Achilles Tendon Ruptures in the NFL

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.

Photo courtesy blog.corewalking.com
Photo courtesy blog.corewalking.com

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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14 thoughts on “Achilles Tendon Ruptures in the NFL

  1. I made a post regarding this in the off-season when it appeared he wouldn’t be back with the Patriots. There have been some rather large studies on Achilles injuries in the NFL and the likelihood of a player returning and what they will do when they get back.  See below:
     
     

    I’m happy with the Revis signing. I’m a big, giant ‘meh’ on Wilfork. Probably one of my favorite players of all time, but I will be surprised if he plays more than 10 games this season. A big, giant man (there is no way in hell he is only 320 pounds, he’s closer to 400 than he is 300) coming off a major Achilles injury? I’m betting against 99% of the time. I’ll root for him anywhere he goes, but when I heard the news yesterday, I was sad that he’s leaving, but no part of me was worried about it being a bad decision, and the Pats have about 1,000x more information than I have about what to expect from him this year. If they somehow work something out, which I doubt, I’ll be happy to see him in a Pats uniform and I’ll hope like hell that he plays like his incredible self and finishes his awesome career here, but it wouldn’t surprise me at all to see us struggling again next year while he is down with an injury.
     And don’t take my word for it either, there is actually research to support this. Of the 31 players that suffered Achilles injuries over a 5 year period, only 21 actually returned to play (an average of 11 months later). That’s 36% that never played again. Of the 21 that came back, they averaged 5 less games per year over their next 3 years and a 50% average drop in power ratings across the board. Check out this very, lengthy article on the topic:
    External
     

     
     
     And here is another article, which cites that one in support of the fact that Terrell Suggs’ return from an Achilles injury was not the norm:

  2. Dr. Awesome is probably in surgery or something right now but this week’s installment of “DRS educates football fans” is a must-read. 
     
    Please, share this piece on facebook, twitter or print it out and put it in your dorm room bathroom. No $10 co-pay owed, so long as you spread the word about Football Central and Dr. Awesome. 

  3. I performed a quick and dirty literature search on rates of return of NFL players after repair of various musculoskeletal injuries. Basically, small sample sizes, but it seems the rate of return for players after an Achilles rupture is on the lower end of the spectrum compared to others.
     

    Injury type/surgery                                           Proportion that returned to play

     

    Achilles tendon rupture                                    68% (21 of 31)

    ACL repair (2010)                                             63% (31 of 49)

    ACL repair, quarterbacks only (2014)              92% (12 of 13) (14 knees)

    ACL repair (2006)                                             77% (24 of 31) (33 knees)

        ACL repair (aggregate)                                 72% (67 of 93)

    Patellar tendon repair                                       79% (19 of 24) (some with concomitant ACL repair)

    Lateral meniscectomy                                      61% (47 of 77)

    Proximal hamstring repair                                100% (10 of 10)

    Distal quadriceps repair                                   50% (7 of 14)

    Shoulder stabilization                                       90% (54 of 60)

    Cervical disc herniation                                    72% if operative treatment (38 of 53), 46% if nonoperative (21 of 46)

    Lumbar disc herniation                                     81% inoperative treatment (42 of 52), 29% if nonoperative (4 of 14)

     

     

    References:

     

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  4. Doc, this is fantastic! 
     
    I also am befuddled by high-ankle sprains. It seems like one of those lisfranc types where athletes try too soon to come back from (see Gronk, Dee Milliner) and just never get healed properly until a lot of rest. 

  5. I also am befuddled by high-ankle sprains. It seems like one of those lisfranc types where athletes try too soon to come back from (see Gronk, Dee Milliner) and just never get healed properly until a lot of rest. 

     
    I’m sure DRS will have a more accurate and sophisticated answer, but my sense is that because high ankle sprains are often initially treated non-operatively, there will be a percentage that fail non-operative treatment and then will have to go for more rehabilitation or surgery. Whereas, ACL tears and other injuries are almost always treated with surgery.

  6. I performed a quick and dirty literature search on rates of return of NFL players after repair of various musculoskeletal injuries. Basically, small sample sizes and many other sampling caveats, but it seems the rate of return for players after an Achilles rupture is on the lower end of the spectrum compared to others.
     
    Injury type/surgery                                           Proportion that returned to play
     
    Achilles tendon rupture                                    68% (21 of 31)

    Anecdotally, it seems like recent cases have been more successful. Terrell Suggs and Michael Crabtree both tore their Achilles in the offseason but didn’t even miss the whole year. Jason Peters ruptured his twice in the same offseason but returned to play 16 games last year. Wilfork was a full participant in offseason stuff after less than a full year. Crabtree’s pretty young but Suggs, Peters, and Wilfork aren’t. Kobe Bryant’s a recent non-football example? Is this a procedure where improvements have been made in the last five years or so? Or is my memory selective here?

  7. Well, assuming that the average career length for NFL players who make an opening day roster is 6.0 years (reference), that would make for an average annual attrition rate of 17%. Assuming that the cohort of players who have suffered Achilles ruptures is a subset of the above group, then the relative increased risk of not returning at all from an Achilles rupture is 32/17 = 1.9. 
     
    So, with numerous caveats, the relative increased risk that an Achilles injury ends an NFL player’s career is approximately 2x greater than the normal attrition rate for an NFL player. High, but not insurmountable, especially if there are no subsequent complications and the player played at a high level prior to his injury.
     
    External

  8. Well, assuming that the average career length for NFL players who make an opening day roster is 6.0 years (reference), that would make for an average annual attrition rate of 17%. Assuming that the cohort of players who have suffered Achilles ruptures is a subset of the above group, then the relative increased risk of not returning at all from an Achilles rupture is 32/17 = 1.9. 
     
    So, with numerous caveats, the relative increased risk that an Achilles injury ends an NFL player’s career is approximately 2x greater than the normal attrition rate for an NFL player. High, but not insurmountable, especially if there are no subsequent complications and the player played at a high level prior to his injury.
     
    External

    Is there a risk factor involved with age here? Four of the five examples I named are towards the older side, and all the 2014 injuries Chris mentioned in the article are to players 30 or over. If the injury disproportionately affects older players, the aggregate numbers might overstate the risk of not coming back (since the affected group might be towards the end of their careers anyway).

  9. I don’t know the answer to your specific question — for some reason I am unable to access the full article from the hospital/university network. But there is also a survivorship bias involved — players who are older are more likely to have had very successful careers, but also, the increased playing time over the years increases the overall likelihood that the player would sustain a serious injury during that career. On top of that, I would think that the incidence rate of injury also likely increases with age, just because body tissues start breaking down after all that abuse. Older people are more prone to hip fractures, etc. It wouldn’t surprise me that this holds true for Achilles injuries also, that’s just my guess.

  10. Great article. In it you say:
     

    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

     
    But is there any idea why this occurs? Seems like most players are doing a very repetitive action? Is it a case that the rupture occurs due to that repetition or just because that one time the load suddenly went through the roof through body mechanics or whatever.

  11. I tore my right achilles this July, and my recovery approach has been what the industry refers to as “the neglected achilles rupture”, which means I am doing nothing special to it (no surgery, no boot, no immobilization, etc.); I am just basically walking it off. Yes, it’s a long walk, and there seems to be a long walk ahead of me. Need to understand that when the achilles pops, there is a perimeter sheath around it that remains intact. My tear was about 4-5 inches up from the ground, and it left about a 3/4 inch gap/dent between the two ends. What happens over the subsequent weeks is that gap gets filled with fluids that will eventually reform the tendon. The entire process obviously takes up to a year. At just over three months now, the dent I had is just starting to get solid again, which is part of the reforming process that comes before the tendon gets fibrous again. So instead of having my tendon stitched back together tight, or having my heel immobilized at a flexed angle to allow it to reform tightly together, I am allowing the extra length for the recovery. I believe this will prevent the possibility of re-rupture, as extra temporary length is more forgiving. Eventually, the tendon will shorten again to optimal length. The industry says I will never regain full strength back this way, but I don’t believe that. I just think the body knows more what to do than the surgeons who have a profession to maintain. I also didn’t like the idea of having the sheath cut or poked into, which allows outer and inner fluids to mix, which is unnatural. We shall see in the end how much approach fares, and what excuses the industry come up with for proving the body smarter than the industry. Although my right calf still show signs of a failed Thompson test due to the extra interim length, I have seen no muscle atrophy, as my total body training has continued despite the tear. I believe my Planteris muscles (other smaller muscle group in the lower leg) have bulked to carry the load on that side during the recovery. I am thinking, in the long run, my right leg may actually become stronger as a result of the tear with this approach. If interested you can follow my progress at youtube channel “61 Custom Rebuild”.

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