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Injuries can be scary, so let's talk about them and understand them.
Back in June during the United States Olympic trials for artistic gymnastics, gymnast Emily Lee had a bad landing on floor, resulting in an injury. In Part 1 we're talking about the injury itself, the how, why, and what now. In Part 2 we talk about the role of the athletic therapist or athletic trainer in management of this injury from when it happened on floor up into return to sport.
Check out Part 1 here. If videos/auditory processing isn't your thing, scroll down for a written version.
What Happened?
During a tumbling pass, Emily ruptured her Achilles tendon on the take off
/punch of her last tumbling component.
So while it looked like she hurt herself on the landing, the Achilles rupture actually happened before that, and resulted in a decreased power output and therefore under rotation in her twist, making her land the way she did. Thankfully, Emily is an extremely talented gymnast and was able to still spot her landing and keep her head and neck safe.
What is an Achilles Tendon Rupture?
Tendons are the connective tissue that attach muscle to bone. The Achilles Tendon comes from our two superficial muscles of the calf, the gastrocnemius and the soleus, and attaches into the base of the heal.
These muscles function to plantarflex the ankle, i.e. the motion that we do when pointing the toe or doing a calf raise. This means that they are also working super hard when we are jumping, and we push off the feet and toes to propel the body up.
A rupture refers to a complete disruption of the tendon fibres. Moreso than just a strain, where there may just be stretching or partial separation of the tendon fibres, no aspect of the tendon remains continuous with a rupture.
There may also be complete separation of the nerve with this injury. In Emily's case, many people were saying that it was weird (and impressive!) how easily she was able to get up and walk to the side of the floor after falling. Often with this injury, and especially when there is complete separation of the nerve, there will be a quick snap or popping sensation and sharp pain at the moment of injury, but that dissipates quickly as the nerve can no longer transmit pain signals, and pain levels are relatively low compared to the severity of the injury. This is potentially what happened to Emily.
How do Tendon Ruptures Happen?
There are two main mechanisms of injury that we see with tendon ruptures:
Deceleration, i.e. slowing down; when we slow down a movement, whether we are running, landing, throwing, etc., we are asking the working muscle to stay contracted and stay working while still lengthening. This is harder for the muscle than contracting while coming into a shortened position and places more force through the tendon. Think about how your bicep is working during the curling portion of a bicep curl, compared to how it works while you lower that weight down slowly back to a straight arm position. The biceps still controls that downward motion/extension of the arm even though it is lengthening.
Explosive contraction; this refers to a fast and powerful concentric contraction (i.e. shortening, think about the curl portion of your bicep curl). While the muscle belly shortens very quickly, this can pull too hard on the tendon and result in a rupture.
In Emily's injury, as it happened on the take off of her tumbling component, it is more likely that her injury occurred via the second mechanism, the explosive contraction .
What are the risk factors for tendon rupture?
History of ankle injury; a history of injury to any aspect of the ankle, not just the Achilles tendon, increases risk for injury to Achilles tendon. This is significant as the ankle is the most commonly injured body part in women's artistic gymnastics. It is therefore more likely than not that Emily has had a previous ankle injury.
history of tendonitis or tendinosis; tendonitis (inflammation of the tendon) and tendinosis (degeneration of the tendon) decreases the integrity of the tendon fibres and increases risk for total rupture
use of certain antibiotics; antiobiotics, specifically flouroquinolones, that are used to treat certain bacterial infections have been shown to increase risk of Achilles tendon rupture in those who are using or have used them recently. This is a well known phenomenon and we can assume that a doctor prescribing these to a high level athlete would inform them of the risks and modify either training or treatment accordingly
muscle tension; a tighter muscle is going to put more tension on the tendon, increasing the risk of a tear or rupture. This is an important one to consider as we look at some causes of muscle tension and the context of the competition.
Nerves/anxiety; when we are nervous or anxious, we tend to hold more tension in our muscles. It may be a fair assumption that Emily was experiencing some nerves or anxiety that evening due to the scale and implications of the competition
Nutrition/hydration status; our muscles will be tighter and hold more tension if we are dehydrated, or if we are lacking certain nutrients. In the context of a big competition, it is easy for an athlete to forget to eat or drink enough, especially during the competition. Anxiety and nerves can also contribute to an athlete have GI distress, such as a stomach ache, or diarrhea. This can lead them to ignore or to misread their bodies' hunger or thirst cues, leading to dehydration or a lack of fuel.
Recent Injury; when we get hurt, even minor injuries, our surrounding muscles will tense up as a means of "guarding" i.e. trying to restrict movement about the injured area to decrease risk of further injury. In Emily's case this is super relevant, as she actually hit both her calves against the uneven bars in the previous evening's competition. While she was able to still catch the bar (in an amazing feat of gymnastics wizardry) and finish her routine, there was likely to be some bruising or minor injury there. Even with a minor injury, we can still see that increased tension due to muscle guarding.
What is Rehab Going to Look Like?
Especially for high level athletes who want to get back to their previous level of performance, surgery is necessary is to reattach the two ends of the tendon. Please keep in mind that this a general timeline, and individual surgeon protocols will vary.
After surgery, the athlete will be in an immobilizing boot with a heel lift, to keep the tendon in a shortened position and promote healing. Initially, the athlete will not be allowed to place any weight on the healing leg.
Over 2-3 months, paired with appropriately rehabilitation, there will be a slow transition to partial and then full weight bearing in the boot, as well as a thinning and eventual removal of the heel lift.
To regain range of motion and strength, in the first 8 weeks after surgery, only passive range of motion is allowed at the ankle, meaning that you or someone else manually moves the ankle around, rather than using and activating the muscles around the ankle joint. Exercises like toe scrunching and splaying, as well as basic strengthening exercises of the core, hip and knee are done to maintain blood flow and mitigate strength loss in the effected limb.
After 2 months, active range of motion and strengthening exercise can start, starting with therabands and or tubing and progressing to body weight movements and eventually plyometric exercise over the next 8 weeks. We'll also start working on regaining balance and proprioception (sense of ourselves/ our limb in space) using various exercises with single leg activity, wobble boards, bosu balls, etc. It is important to take this part of rehab slowly so as to not increase risk of reinjury.
Generally, we do not see a full return to pre-injury strength and skill levels, and return to sport until 9-12 months post surgery.
Thank you for reading! Any questions? Leave a comment below.
Stay tuned for Part 2, where we'll talk about the role of the athletic trainer or athletic therapist in this injury, from the time it happens, up into return to sport.
Wishing Emily a speedy and easy recovery <3