Tuesday, September 29, 2015
Writing about injuries is not always easy when relying on press releases, sports stories and snippets of interviews. Sometimes, the story falls in your lap. The Steelers’ Ben Rothlisberger gets hit, hurts his knee, hobbles off the field and by morning has an MRI confirming a medial collateral ligament tear…prognosis 4-6 weeks before return to play. Sometimes, though, there needs to be detective work because the information is more opaque. The NHL is a constant frustration with their upper body/lower body injury mantra.
But it’s Lionel Messi’s knee injury that posed a challenge. His team FC Barcelona tweeted that “Messi has a tear in the internal collateral ligament of his left knee. He will be out for around 7-8 weeks.” It seems relatively transparent and open, telling the world and especially Barca fans about Messi’s injury. The only problem is that the knee doesn’t have an internal collateral ligament, so tearing it is a little problematic. The challenge then, is to sort out the real injury.
Clue one is provided by photos of the injury. As he lay on the ground, Mr. Messi reaches down and rubs the inside part of his left knee.
Clue two is that the recovery time is measured in weeks, not months.
Clue three is that no surgery is planned. Argentina national team doctor, Donato Villani, was quoted by the Argentine paper, Ole: “The injury was to the ligament on the inner part of the knee, a ligament that is extra-articular, that obviously suffers injury like any other ligament, but this one is outside the joint. He avoided a valgus force injury of the joint; it is not a tear that needs surgery.”
As it turns out, the knee joint has four ligaments that provide it support and stability. The anterior and posterior cruciate ligaments prevent the knee from sliding forward and backward, while the medial and collateral ligaments prevent side to side motion. This allows the knee to do what it’s supposed to do, flex and extend, like a hinge. Each ligament has the potential to be torn and the treatment approach is different for each.
It’s important to remember that a torn ligament is called a sprain. Grade 1 sprains describe a ligament whose fibers have been stretch and a grade 2 sprain happens when the fibers are partially torn. A grade 3 sprain occurs when the ligament has been completely torn.
In athletes, each knee ligament has its own treatment, healing and return to play time frame.
- Anterior cruciate ligament tears almost always need surgery and recovery time is measured in many months.
- Posterior cruciate ligaments may not need surgery but rehabilitation may take 3 months or more to return range of motion, stability and strength. For those with a PCL tear who undergo surgery, the rehab time may stretch to 9-12 months.
- Medial collateral ligament tears used to be treated with surgery but non operative treatment is found to be more successful. Grade 1 and 2 sprains often heal well enough in 1-2 weeks to allow return to play while a grade 3 sprain may need 6 weeks or longer. While early return to play is allowed, the MCL continued to heal for many more months. Surgery may be required if there is recurrent injury or chronic instability.
- Lateral collateral ligaments tend to heal less well than the MCL and it completely torn, the LCL injury may also involve damage to the posterolateral corner of the knee. This is a group of structures that provide knee stability (and include the fibular collateral ligament, the popliteofibular ligament, the mid-third lateral capsular ligament, the biceps femoris head and the lateral gastrocnemius tendon and the IT band). A grade 3 tears often needs surgery and rehab time that can last a year.
Mr. Messi had an “internal” ligament injury that does not need surgery and will heal in 7-8 weeks. The medial collateral ligament fits that description but the clincher is that the medical collateral ligament has fibers that are both external (outside of) and internal to the joint. While it is a thick band of tissue that covers the whole of the m3edial or inner side of the knee, there are many layers that are outside of the knee joint and others that are internal to the joint. That division is based upon the capsule that is the boundary of the joint itself.
Medical commentary by proxy can be harrowing but sometimes, understanding anatomy, injury patterns and treatment options can uncover the mysteries that are contained in press releases and twitter feeds. And at the end of the day Ben Roethlisberger and Lionel Messi are related by MCL sprain.
This entry was tagged ACL, knee, LCL, MCL, medial collateral ligament, Messi, PCL, Roethlisberger, sprain
Monday, September 14, 2015
Football is a violent sport as witnessed by the length of the injury report every Monday morning. From torn ligaments and broken bones to cuts and scrapes, players accept a fair amount of risk to play a game that they love. Injuries to the brain are becoming less acceptable with concussion being front and center on the field and in the press.
Lorenzo Mauldin of the New York Jets was slow to get up after a play this past weekend, and when he eventually stood, collapsed to the ground, face down and didn’t move. Medical staff converged, finding him unconscious and not moving, and still not moving even after he wakened. There was fear of a head injury and the fear of a damaged spinal cord. The stadium was silent as Mr. Mauldin was immobilized on a board and taken from the field. The good news came after hours in the hospital. Mr. Mauldin had sustained a concussion but his neck was all right.
Most people understand the concept of concussion. The brain is shaken and briefly turns off and then gradually returns to normal. Symptoms may occur immediately or they may be delayed, Symptoms may be dramatic, like being knocked unconscious, or very subtle, like having difficulty concentrating or experiencing changing sleep patterns. Imaging the brain with CT scan or MRI does not usually find any damage.
People also understand broken necks and being paralyzed because of spinal cord injury. The neck attaches the head to the body and allows it to swivel and enjoy the world around it. It is also the conduit where the spinal cord runs inside the spinal canal, attaching the brain to the nerves in the rest of the body. The cervical spine is made up of seven interlocking vertebrae and held stable by a variety of ligaments and muscles. Even with broken bones, if the spinal canal is not compromised, the spinal cord can survived intact and undamaged with no symptoms. However, if the vertebrae fracture in such a way that the spinal canal is narrowed, the spinal cord can be injured and that results in badness. Football players can tolerate the risk of knee injuries but no so much that of being paralyzed.
And then there is SCIWORA: spinal cord injury without radiographic abnormalities. Most often seen in children and adolescents, but also in adults, it is a form of spinal cord injury, where there are signs or symptoms of weakness, paralysis or change in sensation without any evidence of fracture, dislocation, or misalignment of bones on X-ray or CT scan. The symptoms can be transient where the spinal cord stops working and then recovers, almost like the brain that has been concussed. But sometimes there can be permanent damage. SCIWORA was much more of a mystery before MRI but with these scans, some of these injuries may be explained by ligament damage or subtle bleeding into the spinal cord. Many victims though, have no obvious spinal cord injury, even though damage exists because the spinal cord has stopped working.
SCIWORA is a frustrating situation for doctors. Doctors like to make a diagnosis but they also like to fix things. But how can something be fixed, if there is nothing that can be done? The treatment is immobilizing the neck and observation, the watchful waiting to see what nature brings, just like a brain concussion. But when there are some agreement as to how long to keep a concussed player off the field, there is much more caution with the SCIWORA patient: “high risk” activity should be avoided for up to six months.
Mr. Maudlin was discharged from hospital after an overnight stay having suffered “only” a concussion and hopefully his brain will recover quickly. The inability to actually see an injury of the brain or spinal cord remains a frustration for the medical community. The patient knows that it’s there. The doctor knows that it’s there. And the treatment options are the same as in the time of Hippocrates, who wrote: “Healing is a matter of time, but it is sometimes also a matter of opportunity”This entry was tagged broken neck, concussion, head injury, SCIWORA, spinal cord injury
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”