Did I Rupture My Achilles Tendon?

I had an interesting case hobble into the clinic yesterday. An 87 year old man tells me he awoke one morning with some pain in his left foot. He swears up and down that he didn't injure it in any way, but he now can't walk on it normally. Sure enough, as I watch him come down the hall, he's moving, but only with the assistance of heavily leaning on his cane. I know this guy and he usually can move better than this.

After some gentle examination, his left calf is certainly a bit swollen, and there appears to be a gap in his Achilles tendon. I ask him to get up onto his tiptoes, and he has no strength to do so. A few other physical tests confirm my thoughts, and a diagnostic ultrasound confirms a complete rupture of the tendon!

How Does The Achilles Tendon Get Torn?
This example is certainly the exception to the rule.  The Achilles tendon is the connection between the calf muscles (gastrocnemius and soleus), and the heel bone (calcaneus). It helps the foot push off the ground when running or jumping. When it is torn, therefore, people can't get up on their tip-toes with any strength.



The classic history is a middle aged person playing a sport where quick movements or explosive jumping is involved like sprinting, basketball, tennis or squash. The person will often feel like they've been hit or shot in the back of the leg, and often either blame their playing partner for hitting them or look for the object that "hit" them. The event is usually sudden and therefore very memorable. The examination is also usually fairly straightforward with an obvious gap in the tendon, and no passive motion of the foot when testing the calf. The diagnosis is usually then confirmed by diagnostic ultrasound.

One other uncommon, but not unheard of cause is from taking quinolone antibiotics, of which Cipro is best known.

How Do You Fix It?
Generally speaking, there are TWO options - surgical or non-surgical.

Surgical management essentially sews back the two ends repairing the connection. The risks include bleeding, infection and a small risk of re-rupture in the range of 4-5%.

Non-surgical management involves wearing a boot cast with the foot slightly plantarflexed (toes pointing down) for 6-8 weeks. This allows the torn ends to come into contact with each other and heal while immobilized. Benefits are that one avoids surgery, but the risk of re-rupturing the tendon is significantly higher, in the range of 10-15%.

One should never generalize, but "generally speaking", I recommend surgery for younger athletes, and those who are going to go back to explosive type sports. For older athletes (ie over 40), I try to guide them towards non-surgical management, as the outcome is still quite good (ie 85-90%), and only go to surgery if this route fails.

Have you every torn your Achilles?
How was it managed?
Let me know!

Torn Labrum: Now What?

One of the great things about using pro athletes as a jumping off point for topics is that there is an endless supply of material. One of the worst things is that these injuries often happen to my favourite players. Marian Gaborik, star player with the New York Rangers, injured his shoulder during this season's NHL playoffs.
He thinks he injured the shoulder during the 1st round of the playoffs against Ottawa, but was able to play through the pain for two more rounds until the Rangers were knocked out by cross town rivals, the New Jersey Devils. This injury was finally diagnosed as a torn labrum of his shoulder, and will require surgery to repair, with recovery time of up to 6 months!


Torn labrums in the shoulder are more commonly associated with pitchers, who stress the joint much more, and some of the notable victims include Curt Schilling, Chris Carpenter, and most recently Michael Pineda of the New York Yankees.

What is the Labrum?


The simplest way to think of the labrum of the shoulder is as a lip of fibrous cartilage around the glenoid; or socket part of the shoulder. This lip of cartilage serves to deepen the socket (glenoid) by up to 50%, helping keep the head of the humerus (the ball of the ball and socket), from popping out.
Unfortunately it is NOT uniformly thick all the way around and certain areas are prone to tearing, especially where the long head of the biceps tendon attaches into it.

When this cartilage tears, it can cause pain, catching, popping and limit strength and range of motion.





Mechanism of Injury


Labral injuries most commonly occur either from trauma, or repetitive overhead activity, like throwing or swimming.

Traumatic injuries are usually due to a result of a fall with the arm outstretched above. This is thought to causes a pinching mechanism of the humeral head catching the labrum.

In the case of repetitive overhead activity, it is thought that the biceps tendon chronically irritates the weak spot of the labrum where it attaches.

How do I Find out of My Labrum is Torn?


Good question. In most of medicine, a well taken history and focused physical exam can often provide a clear diagnosis, without resorting to expensive imaging. In the case of the shoulder labral tear, this unfortunately is not quite true.
Labral tears in overhead athletes can mimic rotator cuff injuries, which can often be settled down with some relative rest, review of mechanics and rehab.  The history for both is similar. The clinical tests for labral injuries, have NOT been shown to be particularly accurate, and can vary dramatically depending on who is conducting the examination!

So, for labral tears, if there is a high degree of suspicion, and a failed course of conservative management, I tend to order an MRI with dye (gadollinium), to assess the labrum specifically. Unfortunately, even the MRI can miss this diagnosis, and sometimes the definitive test is to scope the shoulder to directly visualize and repair the labrum if it is still torn.

Recovery Time


Once the diagnosis has been made, if the labrum is torn, it likely needs surgery to repair, as cartilage has a poor blood supply and tends NOT to heal.

Shoulders tend to take a relatively long time to recover, due the complex interplay of inherent instability, and the degree of freedom the joint has.

It usually take 4-6 weeks just for the initial pain to settle, then true rehab can begin on range of motion and gradual strength. This can be another 4-6 weeks just to get function back.  The next step is then trying to return to activities that caused the problem in the first place like throwing or swimming.

This is the most important part of the recovery as mechanics and strength need to be changed, or the same injury can recur again.

Going back to Marian Gaborik, my hope would be a hockey player is more likely to come back from this injury than the Yankees new pitcher. (sorry baseball fans!)

Let me know if this helps!

Torn ACL. Now What?

I was saddened to hear last week that Mariano Rivera, one of the greatest closers in baseball of all-time (Rivera career stats), tore his ACL in a freak accident shagging fly balls in the outfield.

We hear commentators on SportsCentre talk about ACL injuries fairly frequently in various sports, and you may hear guys throw the term around as well, but, really, what the heck is an ACL anyway?

Some Basic Anatomy.


The ACL, or anterior cruciate ligament, is the critical ligament that prevents the shin bone from separating from the thigh bone above. Secondarily, it also keeps the lower leg from twisting too much.  Think of it like a rope that keep the bones from separating. Too much strain on it, and the ACL might tear.

The "anterior" part of the acronym is because it sits in front of the PCL (posterior cruciate), and "cruciate", which means "cross", because the ACL and PCL criss-cross each other in the centre of the knee.

There you go. Might win you a bar bet some night.

Epidemiolgy.


So, who typically tears their ACL? And how? And how often?
Well, ACL tears certainly are common. 1 in 3000 people tear their ACL per year, and appproximately 70% of those occur during some sort of sporting activity.

For whatever reason, Females tend to tear the ACL significantly more than men. For example, Linendfeld et al (http://ajs.sagepub.com/content/22/3/364.short)  reported a SIX-FOLD increase in ACL injuries in female soccer players than men, and Ferreti et al, (http://ajs.sagepub.com/content/20/2/203.short) noted a FOUR-FOLD increased incidence in women Volleyball players.

Mechanisms of Injury.

When I'm taking a history from a patient about their injury, if I've done my job right, I usually have a pretty good idea of what they might have done to themselves, even before examining them. This is crucial in eliciting the history of a possible ACL injury, as they can be easily missed, if you're not careful.

The classic injury, is very much what Rivera did. The athlete will describe a non-contact, sudden decelerating move. Very often the player will plant their foot and hyperextend and/or twist the knee, while trying to cut, or change direction. If the foot doesn't slide, (ie, a cleat or shoe gets stuck), the knee may strain and injure the ACL.

The patient may describe a "POPPING" sensation, as the ACL finally gives out and tears. If the injury is isolated, there may be very little swelling associated.

In this case, raw video footage demonstrates one of the mechanisms of injury; hyperextending the knee.

It's Torn. Now What?


At our sport clinic, after the diagnosis is made, the question then becomes, should this be fixed or not?
Watching ESPN, or TSN, or any of the other SN's, you'd think it's "to the operating room as soon as possible".

It actually shouldn't be. The human body is a funny thing. For some people, their proprioceptive ability (or position sense), can compensate for the loss of the ACL dramatically. If their activity or sport consists mostly of straight ahead running only, they may do ok without fixing it. I'm thinking of runners, cylcists, swimmers, and perhaps a few others.

However, sports that are stop and go, like basketball, soccer, football and the like, do depend on the ACL greatly, and probably require fixing, no matter how good your proprioception is.

Our usual protocol following an ACL injury, is quieting the knee down (ie getting any swelling settled),
getting as much range of motion back, and getting the knee (especially the hamstrings) as strong as possible, before an operation. A good physiotherapist is your best friend.

The operation to fix the ACL, usually involves replacing it with a hamstring or part of the quadriceps tendon from the patient. This can be done as day-surgery, but then the true work for the athlete begins.

Rehab should be intensive, with reasonable time lines being about 3 months to get back to straight ahead activity, and 6 months to stop and go sport.

Best wishes to Rivera. I'd hate to see him end his career this way.