Sports Knee Injuries & Procedures

sports-knee-injury-1 Sports are a part of the Australian lifestyle and sports Injuries often go hand in hand. Common sports like rugby (all codes, even touch and Oz tag!!), soccer, netball, basketball are the common culprits although CrossFit, Zumba, tennis, dancing, a big night out, even table tennis has been reported to cause Knee injuries.

The injuries also vary from isolated cartilage injuries to severe Multi ligament major injuries. The common injuries we see are Meniscus, Ligament (ACL, PCL, MCL) and Patellar dislocation.

Knee Arthroscopy

sports-knee-injury-2c Arthroscopy refers to examination of the knee joint using a camera connected to a fiber optic cable. This is a way of examining the knee joint under direct camera vision to diagnose and treat many conditions of the knee joint. It is performed under general anaesthesia and using small key hole size incisions. The procedure is a day only operation and patients usually go home on the day of their surgery with or without crutches.

Common indications (reasons) for Knee arthroscopy include:

Large tears of the meniscus (Shock absorbers) causing symptoms not responding to non-operative treatment. These may at times be repairable
Loose bodies (pieces of bone or cartilage floating free) in the joint causing pain or locking of the joint
Torn flaps of cartilage causing mechanical symptoms
In conjunction with other reconstructive procedure of the knee (commonly ACL or other ligament reconstruction, patellar realignment etc.,)
Washout of the joint
Very occasionally for diagnostic purposes when other non-invasive investigations have not been sufficient

Functional recovery in most cases is fairly quick but will vary according to associated individual procedures and guided by the surgeon’s findings during surgery.

Knee Arthroscopy is NOT A TREATMENT FOR ARTHRITIS and will not change the long term outcomes in established arthritis, however, when performed for the right reason in the right patient, can be very successful.

Meniscal Repair

sports-knee-injury-3 Menisci are the shock absorbers that protect the cartilage surface form wearing. Meniscus can get torn very easily. Sometimes as a part of a major injury and at other times the patient may not even remember injuring themselves. Some tears cause sharp pains and aching including with turning and twisting or even at night in bed. Large displaced tears can even cause locking and often an inability to straighten the Knee Joint. This is especially common for the displaced large ‘Bucket Handle’ Tears.

Meniscal tears alter the function of the Meniscus and lead to Arthritis. In some instances, large meniscal tears that have separated from the periphery, where their blood supply comes from, may be amenable to repair at the time of the Arthroscopy.

There are certain factors that influence the success rate of meniscal repairs. These include:

Age
Duration since injury and
Associated injuries (ligament injuries)

A successful repair, resulting in healing of a meniscus though is a big favour to the Knee Joint for decades to come by avoiding early Arthritis.

ACL Reconstruction

What is the ACL?

The anterior cruciate ligament or ‘ACL’ is one of the major stabilizing ligaments in the knee and probably also one of the most commonly injured ligament, often as a result of sporting injuries.

Why is it a problem if I damage my ACL?

An incompetent ACL can result in instability of the knee often experienced by patients as a sensation of ‘giving way’ or not feeling secure on the knee.

Whilst in some people instability can happen in day to day activities, many people experience it with tasks that require sudden turning or change of direction, cross cutting or pivoting activities. These activities include most outdoor sports and working on uneven surfaces.

Ongoing instability resulting from ACL incompetence can result in damage to the menisci (shock absorbers) which in turn leads to arthritis. ACL instability may also make it difficult to participate in sporting activities or activities requiring cross cutting, sudden change of direction or pivoting.

What are the treatment options for an ACL injury?

The treatment for ACL incompetence can be non-operative or operative by reconstruction of the ACL. However, sometimes, other associated injuries (for e.g., injuries to meniscus, other ligaments) may influence the recommended choice of treatment.

Non Operative Treatment

Non operative treatment comprises of aggressive rehabilitation and focused physiotherapy aiming to strengthen the muscle envelope around the knee which act like a ‘brace’. Rehabilitation also improves our proprioception. Proprioception is our body’s ability to decipher a change in direction, similar to the ‘Electronic Stability Control’ in cars to stop them from rolling over when turning. By improving the proprioception and muscle power, we can avoid getting into positions that may make the knee ‘give way’.

In some people, this may be enough and they may not need an operation to stabilize the ACL.

Surgery

In people that are still experiencing functional instability, or wish to participate in activities that test the ACL (such as those requiring sudden turning, cross cutting or pivoting), a reconstruction of the ACL would also be a reasonable option.

In a reconstruction, a graft (whatever is being used to replace the ACL) is passed along the path of the old ACL (now dysfunctional), tensioned and secured into the bones using tunnels and hardware. The aim is that this graft will reproduce the function of the ACL and keep the knee stable. The ACL Graft can be Autograft (form oneself, commonly Hamstrings), Allograft (from someone else, Cadaveric or Live Donor) or Synthetic Graft (artificial, common one being LARS) or a combination. They all have their perceived pros and cons.

Surgery, in the vast majority of patients, will lead to a successful return to sport and most pre injury activities. However, it is worth emphasizing that the prerequisite for a successful result is compliance (to do as you are told) and a strict intensive rehab program that will go on for a good 6 months. Whilst in most cases return to day-to-day function including work can be expected within a few weeks, sports requiring sudden turning cross cutting and pivoting must be avoided for 8-10 months.

PCL Reconstruction

PCL or Posterior cruciate reconstruction is a relatively less common procedure. Whilst a PCL injury is one of the most commonly missed injuries, Knee instability or ‘giving way’ as a result of PCL incompetence is very uncommon.

Apart from instability though, PCL incompetence can lead to Knee Pain at the front of the knee due to Patellar (Knee Cap) overload. This is because the main function of the PCL is to stop the Tibia (Shin bone) from sagging back. Once the PCL is torn or stretched, the Tibia sags back taking with it the Patella (Knee Cap) as it is attached to the Patellar Tendon. This leads to increased pressure in the Patellofemoral joint and early degeneration to Arthritis.

PCL Reconstruction is similar to an ACL reconstruction however the rehabilitation process is not as long.

Patellar Dislocation and Stabilisation

This has been discussed in Patellar Realignment – read more here.

Enquiries