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1. Knee Ligament
Injuries

2. The ligaments around the knee are strong. However,
sometimes they can become injured.
Ligaments injury
Sprained Ruptured
Majority tend to
stretched and quickly
settle down
Complete
Partial

3. There are a number of different things that can cause
injury to the ligaments in your knee:
You may have a direct blow to your knee or knock
into something with your knee.
Your knee may be moved outside of its usual range of
movement. For example, this can happen during a
fall, if you land awkwardly during sport, or after a
sudden movement.

4. Sprains and partial tears
• Intact fibers splint the torn ones and so spontaneous healing will
occur
• Adhesions may result, so active exercise is prescribed
• Aspirating the haemarthrosis and applying ice packs intermittently
relieves pain
• Weight-bearing is allowed
• Knee is protected from rotation or angulation strains by a heavily
padded bandage or a functional brace

5. Complete tears
• Isolated MCL or LCL treated as above
• Isolated tears of ACL may be treated by early operative
reconstruction if the individual is a professional sportsman
• Cast-brace is worn until symptoms subside, thereafter movement
and muscle-strengthening exercise. This is sufficient in about half of
the patients as they regain good function and need no further
treatment.
• Remainder will have varying instability, late assessment will identify
those who will benefit from ligament reconstruction.
• Isolated tears of the PCL are usually treated conservatively

6. Combined injuries
• In ACL and collateral ligament injury treatment starts with joint
bracing and physiotherapy to restore a good range of movements
before ACL reconstruction
• Combined injuries involving the PCL the same approach is used
however all damaged structures need to be repaired

7. Complications
 Adhesions
• If the knee with a partial ligament tear is not actively exercised, torn
fibers will stick to intact fibers and bone.
• The knee gives way with catches of pain, localized tenderness and
pain on lateral or medial rotation occur
• Confusion with a torn meniscus can be resolved by the grinding test
or arthroscopy
 Instability
• The knee continues to give way and tends to get worse predisposing
to osteoarthritis. Reconstruction before degeneration is wise.

8. Grading Ligament Injuries
GRADE 1 No instability Good
endpoint
GRADE 2 Some instability Fair endpoint
GRADE 3 Opens wide Poor endpoint

9. Anterior cruciate ligament injury
ACL injury most often occurs during sports such as
football, basketball, skiing and tennis.
The injury often happens if you land on your leg and
then quickly pivot or twist your knee in the opposite
direction.
About half of people with an ACL injury also have injury
to their meniscus or another ligament in the same knee.
Woman > men

10. Types of ACL Tears

11. Physical Exam of the Knee
• Inspection
• Palpation
• Range of Motion
• Special tests
• Neurovascular
assessment

12. ACL: HISTORY
• Contact vs noncontact
• Immediate effusion (first 4-12 hr)
• Unable to continue
• Mechanism = pivot, hyperextension

13. ACL Special Tests
• Anterior drawer
• Lachman test
• Pivot shift test
• Valgus stress test at
full extension!

14. ACL: PHYSICAL EXAM
• Decreased ROM
• Effusion-hemarthrosis, immediate
• + Instability tests
• Lachman: most accurate
• Pivot shift
• Anterior drawer
• + MCL and meniscus tests

15. “Partial” ACL tear
• > 40% ACL substance
• + Lachman, - pivot shift
• Clinically
• Most behave functionally
as full tears
• Continued shifting ↑’s risk
of meniscus damage
• Rx as full tear

16. ACL TREATMENT
• Grade 3- Nonsurgical
• modify activity
• splint & crutches, Closed chain WB to strengthen
• PRICES
• Hamstrings, gastroc!
• Functional bracing
• 100% @ 9-12 months

17. ACL TREATMENT
• Grade 3 Injuries- Surgery
• Indications
• Most active people will require surgery to
restore adequate function and decrease
instability
• Recurrent instability
• Inability to modify activity
• Associated injuries: meniscus
• Age
• Wait three weeks due to arthrofibrosis risk
• 100% @ 6-12 months

18. Posterior cruciate ligament injury
Not as common as an ACL injury.
Because the PCL is wider and stronger than the ACL.
PCL sprains usually occur because the ligament was
pulled or stretched too far, anterior force to the knee, or a
simple misstep.
PCL injuries disrupt knee joint stability because the tibia
can sag posteriorly.

19. The ends of the femur and tibia rub directly against
each other, causing wear and tear to the thin, smooth
articular cartilage.
This abrasion may lead to arthritis in the knee
There are a number of ways that the PCL can become
injured.
For example,
It may be injured during a car accident if the front of
your bent knee hits the dashboard.

20.  It may also be injured from falling on to your bent knee.
Your PCL can also be injured if your knee is hit from the
front whilst your leg is stretched out in front of you with your
foot on the ground - for example, during a game of football.

21. At first, some people with a PCL injury may not have
much in the way of symptoms .
It may take a while for you to realize that there is a
problem.
For example, you may later notice pain that comes on
when going up and down stairs or when starting a run; or,
your knee may feel unstable when walking on uneven
ground.

22. PCL INJURIES
PHYSICAL EXAM
• + Effusion
• + Posterior drawer test
• + Posterior sag sign
• False positive Lachman test
• Common to have isolated injuries

23. PCL INJURIES
TREATMENT
• PRICES
• Functional bracing (early)
• Rehab
• Surgery if continued instability, effusions
Non-operative
• Aggressive rehab
• Focus quadriceps
• No support for bracing
• closed kinetic chain
• Open kinetic chain extension avoided
• 90% quads strength prior to normal athletics

24. Medial collateral ligament injury
Injuries to the MCL can happen in almost any sport and
can affect people of all age groups.
They often happen when your leg is stretched out in front
of you and the outer side of your knee is knocked at the
same time - for example, during a rugby or football tackle.

25. MCL INJURIES
PHYSICAL EXAM
• Tender to palpation along MCL
• Pain + instability with valgus stress
• 30o flexion = MCL
• 90o flexion = associated ACL
• Pain with Apley’s distraction test
• COMPARE SIDES

26. MCL INJURIES
Treatment Of Grade 1 &2
• Early mobilization
• Weight-bearing as tolerated
• Hinged knee brace
• PRICES
• Recovery 4-6 weeks

27. MCL INJURIES
Treatment of Grade 3 (full tears)
• Isolated = nonsurgical management
• Combined = surgery consistent with associated
injuries
• Natural Hx = lack of long-term degenerative changes
seen with ACL, meniscus

28. Lateral collateral ligament injury
Injury to the LCL is less common than injury to the MCL. This
is because your other leg usually protects against injury to the
inner side of your knee.
(It is usually a direct blow to the inner side of your knee that
causes an LCL injury.)
But, this ligament injury can sometimes happen if one leg is
stretched out in front of you and doesn't have the other leg for
protection - for example , during a rugby or football tackle.

29. What are the symptoms of a knee
ligament injury?
If you have injured one or more of the ligaments in your knee,
the symptoms are likely to be similar regardless of the ligament
that is injured.
The severity of the symptoms depends on the degree of the
injury to the ligament. For example, a ligament that is
completely torn may produce more in the way of symptoms
than a ligament that is just sprained (stretched).

30. Symptoms can include:
1.A popping sound,
or a popping
or snapping feeling
2. Swelling of your knee.
Can hear at the time of injury if
ligament completely torn
Bleeding inside from the damaged ligament
It leads to swelling
Completely torn ligament Minor ligament sprains

31. 3. Pain in your knee.
depend on the severity of the knee injury.
4.Tenderness around your knee on touching. This may be
minor sprains ----mild tenderness over the actual ligament
ligament torn -----more generalised and severe tenderness
5. Not being able to use or move your knee normally.
complete ligament tears--- severely reduce
minor sprains----relatively good

32. 6. A feeling that your knee is unstable or perhaps giving
way if you try to stand on it. This may cause you to
limp. Again, this depends on how severe the ligament
injury is. You may be able to stand if you only have a
minor sprain.
7. Bruising around your knee can sometimes appear,
although not always. It may take some time for bruising
to develop.

33. Historical Clues to Knee Injury Diagnoses
Noncontact injury with “pop” ACL tear
Contact injury with “pop” MCL or LCL tear, meniscus
tear, fracture
Acute swelling ACL tear, PCL tear, fracture,
knee dislocation, patellar
dislocation
Lateral blow to the knee MCL tear
Medial blow to the knee LCL tear
Knee “gave out” or “buckled” ACL tear, patellar dislocation
Fall onto a flexed knee PCL tear

34. Special tests for ligaments
• Assess stability
of 4 knee
ligaments via
applied
stresses*
Anterior Cruciate
Posterior
Cruciate
Lateral Collateral
Medial Collateral

35. The stabilizing roles of each ligament include:
prevents the knee from buckling inwards (valgus injury)
prevents the knee from buckling outwards (varus injury)
prevents the tibia from sliding forward under the femur
prevents the tibial from sliding backward under the femur
MCL
LCL
ACL
PCL

36. Stress Testing of Ligaments
Use a standard exam routine
 Direct, gentle pressure
 No sudden forces
Abnormal test
 Excessive motion = laxity
 Soft/mushy end point**

37. Normal Stability
•Normal test is no motion with varus and/or valgus stress
with knee in neutral and 30 degrees of flexion
•Lachman’s test assesses Anterior Cruciate Ligament:
•Normal test is <5mm of forward movement of tibia on
femur with knee at 30 degrees of flexion
With knee in 90 degrees of flexion and foot stabilized,
normal test will have <5mm of anterior motion (assessing
ACL) or <5mm of posterior motion (assessing PCL)
Medial and Lateral collateral ligaments
Anterior and posterior drawer testing assesses ACL and PCL
Anterior and Posterior Cruciate Ligaments' control anterior/posterior motion

38. Normal end point of ligament that examiner feels with
applied stress is FIRM.
A soft or mushy end point implies ligament damage
(stretching or complete tear).

39. Collateral Ligament Assessment
Patient and Examiner
Position*

40. *Position patient supine on table with thigh resting on edge of
exam table and foot supported by examiner
•Knee in 30 degrees of flexion –
WHY? Increased laxity of medial side of knee in
extension may indicate additional damage to posterior
structures (posterior joint capsule & PCL)

41. Valgus Stress Test for MCL*
Note Direction Of Forces

42. *VALGUS (MCL) stress
•Proximal hand on lateral aspect of knee holds and
stabilizes thigh
•Distal hand directs ankle laterally
•Attempt to open knee joint on medial side
•Estimate the medial joint space and evaluate the
stiffness of motion.
• Positive test = Significant gap in medial aspect of
knee with valgus stress = MCL injury.

43. Varus Stress Test for LCL*
Note direction of forces

44. *VARUS (LCL) Stress
•Supine position, with knee at 20 to 30 degrees
of flexion and thigh supported.
•Stabilize medial aspect of knee and push ankle
medially, trying to open knee joint on lateral side
•Disruption of LCL is indicated by difference in
degree of lateral knee tautness with varus stress.
Compare affected knee to uninjured side

45. 45
Lachman Test*
• Patient Position
• Physician hand placement

46. *Lachman Maneuver more sensitive and specific for
ligamentous tears than drawer sign.
•Patient is supine
•Knee flexed to 20-30 degrees
•Hand placement:
•Grasp and stabilize patient’s thigh just proximal to patella
•With opposite hand, try to move proximal tibia forward on femur
•POSITIVE TEST = Excessive forward motion of tibia (>5mm)
without firm endpoint indicates ACL damage

47. •Modification for patient with large thighs:
•Thigh placed over knee of examiner
•Push downward on femur with hand while
other hand grasps proximal tibia, attempting
to move it anteriorly

48. 48
Lachman Test
• View from lateral aspect*
Note direction of forces

49. Anterior Drawer Test for ACL
• Physician Position & Movements*
• Patient Position
Note direction of forces

50. *Patient Position
•Supine
•Flex hip of affected knee to 45 degrees
•Bend knee to 90 degrees
•Patient's foot planted firmly on examination table
Physician position:
Sitting on dorsum of foot, place both hands behind knee
Once hamstrings relaxed, try to displace proximal leg anteriorly
Anterior drawer test is LESS SENSITIVE for ACL damage than Lachman’s
Maneuver

51. Posterior Drawer Testing- PCL*
Note direction of forces

52. *Patient Position
•Supine
•Affected knee at 90 degrees of flexion
•Determine ‘neutral’ position by comparing resting position with unaffected
knee
Physician Position & Movements
•Patient's foot placed between examiner's legs while the palms of the hands are
used to push the tibia posteriorly.
•Tester directs pressure backward upon proximal tibia, similar to Anterior Drawer
Testing
Interpretation of test:
•Posterior instability - PCL injury indicated by increased posterior tibial
translation
•Confusion - trying to distinguish abnormal translation of tibia on femur - from
excessive ACL or PCL laxity

53. Signs
•tenderness
•possible clicking
Symptoms
•Pain
• catching
•buckling
• Commonly
injured part
Meniscal Tears
• Can occur combine
with other ligament –
ACL mostly
Occur during twisting
motions with the
knee flexed

54. • Older people can injure the meniscus without any
trauma as the cartilage weakens and wears thin over
time, setting the stage for a degenerative tear.
• Medial Menisci: more prone to injury because of its
restricted anatomy due to attachment to the joint
capsule and to the tibial collateral ligament make it
less mobile.

55. Meniscus Tears
Mechanism Pattern of tear
bucket handle horizontal
degenerative
traumatic
The split is vertical, along the circumference
of the meniscus leaving anterior and
posterior segments attached loosely.
Sometimes the torn part displaces towards
the center, causing “locking” (extension
block).
Usually degenerative in origin or due to repetitive
minor trauma, or with association with meniscal
cysts.
Generally speaking, most of the meniscus is
avascular, except the outer third-from capsule-, due
to this spontaneous repair doesn’t occur.
*The loose part act as a mechanical irritant causing
recurrent synovial effusion, and in severe cases
secondary osteoarthritis.

57. Menisci Tears
Clinical Features:
Patients may complain of pain at the joint line area, locking, clicking,
giving way, and swelling with activity.
In ptn >40yrs the main complaint is recurrent giving way or locking.
Physical exam:
•Joint line tenderness (Mostly medial).
•Joint held slightly flexed.
•Joint effusion may be present.
•In late cases quadriceps are wasted.
•Flexion is full , extension limited.

58. 58
Assess Meniscus – Knee Flexion
• Most sensitive test is full flexion*
• Examiner passively flexes the knee or has patient
perform a full two-legged squat to test for meniscal
injury
• Joint line tenderness**
• Flexion of the knee enhances palpation of the anterior
half of each meniscus

59. Joint line tenderness:
the most imp and specific test
_ Apley’s grind test:
• Isolates meniscii
• Prone with knee flexed, axial load
and rotation.
- McMurray’s test
• Flex/ext with varus / valgus and
int/ext rotation.
• Goal is to get torn piece to pop
in and out of place.
• Positive if pop or reproduction of pain.

60. Menisci Tears
Imaging
X-ray – Normal
MRI – most useful may reveal tears missed by arthroscopy
Arthroscopy : Diagnostic and therapeutic.
You have to be certain that the lesion you can see is the one causing
the patient’s symptoms.

61. Menisci Tears
Treatment
 Conservative treatment of meniscal injuries begins with RICE (Rest, Ice,
Compression, and Elevation).
 Arthroscopy is the preferred method.
 peripheral tears – surgery.
 The displaced portion should be excised.
 Postoperative physiotherapy.
 Surgical treatment of symptomatic meniscal tears is recommended because
untreated tears may increase in size and may abrade articular cartilage, resulting
in arthritis.