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Friday, August 05, 2005
Football 101...Knees and Ligaments
by Mark Lawrence
Your favorite player just went down with a knee injury. You're reading all this stuff about ACL, MCL, Scoping, Surgery. What does it all mean?
First, let's agree on the basics. The human knee is not one of the engineering wonders of the world. It was "designed" (let's just take that word at whatever face value you prefer) for a 4-legged creature then pressed into service for a roughly 100 pound upright ape. 350 pound linemen are going to wind up having knee problems, it's really that simple.
You have two leg bones that join together, and you want a hinge. The hinge you're looking for should be quite solid side to side, reasonably frictionless, and swing in one dimension only. The knee is made to accomplish these goals. There's this very slippery almost teflon-like stuff, Cartilage, that covers the ends of the bones, and there's some lubricating fluid called synovial fluid that makes everything slide very easily. There are a couple pieces of wedge shaped cartilage called the Meniscus that help the knee hinge in one direction only.
There are four ligaments, tough string-like pieces that hold the knee together. These ligaments can be damaged by large forces. The damage is almost always a tear. A small tear is called a "sprain" or grade I injury. These heal themselves in time, requiring only that you work to keep the swelling down with anti-inflamitories like advil (ibuprofen) or cortisone. A medium sized tear is also called a sprain or grade II injury. These tears will usually require a knee brace to aid with knee stability while the joint heals. If the ligament is torn completely in two it's called grade III and usually surgery is required, along with a long recuperation.
There's a ligament on each side of the knee called the collateral ligaments. The one to the outside of your body is called the lateral collateral ligament (LCL). The LCL holds the outside of your knee together, keeping your leg from collapsing outwards. The LCL is rarely damaged in football.
The ligament to the inside of your body is called the medial collateral ligament (MCL). The MCL holds the inside of your knee together, and keeps your leg from collapsing inwards. This ligament can be damaged by a blow to the outside of the knee pushing inwards. MCL injuries are moderately common in football. Usually the player can continue playing, perhaps with a brace. The MCL is not critical to knee stability in most football situations.
At the back of the knee there's a ligament, the posterior cruciate ligament (PCL), that keeps the knee from hyper-extending. Grade III injuries to this ligament are not common in football. Typically a hyper-extended knee will result in a grade I or II injury to the PCL which can be healed with time, anti-inflammitories, and a knee brace. PCL injuries are more common in auto accidents due to a large impact on the bent knee with the dash board.
Right in the middle of the knee there's a ligament that holds the whole joint together, the anterior cruciate ligament (ACL). This is the big one. If you tear this completely, your knee is completely destabilized and you can't trust it at all. A grade III injury to the ACL requires highly invasive surgery where they will open up the entire knee and re-attach the ACL to the bone. Then you're in a cast for several weeks, crutches for several more weeks, and recuperating for a long, long time. The joint will typically be healed and rehabilitated enough to get medical clearance to play in about a year. However, it's well known in the NFL that it takes another complete year before the player trusts his knee again. A torn ACL is a large setback for a lineman, and can be career ending for a running back. Without a solid ACL, you cannot pivot or cut. ACL injuries were the end of Terrell Davis' career.
The knee also has a lubrication system, the cartilage and meniscus. These are white solids that your body makes to keep your joints friction free. Unfortunately, only the very outer edge of the meniscus and cartilage are alive. They grow slowly to fill in the parts that have been gradually worn away. However, if you injure the outer parts, they stop growing and it's all over for you, it's just a matter of time.
The cartilage can be torn, broken, or worn away. If it's worn away, you will have knee pain for the rest of your life. Eventually your body will lay down calcium to try to substitute for the cartilage. When the cartilage is severely damaged and you have bone-bone contact, you have Osteoarthritis.
If the cartilage is torn, then there can be a loose piece or a flap that moves around. These can cause your knee to "lock up," or at the minimum cause a fair amount of pain. These injuries will be "scoped." This means they make a cut into your knee about 1/2" wide, then push in with a little tiny tube with a light and a camera and look around. When they find the problem, they push in another small tube with tiny cutters and pinchers and pull the offending piece out. Then they pull out the tubes, give you a Snoopy band-aid, and loan you some crutches for about a week. A couple weeks later you're on the field with minor pain, and a couple months later you're back to normal.
Finally, you can have a tear of the meniscus. These are wedge-shaped pieces of cartilage that help with knee stability and low friction. If you have a small tear, they might scope it and "clean it up" a bit. If you have torn your meniscus in two, it's likely they will cut into your knee and remove part or all the meniscus. You can then play with a bit of pain, and are looking forward to more serious pain when / if you hit 50.