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Bob's ACL WWWBoard
Re: MRI says ACL sheath inflamed -- Wonky knee needs thorough manual testing....
Posted By: Michael Frind
Date: Monday, 1 February 2010, at 11:45 p.m.
In Response To: MRI says, ACL sheath is inflamed and small tear (Rubyroo)
Dear Ruby,
A few questions and comments for you:
1. Is the doctor you consulted today a knee-experienced orthopedist, or just a family doctor (general practitioner) or emergency-room physician? In posting 364874, you noted that your knee is painful and unsteady. In posting 364862, you noted that you will be seeing an orthopedist this week, but it is unclear whether this is the doctor you saw today.
2. The fact that your ACL sheath is inflamed is cause for serious concern, because it immediately raises the question of why this sheath would have such an inflammation. The most logical explanation for this is that the entire ACL (or at least, a large part of it) is injured in some way. This is strongly corroborated by the knee being painful and unsteady.
3. Please note that, with an ACL tear, it is extremely common for the swelling and pain to decline quite soon after the initial injury event. It is most common in cases where the ACL has been fully torn, or so badly stretched out that it is biomechanically useless anyway. It is very plausible that your ACL falls into the latter category.
4. Please note that MRI scans are not always accurate in ascertaining the severity of an ACL tear. What appears as a "slight disruption" on an MRI scan could in fact be a microscale tearing (i.e. stretching-out) so severe that the ACL might as well be fully torn anyway. What is needed here is for the knee to be tested via the standard suite of manual-manipulation tests (Lachmann drawer test, anterior drawer test, dial test, pivot-shift test, Macintosh test, etc.). Ideally, these tests should be done under anesthesia, in order to guarantee that residual muscle tenseness is not masking any ligamentous deficiencies. (The fact that you were able to walk into a doctor's office and receive an MRI on the spot shows that expensive, high-tech imaging is readily available. This is good, but it is no substitute for rigorously done low-tech manual-manipulation testing.)
5. What is the injury history of your knee? Was there any memorable incident that triggered the recent spate of problems? Was there any event in which the knee was forced sideways, twisted, or forced backwards? If so, in what type of activity did it occur? Did you fall to the ground? The more details you can provide about the injury event (or events) and any subsequent history, the more insight can be provided.
6. In posting 364874, you noted that your doctor gave you "a shot". Was this a cortisone shot directly into the joint space? These injections can sometimes relieve pain, but they can cause serious long-term problems, particularly if repeated.
7. The instability in your knee is extremely unlikely to go away on its own, particularly given that it is almost certainly ACL-related. ACL tears are notorious for not healing in a meaningful way. Because your ACL is (according to the MRI) not completely severed, some rudimentary scarring-over might occur, but the result would be a stretched-out bundle of scar tissue that would not properly fulfill its biomechanical roles anyway. However, if you avoid abrupt twisting-type movements, you might be able to prevent most of the giving-way incidents. But given how the human knee is so essential to a wide variety of everyday activities, the inherent instability of your knee will make itself apparent, at least occasionally. Please remember that each and every giving-way incident brings cumulative and permanent damage to the knee's remaining intact structures (e.g. the menisci). The more such damage you accumulate, the sooner your knee will become painfully arthritic.
8. If your orthopedist suggests you just leave the knee alone and see how it responds, I recommend consulting two additional knee-experienced orthopedists. As I noted above, experimenting with an intrinsically unstable knee is risky.
9. At the very least, some sort of physiotherapy program should be prescribed for your knee, in order to build up the knee-surrounding musculature. Such strength might help avoid certain giving-way episodes, but it would also be valuable in terms of facilitating rehabilitation from any type of surgery (given that any knee surgery results in a certain degree of muscular atrophy).
Yours truly,
Michael Frind.
Knee Library http://factotem.org/library
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