Knee Pain & Injury

An ACL injury is one of the most common injuries in sports, and it is one of the main injuries that can occur in the knee joint. A torn ACL is most likely to occur in sports that involve planting the foot and rotating the leg at the knee joint, such as soccer, basketball, gymnastics, and football.

If the goal is to return to playing sports, ACL injury treatment usually involves surgery. However, nonsurgical ACL injury treatments are available for non-athletes who simply want to have a functional knee joint.

What Is the Anterior Cruciate Ligament (ACL)?

The anterior cruciate ligament, or ACL, is one of the four main ligaments in the knee. It runs in the center of the knee joint and connects femur to the tibia. It is called a “cruciate” ligament because it forms a cross or “X” with the posterior cruciate ligament (PCL) in the center of the knee joint.

The main purpose of the ACL is to keep the tibia from moving too far forward in relation to the femur. In other words, it helps stabilize the knee joint. Another important purpose of the ACL is to keep the lower leg from over-rotating.

Symptoms and Causes of ACL Injuries

Most people who suffer from a torn ACL state that they heard a “popping” noise in their knee at the time of the ACL injury. Some people also feel as if their knee gave out, either at the time of injury or soon afterwards.

Other classic symptoms of a torn ACL include severe pain, swelling (within 2 to 24 hours after the injury), tenderness, difficulty walking because of knee pain, and trouble bending the joint. During physical examination, your torn ACL doctor will also be able to move lower leg farther forward at the knee than it should normally move.

Simply put, a torn ACL is caused by moving the knee beyond what the ligament can handle. The most common activities that lead to an ACL injury (ACL tear) include:

• Quickly and forcefully changing direction (e.g. a wide receiver making a “cut” while running a pattern)
• Pivoting the leg while the foot is planted (e.g. may occur during an awkward pass in basketball)
• Landing incorrectly after a jump (e.g. an awkward dismount from a gymnastics apparatus)
• Forceful overextension of the knee joint (e.g. taking a hit to the front of the knee during a football tackle)
• Slowing down rapidly (e.g. responding to a steal by the other team in basketball)
• General Treatment of ACL Injuries

Initial ACL injury treatment involves PRICE: protection, rest, ice, compression, and elevation. Protect the knee joint from movement and further injury, take weight off the leg, put a compressive bandage around the knee, and keep your leg elevated. This should reduce pain and swelling until you can be evaluated by an experienced professional.

Surgical Treatment of ACL Injuries

Most young, active people — especially athletes who want to continue playing competitively — will opt for surgical ACL treatment.

The orthopedic surgeon will remove the damaged ligament and replace it with a graft. This graft may be one of your own (autograft) or a donor (allograft). Surgical ACL injury treatment is followed by rehab, and patients may be able to return to their chosen sport within 6 to 9 months.

Non-Surgical Treatment of ACL Injuries

Nonsurgical treatment for ACL injuries generally involves bracing and physical rehabilitation. A torn ACL will not heal or repair itself without surgery. However, patients who are low ACL demand and who wish to avoid surgery and have a reasonably functional knee may seek choose nonsurgical ACL injury treatment.

The posterior cruciate ligament (PCL) is one of the four main ligaments in the knee joint that stabilizes the knee. The PCL runs between the femur and the tibia. Together with the anterior cruciate ligament (ACL), the PCL controls and stabilizes the knee joint, preventing it from moving too far back and forth. Certain injuries can cause PCL tears. The role of this ligament in stabilizing the knee is to control posterior displacement of the tibia as well as external rotation relative to the femur.

The PCL originates from the central portion of the tibia posteriorly and inserts on the medial wall of the femoral intercondylar notch. The diameter of the ligament varies based upon the size of the knee but generally averages in the range of 10mm. Incidence and Pathophysiology PCL tears are common sports related injuries. The injury typically occurs as a result of a hyperextension force/load or posterior force at the level of the tibia which is applied to the knee. Under these conditions the tensile strength of the ligament is superseded by the energy of the applied stress and the ligament ruptures. The tear pattern can be a rupture of the ligament at its tibial or femoral attachment or a midsubstance rupture of the ligament.

What Are Posterior Cruciate Ligament (PCL) Tears?

Posterior cruciate ligament tears, or PCL tears, are a partial or complete separation of the posterior cruciate ligament. The diagnosis of a PCL tear can often be made based on history and clinical findings, however, an MRI is the diagnostic imaging test of choice for confirmation. An MRI scan can also give information regarding associated injuries as mentioned above which can be important for planning optimal treatment.

Symptoms and Causes of PCL Injuries

The typical symptoms of a PCL tear are pain and swelling that occur immediately after the PCL injury and reach their peak over a short period. People with PCL tears often have difficulty walking, and the leg may “give out” at the knee. Knee joint swelling may make the knee stiff. In fact, a PCL injury doctor will usually be able to find limited range of motion in the knee during examination, along with the stiffness and swelling. A result of the instability episode and the knee partially dislocating, not infrequently the bones are contused or in some cases even fractured. In addition the medial and or lateral meniscus can be torn. In some cases there can be damage to the articular cartilage surface of either the femoral condyles and or the tibial plateaus. Finally, additional ligaments can be injured along with the ACL, most commonly the MCL (medial collateral ligament).

Nonsurgical Treatments for PCL Tears

Non-surgical treatment is appropriate when there are no associated injuries that require repair, the age range is > 30 and there is no plan to participate in high PCL demand activities. Under these circumstances, the knee can be treated symptomatically initially and then participate in a rehabilitation program to strengthen muscles that also work to dynamically stabilize the knee in the same way that the PCL does.

A local PCL tear doctor can evaluate and determine if your PCL injury will require surgical or nonsurgical treatment. Initial treatment should focus on reducing the severity of the inflammatory response as well as taking precautions so as not to cause further injury to the knee. 

The typical first aid intervention for a PCL tear is PRICE: protection, rest, ice, compression, and elevation. If PRICE is performed soon after the PCL injury, the treatment can relieve pain and help the torn PCL to heal. Over-the-counter pain medications such as ibuprofen are usually enough to control pain after the first 24 hours, but your PCL injury doctor may prescribe more potent pain medications. After the initial swelling has subsided, your PCL tear doctor can recommend a physical therapist to aid you thorough rehabilitation program that will help reduce pain and improve knee function.

Surgical Treatments for PCL Tears

A PCL surgery is generally considered advisable when the individual is likely to return to high demand PCL activities. These can include sports such as football, soccer and basketball or work such as heavy construction or police enforcement. Under these circumstances, the PCL deficient knee will may subluxate (partially dislocate) during high stress activities and cause further and often more serious knee injuries.

Age is also a factor and a younger person may be more likely to benefit from a surgical reconstruction given the propensity for PCL deficient knees to develop osteoarthritis as a result of abnormal kinematics that develop as a result of PCL deficiency. In regard to the types of surgical reconstruction that are available, there are many. At iOrtho our current preference is an anatomic reconstruction using the native footprint for the femoral and tibial attachment of the PCL.

Tunnel preparation is performed independently to allow for matching the natural footprint of the reconstructed PCL. Graft fixation preference on the femoral side is cortical fixation so that there is no hardware inside the knee and the graft and tunnel and incorporate fully without a potential osseous deficiency if the graft ever suffered a subsequent tear and the procedure had to be done again. An interference screw and/or cortical fixation on the tibial side. Graft options include allograft and the type is matched to the patient.

A complete PCL tear will not heal without surgery. While you can live without a PCL, a completely torn PCL will greatly limit your ability to compete in competitive sports and may increase your risk for knee arthritis in the future. Young, otherwise healthy individuals, especially athletes, may wish to pursue surgical treatment for PCL tears.

An experienced PCL tear doctor can repair or rebuild the torn ligament. A partially torn PCL can be repaired by suturing the torn ligament, while a completely torn PCL must be replaced. Tunnel preparation is performed independently to allow for matching the natural footprint of the reconstructed PCL. Graft fixation preference on the femoral side is cortical fixation so that there is no hardware inside the knee and the graft and tunnel and incorporate fully without a potential osseous deficiency if the graft ever suffered a subsequent tear and the procedure had to be done again. An interference screw and/or cortical fixation on the tibial side.

Your PCL injury doctor may use a tissue graft taken from another part of your body or use a donor graft harvested from a cadaver. Remember that while people initially recover quickly after PCL replacement surgery, rehabilitation and full return to activity may take several months, as the PCL takes many months to fully heal.

If you have sustained injury to your knee and think you may have a PCL tear or other PCL injury, contact the PCL injury doctors at iOrtho today for a consultation.

The Medial Collateral Ligament (MCL) connects the femur and tibia. Running along the inner side of the knee, it is a strong connective tissue which can become looser after severe injuries.

An MCL tear causes pain on the inside of the knee. Tearing the MCL is likely to cause immediate pain. A person may notice a popping sound at the time of the injury which is the ligament tearing.

The Lateral Collateral Ligament (LCL) runs along the outer side of the knee and connects the thighbone to the calf bone. It is a strong connective tissue that controls the sideway movement of the knee.

LCL injury is often experienced by athletes who are hurt in direct contact, suddenly change of direction, twist knee while feet are stationary. There are three grades of how doctor categorize sprains Grade 1, Grade 2 and Grade three. Symptoms include instability, tenderness, swelling, decreased motion and difficulty bearing weight.

Arthritis is a condition in which one or more joints are inflamed. Virtually any joint in the body can become inflamed, but arthritis in the knee is very common. Knee arthritis can be very painful and even disabling.

Non-Inflammatory Knee Arthritis (Cartilage Injury)

The hyaline cartilage surfaces can be damaged as a result of repetitive stress and time. This is a degenerative process of cartilage change and is called osteoarthritis. This is the common type of cartilage damage that is experienced by many people.

Damage to the cartilage surface in this category generally occurs along a spectrum of change beginning with softening of the cartilage which then progresses to superficial cracking and then deeper cracks followed by erosions and eventually areas of complete cartilage loss. These spectrums of changes are referred to as chondromalacia.

The cartilage surface can also be damaged as a result of a single traumatic event. This can happen with a dislocation episode such as that encountered in an ACL injury or a patella dislocation. It can also happen with a knee fracture which extends into the joint disrupting the joint surface.

This type of damage is often referred to as a traumatic defect distinguished often by its focal geography and can often be measured in very discrete terms with surrounding healthy cartilage. This appearance could be altered obviously, if the joint was degenerating prior to the traumatic event having occurred. The focal or diffuse nature of the cartilage injury (pattern) is one of the main features, which guides treatment options likely to be effective.

Inflammatory Knee Arthritis (Cartilage Injury)

Inflammatory arthritis is very different than the non-inflammatory type. The cartilage damage is secondary not to repetitive stress or time or a single event trauma but is the result of a chemical process which occurs often because of an autoimmune disease. The autoimmune process causes the synovium to “attack” the cartilage surface. Instead of providing nutrition and support to the cartilage, the synovial cells secrete enzymes which essentially digest the cartilage causing it break down and resorb.

Types of Arthritis That Affect the Knee

There are many different kinds of knee arthritis, but the three most common are osteoarthritis, inflammatory arthritis, and posttraumatic arthritis. Knee cartilage injuries and arthritis are closely related. 

Since knee arthritis treatments are different depending on the type of arthritis, it is important to know which type of arthritis you have.

People with knee arthritis may have trouble with even the simplest of tasks basic mobility, like walking or climbing stairs. Knee arthritis usually occurs in older people, but it can sometimes develop in children as well. Fortunately, many effective knee arthritis treatments are available.

Meniscus tears are among the most common knee injuries, located in the knee, these wedge -shaped pieces of cartilage help cushion the joint and keep it stable.  

Sudden meniscus tears often happen during sports. Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

If your symptoms persist with nonsurgical treatment, your doctor may suggest arthroscopic surgery.

The patellar tendon works with the muscles in the front of your thigh to straighten your leg. Small tears of the tendon can make it difficult to walk and participate in other daily activities but is treated effectively with rest and NSAIDS whereas large tears often require surgery and physical therapy to recover.

One of the main causes of tendon tearing is the weakening of the patellar tendon through repetitive stress and  inflammation, called patellar tendinitis (Jumper’s Knee). 

When a patellar tendon tears there is often a tearing or popping sensation. Pain and swelling typically follow, and you may not be able to straighten your knee. An individual may also experience bruising, tenderness, moving kneecap, difficulty walking and cramping.

The knee is a complex joint and can be discussed as 3 separate smaller joints together making up one;1) patellofemoral 2) medial weight bearing 3) lateral weight-bearing. Osteoarthritis can affect the joints in a limited or diffuse pattern. If the pattern is diffuse and all 3 compartments are affected by arthritis then a total knee replacement (TKR) is the best reconstructive option. If however the damage is limited to 1 or 2 of the compartments then a partial knee replacement (PKR) may be a desirable reconstructive option.

PKR is a ‘joint preservation’ procedure and has the following advantages over TKR

Less invasive- the surgery can be performed without dislocation of the knee and as an ambulatory, same-day surgery.

Natural Result: Placement of the implants is accomplished without sacrificing the Anterior and/or Posterior Cruciate Ligament (ACL/PCL). This allows the knee to maintain natural motion and kinematics resulting in a natural feeling knee. Natural kinematics are lost when performing a TKR.

Quicker Recovery: Rehabilitation time is reduced by up to 100% due to the less-invasive nature of the surgery and the maintenance of natural ligaments.

Return to Sports: Return to sports that require a full range of motion and pivoting is much more likely as a result of ligament and kinematic preservation