Knee Injury in Division 1 Football Player

Abstract

HISTORY: A 20-year-old collegiate football player presented after sustaining an injury to his right leg. His right leg was planted, knee slightly flexed, and he was struck forcefully from the left side. He was unable to ambulate. Swelling was evident 20 minutes later. He had no history of prior injury to the knee and no significant medical history. PHYSICAL EXAMINATION: 5 days post-injury, inspection revealed ecchymosis along the medial aspect of the knee and visible patella alta. ROM was limited due to patient guarding. Palpation revealed 3+ effusion and a defect of the patella tendon. He was unable to perform a straight leg raise and was still unable to ambulate. Grade 3 MCL insufficiency was present. He was stable to varus stress. Lachman and pivot shift tests were limited secondary to pain and swelling. DIFFERENTIAL DIAGNOSIS: Patellar tendon rupture MCL tear Meniscal injury ACL tear Tibial plateau fracture Femoral condyle fracture TESTS AND RESULTS: MRI 4 days post-injury: full thickness tear of the proximal ACL, full thickness tear of the distal tibial insertion of the superficial MCL with 2.5cm of retraction, full thickness rupture of the patella attachment of the patellar tendon with 2cm of retraction, and a posterolateral corner meniscal tear. FINAL/WORKING DIAGNOSIS: Simultaneous rupture of patellar tendon, ACL, and MCL. TREATMENT AND OUTCOMES: He was treated in a staged manner with acute primary repair of the patellar tendon followed by a 3-month rehabilitation period during which serial increases in flexion while in the knee immobilizer were permitted. Physical therapy was begun at 2 weeks post-op. At 2 months, patient had 4/5 quadriceps strength, normal patellar tracking and no MCL instability to lateral stress. At 3 months, he returned to the operating room for ACL reconstruction and intraoperative assessment of the MCL and menisci. The MCL was treated conservatively given its stability with 30 degrees valgus load, and the medial and lateral menisci were found to be normal upon probing. He was placed on a standard postop ACL protocol. At 6 months, he had negative Lachman’s, anterior drawer, and pivot shift tests. He had no effusion and only mild quad atrophy. He was able to straight leg raise and was ambulating well. He returned to sport at 12 months after ACL reconstruction.