Ligament Lesion

A. MCL Knee Injuries

1. Overview
a. medial collateral ligament (MCL) injury results from excessive valgus stress on the knee,
is often an isolated injury and can be managed nonoperatively in the majority of
patients 
2. Epidemiology
a. most common ligamentous injury of the knee
i. 40% of knee ligament injuries
b. incidence is likely higher than reported
i. low grade injuries can be missed
c. males > females
d. commonly occur in athletes
i. account of 8% of all athletic knee injuries
ii. highest risk in skiing, rugby, football, soccer and ice hockey
3. Pathophysiology
a. valgus stress is the most common mechanism of injury
i. usually with the knee held in slight flexion and external rotation
b. contact injury 
 i. more common than noncontact
ii. direct blow to the lateral knee with valgus force
iii. more often result in high grade / complete ligament disruption than noncontact
injury
1. rupture usually occurs at the femoral insertion of the MCL
a. proximal MCL tears have greater healing rates 
b. distal MCL tears have inferior healing and residual valgus laxity
c. noncontact injury
i. less common than contact but more common in skiing
ii. pivoting or cutting activities with valgus and external rotation force 
iii. more often result in low grade / incomplete ligament injury
4. Associated conditions
a. anterior cruciate ligament (ACL) tear
i. most common associated injury
1. make up ~95% of injuries associated with nonisolated MCL injury
2. combined ACL-MCL is the most common multiligamentous knee injury 
ii. presence of hemarthrosis is highly suggestive
iii. often associated with high grade MCL injuries
1. grade III > grade II > grade I
b. meniscus tear
i. medial > lateral
ii. up to 5% of isolated MCL injuries are associated with meniscus tears
c. Pellegrini-Stieda syndrome  
i. calcification at the medial femoral insertion site 
ii. results from chronic MCL deficiency
5. Presentation
 History
o "pop" reported at time of injury
 Symptoms
o medial joint line pain
o difficulty ambulating due to pain or instability
 Physical exam
o inspection and palpation
 tenderness along medial aspect of knee
 ecchymosis 
 knee effusion 
o ROM and stability
 valgus stress testing at 30° knee flexion
 isolates the superficial MCL
 medial gapping as compared to opposite knee indicates grade of injury
 1- 4 mm = grade I
  5-9 mm = grade II
 > or equal to 10 mm = grade III
 valgus stressing at 0° knee extension
 medial laxity with valgus stress indicates posteromedial capsule or
cruciate ligament injury
o neurovascular exam
 saphenous nerve exam

B. LCL Knee Injury

 Injury to the Lateral Collateral Ligament (LCL)

o also referred to as fibular collateral ligament
 Epidemiology
o demographics
 incidence
 isolated injury extremely rare
 7-16% of all knee ligament injuries when combined with lateral
ligamentous complex injuries
 particularly posterolateral corner (PLC) injury  
 Mechanism
o traumatic
 most frequently result from MVAs and athletic injuries
 direct blow or force to weightbearing knee 
 excessive varus stress, external tibial rotation, and/or hyperextension
 Symptoms
o instability near full knee extension
o difficulty ascending and descending stairs
 o difficulty with cutting or pivoting activities
o lateral joint line pain and swelling
 Physical exam
o inspection and palpation
 ecchymosis and lateral joint line tenderness
o ROM & stability
 varus stress test 
 varus instability (lateral opening) at 30° flexion only - isolated LCL
injury  
 varus instability at 0° and 30° flexion - combined LCL and/or ACL/PCL
injuries
 dial test*
 varus instability and increased tibial external rotation at 30° flexion -
combined LCL and posterolateral corner injuries 
o gait assessment
 hyperextension or varus (lateral) thrust gait
o neurovascular exam
 common peroneal nerve injuries may occur with LCL/PLC injury

*The test can be clinically valuable when:

1. Three posterolateral structures (Popliteus tendon, Popliteofibular ligament, Lateral collateral

ligament) are injured.
2. There is combined injury to the PCL and two other posterolateral structures.

C. ACL injury

Incidence

 ~400,000 ACL reconstructions / year

Often associated with a meniscal tear

 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

ACL Blood supply

 middle geniculate artery

ACL Innervation

 posterior articular nerve ( a branch of tibial nerve)

ACL Composition

 90% Type I collagen 

 10% Type III collagen

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 
o most sensitive exam test
o grading
 A= firm endpoint, B= no endpoint
 Grade 1: 3-5 mm translation
 Grade 2 A/B: 5-10mm translation
 Grade 3 A/B: > 10mm translation
o ACL tear may give "false" Lachman due to posterior subluxation

Radiographs
 usually normal
 Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL
tear
o represents bony avulsion by the anterolateral ligament (ALL)
o associated with ACL tear 75-100% of the time
 deep sulcus (terminalis) sign  
o 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.

D. PCL injury

 Injuries may be isolated or combined and often go undiagnosed in the acutely injured knee
 Epidemiology
o incidence
 5-20% of all knee ligamentous injuries
 Pathophysiology
o mechanism
 direct blow to proximal tibia with a flexed knee (dashboard injury)
 noncontact hyperflexion with a plantar-flexed foot
 hyperextension injury
o pathoanatomy
 PCL is the primary restraint to posterior tibial translation
 functions to prevent hyperflexion/sliding
 isolated injuries cause the greatest instability at 90° of flexion
 Associated conditions
o combined PCL and posterolateral corner (PLC) injuries
o multiligamentous knee injuries
o knee dislocation 
  Prognosis
o chronic PCL deficiency
 PCL deficiency leads to increased contact pressures in
the patellofemoral and medial compartments of the knee due to varus
alignment 

History

 differentiate between high- and low-energy trauma

o dashboard injury
o hyperflexion athletic injury with a plantar-flexed foot
 ascertain a history of dislocation or neurologic injury

Symptoms

 posterior knee pain

 instability
o often subtle or asymptomatic in isolated PCL injuries

Physical exam

 varus/valgus stress
o laxity at 0° indicates MCL/LCL and PCL injury
o laxity at 30° alone indicates MCL/LCL injury
 posterior sag sign
o patient lies supine with hips and knees flexed to 90°, examiner supports ankles and
observes for a posterior shift of the tibia as compared to the uninvolved knee 
o the medial tibial plateau of a normal knee at rest is 10 mm anterior to the medial
femoral condyle
 an absent or posteriorly-directed tibial step-off indicates a positive sign
 posterior drawer test (at 90° flexion) 
o with the knee at 90° of flexion, a posteriorly-directed force is applied to the proximal
tibia and posterior tibial translation is quantified 
 isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in
internal rotation
 combined ligamentous injuries translate >15 mm in neutral rotation and >10
mm in internal rotation
o most accurate maneuver for diagnosing PCL injury
 quadriceps active test 
o attempt to extend a knee flexed at 90° to elicit quadriceps contraction
o positive if anterior reduction of the tibia occurs relative to the femur
 dial test 
 o > 10° ER asymmetry at 30° & 90° consistent with PLC and PCL injury
o > 10° ER asymmetry at 30° only consistent with isolated PLC injury

E. Rotator Cuff Tears

Epidemiology

 prevalence
o age >60: 28% have full-thickness tear
o age >70: 65% have full-thickness tear
 risk factors
o age
o smoking
o hypercholesterolemia
o family history

Pathophysiology

 mechanisms of tear includes

o chronic degenerative tear ( intrinsic degeneration is the primary etiology)
 usually seen in older patients
 usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but
may extend anteriorly to involve the superior margin of subscapularis tendon in
larger tears
o chronic impingement
 typically starts on the bursal surface or within the tendon
o acute avulsion injuries
 acute subscapularis tears seen in younger patients following a fall
 acute SIT tears seen in patients > 40 yrs with a shoulder dislocation 
 full thickness rotator cuff tears need to be repaired in throwing athletes 
o iatrogenic injuries
 due to failure of surgical repair
 often seen in repair failure of the subscapularis tendon following open
anterior shoulder surgery.

Associated conditions

 AC joint pathology 
 proximal biceps subluxation 
 proximal biceps tendonitis 
 internal impingement 

Prognosis

 50% of asymptomatic tears become symptomatic in 2-3 years

 50% of symptomatic full-thickness tears progress at 2 years and bigger tears progress faster

Symptoms

 pain
o typically insidious onset of pain exacerbated by overhead activities
o pain located in deltoid region
o night pain, which is a poor indicator for nonoperative management
o can have acute pain and weakness with an traumatic tear
 weakness
o loss of active ROM with greater or intact passive ROM

 Physical exam (complete exam of the shoulder )

Overview of Physical Exam of Rotator Cuff

Cuff Muscle Strength Testing Special Tests
Supraspinatus Weakness to resisted elevation in Jobe  Drop arm test
position  Pain with Jobe test

Infraspinatus ER weakness at 0° abduction  ER lag sign 

Teres minor ER weakness at 90° abduction and 90°  Hornblowers

ER
Subscapularis  IR weakness at 0° abduction  Excessive passive ER
 Belly press  
 Lift off  
  IR lag sign

MRI

 indications
o diagnostic standard for rotator cuff pathology 
o obtain when suspicion for pain or weakness attributable to a rotator cuff tear
 findings
o important to evaluate muscle quality
 size, shape, and degree of retraction of tear
 degree of muscle fatty atrophy (best seen on sagittal image)
o medial biceps tendon subluxation  
 indicative of a subscapularis tear  
o cyst in humeral head on MRI seen in almost all patients with chronic RCT
o tangent sign 
 failure of the supraspinatus to cross a line drawn between the superior borders
of the scapular spine and coracoid process on a sagittal MRI slice

Ruptur Tendon Achilled

 Acute rupture of the achilles tendon

o often misdiagnosed as an ankle sprain
o may be missed in up to 25%
 Epidemiology
o incidence
 18:100,000 per year
o demographics
 more common in men
 most common in ages 30-40
o risk factors
  episodic athletes, "weekend warrior"
 flouroquinolone antibiotics
 steroid injections
 Mechanism
o usually traumatic injury during a sporting event
o may occur with
 sudden forced plantar flexion
 violent dorsiflexion in a plantar flexed foot
 Pathoanatomy
o rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region

Anatomy
 Achilles tendon
o largest tendon in body
o formed by the confluence of
 soleus muscle tendon 
 medial and lateral gastrocnemius tendons 
o blood supply from posterior tibial artery

Presentation
 History
o patient usually reports a "pop"
 Symptoms
o weakness and difficulty walking
o pain in heel
 Physical exam
o inspection
 increased resting ankle dorsiflexion in prone position with knees bent
 calf atrophy may be apparent in chronic cases
o palpation
 palpable gap
o motion
 weakness to ankle plantar flexion
 increased passive dorsiflexion
o provocative test
 Thompson test
 lack of plantar flexion when calf is squeezed

Imaging
 MRI
o indications
 equivocal physical exam findings
  chronic ruptures
o findings
 will show acute rupture with retracted tendon edges

Treatment
 Nonoperative
o functional bracing/casting in resting equinus
 indications
 acute injuries with surgeon or patient preference for non-operative
management
 sedentary patient
 medically frail patients
 outcomes
 equivalent plantar flexion strength compared to operative management
 increased risk of re-rupture compared to operative management
 new studies show that this may not be significant if functional
rehabilitation used 
 fewer complications compared to operative treatment
 Operative
o open end-to-end achilles tendon repair 
 indications
 acute ruptures (approximately <6 weeks)
 outcomes
 decreased rate of re-rupture compared to non-operative management
 new Level 1 evidence has suggested no difference in re-rupture
rates with functional rehab protocol
 no significant difference in plantar flexion strength with functional
rehab protocol
o percutaneous Achilles tendon repair
 indications
 concerns over cosmesis of traditional scar
 outcomes
 higher risk of sural nerve damage
 lesser risk of wound complications/infection compared with open repair

Meniscal Lesion
  Epidemiology
o most common indication for knee surgery
o higher risk in ACL deficient knees
 Location
o 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
o lateral tears
 more common in acute ACL tears

Classification
Presentation
 Symptoms
o pain localizing to medial or lateral side
o mechanical symptoms (locking and clicking)
o delayed or intermittent swelling
 Exam
o joint line tenderness is the most sensitive physical examination finding 
o effusion
o provocative tests
 Apley compression
 prone
 Thessaly test
 standing at 20 degrees of knee flexion on the affected limb, the patient
twists with knee external and internal rotation with positive test being
discomfort or clicking.
 McMurray's test
 flex the knee and place a hand on medial side of knee, externally rotate
 the leg and bring the knee into extension.
 a palpable pop / click + pain is a positive test and can correlate with a
medial meniscus tear.

Imaging
 Radiographs
o Should be normal in young patients with an acute meniscal injury
o Meniscal calcifications may be seen in crystalline arthropathy (ex. CPPD)
 MRI
o indications
 MRI is most sensitive diagnostic test, but also has a high false positive rate 
o findings
 MRI grade III signal is indicative of a tear 
 linear high signal that extends to either superior or inferior surface of
the meniscus  
 parameniscal cyst indicates the presence of a meniscal tear
 bucket handle menscal tears indicated by
  "double PCL"  sign   
 "double anterior horn" sign    

Treatment
 Non-operative
o rest, NSAIDS, rehabilitation
 indications
 indicated as first line of treatment for degenerative tears
 Operative
o partial meniscectomy
 indications
 tears not amenable to repair (complex, degenerative, radial tear
patterns)
 repair failure >2 times
 outcomes
 >80% satisfactory function at minimum follow-up
 50% have Fairbanks radiographic changes (osteophytes, flattening, joint
space narrowing)
 predictors of success
 age <40yo
 normal alignment
 minimal or no arthritis
 single tear