Achilles Tendon Repair: How did Cam Akers do it?

As many of us are avid spectators of collegiate, amateur, and professional sports, we know that injuries are unfortunately part of the process. We wish they weren’t, and many individuals spend hours and hours not only rehabbing them, but finding ways to prevent them from happening to begin with. For many NFL fans and/or fantasy football fans out there, you may be familiar with the name Cam Akers. For those who don’t know him or need a refresher, he is a running back for the Los Angeles Rams, who was recently part of a Super Bowl winning team. In mid-July of 2021, Akers tore his achilles tendon. This recovery typically takes athletes 9-12 months to return to their sport, and some have trouble returning to their prior level of athletic ability. It was expected that Akers’ would be out the entire season. Akers’ was cleared to practice on December 23, 2021 and played in his first game back in the last regular season game in January. So, how was this possible?

What is the achilles tendon?

The Achilles tendon is the largest tendon in the body, and also considered the strongest. It connects the soleus and gastrocnemius muscles of the calf complex to the calcaneus (aka heel), and therefore is rapidly shortened and lengthened during running, jumping, and  repetitive dorsiflexion and plantarflexion of the ankle. It has to absorb a large amount of force in a variety of ranges and often gets injured from overuse or excessive stress beyond one’s capacity. The Achilles also has no tendon sheath, but it does have a highly vascularized paratenon, which supplies blood to the tendon and helps the tendon glide smoothly. One reason it is considered to have a slower healing timeline is because the midsection of the tendon has poor blood supply, which results in slower healing timelines. This area is the most vulnerable to injury, as one would suspect.

There are a variety of injuries that can occur to this area, whether it is a tendinitis, chronic tendinopathy, retrocalcaneal bursitis (inflammation of the bursa near where the achilles inserts), or an acute achilles rupture we are discussing today. As mentioned before, it is the largest and strongest tendon in the body, but it is also the most commonly ruptured tendon. “The overall incidence of Achilles tendon rupture is on the rise recently because of the aging of the population, growing prevalence of obesity, and increased participation in sports.” (Park et. al)

What is a rupture and is surgery always required?

A rupture, also known in the medical community as a grade 3 injury, means the tendon has completely torn and does not have an attachment to the calcaneus (heel). Now, many would assume that this means surgery is ALWAYS required. It is not- there is continued research demonstrating that many individuals can return to a high level of activity with conservative treatment. It is important to understand that conservative treatment doesn’t just mean “sit and wait.” In nonoperative treatment, rehabilitation is an integral component to success rates. Emerging research also has demonstrated the importance of early rehab and loading following cast immobilization.” In a prospective randomized study, Saleh et al. compared 8-week cast immobilization with 3-week cast immobilization followed by early mobilization in a functional brace. They found the use of a functional brace led to more rapid improvement of ankle dorsiflexion and earlier return to normal activities” (Park et. al.). The key to consider after both nonoperative and operative surgery is preventing loaded hyperdorsiflexion, aka rapid loading to the tendon when stretched before one is prepared for this amount of force.

So, when is the achilles tendon repair the optimal option? 

For those looking for a potentially earlier timeline to recovery and a lower risk of retear rates, which often includes athletes, surgery is often the recommended treatment option. Due to advancements in surgical processes and goals to limit retear rates and optimize biomechanical function, this is often the choice of elite athletes. 

Cam Akers- How and why was he able to return so fast!?

Some protocols highlight the 6-9 month mark as the re-introduction of sport related activities and getting back to one’s sport, while other protocols say 9-12 months to allow appropriate time for one to progress through different progressions and criteria, appropriately load the tendon and get one back to their prior level of function. However, more and more research highlights the achievement of specific functional criteria rather than the time elapsed as the best way to manage one’s case. In Cam Akers’ case, he was cited as an extremely hard worker who progressed very well through each phase of rehab. 

Dr. Neal ElAttrache, Akers’ surgeon, discussed Akers’ recovery with several news sources. When interviewed, he highlights this was “not a magic trick”. In 2013, he performed an Achilles tendon repair on Kobe Bryant. He had been incorporating a technique he learned that added an extra suture which was designed to help absorb more tension and avoid all the tension at the repair line. He aso highlights a newer looping technique which would take more tension into various areas and help disperse force. I highlight these advancements in surgical techniques and biomedical engineering because it will continue to challenge what we know in the world of rehabilitation. This is why general timelines are not the best way to gauge an individual’s rehab. 

Akers’ was doing rehab 2 days after surgery, working on the muscles above his knee such as his quads and hamstrings. His rehab team also used blood flow restriction therapy (see our BFR blog we wrote!), to help reduce muscle atrophy and accelerate his rehabilitation timeline and process. He had a nutritionist working with him on his diet, and a rehab team of trainers, PT’s and massage therapists all helping him get back on the field as soon as possible. So while many of us will not have this entire team during a rehab process, it highlights how much is required in order to return to the field that quickly. Akers has served as an inspiration for not only other athletes, but has likely helped other general managers and coaches put more faith in players returning to a high level of competition earlier. David Ojabo, a edge rusher from University of Michigan, tore his achilles in March of 2022. He was still selected in the early second round of the NFL draft by the Ravens, and when asked about it, cited Akers’ returning in 5.5 months. He reported confidence he would be able to return for this season, and clearly the Ravens’ felt this injury wasn’t a big enough risk to outweigh the potential reward for such a talented young athlete. The evolution of surgical techniques and rehabilitation techniques has resulted in what was once feared as one of the worst and hardest injuries to return to an elite level, as one that is not only possible, but highly probable!

Author: Brian McLaughlin, PT, DPT, OCS

Park, S. H., Lee, H. S., Young, K. W., & Seo, S. G. (2020). Treatment of Acute Achilles Tendon Rupture. Clinics in orthopedic surgery, 12(1), 1–8. https://doi.org/10.4055/cios.2020.12.1.1

Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. The American Journal of Sports Medicine. 2021;49(13):3728-3748. doi:10.1177/0363546521998284

Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthopaedic Journal of Sports Medicine. November 2019. doi:10.1177/2325967119884071

Alper, Josh. David Ojabo anticipates playing in 2022, cites Cam Akers’ return from Achilles tear https://profootballtalk.nbcsports.com/2022/05/05/david-ojabo-anticipates-playing-in-2022-cites-cam-akers-return-from-achilles-tear/