Joint aspiration

The anterior cruciate ligament (ACL)
Joint aspiration

Joint aspiration

Synovial fluid analysis is a series of tests performed on synovial (joint) fluid to help diagnose and treat joint-related abnormalities. To obtain a synovial fluid sample, a needle is inserted into the knee between the joint space. When the needle is in place the synovial fluid is then withdrawn. The sample is sent to the lab for analysis.

Synovial fluid analysis

The anterior cruciate ligament (ACL)

Synovial fluid analysis is a group of tests that examine your joint (synovial) fluid. The tests help diagnose and treat joint-related problems.

How the Test is Performed
A sample of synovial fluid is needed for this test. Synovial fluid is normally a thick, straw-colored liquid found in small amounts in joints, bursae (fluid-filled sacs in the joints), and tendon sheaths.

After the area is cleaned, the health care provider will insert a sterile needle through the skin and into the joint space. Once the needle is in the joint, fluid is drawn through it into a sterile syringe.

The fluid sample is sent to the laboratory. The laboratory technician will:

Check the sample’s color and clarity
Place it under a microscope, count the number of red and white blood cells, and then look for crystals (in the case of gout) or bacteria
Measure glucose, proteins, uric acid, and lactic dehydrogenase (LDH)
Culture the fluid to see if any bacteria grow
How to Prepare for the Test
Normally, no special preparation is needed. Tell your health care provider if you are taking blood thinners, because they can affect test results or your ability to take the test.

How the Test Will Feel
Sometimes, the health care provider will first inject numbing medicine into the skin with a small needle, which will sting. A larger needle will be used to draw out the joint fluid or synovial fluid.

This test may also cause some pain if the tip of the needle touches bone. The procedure usually lasts less than 1 to 2 minutes.

Why the Test is Performed
The test can help diagnose the cause of pain, redness, or swelling in joints.

Sometimes, removing the fluid can also help relieve joint pain.

This test may be used when your doctor suspects:

Bleeding in the joint after a joint injury
Gout and other types of arthritis
Infection in a joint
What Abnormal Results Mean
Abnormal joint fluid may look cloudy or abnormally thick.

Blood in the joint fluid may be a sign of injury inside the joint or a body-wide bleeding problem. An excess amount of normal synovial fluid can also be a sign of osteoarthritis.

Infection of the joint — unusual but more common with repeated aspirations
Bleeding into the joint space
Ice or cold packs may be applied to the joint for 24 to 36 hours after the test to reduce the swelling and joint pain. Depending on the exact problem, you can probably resume your normal activities after the procedure. Talk to your health care provider to determine what activity is most appropriate for you.

Alternative Names
Joint fluid analysis; Joint fluid aspiration

Orthopedic services

The anterior cruciate ligament (ACL)

Orthopedics, or orthopedic services, is the medical specialty that involves the treatment of the musculoskeletal system, which is made up of your body’s bones, joints, ligaments, tendons, and muscles.

Any number of medical problems can affect the bones, joints, ligaments, tendons, and muscles.

Bone problems may include:

Bone deformities
Bone infections
Bone problems may include:
Bone tumors
Need for amputation
Nonunions and malunions
Spinal deformities
Joint problems may include:

Joint pain
Joint swelling
Ligament tears
Common orthopedic-related diagnoses based on body part:

Ankle and foot:

Foot and ankle deformities
Hammer toe
Heel pain
Heel spurs
Joint pain and arthritis
Tarsal tunnel syndrome
Hand and wrist

Joint pain
Tendon or ligament injury
Carpal tunnel syndrome
Ganglion cyst
Rheumatoid arthritis

Frozen shoulder (adhesive capsulitis)
Impingement syndrome
Loose or foreign bodies
Rotator cuff tear
Rotator cuff tendinitis
Torn labrum
SLAP tears

Cartilage and meniscus injuries
Dislocation of the kneecap (patella)
Ligament sprains or tears (anterior cruciate, posterior cruciate, medial collateral and lateral collateral ligament tears)
Loose or foreign bodies
Osgood-Schlatter disease

Dislocation or separation
Loose or foreign bodies
Tennis or golfers elbow (epicondylitis or tendinitis)
Elbow stiffness or contractures

Herniated (slipped) disc
Infection of the spine
Injury to the spine
Spinal stenosis
Spinal tumor
Spinal cord injuries

Imaging procedures can help diagnose or even treat many orthopedic conditions. Your doctor may order:

Arthrograms (joint x-ray)
Bone scans
Computed tomography (CT) scan
Magnetic resonance imaging (MRI) scan
Sometimes, treatment involves injections of medicine into the painful area. This may involve:

Corticosteroid injections into joints, tendons and ligaments, and around the spine
Hyaluronic acid injection to help relieve arthritis pain
Surgical procedures used in the treatment of orthopedics include:

Arthroscopic surgeries
Bunionectomy and hammer toe repair
Cartilage repair or resurfacing procedures
Cartilage surgery to knee
Fracture care
Joint replacement (arthroplasty)
Ligament reconstructions
Repair of torn ligaments and tendons
Spine surgery, including diskectomy, foraminotomy, laminectomy, and spinal fusion
Newer orthopedic services procedures include minimally invasive surgery techniques, advanced external fixation, and the use of bone graft substitutes and bone-fusing protein.


Orthopedic care often involves a team approach. Your team may include a doctor as well as a non-doctor specialist such as a physical therapist, as well as others.

Orthopedic surgeons receive 5 or more extra years of training in the care of disorders of the bones, muscles, tendons, ligaments.
Physical medicine and rehabilitation doctors have 4 or more extra years of training in this type of care after they graduated from medical school. They are also referred to as physiatrists. They do not perform surgery although they can give joint injections.
Sports medicine physicians are doctors with experience in sports medicine who have a primary specialty in family practice, internal medicine, emergency medicine, pediatrics, or physical medicine and rehabilitation. Most have 1-2 years of additional training in sports medicine through subspecialty programs in sports medicine. Sports medicine is a special branch of orthopedics designed to provide complete medical care to active people of all ages.
Other doctors that may be a part of the orthopedics team include:

Pain specialists
Primary care doctors
Non-doctor health professionals that may be a part of the orthopedics team include:

Athletic trainers
Physical therapists
Social workers
Vocational workers


The anterior cruciate ligament (ACL)

Arthroscopy is surgery that is done using a tiny camera on the end of a tube to check for and treat joint problems.

See also:

Knee arthroscopy
Rotator cuff repair
Shoulder arthroscopy
This procedure is typically done on the knee, hip, ankle, shoulder, elbow, or wrist.

Three different types of anesthesia (pain management) may be used for arthroscopy surgery:

General anesthesia. You will be unconscious and unable to feel pain.
Painkilling medicine. Your joint may be numbed, and you may be given medicines that relax you. You will stay awake.
Spinal anesthesia. This is also called regional anesthesia. The painkilling medicine is injected into a space in your spine. You will be awake but will not be able to feel anything below your waist.
The area is cleaned and a pressure band (tourniquet) may be applied to restrict blood flow. The health care provider will then make a surgical cut into the joint. Sterile fluid is passed through the joint space to expand the joint and provide a better view.

Next, a tool called an arthroscope is inserted into the area. An arthroscope consists of a tiny tube, a lens, and a light source. It allows the surgeon to look for joint damage or disease.

Images of the inside of the joint are displayed on a monitor. One or two other surgical cuts may be needed so the doctor can use other instruments to remove bits of cartilage or bone, take a tissue biopsy, or perform other minor surgery. In addition, ligament repairs can be done using the arthroscope.

Why the Procedure is Performed
A number of different injuries and diseases may cause joint pain or problems.

Arthroscopy may be needed to:

Diagnose the cause of joint pain after an injury
Perform carpal tunnel surgery
Remove loose bone or cartilage fragments in the joint
Remove the lining of the joint. This lining is called the synovium, and it may become swollen or inflamed from arthritis.
Repair a torn ligament or tendon
Repair damaged cartilage or meniscus (the piece of cartilage that cushions the knee joint area)
The risks from surgery are:

Allergic reactions to medications
Breathing problems
Other risks from this surgery include:

Bleeding into the joint
Blood clot
Damage to the cartilage, meniscus, or ligaments in the knee
Infection in the joint
Injury to a blood vessel or nerve
Joint stiffness
Outlook (Prognosis)
After the procedure, the joint will probably be stiff and sore for a few days. Ice is commonly recommended after arthroscopy to help relieve swelling and pain.

You can resume gentle activities, such as walking, immediately. However, using the joint too much may cause swelling and pain, and may increase the chance of injury. Do not restart normal activity for several days or longer.

You may need to make arrangements for work and other responsibilities. Your doctor may also recommend physical therapy.

Depending on your diagnosis, you may have other resrictions or need to do certain exercises.

Before the Procedure
You will usually have an MRI scan of the joint done before surgery is planned.

Always tell yoru doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

You will be asked to stop taking drugs that make it harder for your blood to clot beginning 2 – 3 weeks before surgery. These drugs include aspirin, ibuprofen (Advil, Motrin), and naproxen (Naprosyn, Aleve).

Ask your doctor which drugs you should still take on the day of your surgery.

You will usually be asked not to eat or drink anything for 6 – 12 hours before the procedure. Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

You must sign a consent form. Make arrangements for transportation from the hospital after the procedure.

Alternative Names
Arthroscopy – hip; Arthroscopy – wrist; Arthroscopy – ankle

Hypermobile joints

The anterior cruciate ligament (ACL)

Hypermobile joints are joints that move beyond the normal range with little effort. Joints most commonly affected are the elbows, wrists, fingers, and knees.

Children are often more flexible than adults, but those with hypermobile joints can flex and extend their joints beyond what is considered normal. The movement is done without too much force and without discomfort.

Thick bands of tissue called ligaments help hold joints together and keep them from moving too much or too far. In children with hypermobility syndrome, those ligaments are loose or weak. This may lead to:

Arthritis, which may develop over time
Dislocated joints, which is a separation of two bones where they meet at a joint
Sprains and strains
Children with hypermobile joints also often have flat feet.

Hypermobile joints often occur in otherwise healthy and normal children. This is called benign hypermobility syndrome.

Rare medical conditions associated with hypermobile joints include:

Cleidocranial dysostosis
Down syndrome
Ehlers-Danlos syndrome
Marfan syndrome
Morquio syndrome
Home Care
There is no specific care for this condition. Persons with hypermobile joints have an increased risk for joint dislocation and other problems.

Extra care may be needed to protect the joints. Ask your health care provider for recommendations.

When to Contact a Medical Professional
Call your health care provider if:

A joint suddenly appears misshapen
An arm or leg suddenly does not move properly
Pain occurs when moving a joint
The ability to move a joint suddenly changes or decreases
What to Expect at Your Office Visit
Hypermobile joints often accompany other symptoms that, taken together, define a specific syndrome or condition. A diagnosis is based on a family history, medical history, and a complete physical exam.

Medical history questions that help document hypermobile joints in detail may include:

When did you first notice the problem?
Is it getting worse or more noticeable?
Are there any other symptoms, such as swelling or redness around the joint?
Is there any history of joint dislocation, difficulty walking, or difficulty using the arms?
The physical exam will include detailed examination of the muscles and skeleton. The joints may be moved to determine the direction and extent of mobility.

Further tests will depend on what condition is suspected.

Alternative Names
Joint hypermobility; Loose joints; Hypermobility syndrome

Joint pain

The anterior cruciate ligament (ACL)

Joint pain can affect one or more joints.

See also:

Arthritis (inflammation of joints)
Muscle pain
Joint pain can be caused by many types of injuries or conditions. No matter what causes it, joint pain can be very bothersome.

Rheumatoid arthritis is an autoimmune disorder that causes stiffness and pain in the joints. Osteoarthritis involves growth of bone spurs and degeneration of cartilage at a joint. It is very common in adults older than 45 and can cause joint pain.

Joint pain may also be caused by bursitis (inflammation of the bursae). The bursae are fluid-filled sacs that cushion and pad bony prominences, allowing muscles and tendons to move freely over the bone.

Autoimmune diseases such as rheumatoid arthritis and lupus
Chondromalacia patellae
Gout (especially found in the big toe)
Infectious diseases, including
Epstein-Barr viral syndrome
Lyme disease
Measles (rubeola)
Rheumatic fever
Rubella (German measles)
Varicella (chickenpox)
Injury, including fracture
Septic arthritis
Unusual exertion or overuse, including strains or sprains
Home Care
Follow prescribed therapy in treating the underlying cause.

For nonarthritis joint pain, both rest and exercise are important. Warm baths, massage, and stretching exercises should be used as frequently as possible.

Anti-inflammatory medications may help relieve pain and swelling. Consult your health care provider before giving aspirin or NSAIDs such as ibuprofen to children.

When to Contact a Medical Professional
Contact your health care provider if:

You have fever that is not associated with flu symptoms
You have lost 10 pounds or more without trying (unintended weight loss)
Your joint pain lasts for more than 3 days
You have severe, unexplained joint pain, particularly if you have other unexplained symptoms
What to Expect at Your Office Visit
Your health care provider will perform a physical exam and ask you about your medical history. The following questions may help identify the cause of your joint pain:

Which joint hurts? Is the pain on one side or both sides?
How long have you been having this pain? Have you had it before?
Did this pain begin suddenly and severely, or slowly and mildly?
Is the pain constant or does it come and go? Has the pain become more severe?
What started your pain?
Have you injured your joint?
Have you had an illness or fever?
Does resting the joint reduce the pain or make it worse?
Does moving the joint reduce the pain or make it worse?
Are certain positions comfortable? Does keeping the joint elevated help?
Do medications, massage, or applying heat reduce the pain?
What other symptoms do you have?
Is there any numbness?
Can you bend and straighten the joint? Does the joint feel stiff?
Are your joints stiff in the morning? If so, how long does the stiffness last?
What makes the stiffness better?
Tests that may be done include:

CBC or blood differential
Joint x-ray
Sedimentation rate, a measure of inflammation
Blood tests specific to various autoimmune disorders
Physical therapy for muscle and joint rehabilitation may be recommended. A procedure called arthrocentesis may be needed to remove fluid from the sore joint.

Joint x-ray

The anterior cruciate ligament (ACL)

This test is an x-ray of a knee, shoulder, hip, wrist, ankle, or other joint.

How the Test is Performed
The test is done in a hospital radiology department or in the health care provider’s office. The x-ray technologist will help you position the joint to be x-rayed on the table. Once in place, pictures are taken. The joint may be repositioned for different views.

How to Prepare for the Test
Inform the health care provider if you are pregnant. Remove all jewelry.

How the Test Will Feel
The x-ray is not uncomfortable, except possibly from positioning the area being x-rayed.

Why the Test is Performed
The x-ray is used to detect fractures, tumors, or degenerative conditions of the joint.

What Abnormal Results Mean
The x-ray may reveal arthritis, fractures, bone tumors, degenerative bone conditions, and osteomyelitis (inflammation of the bone caused by an infection).

The test may also be performed to investigate the following conditions:

Acute gouty arthritis (gout)
Adult still’s disease
Caplan syndrome
Chondromalacia patellae
Chronic gouty arthritis
Congenital dislocation of the hip
Fungal arthritis
Non-gonococcal (septic) bacterial arthritis
Psoriatic arthritis
Reiter syndrome
Rheumatoid arthritis
Runner’s knee
Tuberculous arthritis
There is low radiation exposure. X-rays are monitored and regulated to provide the smallest amount of radiation exposure needed to produce the image. Most experts feel that the risk is low compared with the benefits. Pregnant women and children are more sensitive to the risks of the x-ray.

Alternative Names
X-ray – joint; Arthrography; Arthrogram

Aging changes in the bones – muscles – joints

The anterior cruciate ligament (ACL)

Changes in posture and gait (walking pattern) are as universally associated with aging as changes in the skin and hair.

The skeleton provides support and structure to the body. Joints are the areas where bones come together. They allow the skeleton to be flexible for movement. In a joint, bones do not directly contact each other. Instead, they are cushioned by cartilage in the joint, synovial membranes around the joint, and fluid.

Muscles provide the force and strength to move the body. Coordination is directed by the brain but is affected by changes in the muscles and joints. Changes in the muscles, joints, and bones affect the posture and gait, and lead to weakness and slowed movement.


Bone mass or density is lost as people age, especially in women after menopause. The bones lose calcium and other minerals.

The spine is made up of bones called vertebrae. Between each bone is a gel-like cushion (intervertebral disk). The trunk becomes shorter as the disks gradually lose fluid and become thinner.

In addition, vertebrae lose some of their mineral content, making each bone thinner. The spinal column becomes curved and compressed (packed together). Bone spurs, caused by aging and overall use of the spine, may also form on the vertebrae.

The foot arches become less pronounced, contributing to a slight loss of height.

The long bones of the arms and legs, although more brittle because of mineral loss, do not change length. This makes the arms and legs look longer when compared with the shortened trunk.

The joints become stiffer and less flexible. Fluid in the joints may decrease, and the cartilage may begin to rub together and erode. Minerals may deposit in and around some joints (calcification). This is common in the shoulder.

Hip and knee joints may begin to lose joint cartilage (degenerative changes). The finger joints lose cartilage and the bones thicken slightly. Finger joint changes are more common in women and may be hereditary.

Some joints, such as the ankle, typically change very little with aging.

Lean body mass decreases, caused in part by loss of muscle tissue (atrophy). The rate and extent of muscle changes seem to be genetically determined. Muscle changes often begin in the 20s in men and the 40s in women.

Lipofuscin (an age-related pigment) and fat are deposited in muscle tissue. The muscle fibers shrink. Muscle tissue is replaced more slowly, and lost muscle tissue may be replaced with a tough fibrous tissue. This is most noticeable in the hands, which may appear thin and bony.

Changes in the muscle tissue, combined with normal aging changes in the nervous system, cause muscles to have less tone and ability to contract. Muscles may become rigid with age and may lose tone, even with regular exercise.


Bones become more brittle and may break more easily. Overall height decreases, mainly because of shortening of the trunk and spine.

Inflammation, pain, stiffness, and deformity may result from breakdown of the joint structures. Almost all elderly people are affected by joint changes, ranging from minor stiffness to severe arthritis.

The posture may become more stooped (bent) and the knees and hips more flexed. The neck may become tilted, and the shoulders may narrow while the pelvis becomes wider.

Movement slows and may become limited. The walking pattern (gait) becomes slower and shorter. Walking may become unsteady, and there is less arm swinging. Older people become tired more easily, and have less energy.

Strength and endurance change. Loss of muscle mass reduces strength. However, endurance may be enhanced somewhat by changes in the muscle fibers. Aging athletes with healthy hearts and lungs may find that performance improves in events that require endurance, and decreases in events that require short bursts of high-speed performance.


Osteoporosis is a common problem, especially for older women. Bones break more easily, and compression fractures of the vertebrae can cause pain and reduce mobility.

Muscle weakness contributes to fatigue, weakness, and reduced activity tolerance. Joint problems are extremely common. This may be anything from mild stiffness to debilitating arthritis (see osteoarthritis).

The risk of injury increases because gait changes, instability, and loss of balance may lead to falls.

Some elderly people have reduced reflexes. This is most often caused by changes in the muscles and tendons, rather than changes in the nerves. Decreased knee jerk or ankle jerk can occur. Some changes, such as a positive Babinski’s reflex, are not a normal part of aging.

Involuntary movements (muscle tremors and fine movements called fasciculations) are more common in the elderly. Inactive or immobile elderly people may experience weakness or abnormal sensations (paresthesias).

Muscle contractures may occur in people who are unable to move on their own or have their muscles stretched through exercise.


Exercise is one of the best ways to slow or prevent problems with the muscles, joints, and bones. A moderate exercise program can help you maintain strength and flexibility. Exercise helps the bones stay strong.

Consult with your health care provider before beginning a new exercise program.

A well-balanced diet with adequate amounts of calcium is important. Women need to be especially careful to get enough calcium and vitamin D as they age. Postmenopausal women, and men over age 65, need 1,200 – 1,500 mg of calcium and 400 – 800 international units of vitamin D per day. If you have osteoporosis, talk to your doctor about prescription treatments.

Limited range of motion

The anterior cruciate ligament (ACL)

Limited range of motion is a reduction in the normal distance and direction through which a joint can move.


Range of motion is the distance and direction of movement of a joint. Limited range of motion is a term meaning that a specific joint or body part cannot move through its normal range of motion.

Motion may be limited by a mechanical problem within the joint, by swelling of tissue around the joint, by stiffness of the muscles, or by pain.

Diseases that prevent a joint from fully extending may, over time, produce contracture deformities, causing permanent inability to extend the joint beyond a certain fixed position.


  • Ankylosing spondylitis
  • Cerebral palsy
  • Congenital torticollis
  • Dislocation (of most joints)
  • Fracture of elbow
  • Fractures through most joints
  • Juvenile rheumatoid arthritis
  • Legg-Calve-Perthes disease
  • Nursemaid’s elbow, an injury to the elbow joint — extremely common
  • Osteoarthritis
  • Rheumatoid arthritis
  • Septic joint (especially septic hip)
  • Syphilis

Home Care

Your health care provider may recommend range of motion exercises, designed to increase muscle strength and flexibility. Continue these exercises at home.

When to Contact a Medical Professional

Visit your health care provider if a joint does not move fully and easily in its normal way. If a joint develops (new) changes in its ability to move, the affected part should be examined to determine the cause.

What to Expect at Your Office Visit

The health care provider will perform a physical examination and will ask you about your medical history. Questions may include:

  • When did your symptoms start?
  • How bad is it?
  • What body part is affected?
  • Does the limited range of motion affect more than one body area?
  • Do you also have pain?
  • What other symptoms do you have?

Note: Limited range of motion may be discovered by the health care provider during an examination for other conditions, and the affected person may or may not have been aware of its presence.

The muscular system, nervous system, and skeleton may be examined in detail. Depending on the cause, joint x-rays and spine x-rays may be needed. Other tests may also be done.

Physical therapy may be recommended.

The structure of a joint

The anterior cruciate ligament (ACL)
The structure of a joint

The structure of a joint

Joints, particularly hinge joints like the elbow and the knee, are complex structures made up of bone, muscles, synovium, cartilage, and ligaments that are designed to bear weight and move the body through space. The knee consists of the femur (thigh bone) above, and the tibia (shin bone) and fibula below. The kneecap (patella) glides through a shallow groove on the front part of the lower thigh bone. Ligaments and tendons connect the three bones of the knee, which are contained in the joint capsule (synovium) and are cushioned by cartilage.

Joint swelling

The anterior cruciate ligament (ACL)

Joint swelling is the buildup of fluid in the soft tissue surrounding the joint.


Joint swelling may occur along with joint pain. The swelling may cause the joint to appear larger or abnormally shaped.

Joint swelling can cause pain or stiffness. After an injury, swelling of the joint may mean you have a broken bone or a tear in the muscle tendon or ligament.

Many different types of arthritis may cause swelling, redness, or warmth around the joint.

An infection in the joint can cause swelling, pain, and fever.


Joint swelling may be caused many different things, including:

  • Ankylosing spondylitis
  • Gout
  • Osteoarthritis
  • Pseudogout
  • Psoriatic arthritis
  • Reactive arthritis
  • Rheumatoid arthritis
  • Septic arthritis
  • Systemic lupus erythematosus

Home Care

If the joint swelling occurs after an injury, apply ice packs to reduce pain and swelling. Raise the swollen joint so that it is higher than your heart, if possible. For example, if your ankle is swollen, lay down with pillows comfortably placed underneath your foot so that your ankle and leg is slightly raised.

For those with arthritis, your doctor’s treatment plan should be followed carefully.

When to Contact a Medical Professional

Call your health care provider immediately if you have joint pain and swelling with a fever.

Also call your health provider if you have:

  • Unexplained joint swelling
  • Joint swelling after an injury

Joint Disorders

The anterior cruciate ligament (ACL)

A joint is where two or more bones come together, like the knee, hip, elbow or shoulder. Joints can be damaged by many types of injuries or diseases. Arthritis or simply years of use may cause a joint to wear away. This can cause pain, stiffness and swelling. Over time, a swollen joint can become severely damaged.

Treatment of joint problems depends on the cause. If you have a sports injury, treatment often begins with the RICE (Rest, Ice, Compression and Elevation) method to relieve pain, reduce swelling and speed healing. Other possible treatments include pain relievers, keeping the injured area from moving, rehabilitation, and sometimes surgery. For arthritis, injuries, or other diseases, you may need joint replacement surgery to remove the damaged joint and put in a new one.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases

Medial Collateral Ligament Injuries of the Knee – MCL Tear

The anterior cruciate ligament (ACL)

Medial collateral ligament injuries to the knee are not uncommon. Many well-recognized professional athletes, including Jay Cutler, Hines Ward, Knowshan Moreno, and Troy Polamalu, have suffered from a medial collateral ligament tears after injury on the football field. These can occur alone or in combination with other ligament or cartilage injuries of the knee in athletes.

What is the medial collateral ligament?
The Medial Collateral Ligament (MCL), together with the cruciates and lateral collateral ligament, is critical to the stability of the knee joint. The MCL is a fibrous band of tissue made up of collagen fibers that runs along the inner aspect of the knee from the end of the thigh bone (femur) to the top of the shin bone (tibia). In this location, the MCL provides “side-to-side” stability to the knee and prevents widening of the inner aspect of the joint with forces applied to the outside of aspect of the knee (valgus force). When significant forces are applied to the outside aspect of the knee, as can occur during a tackle in football or awkward slide into base with baseball, the ligament can be stretched (“sprained”) or torn.
The MCL is made up of a superficial and a deep layer. The superficial MCL runs from the distal femur to the tibia 4 or 5 centimeters below the knee joint line, and is found just below the sheath of the sartorius muscle tendon. The deeper MCL layer lies just outside of the knee capsule and inserts directly into the tibial plateau and medial meniscus. The superficial layers is much more mechanically important in resisting forces to the outside aspect of the knee (“valgus” force).
How is the MCL injured in athletes?
Because the MCL resists widening of the inside of the knee joint, the MCL is usually injured indirectly by traumatic forces in the outside of the knee. These are certainly common in contact sports from tackles or “clipping injuries” in football and soccer. However, MCL injuries can also occur from noncontact mechanisms such as awkward landing or pivoting events in basketball or slides into base with baseball. An MCL tear or sprain can occur in isolation or in combination with injury to the meniscus, cartilage, or cruciate ligaments.
What are the signs of a medial collateral ligament (MCL) injury in athletes?
The most common symptom following a MCL injury is pain directly over the medial aspect of the knee. The MCL can be tender to palpation over its attachment to the thighbone (femur) proximally, at its mid-substance, or distally over the shin bone (tibia) depending on the location of injury. The pain may also be reproduced by stressing the knee with a force applied to the outside aspect of the knee (“valgus force”), attempting to widen the inner aspect of the joint and stress the MCL. While a valgus force is applied, the inner aspect of the joint line can be palpated – widening that is 5 to 10mm greater than the normal, uninjured knee is significant for MCL injury. Swelling over the torn ligament may appear, and bruising or general swelling of the joint is not uncommon. In more severe injuries, patients may complain that the knee is unstable and feel as though their knee may ‘give out’ or buckle.
Based on physical examination, MCL injuries are graded in severity on a scale of I to III.
Grade I injuries are incomplete tears of the MCL. The ligament is still intact but stretched, and the symptoms are mild. Patients usually complain of pain with palpation of the MCL.
A grade II MCL tear is a partial or incomplete tear. There is significant pain with valgus stress of the knee and palpation along the medial aspect on the knee over the ligament. Athletes with these tears often complain of knee pain or instability when attempting to cut or pivot.
Grade III tears are complete tears of the MCL. These athletes have significant pain along the medial aspect of the knee. Even deep bending of the knee is uncomfortable. These tears often occur in combination with other injuries in the knee, and complaints of “giving out” or instability with walking, running, or pivoting is common. A knee brace or a knee immobilizer is usually needed for comfort.
What is the role for imaging studies with an MCL tear in athletes?
Plain radiographs can sometimes be helpful with MCL injuries. When the ligament has torn off the thigh bone (“femoral side”), it often tears with a piece of bone that is visible on x-ray. With old or recurrent injuries to the femoral side of the MCL, calcification at its origin can develop – this has been termed the “Pellegrieni-Stieda” lesion. Under most circumstances, however, plain radiographs are most helpful in ruling out associated fractures with MCL injury.
MRI is the imaging study of choice to diagnose MCL tears. Injuries are readily identified on a “T2 sequence” that shows loss of continuity of the ligament and surrounding blood and fluid from the injury. The MRI will also localize the injury to the ligament to be proximal at the femur, in its mid-substance, or distally at the tibia.
How are MCL injuries in athletes treated?
Treatment of an isolated MCL injury in an athlete rarely requires surgical intervention. Usually rest and anti-inflammatory medications followed by rehabilitation will allow patients to resume their previous level of activity. All MCL injuries, however, are not created equal. Therefore, the time for an athlete to return-to-play is highly variable and dependent on the severity of the injury.
Grade I injuries usually resolve without complication. They are typically managed with rest, ice, and nonsteroidal anti-inflammatory medications until the knee is pain-free to examination or routine activities. Most athletes with a grade I MCL tear will be able to return to their sport within 1-2 weeks following their injury.
When a grade II MCL tear occurs, a hinged knee brace is commonly used to protect the knee from valgus forces. Nonoperative treatment also ensues with icing, nonsteroidal medications, and controlled rehabilitation. Athletes with a grade II injury can return to activity once they are not having pain to palpation or stressing of the MCL with a valgus force. Athletes can often return to sports within 3-4 weeks after their injury, but may remain in a protective hinged brace with contact sports.
When a grade III injury occurs, the pain usually significant in the acute post-injury period. Athletes usually require a hinged brace locked in extension and crutches to protect against weightbearing for 1 to 2 weeks. As the pain resolves, the brace can be unlocked to allow range-of-motion as tolerated. Gradual weightbearing can be initiated as well. Once the athlete can comfortably flex the knee to 100 degrees, elliptical and stationary bicycle riding can begin. Light running can begin once the athlete has regained their quadriceps strength compared to the opposite side, and sporting activity can follow as long as the athlete remains pain-free. Complete rehabilitation from a grade III MCL tear can range from 6 weeks to 4 months.
More Information: Read about sports injury treatment using the P.R.I.C.E. principle – Protection, Rest, Icing, Compression, Elevation.
Does an MCL tear require surgery in athletes?
Most MCL tears of the knee do not require surgery and will heal with time and rehabilitation. However, some severe Grade III MCL tears will not heal and residual instability with “opening of the joint” to stress on the outside aspect of the joint (“valgus force”) can persist. These type of MCL injuries are frequently seen in combination with associated ACL tears or high-energy, knee dislocation injuries. Rarely, the ligament stump can retract and become trapped within the joint. When this is seen on MRI, surgical intervention and repair is usually required to restore the normal anatomy. Consultation with a sports medicine doctor is important to examine and monitor the progress of a healing MCL injury. If surgery is required, a ligament repair with or without reconstruction with a tendon graft may be performed depending on the location and severity of the injury.
What about platelet-rich plasma (PRP) injections for MCL injury in an athlete?
PRP injections have been increasingly utilized in the treatment of various soft tissue injuries at athletes. It is thought that the isolated “healing factors” from the athlete’s own blood may accelerate or stimulate healing at the site of injury. This treatment was used in the treatment of Hines Ward’s MCL injury during football season. While this treatment may prove to be effective, studies are currently in progress to evaluate its efficacy.
If you suspect that you have a medial collateral ligament injury – an MCL tear, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care. To locate a top doctor or physical therapist in your area, please visit our Find a Sports Medicine Doctor or Physical Therapist Near You section.

PCL Tear (Posterior Cruciate Ligament)

The anterior cruciate ligament (ACL)

The PCL (posterior cruciate ligament) although not as well known as it’s close neighbor the ACL (anterior cruciate ligament) is a surprisingly commonly injured structured.

What is the relevant anatomy and function of the PCL?

The PCL is one of the two major ligaments crossing (hence the term cruciate) in the center of the knee. It connects on the thigh bone (femur) at the front of the knee and attaches to the lower leg bone (tibia) at the back of the knee. The “posterior” in PCL refers to it’s insertion on the back of the tibia. Although it appears as a single large ligament, on close inspection, there are normally 2 described bundles that the ligament is comprised of. These 2 bundles seem to have differing points of maximum tension during knee range of motion. This has implications on the technique of reconstructing the PCL. There are also 2 smaller ligaments associated with the PCL known as the meniscofemoral ligaments because they attach between the thigh bone (femur) where the PCL does and the menisci (shock absorbing tough cartilage located within the knee joint). These somewhat variable structures provide significant additional strength to the function of the PCL.

The PCL is an extremely strong ligament and is in fact 1.5 times the size of the more commonly discussed ACL. The main role of the PCL is to keep the ends of the 2 bones of the knee (tibia and femur) centered on each other during normal knee activities. Specifically, the PCL resists backwards motion of the lower leg. Unlike the ACL, which is mainly functional during certain high risk athletic activities, the PCL is important and is functioning almost all the time even during simple walking.

What else may be injured along with a PCL tear?

A PCL tear may occur in isolation, however worse injuries and those that often involve a twisting motion during the injury can damage other structures within the knee. The most important of this involves tearing other ligaments in the knee, such as the ACL or the outside (lateral) ligaments of the knee. When this occurs, the injury is no longer considered an isolated PCL tear and has a much higher chance of requiring advanced surgical treatment.

Who most commonly suffers a PCL tear?

An athlete in almost any sports is susceptible to a PCL tear especially if it’s one where there is a risk of contact to their lower leg. Common examples would include soccer, rugby and most frequently football. In fact 2% of all NFL combine attendees have evidence of a PCL tear at some point in the past. There are an estimated 20 PCL injuries each season in the NFL. They more commonly occur during game competition. The great majority of these injuries do no require surgery to reconstruct the knee. Similarly, PCL tears make up about 5% of all knee injuries in rugby.

Just in the past year many notable NFL athletes have had a PCL tear such as Reggie Bush of the New Orlean’s Saints and Felix Jones of the Dallas Cowboys neither of whom required surgery. On the other hand, San Diego Chargers outside linebacker Shawne Merriman sustained a PCL injury complicated by an associated lateral (outside of the knee) ligament injury that he was unable to play with and had to undergo extensive surgical treatment on.


How is a PCL tear diagnosed?

An athlete will describe a history of being struck on the front of the lower leg, falling directly onto the knee with the knee bent or a hyperextension injury as described previously. Often an experienced athletic trainer who is present at the injured athlete’s practice or competition will recognize the mechanism of injury as it occurs. Unlike with an (ACL injury, during a PCL tear there is usually no audible “pop” heard.

Immediately following the injury, there will be swelling in the knee (effusion) from bleeding into the knee from torn blood vessels in the injured ligament. The acute injury will be painful and the patient may hold their knee slightly bent for comfort. The pain experienced may also be in the back of the knee depending on the location of the tear. In the case of an older tear that occurred long prior to evaluation, the patient may complain of instability, or a sensation of the knee giving away. They may also complain of pain which can be in the front of the knee as well.

Immediately following the injury, there will be swelling in the knee (effusion) from bleeding into the knee from torn blood vessels in the injured ligament. The acute injury will be painful and the patient may hold their knee slightly bent for comfort. The pain experienced may also be in the back of the knee depending on the location of the tear. In the case of an older tear that occurred long prior to evaluation, the patient may complain of instability, or a sensation of the knee giving away. They may also complain of pain which can be in the front of the knee as well.

When examined, the hallmark of a PCL tear is that the lower leg (tibia) sags backwards with respect to the end of the thigh bone (femur). How much the tibia sags depends on the severity of the injury and has major implications in treatment as will be discussed below. There may also be evidence of further instability if other ligaments are injured as seen in more severe injuries. This may cause abnormal rotation of the knee on exam in a plane corresponding to the additionally injured structures. If an ACL injury is present as well, then the tibia will be loose when pulled forward (Lachman test).

How is a PCL tear classified?

A PCL tear is classified in a couple different ways. One simple way is to describe them as either an isolated PCL tear, where only the PCL is injured, or as a combined ligament injury. A combined ligament injury would involve a tear of the PCL and at least one other injured ligament. A common example would be a PCL and lateral-sided ligament injury as occurred with Shawne Merriman.

Injuries to the PCL can also be graded as I, II or III. Grade I and II injuries are partial PCL tears. Grade I refers to only a few mm of sag of the tibia backwards while Grade II injuries refer to sagging of the tibia to the level flush with the end of the thigh bone (femur). This roughly corresponds to 1 cm of backwards sag. A grade III injury signifies a complete rupture and the tibia sags backwards even further. It is likely that when a grade III injury occurs, there are other ligaments torn along with the PCL. It is important to scrutinize the type of PCL injury an athlete sustains because there are significant treatment implications, especially for a Grade III or combined ligament injury.


What causes a PCL tear?

A PCL tear occur when a direct blow to the front of the knee or leg just below the knee (tibia) creates a large sudden force directed backwards. This puts a significant amount of stress on the PCL. The stress in the ligament is even higher when the knee is flexed (bent) closed to 90°. The posterior cruciate ligament then stretches to the point of mechanical failure which is considered a tear. This can happen when someone is tackled in football below the knee from the front or when someone in any sport lands forcefully directly onto their knee with their knee simultaneously bent. The PCL can also tear in this manner when in a head-on motor vehicle collision the vehicle’s dashboard strikes directly against the knee.

Sometimes the PCL can be stretched and subsequently torn by forceful hyperextension (bending backwards beyond straight) occurring to the athlete’s knee. This may occur when, in football, a player is hit on the legs just below the knee from the front and their knee hyperextends because their foot is firmly planted in the playing surface. This mechanism, especially when the knee twists during the injury, can lead to tearing of other important knee structures beyond simply the PCL.

Initially, sports injury treatment using the P.R.I.C.E. principle – Protection, Rest, Icing, Compression, Elevation can be applied to a PCL tear.

What is a typical treatment algorithm for a PCL injury?

A partial PCL tear, grade I and II, are typically treated non-operatively with a long course of intensive physical therapy to strengthen the surrounding muscles controlling the knee. Complete PCL tears often require surgical treatment to regain knee stability. When the PCL pulls off a small piece of bone from the back of the lower leg (tibial avulsion), the PCL may be surgically repaired. If the bone fragment is large enough a screw can be place to secure the piece of avulsed bone back to where it was originally. However in the majority of PCL injuries, the ligament tears in the middle of the structure. In this case, the PCL must be reconstructed which refers to replacing the entire ligament with what is known as a graft.

How is the treatment different for a PCL tear when there are other injuries present as well?

When a combined ligament injury is present, the treatment is almost always surgical. All injured structures that do not heal must be addressed at surgery, otherwise the PCL reconstruction will be at a high risk of failing once the athlete returns to sports participation. In this circumstance it is important that the injured athlete be evaluated by a sports medicine trained orthopaedic specialist as surgical treatment of these injuries can be highly complex and pose significant risk to major nerves and arteries around the knee.

What imaging tests are useful to help diagnose and differentiate a PCL tear?

Standard knee radiographs are always important to obtain. These are needed to rule out fractures and look for evidence of other injuries that may be present. When a PCL injury is longstanding, present for years, there is a propensity for the knee to develop arthritis. This is especially the case beneath the knee cap (patellofemoral joint) and on the inside of the knee (medial side). Xrays can see narrowing of a joint and bone spurs that are indicative of arthritis associated with an old PCL injury. Sometimes obtaining a side xray (lateral view) with a backwards force on the lower leg, known as posterior stress views, is useful to quantify the amount of backwards sag. This can sometimes help grade the injury more accurately.

An MRI is useful to evaluate the ligamentous structures of the knee, not just the PCL. It can also evaluate the menisci and the cartilage surfaces of the knee for arthritis. When a PCL injury has just occurred, the PCL will look torn on the MRI. However the PCL has a remarkable ability to heal itself and the farther out from the injury an MRI is performed, the less remarkable the PCL will appear on the MRI. In fact an old PCL injury that occurred months or years ago may show up as normal on an MRI despite clear evidence of a PCL injury on clinical exam.

What is non-operative treatment for a PCL tear?

Non-operative treatment of a partial PCL tear involves a period of immobilization of the knee followed by intensive treatment by a skilled physical therapist. A short period of immobilization of the knee in a brace or even sometimes a cast may be necessary to allow the PCL to heal first. Early emphasis in physical therapy is on reducing knee swelling and obtaining full knee range of motion. Following this, the focus of physical therapy becomes strengthening the surrounding musculature of the knee which provide dynamic stabilization. Most importantly is quadriceps strengthening because they pull the tibia in a forward (anterior) direction and therefore counteract the backwards sag of the tibia seen when a PCL is torn. Also, core and hip stabilization are important to regain maximum control over the entire lower extremity. This also helps develops this muscular control for their sport and maximize athletic performance. In many cases, an injured athlete can return to sports participation in about 4 – 6 weeks although this may be shorter or longer depending on how severe the injury is and how well the athlete responds to therapy.

What is operative treatment for an isolated PCL tear?

In most cases of a complete PCL injury surgical treatment is performed. Most commonly this requires removal of the torn ligament and a new ligament to be reconstructed in the old ligament’s place. The new ligament graft can be from many sources, however most commonly it is an allograft (tissue graft from a cadaveric donor). Which specific allograft tissue is up to the discretion of the operating surgeon and may be taken from one of various tendons of the ankle or from the quadriceps tendon at the knee. Then the injured PCL is removed with the help of the arthroscope (small camera) using a few very small incisions. Any other associated cartilage and meniscus injury can be treated at the same time. Then a tunnel is created in the end of the thigh bone (femur) where the PCL attaches. The bone where the PCL attaches to the back of the lower leg (tibia) is also prepared to receive the graft. The new PCL graft is then connected the bone at each end with one of various fixation devices (screws or staples) and therefore recreates the PCL. Because much of the surgery for a PCL reconstruction is performed in the back of the knee, there is a greater risk of a nerve or blood vessel injury than in most knee surgeries. It is important that an athlete is checked both during and after surgery that damage to one of these important structures did not occur.

There are some hotly debated controversies in PCL reconstruction. These involve whether a single large graft or a double-bundle graft with 2 smaller limbs should be used. There is some evidence the double-bundle graft may be mechanically stronger. However, there has been no clinical evidence that patients do better with one versus the other.

Another, controversy involves how the graft is attached to the back of the tibia. One technique involves performing the surgery almost entirely through the small incisions with the help of the arthroscope. The other technique (tibial inlay) involves making a larger incision at the back of the knee and directly attaching the new PCL graft at that point. There is some evidence that performing the surgery in this manner is more mechanically advantageous to the graft. The graft might not be stretched as much and may have a lower rate of failing. The ideal technique of PCL reconstruction may vary somewhat on a case by case basis and therefore would normally be discussed with the treating sports medicine surgeon.

What is the typical recovery from an operatively treated PCL injury?

Recovery following surgical treatment of a PCL tear requires a long course of physical therapy. Initial treatment focuses on regaining range of motion and decreasing the swelling in and around the knee. Early quadriceps retraining is very important to regain control of the knee. Then over the course of months the rehab is progressed to a functional program with a goal of returning an athlete to their sport. This often takes 6 months to a year of rehab. Early on in returning to sports participation, an athlete may wear a protective brace although for how long is determined by the surgeon who performs the surgical reconstruction.

If you suspect that you have a PCL tear, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care. To locate a top doctor or physical therapist in your area, please visit our Find a Sports Medicine Doctor or Physical Therapist Near You section.

Meniscus Tear – Causes, Symptoms, and Treatment

The anterior cruciate ligament (ACL)

What are the menisci?
The menisci are pieces of cartilage in the knee that play a vital role in athletes. They are two C-shaped structures that lie between the femur and tibia on the inside (“medial”) and outside (“lateral”) aspects of the knee. They predominantly consist of water and collagen fibers. Historically, the function of the menisci was unclear, and some even considered them to be vestigial remnants of embryonic tissue like the appendix. For this reason, complete excision of the meniscus (“total meniscectomy”) was not infrequently performed in the setting a symptomatic meniscus tear . Unfortunately, total meniscectomy in young patients has been shown to dramatically accelerate degenerative wear in the knee. Furthermore, various critical functions of the menisci to the maintenance of knee health have been well-established. These include:

Load Tranmission – the menisci are responsible for transmitting between 50% to 70% of the loads across the knee joint. In their absence, these loads are directly transmitted to the articular cartilage on the ends of the bones.
• Joint Stability – the menisci are secondary stabilizers of the knee in many planes, and become the primary stabilizer for front-to-back (“anteroposterior”) motion of the knee when the athlete suffers a anterior cruciate ligament (torn ACL).
• Shock Absorption
• Joint Lubrication and Nutrition
What is the anatomy of the menisci?

The menisci are “wedge-shaped” pieces of cartilage that rest between the thigh bone (“femur”) and lower leg bone (“tibia”) in the knee joint. There are two menisci, a medial one on the “inside” of the knee and a lateral one on the “outside” of the knee. The medial meniscus is C-shaped, while the lateral meniscus is more semicircular in shape. Both rest on the tibial surface and are anchored to the bone at the front and back of the plateau (“meniscus roots”).
Each meniscus can be divided into portions based on (i) location within the knee, or (ii) blood supply. By location, the meniscus can be divided into a (i) posterior horn, (ii) body, and (iii) anterior horn. These terms are helpful to describe the location of meniscus tears. Tears in the posterior horn are the most common.
The blood supply of the meniscus comes from the periphery where it attaches to the lining of the knee joint (“capsule”). For this reason, the peripheral one-third of the menisci are generally well-perfused, while the inner aspects have a more limited blood supply and correspondingly limited potential for healing. These different locations moving from peripheral-to-central have been termed the “red-red”, “red-white”, and “white-white” zones. This classification becomes important when evaluating meniscus tears and considering their capacity for healing after a meniscus surgery.

What is a meniscus tear in athletes?

A Meniscus tear is among the most common orthopaedic injury and has been colloquially referred to as “torn cartilage” in the knee. They have affected athletes of virtually every sport. While they are most commonly seen in the posterior horn, they can occur in any location and affect either the medial side, lateral side, or both.
In athletes, a meniscus tear usually is a traumatic origin. They result or abnormally high forces that fail the substance of the meniscus. While these are often the result of forceful twisting or pivoting movements, they can also occur with seemingly innocuous activities such as squatting or jogging. From baseball catchers to professional defensive lineman, virtually every sport and position player has been affected by this injury. Some names you will recognize include Osi Umeniyora, Johan Santana, Sedrick Ellis, and Shawne Merriman – all have battled meniscus tears in their athletic career.
In older patients, a meniscus tear may not be of traumatic origin but rather part of degenerative changes in the knee. These tears are often accompanied by some arthritic changes in the knee and are referred to as “degenerative” tears.
How is a meniscus tear classified?

A Meniscus tear can be classified in various ways – by anatomic location, by proximity to blood supply, etc. Various tear patterns and configurations have been described. These include:
• Radial tears
• Flap or Parrot-beak tears
• Peripheral, longitudinal tears
• Bucket-handle tears
• Horizontal cleavage tears
• Complex, degenerative tears
These tears can then further classified by their proximity to meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.
The functional importance of these classifications, however, is to ultimately determine whether a meniscus is REPAIRABLE. Given the critically important functions of the meniscus in athletes, it should be preserved and repaired whenever possible. The repairability of a meniscus is dependent upon a number of factors. These include:
• Age
• Activity Level
• Tear Pattern
• Chronicity of the tear
• Associated Injuries (Anterior Cruciate Ligament Injury)
• Healing Potential
What injuries can accompany a meniscus tear in athletes?

While a meniscus tear can certainly occur in isolation, they are often accompanied by other injuries in the knee as well. In the setting of high-energy trauma, associated fractures of the proximal tibia (“tibial plateau”) can occur. Meniscus tears have been reported to be as common as 50% with these fractures.
A meniscus tear often accompany tears of the anterior cruciate and/or collateral ligaments as well. The posterior horn of the medial meniscus is the secondary stabilizer to anteroposterior translation of the joint, and therefore becomes particularly vulnerable to injury with deficiency of the anterior cruciate ligament (the primary anteroposterior stabilizer of the joint).
How does a meniscus tear present in athletes?

A meniscus tear can present in various ways. Sometimes a “popping” sensation is experienced by the athlete during a traumatic event. There is usually significant pain along the joint line on the side of the tear (medial or lateral). Sometimes the athletes can continue to walk on the knee, while other large tears may cause too much pain to allow for weightbearing. Sometimes the tear pattern can cause a portion of the meniscus to become entrapped between the joint surfaces or within the notch of the knee. In these cases, the knee is often locked and the athlete cannot flex or extend the knee. The classic signs to look for with a meniscus tear include:
• Pain, often along the joint line of the knee
• Swelling (“effusion” in the joint) often develops due to inflammation and/or bleeding from the injury
• Inability to fully extend or flex the knee without discomfort
• Locking or catching of the knee
• Weakness of the leg, particularly the quadriceps muscle. This may be evident when trying to perform a straight leg raise or walk up and down stairs.
In addition to examining for the above signs and symptoms, a physician may check the athlete’s ability to squat on the knee without discomfort. They doctor may also perform a McMurray’ Test in which the knee is bent, straightened, and rotated in an attempt to entrap the meniscus tear within the joint. If you have a meniscus tear, this movement may reproduce clicking and pain.

What imaging studies help to confirm the presence of a meniscus tear?

Plain x-rays (radiographs) of the knee can be useful to evaluate for the presence of associated injuries such as tibial plateau fractures or ligament avulsions. They will not, however, confirm or rule out the presence of a meniscus tear.
Magnetic resonance imaging (MRI) of the knee has become the gold standard of imaging studies for a meniscus tear. These high-resolution pictures from multiple perspectives allow for a greater than 95% sensitivity in detecting a meniscus tear. Furthermore, they provide valuable information regarding the tear pattern and configuration to help preoperative planning and assessment of the repairability of the tear.
MRI of the knee not only helps to define the tear, but allows for evaluation of the other important anatomical structures of the knee. The status of the collateral and cruciate ligaments, as well as the cartilage surfaces of the joint can be carefully evaluated to help design the best treatment plan.
How is a meniscus tear in athletes treated?

With this increased appreciation of meniscus function, surgical techniques have focused on preservation and repair whenever possible in athletes. Arthroscopy has allowed for various repair strategies with minimal invasion and excellent visualization. However, the tear pattern must be repairable and the tissue have the ability to heal for a repair to be successful. In addition, the age of the athlete, expectations, and associated injuries must be considered as well. For this reason, no definitive set of guidelines can be provided for determining which tears should not be treated, which should be repaired, or which should be partially excised (“partial meniscectomy”). However, some good general principles include:
• Rim width is the most important prognostic criteria for healing after meniscus repair. Therefore, peripheral, longitudinal tears within 3-mm (“red-red” vascular zone) of the meniscocapsular junction should be repaired. Longitudinal tears within 3 to 6-mm width (red-white zone) have less predictable success, but should still be considered for repair in younger patients.
• Tears more than 6-mm from the peripheral blood supply are generally avascular and are not suitable for repair.
• Acute, traumatic tears have an improved prognosis for healing compared to chronic, degenerative lesions.
• Longitudinal tears are more amenable to repair than the flap, horizontal cleavage, or complex degenerative patterns.
• The management of the radial tear is controversial. Large radial tears extending to the periphery are technically easy to repair and should be considered for repair in young patients to restore hoop stresses and load transmission function of the meniscus.
• Age should not be used as an absolute criteria for determining the feasibility of repair. While younger patients have a more favorable prognosis, successful healing has been reported in older patients.
• Higher rates of failure have been noted in the setting of unstable knees secondary to excessive shear forces that prevent healing. Therefore, an insufficient anterior cruciate ligament (ACL) should be reconstructed at the time of meniscus repair. Reconstruction of the ACL at the time of meniscus repair has been associated with a more favorable rate of meniscus healing.
• Partial thickness tears that are shallow and stable (<3mm depth and <1cm length) generally heal spontaneously. Unstable partial thickness tears, however, should be repaired.
What is involved with meniscus surgery in athletes?

If a meniscus tear is symptomatic and limiting the ability of an athlete to return to play, it is typically addressed with surgery. The vast majority of meniscus surgery can be performed arthroscopically through small incisions in the skin. The camera is used to carefully visualize and define the tear pattern.
For irreparable tears, the torn fragments are typically excised and the residual meniscus smoothly contoured. Care is taken to preserve as much stable tissue as possible to retain the important load transmitting functions of the meniscus. For repairable tears, instruments are introduced to freshen the torn edges, line them up (“reduce” the tear), and suture the tear. Various techniques to suture the meniscus tear edges have been described. These fall into the general categories of repairing the tear from entirely within the joint (“all-inside”), from inside to out of the joint (“inside-out” repair), or from outside to in the joint (“outside-in”). Each technique has its associated strengths and limitations. Regardless of which is utilized, however, the ultimate goal is a well-reduced meniscus and secure repair across the torn edges.
If the blood supply to the olocation of the tear is tenuous, augmentation with substances to promote healing may be considered. Fibrin clot has been used with some efficacy in this regard. Platelet rich plasma augmentation at the site of the tear may be beneficial, and studies are currently in progress to evaluate its effects on meniscus healing.
What is involved in the recovery for athletes after meniscus surgery, and when can I get back to play?

The recovery program for your knee after meniscus surgery is highly dependent upon the specific procedure performed as well as the specific nature of your tear. Your expectations and sport must be considered as well.
In general, partial meniscectomy for irreparable tears will allow for a more rapid recovery than meniscus repair surgery. This is because the interval time to allow for tissue healing is not required. After partial meniscectomy, weightbearing is gradually allowed as tolerated and exercises are initiated promptly to achieve full range-of-motion of the knee. Strengthening exercises are subsequently initiated. While time to return to sports is variable, a goal of 3 to 4 months is generally feasible.
For meniscus surgery, a period of non-weightbearing and restricted range-of-motion is usually implemented postoperatively to optimize the environment for healing of the tissues. A range-of-motion and strengthening program is subsequently implemented. In general, a goal of 6 months to return to play is typical, but can be much longer depending upon tear severity and functional goals.
Some helpful principles of meniscus repair rehabilitation include:
• The effect of tear configuration and knee range-of-motion on meniscus healing guide rehabilitation.
• Compressive loads on peripheral longitudinal tears with knee in extension typically reduce the tear edges.
• Compressive loads on peripheral longitudinal tears in flexion displace the posterior horn and tear edges.
• The menisci translates posteriorly with knee flexion, but minimally from 0 to 60 degrees. The lateral demonstrates more translation than the medial meniscus.

Some typical protocols for meniscus surgery repair are:
Peripheral, longitudinal tears: Hinged knee brace postoperatively locked in extension for 3-4 weeks. Partial weightbearing for 4 weeks with the brace locked in extension. Advance range-of-motion and weightbearing over 3-6 weeks. Sport-specific training and strengthening at 6-8 weeks. No running for 4 months.
Radial tears/Complex tears: Hinged knee brace postoperatively is locked in extension for 3-4 weeks. Toe-touch weightbearing for 4 weeks with the brace locked in extension. Range-of-motion and weightbearing are gradually advanced in the brace at 4-6 weeks.
If you suspect that you have a meniscus tear, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care. To locate a top doctor or physical therapist in your area, please visit our Find a Sports Medicine Doctor or Physical Therapist Near You section.

Torn ACL (Anterior Cruciate Ligament)

The anterior cruciate ligament (ACL)

The anterior cruciate ligament (ACL) is one of the four major ligaments that connect the bones of the knee joint. The ACL ligament helps to hold the bones in proper alignment and help control the way your knee moves. The ACL provides stability to the knee and prevents excessive forward movement of the lower leg bone (tibia) in relation to the thigh bone (femur).

What causes a torn ACL?

A torn ACL can be grouped into two categories: contact and non-contact. An example of non contact injuries would be when an athlete rapidly decelerates, followed by a sharp or sudden change in direction (cutting). Noncontact torn ACL injuries have also been linked to heavy or stiff-legged landing as well as twisting or turning the knee while landing, especially when the knee is in the valgus (knock-knee) position. Contact injuries most common occur after a blow to the outside of the leg causing the knee to “buckle” and assume a valgus position.

How is a torn ACL classified?
Most clinicians describe a torn ACL as either partial or complete. This is based on physical examination and imaging findings (discussed later).
Do women really tear their ACLs more than men?
Women in sports such as soccer, basketball, tennis and volleyball are significantly more prone to a torn ACL than men. The discrepancy has been attributed to differences between the sexes in anatomy, general muscular strength, reaction time of muscle contraction and coordination, and training techniques. Hormonal causes have also been investigated although it is still unclear what role they may play in a ACL tear if any. Lastly, women have a relatively wider pelvis, requiring the femur to angle toward the knees (knock knee) which may also be a predisposing factor towards a torn ACL.
How do I know if I have a torn ACL?
Patients who suffer an ACL injury often report hearing an audible pop followed by significant swelling. Afterwards, patients will may complain of instability of the knee (i.e., a “wobbly” feeling) especially when try to change directions during sporting activity. Continued athletic activity on a knee with an torn ACL can have devastating consequences, resulting in massive cartilage damage, leading to an increased risk of developing osteoarthritis later in life.
How will my doctor determine if I have a torn ACL?
Several diagnostic maneuvers help clinicians diagnose a torn ACL. In the anterior drawer test, the examiner applies an anterior force on the proximal tibia with the knee in 90 degrees of flexion(picture). The Lachman test is similar, but performed with the knee in only about twenty degrees of flexion, while the pivot-shift test adds a valgus (outside-in) force to the knee while it is moved from flexion to extension. The Lachman and anterior drawer asess purely for translation, whereas the pivot shift test assesses for rotational instability. Any abnormal motion in these maneuvers suggests a tear.
The diagnosis is confirmed by MRI (magnetic resonance imaging) which also is used to assess for other ligament, meniscus, and cartilage pathology.
Can some injuries be treated without ACL surgery?
Nonsurgical options may be used if the knee cartilage is undamaged, the knee proves to be stable during typical daily activities, and if the patient has no desire to ever again participate in high-risk activities (sports involving cutting, pivoting, or jumping). Nonsurgical treatment is typically only considered in cases of low grade partial injuries. If the nonsurgical option is recommended, the physician will recommend physical therapy, wearing a knee brace, and avoiding any provocative maneuvers. The goal of physical therapy is to strengthen the muscles around the knee to compensate for the absence of an ACL. Initially the goal of physical therapy is to restore range of motion; after a period of time, the physician will prescribe a strengthening program that focuses on the hamstrings first and and later the quadriceps, hip, and core musculature. Most ACL-deficient athletes conclude that their knee continues to feel unstable, again confirming the important role of the ACL in normal knee stability. Therefore, most orthopaedic surgeons recommend ACL surgery treatment in the athletic population because repetitive insults to the knee as a result of ACL deficiency often results in meniscal and cartilage injury. Such injuries can ultimately lead to persistent pain, disability, and premature osteoarthritis. However, initially, sports injury treatment using the P.R.I.C.E. principle – Protection, Rest, Icing, Compression, Elevation can be applied to a torn ACL.
What’s involved with ACL surgery?
There are two main options for ACL graft selection: autograft and allograft. Autografts are the patients’ own tissues, and the most common options include the middle third of the patella tendon and the hamstring tendons. Allografts are cadaveric tissue sourced from a tissue bank; the most common allograft tissue used for ACL reconstruction is Achilles tendon. Each method has its own advantages and disadvantages; patellar tendon autografts are the most common and often considered the gold standard for young highly competitive athletes. However, the site of the harvest is often painful for weeks after surgery and some patients can development tendinitis or generalized knee pain that can be difficult to recover from. Such complications are generally avoided when using hamstring autografts, although some clinicians feel hamstring reconstructions become loose over time. It should be noted that many clinicians used both with an extremely high success rate and their use is often surgeon preference or bias. ACL surgery reconstruction using allograft tissue does carry a slightly higher infection risk but patients often recover the fastest of all the graft choices. Although not recommended for young, extremely active athletes, allograft reconstruction is often a popular choice for the older more sedentary athlete. Many patients worry about the transmission of disease from the allograft itself; although this has been reported in the literature, most clinicians feel such risk is extremely low and feel very comfortable using allograft tissue.
The ACL surgery is performed arthroscopically, with tunnels drilled into the femur and tibia at the original of the ACL footprints. The graft is then placed into position and held in place. There are a variety of fixation devices available, particularly for hamstring tendon fixation. These include screws, buttons and post fixation devices. The graft typically attaches to the bone within six to eight weeks. The original collagen tissue in the graft acts as a scaffold and new collagen tissue is laid down in the graft with time.
What is double bundle ACL reconstruction and do I need it?
Since the native ACL consists of two bundles, some clinicians have advocated a double bundle reconstruction which places two separate grafts during surgery instead of just one. Although biomechanical studies have shown an advantage this technique, no clinical studies have demonstrated it to be superior than standard single graft techniques. Furthermore, it is unclear what the potential disadvantages of a double bundle technique are. Most clinicians still use a single graft approach with very high success. It is important to consult your surgeon to discuss what his/her preference is and why.
What will physical therapy be like after ACL surgery?
After ACL surgery, the knee joint loses flexibility, and the muscles around the knee and in the thigh tend to atrophy. All treatment options require extensive physical therapy to regain muscle strength around the knee and restore range of motion (ROM). For some patients, the lengthy rehabilitation period may be more difficult to deal with than the actual ACL surgery. External bracing is recommended for athletes in contact and collision sports for a period of time after reconstruction. It is important however to realize that many of the specific rehabilitation protocols are physician dependent. Generally speaking, most surgeons will prescribe a brace and crutches for post ACL surgery recovery for approximately one month. After that, a rehabilitation period of six months to a year is required to regain pre-surgery strength and use.
Rehab after ACL surgery can vary widely, but there are some general principles that are true for most patient having surgery for treatment of an ACL. Start strengthening exercises only after you have your health professional’s approval. The list below provides links to specific rehab ACL video exercises:
ACL Surgery Recovery. The Quad Set.
ACL Surgery Recovery. Adductor Squeeze.
ACL Surgery Recovery, Wall Squats
ACL Recovery, The Heel Slide

When can I return to athletics?
Most clinicians allow for a competitive return to sport at 6 to 7 months. Also, be sure to take a look at the SportsMD Video on proper icing of an ACL injury.
Proper Icing of the ACL. Ice is Nice!
Can a torn ACL be prevented?
Athletes can lower their risk of torn ACL by participating in performance drills that focus on improving lower extremity strength, agility, flexibility, and power. The Santa Monica ACL Prevention Project developed an ACL Injury Prevention Program specifically designed for female soccer players that can be applicable for all athletes both male and female.
Some videos on improving lower extremity strength are provided below.
Developing Balance for Stronger Knees
Hamstring Strength, Protect Your Knees!
Quad Strength, Protect Your Knees!
Lunges for Strong Knees

If you suspect that you have a torn ACL, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care. To locate a top doctor or physical therapist in your area, please visit our Find a Sports Medicine Doctor or Physical Therapist Near You section.