Kevin Durant – Did previous injury and negligence lead to his Achilles tendon rupture?

Kevin Durant’s right Achilles tendon rupture is one of the most devastating injuries to have occurred in a Finals series. We’ve all seen the visible snapping of KD’s Achilles (video below if you want to re-live it) and there’s been huge debate about whether he should have returned to play in Game 5 and who is at fault for the injury. Klay’s confirmed torn ACL  after suffering a same leg hamstring strain has further increased scepticism regarding the Warriors return to play decisions (my next post will look further into Klay’s injury). There’s a lot to look at here. Working with the available evidence we have (released information and current medical research), I’ll address:

  • How did Durant rupture his Achilles?
  • Was the decision to allow Durant to return the right one? Was he rushed back from his calf injury?
  • How long should it have taken to return?
  • How did the Warriors know right away he had ruptured his Achilles?
  • Why did KD have surgery before the MRI confirmation was released?
  • Who is to blame for Kevin Durant’s Achilles injury?
  • Is there a link between calf strains and Achilles tendon rupture? Did Golden State know he was at risk of this injury?
  • What can we expect from KD in the future? Will he be the same?

Lot of questions to work through. To understand more about KD’s injury and the circumstances surrounding it, let’s quickly touch on exactly how he suffered the AT rupture.


What is the Achilles tendon and how did Durant rupture it?
Tendons are strong fibrous soft tissue structures that attach muscle to bone. The Achilles tendon (AT) runs down the back of the lower leg and connects the calf muscles to the heel bone. It’s the combined tendon of the main calf muscles (gastrocnemius, soleus and plantaris) and is the strongest and thickest tendon in the human body.

Highlighted in blue is the right Achilles tendon. On the superficial layer, we can visibly see the medial and lateral gastrocnemius muscle heads. Soleus and plantaris (not visible) lie deep to the gastrocs.

When the calf muscles contract, they shorten and pull the heel upwards via the AT. This motion is called plantarflexion (bending the foot down). The opposite of plantarflexion is dorsiflexion when the heel goes down and the toes and foot travel upwards. When the foot is dorsiflexed/in dorsiflexion, the calf muscles and the AT are put on stretch.

When the Achilles undergoes loading or stretching beyond its capacity, rupture occurs. With KD’s right foot in a massively dorsiflexed position and pushing off for a drive (plantarflexion movement), there is a massive stress load on the tendon (stretch stress + contraction stress) and this caused the sudden, complete tear that ended Durant’s season.

Watch right after the flash as Durant attempts to plantarflex for the visible snapping of the tendon. Jesus.

With the injury occurring so early in the game, there were huge concerns around the league (and the world) that he had returned too early. Let’s go back and have a deeper look into that return-to-play decision.


The Game-Time Decision
Before Game 5, Kevin Durant had been unable to take the court for 32 days following a reported “mild right calf strain”. With Golden State down 3-1 in the NBA Finals, undoubtedly there was more pressure for KD to come back and help the team. Durant was listed as a “game-time decision” and before he could take the court, he had to prove his fitness.

Calf sprain return-to-play timelines are largely dependent on the severity of the injury and site of injury. Durant’s injury was initially said to be a “mild calf strain” likely meaning a grade 1 injury but because of the length of time taken to return, we can suspect it was more likely a Grade 2 calf strain (moderate strain/partial tear). Grade 2 calf tears are reported to have an average timeline of 25 days to return to sport so from the current research it seems appropriate that KD could return for Game 5 (after having just over a month away).

After satisfying all team and personal medical parties, coaching staff and business partners with his current physical and mental capacity, Durant completed a pre-game shoot-around without any concerns and the former Longhorn was allowed to return. With no time restrictions set for Durant, he played 12 minutes of the 14 game minutes elapsed, playing brilliantly until the moment of his injury.


The Injury
With 9 minutes, 51 seconds left in the second quarter, Durant attempted a drive past Raptors big man Serge Ibaka. After pushing off his right foot, his leg appeared to give and the Warriors forward went down in pain after taking a couple of steps, grabbing near the bottom of his lower leg. Of significance is where Durant clutches after the injury – this gave an immediate clue for what might have happened.

A distinct difference between immediate pain/symptom locations with the two injuries.

At the time, KD could still move his foot around or appeared to be using his knee to passively move the foot. The footage below fuelled initial thoughts that it may be a partial tear of the Achilles because Durant could plantarflex his foot (bend it downwards).

KD appears to be able to actively bend his foot up and down (but only just).

Whilst there is plenty of literature that suggests that complete Achilles rupture prevents active plantarflexion, this is untrue. Even though the tendon connection between the primary plantarflexors and the heel is torn, Durant is still able to weakly plantarflex as he sits on the court (in a non-weight bearing position) using other intact accessory (assisting) muscles such as the tibialis posterior, plantaris and toe flexors to do the same action. Shortly after, KD was assisted off the court and the Warriors medical team were able to assess him. It wouldn’t have taken long to know what happened.


The Quick Diagnosis
How did Golden State know so quickly? Hint: it’s not because Golden State was covering up an Achilles injury!!

As soon as the Warriors brought KD into the locker room they would have been pretty sure he had suffered a complete tear of his Achilles tendon. A calf squeeze test or Thompson/Simmond’s test where a physician squeezes the calf to simulate a calf contraction that will plantarflex the foot is a quick and accurate diagnostic measure – if KD had ruptured his Achilles then his calf and tendon can’t pull on the heel so his foot would remain nearly still.

Other tests would have included observing KD’s ability to actively plantarflex the ankle and also visually detecting/palpating the tendon for defects – deficits in these areas would have been near definitive clues for the Golden State medical staff.


The Confirmation
After flying from Toronto to New York City, Durant reported on Instagram that he ruptured his Achilles and underwent successful surgery to repair the tendon. Dr Martin O’Malley at the Hospital for Special Surgery operated on KD’s right Achilles – notably, Dr O’Malley is the same surgeon who operated on Durant when he suffered a Jones fracture in 2015 and is also a team physician for the Brooklyn Nets AND a foot and ankle consultant for the New York Knicks (cue some NY free-agency conspiracies here!!).

@easymoneysniper giving us the update we were all hanging on for.

Of course, social media was also quick to notice that KD had already finished surgery before the results of his MRI were announced. The surgery occurred approximately 36 hours after the injury. With early repair, it’s likely that Durant will have improved anatomical tendon healing and a more successful post-op rehab results. There are multiple studies that show early surgical repair of the Achilles tendon provides better outcomes (all scientific articles quoted are listed at the end if you want to read further). Specifically, surgical repair within the first 48 hours of acute Achilles tendon rupture achieves superior biomechanical and histological (tissue structure) outcomes, especially if performed within the first 24 hours. This early surgery is great news for KD’s future as current research also shows that early AT surgery significantly reduces the risk of future complications compared to populations that take 72 hours or longer to get surgery. Cowabunga!

But could all this trouble have been avoided in the first place?


The Correct Decision?
Was Golden State wrong to allow Kevin Durant to play in Game 5 of the NBA Finals? Did the Warriors willingly know that he could have ruptured his Achilles tendon if they allowed him to play? I think the answer to both questions is no.

Coach Steve Kerr and Golden State general manager Bob Myers have both repeated that it was a cumulative and collaborative effort to get Durant back on the Court. Kerr reported the decision was discussed among multiple parties including “…Kevin and his business partner Rich Kleiman, our [GSW] medical staff, [Durant’s] own outside opinion, second opinion, doctor outside of our organisation. Kevin checked all the boxes, and he was cleared to play by everybody involved.” That’s a lot of expert opinions coming to a general consensus.

For every athlete coming back from injury, the decision to return to play is multi-factorial: all medical staff parties would have had physical criteria they wanted KD to complete successfully and Durant himself would have to be not only comfortable but confident, in his ability to perform on the court. He would have been educated about the risks involved in returning early if his calf wasn’t completely healed and made the decision to participate. There needed to be confidence from everyone that he could perform AND remain safe on the court. At worst, I think everyone involved in the decision would have suspected a re-injury to the right calf. Knowing this and looking at the available facts, the decision to play appeared to be the correct one.

While I don’t have any specific information from the Warriors about KD’s health and capacity to play, the number of minutes that KD played in the first quarter should have been lower than usual. This is because even when a medical team hands back a player to the coaches, the player must be gradually introduced to the high-level intensity and demand of training and matches. When the importance of this final rehabilitation stage (return to sport) is ignored, this is when re-injuries often occur.

If there was one thing that could have been changed on the night, it’s that Durant could have been eased into the game. Reduced minutes, more rest and a less intense workload, if it was even possible in a game of this magnitude. Ideally, chilling around the perimeter and hanging out for corner 3’s would have been nice but you can’t get an easy introduction into an elimination game in the NBA Finals. These suggestions would have reduced the risk of a calf strain reoccurring. Even with all these measures, nobody could have seriously suspected that KD’s Achilles was at risk of blowing up.

Some say this decision to return to play and the fault rests with Dr Rick Celebrini, the Director of Sports Medicine and Performance for the Golden State Warriors. Celebrini was hired at the start of the season and came from Head of Sports Medicine/Science/Rehabilitation positions at Major League Soccer’s Vancouver Whitecaps FC and the NHL’s Vancouver Canucks. I don’t know much about either of these two teams but some online comments have said that the Canucks were the most injured team in the NHL and were connecting the dots between Celebrini’s hire and the Warriors injury-riddled season.

Some articles putting two and two together…

These correlation = causation hot takes are unfounded and frankly, wrong. Rick Celebrini is one of the most respected sport and orthopaedic physiotherapists in North America. Prior to his positions at the Vancouver MLS and NHL teams, Celebrini had also worked with the Dallas Mavericks, the NFL’s Seattle Seahawks, the Canadian Alpine Ski Team and the Canadian Soccer Association to name a few.

Notably, Celebrini was credited by the legendary Steve Nash back in 2007 for helping to prolong his career past a painful spinal condition (spondylolisthesis) and allowing him to perform exceptionally through his thirties and even at an All-Star level at the age of 37. In his retirement statement, Nash gave Celebrini a ringing endorsement saying “Rick Celebrini has as big an impact on my career as anyone. Physiotherapist, sounding board, accomplice, coach, big brother. World class.” Sounds like he knows what he’s doing. Steve Kerr and forward Draymond Green have also had high praise for Celebrini.

“Rick and his staff have done an amazing job. They are really, really top notch… He has been a huge key for us in this process” Kerr said during the early rounds of the Playoffs. Draymond said of Celebrini “He’s brilliant, first off. A very smart guy… He’s brought a lot of new things in – recovery between games, getting on those things right after the game... The work he’s done to get guys healthy and back on the floorRick is great.”

Rick Celebrini has had a busy year as Golden State went to the final stage of the post-season for the 5th consecutive year.

If we’re looking for concrete examples, let’s squizz at Draymond earlier in the season. At the start of the season, Draymond struggled with a persistent knee injury and gained extra weight. Celebrini guided the Warriors forward through a rehabilitation program and then his team assisted Draymond with his diet. Draymond subsequently dropped ~25 pounds/11 kilos and this weight loss has had a major impact on his overall play. He’s been a monster through the Playoffs, especially in KD’s absence, averaging a near triple-double and demonstrating why he’s one of the most outstanding defensive players in the league.

I think it’s fair to say that Rick Celebrini, a highly praised and internationally recognised physiotherapist, is NOT at fault for what happened to Kevin Durant’s Achilles. It’s been many years of playing into the NBA Finals for a lot of Golden State players and the miles have added up. That’s a whole ‘nother article looking into how the horror run of injuries is linked to the consecutive deep post-seasons.


The Link between Kevin Durant’s Injuries?
The question that so many are wondering after KD’s injury is: can a calf injury make you more susceptible to an Achilles injury?

Dr John Belzer, a former orthopaedic physician for the Warriors was questioned post-KD’s injury and believed that there isn’t a link between the two. “I have never seen that. I’ve never seen any literature to support that… It’s an interesting sequence and a very unfortunate one for Kevin… nobody could have seen that coming” stated Dr Belzer on the matter. The former Golden State physician added “I don’t think there’s any blame to be made on the decision making process on this… I think it was a good decision. I think five weeks is certainly a reasonable opportunity to give him to heal this injury in.”

Whilst there appears to be limited evidence supporting a link between a same-leg calf sprain and subsequent AT rupture, it’s possible that there is a relationship between the two injuries. KD’s right calf muscles returning from injury would have been weaker and not be able to work as effectively until it had adapted to the demands of an intense NBA Finals series. With this deficit in mind, if the calf muscle complex is weaker, then the closely-related Achilles tendon could have to overcompensate and work harder to perform the same tasks. When KD’s tendon ruptured, the calf and AT were under a huge amount of load as he tried to push off when with both structures maximally stretched (pushing off in the dorsiflexed position). All these factors combined may suggest that there is a link between these two injuries but we can’t possibly know for sure.


The Future
What’s next for KD? Will he ever be the same?

The history of NBA players returning from Achilles tendon injuries is concerning. Steve Kerr has already said that Durant will miss the entire 2019-2020 season. Here’s a look at previous days missed from other NBA players coming back from the same injury.

Credit: ESPN Stats & Information

In addition, athletes that return from an Achilles rupture are reported to play fewer games, play less time and perform at a lower level than before the injury. For Durant, the predicted functional deficits (being less explosive, less agile) are expected to last no longer than two years according to current research.

There’s so much variability with players who have returned from an Achilles tendon rupture. Durant’s teammate, Demarcus Cousins, has struggled to play like the same player who made four straight All-Star teams. Kobe Bryant, Chauncey Billups and more were never the same. Dominique Wilkins is the rare case for the All-Star returning to form. When he tore his Achilles in 1992 he was 32 years old. Post-rehab, Wilkins played at an exceptionally high level and returning to the All-Star team for two years before his decline. Check out Howard Beck’s article on the Bleacher Report for a bit more on the past players who have suffered the same injury.

There’s no doubt that Kevin Durant will be a different player when he next steps onto an NBA court. With time, however, there’s a good chance he will be elite again.


Thanks for reading! If you like learning a bit more about NBA player injuries from a medical/physiotherapy perspective you can follow me on Instagram @nbainjuryrep


References
1. Ackermann et al., 2018. Reduced time to surgery improves patient-reported outcome after Achilles tendon rupture. AJSM
2. Brukner & Khan, 2017. Clinical Sports Medicine 5th ed
3. Misir et al., 2019. Repair within the first 48h in the treatment of acute Achilles tendon ruptures achieves the best biomechanical and histological outcomes. KSSTA
4. Prakash et al., 2017. Connective tissue injury in calf muscle tears and return to play: MRI correlation. BJSM
5. Trofa et al., 2017. Professional Athletes’ Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture. AJSM

Please follow and like us:
error

Leave a Reply

Your email address will not be published. Required fields are marked *