Michelle Andrews, MD

Making Sense of Athletic Knee Injuries

To many athletes the prospect of sustaining a knee injury is horrifying. The knee is the most commonly injured joint in sports, and knee injuries have long been seen as a part of the game. In fact, the medical specialty of sports medicine was created largely to improve treatments in this area. We have grown accustomed to hearing of knee injuries in our professional and collegiate athletes from the news, in magazines and on TV shows such as Sports Center. The career threatening injuries last year to Carson Palmer and Dante Culpepper are high profile examples. On the high school level, it is rare for any team (especially football, soccer and volleyball) to make it through a full season without at least one player sustaining a knee injury. Fortunately, the majority of sports related knee injuries will heal with appropriate diagnosis and treatment and will not require surgery. Some, however, will not heal without surgical repair. In these cases, prompt diagnosis and treatment is critical to the success of any surgical procedure and to minimize down time.

The knee is a hinged joint that is lined by articular cartilage, held together by ligaments, and cushioned by the menisci. Ligament injuries or sprains are the most common sports related knee injuries. Of these, injuries to the medial collateral, (MCL), occur most frequently. The MCL is located on the inner side of the knee. It is injured when the knee is twisted or when it is struck from the side, such as when a player falls into the outside portion of another player’s knee. Injuries can range from mild sprains that result in little loss of time from playing to more complete tears that can take weeks to heal. These injuries are often very painful and initially can limit the athlete’s ability to walk without support. In more severe MCL sprains, an athlete will say that the knee feels unstable or “wobbly.” The majority of MCL injuries will not require surgery. These injuries are most often treated with bracing and with physical therapy. Athletes are allowed to return to play when they have full pain movement of their knees and near normal strength. The presence of good strength is essential to prevent recurrent injury.

The anterior cruciate ligament or ACL is the next most commonly injured ligament though it is the most frequently discussed. ACL injuries in females are especially common. 1 in 100 female high school athletes and 1 in 10 collegiate women athletes will sustain an ACL injury. When ACL tears occur, they are usually dramatic and season ending. The ACL is the main stabilizer of the knee for cutting, twisting and jumping movements. Soccer, football, volleyball, field hockey and basketball are sports that place a lot of stress on the ACL. Once the ACL is torn, these types of movements lead to the knee “giving out” or “buckling” so the player falls. When these episodes occur they place the knee at greater risk of injury to other structures. The ACL can be injured through contact with another player, but is most commonly torn when the played lands off balance from a jump, stops or pulls up suddenly, or with sudden changes in direction. The player hears a pop as the knee buckles, and the player falls. It is usually difficult for the player to walk and there is usually swelling within the next few hours. If left untreated, the swelling and pain will improve over the next few weeks but the instability will persist, making it difficult to return to high performance sports.

Early diagnosis of ACL tears is critical because if athletes are allowed to return to sports too early, they risk permanent joint injury that can lead to arthritis. Also, injuries to the ACL are frequently associated damage to the bone surface (articular cartilage) and to the menisci. ACL tears are diagnosed by a physical exam and MRI. Non-surgical treatment of ACL tears is not successful in athletes and places the individual at risk for further injury. ACL tears rarely heal on their own making ACL injuries in athlete’s best treated with surgery. Surgery involves replacing the torn ACL with a portion of tendon that is taken from another part of the knee. Current techniques of ACL reconstruction allow athletes to return running with two months and to sports within six months of their surgery.

Injuries to the menisci round out the most common sports related knee injuries. The menisci can be thought of as the shock absorbers of the knee. They are located between the bones on the inside and the outside of the knee. The menisci are torn by twisting movements but can also be torn with contact. The menisci are frequently torn at the same time that one sustains an ACL injury. With small tears, athletes will have pain along the sides of the knee. With larger tears, the knee can lock so that it is painful and the athlete is unable to straighten the knee. People with meniscal tears may also complain of painful clicking or popping within their joint. Loss of the meniscus places the individual at risk for developing arthritis. As with ACL tears, early diagnosis of meniscal tears is critical for success. The diagnosis is usually established by MRI and physical examination. When diagnosed early, many meniscal tears can be repaired thereby retaining its function and minimizing the risk for arthritis. Since there are no good treatments for arthritis in young people preserving meniscal function is critical. Bracing is usually not helpful for athletes with meniscal injuries.

Unfortunately, knee injuries are a part of sports participation. The key to insuring the best outcome possible is to diagnose any injury early and to institute appropriate treatment. You should seek medical attention following knee injury if you have pain with walking, inability to straighten your knee, or swelling that last more that 24 hours

PRACTICE PROFILE

Dr. Andrews has the distinction of being the first-ever female orthopaedic surgeon to be a team physician for a Major League Baseball team, the Baltimore Orioles, while on the faculty at John Hopkins University. Since returning to Cincinnati SportsMedicine (where she completed her medicine fellowship), her practice has evolved into seeing patients with knee and shoulder problems.

An avid Gardner, Dr. Andrews is very active in the gardening community. In addition to providing lectures on gardening injuries, Dr. Andrews is also asked to lecture on topics ranging from osteoporosis to sports injuries.