It seems as if your vocation in the NHL is a defenseman, do not play for the Flyers, it is guaranteed you will end up on the IR for an extended period of time. The latest two players to be hit by the injury bug are Andrej Meszaros and Andreas Lilja. I am going to cover off on the Meszaros injury here and later in the week post up the Lilja injury.

What I want to go over here, is the process of the surgery Meszaros will have and his journey back to the ice hopefully. I know there have been examples in the past of elite sportspeople getting back to their previous playing level but it is not as common as I like and I hope Meszaros achieves 100% recovery.

Everyone knows how easy it was for Meszaros to tear his Achilles, just some simple plyometric drills and bang, it had snapped. If only the recovery was just as easy, here is a look at the process for Meszaros.

Achilles Tendon Overview
The Achilles tendon, or tendon calcaneus, is a large rope like band of fibrous tissue in the back of the ankle that connects the calf muscles to the heel bone (calcaneus). Sometimes called the heel cord, it is the largest tendon in the human body. When the calf muscles contract, the Achilles tendon is tightened, pulling the heel. This allows you to point your foot and stand on tiptoe. It is vital to such activities as walking, running, and jumping. A complete tear through the tendon, which usually occurs about 2 inches above the heel bone, is called an Achilles tendon rupture.

Achilles Tendon Rupture Causes
The Achilles tendon can grow weak and thin with age and lack of use. Then it becomes prone to injury or rupture. Achilles tendon ruptures are more common in people with preexisting tendinitis of the Achilles tendon. Certain illnesses (such as arthritis and diabetes) can also increase the risk of rupture.

The injury can happen in these situations.

• You make a forceful push-off with your foot while your knee is straightened by the thigh muscles. One example might be starting a foot race or jumping (Meszaros).
• You suddenly trip or stumble, and your foot is thrust in front to break a fall, forcefully over stretching the tendon.
• You fall from a significant height or abruptly step into a hole or off of a curb.

Surgery for Acute Achilles Tendon Tears

There are two types of surgery to repair a ruptured Achilles tendon:

• Open surgery: the surgeon makes a single large incision in the back of the leg.
• Percutaneous surgery: the surgeon makes several small incisions rather than one large incision.

In both types of surgery, the surgeon sews the tendon back together through the incision(s).

• Both open and percutaneous surgeries have successful recoveries. More than 80 out of 100 people who have surgery for an Achilles tendon rupture are able to return to all the activities they did before the injury, including returning to sports.
• Although percutaneous surgery have traditionally been viewed as having higher re-rupture rates than open surgery, studies now show that the re-rupture rates are similar. About 5 out of 100 people who have surgery for an Achilles tendon rupture will re-rupture after surgery.
• Open surgery is more likely than percutaneous surgery to result in wound healing problems. But damage to a nerve is more likely with percutaneous surgery. Newer techniques for percutaneous surgery may make nerve damage less likely than when older techniques are used.

It is sometimes difficult to know how surgeries compare, because the ages and activities of those having the surgeries differ. The success of Meszaros’s surgery can depend on the surgeon's experience, the type of surgical procedure used, the extent of tendon damage, how soon after rupture the surgery is done (Meszaros was within 10 days), and how soon Meszaros’s rehabilitation program starts after surgery and how well he sticks to it.

The objective of the treatment is to restore normal length and tension to the tendon and allow Meszaros to do what he could do before, play at a high level in the NHL. The idea is to perform the repair before scar tissue has formed, which would make the repair more difficult. Some surgeons may recommend delaying surgery a few days from the initial injury to allow swelling to subside before proceeding with the repair.

Surgery for an acute Achilles tendon tear is seemingly straightforward. The ends of the torn tendon are surgically exposed and sutures are used to tie the ends together. The sutures used to tie together the torn tendon ends are thick and strong, and are woven into the Achilles both above and below the tear.

While the concepts of surgery are straightforward, the execution is more complex. Care must be taken to ensure the tendon is repaired with the proper tension -- not too tight or too loose. The skin must be taken care of, as excessive handling of the soft tissues can cause severe problems including infection and skin necrosis. Nerves are located just adjacent to the tendon, and must be protected to prevent nerve injury.

Surgical Complications
There are obviously complications possible with Achilles surgery, or any surgery, that need to be taken into account:

• Wound Complications: The most common complications are problems with the skin healing. These problems can happen with anyone, but are especially common and problematic in diabetics and smokers.

• Infection: Infections are also problematic, and often the cause of wound healing complications.

• Nerve Injury: An important nerve that provides sensation to part of the foot is next to the Achilles tendon. Injury to this nerve can cause numbness in the foot.

• Re-Tear: Achilles tendon healing is not a guarantee, and the repaired tendon can be re-torn.

• Range of Motion: This may decrease due to the shortening of the tendon in the process of piecing it back together.

Rehab After Surgery
There are many protocols for rehabilitation following surgery for an Achilles tendon tear. Most surgeons use some protection including walking boots or splints, but also start early motion. Studies have demonstrated that motion can be started immediately following surgery, but protection is needed while walking. In patients at higher risk for complications, immobilisation with a cast may be continued for several weeks or longer.

In general, most patients return to walking in 4-6 weeks, strengthening after about 8 weeks, and exercising at 3 months. Most patients who are athletes do not return to their sport for about 6 months, and many can take longer to fully recover from Achilles surgery.

For successful healing after surgery it is important to have good blood-flow through the Achilles. Blood pooling is common unless the leg is kept elevated, this is especially important for the first few weeks after surgery, so it will be important for Meszaros to keep this in mind. Promoting ACTIVE blood-flow through the area and preventing the stagnation of blood in the area after surgery is important and probably the single most important point regarding healing of the actual tendon.

Immediately after surgery and for the next 3-4 weeks Meszaros should keep the leg elevated almost constantly.  if the leg is lowered, even for a brief moment, the blood will flow down to the foot and could start to feel ‘full’. So getting the foot higher than the heart is very important to ensure the blood doesn’t pool in the foot. This could cause problems in the hip later, just due to the angle and inactivity through the joint, it is hard to minimise this effect on the body. Sleeping with several pillows under his leg will help Meszaros keep the leg elevated during sleep. Getting good sleep is very important, so much heeling is acheived during sleep, self-hypnosis to get to sleep is a great way of trying to avoid pain killers, it can also help with blood circulation.

Getting out of the traditional plaster cast as early as possible and into a ‘moon boot’ is important as it allows access to the recovering area and will allow light massage to the Achilles to encourage blood flow and healing. The down side to getting into into the 'moon boot’ quickly is the Achilles is very fragile and any sudden movement uncontrolled can snap it again. So Meszaros will have some decisions to make.

Getting a big shoe to match the height of Meszaros’s 'moon-boot', is important for his pelvis and knees. To avoid inflammation in his hips and knees it important when on crutches to make sure he is not leaning off his ‘moon boot’ onto a lopsided shorter leg.

Meszaros will have to wait until the scar has healed to make sure there is no chance of any kind of infection, but swimming and walking in a pool are the single most useful exercise for the leg overall. In each pool session the aim is for an improvement in proprioception (proprioception is your ability to perceive, be aware of and use in fine detail, of the foot) and range of movement, dorsi flexion, plantar flexion etc.

Tasks post ‘moon boot’
Use his toes - doing exercises to use his foot and move his ankle as much as he can. “Grabing” the carpet with his feet, and “walking” his leg forward (from a sitting position) by using his toes.

Do little “push-ups” with his foot - the best way to do this is to “stand on tip-toes” with his injured leg, BUT only from a sitting position at first. So at first Meszaros will only lift the weight of his lower leg, later weights can be added on top of his knee as his Achilles gets progressively stronger. Meszaros should focus more on getting full proprioception of his leg, that is, learn to use the whole foot again as much as possible. Using a ball to increase the foot’s ability to “manipulate” objects and so on. This is key in my opinion for good recovery.

Massage - Liquid accumulates in the injured area and other joints and eventually hardens and solidifies making movement difficult. By massaging the “liquid” up into the main body of the leg Meszaros can promote better circulation and reduce swelling mechanically, which will help Meszaros’s foot, ankle, and leg in general to stay “alive” and not atrophy muscularly (which will happen anyway) but proprioceptively. 

Focus on proprioception more than strength - Meszaros should concentrate on making sure the movement of his foot is correct. As soon as walking without the ‘moon boot’ is possible Meszaros should concentrate on ensuring the motions of his foot are correct, practice in a pool if he needs to.  This could be possible about 7 weeks after surgery, which is way ahead of a traditional schedule, (he could still be in a solid cast). But I must re-iterate, this new found mobility is probably THE MOST DANGEROUS TIME, extra care should be taken. This is a critical period, a simple thing like a wrong step, tripping, or stepping inadvertently off a curb or onto some obstacle will rupture his tendon again.

Use a pool - The use of water to be able to walk with a much lowered weight so Meszaros can make sure the foot is moving correctly when walking, slow motion is very important. A lot of problems can be avoided by ensuring his motion and proprioception are correct. Exercising in the pool will help lower the “fear threshold” his injured leg will have. It is important to make his leg do the right movements, non weight bearing at first.

In fact, Meszaros can begin by manipulating his foot with his hands in the pool, very gently before trying to get his leg to do it by itself. Concentrate on getting the movements to be smooth and natural instead of jerky and sporadic. The smoother and more natural the movement, the easier it will be to use his leg again when it has strength. Strength, of both the tendon and the surrounding muscle tissue, is easily increased once the tendon is fully healed, but recall this takes at least 6 months. So Meszaros will need to make sure all his movements are correct and working well before he has the strength to do the movements with full body weight.

Understanding how important it is to make his leg activate the same way it moved before the injury, while at the same time understanding that his physical strength and structural strength to do so will not be available until months later, is probably the single most important point for correct healing of his Achilles.

Hopefully after five months Meszaros will be back walking again, to a point that a bystander would not know he had been injured.

Activities that should be possible:

• Gentle jogging, cycling, and trying to stand on tip-toes (this could still be the hardest movement for Meszaros and will probably have a lot of assistance from his other leg to take his body weight.
• Stretching, Meszaros should have been doing some form of this throughout his recovery, but now he can attack it with more specificity.
• Re-building calf strength, the best way to do this is by walking and even hiking in gentle hills an hour or so a day. Begin to re-distribute weight evenly and make the injured leg carry its own load as much as possible without straining the leg.

From there the rehab could finish up at 6 months and get back to normal activity. Which should allow Meszaros to get back into playing shape. Hopefully the recovery has gone smoothly and he wont have issues through his hips from being off one leg for so long. How quickly he can get back on the ice will be effected a lot by his mental ability to push his body without fearing the worse, another tear.

I am not sure if he will make it back for this season, it is going to be playoffs by the 6 month estimate comes due. Personally I think it would be folly to push it, rush him in for the playoffs, if snapped again, it could be his career. You never want to see a player injured so here is to a quick and strong recovery.