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Scott Webb (Host): Most of us are familiar with at least a few of the ligaments in our knees, like the ACL, but there are more ligaments than you'd think. And joining me today to discuss the various ligaments, the most common injuries, how we can prevent injuries and what he can do to help us after we've sustained an injury is Dr. Matthew Craig. He's an Orthopedic Surgeon who specializes in Sports Medicine. This is Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. I'm Scott Webb. Dr. Craig, thanks so much for your time. I have a couple of kids. My son played sports. My daughter plays sports now. I played sports when I was a kid and I don't really understand all of this, but that's why it's so great to have your expertise on because I want to find out, you know, what is a ligament exactly. And what are the types of ligaments in the knee?

Matthew Craig, MD (Guest): When we think about the anatomy of the knee, ligaments are an important part, but essentially the knee joint is a few bones that make it up. So we have your femur and your tibia kind of your thighbone and your shinbone. The ends of these bones are lined with cartilage. And then in between the two bones, it's your meniscus, which helps disperse force in the knee. Then you also obviously have your kneecap sitting at the front part of your knee. Which is also lined with cartilage and that actually has two tendons attached to it, your quad tendon, and your patella tendon. And those are important for letting you kind of extend your knee or get your knee all the way straight.

So in this case, tendons attach muscle to bone while the ligaments are this fibrous connective tissue, and they primarily connect bone to bone. And they're important because they help provide stability to structures in the body and they can help the knee or any joint from subluxing or even dislocating.

So when I think about the knee, I think there's really five major ligaments that I mostly deal with in patients. The most common one and the one that we hear about probably the most with sports and TV and everything is your ACL. So that's one of the ligaments that sits in the center of your knee and it's important for preventing your knee from moving too far forward, as well as providing some rotational stability to the knee.

So when athletes and things are cutting, pivoting and twisting, the ACL is really important for letting the two bones, the knee stay in place and not subluxate or dislocate. The PCL is the other ligament that's located in the center of the knee and it functions kind of the opposite way the ACL does. So it's important in preventing the knee from moving too far back.

So then there's also two ligaments that work to stabilize the inside part and the outside part of the knee; the MCL, which is your medial collateral ligament that sits on the inside part of the knee and prevents your knee from kind of buckling towards the inside while the lateral collateral ligament or the LCL sits on the outside part of the knee.

And then there's one final ligament that I think is also important. And that's the MPFL or the medial patellofemoral ligament. So this ligament attaches on the inside part of the kneecap and then attaches over onto your femur. And that's really important for holding the kneecap in place and preventing your kneecap from dislocating.

Host: Well, it sure is great to learn more about these because I think just watching sports in general, we're all pretty familiar with the basic ones ACL, MCL, but knowing that there are other ligaments and those can potentially be damaged and thinking about athletes in general, why do they seem to suffer so many knee injuries?

Dr. Craig: So I think it's really because they place fairly high demands on their knee, right? There's a lot of generally with sports, cutting, pivoting, twisting activities during games, when they're at kind of a high intensity, trying to perform to their absolute maximum level, as well as practice where they're repetitively stressing the ligaments, doing similar things with each practice time after time, trying to get better at their sport.

But obviously repetitive load always puts the ligaments and tendons and things at risk for tearing or having a significant injury. The other thing I think with athletes is that a lot of them in this day and age are kind of involved in year round sports. And sometimes it's just one sport. They're playing soccer year round or doing conditioning and training for baseball year round.

And that repetitive without really having an off season and stuff again, it's just a lot of demand they put on these ligaments. I think athletes are also at risk because of some of the playing conditions they have. So we do know that turf fields can actually put people at a little bit of a higher risk for a ligament tear as compared to a grass-field.

There is a little less give or kind of cushioning with the turf fields as compared to grass fields. But obviously the turf fields are easier to take care of. The other thing is obviously with sports like football and things, there's a lot of trauma and there, right? You can get hit directly from the side or from the front of the knee and they can generate a fair amount of force.

And those contact sports just from the trauma of the injury can certainly cause a ligament tear. I would say looking at all sports, it's actually girls soccer and I'd say for boys football, they generally have the highest number of knee ligament injuries for high school athletes. And there can be upwards from a hundred to 200,000 ACL tears a year in the United States, which is probably the most commonly injured ligament in an athlete and even more and more frequently, we've seen them showing up in kind of younger and younger patients.

Host: Yeah, there's a lot to unpack there, but I think you're so right. And my daughter is one of those who has played multiple sports over the years, but she's now sort of in that phase at 14, 15 years old, where she's kind of more specializing in basketball, that's her first love. She's really good at it. And, good, bad or otherwise, the basketball industry, the shoemakers, whomever, they sorta turn basketball into a year round sport because of course you play indoors. You don't have to worry about weather and conditions and all of that. So I worry about these types of injuries, especially because it seems like ACL's, and MCLs, the injuries that I often see, they're not as a result of contact. And it makes me wonder when we think about athletes and specifically now non-athletes do they suffer the same types of injuries are knee injuries, common for non-athletes and so on.

Dr. Craig: I think you're absolutely right in that some of these injuries in athletes are generally non-contact, where it's just the sudden twist or pivot or something just puts so much stress on the knee that the ligament will tear. These injuries can definitely occur in non-athletes though. I'd say they're probably not as common overall. And when we're looking at our general population, those who aren't athletes, for them, it's usually going to be more of a result of having a trauma to the knee. So whether that's a car or a motorcycle accident, a significant fall down a flight of stairs or maybe a bad slip on the ice. But it's important to realize that if these ligaments are injured in non-athletes, they're still very important just for the day-to-day function and to have a normal knee. So athlete or not, you really need intact knee ligaments to have a stable knee for your day-to-day activities.

Host: Yeah, you really do. And what are the signs of a knee ligament injury, besides that horrific sort of a contact or not injury playing sports?

Dr. Craig: Generally with athletes let's say on a field, they will often tell me they noticed, or they'll feel a significant pop in their knee. And as we've kind of discussed, this can be both a contact or a non-contact injury. Generally, they're going to have the acute onset of pain in the knee.

You often see them collapse on the playing surface, have difficulty getting up or difficulty walking back to the sideline. Pretty quickly after an injury, you can notice some fairly significant swelling of the knee or even some bruising. And they may even say, hey, my knee feels like it's going to give out when they're trying to walk back over to the sidelines or try and walk five, 10 minutes after the injury.

I'd say usually for most of these athletes they are not going to return to practice that day or get back into the game. With more severe ligament injuries, it's important to recognize that they can also sometimes damage other things such as blood vessels or nerves around the knee. So if you see someone who kind of falls down and then they say I've got really bad numbness and tingling in their foot or their leg, or they feel like their foot is getting cold, that's really a sign of a fairly significant potential injury to nerves or blood vessels in the knee. And that's someone who we would say, hey, we got to get that person to the emergency department right away and do some other studies to see what's going on. For your other athlete though, who feels the pop in the knee, it's a little bit swollen, usually the first few days after the injury, there may be more swelling. They may notice more bruising. They generally have difficulty kind of bending their knee or getting it all the way straight. And they're going to say, hey, my knee feels a little bit unstable. And that's usually when that person says, okay, something isn't quite right here. Let me go see someone and get evaluated.

Host: So, let's assume doctor that there was some sort of injury or some sort of trauma, right? And you speak with a patient, you get a patient history and you know, what's going on. You suspect there's a ligament injury. How do you, as sort of the expert in the room, how do you diagnose, which of the ligaments is the problem?

Dr. Craig: So, like you said, you know, the most important thing is really the history because you know how the injury happened, the mechanism, all those kinds of things are important to give me kind of a general idea of, okay, I need to pay more attention to this ligament or that ligament. In clinic when I'm examining someone again, if their knee is big, puffy and swollen, that generally suggests something kind of tore. We also have special examination tests where I can kind of take the ligaments and I try and essentially stress them in clinic. And I looked to see if I stress the MCL, let's say does the patient have a lot of pain on the inside part of the knee, or do I feel like that knee's a little bit looser on that side and it's opening up more.

And what I'll often do is I'll examine the injured side and then I'll also examine the uninjured side and going back and forth between the two, I can say, you know, there's a pretty clear difference in how much I can open the inside part of the knee or how much translation to the tibia I can feel which might say, hey, this person has an MCL or an ACL tear. And the other things that are helpful, so x-rays obviously. Sometimes when you tear a ligament, you can tear a little piece of bone where the ligament attaches and that's something we can easily identify on the x-ray. We can also do special x-ray where we stress the knee under the x-ray and I can objectively look and see on an x-ray say, hey, when I stress you, it opens up an extra 10 millimeters more than the other side does.

And then really if my exam or their history makes me very concerned about a ligament injury, I might feel, you know, a little bit of looseness or something, I'll say, okay, the next step is really to get an MRI. So x-rays can do a good job looking at the bone. The MRI is the best thing to look at the ligaments in the knee, tendons, cartilage, meniscus.

And we can get a little bit more information from the MRI and make sure it confirms what we're seeing on our physical exam. And it's also important to realize that, you know, an isolated ligament injury can happen, but it's not uncommon for them to be associated with a meniscus tear as well, or some damage to the cartilage of the knee.

Host: Yeah, it does seem like when there's a sort of a catastrophic knee event or knee injury that multiple things are going on there. And so let's assume then doctor that you've been able to diagnose through all of this, through patient history and examination and x-rays and MRIs and so okay, you know now which ligament or which ligaments are involved, what are the treatment options and is surgery almost always indicated?

Dr. Craig: So So I think when we're talking about treatment, I think one important thing to realize, first of all, especially for young athletes is kind of, can we avoid this injury happening at all? So, tips for that, making sure you're taking the time to warm up and stretch prior to playing. When you're working with your trainers and stuff there's strengthening and balance exercises, focusing on strengthening your hamstrings, your quad muscles and your core muscles. There's techniques people can be taught for proper ways, how to land and how to jump. Essentially you avoid kind of having your knees turn in when you do that, because that puts you at risk for an ACL tear.

Then obviously, you know, there's a lot of demands placed on young athletes. So making sure you're properly rested, avoiding playing or practicing when you're really fatigued, because when you're tired, you're probably much more likely to make a mistake. So if we can't prevent an injury and one comes to my clinic, there's kind of a wide range of treatment options depending on the injury.

So to go through a couple examples here. So if we look at someone who is an MCL tear, which is that ligament on the inside part of your knee, if you have an isolated MCL tear, most of the time that can actually be treated non-operatively. So for those patients, it's usually a brace and crutches for about six to eight weeks to allow that ligament on the inside part of your knee to heal.

After that we start to wean you out of the brace and crutches, start doing a little bit of strengthening and stuff. And maybe somewhere between three to four months after your injury, you might be starting to get ready to go back to sports. So, that's one that can be treated without surgery fairly well and in many situations.

The one we hear about the most obviously is the ACL. And if you're looking at most athletes, you often read about them tore his ACL he had surgery a little bit afterwards. I'd say that's probably fairly true. Without an ACL, especially for an athlete, they're likely to continue having instability episodes of the knee that can be painful for them, can risk further damage to other ligaments or meniscus and cartilage in the knee, and they're probably unlikely to have a stable enough knee to ever go back to sports. So for an ACL tear in a young athlete is generally going to be something that almost always requires surgery. And usually we're kind of using a another tendon from the body to create a new ACL. The surgery itself, for an ACL can take hour and a half to two hours maybe, but the real problem or challenge these athletes encounter is that the recovery process is fairly extensive. So the surgery is a one day surgery. You go home that same day, but for most athletes, it's going to be two or three times per week going to physical therapy for the next, anywhere from three to six months.

And after an ACL, I'd say it's about nine months before I'd say, okay, you can get back to football or basketball or whatever sport you're hoping to return to. And then one other example, the MPFL. So the ligament I talked about that connects your kneecap to your femur. That's actually some times so if you come in and you dislocate your kneecap, the first time we often will treat that non-operatively, we'll say here's a brace, we'll do some therapy.

We'll see how you do after a few months. And a lot of patients can do great with that. And I never see them again in clinic, but there's a population of patients who will say, hey, I did well for six months, but then my kneecap dislocated again, or it's come out a couple of times. And that person at that point with the multiple events will eventually need surgery. So it's a wide range from nonoperative to operative treatment, just depending on each person's specific situation.

Host: Yeah, I see what you mean. And this has been really informative today, especially as a dad of an athlete who's out there and I'm always worried about her and her health and especially her knees. So great advice today. And as we wrap up your Doctor, whether it's post-op or other treatment options, what's the prognosis for folks to return to normal activities, especially athletes, because I've never torn my ACL or had a sort of traumatic knee injury, but I suspect that one of the issues and certainly anecdotally, I've heard that it's very difficult for athletes to trust that knee. They've had the surgery. They've done all the rehab. They've been out nine, 10 months, maybe even a year. And they've been cleared right by you or some other doctors says, okay, you're good to go trust the knee, go out there and do your thing. I imagine just, it's hard to build that confidence back up.

Right. So anyway, long-winded question basically, what's the prognosis for patients, whether they've had surgery or other treatment?

Dr. Craig: Sure. I mean, I think you're exactly right. I have like a objective criteria where I say that at nine months, the ACL is healed enough that it should be able to hold up to the demands of football or basketball, but there's that objective data and then there's how athletes feel like, do I trust this knee? Exactly like you said. So what I found is that a lot of these athletes can get back to their normal activities and their competitive level of sport, but it can take a while. So I'd say it's not uncommon for an athlete to, you know, reach that nine month mark, let's say play season a of basketball, get through the season, do okay. But not feel like they've quite maximized their playing potential or they weren't playing quite as well as they were prior to the injury. And by the time they get to that second season, you know, then they start to build more confidence with time and feel like that's when they're telling me, okay.

I kind of feel like I'm almost back to a hundred percent, you know, I'm playing as well as I was before. So it's a fairly long process for them, both in terms of just the rehab and then just regaining confidence. But I think it's reasonable to say that for most athletes, if they're willing to put in the time and the rehab and understand that it's going to be a long process, we can get them back to playing the sports they were playing prior to when they were injured.

Host: Yeah, well, that's encouraging and certainly good to hear. And you, and you do see that with athletes, that sometimes they miss a year or two years, Clay Thompson from the golden state warriors was out like a couple of years. And just to think that all the effort all the time, all the rehab to have the confidence in and to get back on the floor and play at that level is really amazing. And they couldn't do it without doctors like yourself. So thank you so much for your time and you stay well.

Dr. Craig: Thank you.

Host: And for more information, go to genesishcs.org. And thanks for listening to Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. If you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.