Philly.com 
Health
12/19/2017
After the Eagles announced Carson Wentz would undergo surgery to reconstruct a torn ACL, everyone is wondering when he can play again. This is the first question athletes ask me after ACL surgery and my answer is always, “when you’re ready.”
Athletes want a definitive time frame but that’s nearly impossible to give.  Return to play is extremely individual and needs to be based on achieving objective, measurable goals and not an arbitrary time frame.
In the past, sports medicine professionals would give an estimated time frame, often six months, for return to play.  But research and clinical experience has shown that athletes rarely fit into arbitrary time frames.  Returning too soon following ACL reconstruction can put an athlete at high risk for re-injury or injuring the opposite knee.  A 2016 study published in the British Journal of Sports showed that athletes returning to play prior to nine months had as high as a 40 percent re-injury rate. More importantly, athletes who passed an objective-based return to play testing battery reduced their re-injury risk to only 6 percent.
So, what is an objective-based return to play testing battery?  There is still debate on which tests are most effective at teasing out any deficits or limitations that would predispose an athlete to re-injury, but most research supports assessing balance, strength, and the athlete’s ability to hop.  I I developed a return to practice battery that I have been using for over five years and my unpublished data shows a significant reduction in re-injury rates for the athletes who have passed all aspects of testing.  The battery assesses balance, strength, power, hopping, and landing mechanics using simple clinic-based tests and incorporating newer technology such as force plates and 2-D video analysis.  This test also helps the athlete return to their pre-injury level of performance.
The last part of the process is the progressive return-to-practice programming.  Athletes need to slowly progress activity from simple, straight drills to higher-level cutting and pivoting.  They need to progress from non-contact to contact practice. There is also a newer term in sports medicine called acute/chronic work load.  This simply means not increasing training load too quickly and not returning a player until they have reached their pre-injury training loads.  Professional sports have high-tech ways of measuring this such as GPS tracking and heart rate monitoring where we use more lo tech monitoring for athletes who don’t have access to GPS monitoring
Returning to play following ACL reconstruction is a measurable process based on testing and training data.  The Eagles will base Wentz’s return on these objective criteria. Eagles fans can be confident that Wentz will be back on the field, at or near his pre-injury performance level, for pre-season next August.

Philly.com
Sports Doc
February 11, 2016 

We all know someone who has torn their ACL.  The vast majority of these athletes have surgery to reconstruct the ACL and return to their previous level of activity.  However, we know that there is a high incidence of arthritis in patients who tear their ACL, whether or not they have surgery.  Research studies show that anywhere from 10% to 90% of people show some level of post-traumatic arthritis following ACL injuries.  This large variation is due the degree of arthritic changes that were used as the cutoff in studies.  Barenius et al American Journal of Sports Medicine 2014 showed that ACL reconstructed knees had a 3 times greater incidence of post-traumatic arthritis regardless of graft type using a grade of 2 or greater on the Kellgren-Lawrence (Scale is 0-4 with grade 2 showing significant osteophytes and/or cartilage reduction up to 50%).  They also showed an even greater incidence of arthritis in patients with combined ACL and meniscus injuries.  Why is this?  Isn’t an ACL reconstruction supposed to fix the knee and prevent arthritis?
An ACL reconstruction will not prevent arthritis.  The surgery is done to regain stability of the knee to prevent further injury to the meniscus and articular cartilage due to episodes of the knee giving way.  Research is still trying to figure out the definitive cause of post-traumatic arthritis in order to effectively minimize or potentially eliminate it.  Currently, we break down the potential causes into two groups: time of the injury and post-surgical.  Time of the injury factors include the “bone bruise”, inflammation, and meniscal injury.  Nearly all ACL injuries show a bone bruise on MRI.  Research has indicated that this bruise results in damage to the articular cartilage and underlying subchondral bone.  The theory is that over time, this damage progresses and eventually results in post-traumatic arthritis.  Inflammation from the initial injury results in a catabolic inflammatory process causing abnormal tissue remodeling and damage.  Meniscal injury has shown to be the greatest predictor of future arthritic changes.  Bindle et al Journal of Athletic Training 2001 showed that as little as a 10% loss of meniscus volume may increase tibiofemoral contact pressure by 65 %.  Potential post-surgical factors include altered knee kinematics, inflammation, and inadequate rehabilitation.  Altered gait kinematics are seen in the reconstructed knee as compared to the uninvolved knee.  These altered kinematics result in an abnormal shift of contact pressures and is likely to contribute to the development of post-traumatic arthritis.  Post-surgical inflammation not only negatively effects the knee cartilage as mentioned above, it can potentially cause surgical tunnel widening resulting in ACL graft laxity which may further alter knee kinematics.  Lastly, inadequate rehabilitation may have an effect on arthritis as well.  Not fully regaining range of motion and strength as well as not fully normalizing gait and movement patterns may negatively alter knee kinematics.
You may be wondering, why the concern about post-traumatic arthritis?  I’ll just get a knee replacement when I’m older, right?  The concern is for the patients that develop significant and symptomatic arthritis at a younger age.  Nebelung et Arthroscopy 2005 found that in a group of elite athletes who underwent ACL reconstruction, all had degenerative changes by 35 years and 42 % had undergone a total knee replacement.  These patients had significant symptoms and functional limitations requiring knee replacement.  Obviously, they were no longer able to participate in sports and had difficulty at work and with daily activities.  As we continue to narrow down on the cause/causes of post-traumatic arthritis in order to better manage, and hopefully eliminate it, we must continue to council athletes on the long term complications of ACL injury and the best evidence in managing these injuries.

Philly.com
Sports Doc
Posted: Tuesday September 22, 2015

We’ve all heard the news that Kiko Alonso injured his left ACL Sunday against Dallas. This is the same knee that he had reconstructed last July. The internet is saying he has a partial tear, while Les Bowen states that it’s a grade 2 sprain. Alonso is to meet with Dr. James Andrews for a second opinion. What exactly is his injury? Is it a partial tear or a sprain? And what does this mean for this season?

A ligament strain is a partial tear. There is a spectrum of sprain/tear from very mild with no laxity, or looseness, to a complete tear. Partial ACL injuries come down to how stable, or loose, the knee is and whether the athlete can play without instability/giving way. Typically, a grade 2 injury stretches the ligament to the point where it becomes loose. This is usually referred to as a partial tear.

An MRI is helpful to see if the reconstructed ACL is injured but can’t assess the degree of laxity/looseness. The stability of the knee is best assessed with a physical examination. Often times, a device called a KT 1000 is used to give an objective measurement of the looseness. Generally, if the involved knee has more than 3-4 mm difference compared to the uninjured side the knee will be unstable.

However, if the ACL laxity is within an acceptable range, rehab may allow the athlete to return without surgery. We call these athletes “copers” as they are able to function with a lax ACL. However, most athletes with a partial ACL injury are unable to return to cutting and pivoting sports without surgery. Another thing to consider is that this is Alonso’s 3rd ACL injury which may mean he is predisposed to repeat injuries. 

As we await the results for Alonso’s second opinion with Dr. Andrews, let’s hope he has a stable, partial tear with only minimal laxity. This would give him the best shot at returning this season.  

Philly.com Sports Doc
Posted: Friday, March 13, 2015, 10:16 AM
Sam Bradford. (Photo by Streeter Lecka/Getty Images)


All the sports buzz in Philly this week is revolving around the Sam Bradford trade. Is he a good QB? Don’t ask me, but ACLs are something I know about. 

His first ACL injury was to his left knee in October 2013. From the video, it looked like it was a contact injury where he was pulled down from behind. It appeared that his foot got caught with a flexion rotation mechanism of injury. He injured the same knee this past August, which also looked like a contact injury from a direct blow to the knee causing hyperextension. 

As we know, there are two types of ACL injury mechanisms, contact and non-contact. Contact injuries like Bradford’s are usually more bad luck than pre-disposition. If he tore them running in the open field I would be more concerned about predisposition. 

That being said, statistically, he is at high risk for re-injury, according to the research.

A study published in Arthroscopy in 2005 found that 12% of patients re-injure their same knee or injure their other knee in the first five years following surgery. Another study published in the British Journal of Sports Medicine 2006 found that soccer players with a previous ACL reconstruction had at least four times the risk of re-injury or injuring their other knee. Numerous research articles show continued deficits in strength and lower extremity control that can persist for years following ACL reconstruction. If you’ve followed ACL injuries in professional athletes, not everyone recovers as quickly as Adrian Peterson. Many end up like Derrick Rose and RG III. 

An article published in Orthopedics 2014 by Erickson titled “Performance and Return-to-Sport After ACL Reconstruction in NFL Quarterbacks” looked at 13 NFL quarterbacks who underwent ACL reconstruction. They concluded that there is a high rate of return to sport in the NFL for quarterbacks and that performance was not significantly different from pre-injury. Another study published in the American Journal of Sports Medicine in 2010 found that only 63% of NFL players returned to play in approximately 11 months after surgery. More experienced and established athletes are more likely to return to competition at the same level than those with less professional experience. Being selected in the first 4 rounds of the NFL draft was highly predictive of return to play (Bradford was the number 1 pick in 2010).

An article published in the American Journal of Sports Medicine in 2009 showed that a history of meniscus surgery, but not ACL reconstruction shortens the expected career in NFL players. They also concluded that a combination of ACL reconstruction and meniscus surgery might be more detrimental to an athlete’s durability than either surgery alone. 

There is a high rate of re-injury or injury to the other knee in patients following ACL reconstruction. NFL players in general show about a 63% return to play after ACL reconstruction. However, quarterbacks showed not only a high rate of return to play but a return to previous levels of performance. That said, we don’t know for sure if other structures were injured in the knee that could affect his return to play. From a research standpoint, the odds are in Bradford’s favor to be back to the player he was prior to his injuries. But the question to be answered is, will he be AP or RG III?

Philly.com Sports Doc
Posted: Monday, April 28, 2014

Injury statistics

A 2007 study by Dick et al in the Journal of Athletic Training looked at injury rates for the women’s lacrosse using the NCAA injury surveillance system from 1988-2004.

The results show the game injury rate was twice the rate for practice (7.15 versus 3.30 injuries per 1000 athlete-exposures [A-Es]). Preseason practice injury rates were almost twice as high as regular-season practice rates. More than 60% of all game and practice injuries were to the lower extremity.

Approximately 22 percent of all game injuries and 12 percent of all practice injuries involved the head and neck. In games, ankle ligament sprains (22.6%), knee internal derangement (14.0%), concussions (9.8%), and upper leg muscle strains (7.2%) accounted for the majority of injuries.

In practices, ankle ligament sprains accounted for the largest proportion of all injuries (15.5%), followed by upper leg muscle strains (11.7%) and knee internal derangements (6.1%).

Participants had almost 5 times the risk of sustaining a concussion or a knee internal derangement during a game compared with practice and 3 times the risk of sustaining an ankle ligament sprain during a game. The greatest proportion of game injuries (44.3%) resulted from no direct contact. A total of 35.9 percent of game injuries were associated with other contact (primarily stick or ball) and 18.6 percent with player contact. The majority of practice injuries (62.0%) involved a non-contact mechanism. A total of 22 percent of game and 24 percent of practice injuries were severe enough to restrict participation for at least 10 days. In games, knee internal derangements accounted for almost half of all severe injuries, followed by ankle ligament sprains. Head injuries represented 7 percent of the severe game injuries. In practices, lower leg stress fractures, knee internal derangements, and ankle ligament sprains were the primary severe injuries.

Lower Extremity

Lower extremity injuries account for over 60 percent of all collegiate women’s lacrosse injuries. The majority of these injuries can be divided into the following diagnoses: ankle sprains, knee internal derangements, upper leg strains, and lower leg stress injuries.

Ankle sprains account for 22.6 percent of game and 15.5 percent of practice injuries. These are primarily lateral ankle sprains which are caused by the ankle rolling inward during cutting and pivoting. Most ankle sprains are minor and players can return quickly to practice and competition. These injuries should initially be evaluated by your team’s athletic trainer. Depending on the severity, players with minor injuries may return immediately with taping or bracing. More severe injuries may require time away from the sport and more substantial treatment including evaluation by a sports medicine physician and subsequent rehab. There may be a period of immobilization and limited weight bearing depending on the extent of the injury. Rehab involves regaining range of motion and flexibility, strength, and balance with a gradual progression to full sports activities.

Knee internal derangements account for 14 percent of game and 6.1 percent of practice injuries. The two most common diagnoses are ACL tears and meniscal tears. In women’s lacrosse, ACL injuries account for a great number of knee internal derangement due to the significantly higher rate of ACL injury in female athletes compared to males. Both meniscus tears and ACL tears are serious injuries and should be evaluated by a sports medicine physician. Although most of these injuries require surgery, there are some players who can finish the season. If an athlete is to finish the season with one of these injuries, she needs to undergo a structured rehabilitation program and meet specific objective goals before being cleared to return to sports.

Upper leg strains account for 7.2 percent of games; 11.7 percent of practice injuries. These injuries are primarily hamstring strains. Hamstring injuries can be difficult to treat and there is still debate on the best course of treatment. In my experience, the initial phase of treatment focuses on reducing pain and inflammation while regaining flexibility. The second phase involves regaining strength in the injured and initiating lower level sport specific activities. The final phase involves higher level sport specific activities and a structured return to sport progression.

6.5 percent of practice injuries involve lower extremity stress injuries. These can include stress reaction or exertional compartment syndrome, which combined are commonly called shin splints, as well as stress fractures. Lower extremity stress injuries are almost always due to repetitive overload stress. This can be caused by increased training loads in under conditioned athletes, overtraining, lower extremity biomechanical issues, or a combination of all three. The first treatment is to reduce the volume and/or intensity of training. At times, athletes need to be shut down depending on the severity of symptoms.

These injuries should be evaluated by both the athlete’s athletic trainer and a sports medicine physician to rule out more serious diagnoses such as a stress fracture. The athlete should also have a biomechanical analysis performed to help correct any underlying dysfunction that may be contributing to the problem such as over pronation or weak gluteus medius.

Concussions

Concussions are the 3rd most common game injury and 6th most common practice injury in collegiate women’s lacrosse. In this study, concussions resulted in 7 percent of all injuries requiring greater than 10 days of missed time. This correlates with concussion research showing that that most concussions resolve within that time frame. As we have learned from contact sports such as football and hockey, concussions are serious injuries and should be treated as such. An evaluation by a sports medicine clinician trained in concussion assessment should be performed in order to develop an appropriate treatment plan. This may include time away from the classroom as well as from the playing field.

Upper Extremity Injuries

Upper extremity injuries in women’s lacrosse account for less than 1 percent of all injuries and therefore were not tabulated in this study. This is likely due to the rules that prohibit checking in women’s lacrosse.

As you can see, ankle sprains and knee internal derangements (ACL tears and meniscus tears) are the two most common injuries followed by upper leg muscle-tendon strains (hamstrings) and concussions. Upper extremity injuries are uncommon in women’s lacrosse. Any injury should be evaluated by your athletic trainer to assess the severity of the injury and determine the appropriate plan of care.

Philly.com Sports Doc
Posted: Friday, April 4, 2014, 5:45 AM

Injury statistics

A 2007 study by Dick et al in the Journal of Athletic Training looked at injury rates for the men’s lacrosse using the NCAA injury surveillance system from 1988-2004. The results show a nearly 4 times higher rate of injury in games than in practice (12.58 versus 3.24 injuries per 1000 athlete-exposures [A-Es]).

Pre-season practice injury rates were more than twice that of in-season. In-season game injury rates were almost twice as high as those in the postseason (12.60 versus 7.54 injuries per 1000 A-Es).


A total of 48.1% of all game and 58.7% of all practice injuries were to the lower extremity. The upper extremity accounted for another 26.2% of game injuries and 16.9% of practice injuries, whereas 11.7% of game and 6.2% of practice injuries involved the head and neck.

• In games, ankle ligament sprains (11.3%), knee internal derangements (9.1%), concussions (8.6%), and upper leg contusions (8.0%) and muscle strains (7.5%) accounted for most of the injuries.
• In practices, ankle ligament sprains accounted for 16.4% of all reported injuries. Upper leg muscle/tendon strains (11.4%) and knee internal derangements (7.1%) were also common injury categories in practices. Concussions accounted for 3.6% of practice injuries.

Players were 9 times more likely to sustain a concussion in a game than in practice, 5 times more likely to sustain a knee internal derangement in a game than in a practice, and almost 3 times more likely to sustain an ankle ligament sprain in a game than in a practice.

Most game injuries (45.9%) resulted from player contact, whereas the rest were equally distributed between other contact (primarily contact with the stick) and no direct contact to the injured body part.

In games, knee internal derangements accounted for 27.3% of all severe injuries, followed by acromioclavicular joint injuries (7.3%), ankle ligament sprains (7.1%), and upper leg muscle strains (5.6%). Concussions accounted for 3% of severe game injuries.

 In practices, these same areas, except for acromioclavicular joint injuries, accounted for most of the severe injuries. 45.9% of game injuries were associated with player contact, and 12.9% were associated with stick contact.

Contact with the ball was associated with only 3% of all game injuries. Most concussions (78.5%) were associated with player contact, with stick contact accounting for another 10.4%.

The majority of practice injuries (50.0%) involved no direct contact. 21% of both game and practice injuries restricted participation for at least 10 days.

Lower Extremity

Lower extremity injuries account for roughly half of all collegiate lacrosse injuries. The majority of injuries can be divided into the following for diagnoses: ankle sprains, knee internal derangements, upper leg strains, and upper leg contusions.

Ankle sprains account for 11.3% of game and 16.4% of practice injuries. These are primarily lateral ankle sprains which are caused by the ankle rolling inward during cutting and pivoting. Most ankle sprains are minor injuries and players can return quickly to practice and competition. These injuries should initially be evaluated by your team’s athletic trainer. Depending on the severity, players with minor injuries may return immediately with taping or bracing. More severe injuries may require time away from the sport and more substantial treatment including evaluation by a sports medicine physician and subsequent rehab.

There may be a period of immobilization and limited weight bearing depending on the extent of the injury. Rehab involves regaining range of motion and flexibility, strength, and balance with a gradual progression to full sports activities.

Knee internal derangements account for 9.1% of game and 7.1% of practice injuries. The two most common diagnoses are meniscus tears and ACL tears. Both of these are serious injuries and should be evaluated by a sports medicine physician. Although most of these injuries require surgery, there are some players who can finish the season. If an athlete is to finish the season with one of these injuries, he needs to undergo a structured rehabilitation program and meet specific objective goals before being cleared to return to sports.

Upper leg strains account for 7.5% of game injuries; 11.4% of practice injuries. These injuries are primarily hamstring strains. Hamstring injuries can be difficult to treat as seen by looking at the length of time missed on an NFL injury report. There is still debate on the best course of treatment for hamstring injuries. In my experience, the initial phase of treatment focuses on reducing pain and inflammation while regaining flexibility. The second phase involves regaining strength in the injured and initiating lower level sport specific activities. The final phase involves higher level sport specific activities and a structured return to sport progression.

Lastly, upper leg contusions account for 8% of game and 3% of practice injuries. These contusions are usually the result of players being hit by balls, sticks, or other players. These injuries are usually minor and involve decreasing pain, regaining flexibility, and regaining strength. Return to sports is usually fairly quick for most of these injuries.

Concussions

Concussions are the 3rd most common game injury and 5th most common practice injury in collegiate lacrosse. The high rate of concussion is likely due to the contact form both stick and body checking. In this study, concussions resulted in only 3% of all injuries requiring greater than 10 days of missed time. This correlates with concussion research showing that that most concussions resolve within that time frame.

As we have learned from contact sports such as football and hockey, concussions are serious injuries and should be treated as such. An evaluation by a sports medicine clinician trained in concussion assessment should be performed in order to develop an appropriate treatment plan. This may include time away from the classroom as well as from the playing field.

Upper Extremity Injuries

AC joint injuries are the most common upper extremity injury in lacrosse accounting for 5.1% of game injuries and 1.9% of practice injuries. These injuries are usually self-resolving and improve with conservative care. AC joint injuries should be evaluated and treated by your athletic trainer. Treatment usually involves a period of rest and immobilization if needed. Initially, goals are to reduce pain and regain range of motion. Once symptoms resolve, a strength program should be initiated with a gradual progression back to sports.

Shoulder sprains/strains account for less than 3% of all injuries in men’s lacrosse. These are minor injuries that resolve with conservative care. As any injury, they should be evaluated by your athletic trainer who will develop a program to regain range of motion and strength with a supervised return to play, if any time away from the sport is needed.

Shoulder subluxations/dislocations account for less than 3% of all injuries. These are more serious and need immediate evaluation by your team’s athletic trainer with a referral to a sports medicine physician. These injuries require a longer time away from sports and a more prolonged rehabilitation program. Dislocations may require surgical stabilization which is why a physician consultation is needed.

Thumb fractures are another uncommon injury in lacrosse. They are almost always the result of being hit by a stick. These injuries are usually significant and require time away from sports and some type of physician treatment. This can be as minimal as splinting or as significant as surgery, depending on the severity of the fracture.

As you can see, ankle sprains and knee internal derangements (meniscus tears and ligament injuries) are the two most common injuries followed by concussions. Upper extremity injuries are much less common and usually less severe as well. Any injury should be evaluated by your athletic trainer to assess the severity of the injury and determine the appropriate plan of care.