Monday, December 11, 2017

Tom Brady and Achilles Tendinitis

Tom Brady sat out of practice Nov 29, 2017 with achilles pain and missed a single practice the week prior (Nov 22) for the same injury. Achilles tendinitis is a problem that is more frequently seen in older athletes given the underlying nature of the problem. As we age, particularly in patients who have used their Achilles more (such as the athlete or overweight patient), the Achilles tendon degenerates. The Achilles is similar to a rope and its function is to connect the heel bone to the calf muscles, such that when the calf muscles fire, the ankle plantar flexes, or points down, thereby propelling the body forward and lifting the heel off the ground. Similar to a rope that you would see at a marina docking a boat, the "rope-like" achilles develops features of wear and tear over time such as fraying and damage to the substance itself. As the tendon degenerates, it typically swells and loses its normal tendon fiber orientation. This results in pain and limited function. We typically do not see tendinitis of the Achilles in younger patients because there is no underlying wear and tear contributing to the problem. In my practice, Achilles pain is seen in a teenager maybe once per year. In patients in their 20s, I see approximately 5 patients per year, in patients in their 30s approximately 20 patients per year, and in patients in their 40s or greater, 300 patients per year. In the setting of disc degeneration, the likelihood of having a tear, either partial or complete, is also higher. Pain prior to an Achilles rupture is known as a "prodromal" symptom. See Richard Sherman. He was dealing with tendinitis in Achilles all season before rupturing it in early November of this year. Achilles tendinitis without rupture or acute tearing is treated in the following ways: 1. NSAIDs (e.g. naproxen or ibuprofen or Celebrex): Dr. Carreira recommends short courses of these non-steroidal anti-inflammatories. This medication should be checked with your primary care physician to make sure that it is safe for you. 2. Activity modification: If it is painful to do a certain activity, try to limit this activity until the pain has improved and then resume gradually. 3. Heel lift: A silicone heel gel inserted into the shoe will lift the heel slightly and offload the tendon. Wearing a shoe with a slight heel will also have the same effect (e.g. a clog). I don’t think we’ll see Brady doing this one! For the insertional type of Achilles injury, a shoe without a heel counter (open back shoe) will decrease pressure on this painful area. 4. Physical Therapy: Minimal stretching is recommendable and a program of heavy load eccentric strengthening may be initiated. 5. Immobilization in a CAM walker: If these initial treatments have failed, immobilization in this boot is recommendable. 6. Surgery: If all else fails, surgery may be performed endoscopically (through small portal incisions) or open. The type of surgery depends on the location within the tendon, the extent of tendon injury, and any associated abnormalities. Shock wave therapy is not covered by insurance in the US but has some evidence of success. Platelet rich plasma is also not covered by insurance and has limited and mixed evidence for and against its efficacy.

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