Knee injuries

Knee injuries

Geschreven door Nathan Albers
Geschatte leestijd: 19 minuten Knee injuries can derail your progress in your fitness schedule. Unfortunately, they are relatively common. In this article, I will discuss the most common knee injuries, how they can be prevented, how they occur, are treated, and how to rehabilitate as quickly as possible.

Anatomy of the knee

As in all articles about injuries, I start with anatomy first. The knee is the largest joint in the body. This joint, the connection between the femur (thigh bone), tibia (shinbone), and fibula (calf bone), is stabilized by various ligaments (bands of connective tissue). These ligaments keep the different parts together and ensure that they can only move in the desired direction under normal circumstances. The knee joint consists of the following components, of which I will first describe the function and then describe possible problems for each component:
  • Kneecap (patella): The kneecap has 3 functions: 1. Ensuring the optimal leverage of the tendon (quadriceps tendon which transitions into the patellar tendon) connecting the quadriceps to the shinbone. 2. Protection/reduction of friction in the knee joint. The kneecap protects the inner knee joint. Friction is reduced because both the back of the kneecap and the part of the thigh bone (femur) along which it slides (together this is the patellofemoral mechanism) are lined with hyaline cartilage (containing many collagen and elastic fibers). 3. Slowing down the forward movement by taking over the force of the quadriceps and the knee’s flexor tendons on the thigh bone.
  • The quadriceps tendon and patellar tendon. This is the large tendon (an attachment) that connects the quadriceps to the shinbone (tibia). The part above the kneecap is called the quadriceps tendon, and the part below it is the patellar tendon, or kneecap tendon. The function is (to transfer the force from the quadriceps resulting in) extending the leg from a bent position (extension). The difference between an attachment and a ligament is that an attachment connects muscle to bone while a ligament connects two pieces of bone together like the cruciate and collateral ligaments described below.
  • The cruciate ligaments. The cruciate ligaments prevent the lower leg from sliding forward (anterior cruciate ligament) or backward (posterior cruciate ligament) relative to the thigh bone. They serve as stabilizers.
  • The medial and lateral collateral ligaments. The medial collateral ligament is located on the inside of the knee and runs from the thigh bone over the knee joint to the shinbone. The lateral collateral ligament is located on the outside and runs from the thigh bone to the fibula. Like the cruciate ligaments prevent the lower leg from sliding forward or backward relative to the thigh bone, collateral ligaments prevent it from sliding inward or outward.
  • The menisci. The knee joint contains two menisci, the medial meniscus, and the lateral meniscus. The menisci are discs of cartilage that distribute the force exerted by the thigh bone on the shinbone. They form a kind of cup that allows the thigh bone to fit better on the shinbone. They also prevent wear of the bones by preventing friction between these bones.
  • Others: The components mentioned above cause the most complaints. I will not delve into the rest of the anatomy of the knee. However, it is useful to know that the hamstring consists of 3 muscles, the biceps femoris, the semitendinosus, and the semimembranosus, all of which have attachments along the shinbone and fibula around the knee. These muscles provide flexion (bending of the knee), endorotation (internal rotation: semitendinosus and semimembranosus), and exorotation (external rotation: biceps femoris).

Prevention of knee injuries

The proper prevention of knee injuries partly depends on the level of and type of activities you do or want to do. For example, if you play basketball or volleyball, sports-specific exercises are recommended. This includes proper techniques for jumping, landing, pivoting, etc. These exercises depend on the sport you practice and are too numerous to cover here. For fitness and strength training, prevention is generally easier because unexpected movements are not often made. To prevent knee injuries from fitness and strength training, you should:
  • Have a good warm-up. Eight to ten minutes at 60-70 percent of your maximum heart rate (220 – age). By warming up your body, synovial fluid is produced in the joints for lubrication. This reduces friction. Cycling or using a cross-trainer is less stressful for the knees than running on a treadmill and is therefore recommended. I know that many guys skip warm-ups due to lack of time or simply a total lack of interest in cardio. As an ectomorph who just wants to gain weight and wants to make the most efficient use of my time in the gym, I used to do the same. However, this is not a good excuse, and now I always do my warm-up properly. I did realize after a few months of warming up on the bike in the gym that I also have a regular bike at home. Nowadays, I cycle to the gym at a brisk pace instead of taking the car. This way, I’ve already done my warm-up and saved time and gasoline, which helps because I live exactly the right distance from the gym, so it takes me about 10 minutes.
  • Gradually increase the load, both during the training session and from session to session. So don’t walk into the gym and immediately start squatting as heavy as possible because there happens to be a pretty girl next to the squat rack. Always start your first set(s) of the first exercise for a muscle group with a weight that you can repeat at least 15-20 times. This increases neuromuscular activation and prepares the muscles for the heavier load that follows.
  • Train all major leg muscles. Imbalance can lead to injuries. For example, weak gluteal muscles can cause the knee to collapse inward. Too strong quadriceps in relation to the hamstrings can put a lot of pressure on the anterior cruciate ligament.
  • Ensure proper technique in performing strength exercises. It’s a waste to hurt yourself more than doing good in the gym because you’re performing the exercise incorrectly.
  • Wear good shoes, especially for explosive sports on a hard surface such as indoor soccer, basketball, and volleyball. This ensures cushioning and proper pressure distribution.
  • A commonly mentioned tip for preventing knee injuries is avoiding overweight (more weight on the knee means more chance of injury). However, if you are overweight due to excess fat, knee problems are probably not the first reason you would want to lose weight. If you’ve never managed to watch your weight, knee problems won’t be a convincing argument either. Even if you have “overweight” like the mass monsters of bodybuilders who weigh 120 kilos or more while having a body fat percentage of under 5%, preventing knee problems will not quickly become a reason to want to lose the muscle mass you have built up with great effort and dedication.
  • Be cautious with Leg Extensions. These put a lot of pressure on the knee. They can be a risk when performed too quickly or too heavily, but with light weight, they can also be a good exercise for warm-up. Start your leg training with leg extensions with a light weight that you can do 20-30 repetitions with. Personally, I do at least 3 sets of 25-30 repetitions. This may seem like a lot, and I don’t do such an extensive muscle-specific warm-up for other muscle groups. However, I am sensitive to knee problems and notice that after such a warm-up, I have no discomfort in my knees during further training or afterwards.

Common knee injuries

Here I will address the common knee injuries. For each injury, I describe what happens in the knee joint, possible causes, consequences (symptoms), how the diagnosis is made, what treatment is performed, and how you can rehabilitate.

Strained, Partially Torn, and Completely Torn Anterior Cruciate Ligament

In a knee dislocation (luxation of the knee), the lower leg moves out of its usual position. Depending on the way this happens (and thus in which direction), certain ligaments can be damaged. If the lower leg moves too far forward (hyperextension) or is twisted too much, the anterior cruciate ligament can be strained (grade 1), partially torn (grade 2), or even completely torn (grade 3). The latter is often accompanied by a ‘snapping’ sound. This often occurs in sports such as soccer and basketball, where the foot is still and quickly changes position and direction. It also commonly occurs in skiing due to the high ski boots that transmit forces to the knee. A completely torn anterior cruciate ligament often involves a torn meniscus as well (see below). The difference between a partially torn and a completely torn ligament is important because the partially torn ligament can heal naturally by growing back, while a completely torn ligament does not grow back. Since the connection is broken in a completely torn ligament and thus cannot be used anymore, it loses its function. As a result, the loose ends, “worms,” die off. In women, the risk of a torn anterior cruciate ligament is two to eight times higher than in men. This varies depending on the sport. For example, in soccer, the risk is twice as high, in basketball four times. This is due to several factors such as:
  • Greater laxity in the joint, smaller space in the groove through which the anterior cruciate ligament runs, making it more prone to getting trapped (impingement),
  • Presence of estrogen and progesterone receptors that have a catabolic (breaking down) effect,
  • The dominance of the quadriceps over the hamstrings, causing more pressure to pull the lower leg forward, and thus putting more pressure on the anterior cruciate ligament. Additionally, men may have four times the stability in the knee joint due to greater muscle strength.

Symptoms of a Torn Anterior Cruciate Ligament

Symptoms of a torn anterior cruciate ligament include:
  • A snapping/popping sound when torn
  • Immediate and persistent pain
  • Often, swelling within an hour caused by damaged blood vessels in the torn ligament. This swelling and pain can last for several weeks (about 2-4).
  • It feels unsafe to fully load the knee due to reduced stability. If this instability lasts too long, cartilage and menisci can be damaged, leading to osteoarthritis, a joint inflammation (see image: osteoarthritis).

Diagnosing a Torn Anterior Cruciate Ligament

A doctor or orthopedist will first ask how and when the knee problems occurred and whether they have already somewhat subsided. If the problems are recent, they will check for swelling, any remaining pain, and determine muscle function. If swelling occurs within two hours after the wrong movement, this is likely due to the torn anterior cruciate ligament and bleeding from the damaged blood vessels. If swelling occurs the next day, it is likely inflammation. In addition, there are tests to determine if the anterior cruciate ligament is torn, such as:
  • The Lachman test. As mentioned, the anterior cruciate ligament prevents the lower leg from sliding forward relative to the thigh. If torn, this can happen. In the Lachman test, the orthopedist therefore bends the knee to 20 degrees and checks if the lower leg can be pulled forward at knee level.
  • The anterior drawer test (video). The same as the Lachman test, but the knee is bent to 90 degrees. In both cases, it is important to relax the hamstring because otherwise, it could affect the result.
  • The pivot shift test (video). In the pivot shift test, the knee is bent to about 30 degrees, internal rotation is performed (lower leg turned inward), and the lower leg is brought into valgus position. Valgus means that the lower leg deviates away from the axis compared to the thigh, as in “knock knees” (as opposed to varus, towards the body axis, “bow legs”). If there is a torn anterior cruciate ligament, the lower leg will shift outward from the joint.
In addition to the tests, fluid can also be taken from the knee. If the fluid contains blood, this indicates damaged blood vessels and thus a torn ligament (70% chance of a torn anterior cruciate ligament). Another cause of bleeding may be a fracture (broken bone) or loose bone fragments. This can be ruled out by an X-ray. Arthroscopy (see image: arthroscopy) can also be performed, where a small camera is inserted into the knee. The advantage of this is that it provides a precise image and allows for immediate (minor) repairs such as removing torn pieces of tissue and floating pieces of meniscus and cartilage, and/or smoothing rough cartilage/meniscus. Another option is an MRI. While an X-ray only shows the bones, an MRI clearly shows the ligaments and any difference between a torn and normal ligament. Since an MRI scan is quite expensive (for a knee, somewhere between €350 and €450), it is only done if previous tests suggest it. The advantage of an MRI is that it provides more certainty than the tests and X-ray and has less risk of infection than injection and arthroscopy.

Recovery and Rehabilitation of Partially Torn or Completely Torn Anterior Cruciate Ligament

What you need to do in case of ACL complaints depends first on the specific complaint, but also on the desired future intensity of activity. The ACL shares its function with other ligaments and attachments that can take over part of the lost capacity. In the case of a strained or partially torn ACL, rest, ice, and physical therapy are usually sufficient. Most of the pain should be gone after two weeks, although complete recovery may take longer. The physiotherapist will then bend the knee to maintain flexibility and prevent stiffness. Additionally, they will prescribe strengthening exercises, especially for the hamstring, so that it can (partially) take over the pressure on the ACL. The quadriceps are also trained to maintain muscle balance. For prevention, it is also useful to train the gluteus maximus because it helps prevent inward collapsing knees. In the case of a torn ACL, approximately 1/3 of people experience no more complaints in daily life after a few weeks of rest. 1/3 of people still experience pain in daily life afterwards, and the last group mainly experiences complaints during activities such as sports. Whether you undergo surgical repair for a completely torn ACL often depends on the desired activity. For most readers of this site, they will want to be able to train as heavily as possible as soon as possible. Research in the Netherlands shows that 79% of those who underwent surgery were satisfied and that 60% had good to excellent knee function. Of the group treated conservatively (physical therapy, etc.), 44% were satisfied, and only 27% found it to function well to excellently.

Torn Meniscus

In the image below, you can see a (horizontal) cross-section of the right knee. As if you have chopped off your right knee and are grabbing your lower leg at the calf to take a good look. Here you can see the menisci well, the subject of another common knee complaint. As described above, it distributes the force of the thigh (and the rest of the body that it supports) on the lower leg and reduces friction. At a young age, the meniscus (a type of cartilage) is quite rubbery and strong. Therefore, when it tears, it is often due to a lot of force being applied, such as twisting the knee forcefully or hyperextension of the leg during sports. As people age, the menisci weaken and can tear much earlier. There are two menisci in the knee joint: the medial and lateral meniscus. The medial one has attachment points at the front, back, and middle, while the lateral one only has attachment points at the front and back. Because the medial one is more firmly attached, it is more often damaged than the lateral one. The meniscus can tear in various ways, often also due to the same cause and in combination with a torn ACL:
  • The entire base can tear
  • A bucket-handle tear
  • The anterior horn may tear, also called a longitudinal or flap tear
  • A transverse tear in the posterior horn
  • A V-shaped tear
These are just a few ways in which a tear commonly occurs. In the image next to this, you can see possible tears.

Symptoms of a Torn Meniscus

A torn meniscus is characterized by:
  • Pain in the knee is experienced with a torn meniscus, sometimes locally, sometimes throughout the knee. Local pain is often felt in the joint space (the space between the thigh and the lower leg) on the side of the torn meniscus (on one of the sides).
  • When the meniscus is just torn, this can often be felt by pain when passively and actively stretching the leg while the knee is still slightly bent.
  • When the tear is so severe that pieces of the meniscus become detached and jammed in the hinge joint, this can cause so-called locking complaints when such a detached part becomes trapped. For example, it may not be possible to fully extend the leg. With less damage, there may also be a “click” audible or palpable, indicating that the joint is partially blocked.
  • Prolonged damage to the meniscus can lead to wear and tear due to excessive friction. This can then lead to swelling due to water in the knee.
  • The knee feels weakened/as if it could collapse.

Diagnosing a Torn Meniscus

A doctor/orthopedic surgeon will, like with a torn ACL, first ask questions about how the problem arose. Then, they will perform a physical examination, looking for:
  • An audible click and/or palpable blockage
  • Presence of pain, specifically on the side of the joint space
In addition, an MRI scan can be performed. This can make any tears in a meniscus clearly visible. The same applies to arthroscopy (keyhole surgery) as with the ACL, namely that it poses a risk of infection (whereas MRI does not), but it offers the advantage of being able to perform small repairs immediately. In both cases, other possible damage is also investigated.

Treatment of a Torn Meniscus

First, it will be examined whether the complaints decrease through cooling (to reduce swelling) and rest. If this does not help, arthroscopy (keyhole surgery) is often the solution by removing damaged parts, as mentioned above. A meniscus consists of a vascularized part (the outer edge, colored red in the image next to this) and a part that is not vascularized. A tear in a vascularized part can often be stitched, but there is also a greater chance that it will heal itself due to the supply of nutrients. In a non-vascularized part (only supplied with synovial fluid), the chance of self-healing is smaller, and stitching is not possible.

Recovery and Rehabilitation of a Torn Meniscus

As long as there is pain immediately after the damage caused by swelling or after surgery, the load must first be relieved, for example, by wearing a compression bandage and using crutches. Whether and how long you use crutches varies from person to person and per practitioner depending on the damage and the procedure performed. In some cases, people leave the hospital without crutches, while in others, they use crutches for a few weeks. On average, this lies somewhere between 3-10 days. During this period, cooling three times a day for about 15 minutes can speed up recovery and alleviate any pain sooner. It is important to start rehabilitation as soon as possible after this by increasing the mobility of the knee by flexing and extending it unloaded, taking into account any pain. Depending on the desired further activity, further rehabilitation may consist of exercises to strengthen strength, stability, and coordination.

Inflamed Patellar Tendon, Jumpers Knee

The quadriceps tendon and patellar tendon, or patellar ligament, are the main extensors of the leg. They are heavily stressed during bending and extending, such as during deadlifts and squats, but especially during jumping activities. This can cause irritation and collagen degeneration (decay of the collagen from which the tendon is built) to the patellar tendon and lead to inflammation below the kneecap. This is also called jumpers knee. I have experienced this myself from basketball, where during a lay-up, you want to jump in two steps and put a lot of pressure on the knee joint, especially during the last push-off. Jumpers knee often occurs due to overtraining, especially due to repetitive peak loads such as jumping, but also due to sprinting and strength training and is relatively common: For example, in basketball, 31% and in volleyball, 44% of practitioners experience it. It occurs more than twice as often in men as in women (14% compared to 6%). Specific causes can be:
  • Land on one leg (leads to a peak load on the attachment of the patellar tendon).
  • Short quadriceps
  • Overweight
  • Reduced flexibility of the patellar tendon and quadriceps.
  • Insufficient strength and imbalance in thigh muscles (e.g., stronger outside, vastus lateralis, than inside, vastus medialis).
  • Bowed legs, knock knees, and flat feet (causes incorrect alignment and higher load on the patellar tendon).
  • (Too) deep squatting during jumping and/or landing.
  • Too high intensity (weight/resistance) and/or volume (number of repetitions) of exercises.
  • Growth spurt

Symptoms of Jumpers Knee

An irritated patellar tendon can cause a local inflammation reaction just below the kneecap. This can be characterized by:
  • Swelling
  • Heating
  • Redness
  • Loss of function
  • Pain
  • Stiffness
The inflammation can be classified into four stages:
  1. Grade 1: Initial stage, there is some pain right after exercising.
  2. Grade 2: Pain when starting to exercise and also right after exercising.
  3. Grade 3: Pain during exertion.
  4. Grade 4: Pain at rest and relaxation, constant pain. Pushing the lower leg with resistance is painful. Pressing on the patellar tendon is painful, as is, for example, climbing stairs. Can increase the risk of tendon tears.

Diagnosing Jumpers Knee

A doctor or physiotherapist, general practitioner will first ask questions about the complaints and perform a physical examination. This includes checking for:
  • Local pain during deep knee bends and quick knee extension.
  • More than six weeks of knee pain, especially below the kneecap.
  • Increase in pain during demanding activities such as jumping, stair climbing, running.
  • Cracking/grinding sensation when palpating the patellar tendon.
Possible further examination such as an MRI scan or arthroscopy may be done to rule out other complaints.

Recovery and Rehabilitation of Jumpers Knee

Just like with meniscus problems, it is important to start rehabilitation as soon as possible. This can be done conservatively (meaning: without surgery) or surgically. The choice of treatment depends, among other things, on the severity of the complaints. Conservative treatment of jumpers knee: Grade 1:
  • Reducing load to reduce irritation, but continue training. Train less intensely and/or less frequently if caused by overtraining. Complete rest is not recommended. While the inflammation may decrease, the strength of the surrounding muscles may also decrease, limiting recovery.
  • Cooling locally with ice after exercising to reduce the inflammatory response, about 15 minutes.
  • Using a patellar strap (see image). This is a strap worn under the kneecap and around the patellar tendon. The patellar tendon can pull outward when the thigh muscles contract because the outside (vastus lateralis) is stronger than the inside (vastus medialis). A patellar strap can limit this pulling. This will temporarily reduce pain. It should fit tightly enough to feel less pain when bending, but not so tight that blood flow is restricted.
  • Following an eccentric training program (“negative repetitions”) to strengthen muscles. For example, a leg press where you push the weight away with two legs and then slowly lower it with one leg. This can also be done with leg extensions. In both cases, use a light weight allowing for many repetitions (at least 20).
  • Cross-friction massage by a physiotherapist (local massage where the fingertips or thumbs move across the muscle fibers).
Grade 2:
  • Again, reducing load to reduce irritation.
  • Avoid sprinting/jumping.
  • Alternative activities to maintain mobility, such as swimming.
  • Avoid too many repeated bending and straightening movements.
  • Cross-friction massage by a physiotherapist.
Grade 3:
  • Completely stop the activities that caused the complaints.
  • Alternative activities to maintain mobility, such as swimming and aqua jogging if it can be done without pain.
  • Cross-friction massage by a physiotherapist.
Grade 4:
  • At least 3 months of rest.
  • Cross-friction massage by a physiotherapist.
If this does not lead to improvement, the following options may be considered:
  • Following an eccentric training program (“negative repetitions”) to strengthen quadriceps muscles.
  • Muscle-strengthening exercises for supporting muscle groups such as the calves and glutes.
  • Anti-inflammatory medication (e.g., Ibuprofen).
If the above does not achieve the desired result, surgical intervention may be considered. In surgical intervention for jumpers knee, the inflamed part is often removed, or small incisions are made on the sides of the tendon to relieve pressure on the middle part. Eccentric muscle-strengthening exercises are also performed afterwards. However, there is little evidence that this yields more than conservative treatment.

Prevention of Jumpers Knee

Since jumpers knee is usually caused by overuse, it is important to consider the following:
  • Gradually increase load, both in intensity and volume. For example, do not start training legs three times a week in the gym right away and/or train very heavily.
  • A proper warm-up to ensure good blood flow, nutrient supply, and waste removal.
  • In basketball, for example, the “line run” is a standard warm-up before the game, where one line performs a lay-up (jumping to the basket) in two steps. When looking at amateur clubs, you often see boys jumping very high immediately. When looking at the pros, you often see them making the first shots while walking, at a leisurely pace.
  • Correct jumping/landing technique, not squatting too low when landing and rolling through the foot.
  • Good shoes with shock-absorbing soles, preferably avoid training on hard surfaces.
  • Muscle-strengthening exercises for all supporting muscles such as hamstrings, quadriceps, calf muscles, glutes, and (lower) abdominal muscles.
  • Stretching the quadriceps.

Torn Patellar Tendon

The quadriceps and patellar tendons are essentially one tendon that allows the leg to be extended. If this tears (above the kneecap: quadriceps tendon rupture, below the kneecap: patellar tendon rupture), the leg cannot be extended. A torn patellar tendon is more common under 40 years of age, while above 40 years it is often the quadriceps tendon. Causes of a torn patellar tendon may include:
  • Use of anabolic steroids in general can be harmful to attachments depending on the type of anabolic-androgenic steroid. For example, testosterone could decrease collagen synthesis (the production of new collagen from which the attachment is built) by 50%-80%. Although research on this is not clear and some steroids may even strengthen attachments (such as Deca-Durabolin), it is plausible that anabolic steroid use, by the fact that muscles grow relatively harder than attachments, can weaken them and lead to tears due to overuse. Anabolic steroid users by definition seek the limits of their own capabilities to then exceed them. Something the body does not always allow.
  • Falling with the knee on the ground.
  • Jumping from a bent position with the foot flat on the floor.
  • A weakened attachment, such as due to an existing inflammation (jumpers knee, especially in grade 4).
  • Injected corticosteroids. These can be administered because they quickly inhibit inflammation, but also weaken attachments because they work catabolically (and thus consume nutrients such as protein at the expense of the attachment). However, this is hardly done anymore for such a knee complaint for this reason.
  • Certain chronic diseases such as diabetes mellitus.

Symptoms of Torn Patellar Tendon

Symptoms of a torn patellar tendon may include:
  • A tearing sensation followed by immediate pain and swelling.
  • The leg cannot be extended.
  • A dent at the site of the tear.
  • Sensitivity.
  • Cramping.
  • The kneecap may ride higher because it is no longer attached to the shinbone due to the tear (see images).

Diagnosis of Torn Patellar Tendon

The diagnosis is made by asking about the medical history, for example, whether there have been previous knee injuries such as jumper’s knee. The physical examination mainly involves assessing the ability to extend the leg. This may lead to an X-ray as shown here, where it can be clearly seen that the kneecap has moved upwards, or an MRI which also shows the tendon itself and any damage.

Treatment of Torn Patellar Tendon

A partially torn patellar tendon can still be conservatively treated by wearing a brace and using crutches (for about six weeks) to unload the tendon, allowing it to grow back together. This is followed by physiotherapy/manual therapy to increase muscle strength. Initially, these are strength exercises with the leg extended. When the brace can be removed, this can be extended to other exercises. Natural healing is not possible with a fully torn patellar tendon because, just like with a torn cruciate ligament, the function cannot be performed anymore, and thus the tendon ends are literally useless, causing the body to let them die off. This should therefore be surgically corrected as soon as possible because the ends become increasingly damaged, frayed, and shortened. During surgery, the torn tendon is reconnected to the shinbone.

Recovery/Rehabilitation of Torn Patellar Tendon

After surgery, rehabilitation occurs in phases, the first of which is pain management and immobilization, meaning that the leg is kept straight by a brace and crutches to facilitate recovery. Additionally, strengthening exercises for the quadriceps are performed with the leg extended (by lying the leg flat and tensing the quadriceps). After 10-14 days, there is a follow-up appointment to remove the screw thread placed during surgery to keep the sutures in place. In phase two (2-6 weeks), the knee remains in a brace, and you continue to walk with crutches, but you gradually work on increasing mobility by doing passive bending exercises (possibly using a machine designed for this purpose) but not beyond 90 degrees. During walking, the brace is locked so that the leg remains straight even during a possible fall. It is only unlocked when sitting down and doing exercises. Additionally, you continue with the quadriceps strengthening exercises.

Torn Medial/Lateral Collateral Ligament

Last but certainly not least (it is in fact one of the most common knee complaints) is the torn collateral ligament. As mentioned, the collateral ligaments run vertically from the femur (thigh bone) to the tibia (medial, inside) and the fibula (lateral, outside). Like the cruciate ligaments prevent the lower leg from moving too far forward or backward relative to the thigh bone, the collateral ligaments restrict sideways movement. This can go wrong when such a sideways movement is done under great pressure. For example, think of the football player trying to kick the ball with the inside of the foot while someone else blocks the shot by placing their foot in front. The thigh bone wants to move forward and inward while the foot is stationary. This puts pressure on the medial collateral ligament, which must absorb this force, potentially causing it to tear. Other possible causes include a sideways kick just above the knee such as the low kick in, among others, kickboxing, but also skiing if the ski gets caught in a twisting motion. The collateral ligament can stretch (grade 1), partially tear (grade 2), and completely tear (grade 3). If the pressure is inward, the medial collateral ligament is strained, and outward, the lateral collateral ligament.

Symptoms of Torn Collateral Ligament

  • The aforementioned swelling of and possible bleeding in the knee.
  • Instability on the side of the torn ligament. The knee may “give way” in this direction.
  • Local pain.

Diagnosing Torn Collateral Ligament

Once again, first, ask how the injury occurred. For example, the example of the stopped kick against the football is a clear indication of a damaged medial collateral ligament. Additionally, (local) pain may be indicative. Especially instability in the direction of the damaged collateral ligament is a possible indication. X-rays can be viewed to see any other damage, but also point to the torn ligament. Although ligaments are not visible on X-rays, there may be widening in the joint space on the damaged side when the knee is pushed in that direction. Finally, an MRI can see the damaged ligament itself.

Treatment and Recovery of Torn Collateral Ligament

The collateral ligament is the only tendon in the knee that can self-heal when torn. It is therefore almost never surgically repaired. A brace prevents movement in the direction of the torn ligament, as well as bending deeper than 90 degrees to avoid pressure on the ligament. Within the allowed range of motion, the knee should be kept moving and muscle strength developed. Recovery takes about 8 weeks.


“Trust me, I’m no doctor” Kenneth
But merely an obsessively interested fitness instructor, martial arts instructor, and natural bodybuilder. This article is not intended as a substitute for a visit to a doctor or physiotherapist. However, I hope that through this article, you understand more about how the knee works, what you can do to prevent injuries, and recognize them if things do go wrong.

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