Achilles Tear and Repair

Fantasy Impact

Position	Average % Difference PPG Change From Pre-Injury Compared to 1st Game After Injury	Average % Difference PPG Change From Pre-Injury Compared to Games 2-3 After Injury	Average % Difference PPG Change From Pre-Injury Compared to Games 4-6 After Injury
QB	N/A	N/A	N/A
RB	-7.4%	+41%	-42%
WR	-35.2%	-14.5%	-44.6%
TE	-55.8%	-77.7%	+1.9%

Position	Average Change in Snap% From Pre-Injury Compared to 1st Game After Injury	Average Change in Snap% From Pre-Injury Compared to Games 2-3 After Injury	Average Change in Snap% From Pre-Injury Compared to Games 4-6 After Injury
QB	N/A	N/A	N/A
RB	-11.5%	+7.1%	-27.9%
WR	-1.5%	+7.1%	-8.3%
TE	-45.9%	-42.9%	-18.1%

Anatomy of Achilles tears

The Achilles tendon is the strongest tendon in the human body.¹ It connects the calf muscles (gastrocnemius and soleus) to the heel allowing the ankle to move into plantarflexion (like pressing the gas pedal) but also controlling the ankle moving into dorsiflexion (foot pointing upward). When running, cutting, and jumping, these motions are constantly occurring at the ankle. Therefore the Achilles is continuously at work during athletic activity. Because of the demand, the Achilles is the strongest tendon in the body as it must be capable of taking on 6-10x the body weight in force during these athletic activities._^1,2

The Achilles begins in the lower leg as the three calf muscles (medial and lateral gastrocnemius and soleus) merge into the tendon that is the Achilles. From there, it attaches to the bottom portion of the heel bone. Therefore, when the calf muscles contract, they pull through the Achilles to move the heel bone. Because of this, when considering an Achilles injury, one must also consider the health of the calf muscles and vice versa. 

Cause of Achilles tears

The Achilles typically won’t tear with straight-line running or even straight-line sprinting as this does not usually place enough force through the tendon to tear. The most common way the Achilles will tear is when an athlete is either landing from a jump or cutting and their ankle excessively dorsiflexes (moves upward) rapidly, which is why you often see a cornerback tearing their Achilles when they are transitioning from their backpedal to sprinting forward or laterally (ex. Richard Sherman).^3,4 In that example, the cornerback will have been backpedaling quickly (creating force through the Achilles) and suddenly plants his foot (foot goes into dorsiflexion) and immediately changes direction, putting stress through the Achilles. As mentioned, the Achilles takes on up to 10x one’s body weight during these motions, and in some instances, these motions create more force than the Achilles can take on, leading to a tear.  

The other method of Achilles tear is when a player is running and gets tackled from behind, and the defender pins the runner’s heel under their body, but the runner’s shin continues to move forward. Consequently, this creates a greater than normal stretch on the Achilles and can lead to tears as well, which is similar to how D’onta Foreman injured his Achilles in 2017. 

Surgical procedure – Achilles tear

For an athlete to return to full athletic function from a torn Achilles tendon, they must undergo surgery as a surgically repaired Achilles tendon has shown superior functional recovery compared to nonsurgical care.⁵ When tendon tears, the torn portions of the tendon must be aligned perfectly to heal, and with the Achilles, this can only happen if the torn portions are surgically sutured together. There are several different techniques surgeons will use to repair the torn Achilles tendon, and often a surgeon’s preference and training will determine the type of surgery performed.  

During surgery, the patient will be under spinal anesthesia and will be face down on the surgery table. The surgeon will make an incision to the skin in the area of the Achilles tear. From here, the surgical technique may vary, but ultimately they will use sutures to put the torn ends in contact with one another, allowing the torn portions of the tendon to heel together.  

In some procedures, the surgeon will create 2 or 3 bundles of the tendon from each end and overlap them. In contrast, other surgeons will place sutures on the top portion of the tear, drill holes near the heel bone, and direct sutures upward through there to meet the sutures at the top of the tear and pull the two ends together.⁵ At the end of the surgery, the surgeon will ensure the torn ends are sutured together by squeezing the calf muscle and ensuring that this leads to a plantarflexion motion at the ankle.  

A significant risk of surgery is an infection or the incision coming undone.^4,5 This is seen in 6% of the population; however, if an athlete undergoing surgery has diabetes, is taking steroidal medications, or smokes, the risk increases to 40%.⁵

Surgical outcomes – Achilles tear

With this extensive surgery, it is interesting to see what the research says about how athletes recover. In modern NFL, more and more athletes are returning to pre-injury or close to pre-injury form. No better example exists than Cam Akers, who tore his Achilles on July 20th and was on the field for their week 18 game on January 9th and went on to help the Rams win Super Bowl LIII. However, this quick return has not always been the case with Achilles repairs. As such, just a few years ago, this type of injury was essentially a death sentence to a player’s career.  

The research tells us that only 30% of NFL players who tear their Achilles are able to return to their professional careers.⁶ The reason that so many struggle to return to pre-injury form is also outlined in the research. In fact, studies have shown that even a full year after surgery, the muscle strength of the calves on the surgical side averages 10-30% weaker compared to the non-surgical side.⁷ Calf muscle endurance averages being only 52-88% when compared to the non-surgical side.⁸ Additionally, altered walking and running mechanics and poor balance have been shown to persist years after surgery.⁹

When an athlete has one leg that is significantly weaker, has less endurance, and worse balance than was pre-injury, and is significantly worse compared to the opposite side, this both impacts his ability to perform, but also renders him prone to another injury. These factors make it very difficult for an athlete to return to their prior level of performance after this type of injury.

Achilles tear rehab process

The rehab process for an Achilles repair is long and will vary slightly depending on the surgeon’s protocol. However, the general principles remain consistent. Often for the first 2-4 weeks, no weight is allowed through the surgical foot, and they will either be in a cast or be wearing a protective boot and using crutches.³ Typically, by the 3rd week, they will be in a boot with several heel risers designed to reduce the stretch through the repaired Achilles. Every so many days (usually 3-5 days), they remove one heel riser to allow the tendon to stretch slightly more. Research does support beginning to put weight through the surgical foot by week two post-op; however, this will be dependent on the surgeon’s recommendations.¹⁰

Swelling management is critical and managed through ice, compression, and elevation of the leg. At first, only some weight is allowed on the surgical leg, and the amount of weight may be indicated as a percentage (25% weight-bearing) or as a weight (50# weight bearing).  

By weeks 4-6, full weight-bearing is allowed, and at this time, balance exercises should be started. Early range of motion exercises without stretching the tendon is incorporated to begin activating the calf muscles, reduce swelling, and bring the cells that will repair the tendon to the area. Strengthening usually starts with elastic bands through a limited range and eventually progresses to strength exercises in standing.

During all phases of rehab, but particularly early on, it is essential to strengthen the core, glutes, quads, and hamstrings. When an athlete cannot bear weight through their leg for several weeks, these muscles get weak very quickly. Below is a general timeline of the rehabilitation from an Achilles tendon repair.

TimeLine	Goals and Weight Bearing Status	Rehab
Post-op Weeks 1-2	Goals: Protect surgical site. Swelling reduction. Weight Bearing No weight through the surgical leg. Foot is in cast positioned in 20 degrees of plantarflexion.	Glute, quad, hamstring, and core strength on treatment table: Clamshells, side-lying leg raises, glute squeezes, straight leg raises laying on back, dead bug
Post-op Weeks 3-6	Goals: Protect surgical site. Swelling reduction. Gradually increase weight-bearing. Weight Bearing Transition from cast to protective walking boot with multiple heel lifts (5-6 2cm heel lifts). At week 3 usually able to put 25% of weight through the surgical leg. Each week increasing by 25% until full weight-bearing at 6 weeks. Walking with crutches.	Gentle ankle exercises: Ankle pumps to neutral, foot side-to-side initially without resistance. Progress to light theraband resistance. Continue with core, glute, quad, hamstring strength.
Post-op Weeks 6-8	Goals: Protect surgical site. Swelling reduction. Full weight-bearing. Weight Bearing Full weight-bearing in boot with heel lifts. Gradually start removing heel lifts (1 every 2-3 days as tolerated)	Continue with previous exercises. Begin seated heel raises if tolerable Calf stretching to neutral with strap Begin balance exercises: Wobble board, standing on foam pad, single-leg stance Gait training with full weight-bearing. Begin with two crutches, advance to one crutch, then no crutch. Deep water pool walking, cycling
Post-op weeks 8-12	Goals: Protect surgical site. Wean off heel lifts. Wean out of boot by weeks 10-12. Weight Bearing: Full weight-bearing. Continue to reduce heel lifts every 2-3 days until no more heel lifts. Gradually wean out of boot and into normal shoe over 4-5 days, can wean compression ankle brace.	Begin standing strength exercises: Body weight squats, standing leg kicks to the side and back, banded walks, lunges, double-leg heel raises from floor. Gentle calf stretch in standing. Balance exercises: Wobble board, progressing balance exercises on foam pad (bringing feet closer together, closing eyes, tossing ball while balancing, single leg), single-leg cone taps with cones in front, to the sides, and behind. Treadmill walking, elliptical, cycling
Post-op Weeks 12-16	Goals: Progress functional strength Weight Bearing: Ensure single leg balance and strength is similar to non-injured leg. Full weight-bearing and now wearing regular shoe all the time.	Increase resistance and number of reps of previous exercises (squats, lunges, leg kicks, band walks) Continue with calf stretching. Increase challenge of balance exercises: Wobble board while tossing ball, single-leg stance on foam pad while tossing ball, add cognitive task (count backwards from 100 by 3’s while balancing) Initiate straight line jogging in anti-gravity treadmill at week 16 IF able to do 75-80% single-leg heel raises compared to other side.
Post-op Month 4-6	Goals: Return to running at week 16. Begin to gradually return to sport-specific movements. Weight Bearing: Full weight-bearing and now wearing regular shoe all the time.	Continue progressing all exercises from previous phase. Straight-line jogging. Ladder drills, throwing, half-speed agility drills
Post-op Months 6-9	Goals: Return to prior level of performance. Weight Bearing: Full weight-bearing and now wearing regular shoe all the time.	Unrestricted training. Sprinting, jumping, cutting, plyometrics, throwing, etc.

References

1. Lee K, Ling S. Controlled trial to compare Achilles tendon load during running in flatfeet participants using a customized arch support orthosis vs and orthotic heel lift. BMC Musculoskeletal Disorders. 2019;20(535).
2. Wong M, Achraf H, Kiel J. Anatomy, Bony Pelvis and Lower Limb, Achilles Tendon. Stat Pearls. 2021.
3. Albin S, Cornwall M, Van Boerum D. Postoperative Management of Orthopaedic Surgeries; Ankle and Foot. 2016.
4. Jiang N, Wang B, Chen A, Dong F, Yu B. Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop. 2012;36(4):765-773.
5. Sandada T, Iwaso H, Fukai A, Honda E, Yoshitomi H. Comparison Study of Mini-Incision Versus Original Open Technique of the Half-Mini-Bunnell Achilles Tendon Repair. The Journal of Foot & Ankle Surgery. 2021: 1-8.
6. Kraemer R, Wuerfel W, Lorenzen J, Busche M, Vogt PM, Knobloch K. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis. Arch Orthop TRauma Surg. 2012;132(6):847-853.
7. Silbernagel KG, Steele R, Manal K. Deficits in heel-rise height and achilles tendon elongation occur in patients recovering from an Achilles tendon rupture. Am J Sports Med. 2012;40(7):1564-1571.
8. 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.
9. Bressel E, Larsen BT, McNair PJ, Cronin J. Ankle joint proprioception and passive mechanical properties of the calf muscles after an Achilles tendon rupture: a comparison with matched controls. Clin Biomech. 2004;19(3):284-291.
10. Costa ML, MacMillan K, Halliday D, et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br. 2006;88(1):69-77.