NFL Injury Series- Achilles Tear

Analyzing the Achilles’ tear, causes, rehab, and return to play rates in the NFL.

Training camp is in full swing and the Buffalo Bills continue to stay healthy despite significant injuries elsewhere in the league. One injury that the Bills have avoided for some time is the Achilles tear which is the topic of today’s article on Banged Up Bills NFL Injury series.

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Credit: http://www.medi.de

The Achilles tendon is a thick tendon that connects the gastrocnemius and soleus muscle to the calcaneus which is the heel bone. The gastrocnemius muscle or calf muscle allows the foot to point down or plantar flex which is required for the leg to push off during walking and running. It also assists in flexing the lower leg at the knee joint along with the hamstrings. The gastrocnemius and soleus help drive the body forward in walking and running and are especially in maximum use during sprinting.

Like other tendons, the Achilles tendon can become injured which can develop into a tendonitis. This occurs when pain/inflammation affects the insertion point of the muscle and it becomes painful with activity. This can eventually lead to microtears occurring in the tissue during injury and the tendon heals improperly. Normal tendon and muscle striations are linear in nature allowing for maximum contraction of the muscle. In the event of tendonitis, the tissue heals improperly and instead of consistent striations, there is a disorganized mess of muscle fibers that does not allow the muscle to contract as efficiently which can lead to further pain and inflammation with continued overuse.

Risk factors seen in football players which could increase the incidence of an Achilles tendon rupture include: excessive body weight, heavy weightlifting, use of anabolic steroids, long term use of corticosteroids, immobilization of the ankle/foot, of the male sex, and muscle weakness/imbalance. While some of these risk factors are preventable, others are not and this is where doctors have to use best judgement when performing interventions for both short term and long term implications following injury.

With improper rest or not performing preventative exercises such as stretching or regular strengthening, an Achilles can eventually tear with either chronic overuse or suddenly. Unfortunately, most traumatic Achilles rupture warning signs can be asymptomatic and do not usually present with problems until after the major injury occurs. This means that because you have Achilles tendinitis, does not mean you will have rupture. However, because you do not have symptoms, does not mean you won’t have further injury.

In the event of a tear, most athletes are jumping, sprinting, or cutting with such great force that the tendon ruptured suddenly. The muscle is stretched past its limits suddenly or asked to do more than it is capable of after periods of inactivity. Even in conditioned athletes, this can still occur as the athlete is continuously pushing themselves to their limits. When rupture occurs, it is likened to a shotgun blast and loss of function and pain is immediate. This is an injury that even the strongest, most determined athletes cannot work through. The ability to push off the foot simply is not there. Here is an excellent clip of an Achilles tendon rupturing in real time.

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Credit: http://www.sportsinjuryclinic.com

In the event that there is a suspected Achilles tear, a Thompson test would be performed. This is where an athlete would lie on their stomach with their foot hanging off a table and the calf would be squeezed. If the foot moves, the Achilles is intact. If there is no movement, then this confirms the tear. Imaging may be done to assess severity but if the Thompson test is positive, then it is a tear. Tests such as this are typically accurate, similar to the anterior drawer test with ACL injuries.

Once the Achilles tear is confirmed, surgery is usually recommended immediately as tendon ruptures tend to retract back to the origin or attachment point of the muscle which means the longer surgery waits, the more difficult it will be to reattach the tendon. Rehab typically takes 6  months to a year to fully recover. Once the procedure is performed, the patient is placed in a boot that encourages the foot to point down to place slack on the tendon so that it can heal properly. If the foot were to be flat, that would place stress on the healing tendon with the foot in neutral and there would be a lesser chance of it healing properly.

Once the foot/ankle is immobilized with progressive weight bearing as instructed until 8 weeks to allow the tendon to fully heal back to the attachment point that is the bone. Light strengthening begins after 8 weeks with active stretching to the surgically repaired area occurring after 12 weeks. Progressive strengthening up to 6 months occurs with focus to avoid high forces on the tendon to reduce re-rupture. Similar to the ACL of the knee, full return to sports takes 9-12 months due to the demands of the structure.

Fortunately, re-rupture rates are exceptionally low in the repaired Achilles. While it is a long recovery, re-rupture rates following a repair are between 3.5%4.5% which indicate the overall long term success of the intervention. Non-surgical methods are available but are not recommended unless the person is a poor surgical candidate. While the re-rupture rates are fairly low, return to play rates are much poorer in comparison. Roughly 30% of athletes who sustain an Achilles tendon rupture and repair are never able to return to the NFL. Those that do typically suffer a decrease in performance up to 50% according to research. Those that do have a surgical repair have about a 6% chance to tear the contralateral or opposite Achilles.

Interestingly, the last confirmed Achilles tear that the Buffalo Bills had suffered dates all the way back to 2005 when LB Takeo Spikes tore his in the early in the season. There may have been more recent ones but pro-football-reference.com only goes back to 2009 with injury reports for the Bills and I was unable to find any Achilles tears after 2009. I pray that this is one streak that we don’t end for some time.

This is another nasty injury that occurs far too often in the NFL. Regrettably, it is a sad reality and there can only be so much done to prevent these injuries. So far, only two have been reported, CB Jason Verett of the LA Chargers and Patriots OL Isaiah Wynn. However, this will not be the last one by any stretch as it is still early in preseason and unfortunately many more injuries will occur.

This wraps up another article in the NFL injury series. As the preseason progresses, continue to watch for more Bills camp updates, injury articles, and any other breaking news coming out of One Bills Drive. Follow Banged Up Bills on Facebook, on Twitter @BangedUpBills, and on reddit at u/BangedUpBills. As always, thank you for reading and GO BILLS!!

Preseason Injury Breakdown- Part I

In depth analysis of the injuries occurring around the league. This article highlights areas of concern and injuries through the 1st preseason games.

Since Sunday’s post, every NFL team has played one preseason game. Depending on which fan base you speak to, it has either been a fantastic or horrible preseason. I’m willing to wager that those that rate their team’s preseason as horrible may be due to injury. If you’ve been following Twitter, ESPN, or local news, there’s been numerous reports about the significant injuries that have possibly derailed the regular season before it has even begun.

I have previously mentioned that I am focusing this blog on Buffalo Bills injuries. However, as I am a Physical Therapist, this allows me to expand as I wish into other areas of interest. Since the beginning of the preseason, I have been tracking nearly every injury that has occurred in camps around the NFL. Injuries that I deem worth tracking are ones that force a player to miss extended time, season ending, or placed on injured reserve. For my analysis, these injuries must have occurred during the preseason. Those that had off season injuries/surgeries or injuries from last year that are still recovering are not included in this analysis. This allows for a more specific time frame to be assessed. As of publication, I fully expect these numbers will change. Players will continue to get injured, waived, and reach injury settlements. My goal with this article is to highlight areas of interest and concern.

Of what has been publicly reported so far, there has been 119 players that have been either placed on injury reserve or expected to miss significant time. Of those 119 players, 26 have been released with injury settlements, allowing them to heal on their own time, get compensated, and seek out opportunities with other teams once they are cleared. If you would like additional information about the waived/injured status and process of injury settlements, please check out this article. Most of these injuries consist of hamstring pulls, ankle sprains, and unknown/undisclosed injuries. The most unique injuries of this group are a bruised lung and a Jones fracture, the same type of foot injury that sent Sammy Watkins packing to the Rams.

Of the 93 remaining players, 16 of these players have not been placed on injured reserve. These injuries consist of rather significant injuries consisting of various fractures and surgeries. These are injuries that the teams has deemed not appropriate to use the designated to return tag on injury reserve. If they used this tag, this would prevent the player from being cleared to play until at least Week 8. Considering that all NFL teams do not have to cut down rosters to 53 until September 2nd, there is incentive to allow these players to rehab and have them ready by Week 1.

This leaves 77 players whose seasons have ended before they even began. Think about that for a second, you have nearly a full roster and a half of NFL caliber players sitting on the sidelines recovering from injuries. Remember, the NFL has only played one preseason game so far. There are 32 teams in the NFL of 53 players on each active roster equating to 1,696 players. With the already injured players, you could add a 33rd team without difficulty if these players were healthy. Most of these teams have been in camp for only 3 weeks. While that is sinking in, I will continue to break down the injuries.

One of the highlighted injuries we see too often is ACL tears. Highlights of the mechanism of injury have been previously highlighted in my Reggie Ragland post. Already, we have seen 18 ACL tears and this is not stopping. Of all of the tears, 16 have been reported as ACL only, 1 reported as ACL, MCL, and 1 reported as ACL, MCL, PCL. Looking back at the past two years of training camp, 2016 training camp totals saw 16 ACL tears and 2015 training camp totals saw 15 ACL tears. At this rate, it would realistic to see the final number for this preseason reach the mid 20’s, possibly even equal the past two years combined. Of the 18 tears, 11 are defensive players, 5 are offensive players, and 1 special teams player.

One area that has improved so far is Achilles’ tears. To date, there have been 3 Achilles’ tears, compared to 6 in 2016 and 7 in 2015. Of the Achilles’ tears, 2 are defensive players, 1 is offensive. Breaking down the rest of the injuries briefly, several injuries of concern consist of spinal injuries which include lumbar and cervical complaints. Other injuries include torn hamstrings, pectoral tears, sports hernias, wrist dislocation/fractures, concussion, or undisclosed.

This is just a small sample size of what we as fans are seeing. There may be even more that have not been publicly disclosed yet or details still emerging. The NFL still has just over 3 weeks until Week 1 kickoff. I can tell you with the utmost certainty that these types of injuries will continue to occur. I expect some types of these injuries to decline as players continue to improve their conditioning and skills required for their position. I also expect these injuries to occur occasionally at practice and but with a higher frequency in preseason games. We have already seen stars such as Ryan Tannehill go down for the season during practice. I expect to see several other bigger name players go down for some time. Assume that players on the roster bubble to be the bulk of the serious injuries that remain. Several veterans have been injured, but of the 119 players injured so far, 98 of these players have 3 years or less NFL experience, which is the typical length of an NFL career.

Finally, I will take a brief look at teams who have been hit hard by the injury bug versus those that have mostly escaped major injury. Of the 32 teams, several have been hit quite hard. Leading the count with 8 players significantly injured or on IR are the 49ers, Dolphins, and Ravens. Following behind with 7 players are the Colts, Jets and Jaguars. Next with 5 players are the Chargers, Chiefs, Lions, and Redskins. The rest of the teams have 4 or less on IR. Two teams that I want to specifically highlight are the Buffalo Bills and the New England Patriots. The Buffalo Bills have only had 1 player be placed on injury reserve so far; Keith Towbridge with a foot injury. As much as I hate to state this, the New England Patriots are the only team that I have found to not have anyone seriously injured during this year’s training camp.

While I am a Physical Therapist and could continue to go down the rabbit hole with these injuries, I will save my commentary for future blog posts. Take these numbers for what they’re worth. Football is a rough sport, these statistics prove it. I would like to give credit to NFL Trade Rumors, Spotrac, and ESPN for providing the raw data and updates necessary for this post. As a fan and professional, I hope that the injuries for the Bills continue to occur at a minimum, allowing them to go into the season with the depth required to be successful. Continue to check back for future posts updating these stats along with further analysis of specific injuries.