By Bill Bradley, contributing editor
Once again, knee injuries are in the news in the NFL. But not all knee injuries are the same.
Houston Texans outside linebacker Jadeveon Clowney is out four to six weeks recovering from a torn meniscus. Philadelphia Eagles left guardEvan Mathis is out four to six weeks with a sprained MCL. And St. Louis Rams quarterback Sam Bradford is out for the season with a torn ACL.
What is the difference between these types of knee injuries? Why does an ACL tear take at least six months from which to return when an MCL needs to six weeks to heal?
NFL Evolution this week talked about this subject with Dr. Matthew Matava, who is the Rams' physician and the president of the NFL Physicians Society. He explained the differences in knee injuries, why a "knee sprain" is an ambiguous term and the mental aspect of knee-surgery recovery.
First, here's a glossary of some terms Matava discusses (source: **WebMD.com*):*
* ACL -- Anterior cruciate ligament: One of the two major ligaments in the knee. It connects the thigh bone (femur) to the shin bone (tibia) in the knee that prevents rotation of the knee.
* PCL -- Posterior cruciate ligament: The second major ligament in the knee connecting femur to the tibia in the knee that prevents the tibia from moving backwards.
* LCL -- Lateral collateral ligament: Connects the femur to the fibula - the smaller bone of the lower leg on the lateral or outer side of the knee.
* MCL -- Medial collateral ligament: Also connects the femur to the tibia on the medial or inside of the knee
* Meniscus -- The rubbery, C-shaped disc that cushions your knee. Each knee has two menisci, one on the outside of the knee and one on the inside.
We hear a lot about knee injuries but we know they are not all the same. What is the difference between injuries to the ACL or the MCL or the LCL or the meniscus?
Ligaments, to put it very simply, connect bones to bones. In this case, we're talking about the femur, which is the thigh bone, and the tibia, which is the shin bone. The ligaments connect one bone to the other and they're on different parts of the knee. The meniscus is an entirely different structure. There are two menisci in each knee and they look like two little C-shaped rings of cartilage. They have the consistency of an eraser. They act as shock absorbers between the femur and the tibia. They're very important in order to enhance the shock absorbing capacity of the knee, like when you jump, run or even walk. Without the meniscus, you significantly increase your probability for arthritis in the future because there's less cushion in the knee joint.
Why do the recovery times vary so widely for the various types of knee injuries? We see ACL injuries take at least a year for recovery while MCL's are about three months.
First, if you have a ligament tear, you have to decide if it needs to be treated operatively with surgery or non-operatively. For the most part, when we talk about the ACL and the LCL, those ligaments require surgery to fix. When I say "fix," you have to be specific with your medical terminology because the ACL cannot be sewn together. It has to be reconstructed because the fluid in the knee joint does not allow the ligament to heal even if you try to sew it together. You have to take the torn ligament out and put a graft in its place. That typically takes six to eight months to heal in order to return to football.
The LCL can either be repaired or reconstructed, depending on how severe the tear was and how long it had been torn.
The MCL virtually always heals on its own. This ligament does not require surgery, but the timing on return to play varies on the severity. We typically describe ligament tears as either a Grade 1 tear, which is mild; a Grade 2 tear, which is moderate or partially torn; or a Grade 3 tear, where it is completely torn. The majority of MCL injuries do not require surgery. A lot of players in the NFL who have an MCL sprain return to play between two to six weeks depending upon the position they play and the severity of the injury.
What's different about arthroscopic knee surgery and why do players return from that so quickly?
In the old days, you used to have to make a long incision in order to expose the internal aspect of the joint. Now, with an arthroscope, surgeons make a quarter-inch incision to insert the scope (which has the diameter of a pencil) into the joint . It has a fiber-optic camera that can look throughout the entire surface with very detailed accuracy. In fact, you can see inside the knee joint better with an arthroscope than you can by making an open incision. By avoiding that long incision, you cut through less muscle and tendon so there is less damage to the joint. Therefore, you should be able to use the knee much quicker.
For example, 20 or 30 years ago, if you had the same injury that Jadeveon Clowney had -- a meniscus tear -- you would have a 3- or 4-inch incision on the side of your knee. You would be admitted into the hospital for four or five days and would be in a cast for several weeks. Now, it's a 15-minute operation to trim out the torn meniscus. There are three or four small holes and no incision. There is no cast or brace. You would be able to return to play within three to six weeks.
When we hear the term knee sprain, but we are almost trained not take that seriously. But how bad is a knee sprain?
That's a big catch-all term. When we use the term "sprain," by definition it means an injury to a ligament. A "strain" is an injury to a muscle or a tendon. A knee sprain, like I said earlier, could be Grade 1, which is mild with microscopic damage to the ligament, or it could be a complete tear of the ligament, which is a Grade 3 sprain. The problem is the term, "knee sprain" doesn't indicate how bad of an injury it is.
We have seen knee braces on the field for decades. But is there anything modern football players can do to prevent knee injuries?
There has been shown to be jumping-exercise programs, where you strengthen the lower extreme musculature by retraining how you land from a jump that's been applied especially to female athletes. There's research that shows those exercises are effective in preventing ACL injuries. There's not any data in the medical literature applying that same sort of preventive technology to NFL players. However, a lot of collegiate and NFL coaches want their offensive linemen to wear a preventative (prophylactic) knee brace. The data is mixed as to whether that actually helps a player prevent a knee injury. A lot of players like to wear braces because it gives them peace of mind they will hopefully be at a lower risk for sustaining an injury.
I think the biggest thing that we do now that perhaps wasn't done 20 or 30 years ago relates to the way players maintain their offseason conditioning. Now the athletic trainers that work with the Rams and other teams do functional movement screenings where they can assess the knee weakness in various physical activities that may be relevant for a football player. They can tailor their strengthening exercises in the preseason to address any of the deficiencies. That's proved to be a very promising area of sports medicine and rehabilitation in order to prevent injuries before they develop.
Is there anything you try to do to help the athletes overcome the mental hurdles of knee injuries?
The first thing I often do is pull up my pants leg and show them my scar. I tore my ACL back in 1983. I have a 14-inch-long scar on my knee. When I show them that and I tell them, "Your scar is going to be about two inches long compared to this monstrosity." It puts them at ease and shows them I've been down the same path they are about to go down. I can empathize with what they're going through, and I can hopefully guide them along in an appropriate fashion.
A big part of how you deal with an athlete is how you dealt with them before the injury, not just after the injury. If you've established a good doctor-patient relationship with them prior to any sort of traumatic experience like this, it makes the discussion once they've had an injury and the ensuring surgery and rehabilitation much easier to go through together.
