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 racket 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 immobilization.  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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Which of Bradshaw’s surgeries was the bigger deal?

Spurring:

Wear and friction at a joint can promote changes in bone, which responds to stresses by growing more bone.  The irregular shape of the joint surfaces that results is due to this extra bone, or spurring.  The spurs then take up space in the joint and, when the joint moves through the range of motion required for function, impingement occurs.  This is painful, as nerve endings and other structures are pinched.  Add impact from running, especially with the cutting patterns involved in football, and the situation can become untenable.  Removing the spurs arthroscopically, if that is all that Bradshaw’s ankle surgery entailed, is a fairly routine procedure, and he likely healed well.  Is it always this simple? – Absolutely not.  Sometimes there is more that might have contributed to an athlete’s condition.  Perhaps there are additional diagnoses that may or may not have been addressed.  Or, there could be underlying factors that predisposed an individual to the formation of spurs, such as structural mal-alignment, mechanical flaws in the manner in which an athlete runs, or even consistently running in one direction on a banked surface.   Simply stepping up a training program too aggressively can create undue stress on the weight-bearing joints.  These and other issues might persist once spurs are removed.  If so, with return to competition, the long-term result would be that over time the spurs will reappear.  I don’t know the specifics of Ahmad Bradshaw’s circumstances and so I make no predictions. 

Fifth Metatarsal Fracture Fixation

Surgical fixation of fractures of the fifth metatarsal (MT), the long bone of the midfoot that connects the little toe to the bone just in front of the heel, can be tricky.  These fractures come in several varieties, based on their exact location and whether they are acute (from a recent trauma) or chronic (typically this is due to an unhealed stress fracture).  The most common fracture of the fifth metatarsal is an avulsion fracture, where a small portion of the base of the bone is pulled away from the body of the bone. At the fifth MT, avulsion is most often due to the pull of the connective tissue at the base of the foot or tension from a particular muscle of the lower leg that attaches at the fifth MT.   A “Dancer’s fracture” of the fifth metatarsal typically occurs with twisting of the ankle, otherwise known as an inversion sprain (O’Malley, 1996).  These MT fractures may be accompanied by fractures of the outer ankle.  Though I’ve not seen detailed reports of his injuries, I would guess that Bradshaw’s fractures were most likely of the Jones’ variety rather than avulsions.  Jones’ fractures occur in an area connecting the base of the fifth metatarsal with the shaft of the bone, and they often prove to be stubborn injuries.

Studies have demonstrated that only about two-thirds of acute fifth metatarsal fractures heal well with non-operative treatment (Wheeless’ Textbook of Orthopaedics).  Conservative care initially entails wearing a non-weight-bearing cast for about 6-8 weeks followed by therapy.  Surgery is the treatment of choice for those with delayed healing or incomplete healing of the bone, known as non-union.  In these chronic cases, only a percentage of the fractures will mend without surgical intervention, and those that do require prolonged treatment during which time an individual cannot participate in sports.  Likewise, when a fracture is displaced (where the two ends of the bone don’t line up) or where an avulsion entails a large piece of bone being pulled away, surgery is warranted.  An athlete, such as Ahmad Bradshaw, may opt for surgery rather than risk being out for an extended period only to find out that his fracture still hasn’t healed.  Post-operatively you can be sure that he was monitored carefully and only allowed to return to activity once full union (mending) of the bone was established.  This is because a premature return to activity can result in failure of the fixation (Larson, 2002).  Some athletes, even after surgery and a carefully executed rehabilitation plan, suffer from re-fracture.

So, the answer to my question is clearly that the fixation of Bradshaw’s metatarsals was the more sensitive of his surgeries.  After working to control his post-operative inflammation and pain, regain his strength, range of motion, endurance, flexibility and balance, Mr. Bradshaw began to run again.  I’ve read that he has been trying to adjust his running technique – attempting to place less stress on the outer border of his feet – to avoid re-injury.  That may be a tough go.  We’ll keep an eye on him…

If you experience the onset of pain at the side or outer edge of your foot, seek treatment.  The pain may seem to have been unprovoked or might have increased gradually.  Don’t hesitate if you find that the pain is more pronounced with walking and is exacerbated by running or sports participation.  A negative x-ray doesn’t even mean that you are in the clear.  Remain on alert because stress fractures often don’t show up on initial x-rays and may only be evident once they begin to heal.

What is Tennis Elbow?
Tennis elbow is an overuse injury and, like other such injuries, is a result of placing too much demand on muscles and tendons that are not equipped to handle the stress.

Lateral Epicondylitis is the technical name for tennis elbow.  The literal definition is that there is an inflammation (“itis”) at the tendons attaching to the bony prominence at the outer (lateral) region of the elbow (the epicondyle).  The lateral epicondyle is on the thumb side of the elbow when your palm is facing forward. The tendons that attach to it are those that connect the muscles that extend the wrist and fingers to the bone.  Though transient symptoms are generally due to a simple extensor tendonitis (Iinflamed tendon), persistent cases of tennis elbow are generally a result of a degenerated or torn tendon (tendinosis).  One tendon in particular is usually the culprit, and that is the extensor carpi radialiis brevis tendon (known as the ECRB).

What Contributes to Tennis Elbow?
First off, you don’t have to play tennis to join the club.  Any repetitive stress that entails use of the wrist and finger extensors can lead to their overuse and subsequent inflammation. If those tissues are not sufficiently strong or flexible it takes less demand to overdo it.  If you begin a new activity or resume playing a sport after a layoff due to injury or seasonal abstinence, it is important to establish a foundation of strength and flexibility that will prepare you to compete safely.  In addition, it is best to ease into the season by ramping up your playing time gradually.

There are other factors besides strength and flexibility that can come into play for tennis buffs looking to prevent lateral epicondylitis. First, consult a pro to help you choose your racquet.  Many pros recommend that you spend the extra money to string your racquet with gut, which is softer and more forgiving than some of the synthetics.  Just as with the wrong strings, a racquet that is too long, too rigid or too light, or one that has the wrong grip size (generally too small) or is strung too tightly will increase the vibrations that travel up through the hand and arm putting a player at greater risk of injury.

Poor stroke mechanics are another big reason that recreational tennis players suffer from tennis elbow.  This is particularly true for those who have a wristy backhand or who maintain a rigid forearm and don’t follow-through properly on their backhands.  Hitting the ball in the sweet spot of the racquet is also a key to minimizing the vibrations that otherwise place excessive stress on the muscles and tendons.  Taking some lessons to perfect your form can go a long way toward helping to prevent unnecessary demands on your body.

Do Tennis Pros Get Tennis Elbow?
The answer to this question isn’t as simple as you might think.  Though there have certainly been instances of high-level competitors suffering from lateral epicondylits, it isn’t common amongst tennis pros.  In spite of the concentration of time they spend on the court, with their excellent conditioning, ongoing coaching and optimal equipment, tennis elbow is not nearly as prevalent in the pro ranks as in the recreational population.

The big however is that pro tennis players are more likely to suffer from Golf Elbow than Tennis Elbow.  This is largely due to the extraordinary spin that many put on the ball when serving or even in their groundstrokes.  This places undue stress on the opposite side of the forearm.

What is Golf Elbow?
Basically, golf elbow is the opposite of tennis elbow – it is tendonitis or tendinosis of the wrist or finger flexor tendons and an inflammation at their attachment to the inner (medial) epicondyle at the elbow (on the pinky side of the elbow with the palm facing forward).  Thus it is also referred to as medial epicondylitis.

Like tennis elbow for recreational tennis players, weekend hackers may wind up with golf elbow because of a lack of conditioning, excessive play, unforgiving or poorly fitted equipment as well as poor form.   An incorrect grip or swing is often at fault.

As for tennis elbow, you don’t have to play the game to suffer the injury.  Any repetitive activity that causes excess demand on the involved tissues can result in their overuse and subsequent inflammation or breakdown.  Home improvement projects that involve hammering or painting, keyboarding for the office worker or even the throwing motion in overhead sports can cause golf elbow.  The latter is again why elite tennis players may suffer this ailment – the serve and overhead strokes being the culprits.

Treatment
Anti-inflammatory medication, ice and cross friction massage can treat the inflammation, and stretching the involved muscles and tendons is also very important.  It is crucial to strengthen the muscles as well but only in a progressive manner that does not provoke any discomfort or pain.  It is also generally helpful to wear a brace designed to lessen the stress to the involved tissues with routine activity.  Of course, it is important to minimize the ongoing stress to the area by limiting or refraining from the offending activities while rehabilitating.   Rest alone is never the answer though, as it will result in further deconditioning of the muscles, leading to recurrent injury once activity is resumed.

Cortisone injections are often used to treat tennis and golf elbow, though they should not be a first resort.  Injections do address the inflammation though they do not impact the cause of the condition.  Without restoring normal joint range of motion and muscle flexibility and strength to the forearm, wrist and hand, the condition is likely to return.  Cortisone combined with other restorative treatments is more beneficial, though it is best to first approach care more conservatively to see if injection can be avoided.

A variety of newer treatments are in use now and their effectiveness is yet to be fully evaluated.  These include PRP (platelet rich plasma therapy), Prolotherapy and Shock Wave Therapy (all of which were detailed in a prior blog entry on Joakim Noah and plantar fasciitis).

Surgery is a last resort and is generally only used in instances of tears common to more chronic conditions or in the instance of a traumatic tear from a violent and sudden cause of injury.

What is fascia?
Fascia is a fibrous connective tissue that occurs throughout the body and overlays the muscles, organs, nerves and blood vessels.  It acts as a restraint to keep our tissues and structures in place. If you have ever prepared chicken you have seen the filmy white tissue between the skin and the meat – that is fascia.  At the bottom of the foot, (the plantar surface), the fascia is particularly fibrous and connects the heel bone to the toes.  It is prone to stresses or small tears that can result in an inflammatory (“itis”) response.

Common causes of Plantar Fasciitis
Fasciitis usually develops over time rather than from trauma and the problem is often stubborn, especially if left untreated. Tightness of the calf muscles and Achilles tendon can predispose to plantar fasciitis, as can tightness of the fascia itself.  A loss of mobility at the ankle or the big toe (not being able to flex up/back sufficiently) can also lead to fasciitis by changing our movement patterns, reducing the shock absorbency of the joints, and limiting the ability of the calf and fascia to stretch to their fullest, resulting in tightness.  Additionally, weakness of the muscles of the calf or foot/ankle impact function and lead to injury by placing more stress on all the related tissues.  Other typical pieces of the cause and effect puzzle may include structural malalignment (such as a high or low arched foot) or the presence of a heel (bone) spur.

Women who wear high heels much of the time are prone to fasciitis because the calf muscles and fascia become tight due to the positioning of the foot and ankle.  People whose work requires that they spend an inordinate amount of time standing or walking (particularly on hard surfaces) and those who are significantly overweight are also more prone to plantar fasciitis.

Symptoms of Plantar Fasciitis
Swelling and tenderness to pressure or touch are generally complaints of those with fasciitis, as is a sharp pain in the heel area or arch of the foot.  One of the most common complaints is morning pain, particularly with the first steps from bed. During a prolonged period of rest, where the foot and ankle are relaxed (with the toes pointed downward), the plantar fascia and muscles of the calf are on slack.  The sudden stretch imposed by putting the foot on the floor and walking can trigger significant pain.  The same might occur after sitting for an extended period.  In very mild cases, after walking a bit and warming up the tissues, pain subsides. Taj Gibson, another Chicago Bull suffering from plantar fasciitis has been receiving treatment but has been able to play through it, an obvious sign that his condition is not as severe as Joakim Noah’s.

Prolonged walking and especially running, which requires a more forceful push-off, are likely to increase the pain and inflammation associated with fasciitis.  Jumping will do likewise.  Not the best scenario for Joakim Noah who, when he began his medical leave, was the NBA’s second leading rebounder.

TREATMENT
Treatment of plantar fasciitis requires a multifaceted approach to reduce inflammation, stimulate healing, stretch tight tissues, strengthen weak musculature and minimize additional stresses.  Here are some tried and true methods of care as well as some of the emerging techniques:

Rest – time off from offending activities is an important part of treatment.

Night Splint – wearing a night boot to keep the ankle at a 90-degree angle maintains some stretch of the calf and fascia and significantly reduces early morning pain.  By helping to lightly stretch tight structures over a prolonged period, resolution of plantar fasciitis is accelerated.

Deep tissue massage – performed manually and also by rolling the foot on massagers or things such as a tennis ball or frozen can of soda can be very helpful.  Deep massage with the ankle held at 90 degrees and the big toe held gently in a backwards-bent position can help to ease fascial pain and tightness.

Stretching – tight calf muscles and fascia must become more flexible to limit recurrence.

Range of motion – treatment to restore motion where it is limited may be necessary to allow for more flexibility of the attached structures.

Cushioned heel lifts – by slightly elevating the heel, stress on the tight structures is minimized during walking or prolonged standing, and the increased shock absorption of a heel lift also decreases the stress from impact.  Choice of footwear factors in here as well (notice that many surgeons and chefs wear clogs).

Ice and electric stimulation – both help to reduce inflammation and swelling

Iontophoreses – another very helpful tool used in physical therapy.  For plantar fasciitis, “ionto” involves the use of a corticosteroid medication that is driven through the skin in the region of the inflammation with a transistor size electric stimulator.  It is painfree, entails only localized use of the drug and does not entail an injection.

Taping – even after returning to competition, taping techniques are used to support the arch.  Taping can be very helpful and enable a player to compete without aggravating a condition as well as reduce the chance for recurrence after a problem resolves.

Strengthening weak muscles throughout the lower body and especially those of the calf and foot is crucial, as is building muscular endurance.  For example weak toe flexors (muscles that let you grip with your toes) are a common problem resulting in fatigue in the foot and strain on the fascia due to poor push-off.  Even the toes must be strengthened when treating foot and ankle conditions.

Balance training is vital as well, working to stabilize while standing on one foot and challenged to reach or bend.  Balance training should be progressed from stable to unstable surfaces to increase the difficulty of the tasks.

Arch supports – if flattened or high arches or other malalignment issues are part of the problem, over-the- counter or custom orthotics (shoe inserts) may be recommended.  It is generally suggested to wait until you have increased your flexibility (if it is one of the causative factors) before getting a custom orthotic because the resting position of the foot may change once greater flexibility is achieved.

Prolotherapy – Prolotherapy treatment involves injecting a sugar water solution into the involved ligament or tendon where it attaches to the bone. This is intended to cause a localized inflammation in these affected areas in order to then increase the blood supply and flow of nutrients.  It is thought to stimulate the tissue to repair itself.  I’m not sold.

Plasma Rich Platelet Therapy (PRP)– Joakim Noah recently underwent PRP and shock wave treatments. Both are relatively new.  Some recent studies on PRP were not as favorable as the original clinical impressions, showing that it was no more effective than injecting saline. Platelets are one of the four components of blood.  The others are red and white blood cells and plasma. The procedure involves taking a patient’s own blood, spinning it down to the platelets, which are said to release proteins called growth factors, then injecting that back into the injured area.  The treatment is thought to accelerate tissue and wound healing.

Shock Wave Therapy – Another emerging treatment, shock waves are said to work by inducing microtrauma to the affected tissue, which then stimulates a healing response. This healing response causes a repair process during which small blood vessels form to increase delivery of nutrients to the affected area.

Injections – Not on my go-to list of treatments for plantar fasciitis, they are still in the arsenal so are included here.  The cortisone injection is occasionally needed to jump start the rehab process by reducing inflammation and pain sufficiently so that the active treatments (such as stretching and strengthening) can be progressed without exacerbating symptoms.  With the potential side effects of injection always at issue, it should not be a first line of defense or used repeatedly in one area of the body.  Nor should cortisone be the entire treatment even if it brings relief.  That is dangerous because it gives a false sense of order when in fact the underlying causes of the problem have yet to be addressed.  Cortisone by injection at the foot is even riskier because of the more fragile nature of the tendons there and their predisposition to rupture.

Surgery – A very last and infrequently relied upon resort, surgery to lengthen the fascia is sometimes the final step when all else has failed.

Wait a minute, isn’t the UCL at the elbow?
Recent columns on this site have discussed UCL injuries to pitchers’ elbows resulting in the need for Tommy John surgery as well as the implications of ankle ligament tears.  First let’s quickly review the basics to help you understand the nature of Shaq’s injury.

A ligament is the connective tissue connecting one bone to another to provide stability at a joint.  Each joint has at least one ligament on each side.  In the hand or elbow, the inner (medial) side, or side of the ulna bone in the forearm, is called the ulnar side and the outer (lateral) side is called the radial side because of its relationship to the radius (the outer bone in the forearm). Hence, at the base of the thumb, just as at the elbow, the ligament stabilizing the innermost part of the joint is called the ulnar collateral (UCL).

Injury to a ligament diminishes stability at the joint it protects, and may do so even on a permanent basis, so Shaq’s prior injury may have predisposed him to re-injury. 

Other names for the UCL tear of the thumb
Most often called “Skiers’ Thumb” these days because of its prevalence on the slopes, this injury used to be known as “Gamekeepers Thumb” because it was commonly found amongst Scottish Gamekeepers (wildlife managers) as a result of a repetitive stress and stretch to the ligament that they suffered when doing their work. 

How does this injury occur?
A force that pulls the thumb away from the hand places stress on the UCL at the joint where the thumb meets the palm.  If the force at this joint (also called the MCP, or metacarpophalangeal joint) is traumatic and causes the joint to exceed its normal limit of movement, the UCL is sprained. And, as for any ligament, a Grade III Sprain is really a complete tear.

A skier who falls while holding the pole, or anyone who tries to break a fall by reaching out with his hand to absorb the impact may suffer a Skiers’ Thumb injury.  If the thumb is bent backwards and a ligament tears, it is unlikely to be able to heal in the anatomical position because of the resultant instability of the joint.  That is why Shaq is having surgery.  Occasionally, just as was previously discussed with regard to ligament injuries at the inner aspect of the ankle, the UCL ligament may not tear but instead might pull off a chip of bone at its point of attachment (at the base of the thumb).  This injury is called an avulsion fracture and it too can result in instability at the joint if not corrected surgically.

So, what did Shaq’s thumb probably feel like after the injury?
Just as after any partial or complete ligament tear, fluid builds up causing swelling.  Visible discoloration is an indication that a ligament (or other vascularized structure like muscle or tendon) was torn.  Naturally, pain is a factor and it will hurt to use the thumb (to grip or squeeze) or to bend it backward.  Reports are that Shaq will be out for six to nine weeks to heal and rehab following today’s surgery.  The Cavs or course, are hoping to have him back in the line-up to help them in the later rounds of the playoffs.