This document discusses principles and management of ligamentous knee injuries. It covers the mechanisms of injury, classification, anatomy and biomechanics of the ACL, PCL and meniscus. It also discusses clinical assessment including special tests, imaging, treatment options of non-surgical rehabilitation versus surgical reconstruction, and post-operative rehabilitation. The take home message is that isolated grade 1-2 ligament injuries can often be managed non-surgically, while reconstruction has better outcomes for collateral ligaments and goals of rehabilitation focus on range of motion, graft protection, proprioception and muscle strength recovery.

1. PRINCIPLES AND MANAGEMENT OF
LIGAMENTOUS INJURY AROUND KNEE
BY Dr Akash Kumar

2. INTRODUCTION
•Kneeligamentsoftenareinjuredinathletic activities,
especiallythoseinvolving contact.
•Motorvehicleaccidents,especially thoseinvolving
Motorcycles.
•Ligamentdisruption canoccurwhensevereloading
ortensionisplacedontheligaments, suchaswhena
running athleteplantsafoottosuddenlydecelerateor
changedirections.

3. MECHANISM OF INJURY
• Four mechanisms capable of disrupting the
ligamentous structures about the knee:
• (1) abduction, flexion, and internal rotation of
the femur on the tibia,
• (2) adduction, flexion, and external rotation of
the femur on the tibia,
• (3) hyperextension,
• (4) anteroposterior displacement

5. CLASSIFICATION

6. ANTERIOR CRUCIATE LIGAMENT AND ITS
BIOMECHANICS:
ORIGIN
- From the posteromedial corner of medial aspect of lateral femoral condyle in
the intercondylar notch
INSERTION
- Fossa in front of & lateral to anterior spine of tibia
Most common knee injury among athletes

7. Anterior CruciateLigament
CLINICAL IMPORTANCE
- Anteromedial bundle is tight in
flexion and
The posterolateral bundle is tight in
extension
- In extension both bundles are
parallel
- In flexion both bundles are crossed (LEFTKNEE)

8. ACTION:
These attachments allow the ACL to resist anterior translation and
medial rotation of the tibia, in relation to the femur.

9. ACL:Diagnosis: Examination
SYPMTOMS:
When ACL is injured , pt might hear a
"popping"noise(breakage of torn ACL)
Other typical symptoms include:
-Pain with swelling (haemarthosis ,
osteochondral fracture +or-patellar
dislocation)
-Loss of full range of motion
-Discomfort while walking
-Feeling of give way/instability?

10. PHYSICAL EXAMINATION:
INCLUDE
ANTERIOR DRAWER TEST(False +?,False -?)
LACHMAN’S TEST(advatages)
PIVOT SHIFT TEST(instability)
Garde
Most sensitive
Firm and soft end point

11. ACL:Diagnosis: Imaging
X-ray

12. MRI

13. ACL:Treatment
Immediately after injury
R.I.C.E (Rest Ice Compression Elevation)
Non surgical treatment
INDICATION
- partial tears and no instability symptoms
- complete tears and no symptoms of knee
instability
- Who do light manual work or live sedentary
lifestyle.

14. NON SURGICAL TREATMENT
•Subjective instability
•Recurrent attack of giving way
•Multiligament injury
Indications:
Surgical Treatment
Activity modification (swimming,
bicycling, jogging on flat
ground)
 Muscle Training (Hamstrings
strength)
 Proprioceptive Training
 Bracing (reduce anterior drawer)

15. SURGICAL TREATMENT:
The grafts commonly used to replace the ACL
Include
AUTOGRAFT:
Hamstring tendon
Bone patella tendon bone
Quadriceps Tendon
Peroneal tendon
ALLOGRAFT:
patellar tendon, fascia lata /iliotibial band
Achilles tendon,tibialis anterior
semitendinosus,gracilis,orposteriortibialistendon

16. TECNIQUES IN ACL RECONSTRUCTION:
•Single bundle reconstruction
• Double bundle ACL reconstruction
Anatomical Single-
Bundle Technique
Advantages:
1) Simplicity
2) Broad spectrum of
grafts
3) Simpler graft passage
4) Lower cost
Double-Bundle Technique
Advantages:
1) ?Better rotational
stability
Disadvantages:
1) technically demanding
2) Longer operating time
3) Limited graft selection

17. REHABILITATION:
Phase 1:(1st 4 weeks)
Limb immobilized in locked hinge brace in extension during
ambulation.
Full EXTENTION TO 100-110 degree of flexion is desirable at end of
this phase
PHASE 2:(5 -12 WEEKS)
AIM: Achieve full ROM.
Exercises for quadriceps.(closed chain and open chain)
PHASE 3:( AFTER 12 weeks)
Impact loading activities like jogging and double leg hopping.
PHASE 4:
Deals with patient getting back to preinjury status.

18. POSTERIOR CRUCIATE LIGAMENTS AND ITS BIOMECHANICS
ORIGIN:
Posterior part of lateral surface of medial femoral condyle.
INSERTION:
Behind the intraarticular portion of tibia, blending with posterior horn
of lateral meniscus.
FUNCTION:
•The function of the PCL is to prevent the femur from sliding off the
anterior edge of the tibia.
• Prevents hyperflexion of the knee to a lesser extent with ACL but its
main function is to check extension and hyperextension.

19. Posterior CruciateLigament
Broader, longer, stronger
MECHANISM:
DASHBOARD INJURY
• Hyperextension injury
• (any mechanism that involves the knee to
be forced posteriorly can leads to pcl injury)
CLINICAL PICTURE
• Patient suffer of:
1. Pain (Specially on walking downstairs)
2. Instability
3. Swelling due to knee effusion(mild)
4.Giving way (+or -)

20. PCL:Diagnosis
Posterior drawertest
Quadriceps active test
Absence of normal tibial
steps
Reverse pivot shift test
Gravity orsag
test(godfrey sign)
Hips at 45 or
90,compare tibial
tuberosities forsag
negative
positive

21. Xray and MRI

22. The aim of the conservative therapy is to regain 90% of the
quadriceps and hamstring strength compared to health side
Treatment steps:
A. Bracing (calf pad)
B.Quadriceps conditioning
C. Proprioceptive training
•Splinting in extension & protected weight-bearing.
•As pain diminished physical therapyis started focusing on
range of motion and quadriceps strengthening.
•4-6 weeks later weight-bearing should start.
•Return to sport should not before 3 months from injury
NON OPERATIVE TREATMENT

23. Indications:
• high grade injuries (grade3).
• AnyPCLinjury withother associatedinjuries.
• Anybony avulsion( internal fixation should be
usedif the fragmentsislarge)
• Reconstructionispreferable if smallfragments.
• Chronic lesion:according to symptomsand
disability and respond to conservation
SURGICAL TREATMENT

24. PCL TEAR without avulsion
• Tibia tends to move posteriorly ..if we
increase the anterior slope of tibia
• Change the slope by high tibial osteotomy
CHRONIC PCL INJURY
• ACL and PCL Both tear …PCL must be
reconstructed…PCL first
• Grade 1 in non active.. conservative brace
• Grade 3 always reconstructed
• Grade 2 depends on need and demand

25. Physiotherapy is crucial after PCL reconstruction.
In contrast to ACL reconstruction, gravity tends to
stretch the PCL graft.
Therefore, some specific techniques of physiotherapy
(prone position) and a slower pace, compared to the
accelerated rehabilitation of ACL injury.
REHABLITATION:

26. MENISCAL TEAR
YOUNGER PEOPLE WITH SIGNIFICANT TRAMA
MEDIAL MENISCCAL TEAR IS MORE COMMON
SIGNS AND SYMPTONS
• JOINT LINE TENDERNESS (POSTERIOR JOINT LINE)
• FEELING OF LOCKING AND GIVING WAY OF
KNEE(LOSS OF TERMINAL EXTENSION)
• DELAYED OR INTERMITTENT SWELLING(DUE TO
REACTION OF SYNOVIUM)
• QUADRICEPS WASTING

27. SPECIAL TEST
McMurray’s test Apley’s test
Thessaly’s test Bounce home test

28. Management
REPAIR
• ACUTE
• OUTER 3rd of
meniscus in young
patient
• Make the knee stable
also by repairing the
other structure
REMOVE
• CHRONIC INJURY
• Inner 23rd of meniscus
• Old individual
• In unstable knee

29. ROTARY INSTABILITY AROUND KNEE
ANTEROMEDIAL ROTARY INSTABILITY:-
• ANTERIOR MEDIAL TIBIAL PLATEAU CAN BE
ROTATED EXTERNALY MORE THAN NORMAL
• Occur due to injury to medial structure like
Medial collateral ligament, posterior oblique
ligament , along with ACL
TEST
Slocum test in ER
valgus stress in 30 deg

30. ANTEROLATERAL ROTARY INSTABILITY:-
• INCREASED INTERNAL ROTATION OF LATERAL TIBIAL
PLATEAU AS COMPARE TO NORMAL
• Occur due to injury to lateral capsular ligaments along with
the ACL
TEST
SLOCUM IN INTERNAL ROTATION
VARUS STRESS IN 30 DEGREE OF FLEXION

31. POSTEROLATERAL ROTARY INSTABILITY:-
(COMMENEST)
• ON EXTERNAL ROTATION
POSTEROLATERAL CORNER OF TIBIAL
PLATEAU ROTATED POSTERIORLY
• Occur due to damage to posterolateral
structure like popliteus tendon , arcuate
ligament complex, lateral capsular
ligament , posterolateral capsule , with
or without PCL

32. TEST
DIAL TEST
POSTEROLATERAL DRAWER TEST
DIAL TEST+ ONLY IN 30
DEGREE FLEXION PLC
INJURY ONLY
DIAL TEST + IN BOTH 30
DEGREE AND 90 DEGREE
FLEXION PLC AND PCL
injury both is present

33. POSTEROMEDIAL ROTARY INSTABILITY:-
(RAREST)
• OCCUR DUE TO INJURY TO MCL,POSTEROMEDIAL
CAPSULE,POSTERIOR OBLIQUE LIGAMENT
,SEMIMEMBRANOSUS
• Medial tibial plateau tends to move posteriorly
differencialy when one try to do posterior drawer
test

34. TAKE HOME MESSAGE
•KNEE LIGAMENT INJURY IS ON A RISE IN OUR COUNTRY AS MANY
TAKING UP SPORTS AS A PROFESSION.
•ALL ISOLATED LIAGAMENT INJURY(GRADE 1 AND 2) CAN BE
MANAGED CONSERVATIVELY
•RECONSTRUCTION OF COLLATERAL LIGAMENTS HAVE BETTER
RESULTS THAN REPAIR.
•GOALS OF REHABILITATION ARE
1.ACHEIVE FILL RANGE OF MOTION.
2.PROTECTION OF GRAFT
3.PROPRIOCEPTION
4.ATTAINING ATLAEST 90% OF MUSCLE STRENGHT COMPARED
TO UNINJURED LIMB.

35. THANK YOU