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Josh McRoberts Tears Right Lateral Meniscus, Possibly Out for Season

December 15th, 2014 Leave a comment Go to comments
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Update (12/22/14): Josh McRoberts had the torn lateral meniscus in his right knee repaired (versus partially removed). A repair approach has a significantly longer recovery time, but much better long-term prognosis. The surgery will be season-ending. The Heat has applied for a $2.65 million disabled player exception. 

The Miami Heat announced that Josh McRoberts has torn the lateral meniscus in his right knee.

McRoberts injured the knee late in the fourth quarter of the Heat’s win in Phoenix last Tuesday when he fell awkwardly to the court while pursuing a loose ball. He is scheduled to undergo surgery this week, and could miss the rest of the season.

“This will not be a short-term thing,” head coach Erik Spoelstra said. “He’ll be out a while, if he even does make it back this season.”

Injury Overview

Each knee has two menisci, which are C-shaped wedges of fibro-cartilage positioned between the femur (thighbone) and the tibia (shinbone), one on the medial (inside) compartment of the knee and the other on the lateral (outside) compartment of the knee.

The mensci serve several functions:

  • They safely transmit loads across the knee, the most weight-bearing joint in the human body. The forces across the joint can reach up to two to four times your body weight while walking and up to six to eight times your body weight while running. The lateral meniscus bears more of the load than the medial meniscus.
  • They act as shock absorbers that protect the femur and tibia from constantly pounding into each other, thus maintaining the health of the articular cartilage that resides at the ends of both of these bones. Articular cartilage is what prevents bone-on-bone interaction as the knee is flexed and extended, called osteoarthritis, which can be excruciatingly painful.
  • They act as secondary stabilizers for the knee (in conjunction with the ligaments which connect the tibia and femur), protecting it from abnormal front-to-back motion.

Proper treatment of a meniscal tear is therefore vital, in order to maintain the structural integrity of the knee and to preserve the health of the articular cartilage.

There are two recognized surgical treatments for meniscal tear: repair and removal (i.e., meniscectomy). 

Years ago, if a patient had a torn meniscus, and surgery was necessary, the entire meniscus was removed. These patients actually did quite well after the surgery. The problem was that over time, the articular cartilage on the ends of the bones were worn away more quickly, due to the loss of the cushioning effect of the menisci and the diminished stability of the knee joint.

When arthroscopic surgery (a minimally invasive surgical procedure in which an examination and treatment of damage to the interior of a joint is performed using a tiny fiber optic camera and tools that are inserted into the joint through two or more tiny incisions) became more popular, more surgeons performed partial meniscus removal – called a partial meniscectomy. A partial meniscectomy is performed to remove only the torn segment of the meniscus. This type of procedure has a better long-term prognosis than a full removal, particularly if the tear is relatively small, but problems can again creep up down the road.

In recent years, given the critical function of the meniscus, there has been great interest in avoiding meniscectomy altogether wherever possible, and repair has grown in popularity. Despite recent advances, however, a large proportion of meniscal tears remain irreparable, and partial meniscectomy is often necessary, regardless of the recognized consequences.

The decision to repair versus remove is generally based on whether the mensical tissue has a chance to heal. The ability of meniscal tissue to heal is closely related to its blood supply.

At birth, the whole meniscus is vascularised (supplied with blood vessels). However, an avascular area soon develops in the inner circumference of the meniscus, and in the second decade of life blood vessels are seen only in the outer third.

Successful repair of meniscus tears therefore depends to a large degree on the age of the patient as well as the size, direction and location of the tear. Tears at the outer edge of the meniscus (the “red zone,” red for blood) tend to heal well. Blood supply to tears that extend into the center of the meniscus (“white zone”) is questionable, and surgical repair of a tear in this zone may not heal well.

The necessary surgical procedure is often not able to be determined until the surgery has begun. Through the use of the arthroscope, the doctor will assess the damage and determine whether he or she believes there is sufficient blood supply at the site of the tear to promote healing. If so, the loose cartilage will be stitched back together and allowed to heal. If not, the torn cartilage will be removed. Chris Paul, for example, was originally going to have his torn left lateral meniscus repaired in February 2010, but once the tear was viewed by renown orthopedic surgeon Dr. James Andrews, partial removal was determined to be the best course of action.

A doctor can choose to be aggressive or conservative in his course of treatment. A repair can always be attempted, but the meniscus may not heal. Many times the correct course of action is clear, other times less so. For example, Dr. Andrews attempted to repair a lateral meniscus tear in Chase Budinger’s left knee in November 2012, and when that failed, subsequently removed it in September 2013.

A repair approach has a significantly longer healing time – many months in fact, as Derrick Rose and Russell Westbrook can attest to – but provides a far better long-term prognosis if successful, with no significant long term consequences in the vast majority of cases. A removal approach has a far quicker healing time – often a few weeks or even just days, as Blake Griffin and Metta World Peace can attest to – but future problems are much more likely to arise.

Partial loss of a meniscus can have damaging effects on a knee, leading to serious longer-term consequences. The increased contact between the tibia and femur within the knee after partial loss of a meniscus can overload the articular cartilage that resides on the ends of these long bones, causing the surface of the articular cartilage to rub away, leading to necrosis and eventually complete loss of the cartilage layer. The resulting bone-on-bone interaction, loose cartilage and excess fluid buildup in the knee causes severe pain, soreness, swelling, bruising and loss of range of motion.

Dwyane Wade, for example, has suggested his current knee troubles stem from a decision to partially remove the lateral meniscus in his left knee after tearing it during his sophomore year of college in 2002.

The surgical technique (repair vs. partial removal), prognosis, and recovery timeframe for McRoberts is, at this point, unclear. More will undoubtedly be known after he has his surgery.

Disabled Player Exception

If the Heat determine that McRoberts will miss the rest of the season, they could apply to the league for a disabled player exception equal to half his salary, or $2.65 million.

This exception allows a team which is over the cap to replace a disabled player who will be out for the remainder of that season. It is granted by the league based on an application from the team and a determination by an NBA-designated physician that the player is substantially more likely than not to be unable to play through the following June 15.

If the application were to be denied, the Heat would not be able to re-apply for the rest of the season.

If the application were to be granted, the exception would enable the Heat to acquire one player via free agent signing, trade or wavier claim, to replace him:

  • The Heat could sign a free agent to a contract for the rest of the season only, with a salary of up to $2.65 million.
  • The Heat could trade for a player in the last season of his contract only (including any option years), who is making no more than $2.75 million.
  • The Heat could claim a player on waivers who is in the last season of his contract only (including any option years), who is making no more than $2.75 million.

Once granted, the exception would expire upon the earliest of: (i) a player being acquired with all or a portion of it, (ii) McRoberts being traded, (iii) McRoberts returning from injury, or (iv) March 10.

The Heat would not be able to exceed the 15-player maximum roster size in utilizing the exception. With the team already at 15 players, the Heat would therefore need to first waive a player currently under contract. If McRoberts were to come back sooner than expected he may be activated immediately, and the replacement player is not affected.

McRoberts can be traded while injured. But if he is, the acquiring team would not be able to apply for a disabled player exception.

Draft Pick Considerations

The Heat, off to their worst start in Spoelstra’s seven years as coach (11-13), is also currently without All Star center Chris Bosh, who is sidelined indefinitely with a calf strain. The Heat now faces the challenge of moving forward for at least the next several weeks with a severely depleted front court. The rash of injuries may put in jeopardy its bid to make the playoffs this season. That, in turn, could have some unintended consequences.

The Heat still owes the Philadelphia 76ers (via the Cleveland Cavaliers) its 2015 first round draft pick to satisfy the conditions of its LeBron James sign-and-trade in July 2010. That pick is lottery protected through 2016, and becomes fully unprotected in 2017.

The Heat, to start the year, had clear expectations to make the playoffs. That would have meant its final pick obligation to the Cavaliers would have been satisfied in 2015. If the Heat are to instead miss the playoffs and, as a result of the draft lottery, are to wind up with a top 10 pick, the Heat would keep the pick but its future pick obligation would roll over to 2016.

***

The hope for now, at least for McRoberts, is that his torn lateral meniscus can be repaired rather than partially removed. The surgical prognosis for such injuries is excellent, and a full recovery is achieved in a majority of such cases.

The list of players currently playing in the NBA after having sustained mensical tears is long and extensive. It is among the more common injuries NBA players sustain.

McRoberts signed a four-year, $22.7 million contract with the Heat this summer.

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