Multiple Ligament Injuries

Multiple ligament injuries, also known as multi-ligament knee injuries (MLKI) or knee dislocations, are severe injuries that involve the damage of two or more of the knee’s primary ligaments: the anterior cruciate ligament (ACL), which prevents the tibia from sliding out in front of the femur and provides rotational stability; the posterior cruciate ligament (PCL), which prevents the tibia from sliding backward under the femur; the medial collateral ligament (MCL), which stabilizes the inner part of the knee and prevents it from buckling inward; and the lateral collateral ligament (LCL), which stabilizes the outer part of the knee and prevents it from buckling outward.

The knee ligaments play a vital role in maintaining the stability and function of the knee joint, which is essential for various movements and activities. Together, these ligaments ensure the knee can support weight, absorb shock, and perform complex movements like walking, running, and jumping, all while maintaining proper alignment and preventing excessive or abnormal movements. Multiple ligament injuries involve severe instability, significant pain, and impaired knee function, typically due to high-energy trauma such as sports accidents or vehicle collisions.

Treatment options in Cuba are carried out by highly experienced orthopaedic specialists and range from non-surgical methods like bracing and physical therapy, which aim to strengthen the surrounding muscles and improve stability, to surgical interventions such as ligament reconstruction or repair. Rehabilitation is a critical aspect of recovery, involving a phased approach to restore knee function, starting with pain and swelling reduction, followed by strengthening exercises, and culminating in balance and agility training.

When a multiple ligament injury is untreated, it can lead to:

• Disruption of blood supply to the leg.
• Damage to the nerves that supply the muscles of the limb.
• Chronic knee instability.
• Persistent pain.
• Limited range of motion.
• Progressive joint damage.
• Long-term functional impairment.
• Increased risk of osteoarthritis.
• Decreased quality of life.

Types of Multiple Ligament Injury

Multiple ligament injuries can be classified based on the specific ligaments involved and the severity of the damage. Here are the common types:

• ACL and MCL Injury: Damage to both the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL), often occurring from a blow to the outer side of the knee or a twisting injury.
• ACL and LCL Injury: Involves the anterior cruciate ligament (ACL) and the lateral collateral ligament (LCL), typically resulting from trauma that forces the knee inward.
• PCL and MCL Injury: Damage to the posterior cruciate ligament (PCL) and the medial collateral ligament (MCL), often due to a direct blow to the front of the knee or a hyperextension injury.
• PCL and LCL Injury: Involves the posterior cruciate ligament (PCL) and the lateral collateral ligament (LCL), usually from a high-energy trauma such as a car accident.
• ACL, PCL, and MCL Injury: Severe injury involving the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and the medial collateral ligament (MCL), resulting in significant knee instability and often requiring extensive surgical intervention.
• ACL, PCL, and LCL Injury: Involves the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and the lateral collateral ligament (LCL), typically caused by a violent impact or high-energy trauma, leading to major knee instability and damage.
• Knee Dislocation: A severe form of multiple ligament injury where the knee joint is dislocated, damaging several ligaments (usually involving ACL, PCL, and at least one collateral ligament) and often associated with vascular and nerve injuries.

Furthermore, multiple ligament injuries are considered sprains and are graded on a severity scale.

• Grade 1: This involves a slight stretching or tearing of the ligament fibers but are still able to help keep the knee joint stable.
• Grade 2: This involves a partial tear of the ligaments, with more significant damage to the fibers.
• Grade 3: This type of sprain is commonly called a complete tear of the ligament. The ligament has been torn in half or pulled directly off the bone, and the knee joint is unstable.

Causes of Multiple Ligament Injury

Multiple ligament injuries are typically caused by high-energy trauma or severe stress to the knee. These include:

• Sudden, high-impact collisions, such as a car accident can cause significant trauma to the knee, leading to multiple ligament injuries.
• Contact sports like football, soccer, rugby, and basketball involve rapid changes in direction, sudden stops, and collisions that can lead to severe knee injuries.
• Falling from a significant height or tripping and landing awkwardly can exert excessive force on the knee, resulting in multiple ligament damage.
• A direct blow to the knee, such as being struck by an object or another person, can cause multiple ligaments to tear.
• Extreme twisting or pivoting motions, especially when the foot is planted and the body rotates, can lead to multiple ligament injuries.
• Industrial accidents, high-energy impacts and falls in the workplace, particularly in construction or heavy industries, can cause severe knee injuries.

Symptoms of Multiple Ligament Injury

Multiple ligament injuries in the knee present a range of symptoms, including:

• Severe pain.
• Difficulty in bearing weight or moving the knee.
• Swelling due to internal bleeding and inflammation.
• Instability and a feeling of the knee giving way or buckling.
• Limited range of motion.
• Visible bruising around the knee and surrounding areas.
• Deformity of the knee in severe cases.
• A noticeable popping or tearing sensation.
• Numbness or tingling below the knee.

Diagnosis of Multiple Ligament Injury 

Diagnosing a multiple ligament injury begins with a thorough medical history review and a physical examination, including:

• Stability Tests.
• Palpation tests.
• Range of motion tests.
• Neurovascular assessment

Other tests include:

• X-rays: Used to rule out fractures and assess any bone involvement or joint dislocation.
• Magnetic Resonance Imaging (MRI): Often used for visualizing soft tissue injuries, providing detailed images of the ligaments, cartilage, menisci, and other structures within the knee.
• Computed Tomography (CT) Scan: Used more in complex cases or when MRI is contraindicated, to provide detailed images of the bone structures
• Arthroscopy: In some cases, minimally invasive surgery may be performed to directly visualize the internal structures of the knee and confirm the extent of ligament damage.

Treatment Options for Multiple Ligament Injury

Treatment for multiple ligament injuries typically involves a combination of surgical and non-surgical approaches to restore knee stability and function. Non-surgical treatments, including bracing and physical therapy, may be sufficient for minor injuries. However, severe injuries often require surgical intervention, such as ligament reconstruction or repair.

Non-Surgical Options

• Bracing: This is a crucial component of the treatment plan for multiple ligament injuries, providing essential support and stability to the injured knee during the healing process. Specifically designed knee braces help immobilize the joint, reduce pain, and prevent further damage by limiting harmful movements that could exacerbate the injury. Wearing a brace can also enhance proprioception, or the body’s ability to sense joint position, which is often compromised after ligament injuries.
• Physical therapy: This therapy is vital for recovery because it facilitates the restoration of knee function, strength, stability and prevents future injuries. Through a structured and progressive exercise regimen, physical therapy helps reduce pain and swelling, promotes healing, and improves muscle strength around the knee, enhancing joint support. Included are:
• Range of motion (ROM) exercises.
• Quadriceps activation.
• Strengthening exercises.
• Weight-bearing activities.
• Proprioception training exercises.
• Patellar mobility.
• Dynamic stability exercises.
• Neuromuscular training.
• Functional training.
• Agility training.
• Aquatic therapy.
• Hip abductor and adductor exercises.
• Manual therapy.
• Functional Electrical Stimulation (FES).

Surgical Option

Surgical intervention for multiple ligament injuries is typically indicated based on several factors, including:

• Severe knee instability.
• Complete ligament tears.
• Associated injuries such as meniscal tears, cartilage damage, or fractures.
• Failure of conservative treatment.
• Acute knee dislocation.
• Chronic instability.
• Recurrent injuries.
• Patient’s overall health.
• Patient’s activity level.

Types of surgical procedures include:

• Ligament Repair: This is a complex surgical procedure aimed at restoring stability and function to a knee and often involves both direct repair techniques, depending on the extent and nature of the ligament injuries. During the surgery, damaged ligaments such as the ACL, PCL, MCL, and LCL are sutured back together.
• Ligament reconstruction: This is an intricate surgical procedure designed to restore knee stability and functionality by replacing severely damaged or torn ligaments with grafts. This procedure typically addresses injuries to the ACL, PCL, MCL, and LCL simultaneously or in stages, depending on the injury’s complexity. The surgery begins with arthroscopic evaluation to determine the precise extent of the damage, followed by the harvesting of grafts either from the patient (autografts) or from a donor (allografts).

For both procedures, postoperative care includes a comprehensive rehabilitation program is necessary with a focus on progressive range of motion, strengthening exercises, and proprioception training to ensure optimal recovery and long-term knee health.