By popular demand from yesterday's post Some Insight on Ekeler's Injury Who am I? By profession I am an Athletic Trainer, I have both my Bachelor's and Master's degree in sports medicine and 10 years of practice in collegiate athletics and Industrial Injury prevention. Full Disclaimer: I am not his Doctor, so I do not fully know the extent of his exact injury, but I will shed some light on the reported injury and what to expect. (Grade 3 MCL Sprain). I will also be as objective as possible. I cant give too much fantasy advice here, as I do not know the philosophy of his medical team and what their exact plans are. My purpose is for you to make an informed decision based on what is reported about the player and the nature of the injury I am describing. EDIT: My Source for His Reported Grade 3, I'm willing to change this if I'm shown better. EDIT 2: There are mixed reports as the 24/7 and The atheltic are speculation. I will keep grade 3 for the sake of overpreparing rather than underpreparing y'all. All the information remains relevant for knee injuries. If he comes back sooner, great for him and you. 4 Major Ligaments of the Knee Ligaments: Structures of the body that connect bone to bone. These are basically the tape that hold our joints together. The major ligaments of the knee are comprised of 2 cruciate (Anterior Cruciate;ACL, Posterior Cruciate;PCL) and 2 Collateral (Medial Collateral;MCL, Lateral Collateral;LCL). What AnterioPosterioLateral/Medial Mean These 4 structures help keep our femur (thigh bone) in place and stable on our tibia (shin bone). Without them, our knees would be unstable and leave us open to a wide array of injuries both in the short term and in the long term. More specifically, the MCL prevents excessive valgus force, the LCL prevents excessive varus force. These are BIG TIME when cutting and running. Valgus/Varus Diagram Ligament Sprains: There are 3 grades of sprains. Not to be confused with strains. Strains are injuries to muscles and tendons, sprains are for ligaments (you sprain you ankle/knee ligaments, you strain a muscle). Although, the grades for them are very similar. (The AC joint in the shoulder has multiple grades but that's another post) Grade 1: There is minor damage to the structure, in terms of sprains, it is usually described as "mild stretch" of the ligament. Most people on here have probably had a grade 1 ankle sprain at some point in their lives. Grade 2: There is mild to moderate tear in the ligament. This is a fairly significant and usually takes 3-6 weeks for full recovery. Michael Thomas, CMC (I'll go over a high ankle in a future post) Grade 3: Near or full rupture of the ligament. This usually means missing significant time. The amount of time missed depends on what can be done to fix it. Why Blood Supply Matters What is a very common theme amongst injury recovery time here is the amount of blood supply the structure has. The MCL has a pretty decent blood supply running to it, the ACL however, does not. Blood is what we use to heal our bodies. It supplies nutrients and carries away debris. So no blood supply = little to no healing. So this is why Chubb is expected back this season and Barkey is not. Barkley's ACL needs to be surgically repaired so he can safely return to his level of activity, where Chubb's MCL needs time to repair itself. What Does This Mean For Chubb? Quite simply, he'll be back (hopefully) this season barring any setbacks or unexpected additional injury (the meniscus can sometimes be involved, but as of now it was not). The average, I stress average, healing and return time for a grade 3 MCL is 6-8 weeks. I would also expect some "easing in" in terms of workload upon return. Please feel free to ask any clarifying questions or if you'd like to dive deeper into the science of it all. I'm trying to keep my posts in the ELI5 theme, but im more than happy to get real technical in the comments Next Up: The High Ankle Sprain, and why this seeming small injury screws you year after year
How to understand and fix your CPPS and Hard Flaccid - (With starting exercises and routines)
(CPPS stands for chronic pelvic pain syndrome and is a term that applies to hard flaccid) Make sure you have read these posts before continuing, any comments that are explained by material in these posts will be answered with a link to the post: Why your Hard Flaccid isn't nerve damage + Understanding the role of fascia - Applies to HF/CPPS Intro to Hard Flaccid - Applies to HF / CPPS How Hard Flaccid works and why it manifests certain symptoms - (Only for those with HF) I recommend you read or brush up on those posts. To fully understand how to fix CPPS and HF you have to buckle down and get some information and understanding. I am compiling ways for you to diagnose your specific problems, with basic exercise links to get you started. This will be a long post, you may have to read a little ways before you find the links. With that being said, lets begin. I am separating this post in 2 parts: The Muscular System, The Fascial System, and Building your own routine. The muscular and fascial system are heavily intertwined and work together in accomplishing the same roles, however, they are fixed differently and cause different problems which is why I am separating them into parts. The Muscular System - The problems here are what allow your fascial system to changed in the first place, and are the physical cause for your HF/CPPS. Therefore, I will be covering this first in the top half of the post. This part will contain: How to correct your muscle imbalances, fix posture, pelvic tilt, and strengthen + stretch the muscles that need it. (It will also come with attached links and examples for you to create your own routine!) The Fascial System - The problems here are what allow your symptoms to be chronic, and be painful. As I explained in my other post, a very low amount of people with these conditions actually have nerve damage, it is pain travelling through the fascial system. Your fascia literally encapsulates the nerves, pain from irritated and tense fascia is normal. Though the medical world is far behind and is bad at treating fascial pain, since it is the main way people experience chronic pain, I will be covering the way to fix it for good. Building your own routine - I've seen a very common problem, people don't know where to start and what to do. I am making a small section for people who cant figure out what they want to do or make for their own exercise routine.
The clear casing over the muscle is fascia, that is how closely related to the muscles it is. The fascial system plays a huge role in many HF/CPPS cases. There are many fascial lines throughout the body that will carry tension and pain, went over in my post about "Why hard flaccid isn't nerve damage", refer to that post for the images. I covered most of the fascial topics in that post but I will go over them shortly again. When your muscular imbalances cause the issues gone over above, it decreases their ROM (Range of motion), which slowly but surely causes your fascia to adapt and compensate for this. It condenses and forms knots and tight cords that reduce range of motion further. In addition, excess fascia builds up to compensate for body orientation issues and around muscles and joints. The fascial system needs hydration, normally, the hydration would be transferred all the time. When the range of motion is reduced, the hydration does not transfer. Causing some fascia to become tight, hard, and dehydrated. This creates "tight" fascia, it binds up in a double helix like DNA. Tight, dehydrated fascia which encases all nerves, muscles, and organs. You do the math one what happens next. Symptoms can be digestive dysfunction, pain, and lost range of motion. This tight fascia causes frictions and irritates the nerves and creates more tightness in the muscles. This is how most cases of HF/CPPS become chronic, by the time you develop CPPS, your fascial issues have probably already started. So how do you get rid of this buildup of fascia? Well, you don’t get rid of your fascia, you’re just unwinding it and untightening it. Here is an analogy: A muscle knot / tightness / trigger point / etc. forms like a screw being driven into a piece of wood. The twisting motion drives the screw down, twisting all the wood (tissue) around and locking it in tight and compacting it, twisting your tissue and muscles and changing your posture and body. So how would you get this screw out? You wouldn't press on it (like a massage). You wouldn't strengthen the wood. You would use force and pressure to to slowly remove the screw which would unlock the area that was screwed tight. But you still need to keep the wood (surrounding muscles) strong so you have the strength to pull out this screw. Analogies aside, the only way to unwind fascia is with gradual, repeated force. Contracting the muscles and bringing back the range of motion, as well as lengthening and slowly unwinding the fascia. The best way to do this is with Eccentric muscle contraction, as was gone over earlier in the post. You need to target your problem areas (where you feel pain, tightness, or symptoms) and find resistance stretches or eccentric contractions to hold to release the fascia over time. Fascia requires approx. 1,800 lbs. of force to change instantly, the only way to make fascial change is through repeated light force over time. This is the reason myofascial release therapy does not work. I cant really list common fascial problems as they are extremely case by case. All I can recommend in this section is googling your problem areas and then searching YouTube for eccentric contractions or resistance stretches to do for your problem areas. While controversial, the program known as DCT (Dynamic Contraction Technique) is very good for releasing fascia and treating CPPS. I will not endorse them, I am just simply letting you know of their existence in case you would like to research them more. A lot of their stuff is available for free on YouTube.
Part Three - Building your own routine
Your routine shouldn't be too hard to make. First set a schedule. Like this: Mondays, Tuesdays, Fridays - [Some exercises] Wednesdays, Thursdays - [Some other exercises] Sunday - [Day off] Feel free to change up the days however you want, but try to get at least 30 minutes of these types exercise into all days except your rest day. Normally you would fill those slots with strengthening, stretching, and resistance stretching. Maybe Monday Tuesday and Friday will be for strength while the other days are for stretching and breaking down fascia. Feel free to throw together the exercises included in the post + some more you find on google and use them in your routine! Its also very important to add a functional, low impact exercise. Swimming is great for passively breaking down some fascia and building strength, and walking is great for re-learning and using our walking mechanics more often. Try to get at least 30 minutes of this type exercises 5 days a weak. Here was my routine while I was fighting HF, I'll use it as an example. You don't need to total as much time as me, but the more time you put in, the quicker results you will get: Monday, Wednesday, Friday - 30 extra min glute activated walking and 1hr swimming, pull-ups, pushups, normal plank, Leg strengthening hold Tuesday, Thursday - 1 hour boxing, glute bridges and 8 point plank, hip adductions and leg lifts weighted) some hamstring resistance stretches and exercises, ab roller, single leg glute bridge, some arch exercises deep squats, lunges, 1 hour glute activated walking, and APT Routine (Core activation exercises, hip flexor resistance stretch, quad stretches and wide squat + deep lunge hold and rotation) Saturday, Sunday - Glute activated walking When I refer to glute activated walking, I refer to the correct type of walking that uses the glutes to push off instead of lifting the leg with the hip flexors. Video tutorial:https://www.youtube.com/watch?v=-fD2TSL2s7I&ab_channel=RehabandRevive I hope this was able to give you guys a good grip of your condition, and where to start. Thanks for reading, and good luck with your recovery! - Benjamin Calvit
Is it more correct to say "the reason for X is because Y is Z" or "the reason for X is that Y is Z"
I have the Grammarly extension for chrome and it keeps telling me I should be using "that" instead of "because." Here is an example of part of one of the sentences it wants me to correct: "The reason the knee is flexed 30 degrees during varus or valgus stress testing is because the ACL and PCL are tight in the neutral position, and have more slack when the knee is slightly flexed, so in the flexed position only the MCL or LCL integrity is being tested when a medial or lateral force is applied."
Flat Feet creates an imbalance in your posture as shown in picture below. At Shapecrunch , We have analysed data of more than 10,000 people, with flat feet. In 90% cases, varus-valgus is not same in both the feet, creating an imbalance. In layman terms, how much is your feet rotating inwards is different for both feet. This does multiple things and has a chain reaction - Basically your body compensates for load unbalance. Creating areas in upper body with higher stress - leading to pain in back and neck. FYI - I have flat foot, I wear orthotics , though if if I don’t wear them for days, my neck hurts while back is fine. So everyone has different stress point.
So my girlfriend usually wakes me up when shes in the mood. I normaly spoon her until im awake, she then makes me hard in various ways. Being as lazy as we are, we start having sex in the spooning position. I've noticed when in this position my left knee would start hurting, but I sometimes push through it, but in most cases I change positions. Once I was at work today, that same knee was hurting. I figured it was due to sex. My question is how can I fix my positioning or should i just stop with the spooning position?
Hey all, first case study I’m posting! I’m trying to make this slightly interactive, to encourage people to get involved and promote discussion. If people like this format let me know! More than happy to take suggestions / criticism, and adapt them moving forward. Clinical Case Study 1 It’s 3:20pm on a Saturday in a quiet suburban neighbourhood, temperature is around 20C. You are dispatched to an apartment block - non emergent “24yoM PT C/O L) lower leg pain for 1/24” - response time is 10 minutes. On Arrival: You find a 24YOM in obvious pain. Pt is 183cm and 84kg. Pt had been playing rugby earlier that day, and had taken a decent blow to the L) lower leg (anterior lower leg made contact with another player) - pt felt a slight pop/ odd sensation at the time. Although painful, after a few minutes he was able to return to play and continue the match. The pain continued, however was a dull ache around 3/10 - ice was applied following the game, pt had a few beers then returned home. It is now approximately 4 hours post injury - Pt states that over the past 1-2 hours, the pain has substantially increased, with the last 60 minutes being borderline unbearable (9/10). Pt reports weakness and difficulty moving the limb, with slight parasthesia distally. On basic inspection of the L) lower leg, there appears to be swelling generalised swelling, however more prominent over the anterior aspect - slight bruising noted. Patient is asking for pain relief at this point, and is obviously distressed.
PMHx - Asthma, R) #Radius 5y ago - plates in place
Medications - Salbutamol/Albuterol as needed
Allergies - Morphine, hayfever
Last oral intake - Lunch and beers 3-4 hours ago
VSS: - HR 106 - RR 22 - GCS 15 - BP 140/90 - SPO2 98%RA - ECG Sinus Tachycardia EDIT / UPDATE WILL BE PROVIDED IN 12 HOURS WITH FURTHER INFORMATION QUESTIONS:
List 3 differential diagnoses
What further information would you like? What additional assessments would you like to perform?
What are you currently concerned about (if anything)?
POST UPDATE: Sorry it’s a bit late, got recalled for a major incident! A few of the main things asked for is a more detailed pain, neurovasuclar and musculoskeletal assessment. Pain - I will be using the DOLORS acronym - Description: Generalised severe pain, alternating from deep burning pain to sharp stabbing pain upon movement. - Onset: Dull pain at time of injury, severity began increasing 2/24 ago - Location: Pain in left lower leg, spread throughout however particularly localised anteriorly. - Other Signs / Symptoms: Parasthesia/numbness in limb, slight nausea - Relieving / Provoking Factors: No relief, has attempted icing intermittently with no effect. Provoking factors include any movement or palpation of the affected limb. - Severity: Currently rated as a 9/10 on the pain scale. Pain seems out of proportion to injury. Neurovascular Assessment: The 6 P’s! - Pain - Yes, severe and localised to lower L) leg - Pallor - Foot appears pale / dusky - Parasthesia - Present in limb distally, felt mainly in toes - Paralysis - Movement is present, however is limited and extremely painful. Weakness in L) limb. - Pulses - Unable to palpate a pedal pulse in the L) foot. - Poikilothermy - Left foot is cold to the touch Musculoskeletal Assessment: Extremely painful to perform, but this is what you would find if you wished to assess. - Anterior & Posterior Drawer test of the L) knee is negative - Varus / Valgus stress tests are negative - Lower limb is grossly intact - tibia and fibula appear stable from what you can assess QUESTIONS 1) What condition is now at the top of your differential? 2) Treatment? (Pre-hospital and in-hospital) UPDATE WILL BE PROVIDED IN 6-8 HOURS
Torn ACL/PCL/MCL/Quad/Patellar Tendon 3 Months Post-op (plus pictures!)
Warning: I wound up writing a novel here, but feel free to just look at the pics. The album contains some gross pictures, including what my knee looked like immediately after the injury as well as some pics of the inside of my knee during surgery. The surgery pics are actually so abstract that they're not that gross, but in case you don't have a strong stomach you've been warned. https://imgur.com/a/G97Dd7E The Injury I'm a 28 year old male (27 when the injury occurred). My initial injury happened in September of 2017. I was running towards a ball flying over my head during a soccer game, and mistimed my control of the ball - rather than get my foot under it, I stepped on the ball as it was landing. My right leg was planted when I did this, and since I was sprinting full speed I slipped, causing my whole body to move except my leg. It immediately twisted and dislocated, and I'm told people heard the pop from 40-50 yards away. An ambulance was called, but the refs were afraid to move me so the game was called off while we waited. I didn't have the guts to look down at my leg (and moving even slightly was unimaginably painful so I didn't wanna try) but I knew I would be curious about what it looked like so I had my girlfriend take pictures (pics #1 and 2 in the album). Initial Treatment Everyone was fascinated with my knee in the emergency department. It was a university hospital, so all sorts of residents and students came by to look at it and ask questions. Most knee dislocations reduce themselves, but mine was stuck. An orthopedic surgeon with decades of experience would later take a picture of the X-ray they took while it was still dislocated because of how bad it looked. I had to wait a couple hours for the orthopedics resident on call to make his way to me and get approval from a full doctor to reduce my knee, and during this time the adrenaline wore off. I could feel my bones pushing into the skin (I came very close to having an open dislocation, which results in amputation about 50% of the time because infections are difficult to manage), and this was probably the worst pain I've felt in my life. Some of the doctors were talking about emergency surgery to reduce my knee, since it didn't look like it would respond to manual reduction. At this point, my hero arrived - the orthopedics resident came in, looked at my knee, and said we were popping it back into place right now. They shot me up with some dilaudid and four doctors did the deed: one resident grabbed my leg around the knee and held it up while the other three grabbed around my ankle and twisted. When I say twisted, I mean three adults pulling as hard as they could. Four incredible pops later, my knee was back in alignment and the pain was immediately resolved. They kept me in the hospital for two days for observation because they were concerned my popliteal artery might have been damaged (see Zach Miller's recent knee dislocation for what happens, emergency surgery is needed to save the leg). The artery was fine, so eventually they released me. They took MRIs while I was in the hospital, and based on the MRI and X-ray reports it initially looked like the following were torn: ACL, PCL, MCL, LCL, lateral and medial menisci, patellar tendon, knee capsule, and quadriceps, with avulsion fractures in the tibia and femur. It later turned out there was so much blood in my knee that some of the structures (mainly my menisci and LCL) looked damaged in the MRI but were actually fine. My patellar tendon was only partially torn. Everything else was completely torn (MCL off the bone, ACL and PCL in the middle), including my quad having been basically sliced by my kneecap. I saw my sports medicine surgeon about a week after the injury (picture #3 in the album, the bruising actually got much worse after this and about 3/4 of my leg was purple) and he did the manual tests - Lachman, drawer, valgus, and varus. My ACL and PCL were definitely torn, and in the valgus test my knee was giving way like it was made of rubber. The varus test looked surprisingly stable though. I was scheduled for surgery just a few days later, and they would basically figure out how much they could do in that surgery (and whether my LCL and menisci were still in good shape) after cutting me open. Surgery 1 The first surgery was in the end of September. There was so much edema, blood, and swelling that they were only able to repair my MCL, reattaching the original ligament to the bone. My LCL and menisci were confirmed to be healthy though, and they stitched my knee capsule and quad back together. My doctor showed me a picture (unfortunately I don't have a copy) immediately after the procedure of what the inside of my knee looked like - he described it as looking like a grenade had gone off inside my knee, and that the giant hole was not something they had done, but what my knee already looked like when they went in to look. A femoral nerve block meant that I felt absolutely no pain post-op, and I stopped taking my prescribed painkillers at the same time the nerve block wore off. The surgery also immediately cleared up a four day calf cramp I had been experiencing, which my surgeon theorized was being caused by blood flowing from the knee down my leg. A week after, I saw my surgeon again (pic #4). The swelling had decreased significantly and I was cleared to start PT, but I was non-weight bearing for the first 4-6 weeks post-op. Surgeon wanted me to get to 120 degrees of flexion before he would operate on the ACL and PCL to avoid permanent stiffness - he seemed to think I'd get that back in about a month or so. My physical therapist was awesome, but flexion came very slowly. I was walking without crutches around December, but it wound up taking until January 2018 for me to hit 115 degrees, which my surgeon deemed good enough. Surgery 2 Surgery #2 was in February 2018. I had been having back of knee pain so they looked at my lateral meniscus again just to verify, but it turned out to be healthy - the pain was probably just a hamstring strain. I received single bundle allografts (hamstring tissue) for both my ACL and PCL, affixed using a button rather than screw (as I understand it, the screw is more beneficial when using patellar grafts that include some bone, but for hamstring grafts the button allows the grafts to be tighter). Autografts were not an option since my knee was so damaged that the doctor didn't feel comfortable harvesting anything else. The nerve block this time was botched so it was only partially effective, but even then pain post-op was minimal. The images labeled 001-009 are of the surgery itself: 001-003 are my medial and lateral meniscus looking good, 004-005 are the drill creating the tunnel in my bones for the grafts, 006-008 are the new ACL and PCL grafts, and 009 is of where my kneecap meets the rest of my knee. After the surgery, I was told that my knee injury was part of an annual presentation by the residents at the university - a dubious honor, but pretty cool. I was allowed to partially weight bear immediately this time, but I had some weird lumpy swelling (see pic #5) that felt pretty uncomfortable when I would put weight on the leg. I was also put on a CPM machine immediately after the surgery, and hit around 85 degrees of flexion (120 on the CPM, but it does not reflect real flexion very well) within a week. After a PCL reconstruction, however, you're not allowed to bend your own knee for the first four weeks - when the hamstring activates during flexion and pulls back the tibia, it puts stress on the PCL graft which can cause it to loosen. I was on strictly PT-assisted or CPM flexion for the first month, and after that I was given a custom-fit PCL brace made by Ossur that applied a force at my tibia during flexion to counteract the stress on the graft. The hamstring strain actually got a lot worse during this period, and started to hurt incredibly while doing heel slides. Between lots of hamstring stretching and slowly working on heel slides, however, it eventually faded. The swelling went down, flexion improved, and I was told to drop the crutches as soon as my PCL brace arrived. Present Day I had my three month followup earlier this week, and my doctor said all of the repaired/reconstructed ligaments felt incredibly stable. I was expecting to be on the PCL brace for 6 months, but got the all-clear to drop the brace immediately. I was so happy to be done with the brace (which was the 5th knee brace I had gotten for this injury) that I went out and tried riding a real bike for the first time - I was a little shaky, but eventually I got comfortable riding. Stationary bikes are nice, but I had been so excited to finally feel the wind on my face while riding. I'm not sure that I'll ever actually want to play soccer again, but my goal for PT is to recover to the point that I could play if I felt like it. Not there yet, but I'm told in 6 weeks I might be able to start jogging. Slow progress, but any progress is awesome considering 6 months ago it felt like I would never be close to normal again. Thanks for reading, and feel free to ask any questions!
Overview of LCL Pathology In patients who have a complete lateral or fibular collateral ligament (LCL) tear and noticeable side-to-side instability with activities, a lateral collateral ligament surgery is recommended. The term fibular collateral ligament (FCL) is more anatomically correct, but is more commonly referred to as lateral collateral ligament (LCL). LCL surgery is very effective in restoring side-to-side stability to the knee and preventing varus gapping. During a clinical exam and varus stress radiographs, we will be able to confirm whether or not there is a complete LCL tear. It is important to note that an MRI scan can be inaccurate – especially in cases of a chronic situation where the LCL heals improperly – that is why it is important to properly analyze the pathology. Treatment for LCL Injury The severity of the LCL injury will determine the treatment method. In less severe cases, a remedy of rest, ice, compression, and elevation (RICE) along with the use of anti-inflammatory medications (NSAIDs) and pain relievers can alleviate discomfort and help diminish swelling. Increasing strength and range-of-motion can be achieved through physical therapy, and ultimately restore the knee back to a healthy state. Typically, patients who have a complete LCL tear will require surgical treatment. This surgical procedure is typically done as an open procedure in conjunct with arthroscopy. Dr. Miten Sheth from The Knee Clinic will replace the torn lateral collateral ligament with a tissue graft. The graft is passed through the bone tunnels and attached to the femur and fibula bone using screws. We prefer an anatomic technique for surgical reconstruction. With this technique, we use either autograft hamstring tendon to reconstruct the lateral collateral ligament between its native course. First, a tunnel is reamed at the femoral attachment site, slightly proximal and posterior to the lateral epicondyle. We then secure the graft at this location with an interference screw in the prepared tunnel. The graft is then passed under the superficial layer of the iliotibial band and the lateral aponeurosis of the long head of the biceps femoris. Next, a tunnel is reamed through the fibular head, starting laterally at the exact attachment site of the LCL on the fibular head, and exits on the medial aspect of the fibular styloid just distal to the popliteofibular ligament. The graft is then passed through this. The graft is placed under tension, the knee is flexed to 20 degrees and a valgus reduction force is applied. A screw is then used to attach the graft in the fibular head. Once one confirms on exam under anesthesia that the varus gapping is eliminated, the procedure can then be ended. Are you a candidate for LCL Reconstruction? There are two ways to initiate a consultation with Dr. Sheth: 1. You can provide X-rays and/or MRIs for a clinical case review with Dr. Sheth. 2. You can schedule an OPD consultation. REQUEST CASE REVIEW OR OPD CONSULTATION (Please keep reading below for more information on this treatment.) Post-Operative Protocol for LCL Surgery Rehabilitation for LCL surgery involves early range of motion of the knee, starting at a minimum of 0 to 90 degrees the first day, and then after 2 weeks progressing further. Isolated hamstring exercises should be avoided for the first 4 months post-operatively. Patients should not place weight on the injured leg for 6 weeks and then may progress to crutches and start the use of a stationary bike starting at week 6. They should avoid side-to-side activities, or step-up activities, until varus stress X-rays are obtained at 5 months post-operatively verify that there is sufficient healing of the reconstruction graft to allow further activities. For athletes, we usually recommend the use of a secure brace to allow them to initiate these activities and request that they wear it through the first year after surgery to maximize graft healing.
"Grade 1 MCL" injury explained (Warning: Block of text)
Hello DubNation! As Steph's injury seems to have caused all sorts of heartache, stress, nervous tension, anxiety, and the like, to this community, I wanted to address this diagnosis to help further our understanding and hopefully enlighten a few individuals into our beloved leader's current situation. I am not an MD. I am a doctor of physical therapy that enjoys all sports and loves the Dubs. I will cover the anatomy, diagnosis, assessment, common symptoms, and recovery expectations with a TL;DR at the bottom!. Anatomy First let's define the MCL (medial collateral ligament) - The MCL is the broad fan-like ligament that provides the stability to the medial (or inside part) of your knee joint . It prevents "valgus" forces (forces pressing from the outside of the knee inward) from completely bending your knee inward. Diagnosis What is the difference between the grades? Here's a nice picture explained in massive block of words below. Grade 1: most mild injury, likely due to slight over-stretching of MCL such as with a rapid valgus movement. At WORST there are minor tears to the MCL, but again, very minimal. It is possible for this to be a contact OR non-contact injury (as with Steph). Note the valgus alignment of Steph's knee in this picture (not terribly gruesome, but if you're squeamish... maybe just leave that link blue...). Grade 2: wide range of moderate to severe injury that includes an over-stretched MCL as well as incomplete tearing of the MCL (or a "partial tear). This is the grade is by far the hardest to predict recovery time as this depends greatly on the extent of the tear. Grade 3: severe injury due to large valgus force at the knee that leads to a complete rupture/tear of the MCL. In a professional athlete this would likely require surgery. Assessment The obvious gold standard for this assessment is an MRI that would be able to show the extend of the damage to the MCL. Within an outpatient clinic or with the trainer prior to the MRI they would also conduct a series of "special tests" to check the stability of the knee ligaments and structures. Here are some of those tests that would be done:
Common Symptoms Steph would most likely experience pain. Duh. Other than this, he may have some slight instability and discomfort with any tasks that would put (here's that buzzword again) a valgus stress on his right knee. This would include pushing off from his right leg in a defensive slide, trying to maintain a right pivot foot with someone (looking at you Beverley) leaning into his leg/knee, or even happening to take the wrong jab-step with his right leg. So why was he limping to the bus in that video o0blarson0o!?!? Well... when your knee hurts you limp. Also, when you have a ligamentous injury such as this, the knee wants to inherently be in its "loose-packed" position (the position that all the joint's surrounding ligaments are most lax) and avoid the "close-packed" position (ligaments are most taut). For the knee, loose-packed = ~25 degrees of bend (which is about where Steph was) and close-packed = full knee extension (which is what a limp avoids). Recovery Expectation As stated millions of times from every Reddit doctor available, MCL injuries are difficult to judge. Grade 3 is easy: out for the season (likely at least 6-8 weeks or possible surgery with appropriate rehab). Grade 2 has slightly more gray area, but still most likely out for the season (probably around the 6-8 weeks guideline, but possibly sooner). Grade 1 is tough as a lot will depend on how painful it is, how long the tissues take to heal, but can range anywhere from as little as 1 week to as long as about 6 weeks (if instability and pain remain with sharp cuts). Important to also note is that this injury possesses a definite possibility of getting worse if Steph is rushed to return to play. Complicating Factors A couple notes: the MCL is very closely tied into the medial meniscus and even has some connecting fibers. It is entirely possible that an MCL injury could have a slight complication of meniscus involvement, but unlikely in Steph's case. Also, there was contact with Steph's medial knee onto the court along with the valgus stretch. This would be comparable to taking a rubber band (his MCL), stretching it to maximum length (valgus stretch), putting it over the sharp corner of a table (his tibia and femur), and then hitting it with a hammer (the court). Probably not fun. So there ya have it... A breakdown of the medical side of things... TL;DR There's a lot of stuff goin' on in Steph's knee. It probably hurts. Possibility of it worsening if rushed, but likely back in 2-4 weeks. I'm sure he's in good hands.
The knee is a frequently injured joint, with its ligaments, menisci (a thin fibrous cartilage between the surfaces of some joints), and patellofemoral (knee) joint vulnerable to acute and repetitive use damage. Most knee injuries require exercise training for rehabilitation, and some require surgery as well. Predisposing factors to knee injury include the following:
Slight predominance in females (particularly for patellofemoral problems).
Ligamentous sprains and tears are common in the knee, particularly in athletes. Because of its structure and insertion points, the anterior cruciate ligament (ACL) is more frequently injured compared with the posterior cruciate ligament (PCL). Classically, the ACL is injured when external rotation of the tibia is coupled with a valgus force on the knee (e.g. direct force from the lateral side of the knee, planting the foot and twisting the knee). Ligamentous sprains and tears are common in the knee, particularly in athletes. The menisciare also frequently injured, particularly in athletes. The medial meniscus is more frequently torn than the lateral meniscus, due in part to its attachment to the medial collateral ligament. The menisci are poorly innervated (supplied with nerves) and relatively avascular (lack of blood vessels); thus, they are not very pain sensitive and are slow to heal following injury. The “terrible triad” is a traumatic sports injury in which the ACL, medial collateral ligament, and medial meniscus are damaged simultaneously Patellofemoral pain syndrome is a common disorder in young athletes (particularly females) that produces anterior knee pain. Often, patellofemoral pain syndrome is caused by an off-center line of pull of the patella, which irritates the joint surfaces and retinaculum of the knee. An off-center pull of the patella can result from insufficiency muscular imbalance during knee extension and from excessive varus and valgus stresses (a deformity involving oblique displacement of part of a limb towards/away from the midline, respectively) from Q angles outside of the normal range of 13° to 18°.
Can someone with a lot of experience in C&P exams help me out this and tell me based on the notes what my rating would be? Thanks, I greatly appreciate it! Indicate method used to obtain medical information to complete this document:
[ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information
on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using
the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.
[ ] Examination via approved video telehealth [X] In-person examination
a. Evidence review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment
records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No
Diagnosis
a. List the claimed condition(s) that pertain to this DBQ: bilateral patellofemoral pain syndrome b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Patellofemoral pain syndrome Side affected: [ ] Right [ ] Left [X] Both ICD Code: M22.2x1 and M22.2x2 Date of diagnosis: Right 2012 Date of diagnosis: Left 2012 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A
Medical history
a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Bilateral patellofemoral pain syndrome diagonsed in the Marines following a fall from a height when he landed on his knees. He has continued to have pain in both anterior kneessince then. He has not had care for his knees since discharge in 2013. b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] Yes [X] No c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No
If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: Pain with walking, climbing or decending stairs, and with prolonged standing. He has pain with pressure on the anterior knees, so he
cannot kneel down.
Range of motion (ROM) and functional limitation
a. Initial range of motion Right Knee [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking.
Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line.
Is there objective evidence of crepitus? [ ] Yes [X] No Left Knee [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking.
Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line.
Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right Knee Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Knee Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing.
Left Knee Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing.
d. Flare-ups No response provided e. Additional factors contributing to disability Right Knee In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left Knee In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
Muscle strength testing
a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided
Ankylosis
Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided
Joint stability tests
a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe b. Is there a history of lateral instability? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Right Knee:
Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)
Left Knee:
Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)
e. Comments, if any: No response provided
Additional conditions
a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No b. Comments, if any: No response provided
Meniscal conditions
a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided
Surgical procedures
No response provided
Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided
Assistive devices
a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided
Remaining effective function of the extremities
Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No
Diagnostic testing
a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided
Functional impact
Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: The Veteran has significant pain in both knees with walking, standing and kneeling so that he would have a difficult time perorming duties which would require those actions.
Patient Position. Supine (or seated) Procedure Steps. Supine testing . Drop the leg off the table and flex the knee to 30°. Put fingers over the lateral joint line.; Grab the ankle/foot and apply a varus stress to the knee (using the medial knee against the outside of the table as a fulcrum and pushing the ankle lateral to medial).; Compare to the opposite, unaffected side. Elbow Varus Stress. Jump to:navigation, search. Original Editor - Tyler Shultz. Top Contributors - Rachael Lowe, Kim Jackson, Tyler Shultz, Laura Ritchie and Redisha Jakibanjar. Purpose. The purpose of the varus stress test of the elbow is to assess the integrity of lateral collateral ligament. To perform the varus stress test at 30° of knee flexion, the leg is placed over the examining table with the knee flexed at between 20°-30°. One’s fingers are then placed over the joint line while the distal femur is stabilized. A varus stress is then applied to the knee while one is holding the foot and ankle. varus stress test. A test of ligament laxity, where a passive force is exerted on a joint that, in the presence of ligamentous insufficiency, would cause the lateral joint space to open, e.g., lateral collateral ligament of the knee and radial collateral ligament of the elbow. See also: stress test. Valgus and Varus Stress Dynamic Maneuvers by. Jamie Bie. in #tuesdaytipswithjamie Posted on . 27/10/2020 09:31 valgus and varus stress tests FREE subscriptions for doctors and students... click here You have 3 open access pages. These tests attempt to reveal instability to medial or lateral displacement within the knee. 46 Elbow Valgus and Varus Stress Tests Elbow Valgus and Varus Stress Tests Elbow Varus Stress Test. Use: Test for varus lateral collateral ligament (LCL) instability at the elbow Procedure: Elbow flexed, slight supination, support forearm, gapping in/out to assess ligament Findings: Positive finding is pain, decreased mobility, laxity as compared with the unaffected side Purpose: The Varus Stress Test is used to assess the integrity of the LCL or lateral collateral ligament of the knee. This is a key test to perform when assessing for posterolateral instability of the knee. How to Perform Varus Stress Test. Position of Patient: The patient should be relaxed in the supine position. Varus stress test elbow. Elbow examination stress tests. Valgus and varus stress test. The therapist applies a valgus stress at the knee while the ankle is stabilized in slight lateral rotation either with the hand or with the leg held between the examiners arm and trunk. A valgus stress test may be done to test the health of ligaments in the Valgus Stress Test. An assessment for one-plane medial instability (gapping of the tibia away from the femur on the medial side). [1] The therapist applies a valgus stress at the knee while the ankle is stabilized in slight lateral rotation either with the hand or with the leg held between the examiner’s arm and trunk.
Dan Smith, DO performs the valgus stress test on a patient as part of a full knee examination. This video demonstrates how to perform a varus stress test and a valgus stress test to diagnose lateral collateral ligament (LCL) and medial collateral ligam... About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators ... Valgus Stress Test of the Knee⎟Medial Collateral Ligament - Duration: ... Varus Stress Test of the Knee⎟Lateral Collateral Ligament - Duration: 2:07. Physiotutors 273,141 views. Varus: Distal end towards midlineValgus: Distal end away from midline About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators ... Demonstration of the varus and valgus stress tests used in the examination of the knee joint. MCL and LCL integrity Enroll in our online course: http://bit.ly/PTMSK DOWNLOAD OUR APP:📱 iPhone/iPad: https://goo.gl/eUuF7w🤖 Android: https://goo.gl/3NKzJX GET OUR ASSESSMENT B...
