Triad: the Runners’ Unhappy Injury Trio



Triad is also known as the terrible triad or horrible triad. It is a type of injury to the knee which is characterized by partial tearing of the anterior cruciate ligament (ACL) and the medical meniscus ligament (MCL).  The meniscus provides a cushioning surface to help reduce friction.

The knee is made up of four types of ligaments;

  • Anterior cruciate ligament.(ACL)
  • Posterior cruciate ligament.
  • Lateral collateral ligament. (LCL)(Fibular collateral ligament).
  • Medical collateral ligament.(MCL)

The post lateral portion is important for maintaining the stability of the knee. The cruciate ligament usually crosses with the knee joint to increase stability and flexible movement of the knee. The injury as a result of hypertensive force or blow to the knee. People suffering from injury of the ACL at a higher chance of acquiring the unhappy triad injury. It is important for an athlete to quit their daily routine in order to treat the unhappy triad injury. The injury occurs when the anterior cruciate ligament prevents the femur from sliding forward over the tibia. An athlete should be prepared to miss out on competitions and daily routine exercise as the rehab takes a lot of time to recover of between 9-12 months to make a full recovery.  The injury occurs when an athlete decelerates immediately or twisting the knee at an uncomfortable angle. A blow to the knee is also a common can cause the injury.  There are certain things that you need to do immediately after sustaining the unhappy triad injury. They include;

  1. Do not use the injured knee to walk. If possible sit down and improvise walking braces by using strong sticks or a metal to aid in walking.
  2. Place ice on your knee to reduce the pain, inflammation.
  3. Visit a doctor as soon as possible to advice on the best next course of action.

Symptoms of the Unhappy Triad


  1. Excessive force applied to the knee.
  2. Injuries acquired when participating in sports or during training.
  3. Tearing of the meniscal ligaments.
  4. Applying too much force when twisting your knee.
  5. Applying too much pressure when the knee is firmly placed on the ground.
  6. Stress
  7. Depression and post-traumatic stress can cause someone’s body to ache.
  8. Lack of enough sleep, sleeping too much and smoking.
  9. Lack of enough vitamins. Vitamin B is important for the growth of healthy bones, when someone is deficient of this vitamin, he/ she may end up experiencing pain.
  10. Diseases of the connective tissue.

Risk Factors

  1. Certain type of professions such as athletes are at a higher risk of the injury due to the type of training, exercises and risks they are faced with as they take part in the sports they play.

2.People who have had injuries in the past or traumas are also at a higher risk of the unhappy triad.

3.People who do not exercise or train their muscles.

4.People who are born with bone deformities.

5.Military men and women who are exposed to explosive devices.


  • MRI to investigate the structure of the knee to see which area is injured.
  • X rays are also a good way to examine the knee to see the fractures or any broken or worn out ligaments.

  • Knee ligament tests to check for the presence of worn out ligaments.
  • Hamstring and quadriceps testing.
  • Physical examination of the knee, knee movement.
  • Comprehensive ligament testing to diagnose even the smallest of injuries to the ligaments.
  • Functional testing where you concentrate on a particular part of the knee and checking it thoroughly before moving to the next
  • Checking your medical history- this is used to identify whether you have suffered from this type of pain before. If that is case, the doctor can order for more tests to be done.
  • CT scan- used to give more details about body parts as well as other hidden body parts that could otherwise have been visible using an X-ray.
  • Checking your medical history- this is used to identify whether you have suffered from this type of pain before. If that is case, the doctor can order for more tests to be done. Also used to check whether there is a history of occurrence of this type of disease in your family.
  • Use of Arthrogram technology- used when doing an x-ray where a dye is injected into the knee bone which makes it easy to see the so see the parts surrounding the joints.


They may be injuries sustained over time due to wearing out muscles or those acquired instantly during exercise or training or when participating in a sport.

  1. ACL sprain-they are relatively common in sport stars especially the sports that require sudden change in direction such as football or rugby. They lead to damage of the collateral ligament or knee cartilage.
  2. Medical ligament sprain- This injury occurs inside of the knee and can be as a result of injury when carrying out normal day to day activities. Occur when one falls or when you twist your knee.
  3. Lateral knee ligament sprain-this is a result of tear of ligaments of the knees on the outside of the knee due to excessive pressure in the knee.
  4. Dislocation of the patella- happens when the patella slides out of its normal location leading to pain when someone tries to walk.
  5. Contusion of the knee– also called the bruising of the knee. It occurs when you fall or hit your knee against something hard. It results in swelling and sharp pain.
  6. Posterior cruciate ligament injury- occurs when the cruciate ligament which prevents the knee from bending in wrong degrees is injured. It results in the knee bending or assuming a bad posture which results in pain and the inability to walk.
  7. Lateral meniscus tear- the meniscus is important in absorbing shock and friction as the knee moves in a certain direction. When the meniscus tears away, it leads to excessive friction resulting to pain and reduced movement of the knee. It tears due to injury or normal wear and tear.
  8. Proximal Tibiofibular Joint Dislocation- it occurs when an athlete twists or falls with the knee in an uncomfortable degree.
  9. Synovial Plica Irritation- this is the part of the knee that makes the knee flexible enough to fold. When this injury occurs, it becomes painful or you are not able to fold your knee at all.

  1. Tibial Plateau Fracture- this type of injury is common in athletes who are involved in fast paced sports such as horse riding.
  2. Knee Sprain- this is one of the most common knee injuries. Almost all individuals have experienced mild to advanced sprain. It mainly occurs when you fall in an uncomfortable angle or when walking on an uneven surface. Results when all four ligaments supporting the knee tear.
  3. Osteochondral Knee Fracture– occurs when a cartilage surrounding a bone wears off over time or due to an injury.
  4. Posterolateral Corner Injury- their occurrence is rare and cause sharp pain at the back and outside of the knee. They may be as a result sustained when playing sports or when one is involved in a car accident.
  5. Tennis Leg – it is a type of pain experienced as a result of the calf muscles.
  6. Acute Patella Injury- this injury is not so serious and it occurs due to an injury in the knee cap. Fracturing the patella is also possible.
  7. Patella tendon rupture
  8. Articular cartilage injury- caused by wearing away of the cartilage that surrounds the bones.
  9. Biceps Femoris Tendon Avulsion- results when the bone and the bone separate.
  10. Coronary ligament sprain- caused by injury to the lateral ligament.
  11. Patellofemoral instability- occurs when there is free movement of the knee.
  12. Pain inside the knee- can be due to excessive friction or wearing away of tendons and ligaments.
  13. Pain outside the knee- it keeps on increasing over time. Can be caused by lateral ligament damage.


Treatment is carried out if the preventive measures that were put in place have not worked effectively. The type of treatment will be determined by the extent of the syndrome. Before any treatment can begin, it is important you take the following considerations into your mind;

  1. The name of the procedure or test
  2. Reasons for having the procedure.
  3. Results you expect to compare the outcomes.
  4. Risks and benefits of the procedure.
  5. Whether you can deal with possible side effects.
  6. When to have the test or procedure.
  7. The person and qualifications of the person who will do the procedure.
  8. Any existing alternatives to the test or procedure.
  9. The cost of the procedure and does the cost justify the cost?

The most common methods of treatment include;

  • Posterior reconstruction
  • Physical therapy- before the exercise can kick off, the therapist should first of all look keenly at the knee injury, use imaging tools to assess the extent of the injury, compare the best course of action and come up with a training guide on duration of each exercise. It is important to know whether your therapist is qualified to administer the therapy. Physical therapy also acts as a method of preventing the injury. There are certain ways that are used to measure the extent of the injury they include; measuring the strength, how well can the knee move, balance when standing on one knee, how smoothly it is for joints to move, pain, how the nerves work.
  • Non- operative treatment-recommended for people who wish to continue with sports and young athletes who have just started playing and have their whole lives ahead of them to continue playing the games..
  • Strengthening and training of muscles regularly to avoid easy tearing of ligaments is a preventive as well as a course of treatment done by starting with easy training and gradually introducing hard training of the muscles.
  • Braces are also used to limit the movement of the knee which helps with fast recovery of the athletes.
  • Ice heat therapy where you apply ice on the area where you are experiencing pain and leave it there for 15-30 minutes. Repeat this procedure in shifts throughout the day. It helps deal with the shoulder pain and numbness. Apply pressure on the ice to help reduce inflammation. The ice should not be used directly but rather use a towel.
  • Supporting the knee and regulating movement helps in quick recovery

  • Non-surgical therapy is one of the best treatment for the disease and it is a good alternative to surgery. It is also called manual therapy. It should be the first therapy used in treatment of the unhappy triad condition. Beyond the many benefits over surgery, manual therapy is a good cost savings method. Therapy is focused mainly on the tissues and tendons to help them heal naturally. It helps in reducing the pain. It can be used to treatment the disease even if it has persisted for a long time. Off all patients treated by physical therapy, only 15 to 20 % require surgery. Surgical methods are risky with patients who have undergone surgery require another surgery to correct the condition. There are many ways physiotherapy can be carried out. Therapy has numerous benefits;Helps in dealing with long lasting pain, reducing sensitivity in nerves, and helping in resuming the normal functioning of your knees and legs in general.
  • Acupuncture– Acupuncture is a technique which was originally used by the Chinese people which involves the insertion of extremely small needles through your skin which targets specific organs of the body which helps in relieving pain as well as stress. It is mostly used after a medical diagnosis. It is believed acupuncture simulates the body to produce its own natural pain killers. It does this by stimulating blood flow to the specific body parts. It is recommended that someone one undergoes several sessions of acupuncture for better results. It will help deal with the pain from the unhappy triad condition.
  • Hot and cold compression– instead of using ice only to treat your condition, it may help to try different methods. Using hot compress fist and applying pressure on the affected area is also a good proven method to deal with pain and pressure that has built on a nerve. Alternate between hot and cold and see which one works best. When using heat, boil water and dip a towel in the water and rinse a little then apply pressure on the part where you are experiencing pain. Keep on dipping the towel in the hot water and applying pressure on the affected surface
  • Targeted massage-Concentrating massage on the areas experiencing pain will help deal with that pain as well as relieving pressure from the knee. It helps in restoring good grip in a hand. – Apart from relaxing the affected area, massage is effective for relieving pressure from that particular area as well as relieving pain from the shoulders. Massage should be done by a trained person in order to apply the right amount of pressure for best results. Pressure should be applied on the muscles which are tense or painful and thoroughly massage them until the pressure is all gone.
  • Hot and cold compression– instead of using ice only to treat your condition, it may help to try different methods. Using hot compress fist and applying pressure on the affected area is also a good proven method to deal with pain and pressure that has built on a nerve. Alternate between hot and cold and see which one works best. When using heat, boil water and dip a towel in the water and rinse a little then apply pressure on the part where you are experiencing pain. Keep on dipping the towel in the hot water and applying pressure on the affected surface.
  • Resting– rest from using your exercises as well as actively participating in your favorite sport. Make sure you take a bed rest and make sure your knee is place properly to prevent repetitive injury.
  • Using injections

Injecting medicines into the affected area is one of the most effective ways to deal with inflammation, pain, pressure and swelling in the joints and other areas of the body. The most used drug here is Cortisone. It deals with the pain and reduces pressure. Injected drugs target the specific affected area to help heal the tissues or tendons.

  • Ultrasound– ultrasound is a very effective, painless method of dealing with the unhappy triad condition. The ultrasound treatment is concentrated on the areas when the patient is experiencing pain.
  • Electrical induction– this is effective for opening up constricted muscles and tendons and reducing pressure on the affected area.
  • Muscle and soft tissue extensibility- most of the most successful athletes in the world practice soft tissue massage. It helps in reducing the chances of occurrence of an injury. Concentrate on the most likely parts to get an injury. It also helps the body to reach its optimum performance. Muscles become healthy, extensible. It is recommended that this exercises be done by a qualified massage therapist who will help to concentrate the exercises on the right places and exert the right amount of pressure. There are a lot of tools and devices used for this and it is good you research well before deciding to buy any of them.
  • Ligament repair and closure-the unhappy triad is sometimes caused by tearing of the ligaments. When you repair the ligaments by tightening them to prevent pain or other medical conditions
  • Resume exercising

It may not be possible for an athlete to resume hard core exercises immediately after surgery. It is advisable you start with light exercises for short time before increasing the time periods and hard exercises.


Used when the injury is so severe and used to repair the meniscus ligament. There are different types of surgeries depending on whether the injury is to the ACL, PCL, LCL or MCL.


  • Grafting of the patellar tendon.
  • Grafting the harm strings tendon.
  • Allograft of the patellar tendon.


  • Allograft of the patellar tendon.
  • Allograft of the Achilles tendon.
  • Auto graft of the quadriceps tendon.


  • Auto graft of the patellar tendon.
  • Allograft of the Achilles tendon.


  • Allograft of the patellar tendon.
  • Auto graft of the arm strings.

There are times when patients are required to undergo a repetitive surgery. This is due to;

  • When there were problems during the surgery such as the way certain parts interlock with each other.
  • Failure of the ligaments to heal properly.
  • In case of infections after surgery.
  • In case of a reoccurring injury in an athlete.
  • Tearing of a ligament.
  • In case post-operative procedures were not adequate to treat the injury


This is a procedure done to replace one of the three components of the knee. Which are the inner knee, the outer knee or the patellofemoral which is the part where kneecap meets the thighbone.


Done to correct poor knee alignment which causes excessive friction in the knee leading to wearing of tendons, meniscus and muscles. A surgeon makes an incision into the femur and or tibia and removes a small part of a bone or adding graft or bone material. It helps deal with excessive pain in the knee and preventing friction of the bones.


This is a delicate procedure that is less intrusive and requires specifically trained surgeons who use tiny cameras to perform the surgery. The surgeon makes tiny incisions in the knee and uses the cameras to navigate through the various parts of the knee.  During this operation, the surgeon does the following;

  • Getting rid of loose bones, tissue and cartilage can cause pain in the knee.
  • Smoothening uneven arranged cartilage.
  • Getting excessive synovial fluid from the tissues.
  • Cleaning out any foreign elements in the knee out to prevent any irritation.


After surgery, patients in most cases may not be able to walk or use their legs as they would normally do. They should be advised on how to cope with their new state before they can be able to resume their exercises and normal routine. The patients at this stage are also taught on how to walk with the help of walking braces.After surgery, some physical therapy in most cases may be used to help regain the proper working of your knee. You can use a series of exercises that can be used t o help regain the normal functioning of your knee and also help the tissues recover. Taking enough risk is recommended to aid in quick recovery and prevent another injury from occurring. People suffering from the condition are also advised to visit a qualified physical therapist who will help them through a series of exercises, massage therapy to kick start natural body healing process. These techniques increase blood flow and unclogging of nerves and other tissues. Recovery depends on an individual as well as the extent of the surgery. There are two different techniques of performing the surgery;

  1. Endoscopic surgery-the therapist uses a tool that looks like a telescope with a camera attached to it. The camera is used as eyes of the surgeon to enable him see throughout the knee. The surgeon then cuts the ligaments through the knee. In the first weeks or months after the surgery, patients may experience pain which will afterwards disappear. If the pain persists, it is advisable to consult your doctor.
  2. Open surgery-involves opening up the hand and making an incision to help view all the internal parts of the knee. It is done by cutting through the knee to enable the worn out ligaments to induce the natural healing process of the body. Anesthesia is used during the operation which helps in eliminating the pain as the surgery is being conducted. The anesthesia should wear off and it is recommended the patient should take adequate  bed rest because the anesthesia has side effects. The operation is not as painful as people might think due to the new technology that is used .Open surgery results in an open wound which must be well taken care of and must be dressed well and cleaned regularly to prevent infection. Everything that has an advantage also has disadvantages: there is a high risk of hemorrhage, usage of more resources of time and money  by patients and plus wounds require regular cleaning which in most cases is done by a qualified person. It is recommended a person should visit a doctor as soon as possible for the surgery to be carried out soonest to increase the chances of recovery and resuming the game after diagnosis of the disease for better results.patients reported improved results in the conditions in their knees after following through with the surgery and should only be carried out if other non-operative procedures fail.

3.Physical training to strengthen muscles after surgery is also done. It should be done to by a qualified person to prevent further injuries which can make a patient go back to surgery. It is at this stage also that a patient is advised on how they can avoid the same type of injuries.

4.In case the injury is as a result of anterior cruciate ligament repairing the ACL is helpful to treat the injury.

5.In case the injury is a result of injuring the medical meniscus ligament, it can be left to heal on its own.

6.Undertaking a full rehabilitation of the injured leg to condition it again to walk as well as run. This helps in strengthening that particular leg. Complications from surgery are very rare with 95% of patients making successful recovery. Most have reported complete relief from pain and other symptoms. Some therapists recommend recovering patients wear a braces as well as suspending their leg upwards to regulate movement of that leg to prevent further injury which might prolong the healing time.  Gentle knee exercises or physiotherapy are also done to help regain normal functioning of the knee.


Prevention is the best cure and it is therefore important that an athlete takes important steps to prevent themselves from any injuries or exposure to things that may cause them harm. Some of the methods used to prevent the disease include;

  • Exercise is the most effective way to prevent any type of injury. It helps in improving flexibility of muscles and tendons as well as increase the strength of bones.
  • Maintaining a healthy diet- eating foods rich in anti-oxidants and vitamins helps to promote growth of healthy bones. Foods rich in proteins are also essential for repairing worn out body parts.
  • You should switch using road transport with other traveling methods such as railway to reduce chances of getting involved in a life-threatening accident.


The unhappy triad injury does occur in athletes. It is not as common as the other running injuries. However, if it does occur, the chances of having another re occurrence are a bit higher.  The disease can be caused by many factors and it is absolutely important for athletes to reduce their exposure to search things to reduce their chances of the injury. However, if the disease does occur, there are a lot of ways that exist to treat the disease. Visiting a qualified person is the first step a person should take in order to be given the best advice on the way forward and the best courses of treatment. There are also many ways to prevent the disease. It goes without say that prevention is the best cure for any disease.

It is therefore important for any athlete to look out for the health of their body by performing exercises on a daily basis, extensibility stretching, practicing a healthy diet and avoiding hard injuries to the knee to prevent a blow to the knee.  The treatment for the unhappy triad is expensive and anyone thinking about going under the knife should be able to part with a few thousand dollars. Surgery however should be your last resort especially for young people who have just recently started playing their favorite sport or people who are contemplating continuing with the sport. You should therefore first try no-operative forms of treatment such as massage and physical therapy before taking on the route of surgery. The unhappy triad is a serious condition, however it can be dealt with by a qualified personnel.

This article used credible sources and is for informational purposes only. It is to open a dialog with your healthcare provider. Do not use any information contained here without their input.


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