Injury Breakdown: Analyzing Achilles Injuries
By Abby Sims
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Baseball is barely out of the gate, with spring training games getting underway this past weekend. Yet, according to CBSSports.com, there are 143 major leaguers who are out with injuries. Though some are listed as day-to-day, many will miss a good deal of spring training. Others led with season-ending surgery. I hate to think of what the list will look like in a few months….
A few NBAers are suffering from big-time Achilles injuries. Pistons' forward Jonas Jerebko tore his Achilles tendon in pre-season and Charlotte back-up center DeSagana Diop underwent an Achilles repair in January. Francisco Garcia, a guard/forward on the Sacramento Kings has been out for weeks with what coach Paul Westphal called "an epic calf strain", and just days ago, Spurs star Tony Parker left the game with a calf contusion after a collision with Mike Conley of the Grizzlies. Celtics Big Man, Shaquille O'Neal, has been resting up for playoffs with a case of Achilles tendinitis.
Shaq's condition appears to be a simple inflammation, an overuse issue. He isn't getting younger after all… Parker's injury, a muscle contusion, was clearly a result of a collision. If it is a significant bruise, it could take a good four to six weeks for him to get back up to speed. The trouble then is that Parker's calf muscles will be somewhat de-conditioned, making them vulnerable should he return to play too early. Of course, with playoffs already in sight, that is exactly what is likely to occur.
Achilles ruptures, on the other hand, are not generally associated with contact. Most who suffer a ruptured Achilles feel or hear a "pop" and think they might have been kicked. Surgery is often performed quickly, to approximate the two ends of the tendon before the tissue shortens permanently.
What is the Achilles tendon?
Tendons attach muscles to bones. The Achilles is thicker and more fibrous than most tendons and it connects the calf muscles (the bulky Gastroc in the upper calf and the smaller Soleus closer to the ankle) to the heel bone (calcaneus). The Achilles tendon and calf muscles are put on stretch when the ankle is flexed up and it is shortened when the toes are pointed. A tight Achilles or one that is overstretched can predispose to rupture.
If you think you have a tight Achilles, before stretching vigorously, it is important to identify whether the problem is actually with the tendon or if it lies with restricted ankle mobility. Have a therapist check the range of motion at your ankle with the knee flexed. The Gastroc muscle crosses the back of your knee as well as the ankle. With the knee bent, the gastroc muscle is in a shortened position and will not restrict movement at the ankle. Compare theses findings with the amount of ankle flexion range with the knee straight (with the Gastroc on stretch). The latter is a measure of flexibility. If your ankle mobility is significantly restricted, no amount of calf stretching will lengthen your Achilles tendon or even stretch your calf muscles. The motion simply isn't accessible to allow that to occur.
What are the consequences of Achilles rupture?
In addition to the pain and swelling that are expected with any sports injury, disruption of the connection between the calf muscles and the heel results in an inability to contract these muscles; That means that you cannot rise up on your toes or walk with a normal push off when weight-bearing on your injured side. Running and jumping are therefore also out of the question. However, it may be possible to actively point your toes while you are not bearing weight due to the action of other muscles that help to provide this movement.
Why do Achilles tendons rupture?
There is an area of the Achilles that has less blood flow than the rest and it is thought that this section of the tendon may not be as strong. As we age, tendons, as other tissues of the body, become less supple and may degenerate. These are some reasons why tendinitis becomes more prevalent and ruptures generally occur in people over 30, especially in middle age. Younger athletes generally experience a higher tear, well above the ankle, where the muscle joins the tendon (musculo-tendinous junction), though they too can experience a tear closer to the heel.
Some sports are more stressful to the calf muscles and Achilles than others. Those that require the powerful push-off needed for running and jumping place the greatest demand, as do those like racquet sports which entail a lot of stutter-steps and quick stops and starts. Men are far more likely to suffer Achilles ruptures than women and it is thought that obesity adds to the stress on the Achilles, increasing risk of rupture. Though this is not a factor for most elite athletes, football linemen and centers built like Shaq do place proportionately greater demand on the tendon.
Other predisposing factors for weekend warriors like you and me include stepping up activity suddenly and significantly – either by increasing the intensity, frequency or duration of participation or perhaps beginning a new activity without preparation. All of these increase the stresses placed on the Achilles. It is thought that weakness of the calf muscles, particularly the Soleus, may also be a factor causing the Achilles to rupture; The Soleus can be strengthened by pointing the foot -- against resistance -- while the knee is bent (as in a sitting position). A history of multiple steroid injections at the Achilles may be to blame in some cases of rupture. Be aware that manufacturers of certain medications, such as the antibiotic Levaquin, name tendon issues as a potential side effect. Inform your physician if you begin to feel Achilles symptoms after beginning a new medication.
One exercise I strongly suggest you avoid is strengthening the Gastroc muscles of the upper calf by hanging the mid-foot and heel off a step or raised platform and doing heel-raises from this position of maximum stretch. Repeatedly lowering the heel below the level of the step (with your body weight and gravity loading the Achilles tendon), puts the tendon at greater risk of rupture and jeopardizes the structures of an unstable mid-foot. This is an exercise I see so often in the gym. Yes, it is important to strengthen the calf, but it is recommended to do so from the more neutral foot–flat position.
How is an Achilles rupture diagnosed?
Physical exam is often pretty conclusive. The first test is simply to squeeze the belly of the calf muscles and observe whether the foot points as the muscles are manually shortened. Another obvious sign is when the examiner can move the ankle excessively into a dorsiflexed position (toes toward your nose) – with the knee straight. As previously discussed, this motion is generally restricted by the tightness of the Achilles and in the case of rupture it is not. A third test involves observing the motion of a needle inserted into the tendon as the foot is passively moved up and down. An ultrasound exam and/or positive x-ray findings -- particularly those in a lateral (side) view – support the diagnosis.
What are the treatment options?
Small tears may do well with immobilzation. Casting is generally done with the foot in a pointed position, which shortens the tendon allowing it to heal. Bracing that restricts motion is an alternative. Athletes are not good candidates for conservative management, and those who do not undergo surgery should expect a long recovery (up to a year) before returning to sports.
Operative treatment is the gold standard for athletes, younger patients and those with a complete rupture. Both treatments are followed by periods of decreased weight-bearing, though the surgical patient progresses at a much faster rate. Rehab includes work on overall strengthening, cardiovascular conditioning and flexibility, as well as a focus on restoration of normal mobility in the ankle and foot, which become restricted from prolonged immobilization.
Outcomes
According to Wheeless' Textbook of Orthopaedics, non-operative patients have an average re-rupture rate of 18% and can expect a decrease in strength and muscle endurance of 30%. 83% of surgical patients and 69 % of immobilization patients can expect to resume their pre-injury level of activity. Wheeless also reported that 93 % of surgical patients were satisfied with the results of treatment, while only 66% of conservatively managed patients felt likewise. Because of the positioning of the foot with the tendon in a shortened position while casted or braced, non-operative treatment generally does not restore the Achilles tendon to its full length. In contrast, if immobilized with the ankle in a neutral position, the tendon is generally lengthened, leading to a poor outcome.
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