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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.

Victor Cruz Ruptures Patellar Tendon: About The Injury

Victor Cruz, a key NY Giants receiver, knew he’d suffered a significant injury before he’d even landed from a leaping attempt to catch a fourth-and-six pass down 20-0 to the Eagles in the fourth quarter on Sunday night. The diagnosis, a ruptured patellar tendon, more than ends Cruz’s season, it puts his career in jeopardy.

The patellar tendon is a part of the extensor mechanism of the knee, connecting the patella, or kneecap, to the tibia of the lower leg. Since tendons connect muscle to bone, enabling them to function, and ligaments provide joint stability by connecting one bone to another, the patellar tendon is actually a ligament. However, this vital structure is referred to as a tendon because rather than serve primarily for stability, its function is to enable the quadriceps muscle to extend the knee.

The extensor mechanism of the knee includes the quadriceps muscle, the quadriceps tendon (which attaches the muscle to the patella), the patellar tendon, the tibial tubercle (which is where the patellar tendon attaches to the tibia), and various ligaments that provide soft tissue restraints to the patella while it rides up and down during knee motion (the medial & lateral retinaculum and patellofemoral & patellotibial ligaments).

Because all the structures of the extensor mechanism are so superficial, they can be easily injured, though complete ruptures occur infrequently. The quadriceps tendon and patellar tendon are most vulnerable to rupture, which can be partial or complete. Rupture of the patellar tendon occurs more frequently amongst those under 40, while quad tendon ruptures occur more typically in the over 40 set. Young athletes generally do not suffer from complete ruptures, though chronic steroid use and diabetes are thought to be predisposing factors.

Another patellar tendon injury more common in the under 40 group is an avulsion of the tendon, which means part of the bone is pulled away along with the tendon, either at its attachment to the inferior pole of the patella itself (the more common avulsion), or at tibial tubercle. Interestingly, patellar tendon avulsions occur more frequently amongst those of African descent.

The most common cause of patellar tendon ruptures is during athletics when resisted knee flexion is accompanied by a violent quadriceps contraction – typically when landing from a jump.

A completely ruptured patellar tendon will not heal sufficiently to provide adequate function without surgical intervention. Surgery is generally performed shortly after incurring the injury and, in the interim, an attempt is made to control the inflammation. The success rate is improved if the procedure is not delayed, as the tissue will have little time to retract. The torn tendon is repaired and then sutured through bone tunnels in either the patella or tibial tubercle.

Post-operative rehab for a patellar tendon repair is a lengthy process. Controlling inflammation, restoring soft tissue and patellar mobility, knee range of motion and strength and power of the muscles that cross the hip and knee are of paramount importance. Return to full weight bearing and routine daily activities can take three months and sports specific activities are generally initiated at four to six months. It takes longer to return to full participation.

Even after a successful patellar tendon repair and when full knee flexion is obtained, the strength and explosiveness of the quadriceps may not be fully restored. This is but one facet of Victor Cruz’s game, though one that has set him apart. He has a lot of work ahead and hopefully will prevail.

Follow Abby Sims on Twitter @abcsims.

Degenerative Articular Cartilage – Explaining Sabathia’s Diagnosis

CC Sabathia, on the DL with what had been diagnosed as inflammation in his right knee, now has a real diagnosis and it is degenerative changes to the articular cartilage. Media reports did not disclose the degree of wearing of the cartilage, a factor that is crucial to understanding the pitcher’s condition.

Sabathia was reportedly slated to receive a cortisone injection and treatment with stem cells. Cortisone is simply a steroidal anti-inflammatory that may reduce the signs and symptoms but has no curative benefit for the cartilage itself. Though worth a try, there is no guarantee that the stem cell procedure will be successful.

A last resort surgical option, should the

current plan not succeed, is micro-fracture surgery, though this also offers no certain outcome.

Let’s backtrack a moment though…

You may recall from my previous post, that articular cartilage provides a smooth glassy surfacing at the ends of many bones. It facilitates movement while also protecting the integrity of the bones.

Though injuries to the articular cartilage – also known as chondral defects – often occur due to direct trauma that entails a rotational component, they may also result from degenerative changes. However, there are often factors that are predictive of the wear and tear that ultimately occurs.

Initial insults to the cartilage from prior injury – such as that causing the meniscal damage Sabathia suffered in 2010 – might have played a role in predisposing his cartilage to break down. The presence of any instability of the knee joint (such as that due to ligament sprains or tears), especially coupled with overuse also predisposes to the onset of degenerative changes, as does removal of a meniscus.

The degree of damage to articular cartilage is classified from zero, being normal cartilage, to Grade 4, which is when the surface is totally worn away exposing the bone below. Grade 4 lesions are often described as being “full thickness” resulting in a joint being “bone on bone”.

Injury to the articular cartilage most often occurs in weight-bearing sections of the bone and on the medial (inner) aspect of the knee. Restoring articular cartilage is a tough order. Due to its poor blood supply – much like the menisci in the knee – it does not heal in the way most of our other tissues generally do. Micro-fracture surgery attempts to remedy this by perforating subchondral bone in regions that are cartilage deficient

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in order to stimulate a sustained reparative response by bringing blood to the region.

As for rehab, maximizing strength in the muscles crossing the hip and knee is crucial when addressing any knee issue. Strong muscles help to take some of the stress off the affected joints. Regardless of the specific treatment he receives, Sabathia will continue to work to optimize his strength.

It should be noted that as a lefty, Sabathia puts a lot of weight, force and torque on his right knee when pitching. Studies have shown that extending the lead knee “may provide stabilization allowing better energy transfer from the trunk to the throwing arm, and could be a critical factor in pitch velocity.”

I would expect CC to be out of action for longer than the 15 days dictated by his being on the DL. If not, he’ll certainly not yet be at 100% and his velocity will likely be an issue.

Follow Abby on Twitter @abcsims.

Playing Hurt – All Season

Bryce Harper, the Washington Nationals outfielder – who bats lefty and throws righty – is a young stud. And hopefully that won’t get in the way of his having a long, productive and potential-reaching career.

Now, with less than a month left in the regular season, we learn Harper supposedly has had hip pain since crashing into the outfield wall on April 29th. He stayed in the lineup in spite of hurting his ribcage that day and then played on after another date with the wall on May 13th when he hurt his left knee. As any headstrong athlete might – but especially one who is a stubborn twenty year old – Harper continued to take the field, aggressively, though less productively, until aggravating

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the knee with a headfirst slide on May 25th. The diagnosis was bursitis and was secondary to the trauma from contact. Harper ultimately voiced his regrets for playing hurt – doing so likely compounmicrosoft software downloads

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Da’Sean Butler and MCL vs. ACL Injuries

uke’s Blue Devils emerged victorious over Butler on Monday to be crowned NCAA Champions, though Butler now occupies an elite position on the college basketball map. However, the Butler whose NCAA story ended far more disastrously than with simply losing the big game was West Virginia’s Da’Sean Butler. The senior combo forward and Mountaineers leading scorer went down with a knee injury while driving into Brian Zoubek on his way to the basket with 8:59 remaining in the second half of the semifinal against Duke. Anyone who saw the play and of course, the slow-motion replay, could see the pain that Butler was in, likely from the injury itself as well as the timing (not that there is ever a good time for a major injury). It isn’t likely that the Mountaineers would have won the game had Butler remained intact, but this injury may have derailed more than his hopes for a championship. Butler’s blown out ACL may have cost him millions by driving down his stock as a possible first round selection in the upcoming NBA draft.

Coach Bob Huggins initially indicated that Butler had sprained his left MCL (medial collateral ligament). However, West Virginia’s Sports Information Director later announced that an MRI performed on Sunday revealed an ACL (Anterior Cruciate Ligament) tear as well as two bone bruises in addition to the MCL sprain. It seemed apparent from the moment Butler planted his left foot and his knee gave way that this was more than a mild sprain.

What is the ACL?
The Anterior Cruciate Ligament is the primary stabilizer of the knee. It is located between (and attaches) the rear outer base of the femur (thigh bone) and the top of the front inner tibia (the larger of the two bones in the lower leg). It is called the anterior (front) cruciate because it crosses another ligament (the posterior cruciate) that is located behind it, with the two ligaments essentially forming an “X”. The role of the ACL is to prevent the top of the tibia from gliding forward. When torn, this motion is not checked and the knee becomes unstable, often buckling.

What is the MCL?
The Medial Collateral Ligament also connects the femur to the tibia but at the inner, or medial compartment of the knee joint. When Butler went down it appeared that his knee buckled inward, permitting excess motion at the inner joint (the foot and lower leg angled outward). This would be indicative of an MCL injury.

What is a bone bruise?
Muscles, nerves and bones can all suffer bruises, which are also known as contusions. Contusions occur because of trauma associated with impact, and the severity of that impact is one important determinant of the degree of injury and rate of recovery. Simple muscle contusions generally resolve in a matter of weeks, and the healing process involves muscle repair, regeneration and scar-tissue formation. All contusions result in localized inflammation as well as pain and they may also inhibit muscle strength. Nerve contusions can precipitate neuralgic symptoms, while bone bruises can be particularly debilitating as well and some studies indicate their relationship to arthritic changes over time.

The specific location and type of bone bruises suffered by Butler were not clarified in reports of the injury. Though they may have resulted because of the impact against Zoubek (in this case they would likely be more superficial) they may also have occurred at the bony surfaces of the knee joint in the course of tearing his ACL. When an ACL injury occurs, excess or abnormal motion (of one bone on the other) is permitted, allowing the bones to bump into each other, resulting in a contusion. The MRI was an important diagnostic tool used to identify the nature and extent of Butler’s injuries, and if he suffered this type of contusion, it likely demonstrated abnormalities in the bone deep to the smooth cartilage that lines the joint.

Da’Sean Butler will have surgery soon and has a long road of aggressive rehab ahead. Therapy will focus on controlling any inflammation and swelling, restoring range of motion, muscle strength and flexibility, balance, and ultimately on movement, agility and plyometrics (jumping, etc). At the same time he will work to maintain his cardiovascular endurance. According to NBADraft.net, Butler is ranked as the 21st-best prospect in the 2010 NBA Draft, while DraftExpress.com has him as 44th in line. In a mock draft that was updated after the injury, DraftExpress had Butler as the 14th pick in the second round. He was interviewed during the championship game yesterday and expressed confidence that he will play in the NBA next season. With a great attitude and work ethic, the advances in surgery and rehab today, and with youth on his side, it is very likely that Da’Sean Butler will achieve his dream

Kalin Lucas and the Debilitating Nature of an Achilles Tendon Rupture

Fifth seeded Michigan State managed a huge win on Sunday over fourth seeded Maryland on a three-point buzzer-beater by Korie Luscious. The biggest surprise was that the Spartans did it without the services of Kalin Lucas who went down with 2:28 left in the first half while clutching his left foot. Though reports have not yet clarified the details of Lucas’ newest injury, Coach Tom Izzo was quoted after the game as having said that he was 99% certain that his star would be out for the balance of the season after what appeared to be an Achilles tendon rupture.

If his coach is correct, Kalin Lucas should give David Beckham a call for a Q & A on what to expect next. Mr. Beckham was headed to his fourth World Cup,

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a record for an English soccer player, when he left the field in tears on March 14th after he too suffered an Achilles rupture. Beckham wasted no time in having surgery, flying to see a specialist in Finland early the next morning for an Achilles repair.

Both Lucas’ and Beckham’s injuries were non-contact, typical of Achilles ruptures. Lucas claimed not to have felt or heard the “pop”, often associated with Achilles injury, though he reportedly did think he might have been kicked — a sensation that is also classic for a rupture. Beckham looked behind him when his injury occurred, as though he too may have suspected a kick to the calf. Both players also likely experienced sharp pain. Post-game, a teammate said that Beckham felt the muscle begin to come up. This too is common; it is almost like firmly pulling an elastic band until it breaks and seeing the top half retract. Surgery is often performed quickly, exactly for that reason to approximate the two ends of the tendon it is often recommended to act before the tissue can shorten permanently.

What is the Achilles tendon?
Tendons attach muscles to bones. The Achilles is thicker and more fibrous than most tendons and it connects the calf muscles (the gastroc in the upper calf and the soleus closer to the ankle) to the heel bone (calcaneus). The Achilles tendon and calf muscles are put on stretch when the ankle is flexed up and it is shortened when the toes are pointed. A tight Achilles or one that is overstretched can predispose to rupture.

What are the consequences of Achilles rupture?
In addition to the pain and swelling that are expected with any sports injury, disruption of the connection between the calf muscles and the heel results in an inability to contract these muscles; That means that you cannot rise up on your toes or walk with a normal push off when weight-bearing on your injured side. Running and jumping are therefore also out of the question.  However, it may be possible to actively point your toes while you are not bearing weight due to the action of other muscles that help to provide this movement.

Why do Achilles tendons rupture?
There is an area of the Achilles that has less blood flow than the rest and it is thought that this section of the tendon may not be as strong. As we age, tendons, as other tissues of the body, become less supple and may degenerate. These are some reasons why ruptures generally occur in people over 30 (Beckham is 34), and especially in middle age. Younger athletes generally experience a higher tear, well above the ankle, where the muscle joins the tendon (musculo-tendinous junction), though they too can experience a tear closer to the heel.

Some sports are more stressful to the calf muscles and Achilles than others. Those that require the powerful push-off needed for running and jumping place the greatest demand, as do those like racquet sports which entail a lot of stutter-steps and quick stops and starts. Men are far more likely to suffer Achilles ruptures than women and though it is thought that obesity adds to the stress to the Achilles, increasing risk of rupture, that is clearly not a factor for elite athletes.

Other predisposing factors for weekend warriors like you and me include stepping up activity suddenly and significantly – either by increasing the intensity, frequency or duration of participation or perhaps beginning a new activity without preparation. All of these increase the demand placed on the Achilles. It is thought that weakness of the calf muscles, particularly the soleus, may also be a factor causing the Achilles to rupture; The soleus can be strengthened by pointing the foot — against resistance — while the knee is bent (as in a sitting position). A history of multiple steroid injections at the Achilles may be to blame in some cases of rupture. Be aware that manufacturers of certain medications, such as the antibiotic Levaquin, name tendon issues as a potential side effect. Inform your physician if you begin to feel Achilles symptoms after beginning a new medication.

One exercise I strongly suggest you avoid is strengthening the gastroc muscles of the upper calf by hanging the mid-foot and heel off a step or raised platform and doing heel-raises from this position of maximum stretch. Repeatedly lowering the heel below the level of the step (with your body weight and gravity loading the Achilles tendon), puts the tendon at greater risk of rupture. This is an exercise I see so often in the gym. Yes, you should strengthen the calf, but it is recommended to do so from the more neutral foot flat position or not fully weight-bearing if on stretch.

How is an Achilles rupture diagnosed?
Physical exam is often pretty conclusive. The first test is simply to squeeze the belly of the calf muscles and observe whether the foot points as the muscles are manually shortened. Another obvious sign is when the examiner can move the ankle excessively into a dorsiflexed position (toes toward your nose) with the knee straight. This motion is generally restricted by the tightness of the Achilles and in the case of rupture it is not. A third test involves observing the motion of a needle inserted into the tendon as the foot is passively moved up and down. An ultrasound exam and/or positive x-ray findings — particularly those in a lateral (side) view – support the diagnosis.

What are the treatment options?
Small tears may do well with immobilzation. Casting is generally done with the foot in a pointed position, which shortens the tendon allowing it to heal. Bracing that restricts motion is an alternative. Athletes are not good candidates for conservative management, and those who do not undergo surgery should expect a long recovery (up to a year) before returning to sports.

Operative treatment is the gold standard for athletes, younger patients and those with a complete rupture. Both treatments are followed by periods of decreased weight-bearing, though the surgical patient progresses at a much faster rate.

Outcomes
According to Wheeless Textbook of Orthopaedics, non-operative patients have an average re-rupture rate of 18% and can expect a decrease in strength and muscle endurance of 30%. 83% of surgical patients and 69 % of immobilization patients can expect to resume their pre-injury level of activity. Wheeless also reported that 93 % of surgical patients were satisfied with the results of treatment, while only 66% of conservatively managed patients felt likewise. Because of the positioning of the foot with the tendon in a shortened position while casted or braced, non-operative treatment generally does not restore the Achilles tendon to its full length. In contrast, if immobilized with the ankle in a neutral position, the tendon is generally lengthened, leading to a poor outcome.

The Spartans of Michigan State will meet up with Cinderella Northern Iowa, a ninth seed, this Friday. Tom Izzo is a great guy and a great coach. His team has stepped up under pressure before, just as they did on Sunday. Kalin Lucas will either be with them in spirit or cheerleading from he bench. Maybe they can pull this one out in his honor.

Brandon Roy’s Meniscus Woes – Different Types of Meniscus Tears & Their Treatment

The Portland Trail Blazers persevered through a myriad of significant injuries, major illnesses and even some image-tarnishing scandals this season and have somehow fought their way into the playoffs.  Now, seeded sixth, Portland will really have to rally to get past the third-seeded Suns in the first round, for they are without their leading scorer, Brandon Roy.  Roy, a three-time All Star shooting guard who averaged 21.5 ppg during the regular season, tore a meniscus in his right knee early in the victory over the Lakers on the 11th of April and on the 15th he had surgery to repair the damage.

Though first quoted as having said he hoped to play through the injury, Roy subsequently decided on the surgery saying, “…If I’m going to be out there, I want to be contributing.  If we’re fortunate enough to advance in the playoffs, having the surgery now gives me the best opportunity to help our team.”  Don’t count on it sports fans. There are more than the two obvious “ifs” in that statement and the one between the lines speaks to the improbability that Roy, or anyone for that matter, could recover sufficiently in such a short time so as to play NBA caliber ball, especially without risking the health of his knee over the long haul.  NBA.com later quoted a more realistic Kevin Pritchard, GM of the Trail Blazers, as saying “We are looking forward to Brandon making a full recovery and expect him to be ready for the start of the regular season.”

So, what is a meniscus anyway?
A meniscus is a cartilagenous structure that appears in a few joints of the body, most notably at the knee.  There is an inner, or medial meniscus and an outer, or lateral meniscus.  Both lie between the tibia (the large bone of the lower leg), and the femur (thigh bone).

The medial meniscus is ‘C’ shaped and the lateral meniscus has more of an ‘O’ shape, and they span the knee joint from front to back.  The menisci serve several important purposes — A primary role is to enable the surfaces of the bones that form the knee joint (the femur and tibia) to fit together better (particularly as the knee is bent).  This prevents excess movement between the bones thus assisting in stabilizing the knee.  This increased stability diminishes wear and tear of the joint surfaces, minimizing arthritic changes.  Menisci also distribute the forces at the joint and bear a good deal of the load that is transmitted during movement and with the compressive forces of activity.  They are like the bumper cushions and shock absorbers of the knee.

Why is the medial (inner) meniscus hurt more often than the lateral one?
A compressive force coupled with rotation at the knee as it moves from a bent to a straight position is thought to be the most likely cause of meniscal tears. However, some tears may be considered degenerative in that there is no known trauma.  The latter type are generally diagnosed in an over 40 population.

The medial and lateral meniscus are anchored (via ligaments) to the femur and tibia.  Other ligaments also connect the two menisci to each other.  However, there is a degree of mobility of the menisci, which enhances their function and helps to prevent injury.  Some studies have demonstrated that the rear portion (called the posterior horn) of the medial meniscus has the least amount of mobility, and this may contribute to the frequency with which it is injured.

Another reason the medial meniscus is frequently injured is that it is attached to the medial collateral ligament (MCL), which stabilizes the inner compartment of the knee joint (take a look at a recent entry on Da’Sean Butler for more on the MCL).  As a result, injuries to the MCL also frequently cause a tear of the medial meniscus.

What is the difference between a meniscal repair and a meniscectomy?
A meniscectomy is the removal of the entire meniscus.  This procedure is rarely performed these days because we have a better understanding of the important role that the menisci play in protecting the knee.  However, many people undergo a partial meniscectomy (using an arthroscope), in which a portion of the meniscus is shaved off, to eliminate the torn section.  The choice to preserve the meniscus is made whenever possible and the determining factor is the type of tear as well as its size and location. Some stable small tears may not require surgery at all.

To oversimplify, the outer section of each meniscus has a better blood supply than the more interior region.  Tears in this outer, or vascularized portion are those that respond to repair.  Where the blood supply is limited, sufficient healing will not take place so rather than repair it, a portion of the meniscus is removed.

Another factor that is important in determining whether a meniscus is repaired or partially removed is the stability of the joint.  If a knee is unstable, a meniscal repair is likely to fail.  If an athlete has an ACL (anterior cruciate ligament) tear along with a meniscal tear, the ACL must be reconstructed at the same time the meniscal surgery is performed to ensure its success.

Is there a difference in the way the two surgeries are rehabilitated?
In the old days (I’ve been around awhile!) meniscal repairs were rehabilitated in a slower more guarded fashion than partial meniscectomies, limiting a patient’s weight-bearing and initially bracing the knee in an extended position. This resulted in more muscle atrophy from disuse, increased difficulty restoring full mobility and delayed progress to full function. The current school of thought is to accelerate the rehab process, much like that for the partial meniscectomy.  However, this still takes at least 6-8 weeks, and for most weekend-warriors and major league spectators, longer.

So, back to Brandon Roy… There is no point in pushing his limit.  Rehab, even for high-level athletes should not be rushed, and when players return to competition too soon they often sacrifice long-term health for short-term rewards.  The Trail Blazers are smart in playing it safe and putting a priority on having a healthy Brandon Roy around for future seasons.