Orthopedics & Sports Medicine

Major League Soccer players who have Achilles tendon surgery show no decrease in performance, but a significant decrease in career length

Nov. 12, 2020

The surgeons at Houston Methodist Orthopedics & Sports Medicine perform more than 20,000 orthopedic procedures each year, utilizing the latest minimally invasive procedures and pain management techniques, supported by our sports medicine physicians, rehabilitation and occupational therapists, and athletic trainers.

Our surgeons are also conducting research to expand our understanding of a variety of orthopedic subjects, and have published data on the first study to measure the ramifications of Achilles tendon surgery among professional soccer players. Their investigation, “There Is a High Return to Sport Rate but With Reduced Career Lengths After Achilles Tendon Repair in Major League Soccer Players,” appeared in February 2019 in the Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine, comparing postoperative performance statistics of players who had Achilles tendon repair with those of matched controls among Major League Soccer (MLS) athletes. On behalf of Houston Methodist Orthopedics & Sports Medicine, authors David N. Lintner, MD; Kevin E. Varner, MD; Pedro E. Cosculluela, MD, and Joshua D. Harris, MD, designed the study to measure 1) return to sport (RTS) rates following Achilles tendon surgery, 2) postoperative career length and games per season, 3) preoperative and postoperative performance, and 4) postoperative performance compared with control players matched by age, body mass index (BMI), sex, years of experience, and performance.

Achilles tendon tear rates in soccer

Elite-level athletes are required to perform explosive changes in direction, which cause extreme loading of the Achilles tendon, putting them at increased risk of sustaining acute Achilles tendon tears requiring surgery. Recent evidence suggests that soccer is the most common sport resulting in Achilles tendon tears in Europe and Canada, and that 2% of all Achilles tendon tears in the United States are a result of soccer-related injuries. Recent studies of the National Football League (NFL) demonstrated that Achilles tendon tears have a negative effect on future performance, and the increasing popularity and revenue of the MLS make it even more vital to understand surgical outcomes of professional soccer players.

Identifying subjects and criteria

Publicly available records were used to identify MLS players who underwent Achilles tendon repair with a minimum of 1 year of follow-up between April 1996 and October 2016. The active population identified included 22 players and 23 tendon repairs (one player had a bilateral injury). Players were included if 2 or more sources confirmed the tear. Players were categorized by position (forward, midfield, defense, goalkeeper). Active players were defined by Achilles repair 3 years into their career, and control players were those who were also 3 years into their career but didn't report Achilles injury. Data studied included year assessment duration; number of patients/surgeries; RTS, defined as playing in one or more MLS games after surgery; and number of games/seasons.


Outcomes by time and position

Years 1-3: Overall 77% RTS at year 1 (return time, 306.6 ±199.2 days), then 50% at year 2, and 23% at year 3.

Greatest impact on defensive players: Defenders were the most likely to undergo repair (11 cases; 50% of total). This may be explained by the constant plantar flexion and eccentric contraction required by defenders for backpedaling. Also, only 9% of active defenders remained in the MLS at 3 years compared with 56% of controls postindex (P=0.02). Furthermore, defenders in the control group were in the MLS significantly longer (3.3 seasons) and played in significantly more games per season (21.9 games) postindex than active defenders (1.8 seasons; 11.1 games) (P=0.032).

Similar impact on other positions: There were no significant differences in performance between active cases and matched controls presurgery and preindex among all positions. There were no significant differences (P>0.05) in execution, career length, or games per season between cases and control groups among forwards, midfielders, or goalkeepers.

These results indicate that Achilles tendon repair did not have significant influence on the development and achievement of these players.


Seasons, games, and level of play

As discussed, defenders in the control group were in the MLS significantly longer and played in significantly more games per season postindex than active defenders. The same was true overall: players in the control group were in the MLS significantly longer (4.5 seasons) and played in significantly more games (23.5) postindex than the active population.

Interestingly, a higher number of fouls were committed per season among postindex control compared with the postoperative active population, which may indicate that following surgery, players may not play as aggressively, compared with preoperative performance or players who have not been injured.

The left side tends to sustain more injuries

In this study, a significantly higher number of Achilles tendon repairs occurred on the left versus the right extremity. It is likely that right-footed kickers have an increased tendency of tearing the left Achilles tendon since during kicking, the left Achilles tendon is eccentrically loaded. A similar injury distribution was seen in an earlier study that noted a significantly greater number of anterior cruciate ligament tears in the left knee versus the right among MLS players, theorized to be due to load and torque on the left knee while kicking.

Conclusion: Shorter careers following Achilles tendon surgery

Although there was a 77% RTS rate in the MLS following Achilles tendon repair, those players had shorter careers and played fewer games per season than matched controls. There was nosignificant decrease in performance postsurgery compared with presurgery, nor in postsurgery compared with postindex. This study, a first of its kind for a sport of increasing relevance and interest, represents how Houston Methodist Orthopedics & Sports Medicine strives to improve treatment of all athletes, professional and amateur.



Ortho Research Sports Medicine