Rehabilitation for Achilles Tendon Rupture: Sporting’s Chance Myers

Chance Myers of Sporting Kansas City tore his Achilles tendon last Friday against Toronto FC.  This is a huge injury both for Sporting KC as well as for Chance Myers.  Achilles tendon reconstructions are arguably the toughest injury for athletes to come back from, even more so than the oft-talked about ACL reconstructions.  For many athletes, this injury has proven to be the “kiss of death” because they struggle to get their elite level of speed and explosiveness fully back.  This injury almost always requires surgery to obtain the best outcome, particularly in elite athletes.  A previous study by Strauss et al (Injury 2007) reported good to excellent results in “active” patients, but few studies have investigated this injury in elite athletes.  Other researchers have found that these injuries don’t respond well to conservative, non-operative treatment (Wong et al, Am J Sports Med 2002) and have better outcomes with reconstruction (Kocher et al, Am J Sports Med 2002).  We’re confident that he’ll be back at some point, but we’re hoping this blog is informative for those rapid Sporting fans as well as those who may have personal experience with the injury.

Why is this injury such a big deal?

The Achilles tendon is vital to not only daily function, but is crucial for an athlete because without a strong, intact Achilles tendon, the athlete cannot push off when running or jumping.  The ankle is basically the “spring” forward on to the next stride and appropriate stiffness in the Achilles is needed for both simple walking as well as running, sprinting, and jumping.

Can we predict success after reconstruction?

Chance will have access to anything he needs to maximize his outcome.  The fact he’s an elite athlete prior to the injury will certainly help his recovery.  Olsson et al (Am J Sports Med, 2014) showed predictors of success after reconstruction were lower age, lower BMI (body mass index), surgical treatment instead of non-operative, and heel-rise height at 6 months.  The ability to perform a single leg heel raise with sufficient height is one objective measure used after surgery to determine physical readiness for running and jumping.  Many athletes are pressured back to their sport quickly and can impede proper strength and power from returning.  Therefore, a graded progression with specific goals is imperative.
One study showed that platelet-rich plasma (PRP) injections lead to faster healing times and faster return to running (Sanchez et al, Am J Sports Med 2006), but this hasn’t been investigated in randomized, controlled studies.  Our guess is that Mr. Myers will have that in surgery to help possibly expedite the healing process.

Any complications with this surgery?

Complications are mostly due to incision/skin healing issues (Wong et al, Strauss et al) and lack of compliance with post-operative protocols.  However, that is not uncommon with any surgery.  In our experience, most complications are due to people trying to do too much after surgery and not using an assistive device long enough.  The assistive device helps facilitate proper gait.  Due to the severe weakness after surgery, patients lack the ability to “push off” to the next step so they often limp.  Discontinuing an assistive device too early can lead to chronic tendinopathy, persistent swelling, and decreased function.

What’s the rehab after an Achilles reconstruction look like?

Without question, controlled, early motion is imperative (Twaddle & Poon, Am J Sports Med 2007) for restoration of function.  A recent meta-analysis showed early weight-bearing and motion lead to improved outcomes and lower rerupture rate (Huang et al, Am J Sports Med 2014) and previous researchers (Speck & Klaue, Am J Sports Med 1998) have supported this as well.  Therefore, it is likely that Mr. Myers will be weight-bearing early with crutches and a “boot.”  After range of motion is restored, the long process of strengthening begins.  Once appropriate strength levels are restored, low impact activities will commence to work on getting power and speed back.

How long will he be out?

At a minimum, it’s likely he’ll be out six months, but expect him to not be at 100% for at least 9-12 months.  He’ll likely return to practice between 6-9 months, but this will be graded exposure to loading to avoid complications.  This is largely due to the fact that he requires an elite level of speed and explosiveness that the “average Joe” or “weekend warrior” doesn’t need.

The SSOR Approach

We agree that early weight-bearing and motion is critical.  Numerous studies have shown that immobilization after a host of injuries can actually impair the healing process and cause a decline in function.  We would ensure that he has normal gait prior to discontinuing an assistive device as stated above.  Sometimes, athletes can be resistant to this, so we would find a way to compromise on this.  However, we’d diligently watch for increased swelling.  Restoration of range of motion would be critical as well as proper joint mobility.  Furthermore, we’d make sure all other joints are doing their jobs because impairments in one joint can affect the Achilles.
At SSOR, we do extensive soft tissue work to augment the healing process.  Therefore, we would work on the incision and any surrounding soft tissues that may be problematic.  Scar tissue can adhere to the tendon sheath (think about a corn dog when you think about the Achilles.  The dog is the Achilles itself, the corn bread being the sheath).  If there are adhesions there, it can impair normal movement of the tendon.
Strengthening is vital and can take several months.  This phase of rehab requires patience and persistence on both the sports physical therapist and the athlete.  We have a specific progression of exercises to restore his strength.  This is where we feel most athletes and the training staff’s struggle – they get impatient and force progress instead of having specific, objective performance goals prior to progression.  We’ll measure his progress by the ability to perform a single leg heel raise throughout the full range of motion with full calcaneal inversion at the peak of plantarflexion.  Until that happens, athletes won’t be appropriate for impact activities like jumping and running.  Total leg strengthening is also an important part of this process as strength in the entire lower extremity will help further attenuate force production and attenuation.
After strength is restored, we have a progression of return to running and jumping is initiated.  Progression is based on proper performance at each step.  Typically, activities begin on a mini-trampoline then shift to ground-based activities in place and then on an agility ladder.  Impact will progress from two-legged movements, then from two legs to one, one to the other leg (“bound”), then same leg to the same leg (“hop”).  As performance of these activities improves, we have our athletes increase the speed of performance or work on time-specific intervals based on their sport.  Outcome measures include subjective testing, single leg hop testing, single leg vertical jump testing, as well as a few other measures.
SSOR has treated many elite and amateur athletes as well as many weekend warriors with this injury.  We’re your first choice for rehabilitation after an Achilles tendon reconstruction.  We’re confident our approach is unmatched and we know what it takes to get you the results you expect.  Even if you’ve long finished rehab and you’re not where you want to be, we hope you’ll trust us and give us an opportunity to show you that you haven’t reached your “ceiling” yet.
Give us a call if you’ve had or are going to have this surgery!  We wish Mr. Myers a speedy recovery.  We’ve worked closely with Sporting’s athletic training staff in the past and know he’s in good hands.

Tags: Overland Park, Physical Therapy, Sporting Kansas City, sports physical therapist