Breaking Down the DeMarcus Cousins Achilles Injury

New Orleans Pelicans All-Star center DeMarcus Cousins ruptured his left Achilles tendon in the final minute of a close victory against the Houston Rockets on Friday night. According to reports, Cousins is expected to have surgery as soon as possible with an estimated recovery timeline of 6-10 months.

Just like with any other muscle, muscle tendon or ligamentous injury, Achilles tears or strains are graded on a scale of 1-3. A Grade 1 strain means that there is no or minimal tearing and typically heal in a week or two, a Grade 2 strain involves partial tearing — approximately 10-50 percent of the muscles fibers — and can take weeks to months to recover from and a Grade 3 strain is the most severe with more than 50 percent of the fibers being torn.

An Achilles injury such as Cousins’ is typically described as a rupture if the diagnosis is a Grade 3 strain.

The Achilles tendon is a taut cord of connective tissue that connects the gastrocnemius and soleus muscles — commonly referred to as “the calf”; scientifically known as the triceps surae — to the calcaneus, or heel bone. Contraction of the calf musculature causes a pull on the Achilles resulting in the foot plantarflexing — bending the foot “down”.

This is an important movement in day-to-day life, but particularly in explosive sports, such as basketball and the 100-meter dash, as forceful plantarflexion helps propel the athlete upward during jumping and forward during sprinting.

The explosive nature of plantarflexion in sport is in part attributable to the strength of the calf muscles, but also the tension of the Achilles tendon itself.

In a way, the tendon acts much like a spring.

Typically an Achilles rupture happens for one of two reasons. Either the tendon gets stretched beyond its limits or it becomes weakened through chronic tendonitis — or, more accurately, tendinosis. as -itis insinuates inflammation and chronic conditions don’t typically have an active inflammatory process.

Overstretch of the Achilles can happen in two ways:

  1. Pushing off on the foot when extending (straightening) the knee
  2. Abrupt dorsiflexion (bending the foot “up”) when the involved leg is bearing weight.

As seen in the video below, Cousins’ injury happened because of scenario No. 1.

The Achilles is most susceptible to rupture 3-6 centimeters from the calcaneus as there is a relative lack of blood flow in that region, particularly in people 30 years of age or older.

Cousins will be 28 in August.

The tension in the tendon is lost when it fails, causing the cord to spring up towards the calf. The knee typically stays bent as the gastrocnemius both plantarflexes the foot and flexes, or bends, the knee and players often describe that it felt like someone kicked them in the back of the knee.

Magnetic resonance imaging (MRI) or ultrasonography are required to officially diagnose an Achilles rupture, but often the patient’s description of the injury mechanism as well as a positive Thompson’s Test is enough.

The Thompson’s Test involves laying the patient prone and squeezing the calf when the patient’s knee is bent. The test is considered positive if their foot doesn’t twitch into plantarflexion. Visual deformity of the calf musculature, as well as significant swelling and bruising, is common.

Surgical repair is the only way to fix a ruptured Achilles tendon, but non-surgical intervention involving undergoing rehab solely is also an option. Both interventions have similar success rates, but there is an ongoing debate in the scientific literature about which option is better.

As of this writing, it appears that non-surgical intervention has a high incidence of re-injury and professional sports teams have relatively limitless resources, so surgical intervention is the path that is usually taken.

The patient is typically in a boot for up to 12 weeks post-surgery with weight-bearing introduced around six weeks and gradually increased over the next couple of weeks. Stretching and light strengthening exercises are initiated at approximately the same time as boot removal and full weight-bearing and are progressed in intensity over the next few months.

Players typically begin running again at the four-to-six month mark and return to their sport in the following months (meaning the report that Cousins will return to basketball in 10 months or less is accurate).

A common narrative surrounding players who’ve suffered Achilles tendon ruptures is that they never return 100 percent back to their pre-injury level, and that is more or less borne out in the scientific research.

The main theory explaining why is that elongation of the Achilles occurs after surgical repair, though it’s unclear as to why this happens. Although it may seem trivial, the elongation of the Achilles has a large ripple effect.

Elongation often results in impaired calf power production, decreased calf strength and abnormalities during gait and running — which may place the player at greater risk for knee injuries and/or re-rupture — among others. Complete, 100-percent recovery is possible, but it is more unlikely than other orthopaedic injuries.

Cousins’ injury is an extremely unfortunate one. He was in the middle of arguably his best season in his career and helped put the Pelicans firmly in playoff contention. He’s set to become an unrestricted free agent this coming off-season and how this injury will affect his contract negotiations remains to be seen.

With surgery expected in the coming days, Cousins will soon be on the long road to recovery.

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