On-the-scene management: When an athlete’s knee is injured during play, the main objective of an exam on the field is to assess the gross neurovascular status of the leg, the stability of the knee, and any deformities that may indicate a fracture. Splinting is not necessary if the knee is stable. A more thorough evaluation and initial treatment of the injury can follow on the sidelines and in the locker room. Rapid swelling and suspected neurovascular injury are among the indications for immediate referral to an orthopedist.

The first minutes after an athlete sustains a knee injury can provide valuable information that is hard to obtain later. After 10-15 minutes, swelling, muscle spasm, and pain may become significant, and they increase overnight, making examination of the knee more and more difficult. Yet the athlete typically has to be removed from the field before being examined thoroughly.* The initial examination, then, is aimed primarily at determining how best to move the patient to a quieter spot for a more thorough examination and initial treatment of the injury.

* This discussion will consider knee injuries primarily in the context of football since that is a sport in which they are particularly common. The same principles can be applied to other sports as well, however.

This initial assessment focuses more on stability than on the location and degree of tenderness or pain because these factors can be misleading. Many major knee injuries do not cause pain until the next day. In addition, stability is particularly difficult to assess once the knee has begun to swell.

Before moving the athlete, check the neurologic function and vascular status of the leg, and palpate the knee to detect false motion or gross deformities. If the patient cannot fully extend the knee immediately following injury, he or she may have a displaced meniscal tear. Do not attempt to unlock a locked knee on the field. Stretcher transfer is not necessary in the absence of obvious fracture or deformity. Perform a brief, on-the-spot ligament exam when there is no obvious fracture.

The exam can be done quickly, using the Lachman test, a posterior drawer test at 90 degrees of flexion, and varus and valgus stress tests (see “Physical examination,’ page 36). For a quick evaluation of the collateral ligaments, apply valgus and varus stress to the knee. If you find excessive laxity in either direction, apply a splint to support the unstable joint. If you decide a stretcher is unnecessary, the athlete can hop off the field on the leg, letting the injured leg dangle, with a person on either side supporting him under the shoulders. Whether the knee is stable or unstable, no weight bearing is permitted until you do a more complete exam at the sidelines and later in the locker room.

As part of the sidelines evaluation, take a more detailed history and perform a more thorough exam with an eye to determining whether the athlete can return to play. Keep him out of the game if he:

Heard a “pop’ or felt the knee give way at the time of injury

Cannot bear weight on the leg

Cannot move the leg

Cannot run or change direction

Has an unstable knee, abnormal motion, or immediate swelling

Says the knee is painful

The locker room allows for a quiet evaluation, away from the scrutiny of coaches and other players. Proceed with a complete history and knee exam as you would in your office (see “Initial impressions in the office,’ right, and “Physical examination,’ page 36).

Immediate treatment at the sidelines or in the locker room involves compression, elevation, and application of ice. Wrap the knee with an elastic bandage (Ace), and apply ice immediately. These measures minimize bleeding and swelling within the joint. Use a knee immobilizer if you have one available. Splinting is necessary for very painful injuries and for unstable ligaments and fractures.

Rapid swelling of the knee–a definite sign of hemarthrosis–a locked knee, ligament instability, and suspected neurovascular injury all necessitate immediate referral to an orthopedic surgeon. Knee dislocation and multiple ligament injuries are often associated with damage to the popliteal artery, personeal nerve, or posterior tibial nerve. Do a more thorough evaluation of nerve function on the sidelines or in the locker room by checking motor control, sensation, and pedal pulses. Pulses usually stay normal for a few hours postinjury.

If you’re already experiencing back trouble you’ve got to take some additional measures. The most important one is to stop whatever you’re doing as soon as you feel pain. An acute back problem can easily become chronic. See your doctor if the pain is severe enough to affect normal activities or if it lasts more than three days.

Heat is sometimes helpful, but don’t leave heat sources in place for more than half an hour every two hours–any longer may cause an increase in lactic acid production, leaving muscles painful and stiff. Ice can break up muscle spasms. If you use ice, shield the skin from the icebag with a towel, and limit applications to half an hour.

But the key to maintaining a healthy back lies in an exercise routine such as the one described here. Some of the 10 exercises can even be done at work.

10 ways to a better back

These exercises will help your back feel better and strengthen your muscles so it will stay feeling good. Remember: The most important factor in an exercise program is consistency. You’re better off exercising for a short time each day than overdoing it one day and taking the rest of the week off.

Begin each period of exercise by relaxing. Take several slow deep breaths and loosen up. Exercise on a firm surface. Do each exercise slowly and smoothly, avoiding jerky movements. Begin by doing these exercises, adapted from those recommended by Riker Laboratories, Inc., twice a day, increasing the number of repetitions of each as you grow more comfortable with them. Above all, if you feel pain, stop. Try again later.

For the first four exercises, lie on your back with your knees bent and your hands clasped behind your neck. Your feet should be flat on the floor.

1 Press the small of your back against the floor while tightening your stomach and buttock muscles. This should rotate the bottom of your pelvis forward and flatten your back against the floor. Hold this position for five seconds, then relax.

2 Grasp one knee with both hands and pull it as close to your chest as you can. Then return that leg to its starting position and do the same thing with the other leg.

3 Grasp both knees and pull them as close to your chest as you can. Hold for three seconds. Then return your legs to the starting position, straighten them, take a deep breath, and relax.

4 Draw one knee to your chest then point that leg upward as far as you can. Return the leg to its starting position, relax, and do the same thing with the other leg. This exercise helps to stretch tight hamstring muscies. Caution: If you are experiencing sciatic pain associated with a hernlated disc, do not attempt this exercise.

5 Lie on your stomach with your hands clasped behind your back. Push your hands down toward your feet, thus pulling your shoulders back and pinching your shoulder blades together, and lift your head from the floor. Take a deep breath and hold it for two seconds, then relax.

6 Stand with your hands behind your back. Grasp the thumb of one hand with the other hand. Pull the thumb downwards toward the floor while you stand on your toes and stretch toward the celling. Repeat 10 times at two-hour intervals during the working day.

7 Stand with your back against a doorjamb and your heels four inches away from it. Press the small of your back against the door-Jamb, tightening you stomach and buttock muscies and bending your knees slightly. This should rotate your pelvis, straightening out your back, much as in the first exercise. Now press the back of your head against the doorjamb and straighten both your knees while pressing both hands against the opposite doorjamb. Hold for two seconds, then relax. Exercises eight through 10 should be attempted only after you’ve been doing the other exercises for several weeks. Do not do them if you are experiencing any back pain.

8 Lie on your back with your legs straight out and your arms at your sides. Raise one leg as high as you can; lower it to the floor as slowly as possible. Repeat five times for each leg.

9 Holding on to a chair or table, squat and, flexing your head forward, bounce up and down three times.

10 Lie on your back with knees bent and your feet flat on the floor. Pull up to a sitting position while keeping your knees bent (you’ll probably need someone to hold down your feet). Then lower yourself back down and relax.