CHAPTER

Knee Sprain 115

Presentation
After twisting the knee from a slip and fall or sports injury, the patient complains of knee pain
and variable ability to bear weight. There may be an effusion or spasm of the quadriceps, forcing
the patient to hold the knee at 10 to 20 degrees of flexion. See Figure 115-1 for normal anatomy.

With an anterior cruciate ligament (ACL) tear, there will most likely be a noncontact injury
involving a sudden deceleration (landing from a jump, cutting, or sidestepping), hyperextension,
or twisting, as is common in basketball, football, and soccer. This may be accompanied by the
sensation of a “pop,” followed by significant nonlocalizing pain and subsequent swelling and
effusion. Significant injuries will have a positive Lachman examination.

The other common knee injury involves the medial collateral ligament (MCL). This may be torn
with a direct blow to the lateral aspect of a partially flexed knee, such as being tackled from the
side in football, or by an external rotational force on the tibia, which can occur in snow skiing
when the tip of the skin is forced out laterally. There may also be an awareness of a “pop” during
the injury, but unlike the ACL tear, it is localized to the medial knee, along with more focal pain
and swelling. Significant injuries cause laxity of the MCL with valgus stress testing at 30 degrees
of flexion.

The meniscus can be torn acutely with a sudden twisting injury of the knee while the knee is
partially flexed, such as may occur when a runner suddenly changes direction or when the foot
is firmly planted, the tibia is rotated, and the knee is forcefully extended. Pain along the joint line
is felt immediately, and there is often a mild effusion with tenderness to palpation along either
that medial or lateral joint line. There may be a positive McMurray test.

Posterior cruciate ligament (PCL) injuries occur with forced hyperflexion, as can occur in high-
contact sports, such as football and rugby. Tears of the PCL can also occur with a posterior
blow to the proximal tibia of a flexed knee, as occurs with dashboard injuries to the knee
during motor vehicle collisions. Hyperextension, most often with an associated varus or valgus
force, can also cause PCL injury. There is no report of a tear or pop, only vague symptoms,
such as unsteadiness or discomfort. There is commonly a mild to moderate knee effusion, and
a significant injury will have a positive posterior drawer test, and a posterior sag sign will be
present.

Injury of the lateral collateral ligament (LCL) is much less common than injury of the MCL. This
usually results from varus stress to the knee, as occurs when a runner plants his foot and then
turns toward the ipsilateral knee or when there is a direct blow to the anteromedial knee. The
patient reports acute onset of lateral knee pain that requires prompt cessation of activity.

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