Achilles tendon ruptures are frequent injuries in the NFL, causing significant loss of playing time. How are they usually treated and what are the probable outcomes for NFL players? Dr. Christopher Geary, Chief of Sports Medicine at Tufts Medical Center, explains why recovery is more certain and shorter than ever for NFL and college football players.
The first two weeks of the NFL season have been like an Oprah Winfrey giveaway, only not with vacations or new cars – “YOU get an Achilles tendon rupture! YOU get an Achilles tendon rupture! And YOU get an Achilles tendon rupture!”
Three front-line NFL players suffered season-ending Achilles tears in Week 1 – Kansas City linebacker Derrick Johnson and his teammate Mike DeVito went down in their season opener against the Titans, and Colts linebacker Robert Mathis tore his during a workout. They join a well-heeled (pun very intended) group of NFL players who have torn their Achilles recently, including Demaryius Thomas, Leon Hall, Terrell Suggs, and Vince Wilfork. While the latter group has made it back to the NFL and the odds of the former doing the same are good, it would seem worthwhile to ask why this injury is seemingly both so prevalent and so devastating in the short-term.
The Achilles tendon attaches the calf muscles (gastrocnemius) to the calcaneus, or heel bone, of the foot. As such, it is responsible for transferring all the power of that muscle to the foot and ankle, allowing for active downward motion (plantarflexion) of the foot and ankle in addition to acting as an active stabilizer of the ankle joint. That being the case, it sees very high stresses that may, on occasion, cause the tendon to rupture. In the case of the Achilles, when we talk about a rupture we are talking about a full-thickness tear which almost always occurs in the middle of the tendon as opposed the tendon tearing off of the bone. While it is possible to have a partial tear of the tendon which can be a source of pain, that is usually more a chronic condition, while the sudden, traumatic tears we see in the course of action are almost inevitably full-thickness tears.
The tendon usually ruptures in a non-contact injury, most often when the foot is forcibly planted with most or all of the athlete’s weight applied to that leg. The classic story is that the player feels immediate pain similar to getting kicked in the back of the leg and is unable to bear weight on that leg due to both pain and weakness. The diagnosis is easily made based on physical examination alone, as the gap in the tendon is usually palpable and squeezing the athlete’s calf will result in no motion of the foot. In some cases an MRI will be obtained to confirm the diagnosis, but even that is usually superfluous.
Once the diagnosis has been confirmed, a treatment plan is put in place, which can be either operative or non-operative. In the case of professional athletes, surgery usually takes place in short order. The advantages of surgical treatment are that the athlete will tend to have a stronger leg after rehabilitation and a lower chance of re-injury to the leg (the re-rupture rate after surgery is around 3-5%), while non-surgically treated Achilles ruptures re-tear twice as often. The main advantage of non-surgical treatment is that you do not have to make an incision in the thin skin over the back of the ankle, and while wound breakdown and infection are rare surgical complications today, they can be disastrous when they do occur. Probably the best-known example of this in recent years was Ryan Howard, the Philadelphia Phillies’ all-star first baseman who suffered a tear during the 2011 playoffs. Howard developed a post-operative infection at his repair site and, while it was successfully treated with additional surgery and antibiotics, it without question prolonged his recovery.
Assuming surgery is undertaken, it is done as an outpatient and usually under general anesthesia. An incision is made over the torn tendon and the torn ends are re-approximated and sewn back together. The best analogy for the repair is that it’s like sewing two mop heads together, so upon completion it’s not ready to endure much stress. Most patients will require crutches for about 6 weeks afterwards and the use of a walking boot for a period beyond that. Physical therapy is obviously important for regaining strength and flexibility as well. Most patients will start running or jogging around 5-6 months after surgery, with a return to more aggressive athletics around 1-3 months after that.
How about football in particular? There has been very little research looking directly at returns to the sport after Achilles tendon repairs. One study from 2009 (Parekh et al., Foot and Ankle 2009) examined 31 pro players who sustained ruptures and found that 32% of them never returned to play in the NFL again. There are obviously multiple factors to consider in terms of who successfully returns to action, and higher caliber players at or near the their career peak (Wilfork, Suggs, etc.) are much more likely to play again than someone who is already near the bottom of the depth chart. For the players injured this past week their season is undoubtedly over, but the odds are in their favor for a return next season.
Now, from a Patriots fan’s perspective: What about Wilfork? He’s obviously back playing, but most likely is not yet at full speed. However, his overall strength and endurance should continue to improve over the course of the season, and he may actually have additional explosiveness as his calf strengthens and he gets used to his “new leg”, much as patients do after an ACL reconstruction. For Johnson, DeVito and Mathis, their road to recovery will start sometime this week on an operating room table and, most likely, won’t lead to their return until training camp next year.
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