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Anterior cruciate ligament (ACL)

The anterior cruciate ligament, or ACL, is one of the major ligaments of the knee that is in the middle of the knee and runs from the femur (thighbone) to the tibia (shinbone). It prevents the tibia from sliding out in front of the femur. Together with posterior cruciate ligament (PCL) it provides rotational stability to the knee. An ACL injury is typically a sports-related injury that occurs when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL. When you injure your ACL, you might hear a “popping” sound and you may feel as though the knee has given way. Within the first two hours after injury, your knee may swell and you may have a buckling sensation in the knee during twisting movements. Diagnosis of an ACL tear is made by knowing your symptoms, medical history, performing a physical examination of the knee, and performing other diagnostic tests such as X-rays, MRI scans, stress tests of the ligament and arthroscopy.

Treatment options include both non-surgical and surgical methods. If the overall stability of the knee is intact, your doctor may recommend non-surgical methods. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee. Young athletes involved in pivoting sports will most likely require surgery to safely return to sports. The usual surgery for an ACL tear is an ACL reconstruction which tightens your knee and restores its stability. Your doctor will replace the torn ligament with a graft that can come from you (autograft) or a donor (allograft). Several graft options exist, including bone-patellar tendon-bone (BTB), hamstring, and quadriceps. Your doctor will choose the appropriate graft with you.

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Posterior cruciate ligament (PCL)

Posterior cruciate ligament (PCL), one of four major ligaments of the knee, is situated at the back of the knee. It connects the thighbone (femur) to the shinbone (tibia). The PCL limits the backward motion of the shinbone. PCL injuries are very rare and are more difficult to detect than other knee ligament injuries. Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries. Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I, the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II, there is partial tear of the ligament. In grade III, there is complete tear of the ligament and the ligament is divided into two halves making the knee joint unstable. The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear. Patients with PCL injuries usually experience knee pain and swelling immediately after the injury. There may also be instability in the knee joint, knee stiffness that causes limping, and difficulty in walking. Diagnosis of a PCL tear is made based on your symptoms, medical history, and by performing a physical examination of the knee. Other diagnostic tests such as X-rays and MRI scan may be ordered. X-rays are useful to rule out avulsion fractures wherein the PCL tears off a piece of bone along with it. An MRI scan is done to help view the images of soft tissues better. Treatment options may include non-surgical and surgical treatment. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee. Crutches may be recommended to protect your knee and avoid bearing weight on your leg. Generally, surgery is considered in patients with dislocated knee and several torn ligaments including the PCL. Surgery involves reconstructing the torn ligament using a tissue graft either coming from another part of your body (autograft) or a donor (allograft).

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Posterolateral corner

Posterolateral corner injury is damage or injury to the structures of the posterolateral corner. The structures of the posterolateral include the lateral collateral ligament, the popliteus tendon, and the popliteo-fibular ligament. Injuries to the posterolateral corner most often occur with athletic trauma, motor-vehicle accidents and falls. An isolated injury to the posterolateral corner is rare, but often occurs with injuries to the cruciate ligaments, the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). The dial test where you doctor will determine the rotation of the knee by turning the foot outwards is the most important test to diagnose posterolateral corner injury. If there is increased rotation, it is indicative of an injury to the posterolateral corner. Depending on the severity and extent of injury PLC injuries can be divided into grade 1, 2 or 3. Grade 1 to 2 injuries show 8mm opening and grade 3 injuries show more than a 10 mm opening. Treatment of a posterolateral corner injury depends on the severity of the injury. Grade 1 and grade 2 injuries may be treated conservatively with a knee brace for 8 to 12 weeks. Surgical PLC reconstruction is required for grade 3 injures. A graft, for the reconstruction of the damaged ligaments, can be taken either from the patient’s own body (autograft) or from the donor (allograft). The autograft commonly used for PLC reconstruction is obtained from the hamstring tendon of either the leg undergoing the surgery or from the other leg. Depending on the severity of the injury a PLC reconstruction can be combined with an anterior cruciate ligament (ACL) or a posterior cruciate ligament (PCL) reconstruction.

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Lateral collateral ligament (LCL)

Lateral collateral ligament (LCL) is a thin set of tissues present on the outer side of the knee, connecting the thighbone (femur) to the fibula (side bone of lower leg). It provides stability as well as limits the sidewise rotation of the knee. Tear or injury of LCL may cause instability of the knee that can be either reconstructed or repaired to regain the strength and movement of the knee. The knee is the largest joint of the body and is stabilized by a set of ligaments. In the knee, there are four primary ligaments viz. anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament.

Lateral collateral ligament may tear due to trauma, sports injuries, or a direct blow to the knee. A torn LCL may result in pain, swelling and even instability of the knee. LCL injuries can be diagnosed through a physical examination and by employing imaging techniques such as X-rays or MRI scan.

The treatment of the torn LCL includes non-surgical interventions such as rest, ice, elevation, bracing and physical therapy to help reduce swelling, and regain activity as well as strength and flexibility of the knee. Surgery is recommended if non-surgical interventions is predicted to fail or when implemented, is unsuccessful. Surgical interventions include repair and reconstruction of the torn ligament. Based on the severity and location of the injury, repair or reconstruction of the LCL is recommended. LCL reconstruction involves replacement of the torn ligament with healthy strong tissue or graft. The tissue or graft can be taken either from a donor (allograft) or from the patient’s body (autograft). The type of graft used depends upon the condition of the patient and choice of your surgeon.

Medial collateral ligament (MCL)

The medial collateral ligament (MCL) is one of four major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and is present on the inside of the knee joint. This ligament helps stabilize the knee. An injury to the MCL may occur as a result of direct impact to the knee. An MCL injury can result in a minor stretch (sprain) or a partial or complete tear of the ligament. The most common symptoms following an MCL injury include pain, swelling, and joint instability. An MCL injury can be diagnosed with a thorough physical examination of the knee and diagnostic imaging tests such as X-rays, arthroscopy, and MRI scans. X-rays may help rule out any fractures. In addition, your doctor will perform a valgus stress test to check for stability of the MCL. In this test, the knee is bent approximately 30° and pressure is applied on the outside surface of the knee. Excessive pain or laxity is indicative of medial collateral ligament injury. If the overall stability of the knee is intact, your doctor will recommend non-surgical methods including ice, physical therapy, and bracing. Surgical reconstruction is rarely recommended for MCL tears, but may be necessary in patients whose injury fails to heal properly with residual knee instability. These cases are often associated with other ligament injuries. If surgery is required, a ligament repair may be performed, with or without reconstruction with a tendon graft; depending on the location and severity of the injury.

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