DEGENBRATIVE MENISCAL TEARS

The meniscal tear most often associated with aging is called a cleavage-type tear. This may sound sexy, but the pain and swelling associated with the horizontal separation is hardly alluring. (To get an idea of this separation, picture the venetian-blind eflect that occurs when a favorite pair of blue jeans wears out at the knee.)

Often the problem can be brought under control with exercises that build power and endurance in the quadriceps and hamstrings. (See Appendix A.) That assumes, however, that you avoid the repetitive squatting or kneeling that most likely caused the problem. Otherwise, arthroscopy can be performed and the torn portion of the meniscus can be removed.

LIGAMENT TEARS (“Sprained Knee”)

We’ve discussed how the ligaments act as the scaffolding for the bones of the knee. The collateral ligaments run up the inside and outside of the knee, while the anterior cruciate ligament and the posterior cruciate ligament cross within the joint. A sprain occurs when any of these ligaments are stretched excessively or tom.


The inner or medial collaterial ligament (MCL) is the most common site of knee sprains. Indeed, the MCL is probably 50 times more likely to be injured than the ACL. (Fortunately, most MCL injuries are of such a minor nature that they are never even called to a doctor’s attention.) The ACL is often tom in contact sports. To give you an idea of the scope of knee sprains, by conservative estimate at least 50,000 occur each year in the United States just among skiers. Fortunately, less than 15 percent require surgery.

Symptoms

The Standard Nomenclature of Athletic Injuries, published by the American Medical Association (impressive, huh), defines three categories of ligamentous injury:

1. Grade 1 “mild” sprains are those with mild tendemess, minimal hemorrhage and swelling, no abnormal motion, and minimal disability. There are minor tears of ligament fibers. There is minimal loss of strength, no lengthening, and no loss of function.

2. Grade 2 “moderate” sprains are those with moderate loss of function, more joint reaction (i.e., swelling and tendemess), slight to moderate abnormal motion, and partial tearing of ligamentous tissues. There is stretching of some ligament fibers and tearing of some.

3. Grade 3 “severe” sprains are those with marked abnormal motion, indicating a complete tear of the ligament. This causes a total loss of strength and functional capacity and may require surgical repair.

Treatment 

Back in the 1950s, casting was the primary treatment for an MCL injury. (Back then ACL injuries were basically ignored!) Then we went through a phase when surgery was the “treatment” of choice. As a matter of fact, during the seventies MCL repair was the most common knee ligament surgery. However, during the last few years there has been an astronomical drop in the incidence of MCL surgical repairs. What we leamed is that Grade 1 and Grade 2 MCL sprains will heal just as well with conservative treatment as they will with surgical intervention. So surgery is now generally reserved for only the most serious, Grade 3, MCL injuries.

In general the treatment for sprains depends on the severity of the injury. For a mild sprain, RICE is advised: rest, ice, compression, and elevation. Usually there is a relatively quick return to activity. Two to three weeks is not uncommon, although we’ll soon explain why the recovery period may be even longer.

If it is a second-degree sprain, the treatment will vary depending on the functional requirements of the individual, the pain and discomfort being experienced, and how badly other knee structures, such as cartilage or muscles, have been damaged. Also, one ligament may have a second-degree injury while another might have suffered a more severe third-degree injury, so strains are often far from cut-and-dried phenomenon.

The knee will need protection for one to six weeks in the form of a removable splint and an intermittent range of motion exercises or a brace that allows for limited movement.

For the most severe (Grade 3) sprains, surgical repair is often considered, with prolonged (three to eight weeks) splint or brace protection generally recommended. Some continued protection may even be appropriate beyond eight weeks. It should be noted that the bracing is not meant to simply provide stability; the surgical repair should do that. Instead, it is to protect and prevent reinjury while allowing for the healing of the ligament.

Perhaps the biggest problem in treating sprains is undertreating mild ones and overtreating the moderate and severe ones. Many mild sprains are functioning again within two to three weeks, yet by definition a Grade 1 sprain has damaged tissue and is weakened for a longer period of time, perhaps several months. The real hazard with Grade 1 sprains is that you will not fully appreciate your injury and you will return to activity too soon and find yourself reinjured. Unfortunately, when this happens the resulting sprain may be much more serious than the original.

While it may take only a few weeks to return to action following a sprain, actual healing may take up to two years. During the first year you will reach a significant plateau of healing and then slow healing will likely continue for another year.

Surgical Repair

Since ligaments do not have a rich blood supply, it should be remembered that they do not heal well. They should be evaluated for possible repair. Well, they can be ignored, but that does engender a certain amount of risk and a definite degree of suspense: When will your trick knee go into its next act?

If you and your doctor decide that surgical repair is necessary, the particular approach will depend on your precise injury. For a severe MCL injury, there needs to be some open surgery since the ligament is not accessible to our arthroscopes. (You’ll read more about arthroscopy later when we detail the advantages of this technology.)

Although the ACL is accessible to our microscopic surgical tools, this ligament is much more difficult to repair. The greatest likelihood for a successful repair occurs when a piece of either the femur or tibia actually breaks off with the ACL attached. That happens when the bone gives way before all of the forces can be transmitted to the ligament. It’s easier to repair a bone than it is a torn ligament, unfortunately.

Most surgeons believe that when the ACL is tom from the bone at either end, it should be reattached, since the chances of normal function after repair are good. Toward this end, orthopedists have developed a number of suturing and stapling techniques. Sadly, despite the initial enthusiasm, we’re finding that many patients undergoing this type of ACL repair really aren’t healing well. When we have had an opportunity to look at some of these patients later, what we find is pretty worthlex scar tissue instead of good resilient
tissue surrounding all that fancy medical handiwork.

Still, even this limited success is better than what we see if the anterior cruciate ligament has been torn interstitially, that is, along the ligament itself as opposed to a break at the point it connects to bone. Although a tear occurs at only one point along the ligament, there is failure all along the ligament before it ruptures. To the eye it appears to be intact, but microscopically there is noticeable damage up and down the ligament. It’s comparable to what you might have experienced if you’ve ever broken a rubber band, tied it back together with a knot, only to have it snap apart again an inch away from the original break. It looked fine, but what you couldn’t see was that in the constant stretching of the rubber band it lost its normal elasticity, its continuity, and even though only one small part broke, the rest of it was severely weakened. That’s what
happens in most ACL tears.

ACL Reconstruction

For these and other reasons, reconstruction is becoming more popular than repair: Other tissue or synthetic material is used to graft or reconstruct the ligament. If possible, someone’s own tissue is preferable to any of the artificial ligaments that are available at this time. (This technology is discussed in great detail in the epilogue.) Rather than repair the torn ACL, a tendon alongside the knee is moved over and down as a replacement. The process may include looping the tendon to actually provide more strength than the original. Some of the patients who have had this surgery were professional or college athletes who had been sidelined by continuing instability following previous surgery. Many were restored to their former levels of performance.

Several popular operations use the patellar tendon to replace the ACL because it’s one of the strongest grafts available. A potential problem with this approach is that the patellar tendon is a vital structure and taking one third to one half of it to do the reconstruction strikes me as robbing Peter to pay Paul. The penalty is often extra wear of the kneecap and difficulty in regaining flexion at the knee.

Non-Surgical Management of the Tom ACL

All of this assumes that you and your doctor decided on a surgical approach. Within the last few years we have come to realize that, contrary to earlier belief, a torn ACL is not necessarily the beginning of the end. Although a complete solution to the torn anterior cruciate ligament has yet to be devised, numerous options are available. And, indeed, one of those options is to learn how to live with it. Probably at least 60 percent or more of all patients can tolerate loss of this ligament. It depends on the amount of laxity present and the desired level of activity.

Age is also a factor. Ninety percent of the people undergoing ACL repairs or reconstruction are between nineteen and twenty-seven years old. The older person probably is not going to place the demand on their knee that someone younger will. And a tom ACL usually implies modification of life-style, including both athletic and vocational endeavors.

For example, living with a tom anterior cruciate ligament probably means living without running-and-cutting sports such as basketball and racquetball. Any activity involving sudden stops and tums would simply be harder to take and much more hazardous. Climbing or working on rough terrain or slippery surfaces would also be ill-advised. Remember, the cruciate ligaments prevent the bones from slipping backward or forward out of joint. Without an ACL for added support, going down hills or stepping in a hole can be a lot more treacherous because you just don’t have the resiliency and protection you once had. This means you can still run after your bus if you have a clear path, but stepping off the curb could send you to the ground.

In our office we’re currently studying the natural histories of patients who had untreated but documented anterior cruciate ligament tears. About 80 percent of them are satisfied, but we are going to find out what they had to change in order to accommodate their knee condition.