Q&A: Dr. Kevin Stone discusses Achilles injuries and how we treat them

Wes Matthews' Achilles rupture came against the Mavericks last March. Just a couple minutes out of halftime, he had ran down the sideline and received an advance pass from Damian Lillard. He was probably going to score -- only Dirk was between him and the basket. But as he caught the ball and planted backwards with his left foot, his Achilles tendon gave way.

It's a frightening injury, one that has ended the careers of seven of the 18 players who we know suffered the injury between 1992 and 2012, per data compiled by CBS Sports. Matthews is one of four players to suffer the injury this year; Brandon Jennings, Anderson Varejao and Xavier Henry all went down with the same ailment before or during the season.

I wrote about Matthews injury the morning after Matthews' injuries happened, long before he signed in Dallas, and had done a few Google searches on Achilles injuries since. No site laid out the information better than the Stone Clinic's recovery timetable, which you can read more about right here. I wanted to know more and Dr. Kevin Stone agreed to chat with me over the phone about the injury directly as it relates to an NBA athlete. Stone is a long-time orthopedic surgeon who has attended Harvard and Stanford University, lectures around the world and even has his own TED Talk.

Here's an edited transcript of our conversation.

Let's start from the top. What does the Achilles tendon do and how can an athlete injure it?

The Achilles tendon attaches the calf muscle to the heel bone. It's designed to stretch, it's designed to absorb force when the athlete lands from a jump. It's designed to provide power for push off when taking a running step. And so, Achilles tendon ruptures are classically the scourge of a 40 to 60-year-old male. It's uncommon in sports injuries for it to be women or it to be younger athletes. So the unusual Achilles rupture in the basketball player or a female is usually bad luck -- landing from a bad position, landing awkwardly hard on the leg. It's much more common in a 40 to 60 year old. If you don't mind, I'll just keep going and tell you the whole story.

For sure.

So traditionally, these injuries have been treated with open Achilles tendon surgery which, while it has a good result, it takes a long time for the athlete to heal, usually not coming back to sports for six months and not really coming back with full power at their previous level for over a year. The reason is that the tendon attaches large muscles, the open surgery is hard to heal from and there's a significant complication rate relative to infection and scarring.

An alternative approach is a percutaneous repair where the surgeon doesn't open the skin, he just leaves sutures underneath to pull the ends of the Achilles tendon together. That tends to have a shorter healing time from the tissue healing point of view because it preserves the blood clot and doesn't have the open scarring but it still takes the athletes about six months to a year to rebuild all of their power. And then newer treatments also add stem cells and growth factors, also trying to speed up the healing of that torn or repaired tissue. Non-operative tear of the Achilles tendon is performed more widely in Europe than the U.S. but the data shows that the athletes don't come back quite as strong an Achilles tendon as they do when the tendon is repaired primarily.

Seven of the last 18 NBA players to suffer an Achilles never returned to the sport. There were other factors, like age -- some of them were in their 30s -- but it's an injury that can end a career very quickly. Is that just the nature of the recovery?

I think that's right and I also think that the rupture rate is higher than that because unfortunately. In the NBA, in a number of other professional sports associations, it doesn't track their injuries and reported injuries quite as accurately or robustly as we'd like to see to do, so the injury rate might actually be quite a bit higher and athletes just don't come back to play or don't come back on the team. So the fact that so many don't come back to the sport is a testament to the fact that no. 1, it's a big injury, but no. 2, that the surgical repair technique and recovery from that has not increased in efficiency or quality as much as we'd like to see. We need better ways to stimulate healing and building of strength and those ways are definitely being studied now with the use of growth factors and stem cells and some anabolic agents as well, but they're not ready for primetime yet.

How far do you think it will be until a breakthrough is made there?

Well, we're using the techniques now, and we're studying them, but we don't have data yet to report whether they do indeed speed the return to playing or return to full strength, because while we're good at getting healing, especially when we do our percutaneous repairs, rather than open surgery, we're still slow at getting muscle development, which is pretty surprising given all we know about muscle training. But remember, the Achilles tendon is exerting on the heel bone the entire body's weight is lifting off and landing on a single limb on a very strong but small tendon relative to the rest of the body. So it takes a tremendous amount of both healing, power, elasticity for it to not re-rupture.

I think the ACL is relatable because it's probably the most common severe injury but an ACL recovery is also consistent. Players usually come back from it after the required recovery time. Would you say the Achilles is more inconsistent, a more difficult recovery than the ACL?

Yeah, it's a good question for the following reasons: no. 1, the ACL is repaired arthroscopically now, which has been true for the last 20 years or so. And Achilles tendons in general many surgeons do open surgeries, and open surgeries take a lot out of an athlete and lengthens the recovery time. No. 2, the Achilles tendon is designed to stretch and absorb all that power and transfer from the muscle to the bone, where the ACL holds together two bones and is designed not to stretch. No. 3, lots of athletes can do well without an ACL. While it may have been repaired, whether it's good or bad or not repaired at all, many athletes can still perform very well without one even though eventually they need another surgery, whereas you can't perform without an Achilles tendon. For each of those reasons, throughout history, we've learned that an athlete's Achilles tendon is really a vulnerability.

Wesley Matthews, one of the NBA players who suffered the injury, he's known as an ironman, is actually nicknamed Ironman, because he's such a hard worker. In general, though, a patient who is a hard worker, would you say that's sometimes not always enough to come back from this injury successfully?

Yeah, the other thing that plays a big role in the return of strength, but the healing time still takes that period of months for the tissue to heal properly and to regain full strength and elasticity. So in that case, it really does help to focus on the strength and conditioning and be extremely dedicated to it, and certainly our patients follow that role model better than those who go, "woe is me, I'm injured, feel bad for me." So motivation of the athlete is a huge hitter.

What's the first thing you tell an Achilles patient when you first get them and preparing for surgery?

The first thing I tell them is, "It's bad luck you've injured your Achilles tendon. Let's use this as an excuse for you to train and come back fitter, faster and stronger six months from now than you've been in years." While we can repair your Achilles percutaneously by not opening the skin, adding growth factors to it, and get that to heal, but what we need you to do is train all around the rest of the body to increase your fitness while the Achilles is healing so that you come back a better athlete.

What week is the worst one during the recovery?

There's two windows. The first is the first week from the pain of the rupture, and then the second is the third or fourth week from the depression of how long it will take to heal.

And I would imagine a lot of it early on is mental. Is that something you have to help your patients with?

It's extremely important that the injured person sees himself as an athlete in training and not a patient in rehab. That helps them recover faster, that helps the circulation of good endorphins, testosterone and all the things we think helps healing, and keeps his mind in a good place as well.

In these six to nine months of rehab, what are you trying to do to the Achilles to make it heal?

You're doing a lot of soft tissue massage, which helps the tissue that's laying down for healing lay down along the lines of stress and not scar. Hands on physical therapy work with soft tissue massage is extremely important component. Range of motion exercise gently within the healing range is very important as well. And then the rest of it careful power development.

The NBA in general has seen a load of injuries this year. Do you feel like the increased workload for high school athletes, with AAU circuits and all this increased, constant "go go go," do you think that's a factor?

We think lack of diversity is a bigger factor than workload. That athletes are so often not three-sport athletes anymore when they're in high school or junior high is a big factor in the type of athlete and the type of injuries they have later on. To return high school athletes to playing two or three sports, to becoming well rounded athletes rather than single sport athletes, we think they'll develop in a better way and reduce their injuries.