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LCL Injury/Lateral Collateral Ligament Injury is the primary varus stabilizer of the tibiofemoral joint. Diagnosing an injury to this ligament can be challenging in the setting of multi ligamentous trauma; however, failure to recognize these injuries can result in instability of the knee and unsatisfactory outcomes after cruciate ligament reconstruction. Recent literature exploring the anatomy and biomechanics of the lateral collateral ligament has enhanced our understanding and improved diagnosis and management of these injuries.

Lateral collateral ligament (LCL) sprain occurs when the ligament on the outer side of the knee is overstretched. LCL sprains mainly happen during sporting activities, including contact and non-contact sports, and affect women and men equally. A physical therapist treats LCL sprains to reduce pain, swelling, stiffness, and any associated weakness in the knee or lower extremity.

The lateral collateral ligament (LCL) is one of four critical ligaments involved in stabilizing the knee joint. Stabilizing the knee on the outside, or lateral side, of the joint, it extends from the top-outside surface of the fibula, the bone on the outside of the lower leg, to the bottom-outside surface of the femur, the thigh bone. A lateral collateral ligament injury involves a stretch, partial tear, or complete tear of this particular knee ligament. In some instances, the injury is significant enough to cause an avulsion fracture of the fibular head (out top area of the shin bone).

Types of  Lateral Collateral Ligament Injury

The lateral collateral ligament injury may be classified as follows

• Grade 1 — Some tenderness and minor pain at the point of the injury. This means there have been small tears in the ligament.
• Grade 2 — Noticeable looseness in the knee (the knee opens up about 5 millimeters) when moved by hand. There is a major pain, tenderness, and swelling on the inner side of the knee. This means there have been larger tears in the ligament, but it is not completely torn.
• Grade 3 — Considerable pain and tenderness at the inner side of the knee; some swelling and marked joint instability. The knee opens up slightly less than half an inch when moved. A grade 3 LCL tear means the ligament is completely torn. There may also be a tear of the anterior cruciate ligament.

Causes of Lateral Collateral Ligament Injury

LCL tears are commonly seen in contact sports or activities that involve twisting and heavy lifting. They can occur in the following instances

• When the inside (medial side) of the knee is hit directly – such as during soccer or a football tackle, putting extra stress on the LCL on the outside (lateral side) the knee
• Quickly changing directions – such as cutting or pivoting maneuvers, which puts unusual pressure on the knee causing the ligament to stretch or tear
• Landing awkwardly on the knee – which may happen after a jump in volleyball or basketball
• Hyperextending the knee – which is caused when the joint is pushed passed its normal range of motion either forwards or backward
• Squatting or lifting heavy objects – such as during weightlifting or in physical occupations.
• Motor vehicle accidents – A dashboard injury occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing a tear.
• Contact sports – Athletes in sports such as football and soccer can tear their ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
• The knee is hit directly – especially during sports like soccer, rugby, and football
• A person lands on a bent knee – such as during a fall or misstep
• Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
• A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
• A person lands on one leg – which can happen after a jump in basketball or volleyball
• A direct blow to the bent knee in an automobile injury
• A sports-related injury in which the knee bends
• Pulling on the ligament in a twisting injury or hyperextension
• A misstep on uneven terrain
• When the knee is hit directly on its outer side, such as from a football tackle
• As a result of cutting maneuvers, when an athlete plants a foot and forcefully shifts direction

Symptoms of Lateral Collateral Ligament Injury

People with knee lateral collateral ligament (LCL) injuries often report a combination of the following symptoms:

• Pain along the outside of the knee – This can be mild to severe depending on the severity of the tear. Pain and swelling on the outside or posterolateral aspect of the knee
• Tenderness – The outside of the knee may be painful to the touch.
• Swelling along the outside of the knee – This can happen immediately following the injury or develop up to 2 or 3 hours after it occurred. Swelling and tenderness along the outside of the knee
• Decreased range of motion – Certain movements, such as bending at the knee, may be difficult.
• Knee catching or locking – The knee may feel like it gets stuck during movement; a person may have difficulty fully bending or extending the knee.
• Bruising – Some people may experience bruising around the outside of the knee, which is caused by tiny blood vessel tears under the skin.
• Trouble bearing weight – Depending on the severity of the injury, a person may have difficulty bearing weight on the affected leg, such as when standing and walking. People with more severe tears may develop instability and feel as if the knee is going to buckle or give way.
• Foot numbness – A person may experience foot numbness if the peroneal nerve, located near the LCL, is stretched during the injury or affected by tissue swelling. Numbness or weakness in the foot may occur if the peroneal nerve, which is near the ligament is stretched during the injury or is pressed by swelling in surrounding tissues.
• Pain with walking or bending the knee
• Feelings of instability (knee giving out) while walking or doing an activity
• Mechanical symptoms (locking, catching) may indicate associated meniscus injury
• A feeling that the knee may give way under stress and isn’t stable
• A locking or catching in the joint when it is moved
• Pain that can be mild or acute
• Stiffness

Diagnosis of Lateral Collateral Ligament Injury

Physical Exam

Testing of the knee joint should be done using the following techniques and the findings compared to the contralateral, normal knee:^[rx][rx]

• Valgus stress at 0° and 20° – This test puts direct stress on the medial knee structures, reproducing the mechanism of injury. Valgus stress testing is done with the patient supine on the exam table. The lower extremity, supported by the examiner, is abducted. The examiner’s fingers monitor the medial joint space for gapping while placing the opposite hand on the ankle. The knee is placed in 20° of flexion. The examiner then uses their own thigh as a fulcrum at the knee and applies a valgus force (pulling the foot and ankle away from the patient’s body). The force is then used to establish the amount of gapping present within the joint. It has been reported that 20° of flexion is best for isolating the MCL, allowing the practitioner to establish the degree of injury (see Classification). Additional testing is done at 0° to determine if a Grade III injury is present.^[rx][rx]
• Valgus stress testing –  is the best way to test the integrity of the MCL directly. The patient should be positioned supine with the hip abducted on the affected side so that the leg is unsupported off the table. The knee should be brought into 30 degrees of flexion. The examiner should grasp the ankle with one hand and push the ankle laterally while applying a valgus force to the knee with the other hand.
• Anteromedial drawer test – This test is performed with the patient supine with the knee flexed to 80-90°. The foot is externally rotated 10-15° and the examiner supplies an anterior and external rotational force. The joint can then be evaluated for tibial anteromedial rotation, taking care to recognize the possibility of posterolateral corner instability giving similar rotational test results. As always, compare the test in the opposite knee.^[rx][rx][rx]
• Dial Test (anteromedial rotation test) – This test should be executed with the patient lying both supine and prone. When the patient is supine, the knees must be flexed 30° off the table. The thigh is then stabilized and the foot externally rotated. The examiner watches for the tibial tubercle of the affected knee to rotate as the foot rotates, comparing it to the contralateral knee. A positive test will show the rotation of greater than 10-15° of rotation compared to the opposite knee. This is most easily assessed with a hand placed over the tibia while testing. When the patient is prone, the knee is flexed to 90° and both feet are externally rotated and compared, noting the difference from the non-injured joint. Similar to the anteromedial drawer test, a false positive test can result from a posterolateral corner injury. Testing at both 30° and 90° helps to distinguish between these injuries: one should monitor where the tibial rotation occurs (anteromedial or posterolateral) in the supine position and also assess for medial or lateral joint line gapping to differentiate between these two injuries.^[rx][rx][rx]

Imaging Test

• X-rays – use low levels of radiation and give doctors a view of a person’s bones. Although LCL injuries do not show up on standard X-ray exams, they are a relatively inexpensive, fast way to rule out other possible injuries that might be causing the symptoms. Additionally, a stress X-ray—where a physician applies a valgus force to the knee during the exam—can help to determine the degree of ligamentous injury.
• Magnetic resonance imaging (MRI) – shows a detailed view of the soft tissue surrounding the knee joint. An MRI can also help a doctor determine the location and grade of an LCL tear.
• Ultrasound imaging – uses high-frequency sound waves to build a picture of the knee’s tissues. Ultrasound can be utilized in situations when an MRI is not recommended. Ultrasound may also be used in an urgent care setting to make an immediate assessment, allowing the injury to be treated more quickly.

Treatment of Lateral Collateral Ligament Injury

Immediately following the injury, the RICE method is recommended

• Rest – Activities that cause knee pain, such as running or walking for long periods of time, should be avoided until pain and swelling go away. The activity that caused the injury should be avoided until fully recovered.
• Ice – A person may wish to apply ice packs to the area to help reduce pain and swelling. Ice packs can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected knee.
• Elevation – Keeping the knee elevated and supported above the waist—for example, sitting in a recliner or lying down with the knee propped up on pillows—may help with swelling.
• Wear a knee cap – that allows the knee to move forward and backward but restricts side-to-side movement. Apply minimally restrictive lateral hinge brace (grade II or III injuries).
• Use crutches – to avoid weight-bearing. Crutches are not needed in all cases. Dispense crutches; allow weight-bearing as tolerated.
• Bracing – Your knee must be protected from the same sideways force that caused the injury. You may need to change your daily activities to avoid risky movements. Your doctor may recommend a brace to protect the injured ligament from stress. To further protect your knee, you may be given crutches to keep you from putting weight on you.

Physiotherapy

• Reduce Pain and Swelling – Your physical therapist may use different types of treatments and technologies to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy, such as massage.
• Improve Motion – Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and leg. These might begin with “passive” motions that your physical therapist performs for you to gently move your leg and knee joint, and progress to active exercises and stretches that you do yourself.
• Improve Flexibility – Your physical therapist will determine if any of your leg muscles are tight, and teach you how to stretch them.
• Improve Strength – Certain exercises will aid healing at each stage of recovery. Your physical therapist will choose the exercises and equipment that are right for your specific condition to steadily restore your strength and agility. These may include cuff weights, stretch bands, weight-lifting equipment, and cardio exercise equipment, such as treadmills or stationary bicycles.
• Improve Balance and Agility – Regaining your sense of balance is important after an injury. For athletes, restoring agility is important, also. Your physical therapist will teach you exercises to improve your balance and agility skills.
• Speed Recovery Time – Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.
• Return to Activities – Your physical therapist will discuss your goals with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.

Medication

If the injury is severe and pain is intolerable the following medicine can be considered to prescribe

• Take anti-inflammatory medications – Non-steroidal anti-inflammatory drugs (NSAIDs), like will help with pain and swelling. However, these drugs can have side effects, such as an increased risk of bleeding and ulcers. They should be only used occasionally unless your doctor specifically says otherwise.
• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with injury and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for a knee injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of ligament injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.
• Platelet-rich plasma (PRP) injection – newer therapy where a blood sample is taken from the patient, spun in a centrifuge, growth factors are isolated and then they are injected back into the affected site to stimulate faster healing.

Rehabilitation

The rehabilitation for a non-operative treatment can be split into four phases:

• Phase one –  is from one to two weeks. Phase one consists of controlling the swelling of the knee by applying ice for 15 minutes every two hours (first two days). The rest of the week the frequency can be reduced to three times a day. Use ice as tolerated and as needed based on symptoms. In the beginning, the patient needs to use crutches. Early weight bearing is encouraged because patients who increasing their weight-bearing, they can progressively reduce their dependence on crutches. Afterward, progress to one crutch and let the patient stop using the crutches only when normal gait is possible. Another aim of this phase is to try to maintain the ability to straighten and bend the knee from 0° to 90° knee flexion. For achieving the range of motion of the knee it is important to emphasize full extension and progress flexion as tolerated. Pain-free stretches for the hamstrings, quads, groin and calf muscles (in particular) are suggested. At last, there are therapeutic exercises. The patient may begin with static strengthening exercises (as soon as pain allows it). They consist for example of Quadricpes sets, straight leg raises, range-of-motion exercises, sitting hip flexion, side-lying hip abduction, standing hip extension, standing, and hamstring curls. As soon as patients can tolerate it, they are encouraged to ride a stationary bike to improve the range of motion of the knee. This would ensure accelerated healing. The amount of time and effort on the stationary bike is increased as tolerated. Obviously, every patient is different and these are not the standard exercises that have to be given to patients. There are no limits on upper extremity workouts that do not affect the injured knee^[rx]. It’s important that the patient rests from all painful activities (use crutches if necessary), and that the MCL is well protected (by wearing a stabilized knee brace).
• Starting at week three-phase two begins – The aims for the range of motion are the same as in phase one. Progress to 20 minutes of biking. Increase also the resistance as tolerated by the patient. Biking will ensure healing, rebuild strength, and maintain aerobic conditioning. The physiotherapist can give other exercises like Hamstring curls, leg presses (double-leg), and step-ups. As a precaution, the patient has the chance to be examined by a physician every three weeks to verify the healing of the ligament^[rx].
• Phase three starts from week five –  A major goal for this phase: full weight-bearing on the injured knee. Discontinue the use of a brace when ambulating with full weight-bearing is possible and there is no gait deviation. The range of motion has to be fully achieved and had to be symmetrical with the not injured knee. The therapeutic exercises are the same as in phase two. They may benefit progression. We continue with cold therapy and compression to eliminate swelling. In this phase, you can commence with balance and proprioceptive activities. To maintain aerobic fitness the patient can use the stepper or (if possible) may begin to swim. As a precaution, the patient has the chance to be examined by a physician every five to six weeks. When needed, you can be allowed to make stress radiography as a precaution.^[rx]
• Six weeks after injuring the knee, phase four can begin – Discontinue wearing the brace during the gait. Athletics can wear the brace for competition through the competitive season for at least three months. Cold therapy still needs to be applied. The aim of the therapeutic exercises is more focused on sport-specific or daily movements. The intensity of the strengthening exercises needs to be increased and instead of double leg exercises, we change to single-leg exercises. The patient may start running again at a comfortable pace (make sure the patient doesn’t make sudden changes of direction). As a precaution, it is best to return the competition once full motion and strength is returned and when the patient passes a sport functional test^[rx].

How To Do The Exercises for Lateral Collateral Ligament Injury

Knee Flexion With Heel Slide

Slide 1 Of 10, Knee Flexion With Heel Slide,

• Lie on your back with your knees bent.
• Slide your heel back by bending your affected knee as far as you can. Then hook your other foot around your ankle to help pull your heel even farther back.
• Hold for about 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Heel Slides On A Wall

Slide 2 Of 10, Heel Slides On A Wall,

• Lie on the floor close enough to a wall so that you can place both legs up on the wall. Your hips should be as close to the wall as is comfortable for you.
• Start with both feet resting on the wall. Slowly let the foot of your affected leg slide down the wall until you feel a stretch in your knee.
• Hold for 15 to 30 seconds.
• Then slowly slide your foot up to where you started.
• Repeat 2 to 4 times.

Quad Sets

Slide 3 Of 10, Quad Sets,

• Sit with your affected leg straight and supported on the floor or a firm bed. Place a small, rolled-up towel under your knee. Your other leg should be bent, with that foot flat on the floor.
• Tighten the thigh muscles of your affected leg by pressing the back of your knee down into the towel.
• Hold for about 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Short-Arc Quad

Slide 4 Of 10, Short-Arc Quad,

• Lie on your back with your knees bent over a foam roll or a large rolled-up towel.
• Lift the lower part of your affected leg and straighten your knee by tightening your thigh muscle. Keep the bottom of your knee on the foam roll or rolled-up towel.
• Hold your knee straight for about 6 seconds, then slowly bend your knee and lower your leg back to the floor. Rest for up to 10 seconds between repetitions.
• Repeat 8 to 12 times.

Straight-Leg Raises To The Front

Slide 5 Of 10, Straight-Leg Raises To The Front,

• Lie on your back with your good knee bent so that your foot rests flat on the floor. Your affected leg should be straight. Make sure that your low back has a normal curve. You should be able to slip your hand in between the floor and the small of your back, with your palm touching the floor and your back touching the back of your hand.
• Tighten the thigh muscles in your affected leg by pressing the back of your knee flat down to the floor. Hold your knee straight.
• Keeping the thigh muscles tight and your leg straight, lift your affected leg up so that your heel is about 30 centimeters off the floor. Hold for about 6 seconds, then lower slowly.
• Relax for up to 10 seconds between repetitions.
• Repeat 8 to 12 times.

Hamstring Set (Heel Dig)

Slide 6 Of 10, Hamstring Set (Heel Dig),

• Sit with your affected leg bent. Your good leg should be straight and supported on the floor.
• Tighten the muscles on the back of your bent leg (hamstring) by pressing your heel into the floor.
• Hold for about 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Hip Adduction

Slide 7 Of 10, Hip Adduction,

• Sit on the floor with your knees bent.
• Place a pillow between your knees.
• Put your hands slightly behind your hips for support.
• Squeeze the pillow by tightening the muscles on the inside of your thighs.
• Hold for 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Hip Abduction

Slide 8 Of 10, Hip Abduction,

• Sit on the floor with your affected knee close to a wall.
• Bend your affected knee but keep the other leg straight in front of you.
• Place a pillow between the outside of your knee and the wall.
• Put your hands slightly behind your hips for support.
• Push the outside of your knee against the pillow and the wall.
• Hold for 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Lateral Step-Up

Slide 9 Of 10, Lateral Step-Up,

• Stand sideways on the bottom step of a staircase with your injured leg on the step and your other foot on the floor. Hold on to the banister or wall.
• Use your injured leg to raise yourself up, bringing your other foot level with the stair step. Make sure to keep your hips level as you do this. And try to keep your knee moving in a straight line with your middle toe. Do not put the foot you are raising on the stair step.
• Slowly lower your foot back down.
• Repeat 8 to 12 times.

Wall Squats With Ball

Slide 10 Of 10, Wall Squats With Ball,

• Stand with your back facing a wall. Place your feet about a shoulder-width apart.
• Place the therapy ball between your back and the wall, and move your feet out in front of you so they are about 30 centimeters in front of your hips.
• Keep your arms at your sides, or put your hands on your hips.
• Slowly squat down as if you are going to sit in a chair, rolling your back over the ball as you squat. The ball should move with you but stay pressed into the wall.
• Be sure that your knees do not go in front of your toes as you squat.
• Hold for 6 seconds.
• Slowly rise to your standing position.
• Repeat 8 to 12 times.

Lateral Meniscus Torn/Lateral Meniscus Injury is a crescent-shaped two semilunar fibrocartilaginous tissue, comprised of both a medial and a lateral component positioned between the corresponding femoral condyle and tibial plateau, and plays important roles in the knee joint, including force transmission, shock absorption, joint lubrication, and the provision of joint stability.^[rx] Together with the medial meniscus, the lateral meniscus provides a concave surface for the convex femoral condyles to articulate superior to the relatively flat tibial plateaus.

The lateral meniscus (external semilunar fibrocartilage) is a fibrocartilaginous band that spans the lateral side of the interior of the knee joint. It is one of two menisci of the knee, the other being the medial meniscus. It is nearly circular and covers a larger portion of the articular surface than the medial. It can occasionally be injured or torn by twisting the knee or applying direct force, as seen in contact sports.

Anatomy of Lateral Meniscus Torn

The anterior and posterior horns of the lateral meniscus both attach to the tibia. The anterior horn of the lateral meniscus inserts anterior to the intercondylar eminence next to the attachment site of the ACL, while the insertion of the posterior horn lies posterior to the lateral tibial spine and anterior to the insertion of the posterior horn of the medial meniscus. The meniscofemoral ligaments attach the posterior horn of the lateral meniscus to the lateral part of the medial femoral condyle. Although the lateral meniscus is attached to the majority of the anterior and posterior capsule of the knee joint, there is an area posterolaterally in the region of the popliteus tendon where the lateral meniscus is not attached to the joint capsule. This arrangement allows the lateral meniscus more mobility than the medial meniscus and is one reason why the lateral meniscus is less susceptible to tearing than its medial counterpart. The lateral meniscus is also larger than the medial meniscus and carries a more significant percentage of the lateral compartment pressure than the medial meniscus carries for the medial compartment.[rx]

The cells of the menisci are termed fibrochondrocytes since they appear morphologically to be a mix of fibroblasts and chondrocytes. Cells in the superficial layers of the meniscus appear more fibroblastic in nature, whereas cells deeper in the meniscus are more chondrocyte. The meniscal extracellular matrix (ECM) is composed primarily of water and collagen with a small percentage of proteoglycans, noncollagenous proteins, and glycoproteins. The collagen found in the meniscus is almost all type I collagen, with some variable amounts of types II, III, V, and VI. Collagen fibers located in the deeper layers of the meniscus are oriented circumferentially, parallel to the peripheral border, while the more superficial layers contain more radially oriented fibers. These radially oriented fibers are interspersed in the deeper layers as well to provide structural integrity. The proteoglycans found in the ECM provide hydration to the tissue, which allows the meniscus a high capacity to resist compressive loads. As a result, the highest concentration of these glycosaminoglycans is present in the primary weight-bearing areas, the meniscal horns and inner half of the menisci.[rx]

Types of Lateral Meniscus Torn

• Longitudinal tear or injury – This is a tear that occurs along the length of the meniscus
• Bucket handle tear or injury – This is an exaggerated form of a longitudinal tear where a portion of the meniscus becomes detached from the tibia forming a flap that looks like a bucket handle

A meniscal tear can be classified in various ways, such as by anatomic location or by proximity to the blood supply. Various tear patterns and configurations have been described.^[rx] These include

• Radial tears
• Flap or parrot-beak tears
• Peripheral, longitudinal tears
• Bucket-handle tears
• Horizontal cleavage tears
• Complex, degenerative tears

These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.

The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:

• Age/strength
• Activity level
• Tear pattern
• Chronicity of the tear
• Associated injuries (anterior cruciate ligament injury)
• Healing potential

Causes Of Lateral Meniscus Torn

Symptoms Of Lateral Meniscus Torn

If you’ve torn your meniscus, you might have the following signs and symptoms in your knee:

• Localized pain near the area of the tear – In tears of the lateral meniscus, this discomfort will be present along the outside edge of the knee. The pain will manifest on the inside edge of the injured knee for tears of the medial meniscus.
• Immediate pain after the injury – A torn lateral meniscus will often be obvious from the moment that the injury occurs. In these instances, the tearing of the meniscus is typically accompanied by the feeling of a pop or snap within the leg during an overexerting twisting or stretching motion.
• Slow onset of symptoms – Conversely, for some, the meniscus can tear without much of a sign or initial pain. This slow onset of symptoms is more common in older individuals and those with damaged knee cartilage from osteoarthritis.
• Pain with movement – The pain will reflect the location of the tear but extend throughout the knee with movement. In the event that the knee has locked, bending it will cause searing pain to worsen.
• Pain after resting – Pain will likely diminish somewhat with rest; however, it will return with movement in most cases. Movement may also exacerbate swelling.
• Fluid accumulation within the knee joint – This accumulated fluid will cause the entire area to swell up and reduce mobility. This symptom, which may occur as a result of a number of knee injuries, is known as water on the knee.
• Knee locking – If a piece of the meniscus breaks free of the disc structure due to a tear, it may lodge within the joint of the knee itself. This lodging can cause knee locking, in which a person loses the ability to fully straighten the leg when sitting or standing.
• Feeling of your knee giving way
• Pain in the knee
• A popping sensation during the injury
• Difficulty bending and straightening the leg
• A tendency for your knee to get “stuck” or lock up
• Tenderness or pain around the lateral surface of the knee joint
• Swelling- usually within 24-48 hours of injury
• Pain, particularly when bending the knee
• Pain when rotating and pressing down on the knee in the prone position.
• Audible popping, cracking or clicking sounds
• Positive ‘McMurray’s‘ test

Diagnosis of Lateral Meniscus Torn

Physical examination

The physical examination must be carried out thoroughly and methodically. Patients with medial meniscal injuries complain of pain in the medial aspect of the knee. McMurray test, Apley grind test, and the bounce home test are positive in medial meniscopathy.

• McMurray test – The patient lies supine, the knee is fully flexed. The surgeon grasps the heel. The leg is rotated on the thigh with the knee in full flexion. The leg is flexed to 90° while the foot is maintained first in full internal rotation and then rotated in full external rotation. In patients with a torn meniscus, a click occurs and the patient complains of pain.
• Apley grind test – With the patient lying prone, the surgeon grasps the foot, rotates it externally as far as possible, and flexes the knee to 90°. The foot is rotated internally, and the knee is extended. The surgeon then applies his left knee to the back of the patient’s thigh. The tibia is then compressed onto the knee joint while being externally rotated. If the addition of compression produces an increase in pain, this grinding test is positive, and meniscal damage is diagnosed.
• Bounce home test – With the patient lying supine, the surgeon grasps the foot, flexes completely the knee. The knee is then passively allowed to extend. The knee should extend completely or bounce home into extension with a sharp endpoint. A positive test occurs when full extension cannot be attained.

Imaging Tests

Imaging tests may be ordered to confirm a tear of the lateral meniscus. These include

Knee X-Ray

• This test won’t show a meniscus tear. However, it can be helpful to determine if there are any other causes of your knee pain, like osteoarthritis and other associated symptoms.

MRI

• An MRI uses a magnetic field to take multiple images of your knee. An MRI will be able to take pictures of cartilage and ligaments to determine if there’s a lateral meniscus tear.
• While MRIs can help your doctor make a diagnosis, they aren’t considered 100 percent reliable. According to a study from 2018 published in the Journal of Trauma Management & OutcomesTrusted Source, the MRI’s accuracy for diagnosing lateral meniscus tears is 77 percent.
• Sometimes, meniscus tears may not show up on an MRI because they can closely resemble degenerative or age-related changes. Additionally, a doctor may make an incorrect diagnosis that a person has a torn meniscus. This is because some structures around the knee can closely resemble a meniscus tear.

Ultrasound

• An ultrasound uses sound waves to take images inside the body. This will determine if you have any loose cartilage that may be getting caught in your knee pain with a lateral meniscus injury.

Arthroscopy

• If your doctor is unable to determine the cause of your knee pain from these techniques, they may suggest arthroscopy to study your knee. If you require surgery, your doctor will also most likely use an arthroscope.
• With arthroscopy, a small incision or cut is made near the knee. The arthroscope is a thin and flexible fiber-optic device that can be inserted through the incision. It has a small light and camera. Surgical instruments can be moved through the arthroscope or through additional incisions in your knee.
• After an arthroscopy, either for surgery or examination, people can often go home the same day.

Treatment of Lateral Meniscus Torn

Non-Surgical 

• Protection  – the joint from further injury by taping/strapping the knee joint, or wearing knee support which has additional support at the sides.
• Rest – Avoid activities that aggravate your knee pain, especially any activity that causes you to twist, rotate, or pivot your knee. If your pain is severe, using crutches can take the pressure off your knee and promote healing.
• Ice – Ice can reduce knee pain and swelling. Use a cold pack, a bag of frozen vegetables, or a towel filled with ice cubes for about 15 minutes at a time, keeping your knee elevated. Do this every four to six hours the first day or two, and then as often as needed. Ice your knee to reduce pain and swelling. Do it for 15-20 minutes every 3-4 hours for 2-3 days or until the pain and swelling are gone.
• Elevate your knee – with a pillow under your heel when you’re sitting or lying down. It helps to reduce swelling and fluid accumulation in knee joint
• A stabilized knee brace –  has flexible springs in the sides for additional support or for more severe injuries a hinged knee brace with solid metal supports linked by a hinge will help protect the joint from sideways or lateral movement. Compression will also help reduce swelling.
• Rest the knee –  Limit activities to include walking if the knee is painful. Use crutches to help relieve pain.
• Compress your knee – Use an elastic bandage or a neoprene type sleeve on your knee to control swelling.
• Use stretching and strengthening exercises to help reduce stress to your knee – Ask your doctor to recommend a physical therapist for guidance.
• Avoid impact activities such as running and jumping 
• Full weight-bearing is not permitted for 1 – 6 weeks – after surgery, depending on the type of injury and repair. Crutches will be used initially following surgery. Many surgeons brace the knee and restrict motion for 6 weeks, to prevent excessive flexion and extension.
• Range of motion exercises – begin anywhere from 0 – 6 weeks after surgery, depending on the type of repair.
• Strengthening exercises – begin once full range of motion has returned.
• Return to vigorous activities – such as sports, may begin 3 – 4 months after repair.

Physiotherapy

• Continuous Passive Motion – Clinicians can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain.
• Early Weight Bearing – Early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function.
• Knee Bracing – The use of functional knee bracing appears to be more beneficial than not using a brace in patients with ACL deficiency.  The use of immediate postoperative knee bracing appears to be no more beneficial than not using a brace in patients following ACL reconstruction. Conflicting evidence exists for the use of functional knee bracing in patients following ACL reconstruction.  Knee bracing can be used for patients with acute posterior cruciate ligament (PCL) injuries, severe medial (tibial) collateral ligament (MCL) injuries, or posterior lateral corner (PLC) injuries.
• Immediate Versus Delayed Mobilization – Clinicians should consider the use of immediate mobilization following ACL reconstruction to increase range of motion, reduce pain, and limit adverse changes to soft tissue structures.
• Cryotherapy – Clinicians should consider the use of cryotherapy to reduce postoperative knee pain immediately post-ACL reconstruction.
• Therapeutic Exercises – Clinicians should consider the use of non–weight-bearing (open chain) exercises in conjunction with weight-bearing (closed-chain) exercises in patients with knee stability and movement coordination impairments.
• Neuromuscular Electrical Stimulation – Neuromuscular electrical stimulation can be used with patients following ACL reconstruction to increase quadriceps muscle strength.
• Neuromuscular Reeducation – Clinicians should consider the use of neuromuscular training as a supplementary program to strength training in patients with knee stability and movement coordination impairments.
• Accelerated” Rehabilitation – Rehabilitation that emphasizes early restoration of knee extension and early weight-bearing activity appears safe for patients with ACL reconstruction. No evidence exists to determine the efficacy and/or safety of early return to sports.
• Eccentric Strengthening – Clinicians should consider the use of an eccentric exercise ergometer in patients following ACL reconstruction to increase muscle strength and functional performance. Clinicians should consider the use of an eccentric squat program in patients with PCL injury to increase muscle strength and functional performance.
• Electrotherapy i.e ultrasound, laser therapy, and TENS.
• Manual therapy
• Once the pain has subsided, exercises to increase range of movement, balance, and maintain quadriceps strength may be prescribed. These may include: squatting, single calf raises, and later, wobble-board techniques.

Medication

If the pain is a serious and intolerable or acute injury the following medicine may prescribe in the lateral meniscus injury

• Take anti-inflammatory medications. Non-steroidal anti-inflammatory drugs (NSAIDs), like will help with pain and swelling. However, these drugs can have side effects, such as an increased risk of bleeding and ulcers. They should be only used occasionally unless your doctor specifically says otherwise.
• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic meniscus injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with a meniscus injury and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee meniscus injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of meniscus injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgery

Lateral Meniscus Tear/Lateral Meniscus Injury is a crescent-shaped two semilunar fibrocartilaginous tissue, comprised of both a medial and a lateral component positioned between the corresponding femoral condyle and tibial plateau, and plays important roles in the knee joint, including force transmission, shock absorption, joint lubrication, and the provision of joint stability.^[rx] Together with the medial meniscus, the lateral meniscus provides a concave surface for the convex femoral condyles to articulate superior to the relatively flat tibial plateaus.

The lateral meniscus (external semilunar fibrocartilage) is a fibrocartilaginous band that spans the lateral side of the interior of the knee joint. It is one of two menisci of the knee, the other being the medial meniscus. It is nearly circular and covers a larger portion of the articular surface than the medial. It can occasionally be injured or torn by twisting the knee or applying direct force, as seen in contact sports.

Anatomy of Lateral Meniscus Tear

The anterior and posterior horns of the lateral meniscus both attach to the tibia. The anterior horn of the lateral meniscus inserts anterior to the intercondylar eminence next to the attachment site of the ACL, while the insertion of the posterior horn lies posterior to the lateral tibial spine and anterior to the insertion of the posterior horn of the medial meniscus. The meniscofemoral ligaments attach the posterior horn of the lateral meniscus to the lateral part of the medial femoral condyle. Although the lateral meniscus is attached to the majority of the anterior and posterior capsule of the knee joint, there is an area posterolaterally in the region of the popliteus tendon where the lateral meniscus is not attached to the joint capsule. This arrangement allows the lateral meniscus more mobility than the medial meniscus and is one reason why the lateral meniscus is less susceptible to tearing than its medial counterpart. The lateral meniscus is also larger than the medial meniscus and carries a more significant percentage of the lateral compartment pressure than the medial meniscus carries for the medial compartment.[rx]

The cells of the menisci are termed fibrochondrocytes since they appear morphologically to be a mix of fibroblasts and chondrocytes. Cells in the superficial layers of the meniscus appear more fibroblastic in nature, whereas cells deeper in the meniscus are more chondrocyte. The meniscal extracellular matrix (ECM) is composed primarily of water and collagen with a small percentage of proteoglycans, noncollagenous proteins, and glycoproteins. The collagen found in the meniscus is almost all type I collagen, with some variable amounts of types II, III, V, and VI. Collagen fibers located in the deeper layers of the meniscus are oriented circumferentially, parallel to the peripheral border, while the more superficial layers contain more radially oriented fibers. These radially oriented fibers are interspersed in the deeper layers as well to provide structural integrity. The proteoglycans found in the ECM provide hydration to the tissue, which allows the meniscus a high capacity to resist compressive loads. As a result, the highest concentration of these glycosaminoglycans is present in the primary weight-bearing areas, the meniscal horns and inner half of the menisci.[rx]

Types of Lateral Meniscus Tear

• Longitudinal tear or injury – This is a tear that occurs along the length of the meniscus
• Bucket handle tear or injury – This is an exaggerated form of a longitudinal tear where a portion of the meniscus becomes detached from the tibia forming a flap that looks like a bucket handle

A meniscal tear can be classified in various ways, such as by anatomic location or by proximity to the blood supply. Various tear patterns and configurations have been described.^[rx] These include

• Radial tears
• Flap or parrot-beak tears
• Peripheral, longitudinal tears
• Bucket-handle tears
• Horizontal cleavage tears
• Complex, degenerative tears

These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.

The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:

• Age/strength
• Activity level
• Tear pattern
• Chronicity of the tear
• Associated injuries (anterior cruciate ligament injury)
• Healing potential

Causes Of Lateral Meniscus Tear

Symptoms Of Lateral Meniscus Tear

If you’ve torn your meniscus, you might have the following signs and symptoms in your knee:

• Localized pain near the area of the tear – In tears of the lateral meniscus, this discomfort will be present along the outside edge of the knee. The pain will manifest on the inside edge of the injured knee for tears of the medial meniscus.
• Immediate pain after the injury – A torn lateral meniscus will often be obvious from the moment that the injury occurs. In these instances, the tearing of the meniscus is typically accompanied by the feeling of a pop or snap within the leg during an overexerting twisting or stretching motion.
• Slow onset of symptoms – Conversely, for some, the meniscus can tear without much of a sign or initial pain. This slow onset of symptoms is more common in older individuals and those with damaged knee cartilage from osteoarthritis.
• Pain with movement – The pain will reflect the location of the tear but extend throughout the knee with movement. In the event that the knee has locked, bending it will cause searing pain to worsen.
• Pain after resting – Pain will likely diminish somewhat with rest; however, it will return with movement in most cases. Movement may also exacerbate swelling.
• Fluid accumulation within the knee joint – This accumulated fluid will cause the entire area to swell up and reduce mobility. This symptom, which may occur as a result of a number of knee injuries, is known as water on the knee.
• Knee locking – If a piece of the meniscus breaks free of the disc structure due to a tear, it may lodge within the joint of the knee itself. This lodging can cause knee locking, in which a person loses the ability to fully straighten the leg when sitting or standing.
• Feeling of your knee giving way
• Pain in the knee
• A popping sensation during the injury
• Difficulty bending and straightening the leg
• A tendency for your knee to get “stuck” or lock up
• Tenderness or pain around the lateral surface of the knee joint
• Swelling- usually within 24-48 hours of injury
• Pain, particularly when bending the knee
• Pain when rotating and pressing down on the knee in the prone position.
• Audible popping, cracking or clicking sounds
• Positive ‘McMurray’s‘ test

Diagnosis of Lateral Meniscus Tear

Physical examination

The physical examination must be carried out thoroughly and methodically. Patients with medial meniscal injuries complain of pain in the medial aspect of the knee. McMurray test, Apley grind test, and the bounce home test are positive in medial meniscopathy.

• McMurray test – The patient lies supine, the knee is fully flexed. The surgeon grasps the heel. The leg is rotated on the thigh with the knee in full flexion. The leg is flexed to 90° while the foot is maintained first in full internal rotation and then rotated in full external rotation. In patients with a torn meniscus, a click occurs and the patient complains of pain.
• Apley grind test – With the patient lying prone, the surgeon grasps the foot, rotates it externally as far as possible, and flexes the knee to 90°. The foot is rotated internally, and the knee is extended. The surgeon then applies his left knee to the back of the patient’s thigh. The tibia is then compressed onto the knee joint while being externally rotated. If the addition of compression produces an increase in pain, this grinding test is positive, and meniscal damage is diagnosed.
• Bounce home test – With the patient lying supine, the surgeon grasps the foot, flexes completely the knee. The knee is then passively allowed to extend. The knee should extend completely or bounce home into extension with a sharp endpoint. A positive test occurs when full extension cannot be attained.

Imaging Tests

Imaging tests may be ordered to confirm a tear of the lateral meniscus. These include

Knee X-Ray

• This test won’t show a meniscus tear. However, it can be helpful to determine if there are any other causes of your knee pain, like osteoarthritis and other associated symptoms.

MRI

• An MRI uses a magnetic field to take multiple images of your knee. An MRI will be able to take pictures of cartilage and ligaments to determine if there’s a lateral meniscus tear.
• While MRIs can help your doctor make a diagnosis, they aren’t considered 100 percent reliable. According to a study from 2018 published in the Journal of Trauma Management & OutcomesTrusted Source, the MRI’s accuracy for diagnosing lateral meniscus tears is 77 percent.
• Sometimes, meniscus tears may not show up on an MRI because they can closely resemble degenerative or age-related changes. Additionally, a doctor may make an incorrect diagnosis that a person has a torn meniscus. This is because some structures around the knee can closely resemble a meniscus tear.

Ultrasound

• An ultrasound uses sound waves to take images inside the body. This will determine if you have any loose cartilage that may be getting caught in your knee pain with a lateral meniscus injury.

Arthroscopy

• If your doctor is unable to determine the cause of your knee pain from these techniques, they may suggest arthroscopy to study your knee. If you require surgery, your doctor will also most likely use an arthroscope.
• With arthroscopy, a small incision or cut is made near the knee. The arthroscope is a thin and flexible fiber-optic device that can be inserted through the incision. It has a small light and camera. Surgical instruments can be moved through the arthroscope or through additional incisions in your knee.
• After an arthroscopy, either for surgery or examination, people can often go home the same day.

Treatment of Lateral Meniscus Tear

Non-Surgical 

• Protection  – the joint from further injury by taping/strapping the knee joint, or wearing knee support which has additional support at the sides.
• Rest – Avoid activities that aggravate your knee pain, especially any activity that causes you to twist, rotate, or pivot your knee. If your pain is severe, using crutches can take the pressure off your knee and promote healing.
• Ice – Ice can reduce knee pain and swelling. Use a cold pack, a bag of frozen vegetables, or a towel filled with ice cubes for about 15 minutes at a time, keeping your knee elevated. Do this every four to six hours the first day or two, and then as often as needed. Ice your knee to reduce pain and swelling. Do it for 15-20 minutes every 3-4 hours for 2-3 days or until the pain and swelling are gone.
• Elevate your knee – with a pillow under your heel when you’re sitting or lying down. It helps to reduce swelling and fluid accumulation in knee joint
• A stabilized knee brace –  has flexible springs in the sides for additional support or for more severe injuries a hinged knee brace with solid metal supports linked by a hinge will help protect the joint from sideways or lateral movement. Compression will also help reduce swelling.
• Rest the knee –  Limit activities to include walking if the knee is painful. Use crutches to help relieve pain.
• Compress your knee – Use an elastic bandage or a neoprene type sleeve on your knee to control swelling.
• Use stretching and strengthening exercises to help reduce stress to your knee – Ask your doctor to recommend a physical therapist for guidance.
• Avoid impact activities such as running and jumping 
• Full weight-bearing is not permitted for 1 – 6 weeks – after surgery, depending on the type of injury and repair. Crutches will be used initially following surgery. Many surgeons brace the knee and restrict motion for 6 weeks, to prevent excessive flexion and extension.
• Range of motion exercises – begin anywhere from 0 – 6 weeks after surgery, depending on the type of repair.
• Strengthening exercises – begin once full range of motion has returned.
• Return to vigorous activities – such as sports, may begin 3 – 4 months after repair.

Physiotherapy

• Continuous Passive Motion – Clinicians can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain.
• Early Weight Bearing – Early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function.
• Knee Bracing – The use of functional knee bracing appears to be more beneficial than not using a brace in patients with ACL deficiency.  The use of immediate postoperative knee bracing appears to be no more beneficial than not using a brace in patients following ACL reconstruction. Conflicting evidence exists for the use of functional knee bracing in patients following ACL reconstruction.  Knee bracing can be used for patients with acute posterior cruciate ligament (PCL) injuries, severe medial (tibial) collateral ligament (MCL) injuries, or posterior lateral corner (PLC) injuries.
• Immediate Versus Delayed Mobilization – Clinicians should consider the use of immediate mobilization following ACL reconstruction to increase range of motion, reduce pain, and limit adverse changes to soft tissue structures.
• Cryotherapy – Clinicians should consider the use of cryotherapy to reduce postoperative knee pain immediately post-ACL reconstruction.
• Therapeutic Exercises – Clinicians should consider the use of non–weight-bearing (open chain) exercises in conjunction with weight-bearing (closed-chain) exercises in patients with knee stability and movement coordination impairments.
• Neuromuscular Electrical Stimulation – Neuromuscular electrical stimulation can be used with patients following ACL reconstruction to increase quadriceps muscle strength.
• Neuromuscular Reeducation – Clinicians should consider the use of neuromuscular training as a supplementary program to strength training in patients with knee stability and movement coordination impairments.
• Accelerated” Rehabilitation – Rehabilitation that emphasizes early restoration of knee extension and early weight-bearing activity appears safe for patients with ACL reconstruction. No evidence exists to determine the efficacy and/or safety of early return to sports.
• Eccentric Strengthening – Clinicians should consider the use of an eccentric exercise ergometer in patients following ACL reconstruction to increase muscle strength and functional performance. Clinicians should consider the use of an eccentric squat program in patients with PCL injury to increase muscle strength and functional performance.
• Electrotherapy i.e ultrasound, laser therapy, and TENS.
• Manual therapy
• Once the pain has subsided, exercises to increase range of movement, balance, and maintain quadriceps strength may be prescribed. These may include: squatting, single calf raises, and later, wobble-board techniques.

Medication

If the pain is a serious and intolerable or acute injury the following medicine may prescribe in the lateral meniscus injury

• Take anti-inflammatory medications. Non-steroidal anti-inflammatory drugs (NSAIDs), like will help with pain and swelling. However, these drugs can have side effects, such as an increased risk of bleeding and ulcers. They should be only used occasionally unless your doctor specifically says otherwise.
• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic meniscus injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with a meniscus injury and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee meniscus injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of meniscus injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgery

Medial Collateral Ligament Sprain (MCL) is a flat band of connective tissue that runs from the medial epicondyle of the femur to the medial condyle of the tibia. Its role is to provide valgus stability to the knee joint. MCL injuries often occur in sports, especially in skiing; in fact, 60% of skiing knee injuries involve the MCL. [rx][rx][rx]

The tibial collateral ligament, also known as the medial collateral ligament (MCL), is a ligament extending from the medial epicondyle of the femur to the posteromedial crest of the tibia. The ligament is a broad and strong band that mainly functions to stabilize the knee joint in the coronal plane on the medial side.

Types of Medial Collateral Ligament Sprain

Doctors categorize MCL injuries according to the following criteria

• Grade I tear –  This is a slight tear (or stretch) of the MCL. Both ends of the ligament are still attached to the bone, but a portion of the ligament may sag and be less taut. Recovery usually takes 1 to 2 weeks; therapy may not be needed.
• Grade II tear – This is a slightly more severe tear of the MCL, with a portion of the ligament sagging. Pain and swelling is usually more severe than with a grade I tear. Kids usually need 3 to 4 weeks of rest and sometimes therapy.
• Grade III tear – With this type of injury, the MCL breaks in half. Many kids are unable to bend the knee or bear weight on it without pain. They might be unstable while walking, and the knee may sometimes “give out.” Kids with this injury need to wear a knee brace and undergo rehab therapy for 6 weeks or longer.

Causes of Medial Collateral Ligament Sprain

MCL injuries are regularly seen in contact and non-contact sports and often occur in the following instances:

• Motor vehicle accidents – A “dashboard injury” occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing a tear.
• Contact sports – Athletes in sports such as football and soccer can tear their ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
• The knee is hit directly – especially during sports like soccer, rugby, and football
• A person lands on a bent knee – such as during a fall or misstep
• Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
• A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
• A person lands on one leg – which can happen after a jump in basketball or volleyball
• A direct blow to the bent knee in an automobile injury
• A sports-related injury in which the knee bends
• Pulling on the ligament in a twisting injury or hyperextension
• A misstep on uneven terrain
• When the knee is hit directly on its outer side, such as from a football tackle
• As a result of cutting maneuvers, when an athlete plants a foot and forcefully shifts direction
• Squatting or lifting heavy objects, such as weight lifting
• Landing awkwardly on the knee, such as when jumping in volleyball
• Hyperextending the knee, such as when skiing
• Through repeated stress to the knee, which causes the ligament to lose its elasticity (like a worn-out rubber band)

While sports injuries are the most common cause of MCL tears and sprains, any direct blow, such as during a car accident, can cause the ligament to be damaged.

Symptoms of Medial Collateral Ligament Sprain

A person who experiences an MCL injury typically reports a combination of the following symptoms:

• A “popping” sound – when the injury occurs. This sound is usually a sign of a grade II or grade III tear.
• Immediate sharp pain – from the inner section of the knee.
• Immediate swelling – at the inner knee. Swelling may increase and spread to the actual knee joint 1 or 2 days following the injury.
• Tenderness –  around the inner knee. This area may be painful to the touch.
• Increased pain – a few hours after the injury.
• Bruising around the knee – especially around the location of the MCL (inner knee).
• Noticeable looseness – in the knee. A person may be able to feel looseness around the inner knee when walking. The knee may feel as if it has a greater range of motion than normal.
• Knee stiffness – may make walking, sitting down, rising from a chair or climbing stairs difficult. A person may have trouble bending or straightening the knee.
• The feeling of knee instability – may be particularly noticeable during activities that strain the knee, such as going downstairs or pivoting on one leg. The knee may feel as if it is about to give out. Instability is usually associated with more severe MCL tears.
• Pain when bearing weight – such as when walking, sitting down, or rising from a chair.

Diagnosis of Medial Collateral Ligament Sprain

Stage

The severity and symptoms of a knee ligament sprain depend on the degree of stretching or tearing of the knee ligament. You may notice an audible snap or tearing sound at the time of your ligament injury.

• In a mild, Grade I MCL sprain –  the knee ligament has a slight stretch, but they don’t tear. Although the knee joint may not hurt or swell very much, a mild ligament sprain can increase the risk of a repeat injury.
• With a moderate Grade II MCL sprain – the knee ligament tears partially. Knee swelling and bruising are common, and the use of the knee joint is usually painful and challenging. You may have some complaints of instability or a feeling of the knee giving way.
  With a severe Grade III MCL sprain – the ligament tears completely, causing swelling and sometimes bleeding under the skin. As a result, the joint is unstable and can be difficult to bear weight. You may have a feeling of the knee giving way. Often there will be no pain or severe pain that subsides quickly following a grade 3 tear as all of the pain fibers are torn at the time of injury. With these more severe tears, other structures are at risk of injury, including the meniscus or ACL.

Physical Exam

Testing of the knee joint should be done using the following techniques and the findings compared to the contralateral, normal knee:^[rx][rx]

• Valgus stress at 0° and 20° – This test puts direct stress on the medial knee structures, reproducing the mechanism of injury. Valgus stress testing is done with the patient supine on the exam table. The lower extremity, supported by the examiner, is abducted. The examiner’s fingers monitor the medial joint space for gapping while placing the opposite hand on the ankle. The knee is placed in 20° of flexion. The examiner then uses their own thigh as a fulcrum at the knee and applies a valgus force (pulling the foot and ankle away from the patient’s body). The force is then used to establish the amount of gapping present within the joint. It has been reported that 20° of flexion is best for isolating the MCL, allowing the practitioner to establish the degree of injury (see Classification). Additional testing is done at 0° to determine if a Grade III injury is present.^[rx][rx]
• Valgus stress testing –  is the best way to test the integrity of the MCL directly. The patient should be positioned supine with the hip abducted on the affected side so that the leg is unsupported off the table. The knee should be brought into 30 degrees of flexion. The examiner should grasp the ankle with one hand and push the ankle laterally while applying a valgus force to the knee with the other hand.
• Anteromedial drawer test – This test is performed with the patient supine with the knee flexed to 80-90°. The foot is externally rotated 10-15° and the examiner supplies an anterior and external rotational force. The joint can then be evaluated for tibial anteromedial rotation, taking care to recognize the possibility of posterolateral corner instability giving similar rotational test results. As always, compare the test in the opposite knee.^[rx][rx][rx]
• Dial Test (anteromedial rotation test) – This test should be executed with the patient lying both supine and prone. When the patient is supine, the knees must be flexed 30° off the table. The thigh is then stabilized and the foot externally rotated. The examiner watches for the tibial tubercle of the affected knee to rotate as the foot rotates, comparing it to the contralateral knee. A positive test will show the rotation of greater than 10-15° of rotation compared to the opposite knee. This is most easily assessed with a hand placed over the tibia while testing. When the patient is prone, the knee is flexed to 90° and both feet are externally rotated and compared, noting the difference from the non-injured joint. Similar to the anteromedial drawer test, a false positive test can result from a posterolateral corner injury. Testing at both 30° and 90° helps to distinguish between these injuries: one should monitor where the tibial rotation occurs (anteromedial or posterolateral) in the supine position and also assess for medial or lateral joint line gapping to differentiate between these two injuries.^[rx][rx][rx]

Imaging Test

• X-rays – use low levels of radiation and give doctors a view of a person’s bones. Although MCL injuries do not show up on standard X-ray exams, they are a relatively inexpensive, fast way to rule out other possible injuries that might be causing the symptoms. Additionally, a stress X-ray—where a physician applies a valgus force to the knee during the exam—can help to determine the degree of ligamentous injury.
• Magnetic resonance imaging (MRI) – shows a detailed view of the soft tissue surrounding the knee joint. An MRI can also help a doctor determine the location and grade of an MCL tear.
• Ultrasound imaging – uses high-frequency sound waves to build a picture of the knee’s tissues. Ultrasound can be utilized in situations when an MRI is not recommended. Ultrasound may also be used in an urgent care setting to make an immediate assessment, allowing the injury to be treated more quickly.

Treatment of Medial Collateral Ligament Sprain

Nonsurgical

Most everyone who has an MCL injury will be advised by a health care professional to follow the RICE method:

• Rest – Activities that irritates the knee, such as pivoting and walking for long periods of time, should be avoided until the symptoms get better.
• Ice – A person may be advised to apply ice packs to the knee to help reduce swelling and decrease pain. Apply ice with a compressive wrap for 20 minutes and repeat every 3-4 hours for the first 24-48 hours.
• Compression – Wearing a tight, elastic bandage around the knee can help stop swelling.
• Elevation – Keeping the knee propped up above the waist can help decrease swelling.
• Wear a knee cap – that allows the knee to move forward and backward but restricts side-to-side movement. Apply minimally restrictive lateral hinge brace (grade II or III injuries).
• Use crutches – to avoid weight-bearing. Crutches are not needed in all cases. Dispense crutches; allow weight-bearing as tolerated.
• Bracing – Your knee must be protected from the same sideways force that caused the injury. You may need to change your daily activities to avoid risky movements. Your doctor may recommend a brace to protect the injured ligament from stress. To further protect your knee, you may be given crutches to keep you from putting weight on your

Medication

If the injury is severe and pain is intolerable the following medicine can be considered to prescribe

• Take anti-inflammatory medications – Non-steroidal anti-inflammatory drugs (NSAIDs), like will help with pain and swelling. However, these drugs can have side effects, such as an increased risk of bleeding and ulcers. They should be only used occasionally unless your doctor specifically says otherwise.
• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with injury and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for a knee injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of ligament injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.
• Platelet-rich plasma (PRP) injection – newer therapy where a blood sample is taken from the patient, spun in a centrifuge, growth factors are isolated and then they are injected back into the affected site to stimulate faster healing.

Surgery

• Knee arthroscopy – minimally invasive surgical procedure to diagnose and repair an MCL injury; small incisions are made in the knee and a camera is inserted to visualize the injury and determine treatment.

Physiotherapy

Depending on the grade of injury, you can start to feel better within days to just a few weeks of the damage. Your physiotherapy treatment will aim to:

• Reduce pain and inflammation.
• Normalize joint range of motion.
• Strengthen your knee: esp quadriceps (esp VMO) and hamstrings.
• Strengthen your lower limb: calves, hip and pelvis muscles.
• Improve patellofemoral (knee cap) alignment
• Normalize your muscle lengths
• Improve your proprioception, agility and balance
• Improve your technique and function, e.g. walking, running, squatting, hopping and landing.
• Guide return to sports activities and exercises
• Minimize your chance of re-injury.

Exercises

A physical therapist will be able to advise on strengthening exercises to aid recovery after an MCL tear. Some possible exercises may include:

Exercise to restore range of motion and increase strength. These exercises typically include gentle stretches and strengthening exercises. People may also do upper body workouts and swim in order to keep up general conditioning. Some people may work with a physical therapist for guided treatment.

1. Hamstring curl

• Stand up straight, engaging the stomach muscles.
• Stand on one leg and slowly bend the opposite knee by bringing the heel up toward the buttocks.
• Hold for 30 seconds before repeating on the other side of the body.
• A person can hold on to a chair or table for support if needed.

2. Wall slide

• Standing up straight, with both feet flat on the ground, place the back firmly against a wall.
• Slowly slide down, keeping the back against the wall until reaching a squatting position.
• Hold for 30 seconds.
• Push up from the feet to stand up, keeping the back flat against the wall.
• Repeat 10 to 15 times.

3. Chair squat

• Standing on one leg, slowly squat toward sitting down onto a chair.
• Return to a standing position, again standing on one leg.
• Bend at the waist and keep the body in a straight line when standing.
• A person may need to build up to sitting fully on the chair

Subsequent treatment

• Begin active range-of-motion exercises in cold whirlpool at least twice daily.
• Begin straight-leg raises and electrical muscle stimulation (if available).
• Maintain general conditioning with upper body ergometer or swimming.

Goal one: Walking unassisted without a limp

• Discard crutches.
• Continue range of motion, isometric strengthening, and conditioning exercises.

Goal two: 90 degrees of knee flexion

• Begin stair climber and bicycle ergometer with seat high; gradually lower seat.
• Begin isotonic progressive restrictive exercise for quadriceps and hamstrings; supplement with isokinetic exercise if available.
• Continue range of motion and conditioning exercises.

Goal Three: Full knee motion

• Begin running and functional exercise program.
• For example:

  • Jog 1 mile.

  • Five successive 100-yard sprints at half speed.

  • Five successive 100-yard sprints at three-quarters speed.

  • Five successive 100-yard sprints at full speed.

  • Five zigzag sprints at half speed.

  • Five zigzag sprints at full speed.

• Other agility drills (e.g. Cariocas).
• Continue conditioning.

Goal four: Complete entire running program in one session

• May return to competition if the athlete has minimal pain, full range of motion, and 90 percent of normal strength.
• Continue to use a brace for all sports participation for the remainder of the season.^[rx]

Rehabilitation

The rehabilitation for a non-operative treatment can be split into four phases:

• Phase one is from one to two weeks. Phase one consists of controlling the swelling of the knee by applying ice for 15 minutes every two hours (first two days). The rest of the week the frequency can be reduced to three times a day. Use ice as tolerated and as needed based on symptoms. In the begin, the patient needs to use crutches. Early weight bearing is encouraged because patients who increasing their weight-bearing, they can progressively reduce their dependence on crutches. Afterward, progress to one crutch and let the patient stop using the crutches only when normal gait is possible. Another aim of this phase is to try to maintain the ability to straighten and bend the knee from 0° to 90° knee flexion. For achieving the range of motion of the knee it is important to emphasize full extension and progress flexion as tolerated. Pain-free stretches for the hamstrings, quads, groin and calf muscles (in particular) are suggested. At last, there are therapeutic exercises. The patient may begin with static strengthening exercises (as soon as pain allows it). They consist for example of Quadricpes sets, straight leg raises, range-of-motion exercises, sitting hip flexion, side-lying hip abduction, standing hip extension, standing, and hamstring curls. As soon as patients can tolerate it, they are encouraged to ride a stationary bike to improve the range of motion of the knee. This would ensure accelerated healing. The amount of time and effort on the stationary bike is increased as tolerated. Obviously, every patient is different and these are not the standard exercises that have to be given to patients. There are no limits on upper extremity workouts that do not affect the injured knee^[rx]. It’s important that the patient rests from all painful activities (use crutches if necessary), and that the MCL is well protected (by wearing a stabilized knee brace).
• Starting at week three-phase two begins – The aims for the range of motion are the same as in phase one. Progress to 20 minutes of biking. Increase also the resistance as tolerated by the patient. Biking will ensure healing, rebuild strength, and maintain aerobic conditioning. The physiotherapist can give other exercises like Hamstring curls, leg presses (double-leg), and step-ups. As a precaution, the patient has the chance to be examined by a physician every three weeks to verify the healing of the ligament^[rx].
• Phase three starts from week five –  A major goal for this phase: full weight-bearing on the injured knee. Discontinue the use of a brace when ambulating with full weight-bearing is possible and there is no gait deviation. The range of motion has to be fully achieved and had to be symmetrical with the not injured knee. The therapeutic exercises are the same as in phase two. They may benefit progression. We continue with cold therapy and compression to eliminate swelling. In this phase, you can commence with balance and proprioceptive activities. To maintain aerobic fitness the patient can use the stepper or (if possible) may begin to swim. As a precaution, the patient has the chance to be examined by a physician every five to six weeks. When needed, you can be allowed to make stress radiography as a precaution.^[rx]
• Six weeks after injuring the knee, phase four can begin – Discontinue wearing the brace during the gait. Athletics can wear the brace for competition through the competitive season for at least three months. Cold therapy still needs to be applied. The aim of the therapeutic exercises is more focused on sport-specific or daily movements. The intensity of the strengthening exercises needs to be increased and instead of double leg exercises, we change to single-leg exercises. The patient may start running again at a comfortable pace (make sure the patient doesn’t make sudden changes of direction). As a precaution, it is best to return the competition once full motion and strength is returned and when the patient passes a sport functional test^[rx].

How to do the exercises

Knee flexion with heel slide

slide 1 of 10, Knee flexion with heel slide,

• Lie on your back with your knees bent.
• Slide your heel back by bending your affected knee as far as you can. Then hook your other foot around your ankle to help pull your heel even farther back.
• Hold for about 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Heel slides on a wall

slide 2 of 10, Heel slides on a wall,

• Lie on the floor close enough to a wall so that you can place both legs up on the wall. Your hips should be as close to the wall as is comfortable for you.
• Start with both feet resting on the wall. Slowly let the foot of your affected leg slide down the wall until you feel a stretch in your knee.
• Hold for 15 to 30 seconds.
• Then slowly slide your foot up to where you started.
• Repeat 2 to 4 times.

Quad sets

slide 3 of 10, Quad sets,

• Sit with your affected leg straight and supported on the floor or a firm bed. Place a small, rolled-up towel under your knee. Your other leg should be bent, with that foot flat on the floor.
• Tighten the thigh muscles of your affected leg by pressing the back of your knee down into the towel.
• Hold for about 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Short-arc quad

slide 4 of 10, Short-arc quad,

• Lie on your back with your knees bent over a foam roll or a large rolled-up towel.
• Lift the lower part of your affected leg and straighten your knee by tightening your thigh muscle. Keep the bottom of your knee on the foam roll or rolled-up towel.
• Hold your knee straight for about 6 seconds, then slowly bend your knee and lower your leg back to the floor. Rest for up to 10 seconds between repetitions.
• Repeat 8 to 12 times.

Straight-leg raises to the front

slide 5 of 10, Straight-leg raises to the front,

• Lie on your back with your good knee bent so that your foot rests flat on the floor. Your affected leg should be straight. Make sure that your low back has a normal curve. You should be able to slip your hand in between the floor and the small of your back, with your palm touching the floor and your back touching the back of your hand.
• Tighten the thigh muscles in your affected leg by pressing the back of your knee flat down to the floor. Hold your knee straight.
• Keeping the thigh muscles tight and your leg straight, lift your affected leg up so that your heel is about 30 centimeters off the floor. Hold for about 6 seconds, then lower slowly.
• Relax for up to 10 seconds between repetitions.
• Repeat 8 to 12 times.

Hamstring set (heel dig)

slide 6 of 10, Hamstring set (heel dig),

• Sit with your affected leg bent. Your good leg should be straight and supported on the floor.
• Tighten the muscles on the back of your bent leg (hamstring) by pressing your heel into the floor.
• Hold for about 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Hip adduction

slide 7 of 10, Hip adduction,

• Sit on the floor with your knees bent.
• Place a pillow between your knees.
• Put your hands slightly behind your hips for support.
• Squeeze the pillow by tightening the muscles on the inside of your thighs.
• Hold for 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Hip abduction

slide 8 of 10, Hip abduction,

• Sit on the floor with your affected knee close to a wall.
• Bend your affected knee but keep the other leg straight in front of you.
• Place a pillow between the outside of your knee and the wall.
• Put your hands slightly behind your hips for support.
• Push the outside of your knee against the pillow and the wall.
• Hold for 6 seconds, then rest for up to 10 seconds.
• Repeat 8 to 12 times.

Lateral step-up

slide 9 of 10, Lateral step-up,

• Stand sideways on the bottom step of a staircase with your injured leg on the step and your other foot on the floor. Hold on to the banister or wall.
• Use your injured leg to raise yourself up, bringing your other foot level with the stair step. Make sure to keep your hips level as you do this. And try to keep your knee moving in a straight line with your middle toe. Do not put the foot you are raising on the stair step.
• Slowly lower your foot back down.
• Repeat 8 to 12 times.

Wall squats with ball

slide 10 of 10, Wall squats with ball,

• Stand with your back facing a wall. Place your feet about a shoulder-width apart.
• Place the therapy ball between your back and the wall, and move your feet out in front of you so they are about 30 centimetres in front of your hips.
• Keep your arms at your sides, or put your hands on your hips.
• Slowly squat down as if you are going to sit in a chair, rolling your back over the ball as you squat. The ball should move with you but stay pressed into the wall.
• Be sure that your knees do not go in front of your toes as you squat.
• Hold for 6 seconds.
• Slowly rise to your standing position.
• Repeat 8 to 12 times.

References

ACL Torn/Anterior Cruciate Ligament Injury (ACL) is one of 2 cruciate ligaments which aids in stabilization of the knee joint. It is a strong band made of connective tissue and collagenous fibers that originate from the anteromedial aspect of the intercondylar region of the tibial plateau and extends posteromedially to attach to the lateral femoral condyle. The anteromedial bundle and posterolateral bundle form the 2 components of the ACL.  [rx][rx][rx] The ACL and the posterior cruciate ligament (PCL) together form a cross (or an “x”) within the knee and prevents excessive forward or backward motion of the tibia in relation to the femur during flexion and extension.

Anterior cruciate ligament injury is when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. The most common injury is a complete tear. Symptoms include pain, a popping sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours.^[rx] In approximately 50% of cases, other structures of the knee such as surrounding ligaments, cartilage, or meniscus are damaged.^[rx]

Causes of Anterior Cruciate Ligament Injury

• A sudden stop, twist, pivot or change in direction at the knee joint  – These knee movements are a routine part of football, basketball, soccer, rugby, gymnastics and skiing. For this reason, athletes who participate in these sports have an especially high risk of ACL tears.
• Extreme hyperextension of the knee – Sometimes, during athletic jumps and landings, the knee straightens out more than it should and extends beyond its normal range of motion, causing an ACL tear. This type of ACL injury often occurs because of a missed dismount in gymnastics or an awkward landing in basketball.
• Direct contact – The ACL may be injured during contact sports, usually during direct impact to the outside of the knee or lower leg. Examples are a sideways football tackle, a misdirected soccer kick that strikes the knee or a sliding tackle in soccer.

• Changing direction rapidly (also known as “cutting”)
• Landing from a jump awkwardly
• Coming to a sudden stop when running
• Direct contact or collision to the knee (e.g. during a football tackle or a motor vehicle collision)
• landing awkwardly from a jump
• twisting movements, particularly when your foot is on the ground
• quickly changing direction when running or walking
• slowing down or stopping suddenly when running

These movements cause the tibia to shift away from the femur rapidly, placing strain on the knee joint and potentially leading to the rupture of the ACL. About 80% of ACL injuries occur without direct trauma. Risk factors include female anatomy, specific sports, poor conditioning, fatigue, and playing on a turf field.^[rx]

Female predominance

Female athletes are two to eight times more likely to strain their ACL in sports that involve cutting and jumping as compared to men who play the same particular sports.^[rx] NCAA data has found relative rates of injury per 1000 athlete exposures as follows:

• Men’s basketball 0.07, women’s basketball 0.23
• Men’s lacrosse 0.12, women’s lacrosse 0.17
• Men’s football 0.09, women’s football 0.28

The highest rate of ACL injury in women occurred in gymnastics, with a rate of injury per 1000 athlete exposures of 0.33. Of the four sports with the highest ACL injury rates, three were women’s – gymnastics, basketball, and soccer.^[rx]

Differences between males and females identified as potential causes are the active muscular protection of the knee joint, differences in leg/pelvis alignment, and relative ligament laxity caused by differences in hormonal activity from estrogen and relaxin.^[rx][rx] Birth control pills appear to decrease the risk.^[rx]

Dominance theories

Some studies have suggested that there are four neuromuscular imbalances that predispose women to a higher incidence of ACL injury. Female athletes are more likely to jump and land with their knees relatively straight and collapsing in towards each other, while most of their body weight falls on a single foot and their upper body tilts to one side.^[rx] Several theories have been described to further explain these imbalances. These include ligament dominance, quadriceps dominance, leg dominance, and trunk dominance theories.

Symptoms of Anterior Cruciate Ligament Injury

When an individual has an ACL injury, they are likely to hear a “pop” in their knee followed by pain and swelling. They may also experience instability in the knee once they resume walking and other activities, as the ligament can no longer stabilize the knee joint and keep the tibia from sliding forward.^[rx].^[rx]

• Feeling a “pop” inside your knee when the ACL tears
• Significant knee swelling and deformity within a few hours after injury
• Severe knee pain that prevents you from continuing to participate in your sport (most common in partial tears of the ACL)
• No knee pain, especially if the ACL has been completely torn and there is no tension across the injured ligament
• A black and blue discoloration around the knee, due to bleeding from inside the knee joint
• A feeling that your injured knee will buckle, “give out” or “give way” if you try to stand

Diagnosis of Anterior Cruciate Ligament Injury

Physical examination

Physical examination of the knee usually follows a relatively standard pattern.

• The knee is examined for obvious swelling, bruising, and deformity.
• Areas of tenderness and subtle evidence of knee joint fluid (effusion) are noted.
• Most importantly, with knee injury ligamentous, stability is assessed. Since there are four ligaments at risk for injury, the examiner may try to test each to determine which one(s) is (are) potentially damaged. It is important to remember that a knee ligament injury might be an isolated structure damaged or there may be more than one ligament and other structures in the knee that are hurt.
• In the acute situation, with a painful, swollen joint, the initial examination may be difficult because both the pain and the fluid limit the patient’s ability to cooperate and relax the leg. Spasm of the quadriceps and hamstring muscles often can make it difficult to assess ACL stability.
• A variety of maneuvers can be used to test the stability and strength of the ACL. These include the Lachman test, the pivot-shift test, and the anterior drawer test. Guidelines from the American Academy of Pediatrics suggest the Lachman test is best for assessing ACL tears.
• The Lachman test is performed as follows:
  • The damaged knee is flexed to 20-30 degrees.
  • The examiner grasps tibia and puts their thumb on the tibial tubercle (the bump of bone just below the knee where the patellar tendon attaches.
  • The examiners other hand grasps the thigh just above the knee.
  • The tibia is pulled forward and normally, there should be a firm stop if the ACL is intact. If the ligament is torn, the tibia will move forward and there will be no endpoint and it feels mushy.
• The unaffected knee may be examined to be used as a comparison.

It may be difficult to examine some patients when muscle strength or spasm can hide an injured ACL because of the knee stabilization that they can provide.

Multiple maneuvers are employed to test the ACL and include the anterior drawer, the pivot shift, and the Lachman tests.[rx][rx] These tests should be performed whenever there is suspicion for injury to the anterior cruciate ligament.

• The anterior drawer test – is performed with the patient lying supine with their affected knee flexed to 90 degrees and the foot in a planted position (Sometimes it is easiest for the clinician to stabilize the patient’s foot by sitting on it). The clinician will grip the proximal tibia with both hands and pull with an anterior motion. If there is excessive anterior motion and instability, then the test is positive. It may also be useful to compare to the unaffected knee as patients may have increased laxity of the ACL that is not pathologic. This test has a sensitivity of 92% and specificity of 91% in chronic injuries, but not acute injuries.
• The pivot shift test – is performed with the patient in the supine position. The clinician should hold the patient’s lower leg and begin with the knee in extension and flexion of the hip to 20 to 30 degrees. Next, the clinician will bring the tibia into the internal rotation with one hand and begin placing valgus stress on the knee using the other hand. While holding this position, the knee should now be flexed. This causes stress, instability, and ultimately subluxation of the ACL of the affected knee. With flexion of the knee, if the tibia subluxes posteriorly and one may feel a “clunk”; this would indicate a positive test. This test can be difficult to perform in patients who are guarding, and some may not allow the clinician to perform the test. This is a highly specific test (98%) when positive, but is insensitive (24%) due to the difficulty in evaluation secondary to patient pain and cooperation.
• The Lachman test – is performed with the patient in the supine position with the knee flexed to about 30 degrees. The clinician should stabilize the distal femur with one hand and with the other hand pull the tibia toward themselves. If there is increased anterior translation, then this is a positive test. Again, comparing to the unaffected side may be helpful. This test has a sensitivity of 95% and specificity of 94% for ACL rupture.

Radiography

Stage  of Anterior Cruciate Ligament

An ACL injury can further classify as a grade I, II, or III sprains.

• Grade I – The ligamental fibers are stretched, with a tear that is less than one-third of the ligament. Mild tenderness and swelling are present. The knee joint feels stable with a knee laxity < 5 mm.
• Grade II – A partial tear (between one-third to two-thirds of the ligamental fibers) is present. Mild tenderness and swelling with some loss of function are present. The joint may feel unstable with increased anterior translation (a knee laxity of 5 to 10 mm). The patient feels pain, and the pain may become exacerbated with Lachman’s and anterior drawer stress tests.
• Grade III – The fibers have completely torn. Tenderness and limited pain (relative to the seriousness of the injury) are features. The degree of swelling may be variable. The knee feels unstable, with rotational instability (positive pivot shift test). A knee laxity is greater than 10  mm. Haemarthrosis (bleeding into the knee joints) is observable within 1 to 2 hours.[rx]

An acute ACL rupture commonly occurs among sports players, especially those aged 14 to 19 years.[rx] The incidence of ACL injury is higher among female athletes due to the following reasons[rx]:

• Smaller ACL and narrower intercondylar notch – Females who are non-athletes and aged 41 to 65 are predisposed to ACL injuries if they have narrow intercondylar notches.[rx]
• Wider pelvis and greater Q angle – A wider pelvis increases the angle of the femur toward the central patella. The greater the Q angle, the greater pressure is applied to the medial aspect of the knee, which can lead to an ACL tear.
• Lax ligaments – Female ligaments with more elastic muscle fibers tend to be laxer than male ligaments. Excessive joint movements with increased flexibility may contribute to the higher incidence of ACL injury among females.[rx]
• Greater quadriceps to hamstring strength ratio – Females tend to have poor hamstring strength compared to men. The imbalance of strength between the hamstring and quadriceps muscles may increase the risk of ACL injury.[rx][rx]

Treatment of Anterior Cruciate Ligament Injury

Non-Surgical Treatment Options

• Patient education
• Activity modification
• Physical therapy
• Weight loss
• Knee bracing
• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• COX-2 inhibitors
• Glucosamine and chondroitin sulfate
• Corticosteroid injections
• Hyaluronic acid (HA)

The American Academy Of Orthopedic Surgeons (AAOS) Recommends This Treatment.

• Weight loss – is valuable in all stages of ACL injury. It is indicated in patients with symptomatic ACL injury with a body mass index greater than 25. The best recommendation to achieve weight loss is with diet control and low-impact aerobic exercise.
• Knee bracing – in the setting of ACL injury includes unloader-type braces that shift the load away from the involved knee compartment. This may be useful in the setting where either the lateral or medial compartment of the knee is involved such as in a valgus or varus deformity.
• Immobilization – Your doctor may recommend that you wear a brace for 3 to 4 weeks. This stabilizes the knee while it heals.
• Weightbearing –  Because putting weight on the knee may cause pain and slow the healing process, your doctor may recommend using crutches for the first week or two after the injury.
• Physical therapy – Once the knee has started to heal, your doctor will recommend physical therapy to help your child regain normal motion. Specific exercises will strengthen the thigh muscles holding the knee joint in place. Your commitment to the exercise program is important for a successful recovery. Typically return to activity 3 to 6 weeks after the injury.
• Emergent closed reduction followed by vascular assessment/consult – If indications to considered an orthopedic emergency, vascular consult indicated if pulses are absent or diminished following reduction if arterial injury confirmed by arterial duplex ultrasound or CT angiography
• Immobilization as definitive management – successful closed reduction without vascular compromise, most cases require some form of surgical stabilization following reduction, outcomes of worse outcomes are seen with nonoperative management/prolonged immobilization will lead to loss of ROM with persistent instability.
• Rest Your Leg – Once you’re discharged from the hospital in a legislating, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your will help the bone mend quicker and the pain fades away sooner.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic ACL injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee ACL injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of  ACL injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgical Treatment

Prevention

Given the importance of neuromuscular factors and the etiology of ACL injuries, numerous programs have aimed to improve neuromuscular control during standing, cutting, jumping, and landing. ^[rx] The components of neuromuscular training are:

• Balance training: balance exercises
• Jump training – plyometrics: landing with increased flexion at the knee and hip
• Strengthening that emphasizes proximal hip control mediated through gluteus and proximal hamstring activation in a close kinetic chain
• Stretching
• Skill training: Controlling body motions, especially in deceleration and pivoting maneuvers
• Movement education and some form of feedback to the athlete during the training of these activities
• Agility training: agility exercises

Examples of more recent neuromuscular training programs include: Sportsmetrics and Prevent Injury and Enhance Performance program. Both programs have a positive influence on injury reduction and improve athletic performance tests. ^[rx] The PEP plan includes: Warm Up, stretching, strengthening, plyometrics, and agility exercises. ^[rx]

References

ACL Tear/Anterior Cruciate Ligament Injury (ACL) is one of 2 cruciate ligaments which aids in stabilization of the knee joint. It is a strong band made of connective tissue and collagenous fibers that originate from the anteromedial aspect of the intercondylar region of the tibial plateau and extends posteromedially to attach to the lateral femoral condyle. The anteromedial bundle and posterolateral bundle form the 2 components of the ACL.  [rx][rx][rx] The ACL and the posterior cruciate ligament (PCL) together form a cross (or an “x”) within the knee and prevents excessive forward or backward motion of the tibia in relation to the femur during flexion and extension.

Anterior cruciate ligament injury is when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. The most common injury is a complete tear. Symptoms include pain, a popping sound during injury, instability of the knee, and joint swelling. Swelling generally appears within a couple of hours.^[rx] In approximately 50% of cases, other structures of the knee such as surrounding ligaments, cartilage, or meniscus are damaged.^[rx]

Causes of Anterior Cruciate Ligament Injury

• A sudden stop, twist, pivot or change in direction at the knee joint  – These knee movements are a routine part of football, basketball, soccer, rugby, gymnastics and skiing. For this reason, athletes who participate in these sports have an especially high risk of ACL tears.
• Extreme hyperextension of the knee – Sometimes, during athletic jumps and landings, the knee straightens out more than it should and extends beyond its normal range of motion, causing an ACL tear. This type of ACL injury often occurs because of a missed dismount in gymnastics or an awkward landing in basketball.
• Direct contact – The ACL may be injured during contact sports, usually during direct impact to the outside of the knee or lower leg. Examples are a sideways football tackle, a misdirected soccer kick that strikes the knee or a sliding tackle in soccer.

• Changing direction rapidly (also known as “cutting”)
• Landing from a jump awkwardly
• Coming to a sudden stop when running
• Direct contact or collision to the knee (e.g. during a football tackle or a motor vehicle collision)
• landing awkwardly from a jump
• twisting movements, particularly when your foot is on the ground
• quickly changing direction when running or walking
• slowing down or stopping suddenly when running

These movements cause the tibia to shift away from the femur rapidly, placing strain on the knee joint and potentially leading to the rupture of the ACL. About 80% of ACL injuries occur without direct trauma. Risk factors include female anatomy, specific sports, poor conditioning, fatigue, and playing on a turf field.^[rx]

Female predominance

Female athletes are two to eight times more likely to strain their ACL in sports that involve cutting and jumping as compared to men who play the same particular sports.^[rx] NCAA data has found relative rates of injury per 1000 athlete exposures as follows:

• Men’s basketball 0.07, women’s basketball 0.23
• Men’s lacrosse 0.12, women’s lacrosse 0.17
• Men’s football 0.09, women’s football 0.28

The highest rate of ACL injury in women occurred in gymnastics, with a rate of injury per 1000 athlete exposures of 0.33. Of the four sports with the highest ACL injury rates, three were women’s – gymnastics, basketball, and soccer.^[rx]

Differences between males and females identified as potential causes are the active muscular protection of the knee joint, differences in leg/pelvis alignment, and relative ligament laxity caused by differences in hormonal activity from estrogen and relaxin.^[rx][rx] Birth control pills appear to decrease the risk.^[rx]

Dominance theories

Some studies have suggested that there are four neuromuscular imbalances that predispose women to a higher incidence of ACL injury. Female athletes are more likely to jump and land with their knees relatively straight and collapsing in towards each other, while most of their body weight falls on a single foot and their upper body tilts to one side.^[rx] Several theories have been described to further explain these imbalances. These include ligament dominance, quadriceps dominance, leg dominance, and trunk dominance theories.

Symptoms of Anterior Cruciate Ligament Injury

When an individual has an ACL injury, they are likely to hear a “pop” in their knee followed by pain and swelling. They may also experience instability in the knee once they resume walking and other activities, as the ligament can no longer stabilize the knee joint and keep the tibia from sliding forward.^[rx].^[rx]

• Feeling a “pop” inside your knee when the ACL tears
• Significant knee swelling and deformity within a few hours after injury
• Severe knee pain that prevents you from continuing to participate in your sport (most common in partial tears of the ACL)
• No knee pain, especially if the ACL has been completely torn and there is no tension across the injured ligament
• A black and blue discoloration around the knee, due to bleeding from inside the knee joint
• A feeling that your injured knee will buckle, “give out” or “give way” if you try to stand

Diagnosis of Anterior Cruciate Ligament Injury

Physical examination

Physical examination of the knee usually follows a relatively standard pattern.

• The knee is examined for obvious swelling, bruising, and deformity.
• Areas of tenderness and subtle evidence of knee joint fluid (effusion) are noted.
• Most importantly, with knee injury ligamentous, stability is assessed. Since there are four ligaments at risk for injury, the examiner may try to test each to determine which one(s) is (are) potentially damaged. It is important to remember that a knee ligament injury might be an isolated structure damaged or there may be more than one ligament and other structures in the knee that are hurt.
• In the acute situation, with a painful, swollen joint, the initial examination may be difficult because both the pain and the fluid limit the patient’s ability to cooperate and relax the leg. Spasm of the quadriceps and hamstring muscles often can make it difficult to assess ACL stability.
• A variety of maneuvers can be used to test the stability and strength of the ACL. These include the Lachman test, the pivot-shift test, and the anterior drawer test. Guidelines from the American Academy of Pediatrics suggest the Lachman test is best for assessing ACL tears.
• The Lachman test is performed as follows:
  • The damaged knee is flexed to 20-30 degrees.
  • The examiner grasps tibia and puts their thumb on the tibial tubercle (the bump of bone just below the knee where the patellar tendon attaches.
  • The examiners other hand grasps the thigh just above the knee.
  • The tibia is pulled forward and normally, there should be a firm stop if the ACL is intact. If the ligament is torn, the tibia will move forward and there will be no endpoint and it feels mushy.
• The unaffected knee may be examined to be used as a comparison.

It may be difficult to examine some patients when muscle strength or spasm can hide an injured ACL because of the knee stabilization that they can provide.

Multiple maneuvers are employed to test the ACL and include the anterior drawer, the pivot shift, and the Lachman tests.[rx][rx] These tests should be performed whenever there is suspicion for injury to the anterior cruciate ligament.

• The anterior drawer test – is performed with the patient lying supine with their affected knee flexed to 90 degrees and the foot in a planted position (Sometimes it is easiest for the clinician to stabilize the patient’s foot by sitting on it). The clinician will grip the proximal tibia with both hands and pull with an anterior motion. If there is excessive anterior motion and instability, then the test is positive. It may also be useful to compare to the unaffected knee as patients may have increased laxity of the ACL that is not pathologic. This test has a sensitivity of 92% and specificity of 91% in chronic injuries, but not acute injuries.
• The pivot shift test – is performed with the patient in the supine position. The clinician should hold the patient’s lower leg and begin with the knee in extension and flexion of the hip to 20 to 30 degrees. Next, the clinician will bring the tibia into the internal rotation with one hand and begin placing valgus stress on the knee using the other hand. While holding this position, the knee should now be flexed. This causes stress, instability, and ultimately subluxation of the ACL of the affected knee. With flexion of the knee, if the tibia subluxes posteriorly and one may feel a “clunk”; this would indicate a positive test. This test can be difficult to perform in patients who are guarding, and some may not allow the clinician to perform the test. This is a highly specific test (98%) when positive, but is insensitive (24%) due to the difficulty in evaluation secondary to patient pain and cooperation.
• The Lachman test – is performed with the patient in the supine position with the knee flexed to about 30 degrees. The clinician should stabilize the distal femur with one hand and with the other hand pull the tibia toward themselves. If there is increased anterior translation, then this is a positive test. Again, comparing to the unaffected side may be helpful. This test has a sensitivity of 95% and specificity of 94% for ACL rupture.

Radiography

Stage  of Anterior Cruciate Ligament

An ACL injury can further classify as a grade I, II, or III sprains.

• Grade I – The ligamental fibers are stretched, with a tear that is less than one-third of the ligament. Mild tenderness and swelling are present. The knee joint feels stable with a knee laxity < 5 mm.
• Grade II – A partial tear (between one-third to two-thirds of the ligamental fibers) is present. Mild tenderness and swelling with some loss of function are present. The joint may feel unstable with increased anterior translation (a knee laxity of 5 to 10 mm). The patient feels pain, and the pain may become exacerbated with Lachman’s and anterior drawer stress tests.
• Grade III – The fibers have completely torn. Tenderness and limited pain (relative to the seriousness of the injury) are features. The degree of swelling may be variable. The knee feels unstable, with rotational instability (positive pivot shift test). A knee laxity is greater than 10  mm. Haemarthrosis (bleeding into the knee joints) is observable within 1 to 2 hours.[rx]

An acute ACL rupture commonly occurs among sports players, especially those aged 14 to 19 years.[rx] The incidence of ACL injury is higher among female athletes due to the following reasons[rx]:

• Smaller ACL and narrower intercondylar notch – Females who are non-athletes and aged 41 to 65 are predisposed to ACL injuries if they have narrow intercondylar notches.[rx]
• Wider pelvis and greater Q angle – A wider pelvis increases the angle of the femur toward the central patella. The greater the Q angle, the greater pressure is applied to the medial aspect of the knee, which can lead to an ACL tear.
• Lax ligaments – Female ligaments with more elastic muscle fibers tend to be laxer than male ligaments. Excessive joint movements with increased flexibility may contribute to the higher incidence of ACL injury among females.[rx]
• Greater quadriceps to hamstring strength ratio – Females tend to have poor hamstring strength compared to men. The imbalance of strength between the hamstring and quadriceps muscles may increase the risk of ACL injury.[rx][rx]

Treatment of Anterior Cruciate Ligament Injury

Non-Surgical Treatment Options

• Patient education
• Activity modification
• Physical therapy
• Weight loss
• Knee bracing
• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• COX-2 inhibitors
• Glucosamine and chondroitin sulfate
• Corticosteroid injections
• Hyaluronic acid (HA)

The American Academy Of Orthopedic Surgeons (AAOS) Recommends This Treatment.

• Weight loss – is valuable in all stages of ACL injury. It is indicated in patients with symptomatic ACL injury with a body mass index greater than 25. The best recommendation to achieve weight loss is with diet control and low-impact aerobic exercise.
• Knee bracing – in the setting of ACL injury includes unloader-type braces that shift the load away from the involved knee compartment. This may be useful in the setting where either the lateral or medial compartment of the knee is involved such as in a valgus or varus deformity.
• Immobilization – Your doctor may recommend that you wear a brace for 3 to 4 weeks. This stabilizes the knee while it heals.
• Weightbearing –  Because putting weight on the knee may cause pain and slow the healing process, your doctor may recommend using crutches for the first week or two after the injury.
• Physical therapy – Once the knee has started to heal, your doctor will recommend physical therapy to help your child regain normal motion. Specific exercises will strengthen the thigh muscles holding the knee joint in place. Your commitment to the exercise program is important for a successful recovery. Typically return to activity 3 to 6 weeks after the injury.
• Emergent closed reduction followed by vascular assessment/consult – If indications to considered an orthopedic emergency, vascular consult indicated if pulses are absent or diminished following reduction if arterial injury confirmed by arterial duplex ultrasound or CT angiography
• Immobilization as definitive management – successful closed reduction without vascular compromise, most cases require some form of surgical stabilization following reduction, outcomes of worse outcomes are seen with nonoperative management/prolonged immobilization will lead to loss of ROM with persistent instability.
• Rest Your Leg – Once you’re discharged from the hospital in a legislating, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your will help the bone mend quicker and the pain fades away sooner.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic ACL injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee ACL injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of  ACL injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgical Treatment

Prevention

Given the importance of neuromuscular factors and the etiology of ACL injuries, numerous programs have aimed to improve neuromuscular control during standing, cutting, jumping, and landing. ^[rx] The components of neuromuscular training are:

• Balance training: balance exercises
• Jump training – plyometrics: landing with increased flexion at the knee and hip
• Strengthening that emphasizes proximal hip control mediated through gluteus and proximal hamstring activation in a close kinetic chain
• Stretching
• Skill training: Controlling body motions, especially in deceleration and pivoting maneuvers
• Movement education and some form of feedback to the athlete during the training of these activities
• Agility training: agility exercises

Examples of more recent neuromuscular training programs include: Sportsmetrics and Prevent Injury and Enhance Performance program. Both programs have a positive influence on injury reduction and improve athletic performance tests. ^[rx] The PEP plan includes: Warm Up, stretching, strengthening, plyometrics, and agility exercises. ^[rx]

References

PCL Torn/Posterior Cruciate Ligament Injury (PCL) is one of the four major ligaments of the knee joint that functions to stabilize the tibia on the femur. It originates from the anterolateral aspect of the medial femoral condyle in the area of the intercondylar notch and inserts onto the posterior aspect of the tibial plateau. It functions to prevent posterior translation of the tibia on the femur. To a lesser extent, the PCL functions to resist varus, valgus, and external rotation forces. It is approximately 1.3 to 2 times as thick and about twice as strong as the anterior cruciate ligament (ACL) and, consequently, less commonly subject to injury.[rx][rx][rx][rx]

The posterior cruciate ligament (PCL) is the largest and strongest ligament in the human knee, and the primary posterior stabilizer. Recent anatomy and biomechanical studies have provided an improved understanding of PCL function. PCL injuries are typically combined with other ligamentous, meniscal and chondral injuries. Stress radiography has become an important and validated objective measure in surgical decision making and post-operative assessment. Isolated grade I or II PCL injuries can usually be treated non-operatively. However, when acute grade III PCL ruptures occur together with other ligamentous injury and/or repairable meniscal body/root tears, surgery is indicated. Anatomic single-bundle PCL reconstruction (SB-PCLR) typically restores the larger anterolateral bundle (ALB) and represents the most commonly performed procedure.

Anatomy of PCL Injury

The PCL is the largest and strongest intraarticular ligament of the knee joint, comprising of 2 functional bundles: the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB) (rx). The size of the femoral attachment of the ALB is nearly twice the size of its tibial attachment and has been reported to range from 112 to 118 mm² (rx–rx). The center of the femoral ALB footprint is located 7.4 mm from the trochlear point, 11.0 mm from the medial arch point, and 7.9 mm from the distal articular cartilage. Furthermore, ALB tibial attachment center is located 6.1 mm posterior to the shiny white fibers of the posterior medial meniscus root, 4.9 mm from the bundle ridge (which separates both bundles), and 10.7 mm from the champagne glass drop-off of the posterior tibia (rx).

The area of the PMB femoral attachment is between 60 mm² and 90 mm² in size and is located between the anterior and posterior meniscofemoral ligaments. The femoral PMB center is located 11.1 mm from the medial arch point and 10.8 mm from the posterior point of the articular cartilage margin. Meanwhile, the PMB tibial attachment center is located 4.4 mm anterior to the champagne glass drop-off of the posterior tibia and 3.1 mm lateral from the medial groove of the medial tibial plateau articular surface (rx). These measures have biomechanical and surgical implications, because an anatomic reconstruction of the ALB and PMB better restores native knee kinematics and has been reported to improve clinical outcomes

Posterior Cruciate Ligament

• Origin – the posterior intercondylar region of the tibia
• Insertion – the anterolateral margin of the medial condyle of the femur
• Function – prevention of posterior translation of the tibia relative to the femur; generalized knee stability
• Blood Supply – middle geniculate artery
• Sensory Innervation – posterior articular nerve

The PCL is composed of two bundles: the anterolateral bundle and the posteromedial bundle

Anterolateral Bundle of the PCL

• Taut in knee flexion
• Lax in knee extension

Posteromedial bundle of the PCL

• Taut in knee extension
• Lax in knee flexion

Types of Posterior Cruciate Ligament Injury

Acute PCL injury

• Isolated injury – Symptoms are often vague and minimal, with patients often not even feeling or noticing the injury. Minimal pain, swelling, instability and full range of motion is present, as well as a near-normal gait pattern.
• Combination with other ligamentous injuries – Symptoms differ according to the extent of the knee injury. This includes swelling, pain, a feeling of instability, limited range of motion and difficulty with mobilisation. Bruising may also be present.

Chronic PCL injury

Patients with a chronic PCL injury are not always able to recall a mechanism of injury. Common complaints are discomfort with weight-bearing in a semi flexed position (e.g. climbing stairs or squatting) and aching in the knee when walking long distances. Complaints of instability are also often present, mostly when walking on an uneven surface. Retropatellar pain and pain in the medial compartment of the knee may also be present. Potential swelling and stiffness depend on the degree of associated chondral damage.

Ligaments

• anterior cruciate ligament tear
  • • anterior tibial translocation sign
    • deep lateral sulcus sign
    • positive PCL line sign
    • reconstruction
      • radiographic evaluation
      • complications
        • cyclops lesion
        • tibial tunnel cyst
• anterior cruciate ligament ganglion cyst
• anterior cruciate ligament mucoid degeneration
• posterior cruciate ligament tear
• medial collateral ligament tear
• lateral collateral ligament tear
• medial patellofemoral ligament tear
• posterolateral corner injury
• posteromedial corner injury

Tendons

• patellar tendon rupture
• quadriceps tendon rupture

Meniscal lesions

• meniscal tear
  • • longitudinal tear
      • horizontal tear
      • longitudinal tear
        • Wrisberg rip
    • radial tear
      • ghost meniscus
    • root tear
    • displaced tear
      • flap tear
      • bucket-handle tear
      • parrot beak tear
    • signs
      • absent bow tie sign
      • double PCL sign
      • Jack and Jill lesion
      • two-slice-touch rule
    • MRI grading system for meniscal signal intensity
• meniscal contusion
• meniscal extrusion
• meniscal/parameniscal cyst
• meniscal flounce
• meniscal fraying
• meniscal maceration
• meniscocapsular separation
  • ramp lesion
  • floating meniscus
• bursosynovial lesions
  • infrapatellar bursitis
  • pes anserinus bursitis
  • prepatellar bursitis
  • medial patellar plica syndrome

Knee Joint Ligaments Anatomy Knee And Ankle Anatomy Musculoskeletal With Seegmiller At – Human Anatomy Library

Causes of Posterior Cruciate Ligament Injury

PCL tears are commonly seen in contact sports and non-contact sports. They often occur when:

• Motor vehicle accidents – A “dashboard injury” occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing the posterior cruciate ligament to tear.
• Contact sports – Athletes in sports such as football and soccer can tear their posterior cruciate ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
• The knee is hit directly – especially during sports like soccer, rugby, and football
• A person lands on a bent knee – such as during a fall or misstep
• Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
• A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
• A person lands on one leg – which can happen after a jump in basketball or volleyball
• A direct blow to the bent knee in an automobile injury
• A sports-related injury in which the knee bends
• Pulling on the ligament in a twisting injury or hyperextension
• A misstep on uneven terrain

Symptoms of PCL Torn

Diagnosis of PCL Torn

History and Physical

Patients often will present with complaints of acute onset of posterior knee pain, swelling, and instability.  A thorough history includes the mechanism of injury, such as trauma from falling onto a flexed knee or recent motor vehicle accident.  There may or may not be a complaint of a “pop” with PCL tears like those frequently reported with ACL tears.

A thorough knee exam should be performed, including gait assessment. The neurovascular integrity of the lower extremity distal to the injury should also be assessed.

• Inspection – Affected knee will often present with mild to moderate joint effusion. Swelling is usually less than an ACL tear. Patients may present with antalgic gait on examination with obvious favoring of affected knee. They may have difficulty walking up or down stairs or at an incline. There may be a positive sag test; The sag test is performed with the patient supine, hip flexed to 45 degrees, and knee flexed to 90 degrees.  The tibia will be noted to sag distally relative to the femur as compared to the opposite knee.
• Palpation – There may be an effusion on physical exam.
• Muscle strength testing – Strength should be normal, but there may be weakness with knee extension and flexion secondary to guarding.
• ROM – The passive range of motion may be limited 10 to 20 degrees with flexion. It may be further decreased with other concomitant injuries such as meniscal, muscular, or ligamentous etiology.
• Special Testing – The posterior drawer test is the most accurate test for assessing PCL integrity.  It is performed with the patient in the supine position with the hip flexed to 45 degrees and knee flexed to 90 degrees. A posterior force is applied to the proximal tibia with one hand with stabilization of the femur with the other. Ligamentous and meniscal testing should be performed to assess the integrity of other structure of the knee. The Dial test can be performed to distinguish isolated PCL injuries with an associated posterolateral joint capsule, popliteus, medial collateral ligament, and posterior oblique ligament injuries.
• The posterolateral drawer test – external rotation recurvatum test, and reverse pivot shift test can also be used to assess injuries to the posterolateral structures. However, a positive external rotation recurvatum test is more indicative of an ACL injury than a PCL injury[rx] and the reverse pivot shift test should be used with care because the test may yield positive results in about 30% of normal knees[rx].

Posterior drawer test

• The test is performed with the person lying on his or her back.
• The examiner will ask the person to bend their hip to 45º with foot flat) and knee to 90º.
• He or she will lean lightly on the person’s foot to stabilize the leg.
• The examiner will wrap both hands around the joint line of the knee and attempt to move the tibia (shin bone) backwards.
• This movement may be done several times to confirm the diagnosis.

By putting pressure on the shin bone, the doctor will be able to gauge resistance from the PCL; an injured PCL will have less resistance than an uninjured ligament, causing the tibia to move backwards.

Treatment of PCL Torn

Nonsurgical Treatment Options for PCL Injuries

Less severe posterior cruciate ligament (PCL) tears of the knee generally heal well without surgery. Immediately after the injury, management consists of the RICE method:

• Rest – Any activities that causes knee pain, such as running or walking, should be avoided until symptoms are relieved.
• Ice – A person may be advised to apply ice to the area to help reduce pain and swelling. Ice can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected knee.
• Elevation – Keeping the knee supported above the waist can help with swelling.
• Wear a knee brace – A knee brace provides stability and restricts side-to-side movement. Some people may choose to wear a functional knee brace, which allows for more movement, when they return to activity.
• Use crutches – Crutches may be recommended to keep weight off the injured knee.

Physical Therapy

• A physical therapist will focus on improving mobility, strength, flexibility, and balance, which can help speed up recovery time and improve performance once the injury has healed.
• Walking (weight-bearing) is initiated as soon as possible.
• Knee straightening (extension) and bending (flexion) are encouraged. Pool therapy is helpful.
• Stationary cycling is initiated as soon as adequate motion is achieved.
• Quadriceps strengthening exercises are started, such as standing squats with toe raises and leg press.
• Hamstring exercise may be modified for 6 months.
• Surgery is avoided in most cases unless other major ligaments are disrupted.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic PCL injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee PCL injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of  PCL injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgery

Arthroscopic transtibial technique

• standard arthroscopic portals with an accessory posteromedial portal posteromedial portal is placed 1 cm proximal to the joint line posterior to the MCL avoid injury to branches of the saphenous nerve during placement.
• posteromedial corner of the knee is best visualized with a 70° arthroscope either through the notch (modified Gillquist view) or using a posteromedial portal transtibial drilling anterior to posterior
• fix graft in 90° flexion with an anterior drawer results in knee biomechanics similar to native knee risk to popliteal vessels

Open (tibial inlay)

• uses a posteromedial incision between medial head of gastrocnemius and semimembranosus used for ORIF of bony avulsion biomechanical advantage with a decrease in the “killer turn” with less graft attenuation and failure  screw fixation of the graft bone block is within 20 mm of the popliteal artery.

Single-bundle technique

• arthroscopic or open reconstruct the anterolateral bundle tension at 90° of flexion

Double-bundle technique

• arthroscopic or open techniques may be utilized anterolateral bundle tensioned in 90° of flexion posteromedial bundle tensioned in extension biomechanical advantage with knee function in flexion and extension clinical advantage has yet to be determined may be advantageous to perform with combined PCL/PLC injuries for better rotational control as PLC reconstructions typically loosen over time.

Rehabilitation of PCL Torn

Conservative management with Physiotherapy management

Grade 1 & II injuries

Two weeks of relative immobilisation of the knee (in a locked range of motion brace) is recommended by orthopaedic surgeons. Physiotherapy in this time period includes

• Partial to full weight-bearing mobilisation
• Reduce pain and inflammation
• Reducing knee joint effusion
• Restore knee range of motion
• Knee strengthening (especially protective quadriceps rehabilitation)
  • Strengthening the quadriceps is a key factor in a successful recovery, as the quadriceps can take the place of the PCL to a certain extent to prevent the femur from moving too far forward over the tibia.
  • Hamstring strengthening can be included
  • Important to incorporate eccentric strengthening of the lower limb muscles
  • Closed chain exercises
• Activity modification until pain and swelling subsides

After 2 weeks (on the orthopaedic surgeon’s recommendation)

• Progress to full weight-bearing mobilisation
• Weaning of range of motion brace
• Proprioception, balance and coordination
• Agility programme when strength and endurance has been regained and the neuromuscular control increased
• Return to play between 2 and 4 weeks of injury

Grade III injuries

The knee is immobilised in range of motion brace, locked in extension, for 2-4 weeks. Physiotherapy management in this time includes:

• Activity modification
• Quadriceps rehabilitation
  • Initially isometric quadriceps exercises and straight-leg raises (SLR)

After 2-4 weeks

• Avoid isolated hamstring strengthening
• Active-assisted knee flexion <70°
• Progress weight-bearing within pain limits
• Quadriceps rehabilitation: Promote dynamic stabilisation and counteract posterior tibial subluxation
  • Closed chain exercises
  • Open kinetic chain eccentric exercises and eventually
  • Progress to functional exercises such as stationary cycling, leg press, elliptical exercises and stair climbing

Return to play is sport specific, and only after 3 months.

Chronic injuries

• Chronic PCL injuries can be adequately treated with physiotherapy. A range of motion brace is used, initially set to prevent the terminal 15° of extension. After a while the brace is opened to full extension.

Post-operative rehabilitation

Post-operative rehabilitation typically lasts 6 to 9 months. The duration of each of the five phases and the total duration of the rehabilitation depends on the age and physical level of the patient, as well as the success of the operation. Also see page on PCL reconstruction.

General Guidelines for the post-operative PCL rehabilitation

• Mobility should be restricted from 0-90 degrees in the first two weeks then facilitated gradually to full ROM.
• Involved leg should be in non-weight bearing for the first 6 weeks then placed in mobilizer brace and progressed to rebound PCL brace for 6 months.
• Avoid isolated hamstrings contraction for 4 months due to the hamstrings force in drawing tibia posteriorly which can apply an elongation force on the PCL graft causing instability
• Avoid unsupported knee flexion for 4 months to prevent any posterior drawing forces on tibia.

Phase I: Early Post-operative phase

Early mobilisation and placing sub-maximal strain on graft lead to better outcomes.

Objectives of maximal protection and early rehabilitation:

• Restore joint homeostasis
• Scar tissue management
• Restore joint ROM
• Re-train quadriceps
• Create an effective plan for your patient

Strategies of rehabilitation:

• Perform ROM exercises from prone position to avoid posterior tibial sag and graft elongation
• Teach patient to perform Quadriceps contraction/sets from day 1 post surgery if the patient is not on strong pain medications.
• Patellofemoral mobilisation is important to prevent scarring and preserve joint volume for full range of flexion and extension
• Ice and elevation for swelling and inflammation management
• Progressing by applying strategies for increasing ROM and terminal knee extension

One of the huge advancement of PCL management is the utilisation of Dynamic PCL braces. This option may not always be available but if found make sure to utilise it. It’s a spring loaded brace aiming to place an anterior force on the tibia preventing posterior tibial sag and graft elongation by placing the graft in a shortened position. Immediately after surgery, it is recommended to place the leg in a mobiliser braces then progress to a dynamic brace once swelling is subsided. It should be used all the time and only taken off to perform exercises for 6 months. Then move into more functional bracing, worn all the time for 12 months.

Building weight bearing tolerance after 6 weeks of non weight bearing (NWB) should take place gradually and progressively between week 7-8 .

Phase II: Later Post-operative Rehabilitation

Begins 8 weeks after surgery. The aim is to create a plan for the patient to prepare them for returning to pre-operative functional capacity by addressing all MSK deficits.

Areas to address in late post-operative rehabilitation and suggested time-frames:

• Muscular endurance (weeks:9-16)
• Strength (weeks 17-22)
• Power (weeks 23-28) with running progression if it needed (weeks 25-28)
• Speed and agility (weeks 29-32 )
• Return to training (week 33).
• Return to sport : It varies from a sport to another but on average takes about with 3-4 weeks of training. Return to play around 36th week.

How can you care for yourself at home?

• Put ice or a cold pack on your knee for 10 to 20 minutes at a time. Try to do this every 1 to 2 hours (when you’re awake) for the first 3 days after your injury or until the swelling goes down. Put a thin cloth between the ice and your skin.
• Prop up your leg on a pillow when you ice it or anytime you sit or lie down. Do this for about 3 days after your injury. Try to keep your knee above the level of your heart. This will help reduce swelling.
• Take anti-inflammatory medicines to reduce pain and swelling. These include ibuprofen (Advil, Motrin) and naproxen (Aleve). Be safe with medicines. Read and follow all instructions on the label.
• Follow instructions about how much weight you can put on your leg and how to walk with crutches, if your doctor recommends them.
• Wear a brace, if your doctor recommends it, to protect and support your knee while it heals. Wear it as directed.
• Do stretches or strength exercises as your doctor suggests.

References

PCL Injury Tear/Posterior Cruciate Ligament Injury (PCL) is one of the four major ligaments of the knee joint that functions to stabilize the tibia on the femur. It originates from the anterolateral aspect of the medial femoral condyle in the area of the intercondylar notch and inserts onto the posterior aspect of the tibial plateau. It functions to prevent posterior translation of the tibia on the femur. To a lesser extent, the PCL functions to resist varus, valgus, and external rotation forces. It is approximately 1.3 to 2 times as thick and about twice as strong as the anterior cruciate ligament (ACL) and, consequently, less commonly subject to injury.[rx][rx][rx][rx]

The posterior cruciate ligament (PCL) is the largest and strongest ligament in the human knee, and the primary posterior stabilizer. Recent anatomy and biomechanical studies have provided an improved understanding of PCL function. PCL injuries are typically combined with other ligamentous, meniscal and chondral injuries. Stress radiography has become an important and validated objective measure in surgical decision making and post-operative assessment. Isolated grade I or II PCL injuries can usually be treated non-operatively. However, when acute grade III PCL ruptures occur together with other ligamentous injury and/or repairable meniscal body/root tears, surgery is indicated. Anatomic single-bundle PCL reconstruction (SB-PCLR) typically restores the larger anterolateral bundle (ALB) and represents the most commonly performed procedure.

Anatomy of PCL Injury

The PCL is the largest and strongest intraarticular ligament of the knee joint, comprising of 2 functional bundles: the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB) (rx). The size of the femoral attachment of the ALB is nearly twice the size of its tibial attachment and has been reported to range from 112 to 118 mm² (rx–rx). The center of the femoral ALB footprint is located 7.4 mm from the trochlear point, 11.0 mm from the medial arch point, and 7.9 mm from the distal articular cartilage. Furthermore, ALB tibial attachment center is located 6.1 mm posterior to the shiny white fibers of the posterior medial meniscus root, 4.9 mm from the bundle ridge (which separates both bundles), and 10.7 mm from the champagne glass drop-off of the posterior tibia (rx).

The area of the PMB femoral attachment is between 60 mm² and 90 mm² in size and is located between the anterior and posterior meniscofemoral ligaments. The femoral PMB center is located 11.1 mm from the medial arch point and 10.8 mm from the posterior point of the articular cartilage margin. Meanwhile, the PMB tibial attachment center is located 4.4 mm anterior to the champagne glass drop-off of the posterior tibia and 3.1 mm lateral from the medial groove of the medial tibial plateau articular surface (rx). These measures have biomechanical and surgical implications, because an anatomic reconstruction of the ALB and PMB better restores native knee kinematics and has been reported to improve clinical outcomes

Posterior Cruciate Ligament

• Origin – the posterior intercondylar region of the tibia
• Insertion – the anterolateral margin of the medial condyle of the femur
• Function – prevention of posterior translation of the tibia relative to the femur; generalized knee stability
• Blood Supply – middle geniculate artery
• Sensory Innervation – posterior articular nerve

The PCL is composed of two bundles: the anterolateral bundle and the posteromedial bundle

Anterolateral Bundle of the PCL

• Taut in knee flexion
• Lax in knee extension

Posteromedial bundle of the PCL

• Taut in knee extension
• Lax in knee flexion

Types of Posterior Cruciate Ligament Injury

Acute PCL injury

• Isolated injury – Symptoms are often vague and minimal, with patients often not even feeling or noticing the injury. Minimal pain, swelling, instability and full range of motion is present, as well as a near-normal gait pattern.
• Combination with other ligamentous injuries – Symptoms differ according to the extent of the knee injury. This includes swelling, pain, a feeling of instability, limited range of motion and difficulty with mobilisation. Bruising may also be present.

Chronic PCL injury

Patients with a chronic PCL injury are not always able to recall a mechanism of injury. Common complaints are discomfort with weight-bearing in a semi flexed position (e.g. climbing stairs or squatting) and aching in the knee when walking long distances. Complaints of instability are also often present, mostly when walking on an uneven surface. Retropatellar pain and pain in the medial compartment of the knee may also be present. Potential swelling and stiffness depend on the degree of associated chondral damage.

Ligaments

• anterior cruciate ligament tear
  • • anterior tibial translocation sign
    • deep lateral sulcus sign
    • positive PCL line sign
    • reconstruction
      • radiographic evaluation
      • complications
        • cyclops lesion
        • tibial tunnel cyst
• anterior cruciate ligament ganglion cyst
• anterior cruciate ligament mucoid degeneration
• posterior cruciate ligament tear
• medial collateral ligament tear
• lateral collateral ligament tear
• medial patellofemoral ligament tear
• posterolateral corner injury
• posteromedial corner injury

Tendons

• patellar tendon rupture
• quadriceps tendon rupture

Meniscal lesions

• meniscal tear
  • • longitudinal tear
      • horizontal tear
      • longitudinal tear
        • Wrisberg rip
    • radial tear
      • ghost meniscus
    • root tear
    • displaced tear
      • flap tear
      • bucket-handle tear
      • parrot beak tear
    • signs
      • absent bow tie sign
      • double PCL sign
      • Jack and Jill lesion
      • two-slice-touch rule
    • MRI grading system for meniscal signal intensity
• meniscal contusion
• meniscal extrusion
• meniscal/parameniscal cyst
• meniscal flounce
• meniscal fraying
• meniscal maceration
• meniscocapsular separation
  • ramp lesion
  • floating meniscus
• bursosynovial lesions
  • infrapatellar bursitis
  • pes anserinus bursitis
  • prepatellar bursitis
  • medial patellar plica syndrome

Knee Joint Ligaments Anatomy Knee And Ankle Anatomy Musculoskeletal With Seegmiller At – Human Anatomy Library

Causes of Posterior Cruciate Ligament Injury

PCL tears are commonly seen in contact sports and non-contact sports. They often occur when:

• Motor vehicle accidents – A “dashboard injury” occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing the posterior cruciate ligament to tear.
• Contact sports – Athletes in sports such as football and soccer can tear their posterior cruciate ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
• The knee is hit directly – especially during sports like soccer, rugby, and football
• A person lands on a bent knee – such as during a fall or misstep
• Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
• A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
• A person lands on one leg – which can happen after a jump in basketball or volleyball
• A direct blow to the bent knee in an automobile injury
• A sports-related injury in which the knee bends
• Pulling on the ligament in a twisting injury or hyperextension
• A misstep on uneven terrain

Symptoms of Posterior Cruciate Ligament Injury/PCL Injury Tear

Diagnosis of PCL Injury Tear

History and Physical

Patients often will present with complaints of acute onset of posterior knee pain, swelling, and instability.  A thorough history includes the mechanism of injury, such as trauma from falling onto a flexed knee or recent motor vehicle accident.  There may or may not be a complaint of a “pop” with PCL tears like those frequently reported with ACL tears.

A thorough knee exam should be performed, including gait assessment. The neurovascular integrity of the lower extremity distal to the injury should also be assessed.

• Inspection – Affected knee will often present with mild to moderate joint effusion. Swelling is usually less than an ACL tear. Patients may present with antalgic gait on examination with obvious favoring of affected knee. They may have difficulty walking up or down stairs or at an incline. There may be a positive sag test; The sag test is performed with the patient supine, hip flexed to 45 degrees, and knee flexed to 90 degrees.  The tibia will be noted to sag distally relative to the femur as compared to the opposite knee.
• Palpation – There may be an effusion on physical exam.
• Muscle strength testing – Strength should be normal, but there may be weakness with knee extension and flexion secondary to guarding.
• ROM – The passive range of motion may be limited 10 to 20 degrees with flexion. It may be further decreased with other concomitant injuries such as meniscal, muscular, or ligamentous etiology.
• Special Testing – The posterior drawer test is the most accurate test for assessing PCL integrity.  It is performed with the patient in the supine position with the hip flexed to 45 degrees and knee flexed to 90 degrees. A posterior force is applied to the proximal tibia with one hand with stabilization of the femur with the other. Ligamentous and meniscal testing should be performed to assess the integrity of other structure of the knee. The Dial test can be performed to distinguish isolated PCL injuries with an associated posterolateral joint capsule, popliteus, medial collateral ligament, and posterior oblique ligament injuries.
• The posterolateral drawer test – external rotation recurvatum test, and reverse pivot shift test can also be used to assess injuries to the posterolateral structures. However, a positive external rotation recurvatum test is more indicative of an ACL injury than a PCL injury[rx] and the reverse pivot shift test should be used with care because the test may yield positive results in about 30% of normal knees[rx].

Posterior drawer test

• The test is performed with the person lying on his or her back.
• The examiner will ask the person to bend their hip to 45º with foot flat) and knee to 90º.
• He or she will lean lightly on the person’s foot to stabilize the leg.
• The examiner will wrap both hands around the joint line of the knee and attempt to move the tibia (shin bone) backwards.
• This movement may be done several times to confirm the diagnosis.

By putting pressure on the shin bone, the doctor will be able to gauge resistance from the PCL; an injured PCL will have less resistance than an uninjured ligament, causing the tibia to move backwards.

Treatment of Posterior Cruciate Ligament Injury/PCL Injury Tear

Nonsurgical Treatment Options for PCL Injuries

Less severe posterior cruciate ligament (PCL) tears of the knee generally heal well without surgery. Immediately after the injury, management consists of the RICE method:

• Rest – Any activities that causes knee pain, such as running or walking, should be avoided until symptoms are relieved.
• Ice – A person may be advised to apply ice to the area to help reduce pain and swelling. Ice can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected knee.
• Elevation – Keeping the knee supported above the waist can help with swelling.
• Wear a knee brace – A knee brace provides stability and restricts side-to-side movement. Some people may choose to wear a functional knee brace, which allows for more movement, when they return to activity.
• Use crutches – Crutches may be recommended to keep weight off the injured knee.

Physical therapist

• A physical therapist will focus on improving mobility, strength, flexibility, and balance, which can help speed up recovery time and improve performance once the injury has healed.
• Walking (weight-bearing) is initiated as soon as possible.
• Knee straightening (extension) and bending (flexion) are encouraged. Pool therapy is helpful.
• Stationary cycling is initiated as soon as adequate motion is achieved.
• Quadriceps strengthening exercises are started, such as standing squats with toe raises and leg press.
• Hamstring exercise may be modified for 6 months.
• Surgery is avoided in most cases unless other major ligaments are disrupted.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic PCL injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee PCL injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of  PCL injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgery

Arthroscopic transtibial technique

• standard arthroscopic portals with an accessory posteromedial portal posteromedial portal is placed 1 cm proximal to the joint line posterior to the MCL avoid injury to branches of the saphenous nerve during placement.
• posteromedial corner of the knee is best visualized with a 70° arthroscope either through the notch (modified Gillquist view) or using a posteromedial portal transtibial drilling anterior to posterior
• fix graft in 90° flexion with an anterior drawer results in knee biomechanics similar to native knee risk to popliteal vessels

Open (tibial inlay)

• uses a posteromedial incision between medial head of gastrocnemius and semimembranosus used for ORIF of bony avulsion biomechanical advantage with a decrease in the “killer turn” with less graft attenuation and failure  screw fixation of the graft bone block is within 20 mm of the popliteal artery.

Single-bundle technique

• arthroscopic or open reconstruct the anterolateral bundle tension at 90° of flexion

Double-bundle technique

• arthroscopic or open techniques may be utilized anterolateral bundle tensioned in 90° of flexion posteromedial bundle tensioned in extension biomechanical advantage with knee function in flexion and extension clinical advantage has yet to be determined may be advantageous to perform with combined PCL/PLC injuries for better rotational control as PLC reconstructions typically loosen over time.

Rehabilitation of PCL Injury Tear

Conservative management with Physiotherapy management

Grade 1 & II injuries

Two weeks of relative immobilisation of the knee (in a locked range of motion brace) is recommended by orthopaedic surgeons. Physiotherapy in this time period includes

• Partial to full weight-bearing mobilisation
• Reduce pain and inflammation
• Reducing knee joint effusion
• Restore knee range of motion
• Knee strengthening (especially protective quadriceps rehabilitation)
  • Strengthening the quadriceps is a key factor in a successful recovery, as the quadriceps can take the place of the PCL to a certain extent to prevent the femur from moving too far forward over the tibia.
  • Hamstring strengthening can be included
  • Important to incorporate eccentric strengthening of the lower limb muscles
  • Closed chain exercises
• Activity modification until pain and swelling subsides

After 2 weeks (on the orthopaedic surgeon’s recommendation)

• Progress to full weight-bearing mobilisation
• Weaning of range of motion brace
• Proprioception, balance and coordination
• Agility programme when strength and endurance has been regained and the neuromuscular control increased
• Return to play between 2 and 4 weeks of injury

Grade III injuries

The knee is immobilised in range of motion brace, locked in extension, for 2-4 weeks. Physiotherapy management in this time includes:

• Activity modification
• Quadriceps rehabilitation
  • Initially isometric quadriceps exercises and straight-leg raises (SLR)

After 2-4 weeks

• Avoid isolated hamstring strengthening
• Active-assisted knee flexion <70°
• Progress weight-bearing within pain limits
• Quadriceps rehabilitation: Promote dynamic stabilisation and counteract posterior tibial subluxation
  • Closed chain exercises
  • Open kinetic chain eccentric exercises and eventually
  • Progress to functional exercises such as stationary cycling, leg press, elliptical exercises and stair climbing

Return to play is sport specific, and only after 3 months.

Chronic injuries

• Chronic PCL injuries can be adequately treated with physiotherapy. A range of motion brace is used, initially set to prevent the terminal 15° of extension. After a while the brace is opened to full extension.

Post-operative rehabilitation

Post-operative rehabilitation typically lasts 6 to 9 months. The duration of each of the five phases and the total duration of the rehabilitation depends on the age and physical level of the patient, as well as the success of the operation. Also see page on PCL reconstruction.

General Guidelines for the post-operative PCL rehabilitation

• Mobility should be restricted from 0-90 degrees in the first two weeks then facilitated gradually to full ROM.
• Involved leg should be in non-weight bearing for the first 6 weeks then placed in mobilizer brace and progressed to rebound PCL brace for 6 months.
• Avoid isolated hamstrings contraction for 4 months due to the hamstrings force in drawing tibia posteriorly which can apply an elongation force on the PCL graft causing instability
• Avoid unsupported knee flexion for 4 months to prevent any posterior drawing forces on tibia.

Phase I: Early Post-operative phase

Early mobilisation and placing sub-maximal strain on graft lead to better outcomes.

Objectives of maximal protection and early rehabilitation:

• Restore joint homeostasis
• Scar tissue management
• Restore joint ROM
• Re-train quadriceps
• Create an effective plan for your patient

Strategies of rehabilitation:

• Perform ROM exercises from prone position to avoid posterior tibial sag and graft elongation
• Teach patient to perform Quadriceps contraction/sets from day 1 post surgery if the patient is not on strong pain medications.
• Patellofemoral mobilisation is important to prevent scarring and preserve joint volume for full range of flexion and extension
• Ice and elevation for swelling and inflammation management
• Progressing by applying strategies for increasing ROM and terminal knee extension

One of the huge advancement of PCL management is the utilisation of Dynamic PCL braces. This option may not always be available but if found make sure to utilise it. It’s a spring loaded brace aiming to place an anterior force on the tibia preventing posterior tibial sag and graft elongation by placing the graft in a shortened position. Immediately after surgery, it is recommended to place the leg in a mobiliser braces then progress to a dynamic brace once swelling is subsided. It should be used all the time and only taken off to perform exercises for 6 months. Then move into more functional bracing, worn all the time for 12 months.

Building weight bearing tolerance after 6 weeks of non weight bearing (NWB) should take place gradually and progressively between week 7-8 .

Phase II: Later Post-operative Rehabilitation

Begins 8 weeks after surgery. The aim is to create a plan for the patient to prepare them for returning to pre-operative functional capacity by addressing all MSK deficits.

Areas to address in late post-operative rehabilitation and suggested time-frames:

• Muscular endurance (weeks:9-16)
• Strength (weeks 17-22)
• Power (weeks 23-28) with running progression if it needed (weeks 25-28)
• Speed and agility (weeks 29-32 )
• Return to training (week 33).
• Return to sport : It varies from a sport to another but on average takes about with 3-4 weeks of training. Return to play around 36th week.

How can you care for yourself at home?

• Put ice or a cold pack on your knee for 10 to 20 minutes at a time. Try to do this every 1 to 2 hours (when you’re awake) for the first 3 days after your injury or until the swelling goes down. Put a thin cloth between the ice and your skin.
• Prop up your leg on a pillow when you ice it or anytime you sit or lie down. Do this for about 3 days after your injury. Try to keep your knee above the level of your heart. This will help reduce swelling.
• Take anti-inflammatory medicines to reduce pain and swelling. These include ibuprofen (Advil, Motrin) and naproxen (Aleve). Be safe with medicines. Read and follow all instructions on the label.
• Follow instructions about how much weight you can put on your leg and how to walk with crutches, if your doctor recommends them.
• Wear a brace, if your doctor recommends it, to protect and support your knee while it heals. Wear it as directed.
• Do stretches or strength exercises as your doctor suggests.

References

Posterior Cruciate Ligament Injury (PCL) is one of the four major ligaments of the knee joint that functions to stabilize the tibia on the femur. It originates from the anterolateral aspect of the medial femoral condyle in the area of the intercondylar notch and inserts onto the posterior aspect of the tibial plateau. It functions to prevent posterior translation of the tibia on the femur. To a lesser extent, the PCL functions to resist varus, valgus, and external rotation forces. It is approximately 1.3 to 2 times as thick and about twice as strong as the anterior cruciate ligament (ACL) and, consequently, less commonly subject to injury.[rx][rx][rx][rx]

The posterior cruciate ligament (PCL) is the largest and strongest ligament in the human knee, and the primary posterior stabilizer. Recent anatomy and biomechanical studies have provided an improved understanding of PCL function. PCL injuries are typically combined with other ligamentous, meniscal and chondral injuries. Stress radiography has become an important and validated objective measure in surgical decision making and post-operative assessment. Isolated grade I or II PCL injuries can usually be treated non-operatively. However, when acute grade III PCL ruptures occur together with other ligamentous injury and/or repairable meniscal body/root tears, surgery is indicated. Anatomic single-bundle PCL reconstruction (SB-PCLR) typically restores the larger anterolateral bundle (ALB) and represents the most commonly performed procedure.

Anatomy

The PCL is the largest and strongest intraarticular ligament of the knee joint, comprising of 2 functional bundles: the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB) (rx). The size of the femoral attachment of the ALB is nearly twice the size of its tibial attachment and has been reported to range from 112 to 118 mm² (rx–rx). The center of the femoral ALB footprint is located 7.4 mm from the trochlear point, 11.0 mm from the medial arch point, and 7.9 mm from the distal articular cartilage. Furthermore, ALB tibial attachment center is located 6.1 mm posterior to the shiny white fibers of the posterior medial meniscus root, 4.9 mm from the bundle ridge (which separates both bundles), and 10.7 mm from the champagne glass drop-off of the posterior tibia (rx).

The area of the PMB femoral attachment is between 60 mm² and 90 mm² in size and is located between the anterior and posterior meniscofemoral ligaments. The femoral PMB center is located 11.1 mm from the medial arch point and 10.8 mm from the posterior point of the articular cartilage margin. Meanwhile, the PMB tibial attachment center is located 4.4 mm anterior to the champagne glass drop-off of the posterior tibia and 3.1 mm lateral from the medial groove of the medial tibial plateau articular surface (rx). These measures have biomechanical and surgical implications, because an anatomic reconstruction of the ALB and PMB better restores native knee kinematics and has been reported to improve clinical outcomes

Posterior Cruciate Ligament

• Origin – the posterior intercondylar region of the tibia
• Insertion – the anterolateral margin of the medial condyle of the femur
• Function – prevention of posterior translation of the tibia relative to the femur; generalized knee stability
• Blood Supply – middle geniculate artery
• Sensory Innervation – posterior articular nerve

The PCL is composed of two bundles: the anterolateral bundle and the posteromedial bundle

Anterolateral Bundle of the PCL

• Taut in knee flexion
• Lax in knee extension

Posteromedial bundle of the PCL

• Taut in knee extension
• Lax in knee flexion

Types of Posterior Cruciate Ligament Injury

Acute PCL injury

• Isolated injury – Symptoms are often vague and minimal, with patients often not even feeling or noticing the injury. Minimal pain, swelling, instability and full range of motion is present, as well as a near-normal gait pattern.
• Combination with other ligamentous injuries – Symptoms differ according to the extent of the knee injury. This includes swelling, pain, a feeling of instability, limited range of motion and difficulty with mobilisation. Bruising may also be present.

Chronic PCL injury

Patients with a chronic PCL injury are not always able to recall a mechanism of injury. Common complaints are discomfort with weight-bearing in a semi flexed position (e.g. climbing stairs or squatting) and aching in the knee when walking long distances. Complaints of instability are also often present, mostly when walking on an uneven surface. Retropatellar pain and pain in the medial compartment of the knee may also be present. Potential swelling and stiffness depend on the degree of associated chondral damage.

Ligaments

• anterior cruciate ligament tear
  • • anterior tibial translocation sign
    • deep lateral sulcus sign
    • positive PCL line sign
    • reconstruction
      • radiographic evaluation
      • complications
        • cyclops lesion
        • tibial tunnel cyst
• anterior cruciate ligament ganglion cyst
• anterior cruciate ligament mucoid degeneration
• posterior cruciate ligament tear
• medial collateral ligament tear
• lateral collateral ligament tear
• medial patellofemoral ligament tear
• posterolateral corner injury
• posteromedial corner injury

Tendons

• patellar tendon rupture
• quadriceps tendon rupture

Meniscal lesions

• meniscal tear
  • • longitudinal tear
      • horizontal tear
      • longitudinal tear
        • Wrisberg rip
    • radial tear
      • ghost meniscus
    • root tear
    • displaced tear
      • flap tear
      • bucket-handle tear
      • parrot beak tear
    • signs
      • absent bow tie sign
      • double PCL sign
      • Jack and Jill lesion
      • two-slice-touch rule
    • MRI grading system for meniscal signal intensity
• meniscal contusion
• meniscal extrusion
• meniscal/parameniscal cyst
• meniscal flounce
• meniscal fraying
• meniscal maceration
• meniscocapsular separation
  • ramp lesion
  • floating meniscus
• bursosynovial lesions
  • infrapatellar bursitis
  • pes anserinus bursitis
  • prepatellar bursitis
  • medial patellar plica syndrome

Knee Joint Ligaments Anatomy Knee And Ankle Anatomy Musculoskeletal With Seegmiller At – Human Anatomy Library

Causes of Posterior Cruciate Ligament Injury

PCL tears are commonly seen in contact sports and non-contact sports. They often occur when:

• Motor vehicle accidents – A “dashboard injury” occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing the posterior cruciate ligament to tear.
• Contact sports – Athletes in sports such as football and soccer can tear their posterior cruciate ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
• The knee is hit directly – especially during sports like soccer, rugby, and football
• A person lands on a bent knee – such as during a fall or misstep
• Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
• A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
• A person lands on one leg – which can happen after a jump in basketball or volleyball
• A direct blow to the bent knee in an automobile injury
• A sports-related injury in which the knee bends
• Pulling on the ligament in a twisting injury or hyperextension
• A misstep on uneven terrain

Symptoms of Posterior Cruciate Ligament Injury

Diagnosis of Posterior Cruciate Ligament Injury

History and Physical

Patients often will present with complaints of acute onset of posterior knee pain, swelling, and instability.  A thorough history includes the mechanism of injury, such as trauma from falling onto a flexed knee or recent motor vehicle accident.  There may or may not be a complaint of a “pop” with PCL tears like those frequently reported with ACL tears.

A thorough knee exam should be performed, including gait assessment. The neurovascular integrity of the lower extremity distal to the injury should also be assessed.

• Inspection – Affected knee will often present with mild to moderate joint effusion. Swelling is usually less than an ACL tear. Patients may present with antalgic gait on examination with obvious favoring of affected knee. They may have difficulty walking up or down stairs or at an incline. There may be a positive sag test; The sag test is performed with the patient supine, hip flexed to 45 degrees, and knee flexed to 90 degrees.  The tibia will be noted to sag distally relative to the femur as compared to the opposite knee.
• Palpation – There may be an effusion on physical exam.
• Muscle strength testing – Strength should be normal, but there may be weakness with knee extension and flexion secondary to guarding.
• ROM – The passive range of motion may be limited 10 to 20 degrees with flexion. It may be further decreased with other concomitant injuries such as meniscal, muscular, or ligamentous etiology.
• Special Testing – The posterior drawer test is the most accurate test for assessing PCL integrity.  It is performed with the patient in the supine position with the hip flexed to 45 degrees and knee flexed to 90 degrees. A posterior force is applied to the proximal tibia with one hand with stabilization of the femur with the other. Ligamentous and meniscal testing should be performed to assess the integrity of other structure of the knee. The Dial test can be performed to distinguish isolated PCL injuries with an associated posterolateral joint capsule, popliteus, medial collateral ligament, and posterior oblique ligament injuries.
• The posterolateral drawer test – external rotation recurvatum test, and reverse pivot shift test can also be used to assess injuries to the posterolateral structures. However, a positive external rotation recurvatum test is more indicative of an ACL injury than a PCL injury[rx] and the reverse pivot shift test should be used with care because the test may yield positive results in about 30% of normal knees[rx].

Posterior drawer test

• The test is performed with the person lying on his or her back.
• The examiner will ask the person to bend their hip to 45º with foot flat) and knee to 90º.
• He or she will lean lightly on the person’s foot to stabilize the leg.
• The examiner will wrap both hands around the joint line of the knee and attempt to move the tibia (shin bone) backwards.
• This movement may be done several times to confirm the diagnosis.

By putting pressure on the shin bone, the doctor will be able to gauge resistance from the PCL; an injured PCL will have less resistance than an uninjured ligament, causing the tibia to move backwards.

Treatment of Posterior Cruciate Ligament Injury

Nonsurgical Treatment Options for PCL Injuries

Less severe posterior cruciate ligament (PCL) tears of the knee generally heal well without surgery. Immediately after the injury, management consists of the RICE method:

• Rest – Any activities that causes knee pain, such as running or walking, should be avoided until symptoms are relieved.
• Ice – A person may be advised to apply ice to the area to help reduce pain and swelling. Ice can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected knee.
• Elevation – Keeping the knee supported above the waist can help with swelling.
• Wear a knee brace – A knee brace provides stability and restricts side-to-side movement. Some people may choose to wear a functional knee brace, which allows for more movement, when they return to activity.
• Use crutches – Crutches may be recommended to keep weight off the injured knee.

Physical Therapy

• A physical therapist will focus on improving mobility, strength, flexibility, and balance, which can help speed up recovery time and improve performance once the injury has healed.
• Walking (weight-bearing) is initiated as soon as possible.
• Knee straightening (extension) and bending (flexion) are encouraged. Pool therapy is helpful.
• Stationary cycling is initiated as soon as adequate motion is achieved.
• Quadriceps strengthening exercises are started, such as standing squats with toe raises and leg press.
• Hamstring exercise may be modified for 6 months.
• Surgery is avoided in most cases unless other major ligaments are disrupted.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Intra-articular corticosteroid injections – may be useful for symptomatic PCL injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with osteoarthritis and minimize the systemic effects of the steroid.
• Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee PCL injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of  PCL injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.

Surgery

Arthroscopic transtibial technique

• standard arthroscopic portals with an accessory posteromedial portal posteromedial portal is placed 1 cm proximal to the joint line posterior to the MCL avoid injury to branches of the saphenous nerve during placement.
• posteromedial corner of the knee is best visualized with a 70° arthroscope either through the notch (modified Gillquist view) or using a posteromedial portal transtibial drilling anterior to posterior
• fix graft in 90° flexion with an anterior drawer results in knee biomechanics similar to native knee risk to popliteal vessels

Open (tibial inlay)

• uses a posteromedial incision between medial head of gastrocnemius and semimembranosus used for ORIF of bony avulsion biomechanical advantage with a decrease in the “killer turn” with less graft attenuation and failure  screw fixation of the graft bone block is within 20 mm of the popliteal artery.

Single-bundle technique

• arthroscopic or open reconstruct the anterolateral bundle tension at 90° of flexion

Double-bundle technique

• arthroscopic or open techniques may be utilized anterolateral bundle tensioned in 90° of flexion posteromedial bundle tensioned in extension biomechanical advantage with knee function in flexion and extension clinical advantage has yet to be determined may be advantageous to perform with combined PCL/PLC injuries for better rotational control as PLC reconstructions typically loosen over time.

Rehabilitation of Posterior Cruciate Ligament Injury

Conservative management with Physiotherapy management

Grade 1 & II injuries

Two weeks of relative immobilisation of the knee (in a locked range of motion brace) is recommended by orthopaedic surgeons. Physiotherapy in this time period includes

• Partial to full weight-bearing mobilisation
• Reduce pain and inflammation
• Reducing knee joint effusion
• Restore knee range of motion
• Knee strengthening (especially protective quadriceps rehabilitation)
  • Strengthening the quadriceps is a key factor in a successful recovery, as the quadriceps can take the place of the PCL to a certain extent to prevent the femur from moving too far forward over the tibia.
  • Hamstring strengthening can be included
  • Important to incorporate eccentric strengthening of the lower limb muscles
  • Closed chain exercises
• Activity modification until pain and swelling subsides

After 2 weeks (on the orthopaedic surgeon’s recommendation)

• Progress to full weight-bearing mobilisation
• Weaning of range of motion brace
• Proprioception, balance and coordination
• Agility programme when strength and endurance has been regained and the neuromuscular control increased
• Return to play between 2 and 4 weeks of injury

Grade III injuries

The knee is immobilised in range of motion brace, locked in extension, for 2-4 weeks. Physiotherapy management in this time includes:

• Activity modification
• Quadriceps rehabilitation
  • Initially isometric quadriceps exercises and straight-leg raises (SLR)

After 2-4 weeks

• Avoid isolated hamstring strengthening
• Active-assisted knee flexion <70°
• Progress weight-bearing within pain limits
• Quadriceps rehabilitation: Promote dynamic stabilisation and counteract posterior tibial subluxation
  • Closed chain exercises
  • Open kinetic chain eccentric exercises and eventually
  • Progress to functional exercises such as stationary cycling, leg press, elliptical exercises and stair climbing

Return to play is sport specific, and only after 3 months.

Chronic injuries

• Chronic PCL injuries can be adequately treated with physiotherapy. A range of motion brace is used, initially set to prevent the terminal 15° of extension. After a while the brace is opened to full extension.

Post-operative rehabilitation

Post-operative rehabilitation typically lasts 6 to 9 months. The duration of each of the five phases and the total duration of the rehabilitation depends on the age and physical level of the patient, as well as the success of the operation. Also see page on PCL reconstruction.

General Guidelines for the post-operative PCL rehabilitation

• Mobility should be restricted from 0-90 degrees in the first two weeks then facilitated gradually to full ROM.
• Involved leg should be in non-weight bearing for the first 6 weeks then placed in mobilizer brace and progressed to rebound PCL brace for 6 months.
• Avoid isolated hamstrings contraction for 4 months due to the hamstrings force in drawing tibia posteriorly which can apply an elongation force on the PCL graft causing instability
• Avoid unsupported knee flexion for 4 months to prevent any posterior drawing forces on tibia.

Phase I: Early Post-operative phase

Early mobilisation and placing sub-maximal strain on graft lead to better outcomes.

Objectives of maximal protection and early rehabilitation:

• Restore joint homeostasis
• Scar tissue management
• Restore joint ROM
• Re-train quadriceps
• Create an effective plan for your patient

Strategies of rehabilitation:

• Perform ROM exercises from prone position to avoid posterior tibial sag and graft elongation
• Teach patient to perform Quadriceps contraction/sets from day 1 post surgery if the patient is not on strong pain medications.
• Patellofemoral mobilisation is important to prevent scarring and preserve joint volume for full range of flexion and extension
• Ice and elevation for swelling and inflammation management
• Progressing by applying strategies for increasing ROM and terminal knee extension

One of the huge advancement of PCL management is the utilisation of Dynamic PCL braces. This option may not always be available but if found make sure to utilise it. It’s a spring loaded brace aiming to place an anterior force on the tibia preventing posterior tibial sag and graft elongation by placing the graft in a shortened position. Immediately after surgery, it is recommended to place the leg in a mobiliser braces then progress to a dynamic brace once swelling is subsided. It should be used all the time and only taken off to perform exercises for 6 months. Then move into more functional bracing, worn all the time for 12 months.

Building weight bearing tolerance after 6 weeks of non weight bearing (NWB) should take place gradually and progressively between week 7-8 .

Phase II: Later Post-operative Rehabilitation

Begins 8 weeks after surgery. The aim is to create a plan for the patient to prepare them for returning to pre-operative functional capacity by addressing all MSK deficits.

Areas to address in late post-operative rehabilitation and suggested time-frames:

• Muscular endurance (weeks:9-16)
• Strength (weeks 17-22)
• Power (weeks 23-28) with running progression if it needed (weeks 25-28)
• Speed and agility (weeks 29-32 )
• Return to training (week 33).
• Return to sport : It varies from a sport to another but on average takes about with 3-4 weeks of training. Return to play around 36th week.

How can you care for yourself at home?

• Put ice or a cold pack on your knee for 10 to 20 minutes at a time. Try to do this every 1 to 2 hours (when you’re awake) for the first 3 days after your injury or until the swelling goes down. Put a thin cloth between the ice and your skin.
• Prop up your leg on a pillow when you ice it or anytime you sit or lie down. Do this for about 3 days after your injury. Try to keep your knee above the level of your heart. This will help reduce swelling.
• Take anti-inflammatory medicines to reduce pain and swelling. These include ibuprofen (Advil, Motrin) and naproxen (Aleve). Be safe with medicines. Read and follow all instructions on the label.
• Follow instructions about how much weight you can put on your leg and how to walk with crutches, if your doctor recommends them.
• Wear a brace, if your doctor recommends it, to protect and support your knee while it heals. Wear it as directed.
• Do stretches or strength exercises as your doctor suggests.

References