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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Small ligament, big consequence

Monday, September 16, 2013

The mantra for a successful quarterback is pretty simple: three to five step drop, set feet, step into the throw and follow through. It is not, as Cleveland Browns’ quarterback Brandon Weeden found out, follow through into the opponent’s helmet. The accidental collision damaged Mr. Weeden’s thumb, making it difficult for him to grip the ball and his game day was over. In the quarterback’s job description, the ability to have a strong grip on the ball is a prerequisite and that ability depends upon an intact ulnar collateral ligament (UCL) of the thumb.

Some quick anatomy.  So that everybody is on the same page when discussing hand injuries, doctors use specific location descriptors. The palm side of the hand is palmar but is sometimes also referred to as volar.  The opposite of palmar is dorsal, the back of the hand. The two wrist bones, the radius and ulna are landmarks that are used as landmarks. The radius is located on the thumb side of the wrist and the ulna on the little finger side.  Each finger then has a radial side and an ulnar side.

UCL diagramassh.org

The genius of the thumb is its ability to oppose and touch all the other fingers. It allows the hand to grasp things and power is generated only if the thumb is stable. That stability is due to a small band of tissue or ligament that runs from the ulnar side of the first metacarpal to the ulnar side of the first phalanx, crossing the metacarpophalangeal joint at the base of the thumb. Tear or sprain the ulnar collateral ligament and grip strength fails because the thumb literally slides off the side of the hand.

When Mr. Weeden followed through and hit his hand on an opponent’s helmet, his thumb was likely stretched away from the hand, spraining the ligament, either stretching or tearing its fibers.  He couldn’t continue because he couldn’t grip the ball. X-rays were normal because it was not a bony injury and he now awaits an MRI to decide his fate.

Sprains are classified as grade 1, 2 or 3. Ligament fibers are stretched but not torn in a grade 1 sprain. Grade 2 sprains describe a ligament that is partially torn and in a grade 3 sprain the ligament is completely disrupted. Physical exam can attempt to decide if the ligament is intact by feeling for a “stop” when the ligament is stressed, but this is not an exact science and sometimes the hand muscles can go into spasm and give a false sense of ligament stability. Stressing the ligament isn’t done until x-rays have been completed and are normal. The mechanism of injury may cause fragments of bone to be pulled away with the damaged UCL and stressing the joint might displace the bone fragments.

Once the bones are found to be normal, an MRI will not only give the answer but direct the treatment.

Grade 1 and 2 UCL sprains can be treated with splinting to allow the ligament to heal itself and it may take 3-4 weeks to get better.

Surgery is reserved for grade 3 UCL sprains because completely ruptured tendon is associated with an unusual complication. The torn end of the ligament can finds itself tucked under the adductor pollicis muscle, making it impossible for it to become reattached. This complication is called a Stener lesion, named after Dr. Stener who first recognized and described it. Surgery is often required for sprains associated with bony fractures.

The use of eponyms or descriptive names is common in medicine and the UCL sprain has two. An acute ulnar collateral ligament sprain is also known as a skier’s thumb, describing the mechanism of falling on outstretched hand where the ski pole grip acts as a fulcrum, splaying the thumb radially away from the rest of the hand and stretching the UCL. Chronic damage to the UCL was first described in European gamekeepers who would wring the neck of game animals like chickens and the repetitive motion would stretch and weaken the UCL.

The bad news for Mr. Weeden is that there is no quick fix to make the ulnar collateral ligament heal itself and there is no mind over matter potential to overcome pain to be able to play. Until the UCL heals, by surgery or with time, the ability to grip, handoff and throw a football is lost. And that is on the top of the quarterback’s job description.

 

 

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