The Achilles Tendon Apocalypse

This last year I have watched more NCAA gymnastics than I ever have. Not only is it more accessible, but for the first time in years, I was also not coaching at meets on the weekends. This gave me the opportunity to tune in to ESPN’s “Friday Night Heights”. Over the last few seasons, I’ve noticed the amount of Achilles tendon injuries in collegiate gymnastics seems to be exponentially rising. This past week, LSU had their third Achilles tear of the season, with Kai Rivers going down during podium training prior to Friday’s meet. This is Kai’s second Achilles tear in 3 years, and unfortunately, this situation is becoming increasingly common. Personally, feel a sense of urgency in addressing this matter, and that something needs to change- NOW. Today, I give you my thoughts on the matter, some suggestions on what I think can be done to mitigate the risk based on current information available, and where I think future research should be directed.

Why is it (seemingly) almost always the ‘power’ gymnasts?

A friend of mine asked me this a few weeks ago. As a person with an education in (and passion) for exercise science, I’ll be honest in saying I did not have an immediate answer. My head started spinning with a million ideas. While I am a firm believer there are multiple factors that contributes to an Achilles tear (which I will get into later), there is one thing that stood out in my informal research. Of the 15-20 videos of Achilles tears I watched, many athletes had inefficient punching and/or landing mechanics.

I started to research Achilles injuries last season when Olivia Gunter (Former LSU gymnast who tore her Achilles in April 2018 on a double arabian) posted her thoughts on Twitter regarding her injury. Gunter revealed in her days as a gymnast, she was one to punch and land flat-footed. In her words, she could “get away with it” because she was a “powerful athlete'”. My first thought in regards to this is that maybe if the gymnast is extremely powerful, they don’t really need to learn correct punching mechanics- ie, fully pushing off the toes to get height, using the entire foot, etc, because they don’t need perfect technique to get height on their tumbling. I also believe that landing positions in women’s gymnastics- the stick position of elite and lunge of DP/college, leave a lot to be desired in terms of functional landing techniques. I don’t think it’s a stretch to say that improper landing techniques often cause injury, and may also be contributing to progressive wear and tear on the Achilles tendon. However, more research needs to be done on the latter at this time. On a more positive note, with the rise of sport science in the gymnastics world in the last 5-10 years, safer landing techniques are increasingly being implemented, so I think we are well on our way to addressing this particular issue.

The Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Every time a gymnast punches, runs or jumps (basically anything that goes through the high toe motion), the calf muscles pulls up on the Achilles. Over time, repetitive use of any muscle/tendon can lead to an overuse injury, This is when the tendon does not have enough time/resources to recover, and begins to lose structural integrity. In my research, I found an article from 2004 that analyzed the Achilles tendon with repetitive use. This study found that the part of the Achilles tendon that inserts onto the calcaneal bone became what they called “stress shielded” with excess repetitive use. Essentially, the tendon had less forces being pulled up on it by the calves, as the body re-directed the forces away from the irritated area. The stress shielded part of the tendon was found to have atrophic changes- decrease in its size and tensile strength. Essentially, this article suggests that when the tendon is irritated, the body tries to protect it, but in doing so, it becomes under-utilized and therefore weaker. Incorrect use of the foot during punching could not only increase the rate at which irritation occurs in the tendon, but also lead to a quicker decline in strength as a result of the “stress shielding” effect. Add in a maximal effort, and then the weakened tendon is more susceptible to tearing.

Why do so many athletes tear their Achilles in competition?

Factors that are said to impose stress on the tendon during activity include the size of the tendon, speed of muscle contraction (in this case, the calf muscles) and amount of contraction. During a competition, the adrenaline caused by competing likely increases the speed of muscle contraction and the size of the contraction, as the gymnast often flips higher and faster. This is great for minimizing amplitude deductions, but can be a problem for a weaker tendon that may not be able to withstand this increased force. Gymnasts often describe adrenaline from competition as giving them a little extra “oomph”- they run a little faster, punch a little harder, etc. This greater force can then exceed the maximum force threshold of the tendon, resulting in a tear.

Why are there so many Achilles injuries in college?

If I’m being honest, I think this could be due to multiple things. The first being related to biomechanics, the maximal load a tendon can endure can decrease over time due to factors like high training volume and relatively inadequate rest. So while the tendon may be undergoing structural changes in the latter years of club gym, the cumulative effect may not be seen until college. I also think there may be a link to nutrition, the onset of puberty linked to hormonal changes, and growth related factors.

Nutrition? Hormones?

The female athlete triad, which I learned in approximately 10 classes during my undergraduate kinesiology degree, is described as a combination of three major things- disordered eating, amenorrhea (absence of menstruation) and osteoporosis (decreased bone density). Past studies related to the female athlete triad have concluded that these factors can lead to increased risk of injury and health problems later in life- including heart problems and infertility. It is no secret that gymnastics has had its issues with disordered eating, and will for the foreseeable future. Part of this directly results from comments from coaches or judges, or more indirectly from feeling the pressure to achieve perfection in all senses. Most obviously, even just the fact that one experiences puberty while wearing a leotard in public can be enough to struggle with body image. In regard to Achilles specific injuries, poor nutrition caused by disordered eating during childhood and puberty can lead to decreased tendon strength. A person requires the correct nutrition to lay down collagen, primarily produced before age 25, which is the primary component of tendons. If a person is under-eating, they do not have the resources to continue to lay down collagen and build the strength in their tendons.

The second aspect, hormones, is also linked to this female athlete triad. Under-eating and extreme exercise is associated with the delaying of puberty and growth, often leading to delayed onset of menstruation. In puberty, the increase in hormones contributes to the increase in both tendon strength and bone density during time of growth. For gymnasts whose puberty is delayed, this could potentially have negative effects. In the non-sporting world, there also appears to be an increased amount of diagnoses of women with hormonal imbalances or struggling with conception. Whether this be attributed to our environment, food quality or simply just increased awareness leading to more diagnoses, it is hard to pinpoint an exact cause. Regardless, hormones need to be more vigorously investigated in the science world, both the impacts they may have on fertility but also female physiology as a whole (including tendon strength).

So, what should we do?

I wish I could wave a magic wand and have this all fixed, but unfortunately, I can’t. The three practical suggestions I have for current coaches are as follows:

  1. Teach proper punching (and landing) techniques

Efficient landings and punching techniques that allow for maximal muscle recruitment and force dissipation/production will only benefit the athlete in all aspects of sport. For this, strength and conditioning coaches can be brought in, and SHIFT movement science is always a good website to further coach self-education. For reference, this is a post I made on proper landing techniques a few years ago.

2. Rest= a crucial part of any training program

Rest if important for all gymnasts regardless if they are injured or not (though it does become even more crucial during injury management). It is also important to note that while not all gymnasts experience pain in their calf/Achilles prior to tendon ruptures, many do. In order for a tendon to recover and maintain its strength, adequate rest must be provided.

3. Implement strategic conditioning

Along with correct technique, gymnasts need great levels of muscle strength to maximize force production and dissipation. One of the ways to do this is to train the glutes (this will also have the bonus of increasing power). This allows the gymnast to add more power to their gymnastics while relying less on the force production from the calves/quads.

Next steps: more research

Ultimately, the greatest need to determine what will be best in preventing these injuries is scientific research specifically related to Achilles Tendons tears in gymnasts. While the suggestions mentioned above will help, only further research will give us insight on how to most accurately prevent these types of injuries. In my opinion, areas of future research should at the very least include:

1. Tendon characteristics and relation to different phases of the menstrual cycle

2. The impact of different landing/punching mechanics on Achilles tendon structure/strength and the long term impact on tendon health

3. Disordered eating and its impact on tendon tensile strength

4. The world we live in today and how our body is affecting the female body’s physiology (specifically- tendon strength)

Risk mitigation strategies, attention to the latest research in sport, and simply a will to improve the training regimen and athlete safety are foundational principles to decreasing the number of Achilles tendon injuries.

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