Why do Achilles ruptures take so long to heal?

Kathryn O’Connor, an assistant professor of clinical orthopaedic surgery at the Perelman School of Medicine, gives the ins and outs of Achilles tears.

Kathryn O’Connor of the Penn Foot and Ankle Treatment Team poses at Penn Medicine University City.

NBA free agency begins on June 30 and enquiring eyes will be on one of the league’s biggest superstars—forward Kevin Durant, a free agent who played for the Golden State Warriors the past three seasons.

Durant, a 10-time All-Star, the 2014 NBA MVP, and a two-time NBA Finals MVP, ruptured his Achilles tendon in Game 5 of the 2019 NBA Finals. He is expected to miss the entire 2019-20 season, although some team will surely pay him tens of millions of dollars while he recuperates.

Kathryn O’Connor, an assistant professor of clinical orthopaedic surgery at the Perelman School of Medicine, who specializes in Achilles injuries, says the tendon functions to help maintain ankle strength and push-off of the foot during gait. 

“Whenever you’re doing any sort of activity like running or jumping and landing, the Achilles tendon is really loaded and controls the way you explode up and the way you land softly,” she says. “People who have injuries to their Achilles definitely develop an abnormal gait pattern afterwards if they’re not treated appropriately, or if there’s some residual deficits in strength or flexibility.”

At Penn Medicine University City, Penn Today spoke with O’Connor, who is also an expert on the Penn Foot and Ankle Treatment Team and works with student-athletes at the University, about Achilles injuries and repairs, and why they take so long to heal. 

It seems like in athletes, an Achilles rupture or maybe Tommy John surgery are two of the worst injuries that you can have, aside from brain or spinal cord injuries. Is that the case?

It’s actually an injury that some people are able to recover from, but certainly it can be a very long recovery, almost up to a year to return to professional sports. And there are some people who don’t ever get back to returning to sports. It is very common just because of the nature of a lot of athletic movements, and sort of controlling landing and jumping. That’s the kind of motion that puts the Achilles tendon at risk.

Why does it take so long to recover from an Achilles tear?

There’s a lot that we don’t totally understand about why it takes so long to recover. In most surgeries, especially tendon-type surgeries, there are changes to the tendon, but at the same time, there are also changes to the muscle. And the combination of the loss of the strength of the muscle fibers and the time it takes for the tendon to heal takes a long time. There’s the time it takes to recover to getting back to walking around, and then there’s the time it takes to recover to return back to playing in the NBA. People who rupture their Achilles tendon generally are back walking—whether they have surgery or don’t have surgery—in about three months. But usually the muscle hasn’t recovered enough strength to get back to jogging until around six months, sometimes even longer. Then the explosive maneuvers like jumping and pivoting and landing, those things take the additional time that gets people up to a nine-to-12-month recovery to return to high-level sports. 

If someone ruptures his or her Achilles, how do you repair it?

There are few different ways you can repair it. First of all, not everybody that ruptures their Achilles tendon needs to have it surgically repaired. There is fairly good literature to say that if you rupture your Achilles tendon, the outcomes aren’t that different between the surgical and non-surgically treated group. And when I say non-surgically treated group, it’s a very regimented protocol of booting and casting and therapy. It’s actually the same protocol that goes on with the surgery, it just starts with a cast as opposed to starting with a surgery.

Some people who are at risk for infection or who are not high-level athletes might be able to get at completely acceptable and adequate recovery without any surgery. For the person who really wants to optimize their function, whether it’s playing basketball or tennis or racquetball—those are typically the sports I see it most with in my clinic—it takes a really long time and we generally recommend to that person that they might want to have surgery, although some people are active and still opt to not have surgery.

It is just a random thing when people rupture their Achilles?

There’s a little bit of randomness to it. There are two populations with which people rupture their Achilles. Of course, there are outliers to this, but generally the most common pool of people to get an Achilles tendon rupture are young, healthy active men ages 20-45. It tends to be men but we see women that do it, too. Then there’s a population in their later 50s, 60s, and 70s who have what is probably an underlying chronic tendinitis and then they do something that tears through that tendinitis. It’s still a rupture, but there are just different populations for it. 

In a person that’s older, a lot of times those people may have some symptoms of chronic tendinitis beforehand where they maybe have been having pain in their Achilles, having some swelling, and they may even be getting treatment for it, and then they do something where they trip or stumble and fall, and then it ruptures. In the younger healthy men that I see and the young healthy women I see, a lot of times they have no what we call prodromal symptoms; they’re just out playing basketball or going dancing like they normally would and all of sudden they just step funny or they land a little awkward and they feel a pop and it’s ruptured. A lot of times, it’s just a little bit of bad luck.

Is it painful when a person ruptures his or her Achilles?

All things considered, it’s actually not that bad. When people rupture it initially, it’s pretty uncomfortable. They sort of feel like they’re having a calf cramp, but it’s not terrible. Once you get past the first few days, once the tendon is immobilized in a cast or a splint, they tend to not have that much pain. Even after surgery, they don’t have that much pain. I’ve had several patients who have ruptured their Achilles and don’t even realize they’ve done it. They just think they sprained their ankle or something feels wrong, but it’s not even so painful that they go to the emergency room. They might walk on it for two or three weeks before they come in.

Is there anything people can do to prevent Achilles injuries?

Probably the best thing to always do is make sure you appropriately warm up and appropriately cool down. That way you’re not jumping into a sporting activity before the tendons and muscles have adequate blood flow and time to respond before they have to take a load like a landing or a jump.

If a person has a prior leg injury, can it lead to an Achilles tear? For example, Kevin Durant had a calf injury in his right leg about a month before he tore his right Achilles. 

I don’t know the answer to that. It’s a little unclear what his initial injury was. I haven’t personally seen that in my practice, that somebody has strained their calf and then ruptured their Achilles. Also, my patients aren’t playing in the NBA, so it’s a different load and different forces because he’s certainly a bigger, larger man who’s doing things at a lot higher velocity and speed than my average weekend warrior. It’s not clear that there is that kind of preceding injury that predisposes someone to it.

You mentioned that you see a lot of Achilles injuries in athletes who play basketball, tennis, and racquetball. Is that because of all the cutting involved in those sports?

It’s the cutting. A lot of times it has to do with the way you either are backpedaling, or step, or land coming down. A lot of times it’s a landing injury more than a jumping injury.

Why is it so hard to return the Achilles tendon to the status it was before it was ruptured?

You’ve ruptured a major tendon and even if you have it repaired, the way things heal, it’s never the original model. It’s never the same, normal, healthy tendon that it was. Even when you repair it, it still has a level of scar tissue in it that may not have the same amount of pliability to allow for the same amount of explosive activity. It may be that when it heals, it doesn’t heal with the right amount of tension. Sometimes it’s just that muscles atrophy enough that it’s just too difficult to really get the strength all the way back. But no matter what you do, the injured side is never as strong as it originally was, or really as strong as the other side because it’s just a different tendon than it was before.