ets’ safety, Jim Leonhard, is the newest member of the NFL’s ruptured patellar tendon club, after suffering the injury in last Sunday’s victory over Kansas City. As expected, surgery will end Leonhard’s season, the second consecutive year that injury has shut him down early. Last year he fractured his right tibia (leg), the same side injured this week.
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…
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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It came as no surprise to me that Darrelle Revis exited yesterday’s game against the Patriots early in the second quarter having aggravated his left hamstring. Revis played limited time in last Thursday’s practice and was listed as probable for Sunday, though reports had him moving well. Evidently Revis and the team’s medical staff felt his hamstring wouldn’t limit his range, and he was cleared to start. This is a cautionary tale however hamstring injuries just don’t resolve in a matter of days, especially so when an athlete is required to jump, leap, run and cut with abandon. Though I didn’t evaluate Revis, those who did evidently felt he had rebounded sufficiently from the mild strain (listed as tightness) he had complained of. And though that may have appeared to be the case, why test such a nagging type injury for a player deemed to be so important, so early in the season? And this after missing camp though I presume, giving him the benefit of the doubt, that Revis did train independently while playing hard-to-get with management. If I am giving him too much credit, shame on him, he asked for this. The Jets however, did not.
Andy Pettitte, though older and with a history of muscle strains, is our current local example of the sometimes arduous process of recovery from this type of injury. Pettitte reportedly had a grade I strain (the mildest version), though his was in the groin (adductor) muscles, which are clearly stressed during the pitching motion. Pettitte had been out of action since July 18th and, though he was initially expected to return to the lineup by mid August, he did not start until yesterday, working six innings in an excellent no-decision game against Baltimore. The Yankees eventually lost the game, but Pettitte’s successful return is good news for the Yankees as they head into the playoffs.
What are the hamstrings and what do they do?
The hamstrings are a group of muscles in the back of the thigh that run from the boney prominence at the bottom of the pelvis (the sit bone, or ischial tuberosity) to just below the knee. Two of the three hamstring muscles attach at the inner (medial) tibia, and the third (which has two sections, or heads) has multiple attachments, primarily into the outer (lateral) side just below the knee at the fibular head, but also into muscles and ligaments of the outer compartment. The tibia is the larger and innermost bone of the lower leg, while the fibula is the thinner outer bone (it is the tibia which forms the knee joint with the femur of the thigh).
The hamstrings act to bend (flex) the knee and also work to extend the hip (bringing the thigh behind the plane of the hip). However, they do not act as the primary movers to do both of these motions simultaneously.
Studies have shown that the hamstrings also act during the last degrees of knee extension (straightening). While the quadriceps (the muscles in the front of the thigh) act to straighten the knee, the hamstrings contract pulling the tibia backward. This helps to prevent excessive extension (hyperextension). You may recall from a prior blog entry that anterior cruciate ligament (ACL) injuries result from traumatic hyperextension. The hamstrings are recruited to help to prevent ACL tears, providing some level of dynamic stabilization.
During the gait cycle (walking) the hamstrings act to decelerate (slow down) the forward swing of the leg. By doing so they help to control the position of the foot when the heel strikes the ground. If the knee is unable to straighten all the way, possibly because of a contracture of the hamstrings, the foot will strike in more of a flat position, changing the way forces are sent up through the chain of the lower extremity. This could cause undue stress on muscles and joints up through that chain.
Why is hamstring tightness such a big deal?
Tight hamstrings can cause a variety of problems due to the excessive pull of the muscles on their attachments. Poor posture and alignment are among the end results. Excessive tightness rotates the pelvis backward, and can cause the spine to be too arched in the low back (lumbar spine) or too rounded in the mid back (thoracic spine). Studies on those with unstable segments in the lumbar spine have found that a significant percentage have particularly tight hamstrings (See Wheeless Textbook of Orthopaedics). Tight hamstrings can also alter a person’s gait pattern (the way he or she walks) and influence the way we sit tight hams prevent sitting with the knees extended unless the back is rounded forward to compensate.
As with other tight muscles, lack of hamstring flexibility prevents the muscles from acting as efficiently to absorb shock, thereby transmitting more force to the joints and predisposing to injury. In addition, sports that require significant hamstring flexibility will likely lead to traumatic strains if the limit of stretch of the muscle is exceeded during play. Remember, a muscle strain comes in three basic varieties, the most involved of which (Grade III) is actually a complete tear.
Can hamstring strains be prevented?
Stretching in order to improve flexibility and warming up to prior to doing so can be very helpful in minimizing the risk of hamstring strains. Stretching has been getting a bad rap in the media lately with studies pointing out that warm-up stretching does not prevent injury. That may very well be the case. However, and it is a very BIG however, in my opinion, being flexible is vital to maintaining musculoskeletal health and minimizing overall risk of injury.
Sufficient strength and endurance of the muscles, both as hip extenders (with the knee straight) and as knee flexors is important to prevent injury. Much has also been said about the need to train the muscles both concentrically (contracting/shortening against resistance) and eccentrically (lengthening contractions that occur with the resisted release of a contraction). Working creatively to include various methods of hamstring strengthening can be instrumental to preventing injury.
Unfortunately, participating in sports sometimes entails making plays that push a muscle to (or beyond) its limit. The baseball player who almost does a split to make a big catch, or the NY Jet who defends Randy Moss as he attempts an acrobatic one-handed catch in the end-zone just may strain a hamstring