Terrell Suggs of the Baltimore Ravens reportedly ruptured his Achilles tenon on Saturday.  Will he return this season?

Anatomy

The Achilles tendon is the longest tendon in the human body.  It is made up of two muscles: the gastrocnemius muscle and the soleus muscle.  The muscular unit of the tendon attaches from the back of the knee to the heel bone.  About 2/3 of the way down the leg, the muscle bellys transition to the Achilles tendon.  The Achilles tendon is prone to injury in the area known as the watershed area.  This area goes from 2-6 centimeters up from the attachment site of the Achilles tendon to the heel bone. In the watershed area, the blood supply to the tendon is poor.  This is an area where the tendon has a poor ability to heal itself.  Most Achilles tendon tears occur in this area. 

The Achilles tendon functions to bring the ankle downward, similar to the motion of press on the gas pedal.  With jumping activities, the Achilles tendon sees forces 8 times that of one's body weight.  With sprinting activities, that force increases to 12 times that of one's body weight.

CAUSES

Achilles tendon tears or ruptures are commonly seen in weekend warriors and those who participate in sports with a lot of push-off actions.  Some patients who have been on an antibiotic from the fluoroquinolone family may be at risk of tearing the Achilles tendon.

SYMPTOMS

Patients will report a sudden pop in the back of the ankle and a rush of blood. Some will say they feel like someone has kicked them in the back of the ankle.  They will notice a loss of strength in the foot when trying to stand on the ball of the feet.  Pain, swelling, and bruising are common.  When carefully touching the Achilles tendon in the watershed area, a gap may be felt in the tendon. Achilles tendon tears can not be seen on xray.  Very rarely is an MRI or ultrasound needed to make the diagnosis.  The diagnosis is usually made with physical exam findings alone.

WHEN TO SEEK MEDICAL CARE

If you are concerned about an Achilles tendon tear, you should see a medical professional within hours or days of the injury.

TREATMENT

Treatment options range from non-surgical options to surgical options using a variety of techniques.

Non-surgical options are reserved for those patients who are against surgery, are elderly, are medically too sick to withstand surgery, or are not active. The treatment involves a short leg, non-weightbearing cast for 8 to 10 weeks, followed by extensive physical therapy.

Surgical options are recommended in the athletes and active population.  There are three techniques that are used:

1. The traditional open technique where an 8 to 10 centimeter incision is made on the back of the ankle.  The tear is cleaned out and the tendon ends are sutured together.  The number one complication of this approach is  wound healing issues. You can see a video of this technique at: http://www.youtube.com/watch?v=uzzV5BRWlIc

2. A percutaneous technique where needles are placed through the skin and Achilles tendon.  The tendon ends are never seen, so it is difficult to be sure that they are toughing when the tendon ends are sutured together.

3. A mini-open technique using a 2 to 3 centimeter incision on the back of the Achilles. In this technique, the tendon ends are seen and cleaned.  A small device is used to place the sutures in the tendon.  The tendon ends are then brought together. You can see a video of this technique at: http://www.youtube.com/watch?v=QgSeD8lyQaM

OUTCOMES

Nonsurgical patients have an 18-20% chance of re-tearing the Achilles and lose some push-off power.  This is a concern for elite athletes.  Surgically treated patients have approximately a 2% chance of re-tearing the tendon and have a more normal push off in the injured ankle.  

RETURN TO ACTIVITIES

We conducted a study on NFL players who had an Achilles tendon tear.  In general, only about 66% of players were able to return to the NFL and took about 11 months to do so.  Furthermore, when they returned to the NFL, their performance was severely affected. To read this paper, see:  http://www.lowerextremityreview.com/index.php/article/return-to-football-after-achilles-tendon-rupture

It is unlikely for Suggs to make it back this coming season. 

VIDEO/ANIMATIONS

To watch a live surgical video of an open Achilles repair, go to:

http://www.youtube.com/watch?v=24jAAZ2s-04&feature=plcp

To watch a live surgical video of a mini open repair, go to:

http://www.youtube.com/watch?v=rD3aI_7EneA&feature=plcp

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Patriot's tight end, Rob Gronkowski, suffered from a high ankle sprain.  How effective will he be in the Super Bowl?  

Ankle sprains are very common injuries.  In the US alone, approximately 25,000 ankle sprains occur every day.  Not all of these individuals seek medical care.  Most walk it off and resume life with little or no consequences.  The question is when should you be concerned that you have a serious ankle sprain or something worse and see a doctor.   I will get to this question later in the blog.

ANATOMY

Most people sprain their ankle with an inversion type injury.  This is where the foot rolls in and the ankle rolls out.  This stretches and may tear the ligaments on the outer part of the ankle.  Outer ligaments of the ankle are always injured in the common ankle sprain.

However, in severe cases, the ligaments on the inner part of the ankle (medial ankle sprain) or between the ankle bones (high ankle sprain) can be injured.  The medial sprain will be a topic for future blogs.

A high ankle sprain occurs when the ankle rolls out to the point where the ligaments between the fibula (outer leg bone) and the tibia (inner leg bone) tear.  This ligament structure is known as the syndesmosis.   This can be a stable or unstable injury.  If the ligament is stretched or strained, the ankle is usually stable and does not require surgery.  If the ligament is fully torn, the ankle is unstable.  This injury pattern requires surgery.

Below is an xray of an individual with an unstable syndesmosis tear.

SYMPTOMS

When an individual has a high ankle sprain, walking and jumping on the injured ankle is difficult.  One may experience pain, swelling, bruising, weakness and even a black and blue mark.  Usually people have some level of pain with motion of the ankle.  Rest, ice, elevation, an ace wrap and antiinflammatories can help relieve some of these symptoms.  But if you suspect a high ankle sprain, you should see a physician sooner than later.

TREATMENTS

Initially, after a high ankle sprain, rest, ice, elevation, an ace wrap and antiinflammatories can help relieve some of these symptoms.  If xrays suggest a stable high ankle sprain, the patient is placed in a boot or short leg cast.  The individual is nonweightbearing (not allowed to placed any weight on the injured ankle) for 4 to 6 weeks.

If the syndesmosis is torn, surgery is needed.  In the operation, the tibia and fibula are put back in their proper position and held in place with screws or a device called a tightrope (see xrays).  These patients are not allowed to put weight on the ankle for 3 months.  

In either injury pattern, physical therapy is necessary to help regain range of motion and strength of the ankle.  Physical therapy has been shown in the medical literature to be very beneficial in preventing what is known as “chronic ankle pain”.  Some physicians may want you to use an ankle brace for a short period of time, while others may not want you to use one at all.  Rarely is surgery needed.

OUTCOMES

Most individuals with high ankle sprains are able to return to their lifestyles and activities after 6 to 8 weeks and a lot of therapy.  Being the Super Bowl, Gronkowski will play.  The question is how effective will be.  Just as Ben Roethlisberger's level of play decreased with this injury, it is likely that Gronkowski's will suffer as well.  Cutting, pushing off defenders, and blocking will all be problematic for him.  

VIDEO/ANIMATIONS

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.

Cowboys DeMarco Murray was hurt in tonights game against the Giants.  He has an ankle fracture and a high ankle sprain.  He was immediately taken out of the game.  What does this mean for his season?   

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

Any of these structures can be injured in an ankle fracture/break.  Typically, the fibula is fractured.  At the same time, the tibia can be broken and/or the syndesmosis can be torn. 

CAUSES

The ankle can break with any type of trauma that causes excessive energy to go through the ankle.  The energy can break 1, 2, or more bones.  Typically, the ankle breaks with a twisting mechanism, when the ankle "rolls", or if one trips and falls.  Occasionally, a direct blow to the ankle or the heel can break the ankle.

SYMPTOMS

A person who breaks their ankle usually experiences immediate pain and swelling.  A pop or crack may be heard or felt.  The ankle will get black and blue.  Often times, the person will not be able to walk on the broken ankle.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an ankle fracture, you should seek medical attention within hours of the injury. A thorough physical exam and xrays will be needed to find out if you have an ankle fracture and the type of fracture you may have.

TREATMENT

Treatment varies depending on the severity of the ankle fracture.  If the fibula has broken, but has not shifted, a non-weight bearing cast may be worn for 8-10 weeks.  If the fibula is fractured and shifted out of place or the tibia is fractured or the syndesmosis is torn, then surgery may be necessary.  In the operating room, an orthopaedic surgeon will usually place a plate and screws in the fibula, screws or a plate in the medial malleolus part of the tibia, and/or screws or a similar device across the syndesmosis.  This allows for the broken bones and ligament to be held in place while the bones and/or ligament heals.  If the syndesmosis is torn, the patient is not allowed to put weight on the foot and ankle for 3 months.  If the syndesmosis is not torn, then the patient is not allowed to put weight on the foot and ankle for approximately 6-10 weeks.  

Below are representations of a type of ankle fracture where the fibula and the syndesmosis were torn and needed to be repaired.

OUTCOMES

Most patients with ankle fractures are able to return to their pre-injury activities with little or no difficulties.  However, there are some long-term implications of this injury.  First, about 30% of the time a "pot-hole" can develop in the ankle at the time of the injury.  This can lead to long-term pain.  Second, the cartilage is damaged at the time of injury.  This causes the development of post-traumatic arthritis in the ankle at a faster rate than an ankle that has never been broken.  Third, many patients will have stiffness and loss of motion following the injury.  Finally, extensive physical therapy is required to regain as much motion and strength in the ankle.

RETURN TO ACTIVITIES

Depending on the type of ankle fracture that Murray has, he will be out of football for at least 8 weeks.  If his syndesmosis is also torn, he will be out for 12 weeks.

VIDEO/ANIMATIONS

Dr. P

 ----------------------------------------------------------------------------------------------All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Boston Red Sox designated hitter David Ortiz has been seen walking in a boot.  He is out of the line-up, being diagnosed with Achilles bursitis.  Most have heard about Achilles tendonitis, but what is the story of Achilles bursitis.

ANATOMY

The Achilles tendon is the longest, strongest, and largest tendon of the human body.  It runs from the back of the knee to the back of the heel bone.  It inserts into the heel bone (also known as the calcaneus).  The insertion is over an area estimated to be roughly 2cm x 3cm.  Between the Achilles tendon and the heel bone is a fluid filled sac known as the retrocalcaneal bursa.  This sac serves the purpose of cushioning the tendon against the bone and minimizing the irritation to the tendon and. providing some sensation feedback to the foot and ankle region.

CAUSES

A retrocalcaneal bursa can become inflamed for a number of reasons.  A tight Achilles tendon can rub on the bone and lead to inflammation of the bursa.  A bump in the back of the heel bone, known as a Halgund’s deformity or “pump bump” can irritate the bursa and the tendon and lead to bursitis as well.  If the tendonitis and bursitis have been present for a long period of time, the inner part of the Achilles tendon can degenerate and lead to “tendinosis.”  Furthermore, irritation of the tendon for a long period of time can cause calcium to be deposited into the tendon.

This entity is usually seen in females, over the age of 40, and obese.  However, it can be seen in any individual.

SYMPTOMS

Individuals usually experience pain in the back part of the heel.  Swelling may be present.  A bump in the Achilles insertion site may also be present.  The pain is usually worsened with shoes with a back on it, activities that require the ankle to be flexed upwards (such as when you walk up a hill), or movement of the ankle in any plane of motion.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an Achilles bursitis, you should seek medical attention within 1-2 weeks, particularly if the pain worsens or does not improve. A physical exam and x-rays will be initially used to assess your condition.  At times, and MRI may also be needed to look for any Achilles tendon involvement.

TREATMENT

Treatment is initially managed with non-surgical options.  These include the short term use of heel lifts, boots, anti-inflammatories (pills or topical creams), physical therapy to stretch the Achilles, night splints used to hold the Achilles stretched out at night.  Ultrasound, shock wave therapy, platelet rich protein, and laser therapy have had mixed results in the medical literature.  Steroid injections should be used with caution, as the steroid can  lead to the Achilles being torn.

If nonsurgical treatments fail for 3 to 6 months, surgical options are explored.  These include shaving the Haglund’s deformity, cleaning the Achilles tendon (if there is degeneration of the tendon), and tendon transfers (if the Achilles tendon is severely involved).  Depending on the severity of the condition, these surgeries can be performed endoscopically with two small incisions and a camera and tools, or with open surgery.

OUTCOMES

Most patients  with a retrocalcaneal bursitis do well with conservative care.  Those who require surgery will recover for up to 1 year and require a lot of physical therapy.

RETURN TO ACTIVITIES

Depending on the severity of the bursitis, Ortiz may be out of play for 1-4 weeks.

VIDEO/ANIMATIONS

A live surgical video can be seen at: 

PART 1: http://www.youtube.com/NCOCatDuke#p/u/13/S_1ur94eXTk

PART 2: http://www.youtube.com/NCOCatDuke#p/u/5/1quCnfbf6Po

 Animated video can be seen below:

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Stephen Drew of the Arizona Diamondbacks underwent ankle fracture surgery yesterday.  He had a plate placed.  What happens in this surgery?

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

Any of these structures can be injured in an ankle fracture/break.  Typically, the fibula is fractured.  At the same time, the tibia can be broken and/or the syndesmosis can be torn. 

CAUSES

The ankle can break with any type of trauma that causes excessive energy to go through the ankle.  The energy can break 1, 2, or more bones.  Typically, the ankle breaks with a twisting mechanism, when the ankle "rolls", or if one trips and falls.  Occasionally, a direct blow to the ankle or the heel can break the ankle.

SYMPTOMS

A person who breaks their ankle usually experiences immediate pain and swelling.  A pop or crack may be heard or felt.  The ankle will get black and blue.  Often times, the person will not be able to walk on the broken ankle.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an ankle fracture, you should seek medical attention within hours of the injury. A thorough physical exam and xrays will be needed to find out if you have an ankle fracture and the type of fracture you may have.

TREATMENT

Treatment varies depending on the severity of the ankle fracture.  If the fibula has broken, but has not shifted, a non-weight bearing cast may be worn for 8-10 weeks.  If the fibula is fractured and shifted out of place or the tibia is fractured or the syndesmosis is torn, then surgery may be necessary.  In the operating room, an orthopaedic surgeon will usually place a plate and screws in the fibula, screws or a plate in the medial malleolus part of the tibia, and/or screws or a similar device across the syndesmosis.  This allows for the broken bones and ligament to be held in place while the bones and/or ligament heals.  If the syndesmosis is torn, the patient is not allowed to put weight on the foot and ankle for 3 months.  If the syndesmosis is not torn, then the patient is not allowed to put weight on the foot and ankle for approximately 6-10 weeks.  

Below are representations of a type of ankle fracture where the fibula and the syndesmosis were torn and needed to be repaired.

OUTCOMES

Most patients with ankle fractures are able to return to their pre-injury activities with little or no difficulties.  However, there are some long-term implications of this injury.  First, about 30% of the time a "pot-hole" can develop in the ankle at the time of the injury.  This can lead to long-term pain.  Second, the cartilage is damaged at the time of injury.  This causes the development of post-traumatic arthritis in the ankle at a faster rate than an ankle that has never been broken.  Third, many patients will have stiffness and loss of motion following the injury.  Finally, extensive physical therapy is required to regain as much motion and strength in the ankle.

RETURN TO ACTIVITIES

Depending on the type of ankle fracture that Drew has, he will be out of baseball for at least 8 weeks.  If his syndesmosis is also torn, he will be out for 12 weeks. He will need significant rehabilitation before he gets back onto the field.

VIDEO/ANIMATIONS

Dr. P

---------------------------------------------------------------------------------

All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics