Ligament injuries are traumatic in nature (with direct or indirect mechanism) and may be associated with meniscal or cartilage injuries. They are frequently due to contact sports (soccer, basketball) or characterized by changes in direction (skiing, volleyball, tennis). Injuries involve:
- Anterior Cruciate Ligament (ACL)
- Posterior Cruciate Ligament (MCL)
- Medial Collateral Ligament (MCL)
- Lateral Collateral Ligament (LCL)
Anterior cruciate ligament (ACL) injury
The most frequent injury involves the anterior cruciate ligament (ACL); in fact, more than 20,000 reconstructions of this ligament are performed each year in Italy alone.
Anterior cruciate ligament injury: how does it happen?
Anterior cruciate ligament injury is, often, caused by trauma in valgus and extrarotation and is characterized by an acute phase with a “crack” sensation and subsequent pain and functional impotence of the joint. In the following hours, there is frequently blood effusion into the joint (hemarthros).
The chronic phase of the injury, in the weeks and months following the injury, is characterized by joint instability with sensation of failure.
How is anterior cruciate ligament injury diagnosed?
Diagnosis is made with clinical tests and an MRI that confirms the specialist’s suspicion.
Conservative therapy and surgical therapy
Conservative (non-surgical) therapy is characterized, initially, by rest and ice, as well as the use of systemic anti-inflammatories and, subsequently, muscle strengthening combined with physical therapies (e.g., Laser, TECAR) .
This type of therapy is reserved for sedentary people with advanced age.
Anterior Cruciate Ligament reconstruction surgical therapy is adopted in most cases and involves replacing the ruptured ligament using either autologous tissue, i.e., from the individual himself (such as his patellar tendon, or the gracilis and semitendinosus tendons) or homologous, i.e., tissue from the bone bank from a donor (this is a choice in anterior cruciate ligament re-ruptures).
Ligament reconstruction in surgical therapy
Ligament reconstruction is performed arthroscopically to make the surgical trauma as minor as possible.
The use of the patellar tendon is characterized by low elasticity of the graft over the years compared with other tendons; however, it involves invasiveness on the extensor apparatus (quadriceps-rotula) with a not inconsiderable percentage (5 to 15%) of anterior residual pain.
For this reason, to date, the most commonly used surgical choice is reconstruction with the tendon of the semitendinosus muscle coupled or not with the tendon of the gracilis muscle.
Gracilis and semitendinosus muscle tendons are harvested through a small incision just below the arthroscopic portals of the knee.
These two tendons are then prepared to form the neo ligament.
There are single- or dual-beam (video) reconstruction techniques.
Postoperative rehabilitation
Postoperative rehabilitation normally begins 2-3 weeks after surgery, depending on the associated injuries (meniscal and cartilage). No postoperative knee brace is normally used; partial loading and flexion-extension is allowed at least up to 90° from the 2nd-3rd postoperative day and in any case depending on one’s pain.
Return to walking without crutches is about 25 to 30 days after surgery.
Return to contact sports is about 4-5 months after surgery.
Injury of the posterior cruciate ligament (PCL)
Posterior cruciate ligament (PCL) injury is rare (about 2% of all knee ligament injuries).
Posterior cruciate ligament injury: how does it happen?
Injury of the posterior cruciate ligament is usually associated with high-energy trauma with joint sub-/luxations, more often, therefore, in the context of multi-ligament injuries; rarer, however, is an isolated injury from direct trauma anterior to the tibia (so-called dash injury).
The acute phase is characterized by severe pain with functional impotence.
The chronic phase of the injury is, compared with the ACL picture, less frequently characterized
from joint instability (if the injury is isolated), so, often, surgery is not performed because the condition can be treated with rehabilitative physical therapy that succeeds in giving a good functional result to the patient.
How is posterior cruciate ligament injury diagnosed?
Diagnosis is made with clinical tests and an MRI that confirms the specialist’s suspicion.
Surgical intervention
When the decision is made to operate surgically, posterior cruciate ligament reconstruction is performed arthroscopically using an autologous tendon ( patellar tendon, or the gracilis and semitendinosus tendons ) or homologous (tissue from a donor bone bank).
Postoperative rehabilitation
Postoperative rehabilitation is long and demanding and usually involves the use of a postoperative knee brace for the first month; full load is not achieved until the end of the second month while free flexion-extension is progressively allowed in the first 45-60 days.
Return to contact sports is about 6 months after surgery.
Medial collateral ligament (MCL) injury
Medial collateral ligament (MCL) injury is the most common ligament injury of the knee: it is usually isolated but may be associated, in about 25 percent of cases, with injuries to other ligaments or meniscals.
Medial collateral ligament injury: how does it happen?
The injury occurs due to trauma with stress in valgus, that is, with the foot bearing outward from our axis.
How to diagnose medial collateral ligament injury?
Diagnosis is made with clinical tests and an MRI that confirms the specialist’s suspicion.
How is the injury treated?
The fibers of the collateral ligaments after injury remain, unlike those of the cruciate ligaments, in continuity with each other, soimmobilization of the knee after injury (usually for a fortnight) heals the MCL often without clinically residual laxity.
Most such lesions are, therefore, treatable nonsurgically.
For high-grade injuries or those associated with other surgical conditions, however, direct surgical suturing of the ligament or retentive plastics is performed.
Postoperative rehabilitation
Postoperative rehabilitation involves the use of a postoperative knee brace for the first month.
Partial loading is allowed from the first few days depending on pain. The knee brace is released progressively in flexion-extension during the first month.
Return to contact sports is about 4-5 months after surgery.
The injury of the lateral collateral ligament (LCL)
Lateral collateral ligament (LCL) injury is rare; it is usually associated with cruciate ligament injuries (especially the LCP).
Lateral collateral ligament injury: how does it happen?
The injury occurs due to high-energy trauma with stress in varus, that is, with the foot bearing inward on our axis.
How is lateral collateral injury diagnosed?
Diagnosis is made with clinical tests and an MRI that confirms the specialist’s suspicion.
How is the injury treated?
The fibers of the collateral ligaments, after the injury, remain in continuity with each other. After a period of immobilization of the knee (usually a fortnight), residual stability and frequent associated injuries should be evaluated to decide on the type of treatment.
Most isolated injuries are often nonsurgical, having good healing of the ligamentous bundles.
For isolated high-grade injuries (thus with laxity healing) or injuries associated with other surgical conditions, direct surgical suturing of the ligament or retentive plastics is performed.
Postoperative rehabilitation
Postoperative rehabilitation involves the use of a postoperative knee brace for the first month.
The load will depend on the frequent associated injuries, yes the injury is isolated a partial load is allowed from the first days. The knee brace, similar to medial collateral ligament reconstructions, is released progressively in flexion-extension during the first month.
Return to contact sports is about 4-5 months after surgery.
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