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Friday, May 15, 2009
Favre may explore ways to avoid surgery


ESPN's Ed Werder and Chris Mortensen reported Thursday that Brett Favre paid a visit to Dr. James Andrews to discuss options for his ailing right (throwing) shoulder. According to this latest report, a source indicated that Andrews and Favre "experimented with one of several exercises that could accelerate the process of the tendon releasing on its own." So what are we to make of this latest development?

Brett Favre
Brett Favre could come out of retirement again if he doesn't need major surgery on his arm.
It suggests that there may, indeed, be more than one potential cause of pain in Favre's shoulder. The partially torn biceps tendon may be a big cause of his symptoms (or even the biggest), but with a simple arthroscopic procedure offering such a quick solution for an isolated biceps injury, his apparent reluctance to proceed implies that a "pain-free" outcome is not guaranteed. If there is another associated pathology present in Favre's shoulder (a torn labrum, cartilage damage or, perhaps most likely, rotator cuff involvement), which is often the case with a thrower who has damage to the biceps tendon, then a simple biceps tendon release would not likely suffice. In that case, more extensive surgery could be required to completely alleviate his symptoms, something Favre has indicated he will not endure.

Favre appears to be exceptionally wary of going under the knife. By trying to increase stress on the injured tendon via exercise, he is hoping to speed up a natural solution. Even in the presence of other factors, if the tendon ruptures independently, then Favre can assess, without surgery, just what percentage of his symptoms are due to the biceps tendon. If his pain goes away, then he can presume that the biceps was, indeed, the worst offender. Even if his shoulder is not in pristine condition, Favre could then proceed confidently knowing that the main element that caused him problems last year had been eliminated.

It is not necessarily easy to coax a tendon to rupture on its own, however, and the ease with which it occurs depends on the extent of tissue damage. The biceps tendon in question will be stressed if it is loaded in a way that places particular strain on the attachment near the top of the shoulder. For example, an athlete could perform "dips" (using the arms to lower one's body weight from a bar in a controlled manner so that the shoulders drop below the elbows), the athlete could elevate the arm against resistance from an extended position, or the athlete could bring the arm across the body against resistance (horizontal adduction). There are a multitude of ways in which the tendon can be stressed, but none are guaranteed to make it fail.

Why is Favre so intent on trying to force the tendon to fail without surgery? Remember, Favre had similar pain in his left biceps tendon while playing with the Green Bay Packers. That tendon went on to rupture on its own and the pain in his shoulder was alleviated. Obviously, since that injury was not to his throwing shoulder, it was not as limiting to his game, but it does provide Favre with some frame of reference. Based on experience, he knows that if the biceps tendon is responsible for his pain, the pain will resolve once it ruptures. He was able to avoid surgery in the past, and is clearly hoping to do so again.

But not all injuries are created equally. Favre's left shoulder was not subjected to the repetitive strain of years of overhead throwing, and it is more plausible that an isolated injury to the biceps would occur in his non-throwing arm. In the end, it brings us back to the possibility that there may be more to Favre's right-shoulder situation than a simple ailing biceps tendon.

Since there are two biceps tendon attachments, an athlete can still function with only one of those attachments intact, and could do so without pain. The recovery would be quick enough to allow Favre to throw lightly in as little as four weeks. Werder and Mortensen report that a "projected three- to six-week rehabilitation is unappealing." Let's be clear. Even if the tendon ruptures on its own, there still can be some minor discomfort post-rupture for several days, including some cramping or twitching in the muscle. And Favre would no doubt be placed on an exercise program to strengthen the shoulder and ultimately graduate to throwing, not unlike a projected postoperative regimen. So it really comes down to the issue of Favre going to great lengths to avoid surgery altogether.

For those wondering whether Favre could really function with only one biceps tendon attachment, there is some precedent. Former Denver Broncos quarterback John Elway dealt with biceps tendon issues intermittently throughout his career. In August 1997, Elway's partially torn biceps progressed to a complete rupture and he managed to carry on just fine. In fact, he went on that season to win the first of two Super Bowls. In January 1998, Elway, armed with a single-anchored biceps, led the Broncos to victory over the Green Bay Packers. Maybe Favre remembers this. And maybe he believes if his tendon ruptures naturally, as Elway's did, that fate will lead him to finish the season hoisting the Vince Lombardi Trophy. And, yes, you only need one biceps tendon attachment to do that, too.