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After earning a degree in molecular genetics from Ohio
State, Canales got his doctorate from Ohio College of
Podiatric Medicine. A gymnast at OSU from 1996-99,
Canales, who is married to 1996 Olympic gold medalist
Dominique Moceanu, now specializes in foot and ankle
surgery at St. Vincent’s Spine & Orthopaedic Institute in
Cleveland. He recently discussed the topic of Achilles’
tendon injuries with IG Editor Dwight Normile.
MikeCanales
Are Achilles’ tendon injuries
more likely to occur with forward
or backward tumbling?
Anecdotally, in my experiences as a
gymnast, fan, and physician, I’d say
backward tumbling.
As a former gymnast and now a doctor specializing in foot
and ankle surgery, are you surprised by the amount of recent
Achilles’ tendon injuries? Absolutely not. Achilles ruptures are
becoming a hot-button topic, but I forecasted this back in 2006
when I spoke on them at the USA Gymnastics National Congress.
I closed my presentation by saying, “It’s never too late to do the
wrong thing.” In other words, emphasizing difficulty and amplifying
training demands with a lack of knowledge would create the perfect
storm. With recent ruptures suffered by Anja Brinker, Benoit
Caranobe, Becky Downie, Fabian Hambüchen and Vanessa
Zamarippa, we’re in the eye of that storm right now.
How much of this trend can be blamed on the modern tumbling style, which includes numerous combination passes
with consecutive punching of the feet, ankles and legs?
Partly, since learning, training and performing these passes puts
more mileage on the lower extremities. There are other culprits.
Lack of understanding in the gymnastics and medical communities
is also to blame. No snowflake in an avalanche feels responsible,
but as a constituent of the gymnastics community, I accept blame
for not alerting Dr. Michel Léglise and the rest of the FIG Medical
Commission to take a grave look at this mounting problem.
“Emphasizing
difficulty and
amplifying training
demands with a
lack of knowledge
would create the
perfect storm.
…we’re in the eye
of that storm
right now.”
Compare the amount of body stress caused by a roundoff-back handspring-double layout, and a roundoff-back hand-
spring-2.5 twist-punch front layout-full. The first redirects
horizontal momentum upward, while the latter represents
almost a complete momentum reversal with the last skill.
Stress is an average force per unit of area. Intuitively, the takeoff
for the former would create more stress, although it’s tricky to
quantify the cumulative force per area of the combination pass. So
while the stress incurred by a double layout appears more dramatic,
perhaps the cumulative damage incurred by the latter may be more
severe.
David Beckham’s (soccer player) Achilles rupture didn’t appear to
be the result of great stress, so I’m not convinced stress is the
entire issue. In my mind, the quantity of tendon degeneration is
another key cause.
What causes the Achilles tendon
to rupture? I don’t know. The
Achilles is the strongest, thickest tendon in the body, and it’s
responsible for transmitting force from the calf to the foot. It’s set
quite a distance from the ankle, [which is] perhaps the main reason for its vulnerability. I used to think an abrupt force—the takeoff after a back-handspring—caused a violent contraction of the
calf which resulted in a saw-like force through the tendon and
hence the “mop-end appearance” after ruptures. But now I’m not
so sure.
Cadaveric studies show a decrease in the blood supply in the
mid portion of the Achilles about half an inch to 2 inches above
its insertion. And it’s thought by
much of the medical communi-
ty—not by me—that this causes
the tendon to be less resilient to
repetitive microtrauma.
The fibers of the tendon actually twist as they meet the heel
at the anchorage point. So possibly the tendon undergoes a
“wringing effect”—like wringing
out a wet towel—when it’s
loaded and results in a fraying
rupture.
Kangaroos have the ability to
do an astonishing sum of plyo-
metrics. Researchers placed
probes in kangaroos’ Achilles’ tendons and realized the tempera-
ture goes up when the tendon is stressed. So maybe rupture is
caused by an internal friction between the collagen fibers and
causes heat and rupture. This isn’t proven, but it’s an attractive
theory.
My current belief has to do with an imbalance in the collagen to
water ratio in the Achilles similar to what’s found in other tendons
that rupture in the ankle and foot.
Why are some Achilles’ tendon tears a complete surprise to
gymnasts? When ruptured ends are examined under a microscope, they show chronic degeneration, which suggests healthy
tendons don’t tear. I believe a gymnast accumulates microtears
that are replaced by poor quality collagen. In fact, many tendons
with pathology detected on MRI or ultrasound are not painful.
Consequently, the straw that breaks the camel’s back appears to
come out of nowhere. …Continued on page 44
