Wednesday 7 September 2011

Vermaelen's injury - a specialist update

There has been much in the media of late on Thomas Vermaelen's recent injury and subsequent surgery, I intend to explain exactly what is going on to clear up any misunderstanding they may be on the subject. The following is written by a specialist Orthopaedic doctor.

Firstly the Achilles tendon is the main tendon that attaches to the back of the heel bone (calcaneus) which bends the foot/ankle down to the ground, it is obviously of key importance in jumping and athletic activity. The plantaris muscle is a small muscle of unknown importance, it attaches at the back of the knee joint at the top end, and down on the heel bone at the bottom end.

The statements released by various parties explaining Vermaelen's surgery/injury last season and this season do not all add up in a consistent fashion. Firstly he was out for a prolonged period last year after having surgery to address the 'inflamed' plantaris tendon, from this it has to be assumed that he had a degree of Achilles tendinosis, meaning 'degeneration' of the tendon, a condition which is particularly tricky to treat and which obviously took Vermaelen some time to settle down.Link
This season, the other side has flared up after an incident in the Udinese game and obviously the same surgery has been performed. The following statement was released by Arsenal FC:

"Vermaelen has undergone a minor procedure to remove an inflamed plantaris tendon from his left ankle. This is the same treatment that he had on his right ankle in January this year and has nothing to do with his Achilles tendon."

This statement is slightly economical with the truth in my opinion, it has everything to do with his Achilles tendon just as the same surgery did last season. In the scientific literature there is only a small amount of evidence relating to removing the plantaris tendon and it all links in with Achilles tendinosis. There is one large case series of re-operations involving removing the plantaris tendon in Achilles tendinosis and one far smaller series of cases involving removing the plantaris tendon in chronic Achilles tendinosis. The conclusions of these low quality studies state:

"The medial pain might be based on the involvement of the plantaris tendon in the process." and "The role of the plantaris tendon in midportion Achilles tendinosis needs to be further evaluated and should be kept in mind when treating this condition."

In conclusion Vermaelen's surgery is based on very little scientific evidence. Many experts would say that the surgery is of very dubious benefit, ie it is almost 'sham' surgery, a placebo treatment that only works because the patient is forced to rest for a decent period. Certainly no one could argue that there is any strong evidence to say that this surgery will definitely settle down his Achilles problems. It is worth remembering last season it took him many months to get back to full training, he experienced several setbacks after his plantaris surgery.

Achilles tendinosis is frequently a chronically painful condition, much like patella tendinosis (Owen Hargreaves has this), and there are few reliable treatments for them. Personally I am not quite sure why Arsenal are being slightly economical with the truth in this instance, it appears likely that they do not wish to scare supporters by revealing that Thomas Vermaelen's surgery may not be the long term definitive cure for his pain that they pretend it is. In reality we simply cannot reliably predict whether or not Thomas Vermaelen will recover fully, he may do, he may not. This is the truth about Thomas Vermalen's injury, it is not reassuring but it is the truth.


Anonymous said...

But they haven't said the surgery was to help the achilles tendon, so evidence of surgery on the plantaris effect on the achilles tendon is moot. He may have a susceptibility on his plantaris, rather than waiting around, letting it heal and then get set back every three weeks, they removed it.

There is no reason to believe they are treating tendonosis by removing the plantaris, they are removimg the plantaris so he can play without the chance of reoccurring inflation and set backs.

Kizito (from uganda) said...

Wow! Now ARSENE should move fast to secure Cahill!
We may have got our own Hargreves

Anonymous said...


There is absolutely zero in the scientific literature on plantaris tendinosis or removing plantaris for any other reason!

Last season he had the same operation, a well documented Achilles problem and suffered several setbacks after the operation.

Evidence on either is minimal or nonexistent!

I am sorry but your comments show you don't understand the conditions and their treatment.


Anonymous said...

I think last season's injury was on the other foot/leg than this season's.

Anonymous said...

Anonymous 1815

it is, read the article

he has the same problem on both sides


Anonymous said...

Last season they failed to figure out what the problem was and the operation was delayed. Instead they put him on a boot and waited till it healed. This time around they operated well in advance to avoid the mistake they made last time. Get your facts straight !!!

Anonymous said...

anonymous 1711

actually your argument and facts are plain wrong

he had it operated on last time, then suffered numerous setbacks after the surgery!

it took him months and months after the surgery to get back to matches!

your facts are just way off!

I am quite frankly amazed at some of the rubbish spouted in some of your comments

You clearly have no insight into your own lack of medical knowledge!!


Anonymous said...

Regadless of authenticity of d injury report, it is certain dat vermaelen's injury was caused by overworking brot about by wenger refusal to buy players who culd av lesened d poor mans defensive zeal. A look at Lionel Messi style of play, he doesn't burn much energy tru d use of skills and more dan enof gud players like him in d team to suport him. Arsenal as a club nids first eleven players and gud bench period. D era of living from hand to mouth is over if d team wsh to win trophis. Up gunners.

Anonymous said...

Slightly off-subject guys but Arsenal a lacking a bit of support over at the new My Team Tweet site. Plus it looks like quite a cool site for keeping tabs on the players on Twitter.

Anonymous said...

latest anon

vermaelen's injuries have been nothing to do with that

they are bad luck, he is just predisposed to these issues and there's nothing that could have been done differently I'm afraid


Anonymous said...

Gooner 1979

There may be no literature because there is no need to remove a plantaris tendon in a lay person, it's a rare injury in athletes, let alone an ordinary person.

The fact that two cases removed the plantaris, as an experiment on people who already suffered Achilles tendonosis, has no bearing on TV's removal, he's an athlete who can't afford to lose games due to an inflamation of a useless tendon.

There has been no diagnosis of tendonosis, he said in the interview the problem was not his Achillies even after all the setbacks.

Now he is either being lied to by the experts, and the club, or he is a liar himself.

This article is low on facts, high on conjecture and guesswork, and the literature cited is based soley on the Achilles.

To say that removal of the plantaris must always be due to the Achilles, based on two 'low quality' studies, is not convincing. An inflamed tendon that is of no use naturally could be removed for it's own sake, to save future flare ups. Makes absolute sense.

Anonymous said...

Anonymous 2053

With respect you are clearly not from a medical backgound and this is clear from your argument.

Utter nonsense about the reasons for plantaris removal not being documented EVER in isolation.

Ever heard of case reports?

Lots of super super rare stuff is written up as case reports, it is highly unlikely that TV has the first ever case, either that or there have been others and it has never been written up, that is also highly highly improbable.

The plantaris is a tiny muscle, arguably of no functional importance, thus claiming that 'plantaris inflammation' is the cause of someone's pain is a slightly silly thing to argue, especially in the conext of there being sod all evidence to back up your case!!

If your argument makes sense to you that that just proves how your lack of inside knowledge makes you incapable of understanding this whole thing.

It makes no sense at all.

If the achilles wasn't the problem lasy year, why was it widely documented as being the case?

Even have repeatedly called it an Achilles injury.

If it was just plantaris then why did he break down six times in coming back and take many months to get over such a 'minor' ailment?

I'm sorry but this smells of quackery of the highest order, as does your nonsensical and illogical argument.

Your argument is lacking in any logic or coherence, and your reasons for calling my piece 'conjecture' are based in rank ignorance I'm afraid.

Come back with some decent argument backed up by logic and evidence then you have a case, until then I'd educate yourself before exposing your ignorance to us all.

There is no case ever ever documented of the plantaris tendon causing any kind of disabling symptoms around the ankle.

Your argument that this is the case for Vermaelen is deeplu foolish and ignorant I'm afraid.


Anonymous said...

ps if you knew anything about footballers and medicine/surgeons

you would know that lots of surgeons do some very very dubious things to footballers because it makes them money

the footballer's groin is the classic example of this

and yet again there is zero decent evidence to back up the surgery done in lots of these groups of cases


Anonymous said...

You haven't backed up your thesis with any evidence though, it's complete guesswork, you or the person who wrote it, conclude

Vermaelen's surgery is based on very little scientific evidence

by quoting the basic notes of two low quality surgeries.

Why would i need a medical backround to be dubious of someone concluding something, with zero information of the state patients tendon.

This is not very scientific, and carries no weight. Not one expert opinion is quoted. Are you even sure you have access to the correct journals, are there only two cases worldwide of removal of this tendon?

Do you know the name or the surgeon who operated on TV, his credentials, would take a tiny guess he knows a lot more about the tendon than any of us speculating, and, yes, what you have done is speculation.

Anonymous said...

As a very experienced, very qualified medical professional (who also happens to be a fan) i can assure you all that this is a recognised condition amongst athletes/sportsman. There are many cases though not all documented(yet).The surgeon, in Sweden, has a vast experience in this area and let's not forget he solved the problem last year after the Arsenal docs/physios consulted him. Surgery to training was around six weeks i think. good outcome no matter how you look at it. Last year and this year it has been stated that the achilles was not to blame. it seems to me that this season they have acted quickly and we will see in six weeks if they have acted correctly. Please stop speculating especially if you do not know the facts (and i do not know them all...) The elite surgeons work on the unusual stuff and as for your comments on sportsmans groin.... ridiculous. there is so so much evidence out there.

Anonymous said...

Wow, slagging off your readers because they don't agree/are dubious of your knowledge..

1970's gooner - I shall not be visitng this site again.

Anonymous said...

2131 anon

how about you bother to look at the references, one is a series of over 70 patients

Until you can actually say anything of value or coherence, I suggest you put a large sock in it.

You consistently fail to understand the argument put forward, it is pointless engaging with someone of such ilk I'm afraid.

anon 2208


Give me one case documented of planaris inflammation leading to pain distally over the achilles area? (as you state)

Just one to back yourself up. If not then it's just hot air.

Last season's injury saw him suffer numerous setbacks and months to get back to a match, it was many months not six weeks I'm afraid, so facts are wrong there.

Again this backs up the case for it being sham surgery.

Surgery was in January and didn't make it back to the first team til middle of may! 6 weeks my arse.

Sportmens groins is another topic, but there is a hell of a lot of sham surgery out there.

The marvels of the placebo effect.

I may be speculating but I am pointing out several massive inconsistencies with the official line, and you have failed to adequately address any of these inconsistencies I'm afraid.


Anonymous said...

anon 2216

oh dear, what a loss

there has been 6 of one, half a dozen of the other here

if you cannot engage in the argument then cheerio, that's just a bit sad, you obviously found time for your spiteful little comment


Anonymous said...

Sorry Gooner, you are the one who can't understand.

You put forward the circular position that

a) The only reason for the operation was to do with the achilles.

b) The achilles cannot be treated that way effectively

And conclude that there is no merit to the Swedish specialists diagnosis, and/or the club are liars.

The burden of proof lies with you, and so far the evidence shown is two flimsy reports on the Achilles tendon.

You refuse to accept that maybe, just maybe the whole team of specialists, consultants, and surgeons Arsenal used, had access to google and a first year medical book, and yet went ahead like idiots and sacraficed a player as valuable to the club as TV based on no solid theory.

They only had from September to the end of January to do tests, research, and diagnose, being at the top of their field, you assume they didn't find good reason to believe they had found the problem, and that surgery was the correct solution?

Sorry, but you haven't discharged any of the burden the accusations warrant, don't get pissy when people point it out.

1979gooner said...

Latest anon0026

For the umpteenth time

I am not calling the club liars! I am saying they are being economical with the truth, there is a difference.

My 'circular' argument as you call it, is misrepresented by your own ignorant and naive assumptions. Due to your own lack of knowledge, you have made too many assumptions of your own that are based on foundations of sand.

The achilles can be treated with plantaris excision and there is a growing evidence base to support this, this is probably why Vermaelen has had his surgery, if you had bothered to read the articles references, you may have realised this.

Plantaris inflammation in isolation as a cause of disabling ankle pain has never ever ever been written up, even as a case report.

Your failure to even find a single case report or single piece of evidence to prove that this condition can exist in isolation gives your weak case away, you ignore this don't you? I am waiting.

Until then your argument is exactly what you accuse mine of being, it is a weak circular argument based on a lack of knowledge and faulty assumptions.

I would love to know if you think 'plantaris inflammation' kept Vermaelen out of action for almost the whole of last season?

Also after surgery it took him about four months to get back to action, hardly a rapid straightforward cure was it?

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