Guard, Derrick Rose of the Chicago Bulls injured his right knee.  He was diagnosed with an ACL tear.  

Will he be able to return next year?

ANATOMY

The knee is a complex joint, with four main ligaments that stabilize the joint: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the lateral collateral ligament (LCL) tear, and the medial collateral ligament (MCL).  Together, these four ligaments help to stabilize the knee in all planes of motion. 

The ACL stabilizes the knee and prevents it from "giving out," particularly when twisting or bending on the knee.  

CAUSES

An ACL tear is usually seen in the athlete during sporting activities, but it can happen with other mechanisms, such as motor vehicle accidents and falls. Usually these injuries are "non-contact" injuries, occurring when the athlete lands on the knee after jumping.  The pivoting or twisting of the knee stresses the ACL and causes it to tear.  

Female athletes are at a higher risk of developing an ACL tear.  It is not enirely clear why this is the case.  However there are thoughts that the anatomical differences in a woman, hormones, or even biomachanical differences in a female versus a male may account for this higher risk.  

WHEN TO SEEK MEDICAL CARE

If you believe you have an ACL tear, you should seek medical attention immediately.

SIGNS

When one tears the ACL, there is usually a pop that is heard with sudden pain in the knee. There may be swelling of the knee (effusion), black and blue discoloration, knee stiffness, or the feeling of instability.  The individual may have difficulty walking on the knee.  An MRI can diagnose the ACL tear and any other injuries of the knee.

TREATMENT 

Not all individuals with ACL tears require surgery.  If there are symptoms of instability of the knee or if one is a high level athlete, then the surgery would be preferred.  If you do not fall into any of these categories, then a knee brace, followed by extensive physical therapy can be used to treat these injuries.

Surgical reconstruction of the ACL can be performed in a variety of different ways.  The ACL can be reconstructed with the patients own tisssues (autograft) or tissues from a person who has died (allograft).  Autograft reconsturction may require harvesting the "new" tendon from either the patellar tendon or the semitendinosus tendon (one of the hamstring tendons).  Different techniques can also be used to reconstruct the tendon, such as single bundle or double bundle techniques.  These discussions are beyond the scope of this blog.

Rehabilitation is critical to the success of surgical or non-surgical treatments for ACL tears.  

OUTCOMES

In 2005, we presented data on NFL athletes with ACL injuries.  Of the 31 running backs and wide receivers with 33 anterior cruciate ligament injuries, more than one fifth of players never returned to a National Football League game. Returning players first competed in a game 55.8 ± 5.4 weeks (mean ± standard error) after injury. For the 24 anterior cruciate ligament–injured players with a minimum total power rating (sum of all 7 seasons) of 200 points, power rating per game played decreased from 9.9 ± 1.1 preinjury to 6.5 ± 0.9 postinjury. This decline in power rating per game played was statistically significant (P = .002) when compared with the change for the 146 control players.  http://ajs.sagepub.com/content/34/12/1911.abstract

RETURN TO ACTIVITIES

If we use the above study as a guideline for the return to professional sports, it is likely that Rose will be back on the court somewhere between six and nine months.  He will need a lot of work and rehabilitation in order to return to his pre-injury level.

VIDEO/ANIMATIONS 

Good luck Rose.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

The Orlando Magic received devastating news today: center Dwight Howard will be undergoing back surgery for a herniated disc.  When will he be back?

ANATOMY

The spine is made up of vertebral bodies that make the vertebral column.  In the neck (cervical) region, there are 7 bones, in the back (thorax) region, there are 12 bones, and in the lower back (lumbar) region there are 5 bones.  

Each bone interacts in a complex manner with the bone above and beneath it. Furthermore, the spinal canal is home to the spinal cord.  Throughout the length of the spinal cord, nerves (known as nerve roots) come off the cord to provide function to that level of the body. 

In addition, between the bones are cushioned disks, known as vertebral discs, which act as shock absorbers along the length of the vertebral column. The intervertebral disc acts as a shock absorber for the spine.  It is made of two parts: a soft inner core and a tougher fibrous outer wall.  Finally a series of ligaments and muscles attach to the bones to provide stability and flexibility to the spine.

CAUSES

Herniated discs can occur for a number of reasons.  Most disc herniations occurring in the lower back occur with the normal aging process.  People who perform a lot of bending and twisting activities are at particular risk.  However, traumatic herniations are also possible. 

In a disc herniation, small tears develop in the tough outer wall of the disc.  Damaged pieces of the soft inner core bulge through the tear and out of the disc wall.  This part of the disc bulges into the spinal canal.  It can then push on the nerves.

SYMPTOMS

In the lower back, depending on the location of the herniation, the pressure on the nerve can cause pain, numbness, tingling, and loss of strength into one or both legs and feet, or even the buttocks region.  Some time bowel and bladder incontinence can develop, in a condition called cauda equina syndrome.

WHEN TO SEEK MEDICAL CARE

If you have pain shooting in to the legs or feet with associated weakness that does not improve, you should seek the care of a health care provider.  If you develop symptoms of cauda equina syndrome, you should seek help emergently.

A thorough physical exam, xrays, and often an MRI is needed to evaluate the spine.

TREATMENT

Most disc herniations are minor and can often be treated without surgery.  Anti-inflammatories, steroids, physical therapy, back supports, and epidurals can help relieve symptoms.

Surgery is considered for larger herniations, for patients whose pain does not improve or worsens.  In surgery, the herniated part of the disc is removed to decompress the nerve (discectomy).  If this is done through a small incision, it is known as a microdiscectomy.  Sometimes, a part of the vertebral bone, known as the lamina, may need to be removed as well. 

OUTCOMES

Most individuals are able to return to activities with associated pain relief.  This can take up to two years to occur.  Furthermore, at times, the disc can herniate again.

RETURN TO ACTIVITIES

With a microdiscectomy, Howard can take up to 4 to 6 months to return to sporting activities.  

VIDEO/ANIMATIONS 

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Linsanity will be pausing briefly.  Jeremy Lin, point guard for the New York Knicks, was diagnosed with a meniscal tear in his left knee.  He will undergo surgery later this week.  What is being done?

ANATOMY

The knee consists of 3 bones: the knee cap (patella), the thigh bone (femur), and the leg bone (tibia).  These three bones interact to give range of motion to the knee.  Inside the knee joint, the bones are covered with a substance known as cartilage.  The cartilage allows the bones to glide together, painlessly.  This substance is critical to the function of any joint in the human body.  Between the bones are cartilage discs, known as menisci.  These discs cushion the knee.

The meniscus can tear anywhere along its course.  These tears come in a variety of forms and can lead to pain, catching, popping, or clicking of the knee.

CAUSES

Meniscal tears can occur with trauma, twisting injuries, and arthritis.  Tears that are towards the central portion of the knee can be cleaned up, whereas those that are towards the periphery may be repaired.

SYMPTOMS

Not all meniscal tears cause symptoms.  However, symptoms can include pain, swelling, clicking, popping, or even catching.

TREATMENTS

Meniscal tears are treated with shaving procedure to “clean-up” the tear.  

Occasionally, if the tear is located towards the periphery of the meniscus, a repair can be attempted.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have symptoms concerning for a cartilage injury of the meniscus, you should seek medical attention.  A good physical exam, x-rays, and an MRI may be needed to evaluate the injury.

RETURN TO ACTIVITIES/OUTCOMES

Most athletes with meniscal tears that are treated with a shaving procedure are out of competitive play for 3-4 weeks. Those with meniscal tears that need to be repaired are out from competitive plays for at least 3 to 4 months. Extensive rehabilitation is needed to optimize the range of motion and strength of the knee.

VIDEO/ANIMATION

For a video animation of "Anatomy of the Knee", please see the “Education” tab of my website.  Click orthopaedics, then knee, then conditions, then "Anatomy of the Knee".

For a video animation of "Meniscus Tears", please see the “Education” tab of my website.  Click orthopaedics, then knee, then conditions, then "Meniscus Tears".

For a video animation of "Partial Meniscectomy", please see the “Education” tab of my website.  Click orthopaedics, then knee, then procedures, then “Partial Meniscectomy".

For a video animation of "Meniscal Repair", please see the “Education” tab of my website.  Click orthopaedics, then knee, then procedures, then “Meniscal Repair ".

Lin will be out for 4-6 weeks. If the Knicks make it to the payoffs, he may be ready for play in mid to late May.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

New Jersey Nets Center, Brook Lopez has a Jones fracture.  When will he return to this already shortened season?

ANATOMY

The metatarsal are a series of bones in the foot that lead to the toes.  There are five metatarsal in each foot, correlating to the five toes.  The fifth metatarsal interacts with the fifth or pinky toe.  This bone is particularly important, as breaks at the base of this bone can be difficult to heal. 

To understand breaks of the fifth metatarsal, one needs to know the type of break present.  The breaks at the base of the fifth metatarsal are divided into three types:

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. 

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor. 

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal.

CAUSES

Fractures of the base of the 5^th metatarsal occur when the ankle is twisted in inversion, or the ankle rolls outward.  Extra pressure is placed on the base of the 5^th metatarsal, causing it to break.

SYMPTOMS

A person who breaks their 5^th metatarsal may have pain at the base of the bone, with swelling pain, and possible difficulty with walking.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have a 5^th metatarsal fracture, you should see an orthopaedic surgeon.  They will require a thorough physical exam and x-rays will be needed to determine where the break is located.

TREATMENT

Treatment varies depending on the location of the 5^th metatarsal fracture and the type of break present.

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. It usually requires a boot and walking cast for 4 weeks.

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor.  The break can be treated with a cast or surgery. For those patients who decide to have a cast, they may be non-weight bearing on the injured leg for 12 or more weeks.  There is approximately a 20% non healing rate of this fracture, when treated without surgery.  With surgery, the patient is usually allowed to wear protective boots or insoles and walk 4 weeks following surgery.  In surgery, a screw or plate with screws can be used to span the break and hold the pieces together.

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal, This break can be treated in a non-weight bearing cast for approximately 6-8 weeks.  It requires surgery if it has moved out of place, or is not positioned correctly.

OUTCOMES

Most patients with 5^th metatarsal fractures are able to return to play.  For type 1 and 3 breaks, return to competitive sports may take 3-4 months.  For type 2 breaks, return to competitive play occurs 6-8 weeks after the surgery.

RETURN TO ACTIVITIES

Depending on the type of fracture Lopez has sustained, he should be back to football in 6-8 weeks.

VIDEO/ANIMATIONS

A live surgical video can be seen at: http://www.youtube.com/NCOCatDuke

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

13^th ranked, University of North Carolina (UNC) Tar Heels, will continue the rest of the season without reserve Reggie Bullock. Bullock tore the lateral meniscus in his left knee during UNC’s victory on Sunday against Maryland.  What is the meniscus and what role does it play?

ANATOMY

The knee consists of 3 bones: the knee cap (patella), the thigh bone (femur), and the leg bone (tibia).  These three bones interact to give range of motion to the knee.  Inside the knee joint, the bones are covered with a substance known as cartilage.  The cartilage allows the bones to glide together, painlessly.  This substance is critical to the function of any joint in the human body.  Between the bones are cartilage discs, known as menisci.  These discs cushion the knee.

The meniscus can tear anywhere along its course.  These tears come in a variety of forms and can lead to pain, catching, popping, or clicking of the knee.

CAUSES

Meniscal tears can occur with trauma, twisting injuries, and arthritis.  Tears that are towards the central portion of the knee can be cleaned up, whereas those that are towards the periphery may be repaired.

SYMPTOMS

Not all meniscal tears cause symptoms.  However, symptoms can include pain, swelling, clicking, popping, or even catching.

TREATMENTS

Meniscal tears are treated with shaving procedure to “clean-up” the tear.  

Occasionally, if the tear is located towards the periphery of the meniscus, a repair can be attempted.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have symptoms concerning for a cartilage injury of the meniscus, you should seek medical attention.  A good physical exam, x-rays, and an MRI may be needed to evaluate the injury.

RETURN TO ACTIVITIES/OUTCOMES

Most athletes with meniscal tears that are treated with a shaving procedure are out of competitive play for 3-4 weeks. Those with meniscal tears that need to be repaired are out from competitive plays for at least 3 to 4 months. Extensive rehabilitation is needed to optimize the range of motion and strength of the knee.

VIDEO/ANIMATION

For a video animation of "Anatomy of the Knee", please see the “Education” tab of my website.  Click orthopaedics, then knee, then conditions, then "Anatomy of the Knee".

For a video animation of "Meniscus Tears", please see the “Education” tab of my website.  Click orthopaedics, then knee, then conditions, then "Meniscus Tears".

For a video animation of "Partial Meniscectomy", please see the “Education” tab of my website.  Click orthopaedics, then knee, then procedures, then “Partial Meniscectomy".

For a video animation of "Meniscal Repair", please see the “Education” tab of my website.  Click orthopaedics, then knee, then procedures, then “Meniscal Repair ".

Bullock will be out for the remainder of this season, but I am sure we will see him ready for action next year.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog. For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics.

Tony Parker, guard of the San Antonio Spurs, suffered from a calf strain on his left leg against Memphis.  What is a calf strain?

ANATOMY

The calf muscle, also known as the gastrocsoleus complex (GSC), runs from the top of the knee to the back of the heel bone.  It begins as two muscles bellies (the gastrocnemius muscle and the soleus muscle) and then merges to become one tendon – the Achilles tendon.  The Achilles tendon is the largest tendon in the human body.

The GSC is in charge of pointing the ankle towards the floor (plantarflexion), as you would do when pushing on a gas pedal.  The complex also functions to give you push off strength.

CAUSES

The GSC complex can be injured with direct trauma, sudden changes in direction when running, or pushing up on a plantarflexed ankle.

SYMPTOMS

There are different grades of muscle strains:

Grade I – the tearing is microscopic with stretching of the fibers.  Bleeding occurs in the muscle. These injuries associated with a twinge of pain.  Athletes may be able to return to play, but the soreness last for 3-5 days.

Grade II – the tearing is more severe. More bleeding occurs in the muscle.  There is a sharper pain in the back portion of the leg.  There is usually pain with walking and with plantarflexion. The soreness and tightness last for 7-10 days.

Grade III – this is a complete tear of the muscle.  There is sudden, intense pain in the calf.    The athlete is unable to plantarflex the ankle.  The entire muscle or tendon may be torn.  Athletes can be out of competitive play for 3-6 weeks.

TREATMENTS

Treatment is based on the severity of the injury.  Rest, ice, compression, and elevation (RICE) begin immediately.  Cold/ice therapy is applied first to minimize the bleeding and swelling in the calf.  Anti-inflammatories can help with the pain and inflammation.  A compression sleeve, sock, or stocking can help with the swelling. Physical therapy, with massage, ultrasound, stretching and strengthening exercises is essential.  Surgery is rarely needed, unless the tendon has torn.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have symptoms concerning for a calf strain, you should seek medical attention within a few days.

RETURN TO ACTIVITIES/OUTCOMES

The timing for a return to play depends on the severity of the strain:

Grade I – Athletes may be able to return to play, but the soreness last for 3-5 days.

Grade II – The soreness and tightness last for 7-10 days.

Grade III –  Athletes can be out of competitive play for 3-6 weeks.

VIDEO/ANIMATION

To watch a surgical video of Achilles tendon repairs, go to:http://www.youtube.com/NCOCatDuke#p/u/5/rD3aI_7EneA

Based on reports on his injury, Parker will likely be back to action within 4 weeks.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics.