Twist and Shout
Written by John Ferrari | Photographed by Philicia Endelman
Ouch! You landed hard on one leg while you pivoted to return a tennis serve … or you twisted coming down from a layup in your pickup basketball game … or your daughter cut to the side to avoid a defender in her playoff soccer game.
Whatever the action, the result was the same: a sudden, sharp pain in the knee. Uh-oh, you think, that could be a meniscus tear. Or an ACL injury. That’s what happens to professional athletes, anyway. But what does that mean? How do you tear your meniscus? And just what is your ACL?
The knee is a complex joint, and it works well. Take a wrong turn though, and it can be stretched to the breaking point. The good news? There are options—from rest and physical therapy to surgery—to get you (or your daughter) back in the game.
Meniscus tears are the most common sports-related knee injury, says Donald Striplin, MD, a Torrance Memorial Physician Network orthopedic surgeon and sports medicine specialist. The menisci are two C-shaped pieces of cartilage cushioning your knee, between your shinbone and your thighbone. As you walk—and even more so as you run or jump—the shock of your foot hitting the ground travels up your shinbone. The menisci act as shock absorbers.
Meniscus tears occur when the knee twists under strain—a movement common in many sports. Menisci lose flexibility with age, putting older adults at risk of a meniscus tear, Dr. Striplin says. But at the same time, younger athletes may play harder, which also raises the risk of meniscus tears and other knee injuries.
Meniscus tears cause localized pain, swelling and stiffness in the joint. “We don’t always jump to surgery, though,” Dr. Striplin says. “Some tears heal on their own with anti-inflammatories and physical therapy.” Other meniscus tears don’t fully heal but become asymptomatic.
“Younger, more active individuals are more likely to opt for surgery,” notes Torrance Memorial Physician Network orthopedic surgeon Stephen Nuccion, MD. Typically, orthopedic surgeons give a torn meniscus about six weeks to improve. If there are still symptoms—if movement is impaired or if the knee remains painful or swollen—arthroscopic surgery is an option.
Some meniscus tears can be sewn together, while others are just cleaned up. Platelet-rich plasma injections, which stimulate healing in the area of the injury, are another treatment option. While less invasive than surgery, the injections do take more time to have an effect.
Like meniscus tears, ACL injuries are common among athletes and are caused by a sudden change in movement or direction that twists the knee. The anterior cruciate ligament (ACL) connects the shin and the thigh bones, providing stability by keeping the two bones positioned correctly.
ACL injuries can be strains or tears. Either way, the initial symptoms are pain, swelling, and a loss of stability in the knee and leg. While ACL strains can be treated with rest, ice and anti-inflammatories, surgery may be the best treatment for tears.
“Ligament tears present a difficult set of problems,” explains Dr. Nuccion. “They don’t heal and can’t be sewn together. They’re like a rope that’s been ripped.”
Untreated ACL tears can cause a cascade of other problems too. The instability caused by a torn ACL can lead to meniscus tears and, over time, arthritis. So for both short- and long-term recovery, surgery is often the preferred option.
ACL reconstruction involves removing the torn ligament and replacing it with a section of ligament taken from somewhere else (the quadriceps tendon, for example). The ligament is attached to the femur and tibia and effectively becomes a new ACL.
It’s a procedure Dr. Striplin knows well. He’s had both of his ACLs reconstructed after tearing them, a year apart, skiing down the same double black diamond run. In both instances, the binding on a ski didn’t come loose when he fell, causing his knee to twist.
An audible pop is the hallmark of an ACL tear, Dr. Striplin says. “When I heard that pop, there was no question what my injury was. Nine times out of 10, when a skier hears a pop and twists a knee, it’s a complete ACL tear.”
He advises getting an evaluation if you hear or feel that pop. “It may not be an emergency needing to be seen that day—unless there’s also a fracture and the patient is unable to bear weight—but it can lead to continuing or secondary injuries.”
Not everyone needs surgery for an ACL tear, though. “Some people have tight ligaments that can hold everything in place,” Dr. Striplin explains. “Surgery is more common in younger, more aggressive athletes, where the injury is more common—less so in older athletes.”
He recalls when he tore his ACLs in the late 1980s, reconstructions were a fairly new thing. “The standard after surgery was to keep the knee immobile. Now we emphasize getting a person back to normal activities as soon as possible. ACL reconstruction is an outpatient surgery. Patients can bear their full weight the day the procedure is done and return immediately to many daily activities. The return to sports depends on how hard you work to rebuild strength through physical therapy.”
Patella dislocations are another common type of knee injury. You know the patella as your kneecap. More precisely, it’s a bony fulcrum at the front of your knee, inside the quadriceps tendon, held in place in a groove in your thighbone. A sudden twist can cause your patella to pop out of that groove (like an ACL tear, it can be accompanied by an audible pop).
A dislocated patella usually can be relocated. The initial treatment, as with so many injuries, is rest, ice and compression. Bracing and physical therapy are often all that are needed for a full recovery. In some instances—successive patella dislocations, for example—patella stabilization may be the best option. An outpatient procedure to reconstruct the ligament holding the patella in place, stabilization involves local anesthesia only—minimizing pain and anesthesia effects and allowing the patient to begin postoperative physical therapy quickly.
While there are options to treat sports-related knee injuries, prevention is even better. Dr. Nuccion recommends preparticipation conditioning: preparing yourself to take on a new activity (or return to an activity you’ve been away from) for at least six weeks before hitting the field, court or slope. “Work on your strength and agility before entering the sport,” Dr. Striplin agrees.
If you do find yourself with a knee injury, the first step to recovery is an accurate diagnosis. “That’s the key,” Dr. Nuccion says. “An accurate diagnosis gives you information about initial management of the injury and how to best proceed with your recovery. We start with a physical exam and X-ray or MRI imaging, and together with the patient we assess where we are and where we want to end in terms of recovery. This allows us to individualize treatment options for the specific patient. It isn’t a one-size-fits-all scenario.”
