Monday, March 12, 2012
The image of Tiger Woods limping off the golf course is a reminder that pro athletes who have access to the best care still can have their bodies fail in the middle of competition. Conceding to an opponent is humbling but admitting defeat to one’s own body is another story completely. As it turns out, Woods’ Achilles heel at the World Golf Championship was his Achilles tendon and it looks like his body has read the injury textbook.
The Achilles tendon attaches the two calf muscles, the gastrocnemius and soleus to the back of the heel or calcaneus. Those muscles not only are responsible for walking, by flexing the ankle and moving the mid foot, but they also span the knee joint and help flex the knee. The tendon is the longest and thickest in the body and is prone to injury. Experiments show that when running, forces greater than 10 times body weight can be measured within the tendon. It is not unexpected that tendon inflammation (tendinitis) can occur when activity increases dramatically or body mechanics are wrong. It doesn’t help that there is a design flaw in the tendon. Because there is marked decrease in the blood supply to the lower part of the tendon, just a couple inches above where it inserts into the heel, this area is prone to injury (it’s also known as the watershed area of the tendon).
The usual suspects for the cause of Achilles tendinitis include overuse and often a quick increase in the length and intensity of an activity, poor shoes and problems with anatomy. Tight muscles that are asked to quickly contract with movement put stress on the tendon as it tries to stretch from the muscle belly to the bony attachment. Sometimes the tendon is injured and sometimes it’s the muscle itself. A strain describes a tear in the fibers that make up a muscle or tendon and small tears may be the beginning of the inflammation response that progresses to Achilles tendinitis.
When the Achilles becomes inflamed and irritated, pain develops at the watershed area, and is usually worse first thing in the morning after a period of immobility. As the area warms up, the pain can get a little better but activities that require pushing off with the foot, like walking, running, or twisting with a golf swing, will cause significant increase in the pain. Even the most strong-willed athlete may not be able to overcome the body’s want for self-preservation and a limp will develop to protect the inflamed area. The Achilles tendon area is located just beneath the skin in the back of the ankle and the swelling can not only be easily felt but it can often be seen. X-rays tend not to be helpful and the diagnosis is often made by the patient before the first doctor’s visit.
Achilles tendinitis has a good news/bad news prognosis. The good news is that basic treatment with ice, rest, ibuprofen and good shoe orthotics are helpful. Add gentle stretching, muscle strengthening exercises and physical therapy and the inflammation will resolve. The bad news is that it might take 3-6 months. Steroid injections tend not to work and have the risk of causing a tendon rupture. Platelet rich plasma injection therapy also does not seem to have a role. If the symptoms last more than six months, surgery is a potential option but recovery time is more than a year and 20-30% of patients have residual pain.
Mr. Woods’ Achilles woes and his recovery will be followed by his fans in the golf world, hoping that he can recover from this injury like he recovers from an errant drive that puts his ball in the rough. Miracle shots on the golf course have become part of his legend but unfortunately, his body follows the laws of physiology and healing cannot be rushed. Returning too early will potentially weaken the tendon to the point that it risks rupture and the certainty of surgery. As with many things in life, time invested early pays dividends long term.
On a related note, patients who have Achilles tendon inflammation are at risk for spontaneous tendon rupture if they are prescribed a common antibiotic in the floxin family (Cipro, Levaquin or Avelox).