achilles: connecting the calf and the foot

Monday, January 26, 2015

Injuries can be thought of like real estate .What is important is location, location, location. The location of Packer Aaron Rodgers’ calf muscle tear and Pistons Brandon Jennings’ Achilles tendon rupture are separated by only a few inches, but it’s the difference between being oceanfront and being inland, ski in/ski out or a shuttle ride away. For Rodgers it means the ability to play through pain and for Jennings it’s a trip to the OR.

The gastrocnemius and soleus muscles form the muscles in the calf. They are attached to the heel by the Achilles tendon, so that when the muscles contract, the foot and toes plantar flex or point down like a ballerina on point. That motion allows push off by the foot so that walking, running and jumping can occur. Injuries to the muscle tendon unit are called strains and are graded based on severity. Grade 1 strains mean that the fibers have been stretched but not torn. Partial tearing of a muscle or tendon equals a grade 2 strain and grade 3 means that the muscle or tendon is completely torn.

calf

When Green Bay’s Rodgers strained his calf, it made walking and running especially difficult. While he could shuffle his feet to hand the ball off or staying the pocket to pass, the limp was obvious when he attempted to run. There were two reasons for that gait issue. First, the injury weakened the muscle making it difficult to push off with the ball of the foot but second and perhaps more importantly, there is an issue with foot dorsiflexion, or the ability to flex the foot upward. This motion is necessary to get the toes out of the way as the leg swings forward, but it also stretches the calf muscles causing inflammation and pain in the damaged area. Every attempt to run stretches and perhaps causes micro tears in the muscle fibers. Play is possible but performance suffers.

Detroit’s Jennings wasn’t so lucky. He completely tore his Achilles tendon, a grade 3 strain and the connection between the calf muscle and the heel was broken. No matter how much the calf muscles would contract, the foot would not be able to be moved. An Achilles rupture can happen without warning and the player usually complains of an intense pain like being shot or kicked in the back of the calf. The inability to plantar flex means that each step of walking, each running stride or even lifting the toes to climb a single step becomes a major challenge.

The Achilles anatomy allows the body to generate amazing jumping force and is due to the coiling of the tendon as it emerges from the muscle fibers of the calf. It spirals between 30 and 150 degrees to store and release energy and provide more power than what the calf muscle could generate on its own. The bad news happens if the foot gets stuck in an awkward position when that power is released, the tendon cannot withstand its own energy and shreds. This is different than the mechanism of a muscle strain where a single forceful event could cause damage, but just as likely, overuse is a common precursor prior to the muscle tear. The Achilles tendon can become inflamed because of poor body mechanism, age and other underlying diseases, but there may be no warning sign before the acute injury.

The difference between the calf muscle and Achilles treatment is night and day. Most athletes choose to have their Achilles tendon rupture surgically repaired so that they can heal, rehab and get on with their career, with the least time lost as possible. There is good potential to return to the previous level of activity, but there might be some loss of range of motion, and the risk of rerupture after surgery is between 0 and 5%. There are nonsurgical alternatives with aggressive casting, depending upon how the torn tendon ends align, and the outcomes are just as positive but the rerupture rate can be as high as 40%.

Muscle tears usually avoid the operating room. Time and rest are the healer of all. The risk of continued play has to do with worsening the tear but also potentially sustaining another injury, because other nearby structures may not be able to protect themselves from outside forces. Most people understand the concept of hamstring injuries needing months to recover and the same time frame exists for calf injuries as well. On a cellular level, both injuries will heal in the same way. Collagen fibers will cross link at the injury site and begin the building blocks to form scar tissue that will need to be strong enough to withstand the forces of running and jumping.

The distance between the belly of the gastrocnemius muscle and the middle of the Achilles tendon is about 6 inches, give or take, depending upon height. For the Packer faithful, that half foot meant that their quarterback could play but perhaps not as effectively. For Pistons’ fans, that distance caused them to lose their star player for the rest of the season and likely a good part of the one to come. For Rodgers it means extra time in physical therapy, but for Jennings, it is a trip to the operating room before that therapy can begin. Just like real estate, it’s all about location.

 

Image attribution: Orthopedics New England

This entry was tagged , , , , , , ,


shoulders and elbows

Tuesday, January 20, 2015

Medical advice can only work in two given situations: if the patient chooses to seek that care and if the patient chooses to follow that given advice. It comes as no surprise that those two situations were ignored by two Seahawks in their playoff game. Earl Thomas dislocates his shoulder, reluctantly runs to the locker room and is back on the field minutes later. Richard Sherman sprains his elbow and refuses to come near a trainer or doctor, but instead, stays on the field grimacing in pain. NFL players and other driven athletes tend to ignore damage to their body because the will to play and win is stronger than the pain that they experience. But a warning should appear on the video screen: “Trained professionals. Do not try this at home.”

The shoulders is the most common dislocated joint of the body. The mechanism of injury can be a fall on an outstretched arm or from a blow that occurs when the arm is abducted (moved away from the body) and externally rotated it (forearm turned palm side up). The shoulder is a ball and socket joint and when dislocated, the humeral head or the ball of the joint, is ripped out of the socket, the glenoid fossa. The structures that hold the shoulder together are torn, including the labrum, the joint capsule, the cartilage and the ligaments of the rotator cuff. If a player is lucky, the shoulder can be popped back into place immediately on the field before the surrounding muscles start to spasm. That can make it tough to provide the traction needed to reduce the dislocation and return the bones to their normal position. For many patients, mild sedation may be needed to help with reduction, often because there is a significant delay getting to medical care.

 

shouledr norm

Normal

shoulder dislo

Dislocated

Once the shoulder is reduced, the goal is to allow the shoulder to heal and remain stable, meaning that it will not dislocate again. There is a balance between that healing and allowing range of motion to occur. It takes weeks for all the damaged tissue, from muscles and ligament to joint capsules to become strong and stable. If one waited until that happened to move the shoulder, it would stiffen and require weeks of rehab to help return range of motion. It is safe to say that Mr. Thomas did not heal in the few minutes that he was in the locker. Instead, he was fitted with a brace that prevented the shoulder from abducting or rotating, the movements that likely occur with reaching for a football or stretching to make a tackle. It is likely that this was not the first treatment option for the medical staff, but when a patient refuses to consider option one, negotiations likely occur to try to minimize future risk and damage. In general, a shoulder dislocation will require six weeks of treatment before return to play.

It is easier to speculate about the Thomas shoulder dislocation than Mr. Sherman’s elbow sprain. Practically, there are only two types of shoulder dislocation, anterior and posterior, and posterior is rare. The elbow is a much more complicated joint. Three bones come together, the humerus, the radius and the ulna, to allow both flexion and extension (bending and straightening) as well as supination and pronation, turning the palm upwards or toward the ground. The medical collateral and the lateral ligaments hold the elbow stable but they have different bundles that protect the elbow depending upon the position of each bone within the joint and the movement that is trying to be accomplished. As well, the biceps and triceps muscles of the upper arm and the muscles of the forearm also work to promote joint stability. Sprains of the elbow, like any other ligament injury are graded by severity of the damage. In grade 1 sprains, the ligament fibers are stretched, in grade 2, they are partially torn and grade 3 sprains denote a completely torn ligament but even a grade 1 elbow ligament sprain can allow the elbow joint to dislocate completely or partially dislocate (subluxate). Injuries to the area can cause bleeding within the elbow joint and a little blood goes a long way to cause significant pain, even with small movements. Mr. Sherman’s cradling his arm and wincing is a testament to the amount of pain a pro athlete can endure. And while his teammate saw visited the trainer and negotiated his care, Sherman refused to come off the field and when he did, tried his best to avoid being evaluated. Treatment of this injury depends upon what is damaged but the time to recovery is measured in weeks.

elbowligament

 

Playing through injury is the stuff legends are made of, but should not be considered the stuff of role model. The potential for long term damage is real when joints are damaged and not allowed to properly heal. There is a real risk that other injuries might occur because the player cannot react instinctively while still protecting the injured body part, but the invincibility of youth and the athlete often take precedence over common sense.

In the real world, patient compliance in following advice and instruction is somewhat lacking. Moderating diets, alcohol use and smoking are the big three but others follow close behind. Studies show that patients who take blood thinners because of blood clots or atrial fibrillation, often missed taking their medications 30% of the time. Patients do not complete a course of antibiotics, stopping when they begin to feel better. Post op physical therapy sessions get missed when they are not a patient’s priority. At the end of the day, the doctor’s advice has to be practical and apply to that specific patient’s situation and hopefully the patient will buy into that advice…hopefully, because the doc and the patient, just like in football, require teamwork to make the miracle of modern medicine happen.

 

Figure attribution: American academy of Orthopedic Surgery

This entry was tagged , , , , , ,