Beck’s achille’s heel

Wednesday, March 17, 2010

The ability to represent your country on a world stage is a life dream for most athletes. Keeping that athletic performance at such a high level for more than 15 years is a combination of skill and dedication but for David Beckham, luck was not on his side as he bid to represent England in the World Cup this year. A simple kick at the ball caused his Achilles tendon to rupture and his dream of a fourth Cup appearance was lost in an instant.

The Achilles tendon attaches the gastrocnemius muscle of the calf to the calcaneus or heel bone and plantar flexes the foot, allowing it to push off the ground during walking and running. It seems less dramatic to call a torn Achilles tendon a strain but that is the definition of a tendon injury. Stretched tendon fibers are classified as a first degree strain while a partially torn tendon is a second degree strain and a completely torn is classified as a third degree strain.

An Achilles tear is dramatic. The patient is walking, running, climbing or jumping when the excessive stretch is enough to tear the tendon. Pain happens immediately and the ankle fails to move properly. The patient won’t be able to stand on his toes since the foot can’t point downwards. Sometimes the gastroc muscle bunches up high in the calf and sometimes there is a divot or defect that can be felt in the tendon cord. The Thompson test confirms the diagnosis. The patient lays face down on the exam table with the foot hanging over the edge; squeezing the calf muscle fails to cause the foot to move. Prior to the advances of technology no further testing as needed. Now, an MRI may be done to confirm the diagnosis and check out other potential injuries.

Like most things in medicine, there are different ways of doing things and a ruptured Achilles tendon is no different. Surgery to fix the problem by sewing the tendon ends back together is one option but there is a non-surgical option, where the ankle is casted in equines (think of the foot place in a position to look like a horse’s hoof, with the toes pointed like a ballerina) to allow the tendon to heal together by itself. Each option has its benefits and risks and the decision on which option to pursue depends upon the situation.

Once the tendon is repaired, the real work of rehabilitation starts. Not only does the calf muscle need to get strong again to support ankle movement for walking or running, but the range of motion of the ankle and foot has to be restored. Any joint that is held immobile will stiffen quickly even after a few days. One can imagine the work needed to get an ankle moving that has been held in a cast for a few weeks.
The goal of treatment is to return the patient to the activity that they were doing prior to the injury. Unfortunately, for Mr. Beckham timing is everything. Repair and rehab of a ruptured Achilles tendon usually takes six months and the World Cup is but a couple months away. Even the marvels of modern medicine can’t stop the march of time.

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