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Ke'an: Hi.
I'm Ke'an Armstrong, and I'm your host of being well.
And today we're going to be talking about knees.
We're going to be talking about athletic knee injuries, and all types of different injuries
that can happen to the knee.
And so it's going to be very interesting, I think, for a lot of people out there that
are involved in sports.
For the most part.
And joining me today, I have Dr. Timothy Gray.
He's an orthopedic surgeon with Bonutti Clinic and Sarah Bush Lincoln.
So thank you so much for joining us today.
Timothy: Well, thank you for having me.
I really appreciate being here.
Ke'an: There's lots of different things that can
happen with the knee.
Lots of different sports out there that we can talk about.
And the different injuries.
But I think a good place to start would be, let's talk about the anatomy of the knee first.
Timothy: Perfect place to start.
Perfect.
Exactly what I wanted to talk about.
Basically the knee is made up of three bones.
There is the thigh bone, which would be up here, the femur.
There is the shin bone, which is the tibia.
And there's the patella, which is the kneecap.
Those are hard tissues.
Those can be injured, very traumatic injuries.
That would be a hard tackle.
A very hard fall.
To get those to break, it's a major kinetic energy to put that patient down.
I don't really want to talk about the hard tissues.
I really wanna talk more about the soft tissue injuries that can occur.
And those fall in different categories.
I'm gonna let this tear open with another model.
Ke'an: All right.
Timothy: Gonna get that kneecap out of the way.
Because you're gonna see a lot more structures that way.
Two of the stabilizers, the ligaments, ligaments are stabilizers.
They hold the bones together.
They hold the shin bone to the thigh bone.
And there are two different combinations of those.
There is a medial collateral ligament, which runs to the inner aspect of the knee.
And there is a lateral collateral ligament.
Those are ligaments that will keep the knee from opening up from a side to side fashion.
So those would be injured most commonly.
You can sprain, strain, irritate a ligament.
What it is, it's a stretch all the way up to possible tear, is what it comes down to.
Those are the classic injury of football linemen.
Is gets clipped.
That yellow flag goes up, and he goes down.
And what happens is they get clipped from the side, opening, stressing that knee.
And it can tear this medial collateral ligament.
That is probably the most common injury in football.
In the football player.
Other set of ligaments are the, what's called the ... And they're inside the knee itself.
They're called the anterior and posterior cruciate ligaments.
They are ligaments that had the Latin root cru, and that was just like crucifix.
They're crossing ligaments.
A lot of people feel they are crucial, and they are crucial, but cru is a Latin term
meaning cross.
And there are crossing ligaments.
Ke'an: And those are on the inside here?
Timothy: Those are on the inside.
Basically, what it comes down to is the thigh bone comes down, and you've got a round thigh
bone sitting on a flat shin bone.
And there's two little ball bearings, basically, and those cross in between the ball bearings
in order to provide stability for anterior and posterior, the motion of the knee itself.
Those also can be injured.
The way you would injure those is different.
What happens is the anterior cruciate ligament, you hear a lot of athletes ... Basketball
players, that get the anterior cruciate ligament injury.
That comes about usually that bad layup.
They go up, they come down with a straight knee that causes a twist.
Kind of a hyper-extension of that knee.
And you can tear that anterior cruciate ligament.
Ke'an: Okay.
So is that also what people refer to as ACL?
Timothy: ACL.
Ke'an: Okay.
I was trying to put the words together there.
Timothy: Anterior cruciate ligament, ACL, exactly.
That's the ACL injury, is what would be classic for that.
It's partner, the posterior cruciate ligament, which is the one behind it.
In the United States, we get mostly anterior cruciate ligament injuries, is what we talk
about.
Posterior cruciate ligament is a much more injury that occur in Taiwan.
Ke'an: Really?
Why is that?
Timothy: Taiwan is a scooter driving nation.
And that injury, high speed scooters, direct trauma to the front of the shin can tear the
posterior cruciate ligament.
So they do much more reconstructions, and get much more damage to the posterior cruciate
ligament, than we do to the anterior cruciate ligament.
The other soft structure I'd like to talk about in the knee is what's called the meniscus.
These are the medial and lateral meniscus.
What those are, is those are cushions.
As I said, the thigh bone is round.
The shin bone is flat.
So you don't really have a very good contact point.
You have a kind of isolated contact point for bearing weight on the knee.
So what I always tell my patients, these are kind of gaskets.
They're little soft tissue gaskets that lay around the outside to help expand the weight
bearing zone of the knee to allow it to roll and move.
But then also to have a cup that it can sit in.
Those can be injured in athletics, as well.
What it would be is, in order to injure that, you would load that knee up with weight.
And then twist the knee.
And when that twists, if you pinch that soft tissue, it can tear.
And once it tears, it can then flip around and cause it so that ball bearing can't roll
as well.
It can flip in and out of the joint.
And I could cause catching, popping, grinding.
And a lot of pain.
And along with that is the last one of the soft tissue injuries I wanna talk about.
And each of these bones have cartilage on the end of them.
You've seen a chicken bone that has that glassy tissue on the end.
That's the Hyaline cartilage on the end.
Well any of these injuries can cause direct trauma to those areas.
Which can cause bruising and inflammation of those.
It can cause just softening of it.
It referred to as Chondromalacia.
Which would be chondro is cartilage.
Malacia is damage.
And it's graded from one to four.
One is just bruising.
Four is it's completely sheered off.
And now you've got raw bone underneath.
So those are the major injuries that can occur to the soft tissues about the knee.
And they can occur in any combination.
And to prove that orthopedics has some poetry to it, I guess, one of the most common is
called the unhappy triad of the knee.
Which would be a combination of the anterior-ACL, anterior cruciate ligament, the medial collateral,
and the medial meniscus all being torn together.
And you can well imagine that that's much more devastating than any one of them alone.
Ke'an: Very painful.
Timothy: Yes.
Very painful.
Yes.
Ke'an: Okay.
Well let's go back to we know the anatomy of the knee.
We know the parts of it now.
We've heard about the ACL and the meniscus.
Because I think that's something that more common folk hear people talk about a lot.
Torn meniscus, or the ACL, they've done something to that.
What types of injuries, what types of sports or different things that people do besides
what you mentioned with the clipping of the football, that you see often with those types
of injuries?
Timothy: Well again, all of the sports, as we talked
about.
You would see this in ... a lot of this in football, basketball.
But motor vehicle accidents also increase, and then often they'll try and describe what
happened.
And people will say, "Well, is that a mechanism?"
I think in a motor vehicle accident, there's a lot of things going on at any one time.
So though we don't know what stresses necessarily occurred in that accident, that hitting the
dash, being twisted under the wreckage, so to speak.
It happens so fast that it's very difficult for them to describe exactly what happened.
So you have to piece it together on the exam.
Sometimes [inaudible 00:07:35] what the injuries are, not just by what they said happened.
And even, quite honestly, some of these can be just wear and tear injuries.
As we age, as we become an aging population, weekend athletes are much more likely to have
some of these injuries than those young high school kids that are almost indestructible.
Because some of those cartilages, they start to soften, they start to weaken, and they
can be torn much more easily.
Ke'an: Okay.
Well, a lot of times, when you're watching sports, you'll see a physician run out to
the field and do some field care on an injury.
So talk to me about that.
What's going on when that happens?
Timothy: Well, I think there's two reasons that they
do that.
One, I think everybody's mother likes to see him on camera.
And you know, well that's always a good face time.
Ke'an: Yeah.
Right.
Timothy: But I think the real reason they go out there
is the knee has a bunch of secondary structures in order to the muscles, the tendons which
connect the muscle to bone, add stability and can get them to spasm very quickly after
an injury.
So in order to really get a good feel of what has happened to what ligament, evaluating
that patient on the field before they can really guard.
Before they can really, the muscles go into spasm, you can stress those joints and see
where they're tender.
And see if they really are opening if the ligaments are unstable.
If it slides back and forth.
And your best time is probably within the first twenty 20 of injury.
Because after 20 minutes of injury, the knee will fill with blood on certain injuries.
The muscles will go into spasm.
And they have a lot more, the pain just is on board.
So that you really can't get a good exam for probably a couple weeks.
Just because there's so much guarding, and the patient is so resistant to evaluation.
Ke'an: Okay.
Swelling, I'm sure, as well.
Timothy: The bleeding, the swelling, irritation into
the knee, yes.
Will block that adequate evaluation.
Ke'an: All right.
So it's the blood that's swelling in the knee.
Is that?
Timothy: It can bleed into the knee.
Ke'an: Oh.
Okay.
Timothy: If you tear the anterior ... One of the classic
signs for an anterior cruciate ligament tear is if it tears, it is one of the only vascularized
structures in the knee joint proper.
And it will bleed into the knee.
So the knee will balloon up within the first 20 minutes of that injury.
If you've hurt the other ligaments, they're not really in the joint.
So yes, the knee will swell and get irritated.
But it usually will take a little longer period of time.
Ke'an: Okay.
So if someone isn't playing in a sport where they're on a team, or something like this.
Maybe they're out running by themselves, or they're doing something outside of a group
stetting.
And they feel like they've done something to their knee.
They don't know how bad the injury is.
It might be something where it's just a little painful.
What do you advise when someone's by themselves, and they feel like they've done something?
Timothy: Anytime that any joint has, knee included,
if you've injured yourself, if you're having pain, If you feel unstable.
You're not getting around well.
But you're not really major injury.
No car accident.
Nothing that you really are concerned that you've really caused major damage.
We recommend what we call RICE.
It's a acronym for ... For that first 24 hours, what you wanna do, is you wanna rest the joint
that's involved.
You want to apply ice for 20 minutes at a time.
Don't sleep with ice on it, because you can now turn an injured joint into a frostbitten
joint.
You can actually damage the skin.
So 20 minutes of ice in order to help control that swelling.
Compression, so an ACE wrap in order to kind of, again, keep the swelling down.
So it can't get out of control.
If you put pressure on those, on that joint, it won't swell as much.
And elevation.
If you get it above your heart, again, it kind of puts a lower blood pressure in there.
So it's less likely to swell.
The swelling can cause irritation in and of itself.
And be more difficult.
Usually, patients often ask, "Well, should I be using ice?
Should I be using heat?
Which is better?"
In the initial injury, of any initial injury, you stretch, you pull, you tear.
You can tear some small vessels.
Which will bleed.
So we usually recommend, if it's an isolated injury, 24 hours of ice.
By then, those small vessels should have sealed themselves off so they're not actively bleeding
anymore.
And now what you want to do is, the swelling that has occurred there, you want to apply
heat.
Because now you want to dilate those vessels so that now they can take any fluid that has
accumulated.
They can take it away, and get it out of that area.
In order to decrease the swelling in that way.
Ke'an: All right.
Timothy: So ice for the first 24.
Heat after that.
Ke'an: Heat after that.
So don't heat it first.
Timothy: Nope.
Now on athletes, sometimes what we'll do is, since they are gonna go back to play, and
do more and more micro-trauma to themselves.
We'll condense that.
And we will say, "Okay.
After practice, ice it for 20 minutes.
And then, when you get home, apply heat at that point in time."
Because they're not having one set injury.
They're irritating an old injury over and over again.
Ke'an: All right.
Well, that's what I was gonna ask you.
So do you see a lot of people who maybe wait too long to come see you?
And they're like, "[inaudible 00:12:22] It'll heal.
It'll get better."
And then it just gets worse?
Timothy: Yeah.
We have people that always think they've , "I just strained it.
I just twisted it.
I just irritated it."
And then they'll come in with more problems.
They don't usually cause a lot more trauma to it.
If it's really, if it's really damaged, it gets you to the ... If it's damaged enough
that you're gonna hurt it more, your body's pretty good about protecting itself.
Not walking with a limp and all.
And trying to protect it.
Staying off it.
You won't let you re hurt yourself very well.
The interesting thing is, often with a cartilage tear, some people will tear that meniscus.
And as I said, that piece will flip back and forth into the joint.
Well, it's more likely to flip back and forth if you're rolling the joint back in place.
So often, we'll see patients that will come in a month after they've done it.
And they say, "You know, it's finally getting better."
When you see them walk in, and they walk in with a peg leg.
They don't, as long as they're not rolling, if they're not rolling the knee joint, the
meniscus isn't slipping underneath it.
So they walk around peg-legged, and think they're getting better.
But they're not.
It needs to be addressed.
Ke'an: Right.
They've adapted to the ...
Timothy: They've learned, yeah, they've learned how
to not cause more pain.
Ke'an: Right.
So what can a person expect when they go into either your office, or if they would have
to go into an emergency room situation?
Kind of walk a patient through, I guess, both.
And how you diagnose what the problem is.
Timothy: Well, the first thing that you'd see, you'd
come into the office.
You describe what happened to you.
You go to the emergency room, they'll describe what happened to them.
Pretty much knee jerk treatment for any orthopedic traumatic injury is, we're gonna get an x-ray.
Gonna make sure you didn't injure those hard bones that we talked about.
I guess, I've been watching the soccer, and you would think that every, those soccer floppers,
they're killing themselves.
I can't believe they're not losing legs with the amount of injury, apparently, they're
having.
So you'll make sure there's no patella fracture, no femur fracture, not tibia fracture.
If the x-ray's negative ... And again, before the x-ray, you'll do a physical exam.
You're looking for, if you're looking at a ... You wanna make sure the soft tissues are
intact.
You wanna make sure the patient has active extension.
Because if this patient would rupture this patellar tendon, which holds the patella to
the rest of the bone, they no longer can actively extend the knee.
So you'd know that was a problem.
But if they can actively extend it, they you're going to palpate along the joint line.
If they're tender along the joint line, you can pinch and try and load up that torn meniscus.
And move it through an arc of motion.
If that causes pain, that's gonna make you concerned that he has a meniscus tear.
Or he or she, I shouldn't say.
There's some female athletes just as well.
A meniscus tear.
If you're worried about a possible ligament tear, there again the clipping injury.
What you're gonna do, is you're gonna support that knee, and you're gonna stress it in the
opposite direction.
The ligaments will cause pain and instability on the ... When you put traction on them.
Now, when I'm putting traction on this, I'm putting compression on the lateral meniscus.
So you're kind of evaluating both at the same time.
And then, when you do the opposite way, you're putting traction on the later collateral ligament.
And you're putting compression on the medial meniscus.
So again, you're looking at when you're making that maneuver, you're looking at are you hurting
inside, or outside?
And are you hurting on the compressive?
On the traction side?
Then when you're looking at the crossing ligaments, the anterior and posterior cruciate ligaments,
you're going to basically try and put it in the secondary ligaments in a lax position.
And you're gonna draw forward.
It's called a lockman or drawer test.
Which is trying to see if that tibia slips forward on the femur.
And if you're looking for the posterior, you're gonna hold it flexed, and you're gonna push
back and see if it sags.
Because if it sags, that could be a posterior cruciate ligament injury.
Ke'an: Okay.
Timothy: So those are some of the tests that you do
in order to evaluate in this day of modern medicine.
Also the cartilage, if you're pushing on the ends of the bone, that could be chondromalacia.
That's harder to evaluate on just a simple exam.
'Cause it could just be bruising and irritation.
In the day of modern medicine, we have the luxury of the MRI.
Which is a soft tissue x-ray.
And you would send them to the MRI.
Which is very good at diagnosing these soft tissue tears.
You have a high index of suspicion, and that's not 100% on that test.
But it can also confirm, or rule out, certain injuries.
Ke'an: Well, I was gonna ask what you mentioned the
x-ray.
So you need an MRI to see about the soft tissue?
The x-ray won't show that?
It only shows the bone.
Timothy: It only shows the bone.
X-ray would not really show that, those meniscus, those ligaments, no.
Ke'an: Okay.
Well, let's talk about conservative care of the knee versus maybe you need to get a little
bit more drastic and go into surgery.
And so, when do you know the difference?
Timothy: Well, partly it has to do with what the injury,
we diagnose.
If you're looking at a medial, an isolated medial or lateral collateral ligament tears.
Those are outside of the knee joint proper.
They actually lay on the outside capsule.
They are held in position very well.
So as a general rule, even if you tear that, it almost never needs surgery.
What you would do is, you need to protect it though.
So you would start off, usually to come out of the emergency room, you'd have a knee immobilizer
on.
And unfortunately, that makes you walk like the peg leg, like we talked about the [inaudible
00:17:25] do the no roll.
Well, but it's really trying to keep ... Trying to prevent this varus valgus, this inner and
outer stress on those ligaments that are stretched.
Always refer to those as shoe strings on the outside.
And you can get some partial injury.
You can get a full tear of those, of that shoestring.
But really, it should heal.
As long as you can protect it.
And this is the patient you would see that you put, after the first week or so, you'll
put in a hinged knee brace.
So now it has structure to the inside and outside.
So again, it's gonna prevent that stress of opening up, and let that ligament heal itself.
If you're talking about a anterior cruciate ligament ... Now I haven't treated a posterior
cruciate ligament tear in probably over 20 years.
So I guess I don't know as much about that.
But anterior cruciate ligaments, most of us really can get by without an anterior cruciate
ligament.
Now the young individuals, athletes, they're gonna need to have it taken care of much more
commonly than the older weekend warrior.
What we can do is, first of all, you would put it to rest.
You'd do a hinged brace.
Sometimes you can so a special protective brace.
Which will help hold it in place even better.
Kind of custom type brace.
But the real key is using the secondary stabilizers in the long run to do the work.
What you do is your hamstrings can be very strong.
And the ligaments trying to, the anterior cruciate ligaments trying to keep your tibia
from riding forward on your femur.
Well, if you can strengthen these secondary dynamic ligaments.
Secondary dynamic structures, the hamstrings, you would do therapy in order to strengthen
those.
So they could bypass the function of the anterior cruciate ligament.
Ke'an: So the back up.
Timothy: Those muscles in the back, which are contracting
and holding those, holding that tibia back, with regular activities.
Old number used to say only about a third of the anterior cruciate ligament injuries
had to have surgical intervention.
I think that they probably ... We orthopedists today push that envelope.
'Cause there are some newer techniques that maybe we do more of them than that.
But as a general rule, you can get by without repairing the anterior cruciate ligament.
You just need to have conservative care.
And maybe bracing for special activities.
Meniscus tear, now you've got some bodies floating around inside there.
About five or ten percent of the patients can grind that cartilage up on their own and
get better.
Most of them have to have a small surgery, knee arthroscopy.
I say it's small because they're not doing it on me.
It's on somebody.
They're have to live with it.
Ke'an: But they don't have to make an incision.
It's more of a scope, right?
Timothy: It's a knee arthroscopy.
Two little stab incisions in order to get into the knee.
And clean out that joint.
Remove that debris that's floating around.
So the ball bearing can roll more normal.
Ke'an: Okay.
All right.
So let's talk about healing time when it comes to some of these injuries.
And maybe post-operative.
Talk to me about healing time and what happens afterwards.
Timothy: Okay.
Well, the medial and lateral collateral ligament, as we said, is usually a conservative care.
Usually takes ... We would do some type of protection for 6-8 weeks.
We would start them on a very protected, obviously, for the first three, and then they can start
advancing their activities.
You'd have some type of brace for probably up to eight weeks.
And after eight weeks, if they are clinically doing well, feeling comfortable, confident,
and no pain, you treat it ... You would let them get rid of the brace and maybe use it
if they're gonna do some high stress activities.
Wanna go out and play some basketball.
Or play some sports.
Put the brace back on.
Maybe even up for a full six months to protect that.
But you don't have to have it the whole time.
They used to use, college football players, the linemen, they had enough MCL injuries,
medial collateral ligament injuries, that they started to use hinge knee braces as a
preventative for that.
Well, the problem with that became now you didn't have that give that would occur when
that clipping, when that 300 pound beast landed on your leg.
You didn't have that ligament that could give, so now you would have catastrophic injury.
You could start getting fractures.
So yes, we still use those braces once you've had an injury.
But usually we don't encourage the linemen to wear them until they've had an injury.
So to speak.
As for the anterior cruciate ligament tear, if you can get ... Again, the same type of
treatment.
Bracing for high stress activity.
Eight weeks of protection.
And then, just using it for activities.
If you can ... If they are finding that they can get by without having to have it reconstructed.
If you have to go in for surgery, much more major intervention.
You have to ... It can't repair it.
You can't just sew it up.
It won't heal.
So you have to reconstruct it.
You'd have to harvest graft from either the patient him selves, or you have to harvest
graft from a donor, a cadaver donor, in order to drill holes and reconstruct that ligament.
Well, that has to be incorporated.
Those bone plugs have to heal in.
That itself takes 8-10, up to 12 weeks to heal in.
Then it has to regrow into the ligament itself.
It can be a six month ordeal to try and get over.
So we try and avoid doing that in the older individuals that aren't gonna have that amount
of demand.
Ke'an: Okay.
We've got a couple of minutes left here.
But I wanna talk about, briefly, preventative.
What's some things that you tell people, "Hey.
To prevent injuries if you're involved in sports."
Stretching, what types of things do you tell them to do?
Timothy: Well, exactly right.
Stretching, staying in good condition.
I mean, obviously, weekend warriors are ... We don't do anything all week long, and then
we try and jump out there and play basketball.
Sometimes compress ... if you have a sore, achy joint, some compressive sleeves in order
to help give it some support.
Try and avoid the hinges.
Staying within yourself.
Don't do anything crazy.
And be safe.
Ke'an: Okay.
Now you have a VLOG that folks can tune into on Facebook.
And when do you post that?
Timothy: I post it on Sarah Bush's Facebook every Wednesday.
Its usually like a three, four minute information on different orthopedic injuries.
Trying to get some information out there.
Trying to let people know what we treat.
And what they can do to help themselves.
Ke'an: All right.
Well, we've covered a lot of information today out there for folks involved in sports.
Different knee injuries.
And so, Dr. Timothy Gray, and orthopedic surgeon with Sarah Bush.
It's been a pleasure having you on the show today.
Timothy: Thank you so much.
Ke'an: Lots of different information there.
Know how to take care of the knee.
The RICE method, the VLOG, if they want more information.
So thank you so much for being a part of our show.
Timothy: Thanks for having me.
I really appreciate it.
Ke'an: Yeah.
Sure.
And thank you so much for watching this episode of 'Being Well'.
For more information, you can tune in online and on our YouTube channel.
Thanks for watching.
Lori: Sarah Bush Lincoln Health System supporting
healthy lifestyles, eating heart-healthy diet, staying active, managing stress, and regular
checkups are ways of reducing your health risks.
Proper health is important to all at Sarah Bush Lincoln Health System.
Rameen: At Carle, we dedicate ourselves to helping
you be great.
And we have the expertise and inspiration to help you stay that way.
Rameen: Meeting the ever changing in healthcare needs
of our communities.
Paris Community Hospital/Family Medical Center is now Horizon Health, with the same ownership,
management, providers and employees.
Horizon Health provides patient care and promotes wellness to the communities of East Central
Illinois.
Jeff: At HSHS St. Anthony's Memorial Hospital we
are at work transforming heart care, rebuilding knees and hips, delivering new generations,
and focused on providing healthcare to you.
We are HSHS St. Anthony's Memorial Hospital.
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