Anterior Cruciate Ligament and Lateral Meniscus Tear

Anterior Cruciate Ligament and Lateral Meniscus Tear

Diandra Schonyers

Pathology & Evaluation of Orthopedic Injuries

Dr. Robert Sterner

Abstract

Objective: To highlight this anterior cruciate ligament injury and determine its significance and uniqueness in relation to the other injuries that are currently in the athletic training room.

Background: ACL tears have been researched in several journals and case studies with both noncontact and contact mechanisms. In this report, I will explore an ACL tear with both a contact and a noncontact mechanism.

Differential Diagnosis: Partial or complete tear to the ACL and lateral meniscus

Treatment: Pre-surgery rehabilitation, surgery and post-surgery rehabilitation

Uniqueness: Most ACL tears are as a result of one mechanism, contact or noncontact, this injury is a result of both and most patients with an ACL injury are not able to continue to play on the torn ligament; however, this athlete was able to continue play for a period of time.

Conclusion: The information provided in this case study explores both mechanisms and discloses data that could add further knowledge to the current studies on ACL tears.

Key Words: knee, injury mechanism, ACL tear, lateral meniscus tear

During the time I spent in the athletic training room I observed a vast amount of injuries. I saw injuries ranging from a strained groin to what appeared to be acute compartment syndrome with a possible tibial fracture. All of the injuries were each significant in their own way; however, one specific injury caught my attention. The athlete is a twenty year old African American male who plays football on the university’s varsity team. If you were to look at him you would not think that he is injured. However, he suffered a season ending injury during the football team’s summer camp. The injured limb is the athlete’s left knee. He tore his anterior cruciate ligament and there is also a tear in his lateral meniscus. The anterior cruciate ligament (ACL) originates on the anteromedial portion of the medial tibial plateau. The ligament inserts into the medial wall of the lateral femoral condyle. The function of the anterior cruciate ligament is to prevent anterior translation of the tibia on the fixed femur, to prevent posterior translation of the femur on the fixed tibia and also to assist in guiding the internal and external rotation of the tibia or the femur, depending on whether the knee is in an open or closed position (Starkey and Ryan pg 291). The menisci lie in the tibial plateaus. The function of the menisci is to deepen the geometry of the socket, absorb shock between the tibia and the femur and reduce friction between the tibia and the femur. The lateral meniscus is O shaped and serves as an attachment site for the popliteus muscle (Starkey and Ryan pg 294). The pathology that is involved with this case study is an anterior cruciate ligament tear and a tear to the body of the lateral meniscus. This pathology differs from most ACL tears because the athlete had both a contact and a noncontact mechanism because he injured the ACL twice. The first time the athlete injured his ACL as a result of a rotary force and a blow the femur while the tibia was fixed, at this time he also sustained an injury to his lateral meniscus. The second time the athlete injured his ACL as a result of a rotary force. Yohei Shimokochi (PhD and ATC) and Sandra J. Schultz (PhD, ATC, FNATA, FACSM) wrote in the article “Mechanisms of Noncontact Anterior Cruciate Ligament Tears”, that through their research they found the noncontact anterior cruciate ligament injuries usually are due to “multiplane knee loadings and weight bearing activities” (Shimokchi and Schultz). Medial meniscal tears along with acute anterior cruciate ligament injuries are very common and lateral meniscal tears are not that common. However, in the article “Articular Cartilage Injury of the Posterior Lateral Tibial Plateau Associated with Acute Anterior Cruciate Ligament Injury”, a study on 39 acute anterior cruciate ligament injuries showed that 33 of the 39 cases had tears to the posterior horn of the lateral meniscus. Twenty nine had longitudinal tears, three had horizontal type tears and one case had a radial type tear (Nishimori…Ochi).

This athlete has a history of injuries to his left knee. On August 23, 2009 he went to the athletic training room to have someone evaluate his left knee. During the history portion of the evaluation process the evaluating athletic trainer found that he previously suffered a meniscal injury, the athlete complained of pain shooting down his leg and his knee would give out. On observation the athletic trainer found that he had swelling over the anterior aspect of the tibia, no ecchymosis, and no deformity but, he did have an antalgic gait. With palpation the AT concluded that he was point tender over the anterior tibia and the quad tendon, he had no pain over the medial or lateral joint line, no pain over the fibular head, no pain over the patella, no pain over the LCL or MCL, and no pain over the popliteal fossa. Analysis of the athlete’s range of motion concluded that knee extension was full and painful, flexion was full and painful, ankle dorsiflexion and inversion were full and painful, and ankle inversion and plantar flexion were full and painless. The muscles that were manually muscle tested were the rectus femoris, biceps femoris, semimembranosus, semitendinosus, quadriceps, tibialis anterior, and the peroneals. Each of these muscles was graded 4 out of 5 meaning the patient could resist against moderate force (Starkey & Ryan pg 21). The neurological and circulatory examination determined that his circulation was within normal limits and he had tingling with C10, L4 and L5 dermatomes (the tingling at C10 was due to a “stinger” that was sustained earlier in summer camp). The special tests that were performed were McMurray’s test which was negative, bounce home test which was positive, both valgus and varus stress tests were negative, medial and lateral grind test was positive, anterior lachman’s test was had no solid endfeel, and appley’s compression test was positive. The diagnoses that the AT came upon from the evaluation were a tibial contusion, ACL sprain, and a possible meniscal re-injury.

The athlete was then evaluated again on the following day after suffering an acute injury during summer camp. In the course of the history portion of the examination the athlete said that he planted his left leg and he twisted to cut, he then felt and heard a pop, had immediate pain and fell to the ground. The athlete described his knee as feeling unstable. Also during the history portion, the AT found that the athlete had previously injured the same knee during a pickup football game months before. When the athlete injured his knee in October his foot got caught in a type of indent in the field he was playing on, his leg then twisted and he suffered an anterior blow the femur. As he got hit the athlete heard and felt few pops in his knee and fell to the ground. Immediately following this injury he felt his knee was unstable and was not able to continue playing in the game. Following the October injury the athlete saw an orthopedic doctor who sent him to get an MRI. After viewing the MRI the doctor told the athlete that everything appeared normal and he could resume play. The athlete then began running on his knee four months later in February. The observation segment of the evaluation found that the athlete’s left knee had some moderate swelling and no discoloration. Examination of the athlete’s range of motion concluded that his range of motion was full and painful from 0 to 160 degrees. No manual muscle tests were performed during this evaluation. The neurological and circulatory components were found to be within normal limits. The special tests that were performed were McMurray’s test which was negative, lachman’s test which was positive and the AT was unable to the pivot shift test because the athlete could not relax and it was too painful. The impression following this evaluation was an anterior cruciate ligament tear.

Following the second evaluation the AT referred the athlete to a physician and was he then told to get an MRI. The report from the MRI technician on August 26, 2009 resolved that the athlete’s anterior cruciate ligament and the posterior cruciate ligament both appeared normal, there was no medial meniscus tear, some degeneration of the posterior horn of the lateral meniscus was present and there was a suspected tear in the body of the lateral meniscus, the medial collateral ligament, lateral collateral ligament, quadriceps, and the patella tendon all appeared normal. There was no fracture and there was small to moderate joint effusion. Although the MRI technician reported that the ACL was normal, the images and the special/ligamentous tests that the doctor and the athletic trainers performed concluded that the ACL was in fact torn and there was a tear to the body of the lateral meniscus.

My diagnosis would be an ACL tear. Based on the history portions of each evaluation the athlete described both mechanisms that you hear the most for anterior cruciate ligament tears. The first evaluation indicated a meniscal injury; however, it does not indicate which meniscus or the seriousness of the injury. Therefore, to completely diagnose the severity of this injury I would send the athlete for an MRI. After viewing the images from the test, I would fully diagnose his injury. However, before viewing the MRI I would diagnose this injury as an acute anterior cruciate ligament tear.

To treat the athlete’s injury he will be required to have surgery. Following the second evaluation the athlete participated in a pre-surgical rehabilitation program. This rehabilitation program began on September 1st and ended on September 14th. This program included straight leg raises with a 3lb weight cuff (3 sets of 10), wall squats with and without the stabilization ball (3 sets of 10), hamstring curls with weight (3 sets of 10), ice and electrostimulation for twenty minutes, jump squats, sport specific outside drills, tape and a sprint program. The goals established with this rehabilitation regiment were to have the athlete gain full and painless range of motion. The best case scenario was to get the athlete to return to play; however, the athlete’s doctor did not permit him the play because of the severity of his injury and the instability, pain and swelling that he would consistently experience. The athlete is currently awaiting his surgery, which is December 22nd.

This athlete has a great deal of post surgical rehabilitation ahead of him. The first criteria for return would be to get the ACL reconstructive surgery. Following the surgery the athlete will be put on an extensive post surgical rehabilitation program. According to the Department of Rehabilitation Services at Bringham and Women’s Hospital the athlete’s supervised rehabilitation will take 3-9 months (Cowell and Josee-Paris). After the surgery the athlete will be able to slowly return to his everyday activities. He will be able to bathe/shower without the brace according to the physicians directions, the athlete must sleep with the brace locked in extension for one week, he will be able to resume driving (with left leg surgery) after one week with an automatic car, 4-6 weeks with a manual car or right leg surgery, and the person will be placed on crutches for six weeks (Cowell and Josee-Paris).

It is important to know about this case study because while ACL injuries are not uncommon in football, the mechanisms this athlete sustained and the manner in which it occurred was unique. There are currently about five athletes rehabilitating ACL injuries in the athletic training room, but each injury is post surgical and all except for one had the same mechanism, noncontact. The athlete I described suffered both contact and noncontact mechanisms. He is also pre-surgery; therefore, I can observe his rehabilitation process his progress from start to finish. This is the most unique ACL tear that I have seen because not only did he injure it months prior to the tear, he also played through pain, swelling, and soreness up until he completely tore his ACL. Watching this athlete go through his rehabilitation process is going to be very interesting and seeing his continued advancement and possibly play next football season, depending on the speed of his recovery, is going to be very fulfilling.

Book

1.  Starkey, Chad, Brown, Sara D., Ryan, Jeff. Examination of Orthopedic and Athletic Injuries. Philadelphia: F.A. Davis Company; 2010

Journal or Magazine Article

2.  Shimokochi, Yohei, Shultz, Sandra J. Mechanisms of Noncontact Anterior Cruciate Ligament Injury. J Ath. Train. 43 4: 398-408

3.  Nishimori, Makoto, Deie, Masataka, et. al. Articular Cartilage Injury of the Posterior Lateral Tibial Plateau Associated with Acute Anterior Cruciate Ligament Injury. Knee Surg Sports Traumatol Arthrosc. 16: 270-274

Website

4.  Cowell, Mike, Josee-Paris, Marie. ACL Allograft Reconstruction Protocol. Bringham and Women’s Hosp. Available at: http://www.brighamandwomens.org/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Knee%20-%20ACL%20Allograft%20Protocol.pdf