THE KNEE

MENISCUS INJURIES

There are two menisci in your knee, a medial (inner) and a lateral (outer). They are circular structures made of cartilage – a different type that covers the ends of bones that form joints. They are commonly known as shock absorbers, but they serve an important stabilization function as well. Thus, the preservation of their structure and function is very important to protect the other cartilage in your knee, prevent degeneration and optimize function.

The Knee

Cartilage AKA Chondral Injuries

Cartilage comes in many forms. Here we are talking about the type of cartilage that covers bones that forms a joint. For those interested, this is Type II or Hyaline Cartilage. Have you ever seen the shiny, smooth end of a chicken bone? That is what we are talking about here.

The cartilage injuries we manage in the sports surgery world are different than the more widespread degeneration of cartilage otherwise known as osteoarthritis. Here we are talking of more localized injuries akin to “potholes” in your cartilage. These can come in many sizes and shapes and thus treatment options are many.

Cartilage injuries can occur in the same manner as meniscal or ligament injuries to the knee. A pivoting or twisting motion, an awkward landing from a jump or even direct trauma can result in an acute (sudden) injury to your cartilage.

Symptoms can mimic those of ligament and meniscal injuries. Knee pain, swelling, catching, locking and giving way are common complaints.

For patients experiencing symptoms physical examination in the office diagnoses most injuries, however, a detailed history is as important to help determine severity. We will obtain advanced imaging to further assess the injury and guide the next steps in treatment.

Not all cartilage injuries will require surgery. If the lesion is small and thus likely stable and you are not suffering from mechanical symptoms such as swelling, locking, catching, or giving way nonoperative is a good option. We will focus on the reduction of pain and swelling and strengthening by a dedicated physical therapy and home exercise program.

If the lesion is large and producing mechanical symptoms such as swelling, giving way, locking, and/or catching we will discuss surgical management.

There are many ways to manage these injuries and they must be individualized to the patient goals and lesion characteristics. In general, smaller lesions can be managed with an arthroscopic only approach. Larger lesions, however, will typically require a combination of arthroscopic and open surgery. These can involve grafts taken composed of bone plugs with cartilage caps taken from areas of your knee which do not see much pressure or similar grafts from a cadaver donor. Larger lesions are managed with cadaver grafts as using grafts from your own knee is not ideal, to say the least.

Cartilage defects on the undersurface of the patella (“knee-cap”) deserve special mention. It is not uncommon these lesions exist in the setting of poor knee alignment. We will fully evaluate the alignment of your entire lower extremity (thigh and leg) to determine if a realignment surgery is also necessary. In many cases, alignment is not properly assessed thus dooming your surgery to fail.

Surgery will be done as an outpatient or “Same Day.”

A bracing and protected weight-bearing period of AT LEAST 8 weeks after surgery is nearly universal in my practice. Additionally, I will only allow a range of motion of the knee when it is unloaded, that is no weight is being placed on it. This serves to protect the graft from excessive pressure and force that will hinder healing.

During the first 8 weeks, you will work closely with a physical therapist to reduce swelling, pain and regain your range of motion. After 8 weeks we will sequentially progress through a dedicated strengthening and return to sport protocol.

Return to sport timelines vary widely from 3 months to 6+ months and thus we will discuss this on an individual basis.

The Knee

Anterior Cruciate Ligament Injuries

The Anterior Cruciate Ligament (aka “ACL”) is a very common reason for patients to undergo surgery. This ligament prevents abnormal rotation and translation (back and forth movement) of your knee. For patients wishing to return to activities that require cutting, pivoting, or side to side movements you become a candidate for ACL repair or reconstruction. Without treatment, we know ACL deficiency leads to increased damage to the menisci and cartilage of the knee which can significantly limit your function and activities.

ACL injuries typically occur from an awkward and forceful twisting motion at your knee. Rarely do they occur from direct contact or a direct blow, but they can occur with high-energy trauma (a car accident for example).

Patients commonly experience a “pop” sensation or sound – I know I did with my ACL tear – at the time of injury. A few hours later the knee will swell and pain will begin, the amount will vary between individuals. If left to go without evaluation and treatment patients will sense their knee is less stable, less trustworthy with side to side or pivoting motions.

Physical examination in the office diagnoses most injuries, however, a detailed history is as important to help determine severity. MRI is especially helpful to determine the grade of injury but typically will only be obtained if there is concern surgery is needed.

Do not let an outside practitioner tell you you are “too old” for an ACL reconstruction. Recent evidence has shown patients once thought to be “too old” are indeed candidates. While this is not universally true if you are youthful, active, healthy and without significant arthritis, ACL reconstruction or repair may be a good option.

Is it possible to live without an ACL? Of course, it is. For some patients who do not have high demands on their knee or do not wish to undergo surgery and rigorous postoperative rehabilitation, this may be a good option. What we do know, however, is without an ACL the biomechanics of your knee are different. This leads to an increased risk of meniscal tears, and, more importantly, early degenerative changes.

Operative treatment, as with most things, comes into play when non-operative management fails to achieve your goals. I typically perform tendon repair thru a mini-open approach, but still as a same-day or outpatient procedure.

It is important to note there is no graft nor technique proven in the scientific literature to reliably reduce the time it takes to return to sport. Beware of claims promising a technique or graft will result in an earlier return to sport or activity, they are not founded in current evidence nor science. Only a combination of well-executed surgery with modern techniques and dedication to physical therapy and hard work can guarantee a successful result.

You will meet with a physical therapist to ensure you have a full range of motion before undergoing surgery. This is of crucial importance to insure you can achieve a full range of motion after surgery. You will also learn the exercises I want you to do immediately before surgery. Finally, preoperative appointments make obtaining timely postoperative appointments much easier.

We will meet and review your personal goals and the surgical goals, risks, alternatives, and postoperative rehabilitation timeline. Additionally, we will make sure all your needs are in place: Braces, crutches, pain meds, medical evaluation (if necessary), etc.

Surgery is done on a same-day or outpatient basis. You will be provided with an immediate postoperative brace, detailed postoperative instructions in writing, your physical therapy protocol, and postoperative pain management instructions. Ideally, we will have had a preoperative visit where you received a prescription for pain medication and to ensure all bracing/crutches, medical evaluation, labs, etc. are in place.

The Knee

Medial Collateral Ligament Injuries

The medial collateral ligament (aka MCL) prevents the knee from buckling inward – think of the “knock-kneed” position. As you will see with other knee structures, the MCL also plays a role in stabilizing the knee to rotational and translational (front-to-back movement) forces.

MCL injuries are the most common ligamentous knee injury. It is usually an isolated injury but is known to also occur with an ACL injury. If these two occur together it is termed a “Multi Ligamentous Knee Injury” and should be managed by an ACGME accredited fellowship-trained surgeon. Patients may suffer this injury either from an awkward twisting knee injury or from a direct blow to the outside of the knee.

Pain will occur along the inside of the knee. An MCL injury itself may not lead to knee swelling as this structure is outside the knee joint. If left untreated gross knee instability will persist limiting high-demand activities into the future.

For patients experiencing symptoms physical examination in the office diagnoses most injuries, however, a detailed history is as important to help determine severity. We will obtain advanced imaging to further assess the injury and guide the next steps in treatment.

The vast majority of MCL injuries can be treated nonoperatively with a period of bracing and physical therapy. Because this ligament is outside the knee it has the capacity to heal on its own. ACL injuries are not afforded this luxury as the thick joint fluid (aka synovial fluid) does not allow the torn ends to heal back to themselves.

MCL injuries involving the tibial (shin bone) insertion are less likely to heal on their own. This is due to the anatomy of the insertion, where the torn ends flip over nearby structures and cannot contact their bony insertion to heal to it.

If involved in a “multi-ligamentous” knee injury I am more likely to reconstruct or repair the ligament to ensure your knee is stable during the rehabilitation of the other repaired or reconstructed knee structures.

If possible, I will repair your own tissues. If the tear is unlikely to heal with the repair I will likely use a cadaver tendon (allograft) to reconstruct the damaged ligament.

For nonoperative treatment, you will undergo a period of bracing and controlled range of motion, the length of which varies based on injury severity.

If operative treatment is indicated you can expect this bracing and controlled range of motion period to be approximately 6 weeks.

It is important to note you will be able to put weight on your leg during this time, but will likely require the assistance of crutches for ambulation.

The Knee

Lateral, Collateral Ligament, and Posterolateral Corner Injuries

The Lateral Collateral Ligament aka “LCL” is a part of the Posterolateral Corner Complex aka “PLC” which are structures on the outer aspect of your knee which control outward bowing (as in bow-legged position) and external rotation of your knee. The LCL and PLC are only rarely injured in isolation. If they are injured, I always suspect further structures to be injured.

These injuries can occur from awkward twisting injuries, a direct blow to the inner aspect of the knee, or from higher energy trauma.

You will experience pain on the outer aspect of the knee often with going up and down stairs, if part of a multi-ligamentous knee injury swelling can occur, additionally patients will experience a sensation of instability and you may feel your knee thrusts outward during walking or more strenuous activities.

Injuries to the PLC often are missed and if not addressed can compromise attempts at treating the other damaged structures of the knee. These can be highly complex injuries. This underscores the importance of being seen by a practitioner who has completed an (ACGME) accredited fellowship in sports surgery.

For minor sprains and partial tears of the LCL we can manage the injury with physical therapy, bracing and protected movements. In these relatively less common scenarios, we can reliably expect a return to sport or activity in 6-8 weeks.

For complete tears of the LCL- especially if the bony insertion from the fibula (small bone in the leg beneath the knee) is pulled off (aka avulsion injury), injuries to the PLC causing instability or a multi-ligamentous knee injury, surgical intervention is discussed.

If there is an avulsion injury of the LCL attachment to the fibula we do not delay in attempting to repair this as we would with any fracture.

If there is a complete tear of the LCL with associated instability or further involvement of the PLC in the setting of a multi-ligamentous injury we commonly discuss reconstruction as a part of a staged procedure to address all injuries. The details of which we will discuss at your visit. Graft choices in these situations can be another tendon about the knee (autograft) or that of a cadaver (allograft), depending on the extent of your injury.

If in the rare instance, we repair or reconstruct only the LCL, you will undergo a period of bracing and protected range of motion for approximately 6 weeks. After this, we will advance your physical therapy with an anticipated return to sport or normal activity in 3 months.

In the more common setting where LCL/PLC injuries require surgery, we are dealing with a multi-ligamentous knee injury which can be quite complex. Commonly I will stage the treatment of these injuries. These injuries can be extensive and are highly individualized, thus any expectations of rehabilitation time and return to activity must be discussed on an individual basis. Again, in these instances, it is imperative to seek treatment from a highly trained specialist. Preferably one who has completed an ACGME accredited sports surgery fellowship.

The Knee

Posterior Cruciate Ligament Injuries

The posterior cruciate ligament, aka PCL, is the counterpart to the more commonly known ACL (anterior cruciate ligament). Its main function is to prevent posterior (backward) movement of the tibia (shin bone). In a smaller, although still important, role it helps prevent external rotation and varus (think bow-legged position) forces at the knee. The classic mechanism of injury is during car accidents when the knee strikes the dashboard. Alternatively, sports injuries can occur during knee hyperextension or when the knee is flexed 90 degrees with the ankle pointed down (plantarflexed).

PCL injuries can occur in isolation. However, they are common components of a multi-ligamentous knee injury.

If the PCL is injured, I will look extensively for an additional injury to the knee, especially to the Posterolateral ligamentous complex (aka PLC – see above section).

Not all PCL injuries require surgery. As with all knee injuries, we will discuss the nature of your injury and your treatment goals. Together we will come to a decision as to your treatment protocol.

In general, for those who are less active, the knee is stable, and/or there are no further injuries to the knee we will discuss a period of bracing and physical therapy.

For those patients with complete PCL injuries, knee instability, and those whose PCL injury is part of complex multi-ligamentous injuries we discuss surgical intervention. If initial non-operative management fails and the knee still feels unstable, we will also discuss surgery. In special circumstances, a piece of bone is pulled off the tibial insertion of the ligament. If this occurs, we discuss surgery on a more urgent basis as we would with any fracture scenario.

Similar to ACL injuries you will undergo a period of bracing and early measures directed at reducing swelling, pain and achieving full range of motion. Restrictions will differ from those of the more common ACL surgery although the overall timeline may be similar. You will work closely with me and your physical therapy team to maximize core and especially quadriceps strength over a period of months. A return to sport should not be expected earlier than 6 months postoperatively.

As with ACL surgery, no graft nor technique has been proven in the scientific literature to accelerate return to sport and activity. Beware of claims to the contrary. Only a combination of well-executed surgery, hard work, and a dedication to physical therapy can guarantee a successful result.