A 22-year-old female football player presented complaining of left knee pain following an incident landing from a jump. At the time of the injury, she noted some swelling that subsided quickly, but the pain persisted. She had a history of a left knee ACL reconstruction and MCL repair eleven months previously. Prior to her reinjury, her progress had been good and the knee was symptom-free. At the time of her presentation she had no effusion and full pain-free range of motion. Ligamentous stress testing revealed a stable ACL but a subtle increase in gapping with valgus loading while the knee was flexed. Palpation produced lateral joint line pain.
An MRI scan obtained one month after the injury shows increased signal within the lateral tibial plateau with fissuring of the articular cartilage. There is a subtle change to the subchondral plate of the lateral femoral condyle. A repeat MRI taken 13 months later the persistence of marrow oedema within the lateral tibial plateau but also demonstrates extensive marrow edema of the lateral femoral condyle that was not present previously. A deep subchondral ulceration of the lateral femoral condyle has also developed.
This player had extensive non-surgical treatment including activity modification, physiotherapy, visco supplement injections and a lateral unloading brace. While she was able to return to her university team and partake in occasional practices, she continued to experience symptoms. She subsequently underwent surgery and was noted to have two small loose chondral bodies that were excised. Furthermore, there was a deep full thickness defect of the lateral tibial plateau and deep blistering of the lateral femoral condyle. The plateau defect was curetted and grafted with a chondral allomatrix and fibrin glue while an autologous osteochondral transfer was performed for the femoral lesion. After an intensive rehabilitation program, she returned to regular competitive play nine months following surgery without the recurrence of symptoms.
Articular cartilage injuries of the knee are a difficult clinical challenge because they frequently fail to heal spontaneously. A successful outcome for treatment of chondral injuries in a football player is the ability to return to play and to perform at the pre-injury level. Similarly, treatment must relieve the patient’s symptoms and hopefully prevent the future development of osteoarthritis. As this case illustrates, the treatment can be either non-operative or operative. The choice of treatment depends on the severity of symptoms, the characteristics of the injury (size, location and depth), and patient factors (stage of career, motivation, compliance). To learn more about this consider completing the ‘Meniscus and Cartilage’ module in the FIFA Diploma in Football Medicine.
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