A new season starts

Wednesday, August 27, 2008

While the technical date falls around September 21, Labor Day weekend marks the real end of summer. The change to autumn can be witnessed in many ways, from kids returning to school to the shorter days and cooler evening. This change is probably most evident in locker rooms around the country. Instead of pulled muscles and sore arms, trainers and therapists are being inundated with bruises, breaks and damaged knees.

Orthopedic surgeons around the country probably look at their calendars and cringe when football starts. Friday night games will bring scores of players to their doorsteps looking for the answer to swollen joints and broken bones. Telling a kid that the season is over isn’t a skill often taught in medical school.

Knees are especially tough. Most broken bones are sent from the field to the emergency room, the diagnosis made immediately and the cast is a visual reminder that the next game will be watched from the bench. With knees though, there is always hope that the swelling will go away and the pain resolve. The visit to the orthopedic surgeon will bring good news and all will be well in the world. Welcome to the real world.

Diagnosing a knee injury begins with taking a history. What happened on the field? How did the knee get hurt? Was it a hit from in front or behind? Was it a twisting injury? Did something pop? And when did the swelling occur? Swelling in the knee is not normal. Immediate swelling may point to a cruciate ligament tear or a broken piece of bone. If it comes one gradually then a meniscus or cartilage may be involved.

The exam is equally important. If it is difficult to fully extend the knee and it’s held slightly flexed, this may signal fluid in the joint. The knee has its most room when bent to 15 degrees and since fluid can’t be compressed, attempts to fully extend the knee will be met with resistance and pain Palpating or touching the knee along the joint line and the course of the ligaments and tendons can give more information and the diagnosis may be made at that point. But evaluating a knee gets harder as players get bigger and stronger. The ability to examine the knee and test the stability of the ligament is tough if the quads and hamstrings are large and strong. They may hold the knee joint steady when the doc tries to assess whether a ligament is loose and give the false impression that all is well.

Not so long ago, knee injuries were left alone, allowed to heal on their own and the patient was left with a lifetime of having a “trick” knee. It would occasionally swell, have pain and act up seemingly with a mind of its own. Arthroscopy came along and allowed orthopedic surgeons to look inside the knee and potentially repair damage at the same time. Technology has advanced and MRI scans can be used to make the diagnosis allowing exploratory surgery to become less frequent.

Walking or hobbling into the orthopedic surgeon’s office on the Monday after the game begins a journey of self discovery for many athletes. Step one is learning the diagnosis. Step two is agreeing to the treatment, often a decision between an operation or a more conservative approach. Step three is the rehabilitation.

Regardless of the treatment option, knee function needs to be restored. Range of motion, stability and muscle power are rehab goals. While therapists work to push the patient, the commitment to heal often reveals the strength that lay lies within the patient. It is much harder to sit alone in the gym pushing a knee to recover than it is to do the same work in a crowded weight room surrounded by teammates.

When the injured athlete arrives in the office for the first time, there is a clash of expectations. The patient wants the orthopedic surgeon to fix him immediately and wants to depend upon the surgeon’s skill. The doctor understands that even with good technical outcome from an operation, the end result depends on the inner strength of the patient and the commitment to work in rehab. Once again, it’s the patient that does all the work and the doc that gets the credit.

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