Poor Sam Draper! Why is an Achilles rupture such a big deal?

Being a long-suffering Essendon supporter, I more than most was shattered to see Sam Draper go down against West Coast. Sam was out in space by himself and attempted to change direction to his left by planting his right foot down to push off, and promptly fell over like a sack of spuds, gripping his ankle. The suspicions of the commentators were confirmed within 24 hours; scans revealing Sam had ruptured his Achilles tendon and would be out for the remainder of the season.

How bad is an Achilles rupture?

There is no doubt about it, Achilles ruptures are a big deal! Achilles ruptures rival that of the dreaded ACL tear in terms of recovery time. And they can eclipse ACL injuries in terms of possible complications, and potential longer-term functional challenges. The Achilles tendon connects the calf to the heel, and is the largest tendon in the body, and deals with more load and volume than any other tendon when we run, jump and land. Up to 4 times body weight of load is transmitted through the Achilles even with walking, and up to 8 times body weight when we run. Therefore, a long period of rehabilitation following and Achilles rupture is essential to restore its capacity to perform these tasks effectively again.

Compared to ACL injuries, Achilles ruptures are less common (Achilles = 31 per 100,000 people per year vs ACL = 52), but rates of Achilles ruptures have risen in recent years (45% increase since 2002). Increasing Achilles rupture rates are thought to be multifactorial, although not well researched. Achilles rupture is considered an “older athlete’s” injury (median age of injury = 50yo), mainly due to the changes to tendon health as we age. They are also more common in men (up to 80% of all ruptures). Increased sporting participation in older adults may be a potential contributor to increasing injury rates. But rising rates of obesity and diabetes within these age groups, which negatively affect tendon health, are also thought to be contributors to rising rates. So considering these points, young Sam Draper (26yo) is a bit of an outlier!

Are there warning signs for an Achilles rupture?

Surprisingly, having previous Achilles pain is not a warning sign. Only somewhere between 25% and 40% of people suffering a rupture have had previous Achilles pain – suggesting pain may almost be protective in this population. So, most Achilles ruptures will happen completely unexpectedly.

That said, if you are experiencing ongoing Achilles pain, it could indicate an underlying issue like Achilles tendinopathy, which is worth addressing to maintain tendon health.

Is surgery needed to fix an Achilles rupture?

Most people are unaware that there are actually two treatment pathways someone can take following Achilles rupture – surgical, and non-surgical. Interestingly, both have very similar outcomes. Early studies comparing the two approaches always highlighted a slightly higher re-rupture rate in non-surgical groups. However, a shift to a more “accelerated” rehabilitation protocols for people in non-surgical pathways has changed the game. More recent trials suggest there is no significant difference between the two approaches in physical function or re-rupture rates. It is thought that the addition of load earlier in the process improves the quality of the healing tendon.

Like most athletes, Sam Draper has opted for a surgical approach (or at least has been strongly encouraged!). Although this is of course an excellent option for his recovery in this scenario, it is a theme we see with injuries in professional sports. If provided with two equal or similar options, the surgical option will always tend to be chosen – but this is a topic for another blog!

What does rehabilitation look like following Achilles rupture?

The rehabilitation of an Achilles rupture is a long process, typically 9 to 12 months+ before considering a return to sports. The first 3 months of both surgical and non-surgical pathways is spent in a boot in a toe point position. Importantly, exercise begins while people are still in the boot. Exercises then progress in difficulty and intensity after the boot is removed. Rehab can be slow and tedious (there are only so many ways you can do a calf raise!), but milestones such as return to running (typically around the 6-month mark) and sport specific activities can keep it interesting.

Fortunately, rates of return to sport following Achilles rupture in professional athletes, who typically get quality rehabilitation guidance, are actually quite high. Studies reporting up to 80% of players make a professional return. However, performance after an Achilles rupture is often reduced. One study evaluating NBA basketballers returning after Achilles rupture reported a significant reduction in player rating metrics by up to 24%, suggesting some challenges in regaining full strength and power.

Rates of return to sport in recreational athletes are not as well researched. One recent study reported a 50% return to previous sport in which the injury was sustained. A further 30% returned to a different sport due to a fear of re-injury.

Fear and apprehension is a significant feature affecting rehabilitation and return to sports following any major injury. Fortunately, it is something that can change over the rehabilitation process. In the clinic, I see a much higher volume than most of Achilles ruptures (and other and major and long-term injuries for that matter!), and the reduction in fear across the rehab process is palpable. I always make a point to discuss the goals of each individual at various points along the way. The “post-injury despair” usually results in very modest goals such as, “I just want to get back to walking the dog”. However, as things progress, and capacity improves, fear reduces, and the goals evolve and change. Often towards the end we are discussing higher level goals such as return to previous sports, or running half or full marathons etc.. It is a satisfying process to witness!

In summary – poor Sam Draper has a long road ahead of him! There is a high likelihood he will get back to AFL level. But given the power nature of his sport and position he is returning to, there is also a chance he may not quite be the player he was. However, all Essendon supporters (including the author of this blog!), are hoping for the best!

• Written by David Thwaites

  David is an experienced physiotherapist who enjoys developing strong therapeutic relationships. With a diverse background encompassing various conditions, David has developed a particular interest in exercise rehabilitation of the knee, including osteoarthritis, patellofemoral pain, ACL injury rehab, and running injuries. As a keen runner, David enjoys hitting the pavement in his hometown of Geelong, and along the trails around the surf coast.