The Philadelphia Eagles faced off against NFC rival Los Angeles Rams in a contest that many think could be a potential NFC Championship preview. The Eagles came out with a victory, winning 43-35 but suffered a more important loss. In the third quarter, the Eagles star quarterback Carson Wentz dived forward for what was initially thought was a touchdown but took a big hit to both of his legs. The touchdown was called back on a holding penalty but Wentz went on to complete the drive with several hand offs and a great throw in the pocket to receiver Alshon Jeffery for a touchdown. Wentz left the field on his own volition after the drive and walked back to the locker room amid the long faces of the Eagles support staff. It was reported later that Wentz had torn his left ACL which will end his potential MVP season. This is devastating for the Philadelphia Eagles who were super bowl favorites and currently own a 11-2 record, best in the NFC.
Anterior Cruciate Ligament injuries are a very common orthopedic injury in all sports but most notably in sports played on grass/turf due to the high level of cutting required. ACL injuries are frequently non-contact such as when pushing off or pivoting during which the distal aspect of the lower extremity is pushed laterally causing the knee to buckle inwards (known as a Valgus Stress) which places a large amount of stress on the ligaments of the knee most notably the ACL and the Medial Collateral Ligament. ACL injuries can also be from contact or blunt force trauma as in the case of Wentz. A blow to the lateral side of the knee can cause a large valgus force that can lead to an ACL tear.
The ACL is one of the key stabilizing ligaments of the knee along with the posterior cruciate ligament, medial collateral ligament and the lateral collateral ligament. The ACL’s primary function is to control anterior translation of the lower leg(Tibia) on the upper leg(Femur). When one or more of the knee ligaments are not intact, the knee becomes inherently unstable and can cause the knee to buckle or suffer additional soft tissue injuries. For athletes, this is especially problematic as they will not be able to confidently cut or pivot on their affected knee. When a high level professional athlete suffers a complete rupture of the ACL, reconstruction of the ligament is necessary if the athlete wishes to return to sport.
Rehabilitation for an athlete undergoing ACL reconstruction generally takes about 6-8 months to return to sport but can sometimes take over a year. It is important to make sure that the graft that is used to replace the deficient ACL is as strong as it needs to be to tolerate the extreme stresses at the knee of high level sports. It is also important for the athlete to regain as much knee/hip strength (most notably the hamstring which assists the ACL in preventing anterior translation of the tibias) as possible to regain stability at the knee. The athlete must also gain the confidence to compete at a high level on their affected knee which can often be the limiting factor in returning to sport. Early ACL rehab focuses on the athlete regaining full knee range of motion as well as volitional quadriceps strength to allow them to fully straighten the knee. Focus in the first few months is placed on strengthening all of the muscles of the knee/hip/ankle as well as working on balance and proprioception to help return the knee to its pre-injured state. Once the new graft has been given ample time to set (10-12 weeks) more high level strengthening and some sports specific training can begin.
Congratulations to our colleagues and patients who completed yesterday’s NYC Marathon!
Jenna Daly, David Allen, Zoe Saloniltide, Sam Cesario, Nicole Andreolli, Olutoyin Musa
Bears Tight End Zach Miller has Emergency Vascular Surgery Following Knee Dislocation by Sean Sullivan, PT DPT
While orthopedic injuries tend to dominate the headlines in professional sports leagues such as the NFL, neurological or vascular injuries can occur in conjunction and often can be limb/life threatening. Chicago Bears tight end Zach Miller caught a pass in the end zone during their game against the New Orleans Saints when he landed awkwardly on his left leg and came up lame in obvious pain/distress.
His injury was initially diagnosed as a fracture of his leg but was later diagnosed as a knee dislocation. A dislocation the bones that make up that joint are separated often times due to trauma. In Miller’s case, his Femur(thigh bone) and Tibia(shin bone) were separated. It is not known at this time whether Miller suffered any fractures along with this dislocation but it is likely that he will require surgery to repair any soft tissue(ligament) damage that occurred.
What happened in conjunction with Miller’s dislocation turned out to be the more pressing concern for the NFL veteran. Miller also suffered a rupture of his popliteal artery. Miller’s leg was stabilized by on field medical personnel and was rushed to the University Medical Center of New Orleans where he underwent emergency vascular surgery to repair the damaged blood vessel. He is currently being monitored to ensure proper healing/blood flow following his surgery.
The popliteal artery originates from the femoral artery which runs from our groin down the front/inside of our thigh. The Popliteal artery can be found on the posterior aspect of our knee and branches into its various divisions below the knee where it supplies blood flow to our entire lower leg. It is not difficult to see why a rupture of this artery( or any for that matter) is an emergency medical condition. When an artery is damaged, the blood flow to the areas of the body that are supplied by that vessel is impaired which leads to tissue ischemia. Prolonged ischemia of 6-8 hours can lead to irreversible tissue death and can result in amputation being the only means of preserving a limb.
While Miller’s injury is a very rare case, it is important for all medical personnel (on or off the field) to properly evaluate neurovascular integrity of a patient’s limbs following trauma. This means checking all pulses distal to the injury sight and assessing sensation to rule out any nerve or blood vessel damage. Making sure to not forget this crucial step can ensure that patients do not endure long term health ramifications due to late detection of neurovascular damage.
The 2017-18 NBA season tipped off last night with a rematch of last years Eastern Conference Finals pitting the Cleveland Cavaliers against the Boston Celtics. Just minutes into the first quarter Celtic small Forward Gordon Hayward went up for an alley-oop dunk from guard Kyrie Irving when came down awkwardly on his left ankle. The photo below shows Hayward in the air before landing on his left leg. The next photo shows Hayward sitting on the court in visible pain and gives a great view of how his ankle looked after the fall. Those who are squeamish, scroll down with caution.
While further details are still to come on the specifics of Hayward’s injury, what we do know is that he sustained a fracture of his left Tibia(Shin Bone) and a dislocation of his ankle joint. He is set to have surgery on that ankle Wednesday back in Boston. He will likely require a plate/screw/nail fixation(Open reduction with internal fixation) to keep his ankle joint stable and possibly a repair of the ligaments that work to stabilize his ankle. Luckily the Celtics medical staff were able to reduce/relocate his ankle on the court before placing it in an air cast which helped to reduce his pain. He also likely avoided any nerve/blood vessel damage that can occur with this type of injury as this would require immediate surgery.
Rehab for this type of surgery is likely to be at least 3-4 months but possibly longer depending on the degree of soft tissue damage that Hayward sustained. This is important because when a joint is dislocated, often times the surrounding ligaments become compromised, as they work passively to stabilize the joint. As discussed in my post on high ankle sprains, soft tissue such as ligaments do not heal as quickly as bone due to their poor blood supply. If the damage to the surrounding ligaments of Hayward’s ankle is severe, this will likely add months to his recovery and will make his return this season very unlikely.
Week 4 of the NFL season just concluded on Monday night following the Kansas City Chiefs last second win over the Washington Redskins. As with just about every week of NFL games comes a host of injuries to key players on contending teams, often times of the season ending variety.
Rookie running back Chris Carson of the Seattle Seahawks suffered a season ending left leg injury during the Seahawks win over the Colts on Sunday night. What was originally diagnosed as a fracture of his left lower leg turned out to be more severe. In addition to the fracture that he suffered in his fibula, Carson suffered a severe syndesmosis tear otherwise known as a “High Ankle Sprain”.
The syndesmosis is a series of ligaments that connect the ends of the two lower leg bones, the tibia and the fibula. A tear of one of these ligaments is a common injury in American football and is generally caused when the athlete’s foot/ankle is pushed into extreme external rotation. It can also be caused by a blow to the lateral aspect of the knee/lower leg with the foot planted which causes the syndesmosis to be over stretched which is what happened in Carson’s case as seen in the picture below.
The words “High ankle sprain” are words an athlete never wants to hear. Unlike a typical lateral ankle sprain which is a tear of one of the lateral ankle ligaments, a syndesmosis tear takes more time to heal. If there is a disruption of the any of the syndesmosis ligaments, these ligaments are stressed any time the athlete tries to bear weight on that limb as the athlete’s body weight and gravity put stress through the lower leg and tries to separate the tibia and fibula. This is the primary reason why recovery from a high ankle sprain can take longer to heal and are prone to reoccurrence.
MRIs are the gold standard for diagnosing a high ankle sprain. Depending on the grade of the tear, a patient may or may not be instructed to bear weight following the injury. Upon imaging, if there is no widening of the space between the tibia/fibula, the fracture is considered stable and are treated conservatively with rest/rehab and can weight bear as tolerated. If there is mild widening of less than 4cm, then the athlete is generally immobilized in a walking boot. If there is significant widening of the mortise of greater than 4cm, this will require surgical treatment which unfortunately is what will end Carson’s season. Following surgery, Carson will likely be immobilized in a plaster cast for 2 weeks and transferred to a cast boot for another 4-6 weeks during which he will be non weight bearing to avoid stress to the healing fracture/ligaments.
Jose Reyes, New York Mets’ infielder, left Sunday’s game against the Mariners in the fifth inning after being hit on the left forearm by a 98 mph fastball. X-rays were reportedly negative. Though Reyes noted by end game that he was able to move his fingers, something he wasn’t able to do in the immediate aftermath of the injury, the area remained very sore. Amazingly, reports noted that – due to the absence of fracture – Reyes hopes to return to the lineup as early as Tuesday. That seems unlikely.
The area of the impact to Reyes’ forearm was near the wrist, a region with little soft tissue to soften the blow. Since the injury was to his left and he throws right-handed, it is hitting that will clearly pose the greatest problem. Despite being a switch-hitter, everything from cocking the wrists at the early phase of hitting, to rotating the forearms (the upper pronates, while the lower supinates during the swing) could cause pain. Even simply having to absorb the impact of the ball on the bat – will stress the affected area. Whether he bats righty or lefty, demands will be placed on the extensor and supinator muscles that comprise the extensor (dorsal) surface of Reyes’ left forearm.
Though MRI findings were not reported, a bone contusion (in addition to more superficial bruising) is Reyes likely diagnosis. A bone contusion is a traumatic injury that is caused by forceful impact,
It entails disruption to the bone marrow that rests below the joint cartilage. Microfractures, hemorrhages and edema to the inner layers of the bone (known as cancellous bone) are the result. Since the outer, or cortical layers of bone and the cartilage that surfaces the bone (articular cartilage) are not affected, contusions are not referred to as fractures. MRI assists with diagnosis, as these injuries are not visible on x-ray. Interestingly however, even when initial x-rays are negative, fracture may not be definitively ruled out.
When nerves are involved, a contusion can result in tingling, numbness or burning sensations in the area of impact as well as distal to it (further away from the center of the body).
Time to healing varies and depends on the severity of the injury, the presence of other injuries and the demands placed on healing areas. Mild injury may heal sufficiently within three weeks, and almost half of sufferers have been found by some studies to exhibit no evidence of injury six weeks after insult. Other studies report up to six months to full healing after contusions. One in particular on the scaphoid (a bone at the wrist) demonstrated good outcomes for all patients studied, though eight of 41 subjects remained symptomatic at three months, four of whom continued to exhibit some degree of pathology. These also went on to complete recovery.
Returning to play too soon is likely to prolong recovery and may even result in concomitant pathologies. In the case of muscle contusions these can include excessive scar tissue formation and myositis ossificans. It isn’t worth it.
Recently an article was published in JAMA by Mez, Daneshvar, and Kiernan et al that investigated the frequency of Chronic Traumatic Encephalopathy (CTE) in football players. It has become a topic of controversy because CTE has become a red flag for the public eye. It is now known to be correlated with repetitive trauma from popular impact sports such as hockey, football, and even soccer. While many hope to avoid or prevent the progression of this disease, there is currently no definitive causation and therefore no cure-all. CTE is a post mortem diagnosis that requires evidence of an accumulation of certain proteins along with other neurological criteria.
Mez, Daneshvar, and Kiernan et al used current classification systems to evaluate and assess 207 donated brains of football players. An overwhelming majority of them (87%) met the criteria for neuropathological diagnosis of CTE and the article detailed severity of symptoms (pre-mortem) associated with severity of CTE as well as mean age of death. While the article suggested a relationship between higher level of football participation (NFL) and worse disease presentation, the authors were definitely not stating a cause and effect relationship. The conveniance sample was for investigating possible relationships between activity levels and disease burden. This was an observational study with no constant or variables to compare.
Studies have shown that while living, a person with CTE may present with similar behaviors and cognitive impairments to that of a person with mood disorders, dementia, or Alzheimer’s disease. Mez, Daneshvar, and Kiernan et al outlined common characteristics and behaviors of the people that were diagnosed with CTE and therefore provided a foundation for future studies to help eventually determine causation, a sensitive and specific means of evaluation, and prevention. Until then, athletes of all levels must try their best to avoid repetitive and unecessary microtaumas. Playing smart and competitively, not aggresively, can help minimize repeated impact and trauma in every game.
Elizabeth Lamontagne PT, DPT, SCS, CKTP
Angels outfielder Cameron Maybin, sustained a Grade 1 right knee MCL sprain in a stolen base attempt on Tuesday. Also on Tuesday, Stephen Vogt, Brewers backup catcher, sprained his left MCL in a collision at the plate with Pirates pitcher Chad Kuhl. Kuhl remained in the game. The Grade of Vogt’s injury was not reported.
Some MCL Anatomy
A Medial Collateral Ligament, or MCL, is a ligament that stabilizes the inner (medial), aspect of joints such as at the knee and elbow. At the elbow, it is the ligament that is reconstructed when pitchers undergo Tommy John surgery. It is a fibrous band of tissue and – in the case of the MCL at the knee – it has both a superficial and deeper layer, each of which has different attachments. For more detail on the medial knee and origins and insertions of the ligament take a look here, or here.
The superficial MCL serves as the primary restraint to check against forces to the outer knee that would result in the knee collapsing inward. This is known as a valgus stress. The superficial portion of the MCL has both anterior (front) and posterior (rear) fibers and the degree to which they are effective in this role depends in large part on the position of the knee when the stress occurs. When the knee is almost extended, the ligament contributes somewhat less to the stability of the joint. Therefore, testing for the integrity of the MCL is done with the knee flexed to 30 degrees, an angle at which the ligament is most effectively isolated.
The deep layer of the MCL is often separated from its superficial counterpart by a bursa, which allows for a greater mechanical advantage and smoother gliding of tissues. A point of note with regards to the deeper layer of the MCL is its attachments to the meniscus both from the femur above and the tibia below (it also inserts directly into the top of the tibia at the tibial plateau). Because of its meniscal attachments, MCL injury can result in meniscal injury as well. Though the deeper layer does not contribute much as a restraint against valgus stress, it does serve as a secondary check to anterior translation of the tibia (which would result in knee hyperextension). The Anterior Cruciate Ligament (ACL) serves as the primary restraint to this motion. The relationship between the two ligaments is the reason that ACL injuries are often accompanied by those to the MCL.
Diagnosis and Treatment
Ligament sprains are graded from Grade 1 – which is a mild tweak causing less damage – to a Grade 3, or complete rupture. Time lost to competition depends on the severity of the injury, the specific location of the tear and the individualized nature of the healing process. Pain can be very localized or more diffuse depending on where the tear occurs. MCL tears at the attachment to the femur can result in a portion of the bone being avulsed, while tears more central to the ligament can cause significant soft tissue damage. Tears at or near the tibial attachment may cause pain to run down the shin and it is also possible to experience an MCL tear deep to the pes anserinus, a site of attachment of several muscles/tendons below the knee at the medial aspect of the tibia.
MRI can be helpful in identifying the location of the tear and the degree of damage. Treatment is generally non-operative with a healing response time for significant tears of six weeks. However, because remodeling of the scar tissue involved in the healing process can take up to a year, the tensile strength of the tissues can be compromised during that extended time. Interestingly, studies have noted that even though mature scar tissue has only 60% of the strength of a normal MCL, the fact that there is a proliferation of this tissue compensates sufficiently so that “the ultimate load to failure is unchanged”.
Surgical intervention may be indicated when a significant gap occurs in the MCL at the area of a tear or when a portion of bone is avulsed.
John Lackey, right-handed starting pitcher for the World Champion Chicago Cubs, will be 39 years old in October. He is dealing with plantar fasciitis in his right foot, yet will start Tuesday’s game against the Braves after getting some extended All Star Break rest. Lackey was effective over six innings in his last start on July 5th before going on the 10-day DL the following day. This will be his first start since being activated.
Baseball players have successfully played through fasciitis before, Albert Pujols being one of the most visible and recent examples. But eventually Pujols succumbed to surgery as his condition worsened while he continued to play (even with a reduced role as DH). The condition can be quite painful and – even for a non-athlete – get in the way of performing routine activities. However, surgery is only a last resort.
The likelihood that ten days of rest will have resolved Lackey’s problem is not great. It becomes more about how (or if) the condition can be managed enough for the pitcher – whose numbers have suffered in comparison to the 1916 season – to be effective.
The Plantar fascia
The word plantar refers to the sole of the foot, and the plantar fascia is a thick fibrous band of connective tissue in this region that extends from the heel to the forefoot. It assists with stabilization of the arch. Fascia occurs throughout the body and overlays the muscles, organs, nerves and blood vessels. It acts as a restraint to keep our tissues and structures in place.
“Itis” means inflammation, in this case of the fascia. As with tendinitis, it is generally felt that a degree of degeneration is also occurring. This is known as tendinosis when referring to tendons. It is much like what happens with conditions such as tennis elbow or patellar tendinitis, which are also due to overload.
The fascia in the foot is particularly strong and is prone to stresses and small tears. Plantar fasciitis, a common cause of foot pain, is an overuse syndrome set off by too much tensioning of the fascia’s attachments to the heel. Though there is an increase incidence of heel spurs in sufferers of fasciitis, spurs, which are generally not within the fascia, do not always cause pain. However they may contribute to a predisposition to the condition.
Weakness of the muscles of the calf or foot/ankle impact function and also predispose to injury by placing more stress on all the related tissues. There is reportedly no definitive evidence that either a high or low arched foot predisposes to plantar fasciitis.
The onset of fasciitis is usually gradual rather than from trauma, and the problem is often stubborn, especially if left untreated. Generally speaking, the faster treatment is initiated after the onset of symptoms, the more accelerated is the recovery.
Women who wear high heels much of the time are prone to fasciitis because the calf muscles and fascia become tight due to the positioning of the foot and ankle. People whose work requires that they spend an inordinate amount of time standing or walking (particularly on hard surfaces) and those who are significantly overweight are also more prone to plantar fasciitis. Prolonged walking, and especially running, which requires a more forceful push-off, are likely to increase inflammation and pain. Jumping will do likewise.
The pain that occurs with this condition is often exaggerated in the morning because the fascia and heel cord (Achilles) are relaxed during sleep. Those first steps when the area is put on stretch can be especially problematic. That is why night splinting to keep the area on mild stretch is so helpful in treatment. The pain, which can be either sharp or dull, often feels like a pulling and is more common after inactivity than with movement. Hence standing for long periods worsening symptoms.
Fasciitis can involve tenderness along the band of the fascia in the arch or be more toward the heel. Putting the fascia on stretch by bending the toes back (dorsiflexion) – especially along with dorsiflexing the ankle (flexing it toward one’s head) – makes the area much more tender to touch. Plantar fasciitis must be distinguished from other conditions such as Heel Pain Syndrome, where the pain is more exclusively localized to the heel.
Treatment for plantar fasciitis focuses on relief of inflammation as well as stretching the fascia itself and reducing its soft tissue restrictions as well as stretching the calf and Achilles. Fascia stretching has proven most effective when it is non weight-bearing and specific to the area. There are many other ways in which to stretch, especially by taking a more dynamic approach and focusing on inhibiting muscles that limit the flexibility of the tight structures. One note of caution if stretching statically and when weight-bearing is to AVOID hanging the heel down off a step. This puts the midfoot structures at risk and also increases incidence of future Achilles rupture. It is best to keep the foot supported on the floor or on a wedge when stretching in in this position.
Treatment of fasciitis should also include assessment of, and attention to, areas of the foot that are related and may impact flexibility of the calf or pliability of the fascia. For instance, if the ankle or the joint at the base of the big toe lacks full mobility (into dorsiflexion) the soft tissues may not be able to stretch adequately. In these instances, restoring mobility to the joints may be necessary to get the desired result.
Though cortisone injections may provide temporary relief (studies show most patients have recurrence), they also come with an increased risk of rupture. The interesting thing is that treatment of chronic plantar fasciitis sometimes includes surgically lengthening the fascia (a procedure that Albert Pujols had), something that rupture may accomplish naturally. The downside is the time spent totally out of commission while healing in either case.