At this moment half of the citizens of Ottawa threw up a little in their mouths. The rest are Leafs fans.

At this moment half of the citizens of Ottawa threw up a little in their mouths. The rest are Leafs fans.


Ten weeks ago, Erik Karlsson left the ice on one foot after Pittsburgh’s Matt Cooke sliced his left achilles tendon in an assassination attempt a terrible accident. Shortly thereafter the word was out that he’d need surgery and was done for the season. A city wept (except all those Leafs and Habs fans) and assumed their season was over, since there were only about 6 players left uninjured on the team. How wrong they were, as the team has announced he’s 100% medically cleared to play, and could return any day.

A ruptured achilles is a cruddy injury with a long recovery time. Travis Zajac tried to come back after four months only to drop back out for two more, and Sami Salo missed close to seven months. Of course the difference is that those were ruptured tendons – they happened spontaneously during off-season training (or floorball). Could it be possible that lacerated tendons like Karlsson’s heal better? That a quicker recovery time is the norm? Teemu Selanne’s laceration at the hands of Don McSween kept him out six months, and would seem to argue otherwise. So is the only remaining explanation that Karlsson possesses some sort of evil achilles magic? Much to the disappointment of anti-Sens theorists, the answer is no. Karlsson is young, healthy, in great shape, and like just about any NHL player would probably lie his achilles completely off if it meant getting back on the ice sooner.


The achilles does what?

The achilles is a big, strong, thick tendon that attaches your calf muscles to your heel. Without it, you can’t point your toe. If you can’t point your toe, walking is going to be a problem. If walking is a problem, good luck playing hockey. The achilles is the most frequently ruptured tendon, an injury common in both old out-of-shape runners and elite athletes. For the out-of-shape runners it’s sudden stress on the tendon after not having been used for a while. The stress overwhelms the tendon, and it ruptures. For elite athletes it’s more a question of overuse and the explosive movements dictated by their sport. The achilles is an underacheiver where blood supply is concerned, which is one of the reasons it takes so long to heal. Of course it doesn’t help that it’s responsible for attaching the back of your foot to your leg, and involved in just about every important lower leg movement.




How do you fix that?

Nobody seems to be able to agree on the best method to repair the achilles. You can find studies that recommend nonoperative treatment, studies that say there’s no difference between operative and nonoperative repair, and studies that say operative treatment is the way to go. Achilles tendons can be repaired in an open procedure (big incision) or percutaneous procedure (small incision). Surgery can be followed up with several weeks of immobilization in a non-weightbearing cast, or two weeks in a cast followed by early weightbearing and physiotherapy. One thing just about everyone agrees on is that elite athletes should have a surgical repair because it has lower incidence of re-rupture and an excellent prognosis where regaining pre-injury function is concerned.

The repair itself is simple enough – the tendon is sewn back together with several layers of heavy suture. The trick with operative repair is avoiding postoperative complications like wound infection, breakdown of the tissues over the sutures, or ulcers from the splint you wear afterwards. Doing a percutaneous repair (with a little incision) has less chance of wound complications, so it seems to be the preferred method. Having said that, there’s probably a fistfight going on right now between orthopedic surgeons over how best to manage this injury.


How do you rehab that?

The fistfight continues over the correct answer to this question. More and more we’re seeing shorter intervals in a cast (or no cast at all), and very early mobilization. Generally there’s about a week in a cast with the foot in a slightly flexed (pointed) position. This keeps stress off the tendon. The cast comes off and a cam walker (velcro cast boot) goes on, and as usual I feel the need to point out that you can buy your very own cam walker on Amazon. I don’t know why you would, but the option is there (free shipping!). The boot has a series of heel lifts in ever-decreasing heights, to slowly return to normal tendon length/stretch. Meanwhile once the cast has come off there’s range-of-motion and stretching exercises. Full weightbearing happens around six to eight weeks, and a full return to competition usually happens at five months. What you don’t want is to rerupture your achilles. That happens in about 5% of surgical repairs, and strangely enough is more common in patients under 30. Or not strangely enough, since athletes under 30 may be more likely to push themselves to return to play sooner (AHEM).


So how is Karlsson better already? He’s a wizard, right?

With most athletes taking anywhere from three to six months to return to play (on average), it was a huge surprise when the Senators announced that after only ten weeks, Karlsson was ready to go. Karlsson himself has even said his foot still doesn’t feel normal. Several theories have been floated as to how an early return is possible:

He’s on steroids!

This is an incorrect and stupid theory. The use of anabolic steroids actually leads to an increased incidence of tendon rupture, so taking them would be the exact opposite of a good idea. Injecting steroids into the area of the tendon itself would also weaken it, and thus be very stupid.

He used platelet rich plasma injections!

This one might actually be true. PRP is made by centrifuging the patient’s own blood to produce a derivate that’s rich in platelets (hence the name). Platelets contain growth factors – proteins that are responsible for signaling cell growth and division – and therefore healing. PRP injections aren’t exactly common, but they’re finding their way into sports medicine practices more often. They’re also not illegal according to the World Anti-Doping Agency.

His tendon wasn’t completely severed!

True story. Karlsson’s tendon was only 70% severed. It’s not unreasonable to assume that a tendon that’s still partially intact will be inherently stronger than one that was completely severed, and might avoid the repair separation that can sometimes happen postoperatively.

He’s a wizard!

Maybe. There’s no conclusive proof either way. There is conclusive proof that he’s very young, very healthy, and has access to the best rehabilitation the NHL’s money can buy.


Is this comeback a bad idea or what?

I asked an orthopedic surgeon his thoughts on the Karlsson situation, and his response was “Two months? Damn.” and then he made a hand motion I won’t describe. A return to full competition shouldn’t be contemplated until there’s no pain at full exertion, and comparable strength to the uninjured limb. While Karlsson may be at that point, he may also be doing what many, many NHL players have done before him and putting his long term well-being on the line for a shot at the playoffs. Considering Ottawa’s habit of fizzling out in the first round, there’s questionable value in coming back now versus waiting out the rest of the season.

Or he’s a wizard.

Comments (37)

  1. “I asked an orthopedic surgeon his thoughts on the Karlsson situation, and his response was “Two months? Damn.” and then he made a hand motion I won’t describe.”

    Between that and the fist fights over the best course of treatment recommended by different orthopedic surgeons, I really would like to get to know these people. I want you all to be my doctors. Especially you.

    In regards to the PRP theory…if its not technically illegally do you think he would admit to doing it?

    • Yeah, sure. PRP is a real thing. It’s an accepted treatment for this sort of thing.

    • Hines Ward openly admitted to using that type of therapy to try and repair his knee a few years back to get ready for the Super Bowl, if its not illegal I don’t see why Karlsson wouldn’t admit to doing it.

      I’m actually surprised its not more common in Pro Sports because its not a PED, its just your own blood injected where you need it most.

  2. I’d definitely go with Karlsson being a wizard.

  3. …or, maybe, surgical procedure has evolved in the twenty-years since Selanne busted his tendon?

    • No, not really. Other than the type of suture used or the appliances used to place the sutures. Technique is pretty much unchanged. Look at any number of other athletes with similar injuries and this is a long recovery. Karlsson is clearly the exception to the rule. Or a wizard.

      • Age is a factor, though, right? Zajac was 27, and Salo was 35. Teemu was 22, so he’s the best comparable. But… isn’t the technique for a complete tear different than a partial tear? I was under the impression that a complete tear required the use of cadaver tendon to repair the rupture, while a partial tear can be allowed to mend on its own. There would be different healing times for those since they’re pretty different procedures, no? Or am I talking out of my ass here?

        • Mark, did you READ the post? Yeah, there’s a difference in recovery time. A partial tear isn’t as bad. Even so, this is an insanely fast recovery. As for cadaver graft, that’s more for chronic tears where there’s a huge gap.

        • Most ppl rupture spontaneously, without a laceration. When we fix them, the tendon is basically shredded (like a horses tail and not in great condition). Laceration is different, tendon is in good quality, with a transverse cut.

          Complete rupture just pull the ends together. chronic ones where a bigger gap use V-Y advancement, turndown, or FHL tendon transfer (big toe flexor).

          I haven’t seen percutaneous fixation, and in a laceration you’d debride the wound and do open repair.

          The difference in treatment now is the rehab. Before you’d be stuck in a cast for 2-3 months. now they try to get you moving faster.

      • The use of compression therapy and mild hypothermia therapy might have played a role… similar to what was used to help Kevin Everett. Basically, it’s like wrapping your leg in an ice-pack to reduce swelling, while the compression would help keep up blood flow. It’s not a medical advancement per se, since it’s been around since the 50s… but the millions of dollars that sport’s teams spend on their athlete’s has pushed the use of these techniques to new heights.

        • That has been disproven … One of the top spine surgeons/researches on spinal cord injury presented a grand rounds talk on how this hypothermia therapy has no scientific basis yet millions of ppl believe it works because it was mentioned on tv …. Google “central cord syndrome” – lot of ppl with it get transient paralysis that recovers …

          • Reducing swelling in general is good after surgery (we recommend compression stockings, ice, elevating limbs) but no basis for spinal cord injury recovery

  4. It’s worth noting that in the first video posted of Karlsson skating, after he finishes those backwards figure eights, he clearly says, “No, no pain. There was no pain.” I believe that with an injury like this, you’d be able to see pain in his face if he were still suffering it, so I’m apt to believe the tendon is healed and he is pain-free.

    I’m skeptical that he’s back to pre-injury levels of strength and conditioning, though. Muscle only grows so fast, and the same is true for cardio recovery. If Karlsson does play again this season, I doubt it will be at the same level we saw prior to the injury.

  5. would PRP help a young(ish) guy with busted knees?

    I’m asking for a friend.

  6. Fantastic article as always, Jo.

    If I’m in charge in Ottawa I play this one as safe as possible, no sense risking a huge relapse on a guy who is due $40 million when no one is expecting a legitimate cup run. They should be happy to get the extra playoff revenue the AHL call-up squad got them, even if it means getting swept by Pittsburgh in 3 games as they’re fond of saying around here.

  7. Thanks for the interesting article. The idea that Karlsson will come back too soon and seriously mess up his achilles long-term is one of my greatest fears in life.

    BUT, what was the orthopedic surgeon’s hand motion that you won’t describe?
    Was it an index finger across the throat? Something lewd?

  8. Ah, medical science – disproving wizards since … probably Galen. When was that? 200 CE?

    I’m remined of one Robin van Persie (footballer) and all his ankle problems. He went for traditional, and completely normal, horse placenta treatments. Of which, I’m really not aware of, but the foot seems fine these last two years. Maybe it’s that. :-)

  9. Maybe it wasn’t a 70% tear. Maybe they lied. Speculate as you wish regarding the reason for such a lie, all I have to say is it wouldn’t surprise me.

    Also, why doesn’t someone interview the trainer, the doctor, or the surgeon to understand why his recovery was so quick. I imagine other athletes with the same injury would love to know.

  10. I would imagine the science of treatment has advanced since Teemu had his tear. I tore ACL and MCL in 83, and the ‘scope’ had only been used in the area for a couple years. Dr. Israel in Kitchener (who also did that Al McGinnis guy’s knee) repaired me, but I woke up with plaster from stem to stern. I don’t think they even cast them now, but I wore that mother for 6 weeks and when they cut it off, my leg was half the size it used to be!

  11. In the US the majority of college, university and residency programs, and even the American Academy of Orthopaedic Surgeons, still use the spelling with the Latinate digraph ae. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; orthopaedics usually prevails in the rest of the British Commonwealth, especially in the UK.:..:`

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