There are those who didn’t require a crystal ball to predict that Strasburg would have Tommy John surgery lurking in the shadows of his future.  With youth on his side though, most probably felt he’d buy more time.  Strasburg’s unorthodox delivery coupled with the extraordinary pace of his pitches is thought by many to have made his elbow more vulnerable.  Let’s not forget that Strasburg also missed three weeks of starts earlier this summer with shoulder inflammation.  The kid is breaking down.  A piece by Bill Conlin (posted to Philly.com Sports on August 30^th) details issues with Strasburg’s delivery and the possible repercussions that we may be witnessing.  If you are interested in more on this topic, take a look.

What exactly is the UCL & what is Tommy John Surgery?

Ligaments attach one bone to another and provide much of the stability at a joint.  A partial or complete tear of the ulnar collateral ligament (UCL) of the elbow results in the need for the Tommy John procedure in order to reconstruct this medial ligament. A higher incidence of severe elbow injuries in overhead athletes is partly due to players’ increased size and strength as well as the tremendous forces generated, particularly when pitching.  More frequent use of the slider and split-finger fastball is thought to be another reason.  Advances in medicine have led to an increase in Tommy John surgeries due to better reporting of injuries, an improvement in the ability to diagnose the problem and greater expertise in performing the procedure.

There is a great deal of stress on the inner aspect of the elbow during the throwing motion. A very high velocity (speed) is required to extend (straighten) the elbow, and maximum stress on the inner elbow ligament occurs just after the cocking phase of pitching, when the arm just begins to descend.  In fact, at a 90-degree angle, the ulnar collateral ligament provides at least 54% of the stability of the elbow joint (figures from 54% up to 70% have been reported). Acceleration during the throwing motion also places significant stress on the ligament, while compression forces and a high level of muscular activity are also present.  You can see why the ulnar collateral is so important and why it is so often damaged.

Normal range of motion for a pitcher’s shoulder and elbow is different than that for an average person or even an average player.  Likewise, pitchers are much more developed on their dominant side, enabling them to exert with greater force on that side.  A UCL tear results in pain and a loss of throwing speed.  The instability caused by a tear such as Strasburg’s may also result in a stretching (traction) of the ulnar nerve, causing nerve related symptoms.  The ulnar nerve is the one you provoke when you hit your “funny bone”.

Dr. Frank Jobe pioneered the Tommy John Procedure in 1974.  Studies currently show an extremely high success rate, now at about 90%, while the non-surgical success rate of treating a partial tear is about 45-50%.  Various studies show that major leaguers generally return to action between 9.8 and 11.2 months post-operatively, though their rehab begins to include a low-level throwing program at about the four-month mark.  Even after returning to play however, a pitcher generally is not thought to regain full form for up to two years.  As a result, many reports list the return to play in the 12-18 month range.

Strasburg’s tender age should help with respect to his ability to heal and return to form.  However, it remains to be seen whether his coaches and doctors will encourage him to modify that form in order to protect himself from further injury.

What is the UCL (Ulnar Collateral Ligament) of the Thumb?

A ligament is the connective tissue connecting one bone to another to provide stability at a joint.  Each joint has at least one ligament on each side.  In the hand or elbow, the inner (medial) side, or side of the ulna bone in the forearm, is called the ulnar side, and the outer (lateral) side is called the radial side because of its relationship to the radius (the outer bone in the forearm). Hence, at the base of the thumb, just as at the elbow, the ligament stabilizing the innermost part of the joint is called the ulnar collateral (UCL).  A pitcher who injures the UCL at the elbow is a candidate for Tommy John surgery.

Significant injury to a ligament will permanently diminish stability at the joint it protects.  It may preclude high-level participation in sports and is likely to predispose an athlete to re-injury or to other problems such as arthritic changes at the joint.

Other names for the UCL tear of the thumb

Most often called “Skiers’ Thumb” these days because of its prevalence on the slopes, this injury used to be known as “Gamekeepers Thumb” because it was commonly found amongst Scottish Gamekeepers (wildlife managers) as a result of a repetitive stress and stretch to the ligament that they suffered when doing their work. 

How does this injury occur?

A force that pulls the thumb away from the hand places stress on the UCL at the joint where the thumb meets the palm.  If the force at this joint (also called the MCP, or metacarpophalangeal joint) is traumatic and causes the joint to exceed its normal limit of movement, the UCL is sprained. And, as for any ligament, a Grade III Sprain is really a complete tear.

A skier who falls while holding the pole, or anyone who tries to break a fall by reaching out with his hand to absorb the impact may suffer a Skiers’ Thumb injury.  If the thumb is bent backwards and a ligament tears, it is unlikely to be able to heal in the anatomical position because of the resultant instability of the joint.  That is why KRod is having surgery.  Occasionally, just as was previously discussed with regard to ligament injuries at the inner aspect of the ankle, the UCL ligament may not tear but instead might pull off a chip of bone at its point of attachment (at the base of the thumb).  This injury is called an avulsion fracture and it too can result in instability at the joint if not corrected surgically.

So, what did KRod’s thumb probably feel like after the injury?

Just as after any partial or complete ligament tear, fluid builds up causing swelling.  Visible discoloration is an indication that a ligament (or other vascularized structure like muscle or tendon) was torn.  Naturally, pain is a factor and it will hurt to use the thumb (to grip or squeeze), to bend it backward or to move it away from the palm. KRod will be out of commission for at least six to nine weeks to heal and rehab following his surgery.  With no reason to rush things at this point, the process will likely take even longer.  By all reports, the Mets are already moving on and are trying to figure out how to avoid having to pay out on the remainder of KRod’s contract.  Sounds like a plan.

Of the 199 NFL players who are presently questionable or unable to play – as listed on CBSsports.com’s fantasy football injury website – 13 reportedly suffer from groin injuries and seven others from hip problems.  It should be noted that this figure does not take into account the 14 injuries that are of an undisclosed nature.  To digress for a moment, it probably won’t shock you to learn that six of these mystery injuries belong to players on the New England Patriots, who are evidently much more secretive than their counterparts…

I find it interesting that of the 13 players currently reported to have groin strains, nine are on defense.  Without doing a broader study, it appears that the reactive nature of these positions makes athletes more vulnerable to groin issues.  I’ll follow this throughout the season. For more information on groin strains, take a look at my previous blog post on Andy Pettitte, who continues to struggle in his efforts to return to the line-up. 

Groin strains can be nagging injuries.  Though Pettitte’s issue was reportedly musculo-tendinous, persistent strains of the hip muscles (primarily the flexors, which are at the front of the hip joint and adductors which cross the hip at the inner groin area) may only be a part of an athlete’s overall hip injury picture.  When strains are coupled with internal injuries to the hip joint (intra-articular injuries), the injury profile changes and the condition is more debilitating.  Intra-articular injuries include bone contusions (bone bruises), which are from trauma, degenerative changes to the surface of the bones from wear, as well as hip internal impingement, often as a result of labral tears. 

What is the role of the labrum?

Similar to the anatomy of the shoulder, the hip is a ball and socket joint with the ball at the end of the femur attaching via ligaments to the socket at the pelvis.  The labrum is a fibrous cartilaginous structure that is situated along the inside rim of the socket, serving to deepen it and provide some suction for the ball thereby adding to the stability of the joint.  It can be torn traumatically or by a degenerative process due to repetitive motion that is common in many sports.

What does a labral tear feel like?

Those with labral tears generally complain of joint stiffness and on examination there is typically a loss of range of motion.  These complaints would also be common if there are arthritic changes at the joint, even in the absence of a tear.  Labral complaints might also include a catching or locking of the hip and some people may also complain of a sense that the hip is unstable.  One commonly used test for labral tears is for the examiner to flex the patient’s hip, bringing the knee toward the chest, and to inwardly rotate the hip while putting pressure through the joint and drawing the knee across the patient’s body.  This test causes pain in the presence of a tear, and MRI findings are generally used to support the diagnosis.

Can a labral tear be treated without surgery?

Rehab for a tear focuses on reducing inflammation and restoring range of motion while also addressing muscle strength and flexibility.  For those players with sufficient relief, working back into play with a specificity of training is also important to determine if they will be able to tolerate the demands of sport.  Those with persistent pain go on to have the labrum reattached to the socket or in some cases, a small portion of the labrum may be removed.  These procedures are now performed arthroscopically. 

Post-operative recovery

The goals of post-operative therapy are much like those for the non-operative patient except that the rehab period may last up to about six months.  The exact timeframe would depend on the severity of the injury or injuries, the specific nature of the surgery and whether there were any other complicating factors such as bony changes that may have also been addressed.

Which of Bradshaw’s surgeries was the bigger deal?

Spurring:

Wear and friction at a joint can promote changes in bone, which responds to stresses by growing more bone.  The irregular shape of the joint surfaces that results is due to this extra bone, or spurring.  The spurs then take up space in the joint and, when the joint moves through the range of motion required for function, impingement occurs.  This is painful, as nerve endings and other structures are pinched.  Add impact from running, especially with the cutting patterns involved in football, and the situation can become untenable.  Removing the spurs arthroscopically, if that is all that Bradshaw’s ankle surgery entailed, is a fairly routine procedure, and he likely healed well.  Is it always this simple? – Absolutely not.  Sometimes there is more that might have contributed to an athlete’s condition.  Perhaps there are additional diagnoses that may or may not have been addressed.  Or, there could be underlying factors that predisposed an individual to the formation of spurs, such as structural mal-alignment, mechanical flaws in the manner in which an athlete runs, or even consistently running in one direction on a banked surface.   Simply stepping up a training program too aggressively can create undue stress on the weight-bearing joints.  These and other issues might persist once spurs are removed.  If so, with return to competition, the long-term result would be that over time the spurs will reappear.  I don’t know the specifics of Ahmad Bradshaw’s circumstances and so I make no predictions. 

Fifth Metatarsal Fracture Fixation

Surgical fixation of fractures of the fifth metatarsal (MT), the long bone of the midfoot that connects the little toe to the bone just in front of the heel, can be tricky.  These fractures come in several varieties, based on their exact location and whether they are acute (from a recent trauma) or chronic (typically this is due to an unhealed stress fracture).  The most common fracture of the fifth metatarsal is an avulsion fracture, where a small portion of the base of the bone is pulled away from the body of the bone. At the fifth MT, avulsion is most often due to the pull of the connective tissue at the base of the foot or tension from a particular muscle of the lower leg that attaches at the fifth MT.   A “Dancer’s fracture” of the fifth metatarsal typically occurs with twisting of the ankle, otherwise known as an inversion sprain (O’Malley, 1996).  These MT fractures may be accompanied by fractures of the outer ankle.  Though I’ve not seen detailed reports of his injuries, I would guess that Bradshaw’s fractures were most likely of the Jones’ variety rather than avulsions.  Jones’ fractures occur in an area connecting the base of the fifth metatarsal with the shaft of the bone, and they often prove to be stubborn injuries.

Studies have demonstrated that only about two-thirds of acute fifth metatarsal fractures heal well with non-operative treatment (Wheeless’ Textbook of Orthopaedics).  Conservative care initially entails wearing a non-weight-bearing cast for about 6-8 weeks followed by therapy.  Surgery is the treatment of choice for those with delayed healing or incomplete healing of the bone, known as non-union.  In these chronic cases, only a percentage of the fractures will mend without surgical intervention, and those that do require prolonged treatment during which time an individual cannot participate in sports.  Likewise, when a fracture is displaced (where the two ends of the bone don’t line up) or where an avulsion entails a large piece of bone being pulled away, surgery is warranted.  An athlete, such as Ahmad Bradshaw, may opt for surgery rather than risk being out for an extended period only to find out that his fracture still hasn’t healed.  Post-operatively you can be sure that he was monitored carefully and only allowed to return to activity once full union (mending) of the bone was established.  This is because a premature return to activity can result in failure of the fixation (Larson, 2002).  Some athletes, even after surgery and a carefully executed rehabilitation plan, suffer from re-fracture.

So, the answer to my question is clearly that the fixation of Bradshaw’s metatarsals was the more sensitive of his surgeries.  After working to control his post-operative inflammation and pain, regain his strength, range of motion, endurance, flexibility and balance, Mr. Bradshaw began to run again.  I’ve read that he has been trying to adjust his running technique – attempting to place less stress on the outer border of his feet – to avoid re-injury.  That may be a tough go.  We’ll keep an eye on him…

If you experience the onset of pain at the side or outer edge of your foot, seek treatment.  The pain may seem to have been unprovoked or might have increased gradually.  Don’t hesitate if you find that the pain is more pronounced with walking and is exacerbated by running or sports participation.  A negative x-ray doesn’t even mean that you are in the clear.  Remain on alert because stress fractures often don’t show up on initial x-rays and may only be evident once they begin to heal.

What is a strain?

A strain results from a pull or overuse of a muscle and entails some level of damage to the fibers of the muscle itself or to the tendon that attaches the muscle to bone.  A Grade I strain, such as the one Pettitte’s MRI confirmed, is the least involved, and implies only mild disruption of the tissue.  In a Grade II injury, some of the fibers of the muscle or musculo-tendinous unit have been torn.  The most severe strain, a Grade III, is actually a complete rupture of the structure.

What are some of the signs and symptoms of a strain?

The first and most noticeable issue, of course, is pain.   The injured area also becomes inflamed, with the signs of inflammation being swelling, redness of the skin and warmth to touch.  Bruising may follow as the internal bleed of the muscle (in grades II and III strains) becomes more superficial.  Not only is there likely to be pain with use of the involved muscle, but pain may be present at rest as well.  A consequence of this swelling and pain is the inhibition of the muscle, resulting in weakness.

What muscles are involved in a groin strain?

The most commonly implicated muscles are the adductors, which is a group of four muscles comprising the inner thigh.  These muscles are the primary movers of the hip into adduction, or toward the midline, thus bringing one thigh in toward the other.  To help you remember that this is the action of the ADDuctors, it might help to know that the ABDuctors are those hip muscles that move the thigh away from midline.  Think ABDuct, to take away (from your other leg) versus ADDuct, to add to…

Note that issues with the abdominal wall, at the attachment of the abdominals to the pubic bone, may also be involved in a groin strain.  The adductor muscles are not the only ones that may be at fault.  I have alluded to this type of injury in a prior post and will dedicate a future column to this fairly common athletic injury, known as a sports hernia.

Andy Pettitte’s issue however, was reportedly one that is exclusive to the adductors.
The four adductor muscles are:

1. Adductor Brevis:  The word “brevis” implies that this muscle is shorter than its counterpart (longus).  In addition to adducting the thigh, this muscle laterally (outwardly) rotates the thigh as it adducts.  Its less significant role is to assists with flexing the hip.

2. Adductor Longus:  This is the longer muscle, and it originates at a different region of the pubic bone than does Brevis.  It functions in much the same way however.  Longus inserts further down the femur than Brevis, with both attaching to a ridge on the back region of the bone.

3. Adductor Magnus:  Magnus, as the root word implies, is the largest or broadest adductor muscle.  It originates both at the pubic bone and the lower portion of the pelvic girdle in front as well as at the sit bone (ischial tuberosity) in back.  It has a broad area of attachment at its distal (far) end, extending as far as the very end of the femur, just above the medial (inner) aspect of the knee joint.

In addition to this muscle acting to adduct the hip/thigh, its front (anterior) fibers assist in flexing the hip while the rear fibers assist in extending the hip.  Like Adductor Brevis and Longus, Adductor Magnus also plays a small role in lateral rotation.

4. Gracilis:  The most unique of the adductor muscles, gracilis is the only one of the four that crosses both the hip and knee joint.  It too originates at the pubic bone but inserts at the tibia (of the lower leg) below the inner aspect of the knee joint.  Two of the three hamstring muscles – the medial (inner) ones – also attach at this same area.

Because of its orientation, when it contracts drawing its lower portion toward the upper, Gracilis serves primarily as a hip adductor muscle.  However, because it inserts below the knee, it also assists the hamstrings in flexing (bending) that joint.  Unlike the other adductor muscles, Gracilis assists in rotating the femur (and tibia) medially (inward).  If the leg is stationary, the Gracilis acts as a hip flexor when it contracts, bringing the upper portion of the muscle toward the lower rather than the other way around.

What does treatment entail?

As for any inflammatory condition, ice and electric stimulation are initially used to minimize swelling and other complications of inflammation.  Certain types of massage are generally performed to promote healing and control the formation of scar tissue.  Gentle, pain-free stretching is also employed.  After the acute period, it is likely that heat followed by ice is utilized.  Controlled and progressive strengthening is instituted in a pain-free fashion and return to activity is promoted gradually.  Toward that end, Pettitte has reportedly begun a throwing program from increasing distances before attempting to pitch.  By doing so, he initially avoids the long stride length, ballistic motion and extreme follow-through that would aggravate his condition and would be required of him to pitch effectively.

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What are the Internal Obliques and why is Reyes planning to bat righty against a right-hander?

The Internal Obliques are one several muscles that comprise the abdominals.  They have several points of attachment – at the low back and pelvis, and running diagonally up to the base of the front of the lower ribs and midline of the abdominal group.  The diagonal orientation of the internal obliques is key to understanding their function.  When they contract (shorten), the internal obliques act to side-bend and rotate the torso toward the same side.  In other words, if Jose Reyes and Angel Pagan were to bat left-handed, their right internal obliques would be forced to contract forcefully to rotate the trunk to the right as they move into the swing and follow-through. Since the muscle is already sore due to a strain, this would aggravate the condition. Reyes’ solution for now?  Bat only from the right side so that the right internal obliques don’t have to kick into high gear.  Of course, that is only part of the answer, as he continues to undergo treatment.

Another important function of the internal obliques is to assist in respiration (breathing).  They work when we exhale (breathe out) to push the organs up, thereby forcing air from the lungs.

What are the other abdominal muscles?

The External Obliques

If there is an internal (inner) oblique, it means that there must also be an external (outer) oblique.  And so there is…  Lying just above the inner layer are the external obliques, which basically have the opposite functions.  The external obliques also run on a diagonal, but they are aligned perpendicularly to their more internal counterpart.  These muscles assist in side-bending and rotating the trunk toward the opposite side. That means that the right external obliques take over to swivel the trunk to the left when a batter bats right-handed.  They also serve a role in respiration to assist with inspiration (breathing in) by pulling the chest downward and compressing the abdominal area to allow for expansion of the lungs with air.

Because they have opposite functions with respect to side-bending, when either the external or internal obliques of each side contract together, they simply aid in flexing the trunk forward.  When you do diagonal crunches for strengthening, you are trying to isolate your obliques.  By bringing your right shoulder toward your left hip, you are emphasizing your right external and left internal oblique muscles.

Transversus Abdominus

This is the innermost layer of the abdominal muscles.  The fibers of this muscle run (more-or-less) horizontally to wrap the front and sides of the torso.  It is thought to act as a supportive sling and is likened to a natural weight belt.  

Rectus Abdominus

These are the muscles most commonly thought of when you picture the abdominals.  They are the most visible group and the ones you work on to get that six-pack you long for.  The rectus, located at the front of the abdominals, runs vertically.  The upper end of the muscle is responsible for flexing the trunk forward as well as stabilizing the trunk as the arms are moving.  The lower portion of the rectus acts to flex the pelvis toward the torso and to stabilize the trunk as the legs are moving. The lower portion tends to be weaker than the uppermost section and so including it in your core program is recommended.

All the muscles of the core serve as stabilizers.  They are crucial to all movement to protect the low back from excess demand that can cause injury.  In addition to strains from overuse, the abdominals can be stressed due to the explosive motion involved in batting and even in throwing.  Another common abdominal injury in sports is the sports hernia.  This will be addressed in a later column.

Shoulder problems seem to be the predominant injury of no choice in Major League Baseball, especially amongst pitchers.  Of the 33 players currently out with shoulder diagnoses, 30 are pitchers, six of whom reportedly suffer from rotator cuff issues.  John Maine of the Mets has been out with cuff tendinitis, as has Texas Rangers pitcher Derek Holland.  Bobby Seay of the Tigers was diagnosed with a rotator cuff tear in spring training this year and when given the choice to have surgery or try rehab, he opted to go the conservative route.  Unfortunately though, he remains unable to pitch without pain.  Seay’s teammate, Eric Hurley, was out of action last season after having rotator cuff surgery but is reportedly out at this point due to a third surgery on his wrist – his shoulder remains untested.  As for the 2010 surgical front, both the Astros’ Alberto Arias and Dustin McGowan of Toronto underwent rotator cuff repairs and won’t see any playing time this year. 

Recent blog posts delved into a couple of other shoulder girdle problems – specifically labral tears (Eric Bedard) and AC sprains (Sam Bradford).  This third piece in the shoulder series focuses on the Rotator Cuff and Shoulder Impingement.

What is the Rotator Cuff?

Four muscles that originate on the shoulder blade (scapula) all essentially converge into a common tendon to attach at the front, top and back of the head of the humerus  (the bone of the upper arm).  Collectively, they constitute the rotator cuff.  You may recall that tendons connect muscle to bone.  Those of the rotator cuff are no different.

The muscles that contribute to this tendon are responsible for different actions.  The Subscapularis tendon is the foremost.  Its muscle belly is on the undersurface of the scapula and the tendon wraps around the front of the humeral head.  The action of the muscle is to internally (inwardly) rotate the humerus   By virtue of its location, the subscapularis tendon also helps to protect the front of the shoulder.  The Supraspinatus, insertion is the uppermost of the cuff tendons.  When it contracts, the supraspinatus raises the arm out to the side (abducts).  Infraspinatus & Teres Minor, the next two in order of attachment, are the primary external rotators of the shoulder.  These tendons come around the back of the head of the humerus, thereby providing the leverage to rotate the bone outward.

Why is the Cuff so Important and how is it Injured?

In addition to enabling the shoulder to move in the directions described, the muscles of the rotator cuff help to foster normal mechanics of the joint. Weakness and strength imbalances of the cuff lead to abnormal mechanics, which then result in injury.  This is particularly so when combined with the increased demand of sports or other repetitive overhead activities.

When they have rotator cuff problems, younger people tend to suffer from tendinitis, which is simply an inflammation of a tendon.  The cuff tendon most likely to be involved is the supraspinatus tendon because of its uppermost position immediately below the hood of the shoulder, known as the acromion.

The narrow space below the acromion can be narrowed even further by poor posture, by variations in the shape of the acromion itself and by the presence of bone spurs.  This space also becomes smaller when the outward rotators are weak and do not adequately control the position of the head of the humerus when the arm is elevated overhead.  The end result is impingement of the cuff tendons.

“Impingement” is as it implies – a pinching of the structures involved.  At first the tendons just become inflamed.  The swelling that accompanies this inflammation can further diminish the ”subacromial space” and create a vicious cycle.  Over time, the wear and tear from impingement leads to degenerative changes of the tissue, and that is called tendinosis.  I liken tendinosis to gliding a rope back and forth over a rock until the rope begins to fray.  Give it a little more time and overuse, and the fraying of the cuff tendons in the over 40 crowd (of recreational athletes…) results in degenerative rotator cuff tears. 

Younger athletes with cuff tears are generally those who do an inordinate amount of overhead activities like pitching.  Overuse and irregular pitching mechanics can also play a role in predisposing these players to injury. 

Another cause of rotator cuff tears is outright trauma, such as in a dislocation.  A traumatic tear of the cuff is also the likely outcome for the person who holds onto a banister for dear life as he falls down a flight of stairs.

Loss of mobility in the shoulder joint, whether from inflammation, scar tissue that forms in response to inflammation, immobilization, or disuse can make impingement more likely.  Mobility must be restored to provide normal joint function, lessen the risk of injury and ensure the success of surgery (if it becomes necessary).  If your shoulder hurts and you are simply resting it hoping to feel better, you will likely lose mobility in the joint.  See a medical professional and take a proactive approach to treatment. Rest alone is not the answer.

Does a Tendon Tear All The Way Through?  Then What?

Most degenerative tears of rotator tendons are partial thickness – they don’t extend through the entire structure – as when you just begin to cut a piece of meat.  Other tears are full thickness, as though a piece of meat is cut from top to bottom but remains attached to the rest of the piece.  In the case of a complete tear, or rupture, total detachment occurs, separating one end of the tendon from the other.  These result in complete loss of use of the involved muscle/tendon unit – it cannot be rehabilitated or strengthened without surgical repair.  Repairs are also performed on partial and full thickness tears that are not complete tears.  The choice to have surgery generally depends on the extent of a tear, the age of the patient, the demands of the individual’s activities as well as the mobility and overall health and function of the shoulder joint.  Generally surgery is for more than one condition rather than an isolated cuff repair.  This is because issues such as impingement must also be addressed in order to have a favorable outcome.

What is the Posterior Cruciate Ligament (PCL)?

A previous post on Da’Sean Butler detailed information about the medial collateral (MCL) and anterior cruciate (ACL) ligaments.  You may recall that the ACL is a primary stabilizer of the knee and, along with some less significant stabilizers, prevents the knee from hyperextending.  This means that it prevents the top of the tibia from gliding too far forward on the base of the femur above.   Well, the PCL is also a stabilizer of the knee.  It is centrally located within the knee joint and its position is such that it crosses, or forms an “X” with the ACL.  That is why these ligaments are called cruciates.

Like the ACL, the Posterior Cruciate checks the motion of the tibia.  However, the PCL keeps the tibia from gliding too far backward on the femur.  This means that the ligament is stressed when the knee is bent to its fullest, or hyperflexed. Actually, it is primarily the front/outer (anterolateral) band of the PCL that is on stretch in this position.  Therefore, it follows that forced hyperflexion generally results in an isolated tear of this portion of the ligament. 

Along with other structures, the MCL contributes up to 5% of the restraint of hyperflexion (see Wheeless’ Orthopaedics).  Therefore, a hyperflexion injury can damage both the PCL and MCL.  However, when the MCL and other secondary stabilizers are damaged along with the PCL, the mechanism of injury is more likely to be a traumatic force that pushes the tibia backward on the femur, such as with a “dashboard injury” when a car stops short.  It appeared that this is what happened to Kendrick Perkins when he landed while absorbing the impact of Andrew Bynam’s weight just below his knee after fighting for a rebound.

Do all PCL Tears Require Surgery?

Unlike ACL tears, which generally require surgery (especially for the active individual), isolated PCL tears can often be managed non-operatively.  Perkins is scheduled for surgery because both the PCL and MCL are torn (likely also with contusions or other less significant injuries).  The instability – primarily to the medial (inner) compartment of the knee – that will result if he does not have surgery will be too debilitating and would prevent him from returning to competition.  Instability of a joint is also a precursor to degeneration of that joint (arthrosis).  In the case of PCL injuries, the joint degeneration would occur at the inner compartment as well as at the patello-femoral region (the undersurface of the kneecap).

How is the Ligament Reconstructed?

Surgery is performed arthroscopically and part of the Patellar or Achilles tendon from a cadaver is used as the new ligament.  Rehabilitation follows, with early restrictions on activities that stress the PCL such as those that require bending the knee past 90 degrees.

It is likely that Kendrick Perkins will be back early next season, but not likely that he’ll return to competition much sooner.  Why try to push the pace of recovery in the off-season?  In the meantime, he can compare notes with Andrew Bynam, who will have surgery for his torn meniscus.  Bynam has the better deal on three counts – a less complicated surgery with the expectations of a much faster recovery and the sweet rewards of having won the championship.

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