Teaching Case #1


All cases used in Teaching Cases are provided for educational purposes to help patients understand the variety of injuries that athletes and active patients sustain and what treatment options may be available.

Please realize that every injury has many elements which factor into our treatment plan and all of those elements may not be listed in the brief synopsis here. Additionally, there are a variety of appropriate treatments for most injuries. If you have had a similar injury that was treated differently, do not worry that the treatment you received was inappropriate in any way. The medical literature often documents multiple successful and appropriate methods of approaching the same injury.

No identifying information is present on images provided or in the descriptive text. We believe firmly in protecting the privacy of our patients.

This is a healthy, active 34 year-old male who was injured sparring in martial arts. Upon initial examination this was a severe injury to the knee that involved multiple ligaments. The patient was begun on a Physical Therapy “pre-hab” program and an MRI was obtained.

We use the term “pre-hab” to describe Physical Therapy done before an anticipated surgical reconstruction, since “rehab” is commonly used to describe the therapy after surgery. This period is used to work on improving range-of-motion for the involved joint and to gently work on strengthening. Many of the strengthening exercises done are the very same as the exercises that will be done after the surgery, sometimes at a lesser resistance or with lighter weight. One of the major benefits to “pre-hab” is that the patient can learn the exercises and start to develop the “motor memory” pathways so that after surgery, when the joint may be swollen and the muscles are inhibited, the beneficial exercises are familiar. This way, the exercises are familiar and the inhibited muscles are not trying to learn new exercise, they already know them!

The MRI showed injury to the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL) and the posterolateral corner (PLC) ligament complex. This athlete had sustained substantial injury to 3 out of the 4 main stabilizing groups of the knee, which is a very severe injury. As progress was made in therapy, surgical reconstruction was planned.

The surgical treatment involved reconstruction of the ACL and the PLC with grafts and a repair of the PCL which had sustained a near complete rupture but had some residual fibers intact.

Reconstruction means that the surgeon is using a graft or substitute tissue to re-create the injured part of the body, in this case, ligaments. That graft acts as a combination of a structural substitute for the original ligament as well as a scaffolding for the patient’s own body to incorporate the graft through a process called “ligamentization.” This process basically means that over the course of time, the patient’s body removes some cells from the graft and adds the patient’s own ligament cells. Over time, if we look at biopsies or samples of grafted ligaments, the microscopic breakdown of tissues such as collagen begin to look less like the tissue used for the graft and more like a normal ligament.

Repair means that the patient’s own tissue is re-attached and placed in a setting to optimize healing of that tissue. In this case, the PCL had some structure still attached and most ruptured, so the attachment footprint from the portion that was ruptured was “prepared” to stimulate a healing response prior to re-attaching the ligament to that footprint. This re-attachment was done by passing suture through the torn portion of the ligament and then docking that part of the ligament to the footprint or normal attachment site via a small tunnel for the suture and a metallic button outside the joint to maintain tension and keep the ligament docked to the footprint while the patient’s body heals it back in place.

After the reconstruction of the ACL and PLC as well as the repair of the PCL, the patient’s knee was examined and found to have near normal stability to testing of all ligaments and full range-of-motion.

At this point, only a couple months from surgery, the patient is working on a rehabilitation program with a Physical Therapist and making excellent progress. He is walking without crutches and no limp. His strength is returning well and he is back to work with some partial limitations. He has some residual stiffness in the knee as he brings it into full flexion and cannot yet get his heel all the way to his buttock. Residual stiffness at this stage after such a big surgery is common. Our hopes are high that he will be able to resume a fully active lifestyle without limitations, he is off to a great start!