Description

The anterior cruciate ligament (ACL) is the main stabilizing ligament on the inside of the knee. Its main function is to prevent the tibia (shin bone) from sliding forward and rotating on the femur (thigh bone). Tears/ruptures of the ligament result in knee instability.

What are the causes?

ACL tears are typically caused by twisting or hyperextension injuries. Sports activity like pivoting or sudden deceleration when running and falls during skiing are considered non-contact causes of ACL tears. Direct trauma to the back or side of the knee during collision sports is considered a contact injury to the ACL.

What are the symptoms?

ACL tears cause immediate pain and often swelling. You may feel something “pop” inside the knee. An initial inability to bear weight on the leg may subside and walking may be possible after several minutes. The knee may feel loose or that it is going to “give out” and return to sport is impossible. Over time, swelling will increase and motion may be lost.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the ACL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in surgical planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

ACL tears do not heal. Some patients elect not to have reconstruction surgery. Non-operative treatment increases the risk of “wear and tear” arthritis and meniscus tears because of the instability in the joint. Non-operative treatment consisting of anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed prior to surgery to decrease the swelling, regain motion and strength, as research has demonstrated that surgery is less complicated and patients have better outcomes. Non-operative treatment in surgical patient may be skipped if other injuries to the meniscus and cartilage are present and need to be repaired immediately.

Operative

Operative management of ACL tears depends on the type of tear. ACL repair may be indicated in patients where the ACL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. ACL repair is accomplished through a minimally-invasive arthroscopic procedure and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.

If formal reconstruction is required, a new ACL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive arthroscopic procedure. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

Description

The lateral collateral ligament (LCL) is the main stabilizing ligament on the outer aspect of the knee. Its main function is to prevent the knee from giving way outward (varus motion). Tears/ruptures of the ligament results in knee instability.

What are the causes?

Isolated LCL tears are uncommon. They typically occur from trauma. A direct force to the inside of the knee stresses the ligament. This typically occurs in collision sports like football. LCL tears are also seen in high-energy trauma like motor vehicle accidents and are accompanied by tears in the other ligaments and tendons on the outside of the knee (aka – posterolateral corner injury and knee dislocation).

What are the symptoms?

LCL tears cause immediate pain and often swelling. You may feel something “pop” on the outer aspect of the knee. Pain is centralized over the ligament (outside aspect of the knee). Walking after the injury may be possible but the knee may feel like it’s going to “give out” depending on the severity of the tear.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the LCL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in treatment planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

Almost all minor LCL tears can be treated non-operatively. Non-operative treatment consisting of bracing, anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed to decrease the swelling, regain motion and strength. Most patients may be able to return to normal activity without surgery depending on the type and severity of the tear. A brace may be prescribed to return to sports activities. If symptoms persist (pain, instability), reconstruction surgery may be recommended by your surgeon. If other structures are damaged (i.e.- Posterolateral Corner), surgery is recommended to reconstruct the knee.

Operative

Operative management of LCL tears depends on the type of tear. LCL repair may be indicated in patients where the LCL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. LCL repair is accomplished through a series of small incisions and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.

If formal reconstruction is required, a new LCL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive incision. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

See Posterolateral Corner section for reconstruction surgery description.

Description

The posterior cruciate ligament (PCL) is the other main stabilizing ligament on the inside of the knee. Its main function is to prevent the tibia (shin bone) from sliding backward and rotating on the femur (thigh bone). Tears/ruptures of the ligament results in knee instability. PCL tear is less common than ACL tear.

What are the causes?

PCL tears are typically caused by trauma or a fall on the knee. A direct posterior/backward force on the tibia commonly seen in collision sports or the knee hitting the dashboard in a motor vehicle accident will cause a PCL tear.

What are the symptoms?

PCL tears cause immediate pain and often swelling. You may feel something “pop” inside the knee. An initial inability to bear weight on the leg may subside and walking may be possible after several minutes. The knee may feel loose or that it is going to “give out” and immediate return to sport is impossible. Over time, swelling will increase and motion may be lost. Unlike ACL tears, some patients, even athletes, can return to sport with partial PCL tears (albeit in a knee brace) and never require surgery.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the PCL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in treatment planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

PCL tears do not heal. However, some patients may be able to return to normal activity depending on the type and severity of the tear. Non-operative treatment consisting of anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed to decrease the swelling, regain motion and strength. A brace may be prescribed to return to sports activities. If symptoms persist (pain, instability), reconstruction surgery may be recommended by your surgeon.

Operative

Operative management of PCL tears depends on the type of tear. PCL repair may be indicated in patients where the PCL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. PCL repair is accomplished through a minimally-invasive arthroscopic procedure and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.

If formal reconstruction is required, a new PCL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive arthroscopic procedure. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

Description

The posterolateral corner (PLC) is made up of a series of ligaments and tendons that stabilize the outside and posterior (backside) of the knee: lateral collateral ligament (LCL), popliteaofibular ligament (PFL), lateral capsular ligament, biceps femoris (hamstring) tendon and the popliteus tendon.

What are the causes?

PLC injuries occur from high-energy trauma (motor vehicle accidents), collisions in sports and falls from a height. PLC injuries are common in knee dislocations.

What are the symptoms?

PLC injuries result in immediate pain, swelling and inability to bear weight on the leg. In the setting of knee dislocation, numbness, tingling and a cold sensation to the extremity may be felt due to injury of the nerves and blood vessels.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing injuries to two or more of the structures.

How is it treated?

Non-operative

Non-operative treatment results in instability of the knee. PLC reconstruction may be delayed secondary to other injuries.

Operative

Operative management of PLC injuries is performed through an open incision on the outer aspect of the knee. Several techniques exist for reconstruction, but all include the use of several grafts (typically from a donor) and a series of bone tunnels from which the grafts pass. Fixation of the grafts is either screws or buttons. Postoperative rehabilitation is at your surgeon’s discretion.

Description

The quadriceps tendon attaches the patella (aka-kneecap) to the quadriceps muscle on the front of the thigh. It is responsible for transmitting force from the quadriceps muscle, resulting in the ability to extend the knee. A quadriceps tendon tear is a complete rupture of the tendon, resulting in a non-functional lower leg.

What are the causes?

Quadriceps tendon tears occur from excessive contraction of the quadriceps, resulting in an excessive force transmitted to the tendon. This can be from a fall, jumping or landing from a height.

What are the symptoms?

Quadriceps tendon tears cause immediate pain, swelling, deformity in the front of the leg and inability to bear weight. Patients usually report a “pop” and bruising occurs within the first day. Function is not restored with rest and walking is impossible without assistance.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Patients cannot perform a straight leg raise because the muscle force cannot be transmitted to the lower leg. X-rays may show the patella (kneecap) lower than normal due to lack of tension from the quadriceps tendon. MRI is helpful to confirm the diagnosis and any other injury.

How is it treated?

Non-operative

Unless other injuries are sustained at the time of quadriceps tendon tear that prohibit the patient from surgery, non-operative treatment is not a consideration.

Operative

Quadriceps tendon repair is performed through an incision in the front of the leg just above the knee. Several techniques are used to secure the tendon back to the patella using sutures, anchors and/or screws. Postoperative rehabilitation is at your surgeon’s discretion.

Description

The patella tendon attaches the patella (aka-kneecap) to the tibia (shin bone). It is responsible for transmitting force from the quadriceps muscle from the patella to the lower leg, resulting in the ability to extend the lower leg. A patella tendon tear is a complete rupture of the tendon, resulting in a non-functional lower leg.

What are the causes?

Patella tendon tears occur from excessive contraction of the quadriceps, resulting in an excessive force transmitted to the tendon. This can be from a fall, jumping or landing from a height. Patella tendonitis may predispose the patient to patellae tendon tear.

What are the symptoms?

Patella tendon tears cause immediate pain, swelling, deformity in the front of the leg and inability to bear weight. Patients usually report a “pop” and bruising occurs within the first day. Function is not restored with rest and walking is impossible without assistance.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Patients cannot perform a straight leg raise because the muscle force cannot be transmitted to the lower leg. X-rays may show the patella (kneecap) higher than normal due to lack of attachment on the lower leg. MRI is helpful to confirm the diagnosis and any other injury.

How is it treated?

Non-operative

Unless other injuries are sustained at the time of patella tendon tear that prohibit the patient from surgery, non-operative treatment is not a consideration.

Operative

Patella tendon repair is performed through an incision in the front of the leg just below the knee. Several techniques are used to secure the tendon back to the patella using sutures, anchors and/or screws. Postoperative rehabilitation is at your surgeon’s discretion.

Description

The meniscus is cartilage that acts as a shock absorber between the femur (thigh bone) and tibia (shin bone). Each knee has two distinct menisci: the medial (inner aspect of the knee) and lateral (outer aspect of the knee). Medial meniscus tears are more common in general, and lateral meniscus tears are more common when the ACL is injured. Injuries to the meniscus may lead to eventual degenerative changes in the knee (aka – arthritis).

What are the causes?

The meniscus can be injured several ways. Acute meniscus tears result from a sudden twisting or pivoting maneuver. Acute meniscus tears are associated with ACL injuries. The meniscus can also undergo degeneration as patient age increases. The degenerative meniscus is susceptible to tearing with minimal trauma (i.e.-twisting the knee getting into the car).

What are the symptoms?

Meniscus tears, in the acute setting, cause immediate pain over the specific meniscus, potentially swelling and bruising and loss of motion and strength. The patient may feel clicking or catching with walking and increased pain with twisting on the affected foot. If the meniscus tears and gets stuck out of place, the knee may feel locked (aka - bucket handle meniscus).

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. The knee is painful to touch over the affected meniscus. Your surgeon may perform provocative maneuvers to test each meniscus, resulting in pain and clicking if the meniscus is torn. X-rays are usually normal. MRI is helpful to confirm the diagnosis and characterize the tear for surgical planning. Other injuries can also be identified on the MRI.

How is it treated?

Non-operative

Some meniscus tears are treated successfully without surgery. Your surgeon may prescribe anti-inflammatory medication, physical therapy, cryotherapy and activity modification to reduce pain and inflammation, as well as strengthen the muscles around the knee to decrease the force transmitted to the meniscus. Your surgeon may offer you an injection. Patients with continued symptoms (pain, clicking, etc.) may benefit from surgery. Bucket handle meniscus tears are not treated non-operatively and require surgery.

Operative

Meniscus tears can be treated in most cases with a minimally-invasive arthroscopic surgery. Depending on the size and type of tear, as well as the quality of the torn tissue, your surgeon may choose to remove the torn meniscus or repair it with a series of sutures. Removing large portions of the meniscus will lead to expedited degeneration of the joint cartilage (aka- arthritis). Postoperative rehabilitation is at your surgeon’s discretion.

Description

The anterolateral ligament (ALL) is a ligament on the front and outer aspect of the knee. Its main function is to assist the ACL in the prevention of rotation of the tibia (shin bone) on the femur (thigh bone).

What are the causes?

ALL injuries occur simultaneously with ACL tears. Whether the rotational force is too great for the ACL resulting in ALL tear, or the rotational force is too great for the ALL resulting in ACL injury is unknown. ALL/ ACL tears are typically caused by twisting or hyperextension injuries. Sports activity like pivoting or sudden deceleration when running and falls during skiing are considered non-contact causes of ALL/ACL tears. Direct trauma to the back or side of the knee during collision sports is considered a contact injury to the ALL/ACL.

What are the symptoms?

ACL/ALL tears cause immediate pain and often swelling. You may feel something “pop” inside the knee. An initial inability to bear weight on the leg may subside and walking may be possible after several minutes. The knee may feel loose or that it is going to “give out” and return to sport is impossible. Over time, swelling will increase and motion may be lost. Injuries to the ALL are not typically diagnosed at the initial visit. Symptoms of instability after ACL reconstruction are common if the ALL is torn and not reconstructed at the time of surgery.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. Excessive laxity (“pivot shift) in the knee during ACL examination is indicative of concurrent ALL tear An MRI is helpful to confirm the diagnosis, showing the ACL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in surgical planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Operative

Operative management of ALL tears is performed at the time of ACL reconstruction. If symptoms of instability occur after formal ACL reconstruction, your surgeon may recommend having the ALL reconstruction performed prior to return to sports. Your surgeon may choose to perform the minimally-invasive procedure with or without a graft (from your knee or a donor), supported by high-strength suture. Postoperative rehabilitation is at your surgeon’s discretion.