achilles tendon injuries in professeional athletes

Achilles ruptures in professional athletes

introduction

For all NFL fans, one injury has dominated headlines during this particular year.  Just four plays into the season, many watched Aaron Rodgers suffer an Achilles injury.  There have been multiple similar injuries including quarterback Kirk Cousins, running back JK Dobbins and cornerback Tre’Davious White.  Just last week, Jaelan Phillips unfortunately fell victim to this devastating injury.  

Achilles tendon (AT) injuries are somewhat common among athletes, with ruptures occurring most frequently during athletic participation, notably soccer, tennis, basketball, and football [1]. Professional athletes participating in frequent acceleration and direction changes with excessive eccentric loading of the AT are at a relatively high risk of AT rupture [1].

The incidence of Achilles tendon ruptures in the general population ranges from 8.3 to 24 per 100,000, and it appears to be increasing with time. The majority of Achilles tendon ruptures are sports related.  While the optimal treatment for Achilles tendon ruptures continues to be debated, there are proponents for surgical repair in elite athletes [2].  Considering the financial and career implications in addition to the unique physical demands placed on athletes returning to professional sports, it is paramount to determine the impact that AT rupture and repair can have on the livelihood and career outlook of these athletes [1].  

Video 1: Most recent Achilles rupture in the NFL, Jaelan Phillips.

Despite near limitless resources to help facilitate appropriate rehabilitation, an Achilles tendon rupture can be a career threatening injury among elite athletes. Significant decreases in return to play (RTP), play time, and performance have been shown in NBA and NFL players who sustain an Achilles tendon rupture requiring surgical repair at various investigated time points [2].  Overall, these studies document an approximate 60% to 70% RTP rate among NBA and NFL players [1-3].

One review in 2013 evaluated major professional sports and included a total of 322 athletes.  This group was composed of 59 players in the National Basketball Association (NBA), 221 from the NFL, 18 from the MLB, and 24 from the Union of European Football Associations/Major League Soccer (UEFA/MLS).  The overall return-to-play percentage of the aggregated data was 67.1%, with UEFA/MLS having the highest percentage at 70.8% and MLB with the lowest at 55.6% [4]. The average age of the players returning to play across all studies was 28.9 years, with MLB contributing the oldest players at 31.4 years and NFL the youngest at 27.5 years [4].

Figure 2.  Most recent studies and demographics with professional athletes and AT ruptures.  Adopted from [4].

history/physical examination

The correct diagnosis of AT rupture may be missed in up to 25% of patients at initial presentation [6-8]. The diagnosis relies on clinical examination, and imaging techniques can be useful in providing additional clinical information. Patients with an AT rupture usually report a history of pain in the affected leg and the feeling that, at the time of injury, they had been kicked in the posterior aspect of the lower leg or complain of a popping or giving way sensation in their heel after pushing off [9]. With the instant replays that are available now, many times the Achilles injury can be seen and a band-like snap into the gastrocnemius area can be seen.

On clinical examination, diffuse edema and bruising are usually present the following day.  Initial or immediate examination may have some initial swelling.  A palpable gap may be felt along the course of the tendon, most frequently 2 to 6 cm proximal to the insertion of the tendon [9]. Inspection and palpation should be followed by other tests to confirm the diagnosis, such as the Thomspon (or Simmonds) and Matles test. The O’Brien and Copeland tests have been described but aren’t used as frequently [9]. 

imaging

Diagnostic ultrasound is generally considered the primary imaging method and can possibly be done immediately after the injury depending on the facility resources.  Magnetic resonance imaging (MRI) plays an adjunct role in the diagnosis and monitoring of AT ruptures and may be used in some for presurgical planning. It is recommended to rely primarily on clinical examination and evaluation, and to use imaging for ruling out other injuries.  Lateral radiographs of the ankle can be performed to diagnose an AT rupture. The loss of normal configuration of the Kager triangle, the space between the anterior aspect of the AT, the posterior aspect of the tibia, and the superior aspect of the calcaneus, is pathognomonic of AT rupture [9].

MRI achilles rupture

Figure 2.  MRI image of Achilles rupture. Adopted from [9].

treatment

Elite athletes typically opt for surgical management of these injuries in order to directly restore the native tendon anatomy, particularly muscle-tendon length, and potentially maximize their ability to regain full strength.  There has only been one reported professional basketball athlete that was treated with nonoperative management [11]. 

Surgically, Achilles ruptures may be treated with different techniques, including end-to-end open repair, percutaneous repair, reconstruction with advancement, or tendon transfer.  Postoperatively, the rehabilitation protocol is also critical to the athletes return to play, particularly with regard to the timeline. There is no one established protocol, therefore, details concerning which protocol is used would be useful in the analysis of how quickly the athlete returned, any setbacks encountered, and to what level of performance was ultimately achieved. A lack of complication data also inhibits true data analysis as an unforeseen issue, whether related to the Achilles injury or not, may prolong an athlete’s timeline in returning to play but would likely not be made public information for inclusion in the retrospective studies [4].

Attempts to define the time for return-to-play (RTP) have been made, with some groups recommending 16 weeks for non-contact athletes and 20 weeks for contact athletes. However, these guidelines are not directly evidence-based and seem to be shorter than what is typically seen in professional athletes [5].

Among athletes returning to play, a significant decrease was noted in games played per season when compared with preoperative baseline values.  At 1 and 2 years postoperatively, athletes played an average of 75.4% of the games played in the season before injury [2]. When the 3 leagues were analyzed separately, only NBA players played in significantly fewer games at 1 and 2 years postoperatively, 67.5% and 68.5%, respectively. NFL players were found to play in fewer games only 1 year after injury and no difference was identified in the amount of games played pre- versus post injury in MLB players [2]. NBA players had the greatest reduction in play time: 52.8% and 53.6%, respectively, at 1 and 2 years postoperatively. No significant decreases in playing time were found after injury in either NFL or MLB players at either time points.

Image 3: Graphic showing games played in three major sports pre and post surgery.  Adopted from [2].

When performance statistics were evaluated among all athletes, players were found to have performed at a significantly lower level at 1 year (74.8%) and 2 years (77.7%) postoperatively [2]. NBA players’ performance decreased to 77.0% and 79.4% compared with preinjury baselines, while NFL players performed even worse: 69.6% and 67.1% at 1 and 2 years postoperatively. In contrast, MLB players’ performance was unaffected [2].

Summary

In summary, achilles tendon ruptures are a somewhat common injury among professional athletes and can significantly affect the athlete. The athletic performance varies after RTP in elite athletes with operative intervention for Achilles tendon rupture. The NBA studies all demonstrated significantly worse performance after RTP, while NFL, NCAA football and professional soccer studies reported varying results on performance after Achilles tendon rupture treated by operative intervention. MLB players were not reported to have significant performance decreases after injury.

– More Ankle Pain from Sports Med Reviewhttps://www.sportsmedreview.com/by-joint/ankle/

– Achilles Tendon Rupture @ Wiki Sports Medicinehttps://wikism.org/Achilles_Tendon_Rupture

References

  1. Johns W, Walley KC, Seedat R, Thordarson DB, Jackson B, Gonzalez T. Career Outlook and Performance of Professional Athletes After Achilles Tendon Rupture: A Systematic Review. Foot & Ankle International. 2021;42(4):495-509.
  2. Trofa, David P., et al. “Professional athletes’ return to play and performance after operative repair of an Achilles tendon rupture.” The American Journal of Sports Medicine 45.12 (2017): 2864-2871.
  3. Amin NH, Old AB, Tabb LP, Garg R, Toossi N, Cerynik DL. Performance outcomes after repair of complete Achilles tendon ruptures in National Basketball Association players. Am J Sports Med. 2013;41(8):1864-1868.
  4. Danilkowicz, Richard M., Nathan L. Grimm, and Annunziato Amendola. “Achilles rupture and return to sport in professional athletes.” Duke Orthopedic Journal 9.1 (2019): 26.
  5. Caldwell J-ME, Vosseller JT. Maximizing return to sports after Achilles tendon rupture in athletes. Foot Ankle Clin 2019;24:439–45.
  6. Maffulli, N. Clinical tests in sports medicine: More on Achilles tendon. Br. J. Sports Med. 1996, 30, 250.
  7. Maffulli, N.; Aicale, R.; Tarantino, D. Autograft Reconstruction for Chronic Achilles Tendon Disorders. Tech. Foot Ankle Surg. 2017, 16, 117–123. 
  8. Aicale, R.; Tarantino, D.; Via, A.G.; Oliva, F.; Maffulli, N. Z Shortening of Healed Achilles Tendon Rupture. In The Achilles Tendon: An Atlas of Surgical Procedures; Thermann, H., Becher, C., Carmont, M.R., Karlsson, J., Maffulli, N., Calder, J., van Dijk, C.N., Eds.; Springer: Berlin, Germany, 2017; pp. 125–128.
  9. Longo, U.G.; Petrillo, S.; Maffulli, N.; Denaro, V. Acute Achilles Tendon Rupture in Athletes. Foot Ankle Clin. 2013, 18, 319–338
  10. Bleakney, R.R.; Tallon, C.; Wong, J.K.; Lim, K.P.; Maffulli, N. Long-term Ultrasonographic Features of the Achilles Tendon After Rupture. Clin. J. Sport Med. 2002, 12, 273–278.

LaPrade, Christopher M., et al. “Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review.” British Journal of Sports Medicine 56.9 (2022): 515-520.