Week 6 Injuries: Why we don’t always “KNEED” an MRI

October 13, 2014

Week 6 yielded some big KNEE injuries to players that I’m sure are at least active in your fantasy league, if not starting.  Darren Sproles went down with a MCL sprain, Stevan Ridley has a ACL/MCL tear, and Victor Cruz suffered a patella tendon rupture.  

victor cruz modeling
Victor Cruz may have some more time to advance his modeling career while out with a torn patella tendon

The Science

Instead of going through each injury as per usual, I think this would be a good opportunity to show you how we can diagnose a knee injury in less than 5 minutes, and usually come to the same conclusion that the ever so expensive MRI will give a day or two later.

As you may have seen on Sunday, when these player go down the medical staff comes running out to tend to the player.  Typically with a knee injury, the diagnoses for the player is known within the time that the player goes down and the time that the game returns from commercial.  Here is generally what happens during a knee assessment:

Step 1: Ask  and Look.   (30 seconds)

Ask what happen, what did you feel, where does it hurt? Look at the area.  Hopefully the team Doctor or Trainer sees the injury, which can give good insight to what structures may be injured.  In the cases where the injury is not seen, knowing which direction the knee went, where it was hit, and where the pain is, can fill in the blanks.  While the player is talking, examining the knee with your eyes may show some obvious deformities that will guide or sometimes conclude the examination.

Step 2: Check Movements  and Palpate (Feel) for deformities (1 -2 minutes)

By the time you finish step 1, you may have some idea of what may be going on, and now its time to move the knee.  First. the player will move the knee and then you will move the knee for them.  Because the knee-joint is a simple hinge joint, there are 2 major movements to assess–flexion and extension (bending and straightening).  Although simple, there is valuable information in simply assessing whether a player can bend and straighten the knee, and where the pain is during these movements.  A third movement that the examiner may need to assess is patellar (knee cap) mobility, which can also provide valuable information.

In the case of Victor Cruz of the New York Giants and fantasy teams everywhere, this was likely the end of the evaluation.  Most examiners would suspect a patella tendon rupture during step 1 as it was obvious where Cruz was grabbing and his reaction to the pain, indicated something serious.  The Patella tendon is directly below the knee cap and it connects the knee cap to the lower leg bone (tibia) which allows us to straighten our leg.  With a rupture, there is a good chance that with your eyes you can see that the knee cap is higher (closer to the hip) than usual which indicates that the tendon is torn.  If this is not visually evident, then feeling the patella tendon area and moving the knee cap should be the only additional info needed to diagnose this. Unfortunately, this injury means surgery and 4-6 months out for Cruz.  Although this is a serious injury, the return to full strength and speed is expected in most cases.

patella tendon rupture
This shows how far up the patella may rise after a patella tendon rupture

Step 3: Check ligaments and structures (1-2 min)

In many cases in which there is not an obvious injury, this is where players have to cross their fingers.  Sometimes players think they hear pops or feel their knee twisted or turned too much, and many fear the most notorious 3 letters in the alphabet for an athlete–A C L.  The Anterior Cruciate Ligament (ACL) is known to take players out for at least a full season and most return from the injury needing some time to re-tune their bodies.  For most players, this injury means a full season of being out with additional time of  being less than their normal selves.

The ACL is only one of the ligaments we test during this step.  The examiner can use a variety of test but some of the more basic test are as follows:

Valgus stress test-checks for medial (inner) instability with a primary focus on the Medial Collateral Ligament (MCL)

Varus stress test-checks for lateral (outer) instability with a primary focus on the Lateral Collateral Ligament (LCL)

Anterior Drawer Test-checks for anterior (forward) instability with a primary focus on the Anterior Cruciate Ligament (ACL)

Posterior Drawer Test-checks for posterior instability with a primary focus on the Posterior Cruciate Ligament (PCL)

In the case of both Darren Sproles and Stevan Ridley, the examination would stop here.  For Sproles, the examiner should have felt some extra motion during the valgus stress test described above.  The extra movement indicates that the ligament has been overstretched and possibly torn, although Sproles was able to walk off and state that he thought he was “ok”.  Ridley was not as lucky.  It is likely that Ridley’s description of the injury in step 1 clued the examiner into what may be wrong as tearing your ACL and MCL is painful, and there was likely and audible pop as it happened.  In his case both the Anterior Drawer and the Valgus stress test would be positive for excess movement.   Unfortunately, the ACL is the death sentence for his season.  With a minimum of 6 months to recover, the ACL tear has earned its reputation.  

The remaining two non ligamentous structures that are important to check, especially if the above test yield no apparent injuries are the medial and lateral meniscus.  Meniscus injuries can be conservatively diagnosed in a variety of ways with the simplest way being to feel the joint lines. Both meniscus lay on their respective sides at the joint line.  The examiner can simply put pressure on the area of the meniscus and if this elicits pain, it typically indicates injury.  In the case of the knee being hit during the injury, this may be more difficult to assess as the entire knee may hurt from the trauma of the hit.  In this case, the examiner can use a Mc Murray test which can be adapted to test both meniscus separately.

This may look like a lot of information, but in real life the examiner is talking, feeling, testing, assessing fluidly.  With an experienced examiner, you can expect an accurate diagnoses right there on the spot.  The MRI simply confirms this assessment in most cases.  This is why reporters can give you information on the injury almost immediately or at least the MRI results are publicized.  See how many test you can identify the next time someone hurts their knee and try to appreciate the skill that it requires to assess an injury that could end a players year in mere minutes.

WARNING: The video below may put you to sleep but it is very informative in regard to the information I just shared.  Please watch when you are wide awake!


Fantasy Implications

For those owner who have Sproles, keep him.  I believe there is a chance he may not miss a game.  WIth the Eagles on a bye this week and his general appearance after the injury, I could see him playing in Arizona in week 8.  If he does not play, hopefully he is not your starter and you can simply wait a week.  I doubt that he will miss week 9, unless more information shows the injury to be more serious.  Despite the outlook for this injury, remember that Sproles was listed as one of our Running Backs running out of time http://theinjuryreportdoctor.com/2014/09/27/79/  and at best you can depend on him for spot duty for short periods of time.

As for those who have LeSean McCoy and believe this will boost his touches, I don’t think so.  Chip Kelly and his “Sports Science” approach controls a players touches to get optimal performance, and therefore Sproles being out likely means more touches for the next man up.  My guess is, you see Chris Polk and Josh Huff  take Sproles touches, but neither are viable fantasy options.

Victor Cruz owners may be able to snag Odell Beckham Jr., if available.  His stock should go way up with Cruz out and I think he has the chance to be a stud if his hamstring does not stand in the way.  As for Eli Manning, there may be a temporary adjustment period without his most consistent target; but if he can get comfortable with Beckham Jr. he may even see his numbers improve.

Stevan Ridley owners have probably been done a favor, as predicting what Belichick will do from game to game is nearly impossible.  Starting a New England Patriot player really does feel like playing roulette.  I guess this bumps Vereen’s value up a little, in theory.  Brandon Bolden is an option, but I would look elsewhere like in San Diego for Oliver or Tennessee for Sankey to find a new running back.

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