eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Knee Injury, Soft Tissue: Follow-up

Author: David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Coauthor(s): Howard I Dickey-White, MD, Teaching Attending Physician, Department of Internal Medicine, St Elizabeth Hospital Medical Center; June E Sanson CNRP, MSN, Nurse Practitioner, Take Care Health Systems
Contributor Information and Disclosures

Updated: Dec 15, 2009

Follow-up

Further Inpatient Care

• Consequential soft-tissue damage of the knee with concurrent serious disorder, such as vascular compromise, threatening compartment syndrome, or multiple trauma, warrants admission to the appropriate surgical or orthopedic service for monitoring and potential surgical intervention.
• Injuries requiring timely surgery, such as knee dislocation, complete quadriceps tendon rupture, open knee joint injuries, and total patellar tendon rupture, may necessitate admission to the general orthopedic service.

Further Outpatient Care

• The type and degree of injury dictate the timing and specifics of follow-up care. Arrange checkups, preferably within 24 hours, for any patient sustaining soft-tissue injury of the knee in which (1) muscle spasm precludes adequate knee assessment, (2) the mechanism of injury suggests a more serious injury, or (3) the patient perceives a snap or pop at the time of the incident and a hemarthrosis evolves.
• Promote RICE therapy for mild to moderately severe strains and/or sprains.
  • R - Rest (crutch ambulation without weight bearing for initial 24-48 h)
  • I - Ice (application of ice on injured region for 20 min of each waking hour during the initial 48 h after injury)
  • C - Compression (with knee brace or splint, if necessary)
  • E - Elevation (above the level of the heart)
• After pain and inflammation subside, the goal of the second phase is to regain strength and pain-free range of motion (ROM). Arrangements for physical therapy can be made after reassessment in the next 3-5 days.
• When the diagnosis remains in doubt, the orthopedic consultant usually decides on the necessity for arthroscopy or MRI to clarify the diagnoses.

Transfer

• Patients with soft-tissue knee injuries complicated by vascular impairment or additional confounding trauma may require transfer to a facility capable of evaluating and treating such injuries.

Deterrence/Prevention

• Prophylactic bracing with a knee immobilizer may prevent further injury.
• Conditioning programs strengthen surrounding supporting structures.

Complications

• Specific dislocations and fractures predispose the knee to popliteal artery and/or peroneal nerve damage.
• Significant soft-tissue injuries of the knee and lower leg put the lower leg at risk for compartment syndrome.
• Knee joint instability may follow unrecognized ligament damage.
• Complications of anterior cruciate ligament (ACL) injuries include abnormal knee motion, which eventually causes major degenerative changes in the knee joint.
• Recurrent locking, damage to the articular cartilage, and ensuing arthritis may follow missed meniscal injuries.
• Infection may arise from abrasions, lacerations, aspiration, or injection of the knee. If unrecognized, knee joint destruction results.
• Spontaneous rupture of tendons may follow use of intra-articular steroids.

Prognosis

• Sprains
  • Most grade I or II collateral ligament sprains heal uneventfully after a 4- to 6-week course of conservative therapy; however, patients may have chronic pain and a tendency for recurrent injury.
  • Grade III collateral sprains invariably give rise to tears of the posterior capsule, and patients frequently require bracing and physical therapy for 3 months or longer before returning to unrestricted activity.
• Outlook for ACL injuries depends on numerous factors, including extent of the lesion, age, activity level desired, and presence of coexistent injuries.
• A high rate of recurrence follows simple aspiration of a Baker cyst, while these cysts reappear less than 5% of cases after surgical correction.
• Infection and chronic weakness of the extensor apparatus may follow surgical repair.
• Development of recurrent locking, popping, or effusions subsequent to an adequate trial of conservative therapy for meniscal tears may suggest the need for surgical intervention.

Patient Education

• Failure to respond to conservative treatment may indicate a missed or overlooked diagnosis, such as complicated ligamentous or meniscal damage.
• Follow-up care is essential. Inadequate treatment may result in chronic instability and/or degenerative joint disease. Concurrent collateral ligament injuries and meniscal tears are often difficult to diagnose; this situation increases the importance of follow-up care.
• Physical therapy is focused on quadriceps strengthening and extensor stretching, in conjunction with ultrasound modalities and phonophoresis.
• After the immediate problems are under control in patients recovering from a patellar subluxation or dislocation, focus further therapy on quadriceps strengthening and use of a patellar cutout brace.
• For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Breaks, Fractures, and Dislocations Center, Arthritis Center, and Bone Health Center. Also, see eMedicine's patient education articles, Knee Pain, Knee Injury, Sprains and Strains, and Knee Dislocation.

Miscellaneous

Medicolegal Pitfalls

• Do not automatically focus on the knee if the patient is complaining of knee pain. Hip pathology and disorders of other anatomic sites may masquerade as knee problems, especially in the elderly and in children.
• Although major injuries to the knee often make weight bearing unattainable, the ability to walk does not exclude serious internal derangement; the absence of joint effusion does not rule out clinically significant internal damage.
• Severe pain, muscle spasm, or expansion of an effusion may mask knee joint instability.
• Do not neglect to test the patient for active knee extension. About one half of quadriceps tendon ruptures are initially misdiagnosed. Delayed diagnosis of extensor apparatus disruption may lead to contracture of the affected muscles, impairing the ability for later surgical repair of the lesion.
• Failure to properly diagnose or adequately treat a meniscal tear may result in chronic osteoarthritis in the knee joint.
• Intra-articular corticosteroid injections may produce spontaneous rupture of tendons.
• Document findings on neuromuscular evaluation, including verification of full function of the extensor apparatus.
  • Record observations that excluded obvious dislocations and fractures.
  • Record results of valgus and varus stress testing and the Lachman maneuver.

Special Concerns

• Pregnancy
  • Knee problems, especially underlying meniscal and patellar problems, may worsen with pregnancy because of changes in the biomechanics of weight bearing and shifting in the center of gravity with fetal development.
  • Production of relaxin hormone during pregnancy may modify ligaments of the knee, in addition to those of the pelvis, increasing knee laxity.
  • Radiography in pregnancy is always a concern. Although some risk is associated with obtaining diagnostic radiographs in pregnancy, animal and human data do not reveal an increased risk to the fetus when fetal exposure is limited. After 20 weeks' gestation, the risk of radiation exposure that might cause fetal abnormalities is remote; however, avoid unessential radiography. If radiographs are deemed indispensable, shield the patient's abdomen.
• Pediatric cases
  • In any child with a traumatic injury, be alert to the possibility of child abuse.
  • Children with hip disorders, especially a slipped capital femoral epiphysis and Legg-Calvé-Perthes disease, may have referred pain to the knee. Ligamentous damage, meniscal damage, and dislocations (with the exception of patellar dislocations) are rare in children.
  • Children with open epiphyseal plates may have injuries that can be mistaken for soft-tissue injuries.
  • The missing of growth-plate injuries in children may result in deformity and growth irregularities. If the patient has circumferential tenderness about the lower part of the femur or the proximal tibia, treat it as a Salter-Harris growth-plate injury, even if radiography findings are normal.
  • Impetuous stress testing of the knee joint may induce additional damage, displacing a fracture or worsening a growth-plate disturbance.
  • A completely displaced epiphyseal fracture of the distal femur is the pediatric equivalent of adult knee dislocation. This injury may also harm the popliteal artery.
  • Osteochondritis dissecans, an intra-articular disorder of unclear etiology, is most common in boys during late childhood or in male adolescents. The condition is characterized by degeneration and recalcification of the articular cartilage and underlying bone. Patients tend to report vague, poorly localized knee pain, as well as morning stiffness or recurrent effusions. Osteochondritic lesions can be radiographically occult, and CT, bone scanning, or MRI may be required to make the diagnosis.
  • Although not strictly a disease, Osgood-Schlatter disease probably originates from microtrauma, leading to apophysitis at the insertion of the patellar tendon into the tibial tubercle.
    • Complaints of knee pain generally start in energetic children aged 9-15 years, a time of rapid growth.
    • Discomfort tends to be localized, and palpation reveals swelling and tenderness over the tibial tubercle.
    • Boys are affected more commonly than girls; activity exacerbates pain, and bilateral involvement occurs in about 30% of patients.
    • Initial treatment is conservative, with activity limited to the patient's tolerance.
• Geriatric cases
  • Rupture of the extensor mechanism may precede trivial trauma in the elderly, especially in individuals with coexisting disorders, such as renal failure, systemic lupus erythematosus, hyperparathyroidism, or diabetes mellitus.
  • Because of underlying degenerative disease, meniscal tears may emerge in older patients with a history of minimal or no trauma. For example, simply rising from a squatting position may cause a tear.
  • Discomfort and distention related to the knee after a fall may arise from a fracture of the tibial plateau, especially the lateral plateau.
  • Osteoporosis, commonly in elderly persons, makes bones more vulnerable to fracture. Visualization of fractures on plain images is difficult, and fractures may be overlooked easily. Misdiagnosing this fracture as a soft-tissue injury may lead to additional morbidity, as fracture fragments may be displaced.

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