Knee Sports Med

The knee is the largest joint in the body consisting of four bones, multiple ligaments and muscles, which act as shock absorbers during movement. Several large fibrous bands of tissue, called ligaments, support the knee on both sides. They provide strength and stability to the joint. The four ligaments that connect the thighbone (femur) and shinbone (tibia) are the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL). The ACL and PCL limit tibial movement forward and backward and also limit flexion and extension of the knee. The MCL and LCL provide stability to the inside and outside of the knee.

Contact sports or high-impact activities that feature rapid, twisting movements can place extreme forces on the knee, which can lead to injury.

Sports Knee Injuries

The knee is the largest joint in your body and it is susceptible to injury. Because the knee is a complex joint, made up of many parts, there are numerous things that can go wrong. Knee damage is commonly caused by injuries to the joint.

Common Types of Sports Knee Injuries
  • ACL Tear
  • PCL Tear
  • MCL & LCL Tear
  • Meniscus Tear
  • Cartilage Damage

Anterior Cruciate Ligament (ACL) Tear


The Anterior Cruciate Ligament (ACL) is one of the four main ligaments in the knee. The ligament connects the thigh bone to the shin bone, keeps the knee from hyper extending, prevents anterior dislocation at the tibia, and stabilizes to help prevent unnatural movement in the joint. If the knee is twisted, bent side to side, or hyper extended during physical activity the ACL can be injured. Contact sports involving rapid twisting movements may place harsh force on the knee, which can lead to injury.

There are several different types of ACL tears: a partial tear of the ligament, a complete tear of the ligament, also known as a rupture, and rarely the very end of the ligament remains attached to a small piece of bone which breaks or separates from the lower leg bone which is known as an avulsion. Many patients who sustain an ACL tear may opt to have surgical reconstruction of the ligament, which is most commonly performed arthroscopically.

Symptoms of a torn ACL will usually begin with swelling of the knee immediately after injury or within 24 hours. An ACL tear may cause a loud popping or cracking sound at the time of the injury. There may be some pain at the time of the impact, which over time may be felt in the calf region. The patient may feel some instability of the joint, perhaps creating the feeling of the knee “giving way.”

Posterior Cruciate Ligament (PCL) Tear

A PCL injury is a less common occurrence than that of an ACL injury. This is due to the thickness and strength of the PCL. However, the most common way in which the PCL is injured is by direct force to the front of the knee, when it is bent. The PCL can also be injured by a direct blow to the outside of the knee joint, such as those that occur during soccer or football.

Symptoms of a PCL tear can vary depending on the instability in the knee. Patients usually see swelling in the back of the knee and bruising 24 to 36 hours after the injury occurred. The other major symptoms of a PCL tear include pain, excessive swelling and chronic instability.

Medial Collateral Ligament (MCL) & Lateral Collateral Ligament (LCL) Tear

The MCL connects the femur and tibia on the inner side of the leg and resists forces acting on the outer side of the knee. The LCL connects the femur and tibia on the outside of the leg and resists forces acting on the inner side of the knee. The two ligaments create support and stability for the knee. The MCL is more often injured than the LCL as injuries are often caused by a blow to the outer side of the knee, usually seen in contact sports, that stretches/tears the ligaments on the inner side of the knee. Symptoms of MCL and LCL tears often include pain, stiffness, swelling and tenderness along the inner or outer side of the knee.

Meniscus Tear

A torn meniscus usually occurs when the knee is rotating while it is bearing weight. This type of injury often occurs in field sports such as soccer and football.

An injured or torn meniscus causes mild to severe pain depending upon the position of the leg and the extent of the tear. Swelling is common at the time of injury, but can develop much later. Many times, an injury to the meniscus causes a pop sound, or the knee may lock, or feel weak.

Cartilage Damage

Cartilage acts like a natural shock absorber, preventing both bone on bone contact and providing a smooth, pain-free surface for the bones to glide against. Because cartilage does not have a blood supply to help repair damage, it may not heal quickly or at all. One of the most common and serious types of damage is to the articular cartilage that is between joints.

Symptoms of this articular cartilage damage include swelling, joint pain, stiffness, decreased range of movement and joints that lock or catch.

Anterior Cruciate Ligament (ACL) Tear


The Anterior Cruciate Ligament (ACL) is one of the four main ligaments in the knee. The ligament connects the thigh bone to the shin bone, keeps the knee from hyper extending, prevents anterior dislocation at the tibia, and stabilizes to help prevent unnatural movement in the joint. If the knee is twisted, bent side to side, or hyper extended during physical activity the ACL can be injured. Contact sports involving rapid twisting movements may place harsh force on the knee, which can lead to injury.

There are several different types of ACL tears: a partial tear of the ligament, a complete tear of the ligament, also known as a rupture, and rarely the very end of the ligament remains attached to a small piece of bone which breaks or separates from the lower leg bone which is known as an avulsion. Many patients who sustain an ACL tear may opt to have surgical reconstruction of the ligament, which is most commonly performed arthroscopically.

Symptoms of a torn ACL will usually begin with swelling of the knee immediately after injury or within 24 hours. An ACL tear may cause a loud popping or cracking sound at the time of the injury. There may be some pain at the time of the impact, which over time may be felt in the calf region. The patient may feel some instability of the joint, perhaps creating the feeling of the knee “giving way.”

Posterior Cruciate Ligament (PCL) Tear

A PCL injury is a less common occurrence than that of an ACL injury. This is due to the thickness and strength of the PCL. However, the most common way in which the PCL is injured is by direct force to the front of the knee, when it is bent. The PCL can also be injured by a direct blow to the outside of the knee joint, such as those that occur during soccer or football.

Symptoms of a PCL tear can vary depending on the instability in the knee. Patients usually see swelling in the back on the knee and bruising 24 to 36 hours after the injury occurred. The other major symptoms of a PCL tear include pain, excessive swelling and chronic instability.

Medial Collateral Ligament (MCL) & Lateral Collateral Ligament (LCL) Tear

The MCL connects the femur and tibia on the inner side of the leg and resists forces acting on the outer side of the knee. The LCL connects the femur and tibia on the outside of the leg and resists forces acting on the inner side of the knee. The two ligaments create support and stability for the knee. The MCL is more often injured than the LCL as injuries are often caused by a blow to the outer side of the knee, usually seen in contact sports, that stretches/tears the ligaments on the inner side of the knee.

Symptoms of MCL and LCL tears often include pain, stiffness, swelling and tenderness along the inner or outer side of the knee.

The menisci are small, semi-circular pieces of cartilage that act as a cushion in the knee. The knee has both an inner and outer meniscus. Treatment varies depending upon the extent and location of the tear; however, a large meniscus tear that causes pain or limits knee function may require arthroscopic surgery for repair. Surgeons often refer to this as “debriding” or “smoothing over” the tear.

Procedure

Arthroscopic surgery avoids long, invasive incisions by using an arthroscope, a small tube-like instrument that allows the surgeon to see inside the joint. The arthroscope is inserted into the joint through a short incision generally less than 1/4″ – 1/2″. Several small incisions may be made to see other parts of the joint or to insert instruments. The arthroscope uses a camera that projects the image of the joint onto a monitor. The surgeon is able to view the joint, and its structures, including cartilage, ligaments and surrounding tissue. Once the problem is identified, the surgeon may be able to use specially designed instruments and/or implantable fixation devices to repair conditions or remove any damaged bone or tissue.

Complications

Few complications are to be expected with arthroscopy surgery. Those that may occur are infection, blood clot formation, swelling or bleeding, damage to blood vessels or nerves, failure to improve symptoms and breakage or migration of implants.

Recovery

Arthroscopic surgery rarely takes more than an hour or two for isolated injuries. Most patients who have arthroscopic surgery are discharged within the same day. The small skin incision wounds take several days to heal. Several follow-up appointments may be necessary. Typically, during the first of these, the physician removes the sutures, tape or stitches. The patient can usually resume daily activities within a few days, but the injury may require several weeks to months to fully recover.

Cartilage Damage

Cartilage acts like a natural shock absorber, preventing both bone on bone contact and providing a smooth, pain-free surface for the bones to glide against. Because cartilage does not have a blood supply to help repair damage, it may not heal quickly or at all. One of the most common and serious types of damage is to the articular cartilage that is between joints.

Symptoms of this articular cartilage damage include swelling, joint pain, stiffness, decreased range of movement and joints that lock or catch.

Non-Surgical Treatment

Treatment for knee injuries depends on the severity of the injury. The patient’s activity level and overall health are also important factors to consider before treatment begins.

Depending on the activity level of the patient, most knee tears are treated with physical therapy, which helps build strength and increase flexibility in the knee. Physical therapy usually lasts a few weeks, at which time most patients return to normal activities.

Treatment may include RICE (rest, ice, compression and elevation) muscle-strengthening exercises, and a protective knee brace.

Recovery

Rehabilitation therapy is the key to recovery from most knee injuries. Physical therapy will concentrate on bending and stretching exercises to increase range of motion, flexibility, and strength in the knee. While the knee may feel tight and slightly painful, it is important to keep the joint moving in order to promote healing and to maintain flexibility. Strength building exercises are very important to improve joint stability, and to reduce stress on the ligaments.

Arthroscopic Surgery for the Knee

If the ligament is a complete tear or the patient is physically active, then the surgeon may suggest a complete reconstruction of the ligament in order to prevent further damage and stabilize the knee.

Arthroscopic surgery may be performed. Surgery may involve reconstruction of the damaged ligament using a strip of tendon from the patient’s knee (patellar tendon) or hamstring muscle. A cadaver graft or allograft can also be used. The surgeon may determine to secure the new ligament with an implantable fixation device. A physical therapy program will usually follow the surgery in order to strengthen the muscles and restore full joint mobility.

Arthroscopy is a technique that allows surgeons to visualize, diagnose and treat a variety of joint problems. Ligament tears, meniscal tears, damaged and loose cartilage, and many other conditions can all be treated arthroscopically. Arthroscopy is performed using an arthroscope, a small optic instrument that enables a close look at the inside of a joint through a small skin incision.

Arthroscopic surgery was developed as a way to avoid making long skin incisions. While the long incisions allowed surgeons to fully visualize the joint, the subsequent disruption of tissue created long healing times, increased risk of infection and resulted in long scars.

Recovery

Arthroscopic surgery rarely takes more than an hour or two for isolated injuries. Most patients who have arthroscopic surgery are discharged within the same day. The small skin incision wounds take several days to heal. Several follow-up appointments may be necessary. Typically, during the first of these, the physician removes the sutures, tape or stitches. The patient can usually resume daily activities within a few days, but the injury may require several weeks to months to fully recover.

People use their knee ligaments during many different activities. However, when one of those ligaments is injured or torn, it may affect how well a person can perform those activities. Unlike arthritis, which can progress over time, a person may feel the affects of a torn ligament immediately and an activity may become more difficult or even impossible to perform.

The Knee

The ACL (Anterior Cruciate Ligament) is one of the four main ligaments in the knee. The ligament connects the thigh bone (femur) to the shin bone (tibia), keeping the knee from hyperextending, preventing anterior dislocation at the tibia, providing rotational stability and support to help prevent unnatural movement in the joint. If the knee is twisted, bent side to side, or hyperextended, the ACL can be injured.

Contact sports or high-impact activities involving rapid twisting movements may place extreme forces on the knee, which can lead to injury. Basketball, football, soccer, baseball, tennis, and skiing are common activities that can lead to a tear or rupture of an ACL. However, ACL injuries can also occur in older adults as the ACL becomes weaker with age. Simple activities such as missing a step on a staircase, stepping in a hole, or falling can cause ACL tears.

ACL Injuries

When the ACL tears, the person often describes hearing a pop and feeling the knee “giving out” or buckling. A torn ACL often results in swelling and a loss of stability in the knee, sometimes referred to as “feeling loose.”

There are several different types of ACL tears: a partial tear of the ligament, a complete tear of the ligament (rupture), and rarely the very end of the ligament remains attached to a small piece of bone which breaks or separates from the lower leg bone (avulsion).

Treatment Options

Treatment for ACL injuries depends on the severity of the tear and whether other parts of the knee are injured. The patient’s activity level and overall health are also considered before treatment begins.

Depending on the activity level of the patient, minor ACL tears are usually treated with physical rehabilitation, which will help build strength and increase flexibility in the knee. Rehabilitation normally lasts a few weeks, at which time most patients return to normal activities.

Complete ACL tears, called ruptures, normally require ACL Reconstruction surgery followed by several months to a year of rehabilitation. ACL Reconstruction is the most common form of treatment for patients who require the use of a stable knee for athletic sports, walking, or other low-impact activities.

It is important to get a timely diagnosis of an ACL injury to avoid potentially damaging the knee further. Typically, surgery may be delayed until several weeks after the injury. The delay allows swelling to subside and enables the injured knee to regain some strength, stability, and range of motion. Delaying the surgery also decreases the risk of permanent stiffness or decreased motion following surgery.

Procedure

There are several options available when treating an ACL injury. The most common treatment is to replace your native ACL with a new ligament. Typically, the new ligament material (graft) can be taken from one of the patient’s own tendons (autograft), or the graft can be taken from a tendon in the knee of a tissue donor (allograft). You and your doctor will decide which option is best for your particular situation.

ACL Reconstruction is usually performed as an outpatient procedure and rarely requires an overnight stay in the hospital. The entire procedure requires approximately 1-2 hours to complete and is typically performed under general anesthesia, spinal or epidural.

ACL Reconstruction is most often performed arthroscopically. Arthroscopy is a surgical technique that uses long tube-like scopes that are inserted into the body through very small incisions. These scopes display the inside of your knee joint on a monitor, allowing the surgeon to precisely manipulate the surgical instruments. The benefits of arthroscopic surgery are a shorter recovery period, smaller incisions (one-quarter to one-half inch in length), minimal scarring, and less potential for infection.

The ACL Reconstruction procedure creates tunnels in the thigh bone (femur) and the shin bone (tibia) to make a path for the new graft (tendon). One of the most common graft used is the semi-tendonosis/gracilis graft. This graft is taken from a portion of the muscles in the thigh. The graft is passed through specially designed instruments into the tunnels and fixed inside the tunnels. The new graft is fixed inside the tunnels with screws, buttons, pins, or similar devices. Some of those devices are made out of materials that resorb or dissolve with time and are replaced with bone by the body. The graft crosses the joint in the position as the original ACL after it is fixed with these devices. The small incisions are then closed and a knee compression bandage is applied. Some surgeons prefer to use a long leg brace postoperatively.

Complications

Few complications are to be expected with knee surgery. Those that may occur are infection, blood clot formation, swelling or bleeding, damage to blood vessels or nerves, failure to improve symptoms and breakage or migration of implants.

Rehabilitation

As you and the doctor may have discussed before surgery, extensive rehabilitation is the key to your recovery from ACL reconstruction. Recovery normally requires 5 to 6 months or until the graft is transformed by soft tissue healing into a strong and durable ligament. This can require the better part of one year. If the graft is ruptured or stretched drastically during the recovery, a second surgery will be required.

Your physical therapy for the first three weeks after surgery will concentrate on bending and stretching exercises to increase active range of motion, flexibility, and strength in your knee. While your knee may feel tight and slightly painful, it is important to keep your joint moving to promote healing and to maintain flexibility.

After the first three to four weeks, your physical therapy will concentrate on resistive type strength building exercises (such as cycling or swimming), which are low impact and less harmful to perform. Strength building exercises are extremely important to recover lost muscle mass due to surgery but also to improve joint stability, reducing stress on the ligaments.

Following surgery you may be using crutches as needed for the first few weeks. Crutches are usually not necessary once the knee is comfortable enough to walk. Your surgeon will evaluate your progress and advise you on when you may discontinue using the crutches.

The results of your ACL Reconstruction are based to a great extent on your discipline, motivation, and perseverance in performing the physical therapy program. With your cooperation and dedication, you have an excellent chance to regain the strength, stability, and confidence in your knee that you had before your injury.

Maximum medical improvement should be restored to your knee after 2 to 4 months of following your physical therapy treatment plan. Once your doctor clears you, most patients typically return to unrestricted recreational activities.

All patient education materials are provided by OrthoPatientEd.com and have been reviewed by our Advisory Board of leading Orthopedic Surgeons to ensure accuracy. All materials are provided for informational purposes only and are not intended to be a substitute for medical advice from your orthopedic surgeon. Any medical decisions should be made after consulting a qualified physician.
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