Knee ligament injuries are prevalent in both athletes and the general population, often resulting in discomfort, limited function, and potential long-term complications. Prompt and accurate diagnosis is crucial, typically involving clinical evaluations and, when needed, advanced imaging like MRI and ultrasonography.
Treatment varies from conservative methods, encompassing manual therapy and specific exercises, to surgical procedures for severe injuries. This article focuses on conservative management with manual therapy and rehabilitation exercises. Studies indicate that such conservative treatments can effectively manage many ligament injuries, enhancing recovery and minimizing re-injury risks. A foundational understanding of the knee's ligamentous anatomy, specifically the four main ligaments ensuring joint stability[1], sets the stage for the ensuing discussion.
Article Index:
Introduction
Treatment
Exercise
Conclusion & References
Anatomy
The knee joint is stabilized by four primary ligaments working synergistically[1]:
Anterior Cruciate Ligament (ACL)
ACL injuries are common and typically result from sudden rotational knee movements.
Anatomical Considerations:
Injury cause: Abrupt rotational movements of the knee[2]
Origin: Anterior intercondylar area of the tibia[3]
Insertion: Lateral femoral condyle[3]
Functions: Restrains anterior tibial translation on the femur and prevents knee hyperextension in collaboration with posterior knee musculature[4]
Posterior Cruciate Ligament (PCL)
PCL injuries often arise from direct impacts and can be severe.
Anatomical Considerations:
Injury cause: Direct impacts from sports or motor vehicle accidents[5]
Origin: Posterior intercondylar area of the tibia[6]
Insertion: Medial femoral condyle[6]
Function: Limits posterior tibial translation on the femur
Medial Collateral Ligament (MCL)
MCL injuries are prevalent in high-contact sports and occur due to lateral knee trauma.
Anatomical Considerations:
Injury cause: Lateral knee trauma in high-contact sports[8]
Origin: Medial femoral condyle[9]
Insertion: Upper medial shaft of the tibia[9]
Function: Provides stability to the medial aspect of the knee joint
Lateral Collateral Ligament (LCL)
LCL injuries can result from medial knee impacts.
Anatomical Considerations:
Injury cause: Impacts on the medial side of the knee[10]
Origin: Lateral femoral condyle[11]
Insertion: Head of the fibula[11]
Function: Stabilizes the lateral aspect of the knee joint
These ligaments function synergistically and independently to stabilize the knee without active muscular involvement[12]. For example, when the knee is extended, all ligaments tighten, but when slightly flexed, multiple muscles contribute to knee stability[13].
The body maintains a delicate balance between passive ligament stabilization and active muscular control. Restrictions in ligamentous motion or muscular contraction can create weak links in the knee's kinetic chain, potentially leading to friction-related syndromes, inflammation, and subsequent imbalances or injury[14].
Examination
A thorough knee examination is crucial for accurately diagnosing ligament injuries and other common causes of knee pain. This section will discuss various orthopedic examination techniques and their key components, as demonstrated in the accompanying video.
Knee Examination - Effective Orthopaedic Testing
This video provides a comprehensive guide to diagnosing common causes of knee pain through various orthopaedic examination techniques. The key components covered in the video include inspection and observation of the knee, palpation for tenderness and swelling, assessment of the knee's range of motion, understanding of knee anatomy, and various tests for specific ligamentous and meniscal injuries. Additionally, the video covers the evaluation of joint line tenderness, motion assessment, anterior knee pain, inflammation, swelling, degenerative changes, fractures, and muscle strength and function.
Through a systematic approach, the video demonstrates essential examination techniques for identifying potential knee injuries, such as ACL, PCL, MCL, and LCL injuries, meniscal tears and other common knee issues. Moreover, the video presents tests for assessing knee function during weight-bearing activities and evaluating knee swelling and inflammation types. By mastering these orthopaedic testing techniques, medical professionals can accurately diagnose knee injuries and develop tailored treatment plans to help patients recover effectively and return to their daily activities and sports.
Classification of Ligament Injuries
The management strategy for ligament injuries hinges on the severity of the injury and the patient's expected post-injury activities[15]. Ligament injuries are categorized into three principal grades:
Grade 1 injury comprises microscopic tears, which generally exhibit favourable responses to soft-tissue treatments and rehabilitative interventions[16].
Grade 2 injury involves partial tears and typically does not mandate surgical intervention when adequately managed via soft-tissue treatments[17].
Grade 3 injury consists of complete tears or ligament ruptures, necessitating surgical intervention for repair[18].
Conservative Management
Conservative management encompasses a range of non-surgical manual therapy interventions designed to address and treat ligamentous injuries. Techniques employed in conservative therapy include Motion Specific Release (MSR), Registered Massage Therapy, Graston Technique, Fascial Manipulation, physiotherapy, chiropractic care, and Active Release Techniques (ART)[19]. These therapeutic modalities aim to alleviate pain, restore function, and promote tissue healing by targeting soft tissue structures, enhancing mobility, and facilitating optimal biomechanics in the affected region. Multidisciplinary approaches integrating various conservative management techniques can provide a comprehensive treatment plan tailored to individual patient needs and injury characteristics.
Acute Stage of Ligamentous Injury Management
In the immediate aftermath of a ligamentous injury, appropriate management of the acute stage is essential to prevent further damage and facilitate optimal healing. The following measures should be implemented:
Rest: Minimize stress on the affected knee by refraining from weight-bearing activities or using assistive devices such as crutches if necessary[20]. This helps protect the injured ligament from additional strain and promotes healing.
Ice: Employ cold therapy by applying ice to the injured knee for 20-30 minutes at intervals of 2-3 hours[21]. This intervention aids in vasoconstriction, reducing swelling and inflammation while relieving pain.
Elevation: Position the injured knee above heart level using a rolled-up blanket or pillow to facilitate the venous return and minimize inflammation[22]. Elevating the limb can also help alleviate pain and discomfort associated with the injury.
Compression: Utilize an elastic bandage or a compression sleeve to apply gentle pressure around the knee joint[23]. This intervention aids in reducing swelling and provides additional support to the injured structures, contributing to a more favourable healing environment.
Adhering to these guidelines during the acute stage of injury helps establish a conducive environment for tissue repair and recovery, reducing the risk of complications and optimizing the healing process.
Manual Therapy
Manual therapy, when combined with exercise, can be an effective approach to treating ligamentous knee injuries. By releasing restrictions between ligaments, muscles, and surrounding soft tissues, manual therapy techniques can enhance circulatory function, blood flow, and lymphatic flow, ultimately reducing the time required for healing[24]. Moreover, manual therapy can help prevent the development of related conditions by improving the quality of all soft tissues influencing the knee. Enhanced tissue quality refers to a muscle's ability to store and release energy efficiently, akin to an elastic cord that functions optimally until adhesions accumulate due to repetitive motion, injury, or muscle imbalances[25].
In the subsequent videos, we demonstrate several effective Motion Specific Release procedures for addressing ligament injuries of the knee, highlighting the practical application of manual therapy techniques in promoting recovery and optimal function.
Knee Release Protocol - Motion Specific Release
In the accompanying video, Dr. Abelson demonstrates an effective knee release protocol using Motion Specific Release (MSR) procedures. These procedures address the localized area of pain and the broader kinetic chain, contributing to a more comprehensive treatment approach. It is essential to recognize that each instance of knee pain should be assessed and managed as a unique dysfunction tailored to the individual patient. In some cases, the treatment may focus on local structures, while in other instances, it may involve addressing a more extensive kinetic chain to achieve optimal results. (36)
Increasing Knee Joint Mobility - 4 Point MSR Knee protocol
Effective Motion Specific Release knee mobility procedures are demonstrated in this video, which effectively addresses the body's entire kinetic chain. The femur, tibia, and patella, as well as a large number of muscles and ligaments, make up the complicated structure of the knee joint. (36)
Exercise
In ligamentous knee injuries, rehabilitation exercises are vital in restoring the affected joint's strength, flexibility, and stability [26]. A comprehensive exercise program targeting various aspects of knee function can contribute to recovery and prevent future injuries.
Key components of such a program include:
Mobility: Range of Motion (ROM) exercises involve gentle movements to improve knee flexibility and reduce stiffness, facilitating a more extensive and functional range of motion[27].
Strengthening: Quadriceps and hamstring strengthening exercises are crucial, as these muscle groups are instrumental in maintaining knee stability. Stronger muscles help protect ligaments from further injury and support the joint during dynamic activities[28].
Balance: Incorporating balance and proprioceptive exercises can enhance the body's ability to maintain knee stability during daily activities and sports, promoting overall joint health and function[29].
Sport-Specific Exercises: As the knee regains strength and stability, introducing plyometric and sport-specific exercises can ensure a safe and effective return to athletic activities while minimizing re-injury risk [30].
These exercise categories form the foundation of a well-rounded rehabilitation and preventive program for individuals recovering from ligamentous knee injuries or seeking to optimize knee function and prevent future issues.
Best ACL Exercises - Non-Surgical Rehab
In the following video, Miki Burton, RMT and exercise instructor, in collaboration with Dr. Brian Abelson, developer of Motion Specific Release, demonstrate effective exercise and treatment procedures for rehabilitating ACL injuries. Partially torn ACLs (anterior cruciate ligaments) often have a favourable prognosis, with the recovery and rehabilitation period typically lasting approximately three months. (36)
Conclusion
In conclusion, ligamentous knee injuries are common occurrences that can significantly impact an individual's mobility and quality of life. A thorough understanding of knee anatomy, proper diagnosis, and classification of ligament injuries is essential for determining the most appropriate treatment plan. Conservative therapy, including manual therapy techniques and rehabilitation exercises, has proven effective in treating ligament injuries, particularly when combined with a comprehensive, individualized approach.
The videos and resources in this article demonstrate various manual therapy and exercise techniques that can be applied to ACL injuries and other ligamentous issues. As with any injury, it is crucial to consult a medical practitioner for personalized guidance on your case's most appropriate course of action. By employing evidence-based interventions and adhering to a well-designed rehabilitation program, individuals suffering from knee ligament injuries can work towards regaining strength, stability, and function, ultimately facilitating a successful return to daily activities and sports.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References:
Benjamin, M., & Ralphs, J. R. (1997). Fibrocartilage in tendons and ligaments—an adaptation to compressive load. Journal of anatomy, 191(4), 481-494.
Gianotti, S. M., Marshall, S. W., Hume, P. A., & Bunt, L. (2009). Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. Journal of Science and Medicine in Sport, 12(6), 622-627.
Siebold, R., & Branch, T. P. (2011). Anatomy of the anterior cruciate ligament. Operative techniques in orthopedics, 21(1), 46-52.
Woo, S. L., Hollis, J. M., Adams, D. J., Lyon, R. M., & Takai, S. (1991). Tensile properties of the human femur-anterior cruciate ligament-tibia complex: the effects of specimen age and orientation. The American journal of sports medicine, 19(3), 217-225.
LaPrade, R. F., & Wentorf, F. A. (2002). Diagnosis and treatment of posterolateral knee injuries. Clinics in sports medicine, 21(3), 438-448.
Kennedy, N. I., & LaPrade, R. F. (2015). The anatomy and function of the posterior cruciate ligament. Operative Techniques in Sports Medicine, 23(1), 4-9.
Li, G., DeFrate, L. E., Sun, H., & Gill, T. J. (2004). In vivo elongation of the anterior cruciate ligament and posterior cruciate ligament during knee flexion. The American journal of sports medicine, 32(6), 1415-1420.
Miyamoto, R. G., Bosco, J. A., & Sherman, O. H. (2009). Treatment of medial collateral ligament injuries. Journal of the American Academy of Orthopaedic Surgeons, 17(3), 152-161.
LaPrade, R. F., Wijdicks, C. A., & Engebretsen, L. (2010). Surgical management of the medial collateral ligament and the posteromedial corner. Sports Medicine and Arthroscopy Review, 18(1), 28-34.
Kim, S. J., Shin, S. J., Choi, N. H., & Choo, E. T. (1996). Lateral collateral ligament injury of the knee. The American journal of sports medicine, 24(1), 29-32.
LaPrade, R. F., Engebretsen, A. H., Ly, T. V., Johansen, S., Wentorf, F. A., & Engebretsen, L. (2007). The anatomy of the medial part of the knee. The Journal of Bone and Joint Surgery-American Volume, 89(9), 2000-2010.
Ristanis, S., Giakas, G., Papageorgiou, C. D., Moraiti, T., Stergiou, N., & Georgoulis, A. D. (2003). The effects of anterior cruciate ligament reconstruction on tibial rotation during pivoting after descending stairs. Knee Surgery, Sports Traumatology, Arthroscopy, 11(6), 360-365.
Butler, D. L., Noyes, F. R., & Grood, E. S. (1980). Ligamentous restraints to anterior-posterior drawer in the human knee: a biomechanical study. The Journal of Bone and Joint Surgery-American Volume, 62(2), 259-270.
Wojtys, E. M., & Huston, L. J. (2000). Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. The American journal of sports medicine, 28(1), 10-14.
Wright, R. W., Haas, A. K., Anderson, J., Calabrese, G., Cavanaugh, J., Hewett, T. E., ... & Shultz, S. J. (2015). Anterior cruciate ligament reconstruction rehabilitation: MOON guidelines. Sports health, 7(3), 239-243.
Bollen, S. (2000). Soft tissue injury healing-review. British Journal of Sports Medicine, 34(6), 393-396.
Noyes, F. R., & Barber-Westin, S. D. (2014). Management of acute isolated and combined grade-III medial collateral ligament injuries. Sports Medicine and Arthroscopy Review, 22(4), 222-232.
Myer, G. D., Paterno, M. V., Ford, K. R., Quatman, C. E., & Hewett, T. E. (2006). Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. Journal of Orthopaedic & Sports Physical Therapy, 36(6), 385-402.
Beischer, S., Hamrin Senorski, E., Thomeé, C., Samuelsson, K., & Thomeé, R. (2018). Young athletes return too early to knee-strenuous sport after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 26(7), 1966-1974.
Malliaropoulos, N., Papacostas, E., Kiritsi, O., Papalada, A., Gougoulias, N., & Maffulli, N. (2010). Posterior thigh muscle injuries in elite track and field athletes. The American journal of sports medicine, 38(9), 1813-1819.
Wilk, K. E., Macrina, L. C., Cain, E. L., Dugas, J. R., & Andrews, J. R. (2012). Rehabilitation of the overhead athlete’s elbow. Sports Health, 4(5), 404-414.
Risberg, M. A., Holm, I., Myklebust, G., & Engebretsen, L. (2007). Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Physical therapy, 87(6), 737-750.
Cimino, F., Volk, B. S., & Setter, D. (2010). Anterior cruciate ligament injury: diagnosis, management, and prevention. American family physician, 82(8), 917-922.
Huard, J., Li, Y., & Fu, F. H. (2002). Muscle injuries and repair: current trends in research. The Journal of Bone and Joint Surgery-American Volume, 84(5), 822-832.
Schleip, R., & Müller, D. G. (2013). Training principles for fascial connective tissues: scientific foundation and suggested practical applications. Journal of bodywork and movement therapies, 17(1), 103-115.
Risberg, M. A., Lewek, M., & Snyder-Mackler, L. (2004). A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type?. Physical therapy in sport, 5(3), 125-145.
van Grinsven, S., van Cingel, R. E., Holla, C. J., & van Loon, C. J. (2010). Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 18(8), 1128-1144.
Fitzgerald, G. K., Axe, M. J., & Snyder-Mackler, L. (2000). A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surgery, Sports Traumatology, Arthroscopy, 8(2), 76-82.
Myer, G. D., Ford, K. R., & Hewett, T. E. (2004). Rationale and clinical techniques for anterior cruciate ligament injury prevention among female athletes. Journal of athletic training, 39(4), 352-364.
Hewett, T. E., Ford, K. R., & Myer, G. D. (2006). Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. The American journal of sports medicine, 34(3), 490-498.
Zebis, M. K., Andersen, L. L., Brandt, M., Myklebust, G., Bencke, J., Lauridsen, T. B., ... & Aagaard, P. (2016). Effects of evidence-based prevention training on neuromuscular and biomechanical risk factors for ACL injury in adolescent female athletes: a randomised controlled trial. British Journal of Sports Medicine, 50(9), 552-557.
Kiani, A., Hellquist, E., Ahlqvist, K., Gedeborg, R., Michaëlsson, K., & Byberg, L. (2010). Prevention of soccer-related knee injuries in teenaged girls. Archives of internal medicine, 170(1), 43-49.
Barber Foss, K. D., Myer, G. D., Chen, S. S., & Hewett, T. E. (2012). Expected prevalence from the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening. Journal of athletic training, 47(5), 519-524.
Renström, P., & Ljungqvist, A. (2006). The IOC Centres of Excellence bring prevention to sports medicine. British Journal of Sports Medicine, 40(6), 469-470.
Giza, E., Mithöfer, K., Farrell, L., Zarins, B., & Gill, T. (2005). Injuries in women's professional soccer. British journal of sports medicine, 39(4), 212-216.
Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioner's Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.
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