Victor Cruz, a key NY Giants receiver, knew he’d suffered a significant injury before he’d even landed from a leaping attempt to catch a fourth-and-six pass down 20-0 to the Eagles in the fourth quarter on Sunday night. The diagnosis, a ruptured patellar tendon, more than ends Cruz’s season, it puts his career in jeopardy.
The patellar tendon is a part of the extensor mechanism of the knee, connecting the patella, or kneecap, to the tibia of the lower leg. Since tendons connect muscle to bone, enabling them to function, and ligaments provide joint stability by connecting one bone to another, the patellar tendon is actually a ligament. However, this vital structure is referred to as a tendon because rather than serve primarily for stability, its function is to enable the quadriceps muscle to extend the knee.
The extensor mechanism of the knee includes the quadriceps muscle, the quadriceps tendon (which attaches the muscle to the patella), the patellar tendon, the tibial tubercle (which is where the patellar tendon attaches to the tibia), and various ligaments that provide soft tissue restraints to the patella while it rides up and down during knee motion (the medial & lateral retinaculum and patellofemoral & patellotibial ligaments).
Because all the structures of the extensor mechanism are so superficial, they can be easily injured, though complete ruptures occur infrequently. The quadriceps tendon and patellar tendon are most vulnerable to rupture, which can be partial or complete. Rupture of the patellar tendon occurs more frequently amongst those under 40, while quad tendon ruptures occur more typically in the over 40 set. Young athletes generally do not suffer from complete ruptures, though chronic steroid use and diabetes are thought to be predisposing factors.
Another patellar tendon injury more common in the under 40 group is an avulsion of the tendon, which means part of the bone is pulled away along with the tendon, either at its attachment to the inferior pole of the patella itself (the more common avulsion), or at tibial tubercle. Interestingly, patellar tendon avulsions occur more frequently amongst those of African descent.
The most common cause of patellar tendon ruptures is during athletics when resisted knee flexion is accompanied by a violent quadriceps contraction – typically when landing from a jump.
A completely ruptured patellar tendon will not heal sufficiently to provide adequate function without surgical intervention. Surgery is generally performed shortly after incurring the injury and, in the interim, an attempt is made to control the inflammation. The success rate is improved if the procedure is not delayed, as the tissue will have little time to retract. The torn tendon is repaired and then sutured through bone tunnels in either the patella or tibial tubercle.
Post-operative rehab for a patellar tendon repair is a lengthy process. Controlling inflammation, restoring soft tissue and patellar mobility, knee range of motion and strength and power of the muscles that cross the hip and knee are of paramount importance. Return to full weight bearing and routine daily activities can take three months and sports specific activities are generally initiated at four to six months. It takes longer to return to full participation.
Even after a successful patellar tendon repair and when full knee flexion is obtained, the strength and explosiveness of the quadriceps may not be fully restored. This is but one facet of Victor Cruz’s game, though one that has set him apart. He has a lot of work ahead and hopefully will prevail.
Follow Abby Sims on Twitter @abcsims.
The healing process entails a remodeling of injured tissues, and things don’t always go as planned. Though tissues adapt well to normal stresses, chronic overuse results in maladaptation that includes an increase in scar tissue. This has a number of implications, but the end result is weakening of the tissue – be it tendon or muscle – and an inability for it to function optimally. Inadequate rest after an injury, an overly aggressive rehab program and/or premature return to activity sets the stage for this maladaptation.
A ligament generally remains lengthened after a significant Grade 2 sprain, and therefore no longer stabilizes a joint to the same degree it did before. Sufferers work to overcome injury by maximizing dynamic stability, muscle strength, and proprioception (see below), however re-injury in competitive athletics is common. Playing on an insufficiently healed
sprain will place undue stresses on the damaged tissue as well as on other stabilizing structures, inviting further damage (see RG III).
After injury, there is also a loss of proprioception, or the body’s position sense. Impaired balance is another issue, not only after lower body injuries but after upper body injury as well. Re-training balance and proprioception is included in rehab and – like strength, range of motion and flexibility – it takes time until they are at full capacity. Functional testing to determine a sufficient degree of recovery in all areas should be what dictates a return to competition.
Articular cartilage is the cartilage that lines and cushions the ends of bones, providing smooth gliding surfaces at the joints. It is known to be resistant to compression but with less than ideal tensile strength. Articular, or hyaline cartilage lacks vascularity (blood vessels), nerves and a lymphatic supply. It derives nourishment from the soft tissue that lies between the joint capsule and the joint cavity (the synovium). When overloaded, articular cartilage becomes irreparably damaged; it does not regenerate. Permanent and disabling defects can result from a premature return to sports.
The scenario might go like this: an athlete suffers a ligament sprain that results in a loss of joint position sense (proprioception). This deficit leads to altered mechanics, which would in turn place an excessive load on articular cartilage, resulting in an acute inflammation and lesions in the tissue. Wear and tear of the smooth hyaline cartilage is cumulative and, over time, the athlete’s joint may end up losing this surfacing entirely, resulting in what is known as being “bone on bone”.
The dreaded microfracture surgery – from which not all athletes emerge victorious – is one procedure often performed in an attempt to treat articular cartilage lesions. Holes are drilled through any remaining cartilage into the bone below in an effort to create a bleed. The intention is for blood and fat droplets to migrate into the defect, form a clot, and heal into a form of cartilage that will help protect the area. Rehab after microfracture initially requires a significant protective non-weightbearing phase and, even after a lengthy and cautious program, successful return to high-impact sports may not be possible (see Greg Oden).
Fibrocartilage, present in only several joints, is most recognized for its role at the knee. Known as the menisci, these structures act as the shock absorbers at the joint, also creating a better fit for the femur and tibia. Lacking a substantial blood supply, particularly in the central regions, significant injuries to the menisci (tears) may require surgery. Because of the lack of nourishment from blood, meniscal surgery is more often performed to remove a torn segment rather than to repair the damage. Return to sports too soon after arthroscopic surgery is likely to result in impaired performance. Of even greater significance, is that it may increase the likelihood of arthritic changes down the line.
Bone contusions, and even more so fractures, may seem to be scariest to an athlete. In fact, in most cases, because bone healing generally occurs in a four to six week window, a simple fracture mends in a more straightforward fashion than soft tissue. Contusions also generally resolve by the six to eight week mark. In contrast, displaced fractures – where the ends of the broken bone are out of alignment – require surgery (typically an internal fixation with plates, rods and pins) in order to heal properly. Fractures may be accompanied by soft tissue injury as well. The time required for athletes to return to sports after fracture is obviously greater than the healing time of the bone, as it also entails restoring any joint mobility lost due to immobilization, as well as achieving all the parameters of healing and function required after other musculoskeletal injuries.
When reporters inform us how long an athlete is expected to be out of action from an injury, they are reporting what they’ve been told. No one should base a fantasy team or bet the under on these predictions. In contrast with how most of us have learned to set a low-end realistic bar on expectations in order to exceed them, pro teams generally set our expectations of their athletes’ recovery too high, positioning them for failure. I’ve no idea why.
Follow Abby Sims on Twitter @abcsims.
*Note: My thanks to Michael T. O’Donnell, PT, DPT and Stephen Reischl, PT, DPT, OCS for an excellent presentation on Musculoskeletal Tissue Healing at the APTA conference last week. I’ve taken the liberty of boiling down much of the information (while adding my own two cents) in the writing of this article.
uke’s Blue Devils emerged victorious over Butler on Monday to be crowned NCAA Champions, though Butler now occupies an elite position on the college basketball map. However, the Butler whose NCAA story ended far more disastrously than with simply losing the big game was West Virginia’s Da’Sean Butler. The senior combo forward and Mountaineers leading scorer went down with a knee injury while driving into Brian Zoubek on his way to the basket with 8:59 remaining in the second half of the semifinal against Duke. Anyone who saw the play and of course, the slow-motion replay, could see the pain that Butler was in, likely from the injury itself as well as the timing (not that there is ever a good time for a major injury). It isn’t likely that the Mountaineers would have won the game had Butler remained intact, but this injury may have derailed more than his hopes for a championship. Butler’s blown out ACL may have cost him millions by driving down his stock as a possible first round selection in the upcoming NBA draft.
Coach Bob Huggins initially indicated that Butler had sprained his left MCL (medial collateral ligament). However, West Virginia’s Sports Information Director later announced that an MRI performed on Sunday revealed an ACL (Anterior Cruciate Ligament) tear as well as two bone bruises in addition to the MCL sprain. It seemed apparent from the moment Butler planted his left foot and his knee gave way that this was more than a mild sprain.
What is the ACL?
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 “Xâ€. The role of the ACL is to prevent the top of the tibia from gliding forward. When torn, this motion is not checked and the knee becomes unstable, often buckling.
What is the MCL?
The Medial Collateral Ligament also connects the femur to the tibia but at the inner, or medial compartment of the knee joint. When Butler went down it appeared that his knee buckled inward, permitting excess motion at the inner joint (the foot and lower leg angled outward). This would be indicative of an MCL injury.
What is a bone bruise?
Muscles, nerves and bones can all suffer bruises, which are also known as contusions. Contusions occur because of trauma associated with impact, and the severity of that impact is one important determinant of the degree of injury and rate of recovery. Simple muscle contusions generally resolve in a matter of weeks, and the healing process involves muscle repair, regeneration and scar-tissue formation. All contusions result in localized inflammation as well as pain and they may also inhibit muscle strength. Nerve contusions can precipitate neuralgic symptoms, while bone bruises can be particularly debilitating as well and some studies indicate their relationship to arthritic changes over time.
The specific location and type of bone bruises suffered by Butler were not clarified in reports of the injury. Though they may have resulted because of the impact against Zoubek (in this case they would likely be more superficial) they may also have occurred at the bony surfaces of the knee joint in the course of tearing his ACL. When an ACL injury occurs, excess or abnormal motion (of one bone on the other) is permitted, allowing the bones to bump into each other, resulting in a contusion. The MRI was an important diagnostic tool used to identify the nature and extent of Butler’s injuries, and if he suffered this type of contusion, it likely demonstrated abnormalities in the bone deep to the smooth cartilage that lines the joint.
Da’Sean Butler will have surgery soon and has a long road of aggressive rehab ahead. Therapy will focus on controlling any inflammation and swelling, restoring range of motion, muscle strength and flexibility, balance, and ultimately on movement, agility and plyometrics (jumping, etc). At the same time he will work to maintain his cardiovascular endurance. According to NBADraft.net, Butler is ranked as the 21st-best prospect in the 2010 NBA Draft, while DraftExpress.com has him as 44th in line. In a mock draft that was updated after the injury, DraftExpress had Butler as the 14th pick in the second round. He was interviewed during the championship game yesterday and expressed confidence that he will play in the NBA next season. With a great attitude and work ethic, the advances in surgery and rehab today, and with youth on his side, it is very likely that Da’Sean Butler will achieve his dream
If you follow the NBA you already know that Shaquille Oâ€™NeillÂ recently underwent surgery for a ligament tear in his right thumb.Â The injury was sustained on February 25th when Boston forward Glen Davis defended Shaq during a shot attempt. Though reports have not specified, it is likely that Shaq tore the ulnar collateral ligament (UCL) of the thumb, a common sports injury and also often a byproduct of falling on an outstretched hand.Â Â What you may not recall is that Shaq missed 22 games after suffering a similar (but likely less severe) injury in 1995 while playing with the Magic.
Wait a minute, isnâ€™t the UCL at the elbow?
Recent columns on this site have discussed UCL injuries to pitchersâ€™ elbows resulting in the need for Tommy John surgery as well as the implications of ankle ligament tears.Â First letâ€™s quickly review the basics to help you understand the nature of Shaqâ€™s injury.
A ligament is the connective tissue connecting one bone to another to provide stability at a joint.Â Each joint has at least one ligament on each side.Â In the hand or elbow, the inner (medial) side, or side of the ulna bone in the forearm, is called the ulnar side and the outer (lateral) side is called the radial side because of its relationship to the radius (the outer bone in the forearm). Hence, at the base of the thumb, just as at the elbow, the ligament stabilizing the innermost part of the joint is called the ulnar collateral (UCL).
Injury to a ligament diminishes stability at the joint it protects, and may do so even on a permanent basis, so
Shaqâ€™s prior injury may have predisposed him to re-injury.Â
Other names for the UCL tear of the thumb
Most often called â€œSkiersâ€™ Thumbâ€ these days because of its prevalence on the slopes, this injury used to be known as â€œGamekeepers Thumbâ€ because it was commonly found amongst Scottish Gamekeepers (wildlife managers) as a result of a repetitive stress and stretch to the ligament that they suffered when doing their work.Â
How does this injury occur?
A force that pulls the thumb away from the hand places stress on the UCL at the joint where the thumb meets the palm.Â If the force at this joint (also called the MCP, or metacarpophalangeal joint) is traumatic and causes the joint to exceed its normal limit of movement, the UCL is sprained. And, as for any ligament, a Grade III Sprain is really a complete tear.
A skier who falls while holding the pole, or anyone who tries to break a fall by reaching out with his hand to absorb the impact may suffer a Skiersâ€™ Thumb injury.Â If the thumb is bent backwards and a ligament tears, it is unlikely to be able to heal in the anatomical position because of the resultant instability of the joint.Â That is why Shaq is having surgery.Â Occasionally, just as was previously discussed with regard to ligament injuries at the inner aspect of the ankle, the UCL ligament may not tear but instead might pull off a chip of bone at its point of attachment (at the base of the thumb).Â This injury is
called an avulsion fracture and it too can result in instability at the joint if not corrected surgically.
So, what did Shaqâ€™s thumb probably feel like after the injury?
Just as after any partial or complete ligament tear, fluid builds up causing swelling.Â Visible discoloration is an indication that a ligament (or other vascularized structure like muscle or tendon) was torn.Â Naturally, pain is a factor and it will hurt to use the thumb (to grip or squeeze) or to bend it backward.Â Reports are that Shaq will be out for six to nine weeks to heal and rehab following todayâ€™s surgery.Â The Cavs or course, are hoping to have him back in the line-up to help them in the later rounds of the playoffs.