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Knee Injuries and Recovery

Brad Farra - Friday, October 09, 2009

This is a good follow up from my last blog. I read this from Wikipedia and I thought I might pass it along.

The knee is a core tool for an athlete; it allows football and basketball players to run, cut, and jump. Baseball players use their knees to push off when they throw. The flexibility and rotational ability of a knee is what helps make some tennis players superstars. It’s difficult to return to competitive athletics after any serious injury, but knee injuries takes a lot longer to get over and often end a career. While having a good physical rehab process is very important, the athlete’s ability to overcome the mental hurdles that are created with a knee injury will determine whether or not he will be the same player that he was before the injury.

The words “it’s an ACL” strike fear in the heart of an athlete. The immediate mental translation is will I ever play again and if I do play will I ever be as good? Why do knee injuries cause so much fear in competitive athletes? According to the Brown University Biology and Medicine Web site, athletes in contact sports are 10 times more likely to have a serious knee injury than in non-contact sports, with knee injuries accounting for approximately a quarter of the injuries and generally taking two to three times longer to recovery than injuries to other parts of the body[2][3]. Knee injuries are also increasing, “over the last 15 years, ankle sprains have decreased by 86% and tibia fractures by 88%, but knee ligament injuries have increased by 172%”

What cause knee injuries and what is the prognosis for total rehabilitation? Leg bones are connected to the kneecap by four strong ligaments: Anterior Cruciate Ligament (ACL), Lateral Collateral Ligament (LCL), Medial Collateral Ligament (MCL), and Posterior Cruciate Ligament (PCL). The ACL provides stability and controls stress across the kneecap and keeps the knee from rotating too much or moving too far forward. Around 60% of ligament tears are ACL, most occurring in basketball, skiing, football and soccer. When an ACL tears it unravels like a rope and will not heal on its own. For competitive athletes treatment is almost always surgery. It normally takes 6 to 9 months to recovery from an ACL reconstruction surgery, at which point most athletes had returned to between 80% and 100% of their full level of previous play with about 90% returning to competition [4]. After the first ACL injury, there is a 5 to 15% risk of repeated injury [5]. MCL and LCL ligament tears are less frequent then ACL injuries accounting for about 25% with LCL injury being much less frequent than MCL injuries [6]. MCL injuries are normally caused when a significant force is applied to the side of the knee while the lower leg is held in a fixed position. The MCL is the only ligament that has enough of a blood supply to heal partial tears without surgery [7] PCL injuries account for between 3% and 20% of all tears [8]. Most often the cause is a blow to a bent leg. Because of the type of blow, PCL tears are often accompanied by ACL tears. While conservative treatment is still controversial in some sports for both PCL and MCL tears, it has proven to be as effective in returning an athlete back to his playing condition as has surgery [9]

Why or why not surgery? If an athlete wants to play competitively ACL tears require reconstructive surgery. During surgery the old ACL is removed, a graft from the patellar tendon or the hamstring is prepared, holes are drilled in the tibia and femur and the graft is attached with screws to the bones. Now the tough part begins, surgery is followed by 6 to 9 months of rehabilitation. This rehabilitation is crucial to strengthen the areas surrounding the graft so that it does not fail. Athletes may accept that injuries are part of their lives and may know how to deal with physical rehabilitation, but few are prepared for the emotional pain, fear and anger that also result from injury. Athletes are used to being part of a team. When they are injured they are suddenly on their own. Their teammates will continue on but they now have a new job, physical and emotional rehabilitation of their bodies and much of the work will have to be accomplished on their own. In Sidelines, Psyched Up or Psyched Out? David Doermann describes a University of Utah pamphlet that is given to all student athletes to help them understand what to expect if they are injured. It describes the emotional process that happens when someone is injured as similar to the five stages of grief [10] The first stage is denial. Athletes by their very nature believe that they are superior physically and therefore do not accept the fact they can be injured. When an athlete realizes an injury is real his reaction may be to isolate and blame himself. Denial is followed by anger, particularly at himself for allowing the injury to occur. During the third stage the athlete tries to make bargains with coaches, trainers or God, such as if I spend 2 hours walking every day I can play again in 2 months.

Very often these bargains are unreasonable dreams. The competitive athlete will now move to a period of depression, feeling sorry for themselves, withdrawing or simply giving up. This stage particularly can put an athlete’s rehab off track. To be successful an athlete must finally get to the acceptance stage when he realizes that the only way to handle the injury is to focus on his physical rehab which could result in returning to competition. The factors that contribute the most to helping an athlete reach psychological acceptance and recovery are education, social support, psychological skill training and goal setting; traits that many athletes use in their pre-injury training [11]

Understanding an injury and their reaction to it helps athletes cope with the problems that naturally arrive along with the injury. Support and understanding of team mates, family and friends can also be a critical factor in recovery. Knowing and understanding how others have coped gives athletes mechanisms for starting to construct their own recoveries. While having social support that listens and appreciates the seriousness of an injury is necessary, too much sympathy from family or friends can impair the athlete’s acceptance level which can slow or derail the recovery process. A study done by the Aristotle University of Thessaloniki, Greece concludes that “psychological intervention techniques can aid significantly to the rehabilitation process. In particular, the goal setting process seems to have positive clout in the athletic injury recovery, in the attitude of the injured athlete, in the successful confrontation of the injury, in the recovery of confidence and in the adherence to the rehabilitation program” [12]

[edit] References

  1. ^ Soligard T, Myklebust G, Steffen K, et al. (2008). "Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial". BMJ 337: a2469. doi:10.1136/bmj.a2469. PMID 19066253.
  2. ^ (Lysaght)
  3. ^ (Lysaght)
  4. ^ (Lysaght)
  5. ^ (Lysaght)
  6. ^ (Lysaght)
  7. ^ (Selesnick)
  8. ^ (Lysaght)
  9. ^ (Cluett)
  10. ^ (Doermann)
  11. ^ (Armatas)
  12. ^ (Armatas)

Armatas, V.1, Chondrou, E., Yiannakos, A., Galazoulas, Ch., Velkopoulos, C. Physical Training 2007. January 2007. 21 March 2009 <http://ejmas.com/pt/2007pt/ptart_galazoulas_0707.html>. Cluett, Jonathan M.D. Medial Collateral Ligament Treatment. 29 May 2006. 16 April 2009 <http://orthopedics.about.com/cs/kneeinjuries/a/mclinjury_2.htm>. Doermann, David. Continuum, The Magazine of the University of Utah. Spring 1998. 19 March 2009 <http://www.alumni.utah.edu/continuum/spring98/ sidelines.html>. Lysaght, Michael J. Knee Injuries and Therapies in Competitive Athletes. 20 March 2009 <http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group06/Group6project/ Homepage.htm>. Selesnick, Dr. Harlan. Sports Injuries ESPN. 4 October 2007.

Iliotibial band (ITB) Syndrome

Brad Farra - Thursday, October 08, 2009

I had a patient tell me today that because of me he is back running again and is signed up for an Ironman triathlon next season. Before being treated by me he had other doctors tell him that there is nothing that can be done about his knee and that he should just not run. Iliotibial band (ITB) syndrome should be nothing that keeps you away from running. ITB syndrome can be treated quite successfully.

ITB syndrome is an irritation of a large band of connective tissue that runs from the hip and the tensor fascia lattae and gluteus maximus muscles across the lateral knee to attach below the lateral condyle of the tibia. The pain associated with this can be anywhere along the course of the ITB, but it's usually lateral knee pain. With flexion of the knee the ITB slides over the the lateral distal femur (lateral femoral condyle) and this can cause pain if the ITB is irritated or inflamed due to tension throughout the ITB.

ITB syndrome is very common in distance runners, but can also occur in cyclists. The causes can include but are not limited to: Over training, over pronation and even under pronation due to increased lateral stress on the knee, worn out shoes, hill training, hard surface running, uneven surface running, leg length asymmetry, anterior cruciate ligament laxity, improper use of orthotics, and even weak gluteal muscles.

If you have pain in your knee or hip it is important to have it looked at by a qualified sports physician. Due to the possible contributing factors it's important to consider the entire biomechanical chain when assessing any type of knee pain. This evaluation would include an exam of the low back, hips, knees, and ankles/feet.

Treatment usually includes some type of soft tissue manipulation to the ITB. I use Graston technique (www.grastontechnique.com), but other methods can also be effective. Other treatment would include correction of any biomechanical faults such as over pronation.

Don't let your pain stop you from doing what you want to do!!

Sports Recovery

Brad Farra - Wednesday, October 07, 2009

I get a lot of questions from my athletic patients about how best to recover from sport. Completing two 24 hour races in the past 3 weeks has inspired me to blog a little bit about recovery. Whether you are recovering from a single sporting event or a week long stage race, what you do for recovery can make a big difference in how you perform or how you feel the day after or even weeks after the event.

Recovery starts before the event ends. Ensuring proper hydration and nutrition during your event is the first step to ensure optimal recovery. The event duration will dictate how much and what types of macromolecules you will need to take in during your race. If it's a single sporting event like a soccer match you may only need to get some sports drink in to replenish fluids and electrolytes. If it's a 24 hour race your fueling needs are much more complicated. In a long distance event you will need to intake protein in addition to carbohydrates for your calorie needs. A 3:1 ratio of carbs to protein is a good goal to ensure proper fueling and to reduce the post race protein deficit.

Your next concern is immediately after your event. STRETCH!! I can not emphasize enough how important stretching is after your event. Research is really pointing to post event stretching as being much more beneficial than the pre-event stretch. Pre-event warm-up and post event stretch. Your stretch is preferably done while your muscle are still warm from competition, but don't stop there; stretching more than once the day of the event and depending on the intensity of the event you should be stretching several times a day in the days following the event.

Now it's time to consider post race nutrition. Your big concern here is protein. You need to be sure to recover with more than just carbohydrates. There is a window of time immediately after your event when your body us better able to absorb and store carbs. So, it's important to get those carbs in right after the event. Protein is key to the rebuilding aspect of recovery. If you don't get enough protein in after your event, your recovery will be longer.

You've stretched, you're fed, and now...ice bath. No one likes it, but everyone will benefit. Even if you have only just played in one football game, you will benefit from an ice bath. Shoot for about 55 degrees Fahrenheit for a tolerable yet therapeutic temperature. Ten to fifteen minutes is all you need to reach maximum benefit. Any longer and you reach the point of diminishing return and any less you won't get the maximum benefit. If your event was primarily a running event (soccer, football, etc.) you can just soak from wast down. If you're a baseball pitcher then you'll want to just soak your elbow and shoulder. Soak what you used. You can repeat the ice bath several times a day, just be sure to allow for complete re-warming in between sessions. You can also combine ice baths with warm baths for the complete contrast therapy treatment: 10 minutes ice bath, then 10 minutes warm bath, finishing with 10 minutes ice bath. If you have no time or you're too big a sissy to get in an ice bath then you can elevate your legs above the level of your heart while you are resting and that will improve blood drainage and from the legs while you are resting your muscles, which will speed recovery.

A quick note on supplements. I recommend a multivitamin for daily use, but it's even more important in the days before and after your sports event. Another helpful supplement is omega 3 fatty acids found in fish oil; you'll want to shoot for 1000 mg per day split between EPA and DHA. This will help with reducing inflammation among other important functions. If you are an endurance athlete you should be concerned with the possibility of having a slightly depressed immune system for up to a week following your event. Garlic is a good supplement to help with immune system function and also benefits the cardiovascular system. The world of supplement research changes on a weekly basis, so I won't go into any more detail. You should know that if you are an athlete it's hard to get in enough vitamins, minerals, and other nutrients to ensure the fastest recovery. I do recommend taking advantage of sports science, but each sports supplement should be considered on an individual basis for it's efficacy and safety. If you have questions ask your sports physician before starting any new supplements.

Play hard and recover well.


Dr. Brad Farra

Sports Injuries and Chiropractic Care

Brad Farra - Monday, October 05, 2009

Here is an article written by a colleague of mine.

Many musculoskeletal complaints arise from injuries sustained in sports. Each year we see athletic performance draw closer to the limits of human potential. Understanding the biomechanical principles involved helps us to prevent injury and restore functional integrity and stability through rehabilitation.

While our lever-like extremities transmit forces and motion at a distance, they also favor musculoskeletal injuries by amplifying forces acting on the body's neuromusculoskeletal system.

The sheer volume of time put into training by professional athletes is often quite remarkable. For example, runners may compete and train over 200 miles per week, swimmers may spend four or five hours in the water daily, and the acquisition of skills for an event such as a pentathlon may utilize even longer periods per day. Thus, the exploitation of athletic prowess can easily be disrupted by major and minor injury problems.2

The Garrick and Requa study of injuries in high school sports for two academic years of 1973-74 and 1974-75 revealed 1197 injuries for 3049 participants in 19 different sports.3 These two authors also reported on the number of high school injuries (per 100 participants) for the various specific sports as follows:4





























Track & Field


Track & Field


















Injuries sustained in high school sports: 1973-1978.

There are good reasons why the athlete should seek a sports chiropractor for the treatment and rehabilitation of a sports injury. Active people are physically and emotionally different from sedentary ones. Most physicians have not had special training in sports medicine or rehabilitation. Consequently, even outstanding physicians who don't treat athletes regularly often make mistakes in the diagnosis and treatment of athletes' neuromusculoskeletal problems.5

The opportunity of being a team chiropractic physician is often quite unique for the typical chiropractor, in that he or she is dealing, as a rule, with patients who are usually healthy and physically fit. This is rare in the general chiropractic practice. Young athletes are often in the peak of physical condition and motivation, which accounts for a rapid rate of recovery. While the professional prerequisites are obtained in the regular chiropractic education, on-site athletic care is often a far different experience than that of general practice. Innumerable cranial, spinal, and extremity contusions, strains, sprains, fractures, subluxations, dislocations, and soft tissue trauma are encountered by the chiropractor.1

It is also observed that the cumulative effects of constant athletic small stresses over a long duration can give rise to the same difficulties as severe sudden stress. Spinal injuries in sports constitute only about three percent of all athletic injuries. Thus, the chiropractor must be well prepared to manage the various musculoskeletal injuries that occur away from the spine.6

While conditioning is emphasized in athletics, the motivation is frequently on winning, rather than on prevention of injury. While this seems illogical, chiropractors handling athletic injuries must understand this if they are to properly evaluate and provide service. The development of cooperation between team physician, family physician and chiropractor helps to reduce the problem of conflicting opinions, often delivered to an already confused athlete. The typical family doctor has little knowledge of the practicalities involved in specialized sports injury management, and should accept logical procedures and recommendations when explained by the chiropractor.1

The chiropractic approach toward athletic injuries has demonstrated that everyone is better served by having the injured player promptly and ably treated, thereby obtaining recovery before irreparable damage is done. The chiropractor must become not only the doer, but also the teacher. The chiropractor with a special interest in athletes must be prepared to handle their injuries, and must in turn pass this information on to other physicians. It must be recognized that in the management of athletic injuries, the patient must get complete recovery, or he or she is no longer an athlete. The following concepts (the "Five A's")7 utilizing chiropractic treatment have proved to be of great value:

  1. Accept athletics. The chiropractor -- not the player, not the coach, not the parents, but the chiropractor -- must recognize the value of competitive athletics; that it is vital to the patient to be restored to competitive athletics. If the chiropractor fails in this, the patient-doctor relationship suffers and rapport is lost. The chiropractor who depreciates the player's ambition should not be treating the athlete.
  2. Avoid expediency. Outside influence must not be permitted to outweigh sound chiropractic judgment. Many pressing factors will tend to influence the chiropractor's decision. All concerned are extremely unwilling to believe that the player is really hurt. The athlete's desire to compete, the fear of "failing" teammates, the parents' desire to see their child excel, the coach's hope that the player is not really hurt, all must be ignored if the proper conclusion is to be reached.
  3. Adopt the best method of treatment. Chiropractic evaluation of the nature and extent of injury must be the controlling factor in the choice of treatment. If you really believe that one method is distinctly better than another, you should recommend it and then carry it out. This must be an entirely objective decision.
  4. Act promptly. A definitive decision on the proper method of treatment must be made at the earliest possible moment, and then carried out. Delay has been conclusively shown to be the difference between success and failure of treatment.
  5. Achieve perfection. Make complete recovery the chiropractic goal. While this may not be possible in every case, it must always be the goal. The athlete is basically in good condition and can well tolerate any reasonable measure if it serves to increase the chances for a complete recovery.

Sports chiropractic and chiropractic rehabilitation have received a considerable amount of attention in recent years. Some of the reasons for the increased awareness and interest are the publicity afforded the injuries of professional athletes; the injuries resulting from the increased participation by individuals in physical fitness and recreational athletics; and the government's role in encouraging physical fitness through the president's Council on Physical Fitness and Sports.

Sports chiropractic and chiropractic rehabilitation have developed at a considerable pace over the last decade. As with other areas of chiropractic, where knowledge and understanding are rapidly expanding, it is necessary for the chiropractor to first be given an adequate basic preparation, and then be reminded of the necessity to keep abreast of the latest developments and advances. Thus, appropriate and timely rehabilitation protocols are essential.


  1. Schafer RC. Chiropractic Management of Sports and Recreational Injuries. Baltimore: Williams & Wilkins, 1982.
  2. Muckle DS. Injuries in Sport. Chicago: Year Book Medical Publishers, Inc., 1978.
  3. Roy S, Irvin R. Sports Medicine Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983.
  4. Garrick JG, Requa RK. Injuries in high school sports. Pediatrics 1978; 61:465-469.
  5. Mirkin G, Hoffman M. The Sports Medicine Book. Boston: Little, Brown and Company, 1978.
  6. White AA, Panjabi MM. Clinical Biomechanics of the Spine. Philadelphia: J.B. Lippincott Company, 1978.
  7. O'Donoghue DH. Treatment of Injures to Athletes (3rd ed.). Philadelphia: W.B. Saunders, 1976.

Kim D. Christensen, DC, DACRB, CCSP