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Knee Articles

Jumper's Knee

The Toronto Raptors are now quickly getting ready to play next season in the NBA. This summer they will participate in the NBA draft and by this time next year will be half way through their inaugural season. At the present time high school basketball is gearing up for the play offs. It only makes sense to write about the most common basketball injury that plagues many high school, college, and profressional players alike. The most common part of the body to be injured in basketball is in the knee. While we have all heard about the major ligament injuries that can happen, the fact is that the most common knee problem in basketball is one that comes on slowly.

The injury is patellar tendinitis. We affectionately call it ""jumper's knee"" because it is so common in athletes that play sports like basketball or volleyball that require a lot of repetitive jumping. The patellar tendon goes from the bottom of the patella and inserts into the lower leg bone(tibia) about two inches below. The tendon becomes inflamed where it attaches to the patella. The athlete will initially complain of a dull ache in the front part of the knee during the sport and for a short time after. The pain may be felt going downstairs. As the pain gets worse it starts to affect performance.

To no surprise it is the jumping that is affected most. Gradually the vertical jump becomes more painful and the athlete will complain that they can not jump as high. It is not uncommon that a basketball player will tell me that their vertical jump is down 11/2 to 2 feet. Eventually if not treated the player can not play because of the pain and poor performance. The key thing is to treat this injury early before it becomes chronic and very hard to treat. The following are the basic principles to eliminate the pain and a quick return to performing at an optimal level.

1/ MODIFY ACTIVITY Initially we have to eliminate the offending actions. If you have a bruise on your arm and every day you keep punching it, it will never go away. The same applies to patellar tendinitis. We know that it is the jumping and lunging activities which are aggravating the tendon. I tell the players that they have to cut down or eliminate the jumping depending how bad the tendinitis is. All those repetitive jumping drills which are so important have to be put on hold until the inflammation is better.

2/ ICE The tendon must be iced for 10-15 minutes several times a day and after any activity.

3/ PHYSIOTHERAPY This is the key to a quick recovery and preventing the problem from coming back. Initially the therapist will use various modalities to reduce the inflammation. Once this is accomplished the key thing is to strengthen the muscle and tendon to make it stronger so the athlete can jump higher and not get pain in the tendon. Specific exercise called ""eccentric"" exercises and then followed by ""plyometric"" exercises will be given to the athlete by the therapist when the therapist feel that the tendon can tolerate the increased stress.

4/ PATELLAR STRAP I often will recommend a special patellar strap which functions to take some of the force off the inflamed part of the tendon.

5/ SURGERY In extreme cases surgery must be performed to scrape the inflamed tissue away from the tendon. Hopefully, the Raptor players will not suffer from this common basketball injury, but if they do the treatment is excellent with the key being treated early as opposed to late. It is frustrating that I have seen several player's careers ruined by this problem because the problem was not treated properly and the pain became so bad that they were not able to play at all.

Bracing The Unstable Knee

The knee is the most unstable joint in the body. It is subject to the most stress and the most often injured joint in the body. In our sports clinic almost one third of all injuries seen are to the knee. In order for the knee to perform all the twisting/pivoting functions it must carry on, it leaves itself open to injury. Once the knee has been injured the question is when and with what to brace the knee with. I was recently asked to talk to a group of Physicians who treat knees at a symposium in Toronto. The question of whether to use a functional brace on their own patients knees is raised all day long in their practice. Functional bracing of the knee first became prominent when a brace was designed for Joe Namath in the late 1960's. The brace designed for Joe's knee enabled him to play football with an unstable knee and everyone knows how he guided the Jet's to an incredible Super Bowl victory. Since that time the brace industry has flourished.

There are now over thirty different manufacturers of functional braces that compete for millions of dollars of business. Most of these braces are custom fit to the individual and cost in excess of a $1,000. The first question to ask is if in fact these braces actually work. Physicians like to see scientific proof that something is effective before they prescribe it to their patients. Braces are hard to test. You wouldn't want to apply a large force to the knee to test the brace as you might injure the person who was being tested, but when we apply lower loads to the knee we know braces do limit the amount of force being placed on the knee. We can apply higher loads to a cadaver knee to test braces, but other factors such as muscle function which work in conjunction with the brace obviously do not effect these tests. Again braces have been shown to limit the loads applied to these cadaver knees, but fail at higher loads. Two recent studies have been more realistic. Doctors in Vermont somehow got volunteers to have a transducer placed on their anterior cruciate ligament in their knee.

The knee was then tested with and without the brace. The stress was reduced in the ligament in the knees that were braced showing braces to be effective at reducing the stress on the ligament. The other study measured muscle control in the braced versus unbraced knee of athletes who had torn their anterior cruciate ligament. On a special computerized balance machine(that we have in our clinic) the braced knees demonstrated enhanced motor control. The type and intensity of the sport may affect your decision to use a brace if you have a damaged knee. Some sports like cycling or jogging have no need for a brace at all. Other sports such as rugby do not allow an athlete to wear a brace. The highest demand sports are the twisting/pivoting sports such as basketball. The brace may be very effective to protect the knee in contact sports.

Professional hockey players all wear braces once their knee has been injured. Knee surgery is a very common operation today. Most athletes will wear a brace at least a year after the operation to protect the knee as well as benefit from the enhanced motor control that the brace offers. After a year many athletes will not wear the brace if the surgery has gone well, and they are back to full functional strength and proprioception. Some athletes may have a malalignement in their knee which places uneven stress through the knee joint. This combined with damaged ligamentous and meniscus usually leads to osteoarthritis or a degenerative knee. Knee braces can know be designed to angle the knee to help put the stress on the better part of the knee and help preserve the affected side. Functional bracing has come a long way since the 1960's and plays a big part in the care of the injured knee. It is a rare sporting event that you do not see a sport participant wearing one of the new colourful functional braces.




Craig Wolanin's Knee

Not only was the loss to the Montreal Canadians last weekend painful, but the Leafs also have to endure the injury suffered by Craig Wolanin. Those of you who watched the game I am sure cringed when they saw what happened to Wolanins knee. He obviously did not finish the game and we examined him back in Toronto the next day. The news was not good. He is in good company of other NHL'ers who have damaged their anterior cruciate ligament. The ACL is the leader in incidence and severity of knee injuries. Athletes dread this injury and often the first words out of an athletes mouth after I examine their injured knee is ""How is my ACL?"" How common is this injury? Well, in one word""very"". Craig is a member of the club with Pavel Bure, Pat Lafontaine, Rob Blake, Uwe Krupp, Bob Bassen, Richard Smelik who have injured their anterior cruciate ligament. In Toronto we have seen Al Iafrate tear his and Drake Berehowsky tear both his anterior cruciates.

Relatively speaking hockey is not even a sport where this injury is common. I can not recall a male or female Canadian downhill skier who has not torn their cruciate ligament. Sports where there is a lot of twisting and pivoting like basketball or soccer are more likely to injure this ligament. For several reasons females are more susceptible to tearing their anterior cruciate ligament. It has got to the point where I see a young female in my office who has an acute injury to their knee from a sport like basketball, I almost assume that the will have a torn anterior cruciate ligament until proven otherwise. Does this injury happen to only high level professional and Olympic athletes? Not at all. Rarely a day goes by when I do not see at least one of these injuries and often I will see several. Some surgeons will spend most of their time operating on these knees. It is the most common procedure done by knee surgeons.

It was not that many years ago that we thought that the anterior cruciate ligament was not that an important structure. It is only in the last couple of decades that we have realized the importance of this ligament to the stability of the knee. The anterior cruciate ligament runs in two bands upwards and backwards from the bottom knee bone(tibia) to the top knee bone(femur). It prevents the tibia from moving forward on the top bone and more importantly provides rotational stability to the knee. Basically it acts as a restraining guidewire to keep the two bones in proper relationship to each other. The ligament can be injured by a contact injury such as in football where a defensive player hits the ball carrier and damages the knee. The ligament is also commonly injured in a non contact setting. A basketball player plants his foot and as he rotates his upper body over his knee the force is too great and the ligament ruptures.

It is actually more commonly injured in the non contact mechanism. Although you can partially tear your cruciate ligament, it unfortunately usually tears totally when it goes. When you tear your anterior cruciate ligament you will often hear a pop in your knee. Their will usually be immediate severe pain followed by a nauseous feeling. Bleeding into the knee will cause the knee to swell usually quite dramatically within four hours. Most commonly you will not be able to continue to play and the athlete will come hobbling into the office on crutches, but other athletes walk quite comfortably and are shocked to hear that their injury is more than a minor sprain. The major decision is whether to operate on this knee or not. Once the ligament tears it can not be sewn together again. Therefore; you have to make a new ligament from usually another tendon around your knee(patellar tendon or hamstring tendon). This new ligament is threaded through the knee through a drilled tunnel. While in a sport like hockey where you are gliding on skates and the demand on this ligament is not as great as in some other sports, some players will continue to play without a major operation, but most athletes will opt for the reconstructed knee.



ACL Surgery
There is always a lot of media coverage of knee injuries in sport. The one knee injury that receives the most attention is the Anterior Cruciate Ligament. This is one of the four main ligaments of the knee. It is perhaps the most important as it provides both anterior and rotational stability to the knee. This week, Popeye Jones another Toronto professional athlete tore this very important ligament. Chris Wolanin, another prominent Toronto athlete had surgery this week to repair his knee after the ligament was torn. Unfortunately, once this ligament is torn, it does not heal together. The ligament virtually disrupts and looking in the knee it looks like two ends of crab meat that are floating in the breeze. At this point one must decide whether to operate on this knee or not. The decision is based on the age, type of sport, and level at which one plays. Certain sports like basketball or soccer would be very hard to play at a high level due to the twisting, pivoting nature of the sport.

Other sports like hockey and skiing have less demands on the knee and there have been several athletes who have competed at a high level with an anterior cruciate deficient knee. However, in todays world there would be very few athletes who compete at a high level who would not undergo surgery. Repair of the Anterior Cruciate Ligament is the most common procedure done by sport surgeons. There are many surgeons in North America who do well in excess of 100 of this type of surgery a year. The surgery is almost done on an out patient basis where you only stay in hospital the night after the procedure. After a general anaesthesia and you are put to sleep, the surgeon will put a small telescope(the arthroscope) into the knee. The picture is transmitted to a television screen. The ligament is first visualized to confirm the tear. It is not uncommon to tear a meniscus cartilage at the same time as you tear the ligament.

If the surgeon sees a tear in the meniscus it will be ideally repaired with sutures or small tacks. Sometimes part of the meniscus has to be removed, but we are careful to preserve as much as possible. The surgeon will then do a few small things in the joint to prepare it for the new ligament. Because the cruciate ligament will not heal even if you try and sew it together, some other tissue must be used to make a new ligament. The two most common tissues taken are the middle third of the large patellar tendon below your knee cap or part of your hamstring tendons as they attach on the inside of the knee. The surgeon will then cut out what they are using to replace the cruciate ligament. This graft is then prepared to be put into the knee. A drill is used to drill a tunnel through the knee to hold the graft.

The placement of this tunnel is one of the most crucial parts of the surgery. The tunnel must be in place to allow the new graft to function as closely as possible to the original ligament which was damaged. The graft is then threaded through the tunnel. It is pulled to the desired tension and then attached at either end with either a screw or a staple. The screws used now are biodegradable and dissolve within a year. The athlete uses crutches until they can weight bear on the leg which takes 2-5 weeks. The important thing is a focussed accelerated rehabilitation program to bring the leg and body back to function. Although we have heard of some athletes aggressively being brought to play within five months, it usually a few months longer before they can compete at the high level that they are accustomed to. The surgery is excellent and most athletes do very well and get back to compete at the sport in which they were injured.


The Torn Medial Collateral Ligament
Fall 1991-Wendyl Clark picks up speed as he crosses center ice towards the opponents net. As he crosses the blue line he veers to his right to avoid the defencemen. Unfortunately he is hit and as his skate gets caught in a rut his knee is forced inward. He feels immediate pain and has to be helped off the ice. I examine him in the dressing room and diagnose a torn knee ligament. I tell Wendyl there is good news and bad news. The good news is that he will not need surgery, but the bad news is that he will be out 4-6 weeks. Wendyl had torn his medial collateral ligament. This is a common injury and one in which Eric Lindros just returned from. The knee has a collateral ligament on either side of the knee(medial and lateral). Their function is to prevent the knee from hinging sideways.

The lateral collateral is rarely injured. The medial is usually injured when the knee is hit from the outside. The knee is bent in and damages the ligament. The same injury would occur if you were a pedestrian and your knee was hit by the bumper of a car as you crossed the street. We grade these injuries into three degrees. A first degree is a mild stretch to the ligament and the athlete is not impaired for very long. The knee is iced 20 minutes every 1 1/2 hours to control the pain and swelling. The athlete can return to play anywhere from one day to one week depending on the pain. A second degree sprain such as Wendyl's is more serious and involves partial tearing of the ligament. The knee is quite painful and often the athlete can not walk on the knee let alone continue to play. I place the knee in a brace to allow the knee to keep moving but to protect the ligament from further damage.

This is the same brace that the athlete will wear when they go back to their sport. I never place the knee in cast or straight leg brace. The knee is iced on a regular basis and the athlete is placed on medication to control pain and inflammation from the injury. Sports therapy is started as son as possible. Initially we work to get the range of motion back in the knee and reduce the swelling. The athlete is weaned off the crutches as soon as they feel comfortable to walk on the knee(a few days). A cycling program is started to maintain conditioning as soon as the knee has enough range of motion. After a few weeks Chris Broadhurst our team therapist has Wendyl exercising his leg to get back his full functional strength. He soon starts skating and over the next few weeks we increase his skating, conditioning and strength.

We then test his knee on a computerized machine to make sure he has full strength in his knee. Finally he is ready to practice fully with the team and begin to play. He will wear a brace to protect the knee. Your knee will remain loose when the doctor examines your knee after you injure your medial collateral ligament. Many players I have examined on the Maple Leafs over the years have had loose knees from a previous injury to this ligament. This does not affect the function of the knee and the really good news for Wendyl is that this is not a long term problem and the knee will function 100%. A third degree injury to this ligament usually involves other structures of the knee and the treatment will depend on the extent of the damage. The medial collateral ligament is a ""good"" ligament of the knee to injure as it heals well and there are no long term problems. This is not true for the Anterior Cruciate ligament, the topic of next weeks column.


The Anterior Cruciate Ligament
The anterior cruciate is the most popular sports injury today. Rarely a week goes by where we do not read in the sports pages of another athlete who has torn their anterior cruciate ligament. Pat Lafontaine just had his knee operated on for this injury. Drake Berehowsky injured his just before the playoffs last season. Steve Podborsky tore his anterior cruciate the same year as have most of the Canadian mens and womens downhill ski team. It was not many years ago that we thought the anterior cruciate ligament was not that an important structure. It is only in the past couple of decades that we have realized the importance of this structure to the stability of the knee. The injury is now almost epidemic in athletes and the most common major surgery performed by knee surgeons. The anterior cruciate runs in two bands upwards and backwards from the bottom knee bone to the top knee bone. It prevents the bottom bone from moving forward on the top bone and more importantly provides rotational stability to the knee. Basically it acts as a restraining guidewire to keep the two bones in proper relationship to each other.

The ligament can be injured by a contact injury such as in football where a defensive player hits the ball carrier and damages their knee. The ligament is also commonly injured in a non-contact injury. A basketball player plants his foot and as he rotates his upper body over his knee the force is too great and the cruciate tears. The injury is as common in non-contact sports such as soccer and basketball than contact sports. Although you can partially tear your anterior cruciate ligament it unfortunately usually tears totally when it goes.When you tear your anterior cruciate ligament you will often hear a pop in your knee. Their will be immediate severe pain. The severe pain will only last a few minutes leaving a duller pain. Often you will feel nauseous. The knee will usually swell very large within four hours. This is caused by bleeding in the joint. Most commonly you can not continue to play and the athlete will come hobbling into the office on crutches there are some people who are walking quite comfortably and do not think their knee is that badly injured.

Often the anterior cruciate is torn along with other ligaments and these knees almost always require surgery to repair the knee. The problem exists when the anterior cruciate is the only ligament injured. The athlete then has the choice of either an operation or to treat their injury without surgery. When you tear your anterior cruciate ligament it can not be sewn back together. The ends of the ligament look like and act like crab meat and therefore if you try and sew them together they will not hold the sutures. Therefore to fix the knee you have to reconstruct the missing ligament with another structure and it is major knee surgery. I spend a lot of time counselling patients who have had an anterior cruciate ligament tear on how to treat their knee. The decision is based on several factors. They are mainly age, sport, arthritis, and expectations of the patient. AGE: Generally I recommend surgery for the younger athlete(under 35) as opposed to the older athlete. SPORT: You need your anterior ligament more for twisting, pivoting type sports such as basketball and squash as opposed to sports like skiing, cycling and even hockey.

ARTHRITIS: It is believed although not proven that a knee which is left unstable with a torn cruciate will develop arthritis earlier than knee which is stabilized with an operation. EXPECTATIONS: Surgery is a big commitment of time where you will be in hospital several days, crutches and a brace for up to two months, and close to a year before a return to full activity. There are inherent risks in any surgery. The athlete may decide to modify their sports and activities to ones that will be less demanding on their knee. If the athlete decides to not operate they are immediately placed on a rehabilitation program . Once the swelling is diminished and the range of motion is returned we concentrate on developing the strength of the muscles around the knee to support the unstable knee. A custom made knee brace is used for sports to help prevent the knee form giving way. The athlete is educated on the most appropriate activities and followed up on a regular basis to make sure the knee is okay. The most important thing is to maintain the strength of the muscles around the knee and we will test these on a special computerized machine (Kin Com) on a yearly basis. Next week we will discuss the operative management of the torn anterior cruciate.


The Torn Anterior Cruciate: Surgery

Repairing the torn anterior cruciate is now probably the most common surgery for a sports surgeon. It is only in the last couple of decades that we have developed good procedures to repair these knees. A lot of the early work was actually done in Toronto. The procedures have now become more refined with shorter recovery times. Drake Berehowsky in the extreme case was back playing professional hockey less than six months after his surgery. Last weeks column discussed the options of surgery vs. conservative management of the knee with a torn anterior cruciate ligament. Dr. Ogilvie-Harris will now explain the procedure that he uses to repair these injured knees.


Rehabilitation of The Injured Knee

In Sports Medicine the most important people are perhaps the therapists who work diligently with the athletes on a daily basis to heal their injury and get them back on to the field as soon as possible. The therapy for the athlete after an injury is the most important component of the treatment. Their job is to restore the athletes body to their preinjured condition or better. Even after surgery the most important element in that athletes recovery is the rehabilitation. In working with the Maple Leafs I am lucky to be working with some of the best therapists in the league. Chris Broadhurst our head therapist will now explain his approach to the rehabilitation of the knee.


Damon's Knee
Perhaps the brightest spot in Toronto this year has been the surprise play of the Toronto Raptors rookie Damon Stoudimire. The criticism on draft day has turned into this rookie a top choice for rookie of the year in the NBA. The Raptors have a much better chance of winning with Damon in the line up. But Damon has now come down with an injury that has prevented him from playing this last week as the season comes towards the end. What is this injury that has prevented this iron man all season from not playing at all? Damon has a tendinitis in his knee. This is a tendinitis of the big patellar tendon that joins the bottom of the knee cap to the top of the tibia(shin bone). This is the most common tendon around the knee to become inflamed. It is called JUMPER""S KNEE and thus it is no wonder that it is so common in Basketball . In fact it is the most common injury in high level basketball players. It starts as a dull ache in the front of the knee.

It gradually gets worse until the player feels a sharp pain whenever he/she jumps or lunges to change direction. The player usually comes to see me when there is a significant problem in their performance. The first question I ask is how much is their vertical jump reduced? Often their vertical jump is reduced up to 24 INCHES. This is Obviously a big problem for a basketball player. Damon is a rookie who hopefully will have a long and proliferative career ahead of him. The important thing is to cure his knee and allow him to perform at the best of his ability. The following is the treatment protocol for a player with Patellar Tendinitis:

1/ MODIFY ACTIVITY Damon has not played in the last few games to rest his knee. In practice he must avoid repetitive jumping drills to avoid iritating the knee. Once it is calmed down it is important to increase playing time very gradually to prevent the problem coming back with a vengeance. Other skills that will not irritate the knee such as three point shooting are emphasized. Cardiovascular fitness is maintained with cycling or similar activities which again will not irritate the tendon.

2/ICE The knee must be iced for 10-15 minutes several times a day and after any activity.

3/MEDICATION Anti-inflammatory medication is very beneficial to help reduce the inflammation.
4/PHYSIOTHERAPY This is the most important part of the treatment. Initially various modalities are used to reduce the inflammation. The therapist will use things like ultra sound and laser. Recently we have had great results penetrating into the tendon with a cortisone preparation with a current created by negative and positive ions. As the inflammation is reduced the key is to strengthen the tendon to tolerate the stress that caused the problem in their training. Specific exercises are designed to strengthen the knee and prevent further problems.

5/BRACE Damon has been wearing a brace on his knee for the last few games. The purpose of this brace is to take some of the stress from the patellar tendon as it attaches into the patella.

6/SURGERY Fortunately this is one knee problem that rarely requires surgery. In the rare resistant case surgery is performed to scrape away the chronic inflamed tissue. Damon's knee is hopefully getting better, but in this problem it is important to ensure the knee is well healed before he returns to his full playing potential. I have seen several careers in basketball ruined by this chronic problem. Although this problem is well controlled and easily cured if treated early, the results of a chronic problem that is allowed to fester can be devastating to any athlete that depends on their knee to jump. Therefore ""Get the jump on Jumper's Knee""


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