To The Editor:
I read carefully the Current Concepts Review "Rupture
of the Achilles Tendon" (1999;81:1019-36), by Maffulli.
I also scrutinized other articles about rupture of the Achilles
tendon1-5.
In his article, Maffulli explained the epidemiology and etiology
of rupture of the Achilles tendon and mentioned its association
with sports activity involving jumping, sprinting, and change of direction.
However, I could not find any information about the features of
either synthetic grass playing fields or the sports shoes worn for
play on these fields that may contribute to the incidence of these
injuries.
Thus, I believe that research on the contribution of synthetic
playing surfaces and sports shoe design to the incidence of Achilles
tendon rupture in athletes would be useful for professional and amateur
sportsmen as well as medical researchers and clinicians. I have
been working in orthopaedic clinics for nine years. For the first
time, I treated an amateur soccer player who had an Achilles tendon
rupture while wearing sports shoes and playing soccer on a synthetic
grass field. I could not find enough information about synthetic grass
playing fields and sports shoes designed for play on this surface.
So, I would be very glad to obtain such information.
N. Maffulli replies:
I thank Dr. Mert for the time and attention that he has devoted
to my article. To my knowledge, there has been no single study that
has directly correlated shoe wear and ground characteristics with
the occurrence of an Achilles tendon rupture. This is hardly surprising, as
the present evidence suggests that Achilles tendon rupture is a
late event, the end result of long-standing, most often clinically
silent, degenerative changes. Also, in the Nordic European countries,
where there is the highest incidence of such injuries, the majority of
patients are involved in badminton or squash at the time of rupture.
Both are indoor sports played on synthetic surfaces. In this respect,
therefore, some of the evidence that Dr. Mert is seeking may well
be available, only not quite in the precise format that he requests.
However, to mount a study that would show a cause-effect relationship between
shoe design, type of playing surface, and the incidence of Achilles tendon
rupture in athletes would require a randomized clinical trial to
be conducted with a cohort of a few thousand patients and a duration
of at least a couple of decades. I do not believe that those who
allocate grant funds or prospective researchers would find it feasible
to plan, administer, and complete such a study.