knee ligament sprains

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.

messi-down-injured-1443278439399

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.

 

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ACL, LCL and knee rehab

Wednesday, January 9, 2013

RG III has the most talked about knee in football since Adrian Peterson’s ACL injury, repair and return to brilliance in the past year. Now it is Robert Griffin’s turn to take his turn and try to follow in AD’s footsteps. Being in the injury spotlight is never an athlete’s dream but Griffin had the misfortune of injuring his knee twice on national television and the media has pounced on his decision to play with a lateral collateral ligament sprain. The question whether he should have been allowed to continue is made moot with the news that with the second injury, the LCL tear is now joined by an ACL injury. While the lateral collateral is the least commonly sprained ligament in the knee and gets little respect, the anterior cruciate is the rock star of knee injuries.  An ACL tear is the fear of both elite athletes and weekend warriors alike, since the injury takes at least 6 months of rehab after surgery to return to play. That time requires commitment to rehabilitation and training of hours a day and on occasion, that rehab time can stretch to a year or longer.

Robert Griffin had the unfortunate history of injuring his same knee and undergoing ACL reconstruction and rehabilitation in college, but was able to return to his elite status because of the success of the surgery. The ability to perform demanded that the knee be able to function under stress and protect itself from injury. The athlete needs to trust the knee to do just that and not be afraid of the consequences of a twist or a direct hit. For that to happen, the knee must have full range of motion and the muscles that surround it, the quadriceps and hamstrings, must be at full strength, not only to move the knee but also to stabilize it. While the four ligaments (ACL,PCl,MCL, LCL) all have a role in stability, it’s the power of the muscles that keep the knee intact. When Griffin damaged the lateral collateral ligament, the ability of the knee to protect itself was compromised.

The LCL prevents the knee from buckling laterally when a blow is delivered on the inside or medial part of the knee. The ligament, along with two others, form the posterolateral corner of the knee that helps stabilize the joint from rotational stress. When damaged, not only does the knee become lax, but the hams and quads have their power and function compromised. It seemed that in last week’s game, Griffin was struggling to run at full speed and to the untrained eye, seemed to be limping appreciably and that left his knee unprotected for potential injury. Late in the game, he twisted to reach for a fumble, his knee collapsed and his previously repaired ACL failed.

Reconstruction is an interesting word for knee surgery since there is plenty of carpentry involved in replacing the torn ACL with other structures. The ligament cannot be sewn back together, so other structures near the knee are used to make a new “ACL”. Slips of tendon from adjacent muscles are anchored into holes drilled into bone. For Griffin, the first surgery used part of the patellar tendon; surgery number two will look for another option, likely using part of the hamstring tendon or quadriceps tendon to replace the replaced ACL. The surgery will be technically more difficult because the knee is no longer virginal, it has been invaded and the anatomy rearranged. Once completed, the rehabilitation process should be the same as the first time through.

For Griffin, another complication is that he needs the LCL repaired at the same time. While this takes more surgical skill, the time to heal and return to play should not be affected. The hardest part of the injury is not the post op pain that is short lived, but instead, it is the mental strength to go through six or more months of physical therapy to get a knee that has full range of motion and muscles that are back to full strength.  When the time comes to step on the field, Griffin will need to trust that the knee is “back to normal” and that emotional rehab will take time as well.

Adrian Peterson has shown that it is possible to not miss an NFL game after an ACL injury, to be able to absorb the trauma inflicted upon a running back and set rushing records. His surgery on New Year’s Eve allowed him to be ready the first game of the season. Only a week has gone by in this new year and Robert Griffin will have the same time frame to fully recover to take the first snap in the 2013 Redskin season.

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