You're pottering along, walking the trail, cycling along the beach, running your training run or doing drills on the football pitch when - BANG!!! There's an almost loud gun shot sound from somewhere and all of a sudden you are on the floor and wondering how you got there? It's not uncommon for you to go to stand up and resume activity but all of a sudden, you can't stand on your leg at all, and down you go again. You look perplexed and amazed at this apparent interruption to your activity, and wondering what is going on? This is the situation of a full tendinous rupture.
What's so bad about a rupture?
There are many varying types of strains and pulls that happen to musculo-tendinous structures. We tear fibres every time we exercise. It’s how well we repair those small tears with more fibres and stronger fibres that enables us to get stronger and do the action better. That’s how we build fitness. However when we push too much and go too hard we make more tears than we are able to repair – hence strains, microtears and injuries.
A rupture is the big Daddy, the Nebuchanezzer of the muscular strain. Whereas a strain is a section of the muscular fibres (say a bicep) that have been torn or frayed, a rupture is a majority disconnection of the entire muscle from its tendinous connection. Usually, the ‘rupture’ is actually occurring not within the muscle itself but in the tendon that attaches the muscle to its bony connections. By definition, a rupture is ‘to burst, break through or split under pressure’. In the case of a tendon a rupture is defined by the muscle being unable to perform it's action. The rupture can be partial or complete, both requiring surgery to ‘re-attach’ the torn tendon. In the case of a 'complete rupture', the muscle is separated from the bony insertion and the muscle will ‘coil up’ like a string that has been cut, often producing notable, visual difference in muscular definition. i.e there is no muscular tension as the whole tendon is like a coiled up as roller blind that has lost it's spring.
The tendon rupture is prevalent in athletic individuals who are involved in explosive movements. Sufferers are often aged between 24-45yo who often have no presenting injury or history of pain in the structure but are involved in repetitive, constant recurring stress on the affected joint. It is most often caused by poor form in biomechanics and often it is an explosive or sudden movement that generates the rupture. Overloading the tendon is where the tear results and this is often in jumping, sprinting or throwing where maximum power is used to generate optimal force. These types of explosive actions often rely on muscular tension so especially in the cases of repetitive sports movements where you are involved in continuous actions for months at a time, tension and muscular strength builds up over time which can result in shortening of the muscular fibres. Placing these shortened fibres under that maximum load can result in a rupture where the load is unable to be sustained and the tearing of the tendon occurs.
A rupture needs surgery. The re-attachment of the tendon to the muscular fibres must be done surgically to ensure integrity of the fibres. This surgery can be done in an open or closed technique where incisions are made to re-attach the fibres. The all important factor associated with full ruptures is not necessarily the repair of the torn fibres, but the management and rehabilitation of the muscle itself.
With any rehabilitation of a ruptured tendon, there are certain timeframes that should be strictly adhered to. With any return to function, there has be a graduated return to load and movement so that re-injury is avoided.
At the outset of the initial injury, the acute phase involves immobilisation and restriction of the injury. This is where the body is trying to knit the broken fibres back together and like a frayed rope, you don't want to pulling on it and making the fray worse. This is where the body begins to lay down a haphazard matrix of collagen fibres to get some sort of connection back into the broken structure. Often there will be a form of immobilisation of the joint involved to prevent any risk of destabilising or further damage to the area. This is for approximately 2-3 weeks and usually in the form of a boot, brace or cast. Once this is removed after 2-3 weeks there may be further immobilisation that restricts rather than immobilises for up to 9 weeks depending on the severity of the injury.
Once the acute healing phase is done with and you have some integrity back into the structure, mobility is VITAL. Light movement and getting all soft tissues and muscular connections to once again be active and functioning is the primary focus of this stage. Re-introducing movement patterns and re-establishing the fluidity and range of motion to the joint space must begin here to enable full function to return later. It is very much like you are learning to walk again or just even get control back over the joint space. Not worrying so much about the injury itself at this stage but moreso the movement back into the primary joint space or articulation is most important. We need to get movement and co-ordination back on deck.
Then comes weight-bearing. Actually being able put a load or stress the injury to a point where it can begin to re-connect with normal function. Mucles respond to stresss. IT's how we get stronger and better. So we need to start stressin ghte injury without too much load or pressure so as not to re-injure the fibres. Here is where patience is key. So many eager beavers get excited that they are returning to movement or returning to activity and take it too far and too quickly and here is where the STOP sign of the therapist needs to be firmly in place. Restraining those who want to jump before they have walked.
Stressing the joint in all planes of motion is vital as well. It is great to be able to push or stand, but to be able to do this in different directions is where true recovery is important. Once you have established that you can put pressure on the joint space, you then need to start introducing pressure or load in differing directions or positions. Working through the FULL RANGE OF MOTION of a joint in this period is vital. Of course knowing when you can do a full squat is important, but understanding that this is the goal is a good way to head back to working with the joint space in a stable and structurally sound way.
After you have managed to establish weight bearing and movement, then comes the time to start ramping up the load. Small increases in weight and strength are important to get the fibres used to being able to handle loads more than just your own body weight or small stresses. Gradual increases in weight, or stress (therabands) are important here - again keeping in mind that you wan to work in a full Range of motion and in all planes of movement before progressing to stronger are increased weight. This is where the 'real work' of this rehabilitation begins. Slowly and conscientiously working that final goal of complete recovery starts here. There is still a long way to go but here is where YOU must put the work in that will establish your complete recovery.
As you begin to gain strength and power, you must then start to test the 'type' of stress you are placing under the injury. It is one thing to work the injury in a controlled and stable environment but when you are on the sporting field, the environment is anything but controlled. Speed and timing needs to be brought into the equation to encourage the stabilty of the joint and soft tissue when it is not only placed under load but also under time. Short sharp contractions and red fibre (fast twitch) contractions take a different type of approach and this is where you need to be working on stability and strength under SPEED to be able to be fully ready to return to full function. Committing to this stage of the recovery is often where 'weekend warriors' fail to make the distinction. Ensuring that the actions and the speed of the 'on court' experience aren't repliacated in this recovery phase. This is the boring stuff - where you are almost ready to get back into training but still need to work this all important phase of doing small, sharp, fast twitch exercises to be truly ready for competition.
It is worth mentioning that throughout this entire latter process of recovery, it is so important that you maintain health and length of soft tissue. This is the stretching, lengthening, foam-rollering, golf-balling maintenance of the injury. You want to make the fibres as malleable as possible and reduce any formation of scar tissue. Scar tissue is a haphazard arrangement of fibres and you want a nice 'parallel' configuration of fibres to ensure length and the most efficient contraction of soft tissue post injury. This is vital if you intend to be back to 100%, if not 110% of your former self. Bailing on this part of the process will mean that the injury will come back to haunt you.
It is worth noting that this long term projection of timeframe is indeed necessary as a rupture is very different to a strain. A rupture means that the muscle (or soft tissue) has been rendered 'useless' so all tone and integrity has been lost. You cannot expect to get this function back in the short space of 6 weeks. A strain = yes. A rupture = NO. A strain is like part of the rope has frayed - that there are a whole myriad of other connections still in tact to render the rope strong. A rupture is not - it is a cut that means the rope cannot bear the load and you need to take the time to reform this connection.
Being patient is so difficult. Understanding and committing to rehabilitation is frustrating, depressing, and boring. But as an old teacher said to me "injury is an opportunity to learn. Learn more about your body, learn how to be mindful of your limits and to learn how to do it BETTER". Like any monk-like sage, this comes with a certain amount of humility, focus and understanding that with time, all can be achieved and greatness can be the result. With daily and mindful investment and care to continue to work better towards the final goal.