On Monday night, the San Antonio Spurs bowed to the Golden State Warriors in Game 4 of the Western Conference Finals. It wasn’t much of a contest. After another stellar regular season, early playoff injuries robbed the Spurs of veteran point guard, Tony Parker (quad tendon rupture), and the electric small forward, Kawhi Leonard (ankle sprain). On Saturday, when Spurs’ center/power forward, David Lee partially tore his patellar tendon, it was all but over. This wasn’t the first time that the 34 year-old Lee underwent significant post season surgery. He’d had a torn hip flexor repaired in May of 2013 having seen very limited playoff action once sustaining the injury the month prior.
The Patellar Tendon & Extensor Mechanism
Because tendons connect muscle to bone, and ligaments connect bone to bone, the patellar tendon is actually misnamed. The structure is actually a ligament, connecting the base of the patella (kneecap) to a prominence at the upper tibia of the lower leg. The patellar tendon is one component of the extensor mechanism of the knee.
The quadriceps muscle – which attaches to the patella via the quad tendon – is the featured player of the extensor mechanism. However, the functional unit is also comprised of bands of fibrous tissue known as the medial & lateral retinaculum, which help maintain the alignment of the patella (kneecap), as well as ligaments that provide patellar stability by connecting the patella to the femur and tibia (patellofemoral and patellotibial ligaments). The tibial tubercle, the prominence on the upper tibia that serves as the attachment for the patellar tendon completes the extensor mechanism.
Ruptures of the extensor mechanism occur either to the quadriceps tendon or patellar tendon and may be complete or partial. Patellar tendon ruptures generally occur in those younger than 40 years of age, while quad tendons are more likely to rupture in those over 40. Prolonged steroid use (resulting in tendon weakness) is thought to increase the risk of complete rupture, as are chronic diseases that adversely impact blood supply, such as Diabetes, Rheumatoid Arthritis, Lupus, or infection.
Patellar Tendon Ruptures
When either the quad or patellar tendons are completely ruptured, the knee cannot be actively straightened at all. With a partial tear, it is generally possible to extend it at least somewhat.
Most ruptures of the patellar tendon occur when the knee is bent and subject to more demand than it can tolerate. Ruptures occur more frequently at the upper part of the tendon and its attachment to the patella than at the lowermost portion where it attaches to the tibia. A patellar tendon rupture may also be referred to as an avulsion, which is the term used to describe the tearing away of a body part. In the case of a tendon tear, a portion of the attaching bone may be torn away as well. Without the tendon to anchor it, when someone has a torn patellar tendon, the kneecap will ride upward and remain there. Interestingly, there is a greater incidence of patellar tendon ruptures amongst those of African decent. The reason for this is not absolutely clear.
Complete rupture of the patellar tendon requires surgical repair, and surgery is best if performed promptly to optimize outcomes. Partial tears may heal sufficiently depending on the degree of disruption and the demands placed on the muscle tendon unit. Newer operative procedures allow patients to avoid prolonged immobilization in a cast and work on mobility of the knee in the post-operative period. This generally accelerates recovery. However, healing and rehab is a process that cannot be rushed. A gradual restoration of full range of motion, soft tissue and muscle flexibility, strength and endurance as well as balance and agility is all a part of that process.
The Boston Celtics announced on Saturday that Isaiah Thomas, their 28-year-old star point guard, re-aggravated a “right femoral-acetabular impingement with labral tear” in game two of the Eastern Conference Finals against Cleveland. The injury will keep him out for the remainder of the playoffs and may require surgery. The initial insult to the hip occurred on March 15th and it was evidently exacerbated in a semifinal round contest on May 12th.
First a little anatomy
The hip is a ball and socket joint that offers freedom of movement in three planes as well as translational movement that some conclude contributes an additional three degrees of freedom. The ball is the head of the femur, and the acetabulum is the concave socket in the pelvis. It is deepened by the presence of the labrum, a fibrocartilagenous structure that rings the area, providing a seal that increases the stability of the joint.
What is Femoroacetabular Impingement (FAI)?
When abnormal contact occurs between the head of the femur and the acetabulum, it generally results in damage to the labrum and to the smooth cartilage that surfaces the acetabulum and femoral head.
This abutment of the two structures is caused either by an acetabulum that extends out over the ball of the femur further than it should, or an irregularly shaped femoral head and abnormal junction between the neck and head of the femur. The former is known as a Pincer type FAI and the latter a Cam FAI.
These bony abnormalities can result either developmentally or in response to trauma. However, the majority of cases have been found to have a developmental predisposition. It is possible to have the underlying features without ever experiencing symptoms in the absence of consistent overload to the joint.
With a Cam impingement, the extremes of motion of the hip joint increase the compression and shearing stresses to the joint surfaces. This is particularly so for hip flexion (bending), adduction (moving toward and across the midline of the body bringing the leg toward the opposite side) and internal (inward) rotation. The offending motions in a Pincer impingement can vary depending on the specific nature of the bony abnormality. However, both pincer and Cam hip impingements result in degenerative (arthritic) changes.
Imaging studies can help identify the nature of the injury. In addition to noting inflammation and bony abnormalities, measures are taken to quantify the anatomic deformity.
In some cases, rehab to promote increased hip range of motion and strengthening of the hip musculature can resolve symptoms. Should conservative management prove insufficient, or In the presence of more pronounced pathology, surgery may be indicated. Generally performed with a scope, the procedures involved may include cleaning debris from the area, smoothing the joint cartilage, repairing a torn labrum, and shaving irregular bony surfaces to decrease surface contact.
Yankees’ closer Aroldis Chapman was placed on the 10 day DL last Sunday with what was reportedly diagnosed as a rotator cuff strain. He had evidently tried to work through discomfort in his last two outings, the combination of which caused his ERA to jump from 0.79 to 3.55.
The Rotator Cuff
Four muscles that serve different functions essentially fuse at the shoulder to form the rotator cuff tendon. However, each inserts on a slightly different aspect of the humeral head and can be stressed in unique ways. The cuff can be especially vulnerable to injury for overhead athletes, particularly pitchers, who repetitively place extreme forces on the area.
The rotator cuff muscles are the subscapularis, supraspinatus, infraspinatus and teres minor.
Because of its position directly over the top of the head of the humerus, supraspinatus acts to raise the arm out to the side (abduction). This portion of the tendon is often subjected to wear and tear from chronic impingement (compression) in the narrow space it occupies between the acromion (a portion of bone that appears like a hood over the shoulder), and the head of the humerus (the bone of the upper arm).
Weakness of the outward rotators of the cuff – the infraspinatus and teres minor – which insert at the back of the humeral head, can contribute to impingement risk. This is because it renders them less effective at stabilizing the head of the humerus and depressing it with overhead motions. Instability at the anterior (front) aspect of the shoulder joint also contributes to impingement. The degree of the distractive forces at the shoulder in the extreme position of external rotation required during the cocking phase of pitching are what is at issue here.
If rotator cuff tendons become inflamed, swelling can further compromise the joint space, creating more impingement. Additionally, excessive demand on fatigued, weakened or inflamed tissue leads to further breakdown. Hence, working through the symptoms, as Chapman evidently attempted to do, is not helpful. Degenerative rotator cuff tears can ultimately result in complete rupture and are often associated with biceps tendon rupture as well.
The fourth rotator cuff tendon is that of subscapularis, which crosses the front of the shoulder joint. This muscle, which lies on the undersurface of the shoulder blade, is one of the internal (inward) rotators (teres major is another). Because of its position, this portion of the tendon also reinforces the anterior capsule of the shoulder, providing some restraint to the forward translation of the humeral head that occurs with outward rotation.
Rotator Cuff Strains
It is possible to strain any of the individual muscles of the rotator cuff. When strength testing these muscles in isolation, it can be determined which is involved by which resisted action results in pain. Other tests on physical exam can also be revealing, as is MRI.
Strains are graded on a scale from one to three, with a Grade 1 being a mild inflammation and a Grade 3 being a complete rupture. Even if his is only a Grade 1 strain (the likely scenario, though no specifics have been reported), Chapman is likely to be out at least a month to six weeks – and quite possibly longer – as he works his way back to competition after a period focused on rest and rehab. The worst thing he could do is return to the mound prematurely.
Jeurys Familia, The Mets’ 27-year-old closer, was diagnosed with an arterial blood clot in his right shoulder yesterday. Though he’ll likely be out for a while, if not the duration of the season, Familia is fortunate that this was caught now. Further testing is underway to determine if surgery is indicated.
Familia, whose command was an issue this season, especially so in his first blown save this week, said “I just didn’t have it today.” But it proved so much more than that once he was examined by team physicians.
The NY Daily News reported that a scout had noted that Familia’s velocity had been down this season and his “splitter had less drop”, leaving the ball up far too much. He had pitched Monday,Tuesday and Wednesday, this week, his second three consecutive game stretch of the season and 11th appearance out of the 18 games played since his return from suspension. Last year Familia closed on three consecutive days six times and risk of overuse was discussed in the media.
Others Who Have Been There
Blood clots in the axillary artery or compression in the thoracic outlet are not as uncommon as one may think in a population of young, otherwise healthy overhead athletes. The Mets know this all too well, with Matt Harvey having had surgery 2016, and Dillon Gee in 2012.
Symptoms of a clot in the region of the shoulder can include arm fatigue, complaints of a “dead arm”, or numbness and tingling in the arm or hand. All of these symptoms can also have alternate causes.
The significance of a blood clot cannot be overstated. If dislodged, clots can cause stroke or heart attack. J.R. Richard, who might have been the most dominant pitcher in 1980 when he began to complain of arm fatigue, suffered a severe stroke when his symptoms were initially ignored by the medical team and then his clot went undetected on physical exam. For Richard’s account of his ordeal, read this.
Cause and Effect of Axillary Vascular Issues
The repetitive and extreme demand that the young overhead athlete places on his or her shoulder causes the developing skeletal system to adapt. Pitchers in particular succeed in part because of these adaptations: increased external (outward) rotation at the shoulder, an altered position of the head of the humerus and of the joint itself (which become more retroverted), and laxity in the front of the shoulder. Not only do these changes impact the stability of the shoulder, but they have also been shown to place the muscles, other joint components as well as the vascular structures at greater risk of injury.
When the ability of any tissue to withstand the demand placed upon it is exceeded, the dynamic is altered and results in tissue failure and injury. Damage can be acute but also progressive and chronic. The torque and shearing forces produced during the pitching motion are so extreme as to make injury more likely.
A study that examined the effects of throwing on upper extremity arterial blood flow found that “pitchers with signs of shoulder laxity had a significant decrease in arterial blood flow compared with throwers with no evidence of laxity. This vascular insufficiency probably occurs because of the repetitive positional compression onto the third portion of the axillary artery as the humeral head translates anteriorly during the late cocking phase of throwing.”
Aneurysms and Thoracic Outlet Syndrome
Other studies using ultrasound concurred with the above, finding that “intermittent compression can cause chronic changes in downstream vascular sufficiency and potentially lead to an axillary artery aneurysm or thrombus in the overhead throwing athlete.”
An aneurysm is an enlargement caused by the weakening of the walls of an artery. A thrombus is a clot that forms in the blood vessel thereby disrupting blood flow. When such a clot dislodges and travels through the bloodstream it is called an embolus.
In 1996, David Cone, a pitcher on the NY Yankees, was diagnosed with an axillary aneurysm. In his case clots formed in the area and broke away causing symptoms in his hand and fingers. For more on aneurysms in pitchers read here.
Thoracic Outlet Syndrome (TOS) entails the compression of the neurovascular bundle (nerves and/or blood vessels) that lies in the area known as the thoracic outlet.
The boundaries of this space are the clavicle (collarbone), the first rib, the subclavius and scalene muscles of the neck as well as the costoclavicular ligament (which connects the first rib to the clavicle). This positional compression, causing reduced blood flow or neurologic symptoms down the arm and to the hand, is more likely to be symptomatic amongst elite overhead athletes. Matt Harvey had surgery last year to treat the condition by removing a rib.
On any given day there are a significant number of MLB players out with oblique strains. These injuries can keep a player on the DL for longer than expected. Here’s a little insight as to what these muscles do and why injury is so prevalent.
First a little background on the “core”
The internal and external obliques are just two of the abdominal muscles that are part of a group often referred to as core muscles. The core is comprised of the more central muscles of the body, those that are part of the lumbo-pelvic-hip complex. Not all core muscles attach directly to the vertebrae, yet they provide stability, enabling safe and efficient movement throughout the body while minimizing injury risk. Some core muscles also serve to support our internal organs. A table of core muscles is provided here.
The abdominals include the transverse abdominus (the innermost layer that you can feel contract when you cough), retctus abdominus (the six-pack in front), and the internal and external obliques (see below). Other core muscles include the quadratus lumborum (a broad muscle in the low back), multifidus (a deep muscle that runs along the spine), muscles of the pelvic floor, the diaphragm, as well as the psoas (a hip flexor), gluteus medius and other muscles of the hip.
When strengthening the core it is ideal to work on controlled functional movements with sustained core stabilization rather than isolating the muscles with exercises such as sit-ups; hence the popularity of planks and a variety of other exercise programs like Pilates. Strengthening that addresses the extremities to the exclusion of the core will not optimize functional strength, and will likely lead to injury from undue stress – whether to the spine or the extremities themselves. Even “isolated” strengthening of the extremities should include a focus on a stable core and avoid compensatory movements in the spine. For instance, if you have to arch your back to do a bicep curl, you are lifting too much weight, doing too many reps, or simply not engaging your core musculature properly.
The obliques are the abdominal muscles that rotate and side-bend the trunk. The fibers of the obliques are oriented in a diagonal pattern, with the internal obliques (the innermost layer) going in one direction and the external obliques (the outer layer) in the other. They attach to the low back, ribs, the pelvis and the midline of the abdominals. For pictures of these muscles, look here.
What do the obliques do and how are they hurt?
Though the internal and external obliques have opposing functions, when working together they assist in forward flexing the trunk. In baseball, these muscles are most likely to be strained due to the powerful and explosive torsion motions required when batting and pitching. In addition, strong lower bodies resulting from focused conditioning generate powerful forces that translate up through the trunk during sports. This as well as restricted hip mobility – not unusual in this population – can also predispose to oblique injury by placing excess demand causing strain.
The Internal Obliques
The diagonal orientation of the internal obliques is key to understanding their function. When they contract (shorten), the internal obliques act to side-bend and rotate the torso toward the same side. In other words, a right-handed batter forcefully contracts his left internal obliques to rotate his trunk to the left as he moves into the swing and follow-through. That is why occasionally, when a switch hitter returns to the line-up after resting and rehabbing an oblique injury, you will see him bat only from the side that does not emphasize the oblique that is injured.
Another important function of the internal obliques is to assist in respiration. They work when we exhale forcefully to draw the diaphragm up, thereby forcing air from the lungs. Normal exhalation, which is a more passive motion, does not involve the obliques.
The External Obliques
The external obliques run on a diagonal that is more or less perpendicular to their more internal counterpart. They assist in side-bending and rotating the trunk toward the opposite side. That means that the right external obliques act with the left internal obliques to swivel the trunk to the left when a batter bats right-handed. They also serve a role in respiration, and that is to assist with inspiration (breathing in) by pulling the chest downward and compressing the abdominal area to allow for expansion of the lungs with air.
Houston Rockets’ 34 year-old backup-center Nenê Hilario suffered a tear of his left hip adductor muscle in the first quarter of yesterday’s playoff game against the San Antonio Spurs. Though the Rockets’ subsequent win tied the series at two apiece, Nenê will be out for the duration. An MRI reportedly revealed the tear. A treatment plan has yet to be announced.
A Groin Strain
A groin strain can entail any of the six muscles in the group known as the hip adductors. These muscles originate on the lower pelvic girdle (at the ischium) and bottom portion of the pubic bones, and insert in the thigh on the inner side of the femur.
Strains are graded from a Grade 1, which is a mild disruption of the muscle fibers to a Grade 3, which is a complete rupture. Reports on Nenê’s injury did not indicate whether he was diagnosed with a Grade 2 (a partial tear) or Grade 3.
Adductor strains can be triggered by traumatic over-stretching of the muscles or with agility activities, which entail a quick change of direction. Other common causes involve applied resistance to the muscles such as when strengthening, with rapid movement of the limb as when kicking a ball, or even simply using your foot to push something along (particularly with the hip in an outwardly rotated kicking position). Soccer and hockey players exhibit the highest incidences of sports related adductor strains.
The Hip Adductors
The primary function of the adductors is to draw the thigh toward the midline of the body when the foot is not planted and to help stabilize the lower extremity and pelvis when the foot is fixed. One of the adductors in particular, the adductor longus is the one most often injured in sports. The orientation of this very long muscle puts it at a relative mechanical disadvantage, which is thought to be the reason it is more susceptible.
Other factors found to increase the vulnerability of the adductors include: weakness, (particularly relative to the strength of the hip abductor muscles, which are their counterparts), and the strength of the forceful lengthening type of contractions (known as eccentric contractions) that are required of these muscles to play sports such as hockey. In addition, decreased muscle flexibility, a history of prior injury or even weakness of core muscles in the region resulting in altered mechanics can also predispose to adductor strains.
The primary hip adductor muscles are the: adductor longus, adductor magnus, adductor brevis, gracilis, and pectineus, A sixth muscle, obturator externus, also contributes secondarily to hip adduction when the hip is in flexion (bent). This muscle’s primary functions are to stabilize the head of the femur in the socket at the hip and to outwardly rotate the hip.
Though specific training programs can reduce the incidence of injury, there are no guarantees. Progressive rehabilitation is important once injury does occur to control inflammation, restore strength and flexibility, as well as to prevent a strain from becoming a chronic or recurring issue.
Occasionally, more chronic groin problems are associated with other diagnoses, such as a sports hernia, that may require surgery. This diagnosis is made when there is weakening or tears in the muscles of the abdominal wall.
The San Antonio Spurs lost point guard Tony Parker to a quadriceps tendon tear in the fourth quarter of game two in their series against the Rockets on Wednesday. Parker, who now faces surgery, was a big reason that San Antonio evened up the series that night at one apiece. Like the Clippers’ loss of Blake Griffin to a season-ending playoff injury, this one could cost the Spurs the ability to advance.
At age 34, Parker’s numbers this season were at a career low (10.1 ppg), though he’d ramped that up to an eight game playoff average of 15.9 on 53 percent shooting. Now he faces a long road back and, with his age and overall declining regular season numbers, a questionable return to the NBA.
The Extensor Mechanism
The quadriceps is a vital part of what is called the extensor mechanism of the knee, with the muscles acting in unison for that purpose. One of the four muscles, the Rectus Femoris (RF) also serves as a hip flexor because of its origin at the pelvis.
The extensor mechanism includes much more than just the quadriceps muscle and the quad tendon. It is also comprised of bands of fibrous tissue known as the medial & lateral retinaculum, which help maintain the alignment of the patella (kneecap), as well as ligaments that provide patellar stability by connecting the patella to the femur and tibia (patellofemoral and patellotibial ligaments). Another important ligament in the extensor mechanism is really misnamed – the patellar tendon – which connects the base of the kneecap to the tibia of the lower leg. The final component is the tibial tubercle, a prominence on the upper tibia that serves as its attachment.
The four muscles of the quad are the Rectus Femoris (RF), the Vastus Medialis (VM), the Vastus Lateralis (VL), and the Vastus Intermedius (VI). The lowermost fibers of the VM are more horizontal in their orientation, and are traditionally known as the VMO (Vastus Medialis Obliquus). In addition to their role as knee extenders, these fibers have a distinct function in helping to maintain patellar alignment. A relatively new study points to the fact that a fifth muscular component, the Tensor Vastus Intermedius, also contributes to the quad tendon.
The Quad Tendon
Tendons connect muscle to bone enabling the muscles to function. Though the quad is made up of distinct muscles with differing attachments at the pelvis, hip region and femur (thigh bone) the tendons fuse to form a layered insertion at the patella.
The majority of quad tendons are three-layered, though studies show some variability. The quad tendon inserts at the base and sides of the patella in addition to having fibers that attach to the patellar ligament.
Quad Tendon Rupture
Quad tendon tears are painful injuries that are not as common as those of the patellar tendon in younger athletes (less than 40 years of age). They can be either partial or complete (rupture), and occur far more often amongst men than women. Rupture may be associated with weakened tissue (such as with a history of prior injury or tendinitis) and may be due to diminished circulation in the area. Increased risk is also a factor with a history of local cortisone injections, and medical issues such as diabetes, gout and others.
Injury generally occurs on a loaded limb with the foot planted and the knee in some degree of flexion (bent). The specific location of a tear is reported to correspond with the amount the knee is bent at the time it is injured.
A person is not able to walk following quad tendon rupture, as the ability to extend the knee is lost. After partial rupture the knee can be extended, though not fully. This is known as an extensor lag.
Rupture entails bleeding into the joint (hemarthrosis) that is often experienced as a burning sensation, and swelling is present. A complete rupture must be treated surgically to restore function. The tendon is repaired as well as anchored to the bone. It is preferable for surgery to take place within a week after injury in order to prevent retraction of the tissue.
There are various protocols for treatment following surgery. Some entail periods of immobilization for four to six weeks during which a hinged brace progressively restricts the amount of bending that is permitted. This allows the quad tendon to heal without being unduly stretched. Others involve earlier mobility and functional rehab.
Passive and active range of motion activities are important either way. Full weightbearing is now recommended, though with a progression from crutches to without, as pain and function allow.
Soft tissue mobilization is employed throughout to minimize adhesive scarring and restriction. Restoring strength is paramount as is restoring range of motion, muscle flexibility and ultimately, muscle endurance and power.
Studies done comparing the more conservative post-op approach with that of earlier functional rehab show no appreciable difference in outcomes. This affirms the safety of the latter.
In the case of a partial rupture, treatment is often non-surgical, involving immobilization and therapy to preserve/restore joint mobility followed by addressing other facets of muscle function as noted above.
More specifics regarding quad tendon rupture and surgery can be found here.
Greg Bird, the Yankees’ 24-year-old first baseman, was placed on the 10-day DL yesterday because of a right ankle contusion he’d sustained as spring training drew to a close. With the exception of missing four games shortly after the start of the season, Bird has played through since fouling a ball off his foot to cause the injury. However, his sluggish performance at the plate – a big departure from his sizzling March stats – belied an issue.
Manager Joe Girardi noted that “In watching (Bird on Monday) and talking to (hitting coach) Alan (Cockrell) about his work (Monday), I just didn’t feel like there was a lot of explosion in his lower half,”
When new MRI’s this week did not show significant healing, rest from baseball activities was prescribed.
One has to wonder if Bird had been participating in drills and other warm-up activities during the past month that entailed running or jumping. I’ve no idea, though in deference to his ankle injury, I suspect not. Thus it seems likely that had the injury not adversely impacted Bird’s hitting, running the bases more frequently might have exacerbated his symptoms, calling more immediate attention to the consequences of his playing hurt. Additionally, had he altered his running mechanics, he would have risked injury to other areas of the foot and onward up the chain.
In the absence of a period of sustained rest in the acute phase after injury, pain exacerbated by running may have translated to an earlier stint on the DL. This could have accelerated healing resulting in a delayed but more productive start.
In mid April, Bird was quoted saying that his injury was “in a weird spot” and that “If it was an inch higher, I think it would be just a bruise. Where it’s at, there’s a lot of movement there. At least that’s how they explained it to me. I think it’s just going to take time. I feel better. Get the cleats on and kind of see where it goes. It’s kind of a weird thing where just certain things bug it.” And now we’ve seen where it went.
Take a moment to recall Derek Jeter, who in 2012 played through with an ankle contusion (though perhaps his was more involved) and went on to lose significant time because he then developed compensatory stress fractures.
A bone contusion is a traumatic injury that is caused by forceful impact.
A contusion is really more than just a bruise. Though not evident on x-ray, MRIs have revealed that this pathology entails disruption to the bone marrow that rests below the joint cartilage and represents microfractures, hemorrhages and edema to the inner layers of the bone (known as cancellous bone). These do not affect the outer (cortical) layers or articular cartilage.
Research on healing time of contusions has mostly been concerned with those that occurred with knee hyperextensnion and ACL tears. Time to healing has varied and appears to also depend on the presence of other injuries. While one study showed that 48% of sufferers showed no evidence of injury six weeks after insult, others report up to six months as being expected. One study revealed that a percentage of sufferers showed evidence of pathology on MRI even two years post injury.
Anatomy of the Ankle
The ankle joint is also known as the talocrural joint and is comprised of three bones connected by ligaments. The bases of the two bones of the lower leg – the larger tibia and smaller and outer fibula – form a socket (known as a mortise) at the upper portion of the joint in which the talus bone of the foot rests. This is the ankle joint. The calcaneus, or heel bone, sits below the talus, and together they form what is called the subtalar joint. The calcaneus is the largest bone in the foot.
Forces distributed to the talus are from five to ten times body weight during walking. This load increases dramatically with running. Like joint surfaces throughout the body, the surface of the talus is lined by smooth articular cartilage that can be damaged due to trauma (such as fracture or sprain) or other factors. These pathologies are known as osteochondral lesions (osteo=bone, chondral=cartilage). Interestingly, the talus does not serve as an attachment for any muscles of the leg or foot and its blood supply is not robust.
When Noah Syndergaard missed his start on Thursday, it was reported that he had biceps discomfort. On Friday, the Mets’ right-hander reportedly not only said he felt great, but that he should have pitched the day prior. Evidently he had declined a suggested MRI. We all know how that turned out when – only four outs into his start yesterday – Syndergaard clutched his right underarm before exiting the field in pain.
The New York Times then reported that GM Sandy Alderson noted that the pitcher’s latest issue “may or may not be related to his previous complaint, which was biceps, so we have to wait and see what happens.” However, Manager Terry Collins commented that the current injury is likely to the lat and is “not even close to the same area.”
The mystery was solved today when MRI results revealed a partial tear of the right lat (which is a Grade Two injury). Syndergaard was placed on the 10-day DL, though there is no way he’ll return that quickly. This story – and its consequences – won’t end here.
One point of concern is that whether this represents an entirely new injury or not, Syndergaard would have been predisposed to something getting tweaked if he did, in fact, have even a mild underlying condition; Particularly if it caused him to alter his mechanics. Without an MRI last week, however, we’ll never know whether it was the biceps or lat causing Syndergaards original symptoms.
Though we now know the source of the pitchers problem, it is a perfect time to explain a little about the biceps and the latissimus and their relationship with the pitching shoulder.
Though the biceps and the lat muscles occupy totally different parts of the body and serve very different functions, they exist in close proximity near their attachments. Though a physical exam and diagnostic imaging studies can differentiate which of the two muscles is involved in an injury, each might cause a pitcher to complain of pain at the shoulder.
The Biceps Brachii
The primary actions of the biceps are to flex the elbow and supinate the forearm (turn the palm upwards). However, it contributes to the action of shoulder flexion (raising the arm upward in front of the body), and is thought to offer a degree of shoulder stability by depressing the head of the humerus at the shoulder joint, thereby helping to prevent impingement of other soft tissues in the area.
The biceps has two heads. At the shoulder, its long head attaches to a bony prominence (the supraglenoid tubercle), via a tendon that runs in a groove in the upper humerus (called the intertubercular groove or the bicipital groove). The shorter head attaches nearby, at a bony process (the coracoid) that juts forward from the shoulder blade (scapula) and lies under the collarbone (clavicle).
The Latissimus Dorsi
The lats are very large muscles whose primary functions are to inwardly rotate the shoulder as well as to extend it (bring the arm from the front of the body toward the back) and draw the arm toward one’s side (adduct the shoulder).
The lat tendon inserts into the lower portion of the bicipital groove mentioned above. The broad fan-shaped muscle originates at the spine from the mid back to the base of the lumbar region, at the fascia in this area, as well as from the lower ribs and the lowermost portion of the shoulder blade.
The biceps and lats during the pitching motion
EMG studies have identified that the lat is eccentrically stressed during the cocking phase of the pitching motion and the biceps are activated late in this phase as well. During the acceleration phase the lat is active while the biceps are not. This phase begins with muscles first acting to decelerate the arm, limiting the shoulder outward rotation and elbow flexion before initiating the opposite actions to impart acceleration to the ball. Follow-through also entails deceleration of the upper extremity via eccentric contraction of the musculature. During this phase the elbow and forearm move into extension and pronation (palm turns downward). The biceps contract to help prevent hyperextension at the elbow in this phase.
For more on muscle actions and injuries as they relate to the throwing shoulder read here.
Non-traumatic Injuries to the lat are more common amongst pitchers than for the rest of us. Symptoms are often greatest with the release of the ball and with follow-through. Pain is generally reported in the back of the armpit as well as the upper arm.
The lat is a forceful muscle important for the performance of many sports. As with other muscular strains, the severity of lat injuries are graded on a spectrum from Grade 1 being very mild to a Grade 3 when it is completely torn. In some cases the muscle tears away from its attachment to the humerus. This is called an avulsion and it is an injury that requires surgical repair.
Blake Griffin, Los Angeles Clippers’ star power forward, did not return to play the second half in last Friday’s first round playoff game against the Utah Jazz. The 28 year-old reportedly suffered an injury to the plantar plate of his right big toe. It is a big loss for the Clippers, who now trail the Jazz 3-2 in their best of seven series. Griffin, who will not return to action this post season, was evaluated Tuesday by a foot and ankle specialist. Accounts say that he will seek several other opinions prior to undergoing surgery.
What is the plantar plate?
The plantar plate is a structure that functions as an especially strong ligament. It is thicker and stronger than most ligaments, and rests on the plantar (bottom) surface of the joints formed by the long bones of the forefoot (the metatarsals) and their corresponding proximal phalanges – the lowermost bones at the base of the toes. These are referred to as the MTP joints. The plantar plate connects the bones that form these joints with an attachment to the metatarsal that is less firm than that to the phalanx. It arises from the plantar aponeurosis and plantar capsule of the MTP joints and serves as an attachment for a number of ligaments and tendons in the area.
Because the bony surfaces at the first MTP joint are quite shallow, it relies on the capsule, ligaments, and flexor tendons for its stability. The medial and lateral collateral ligaments are those that check against lateral and medial forces, providing valgus and varus stability,
An important stabilizing function of the plantar plate is to offer a restraint that checks against subluxation or dislocation of the joint – generally toward the top of the foot (dorsally). The plantar plate at the first toe, the hallux, which Griffin injured, is distinguished from those at the other toes because of the two small sesamoid bones that lie within the complex.
Though more passive in offering support while simply standing, structures of the foot that support our body weight are most critical during propulsion, and are stressed even further with the actions required in playing sports.
How is the plantar plate injured?
Pathology at the plantar plates of the second and third toes is diagnosed more often than that at the first toe. In these cases however, the diagnosis is generally of a more chronic and degenerative nature and is also referred to as metatarsalgia. It can result from abnormalities in the alignment at the foot (i.e. from a bunion), biomechanical issues or, as some literature notes, repeated steroid injections.
In athletics, it is the plantar plate at the big toe that is injured most often. This traumatic injury, which is likely that suffered by Blake Griffin, is also known as turf toe. The hallmark of this diagnosis is a tear of the joint capsule from the metatarsal head. This allows the proximal phalanx of the toe to drift upward, subluxing or dislocating the joint.
Injury to the articular cartilage and adjacent tendons can also be involved with traumatic plantar plate disruption at the first MTP joint.
Turf toe is most commonly caused by a hyperdorsiflexion trauma to the plantar plate at the big toe. Hyperdorsiflexion is when the toe is forced upwards/backwards (from the MTP joint) beyond its normal range of extension. This is particularly prevalent in football due either to the nature of certain tackles or from the grip that flexible cleated shoes have on artificial turf.
The injury also less commonly results from hyperflexion of the MTP or from a valgus force.
Diagnosis and Treatment
Blake Griffin undoubtedly underwent several different imaging studies in order to identify the type of plantar plate injury he has and whether it is accompanied by fracture. Detail on the types of imaging generally used, and the advantages of each option, can be found here.
As with many orthopedic injuries, dislocations of the first MTP are classified as either type one, two, or three. Unlike most injuries, where type three requires the most aggressive surgical care, that is not the case with MTP dislocations. Type one MTP dislocations are the only one of the three categories that typically requires surgical intervention. Features of type one MTP dislocations are noted by Wheeless’ Textbook of Orthopaedics to be as follows:
- Plantar plate ruptures at its proximal attachment to metatarsal neck & dislocates with attached sesamoids riding over metatarsal head
- Plantar plate-sesamoid complex follows the proximal phalanx
- Metatarsal head can buttonhole into the plantar capsule which prevents closed reduction
- Disruption of volar plate – sesamoid complex
- No sesamoid fracture
- No widening of inter-sesamoid space
- Reduction is blocked by the interposed volar plate;
Treatment for these entails an open reduction via a dorsal approach.
Following types two and three traumatic subluxation or dislocation of the MTP joint, alignment is often restored with a closed reduction (repositioning manually and without surgical intervention). This is followed by a period of reduced activity and wearing a brace to restrict mobility into dorsiflexion once activities are resumed.