As every New England Patriots fan is aware, big Vince Wilfork, the irreplaceable Defensive Tackle suffered a torn Achilles tendon in the pats’ win over Atlanta. As is normal with the loss of any crucial player, fans begin to wonder when or if their favorite stars will be back on the field. As with all of my articles, I enjoy being able to discuss, educate and help athletes, coaches, parents and concerned fans to understand common sports medicine and orthopaedic injuries that they may have suffered or may be interested in understanding more about.
Since there has been a lot of media hype regarding Wilfork’s injury and the implications it may have on the team, I figured it would be a great opportunity to take some time to talk about the Achilles tendon and the associated injuries and treatment options that we currently have available in order to hopefully answer some of the questions that many concerned fans may have about such injuries.
To start, let’s do a quick review of the anatomy and function of the structures related to the Achilles tendon in order to fully understand more about the Achilles tendon and the possible injuries it may sustain.
When we are talking about tendons in general, we are referring to a thick band of fibrous connective tissue that is serves to connect any muscle to a bony origin or insertion. This is how muscles are able to move our various body parts because of the way they directly attach to the bones via tendons.
The Achilles tendon happens to not only be the strongest tendon in the human body, but also the thickest. The thickness and strength go hand in hand because the more Type I collagen that is present in a tendon, the stronger and thicker it typically is. In fact, the Achilles tendon is so strong that a healthy adult tendon has been shown to be able to endure approximately 9 kilonewtons, or 12.5x an individuals own body weight while running.
The Achilles serves as the attachment for 3 muscles of the posterior compartment of the leg that come together to form a tendon that attaches to the posterior (back) side of the foot at the calcaneus bone (heel bone). Those three muscles are commonly referred to as the calf, but are respectively named: gastrocnemius, soleus, and plantaris. If you feel just above your heel, there is a thick band that seems to lead you’re your calf muscles and this is the Achilles.
The 3 muscles that comprise the Achilles tendon are responsible for an action known as plantarflexion. That is to say when these muscles contract, we are able to push our foot downwards. This action is critical in everything from walking to running and jumping. It is an especially critical action in football that is useful for the lineman to be able to quickly and powerfully get from their 3-point stance to blocking the offensive guards and tackles that are up against them.
The Achilles tendon is the most commonly injured tendon in sports related injuries. This makes sense due to it’s critical role in producing an action that is essential to most every sport or exercise that involves the use of the lower extremities. There are a number of injuries that one may sustain to his or her Achilles tendon. These injuries range from Achilles tendonitis/tendinosis (insertional and non-insertional), which is simply inflammation (tendinitis) of the tendon due to overuse, direct trauma, or aggravation from improper footwear or bonespurs, to a complete rupture/tear of the tendon. Though this article will mainly focus on Achilles tendon rupture, the following list describes the majority of injuries that are commonly sustained to the Achilles tendon:
- Achilles Tendinosis
- Achilles Tendinitis
- Insertional vs. Non-Insertional
- Tennis Leg
- Achilles Tendon Laceration/Crush Trauma
- Partial rupture of the Achilles Tendon
- Complete Achilles Tendon Rupture
Achilles tendinosus vs. tendinitis is a commonly asked question and is fairly simple to describe. Though most individuals have heard of Achilles tendinitis and have likely at some point in their lives been told they have experienced it, it is much less common than many believe. Tendinitis refers to an inflammatory process that involves certain inflammatory cells and chemical mediators whereas tendinosis is a chronic use injury that refers to a disorganization or disruption of the normal collagen and fibers that comprise the Achilles without markers of inflammation.
Tennis leg refers to a rupture or tearing of the gastrocnemius muscle from its connection to the Achilles tendon. These are the types of injuries that many soccer players describe as feeling as if they got kicked from behind and hearing a popping sound. It commonly occurs when an individual performs a lunging motion.
With a brief discussion of the anatomy, function, and some of the other injuries that may be sustained to the Achilles, this brings us to the highlight of this article: Achilles Tendon ruptures.
As reported by the media, an Achilles tendon rupture is the injury that Vince Wilfork sustained during last weeks game. An Achilles tendon rupture can either be partial or full and refers to whether or not the entire tendon was fully torn through, or if there was only a partial tear through the thickness of the tendon.
How do they happen? Achilles tendons are most commonly ruptured during participation in athletics, but may also occur with any forceful dorsiflexion imposed upon the foot while the individual is trying to plantarflex. Typically we see complete tendon rupture with the foot completely in plantarflexion and planted on the ground. In Wilfork’s injury we can see that this seems to be the unfortunate cause of his injury.
Impact and Implications on an Athlete. Though painful and debilitating for anybody who sustains this type of injury, an Achilles tendon rupture is particularly devastating to an athlete because without an intact Achilles tendon, the individual is virtually unable to point his or her toes downwards and create the explosive power needed to participate in athletics. Furthermore, due to the fact that tendinous and ligamentous structures have a poor blood supply and regenerative capacity, it takes a much longer period of time to fully heal and recover from these injuries, further adding to the deconditioning of the athlete and time away from competition.
How is a rupture diagnosed? With any orthopaedic sports medicine injury, people always want to know how it is diagnosed, especially when they see one of their favorite players rolling in pain on the turf, ice, or court. For an Achilles tendon rupture the diagnosis can begin in the training room/locker room with the Thompson test which requires the player to lay prone (face down) on an exam table and the examiner then squeezes the affected legs’ calf muscle. If the foot and toes do not move in plantarflexion, then the test is considered positive. Furthermore, the examinee may palpate the player’s posterior leg and typically feel a gap where the tendon should be laying.
This is not the best way of diagnosing it, but a good preliminary look. We then can move on to either an ultrasound or an MRI to help use to see the soft tissue injury much better. The MRI is then used to help in operative planning if the patient elects to undergo surgery.
There is essentially two major treatment options for a patient whom ruptures his or her Achilles. The non-operative treatment that can involve casting of the leg or the use of a walker boot with the intention that the Achilles as long as it is approximated enough will heal on its own over a longer period of time. Though patients typically recover, this method has been associated with a higher rate of re-rupture as well as a longer time to recover and we typically suggest surgical treatment over the non-operative approach.
The operative options for a patient with an Achilles rupture is somewhat of a controversial topic in orthopaedics because there are several operative techniques that a surgeon may use and not an incredible amount of data to support the use of one recommended method of operative treatment.
The Achilles may be repaired in an end-to-end open procedure in which an incision is made in a posteromedial fashion (back and closer to the inside of the leg) near the rupture sight and the tendon ends are re-approximated with a locking loop suture method into the viable portions of the tendon.
Additionally, there are some surgeons who in addition to simply suturing the tendon back together advocate the use of graft material such as the GraftJacket matrix with the intention to create a stronger repair that can withstand a significantly higher failure load.
Furthermore, some surgeons may use a percutaneous method of Achilles tendon repair in which minimal incisions are made in the skin and the cosmetic outcome is typically much better. This has recently been shown to have similar outcomes to the open end-to-end procedures. There is, however, a greater risk of a sural nerve injury with this procedure.
Return to Sports.
As with most athletic injuries this is a typically one of the more difficult questions to answer. Athletes are typically fierce competitors that are highly motivated to get back to work, but an Achilles tendon rupture is quite a severe injury that can take months to heal. In fact, the road to full recovery in an NFL caliber player takes an average of approximately 11 months.
One can typically return to full sport activity in 4-6 months after the injury, but at the athletic level of the NFL, an additional period of time is typically necessary to focus on reconditioning and training before the player is cleared and comfortable to return to such physically demanding play.
An athlete’s return to play is complicated by the long time it takes the tendon to heal in addition to deconditioning and the fact that after a tendon rupture, it is not uncommon for the force of plantarflexion to be permanently reduced. In a paper by Parekh et al, 36% of NFL players who sustain such an injury never return to playing at the NFL level after their rehabilitation.
Lastly, the type of therapy post-operatively can play a major role in an athlete’s ability to return to play. In the past it was believed that patient’s should undergo a fairly lengthy post-operative period of non-weight bearing status on their affected leg. This has recently been replaced by the ideology that early movement may help speed up the recovery and increase functional outcome.
So as one can see, there is a lot more regarding Achilles injuries than what is outwardly apparent to most people. It is an unfortunate and long road to recovery after an individual sustains an Achilles rupture that is further complicated by a number of various treatment options and post-operative rehabilitation protocols. Hopefully this review of anatomy, function, and treatment options/implications serves to provide the necessary knowledge to understand these types of injuries and the methods in which we treat them and help patients to undergo rehabilitation and recovery.
With the rest of New England, I’m wishing Vince Wilfork the most successful and speediest of recoveries, and like every other Pats fan, I’m looking forward to seeing him suited up once again at Gillete stadium! Get well soon, Vince!
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