Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 1 February 2006

THOSE TRAGIC KNEE INJURIES

            The young man was 17 years old and playing guard for his high school basketball team.  It was an innocent situation at practice as he planted his foot and pivoted quickly to make a break for the basket.  He crumpled to the floor and was unable to get up and walk.  As everyone knows, knees are not designed to bend sideways but now his did.  He went home after practice, put ice on his knee.  He had a painful night and I got to see him the next day.

            On examination, his knee was not particularly swollen but there was obvious loss of stability and the knee definitely bent sideways which, as mentioned, knees are not supposed to do.  It wasn’t a big bend sideways but enough to notice.  And he noticed the instability in his leg at this time even though he was now able to walk on the knee.

            An MRI scan of the knee was done.  It is able to see the ligaments in addition to the bones.  It was seen that a structure called the anterior cruciate ligament was completely torn in this young man’s knee.  His basketball season was over.  His ability to play again next year was in limbo.

            Long discussion ensued regarding alternatives available to him for treatment.  He first wondered what would happen if he would rest the knee and let it get strong again.  I told him I could testify to what would happen with that course from personal experience.  When I was 19 years old, I had a similar injury playing football.  In 1957, we didn’t have MRI machines and the surgery to fix this injury was still not developed.  The doctors taking care of me said that I should rest the knee, work vigorously on straight leg raising exercises with a weight on my foot to get my quadriceps thigh muscle very strong and in a year I would be able to play again.  Four months later, I was able to play basketball although not very well.  The stability of my knee was not normal and it began to wear.  Sixteen years later at age 35, I had the cartilage removed from my knee because it was completely worn out by then from the wear and tear.  Then without a cartilage present really bad wear and tear began to take hold and 30 years later, I got a new knee.  Now I am not to run or get involved in any type of athletic endeavor such as basketball or racquet ball.

            Modern methods of dealing with knee injuries haven’t been around for the 40 years of my natural history.  Thus what will happen to somebody like this young man in 40-50 years, really isn’t known.  But we believe that a better choice than pursuing natural history of an injury is to have the anterior cruciate ligament surgically repaired.  Modern surgical methods involve taking a portion of the tendon that connects the knee cap to the lower leg bone (tibia) and using this to replace the torn ligament.  This surgery requires approximately 8 months of recovery time before the person can again participate in athletics.  But even professional level athletes have returned to competition after this type of surgical intervention.

            Another method of correcting the injury is to use one of the hamstring muscles with those very strong tendons that we can feel immediately behind our knees.  These are threaded through the tibia and connected backward to the long bone in the upper thigh.  This is not a preferred method but can be used for those whose patellar tendons are not felt acceptable.

            The question of how soon to fix the knee is tricky.  If one waits too long, the big quadriceps muscle in the upper thigh begins to shrink and get weaker because it is not used in the same way.  However, if the surgery is done too soon, there is a great deal of blood and inflammation.  The knee heals with a great deal of scarring and full range of motion and strength are not recovered.  Thus, the inflammation from the injury needs to quiet down while the person lets the knee rest for 1-4 weeks and then get the surgery done.

            This tearing of the anterior cruciate ligament in the knee is the most devastating injury.  The other one that is very common is called a torn cartilage.  Torn cartilages tend to happen when the person already has the knee bent and then an unusual strain is placed upon it.  Cartilage injuries are usually very painful and can result in a great deal of swelling about the knee.  The knee joint itself remains stable and doesn’t have the sideways bending that occurs with ligament tears.  In the good old days when an athlete injured his cartilage, surgeons simply removed it.  But this was the beginning of the end because without that cartilage cushion to pad the knee, wear and tear on the bones began.  Severe degenerative change was a predictable outcome 10-20 years later.

            Today, cartilage tears in young individuals are usually surgically repaired with good long term outcomes.  If this occurs in an athletic situation, the season is over for that individual unless he wants to risk repeated injury, swelling and pain in the knee.  Some unusual devoted athletes will play through a cartilage injury to the end of season and get it fixed then.  It is a risky business with a high price to pay.

            Athletic injuries that break the bones around the knee are remarkably rare.  Broken ankles are common and breaking the mid shaft of the bones of the lower leg is relatively common.  But actually breaking the bones around the knee is rare in young athletes.  The bones around the knee can be broken in automobile accidents but when this happens the injuries are devastating and require extensive surgical repair with prolonged convalescence.

            Non-athletic adults and those over-fifty-year-old -athletes also get knee injuries.  Most commonly the injuries are cartilage tears.  Because the cartilage is older and often very degenerated, surgically repairing the cartilage may not be possible and removal of the injured portion may have to be done.  This will alleviate the pain that the person is having but the person will also be strongly advised to stop the activity that led to the injury.

            Where as 50 years ago, there were no diagnostic procedures that could immediately detect knee injuries, today an MRI scan can detect cartilage tears and torn ligaments with great ease.  Surgical techniques for repair of these injuries are now available.  Speaking of myself, I would get my knee fixed in an instant if it had been available 50 years ago.