quad rupture and false hope

Monday, May 8, 2017

“We can rebuild him.. We have the technology…We can make him better than he was. Better, stronger, faster.”

The concept of elite athlete as superhero may be well deserved. It’s sometimes difficult to believe that football, basketball or hockey players aren’t performing as part of a video game, Faster, higher, stronger does not equate to invincible and injuries will happen, and the expectation of a “six-million-dollar repair and recovery” is not always possible.

So begins the injury saga of Tony Parker of the San Antonio Spurs, who tore his quadriceps tendon and will require surgery and months of rehabilitation. The goal with all injury care is to return the person to their previous level of function, but sometimes the odds are stacked against the patient.

There are four muscles in the front of the thigh that make up the quadriceps muscle group. Its job is to extend (straighten) the knee and to a lesser extent flex the hip. The quad transitions from muscle fibers into a tendon just above the knee cap (patella) which it envelops. The tendon is renamed the patellar tendon below the knee cap and then attaches to the tibia or shinbone at the tibial tubercle. The quad is balanced by the hamstring on the back of the thigh, and the two muscle groups work together to allow normal and protected knee function, not allowing it to hyperflex or to hyperextended.

A torn quadriceps tendon is an uncommon injury and usually there is underlying damage either from previous injury or another medical condition. By definition, a torn tendon is a grade 3 strain and when it occurs, the ability to extend the knee is lost. It can occur because the knee is flexed to the point where the tendon tears, or it may occur when the quadriceps muscles is trying to cushion the force of landing from a jump and tears on landing.  The injury causes significant pain and inability to walk. There can be immediate swelling just above the kneecap and physical examination may be able to feel the defect where the tear occurred, clinically confirming the diagnosis. An MRI is usually done to help the orthopedic surgeon with planning

A quadricep tear is a devastating injury. It requires surgery to reattach the ends of the tendon, like sewing and reattaching the ends of an elastic band together. Then comes weeks of rest to allow the tendon to scar and heal, followed by months of physical therapy and rehabilitation to return range of motion of the knee and strength to the quad muscles.


For most mere mortals, there is good news and bad news for recovery. More than 80% of patients can return to their previous job, but only half were able to return to their pre-injury activity levels and there was a 50% chance that there would be a significant loss of strength in the quad muscle.

Unfortunately for the elite athlete, the odds of being rebuilt, stronger and better are not great. Because the injury tends to occur in older patients, there isn’t a lot of research to review. A study of NFL injuries over a ten-year period found 14 players who sustained a quadriceps rupture and only half were able to return to play again, averaging 40 games played after rehab. That makes the odds of a Tony Parker full recovery and return to play less than certain.

Medical science often suffers from expectation exaggeration. Perhaps it’s due to television storylines that seem to have patients waken from coma, survive unscathed cardiac arrest and not seem to have complications from devastating injury or illness. The pain and suffering that is felt by patient, family, friends and the medical staff is lost when a story timeline lasts an hour and has to include 20 minutes of commercials and a minute preview of the next week’s episode. Audiences need to be reminded that even with elite athlete video game superheroes, the fragility of the body can be exposed and damage can overwhelm the reality of what medical science is actually able to do.

May Tony Parker beat the odds.


Image attributions:clutchpoint.com, medicalphoto.com



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concussions; what we don’t know

Thursday, October 13, 2016

Carson Palmer: concussion

Cam Newton- concussion

Sydney Crosby: concussion

NHL: new concussion screening policy.

Donald Trump- NFL need to toughen up; concussions around so bad.

And then there’s the knowledge gap.

“I don’t know.” Not the best thing to hear from your doctor after you’ve been examined. The expectation is that you go to the doc, get examined, you’re told what’s wrong, how you’re going to be fixed and when you’ll get better. That drill breaks down when the doc says “I don’t know”. Welcome to world of concussion.

Players and fans appreciate a potential head injury may occur with every play, but nothing is worse for the fan when the commentator announces that your favorite player is being evaluated for a concussion or in the concussion protocol. Those words are probably worse for the player. Whether it’s the NFL, NHL, MLB, NBA or MLS, the concussion protocol usually means that the player is gone for the game and perhaps, at least another week. The good news is that it may protect athletes after a concussion (regardless of Trump’s medical expertise), but the bad news is that nobody knows exactly how long to protect an athlete. Carson Palmer, Cam Newton, Sydney Crosby and the many other players who get hit in the head every week need to be protected, sometimes even from themselves, but how that’s done is up for debate.


Concussion diagnosis is defined as brain injury and it’s easy to diagnose easy if the athlete is knocked unconscious, has visible signs of confusion or behavior changes. But the Zurich consensus on concussion in sports doesn’t require head trauma to make the diagnosis. Instead, the diagnosis only requires the head to be shaken, and just one symptom. That symptom might be as non-specific as not feeling right, being tired and fatigued, or becoming more emotional or irritable. There is no finding on physical exam, brain imaging (CT/MRI) or psychologic testing that can confirm or rule out the diagnosis. It is all based on self-reported symptoms.


Concussion treatment is not necessarily evidence based. We don’t know how long it takes for the brain to heal after being concussed and the assessment decisions to allow sport participation often depend upon the athlete self-reporting symptoms and healing. And since many elite athletes are motivated to play, there are no tests available to confirm that the athlete is telling the truth and the brain is actually better. Anecdotes exist that suggest some athletes try to do poorly on preseason brain testing, so that if a concussion occurs, they can “pass” a test that compare brain performance before and after the injury. They set the bar low early to be able to clear it later.

Return to Play

The protocols that allow return to play protocol are arbitrary and while most concussion may resolve within 7-10 days, there is no objective test to know whether complete healing of the brain has occurred. According to the Zurich consensus, after a concussion, the athlete moves from one activity level to the next, as long as they are symptom free. If symptoms occur, then the progression through the protocol is delayed:

  • Day 1     No activity
  • Day 2     Walking, swimming or stat8ionary bike to increase the heart rate but no too much (just 70% of max)
  • Day 3     Sport specific exercise but no head impact activities, like heading a ball in soccer, or leading with the head or tackle in football
  • Day 4     Noncontact training drills that require increase information processing of the brian like passing drills in football or hockey
  • Day 5     If medically cleared, full contact practice
  • Day 6     Return to play

The long term effects of a concussion are still unknown. Does it take just one? Are lots of “small” concussions as ominous as one “big’ concussion? Can the effects of concussion be reversed?

In the real world of concussion, there is a lot of “I don’t know”. While the NFL and the NHL have empowered referees to pull players out of the game and have independent spotters monitoring replay video, it’s important to remember that concussion symptoms can be delayed. The Zurich consensus states it plainly, “…that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage.”

The logical application should be that if a player is pulled out of a game for fear of concussion, regardless of the sideline testing result, that player should be done for the day, since the sideline medical crew “won’t know” if symptoms will progress over time and in medicine, erring on the side of caution is never a bad thing.

But logic and pro sports don’t always go hand in hand. What we see on any given Sunday tends to filter down to the college, high school and even middle school levels. Pro athletes get paid to abuse their body and should know the inherent risks of their profession. Amateurs are trying to grab the brass ring to compete at the highest level of their sport. Most won’t get there and it’s the medical and coaching communities’ responsibility to protect younger, more fragile brains from long term damage. The problem is that we don’t just don’t know how.


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