Tag Archives: tendons

ACL Reconstruction: Which Option Is Best For You?

200,000 ACL injuries occur each year, and ACL reconstruction is the 6th most performed surgery in the United States, so to come back bigger, faster, and stronger, the right recovery path is critical.

The anterior cruciate ligament (ACL) is a critical part of the knee joint that connects the femur (‘thighbone’) to the tibia (‘shinbone’). Its main functions are to support the knee joint during side-to-side motion, such as cutting, shuffling, or pivoting, and to prevent the tibia from moving too far forward relative to the femur. When an ACL ruptures, it is very common to reconstruct it to bring someone back to performance level.

Location of the ACL inside the knee joint with other labeled bones and ligaments with another diagram showing a ruptured ACL.
Image from Wikimedia Commons “Anterior Cruciate Ligament”

The basis of ACL reconstruction is using living tissue, also known as grafts, to replace, and function as a substitute, for the torn ACL. There are four types of ACL reconstruction surgeries that use different types of grafts. Those four types of surgeries are classified as autograft reconstruction, allograft reconstruction, xenograft reconstruction, and synthetic reconstruction. Autograft surgeries require one’s own grafts to repair the ACL, allografts require a cadaver’s grafts to repair the ACL, xenografts require an animal’s grafts, and synthetics require manufactured materials. Additional articles on xenograft reconstruction and synthetic reconstruction can be accessed here and here.

Each surgery requires the removal of the damaged ACL, and then the incorporation of a new substitute by tunneling the newly selected graft through the femur and tibia. Within the autograft group, the two popular grafts for reconstruction are patellar tendon and hamstring tendon, with quadricep tendon being another, less popular, choice. The patellar tendon surgery takes the middle third of the patellar tendon, a tendon that connects the kneecap to the tibia, and makes sure to include the bony ends.

The hamstring tendon surgery takes two small slivers of each of the two hamstring tendons, connecting the hamstring muscle to the tibia, coils them up, and then finally bundling them to increase strength.

A knee joint with bones, ligaments, and tendons labeled.
Image from Wikipedia “Knee Joint”

For the allograft surgeries, a surgeon may select an Achilles, patellar, hamstring, or quadricep tendon from the donor.

It is very important to choose the right surgery. While the determination of which surgery and technique to perform falls heavily on the surgeon’s and patient’s preference, there are advantages and disadvantages of each technique which tend to persuade the choice of surgery. The main concepts surrounding the decision of which surgery to perform are the activeness of the patient, muscle strength, and previous knee injuries. Depending on the job, sport, or activity of the patient and the desired return time, one technique may be a better fit.

For a patient participating in low demand activities, allograft surgery may be the best fit due to less post-surgery pain and quicker surgery time, however it is very expensive and offers less tensile strength compared to autografts. As for autograft surgeries, patellar tendon reconstruction allows faster recovery time due to the bone-to-bone bonding and offers a strong substitute for a torn ACL, however future knee pain is very common. Hamstring tendon reconstruction requires more recovery time; however, the post-surgery pain is significantly less than the patellar tendon reconstruction and the tensile strength of the hamstring tendon is the strongest possible substitute.

Additional reading and comparisons between the popular autografts and allograft techniques can be accessed here and here.

What’s more important for athletes: training or genetics?

Usain Bolt, Michael Jordan, and Wayne Gretzky are arguably some of the greatest athletes of all time. You watch them on the television breaking record, winning titles or making impossible shots, and you can’t help to wonder, how are they that good? Do they use some secret training method, maybe even a special diet? Possibly, they are genetically gifted? Sports author David Epstein tackles this debate of training versus genetics in his book, “The Sports Gene”. Yes, athletes need to practice to become good, but some are just going to be naturally better than others. If you are 5’6” inches you are going to have to practice dunking a basketball a lot longer than someone who 6’6”. To see how some athletes are naturally better than others lets look at some talented athletes and see what makes them biomechanical specimens. First, we’ll look at Michael Phelps, an American swimmer who not only has multiple world records but also the most decorated Olympian of all time with 28 Olympic medals.

 

For swimmers, biomechanics have found the ideal body for performance. Body features that have been found helpful for swimming is a long torso and long arms.  The long torso reduces the drag on the swimmer and long arms allow for more powerful strokes. Michael Phelps’, who is 6’4”, has the torso proportions of someone who is 6’8” and the leg proportions of someone who is 5’9”, giving him an extremely high torso-to-leg ratio. Not only is Phelps’ torso long, but he also has a long wingspan, measured at 6’7”. Along with Phelps’ unreal proportions, his feet are another huge advantage when it comes to swimming. His size 14 feet help place more force into the water when he kicks. This is a benefit because 90% of a swimmer’s thrust comes from their feet. His ankles also hyperextend 15-degree when he kicks, creating more force. Biomechanically, Michael Phelps’s is a walking fish.

Modified from Hart Blenkinsop, Michael Phelps: The man who was built to be a swimmer 2014

You might be wondering, what would happen if you took someone who has trained to mastery and put them up against someone who is just perfectly gifted. David Epstein mentions this scenario in his book a battle between training and genetics. In the 2007 world high jump final, there are two jumpers left, Stefan Holm and Donald Thomas. Stefan Holm, has a personal best of 7’10.5”, only 2 inches off the world record. Holm has been training most of his life, since he was a child and even won the previous Olympic High Jump final. He is also 5’10” tall, which is very small for a high jumper. Donald Thomas, has a personal best of 7’8.5”. Thomas, on the other hand, is 6’3” and has been jumping for a little over a year and had started high jumping because of a bet with a friend. The two finish the completion and Thomas won clearing a 7’8.5” bar. Even though Holm’s technique was near perfect, Thomas just had the athletic edge. Being taller, Thomas already had a higher center of gravity meaning he had to travel less distance to get over the bar. Thomas also had much longer legs and Achilles tendon. This allows him to store and transfer much more energy into a jump. Thomas was just made to win.

 

For more information:

Michael Phelps: The man who was built to be a swimmer

Nature or Nurture?

High Heels: How They Can Affect You Even After You Take Them Off

Anyone who has worn high heels, or has even simply seen a person in high heels, knows that the foot is definitely not in its usual position in that kind of shoe – walking is more difficult and forget about even trying to run in high heels. Researchers from Manchester Metropolitan University and the University of Vienna wanted to investigate if frequent, long term use of high heels caused lasting changes in the calf, in addition to the normal discomfort experienced by high heel wearers. Previous studies have shown that muscles that are regularly used in unusual ways will often adjust to this new scenario to maintain functionality. These researchers, more specifically, investigated whether the regular wearing of high heels would result in physiological changes to the calf (gastrocnemius) muscle and Achilles’ tendon, and if these changes would then affect the normal functioning of the calf and ankle. In order to determine if and what changes occur, the researchers observed a group of women who regularly wore high heels and a control group who did not to compare their calves and ankles.

two women walking in stillettos
Modified Image by StockSnap on Pixabay

The calf muscle and Achilles’ tendon make up the top and bottom of the rear of the calf respectively. They play a crucial role in controlling ankle motion and in general mobility. Dimensions of the muscles, including length, were measured using ultrasound, and the cross sectional areas of the tendons were measured using MRI imaging. The torque and motion of the ankle were measured by an isokinetic dynamometer. From these values, the researches could determine other important characteristics of the tendon such as the force on it, the strain it experienced, the stiffness, and the modulus of elasticity. The strain value indicates how much the tendon is stretched from its relaxed position since it is the ratio of the change in length to the original length. The stiffness is the ratio of the force experienced to the amount of length change the tendon experienced. The modulus of elasticity, or Young’s modulus, is the ratio of how much force per area the tendon experiences to the strain.

muscles and tendons in the calf and ankle
Modified Image on Smart Servier Medical Art
MRI image of the side of two ankles with one having the foot on a wedge mimicking wearing high heels and one having the foot flat on the ground
From Csapo, Maganaris, Seynnes, and Narici, Journal of Experimental Biology 2010

 

The results of their analysis showed that people who regularly wore high heels had a resting ankle position that made the foot further from perpendicular with the leg than that of someone who did not regularly wear high heels. Additionally, generally the calf muscles of high heel wearers were shorter and the stiffnesses of their Achilles’ tendons were higher due to greater cross sectional areas of the tendons. The maximum strain in the Achilles’ tendon was lower in high heel wearers because of the reduction in length. However, no significant difference in the Young’s modulus of the tendon was observed. Similar torque-angle relationships were observed between the two study groups, so the researchers inferred that the body must have compensated for this new positioning. Additionally, these results explain the observation that high heel wearers had a reduced active range of motion in their ankles because of shorter, stiffer muscles and tendons. What the new normal ankle position means for regular high heel wearers is that their bodies are adjusting to shifts in gait, center of mass, and ground reaction forces if they wear high heels very often. The researchers infer that this physical change to the calf can also account for the discomfort women who regularly wear high heels experience when switching to flat shoes.

For additional discussion of this topic, take a look at Discover Magazine.

Back Against the (John) Wall

What would you do if you went to the doctor expecting to get back to work, only to be told you might not ever be able to go back to work again?

According to ESPN, on February 4, John Wall visited his doctor regarding an infection in his heel after a previous operation. The doctor checked the infection, but upon further analysis, realized that Wall had suffered a partial Achilles tear. Unlike former teammate Boogie Cousins, he did not suffer the tear on the court, but at home. It was reported that while at home he fell and experienced extra discomfort in his heel. His doctor reported that he will undergo surgery and will likely rehab for the next 11 to 15 months.

Achilles Ache

The Achilles is a tendon (tissue that attaches muscle to bone) connecting the bottom of one’s calf to the back of the heel, as shown in Figure 1. It is famously named after the Greek hero whose only weakness was the back of his heel.

An Achilles tendon attached to the heel and calf (Soleus).
Figure 1: This shows the lower half of a human’s leg, where the Achilles tendon is attached to both the heel and calf (Soleus). Modified from Wikimedia Commons.

According to “The Achilles tendon: fundamental properties and mechanisms governing healing” by Freedman et al, the Achilles tendon is the strongest and largest tendon in the entire body, and can bear up to 3500N, or almost 800lb, before completely rupturing. This is a result of the materials that the Achilles is made of. The tendon is 90% collagen, which forms a structure full of fibers that are bound together by other molecules. The tendon is 2% elastin, which like the name suggests, adds some elastic, or stretchy, properties. The tendon is sometimes characterized as a viscoelastic material, meaning it has both viscous (slow to deform) and elastic properties. However, the Achilles is mostly elastic, allowing it to bear relatively high impacts and loads.

Healing the Heel

The Achilles, much like other tendons and ligaments, has interesting healing characteristics and procedures. There are two common recoveries for a tear in the Achilles: a surgery that stitches the ends of the tears together followed by rehabilitation, or a period of rest followed by rehabilitation. For a full tear, surgery is very common, as the torn tendon ends are not always spatially close enough for natural healing processes to occur. For a partial tear, a doctor in consultation with the patient will decide which of the two options will be best.

Experimental Excitement

While there is much more to study with regards to Achilles tear recovery, there is a lot of exciting research being performed on animal models. One study shows that stretching and compressing the Achilles at certain angles during recovery may lead to better long term health of the Achilles. Another study shows the efficacy of stem cell therapies. A third study shows the usefulness of incorporating a 3D printed structure to integrate the ends of torn Achilles. Essentially, this would connect each end with a scaffold that allows for the reintegration of the tendon. This is very similar to an experimental ACL reconstruction technique called BEAR. A video about BEAR can be seen below.

Although John Wall’s career may be in doubt, the future for effective therapies in treating Achilles related injuries is promising. This is exciting for the future, and hopefully will make for a better patient experience. To read more about the Achilles, click here or here.