Add another player to the Eagles “out for the season” list. Jordan Hicks ruptured his left pectoralis major in the final minutes of this past Sunday’s game against Dallas. The injury occurred as Hicks reached his left arm out to tackle Cowboys receiver Cole Beasley. These injuries are usually the result of an eccentric overload on an outstretched arm. The injury occurs as the player is trying to move the arm forward (ie tackle) as the arm is forcefully pushed backwards (ie player running through the tackle). This sudden eccentric load causes the tendon to either rupture near its attachment on the humerus or to pull off of the humerus itself.
The pectoralis major muscle originates on the sternum and ribs and inserts on the proximal humerus at the bicipital grove. The main function of the pectoralis major is to elevate and internally rotate the arm and is the key muscle when performing activities that require power in these planes of motion. Most athletes are unable to return sports that require pushing and tackling, such as football and wrestling, without surgical repair.
A 2014 study by Tarity et al looked at pectoralis major ruptures in the NFL from 200-2010. They found 10 complete ruptures during this period. 5 of 10 were in defensive players and 9 of 10 occurred during games. All 10 occurred on the football field with none occurring in the weight room. The authors were able to obtain the mechanism of injury for 6 of 10, with all of the reported mechanisms involving either tackling or blocking. The incidence of pectoralis major ruptures during the 11-year study was 0.004 showing that it is a rare injury in professional football. All 10 athletes returned to play in the NFL but the study was unable to obtain data to further investigate the long term effect the injury may or may not have had on their careers. Previous studies have shown a much higher success rate with surgical repair versus non-operative treatment with 70% of athletes having excellent results.
The results of the NFL study are very promising for return to play after pectoralis major injuries. This is great news for Jordan Hicks. I’m sure we’ll see him back on the practice field sometime this summer and in the starting lineup come August.
Posted: Tuesday September 22, 2015
We’ve all heard the news that Kiko Alonso injured his left ACL Sunday against Dallas. This is the same knee that he had reconstructed last July. The internet is saying he has a partial tear, while Les Bowen states that it’s a grade 2 sprain. Alonso is to meet with Dr. James Andrews for a second opinion. What exactly is his injury? Is it a partial tear or a sprain? And what does this mean for this season?
A ligament strain is a partial tear. There is a spectrum of sprain/tear from very mild with no laxity, or looseness, to a complete tear. Partial ACL injuries come down to how stable, or loose, the knee is and whether the athlete can play without instability/giving way. Typically, a grade 2 injury stretches the ligament to the point where it becomes loose. This is usually referred to as a partial tear.
An MRI is helpful to see if the reconstructed ACL is injured but can’t assess the degree of laxity/looseness. The stability of the knee is best assessed with a physical examination. Often times, a device called a KT 1000 is used to give an objective measurement of the looseness. Generally, if the involved knee has more than 3-4 mm difference compared to the uninjured side the knee will be unstable.
However, if the ACL laxity is within an acceptable range, rehab may allow the athlete to return without surgery. We call these athletes “copers” as they are able to function with a lax ACL. However, most athletes with a partial ACL injury are unable to return to cutting and pivoting sports without surgery. Another thing to consider is that this is Alonso’s 3rd ACL injury which may mean he is predisposed to repeat injuries.
As we await the results for Alonso’s second opinion with Dr. Andrews, let’s hope he has a stable, partial tear with only minimal laxity. This would give him the best shot at returning this season.
Posted: Thursday, September 17, 2015
I know, why in the world am I writing a blog post about a Dallas player? We know Dez Bryant is out next week after surgery on his 5th metatarsal. But will he be back for the November 8th game against Philadelphia which is 7 weeks away?
Here is what we know. He fractured his 5th metatarsal Sunday and had surgery Monday. The team is giving a time frame of 4-6 weeks to return. What we don’t know if it’s it a mid-shaft fracture, a tuberosity fracture, a Jones fracture, or a diaphyseal fracture. These are all different fractures with different treatment options, return to play considerations, and complications.
In a pro athlete, surgery to stabilize the fracture is almost always done regardless of the type of fracture. Screw fixation allows earlier weight bearing and rehabilitation, decreases the risk of malunion/non-union, and ultimately helps with a faster return to sports. Complications following surgery include malunion/non-union of the fracture, bending or breaking of the screw, re-fracture, and persistent pain that can limit athletic ability.
What does Dez’s rehab program look likely following surgery? Weight bearing typically begins around 7-10 days post-surgery. Running is often started around 6 weeks if early healing is occurring and the athlete doesn’t have pain. CT scans can be helpful to document healing of the fracture. Typical return to play in a high level athlete is 8-12 weeks. With Dez Bryant, the Cowboys will throw the kitchen sink at him to help speed up his recovery. This will likely include a bone stimulator to facilitate fracture healing; accelerated rehabilitation to regain flexibility, strength and balance as well as maintain fitness and football specific skills; and possibly other modalities that “may” influence recovery such as hyperbaric treatment, laser therapy, etc.
A study published in 2015 in Foot & Ankle International looked at 25 consecutive NFL players who underwent surgery for 5th metatarsal fractures by a single surgeon. There was a 100% return to play with an average return in 8.7 weeks (range 5.9-13.6). The fastest return to play was 5.9 weeks. However, the fastest return to play for a wide receiver was 8 weeks. Re-fracture was fairly low with only 4 players experiencing re-fractures.
So, will Dez be ready to play against the Eagles on November 8th? The statistics are not in his favor. And if he does play, it will likely be his first game back. Will he be performing at his pre-injury level by then? Time will tell but the research shows that Eagles will likely be putting together a game plan against a Dallas team that won’t include Dez Bryant.
Posted: Tuesday, September 15th, 2015
It’s that time of year. Fall sports are in full swing. Hopefully you had a productive pre-season that prepared you for the fall. Here are some tips to keep players safe and injury free this fall.
Fitness: If you weren’t in shape going into pre-season, hopefully you survived it without any injuries. If you did sustain an injury in pre-season, make sure you address it now as it will only linger and will likely get worse during the season. Next summer, make sure you get in shape prior to pre-season in order to avoid the same problems.
Overuse Injuries: Stress fractures, shin splints, tendonitis, etc These all occur because of ramping up intensity too quickly. Two and three a day practices on hard fields or indoor courts after a summer off is a recipe for disaster for overuse injuries. If you sustained an injury during pre-season, you need to be evaluated by your athletic trainer as playing through it never works and almost always makes the injury worse and prolongs recovery.
Heat Illness: This is hot topic. The myth of hydrating is finally being dispelled. You should drink when you are thirsty and not be forced to drink excessive fluids. But, you also need to be allowed to drink freely and coaches cannot restrict fluid intake either. And sports drinks, they’re not really needed. Water is the best along with meals that include some salty food to replace the electrolytes lost during training. For players with cramping, sweat testing can be done to assess the cause and how to replace fluids and electrolytes appropriately. The Heat Institute at West Chester University is a local facility that can perform sweat testing with the appropriate replenishment recommendations.
Concussions: I don’t think we need to talk too much about concussions as we all know the significance of these injuries. Any concussion should be taken seriously and needs to be evaluated by your team’s athletic trainer and a physician who specializes in concussion evaluation and management. The current medical guidelines from the most recent consensus statement say “no return to play on the day of concussive injury should occur.” And the “athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise.” Please take concussions seriously as athletes can suffer lifelong post-concussive symptoms if not managed appropriately.
Best of luck to all of the athletes and their teams this fall. Hopefully we only see you in the newspaper and not in the athletic training room or physician’s office.
Posted: Wednesday, July 29, 2015, 3:38 PM
Sunday while the celebrations for the Mexico win over Jamaica in this year’s CONCACAF Gold Cup final at Lincoln Financial Field continued into the night, the work of the venue medical staff wasn’t quite done yet. We still had to conduct the doping control testing where two players from each team are required to undergo drug tests following each match. I didn’t know who had it harder, those who had to grab two players from the losing team or those who had to pull away two players from the winner’s celebration. Luckily, this was the busiest the venue medical staff would be that night.
While all teams travel with their own medical staff, each venue is required to have their own people for all of the behind-the-scenes coverage and 3B Orthopaedics had the honor to coordinate the venue medical staff for this Sunday’s big match. With good planning, most of our work was completed long before the players hit the field.
Three months prior to the tournament, Dr Arthur Bartolozzi MD (Venue Medical Director), Matt Hay PA-C, ATC (Assistant Venue Medical Director), and I had to put together the game day venue medical staff as well as local medical specialists to have on call to cover any need that may arise for both the teams and CONCACAF staff members.
The venue medical staff consists of the stretcher crews and doping control chaperones. While often times, stretcher crews are staffed with volunteers with no medical background, with the recent changes in protocols implemented by CONCACAF for head injuries, sudden cardiac events, and heat and hydration management, we wanted to make sure we had the most qualified medical staff available. Our stretcher crews consisted of athletic trainers, physical therapists, and sports medicine physicians.
Along with the stretcher crews and doping chaperones, we also coordinated stadium X-ray coverage as well as ER trauma coverage. Discussions took place prior to the match with each team’s medical staff as well as the officiating crew regarding the new protocols, emergency management plans, and when to enter the field of play for injuries. Plan for the worst and hope for the best.
We’re happy to say that everything went smoothly and we all got to sit back and watch a great soccer match. As we look forward to the CONCACAF Confederation’s Cup playoff in October between the US and Mexico, I’m excited that I’ll be able to watch it as a fan and let all of the venue medical planning be handled by the Rose Bowl staff.
Posted: Thursday, June 11, 2015, 5:30 AM
“Sports hernia” is a term that sports fans are pretty familiar with. It seems every week another player is having surgery for it. But what is it really? That is the age old question. The sports medicine community recently published a consensus paper in the British Journal of Sports Medicine, June 2015, entitled “Doha agreement meeting on terminology and definitions in groin pain in athletes.” What the authors attempted to do was to change the terminology used for “sports hernia” in order to provide specific and precise definitions to the different categories of groin pain in athletes.
Sports hernia, along with athletic pubalgia, Gilmore’s groin, Hockey-goalie syndrome, Hockey groin, osteitis pubis, and sportsman’s hernia, were some of the many terms that were used interchangeably but were incorrect in their definition of the problem. Groin pain in athletes is the new general term agreed upon as an umbrella term without an implied specific diagnosis.
The consensus group broke down groin pain in athletes into 7 different categories: adductor-related groin pain, iliopsoas-related groin pain, inguinal-related groin pain, pubic-related groin pain, hip-related groin pain, other musculoskeletal cause (inguinal hernia, referred low back pain, fracture, etc), and non-musculoskeletal pain (gynecological conditions, tumors, etc). These sub-groups help to better define the true diagnoses and in turn the most appropriate treatment.
Adductor-related groin pain involves the structures that bring the leg across one’s body (adduct). They defined it as “adductor tenderness AND pain on resisted adduction testing.” Iliopsoas-related groin pain is defined as “iliopsoas tenderness” and “is more likely if there is pain on resisted hip flexion AND/OR pain on stretching the hip flexors.” Inguinal-related groin pain is defined as “pain location in the inguinal canal region AND tenderness of the inguinal canal.” Pubic-related groin pain is defined as “local tenderness of the pubic symphysis and the immediately adjacent bone” and “no particular resistance test that specifically provoked symptoms related to pubic-related groin pain that could be used in conjunction with palpation.” These definitions help to narrow down which structure/structures are directly involved in order to most effectively treat the problem.
This article helps to clarify a complex problem with confusing terminology. With more specific and precise terminology, future research should be able to more accurately define the specific problem and it’s underlying structure, enable comparison of research studies instead of comparing “apples to oranges,” and ultimately improve non-operative and post-operative treatment for athletes with groin pain.
Philly.com Sports Doc
Posted: Friday, March 13, 2015, 10:16 AM
Sam Bradford. (Photo by Streeter Lecka/Getty Images)
All the sports buzz in Philly this week is revolving around the Sam Bradford trade. Is he a good QB? Don’t ask me, but ACLs are something I know about.
His first ACL injury was to his left knee in October 2013. From the video, it looked like it was a contact injury where he was pulled down from behind. It appeared that his foot got caught with a flexion rotation mechanism of injury. He injured the same knee this past August, which also looked like a contact injury from a direct blow to the knee causing hyperextension.
As we know, there are two types of ACL injury mechanisms, contact and non-contact. Contact injuries like Bradford’s are usually more bad luck than pre-disposition. If he tore them running in the open field I would be more concerned about predisposition.
That being said, statistically, he is at high risk for re-injury, according to the research.
A study published in Arthroscopy in 2005 found that 12% of patients re-injure their same knee or injure their other knee in the first five years following surgery. Another study published in the British Journal of Sports Medicine 2006 found that soccer players with a previous ACL reconstruction had at least four times the risk of re-injury or injuring their other knee. Numerous research articles show continued deficits in strength and lower extremity control that can persist for years following ACL reconstruction. If you’ve followed ACL injuries in professional athletes, not everyone recovers as quickly as Adrian Peterson. Many end up like Derrick Rose and RG III.
An article published in Orthopedics 2014 by Erickson titled “Performance and Return-to-Sport After ACL Reconstruction in NFL Quarterbacks” looked at 13 NFL quarterbacks who underwent ACL reconstruction. They concluded that there is a high rate of return to sport in the NFL for quarterbacks and that performance was not significantly different from pre-injury. Another study published in the American Journal of Sports Medicine in 2010 found that only 63% of NFL players returned to play in approximately 11 months after surgery. More experienced and established athletes are more likely to return to competition at the same level than those with less professional experience. Being selected in the first 4 rounds of the NFL draft was highly predictive of return to play (Bradford was the number 1 pick in 2010).
An article published in the American Journal of Sports Medicine in 2009 showed that a history of meniscus surgery, but not ACL reconstruction shortens the expected career in NFL players. They also concluded that a combination of ACL reconstruction and meniscus surgery might be more detrimental to an athlete’s durability than either surgery alone.
There is a high rate of re-injury or injury to the other knee in patients following ACL reconstruction. NFL players in general show about a 63% return to play after ACL reconstruction. However, quarterbacks showed not only a high rate of return to play but a return to previous levels of performance. That said, we don’t know for sure if other structures were injured in the knee that could affect his return to play. From a research standpoint, the odds are in Bradford’s favor to be back to the player he was prior to his injuries. But the question to be answered is, will he be AP or RG III?
Philly.com Sports Doc
Posted: Friday, February 27, 2015, 5:30 AM
If you’ve joined a gym recently, you were probably offered a free fitness assessment. There are numerous different assessments available to exercise professionals. One of the more popular screening tools is the Functional Movement Screen (FMS). The FMS was developed as a tool to identify movement asymmetries or major limitations in movement patterns. The underlying principal of the FMS is that movement quality is essential to reducing injury and optimizing performance. It is used to identify limitations or asymmetries in 7 fundamental movement patterns. The screening places an individual in extreme positions where weaknesses and imbalances become noticeable if appropriate mobility and motor control is not utilized. The focus of the FMS is movement quality and to identify any movement deficiencies or limitations. Individuals must not have current pain or musculoskeletal injury.
The Functional Movement Screen consists of 7 specific tests and 3 clearing exams. The 7 tests are the hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotational stability. The scoring system used is a 0-3 scale with 0 being a painful test and 3 being the highest score possible. 5 of the 7 tests are performed bilaterally looking for side-to-side differences as well as a combined score for the test.
The 3 clearing tests are the active impingement, spinal extension, and spinal flexion tests which are scored positive or negative for pain.
The FMS is used to assess an individual’s movement quality and asymmetries to help better design exercise or training programs which should allow a safe progression to higher level exercises/training. The theory is that by addressing any dysfunctions noted on the FMS, one can reduce their risk of injury and improve their performance in sports. Let’s look at the published research on the FMS and see what it says.
There are numerous studies looking at the reliability of the FMS screen with varying results. Overall, the studies show good to excellent intrarater reliability (the same assessor) for both experienced and novice assessors. There is generally fair to good interrater reliability (between assessors) in most published studies as well.
A study by Frost in the Journal of Strength and Conditioning Research from 2013 questions the ability of the FMS to assess dysfunction. They looked at 21 firefighters who initially performed a standard screen followed by a repeat screen 5 minutes later. The participants were provided with a verbal description of the grading criteria immediately before performing each task during the second screen. All firefighters improved their scores within minutes of being told what movement patterns were required. The authors conclude that it may be inappropriate to assume that movement patterns are the direct result of a specific “dysfunction” or “impairment” that could be rectified via “corrective” exercise.
Keisel has published two studies involving NFL players showing that a total score of less than 14 or an asymmetry on any of the bilateral tests place players at a higher risk of injury. Players’ having both a total score of less than 14 and one or more asymmetries are at an even greater risk of injury. Lisman published in the journal Medicine & Science in Sports & Exercise in 2013 that military recruits who had a 3 mile run time less than 20.5 minutes and scored less than 14 on the FMS were 4.2 times more likely to experience an injury. These two studies support an overall score of 14 as the cut off for increased injury risk.
However, a study by Warren in the Journal of Sports Rehabilitation in 2014 showed a poor correlation with scores and asymmetries for both contact and non-contact injuries. In another article by Dossa in Journal of the Canadian Chiropractic Association in 2014, they concluded that the FMS couldn’t be recommended as a pre-season screening tool for injury prevention in major junior hockey players. Lastly, McCall gave a recommendation of “D” for the FMS as a screening test to identify professional football players (soccer) at risk of injury in the British Journal of Sports Medicine 2015.
A 2011 study by Parchmann in the Journal of Strength and Conditioning Research found that there were no significant correlations between the FMS and on the field sports performance tests whereas the 1 rep max back squat showed a significant correlation to these field tests. Lockie in the Journal of Strength and Conditioning Research in 2015 found few significant correlations between FMS scores and multidirectional speed and jumping tests. Lastly, Okada published in the Journal of Strength and Conditioning Research in 2011 that core stability and the FMS are not strong predictors of sports performance.
All this research shows that the FMS is a reliable screen able to score movement patterns and assess for side-to-side asymmetries. It may not truly assess movement dysfunction and may just be showing unfamiliarity with the activity, which may be easily improved with verbal cuing and repeat performance. The research shows conflicting studies on whether or not it can predict injury risk in a variety of sports. Lastly, the research shows little correlation with specific sports performance tests and FMS results.
So, what does this all mean? Does the FMS truly screen for movement flaws or is there a spectrum of what constitutes “normal” movement? The FMS still shows potential for assessing an individual’s risk of injury but it should not be the only criteria as risk is multi-factorial and the FMS may not be specific enough to detect all of the underlying components. Although research doesn’t show any significant relationship between the FMS and specific sports performance tests, there may still be a correlation between FMS scores and how well and individual does in a specific sport. Sports performance tests, such as the 40-yard dash, do not show a high correlation to specific indicators of success in sports (ie batting average, points per game, touchdowns scored, etc).
My personal experience with the Functional Movement Screen is that it is a great tool to quickly assess “healthy” athletes for “abnormal” movement patterns that may be secondary to limitations with mobility and stability. However, it should not be the only assessment used and should not take the place of a more detailed individual assessment looking at specific areas such as joint ROM and mobility, specific muscle strength testing, on-the-field testing (ie pro agility), and fitness testing (ie beep test).
Philly.com Sports Doc
POSTED: TUESDAY, NOVEMBER 25, 2014
If you’re a power lifter or body builder, please stop reading. If you’re a high level athlete, please read with an open mind. Now for the rest of us… My patients ask me all of the time, “What can I do in the gym?” For me, it’s not what you can and can’t do but what you should or shouldn't do.
Why do I say that? Here are just a few of the injuries we've seen in the office from doing the wrong things in the gym: a middle aged women who tore her ACL doing jumping jacks onto a plyometric box, a 60 year old who tore his meniscus when he was forced into deep knee flexion during yoga, and a broken tibia from the bar hitting her leg during Olympic lifting. It’s not that some people can’t do these things; it’s just that most of us shouldn't be doing them.
Here are my top 5 things you should avoid at the gym.
1. Deep squats
I always have this debate with strength and conditioning coaches. Why do they have their athletes squat past 90 with resistance? It’s not functional except for maybe wrestlers and football lineman, and even with them, is it worth the risk of injury? For the rest of us who are just trying to stay in shape it is a recipe for knee pain and meniscus tears. Deep squats put significant strain on the knee ligaments, significant pressure on your patellofemoral joint (knee cap), and it puts your meniscus at significant risk for tearing.
Let’s talk about the meniscus tear more specifically. As we squat down, the knee not only flexes but the femur glides posteriorly on the tibia. From about 90 degrees and beyond, we are putting almost all of the pressure on the posterior horn of the meniscus. Now just add a little rotation and pop, there goes your meniscus. And we know that our menisci start to degenerate over time (starting at about 35-40) placing us at even greater risk for a meniscus tear. Do the theoretical benefits of deep squatting out weigh the risks, absolutely not! So let’s please stop at 90 degrees.
2. Dead lifts
This is another exercise where I also debate people on the risk/benefit of the exercise. Yes, it’s a great exercise to strengthen your hip extensors (glutes and hamstrings) but it’s an even better way to injure your back. Repetitive flexion activities have been shown to be a significant factor in back injuries, specifically bulging and herniated disks. Even if you perform the exercise with perfect mechanics, which none of us do all the time, you’re still setting yourself up for a problem. Just like the meniscus in the knee, the discs in the spine start to degenerate with age. Combine this with an exercise that puts significant strain on the posterior annulus of the disc and you’re in for a lifetime of intermittent back pain. Instead of dead lifts, let’s focus on exercises that will still strengthen your hip extensors with less risk of injury. Lunges, step ups, bridging, and squats above 90 can all accomplish this while limiting the risk of low back injury.
3. Overhead presses
Overhead military press, dumbbell shoulder press, etc., all put your rotator cuff at risk for injury. Every time we lift our arms over head we have the potential for some impingement of our rotator cuff under our acromion. Now add weight and we’re just tempting fate. There is also a common theme with all these problematic exercises I’m writing about: our tissue starts to wear down and degenerate with age.
This is once again true for the rotator cuff. So why do an exercise to strengthen our shoulders that puts our rotator cuff at significant risk for injury? If you want to strengthen your deltoid you just need to do some pushing and pulling exercises. Overhead exercises aren't functional and the risk of injury just isn't worth it. Don’t try to “isolate” your shoulders and instead strengthen them functionally with pushing and pulling exercises such as push-ups and incline pull-ups on the smith press or TRX.
4. Bench press to your chest
I don’t like the bench press because it’s not a functional exercise, but that’s another discussion. The risk with bench press is that when your elbows break the plane of your chest, you’re putting significant strain on the stabilizing structures of the shoulder, specifically the labrum and capsule. Now add heavy weight and it’s a labral tear waiting to happen. And like everything else, the labrum degenerates over time. Clicking in your shoulder? It’s probably a labral tear. If you have to bench, keep the weight reasonable and don’t let your elbows break the plane of your chest. Better yet, do a standing cable column press as it is a much more functional position; just don’t go too deep and your shoulders will thank you.
5. Anything with heavy weights
I’ll be the first to admit that I loved lifting heavy weights when I wrestled in college. It was always a competition of who could bench and squat more. Looking back, bench pressing did nothing for me as a wrestler as I should have been doing more pulling exercises. After two shoulder surgeries, a hip labral tear which has likely progressed to arthritis (no MRI as I don’t want to know), focal arthritis in my knee as well numerous other chronic injuries, my joints wish I had focused on functional training and not weight lifting.
There is starting to be a paradigm shift in the strength and conditioning world. People are turning away from weight lifting and focusing on functional training and injury prevention. Stanford University’s director of football sports performance Shannon Turley is on the forefront of this movement. Instead of having freshman players hit the weight room when they get to school, they focus on regaining flexibility, improving core stability, and relearning correct movement patterns. He has had to write letters to NFL scouts about his program and why his players don’t have a record setting combine bench press but excel on the field and are injury free.
EXOS, formerly Athlete’s Performance, is the provider for strength and conditioning for the Men’s U.S. National Soccer team. Their approach to sports performance is to fix an athlete’s problems/weaknesses. There is little return in trying to improve quad strength in soccer players who already have super strong quads. Instead, you’ll see more gains by focusing on correcting their weaknesses such as limited hip mobility and glute med weakness. Even though we’re not professional athletes, let’s take a page out of their training programs and try to fix our deficits such as flexibility, core strength, and movement patterns and leave the heavy weights on the rack.
As I’m writing this, I’m envisioning the comments that I’ll be getting. But as I always tell my patients, “Is it better to look good or to feel good?” Let’s move away from working out the way we always have and start thinking about our long term health, as many of the exercises we do are counterproductive to our overall goal of living a healthy, happy, and pain free life.
Philly.com Sports Doc
Posted Monday, October 20, 2014
If you didn’t see it live, I’m sure you’ve seen the video of New York Giants' Victor Cruz’s knee injury. He wasn’t tackled. His knee didn’t twist in some abnormal way. How did he tear his tendon on such a routine play?
Patellar tendon ruptures are a rare injury. A 2011 study in the American Journal of Sports Medicine showed that there were only 21 isolated patellar tendon ruptures over a ten year period from 1994-2004. This study showed an 80% return to play in the NFL following surgery. The big question is even with a return to football, will he be the same player he was before surgery?
The mechanism of injury is still debatable. Research shows that it takes a force of approximately 17 times body weight to tear the patellar tendon which is why this is such an uncommon injury. In sports, it appears to be the result of an eccentric flexion load followed by forceful knee extension. If you watch Cruz’s injury closely, it appears that his knee is flexing under his body weight as he forcefully tries to push off to catch the pass. The eccentric loading combined with the concentric push off likely created an extreme amount of strain on the tendon resulting in rupture. (Get a rehash of injury here)
Patellar tendon rupture requires an immediate repair of the torn tendon. The type of surgery performed is dictated by where the tendon tore and if the tendon tissue is healthy. If the tendon tore in the middle, the two ends are sewn back together. If the tendon tore closer to the bone, it can be sutured back down. If the tissue is not healthy, i.e. chronic patellar tendonitis, the repair can be augmented with a cadaver graft.
Rehab involves a period of immobilization followed by rehabilitation to regain range of motion and strength. Players are usually braced for approximately 6 weeks following surgery. During this time there is a gradual progression of knee flexion range of motion to allow the tendon to heal while trying to limit the amount of post-operative stiffness that will occur. Over the next 4-5 months rehab focuses on regaining full flexibility and strength with gradual progression to sports activities such as running, agility exercises, and plyometrics. Return to sports usually takes a minimum of 6 months.
As the NFL study showed, 80 percent of players return to football, but their definition of return to play was participating in one regular season NFL game. There is a big difference between playing in one NFL game and returning to pro bowl level of play. Only time will tell if Cruz will be celebrating touchdown receptions with his salsa dance next season.