Which ligaments are damaged?
The knee is held together by four major ligaments. The internal and external collateral ligaments limit the deviation of the tibia to the sides, the anterior and posterior cruciate ligaments limit the displacement of the tibia forward and backward. The medial collateral ligament is the most commonly injured ligament and usually heals well conservatively. The anterior cruciate ligament ruptures when turning the body on a fixed foot, often in football and alpine skiing, and heals poorly on its own. Often the injury is combined with damage to the meniscus. The posterior cruciate ligament is less commonly affected, usually when there is a blow to the front of a bent knee.
- Internal collateral ligament is the most common injury
- Anterior cruciate ligament - rotation on a fixed foot
- Posterior cruciate ligament - impact on bent knee
- External collateral ligament
- Frequent combinations with meniscus damage
- Degrees: 1 - micro-tears, 2 - partial tear, 3 - complete tear
Symptoms by degree
In the first degree, the pain is moderate, the swelling is small, support on the leg is possible, the joint is stable. In the second degree, the pain is stronger, the swelling is noticeable, there is a feeling of uncertainty in the knee when loaded, the joint is slightly loose when checked by a doctor. In the third degree, the ligament is completely torn: the knee swells greatly, often within the first hour due to blood in the joint, support is painful or impossible, and the joint feels unstable. A characteristic sign of an anterior cruciate ligament rupture is an audible click at the time of injury.
- Grade 1: moderate pain, stability maintained
- Grade 2: noticeable swelling, feeling of unsteadiness
- Grade 3: rupture, severe instability
- Rapid swelling in the first hour - blood in the joint
- Clicking when injured
- Limitation of flexion and extension
What to do in the first days
The load on the leg is limited; crutches are used if necessary. Cold is applied through a cloth for 15–20 minutes several times a day in the first two days. Elastic bandaging or an orthosis helps, as does an elevated position of the leg. You should not try to straighten the knee yourself, massage it intensively, warm it up or take a hot bath. Pain medication is acceptable, but it masks the symptoms, so an examination by a traumatologist is still necessary, especially if there is severe swelling, a feeling of instability, or the inability to put weight on the leg.
- Unloading the leg, crutches if necessary
- Cold through fabric in the first 48 hours
- Elastic fixation or orthosis
- Elevated leg position
- Avoiding warming up and massage
- Examination by a traumatologist in the coming days
Diagnostics
The doctor checks the stability of the joint with special tests, assesses the presence of fluid in the knee, range of motion and pain along the ligaments and joint space. An x-ray does not show the ligament, but is necessary to rule out a fracture or avulsion of a bone fragment. MRI of the knee is the primary method for evaluating ligaments, menisci, and cartilage, especially when a cruciate ligament tear is suspected. Ultrasound shows the lateral ligaments and effusion well. If there is a large, tense collection of blood, the doctor may perform a puncture.
- Knee Stability Tests
- X-ray to rule out a fracture
- MRI of the knee joint
- Ultrasound of the lateral ligaments and effusion
- Puncture for intense hemarthrosis
- Re-examination after swelling subsides
Treatment and rehabilitation
Injuries of the first and second degrees, especially the internal collateral ligament, are treated conservatively: orthosis, dosed loading and gradual physical therapy. Recovery is built in stages: first, swelling is removed and full extension is restored, then the quadriceps and hamstring muscles are strengthened, then balance and movement control exercises are added, and only then running and sports activities. For complete rupture of the anterior cruciate ligament in active people, arthroscopic repair is discussed. The key role in the outcome is played by rehabilitation, and not the operation itself.
- Orthosis and dosed load
- Restoring full extension first
- Strengthening the thigh muscles
- Balance and movement control training
- Arthroscopic cruciate ligament plasty according to indications
- Return to sport only after strength and stability tests