Sports Related Knee Injuries
Mark S. Sanders, M.D.
www.sandersclinic.net
Sports Related Knee
Ligament Injuries
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Anatomy of the Knee
Mechanisms of Injury
Diagnosis
Reconstruction
Therapy and Rehabilitation
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Frank H. Netter, Atlas of Human Anatomy 4th Ed.
Anterior Cruciate Ligament
• Major stabilizing ligament in the knee
connecting the tibia to the femur
preventing pathologic anterior excursion of
the tibia on the femur
• Contains mechanoreceptors which supply
the nervous system with real time
information regarding the limb’s position in
space
Mechanisms of Injury
• Can be torn by a sudden violent contraction of
the quadriceps occurring on the misplanted foot
– Most common cause of ACL injuries in noncontact
sports
• In collision sports it occurs as a result of an
externally applied force projected directly on the
medial or lateral surface of the knee
• Hyperextension
When the ACL Tears
• A patient reports hearing or feeling a “pop”
• There is a sense that the knee “went out”
or dislocated
• The pain typically makes it impossible to
finish the day's activities
• May also result in collateral ligament,
articular surface, and/or meniscal cartilage
damage
http://www.youcanbefit.com/images/ACL%20tear%20cause.bmp
http://www.hughston.com/hha/b_11_3_2b.jpg
http://www.weissortho.com/images/sectionimages/commoninj
uries/bodyparts/big/acltear.jpg
http://cms.depuy.com/display?docId=20157
Diagnosis
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History
Physical Examination
Straight leg raising possible
large knee effusion
loss of active knee motion
Lachman’s sign (anterior draw in mild flexion)
Pivot shift sign (uncommon in acute situation)
Collateral ligament examination in full extension and 30 degrees of flexion
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KT-1000
X-ray
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MRI
Arthroscopy
http://www.jfponline.com/images/5209/5209JFP_AppliedEvidence-fig2.jpg
MEDmetric® Knee Ligament
ARTHROMETER® Model
KT1000™
MRI
• Advantages/Disadvantages?
http://www.emedx.com/emedx/diagnosis_information/diagnosis_information_image
_files/knee_images/acl_mri_torn.JPG
http://www.rad.washington.edu/staticpix/anatomy/ACL1.jpg
Arthroscopy
• Not typically necessary for diagnosis, which
should be obvious from History, Physical
Examination, KT-1000 testing, and/OR MRI
• Most often MRI is not necessary for diagnosis,
but can be helpful in determing the presence of
other injuries
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bone contusion (bone marrow edema)
– articular or meniscal cartlage injury
– collateral ligament injury (should be obvious
from physical exam)
http://www.yoursurgery.com/procedures/arthroscopy/images/ACL_PCL.jpg
http://www.genou.com/LCAnormal.jif
http://www.emedx.com/emedx/diagnosis_information/diagnos
is_information_image_files/knee_images/acl_normal_arthros
copic_picture.JPG
Initial Treatment
• Surgery NOT INDICATED
– Immediate surgery leads to an unacceptable incidence of
arthrofibrosis (loss of ROM)
• RICE
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Rest
Ice
Compression
Elevation
• Range of Motion exercises
• Gait reeducation
– quickly eliminates the need for crutches
• Cold/compression CryoCuff®
• Strengthening and flexibility program for hamstrings and
quadriceps
• Emphasize extension equal to the other leg
• Cycling
Options?
• Non-surgical
– Must be willing to give up sports with
exception of cycling and activities in a health
club
• Strength and conditioning program
• Surgical
– For people that want to return to sports and
need the stability (athletes)
Allografts
• Advantages
– Technically easy
• Biological Considerations
– Greater than one year for revascularization
– Rejection
– Infectious transmission
• Technically easy
• Economic considerations
– Very expensive
• Success Rate 80% stable knees
• Return to sports not before one year
• Indications
– Non-athletic patients over 40
Hamstring Tendon
• Advantages
– Technically easy
• Disadvantages
– Lack of bone to bone healing
– Maturation takes one year
– Sacrifice of a major muscle group that provides major
posterior translation of the tibia (the hamstring
tendons are the allies of the ACL)
• Success rate 90% stable knees
• Return to sports 9 months to one year
• Long term hamstring weakness present
Bone-Patellar Ligament-Bone
• GOLD Standard
• Advantages
– Bone to bone healing
– Strongest graft
– Maturation occurs rapidly
• Return to sports 6 months
• Disadvantage
– Requires attention to detail at surgery and
rehab
Contra lateral patella tendon
• (PLATINUM standard)
• Less postop pain
• Faster rehab
– Divide the problem into two parts
– ACL leg concentrates on ROM
– Graft leg concentrates on Strength
• No braces or crutches
• Return to sports 3 months
– Improvement continues over first year
Procedure
• A short straight incision is made on the ACL knee superficial to the
patella and a small incision is made lateral and superficial to the
distal femur
• Drill holes are placed into the knee - from the leg and thigh - into the
places where the native ACL inserts into the femur and tibia
• A similar incision is made onto the front of the healthy “graft” leg
• The graft is harvested and the wound is closed over a drain
• The new graft is then placed through the ACL knee and sutures are
tied over buttons
• The wounds are then closed over drains - preventing excessive fluid
build up for optimal recovery and movement
• Cold compression is applied on both legs and strengthening
movements begin that day
Full extension equal to the other leg necessary
on the operating table and at all other times
Therapy and Rehabilitation
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Immediate!
ROM key on ACL leg!
Strengthening key on graft leg
Gait training
Jogging in 1 month
Sports specific drills 6 weeks
Criteria for returning to sports
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Full and equal motion in both knees
Strength equal to 80% of preop graft leg both knees
Swelling absent
Plyometrics
Neuromuscular reeducation
• Average return to sports 3 months
– Confidence and performance continue to improve for one year
3 Days
Postop
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Angela hall website
For More Information
• Visit our website at www.sandersclinic.net