October 2017

Return-to-play concerns following Achilles tears

Los Angeles Lakers star Kobe Bryant tore his Achilles tendon in 2013. (Photo by Keith Allison, licensed by Creative Commons.)

Achilles tendon ruptures are severe injuries that are associated with a long recovery and significantly affect an athlete’s ability to function at a high level. In devising strategies for rehabilitation and return to play, the goal of clinicians and athletes alike is to try to minimize this impact.

By J. Turner Vosseller, MD

Achilles tendon ruptures are common injuries that affect those at the pinnacle of athleticism, as well as those who only irregularly engage in physical activity. Generally, frequent athletic activity is a consistent risk factor for Achilles tendon rupture. Historically, the over­whelming majority of these injuries occurred in young (aged 20-30 years) active men. However, there is some evidence to suggest the mean age at which patients rupture their Achilles tendons has increased with time, as has the proportion of women sustaining these injuries.

While the optimal treatment of an Achilles tendon rupture has been and continues to be a subject of debate, a consistent truth is that, irrespective of how the rupture is treated, patients take a long time to return to preinjury levels of function.

Formal return-to-play (RTP) criteria have been developed for some orthopedic injuries, most notably anterior cruciate ligament (ACL) reconstruction, though many of these guidelines are still being developed.3 However, objective criteria for RTP still do not exist for many other types of injuries, which can make decisions regarding RTP more difficult. The higher the level of sport, the higher the stakes can be, as well as the pressure on medical professionals to get athletes back to play as expeditiously as possible. In this review, we will look briefly at the current state of Achilles tendon rupture treatment and assess expected outcomes after Achilles rupture in athletes, as well as the data that exist with regard to RTP following these injuries.

Identifying return-to-play benchmarks and risk factors for slow recovery are critical for developing effective rehabilitation protocols following Achilles tendon rupture in athletes.

In higher-level athletes, and certainly in professional athletes, ­­the clinical bias continues to be toward surgical rather than non­surgical treatment of these patients.4 This is most likely because the tension of the tendon can be directly restored surgically and because most of these patients will be young and very healthy, which minimizes the risks associated with surgical treatment, namely wound healing issues. Moreover, high-level athletes are the patients most likely to have every facet of rehabilitation optimized post­operatively.

However, even professional athletes often require a long time to return to preinjury function, if they are ever able to attain that level. This underscores the extent to which these injuries—in any patient—constitute a significant blow to functional capability that will necessitate a long period of functional recovery.

Robert Mathis of the Indianapolis Colts suffered a torn Achilles tendon in 2014. (Photo courtesy of Wikipedia.)

Treatment risks vs benefits

Discussion of Achilles rupture treatment has traditionally been framed by the balance between the risk of rerupture associated with nonoperative treatment versus the risk of wound issues associated with operative treatment.5 For the purposes of this article, we will confine our discussion to Achilles rupture in athletes.

With regard to rerupture versus wound issues, operative treatment of Achilles rupture is most commonly chosen in athletes because, given the long recovery associated with these injuries, a rerupture would be a disaster for an athlete. Although it could be reasonably argued that a wound complication would be no less a disaster, the reality is that most athletes—and certainly most professional athletes—are in tip-top physiological health, potentially mitigating the risk of wound issues.

A second concept may be in play, as well. There is some evidence to suggest strength is better after surgical repair of an Achilles tendon rupture than after nonoperative treatment.

In perhaps the most influential recent article on Achilles rupture treatment, Willitts et al5 promulgated nonoperative treatment, noting no significant difference in rerupture rate between operative and nonoperative treatment arms. However, these authors did note the surgical patients were significantly stronger than the nonoperative ones at final follow-up, though they deemed that difference not clinically significant. The assertion of a lack of clinical significance is perhaps true for some athletes, but it is certainly reasonable that the higher the skill level of the athlete, the more important even seemingly negligible strength differences may be. Other authors have noted this trend, as well,6 though the literature suffers from inconsistency in reporting strength data during follow-up with these patients.

A final reason that may influence the frequency of surgical treatment of athletes after Achilles rupture is that there is an assumption among these patients that surgical treatment is most appropriate, and “better.”  It is no doubt the job of clinicians to educate the patient as to his or her options, but a patient who has decided on surgery will likely ultimately find a surgeon who will do it.

RTP outcomes

Many authors have looked at the effect of an Achilles tendon rupture on professional athletes in various sports. Parekh et al assessed the epidemiology and outcomes of Achilles ruptures in the National Football League (NFL), retrospectively reviewing 31 such injuries over a five-year period (1997-2002).7 In this cohort, only 68% of athletes were able to return to the sport, and those that did generally returned at a lower level of efficacy compared with preinjury.

Another study used the NFL Orthopaedic Surgery Outcomes Database to assess all injuries, treated both surgically and nonsurgically, over a 10-year period (2003-2013).8 Achilles tendon repair, along with patellar tendon repair, led to significantly fewer games played than other surgeries. Moreover, Achilles repair, along with ACL reconstruction, patellar tendon repair, and tibia intramedullary nailing, were associated with significant decreases in performance in the first year after injury, though the Achilles repair patients returned to preinjury performance levels in the second and third year postinjury.

Finally, Jack et al most recently and comprehensively assessed Achilles ruptures in the NFL using data on 95 players.9 Seventy-one players were able to return to competition (72.4%); a player’s ability to return to a certain level of performance depended in large part on the player’s position.

Achilles ruptures have been assessed in other sports, as well. Amin et al assessed 18 players from the National Basketball Association (NBA) who had Achilles ruptures over a 23-year period (1988-2011).10 The injuries had a profound negative impact on the athletes, as 39% were unable to return to competition, and those who did return had a significant decrease in both playing time and performance. Further data suggest Achilles tendon repair is associated with the lowest RTP rates among NBA players of any orthopedic surgical procedure.11

Other authors have assessed Achilles ruptures in Major League Baseball (MLB).12 Given the nature of the sport, the incidence of Achilles rupture is significantly lower than in sports such as basketball and football, which require frequent eccentric contractures. However, only 62% of MLB position players who sustained Achilles tendon ruptures were able to return to play.

A few studies from Europe have assessed athletes from other sports. Maffulli et al compiled data on 17 elite athletes from sports as diverse as badminton and martial arts, though most were soccer players.13 All athletes were able to return to competition after Achilles rupture, but one was not able to compete at the same level as before the injury. The authors did not assess performance capacity objectively; RTP was ultimately a binary variable. Additional research has found that Achilles ruptures are relatively uncommon in soccer, a somewhat unexpected finding, though there are limited data on postinjury performance in these patients.14

Synthesizing much of these data, Trofa et al assessed the major professional sports in the US for Achilles ruptures over a 24-year period.15 Only established professional athletes were included, and control players were used to assess the injury’s effect on the player’s career trajectory. Only 70% of athletes were able to return to play; those who did return to play did so at a lower level than matched controls one year after injury, but their level of play normalized relative to controls two years after injury.

Ryan Howard tore his Achilles tendon in 2011, while playing for the Philadelphia Phillies. (Photo courtesy of Wikimedia Commons.)

RTP strategies

Clearly, Achilles ruptures are severe injuries that significantly affect an athlete’s ability to function at a high level. The goal of clinicians and athletes alike is to try to minimize this impact.

One aspect of treatment that appears to lower the rate of rerupture among patients with this injury, whether the patient is treated operatively or nonoperatively, is early functional rehabilitation. There are now reams of data showing early weightbearing and early functional rehabilitation lead to both stronger new tendon formation and better ultimate functional outcomes.8-10,16 Many treatment protocols do not differentiate much between operative and nonoperative treatment when it comes to the rehabilitation progression. As a gross simplification, rehabilitation focuses on motion for roughly the first two months and thereafter on strengthening.

Some authors have suggested optimal RTP protocols for Achilles rupture patients.  Silbernagel and Crossley offered a possible starting point in their proposed program for noninsertional Achilles tendinopathy,17 primarily just by codifying a protocol and a proposed progression. Of course, Achilles tendinopathy, though related and on the same continuum of disease, is not the same as an Achilles rupture. Any protocol, however, should include some ability to assess where a patient is in their recovery relative to where they should be.

Hansen et al noted that a patient’s Achilles tendon Total Rupture Score (ATRS) at three months postinjury could predict their ability to return to sports at one year.18 Establishing these objective benchmarks is a critical step toward being able to provide the most useful criteria for RTP.

Others have noted that men, patients with Achilles pain at rest three months after injury, and patients with lower physical functioning and calf endurance at six months all have delayed recovery of calf endurance at one year.19 Although these data may be skewed slightly, given the relative infrequence of Achilles rupture in women, Achilles pain at rest at three months could help identify those patients at risk for slower recovery so that additional interventions could be made to try to fortify their recovery and to adjust their RTP expectations.

Explicit criteria and protocols for RTP after Achilles rupture, however, are generally lacking. Fanchini et al offered a case report of an Italian professional soccer player as an example of a potential protocol.4 Indeed, this report mainly highlights the vast difference between the resources at the disposal of a pro athlete versus almost anyone else, as the attention paid to this one athlete—including hi-tech monitoring of training-load variables—is likely not possible for the overwhelming majority of the public or for most amateur athletes. Despite that, though, the case study does provide some sense of how the progression should work and what the stages of recovery are.

Summing up

There has been one systematic review with meta-analysis on this topic.20 The mean RTP rate across all included studies was about 80%. However, the authors noted the studies that were more objective about how RTP was defined (vs a binary did/did not return to play, or studies that did not describe the metrics used) were generally associated with lower RTP rates. Perhaps unsurprisingly, the analysis also found that measures used to evaluate RTP are variable and inconsistent.

Achilles tendon ruptures can be devastating injuries for athletes who require a long recovery, and may not allow them to achieve the degree of athletic prowess they had before the injury. The understanding of RTP following these injuries is in its infancy; as this understanding expands, the negative impact of these injuries may be lessened.

Turner Vosseller, MD, is an assistant professor of orthopedic surgery specializing in orthopedic foot and ankle surgery at Columbia University Medical Center/New York Presbyterian Hospital in New York City.

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  5. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010;92(17):2767-2775.
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  7. Parekh SG, Wray WH, Brimmo O, et al. Epidemiology and outcomes of Achilles tendon ruptures in the National Football League. Foot Ankle Spec 2009;2(6):283-286.
  8. Mai HT, Alvarez AP, Freshman RD, et al. The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): The effect of common orthopaedic procedures on football careers. Am J Sports Med 2016;44(9):2255-2262.
  9. Jack RA, Sochacki KR, Gardner SS, et al. Performance and return to sport after Achilles tendon repair in National Football League players. Foot Ankle Int 2017 Jul 1. [Epub ahead of print]
  10. Amin NH, Old AB, Tabb LP, et al. Performance outcomes after repair of complete Achilles tendon ruptures in National Basketball Association players. Am J Sports Med 2013;41(8):1864-1868.
  11. Minhas SV, Kester BS, Larkin KE, Hsu WK. The effect of an orthopaedic surgical procedure in the National Basketball Association. Am J Sports Med 2016;44(4):1056-1061.
  12. Saltzman BM, Tetreault MW, Bohl DD, et al. Analysis of player statistics in Major League Baseball players before and after Achilles tendon repair. HSS Journal 2017;13(2):108-118.
  13. Maffulli N, Longo UG, Maffulli GD, et al. Achilles tendon ruptures in elite athletes. Foot Ankle Int 2011;32(1):9-15.
  14. Gajhede-Knudsen M, Ekstrand J, Magnusson H, Maffulli N. Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: an 11-year follow-up study of the UEFA Champions League injury study. Br J Sports Med 2013;47(12):763-768.
  15. Trofa DP, Miller JC, Jang ES, et al. Professional athletes’ return to play and performance after operative repair of an Achilles tendon rupture. Am J Sports Med 2017 Jun 1. [Epub ahead of print]
  16. Enwemeka CS. Functional loading augments the initial tensile strength and energy absorption capacity of regenerating rabbit Achilles tendons. Am J Phys Med Rehabil 1992;71(1):31-38.
  17. Silbernagel KG, Crossley KM. A proposed return-to-sport program for patients with midportion Achilles tendinopathy: Rationale and implementation. J Orthop Sports Phys Ther 2015;45(11):876-886.
  18. Hansen MS, Christensen M, Budolfsen T, et al. Achilles tendon Total Rupture Score at 3 months can predict patients’ ability to return to sport 1 year after injury. Knee Surg Sports Traumatol Arthrosc 2016;24(4):1365-1371.
  19. Bostick GP, Jomha NM, Suchak AA, Beaupre LA. Factors associated with calf muscle endurance recovery 1 year after Achilles tendon rupture repair. J Orthop Sports Phys Ther 2010;40(6):345-351.
  20. Zellers JA, Carmont MR, Silbernagel KG. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med 2016;50(21):1325-1332.

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