Knee Injuries

Meniscal transplantation is a procedure that can be performed when your meniscus has been completely removed or is no longer functioning.  If you meet the indications for a meniscal transplant, this can be a successful surgery to help regain knee function.  The procedure is performed by implanting a whole meniscus from cadaver tissue and repaired into place (see picture below of meniscus graft).  The goal of transplanting a new meniscus is to give the knee more protection to compression and help prevent further development of arthritis and help to eliminate pain in the knee.

ACL tears are some of the most common knee injuries in athletic, active individuals.  An ACL tear can be a devastating injury.  However, we treat ACL injuries in athletes and active individuals of all levels at both our Rochester, MI and Shelby Township, MI locations.  Regardless if this is your first ACL tear or an injury to a reconstructed ACL needing revision ACL reconstruction, our goal is to give you a strong stable knee to return to your active lifestyle.  We have done a good deal of research on ACL tears and performance in professional athletes after reconstruction and these studies can be found in the research area.

Cause

An ACL tear is most commonly caused by a non-contact twisting injury to the knee.  An ACL tear can also come from a direct blow to the knee, but this is less common.  ACL tears are seen most commonly and planting and twisting sports like football and soccer, but can also come from jumping sports like basketball and volleyball, and cutting activities like skiing.  Patients will often feel a “pop” in the knee with an ACL tear and may feel the knee shift.  The knee will often have a large amount of swelling after an injury.  After a knee injury, an ACL tear may be present if the knee continues to “shift” or “buckle” with twisting or cutting activities.

Anatomy

The ACL is the strong ligament located in the center of the knee.  The ACL crosses anteriorly in the knee and the PCL crosses posteriorly in the knee, which is why the ACL is known as the anterior cruciate ligament.  There are two bundles to the ACL, with the anteriomedial bundle responsible for preventing movement of the knee forward and the posteriolateral bundle responsible for preventing twisting of the knee.  Because of this important function of the ACL, if it is torn, the knee is more unstable and prevents full function of the knee with cutting and twisting activites.

Imaging

An X-ray is initially performed to make sure no fractures are present and also help determine the alignment of you leg.  An MRI is necessary to evaluate the extent of the ACL tear and evaluate any injury to the meniscus as these can commonly be torn with ACL injuries.  It is important to evaluate the ACL tear, because, rarely, some ACL tears may be amenable to repair rather than full reconstruction.

Treatment

Many ACL tears will require surgery if you wish to return to an active lifestyle.  Depending on your activity level, it is not always required to have an ACL reconstruction.  However, because most ACL injuries occur during sports and activity, many patients wish to return to this level and an ACL reconstruction will provide a stable knee to return to sport.  The ACL can be reconstructed using several different grafts including a portion of the patella tendon (BTB, bone tendon bone), hamstrings, a portion of the quadriceps tendon or cadaver graft.  A discussion can be had about the best graft for you.  Surgery is performed using arthroscopy to address any other injuries such as meniscus tears and aid in placing your ACL graft.  The graft is secured in place commonly using interference screws or strong suture with a metal button.  It is important when placing the ACL graft to get the correct position of the ACL in the anatomic position to reestablish the rotational stability of the knee.

Recovery

A brace is typically worn immediately after surgery and crutches are given.  If you had a meniscal repair with the ACL, then you will not be allowed full weight immediately.  If you had an ACL reconstruction alone, you can put full weight on your leg in the brace.  Initially, it will be important to work on knee range of motion and reactivating your quadriceps muscle, which becomes very weak after surgery.  You will be able to use a stationary bike as range of motion permits.  After range of motion is obtained, further strengthening can begin.  The new ACL graft takes time to heal in place and to completely become a new ligament.  Therefore, it is important to work with therapy and your surgeon to avoid excessive activity to stress the new ligament.  Running can typically begin around 3-4 months and some agility exercises after this.  As strength and control of the leg is regained, you will begin to transition to sport and activity specific drills.  Full return to sport is typically at least 6-8 months depending on your activity and progress with therapy.

Cause

MCL tears typically occur due to direct trauma to the knee, usually from someone or something landing on the outside of the knee creating an opening force on the inside of the knee.  This can also occur if the knee comes down wrong and places more force on the inside of the knee.

Anatomy

The MCL is a ligament that goes from the medial (inside portion of the knee) side of femur and attaches to the tibia, crossing the knee joint.  The MCL gives side to side stability to the knee, particularly preventing valgus stress (leg moving outward).  Depending on the degree of sprain on the MCL, the stressing of the knee can just cause pain in the knee, or the knee can be unstable and gap open with stressing.

Imaging

Much of the diagnosis is based on exam, however, X-rays are obtained to rule out any fractures and an MRI is typically ordered if the injury is more severe to evaluate the severity of the tear or any concurrent injuries.

Treatment

Treatment will depend on the extent of injury and if it is an isolated MCL injury or not.  If isolated, this can typically be treated with a brace to allow the ligament to heal, however, if a complete tear and instability remains, surgery would be indicated to repair the ligament.

Recovery

Recovery will depend on the severity of the tear, but will typically take 4-6 weeks to recover.

Cause

PCL injuries typically occur from a direct blow to the knee forcing the knee back.  This can occur from a car accident where the knee hits the dashboard, or can occur from a fall or strike with the knee directly on the ground.  There will typically be a significant amount of swelling in the knee with this type of injury.  PCL injuries can occur as an isolated injury, but is often associated with another ligament tear such as an ACL, MCL or LCL.

Anatomy

The PCL is posterior (behind) the ACL in the center of the knee.  It works to prevent the knee from shifting backward.

Imaging

X-rays are typically obtained initially to rule out any fractures, but an MRI is often required to assess the extent of the PCL injury and evaluate any other ligament or cartilage injuries.

Treatment

Treatment will depend on the occurrence of any other ligament injuries to the knee.  If the PCL is the only ligament injured, this can often times be treated without surgery.  However, if other ligaments are torn as well, this will often require reconstruction of the ligaments that are torn.

Recovery

Recovery will depend on if you need surgery or not and the extent of your other injuries.

Cause

The LCL is typically injured by a direct blow to the knee or a cutting injury to the knee causing a varus force (the leg going inward) to created stress on the outside of the knee.  The LCL is not commonly injured in isolation, but is commonly injured with other structures on the outside of the knee known as the posterolateral corner.

Anatomy

The LCL is a ligament on the lateral side (outside) of the knee that goes from the femur to the fibula.  It is often times injured with other ligaments on the lateral side of the knee, known as the posterolateral corner.  These structures in combination provide stability of the knee when rotating externally or outward.

Imaging

X-rays are typically performed to evaluate for any fractures and an MRI is often required to evaluate the extent of a tear and also an other concomitant tears of ligaments.

Treatment

Treatment depends on the extent of other injuries to the knee.  Often times the posteriolateral corner is torn with the LCL and these typically require surgery.  At the time of surgery, the LCL and posteriolateral corner is reconstructed using a tendon graft.  Depending on your injury, the ACL or the PCL may need to be reconstructed at the same time.

Recovery

Recovery again will depend on the extent of your injury, but it is important if you have surgery to give your graft time to heal in place and the new ligament to heal.

Cause

A patella dislocation is typically caused by a direct hit to the knee or the knee is turned in such a way that the patella dislocates.  The most common dislocation is laterally or to the outside of the knee in which the patella can be seen to the side of the knee.  If you have had multiple dislocations, the patella may dislocate with very minor events and don’t always occur from a specific trauma.

Anatomy

The patella is the bone that sits on top of the knee.  It is the attachment for the quadriceps tendon and the patellar tendon which attaches to the tibia.  The patella has thick cartilage on the underside of the bone that articulates with the femur.  A dislocation of the patella commonly occurs to the outside of the knee (lateral) and will tear a ligament from the medial side (inner side) of the knee known as the MPFL.  A dislocation can also cause damage to the cartilage, so it is important to have this evaluated to prevent further issues.

Imaging

An x-ray will be obtained to make sure the patella is currently not dislocated and also to assess for any fractures.  An MRI is often obtained to evaluate for the extent of ligament damage but more importantly and cartilage damage that may cause loose pieces in the joint.

Treatment

Treatment will depend on the number of times your patella has dislocated as well as any cartilage damage leading to loose pieces.  First time dislocations often times are treated with a brace and physical therapy.  Any one with multiple dislocations or a loose piece of cartilage will likely benefit from surgery.  Surgery is typically performed to reconstruct the torn ligament that prevents the patella to dislocation, known as an MPFL reconstruction.  If your bone is off track enough to lead to continued instability of the patella, a realignment procedure may be added as well known as a tibial tubercle osteotomy (or TTO).

Recovery

For first time dislocations treated without surgery, recovery is typically a few months.  If surgery is required, recovery will be longer in order to allow the tissues to completely heal and you leg to regain strength to prevent re-injury.

Cause

The cause is from a traumatic injury, which can occur during sport from a fall or a car accident.

Anatomy

The knee is stabilized by several ligaments of the knee including the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament (LCL).  Any or all of these ligaments can be torn with a traumatic injury to the knee.

Imaging

X-ray is used to confirm no fractures and an MRI is needed to assess the full amount of damage to the ligaments of the knee

Treatment

Initial treatment is to stabilize the knee and assess for injury to the important nerve and vessels of the leg.  Due to significant injury to the knee, the ligaments often need to be repaired or reconstructed in order to give a stable and functional knee.  Surgery depends on the ligaments torn, but will often times involved arthroscopic reconstruction, which can fix either the ACL or PCL and with incisions to repair or reconstruct the LCL or MCL.

Recovery

Recovery depends on the number of ligaments fixed, but will initially involve several weeks of immobilization in a brace followed by progressive range of motion.  As the ligaments continue to heal, strengthening will slowly be allowed.  Because of the extent of injury, recovery is often times up to a full year to return to full sport.

Cause

A quadriceps or patellar tendon rupture occurs from a strong extension force at the knee, often times can occur from jumping down or from a trauma during running or sport.  Quadriceps tendon ruptures typically occur in patients older than 40 and patellar tendon ruptures in patients under the age of 40.

Anatomy

The quadriceps tendon inserts on the patella (knee cap) and the patella attaches to the patella tendon to the tibia.  These connections allow the quadriceps muscles to contract and extend the leg, any disruption in this leads to an inability to extend the leg properly.

Imaging

The diagnosis is typically made on exam, but in chronic or unusual cases an MRI may be needed.

Treatment

Because the knee is unable to extend and therefore significant disability in running or walking develops, these injuries are often times treated with surgery.  Surgery entails using strong suture to secure the quadriceps tendon or the patella tendon and then reattach the tendon to the patella.  A brace is then worn, locked in extension after surgery.

Recovery

The knee is initially placed in full extension at all times to decrease tension on the repaired tendon.  As the tendon heals, gradual range of motion is begun and once full range of motion is obtained and the tendon is healed, strengthening can begin.  You will be able to walk with your brace immediately after surgery, however, normal walking and full activity will take several months.

Cause

Patellar tendonitis develops from continued increased stress to the patellar tendon.  Commonly it is seen in jumping athletes like in basketball or in running.  Weakness and instability is the true cause that leads to patellar tendonitis.  Weakness in the control of the quadriceps, hip abductors, core and inflexibility of the hamstrings all lead to increased stress on the patella and patella tendon and accelerate any stresses placed on the patella and tendon.

Anatomy

The most common area effected in patellar tendonitis is as the tendon inserts at the patella.

Imaging

X-rays can confirm any changes to the tilt of the patella, but the diagnosis is made on physical exam and MRI is used only if further treatment is warranted.

Treatment

Treatment often involves reversing the factors that led to the issue in the first place. Antiinflammatories can be used to decrease inflammation acutely and avoiding activities that cause the pain can help it initially feel better.  Physical therapy can then be done to strengthening and stabilize muscles like the quadriceps, hip abductors and core as well as stretch the hamstring to decrease the stress to the patella and tendon.  If this does not help, injections such as PRP can be used to accelerate the healing process or at times arthroscopic surgery can be performed to debride and possibly repair the damaged tissue.

Recovery

Recovery depends on the amount or irritation and inflammation you present with.  Decreasing initial inflammation can take a few weeks, but full strengthening and rehab can take several weeks.

Cause

The cause of a cartilage defect in the knee other than arthritis is typically from direct trauma to the knee causes a focal cartilage defect.  A condition known as an OCD lesion can also cause a defect.

Anatomy

The cartilage of the knee is a thick layer of coating over the bone that allows the knee to glide smoothly.  The cartilage covers the end of the femur, top of the tibia and under the patella.  Cartilage has very limited potential to heal and therefore any defect in the cartilage can lead to significant issues with pain and chronic damage.

Imaging

X-rays can be used to assess some cartilage defects, however, MRI is typically needed to assess the size and full extent of the cartilage damage.

Treatment

Treatment of these lesions can be difficult and will depend on the size and location of the defect.  Treatments can include debridement or trimming the lesion to a stable base.  The lesion can also be filled back in with a variety of techniques.  Microfracture can be performed where the defect fills with a cartilage like scar tissue.  Cartilage can also be transferred from non-weight bearing areas of the same knee or cartilage can be used from a cadaver.  Finally, the defect can be filled with cells that are grown from your own cartilage to regrow and surface the area known as MACI.  At times, the cartilage piece may be able to be fixed back to the previous position as well.

Recovery

Recovery depends on the treatment that you undergo for your cartilage defect.  If the defect is filled in or fixed, you will have to not put full weight on your leg for several weeks and gradually begin weight bearing and strengthening as the defect fills in.  This will require several months of recovery.