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The MCL – Two MLB Players Out With Sprains

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 – Pitching With Plantar Fasciitis

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.

Thumb UCL Sprains – Understanding Mike Trout’s Injury

Mike Trout, the Los Angeles Angels’ star outfielder, will undergo surgery tomorrow for a torn ulnar collateral ligament (UCL) in his left thumb. The injury occurred – as most of these do in baseball – when the 25 year-old slid into second on a stolen-base attempt on Sunday. Trout, who throws and bats right handed, had an MRI later that day that confirmed the tear. This will be Trout’s first stint on the DL and it will be for a significant period. Read More ›

Patellar Tendon Rupture – The Final Post Season Injury That Sunk The Spurs

On Monday night, the San Antonio Spurs bowed to the Golden State Warriors in Game 4 of the Western Conference Finals. It wasn’t much of a contest. After another stellar regular season, early playoff injuries robbed the Spurs of veteran point guard, Tony Parker (quad tendon rupture), and the electric small forward, Kawhi Leonard (ankle sprain). On Saturday, when Spurs’ center/power forward, David Lee partially tore his patellar tendon, it was all but over. This wasn’t the first time that the 34 year-old Lee underwent significant post season surgery. He’d had a torn hip flexor repaired in May of 2013 having seen very limited playoff action once sustaining the injury the month prior. Read More ›

Explaining Isaiah Thomas’ Hip Impingement

The Boston Celtics announced on Saturday that Isaiah Thomas, their 28-year-old star point guard, re-aggravated a “right femoral-acetabular impingement with labral tear” in game two of the Eastern Conference Finals against Cleveland. The injury will keep him out for the remainder of the playoffs and may require surgery. The initial insult to the hip occurred on March 15th and it was evidently exacerbated in a semifinal round contest on May 12th. Read More ›

Explaining Adductor Tears: The NBA’s Latest Playoff Injury

Houston Rockets’ 34 year-old backup-center Nenê Hilario suffered a tear of his left hip adductor muscle in the first quarter of yesterday’s playoff game against the San Antonio Spurs. Though the Rockets’ subsequent win tied the series at two apiece, Nenê will be out for the duration. An MRI reportedly revealed the tear. A treatment plan has yet to be announced. Read More ›

Understanding Tony Parker’s Quad Tendon Rupture

The San Antonio Spurs lost point guard Tony Parker to a quadriceps tendon tear in the fourth quarter of game two in their series against the Rockets on Wednesday. Parker, who now faces surgery, was a big reason that San Antonio evened up the series that night at one apiece. Like the Clippers’ loss of Blake Griffin to a season-ending playoff injury, this one could cost the Spurs the ability to advance.

At age 34, Parker’s numbers this season were at a career low (10.1 ppg), though he’d ramped that up to an eight game playoff average of 15.9 on 53 percent shooting. Now he faces a long road back and, with his age and overall declining regular season numbers, a questionable return to the NBA. Read More ›