#fantasyphysio

[fantasyphysio]

The Torn Patellar Tendon

Starring Victor Cruz

      The 2014-2015 fantasy footballseason was not my year. It was a year where Adrian Peterson, my #1 overallpick, lost for the year due to child abuse charges. It was a year where I bounced back, wheeled and dealed to get LeSean McCoy AND Eddie Lacy BUT STILL missed the playoffs. It was a year where Jay Cutler threw 18 interceptions and lost the confidence of his head coach despite having two #1 WRs in Brandon Marshall and Alshon Jeffrey. It was a year where the tone was set when I saw my Victor Cruz carted off the field, bawling because he will no longer be able to salsa for the rest of the season.

      Before the Cruz injury, I was holding on to the thread of hope of scoring a garbage time TD during the 27-0, Philadelphia Eagles pounding of the New York Giants. While running a route to the back corner of the end zone, my hopes were dashed as Victor Cruz jumped awkwardly and clutched his knee in pain throughout his flight. A torn ACL was the first thing that jumped into mind when I saw the year ending prognosis. However, the salsa dancer was diagnosed with a torn patellar tendon, a much less common injury for those under 40 years old but usually occurring during an explosive movement (Saragaglia et al., 2013).

      The patellar tendon connects the quadriceps muscle to the shinbone or tibia. It may be confused as a ligament, connective tissue that links bone to bone, because it helps in keeping the patella (kneecap) attached to the tibia. However, it is most commonly called a tendon, connective tissue that connects muscle to bone, because it is part of the quadriceps tendon that stretches from the quad muscle to the tibia, which helps extend the leg. The patellar tendon originates at the inferior end, distal to the patella and inserts at the tibia turbecle. In contrast, the quadriceps tendon lies proximal to the patella (Hak et al., 2010).Complete tendon tears usually occur 2 cm distal to the patellar tendon insertion or 2 cm proximal to the quadriceps tendon insertion. Many patellar tendon tears are often associated with patellar avulsion fractures, which is when a fragment of bone is separated from the main mass of bone as a result of trauma. ACL tears and other injuries may also be associated.

      A patellar tendon rupture usually occurs during an acute, explosive event where a sudden, strong contraction of the quad muscles occurs (jumping or changing direction) or when the knee is flexed, fixed to the ground while the upper trunk is driven backwards (Brooks, 2009). Another instance is when the knee is already flexed at least 60 degrees and an external force causes the knee to increase its degree of flexion. For example, a volley ball player that lands on someone's foot so that their already flexed knee suddenly has to flex even more while absorbing the force of the landing. A pop, followed by swelling, sharp knee pain and difficulty to bear weight ensues. Chronically, patients may suffer from patellar tendinopathy which is prevalent in 50% of jumping sport athletes (Lian et al., 2005; Peers & Lysens, 2005). Glucocorticoid injections also may pose a higher risk for such injuries to occur (Chen et al., 2008). Patients suffering from a torn patellar tendon will have limited knee extension, can't maintain a straight leg, or raise the leg against gravity while laying down (supine).

      Non-surgical and surgical options can be effective but the time of diagnosis is one of the biggest influences on its recovery. Early diagnosis, within one week of injury, and prompt surgical intervention for repair vastly improves outcomes (Ilan et al., 2003). Conservative approaches include RICE (rest, ice, compress, elevate), stretching to improve range of motion, and isometric strengthening to restore the extensor mechanism muscles. However, for more serious ruptures, surgical procedures are required to manually tie the torn ends of the tendon together and apply the proper tension. In serious cases, the surgeon may need to reattach the tendons to the bone itself. The trickiest part of the procedure is in determining the proper amount of tension that needs to be applied on the tendon. Too lose, and the knee cap will be unstable, but too tight, and range of motion will be compromised. The normal timetable for recovery is 3 months until normal daily activity and 4-6 months until sport can be resumed. However, long term weakness may be experienced and Victor Cruz may not be the same receiver who reeled off more than 2,000 yards and 19 TDs in two seasons before the injury.

 Relevant Players:

Victor Cruz, WR, New York Giants: Speaking of the importance of an early diagnosis, Victor Cruz was wheeled into the operating room less than 24 hours after the Giant's Sunday Night loss in Philly. Dr. Russell Warren, the Giant's team physician, performed the surgery at the Hospital for Special Surgery in Manhattan. Cruz may never be the receiver he once was and if you have the kind of luck I do, I think it is best to approach him with caution next year. Odell Beckham Jr.'s torrid 2014 campaign in which he put up 91 receptions, 1,305 yards, and 12 TDs in 12 games will be Eli's first option next year. To put Beckham's incredible year in perspective, only the great Randy Moss has had a better fantasy season in their rookie year except Moss had all 16 games to put up his numbers (1,313 yards, 17 TDs). I think Victor Cruz's return will benefit the teammates around him, especially Beckham's, because defenses still need to respect Cruz's resume. Even when Cruz was 100% in 2013 and 2011, compared to Beckham's 2014 in which he had similar numbers of targets, Beckham still posted the better stats. Simply put, Beckham is the more explosive player and the New York Giant you want to target. In addition, I think Cruz’s return makes Eli Manning an interesting sleeper. Only if the time is right and Cruz free falls down draft boards, can Cruz be a great value pick. As it stands, I would put Cruz currently standing at a WR5 tier with a ceiling of a WR3.

On Deck: Carson Palmer’s Nerve 

In the Hole: Todd Gurley’s ACL

References

Hak, DJ., Sanchez, A., Trobisch, P. Quadriceps tendon injuries. Orthopedics 2010; 33:40

Ilan, DI., Tejwani, NM., Keschner, M., Leibman, M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003; 11:192

Lian, OB., Engebretsen, L., Bahr, R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med 2005; 33:561

Peers, KH., Lysens, RJ. Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations. Sports Med 2005; 35:71

Saragaglia, D., Pison, A., Rubens-Duval, B., Acute and old ruptures of the extensor apparatus of the knee in adults (excluding knee replacement). Orthop Traumatol Surg Res 2013; 99:S67

[fantasyphysio]

The Ulnar (Medial) Collateral Ligament - Tommy John Surgery

Starring Richard Sherman

UPDATE: Sherman will opt for conservative measures and rehab, for now, instead of surgery per SB Nation. 

        Last week, I raved about the exciting 2015 NFC Championship game finish between the Seattle Seahawks and Green Bay Packers. But, your 2014-2015 NFL experience would not be complete if you missed the Super Bowl last Sunday. After a ridiculously miraculous Jermaine Kearse catch, the Seahawks looked like they were destined for back-to-back championships. However, unheralded Patriots safety, Malcolm Butler, had other plans and picked off Russell Wilson’s pass at the 45th second mark in their own one-yard line to bring Super Bowl XLIX to an abrupt end. The 28-24 Patriots victory was chock-full of storylines: Pete Carroll’s decision to pass on the two-yard line instead of handing the ball off to BeastMode; Bill Belichick’s choice to withhold a timeout and let the clock tick below the minute mark with the Seahawks inches away from taking the lead; Chris Matthews’ heroic 109 yards, 1 TD performance only months after jumping out of his Foot Locker day job; “Deflate Gate”; Tom Brady’s 4th Super Bowl win.

        Buried under the pile of headlines was the injury status of the Seattle Seahawks’ Legion of Boom. Even more criminal is the absence of debate of who was the best cornerback in the NFL between Richard Sherman and Darrelle Revis. The injury that Sherman sustained in the NFC Championship game may have averted such comparisons for another time. As James Starks raced down the right sideline, Sherman and “Bam Bam” Kam Chancellor converged to maul Starks out of bounds. It seemed like a routine tackle, but Sherman was visibly in pain as he picked himself up, favoring his left elbow. Instead of calling it a night, Sherman stayed in the game and kept his elbow in a bent position as if it was in an invisible sling. After the inspiring performance, an MRI indicated a sprained elbow, which Sherman played through again after two weeks of rest. Once the confetti has settled, Coach Pete Carroll told the media that Sherman may have suffered ulnar nerve damage and may need Tommy John surgery to repair the ulnar collateral ligaments (UCL).

        Elbow pain may be caused by damage to the joint or it surrounding structures. The elbow joint most resembles the hinge model, which consists of the humerus (bone of upper arm), ulna (larger bone of lower arm), and radius (smaller bone of lower arm). Surrounding structures of the joint include:

Epicondyles (medial and lateral) – Bony prominences on the sides of your elbow. Origin of most tendons of muscles that flex and extend the wrist. Most common source of pain.

Olecranon bursa – the hard part of your elbow.

Radial and Ulnar nerves – courses through the elbow joint. May cause pain when pinched as a result of trauma or repetitive elbow flexions.

Biceps and Triceps – controls arm flexion and extension.

Radiohumeral and proximal radioulnar articulation – located below the elbow joint and play a role in palm rotation. Biceps muscles supinate (palm face up) while the pronator teres pronates (palm face downward).

        Sherman’s sprained elbow is the result of a ligament strain that is seen most often in throwing athletes. The UCL is part of the network of ligaments that support the elbow.  Tears in the UCL may occur when there is an acute, traumatic injury to the elbow resulting from a fall on an outstretched arm or a twist on a planted hand.  Research on throwers with ruptured UCLs found that 50% had a single catastrophic event while the other half had symptoms before the event itself (Jobe et al., 1986). The cumulative effect of repetitive throwing may chip away at the ligament because the force generated during the cocking and acceleration phases of throwing causes valgus stress on the elbow (Behr & Altchek, 1997).  When the arm is fully extended, valgus stability is divided equally among the medial collateral ligament, anterior capsule, and bony articulation. When the elbow is flexed 90 degrees, the anterior capsule’s load is taken up by the medial collateral ligament, which contributes about 55% of the stabilizing contribution to valgus stress. Meanwhile, varus stress is resisted by the anterior capsule (32%), joint articulation (55%) and radial collateral ligament (14%) (Morrey & An, 1983). These studies elucidate that the UCL is under the most stress and subject to injury during the throwing motion.

        Tommy John Surgery is the premiere surgical operation for UCL damage. Previously known as ulnar collateral ligament reconstruction surgery, the procedure involves replacing the damaged UCL with a tendon from elsewhere in the body. Donor tendons are usually spliced from the palmaris tendon in the forearm of the same or opposite elbow, patellar tendon from below the knee, or a cadaver (donor). Dr. Frank Jobe, orthopedic surgeon and Los Angeles Dodgers team physician in 1968-2008, performed the first UCL reconstruction surgery procedure and coined the term after the patient of his first case. Tommy John, pitcher for the Dodgers, missed the entire 1975 season rehabbing his arm after going under the knife in 1974. Before the surgery, he had won 124 games. After 1975, Tommy John won 164 games and pitched until he was 46 years old. Dr. Jobe’s Tommy John surgery resurrected Tommy John’s career that included an NL Comeback Player of the Year in 1976 and 2nd place finish in the Cy Young voting of 1997. At the time of Tommy John’s operation, Jobe put his chances at 1 in 100. Today, 83% of throwing athletes who have the procedure will return to previous or high levels of competition in less than 1 year (Cain et al., 2010).

Relevant Players:

Richard Sherman, CB, Seattle Seahawks: When asked about Sherman’s recovery timetable, Pete Carroll joked, “I really don’t think so [it will take a long time], as long as Sherm doesn’t want to become a late-inning reliever.” Organized team activities (OTAs) generally start around June, which will give Sherman a good 6 months to have the surgery and recover. Like Carroll said, the Seahawks are lucky this isn’t Russell Wilson we’re talking about because Sherman’s positional demands don’t require him to make throws downfield. All-Pro defensive end, DeMarcus Ware, had a similar elbow surgery in February 2014 and was able to recover in time for the season. There won’t be any question that Sherman can return with full force, in time for the upcoming season and thrusting himself back in the discussion of who is the best cornerback in the game. The only question that still lingers is if there would have been a different Super Bowl XLIX outcome had the heart (and the mouth) of the Legion of Boom been healthy.

On Deck: Victor Cruz's PCL

In the Hole: Carson Palmer's Nerve

References:

Behr CT, Altchek DW. The elbow. Clin Sports Med 1997; 4:681-704

Cain EL, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter JC, Riley RS, Arthur ST. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med 2010; 12:2426-34

Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. AM J Sports Med 1983; 11:315

Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 1986; 68:1158

[fantasyphysio]

The Calf Strain

Starring Aaron Rodgers 

       WHAT. A. GAME. Last year’s NFC Championship game had set the bar high on the thriller scale and this year’s game did not disappoint. Up until the last 3 minutes of the game, the Seattle Seahawks were still down 19-7 against the Green BayPacker. Russell Wilson had already thrown, a personal worst, four interceptions and the 12th man were starting file towards the aisles. But with Richard Sherman playing through an elbow injury and Marshawn Lynch who refused to be denied, an inspired Seahawks team scored a touchdown to make it 19-14 at the 2:09 mark. An onside kick recovery, another Marshawn Lynch touchdown, and a2-point conversion later put the Seahawks up by 3; 19-22. Mason Crosby drilled a 48-yard field goal as time expired to push the game to overtime but the Seahawks, riding on a wave of momentum, threw a 35-yard touchdown bomb against a Packer defense that was expecting a run. Game Over. Seahawks are Super Bowl bound. The end to the top 5 games I have ever seen in my 23 years of life.

       The biggest headline before the momentous game was zeroed in on Aaron Rodgers’ “severely”strained calf and partial tear as reported by ESPN’s Chris Morenson. There aremany overlapping muscles and tendons that make up the anatomy of the calf, butwe will focus our attention to two of it’s main muscles: the gastrocnemius and soleus (Bianchi & Martinoli 2007; Dixon, 2009). Both muscles are attached to the Achilles tendon, a tendon that stretches all the way down and attaches to the calcaneus (the heel bone), and play a role in ankle plantar flexion (pointing the foot away from the body). A calf strain involves a tear to either of the two calf muscles and occurs at the muscular tendinous junction where the muscles meet the Achilles tendon. About 20% of patients report prodromal symptoms like soreness/tightness in their calf muscles prior to the injury (Campbell 2009).

       The gastrocnemius is the biggest of the two calf muscles, attaches above the knee joint, and lies at the middle of the junction between the muscle and tendon. It contains both slow and fast twitch muscle fibers, thus accounting for most of the power generated by the calf during plyometric exercises such as sprinting or jumping. Most injuries occur at the musculoskeletal junction of the gastrocnemius or the aponeurosis between the medial head of the gastrocnemius and soleus muscles (Delgado et al., 2002). This injury is most commonly known as “Tennis Leg” because of it’s high occurance in tennis players.

       Complementarily, the smaller soleus muscle originates below the knee joint and lies underneath the gastrocnemius. Composed of mostly slow twitch muscle fibers, the soleus maintains the strength and endurance for repeated plantar flexion during activity. Soleus strains can develop when the ankle is passively dorsiflexed while the knee is flexed like during a landing when running up hill (Campbell 2009). Strains of this nature usually develop chronically, stemming from overuse.

As with any strain, each are graded based on level of severity:

Grade 1: minor tear, up to 10% of muscle fibers effected. Experience tightness and mild discomfort.

Grade 2: up to 90% of the muscle fibers torn. Sharp pain when walking. Swelling and mild to moderate bruising.

Grade 3: severe pain. Will likely be unable to walk. Considerable bruising and swelling. During a full rupture, the muscle can be seen bunched up towards the top of the calf.

Relevant Players

 Aaron Rodgers, QB, Green Bay Packers: Rodgers sustained the injury in Week 16 against the Tampa Bay Buccaneers and didn’t receive any favors when N'Damukong Suh “inadvertently” stepped on his leg in Week 17. Nevertheless, Rodgers threw for 316 yards and 3TDs, shredding the Dallas Cowboys in the NFC Divisional Playoff game. However, once he faced Seattle, he struggled to repeat his performance, throwing for only 178 yards, 1 TD, and 2 interceptions. Many people forget that Aaron Rodgers mobile ability is an ace that he likes to keep up his sleeve. I’m not saying that his mobile ability is what his success is attributed to, but you could tell that Seattle were not worried about him scrambling out of the pocket during the game. Rodgers, with his new MVP award, will likely be the top QB drafted in next year’s fantasy football drafts

On Deck: Richard Sherman's elbow

In the Hole: Victor Cruz's PCL

References

Bianchi S, Martinoli C. Leg in : Ultrasound of the musculoskeletal system. Springer, New York 2007. p. 745

Campbell JT. Posterior calf injury. Foot Ankle Clin 2009; 14:761

Delgado GJ, Chung CB, Lektrakul N, Azocar P, Botte MJ, Coria D, Bosch E, Resnick D. Tennis leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology 2002; 224;112 

Dixon BJ. Gastrocnemius vs. soleus strain; how to differentiate and deal with calf muscle injuries. Curr Rev Musculoskeletal Med 2009; 2:74