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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 26-29

Achilles rupture and return to sport in professional athletes


Duke University Medical Center, Durham, NC, USA

Date of Submission30-Aug-2019
Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Richard M Danilkowicz
Department of Orthopaedic Surgery, Duke University Medical Center, BOX 3000, Durham, NC 27710
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DORJ.DORJ_1_19

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  Abstract 


Context: Despite Achilles rupture posing a potentially career-threatening injury to professional athletes, limited sports medicine research has been conducted to investigate how to improve the ability of players to return to sport after sustaining the injury.
Objective: The main objective of the study is to aggregate the current literature on professional athlete return to play after Achilles tendon rupture in an attempt to identify the current strengths and gaps in knowledge.
Materials and Methods: A PubMed literature reviews was performed using the terms “Achilles”and/or “elite,” “professional,” “return,” “sport,” “national basketball association”, “national football league,” “major league baseball,” “major league soccer,” “national hockey league,” “injury” to identify articles of interest. Only studies involving professional athletes in the major United States football, soccer, basketball, baseball, and hockey leagues as well as European Soccer Leagues who sustained a torn or ruptured Achilles tendon were included.
Data Sources: PubMed literature search utilizing the key words, “Achilles” and/or “elite,” “professional,” “return,” “sport,” “national basketball association,” “national football league,” “major league baseball,” “Major League Soccer (MLS),” “national hockey league,” “injury.”
Study Selection: Studies found using the keywords above were considered for inclusion. Individual case studies, injuries other than tear or rupture, and studies with unclear methodology were excluded. Nine studies met inclusion criteria.
Study Design: This study is a review of published literature.
Level of Evidence-IV: IV.
Data Extraction: Data were taken directly from the included studies and aggregated. The quality and validity of the data is limited by the collection methodology of each individual study included.
Results: Overall return-to-play percentage of 67.1% across all included studies with a total of 322 included participants. Soccer athletes were found to have the highest return percentage at 70.8% and baseball with the lowest at 55.6%. The average age of the players returning to play across all studies was 28.9 years, with football players comprising the youngest group at 27.5 years and baseball the oldest at 31.4 years.
Conclusions: A lack of reliable data has made the study of professional athlete Achilles rupture and return to play a difficult endeavor. Despite the limitations, studies have shown that over 30% of players do not return to their respective sports, with no statistically significant correlation to age or position played. More research is needed to determine how specific injury patterns, rehabilitation protocols, and functional testing plays into the athletes' ability to return to play.

Keywords: Achilles, athlete, return


How to cite this article:
Danilkowicz RM, Grimm NL, Amendola A. Achilles rupture and return to sport in professional athletes. Duke Orthop J 2019;9:26-9

How to cite this URL:
Danilkowicz RM, Grimm NL, Amendola A. Achilles rupture and return to sport in professional athletes. Duke Orthop J [serial online] 2019 [cited 2020 Oct 30];9:26-9. Available from: https://www.dukeorthojournal.com/text.asp?2019/9/1/26/279427




  Introduction Top


Achilles rupture incidence has been increasing in the general population over the past 30+ years, from an estimated 2 to 22/100,000 person-years;[1] however, it is a relatively uncommon occurrence in professional athletes.[1],[2],[3] For example, in the National Football League (NFL), the incidence has been quoted to be as low as 0.015% per player per game, but 32% of players sustaining an injury will never return to professional sport.[4] In Major League Baseball (MLB), the incidence is even lower, with only 26 reported cases between the years of 1972 and 2015.[5] While more common in sports that require quick, explosive movements, Achilles ruptures have been described in elite athletes across a wide spectrum of sports.[6] When these injuries do occur, the consequences can be devastating. Achilles rupture represents a serious, potentially career-threatening injury for these athletes who may never return to prior form and lose out on significant earning potential as a result.[7],[8] Unlike more commonly injured structures, there remains a significant paucity of sports medicine literature on the topic.

The major roadblock in studying professional athlete Achilles injuries is access to injury specific information. The aim of this study is to aggregate the current literature on Achilles rupture in professional athletes in an effort to both strengthen the current fund of knowledge, as well as clearly identify the significant knowledge gaps and limitations that remain.


  Methods Top


A PubMed search was performed using the terms “Achilles” and/or “elite,” “professional,” “return,” “sport,” “National Basketball Association”, “national football league,” “major league baseball,” “major league soccer,” “national hockey league,” “injury” to identify articles of interest. Only studies involving professional athletes in the major United States football, soccer, basketball, baseball, and hockey leagues as well as European Soccer Leagues who sustained a torn or ruptured Achilles tendon were included. Individual case studies, studies involving tendinopathy, and studies with unclear tear extent in the included subjects were excluded. One study was excluded due to unclear methodology. This search yielded nine retrospective studies that met the inclusion criteria which were each independently reviewed by the authors for final inclusion.


  Results Top


A total of 322 athletes were included for analysis, comprised of 59 players in the National Basketball Association (NBA), 221 from the NFL, 18 from the MLB, and 24 from the Union of European Football Associations/Major League Soccer (UEFA/MLS). Information obtained from each study included return-to-play rate, age of athletes, study years covered, and which quantitative measure the study utilized to assess postinjury performance. Complete details of the included studies can be found in [Table 1]. The overall return-to-play percentage of the aggregated data was 67.1%, with UEFA/MLS having the highest percentage at 70.8% and MLB with the lowest at 55.6% [Figure 1]. The average age of the players returning to play across all studies was 28.9 years, with MLB contributing the oldest players at 31.4 years and NFL the youngest at 27.5 years. Only the case series of 9 NFL athletes by McCullough et al. included the specific surgery performed, which was a mini open repair.[9] No studies outlined specific rehabilitation protocols. Return-to-play timelines and complete study descriptive information can be found in [Table 1].
Table 1: Study descriptive information

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Figure 1: Return-to-play percentages across major professional sports

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  Discussion Top


Achilles rupture is relatively uncommon in professional athletes but poses a significant rehabilitation burden regardless of sport. As previously mentioned, the incidence has been quoted to be quite low in the major US professional leagues, but with a correspondingly low return-to-sport percentage. This study corroborates the low return-to-sport rates reported in individual studies with aggregated data. Despite the clear differences in athletic demands across the major professional sports and no clear correlation identified between position played and ability to return, it is noteworthy that nearly 30% or more of all athletes sustaining this injury never return to their respective sport. There also appears to be an association with age and injury. The mean age of injured athletes included in the study was >27.5 years, which is older than the average professional athlete in each of the professional leagues other than baseball, suggesting that the injury is occurring more frequently in older individuals.[10] Consequentially, of all orthopedic procedures performed on NBA players, it was Achilles tendon repair that correlated to the most profound negative career impact and highest rate of retirement without returning to play.[11] With the seemingly disproportionate percentage of professional athletes unable to return to sport, the specifics on injury type, repair method, and rehabilitation protocol may provide crucial detail.

Obtaining injury-specific details for professional athletes has been a hurdle for independent investigators due to a lack of access to this highly protected information. While there are some databases in place, notably, the MLB Health and Injury Tracking System and the National Collegiate Athletic Association (NCAA) Surveillance System, these databases are not widely accessible to researchers and are often reportedly incomplete.[12],[13] Even at the collegiate level, the NCAA injury database is merely a sample of voluntarily provided information entered by athletic trainers and released in 5 years intervals only upon formal request.[12] Without access to a central, validated database with key demographic and injury-specific details, investigators turn to publicly available information provided through media outlets to infer key data points, including return-to-play dates, which are often nonverifiable and inaccurate.[14] Attempting to draw conclusions and make recommendations is therefore based on inherently flawed data and serves merely to highlight trends at best.

The primary issue in the current Achilles rupture literature is the lack of specifics regarding the injury and treatment. Achilles injuries can be classified into subsets of midsubstance, musculocutaneous junction, and avulsion types with further differentiation by the degree and severity of the tear. This significance of this differentiation lies in the potential treatment options, which include nonoperative functional bracing, casting, and multiple surgical procedures. Surgically, Achilles ruptures may be treated with different techniques, including end-to-end open repair, percutaneous repair, reconstruction with advancement, or tendon transfer, each with benefits and drawbacks that may fit a particular injury pattern better than another. Postoperatively, the rehabilitation protocol is also critical to the athletes return to play, particularly with regard to the timeline. There is no one established protocol, therefore, details concerning which protocol is used would be useful in the analysis of how quickly the athlete returned, any setbacks encountered, and to what level of performance was ultimately achieved. A lack of complication data also inhibits true data analysis as an unforeseen issue, whether related to the Achilles injury or not, may prolong an athlete's timeline in returning to play but would likely not be made public information for inclusion in the retrospective studies.

Currently, use of sport-specific statistics is the primary outcome measure being used to evaluate athletes after Achilles rupture.[4],[5],[15],[16],[17] The issue with these metrics is that the statistical outcomes are likely a result of underlying physical factors related to post-Achilles rupture recovery that are enabling players to return at a high level or conversely, never achieve the same level of success in sport. For example, if an NBA player has lost a significant portion of their vertical leaping ability that may be reflected in certain statistical categories, whereas the inability to change directions at high speeds may be reflected in others. These details become even more important when taking specific sport position into consideration. If these functional measures are unchanged postinjury and the statistics still change, the injury may not be directly implicated in the player's decline. In addition, the athletes that do not return are simply grouped together, with no further analysis of the underlying rationale of why they did not return, which is arguably of more importance. Studies are unable to determine what specifically is stopping the players from returning to sport at a 30% rate, or what is stopping those that do return from achieving their previous form. With sport-specific functional testing data, we might be able to tailor both treatments and rehabilitation protocols to players individually and then study their results, thus optimizing future intervention. Ultimately, the goal would be to increase not only the professional athlete return-to-play numbers, but also those of the weekend warrior who wishes to continue recreational sports activity.

The limitations of this study are the retrospective nature of the analysis and the underlying limitations cited in each of the included studies, including inherent heterogeneity within specific sport populations, e.g., basketball point guards and centers or football lineman and skill position players. There is also significant overlap in the data contained in each of the included studies, as the timeframes for analysis would invariably include many of the same athletes in each return-to-play analysis for a particular sport. Despite these limitations, the aggregation of data provides an opportunity to identify larger trends that are useful in identifying future study opportunities that may provide a more significant impact on the sports medicine field.


  Conclusions Top


Despite the significant impact an Achilles rupture can have on the career of a professional athlete, this injury remains underinvestigated in the sports medicine literature. Due to lack of access and incomplete data, researchers have turned to injury information gleaned from newspaper reports and other public domain sources to obtain critical injury details that are used to make conclusions about player outcomes. The ability to obtain functional testing postinjury may provide important insight into how to best rehabilitate athletes after an Achilles rupture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jandacka D, Silvernail JF, Uchytil J, Zahradnik D, Farana R, Hamill J. Do athletes alter their running mechanics after an Achilles tendon rupture? J Foot Ankle Res 2017;10:53.  Back to cited text no. 1
    
2.
Huttunen TT, Kannus P, Rolf C, Felländer-Tsai L, Mattila VM. Acute Achilles tendon ruptures: Incidence of injury and surgery in sweden between 2001 and 2012. Am J Sports Med 2014;42:2419-23.  Back to cited text no. 2
    
3.
Lantto I, Heikkinen J, Flinkkilä T, Ohtonen P, Leppilahti J. Epidemiology of Achilles tendon ruptures: Increasing incidence over a 33-year period. Scand J Med Sci Sports 2015;25:e133-8.  Back to cited text no. 3
    
4.
Parekh SG, Wray WH 3rd, Brimmo O, Sennett BJ, Wapner KL. Epidemiology and outcomes of Achilles tendon ruptures in the national football league. Foot Ankle Spec 2009;2:283-6.  Back to cited text no. 4
    
5.
Saltzman BM, Tetreault MW, Bohl DD, Tetreault D, Lee S, Bach BR Jr. Analysis of player statistics in major league baseball players before and after Achilles tendon repair. HSS J 2017;13:108-18.  Back to cited text no. 5
    
6.
Maffulli N, Longo UG, Maffulli GD, Khanna A, Denaro V. Achilles tendon ruptures in elite athletes. Foot Ankle Int 2011;32:9-15.  Back to cited text no. 6
    
7.
Mai HT, Alvarez AP, Freshman RD, Chun DS, Minhas SV, Patel AA, et al. The NFL orthopaedic surgery outcomes database (NO-SOD): The effect of common orthopaedic procedures on football careers. Am J Sports Med 2016;44:2255-62.  Back to cited text no. 7
    
8.
Yang J, Hodax JD, Machan JT, Krill MK, Lemme NJ, Durand WM, et al. Factors affecting return to play after primary Achilles tendon tear: A cohort of NFL players. Orthop J Sports Med 2019;7.  Back to cited text no. 8
    
9.
McCullough KA, Shaw CM, Anderson RB. Mini-open repair of achilles rupture in the national football league. J Surg Orthop Adv 2014;23:179-83.  Back to cited text no. 9
    
10.
Info ESPN Stats. Average Age in Esports Vs. Major Sports; 2017. Available from: http://www.espn.com/esports/story/_/id/20733853/the-average-age-esports-versus-nfl-nba-mlb-nhl. [Last accessed on 2019 Apr 02].  Back to cited text no. 10
    
11.
Minhas SV, Kester BS, Larkin KE, Hsu WK. The effect of an orthopaedic surgical procedure in the national basketball association. Am J Sports Med 2016;44:1056-61.  Back to cited text no. 11
    
12.
Kerr ZY, Dompier TP, Snook EM, Marshall SW, Klossner D, Hainline B, et al. National collegiate athletic association injury surveillance system: Review of methods for 2004-2005 through 2013-2014 data collection. J Athl Train 2014;49:552-60.  Back to cited text no. 12
    
13.
Pollack KM, D'Angelo J, Green G, Conte S, Fealy S, Marinak C, et al. Developing and implementing major league baseball's health and injury tracking system. Am J Epidemiol 2016;183:490-6.  Back to cited text no. 13
    
14.
Ekegren CL, Gabbe BJ, Finch CF. Sports injury surveillance systems: A review of methods and data quality. Sports Med 2016;46:49-65.  Back to cited text no. 14
    
15.
Amin NH, McCullough KC, Mills GL, Jones MH, Cerynik DL, Rosneck J, et al. The impact and functional outcomes of Achilles tendon pathology in national basketball association players. Clin Res Foot Ankle 2016;4. pii: 205.  Back to cited text no. 15
    
16.
Trofa DP, Miller JC, Jang ES, Woode DR, Greisberg JK, Vosseller JT. Professional athletes' return to play and performance after operative repair of an Achilles tendon rupture. Am J Sports Med 2017;45:2864-71.  Back to cited text no. 16
    
17.
Trofa DP, Noback PC, Caldwell JE, Miller JC, Greisberg JK, Ahmad CS, et al. Professional soccer players' return to play and performance after operative repair of Achilles tendon rupture. Orthop J Sports Med 2018;6.  Back to cited text no. 17
    


    Figures

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    Tables

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