Ligament Tears/Sprains

• Any age but commonly 16-50
• Mechanism of injury suggestive of ligament damage
• Consider impact on professional or physical activity

Tears:

• ACL ruptures can be difficult to diagnose from clinical examination in the early stages due to patient pain and muscle guarding. Diagnosis is often suspected from the history.
• Valgus / varus stress or a twisting injury - Opening up on valgus stressing in full extension means that either ACL or PCL is also ruptured.
• Feeling of a pop or a snap at injury

Sprains:

• History suggestive of valgus/varus stress

Tears:

• Rapid developing effusion / haemarthrosis
• Joint line pain/ tenderness- pain from an MCL sprain can take a few months to fully settle.
• Instability/ knee true giving way (not just fear)
• Inability to complete physical activity.
• ACL: laxity on Anterior drawer and Lachman’s test if able to test.

Sprains:

• Pain on movement and palpation
• Absence of effusion

• PRICE treatment
• Analgesia & NSAIDs as appropriate
• Refer to MSK physiotherapy- Based on current clinical evidence, all uncomplicated ACL ruptures should be managed initially with at least 6 months of a contemporary physiotherapy ACL rehabilitation programme. For many patients who have ruptured their ACL, ACL reconstruction surgery gives no functional benefit over physiotherapy alone. Only those who continue to have symptoms of rotatory instability despite having been compliant with physiotherapy and met their functional and strength test targets will be considered for ACL reconstruction
• MCL sprains or partial tears (grade 1 or 2) typically heal without chronic problems and can be managed in primary care with MSK physiotherapy and a rehab programme. The pain from an MCL sprain can take a few months to settle

XR/MRI prior to referral if possible

• CKS traumatic causes of knee pain
• Exercises for knee pain (NHS Inform)

 

• Rapid hemarthrosis with knee instability. Phone on call orthopaedic registrar bleep 4561
• Any acute grade 3 or suspected grade 3 MCL tear warrants further evaluation (clinical assessment +/-MRI) to look for other coexisting injuries. Referral should be made to the Knee service (will be vetted to soft tissue knee) clinic
• Rotatory instability six months post injury despite having been compliant with physiotherapy

Exceptions who might be considered for early ACL reconstruction include:
• A co-existing bucket-handle meniscal tear or large peripheral meniscal tear which may be considered for repair
• An ACL rupture as part of a combined or multi-ligament injury which renders the knee highly unstable
• Professional athletes where it could be argued that reconstruction may provide the best chance of returning to their profession. N.B. Only around 40-50% of amateur athletes get back to high impact sport after reconstruction. It is not known if this can be achieved with contemporary high-quality rehabilitation alone but there are case reports of athletes getting back to professional football and rugby with non-operatively managed ACL ruptures, Current guidance is that those who have undergone ACL reconstruction should wait at least 9 months after surgery to resume high impact sport whilst many take 2 years to achieve their physiotherapy targets required to return to sport.
• Children <13 with ACL rupture which may be amenable to repair

• Rapid hemarthrosis with knee instability - Phone on call orthopaedic registrar bleep 4561
• SCI Gateway/Orthopaedics/Knee
• If the patient is under the care of NHS Physiotherapy, investigations and onward referral to knee service, if appropriate, will be organised by Physiotherapy service without the need for further GP intervention

Information to include when referring:

• Duration. mechanism of injury or any cause of symptoms
• Indicate site/ spread of pain and if constant or intermittent, and/or waking at night
• Indicate active and passive ROM
• Include treatment to date
• XR/MRI results.