By Donald J. Zoltan M.D.

Biographical Sketch

Dr. Zoltan is an orthopedic surgeon, who enjoys golf, biking and watching his children’s baseball games. He is a graduate of Haverford College, the University of Ilinois Medical School, and completed his orthopedic residency at the University of Wisconsin. In addition, he attended the University of Florida for a Sports Medicine Fellowship. His practice emphasizes arthroscopy, sports medicine and joint replacements.


Outdoor recreational activities are extremely popular worldwide, with millions of people participating in a wide variety of activities. Most people do not think of these activities as being high risk with regard to serious injuries; however, a significant amount of injuries do occur.

The knee is one of the most commonly injured joints in recreational activities. Twisting injuries of the knee can occur in both contact and non-contact settings.

The non-contact injuries are:

  • Torn meniscus
  • Anterior cruciate ligament tear
  • Quadriceps Muscle tear
  • Hamstring muscle tear
  • Patella dislocation

The contact injuries are:

  • Medial collateral ligament tear
  • Posterior cruciate ligament tear
  • Quadriceps contusion

Non-contact injuries

Torn meniscus

Knee injuries often involve meniscus tears (torn cartilage). The meniscus is a firm, rubbery, “C-shaped” tissue that helps cushion and stabilize the knee joint surface. Tears usually result from a twisting type of stress to the joint. The symptoms include painful locking and catching of the knee and a small to moderate amount of swelling. Swelling, if present, usually occurs the day after the injury.

Treatment for torn cartilage nearly always involves arthroscopic surgery. The arthroscope – a fiberoptic telescope approximately the size of a thin pencil, is used to repair or remove part of the torn meniscus. Whether the meniscus is repaired or removed depends on the extent or location of the tear.

Anterior Cruciate Ligament Tear

Knee injuries that involve ligaments are usually the most serious. Ligaments are bands or sheets of fibrous tissue that connect bones to one another. One of the most serious knee ligament injuries involves the anterior cruciate ligament. This ligament connects the tibia to the femur within the knee joint, and prevents excessive forward movement of the leg in relation to the thigh.

It is commonly thought that anterior cruciate ligament tears can only occur from a direct contact blow to the knee; however, this is usually not the case. Tearing of the ligament is usually caused by a non-contact twisting injury. The twisting force that causes this ligament tear is usually much greater than the force that causes a meniscus tear. People will usually hear or feel a “pop” at the time of injury, and will notice a large amount of swelling an hour or two after the injury occurs.

Two treatment options are commonly recommended for anterior cruciate ligament tears. One option involves a nonoperative approach. This requires an extensive physical therapy rehabilitation program to strengthen the quadriceps and hamstring muscles, and also involves obtaining a special stabilizing knee brace.

The other option of treatment involves ligament reconstruction surgery. This procedure is followed by an extensive physical therapy rehabilitation program. The type of treatment selected is determined by each person’s desires and future recreational goals.

Quadriceps Muscle Tear

The quadriceps muscles are located in the front of the thigh and are responsible for straightening the knee. Tears, or muscles strains, usually occur from a sudden stretch of a contracted muscle. The result is pain, swelling and weakness of the muscle.

Treatment of quadriceps muscle tears is non-surgical. Initial treatment involves rest, ice and elastic wrap compression.

After the acute inflammation subsides, stretching and strengthening is initiated. Upon returning to vigorous outdoor activities, a neoprene compression thigh sleeve is often beneficial.

Hamstring Muscle Tear

The hamstring muscles are located in the back of the thigh, and are responsible for bending the knee. The cause, symptoms and treatment are the same as that described for quadriceps muscle tears.

Patella Dislocation

The patella, or kneecap can pop out of joint with a significant twisting injury to the knee. When the patella dislocates towards the outside of the knee, most of the muscle and ligament attachments on the inside of the kneecap are torn. A large amount of knee swelling occurs almost immediately. A person may feel two “clunks” when this injury occurs, the first when the patella pops out of joint, and the second when it spontaneously slips back into place very soon after the dislocation.

The initial treatment of kneecap dislocation is non-surgical. After the acute swelling subsides, a vigorous physical therapy rehabilitation program is initiated to strengthen the quadriceps muscles. Use of a patellar stabilizing brace upon return to recreational activities is also recommended.

Unfortunately, this nonoperative approach is sometimes unsuccessful. If recurrent dislocation should occur, surgical reconstruction to realign the patella is usually required.

Contact Injuries

Medial Collateral Ligament Tear

The medial collateral ligament, which extends from the thigh bone (femur) to the lower leg bone (tibia) on the inner side of the knee can be injured by a direct blow to the outside of the knee. Pain and localized swelling are present on the inside of the knee.

Medial collateral ligament tears heal well without surgery. After a brief period of immobilization in a brace, a rehabilitation program is initiated emphasizing thigh muscle strengthening.

Posterior Cruciate Ligament Tear

The posterior cruciate ligament connects the femur to the tibia within the knee joint and prevents excessive backward movement of the leg in relation to the thigh. Unlike anterior cruciate ligament tears, posterior cruciate ligament tears are contact injuries. They occur from a direct impact to the front of the upper leg pushing the tibia in a backwards direction. In outdoor recreational activities, this occurs most commonly from a fall, when the ground makes contact with the front of the upper leg below the knee joint.

Initial treatment of posterior cruciate ligament tears is generally non-surgical. Early immobilization followed by a vigorous physical therapy rehabilitation program stressing quadriceps strengthening is instituted. When full strength and flexibility are regained, return to full recreational activities is allowed, often with a special stabilizing brace. If persistent looseness and instability of the knee is present, surgical reconstruction of the posterior cruciate ligament can be considered.

Quadriceps Contusion

A direct impact injury to the front of the thigh can cause a quadriceps contusion, or deep thigh bruise, and results in pain, swelling, stiffness and weakness of the muscle. This injury is often more serious than most people expect. While full recovery is anticipated, recovery time is often prolonged. Early muscle stretching is potentially harmful and should be delayed until later in the healing process.


While not common in most outdoor recreational activities, serious twisting injuries of the knee can occur. These injuries can be classified as contact or non-contact. Treatment depends on the diagnosis, severity and future recreational goals.

While some injuries are unavoidable, a certain percentage of injuries can be prevented. Proper conditioning along with muscle stretching and strengthening programs are important preventative measures. In addition, proper equipment that is well adjusted to the individual is crucial. If an injury does occur, recognizing and treating it early in its course can help people return to their recreational activities as safely and quickly as possible.