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.
Philly.com Sports Doc
POSTED: Saturday, June 8, 2013, 6:00 AM
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation
With the outdoor tennis season comes sprains and strains, aching knees and shoulders. Today, we will focus on common tennis injuries, how to prevent them, and how to treat them when they occur:
This seems to be the bane of tennis players as it can be very difficult to treat. Not all tennis players get tennis elbow as some get golfer’s elbow and vice versa. Tennis elbow starts with pain in the lateral elbow where the wrist extensor muscles attach. Golfer’s elbow presents with medial elbow pain where the wrist flexors attach.
There can be many causes of elbow pain including acute soreness from getting back on the court, overuse from playing too much, incorrect grip size, and inappropriate string tension to name a few. One thing that is often a major contributor and is usually overlooked is the shoulder. A loss of internal rotation known as glenohumeral internal rotation deficit (GIRD) and scapular dyskinesis are often times the underlying causes of elbow pain in tennis.
Once symptoms have occurred, rest and ice can help with acute pain. If symptoms persist, it is best to see a sports medicine physician, athletic trainer, or physical therapist that specializes in overhead athletes for an evaluation and treatment recommendations.
Shoulder pain accounts for the majority of tennis injuries. In younger players (under 40) the common culprit is a labral tear. In older players (over 40) we start suspecting rotator cuff involvement. There are numerous causes of shoulder injuries such as overuse, incorrect racket and string tension, and poor form/hitting mechanics. But just as with elbow pain, GIRD and scapular dyskinesis are often times the root of the problem.
This is a problem that we really only see in our high level youth and professional players. In a closed or neutral hitting stance, the majority of power is created from the legs. An open stance limits the legs ability to develop power and instead it is produced through the abdominals via trunk rotation.
With the open hitting stance becoming the norm, we are treating more and more of these injuries. In the past we would usually saw a few rectus abdominus injuries from serves per season. Now, we are seeing a dramatic increase in oblique injuries due to the rotational force with the open stance. Two ways to prevent this injury are to change your stance back to a neutral/closed position and the other is to develop a strong core. If you do experience an abdominal injury, make sure to see a sports medicine specialist as these injuries need to be evaluated and treated appropriately.
There are 3 main injuries to the knee in tennis. The first is an ACL injury, which rarely occurs in tennis due to the mainly linear movement patterns as compared to cutting and pivoting sports such as soccer and football. When an ACL injury does occur, one should see an orthopedic surgeon who specializes in ACL reconstruction to discuss surgical and non-surgical options.
The second and more common knee injury is a meniscal tear. These can be acute in nature in our younger players (under 40) or chronic and degenerative in our older players (over 40). As with ACL injuries, one should see a sports medicine physician to discuss treatment options.
The third and most common knee injury in everyday tennis players is an aggravation to underlying arthritis. This occurs from either overuse or an acute irritation to a pre-existing arthritic condition. The best treatment for these injuries is the old RICE method (rest, ice, elevation, and compression).
Please click on the link to view these exercises. http://www.justinshaginawptatc.com/exercise-programs.html
As with any exercise program, please consult a medical professional if you have any questions or concerns.
There are a few simple exercises that will help keep you in the game. They should be performed 2-4 times a week at the recommended number of sets and repetitions. When in doubt, see an athletic trainer or physical therapist for an individualized program specific to you.
Sleeper stretch: this stretch helps to improve shoulder internal range of motion. Stretches should be pain free. Perform 3-5 repetitions holding for 30 seconds.
No moneys: Will help to improve scapular strength and control. Key is to squeeze your shoulders down and back. Only rotate arms out in a pain free range of motion. Do 2 sets to fatigue.
Timothy Tyler, PT, ATC from the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City has developed an eccentric exercise program for tennis elbow using a rubber bar. His program has been validated by research and has been able to reduce symptoms fairly quickly.
Plank exercises are probably the best and simplest exercises for core strengthening. Key is to contact not only your rectus abdominus (your 6 pack abs) but also your rotators and deep stabilizers (obliques, quadratus lumborum, and multifidus). To do this, suck in your belly button like you are trying to get into a tight pair of pants. Don’t hold your breath. You should feel your abs tight above and below your belly button and more importantly around your sides in your love handle region. Make sure to have good form with the planks (straight as an arrow through your ankles, knees, hips, shoulder and head) and only hold the position as long as you can maintain good form and tightened abs.
Flexibility is important in your thoracic and lumbar spine with extension and rotation being the key factors. Prone press ups or the cobra yoga pose is an excellent way to improve extension. Supine trunk rotation stretches will help maintain and improve rotational range of motion. These should be performed for 3-5 repetitions with 30 second hold. Do not work through pain with stretching.
Flexibility is also key in the lower extremities. Quad, hamstring, and calf stretches should be performed for 3-5 repetitions holding 30 seconds on each side. Once again, stretching should be pain free.
Justin Shaginaw, MPT, ATC is lead therapist and coordinator of sports medicine at Aria 3B Orthopaedic institute.
Tennis elbow can be a debilitating problem for the player and one that is even harder to treat by the sports medicine specialist. New research is showing the benefits of eccentric exercises for chronic tendonopathies such as tennis elbow, runner's/jumper's knee, and achilles tendonitis. These exercises are thought to facilitate tendon healing instead of just treating the symptoms with anti-inflammatory medication. Other treatments such as dynamic myofascial release, augmented soft tissue mobilization, and platelet rich plasma injections (PRP) are showing some promising results as well. What the New York Times article failed to mention is the relationship between kinetic chain dysfunctions and tennis elbow. Often times, tennis elbow is the result of problems somewhere else such as the shoulder or hips. Decreased shoulder flexibility and/or lack of core strength can be cause of elbow pain. It's like driving a car that is out of alignment, the tires wear unevenly until the alignment is corrected. So besides starting the above mentioned eccentric exercise program, make sure to see a sports medicine specialist to assess for any kinetic chain dysfunctions that may be the underlying cause of tennis elbow.