pathology: lateral and cruciate ligament injuries

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lateral and cruciate ligament injuries (knee joint)

Definition of

Partial or complete rupture of one or more ligaments:

  1. Anterior cruciate ligament (one attachment on the femur, two (anterior and posterior) on the tibia), tears m:w 2:1, usually 20-30 years, active in sports. The AC consists of two fiber bundles twisted spirally against each other, limits the forward movement of the lower leg in relation to the thigh(anterior translation); tensile strength approx. 240 kg (men), tears far more frequently than the posterior cruciate ligament; if the AC tears from the femur, it sinks and cannot grow back; if only the inner AC tears, there is only a gradual loss of stability and the inner AC can heal again; if the anchoring in the tibia tears out with a piece of bone, this can be surgically fixed; the most common cause is falls with twisting of the lower leg, most frequently during soccer or skiing. The causes are usually traumatic hyperextension, hyperflexion, varus or valgus rotation trauma, sometimes also abrupt tensing of the quadriceps when the knee joint is flexed, usually with a large eccentric load, e.g. during downhill skiing. In women, the AC tears more frequently because it is thinner in comparison to body weight.
  2. The posterior cruciate ligament (one attachment on the tibia, two (anterior and posterior) on the femur) is more stable than the AC and the kinetics of most injuries do not threaten it. It limits the posterior movement of the lower leg relative to the thigh; the most common causes of posterior cruciate ligament tears are car accidents with impact of the knee on the dashboard, further falls for the ventral proximal tibia and hyperextension trauma.
  3. Inner ligament: runs medially from femur to tibia, approx. 10 cm long and connected to the medial meniscus, prevents the knee from buckling inwards
  4. Outer ligament: runs laterally from femur to tibia, prevents the knee from buckling outwards

There are three degrees of collateral ligament damage:

  1. Straining of the ligament, tears are minimal at best. The joint can be opened a maximum of 5°, pressure pain is quite limited locally, hematoma and swelling are minimal. Full joint stability
  2. Partial rupture of the ligament, can be opened up to 10°, localized tenderness and swelling. The stress test (varus or valgus, depending on the ligament affected) shows a clear limit of movement
  3. Complete rupture, marked tenderness, instability of the joint. The stress test lacks a clear stop.

40% of all knee injuries are ligament injuries, 60% of which are anterior cruciate ligament injuries; anterior cruciate ligaments are 10 times more common than posterior cruciate ligaments. In Germany, a cruciate ligament is torn every 6.5 minutes. When a cruciate ligament ruptures, other injuries often occur at the same time: Inner meniscus tear 69%, outer meniscus tear 49%, chondropathies 20-50%, secondary arthrosis after meniscus removal; frequently inner ligament injuries, less frequently outer ligament injuries; capsule tear; 80% of all cruciate ligament tears are accompanied by bone bruise (bone trauma with painful bone edema). 50% of these show cartilage softening or damage in follow-up examinations. The unhappy triad often occurs: Lesion of the anterior cruciate ligament with lesion of the medial meniscus and medial collateral ligament. Here are a few figures from English women’s soccer on ACL tears: women are 3.5 times more likely to suffer ACL tears triggered without contact with an opponent than men, 45% of whom retire from competition due to inadequate post-rehabilitative performance levels, of the remaining 55% 35% no longer reach their original performance level. Among the 15-30 year olds affected by ACL tears, around 50% show signs of osteoarthritis 10 years later compared to 7% in the group without ACL tears. Most people involved in sport and science agree that endurance training and strength training are among the most important preventive measures.

The statement that ligament deficits can be compensated for muscularly is not entirely correct: the stretch receptors in the cruciate ligament and in the joint capsule are used for muscular stabilization of the knee, which requires processing time during which the knee is exposed to „uncontrolled“ and increased wear. Although ruptures of the posterior cruciate ligament are significantly rarer than those of the anterior cruciate ligament, they are difficult to compensate for muscularly. They cause increased retropatellar pressures and a ventral translation of the femur in relation to the tibia when the foot is punctum fixum of the standing leg in a running movement or when stopping from running. The untreated rupture appears to be unproblematic in the short and medium term, but medial(knee joint) and retropatellar arthrosis often occurs later. Depending on behavior (sports, etc.) and age, conservative therapy can be considered here, whereby a posterior shear ligament must be prevented with an orthosis in the early stages. Among the collateral ligaments, the medial collateral ligament is particularly painful when damaged in the distal area (up to caudal to the pes anserinus). However, the tendency to heal spontaneouslyis good, even if the joint is initially very open, so that a conservative approach can usually be taken. An orthosis is prescribed for this purpose. As with the anterior cruciate ligament, muscular strengthening and proprioceptive training is also recommended here.

ICD M23.*

Cause

  1. Exceeding the tensile strength of the ligament, usually impact-like; mostly traumatic: sports injuries due to non-physiological movements, tennis, squash, ball sports, skiing, falls.
  2. Anterior cruciate ligament ruptures: mostly twisting traumas
  3. posterior cruciate ligament ruptures: ventral knee trauma and hyperextension trauma as well as severe varus or valgus stress with existing collateral ligament injury
  4. Collateral ligament tears: Impact from the outside(inner ligament tear) or inside(outer ligament tear).

Predisposing

  1. Sports on indoor floors with extreme friction between the floor and shoe or with contact with opponents and uncontrolled jumps and falls: footballs, handball, rugby, American football, basketball, judo, wrestling. Next: Ski
  2. genetic
  3. Untrained, resumption of sport after a long break
  4. Overweight
  5. „Neuromuscular fatigue“ towards the end of a game/competition

Diagnosis

  1. X-ray only for the detection of tears
  2. CT
  3. MRI (partial ruptures, especially of the inner part of the anterior cruciate ligament, are difficult to detect)
  4. Lateral ligament tear: abnormal lateral flexibility of the lower leg with the knee joint extended
  5. Tests and signs
    Collateral ligaments: Tests in 0° and 30° flexion: Böhler (Krömer) sign;
    Inner ligament: Varus stress test
    Outer ligament: Valgus stress test
    Anterior cruciate ligament: Lachman test, anterior drawer phenomenon, pivot shift test, Lelli (lever sign)
    posterior cruciate ligament: posterior drawer phenomenon, posterior sag sign/gravity/godfrey sign, reversed pivot shift test, dial test, quadriceps active test, hyperextension test

In the Lachmann test for the cruciate ligaments, the lateral comparison is also determined and divided into three degrees: Multiple displacement up to 5 mm, up to 10 mm and above. If both cruciate ligaments are torn, the examiner must not be deceived by the increased displacement of the other ligament. In acute injuries with hemarthrosis, the pivot shift test may not be feasible.

Symptoms

  1. Loud plop when cracked
  2. Joint instability, lateral in the case of a torn collateral ligament; in the case of a torn cruciate ligament, especially when walking downhill
  3. Significant pain, especially pain on exertion
  4. Painful restriction of movement
  5. Pressure soreness
  6. Cruciate ligamentrupture: Hemarthrosis (hematoma in the joint) during the day(cruciate ligaments are well supplied with blood)
  7. Cruciateligamentrupture: extensor deficit; clear subjective instability dorsal/ventral from approx. 30° flexion (especially ACL). With older ACL tears: Giving way phenomenon, rotational instability when the foot is placed on the ground. With ACL tears, pain and swelling are even more pronounced than with ACL tears. Older ACL tears mainly lead to retropatellar pain and instability.
  8. Lateralligamentrupture: lateral instability, decreasing pain that returns with exertion
  9. Innerligamentrupture: swelling of the inside of the knee, severe pain, possibly hematoma
  10. Externalligamentrupture: pain in the outer knee, slightly dorsal; possibly effusion or hemarthrosis

Complications

  1. Untreated: increased risk of arthrosisin many cases; increased meniscus wear (40% after 1 and 5 years, 80% after 10 years); instability with increased risk of re-injury
  2. Anterior cruciate ligament: significant risk of meniscus damage and osteoarthritis without surgery during high levels of sporting activity. Indication factors for a conservative approach are: advanced age, pre-existing osteoarthritis, only minor instability, low level of sporting activity. Intensive muscle training for the quadriceps and hamstrings as well as proprioceptive training (reflexes and coordination) are then obligatory. A part of the quadriceps tendon is surgically transplanted arthroscopically with two bone blocks or a multi-stranded tendon from the pes anserinus complex, usually gracilis tendon and semitendinosus tendon. Double open surgery with replacement from the archilles tendon or tendon of the tibialis anterior is only advisable in exceptional cases due to the significantly higher risk of infection. Even after surgery, residual instability cannot be completely ruled out, the transplant may fail, become loose, knee flexion may be limited or strength reduced, movement-restricting arthrofibrosis (early revision if suspected) or retropatellar complaints may occur.
  3. Later: medial(knee joint) and retropatellar arthrosis.

Therapy

  1. Immediate measures: PEH, relief, crutches, NSAIDs if necessary
  2. KG
  3. Cruciate ligament rupture: no spontaneous healing, surgery (depending on restitution expectations),
    Anterior cruciate ligament rupture: without concomitant injury and major sporting expectations, possibly conservative. Depending on movement expectations, autologous tendonplasty. Surgery does not guarantee that the patient will be able to continue playing the sport successfully. The surgical decision should take into account
    • Age
    • occupation
    • compliance
    • Expectation of movement
    • Feeling of instability
    • General condition of the knee joint
    • Concomitant injuries.
      Early functional follow-up treatment with progressive loading
      Posterior cruciate ligament rupture: Surgery often does not produce better results than conservative treatment and is therefore only considered in cases of high stress expectation and pronounced instability. Risks after surgery: significantly poorer reconstructability than ACL, restriction of movement possible, recurrent instability. If the posterior lateral capsular leak (popliteus corner) is also injured, the prognosis for surgery is rather poor. A plasty can be created from the tendon of the medial gastrocnemius origin or a third of the patellar tendon.
  4. Lateral ligament rupture: good spontaneous healing, surgery only if bone is torn out, otherwise movement splint for 6-8 weeks
  5. Inner ligament rupture: usually conservative, surgery only in the case of bony avulsion
  6. Torn collateral ligament: surgical in 50% of cases, as other knee structures are usually damaged
  7. Preventive: balance exercises, balance board/pad, special jump training for at-risk athletes
  8. Patients with a cruciate ligament rupture have a five-fold increased risk of a new rupture, even contralaterally.

Asana practice

As the causes are usually traumatic and are generally not or only to a small extent due to muscular deficits or imbalances, there is often far less to work out here than with other disorders. Nevertheless, healing can be promoted – whether conservative or surgical treatment is used. First and foremost, the statics and above all the kinetics emanating from the foot must be secured, i.e. the ankle joint must be secured and the moving muscles must be trained so that the transmission of force between the ground on the one hand and the knee joint, pelvis and upper body on the other has the best possible conditions for future movements. If early loading is permitted, it should be started as soon as possible, otherwise as soon as the target allows. Strengthening the pronators and supinators is at the forefront here, followed by the triceps surae and the thigh muscles that influence the knee joint proximally, i.e. the quadriceps as the extensor of the knee joint, the hamstrings as flexors of the knee joint and the endorotator and exorotator muscles in the knee joint, the adductors and abductors, as well as the exorotators and endorotators, in short, the entire thigh and hip musculature. For the supinators and pronators of the ankle, standing postures with a narrow pyhsical base of support in which the pelvis is rotated towards one foot, such as parivrtta trikonasana, parsvottanasana and 1st warrior pose, and secondarily trikonasana, are particularly suitable.

Depending on which ligament is affected, special attention must be paid to the design, so that in the case of collateral ligament damage, for example, any varus stress (external ligament damage) or valgus stress (internal ligament damage) is avoided at all costs. In the case of the cruciate ligaments, translations of the tibia in a ventral direction (in the case of the anterior cruciate ligament) or in a dorsal direction (in the case of the posterior cruciate ligament) must be avoided.

Apart from general strengthening, muscular imbalances that predispose to disorders must of course be eliminated and flexibility deficits that might otherwise preclude or restrict physiological movement in the affected joints, even at larger angles, must be remedied.

Asanas

Strengthening:

The stretching of these muscles should be regarded as somewhat inferior to strengthening, unless flexibility deficits need to be worked on or excessive tone needs to be reduced: