Mobile, Alabama native Demarcus Cousins was trying to rebound his missed free throw last January, came down hard on his heel, felt severe pain, and collapsed on the court. The New Orleans Pelicans star had just ruptured his Achilles’ tendon, and underwent surgical repair 5 days later. Now ten months into his rehab, Cousins is trying to get back to action with the Golden State Warriors, but still is not cleared to play. Philadelphia Phillies’ All-Star and MVP first baseman Ryan Howard was trying to beat out a single in the final 2011 playoff game against the St. Louis Cardinals and felt the same pain. Howard also tore his Achilles, requiring surgical repair. His recovery was complicated by infection necessitating repeat surgeries and prolonged recovery. While Howard eventually made it back to the big leagues, he never regained the form that led to his former accolades and achievements.
Achilles tendon injuries are one of the most common sports injuries seen in athletes in their 30’s and older. They are potentially career-ending injuries for high level athletes, and result in significant down time for both recreational and competitive athletes. What is the best approach to evaluation and treatment of these injuries?
Tendons are the structures that connect muscles to bones. They transfer the strength of a muscle contraction into the action of joint movement. As aging occurs, most tendons progressively lose their blood supply, and this loss of vascularity leads to impaired mechanical strength. This process results in tendon rupture when mechanical loads exceed the strength of the tendon transferring that load.
The Achilles’ tendon is the connection of the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Injuries occur with jumping and sprinting, and are commonly seen in basketball, tennis and other sports requiring rapid acceleration and deceleration. A patient will often think he/she was hit in the back of the leg and subsequently be unable to run. On exam, there will be a palpable defect in the tendon, usually 5-10 centimeters above the heel, and weakness on plantarflexion (pointing the toes forcefully). These injuries need to be differentiated from medial gastrocnemius strains/plantaris ruptures, which occur in the muscle belly, closer to the knee. Medial gastroc strains do not require surgery, while Achilles’ tendon tears often do.
Initial treatment of these injuries is protection with a splint or boot, and evaluation by an orthopaedic surgeon. Achilles’ tendon ruptures can be diagnosed on physical exam, but if there is any uncertainty, MRI is confirmatory. Treatment options are surgical repair or non-surgical treatment in a boot or cast. In general, surgical repair in healthy patients is the standard treatment in the US. Recent studies, mostly European, have advocated non-surgical treatment for acute tears, reporting good functional outcomes in most patients. However, when Achilles injuries do not heal properly, delayed repair is challenging and results are inferior to early repair. In delayed scenarios, anatomic repair of the tendon is often not possible due to scarring and contracture of soft tissues, necessitating use of other tendons and soft tissues to try to repair the injured tissues. For this reason, acute repair of complete Achilles tears remains standard treatment. This surgery involves making an incision over the tendon and repairing the injured tissues with strong suture. After surgery, the leg is usually immobilized in a boot and protected from excess stress for 2-3 months. During that time, flexibility is progressively increased as tendon healing occurs. Unrestricted strengthening is generally allowed after 3 months, and total recovery for sports and aggressive activities takes 6-12 months. In general, full recovery and return to sport is possible, but not quick. The primary risks with this surgery are re-rupture and wound healing problems/infection. Re-rupture is rare if post-operative restrictions are adhered to. Soft tissue healing complications are higher in this area due to decreased blood flow and soft tissue coverage (muscle) overlying the Achilles insertion. This makes meticulous wound care in the post-operative period critical for an optimal result.
Non-standard interventions for these injuries include minimally-invasive repair and biological enhancement of repair. Variations in technique using smaller incisions and percutaneous suture passage (without making incision over tendon tear) are an option to decrease surgical trauma, but may increase risk of nerve damage. Biologic enhancement (stem cell/PRP application) has had mixed results in medical literature and is generally not covered by medical insurance. Stem cell therapy is currently not an accepted option for treatment of these injuries as an isolated intervention. Hopefully future research will refine and improve these techniques.
In terms of prevention, pre-exercise stretching is key. Stretching a tendon, such as the Achilles, increases load-to-failure by 50%. This means the tendon can sustain a force 50% greater without tearing if it is pre-stretched – so stretch before you play.
I hope this information has been helpful. If you or your family member are dealing with an Achilles injury, feel free to contact my office for an appointment at (205) 802-6700 or (205) 443-2797.