The Middletown Press (Middletown, CT)
Achilles tendon a severe injury for athletes
Injury suffered by UConn freshman, Sun player
Connecticut Sun star Brionna Jones immediately fell to the floor and grabbed her lower right ankle. For a brief second, she locked eyes with Sun head athletic trainer Nicole Alexander on the bench.
Jones shook her head and mouthed the word, “No,” to Alexander before rolling over in visible pain.
Alexander sprinted onto the court to console Jones. While she couldn’t officially diagnose her until they got Jones in the locker room, she could already tell it was her Achilles.
“Once we got her in the back and took her ankle brace and her sock off, you could see it,” Alexander said. “You can just see where the calf is shorter. You can see where it’s supposed to be.”
Jones simply had pushed off her right leg when her Achilles tendon gave out and threw her forward onto the ground.
A month later, in Madrid during the FIBA U19
World Cup, UConn women’s basketball redshirt freshman Jana El Alfy fell over after attempting to push off her left leg.
In a video replay, the Egyptian is seen bracing herself with her right arm while momentarily looking over her shoulder. Her left arm immediately reached for her left ankle.
We don’t know exactly what causes Achilles tendon injuries to occur, but it remains one of the most long-term severe injuries for athletes. Both Jones and El Alfy were diagnosed with ruptured Achilles tendons and are out for their respective seasons.
While science is still out on the exact cause and effect of Achilles tendon injuries, here’s what we do know:
What is your Achilles tendon?
In Greek mythology, Achilles was the ultimate war hero. He was strong and immortal — that is, except for his heels.
Per the myth, Achilles’ mother, Thetis, dipped his body in the River Styx to grant him immortality. However, because she held him over the water by his heels, they remained mortal. Achilles’ story comes to an end after the Trojan prince Paris shoots Achilles in the ankle with an arrow, killing him.
It’s the origin story of the saying “your Achilles heel” when referring to someone’s biggest weakness.
It’s also what we call the tendon that runs along the back of your ankle, connecting your calf muscles (the gastrocnemius and the soleus) to your heel bone — perhaps because, despite being the largest tendon in the body, it’s also the weakest.
“It’s the most commonly ruptured tendon in the body,” said Dr. George Theodore MD, an orthopedic foot and ankle surgeon with Mass General Brigham Sports Medicine in Boston and an orthopedic foot and ankle consultant for the New England Patriots, Boston Red Sox and the Boston Bruins.
“Unlike other tendons in the body, which you may not be walking on, this is one that you’re walking on, and you have a lot of pressure going through it and pushing it off the foot.”
The Achilles tendon acts like a rubber band and uses the force from your calf muscles to propel your foot forward when you walk, jump and run. In order to complete those actions, it has to absorb an extensive amount of force. And because of that stress, one small ounce of trauma can cause injury to the tendon.
“That tendon mechanically, levers anywhere from nine to 20 times your body weight every time you push or step,” said Dr. Adam Ferguson D.O., an orthopedic foot and ankle surgeon from Comprehensive Orthopedics and the Connecticut Orthopedic Institute. “So, let’s just kind of do the math on that; let’s say someone weighs 150 pounds.
Twenty times that is 3000 pounds. That’s a lot of force being driven through that tendon in a single action.”
What causes Achilles tendon injuries?
There’s no exact reason as to why Achilles tendon injuries occur.
“A lot of it just has to do with bad luck,” Dr. Ferguson said.
Sometimes it’s because a person is attempting intense physical activity that they’re not properly conditioned for (lack of hydration and training), but more often than not, Achilles tendon injuries occur when someone is making an explosive, cutting movement.
“Basically, what happens is, for whatever reason, that that particular incident and that particular action was more force than the tendon at that point was able to tolerate even if they’ve done that action thousands and thousands of times (before) in their career,” Dr. Ferguson said. “… Just that was the one unfortunate time that that particular action overcame the tensile strength of the tendon.”
Dr. Elizabeth Cody MD, an orthopedic foot and ankle surgeon at Hospital for Special Surgery in New York, says the Achilles tendon doesn’t receive great blood supply — because of its location on the back of the ankle — which can cause the tendon to weaken overtime too.
“Tendons can develop degeneration or small tears over time. The Achilles tendon is especially prone to this because there’s so much stress on it,” she said. “So what happens over time is you can get this kind of progressive degeneration of the tendon, where the tendon is unable to heal at the same rate as you’re producing damage. Over time this weakens the tendon and can contribute to a tendon rupture. But also, sometimes the tendon can just tear if you put too much stress on it all at once, even if it’s a healthy, normal tendon.”
In the video replays of both El Alfy and Jones, you can see each player was not heavily guarded when they went to push off their back leg. Both players immediately crumple to the floor and grab at the ankle of the leg they pushed from.
El Alfy is seen looking over her shoulder once she’s on the ground as if something had struck her from behind. Except there’s no one directly behind her.
Doctors said they can often work toward diagnosing an Achilles tendon injury based on the patient’s description of what happened. Some say they felt like they were kicked in the back of the leg, yet no one was there or they felt as if someone snapped a rubber band on their calf, yet again, no one was behind them. It’s also common for someone who tears their Achilles to hear and feel a sudden “pop” when the injury occurs.
“I think the perception that your body has at that point is that ‘Something must have happened because this is an action I’ve done hundreds of thousands of times in my life and all of a sudden I can’t, so there must be an external force.’ ” Dr. Ferguson said.
There is really nothing someone can do to specifically prevent or predict a noncontact Achilles tendon injury. Doing exercises that strengthen the calf muscle (like calf raises) and always properly conditioning your body before physical activity, can help reduce risk but won’t completely prevent an injury from occurring.
It’s possible an athlete could feel some soreness/discomfort around their ankle and Achilles tendon prior to an injury occurring (Achilles tendinitis), however; most Achilles tendon injuries can’t be prevented.
“It’s just the right amount of stress at the wrong time,” Dr. Cody said.
“We don’t know why some people get a rupture and others don’t,” Dr. Theodore added “… In a particular day playing basketball, why will someone injure, rupture it, but not the others who are of the same age, maybe, same level of play, doing the same movements? We’re not sure of a cause-and-effect relationship between the particular sport and the tear.”
While most Achilles tendon injuries occur noncontact, it’s also possible to injure your Achilles tendon from contact. Dr. Theodore said he’s seen cases in hockey where someone’s skate will catch someone else’s ankle and cause a laceration on the tendon.
Athletes that play sports that feature explosive movements, like basketball, soccer, and pickleball, are more likely to suffer Achilles tendon injuries because these quick movements put strain on the tendon. Dr. Ferguson said he’s recently seen an increase in people in their 60s and 70s who have Achilles tendon injuries due to picking up pickleball.
Dr. Ferguson and Dr. Theodore said they see more men experience Achilles injuries than women, but there isn’t any science out yet that explains why.
Achilles tendon injuries are also more common with people in their 20s and 30s instead of young children. Dr. Theodore said the injury can occur “in almost 12 per 100,000 adults.”
“It’s becoming, unfortunately, as common as ACL tears,” Alexander said.
Besides elite and pro-level athletes, Achilles tendon injuries are also common with what doctors refer to as “weekend warriors” — average-day people who attempt high-volume physical activity without being properly conditioned.
“If someone goes out and tries to do a Tough Mudder or starts CrossFit, or something like that, who’s not been working out for some period of time, that’s the person that potentially get an Achilles tear,” Dr. Ferguson said.
After the injury occurs, a physician can diagnose the athlete through an MRI and also through the Thompson Test. This is when a patient lies flat on their stomach with their knees bent up and a physician will squeeze their calf muscle to see if it triggers the foot to react.
“If you squeeze the calf, then normally you should see the foot point down because you’re squeezing the calf and that’s connected to the Achilles tendon,” Dr. Cody said. “But if the Achilles tendon is torn, if you squeeze the calf, you won’t see the foot bend down at all.”
In the case of Jones, Alexander said she could feel and see that Jones’ calf muscle had “recoiled” up her calf since the tendon was no longer connecting it to her heel.
Achilles tendon injuries are classified by how bad the tendon is torn with a ‘rupture’ being a grade three level tear, the most severe.
It is possible to walk on an injured Achilles tendon, yet you’d most likely suffer a limp and swelling around the ankle. Dr. Ferguson said that often times you’ll see someone swing their leg to the side when walking on an injured Achilles tendon because they lack the ability to push off the ground with their foot.
Surgery, recovery timeline
Achilles tendon injuries can be repaired surgically and non-surgically.
Most elite athletes choose to undergo surgery since the recovery timeline is often a little faster, there’s less risk for re-rupture, and there’s a better chance at restoring the original retention of the tendon.
During surgery, which can last about an hour and a half, the surgeon will reconnect the two ends of the tendon by “essentially sewing them back together,” says Dr. Ferguson. The patient returns home the same day they check-in for the surgery. Both Jones and El Alfy underwent surgery for their respective injuries.
In the case of someone electing not to undergo surgery, the patient is put in a cast with their foot positioned downward to push the tendon’s two pieces together and allow for healing before progressing to a walking boot with a heel lift.
“What’s important to know is that non-operative treatment does give good functional results in the correct profile of person who’s injured and they can have good functional outcomes, but there can be a higher re-rupture rate,” Dr. Theodore said.
Whether a patient chooses to have surgery or go the nonoperative route, rehabilitation for Achilles tendon injuries is relatively similar. At around six months, the patient is walking again. But in both cases, the patient is often not back to their normal level of strength until around the 12-month mark.
“For the professional athlete, this a year-(long) injury from when you sustain it to when you’re back pretty close to where you were prior to the injury is essentially a full calendar year,” Dr. Ferguson said. “For more basic activities, like walking around the block, maybe a light jog, you’re probably looking at six to nine months.”
Exact recovery timelines vary based on each individual. Dr. Ferguson said he’s seen someone come back as early as four-anda-half months, while Dr. Cody said sometimes the recovery can last up to two years. When Sun star Alyssa Thomas tore her Achilles tendon in 2021, it took her just nine months to return to the court.
“It depends on the person,” Alexander said. “A lot of people have asked me how Alyssa Thomas came back really fast. Alyssa Thomas is one on one . ... Every athlete is different. Every human body is different. Their mindsets are different.”
Patients undergo extensive rehabilitation once they begin recovery. The biggest priority in rehab becomes regaining strength in your calf muscle and your ankle’s range of motion.
Because of the intense recovery process and long timeline, sometimes a patient is never able to get back to the strength they once were, especially if they tear the tenon later in life. Maybe that leg becomes slightly weaker than the other and not as quick.
“Whether you’re treated with or without surgery, for most people that leg will always be a little bit weaker, and the calf muscle will always be a little smaller,” Dr. Cody said. “… For casual athletes, it shouldn’t ever have an effect on your ability to do sports. For somebody where explosive strength is important, so like an elite sprinter or an elite basketball player, then yes, it could be (have a lasting impact). For like a professional athlete, it can be a career-ending injury.”