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Knee Arthroscopy and Meniscal Tears – Part Two

The treatment of meniscal tears has advanced over the years. Forty years ago it would not have been unheard of to excise in an open fashion the entire meniscus. This led to the development of arthritis earlier than was expected. With the development of knee arthroscopy and the small instruments to work inside the knee, debrided (shaving) just the tear became more common. This allowed meniscal tissue to be preserved.

As studies have shown the benefits of preserving meniscal tissue, repairing the meniscus, if possible, has become a goal. Several techniques including “outside-in”, “inside-out”, and “all inside” were developed. The term “all-inside” means the stiches are tied or the device deploys inside the knee without the need for additional incisions. This is also known as “all arthroscopic.” Regardless of the technique, the goal is to repair the meniscus in a stable manner so that early range of motion and healing are possible.

The indications for repair continue to expand with tears greater than one centimeter in the area of good blood supply and in patients less than 40 being common. Additionally, repairs at the time of ACL reconstruction, vertical tears, and acute tears also being good candidates for repair. As the technology improves the candidates for repair are expanding.

When meniscal tissue is severely lost in young patients with good alignment, intact ligaments, and no significant arthritis, meniscal transplant has been developed as an option. Taking a meniscus from a young donor and either suturing it in the knee with or without a piece of bone attached can restore needed meniscus tissue. Long term studies of meniscal transplant are on-going. Hopefully as studies are produced and technology develops, preservation of meniscal tissue will continue to advance in the hope of preserving the articular cartilage and normal biomechanics of the knee.


Knee Arthroscopy and Meniscal Tears – Part One


Knee arthroscopy (the placing of a small camera into the knee and performing surgery through small holes) is one of the most common orthopaedic procedures performed in the United States. Over 900,000 of these are performed each year, and over half are done to operate on a torn meniscus.1 The meniscus is a C-shaped cartilage structure on the inside (medial) and outside (lateral) of the knee. Acute traumatic tears of the meniscus are often caused by sporting activities or an activity where there is a sudden twisting of the knee. Hyperflexion of the knee can cause meniscal tears also. Degenerative type tears can be caused by age or untreated instability of the knee.

The meniscus serves an important function in the knee by acting as a cushion to the underlying joint cartilage called the articular cartilage. Loss of meniscus tissue through tearing or surgical removal can lead to increases in stress placed upon the articular cartilage. This can lead to arthritis. Additionally, the meniscus acts as a joint stabilizer. Loss of the meniscus can place increased stress on the major ligaments of the knee such as the anterior cruciate ligament (ACL). Therefore, preserving as much meniscus as possible is a goal for orthopaedic surgeons.

The diagnosis of a meniscal tear requires taking a history, performing a physical exam of the entire knee and surrounding structures, and performing additional diagnostic tests. As stated above, a history of a twisting injury or hyperflexion injury of the knee can lead to a meniscal tear. Common physical exam findings include swelling of the knee, joint line tenderness on the side of the tear, and pain with certain maneuvers that the physician performs such as a McMurray’s test. (The McMurray’s test is performed by taking the knee from a flexed position to an extended position while the tibia is kept internally rotated (for the lateral meniscus) or externally rotated (for medial meniscus). McMurray described a palpable click as being “positive”.2

Diagnostic tests for evaluating a torn meniscus include X-rays of the knee, MRI and knee arthroscopy. The plain X-rays do not detect the torn meniscus, but they rule out other causes of knee pain such as loose bodies and arthritis. The most common non-surgical diagnostic test for meniscal tears is the MRI. It has a high sensitivity and does not involve radiation. MRI can detect both meniscal and ligamentous tears. The “gold standard” test for diagnosing meniscal tears is actually seeing it with knee arthroscopy. This common outpatient procedure can be performed under general or spinal anesthesia.

1Kim et al: Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am. 2011 Jun 1;93(11):994-1000.
2 McMurray TP: The semilunar cartilages. Br J Surg 1942;29(116):407–414

Sports Injury Analysis: Louisville Player Kevin Ware


Portrait of a pretty young girl enjoying a swim on a hot day looking at you

Did you see the Gruesome injury sustained by Kevin Ware? Pitino said “it was as bad as I’ve ever been.” Ware was taken to the Methodist Hospital, which is two miles away from the arena. He had surgery later Sunday night and will remain in Indianapolis for at least two days.

The open (compound) tibia fracture sustained by Ware is a serious injury with several possible short term and long term complications. Placing a rod into the bone to stabilize and realign it is the preferred method, if possible.  Infection is one of the main concerns given the fact that the bone broke through the skin. Open tibia fracture can potentially take months to heal. However, return to basketball is possible.

We will keep up with Kevin’s healing progress and we hope this young athlete has a full recovery and is quickly back on the court competing at a high level again soon.

Click her for complete article, Louisville’s Kevin Ware suffers gruesome broken leg by Jeff Goodman

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During the countdown to the 2012 London Olympics AOC is going to spotlight some USA Team members who have came back from injury and fulfilled their dream of making the team. AOC loves when an athlete has a real COMEBACK RECOVERY and PERFORMANCE and is able to return to their passion.


Tyson Gay saw his Olympic dream shattered in 2008 by a hamstring injury and now the former world champion comes to the London Olympics after needing nearly a year to recover from right hip surgery.

In 2010, Gay delivered reigning Olympic champion Bolt’s first defeat in two years on his way to capturing the Diamond League 100m crown.

But in 2011, Gay underwent hip surgery to solve several chronic problems. There were times during the recovery when Gay doubted he might ever run again at a world-class level.

“It was a slower process with me,” Gay said. “I had a lot of doubts. I tried to tune them out. It was just everything I had to go through. I couldn’t even jog until March.”

Gay made his competitive comeback after being idled for 50 weeks on June 9 in a secondary race at the Diamond League meet in New York, winning in 10.00 seconds running into a 1.5m/sec headwind.

That was Gay’s only tuneup race for the US Olympic trials, where he finished second in the final to 2004 Olympic champion Justin Gatlin’s career-best 9.80, qualifying for London in 9.86.

Gay remains cautious about his health.
“The plan worked. It held up pretty well,” Gay said. “I’m just going to continue to take care of my body and stay healthy. That is the big thing.”

(via: www.indianexpress.com)

The men’s 100m dash is one of the most popular and most watched events of the Olympic Games, and this year is shaping up to be one of the best in Olympic history. The door is wide open; it’s anybody’s race. Tyson Gay, after his great COMEBACK PERFORMANCE, is hoping that he will be the one to cross the finish line and achieve his lifelong dream of Olympic gold.

(via: www.rantsports.com)

Keep up with Tyson Gay in this year’s London Olympics. You can follow him on twitter at @TysonLGay and we will keep you updated on our blog and Facebook page.

Click here for more information on Tyson Gay.

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Injury Analysis: University of Alabama RB Jalston Fowler


Portrait of a pretty young girl enjoying a swim on a hot day looking at you

The recent injury to the knee of University of Alabama RB Jalston Fowler reminds us of how debilitating such injuries can be. Although no official report of the exact structures that have been damaged has been released, the video shows hyperextension of his knee which can damage major ligaments such as the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), side ligaments (collateral ligaments) or cause fractures to occur.

Seventy percent of non-contact injuries that result in swelling within one hour are ACL injuries. Furthermore, the C-shaped cartilages, called the menisci, can be torn during sporting injuries.

Treatment of knee injuries during football or other sports is most often treated arthroscopically– meaning via small incisions using a small camera to assist in visualizing the injured structures. Over 400,000 ACL reconstructions alone are done in the United States yearly.

According to R. Kavner’s article on collegesportsblog.dallasnews.com, Alabama coach Nick Saban announced Monday that running back Jalston Fowler will have surgery on his injured knee and is most likely going to be out for the season. Regaining muscle tone, control and joint range of motion is important if returning to sports is desired. This can take many months of hard work and dedication. AOC hopes Jalston has a good recovery and can return to the sport as soon as he is able.

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Return to Sports After ACL Reconstruction


One question often asked by athletes before they undergo ACL reconstruction is “When and will I be able to return to sports?” This is an important question because returning to play (RTP) is just one of the factors taken into consideration as to the decision to undergo this invasive procedure. The answer to this question depends on many factors: level of activity before the injury, extent of the damage inside the knee, and level of competition.

Namdari et al in The Physician and Sportsmedicine in February 2011 reported on a study of 18 WNBA basketball players who underwent ACL reconstruction. They found reported that 78% returned to play in the WNBA. For those that did return, changes in performance were not statistically reduced compared to a comparison group.

Shah et al reported in The American Journal of Sports Medicine in November 2010 on a group of NFL athletes who had ACL reconstruction.  This study of 49 NFL players who underwent primary (first-time) ACL surgery found that 63% returned to NFL game play at an average of 10.8 months.  They found that the odds of returning to play were higher for those with more than four years of NFL experience.  Furthermore, Shah et al found that those drafted in the first four rounds of the NFL draft had higher odds of returning to play than those drafted later. They concluded that more experienced and established athletes are more likely to return to competition at the same level after ACL reconstruction than those with less experience.

Return to sports two to seven years after ACL reconstruction was studied by Ardern et al and reported in The American Journal of Sports Medicine in January 2012.  This medium-term analysis of 314 patients with the average age of 32.5 years used a self-reported questionnaire to ask questions regarding knee function and attempt to RTP.  Adern et al found that 45% of participants reported playing sports at their pre-injury level and 29% were playing competitive sports. However, younger patients were more likely to return to pre-injury levels of participation, and most patients reported good postoperative function of their knee.

In a separate study reported in The American Journal of Sports Medicine in March 2011, Adern et al reported on RTP 12 months after ACL reconstruction in Australian athletes. These athletes in competitive level Australian football, basketball, netball, or soccer had a return rate to competitive sport of 33% at twelve months. However, 47% indicated in this short term study that they planned on returning.  Ardern et al concluded that people may require a longer rehabilitation period to return to competitive sports than previously believed.

As you can see just from these few studies here, more research is needed to provide patients with the answer of returning to play after ACL reconstruction. Currently, there is a wide range of answers depending on age, athletic ability, and lifestyle that has to be factored into this important issue.


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ACL Injuries. What ESPN doesn’t tell you.


Knee injuries in sports are a common occurrence. One dreaded injury is a tear of the anterior cruciate ligament (ACL). Most ACL tears occur after a non-contact injury such as a wide receiver or soccer player making a sudden change in direction. The leg planted on the ground during the cutting move may experience enough force to tear the ACL. Seventy percent of acute hemarthosis (blood in the knee) after such injury is an ACL tear.

Non-surgical treatment for complete ACL tears in young, active patients has generally been met with less than satisfactory results. Loss of the ACL can result in instability or the feeling that the knee is loose. The knee wants to “give way” when a change in direction occurs.  This instability can result in further damage to the knee and the C-shaped cartilages called the meniscus. Rebuilding the ACL and restoring stability to the knee can protect the meniscus from further damage.

There are over 400,000 ACL reconstructions a year in the United States. Much research has occurred and is on-going into different techniques and choices of tissue to use to rebuild the damaged ACL. Two of the more common tissue (graft) choices are hamstrings and patellar tendon.  Both are usually taken (harvested) from the same knee and used in the reconstruction process. Other options include quadriceps tendon and tissue that has been donated to tissue banks (allografts). There are pros and cons to each graft choice, but analysis of multiple recent studies show little difference in long term outcomes between hamstring and patellar tendon autograft (tissue taken from the same patient.)

In part two of “ACL Injuries in Sports” we shall discuss current data on the return to sports after ACL reconstruction.


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Picking The Right Sports WITH Your Kids


When parents read stories of childhood “prodigies” such as Michelle Wie learning a sport as young as 3 years old, it is natural for us to wonder what sports are best for our child and at what age they should start. While there are no sure answers as to when a particular child is ready for a sport, there are well-studied developmental patterns that can guide us.

Infants and toddlers, for example, gain gross and fine motor skills along a predetermined path, and any attempts to speed this up with training will fail. That being said, there are windows of opportunity in which a toddler learns certain movements more readily and should not be missed. So, the best course in this age-group is to expose the child to a wide variety of interactive games so that they can have the tools to progress at their own pace. Mom and Dad can create a variety of activities with a ball and things around the house or get some ideas at the local toddler gym.
In preschool a child can follow simple instructions and has basic postural control and balance to allow sports participation. Soccer is a great activity at this level because it can be played by following one simple instruction; “kick this ball in that goal!” Preschoolers do not have the ability to engage in rapid decision-making to account for unexpected events. So, they all stick with the one thing they do get – kick the ball! The result is the “swarm” phenomena we see in all soccer games at this level. This is normal behavior and should not be a source of frustration to parents—and oh, by the way, kids this age cannot distinguish multiple instructions coming from the crowd, so you can save your breath!

A classic study has shown that by elementary school, 6 out of 10 children can throw, kick, run, jump, catch, strike, hop and skip. This opens the door to a wide variety of sports. However, children this age also become aware of their status among their peers and their own inadequacies (they know who is “cool”, who is “athletic”, etc.). Keep in mind that children of the same age and grade may be at very different developmental stages, so comparing them to their peers is misguided. For these reasons, confidence-enhancing activities for all children are important. Parents should choose at least one noncompetitive activity and always emphasize socialization and sportsmanship more than physical performance. Additionally, contact sports are not ideal because coordination is not fully developed and children have little ability to consider future consequences of current behavior. For example, they cannot think through the consequences of spear-tackling. Weight-training with light weights under strict supervision can begin as early as 8 years of age. Strength gains can be achieved in pre-pubescent children, but no gains in muscle size will occur until the hormones kick in at puberty.

As a child transitions to adolescence, their growth dramatically increases. Bones grow faster than tendons which can result in loss of flexibility and “growing pains”. This is a crucial time for skills development, and most are ready for organized sports of all types. However, precautions, such as pitch counts and cross-training, must be taken to avoid overuse injuries to the growth plates. This is the most appropriate time to begin weight-training. There is no evidence that a proper weight-training program during adolescence stunts growth. However, to avoid injury, explosive exercises such as clean-and jerk should not be done until skeletal maturity (15-16 years old).

In summary, children are not just “little adults”. They react to physical and emotional stress at different developmental stages in different ways. Moderation should always rule, and as my grandmother used to say about raising children, “the best that we can hope for is to not mess ‘em up.”


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