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.