Thursday, June 19, 2008

The Pain, function, impact and outcome for Mr. Lyons

Today class, we are dealing with Mr. Lyon, a famous country club golfer who always goes for the highest bid in the Calcutta at Shady Rolling Green Acres Hills C.C. Mr. Lyon won yet again, but he appears to have some medical problems that need attention

Since we are little kids we are taught that pain is a bad thing and that bad pain is a bad thing. People who work through the pain often take on Herculean proportions in other's eyes. We use pain to get sympathy, be taken more seriously and sometimes to imply that somehow we are more noble. Pain has many causes and knowing what is the pain generator is a key thing.

What is of interest in this whole Mr. Lyon thing is the focus on the pain. Feiter Nesoog got his ass in a sling he tried to wriggle out of claiming Mr. Lyon was faking. Why? Because athletes do just that and he was just guessing as most of the rest of the club was. Feiter observed Mr. Lyon's function. Bad result - grimacing, good result - no grimacing, but Feiter appeared to overlook one thing - what function was Mr. Lyon exhibiting when he was grimacing. Don't think for a second that I'm implying faking or even embellishment. Mr. Lyon managed his pain fairly well, but he may not have really understood it.

Mr. Lyon had the pain of the stress fractures which is a constant, known entity that a fine athlete, a well-motivated injured or ill person can deal with by "owning it". That takes a bit of effort, but one can do it.

Function, that's the key. How is your function impacted? The stress fractures didn't likely impact Mr. Lyon's golf swing or even his walking, but I am certain that he was loaded up with the ice afterwards because you deal with "owned pain" eventually.

There's another kind of pain -paroxysmal - that means that it comes on instantly, surprisingly, never insidiously but always in a shock. It takes us by surprise. Perhaps that's what Feiter was observing and not understanding and winding up looking like a total bonehead. One thing I think was happening is easy to explain. When Mr. Lyon during the member-guest swung with more than a certain force, he caused something to happen in his ACL-deficient knee. That thing called a Jerk or Pivot Shift gave him paroxysmal pain and we all saw the results. Grimacing, favoring limping - all that that got Feiter in the crapper. What we also don't know is what was the state of Lyon's meniscus cartilages at this point - was he damaging them more - or not? No guarantees.

In simplest engineering terms a "jerk" is not a guy saying that Mr. Lyon was tougher and suffered more than Hogan (that's just misinformed), but rather a change in acceleration of in this case two different surfaces of a knee joint. In true engineering or physical circumstances this can be a very important fact to calculate such as in the wear of a structure due to harmonic oscillations or repeated force applications. In the knee we cannot calculate these but rather we see the effects - Mr. Lyon's knee specialists who stick the scope back in there will see what the medial and especially the lateral meniscii have thought about all this jerking they've been subjected to.

Pivot Shift is the very specific term used for a test and this specific Jerk (google both, I don't have time); in short this involves an intact PCL and the resultant loss of secondary stabilizers in an ACL deficient knee. (I warned you I could go 40 pages). Specifically, the lateral (Outside) part of the Tibia (lower knee bone) rotates forward to varying degrees - when subjected to torque - as relates to the its normal articulation with the Femur (upper knee bone). This happens during the last 30* of extension or straightening of the knee such that extended the shift will occur and bent more than 30* the knee will snap back into place. Caught in all of this is the lateral meniscus, ergo the site of the impact and determining the outcome.

In a golf swing based upon posting the knee in full extension at and just before impact, if enough laxity is present and enough force applied, the jerk will occur and in a chronically inflamed knee this does cause a paroxysm of sharp, quick, intense pain. Few people can deal with a paroxysm and hide it. That's likely what we saw.

So how did we get there?

Mr Lyon's left knee has always been under stress at impact, that's been key to how he swings with such violence. We also know that he has had a "Partial ACL Tear" (there is no such thing) for a long time. Remember he had "Fluid removed from around the ACL"? (Gooogle that)... He had one since before that surgery. He's simply loosened the secondary stabilizers over time (natural history of ACL injuries) to the point that he has had full ALRI (antero-lateral rotational instability) develop and has put his knee in jeopardy of needing much more extensive surgery (or not, if he's lucky).

The stress fractures just developed because Mr Lyon is likely an exercise addict (I don't know Him, but multiple sources suggest this and replicate each other). As I said yesterday, these are trivial.

"Oh wise and pompous one, what would you have done?" (Hey, I'm trying to explain here, don't shoot the messenger).

Armchair quarterbacking with 20-20 hindsight is sure easier than making the decision in the moment, but some of it would depend on what the hypothetical patient (Mr. Lyon) might or might not listen to. Mr Lyon seems stubborn and we don't know the exact timetable of the instability, but Mr. Lyon's ortho guy called the ACL deficient knee long time ago. We don't know what Mr. Lyon did with that.

Certainly since fall 2007 or so Mr. Lyon might have worn a brace, but they only help so much. He might have been perceived as vulnerable rather than stoic, so it may not have fit his needs, but Mr. Lyon certainly could have gone at the ball with less that a full chop and not pivot shift or jerk that left knee. But he'd have eventually wound up in hte O.R. again and may not be done yet.

We'll follow Mr. Lyon carefully.


Dan Herrmann said...

Dr. Redanman,
Do you think we should invite Mr. Lyon to our toon-a-mint next April, or will he still be rehabbing his knee?

The Green Jackets

the redanman said...

Unless there is more to Mr. Lyons knee than has been revealed so far, April seems just peachy for GA.