

• Soft tissue Swelling ( not effusion)

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 Lateral Collateral Ligament
Deficiency

Clinical Signs

• focal tenderness along lateral condyle and/or

joint line or the fibular head

• focal soft tissue swelling laterally

• + varus laxity of the knee

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 Lateral
Collateral
Ligament
Deficiency
Radiographic
Evaluation

• X-ray series
• MRI

64
 Lateral Collateral Ligament
Deficiency

Treatment
• Conservative (bracing, rehabilitation)

• low grade tears, sedentary patients

• Surgical reconstruction

• high grade tears, high level athletes

65
 Tendon Injuries
Quadricep tendon deficiency

Patellar tendon deficiency

Irritation, partial or complete tear or loss of

function of the Quadricep or Patellar tendon

66
 Quadricep/Patellar Tendon
Deficiency
Mechanism of Injury

The injury involves an awkward landing from a

jumping position where the quadriceps muscle is
contracting, but the knee is being forcefully
straightened. This is a so-called eccentric
contraction.

Eccentric load: An eccentric contraction is the motion of

an active muscle while it is lengthening under load.
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 Quadricep/Patellar Tendon
Deficiency
Common Examples of Mechanism of Injury

• An eccentric load placed across the knee

• Fall from height

• MVA

• Knee dislocation

• Penetrating trauma

68
 Quadricep/Patellar Tendon
Deficiency
Symptoms
• Immediate pain, snapping or popping sensation

• acute deformity about the knee

• weakness, inability to extend(straighten) knee

• instability

• inability to stand or walk

69
 Quadricep/Patellar Tendon
Deficiency
Clinical Signs
• Physical deformity

• weakness (knee extension) against gravity

• Soft tissue swelling/ effusion

• Palpable defect in the tendon

• bruising
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Quadricep/Pat
ellar Tendon
Deficiency
Radiographic
Evaluation
• X-Ray series
• MRI

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 Quadricep/Patellar Tendon
Deficiency
Treatment

• Surgical Treatment usually required

• 3-6 month recovery

• residual weakness may persist despite repair

• Conservative treatment (poor prognosis)

• medical issue prevent surgery

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 Cartilage Injuries

• Articular cartilage (Hyaline)

• Meniscal cartilage

73
 Meniscal Tears

Medial / Lateral meniscus

Tear of the meniscal cartilage in the medial or

lateral compartment of the knee

74
 Meniscal Tears

Mechanism of Injury
• Caused by a shearing or rotational force placed
through a knee that is loaded (weight bearing).

• Caused by a hyper flexion force placed through a

knee.

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 Meniscal Tears
Common examples of mechanism of injury

• Twisting injury to the knee (low energy)

• Squatting down

• getting up from a kneeling position

• MVA

• Penetrating trauma
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 Meniscal Tears
Symptoms

• Pain

• Mechanical symptoms

• popping, clicking, locking

• slow effusion

• instability
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 Meniscal Tears
Clinical Signs
• small effusion

• joint line tenderness to palpation

• + McMurray’s sign

• limited range of motion

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 Meniscal
Tears
Radiographic
evaluation

X-Ray series
MRI
MRI w GAD Arthrogram

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 Meniscal Tears
Treatment

• “RICE”

• Conservative

• Rehabilitation, NSAIDs, Modification of Activities, Brace

• Surgical intervention

• Arthroscopic debridement / repair

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81
Articular (Hyaline) Cartilage
Deficiency

Chondral defect

Osteochondral defect

Chondromalacia

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 Articular (Hyaline) Cartilage
Deficiency

Chondral / Osteochondral defects

Focal areas of articular damage with cartilage

damage and injury of the adjacent subchondral
bone.

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 Chondral / Osteochondral
Defect

Mechanism of Injury
• A direct or repetitive trauma with in a joint

• Often accompanies injuries associated with

twisting forces

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 Chondral / Osteochondral
Defect
Common examples of mechanism of injury

• Contact/collision sports

• Activity requiring a quick change of direction

• Blunt trauma

• MVA

• Fall from heights

• Penetrating trauma
85
 Chondral / Osteochondral
Defect
Symptoms
• Pain

• Effusion

• Increased pain with weight bearing

• Limited range of motion

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 Chondral / Osteochondral
Defect

Clinical Signs
• Effusion

• Limited range of motion

• Focal tenderness to palpation over joint line or

femoral condyle

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 Chondral /
Osteochondral
Defect
Radiographic
Evaluation

X-Ray series
MRI w GAD Arthrogram
CT Scan

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 Chondral / Osteochondral
Defect
Treatment

• Immobilization / Observation

• Surgical (Arthroscopic)

• Chondroplasty

• Microfracture/drilling

• Arthroscopic reduction & fixation

• Cartilage transplantation

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90
 Articular (Hyaline) Cartilage
Deficiency
Chondromalacia
Abnormal softening or degeneration of the cartilage in a joint,
especially the knee.

Chondromalacia is often seen as an overuse injury in sports and

work. In other cases, improper knee & muscle alignment is the
cause.

A progressive, degenerative process in older patients.

It is not felt to be a precursor to DJD when it occurs in the young.

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92
 Chondromalacia
Common etiology
• Trauma, especially a fracture (break) or dislocation of the kneecap
• An imbalance of the muscles around the knee (Some muscles are
weaker than others.)
• Overuse (repeated bending or twisting) of the knee joint, especially
during sports
• Poorly aligned muscles or bones near the knee joint
• Injury to a meniscus (C-shaped cartilage inside the knee joint)
• Rheumatoid arthritis or osteoarthritis
• An infection in the knee joint
• Repeated episodes of bleeding inside the knee joint
• Repeated injections of steroid drugs into the knee
Harvard Health Publication

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 Chondromalacia
Symptoms
• Dull ache/pain in front half of knee

• Effusion

• Grinding sensation

• Mechanical symptoms

• popping, catching, locking

• Instability

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 Chondromalacia
Clinical Signs
• Effusion

• Crepitation

• + patellar grind test

• loss of range of motion

95
 Chondromalacia
Treatment
• NSAID’s, Ice regimen

• Low impact exercise/strengthening program

• Bracing / taping techniques

• Avoid high impact activity, kneeling, squatting

• Arthroscopic chondroplasty (rare)

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Fractures & Dislocations
involving the Knee

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• Patella: accounts for 1% of all fractures, most common in
ages 20-50

• Femoral condyles: these usually fracture when the knee

is stressed.

• Tibial plateau: compressive fractures of the articular

surface, typically from extreme force such as fall from a
height or being hit by a vehicle, although in patients with
osteoporosis minimal force may be needed.

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99
Knee dislocation
This is a relatively rare injury resulting from dislocation between the femur
and tibia. It is a highly traumatic event which may be associated with
serious vascular injury. It often presents with multisystem trauma, and it is a
high-energy traumatic injury usually associated with road traffic accidents
and severe falls. It results in marked soft tissue damage.
A surgical emergency!!

Patellar dislocation
This is common, especially in young active individuals. Most dislocations
are lateral, and are accompanied by pain and swelling. Damage to the
medial ligaments is common. Dislocation may occur when the foot is
planted on the ground and a rapid change of direction or twisting occurs.
Usually pre-existing ligamentous laxity is present, and when patellar
dislocation has occurred once, it may recur owing to the consequent
ligament damage. Relocation to the patellar groove is often spontaneous as
the leg is straightened.[

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Knee dislocations are an
orthopedic
surgical emergency

101
 Treatment of a W/C Knee Injury
Primary Goals
• Treat an injured worker in the most
appropriate, cost effective, efficient manner

• Return a patient to their pre-injury level of

activity as soon as possible (maximize
functional outcomes)

• Minimize impairment (limit morbidity)

102
Treatment of a W/C Knee Injury

Maximal Medical Improvement (MMI)

When a condition is well stabilized and unlikely to change
substantially in the next year with or with out medical
treatment.

May or may not be a permanent impairment associated with

the injury

103
Treatment of a W/C Knee Injury

Treatment “Guidelines”
ODG

ACOM

Presley Reed Disability Guidelines

104
Treatment of a W/C Knee Injury

W/C guidelines are NOT Standard of Care or

based on Evidenced Based Medicine for the
treatment of specific orthopedic injuries.

105
 Impairment Ratings
Different ways of measuring impairment

Anatomic loss - damage to an organ or body structure

Functional loss - change in the function of the organ or

body structure (range of motion, strength, stability)

Diagnosis Based Estimate - impairment based on

diagnosis rather than on physical findings

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 Impairment Rating
Table 17-10 Knee Impairment
Whole Person (lower extremity) Impairment (%)

Motion Mild Moderate Severe

4% (10%) 8% (20%) 14% (35%)

Flexion < 110 deg < 80 deg < 60 deg

Extension 5-9 deg 10-19 deg > 20 deg

AMA Guides 5th Edition

107
 Functional Targets
Critical objective measurements obtained to
maximize functional outcome and minimize
impairment ratings

range of motion

strength

stability

108
 Functional Targets

Example of functional target utilization

in the overall outcome & rating process.

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 Example Rating
General Assumptions
Median Annual Income Las Vegas, 2006

$35,000

(~$730/week)

66.6% = $480/week

Physical Therapy cost/visit = ~$100

110
 Example Rating
• 25 y.o male underwent an uncomplicated ACL
reconstruction ~12 weeks ago.

• ~12 weeks (33-36 visits) of P.T. to date. His R.O.M. is

progressing albeit slowly

• Current R.O.M.; -7 to 105 degrees

current rating

4%WP (-7 ext) + 4%WP (105 flexion) = 8% WP

PPD Award = $25,935

111
 Example Rating
2 additional weeks PT (6 visits x $100/visit)

2 additional weeks of modified work ($480 x 2)

Additional cost of 2 weeks care

($480 x 2) + ($100 x 6) = $1560

Functional Target knee: (-4 ext, 110 flexion)

Pt’s range of motion improves to -4 to 112 degrees

112
 Example Rating

loss of function no longer applies to this patient’s

rating. Reverts back to a diagnosis based estimate,
which is typically 3% WP rating.

PPD award = ~ $9,725

113
 Example Rating

Total Savings
$25,935 (original PPD award) - $9,725 (PPD
award after 6 additional PT) - $1,560 (additional
costs of treatment = $14,650 savings

114
 Functional Targets

Physicians responsible for the care of W/C

patients must know, understand and strive for
the functional targets of the knee.

Being able to communicate with a “peer”

during “peer reviews” when discussing a
patient’s care that is falling outside of the W/C
“guidelines” is critical.

115
 Conclusion
The knee is an amazing structure, but it must
observe the laws of physics (biomechanics)
to maintain it’s integrity….. just like a bridge
or skyscraper.

When abnormal or excessive forces (loads)

overcome a specific structure within the
knee a traumatic injury (failure) occurs.

116
 Conclusion

A basic understanding of the actual

mechanisms of injury (forces) that can (cannot)
cause a specific structure in the knee to fail can
help determine if a specific accident/event
caused a medically identified injury,
(causation).

117
 Conclusion

Ultimately, the goal in treatment of an injured

knee structure is to restore functional stability,
strength and motion to that knee.

This maximizes functional outcome for the

patient, minimizes their impairment.

118
 Conclusion

Allowing treatment to continue @ times longer

than the suggested “guidelines” may benefit
the patient, insurance company and employer
by achieving functional targets, hence
increasing the functional outcome of a patient
and decreasing the impairment/ impairment
rating/PPD award.

119
 Conclusion

Each knee injury requires a multi-faceted

approach when striving to return patient to a
pre-injury level or to maximize their functional
outcome.

Physician, patient and 3rd party payer must

partner and communicate with each other to
achieve a functional outcome.

120
 Conclusion
For the most appropriate, efficient and cost effective
treatment of an injured worker, treating physicians and
decision makers must familiarize themselves with functional
targets when making critical treatment decisions.

Rigidity when working with the “guidelines” is not in the

best interest of any party or individual involved.

Last Slide!!!!!!

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Thank You!!!!!!

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