Examining the Nature, Effects of Ray Lewis', Justin Smith's Triceps Injuries

Dave Siebert, M.D.@DaveMSiebertFeatured ColumnistJanuary 29, 2013

Ray Lewis, linebacker for the Baltimore Ravens.
Ray Lewis, linebacker for the Baltimore Ravens.Dustin Bradford/Getty Images

Neither the Baltimore Ravens nor the San Francisco 49ers looked the same this season after their respective defensive stars, linebacker Ray Lewis and defensive end Justin Smith, went down with torn triceps.

Lewis originally suffered his injury back in October—a complete tendon rupture that he had surgically repaired—while Smith's partial tear occurred in late December.

Both teams felt the effects of the injuries during their trek to the playoffs.

While Lewis sat out, the Ravens missed his veteran leadership, raw talent and knack for quickly identifying offensive schemes. Once he returned, the Ravens marched through the postseason, winning at home against the upstart Indianapolis Colts, following with a victory at the Denver Broncos, and finally triumphing on the road against the New England Patriots to take the AFC Championship and advance to the Super Bowl.

As for Justin Smith, his value made itself painfully clear to 49ers fans during Week 15's installment of Sunday Night Football.

No hole in a defense became more obvious than the one left by Smith during the 49ers' Dec. 23 42-13 dismantling at the hands of the Seattle Seahawks. With Smith on the sidelines, the Seattle offense—led by the mobile Russell Wilson and punishing Marshawn Lynch—moved the ball up-and-down the field seemingly at will, making the 49ers defense look foolish in the process.

Fast forward to the Super Bowl.

Lewis is currently listed as questionable due to his triceps injury, and Smith is listed as probable. However, given the fact that—according to the NFL Inactives Report—both played during their respective conference championships, it is safe to expect to see them on the field on Super Bowl Sunday barring any setbacks.

Yet that does not mean they will be playing at 100 percent. In fact, Smith will need surgery sometime after the Super Bowl to repair his triceps. Additionally, both will likely wear protective braces on their arms, and both will be risking further injury while also undoubtedly playing through pain.

Can Lewis and Smith be effective playing with injured triceps? Are they risking further injury?

The answer to both questions is a definite "yes."

The triceps—also known as the triceps brachii—are actually group of three muscle bodies running from the back of the upper arm and shoulder blade to the olecranon—the part of the elbow used to lean on a table. By serving to straighten the arm, the triceps muscles are crucial when it comes to pushing off of opposing players.

In football, triceps injuries usually occur when a hit to the inside of the elbow causes it to bend at the exact same time a player pushes off from an opponent. The sudden, forced elbow bending stretches the tight, contracted triceps, representing two opposing forces acting simultaneously. When the triceps loosen out to hit, a strain results.

Triceps strains—like all muscle strains—can be classified as grade-one, grade-two or grade-three. Grade-one strains are mere over-stretches without a visible tear. Grade-two and grade-three strains are partial and complete tears, respectively.

Grade-one and grade-two strains cause pain with elbow straightening and pushing, while grade-three strains limit a player's ability to straighten the arm at all—the muscle is no longer intact.

In addition, all strains result in muscle weakness, predisposing a player to further injury. A weakened muscle is less able to resist outside hits similar to the one that caused the original damage in the first place.

Though not always the case, lower-grade strains usually heal on their own with time, rest and physical therapy. The triceps also remain at least partly functional in grade-one or grade-two strains, and the amount of weakness depends on the severity of the injury.

In contrast, grade-three strains render the triceps useless and require surgical re-attachment to restore arm motion.

That is what Ray Lewis elected to do back in October. During his surgery, doctors likely exposed the ruptured tendon and reattached it to the olecranon using sutures that were sewn through holes drilled in the bone.

Sound simple?

Relatively speaking, it is. Unfortunately, the rehab is not.

Doctors originally projected Lewis to be out for the entire season, as following surgery, a repaired tendon needs to cement itself into place during a slow, steady process of strength training, conditioning and stretching.

Usually, that takes months.

Lewis was not interested in such a timetable. He defied the odds and returned to the field much earlier than expected, once he showed his triceps tendon was sufficiently strong for play. However, it is almost certainly not yet at full strength, evidenced by the brace he wears.

The brace protects his still weaker-than-normal triceps by helping maintain a straight arm and deterring some of the force that would otherwise bend his elbow. Remember, forceful bending at the elbow occurring while Lewis pushed off an opponent is likely what caused the original injury.

In other words, while the brace protects the arm, it also limits the arm's mobility. In addition, the size and bulk of the brace can directly interfere with play.

For example, during the Ravens' Wild Card Playoff contest against the Colts, Lewis dropped a sure interception. He later blamed the drop on the brace when he said (h/t Aaron Wilson of the Baltimore Sun), "I'm going to put that one on the brace because I tried to put my arm up, but the brace wouldn't come up."

Justin Smith will also likely be braced up on Sunday.

As mentioned, Smith's triceps tear is only partial—grade-two—meaning he still has the ability to extend his arm and push off of blockers. However, the tear is in the tendon—the thick, tough part of muscle tissue that connects the bulk of the muscle to the bone.

Tendons—like cartilage and ligaments—have relatively poor blood supply when compared to tissues such as muscle bodies and skin, which limits their healing ability. Surgical assistance is usually necessary to facilitate full healing.

Until he receives that surgery, Smith will play through not only pain but likely also relative weakness on his injured side. His triceps are also more prone to further injury until they are fully healed—the reason for the brace.

Regardless, Smith is willing to take that risk.

As long as he can be more effective than his would-be replacement, it makes sense for the 49ers to take that risk as well.

The same logic applies to the Baltimore Ravens and Ray Lewis.

It is the Super Bowl after all.


Dave Siebert is a medical/injury Featured Columnist for Bleacher Report who will graduate from medical school in June. He plans to specialize in both Family Medicine and Primary Care (non-operative) Sports Medicine. Injury and anatomical information discussed above is based on his own knowledge.


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