The Verminator disabled: Thomas Vermaelen's year of achilles agony

Having only played three games at the beginning of the 2010-2011 season, Thomas Vermaelen suffered an Achilles ‘issue’ at the Euro qualifiers with Belgium on Sep 7th. It was thought to be a minor injury and the Arsenal medical team expected him to return to play within a few weeks. He actually didn’t return to play until eight months later in April 2011, only to play two games at the end of the season before finally having to go for surgery in September 2011 – almost a year to the day he first suffered the injury.

Thomas finally made a full recovery and returned six weeks later in October 2011, returning in the Carling Cup 4th round against Bolton only to come off in the 84th minute limping… But, much to everyone’s relief, with just some cramp, he then completed the rest of the 2011-2012 season with six goals and was called ‘Arsenal’s defensive rock’ by the manager.

Now a lot of people criticised the Arsenal medical team, asking why they just didn’t send Thomas for surgery in the first place – he would’ve been fit to play in six weeks, wouldn’t he? Well let me explain why it’s not that simple.

Firstly the Achilles is a notoriously weak spot in the human body, just as in the Greek myth, which is after all how it got its name. It’s easily overloaded and irritated, especially in those who run, especially in those who run and sprint, and especially in those who run and sprint in football boots.

It starts with pain and inflammation around the tendon – which is termed a ‘tendinitis’ – and normally a period of rest, ice, compression and elevation – known as ‘RICE’ – works wonders. Which is exactly what the Arsenal medical team would have done in those early weeks.

However, in some cases, and for reasons unknown, the tendon itself starts to ‘break down’ and small micro tears appear in the tendon. The body responds by trying to fix these tears by laying down scar tissue, which in turn causes the tendon to thicken and stiffen. This then produces more overload with normal activities, such as walking and going up and down stairs etc., which causes more micro tears to appear; causing more scar tissue, which causes more stiffness… And off we go in a continuous cycle. This is what’s termed as ‘tendinosis’ – only a small change of letters, but a completely different animal to treat.

Now the dilemma that the medical team at Arsenal would have had at this point of Thomas’s injury would be the pros and cons of how surgical to non-surgical treatment would have to get him back to playing.

Research and experience of the ways to treat Achilles tendinosis show that non-surgical management always works better than surgery, which involves scrapping the tendon clear of the thickened scar tissue wrapped around it, followed by a long period of rest and months of rehab after.

The main non-surgical way to manage an Achilles tendinosis for the ’long term’ (there are lots of short term fixes and fish oil remedies that don’t work) is through an ‘eccentric’ loading programme.

An eccentric loading programme is the process of putting the tendon under load whilst it is lengthening, this is normally done by dropping your heel over the edge of a step with all your body weight, even adding extra weight in a backpack. This has to be done often and regularly, with 100s of reps per day.

Sounds simple doesn’t it, but this process has been shown to ‘remodel’ the cellular structure of the tendon and reverse the effects of the micro tears and the adverse scar tissue. It doesn’t, however, happen overnight. Instead it takes months before these changes start to appear. Thomas would have been given this programme and would have been working through this for months, gradually getting his Achilles tendon to revert to the way it was before those Euro qualifiers in Sept 2010, and allowing him to return to those final two games at the end of the season.

Although there’s a twist in Thomas’s injury, caused by a rather odd condition from small, thin and insignificant tendon called ‘Plantaris’. The ‘Plantaris’ is a redundant muscle in humans (marked by the arrow); its left over from when we walked on all fours – and evolution is slowly getting rid of it for us, with 10% of us no longer having it at all. It sits so close to the Achilles tendon that when it thickens it can adhere or stick to this Plantaris tendon, and so continues to irritate it no matter how often you stretch it. The only way to stop this from continuing to irritate the Achilles tendon is to remove it surgically, just as Thomas had in September 2011.

So through a rare complication, a simple injury that should have at worst taken a few months to rectify took Thomas over a year, but thanks to Arsenal’s medical team you can be sure that Thomas won’t be out with a reoccurrence of the same injury. It may seem a tough call but what would you prefer to have…

1. a player out for one season and to return 100%
2. a player out for a few months who can give at best 50% for three or four seasons

It’s not easy is it? But it’s these sort of decisions that the medical team at Arsenal have to make on a regular basis, and for which I think we should all be a bit more forgiving and not so quick to criticise, as Arsenal now have their ‘defensive rock’ back for the long term…