Traumatic and operative knee operations

The knee contains two joints; the tibiofemoral joint with its associated collateral ligaments, cruciate ligaments (anterior and posterior) and menisci (shock absorbers); and the patellofemoral joint.

In the majority of cases an acute knee injury can be diagnosed with an appropriate history and thorough examination. The skilled examination techniques and the in-depth knowledge of functional anatomy allow the therapists at Stockport Physio to predict which structures are likely to be damaged.

Stockport Physio are experienced in treating:

• Anterior Cruciate Ligament (ACL) Tears
• Posterior Cruciate Ligament (PCL) Tear
• Meniscal Injuries
• Medial Collateral Ligament (MCL) Injury
• Lateral Collateral Ligament Tears
• Acute Patella Trauma
• Fracture of the patella
• Patella Dislocation
• Other Conditions

Anterior Cruciate Ligament (ACL) Tears

Tears of the ACL are not uncommon and occur in footballers, netballers and down hill skiers. Most ACL tears occur when the person is landing from a jump, pivoting or decelerating suddenly. Occasionally a tear will occur as the result of another player falling across the knee. At the time of the injury the patient often describes an audible 'pop' or 'crack' or feeling of 'something going out and then going back'. Tear of the ACL is usually accompanied by the development of a hemarthrosis (bleeding into the joint). This may be visible as a large, tense swelling of the knee joint within a few hours of the injury. Occasionally swelling is minimal or delayed.

The best time to have the knee examined is in the first hour following the injury before the development of the hemarthrosis, and then after a few days when the swelling has started to settle and the pain is less intense. There is often restriction of movement particularly loss of extension (straightening). MRI scans are useful in showing an ACL tear.

Treatment: once the diagnosis is made the decision on whether to opt for initial conservative or surgical management is dependent on a number of factors including,

• The age of the person
• The degree of instability
• Associated abnormalities (e.g. a tear of the medial collateral ligament or a meniscal tear)
• Whether or not the person performs pivoting sports
• The patient's occupation (e.g. fire-fighter, police)
• Social factors such as cost of treatment or time off work

Surgical Treatment

The aim of ACL reconstructions is to replace the torn ACL with a graft that reproduces the normal kinetic functions of the ligament. In most cases a graft taken from around the knee joint is used. The most common grafts used are the bone-patellar tendon-bone, a graft involving the central third of the patella tendon; or the hamstring graft.

Management principles following ACL reconstruction have changed dramatically in recent years. StockportPhysio aims to provide an accelerated rehabilitation programme. This requires early commencement of a strengthening programme and rapid progression to functional exercises. The average time for rehabilitation after ACL reconstruction to return to sport is 6-9 months.

Posterior Cruciate Ligament (PCL) Tear

Tears of the PCL are not as common as those of the ACL, due partly to the greater strength of the PCL.

The mechanism of PCL injury is either a hyperextension injury or, more commonly, a direct blow to the front of the tibia (shin bone) with the knee bent. The pain is normally poorly defined, mainly at the back of the knee, sometimes involving the calf. There is usually minimal swelling. PCL rupture can generally be managed conservatively with a comprehensive rehabilitation programme.

The programme emphasizes intensive quadriceps exercises. Surgery is indicated when PCL injury occurs in combination with other structures.

Meniscal Injuries

There are two menisci, medial and lateral, they are within the knee joint and attach to the tibial plateau. They have an important role as a buffer absorbing some of the forces placed through the knee joint. They play a role in stabilizing the knee and also contribute to lubrication and nutrition of the knee joint.

The most common mechanism of injury is a twisting injury with the foot anchored on the ground. There can be a tearing sensation at the time of injury. A small meniscal tear may cause no immediate symptoms. Typically these injuries are associated with an increase in pain and swelling over 24hours. With more severe meniscal tears (bucket handle tears) pain and restriction of movement occur soon after injury. Intermittent locking may occur as a result of the torn flap impinging between the joint surfaces.

Treatment: the management of meniscal tears varies depending on the severity of the condition. Small tears should initially be treated conservatively with a rehabilitation programme to restore full range of movement and strength. A large tear requires immediate arthroscopic surgery. The aim of surgery is to preserve as much of the meniscus as possible. Rehabilitation principles after surgery are:

• To control pain and swelling
• To regain pain-free range of movement
• Graduated strengthening
• Return to functional activities

Stockport Physio ensure that our patients are closely monitored during post-menisectomy rehabilitation as the remaining meniscus and underlying cartilage slowly increase their tolerance to weight-bearing. We constantly re-assess after progressively more difficult activities are performed, with the development of increased pain or swelling resulting in modification of the rehabilitation programme.

Medial Collateral Ligament (MCL) Injury

Injury to this ligament usually occurs as a result of an inward stress to a partially bent knee. They are classified on the basis of their severity into grade I (mild), grade II (moderate) and grade III (complete tear). The rehabilitation programme following MCL injury varies depending on the severity.

Lateral Collateral Ligament Tears

These are much less common than MCL tears. They are usually due to a direct stress to the inside aspect of the knee joint. Complete tears are usually associated with other injuries. These tears are usually treated by acute surgical repair in conjunction with repair of other damaged ligaments.

Acute Patella Trauma

Acute trauma to the patella (kneecap) for example, from a hockey stick or from a fall onto the kneecap, can cause a range of injuries from a fracture of the patella to osteochondral damage to the patellofemoral joint.

Fracture of the patella

Undisplaced fractures of the patella can be managed conservatively initially with a splint to keep the leg straight. Over the next few weeks as the fracture unites, the range of bending can be gradually increased and the quadriceps strengthened. Fractures with significant displacement require surgical treatment. This involves fixing the patella usually with a tension band wire technique. The rehabilitation is as for an undisplaced fracture.

Patella Dislocation

This occurs when the patella moves out of its groove onto the outside aspect of the knee joint. This can be either traumatic, as a result of an injury, or atraumatic, which usually occurs in young girls with ligament laxity. With traumatic dislocation people usually complain that, on twisting or jumping the knee suddenly gave way with the development of severe pain. Often there is a feeling of something 'popping out'. Swelling develops almost immediately. The patella often goes back into place spontaneously however; in some cases this may require some assistance or anaesthesia.

The most important aim of rehabilitation after dislocation is to reduce the chances of a recurrence of the injury. As a result, the rehabilitation programme is lengthy. Recurrent patella dislocation requires surgery.

Other Conditions

Patella Tendon Rupture - The patella tendon occasionally ruptures spontaneously. It is usually in association with a sudden severe eccentric (lengthening) contraction of the quadriceps muscle. Surgical repair of the tendon must be followed by intensive rehabilitation. Full recovery takes 6-9 months.

Fat Pad Impingement - Occurs as a result of a hyperextension injury

Fracture of the Tibial Plateau - Seen in high-speed injuries such as falls while skiing, wave jumping or horse-riding.

Ruptured Hamstring Tendon

Coronary Ligament Sprain - The coronary ligament is the name given to the deep portion of the joint capsule attached to the edge of each meniscus. A sprain of this ligament may occur as a result of a twisting injury.

Chronic Instability of the Knee

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