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, NOVEMBER 25, 2014
If you’re a power lifter or body builder, please stop reading. If you’re a high level athlete, please read with an open mind. Now for the rest of us… My patients ask me all of the time, “What can I do in the gym?” For me, it’s not what you can and can’t do but what you should or shouldn't do.
Why do I say that? Here are just a few of the injuries we've seen in the office from doing the wrong things in the gym: a middle aged women who tore her ACL doing jumping jacks onto a plyometric box, a 60 year old who tore his meniscus when he was forced into deep knee flexion during yoga, and a broken tibia from the bar hitting her leg during Olympic lifting. It’s not that some people can’t do these things; it’s just that most of us shouldn't be doing them.
Here are my top 5 things you should avoid at the gym.
1. Deep squats
I always have this debate with strength and conditioning coaches. Why do they have their athletes squat past 90 with resistance? It’s not functional except for maybe wrestlers and football lineman, and even with them, is it worth the risk of injury? For the rest of us who are just trying to stay in shape it is a recipe for knee pain and meniscus tears. Deep squats put significant strain on the knee ligaments, significant pressure on your patellofemoral joint (knee cap), and it puts your meniscus at significant risk for tearing.
Let’s talk about the meniscus tear more specifically. As we squat down, the knee not only flexes but the femur glides posteriorly on the tibia. From about 90 degrees and beyond, we are putting almost all of the pressure on the posterior horn of the meniscus. Now just add a little rotation and pop, there goes your meniscus. And we know that our menisci start to degenerate over time (starting at about 35-40) placing us at even greater risk for a meniscus tear. Do the theoretical benefits of deep squatting out weigh the risks, absolutely not! So let’s please stop at 90 degrees.
2. Dead lifts
This is another exercise where I also debate people on the risk/benefit of the exercise. Yes, it’s a great exercise to strengthen your hip extensors (glutes and hamstrings) but it’s an even better way to injure your back. Repetitive flexion activities have been shown to be a significant factor in back injuries, specifically bulging and herniated disks. Even if you perform the exercise with perfect mechanics, which none of us do all the time, you’re still setting yourself up for a problem. Just like the meniscus in the knee, the discs in the spine start to degenerate with age. Combine this with an exercise that puts significant strain on the posterior annulus of the disc and you’re in for a lifetime of intermittent back pain. Instead of dead lifts, let’s focus on exercises that will still strengthen your hip extensors with less risk of injury. Lunges, step ups, bridging, and squats above 90 can all accomplish this while limiting the risk of low back injury.
3. Overhead presses
Overhead military press, dumbbell shoulder press, etc., all put your rotator cuff at risk for injury. Every time we lift our arms over head we have the potential for some impingement of our rotator cuff under our acromion. Now add weight and we’re just tempting fate. There is also a common theme with all these problematic exercises I’m writing about: our tissue starts to wear down and degenerate with age.
This is once again true for the rotator cuff. So why do an exercise to strengthen our shoulders that puts our rotator cuff at significant risk for injury? If you want to strengthen your deltoid you just need to do some pushing and pulling exercises. Overhead exercises aren't functional and the risk of injury just isn't worth it. Don’t try to “isolate” your shoulders and instead strengthen them functionally with pushing and pulling exercises such as push-ups and incline pull-ups on the smith press or TRX.
4. Bench press to your chest
I don’t like the bench press because it’s not a functional exercise, but that’s another discussion. The risk with bench press is that when your elbows break the plane of your chest, you’re putting significant strain on the stabilizing structures of the shoulder, specifically the labrum and capsule. Now add heavy weight and it’s a labral tear waiting to happen. And like everything else, the labrum degenerates over time. Clicking in your shoulder? It’s probably a labral tear. If you have to bench, keep the weight reasonable and don’t let your elbows break the plane of your chest. Better yet, do a standing cable column press as it is a much more functional position; just don’t go too deep and your shoulders will thank you.
5. Anything with heavy weights
I’ll be the first to admit that I loved lifting heavy weights when I wrestled in college. It was always a competition of who could bench and squat more. Looking back, bench pressing did nothing for me as a wrestler as I should have been doing more pulling exercises. After two shoulder surgeries, a hip labral tear which has likely progressed to arthritis (no MRI as I don’t want to know), focal arthritis in my knee as well numerous other chronic injuries, my joints wish I had focused on functional training and not weight lifting.
There is starting to be a paradigm shift in the strength and conditioning world. People are turning away from weight lifting and focusing on functional training and injury prevention. Stanford University’s director of football sports performance Shannon Turley is on the forefront of this movement. Instead of having freshman players hit the weight room when they get to school, they focus on regaining flexibility, improving core stability, and relearning correct movement patterns. He has had to write letters to NFL scouts about his program and why his players don’t have a record setting combine bench press but excel on the field and are injury free.
EXOS, formerly Athlete’s Performance, is the provider for strength and conditioning for the Men’s U.S. National Soccer team. Their approach to sports performance is to fix an athlete’s problems/weaknesses. There is little return in trying to improve quad strength in soccer players who already have super strong quads. Instead, you’ll see more gains by focusing on correcting their weaknesses such as limited hip mobility and glute med weakness. Even though we’re not professional athletes, let’s take a page out of their training programs and try to fix our deficits such as flexibility, core strength, and movement patterns and leave the heavy weights on the rack.
As I’m writing this, I’m envisioning the comments that I’ll be getting. But as I always tell my patients, “Is it better to look good or to feel good?” Let’s move away from working out the way we always have and start thinking about our long term health, as many of the exercises we do are counterproductive to our overall goal of living a healthy, happy, and pain free life.
Philly.com Sports Doc
Posted: Monday, April 28, 2014
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 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 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
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.
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 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 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.
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.
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 (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.
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.
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.
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.
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.