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Saving Knees
The sight of Bobby Orr hobbling around makes us all cringe. Bobby Orr has a bad knee. Not only did it shorten a great career of perhaps the greatest hockey player that ever played defence, but it has affected his whole quality of life. He certainly can not enjoy the simple pleasures of sport, let alone getting around through the day without pain and disability. Bobby Orr has osteoarthritis of his knee. We al fear developing arthritis. We envision granny all crooked and bent riddled with arthritis. There are many different kinds of arthritis, but by far this most common kind of arthritis is osteoarthritis. This is the classic wear and tear arthritis. There are several factors that can lead to developing osteoarthritis. There is no doubt a genetic component. The most common predisposing factor is an injury to joint.

After the injury, the joint does not function properly and starts a slow process of degeneration. After Bobby?s first injury as teenager in junior hockey his knee started to degenerate, greatly affecting his career in quality of play and longevity as a player and now as a retired civilian. The most common joints to degenerate is the knee and the hip. The knee is the most common of the two due to the abuse of what we do to it in our lives. The bone in the joint is lined by a smooth layer of what we call articular cartilage. When we are born this is smooth like a Teflon surface. This articular cartilage allows the joint to move smoothly and protects the underlying bone. When this protective surface is damaged the joint does not work as well. It can be painful and can lead to swelling and instability of the joint. Unfortunately, it has no ability to heal once it has been damaged.

Previous columns of dealt with how to deal with osteoarthritis of a damaged joint. All of these solutions are only how to deal with the pain or how to make the pain less until the joint under goes further degeneration. What would be really exciting is if we could actually do something to prevent this arthritis occurring. Since the beginning of the end is the initial damage of the protective layer of articular cartilage, it would be great if we could repair this damaged articular cartilage. It is in the last couple of years that we are experimenting with repairing isolated areas of articular cartilage damage. Although this is early in the experimental stage the results have been promising. We are now repairing areas of damage. The goal is to allow someone to have less pain and swelling in the short term, and more importantly not to develop osteoarthritis in the long term.

It will take us years to actually determine which is the best procedure and if in fact it will have any impact in the long term. There are now several different ways surgeons are trying to repair this very important layer of articular cartilage.

1/ The oldest and most common way is to penetrate the bone underneath the damaged cartilage. This is done by drilling multiple small holes through the arthroscope. The idea is to stimulate new bone formation. It works to produce some tissue but the new tissue is not as soft and pliable as the original cartilage. It has been fairly unpredictable. Not only that but the results probably deteriorate over time.

2/ One of the newer methods takes little plugs of bone and cartilage from part of the joint that is not on a weight bearing surface. These plugs are then transplanted to the area of damaged articular cartilage which is on the more important weight bearing surface. The idea is to steal good tissue from a hopefully unimportant part of the joint and use it on the damaged important weight bearing surface. This may require 3-6 plugs of between 5-10n mm.

3/ Other surgeons are transplanting areas of cartilage from cadavers in the same way we would transplant a kidney or any other organ. This can be used to repair larger or more traumatic defects.

4/ The last method being used requires tissue engineering. In the first procedure the surgeon takes a small amount of cartilage from a non weight bearing portion of the knee. The cells are then grown and expanded in the laboratory. Approximately one month later this newly expanded area of cartilage is transplanted into the damaged area in the knee. All these new techniques are very exciting and hopefully will be able to preserve the function and longevity of our knees.


The Iliotibial Band Syndrome

You are 20 miles into your first marathon. The training was perfect without any problems. Suddenly, you start to develop a twinge on the outside of your knee and before you know it you can barely run. You have to finish with a peg straight leg gait and barely manage to cross the finish line. What went wrong? One of the most common knee injuries I see in the running season is the Iliotibial Band Syndrome. Often referred to as runners knee, it happens almost exclusively to runners. There are other knee problems that people will refer to as runners knee, but this is the most common. It is a very easy injury to diagnose as the story is usually so classic.


Osgoode Schlatters Disease
The nemesis of many a teenage male athlete is Osgoode Schlatters Disease. It occurs almost always in males and only rarely in females. The name is really a misnomer as it is not truly a disease. The problem occurs in the knee. It starts as the adolescent starts their growth spurt. Therefore I usually see it young males between 11 and 13. The pain is just below knee where the patellar tendon inserts into the lower leg bone(tibia). The growing bone has a growth plate at ether end of the bone. This is where the bone produces to new bone to allow the bone to grow. When the child is growing this growth plate becomes very active. This is the weak spot in the bone. As the child starts to grow and gain weight they become bigger and stronger. They play sports with more vigor and put more stress on the body. As the bones become longer they become longer levers and therefore put more stress through the joints.

The large thigh muscle(quadricep) inserts into the kneecap. The patellar tendon comes off the patella and inserts into the tibia to complete the unit. The tendon inserts into the growth plate area on the upper tibia. Whenever you contract the quadricep the tendon pulls on the growth plate area on the tibia. With constant pulling bone fragments are pulled off the growth plate. This creates a bump on the tibia and swelling on the area. The area is exquisitely tender to touch. It is usually worse in those who have a very large growth spurt combined with an active lifestyle. The good news is that it will not affect the growth of the leg. The bump on the knee will remain for life, but the pain will not. The pain will go away when the bone is finished growing, and the growth plate turns into normal bone. The treatment is as follows:

1/MODIFY The athlete can use pain as their guide. If there is only an ache with activity then the athlete can continue to do their sport. If the pain becomes more severe and it affects their ability or causes them to limp then they will have to back off their sport until it calms down. The sports that require a lot of pounding or lunging such as basketball are hardest on the knee. If the pain is severe in these type of sports the child should be able to cycle or skate or swim to keep active.

2/ICE Ice is applied a few times a day for 15 minutes to reduce the inflammation. This should also be applied immediately after sports for the same mount of time.

3/ PHYSIOTHERAPY Initially the inflammation is reduced. Flexibility is important to decrease the stress on the tendon. As the pain is diminished the athlete will be guided on how to strengthen their leg without aggravating their condition.

4/ BRACE We will design a special brace which will have two functions. The first is to protect the area from contact as the area is so sensitive to pressure. The second aspect is a special strap which will goes across the patellar tendon decrease the stress that goes into the growth plate where the tendon inserts.

MEDICATION Occasionally we will use a light anti- inflammatory pill to help reduce the inflammation in the more severe or resistant cases. Osgoode Schlatters is not a disease, but an inflammation or fracture through the growth plate of the tibia.

This problem, except in a few unusual cases is self limiting and goes away as you finish growing. In most cases the athlete can play through the problem by following the above protocol. Only the small bump remains as a reminder of a problem that you once had as an adolescent athlete.


The Athletes Knee

Often I am asked what the most common injury there is in sports. There is no doubt that the knee is the most common injured joint. There are very few activities that the knee is not asked to take the brunt of the work. You will often hear about famous athletes or your friends having major traumatic injuries to their knees where they will tear ligaments or their meniscus cartilage. Although these are the most damaging to the knee, it is not the most common injury that we see in the knee. The most common injury that we see in the world of Sport Medicine is what we call Patello Femoral Syndrome. This is often called Runner's Knee or Cyclist Knee or whatever sport that you happen to be participating in knee. It occurs in any sport which requires you to repeatedly bend your knee. The pain in the knee comes from the joint surface of the patella or knee cap. Although the top of the patella you can feel is flat, the bottom is shaped like a pyramid. This inverted pyramid moves up and down a corresponding grove in the large leg bone(the Femur).

You can get an idea of how this works by moving a bent joint of your finger back and forth between two knuckles. When you are born the bone in joints is lined by a smooth layer of ""articular"" cartilage like a Teflon surface. From the repetitive stress on the joint surface you eventually get some wear on this surface. Often you will hear a noise in your knee as you bend and straighten it, which we call crepitus. The pressure on the knee cap starts when you bend your knee past the first 20-30 degrees or a quarter squat. Therefore the sports which require a deeper knee bend will be harder on the patello femoral joint. The pain you feel is more a dull type of pain. The pain can be there during your activity and/or after activity. It is usually painful on stairs and with prolonged sitting (positive theatre sign). It usually is not limiting and the athlete can usually continue to do sports with some modifications. The key point is that it is not arthritis which many people have a fear that it is and in fact will only rarely lead to arthritis. There are many causes for this problem. The following are the most common.

1/AGE The problem usually first starts in the adolescent years when you are very active. For some reason it is most severe in adolescent females and has prompted authors to write books on the ""Adolescent Female Knee Syndrome"". After a period of rapid growth there is much more pressure on the patello femoral joint as the long femur acts as a longer lever to the knee. Not only that, the bones grow faster than the muscles, so the tighter muscles put more compression in the joint. I will tell patients who see me in their adolescent years that they will usually grow out of the problem as they get a few years older.

2/OVERUSE As in any sports injury, if you increase your activity level quickly you will fall into the ""too much,too soon"" group where their is too much stress placed on the joint surface and it begins to break down.

3/BIOMECHANICS Malalignment of the lower legs can put more stress on certain parts of the patella. The classic scenario of wide hips, knocked knees, and flat pronated feet will cause the knee cap to track unevenly to the outside of the knee and put more compression to the outside of the patello femoral joint.

4/ MUSCLE IMBALANCE There is a tendency for the outside muscles of the leg to develop more than the inner quadriceps muscles. This will again cause the patella to track towards the outside. Tight hip and leg muscles will put more compression in the joint. So join the club, every one of us who has participated in some form of physical activity has at one time or another experienced the pain of the ""Athletes Knee"". Stay tuned to next weeks column when I will tell you how to treat the most common of all sports injuries.


The Athletes Knee Part II
Last weeks column disclosed the most common of all sports injuries, something which most of us have experienced sometime it our active lives. The Patello Femoral Syndrome causes a dull aching in the knee which comes from an irritation on the back of the patella of knee cap. While this problem does not usually make the person stop all activities it can be quite annoying. Last weeks column talked about what cause the problem but read on here to hear how to treat this most common knee problem. Whenever we treat a sports injury, we have to look at all the predisposing causes. When we correct these we can intelligently deal with the pain. The following is the treatment program.

1/MODIFY We know that there is more compression in the patello femoral joint after 20 degrees of knee flexion. Therefore the sports that limit knee flexion will be easier on the knee. This includes swimming, walking, slow jogging, cross country skiing, and light cycling. The most aggravating sports are the deep lunging type sports such as squash and basketball. I tell my patients that they should not worry about a bit of an ache in their knees and to only start to curtail or modify their activities when the pain gets more severe.

2/ICE The knee should be iced for 15- 20 minutes after activity to reduce the inflammation in the knee. This can be done with a commercial ice pack or frozen peas, but NOT with a rub or balm. Remember to protect the skin with a paper towel a thin towel to prevent frostbite.

3/ PHYSIOTHERAPY Initially the therapist will work to reduce the inflammation. The most important part of the treatment is to correct the muscle imbalance to help the patella to track more centrally in the grove in the femur(long bone). The important muscle is the vastus mediallus obliques which controls the patella from the inside of the knee. The strengthening as you progress must be tailored to be specific for your sport or activity. The therapist will also work on your flexibility of your hips and legs.

4/MEDICATION If the knee is swollen then the physician will sometimes place you on anti-inflammatory medicine, but this is not usually need for most people.

5/ BRACE A special brace designed to help control the patella is often useful in people with persistent problems. This is worn only during the activities that cause the problem and often for a limited period of time and not the rest of your life.

6/ FOOT ORTHOTICS If the physician determines that a lot of the problems are biomechanical in nature then a custom foot orthotic is prescribed. This is beneficial in people have a lower leg malalignment problem where their knocked knees and flat pronated feet will cause the knee cap to be pulled to the outside. The foot orthotic will function to straighten the leg.

The knee cap will then track more centrally in the grove to be not only more efficient, but more importantly take the stress off the irritated part of the joint surface. Often a proper shoe can sufficiently correct the problem without the expense and inconvenience of a custom orthotic. 7/ SURGERY Very rarely surgery is required for this problem. The basis of the surgery is to possibly smooth down roughened areas on the joint surface.

The surgeon may also release the structures on the outside of the knee if they are too tight causing the patella to track more to the outside of the grove in the femur. So for all of us with some form of ""The Athletes Knee"" or as we call it Patello Femoral Syndrome we now know how to deal with this most common but usually not very severe problem. Sometimes it is nice to know that all of us are in this together as it is the rare person that will not get some form of this aching in their knees in their life.


Shin Splints

""Shin Splints"" is nothing more than a lyman's term for any pain between between the knee and the ankle. I have seen patients with everything from patellar tendinitis to having tumors of the lower leg who came in to see me telling me that they had shin splints. Nonetheless there is a distinct entity that we refer to as shin splints. In the medical literature there are numerous terms that physicians use to label this entity, the most common being medial tibial stress syndrome. The classic area of pain is an area on the medial aspect of the tibia. The area starts about half way down the tibia and ends several inches above the medial malleolus. The pain will differ both in quality and duration depending on the exact etiology of the pain. You obviously can get pain in other parts of the lower leg but the causes of these entities are beyond the scope of this article.

Classic medial shin pain is almost always caused by one of tendinitis, periostitis, stress fracture, and compartment syndrome. TENDINITIS: Tendinitis of the broad based Tibialis Posterior Tendon is the most common cause of medial tibial pain. Some authors have also blamed the soleus insertion for the pain. With repetitive pulling on the tibialis posterior tendon such as which occurs in running and aerobics the tendon will develop microscopic tears and become inflamed. The pain will start slowly into activity and may even disipate as the activity continues and rarely bothers the athlete during daily activities. PERIOSTITIS: With repetitive pulling of the tibialis tendon on the periostial-fascial junction the periosteum will eventually become inflamed as well(traction periostitis). The pain is increased. It may not go away or in fact might get worse with activity.

The pain will last well after activity as well. The may be swelling and bruising over the area. STRESS FRACTURES: Stress fractures of the tibia are not incommon in athletes. Althouogh they can occur at the upper 1/3 junction and at the mid tibia level, they are most common at the lower 1/3 level( the ""shin splint area""). Stress fractures in the tibia can occur in two ways. They can occur de novo without any preceding pain. They can also occur as progression from a chronic periostitis. COMPARTMENT SYNDROME: A compartment syndrome of the posterior compartment can lead to medial pain. The pain from a compartment syndrome will come on as exercise progresses. With the build up in pressure nerve compression may cause parasthesiaes on the sole of the foot. The pain may increase to force the athlete to stop the activity and the pain may last from several hours to several days after an exercise bout. The challenge then is to diferentiate what the exact problem is.

The first thing is to listen to the history. The type of pain and the timing of the pain may be charachteristic. Palpation of the tibia may also be diagnostic. A stress fracture may present with very localized pain, this is one area of the body where a stress fracture may not present with localized pain, especially if the stress fracture is a result of a progression from a chronic periostitis. A technitium 99 bone scan will diferentiate between a tendinitis, periostitis, and a stress fracture. A normal scan may indicate a tendinitis. Periostitis will present with diffuse uptake along the periostial border. A stress fracture will have the typical localized fusiform appearance. Compartment pressures before, during and after exercise will cvonfirm the diagnosis of a compartment syndrome. The key is not only how high the pressure rises within the compartment, but how lomg it stays elevated once the exercise bout is stopped. TREATMENT The treatment of this medial shin pain will obviously depend on the diagnosis. The treatment of tendinitis and periostitis is very similar.

1/MODIFY The important thing is to minimize the offending sports. This may mean decreasing either the amount and/or intensity of the activity. The more severe the pain as in periostitis will necessitate more restricted activity. Non weight bearing activities such as cycling and swimming can be used to maintain fitness.

2/ICE Ice is used on a regular basis and after activity for 15-20 minutes to reduce the inflamation.

3/MEDICATION Anti-inflamatories can be used as well to reduce the inflamation.

4/PHYSIOTHERAPY Initially the sports therapists wil use specific modalities to reduce the inflamation. They will then correct any muscle weakness and inflexibity to allow the athlete to return to their sport without a recurrence.

5/BIOMECHANICS Sub talar pronation and tibial torsion may cause increased stress on the tibialis posterior muscle tendon unit. Check the patients shoes. Proper shoes and/or custom foot orthotics are beneficial to those athletes whose medial shin pain may be precipitated by a biomechanical imbalance.

6/BRACE Although not commonly used, some athletes have found a special brace allowed them to still compete without pain. Once a stress fracture is diagnosed, the athlete will require at least six weeks rest from the offending activities. As in the treatment for tendinitis/periostitis all predisposing and precipitating factors must be corrected before the athlete is SLOWLY allowed to return to their activity. If conservative methods have failed and a compartment syndrome is confirmed by pressure studies, then an operative fascial release of the posterior compartment may be indicated to relieve the pain.


Pavel's Conkneedrum

A couple of weeks ago it was announced that yet another star player was through for the season. Pavel Bure joined the growing list of NHL stars that are side lined. Although it looked fairly harmless as Bure circled behind the opponents net, if you watch the replay in slow motion you can see the bottom part of his leg shifting sideways at the knee. Pavel Bure tore his anterior cruciate ligament in his knee. This is the leader in incidence and severity of all sport 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. Pavel joins the club of 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. Is this injury to 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 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. I talked to Pavel's surgeon this week and his surgery went well. Should we operate on everyone who tears their anterior cruciate ligament? The answer is no and I will discuss the pros and cons on whether one should have their knee operated if they tear this ligament in my next article.


The Torn Anterior Cruciate Part II
The torn anterior cruciate ligament. For any athlete this diagnosis is a nightmare. A s this injury can be so devastating and has received so much media attention it is the most dreaded of all sport injuries. Every professional sport can name numerous stars that have suffered this injury. Not only that is prevalent in amateur sports and the weekend warrior. There is a rare day that I do not see a torn anterior cruciate ligament present in my sport clinic if not several. In my last column I described how this ligament is injured and why it is so important. The big question is what to do with the knee when a diagnosis of a torn anterior cruciate is made. We often hear in the media of a star player tearing their anterior cruciate ligament and like Pavel Bure several weeks ago, having it operated on and being lost for the season. But, is this what everyone should do? Often, especially in contact injuries there are other structures(ligament and meniscus) that are injured when the anterior cruciate is torn. For the most part these knees do require surgery.

The bigger question is what to do with the athlete who have only torn their anterior cruciate. While the cruciate can be partially torn and heal and function well, this is a rare occurrence. The usually scenario is that the ligament totally disrupts(the cause of the pop)when it is torn. The ligament tears in the middle and can not be sewn together. The two 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, if you are going to operate on the knee you have to reconstruct the missing ligament with another structure and it is major surgery. I will discuss the surgery in detail in my next column. Once I make the diagnosis of a torn anterior cruciate ligament I spend a lot of time counselling the patient and their family on their options on how to treat their knee. The decision is based on several factors. They are mainly age, level and type of sport, expectations of the patient, and arthritis. AGE: Generally, the younger the patient the more aggressive I am in recomendending surgery.

In athletes age is both physical and psychological. SPORT: Certain spots rely more on the anterior cruciate than others. Sports that require twisting and pivoting such as basketball and soccer depend heavily on the anterior cruciate ligament for knee stability. Other sports where the knee is bent most of the time such as skiing and even hockey are not so dependant on the anterior cruciate. There are players playing in the NHL with a torn anterior cruciate ligament. The ligament is almost a non factor in sports like cycling and rowing. The other factor in sports is the level in which the sport is played. A skier who on one extreme only skis on groomed trails will generally do well without their anterior cruciate as opposed to someone who is an extreme skier or racer and placing more stress on the knee. EXPECTATIONS: Surgery is a big commitment of time. Not only will you be in hospital for a couple of days, you must commit to a long period of rehabilitation. It will be 6 to 18 months before you are back to your full level of activity. There are other inherent risks in surgery.

An athlete may decide to modify their sports and activities to ones that will be less demanding on their knee. ARTHRITIS: It is believed although not conclusively proven that if you reconstruct the knee after tearing your anterior cruciate ligament you will be less prone to developing degenerative arthritis of the knee. The athlete must decide for themselves if they want to operate on their knee. If they do not they are immediately placed on a rehabilitation program. Initially the swelling is reduced and we work to regain full range of motion of the knee. The most important part of the rehabilitation is to develop the strength of the muscles around the knee to help support the unstable knee. A custom made knee brace is used for sports to help prevent the knee from giving way. The athlete is advised on which sports are better for the knee. The most important thing is to maintain the strength of the knee and this should be checked yearly on a computerized machine like a Kin Com. It is often a tough decision on what to do with this very common injury. I have outlined the key factors the you need to consider in making this important decision. I will discuss the operation in my next article.


To Cut Or Not To Cut
Pavel Bure has torn his anterior cruciate ligament. The physician for the Vancouver Canucks has discussed the various options with him. The ultimate decision is that he had surgery on his knee. Surgery for the anterior cruciate ligament is the most common procedure done by a sports surgeon. It has only been in the last couple of decades that we have good procedures for this problem. In fact much of the early work was done in Toronto. Over the years the procedures have become more refined with a much faster recovery. A professional athlete can be back playing within six months if everything goes according to schedule. There are several procedures that surgeons do to repair the anterior cruciate ligament(last column discussed why you should or should not have this surgery). Dr. Darrell Ogilvie-Harris who is a orthopedic consultant to the Toronto Maple Leafs uses the following method. ""I prefer the gold standard for ligament repairs known as the ""bone tendon bone"" method.

This provides the strongest repair tissue. Since we can not repair the actual ligament I must use other tissue to make a new ligament. The strongest tissue to use is a piece of the patellar tendon(the strong tendon in the front of the knee). The first step is to prepare the new ligament. I remove a piece of the patellar tendon with a bit of bone at each end which will become the new ligament when it is transplanted into the knee joint. I then prepare the knee by looking inside with an athroscope and removing or repairing any damage to the cartilage or meniscus. A 1 cm. hole is drilled through the knee joint. Great care is taken and special instruments are used to make sure the hole matches the site of the torn ligament. The previously harvested bone tendon bone graft is pulled through the tunnel.

Titanium screws are used to attach the bone plugs at each end of the graft to the knee. The graft is now held securely in place in the exact location of the previous normal anterior cruciate ligament. The new ligament is stronger than the original. Because it is so firmly fixed the patient can start moving immediately - not being kept in a plaster cast for several weeks as in the old days. An aggressive rehabilitation program is started right after the surgery. I strive to regain the movement of the knee first. Then exercises are given to strengthen the muscles. The process will take up to six months of hard work. The final phase will be to build up endurance and the sports specific skills necessary to compete or train at the level they were at prior to their knee injury.

The key is to train the athlete as specific as possible to their sport. Elite athletes will use computerized muscle strengthening equipment. Overall the injured athlete will take 9 to 12 months to recover to sporting fitness. Between 80% and 90% of torn anterior cruciate ligaments can be successfully repaired surgically, but it must be emphasized that the eventual recovery depends on conscientious and dedicated work for many months."" The decision is often a difficult one to make, but not one you can make without knowing all the implications of conservative versus surgical management of a torn anterior cruciate ligament. What is nice to know is that the surgery is usually very successful in the proper candidate and although the knee is never 100%, it certainly is close enabling even the highest performing athletes to compete at the same level that they were previously accustomed to.


Leafs Knees Woes

The Leafs are heading into a crucial part of their schedule.The two weeks leading into the All-Star break finds the Leafs on an extended road trip against the Eastern division rivals against whom they have not fared that well thus far this season. At the same time this has been the busiest I have been this season. I am sure Pat Quinn is dreading seeing me after every game with a new injury to report. The ironic thing is that Alan McCauley, Tie Domi, and Glen Healy are all out with the same type of knee injury. They have suffered the most common knee injury that a hockey palyer will recieve. They have to some degree injured their medial collateral ligament. 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 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 soon 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. As soon as possible we start to strengthen the knee to ultimately return to its full functional strength. As the ligament is healing skating is slowly introduced. Conditioning is maintained on the exercise bike. When the knee is close to being ready we test the knee on a computerized machine to make sure the athlete has regained the full strength to be able to play at their pre-injury level without risk of further injury. The final phase is when the athlete is ready to practice with the team. Then they will regain the full sport specific function of the knee before full game playing. It is crucial that the athlete where the appropriate brace to protect the knee.

There are many inferior hinged braces on the market that will not be strong enough to protect the knee in a contact sport. 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 their is very little effect on the knee in the long term. A third degree injury is not that common by itself but usually occurs with damage to other structures of the knee at the same time. The treatment depends on what other structures are damaged . Fortunately, all three of our Leaf injuries seem to be isolated to the medial ligament and all of them will be back shortly to continue our quest for the Cup. 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.


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