All posts by David Ring

All Blogs, Elbow, Football

Landon Collins Forearm Fracture

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New York Giants Safety and Linebacker Landon Collins broke his forearm on December 24, 2017 and had open reduction and internal fixation with plates and screws. He will undergo a second surgery on April 23, 2018 because, by report, one or both of the bones is not healing as expected.
It’s relatively unusual for a fracture of the diaphyseal radius or ulna not to heal after plate and screw fixation. Often there is a technical shortcoming (plate too short or too small), infection, or relatively severe soft-tissue injury and decreased blood supply to the bones (see: https://www.ncbi.nlm.nih.gov/pubmed/15523016 ).
X-Rays are used to see if the plate and screws are loose or broken and if bone has crossed the fracture line. When the implants loosen or break, the need for more surgery is clear. Sometimes doctors get concerned about what seems to be a persistent fracture line and offer patients a second surgery before the plates loosen or break, but that is a debatable approach.
The surgery will likely place a new plate and screws and apply some bone taken from another part of the body in order to stimulate healing.
In most cases, forearm bone fractures need about six months of healing in order to play contact sports with a reasonable level of risk.

This article was made by Paul Bonilla and David Ring

All Blogs, Hockey, Knee

Sean Couturier Torn MCL

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Sean Couturier, center of the Philadelphia Flyers, was diagnosed with a torn MCL of his right knee after a collision with a teammate in practice on April 17th. He missed game 4 of the playoff series. With game 5 approaching and the Flyers down 3-1 in the series, Couturier played with his injury and even scored the game winner on April 20th. The injury did not seem to affect his play, a testament to his resiliency and adaptiveness. He continued to play in game 6 April 22nd, but Philadelphia lost to Pittsburgh and was knocked out of the Stanley Cup playoffs.
MCL stands for the medial collateral ligament in the knee. This ligament connects the top of the tibia (shinbone) to the bottom of the femur (thigh bone). It runs over the knee along the inside of the leg. This ligament stabilizes the knee joint under valgus stress (attempts to bend the knee outwards). This injury is common in sports and is usually caused by a direct blow to the outside of the knee, which stretches or tears the MCL. The injury results in pain and swelling, and—with severe tears–instability of the knee.
This type of injury can be detected on physical examination. X-rays and MRI’s can be used selectively to rule out fracture and anterior cruciate ligament injury. Most people would not have an MRI for an MCL sprain. Professional athletes may have an MRI to rule out other problems because return to play is safe with mild to moderate MCL sprains.
After the loss and exit of the team from the playoffs, Couturier informed reporters his injury would not benefit from surgery, but that if he were injured mid-season he probably would have stayed out of play for 4 weeks. He accepted the discomfort and some risk for additional damage (for example to the anterior cruciate ligament) if the knee were to be injured again. The MCL injury potentially increases the vulnerability of the knee. It’s important to understand that return to play is always a matter of accepting some risk and discomfort.

This article was made by Alexa Ryder and David Ring

All Blogs, Baseball, Shoulder

Tommy Kahnle’s Bicep/Shoulder Tendonitis

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Tommy Kahnle—one of the New York Yankees’ most reliable relief pitchers last year—is going on the disabled list. His performance was poor early in the season, which he ascribed to lost velocity in his fastball. While shoulder pain was never mentioned, a recent news report describes MRI findings of “biceps and shoulder tendinitis”.

The biceps anchors in two places in the shoulder. One of the anchor tendons passes right through the joint. Changes in this part of the biceps tendon are expected with age. They accompany the expected age-related changes in the small muscles that rotate the shoulder. The tendons (parts that the muscles use to move the bones) of those small muscles are flat and thin and cover (or cuff) the head (the ball) of the shoulder joint. After age 40, we all develop rotator cuff tendinopathy. There is thinning of the tendons and defects may develop. Genetic factors likely affect how quickly this advances.

Throwing athletes get tendinopathy at a younger age and in a slightly different form. Studies of professional baseball pitchers with no symptoms often find MRI changes in the biceps and rotator cuff tendons (https://www.ncbi.nlm.nih.gov/pubmed/12975193). That makes it difficult to be sure when an MRI finding is causing symptoms and when it is just an incidental finding.

It’s not clear if the doctors treating Tommy found something more than the typical changes on MRI. And it’s not clear how they have decided that Tommy’s symptoms are likely related to the findings. Periods of rest and a routine of shoulder strengthening exercises are often tried to calm the symptoms and increase throwing effectiveness.

This article was made by Paul Bonilla and David Ring