Management of Right Knee Injuries — Gaurav Sawant, 26Y/M

MRI Summary (Key Pathology)

Phase 1: Acute / Initial Orthopedic Management (Weeks 0–3)

Immediate Measures

• RICE protocol: Rest, Ice (15–20 min, 3–4×/day), Compression bandage, Elevation
• Weight-bearing: Partial weight-bearing with crutches; no full weight-bearing until swelling controlled
• Knee immobilizer / hinged knee brace: 0–30° range initially, protecting MCL and MPFL during early healing
• NSAIDs: Diclofenac 50 mg BD or Ibuprofen 400 mg TDS × 5–7 days for pain and effusion; add a PPI (Pantoprazole) for gastric protection
• Aspiration: If effusion is tense and causing significant pain, aspiration under aseptic conditions can provide relief
• Imaging review: Weight-bearing X-rays of both knees (AP, lateral, merchant views) to rule out associated fractures

Phase 2: Definitive Management Decision

Surgical Management

1. ACL Reconstruction (Primary Indication)

• Complete ACL tear with retraction in a young, active male
• Combined with meniscal tear (makes instability worse)
• High risk of secondary articular cartilage damage if untreated

• Resolution of acute swelling and effusion
• Recovery of full ROM (especially extension)
• Quadriceps strength recovery (to reduce arthrofibrosis risk)

• Arthroscopic technique (standard of care)
• Portals: Anteromedial (AM) and anterolateral (AL) portals; accessory AM portal used for femoral tunnel drilling
• Femoral tunnel: Drilled via AM portal at anatomic ACL footprint (10–11 o'clock position, right knee) — gives better rotational stability than transtibial technique
• Tibial tunnel: Drilled at native ACL tibial footprint, angled ~55° to tibial axis
• Fixation: Interference screws (bioabsorbable or titanium) at both ends; supplementary cortical button fixation at femoral side (Endobutton) is common with hamstring grafts
• Graft tensioning: At 20–30° flexion with anterior drawer stress

2. Medial Meniscus — Complex Tear (Posterior Horn)

• All-inside repair devices (e.g., FasT-Fix, Meniscal Cinch) or inside-out sutures used for peripheral tears
• Concurrent ACL reconstruction enhances meniscal repair healing (improved vascularization)

3. MCL and MPFL

• Grade 2 MCL tear: Does not require surgical repair in isolation. Protected with hinged brace post-operatively. Heals with conservative management in 6–8 weeks.
• Grade 2 MPFL tear: Conservative management. If patellar instability develops later, MPFL reconstruction may be considered, but not acutely required.
• Grade 1 LCL: Conservative management only.

Combined Surgery Plan

Conservative Management (For Patients Who Decline Surgery or Pre-operative Phase)

Indications for Non-surgical ACL Management:

• Low-demand, sedentary patients
• Elderly patients
• Isolated ACL tears without meniscal involvement
• Patient refusal of surgery

• Hinged knee brace (0–90° range, adjustable)
• Activity modification — avoid cutting, pivoting, jumping
• Neuromuscular training
• NSAIDs / analgesics
• Joint aspiration if recurrent effusion

Physiotherapy / Rehabilitation Protocol

Pre-operative Physiotherapy ("Pre-hab") — Weeks 1–4

Post-operative Physiotherapy — ACL + Meniscal Repair Protocol

Note: Timeline is modified if meniscal repair is done (more conservative) vs. partial meniscectomy (faster progression)

Phase 1 — Protection Phase (Weeks 0–2)

• Weight-bearing: Toe-touch → partial WB with crutches (meniscal repair: non-WB × 4–6 weeks)
• Brace: Locked in extension for ambulation; 0–90° for exercises
• Exercises: Quad sets, ankle pumps, SLR (all planes), prone hip extension, patellar mobilizations
• Cryotherapy: After each session, 20 minutes
• Swelling control: Elevation + compression

Phase 2 — Early Motion (Weeks 2–6)

• ROM target: 0–120° by week 6
• Closed kinetic chain (CKC) exercises: Mini squats (0–60°), step-ups, leg press (0–60°)
• Open kinetic chain (OKC) exercises: Avoided in 0–60° range (graft protection); terminal knee extension with resistance allowed
• Hip strengthening: Abductors, external rotators — critical for knee valgus control
• Balance training: Single-leg stance progression
• Aquatic therapy: Can start at week 4 if wound healed (offloads joints, allows early motion)
• Cycling: Stationary bike from week 4–6 (low resistance)

Phase 3 — Strengthening (Weeks 6–12)

• Progressive resistance exercises: Leg press, step-downs, lunges, hip abduction
• Proprioception: BOSU ball, wobble board, perturbation training
• Hamstring curls: Begin at week 6–8 (carefully monitor graft if hamstring graft used — donor site)
• Swimming (freestyle, no breaststroke): From week 6–8
• Jogging (if meniscal repair healed): From week 10–12 on flat surface

Phase 4 — Return to Sport (Months 3–6+)

• Running progression: Straight line → change of direction → sport-specific drills
• Plyometrics: Box jumps, single-leg jumps — from month 4–5
• Agility drills: Ladder drills, cone drills, cutting
• Criteria for return to sport (all must be met):
  • Limb Symmetry Index (LSI) ≥ 90% on hop tests (single-leg hop, triple hop, crossover hop)
  • Quadriceps strength ≥ 90% of contralateral limb (isokinetic testing)
  • Hamstring: Quad ratio ≥ 60%
  • Full pain-free ROM
  • Psychological readiness (ACL-RSI score)
• Return to competitive sport: Typically 9–12 months for contact/pivot sports (football, basketball)

Physiotherapy for Associated Injuries

• VMO (Vastus Medialis Oblique) strengthening: terminal knee extensions, quad sets
• Patellar taping (McConnell taping) for MPFL-related patellar tracking issues
• Hip external rotator and abductor strengthening to reduce valgus stress on MCL
• Functional bracing during sports for 3–6 months

• Protected weight-bearing early
• Avoid high-impact loading until contusion resolves (typically 6–8 weeks on MRI)
• Aquatic therapy preferred in early phases

• Cold compression therapy
• Patellar mobilizations
• Avoid prolonged kneeling
• NSAID iontophoresis if persistent

Summary Decision Tree

26-year-old male, right knee:
Complete ACL tear + Complex medial meniscus tear + Grade 2 MCL/MPFL + Bone bruises

→ SURGICAL CANDIDATE (strong indication)
   ├── Pre-operative physiotherapy (3–4 weeks)
   ├── Arthroscopic ACL reconstruction (hamstring autograft)
   │   + Meniscal repair / partial meniscectomy (same sitting)
   ├── Post-op bracing (MCL protection × 6–8 weeks)
   └── Structured rehabilitation (9–12 month return to sport)

→ IF SURGERY DECLINED:
   Conservative brace + PT, but high risk of instability,
   secondary meniscal and cartilage damage, early OA

Key Monitoring Points

• DVT prophylaxis: LMWH (e.g., Enoxaparin 40 mg SC OD) for first 2 weeks post-op; compression stockings
• Follow-up MRI: At 6 months post-op to assess graft integration and meniscal healing
• Physiotherapy compliance: The single most important factor in outcome — structured, supervised rehab is mandatory
• Psychological support: Fear of re-injury is common; address proactively with sport psychology if needed