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Athletes’ Recovery From Injury – Are They Set Up To Fail? Part II

The healing process entails a remodeling of injured tissues, and things don’t always go as planned. Though tissues adapt well to normal stresses, chronic overuse results in maladaptation that includes an increase in scar tissue. This has a number of implications, but the end result is weakening of the tissue – be it tendon or muscle – and an inability for it to function optimally. Inadequate rest after an injury, an overly aggressive rehab program and/or premature return to activity sets the stage for this maladaptation.

A ligament generally remains lengthened after a significant Grade 2 sprain, and therefore no longer stabilizes a joint to the same degree it did before. Sufferers work to overcome injury by maximizing dynamic stability, muscle strength, and proprioception (see below), however re-injury in competitive athletics is common. Playing on an insufficiently healed

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sprain will place undue stresses on the damaged tissue as well as on other stabilizing structures, inviting further damage (see RG III).

After injury, there is also a loss of proprioception, or the body’s position sense. Impaired balance is another issue, not only after lower body injuries but after upper body injury as well. Re-training balance and proprioception is included in rehab and – like strength, range of motion and flexibility – it takes time until they are at full capacity. Functional testing to determine a sufficient degree of recovery in all areas should be what dictates a return to competition.

Articular cartilage is the cartilage that lines and cushions the ends of bones, providing smooth gliding surfaces at the joints. It is known to be resistant to compression but with less than ideal tensile strength. Articular, or hyaline cartilage lacks vascularity (blood vessels), nerves and a lymphatic supply. It derives nourishment from the soft tissue that lies between the joint capsule and the joint cavity (the synovium). When overloaded, articular cartilage becomes irreparably damaged; it does not regenerate. Permanent and disabling defects can result from a premature return to sports.

The scenario might go like this: an athlete suffers a ligament sprain that results in a loss of joint position sense (proprioception). This deficit leads to altered mechanics, which would in turn place an excessive load on articular cartilage, resulting in an acute inflammation and lesions in the tissue. Wear and tear of the smooth hyaline cartilage is cumulative and, over time, the athlete’s joint may end up losing this surfacing entirely, resulting in what is known as being “bone on bone”.

The dreaded microfracture surgery – from which not all athletes emerge victorious – is one procedure often performed in an attempt to treat articular cartilage lesions. Holes are drilled through any remaining cartilage into the bone below in an effort to create a bleed. The intention is for blood and fat droplets to migrate into the defect, form a clot, and heal into a form of cartilage that will help protect the area. Rehab after microfracture initially requires a significant protective non-weightbearing phase and, even after a lengthy and cautious program, successful return to high-impact sports may not be possible (see Greg Oden).

Fibrocartilage, present in only several joints, is most recognized for its role at the knee. Known as the menisci, these structures act as the shock absorbers at the joint, also creating a better fit for the femur and tibia. Lacking a substantial blood supply, particularly in the central regions, significant injuries to the menisci (tears) may require surgery. Because of the lack of nourishment from blood, meniscal surgery is more often performed to remove a torn segment rather than to repair the damage. Return to sports too soon after arthroscopic surgery is likely to result in impaired performance. Of even greater significance, is that it may increase the likelihood of arthritic changes down the line.

Bone contusions, and even more so fractures, may seem to be scariest to an athlete. In fact, in most cases, because bone healing generally occurs in a four to six week window, a simple fracture mends in a more straightforward fashion than soft tissue. Contusions also generally resolve by the six to eight week mark. In contrast, displaced fractures – where the ends of the broken bone are out of alignment – require surgery (typically an internal fixation with plates, rods and pins) in order to heal properly. Fractures may be accompanied by soft tissue injury as well. The time required for athletes to return to sports after fracture is obviously greater than the healing time of the bone, as it also entails restoring any joint mobility lost due to immobilization, as well as achieving all the parameters of healing and function required after other musculoskeletal injuries.

When reporters inform us how long an athlete is expected to be out of action from an injury, they are reporting what they’ve been told. No one should base a fantasy team or bet the under on these predictions. In contrast with how most of us have learned to set a low-end realistic bar on expectations in order to exceed them, pro teams generally set our expectations of their athletes’ recovery too high, positioning them for failure. I’ve no idea why.

Follow Abby Sims on Twitter @abcsims.

*Note: My thanks to Michael T. O’Donnell, PT, DPT and Stephen Reischl, PT, DPT, OCS for an excellent presentation on Musculoskeletal Tissue Healing at the APTA conference last week. I’ve taken the liberty of boiling down much of the information (while adding my own two cents) in the writing of this article.


Amar’e Stoudemire’s Burst Popliteal Cyst

Amar’e Stoudemire, New York Knicks Center-Forward, may actually be fortunate to have suffered a ruptured popliteal cyst this week, though it will keep him out of action for at least two to three weeks. What is more worrisome than this new wrinkle is whether any of the knee diagnoses Stoudemire has dealt with in the past are more of an issue than the Knicks are aware of or are letting on. In addition, there is the bone contusion (bruise) Stoudemire reportedly sustained on October 10th. With the burst cyst, Stoudemire will get some needed rest to allow the contusion to heal and the medical team will undoubtedly be working to figure out the bigger picture. It is this more complete understanding that will determine how quickly Stoudemire returns to action and how robust his knee will be. That is the Knicks 100 million dollar question.

What is a popliteal cyst?

Also known as a Bakers cyst, a popliteal cyst is a collection of joint fluid that escapes into the back of the knee through a bursa or a rupture of the synovial membrane that surrounds the joint. Bakers cysts are usually located at or below the joint line and are generally visible and palpable in the region of the crease at the back of the knee, which is known as the popliteal fossa.

What leads to the cyst forming?

In adults, popliteal cysts are generally associated with other pathologies within the joint. As a result, procedures to simply aspirate (drain) or remove these cysts have poor long-term outcomes due to recurrence.

The most common underlying issues include meniscal (fibrocartilage) tears and chondral lesions. The former are generally in the posterior horn (rear portion) of the medial (inner) meniscus. Chondral lesions refer to a loss of the articular cartilage also known as hyaline cartilage that lines the ends of most bones where they form joints. Stoudemire has a history of chondral problems in his left knee, and it was for this reason that he underwent the dreaded mircrofracture surgery in 2005. Though he returned to form the following season, most knees with a history of articular (joint) cartilage damage have a shelf-life. Is Stoudemire’s knee reaching its competitive expiration date? It didn’t

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seem so when the pre-season got underway.

What happens when a popliteal cyst

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When a popliteal cyst bursts, the fluid moves downward into the calf. This may create some short-term swelling, bruising and discomfort in the area. There is no cause for alarm, though symptoms mimic those of a blood clot.

The fact that Stoudemire’s cyst burst likely alleviated his popliteal pain and swelling and will both buy him time and help him avoid arthroscopic procedures that might have been considered

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to address the cyst itself. However, if there was an underlying cause, what was it?

Follow Abby on Twitter @abcsims