Star Third Baseman Brandon Inge Joins Rafael Nadal in the Battle with Patellar Tendinitis

The anterior cruciate ligament (ACL)

It was announced this week that Detroit Tiger’s All Star will have surgical treatment of patellar tendinitis in both knees in the upcoming weeks with the hope of achieving a full recovery from an injury that plagued him the entire past season.

The patellar tendon is the strong tissue that connects the patella (“kneecap”) to the tibia (“shinbone”). This patellar tendon is remarkably important, as it is the critical structure that connects the powerful quadriceps muscles of the thigh to the tibia and allows for extension of the leg. Walking, jumping, running, and virtually all athletic activities require a functioning patellar tendon. Correspondingly, degeneration and inflammation of the patellar tendon (“patellar tendinitis”) can be both painful and debilitating for the elite athlete.
Patellar tendinitis is typically an overuse injury. Jumping sports, such as volleyball, tennis, basketball, or track and field, may pose a greater risk from the recurrent stretch and injury to the tendon. Sports with long, often grinding seasons, such as baseball, soccer, and basketball, may also be particularly difficult on players. However, athletes of virtually every sport can develop patellar tendinitis. Tennis star Rafa Nadal and Mets pitcher Oliver Perez are no strangers to this chronic, nagging injury.
The diagnosis of patellar tendinitis is relatively straightforward, and will be manifest by tenderness of the patellar tendon. The most common location is directly below the kneecap at the origin of the tendon. This area may be swollen as well. The pain may be worsened with resisted leg extension, kneeling, or jumping exercises. Plain x-rays are usually normal, but occasionally will show some irregular bone spurs or fragments. MRI or US usually confirm the diagnosis, showing a localized area of inflammation with tendon degeneration and disorganized scar tissue.
The first line of treatment for patellar tendinitis is nonoperative. Rest, ice, and anti-inflammatory medications are often very effective. Stretching of the quadriceps and hamstrings is followed by a supervised rehabilitation program of strengthening. Sometimes, a knee sleeve brace or strap for the tendon (“Chopat strap”) can provide significant pain relief also. Despite these interventions, however, some athletes only partially benefit and are unable to return to their previous level of competition. Surgery for these refractory cases is performed to remove the area of tendon damage and inflammation and can be very effective. It is important to consult with your SportsMD physician to get prompt and effective treatment if you suspect that you have patellar tendinitis.
If you suspect that you have patellar tendinitis, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care. To locate a top doctor or physical therapist in your area, please visit our Find a Sports Medicine Doctor or Physical Therapist Near You section.

What is a dead leg?

The anterior cruciate ligament (ACL)
A dead leg

A dead leg

A dead leg can be extremely painful and is a frequent injury in contact sports.

Footballers and any other people involved in contact sports.

Heavy impact to the quadriceps causing the muscle to be crushed against the bone.

This causes a tearing of the muscle within the sheath that surrounds it.

What kind of pain?
Hurts at point of impact and usually tingling in leg. Also swelling, bruising and sometimes restricted movement.

Rest, ice, compress and elevate. Use a compression bandage until pain ceases.

Can take days or weeks to recover.

What’s a sprained ankle?

The anterior cruciate ligament (ACL)
Sprained ankles

Sprained ankles

Sprained ankles are one of the most common injuries in sport. They can be extremely painful and often involve ligament damage.

Common for anyone involved in sport or outdoor activities.

Going over on your ankle – sometimes a “snap” or “tear” is felt or heard.

What kind of pain?

  • Grade 1: Pain turning foot in or out
  • Grade 2: Swelling
  • Grade 3: Huge swelling and problems walking
    Rest, ice, compression and elevation. Do not remove the shoe until ice has reduced the swelling.Return?
    Between one week and three months depending on grade of injury. Usually two weeks.

What are shin splints?

The anterior cruciate ligament (ACL)
Shin splints

Shin splints

Shin splints are a common problem in the lower leg for athletes who change from one playing surface to another between seasons.

Common in young sportstars who play too much sport.

Cricketer James Kirtley has suffered, and many footballers such as Andrew Cole have been temporarily laid off by it.

It is an injury that can be caused in several ways.

The muscles at the front of the leg get injured or inflamed.

This can stem from playing too much sport on hard surfaces.

Or because of a weakness in the leg muscles, your running technique or even whether you have flat feet or high arches.

Tenderness in tibia (shin) area.

The affected muscles in the tibia also help maintain the arch of the foot which means there may also be pain when the toes or ankle is bent.

The pain stops when resting, but the injury will often remain unless the above causes are treated.

Rest will help to relieve the injury, but does not neccessarily cure it.

Physiotherapists may ensure you are wearing proper footwear, tape your shins or even recommend a leg brace.

Cooling the injury in acute stages and then applying heat may also help.

Building up your muscles around your ankles will help to support those leg muscles causing the pain.

And getting yourself some proper cushioned footwear will help to soften the impact when your feet hit the ground when running.

Changing the way you run may also need to be considered. Having a smoother stride will again mean that the impact is spread more evenly throughout your feet and legs.

Can vary hugely but usually between two to four months. Do not start training until pain and tenderness in tibia has gone.

Hamstring strains explained

The anterior cruciate ligament (ACL)
Hamstring strains explained

Hamstring strains explained

Hamstring injuries are every young athlete’s biggest nightmare.

Once you have problems with your hamstring, it can trouble you for the rest of your sporting life.

Real Madrid striker Michael Owen has always been plagued with injuries to his hamstring, and his former Liverpool team mate, Milan Baros, has also suffered.

They occur when you over-extend the muscle in the back of the leg.

Warming up properly is the best way to prevent this injury.

Sudden onset of pain or a pop in the thigh.

Rest, ice, elevation of leg and recovery program.

Within 2-4 weeks depending on severity. It can also recur for the rest of your sporting career unless it is properly dealt with.

Our guide to broken bones

The anterior cruciate ligament (ACL)
Bone fractures

Bone fractures

Bone fractures are potentially serious injuries.

As well as damaging the bone they often injure the tissues around the bone such as tendons, ligaments, muscles and even the skin.

Anyone involved in contact sports.

There are four different types of fracture:

  • Transverse: Straight across bone
  • Oblique: Diagonal break across bone
  • Spiral: Around the bone
  • Comminuted: Bone is shatteredHow? 
    Impact to the arm, leg or bone or indirect blow.What?
    Swelling and progressive bruising, pain during movement.

    You may also be able to see that the affected limb look awkward and that the bone isn’t in the right place.

    Cover and elevate the injured limb and keep it completely still. Go to hospital for treatment.

    They will probably put your limb in a cast to keep it completely still while the bone heals.

    These can be made of plaster, which can be quite heavy, but doctors are increasingly using lightweight plastic casts.

Recovering from an ACL injury

The anterior cruciate ligament (ACL)
Gaizka Mendieta is the latest star to suffer

Gaizka Mendieta is the latest star to suffer

Medical expert Bevan Ellis talks the Academy through a typical rehabilitation programme for an anterior cruciate ligament injury.

Many top athletes will go through an accelerated rehabilitation programme to get them back in action within six months.

It requires intensive physiotherapy which needs to be monitored very closely at every stage.

For a typical person, an ACL injury would normally take between 8-12 months to get back to full fitness.

Phase one (0-2 weeks after surgery)

The knee will be swollen after the operation, so the first job is to reduce the swelling.

After that, the physio will make the patient do a few light exercises like isometric contractions – keeping the leg still but moving the muscles around the knee.

Phase two (2-6 weeks after surgery)

The swelling should have disappeared, but the graft usually weakens around this time.

The physio may have to back off from the rehabilitation programme until the ligament is up to more exercises.

The patient should be walking normally by then.

Phase three (6-12 weeks after surgery)

By this stage, the knee should be getting stronger and able to take more strain.

The patient should be able to go swimming and use a road bike to get the knee back on track, as well as doing more strength exercises.

Phase three (3-6 months)

The patient will have their full range of movement and strength back, so they can start running properly once more.

They should be able to get back to specific drills and training.

Phase four (6-12 months)

The patient should be able to return to playing sport with their surgeon’s approval.


The anterior cruciate ligament (ACL)
Department Highlights
  • Experienced faculty
  • Dynamic team of specialist Orthopedics
  • Fully equipped Joint Replacement operation theatre
  • Unit with Highest numbers of Joint Replacement Surgeries in Rajasthan
  • Computer assisted surgeries
  • Rare centre performing Arthroscopic surgery

Medical specialty concerned with the skeleton and its associated structures. Orthopedists treat fractures, strained muscles, torn ligaments and tendons, and other injuries and deal with acquired and congenital skeletal deformities and the effects of degenerative diseases such as osteoarthritis. Originally dependent on heavy braces and splints, orthopedics now uses bone grafts, hip and other joint replacements, prostheses to enhance mobility. Orthopedics uses the techniques of physical medicine and rehabilitation and occupational therapy in addition to those of traditional medicine and surgery

Specialized treatments are available for:

  • Joint Replacement Surgery -Hip, Knee & Shoulder
  • CAS (Computer Assisted Surgery) in Joint Replacements.
  • Revision Hip & Knee Replacement Surgery.
  • Complex Poly-trauma Procedures
  • Limb Salvage
  • Limb Reconstruction
  • Bone tumors
  • Spine surgery

All surgeries are performed by minimally invasive methods.

Services/Treatments Offered

  • Total Knee Replacement
  • Total Hip Replacement
  • Shoulder Replacement
  • ACL Repair
  • Operative Arthroscopy
  • Arthroplasty
  • Rehabilitation
  • Fractures
  • Trauma
  • Spine surgery

The anterior cruciate ligament (ACL)

The anterior cruciate ligament (ACL)

Let’s begin with the basics of knee anatomy. The knee joint is made up of three bones and a variety of ligaments. The knee is formed by the femur (the thigh bone), the tibia (the shin bone), and the patella (the kneecap). Several muscles and ligaments control the motion of the knee and protect it from damage at the same time. Two ligaments on either side of the knee, called the medial and lateral collateral ligaments, stabilize the knee from side-to-side.

The anterior cruciate ligament (ACL) is one of a pair of ligaments in the center of the knee joint that form a cross, and this is where the name “cruciate” comes from. There is both an anterior cruciate ligament (ACL) and a posterior cruciate ligament (PCL). Both of these ligaments function to stabilize the knee from front-to-back during normal and athletic activities. The ligaments of the knee make sure that the weight that is transmitted through the knee joint is centered within the joint minimizing the amount of wear and tear on the cartilage inside the knee.
The weight-bearing surfaces of your knees are covered with a layer of cartilage (referred to by doctors as”articular cartilage”). There are also two shock absorbers in your knee on either side of the joint between the cartilage surfaces of the femur and

the tibia. These two structures are called the medial meniscus and the lateral meniscus. The menisci are horseshoe-shaped shock absorbers that help to both center the knee joint during activity and to minimize the amount of stress on the articular cartilage. The combination of the menisci and the surface cartilage in your knee produces a nearly frictionless gliding surface. The knee is an incredible joint. It is strong, flexible, and very tough.


The anterior cruciate ligament (ACL)

Figure 1: Right Knee – Frontal View with Patella Removed

The anterior cruciate ligament (ACL) is the major stabilizing ligament of the knee. The ACL is located in the center of the knee joint and runs from the femur (thigh bone) to the tibia (shin bone), through the center of the knee. In this position, it functions to prevent a buckling type of instability of the knee. (For more information on the ACL: KNEE JOINT – ANATOMY & FUNCTION.)

Figure 2: Right Knee – Arthroscopic View of Intact Anterior Cruciate Ligament

Usually the tearing of the ACL occurs with a sudden direction change or when a deceleration force crosses the knee. The patient often feels or hears a popping sensation, has the rapid onset of swelling, and develops a buckling sensation in the knee when attempting to change direction. (Click HERE for an animation of an ACL tear.)


The diagnosis of an ACL injury is usually arrived at by determining the mechanism of injury, examining the knee, determining the presence or absence of blood within the joint, and performing diagnostic studies. These may include x-rays, MRI scans and stress tests of the ligament.
The initial treatment of an acute ACL injury often includes ice, anti-inflammatory medication, and physical therapy which is directed at restoring the range of motion of the injured knee.

                                                     Figure 3: Right Knee

Surgical treatment of the torn ACL usually involves an arthroscopic surgical reconstruction of the injured ligament.

Figure 4: Arthroscopic Knee Surgery with Instruments in Place

Although a number of different types of tissue have been utilized to reconstruct the ACL, the most common type of ACL reconstruction involves harvesting the central third of the patellar tendon with a bone block at each end of the tendon graft. After performing a diagnostic arthroscopic examination of the knee, the central third of the patellar tendon is harvested. (Click HERE for a computer animation of tendon harvesting (mpg file) courtesy of Rob Kroeger.)

                                          Figure 5: Left Knee – Graft Harvest

The remaining tendon is then repaired. After harvesting the tissue, drill guides are used to place holes into the tibia (bone below the knee)

                                                       Figure 6: Left Knee

            Figure 7:Intraoperative photo of drill hole in femur for ACL

and femur (bone above the knee). By placing the drill holes at the attachment sites of the original ligament, when the graft is pulled through the drill hole and into the knee, it will be placed in the same position as the original ACL. (Click HERE for a computer animation of drilling the holes (mpg file) courtesy of Rob Kroeger.)
After pulling the graft through the drill holes and into the joint to replace the torn ACL, the graft is then held in place with bioabsorbable screws or metallic screws.

                                                      Figure 8: Left Knee

Fastening the graft in this manner allows new blood vessels to grow into the transferred graft and for healing to occur. Typically, the procedure is performed on an outpatient basis.

Figure 9: Lateral Intraoperative X-Ray demonstrating Placement of Metallic Screw for ACL Graft Fixation in the Femur


The anterior cruciate ligament (ACL)

Postoperatively, it is possible to bear weight (partial weight bearing) on the surgically treated leg by using crutches for the first 7 – 10 days after surgery. Patients may stop using crutches when comfortable. Supervised physical therapy often is started by the second to third day after surgery.



In addition, a continuous passive motion device is applied to the injured leg post-operatively. Most patients use this device while sleeping for the first two weeks. This device very slowly moves the knee, thereby decreasing the risk of stiffness and loss of motion. Following an initial 6-10 week period of supervised physical therapy, most patients will progress to a self-directed program that is done in a health club. Typically, it takes the reconstructed ligament approximately 9 months to heal. Until released by your physician, contact sports, racquet sports, skiing, tennis, martial arts, and sports that require rapid direction changes must be avoided.


The anterior cruciate ligament (ACL)

Arthroscopy: What is it?

Arthroscopy is a surgical procedure in which a small fiberoptic telescope (arthroscope) is inserted into a joint. Fluid is then inserted into the joint to distend the joint and to allow for the visualization of the structures within that joint. Usually the surgery is viewed on a moniter so that the whole operating team is aware of the type of surgical procedure that is being performed.

Arthroscopes are approximately 5 mm in diameter, so the incisions are very small (approximately 1/8 inch). During the procedure, which is conducted under anesthesia, the inside of the joint is examined for damaged tissue. The most common types of arthroscopic surgery include removal or repair of a torn meniscus (cartilage), ligament reconstruction, removal of loose debris, and trimming damaged cartilage.

Arthroscopy is much less traumatic to the muscles, ligaments, and tissues than the traditional method of surgically opening the knee with long incisions (arthrotomy). The benefits of arthroscopy involve smaller incisions, faster healing, a more rapid recovery, and less scarring. Arthroscopic surgical procedures are often performed on an outpatient basis and the patient is able to return home on the same day.

While an arthroscope is used in many different types of surgical procedures, the recovery time and outcome of the procedure is related to the type of injury and the type of arthroscopic surgical procedure performed. For example, an arthroscopic surgical ligament reconstruction will take longer to heal and the recovery time will be longer then the patient who has an arthroscopic removal of a loose body.


Important exercises you will begin the day of surgery

The anterior cruciate ligament (ACL)

These exercises are crucial to your rehabilitation and the following is a general guide for the rehabilitation following knee surgery. Physical Therapy Programs are individualized for each patient by a doctor or physical therapist and a successful outcome is dependent on adequate communication between the patient, therapist and surgeon. Considering those points, these are just guidelines.

Elevate your affected leg, it must be elevated above heart level, usually requiring 4 or 5 pillows. under your leg. Just propping it on the couch, or recliner is not enough, and the more you can elevate and ice, the less pain and swelling you will have.

Squeeze & tighten this muscle tight for 2 seconds, twenty times, and try to do 10 or more sessions each day. Monitor your progress by comparing your muscle contraction to your unaffected leg, and it is wise to do these exercises for both legs

The Heel Prop is The Most Important Exercise You Will Do.
Prop your heel as shown in the photo above. Relax your leg (when you are relaxed, your leg and foot will rotate out slightly and this is good). Allow your knee to straighten as much as possible. This can also be achieved by propping your heel on a chair facing you or on the arm of a couch. as long as nothing is under your knee. Do this every hour for 3-10 minutes.

USA new york hospitals

The anterior cruciate ligament (ACL)


Advanced Diagnostics

An acute or chronic heart condition can become evident during a routine annual physical exam or through a specific set of symptoms, and expert diagnosis is crucial in determining the most appropriate course of treatment. Patients at NewYork-Presbyterian are examined by world-class physicians who provide a full range of diagnostic services for adults and children with heart disease.
As one of the nation’s largest clinical and research institutions, NewYork- Presbyterian has access to the most advanced diagnostic equipment, often years before other hospitals. Our state-of-the-art diagnostic services include:
Cardiac catheterization, when making an accurate diagnosis must rely on more invasive procedures. NewYork-Presbyterian?s cardiac catheterization laboratories offer coronary angiography for the detailed evaluation of the extent of anatomic blockages in the coronary arteries as well as intravascular and intracoronary ultrasound, in which detailed images of the heart and coronary arteries are created using sound waves.
At NewYork-Presbyterian, we are now also evaluating the functional significance of arterial blockages, using a tool called fractional flow reserve (FFR). This involves placing a tiny catheter across a blockage, to measure the difference in pressure before and after the use of a drug that challenges the heart’s ability to function. It allows us to see the effects of a narrowed vessel in real time.
Electrocardiographic tests, considered the first diagnostic tools for evaluation of anatomic changes and arrhythmias, use an electrocardiogram (ECG) to assess the electrical activity produced by the heart. In addition to the resting 12-lead ECG, the electrical activity of the heart can be examined over 24 hours, by using portable ambulatory recorders. Event recorders can be used over even longer time periods to detect infrequent rhythm irregularities. The ECG can also be examined during exercise testing.
Electrophysiological studies that allow physicians to expertly diagnose irregularities in heart rhythm. These studies are useful for defining the origin and risk of supraventricular and ventricular tachycardias and in designing the appropriate therapy for these conditions.
Advanced imaging techniques such as
  • Echocardiography, a noninvasive procedure that produces a graphic image of the heart’s movement, valves, and chambers using high-frequency sound waves.
  • Magnetic Resonance Imaging (MRI), which creates high quality images of the heart throughout its pumping cycle. MRI is also important to help distinguish heart muscle that is irreversibly damaged from muscle that can be restored to some degree of function.
  • Nuclear imaging techniques such as single photon emission computer tomography (SPECT), positron emission tomography (PET), and MUGA scans, which evaluate not just how organs appear but how well they are functioning.
Tilt table testing for evaluation of patients with syncope (fainting). Syncope is a sudden loss of consciousness due to a transient drop in blood pressure. At NewYork-Presbyterian, physicians with expertise in the diagnosis and treatment of syncope use the most advanced techniques to determine whether syncope is being caused by an underlying cardiac arrhythmia.

Cardiothoracic Surgery Artificial Heart Devices: LVAD

The anterior cruciate ligament (ACL)
NewYork-Presbyterian is a leader in the development and implantation of the LVAD (left ventricular assist device), a mechanical pump that augments the function of the left ventricle – the heart’s most critical pumping chamber. These artificial heart devices consist of an electric pump, an electronic control system, and a power supply. The pump is implanted into the upper part of the abdominal wall and is connected to the heart at two points. A tube carries blood from the left ventricle to the pump.
Blood is pumped through a second tube to the aorta, from which it is distributed to all parts of the body, thereby helping a weakened heart circulate blood. A third tube extends to the outside of the body. In this tube are wires that connect the pump to the small controller which can be worn on a belt. The controller is connected to small batteries that are worn on a shoulder holster.
NewYork-Presbyterian offers several types of FDA-approved LVADs for use as a bridge to transplantation, allowing critically ill patients to live productive lives at home while waiting for a heart donor. NewYork-Presbyterian is also participating in ongoing clinical investigations of the next generation of LVADs.
In addition to patients who are waiting for a heart transplant, there are up to 100,000 people who are terminally ill with end-stage heart failure and for whom transplant is not possible. Clinical trials conducted at NewYork-Presbyterian have led to FDA approval of one of these devices — the HeartMate LVAD — for use both as a bridge to transplantation as well as for long-term therapy in the treatment of end-stage heart disease in patients who are not eligible for heart transplantation. Research conducted at NewYork-Presbyterian has demonstrated that patients with the implanted HeartMate LVAD had much better survival rates and quality of life compared patients who were treated with medication and medically monitored. Ongoing and future clinical investigations at NewYork-Presbyterian will examine other LVADs that are much smaller and more durable for long-term use in heart failure patients.
Current LVAD Clinical Investigations
  • Micromed DeBakey VAD bridge to transplant trial. A small axial flow pump is used to bridge patients to transplant who are on the transplant waiting list and have become too sick for transplant. The trial is a multi-institutional pivotal trial.
  • Thoratec HeartMate II Bridge to Transplant Trial. Another small axial flow pump is used to bridge patients to transplant who are on the transplant waiting list and have become too sick for transplant. The trial completed the feasibility study phase in which we enrolled the largest number of patients in the country.

    We are currently conducting pivotal trials using the same device. The pivotal trials consist of two studies. One is a bridge to transplant therapy and the other a destination therapy. In the multi-institutional bridge to transplant trial, a small axial flow pump, HeartMate II, is used to bridge patients to transplant who are on the transplant waiting list but who have become too sick for transplant.

    In the HeartMate II Destination Trial, the device is used to help patients with end-stage heart failure who not eligible for heart transplantation. We are enrolling patients for this multi-institutional, randomized trial.

  • Impella Feasibility Trial . The device is a small axial flow pump that can be inserted through the ascending aorta or the femoral or axillary artery. The device is designed to help patients in acute cardiogenic shock, such as large myocardial infarction, severe myocarditis, and post-cardiotomy shock. The trial is now completed and we are in the process of conducting a pivotal trial.
  • VentrAssist VAD Bridge to Transplant Trial. A small centrifugal flow pump, a third generaton pump, is used to bridge patients to transplant who are on the transplant waiting list but who have become too sick for transplant. The trial is a multi-institutional feasibility trial.

Knee Brace Fitting

The anterior cruciate ligament (ACL)
Most knee braces come with specific instructions for fitting.

Most knee braces come with specific instructions for fitting.

Your doctor will take measurements to fit you for your knee brace. Sizing is determined by taking a measurement of the circumference of the thigh, six inches above the knee cap.

Each knee brace comes with detailed instructions on how to put it on. It is very important that you follow the exact sequence of inserting and tightening the straps. If you need to tighten any one strap after you have been wearing the brace, you will need to redo all of the straps in the proper sequence, not just the one strap that needs tightening. It is recommended that you work with a physical therapist or other healthcare provider and practice fitting your brace until you are comfortable with the procedure.

Most braces also come with specific instructions for that brace which should be followed carefully.

Most websites also provide fitting instructions specific to the particular knee brace if you are ordering one online.

Knee Brace Care

The anterior cruciate ligament (ACL)
Inspect your knee brace regularly

Inspect your knee brace regularly

o get the most benefit and the longest life from your knee brace, use it as instructed by your doctor and the specific fitting and care instructions for the relevant brace. Every time you put the brace on, make sure the hinges are situated where the knee bends, and that the straps and tapes are fastened securely around your leg as instructed. During activities, check the position of the brace to make sure it has not moved.

Inspect your knee brace regularly for signs of wear and damage, and have any problems repaired immediately. A well-worn brace should be replaced to ensure you get the most benefit from it. Follow the cleaning instructions that come with the brace. Typically, any fabric on knee braces should be cleaned regularly with soap and water. Exposed metal should be covered to protect others from harm.