Philly.com Sports Doc
Posted: Friday September 19, 2014
Most of us by now have at least heard about, if not seen, RG III’s ankle injury against the Jaguars on Sunday, September 14. The sports media reports that he suffered an ankle dislocation without fracture. This type of ankle injury is very rare as ankle dislocations almost always happen in conjunction with a fracture of the lateral malleolus, medial malleolus and/or the distal posterior aspect of the tibia.
From watching the video of the injury, RG III’s ankle looks to roll inward. It is unclear which direction his ankle dislocated and whether it was an open or closed dislocation but one would assume that there is significant damage to his ankle ligaments, specifically his deltoid ligament.
Treatment for this injury will involve a period of non-weight bearing with cast immobilization. Once the cast is removed, his ankle will be re-assessed for any ligament laxity that may not have healed with immobilization and may require subsequent surgery. If surgery is required, the loose ligaments will either be repaired (sewn together) or reconstructed (other tissue used to replace the injured ligament).
Return to sports after ankle ligament surgery usually takes 3-6 months. If surgery is not required, he will start progressive weight bearing and rehabilitation to regain ankle range of motion/flexibility, ankle and general lower extremity strength, and lower leg balance and motor control. From there, he will initiate sports-specific activities including running. This rehab program is relatively the same whether he undergoes surgery or not. There is less published research on return to sports following ankle dislocation without fracture, but one case study showed a time frame of 6 months in a recreational athlete.
The latest news coming from the team is that he will be casted for about 10 days, will not require surgery, and that he will be back in 4-6 weeks. That time frame is extremely optimistic if it was truly an ankle dislocation. There should be a much clearer prognosis once he is out of the cast and re-evaluated. But until then, make sure you don’t have him in your starting fantasy line up.
Philly.com Sports Doc
Posted: Monday, August 25, 2014, 5:30 AM
Achilles tendon rupture, the fear of every middle age man on the basketball and tennis court. Now that I am in my 40s I fall into that category. And unfortunately for me, I recently felt the dreaded “pop” while playing doubles tennis. At first, I thought the ball came from the next court and hit me on the back of the leg. Then I came to my senses and realized I had torn my Achilles. The people who stopped playing on the courts next to us must have thought I was in a lot of pain the way I was yelling while lying on the baseline. In truth, I didn’t really have much pain. I was yelling because I knew what was to come: Surgery, weeks of non-weight bearing and partial weight bearing, and the huge inconvenience this would be for work and life in general. My father-in-law, who was my partner in this ill-fated doubles match pointed out, “Hey, at least you won the point.” Not much consolation. My summer fun was over.
So what happened? How did I tear my Achilles? As I am known to do, I reviewed all the research hoping to figure out the cause. Maybe I was fatigued which may have contributed to the injury. More likely I’m predisposed as I tore the other side over a decade ago playing soccer. Neither time did I have any Achilles pain leading up to the injury.
There are some studies showing possible relationships with risk factors and Achilles ruptures. In the June 2014 edition of the journal Sports Medicine, Claessen et al categorized these potential risk factors into two categories: non-modifiable and modifiable. Non-modifiable factors include age, race, sex, medical issues, pre-existing musculoskeletal disease/tendon changes, ankle/foot alignment and genetic factors. Modifiable risk factors include obesity, sports activity, medication and smoking. From a specific sport perspective, Achilles tendon ruptures are found more frequently in athletes who participate in sports involving explosive acceleration such as basketball, tennis, baseball, and softball. Of the above factors, medications, especially Quinolones (specific antibiotics) and Corticosteroids, have shown to have the greatest risk for Achilles rupture.
There are multiple potential risk factors for Achilles tendon ruptures but none have been proven to be key factors. One risk factor that I definitely have is O blood type. A study from 1989 in the American Journal of Sports Medicine stated “In cases of multiple ruptures and re-ruptures, the frequency of blood group O was 71%.” However, the O blood type correlation is still up for debate.
Although the mechanism is still up for debate, what you’ll see if you slow down a video of the injury is the player taking a back step to push off and the knee forcibly extending at the same time. The combined force of foot plantar flexion and knee extension is likely too much stress for the tendon to handle. Watch the video of David Beckham tearing his Achilles for the prototypical mechanism of injury.
Strauss et al reported the following statistics in 2007 in the International Journal of the Care of the Injured. The incidence of Achilles tendon rupture is approximately 18 per 100,000 people. Ruptures typically occur in males between 30 and 50 years old and account for approximately 40% of all operative tendon repairs. Approximately 75-80% of cases can be attributed to participation in athletic activities, including ball and racquet sports.
Surgery or not?
There is ongoing debate as to what is the best course of treatment: Surgical repair or non-operative treatment. Surgery involves bringing the two ends of the tear together and suturing them in place while the tendon heals. Non-surgical treatment involves casting the foot in plantarflexion (toes pointed down) and recasting weekly with gradual progression into dorsiflexion (toes up). Non-operative care has demonstrated a re-rupture rate from 10-30% where surgical re-rupture rates are around 3-4%. Surgical complications have been reported to occur in 7-42% of all cases and include difficulty with wound healing, skin necrosis, infection, and sensory loss. For me, it wasn’t a question. I elected to have surgery as I want the best chance at a full recovery.
This is the most frustrating part for me. For surgeries such as an ACL reconstruction, the harder you work the quicker you recover. It’s just the opposite with an Achilles repair. The tendon needs time to heel so for the first 2-4 weeks you can’t put any weight on the foot. Then, over the next 3-4 weeks you gradually increase weight bearing in a boot with a heel lift to take pressure off the tendon. Strengthening is started late in the rehab process which means it takes a long time to get your full strength back, and many people never regain full strength after this injury. I never regained full strength after my first surgery and definitely lost a step with sports (although that could just be me getting older but I’m going with the injury). It takes approximately 4-6 months to start back to running and to initiate sports activities with complete recovery taking close to a year. As you can guess, I’m in for a long and slow recovery following Achilles surgery.
Is there any way to prevent an Achilles injury? There isn’t much research on this topic. In younger, high level athletes, there probably isn’t a way to prevent it other than not playing as intensely. For someone older like me, there is the possibility that by improving flexibility and fitness you may be able to reduce the risk of injury, but it is still probably just bad luck.
For me, I’ll do my rehab and get back on the tennis court and the soccer field in the spring. Unless my surgeon and my wife force me to take up a sport with a lower risk of traumatic injuries, but with my luck, I’ll probably fall off the elliptical and break an arm.