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Women in sports such as association football, basketball, and tennis are significantly more prone to ACL injuries than men. The discrepancy has been attributed to gender differences in anatomy, general muscular strength, reaction time of muscle contraction and coordination, and training techniques.
Gender differences in ACL injury rates become evident when specific sports are compared. A review of NCAA data has found relative rates of injury per 1000 athlete exposures as follows:
- Men's basketball 0.07, women's basketball 0.23
- Men's lacrosse 0.12, women's lacrosse 0.17
- Men's football 0.09, women's football 0.28
The highest rate of ACL injury in women occurred in gymnastics, with a rate of injury per 1000 athlete exposures of 0.33
Of the four sports with the highest ACL injury rates, three were women's – gymnastics, basketball and soccer.
According to recent studies, female athletes are two to eight times more likely to strain their anterior cruciate ligament (ACL) in sports that involve cutting and jumping as compared to men who play the same particular sports (soccer, basketball, and volleyball). Differences between males and females identified as potential causes are the active muscular protection of the knee joint, the greater Q angle putting more medial torque on the knee joint, relative ligament laxity caused by differences in hormonal activity from estrogen and relaxin, intercondylar notch dimensions, and muscular strength.
High school athletes are at increased risk for ACL tears when compared to non-athletes. This risk increases with certain types of sports. Among high school girls, the sport with the highest risk of ACL tear is soccer, followed by basketball and lacrosse. The highest risk sport for boys was basketball, followed by lacrosse and soccer. Children and young athletes may benefit from early surgical reconstruction after ACL injury. Young athletes who have early surgical reconstruction of their torn ACL are more likely to return to their previous level of athletic ability when compared to those who underwent delayed surgery or nonoperative treatment. They are also less likely to experience instability in their knee if they undergo early surgery.
Specific populations at high risk of primary PFPS include runners, bicyclists, basketball players, young athletes and females.
In 2010 national statistics was done by Agency for Healthcare Research and Quality for posterior cruciate ligaments injuries. They found that 463 patients were discharge for having some type of PCL injury. The 18- to 44-year-old age group was found to have the highest injuries reported (figure 1). One reason why this age group consists of the majority of injuries to the PCL is because people are still very active in sports at this age. Men were also reported having more injuries to the PCL (figure 3).
Rate in the United States have been estimated to occur among an at-risk population of 1,774,210,081 people each year. Incidence rates published in the American Journal of Sports Medicine for ages 10–17 were found to be about 29 per 100,000 persons per year, while the adult population average for this type of injury ranged between 5.8 and 7.0 per 100,000 persons per year. The highest rates of patellar dislocation were found in the youngest age groups, while the rates declined with increasing ages. Females are more susceptible to patellar dislocation. Race is a significant factor for this injury, where Hispanics, African-Americans and Caucasians had slightly higher rates of patellar dislocation due to the types of athletic activity involved in: basketball (18.2%), soccer (6.9%), and football (6.9%), according to Brian Waterman.
Lateral Patellar dislocation is common among the child population. Some studies suggest that the annual patellar dislocation rate in children is 43/100,000. The treatment of the skeletally immature is controversial due to the fact that they are so young and are still growing. Surgery is recommended by some experts in order to repair the medial structures early, while others recommend treating it non operatively with physical therapy. If re-dislocation occurs then reconstruction of the medial patellofemoral ligament (MPFL) is the recommended surgical option.
Isolated and combined posterolateral knee injuries are difficult to accurately diagnose in patients presenting with acute knee injuries. The incidence of isolated posterolateral corner injuries has been reported to be between 13% and 28%. Most PLC injuries accompany an ACL or PCL tear, and can contribute to ACL or PCL reconstruction graft failure if not recognized and treated. A study by LaPrade "et al." in 2007 showed the incidence of posterolateral knee injuries in patients presenting with acute knee injuries and hemarthrosis (blood in the knee joint) was 9.1%.
The meniscal tear is the most common knee injury. A meniscal tear tends to be more frequent in sports that have rough contact or pivoting sports such as soccer. The meniscal tear is more common in males than females. The ratio is about two and a half males to one female. Males between the ages of thirty-one and forty tend to tear their meniscus more frequently than younger men. Females on the other hand, seem to be more likely to tear their meniscus between the ages of eleven and twenty. People who work in straining jobs such as construction or pro athletes are also more likely to have a meniscal tear because of all the different tensions of their knees. According to the United States National Library of Medicine, the isolated medial meniscal tear occurs more frequently than any other tear associated with the meniscus. The prevalence of meniscus tears is the same for both knees. In a few different studies the BMI of a person can have a greater effect on the frequency of a meniscus tear because having a higher BMI will result in more weight on the joints which can cause the knee to be non-aligned which causes more weight on the muscles resulting in an easier tear. In 2008 the U.S Department of Health and Human Services reported a combined total of 2,295 discharges for the principal diagnosis of tear of lateral cartilage/meniscus (836.0), tear of medial cartilage/meniscus (836.1), and tear of cartilage/meniscus (836.2). Females had a total of 53.49% discharges while males had 45.72%. Individuals between the ages of 45–68 years had an average of 31.73% discharges followed by age group 65–84 with 28.82%. The average length of stay for a patient diagnosed with torn menisci was 2.7 days for males and 3.7 days for females. There was a report of 6,941 hospital discharges for knee repair. Individuals between 18–44 years of age were among the highest with 37.37% total of discharges followed by the age group 45–64 with a percentage of 36.34%. Males had a slightly higher number of discharges (50.78%) than females (48.66%). The average length of stay for both male and female patients in a hospital setting was 3.1.
The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity. Following an adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity. This can cause multiple subacute avulsion fractures along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful, especially when hit. Activities such as kneeling may also irritate the tendon.
The syndrome may develop without trauma or other apparent cause; however, some studies report up to 50% of patients relate a history of precipitating trauma. Several authors have tried to identify the actual underlying etiology and risk factors that predispose Osgood–Schlatter disease and postulated various theories. However, currently it is widely accepted that Osgood–Schlatter disease is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon caused by repetitive micro-trauma. In other
words, Osgood–Schlatter disease is an overuse injury and closely related to the physical activity of the child. It was shown that children
who actively participate in sports are affected more frequently as compared with non-participants. In a retrospective study of adolescents, old athletes actively participating in sports showed a frequency of 21% reporting the syndrome compared with only 4.5% of age-matched nonathletic controls.
The symptoms usually resolve with treatment but may recur for 12–24 months before complete resolution at skeletal maturity, when the tibial epiphysis fuses. In some cases the symptoms do not resolve until the patient is fully grown. In approximately 10% of patients the symptoms continue unabated into adulthood, despite all conservative measures.
OSD occurs from the combined effects of tibial tuberosity immaturity and quadriceps tightness. There is a possibility of migration of the ossicle or fragmentation in Osgood-Schlatter patients. The implications of OSD and the ossification of the tubercle can lead to functional limitations and pain for patients into adulthood.
Of people admitted with OSD, about half were children who were between the ages of 1 and 17. In addition, in 2014, a case study of 261 patients was observed over 12 to 24 months. 237 of these people responded well to sport restriction and non-steroid anti-inflammatory agents, which resulted in recovery to normal athletic activity.
According to the posterior cruciate ligament injuries only account for 1.5 percent of all knee injuries (figure 2). If it is a single injury to the posterior cruciate ligament that requires surgery only accounted for 1.1 percent compared to all other cruciate surgeries but when there was multiple injuries to the knee the posterior cruciate ligament accounted for 1.2 percent of injuries.
It is possible to prevent the onset of prepatellar bursitis, or prevent the symptoms from worsening, by avoiding trauma to the knee or frequent kneeling. Protective knee pads can also help prevent prepatellar bursitis for those whose professions require frequent kneeling and for athletes who play contact sports, such as American football, basketball, and wrestling.
About 25% of people over the age of 50 experience knee pain from degenerative knee diseases.
A study containing 100 consecutive patients with a recent anterior cruciate ligament injury were examined with respect to type of sports activity that caused the injury. Of the 100 consecutive ACL injuries, there were also 53 medial collateral ligament injuries, 12 medial, 35 lateral and 11 bicompartmental meniscal lesions. 59/100 patients were injured during contact sports, 30/100 in downhill skiing and 11/100 in other recreational activities, traffic accidents or at work.
An associated medial collateral ligament tear was more common in skiing (22/30) than during contact sports (23/59), whereas a bicompartmental meniscal lesion was found more frequently in contact sports (9/59) than in skiing (0/30). Weightbearing was reported by 56/59 of the patients with contact sports injuries whereas 8/30 of those with skiing injuries. Non-weightbearing in the injury situation led to the same rate of MCL tears (18/28) as weightbearing (35/72) but significantly more intact menisci (19/28 vs 23/72). Thus, contact sports injuries were more often sustained during weightbearing, with a resultant joint compression of both femuro-tibial compartments as shown by the higher incidence of bicompartmental meniscal lesions. The classic "unhappy triad" was a rare finding (8/100) and Fridén T, Erlandsson T, Zätterström R, Lindstrand A, and Moritz U. suggest that this entity should be replaced by the "unhappy compression injury".
Tear of a meniscus is a common injury in many sports. The menisci hold 30–50% of the body load in standing position. Some sports where a meniscus tear is common are American football, association football, ice hockey and tennis. Regardless of what the activity is, it is important to take the correct precautions to prevent a meniscus tear from happening.
In the United States, more than US $3 billion is spent each year on arthroscopic knee surgeries that are known to be ineffective in people with degenerative knee pain.
The various nicknames associated with prepatellar bursitis arise from the fact that it commonly occurs among those individuals whose professions require frequent kneeling, such as carpenters, carpet layers, gardeners, housemaids, mechanics, miners, plumbers, and roofers. The exact incidence of the condition is not known; it is difficult to estimate because only severe septic cases require hospital admission, and mild non-septic cases generally go unreported. Prepatellar bursitis is more common among males than females. It affects all age groups, but is more likely to be septic when it occurs in children.
Future research into posterolateral injuries will focus on both the treatment and diagnosis of these types of injuries to improve PLC injury outcomes. Studies are needed to correlate injury patterns and mechanisms with clinical measures of knee instability and laxity.
In most patients with PFPS an examination of their history will highlight a precipitating event that caused the injury. Changes in activity patterns such as excessive increases in running mileage, repetitions such as running up steps and the addition of strength exercises that affect the patellofemoral joint are commonly associated with symptom onset. Excessively worn or poorly fitted footwear may be a contributing factor. To prevent recurrence the causal behaviour should be identified and managed correctly.
The medical cause of PFPS is thought to be increased pressure on the patellofemoral joint. There are several theorized mechanisms relating to how this increased pressure occurs:
- Increased levels of physical activity
- Malalignment of the patella as it moves through the femoral groove
- Quadriceps muscle imbalance
- Tight anatomical structures, e.g. retinaculum or iliotibial band.
The cause of pain and dysfunction often results from either abnormal forces (e.g. increased pull of the lateral quadriceps retinaculum with acute or chronic lateral PF subluxation/dislocation) or prolonged repetitive compressive or shearing forces (running or jumping) on the PF joint. The result is synovial irritation and inflammation and subchondral bony changes in the distal femur or patella known as "bone bruises". Secondary causes of PF Syndrome are fractures, internal knee derangement, osteoarthritis of the knee and bony tumors in or around the knee.
It is an overuse injury from repetitive overloading of the extensor mechanism of the knee. The microtears exceed the body's healing mechanism unless the activity is stopped.
Among the risk factors for patellar tendonitis are low ankle dorsiflexion, weak gluteal muscles, and muscle tightness, particularly in the calves, quadriceps muscle, and hamstrings.
The injury occurs to athletes in many sports.
Damage can occur to the ligaments surrounding and bridging the pubic joint (symphysis) as a result of the hormone relaxin, which is secreted around the time of birth to soften the pelvic ligaments for labor. At this time repetitive stress or falling, tripping, and slipping can injure ligaments more easily. The hormone usually disappears after childbirth and the ligaments become strong again. In some women the weakness persists, and activities such as carrying their baby or stepping up even a small step can cause a slight but continuous separation or shearing in the ligaments of the symphysis where they attach to the joint surfaces, even causing lesions in the fibrocartilage and pubic bones. Symptoms include one or more of the following: pain in the pubic area, hips, lower back, and thighs. This can take months (or even years) to go away.
X-rays taken during the early stages of osteitis pubis can be misleading - pain may be felt, but the damage doesn't appear on the films unless stork views (i.e. standing on one leg) are obtained. As the process continues and progresses, later pictures will show evidence of bony erosion in the pubic bones. Osteitis pubis can also be associated with pelvic girdle pain.
An effective rehabilitation program reduces the chances of reinjury and of other knee-related problems such as patellofemoral pain syndrome and osteoarthritis. Rehabilitation focuses on maintaining strength and range of motion to reduce pain and maintain the health of the muscles and tissues around the knee joint.
An unhappy triad (or terrible triad, "horrible triangle", O'Donoghue's triad or a "blown knee") is an injury to the anterior cruciate ligament, medial collateral ligament, and medial meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, acute tears of the medial meniscus always present with a concomitant lateral meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.
The incidence of osteitis pubis among Australian footballers has increased sharply over the past decade. There are believed to be three reasons for this:
- The increasing physical demands of Australian rules football. As the game has become more professionalised, with players becoming full-time athletes, such factors as running speed, kicking length, jumping, and tackling have all increased, placing increasing stress on the pubic region.
- The increasing hardness of the surfaces of football grounds. Grounds are better drained than in the past, and the game is increasingly played in roofed stadiums, in which the grounds receive no rain. Australian football evolved as a winter game played on soft, muddy grounds, and modern surfaces have made muscle and bone injuries more common.
- The increasing demand for size and strength among footballers. This has led young players to concentrate on building muscle mass before their bodies are fully mature. The additional strain that highly developed abdominal muscles place on the pubic bone explains the higher prevalence of osteitis pubis in young players. Some develop the condition while still playing school-level football.
Medial knee injuries are those to the medial side – the inside of the knee – are the most common. The medial ligament complex of the knee is composed of the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), and the posterior oblique ligament (POL). These ligaments have also been called the medial collateral ligament (MCL), tibial collateral ligament, mid-third capsular ligament, and oblique fibers of the sMCL, respectively. This complex is the major stabilizer of the medial knee. Injuries to the medial side of the knee are most commonly isolated to these ligaments. A thorough understanding of the anatomy and function of the medial knee structures, along with a detailed history and physical exam, are imperative to diagnosing and treating these injuries.
ITBS can result from one or more of the following: training habits, anatomical abnormalities, or muscular imbalances:
Training habits
- Spending long periods of time/regularly sitting in lotus posture in yoga. Esp beginners forcing the feet onto the top of the thighs
- Consistently running on a horizontally banked surface (such as the shoulder of a road or an indoor track) on which the downhill leg is bent slightly inward, causing extreme stretching of the band against the femur
- Inadequate warm-up or cool-down
- Excessive up-hill and down-hill running
- Positioning the feet "toed-in" to an excessive angle when cycling
- Running up and down stairs
- Hiking long distances
- Rowing
- Breaststroke
- Treading water
Abnormalities in leg/feet anatomy
- High or low arches
- Supination of the foot
- Excessive lower-leg rotation due to over-pronation
- Excessive foot-strike force
- Uneven leg lengths
- Bowlegs or tightness about the iliotibial band.
Muscle imbalance
- Weak hip abductor muscles
- Weak/non-firing multifidus muscle
- Uneven left-right stretching of the band, which could be caused by habits such as sitting cross-legged