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Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and joining me today is Dr. Jonathan Aubry. He's a Sports Medicine Physician at Carle BroMenn in Bloomington, Illinois. And he's here to offer advice and tips on prevention, what's new in diagnosis and treatment and the parameters for return to play when we're dealing with athletic knee injuries. Dr. Aubry, it's a pleasure to have you join us today. What are some of the most common causes of knee injuries in athletes that you see? Discuss them for us.

Jonathan Aubry, MD (Guest): Hi, Melanie, great to be on board with you guys today. And so as a non-operative sports medicine physician, we see all kinds of knee injuries. And it's one of the more common things that come through the door. This morning, we had some folks just come on in that had hurt themselves over the weekend, but we see a lot of people that have when we were thinking of athletics, kind of a twisting type injury where they're unsure if there's been structural damage to their knee. And so that oftentimes there's an acute issue, whether it was you're playing basketball or any sport specifically. And then secondly, we also see some knee injuries that are more over timeframes. More so, maybe I've been training or I've been doing something specifically, and maybe this is bothering me a little bit more, I'm feeling some catching or clicking, popping something along those lines while I'm training. And so we kind of see the full gamut. And then lastly, we see some of the older folks with arthritis injuries, and we have to also play a factor into that the arthritis has played a factor, but that might be more of a chronic disease process. So I'll focus on, some of the acute things right away. And then we can talk about maybe some of the non acute things that have developing over time. And from my standpoint, we see people come in with twisting type injury.

Our big job is to triage, what do we need to do from this standpoint? If someone has a lot of swelling, we have to consider that, is there a fracture? Is there ligamentous damage or is there cartilage damage going on and weigh the risks and benefits of needing x-rays, MRIs, those types of things and try to work those up for the patients and make sure that we're protecting them at that point in time at the visit.

And so we're kind of steering the ship as far as making sure that they're not walking on something dangerous, such as a fracture. And then potentially some advanced imaging to see if something like their ACL, their anterior cruciate ligament, or some of the structures in the knee are stable or not. And so I would say ACL tears are the things that we see often and then meniscal injuries such as these C-shaped rings of cartilage that we have laterally and medially. Those are the big things we're trying to see and kind of rule out. Cause we don't want someone continuing to play sports and be active on those things without either surgical attention or just information regarding their care.

Host: Well, so, as long as we're talking about acute and not overuse or arthritis, as you said, the conditions and factors that lead, because we're going to be talking about prevention, obviously and you mentioned ACL and now it's soccer season and girls seem to have a higher prevalence of this than boys. Do we know why that is? Tell us a little bit about ACL injuries.

Dr. Aubry: Yes the studies have shown that there is a slight propensity to females having ACL injuries versus males, but it's quite common in both. I think from our standpoint, and this is little bit of my personal knowledge and seeing patients is that way the female knee and pelvis are set up, there's often a little bit of a valgus turn. So kind of some internal rotation of the knee. Just kind of the way pelvis is set up in a female. And I do find a lot of my athletes have some hip and core weakness that you don't necessarily think of with a knee injury. But I like make sure that when someone comes to my office, I'm evaluating not just their knee, but a lot of different things, especially if they're coming in for a preventative screen or they've had some issues and had some pain because the ACL is one of the tougher things we have conversations about. I'm family medicine trained. We used to have a lot of harder conversations about bad illness. But now I have ACL conversations that are really tough with patients because their seasons are over.

When we look at the way of a female set up. I just think that the way that their knee moves, can just set up more tragic and more traumatic knee injury. But in general, I don't have an answer as to why more females versus males in general, but, that would be my best advice. And so a lot of my females that are active, I really try to get them into some strengthening programs specifically for the hip and knee. And try to try to prevent some of that extra movement of the knee that can happen and lead to a worsening twisting event.

Host: Well, there certainly has been theories about just as you were saying, and then many different forms of exercise, plyometrics and lateral movements, things we're doing now to try and help strengthen up the knee joint as a whole for these athletes. Tell us a little bit about injury prevention. So, first of all, what would you like to tell other providers, coaches, parents listening about prevention of some of these knee injuries and the things that they can try. Some of those exercises that we're learning more and more that can help the knee.

Dr. Aubry: So my advice would be to really just try to have a good baseline fitness level before beginning a significant sport. Like we think of the soccers and the basketballs and all these things. So I think from a coach and a training standpoint, I'd want to make sure that these kids aren't just coming off the couch and now we're playing soccer or we're doing something else.

So to try to build up a baseline to prevent the injury going forward. And we actually have some programs here where we kind of do some screening of quadricep strength and try to isolate some athletes that made it a little bit of help, like before football season in general.

So my advice would honestly be to either talk to primary care or talk to one of us maybe before you're thinking of starting a sport or developing just a plan of going through a general knee strengthening program. We have some really good things in our office where it's not too exciting, but it's building up strength in your quad, hamstring, core, making sure that your lower extremity is loose and ready to have the force of a sports brought on it.

And so I think if the athletes were able to kind of go through a little bit of a program, build up a foundation before day one of intense practice, that would be ideal, but we all know children. And it's tough to get anybody to do anything a little bit extra in general. So that would be if the trainer is really on board and the coaches are on board and trying to prevent these sorts of injuries, that would probably be my number one program.

And then if there are significant deficits, if the training staff or whoever's looking at these folks are able to isolate something, maybe even getting them into physical therapy or a personal training sessions to try to really get them as strong as possible and make sure that their joints are ready for this. I have a lot of athletes that just really probably shouldn't have been on the field, from a strength standpoint. So we may have been able to prevent this and it's a tough injury, but I think, we're gaining more and more traction and more information.

And there's some studies out. I just was at a conference and we're looking into a little bit of the mental status of some of these athletes too. Like, were they quite ready to be on the field, all these things and we actually have some data with like post-concussive patients that they have higher rates of ACL tears and those types of things.

So it's physical, making sure that your body's ready, but mentally making sure too that you're not off a little bit. And then all of a sudden that leads to a traumatic knee injury that, you know, you're out for 6, 8, 10 months after a tough surgery.

Host: Well, sports psychology is in itself, a burgeoning field. And as we talk about what you do for knee injuries, ACL or arthritis, that sort of thing. There's always home things people want to try first. Can you tell us a little bit about wrapping, ice, heat, any of the things that you typically recommend to coaches and providers and parents and anybody else dealing with knee pain?

Dr. Aubry: So it kind of depends on you're at, particularly. If we're in the setting of an acute injury where we think there's internal derangement, then I typically have people get on some of the basic non-steroidal anti-inflammatories for five to seven days, ice, 15 minutes, two to three times a day. And then wrapping typically is more for a comfort level. When we're considering that there may be, information from an exam or from an MRI, showing that there could be some instability, I will provide patients options of typically a basic hinged knee brace that provides some lateral and medial stability in general, because the last thing we want them to do is to have any issue such as, another twisting event or slip down the stairs or something because there's some instability.

And then when we think of more some of the chronic issues, people with arthritis or people with just some chronic knee pain, I'll offer some brace very similarly to an athlete going forward, that would be hinged and provide some support. There's a whole menagerie of other sorts of things we can do, but in general, the knee should support itself. But in those cases where I'm afraid that someone's going to potentially hurt themselves worse, we'll provide them some support. Wraps and neoprene sleeves can make someone feel a little bit better. I think that athletes often, we continue to think about their knee and it provides a little bit of pain relief, but doesn't really do much as far as their structure and their function.

And so I just want to make sure I try to counsel people as best as I can if they think that they shouldn't be on it to make sure that you're taking some weight off it, if you think there's a severe injury, but once we kind of have some information, I like to have people build up as much strength and do PT, do the home programs, do the things to try to build, not need a device like a brace or anything going forward.

And so it's pretty simple. It's kind of the rest, ice, elevation, anti-inflammatories; all those things are definitely fair game. And I do get a lot of questions about heat versus ice for pain relief and anti-inflammatory relief. And so from that standpoint, I usually do recommend ice in the acute phase of an injury, but heat won't hurt, it's not going to cause any trouble, but it's not going to have that anti-inflammatory effect that ice has.

Host: Well, I think one of the bigger discussions and you mentioned is return to play. Why don't you wrap this up for us with anything exciting in the world of knee injuries and how return to play is determined, how you work with these athletes for other referring physicians and what you'd like them to know about athletic knee injuries and the Sports Medicine Program at Carle Foundation Hospital.

Dr. Aubry: The thing that I try to tell all of my athletes is that there isn't a cookie cutter return to play. You kind of mentioned that there's home programs that are built for knee strengthening, and things like that. But in this case, we're isolating and making this personalized to everyone we see. I hadn't went into a ton of non-operative or basic knee injuries, but there's things that are going to take one to two weeks before someone's back fully to a football game or soccer, things like that. And maybe they wear a brace versus the traumatic knee injury where there's an ACL and a meniscal injury.

And half of the year is gone and depending on your rehab, you're really kind of progressing. And so from the more basic knee injuries, I really like to be simple and let pain kind of be a guide to get you back to activity. And so we see a lot of people that come in for overuse or tendonitis. And so maybe we put them on some medicine or anti-inflammatory show him some things to do. And I often let them just go and be on their own and progress as they see tolerated, unless they're really in high school sport where we can follow them a little bit closer. As we get more severe, that just depends on the timeframe and we get past the few weeks, that's often when I bring in either athletic trainers or physical therapists to make sure that this person is truly ready to get back. And some of the cool things we do specifically when coming back from traumatic knee injuries like ACL is, at some points, depending on the surgeon's postoperative schedules and things like that.

We'll do some specific testing to make sure that there's not a significant strength deficit between the affected knee and the non-affected knee. So there's biotechs training and testing where we are comparing strength and making sure that this knee should be stable. The research is showing that if you're passing this test that you have a lower injury recurrence rate.

And so there's some really cool stuff and I think most of the advancements in like the post-surgical care is more so in the PT and rehab departments on the back end. And so making sure that we're optimizing those things to get this person back in a quicker fashion and the surgeries haven't changed a whole lot. The arthroscopic procedures are still great. But I think that that's, what's really the most exciting part of some of these injuries is getting people back sooner because we're rehabbing better. And here at Carle BroMenn, we have a handful of great sports surgeons along with our non-operative care, that we're getting people back pretty quick. And I think we're doing a great job with our multidisciplinary team, with our physical therapists, with our occupational therapists and really getting people what they need, in a timely fashion, and then getting them back on the field, as soon as we can.

Host: Great points. And what an informative episode. Thank you so much, Dr. Aubry for joining us today and for more information, and to get connected with one of our providers, you can visit carle.org. Or for a listing of Carle providers and to view Carle sponsored educational activities, please head over to our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.