 Philly Sports Doc
Justin Shaginaw, M.P.T., A.T.C. Posted: Monday, March 10, 2014 It’s that time of year. Spring sports are in the air, even if the spring weather isn’t. Let’s head to the ballpark and start with baseball. Upper Extremity Upper extremity injuries are the most common area injured for both college and pro baseball players. Shoulder injuries account for approximately 20 percent of all injuries in both pro and college players. These injuries include dislocations, sprains and strains, labral injuries, and rotator cuff injuries. Stats and facts about baseball injuries Dislocations are an emergent injury and immediate medical attention should be sought. In the above research studies, injuries diagnosed as sprains and strains were likely either misdiagnosed or players were given this diagnosis to down play the severity of the injury. Sprains and strains are more likely an underlying rotator cuff or labral injury. Both of these are usually the result of a kinetic chain dysfunction, which is like having your car’s steering out of alignment. By correcting the alignment issues, most shoulder problems can be resolved as long as they haven’t passed the point of no return. Once this happens, surgery is usually the only option to truly fix the problem. Elbow injuries account for approximately 16 percent of pro and 8 percent of college injuries. These injuries include sprains and strains, contusions, and more severe injuries such as ulnar collateral ligament injuries (Tommy John) and posterior impingement. As with the shoulder, elbow injuries diagnosed as sprains and strains were either misdiagnosed or players were given this diagnosis to down play the severity of the injury. Elbow sprains and strains are more likely the precursor to an ulnar collateral injury. And just as in the shoulder, by correcting alignment issues, most elbow problems can be resolved as long as they haven’t passed the point of no return. Pediatric and early adolescent shoulder and elbow injuries need to be assessed by a physician who specializes in pediatric sports medicine. These injuries can be different than the adult injuries due to open growth plates. Two such examples are little leaguer’s elbow and osteochondritis dissecans (OCD). These injuries are the result of throwing too much and overloading the elbow. This is why pitch counts are so important in little league through high school aged players. The first step in treating upper extremity problems in a throwing athlete is to be evaluated by a sports medicine clinician who specializes in the assessment of the kinetic chain. These problems include loss of shoulder range of motion (specifically internal rotation), scapular dyskinesia (shoulder blade weakness/abnormal movement), trunk and hip range of motion, core strength/stability, balance, and lower extremity flexibility and strength (specifically hip rotation range of motion and gluteus medius strength). Rehabilitation is the first step in correcting the underlying kinetic chain issues. Please be aware that not all rehab is the same. An athlete that did rehab and did not get better may not have done the correct rehab. Players should not throw until significant improvement has been made with rehab. In cases where players do not improve with the correct rehab, surgical consultation is the next step if the athlete wants to continue to play. Lower Extremity The 3 main lower extremity injuries in baseball are:
Hand/wrist Hand and wrist injuries account for approximately 10 percent of baseball injuries. These can be minor such as contusions to more serious injuries such as fractures and dislocations. The majority of these injuries are from being hit by a pitch or from sliding. Hand and wrist injuries should be evaluated by your athletic trainer who will refer to a sports medicine physician for more server injuries such as dislocations and fractures. Minor injuries are usually treated with rest, rehabilitation, and taping/bracing if needed. Other injuries Facial injuries are rare in baseball. When they occur, they are usually the result of being hit by a pitch. Examples of these injuries include facial fractures and eye injuries. These can be very serious and need immediate medical attention. Other less common injuries seen in baseball include core injuries/sports hernia, back/neck pain, and foot injuries. All of these should be initially evaluated by your athletic trainer who can develop an appropriate rehab plan as these injuries are usually minor and resolve with conservative treatment. As you can see, upper extremity injuries in baseball are the most common and tend to be the ones that will cause significant time missed from play. The cause of most shoulder and elbow injuries is an underlying kinetic chain problem. Brian Cammarota, MEd, ATC, CSCS, CES, another contributor to the Sports Doc blog, has some great posts on kinetic chain problems, throwing programs, and injury prevention for throwers. Please review some of his posts for further insight into upper extremity injuries in throwers.
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 Justin Shaginaw, M.P.T., A.T.C.
POSTED: WEDNESDAY, FEBRUARY 5, 2014, 6:00 AM This is the last blog of a three part series on winter scholastic sports. Let’s head to the mat. Sprains/Strains Sprains and strains account for nearly half of all wrestling injuries with the shoulder being more common in high school wrestlers and the knee more common in college. About 40 percent of those injured return to the mat within 1 week. These injuries should be evaluated by your team’s athletic trainer and appropriate treatment plan developed. This usually includes some time off the mat, rehabilitation exercises (strengthening, stretching, balance, etc), and modalities (heat, ice, etc). For more serious injuries, schedule an appointment with a sports medicine physician for further work up (x-rays, MRI, etc) and other treatment options . Dislocations/subluxations Dislocations/subluxations account for approximately 10% of all wrestling injuries. These are urgent and often times emergent injuries requiring immediate care from an athletic trainer followed by a referral to a sports medicine physician or the emergency room. These injuries most commonly occur to the shoulder, elbow, and patella and require a prolonged period off the mat and rehabilitation. Lacerations Lacerations are much more common in college wrestling and account for approximately 10 percent of collegiate injuries. These injuries vary in severity with some being managed by your athletic trainer with an immediate return to practice or the match while others require physician referral for sutures. Suturing may require a period of time off the mat depending on the location. Fractures Fractures are the second most common injury in high school wrestlers accounting for approximately 15 percent of all injuries. These are emergent injuries requiring immediate care from an athletic trainer and referral to a sports medicine physician or the emergency room. Fractures require a significant period of time off the mat and are often season-ending. Concussions Concussions account for approximately 5 percent of injuries for both high school and college wrestlers. The majority of concussions resolve within a week. A small portion will require a prolonged recovery period and may require a significant amount of time away from the sport. All concussions should be taken seriously and evaluated initially by the team’s athletic trainer with a referral to s sports medicine physician trained in evaluation and management of athletic concussions. Skin infections Skin infections represented 8.5% and 20.3% of all reported high school and college adverse events respectively.
All wrestlers with a skin infection should be evaluated by a physician for appropriate medical treatment as dictated by National Federation of State High School Associations (NFHS) and the National Collegiate Athletic Association (NCAA). Wrestlers will also need a clearance letter from their physician clearing them to return to practice and competition. There are also prophylactic treatment options for some dermatologic conditions such as herpes which can be prescribed by a physician. Wrestling injuries are usually due to the combative nature of the sport. As you can see, sprains and strains account for the majority of wrestling injuries. Most of these are minor and can be managed conservatively with a quick return to sports. The above treatment recommendations are just a guideline and any injury should be evaluated by your team’s athletic trainer or a sports medicine physician to accurately diagnose the injury and provide appropriate care. Justin Shaginaw, M.P.T., A.T.C.
POSTED: WEDNESDAY, FEBRUARY 5, 2014, 6:00 AM A 2008 article by Yard et al in The American Journal of Sports Medicine calculated rates of injury among high school and college wrestlers during the 2005-2006 season using the High School Reporting Information Online (RIOTM) and the NCAA Injury Surveillance System (ISS). It also characterized the incidence and type injuries and compared risk factors for high school and college wrestling injuries. There were 387 injuries among participating high school wrestlers during 166,279 athlete-exposures, for an injury rate of 2.33 injuries per 1000 athlete-exposures (AE). 258 injuries occurred among college wrestlers during 35,599 athlete-exposures, for an injury rate of 7.25 injuries per 1000 AE. The injury rate was higher in college than in high school. Injury rates were higher in matches than in practices for both high school and college. Strains/sprains accounted for approximately half of all high school (48.1%) and college (49.2%) injuries. The most common high school injury sites were the shoulder (18.6%) and knee (15.4%) while the knee (24.8%), shoulder (17.8%), and head/face (16.6%) were most common in college. The most frequent high school injuries were:
 Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation Robert Senior, Sports Doc blog Editor Posted: Monday, January 13, 2014, 6:00 AM The winter sports season is in full swing. In gyms everywhere the squeak of basketball shoes on the court can be heard. Along with the layups and 3 pointers, there are common injuries that occur. Let’s talk about some of these common basketball injuries and the appropriate treatment. Ankle Sprains This is the most common injury in basketball, accounting for 24.6 percent of women’s game injuries and 26.2 percent for men. It occurs when the foot rolls inward spraining the ligaments on the outside of the ankle. Swelling and bruising often occur with the severity of the injury dictating the athlete’s ability to return to play. Mild ankle sprains can return fairly quickly, sometimes even in the same game with taping or a brace. More serve injuries can take weeks to months to recover. Immediate treatment involves immobilization and ice followed by range of motion, strengthening, and balance/proprioceptive exercises. For athletes that cannot bear weight on their foot, they should be put on crutches and see a physician to rule out a fracture as well as assess the extent of the injury. For prevention, taping and bracing has been shown to reduce the rate of ankle injuries in sports. Stress Injuries Stress injuries (shin splints, stress fracture, etc) are another common basketball injury, usually seen during preseason as athletes transition from softer outdoor fields in fall sports to the hard indoor courts. Initially, symptoms are only with activity. As the problem worsens, pain can occur with walking and even at rest. If not addressed early, it can lead to a stress fracture requiring the patient to stop sports for a prolonged period of time. The common locations of these injuries are the tibia, medial malleolus, fifth metatarsal, and navicular. Initial treatment involves decreasing impact activities until symptoms resolve and assessing the athlete’s feet for appropriate shoes and possibly supportive inserts. It’s also a good idea to progress practice intensity gradually to allow players to acclimate to the new playing surface. Players that do not respond to conservative measures should be seen by a sports medicine physician for further evaluation. ACL/Meniscus Knee injuries are the second most common injury in basketball, with ACL injuries being more common in female players. Both meniscal tears and ACL injuries are caused by deceleration and pivoting on a planted foot. The common signs of an internal knee injury include swelling and a feeling of a “pop” or “catching and locking.” Immediate treatment should include ice and crutches if the athlete cannot walk normally followed by a referral to a sports medicine doctor to diagnose the injury. Research has shown that ACL prevention programs have been effective in reducing the incidence of injury. Some well-known programs are the PEP program (http://smsmf.org/smsf-programs/pep-program), Sportsmetrics (http://sportsmetrics.org/), and the FIFA 11+ program (http://f-marc.com/11plus/home/) . Although some of these are sports specific, they can be easily modified for basketball. Patellar Tendinopathy Commonly known as patellar tendonitis or jumper’s knee, this injury presents as pain and tenderness of the patellar tendon. The mechanism of injury is believed to be due to repetitive strain to the tendon from jumping, cutting, and deceleration activities involved in basketball. Treatment includes limiting activity until symptoms improve, as well as ice, quad stretching, eccentric quadriceps exercises, and soft tissue treatments. Patellar tendon straps can also be beneficial. In more chronic cases, medications, injection therapies, and surgery are other options. In younger patients whose growth plates are not closed, usually under 15, Osgood-Schlatter syndrome is more common. This is an injury to the attachment of the patellar tendon to the tibia. The tendon actually pulls away from the bone causing a boney protuberance that can become painful and tender. The treatment for Osgood-Schlatter syndrome is rest and ice as it is almost always self-limiting. Hand Injuries Finger injuries are fairly common in basketball and occur when players “jam” their fingers on the ball. The injuries are usually simple sprains that can be treated symptomatically with ice and buddy taping. Occasionally these injuries can be more serious such a fracture and tendon rupture. If the player’s finger looks deformed or if they are unable to move it, they should be evaluated by a sports medicine physician to accurately diagnose the injury. Upper Extremity Shoulder injuries are relatively rare in basketball with the most common being dislocations and labral tears. These injuries usually occur when a player is blocked during a shot forcing the arm backwards. For a dislocation, urgent treatment should be sought from the team’s athletic trainer and a physician if necessary. Labral tears should be considered for players with chronic shoulder pain with overhead activities such as shooting, and an appointment with a sports medicine physician should be schedule to accurately diagnose the injury. The other upper extremity injury seen in basketball is a fracture. These usually occur from falling on an outstretched arm. As with dislocations, the player should be evaluated by the team’s athletic trainer and referred to a physician for urgent care. As you can see, lower extremity injuries account for the majority of basketball injuries. Many of these are minor and can be managed conservatively with a quick return to sports. With more serious injuries such as ligament/tendon ruptures and fractures, urgent care by a sports medicine physician is advised. The above treatment recommendations are just a guideline and any injury should be evaluated by your team’s athletic trainer or a sports medicine physician to accurately diagnose the injury and provide appropriate care.  Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation POSTED: WEDNESDAY, OCTOBER 2, 2013, Whenever I see a patient with an ACL tear, they always want to blame something or someone for their injury. The biggest culprit in the blame game seems to be turf fields. If you’re old enough you might remember the original AstroTurf, and by all means plenty of blame can be placed on it for athletic injuries. But now we have new 3rd and 4th generation turf fields that are much more similar to natural grass. They are used in the NFL, MLB, MLS, and even international soccer matches are being played on them. People still love to blame turf for their injuries. But are there any facts behind these assumptions that more injuries occur on turf than grass? Research has shown that as the coefficient of friction increases there is an increase in the rate of lower extremity injuries. This means that the more traction you get on the field or court, the higher the risk of injury. The common thought is that turf has more traction than grass and therefore we will see more injuries on turf. Increased injury rate on artificial turf: A study published in 2011 looking at football, rugby, and soccer injuries showed that there was a higher incidence of ankle injuries on artificial turf. In 2012, another study looking at NCAA football injuries showed an increased risk of ACL injuries on artificial turf. Lastly, a 2013 study looking at amateur soccer players in Portugal showed a greater rate of lower extremity injuries on turf during matches vs. training. No difference in injury rates: A 2010 study looking at collegiate football injuries showed that FieldTurf may actually be safer than natural grass for injuries in general. This study also found no significant difference in knee injuries between surfaces. Another study in 2013 looked at injury rates between grass and artificial turf in female collegiate soccer players. This study actually showed a significantly lower total injury incidence rate and a lower rate of substantial injuries on FieldTurf. This study also showed no significant difference in knee injury rates between the two surfaces. Since the research doesn’t give us a definitive answer regarding injury rates and artificial turf, what is the best advice regarding artificial turf? We know that the greater the traction, the higher the rate of injury. Wearing cleats made specifically for artificial turf, or better yet turf shoes, may help to decrease traction and therefore reduce lower extremity injuries. We can apply this same thought process to grass regarding increased traction and increased injury rates. Unfortunately, there may be a decrease in performance as shoes with less traction may cause players to slip. Previous sports doc blogs have discussed ACL reduction programs. For those at higher risk for ACL injuries, maybe the type of shoe you practice and play in should be part of an injury reduction program. So don’t just choose your cleats for the color, but instead pick the ones that are appropriate for the playing surface.  Philly.com Sports Doc
POSTED: Saturday, June 8, 2013, 6:00 AM Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation With the outdoor tennis season comes sprains and strains, aching knees and shoulders. Today, we will focus on common tennis injuries, how to prevent them, and how to treat them when they occur: Tennis elbow This seems to be the bane of tennis players as it can be very difficult to treat. Not all tennis players get tennis elbow as some get golfer’s elbow and vice versa. Tennis elbow starts with pain in the lateral elbow where the wrist extensor muscles attach. Golfer’s elbow presents with medial elbow pain where the wrist flexors attach. There can be many causes of elbow pain including acute soreness from getting back on the court, overuse from playing too much, incorrect grip size, and inappropriate string tension to name a few. One thing that is often a major contributor and is usually overlooked is the shoulder. A loss of internal rotation known as glenohumeral internal rotation deficit (GIRD) and scapular dyskinesis are often times the underlying causes of elbow pain in tennis. Once symptoms have occurred, rest and ice can help with acute pain. If symptoms persist, it is best to see a sports medicine physician, athletic trainer, or physical therapist that specializes in overhead athletes for an evaluation and treatment recommendations. Shoulder Shoulder pain accounts for the majority of tennis injuries. In younger players (under 40) the common culprit is a labral tear. In older players (over 40) we start suspecting rotator cuff involvement. There are numerous causes of shoulder injuries such as overuse, incorrect racket and string tension, and poor form/hitting mechanics. But just as with elbow pain, GIRD and scapular dyskinesis are often times the root of the problem. Abdominal/oblique injuries This is a problem that we really only see in our high level youth and professional players. In a closed or neutral hitting stance, the majority of power is created from the legs. An open stance limits the legs ability to develop power and instead it is produced through the abdominals via trunk rotation. With the open hitting stance becoming the norm, we are treating more and more of these injuries. In the past we would usually saw a few rectus abdominus injuries from serves per season. Now, we are seeing a dramatic increase in oblique injuries due to the rotational force with the open stance. Two ways to prevent this injury are to change your stance back to a neutral/closed position and the other is to develop a strong core. If you do experience an abdominal injury, make sure to see a sports medicine specialist as these injuries need to be evaluated and treated appropriately. Knee pain There are 3 main injuries to the knee in tennis. The first is an ACL injury, which rarely occurs in tennis due to the mainly linear movement patterns as compared to cutting and pivoting sports such as soccer and football. When an ACL injury does occur, one should see an orthopedic surgeon who specializes in ACL reconstruction to discuss surgical and non-surgical options. The second and more common knee injury is a meniscal tear. These can be acute in nature in our younger players (under 40) or chronic and degenerative in our older players (over 40). As with ACL injuries, one should see a sports medicine physician to discuss treatment options. The third and most common knee injury in everyday tennis players is an aggravation to underlying arthritis. This occurs from either overuse or an acute irritation to a pre-existing arthritic condition. The best treatment for these injuries is the old RICE method (rest, ice, elevation, and compression). Injury prevention Please click on the link to view these exercises. http://www.justinshaginawptatc.com/exercise-programs.html As with any exercise program, please consult a medical professional if you have any questions or concerns. There are a few simple exercises that will help keep you in the game. They should be performed 2-4 times a week at the recommended number of sets and repetitions. When in doubt, see an athletic trainer or physical therapist for an individualized program specific to you. Shoulder Sleeper stretch: this stretch helps to improve shoulder internal range of motion. Stretches should be pain free. Perform 3-5 repetitions holding for 30 seconds. No moneys: Will help to improve scapular strength and control. Key is to squeeze your shoulders down and back. Only rotate arms out in a pain free range of motion. Do 2 sets to fatigue. Elbow Timothy Tyler, PT, ATC from the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City has developed an eccentric exercise program for tennis elbow using a rubber bar. His program has been validated by research and has been able to reduce symptoms fairly quickly. Abdominals/obliques Plank exercises are probably the best and simplest exercises for core strengthening. Key is to contact not only your rectus abdominus (your 6 pack abs) but also your rotators and deep stabilizers (obliques, quadratus lumborum, and multifidus). To do this, suck in your belly button like you are trying to get into a tight pair of pants. Don’t hold your breath. You should feel your abs tight above and below your belly button and more importantly around your sides in your love handle region. Make sure to have good form with the planks (straight as an arrow through your ankles, knees, hips, shoulder and head) and only hold the position as long as you can maintain good form and tightened abs. Spine Flexibility is important in your thoracic and lumbar spine with extension and rotation being the key factors. Prone press ups or the cobra yoga pose is an excellent way to improve extension. Supine trunk rotation stretches will help maintain and improve rotational range of motion. These should be performed for 3-5 repetitions with 30 second hold. Do not work through pain with stretching. Knees/lower extremities Flexibility is also key in the lower extremities. Quad, hamstring, and calf stretches should be performed for 3-5 repetitions holding 30 seconds on each side. Once again, stretching should be pain free. Justin Shaginaw, MPT, ATC is lead therapist and coordinator of sports medicine at Aria 3B Orthopaedic institute.  Philly.com Sports Doc
POSTED: Tuesday, May 14, 2013, 6:00 AM Justin Shaginaw MPT, ATC Baltimore Ravens linebacker Ray Lewis speaks during an NFL Super Bowl XLVII football news conference on Wednesday, Jan. 30, 2013, in New Orleans. Lewis denied a report linking him to a company that purports to make performance-enhancers. The Ravens face the San Francisco 49ers in the Super Bowl on Sunday. (AP Photo/Patrick Semansky) We all marvel in the extraordinary recovery of athletes following injury. Ray Lewis returned to play less than 3 months following tricep repair surgery. Adrian Peterson nearly broke the single season NFL rushing record less than a year after ACL reconstruction. Kyle Lowry played point guard for Villanova less than 4 months following his own ACL reconstruction. How is this possible? Do these gifted athletes just work harder during rehab? Do their bodies heal faster than the rest of us? Or could it be the fear of most sports fans in the 21st century? Could these be using performance enhancing agents to speed up their recovery? Let’s discuss the factors and controversies that contribute to a speedy recovery in more detail. Ray Lewis and his tricep. Ray injured his tricep on October 14th, 2012. He had surgery three days later and played in his first game on January 6th, 2013. That’s less than 3 months after injury—an unheard of turnaround time. There are many factors contributing to his extraordinary recovery. First and foremost, Ray took a great risk at returning that soon. His chance of re-tear was very high as the surgical repair takes at least 3-4 months to be even close to being strong enough to withstand the forces involved in football. I’m sure that his rehab was rigorous in regaining the strength needed to block and tackle in the NFL. One would think his age would be a detriment to a speedy recovery, but it doesn’t seem to have been a factor. The big question: did the deer antler spray help? There is little scientific evidence that IGF-1 (insulin-like growth factor) has any performance enhancing or injury recovery benefit. And IGF-1 is not affected when delivered through a spray. In Ray Lewis’ case, he probably beat the odds of re-injury by playing as early as he did vs. having an amazing recovery aided by performance enhancing supplements. Adrian Peterson. He is still the talk of the town when it comes to returning from ACL surgery. In his first season back, he nearly sets the NFL rushing record. Adrian’s first game back was 9 months after his ACL surgery. Although his level of play was astonishing— many players never quite get back to their pre-injury level—the time frame that he returned to play in is within the normal range of 9-12 months. Was there anything more than hard work and determination that contributed to his recovery? A good surgeon and rehab staff helps. But probably more than anything is what makes him such an amazing athlete is the same thing that gave him such a remarkable recovery… great DNA. There are no rumors or whispers about deer spray or any other performance enhancing substances with Peterson, just old fashioned hard work. When we look for an unbelievably quick recovery from ACL rehabilitation, we don’t need to look any further than the Main Line and former Villanova basketball star Kyle Lowry. Kyle tore his ACL the summer before his freshman year at Villanova. He had surgery on September 17th and played in his first collegiate game on December 31st. That’s just 3 ½ months after ACL reconstruction! Not only did he return to play so quickly, but he had a great season and was named to the Big East All-Rookie team as well as being tabbed Philadelphia Big Five Rookie of the Year. Kyle has gone on to have a successful NBA career without any inkling of a previous ACL injury. In Lowry’s case, his recovery can be based almost exclusively on his genetics as even performance enhancing substances couldn’t have produced such as a rapid return to basketball. Genetics, hard work, or performance enhancement? How do these athletes return so quickly? Even though in Ray Lewis’ case there are questions regarding hormone usage, all the deer antler spray in the world won’t get players back on the court and field as quickly as these players returned. These players get back to sports on the accelerated track due to their genetic makeup, excellent surgeons and rehab staff, hard work, and willingness to play in a time frame that puts them at higher risk for re-injury. The most recent information on Marcus Lattimore's knee injury is that he sustained a knee dislocation without fracture. This is a devastating injury for a high level athlete and likely jeopardizes his chances to play professionally. Knee dislocations are a complex injury requiring precise diagnosis of which structures are injured and subsequent surgical procedure/procedures to reconstruct and repair the involved structures. By definition, a knee dislocation involves at least 3 of the 4 main ligaments in the knee. The injuries sustained in a knee dislocation can include the cruciate (ACL, PCL) and collateral ligaments (MCL, LCL), posterolateral corner, menisci, articular cartilage, fractures, and vascular injuries just to name a few. Most of the the research on these injuries involve significant traumatic injuries such as automobile accidents. There are few papers on return to sports following knee dislocation.
Hirschmann MT published an article in 2010 in the American Journal of Sports Medicine titled "Surgical Treatment of the Complex Bicruciate Knee Ligament Injuries in Elite Athletes: What Long-term Outcome Can we Expect?" The results showed that only 8 of 24 athletes returned to their pre-injury level of sports activity. This is dramatically different from isolated ACL injuries where almost all athletes return to their pre-injury level of play. The athletes that had the best outcomes had early, open, complete single stage surgery. Luckily Marcus will have the best care possible increasing his odds for a full recovery. I am hoping that he proves the statistics wrong with a return to his football career. Combined ACL and MCL injuries can be difficult to treat, especially in the high level athlete. Partial MCL injuries (grade 1 & 2) will heal and standard ACL reconstruction can be performed without significant risk of complications. Complete MCL injuries (grade 3) need to be repaired or reconstructed to regain valgus stability. There is debate on the timing of these surgeries. Should the ACL reconstruction and MCL repair/reconstruction be performed at the same time or done as two separate procedures?
The results of a recent study by Grant in the journal of Arthroscopy showed that "Outcomes were better if the ACL was reconstructed and reconstruction was delayed to allow a return of knee range of motion. In many cases, this delay may allow the MCL to heal. MCL repair or reconstruction may be required if valgus instability remains after an appropriate rehabilitation period." It concludes that "ACL reconstruction should be performed in a subacute time frame once full motion has returned. Valgus instability should be assessed at that time and MCL repair or reconstruction performed in those patients with persistent valgus instability." Partial ACL injuries pose a problem of their own. Is the knee stable enough to return to high level sports without ACL reconstruction? Patients that are able to return sports without surgery are considered "copers." In 2011 Tjoumakaris published an article in the American Journal of Orthopedics, "Partial Tears of the Anterior Cruciate Ligament: Diagnosis and Treatment." The article states that the "Natural history studies following patients with these injuries have demonstrated that fewer than 50% of patients return to their preinjury activity level. Several studies have also documented that progression to complete rupture is a common outcome for patients who want to return to an active lifestyle." Although the research isn't conclusive, the evidence supports subacute ACL reconstruction with concurrent MCL repair/reconstruction if valgus laxity persists. In the case of partial ACL injuries, reconstruction may be the best option due to their high likelihood of progression to complete rupture and the poor rate of return to pre-injury levels of sports participation. |
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