Joey Wahler (Host): They're seeing a recent rise, so we're discussing Achilles injuries. Our guest is Dr. William Corey. He's an orthopedic surgeon specializing in foot and ankle surgery for Novant Health. This is Meaningful Medicine, a podcast from Novant Health. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Corey. Welcome.

William Corey, MD: Hi, Joey.

Host: Great to have you aboard. So, first, pickleball, of course, is exploding in popularity these days, especially among adults over 50. So, what do you think is driving this trend and why as a result are you seeing more Achilles injuries?

William Corey, MD: Well, pickleball first off is very fun. I've done it several times with my kids. It's grown in popularity, I believe, because not to take away from any professional pickleball players, but it's very easy for people to pick up at any age from young to old. So, it's very easy for people that aren't necessarily active to pick it up and go play with friends. And it's a nice social event. So, I believe that's why it's picked up in popularity.

Host: Gotcha. Now, one thing that puzzles me about pickleball-related injuries is one of the advantages of pickleball is supposed to be the fact that compared with tennis, it's a smaller court, less running around. So, why all the Achilles injuries?

William Corey, MD: Well, I think that's exactly why we're having so many Achilles injuries. One is the clientele or the people playing pickleball sometimes aren't necessarily those that have remained active their entire lives. They've decided to pick it up later in life. And two, it is a lot of stop and go, a lot of lunging, instead of tennis where you have a larger court and you're running for longer distances. I think that's why we're seeing a rise in Achilles injuries with pickleball.

Host: So, more sudden movements as opposed to having to run around more and cover more court then, right?

William Corey, MD: Correct.

Host: Gotcha. So for people new to pickleball, what are some early signs of Achilles strain or overuse that shouldn't be ignored so that hopefully you can fend off that more serious injury?

William Corey, MD: You might feel a little bit of tightness in your heel cord. Sometimes you'll feel pain at the end of playing or tightness when you first wake up. But unfortunately with a lot of Achilles ruptures, there's no prodromal phase before it. You'll just feel a pop in the back of your leg. It'll feel like somebody kicked you in the back of the leg or you got hit with a rock. And there's really no way to know that it's coming.

Host: How about prevetative steps we can take as pickleball players-- I say we, even though I've never played pickleball, but speaking for those who do-- to protect their Achilles and other foot or ankle structures? How about if we start with stretching? We all hate to stretch. But especially as you get older, you have to do it if you really want to do everything you can to avoid these injuries, right?

William Corey, MD: Sure. Achilles stretches, there's a runner's lunge with a hands on the wall, one foot behind you, bending the front knee. Getting up on stairs and letting one heel fall down towards the ground, like gravity taking it towards the ground. And you'll feel it stretch in your Achilles and your calf muscle. And then, stretching all your other muscles as well, quads, hamstrings. Those are very important before and after playing.

Host: Anything else pickleball players should do as part of their warmup routine?

William Corey, MD: Certainly warming up by running around the court, doing stretches. And then, maybe just hitting the ball back and forth before just getting right into the game.

Host: How about footwear? We know that they have tennis sneakers for years for that sport. How about for pickleball? What should you be wearing?

William Corey, MD: A good supportive shoe. Making sure that the age of your shoe is not old. You know, if you're playing pickleball frequently, I would say have a pair of shoes that you have set aside strictly for pickleball, and should probably be changing those shoes out at least every six months. For runners, we tell them they should be changing them out every 400 to 600 miles or at least every six months. And non-slip shoes. So just like in tennis when you're playing on a clay court, you don't want to go out in your running shoes and slide all around. So, you want to make sure that there's a good amount of grip on the shoes so they're supporting you when you're running back and forth.

Host: So simply put, Doctor, is it safe to say that a lot of these Achilles injury in pickleball occur for much the same reason among older folks that other sports-related injuries do, which is oftentimes it's people trying to do too much too soon, right?

William Corey, MD: Correct. But prior to pickleball, probably the number one injury we would see it in is what we would call weekend warriors or girls and guys in their 30s and 40s, say, a guy wanted to go play pick-up basketball with his son, and he hasn't necessarily played for maybe 10 years. He goes out and tries to play and ruptures his Achilles. But again, we see it in professional athletes as well. Kobe Bryant ruptured his playing basketball. Recently, Daniel Jones, the quarterback for the Indianapolis Colts ruptured his. So, you see it in really all age groups and all levels of athletes.

Host: So if someone does experience an Achilles injury, at what point should they consider seeing a specialist like yourself? Where is the line do you think?

William Corey, MD: Well, I would say if somebody believes that they ruptured their Achilles, they probably should be seen the same-day in an urgent care center or the emergency room. Certainly if it's during business hours, you could call straight to an orthopedic office like ours and get put on the schedule same-day or next day, preferably the same-day. Oftentimes, we will order an MRI and discuss options for conservative or operative management depending on the injury and the patient.

Host: And before we talk about those options in just a moment or two, what's the basic range of Achilles injuries themselves from say least to most serious? What can you wind up suffering?

William Corey, MD: Probably least would be a strain of the calf muscle or the Achilles, you feel a little twinge or maybe a little bit of pain, but you don't have a complete rupture of the Achilles. We oftentimes see chronic injury, more often in the older population, which is Achilles tendonitis, both insertional tendonitis, which is inflammation of the tendon itself, where it inserts into the heel bone, and also sometimes higher up in the Achilles proper. And then, Achilles ruptures, like we talked about, would be the most severe.

Host: And when we say rupture, is that the same as tear?

William Corey, MD: A complete tear. So, you can have a partial tear where the two tendon ends don't completely separate, where a rupture is typically 80%, 90% to a complete rupture.

Host: And a completely ruptured or torn Achilles is really one of the top dreaded injuries in all of sports, isn't it?

William Corey, MD: Yes, it definitely can be, especially for specific athletes that require bursts of speed, acceleration, like a running back or a wide receiver or a cornerback. In basketball players, like when Kobe Bryant ruptured his, he went from doing, you know, 360 dunks to become, you know, more of a jump shooter. You don't get that explosive power through your Achilles. And often, these can lead to really the detriment of athletes like a running back. You very rarely see a running back get back to their peak potential after ruptures of their Achilles. Where somebody like Aaron Rogers that ruptured his, he's not a very mobile quarterback. So, getting back on the field and throwing in the pocket is not as difficult as say if Lamar Jackson ruptured his Achilles, he is known as a dual threat quarterback, it would be very difficult for him to get back to that top line speed. And it'll be interesting for Daniel Jones because he is a dual threat quarterback as well if he changes his play after he comes back from his rupture.

Host: Yeah. Very good analogy there. So, how about treatment options? What are the typical choices there?

William Corey, MD: So to go back the history of Achilles ruptures, for a while, everybody treated all Achilles ruptures with these big incisions in the back of the heel. And we would suture the tendons end to end with a bunch of suture, and close it up. And occasionally, it is an area that doesn't have great blood supply. The skin doesn't have great blood supply. So occasionally, we would see wound dehiscence, which means that the wound opens up. Sometimes infections. So, way back, people decided to try to treat Achilles ruptures conservatively, and they would do that with casting. And then, they found that with casting, once they took the patient out of the cast and did their therapy, that they would be more likely to re-rupture their Achilles tendons. So then, people went back to treating Achilles ruptures open through smaller incisions, and now through the advent of minimally invasive surgery. We started treating patients with what's called the PARS technique or the percutaneous achilles repair system. So, we can treat the Achilles through a tiny little incision and percutaneous suture technique, which has been fabulous for recovery, very minimal risks involved with it, faster recovery. So, that's been great.

But also recently, there's been studies where they've started treating patients again conservatively. They did it with immobilization for two weeks, and then early range of motion and early weightbearing through a boot. And with frequent physical therapy or range of motion, they've actually found that these patients, the re-rupture rate is equal to operative management and they actually do fairly well. So, there's times when we can treat patient's conservatively without surgery. That being said, I have yet to hear of any professional athlete treating their Achilles rupture conservatively. But for the lay person, that is not very active, that is an option.

Host: And then, you mentioned recovery time. What is the typical surgery recovery time?

William Corey, MD: Typically, after surgery, the patient's splinted for two weeks. They have their sutures removed at two weeks in the office. And then, they go into a range of motion boot and slowly bring their ankle back into neutral dorsiflexion, allowing them to bear weight at six weeks in the boot. Starting early range of motion and the early physical therapy. And then, they're allowed to start bearing weight in the boot at six weeks. And the boot typically comes off by 10 to 12 weeks. Starting light jogging at 12 weeks. Some more aggressive cutting exercises by six months. And occasionally, you'll see athletes back in the seven to nine-month range. But typically, it's a one-year to 18 months before you're really back fully.

Host: Yeah, that's what we often hear with these big pro athletes. Like some of those you mentioned, right? Guy tears it or gal. And boom, that's a year. So, you have an idea there. In summary, finally, Doctor, simply put, you've covered a lot of great details for us here, but overall, how can older or recreational athletes continue enjoying pickleball and other active hobbies, while minimizing their risk for injury on a long-term basis?

William Corey, MD: Like we talked about slowly getting into the sport, not just going out and playing a match right at the beginning, getting lessons, proper shoe wear, stretching. And also, just knowing that there is that risk involved. But I always tell people that being inactive is much more risky than taking a risk and going out and being active because there's so many comorbidities that go along with sedentary lifestyle, obesity, heart disease, diabetes, that I think the risk of going out there and being active is better than the alternative.

And also, I always tell patients cross training is very important. If you do the same thing over and over again, there's a very high-risk of just repetitive use injuries. So, walking, weight training, especially for the older patient is very important for bone strength. And working in a sedentary bike or a regular bike or rowing, yoga, instead of just doing the same thing over and over.

Host: Yeah. Just basically try and prep your body so that it's not a complete shock to the system, whether it's pickleball or anything else. Well, folks, we trust you're now more familiar with Achilles injuries. Dr. Corey, appreciate it. Keep up all your great work and thanks so much again.

William Corey, MD: Thank you, Joey.

Host: And for more information, please do visit novanthealth.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of Meaningful Medicine, a podcast from Novant Health.