This 31-year-old male recreational player presented following two discrete injuries to his knee. This first injury involved a twisting mechanism. This was associated with a popping sensation, near immediate swelling and an inability to play on. He was diagnosed with a medial collateral ligament injury and was able to return to football several months later. Approximately one month after returning to play he described a further injury, again as he changed direction. This injury was much more painful. He was unable to continue play and was still unable to extend his knee or walk unaided when he presented ten days later.
On examination he had a grossly restricted knee range of motion with flexion from 30-80 degrees only. He had a large effusion, localised medial joint line tenderness and equivocal laxity with Lachman’s test. There was no other ligamentous laxity.
An x-ray series of the knee is normal. The MRI sequences show that the anterior cruciate ligament (ACL) is ruptured proximally. In association with this there is a complex medial meniscus tear with a large, displaced bucket-handle flap folded into the intercondylar notch. Both the medial and fibular collateral ligaments are thickened with peri-ligamentous oedema, consistent with a grade one sprain.
This player was managed with a hamstring ACL reconstruction. Unfortunately, it was not possible to repair his meniscal tear and he underwent a partial medial meniscectomy. He has been making a routine recovery and is on track to return to football approximately 12 months following his surgery.
Based on this player’s history it is likely that he injured his ACL during the first injury. Given his relatively rapid recovery and ability to return to football, it is unlikely that he injured his meniscus at this time. The meniscal tear likely occurred during the second instability episode. This may not have happened had his initial injury been diagnosed. It is important to consider an ACL injury when a patient describes a twisting injury and an inability to continue. This is especially true when there is an associated popping/snapping sensation or rapid swelling (although this happens in only 50% of patients). Reducing the risk of subsequent meniscal injury is also one of the justifications used for pursuing an ACL reconstruction. There is some evidence to suggest that this risk might be reduced by conducting surgery within three months of the initial injury.
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