Sport and Knee

injuries
Dr.Yasir Korak
Truama and orthopedic surgeon
2019
Ligaments of the Knee

Overview of Knee Ligament Function

Ligament Primary function Secondary function
Anterior Cruciate Ligament Resists anterolateral displacement Resists varus displacement at
(ACL) of the tibia on the femur 0 degrees of flexion
Posterior Cruciate Resists posterior tibial Resists varus displacement at
Ligament (PCL) displacement, especially at 90 0 degrees of flexion
degrees of flexion
Lateral Collateral Ligament Resists varus displacement at 30 Resists posterolateral rotatory
(LCL) degrees of flexion displacement with flexion that
is less than approximately 50
degrees

Popliteofibular Ligament / Resists posterolateral rotation of Resists varus angulation

Posterior Lateral the tibia on the femur and posterior displacement of
Corner (PLC) the tibia on the femur

Medial Collateral Ligament Resists valgus angulation Works in concert with ACL to
(MCL) provide restraint
to axial rotation
ACL
•Function
• prevents anterior translation of the tibia relative to the femur
•Anatomy
• extrasynovial but intracapsular
• origin
• lateral femoral condyle
• PL bundle originates posterior and distal to AM bundle (on femur)
• insertion
• broad and irregular
• anterior and between the intercondylar eminences of the tibia
• structure
• 33mm x 11mm in size
• two bundles
PCL

•Function
• prevents posterior translation of the tibia relative to the femur
• PCL and PLC work in concert to resist posterior translation and posterolateral
rotatory instability
•Anatomy
• extrasynovial but intracapsular
• origin
• medial femoral condyle
• insertion
• tibial sulcus

• structure
• 38mm x 13mm in size
• two bundles
LCL (lateral collateral ligament or fibular collateral ligament)

•Function
• resists varus angulation
• works in concert with MCL to provide restraint to axial rotation
•Anatomy
• origin
• on lateral femoral condyle posterior and superior to insertion
of popliteus
• path
• runs superficial to popliteus
• insertion
• on the fibula anterior to the popliteofibular ligament on the fibula
• capsule's most distal extent is just posterior to the fibula
• structure
• cord-like
•Biomechanics
• tight in extension and lax in flexion
• strength: 750 N (vs varus stress)
PLC (posterolateral corner)

•Function
• works synergistically with the PCL to control external rotation and posterior
translation
•Anatomy
• included structures
• LCL (295N)
• popliteus muscle and tendon (680N)
• popliteofibular ligament (229N)
• lateral capsule
MCL

•Function
• resists valgus angulation
• works in concert with ACL to provide restraint to axial rotation
•Anatomy
• origin
• MFC to medial tibia extending down several centimeters
Posteromedial corner

•Function
• important for rotatory stability
•Anatomy
• lies deep to MCL
• formed by
• insertion of semimembranosus
• posterior oblique ligament
• resists tibial internal rotation in full extension
• oblique popliteal ligament
• posterior capsule
Anterolateral Ligament

•Function
• rotational stability
•Anatomy
• lies in Layer 3 with LCL
• characteristics
• width 7mm at midpoint/near joint line
• femoral attachment width 8mm
• tibial attachment width 11mm
• length 59mm
• attachments
• femoral
• lateral femoral epicondyle
• tibial
• midway between Gerdy's tubercle and head of fibula
• attachments to middle third of lateral meniscus body
• meniscotibial portion (dot)
• meniscofemoral portion (asterisk)
• lateral inferior genicular artery and vein contained between lateral
meniscus and ALL at level of joint line
• NO connections to ITB
ACL Tear

 Incidence
◦ ~400,000 ACL reconstructions / year
 Mechanism is a non-contact pivoting injury
◦ lateral meniscal tears in 54% of acute ACL tears
 Chronic ACL deficient knees associated with
◦ chondral injuries
◦ complex unrepairable meniscal tears
◦ relation with arthritis is controversial
 Sex-related differences
◦ ACL injury more common in female athlete (4.5:1
ratio
Presentation

•Presentation
• felt a "pop"
• pain deep in the knee
• immediate swelling (70%) / hemarthrosis
•Physical exam
• effusion
• quadricep avoidance gait (does not actively extend knee)
• Lachman's test
• most sensitive exam test
Imaging
•Radiographs
• usually normal
• Segond fracture (avulsion fracture of the proximal lateral tibia) is
pathognomonic for an ACL tear
• represents bony avulsion by the anterolateral ligament (ALL)
• associated with ACL tear 75-100% of the time
• deep sulcus (terminalis) sign
• depression on the lateral femoral condyle at the terminal sulcus, a
junction between the weight bearing tibial articular surface and the
patellar articular surface of the femoral condyle.

•MRI
• findings of torn ACL
Treatment

•Nonoperative
• physical therapy & lifestyle modifications
• low demand patients with decreased laxity
• increased meniscal/cartilage damage linked to
• loss of meniscal integrity
• the frequency of buckling episodes
• level I and II activity (e.g. jumping, cutting, side-to-side sports, heavy
manual labor)
•Operative
• ACL reconstruction
PCL Injury
Presentation

•History

• differentiate between high- and low-energy trauma

• dashboard injury
• hyperflexion athletic injury with a plantar-flexed foot
•Symptoms
• posterior knee pain
• instability
• often subtle or asymptomatic in isolated PCL injurie
Physical exam
varus/valgus stress
laxity at 0° indicates MCL/LCL and PCL injury
laxity at 30° alone indicates MCL/LCL injury
posterior sag sign
posterior drawer test (at 90° flexion)
 Meniscus

Function

• Force transmission
• the meniscus functions to optimize force transmission across the knee. It does this by
• increasing congruency
• increases contact area leads to decreased point loading
• shock-absorption
• the meniscus is more elastic than articular cartilage, and therefore absorbs shock
• transmits 50% weight-bearing load in extension, 85% in flexion
•Stability
• the meniscus deepens tibial surface and acts as secondary stabilizer
• medial meniscus
• posterior horn of medial meniscus is the main secondary stabilizer to anterior
translation
• lateral meniscus
• is less stabilizing and has 2X the excursion of the medial meniscus
• the menisci become primary stabilizers in the ACL-deficient knee
Composition

•Made of fibroelastic cartilage

• interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements
• composed of 65-75% water
•Collagen
• 90 % Type I collagen
•Fibers
• composed of two types of fibers which allow the meniscus to expand under compressive
forces and increase contact area of the joint
• radial
• longitudinal (circumferential)
• help dissipate hoop stresses
• vertical mattress captures
Anatomy
•Gross Shape
• medial meniscus
• C-shaped with triangular cross section
• avarage width of 9 to 10mm
• average thickness of 3 to 5mm
• lateral meniscus
• is more circular (the horns are closer together and approximate the ACL)
• covers a larger portion of the articular surface
• average width is 10 to 12mm
• average thickness is 4 to 5mm
Blood supply
middle genicular artery
supply to posterior horns
medial inferior genicular artery
supplies peripheral 20-30% of medial meniscus
lateral inferior genicular artery
supplies peripheral 10-25% of lateral meniscus
central 75% receive nutrition through diffusion
Innervation
peripheral two-thirds innervated by Type I and II nerve endings
posterior horns have highest concentration of mechanoreceptors
Meniscal Injury

 Epidemiology
◦ most common indication for knee surgery
◦ higher risk in ACL deficient knees
 Location
◦ medial tears
 more common than lateral tears
 the exception is in the setting of an acute ACL tear
where lateral tears are more common
 degenerative tears in older patients usually occur in
the posterior horn medial meniscus

◦ lateral tears
 more common in acute ACL tears
Classification

•Descriptive classification
• location
• red zone (outer third, vascularized)
• red-white zone (middle third)
• white zone (inner third, avascular)
• size
• pattern
• vertical/longitudinal
• common, especially with ACL tears
• repair when peripheral
• bucket handle
• vertical tear which may displace into the notch
• oblique/flap/parrot beak
• may cause mechanical locking symptoms
• radial
• horizontal
• more common in older population
• may be associated with meniscal cysts
• complex
• root
Imaging

•Radiographs
• Should be normal in young patients with an acute meniscal injury
• Meniscal calcifications may be seen in crystalline arthropathy

• MRI is most sensitive diagnostic test, but also has a high false positive rate
Treatment

•Non-operative
• rest, NSAIDS, rehabilitation
• indications
• indicated as first line of treatment for degenerative tears
•Operative
• partial meniscectomy
• indications
• tears not amenable to repair (complex, degenerative, radial tear patterns)
• repair failure >2 times
• meniscal repair