Common Sports Knee Injuries

If you’ve watched sports games, especially football, you’ve probably seen a game getting stopped with a player down. You’d instantly see one or two people running to the field carrying a small kit. As the player is in pain holding—let’s say—the knee, these people would examine him. After some tests, these people go off either with or without carrying the player out. Maybe, if you’re unlucky, you might be the one who’s experienced this. When an injury is bad, like Liverpool player Virgil van Dijk’s knee (ACL) injury, chances are the physiotherapists (the “two people”) would not allow the player to continue the game. In the realm of sports, knee injuries are common and can be detrimental. Several types of knee injuries are common among sportspeople, which you may or may not also have.

Knee Ligament Sprains/Ruptures

A common structure of the knee joint to get injured is the ligament (Bollen, 2000). This structure connects bone to bone and limits joint movement past the normal range (Sproule, 2012). There are 4 key ligaments helping with joint stability: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament

(MCL) and lateral collateral ligament (LCL). The ACL is the most commonly injured knee ligament, occurring frequently in sports such as football, soccer and basketball (Evans et al., 2023).

Knee anatomy (left). From "The Ligaments" by J. Berman, n.d., Joint Preservation Center (http://josephbermanmd.com/anatomy-of-the-knee/the-ligaments/). Copyright 2013 by ION Medical Designs, LLC.

Different movements can injure the different ligaments (Woo et al., 2006; Raines et al., 2017). The ACL is the most commonly injured ligament out of the four, followed by the MCL, LCL and PCL (Majewski et al., 2006). The PCL is the ligament least commonly injured and is thicker and stronger than the ACL (Raj et al., 2023). Injury to ligaments are called sprains, which can be classified into three categories based on severity: grade I (overstretched or very slight tear of the ligament), grade II (partially torn ligament) and grade III (completely torn, or ruptured, ligament) (Maryland Orthopedic Specialists, n.d.).

ACL	Knee pushed inwards + knee rotates internally + slight knee flexion/bend + tibia pushed forward (can be direct contact or non-contact, usually in sudden twisting and/or stopping motions)
MCL	Knee pushed inwards (usually direct contact)
LCL	Knee pushed outwards (usually direct contact)
PCL	Knee flexion + tibia pushed backwards or rotational hyperextension of the knee (can be direct contact or non-contact, but requires much force)

In ligament injuries, there is usually a loss of stability accompanied by pain and swelling. To test for specific ligament injuries, physical examinations are done with special tests for the suspected ligament of injury. For example, to test for MCL sprains, the valgus test is done. Imaging using magnetic resonance imaging (MRI) can be done to help confirm the diagnosis. (Evans et al., 2023; Naqvi & Sherman, 2023)

Acute management of ligament injuries includes PRICE, which includes protection (protect the injured area from further damage, e.g. using a brace/support), rest (rest the injury and reduce movement), ice (regularly ice the injury for 10-15 minutes), compression (compress the injured area using, e.g. a bandage) and elevation (rest the injured area above heart level) to reduce pain, inflammation and swelling. For grades I and II sprains, physiotherapy is done to help strengthen the muscles around the knee to aid in dynamic stabilisation. For ruptured ligaments, surgeries are typically performed, e.g. an ACL reconstruction surgery for ACL ruptures. (Evans et al., 2023)

Meniscus Injuries (Tears)

Another commonly injured structure of the knee is the meniscus (can be seen in the photograph above). The medial (inside) and lateral (outside) menisci primarily function in load distribution and shock absorption through the tibiofemoral joint. The medial meniscus is found to be injured more often than the lateral meniscus as the medial meniscus is more secured to the medial tibial plateau and attached to the MCL, whereas the lateral meniscus is not as secured to the lateral tibial plateau and is more mobile. (Majewski et al., 2006; Raj & Bubnis, 2023)

The menisci are usually injured with similar movements (Lento & Akuthota, 2000).

Medial meniscus	Sudden knee flexion + knee internal rotation
Lateral meniscus	Sudden knee flexion + knee external rotation

The risk for meniscal injuries is increased in sports requiring frequent squatting and kneeling, e.g. soccer, rugby, football, basketball, baseball, skiing and wrestling. Patients with ACL and MCL injuries also have an increased risk for meniscus injuries due to the involvement of the menisci in the ACL and MCL pattern of injury. Meniscal tears can be tested using several special tests, e.g. McMurray’s, Apley’s compression, Thessaly tests and joint line tenderness. There are various types of meniscal tears, e.g. flap, bucket-handle and longitudinal. There are a variety of symptoms depending on the mechanism and extent of injury, some of which include pain, swelling, stiffness, locking, clicking and difficulty fully extending the knee. MRIs can also be used to confirm the diagnosis and type of tear. (Raj & Bubnis, 2023; Hoveidaei et al., 2023)

Acute management of meniscal injuries is similar to that of ligament injuries, i.e. PRICE. Physiotherapy (conservative treatment) is typically done for simple tears, while surgery such as meniscal repair and meniscectomy can be done for more complex tears. (Raj & Bubnis, 2023; Lento & Akuthota, 2000)

Osgood-Schlatter Disease

Another common injury to the knee in sports is Osgood-Schlatter Disease (OSD), also known as osteochondrosis, tibial tubercle apophysitis or traction apophysitis of the tibial tubercle (structure can be seen in the photograph above). This condition causes microvascular tears, fractures and inflammation as patients experience pain and swelling in the tibial tuberosity area. This is especially common in youth/adolescent sportspeople whose skeletons have not fully developed as the tibial tuberosity (an apophysis, growth zone on a bone) has not fully fused with the rest of the tibia bone and is vulnerable to traction (pull) stress. (Smith & Varacallo, 2023

OSD diagram and x-ray. From “Osgood-Schlatter Disease: Appearance, Diagnosis and Treatment: A Narrative Review,” by F. Corbi, S. Matas, J. Álvarez-Herms, S. Sitko, E. Baiget, J. Reverter-Masia and I. López-Laval, 2022, Healthcare, 10(6), 1011 (https://doi.org/10.3390/healthcare10061011). Copyright 2022 by the authors.

This condition arises from an overused patellar tendon (the structure joining the patella to the tibial tuberosity) due to repeated contractions of the quadriceps. When the leg is extended, the quadricep (front, upper thigh) muscle pulls on the patella, putting tension on the patellar tendon, allowing this tendon to pull on the tibia to perform this extension movement. With repetitive contractions in skeletally immature individuals, the insertion of the patellar tendon to the tibial tuberosity is inflamed as the tuberosity is under constant traction stress. Sports where OSD is prevalent include basketball, volleyball, gymnastics, sprinting and football, where running and jumping are frequently performed. (Corbi et al., 2022; Osgood-Schlatter disease, n.d.)

OSD diagnosis is typically clinical and based on symptoms. However, an X-ray, ultrasound or MRI can be done to confirm the diagnosis and rule out other possible diagnoses as well as determine the grade (severity) of the condition. Grade I shows a slight tuberosity elevation, grade II shows radio lucidity of the tuberosity (decreased bone density in the tuberosity area) and grade III shows tuberosity fragmentation. (Corbi et al., 2022)

Usually, OSD improves with rest and activity modifications and goes away when the apophysis fuses with the rest of the tibia when the skeleton matures. Physiotherapy may also help correct underlying biomechanical factors that may lead to OSD. Similarly, PRICE is administered for pain and swelling management. Usually, surgery is not needed for this condition. (Smith & Varacallo, 2023)

All in all, sports injuries to the knee are common and can affect a variety of structures. While different injuries are treated differently, pain from the conditions above can generally be managed with PRICE and modifications of the sports activity, whereas surgery only applies to certain conditions at certain severities. If you suspect you or someone you know have the above condition(s), make sure to consult with a medical practitioner regarding injury diagnosis and treatment.

This article has been reviewed by licensed physiotherapist Fery Abdillah Haris, S.Tr.Ft.

References

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Bollen, S. (2000, June 1). Epidemiology of knee injuries: Diagnosis and triage. British Journal of Sports Medicine, 34(3), 227-228. https://doi.org/10.1136/bjsm.34.3.227-a

Corbi, F., Matas, S., Álvarez-Herms, J., Sitko, S., Baiget, E., Reverter-Masia, J., & López-Laval, I. (2022, June). Osgood-Schlatter disease: Appearance, diagnosis and treatment: A narrative review. Healthcare, 10(6), 1011. https://doi.org/10.3390/healthcare10061011 

Evans, J., Mabrouk, A., & Nielson, J. I. (2023, November 17). Anterior cruciate ligament knee injury. In StatPearls. StatPearls Publishing.

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Majewski, M., Susanne, H., & Klaus, S. (2006, June). Epidemiology of athletic knee injuries: A 10-year study. The Knee, 13(3), 184-188. https://doi.org/10.1016/j.knee.2006.01.005

Maryland Orthopedic Specialists. (n.d.). Grading your ACL tear. The Centers for Advanced Orthopaedics. Retrieved April 15, 2024, from https://www.mdorthospecialists.com/blog/grading-your-acl-tear

Naqvi, U., & Sherman, A. I. (2023, July 17). Medial collateral ligament knee injury. In StatsPearls. StatPearls Publishing.

Osgood-Schlatter disease. (n.d.). Johns Hopkins Medicine. Retrieved April 15, 2024, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/osgoodschlatter-disease 

Raines, B. T., Naclerio, E., & Sherman, S. L. (2017, September-October). Management of anterior cruciate ligament injury: What’s in and what’s out? Indian Journal of Orthopaedics, 51(5), 563-575. https://doi.org/10.4103%2Fortho.IJOrtho_245_17 

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Woo, S. L. -Y., Abramowitch, S. D., Kilger, R., & Liang, R. (2006). Biomechanics of knee ligaments: Injury, healing, and repair. Journal of Biomechanics, 39(1), 1-20. https://doi.org/10.1016/j.jbiomech.2004.10.025