A common injury that occurs in sports people who are involved in explosive sports that change direction quickly or impact sports is an injury to the ligaments of the knee.
The knee is made up of 2 primary ligaments that hold the structure in place and prevent movement of the bones in 2 distinct planes. The collateral ligaments run parallel to each other , superior to inferior along the lines of the leg. They almost form a natural splint like structure that holds the knee in place and prevents the bones from sliding sideways out of alignment. The other ligament is the Cruciate ligament which is a crossed ligament deep in the posterior knee space that resembles a cross (hence the name) or two fingers crossed.
This structure is often a ligament that gets worn and stressed as it stabilises the knee joint in the frontal plane and during ‘rotation’. Imagine your foot being planted and you trying to turn a corner sharply on a turf field. The bones are rotating against each other like a twisted tea towel. To stabilise this motion, the Cruciate Ligament is there to keep the bones from over-rotating and rupturing the knee capsule.
You often hear of athletes rupturing their anterior cruciate ligament (ACL) – this refers to the ligament that is at the front of the cross – the ligament that crosses in front. It’s a dramatic injury often associated with an audible pop after a landing from a jump or a sharp turn on a sporting field. The Cruciate Ligament attaches from the Femoral Head (thigh bone) to the Tibia (the larger of the two bones in the lower leg) Injury here creates a looseness of the knee whereby the end ROM when you bend the knee is not solid and has a ‘squidgy’ feel (Yep that is the technical term - SQUIDGY).
Many factors determine how to treat a torn (partial tear ) or ruptured (complete tear) of the ACL. The severity of the tear and the degree of movement or impact that the client may be likely undertake in the future is a major concern. Is the client likely to undertake impact sports in the future or are they at the tail end of their career? This is a very real concern for those facing ACL surgical repair.
The big debate in injury rehabilitation circles is whether to surgically re-attach the tendon or not. Many patients find that with good muscular stability and development, it is not necessary to surgically mend the tendon.
As the nature of the injury depends on stiff legged landing or twisting of the knee, if an athlete is able to sufficiently stabilise the knee via development of the muscles that surround the knee such as the quadriceps, hamstrings, popliteus and to a lesser extent the plantaris and gastrocnemius, then they may find that they have enough stability in the knee joint to not warrant surgery.
The main concern is the rehabilitation time. Non-surgical rehabilitation can have the athlete back on the field in 3 months. Surgical repair often takes up to a year to get an athlete back onto the field. Hence you can suspect why a number of athletes are keen to NOT have surgical repair.
The surgical procedure is a graft of the ligament taken from another structure, nominally the patella tendon or hamstring tendon. Like a skin graft this means taking tissue from another structure and hence the recovery from that technique impacts on the overall recovery time. The consideration is also impacting on the area used for the graft.
For example in the patella tendon graft, the risk is that the segment of bone removed from the patella actually creates a risk of patella fracture and a different type of pain at the front of the knee. Here you may be sacrificing one area of injury for another – in effect taking the lesser of two evils. Some athletes find it difficult to kneel for years after this type of surgery due to the loss of bone from the patella.
With hamstring grafts the healing required from the incisions in the bone takes longer and may not result in a complete ‘bone to bone’ healing of the incisions necessary for the graft. In the patella, the bones heal to the end of the incisions but with the hamstring tendon, often the incisions can create an incomplete bone healing which may have implications later in life.
There is also the possibility of an allograft or use of tissue from a donor (usually a cadaver). This type of surgery has proven to not be as effective as an autograft (taking tissue from the patient) and the strength of the tissue from the cadaver is not as strong as the patient’s own tissue.
Non-surgical treatment focuses on stabilising neuromuscular control of the lower limb. This is training the articulation of the whole lower leg, including ankle stability and smaller muscles such as the plantaris and popliteus to become stronger and more stable. The other option is the use of specific supports when engaging in sporting activity. Knee braces and specific supportive materials provide the stability of the knee in the sporting motions and can help a recovering athlete to feel confident in their movement.
As the name implies – training requires COMMITMENT to the program. Doing all those boring small exercises that will stabilise the knee and train your body to perform in a certain way. Daily reinforcement of movement patterns is required so that your body performs in a way that is habit and the muscles help to stabilise the knee in it’s movements. This is not for the faint hearted or (dare I say it) lazy athlete. Professional athletes who are the tail end of their career may choose to opt for this type of recovery.