Achilles Tendon Rupture: Diagnosis, Treatment and Recovery – The Kobe Bryant case

CC image Wikiipedia.orgKobe Bryant has earned many distinctions throughout his NBA career.  He’s a 15-time All-Star, 5-time NBA Champion, and 2-time Finals MVP, and he also holds the unofficial record for most tweeted about Achilles tendon.

Bryant injured his Achilles on Friday in the closing minutes against the Warriors, and although he was able to walk off the court, he underwent surgery on Saturday and is expected to miss 6-9 months.  Because many people were looking for more information about Bryant’s injury, and the Achilles tendon in general, Dr. Silverman decided to address some common questions in Q&A form.

What happened to Kobe Bryant?  As Kobe planted his left foot while driving to the left, his calf muscle began to contract at the same time his ankle was dorsiflexing. This is called an “Eccentric Contraction”, and it is incredibly powerful. His Achilles tendon ruptured due to the tensile force he created with this action.

Why did it happen? Simply put, the force on Kobe’s tendon exceeded the tendon strength of the tendon.

Was Kobe’s tendon in a weakened state because he played too many minutes? Although many NBA pundits are looking to blame coach Mike D’Antoni for playing Bryant for so many minutes over the season, Kobe’s tendon was in a weakened state because he’s been playing professional basketball for nearly 20 years, not because he played a couple extra minutes each night over the last month. This is what is commonly known as “silent degeneration”.  Over the course of time, normal tendon fibers slowly and painlessly tear to the point that less than 50% of the tendon remains. People will still be able to function with a deteriorated Achilles, but the tendon will not be able to tolerate normal stress, like an explosive move in basketball.

Why did it happen that day? Sooner or later it was bound to happen. The Achilles was going to give out as soon as he attempted to generate a high amount of force on a degenerative tendon.

Where does the Achilles tendon rupture? With a classic rupture (like the one Bryant sustained) the tendon ruptures around 4-6 centimeters above its insertion point on the heel bone (the calcaneus).

What other injuries happen to the Achilles tendon? Less commonly, tears of the junction between the muscle and the tendon which are much higher in the calf can occur.  These injuries are treated best with casting, and they have a great recovery rate. In older individuals, chronic tears slowly develop and are progressively painful at the insertion.

What is done to treat Achilles tendon tears? In active individuals, surgery is recommended for the most rapid return to sport, highest likelihood of full strength return, and lowest rate of re-rupture.

How quickly should Achilles tendon tears be fixed? Achilles tendon tears should be surgically fixed before the tendon retracts, and the best results can be attained with standard techniques within 15 days from the initial injury. The faster the repair is done, the faster the recovery begins.

What happens in Achilles tendon surgery? After anesthesia (by regional nerve block or by general means) an incision is made over the torn Achilles tendon.  The tendon edges are then exposed, addressed, and sutured together in a variety of techniques. For the best results, a repair must be strong enough to handle early weight bearing. The surgery takes between 30 minutes to one hour to perform. A cast is applied to protect the skin while it heals.

How long will it take Kobe to recover? While surgery is quick, the recovery is not. Patients will spend anywhere from 1-2 weeks before walking on their foot. During an active athletic rehabilitation protocol, patients can be removed from their cast about two weeks after surgery and placed into a removable walking boot with a heel lift. The heel lift is gradually decreased over six weeks. Physical therapy can start after six weeks, and it continues for several months. The first stage involves obtaining full range of motion; then strength and balance training begins. It is not safe to begin sprint acceleration activities until four months after surgery. The tendon takes that long to remodel and become strong enough to handle the stress. By six months, strength should be adequate to return to any sport, but it continues to improve and the calf size increases up to two years post-injury. Kobe’s doctors have pegged his return at nine months post-operatively. When he returns to the court before the nine months, he’ll get to look like Superman.

What are the most common complications after Achilles surgery? In the early healing period, infections and skin breakdowns are common. As we have discussed before, certain sutures like Vicryl can contribute to this risk. To prevent wound complications it is important to stay elevated during the first few days to prevent swelling of the wound. Later, immediately after weaning from the walking cast boot around 6-8 weeks, a fall, jump, or slip can re-rupture the tendon.

Finally, not all patients get full strength returns and some cannot return the same level of play; the reason for this is not clear.

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Lance Silverman, MD

Orthopaedic Surgeon and founder of Silverman Ankle & Foot. Treating Minnesotans with Ankle & Foot problems since 2004.

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