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Ryan Howard's Achilles Saga

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Philadelphia's Ryan Howard hit two homeruns in a Florida exhibition game on June 15, but reportedly only jogged to first base, later doing some base-running drills on another field. These were the most recent steps in the 32-year-old first baseman's long rehab from an October 12, 2011 repair of his left Achilles, and a subsequent surgery (February 27) to address an infection that developed. Predictions that Howard would return to the lineup in late spring, and then before June, have been blown away, and it appears he still has a ways to go.

Anatomy of the Achilles

To understand the process, let's first look at the anatomy and the injury. The Achilles tendon is a fibrous band that attaches the calf muscles (gastrocnemius and soleus) to the calcaneus (heel bone). Both of these muscles act to point the foot downward (ankle plantar flexion). The gastroc, a two-headed muscle that comprises the bulk of the calf, originates above the knee at the posterior (rear) lower end of the femur; its activity is heightened when the knee is extended (straight). The soleus, a much smaller muscle, originates on the tibia of the lower leg, and is the prime mover when the knee is flexed (bent). The calf muscles, also known collectively as the triceps surae, are powerful muscles that propel us as we push off in walking, running and jumping and they enable us to walk on tiptoes.

Conditions that affect the Achilles

The Achilles tendon can become inflamed which is known as tendinitis. More chronic problems arise with damage at the cellular level in the form of microtears that ultimately result in a painful thickening and swelling of the tendon. This is known as tendinosis or tendinopathy. Inflammation of the bursa, a fluid filled sac that cushions the Achilles, separating it from the bone above its attachment, is known as retrocalcaneal bursitis, or Achilles bursitis.

The Achilles tendon is prone to rupture, particularly in males more than 30 years of age.

Incidence of rupture rises along with age in an active population. Predisposition to Achilles rupture is heightened with a history of cortisone injections to the area, weakness/atrophy of the soleus muscle, or with use of prescription medications known as flouroquinolones, (one of which, the drug Levaquin is often prescribed for conditions such as urinary tract infections). Certain systemic conditions, such as gout can also be a factor. Oftentimes, a rupture of the Achilles is preceded by mild symptoms.

Avoid this exercise!

A crucial point of note, and one about which even many physical therapists are unaware, is that even certain exercises can predispose to Achilles rupture. Slowly lowering the heels from a tiptoe position while standing is a wonderful exercise. This type of contraction, during which the calf and Achilles go from a shortened to a lengthened position, is known as an eccentric contraction. Eccentric calf strengthening is extremely beneficial EXCEPT when the heels are lowered below the plane of the toes. Eccentric strengthening into this position (one in which the foot is dorsi-flexed - toes toward the knee) puts the Achilles on stretch with the knee extended. Doing so repeatedly, and while weight-bearing, is a common cause of rupture. If you have been advised to perform this type of loading of the calf muscles, seek guidance elsewhere.

Howard's road back

Recovery even in the best of circumstances is a process. Studies have shown that return to function after non-operative care is almost the same as after surgery. However, there is greater incidence of infection in the post-op population. In both cases treatment begins with a period of immobilization with the tendon in a shortened position (the foot pointed downward), in order for the tendon to heal. This is followed by restoration of soft tissue mobility and mobility at the ankle and foot, as well as calf flexibility and strengthening, Power and agility are addressed in the later stages of rehab prior to a return to competitive play. Any weakness or ongoing symptoms are clear signs that an athlete is not ready. For Ryan Howard, this has taken longer than the Phillies expected.

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