Re: Torn MCL But No Pain -- Worrisome tibiofemoral gapping, 3 wks post-injury...

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Re: Torn MCL But No Pain -- Worrisome tibiofemoral gapping, 3 wks post-injury...

Posted By: Michael Frind
Date: Saturday, 30 January 2010, at 3:05 a.m.

In Response To: Torn MCL But No Pain... WHY? (Sandradee)

Dear Sandra,
With an avulsion-type fracture, basically what happens is that the ligament is torn off from the bone, alone with a small sliver of bone. It is possible to tear off a ligament in such a way that the nerve endings die off, thus enabling the initial pain of the injury to subside rather rapidly. (I note that this phenomenon is very common with ACL tears [both the more common midsubstance-type tears and the less-common avulsion-type tear-offs], which result in explosive pain in the knee that vanishes quite quickly. Incidentally, avulsion-type injuries can also occur with tendons...just like midsubstance tears can also occur here.)
With MCL tears (midsubstance-type tears, which I realize is not what you have but which provides a useful reference point for discussion), the standard rehabilitation entails protecting the knee from sideways (inwards-type) forcing, generally through the use of a hinged brace. Physiotherapy and range-of-motion exercises are prescribed as well. The goal is to let the MCL scar over and heal on its own. (The MCL is unique among the four main knee ligaments in its ability to self-heal. This is due to the fact that this ligament is surrounded by the joint-capsule tissue.)
In cases where the MCL is so badly torn that it cannot self-heal, then surgical repair is usually recommended.
With avulsion-type ligament tear-offs, such as what you have, the rehabilitation would also involve giving the injured ligament time to self-heal. In this case, the self-healing would entail having the avulsed bone fragment regrow onto the bone. To ensure that the avulsed fragment has the best opportunity to heal onto its bone site, the knee must be protected against sideways forcing. A rigid brace, with hinged uprights on each side of the knee, would be ideal here.
Of course, how well the avulsed fragment can regrow onto its home location is influenced by the severity of the original injury. Given that your injury occurred during snowboarding, and given that snowboarding is a high-energy sport, it is possible that the injury is at the more severe end of the spectrum.
Kinetic energy, the energy of motion, is the single most important determinant of injury severity. Kinetic energy increases with the square of speed. So, a snowboarding accident occurring while you are moving at 30 miles per hour would be nine times as severe as one occurring at 10 miles per hour. Considering that competitive downhill skiers routinely race at speeds in excess of 60 miles per hour, it is conceivable that a snowboarder could easily reach speeds of over 30 miles per hour. This is why your injury should not be taken lightly.
From your description, is seems that no brace was ever provided to you. Although the avulsed fragment could have made good progress in healing onto the bone by 3 weeks post-injury, the fact that your physiotherapist notes gapping (between the medial femoral condyle and the tibial plateau) when the knee is forced inwards indicates that satisfactory healing has not occurred. Another possible explanation is that the MCL itself has stretched out or incurred tearing-type damage just prior to the avulsion.
I think it behooves you to see a knee-experienced orthopedist as soon as possible. The longer your knee is left without a functional MCL, the greater the risk of injury to the ACL, PCL, and also the menisci. In the meantime, wearing a good-quality functional knee brace (a rigid frame, either off-the-shelf or custom-made, with hinged uprights on each side of the knee) would not be a bad idea.
Please note that the fact that you do not currently feel pain does not mean that the knee is ready to return to knee-demanding sports. I recommend staying away from skiing and snowboarding until the gapping problem has been addressed, and until an orthopedist has declared the knee ready for return to knee-demanding sports.
Yours truly,
Michael Frind.
Knee Library http://factotem.org/library

Messages In This Thread

Torn MCL But No Pain... WHY? (views: 101) -- Sandradee -- Thursday, 28 January 2010, at 7:09 p.m.
- Re: Torn MCL But No Pain -- Worrisome tibiofemoral gapping, 3 wks post-injury... (views: 132) -- Michael Frind -- Saturday, 30 January 2010, at 3:05 a.m.

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Message: > Dear Sandra, > With an avulsion-type fracture, basically what happens is > that the ligament is torn off from the bone, alone with a > small sliver of bone. It is possible to tear off a ligament > in such a way that the nerve endings die off, thus enabling > the initial pain of the injury to subside rather rapidly. > (I note that this phenomenon is very common with ACL tears > [both the more common midsubstance-type tears and the > less-common avulsion-type tear-offs], which result in > explosive pain in the knee that vanishes quite quickly. > Incidentally, avulsion-type injuries can also occur with > tendons...just like midsubstance tears can also occur > here.) > With MCL tears (midsubstance-type tears, which I realize is > not what you have but which provides a useful reference > point for discussion), the standard rehabilitation entails > protecting the knee from sideways (inwards-type) forcing, > generally through the use of a hinged brace. Physiotherapy > and range-of-motion exercises are prescribed as well. The > goal is to let the MCL scar over and heal on its own. (The > MCL is unique among the four main knee ligaments in its > ability to self-heal. This is due to the fact that this > ligament is surrounded by the joint-capsule tissue.) > In cases where the MCL is so badly torn that it cannot > self-heal, then surgical repair is usually recommended. > With avulsion-type ligament tear-offs, such as what you > have, the rehabilitation would also involve giving the > injured ligament time to self-heal. In this case, the > self-healing would entail having the avulsed bone fragment > regrow onto the bone. To ensure that the avulsed fragment > has the best opportunity to heal onto its bone site, the > knee must be protected against sideways forcing. A rigid > brace, with hinged uprights on each side of the knee, would > be ideal here. > Of course, how well the avulsed fragment can regrow onto > its home location is influenced by the severity of the > original injury. Given that your injury occurred during > snowboarding, and given that snowboarding is a high-energy > sport, it is possible that the injury is at the more severe > end of the spectrum. > Kinetic energy, the energy of motion, is the single most > important determinant of injury severity. Kinetic energy > increases with the square of speed. So, a snowboarding > accident occurring while you are moving at 30 miles per > hour would be nine times as severe as one occurring at 10 > miles per hour. Considering that competitive downhill > skiers routinely race at speeds in excess of 60 miles per > hour, it is conceivable that a snowboarder could easily > reach speeds of over 30 miles per hour. This is why your > injury should not be taken lightly. > From your description, is seems that no brace was ever > provided to you. Although the avulsed fragment could have > made good progress in healing onto the bone by 3 weeks > post-injury, the fact that your physiotherapist notes > gapping (between the medial femoral condyle and the tibial > plateau) when the knee is forced inwards indicates that > satisfactory healing has not occurred. Another possible > explanation is that the MCL itself has stretched out or > incurred tearing-type damage just prior to the avulsion. > I think it behooves you to see a knee-experienced > orthopedist as soon as possible. The longer your knee is > left without a functional MCL, the greater the risk of > injury to the ACL, PCL, and also the menisci. In the > meantime, wearing a good-quality functional knee brace (a > rigid frame, either off-the-shelf or custom-made, with > hinged uprights on each side of the knee) would not be a > bad idea. > Please note that the fact that you do not currently feel > pain does not mean that the knee is ready to return to > knee-demanding sports. I recommend staying away from skiing > and snowboarding until the gapping problem has been > addressed, and until an orthopedist has declared the knee > ready for return to knee-demanding sports. > Yours truly, > Michael Frind. > Knee Library http://factotem.org/library
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