of medial knee injuries varies depending on location and classification of the injuries. the consensus of many studies is that isolated grade i, ii, and iii injuries are usually well suited to non-operative treatment protocols. acute grade iii injuries with concomitant multiligament injuries or knee dislocation involving medial side injury should undergo surgical treatment. chronic grade iii injuries should also undergo surgical treatment if the patient is experiencing rotational instability or side-to-side instability. nonoperative treatment conservative treatment of isolated medial knee injuries (grades i-iii) begins with controlling swelling and protecting the knee. swelling is managed well with rest, ice, elevation, and compression wraps. protection can be performed using a hinged brace that stabilizes against varus and valgus stress but allows full flexion and extension. the brace should be worn for the first four to six weeks of rehabilitation, especially during physical exercise to prevent trauma to the healing ligament. stationary bike exercises are the recommended exercise for active range of motion and should be increased as tolerated by the patient. side-to-side movements of the knee should be avoided. the patient is allowed to bear weight as tolerated and should perform quadriceps strengthening exercises along with range of motion exercises. the typical return-to-play time frame for most athletes with a grade iii medial knee injury undergoing a rehabilitation program is 5 to 7 weeks. operative treatment it has been reported that severe acute and chronic grade iii medial knee injuries often involve the smcl in combination with the pol. direct surgical repair or reconstruction, therefore, should be performed for both of these ligaments because they both play an important role in static medial knee stability. the biomechanically validated approach is to reconstruct both the pol and both divisions of the smcl. severe acute tears surgery involving direct repair (with or without augmentation from a hamstring autograft), among other previously used techniques, have not been biomechanically tested. an anatomical reconstruction of the smcl and pol has been biomechanically validated. chronic instability underlying causes of chronic medial knee instability must be identified before surgical reconstruction is performed. more specifically, patients with genu valgum (knock-kneed) alignment must be evaluated and treated with an osteotomy(s) to establish balanced forces on knee ligaments, preventing premature failure of concurrent cruciate ligament reconstruction. these patients should be rehabilitated after the osteotomy heals before it can be verified that they do not still have functional limitations. once proper alignment is achieved, reconstruction can be performed. anatomic medial knee reconstruction this technique, described in detail by laprade et al., uses two grafts in four separate tunnels. an incision is made over the medial knee 4 cm medial to the patella, and extended distally 7 to 8 cm past the joint line, directly over the pes anserinus tendons. within the distal borders of the incision, the semitendinosus and gracilis tendons are found beneath the sartorius muscle fascia. the distal tibial attachment of the smcl can be found under these identified tendons, making up the floor of the pes anserine bursa, 6 cm distal to the joint line. once identified, the remaining soft tissue is removed from the attachment site. an eyelet pin is then drilled through attachment site transversely through the tibia, making sure the starting point is located at the posterior aspect of the site to ensure better biomechanical outcomes. over the eyelet pin, a 7-mm reamer (6 mm considered in smaller patients) is reamed to a depth of 25 mm. once prepared, attention is directed to preparing the reconstruction tunnel for the tibial attachment of the pol. above the anterior arm attachment of the semimembranosus muscle tendon, the tibial attachment of the central arm of the pol is identified. this attachment is exposed by making a small incision parallel to the fibers along the posterior edge of the anterior arm of the semimembranosus tendon. once exposed, an eyelet pin is drilled through the tibia toward gerdy's tubercle (anterolateral tibia). after verifying the correct anatomic eyelet pin placement, a 7-mm reamer is used over the pin to drill a tunnel depth of 25 mm. moving to the femoral attachments of the ligaments, the first step is identifying the adductor magnus muscle tendon, and its corresponding attachment site, near the adductor tubercle. just distal and slightly anterior to this tubercle is the bony prominence of the medial epicondyle. the attachment site of the smcl can be identified slightly proximal and posterior to the epicondyle. an eyelet pin can now be passed transversely through the femur at this site. the tunnel at this location, however, should be drilled after identifying the pol attachment site. the next step of identifying the pol femoral attachment is done by locating the gastrocnemius tubercle (2.6 mm distal and 3.1 mm anterior to the medial gastrocnemius tendon attachment on the femur). if the posteromedial capsule is not intact, the pol attachment site is located 7.7 mm distal and 2.9 mm anterior to the gastrocnemius tubercle. with the capsule intact, however, an incision is made along the posterior aspect of the smcl, parallel to its fibers. the central arm of the pol can then be found at its femoral attachment site. once identified, an eyelet pin is passed transversely through the femur. the distances between the femoral attachment site of the pol and the smcl (on average, 11mm) should now be measured to verify that the anatomic attachment sites have been correctly identified. once this is done, the femoral tunnels for the smcl and pol can be reamed to a depth of 25 mm using a 7-mm reamer. the next aspect of the surgery is preparation and placement of the reconstruction grafts. the preparation can be done while the other steps are being completed by another surgeon or physician's assistant. the semitendinosus tendon can be harvested using a hamstring stripper for use as the reconstruction autograft. the autograft is sectioned into a 16-cm length for the smcl reconstruction and 12-cm length for the pol reconstruction. these lengths are also used if the surgery is done with cadaver allograft. the smcl and pol grafts are pulled into their respective femoral tunnels and each secured with a cannulated bioabsorbable screw. the grafts are passed distally along their native courses to the tibial attachments. the smcl is passed under sartorius fascia (and any remaining smcl fibers). both grafts are passed (but not yet secured) into their respective tibial tunnels using the existing eyelet pins. if simultaneous cruciate ligament surgery is underway, the cruciate reconstructions are secured before securing the medial ligaments. securing the pol graft is done in full knee extension. the graft is pulled tight and fixed using a bioabsorbable screw. the knee is then flexed to 20°. making sure the tibia remains in neutral rotation, a varus force is used to ensure there is no medial compartment gapping of the knee. the smcl graft is then tightened and fixed with a bioabsorbable screw. the final step of reconstruction ligament fixation is the proximal tibial attachment of the smcl. this soft-tissue attachment can be reproduced with a suture anchor placed 12.2 mm distal to the medial joint line (average location), directly medial to the anterior arm of the semimembranosus tibial attachment. once this aspect of the smcl is secured to the suture anchor, the knee is put through range of motion testing by the physician to determine the "safe zone" of knee motion which is used during the first post-operative day rehabilitation (below). rehabilitation nonoperative rehabilitation as mentioned in the nonoperative treatment section, the principles of rehabilitation are to control swelling, protect the knee (bracing), reactivate the quadriceps muscle, and restore range of motion. early weight bearing is encouraged as tolerated, using crutches as little as possible, with a goal of walking without a limp. stationary biking is the preferred range of motion exercise, stimulating the ligament to heal faster. time on the bike and resistance should be increased as tolerated by the patient. side-to-side movement should be restricted until after 3 to 4 weeks to allow the adequate healing. proprioceptive and balance activities can progress after clinical exam or valgus stress radiographs reveal healing. athletes can often resume full activities within 5 to 7 weeks after an isolated smcl injury. postoperative rehabilitation postoperative rehabilitation protocols for reconstructed or repaired medial knee injuries focus on protecting the ligaments/grafts, managing swelling, reactivating the quadriceps, and establishing range of motion. a safe range of motion ("safe zone") should be measured by the surgeon intraoperatively and relayed to the rehabilitation specialist to prevent overstressing the ligaments during rehabilitation. the ideal passive range of motion is 0 to 90° of flexion on postoperative day one after surgery and should be followed for 2 weeks, as tolerated, with a goal of 130° of flexion at the end of the 6th week. to protect the newly reconstructed ligaments, a hinged knee brace should be used. swelling should be managed with cryotherapy and compression. patellofemoral mobilization, quadriceps reactivation, and frequent ankle pumps are also utilized right after surgery to prevent arthrofibrosis. non-weight bearing to touch-down weight bearing is recommended for the first 6 weeks, progressing to closed-kinetic-chain exercises thereafter. light-resistance stationary biking is also started at 2 weeks and can be increased as tolerated. gait mechanics are addressed when the patient is able to bear their full weight. the patient should be able to walk without limping or developing swelling in the joint. rehabilitation can only move as fast as tolerated and effusion must be monitored and managed at all times to ensure good results. once motion, strength, and balance are regained, plyometric and agility exercises are started at 16 weeks. brisk walking for 1 to 2 miles should be well tolerated before the patient starts a jogging program. return to sports may be assessed at this point, providing no functional or stability deficits are present. rehabilitation should be supervised by a professional specialist working along with the surgeon. protocols may be adjusted in the presence of concomitant ligament reconstructions or osteotomies. valgus stress ap radiographs (mentioned above) are an excellent and cost-effective way to monitor postoperative results and follow-up. history during the troubles in northern ireland, paramilitaries considered themselves to be law enforcers in their own areas. they used limb punishment shootings, commonly referred to as kneecapping, to punish petty criminals and other individuals whose behavior they deemed to be unacceptable. if the crime was considered to be grave, the victim was also shot in the ankles and elbows, leaving them with six gunshot wounds (colloquially known as a six pack). approximately 2,500 people were victims of these punishment shootings through the duration of the conflict. those who were attacked carried a social stigma with them. the red brigades, an italian militant organization, employed these punishment shootings to warn their opponents. they used the method to punish at least 75 people up to december 1978. more recently this kind of punishment shooting has been employed by hamas in the gaza strip to silence their political opponents. the bangladesh police have started kneecapping in the country since 2009 to punish the opposition and preventing them from participating in protests against the government. human rights watch (hrw) has published a report on kneecapping in bangladesh. future research future research with regard to medial knee injuries should evaluate clinical outcomes between different reconstruction techniques. determining the advantages and disadvantages of these techniques would also be beneficial for optimizing treatment.