Experts cite overuse in spate of Achilles injuries in NBA

Achilles tendon injuries have become all-too-familiar headlines in professional sports, and this NBA season saw more than its usual share. During the NBA playoffs alone, Milwaukee Bucks guard Damian Lillard tore his left Achilles in the first round against the Indiana Pacers, Boston Celtics forward Jayson Tatum ruptured his right Achilles tendon in the second round against the New York Knicks, and Pacers guard Tyrese Haliburton tore his right Achilles in Game 7 of the NBA Finals.

Two other players, centers James Wiseman and Isaiah Jackson, tore their Achilles earlier in the season, as did New Orleans guard Dejounte Murray and Miami Heat guard Dru Smith.

Other high-profile athletes have suffered Achilles tendon injuries beyond the NBA, such as USMNT forward Haji Wright, whose recent Achilles injury has ruled him out for the remainder of the Concacaf Gold Cup, and Cleveland Browns quarterback Deshaun Watson, who had surgery earlier this year for his second right Achilles tendon tear.

Medical experts attribute these injuries to overuse and accidental circumstances.

Karin Gravare Silbernagel, a physical therapist and professor at the University of Delaware, compared today's calf injuries to the kind of hamstring strains seen five to 10 years ago and pointed out that as athletes have prioritized upper-leg strength, their lower legs need to have the strength to keep up.

"At this point, we need to start thinking about the calf and Achilles in the same way," she said. "Do we have enough strength ... to be able to tolerate the sport that we're doing? The lower leg is lagging behind some of the other things that we do."

ESPN spoke with four experts about Achilles tendon injuries during this past NBA season, and more broadly about why the Achilles is so vulnerable and whether painkillers could be masking warning signs. Their responses have been edited for clarity.

Q: How easy is it to injure a calf?

"It's not hard at all," said Dr. Michael Fredericson, director of physical medicine and rehabilitation for sports at Stanford.

"You use the calf in virtually every movement when you're walking or running," Fredericson said, "so it is one of the most common injuries if you combine calf injuries and Achilles injuries."

For NBA players, in particular, the most common cause is overuse, said Dr. Nirav Pandya, a professor of orthopedic surgery at the University of California San Francisco.

"As the season goes on," he said, "you see a lot of these calf injuries crop up from the wear and tear of playing an explosive game." He also said some injuries happen by chance, often from explosive movements, such as layups, that result in too much force for the body.

Q: What makes the Achilles tendon so vulnerable?

Unlike most muscles and tendons, the Achilles is under constant tension. It's built for power and speed, but that means it's always "wound up and stressed," said Dr. Justin Greisberg, professor of orthopedic surgery and chief of foot and ankle surgery at NewYork-Presbyterian and Columbia University Medical Center.

"The stresses that go through the Achilles tendon are probably the highest in the body, many times body weight, [just from] walking," he said. "... When you're talking about a professional athlete who's big and strong and doing serious running and jumping, you're talking huge loads."

When it ruptures, it's not just a simple tear.

"The explosion of the rupture really affects the ... muscle, the part that does the work," Greisberg said. "... The whole muscle goes into a coma."

For athletes, all it takes for injury is a simple misstep, like slipping on sweat, landing off balance or planting on another player's foot, Greisberg said.

Q: Do calf strains lead to Achilles tears?

Not always. Greisberg said that many athletes who have Achilles ruptures have never had an injury to that leg before, so there often isn't a warning sign.

Gravare Silbernagel said the data she has seen doesn't point to a correlation, but as soon as there's a deficit at one point in the leg, like a calf muscle, then the leg is vulnerable for other injuries.

"We don't necessarily see them going from having a calf strain and then rupturing the Achilles," Gravere Silbernagel said, "but they're all attached."

The key to preventing further injuries after a calf strain is recovery, Fredericson said.

"If those muscles don't fully recover," he said, "then that muscle is going to be weaker and it can't handle high-end stress as well."

Q: Could painkillers be masking warning signs?

The use of anti-inflammatories like strong ibuprofen is common in pro sports, but in Greisberg's view, painkillers aren't the culprits for Achilles injuries. He said he doesn't think the idea of athletes being numbed and playing through pain applies in most situations.

"The reality is that [in] the majority of Achilles rupture, athletes didn't have any symptoms," he said. "... It was out of nowhere."

For Fredericson, the issue isn't the medication, but rather if it interferes with an athlete's ability to listen to their body. Gravare Silbernagel said that if an athlete doesn't feel intense pain, they might not have any inhibition in how heavy they can load it,

"The concern is if you don't have the pain," she said. "If you take away the pain, then do you have these inhibitions or not?"

Q: Why were there so many Achilles injuries this NBA season?

Fredericson said Achilles injuries for athletes come from overuse, meaning they need to "look at the amount of load that the athletes are putting on their body and the amount of recovery." It's a combination of athletes playing through injury and not getting enough recovery, he said.

"These athletes are some of the most supremely conditioned athletes we've ever had," Fredericson said, "so I don't think it's a conditioning issue."

Greisberg called it a mix of random chance and circumstances, and said athletes continue to play at higher levels and push the limits of what the body can do.

Between every-other-night playoff game and offseason Olympic training, Pandya said athletes have been training even harder than normal this year. Star players spent 39 or 40 minutes on the court per playoff game rather than 25-30 minutes of playing time with break games during the regular season.

"One of the things we know is whenever you increase the minutes you play over a period of five to 10 games, there's an increase in injury risk," Pandya said.

Pandya also said today's athletes bring more "mileage" than older athletes because they start playing at a high level at a young age.

"If you're looking at a calf muscle or the ligaments and tendons of the average 22-year-old player," he said, "they've already had so much mileage on them, compared to players 30 or 40 years ago who weren't doing that."

Q: How can athletes prevent these injuries?

Stretching, especially hamstrings and calves, along with solid and supportive footwear can help avoid injuries, Greisberg said. Traditional sneakers with a slight heel lift can help reduce stress on the Achilles, while super-flat shoes might increase it by "pre-exposing people to Achilles injuries," he said, although noting that those shoes are more likely to cause tendonitis than full-blown ruptures.

Gravare Silbernagel also said that calf-strengthening exercises can improve tendon strength. Pandya said that players also need to be mindful of discomfort and pain to prevent further, catastrophic injuries.

"Even though we've advanced surgery wise, it's still a career-altering injury," he said.

Q: What can teams learn from this season?

With multiple star players suffering from Achilles injuries, teams should take a harder look at how they're training, monitoring and resting athletes, experts said.