Rotator cuff tears are a common source of shoulder pain. The rotator cuff consists of four shoulder muscles and their tendons. Tendons are strong fibers that connect our muscles to our bones. The shoulder muscles and tendons cover the upper end of our arm bone forming a cuff.

The risk of rotator cuff tears increases with age. The aging process can cause the tendons and muscles to degenerate and weaken. Rotator cuff tears can also result from sudden shoulder movements or overuse, for instance during sports, such as pitching in baseball or playing tennis, or falls.

The decision on how to treat rotator cuff tears is very individualized. Some rotator cuff tears can be treated with non-surgical methods. However, surgical procedures have become less invasive, resulting in good outcomes with improved recovery times.

ANATOMY

Our shoulder is composed of three bones. The humerus is our upper arm bone. The clavicle is what we call our collarbone. The scapula is the shoulder blade that moves on our back. An edge of the scapula, called the acromion, forms the top of the shoulder. There are a total of four joints in our shoulder complex. The humerus and the scapula form the main shoulder joint, the glenohumeral joint.

The glenohumeral joint is not a true ball-in-socket joint like the hip, but it is similar in structure. The top of the humerus is round like a ball. It rotates in a shallow basin, called the glenoid, on the scapula. A group of ligaments, called the joint capsule, hold the ball of the humerus in position. Ligaments are strong tissues that provide stability. In other words, the joint capsule is responsible for holding our upper arm in place at our shoulder.

The four rotator cuff muscles form a single cuff of tendon that connects to the head of the humerus bone. The muscles allow the arm to rotate and move upward to the front, back, and side. A fluid-filled sac, called the subacromial bursa, lubricates the rotator cuff tendons allowing us to perform smooth and painless motions. We use the rotator cuff muscles to perform overhead motions, such as lifting up our arms to put on a shirt, comb our hair, or reach for an item on a top grocery shelf.

These motions are used repeatedly during sports, such as serving in tennis and passing in football. The rotator cuff also provides stability when our elbow flexes and as we lift objects.

CAUSES

Rotator cuff tears most frequently occur in the dominant arm but commonly occur in the non-dominant arm. The risk of rotator cuff damage increases with age. With age, the blood supply to our tendons decreases. This causes the tendons and muscles to degenerate, weaken, and become susceptible to tearing. Additionally, the tendon degenerates with age. The body’s ability to repair the tendon decreases over time because of the reduced blood supply.

Sometimes the aging process can cause bone spurs to grow on the scapula, particularly in the acromion area. Shoulder impingement syndrome occurs when bone spurs or bursa inflammation narrows the space that is available for the rotator cuff tendons. The tendons can tear as they rub across the bone spur, particularly when the arm is elevated. Inflamed tendon membranes may develop tendonitis, a painful condition. Shoulder impingement syndrome may even cause the rotator cuff tendons to detach from the top of the humerus.

Rotator cuff injuries can occur in younger people following a shoulder injury, such as a fracture or dislocation. Overuse or repetitive activity can also cause rotator cuff tears. This includes athletes that perform overhead movements during such sports as tennis, swimming, or baseball. This also includes workers who reach upwards repetitively during construction, painting, or stocking shelves.

SYMPTOMS

The symptoms of a rotator cuff tear tend to appear gradually. You may first develop pain in the front part of your shoulder. Your pain may spread down the side of your arm. The pain may be mild at first and increase when you lift your arm or lower your arm from a fully raised position. Over time, the pain may be present when you rest and even wake you while you sleep. However, some rotator cuff tears are not painful at all.

Your shoulder may feel stiff. It may be difficult for you to move your arm. You may hear a crackling noise when you do so. Your arm may feel weak, especially when your lift or rotate it.

The symptoms of a rotator cuff tear caused by traumatic injury occur suddenly. You may feel a snap and sudden pain. Your arm will immediately feel weak, and you will have difficulty moving it.

DIAGNOSIS

A doctor can evaluate your shoulder by performing a physical examination and viewing medical images. Your doctor will ask you about your symptoms and medical history. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and shoulder stability.

Your physician will order X-rays to see the condition of the bones in your shoulder and to identify arthritis or bone spurs. A special dye may be used with the X-ray in a procedure called an Arthrogram. Sometimes a soft tissue injury does not show up on an X-ray. In this case, your doctor may order a Magnetic Resonance Imaging (MRI) scan or an ultrasound. A MRI scan will provide a very detailed view of your shoulder structure. It will help your doctor determine the location and type of your rotator cuff tear. An ultrasound uses sound waves to create an image when a device is gently placed on your skin. These tests do not hurt but require that you remain very still while a camera takes images.

TREATMENT

Many rotator cuff tears can be treated with non-surgical methods including rest and pain relief. Limiting overhead arm movements and wearing a sling may help to reduce symptoms. Over-the-counter medication or prescription medication may be used to reduce pain and swelling. If your symptoms do not improve significantly with these medications, your doctor may inject your joint with corticosteroid medication. Corticosteroid medication is a relatively safe pain reliever. Physical and occupational therapy can be helpful to restore strength and function.

SURGERY

Surgery is recommended when non-operative treatments have provided minimal or no improvement of your symptoms. Surgery may also be recommended for painful injuries or for people who rely on their arm strength for work or sports. There are several types of surgeries that can be performed for rotator cuff tears. The type of surgery that you have depends on the size, shape, and location of your tear.

Partial rotator cuff tears may only require debridement. This surgical procedure simply trims the tendon. Suturing the tendon together repairs a complete tear. Additionally, tendons can be reattached to the bone. Many of these surgeries can be done as outpatient procedures. You will be anesthetized for the surgery. Three common surgical approaches include Open Surgical Repair, Mini-Open Repair, and Arthroscopic Repair.

Open Surgical Repair is the original type of surgery for rotator cuff tears. During Open Surgical Repair, the surgeon opens the shoulder complex to gain access to the torn rotator cuff. Your surgeon will make an incision over your shoulder and detach a small portion of the deltoid muscle for the surgery. An Acromioplasty is often performed at the same time. An acromioplasty removes bone spurs from underneath the acromion.

A Mini-Open Repair of the rotator cuff is a variation of the Open Surgical Repair. The Mini-Open Repair uses much smaller incisions, typically three to five cm. in length. The deltoid muscle is not detached in this procedure. Instead, the surgeon views and evaluates the joint using an arthroscope.

An arthroscope is a very small surgical instrument. It is about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to view inside of a joint. The arthroscope can be attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape. With this technology, your surgeon will only need to make small incisions and will not need to open up your joint fully.

The arthroscope is used to remove bone spurs under the acromion and to treat other structures in the shoulder joint. Your surgeon will then use a mini-open incision to repair the rotator cuff. Results of the Mini-Open Repair are equal to the Open Repair surgical method.

Another option for rotator cuff repair is All-Arthroscopic Repair. This technique is commonly used to reconstruct ligaments or remove damaged tissue and bone spurs. Arthroscopy is less invasive than traditional surgical methods. It has a decreased risk of infection and a shorter recovery period.

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your shoulder joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert the arthroscope and may reposition it to see your joint from different angles.

Your surgeon may make additional small incisions and use other slender surgical instruments for surgical treatments. Because the surgical incisions are so small, they will require just a few stitches or Steri-Strips. Your surgeon will cover them with a bandage.

RECOVERY

Your shoulder will need several weeks to heal from the surgery. Your surgeon will restrict your arm movements for a short period of time following your procedure. You will most likely wear an arm sling for four to six weeks. An occupational or physical therapist will gently help you move your arm at first, and then you will progress to strengthening exercises.

Generally, most individuals regain functional movement and strength by four to six months after surgery. Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect.

Overall, arthroscopic shoulder surgery requires a shorter length of time for recovery than open joint surgery. It also has a reduced risk of infection, less blood loss, and less pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed. Most individuals achieve good results with rotator cuff repair. All methods of surgery appear to produce equal results.

PREVENTION

It may be helpful to exercise to maintain a strong, stable, and flexible shoulder. Avoiding repetitive overhead movements may help to prevent rotator cuff tears. Further, it is important to follow your doctor’s instructions for any weight lifting or motion restrictions.

Golfer's Elbow (medial epicondylitis) is a type of cumulative trauma injury. Golfer's Elbow results when the tendons that attach to the inner elbow degenerate. Tendons do not stretch easily and are vulnerable to degeneration during repetitive motions, such as those used during a golf swing or work activities. The pain of Golfer's Elbow occurs where the tendons attach to the elbow bone (medial epicondyle) and can radiate down the forearm. The majority of people with Golfer's Elbow find symptom relief with non-surgical methods. If surgery is necessary, there are open and arthroscopic methods to fix the problem.

ANATOMY

Golfer's Elbow involves the common flexor tendon that connects flexor forearm muscles to the inner (medial) side of the elbow bone (epicondyle). The forearm muscles that flex the wrist move it downward towards the palm side of the hand.

CAUSES

Repetitive motions and cumulative stress cause the tendons at the inner side of the elbow to deteriorate. Such motions may occur while playing golf, but also during periods of muscle overuse.

SYMPTOMS

A main symptom of Golfer's Elbow is pain and tenderness at the inner side of the elbow that increases during wrist flexion or grasping motions. The pain may radiate down the forearm.

DIAGNOSIS

A physician performs an examination and reviews the individual's medical and activity history to make a diagnosis of Golfer's Elbow. The physician evaluates the forearm and elbow structures with simple tests. X-Rays and, more rarely, MRI imaging, are used to confirm the diagnosis and rule out other causes of elbow pain.

TREATMENT

Most cases of Golfer's Elbow respond to non-surgical treatments. Treatment typically includes rest or activity restriction or alteration. Specific stretching and exercises under the guidance of a therapist are often prescribed. The therapist may use ultrasound or other modalities to promote healing. A splint, brace, or elbow wrapping may be recommended. Physicians may instruct the application of ice to the affected areas or recommend medication to relieve pain. Cortisone shots are often used, but have little evidence that they are useful.

SURGERY

The majority of people with Golfer's Elbow do not require surgery. Surgery is considered if significant pain continues after nonsurgical treatments have failed over a long time. Surgery for Golfer's Elbow is usually an outpatient procedure. The goal of surgery is to remove the damaged tendon and reattach the healthy tendon to the bone. There are several approaches to the surgery including open surgery, percutaneous, and arthroscopic surgery.

Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery. Only small incisions are used and the joint is not opened. Arthroscopic surgery for Golfer's Elbow is associated with a positive outcome and potential shortened recovery time.

Elbow motion begins almost immediately following surgery, and is gradually increased per the surgeons instructions. Full recovery from elbow surgery may take several months.

RECOVERY

Recovery from Golfer's Elbow can take several months. It is important to manage the condition with rest, rehabilitation, and lifestyle or sports modifications, such as changing the technique of a golf swing.

Tennis Elbow is a condition that results in deterioration of the tendon fibers that attach to the bone at the outside of the elbow. Tendons are strong fibers that attach muscles to bone. They are tissues that do not stretch easily and are susceptible to degeneration under repeated or traumatic stress. Another name for Tennis Elbow is Lateral Epicondylitis. The pain of Tennis Elbow occurs primarily where the tendons of the forearm muscles attach to the elbow bone at the Lateral Epicondyle. Playing racquet sports is only one cause of Tennis Elbow.

ANATOMY

A tendon anchors the forearm muscles to the outer (Lateral) side of the elbow bone (Epicondyle). The forearm muscles, particularly one called the Extensor Carpi Radialis Brevis, work together to raise the hand at the wrist joint. These forearm muscles are called the “wrist extensors” because they allow the hand to move upward or extend, such as when making the hand motion for “stop.” Repeated use of the wrist extensors can cause microscopic tears in the tendon. Individuals with tendon tears or degeneration can develop forearm muscle weakness along with swelling and pain at the outside of the elbow.

CAUSES

Tennis Elbow most commonly occurs in individuals between the ages of 30 and 50 years old. Tennis Elbow is caused by chronic stress to the forearm muscles, especially the Extensor Carpi Radialis Brevis. The repeated motions and stress can cause the tendon to degenerate (tendonopathy). As the name Tennis Elbow implies, playing tennis or other racquet sports is one cause of the condition; particularly, repeated use of the backhand stroke, forearm stroke, or serve with poor athletic form. Many individuals develop Tennis Elbow for no identifiable reason.

SYMPTOMS

Individuals with Tennis Elbow frequently experience severe burning pain and tenderness at the outer side of their elbow and forearm. In most cases, the pain starts out slow and mild but gradually increases over weeks or months. The pain may increase with movement or when pressure is applied to the outer elbow area. Some individuals experience morning stiffness, muscle weakness, and aching throughout the day. They may be unable to perform the motions necessary to complete various tasks. Some individuals may even feel pain when they are not moving their arm.

DIAGNOSIS

A physician will perform an examination and review the individual’s medical and activity history to make a diagnosis of Tennis Elbow. The physician evaluates the forearm structures by using simple tests. The history and examination, supplemented with X-rays of the elbow are sufficient to make the diagnosis. X-rays may be used to assess if the elbow bone was injured and help rule out other possible causes of elbow pain, such as arthritis. When taking an x-ray, a camera focuses on the elbow area and a picture is taken. Magnetic Resonance Imaging (MRI) scans are rarely used to diagnose Tennis Elbow however MRI scans may be used to provide a very detailed view of the tendon injury. The MRI equipment takes images by focusing on the elbow area. Both imaging techniques are painless and require that the individual remain very still.

TREATMENT

Most cases of Tennis Elbow respond to non-surgical treatments. Treatment typically includes rest or activity restriction/alteration. Specific exercises, often under the guidance of a therapist, are often prescribed. Physicians may instruct the application of ice to the affected areas or recommend medication to relieve pain. Wrist splints and forearm bands can be used to relieve symptoms and promote healing.

Tennis Elbow may also be treated with corticosteroid medications. Corticosteroid medication is a relatively safe pain reliever and in the case of tennis elbow would be injected at the outside of the elbow. After the pain is relieved, physical or occupational therapy may be needed. The physical or occupational therapists focus on improving physical functioning for participation in activities. The therapies address muscle strength, flexibility, endurance, and coordination. This method is successful for many individuals with Tennis Elbow.

SURGERY

The majority of individuals with Tennis Elbow do not require surgery. Surgery is considered if significant pain continues after at least six months of treatment. The surgery is performed as an outpatient procedure. The individual may remain alert with regional anesthesia or be sedated for the surgery. The surgeon makes a small opening at outside of the elbow bone and then removes any injured tissue and reattaches the tendon to the bone. Recently, an arthroscopic surgery method has been developed. Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery. Only small incisions need to be made and the joint does not have to be opened up fully. This technique can provide a positive outcome and a shortened recovery time.

Following surgery, the elbow is placed in a small splint. After about one week, the individual can begin physical or occupational therapy to stretch the elbow joint and increase motion. Muscle strengthening can begin at about two months after the surgery. Individuals typically return to full activity levels four to six months after surgery. Tennis Elbow surgery produces successful outcomes for the vast majority of individuals.

RECOVERY

With non-surgical treatments, symptoms of Tennis Elbow may be relieved as early as four to six weeks. However, many individuals have chronic symptoms for many months. Individuals requiring corticosteroid injections or surgery may take several months to recover, but typically can achieve good results. Tennis Elbow does not usually lead to severe problems if it is treated. If left untreated, it rarely leads to loss of motion and function.

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. Ligaments are strong non-elastic fibers that connect our bones together. The ACL crosses inside of the knee, connecting the thighbone to the leg. It provides stability to the knee joint.

ACL tears most commonly occur in very active people or athletes. The ACL can tear when people abruptly slow down from running, land from a jump, or change directions rapidly. These types of actions are frequently performed during sports, such as football, basketball, skiing, and soccer. Athletes are especially at risk for ACL tears, although they may occur in active workers and the general population as well.

The ACL can tear completely or partially. It is unable to repair itself. When the ACL is injured, it is common to see other surrounding knee structures damaged as well. Some cases of ACL tears are treated with non-surgical methods. However, there are several surgical options that successfully restore knee strength and stability.

ANATOMY

The knee is structurally complex. Our knee is composed of three bones. The femur, or thighbone, sits on top of the tibia, the larger leg bone. The patella, or kneecap, glides in a groove on the end of the femur.

Large muscle groups in the thigh give the knee strength and stability. The quadriceps muscles are a large group of muscles on the front of our thigh that straighten and rotate the leg. The hamstring muscles are located on the back of the thigh and bend or flex the knee.

Four ligaments connect our knee bones together. The ligaments are strong tissues that provide stability and allow motion. The ligaments enable our knee to have the flexibility to move in various directions while maintaining balance. The medial collateral ligament is located on the inner side of our knee. The lateral collateral ligament is at the outer side of our knee. These two ligaments help the joint to resist side to side stress and maintain positioning.

The anterior cruciate ligament and the posterior cruciate ligament cross inside of the knee joint. These two ligaments help to keep the joint aligned. They counteract excessive forward and backward forces and prohibit displacement of the bones. They also produce and control rotation of the tibia. We rotate our tibia when we turn our leg outward to push off the ground with our foot. We use this motion to push off from the side when skate, run, or move our body to get into a car.

Two cartilage disks, called menisci, are located on the end of the tibia. The cartilage forms a smooth surface and allows our bones to glide easily during motion. The menisci also act as shock absorbers when we walk or run.

A smooth tissue capsule covers the bones in our knee joint. A thin synovial membrane lines the capsule. The synovium secretes a thick liquid called synovial fluid. The synovial fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.

Proprioceptive nerve fibers are contained in the ligaments and joint capsule. The proprioceptive nerve endings send signals about body movements and positioning. For instance, the proprioceptors in the knee send signals to let us know how far to bend our joint in order to place our foot for a step. They plan and coordinate our leg movements whenever we move.

CAUSES

The ACL can tear during strong twisting motions of the knee. The ACL can also tear if the knee is hyperextended or bent backwards. People frequently tear the ACL while pivoting, landing awkwardly from a jump, changing directions suddenly, or abruptly slowing down from running. ACL tears occur most frequently in young athletes. Football, basketball, skiing, and soccer are sports associated with the highest injury rates.

Researchers show that female athletes have a higher rate of ACL injury than males in certain sports. They suspect the greater angles in the female hip and leg alignment may make the knee more vulnerable to force. Additionally, female hormones can relax ligaments and make them less stable, making some women more susceptible to knee injury.

It is common for additional injuries to result when an ACL tear occurs. Surrounding structures, such as the meniscus, cartilage, and ligaments can be injured as well. Some people may also experience bruised or broken bones. The ACL can tear during strong twisting motions of the knee. The ACL can also tear if the knee hyperextends or bends backwards. People frequently tear the ACL while pivoting, landing awkwardly from a jump, changing directions suddenly, or abruptly slowing down from running.

ACL tears occur most frequently in young athletes. Football, basketball, skiing, and soccer are sports associated with the highest injury rates.

SYMPTOMS

People usually experience pain, swelling, and knee instability immediately after the ACL tears. Your knee may buckle or give out on you. You may not be able to fully straighten your knee. You may have difficulty moving your knee and walking. Typically, within a few hours the swelling in the knee increases dramatically.

DIAGNOSIS

If you suspect you have torn your ACL, you should go to your doctor or an emergency room right away. A doctor can evaluate your knee by gathering your medical history, performing a physical examination, and viewing medical images. Your doctor will ask you about your symptoms and what happened if you were injured. Your doctor will examine your knee and your leg alignment. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and stability.

Doctors typically perform the Lachman Test to determine if the ACL is intact. For this test, you will lie on your back and slightly bend your knees. Your doctor will place one hand on your thigh and attempt to pull your leg forward with the other hand. Your doctor will test both of your legs to compare the results. If you can move your leg three to five millimeters, the test is positive.

The Pivot Shift Test is another test to determine if the ACL is functioning. For this test, you will straighten your leg. Your doctor will hold your leg while turning it and moving it toward your body. If your leg moves in and out of position, the test is positive for an ACL tear.

Your physician will order X-rays to see the condition of the bones in your knee and to identify fractures. Sometimes a fracture or soft tissue injury does not show up on an X-ray. In this case, your doctor may order a magnetic resonance imaging (MRI) scan. An MRI scan will provide a very detailed view of your knee structure. Like the X-ray, the MRI does not hurt and you need to remain very still while the images are taken.

TREATMENT

Initially following an injury, your knee will be treated with rest, ice, compression, and elevation. You should rest your knee by not placing weight on it. You may use crutches to help you walk. Applying ice packs to your knee can help reduce pain and swelling. You should apply ice immediately after injuring your knee. Your doctor will provide you with a continued icing schedule. Your doctor may provide over-the-counter or prescription pain medication. In some cases, a knee brace may be recommended to immobilize and support the knee. A knee immobilizer is used for only a short period of time. Elevating your knee at a level above your heart helps to reduce swelling.

Treatment for ACL tears is very individualized. Many factors need to be considered, such as your activity level, severity of injury, and degree of knee instability. Treatments may include physical therapy, surgery, or a combination of both. The most likely candidates for non-surgical treatments have partial ACL tears without knee instability, complete tears without knee instability, sedentary lifestyles or are willing to give up high-demand sports, or are children whose knees are still developing.

Physical therapy and rehabilitation can help restore knee functioning for some individuals. Your physical therapist will help you strengthen your knee. Special emphasis is placed on exercising the quadriceps muscles on the front of the thigh and the hamstring muscles on the back of the thigh. Eventually, you will learn exercises to improve your balance and coordination. You may need to wear a knee brace during activities. Your therapists will educate you on how to prevent further injury.

SURGERY

Surgical treatment is most frequently recommended for individuals with ACL tears accompanied with other injuries. The most likely candidates for surgical treatment are active individuals in sports or jobs with heavy manual work that requires pivoting or pushing off with the knee. Surgery is also recommended for people with unstable knees or injuries combined with damage to the menisci, articular cartilage, joint capsule, or ligaments.

Prior to surgery, most people participate in physical therapy. Swelling can make the knee stiff. Immobility can cause the muscles and ligaments to shorten. Your physical therapist will help you stretch your knee to regain full movement. If your collateral ligaments are involved, you may need to wear a brace to allow them to heal prior to your surgery. These steps will help you prepare for a successful recovery after your surgery.

The goal of ACL repair is to reconstruct your knee joint to restore its function and stability, and prevent further injury. During surgery, your doctor will replace your damaged ACL with a healthy tendon, called a graft. There are several options for acquiring grafts. They may be taken from an area near your knee or from a donor cadaver.

A patellar tendon autograft uses the middle third of the patellar tendon and bone plugs from the shin and kneecap. This type of reconstruction is most often recommended for high-demand athletes and individuals that do not have to perform a lot of kneeling activities. This grafting procedure has been considered the “gold standard” for ACL repair.

A hamstring tendon autograft uses one or two tendons from the hamstring muscles at the inner side of the knee. The hamstring tendon autograft is most appropriate for lighter-weight individuals with a small patella bone and a history of pain. This method can be associated with a faster recovery.

A quadriceps tendon autograft uses the middle third of the quadricep tendon and a bone plug from the upper end of the kneecap. The quadricep graft is large. It is most appropriate for taller and heavier individuals. It is also used for individuals with prior failed ACL reconstructions. Because it is a large graft, this method uses a larger incision.

Allografts are tendon grafts taken from cadavers. Allografts are most appropriate for older individuals that are moderately active or those with a history of pain. It is also used for individuals with prior failed ACL reconstructions, those attempting to return to sports more quickly, and those that need more than one ligament reconstructed. Because the graft is not taken from the individual, this method is associated with less pain, smaller incisions, and a shorter surgery time.

Many ACL reconstructions are performed as outpatient procedures. You can be anesthetized for surgery or receive a nerve block to numb your knee and leg area. After you have received your anesthesia and your leg is relaxed, your doctor will examine your knee by performing similar tests that were done in your clinical examination. This provides your doctor with more information about your knee and helps to formulate the surgical plan.

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert an arthroscope and will reposition it to see your joint from different angles.

An arthroscope is a very small surgical instrument. It is about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to see inside of a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope is attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.

Your surgeon may make additional small incisions and use other slender surgical instruments if you are having your meniscus, cartilage, or ligaments repaired or removed. Your new graft will be attached using surgical hardware. Your surgeon will test the new graft and your knee function. Again, your doctor will examine your knee by performing similar muscle tests that were done in your clinical examination. This is to ensure that your knee is stable and has full range of motion. In addition to bandages, some surgeons apply a knee brace or a cold therapy device to help reduce swelling at the completion of your surgery.

RECOVERY

You will most likely go home on the same day of your surgery. You will receive pain medication to make you feel as comfortable as possible. In some cases, ice is applied to the knee throughout the day to help to reduce pain and swelling. Your doctor may prescribe blood thinning medication and special support stockings. You should keep your leg elevated and move or pump your foot and ankle.

In some cases, doctors prescribe compression boots and a continuous passive motion (CPM) machine. Compression boots are inflatable leg coverings that are attached to a machine. They work to gently squeeze your legs to aid blood circulation. A CPM machine will move your leg in a cycling motion while you are in bed. The CPM machine is helpful to improve circulation, decrease swelling, and restore movement in your knee.

Walking and knee movements are very important to your recovery. Exercising will begin immediately after your surgery. You will begin physical therapy soon after your surgery. Your first goals will include straightening your knee and strengthening your quadriceps muscles.

At first, you will need to use a walker or crutches while standing and walking. Your doctor may also prescribe a knee brace for you to wear during activities. Your physical therapist will help you walk and show you how to go up and down stairs. You will also learn ways to exercise to further strengthen your quadriceps and hamstring muscles and regain balance and coordination. It can take up to four to six months to restore proprioception and coordinated leg movements.

An occupational therapist can show you ways to dress and bathe within your movement restrictions. Your therapists can also recommend durable medical equipment for your home, such as a raised toilet seat or a shower chair. The equipment may make it easier for you to take care of yourself as you heal and help to prevent further injury.

The success of your surgery will depend, in part, on how well you follow your home care instructions and participate in exercise during the weeks following your ACL reconstruction. You may need a little help from another person during the first few days at home. If you do not have family members or a friend nearby, talk to your physician about possible alternative arrangements.

Recovery times differ depending on the severity of your injury, the type of procedure that you had, and your health at the time of your injury. Your doctor will let you know what to expect. Generally, you should be able to resume some of your regular activities in one to three weeks after your procedure and progress to full sporting activity in about six months. Overall, you should notice a steady improvement in your strength and endurance over the next six to twelve months. The majority of people are able to resume functional activities after ACL reconstruction.

PREVENTION

It is important that you adhere to your exercise program and safety precautions when you return home. You should stay as active as possible. It is especially important to keep your quadriceps and hamstrings very strong. You should also continue to use the durable medical equipment as advised.

It is also important to avoid injuring your ACL again. Depending on your injury, your surgeon may provide you with temporary or permanent activity or lifting restrictions. In some cases, specialized knee braces may be recommended for specific activities.

The posterior cruciate ligament (PCL) crosses inside of the knee joint with the anterior cruciate ligament (ACL), connecting the thighbone to the leg. Ligaments are strong non-elastic fibers that connect your bones together. PCL tears are not as common as ACL tears, but can result from certain twisting movements, falls, or direct contact to the knee or shinbone during contact sports. Some PCL tears are treated with nonsurgical methods. However, if other knee structures are injured as well, arthroscopic surgery is used to restore knee strength, stability, and motion.

ANATOMY

The knee is structurally complex. It is composed of three bones. The thighbone (femur), sits on the larger leg bone (tibia). The kneecap (patella) glides in a groove on the end of the femur.

Large muscle groups in the thigh give the knee joint strength and stability. The quadriceps muscles are a large group of muscles on the front of the thigh that straighten and rotate the leg. The hamstring muscles are located at the back of the thigh. The hamstring muscles bend or flex the knee.

Four ligaments connect the knee bones together. Ligaments are strong tissues that provide stability and allow motion. The ligaments enable the knee to have the flexibility to move in various directions while maintaining stability.

The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) cross inside of the knee joint. The ACL and PCL help to keep the joint aligned. The ACL and PCL counteract excessive forward and backward forces and prohibit displacement of the bones. The ACL and PCL control rotation of the tibia. You rotate your tibia when you turn your leg outward to push off the ground with the foot. For example, you use this motion to push off from the side to skate, run, or move your body to get into a car seat.

The medial collateral ligament is located on the inner side of the knee. The lateral collateral ligament is at the outer side of the knee. The medial collateral ligament and the lateral collateral ligament help the knee joint resist side to side stress and maintain position.

CAUSES

PCL injuries take place if the shinbone is impacted by force just below the knee or on the side of the knee while the leg is twisted, bending the knee more than its normal range, or from falling on a flexed knee with the toe pointed. PCL injuries can occur during contact sports, such as football or soccer. They can also result from car crashes.

SYMPTOMS

Because initial symptoms can be vague, some people may not know that they have a posterior cruciate ligament injury until the pain worsens over time and the knee feels unstable. PCL tears can cause:

• Knee pain ranging from mild to moderate

• Rapid knee swelling and; tenderness

• Pain while kneeling, squatting, running, slowing down, or walking stairs or ramps

• Limping or problems walking

• Knee instability, a feeling that the knee is "giving out"

DIAGNOSIS

If you suspect that you have a posterior cruciate ligament tear, you should go to your doctor or an emergency department. A doctor can evaluate your knee for a PCL injury by reviewing your history, examining your knee, and reviewing medical images. Your doctor will ask about your symptoms and the circumstances of your injury.

Your doctor will order X-Rays to see the condition of the bones in your knee and to identify fractures. It is not uncommon for bone or cartilage to be injured with the ligaments in a knee injury. Commonly magnetic imaging (MRI) scans are used to best see the ligament injury, and associated injuries.

TREATMENT

Initially following a posterior cruciate ligament injury, you should treat your knee with rest, ice, gentle compression, and elevation (R.I.C.E. Method). You should rest your knee by not placing weight on it. You may use crutches to help you walk. Applying ice to your knee can help reduce pain and swelling. Apply ice to your knee immediately following injury and then comply with your doctor's icing schedule. Elevating your knee at a level above your heart can help reduce swelling.

Your doctor may recommend over-the-counter or prescription pain medication. In some cases, people with a PCL tear wear a knee brace to support the knee.

Physical therapy rehabilitation begins as the swelling diminishes. A physical therapist will show you specific exercises to strengthen the quadriceps muscles and other muscles that support the knee joint. The goal of physical therapy is to strengthen the knee and restore function.

SURGERY

Surgery is almost always necessary for people with posterior cruciate ligament occurring with other types of knee injuries, such as cartilage or other ligament tears. Your orthopedic surgeon may recommend that you participate in physical therapy prior to surgery to ensure that the muscles surrounding your knee are strong. PCL surgery is usually an outpatient procedure. The goal of PCL repair surgery is to restore the function of the PCL to maintain the knees mobility, stability, and function, while preventing further injury.

During PCL surgery, the damaged PCL is removed and replaced with a healthy ligament, a graft. There are a few options for acquiring grafts. Grafts may be taken from another part of the body or from a donor cadaver. An orthopedic surgeon uses an arthroscope to perform surgery on a PCL tear.

An arthroscope is a very thin surgical instrument, about the size of a pencil. It contains a lens and lighting system that allows a surgeon to see inside a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope is attached to a miniature camera. The camera allows the orthopedic surgeon to view the magnified images on a video screen. Arthroscopic PCL repair is associated with less pain, reduced risk of infection, decreased swelling, and faster recovery times than open PCL surgery.

RECOVERY

Surgically placed grafts may take several months to heal to the knee bones. Physical therapy rehabilitation follows PCL surgery to help decrease swelling, increase mobility and stability, and increase strength and knee function.

The menisci are cartilage structures in the knee joint that act as buffers between the bones. The menisci are vulnerable to injury, especially during twisting motions used for sports. Some tears in certain parts of the meniscus may heal on their own, but in many cases surgery is necessary. Arthroscopic surgery is the accepted method of treating meniscus tears. Because the joint is not fully opened, recovery is faster and has fewer complications than with older open surgery methods.

ANATOMY

The knee joint is composed of three bones. The thigh bone (femur) sits on top of the larger leg bone (tibia). The kneecap (patella) glides in a groove on the end of the thigh bone. The menisci are two C-shaped cartilage discs that are located on the end of the tibia.

The outer edges of the menisci have a blood supply, which can allow injuries to heal. The inner part of the menisci does not have a good blood supply, and tears in this area cannot heal on their own. The menisci help to support your body weight and act as shock absorbers when you walk or run. They also allow your knee bones to glide easily during motion.

CAUSES

The menisci can tear during strong twisting motions of the knee, especially when the foot remains firmly planted on the ground and the knee is bent. Pivoting, cutting, changing directions quickly, or slowing down quickly during sports, such as football, tennis, or soccer, can cause a meniscus tear. Older adults can experience a meniscus tear as the result of weakened cartilage and knee degeneration.

SYMPTOMS

You may hear a popping noise when the meniscus tears. Swelling, pain, and tightness may increase over several days. You may not be able to straighten your knee, and it may buckle, catch, or lock in position. It may be difficult for you to put weight on your leg or walk.

DIAGNOSIS

You should contact your doctor if you suspect you have torn your meniscus. Your doctor will review your medical history, the circumstances leading to your injury, and conduct a physical exam. Clinical exams, the McMurray’s test and Apley’s compression test, involve bending your knee while the doctor moves your foot and leg in different positions to assess the menisci. Your doctor will evaluate excess fluid and swelling around your knee joint. An X-ray may be used to see the condition of your bones. A magnetic resonance imaging (MRI) scan may be used to create a picture of your menisci and inner knee structures to help your doctor diagnose your injury.

TREATMENT

Minor tears on the outer sections of the meniscus may be able to heal on their own if there is a good blood supply. Ice packs, rest, and medications can help relieve pain and swelling. Physical therapy can help strengthen the muscles that move the knee joint. Your doctor may recommend a knee brace for sports or custom shoe inserts to support the arch of the foot.

SURGERY

Surgery may be recommended for larger tears on the outer section of the meniscus or for tears in the inner areas. Most meniscus repairs are performed as outpatient surgeries. You can be anesthetized for surgery so you are not alert or receive a nerve block to numb your knee and leg area. Arthroscopic surgery is favored because it is less invasive and is associated with less pain, swelling, infection, and bleeding and has a faster recovery time than open surgery.

An arthroscope is a very small surgical instrument. It consists of a narrow tube that contains a lens and a lighting system that allows a surgeon to see inside of the joint. Narrow surgical instruments are inserted through small incisions. With an arthroscope, only small incisions, about ¼” to ½” in length, are needed, and the joint does not need to be fully opened.

After making the small incisions, the surgeon will fill the joint space with a sterile saline (salt-water) solution. The fluid expands the joint and allows your surgeon to have a better view of your knee. Next, the arthroscope is inserted. It may be repositioned to view the joint from various angles. Your surgeon may make additional small incisions and use other slender surgical instruments to trim torn meniscus pieces. A surgical shaver is used to smooth the remaining meniscus.

RECOVERY

After surgery, you will be instructed to elevate your leg and apply ice to your joint to help reduce pain and swelling. You may wear a cast or knee brace for a short period of time. You will need to use crutches, a walker, or a cane to help you stand and walk, at first. Your surgeon may initially restrict the amount of weight that you can put on your foot but will gradually increase it as you heal. Physical therapy will help you gain strength and movement in your knee.

The recovery time is different for everyone. It depends on the extent of your condition and the type of surgery that you had. Full recovery can take several weeks or months.

PREVENTION

Your doctor may set restrictions on your activities depending on the nature of your injury. For example, if part of your meniscus is removed, you may be restricted from running activities or lifting large amounts of weight. Return to intense physical activity should only be done with the clearance of your doctor. You should always wear your knee brace or protective sports gear as directed by your surgeon.

Ankle Sprains are a very common injury that can happen to anyone. Our ankles support our entire body weight and are vulnerable to instability. Walking on an uneven surface or wearing the wrong shoes can cause a sudden loss of balance that makes the ankle twist. If the ankle turns far enough, the ligaments that hold the bones together can overstretch or tear, resulting in a sprain. A major sprain or several minor sprains can lead to permanent ankle instability.

ANATOMY

The bones in our leg and foot meet to form our ankle joint. The leg contains a large bone, called the Tibia and a small bone called the Fibula. These bones rest on the Talus bone in the foot. The Talus bone is supported by the Calcaneus bone, our heel. Our heels bear 85% to 100% of our total body weight. Strong tissues, called ligaments, connect our leg and foot bones together. One ligament, called the Lateral Collateral Ligament (LCL), is very susceptible to ankle sprains. The LCL is located on the outer side of our ankle. It contributes to balance and stability when we are standing or walking and moving. The LCL also protects the ankle joint from abnormal movements, such as extreme ranges of motion, twisting, and rolling. The LCL is composed of three separate bands commonly referred to as separate ligaments. The Anterior Talofibular Ligament is the weakest and most commonly torn, followed by the Calcaneofibular Ligament. The Posterior Talofibular Ligament is the strongest and is rarely injured.

CAUSES

Our ankles are susceptible to instability, especially when walking on uneven surfaces, stepping down at an angle, playing sports, or when wearing certain shoes, such as high heels. Everyone, even the fittest athlete, is vulnerable to a sudden loss of balance under these conditions. Our ankles support our entire body weight. When the foot is placed at an abnormal angle, the weight of our body places an abnormal amount of force on the ligaments causing them to stretch. When a ligament is forced to stretch beyond its limit, it may overstretch, tear, or disconnect from the bone.

SYMPTOMS

You may lose your balance and fall if your foot is placed at a poor angle on the ground. Some individuals may hear a “pop” noise when the injury takes place. You will probably have difficulty putting weight on your foot or walking. Pain is usually the first symptom of a Sprained Ankle. Swelling, stiffness, and skin discoloration from bruising may occur right away or take a few hours to develop.

DIAGNOSIS

Your doctor can diagnose a Sprained Ankle by conducting a physical examination and asking you what happened to cause the injury. Your doctor will move your ankle in various positions to determine which ligament was injured. Your ankle may be X-rayed to make sure that you do not have a broken bone in your ankle or foot. In severe cases, a Magnetic Resonance Imaging (MRI) scan may be ordered to view the ankle structures in more detail. The X-ray and the MRI scan are painless and require that you remain very still while the images are taken.

Ankle Sprains are categorized by the amount of injury to the ligaments. A Grade One sprain has minimal impairment. The ligament has sustained slight stretching and some damage to the fibers. A Grade Two sprain is characterized by partial tearing of the ligament. The ankle joint is lax or looser than normal. A Grade Three Spain describes a complete tear of the ligament. The ankle joint is completely unstable.

TREATMENT

The majority of Ankle Sprains heal with non-surgical treatment methods. It is imperative that you seek evaluation and treatment for any ankle injury, as sometimes fractures are mistaken for sprains.

The treatment of an Ankle Sprain depends on its Grade. Grade One sprains are treated with the RICE method - Rest, Ice, Compression, and Elevation. You should rest your ankle by not placing weight on it. You may use crutches to help you walk. Applying ice packs to your ankle can help keep the swelling down and reduce pain. You should apply ice immediately after spraining your ankle. Your doctor will provide you with a continued icing schedule. Your doctor may recommend over-the-counter or prescription pain medication. Compression bandages, such as elastic wraps, are helpful to immobilize and support the ankle. You should also elevate your ankle at a level above your heart for 48 hours to help reduce swelling.

Care for Grade Two sprains includes applying the RICE method of treatment and in most cases your doctor will prescribe an ankle air cast or soft splint for positioning and stability. As healing takes place, your doctor will gradually increase your activities. Your doctor may recommend that you wear an ankle brace for stability as your healing continues.

In addition to the primary care, your doctor may recommend a short leg cast or a cast-brace system for a Grade Three sprain. The cast is typically worn for two or three weeks and followed by rehabilitation. Rehabilitation is helpful to decrease pain and swelling and to increase movement, coordination, and strength. Your doctor may recommend customized inserts called orthotics for your shoe or special shoes to help you maintain proper ankle positioning.

The recovery time is shorter for ankle sprains that do not require surgery. Grade One sprains may heal in about six weeks. Grade Two and Three Sprains may take several months to heal. Grade Three Sprains usually involve a period of physical therapy to promote healing.

SURGERY

Ankle Sprains rarely require surgery; however, it is an option when non-surgical treatments and rehabilitation fail. Your physician will evaluate each case of Ankle Sprain on an individual basis. Your physician will discuss surgical options and help you determine the most appropriate choice for you.

One type of surgery, termed Ligament Tightening, is performed to tighten the overstretched ligaments. This usually involves the Anterior Talofibular Ligament (ATFL) and the Calcaneofibular Ligament (CFL). The surgeon will make an opening over the ligaments and separate the ATFL and the CFL in half. The ends of these two ligaments are surgically attached to the Fibula. The surgeon will further reinforce the ligaments by also attaching the top edge of the Ankle Retinaculum. The Ankle Retinaculum is a large band of connective tissue located at the front of the ankle.

If the ligaments are severely damaged or not appropriate for a Ligament Tightening procedure, the surgeon may perform a Tendon Graft. For this procedure, the surgeon will use a portion of a nearby tendon for a tendon graft. The tendon from the Peroneus Brevis muscle in the foot is most commonly used. The tendon graft is surgically attached to the Fibula and the Talus, near the attachment sites of the original tendon.

In some cases of chronic pain, an Arthroscopic Surgery may be performed to remove bone fragments, scar tissue, and damaged cartilage. Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery. Only small incisions need to be made and the joint does not have to be opened up fully. This can shorten the recovery time.

RECOVERY

Depending on the grade of the injury and what surgical or non-surgical methods are applied to repair the ankle, will determine the rate of recovery.

Grade 1 sprains should only experience slight limits to range of motion, and the recovery process is approximately six weeks.

Grade 2 sprains experience moderate impairment and recovery may take a few months.

Grade 3 sprains have severe impairment and may take several months to fully recover. Even after a full recovery, some patients find that swelling still might occur. In most cases, rehabilitation will help restore strength, mobility and range of motion.

Recovery from surgery differs and depends on the extent of your injury and the type of surgery that was performed. Your physician will let you know what to expect. Individuals usually wear a cast for up to 2 months following surgery. Your doctor will instruct you to carefully increase the amount of weight that you put on your foot. Rehabilitation following surgery is a slow process. Individuals typically participate in physical therapy for two to three months. Physical therapy helps to strengthen the ankle muscles and increase movement. Success rates are high for both surgical procedures. The majority of individuals achieve an excellent recovery in about six months.

PREVENTION

Individuals that experience one ankle sprain are at an increased risk to experience another. It may be helpful to wear shoes that provide extra ankle support and stability. Shoes with low heels and flared heels may feel steadier. In some cases, doctors recommend a heel wedge or prescribe an orthosis, a plastic brace, to help position the foot inside of the shoe.