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Antonio Cromarie: Breaking Down The Hyperextended Knee

Antonio Cromartie reportedly suffered a hyperextended knee during practice on Thursday, in what was noted to be a non-contact situation. The surprising Jets could suffer on defense without their first line player, whose status for this weekend is uncertain.

Though an MRI evidently did not reveal significant injury, and no specific diagnoses were made public, Cromartie is clearly not up to speed.

What is the significance of a hyperextended knee?

Ligaments – which attach bone to bone – provide stability by restraining excessive movement in our joints. When a joint goes beyond its normal range of motion, the integrity of certain ligaments becomes compromised, resulting in a sprain. In the case of the knee, forceful or traumatic hyperextension into a bowed position stresses the anterior cruciate ligament (ACL) – which is the primary stabilizer of the joint – and may also impact other secondary stabilizers. Worst-case scenario for Cromartie would have been a Grade 3 sprain, otherwise known as an ACL tear. A likely best case was a Grade 1 sprain, with only mild tweaking of the ligament.

When the knee hyperextends, the tibia (the larger bone in the lower leg) glides forward excessively on the femur (the thigh bone) at the knee joint. This abnormal movement, whether caused by trauma or a non-contact situation, can also result in a bone bruise, or contusion. As with a sprain, the extent of the contusion would be proportional to the degree of hyperextension that occurred and whether trauma played a role. Another factor is the athlete’s baseline – or normal – range of motion.

A prior history of ligament sprain that results in persistent joint laxity predisposes an athlete to excessive joint mobility. This may set the stage for a non-contact injury such as Cromartie suffered. Many people – particularly ballet dancers and gymnasts – have hypermobile knees, enabling extension beyond a level plane and into a hyperextended position. This expanded range of motion is their “normal”. For a hyperextension injury to occur in these populations, the tibia would have to glide that much further forward, still stressing its restraints.

It is important for an athlete or dancer to have exceptional muscle strength, particularly in those muscles surrounding a less than stable joint. It is also vital that strength is optimized at the end-ranges of motion. The hamstrings become particularly vital in the case of the knee, for in their role as knee flexors (in addition to bending the knee, the hamstrings act to extend the hip), they provide a degree of dynamic restraint to limit hyperextension.

Adrian Peterson And The Unhappy Triad

Adrian Peterson, 26-year-old Minnesota Vikings’ running back, went down last Saturday with what is sometimes called an “Unhappy Triad”. The “unhappy” part is obvious. The “triad” is, because the injury represents a triple threat, with tears of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and medial (innermost) meniscus of the knee. Surgery is a given in these cases to reconstruct the ACL and either repair the meniscus or remove the torn portion. MCL tears are often treated non-operatively, with surgery reserved for only certain circumstances, as when a portion of the bone is pulled away (an avulsion).

The ACL is the primary stabilizer of the knee, while the MCL protects the medial (inner) compartment of the knee. Both ligaments attach to the femur (of the thigh) and the tibia (of the lower leg). The medial and lateral (outer) menisci are the pieces of fibrocartilage that lie between these two bones. They serve to create a better fit at the joint, and act as secondary stabilizers as well as shock absorbers.

These three structures are oftentimes injured together because the nature of the trauma forces the joint into a position that stresses the ligaments beyond their capacity to check the motion and simply tears these stabilizing structures. According to Wheeless’ Orthopaedics, the mechanism of injury most often involves internal rotation of the femur on the tibia with the knee in flexion (bent). The femur tends to position the medial meniscus toward the back of the center of knee joint, catching the posterior portion between the femur and tibia. When the joint is suddenly extended, the meniscus tears along its length.

The medial meniscus is affected more often than the lateral both because of the way in which the knee is generally stressed and because it is attached to the deep fibers of the MCL. Thus, stress to the medial collateral also pulls on the medial meniscus. The lateral meniscus is not anchored to the lateral collateral on the outer side of the knee.

Peterson will have a challenging rehab ahead of him, but he is young and motivated. Willis McGahee did even more damage to his knee in the Fiesta Bowl in 2002 and continues

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to be a very productive running back, even in spite of a string of new injuries. Don’t count Peterson out. If he’s not back for the start of the season, he will likely join the Vikings midway.
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Willis McGahee and Fractured Metacarpals

Denver RB, Willis McGahee, returned to the field in Oakland on Sunday, and powered the Broncos past the Raiders.  He took some of the heat off Tim Tebow with 163 rushing yards  and two touchdowns.  Quite an accomplishment for a guy thought to be a back-up at best at the start of this season, and one whose best days were behind him. With his numbers this week, McGahee leads all NFL running backs in both rushing and TDs.

What makes McGahee’s accomplishments even more remarkable is that he played less than two weeks after surgery to repair a fractured fourth metacarpal in his right hand. McGahee had suffered the impact injury against a defenders mask versus the Dolphins on October 23rd.

The procedure performed on McGahee reportedly entailed stabilizing the fracture in his ball-carrying hand with a plate and five pins.  Originally casted, he reportedly wore only padding over his incision during practice last week and was absent that at game time. McGahee was quoted as saying that he  “suffered what doctors call a boxer’s fracture.” but could now “bend my hand without it hurting or anything”.  Improbable but we’ll take him at his word.

McGahee is no stranger to an accelerated return to action.  Having ended his college career in the 2003 Fiesta Bowl with devastating tears of his left ACL (anterior cruciate ligament), PCL (posterior cruciate ligament) and MCL (medial collateral ligament), he was drafted in the first round after an early return at the combines, and went on to a brilliant rookie season with Buffalo.

So what are the Metacarpals, and what is a Boxer’s Fracture?

The metacarpals (MCs) are the long bones in the hand that extend from the small carpal bones (that comprise part of the wrist) to the base of the fingers. Each metacarpal has a base near the wrist and a head at the knuckle (forming a joint with the lower bone of the finger – the proximal phalange) and a shaft and neck in between.

The MCs are most often fractured due to impact with a closed fist.  I know of too many people who’ve had this injury from punching a wall in anger.

Some metacarpal fractures can be treated conservatively with splinting. Others, like McGahee’s, require surgery, either because they are displaced (the segments of the bone no longer line up) and involve the joint, because more than one MC is fractured, or due to soft tissue that is in the way, preventing the bone from being set. I have not seen reports of the specific nature of McGahee’s fracture, but it is likely his falls into one of the first two categories.

Fractures can occur at any point in the metacarpals, though the very common  Boxer’s Fracture  is technically considered one that occurs at the “neck”of the fifth metacarpal, which is the MC leading to the little finger.  Therefore, with his fourth MC injured, McGahee may have been misinformed.

Typically the union (mending) of a metacarpal fracture occurs in six weeks.  Indeed, that is considered to be the response time for the healing of many fractures. Generally, due to splinting of the injury, whether managed conservatively or surgically, some loss of motion is expected, and rehab to restore mobility, strength and muscle flexibility is important. Inflammation must also be managed to control swelling. McGahee’s return in less than two weeks and his effectiveness is doing so is astounding.  His hand can’t be feeling too good right now though.

Follow Abby on Twitter @abcsims

NFL ACL Recount

Re-reviewing the updated NfL injury reports, I stand corrected on Tuesday’s post regarding the prevalence of ACL tears suffered by players this season. I’d counted ten, and the number appears to be at least 15, or possibly 16.

Joining his colleague Ernest Graham on my list is Tampa Bay Safety Cody Grimm, who tore his right ACL and MCL and was placed on IR at end-September. Like Grimm, Dominique Foxworth, a Baltimore Ravens CB, was placed on Injured Reserve on 9/28, only in his case, this was reportedly due to post-op complications that have rendered him ineffective following ACL surgery that took place after he suffered the injury during practice in July of 2010. Foxworth should get honorary mention on this list. Jameson Konz, Seahawks TE, is out for the season after tearing his ACL during his NFL debut in the Seahawks upset of the Giants on October 9th. Other October ACL injuries include those to Indianapolis Colts rookie Tight-end Ben Ijalana, who was hurt in week 4, and Green Bay Packers RB , Alex Green, who succumbed to his ACL in week 7.

I couldn’t get a read on what is going on with Michael Sims-Walker, Jacksonville Jaguars wide-receiver, whose still or again ailing knee put him on IR this week. At 27, Sims-Walker has a “long” history of knee issues that included ACL surgery while in college, and a knee sprain and staph infection in 2008. Sims-Walker is slated to undergo a new knee surgery, the details of which have not been reported. He was added to this ACL list as a result.

Keep in mind that there are so many more players out with knee injuries, many of them sprains or cartilage damage. ACLs by no means corner this market. Add to that the insane number of hamstring strains and other extraneous related injuries and you will be astounded at the number of guys who are out or playing hurt. Also staggering are the stats on achilles, foot and ankle injuries, which seem far more prevalent than shoulder and back problems this season. Concussions, as always, remain a big concern as well.

My next post will be on hand fractures, such as the one with which Chargers RB Willis McGahee plans to play this weekend.

What injuries would you like to read about? Let me know!

Follow Abby on Twitter @abcsims

Season-Ending ACL Injuries in the NFL

There have been so many season-ending injuries in the NFL this season,and complete ACL tears seem to lead this category. By my count, there are already 10 players who are looking on from the sidelines after having ACL surgery.

When watching replays on TV or at the stadium, I’m actually amazed there aren’t even more ACL tears. Feet are planted while the

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body rotates, a tackle forces a knee to hyperextend, pushing it beyond the straight or locked out position, or most commonly, a players legs are grabbed in a tackle while his body keeps moving (generally with the knee bent), forcing his knee to move in a manner that is simply not possible with the ligaments intact. It is so easy to wind up injured.

NFLers currently nursing post-operative ACL’s include:
Running Backs Ernest Graham (Tampa Bay), Tim Hightower (Redskins) and Jamaal Charles (Chiefs)
Wide Receivers Kenny Brit (Titans) and Domenik Hixon (Giants)
Tight End Tony Moeaki (Chiefs)
Safety Eric Berry (Chiefs)
Cornerback Bradley Fletcher
Linebacker Thomas Davis (Panthers)
And even kicker, Nate Kaeding (Chargers)

Hixon is on his second ACL surgery in just two seasons, Fletcher tore his in a practice collision and Moeaki was injured in the final game of the rushed pre-season. Taking the trophy in this unwanted competition, Davis is on ACL surgery number three in less than two years. I hope he’s been saving his money and has a plan B.

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 ACL is comprised of two distinct bundles which serve complementary functions. The posterolateral (outer/rear) bundle restricts or checks the motions of hyperextension and excessive forward gliding of the upper tibia with the knee straight. It also limits internal rotation in the knee. When the knee is forced into hyperextension or inward rotation, this larger band risks injury.

The smaller anteromedial (front/innermost) band is taut in flexion (when the knee is bent) and is therefore most likely to be injured with force to the knee in a bent position.

The anatomy of the ACL explains why it can sometimes suffer only a partial tear, and why in these cases, it may be possible for an athlete to avoid surgery.

Follow Abby on Twitter @abcsims

More Mets Injuries — My Take on Jose Reyes and Daniel Murphy

Injuries seem to keep the Mets in the news on an almost daily basis.

Monday’s lowlights featured the announcement that first baseman Daniel Murphy’s MRI revealed a Grade 2 MCL sprain that will keep him out for the remainder of the season. The team also announced that Jose Reyes had been diagnosed (yet again) with a mild left hamstring strain that will sideline him for an indeterminate period.

Naturally, these are two of the Mets best hitters, and what was left of their team’s season will likely limp

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along in their absence. This only adds to the groaning that accompanied last week’s news that Johan Santana’s shoulder rehab had hit a glitch, and

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that Ike Davis may be a candidate for microfracture surgery on his left ankle due to a stubborn bone contusion.

Santana’s return this season seems unlikely – why push it when the team won’t be playoff bound? And Davis’ career, not simply his season is now in doubt.

A muscle strain occurs when the excessive load applied to a given muscle creates undue stress in the tissue, resulting in injury. Reyes’ proclivity to recurrent hamstring strains isn’t unique amongst athletes who have a history of suffering even one significant strain. Vulnerability to re-injury requires vigilance in conditioning, and the nature of baseball puts a sensitive hamstring at frequent risk.

Reyes generates a lot of speed and power with his legs and he has not been quite as effective since his hamstring injury of early July. You may recall that Reyes also had surgery in 2009 to repair a torn right hamstring tendon (otherwise referred to as a Grade 3 strain). These issues are likely to plague him for the duration of his career.

Murphy’s injury is quite different. Ligaments connect bone to bone, providing stability at joints. A ligament sprain occurs with trauma when a ligament is stressed beyond its capacity to tolerate the load. Mild disruption of the fibers occurs with a Grade I sprain, a Grade II (like Murphy’s) causes more significant damage (considered a partial tear) and a Grade 3 is a complete rupture of the ligament.

Unlike tears of the anterior cruciate ligament (ACL), which are generally repaired surgically, medial collateral ligament (MCL) tears are more often managed conservatively.

The MCL connects the femur (of the thigh) to the tibia in the lower leg, at the inner, or medial compartment of the knee joint. Laxity of the MCL permits excess motion at the inner joint (allowing the foot and lower leg to angle outward). 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). Throughout, he will work to maintain his cardiovascular endurance.

Follow Abby on Twitter @abcsims

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