Torn Anterior Cruciate Ligament

The diagram depicts how an ACL can be surgically reconstructed.

Anterior Cruciate Ligament

Your knee joint consists of three bones; femur (thigh bone), tibia (shin bone), and patella (knee cap). There are four ligaments that hold these bones together and provide stability;

– Collateral Ligaments: The medial (inside of the knee) and lateral (outside of the knee) collateral ligaments control sideways motion within the knee.
– Cruciate Ligaments: The anterior (front) cruciate ligament (ACL), and the posterior (rear) cruciate ligament cross each other to make an ‘X’. They control the forward and backward motion on the knee.

Most ACL tears are the result of a specific trauma and are associated with pivoting or twisting motions. Patients often describe a ‘popping’ feeling or sound when the injury occurs. ACL injuries are measured by grade:
– Grade 1: There is mild damage to the ACL and it is only slightly stretched. The ACL is still able to maintain joint stability.
– Grade 2: The ACL is stretched and becomes loose, this is referred to as a partial tear and is rare. The ACL can maintain minimal joint stability
– Grade 3: The damage to the ACL has severed it into two pieces, also known as a complete tear. This leaves the knee joint unstable.

ACL tears are commonly seen in athletes who play contact sports such as; football, basketball, field hockey, and soccer.

Symptoms
– Popping sound/sensation at the time of the injury
– Joint instability
– Inability to bare weight
– Swelling
– Grinding sensation
– Joint stiffness
– Pain with:
– Weight baring activities like walking and standing
– Movement
– Daily activity

If your symptoms last longer than 2 weeks and interfere with daily activity you should consult your primary doctor for a referral.

Your Appointment with Dr. McMillan

During your appointment Dr. McMillan will perform a physical exam to test your knee’s range of motion and your leg strength. You may also get X-rays in the office and set up an MRI to diagnose the cause of your pain. Once the results of your MRI come back, Dr. McMillan will map out your treatment options and help you decide of the course of action that is best for you.

Treatment

Dr. McMillan examining a patient for an injury to the ACL.

Non-surgical:
ACL tears require surgery in order to heal, however non-surgical treatments may help the elderly and those with low activity levels.

– Rest
– Bracing: Bracing the joint will help provide stability that the ACL no longer supports.
– Medication: Non-steroidal anti-inflammatories to minimize swelling and pain.
– Physical Therapy: Strengthening your knee will help relieve pain and prevent further injury. You will also work on stretches to help regaining mobility.
– Injections: If the other non-surgical treatments fail Dr. McMillan can use injections to help reduce pain.
– Steroid Injection (Cortisone): Has been proven to be very effective at reducing inflammation and pain.
– Platelet Rich Plasma (PRP): Your own blood is used to extract plasma plateletS, which are then injected into your hip joint. These platelets stimulate the body to repair itself.

Surgical:
Once torn, an ACL cannot be repaired. Instead, it must be replaced using a tissue graft. A graft is a piece living tissue that is transplanted to the patient. There are two different sources of tissue grafts:

– Autograft: Autograft tissues are harvested from the patient’s own body, usually from the patellar tendon, hamstring, or quadriceps. Autografts decrease the risk of an immune system response and bacterial infections. However, autografts create a second surgical sight which can delay recovery. The literature demonstrates that allografts produce better results in a younger patient population. After the age of 35, the postoperative differences between patients receiving autografts and those receiving allografts are negligible.
– Allograft: Allograft tissues are harvested from a cadaver, usually from the patellar tendon, hamstring, or quadriceps. Allografts decrease surgical time, postoperative pain, joint stiffness and atrophy, and eliminate pain and scarring from a donor site. However, allograft tissue cannot be completely sterilized, causing an increased risk of bacterial infection. Potential cadaver donors are screened extensively before tissues are harvested. Once harvested, cadaver tissues are cleaned and frozen in liquid nitrogen.

There are three standard types of graft:

– Patellar Tendon Bone-Tendon-Bone (BTB) Graft: BTB grafts consist of the middle third of the patella tendon and bone blocks, from the tibial tubercle and patella, on each end of the tendon. The bone blocks are attached to the femur and tibia using a specific type of screw called an interference screw. Interference screws provide immediate stabilization which allows for decreased postoperative pain and an accelerated rehabilitation.

– Hamstring Tendon Graft: There are several variations on hamstring grafts. Generally Dr. McMillan folds the two ends of the harvested hamstring tendons into a quadruple stranded graft. This configuration allows for the strongest tensile construct for repair. Hamstring grafts have shown similar post-operative success rates as other graft choices and can be associated with lower post-operative morbidity. The hamstrings are fixed into the bone tunnels via the use of either an interference screw or a cortical button and immediate weight bearing is allowed.

– Quadricep Tendon Graft: Quadricep tendon grafts combine soft tissue-to-bone and bone-to-bone grafting techniques. The graft consists of a strip of the end of the quadricep tendon and a bone block, from the top of the patella, on one end of the graft. The bone end of the graft is typically fixed to the femur with an interference screw and the soft tissue end is fixed to the tibia in a similar fashion. Quadricep tendon grafts are often used for ACL revision cases.

Dr. McMillan tailors graft choices to the individual based upon his or her needs. Recovery after ACL reconstruction can be lengthy, and it may take up to six months before an athlete is ready to return to his or her sport. Every tear and patient is different; however, most ACL reconstructions can be performed arthroscopically. For more information on arthroscopic surgery please see “What is arthroscopic surgery?”

Torn Meniscus

The meniscus is a crescent shaped cartilage that acts as a shock absorber between the femur (thigh bone) and tibia (shin bone). Each knee has two menisci: medial (inner) and lateral (outer). There is an additional type of cartilage in the knee joint called articular cartilage. This is a smooth, white glistening surface that covers the ends of the bones. The articular cartilage provides lubrication and as a result, there is very little friction when the joint moves. Either by degenerative wear and tear or an acute injury these cartilages can tear and cause pain. Acute injuries resulting in meniscal tears often cause damage to other structures in the knee, such as ACL tears.

ACL tears are associated with squatting and twisting motions as well as direct impact to the knee, like in a tackle. Athletes who are most susceptible to ACL tears are those who play contact sports like; football, basketball, soccer, field and ice hockey.

Symptoms
– Popping: sensation when the injury occurs
– Stiffness: increases 2-3 days after injury
– Swelling: increases 2-3 days after injury
– Catching sensation
– Weakness
– Decreased range of motion
– Pain with:
– Daily activity
– Walking
– Bending the knee
– Sleeping on the affected side

If your symptoms last longer than 2 weeks and interfere with daily activity you should consult your primary doctor for a referral.

Your Appointment with Dr. McMillan

During your appointment Dr. McMillan will perform a physical exam to test your knee’s range of motion and your leg strength. You may also get X-rays in the office and set up an MRI to diagnose the cause of your pain. Once the results of your MRI come back, Dr. McMillan will map out your treatment options and help you decide of the course of action that is best for you.

Dr. McMillan examining a patient’s range of motion in the knee joint.

Treatment

Non-surgical:
Treatment will depend on the size, shape, and location of your tear, some tears can heal with non-surgical treatment.

– Rest
– Bracing: Bracing provides compression which reduces swelling.
– Medication: Non-steroidal anti-inflammatories to minimize swelling and pain.
– Physical Therapy: Strengthening your knee will help relieve pain and prevent further injury. You will also work on stretches to help regaining mobility.
– Injections: If the other non-surgical treatments fail Dr. McMillan can use injections to help reduce pain.
– Steroid Injection (Cortisone): Has been proven to be very effective at reducing inflammation and pain.
– Platelet Rich Plasma (PRP): Your own blood is used to extract plasma platelets, which are then injected into your hip joint. These platelets stimulate the body to repair itself.

Surgical:
If non-surgical methods fail to improve pain Dr. McMillan will discuss surgery as an option. Each patient and tear is different, but most tears can be treated arthroscopically. For more information of Arthroscopic surgery please see ‘What is Arthroscopic surgery?”

Arthritis

The diagram depicts two types of knee arthritis compared to a non-arthritic healthy knee.

Your knee joint consists of three bones; femur (thigh bone), tibia (shin bone), and patella (knee cap). Between the femur and tibia is cartilage, called the meniscus, which acts as a shock absorber. Arthritis is a disease that breaks down cartilage, there are three main types of arthritis that affect the knee:
– Osteoarthritis (OA): OA is the most common form of knee arthritis. It is a degenerative disease of the joint that usually affects middle-aged and older people.

– Rheumatoid Arthritis (RA): RA is an inflammatory disease that usually affects both sides of the body equally. RA can affect patients of any age.

– Post-Traumatic Arthritis: Post-traumatic arthritis is similar to OS and develops years after an injury to the knee.

Symptoms
– Stiffness
– Swelling
– Buckling/locking sensation
– Weakness
– Decreased range of motion
– Pain with:
– Daily activity
– Climbing stairs
– Change in weather
– Pain is worse in the morning

If your symptoms last longer than 2 weeks and interfere with daily activity you should consult your primary doctor for a referral.

Your Appointment with Dr. McMillan

During your appointment Dr. McMillan will perform a physical exam to test your knee’s range of motion and your leg strength. You may also get X-rays in the office and set up an MRI to diagnose the cause of your pain. Once the results of your MRI come back, Dr. McMillan will map out your treatment options and help you decide of the course of action that is best for you.

Dr. McMillan examining a patient’s range of motion in the knee joint.

Treatment

Non-surgical:
– Rest
– Supportive Devices: In early stages on the disease the use of shoe inserts and braces may help relieve pain. In later stages the use of a cane may also help relieve some of the stress on the joint.
– Medication: Non-steroidal anti-inflammatories to minimize swelling and pain. There are also specific medications to help reduce the affects of RA.
– Physical Therapy: May help regain range of motion.
– Injections: There are various types of injections available to alleviate your pain and other symptoms;
– Steroid Injections (Cortisone): Cortisone has been proven to be very effective at reducing inflammation and pain.
– Lubricating Injections: Lubricating injections use a synthetic joint fluid to help smooth the cartilage of the knee.
– Platelet Rich Plasma (PRP): Your own blood is used to extract plasma platelets, which are then injected into your shoulder joint. These platelets stimulate the body to repair itself.

Surgical:
If non-surgical methods fail to improve pain Dr. McMillan will discuss surgery as an option. Each patient is different so surgical plans very greatly depending on your needs and stage of arthritis.