Approximately 1.2 out of 100,000 people annually will sustain a Distal Biceps Rupture. This means that the lower attachment of the biceps muscle tendon at the elbow has torn away from the bone. Most often these are traumatic injuries that occur when the arm is resisting a heavy downward motion and the tendon tears away from the forearm bone. This is commonly seen in weight lifters while doing biceps curls or workers lifting or trying to catch a falling heavy box or object. Other sporting activities have been reported such as doing “muscle-ups” in Crossfit.
The biceps muscle attaches at two points in the shoulder and attaches at one point in the elbow to the radius bone in the upper forearm. This lower or “distal” attachment provides added strength for bending or flexion of the elbow and also provides strength for supination of the forearm which is turning the palm upward. The brachialis muscle also bends the elbow and the supinator also provides rotational strength to the forearm.
The vast majority of these injuries occur in males with average age around 50 years old, and many are weight lifters. Other risk factors include smoking and anabolic steroid use both of which may weaken the Distal Biceps tendon allowing for rupture when it is over-stressed.
When catching a heavy object or when bringing down weights during a biceps curl the muscle is contracting, but also lengthening at the same time. This generates the highest possible forces in the muscle and tendon and is a typical moment at which the Distal Biceps Rupture occurs. Typically the tendon will tear away from the bone (radius) of the forearm, and less commonly it will tear in mid-tendon or at the junction where muscle turns into tendon.
Most people will notice a sharp pain and pop when the tear occurs and notice a loss of normal contour to the biceps in the upper arm. It will appear to be retracting upwards. There will also be swelling and bruising and pain with movement. After the initial injury people are still able to bend and move the elbow. Orthopedic surgeons use what is called a “hook test” which is hooking your finger around the intact biceps tendon on the uninjured arm. Then the same is attempted on the injured arm. If the tendon cannot be felt or “hooked” then it is likely torn. MRI will be done to confirm is the tear is from the bone or other location.
Seeking an orthopedic surgeon evaluation immediately after a suspected Distal Biceps Rupture is very important. The vast majority of these are recommended for surgical repair and the best repair can be achieved if done within the first 1-2 weeks of injury. Surgical treatment 3-4 weeks and beyond after injury can create significant technical challenges and worse outcomes as the tendon continues to retract. The may lead to an inability by the surgeon to get the tendon all the way back to the radius bone for repair. This may then require more complex reconstructive types of procedures to achieve an intact distal biceps.
In some older and less active patients it may be acceptable to leave the biceps tendon torn, and over time they will regain most of their elbow flexion (bending) strength, but will typically lose about 30-40% of their supination (palm upward) strength. For most active patients we recommend surgical repair to obtain the best possible future outcome.
The surgical procedure for Distal Biceps Rupture is outpatient and typically 1-2 hours. Through either 1 or 2 incisions, depending on surgeon preference, the tendon is re-inserted into the radius bone at its normal location. It is held in place either with suture anchors, metal button, or a screw. The arm is typically immobilized for 7-10 days after surgery and then range of motion with a physical therapist will begin. No resistance of any kind will be allowed for 6-8 weeks after the surgery to allow for tendon to bone healing. At this time a resistance program will being with most patient returning to normal activity in 4-5 months after surgery.
It is very important to be aware of the risk factors for Distal Biceps Rupture especially if you are in the 35-60 age group, and engaging in any heavy lifting or weight lifting activities. Proper warm-up and stretching is important. If you suspect you may have a Distal Biceps Rupture immediate evaluation by an orthopedic surgeon can help to ensure you have to best available treatment options for this injury.

Tearing away or rupture of the Pectoralis Major tendon from the humerus (upper arm bone) is a relatively uncommon injury.  These injuries typically occur in weight-lifters especially during bench press.  The most severe muscle contraction occurs during the downward motion of the bench press and it is at this moment when most pectoralis ruptures occur.  In these moments the muscle is contracting with great force while at the same time the muscle is lengthening allowing extension of the arm.  These injuries can also happen in football players, especially lineman, and in wrestlers.  Because of the infrequent nature of these injuries they can often be missed or not diagnosed, however most bench pressing injuries are obvious to the patient as they feel a tearing or popping at the moment of injury and will drop the weight bar.

The pectoralis major is a very large muscle that originates from the clavicle or collar bone at its upper end and the sternum or breast bone and even has some attachments to the upper ribs.  It travels outward toward the arm and attaches to the humerus with a large tendon.  It is responsible for the majority of force required to internally rotate the arm, bring the arm towards the body, and also is involved with elevation of the arm.    

The most common portion of the pectoralis tendon to rupture is the lower half and it is this portion that normally forms the contour of the upper axilla or arm pit.  When the rupture occurs there is swelling and bruising evident on the pectoralis and upper arm.  Patients, especially body builders will notice a lack of the normal contour of the axila and will see abnormal movement of the muscle when trying to contract their pectoralis. 

Typically xrays will not reveal any type of bone injury and MRI is required to further define the injury.  MRI is important to distinguish a ruptured tendon from an injury further over into the muscle itself as the treatment for these will vary.  The most common form of the injury is tearing away of the tendon directly off the bone.  The MRI will also help to distinguish partial from complete injuries, which will help determine treatment options.

When there is a complete tearing of the tendon away from bone treatment usually consists of surgical repair of the torn tendon.  However some patients may not require or desire surgery.  In the case of a purely muscular tear without a ruptured tendon time and therapy will usually suffice for healing.  In the case of a tendon tear in an elderly patient with low physical demands repair may not be required although some strength will be lost.  The vast majority of these injuries are in young and active people and repair is recommended to restore strength and function.

Successful repair is obtained in nearly 90% of cases with return of strength and mobility.  The optimum time frame for repair is within 1-2 weeks from injury.  Older injuries can be repaired, but success rate will depend on length of time from injury to surgery and quality of the tendon. 

The procedure for repair involves an incision near the axillary fold in the front of the arm/shoulder.  Strong sutures are placed in a locking fashion into the ruptured end of the tendon.  Various methods are then used to re-attach the pectoralis tendon to the bone.  Effective methods include tunnels in the bone, suture anchors, and suture buttons.  All of the methods can provide secure repair to the bone and allow for the body the heal the tendon back into place.  This is an out-patient procedure done under general anesthesia.  Patients will use a sling for about 1 month after surgery and will begin a physical therapy protocol usually within the first week.  Over the course of 6 weeks the patient will regain full range of motion and strength training will begin at that time.  Typically return to full strength and activity is in the 4-6 months range.  However bench pressing is usually discouraged for 6-9 months.  

Overall surgical repair is a highly successful procedure for this somewhat rare injury.  It is of great importance to be evaluated by an orthopedic surgeon if you suspect a pectoralis injury has occurred. Things to look for are severe pain/tearing during bench press or other sport, bruising along the pec muscle, or deformity of the pec muscle or abnormal appearance of the upper fold of the arm pit.  If these are present there is a high likelihood of pectoralis rupture.   

 

In the U.S. nearly 300,000 each of Knee and Hip replacements are performed annually, and slowly increasing is the number of Shoulder Replacements at around 50,000.  A growing segment of the population needed shoulder replacement or resurfacing options is the 35-50 year-old group who have either had prior injury or surgery, or both to the shoulder

The shoulder is a ball and socket joint which can wear down in the same way that knees and hips can wear. There are somewhat fewer people who reach the stage of needing shoulder replacement, likely due in part to our ability to accommodate the upper extremity problems better than lower extremity. For example with an arthritic, bone on bone knee it hurts with every step you take, but as we don’t walk on our hands a person can guard a worn shoulder by becoming somewhat one-handed.

When someone reaches the stage where they cannot function properly and enjoy life due to an arthritic shoulder, many options exist to improve the shoulder. Physical therapy and medication will help some people, and for others there are surgical options. Newer approaches to surgical treatment of shoulder arthritis include arthroscopic cleaning of the joint and release of tight ligaments and removal of bone spurs to improve mobility and in some cases reduce pain. And for more severe cases shoulder replacement is a viable option. This can be done replacing the ball only, or the ball and socket depending on amount of wear of the joint and surgeon preference.

A major challenge of shoulder replacement is the requirement to cut and detach one of the rotator cuff muscles at the front of the shoulder as a window of access to be able to do the operation. After re-attachment this muscle must heal first before more intensive therapy can be done, usually requiring 6 weeks. In addition research shows that the long term function of this muscle never fully returns to normal after even the most successful shoulder replacement.

Over the past 3-4 years a new approach to this operation has been developed by which the shoulder is replaced entering the shoulder between two of the rotator cuff muscles without detaching them. The level of difficulty with this rotator cuff sparing shoulder replacement approach is higher than traditional shoulder replacement, but the benefit for the patient when performed correctly is enormous. This is a game-changing advancement as it allows shoulder replacement to be done as an outpatient, allows immediate active movement of the shoulder, and prevents the long term damage to the rotator cuff seen in traditional shoulder replacement. In this novel approach there is no need to protect the shoulder intensively for the first 6 weeks, but rather the patient can begin to move the arm on their own without restriction almost immediately after the surgery because the rotator cuff muscle did not have to be detached and re-attached as a part of the surgery.

This type of advancement is revolutionary and will become even more important over the next 10 to 20 years as we see more young patients in need of shoulder replacement options. This group of patients will be the young men and women in their late 30’s to late 50’s that have had prior shoulder trauma from high intensity sports, and more aggressive recreational activities. Many of them will have had prior shoulder surgery at a young age to correct labrum or rotator cuff issues, or surgery to correct recurrent dislocations. In this population we are already starting to see the difficult problem of a 40 year-old patient with the arthritic shoulder of a 75 year-old. These patients need less invasive and potentially longer lasting results to be able to enjoy their remaining years, and to withstand the higher demands placed on the shoulder joint by a younger population after replacement.

Various technologies are already being developed, and some already in use, to improve the life-span of the implants that are used for shoulder replacement. In the future this may even include arthroscopic options for shoulder replacement. This rotator cuff sparing approach to shoulder replacement surgery is a major step in the right direction and a welcome addition to help improve the overall longevity and performance for the growing number of patients who are opting for this procedure.

In the wake of this week’s contralateral (opposite side) knee injury sustained by Derek Rose we should take time to consider the phenomenon of injury to the “good knee” after recovery from ACL reconstruction.

For competitive athletes a torn ACL is a devastating and life-altering injury. The overall success rate for return to competitive sport after surgery is in the range of 75% to 90%. But this return to competitive sports is also one of the known risk factors for contralateral, or opposite knee injury and it is more common than you might think. Research shows a tear of the ACL in the previously un-injured knee after successful return to sport status post ACL reconstruction can range from 3%-11%.

Factors that have been shown to increase risk of opposite side ACL tear include age of 18 and younger, return to competitive sports, and male gender. The highest risk time period is within 1-4 years after the ACL surgery.

In recent years many surgeons have begun to extend the recovery time for ACL reconstruction from a range of 4-6 months to longer time frames averaging 9-12 months. This may be beneficial to allow more time for surgical healing and rehabilitation of the knee to re-gain strength, agility, and overall performance. But despite this a certain number of young athletes will face a new ACL tear in the previously normal opposite knee.

One key concept in the realm of ACL tears is proprioception. This is the body’s ability to know where a body part is in time and space, and to respond appropriately to protect the joint. There are several nerve fibers in the normal ACL that communicate this information to the central nervous system and Brain. We know that this feedback loop is disrupted when the ACL is torn and a large part of the struggle with postoperative rehabilitation is trying to re-establish these neural connections. Some research has shown that an ACL tear in one knee may also disrupt this feedback loop in the central nervous system for the opposite normal knee and leave it more vulnerable to a tear.

Another risk factor for contralateral ACL tear is fatigue in the good knee post surgery. It is very common to focus diligently on the surgical knee during recovery while allowing the good knee to become fatigued and weak while it is carrying the extra load. So longer recovery times may benefit the surgical knee, but could add to the fatigue of the good knee. It can often be imperceptible that by the time the surgical knee is ready, the good knee may be worn out, and it is at this very moment that many athletes are returning to sports. A strong focus on strength and function of the good knee when nearing the return to sport may help to decrease this risk.

Thankfully, in the case of Derek Rose this week he did not sustain another ACL tear, but rather a torn meniscus. However the issues mentioned above certainly may have played a role in this new injury. He is a young, highly competitive athlete who underwent ACL surgery, had a prolonged recovery time, and likely had fatigue in the good knee. We will watch with interest as he makes his recovery.

Our American appetite for year-round sports has grown over the past 20 years and with that has come a new generation of young athletes suffering the consequences. In the overhand, or throwing athlete a torn or partially torn Labrum has become as feared as the torn ACL in the knee. Tremendous pressure is placed today on these young athletes to push the boundaries of play, with the hope gaining a college scholarship, but are we pushing them too far? And are we leveraging the cost of higher education on the risk of overuse sporting injury?

Tens of thousands of young overhand athletes undergo labral surgery every year in the U.S. Of these some have sustained a traumatic injury such as a dislocated shoulder, but the majority have worn and stressed the Labrum slowly over a long period of time. The daily grind, year-round competition, and concurrent multi-sport participation all are taking their toll on our young overhand athletes. There is no real off-season anymore and young bodies and joints are not getting the downtime they need and deserve. So it’s a bitter pill to swallow when at the very moment they are poised to go to the next level, and reap the fruits of their labor, a torn Labrum strikes and puts them on the bench. This is not just an inconvenient bump in the road, but potentially a road-block influencing their activity and their future.

Return to the previous or higher level of play in overhand athletes such as pitchers, volleyball hitters, swimmers, or javelin throwers, to name a few, runs in the neighborhood of 60-80% on average versus 80-90% with ACL reconstruction. The reasons for this are not fully understood, but we do know that the shoulder joint is more complex in its movement that any other joint in the body, and the demands placed on it especially with pitching and volleyball hitting are extreme. Often the torn labrum is simply the body’s way of adapting to these demands, allowing the excessive range of movement and forces required to launch a baseball or softball or volleyball at high velocity. But this comes at the price of potential injury in the end.

The Labrum is a rubbery bumper of cartilage that runs the circumference of the socket (Glenoid) of the shoulder joint. It helps to cushion and stabilize the joint, but when torn or injured it causes pain and dysfunction. Before the Labrum actually tears pitchers and other throwers will begin to experience symptoms of tightness, weakness, and lack of ball control. They will be unable to get the shoulder warmed-up and loose and they cannot find their “slot.” Over time they will lose speed and finally the pain begins. The shoulder begins to pop and catch, and they are unable to throw at all. A similar progression occurs with volleyball hitters and swimmers, however they will often feel shifting and too much looseness in the shoulder, along with the pain. This culminates in symptoms that sideline them from their sport. Some athletes will think that a single injury has occurred at this point, but in reality this is the Labrum finally giving way to the pressure and trauma of years of over-use.

When these symptoms of pain, catching, popping, weakness, loss of control occur it’s important to have a formal evaluation by an orthopaedic surgeon with knowledge and experience in the realm of the throwing/overhand athlete. Talking to the athlete about the symptoms often is more critical even then physical examination or MRI in understanding the chronology of events. On examination the shoulder is weak and the rotator cuff muscles although not torn are fatigued and contributing to the dysfunction of the shoulder. The muscles that control the shoulder blade are also weak and worsening the problem. MRI with a fluid injection into the joint called and arthrogram is the best imaging tool to identify a tear. Even then many tears will not be seen with MRI and the final diagnosis is made with the arthroscopic surgical camera at the time of surgery.

For some athletes rehabilitation and physical therapy alone will bring them back to normal function and no pain, even in the face of a torn Labrum. However for the overhand athlete it is much more difficult to get back in the game with therapy. If they have failed in conservative care then arthroscopic suturing or repair of the labrum is the treatment of choice. As mentioned above the majority will be able to return to their sport after surgery, but not as many as we would like, and perhaps not at the same level as before. So the question remains, to Throw or not to Throw?

Overhand athletes who have undergone surgery but have not made it back to the level that they desire hit a crossroads. The can continue to push the envelope and risk re-injury or potentially more surgery, or “not throw” and hang it up on the competitive scene, saving their shoulder for a healthy and happy life. Some will take the risk and push on with the sport, but many will step down from competition and save their shoulder to live and enjoy another day. Some are compelled to continue on through the pain to maintain or gain a scholarship.

For overhand athletes who are not yet injured, but pushing themselves year-round in their sport the real question becomes “am I going to be good to my shoulder and give it some rest?” The answer should be yes, and for those of you out there with no symptoms prevention is the key. Little League Baseball along with American Sports Medicine Institute have provided our young throwers with a template for some level of restraint and common sense with its guidelines that not only limit pitch counts, but also recommend total rest from the overhand sport for 3 months out of every year. Meeting with a physical therapist to get on a thrower’s exercise program is also the smart way to go. These are the types of common sense steps that we can take for prevention in our current environment of hyper –competitive youth sports.

Finally, for those of you struggling with your shoulder, unsure if there is a problem, it’s time to see an orthopedic sports medicine specialist to be evaluated and treated before your shoulder crosses the line into the realm of surgery. Often you can make it back without invasive procedures, and you can learn strategies to keep it that way for life.

In the last several years, we have seen a variety of new fitness programs hit the market. From P90X to Insanity to CrossFit, active (and inactive) adults are flocking to these high-intensity workouts for fast results. With proper execution many will achieve life-changing improvement in health and fitness. But many more are sidelined with unexpected and certainly unwanted knee injuries.

One of the most common injuries seen in adults who embark upon a new, high-intensity workout program is a torn meniscus. Nearly 1 million knee arthroscopic procedures are performed annually in the United States, and the majority of those include some form of treatment to the meniscus.

The meniscus is a rubbery shock-absorber that provides cushion and transmission of force across the knee joint, preventing the breakdown of the knee. As we age into our 30s and beyond, this tissue is not as resilient as before and becomes more easily susceptible to injury. When the meniscus tears, you will feel pain, locking and catching, and experience swelling and tightness in the knee. It can be disabling and derail your journey back to health via the high-intensity workout pathway.

Many of these newer programs push our bodies to extreme limits and involve high-impact techniques such as box-jumps, squats, lunges, jump-landing, single leg hops and twisting and pivoting motions. These put the knee and the meniscus at risk. Below are a few guidelines that may help to keep your knee out of trouble when starting a new program.

  1. Keep the knee flexion below 90 degrees: When the knee bends past 90 degrees, more pressure is placed on the back portion of the meniscus. Adding weight-bearing movement or higher impact such as landing from a jump, squat or lunge then increases the forces acting on the back portion of the meniscus into the range of 8-10 times your body weight. It is no surprise, then, that the back portion of the meniscus is the most commonly torn area. Staying below 90 degrees of knee flexion can decrease your risk for meniscus tear. This can also apply to any knee “dips” or any leg-press activities in the weight room. The deeper you go, the higher the risk of a tear. So keep it below 90.
  2. Modify: All of the programs mentioned above and the myriad of others out there allow for lower-impact or no-impact modification of the routines. Even if you feel that you are highly fit, it’s advisable to start slowly with modifications and gradually work your way up. Use the non-jumping and lower impact alternatives to the routine. But again, those of us in our 30s and beyond need to be aware that Mother Nature does not have our backs when it comes to high-intensity loading of the meniscus. No matter how athletic you are, as you age so does your meniscus. Avoid high-impact jumps/twists/landings when at all possible, and again keep the flexion below 90 degrees.
  3. Proper warm-up and stretch: If your program does not include a slow, 10-15 warm-up and stretching phase, then add this to your workout. Muscular tone and flexibility across the knee joint will help to protect you from extreme positions and provide better control to avoid injury. The stronger your knee is, the better it will protect your aging meniscus.
  4. It’s your knee, not your trainer’s: We all feel obliged to persevere and give workouts our best, especially when investing our precious time and money into a new fitness program. We want to succeed and please those around us, especially our coach or trainer. But don’t let the excitement or intensity of the workout cloud your common sense. If you haven’t worked out in years, or if you are trying to go to a completely new and higher level than you’ve been before, then take it slow and don’t be pressured. You take that knee home at night and you have to protect it. If it doesn’t feel right, don’t do it. You are paying the trainer to teach you and help motivate you, but not to tear up your knee. So feel good about yourself when you back it down a few notches to stay in your safe zone for your knee.
  5. Don’t ignore meniscus tear symptoms: If injury to the meniscus has occurred, you may feel sharp pain, swelling, stiffness, locking, catching or giving way of the knee. The majority of meniscus tears don’t occur with a single traumatic event. So even if you cannot determine a particular time when you may have injured the knee, don’t ignore the symptoms above, as they likely indicate a tear. Once the meniscus tears, it does not heal on its own and will continue to cause pain and further damage to the knee. When you have the symptoms of a tear, it’s time to consult with a board-certified orthopaedic surgeon, and preferably one who is fellowship-trained in sports medicine to accurately diagnose and treat your knee.

You should always be aware of your overall health and any medical conditions that may affect your ability to participate in activities that stress your cardiovascular system. Seek out the advice of your primary physician for general health risks before engaging in a high-intensity or high-impact workout program. Please also feel free to contact the Midwest Sports Medicine Institute with further questions or to schedule a consultation.

And keep these tips in mind when embarking on your new fitness program. Be independent and remember that it’s your knee and it’s up to you to protect it!