Thursday, September 10, 2009

Favre and Biceps Tendon Tears

So how will Favre hold up this season?

Well, on Wednesday he told reporters he may not be able to play all 16 games.


Not really.

It is reported that he had a torn biceps tendon surgically ‘repaired’ last spring and that at the time of surgery his rotator cuff was found to have a tear also.

It is well known in the scientific literature that tears of the long head of the biceps tendon (biceps tendon in the shoulder joint where Favre’s is reported to have been torn) are a general component of a diffuse degenerative process involving the subacromial space (space above the shoulder ball and socket) associated with rotator cuff tears, bursitis, labral tears, and acromioclavicular joint arthritis (Warren 1985). It is also known that the blood supply to the tendon diminishes with age (meaning your old at 40).

James Andrews, the surgeon who is reported to have operated on Favre, did a sentinel study in 1985 on the biceps tendon and labral tears and concluded “the biceps tendon is subjected to large forces during throwing” and can tear the labrum off the glenoid (socket) when its muscle is stimulated.

From subsequent work by Andrews and others, it has been concluded that the long head of the biceps muscle and its attachment at the superior glenoid labrum contributes greatly to the stability of the shoulder in an overhead throwing position and helps to diminish the stress placed on the ligaments of the shoulder.

Summary: Biceps injuries in throwing athletes rarely occur alone and are part of a constellation of other problems related to degenerative aging and use. The biceps tendon helps to stabilize the shoulder joint and is under considerable stress during throwing.
So what does a ‘biceps tendon tear’ mean?

If the long head ruptures and completely tears it retracts into the arm and one get’s a pop-eye deformity or prominent bulge in the biceps region of the upper arm. These are rarely surgically repaired.

Other times just portions of the tendon can tear or fray, like a worn out end of rope.
Other times the tendon can avulse or tear off from its origin on the top of the shoulder socket tissue (glenoid labrum) known as a SLAP lesion.

So how does one ‘repair’ a biceps tear?

Number one there is no scientific evidence for their most appropriate management.

Three common procedures may be performed:

1. ‘Simple’ Debridement may be used for partially torn fibers and involves shaving away the torn fibers and leaving the rest of the tendon (and shoulder) intact. Quick return to play. Some might call it like ‘going to the dentist’. Only ‘simple’ in comparison to other treatments.
2. Tenodesis can be performed if a significant portion of tendon is torn, whereby the torn tendon from ‘inside’ the shoulder joint is removed and the remaining tendon is reattached to the humerus or upper arm ‘outside’ the shoulder joint. Usually done along with other shoulder procedures like rotator cuff repair. Long recovery. Changes mechanics of the shoulder.
3. Tenotomy involves cutting the biceps or releasing the tendon which will cause the ‘pop-eye’ deformity. Also changes mechanics of the shoulder. Shorter recovery.
4. Major shoulder surgery would address the biceps tendon tear with debridement or tenodesis, rotator cuff tears, labral tear, and AC arthritis (shaving away extra bone that pinches down on tissue). Long long rehab.

So how will Favre hold up this season?

“I may not finish the year”, Brett Favre.

Better eat your spinach.

Marc Silberman, M.D.
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