MANAGEMENT
- Overall patient selection for operative versus nonop-
erative treatment is still somewhat ill-defined in part
because of the controversy surrounding the natural
history of the injury. - Most avulsion fractures require acute fixation.
Injuries with large avulsion fragments can be fixed
with reduction and lag screw fixation, while those
with small avulsion fragments are better repaired with
reduction and suture fixation through small drill holes
(St Pierre and Miller, 1999; Meyers, 1975). - The treatment of midsubstance PCL tears is somewhat
more complicated. The severity of injury (grade/
amount of posterior translation) and the presence or
absence of associated ligament injuries must both be
considered. Nonoperative treatment is often advo-
cated for isolated grade I or grade II injuries. Such
treatment includes initially splinting the knee in
extension, followed by early motion and aggressive
quadriceps rehabilitation (St Pierre and Miller, 1999).
•Surgical intervention is indicated for severe grade III
PCL injuries, symptomatic chronic PCL tears causing
significant pain or instability despite appropriate reha-
bilitation, and PCL injuries in combination with
injuries to the ACL, MCL, or posterolateral structures.
•Traditional single bundle transtibial (anterior-poste-
rior) techniques involve passing a graft through a
tibial tunnel and into a femoral tunnel to mimic the
native function of the PCL. This technique results in
the graft passing over a killer turnon the posterior
edge of the tibial tunnel and may cause the graft to
stretch and loosen with time. - The double-bundle PCL reconstruction utilizes two
femoral tunnels in order to better recreate the func-
tional PCL anatomy of the distinct anterolateral and
posteromedial bands. One study indicates that the
double-bundle reconstruction using two grafts of a
split graft may better reproduce the biomechanical
functioning of the native PCL. Again, the killer turn
may lead to eventual graft loosening. - The modified arthroscopic technique developed by
Harner et al (Harner, Miller, and Swenson, 1994)
places the tendon-bone interface of the graft flush
with the intra-articular edge of the tibial bone tunnel
thereby effectively reducing the graft bending angle
by 50% (Harner, Miller, and Swenson, 1994).
•More recently, tibial inlay reconstruction has been
developed (Berg, 1995). This technique utilizes a
bone trough at the tibial PCL insertion site rather than
the traditional tibial tunnel. The bone block of the
graft is directly fixed into the trough, thereby obviat-
ing the need to negotiate the killer turn. Studies indi-
cate that this technique results in significantly less
posterior laxity and graft degradation as compared
with the traditional transtibial method (Bergfeld et al,
2001).COLLATERAL LIGAMENT INJURIESMEDIALCOLLATERALLIGAMENT- Most often injured by a direct blow to the lateral side
of the knee causing valgus stress. Such a blow may
lead to the unhappy triad of ACL, MCL, and medial
meniscus tears. Injuries most commonly occur at the
femoral insertion of the ligament, and tenderness may
be localized to the medial epicondyle.
•Diagnosed by a valgus stress test. This is performed
with the knee in 30°of flexion in order to relax the
ACL and PCL, making the test more specific for the
MCL. At full extension, the MCL, posterior oblique
ligament, the medial portion of the posterior capsule,
the PCL, and the ACL all contribute to valgus stabil-
ity (Harmon and Ireland, 2000). - In chronic tears, radiographs may show calcification
at the medial femoral condyle insertion site (the so-
called Pellegrini-Stieda sign). - Most tears are amenable to nonoperative management
with a hinged knee brace and range-of-motion exer-
cises. After successful initial rehabilitation, football
players may choose to wear a prophylactic brace for
the remainder of that season. - Some Grade III tears associated with associated cru-
ciate ligament injuries or repairable meniscal injuries
may require surgery (Indelicato, 1995).
LATERALCOLLATERALLIGAMENT- Most commonly injured by direct blow to medial knee
causing varus stress. Isolated injuries are quite rare,
and as such the knee must be thoroughly evaluated for
accompanying injuries.
•Diagnosed by varus stress test. Again, the knee is
placed in 30°of flexion so the test is more specific for
the LCL. It is also important to assess the function of
the peroneal nerve, as it courses around the neck of
the fibula and may be injured concomitantly with the
LCL. Tests of peroneal nerve function include foot
dorsiflexion, foot eversion, and sensation to the lateral
lower leg (Silbey and Fu, 2001). - Isolated LCL injuries are usually treated conserva-
tively.
POSTEROLATERAL CORNER INJURIES- The primary static stabilizers against abnormal pos-
terolateral movements are the fibular collateral liga-
ment, the popliteus tendon, and the popliteofibular
354 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE