Torn Achilles (Again!) Ends Pacioretty's Season and Maybe His Career
Unfortunate Incident or a Case of Mismanagement?
A very harmless play late in a game last Thursday night has ended Hurricanes player, Max Pacioretty’s season and could potentially end his hockey career, considering this is his second Achilles tear in the last 6 months.
Watch the play here:
As you can see, Pacioretty accelerates to the net, stops to pivot in the other direction and pulls up as a result of the Achilles rupturing. He quickly grabs the back of his leg before falling over. He was unable to put any weight on the leg as he was helped off by his teammates.
This is extremely concerning from a player health and longevity perspective in that Pacioretty who is 34 years old and was traded from Vegas to Carolina this past off-season, tore the same Achilles tendon back in August and was just cleared to return to game action on January 5th. Less than two weeks later his future in the NHL may be in jeopardy.
The Risk for an Injury Increases Based on Previous Injury
The last few years have not been kind to Pacioretty’s health as he has had a fair number of injury related setbacks that have cumulatively caused him to miss a significant amount of time.
His most significant injury occurred this past August when training for the upcoming season he tore his right Achilles tendon. As is the case with player injuries in professional sports the details surrounding the injury and how it occurred are scarce. What is confirmed is that Pacioretty had surgery to repair his torn right Achilles on August 10th, 2022 in Raleigh NC by the team Orthopedic Surgeon.
The original timetable for Pacioretty’s return was to be late February or early. March 2023. This does align with current return to play times post Achilles repair which is in the vicinity of six months. The question then becomes why was Pacioretty cleared to play 6-8 weeks early? What were the outcomes used by the Hurricanes that satisfied their decision to allow Pacioretty to return to the Level of Competition? It is easy to look back now and say he wasn’t ready based on the resultant re-tear two weeks later, but there had to be some indications that Pacioretty had not fulfilled all of the necessary physical capacity requirements that would allow him to return to hockey with success considering the strict demands of this region of anatomy.
Anatomy of the Achilles
The Achilles tendon is the largest tendon in the human body. It is a confluence of connective tissue from the superficial gastrocnemius muscle as well as the soleus. In addition, it has been shown that plantaris although not attached to the Achilles tendon does ultimately give fibres to it distally (shown in the top picture)
There are two interesting features to note regarding the Achilles tendon that all practitioners should be aware of.
The first is that there is a very specific fibre orientation of the connective tissue contributions from the posterior leg. Due to our current methods of anatomical instruction, we often think that tendons are simply just the ends of muscle that attach the muscle to bone that allows for movement and therefore the tendon will just align in the same direction of the muscle’s primary line of pull. Although not the case anywhere in the human body, it is surely not the case in the Achilles. It is evident in the picture below, that there is specific directionality of the connective tissue fibres that come from the heads of the gastroc and the soleal contributions, such that the angles of the fibres within the Achilles itself have varying degrees of orientation.
The second is that as a result of this fibre orientation it creates a large amount of torsion within the Achilles tendon. This goes against our traditional understanding of tendons: which are often depicted as being flat structures that lie on top of other structures with no interaction between them or the surrounding anatomy. Within the Achilles as the fibres come in and blend they wind around each other creating depth to the tendon as well as an increase in tensile strength.
Both of these anatomical features are what allow the behaviours of the posterior leg to be stiff when required to generate an impulse into the ground (or ice), or to strain more to absorb force as in decelerating or changing direction. The reason these behaviours occur and are able to occur in various positions of the foot and ankle complex is a result of the Achilles tendon.
Although not shown in human tissue as of yet (to our knowledge) there is another detailed anatomical feature that is potentially relevant to understand with respect to the injuries that occur at tendinous tissue, which is that there is a very specific anatomical continuum between the perimysial layer of the intermuscular connective tissue and the tendon. This has been shown so far only in a bovine model1 (there are obvious limitations) but is an interesting line of research that hopefully will become fruitful in human tissue. Recall that the layer of perimysial tissue covers the fascicles of a muscle. It is at the layer of fascicles where significant intermuscular movement and force transmission occurs that will ultimately dictate the strain behaviour of the tendon under load. A change in fascicular length, which can then impact the tensile properties of the perimysium has the potential to impair muscle movement mechanics and the flow of force through the connective tissue matrix of the musculotendinous unit and has been shown in the evidence to be a risk factor for hamstring injury2. This important anatomical relationship cannot be ignored in the understanding of Achilles injuries and their management.
Management of Achilles Ruptures
The are two methods of managing an Achilles rupture: surgical or non-surgical. A decade ago, all Achilles ruptures would have been managed surgically, however there has been some good outcomes presented in the research evidence for the non-surgical management of these injuries citing less risk, and similar long term results.
In the case of elite athletes, as it was ( and potentially will be) with Pacioretty, surgery is the method of choice. As a result of his second rupture he will undergo his second surgical procedure.
Point B - Pacioretty was not at Point B
It is obvious that Max Pacioretty was not at Point B upon his return to the Hurricane’s lineup. He could not have been simply based on the rapid timing upon which he is out of the lineup again with the same severe injury awaiting another potential surgical repair.
According to Absolute there are four fundamental physical capacities that all athletes should possess in various quantities depending on their demands at the Level of Competition. In the case of rehabilitating an athlete post-injury or in this case post-surgery the rules of the game are the same - it must be our intent and our goal as practitioners to prepare the athlete and their injury for the demands they need to return to.
With no specific information on the original rehabilitation program it is difficult to ascertain exactly what may have been missing that lead to a re-rupture, however the injury as viewed in the video above shows that it was non-contact meaning the tissue didn’t fail as a result of an extreme amount of external force that may occur as a result of body contact, it failed as a result of an amount of internal tension generated that exceeded the current stiffness capacity of the tissue. As viewed above the strides taken by Pacioretty in the moments before the Achilles rupture were not necessarily high impact strides that would be considered stressful enough to shred the Achilles. In our mind, this must mean that there were serious qualities of the tendon that were lacking prior to Pacioretty returning to game action. In essence this left the tendon and the necessary sporting behaviours required of it, stagnant and unable to adapt to the movement demands or the loads put upon it. This begs the question as to whether the internal ecosystem, the training of tissue specific qualities and tissue specific behaviours was adequately progressed that would have allowed for a myriad of emergent behaviours when returning to sport.
Player health should not be rushed. Athlete injuries and the tissues they impact should be held to the standard of the Level of Competition, not managed in isolation according to a protocol that has been generally defined not based on tissue science, but on the gradual accomplishment of movement norms. Managed in this way, will always set the athlete up to regress to the mean, some quicker than others.
The internal ecosystem has to always be the lens through which athlete health is managed. When viewed through this lens it becomes easier to observe how tissue specific behaviours can be scaled up to the external ecosystem to allow the athlete to succeed within the Level of Competition.
I worked with 2 young figure skating national interest athletes, here in CT, I was amazed to observe how limited their dorsiflexion! Without a proper ankles/feet program to cope with 4/5 hours a day spent in those skating boots, injuries are just around the corner and for sure influence performance in terms of length tension relationship and force production.