My Doctor Online The Permanente Medical Group

Causes

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There are a number of risk factors and activities that increase your risk of damaging your ligaments. You can injure just one ligament or several at the same time. Knee ligament injuries are often caused by:

• Athletic activities that involve sudden stopping associated with another movement like turning or twisting.
• Direct contact against the knee during a sport like football.
• A blow to the knee.
• Trauma such as a car collision.

Anterior cruciate ligament (ACL) injuries involve sudden stopping or slowing of movement.  Most injuries do not involve a direct impact or trauma but are due to a sudden stop or change of direction while running or playing basketball, volleyball, football, tennis, or soccer. About half of ACL injuries are associated with damage to the meniscus cartilage, the articular cartilage that lines the bones, and/or other ligaments.

Medial collateral ligament (MCL) injuries occur when the knee suffers a direct hit, pushing it toward the other knee.

Posterior cruciate ligament (PCL) injuries are caused by a powerful impact to the knee; for example, a car collision that forces the bent knee up against the dashboard or a hard fall on a bent knee while running.  A twisting injury with the leg overstretched can also injure the PCL.

Lateral collateral ligament injuries may occur if the knee is pushed outward.

Symptoms

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Although knee injuries can involve different structures in the knee joint, there are a number of symptoms that are common to all knee injuries. These include:

• Pain, tenderness and swelling. 
• Difficulty moving the knee, standing, or walking.
• Instability, where the knee "gives out," often resulting in a fall.
  

People who injure their ACL usually know exactly when they did it. You may feel or hear a “popping” sensation at the time of the injury. You typically have significant pain and swelling.

For the medial collateral ligament injury, the pain is usually located on the inside of the knee. In the case of the lateral collateral ligament injury, people with this injury report pain on the outside of the knee.

Diagnosis

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In order to diagnose the cause of your knee pain, we rely on the results of a physical examination and what you tell us about your symptoms. 

Medical history

We will ask you about your symptoms and about how the injury occurred. Our questions usually include:

• When did the pain start?
• Did you injure your knee?
• Do you have pain in other parts of the knee or hip, or swelling in any other joints?
• What kind of work or activities do you engage in?
• How have you tried to treat it? Do over-the-counter pain medications help?

Physical examination

We will ask you about your symptoms and how the injury occurred. We will perform a physical exam of your knee to look for swelling, redness, or any asymmetry compared to the other knee. We will also move your knee in certain ways to test the stability of the ligaments and the integrity of the meniscus cartilage. It is important to tell us if you have pain or discomfort during the exam.

Depending on the results of this exam, we may order X-rays or other imaging studies to check for any evidence of arthritis or fracture of the bones.

Arthroscopic examination

If we suspect a torn ligament, we may look inside your knee with a tiny camera to see if you have injuries to other parts of your knee. This outpatient procedure is called knee arthroscopy.

We will give you an anesthetic prior to the procedure, which can be general or local anesthesia with sedation. We insert a miniature camera into your knee through a small incision and can even repair the knee using appropriate instruments.

Nonsurgical Treatments

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If your knee is stable and your tear is not severe, we will usually recommend trying a combination of nonsurgical treatments first to reduce your pain and strengthen the muscles in your leg. These may include:

• Ice, rest, and anti-inflammatory medications like ibuprofen immediately after the injury.
• A brace to protect the knee from further injury.
• Crutches to keep you from putting weight on the knee.
• Physical therapy to help you learn exercises that strengthen the muscles that stabilize the knee and to help maintain range of movement.

Partial tears usually take around 3 months to heal using these methods.

Surgical Procedures

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We do not recommend surgery for all types of ligament tears. The decision to proceed or not to proceed with surgery depends on the severity of your tear and your lifestyle. We will consider a number of factors when discussing surgical options with you:

• The type of tear. Surgery is often not necessary for collateral ligament tears or for posterior cruciate ligament tears. Surgery is an effective approach for serious tears to the anterior cruciate ligament.
• The severity of your tear. Surgery may be needed to repair a complete ligament tear.
• Your work and sports activities. If your job or hobbies place a great deal of stress on your knee, then surgery may be the most appropriate approach.

Ligament surgery is successful in most cases. However, some patients do not get back sufficient function to continue participating in activities that stress the knee.

Anterior Cruciate Ligament (ACL) Surgery

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If you have a serious, or complete, tear to your anterior cruciate ligament, surgery is usually an option. ACL surgery is usually an outpatient surgery and you should be able to go home the same day. During this procedure, we replace the anterior cruciate ligament with a graft of tissue. We either use tissue from one of your own tendons, from your knee or hamstring, or a graft from a donor. 

We insert a miniature camera and tiny surgical instruments into your knee through small incisions and remove the injured ACL. We drill bone tunnels above and below the knee joint. and insert the replacement graft. We then secure the graft with screws or sutures before closing the incisions.

Possible complications

As with any surgical procedure, there is a risk of complications. However the risks are very low. Potential complications include:

• Infection. 
• Bleeding. This can occur if the artery that feeds the knee is injured.
• Blood clots. These can be very serious, however when they are found early they are treated with blood thinners.
• Graft failure. Failure of the graft may cause instability or pain.
• Knee stiffness. This may occur in up to 10 percent of cases.
• Tendon rupture. The knee cap tendon may rupture if it was used to provide the graft.
• Increased pain.

Pre- and Postsurgery Physical Therapy

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Physical therapy is an essential component of preparing for your surgery and recovering afterwards.

Prior to surgery, our physical therapists will work with you, for at least a month before your surgery, to improve your leg strength and range of movement. The stronger your legs are the more successful your surgery is likely to be. 

After surgery, it can take up to 6 months or longer of strengthening and stabilization exercises to regain balance, strength, and control of the knee. We supervise your exercises during the first few weeks after surgery, but we will expect you to continue them at home. People who commit to following the exercise program are more likely to recover full use of their knee.

Prevention

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Although it is not always possible to avoid injuring your knee and specifically your ligaments, there are a number of things you can do to reduce your risk of developing knee problems. It is also important to follow these guidelines to protect your knee if you have had surgery to repair a damaged or torn ligament:

• Maintain an ideal weight for your height. Excess weight puts additional stress on your knee.
• Exercise. Following a regular exercise program keeps your muscles strong and your ligaments flexible. Try exercises that do not stress your knee like swimming, stationary bicycling, elliptical machines, or water aerobics.
• Wear shoes that support and cushion your feet.
• Prevent falls in the home. Keep your home well lighted, use handrails going downstairs, and use sturdy ladders or foot stools if you need to reach for items kept on high shelves. Do not use a chair or step on the counters.
• Avoid prolonged and repetitive kneeling, squatting, or frequent knee bends.
• Use walking sticks if you have to walk up and down steep hills.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

We will ask you to come in 30 minutes before your appointment so that we can X-ray your knee.  During your office visit, we will review your X-rays, discuss your medical and family history and I will examine your knee. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options and develop a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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