triceps tear

Monday, October 23, 2017

When people take about the ironmen of sport, Cal Ripken’s name often heads the list, but it’s Joe Thomas of the Cleveland Browns who should be considered the ultimate sports warrior. As a lineman, there are never any plays off and each play is a battle against the largest players on the opposing team. Mr. Thomas’ streak of more than 10,000 consecutive players that began in 2007, has ended with a torn triceps muscle. It may be appropriate that to sideline this player, it required a triceps tendon rupture that is the rarest of tendon injuries.

The triceps muscle is located on the back (posterior) of the upper arm and is responsible for extending or straightening the elbow. It is balanced by the bicep, located on the front (anterior) of the arm, which flexes or bends the elbow. As its name implies, the triceps has three heads that arise from bones in the shoulder and join together to form the muscle. It then morphs into a tendon that crosses the elbow and attaches into the olecranon, the bony outcropping that can be felt at the back of the elbow joint.

It takes a lot of force to tear the muscle or pull the tendon off the bone and the mechanism is usually a fall on an outstretched arm with the muscle contracted, and there may or may not be a direct blow to the area. The arm collapses and the elbow hyperflexes, pulling on the triceps muscle that can’t protect itself. The injury causes either the muscle to tear in two,  pulls the tendon away from the bone or fractures the part of the olecranon where the tendon attaches. Regardless, the end result is an arm that the player cannot straighten and the diagnosis is pretty obvious to the trainer on the field.

While many athletic injuries have options for treatment, the complete disruption of the muscle, tendon or bone, needs an operation to reattach the pieces and put them where they belong.

The purpose of a muscle is to move a joint. It usually arises from a bony prominence on one side of a joint and then attaches via a tendon across the joint to another bone. When the muscle contracts, the joint moves. If the muscle tendon unit is torn completely (a third-degree strain), The ability to move the joint is lost. Without repair, power and range of motion may never return completely. Interestingly. Some third-degree tears can be treated without an operation with satisfactory results, but not in athletes or active people.

The concept of the operation is easy, but requires skill to prevent nerve or blood vessel damage. Rehab is measured in months returning range of motion is balanced against ripping the repair and having to start over. For that reason, physical therapy is an important part of returning to play. Elite athletes strain to test their repaired body parts too early and need to rein in their enthusiasm to do too much too quickly. Mother Nature and Father Time don’t like to be rushed.

All streaks must come to an end. Cal Ripken was able to orchestrate his last game but most athletes have their streaks ended without knowing when their last play might be. To be fair, that can be said for every athlete, regardless of age. Faster, higher, stronger pits performance against anatomy and physiology, and sometimes the body loses.

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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.





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