Why is the Achilles Tendon so Vulnerable?
The basketball world turned upside down yesterday when Golden State Warriors star Forward Kevin Durant ruptured his right Achilles in Game 5 of the 2019 NBA Finals. With 9:55 left in the second quarter, Durant made a move off the dribble when he suddenly grabbed his right ankle. Previously, Durant had missed several weeks with reportedly a right calf strain. There was a lot of controversy surrounding Durant's decision to return to basketball activities within 3 weeks of his right calf injury. Many believe that premature recovery to his calf injury was what had ultimately led to a complete rupture of his Achilles.
I had a chance to talk about Durant's injury with the doctor that I intern for - Dr. Leslie G. Levy, a Podiatrist in Valencia that also specializes in foot and ankle surgery. He also gave me texts from the Foot and Ankle Clinic to enhance my knowledge about the injury. Levy has conducted several Achilles repair surgeries throughout his career, and he was able to discuss the different surgical procedures for repairing a ruptured Achilles tendon, as well as potential rehab techniques and possibilities for returning to full strength. As a high profile athlete, Durant's surgical procedures and rehabilitation techniques differ from the typical Achilles tear.
Achilles Tendon Background
The Achilles tendon is the longest tendon in the body, and it is commonly injured when there is a sudden eccentric movement to the foot. It usually occurs in the hypervascular zone, which is an area of the Achilles tendon that has a low blood supply and is located 4-6 mm above the Achilles insertion point where the Achilles inserts at the calcaneous, or heel bone. The Achilles tendon is one of the most commonly ruptured tendons in the human body. According to Mark A. Krahe, DO, there are 18 ruptures per 100,000 people, with the injuries typically occurring in males between the ages of 30 to 50 years. Common symptoms typically include the feeling of being kicked or shot above the heel following a traumatic event, a felt absence of tendon in the affected area, the feeling of the tendon 'popping,' a feeling of weakness near the ankle, and difficulty walking.
Radiographs are not used to diagnose an Achilles rupture, but they may provide information about the alignment of the foot and ankle. An MRI and ultrasonography are used to confirm diagnosis and are used to determine the extent of tendon retraction. An ultrasound is dynamic for examination and is cost-effective, but an MRI allows for multi-planar imaging and is useful for planning surgical reconstruction. Typically, imaging is not routinely required to diagnose an Achilles rupture, since physical examination (the Thompson test) is sufficient enough to identify whether or not the ligament is torn.
Surgical Techniques for Achilles Tears
There are both invasive and non-invasive methods of treatment for an Achilles tear, but high profile athletes typically follow the surgical route in order to expedite the recovery process. In an open repair, a small incision of the ankle, going down to the Achilles tendon and putting sutures into the tendon edges to approximate the tendons so that they heal in that particular position. In a mini-open repair, a smaller incision is made over the tendon. A special tool covered in holes is inserted into the area, and it shows the surgeon where to place the stitches. The stitches will pass through each hole, into the skin, and the tendon. The tool is then removed, which pulls the suture under the skin, so only the tendon remains attached to the suture. The surgeon repeats these steps on the other side, then ties the sutures together, holding the tendon in place. For Durant, a high profile athlete, his surgeon likely used the percutaneous method, where 3 to 6 small incisions are made under the skin. The stitches are criss-crossed as they pass through each hole and through each end of the tendon, where they are then pulled together, reconnecting the tendon.
Recovery + Possibilities of Full Strength, When to Return
The recovery is always long for those that suffer Achilles ruptures, typically ranging from 9-12 months, or sometimes even longer. At best, the patient can regain 90% of their strength in the tendon. Durant is likely to regain around 80% strength after the first year of recovery, and another year of recovery will allow him to reach 90% strength. The biggest obstacle in his return to basketball would be his body's ability to regain strength in his right leg, and Durant's return is not feasible until there is complete confidence that he no longer compensates for the fragility of the injured tendon by over-using other muscles.