Achilles Tendon Injuries

Achilles tendon and calf muscle tears are problems that have recently become near and dear to my heart. This, much like tennis elbow is the source of many athletic midlife crises. The Achilles tendon is actually a combination of three separate tendons. The Gastrocnemius is the big, bulbous muscle that gives the calf muscle shape. The Soleus is a flat muscle that sort of resembles a fillet of sole, and the Plantaris is a very small muscle that does not seem to provide any substantial function.  The tendons of these three muscles come together to form the thick heel cord that is the source of many problems. 

Unfortunately, as we age the healing process is not quite enough to support the constant pounding that the Achilles tendon receives.  When an injury occurs, it is typically described as a feeling of being kicked in the back of the leg.  Typically these tendons are injured during an explosive events such as jumping, landing or starting a "sprint".  The typical age for this type of injury is between 40 and 50 years old and occurs predominantly in male patients. Up until recently, the recommendation was almost universally for surgical repair.  The rationale behind this was to decrease the rate of rerupture.  Now, with more advanced rehabilitation techniques, we are able to spare many people the pain of surgery.  In the highly athletic population however, there is still the belief that surgical repair improves the strength and function in the long run.  The recovery from any type of Achilles tendon rupture is quite long.  It frequently takes 6-12 months to completely recover from such an injury and requires intensive rehab.

-J Fallon

Do I need an MRI before I see an Orthopedic Surgeon?

The short answer to this is no.  Well, not usually.  MRIs are a very useful tool in orthopedic surgery, and we have come to depend on them for many facets of diagnosis and surgical planning.

There is commonly the thought that obtaining an MRI before your visit will "Save a step" in getting you better.  What I frequently tell patients is that "I treat people, not MRIs".  What that means is that I am far more interested in what you have to say and what your knee feels like, than what an MRI can tell me about your knee.  So, getting an MRI may be necessary at some point, but may not be necessary.

MRIs also come in different varieties and I order special MRI sequences depending on the question I want answered.  For example, if I suspect a SLAP tear in a young pitcher I will order dye injected into the shoulder joint prior to the MRI, making it an MR arthrogram.  I will also request that their arm be placed in a certain position.  I will not typically ask for an MR arthrogam in a 50 year old carpenter with shoulder pain in which I suspect a rotator cuff tear.  If a patient has had previous surgery, metallic anchors would make an MRI useless because the metal would interfere with the magnets and the picture would be blurry.  In that case, a CAT scan with dye injected into the shoulder would be a more useful way to see the structure of the shoulder.

The final reason not to try to get an MRI before you see me is that most primary care doctors have difficulty convincing your insurance that they should pay for an MRI.  Their staff has to argue and struggle with the insurance companies to get the MRI "pre-approved".  Frequently, despite all of their efforts, the insurance companies feel that the MRI is not warranted.  Our office, on the other hand has a near flawless record of getting these approved.  Part of this is my wonderful staff and their familiarity with the nuances of MRI scheduling and part of it is that for better or worse, my recommendation as a specialist carries more weight with the insurance companies than your PCP.  So, let us do the work for you and save yourself the aggravation.



- J. Fallon

The Biology of ACL Reconstruction and Regeneration

One of the best examples of the wonders of modern medicine is Anterior Cruciate Ligament reconstruction.  Because the body is unable to heal the ACL on its own, it requires reconstruction in order to restore normal function to the knee.  The process of ACL regeneration relies heavily on the biology of your knee.

When I reconstruct your ACL, I take a tendon, either from an organ donor or from a different part of your body, then place it where I want a ligament to grow.  Your body uses this tendon as a scaffolding to regenerate a new anterior cruciate ligament.  This process occurs and 3 phases.  The initial phase is characterized by necrosis or cell death.  During the first 4 weeks after surgery, your body tears down all of the living cells in the graft, leaving only nonliving tissue as a blueprint for the final ligament.  The second portion of the regeneration process is called the proliferation phase.  This usually occurs in the second and third month after surgery.  This is characterized by influx in your own body’s cells into the remaining scaffolding.  The scaffolding also undergoes changes that cause significant weakness in the graft.  6-8 weeks after surgery is typically thought of as the weakest point and the time where of the structure of the graft needs the most protection.  The final phase, the ligamentization phase begins about 3 months after surgery.  During this time, the graft is slowly and steadily getting stronger and becoming more like the original ACL.  There is no clear end point however there is plenty of evidence suggesting that the graft will continue to mature over the following year.

I am a 43 year old Athlete and I tore my ACL, now what?

The short answer is, you don't need it.  As a sports medicine surgeon, I live to get people "back in the game", be that Eathampton HS football or the over 40 soccer leage at Allsports.  However, most of life does not require an ACL.  So why can I ski bumps without an ACL, but my kid's babysitter should have it reconstructed?  The answer lies with age.  In the over 40 population, it has long been thought that there are 3 groups of people who tear their ACLs: Copers, Adapters, and non-Copers.

If you are a Coper, with some dedicated rehab and a brace, you can return to all of the dumb things you were doing before you tore your ACL.  If you are an Adapter, with some good rehab and a whiff of mortality, you get back to life and many of the things you were doing before, but you take a less aggressive approach to athletics.  You limit the cutting, twisting, pivoting sports, but can remain active in athletics that are less "ACL Dependant".  If you are a non-Coper, you knee feels unstable inspite of dedicated rehab and a brace, and you are unwilling to accept the limitations that this injury has foisted on you.  In this case, there is decent evidence that an ACL reconstruction will help you stabilize your knee and get you "Back in the Game".  For most middle aged athletes, life is busy and they don't have the time to jump right into the 6-9 month rehab that an ACL recontruction requires, so the most common recommendation is to try non-surgical management of the ACL tear and see how it goes.

Sports Medicine Lecture Series Kicks Off!

This May, the physicians at HampOrtho successfully kicked off a Sports Medicine lecture series at CDH.   Drs. Fallon and McBride lead a fun and informative discussion on the Anatomy of Athletic Knee Injuries at the Cooley-Dickinson OR while giving a cadaveric demonstration of ACL reconstructions.  It gave the participants the chance to see first hand the surgical anatomy of the knee and try their hand at arthroscopic surgery on a cadaver.  Similar events are planned for this summer.  It is designed as a free service to our local Athletic Trainers, so if you are an AT-C and interested, please contact our office manager and we will put you on the list.