Posts Tagged ‘NBA’

The Achilles’: Your Weakest Link

by G. John Mullen, DPT 2011 |

Achilles’ tendon injuries have been present since the time of the Greek Gods and Goddesses, (remember Achilles from Greek Mythology?).  Achilles’ is the burly, handsome warrior from the Trojan War legends who could only be harmed by a lethal blow to his Achilles tendon…and the name was born.  Contrary to popular belief, this warrior’s surname was not Pitt.  What we really want to know, however, is how does the Achilles tendon affect us today?

We all witnessed the devastating loss Michigan State suffered to underdog, Butler University, in the men’s NCAA basketball tournament. The Spartans put in a valiant effort despite the season-ending loss of Kalin Lucas, a pivotal player averaging 12.3 points per game.  Lucas tore his Achilles’ tendon during the game against Maryland (tragic, we know). Achilles’ tendon tears are not unique to the collegiate super-athlete; weekend warriors are just as susceptible to Achilles’ tendon tears as the pros.  An Achilles’ tear is debilitating, requiring surgery and extensive rehabilitation in most cases.  Successful surgery and rehabilitation of a torn Achilles’ tendon requires a thorough understanding of the anatomy, cause of the injury, patient’s unique health condition & lifestyle and patient’s athletic activities.  These factors are essential to preventing a re-repture of the tendon.

Stat Fact: Most Achilles’ tears occur 2-6 cm above the Achilles’ insertion into the calcaneus, the heel bone in the foot (3).


The Achilles’ is a complex tendon whose rarity is secondary to the fact that the tendon crosses two joints.  Multi-joint crossing places increased stress on the Achilles’, resulting in the tendon’s high injury rate.  Everyday activities like walking place repeated stress on the tendon.  The tendon is the composite of two muscles in the calf: the gastrocnemius (the medial and lateral heads which cross the back of the knee) and the soleus (the bulk of the calf). The tendon is surrounded by two sheaths (which are called “paratendon” and “mesotenon”).  The mesotenon is responsible for the nourishing blood flow to the tendon.  Diminished blood flow is seen at the bottom of the Achilles’ tendon and is responsible for the high rate of tears in this region. The majority of the tendon is made of Type 1 collagen (4).

Stat Fact: The Achilles’ tendon twists in a spiral motion as it wraps around the foot and inserts into the calcaneous.

Types of Achilles’ Tears and Risk Factors

Athletic Achilles’ tears are typically acute injuries caused by a “high rate of loading” associated with specific movements which include landing, pivoting or sweet juke moves on the field…talk about all-time backfires! Acute injuries commonly occur at the distal portion (i.e. the point farthest towards your heel) of the tendon where blood flow is diminished. Out-of-shape athletes returning to high-impact sports make up the largest portion of these injuries.  Trauma from a foreign object is another common cause of an acute Achilles’ tear (i.e. Tonya Harding action to the back of your ankle).  These injuries are not pretty, but if you’ve seen the movie, Saw, you may remember one of the hostages having their Achilles’ sliced to prevent escape.  Uncommon but horrific to say the least.  Tears during motor vehicle crashes are more typical and can be equally debilitating.  Chronic Achilles’ tendon injuries can also eventually lead to tears. Nagging Achilles’ tendonosis (chronic inflammation of the Achilles’ tendon) transforms the molecular properties of the tendinous collagen making the tendon soft and pliable.  Pliability is the Achilles’ kryptonite (not arrows as Hollywood would have you believe)!  As we age, we are more prone to tendon tears.  Two factors lead to increased Achilles’ tears as we age: 1) the transformation that takes place in your tendon’s cartilage and 2) hypovascularity (impaired blood flow) making previously injured, older athletes more prone to Achilles’ tears.

Stat Fact: The Achilles’ tendon is the strongest tendon in the body, absorbing up to 8x our body weight in force during athletic movements (2).

Surgery and Rehabilitation

Surgery is always the last option.  Debate surrounds the efficacy of surgery and rehabilitation in Achilles’ tears.  Studies show conflicting evidence in terms of recovery speed and re-rupture rates for individuals with and without surgery (5). There is further debate on the first phase of rehabilitation for both groups. One theory of rehabilitation promotes 6-8 weeks of immobilization via casting.  Casting is typically done in plantar-flexion (with your foot bent at 90 degrees to your calf) or in the neutral position (imagine your foot’s position as your leg hangs over the edge of the bed).  Immobilization is thought to allow collagen repair following surgery increasing stiffness and strength of the tendon. The other accepted method of rehabilitation is the exact opposite of immobilization: early mobilization. Early mobilization is believed to promote revascularization of the injured tendon. Revascularization is believed to enhance strength (4).  More importantly early mobilization is associated with similar functional gains and a low re-rupture rate (5).  These positive attributes make early mobilization an important variable for surgical and non-surgical treatment of Achilles’ tendon tears.

Rehabilitation regimens vary depending on the surgeon’s approach (early mobility vs. early immobilization).  Early mobilization seems to be gaining momentum with recent publications.  A typical early mobility rehabilitation protocol is listed below:

Postoperative Exercise Program (1)

Group 1 (early mobilization)

Time: 0-3 wk

  1. Flexion and extension of the toes in a supine position; 25 × 3 series

  2. Plantar flexion of the ankle and dorsiflexion to neutral in supine position

  3. Extension of the knee in a sitting position (hold 2 s); 10 × 3 series

  4. Flexion of the knee in a prone position; 10 × 3 series, 3 times daily

  5. Extension of the hip in a prone position (hold 2 s); 10 × 3 series

Time: 3-6 wk

Same as week 0-3

Time: 6-9 wk

1. Ankle flexion and extension exercises with manual help

2. Rotation of the ankles in both directions; 30 × 3 series, 3 times daily

3. Standing on the toes and heels alternately; 30 × 3 series, 3 times daily

4. Ankle extension exercises against a rubber strip; 20 × 3 series, 3 times daily

5. Ankle stretching exercises to flexion with the help of a rubber strip; 30 s × 5 series, 3 times daily

6. Stretching of the calf muscle by standing with the leg to be stretched straight behind and the other leg bent in front and leaning the body forward, with support from a wall or chair; 30 s × 5 series, 3 times daily

7. Stretching exercises for the toes and ankle against the hand in a sitting position; 30 s × 5 series, 3 times daily

Time: 9 wk

1. Raising and lowering of the heel, first with both feet at the same time and later with 1 foot; 20 × 5 series, 3 times daily

Exercises against a rubber strip for

Ankle extension 20 × 5 series, 3 times daily

Ankle flexion 20 × 5 series, 3 times daily

Ankle abduction 20 × 5 series, 3 times daily

Ankle adduction 20 × 5 series, 3 times daily

Stretching of the calf muscle against the wall; 30 × 5 series, 3 times daily

Standing with the knee somewhat flexed; 30 × 5 series, 3 times daily

With any surgery, you must take note of the potential complications. At the same time, the re-rupture rates in Achilles’ tendon tears are significant in the conservative non-surgical group.  A notable complication with Achilles’ Tendon surgical repair is sural nerve dissection.  The sural nerve is damaged in approximately 6% of Achilles’ tendon repairs.  Sural nerve damage can lead to impaired sensation to the dorsal (back) aspect of the heel (2).

Stat Fact: Non-surgical Achilles’ Tendon treatment has a re-rupture rate of 12.6%, nearly 4x the 3.5% re-rupture rate seen in the surgical repair group (2).


While many people believe that stretching is the key to preventing Achilles’ tendon rupture, this may not actually be the case.  Stretching may reduce the number of tendon injuries, but a more thorough approach is needed to further minimize your risk of injury.  Most Achilles’ tendon tears are caused by high force movements.  As your coach always said, “Practice like your play!”  It only makes sense to practice these high force movements via plyometrics to train your body to adapt to these high levels of strain. Therefore a stretching regimen in combination with a light plyometric routine makes perfect sense.  A simple plyometric routine (for example, ankle hops progressing to higher impact squat jumps and then repeated hops) can be utilized before exercise to minimize your risk of injury.  Who doesn’t want strong enough Achilles’ tendons to dunk like Dwight Howard?

Questions? E-mail G. John Mullen:


1. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. Jan 2007;35(1):59-64.

2. Molloy A, Wood E. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. Dec 2009;14(4):745-759.

3. Park D, Chou L. Stretching for prevention of Achilles tendon injuries: a review of the literature. Foot Ankle Int. Dec 2006;27(12):1086-1095.

4. Strom A, Casillas M. Achilles tendon rehabilitation. Foot Ankle Clin. Dec 2009;14(4):773-782.

5. Twaddle B, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. Dec 2007;35(12):2033-2038.


04 2010

The Power of Touch: Snuggling = Better Performance?

by Kelly Erickson, MD 2010 |

We, at House Call, MD, are big fans of the “snuggle.”  There are few people on this planet who will not benefit in some way from a hug, massage or simple back rub.  A recent New York Times article suggests that we may be on to something (1).  While outright snuggling may create interesting and awkward scenes in the workplace, recent studies are showing that positive interactions involving touch may increase in human performance.

Before we dive into the details of the research on this topic and the science behind them, let’s start with some simple logic: If touch makes us “feel better” and “feeling better” makes us work harder, then it follows that positive or cooperative touch can improve performance.  Seems fairly reasonable to us.  Now on to the science behind the theory.

First, we must show that touching someone is a means of communicating—right?   Some of the most compelling studies regarding the role of touch in communicating emotion are currently being performed at UC Berkeley.  The most recent study sought to show that a wide array of emotions could be conveyed between two complete strangers using only touch.  What is interesting to us is how they conducted their study…

Imagine you are a freshman in college taking a Psychology course and, as part of your grade, you are required to participate in a study currently taking place on campus.  As part of the study you are taken to a small room and blindfolded (and yes, this does sound like the opening scene of a cheesy horror film, but stick with us).  After a minute, an individual enters the room, slaps your wrist, and walks out.  You are then given a list of emotions and asked to identify the emotion the other person was trying to convey to you.  You circle your answer (What would you answer, by the way?), re-blindfold yourself and wait for the next assault.  An individual walks in for the second time, hugs you, and leaves.  You are given the same list of emotions to choose from…etc.

The experiment showed that touch, independent of words, sounds or facial expressions, functions as a distinct means of communicating emotion.  The emotions that were successfully communicated in this study include: anger, fear, disgust, love, gratitude, sympathy, happiness and sadness.  Pretty impressive, right?

You may still be thinking “OK, so how is snuggling supposed to make me perform better?”  This is where the fun comes in.  Michael Kraus of UC Berkeley conducted a study examining the role of “tactile communication” (a.k.a. touching) and its effects on the performance of NBA players (2).  The study hypothesized that players who touched fellow teammates more often throughout a game would be more successful on the court.  They believed that the same would be true for entire teams as well (i.e. the more high-fives and butt pats, the better the team would play).  They watched each individual player in the NBA for an early season game and tallied the number of times the player touched a teammate. “These celebratory touches included fist bumps, high fives, chest bumps, leaping shoulder bumps, chest punches, head slaps, head grabs, low fives, high tens, full hugs, half hugs, and team huddles.”  Can you imagine a bunch of scientists sitting around a television tallying “chest bumps”?  Welcome to the wacky world of UC Berkeley.  After assigning each player a score based on the number of touches throughout the game, the researchers quantified each player’s performance throughout the season in terms of points scored, rebounds gained, successful passes completed, and a number of other parameters that make a player valuable.  The researchers found that the more a player touched his teammates in that early season game, the more successful the player was that season. Teams that had the highest number of positive touches between players were also the most successful teams in the NBA!

According to the study, the Boston Celtics and the Los Angeles Lakers were at the top of the list of the touchiest teams, while the Sacramento Kings and Charlotte Bobcats were the least touchy teams in the league (1).  And the league’s most touchy-feely player?  Kevin Garnett of the Celtics (see photo of picture-worthy hug at left).  While the study showed a correlation between touching and performance, they did not prove that touching causes improved performance.

This observation has been studied in other settings as well.  Tiffany Field, one of the more prolific touch researchers, studied women with prenatal depression.  In the study, they compared participants whose partners gave them a regular massage to a control group in which the subjects got didily-squat (isn’t that sad?).  Guess what they found? Yep, those receiving regular rub-downs reported both a decrease in pain as well as improved relationships with their partners (3).  The same group of researchers studied autistic children and showed that touch therapy (which consisted of 15 minutes of physical contact two times per week for four weeks) was associated with less touch aversion, off-task behavior and stereotypic behavior and improved attention, behavior regulation, social behavior and initiating behavior (4).  Put simply, autistic kids were able to more easily control their behavior (this is one of the biggest challenges of the disease).

What is the science behind these observations?

Lets look at two hormones the body produces in relation to touch: oxytocin and cortisol.


Oxytocin is the ultimate snuggle hormone.  It is best known for its action in pregnant women and is particularly responsible for milk “let-down” (a.k.a. allowing the milk made in the mammary glands of the breast to move to a “holding chamber” so that when the baby sucks on the nipple, milk is actually released).  Interestingly enough, the very act of suckling causes an increase in release of oxytocin by the pituitary gland (we have no political position regarding that statement.  Use this newfound knowledge at your own risk).  It is a self-perpetuating cycle to make sure babies get the food they need!  In terms of pregnancy, oxytocin also prepares the cervix for the birthing process (“Pitocin”, as oxytocin is called in this setting, is used as a topical gel to move things along and get the baby out faster).

Oxytocin is not only found in pregnant women…no need to feel left out, gentlemen.  Both men and women release oxytocin in relation to touch.  Studies have even found an increase in its release with warm contact on the skin.   Increases in oxytocin levels have been correlated with an increase in trusting behavior and decrease in fear.  It has also shown to be associated with generosity, empathy and even sexual arousal.   All of these emotions contribute to the formation of a bond between individuals.


On the opposite end of the spectrum, cortisol is commonly referred to as the “stress hormone.”  It raises blood pressure, spikes your blood sugar and suppresses the immune system among other things.   The body naturally increases its levels of this hormone in times of stress and anxiety (Remember “fight or flight” from high school biology?  This is a related chemical reaction).  Interestingly, one of the actions of oxytocin is the inhibition of cortisol.  One would think that a peak in cortisol levels in situations like an NBA game would help with performance.   The research, however, shows that it may actually be beneficial to have some level of suppression of cortisol in this scenario.

Therefore, when an NBA player high-fives his fellow teammate, he is triggering a biochemical signal in his teammate’s mind and body that says, “You can trust me.”  Perhaps it is this sense of security that allows players to push themselves physically and out-perform their rivals.  So next time you are on the spot, whether it be before shooting the game-winning free throw or as you sit down to take that final exam, giving the person next to you a motivating high-five will make a lot more sense.  It may be the “secret-weapon” you have been looking for.

Questions? E-mail Kelly:


1. Carey, B. Evidence That Little Touches Do Mean So Much.  The New York Times.  February 22, 2010.

2. Kraus, M, Huang, C,  and Keltner, D. Running Head: Touch, Cooperation and Performance.

3. Field T, Figueiredo B, Hernandez-Reif M, Diego M, Deeds O, Ascencio A.  Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. J Bodyw Mov Ther. 2008 Apr;12(2):146-50. Epub 2007 Oct 2.

4. Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S., Dowling, M. Brief Report: Autistic Children’s Attentiveness and Responsivity Improve After Touch Therapy. Journal of Autism and Developmental Disorders.   Volume 27(3), June 1997, pp 333-338


03 2010

Busted Ankles: Preventing yourself from becoming the next Dwight Freeney

by G. John Mullen, DPT 2011

Dwight FreeneyWith the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return.  The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle.  The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday.  As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination.  Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.

Stat Fact: Ankle sprains in men and women whose average age was 23 had an injury rate of 10 per 1,000 hours of sports participation.

What is an ankle sprain?

An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments.  These injuries are caused by running, jumping, landing on an uneven surface or awkwardly planting your foot (or tackling a quarterback in the NLF in Freeney’s case).  Ankle AnatomyThe most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot.  You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them.  This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined).  There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments.  In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.

The signs and symptoms of a sprained ankle are similar to most musculoskeletal injuries:

  • Pain and swelling Grade 3 Ankle Sprain

  • Bruising

  • Difficulty walking

  • Stiffness

Stat Fact: Sprains of the lateral ankle make up 85% of all ankle sprains.

Acute Ankle Sprain:

Now that you know some basic facts about the ankle, we will discuss what to do if you have just sprained your ankle playing a pick-up game of basketball or Louisville Chugger.  Most ankle sprains are Grade I (i.e. relatively benign) and will begin to feel better within a few days.  To help speed up the healing process, most physicians, physical therapist and medicine men will tell you to R.I.C.E. your ankle.

  • Rest: For 24-48 hours after an injury, rest your ankle and allow it proper time to heal.  During this time sit back, relax, watch The Office and discontinue any physical activity.

  • Ice: Icing can be used to decrease swelling of the injured ankle.  Ice should be used for approximately 20 minutes (about the same length as an office episode…) at a time and should be used intermittently throughout the day (about 6 times).  Make sure the injury site does not go numb when icing the injury.  When the injury becomes numb, tissue can be damaged and more harm can be done!  The type of cooling method is irrelevant, but make sure the ice pack, pack of frozen corn or cold pack covers the inflamed area. Additionally, make sure not to leave the ice on for longer than 20 minutes.  The ice is used to reduce the swelling in the area.  When ice is left on for longer than 20 minutes, the body begins to think that it is freezing and increases the amount of blood to the area to warm it up (thus increasing the swelling!).   The take home: 20 minute on, 20 minutes off!

  • Compression: An ACE bandage works best, but any type of garment can be used to compress the injury site.  Ankle BandagingWrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done.  Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).

  • Elevate: This is simple, keep your ankle higher than your heart…lying down is key here (for those of you trying to maintain the kung fu position with one leg in the air) and remember to keep your ankle elevated with a pillow while you sleep.

If the ankle swelling does not subside after a few days (~7 days) or if the ankle is preventing you from everyday activites, it may be necessary to see the physician or physical therapist and it is likely you have suffered a Grade II or III sprain…our hearts go out to you.

Chronic Ankle Instability/Functional Ankle Instability

Now that you’ve sprained your ankle and the pain and inflammation has gone by the wayside, you may be interested in preventing future ankle sprains. If you are a bit of a couch potato (not recommended by physicians) it is likely the sprain was a freak accident and is unlikely to occur again.  On the other hand, if you are an active individual, the ankle is likely to be reaggrevated by future activities.   The good news is that future ankle injury can be prevented by non-surgical options including ankle braces (orthosis), strengthening and improving balance.

  1. Ankle BraceAnkle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity.  This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly.  If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).

  2. Balance: Balance exercises include: single leg standing, single leg squats, single leg calf raises, etc. Any of these single leg activities helps improve your balance while strengthening Dyna Discyour ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging.  A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles.  Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.

  3. Bosu Ball PlyometricsStrengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual.  Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball.   One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock.  I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock,Elastic Band Ankle Exercise and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left.   Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle).   Movements in all these planes of direction will greatly strengthen your ankle and improve your balance.  These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult.  A little TV time makes them infinitely more enjoyable.

Stat Fact: Basketball players with a history of ankle sprains were nearly five times as likely to sustain another ankle injury.

If these non-invasive interventions do not help the ankle instability, surgery may be considered.  Ankle surgery is done only in the most severe cases of ankle instability and would have to be recommended to you by an experienced orthopedic surgeon.

Ankle instability and sprains can hamper one’s recreational football and basketball career, but implementing these three main sources of rehabilitation (bracing, balance, and strengthening) can get you back in action sooner and keep you there longer.  Rehabilitation programs vary greatly from injury to injury and if you have chronic ankle instability it is recommended to see your physician or physical therapist to implement an individualized plan to help strengthen your ankle and get you back to 100%.  Let’s hope Dwight Freeney is doing his ankle exercises (enter his long walks on the beach) and keeping that ankle elevated (for the Colts’ sake that is!).

Dwight Freeney back in Action


Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. Review.

Loudon JK, Santos MJ, Franks L, Liu W. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review.  Sports Med. 2008;38(7):553-63.


02 2010

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