A 24-year-old male semi-professional player presented with a two-month history of lateral knee pain and swelling. This appeared to have started after an innocuous twisting injury during a training session. He reported that the symptoms fluctuated by that there was a clear relationship to physical activity. He had a bone-patella-bone anterior cruciate ligament reconstruction six years previously. At the time of surgery he also underwent a lateral meniscal repair. On examination, he had pain with terminal knee flexion, localised lateral joint line tenderness and pain with tibial rotation. His Lachman’s test was normal with a firm end point.
An x-ray of the knee shows evidence of the ACL reconstruction but no bony abnormality or gross malignment. A subsequent MRI scan shows that the ACL graft is intact. There is a 15 x 6 mm full thickness (grade 4) chondral injury involving the lateral femoral condyle with moderate associated bone marrow oedema. There is also thinning of articular cartilage on the posterior aspect of the lateral tibial plateau. The posterior third of the lateral meniscus is reduced in volume and frayed. The middle and anterior thirds of the meniscus are normal.
After a discussion about the various treatment options this player was managed with a platelet rich plasma (PRP) injection and a period of relative rest. The player had a strong desire to avoid further surgical treatment and was not interested in pursuing the options that were discussed. During the rehabilitation programme he avoided running based training for a one-month period. During this time, he participated in a cycle-based rehabilitation programme, continued resistance training and participated in regular physiotherapy sessions. After one month his symptoms had dramatically improved. He was able to progress a running programme and was able to return to a competitive match eight weeks after his initial presentation. He has continued to experience some occasional, low level lateral knee pain as well as some occasional swelling. This has not impacted his ability to play or train.
Post-traumatic chondral disease and osteoarthritis are common problems following ACL injuries. Reports suggest that the incidence of this problem may be as high as 87%. Grade III or IV radiologic changes in the Kellgren–Lawrence classification system are nearly 5 times more likely than in contralateral knees without a history of ACL injury. A range of structural, biological, mechanical, and neuromuscular factors have been identified as possible causative factors. There are a range of things that may influence the development of post-traumatic OA. Some of these are not modifiable, including being female and having varus knee alignment, while many potentially modifiable. Given that OA can be both very problematic and difficult to treat, these should be aggressively targeted as part of a player’s rehabilitation programme. Modifiable risk factors include a high body mass index, smoking and the need for further surgery (the risk of which may be mitigated by ongoing injury prevention strategies). The time between injury and surgery and the provision of better education about the injury may also have an influence on the development of OA.
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