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A Look at Achilles Tendon Injuries in Pro Sports

Baseball is barely out of the gate, with spring training games getting underway this weekend. Yet, according to, there are 143 major leaguers who are out with injuries. Though some are listed as day-to-day, many will miss a good deal of spring training. Others led with season-ending surgery. I hate to think of what the list will look like in a few months…

A few NBAers are suffering from big-time Achilles injuries. Piston’s forward Jonas Jerebko tore his Achilles tendon in pre-season and Charlotte back-up center DeSagana Diop underwent an Achilles repair in January. Francisco Garcia, a guard/forward on the Sacramento Kings has been out for weeks with what coach Paul Westphal called “an epic calf strain”, and just days ago, Spurs star Tony Parker left the game with a calf contusion after a collision with Mike Conley of the Grizzlies. Celtics Big Man, Shaquille O’Neill, has been resting up for playoffs with a case of Achilles tendinitis.

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

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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.


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.

Follow Abby on Twitter @abcsims


Stephen Strasberg’s Troublesome UCL

2 year-old Nationals phenom Stephen Strasberg was placed on the disabled list last week for the second time in his brief major league career after suffering what was termed a “significant tear” of the ulnar (medial) collateral ligament (UCL) in his right elbow.  He’d also exited the game early only days before, with what was reportedly flexor tendinitis in his right forearm. Team officials have been quoted as saying that Strasburg’s newest injury likely occurred during one particular pitch.   Were the two injuries related?  Was the earlier injury a warning sign?  For the record, it should be noted that stress to the medial (inner) compartment of the elbow – a common problem for pitchers – can impact not only the UCL but can also create inflammatory conditions in all of the structures that occupy this region.  These include the wrist flexor muscles (which are in the forearm), the forearm pronators (which turn the palm downward), the joint capsule and the ulnar nerve.  The repetitive demands of pitching, and the nature of the motion itself – particularly the phase of acceleration – are generally the primary culprits.  The end result of moderate UCL sprains (Grade II) is laxity (looseness) of the ligaments, which results in joint instability.  This instability causes even greater strain on the surrounding tissues.  If the offending activity is continued, tissues are prone to inflammation.  At worst, they could tear further.  Of course, a severe sprain (Grade III) is actually a complete tear of the ligament.  These generally occur traumatically, as with one pitch as is claimed in Strasburg’s case. However, for many, earlier injuries often set the stage.  Either way, it is a sad end to Strasburg’s rookie campaign.

There are those who didn’t require a crystal ball to predict that Strasburg would have Tommy John surgery lurking in the shadows of his future.  With youth on his side though, most probably felt he’d buy more time.  Strasburg’s unorthodox delivery coupled with the extraordinary pace of his pitches is thought by many to have made his elbow more vulnerable.  Let’s not forget that Strasburg also missed three weeks of starts earlier this summer with shoulder inflammation.  The kid is breaking down.  A piece by Bill Conlin (posted to Sports on August 30th) details issues with Strasburg’s delivery and the possible repercussions that we may be witnessing.  If you are interested in more on this topic, take a look.

What exactly is the UCL & what is Tommy John Surgery?

Ligaments attach one bone to another and provide much of the stability at a joint.  A partial or complete tear of the ulnar collateral ligament (UCL) of the elbow results in the need for the Tommy John procedure in order to reconstruct this medial ligament. A higher incidence of severe elbow injuries in overhead athletes is partly due to players’ increased size and strength as well as the tremendous forces generated, particularly when pitching.  More frequent use of the slider and split-finger fastball is thought to be another reason.  Advances in medicine have led to an increase in Tommy John surgeries due to better reporting of injuries, an improvement in the ability to diagnose the problem and greater expertise in performing the procedure.

There is a great deal of stress on the inner aspect of the elbow during the throwing motion. A very high velocity (speed) is required to extend (straighten) the elbow, and maximum stress on the inner elbow ligament occurs just after the cocking phase of pitching, when the arm just begins to descend.  In fact, at a 90-degree angle, the ulnar collateral ligament provides at least 54% of the stability of the elbow joint (figures from 54% up to 70% have been reported). Acceleration during the throwing motion also places significant stress on the ligament, while compression forces and a high level of muscular activity are also present.  You can see why the ulnar collateral is so important and why it is so often damaged.

Normal range of motion for a pitcher’s shoulder and elbow is different than that for an average person or even an average player.  Likewise, pitchers are much more developed on their dominant side, enabling them to exert with greater force on that side.  A UCL tear results in pain and a loss of throwing speed.  The instability caused by a tear such as Strasburg’s may also result in a stretching (traction) of the ulnar nerve, causing nerve related symptoms.  The ulnar nerve is the one you provoke when you hit your “funny bone”.

Dr. Frank Jobe pioneered the Tommy John Procedure in 1974.  Studies currently show an extremely high success rate, now at about 90%, while the non-surgical success rate of treating a partial tear is about 45-50%.  Various studies show that major leaguers generally return to action between 9.8 and 11.2 months post-operatively, though their rehab begins to include a low-level throwing program at about the four-month mark.  Even after returning to play however, a pitcher generally is not thought to regain full form for up to two years.  As a result, many reports list the return to play in the 12-18 month range.

Strasburg’s tender age should help with respect to his ability to heal and return to form.  However, it remains to be seen whether his coaches and doctors will encourage him to modify that form in order to protect himself from further injury