Ligament Tears

What are Knee Ligament Tears?

The knee ligaments are strong bands of connective tissue that surround and support the knee joint. These ligaments may be damaged during physical activity or by direct injury resulting in ligament tears.

Types of Ligament Tears

ACL tear

An ACL injury is a common  sports and work related injury that at times occurs when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL. With ageing and or repetitive loading the ACL may in some people weaken and the energy of “injury” that tears the ACL may appear trivial. Read More

What is an ACL Tear?

The anterior cruciate ligament, or ACL, is one of the major ligaments of the knee that is in the middle of the knee and runs from the femur (thighbone) to the tibia (shinbone). It prevents the tibia from sliding out in front of the femur. Together with posterior cruciate ligament (PCL) it provides rotational stability to the knee.

Causes of ACL Tears

An ACL injury is a common  sports and work related injury that at times occurs when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL. With ageing and or repetitive loading the ACL may in some people weaken and the energy of “injury” that tears the ACL may appear trivial.

Symptoms of ACL Tears

When you injure your ACL typically you might hear a "popping" sound and you may feel as though the knee has given way.  The “pop” is thought to be the ends of the femur and tibia compressing violently which can then cause bone bruising which is an undisplaced fracture of the bone. This bone bruising can cause pain as can the damaged soft tissues including the menisci which are damaged in about half of all acute ACL injuries..

Within the first 24 hours after injury, your knee may swell or feel stiff. Sometimes this swelling can be within a few hours .The swelling causing stiffness is from bleeding from the torn ACL which has a good blood supply. With early ice application swelling may be minimal. You may have a buckling sensation in the knee during twisting movements or with stair or slope descent.

Some people present with a lack of confidence in their knee stating “its just not right” rather than complaining of frank buckling or giving way.

The symptoms mentioned above  can commonly occur with meniscal injury, patellar instability or plateau fractures.

The history can heighten clinical suspicion but is of little value in distinguishing between meniscal and ligamentous injury or in pinpointing which ligament has sustained damage.

Diagnosis of ACL Tears

Diagnosis of an ACL tear is made by taking a detailed  medical history and performing a physical examination of the knee. Other diagnostic tests such as X-rays and  MRI scans will often allow a diagnosis to be made.  At times examination under anaesthetic and arthroscopy which is the gold standard for diagnosis of ACL injury , in particular partial tears , is required.

Grading of ACL Tears

• Grade I Injury: A Grade I injury of the ACL is a intra substance [interstitial] stretching of the ligament with maintained function
• Grade II Injury: This injury represents a partially torn ACL (usually one of the two bundles) or an interstitial stretch with loss of function . The ligament may still be “intact” or be continuous
• Grade III Injury: This injury occurs when the ACL is torn completely, that is a rupture. There is initial loss of continuity of the ligament and loss of function. In some cases over time a complete grade III tear can re attach with scar tissue to become a grade II tear .

Treatment of ACL Tears

Treatment options may include both non-surgical and surgical methods. If the overall stability of the knee appears stable or near stable , your doctor may recommend non-surgical methods. Initial non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. A period of protected weight bearing with crutches may be helpful. Physical therapy may be recommended to improve knee motion and strength.

The correct treatment starts with the correct diagnosis with MRI within 6 weeks of injury recommended. MRI performed greater than 6 weeks after initial injury is not as accurate for diagnosis of ACL tear .

The initial recovery from ACL injury varies.

About 1 in 3 people seemingly recover and may “cope” with activities of daily living for a variable period of time.. About 1 in 3 “adapt” and about 1 in 3 “don’t cope” and have a knee which feels unstable or which can frankly give way.

The long term outlook after ACL injury depends on the grade of ACL injury and whether the menisci are intact , torn or repairable.  If there is a repairable meniscal tear present then early ACL reconstruction combined with meniscal repair can help decrease risk of early arthritis.

People of all ages including those over fifty involved in pivoting hobbies, sports or work may require ACL reconstructive surgery to safely return to unrestricted activity .  The usual surgery for an ACL tear is an ACL reconstruction which tightens your knee and restores its stability. Surgery to reconstruct an ACL is done with an arthroscope using small incisions. Your doctor will replace the torn ligament usually with a tissue graft that can be usually obtained from your hamstring .

Following ACL reconstruction, an individualized  rehabilitation program under the supervision of a physiotherapist is started to help you to safely resume a wider range of activities and accelerate your recovery

Recommended Resource   Ortho Info : ACL INJURY :DOES IT REQUIRE SURGERY ? Weblink https://orthoinfo.aaos.org/en/treatment/acl-injury-does-it-require-surgery/

MCL tear

The medial collateral ligament (MCL) is the ligament that is located on the inner part of the knee joint. It runs from the femur (thighbone) to the top of the tibia (shinbone) and helps in stabilising the knee. Medial collateral ligament (MCL) injury can result in a stretch, partial tear, or complete tear of the ligament. Injuries to the MCL commonly occur because of pressure or stress on the outside part of the knee.

MCL tears are usually managed with knee braces and protected weight bearing with crutches.

Recommended Ortho Info https://orthoinfo.aaos.org/en/diseases--conditions/collateral-ligament-injuries/

Posterior Cruciate Ligament  tear :

Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I, the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II, there is a partial tear of the ligament with loss of function. In grade III, there is a complete tear of the ligament.

The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear.

Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries.

Recent advances in brace technology has resulted in the development of the dynamic PCL bracing   allowing functional healing of the PCL tear if brace applied in a timely manner.

Recommended  Ortho Info : https://orthoinfo.aaos.org/en/diseases--conditions/posterior-cruciate-ligament-injuries

Treatments for Ligament Tears

Immediately following a knee injury, before being evaluated by a doctor, you can initiate the R.I.C.E. method of treatment:

• Rest: Rest the knee, as more damage could result from pressure on the injury
• Ice: Ice packs can be applied to the injured area to reduce swelling and pain. Never place ice directly over the skin. Ice should be wrapped in a towel and applied to the affected area for 15-20 minutes four times a day for several days.
• Compression: Wrapping the knee with an elastic bandage or compression stocking can help minimise the swelling and support your knee.
• Elevation: Elevating the knee above the heart level will also help reduce swelling and pain.

It is important to seek your doctor’s advice if you hear a popping noise or feel as if your knee has given way at the time of injury and if you are unable to move your knee because of severe pain.

The correct treatment requires an accurate early diagnosis so early medical review is important .