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Soft tissue knee injuries
Jonathan N Lamb
Stephen P Guy
Abstract
Soft tissue knee injuries represent a large spectrum of pathology from
the minor sprain to devastating knee dislocations. Taking a clear,
focussed history and listening to the minutiae that the patient divulges
give clues to the mechanism and thus the suspected patterns of injury.
A thorough knee examination will allow you to narrow your differential
and organize appropriate timely investigations to assist your diag-
nosis. This article aims to give you background information about
the structure and function of the knee and diagnosis of common
knee complaints.
Keywords Collateral ligament; cruciate ligament; knee injury; knee
ligament; Lachman test; meniscus; patella; pivot shift test
Basic functional anatomy
It is vitally important to understand the anatomy and normal
movement of the salient structures of the knee to help you work
out how and why the knee may be injured.
The synovial knee joint consists of three bony structures, the
femur, tibia and patella that form three distinct compartments;
the medial tibiofemoral, the lateral tibiofemoral and the patel-
lofemoral. The knee is held in place by the interplay of the
articular surfaces, the joint capsule the static ligaments and the
dynamic musculotendinous stabilisers.
Patellofemoral joint
This is the largest sesamoid bone in the body and is enveloped by
the fibres of the quadriceps proximally and distally the patella
tendon. The articular surface of the patella has the thickest hy-
aline cartilage in the body, essential because of the large forces
that pass through the joint. There are seven facets to the patella
but it is easier to break it down into a medial and lateral facet and
a median ridge. The patella can be thought of as the under sur-
face of a boat, the keel, that articulates and is stabilized by the
deepened groove of the femoral trochlea. The patella fits
imperfectly into the trochlea groove and the surface contact area
that articulates varies with the degrees of flexion of the knee. For
example the distal patella contacts the trochlea first and with
increasing flexion the contact area migrates proximally up the
patella with increasing knee flexion. Thus direct trauma to the
patella at different flexion angles can cause pathology in different
areas of the patellofemoral joint. The patella stability is main-
tained by different constraints at different flexion angles. In a
fully extended leg the patella is relatively more mobile and is
constrained by both dynamic and static stabilizing structures.
Stability comes from the quadriceps tension, patella retinaculum
and the lateral and medial patellofemoral ligaments (MPFL). The
MPFL conveys as much as 60% of the resistance to lateral
displacement of the patella.
1
As the knee flexes to 30e40the
patella engages with the trochlea which takes over as a bony
constraint. Thus if a patella injury occurs beyond this degree of
flexion then concern has to be raised for an osteochondral injury
to the lateral side of the trochlea or the medial facet of the patella.
Individuals can be at increased risk of patella injury if they have
inadequate depth to their trochlea groove termed trochlea
dysplasia or if their patella is too high (patella alta) (Figure 1).
Tibiofemoral joint
The tibiofemoral joints are condyloid in nature. There is asym-
metry seen in the tibial plateaus with the medial tibial plateau
being more deeply dished or concave and the lateral tibial
plateau being convex. The knee joint is made more congruent by
the menisci.
Menisci
The menisci are crescentic fibrocartilage structures between the
femur and the tibia. Meniscal tears are the most common indica-
tion for surgery to the knee. Each meniscus covers the peripheral
two-thirds of the corresponding surface of the tibia. The peripheral
edge of the meniscus is thick, convex, and attached to the capsule
of the joint. The inner border tapers away to a thin edge. The
meniscus is essentially an avascular structure with only the pe-
ripheral edge (10e20%) having a blood supply from a peri-
meniscal capillary plexus. The blood supply to a torn meniscus
will be important in the decision making whether to preserve and
repair the meniscus or to perform a partial meniscectomy. The
collagen fibres within the menisci are arranged radially and
longitudinally, which gives the menisci strength under compres-
sive loading. The relationship between the loss of a meniscus
leading to early joint arthritis is historically well known.
2
The meniscus has several roles in the knee:
load transmission across the joint
enhances the articular conformity and improves ante-
roposterior stability of the knee
prevents soft tissue impingement during movement
distributes synovial fluid across the articular surface.
Anterior cruciate ligament (ACL)
Despite a lot of research in this area the ACL functional anatomy is
still being explored. The current concept is that the ACL consists of
two bundles
3
ean anteromedial and posterolateral bundle ebut
recent basic science studies have shown that the functional fibres
of the ACL have no bundles and behave more like a ribbon.
4
The
tibial attachment is a broad, oval area just anterior to and between
the intercondylar eminences. The femoral attachment is a semi-
circular area on the posteromedial aspect of the lateral femoral
condyle. The anteromedial bundle is tight in flexion and the
Jonathan N Lamb BSc(Hons) MBBS MRCS is a Specialist Trainee in
Trauma and Orthopaedics at Bradford Teaching Hospitals NHS
Foundation Trust, UK. Conflict of interest: none.
Stephen P Guy BMedSci(Hons) MBBS MRCS(Eng) DipSEM (UK&I) FRCS(Tr &
Orth) is a Consultant Soft Tissue Knee Surgeon at Bradford Teaching
Hospitals NHS Foundation Trust, UK. Conflict of interest: none.
ORTHOPAEDICS IV: LOWER LIMB
SURGERY 34:9 453 Ó2016 Published by Elsevier Ltd.
posterolateral bundle is tight in extension. The ACL is the main
restraint to anterior translation of the tibia on the femur.
Posterior cruciate ligament (PCL)
The PCL attaches to the femur from a broad, crescent-shaped area
in the intercondylar notch on the anterolateral border of the
medial femoral condyle and inserts into a tibial sulcus on the
posterior aspect of the tibia 1 cm below the joint line. The PCL has
two bundles ean anterolateral bundle that is tight in flexion and a
posteromedial bundle that is tight in extension. The PCL is the
main restraint to posterior translation of the tibia on the femur.
Medial collateral ligament (MCL)
The MCL is composed of deep and superficial elements. The
superficial fibres originate from the medial femoral epicondyle
and insert into the periosteum of the proximal medial tibia. The
anterior fibres tighten up during the first 90of flexion and
conversely the posterior fibres tighten up in extension. The deep
MCL is a thickening of the capsule and blends intimately with the
periphery of the meniscus and tibial plateau. The MCL is the
main restraint to valgus force.
Lateral collateral ligament (LCL)
This is a cord-like structure easily palpated when the leg is placed
in a ‘figure of 4’ position. It originates from the lateral femoral
epicondyle and inserts onto the lateral aspect of the fibula head.
As it is posterior to the axis of knee rotation the LCL is tight in
extension and lax in flexion. The LCL helps resist varus force.
Posterolateral corner (PLC)
This is a complex area of the knee with more than 25 elements
described, of which the LCL is a constituent. Some structures are
not always present. The main stabilizers consist of the biceps
femoris, iliotibial band, popliteus, popliteofibular ligament and
thickenings of the joint capsule.
Posteromedial corner (PMC)
This is becoming increasingly recognized now during injury
patterns and injury to this area will convey rotational instability.
The posteromedial corner consists of capsular thickening of the
numerous insertions of semimembranosus and the posterior
oblique ligament (POL).
Movement of the knee (kinematics)
The motion seen on the knee joint is a combination of rollback
and sliding at the articular surfaces. This allows for the femur to
clear the tibia and thus allow for a greater degree of flexion. This
also increases the lever arm of the quadriceps muscles
increasing the efficiency. During knee flexion the centre of
rotation of the joint moves posteriorly. MRI has shown that the
rollback seen is much more in the lateral compartment of the
knee compared to the medial compartment hence the tibia
internally rotates relative to the femur in flexion. The asym-
metry of the tibiofemoral compartments allows almost 30of
axial rotation through the full range of motion. As the knee
enters final extension, the tibia externally rotates relative to the
femur. This is termed the screw-home mechanism and helps
lock the knee in maximum stability in full extension. The action
of popliteus muscle causes internal rotation of the tibia relative
to the femur and ‘unlocks’ the knee.
History
There is no doubt that when faced with an acutely injured knee it
can be a daunting prospect, but taking a focussed history is the
most effective way to elucidate and narrow down how significant
the knee injury may be and where the pathology or pathologies
lie. Also be mindful in children that a history of a knee injury
does not exclude the possibility of a sarcoma. Did they land
awkwardly? Was the foot fixed when they changed direction
quickly? Are they on anticoagulants? Depending on the force that
was passed through the knee will lead you to suspect certain
patterns of injury (Table 1). I like to use a ‘LIMP’ index I
devised.
5
Key symptoms of a sporting intraarticular injury
include Leg giving way, Inability to play on, Marked effusion and
aPop or snap eLIMP. This is easy to remember specifically for
non-specialists and allows healthcare professionals to identify
potentially significant soft tissue knee injuries so they are not
discharged to re-injure their knee. Below are some examples of
salient questions to ask and examples of issues they will uncover.
This list is not exhaustive and there will be overlapping potential
pathology that can be further explored during examination.
Pain?
Point with one finger as to where the pain is. Onset,
duration, exacerbating and relieving factors. Someone who
has posterior pain in the popliteal fossa area and pain
made worse by kneeling would raise concern for a PCL
injury. Posteromedial joint line pain implies meniscal
pathology.
Figure 1 Axial MRI scan showing characteristic ‘bone bruising’to the
medial aspect of the patella and the lateral femoral condyle seen in a
patella dislocation. In this case the trochlea is flat and dysplastic and is
a significant risk factor for patella dislocation. They also have an
effusion and have injured their medial patellofemoral ligament.
ORTHOPAEDICS IV: LOWER LIMB
SURGERY 34:9 454 Ó2016 Published by Elsevier Ltd.
Giving way, locking, tearing sensations, pops or
snaps?
Locking usually indicative of a meniscal injury or ACL
injury. Locking is when the knee is unable to be fully
extended.
Popping or tearing implies significant meniscal or ligament
injury
Swelling, speed of onset?
Rapid onset swelling implies something is bleeding inside
the knee. Can be seen with patella dislocation, intra-
articular fracture, osteochondral injury, ACL rupture, pe-
ripheral meniscal tear.
Recurrent swelling after repeated activity implies meniscal
pathology.
Examination
Look
Inspection of the standing patient is not always possible due to
pain but it will give more information regarding alignment of the
non-injured leg and injured leg in coronal (fixed flexion or gross
hyperextension) and sagittal planes (varus and valgus align-
ment). Expose the patient to have a view of the injured leg and
always compare with the uninjured side. Look for scars of pre-
vious surgery and an effusion. Bruising is a sign that the capsule
has been torn or extra-articular structures are injured. Bruising is
certainly worrying for a more significant knee injury. Bruising in
the popliteal fossa or posterolateral corner implies PCL or PLC
injury. If bruising is severe and global then concern has to be
raised about the possibility of a knee that has dislocated. If the
knee is able to flex then you may see a posterior sag, implying an
incompetent PCL. A gap may be visible in the extensor mecha-
nism with an associated high or low riding patella when the
patella or quadriceps tendons have torn respectively.
Feel
Feel for temperature of the knee. Assess for minimal effusion by
sweeping fluid from medial to lateral and back again for a sweep
test. For large effusions a patella tap may be possible. An effusion
may not be sizeable in injuries that have torn the capsule of the
knee as seen in higher energy knee injuries. Thus a small
effusion may not be a reassuring sign in the presence of bruising
and swelling around the knee and calf. Bony landmarks should
then be palpated including the joint lines. You will put the patient
more at ease by feeling the non-tender structures of the knee
first. Gaps may be palpable in extensor mechanism injuries. In
PCL injuries the prominence of the anteromedial tibial joint line
may be indistinct (step-off test) compared to the other side
implying PCL injury. Tenderness on the medial and lateral joint
line implies meniscal injury. Finally check for a popliteal artery
aneurysm and neurovascular status of the limb.
Move
With the leg outstretched perform a straight leg raise to assess
extensor mechanism function. If it is weak or painful then there
may be an extensor lag. Now ask the patient to flex and extend the
knee. In a minimally swollen knee it may be possible to visually
assess patella tracking during flexion and extension. Document
the range of motion and any loss of movement in comparison to
the non-injured side and measure the passive range of motion. If
there is limited flexion it may help to sit the patient up and allow
the knee to bend under gravity over the side of the examination
couch. A very sensitive test for an injured limb is the loss of end
extension, easily checked by picking up both legs by the great toes
at the end of the bed. This also will pick up any abnormal hyper-
extension in the limb and concern for combined serious knee lig-
ament injuries that involve the posterior capsule. Injured menisci
may cause a true locked knee (one that can flex well but will not
fully extend) and injuries to the patella can cause pseudo locking
(one that can fully extend but will not flex). Always examine the
joint above and below. ALWAYS examine the hip in children.
Special tests
Collateral ligament stress testing
Varus or valgus stress testing of the collateral ligaments should be
performed with the knee in full extension and at approximately
30of flexion. Collateral ligament injuries can be graded according
the American Medical Association
6
(Table 2). The gaps may be
hard to feel to an inexperienced examiner. A simplified assess-
ment is Grade I injuries generally include tender ligaments but no
real laxity, Grade II injuries have increased laxity with a solid end
point and Grade III injuries have large laxity with no end point.
Significant joint opening with the knee extended usually infers a
Grade III collateral injury with a cruciate and capsular injury.
Anterior cruciate ligament (ACL)
The Lachman test demonstrates increased anterior translation of
the tibia in comparison to the femur in a knee bent to 30(video).
The distal femur can either be held between the examiner’s thigh
and hand (big legs) or in the examiners hand (small legs). This
test has sensitivity of 80% and specificity of 95%.
7
The degree of
laxity and end feel (soft or hard) of the Lachman test is what needs
to be recorded in the notes. Laxity is graded in 5-mm increments
compared to the uninjured side just like the MCL laxity grading.
Supplementary data related to this article can be found online
at http://dx.doi.org/10.1016/j.mpsur.2016.07.008.
The pivot shift test has a sensitivity of 90% and specificity of
95%.
7
The pivot shift test is a rotational test of the knee. This can
Suspicion of injury based on direction of force
Mechanism/direction of
force
Suspicion of injury
Twisting Anterior cruciate ligament (ACL), posterior
cruciate ligament (PCL), meniscus,
osteochondral injury
Varus Lateral collateral ligament, posterolateral
corner, PCL, meniscus
Valgus ACL, medial collateral ligament, meniscus
Hyperflexion Meniscus, patella, quadriceps and patella
tendon
Direct blow Fracture, osteochondral injury, PCL,
extensor mechanism
Table 1
ORTHOPAEDICS IV: LOWER LIMB
SURGERY 34:9 455 Ó2016 Published by Elsevier Ltd.
be hard to achieve in an acutely injured knee and at best you will
have one chance of getting it right. The patient has to be put at
ease and has to be confident you are protecting the knee. The test
is then commenced by extending the knee and gently internally
rotating the tibia. The hip is abducted to relax the iliotibial band
and a valgus force is applied to the knee. If the ACL is abnormal
then the internal rotation movement will cause anterior sublux-
ation of the anterolateral tibia relative to the femur. The tibia is
held in this position and the knee is flexed slowly. As the knee is
flexed the tibiofemoral joint is reduced with a palpable clunk due
to the iliotibial band moving from anterior to posterior to the
centre of rotation of the knee. This test relies on an intact or non-
tender MCL to put valgus force against. Equally if there is a torn
displaced meniscus into the intercondylar notch then the test will
not work. Anterior drawer testing is the most well known but has
poor sensitivity and specificity in comparison to other tests.
Posterior cruciate ligament (PCL) stress testing
An incompetent PCL can be demonstrated by posterior sag of the
tibia with the knee bent to 90(Figure 2). PCL incompetence is
also demonstrated by reduced prominence (step off sign) of the
anteromedial tibial plateau with the knee bent to 90. Grading of
the PCL injury is based on posterior subluxation of the tibia
relative to the femur and compared to the uninjured knee. Grade
I tear is a minor sprain with up to 5 mm of laxity and the tibia still
feels anterior to the femur. Grade II tears the tibial step off feels
indistinct, representing 6e10 mm of posterior sag. With grade III
tears the PCL is injured with greater than 10 mm of posterior
translation. The PCL can be stressed by pushing the proximal
tibia backward and feeling for range of motion, tenderness and
the end point feel.
Posterolateral corner stress testing
With the patient prone on the examination couch and knees held
together by an assistant, the knees are flexed to 30and the feet
firmly externally rotated. The examiner compares the external
rotation seen and any increased rotation beyond 15is seen to be
abnormal. This test can be repeated at 90of flexion to examine
the PCL. An injured PCL is demonstrated when the injured leg
externally rotates more than 15than the normal side at 90knee
flexion.
Meniscal provocation tests
Many tests exist to provoke an injured meniscus. The least
painful and most sensitive is the demonstration of tenderness in
the medial or lateral joint line. The most notable is the McMurray
test, which has a reposted sensitivity of 27e70% and poor inter-
rater reliability.
7
The patients knee is fully flexed and either
internally rotated (to provoke the medial meniscus) or externally
rotated (to provoke the lateral meniscus) then extended. A
meniscal tear may become apparent when the examiner feels a
click in the joint line.
Imaging
Anteroposterior X-rays
The Ottawa knee rules
8
are helpful in emergency practice to help
in decision-making but in practice all soft tissue knee injuries I
see have plain radiography performed (Box 1). Look out for
subtle fracture lines along the joint surfaces. In younger patients
assess tibial spines to rule out tibial spine avulsion, which is the
Clinical grading of medial collateral ligament injuries
Grade I 0e5 mm opening
Grade II 5e10 mm opening
Grade III >10 mm opening or no end point
Table 2
Figure 2 These surgical images are from a dislocated knee. Bruising can be seen in the thigh and calf areas. The image on the left shows the
tibia reduced under the femur at 90. The image on the right shows a minimal posterior force applied to the knee revealing a grade III posterior
drawer test.
ORTHOPAEDICS IV: LOWER LIMB
SURGERY 34:9 456 Ó2016 Published by Elsevier Ltd.
paediatric manifestation of a cruciate ligament injury. In adults
ACL injury is predicted by the presence of lateral tibial avulsion
fractures or ‘Segond fractures’. This is seen now as an avulsion of
the anterolateral ligament (ALL) of the knee. The ALL remains an
area of discussion at present about both the anatomy of the lig-
ament and thus the techniques and indications to reconstruct the
ligament.
9
Increased joint spaces suggest medial or lateral
collateral ligament injury. Collateral ligament injury may also be
demonstrated by small avulsion fractures about their respective
points of origin and insertion. Posterior lateral corner injuries
may be demonstrated with proximal fibula avulsion fractures.
Lateral X-ray
Subtle patella fractures that are unclear on an anteroposterior
X-ray will be more visible on a lateral film (Figure 3). Look for fat
fluid interface of a lipohaemarthrosis in the suprapatella pouch
which will suggest fracture or osteochondral injury. Assess pa-
tella height and parapatella soft tissue shadow. Patella alta with
large soft tissue swelling about the infrapatella area may suggest
patella tendon injury. A low patella (baja) with large supra-
patellar soft tissue swelling may suggest quadriceps tendon
rupture. Assess the relative position of the tibia with respect to
the femur. An injured PCL can lead to a posterior sag of the tibia
on lateral radiograph.
Magnetic resonance imaging (MRI)
MRI is a highly sensitive and specific mode of imaging in the
acutely injured knee. It is the most useful imaging modality for
assessment of ligament injuries, meniscal injuries and osteo-
chondral injuries. It can also pick up avascular necrosis (AVN)
and spontaneous osteonecrosis of the knee (SONK) which may
present as an injury (Figure 4).
Computed tomography (CT)
CT is better at picking up and defining fractures that extend into
the joint. The images can be helpfully reconstructed to provide
three-dimensional images (Figure 5).
Ultrasonography (US)
The main benefit from this modality is that it is a dynamic and
readily available test to perform. The main negative is that ul-
trasound is dependent on the skill-set of the person performing
the scan. The main role is in imaging the extensor tendons.
Common injury patterns and management
Anterior cruciate ligament injury
History:
Classically a non-contact pivoting injury. ‘My foot was
fixed.’
Audible pop with rapid haemarthrosis
Inability to play on
Examination:
Lachman and pivot shift positive
Tender lateral joint line from bone bruising or meniscal
tear
Investigation:
X-ray eeffusion/lipohaemarthrosis, Segond fracture,
tibial spine avulsion
MRI epivot shift pattern of bone bruising affecting the
posterior aspect of the lateral tibial plateau and ‘sulcus’
area of the lateral femoral condyle. Associated lateral
meniscal tears. Indistinct ACL or PCL appearing buckled.
Treatment:
Low physiological demand patients may benefit from non-
operative management with focussed physiotherapy.
Figure 3 Lateral X-ray showing clearly a fracture to the patella sus-
tained from a direct anterior blow to the knee.
Ottawa knee rules: indication for radiology
CAge 55
CIsolated patella tenderness
CTenderness at head of fibula
CInability to flex knee to >90
CInability to weight bare (>4 steps) at time of injury or in emer-
gency department
Box 1
Figure 4 MRI scan showing the characteristic findings of increased
oedema around the lateral femoral condyle (at the sulcus terminals)
and the posterior tibial plateau.
ORTHOPAEDICS IV: LOWER LIMB
SURGERY 34:9 457 Ó2016 Published by Elsevier Ltd.
ACL reconstruction as soon as inflammatory stage settled
after pre-habilitation from physiotherapy. Concomitant
meniscal injuries repaired if able.
Posterior cruciate ligament injury
History:
Direct blow to the anterior tibia with the knee flexed e
‘dashboard injury’.
Hyperextension/hyperflexion or a fall from height onto
plantarflexed foot
May have ‘played on’
Examination:
Posterior drawer test with loss of normal tibial step off/
tibial sag
Collateral or posteromedial/posterolateral corner injury
neurovascular injury with foot drop.
Bruising posteriorly
Minimal effusion if the capsule is torn
Investigation:
X-ray eavulsion fractures of the posterior cruciate
ligament
MRI esoft tissue avulsion/rupture of the PCL and asso-
ciated injuries.
Management:
Lower grade injuries splinted to correct tibial sag and
rehabilitated
Operative intervention in bony avulsion fractures, when
associated with other ligament injuries and in failed con-
servative measures.
Medial collateral ligament injury
History:
Valgus stress to the knee
Make sure not dislocated the patella emedial pain may be
due to retinacular/MPFL tear not MCL tear.
Examination:
Pain and laxity on valgus stress testing
Tender mainly at the femoral insertion of the MCL
Medial bruising
Investigation:
X-ray eavulsion fractures mainly seen from femoral
insertion.
MRI enot usually needed as MCL injury is clinical. Helps
with associated injuries such as meniscal tears. If the MCL
grossly lax then an urgent MRI helpful to see if the MCL
has flipped into the joint or outside the pes anserinus
tendons in which case the MCL will not spontaneously
heal and need surgical intervention.
Posterolateral corner injury
History:
Varus/hyperextension injury to the knee
Injuries rarely isolated
High index of suspicion from foot drop or ‘pins and nee-
dles’ down lateral side of the leg
Examination:
Hyperextension and varus of the knee when lifted up by
great toe
Abnormal neurology in the territory of the peroneal nerve
Bruising and tenderness around the posterolateral corner
Increased varus on stress testing
Positive dial test
Associated ligament injury
Investigation:
X-ray eavulsion fracture or fracture around the fibula
head
MRI eoedema and swelling around the multiple struc-
tures of the posterolateral corner
Treatment:
Low-grade injuries can be braced and must be initially
non-weight bearing
Figure 5 Three-dimensional reconstruction views of a complex frac-
ture involving the distal femur and the knee. The images can be rotated
and viewed from numerous angles and assists greatly with surgical
planning.
ORTHOPAEDICS IV: LOWER LIMB
SURGERY 34:9 458 Ó2016 Published by Elsevier Ltd.
High-grade injuries if picked up within 2 weeks benefit
from early repair/reconstruction/augmentation. Chronic
instability may require an osteotomy prior to posterolateral
corner reconstruction.
Multi-ligament knee injury/dislocated knee
History:
High-energy injury. High index of suspicion in any
motorcycle injury
Low-energy injury in obese, valgus, hypermobile patient
Beware knee may have ‘come out of joint’ and may present
spontaneously relocated
Pins and needles, numbness, foot drop.
Examination:
Pain
Diffuse bruising and swelling
Full neurovascular examination efirst dorsal webspace,
peroneal muscle power, pulses, ankle brachial pressure
index (ABPI) (involve vascular/plastics team early if sus-
pect dislocated knee)
Investigation:
X-ray
MRI (MR angiogram)
VasculareABPI/duplex/angiogram
Treatment:
Multidisciplinary approach
Urgent surgery if open dislocation, irreducible dislocation
‘medial pucker sign’ or a vascular injury.
Soft tissue resuscitation and reduction of inflammation.
Decision-making to operate is unique to the injury pattern
and the patient. Some injury patterns can be braced and
have delayed reconstruction (ACL and MCL). Some pat-
terns will require early definitive surgery (PCL and PLC or
PMC).
Meniscal injury
History:
Traumatic in the younger athlete, degenerate in older pa-
tients with insidious onset
Twisting/deep flexion
Swelling
Locking/popping/clicking/giving way
Examination:
Effusion
Joint line tenderness
Locked knee
Investigation:
X-ray
MRI
Treatment:
Meniscal repair in peripheral longitudinal tears in physio-
logically young patients. Simple augmentation of the repair
may improve healing rates evascular channels, micro-
fracture to the notch
Higher healing rates with concomitant ACL reconstruction
Partial resection to all complex/degenerate tears
Consideration in select individuals a meniscal scaffold or
meniscal allograft
10
A
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FURTHER READING
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