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The most common types of knee ligament injuries include:
Pathologies connected with dysmorphology of knee joint often cause pains in people whose lives are connected with sports. Depending on the level of trauma, there can be partial or total tear of cruciate ligaments of knee.
The outcomes after falls and tears can be eliminated with conservative methods, if a person seeks for medical help in time, and there are no complications.
Doctors distinguish back and front knee ligaments – tears and treatment are different in both cases. The back ligament doesn’t let shin bend backwards. Tear of the front knee joint ligament happens more often – it bears a higher load. Operations to treat both problems are made in any German clinic.
The symptoms that require immediate treatment of knee cruciate ligaments tearing are:
Specialists in German clinics perform diagnostics, treatment and surgeries for knee cruciate ligaments tearing. First, our patients go through magnetic resonance tomography and arthroscopy to get detailed information about the inner organs. If joints are damaged, normal blood flow to it is obstructed, and hemarthrosis starts developing. Treatment of knee cruciate ligaments tearing with balms and unorthodox methods is dangerous and non-efficient – a person can become disabled.
Anatomic peculiarities often pose risks of problems with knees. Strengthening of hip muscles, the angle of connection between hip and shin, and the size of intercondyloid fossa degine the risk of disease progression. Another crucial aspect is endocrine profile and hip deflate rate – they also affect joint health. Total tear of cruciate ligaments can be treated with a surgery only, while partial tear of cruciate ligaments can be treated with conservative methods.
The main signs of a rupture:
In case of a partial tear of the knee ligaments, the pain is often not very severe. In this situation, it is necessary to exclude the load to the limb to avoid the complete knee joint ligament tear.
With the torn ligament, the pain is severe and accompanied by swelling of the joint. Usually, swelling appears in a few hours after injury. It is difficult for a patient to step on an injured limb. Together with this, there is hypermobility in the joint.
Symptoms of the lateral ligament tear are unnatural knee mobility toward the sides. When pressing on the shin from the sides, this deviation increases.
A severe lateral ligament tear in the knee joint causes a significant accumulation of blood in the articular cavity, which makes diagnosis difficult.
When the cruciate ligament is torn, there are so-called “drawer symptoms” accompanied shin displacement.
The doctor determines the location of the pathology by visual signs, such as a direction of joint displacement
In an acute period, the pain syndrome is obvious and any movement increases painful sensations. The patient is not able to step on the injured limb and to move.
As the pain diminishes, the functional abilities gradually return, but the hypermobility of the joint remains for a long time.
When increasing the load on the joint in this period, there is a greater risk of chronic joint instability.
Injuries of the lateral collateral ligament (LCL) are mostly caused by a direct blow to the knee from the outside when the leg is bent.
With indirect injuries, a medial (inner) lateral ligament (MCL) tear occurs.
When stumbling or slipping, you lean back. In this case, torsion in the knee join happens, while the foot and shin do not move, which causes a tear of the inner ligament.
Such traumas lead to numerous knee problems. Along with the tear of the medial ligament, the meniscus also can be damaged or the anterior cruciate ligament (ACL) is torn.
Women who wear high heels often face a partial tear of the medial ligament.
How to treat a torn ligament? Conservative therapy is used in case of a partial tear. With a complete ligament tear, surgery is preferable.
To assess the degree of injury and choose the best method of treatment, a doctor, first, examines the knee visually and, then, undertakes in-depth diagnosis using X-rays.
For successful conservative treatment of partial ligament tear, it is important to follow all medical recommendations of your doctor.
At the first stage, an injured limb requires complete immobilization.
The first aid measures:
Further treatment includes:
To eliminate pain, the doctor can recommend:
The anterior cruciate ligament (ACL), which connects the femur with the shin, is one of the ligaments of the knee joint. ACL carries the load on the knee joint and helps prevent the joint from displacement. Furthermore, together with other ligaments, it reduces the knee joint rotation.
The tear of the anterior cruciate ligament joint is one of the most common injuries. Mostly, it occurs in sports such as football, hockey, basketball and downhill skiing, all of which are in a high risk of injury. The ACL tear is mainly caused by a combination of rotational trauma and knee injury. In 50% of cases, the ACL injury is accompanied with meniscus and articular cartilage injuries, and tear of other ligaments.
When the anterior cruciate ligament tears, you may hear a popping sound in the knee, while bleeding into the knee joint may lead to edema that increases with physical exertion. It becomes difficult to bend and straighten the knee. After the acute symptoms are relieved a little, the patients experience a feeling of instability of the knee joint which is usually expressed in complaints for insecurity in the knee joint, buckling of the knee and difficulties to control the joint, especially, at a sudden stop or when turning the leg. Due to changes in biomechanics, this instability leads to an extra load to the knee joint and, sooner or later, to secondary injuries of the meniscus and cartilage tissues.
For successful treatment, you need a targeted clinical examination. MRI is done to exclude concomitant traumas, such as meniscus injuries, and determine strategy of treatment. Accurate diagnosis plays an important role when surgery is considered.
Surgery is not always required in case of anterior cruciate ligament tear. Depending on complaints, the degree of instability in the knee joint, the presence of concomitant injuries and the patient's age, an individual treatment regimen is selected. With conservative therapy, the main goal is to strengthen the muscles and restore the normal mobility of the joint as soon as possible.
For physically active patients, stabilizing the knee joint is extremely important. During arthroscopy of the torn anterior cruciate ligament, the following options are available: reconstruction of the anterior cruciate ligament with the tendons of the semitendinous and gracilis muscles; removal of the damaged part of the meniscus and stitching; cartilage transplantation, etc. Treatment of concomitant injuries can be performed simultaneously with the main procedure.
In case of repeated tear of the cruciate ligament after plastic surgery, we mainly use tendons of the semitendinous and gracilis muscles from the opposite side for a patellar tendon graft. Depending on the location of a hole drilled and its width, it is, first, necessary to fill a canal with spongy bone from the iliac crest. After this, repeated plastic surgery of the cruciate ligament can be performed in 3-6 months.
Hirudotherapy is a non-traditional method of treatment. Thanks to it, local stasis of blood and pain can be eliminated, and an anti-inflammatory effect is achieved.
Indications
Acupuncture with needles stimulates certain points on the human body. The energy in the body starts flowing in the right direction, which compensates the imbalance between body systems.
What to do after the surgery?
Only limited physical activity is recommended for 2 weeks after surgery. Then, if there is no pain, the physical exertion can be increased. For about 6 weeks, it is recommended to wear a knee joint stabilizer. It is also necessary to prevent thrombosis. After discharge, a patient is prescribed an outpatient physiotherapy (a smooth transition to it is planned in advance). In the first weeks, the main focus is on the restoring mobility of the knee joint. Starting from the 7th week, you can increase the load when exercising to strengthen the muscles.
When can I do sports again?
This is individual. As a rule, if there is a good mobility of the knee joint, it is possible to start training on a stationary bike starting from the second week after the surgery, swimming – from 6th weeks, and jogging – from the 12th week. You can do contact sports, such as football, basketball, etc. not earlier than 8 months after the surgery.
When can I drive again?
Driving is not recommended immediately after eliminating pain and restoring the mobility of the knee joint. It should be also noted that you cannot drive a car if you have a knee joint stabilizer.
There are two crossing ligaments in the center of the knee joint: anterior cruciate ligament and posterior cruciate ligaments. They are located between the upper articular surface of the tibia and the head of the femur and serve to stabilize the knee joint. The posterior cruciate ligament prevents the shin from displacement back relative to the hip and, thus, together with the anterior cruciate ligament, it is responsible for the stability of the knee joint.
Injuries of the posterior cruciate ligament are much rarer than anterior cruciate ligament tears. In case of a posterior cruciate ligament injury, knee stability usually restores by scarring. This injury happens when you fall and the shank is displaced backward by force. The most common cause of the posterior cruciate ligament tear is doing sports, especially, football or basketball, as well as mountain skiing and skating. Often, the trauma is preceded by a sudden change in the movement direction caused by an external impact, for example, a blow in a single combat or fall.
When the posterior cruciate ligament tears, you may hear a popping sound in the knee, while bleeding into the knee joint may lead to edema that increases with physical exertion. It becomes difficult to bend and straiten the knee. After the acute symptoms are relieved a little, the patients experience a feeling of instability of the knee joint, which is usually expressed in complaints for insecurity in the knee joint, buckling of the knee and difficulties to control the joint, especially, at a sudden stop or when turning the leg. Due to changes in biomechanics, this instability leads to an extra load to the knee joint and, sooner or later, to secondary injuries of meniscus and cartilage tissues.
Consequences: instability in the knee caused by the tear of the posterior cruciate ligament results from the displacement of the upper and lower parts of the hip joint. This unwanted sliding of the articular surfaces towards each other causes meniscus wear and, over time, can lead to arthrosis.
After elucidating the circumstances of an accident and examining a patient, it is necessary to conduct the clinical assessment. Due to severe pain, the new tear of the posterior cruciate ligament is more difficult to treat than the one obtained some time ago. An experienced physician can diagnose a displacement of the shank toward the hip using various tests (for example, the drawer test). Comparing the injured knee with the healthy one also plays an important role.
To exclude the possibility of a fracture, you also need X-rays. If there is any suspicion of a concomitant injury, for example, damage to the cartilage or torn meniscus, it is recommended to have an MRI.
Not all posterior cruciate ligament tears require surgery; the decision for surgery depends on a few factors and is always discussed with the patient. Depending on the complaints, the degree of instability of the knee joint, concomitant injuries and the patient's age, an individual treatment regimen is selected. The main criteria are the degree of instability and the patient’s feeling of knee instability. In addition, other knee joint damages and disorders, concomitant injuries, ability to rehabilitate, profession and sports that the patient do are taken into account. If, after the injury, the patient has only slight instability in the knee, surgery is not required.
When there are no indications for surgery, training for coordination is assigned to stabilize the knee muscles. This works together with so-called conservative therapy, when the tear of the posterior cruciate ligament heals well without surgical intervention. In case of surgery, tissues of the torn posterior cruciate ligament are replaced, most often with a tendon graft taken from the semitendinous and gracilis muscles or patella tendons. Treatment of concomitant injuries can be performed in the same surgery.
Today, arthroscopy is mostly used for intervention. This minimally invasive surgical method allows avoiding deep incisions to open the knee joint. Through two small incisions (one in a shin and another one in a thigh bone), the tendon is transplanted directly to the knee joint.
This tendon graft serves as the cruciate ligament and grows in the course of the healing process. Stabilizing the tendon immediately after surgery helps maintain sufficient stability and the ability to bend the knee and carry the load to the joint. This surgical method significantly shortens the rehabilitation period and lessens post-operative pain. After the surgery only minor scars remain.
Hirudotherapy is a non-traditional method of treatment. Thanks to it, local stasis of blood and pain can be eliminated, and an anti-inflammatory effect is achieved.
Acupuncture with needles stimulates certain points on the human body. The energy in the body starts flowing in the right direction, which compensates the imbalance between body systems.
The medial collateral ligament (inner ligament) runs from the femur to the tibia. It runs diagonally, so a little forward down. The ligament is relatively wide and fuses with the joint capsule and thus stabilizes it.
In addition, it is firmly connected to the medial meniscus by means of a few fibers. The inner ligament is tensioned when the knee is extended and rotated outwards. When the knee is extended, it is used for stabilization together with the outer ligament, and when the knee is flexed, the two ligaments limit the external rotation.
Internal ligament injuries are usually a tear of the same. The crack is usually complete - there are hardly any incomplete tears.
An internal ligament tear at the knee can usually be treated well and has a good prognosis. Conservative treatment in the form of immobilization and physiotherapy is usually sufficient to build muscle. Surgery is usually only necessary for more complex injuries when other structures in the knee are involved.
The inner ligament usually tears only as a result of a trauma. This can be a kink, a rotational trauma or a knee joint dislocation, such as occurs in skiing or soccer.
Symptoms of an internal ligament tear include:
The pain typically occurs on the inside of the knee, i.e. directly above the affected inner ligament. There they can usually be reinforced by pressure. They are often accompanied by swelling in this area. However, pain can also occur in the entire knee joint, especially if this is also burdened by the unstable ligament. This pain often increases when you bend. Likewise, if you push your knee in with your leg straight. The pain is also intensified in most movements, which, together with the instability in the knee that is usually felt, makes every movement difficult. However, it is often difficult to localize the pain directly after the injury. This is because a joint effusion or swelling has often formed that irritates the entire knee. As part of the treatment, it is important to do something about this pain, otherwise it can delay healing and lead to gentle postures. As a simple measure, cooling and elevating the knee often helps. In addition, you can use painkillers from the NSAID group, e.g. Ibuprofen or diclofenac, which usually manage pain well. Overall, it is better to take pain relievers for a few weeks and make good progress in therapy than to endure the pain and therefore not be able to train properly.
For the sidebands, it is particularly important to assess the foldability when making a diagnosis. This must be assessed with both the knee extended and the knee bent at 30 °. If the inner ligament is injured, i.e. torn, the knee joint can be “opened” from the inside. For this purpose, the examiner presses against the lower leg from the inside with the thigh fixed. You can feel that the joint gap opens slightly.
For more precise diagnostics, MRI images are taken in the case of external ligament ruptures in the knee joint.
X-ray only allows an assessment of the bony involvement, but cannot directly prove the ligament injury. Theoretically, knee mirroring, the so-called arthroscopy of the knee, is also possible, but this has given way to the MRI examination of the knee.
In addition, it is used more for cruciate ligament tears, since an arthroscopic operation is also possible here.
Therapy of an internal ligament tear in the knee can be conservative or surgical, depending on the severity. The choice of therapy depends above all on the extent to which the rupture of the inner ligament can be opened and to what extent there is instability.
The indication of an operation as therapy for an internal ligament tear in the knee is much rarer than the conservative treatment in the form of immobilization, protection and physiotherapy. Nonetheless, there are reasons that require surgical treatment of the inner ligament tear.
An important indication for the operation is a pronounced opening. This is checked by bending the knee 30 ° and subjecting it to a valgus stress (lateral angling movement of the lower leg to the thigh). If there is enormous instability at the same time, surgery is essential.
Further criteria in favor of an operation are the fact that the inner ligament is completely ruptured, the involvement of further structures and the age. If the inner ligament is completely torn, it is a more serious lesion than if it is only partially ruptured or torn.
The injury is also subject to surgery if there is bony involvement. In this case, the bone fracture parts must be reconstructed intraoperatively so that the anatomically correct position is restored. Various osteosynthesis procedures are available for this purpose, for example the supply of screws to refix a chipped bone fragment.
The age aspect is important because younger patients are operated on more often than older ones. There is no limit to the age from which surgery should no longer be performed, but patients over 50 years of age are operated less frequently than younger people. In general, however, an individual clarification is useful, since it depends on the extent to which the joint is / was currently stressed and how long it will be exposed to the stress. Due to sporting activities, younger patients put more strain on their knee joints and thus the side ligaments than older patients. In addition, young patients have a longer life expectancy, which is associated with a longer stress on the inner ligaments.
Once the decision for an operation has been made, the inner ligament is treated with a minimally invasive procedure. A prerequisite for being able to perform the arthroscopic intervention (arthroscopy = joint mirroring) is the fact that the region near the inner ligament tear has swollen and that there are no significant movement restrictions. This means that surgery cannot always be carried out immediately after an internal ligament tear. As long as the inner ligament tear should be treated by immobilization and protection with physiotherapy, which may promote healing.
In the event of fresh internal ligament tears, the ligament is restored or refixed intraoperatively. Either you sew the two ends of the inner ligament together again or fix the torn off attachment - or the origin of the ligament back on the bone.
Older internal ligament tears, on the other hand, are treated with a ligament replacement. There are two options here, either using the body's own or foreign material as a transplant. The former has proven to be a better option in the past for healing and prognosis.
A final typical indication for the operative treatment of the inner ligament tear is the so-called “Unhappy Triad”. The three structures are injured simultaneously: inner ligament, inner meniscus and anterior cruciate ligament. In this case, of course, in addition to the ruptured inner ligament, the other two structures must also be treated surgically.
Benefits of surgery
An inner ligament rupture is only operated if the damage to the ligament is complex and, for example, a piece of the bone has also been torn out. Then conservative (i.e. non-operative) therapy is not possible and surgery is the only way to achieve healing or sufficient stabilization of the knee.
An advantage of surgery on the knee joint is, of course, that the ligament can be directly fixed on the knee, thus correcting the injury again. As a result, stability in the knee is restored. In addition, chronic pain should occur less frequently (permanently) after an operation.
Every intervention carries the risk that complications can occur. This includes, for example, the possibility of injury to structures such as nerves or blood vessels during the operation. Another complication is inflammation of the knee joint, which would then result in a longer duration of treatment.
The time until the knee joint is fully stressed is not necessarily shorter than with conservative therapy. Therefore, surgery on an internal ligament tear should only be performed if the prospects of healing using conservative therapy are not promising.
A bandage serves to stabilize and protect the knee and to relieve knee pain.
Since the stability after an inner ligament rupture can be limited or to prevent the tear from progressing, a bandage should be worn when the knee is under stress. Even after surgery, a bandage is used to stabilize and immobilize the knee. The pressure that the bandage has on the knee joint promotes blood circulation in the knee, which also supports healing. It is important that the bandage fits and fits well on the knee, otherwise the bandage will not have a stabilizing effect.
An orthosis is an aid that is used to stabilize, immobilize and relieve injuries to the knee.
The orthosis can be used in conservative therapy to support the healing process or after an operation to prevent the knee joint from being subjected to excessive stress after the operation. Orthotics can offer particularly active people a way to move more easily during the healing phase. The orthosis is prescribed by a doctor and then made by an orthopedic technician. It is also important - as with a knee brace - that the orthosis fits so that stability is guaranteed in the knee.
Taping the knee with kinesiotapes in the event of an internal ligament tear can also be used to support conservative (non-surgical) or surgical therapy.
The tape, like bandages or orthoses, serves to stabilize the knee. The blood circulation in the knee can also be stimulated, so that healing is promoted. It is important that the taping is carried out according to correct instructions and that these are followed.
Physiotherapy is considered a conservative therapy in the treatment of the inner ligament tear in the knee. Since in most cases this is not treated surgically compared to the external ligament tear in the knee, physiotherapy is of great importance and can be regarded as standard therapy. However, if an inner ligament tear has to be operated on, the rehabilitation is also followed by post-operative physiotherapy, so that the physiotherapy is not only used as a stand-alone therapy approach, but also in combination with the operative care.
In both cases, the primary goal of physiotherapy is to stabilize the knee joint and to positively influence the healing process. The instability in the knee increases with the severity of the inner ligament injury. Therefore, depending on the shape of the inner ligament tear, special attention must be paid to restoring stability.
Training the leg muscles is particularly suitable for this. By strengthening the muscles, the knee joint can be stabilized and ligament support can be supported. The aspect of muscle building is especially important if an operation has been performed beforehand and the surrounding leg muscles are atrophied due to a long immobilization of the knee joint, i.e. if it has regressed. To ensure sufficient stability, the musculoskeletal system must first be rebuilt through training. Leg muscle training is also important from a preventive perspective.
Once an internal ligament tear occurs, the risk of further injury is increased. Therefore, the muscles should be strengthened in order to be able to absorb and compensate for loads or strong forces on the knee joint, more precisely on the inner ligament. In addition to muscle building training, exercises on movement and coordination are also part of physiotherapy. In addition, the patients receive a kind of training to raise awareness of dangerous movements and to avoid unfavorable movement patterns.
Pain occurs immediately after the injury and is often accompanied by other symptoms.
Therefore, the so-called PECH scheme (pause, ice, compression, high camp) should be used immediately after the injury. Cooling the knee against the pain is particularly helpful here. Furthermore, painkillers, so-called NSAIDs (non-steroidal anti-inflammatory drugs), can be taken for a short period of time. These include drugs such as ibuprofen or diclofenac. These drugs also work against inflammation in the knee joint. Furthermore, ointments with pain-relieving active ingredients such as diclofenac, which are applied to the knee, are one way to counteract the pain.
Homeopathic remedies for pain can also be taken as support. Globules with the contents Arnica, Calendula, Apis mellifica or Ruta graveolens act against the pain. Physiotherapy is also important and can relieve pain. If the pain occurs during exercise, bandages can stabilize the knee joint and reduce pain. Taping the knee can also counteract pain.
The duration of therapy depends, of course, on how severe the inner ligament tear is and which treatment is then indicated. A relevant aspect is also whether other structures are affected. As soon as menisci, cruciate ligaments or even bony parts are damaged in addition to the inner ligament, the healing period is extended by several weeks.
In general, healing takes at least a few weeks, but should take a maximum of 12 months. Slight injuries where the inner ligament is not completely torn are usually treated conservatively, so that stress or light sporting activity is possible again after 2-8 weeks. A complete recovery usually occurs after about 3-4 months.
Of course, the healing process is very individual, so that some patients can only relieve the knee after 6-9 months without symptoms. In any case, it is important that the aftercare is under medical supervision. The rehabilitation should also be long enough so that the once injured inner ligament has enough time to heal, otherwise the risk of chronic ligament instability or a new ligament lesion is increased.
In general, however, the inner ligament tear is an uncomplicated healing injury with a good prognosis. In order to protect the knee for the period immediately after the injury, it is particularly useful, depending on the job, to take sick leave for a certain period of time. The sick leave is usually issued by the family doctor. The duration of the sick leave depends on certain factors such as severity, choice of therapy and occupational stress on the inner ligaments.
Outer ligament injuries are usually a tear of the same. The crack is usually complete - there are hardly any incomplete tears.
The outer ligament of the knee joint belongs to the so-called side ligaments and runs - as the name suggests - on the outside of the knee joint. It serves for lateral stabilization. If it breaks, pain and instability occur.
The cause is usually trauma (rotation, dislocation). The doctor (usually an orthopedic surgeon and / or sports physician) has a simple manual option to test the stability of the knee joint by checking the foldability. However, more precise statements can only be made from the knee by means of the MRI examination.
Depending on the extent of the injury (external ligament rupture), the therapy is directed, which can range from immobilization from a few days to surgery. The prognosis is usually good.
The outer ligament usually tears only as a result of a trauma (medical term for accident). This can be a kink, a rotational trauma or a knee joint dislocation, such as occurs in skiing or soccer.
General symptoms of an external ligament tear include pain and a certain instability of the knee joint.
Other symptoms include:
If there is a tear in the outer ligament of the knee joint, this is immediately associated with the most severe pain.
In addition, there is usually pressure pain on the torn outer ligament and the knee joint is no longer resilient due to pain, swelling and lateral instability.
In order to reduce pain in the outer ligament rupture of the knee joint as quickly as possible, the immediate measure should be taken according to the so-called PECH scheme.
The P stands for pause and means that all physical activity should be stopped for the time being and the affected leg should be rested.
The E stands for ice, the injured knee should be cooled immediately with an ice pack, ice gel or ice spray. This can significantly reduce the swelling and pain.
The C stands for compression and means that an additional pressure bandage or similar is put on to further reduce the swelling.
The H stands for high storage. The injured leg should be raised to promote venous reflux and cause the knee to swell.
In addition, pain-relieving medications, such as ibuprofen, can be used to treat the pain caused by the torn ligament.
If this scheme is not followed and the knee injury is ignored, the injury can become chronic and instability and knee pain persist.
In general, it can be said that the examination of the injured knee can be difficult due to pain. An outer ligament tear must also be distinguished from an outer ligament stretch.
The side stability test is used to examine the integrity of the sidebands. The knee joint is tried in full extension but also in a 20 degree bend “to open” to the side. If the inner side band is torn, it can be opened outwards and vice versa. If the outer ligament is injured, i.e. torn, the knee joint can be “opened” from the outside. For this purpose, the examiner presses against the lower leg from the outside with the thigh fixed. You can feel that the joint gap opens slightly.
For more precise diagnostics, MRI images are taken in the case of external ligament ruptures in the knee joint. X-ray only allows an assessment of the bony involvement, but cannot directly prove the ligament injury. Theoretically, knee mirroring, so-called arthroscopy, is also possible, but this has left the knee for the MRI examination. In addition, it is used more for cruciate ligament tears, since an arthroscopic operation is also possible here.
With a knee MRI, additional diagnoses such as a meniscus tear, cruciate ligament tear, etc. are shown. An MRI from the knee is now almost always necessary, especially for major injuries.
An MRI scan of the knee may be required to diagnose an external ligament tear at the knee.
An MRI scan (magnetic resonance imaging) is a non-invasive imaging procedure. This means that no instruments have to be inserted into the body during this examination.
With the help of a strong magnetic field, organs, tissues and joints can be shown in the form of sectional images during an MRI examination and finally assessed for pathological changes.
The MRI examination is characterized by a good soft tissue contrast and a high resolution and is therefore very suitable, among other things, for displaying ligament structures and cartilage parts of the knee joint.
An MRI examination can also be used to diagnose injuries to the knee, such as torn ligaments. The involvement of other ligament structures or parts of the cartilage of the knee joint, such as the meniscus or cruciate ligament, can also be detected in the MRI.
In the case of external ligament tears with additional damage to bone parts, an X-ray examination may be required in addition to the MRI examination, since bony structures can be better delineated here.
According to the current study situation, the MRI examination is an examination procedure free of side effects and, in contrast to the X-ray examination, does not require any harmful X-rays. The MRI examination is therefore used today for a large number of injuries to the musculoskeletal system.
The therapy of the external ligament rupture depends on the extent of the injury. If the ligament is just pulled or overstretched, a brief immobilization (a few days) of the joint is sufficient, followed by muscle building training.
In the event of a rupture (med. Term for tear) of the external ligament, it depends on whether this injury has complex side effects. If there are no bony participations (that is, the structure of the thigh - and the lower leg bone is not damaged) and the knee is unstable, conservative treatment in the form of a splint also takes place for about 6 weeks.
Complex ligament ruptures (ligament tears) with bony involvement and / or instability of the knee joint must be treated surgically. The torn band is refixed using a seam. If bone parts are torn out, they are fixed with screws.
Depending on the extent of the injury, conservative procedures such as wearing a splint and regular muscle building training and surgical procedures can be considered in the event of an external ligament tear on the knee.
Surgical procedures are very rarely used for torn ligaments.
Only complicated external ligament tears, in which additional bone parts are injured, or which are accompanied by significant instability in the knee joint, are treated with surgery.
In addition to the extent of the injury, the age of the person affected and other underlying diseases play a major role in deciding whether the external ligament tear is treated conservatively or surgically.
In the course of the operation, either the torn ligament portions are sewn together again or the torn ligament portions are completely removed and replaced by another healthy tendon, for example the patellar tendon.
The procedure is usually minimally invasive as a mirror examination (arthroscopy of the knee joint) and the duration of the procedure is up to two hours depending on the extent of the injury.
As a rule, surgical interventions on the outer ligament are carried out under general anesthesia or under spinal anesthesia. Outer ligament surgery is basically a low-risk procedure, but complications such as knee joint infections, bleeding from the knee or cartilage damage can occur.
After the operation, the leg should first be spared, cooled and elevated. Physiotherapy with muscle building training should also be carried out as soon as possible.
In the event of injury to the side ligaments (outer ligament tear / inner ligament tear), there is usually a good chance of unrestricted usability of the joint after a corresponding recovery phase.
How long this lasts depends on the type and severity of the previous injury. The worse the injury was (only stretching vs complex crack with bone involvement) the longer the complete rehabilitation, of course.
The duration of the healing process of an external ligament tear on the knee joint is several weeks, depending on the extent of the injury.
Immediate measures according to the PECH-scheme (break-ice-high-storage-compression) can reduce consequential damage and shorten the duration of the healing process.
As a rule, the injured leg should first be immobilized for at least six weeks using forearm supports or a splint (so-called orthosis). At the same time, regular physiotherapy should be started as soon as possible and muscle building exercises should be carried out in order to regain the stability of the injured knee joint. The knee can then gradually be subjected to more stress in consultation with the attending doctor.
The time until the injured knee can be fully loaded again can be up to one year.
If there is an external ligament tear on the knee joint during exercise, further stress on the knee joint should be avoided and a sports break should be taken.
The injured leg should first be treated according to the PECH (break-ice-high-compression compression) scheme.
The leg should then be immobilized for at least six weeks using forearm supports or a splint.
Over the course of time, the injured leg can gradually become more stressed. This should only be done in consultation with the treating doctor and with regular physiotherapeutic care.
Through targeted muscle building as part of physiotherapy, the stability of the injured knee joint can be rebuilt and full fitness for sports can be achieved. After an external ligament rupture of the knee joint, a sports break of up to one year may be necessary, depending on the severity of the injury. If the exercise is not paused, the injury can become chronic and instability and pain in the knee joint can persist.
A ligament extension (syn. Ligament strain) of the knee is caused by a violent movement of the knee joint that goes beyond the normal extent and can affect both the inner ligament and the outer ligament.
It is one of the most common sports injuries and can be caused, for example, by a sudden rotation of the knee.
The transitions to a ligament tear or a sprain are often fluid and therefore not always clearly distinguishable. However, the joint remains stable when the ligament is stretched, while tearing usually makes it unstable. In order to heal as quickly as possible, the knee joint should be stabilized at an early stage to protect the ligaments of the joint.
The causes of ligament stretching are many. In most cases, extreme movements are the cause of the ligament stretching in the knee. The natural movement of the ligaments is exceeded due to the strong movement.
Since these situations occur frequently in sports, ligament stretching is the most common sports injury. The ligament stretching occurs particularly frequently in sports with rapid changes of direction or contact with opponents.
These include in particular:
However, ligament stretching can also result from violent overstretching from the outside, for example when the opponent hits the knee joint from one side during sport.
The most common symptoms of ligament stretching are pain and swelling. The pain persists especially when the affected joint moves. In contrast to a ligament tear, the swellings are often rather slight.
Since the affected ligament of the knee joint has not torn, the joint remains stable and resilient despite the pain. So walking and standing are still possible, but not always painless. In addition, there is usually no bruising (hematoma) when the ligament is stretched in the knee since there is no injury to the blood vessels. This makes the hematoma a further distinguishing criterion for a ligament tear.
Pain is the main symptom of knee ligament stretching. In addition, knee swelling can also occur. However, both symptoms are less severe than, for example, with a ligament tear.
The swelling is slight, sometimes even completely absent. The reason for this is that no or only little surrounding tissue is damaged during stretching and there is no tearing of blood vessels, as would be the case with a torn ligament. Therefore bruises (hematomas) are also absent when the ligaments are stretched.
If there is swelling, it usually goes back quickly if the knee is cooled and protected.
The diagnosis usually results from the
First, the doctor checks whether the joint is stable and there is pressure pain from the outside. The doctor also determines whether a bruise has occurred; this would be an indication of a ligament tear. If there is only swelling of the joint, the knee joint is stable and bruising has not developed, this is clear evidence of the presence of ligament stretching.
The drawer test can be performed to clinically check the stability of the knee joint. This makes it possible to determine whether the cruciate ligaments of the knee joint are intact. The opening test can be used to determine whether the inner or outer ligaments of the knee are damaged. The knee joint is moved outwards and inwards against pressure. Intact ligaments severely restrict this movement; in the event of a ligament tear, the knee joint can be moved outwards or inwards beyond the normal range of movement.
These clinical examinations can give the doctor an indication of the extent of the injury. However, the exact diagnosis can be difficult because the muscles are reflexively more tense due to the injury and the examination of the ligaments cannot always be carried out meaningfully.
Stretching of the knee ligament can only be visualized by ultrasound or MRI of the knee. If the examiner is sure that the ligament is stretched, an ultrasound or MRI of the knee can be dispensed with. Since the transition to a partial ligament tear or even ligament tear is fluid, an imaging procedure can often be useful.
The BICE rule should be started immediately after the accident. The individual letters in "BICE" stand for the first letters of the four most important initial measures after ligament stretching:
In any case, the sporting activity should be interrupted immediately to avoid further damage to the ligaments. By cooling the knee joint, the pain is relieved on the one hand and swelling of the joint is prevented. Increased swelling is also prevented by a compression bandage. Since there is increased reflex blood flow to the tissue after cooling, this would lead to increased swelling without compression. Elevating also serves to counteract severe swelling of the knee joint.
Basically, ligament stretching should not be treated exclusively by immobilizing the joint and ligaments. As a rule, it is important to stabilize the ligaments functionally. This relieves the stretched ligaments, but the joint can still be moved within a limited range.
Stretch splints are used to treat ligament stretching of the knee. Bandages or a plaster sleeve ("tutor") can be used for this. This extends from the thigh to the ankle and keeps the knee in a stretched position. Exaggerated movements of the knee joint are therefore not possible and the damaged ligaments are protected and relieved, while the movements of the other ligaments and muscles are not severely restricted.
Since the ligaments are intact and therefore stable after a ligament stretch, the knee joint can continue to be stressed. However, there should be no pain. If the ligaments are stretched very much, a break of 6 to 8 weeks may be necessary.
If there is no more pain afterwards, the load can slowly be increased again. Since the ligaments were intact all the time, the sport can be carried out again without restriction after healing.
The treatment of the ligament tear on the knee is individually tailored to the particular case.
In addition to support bandages, there are so-called tapes. Tapes are elastic, self-adhesive rubber bands that can only be stretched lengthways. They thus stabilize the knee and the stretched ligaments.
Tapes are applied directly to the skin. This can either be done by a physiotherapist or orthopedist, or you can stick the tapes on yourself. Depending on the injury pattern, there are different ways to stick the tape on.
If you tap a stretch on the knee itself, it should be noted that the tape is placed around the kneecap and does not run over it. It starts above the kneecap with the knee bent. Then the tape is pulled taut past the knee and glued under the kneecap. Do the same with the other side of the kneecap. For even more stability, you can put the ends of the tapes on top of each other or alternatively attach a small cross tape.
Although tapes stabilize, in some cases they also relieve the pain of stretching the knee, but they are not a substitute for full therapy. Before you use tapes, you should have a doctor check whether it is really just a ligament extension in the knee and not a torn ligament or something similar.
If you still have pain despite the tapes, the question arises whether you should not spare your leg for a while to allow the ligament to heal completely.
As a rule, simple ligament stretching is harmless and only associated with temporary impairments. As a rule, the ligament healing heals without complications if the affected knee joint is spared in pain. If the sporting activities are interrupted for a few days and there is no more pain, the knee joint can then be fully loaded again.
However, if the ligament extension of the knee joint is not spared enough, instabilities of the knee joint can result from further injuries to the ligamentous apparatus. This affects the function of the knee joint and the uneven loading of the joint surfaces causes premature wear of the cartilage surfaces. The result is early osteoarthritis with permanent pain in the knee joint.
In addition, a damaged ligament can be damaged again much more quickly than a previously healthy ligament. This can result in repeated strains or tears in the knee ligaments. As a result, the chances of recovery are getting worse and, if not treated, can lead to permanent instability of the knee ligament.
Stretching the ligaments in the knee joint is a painful affair. Depending on the severity of the injury, it takes a different amount of time until the joint is fully resilient.
The pain caused by ligament stretching often subsides after a few days. Cooling and reduced stress on the knee help to speed up this process so that the pain is no longer noticeable after 1-2 days.
The knee should be given 1-2 weeks to fully heal the injury. During these weeks you should also try to put as little strain on the leg as possible. Cooling, compression and elevation of the leg according to the PECH rule also accelerate the healing process here.
If the ligament in the knee is severely stretched, the recovery process can also take longer.
The knee should not be strained again until the swelling has completely subsided and the pain has disappeared.
You can start with sports activities as soon as you are completely pain-free for about a week and the pain does not recur even when you exercise. To support the stability in the knee, it is still possible to wear support bandages months after the injury. These reduce the risk of instability in the knee joint and prevent the development of osteoarthritis.
Stretching the knee ligaments does not necessarily require sick leave. People who sit mainly during their work are only on sick leave for a few days, if at all.
In the case of work that is performed continuously or standing up, such as waiters or manual work, the duration of the sick leave depends on the severity of the ligament extension in the knee or on the course of the injury.
After 1-2 weeks, most patients are able to go back to work without restrictions because the pain has disappeared.
Professional athletes are often on sick leave for longer. There is too great a risk of injuring yourself again if you return to sport early. Subsequent injuries are usually more serious and last longer than the first injury. In addition, there is also the risk that instabilities develop that favor joint wear and thus increase the risk of osteoarthritis.
One speaks of a patellar tendon tear if the tendon tears partially or completely between the front thigh muscles and the lower part of the patella. The term patellar tendon rupture is also used synonymously with patellar tendon rupture.
Patellar tendon rupture is a relatively rare disease that can occur if the tendon is already damaged or due to lifting effects. It mainly occurs in younger people and should be given medical attention in order to avoid a subsequent limitation of movement as a late consequence.
From an anatomical point of view, this tendon is indispensable for stretching in the knee joint, since it is the starting point for the extensor muscles above the thigh. This is primarily the four-headed extensor muscle (Quadriceps femoris muscle), which lies on the front of the thigh and whose four parts open together into the patellar tendon at the lower pole of the patella (patella). In addition, the patella tendon fixes the kneecap in its slide bearing and serves as a deflection roller when bending in the knee joint.
Patellar tendon rupture usually occurs spontaneously due to excessive tension in the leg against resistance or when the knee is flexed in the bent position. Such accident mechanisms often occur in sports such as skiing or tennis.
With a completely healthy tendon, however, it is hardly to be expected that it will tear. There is usually another pre-damage that increases the likelihood of a crack in such an event. These are, for example, degenerative changes in the tendon as part of other comorbidities, patellar tendon irritation, previous operations or, in rare cases, cortisone injections into the knee joint.
In children and adolescents, the patellar tendon tear usually occurs at the transition from the tendon to the shin. In adults, the tear is usually further up, at the lower transition of the tendon to the kneecap.
Sometimes a bone fragment of the kneecap is also torn off, which is then called a bony tendon rupture.
The tendon tears in the middle only in the context of injuries with direct violence.
The patellar tendon tear is usually expressed by a sudden pain in those affected. In addition, walking and standing insecurity occurs due to the loss of stability, as well as a loss of strength in the knee joint. The active extension in the knee joint is usually limited or no longer possible. In addition, one can observe that the kneecap is higher than the opposite side (patella height) and a dent is often palpable at the location of the tear.
Another phenomenon that occurs when the patellar tendon is torn is that the kneecap slides up when the thigh muscles are tightened or when the knee is flexed, because the torn tendon no longer fixes it to the shin.
When the palpation of the patellar tendon tear is palpated, one notices the protrusion of the patella and the palpable dent. In addition, the continuity of the tendon can no longer be palpated.
The exact nature of the crack can be easily assessed on an x-ray. You can also see whether there is an additional bony tendon tear or not. In the side view, other diagnoses with similar symptoms (e.g. patellar rupture) can also be excluded, which is of fundamental importance for further therapy.
The diagnosis is ultimately secured by means of an ultrasound examination. With more complicated variants of the patellar tendon tear or in order to be able to exclude accompanying injuries to the knee joint, further imaging diagnostics may be necessary. This is, for example, the MRI of the knee. Especially with partial tears of the patellar tendon, an MRI from the knee can provide valuable information about the condition of the remaining patellar tendon.
In the acute phase of the patellar tendon tear, you can try to relieve pain with ice and raise your leg.
If the tendon is completely torn, it should always be sutured together using an operative procedure. An exception would be if the patient is in acute danger to life or if there is additional extensive soft tissue damage. Then it makes more sense to wait a bit and stabilize the overall situation of the affected person before performing the operation of the patellar tendon tear.
Without any surgical intervention, however, only strains or small tears in the tendon can be treated that do not result in a relevant reduction in strength.
Depending on the location of the patellar tendon, a different procedure is used.
In the case of a deep patellar tendon tear at the transition to the tibia, which often occurs in children and adolescents, the tendon suture is carried out on the one hand and the tendon is additionally fixed to the bone using a suture anchor.
To protect the newly fixed tendon from mechanical overload, a so-called McLaughlin cerclage is usually used. It is a wire loop that is fixed between the kneecap and the shin to relieve the tendon during the healing process. This enables early treatment to quickly regain the full range of motion of the knee joint. After three to six months, this wire loop is removed again, provided that it has not loosened or detached beforehand.
In addition, care must be taken to restore the previous length of the tendon, since too tight a fixation can lead to late effects such as restricted movement or osteoarthritis.
The operation of the patellar tendon tear is carried out under general anesthesia and usually lasts no longer than 30 to 45 minutes.
Complications that can arise during this procedure include bleeding in the area of the knee joint, possible infection and injury to neighboring structures, as with all surgical measures.
Overall, the healing phase for tearing the patellar tendon takes a relatively long time because tendons are one of the types of tissue that are less well supplied with blood. Immobilization is therefore of the utmost importance for the healing process.
Various aids are used for this, such as a so-called extensor orthosis or a thigh tutu. The extensor orthosis is an aluminum splint that is padded from the inside and keeps the knee bent at a certain angle. The thigh guide rail is a plaster cast that extends from the groin to the ankle and also holds the knee at a defined flexion angle.
With such an aid, the leg can be fully loaded immediately after the operation, only the knee should be performed gradually. The knee should be bent a maximum of 30 degrees for the first two weeks, followed by an increase every two weeks to 60 and 90 degrees. About seven weeks after the operation, the knee should move without splinting if no other factors speak against it.
Despite the immobilization, however, it is extremely important to start knee training early in order to be able to achieve the full range of motion again and to avoid further complications from immobilization. These include thrombosis or embolic events, soft tissue damage due to splinting and muscle regression (atrophy) due to lack of movement.
Physiotherapy is very suitable for the early mobilization of the knee and the avoidance of these complications. This specifically trains the affected muscle groups and carries out exercises adapted to the respective healing step for knee mobility.
Many sufferers report a restriction of the knee extension, which can usually be remedied by targeted training.
For a good prognosis of the patellar tendon tear, it is important to start mobilizing early despite the immobilization in order to regain the previous range of motion. Most of the time this works well.
However, factors that can delay the healing process are too early or unadjusted full loading of the knee, which can tear the wire loop, or postoperative wound infections. In the case of tendons which have been damaged in advance, the tendon may tear again.
However, if there are no negative factors, the patellar tendon will heal completely and there will be no further restrictions in everyday life or other sports activities.
04.09.2019
Snow where the eye gazes and a few free days around carnival: "Skiing healthy", one wishes oneself there, but not always well. One of the most common, most painful, and most protracted skier injuries is cruciate ligament rupture. So far, the operation is considered standard. But is it always necessary?
No - at least that is the conclusion of a study by Prof. dr. Robert Marx from the Hospital of Special Surgery (HSS) in New York. According to the results, in 25% of those affected the ruptured anterior cruciate ligament (ACL) heals itself satisfactorily, the knee remains stable and mobility is maintained. However, German experts are rather skeptical.
Marx and his team have published their analyzes in the journal Knee Surgery, Sports Traumatology, Arthroscopy.
From the clinical documentation, the authors identified 63 recreational skiers treated by study senior Marx within 6 weeks of anterior cruciate ligament injury between 2003 and 2008. Of these, 34 patients had an early ACL reconstruction, while the other 29 patients were monitored and followed up. Inclusion criteria were an MRI-documented ACL rupture and a minimum follow-up of 2 years, while the exclusion criterion was a contralateral cruciate ligament injury.
Lachman and subluxation test as predictors
Using Lachman's test and subluxation test, the authors had filtered out the patients who appeared to be eligible for conservative treatment. The prerequisite for this was that the subluxation test was negative 6 to 12 weeks after cruciate ligament rupture, and at best a slight instability was evident in the Lachman test. 17 patients fell into this category, of which 6 then did not participate in the follow-up.
Finally, 11 patients remained - unfortunately a very small study collective. The median age of the patients was 43 years and the median follow-up was 42 months. At the recall, patients underwent an accidental surgical battery, including the activity score developed by Marx, the Tegner Activity Score (TAS), the IKDC Score, and the KT-1000 Arthrometer.
Would you rather review it instead of operating it now?
Leisure ski racers with cruciate ligament tears should be re-examined 6 to 12 weeks after the damage, rather than they operate acutely, the authors conclude. And go on to say: "If the Lachman test and the subluxation test give the all-clear at this time, patients can be treated conservatively because a good end result and good knee mobility can be expected 2 years after injury."
Marx continues: "For people who are 40 years or older and have low muscle mass, convalescence after ACL surgery takes a long time, sometimes even 1 year." This period should be related to the 12 weeks. After all, it is no small matter to be able to avoid surgery. In addition to the shortened convalescence of patients, a conservative treatment not least reduce the medical costs.
And what about the long-term success?
Skeptical, especially with regard to the long-term prognosis, is Prof. Dr. med Karl-Heinz Frosch, Chief Physician of the Trauma Surgery of the Asklepios-Klinik St. Georg in Hamburg and member of the Society for Trauma Surgery for many years. Frosch, an expert in knee joint injuries, has several objections:
"It starts at the follow-up, it is said that after 2 years the knee is stable", but that is not yet time, even after 10 years, patients come again and again; who had a cruciate ligament tear and were treated conservatively at that time and complain about problems, "Frosch clarifies. Often, then, the meniscus has long been affected.
The oldest cruciate ligament examined in the study of Marx and his team is 6 or 7 years old, but this is not really a relevant period, warns Frosch: "Any bet from the conservatively treated people will come years later in practice, at the latest then if the muscle builds up and so the muscular support function is lower.
In addition: after conservative therapy, the risk of osteoarthritis after 20 years is significantly higher (60 - 100%) than after a timely ACL operation (14 - 36%). Even children, according to Frosch, often would not be aware of conservative treatment over the long term. If an anterior cruciate ligament rupture is treated conservatively in children, instability of the knee joint develops in over 90% of the cases:
"The children simply bend over and over again and in the long-term threaten degenerative meniscal and cartilage damage," Frosch refers to a German publication in a meta-analysis, the conservative treatment and ACL surgery were compared to more than 1,000 children.
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