Philly.com
Sports Doc
May 1st, 2017

With their second pick in the 2017 draft the Eagles chose cornerback Sidney Jones.  Jones was originally projected as a high first round pick with a lot of potential but then he ruptured his left Achilles tendon during his pro day workout in early March.  Howie Roseman has stated that the Eagles medical staff are confident that Jones will make a full recovery from his surgery.  But what does the research say on returning to the NFL following an Achilles tendon rupture?  Will the Eagles' 43rd pick be a steal or a bust?

The risk of Achilles tendon rupture is low — around 18 per 100,000 people. Ruptures typically occur in males between 30 and 50 years old and account for around 40 percent of all operative tendon repairs. Approximately 75-80 percent of cases can be attributed to participation in athletic activities, including ball and racquet sports. Re-rupture rates for surgical repair is low at 3-4 percent.

However, returning to sports following Achilles tendon rupture can be difficult. A 2009 study by Parekh et al showed that 30 percent of NFL players did not return to play following this injury.
A more recent article from 2016 in the American Journal of Sports Medicine reported on 80 Achilles tendon ruptures from March 2003 to 2013.  They found a return to play rate of 72.5 percent with a return to play time frame of one year +/- four months.  The study showed a significantly higher proportion of defensive lineman who sustained the injury.  Their results showed a 9.3 percent decrease in return to play with each increasing year of age and 6.3 percent decrease with each increasing year of experience. 

Achilles tendon repairs led to significantly fewer games played following return (27 games) compared to many other procedures. These players showed a reduction in performance during their first season following surgery but returned to pre-injury levels between their second and third years.  Findings showed that Achilles tendon repair — as well as ACL reconstruction and patellar tendon repair — have the greatest effect on the careers of NFL players.
What does this all mean for Sidney Jones?  Although Achilles tendon ruptures are a difficult injury to recover from, Jones has some advantages.  His young age, 20, and limited NFL seasons are a positive predictor for return to play.  Although research hasn’t looked at draft position and return to play from Achilles tendon injury, this has been studied for injuries to the ACL.  A 2010 paper in the American Journal of Sports Medicine showed that being selected in the first 4 rounds of the NFL draft was highly predictive of return to play. 

With this information, the odds are with Jones to have a successful recovery from Achilles tendon surgery.  Jones may not be ready for the 2017-18 season but we can hope to see him in an Eagles jersey for years to come.

Philly.com
Sports Doc
Posted 11/17/15

Achilles tendon ruptures seem to be on the rise this NFL season. No new Achilles injuries occurred in week 9, but week 8 had 3. So far this season, including summer work outs and pre-season, there have been a total of 15 Achilles ruptures. Is it bad luck or is there a higher incidence this season?
Previous research studies show an Achilles rupture rate of 4-10 per season in the NFL. We are a little more than half way through the 2015-16 season and we’ve already exceeded the published injury rates. Do Achilles injuries fluctuate just like anything else or is there a rise in these injuries in the NFL?
A quick Google search shows sports articles from 2013 and 2014 discussing how Achilles injuries are “plaguing” the NFL season. Recent research articles do show a rise of Achilles tendon ruptures in the NFL.  But, we are also seeing a rise in ACL injuries as well. Some thought is that with a decrease in voluntary off-season workouts and mini-camps, athletes may be less prepared for the rigors of pre-season and a 17 game NFL season (Myer et al, JOSPT, 2011). However, there are many theories behind achilles tendon ruptures with no specific mechanism reported to be the primary cause of these injuries.

There are many factors considered to be potential causes of Achilles injuries. These include underlying tendonosis, use of corticosteroids, use of specific antibiotics (fluoroquinolones), as well as biomechanical mechanisms such as rapid lengthening of the tendon. After watching videos of many of this season’s injuries, I saw a common mechanism for most of them. The athlete takes some kind of back step and as he pushes off, his knee extends at the same time. Arian Foster’s injury in the fourth quarter is a perfect example of this. This combination of eccentric loading of the Achilles followed by forceful plantar flexion and knee extension may overload the tendon causing rupture. There is some thought that the knee extension may be due to fatigue, and in Arian Foster’s case his injury did occur toward the end of the 4th quarter. 

​Return from sports following Achilles tendon ruptures can be difficult. A study by Parekh et from 2009 showed that 30% of NFL players did not return to play. That’s a pretty significant number of career ending injuries. And unlike ACL injuries, there are no prevention programs that have been shown to be successful in reducing the risk of injury. We will see how many more Achilles rupture occur in the second half of this season and we will continue to track injury rates across season to see if this year is an anomaly or if there is an increasing incidence of Achilles tendon ruptures in the NFL.

Philly.com Sports Doc
Posted: Monday, August 25, 2014, 5:30 AM

Achilles tendon rupture, the fear of every middle age man on the basketball and tennis court.  Now that I am in my 40s I fall into that category.  And unfortunately for me, I recently felt the dreaded “pop” while playing doubles tennis.  At first, I thought the ball came from the next court and hit me on the back of the leg.  Then I came to my senses and realized I had torn my Achilles.  The people who stopped playing on the courts next to us must have thought I was in a lot of pain the way I was yelling while lying on the baseline.  In truth, I didn’t really have much pain.  I was yelling because I knew what was to come: Surgery, weeks of non-weight bearing and partial weight bearing, and the huge inconvenience this would be for work and life in general.  My father-in-law, who was my partner in this ill-fated doubles match pointed out, “Hey, at least you won the point.”  Not much consolation.  My summer fun was over.

So what happened?  How did I tear my Achilles?  As I am known to do, I reviewed all the research hoping to figure out the cause. Maybe I was fatigued which may have contributed to the injury.  More likely I’m predisposed as I tore the other side over a decade ago playing soccer. Neither time did I have any Achilles pain leading up to the injury. 

There are some studies showing possible relationships with risk factors and Achilles ruptures.  In the June 2014 edition of the journal Sports Medicine, Claessen et al categorized these potential risk factors into two categories: non-modifiable and modifiable.  Non-modifiable factors include age, race, sex, medical issues, pre-existing musculoskeletal disease/tendon changes, ankle/foot alignment and genetic factors. Modifiable risk factors include obesity, sports activity, medication and smoking.  From a specific sport perspective, Achilles tendon ruptures are found more frequently in athletes who participate in sports involving explosive acceleration such as basketball, tennis, baseball, and softball.  Of the above factors, medications, especially Quinolones (specific antibiotics) and Corticosteroids, have shown to have the greatest risk for Achilles rupture.

There are multiple potential risk factors for Achilles tendon ruptures but none have been proven to be key factors.  One risk factor that I definitely have is O blood type.  A study from 1989 in the American Journal of Sports Medicine stated “In cases of multiple ruptures and re-ruptures, the frequency of blood group O was 71%.”  However, the O blood type correlation is still up for debate. 


Although the mechanism is still up for debate, what you’ll see if you slow down a video of the injury is the player taking a back step to push off and the knee forcibly extending at the same time. The combined force of foot plantar flexion and knee extension is likely too much stress for the tendon to handle. Watch the video of David Beckham tearing his Achilles for the prototypical mechanism of injury.

Strauss et al reported the following statistics in 2007 in the International Journal of the Care of the Injured.  The incidence of Achilles tendon rupture is approximately 18 per 100,000 people. Ruptures typically occur in males between 30 and 50 years old and account for approximately 40% of all operative tendon repairs. Approximately 75-80% of cases can be attributed to participation in athletic activities, including ball and racquet sports. 

Surgery or not? 

There is ongoing debate as to what is the best course of treatment: Surgical repair or non-operative treatment.  Surgery involves bringing the two ends of the tear together and suturing them in place while the tendon heals.  Non-surgical treatment involves casting the foot in plantarflexion (toes pointed down) and recasting weekly with gradual progression into dorsiflexion (toes up).  Non-operative care has demonstrated a re-rupture rate from 10-30% where surgical re-rupture rates are around 3-4%.  Surgical complications have been reported to occur in 7-42% of all cases and include difficulty with wound healing, skin necrosis, infection, and sensory loss.  For me, it wasn’t a question. I elected to have surgery as I want the best chance at a full recovery.

Rehabilitation

This is the most frustrating part for me.  For surgeries such as an ACL reconstruction, the harder you work the quicker you recover.  It’s just the opposite with an Achilles repair. The tendon needs time to heel so for the first 2-4 weeks you can’t put any weight on the foot.  Then, over the next 3-4 weeks you gradually increase weight bearing in a boot with a heel lift to take pressure off the tendon. Strengthening is started late in the rehab process which means it takes a long time to get your full strength back, and many people never regain full strength after this injury.  I never regained full strength after my first surgery and definitely lost a step with sports (although that could just be me getting older but I’m going with the injury).  It takes approximately 4-6 months to start back to running and to initiate sports activities with complete recovery taking close to a year. As you can guess, I’m in for a long and slow recovery following Achilles surgery. 

Prevention

Is there any way to prevent an Achilles injury?  There isn’t much research on this topic. In younger, high level athletes, there probably isn’t a way to prevent it other than not playing as intensely.  For someone older like me, there is the possibility that by improving flexibility and fitness you may be able to reduce the risk of injury, but it is still probably just bad luck.

For me, I’ll do my rehab and get back on the tennis court and the soccer field in the spring. Unless my surgeon and my wife force me to take up a sport with a lower risk of traumatic injuries, but with my luck, I’ll probably fall off the elliptical and break an arm.