NFL Injury Series- Meniscus Tear

Read up on what the meniscus is, how it is injured, indications for surgery, and recovery times.

Today on Banged Up Bills, we will detail the ever common meniscus tear. This post will identify what the meniscus is, it’s function, and the severity of a tear which could affect whether a player misses weeks or the season. This is an injury that we have seen in past seasons and will continue to see.

Last season, we saw TE Charles Clay and WR Kelvin Benjamin both tear their meniscus during different points of the season with varying availability following the injury. Clay missed 3 games while Benjamin missed 2. Clay required surgery to fix his issue immediately while Benjamin was able to tough it out the rest of the season with eventual surgery. There are many reasons why there are differences in meniscus tear management despite the same outcomes.

To understand proper management of the meniscus after injury, the structure must be understood. The meniscus is two concave structures that are c-shaped and lie over the tibia in each knee. The meniscus is comprised of a medial and lateral meniscus and act as shock absorbers during activity. These meniscus also help deepen the joint so that the femur can articulate with the tibia, providing stability. During meniscus tears, a rotational force is applied to the area while the knee is bent and causes a shearing motion, causing a portion of the meniscus to tear.

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Credit: physio-pedia.com

There are various types of tears which include but are not limited to: complete or partial, horizontal or vertical, longitudinal or transverse. Acute tears are more likely to present as longitudinal/bucket handle and radial tears most likely seen in football players. Symptoms of a meniscal tear typically consist of pain, tenderness, and swelling, locking or clicking during knee movement, and initially difficulty in placing weight through the knee. Meniscal tears are typically seen in conjunction with MCL sprains/tears and ACL tears due to the rotational forces through the knee during impact.

Overall, these types of injuries can slow up a player but not entirely derail their season. Several tests to identify meniscal tears include Apley’s, McMurray’s, joint line tenderness, and Thessaly’s test all assist in identifying whether a meniscal tear is present. However, these tests are not always reliable or specific which means they may identify pain and restrictions but will not be able to identify type or severity of tear. These tests replicate the mechanism that would cause the meniscal tear. This typically warrants further imaging such as MRI to identify specific lesions which will determine the appropriate interventions.

Once a tear has been identified, the type of tear can affect healing rates: longitudinal tears heal better than radial; simple tears heal better than complex; traumatic and acute tears heal better than degenerative. Based on location and length of tear will determine proper management. The meniscus has several “zones of vascularity” which include: red-red zone, red-white zone, and white-white zone. The red-red zone has the highest blood supply and lie on the outermost portion of the meniscus. The red-white zone is the area that connects the red-red and white-white zone and contains some blood supply. The white-white zone has a poor blood supply and demonstrate the poorest area for healing. If the tear is small, conservative management or a meniscectomy may be performed to remove to remove the offending piece. If the tear is larger, then a suture repair of the meniscus is warranted and an extended rehab is required.

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Credit: physio-pedia.com

Regardless of whether surgery is required, rehab typically consists of restoring range of motion, controlling swelling/pain, and restoring strength to the knee. Once the immediate objectives are met, then further increasing strength and return to play activities are initiated to ensure that the athlete can play at their full abilities. In the event of WR Kelvin Benjamin, he was able to play through his minor tear due to effective rehab and an understanding of the type of tear which most likely allowed him to rest, recover, and eventually return to full participation knowing the tear was stable enough to play through. In the event of TE Charles Clay, his tear may have been blocking motion and been more severe, warranting surgery to remove the offending piece before rehab could begin.

In the option that surgery is performed during the season, recovery times for a meniscectomy can last anywhere from 2-6 weeks or even longer based on the severity of the tear and corresponding damage. In the event of a major tear, surgery is indicated and recovery time can last for up to 3 months which could end a season for most players depending on the time in the season it was torn. The preferred method years ago used to be cut out the offending piece. However, surgeons later found out that each time they cut a piece out, it accelerated arthritic changes in the knee which reduced healing and the ability for players to return to full health for a prolonged career. They have also found recently that surgeries do no better than rehab alone when compared to long term results in the normal population. However, surgery is still recommended when a return to sport is necessary and will quicken the recovery in dealing with the NFL.

Meniscal injuries are still concerning but can still allow a player to play through the injury despite requiring further interventions in the future. If a player sustains a meniscus injury, they will miss some time but can return to play later in the season with favorable results after testing and a positive response to rehab. Despite returning to play, there are still instances where players will not be 100% and their production will noticeably decrease. Overall, a concerning but not season ending injury.

Continue to check back regarding further updates and injuries throughout the season. Follow on Twitter @BangedUpBills, Facebook at Banged Up Bills, on Reddit at u/BangedUpBills and http://www.bangedupbills.com. As always, thank you for reading and GO BILLS!

Kelvin Benjamin’s Meniscus Tear

Detailing Kelvin Benjamin’s knee injury, causes and types of meniscus tears, and expectations for the rest of the season.

Big news coming out of One Bills Drive today! It has been reported that WR Kelvin Benjamin suffered a meniscus tear during the 1st quarter of the disastrous Chargers game last week and will be out multiple weeks per reports. Benjamin was unable to return following the hit and had already had ligament damage ruled out via MRI. This is another blow to the WR corps that has been inconsistent this season due to the inability of Tyrod Taylor to move the ball effectively, opting for check-down passes to his RB’s. Today’s post will analyze Benjamin why suffered a meniscus tear, types of meniscus tears, and expectations for the rest of the season.

The meniscus lies over the tibia and acts as a shock absorber between the tibia and femur. It is made up two wedge shaped areas to assist in deepening the area that the femur articulates with the tibia. During meniscus tears, a rotational force is applied to the area while the knee is bent and causes a shearing motion, causing a portion of the meniscus to tear.

Types_of_meniscal_tears.jpg
Credit: physio-pedia.com

There are various types of tears which include but are not limited to: complete or partial, horizontal or vertical, longitudinal or transverse. Acute tears are more likely to present as longitudinal/bucket handle and radial tears. It is very hard to determine the type of meniscal tear that occurred, but may be a longitudinal/bucket handle tear upon video review. The knee was hit from the front and partially to the outside, causing hyperextension to his knee. As mentioned above, a rotational force or bent knee is far more likely to cause the tear. In Kelvin Benjamin’s case, a hyperextended knee caused the tear, but is usually less likely.

Symptoms of a meniscal tear typically consist of pain, tenderness, and swelling, locking or clicking during knee movement, and initially difficulty in placing weight through the knee. Meniscal tears are typically seen in conjunction with MCL sprains/tears and ACL tears due to the rotational forces through the knee during impact. Thankfully, Benjamin’s injury was isolated to only the meniscus and did not affect other structures.

Meniscus-blood-supply-zones.jpg
Credit: physio-pedia.com

The type of tear can affect healing rates: longitudinal tears heal better than radial; simple tears heal better than complex; traumatic and acute tears heal better than degenerative. Based on location and length of tear will determine management. The meniscus has several “zones of vascularity” which include: red-red zone, red-white zone, and white-white zone. The red-red zone has the highest blood supply and lie on the outermost portion of the meniscus. The red-white zone is the area that connects the red-red and white-white zone and contains some blood supply. The white-white zone has a poor blood supply and demonstrate the poorest area for healing. If the tear is small, conservative management or a meniscectomy may be performed to remove to remove the offending piece. If the tear is larger, then a suture repair of the meniscus is warranted and an extended rehab is required. As Benjamin is slated to miss weeks, this appears to be a minor tear and could come back this season.

I’m sure most people’s thoughts are why WR Zay Jones did not sustain the same injury that Benjamin did? Why Benjamin tore a portion of his meniscus and not WR Zay Jones against the Jets game is certainly confusing. My thought is that Jones got tripped , attempted to regain his footing, and merely fell; Benjamin got hit while his foot was planted causing more of a shearing motion, causing the tear. Whether Benjamin has surgery or not, he will be out several weeks. How long Benjamin is out is unknown at this time, but I foresee him missing most likely a month. Could he come back sooner such as 2-3 weeks? Possibly but highly unlikely pending the location of the tear. He could attempt to rehab without surgery which does show good results compared to surgical intervention but this is the NFL and time is a premium. If he were to be out a month, he could return by the 1st Dolphins or 2nd Patriots game if there is still playoff hope if his recovery went incredibly well.

Finally, Benjamin did suffer a knee injury earlier this season with the Panthers but I do not believe that he was traded to the Bills with a torn meniscus. His play would have been greatly affected and team doctor’s would have caught that. Add in the fact that the knee he hurt this season was on the other side and that was his surgically repaired ACL. There is also delays in reporting of the injury due to the fact that additional imaging is sometimes required along with a clinical evaluation and testing once swelling has reduced. Most likely, the team was waiting to see if the knee would resolve on its own or whether anything would present itself after several day.

The approach should be to rehab him with the hopes that the Bills are still in the hunt. If they fall out of contention, shut him down for the year. Even with the best rehab and doctors, his body still needs to heal and return to playing form. While QB Tyrod Taylor has not built up the rapport that he has with other receivers, it is still a starting caliber receiver that is not able to contribute.

Continue to check back regarding further updates and injuries following the Bills game. Follow me on Twitter at @kyletrimble88 for the latest updates and news. As always, thank you for reading and GO BILLS!

Charles Clay Clunky Knee

Reviewing Week 5 loss against the Bengals and impact of Charles Clay knee injury including long term outlook.

The Bills, well, the Bills lost. They lost a very winnable game by a score of 20-16 in Cincinnati. The offense never got going, the run game doesn’t look anything like it has the past 2 seasons, and this Bills team continues to make this fan base crazy. That’s the nice, politically correct way of saying that. Two years from now, this will be a game that won’t be marked as a trap game, the kind of game that is an expected win. However, we all have to “Trust the Process” and trust I will!

Sunday was one of those games that while the depth that has been lacking in past seasons was there, the talent and cohesiveness was not. The team continues to stay relatively healthy, not losing anyone to season ending injuries. Notable injuries to the Bills are CB Leonard Johnson who left with a hamstring injury in the first half and did not return. However, the focus of today’s article is TE Charles Clay’s left knee injury sustained after catching a pass and getting hit in the knee going out of bounds towards the end of the first quarter. This resulted in Clay ending his day early and getting carted off the field.

Anytime someone sees an elite player go down with a knee or leg injury, they automatically think ACL tear. Why do we think that? Because the ACL is the sexy injury that the media loves to talk about. Everyone knows its serious, everyone knows its season ending, and it’s all over the news constantly. As you begin to hyperventilate or start cursing the Bills, R-E-L-A-X. Clay did get injured, it didn’t look pretty, and the results aren’t great. If you care to continue reading, I will help you step back from the edge and explain what really happened.

Based on reports, Charles Clay sprained his MCL, tore his meniscus, and will be out for an extended time with surgery to fix the meniscus. Most people know that if the ACL is bad, then the MCL must be bad as well. It is but it isn’t. The knee is comprised of many different structures including but not limited to: bones of the knee: femur, tibia, patella; ligaments including: medial collateral ligament, anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament; soft tissue includes cartilage and medial/lateral meniscus.

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Credit: webmd.com

The MCL runs on the inside portion of the knee connecting the femur to the tibia. The MCL allows for stabilization medially and along with the LCL, prevents the knee from going east/west and ensures that knee works as a hinge joint. When the MCL is sprained, the ligament is stretched and partially torn as with any other sprain. However, the MCL is more dynamic in that it connects into several muscles in the knee including the vastus medialis, sartorius, semimembranosus, semitendiosus, and gracillis. The MCL also attacks to the posteromedial portion of the medial meniscus. To simplify it, at various points, the MCL connects to parts of the quadriceps, hamstrings, adductor muscles, and part of the meniscus. Without these many connections, the knee would be far less stable and would not be able to change direction suddenly.

Despite a fantastic design by nature, design only allows for so much prevention. The MCL typically gets injured during sudden changes in movement such as cutting and pivoting. The MCL also becomes damaged during direct blows to the outside part of the knee during knee flexion, which is what occurred with Clay when a low tackle hit him out of bounds.

The MCL severity grades are broken down into 3 grades with the increasing grade indicate level of severity. Level 1 consists of some fibers torn with tenderness and no instability. There is some pain during application of force to the outside of the bent knee, but nothing else significant.

Grade 2 consists of increased pain and more noted swelling. There is moderate tenderness and laxity in the joint. Most of the pain is on the inside of the knee and patients typically poorly tolerate laxity testing to the MCL. There are varying degrees of a grade 2 sprain including 2- and 2+ depending on amount of damage.

Grade 3 is a complete rupture of the MCL, leading to instability along with extreme pain and swelling, resulting in difficulty with bending the knee. The knee also gives away during a valgus force which is when pressure is applied to the outside of the knee. Surgery is usually indicated as the ligament has been totally torn from the bone.

Credit: http://kingbrand.com/MCL-Injury-Information.php

Based on video of the play and difficulty with placing weight through the leg afterward, this indicates that he may have suffered a partial tear, possibly a Grade 2+. This is supported by the fact that he did not have surgery to repair the MCL itself.

To add insult to injury, Clay also tore his lateral meniscus. The meniscus acts as the shock absorber in the knee and helps with keeping the knee healthy during movement. Unfortunately, part of the lateral meniscus became torn during the hit. This likely occurred due to the direct blow along with the knee bent and planted on the ground, leading to twisting of the knee, resulting in a partial tear. Presentation of a partial tear involves pain, catching, and clicking during knee movement. While research has been proven that a nonsurgical approach can be just as effective as surgery to trim down the meniscus, this is the NFL and there is no wait and see approach. The procedure that Clay had today is called a meniscectomy which involved cutting out the frayed piece of meniscus and shaving down the area to smooth it over to ensure that more pieces do not fray off.

Reports indicate that Clay will be out at least a month, possibly indefinitely. I believe that he will be out closer to 6-8 weeks. The meniscus is something that could keep him out 2-3 weeks; the problem is the MCL. The body will need to heal and restore proper range of motion to the knee while regaining strength. There are therapeutic interventions that can encourage healing, but the body still has to do its job. Professionally, I would say place him on IR with designation to return. This gives him a guaranteed 8 weeks to heal up and return to full form. This would also allow the team to bring in another TE and not use up a valuable roster spot. This would place him on track for the Colts game in December. Considering the Bills have two games against Miami and one against New England after that, it would be an excellent time to come back healthy.

My final thoughts on Clay is that he has had several years of reported knee issues, of which I wrote about during the preseason. From observation during practice, I believe he had most of the issues on the left knee, of which he injured Sunday. However, this injury is independent from his previous issues. He was not at a higher risk for this injury as the result of the previous problems. If anything, this may help take care of the other issues by giving him time to rest.

The Bills are certainly hurting from this one. Clay has been a consistent producer and a favorite target of Tyrod Taylor. Clay should be back later this season, but whether his return will make a difference remains to be seen. I still believe that this season we have more depth than in previous years, but having depth just is not the same as the starters. That was evident in the secondary and linebackers on Sunday. Thankfully, the bye week could have not come at a better time. I still believe the Bills have a shot to stay competitive this season with how the rest of the AFC is playing this season. The Bills still control their destiny, Charles Clay injury will not define the season.

Continue to check back for further updates regarding new injuries and posts designed to educate my fellow Bills fans and keep you from the edge. Thank you and GO BILLS!!