Ligament and tendon ruptures. Treatment of knee ligament rupture

People are exposed to injury every day. Injuries that are localized in the area of ​​the ligamentous apparatus of the ankle joint account for the lion's share of all injuries to ligaments and tendons in the human body (50-60%). The most commonly injured ligaments are:

• 8% deltoid,
• 6% tibiofibular,
• 3% calcaneofibular,
• 3% joint capsule,
• 80% talofibular.

Due to the fact that the posterior talofibular ligament does not stretch when the talus of the foot is displaced, its injuries are very rare.

All talofibular ligaments have their own sheath; thanks to this anatomy, the latter are defined as separate structures. In practice, an isolated type of injury occurs in 70% of cases; in the remaining 30%, damage to the talus ligaments is combined with damage to the calcaneofibular ligament.

Degree of damage

Depending on the severity, the following degrees of ligament and tendon ruptures are distinguished:

• I degree – minimal gap;
• II degree – moderate and severe;
• III degree – complete.

Complete tendon ruptures are less common than ligament ruptures because they are stronger than ligaments—for example, ankle ligament ruptures are diagnosed more often than Achilles tendon ruptures. Complete rupture of the ligaments in most cases causes instability of the joint. Due to a complete rupture of the tendon, the muscle ceases to function because it is not attached to the bone.

Ligament and tendon ruptures most often occur in:

• athletes (for example, football players are often diagnosed with a rupture of the anterior cruciate ligament, which stabilizes the knee joint);
• victims of accidents.

Most often, partial or complete ligament ruptures are diagnosed:

• acromioclavicular joint;
• proximal interphalangeal joints (PMFP - joints between adjacent phalanges of the fingers and toes, which are located closer to the center of the body);
• knee joint;
• ankle joint;
• Achilles tendon. Partial rupture of the Achilles tendon is a common sports injury.

Tendon ruptures are most common for:

• knee extensors;
• calcaneal (Achilles) tendon.

Often, when an injury occurs, ligaments and tendons rupture - for example, when the extensor tendon of the hand ruptures, the ligaments of the hand are damaged.

Treatment of ankle ligament injuries

The use of platelet-derived growth factors in the treatment of grade 1-2 injuries of the lateral ligaments of the ankle joint

E.N.Bezuglov 2, E.E.Achkasov 1, E.M.Usmanova 3, 1. Department of Physical Therapy and Sports Medicine 2. Continental Hockey League 3. PFC CSKA
SUMMARY

In our clinic, doctor Bezuglov E.N. conducts consultations. Performs: - conservative treatment of musculoskeletal joint injuries; -groin pain; - damage to the muscles and capsular-ligamentous apparatus of large joints; -rehabilitation after surgical interventions on the musculoskeletal system

The article presents the results of treatment of damage to the lateral ligaments of the ankle joint in 40 male football players (average age - 24.0±1.3 years), who were divided into two groups of 25 athletes depending on the treatment methods used.

The timing of treatment and the duration of pain persistence depending on the treatment method were analyzed. A new method for treating the ligaments of large joints using platelet-derived growth factors has been proposed, which can significantly reduce treatment time, reduce the severity of pain and reduce the number of recurrent injuries. It has been shown that the effectiveness of using platelet-derived growth factors is equally high in the treatment of both first and second degree injuries.

Introduction.

Introduction. Injuries become an indispensable attribute of the career of almost any athlete.

According to European experts, up to 50% of all sports injuries, as well as 3.5-10% of all injuries treated in hospitals, are associated with playing football [7]. Among all sports injuries, the most common are injuries to the ligamentous apparatus of large joints, and that is why the full treatment of these injuries, as well as the fastest possible rehabilitation with a return to the previous level of activity, becomes of utmost importance [9].

The maximum number of injuries occurs in the capsular-ligamentous apparatus of the ankle joint—up to 17% of all sports injuries. Most often he is injured when playing football, which is one of the most traumatic sports [3]. Ankle joint injuries account for 15% of all emergency sports injuries, of which 85% are inversion injuries [5].

According to a study conducted by the UEFA Medical Committee, more than 12% of all injuries to football players of leading European clubs were injuries to the ankle joint, of which about 38% were injuries to the lateral lateral ligaments, which, in turn, significantly prevail in the structure of all injuries to the ankle ligaments - more than 80% of all cases.

The lateral group of ligaments of the ankle joint is represented by the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL).

The severity of damage to the PTMS and PMS is the basis of functional tests that determine the extent of injury. There are several classifications of damage to the capsular-ligamentous apparatus of the ankle joint, which are based on assessing the degree of damage to certain anatomical structures [2].

In our opinion, the most revealing is Hamilton’s classification [4]. Since it better displays the relationship between diagnosis and anatomical structure, as well as the mechanism of injury:

• Grade I – sprain of any ligament
• grade II – PTMS rupture, PMS is not damaged
• degree III – rupture of the PTMS and PMS.

A very important aspect in the treatment of damage to the capsular-ligamentous apparatus specifically in highly qualified athletes is an adequate assessment of the pain syndrome immediately after injury, as well as during treatment, since in some cases it is the pain syndrome, and not the degree verified using instrumental research methods. Ligament damage becomes the main limiting factor for starting full-fledged training.

Pain syndrome is most often assessed based on the patient’s subjective sensations using developed pain scales.

To assess the intensity of acute pain in clinical practice, the Visual Analog Scale (VAS), the Numerical Rating Scale (NRS) and the categorical Verbal Rating Scale (VRS) are widely used.

The main drawback of all the described scales is the assessment of pain at rest or during the usual load for the patient being interviewed. At the same time, the absence of pain at rest or during routine exercise is not an indicator for athletes of the positive dynamics of the healing process, or even more so of recovery, since limiting pain can appear during or after a specific load. Taking into account the above disadvantages, we developed and for the first time introduced into practice a scoring system for assessing pain specifically among highly qualified football players.

Classification of pain syndrome in football players

1. there is no pain when performing physical exercises of any intensity and does not appear after it
2. there is minor discomfort, appearing only after exercise and spontaneously stopping
3. does not interfere with exercise of any intensity and does not intensify after it
4. limiting pain appears only at the peak of a specific load
5. limiting pain appears when performing a specific load of moderate intensity
6. pain appears during clinical tests
7. pain occurs when running
8. pain occurs when walking fast or doing other similar activities
9. pain occurs with any movement
10. -pain at rest

A method for selecting diagnostics of damage to the ligamentous apparatus, which can be used both for and for assessing the course of the process.

In addition to the mandatory methods (ultrasound and radiography) of examination for damage to the ankle ligaments, computed tomography can be used to exclude osteochondral damage and help diagnose concomitant bone contusion and swelling, the presence of which affects the duration of recovery[18].

Over the past decades, in the world practice of treating injuries to the ligamentous apparatus of the ankle joint, the opinion has been established about the need for minimal immobilization of the joint in order to quickly stop the accompanying inflammation and accelerate repair 8].

Treatment of ankle ligament injuries is 14].

Damage to the ligaments of the ankle joint is accompanied by Therefore, all initial treatment tactics should be based on the elimination of pain.

RICE therapy is used as a starting therapy, which includes resting the joint through partial immobilization, accompanied by cooling, compression and elevation [17].

The end of the treatment of all types of ligament injuries in athletes is the absence of pain in the absence of pain.

One of the simplest and at the same time safest and -ligamentous apparatus in athletes is infiltration of the place obtained from.

This technique has been used for quite a long time in leading European and American clinics, and in the CIS it is most actively used in Donetsk [1].

In recent years, numerous studies have proven the important regulatory role of various growth factors in the healing processes of damaged tissues[6].

The use of platelet-derived growth factors in clinical practice can significantly accelerate tissue healing processes while simultaneously improving the quality of the scar) [13].

The pathogenetic basis of this method is the presence in platelets of alpha granules containing a large number of growth factors, which are stimulators of regeneration processes [16]

For athletes or professional athletes, the impact of musculoskeletal injuries on life and work is much greater than for ordinary people, so rapid restoration of full performance and return to competition is of paramount importance [15].

Optimal treatment of injuries in this group of patients should be aimed at returning to the previous functional level of activity as quickly as possible in the safest and most cost-effective manner [12].

The purpose of this study was to comparatively evaluate the effectiveness of treatment of grade 1-2 injuries of the lateral ligaments of the ankle joint using TFR and the standard method of treating such injuries.

Materials and methods. This paper summarizes the results of examination and treatment of 40 patients aged from 18 to 32 years (average age - 24.0±1.3 years) with injuries to the lateral ligaments of the ankle joint, who were treated at the medical center of the Luzhniki Olympic complex. Moscow in the period from 2009 to 2012. The degree of damage to the ligamentous apparatus was assessed according to the Hamilton classification. The duration of injury in all cases was 1-3 days.

All patients were male football players playing for clubs in the Russian Premier League and the National Football League.

In this study, only primary isolated injuries of the lateral ankle ligaments were analyzed.

At the time of the initial examination and functional tests for joint stability (“anterior” and “lateral” drawers), all patients underwent ultrasound examination (US) and radiography of the ankle joint, thus all diagnoses were verified.

The indication for the use of TGF injections was the desire of the patients.

All patients gave informed consent to treatment. All patients were divided into two groups depending on whether injections of platelet-derived growth factors were used or not.

Group I included 20 patients (50.0%) who received TGF injections as part of standard treatment. A blood sample of 36 ml (4 tubes of 9 ml each) was taken from the cubital vein. Platelet-rich plasma was obtained using a centrifuge from BTI (Spain), using a standard protocol of 1800 rpm for 8 minutes. The minimum platelet content in the plasma concentrate injected into the injury site was 800,000 per milliliter. TGF injection was performed once in a volume of 4 ml, injected into the injury site.

Group II included 20 patients (50.0%) who did not undergo TGF injections. Before starting therapy, all patients were assessed for the severity of pain using a developed scale. In both groups it was 7-10 points. All patients, regardless of the timing of the injury, received conservative therapy aimed at eliminating existing symptoms. Correction of existing pathological changes was carried out by intramuscular injection of Voltaren at a dosage of 3.0 ml once a day for three days, as well as by local treatment in the form of compresses with Lyoton and Voltaren gels. In both groups, physiotherapeutic treatment was carried out according to a standard regimen (cryotherapy 30 minutes 5 times a day for the first three days, magnetic therapy 30 minutes 1 time a day for the first 7 days). Considering that grades 1 and 2 injuries are stable and that functional tests did not reveal joint instability, joint immobilization was not performed [18].

The results obtained were assessed based on the number of days from the moment of injury to the start of full testing training and the number of relapses of injury over the next 6 months. The criterion for admission to the testing training, which included football-specific exercises of maximum intensity (Table 3), was a reduction in pain to 2-3 points on the developed scale.

Results and discussion: References: 1. Bezuglov E.N., Glushchenko A.L., Achkasov E.E., Yardoshvili A.E., Karkishchenko N.N. The first experience of using platelet-derived growth factors in the treatment of injuries to the musculoskeletal system of highly qualified athletes……………. 2. Renstrom P. Sports injuries. Clinical practice of prevention and treatment. - Kyiv: Olympic literature, 2003. - 93-94 p. 3. Ekstrand J. Soccer injuries and their prevention. // Linkoping University Medical Dissertations. 1982.- N.130. 4. Hamilton W. Stenosing tenosynovitis of the flexor hallucis longus tendon and posterior impingement upon the os trigonum in ballet dancers. Foot Ankle. // International SportMed Journal. 1982.-N.3.-P.74-80. 5. Henry J. Lateral ligament tears of the ankle, 1-6 years follow-up: study of 202 ankles//Orhop.Rew.1983.- Vol.10.- P.31-39. 6. Kasemkijwattana C., Menetrey J., Bosch P., Somogyi G., Moreland M., Fu F., Buranapanitkit B., Watkins S., Huard J. Use of growth factors to improve muscle healing after strain Injury// . Clin Orthop Relat Res.2000.- P.272–285. 7. Keller S., F. Noyes F., Buncher C. The medical aspects of soccer injury epidemiology // AM. J.SPORTS MED. 1987.-N.15.- P. 5-12. 8. Kerkhoffs G., Rowe B., Assendelft W. Immobilization for acute ankle sprain.//A systematic review. Arch Orthop Trauma Surg. 2001.- N.8.- P.46. 9. Kon E., Filardo G., Di Martino M., Marcacci M. Platelet-rich plasma (PRP) to treat sports injuries: evidence to support its use Knee // Surg Sports Traumatol Arthrosc.2007/-N.10. - DOI 10.1007/s00167-010-1306-y 10. Langer H. (2010) Platelets in regeneration.// Semin Thromb Hemost.2010.-N. 36.-P.175–184. 11. Lopez-Vidriero E., Goulding K., Simon D., Sanchez M., Johnson D. The use of platelet-rich plasma in arthroscopy and sports medicine: optimizing the healing environment // Arthroscopy.2010.-N. 26.-P.269–278. 12. Molloy T., Wang Y., Murrell G. (2003) The roles of growth factors in tendon and ligament healing// Sports Med.2003.- N. 33.-P.381–394. 13. Nagumo A., Yasuda K., Numazaki H., Azuma H., Tanabe Y., Kikuchi S., Harata S., Tohyama H. ​​Effects of separate application of three growth factors (TGF-beta1, EGF, and PDGF -BB) on mechanical properties of the in situ frozenthawed anterior cruciate ligament // Clin Biomech.2005.-N. 20.-P.283–290 14. P. Renstrom. Persistently painful sprained ancle // J Am Acad Orthop Surg. 1994.-N.2.-P.270. 15. Sampson S., Gerhardt M., Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries // A review. Curr Rev Musculoskelet Med.2008.- N. 1-P.-165–174. 16. Stellos K., Kopf S., Paul A., Marquardt J., Gawaz M., Huard J., Foster T., Puskas B., Mandelbaum B., Gerhardt M., Rodeo S. Platelet-rich plasma: from basic science to clinical applications// Am J Sports Med.2009.- N.-37.-P.-59–72. 17. Wedmore J. Emergency department evalution end treatment of ankle and foot injuries // Emerg Med Clin North Am. 2000.-N.18(1).-P.127. 18. Wolfe M., Uhl T., Mattacol C. Management of ankle sprains // Am Fain Physician. 2001.-N.63(1).-P.93.

Symptoms

When ligaments and tendons rupture, the following symptoms occur:

• soreness;
• pronounced swelling of soft tissues;
• subcutaneous hematoma (with damage to blood vessels);
• a sharp deterioration or complete inability of one or another group of muscles and/or joints to perform normal work;
• forced position of the limb.

The clinic may depend on how often the same structures are injured. Symptoms of rupture of the collateral ligaments of the knee joint may be more pronounced if the injury is repeated.

Diagnostics

The diagnosis is made based on examination and stress tests. Sometimes additional examination methods (instrumental and laboratory) are used to identify damage to other structures. Before treating a torn meniscal ligament, you need to make sure that the meniscus itself is not damaged.

Stress tests represent a certain load on the ligaments and tendons - such tests help determine which specific elements are damaged. When performing the test, the patient must abduct the joint in a direction that is opposite to the natural direction.

Due to severe pain during the test, muscle spasm may occur, which will not allow the instability of the limb fragment to be detected. To avoid inaccurate results, you should wait until the muscles relax as much as possible and repeat the test. If muscle tension is severe, pain relief should be administered, and then the test should be repeated. It is necessary to test all ligaments and tendons if there is a suspicion that more than one group has been damaged. Diagnosis and treatment of knee ligament rupture may be combined with diagnosis and treatment of Achilles tendon rupture.

Simultaneously with testing the affected limb, the healthy limb is loaded, the results are compared:

• in case of 1st degree ruptures of joint function - in the same volume, but the functional load is painful;
• in case of II degree ruptures, the pain during the performance of functions is severe, the functions of the joint are limited;
• with third-degree ruptures, the pain is weaker. This is because the ligaments or tendons are completely torn and are not strained during testing.

Features of ruptures of different localization

How long can rehabilitation last after rupture of foot or hand ligaments, as well as tendons? It depends on their location. Based on the severity of symptoms, approximate predictions can be made.

The signs of rupture of different ligaments and tendons differ.

Damage to the acromioclavicular joint

Occurs when falling with support on the shoulder or abducted arm.

If the coracoclavicular ligament is severely torn, the clavicle may move forward from the acromion process.

Ankle ligament damage

This is a very common type of damage. It is mainly observed when the foot is turned inward. This may damage:

• deltoid ligament;
• anterior and posterior fragments of the talofibular ligament;
• calcaneofibular ligament.

In case of severe ruptures (grades II and III), chronic misalignment of the ankle joint may occur. With a third degree rupture, the joint looks like a large egg due to swelling. Swelling and pain are most pronounced on the anterolateral surface of the joint. How long it takes to recover from a torn ankle ligament may depend on which ligaments were injured.

Damage to the collateral ligament of the thumb

The so-called “hunger's finger” is observed - abduction of the finger. The stress test involves moving the finger toward the radius.

Heel tendon injury

The stress test is dorsiflexion of the foot. When the patient's calf is compressed, passive plantar flexion of the foot is weakened. Partial breaks may not be detected.

Types of injury diagnosis

Diagnosis begins with collecting an anamnesis of the disease; the doctor must find out how the injury was received, how much time has passed since it was received, and what treatment measures were taken by the patient.

The next step is an objective examination; the doctor palpates the area of ​​damage and the ankle joint itself. Checks for active and passive movements in the joint by flexing and extending the foot. The tibialis posterior tendon should also be examined.

During an objective examination, the doctor pays attention to the following symptoms:

• joint or muscle pain,
• the ability to move joints in the area of ​​injury,
• joint deformity,
• swelling,
• damage to the skin and nearby structures.

To confirm the diagnosis, radiation diagnostic methods are used:

Read also: Nordic walking for arthrosis of the knee joint

• radiography,
• Ultrasound examination,
• MRI and CT diagnostics.

These methods allow you to exclude conditions such as:

• fracture of the leg and foot bones,
• hemarthrosis of the joints of the leg and foot,
• damage to the articular surface of the ankle joint,
• ankle sprain.

Sometimes it is necessary to conduct an X-ray examination with intra-articular contrast.

A torn anterior talofibular ligament is easily diagnosed using an MRI. The accuracy of this examination allows us to determine the location of the rupture and the extent of damage. If there is blood in the joint, it is necessary to puncture the latter and examine the punctate.