1 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
1.Describe the management of an acute on-field knee injury.
2.Determine the need for immediate medical attention of a patient with an acute on-field knee injury.
3.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. 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?
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 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:...
