ACL Rupture - Joint Aspiration

Photos taken from a karatedo athlete who twisted his knee during competition. Note that the aspirate always consist of blood. He also complains of his knee 'giving-way' and locking.

When you know you have a Torn ACL? (Part II)

Here's what happens when he tells me that the previous video wasn't clear enough for some to visualise the laxity.

When you know you have a Torn ACL?

Here's how a soccer player demonstrates his loose ACL ligament 'without moving a limb'.

Vastus lateralis tendinitis (tendinoses) and Iliotibial Band Syndrome

A forklift driver came this morning with complaints of left knee pain since the past 1 week with prolonged driving. His pain is worse at the end of the day and it was so bad that he could not sit or squat. He apparently felt better after massaging his thigh.

He had tenderness at the insertion of the vastus lateralis tendon, Iliotibial band (ITB)insertion and gluteus medius origin. He also had restriction of knee flexion (0-80 degrees) and had pain extending his knee against resistance.

As part of the treatment, he was given a day off, reassigned to other duties, told to do RICE treatment,given some stretching exercises for gluteal muscles, quadriceps and ITB and some NSAIDS for 5 days. He would also benefit from ultrasound, TENS, myofascial release and he had some taping done to restrict the pull on the vastus lateralis tendon.

Knee Hyperextension in Ex-Rhythimic Gymnast

Ms Lim is a 35 yrs old ex-rhythmic gymnast who came to see me after a fall on her right knee. It was interesting that she had an extremely flexible left knee with an additional range of 35 degrees in extension. She had been perfectly normal in the left knee and did not suffer from any nagging pain.

She was advised to maintain an active lifestyle to ensure that she looses some weight and also strengthen her back, abdomen, hip and lower limb muscles to prevent injuries.

Right knee lateral meniscus tear

Ms JW, a 21 yrs old lady was walking on her high-heels when she suddenly twisted her ankle and knee yesterday. The knee swelled up slightly and she could hardly walk. She was brought in by her father yesterday evening and could not bear her weight on the right knee.

Clinically, she had moderate effusion and slight slight restriction of knee flexion. She had tenderness of the joint line (lateral aspect) and a positive McMurray's test. She also had mild tenderness of the proximal attachment of the Lateral Collateral Ligament (LCL). She was treated with RICE treatment and sent for further evaluation with plain X-rays and MRI of the Right knee (to evaluate extent of meniscus injury and injury to other structures e.g. ACL). She has been started on isometric exercises. However, she may require early surgical intervention if the meniscus tear restricts movement or can be repaired. Post-surgical rehabilitation would often require up to 12 weeks commitment before return to play.

FOr further reading:-
Meniscus injury
Lateral discoid meniscus

Posterior Cruciate Ligament Rupture

Posterior Drawer Test

Pretibial Bursitis (Preacher's Bursitis)

Ms Lee is a lady in her 30s who came to see me with a painless swelling in her right knee for the past 2 weeks. She mentioned to me that she knocked her knee at a pillar last month but it did not swell then. The swelling came after she started doing more home cleaning on her knees.

I found the swelling to be non-tender, soft and cystic, sitting just on top of the tibial tuberosity. I suggested that she stay away from doing work on her knees for another 2 weeks. Meanwhile, the X-ray of her Right tibia was normal (to rule out any bony abnormality due to her fall or any tumours). An ultrasound of the swelling would be able to demonstrate any fluid. If the swelling failed to subside after 1-2 weeks we would investigate further.

If she was an athlete playing field hockey, soccer or rugby, we would investigate for infection (abscess).

Bilateral Knee Osgood Schlatter's Disease

Jimmy (not his real name) is a 15 yrs old hockey junior state player who has been suffering from pain in both knees since 3 years ago. He also noticed that his tibial tuberosity was more prominent than other players. The pain would worsen with intensive weight training and running on hard turf surface. His dad was planning to give him some additional quadriceps strengthening exercises for his 'thin' legs but decided to ask for my opinion.

I examined his knees and found that he indeed has a protruding tibial tuberosity on both knees. It was painful for him to attempt to bend his knees fully but he was able to do so with my assistance (passive movement). He had pain squatting beyond 120 degrees.

In most cases, Osgood-Schlatter disease is caused by microtrauma in the deep fibers of the patellar tendon at its insertion on the tibial tuberosity and which may be associated with avulsion. The condition is usually self-limiting and symptoms resolve with skeletal maturity in over 90% of cases, when the tibial tubercle fuses to the remainder of the tibia.

He would require a plain X-ray to demonstrate any bone ossicles or avulsion and an ultrasound scan by an experienced sonographer may confirm the diagnoses.

I advised him to lay off running on the turf and focus on light skill workout. He was also encouraged to do some aqua-jogging for fitness. His pain would usually take 2-4 weeks to subside. He was also prescribed NSAIDS to relieve his pain and a patella band to unload the stress from the tibial tuberosity. Surgery is very rarely indicated.

Links of Interest:
Osgood Shlatter's Disease
Tibial tubercle avulsion

Lateral Collateral Ligament Ganglion Cyst or Meniscal cyst?

Mr Tan came with a localised swelling in his right knee since 4 years ago. He told me that he landed awkwardly and subsequently a month later a swelling progressively developed. He would have pain with jogging or sitting cross-legged. He had seen an Orthopaedic surgeon who told him to undergo Arthroscopic surgery to determine the extent of damage.

I examined his knee and found that he had normal range of motion and his ligaments were all intact. He only localised tenderness over the 2cm by 2cm cystic swelling which appeared to be arising adjacent to the lateral collateral ligament and lateral meniscus. His tests for meniscus were inconclusive. I have referred him for another Orthopaedic surgeon for a thorough work-up (X-ray and MRI Right knee).

Since he is usually asymptomatic, if the swelling does not affect his normal function I would tend to leave the swelling alone.

Knee pain after swimming breaststroke

Ms Lim is a lady is her twenties who walked in limping this morning with complaints of left knee pain after swimming breaststroke for an hour the previous day. She does 'gym-workout' for 2 sessions per week, dance lessons for 3 sessions per week and swimming for 2 sessions a week. She has never had any previous falls or similar episode.

She had tenderness on the femoral attachment of the medial collateral ligament. She had no laxity of the ligament. I taped her knee to give her some pain relief while putting on a knee sleeve. She was given several strengthening exercises for her quadriceps, hamstrings and gluteal muscles. I will review her condition in 2 weeks duration to decide on return to play.

Osgood Schlatter's Disease

Matt is a 23 years old store-keeper who doubles up as a forklift driver. He recently developed a left knee painful swelling during work and prolonged walking. He used to have knee pain during his teens when he was actively playing sports.

I examined his knee and found that he had a prominent tibial tuberosity which was tender and inflammed. I applied a patella knee brace for him but he refused to wear it. We ended up taping his knee (see photo) and it seemed to offer him some pain relief. I sent him off with some NSAIDS and advised him about RICE treatment.

Since it was quite mild, I would expect his pain to subside in 2 weeks but he should strengthen his core muscles, hamstring and quadriceps. He would only be fit to lift heavy weights after at least 4 weeks.

Medial Collateral Ligament Rupture

Ahmad is a 24 yrs old cook with a gourmet restaurant met with an accident on his way back from work. He had severe pain on the inner aspect of his left knee and could hardly walk. He had difficulty straightening his knee fully and could not bend his knee.















I examined his knee and found that he had some localised swelling over the femoral attachment of the Medial Collateral Ligament (MCL). Ahmed told me that that was the spot that he collided with the motorcycle. I did the valgus stress test and found that the MCL was torn completely. He was advised to use a Functional knee brace for another 4 weeks while starting his rehabilitation programme. He was concerned as he would not be able to come for the rehabiltiation exercises. He opted instead to use a crepe bandaged wrapped to support the MCL. He was advised to apply RICE treatment to reduce the pain and swelling. He may benefit from an X-ray of his knee and an Ultrasound scan of the MCL.

To be continued...

Knee Gouty Arthritis

Mr Loh is a odd-job worker who came to see me with a painful and swollen left knee this since 3 days duration. He told me that he gets the swelling every time he ate Bak Kut Teh (pork herbal soup). He had been told that he had gout by his doctor but he defaulted his treatment.

I examined him and found that he had a tense left knee joint effusion and restricted joint flexion due to the pain and swelling. He refused to do the X-ray and requested that I remove the joint fluid (he had it done on an earlier episode in a hospital). I aspirated 50ml of bright yellow fluid. He also did not want to send the aspirate sample to the laboratory for analysis. He was also advised to use RICE treatment to assist recovery.



He felt much better after the joint aspiration and was given NSAIDS and told to continue with his gout (Allopurinol) medication with his doctor. He was also advised to avoid high-purine foods.

Knee Contusion

A young lady came in this morning with a swollen knee complaining that she could not kneel down and pray as her knee hurts. She informed me that she slipped after cleaning the floor the previous day.
She had normal range of movement but the bruised area (see photo) was tender and swollen. I advised her to use a pillow to support the knee during prayer, apply Arnica Comp gel and use a Cox-2 selective NSAIDS for 5 days. She was also encouraged to use to use the RICE treatment. The bruising would probably get worse after a day or two and then subside within 1-2 weeks.

Glucosamine for knee osteoarthritis

Athletes with osteoarthritis of the knee joint often suffer from recurrent pain and swelling of the joints after intensive running and jumping. Current research provides good evidence to support the use of glucosamine sulfate in the treatment of mild-to-moderate knee osteoarthritis. Most studies have used crystalline glucosamine sulfate supplied by one European manufacturer (Rotta Research Laboratorium). Results of a recent large clinical trial (GAIT) comparing the effects of glucosamine / chondroitin sulphate for treatment of knee osteoarthritis did not show any additional benefit except in the patients with moderate to severe pain from osteoarthritis. A more recent study (GUIDE) shows in a 6 months random placebo controlled trial that oral glucosamine sulphate (1500mg/day)is more effective that placebo or acetamenophen (3gm/day). ARTHRITIS & RHEUMATISM Vol. 56, No. 2, February 2007, pp 555–567

Most of my athletes with mild to moderate Osteoarthritis have had symptom relief and functional improvement after taking Glucosamine for a tleast 1 to 3 months. Those with recurrent swelling and pain would also benefit from a course of three to five Intra-articular Hyaluronic Acid weekly injections. Athletes who undergo this injection are advised not to continue with vigorous running and jumping during the course of treatment. These athletes would also be given other forms of exercises to improve strength and stability.

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Medial Collateral Ruptured!

She was running down the hill slope when she landed her foot into a small hole and felt something snap and felt a sharp pain in the inner part of her left knee. She fell over and grimaced in pain. Her athlete quickly took her by the shoulders and helped her up to the clinic at the sports complex.

Elaine knew that her knee was in bad shape. She could hardly stand properly and the knee seemed to be twisted outwards. 10 years ago she had an injury to the same knee but she could still walk with little support.

"Looks like you've really torn your medial collateral ligament", I said to her. We quickly got her to ice the knee and prepared her file for physical examination. She had the full range of movement(ROM) which was quite 'pain-free' but she had severe tenderness and moderate swelling at the femoral attachment of the MCL. There was mobility of the leg when it was stressed outwards. Her tests for Anterior Cruciate and Posterior Cruciate ligaments were normal. She was lucky that there was no joint effusion (swelling in the joint due to accumulation of fluid e.g. joint fluid, blood, pus).

"Your MCL is complete torn clinically, but you should be back in 2-3 months time with rehabilitation if nothing else is torn", I said. She was given a functional knee brace and sent for an X-ray. Her X-rays came back normal except for the fluid shadow. We planned her for an MRI within the next 3 days to ensure that the other structures like meniscus and cruciate ligaments were not torn.

She was told to continue icing her knee every 4 hourly and focus on isometric exercises for her quadriceps and hamstrings for the next 1 week. Zul, the physiotherapist was quick to show her the rehabilitation chart. He told Elaine that she would need to progress in stages as she improves her strength, stability and function of her knees. he also planned hydrotherapy sessions for her to maintain her 'aerobic' fitness

Non-specific Knee pain

She could not bear the pain in her left knee anymore. It has been 1 month and the pain was still present. In fact, it worsened after she went to 'service' her clients to ensure that they continued her company's products. She thought it felt better after application of 'the stinking yellow stuff' the chinese doctor applied. "Maybe I should have rested", she thought.

Mei Lee then decided to see sports physician in the neighbourhood. "My knee is more important than the job", she said gritting her teeth in pain as she hobbled along the corridor (as she could not find parking in the Subang Jaya business area).

I was surprised that she was having recurring episodes of left knee pain over the past few years and lived with it. She has had blood test, several X-rays and even an Ultrasound scan done but nobody prescribed exercises to get her back on her feet. "Uhmm..., where did we go wrong in medical school? Or is it just that it's difficult for clinicians to spend time talking to the patient and teaching some basic exercises? Or it's just that nobody bothered to send her to the physiotherapist. At least that could have helped!", I said. "I did see the physio, but they only did electrical stimulation. Since it didn't seem to help, I decided to seek treatment elsewhere", she lamented. Maybe they tried to help her but she was not receptive to their suggestions.

Back to the drawing board!. Her blood investigations for joint disease and inflammatory markers were normal. Her left knee X-rays were normal and so was the ultrasound scan. She had a painful gait, sacroiliac joint inflammation (dysfunction), tight hip adductors, knocked knees and hyperlaxity of both knee joints (in extension)but she had a very tight Achilles tendon due to frequent use of high heels and not enough stretching. This would take a lot more time to unravel the problems.

She was prescribed topical NSAIDS gel and a whole series of exercises to strengthen her quadriceps, hamstring, gluteal muscles, abdomen and lower back. I also did some myofascial release (manual work to release muscle spasm and pain) for immediate effect. After 2 weeks, she was much better and able to run upstairs without pain. She was prescribed more exercises and we added a weight reduction programme for her too!

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