treatment ed

Bronx Bummer

Written By: DrGayedDPT - Oct• 23•12


Down goes the Yankees! Down goes the Yankees! A rough ending for the bronx bombers this season without question; but no one is feeling the free fall to rock bottom more than beloved team captain, Derek Jeter. Its like an army going to war and finding out their General – the physical and emotional leader – has been eliminated. Tough blow for Yankee nation.

So what exactly happened? He just stepped and all the sudden he broke his ankle?! Seriously?!? Simply put…yes, seriously! There are many factors that could have come into play; but one key thing to look at is not just how it happened but when it happened. For those watching the game, you know that Derek Jeter suffered the injury in the 12th inning. Overtime physical work means extra wear and tear and, ultimately, more muscle fatigue. Muscle fatigue is the most likely culprit in this scenario. I’ll explain…

At the ankle there are many muscles to carry out the demands we place on such a relatively tiny joint. Running, jumping, sliding, hopping, skipping, etc. We ask the muscles of our ankle to move in poetic synchronization to accommodate those tasks across varying surfaces and an athlete is no different. In fact, for a high level athlete you can imagine those ankles get beat up; So is the case for Jeter in the 12th inning of a very long and strenuous game.

If you look at the video closely, Jeter stepped on the left ankle as he was falling forward with such speed and force and it was juuuust slightly bent inwards – we call this motion inversion. The muscle responsible for preventing this motion from happening is the peroneals (2 of them actually; peroneus longus (blue) and peroneus brevis (green)). These muscle oppose the motion of inversion – this is called eversion. After playing such a long game, these muscles could have been fatigued juuuust enough to allow his foot to bend in a few degrees.

What?! That’s enough to break an ankle?! Well yes and no. Yes that’s enough motion to break an ankle but you have to keep in mind his weight was displaced forward over the ankle AND he was running. That is a lot of force and there is, in addition to the peroneal muscles, a ligament that is meant to secure the heel (calcaneal bone) to the leg bone that he fractured (fibula). A ligament connecting the calcaneus to the fibula? Must have some weird scientific name! Yes, it indeed has a weird scientific name – this ligament is called the calcaneofibular ligament. Brilliant!! Yes, very creative indeed.

With the great amount of force and direction applied to the ankle you essentially have a tug of war between the calcaneal fibular ligament and the fibula. And as with all these injuries, something has got to give. In the battle of ligament verse bone…ligament triumphs. The ligament effectively pulls the bone apart – this is called an avulsion fracture. Yes, these ligaments are that strong. If the ligament had given out, we would be talking about a sprain rather than a fracture.

Oooooh! So close to a sprain!! In talking with patients it seems that most people tend to favor the sprain over the fractures. Well, its not always that simple. There are some severe sprains that are extremely tough to recover from. Once a ligament is sprained theres no going back to the way it was for that ligament. In fact, the rehabilitation for severe sprains (if surgery is not needed) is to strengthen the muscles around the sprain to support it the way it would have been supported if the ligament was not compromised. To keep things simple, in the case of Jeter, imagine it was not a fracture and he sprained the cleverly named calcanofibular ligament. Rehabilitation for that would require strengthening the muscles of the ankle, especially the peroneus longus and peroneus brevis. Make sense?

But with a fracture, after the normal healing time of 6-8 weeks, you can have the bone return back to its normal strength; possibly even stronger! Jeter should return after roughly 4-5 months. After 6-8 weeks of allowing the injury to heal, he’ll need about 2 months to rehab it and possibly another 4 weeks to get back to form.

So there is a little good news for the mourning Yankee nation out there. At least the general will return to full strength. Unfortunately by the looks of it, full strength Yankee is not what it used to be.

Breakdown
Time out: 4-5 months
Severity:

70 %

Chance of Reinjury:
15 %

Performance Upon Return:
99 %

Life and Inches

Written By: DrGayedDPT - Oct• 11•12

The casual fan watches with sub-50% attention to the screen as the previously irrelevant Rams and Cardinals square off (not as irrelevant this year but no one expects to see them in New Orleans come February). The casual fan sits and glazes over the screen, the rams offense sets up as they had done already many times that game. A play like no other seemingly. Fantasy owners look on cheering for their respective players to make a mark on the game. All is business as usual in the NFL with a primetime game.

Then in the stadium there’s the die-hard fan. The one who stuck with the Rams through the bad times and….well…more bad times. The navy blue and gold draped all over his body with various Rams apparel. He sees his team break the huddle and set up at the line of scrimmage. Intently watching with great hope yet slight skepticism as he is conditioned to be upset by his beloved St. Louis Rams. Hopes are high as a victory over the undefeated Cardinals is certainly within reach but he’s no stranger to disappointment. All is business as usual.

In the huddle is Danny Amendola; a “made-man” one might say. Trained his whole life and was never much on the radar but certainly is now. Fresh off a 160 receiving yard week and certainly the go-to-guy for this offense. He lines up at the line of scrimmage. Its primetime. Its business as usual. The play is set for him. A fade route up the left sideline that he’s trained his whole life to perfect against defenders who’ve also trained their whole lives to stop such a route. Man coverage and a safety waiting his arrival 20 yards out.

Hike!

Danny races up the sidelines and the window is there. Bradford makes the routine read, Danny makes the routine catch, the defender makes the routine tackle. All seems business as usual from the fan in the stands cheering to the casual fan at home; but it’s not business as usual. In fact, nothing is usual at all. Danny stays down. The team’s trainers rush to the field to decipher his symptoms and come up with a plan. But this is not a usual injury. They know the area affected but are unsure of how to handle it. He gets carted of with caution.

Reports state that the Rams medical team reached out to other medical teams in the league to figure out how to handle Danny’s rare injury. Landing on your shoulder and staying down from the pain usually screams out a broken clavicle (collar bone); but this wasn’t the case. Danny actually separated his SC joint (circled in the picture below).

 

Above is the site of the injury for Amendola. The ligaments keeping the clavicle attached to the sternum failed and couldn’t handle the load that was transferred through his shoulder into his sternum (chest bone). If you can picture the shoulder as the 3-dimensional structure that it is (or look below), Amendola landed on the outside of his shoulder pushing his clavicle in. And with the ligaments unable to withstand the force they snapped allowing the clavicle to continue to separate back behind his sternum. The picture below shows the forces (in purple) acting on the shoulder as he lands forcing the clavicle back behind the sternum.

Ok…whats the big fuss? Sucky injury, so what? Its football, stuff happens. Well, if his clavicle went back even just another inch it could have punctured his trachea which would have compromised his breathing.

Feel your sternum with your fingers (the bone in the center of your chest where your chest muscles – pectorals – meet). Now with your fingers, travel up your sternum up to your throat. If you feel a firm bumpy surface then you found your trachea; simply put, it is your “breathing tube”. You inhale the oxygen from your mouth or nose and it travels down the trachea into your lungs. If the clavicle dislocates from its normal position (attached to the sternum that you felt) and it goes back into the trachea and pierces it, then the oxygen can no longer go from outside the body to inside the lungs. From there we have a serious medical emergency and Amendola’s jersey wouldn’t be the only thing thats blue. With a lack of oxygen to the body the affected person would actually turn slightly bluish.

Say the the clavicle goes back far enough missing the trachea; The aorta is also back there. The aorta is the largest artery in the body and is actually the first artery to come off the heart (not necessarily true – there is another artery going from the heart to the lungs but the aorta is certainly the largest). If the aorta gets punctured and disrupted then Amendola would bleed out within minutes; the only thing that can save his life from there is to have him prepped, on a surgical table, ready to be cut open in 3-4 minutes or less – that’s not very likely, in case you’re wondering. But why so fatal? The heart is essentially a pump. The “pump” has to send blood all the way from your chest to all parts of your body – including all the way down to your big toe nail. So when you see the aorta come straight from that “pump”, you can imagine that the force of the blood in the aorta is much higher than the force at your toe (by the time it gets to your toe, it slows down – note: I am severely over-simplifying it). So if Amendola punctures the aorta right where it comes out of the heart, the heart would then essentially be pumping the blood out of the wound at a very very fast rate (hence the limited time to get to a surgical table).

This was a very unusual injury that at first glance seemed all too common. Amendola did not break his clavicle (collarbone) as expected which would’ve required surgery. He is looking at about 6-8 weeks heeling time for the shoulder. This is the most common time to allow a ligament to appropriately heal. Expect him back with 100% function in that time period – back to business as usual.

Breakdown
Time out: 6-8 weeks
Severity:

55 %

Chance of Reinjury:
20 %

Performance Upon Return:
100 %

Let’s Be Franc!

Written By: DrGayedDPT - Oct• 05•12

Revis goes down with and ACL tear and is out for the year – oh, and despite what coach Rex Ryan will tell you, Revis is definitely out for the year – and now Holmes is out. The Jets’ season is looking as grim as ever as the fans seem to to be at the end of their ropes as cries for Tebow time get louder at MetLife stadium. If you are a Jets fan and looking for some consolation well…you wont find it here. What you will find is details on Santonio’s relatively uncommon injury and you will hopefully learn what to expect in terms of his comeback.

First, a little background on the anatomy of the foot. As you can see in the picture, there are 26 bones in the foot. No need to go through all of them for this injury but the main ones to look at are the 5 I have numbered in the picture. These bones are called metatarsals and make up your mid foot. Most importantly for the Lisfranc injury that Santonio sustained is the 2nd metatarsal. This is the main bone that is affected in this type of injury. You might be saying, “Oh that’s not that bad. That isn’t even the big toe.” Well yes, while walking and running you mostly push off that big toe but take a look at the picture again. Which of those metatarsals is the apex of the natural arch in the foot? You guessed it. Its the 2nd metatarsal. The arch in the foot is vital to proper mechanics during walking and running. It essentially acts as a natural shock absorber.

Think of how much you weigh…now look at your foot. Your foot has to be able to hold and propel (obviously with the help of muscles) your body wherever you want it to go. It must be able to withstand all those various terrains we negotiate as well as handle all the pulls in various directions from the muscles acting on the foot. Without boring you with details, the arch in your foot allows it to efficiently complete the aforementioned tasks.

Obviously the bones do not just magically float in that arch; they are held together by many ligaments. These ligaments are small, strong, and most are rarely injured. In the case of the Lisfranc injury, the demand on that arch exceeds the compliance of the ligaments and, well…something’s gotta give. And in the battle of turf vs foot arch…turf triumphs.

At the moment Santonio incorrectly steps on that foot, the demands on the ligaments supporting that second metatarsal and essentially holding that arch are asked to hold more than they can handle. Snap! The ligament tears. Now the bones that are not supported in the arch come crashing together like a huge wave hitting the shore line. As the bones smash together it can cause some of the bone to chip off and at the very least it will damage the cartilage surrounding the bones (cartilage allows for smooth gliding of joints – cartilage is around all the bones of your joints throughout your body).

As with Santonio’s mechanism of injury; his was a fairly “textbook” Lisfranc injury. This type of injury is most common in football and soccer players who roll over the front part of their foot. This injury is really painful and makes walking, or even standing, nearly impossible secondary to pain.

Ok, ok…that is enough detail on the injury. You’re asking, “When is this dude coming back?!” News on recovery can be pretty scary. For starters, let’s just get it out of the way and say that Santonio will not be playing football this season. With that said, recovery is variable with these injuries; recovery is highly dependent on the extent of the injury. How many ligaments were damaged? How much bone was damaged? How much cartilage damage was there?

They have not announced it yet, but most likely with an actual fracture (bone breaking off from the impact of the bones following ligament failure), Santonio will likely need surgery. Following surgery he will not be allowed to bear weight through the foot to allow healing for about 6-8 weeks; this is to allow proper healing before stressing the foot again. Then, again depending on the extent of the injury and at the surgeons discretion, Santonio will be allowed to bear partial weight through the foot for another roughly 4-8 weeks. We are already at 4 months of him not bearing weight through the foot. Recent studies have shown that muscle atrophy can set in after less than a week of weightlessness. One study detailed that astronauts experienced atrophy after as little as 3 days of not weight-bearing.

So what does that mean? By the time Santonio is ready to rehab, there would have been 4 months of non or partial weightbearing through his whole leg. That is a good amount of atrophy! Don’t freak out Jets fans…they have equipment out there to stimulate the muscles in the thigh and calf to keep these muscle active, contracting, and ultimately healthy throughout the non-weightbearing period but none are as good as the real thing!

Essentially, following the 4 months of non to partial weightbearing, you are looking at at least another 4 months of rehab, more likely 6 months. And again, depending on how severe the injury is, a high level athlete like Santonio may never return to his old self. But that is the worst case scenario.

Look for Santonio to be out on the field with his fellow Jets a year from now. Not that it makes the biggest of differences; with Santonio on the field, the Jets put up a whopping zero points this past Sunday…but who knows, a year from now maybe another quarterback will be throwing it his way. Tebow! Tebow! Tebow!

Breakdown
Time out: 8-10 months
Severity:

85 %

Chance of Reinjury:
20 %

Performance Upon Return:
85 %