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.

Isaiah Thomas, Labral Tearing, and Femoroacetabular Impingement

The Celtics issued the following statement related to the hip injury during the 2016 playoffs: “Isaiah Thomas will miss the remainder of this year's postseason following re-aggravation of a right femoral-acetabular impingement with labral tear during Game 2 of the Eastern Conference Finals against Cleveland. Thomas initially injured the hip during the third quarter of the Celtics' March 15 game against Minnesota, forcing him to miss the next two regular season contests. The injury was further aggravated during Game 6 of the Eastern Conference Semifinals at Washington on May 12." In this case, the diagnosis appears clear in terms of the injury. Femoral acetabular impingement (FAI) is an abnormal alignment of bone either on the acetabular (cup side of the joint) and/or on the femoral side (ball side of the joint) that causes abnormal mechanics of the joint, particularly in positions of extremes of motion (most often flexion). FAI is correlated with hip injury, although there is not a direct cause and effect association. In other words, patients with femoral acetabular impingement (FAI) do not necessarily develop tears or need treatment for the impingement.Femoral acetabular impingement alone is not a reason for surgical treatment, although in the setting of hip injuries and labral tears, surgical treatment may be appropriate. In those cases in which surgical treatment of the labral tear is performed, the femoral acetabular impingement is treated at the same time, with the goal of removing any abnormal shear forces on the repaired joint and thereby prevent further future injury. Labral tears can be present in patients who have no symptoms. This has been shown in several studies, including studies performed in the NHL, in which players who had no symptoms were noted to have labral tears on MRI. Especially in patients who have a very recent onset of symptoms (< 3 months), a trial of nonoperative treatment in the setting of labral tears is a reasonable option. However, labral tears generally are not thought to repair themselves and subsequent imaging will oftentimes continue to show tears. For these reasons, in patients who have persistent symptoms with labral tears and femoral acetabular impingement, it is reasonable to consider surgical treatment. When considering surgery, factors that should be evaluated are the extent of symptoms, the condition of the joint in terms of potential articular cartilage injury, and whether improvement is ongoing. As the duration of symptoms becomes longer, the likelihood of pain resolving and function improving becomes even lower. The decision for surgical treatment is complex and many patient specific factors should be taken into account. Hip arthroscopy is a treatment for hip preservation, and the condition of the joint is very important in terms of predicting success. I like to use the analogy of a “broken car”. When taking a car to the mechanic, the likelihood of getting a 1990 car to run well and function well into the future is lower than fixing a 2016 car with minor damage. Similarly, the extent of injury to the labrum and articular cartilage is an important factor in predicting success. MRI scanning, x-rays, physical examination, and previous surgeries are all important factors to determine the extent of the problem and all may help to predict success.

A Focus on Injury in Sport

The reason for creating this blog is because of the interest that I’ve noted from patients, friends and family who ask me about injured players. Most frequently, the interest is related to how it compares to their problem, or because they are big fans of a particular team , or they want to know more about the status of a fantasy football player. I’ve been practicing for over 10 years, specifically in the areas of hip preservation and foot and ankle surgery and sports related injuries of the hip, foot and ankle. This blog will only cover injuries related to my areas of expertise. My experience comes from the treatment of players at all levels from high school to collegiate to professional in a variety of different sports. An important disclosure related to this blog is that the information that is made public, that is found in newspapers and on the Internet, may not be correct or may be incomplete. I have no firsthand knowledge of these players and their injuries and my discussion is based on public information. When I treat professional players myself, their privacy is essential and required. My personal care of any athlete would never be made public in a blog such as this.

Posterior Impingement of the Ankle

Patients with posterior impingement of the ankle oftentimes complain of pain in the posterior, or back of, the ankle. There may be an associated snap or catching sensation along with it, which may be caused by the tendon which lies next to this area, called the FHL (Flexor Hallucis Longus). Along with physical examination and plain x-rays, an MRI may be useful in making the diagnosis. The nonoperative treatment typically consists of NSAIDS, injections, and rest. If these fail, an endoscopic surgical technique may be used to remove the excess bone (Os trigonum or trigonal process) with release of the FHL (Flexor Hallucis Longus) tendon. This endoscopic technique is a minimally invasive technique that has the potential advantages of less bleeding, faster recovery, less scarring, and less pain.

Internal Snap of the Psoas (Iliopsoas) Tendon

The treatment for internal snapping of the hip may consist of a psoas tendon release in those patients who have failed nonoperative treatments and who have persistent pain. Nonoperative treatment for an internal snap typically consists of injections and avoidance of repetitive snapping if possible. Patients typically complain of a snap or click in the hip and on physical examination the snap can often be reproduced. Oftentimes there are other associated abnormalities in the hip that may be causing pain and that may need to be addressed. If there is no pain associated with the snap, typically no additional treatments are necessary. I have recently added a video to my website through youtube that demonstrates the arthroscopic surgical technique. Once the joint has been accessed arthroscopically, the procedure typically takes about 5 minutes to complete.

Types of treatment of hip labral (labrum) tears

There are 4 main treatment options for the treatment of labral tears. The best way to treat specific patterns of damage has not been fully clarified in publications on hip arthroscopy, but here I present some guidelines:
1. Debridement: This has been historically the main treatment for labral injury. This treatment is performed via hip arthroscopy and essentially consists of removing the damaged tissue with a shaver and/or with an electrocautery device. I perform this technique rarely, as preservation of this tissue when possible is beneficial.
2. Repair: This treatment also is performed via hip arthroscopy and consists of placing suture anchors in the bone and reattaching the labral tissue after it has been prepared. There is increasing evidence that this technique of repair is superior to debridement when possible.
3. Reconstruction: Also performed via hip arthroscopy, this technique may be performed when the labral tissue is too damaged or too small to be repaired. The technique consists of replacing the labrum with new tissue, and may be performed with autograft or allograft tissue.
4. Joint replacement: When the labral damage is associated with significant hip arthritis, the best treatment option is a hip replacement.

All arthroscopic allograft reconstruction of hip labral tear and deficiency

A young active patient who had previously undergone hip arthroscopy and labral debridement was reconstructed with allograft tissue. This was featured in a Channel 10 news story