Even before an MRI Saturday confirmed a complete (Grade III) rupture of Kobe Bryant's left Achilles tendon, everyone, especially Bryant, already knew the extent of the injury. After all, Bryant had experienced the telltale symptom of a torn Achilles, saying after Friday night's game that he felt like he "had been kicked." If not literally, Bryant was at least figuratively struck by an injury that will force a premature end to his season and raise the question in everyone's minds as to what happens next.
As it turns out, Bryant didn't waste much time deliberating the future. On Saturday he underwent surgery to repair his Achilles with orthopedic surgeons Dr. Neal ElAttrache and Lakers team physician Stephen Lombardo, and in that moment began his road to recovery. All indications are that Bryant intends to play again, and while the rehabilitation process is lengthy and intense, there is reason to believe he will indeed see the court in the 2013-14 season.
Here are some of the key points to consider in recovering from an Achilles tendon repair:
1. Controlling swelling: The first few days following surgery are targeted at controlling swelling as much as possible and promoting healing of the wound (where the surgical incision was made). Guarding against infection is essential in moving the recovery forward. There is always a risk of infection with any surgical procedure, so close monitoring of the wound and controlling inflammation are imperative.
2. Protect the repair: The most important element in the early stages of recovery is protecting the Achilles repair. Specifically, it is critical not to overstretch the tendon, which would result in over-lengthening, which would then be impossible to reverse. Consider that the functionality of the tendon is dependent on energy and explosiveness that comes when pushing off the foot. If the tendon loses elasticity -- which would happen if it were to lengthen excessively -- the athlete would lose the ability to push off the foot effectively, a requisite skill for any sport, especially basketball.
To guard against this, the tendon is protected in a shortened position in the early phase post-surgery. Bryant's ankle will be maintained in a slightly plantar-flexed position (toes pointing downward) with the assistance of a splint and he will not be allowed to bear weight initially. Even his early range-of-motion exercises will be limited to focusing on pointing the ankle down; there will be no stretching of the calf.
3. Progress to normal walking: Bryant will be transitioned from an immobilizing splint to a boot with extra heel support inside (again, to avoid overstretching the tendon) but will still be on crutches and bear only partial weight. Gradually he will progress off crutches while still in the boot, then eventually he will move to a normal (athletic) shoe with a heel support inside. The final step is moving the heel support out of the shoe and getting the foot to its normal resting (neutral) position. Throughout this time, Bryant will be working on range of motion, light strengthening and cardiovascular exercise (such as stationary bike).
4. Restore movement patterns: By approximately three months, Bryant should be approaching full range of motion. He will likely have incorporated walking on an Alter-G treadmill, which reduces total body weight so that there is less load on the healing tissue but still permits the athlete to restore normal movement patterns. It's important for the body's nervous system to relearn normal motion after that motion has been forcibly interrupted for a period of time. The sooner that process begins, the less likelihood of developing compensations which can lead to additional problems down the line.
5. Rebuild sports-specific skills, training: Once the repair has had the opportunity to heal and normal walking has been restored, then it's a matter of pushing the athlete's cardiovascular training, strength, balance and coordination. Agility and sports-specific drills are added later with an eventual return to basketball activity. Controlled time and exposure to contact progresses to increasing minutes and unrestricted contact.
For the first few months, the athlete has to be restrained from progressing too quickly in order to protect the repair. Once the repair has healed to the point where it is safe to resume more aggressive activity, the athlete then has to push himself hard to regain what he's lost during the protective period.
If all goes well, the hope is that Bryant will be able to return to play within six to nine months, the timetable offered by the Lakers. It's worth noting that there isn't a large pool of comparables in the NBA when it comes to return to play following an Achilles tendon repair. Some have returned to play successfully (Dominique Wilkins) and others have retired in the wake of the injury (Isaiah Thomas). Chauncey Billups of the Los Angeles Clippers is perhaps the most recent example of an NBA player to return from a torn Achilles. After tearing his Achilles in February 2012, Billups returned to play in late November of the same year. However, he has been challenged by several other ailments (foot, back, groin) throughout the season.
The obvious and most routine demands on the Achilles of running up and down the court and jumping and landing repeatedly can be more easily overcome by the athlete. Perhaps the most challenging element of a basketball player's game to regain following this type of surgery, however, is sudden acceleration, the quickness off the foot necessary to make a sharp move around an opponent.
Athletes will often say that it is this explosiveness, this quickness that takes nearly a year to regain, perhaps long after returning to competition. Internally, the tendon continues to be shaped and modeled by the stress the athlete places on it as he returns to increasingly demanding activity. That internal adaptation is essential for the athlete to ultimately regain the feel of a "normal" leg, one that no longer feels different than the other. Simply put, it takes time.
Of course, Bryant is anything but normal even within the sphere of elite athletes. He has proved that he has the mental toughness and physical fortitude to push himself beyond what others around him might be doing. He will need to call on both, particularly in the later stages of his recovery from this Achilles repair, in order to return to the court this fall.
By then, Bryant might have everyone thinking back to the sight of him limping off the court in April and wondering whether there was ever really any doubt about what would happen next.