clinical cases

Clinical Case 1: Kevin Ware

So I want to present a new type of post called “Clinical Cases”.  This type of post will show a video and then ask the viewers of this site to not only give their impressions on  the anatomy and physiology involved in the injury but also the societal impact of the video, psychological variables that may impact or hinder recovery, personal and clinical “feelings” when viewing the video, potential rehabilitation, etc.   Let’s learn how to utilize a “biopsychosocial” model in understanding injury and recovery.

So here is video #1 showing an injury sustained by Kevin Ware from this weekend’s Louisville/Duke game .  Please note, this is not an easy video to watch.  Let’s begin a discussion below:

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Categories: clinical cases

12 replies »

  1. I think this Clinical Cases discussion sounds like a great idea. Good thinking Joe.

    First I’ll start with the more anatomical/biomechanical reactions to this video. One of the first things that I thought of while watching this video was the pathology related to the mechanism of injury. To me, that mechanism of injury did not seem to be the usual magnitude or type of force one would expect to see cause a compound fracture. ACL tear maybe, sprained ankle obviously, but not a compound fracture of the tib/fib. It almost makes me wonder if there is an underlying cause which put him more at risk for such an injury, such as prolonged corticosteriod use, injections, previous injury, etc. However weirder things have happened. We all know he underwent surgery that night, most likely including rod insertion. I would think he’s looking at about 1 year until return to sport.

    Now to touch on the societal and psychological aspect of this injury in order to tie into the biopsychosocial model. Pain science guy or not, nobody can ignore the impact that this injury has on Ware. We have a 20 year old playing on one of the top college basketball teams in the country, now going to the final four, and he gets injured. I’m sure some would assume that he’s absolutely devastated and miserable. i would disagree. After the injury Ware was quoted as telling his team to “win the game, win the game.” This reaction to his injury tells me that Ware is able to focus on other things, and I think this will be a good prognostic factor for his recovery. This response makes me think that Kevin will bounce back well compared to someone who might focus on the injury, focus on what they CAN’T do, focus on how they SHOULD be in that final four. This is a huge tool that Kevin probably isn’t even away he has, however will help in his recovery.

    I’m still learning and education myself on the field of pain science but I think Kevin would score relatively low on pain catastrophizing scale and other scales of that nature, as he is already looking past is injury and onto the final four and what his teammates can accomplish. If I’m off base or anyone thinks I may be misguided please let me know, I think this is a great learning experience.

  2. Awesome response Mark. Now lets shift to the environment and the immediate reaction by those who witnessed this. Look at how their nervous systems cause them to react. Activation of mirror neurons creates a heightened empathetic response towards Ware. The individual neuromatrices of the players activates and most revert to an altered action program where they lay down on the court or move away from Ware. They did not experience the physical injury but their nervous systems appear to be defensive. Isn’t this fascinating?

  3. Yes, fascinating indeed! I wish I could hear what was being said on the court because it seemed as though someone even shouted to the players to come to, and huddle around Ware when they seemed to want to huddle together away from him.

    That was hard to watch for me. The kind of thing I try not to look at, and so was a good exercise for me. This is a great idea. I hope to learn a lot from the follow-up.

  4. It’s a horrific incident especially in the eyes of the audience and other players. Both teams are grief-stricken, there is almost nervous shut down in most players.

  5. Six years ago I fractured my right tibia in a skiing accident. It was a closed spiral fracture with an ORIF. Watching the injury many times had no impact on my reaction. I remember the feeling of the break, the feeling of my lower tibia shifting (flopping) on my upper tibia, and seeing my crooked leg. Immediately after the injury I kept telling my friend “maybe it’s a high ankle sprain.” I was is denial as my leg shifted out of my control.

    I was sent to the ER immediately where x-rays were taken. The fracture was shown to me. At the time I was currently training for an olympic weightlifting meet. My first question was “will I be competing in three months.” The MD said NO, told me he had to set the leg and would give me morphine. I asked the MD how he planned to give me the medication. The obvious answer was to inject it. Lying there, fractured tibia, I told the doctor he was not going to put a needle in my arm. I do not like needles. I was more threatened by the needle than the fracture. He gave me a bewildered look to say the least. They gave me some vicodin and then set the leg. I wish I took the morphine. I underwent the ORIF, was dunking a basketball at 6 months and on the platform competing in olympic weightlifting at 9 months.

    To this day I have dreams of the injury. I hear and feel the fracture. It wakes me up, I take a breath and go back sleep. Our brain has a better memory than we can imagine. No differnet than bending over for those with low back pain, checking your blind spot with neck pain, reaching behind your back with shoulder pain, returning to sport s/p ACL repair, etc etc.

    Even thinking about it can be enough light up a neurosignature. Given a traumatic enough experience, the signature can fire at any given time for no apparent reason creating a defensive system. It’s like watching the wasp as it gets ready to land on your hand.

  6. That was indeed an incredible injury caught on camera. i almost expect to see that on the world’s most amazing /stupidest videos with these guys on skateboards and bmx bikes. It is very rare for see that kind of trauma from a jump and land scenario. However we would comment on height of the jump, his motivation to block the shot and the speed and the fact that he started to turn back to the court when he missed blocking the shot hence putting his foot perpendicular to his direction of the direction of his mass and momentum. Possible different outcome if he lands with his foot facing forward. It underscores the need to train for multiple different angles and progression into higher force ,motion and speed with all movement . Not discounting the possibility of underlying pathology either but I wonder if his training program progressively trained for the multitude of scenarios that he would have to get into playing basketball. Was his nervous system prepared adequately and authentically to handle that force.My guess is not hence exposing the gap in his movement repetoire.I could not watch it more than 2 times without feeling my own and ankle previous sprains, my nervous system was nervous. I wish him a speedy recovery and hopefully he has somebody to train him beyond the fear that he will obviously have for jumping and landing. thanks for creating an environment for exchange of ideas.

  7. What I find really interesting about this video is that reactions almost happens in stages.

    The first stage: everyone’s unconscious, immediate reaction is withdrawal…

    Check out his bench once the see the injury – they visibly and physically recoil away from Ware – one of them throws his towel over his face. The players on court are hiding their faces in their hands and even Thornton (the blue player on the other team) physically turns away from Ware and covers his face with his hands. People in the crowd react in a similar way.

    It’s almost like it’s a protective mechanism of the nervous system –automatic withdrawal – get the heck out of there in case it’s contagious? Like protecting the herd, don’t go near him until we are sure that it is safe.

    It’s only after some time has passed that everyone moves onto a more conscious stage of “hey we need to support this guy” and they move from withdrawal to approach. A fair bit of time elapses before his team mates physically gather round him… and is it only after he calls to them “I want to talk to you”?

    If mirror neurones were only about empathy, wouldn’t they have run over straight away? Perhaps mirror neurones are also about learning and self-preservation/protection? It’s interesting that the mirror neurones where firing so strongly in Ware’s teammates that their first reaction was withdrawal and not approach. I’m sure it has nothing to do with how much they like the guy – it’s just that instinct overrode camaraderie.

    The other interesting thing, is that when they do go to him, they get applauded by the crowd… almost a recognition that moving from withdrawal to approach is a difficult and uncomfortable thing to do.

    Did the game carry on after Ware was taken off? If so, I imagine it was a much more ‘sedate’ game than that which preceded the injury? I’m sure the motor activity output of the brain would have been altered by the huge ‘threat’ they had all just witnessed, whether conscious or not.

  8. I have to think he will have a faster recovery than one year as mark stated. I had a closed Tib-fib fracture playing soccer (futsal soccer ball that was weighted, myself & other player strikes the ball at exact same moment that caused the forces to snap my leg in half. Definitely a freak soccer accident). But I had it reduced & casted. No ORIF by choice of dad that is a PT. Thus a much slower rate of recovery. Took 8 months until cleared for contact. 6 months to run.

    Yes his was a compound fracture but that does effect the bone healing time. The fx should be healed by 12 weeks if no complications. Rehab 3 months. That’s 6 months just in time for midnight madness

  9. Looking back I’m not really sure why I said a year, it’ll be faster than that; although healing times won’t be the deciding factor in return to sport. I would assume neuro retraining will play more of a factor than pure healing times.

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