Vermaelen and his Achilles heel

It appears that Thomas Vermaelen is having surgery on his troublesome Achilles tendon in an attempt to rid him of the pain that has blighted his season thus far. I am sure there will be much comment in the media and many people will claim to know when Vermaelen will return. Sadly the truth about Achilles tendon problems is that no one really understands them and their treatment is also far from reliable. Anyone pretending to understand the Achilles is lying and ironically those who make it clear how unknown this area is are probably far nearer to the truth.

This piece by a Physio was far more accurate than most and the best thing about it was the fact that the author got across the unknown of the whole subject, he made it clear that we simply do not understand what goes wrong when people get pain in the Achilles tendons and consequently the treatments for it are erratic at best, if rest doesn't work then the surgery isn't the most reliable. I shall try to explain precisely what I mean in all this.

The most reliable term for the diagnosis is 'Achilles tendinopathy', essentially 'tendinitis' is inaccurate as 'inflammatory changes' are not found in problem tendons. Achilles tendinopathy is common in athletes but the mechanisms behind its development are poorly understood. The classical clinical features of the condition are pain and swelling in the region. In the acute phase there may be no abnormalities in the tissue and on imaging, however as the condition becomes chronic degeneration and scarring of the tendon will become more prominent. Of note Thomas Vermaelen's scan was normal, further muddying the water as it were.

Typically the initial treatment is conservative and involves resting, then hoping that things just do away. This works in about a third of patients or so. Surgery is then the next treatment if the conservative 'wait and see' strategy has failed after a period of months. The surgical techniques vary from surgeon to surgeon and the word 'witch craft' does spring to mind when talking about it, generally most of them involved cleaning away unhealthy tissue ('debriding') and trying to stimulate the body's natural processes of healing.

The results of surgery are pretty good overall with a majority of patients getting back to a pretty good level of function, however there is a significant complication rate (approximately 5-10%) and a lot of time is needed for full recovery. Realistically it is unlikely that a professional footballer will be back in full training for 2-3 months following surgery, meaning that Thomas Vermaelen's season may well be over. There is also a chance in the untroubled Achilles becoming troublesome at a later date, this has been reported to occur in up to around 50% of cases.

I am not trying to be deliberately gloomy but the talk of a March return for Thomas Vermaelen looks more than just a tad optimistic. Have a read of the above paper if you are scientifically inclined, it will help you realise that a lot in medicine is not black and white, this is most definitely the case for Achilles tendinopathy. If any of you have any questions about this condition then please feel free to ask away, my fingers are currently crossed for TV, let's hope he can finally get lucky.