Arizona Cardinals’ rookie, and second round draft pick, Ryan Williams, has been sitting out the entire 2011 season with a right patellar tendon rupture that he sustained during a pre-season game. Only 20 years old at the time of his injury, Williams is missed on a Cardinals team that has been rebounding from a rough start and might be playoff bound if he’d been out there.

Last year’s victims of a torn right patellar tendon included Nate Allen, a rookie safety on the Eagles who was injured in December of 2010, and Clint Sintim, NY Giants linebacker, who was sidelined during a pre-season game.

Interesting that all the injuries were on the right side…

The patellar tendon is a part of the extensor mechanism of the knee and it serves to connect the patella (kneecap) to the tibia (larger bone of the lower leg). The extensor mechanism acts to straighten (extend) the knee, and is also comprised of the four quadriceps muscles of the front of the thigh, the quadriceps tendon (which attaches the quads to the patella), the ligaments that help to stabilize the patella (by providing a connection to the femur (thigh bone) above and to the tibia below), and also by other soft tissues on either side that help stabilize the patella and other structures of the knee.

Patellar tendon ruptures are relatively rare and they occur most often in people younger than 40 (most are in their teens or twenties). Ruptures can either be partial or complete. Complete ruptures should be surgically repaired quickly in order to enable the tendon to be sutured end-to-end. This also optimizes outcome. Waiting would result in retraction of the tissue and make a repair more difficult. The upper (proximal) portion of the patellar tendon ruptures more often than the lower. Some of these proximal ruptures pull a piece of bone away from the lower part of the patella; this type of injury is called an avulsion of the patella. It has been noted that African Americans have a greater predominance of patellar avulsions than other groups.

A complete rupture of the patellar tendon renders the quadriceps helpless, making it impossible to straighten the knee. A partial rupture makes extension difficult and is likely to make it impossible to straighten the knee through the end-range of motion.

Post-operative rehab is (as coaches say about almost everything), a process. Controlling pain and swelling in the initial phase, while also addressing mobility of the scar and surrounding soft tissue is crucial. Care must be taken to protect the repair and avoid stretching the sutured tendon too quickly, while ultimately restoring full range of motion – thereby enabling the knee to bend. Weight bearing is gradually resumed and assistive devices (crutches and canes) are eliminated once the extensor mechanism is strengthened sufficiently to fully support ambulation without significant gait abnormalities. Muscle strengthening, flexibility and endurance, as well as overall mobility and agility are all a part of rehabilitation.

A study on the recovery of NFL players who suffered patellar tendon ruptures concluded that the injury occurs most often with eccentric overload* of the extensor mechanism. It also noted that anterior cruciate ligament (ACL) tears occasionally accompany patellar tendon ruptures in the NFL, and that players without complications from other injuries generally return to play the following season. The study also found that players who’d been chosen earlier in the draft were more successful in returning to play.

• An eccentric muscle contraction is one when the muscle is actually lengthening while it is working. An example would be the second phase of a biceps curl when the elbow is straightening, thereby lengthening the biceps while the muscle works against gravity (and added weight) to slowly return the arm to its resting position.

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What makes McGahee’s accomplishments even more remarkable is that he played less than two weeks after surgery to repair a fractured fourth metacarpal in his right hand. McGahee had suffered the impact injury against a defenders mask versus the Dolphins on October 23rd.

The procedure performed on McGahee reportedly entailed stabilizing the fracture in his ball-carrying hand with a plate and five pins.  Originally casted, he reportedly wore only padding over his incision during practice last week and was absent that at game time. McGahee was quoted as saying that he  ”suffered what doctors call a boxer’s fracture.” but could now ”bend my hand without it hurting or anything”.  Improbable but we’ll take him at his word.

McGahee is no stranger to an accelerated return to action.  Having ended his college career in the 2003 Fiesta Bowl with devastating tears of his left ACL (anterior cruciate ligament), PCL (posterior cruciate ligament) and MCL (medial collateral ligament), he was drafted in the first round after an early return at the combines, and went on to a brilliant rookie season with Buffalo.

So what are the Metacarpals, and what is a Boxer’s Fracture?

The metacarpals (MCs) are the long bones in the hand that extend from the small carpal bones (that comprise part of the wrist) to the base of the fingers. Each metacarpal has a base near the wrist and a head at the knuckle (forming a joint with the lower bone of the finger – the proximal phalange) and a shaft and neck in between.

The MCs are most often fractured due to impact with a closed fist.  I know of too many people who’ve had this injury from punching a wall in anger.

Some metacarpal fractures can be treated conservatively with splinting. Others, like McGahee’s, require surgery, either because they are displaced (the segments of the bone no longer line up) and involve the joint, because more than one MC is fractured, or due to soft tissue that is in the way, preventing the bone from being set. I have not seen reports of the specific nature of McGahee’s fracture, but it is likely his falls into one of the first two categories.

Fractures can occur at any point in the metacarpals, though the very common  Boxer’s Fracture  is technically considered one that occurs at the “neck”of the fifth metacarpal, which is the MC leading to the little finger.  Therefore, with his fourth MC injured, McGahee may have been misinformed.

Typically the union (mending) of a metacarpal fracture occurs in six weeks.  Indeed, that is considered to be the response time for the healing of many fractures. Generally, due to splinting of the injury, whether managed conservatively or surgically, some loss of motion is expected, and rehab to restore mobility, strength and muscle flexibility is important. Inflammation must also be managed to control swelling. McGahee’s return in less than two weeks and his effectiveness is doing so is astounding.  His hand can’t be feeling too good right now though.

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When watching replays on TV or at the stadium, I’m actually amazed there aren’t even more ACL tears.  Feet are planted while the body rotates, a tackle forces a knee to hyperextend, pushing it beyond the straight or locked out position, or most commonly, a players legs are grabbed in a tackle while his body keeps moving (generally with the knee bent), forcing his knee to move in a manner that is simply not possible with the ligaments intact.  It is so easy to wind up injured.

NFLers currently nursing post-operative ACL’s include:
Running Backs Ernest Graham (Tampa Bay), Tim Hightower (Redskins) and Jamaal Charles (Chiefs)
Wide Receivers Kenny Brit (Titans) and Domenik Hixon (Giants)
Tight End Tony Moeaki (Chiefs)
Safety Eric Berry (Chiefs)
Cornerback Bradley Fletcher
Linebacker Thomas Davis (Panthers)
And even kicker, Nate Kaeding (Chargers)

Hixon is on his second ACL surgery in just two seasons, Fletcher tore his in a practice collision and Moeaki was injured in the final game of the rushed pre-season.  Taking the trophy in this unwanted competition, Davis is on ACL surgery number three in less than two years. I hope he’s been saving his money and has a plan B.

The Anterior Cruciate Ligament is the primary stabilizer of the knee. It is located between (and attaches) the rear outer base of the femur (thigh bone) and the top of the front inner tibia (the larger of the two bones in the lower leg). It is called the anterior (front) cruciate because it crosses another ligament (the posterior cruciate) that is located behind it, with the two ligaments essentially forming an “X”.

The ACL is comprised of two distinct bundles which serve complementary functions.  The posterolateral (outer/rear) bundle restricts or checks the motions of  hyperextension  and excessive forward gliding of the upper tibia with the knee straight.  It also limits internal rotation in the knee. When the knee is forced into hyperextension or inward rotation, this larger band risks injury.

The smaller anteromedial (front/innermost) band is taut in flexion (when the knee is bent) and is therefore most likely to be injured with force to the knee in a bent position.

The anatomy of the ACL explains why it can sometimes suffer only a partial tear, and why in these cases, it may be possible for an athlete to avoid surgery.

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Dallas’ Tony Romo is another one of those guys.– a selfless leader. He completed the game in week two against the 49ers, returning in the third quarter  having knowingly suffered a rib fracture in the first half.  Romo painfully, but heroically, went on to make a 77 yard pass to set up a win in OT.  It was only later that he was also diagnosed with a small lung puncture along with the isolated rib fracture.

Romo also played last Monday night in a boring squeaker against the Redskins. His performance was  clearly hampered by his injury and the offense sputtered. It would be surprising if Romo did not taken pain meds or have an injection to combat the pain associated with his issues. His breathing was likely still painful and throwing, especially for distance, had to have heightened his symptoms. Should he have played?

Jay Cutler went to fan and media purgatory after taking himself out of the NFC title game with a knee injury last January.  Cutler even came under fire from some fellow players.  Turned out, to everyone but Cutler’s surprise, the injury was real and it was significant.  He’d suffered a Grade 2 MCL (medial collateral ligament) sprain/tear.  Though he’d been known more as the warrior type prior to this incident, that didn’t shield Cutler from the abuse.  I wrote about it then, but Vick and Romo bring the dilemma of the injured player back to the headlines.

I’m not of the mind that players should simply tough it out when doing so is likely to contribute to an exacerbation of their  injuries.  Not allowing for a proper healing response delays recovery, often causing an injury to become an even bigger issue both on and off the field.  Such situations can also result in chronic conditions.  Not only can this potentially  impact performance, it can, and often does, impact life. Just look at the struggles of many NFL veterans.

Football being football, there is  the unwritten rule to target an opposing team’s weaknesses. We all know that doesn’t just mean a hole in the defense or a size mismatch on coverage.  Football puts a target on each players back under the best of circumstances. The already vulnerable become even more so.

The Cowboys were fortunate to come away from the Redskins game with a win. They didn’t win because of Tony Romo, and, if you ask me, Tony Romo didn’t win at all. He lost a week to help him recover.

Your thoughts?

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It generally isn’t the media at fault, but I question the wisdom of the collective universe of team spokespeople and medical departments. Unless the motivation is to mess with the heads of fantasy team managers, which is highly unlikely, why tell us players are questionable when there has to be no doubt.

Why take it day-to-day when week-to-week or month-to-month is more like it? Is management setting the players up for unrealistic expectations or just us fans. Is this supposed to be a motivating tool? If so, I don’t think it is working.

With my background in rehab, if reporting has been accurate, and even without the opportunity to personally assess an injury, I am rarely fooled. Ask my husband — I am always muttering when I read the injury reports — first because I hate to see anyone hurt, and second because the outcomes of competition will obviously be influenced accordingly.

Most disconcerting is the feeling I have that many players will push themselves to return too soon. Maybe it’s a contract year. Perhaps there is a back-up who’ll be given the chance to shine. Or it could simply be that losing just isn’t in the vocabulary. Then there’s the ridiculous “no pain, no gain” mantra.

Players want to play.

However, that doesn’t make it sensible to assume muscle strains will heal in a couple of weeks or that a neck injury that entails neurologic symptoms (see Peyton Manning) can be managed while the player sits out practice, or even worse, doesn’t! We’ve seen every kind of example, even when there hasn’t been time to assess a player’s healing response (i.e., Ike Davis).

Clearly money is a factor, and player contracts as well as the desire to win can override sensibility. Just look at what it’s taken to finally take concussions seriously.

In this age of “need to know” and instantaneous reporting, we sometimes even see predictions before an accurate diagnosis is made (Ike Davis again comes to mind). What ever happened to saying “We’ll let you know when we have all the information?” Why isn’t that enough?

Timetables for recovery only work if we know what is going on, allow for the body’s necessary natural healing response, see how the initial phase of recovery is progressing and have a motivated patient without medical complications coming into play. It isn’t magic but there is an element of guesswork. I’ve always found it better to err on the side of conservative estimations that may need to be upgraded during the rehab process.

Better to exceed them than not live up to them.

I’m also confused about pitchers returning from surgery, rehab and rehab starts just in time to close out a season that isn’t playoff bound. As they say on Saturday Night Live, “What’s up with that?” An entire off-season awaits and there is no prize for rehabbing fastest.

The prize of winning and career longevity may be thwarted by pushing the limits of recovery when there is no real need.

What do you think?

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In today’s world, health and exercise are very important and
many people choose to “pay out of pocket” in order to afford a personal
trainer. The role of a personal trainer is to develop a personalized exercise
program for a client and progress that exercise program based on the client’s needs
and stated goals. Well, what happens when you aren’t seeing any results from
working with a personal trainer because their education isn’t advanced or
because they “over worked” you and now you are injured?

That is where the licensed Physical Therapist steps in.  A Physical Therapist not only prescribes a
tailored exercise program to meet aesthetic or athletic goals but we can also
rehabilitate the mistakes that a personal trainer can make.  A Physical Therapist now holds a Doctorate
degree whereas a personal trainer holds a certificate that DOES NOT require any
formal education and can be attained online for a cost.

It just makes sense that if you are going to pay out of pocket
to have a trainer that you should hire the most qualified professional. A
Physical Therapist has a vast educational background in exercise as well as a
complete understanding of the muscular system which will allow for a
better-tailored exercise program for each individual client. A Physical
Therapist also understands how to AVOID causing an injury which will allow the
client to exercise to the maximum without risking injury. The bottom line is
that if you are just looking to get fit or if you have a history of injury and want
to achieve your fitness goals by using the “gold standard” then the choice is
clear, you will seek the help of a Physical Therapist.

http://www.nytimes.com/2011/07/19/health/nutrition/19best.html?partner=rss&emc=rss

There has been the long standing notion that softer surfaces would be more forgiving on the body; decreasing the compressive loading forces as the foot hit the ground and the ground reaction forces were transmitted  through the foot and corresponding kinetic chain of the knee, hip and spine.

The hard science hasn’t fully supported this, while the empirical evidence was that many runners did experience other soft tissue injuries like sprains and strains as a result of encountering unstable yet softer surfaces. Dr. Warden’s point about abrupt changes being risky is clearly worth noting as is the fact that gradual changes allows for adaptation by the body. Runners have always been advised to make training changes gradually and methodically, and for good reason.

For further information, please check with your Doctor or physical therapist.

As discussed in yesterday’s Injury Breakdown post, symptoms of an Ulnar Collateral tear, medical eipcondylitis and  irritation  or entrapment of the ulnar nerve share many similarities.  When it is an overhead athlete doing the complaining – particularly a pitcher who must put repetitive stress on the inner elbow – a tear is one likely culprit.  What is remarkable however, is the success with which Joba pitched while injured.

Comparing these diagrams will help you to see the intimate relationship of the ulnar collateral ligament and the tendons that were initially suspected of causing Chamberlain’s pain..

Elbow Ligaments:

Flexor Tendons at the Medial Epicondyle:

Take a look at an Injury Breakdown post from August of 2010, on then 22 year-old Nationals phenom Stephen Strasburg, to learn more about UCL tears and the Tommy John procedure. http://newyork.cbslocal.com/2010/08/31/injury-breakdown-strasburgs-predictable-tear/

Though Mets General Manager, John Ricco, was quoted saying that Davis would likely be out at least two weeks, and hopefully not longer, that sounds optimistic… as in very.  Bone contusions, or bruises, can take six weeks to heal, particularly those that are severe.  Fortunately, Davis’ contusion sounds like it is more on the mild side.

As for the ankle sprain, here too, recovery depends on the degree of injury.  Also at issue is which ligaments are involved.  A “high” ankle sprain, affects the connective tissue that attaches the two bones of the lower leg just above the foot (the tibia and fibula). A “low” sprain injures the ligaments that connect the base of these bones to the foot – either on the outer (lateral) side of the ankle (the more common inversion sprain), or at the inner (medial) compartment. Sprains are actually tears, be they microscopic or profound, depending on the grade of the injury. And, though return to full activity generally comes much sooner, complete healing can take a year!

After suffering an involved ligament sprain, even once healed, a joint is no longer as stable as it was prior to injury; hence a vulnerability to recurrence. High ankle sprains can be more of a challenge than the lower versions.  With his diagnosis of a bone bruise as well, it would not surprise me if Davis took the high road.

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What muscles might have been strained?

The inner (medial) and outer (lateral) heads of the gastroc (gastrocnemius) comprise the bulk of the calf muscles.  Deep to the gastroc is the soleus, and both attach to the heel bone via the Achilles tendon.  The primary difference between these two muscles is that the gastroc is a two-joint muscle, crossing both the knee and ankle, while the soleus originates below the knee, and crosses only the ankle.  Both muscles act to point the foot downward/forward (plantarflexion of the ankle), allowing you to do heel raises or walk on your tip-toes (other muscles also assist in this action).  They are crucial for push off with walking, running or jumping.  Because of their attachments, the gastroc is in charge of plantarflexion when the knee is straight, while the soleus is the prime mover when the knee is flexed.  As a result, they are also strengthened differently.

 

How do you stretch the calf muscles?

To stretch any muscle, it must be distended from its origin to its insertion.  Because it is a two-joint muscle, the gastroc is put on stretch when ankle is dorsiflexed (the foot positioned up and back) while the knee is straight (extended).  This is the traditional runners stretch.  In contrast, the soleus is stretched when the ankle is placed at its end-range of motion into dorsiflexion, with the knee flexed (bent).  As a special reminder, readers are cautioned NOT to stretch or strengthen either muscle by hanging their heels off the edge of a step or other elevated surface.  Repeatedly doing so can be damaging to structures in the foot.

A strain of the calf can occur with trauma, such as may have happened to Ike Davis, or may be due to overuse. Like sprains (of ligaments), muscle strains are graded based on the degree of damage to the tissue, with a grade III representing a complete tear.  Just as with the hamstring strains we hear so much about in baseball, a calf strain can become a nagging or recurrent issue and taking care to accurately assess the degree of Davis’ damage is the smart approach to drive the treatment that will follow.  His care and return to play will be based on his tolerance to anti-inflammatory measures, soft-tissue massage, progressive stretching and strengthening, as well as his ability to restore full function with respect to movement and balance.  Pain-free management will be a focus throughout.

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