Anterior Cruciate Ligament (ACL) Injury
Clinical exam and weight-bearing X-rays (PA standing flexion - independent, AP weight-bearing - independent, lateral and skyline views)
Education is the key to help patients self-manage their symptoms and adapt their lifestyle to an Osteoarthritis (OA) diagnosis.
Promotion of general health and weight loss as well as exercise are mainstays in the management of knee OA. Weight reduction of 10% improves function by 28% in patients with knee OA.
Avoiding passive therapies and focusing on self-help and patient-driven treatments are approaches that have proven effective. Group and home exercise programs should be considered.
Hydrotherapy, aqua-fit or cycling should be recommended. Adherence to a program is the principal predictor of long-term outcome from exercise in patients with OA. It is therefore important to discuss patient likes and preferences when it comes to exercise. It is important to reassure patients that it is possible to remain active and relatively pain free despite a diagnosis of osteoarthritis. Many patients have minimal or no pain despite having arthritis.
The first line of treatment should be conservative measures including:
- Rest and/or activity modification
- Use of oral or topical NSAIDs and/or pain relief medication (opioids not recommended for arthritic pain)
- Physiotherapy and exercises
- Weight loss
- Compression sleeve (for compressive benefits)
- Unloader brace (patient needs a prescription identifying which knee compartment needs unloading)
- Shoe orthotics and supportive footwear
- Walking aid (cane, walker, walking poles); cane should be held in the opposite hand from the painful limb
- Cortisone injection, Viscosupplementation (in mild to moderate OA with effusion)
- If you do not give injections, please refer to a sports medicine doctor
- Physiotherapy can aid in the management of OA with:
- symptom management information and education
- gait analysis
- prescription and education about mobility aids as well as proper measurement
- develop a general strength, mobility and proprioception exercise program
The therapist might introduce yoga or tai-chi as well as other non-weight-bearing exercise options such as swimming, aqua-fit and cycling as well as a home exercise program.
Such an approach is proven to help with fall risk prevention.
Surgical treatment is considered if the conservative measures do not help with pain and function is compromised. The primary reasons to refer for a knee replacement is to relieve pain and improve quality of life. Depending on the patient’s wear pattern, the surgeon may choose to do an osteotomy, a lateral, medial or patella unicompartmental knee replacement or a total knee replacement.
Clinical exam, weight-bearing X-Ray (to r/o fracture) and MRI (to confirm and help plan for surgery)
An X-ray at the time of injury is often recommended to ensure there are no associated fractures.
X-rays for older patients with torn ACLs are a good idea to identify how much OA is present. This can help determine their surgical treatment, if needed. (e.g.: TKA vs ACL reconstruction)
The decision on whether surgery is necessary will depend on the function of the knee and patient’s activity level and goals. Not all ACL tears require surgery, but rehabilitation is needed after most ACL injuries whether surgery is necessary or not.
Surgical referral criteria:
- Complete ACL tear or a partial tear with a very unstable knee
- Trial of a rehab program and the knee remains unstable
- Active in sports or have a physical job that requires knee stability (such as construction work, police work, firefighting, military)
- Willing to commit to a long and demanding rehabilitation program
- Knee instability that affects quality of life
- Other injured structures in the knee (meniscus or cartilage, other ligaments)
However, it is possible that regular, progressive and guided rehabilitation can allow a person to resume high-level activities and “cope” with such an injury without having surgery.
is chosen when:
- There is an incomplete tear in the ACL
- Patient lifestyle is sedentary, and occupation does not require a stable knee
- Patient is willing to stop doing activities that require a stable knee (dancing, skiing, hockey)
- Patient’s knee feels stable and doesn’t buckle or give out despite having a significant ACL tear (some patients have no knee instability despite having a completely torn ACL)
- Patient chooses to follow a rehab program that will help strengthen and stabilize the knee to reduce the chances of re-injury and is willing to live with a small amount of knee instability
- Patient not motivated or willing to complete a long and demanding rehab process after surgery
- Health issues that are a contraindication to surgery
- Aggressive management of the hemarthrosis
- Pain control medication – Acetaminophen/Tylenol
- Immobilization in a Zimmer for 1-2 weeks and crutches until muscular control is restored
Non-surgical treatment will usually involve physiotherapy and is most successful if therapy is initiated early (in the first 90 days) after ACL injury.
The rehabilitation program will have a goal of restoring strength and function and should include some low-impact cardiovascular exercise (swimming, cycling), range of motion exercises to gain as much movement of the knee as possible, quadriceps and hamstring strengthening exercises, and proprioception. If the patient is an athlete, there will be a sport-specific component to the rehabilitation program. If the knee remains unstable despite rehabilitation it might be necessary for the patient to wear a brace for activity.
Current research shows that patients who follow a pre-operative rehabilitation program that primarily focuses on gluteal, hamstring and quadriceps strength as well as neuromuscular function will show improved outcomes 2 years post ACL reconstruction.
Surgery involves ligament grafting, and this is usually done through an arthroscopic approach. Post-surgery, the patient may need to wear a brace for physical activity and will usually require a 6-12 month structured, progressive, rigorous rehabilitation program
Following an ACL injury … REGARDLESS OF WHETHER SURGERY IS PERFORMED OR NOT, IT IS ESSENTIAL TO REGAIN FULL KNEE EXTENSION (STRAIGHTENING) AFTER THE INJURY. A KNEE THAT DOES NOT STRAIGHTEN FULLY WILL NOT FUNCTION NORMALLY AND WILL DEVELOP ARTHRITIS AT AN ACCELERATED RATE.
Osteonecrosis/Avascular Necrosis/SONK of the Knee
Weight-bearing X-ray to rule-out arthritis (PA standing flexion - independent, AP weight-bearing - independent, lateral and skyline views)
If a weight-bearing X-ray shows more than mild arthritis, an MRI is not needed because it will likely show a meniscal tear. The majority of patients with knee arthritis also have meniscus tears, but for the vast majority of these patients the arthritis is the cause of pain and not the meniscus tear.
An MRI may be useful to look for other causes of pain if there is minimal or no sign of arthritis.
Most often small tears do not require surgery and will stop hurting after 6 months.
- Rest/activity modification
- Ice (for first 48-72 hours)
- Compression (knee sleeve)
- Physiotherapy (typically up to 6-8 weeks of treatment)
- Oral or topical NSAID medications and/or pain relief medication
IT IS ESSENTIAL TO REGAIN FULL KNEE STRAIGHTENING (EXTENSION) AND TO REGAIN AS MUCH BENDING (FLEXION) AS POSSIBLE AFTER THE INJURY. STIFF KNEES DO NOT FUNCTION NORMALLY AND DEVELOP ARTHRITIS AT AN ACCELERATED RATE.
Indications for surgical treatment of a torn meniscus include:
- A displaced meniscus tear especially if the displaced piece is blocking the knee from straightening or bending fully – this is called a “locked knee”. If the patient has a displaced meniscus tear which is interfering with knee motion, then surgery is usually performed within a few days to weeks in order to restore knee motion
- Intermittent “locking” where the knee is temporarily unable to straighten of bend fully when the torn meniscus moves out of position. The knee “unlocks” when the piece moves back into correct position however it can “lock” again if the piece moves out of position in the future.
- Pain at the joint line corresponding to the meniscus tear despite an attempt at conservative treatment
When moderate or severe knee arthritis is present:
- Arthroscopy to address a DISPLACED tear may be helpful
- Arthroscopy to address an UNDISPLACED meniscus tear is unlikely to help because the pain is very likely coming from the arthritis and not the torn meniscus
- Arthroscopy to address the meniscus tear may worsen arthritis pain in some patients
- Arthroscopy to address the meniscus tear should be performed only after a minimum 6 months of conservative treatment (except for a locked knee – see above) with the understanding that knee pain may not improve
If the patient has meniscal tears and moderate to severe arthritis, knee replacement is the treatment (see above under “arthritis”).
A meniscectomy or meniscal repair are the surgical options.
Recovery may take 4-8 weeks with return to sports being possible for most patients within 8 weeks after surgery.
Meniscus repair is only possible for some patients. For it to be considered, the tear must be in the portion of the meniscus that has a good blood supply (outer 1/3) and the torn piece must be relatively undamaged. No weight-bearing is allowed for 4-8 weeks after a meniscus repair and the patient may be asked to use a splint during this time. After a meniscus repair the patient will usually not be allowed to run, jump or do deep squats for 4 months. Return to sports is usually possible at 6 months to one year following surgery.
Patello-Femoral Syndrome (PFS)
Weight-bearing X-ray (PA standing flexion - independent, AP weight-bearing - independent, lateral and skyline views) and/or bone scan
The condition may cause pain for months. It is usually a slowly progressing disease. In some cases, the pain may stop without surgery over time
In early stages of osteonecrosis, non-surgical treatment is tried first. This includes:
- Pain relief medication
- Use of crutches or brace
- Rest and/or activity modification
If this is not helpful with pain relief and improving function, a referral to Central Intake is indicated.
- Young or very active patients may benefit from debridement of the necrotic region with removal of loose fragments and possibly drilling of the necrotic bone to stimulate blood flow (core decompression)
- Older patients with underlying osteoarthritis may benefit from a partial or total knee replacement
A conservative treatment
approach is generally very effective:
- Rest and/or activity modification
- it is essential not to “push through” patellar pain
- aggravating exercises and activities should be stopped until the pain improves and then restarted gradually
- non-aggravating aerobic exercises can be helpful
- if stationary biking is painful encourage patients to try an elliptical – it may feel better because there is less knee bending required
- Oral or topical NSAIDs and/or pain relief medication
- A patellar tracking brace or taping (McConnell taping)
- Proper fitting supportive footwear
- Custom orthotics or over the counter insoles (eg: Superfeet)
- Strongly discourage the wearing of “flip flops”
Physiotherapy is very effective in treating patella-femoral pain; 90% of PFS sufferers will improve within 6 weeks of starting a physiotherapy-guided rehabilitation program.
Physiotherapy treatment will focus on pain control, education, gait analysis, range of motion, balance, stretching and specific strengthening exercises for the VMO, hamstrings, glute and core.
Surgery is rarely necessary, however it may be required in certain cases with persistent pain despite a prolonged trial of non-operative treatment AND improvement in symptoms when the patella is pulled inwardly with taping (McConnell taping).
Surgery is rarely necessary, however it may be required in certain cases:
- persistent pain despite a prolonged trial of non-operative treatment AND improvement in symptoms when the patella is pulled inwardly with taping (McConnell taping)
- severe patello-femoral arthritis