Knee Injuries by Sport
Football (soccer) is the most popular team sport in the UK and internationally. Amateur leagues are almost as keenly followed as the professionals. Football requires physical fitness involved in running as well as the ability to withstand contact, particularly to the legs. The sharp turns and pivoting on one leg places huge strains on the knees, therefore knee ligament injuries are common, with the most common ligament injured being the ACL. It is generally impossible to return to the same level of football following an ACL rupture, therefore early reconstruction is recommended. Muscle and tendon injuries where the muscle attaches to bone are also common, with groin and hamstring injuries being the most common. These can become chronic if not managed appropriately from the time of injury. The forces of sudden twists and turns place huge strain on the ankles, thus ankle ligament injuries (sprained ankle) occur commonly. Ankle sprain may not be entirely minor and some can lead to chronic ankle instability (repeated ‘giving way’ of the ankle). Foot and toe injuries are frequent. ‘Turf Toe’ is related to footwear and particular grounds. Arm injuries are less common in football but can occur with falls. Goalkeepers are prone to shoulder injuries and finger injuries.
Rugby union is a full contact sport, where not only stamina and speed is required, but upper body strength and resilience is essential. The different team positions are prone to slightly different injuries. Shoulder and knee injuries are most common. Knee injuries are similar to football with the ACL being the most frequently injured. Shoulder dislocations are particularly disabling and early surgical repair should be considered. With repeated tackling and falling the shoulders suffer significant trauma which results in Acromioclavicular joint injuries, Labral injuries, Internal impingement and tendon ruptures. Rugby players are also prone to throwing injuries of the shoulder and elbow. Repetitive elbow trauma can result in early degeneration and loose bodies with a clicking, locking and painful elbow joint. Hand and foot fractures are a result of the contact nature of the sport. Neck and spinal injuries are very rare and have become less frequent due to the changes in the rules to protect players from serious neck injuries.
We have all witnessed horrific accidents in motor sports and these can lead to major fractures and trauma. However, racing drivers are also prone to repetitive and less dramatic injuries. Motorcyclists commonly injure their knees, shoulders and ankles as a result of repeated less severe falls and knocks.
For details on Motor Sports Safety see http://www.benchapman.com/project/current1.html
Athletes are prone to soft tissue injuries of the Upper and Lower limbs, particularly of the muscles and tendons. The most commonly affected are: Thigh Muscles, Hamstrings, Kneecap (Patella), Calf muscles, Achilles tendon, Shoulder Rotator Cuff and scapular muscles.
Ballerinas appear to have less leg strength than other groups of athletes, having only 77% of the weight-predicted norms. However, they have more flexibility and agility. The unique flexibility and mobility of ballet dancers makes them prone to specific injuries, particularly around the hip joint (10% of ballet injuries), knees (20%) feet and ankles. Patellar problems of the knee are common and need specific treatment to return dancers to their previous level of performance. The young age at which serious dance training begins, the long and rigorous hours of practice, the thin ballet slipper and dancing en pointe all contribute to injury patterns in varying degrees. This all needs to be appreciated and managed holistically.
The most common injuries in Basketball are ACL injuries of the knee, ankle injuries and finger injuries.
Injuries to the knee are common in cricket, including meniscal tears, damage to the lining surface of the knee, ligament injuries including ACL tears and patella dislocations.
Golfers are prone to back injuries due to the large bending and twisting forces on the spine in the golf swing. Knee injuries can also occur due to twisting forces (like Tiger Woods).
Hockey / Ice Hockey
Each year, almost 67,000 hockey-related injuries to youths under age 15 are treated in hospitals, doctors’ offices, clinics, ambulatory surgery centers and hospital emergency rooms. Protective equipment is one of the most important factors in minimizing the risk of injury in hockey. Injuries occur from direct contact and indirect injury with a wide range of injuries occurring in Hockey.
Like rugby, the martial arts also has a injury rate of about one per 50 hours of individual participation, although rugby injuries probably tend to be more catastrophic. Injuries primarily consist of bruises, strains, sprains, and lacerations. However, joint dislocations are seen and knee injuries. The fairly high injury rates – especially among women – suggest that martial arts participants should embark on a programme of overall conditioning and muscle strengthening before they actually begin intensive martial arts training.
The exhilaration of this sport can engender an exaggerated sense of confidence!! Unfortunately this can result in serious limb injuries particularly to the knee, ankle, tibia (the main load bearing bone of the lower limb) or to the fibula (lower limb, ‘supporting strut’ ) These are often secondary to the twisting forces encountered in falls while the foot is anchored in skis. Upper limb injuries are the consequence of attempting to moderate the impact of falls and commonly involve the scaphoid and other wrist bones. Skier’s thumb is also recognised whereby there is disruption of the ligaments supporting the digit resulting in instability.
The high speeds involved in this sport may put the participant at risk of significant rotational lower limb injuries, particularly twisting injuries to the knee and ankle, compounded by the limb being fixed in a ski. This is of special relevance to skiers using jumps at speed and then landing symmetrically.
Adductor injuries to the origin of the inner lower limb tendon may result from similar forced movements particularly if there has been a misjudgement in ascending a ramp at high speed.
Rotator cuff shoulder injuries are common in tennis players. The condition of ‘tennis elbow’ an inflammation of a tendon origin is also well recognised. The forceful stretching involved in delivering ‘the serve’ can precipitate back pain and abdominal muscle tears. Finally, attempts to reach the ball ‘off balance’ may result in a fall. The ankle appears to be a common site of injury in this scenario.
Anterior Cruciate Ligament (ACL) Tears
ACL tears are a very common sporting injury. They are most frequent in twisting and cutting sports such as football, basketball, netball, volleyball, rugby, skiing, waterskiing and so on. They are much more frequent in women than in men. Typically they are a non contact injury and occur when landing awkwardly from a jump and the knee gives way. The other classical mechanism is to be running, then suddenly to decelerate and change direction and the knee twists and buckles. You will commonly hear a ‘pop’, fall to the floor, the knee will swell up immediately, you will be unable to continue with the game and you will have to be helped off limping on your injured leg. Normally you will attend the A&E Department where your knee will be x-rayed. You will be told that nothing is broken and you will be sent on your way. Within about 4 to 5 weeks the knee starts to feel normal, except that every time you twist or something unexpected happens to your leg your knee gives way. Unfortunately ACL tears are all too commonly missed.
ACL tears used to be career ending injuries, not that many years ago, but now we have very reproducible surgical techniques to reconstruct the ACL. It is important to stabilise the knee and prevent giving way episodes as this lead on to further damage to the meniscal cartilages and chondral surfaces, ultimately leading to accelerated arthritis development.
TheKneeDoc surgeonis highly trained in the assessment, diagnosis and treatment of ACL tears. We offer KT1000 biomechanical knee assessments to confirm diagnosis quickly. We use aggressive accelerated rehabilitation programmes following surgery to get you back to your sport, at the same level you were playing prior to your injury, within 3 to 6 months. Many surgeons within the United Kingdom try and manage ACL tears non operatively but unfortunately this does not work in the vast majority of cases as it leads to recurrent giving way, causing further damage to the knee. Following surgery, we have aggressive rehabilitation protocols to get you back quickly and safely by monitoring your strength and co-ordination using state of the art equipment. All of this allows earlier return to full activity.
Posterior Cruciate Ligament (PCL) Tears
The PCL is also a commonly injured ligament but once again is frequently mis-diagnosed. It is common in sports such as rugby and can occur in football. It tends to occur when you fall on your bent knee. It also occurs in road traffic accidents when your knee hits the dashboard of the car.
In a sporting situation, PCL tears are usually not as dramatic as ACL tears. The knee does not quite feel right following injury and is painful at the back of the knee. It is not uncommon for people with PCL tears following injury to continue playing through the game.
Most people with PCL injuries do not require surgical reconstruction but it is important to make the diagnosis early and treat it appropriately with rehabilitation and/or bracing so as to minimise the time off from your sport. We have the facility to provide rapid diagnosis using clinical, radiological (MRI scans) and knee biomechanical testing methods (KT1000).
Medial Collateral Ligament (MCL) Tears
Medial collateral ligament injuries are usually contact injuries and can occur in any contact sport. They are commonly combined with ACL and/or PCL tears. The usual mechanism is a blow to the weight bearing limb on the inside of the leg.
MCL tears have a good propensity to heal if treated accurately. The diagnosis needs to be made rapidly and treatment instituted to minimise the time off your sport. Most people do not require surgery and can be treated with an appropriately timed rehabilitation programme which we can organise.
Lateral Side Knee Injuries/Lateral Collateral Ligament (LCL) Injuries
The lateral side of the knee is the outer side. The lateral side is a very important stabilising structure to the knee and consists of six major structures, including the LCL. Isolated injuries to one or two of the six structures can usually be treated non-operatively with an appropriate bracing and supervised rehabilitation programme. The mechanism of injury is usually a twisting injury combined with hyperextension or a blow to the outer aspect of the weight bearing knee. Lateral side injuries are commonly combined with ACL and/or PCL tears.
When combined with other ligaments or if involving a number of structures on the outside, this then becomes a major injury which requires rapid diagnosis and surgery within 10 to 14 days in order to optimise recovery. Should this window of opportunity be missed the treatment will then require more complex reconstructive surgery. Both the acute and chronic facets of treatment combined with initial diagnosis and appropriate rehabilitation programmes can bearranged by TheKneeDoc.
Combined Ligament Injuries
The ligaments of the knee including the ACL, PCL, MCL, LCL and lateral side can all be injured in combination. Combined injuries are more significant and major injuries and it is important that these are diagnosed accurately and early and appropriate treatment instituted. Methods of diagnosis and assessment are offered by TheKneeDoc, including biomechanical methods using the KT1000, radiological methods and, above all, clinical methods, using the wide experience base of TheKneeDoc.
The knee contains two menisci, the medial and lateral, one in each half of the knee. The meniscus acts as a shock absorber to dissipate force within the knee. They work very well in compression and axial loading but are not as good in rotation and sheer. Meniscal tears can occur in all age groups and more commonly affect the medial meniscus. They can occur as a result of sporting injuries in the young or in the elderly population, an act as simple as getting up from a kneeling position can be enough to tear a more degenerate, stiffer meniscus.
Meniscus tears do not heal and once the meniscus is torn the torn piece is dysfunctional. The symptoms from a torn meniscus include localised pain around the knee which is worse when you twist on the knee. Commonly people complain of pain at night when their knees rub on each other (with medial meniscus tears). The knee also usually swells and can cause locking and giving way of the knee.
TheKneeDoc provides the clinical experience and radiological tools to facilitate rapid diagnosis. Using keyhole surgical techniques, meniscus tears can be treated and allow a rapid return to function.
Acute meniscal tears where appropriate can be repaired. This is a technique that is offered by TheKneeDoc. The surgery involves minimally invasive keyhole surgery to allow the meniscus to be repaired. A specific graduated rehabilitation is then followed as supervised by the surgeons at the clinic. Obviously a well repaired meniscus which heals offers a major advantage compared to having to remove a torn meniscus.
The patella is an intrinsically unstable joint due to its shallow bony geometry. It is stabilised by the muscles and ligaments surrounding it. Patella dislocation is a common injury which tends to occur in twisting sports. It can occur by contact and non contact mechanisms and is common in sports such as basketball, netball, football and rugby. When the patella dislocates you usually feel 2 ‘pops’, one when it ‘pops’ out and the other when it ‘pops’ back in. The knee usually swells immediately and is associated with pain around the front and side of the knee. Usually you are unable to continue with the game. Unfortunately ACL tears are not uncommonly mis-diagnosed as patella dislocations, which can lead on to problems in the future.
In a young sporting and active population the risk of recurrent repeated patella dislocation approaches at least 50 to 60%. This can be prevented with early diagnosis and acute minimally invasive surgery to repair the injured ligaments. This surgery however has to be done within 2 weeks of the injury otherwise the window of opportunity is missed. TheKneeDoc offers the facilities for rapid diagnosis and treatment. The surgery is followed by an accelerated rehabilitation programme under our direct supervision.
Chronic Recurrent Patella Dislocation
If the acute dislocation is mis-diagnosed or missed the condition can become recurrent. You tend to get repeated dislocation with twisting activities and many people will have reduced their activity level prior to seeking treatment.
TheKneeDoc offers specific surgery to correct all of the multiple disorders that can cause recurrent patella instability. By addressing all of the components of the instability it should prevent further instability episodes. The surgery is tailored to the individual’s abnormalities and requires a detailed assessment both clinically and radiologically before a treatment plan can be formulated. It is followed by a rehabilitation programme which is supervised by TheKneeDoc to allow return to function.
Chondral Injuries/OsteochondritisDissecans (OCD)
Damage to the lining (articular) cartilage of the knee joint is actually quite common. It can be traumatic or something that develops insidiously, when it is called OCD. If the piece of cartilage is knocked off it can act as a loose body causing the knee to lock and jam. This would require keyhole surgery to remove the piece. The more challenging aspect of treating this condition is what to do with the area in the cartilage which has been damaged and is now absent from. There are a number of techniques which can be used. TheKneeDocutilises state of the art, cutting edge technology to undertake cartilage transplantation where appropriate. This involves a keyhole procedure to take some cartilage from your joint from where it is sent to the lab to grow more cells. At the second operation the cells are then implanted into the knee. A specific rehabilitation programme is then followed and your progress is constantly monitored by TheKneeDoc. This is the only technique that will allow normal cartilage to redevelop in the knee and it is not widely available in the United Kingdom. There are only certain surgeons and centres available to offer this, of which TheKneeDoc is one.
Chondral injuries commonly occur in conjunction with ligament injuries of the knee and kneecap dislocation.
Fibula Head Dislocation
The fibula is the smaller of the two bones in the leg. It is joined to the shin bone at the top and at the bottom. Occasionally the joint at the top can be disrupted with certain knee injuries. It is an uncommon injury but can lead to problematic pain around the upper part of the shin bone and around the knee. It is commonly mis-diagnosed. There are a number of treatment options for this condition and as a last resort, should they not work, there is a surgical option available.
Hamstring tears do commonly occur in the muscles when they are exposed to explosive contraction. This can occur in sprinting when the muscle is not warmed up, or trying to resist a twisting or falling action. Most commonly the tears occur within the muscle belly. However, occasionally the tear can be powerful enough to pull of the bone on the pelvis that the hamstring muscles are attached to. In this latter scenario the optimal treatment is for early surgical reattachment but this requires diagnosis with appropriate MRI scanning, to enable early surgery and appropriate rehabilitation.
For the more common tears within the muscle belly, the treatment involves rehabilitation using physiotherapy modalities. We are able to offer, through our mantylinks with physiotherapists, a technique in treatment, which will speed up recovery significantly.
Occasionally, for people who get recurrent hamstring strains there is an underlying biomechanical abnormality predisposing them to this. TheKneeDoc has close links with biomechanical gait laboratories where we can undertake high tech state of the art gait analysis as an aid to diagnosis, treatment and recovery.
Patellar Tendonitis (Jumper’s Knee)
Patellar tendonitis is a cause of pain at the front of the knee below the kneecap. It is an overuse condition and is common in sports involving repeated jumping such as volleyball, netball and basketball. The symptoms associated with this develop through a number of stages. Initially the pain may be felt sometime after the exercise is finished. As it develops pain can be felt during exercise with a reduced time span from the start of the exercise. Eventually pain can be felt at rest.
The treatment of jumper’s knee is primarily rehabilitation associated and requires specific protocols of rest, stretching and appropriate conditioning exercises with medications. In addition TheKneeDoc also offers cutting edge treatments for tendonitis including Platelet Rich Plasma (PRP) injections which are a stem cell injection technique using your own blood cells and Dry-Needling of the tendon which can also stimulate healing of the tendon and so speed up recovery.
Should it not respond to treatment then surgery is indicated to decompress the tendon followed by a specific rehabilitation protocol to get you back to playing without recurrent symptoms.
Ilio-tibial Band Syndrome
This is a condition that causes pain on the outer aspect of the knee. Once again it is an overuse phenomenon and is common in sports such as running. The pain only occurs during weight bearing sports. Initially the pain comes on the outer aspect of the knee after the sport is over but as the severity increases it starts to occur during the sport and can eventually cause pain at rest. It commonly occurs in runners who suddenly increase their weekly distance which ideally should be increased at no more than 10% per week. IT band syndrome may have an underlying biomechanical cause, predisposing the individual to developing the syndrome.
The treatment involves appropriate rest and rehabilitation. Should the symptoms not respond then steroid injection under the tendon, PRP injection (see above) into the damaged tendon or surgical decompression or release is indicated. Also TheKneeDoc has access to state of the art gait analysis facilities, which may be indicated in the treatment of this condition to allow appropriate orthotic management to treat and prevent further recurrences.
Osgood Schlatter’s Disease/Sindig-Larsson-Johansson Syndrome
They may once again be considered as overuse phenomena. These are causes of anterior knee pain in adolescents. Osgood Schlatter’s disease causes pain at the point where the patellar tendon joins the shin bone. It can be one of the causes of knobbly knees in adulthood. Sindig-Larsson-Johansson syndrome is the childhood variant of patellar tendonitis and causes pain at the lower pole of the kneecap. These occur due to traction on the bone by the tendons during the growth spurt in childhood. They are both self limiting conditions and require appropriate rehabilitation and supervision. TheKneeDoc surgeon has had good results with a specifically designed rehabilitation programme which combines stretching and massage.
Anterior Knee Pain/Chondromalacia Patellae
This is a very common diagnosis in both sportsman and non sportsman. It is a descriptive term describing any cause of pain at the front of the knee. There are numerous causes of pain including kneecap malalignment and instability, softening of the cartilage behind the kneecap, overuse tendonitis, cartilage defects, muscle tears, fat pad impingement within the knee, hip disorders and spinal disorders.
Accurate diagnosis requires assessment by a physician used to dealing with this condition as is available by TheKneeDoc. Once the diagnosis is made appropriate treatment is instituted whether non surgical or surgical.
Extensor Mechanism Rupture (Quadriceps Tendon Rupture and Patellar Tendon Rupture)
Rupture of the extensor mechanism is not uncommon. Usually people above the age of 40 tend to rupture their quadriceps tendon and people less than 40 years of age tend to rupture their patellar tendon. The condition is usually associated with some intrinsic degeneration or weakness of the tendons. It can occur in athletes who are using steroids illicitly to put on muscle bulk as the steroids cause increasing muscle size and strength but do not affect tendons and the muscles therefore overpower the tendons.
The treatment for this in every case is usually surgical and accurate rapid diagnosis needs to be made.
Acute Swollen Knee
Swelling of the knee is common following knee injuries. There are a multitude of causes of knee swelling including fractures, patella dislocation, cartilage injuries, meniscus tears, ligament tears and so forth. Diagnosis can be made by early assessment and investigation which will allow appropriate treatment to be undertaken. Occasionally more serious conditions can present as swollen knees which needs to be further investigated and treated.
Knee fractures can occur and include fractures of the kneecap, the end of the thigh bone or top of the shin bone. They are uncommon in sports but do occur. Fractures of the shaft of the shin bone and occasionally the shaft of the thigh bone can indeed occur in sports such as football, American football, rugby, hockey and motor sports. They are usually direct contact injuries. The treatment for most of these in athletes is surgical.
Once the fractures are fixed using appropriate implants and technology to allow early rehabilitation, the regaining of function can be commenced. In athletes and people participating in contact sports, the metalwork usually needs to be removed prior to returning to the sport.
Knee pain can commonly be due to the development of early wear and tear/osteoarthritis. This can occur in athletes of all ages but tends to be more common in the above 30 age group. The diagnosis of early osteoarthritis does not mean the end of your sporting career but may require some degree of sports modification.
After assessment by TheKneeDoc appropriate treatment can be instituted, which may include state of the art injection therapy, cartilage transplantation, realignment of the bones in the leg and eventually may also require minimally invasive half and total knee replacement. After knee replacement surgery sports are not out of the question but only certain sports can be played, such as golf, doubles tennis, swimming, use of various cardiovascular machines and certain other sports that you can discuss with TheKneeDoc. Impact sports are usually not permitted as this causes the knee replacement to wear out.
Exercise Induced Compartment Syndrome
Occasionally, athletes will get pain in their legs from the knee downwards towards the ankle which is related to exercise. It tends to occur within a few minutes of commencing the exercise and gets worse as the exercise proceeds. As you stop the exercise the symptoms improve. It is reproducible in that it occurs every time you exercise. It is common in runners but can occur in other sports such as gymnastics and volleyball. The cause of this is related to the fact that the muscles swell within the leg as the exercise proceeds but the leg will only allow a certain amount of swelling and once the muscle reaches this level an inadequate amount of blood flow gets into the muscles causing pain. As soon as the exercise is stopped the swelling decreases, the blood flow increases and the pain diminishes.
Diagnosis of this condition requires experience of dealing with the condition. It also requires specific diagnostictests whichcan be arranged by TheKneeDoc. Initially a rehabilitation programme is the treatment of choice but should this fail the treatment will require surgical intervention following which you should be able to return back to your sport after completing an appropriate supervised rehabilitation programme.
Shin splints is a term used to describe the onset of pain in the shin and muscles surrounding the shin with exercise. It is common in gymnastics, running, football and rugby. It can be confused with exercise induced compartment syndrome. Occasionally the two conditions may co-exist. The diagnosis is made using appropriate imaging modalities. The treatment usually involves rehabilitation and modification of training patterns which can be supervised by MSMC physicians.
Stress fractures are an overuse phenomenon which can occur in many of the bones in the body. They only usually occur in weight bearing bones which would mean lower limbs. Locations can be varied and include the hip joint, the ankle joint on the inner aspect, the fibula, kneecap, shin bone where it can occur at a number of locations. The symptoms associated with stress fractures are essentially pain. Initially this will come on during the rest period after exercise but as the stress fracture progresses the symptoms will come on earlier and earlier during the course of exercise and eventually can occur at rest.
The treatment of stress fractures depend on their specific location but in many cases, and in athletic individuals, the optimal treatment is surgical to get people back to function, be that sports or occupation, quickly. This is something that TheKneeDoc has experience of dealing with to allow rapid return to function.