and Ligament Injuries: An Overview
Guest: Dr. David Geier –
Host: Dr. Linda Austin –
Dr. Linda Austin: I’m Dr.
Linda Austin. I’m talking, today, with
Dr. David Geier, who is Assistant Professor of Orthopedics and Director of MUSC
Sports Medicine Clinic. Dr. Geier, let’s
talk, now, about a fairly common problem, I suppose, which is rupture of the
tendons and ligaments. First of all,
what are tendons, and what are ligaments?
Dr. David Geier: One of the
misconceptions of what those are is that they’re very similar structures. In laymen’s terms, a tendon is a piece of
connective tissue that connects muscle to bone, whereas a ligament, which is
also a structure consisting of collagen, which is kind of a connective tissue
substance, connects bone to bone. So,
say, for instance, the anterior cruciate ligament of the knee connects part of
the femur, or thigh bone, to part of the tibia, or shin bone. A tendon, on the other hand, is where you
have muscle on a certain part of your body and then it converts to this tendon
that attaches it to a bone across the joint, helping that joint to move. So, when we talk about tendon injuries, for
instance, they’re a variant of muscle injuries, where the muscle pulls that
tendon off of bone.
Dr. Linda Austin: I guess
the easiest way to remember that is everybody knows what the Achilles tendon
Dr. David Geier: Correct.
Dr. Linda Austin: That’s
the calf muscle attachment to the heel bone, right?
Dr. David Geier:
Exactly. And that’s a great
example, a very common injury whereby an athlete, say, someone in their 30s,
40s or 50s is running and goes to turn a certain direction or lands from a jump
and feels a sharp pain or a pop in the back of the ankle. Sometimes they’ll even say that they feel
like another player hit them or kicked them on the back of the ankle and they
fall down and turn around and nobody’s there.
It’s a sharp stabbing sensation when that tendon goes. And, as with most tendon injuries, many times
an Achilles rupture is a surgical problem.
Dr. Linda Austin: What are
some other common areas of the body where tendon ruptures can occur?
Dr. David Geier: Very
commonly, especially, again, with your kind of weekend warrior type of person,
in your 30, 40, 50-year-old athlete, it’s very common to get a tella (patellar)
tendon rupture, the tendon below the kneecap, also the quadriceps tendon, which
is the tendon above the kneecap that connects the quadriceps muscle to the
kneecap. Those are both very common in
athletes in adulthood. It’s not uncommon to tear the biceps tendon, which is
the tendon in your elbow that helps the biceps muscle flex your elbow. A more common one, but one we’ve discussed in
detail in previous sessions, would be the rotator cuff. Again, that’s a connective tissue substance
that comes off the muscles of the rotator cuff, forms a tendon that inserts on
the humeral head, or the ball of the ball and socket part of the shoulder, and
very frequently a site of injury as well.
Dr. Linda Austin: You
mentioned that ligaments can also rupture.
Where do those commonly occur?
Dr. David Geier: The knee
and shoulder, that’s very common, especially in the knee, which has four main ligaments. Obviously, there are some secondary
supporting ligaments. You have your
anterior cruciate ligament which is one of the most common ligaments injured in
the knee, and in the whole body and, unfortunately, very serious in the sense
that it is a season ending injury and almost always requires surgery. You have the MCL (medial collateral ligament) of the knee,
which is also very commonly torn. Also,
as we talk frequently about ankle sprains, and those are, essentially,
different levels of tears to the ligaments of the ankle, on the inside or, more
commonly, on the outside of the ankle.
Those are probably the two most common ligament injuries. You get some in the shoulder with shoulder
dislocations or shoulder separations, which are two very different injuries but
involve torn ligaments.
Austin: Now, to take the Achilles
tendon, which I can visualize the most easily, when it ruptures, where does it
rupture? Is it actually pulling off the
attachment to the bone, or is snapping in the middle, or closer to where it
attaches to the muscle?
Dr. David Geier: No.
Great question, and it’s not always the same. As far as the Achilles goes, it’s not
typically pulling off of bone. It
typically ruptures in the midsubstance, not so much at the bone where it
inserts, and not up high enough where it’s toward the muscle, but kind of right
in between there, which is one of
actually, that it does need to be fixed, because that area has a low blood
supply. But different ligaments tear in different
places. Different tendons tear in
different places. The patellar tendon, a
lot of times, pulls right off the bottom or the inferior aspect of the kneecap. The quadriceps tendon does the same
thing. The biceps tendon typically pulls
right off of bone. So, the different
tendon ruptures have different locations, different mechanisms of injury and,
therefore, a lot of times, have different requirements as to which ones need
surgical fixation and which ones don’t.
Austin: Now, I can imagine how one might
stitch together torn ligament tissue into ligament tissue. I have a little difficulty imagining how you
reattach a ligament to a bone, which is a hard surface. How the heck do you do that?
Dr. David Geier: There are different ways to do it. What we’ve gone to recently is to anchor it
into bone, and I mean that literally.
There are these devices called suture anchors that screw into the bones
so that they’re below the surface of the bone.
Those anchors, made out of metal or plastic, have these stitches that
come off of them so the anchor is in bone and you weave the stitch, or the
suture, through the tendon and essentially pull it down into the anchor so it
attaches the tendon, now, down to bone.
There are other ways to do it, but that’s the way that we’ve gone
because it’s probably the least invasive and it has worked very well. They have good strength which you need to
protect the repair.
One of the
misconceptions patients often have is they assume because they’ve had surgery to
repair their tendon, they think, well, I’m as
good as new. But the trick is, yes, it’s
repaired, meaning sewn together, but now you have to rehab it and get the body
to heal that, send a blood supply to it and get the body to reinforce that
repair with new tissue. So, that’s a lot
of the reason why we immobilize these with a splint or a brace after surgery
and go slow with the rehabilitation process.
One or two days after surgery, they’re not good as new.
Austin: So, even though the anchor
brings the tendon so it’s touching the bone, the tendon has to then grow into
the bone and reattach itself?
Dr. David Geier: Exactly.
Austin: And then once that happens,
eventually, are you as good as new?
Dr. David Geier: Yes.
Dr. Linda Austin: Or, is that always a vulnerable place?
Dr. David Geier: That’s a common question, and it’s hard to
generalize. But the goal is to get
people back to the same way they were and, in so doing, get the tendon or
ligament to heal and be just as strong as what they had. Clearly, there are some situations where
that’s not the case. But, yes, generally
we’re trying to get them to be just as strong, if not stronger than before.
Austin: Now, I’m sure this is another it depends kind of question, but what is the range of time that it takes for a
ligament or tendon rupture to heal?
Dr. David Geier: It can take anywhere from six to eight
weeks. If we’re talking serious
injuries, up to three or four months.
Obviously, if it’s a mild sprain of a ligament or a partial tear, it may
only be a few days. Certain ligaments,
such as the MCL of the knee or some of your milder ankle sprains, that may only
be a few days. But, complete rupture and
trying to get that to heal, immobilizing the joint to allow the ends of the
ligament to line up and then the body sending inflammatory cells to get it to
heal and remodel can take a minimum, sometimes, of six to eight weeks. But it may be three of four months for that
to really be as strong as it was.
Austin: I’m sure that anybody who has
ever had one of these ruptures wants to know how they can avoid them in the
Dr. David Geier: Certainly, there are risks in general s you
get older, the more stress you put on it.
I would say to stretch, warm up appropriately before activity, maybe
five minutes of light activity to get the heart rate up, to get the blood
flowing and warm up the muscles, and then stretch after that, before starting
the activity, to prevent a sudden stretch or pull on the tendon which may cause
it to rupture. Cold muscles and
insufficiently stretched out tendons and ligaments probably are more likely to
suffer an acute injury in the first few minutes of activity.
Austin: So, that raises a question I’ve
always wondered about. You hear people
talk about cold muscles or warming up a muscle, but isn’t the whole body at 98.6?
Are the muscles really literally cold, or is that just a figure of
Dr. David Geier: Yes and no.
I think you’re right about the body temperature. I think with normal activity though, you’re
not using, say, your quadriceps or hamstring, the bigger muscle groups, and, in
so doing, the blood is not flowing as much to those that are not being used. So, I think the benefit is not to heat them
up so much as to deliver blood to that area, to get blood circulating to that
area, and make the muscle essentially more efficient, make it work better. And, yes, there is a warming element, but
it’s more of a delivery of blood to that area of necessity.
Dr. Linda Austin: What would be your take home message then for
somebody who is sitting there laid-up with their ankle casted or
something? How can they think about this
Dr. David Geier: I think there are several things to take
home. One is that if this is a
significant enough injury that you’re not able to participate in your sport or
activity, I would certainly seek the advice of somebody that specializes in
sports medicine injuries, if only to help differentiate between a one or two-day
injury and a three or four-month injury.
The other thing I would keep in mind is, yes, most of these injuries are
fixable if they’re not going to heal on their own, and sometimes it’s hard to
know one from the other. But there are
good treatment options for almost all muscle, tendon, and ligament
injuries. Having said that, the athlete,
the exercise fanatic, needs to remember that these injuries take a long time to
get over. They require a lot of time, a
lot or rehab, to get back to their previous level. So, there’s a certain amount of patience that
we have to instill in patients once we’ve seen them. You’ll get back to your sport, but it may
take several months.
Dr. Linda Austin: Which seems like an eternity to a young
Dr. David Geier: No question.
Several months can be a whole season of games. It could be missing a few races as a
runner. It is a long time and it’s very frustrating
a lot of times for some of these high-level athletes.
Dr. Linda Austin: Dr. Geier, thank you so much.
Dr. David Geier: Thank you.
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