Why the Achilles is such a perilous area

When Boston Celtics sensation Jayson Tatum fell to the floor and clutched his right foot in pain during Monday’s playoff contest with the New York Knicks, fans were filled with dread.

They had reason to be concerned. On Tuesday, the team revealed that Tatum had undergone surgery to mend a torn Achilles tendon. He will be sidelined for the remainder of the playoffs and potentially the entire 2025-2026 season.

In this revised discussion with the Gazette, George Theodore, a Medical School graduate and orthopedic surgeon at Mass General Brigham, elucidates why the Achilles tear is the injury that athletes fear the most. Theodore serves as a foot and ankle consultant for Harvard’s men’s and women’s athletic programs and treats patients from local professional teams, including the Boston Red Sox, for whom he is the team physician, along with the New England Patriots and Boston Bruins.

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What causes an Achilles tendon rupture?

Firstly, it’s crucial to understand that it’s the largest tendon in the human body, making it essential for sports and recreation during push-off movements. When there’s a forceful action at the Achilles or ankle region, such as during a dorsiflexion, it can lead to an injury. Furthermore, the location where it typically ruptures has poor blood circulation compared to other body areas. This low blood supply, combined with a vigorous flexing of the ankle, contributes to the injury. Often, the exact reason remains unclear. Athletes may possess risk factors, but prevention is frequently challenging.

Tatum appeared to be fine just before the incident. Can a minor pre-existing injury lead to a rupture?

We know in older individuals experiencing Achilles tendon ruptures — which we often observe in pickleball and tennis — there is typically longstanding tendon damage. In younger individuals, the rupture often results from a forceful injury. While pre-existing issues may be present, they are less common compared to older athletes.

A tear can vary widely, ranging from a strain — a slight stretch — to a partial tear or a complete tear. A rupture is classified as a complete tear. Strains are generally managed with a period of rest followed by rehabilitation. Likewise, partial tears usually do not require surgical intervention, but are treated with rest and rehabilitation, often leading to a successful return to sport. The rupture is the most severe and necessitates significant decision-making regarding repair, with future implications for the patient’s recovery.

What does the surgical repair of the Achilles entail?

During surgery, the two ends are brought together and secured with sutures. This can be accomplished via an open incision or a mini percutaneous incision: an open incision allows for the two ends to be joined directly, or sometimes, sutures are passed beneath the skin to tie the ends together.

Is surgical repair the only option for a rupture?

In specific populations, we can effectively treat ruptures non-operatively. This often applies to patients whose need to return to a high-impact, push-off lifestyle may not be as critical. It may also involve patients who are not healthy enough for surgery. For instance, there are patients who are just looking to engage in regular walking and low-impact activities. These individuals can be treated non-operatively. This alternative involves a distinct protocol, sometimes using a cast or boot with heel lifts, followed by a physical therapy regimen.

What is the usual recovery timeline and protocol for individuals like Tatum, who had surgery after a complete Achilles tear?

Initially, the patient will be immobilized, which means they will wear a cast to promote incision healing. Following this period, they can start bearing weight in a walking boot, after which they can begin a thorough rehabilitation program. The return to sport for someone of his caliber generally takes around nine to twelve months. Research has indicated that 80 percent of elite athletes ultimately return to their previous performance level.

How does contemporary recovery compare to five or ten years ago — have there been any major improvements?

I believe the three key advancements are: 1. More minimally invasive surgical techniques with smaller incisions; 2. A more proactive rehabilitation protocol allowing earlier weight-bearing, ankle movement, and expedited entry into physical therapy; 3. Assessments that pinpoint patients’ limitations, enabling us to understand these constraints — functional, physical, and psychological — to assist patients in achieving their desired outcomes. This comprehensive approach requires significant resources and collaboration among the surgeon, patient, physical therapist, and psychologist.