Achilles Tendon Rupture: Injury, Recovery & Return
In light of the recent Achilles tendon rupture to Kevin Durant and the anticipated recovery of Philadelphia Eagles Brandon Brooks, let’s take a deeper look at the Achilles tendon rupture in sports. Hint: It takes about 12 months to truly return back to normal and it is common to have a 10-30% permanent loss of strength.
If we are talking about a complete rupture of the Achilles the most common age in competitive athletes is around age 30, whereas recreation athletes tend to be in their 40's. To put that in perspective Kobe Bryant - 34, Dez Bryant - 29, Kevin Durant - 30 and Brandon Brooks - 29. It is typically not an injury we are going to see in the 21-year-old rookie. The presentation is similar to that of a calf tear but in my opinion, is much more dramatic. Athletes typically feel a snap or pop and immediately drop to the ground. In my experience when the calf is torn there is a similar feeling as though they were hit the back of the leg, but usually does not drop them to the ground. Also when analyzing video with an Achilles injury there is a classic grab of the heel rather than the upper portion of the lower leg.
A few things to note in the full video is that Durant's left-hand grabs down low at the site of the Achilles rather than higher up on a calf strain. A key point you will notice at the 0:20-sec mark is that he is able to point his ankle down (plantarflex), which you shouldn't be able to do. However, there are other muscles that plantarflex the foot, they just are very weak so some motion may still be intact. Lastly, at the 0:50-second mark, in the replay, you will notice the recoil of the right calf muscle after the tendon is ruptured.
The diagnosis is pretty straightforward based on the history, however, when examining the patient there are a few findings to help confirm the diagnosis. First, there may be a gap that you can feel in the belly of the tendon indicating a tear. Additionally, a Thompson's test can be performed. Normally when you squeeze a resting calf muscle the foot will point down slightly. However, with a positive test indicating a rupture there will be no movement at all with the exam maneuver (see below).
The last step in diagnosis is imaging. Honestly, most practitioners should be able to make the diagnosis clinically and only obtain advanced imaging to confirm their diagnosis and prepare for surgical intervention. Nowadays a bedside ultrasound can be easily used to confirm the tendon rupture, however, the gold standard is the MRI (see below).
(Modified) Case courtesy of Radswiki, Radiopaedia.org, rID: 11159
I think it is safe to say that most elite athletes are going to have surgery for an Achilles tendon rupture. Surgical options primarily include an open technique or a percutaneous (through the skin) technique. Contrary to popular belief there is convincing evidence that non-surgical treatment may provide the same long-term outcomes. Both surgical and non-surgical patients follow a similar treatment plan (varies based on physician).
Weeks 0 - 2: Cast or Boot with the ankle pointed down to either close the gap (non-surgical) or relieve stress at the surgical site of the Achilles tendon repair.
Weeks 3 - 8: Allow the ankle to have gradually increased ROM usually to a neutral position so there still not significant stress on the Achilles
Weeks 8 - 12: Allow full weight bearing in shoe with heel lift. Typically will be allowed to gradually wean off the heel lift and continue a program under the guidance of a physical therapist.
Here is a summary of what the data on Achilles tendon ruptures shows us. The re-rupture rate is reported around 2-4% after surgery and slightly higher for non-surgical cases. Return to play is highly variable and can be anywhere from 6 months to 12 months. Surgical patients may show greater improvements in strength and heel raise at 6 months however there tends to be no difference at 12 months. Additionally surgery is not without complications such as possible nerve damage, infection or complaints concerning the scar. In both groups, neither was returned back to baseline strength compared to the unaffected side. It is common to have a permanent strength deficit on the affected side.
Here is a look at Brandon Brooks about 6 months out from surgery. Notice in the running video a reduced lack of toe off on the right compared to the left.
Source: Nilsson-Helander K, Silbernagel KG, Thomeé R, Faxén E, Olsson N, Eriksson BI, Karlsson J. Am J Sports Med. 2010 Nov;38(11):2186-93. doi: 10.1177/0363546510376052. Epub 2010 Aug 27.