MEDIAL COLLATERAL LIGAMENT SPRAIN
- Ligament injuries of the knee can occur in combination
or in isolation. Depending on the application of the forces,
a ligament injury can occur from a direct force, a rotary force,
or a combination of the two.
- The majority of knee sprains can affect the MCL from
1. direct blow to the lateral aspect of the knee or
2. from a forceful outward twist.
- The MCL has fibers that connect to the medial meniscus,
so injury to the MCL can also damage the meniscus structure.
- The LCL, on the other hand, does not have fibers
that connect to the lateral meniscus, so when the LCL is
damaged, the meniscus is usually in tact.
- This is why injuries to the MCL are more severe than
injuries to the LCL.
- Some medical authorities suggest
that a torn meniscus seldom occurs as a result of
initial trauma, rather resulting from past trauma to
- MCL sprains vary in degree:
a. depending on the position of
the knee at the time of injury,
b. past injuries to the knee,
c. the strength of the muscles crossing
d. the force and angle of trauma,
e. fixation of the foot, and
f. conditions of the playing surface.
- Full extension of the knee tightens both
the MCL and the LCL and is the most stable position
of the knee.
- Full flexion is the most unstable position for the knee.
- In general, instability increases as flexion increases.
- In full flexion, the LCL is very unstable, while the MCL
still provides some strong stability to the knee joint.
Suffice to say, the MCL is the primary stabilizer of the knee
in knee joint flexion.
- Mild or moderate strains to the knee can leave the
structure relatively unstable and can increase the probability
- The force and the angle of the trauma determine the
location and degree of the trauma incurred.
GRADING OF SEVERITY:
Grade 1 Medial Collateral Ligament Sprain
– In a grade 1 sprain, a few ligamentous fibers
are torn or stretched.
- However, the joint still remains
stable, with little to no joint effusion
(fluid accumulation). There may be some local
stiffness and/or point tenderness along the
medial aspect of the joint line but even
during minor stiffness, range of motion is
- After this injury is incurred, the PRICE
acronym should be observed for the first
24 hours following trauma.
- Crutches can be prescribed, but this is
usually not the case with a grade 1.
- Ice may be applied for 5 minutes before
activity for the next 48-72 hours.
- Knee joint rehabilitation techniques
should be employed at this time as well.
- Begin with isometric exercises until the
knee can be flexed without pain.
- Then the stationary bike can be used
to integrate the knee back into the kinetic
chain of movement.
-It usually takes about one to three weeks
for an athlete to return to normal athletic activity
after suffering this injury. When returning to activity,
taping or bracing may be necessary for a short time,
but these methods should not be heavily relied upon
for preventing another injury.
Grade 2 Medial Collateral Ligament Sprain
– A grade 2 MCL sprain consists of both microscopic
and gross disruption of ligamentous fibers.
- The structures commonly involved are the MCL
and the medial capsular ligament.
- A complete tear of the deep capsular ligament
and a partial tear of the superficial layer of the MCL
or a partial tear of both areas can be present.
- There is usually little instability, but there will
be slight laxity of the knee joint in extension,
and increases with knee joint flexion.
- Swelling will be minimal unless the meniscus or
ACL has been torn.
- Extensive swelling in the acute stage of a
grade 2 injury may indicate a torn synovial membrane,
subluxated or dislocated patella, or an
- Moderate to severe joint tightness will also
- The athlete will be unable to place the heel
flat on the ground.
- A severe loss of range of motion will be present,
as well as pain on the medial aspect of the knee.
- PRICE should be observed immediately and last for
48 to 72 hours.
- Crutches are mandatory, as well as a three point
gait device until the athlete can walk without a limp.
- Depending on the severity of the injury,
a full leg cast may be necessary, but should only be
applied for two to five days.
- Range of Motion exercises should begin
immediately following the acute stages of the injury.
- During rehabilitation, isometric exercises,
especially for the quadriceps, should be conducted,
as well as closed kinetic chain exercises.
Grade 3 Medial Collateral Ligament Sprain
– A grade 3 MCL sprain consists of a complete
tear of the supporting ligaments.
- Some signs of a complete tear include a
complete loss of medial stability, minimum
to moderate swelling, immediate and severe pain
followed by a dull ache, severe loss of range of
motion due to effusion, and positive stress tests.
- Isolated grade 3 MCL sprains occur when a direct
force is applied laterally to the knee when the foot
- Grade 3 tears of the MCL due to a rotation
movement usually results in ACL and sometimes
PCL tears as well.
- PRICE should be followed
for twenty minutes every two hours throughout
the day for at least 72 hours.
- Surgery may be imminent, but new evidence
suggests that non-surgical procedures treating an
MCL tear where the ACL and PCL are also affected
may be more beneficial to knee joint stability than
LATERAL COLLATERAL LIGAMENT SPRAIN
- Sprain of the LCL is much less common than sprains to
- Varus forces with the tibia internally rotated will cause
- A direct blow to the medial aspect of the knee is rare,
so it is usually indirect forces that cause the sprain.
- If the force is severe enough, the cruciate ligaments,
the iliotibial band, and the biceps femoris muscle may be torn.
- The meniscus structures may be damaged as well.
- Avulsion fractures can occur on the femur or the tibia,
and sometimes on the fibula via a combined pull of the
LCL and the biceps femoris on the head of the fibula.
- The collateral ligaments are so strong that they can break
the bone before they tear off of it.
- Major signs of an LCL injury:
a. pain and point tenderness over the LCL
b.palpable deformation when the knee is
flexed and internally rotated.
c. Swelling and effusion will also be present
over the LCL,
d. joint laxity and
e. degrees of pain
- An injury to the peroneal nerve may also be present,
causing temporary or sometimes permanent palsy.
common peroneal nerve
- originates from the sciatic nerve and lies
beneath the head of the fibula and winds laterally
around the neck of the fibula, where it branches
off to form the deep and superficial peroneal nerves.
-A tear of this nerve can produce weakness
and paralysis to the lateral aspect of the lower leg.
- Management of LCL sprains is nearly identical to that
of MCL sprains.
ANTERIOR CRUCIATE LIGAMENT SPRAIN
- An ACL sprain is the most critical ligament injury in
- When the tibia is externally rotated and the knee
is in a valgus position, the ACL is most vulnerable.
- The ACL can sustain an injury from a direct blow to
the knee when the leg is rotated while the knee is fixed.
- In this position, the ACL becomes taut and susceptible to
- Tears of the ACL, combined with injury to other
surrounding structures in the knee, can produce rotary
- Anterolateral rotary instability may involve injury to
the anterolateral joint capsule, the LCL, and possibly
the PCL and structures in the posterolateral corner.
- Anteromedial rotary instability usually involves injury to the
antermedial capsule, the MCL, PCL, and posteromeidal corner.
- A hyperextension from a blow to the front of the knee
with the foot planted can tear the ACL and possibly sprain
- Female athletes are much more likely to suffer noncontact
ACL injuries than are males.
Extrinsic factors include the
a.level of conditioning,
b. skill acquisition,
c. playing style,
d.the amount of physical preparation and practice,
e. environmental considerations, and
f. types of equipment used.
- These factors can be somewhat controllable
Intrinsic factors involve:
a. individual physiological and
b. psychological factors
1.Femoral condyler notch size,
3. ACL laxity, and
4.lower extremity anatomic malalignment
- There is no consensus on whether sex-specific
hormones play a role in the increased incidence of
ACL injury in female athletes, thus there appears to be
no reason to modify activity or restriction from sport of
female athletes at any time during the menstrual cycle.
- Since the ACL is intimately connected into the kinetic
chain, forces acting upon other body parts can have an
effect on the ACL.
- Impact on the foot or heel rather than on the toes
during landing from a jump or changing directions while
running, awkward running, and biomechanical perturbations
may all result in an ACL injury.
- Deceleration with valgus stress and rotation appears
to be the most common mechanism of injury to the ACL.
Neuromuscular factors such as:
a. joint stiffness,
b. muscle activation latencies, and
c.muscular recruitment patterns
- are important contributors to the increased risk
of ACL injuries in female athletes.
- Quadriceps activation during eccentric contraction is
also considered to be a major factor in ACL injury.
- As soon as injury is incurred, a pop or a snap is felt or
heard, followed by immediate disability. The knee will feel
like it is “coming apart.”
- Anterior cruciate ligament tears produce rapid
swelling at the joint line.
- Proprioception is also decreased following an ACL
- Even if PRICE is followed immediately, within one to
two hours following the initial trauma, swelling
become prominent and, after six hours, notable
hemarthrosis is present.
- After injury, the athlete will be unable to walk
- ACL injuries lead to serious knee instability.
- Controversy exists among physicians as to how
to best treat an ACL rupture, and when surgery is warranted.
- ACL rupture will lead to severe joint degeneration.
- A decision for or against knee surgery must be based
on the athlete’s age, the type of stress applied to the
knee, and the amount of instability present.
- Even a simple surgical repair of the ligament may not
be adequate in establishing proper joint stability.
- Joint reconstruction surgeries, however, are much
more common and much more effective.
- Transplantation of another ligament or tendon
(pes anserinus, semitendonosis tendon, tensor fasciae latae,
or patellar tendon) is used in this procedure to replace
part or all of the ACL.
- This surgery requires three to five weeks in
braces and four to six months in rehabilitation.
It has been suggested that it may take up to two years
to regain normal quadriceps muscle function following an
- At the present time, little scientific evidence exists
that suggests the use of a functional knee brace,
however some physicians still hold to the belief that
bracing can provide some protection during activity.
POSTERIOR CRUCIATE LIGAMENT SPRAIN
- Shelbourne and colleagues refer to the PCL as being the most
important ligament in the knee because it provides a central axis of
- The PCL provides roughly 90% of the total restraining force to
straight posterior displacement of the tibia.
- When the knee is flexed at 90 degrees, the PCL is in its most
- A fall with weight on the anterior aspect of the bent knee with
the foot in plantar flexion or a hard blow to the front of the knee
can cause a tear of the PCL.
- The PCL can also be injured by a rotational force,
which, according to Shelbourne, causes damage to the medial or
lateral side of the knee.
Symptoms of a posterior cruciate ligament sprain
a. feeling of a pop or snap in the back of the knee
b. tenderness and little swelling will be evident in the
c. laxity will be felt during stress tests.
- PRICE should be implemented immediately.
- Non-operative rehabilitation of grade 1 and grade 2 injuries must
focus on quadriceps strengthening.
- M. Safran et al states that there is much controversy over whether
PCL tears should be treated operatively or non-operatively ).
- Satisfactory outcomes achieved by non-operative means have been
reported. However, surgery is sometimes unavoidable.
- Rehabilitation following surgery often takes six weeks
of immobilization in extension with full weight bearing on crutches.
- ROM exercises are begun at six weeks.
- Isolated injuries to the distal tibiofemoral joint are referred
to as syndesmotic sprains.
- The anterior and posterior tibiofibular ligaments are found
between the distal tibia and fibula and extend up the lower leg
as the interosseous ligament. Sprains of these ligaments appears
to be more common than previously believed.
- Increased external rotation, or forced dorsi flexion may cause
these ligaments to tear as well as causing a severe sprain of the
medial and lateral ligament complexes.
- Initial rupture of the ligaments occurs distally at the tibiofibular
ligament, as the force of disruption is increased, the interosseous
ligament is torn proximally. Severe pain and loss of function will
be present in the ankle region.
- The pain occurs along the anterolateral region of the leg. J. Tauton
reminds us that sprains to the syndesmotic ligaments are extremely
hard to treat and take months to heal.
- Treatments of these sprains are nearly identical to that of medial
or lateral sprains, however, a longer period of immobilization must
- Return to activity will take much longer than other sprains around
- A direct blow to any of the muscles
crossing the knee joint can result in a
temporarily handicapping condition.
- One of the muscles frequently involved
is the vastus medialis muscle, which
is highly involved in locking the knee in full
- Bruises on the vastus medialis may appear to be a knee sprain.
- Some of these symptoms include
- severe pain,
- loss of movement and
- acute inflammation.
- Swelling and discoloration resulting
from the tearing of muscle fibers and blood vessels
will indicate such an injury.
- If PRICE is observed immediately following
injury, the knee will usually return to functional
use within 48-hours after the trauma was incurred.
- Bruising on the capsular tissue that
surrounds the knee joint is associated with
muscle contusions and bruises to the periosteum
of the bone.
- Traumatic force applied to the capsular tissue
- capillary tearing and bleeding,
- synovial membrane irritation and
- profuse fluid effusion into the joint cavity,
resulting in intraarticular swelling.
- This effusion occurs slowly, so it
is often unnoticed. Scar tissue will develop eventually.
- Care are of this injury depends on both the exact
location and severity of the contusion.
- PRICE, along with 24 hours rest should be observed.
- PRICE may last up to 72-hours after the initial trauma.
- ROM exercises, should be introduced when the inflammation
- The heat modality can be introduced post 72-hours,
but great caution should be used to prevent swelling.
- If the swelling has not resolved within a week,
chronic inflammation may be present in the form
of either synovitis or bursitis.
PERONEAL NERVE CONTUSION
- The peroneal nerve crosses directly behind
the underlying neck of the fibula.
- A kick or blow to the area can cause a compression
injury to the nerve.
- Immediately following impact,local pain
- from the contusion and
- from an electric shock will radiate down the
anterior portion of the lower leg and into
the dorsum of the foot.
- Paresthesia and numbness along the distribution
of the nerve will also be present.
- Skin abrasions and ecchymosis with tenderness
of the underlying peroneal nerve will cause a
tingling sensation, which can be relieved with
- Neuropraxia, will last only the first few seconds,
but if the injury is severe, hypesthesia and weakness
of the peroneals and dorsiflexors will persist,
possibly leading to a drop foot
- Usually, just a minor injury is incurred and
the athlete recovers within a few days.
- When the injury is sustained, PRICE should be
- As soon as the symptoms are gone, the athlete can
return to activity, as long as there is no weakness
in the peroneals and dorsiflexors.
- Protective padding may be used to help protect the
tender area from further injury after return to activity.
- Medial meniscus is much more prone to injury
than the lateral meniscus because of the attachment
of the coronary ligament.
- The lateral ligament does not attach to the
coronary ligament and is more mobile during knee movement.
- The medial meniscus is prone to disruption from valgus
and torsal forces.
- A valgus force can cause the knee to adduct,
which will tear and stretch the medial collateral ligament.
- Its fibers twist the medial meniscus outward.
- Repeated mild sprains will make the athlete more prone
to this injury due to a lessening of ligamentous stability.
- The most common mechanism of injury is weight
bearing combined with a rotary force,/b> while the knee
is extended or flexed.
- Cutting motions can also cause injury to the medial meniscus.
- Stretching of the anterior and posterior portions of the
meniscus can produce a vertical-longitudinal tear.
- The lateral meniscus can sustain an oblique tear by a
forceful knee extension with the femur externally rotated.
- Meniscal lesions can be
- oblique, or
- Because of the blood supply (mentioned earlier), tears in
the outer one-third of a meniscus may heal over
time if tress in the area is kept to a minimum.
- Tears that occur within the midsubstance of the meniscus
often fail to heal because of a lack of adequate blood
- Diagnosis of a meniscal legion is difficult,
even for skilled sports medicine physicians.
- Diagnosis of the injury should be made immediately
before muscle spasming and swelling obscure the normal
shape of the knee.
- A meniscal tear may or may not result in an effusion
developing gradually over 48- to 72-hours, joint-line
pain and loss of motion, intermittent locking and giving
way of the knee, and pain when the athlete squats.
- Once a tear occurs, the ruptured edges harden and may
- Portions of the meniscus can become detached resulting
in loose bodies.
- Chronic meniscal lesions will display recurrent swelling
and obvious muscle atrophy.
- The athlete will have a sense of the knee “collapsing,”
a popping sensation, or of an inability to perform a full
- Such signs usually indicate the necessity of surgical
intervention locked but shows indications of a tear,
an MRI may be needed, as well as a diagnostic
- A knee that is locked in place by a displaced meniscus
needs to be unlocked with the patient under anesthesia.
- A portion of the meniscus may have to be removed if
chronic locking occurs.
- Brindle states that surgical management of meniscal
tears should make every effort to minimize loss of
any portion of the meniscus.
- The meniscus structures are important in
- shock absorption and
- in preventing degenerative joint disease
- Post-surgical management for a partial
manisectomy (partial removal of the meniscus) does
not require bracing and allows partial to full weight
bearing on crutches in about two weeks.
- An athlete can sometimes return to activity within
six to fourteen days following surgery.
- A repaired meniscus, on the other hand, requires
immobilization in a rehabilitative brace for five
to six weeks.
- During immobilization, ROM exercises between 0 and 90
degrees should be conducted.
- Rehabilitation should concentrate on endurance.
- Dr. T. Blackburn notes that before birth, a child has
three synovial knee cavities whose internal walls,
at four months, are gradually absorbed to
form a single chamber; however, in roughly 20% of all
individuals, the knee fails to fully absorb these cavities.
- In adulthood, these septa form synovial folds known as
- The most common of these folds is called
the infrapatellar plica, which originates from the
infrapatellar fat pad and extends superiorly in a fanlike
- The second most common synovial fold is the
suprapatellar plica, located in the suprapatellar
- The least common, but the most subject to injury,
is the mediopatellar plica, which is bandlike and begins
on the medial wall of the knee joint and extends downward
to insert into the synovial tissue that covers the
infrapatellar fat pad.
- Because most synovial plicae are pliable, most are
asymptomatic; however, the mediopatellar plica
may be thick, nonyielding, and fibrotic, causing a number
- The meadiopatellar plica is associated with chondromalacia
of the medial femoral condyle and patella.
- If the symptoms originate after trauma, the trauma is
usually a blunt force or twist when the foot is planted.
- Recurrent episodes of pseudolocking of the knee when the
individualhas been sitting for a period of time may be
a positive indicator.
- As the knee passes 15 to 20 percent flexion, a snap may
be felt or heard.
- These symptoms can easily be misinterpreted as a torn
- However, unlike meniscal tears, there is little or no
swelling and no ligamentous laxity.
- Rest, NSAIDs and localized heat are common ways
to treat knee plica.
- If the plica develops into chondromalacia, surgery
OSTEOCHONDRAL KNEE FRACTURE
- Sometimes the same mechanisms that cause collateral
ligamentous, crucial ligamentous, and meniscal tears can
shear off either a piece of bone attached to the anterior
cartilage or the cartilage alone.
- Twisting, a sudden cutting motion, or a direct blow to
the knee can cause such a fracture.
- A snap is heard and the knee gives away immediately
following this injury.
- Swelling tends to be immediate and extensive due to
hemarthrosis, and pain is very intense.
- Surgery must be performed to replace the fragment as soon
as possible to avoid degeneration.
- Osteochondritis dissecans is a painful condition,
which involves a partial or complete separation of a
piece of articular cartilage and subchondral bone.
- The majority of these fragments (more than 85%) occur
in the lateral portion of the medial femoral condyle.
- Lesions will result in normal articular cartilage with
dead subchondral bone underneath separated by a layer of
- The cause of this condition is yet to be
discovered, but it seems to have a slow onset.
- Possible factors may include
- either direct or
- indirect trauma,
- skeletal or endocrine abnormalities,
- a prominent tibial spine impinging on
the medial femoral condyle, or
- a facet of the patella impinging on the medial
- When osteochondritis dissecans is present, an aching
sensation in the knee will be almost constant, as well
as recurrent swelling, and an occasional locking sensation.
- Point tenderness and atrophy of the quadriceps may
also be present.
- Immobilization and usually a cast is prescribed
- This allows for resolution of the cartilage and
ossification of the underlying bone.
- This condition may take as long as a year to resolve,
and surgery may be the best way to correct the injury.
LOOSE BODIES WITHIN THE KNEE
- Osteochondral fragments, or loose bodies, can develop
within the joint cavity due to repeated injury to the knee.
- Loose bodies, also called joint mice, can stem
- osteochondritis dissecans,
- menisci fragments,
- pieces of torn synovial tissue or
- a torn cruciate ligament
- The loose body can move around in the joint and become
lodged, causing a locking or popping sensation.
- Pain and instability may be present.
- If the loose body becomes lodged in between articulating
surfaces, irritation will occur.
- Joint degeneration can occur if the loose body is not
- Bursitis of the knee, as well as in other body regions,
can be classified as
- chronic, or
- As mentioned earlier, nearly two dozen bursa sacks have
been identified around the knee, however, the
prepatellar, deep infrapatellar, and suprapatellar bursa
are the most likely to become inflamed in sports.
- Overuse of the patellar tendon is the most common
cause of bursitis at the knee.
- ,b>Localized swelling will be present above the knee.
- Since the swelling will occur outside of the
joint capsule, skin discoloration and increased localized
- Ceasing activity that irritates the bursa, and techniques
aimed to reduce inflammation (PRICE) should be used to
- Arguably the two most important modalities for treating
bursitis are the use of a compression wrap and NSAIDs.
- If chronic bursitis is the condition,
injected antiinflammatories may be used.
- Fractures of the patella are not unlike fractures of
other bones in that they can occur from both direct or
indirect trauma applied to the bone.
- Most patellar fractures are acquired by indirect
means consisting of a sudden and forceful pull on the
patellar tendon against the femur when the knee is
- In this position, maximum stress is placed on the bone
from the quadriceps and the patellar ligament.
- Direct injury often produces fragmentation with little
displacement. In other words, the patella is likely to
crack (shatter) rather than snap.
- or running activities
may result in a fractured patella.
- Side Note:
- Oddly enough, roughly three percent of the
population have what is known as a bipartite patella.
- This means that the patella consists of two
portions, rather than just one.
- When X-rayed, this condition, which is
in no way harmful, can be misdiagnosed as a
- A fractured patella causes hemorrhaging and joint
effusion, which causes swelling.
- Indirect fractures cause
- a tear in the joint capsule,
- separation of bone fragments,
- and possible tearing of the quadriceps
- In a direct injury, little bone separation
- The separated patellar fragments can be easily
palpated, and an X-ray will confirm the extent of
- In the acute stage, PRICE should be
followed with splinting (this goes under “protection”).
- Immobilization for two to three months is expected.
PATELLOFEMORAL STRESS SYNDROME
- This condition results from lateral deviation of
the patella as it tracks in the femoral groove
- W. Prentice and colleagues identified several factors
that may cause lateral tracking:
- Tightness of the hamstrings and gastrocnemius,
- tightness of the lateral retinaculum (which
compresses the lateral facet of the patella against
the lateral femoral condyle),
- increased Q angle (angle made between the
head and shaft of the femur),
- tightness of the iliotibial band,
- pronation of the foot,
- patella alta (lengthening of the patellar tendon,
making it longer than the patella itself),
- vastus medialis oblique insufficiency
- caused by imbalance with the strength of
the vastus lateralis or by inhibition
resulting from the presence of 20 to 30 ml
of effusion in the knee, and weak hip a
dductors to which the vastus medialis
- Tenderness on the lateral aspect of the patella will
be present as well as some swelling associated with
irritation of the synovium as well as
reports of a dull ache in the center of the knee.
- Patellar compression will elicit pain and crepitus.
- W.R. Post cautions us that the causes
underlying patellofemoral pain as identified during
the evaluation process
should provide the basis for treatment.
- A strengthening program should be started for the
adductor muscles and for correcting the imbalance
made between the vastus medialis oblique and the
vastus lateralis through the use of biofeedback techniques.
- Stretching of the hamstrings, gastrocnemius and iliotibial
band should also be implemented.
- W. Gilleard reports that foot orthotics can be used
to correct pronation and other malalignments, as well
as specific taping techniques.
- Taping can be used to help correct the orientation of
the patella. In extreme cases, lateral
retinacular release can be used.
OSGOOD_SCHLATTER DISEASE AND LARSEN JOHANSSON DISEASE
- These two conditions are common to adolescent athletes.
- Osgood-Schlatters disease is an apophysitis
characterized by severe pain at the attachment of
the patellar tendon into the tibial tubercle.
- Thus, an avulsion fracture of the tibial tubercle will be
- The fragment starts off as being cartilaginous,
but with growth a bony callus forms and the tuberosity
- This condition usually resolves itself once the adolescent
finishes puberty, and the only remnant is an enlarged
- Although several mechanisms have been postulated,
the most widely accepted cause of this disease is by
repeated avulsion of the patellar tendon at the
apophysis of the tibial tubercle.
- In severe cases, a complete avulsion may be present.
- Larsen-Johansson disease is very similar to
Osgood-Schlatter disease, but it occurs
at the inferior surface of the patella.
- The mechanisms of the onset of this disease is the same
as that of Osgood-Schlatter disease.
- Swelling, pain, and point tenderness are all
characteristics of this disease, as well as
degeneration of tendonous fibers.
- Repeated irritation will cause
- hemorrhage, and
- gradual degeneration of the apophysis
as a result of impaired circulation.
- Severe pain will be present with knee flexion, with
point tenderness over the anterior proximal tibial tubercle.
- Management of both diseases is usually very conservative.
- Some treatments include
- a decrease in stressful activities
until epiphyseal union takes place (six months to a year),
- a cylindrical cast (in severe cases),
- ice applied before and after activities, and
- isometric strengthening of the quadriceps and
- Jumping, kicking and running places great
stress on the knee extensor muscle complex.
- As a result, tendinitis can occur in the patellar
tendon or quadriceps tendon.
- In some cases, the patellar tendon can completely
ear from the bone.
- Chronic inflammatory conditions of the area may
predispose an athlete to a tear or rupture.
- Tenderness and pain will be present on the
inferior surface of the patella, as well as the posterior
- There are three stages of pain associated with patellar
- Stage 1
– Pain immediately following activity.
- Stage 2
– Pain both during and after activity,
but the athlete is still able to perform
- Stage 3
– Pain both during and after activity,
but lasting a long duration.
Athletic performance is compromised and
may progress to constant pain and
- Any pain in the patellar tendon indicates a sudden,
forceful movement that would lead to the pain.
- J.K. Wilson states that many different approaches
have been reported to treat this inflammatory
condition including the
- use of ice,
- ultrasound, and
- various forms of superficial heat modalities such as
- whirlpool coupled with a rehabilitation
- Bracing may also be used.
- G. Pellecchia reported that a deep transverse friction
massage has been a successful modality of treatment
for patellar tendinitis.
- The friction is created via a firm massage of the
patellar tendon on the inferior surface
of the patella perpendicular to the direction of
- A friction massage is actually used to increase
the inflammatory response as to speed healing and push
the body into the fibroblastic repair phase.
Therefore, when the transverse friction massage modality
is used, techniques designed to reduce inflammation
should not be used.
PATELLAR TENDON RUPTURE
- A rupture of the patellar tendon can be caused by a
sudden and powerful contraction of the quadriceps
muscle group with weight bearing.
- The rupture may occur in either the patellar tendon or
the tendon of the quadriceps.
- This rupture usually only occurs during a
chronic inflammatory condition of the tendons involved where
tissue degeneration has taken place.
- Ruptures, in general, rarely occur in the middle of
the tendon, rather at their insertion to the bone.
- If the patellar tendon is ruptured, the rupture will occur
on the inferior portion of the patella, whereas if
the quadriceps tendon is ruptured, the rupture will occur
on the superior portion of the patella. When the tendon
is ruptured, it moves upward toward the thigh creating an
- Knee extension is not possible, and there will
be excessive swelling present as well as extreme
initial pain followed by a minor dull ache.
- A rupture of the patellar tendon most likely will require
- Jumper’s knee may lead to this injury, thus proper
care of that condition may reduce the risk of acquiring
- Steroid users are also susceptible to this injury.
- Steroids injected directly into these tendons weaken
collagen fibers and mask pain.
ACUTE PATELLAR SUBLUXATION AND DISEASE
- Forced knee valgus can occur when the thigh rotates
internally while the lower leg rotates externally
(this often occurs during deceleration and
cutting movements when the foot is planted).
- If this occurs, the quadriceps attempts to pull in a strait
line, thus pulling the patella laterally which
may dislocate the bone.
- The patella always displaces laterally under these
- Some athletes may be prone to this injury if they have a
- wide pelvis with anteverted hips,
- genu valgum (which increases the Q angle),
- shallow femoral grooves,
- flat lateral femoral chondyles,
- flat patellas,
- vastus medialis and ligamentous laxity with genu
recurvatum and externally rotated tibialis,
- pronated feet and
- externally pointing tibias.
- Pain, swelling and a complete loss of knee function, as
well as a obvious deformity may all be present in the acute
stage of injury.
- The dislocation must be reduces immediately by placing
mild pressure on the patella with the knee extended.
- The PRICE acronym should then be implemented, with
emphasis on ice and splinting.
- If this is a first-time occurrence, a fracture may be
- During treatment, the knee will need to be immobilized
for at least four weeks.
- During this period, isometric exercises can be performed.
- Horseshoe padding and bracing should be used upon return
- Muscles of the thigh and hip should be performed,
especially strait leg raises.
- In some cases, surgery may be required.
INJURY TO THE INFRAPATELLAR FAT PAD
- The infrapatellar fat pad
- aids in protection and
- shock absorption of the knee.
- It lies between the synovial membrane on the anterior
aspect of the joint and the patellar tendon.
- The infrapatellar fat pad is particularly vulnerable
during athletic activity, and can be injured if wedged
between the tibia and patella, irritated by chronic flexion
pressures, or via a direct blow.
- Capillary hemorrhaging can be present due to
repeated trauma and localized swelling.
- If the irritation continues, scaring and
calcification may develop.
- Pain may be present below the patellar ligament
during knee extension, and the knee may become weak
with mild swelling and stiffness.
- Rest from activities, which irritate the area,
heel elevation, and ice modalities should be utilized
to treat acute injury.
- Hyperextension taping may also be necessary to
prevent against full extension.
- Chondromalacia patella is a softening and deterioration
of the articular cartilage on the backside of the patella.
- Chondromalacia can be identified in three separate stages.
- Stage 1
– Swelling and softening of the articular
- Stage 2
– Fissuring of the softened articular
- Stage 3
– Deformation of the surface of the
articular cartilage caused by fragmenta-
- To date, the cause of chondromalacia is unknown.
- Some experts suggest abnormal patellar tracking may be
a factor, however individuals with normal tracking have
sustained this condition, and others with abnormal tracking
are free of it.
- Pain on the anterior aspect of the knee while walking,
running, ascending and descending stairs or squatting
will be present.
- Recurrent swelling around the patella will be seen,
and a grating sensation will be felt during knee flexion
- Palpable pain will also be present on the inferior
border of the patella and when the patella is compressed
within the femoral groove during passive flexion and
- One or more alignment deviations may also signal
the presence of chondromalacia.
- M. Baker reported degenerative arthritis on the medial
facet of the patella, which makes contact with the femur
when the athlete performs a squat.
- Both Baker and A. Boland report that degeneration first
occurs in the deeper portions of the articular cartilage,
followed by blistering and fissuring that stems from the
subchondral bone and appears on the surface of the patella.
- Conservative treatments include
- avoidance of activities which irritate the area,
- isometric exercises for the quadriceps and
- NSAIDs and small doses of aspirin,
- a knee sleeve,
- an orthotic device used to correct pronation and
reduce tibial torsion.
- Boland states that if these measures fail, surgery may
be the only option.
- Surgical procedures include
- moving the insertion of the vastus medialis
muscle forward through realignment procedures such as
- lateral release of the retinaculum,
- shaving and smoothing the irregular surfaces
of the patella and femoral condyle,
- removing the blister with drilling,
- elevating the tibial tubercle, and as a
last resort completely removing the patella
- Runners knee is a general term used to define overuse
injuries of the knee.
- Malalignment and structural asymmetries of the leg and
foot can cause an overuse condition.
- Patellar tendinitis and patrellofemoral conditions
may led to chondromalacia.
- Two conditions that are common among distance athletes
- iliotibial band friction syndrome and
- pes anserinus tendinits or bursitis.
- Iliotibial band friction syndrome is an overuse
injury, which is common in distance athletes who have
genu varum and a pronated foot.
- Irritation develops at the bands insertion point and on
the lateral condyle of the femur.
- Treatment for this condition consists of
- stretching iliotibial band and
- reducing inflammation.
- The pes anserinus is the location where the gracilis,
sartorius, and semitendonosus muscles attach to the
- Pes anserinus tendinitis and pes anserinus bursitis
go hand in hand with one another.
- Inflammation can result from a weak vastus medialis muscle.
- Running on a slope with one foot higher than the other over
time can cause this condition.
- Alignment problems must be corrected in order to help
correct this condition.
- Acute treatment includes ice and a deep tissue
massage before and/or after activity as well as a
proper warm-up with stretching.
- It is also important to avoid activities that
aggravate the condition, such as running on an incline.
- NSAIDs and foot orthotics may help reduce the condition