March 14th David Beckham completely tore his left Achilles tendon while playing for AC Milan in an Italian Series A game. With that injury went Beckham's opportunity to represent England for the 4th time in the World Cup. While he won't be suiting up in South Africa this June once his Achilles is fully recovered, he is expected to see action back on the pitch later this year with his Major League Soccer club the L.A. Galaxy.
Beckham had his Achilles surgically repaired by Dr. Sakari Orava in Finland the following day. “He will have to take it very easy during the next two to three weeks or a month, and then he will continue with a recuperation program slowly,” Orava told The Associated Press. “The foot won't take much strain for two to three months.” Orava also said it would be “four months to running,” and another two months before playing. Beckham's spokesman, Simon Oliveira, said the tendon was completely repaired, and he expected Beckham to return to the game. “David is expected to make a full recovery”.
An AC Milan press release - the club that Beckham is on loan until June with - spoke about his recovery very optimistically: "For the first two weeks, the footballer must not put pressure on the injured limb and then he will do so progressively and partially for six weeks before doing specific therapy in the swimming pool." The plan foresees a complete recovery in six months, after which he will be able to play again." Here is a link to a BBC story with Dr. Orava speaking on video about treating Beckham how long he expects recovery to take.
We turned to the physiotherapist for the Vancouver Whitecap’s Men’s team Graeme Poole - he himself recently experienced an Achilles tear - for the overview on Achilles injuries, including their causes, treatment and the recovery process:
To be honest with you I haven't spent a lot of time or energy on the "Why did it happen?" question. Although there are a number of variables that may have contributed: prior Achilles tendonopaty, calf flexibility, ankle ROM, fitness, proper warm-up, none of them played a large role in my Achilles rupture, and I doubt they did in David Beckham's either. He was surely well warmed-up at that time in the game, and I don't think fitness was an issue!. In fact, most Achilles ruptures happen in activities that people have done thousands of times before. Unfortunately for me and Becks, the statistics aren't that good once you have ruptured, some studies show re-rupture rates as high as 15%, with a bias towards those who rupture at a younger age.
Once you have ruptured your Achilles the process is actually quite seamless. Going to the ER is the first step, because having your tendon surgically repaired in the first 48 hours is quite important in having a full recovery. If you wait too long too much scar tissue will be laid down, and the tendon will lose some extensibility. Most of the time it is quite clear that you have injured the tendon. A simple physical test named the Thompson test will reveal a torn tendon. This is why you are able to get in to surgery so quickly, there is no need for an MRI to confirm a tear, unlike an ACL injury. There is also a non-operative option, but the recovery is usually a bit longer, and the rates of re-rupture 5-10% higher. For active young people, surgery is the way to go.
Surprisingly, there is not that much pain involved in complete rupture. If you watch the video of Beckham, he immediately looks behind him as if someone has kicked him in the back of the leg--this is the most typical response--it feels like someone sticks you in the calf! It stings for about 30 seconds and then it just feels kind of numb. You lose almost all the strength in pointing your foot, but you are not that keen on testing it out anyway! Unlike some urban legends, the muscle doesn't always ball up in your calf, sometimes it actually looks pretty normal. You can still move your foot up and down too, it doesn't go floppy, that is thanks to toe flexors that actually move the ankle as well.
Recovery is variable and depends on the surgeon and the quality of the repair. I was casted in neutral ankle position and NWB (non-weight bearing) and transferred to a immobilizer walking boot at 2 weeks. Some people will be casted in plantar flexion and NWB for 6 weeks, it depends on your injury, age, surgeon and time to surgery. The calf muscle gets incredibly weak, and you will lose most of the muscle tone in your calf. Tendon repairs are pretty weak, I've been told that it is like sewing together two pieces of cooked fettuccine, so it is vital not to stress or stretch the repair until you doctor gives you clearance. This is usually at 6 weeks. From there, active range of motion exercises are followed by light theraband, and a very gradual increase to strengthening. Running usually won't occur until 4 months, and return to sport is at 6 months.
Physio is important to make sure that all the joints in your ankle are moving properly, and you will probably need someone to mobilize those joints to ensure this. Another issue is scar tissue. There is a massive amount of scar tissue laid down in the healing of this injury. In fact, most people's tendons remain 2-3 times thicker than the uninjured side for the rest of their lives. A physio can help you to make sure that this matrix of tissue is as strong, flexible and extensible as possible. They should also take you through proper gait re-training, proprioception, strengthening and sport-specific bio-mechanics.
From my perspective the hardest thing about this injury is the mental aspect--the fear of re-rupture. There is a little bit of pain after surgery, but for the most part this doesn't hurt that much. Because most people rupture doing something they've done thousands of times before, there is a feeling that it is going to happen again. For me, it will be very difficult to gain the confidence to run and jump again.
As with any injury there is a physical component and a mental component. I am sure David Beckham is wondering if he will ever be the same again.....as am I.
When the Achilles tendon starts to wear, the cells in the tendon start to die causing the tissue to shrivel and dry out. Tendons take much longer to heal and if done right can prevent a rupture.
Dr. Karim Kahn at UBC explains that tendons undergo a cell based repair that is achieved through exercise. When the cells are stretched they send signals that trigger a protein synthesis within the cell that stimulates the creation of new collagen fibers which then repair the damaged tissue.
Turning Movement into Repair
If you are suffering from a hot Achilles tendon and are thinking about going out for a run, do a simple pinch test. Gently pinch the tendon between your thumb and fingers. If it is sore, consider straddling the stationary bike and stretch for the day instead of heading out for your Sun Run training session.
The Achilles Tendon Repair Exercise:
Heel Drops: 3 sets of 15, 2 times a day for 12 weeks. Try the 4X4 Calf stretch in the Sun Run Video series or while holding onto the rails, walk backwards down a set of stairs a few times a day.
There will be some pain. Monitor any pain, allow the pain to go to 5 on a 1-10 scale. If the pain decreases at the end of the exercise or subsides the next day and does not increase from day to day or week to week, continue as the tendon is healing.
Mafi, Anderson (2001) found a 82% success rate in those that did Heel Drops in comparison to a 36% success rate of those that did Heel Raises as a treatment for Achilles tendon injuries.
Tilman von der Linde, RMT.
Muscles in Motion - Vancouver