Anterior Cruciate Ligament (ACL) injury
How the ACL is injured: The ACL is the most common serious sporting knee ligament injury, usually damaged from a non-contact twisting injury where the injured leg is caught in the ground. A pop may be felt and rapid knee swelling often follows.
Symptoms of ACL injury: Rapid diagnosis is important because the knee will commonly become unstable. Regular “give-aways”, clunks or clicks are damaging to the internal structures of the knee and, importantly, the 3 layers of protective cartilage that form the smooth gliding surfaces in our knee joint. Once damaged these layers have limited healing potential. Ongoing damage leads to the early onset of arthritis. It is therefore imperative to have an early diagnosis of your sporting knee injury and, when required, early repair or reconstruction of the injured structures such as cartilage, meniscus and the ligaments themselves.
Diagnosis: The mechanism of your injury in combination with a thorough clinical examination will diagnose the vast majority of these injuries. We do arrange an Xray in the acute setting and an early MRI to confirm it but also to evaluate the other knee structures that are commonly injured at the same time. This allows for a thorough planning of any necessary surgical repair or reconstruction.
Treatment: Not every ACL injury needs surgery. The general rule is that ongoing knee instability must be avoided because we know from research studies that ongoing symptomatic instability (give way episides or a “wobbly knee”) leads to further damage inside the knee and early onset of arthritis. Treatment options are generally threefold:-
Considerable lifestyle change – the avoidance of twisting, turning and therefore a largely sedentary lifestyle is an option for a small proportion of people.
Maximal Non-operative treatment – Physiotherapy and a dedicated ACL rehabilitation & strengthening programme are vital. The important internal stabiliser is missing so stability is achieved by creating an immensely strong muscle envelope outside the knee (Hamstrings and Quadriceps). This approach relies on an ongoing strengthening programme for life. In my experience it is not usual practice to allow return to high level activities and particularly twisting, turning or cutting sports. Once again, should there be any ongoing feelings of instability then this should not be accepted and other treatment options should be sought.
Operative management – Surgery remains the gold standard for the majority of patients. This may be in the form of an ACL repair (if diagnosed within 3 weeks of injury) or reconstruction. Other associated knee ligament, meniscal or cartilage injuries can then be addressed at the same time. If reconstruction is performed then this is commonly using your own hamstrings tendons – this technique is widely accepted as the gold standard with excellent outcomes.
Rehabilitation: My ACL rehabilitation protocol is available here. The rehabilitation process after ACL reconstruction is 9 months minimum and 18 months in the Under 16 age group. There are no short cuts. The body has to grow new blood vessels in to your hamstring graft and then make a new ligament using this graft as a scaffold. ACL repair does have a faster recovery because a new ligament does not have to be made but even this is at least 6 months.
Further information on ACL Ruptures is available Here
Does my ACL Rupture need surgery? The current evidence is discussed Here
Medial Collateral Ligament (MCL) injury
How the MCL is injured: The MCL is located on the inner side of the knee and is a commonly injured knee ligament. The usual injury patterns are either a direct blow to the outer side of the knee causing it to buckle inwards or a non-contact situation where the foot slips producing this same stretching to the inner side of the knee. It may be injured in isolation or sometimes in combination with other knee ligament injuries, most commonly an ACL injury. These injuries are classified into three groups depending on the degree of injury:-
Grade 1 – A partial sprain of the ligament which remains grossly intact
Grade 2 – A partial tear with some laxity but usually no functional deficit
Grade 3 – A complete ligament tear
Symptoms: Sharp pain may be felt on the inside of the knee. Your knee may swell and feel unstable.
Diagnosis: A thorough history and clinical examination in combination with an Xray and MRI scan will allow a precise diagnosis to be made. The degree of injury can then be classified into one of the groups listed above and any other problems can also be identified.
Treatment Options: Most MCL injuries will heal without the need for surgery. A hinged knee brace with gradual increases in range of movement (over 6 weeks) and physiotherapy to assist with range of movement and strengthening will often be sufficient for the ligament to heal without compromise. With severe injuries in athletes wishing to return to dynamic twisting/turning/cutting/jumping sports then early surgery to repair the ligament may be beneficial particularly when surgery for other ligament injuries or cartilage damage is planned.
Rehabilitation: My Rehabilitation protocols are available through the dropdown menu.
Further information on Collateral Ligament Injuries can be found Here
Lateral Collateral Ligament (LCL) and Postero-Lateral Corner (PLC) injuries
The outer side of the knee is stabilised by a complex group of supporting structures that includes the LCL. Together these are termed the Postero-Lateral Corner, or PLC for short. Although less common than inner side MCL injuries, the complex anatomy on the outer side of the knee means that LCL/PLC damage is often in combination with other structures.
Symptoms: Sharp pain is common on the outer side of the knee. Swelling may also be seen and it is not uncommon for your knee to feel wobbly and unstable.
Diagnosis: Careful clinical examination in combination with xrays and an MRI scan will allow the injury and any other internal knee damage to be diagnosed, evaluated and a treatment plan constructed.
Treatment Options: Initial treatment often involves wearing a knee brace with a hinge to restrict movement. In some cases surgery may be necessary, particularly if there is a complete injury with significant instability and when other ligaments or knee structures (cartilage or meniscus) are also damaged. Physiotherapy to help you regain your strength and control will ultimately form an important phase of your recovery.
Further information on Collateral Ligament Injuries can be found Here
Posterior Cruciate Ligament (PCL) Injuries
PCL Injury: The PCL is most commonly injured when there is direct blow to the tibia (shin bone) whilst the knee is bent. Common examples include sports injuries but also direct impacts such as a collision or car accident.
Symptoms of a PCL Injury: There is commonly a sharp pain felt inside the knee or at the back of the knee. Swelling may follow. PCL injuries are often found in combination with other knee ligament injuries and rarely occur. The knee may feel unstable.
Diagnosis: PCL rupture is diagnosed by both a thorough clinical consultation and with imaging via an Xray and MRI scan.
Treatment Options: PCL injuries can range from partial tears to full tears. The degree of instability varies accordingly.
Non-operative management: For the majority of these injuries a period of rehabilitation, sometimes with the use of a PCL-specific brace, is all that is necessary. This will usually restore PCL stability and allow a return to activity. However, in certain circumstances operative management will be necessary.
Operative management: If, despite a period of bracing and subsequent dedicated rehabilitation and strengthening, your knee is still problematic then a PCL reconstruction may be required but this is not common with isolated tears of the PCL. When multiple knee ligaments are injured then a reconstruction can be undertaken at the same time as that of the other knee ligaments.
Take home message – “Acute knee injuries should be diagnosed accurately and quickly in order to achieve the best outcomes. There really is little to be gained from a “watch and wait” approach. An early specialist review, X-ray and MRI scan should be sought whenever the knee swells at the time of an injury or when there is a feeling of instability, mechanical symptoms (locking, catching or giving way) or pain that doesn’t settle within a few days.”