Ligaments are thick collagen fibers that provide stability to joints. They can’t contract like muscles do, but they stretch and pull tight when put in certain positions. There are four ligaments in and around your knee. Each of them stabilize the knee in such a way to limit joint movement in all the different directions. When these knee ligaments are ‘overstretched’ and injured, it leads to a knee ligament sprain or a torn knee ligament. Most knee ligament injuries occur from awkward twisting movements of the knee. Examples include landing awkwardly from a height, getting tackled during rugby, suddenly changing direction on the soccer field or keeping your foot planted while twisting your body away during turns in ballet.

Injuries to your knee ligaments don’t necessarily happen only during sport activities. It can happen during any activity in your daily life, for example walking down stairs, getting out of your car or slipping in your shower.

Each person’s case is unique and we want to address your specific needs. If you would like us to investigate or provide some insight, we invite you to contact us by clicking the link below.

When a ligament tears, it reacts very similarly to plastic that is heated. The plastic starts to separate and it takes on a new form. It does not return to its original state. This is a very unique characteristic in ligament tears, causing deformation of the collagen fibers in the structure of the ligament. This is why even a small injury to a ligament can cause a ripple effect with re-injury. With re-injury, ligaments are stretched apart over and over again and they do not return to their original state.

With a ligament injury, the collagen fibers in the ligament tear like a rope. On a cellular level, the injury will cause inflammation along the sheath of the ligament (a membrane that gives the ligament its nutrients). In turn, the inflammation causes swelling, pain and loss of function of the ligament. The swelling along the sheath causes loss of space, limiting normal slide of the ligament.

Instability becomes a major concern, seeing that ligaments provide stability to the joint. Knee ligament injuries can put you at risk of serious future problems if it isn’t treated adequately.

Your knee joint is made up of mainly four structures, namely: bone, ligaments, cartilage (meniscus), and muscles.

• Bones: Three bones form your knee joint: thigh bone (femur), shin bone (tibia), and kneecap (patella).
• Articular cartilage: Inside your knee joint and behind the patella there is cartilage that covers the ends of the femur and tibia bones. The cartilage ensures that the bones in the joint glide over each other easily. This makes movement of your knee smooth and easy.
• Meniscus: This is also a type of cartilage. They are wedge shaped discs and situated on the medial (inside) and lateral (outside) sides of your tibia (shin bone). The meniscus helps to absorb shock through the knee joint, to stabilize movement through the joint and to make movement easier.
• Tendons: Muscles connect to bones via tendons. The quadriceps tendon connects the muscles at the front of your thigh (quads) to your patella. The patellar tendon stretches from your patella to your tibia (shin bone). The hamstring muscle tendons and calf muscle tendons connect the muscles to the back of your knee.
• Muscles: The quadriceps muscle at the front of your thigh acts to straighten (extend) your knee. Important here is the VMO muscle (the inside part of your quadriceps muscle), because of its stability function in the knee. If the VMO muscle doesn’t activate properly, the knee will inevitably be unstable. The hamstring and calf muscles act to bend your knee.

With a grade 1 knee ligament sprain your ligament will be slightly overstretched. Only a small amount of ligament fibers will be torn. You will experience some discomfort and pain with minimal swelling and bruising. You won’t really experience a loss of function or range of movement in your knee, but it may become painful at some point during movement. Most people will be able to continue taking part in sport activities. However, you may run into trouble if the cycle repeats itself again. With re-injury, recurring micro tears in the ligament could lead to your knee ligament sprain progressing into a more severe tear.

With a grade 2 knee ligament sprain, your ligament is partially torn. 20% to 80% of the collagen fibers in the structure of the ligament are torn with a grade 2 sprain. There will be swelling around your knee joint and there might be visible bruising. The level of pain will be higher compared to a grade 1 ligament sprain.  Moving your knee will not be possible without pain. Movements like bending or straightening your knee will feel uncomfortable and your knee will feel unstable. Walking or running will be very painful. So, even if you try to continue to take part in your sport, you will have a considerable amount of pain and will feel the need to limp.

A grade 3 knee ligament injury is when all the fibers of your ligament are completely torn. The ligament itself has torn (ruptured) into two parts. Usually, it’s a lot less painful than a grade 2 ligament sprain (which might seem abnormal especially when compared to the seriousness of the injury). Putting weight on your knee will give you an overwhelming feeling of instability. Patients recall hearing a ‘pop’ in their knee as it gives out under them. With every step you take after the initial injury, your knee will feel like it’s going to give in underneath you.

Stability is the main concern with an injury like this.
The main concern with a grade 3 tear, is the ligament’s ability to stabilize the knee joint. If a ligament tears into two separate parts, there is no way that it can ‘heal’ or reattach without surgery.

Often there will be no pain, but the disfigurement is quite obvious, since all the knee ligament fibers are torn. It is important to know that there could be other structures involved with such an injury. For example: over 50% of all ACL ruptures have associated meniscus injuries.

Physiotherapists will be able to accurately diagnose a ligament tear and diagnose other injured structures without expensive scans. We know and understand the anatomy of the knee and we know which structures could be injured with a knee ligament sprain. We take into account the the intricacy of the biomechanics of the knee. During your physiotherapy evaluation, we will be able to determine how bad your ligament injury is by stretching and stressing the ligaments in the area. We test the different ligaments by stressing each one individually using its direction of pull. This can give us a very clear picture of how many of the ligaments are injured. 

The following tests can be used to test for knee ligament injuries:

• ACL sprain: Lachman Test, Anterior Drawer Test and Pivot Shift test
• PCL sprain: Posterior drawer or lag test
• MCL sprain: MCL stress test (otherwise known as the Valgus test)
• LCL sprain: LCL stress test (also known as the Varus test)

We will also be looking at other structures in and around your knee that could have been injured as well. We can reach a conclusive diagnosis by also testing muscle strength and length, range of movement and measuring swelling in the area. This is why our physiotherapists are the best at diagnosing this type of problem.

X-rays

X-rays can be helpful to exclude fractures of any bones in and around your knee, but will not show evidence of a knee ligament sprain or tear. This is usually the test most emergency rooms will opt for. If no fractures can be seen on the x-rays, they conclude that the ‘knee ligaments are torn’, but this still doesn’t tell us much.

Children have softer bones. If a child has a ligament injury, often the anchor of the ligament tears away from the bone, resulting in an avulsion fracture (a piece of the bone breaks off with the ligament). This will be visible on a x-ray. It is essential to make sure there are no fractures, if we suspect a ligament injury in a child, before proceeding with further tests.

If your physiotherapist feels that its necessary to refer you for X-rays (in the case of a possible fracture) they will discuss this with you.

MRI

The golden standard (best in the industry) to diagnose a knee ligament tear would be through an MRI, then a CT scan. MRI has the advantage of providing a clear image of all the anatomic structures of the knee. MRI can diagnose an ACL injury with an accuracy of 95%. It will also reveal any related meniscal tears, chondral injuries, or bone bruises. However, it is a very expensive test. You will need to be referred to an orthopedic surgeon who will then send you for this test.

Your physiotherapist will be able to refer you to an orthopedic surgeon if necessary.

Ultrasound

If you have limited funds, but you would like to confirm a knee ligament injury with a scan, we will advise you to get a sonar (also called diagnostic ultrasound) done at a reputable musculoskeletal sonographer. In this case, the ligament itself won’t be visible on the scan, but trauma to the structures around the ligament will be visible and this can lead us to assume that you have a knee ligament sprain.  If this is the case, we may refer you for further testing to confirm your diagnosis, such as getting a MRI or CT scan done.

Your physiotherapist will be able to refer you to get a sonar (diagnostic ultrasound) done.

When a ligament tears, the body attempts to repair the injured fibers by sending cells to reattach the torn ends of the fibers. It will respond in a similar way when trying to repair an open wound. When you have a cut at the bottom of your foot and you keep on walking on it, you will shear away the cells that are healing and closing the wound. The more you walk or run through the pain, the longer it will take to heal.

Not attending to your sprained knee ligament becomes a problem as well. Your physiotherapist will give you a home program with exercises that you need to do. We only see you an hour at a time, once or maybe twice a week. The rest of the time, it is your responsibility to do what is needed in order for complete healing to take place.

Another problem we see is that patients wear generic types of braces, which only gives compression but doesn’t restrict certain ranges. It merely provides a false sense of stability of the knee, even though the ligament might be severely injured.

Swelling can hinder any medical professional that has to diagnose the problem after 48 hours. Ever wondered why there is a full medical team at the side of a sport field? Well, swelling can make our job quite difficult if we need to accurately determine which structures were injured. Even with the best scans like MRI or diagnostic ultrasound, the swelling casts a shadow over the deeper structures and distorts the image. This is why we recommend you get to a physiotherapist as fast as possible if you suspect that you have a knee ligament sprain.

We receive frantic calls from patients (usually on Friday afternoons – due to major games and events that take place on weekends), hysterical parents or coaches. We encourage them to come to the practice so that we can screen their knee, before the swelling sets in. This enables us to quickly identify the ligament, menisci, tendon or muscle that has been injured. This enables us to fast-track the healing by knowing exactly whats wrong from the get go.

After any injury swelling is normal, but too much swelling can cause intense and constant pain. Swelling in the knee is an accumulation of inflammatory cells that has come to heal the tissue. The greater the damage, the more cells your body will send to your knee. Think of your knee as a blown up water balloon between two rocks. The more cells that enter the knee joint, the more pressure inside your knee. Not to mention the small arteries and veins that rupture and spill blood directly into the knee joint. This increase in pressure inside the knee puts pressure on pain sensitive structures that keeps on overloading your brain with these pain impulses. Hence, the more the swelling, the more the pain.

Inflammation is not always a bad thing. It kick-starts the healing process and is an essential part in healing. There is a reason the body produces inflammatory markers when you injure yourself. However, if this cycle continues for too long, the unnecessary amount of swelling becomes a problem.

Therefore, we suggest that you do not use anti-inflammatory medication in the acute phase (the first 48 hours), after the onset of your injury. Let the inflammation “do its job”. You may use pain medication without an anti-inflammatory component if the pain is very severe. You may then start using anti-inflammatory medication after those first 48 hours to aid in the management of pain, swelling and the discomfort inflammation brings along with it.

Anti-inflammatory medication can mask pain and with it the effect of the trauma on the tissue if you return to your sport activity while still taking anti-inflammatory medications.

We have seen many patients with knee ligament injuries and provide the best possible treatment that lead to faster recovery. Conservative physiotherapy treatment of a grade 1 or 2 knee ligament sprain is very successful. We understand that patients are often anxious to get back to their normal activities, so that is why we are here to provide guidance and answers. However, it’s important that you commit to the treatment plan as this improves your chances of successful long-term recovery.

The basic structure of our treatments:

1. Determine what is injured.
2. How bad is it injured?
3. Protect it from further injury.
4. Give it time to heal.
5. Strengthen surrounding muscles.
6. Re-evaluate to monitor progress.

We will be looking at different aspects like muscle strength, range of motion, flexibility and stability. Treatment techniques will include: soft tissue massage, joint mobilisations, dry needling, strapping, laser therapy, nerve mobilisations and prescribing exercises.

Your best bet would be to come and see us for comprehensive rehabilitation. We work on all the phases of healing until we can get you back to where you were before your injury.

1st Phase: Protection & initial Healing (Week 1-2)

P

Protect.

We have found that patients tend to continue walking on the injured leg with a limp. The joint still has to carry the load every time that your weight is put onto the leg. It’s better to get crutches and wear a brace to keep the load off your knee and to stabilize your knee joint. The main concern is to prevent your knee ligament sprain from tearing even further.

R 

Rest.

Rest from activities that is worsening your pain.

Reduce the weight taken on the injured leg. Use crutches to take the load off your knee joint.

As soon as there’s no pain, don’t test it. Give it time to heal.

I

Ice.

Ice cubes wrapped in a towel, tied around your knee reduces pain & inflammation and speeds up the healing process. For at least the first 3 days or until the swelling goes down, apply an ice pack for 20 minutes every two hours. Always keep a towel between the ice and your skin (to prevent freeze burn).

C

Compress.

Use strapping or elastic compression bandage to keep your knee joint supported and prevent blood pooling around your knee and calf. This can be done either with taping or tube grip bandage and this helps to control swelling.

E

Elevate.

Lying on your back with your foot on a chair (your knee must be higher than your heart to allow gravity to assist in draining extra fluid around your knee) Raise your knee and leg for 15 minute intervals during the day.

2nd Phase: Regain Full Range of Movement (week 2-3)

The most important component of rehabilitation is to regain full range of movement of the joint and surrounding muscles. The scar tissue that form around the site of the injury must be lengthened and orientated to allow full movement. We use massage, stretches and neurodynamic mobilizations to achieve full range of movement.

3rd Phase:  Muscle Strength (week 3-4)

Muscles around the knee provide stability together with the ligaments of the knee. That is why it is so important to improve muscle strength after a knee ligament injury. It is common for the affected leg to feel weak during recovery. The muscles will need to carry some of the weight on the affected leg. Different kind of exercises and resistance will be used during this phase.

4th Phase: Improving stability and control of the knee (week 4-5)

You might feel stronger during this phase, but find that you are struggling to control knee movements. Struggling to stabilize the knee. Something as simple as balancing on one leg will prove to be difficult. Retraining balance and muscle control is important during this phase.

5th Phase: Agility and advanced strengthening (week 5-6)

The knee joint can now be tested under high load and speed to ensure that it will be able to keep up with the demand of your body. During this phase the physiotherapist will guide you to return to normal activities, this includes challenging your knee joint past its ‘normal’ boundaries to determine how it reacts to different forces. Ultimately we prepare you to return to participating in your sport.

Whatever must be done – we’ll get you there. Jumps, changing direction, twisting, running and much more.

6th Phase: Sport Specific Training (week 6-8 and after)

Depending on your sport, your physiotherapist will tailor specific exercises that will help strengthen the muscles pertaining to your sport. A successful outcome is when you have gained knowledge throughout the rehabilitation program and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury.

Only with a grade 3 knee ligament injury, where the specific knee ligament has been completely torn, will you need surgery. In this case the torn sections of the knee ligament will not be able to reattach by themselves and you would need surgery to reattach them. An arthroscopy of your knee is the way to go, due to its minimal invasive technique. With this technique, an orthopedic surgeon is able to get a clear view of the torn knee ligament and able to also repair other structures like cartilage or menisci.

If you did have reconstructive ligament surgery, you will need rehabilitation afterwards. Your doctor and surgeon will give you guidance regarding the kind of brace you should wear, how long you should wear it and if there are any movements you are not allowed to do.

Our physiotherapists are well equipped to help you with your recovery after surgery for your torn ligament.

• ITB syndrome – Its a sharper pain on the outside of the knee or thigh that only comes on during running, and subsides.
• Pes anserinus Bursitis – Pain on the anteromedial side of the knee at the insertion site of sartorius, gracilis and semitendinosis muscles.
• Meniscus tear – This involves the disc on the inside and outside of the knee joint. It will lead to the knee ‘clicking’ and ‘grinding’ or ‘locking’ in one place.
• Peroneal nerve entrapment – nerve type pain radiating down the outside of the lower leg.
• Fractures of the patella, femur or tibia – Fractures or avution may happen with a direct impact to your knee.
• Muscle strain – Muscles controlling the knee movements can be injured due to overstretching or overloading of the thigh muscles. Pain with movement of the muscle like Quadriceps, Hamsting, Gastrocnemius.
• Tendinopathy  – Pain arising from a tendon around the knee. Usually due to loading (too much or too little).
• Knee or Patella (knee cap) dislocation – Usually due to trauma/impact. Clear deformity can be seen.
• Patella fat pad syndrome – Pain at the front of the knee right beneath the patella. Worsens with forced extension or pressure
• Patellofemoral pain syndrome – Pain due to tracking issues of the patella when using the quadriceps muscle and patella tendon.