Should Nic Naitanui return to football in the Derby?

It’s only 7 weeks since the West Coast Eagles star ruckman Nic Naitanui underwent Achilles tendon surgery on both ankles (Hagdorn, 2016). How can he have recovered so quickly to be picked to play in this weekend’s Derby, against cross town rivals Fremantle? All those who watch Australian Rules Football know how tough a local derby can be, so players need to be fully fit to make an impact. With the resources and expertise at every professional sporting organisation it would be expected that if a player is selected to play, they are ready to play. For all those, who have had a painful Achilles tendon it’s hard to believe that a player can be ready to play professional football only 7 weeks from surgery. How have they achieved it?

Achilles tendinopathy is an overuse injury that occurs frequently in athletes who compete in jumping and running sports (Grävare Silbernagel & Crossley, 2015). It is known as a failed healing condition with no evidence of active inflammation (Malliaras, Barton, Reeves, & Langberg, 2013). Appropriate loading of the tendon via exercise has been found to be the most effective treatment. As Cook, Rio, Purdam and Docking (2016) point out exercise and load management are fundamental to treatment. However when conservative management fails then surgery may be considered.

This is where it gets interesting. As early as 2002 it was identified that acceptable short term results could be gained from surgery for Achilles tendinopathy if patients only had peritendinous adhesions (Paavola, Kannus, Orava, Pasanen, & Järvinen, 2002). This means surgery is only conducted around the tendon and releases tissue rather than operating on the Achilles tendon itself. Added to this, recent research has shown a small muscle known as plantaris might actually be the cause of pain around the mid Achilles tendon. When removed, symptoms can reduce dramatically and 94% of elite athletes treated this way were able to return to competition at an average of 10.3 weeks (Calder, Freeman, & Pollock, 2014). Midportion Achilles tendinopathy can reoccur in these patients however it was reported as low as 5% (Alfredson, 2016). Open surgery on the Achilles has also been found to be effective but its important to realise that when the tendon is disrupted return to sport may take as long as 18 months (Calder et al., 2014).

It appears then, that Nic Naitanui had either both his plantaris muscles excised or adhesions removed from around his Achilles tendon. This has allowed his rehabilitation team to load his tendons earlier and progressively add to this so he is ready to return to play this weekend. One word of caution; most of the studies in this blog refer to recurrence rates for mid portion Achilles tendinopathy and this is certainly the case when surgery is part of treatment. At the end of the day good load management and gradual increase in activity is the proven methodology for treating Achilles tendinopathy. However if you’re like Nic Nat and you’re a professional footballer with a big game to play then surgery may be the option. For his sake let’s hope he’s one of the success stories.

Comments and feedback are always welcome.

Alfredson, H. (2016). Low recurrence rate after mini surgery outside the tendon combined with short rehabilitation in patients with midportion Achilles tendinopathy. Open Access Journal of Sports Medicine, 7, 51–54.

Calder, J. D. F., Freeman, R., & Pollock, N. (2014). Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes. British Journal of Sports Medicine, 1–4. doi:10.1136/bjsports-2014-093827

Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine, bjsports–2015–095422–. doi:10.1136/bjsports-2015-095422

Grävare Silbernagel, K., & Crossley, K. M. (2015). A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 876–886. doi:10.2519/jospt.2015.5885

Hagdorn, K. (2016, June). Prolonged time out for Nic Naitanui with news of surgery on BOTH ankles. WA Today. Perth. Retrieved from http://www.watoday.com.au/afl/west-coast-eagles/prolonged-time-out-for-nic-naitanui-with-news-of-surgery-on-both-ankles-20160615-gpjxpt.html

Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes: A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine, 43(4), 267–286. doi:10.1007/s40279-013-0019-z

Paavola, M., Kannus, P., Orava, S., Pasanen, M., & Järvinen, M. (2002). Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study. British Journal of Sports Medicine, 36(3), 178–182. doi:10.1136/bjsm.36.3.178