NFL Injury Series- Meniscus Tear

Read up on what the meniscus is, how it is injured, indications for surgery, and recovery times.

Today on Banged Up Bills, we will detail the ever common meniscus tear. This post will identify what the meniscus is, it’s function, and the severity of a tear which could affect whether a player misses weeks or the season. This is an injury that we have seen in past seasons and will continue to see.

Last season, we saw TE Charles Clay and WR Kelvin Benjamin both tear their meniscus during different points of the season with varying availability following the injury. Clay missed 3 games while Benjamin missed 2. Clay required surgery to fix his issue immediately while Benjamin was able to tough it out the rest of the season with eventual surgery. There are many reasons why there are differences in meniscus tear management despite the same outcomes.

To understand proper management of the meniscus after injury, the structure must be understood. The meniscus is two concave structures that are c-shaped and lie over the tibia in each knee. The meniscus is comprised of a medial and lateral meniscus and act as shock absorbers during activity. These meniscus also help deepen the joint so that the femur can articulate with the tibia, providing stability. During meniscus tears, a rotational force is applied to the area while the knee is bent and causes a shearing motion, causing a portion of the meniscus to tear.

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Credit: physio-pedia.com

There are various types of tears which include but are not limited to: complete or partial, horizontal or vertical, longitudinal or transverse. Acute tears are more likely to present as longitudinal/bucket handle and radial tears most likely seen in football players. Symptoms of a meniscal tear typically consist of pain, tenderness, and swelling, locking or clicking during knee movement, and initially difficulty in placing weight through the knee. Meniscal tears are typically seen in conjunction with MCL sprains/tears and ACL tears due to the rotational forces through the knee during impact.

Overall, these types of injuries can slow up a player but not entirely derail their season. Several tests to identify meniscal tears include Apley’s, McMurray’s, joint line tenderness, and Thessaly’s test all assist in identifying whether a meniscal tear is present. However, these tests are not always reliable or specific which means they may identify pain and restrictions but will not be able to identify type or severity of tear. These tests replicate the mechanism that would cause the meniscal tear. This typically warrants further imaging such as MRI to identify specific lesions which will determine the appropriate interventions.

Once a tear has been identified, the type of tear can affect healing rates: longitudinal tears heal better than radial; simple tears heal better than complex; traumatic and acute tears heal better than degenerative. Based on location and length of tear will determine proper management. The meniscus has several “zones of vascularity” which include: red-red zone, red-white zone, and white-white zone. The red-red zone has the highest blood supply and lie on the outermost portion of the meniscus. The red-white zone is the area that connects the red-red and white-white zone and contains some blood supply. The white-white zone has a poor blood supply and demonstrate the poorest area for healing. If the tear is small, conservative management or a meniscectomy may be performed to remove to remove the offending piece. If the tear is larger, then a suture repair of the meniscus is warranted and an extended rehab is required.

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Credit: physio-pedia.com

Regardless of whether surgery is required, rehab typically consists of restoring range of motion, controlling swelling/pain, and restoring strength to the knee. Once the immediate objectives are met, then further increasing strength and return to play activities are initiated to ensure that the athlete can play at their full abilities. In the event of WR Kelvin Benjamin, he was able to play through his minor tear due to effective rehab and an understanding of the type of tear which most likely allowed him to rest, recover, and eventually return to full participation knowing the tear was stable enough to play through. In the event of TE Charles Clay, his tear may have been blocking motion and been more severe, warranting surgery to remove the offending piece before rehab could begin.

In the option that surgery is performed during the season, recovery times for a meniscectomy can last anywhere from 2-6 weeks or even longer based on the severity of the tear and corresponding damage. In the event of a major tear, surgery is indicated and recovery time can last for up to 3 months which could end a season for most players depending on the time in the season it was torn. The preferred method years ago used to be cut out the offending piece. However, surgeons later found out that each time they cut a piece out, it accelerated arthritic changes in the knee which reduced healing and the ability for players to return to full health for a prolonged career. They have also found recently that surgeries do no better than rehab alone when compared to long term results in the normal population. However, surgery is still recommended when a return to sport is necessary and will quicken the recovery in dealing with the NFL.

Meniscal injuries are still concerning but can still allow a player to play through the injury despite requiring further interventions in the future. If a player sustains a meniscus injury, they will miss some time but can return to play later in the season with favorable results after testing and a positive response to rehab. Despite returning to play, there are still instances where players will not be 100% and their production will noticeably decrease. Overall, a concerning but not season ending injury.

Continue to check back regarding further updates and injuries throughout the season. Follow on Twitter @BangedUpBills, Facebook at Banged Up Bills, on Reddit at u/BangedUpBills and http://www.bangedupbills.com. As always, thank you for reading and GO BILLS!

NFL Injury Series- Achilles Tear

Analyzing the Achilles’ tear, causes, rehab, and return to play rates in the NFL.

Training camp is in full swing and the Buffalo Bills continue to stay healthy despite significant injuries elsewhere in the league. One injury that the Bills have avoided for some time is the Achilles tear which is the topic of today’s article on Banged Up Bills NFL Injury series.

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Credit: http://www.medi.de

The Achilles tendon is a thick tendon that connects the gastrocnemius and soleus muscle to the calcaneus which is the heel bone. The gastrocnemius muscle or calf muscle allows the foot to point down or plantar flex which is required for the leg to push off during walking and running. It also assists in flexing the lower leg at the knee joint along with the hamstrings. The gastrocnemius and soleus help drive the body forward in walking and running and are especially in maximum use during sprinting.

Like other tendons, the Achilles tendon can become injured which can develop into a tendonitis. This occurs when pain/inflammation affects the insertion point of the muscle and it becomes painful with activity. This can eventually lead to microtears occurring in the tissue during injury and the tendon heals improperly. Normal tendon and muscle striations are linear in nature allowing for maximum contraction of the muscle. In the event of tendonitis, the tissue heals improperly and instead of consistent striations, there is a disorganized mess of muscle fibers that does not allow the muscle to contract as efficiently which can lead to further pain and inflammation with continued overuse.

Risk factors seen in football players which could increase the incidence of an Achilles tendon rupture include: excessive body weight, heavy weightlifting, use of anabolic steroids, long term use of corticosteroids, immobilization of the ankle/foot, of the male sex, and muscle weakness/imbalance. While some of these risk factors are preventable, others are not and this is where doctors have to use best judgement when performing interventions for both short term and long term implications following injury.

With improper rest or not performing preventative exercises such as stretching or regular strengthening, an Achilles can eventually tear with either chronic overuse or suddenly. Unfortunately, most traumatic Achilles rupture warning signs can be asymptomatic and do not usually present with problems until after the major injury occurs. This means that because you have Achilles tendinitis, does not mean you will have rupture. However, because you do not have symptoms, does not mean you won’t have further injury.

In the event of a tear, most athletes are jumping, sprinting, or cutting with such great force that the tendon ruptured suddenly. The muscle is stretched past its limits suddenly or asked to do more than it is capable of after periods of inactivity. Even in conditioned athletes, this can still occur as the athlete is continuously pushing themselves to their limits. When rupture occurs, it is likened to a shotgun blast and loss of function and pain is immediate. This is an injury that even the strongest, most determined athletes cannot work through. The ability to push off the foot simply is not there. Here is an excellent clip of an Achilles tendon rupturing in real time.

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Credit: http://www.sportsinjuryclinic.com

In the event that there is a suspected Achilles tear, a Thompson test would be performed. This is where an athlete would lie on their stomach with their foot hanging off a table and the calf would be squeezed. If the foot moves, the Achilles is intact. If there is no movement, then this confirms the tear. Imaging may be done to assess severity but if the Thompson test is positive, then it is a tear. Tests such as this are typically accurate, similar to the anterior drawer test with ACL injuries.

Once the Achilles tear is confirmed, surgery is usually recommended immediately as tendon ruptures tend to retract back to the origin or attachment point of the muscle which means the longer surgery waits, the more difficult it will be to reattach the tendon. Rehab typically takes 6  months to a year to fully recover. Once the procedure is performed, the patient is placed in a boot that encourages the foot to point down to place slack on the tendon so that it can heal properly. If the foot were to be flat, that would place stress on the healing tendon with the foot in neutral and there would be a lesser chance of it healing properly.

Once the foot/ankle is immobilized with progressive weight bearing as instructed until 8 weeks to allow the tendon to fully heal back to the attachment point that is the bone. Light strengthening begins after 8 weeks with active stretching to the surgically repaired area occurring after 12 weeks. Progressive strengthening up to 6 months occurs with focus to avoid high forces on the tendon to reduce re-rupture. Similar to the ACL of the knee, full return to sports takes 9-12 months due to the demands of the structure.

Fortunately, re-rupture rates are exceptionally low in the repaired Achilles. While it is a long recovery, re-rupture rates following a repair are between 3.5%4.5% which indicate the overall long term success of the intervention. Non-surgical methods are available but are not recommended unless the person is a poor surgical candidate. While the re-rupture rates are fairly low, return to play rates are much poorer in comparison. Roughly 30% of athletes who sustain an Achilles tendon rupture and repair are never able to return to the NFL. Those that do typically suffer a decrease in performance up to 50% according to research. Those that do have a surgical repair have about a 6% chance to tear the contralateral or opposite Achilles.

Interestingly, the last confirmed Achilles tear that the Buffalo Bills had suffered dates all the way back to 2005 when LB Takeo Spikes tore his in the early in the season. There may have been more recent ones but pro-football-reference.com only goes back to 2009 with injury reports for the Bills and I was unable to find any Achilles tears after 2009. I pray that this is one streak that we don’t end for some time.

This is another nasty injury that occurs far too often in the NFL. Regrettably, it is a sad reality and there can only be so much done to prevent these injuries. So far, only two have been reported, CB Jason Verett of the LA Chargers and Patriots OL Isaiah Wynn. However, this will not be the last one by any stretch as it is still early in preseason and unfortunately many more injuries will occur.

This wraps up another article in the NFL injury series. As the preseason progresses, continue to watch for more Bills camp updates, injury articles, and any other breaking news coming out of One Bills Drive. Follow Banged Up Bills on Facebook, on Twitter @BangedUpBills, and on reddit at u/BangedUpBills. As always, thank you for reading and GO BILLS!!

NFL Injury Series- Hamstrings

Reviewing the hamstring strain, severity, and rehabilitation.

Today’s post will look at the all too common hamstring strain. This is an injury even the best conditioned athlete can sustain. This article will not focus on one specific player, but rather educate and inform what the hamstrings are, how they operate, why they’re injured, and prevention.

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Credit: myprotein.com

The hamstrings are made up of 3 muscles in the back of the thigh consisting of the biceps femoris on the outside and the semimembranosis and semitendonosis on the inside. Together these three muscles attach to parts of the upper femur and bottom of the hip which is called the ischial tuberosity . This is the bony part that everyone sits on when they are in a chair. At the other end, they connect to the top of the tibia and fibula, which is the lower leg bones. Due to the muscles crossing over two joints, they have different functions. Together, these muscles allow the leg to extend and drive the body forward, along with bending the knee. During running and blocking, these muscles cycle through the process of shortening and lengthening at regular intervals depending on the position of the leg.

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Credit: livestrong.com

To help you envision the hamstring functioning, picture a sprinting athlete. Typically, one foot is in contact with the ground, the other in the air. During the foot that is in contact with the ground, the hamstrings with other muscles assist in extending the thigh to assist in moving the body forward. As the body moves forward and begins to push off, the other leg begins the process towards beginning to make contact with the ground. Once the original leg finishes pushing off, the knee begins to bend to assist in clearing the foot to bring the leg forward. Even during the portion where the leg makes contact with the ground, the hamstring is loading back up and eccentrically contracting which means that it is accepting a load while lengthening, which is the most taxing type of muscle contraction. When the foot makes contact with the ground is where most hamstring injuries can occur which is why you see most players stop quickly due to the sudden nature of the injury. While the hamstring does sound confusing, it can be, but know that without them, you’re not doing much walking without them

During times of injury, the muscle can be overworked, overstretched, or fatigued, leading to part of the muscle to become injured. Depending on the severity and location can dictate the recovery time. A strain is due to the injury to the muscle or the muscle bone attachment. Grade 1 tears are the least severe in which a small portion of the muscle tears during excessive activity. This can heal up rather quickly but several days of rest, stretching, and light exercise can remedy the muscle.

Grade 2 hamstring tear is where at a moderate portion of the muscle tears with a greater force, leading the player to limp and be unable to properly use the affected leg as intended. Typically, there is greater bruising and swelling with initial difficulty placing weight, keeping the player off it for some time. Bruising, poor functional control, and tenderness may occur during this time which could cause the athlete to miss several weeks before they are back to playing shape.

Grade 3 hamstring tear is where the muscle nearly or completely tears. It can also pull a chunk of the bone away from the bony attachment, most likely at the ischial tuberosity, known as an avulsion. This is due to this area being the anchor point, meaning the harder the muscle contracts, the harder it pulls on the anchor point, leading to eventual overload. At this level of injury, the muscle is quite weak and function is no longer normal. With this injury, the athlete is in danger of missing significant time or can be potentially season ending. Recovery time with surgery can be anywhere from 3-6 months with some resources stating closer to 8 months.

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Credit: physioprescription.com

These types of injuries occur when an athlete suddenly tries to decelerate and change direction, hurdling a player, or trying to push their body faster and faster. This can also occur during blocking, trying to maintain their ground as their being pushed forward and backwards, eventually the muscle gives out and the player becomes injured as a result. There are countless ways for the hamstring to be injured, these are just several of the more common mechanisms of injury.

While the injury is not fully preventable, there are certain steps that can be taken to reduce the incidence. Some preventable measures that can be taken is ensuring proper hydration, conditioning, stretching, and strengthening. Some things that can’t be controlled is previous hamstring injury and increased age. The best method to treat an injury is to prevent. However, I would be hard pressed to find an athlete that has not sustained some sort of hamstring injury during the course of their athletic endeavors.

As Bills fan, we have already seen several players deal with hamstring injuries this season with varying degrees of severity. As a PT, I am not concerned about the long term management of the injuries. I know these players need time to rest, recover, and not to rush back. I would expect to see these injuries increase as the season wears on and the bodies begin to break down. So far, only Matt Milano has been slowed up by hamstring strains and has been brought along slow so far in training camp after re-injuring in OTA’s.

Continue to check back for the latest Bills news and injury updates. Follow on Twitter @BangedUpBills, on Facebook at Banged Up Bills and on reddit at u/BangedUpBills. As always, thank you and GO BILLS!!

NFL Injury Series- Contusions

Reviewing what contusions are, severities, and recovery times.

Today’s post will consist of several terms that come up often but aren’t well defined. My goal is to identify the rest of the terms and continue to further the knowledge base. There are many terms for the same problem or based on location, which define how it is described.

First up is the common contusion. A contusion is defined as a blow to an area that damages the small blood vessels and connective tissue in the area. This can be caused by getting hit hard or falling the ground which if severe enough can impact function. While everyone has dealt with a bruise at some point or another, not everyone gets hit by a 250 lb linebacker going at full speed.

When the contusion occurs, the blood vessels do burst and the discoloration is the result of the burst blood vessels releasing blood, rising up to the surface, then slowly reabsorbed by the body. This is why a bruise fades over time. The more severe the contusion, the more impact it can have. While nothing has been torn, the connective tissue of the muscles and other tissues including fat and skin are still impacted. The tissues of the body are quite pliable and if damaged, will respond to pain as any other portion of the body, except brain tissue. Contusions vary in recovery times to no time missed to several weeks based on location and severity.

Contusions, if severe enough can cause compartment syndrome in the area. This occurs when swelling becomes excessive and pushes on the connective tissues surrounding the muscles. If not managed quickly, the excessive pressure can begin to kill the muscle, leading to permanent damage.

Various types of contusions include hip pointer, nerve contusion, stingers, and bone bruises. Hip pointer injuries are to the bony portion of the hip known as the iliac crest. This is right above the waist line and are common due to the location players fall to the ground or are tackled in the area. This area is also where the abdominal wall attaches to which limits trunk motion and the hip abductors connect right below the area, which allow for a player to run and perform lateral movements. These can take 1-3 weeks to recover based on severity of the injury.

Nerve contusions, such as what Shaq Lawson dealt with last season, is when bruising occurs to a nerve. In most cases in the body, the nerve is well insulated and protected from injury. However, in certain cases, these nerves sometimes exit the body temporarily and are exposed. Cases include the ulnar nerve that exits temporarily near the elbow and the peroneal nerve which is on the outside portion of the knee near the fibula. If you’ve ever hit your funny bone, that’s your ulnar nerve screaming at you. In Lawson’s case, he hit the peroneal nerve which causes pain and weakness to the area. These injuries can resolve relatively quickly, but are quite painful and may take some time to rehab from to ensure proper movement. Once again, depending on the location and severity determines recovery time.

Stingers are another type of nerve injury that can be incredibly painful, but can quickly resolved if managed correctly. Stingers occur when a player gets tackled violently and the shoulder is pushed in one direction and the head in the opposite, leading to traction on cervical or neck nerves. Compressive forces can also cause similar symptoms, such as a direct head blow during a poor tackle or when driven into the ground. Pain is typically felt in the neck and shoulder region, with pain also produced sometimes all the way down the arm causing pain, weakness, and numbness. Due to how the nerves connect all back to the spinal cord and brain, this is why pain can travel down the arm despite the injury occurring in a different area. These injuries can resolve with rest and proper stretching, but is not something that can be rushed.

Finally, bone bruises complete this article. Bone bruises are actually a type of fracture that is less severe than a true bone fracture that we all think of. Keeping it brief, there are 3 types of bone bruises: Sub-periosteal hematoma, inter-osseous bruising, and sub-chondral lesion.

Sub-periosteal hematoma occurs when a direct high force trauma occurs and blood forms under the periosteum, which is a membrane that covers the outside of the bone. Inter-osseous bruising occurs when the bone marrow of the bone becomes damaged, specifically the blood supply. This occurs as the result of a repetitive high compressive forces on the bone, such as excessive running or jumping. These are seen more common in the knees and ankles.

Sub-chondral lesions occur when the cartilage layer of the bone becomes damaged. This area is found at the end of the bone and is the part that articulates with another bone. An extreme crushing force or rotational/shearing force may also cause this, commonly seen in injuries such as ACL tears. ACL tears typically not isolated, but MCL damage, meniscus damage, and even a sub-chondral lesion due to the forces that occur on the joint during the injury also occur.

Recovery times are difficult to manage with mild bone bruises recover in several weeks with more severe instances can be months. It really is specific to each person and how the injury was sustained. I wish I could give a more specific timeline for these recoveries but some players respond quickly and others such as Sam Bradford could take several weeks and leave uncertainty regarding their availability for future games.

These injuries happen far too often and are a part of football. While padding, playing surfaces, and proper tackling can reduce incidence of injury; these are the types of injuries that come with playing football. Most of these injuries can be managed conservatively with rest, icing, stretching, and padding. These are injuries that do not keep players out for extended time, but can be injuries that knock out players during key games.

Continue to check back for regular updates and further in depth analysis of the latest Bills injuries. Follow on Twitter @BangedUpBills, on Facebook at Banged Up Bills and at http://www.bangedupbills.com. As always, thank you and GO BILLS!!

NFL Injury Series- Sprains

An overview of general sprains, severity, and recovery times

As we continue to delve into common injuries seen around the NFL, today’s post will consist of an overview of general sprains. Sprains are very similar to strains, but differ in function and location. Sprains are an injury to a ligament or multiple ligaments based on location. Ligaments are found all over the body and provide connections between bones to create a joint. When an injury occurs to the area, instability, pain, and swelling occurs based on severity.

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Credit: therapydiadenver.com

Grade 1 sprains are when the ligament is stretched minimally and minor swelling/pain occurs. This can cause some players to miss time based on location and position, but typically can be managed conservatively in order to return to prior level of function. These types of injuries are week-to-week and can be played through if absolutely required, though increased risk of injury occurs. X-rays may be performed to ensure no fractures have occurred but are usually diagnosed through physical examination.

Grade 2 sprains are when the ligament is partially torn and moderate swelling/pain occur. These types of sprains typically keep players out for some time and cause moderate loss of function. A conservative expectation for a Grade 2 sprain could be anywhere from 4-6 weeks, though could vary based on location. At this time, an X-ray is performed to rule out any fractures. An MRI is performed to support physical examination and determine extent of damage.

Grade 3 sprains typically involve near or complete tearing of the ligament leading to significant loss of function and possible season ending surgery based on location of area. At this point, the ligament is classified more of a tear than a sprain which is why you do not see this as a Grade 3 sprain. Typically, ACL, PCL, and severe MCL tears can be categorized as such along with AC joint sprains. Ankles, shoulders, and wrists are also common areas for complex ligament damage to occur. It is common to see other structures become damaged as the result of a severe sprain/tear. MRI’s are performed to determine severity of tear and to assess for any injuries missed by physical examination or initial swelling.

In most cases, a sprain can be due to an overload to the joint as a direct blow, violent twisting/pivoting, or excessive tension on the ligament. As with all other materials in the body and in nature, everything has a breaking point. Injuries such as these can be reduced but not totally prevented. Preventative measures include playing on forgiving surfaces such as grass which reduce the friction and prevent cleats from sticking in the surface. Proper strengthening to the area and proprioceptive exercises which include body awareness activities help keep the body from overloading the joint. Bracing and taping may also give support to an area if there is a high risk for injury or prior instability. Taped wrists, knee braces on lineman, and ankles braces assist in limiting excessive range of motion, reducing the risk.

Continue to check back regarding updates on Bills news and general injuries in the coming days. While it is impossible to review every injury, this is merely a guide to assist you in understanding the severity and expected timeline upon injury. Follow on Twitter @BangedUpBills and at http://www.bangedupbills. As always, thank you and GO BILLS!!

NFL Injury Series- Muscle Strain

An overview of general muscle strains, grade severities, and recovery times.

The Buffalo Bills training camp continues to roll right along with no major injuries to report. The only reported injuries so far is TE Nick O’Leary who suffered an ankle injury which kept him out of practice for a short time but did not appear to be anything serious as he was able to return to full practice after several days rest. TE Logan Thomas was limited in practice but no further updates have been released regarding his current injury.

As we continue with the NFL injury series, today’s post will consist of identifying several terms used to describe injuries and educate on how to differentiate on what is being reported. I have used many of these terms before and have done my best to describe them, but I believe they are worthy of their own article. Today’s overviews will consist of the common muscle strain.

A muscle strain can occur in virtually any muscle within the body if the muscle is suddenly overworked, stretched, or fatigued to the point where the muscle becomes injured. A strain is classified as a strain due to an injury to the muscle itself or the muscle bone attachment which is called the tendon. There are varying grades of muscle strains which can progress up to a muscle tear, avulsion fracture, or rupture.

Grade 1 muscle strains are relatively minor and is when a small portion of the muscle is torn; function may be limited, but is typically not serious and can heal up relatively quickly with proper management. This usually consists of stretching, icing, anti-inflammatory medications, and light strengthening exercises to restore proper movement. With effective management, this can be a day-to-day injury with some lasting up to a week or two. Most of these injuries are able to be played through with proper rehab and rest.

Grade 2 muscle strains are where a moderate portion of the muscle is torn which is typically associated with bruising, swelling, and partial loss of function which is demonstrated as difficulty performing the muscle movement and is typically limited secondary to pain. Rehab management will consist of generally the same procedures as Grade 1, but will require a longer duration to recover. I can not make a blanket statement and state that a Grade 2 muscle strain will take “X” number of weeks to heal up. It is typically more than week-to-week, but based on location and job duties of the position may dictate how long the player is out.

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Credit: eorthopod.com

If a Grade 1 or 2 muscle strain occurs close to the tendon attachment, if not healed up correctly or chronically injured/overused, the muscle or tendon may develop into a tendinitis based on healing. The suffix “-itis” is Latin for inflammation, which indicates that the tendon is irritated and may become painful over time. Most muscle/tendon fibers have consistent, linear striations, such as in a nice cut of beef or in the picture above. When the tendon does not heal correctly, the connective tissue heals in an uneven pattern as seen in the picture below. This does not allow for effective contraction of the tendon, leading to increased pain, weakness, and loss of function. This could lead to tendonosis which is the chronic form of tendinitis and becomes even more difficult to treat. Eventually, this can lead to a higher risk of rupture in the tendon later but is not a requirement for a rupture to occur.

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Credit: mendmeshop.com

However, when a severe muscle strain occurs, this is classified as Grade 3. This is where most of the muscle is torn, there is typically significant damage and surgery is possibly required to repair the structural damage. There is significant swelling, bruising, and pain to the area due to the sudden and forceful nature of the injury. The muscle no longer is able to function as intended and pain limits the possibility to attempt. At this point, several other injuries may have occurred including an avulsion fracture or ruptures. If an avulsion fracture or rupture has not occurred, surgery still many be indicated to assist the muscle in healing correctly.

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Credit: physicaltherapyct.com

In the case of an avulsion fracture, the tendon that attaches the muscle to the bone and acts as the anchor pulls away from the attachment point and takes a chunk of the bone with it. While this injury is uncommon, it still does happen. Surgery is sometimes indicated to reattach the bone to the original area and requires extended time missed, requiring the body to build up toleration to the muscle pulling on the attachment point without re-injuring the area.

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Credit: tylerfootclinic.com

Finally, a tendon rupture is when the tendon tears away from the attachment point but does not take a piece of bone with it. This is commonly seen in biceps and Achilles’ injuries, among other areas. If this injury occurs, the player may feel a pop with immediate loss of function. The muscle may act like a bungee cord and rebound violently and become balled up, leading to a deformity. These types of injuries also require surgery and cause a player to miss extended time due to the requirements of the muscle contraction and the actions of the muscle. As there are a variety of potential tendon ruptures and recovery times, it is difficult to state a general timeline without having specific information.

This is just a brief overview of the muscle strain and how to understand the various nuances of the wording and injury. Sometimes injuries such as calf and hamstring strains can appear to follow a player for their career or never fully heal without significant rest. The best thing that a player can do is hydrate well, stretch effectively, strengthen properly, and listen to their bodies. While the NFL is a tough sport, pain is expected, but trying to play through an injury may only worsen it and cause further complications down the line.

This completes another article in the NFL injury series as we prepare for pre-season games and the regular season. There is much more to come regarding the common injuries we will inevitably see over the next several weeks. Continue to check back for posts regarding other general injuries and broaden your knowledge base. Follow on Twitter @BangedUpBills and at http://www.bangedupbills.com. As always, thank you for reading and GO BILLS!!

History of the ACL Reconstruction

Analyzing the history of the ACL injury including high level athletes who were able to succeed without an ACL and potential complications later in life.

Welcome back to Banged Up Bills! Today’s post will take us back in time to the 1970’s and 80’s, before the Bills reached untold greatness and the legends of Orchard Park were coming into their own. Looking back to 1986, RB Thurman Thomas of the Oklahoma State Cowboys partially tore his left ACL in a pickup basketball game in the off-season, placing his junior season into question. Fortunately, despite recovering and achieving All-American status his senior year, the known history of this partially torn ACL ultimately caused his draft stock to slip, allowing the Bills to steal the future HOF in the 2nd round of 1988. The article above mentions that he suffered the ACL injury and had arthroscopic surgery to assess the damage, but the ACL was ultimately never reconstructed at the time. Recently, it was revealed on Twitter that Thomas successfully played his entire career with a partially torn ACL; according to him, 85%.

While some said he was a GOAT for playing with an injury of that magnitude, it is more astonishing that he was able to perform at such a high level despite knowing what we know now about ACL tears. Today’s post will explore the history of ACL repair, why Thomas most likely did not have the surgery, other NFL players who were able to succeed without an ACL, and potential complications they may have today as a result.

Looking at a brief history of the ACL injury, these types of maladies have been explored for centuries, going back to ancient times when the true gladiators battled against each other. When injuries such as the ACL tear occurred, doctors such as Galen would be able to further explore the inner workings of the knee through gashes suffered in battle and identify these complaints, though surgical intervention was centuries away. Fast forward to the late 1800’s, further examination and surgical intervention came into vogue with the advent of X-ray and a better understanding of the function of the ACL.

However, it would still take nearly 100 years to develop effective treatment of the ACL to what it is known today. In the 1970’s, doctors were aware that the ACL had an impact on knee function but testing for injury and surgical intervention were still in its infancy which led to many methods of repair with a wide variety of overall poor outcomes. Initial surgeries would open the knee up with rather large incisions and attempt to repair the knee with a variety of material including hamstring, patellar, cadaver, and synthetic grafts.

Surgical techniques were improved in the 1980’s with the use of arthroscopy, however, this time period also saw high rates of materials failure and complications several years after a repair due to synthetic grafts. There was also not a general consensus on the best method to repair the damaged ligament. In addition, there was published research arguing that nonsurgical interventions was just as effective as surgery in outcome scores with regards to function, though they did note that surgical repairs led to a more stable knee in comparison.

Attempts were made to identify a consistent rehab plan for the ACL as surgery techniques improved. Regrettably, the rehab plans were determined later to hinder the patient recovery and led to greater failure rates after returning to sport. Several pearls from the above mentioned ACL rehab plan that would not be considered today include:

  • casting and immobilization of the surgically repaired leg for 6-8 weeks
  • immobilization between 30-60 degrees in flexion
  • either toe touch weight-bearing or no weight-bearing allowed during this time frame

Most of these interventions were thought to preserve the integrity of the ligament by limiting movement with the ACL on slack with the knee in a flexed position. The thought was a fully extended knee placed undue stress on the repair and could cause premature rupture in weight-bearing.

Research later found patients that were non-compliant with their rehab protocol actually had better outcomes than those who followed the rehab precisely. Those that were non-compliant were removing their casts and beginning movement/strengthening sooner than advised but were found to be able to return to full function with less pain and overall greater satisfaction which forced the medical community to reevaluate the protocols.

As there was so many varieties of materials for repair, no gold standard for repair technique, and a poor understanding on proper rehabilitation, its no wonder that Thurman Thomas avoided having the surgery all together. He would most likely been worse off having the surgery than playing without a repair. I believe that with all the uncertainty of surgery methods/outcomes, the experience with ACL repairs of the treating orthopedic surgeon, and his potential career prospects, reconstruction was not performed. Fortunately, his knee was able to withstand the demands required of his position with protective bracing throughout his career despite the tear.

Thomas was not the only one that declined surgery and managed to play with an ACL deficient knee through their career. HOF QB John Elway tore his ACL in high school but was still able to recover without surgery and have a long career in the NFL. It is noted that this was his non-plant leg which reduced the incidence of pivoting which may have allowed him to avoid further issues. It has also been reported that Yankees great OF Mickey Mantle tore his ACL during his rookie season and was able to play his entire career without an ACL. I believe that Yankee fans are unanimous with how great he was despite his injuries. As I stated in my previous article, it is possible to live a normal life without an ACL, though still very difficult to play at a high level without one. Thomas, Elway, Mantle, and a more recent example of WR Hines Ward of the Steelers are several exceptions.

The only consistency that I see is that all of these players were relatively young; >20 years when they tore and may have still been growing into themselves, which allowed their bodies to adapt and compensate with the deficiency. However, pediatric ACL tears still benefit from surgical intervention with nonoperative management and potentially causes problems later in life which refutes the statement above regarding youth ACL tears.

Research supports the use of surgical intervention with some variances in techniques and rehab but generally, surgery is the gold standard in order to return to full ability. We have seen the power to return to sport after ACL reconstruction with an 82-95% success rate. Through rigorous studies, the medical community has also found that proper reconstruction has reduced future injuries and complications significantly. These included future meniscus tears, corresponding ligament injuries, and arthritis. In Thurman Thomas’ case, it is unknown whether he has had any further complications, though several reports in 2001 indicate that he tore the right ACL which ended his NFL career in Miami.

With these complications arising from avoiding ACL surgery as several studies supported in the 1980’s, eventually the ACL injury could have degraded the knee to where loss of function was significant and few interventions available to provide relief once it got to that stage. Knee replacements are available which restore function and movement, but those are typically reserved for those patients that are much older with ages into 50+ and have reduced their athletic activities. People in their 20’s-30’s are not ideal for a knee replacement and should not be considered unless certain exceptions arise which are typically not sport related. If the players mentioned above have not already had a knee replacement due to the punishment of the sport, they are most likely considering the possibility.

As a whole, ACL reconstruction continues to be the primary intervention to allow athletes to return to sport. There are doctors that have begun to swing the other way again, rejecting surgery in the case of Miami Dolphins QB Ryan Tannehill when he partially tore his ACL late in the 2016 season. The corresponding rehab was ultimately unsuccessful as he re-injured his knee in training camp the next year. Eventually there will be interventions which reduce the healing time in the surgically repaired knee or there may be effective non-surgical interventions. It took over 20 years to really establish a consistency for ACL repair; it may take even longer to identify interventions that don’t involve surgery.

I found this research to be fascinating as the history of medicine has changed so drastically over the years and its incredible to think that these previous methods were cutting edge at the time. Thankfully, studies and constant refinement of the process has allowed high level athletes return to full ability instead of potentially ending their careers. The quality of interventions will continue to improve with medical advances and maybe 30 years from now, we will be looking back and say “what were we thinking?” Until then, we will work with what we know best.

Continue to check back for the latest updates from @BangedUpBills on Twitter and at www.bangedupbills.com. I will be pumping out a lot of content with training camp coming up and as players begin to suffer injuries. As always, thank you for reading and GO BILLS!!