THE TERRIBLE TRIAD

Of all the possible traumatic injuries, there is one that is a four star pain in the knee. A player whose foot is planted receives a blow to the outside of the joint, forcing the large bones inward. This puts an extraordinary amount of pressure on internal structures and may stretch or tear the meniscus when it is crushed between the bones; the anterior cruciate ligament may also give way, and the medical collateral ligament also stretches or tears. This orthopedic nightmare is called “the tenible triad.”

Treatment

Due to the magnitude of the injury, 90 percent of the time this means surgery, and generally not a simple arthroscopic procedure but a combination of open and arthroscopic surgery. Recovery for ligamentous injuries in general ranges from nine to eighteen months and in the case mentioned above we’re probably talking about the high end of that range. Someone who has suffered the terrible triad has actually suffered two traumas: an injury trauma and a surgical trauma. It is big surgery to put it all back together. A lot of tissue must be cut through to work on the areas affected. All of that has to heal while the person undergoes all types of muscular rehabilitation.

The prognosis is pretty good, however. ln my experience 85 percent of all patients report good or excellent results postoperaiively. Only 5 percent report fair results, and 10 percent say their condition is unsatisfactory.

FRACTURES

There are two types of fractures affecting athletes: traumatic and stress. Major trauma, such as a fall down a flight of stairs or a car accident, often causes a fracture. One traumatic blow in sports, which could be the indelicate landing of a 250-pound tackle or a knee dive into the floor, is all it takes to cause a fracture.

A sheer force crashing into the kneecap can knock a piece of bone off of the patella or the patella track. A direct blow can crack or damage the kneecap’s surface or it can force the patella back into its groove and fracture the backside of the patella.

The other type of fracture, a stress fracture, may comprise as much as 10 percent of all sports injuries and up to 16 percent of all injuries to runners. A stress fracture is the result of repeated stress from excessive motion or impact shock. The result is a series of microscopic cracks that, over time, become larger and larger until eventually symptoms develop. Because the symptoms are similar to a number of other conditions, the first diagnosis is often wrong. The most common misdiagnosis is probably tendinitis, with bursitis and “runner’s knee” also getting a share of blame. If your knee doesn’t respond to therapy within a couple of weeks, a physician will usually become suspicious and order further tests, hoping to find evidence of a stress fracture. Thus, stress fractures are often a diagnosis of exclusion, which means the examining physician first figures out what is not causing the pain and then proceeds toward a diagnosis of stress fracture.

Don’t be too hard on your doctor if he or she first misses a stress fracture. Besides the fact that the symptoms echo a number of other complaints, another confounder is that symptoms may pre-L cede X-ray evidence by up to three months and, in a significant number of stress fractures, there may never be positive X-ray evidence at all. Fortunately, conventional X rays may be supplemented by a bone scan (radionuclide bone scintigraphy) if there is a high suspicion of stress fracture. This has shown to be a very sensitive diagnostic tool, capable of detecting stress fractures within seventy-two hours of onset of pain. A few facilities are also beginning to use magnetic resonance imaging for stress fracture detection.

Symptoms

Bone pain is the primary symptom of fractures. The pain begins mildly and gradually worsens. The longer the stress fracture continues to be stressed and goes untreated, the more severe the pain becomes. Localized tenderness and swelling, as well as pain related to activity, are also common, but again these are hardly specific complaints.

Treatment

For traumatic fractures, the first step of all treatment is to recognize the fracture. lt’s important that fractures be treated within the first week in order to avoid further injury and to guide healing. Sometimes treatment is limited to immobilization (usually a brace or a cast), rest, and protection. For complicated fractures, surgery may be necessary to do internal repair with pins, wires, screws, and plates in order to hold everything in place during healing. The patient often retums quickly to day-to-day activities, but recreational activities are severely limited during recovery. Cycling, swimming, and running in water are sometimes permitted as alter-
native activities to maintain fitness. Stretching and flexibility exercises are emphasized, as well as local muscle strengthening, stretching, and retraining.

Once an individual has been pain-free for ten to fourteen days, there is a gradual reintroduction to sports.
Perhaps the single most important factor in avoiding stress fracture reinjury is a schedule of alternate-day activity. ln other words, if you’ re a runner, your best bet for avoiding stress fractures might be to alternate running with bicycling, or just take a day off between runs. One study reported in Military Medicine (147:285-87, 1982), found that such a recovery period during training cut the stress fracture rate in military recruits by one third. , The average time to recovery for traumatic fractures is ten to thirteen weeks. For stress fractures, four to ten weeks is generally required.