Oct 15 2009

Will I play again?

Published by doctorj at 11:17 pm under Uncategorized

My first AT rupture happened when I was 54 years old, the second at 56, both while playing basketball. I have always been physically active, so I know those tendons have gone through some wear and tear over the years, but my Achilles tendons were never painful or tender before the acute episodes. The medical literature suggests that re-rupture of a surgically repaired tendon, or rupture of the opposite AT, are rare, with a risk of less than 5%, though those studies cannot control for changes in behavior after major injury.

I could say, then, that the second tear was “unpredictable,” but in fact I put myself in a position of risk by playing again. After the first rupture, I seriously considered quitting forever. Basketball is the most physically demanding thing I do and presents the greatest risk of further injury. But I went back. I talked about this decison with friends of my generation, and despite a host of different injuries, we love the games we play and return to them. Certainly, nothing gives me quite the visceral pleasure as a good pickup game. At the same time, the burden of a major injury is great, and falls not just on the individual, but on a lot of other people including family and friends, and even on fellow workers.

During my ongoing recovery, I watched Michael Jordan’s acceptance speech as he was inducted into the Basketball Hall of Fame. Unlike the standard player’s contract that prohibits playing basketball outside of official practices and games, Jordan’s contacts always included a “Love of the Game” clause permitting him to play anytime and anywhere he wanted, even given the risk of injury to an NBA superstar. I’m no superstar, but I understand that “Love of the Game.”

Will I play again? I have not yet decided. Logic tells me I should not. I certainly see few players my age out there on the basketball court, and lots on the golf course. We’ll see.

20 Responses to “Will I play again?”

  1. grahamon 16 Oct 2009 at 6:13 am

    I guess listen to your surgeon and see what they say before dismissing it already. I desperately want to get back to long distance running after my ATR and at first I was saying ‘never again’ But time is a great healer and now I am saying ‘I will be back’. All the best.

  2. doug53on 16 Oct 2009 at 8:04 am

    Doctor J:

    It is likely that you, like most of us, had asymptomatic Achilles tendinosis and didn’t know it. Oddly enough, rupturing the tendon “cures” the tendinosis. Once a tendon is fully healed after a rupture, it is not as strong as a truly normal tendon, but it is a lot stronger than it was, with that tendinosis, before the rupture.

    This is reflected in one followup study that showed that, after having an ATR surgery, rupture of the *other* Achilles is three times more likely than rerupturing on the same side. Furthermore, all of the same side reruptures in that study were clearly during the rehab period. Therefore, you could reasonably assume that, once the rehab period is over, the ratio of ruptures between the other side and the same side is probably quite high.

    So, by having “cured” the only two Achilles tendons you have, (I’m assuming…), you may be in much better shape than you think.

    The only remaining question is whether or not tendinosis can make a comeback years after a surgery. I’ve not seen any reports of that. I also asked my ortho doc that specific question, and he said he had not seen or read of that being a problem.

    So go hoop your brains out when you’re healed!

    Your blog name reminds me of the guy who took his young son to see the 76ers play back in the Julius Erving era. Following the rules, he sent a note to his son’s school, explaining that he would be absent “because he was going to see the Doctor.”

    Doug

  3. Joeon 16 Oct 2009 at 9:47 am

    After my injury playing basketball I’ve said I won’t play again either. But getting back into the gym now and seeing those games going on I can see how easy it would be to go play again. Same question though…is it worth it? For me I doubt I’ll go back out there again. I just can’t imagin going through this another time.

  4. smoleyon 16 Oct 2009 at 10:42 am

    Regarding the whole ‘going back to sport’ debate - I’m sure we are all going through the same process to a lesser or greater extent. Being a good first-world girl my usual instinct with any problem is to throw some money at it ( and I think we can all relate to that approach)! So are there any clever supports/straps (probably made of blue neoprene) to make me just that little bit more bionic than I naturally am? I’ve found a good company in the UK called Physio Med who do all sorts of marvellous gadgets. Sometimes having a smart looking piece of kit just gives you that little bit of confidence, even if the effect is mostly psychological. Any thoughts anyone?
    Smoley

  5. Tomon 16 Oct 2009 at 11:14 am

    Re. Will I Play Again …

    I think (today) I’m going to go back to full-throttle. I don’t want to spend the rest of my life wondering if I gave it up too soon. I just love playing sports too much. I could live with another ATR (please, please please let it be the left leg again though), but that would be it.

  6. heelpatchon 16 Oct 2009 at 11:41 am

    I agree with Doug. With so many variables, there can be no guaranties, but if you’ve had surgery on both tendons your risk of re-rupture should be low. I’ve returned to playing soccer and I am much more worried about rupturing my “good” tendon than I am about re-rupturing my “bad” one. It’s almost (but not quite) worth it to have the surgery on a prophylactic basis. Likewise, I almost (but not quite) envy you for having gotten the second rupture out of the way. I am 1000 times smarter about this injury now though and hopefully that will be enough to avoid the need.

  7. 2ndtimeron 16 Oct 2009 at 12:35 pm

    When I re-ruptured my tendon I was so desperate I said I did not want anything anymore just be able to walk again. Now that I start to feel better, I am thinking of going back to fitness classes eventually…. sports are addictive. You might feel depressed without it. Anyways, you could rupture it by dancing at a wedding, helping your neighbour lifting that hot tub as we heard….

  8. tomtomon 16 Oct 2009 at 12:49 pm

    Smoley - I don’t think there are any braces or supports that would prevent a ruputre aside from ones that would significantly reduce your ability to perform (i.e., the boot or something else that would keep the tendon stationary). In most cases the tendon ruptures because it cannot handle the tensile force being applied. I can’t think of any way to reduce the tensile force without basically immobilizing your ankle or your calf muscle. However, if it’s just about confidence, there are hundreds of ankle braces available. You could also try heel lifts in your shoes which would reduce the stretch of the tendon after heel strike.

  9. smoleyon 16 Oct 2009 at 12:59 pm

    tomtom - I suppose you are right. Will certainly look into the heel lifts (although that is a few weeks away yet). Getting good advice in a proper sports shop when buying trainers is probably one of the best investments. And as 2nd timer says, they can rupture in such random circumstances. I can live without tennis, but give up hot tub lifting? I’d rather die!
    Smoley

  10. ultidadon 16 Oct 2009 at 5:48 pm

    One more comment on this thread, my asthma doctor ruptured his achilles while downhill skiing - you can’t get much more immobilized than in a ski boot.
    As far as the original question, I hope that you aren’t ready to hang up your shoes. My dad ruptured an achilles (same side as I did) at 58 playing tennis and never went back - took up golf instead. For a guy who used to say that he was too young to golf, I felt sadness that he gave up tennis. I don’t plan to give up my sport (Ultimate Frisbee) until they kick me off the field!

  11. Tinaon 16 Oct 2009 at 9:38 pm

    Great, now i am freaking out that i am going to rupture my other tendon. The fact that Doc J had no symptoms and still ruptured his “good” tendon has got me worried as i have a very sore tendon on my “good” leg and my physio said it is very tight. All she said to do was rest and ice it but is there anything else that i can do to prevent a rupture? I know i have to stop favouring my ruptured one so am slowing down my walk to ease the pressure off the other side, but has anyone else had a sore tendon on their “good” leg and then had no problems with it? Thanking any advice in advance, Tina (nervous nelly!!)

  12. tedbon 17 Oct 2009 at 6:09 am

    i guess there is middle ground between playing and not playing.. and that is playing at a lower level than you used to so you reduce your chances of injury.. and don’t forget to listen to your body if you play.. if you are have any pains, get it fixed before you continue

  13. doctorjon 19 Oct 2009 at 9:54 pm

    Doug53, I had not thought of my injuries as “curative,” but I guess they are in a way, if they reduce the risk of future rupture. Your comments were both informative and encouraging. Thank you.

    doctorj

  14. doug53on 20 Oct 2009 at 7:00 pm

    Dr. J,

    The study I referenced is at
    ncbi.nlm.nih.gov/pubmed/14723785
    if you’re interested in the specifics.

    When my ortho told me how shredded my tendon was, I originally thought that must be a bad thing, harder to heal. But maybe it’s actually better that way, to scar up all of that tendinosis, so no weak spot is left to rupture later on.

    I hear you about the injury’s burden on others. We have lots of caregiving to be done in our house already, with an severely autistic teenager, so I pushed my rehab and got back on my feet as quickly as I dared.

    I haven’t decided about future basketball yet. I’m going to wait at least until my favorite pickup group gets going again after the summer break next year, and see how I feel about it then. After all these years, it’s hard to imagine not playing anymore, but I guess I have to stop someday.

    You’re the right age to appreciate the reaction I get from the younger guys I play with when I tell them that, during my high school and college days, there was no time clock, no three point line, and dunking was illegal. They look at me like I’m from outer space.

    Doug

  15. normofthenorthon 28 Jan 2010 at 12:27 am

    Me, I had the luxury of an 8-year span between my two ATRs (opposite sides), and I had 7 excellent years of super-aggressive court and beach volleyball in the interim — not to mention the skiing, bicycling, dinghy racing, and other AT-risking activities. The second one popped while I was playing volleyball in a more aggressive league (4-on-4 on a full-sized court!) than 8 years prior, though I’d progressed from a 56-year-old to a 64-year-old in the interim!

    (One young buddy I play beach 2-on-2 ball with has noticed that some teams turn down games with us after checking out my grey hair. So he’s started asking them if they mind giving a game to “me and my Dad”! They almost always say yes!!)

    I have no regrets about going back to the “high-risk” sports I love, despite the 2nd ATR. If this one heals as well as the first, I plan to return again. (BTW, I’m going the new-fangled non-surgical route this time, with rapid rehab — check out the first post on my blog for details and links to randomized trials!)

  16. Tim Martinon 28 Jan 2010 at 9:15 am

    Hi GerryR and everyone else,
    I totally ruptured my achilles two weeks short of three months ago. I am doing very well and have been in two shoes for over three weeks. I am in the gym doing all the exercises to strengthen my thigh and calf. I am very concerned that I will never play squash again. Can anyone advise if after a year or so I might be able to get back into squash.
    Thanks,
    Tim Martin

  17. normofthenorthon 31 Jan 2010 at 1:05 pm

    Tim, as you can see from the above, at least some of us went back to the same high-risk sports (like squash) that tore our AT. In my case that was competitive volleyball, and I even upped the ante a notch, by switching from 6-on-6 court v-ball to a combo of 4-on-4 court v-ball and (indoor) beach v-ball, mostly 4-on-4 with some 3-on-3 and some “real” 2-on-2 (this as I moved from my 50s to my 60s!)

    It all depends on a good solid heal (and heel!), of course. I’ve been spreading around my 8-years-ago surgeon’s rule of thumb: When you can do 8 single-leg calf raises on the “bad” foot without grunting or grimacing, you’re ready.

    The main downside is that the various risk factors that led to your original ATR makes you statistically (and really) vulnerable to tearing the other AT, as I did 8 years later (~7 weeks ago). So far, I’m content with that “bargain”, even though I actually tore the other one, since I had 7 excellent years of great fun and serious workouts. (I didn’t notice any deficit in my agility or vertical on the court, either from the AT repair or my advancing age. And my passing hasn’t improved a whole lot, either! ;o) )

    Of course, I am counting on another near-perfect heal-up from this ATR, and I expect to be returning to all my AT-scary activities after that happens. There are also a bunch of slow-healing and non-healing “horror stories” on the blogs here, and if I turn into one of those, I may change my mind about regretting my high-risk high-fun decision.

    I bumped into one guy in the sports-med-clinic waiting room who told me he used to work in one, as a physio I think. He said that whenever they said goodbye to somebody who’d recovered from a torn AT, they’d say “See you soon, when you tear the other one!”

    There’s an article linked here somewhere that estimates that single-ATR people are “only” 200 times more likely to tear the other AT than the general public — that’s only about 3% of the whole group (in the first 4 or 5 yrs), IIRC. But the 97% non-repeaters probably includes a bunch of people who DIDN’T return to v-ball or squash etc., and also a bunch of people (like me) who didn’t tear the other one within the time-span of the study, but did so a few years later.

    Your mileage — and your values — may vary. . .

    BTW, of the various risk factors that led to your original ATR, the only one you can control is probably the decision to return to squash (or something else equally explosive and “violent”). Warmups and stretches and exercise and the like seem to be only minor influences, the way I read the literature. The main risk factors seem to be (a) a genetic tendency, like an area in the AT that doesn’t get good blood circulation, and (b) participating in aggressive “high-risk” sports, especially those where you have to switch from reverse to forward in a hurry, and where you’re on a hard unyielding surface in high-friction footgear.

    (I think I didn’t tear either AT in BEACH volleyball because “the move” that tore my tendons on the floor digs the ball of my foot into the sand on the beach, so there isn’t as much force on the AT. You can’t switch as fast from reverse to forward on the sand, because you “spin your wheels” more. That’s frustrating for getting to the ball, but it limits the tearing force on the Achilles.)

  18. Tim Martinon 01 Feb 2010 at 5:26 am

    Well thanks all for the comments, I suppose if one is going to give up squash and take up going for an evening stroll down the beach then the risk is nowhere as high. So 8 calf lifts on the bad leg is a sign that one is almost back to normal. I am not even close to 8.
    If one does longer warm ups before a game of squash or whatever it may be, would this lessen the risk of another rupture.
    My surgeon told me that when the bad one is healed it will be stronger than the good one, is this true??
    Once again thanks for all the discussions.

  19. tomon 01 Feb 2010 at 5:40 am

    Tim: That’s what I’m hoping (warmups to avoid a future rupture). When I played my first game of basketball (6 months after surgery), I warmed up and stretched for 10 minutes or so and I was good to go. Time will tell I guess. My plan is to continue to do leg strengthening exercises (which I really never did pre-injury) and always warm-up and stretch.

    My doc said my repaired Achilles is now titanium and that it’s the other one that would blow, if either. He said that rupturing both, although not impossible, would be very rare in his experience. I think that’s likely because most people give up the explosive sports after achilles #1 blows. If I have learned anything through this all, it’s to take everything your doc says with a grain of salt. The amount of conflicting counsel from medical professionals is astounding.

  20. normofthenorthon 01 Feb 2010 at 2:16 pm

    I think the docs are right, that after a full recovery (around a year, in my experience), the healed AT is probably the soundest part of your whole body. And the other AT is one of the parts most at risk of injury.

    Whether that info changes your lifestyle or not is a decision that nobody else can make for you.

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