• Acute care of the injury involves the principles of PRICE ⁶ for several days after the injury—protection, rest, ice, compression and elevation of the affected area.

• Ice (wrapped in a cloth or a towel; do not apply ice directly to the skin)—reduces pain, bleeding and inflammation.

• Analgesia may be required, particularly for more severe injuries.

• Short-term walking cast immobilisation may be necessary, particularly in severe grades of tears or where there is an associated avulsion fracture ⁷; followed by functional bracing.

• Taping—the use of an elastic bandage has fewer complications than taping (especially skin irritation), but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support.⁸

• Proprioceptive balance training ¹¹ in pre-season preparation and in-season training programs. This may be taught to individuals by a sports physiotherapist.

• Avoid over-training fatigued muscles.

KNEE INJURIES

Knee injuries are common in many sports, with surgical procedures performed on the knee joint more commonly than on virtually any other structure in the body. The combination of increasing average life expectancy and increasing body mass index means that most of the population will suffer from a knee complaint at some time during their life.

Although knee MRI is more sensitive than clinical examination for certain conditions, because the knee is an accessible peripheral joint it is generally possible for an experienced clinician to make an accurate diagnosis of many knee injuries using history and clinical examination. For a GP assessing a knee injury it is most important to recognise the diagnostic possibilities from the history (Table 44.1) and to be aware of which clinical diagnoses can be made without the need for imaging or specialist assessment.

TABLE 44.1 Diagnosing the major knee injuries (clinical and imaging)

Diagnosis	Clinical diagnosis	Investigations
Anterior cruciate ligament (ACL) tear	History of suddenly giving way. Experienced examiners can confirm with Lachman’s and pivot shift tests in most cases	MRI useful for high-level athletes with haemarthrosis when early diagnosis is required
Posterior cruciate ligament tear	Contact injury to the ground (on a flexed knee) or clash of knees (AFL ruckmen). Positive posterior drawer	Usually not necessary
Medial collateral ligament tear	Contact valgus injury, increased valgus stress	Usually not necessary
Tibio-fibular sprains/posterolateral complex injuries	Generally hyperextension mechanism (rare injury)	MRI to assess severity and whether surgery may be required (only required in severe cases)
Meniscal tears	Combination of medial or lateral pain and joint-line tenderness, mechanical symptoms, effusion and positive McMurray’s test	MRI scanning useful for confirming that surgery is indicated
Articular cartilage injuries	Knee effusion and history of locking or catching may indicate a significant lesion	X-ray to assess overall state of knee degeneration. MRI for pinpointing specific lesions, but X-ray is more likely than MRI to alter management
Knee inflammatory or infective conditions	Knee effusion, pain, fever, no history of trauma (or history of invasive procedure, e.g. injection or arthroscopy)	X-ray and pathology tests indicated (FBC, ESR, C-reactive protein, uric acid)
Patellar tendinopathy (or Osgood-Schlatter syndrome in adolescents)	History of sporting activity, gradual onset of pain, tenderness at either end of the patellar tendon	Ultrasound or MRI may assist with prognosis but do not generally alter management. Use X-ray instead in adolescents
Patellar tendon rupture	Sudden-onset injury, inability to support weight	Investigations indicated before surgery (ultrasound or MRI)
Hamstring insertional tendinopathy	Tenderness on medial side below joint line	Usually not necessary
Iliotibial band syndrome	History of running (or cycling), pain on slow running. Tenderness on lateral side above joint line	Usually not necessary
Patellofemoral pain	Pain with the knee bent (sitting or squatting)	Usually not necessary
Prepatellar bursitis	History of kneeling or landing on kneecap. Swelling cannot be balloted underneath the patella	Usually not necessary
Patellofemoral instability	Patellofemoral apprehension, history of dislocations	X-ray (with skyline view of patellofemoral joint) helpful

Clinical diagnosis of some injuries such as those to the anterior cruciate ligament (ACL) can be difficult for examiners who lack regular exposure to managing such injuries. However, a GP with a special interest in sports injuries and who is confident with using the Lachman (Fig 44.1) and pivot shift tests can often make this diagnosis. It is equally appropriate, when this diagnosis is suspected, to refer for MRI or specialist assessment when the diagnosis is in doubt. Although modern radiological techniques such as MRI can assist in the diagnosis of knee injuries, there is a tendency for overuse of investigations in cases where the diagnosis can be clearly established using clinical examination alone.⁵ It is important to remember that a high incidence of abnormality in normal asymptomatic knees is detected on knee MRI.¹² In general the attitude towards investigation of knee injuries should fall somewhere between the potential mismanagement in an emergency department when a normal knee X-ray is used to declare that the injury is ‘minor’, and the modern (equally inappropriate) tendency to use MRI scanning to confirm every clinical diagnosis.