MBBS, MS(Ortho), MRCS(Eng), MRCS(Ire), MRCPS(Glasgow)
Fellowship in Arthroscopy and Knee surgery (South Korea, USA)
Consultant Orthopaedic, Sports Medicine and Joint Replacement Surgeon
August 4, 2015
Our society is obsessed with sport. Sport allows one an escape from the pressures of modern life and it is now an established part of recreation. At all levels of sport, injury is a constant threat. Knee injuries form a bulk of sports injuries.
The knee is the most commonly injured joint in football, basketball and kabaddi.
An injury to the knee can have a long term effect, especially in younger patients. This article highlights briefly the structure of the knee joint, types of knee injuries, their presentation and treatment.
Structure of the human knee joint:
The knee joint has two cruciate ligaments – anterior and posterior cruciate ligaments(ACL and PCL). These ligaments support the knee joint.
In addition, the knee joint has two menisci (act like shock absorbers). These protect the knee joint.
Collateral ligaments - give side to side support to the knee joint.
There are four types of knee injuries associated with sports:
• Anterior and Posterior Cruciate Ligament injuries
• Medial and Lateral Collateral Ligament injuries
• Meniscal tears
• Fracture and cartilage injuries.
The Anterior cruciate ligament (ACL) injury (or rupture) is the most common. Patients usually complain of a sudden “ pop” sensation in the knee with immediate pain.Swelling occurs and increases over 4-6 hours . Other symptoms are reduced knee movements and difficulty in walking. A sudden change in the direction of movement of the knee can provoke such an injury.
Though X rays are taken for the initial evaluation, the investigation of choice is an MRI of the knee.
Once the injury is diagnosed, in acute cases, the management of ACL injury includes splinting the joint and pain relief. In older individuals a non operative approach can be followed. However a younger individual with this injuryis more likely to develop long term instability, and therefore damage to the joint. Hence surgery is recommended.
The surgery in ACL injuries is Arthroscopy guided reconstruction of the ACL. Arthroscopy is a minimally invasive (key hole) operative technique where a camera is inserted into the knee joint through a small wound and high precision surgical instruments are used to reconstruct the torn ACL.
The ideal time for the surgery is usually between 3 weeks after injury as surgery, if done too early, can result in stiffness and failure. Unless there are associated injuries, a good range of motion can be ensured after a knee arthroscopy surgery for the ACL tear.
Post operatively the patient would have to be off work ideally for 4 weeks and can return to contact sports in 6 months.
Another common knee injury is that of the Posterior Cruciate Ligament Mechanism (PCL). It usually occurs due to backward directed force . The symptoms are similar to the ACL injury.
Treatment is usually non operative for isolated PCL ruptures.
Operative treatment is preferred if other ligaments also are injured and the patient has a significant joint instability and pain.
Medial collateral ligament (MCL) Injuries occur due to a sidewards directed force on the knee joint and is the second most common knee injury.
Repair or reconstruction can be done if symptoms are severe.
The classical history in a Meniscal injury (lateral or medial meniscal) is a "locking" or "clicking" sensation in the joint (mechanical symptoms). There will also be localised swelling.
An MRI is the gold standard investigation for diagnosis.
For Meniscal Tears the treatment can be executed in two ways:
1. Arthroscopic Debridement of tear/meniscectomy (cleansing the joint): this can be done as a Day care surgery and allows Quick recovery. Post operatively patients can mobilise early. Effective Physiotherapy is a must post surgery.
2. Arthroscopic Repair of meniscal tear: This surgery needs a longer recovery period with post operativesplinting and non weight bearing for 4-6 weeks. Only certain tears can be repaired as the blood supply to meniscus is poor.
Fracture of the knee: can be clinically subtle and associated with pain. Patients are usually unable to weight bear and have an occasional deformity and associated injuries. The lower bone is fractured more commonly than the upper (tibia > femur).
Initial assessment is done for associated nerve and blood vessel injury . The recommended treatment for fracture knee is to immobilise the joint, administer pain killers, X-rays and MRI. The surgery is Open Reduction and Internal Fixationof the knee and complete union occurs by usually 4 months.
One must bear in mind that physiotherapy is an integral part of the management of knee injuries in both the conservative and surgical settings. Immediate rescue management for knee injury includes rest, icing for 15 minutes, every 2 hours, compression and elevation (RICE). A compression stocking from ankle to upper thigh can help minimise soft tissue swelling .Early orthopaedic referralcan help optimise recovery.
In summary medial collateral ligament, posterior cruciate ligament and some small meniscal injuries can usually be managed without surgery. Most meniscal injuries, anterior cruciate ligament and lateral collateral ligament injuries require surgical management.
The sporting knee and its injuries are increasingly common nowadays. Newer advances in surgical treatment like arthroscopy and repair are highly successful in restoring its function.
Tips to prevent sports injuries of the knee
• Every workout should start with a gentle warm-up to prevent common sports injuries. Getting warmed up increases blood flow to the muscles, makes you more flexible, and can decrease injuries.
• Whether it's hiking, running, or team sports, do some “pre-participation training” first by lightly working the relevant muscle groups in the weeks before the activity.
• Stop when you are fatigued.Muscle fatigue takes away all your protective mechanisms andincreases your risk of all injuries.
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