Michael Crabtree, San Francisco 49ers, sustained an injury to his ankle. More precisely, he had a complete rupture of his Achilles tendon, necessitating surgical repair.”
To understand the above, one should understand Achilles tendon first. This is the area at the back of the calf where an active individual may suffer pain, in more severe cases rupture or tear of the Achilles tendon.
Anatomy of the Calf Muscles
Calf is a junction of two powerful muscles, namely gastrocnemius and soleus. The two thick and large triceps muscles of the calf unite at heel bone or calcaneus to form calcaneal tendon or Achilles tendon. It is strong and fibrous band like structure. When one performs jumping, sprinting, walking, calf muscles contract causing Achilles tendon to pull which in turn pulls the forefoot down and help us balance our body weight on toes. This movement is called plantarflexion. To keep a person in motion this movement plays a vital role. This whole process is powered by gastroc-soleus muscle group.
Though this type of injury is very common in an avid runner or athlete, but mostly this happens when a perfectly healthy tendon is exposed to a sudden unexpected force.
To shed more light on this injury, Dr. Nicholas Abidi states – “Crabtree’s activity level and demands are very large. In general individuals, who experience this, sometimes have predisposing issues such as altered running style, tight hamstrings or calve muscles which put the tendon at risk for rupture. Watershed distribution (less blood supply) is the typical site for the tendon tears, which as a result does not have a chance to heal when overused. Testosterone is responsible for making tendons brittle which is why males are at least three times more prone to Achilles tears as compared to females. Estrogen is protective. The patients who typically rupture the Achilles primarily are athletes in their 30’s. Based on patient’s age; old or young, we look for underlying health or mechanical issues.”
The physical examination is essential to perfectly diagnose Achilles tendon rupture. Often the defect is of 2-5 cm from Achilles before it inserts into the heel bone. Thompson test is the key for the diagnosis. This involves placing the patient prone and squeezing the calf muscle. Plantarflexion will occur if the Achilles is intact. If Achilles got ruptured, the foot would not move. In such cases, the patients can move their foot up and down because there is no harm to the other surrounding muscles and tendons. Sensation and circulation to the foot and ankle would be a normal finding in such instances.
Treatment may vary from patient to patient, but primarily in Crabtree’s case Achilles tendon repair is the only treatment per Dr. Abidi.
“In general, initial treatment depends upon underlying anatomy of the patient and predisposing factors such as excessive high arch, low arch, and ankle instability. In addition, strenuous athletic activity may create this scenario with explosive muscles and chronic thickening and intrinsic ruptures of the tendon. It can first start to deteriorate and stretch like salt water taffy, then suddenly gives out under load. NSAIDS, gentle stretching, and rest are the initial treatment for chronic Achilles tendinopathy in order to avoid rupture – Dr. Abidi.”
In less pressing cases, non-operative method for non-athletes is used. Ultrasound imaging can determine if the edges are close enough together in order to treat a patient non-operatively. The incidence of weakness and re-rupture with non-op treatment is higher than operative treatment. MRI is rarely indicated for diagnosis.
Treating this surgically, there are numerous methods to repair the tendon. Most commonly, Achilles tendon is exposed through an incision at the back of the ankle. After identifying both ends of ruptured tendon, the edges got trimmed and then both ends were sutured together with optimal tension. To get a better outcome with fixation, an anchor may have to be in place in calcaneus, provided the rupture is very low. Care must be taken to avoid injuries to the nerves located adjacent to the tendon.
Per Dr. Abidi when patients are above age 50, the flexor longus hallucis tendon is used for augmentation of operative repair due to the condition of the tendon in these patients.
Recommendations for course to follow postop period in above mentioned injury case are for 2 weeks of non-weightbearing, then starts PT at 2 weeks, use an Achilles boot for 2-4 weeks with wedges, removing one wedge per week out of three wedges. The patient should start non-impact exercise at 6 weeks in general depending upon the condition and finally start impact exercise 12-16 weeks post‑op.
At the conclusion, Dr. Abidi states, “although we know more about this, it is still a bad injury. Prevention through stretching, good shoes, and conditioning are key. Hydration helps as well.”