Overview
There are 4 main ligaments that provide stability to the knee: 
• Anterior Cruciate Ligament ( ACL )
• Keeps the tibia (shin bone) from moving forward on the femur (thigh bone)
• Posterior Cruciate Ligament ( PCL )
• Keeps the tibia (shin bone) from moving backward on the femur (thigh bone)
• Medial Collateral Ligament ( MCL )
• Prevents the knee from buckling inward
• Lateral Collateral Ligament (LCL)
• Prevents the knee from buckling outward.
Injuries to the knee can cause these ligaments to tear. A torn ligament may cause your knee to feel loose or unstable. Sometimes knee injuries will cause more than one of these ligaments to be injured at the same time.
Symptoms of a Knee Ligament Injury
Common symptoms:
• Pain in the knee joint following the injury
• Swelling (may not always be present)
• Feelings of instability
Treatment of Knee Ligament Injuries
Knee ligament injuries may or may not need surgery. This depends on which ligament is torn. MCL and PCL tears usually heal without surgery. ACL tears should be treated with surgery in active patients who want to return to recreational or competitive athletic sports.
People who have a torn ACL can participate in some sports that don’t involve a lot of cutting or changes of direction. The decision of how to treat your injury will be discussed with you at your appointment.
Anterior Cruciate Ligament Reconstruction:
Overview
Anterior Cruciate Ligament (ACL) reconstruction surgery creates a new ligament inside your knee to replace the torn ACL. This will restore stability to the knee joint.
ACL tears typically occur:
Symptoms of an ACL Tear
Common symptoms:
• Significant swelling soon after the injury
• Hear/feel a “pop” during the injury
• Feeling like the knee “comes apart” during the injury
• Walking on your toes immediately after the injury
• Unable to continue with the sport or activity you were doing at the time of the injury
• Feelings of instability or fear that the knee will give way following the acute injury
Treatment of an ACL Tear
A normal ACL provides stability to the knee joint during activities such as cutting, pivoting, and jumping. A patient who wants to return to their previous level of activity in sports that require these types of movements, should have the torn ACL surgically reconstructed. For patients with lower activity levels, ACL surgery may not be needed. We will review these options with you during your appointment.
ACL reconstruction surgery is performed when you are completely asleep, which is called general anesthesia. During surgery, a knee arthroscopy will be done first. The surgeon inserts a small camera into your knee to look at the joint. If there is damage to the joint, the surgeon will use small tools to fix these problems during this part of the surgery.
After the arthroscopy, your surgeon will begin the ACL reconstruction.
After surgery, you will spend one night in the hospital. The first 7 days after surgery are spent lying flat in bed with the knee elevated. The only time you should get up is for restroom breaks.
Sitting, standing, and walking cause the knee to become more swollen. The goal during the first week is to prevent as much swelling as possible to allow for a faster recovery.
Someone needs to be present full-time to take care of the patient for the first week. A hotel room can be arranged for the first week for our patients who do not live within 3 hours of our clinic.
ACL surgery requires a commitment to completing rehabilitation exercises before and after surgery. We have tracked the outcomes of our patients for over 20 years. Through this process we have learned many things and made changes to our program to keep getting better.
Our rehabilitation program relies on your commitment to follow a prescribed program at home. You will work one-on-one with your therapist who will monitor your progress and make appropriate changes to your program.
Pre-surgery rehabilitation goals:
The graft of choice for ACL reconstruction is a portion of the patellar tendon. This can be taken from either knee. After years of experience we have found that taking the graft from the opposite knee allows for a faster, more predictable recovery.
Rehabilitation goals for the ACL reconstructed knee:
Rehabilitation goals for the graft (opposite) knee:
- Note: If the graft is taken from the same knee, strengthening exercises are started after full range of motion is regained and swelling goes away.
To make sure you are progressing as expected after surgery, we will monitor your strength by performing a series of strength tests at regular intervals. The ultimate goal is to restore symmetric strength as well as range of motion that is equal to or better than they were before surgery.
Osteoarthritis
Overview
Healthy joints have a layer of cartilage lining the bone surfaces. Osteoarthritis occurs when this cartilage breaks down and the joint space becomes narrowed.
Osteoarthritis affects weight-bearing joints such as the hips, knees, and spine. The pain may worsen after repetitive use (walking or standing), or after periods of inactivity (sitting or sleeping).
Common symptoms:
• Pain in your joint
• Stiffness or loss of motion
• Swelling
• “Creaking” in the joint
Treatment of Osteoarthritis
Our knee rehabilitation program can often decrease or eliminate the pain caused by osteoarthritis. Many patients who think or have been told they need a knee replacement have been able to delay or avoid surgery with our rehabilitation program.
We have found that knee stiffness makes the pain of osteoarthritis worse, so our rehabilitation program focuses on reducing the stiffness of the knee. We begin by working to improve the knee extension (straightening) motion first. Once movement in this direction is maximized, we shift our focus toward improving knee flexion (bending). Finally, some gentle strengthening exercises may be used. Patients are also educated about the use of cold and compression to reduce pain and swelling.
If the rehabilitation program does not bring adequate relief, knee replacement surgery is an option. The improvements made during rehabilitation allow for a faster, easier recovery after surgery
Deconditioned Knee
Overview
Knees work at their best level when they have full range of motion (ROM) and strength. Another important concept that is often overlooked is symmetry.
The right and left knee should have the same range of motion (ROM) and strength when compared to one another.
Occasionally, an injury or pain in the knee joint will cause a person to favor one knee over a period of time. People with knee pain will habitually stand with their weight shifted away from the knee that is bothering them. Patients also unknowingly make other compensations in an effort to protect that knee when walking, squatting, and climbing stairs. Over time, this can cause a significant decrease in the strength and range of motion in that leg. Consequently, decreased strength and range of motion (ROM) cause further pain. Increased pain causes the person to favor their knee more which perpetuates the cycle.
Diagnosis
Our rehabilitation staff can perform an evaluation and series of strength tests to isolate the source of your problem. Range of motion is also evaluated at each visit. A significant side-to-side difference in strength or range of motion (ROM) causes a deconditioned knee.
Treatment
An individualized rehabilitation program will be developed to help you regain full, symmetric range of motion and strength. Our therapists specialize in treating knee problems and will tailor your program to address your specific needs.
Strength and range of motion will be closely monitored to make sure that you are making progress.
Patellofemoral Disorders
Overview
The patellofemoral joint is made up of two bones: the patella (the knee cap) and the femur (the thigh bone). When the knee bends and straightens, the patella glides along a groove on the femur called the trochlea. Some people have differences in the way the knee cap and this bone fit together.
These variations can lead to problems with the patellofemoral joint. For example, when the patella sits too high in this groove, the patella is prone to dislocations. Altered alignment may also cause the joint surfaces to wear down which can cause pain. Problems in the patellofemoral joint can be divided into several groups:
- Chondromalacia Patellae
- Patellar Malalignment
- Patellar Subluxation/Dislocation
Chondromalacia Patellae
The undersurface of the patella is lined with cartilage. This cartilage provides a smooth surface for the patella to glide during knee movement. Chondromalacia is when this cartilage breaks down. The pain may be along the sides of the patella or it may feel like it is deep inside the knee.
Treatment of Chondromalacia Patellae
Treatment focuses on emphasizing full range of motion and strength. Rehabilitation will also address any muscle imbalances that may be contributing to the patellofemoral pain.
Patellar Malalignment
Patellar malalignment occurs when the patella does not contact the femur in an ideal position. The patella can sit too high or too far toward the outer (lateral) side of the knee. People who have patellofemoral pain often complain of pain after sitting for prolonged periods and with stair climbing.
Treatment of Patellar Malalignment
Problems with the alignment of the patella may require surgery. This can be determined on an individual basis after an evaluation by Dr. Shelbourne or Dr. Urch. Rehabilitation focuses on restoring full, symmetric range of motion and strength.
Patellar Subluxation/Dislocation
Some people experience episodes where their patella will dislocate, or slip to the side. The injury is usually followed by swelling, stiffness, and pain. It is important to have a thorough knee examination to assess for any damage that may have occurred at the time of the dislocation.
Treatment of Patellar Subluxation/Dislocation
At first, treatment will focus on minimizing the swelling, walking normally without a limp, and restoring full range of motion. Once range of motion is full and the swelling has resolved, treatment will focus on strengthening. Sometimes surgery is needed after a patellar dislocation. This can be determined on an individual basis after your evaluation.
Tendonitis
Overview
Sports that involve a lot of running, jumping, and kicking can lead to pain in the front of the knee.
Adolescents often develop this pain during or after growth spurts. Bone growth occurs faster than soft tissue growth, resulting in tightness in the tendon across the front of the knee joint. This tightness combined with repetitive movements can result in tendonitis.
The tendon in the front of your knee is called the patellar tendon. This tendon connects the quadriceps muscle to the shin bone (tibia). This tendon can be divided into two areas: the quadriceps tendon and the patellar tendon. The quadriceps tendon is above the knee cap (patella) and the patellar tendon is below the knee cap. When the quadriceps muscle tightens, it pulls on the tendon and the knee straightens. This muscle is used during many activities including: squatting, stair climbing, kicking, running, and jumping.
Osgood Schlatter disease occurs in the lower part of the tendon where it attaches to the shin bone. Contraction of the quadriceps muscle pulls on the tendon and the bone where the tendon inserts. Repetitive stress through this area can cause a bump to form on the front of the shin bone.
Sinding Larson Johansson disease is similar to Osgood Schlatter disease, but occurs in a different location. Sinding Larson Johansson disease occurs just below the knee cap (patella). A bump can sometimes be felt just below the knee cap.
Patellar tendinitis is when the tendon gets irritated. It is different from the above conditions because it does not happen near the insertion of the tendon into the bone.
The above conditions result in similar symptoms such as:
- Pain in the front of the knee with running, jumping, kneeling, squatting, or climbing stairs
- Pain during full flexion (bending) of the knee
- Pain in both knees
- May be able to feel a bump in the area that is tender/painful
An evaluation by Dr. Shelbourne or Dr. Urch can help isolate the specific cause of your symptoms.
Treatment
Rehabilitation to improve flexibility in the muscles around your knee often helps alleviate symptoms. Sometimes surgery is needed to remove the damaged part of the tendon. Rehabilitation is necessary to allow for a return to normal activities following surgery. Rehabilitation focuses on restoring full, symmetric range of motion and strength.
Menicus Injuries
Overview
The menisci are two cartilage discs that sit between the tibia (shin bone) and the femur (thigh bone). The word menisci is the plural term for meniscus. The two menisci are the medial meniscus and the lateral meniscus. The medial meniscus is on the inner side of the knee while the lateral meniscus is on the outer side of the knee.
The menisci serve two important roles. First, they help make the tibia and the femur fit together better. Second, the menisci act as cushions to distribute the impact of weight bearing across the joint surface.
A normal meniscus in a young, healthy person is very firm with smooth edges. Damage to the meniscus in younger people is rare and is normally caused by a traumatic injury.
The menisci slowly degenerate as people age. Over time this can cause small tears to develop within the meniscus that can get caught during bending and straightening movements of the knee. This is a very common problem in people over the age of 40. Patients commonly complain of locking or catching in the knee when there is a meniscus tear. Often times, the knee also becomes swollen and stiff. The pain can start with or without a specific injury.
Common Symptoms of a Meniscus Tear
Treatment of Meniscus Tears
The symptoms from a meniscus tear occasionally go away with time and rehabilitation. In these cases surgery may not be necessary.In some situations a knee arthroscopy is required to remove the torn piece.
A meniscus tear can be compared to having a pebble in your shoe. If the pebble doesn’t prevent you from doing normal activities and is not too uncomfortable, it doesn’t necessarily need to be removed.
If surgery is indicated, a knee arthrocopy will be scheduled. This is an outpatient surgery, but is done under a general anesthesia meaning you will be completely asleep during the surgery. A small camera is inserted into the knee through a very small incision. This allows the surgeon to look at the menisci and the joint surfaces. The torn piece of meniscus is removed with small tools that are inserted through another small incision. Knee arthroscopy can also address other problems such as: a painful plica, scar tissue formation, and chondral defects. Following surgery, rehabilitation focuses on preventing and eliminating swelling, restoring full range of motion, normal gait (walking), and full strength.
Arthrofibrosis
Overview
“Arthro” means joint and “fibrosis” means the formation of scar tissue. Therefore, arthrofibrosis is the abnormal or excessive growth of scar tissue. In the knee joint, this causes stiffness and loss of range of motion. Arthrofibrosis can occur after knee surgery or trauma. Appropriately directed rehabilitation can prevent the occurrence of arthrofibrosis.
Symptoms of Arthrofibrosis
- Decreased range of motion compared to the other knee after surgery/trauma
Treatment of Arthrofibrosis
The non-operative treatment of arthrofibrosis focuses on rehabilitation to regain range of motion. An Elite Seat or Flex Seat may be prescribed for daily treatments to regain your full range of motion. Other range of motion exercises will also be prescribed. If range of motion is not regained through non-operative treatment methods, surgery may be needed. Scar tissue can be removed during a knee arthroscopy.
Knee Anatomy (Interactive)
Learning about normal knee anatomy will help you to better understand your knee condition. Many of the structures in the knee are named for their location. Learning some of the medical terminology will help you to understand the knee anatomy. The following terms are often used in anatomy:
- Anterior: refers to a structure toward the front of the body
- Posterior: refers to a structure toward the back of the body
- Midline: an imaginary line running down the center of the body
- Medial: refers to a structure closer to the midline (the medial side of the knee is the inner side of the knee)
- Lateral: refers to a structure farther away from the center of the body (the lateral side of the knee is the outer side of the knee)
The knee joint consists of the femur (thigh bone) and the tibia (shin bone). The patella (knee cap) is located on the front of the knee joint. The joint surfaces of these bones are lined with articular cartilage. Articular cartilage provides a smooth joint surface. The knee joint is a synovial joint. Synovial joints are surrounded by a joint capsule and filled with a fluid called synovial fluid. Synovial fluid lubricates the joint
Two cartilage cushions called menisci separate the tibia (shin bone) and the femur (thigh bone). Menisci is the plural term for meniscus. The two menisci are the medial meniscus and the lateral meniscus. The menisci serve two important roles. First, they help make the tibia and the femur fit together better. Second, the menisci act as cushions to distribute the impact of weight bearing across the joint surface.
There are 4 main ligaments that provide stability to the knee:
• Anterior Cruciate Ligament ( ACL )
• Keeps the tibia (shin bone) from moving forward on the femur (thigh bone)
• Posterior Cruciate Ligament ( PCL )
• Keeps the tibia (shin bone) from moving backward on the femur (thigh bone)
• Medial Collateral Ligament ( MCL )
• Prevents the knee from buckling inward
• Lateral Collateral Ligament (LCL)
• Prevents the knee from buckling outward
The quadriceps muscle is located on the front of the thigh. When the quadriceps muscle tightens, the knee extends (straightens). The quadriceps connect to the tibia (shin bone) via a long tendon across the front of the knee joint. The patella (knee cap) sits within this tendon. This tendon is divided into two parts. The quadriceps tendon attaches the quadriceps muscle to the top of the patella. The patellar tendon attaches the patella to the tibia. (Identify both quadriceps tendon and patellar tendon on diagram).
Another major muscle group near the knee is the hamstring muscle group. The hamstring group is made up of three muscles that cross the back of the knee. These muscles form the muscle mass along the back of the thigh.