Artur and The Achilles

By Gina Pongetti Angeletti, MPT, MA, CSCS-ART,Cert. 

Most athletes are elated to be a part of one Olympics, a feat that millions dream to do, thousands make every four years, and only a handful medal. However, the sport of gymnastics, particularly men’s, is home to many who are repeat Olympic qualifiers, have extraordinary longevity in the sport, and even sit atop the medal stand quad after quad. 

Two weeks before European Championships in April, ROC’s Artur Dalaloyan severed his Achilles tendon in training and had surgery. Surprisingly, he is here, as we knew he would be. And after qualifications, he’s sitting in sixth place in the All-Around. At 25 years-old, he is young and ready to be around for a while. Maybe even two more cycles. The Russian team needed him for this year, though, which outweighed the risk of potentially challenging his next steps and future competitions beyond Tokyo.

Dalaloyan took this rehab into his own hands…well, partially. After being told conservatively that he couldn’t run for six months, he went off of how he felt in the gym, and pushed forward. 

Why? 

Let’s nerd out on communication theory and values for a moment. 

First, we have to talk about how the brain thinks and how our values are calculated and played out. There are two main researched communication theories to touch on.  The Health Belief Model (Hochbaum, 1958) explains how people weigh the benefits of a specific action against the perceived costs.  This does not mean the actual costs, but those perceived by them because of what they were exposed to, and what means something to them. 

For Dalaloyan, the end game of medaling and representing his country means something to him after all these years of training. This theory was often used in analyzing the original AIDS crisis (incentive vs. risk), motivations for under age drinking (acceptance of peers is worth the risk of being grounded). 

The second is the Expectancy-Value Theory (Atkinson) where researchers assess people’s motivation for achievement, based on expectations for success and how valuable the task is in importance. This is, in today’s climate, heavily based on the influence of common culture (idealization of pain-tolerating characters in movies, other athletes, lauding of people persevering on social media, etc.) 

This is also, and possibly most importantly, influenced by the culture within the specific sport, in this case, men’s gymnastics. The tolerance given (or not) by coaches and staff, the encouragement to push from peers, wanting to be like those previous athletes that paved the way all factor in. And in the end, getting the distinction of having done so, plays heavily into the picture.

Rehab

As a physical therapist specializing in elite-level sports medicine, and having over 20 years of focusing on world and Olympic gymnasts, I can assure you that there are protocols in place for best outcome potentials. And in general, we try to follow them. Sport specific protocols as well, which really take flight toward the end of rehab, and in the beginning with keeping the rest of the body healthy. 

But, pushing the limits is always possible. It is what athletes do. Every day. Hence why sports medicine, and taking care of world-class athletes, is almost a separate genre of medicine, mixing actual sport biomechanics knowledge, surface understanding, strengthening, conditioning, psychology and most importantly, the timeline and culture of the sport itself. 

Which brings us back to Dalaloyan. 

He won Worlds in 2018, so he does understand perseverance and dedication to sport. Now, he understands how dedicated one must be to rehab as well. 

Today, after he finished all six events (and quite well, I may add), he sat in fourth place in the first of three subdivisions for the All-Around finals. He broke down in tears.  

I asked him what brought these emotions out. Pain? Gratefulness? Fear?

I couldn’t control my emotions. To be honest, it was like a storm inside. On one hand, I was overcome with joyful emotions because I would have the strength, because I was able to go out and do vault and floor. And, on the other hand, these are sad emotions, because I expected from myself and was confident that I’d be able to do the floor routine – the one that is better than what I managed to do today. Because I didn’t make some of the connections and did lower difficulty than I planned to. So, that’s why I didn’t quite meet my expectations and I expected a better result from myself on floor.”

Only an athlete of the highest caliber in the world can be actually disappointed with themselves for not fulfilling self-made standards. Three and a half MONTHS after an achilles surgery. 

It ends up that it was not even because of pain. 

There are rules, you know, governed by USADA, as to what medicines (and levels of said medicines) that one can have in their bodies during competition. 

Dalaloyan competed equally today for his team and for himself. In the end, he did not even know how high he was sitting after the first subdivision. 

“I don’t know if I made the final. I haven’t looked at the scores,” Dalaloyan stated in the Mixed Zone right before he learned that he was currently in fourth. I watched him bow his head in his hand, and took a moment to relish and let it sink fully in. 

He responded in English, “Ok, it’s not a problem for me, yes, I go,” with a huge smile and nod. 

Ethics of Medicine and Heroizing Pain

I want to make myself very clear in this. Yes, what he is doing is amazing. And yes, it is part magic and part medicine. And part Olympic adrenaline. And most importantly, part really hard work that most people rehabilitating injuries do not understand. 

I don’t condone this kind of rushed rehab on the average bear. I also do not think that many, if not most, physical therapists and athletic trainers can handle the sport-specific aspect and physiologic knowledge that this level requires. And, I don’t think that we should be a society of idealizing the process of dealing with pain, and the lauding that comes with “being tough,” or better than others. 

For centuries, we have applauded the bleeding feet of the Ironman finisher, Kerri Strug’s vault on a severely injured ankle in Atlanta 1996. The major league pitcher who, essentially, cannot lift his arm the day after throwing. 

Gymnastics, however, comes with some aches and tribulations. It is, after all, the toughest physical sport in the world. Period. It is when it may lead to life-long implications that the options need to be weighed. Dalaloyan is a grown man. Married, with kids. Ankle replacements exist. If it tears again, or pulls bone off, he is welcome to have one. He can pay for it with his gold medal and subsequent endorsement. And he is well aware of this risk.

 A “Light” Science Lesson

Let’s do a quick anatomy lesson for everyone. You have two calf muscles. One splits into two parts, called your gastroc, which is made mostly of fast or short-twitch muscle fibers. The other is the center one called the soleus, made mostly of long twitch or more endurance-based muscles. They come together to form the achilles tendon, which inserts at the back of your heel (calcaneus). The calf muscles, along with ankle control muscles on the inside and outside (which are much smaller and responsible as well for balance) are what push you into a heel raise, releve position, help you jump, control landings, push off to walk and more. 

Essentially, injuring the tendon or the muscle is devastating for an athlete who relies on jumping and landing for a living. Pushing off in any manner. Truly, even for walking. 

There are multiple ways to injure the calf area. Most minimally, you can overstretch it or have the smallest of tears. You can cramp or strain it by trying to use it too hard (landing short and trying to save it, jumping with too much force). 

A bit worse is that the muscle can be torn and have a relative hematoma, or blood pooling. The tendon can also be injured itself (if it is dry, full of scar tissue, weak). This can happen from micro-trauma that builds up, without stretching properly or recovering daily. It can also come about from mere overuse. 

The tendon can thicken, and thereby lose the ability to work properly, and respond to outside forces. Tendinitis is when it is irritated and inflamed.  Tendinopathy is when the range of motion decreases due to the decrease in collagen fibers, which are needed to allow flexibility and mobility. Tendinosis is a step farther- when it is thickened, hardened and even scarred. The pliability is almost not there, it is degenerating over time and it is incredibly susceptible to tearing. This is because of years of small injuries and not paying attention to the symptoms. 

Dalaloyan specifically said his was ruptured. He explained in the Mixed Zone today that it was literally hanging and dangling (he showed us a limp hand in motion, actually). 

Surgical options are based on the severity of the tear (full or partial), location of the tear (vertical or horizontal, at the tendon or insertion), and whether or not the muscle has recessed (rolled up) among other considerations. When the ends are frayed, they must be cleaned up in order to accept each other when brought back together. Soochers (non dissolvable, need to stay for strength) are used to pull the end back together.

Sometimes, other tendons need to be taken from the ankle and used to connect or layer in, most often the peroneus brevis (an outside ankle stabilizer, and one of three peroneal muscles). It needs to match the “tension” of the other calf, meaning resting length and resistance. If it’s too long? It cannot activate as well (think pulley system being loose). If it’s too tight? There will not be enough range of motion, which an athlete needs for landings, and to tolerate short landings. 

Most are kept in a plantar flexed (pointed) position, just a bit, to take pressure off of the length of the tendon and allow healing and proliferation. Then to neutral, then adding in motion and weight bearing. 

After an injury which needs surgery or immobilization, there are other things that the athlete can do that will help keep muscles from having atrophy, or muscle wasting: 

  • Blood Flow Restriction (BFR) therapy is popular to allow the muscle to strengthen without having to have as much external force by means of circumferential gauged pressure. 
  • Electric stim to activate muscles. 
  • Massage, cupping and other techniques to drain lymphatics and help reduce swelling.
  • Trigger Point Dry Needling (TrPDN) is done with acupuncture needles, placing them where trigger points exist, and encouraging a non-voluntary contraction, thereby resetting the tension in the muscle which is in protective mode and not able to activate or relax properly.
  • Acupuncture will assist in edema control and blood flow. 
  • Active Release Techniques (ART) can be used to eliminate intermuscular scarring and naturally increase relative motion and pliability. 
  • Graston, or scraping, can be used to encourage blood flow along the way and stop new scar tissue from forming. 
  • Taping techniques can not only support the ankle, but also encourage muscle activation and response time. 
  • Strengthening, literally the day after, of other muscles that are affected (quads, glutes, hamstring) will help return to weight bearing, walking, jumping and running when ready.
  • Any arm, ab, spine or hip exercises are fair game immediately after, as long as there is no weight bearing in the leg. 
  • Avoiding other injuries upon return is key. Running on an anti-gravity treadmill such as the AlterG to offload body weight and slowly return. 

Still, how could Dalaloyan get here this fast? Access to amazing physicians, Physical Therapists and Athletic Trainers. Having a sport as your job means that you can put effort multiple times a day into rehab.

Usually, an athlete returns to partial weight bearing, then weight bearing. Squatting on two feet, then one. Strength to heel raises partial body weight, then full, then one foot, then into the negative (below neutral) and so on. Varying landing surfaces – soft, compliant, and hard. Front tumbling, then back (because of take-off angles for twisting) and the possibility of landing short, etc.

To offer some perspective, at 12 weeks, 25 single heel raises in strength is celebrated. 

Dalaloyan committed to listening to his body, not his protocol. He has stated that his medical staff has not cleared him. So why take the risk? The Olympic Games.

There is also this perspective. Sport is sport, not life. And eventually, after the meets are done and there are no more training days, you need your family, your loved ones, and your body to take you through. Including a working ankle. 

“My wife played a very big role in my recovery,” Dalaloyan told us. “The moment I got injured, she and our team doctor took me to the hospital together. When my leg was hanging loose, I had a full Achilles tear, I couldn’t move it, nothing. But Olga said: ‘Calm down, it’s a sport, it’s not a big deal, it will all pass.’”

So, what brought him to think he could even do this amazing feat of recovery?

“I have just been working for 24 hours a day. The Olympic Games mean a lot to me. Many athletes don’t get to go to the Olympic Games even once in their lives. But thanks to the support of my family, my loved ones, wife, kids, the support of the whole team, I managed to find strength and start working right after I had surgery.”

In the end, he survived today. Monday will be an equal show of skill, guts and just luck. Trust in one’s body and willpower. A true example of how the dedication and persistence that makes him one of the best athletes in the world also gave him the edge in rehab. 

Now, let’s just pray it works. 

Photos by Ricardo Bufolin for Inside Gymnastics.

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