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What Kobe Bryant Must Do to Come Back from Surgery and Prove 'Doubters' Wrong

Will CarrollSports Injuries Lead WriterApril 15, 2013

What Kobe Bryant Must Do to Come Back from Surgery and Prove 'Doubters' Wrong

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    Kobe Bryant ruptured his left Achilles tendon on Friday night and was on a surgeon's table less than a day later. This kind of rapid response is normal for a high-level athlete, but the surgery is just the beginning.

    Many NBA fans, and Bryant himself, are questioning what happened in the surgery. They're wondering what the next eight to 12 months will bring for Bryant. They're questioning whether or not he can return to play and what kind of player he will be if he does. Bryant himself addressed the "doubters and haters."

    While the media and fans speculate about what might happen, the medical processes in place are often hidden but are the most important thing to understand if you want to know why some players succeed after a major injury and why some don't. Much of that comes down to the athlete, his rehab team and a little bit of luck.

    Professional athletes, especially elite ones like Bryant, have a better base to work from. They are in great physical condition, have good muscle tone and an unquestioned work ethic. A player like Bryant, who has had to work to maintain his knee injuries over the past few seasons, understands the process as well and has shown that he is willing to put in the time. That's a major plus. 

    All rehabilitation information is taken from a standard post-surgical Achilles tendon rupture protocol created at the University of Missouri. There are many of these protocols out there, including one used by the Kerlan-Jobe Clinic, that will have minor variations. While none of this information is specific to Kobe Bryant or his rehabilitation plan, it will give you a general idea of how his rehab process will go.

    I also spoke at length with several doctors and athletic trainers, including Dr. Bob Baravarian of Saint John's Health Center in Santa Monica, Calf., who provided invaluable insight into the process. Most of these conversations were off the record due to NBA and privacy regulations. 

Surgery

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    There are three normal scenarios for how an Achilles tendon is repaired. We do not know exactly which type of repair that Drs. Neal ElAttrache and Steve Lombardo performed Saturday on Kobe Bryant, but the length of time missed and rehabilitation process is the same for each.

    The key for each type of repair is returning the Achilles tendon to the proper tension. Ideally, it would be the same length as it was prior to the injury, but there is often some damage that needs to be excised.

    Also, most people do not have legs or tendons that are the same length. It is easy in most cases to check this, because the opposite leg is normally intact and can be used for a broad comparison. 

    The first type, and most common, is a "mid-substance tear." In this kind of rupture, the tendon separates in the middle, like a rope breaking. The repair requires skill in preparing the tendon by removing any fraying or other damage from the injury itself and then sewing the two ends back together. A special type of suture is used along with one of several suturing techniques in order to hold the tendon together. The suture itself will be absorbed into the body in about six weeks, allowing the body time to rebuild the tendon.

    (To see how this type of repair looks, click here. Warning: This link shows a surgical procedure.

    The second type is a tear away from the muscle. When this happens, the tendon remains largely intact but removes itself from its origin at the lower end of the calf muscle. This is an exceptionally difficult repair due to the high stress on the area and the difficulty re-connecting into the muscle. If you're curious why this is so hard, try cutting an uncooked steak and then sewing it back together.

    The final type is a tear away from the heel. This is a simple repair because the tendon is intact. The surgeon merely needs to re-anchor it to the bone using a pin or screw, making sure that he again keeps the normal length and tension.

    Dr. Bob Baravarian, a top foot and ankle doctor who literally wrote the book on athletic foot and ankle surgery, called this operation one of the simplest to do. "The tendon is huge compared to some of the others we work on in the foot and ankle. There's plenty of material to work with," he told me. "There are some tricks to the suturing and how we put it together, but it's very simple."

    Dr. Baravarian explained that there are some new techniques being used that have helped results. While he did not know whether either was used on Bryant, it's reasonable to believe that they were.

    The first is the increasingly popular use of PRP (platelet-rich plasma). The PRP could be injected in and around the tendon in order to reduce scarring and to increase the healing response. (Dr. ElAttrache has spoken on occasion about his use of PRP and recently used it on Zack Greinke's elbow when he had pain during spring training.) 

    The other technique is the use of membrane around the tendon. A product such as Graftjacket could be placed around the repair to increase the strength of the area. Another similar product is called AmnioFix, which has some interesting healing properties due to its unique structure.

    Overall, this is a simple and common surgery that has very good outcomes. 

Phase I: Healing

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    It is often said that "successful surgery" is defined by two things: 1) The surgeon did what he said he was going to do when going in, and 2) the patient woke up from anesthesia. As with most surgeries, Bryant's was successful, and the hard work of rehabilitation begins almost immediately.

    Because of the tenuous nature of the repair early on, there is little active work in the first four to six weeks of rehab from an Achilles rupture. The focus is to allow the repair to heal.

    As I said, the special sutures will be absorbed by the body as the Achilles itself fills in the damaged area. The body will take several weeks to fully "re-tendonize" the area, and there will be some scarring. "Not all scarring is bad," Dr. Baravarian explained. 

    The tendon is protected by the use of a walking boot that keeps the foot from dorsiflexing. Dorsiflexion is the act of moving the top of the foot toward the leg. The opposite action, plantarflexion, is pointing the toes downward and moving the foot away from the leg. Dorsiflexion puts the Achilles under tension, and in early rehab, when the tendon has not fully healed, it could split the repair. 

    The major worry is that the tendon itself is not lengthened to a point where the sutures or the body's natural healing responses would lengthen the tendon. The surgeon will have made a point of trying to keep as close as possible to the natural length of the tendon, though some was likely excised.

    If the tendon is lengthened during healing, it's like the waistband of an old pair of sweatpants, stretching out and not being very useful for its intended function. In this case, function would be lost, especially athletic function important to Bryant, like jumping and acceleration.

    Exercise during this phase will focus on high-frequency, high-repetition activity that will help the calf maintain some strength and create a "pump," getting more oxygenated blood to the area. After a week, Bryant will be able to start simple cardio like a stationary bike and can begin limited range-of-motion exercises after two weeks.

    The repair and strength will be tested at the one-, two- and six-week marks, though the final phase of testing can be moved up if all tests are passed in the areas of healing, strength, range of motion and proprioception.

    Dr. Baravarian explained that in this early phase, keeping Bryant fit and engaged is key. There are many things he can do without taxing the repaired area, such as a hand bike. In addition, he can work with film and watch games during the playoffs to stay mentally engaged. 

    Another key point in the early stages of rehab is watching for any sign of infection. As sports fans have seen more and more in cases like that of Rob Gronkowski's arm, infection can set back the process by months and can be life-threatening in some instances. 

Phase II: Movement

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    Rehabilitation progresses once the surgical healing has completed. With the tendon in-filling the damage after being re-attached, it should now have structural integrity. It is not at full strength, and weight-bearing is added slowly and carefully, according to the University of Missouri protocol.

    Bryant will be weaned from his boot and put into a situation where he is still required to wear a heel lift inside his shoes to create an enforced plantarflexion. There is still to be no dorsiflexion, so as to keep any taxing forces from the still-healing tendon.

    Most of the rehab focus is on range of motion. Bryant and his therapists will work on gaining active range of motion in all planes, though once again avoiding any dorsiflexion. He will also work extensively on strengthening the calf muscle and the smaller muscles of the lower leg, ankle and foot.

    He will also be able to do more cardio work, focused on non-impact solutions like an elliptical trainer or stationary bike. (The bike will have to be adjusted to—you guessed it—avoid dorsiflexion.) 

    Bryant will not be able to take part in any physical basketball activities, but rehabbing players are often included in meetings and film study. The downside is that the timing here is over the summer, when many team activities won't be going on. That will put more pressure on Bryant to remain mentally engaged.

    This phase normally goes through 10 weeks. That point could be very key for the Lakers, as they will want to have a better idea of when Bryant will be back on the floor, allowing them to plan for free agency and the NBA draft. If Bryant is ahead of schedule by this phase, it will be a very positive sign.

    While it is unlikely to be seen in public, the key milestone for Bryant will be a simple heel raise. If he can do that before the NBA draft, it will be a positive sign.

Phase III: Full Range of Motion

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    By the 10-week mark, Bryant should be ready to incorporate light dorsiflexion into his rehabilitation, at least according to a standard protocol. This final phase of range-of-motion exercises is one of the most dangerous parts of the rehab. The worry is that the tendon will be overstretched and lengthened, a process that simply cannot be reversed.

    An overlengthened tendon does not have the same tension as the pre-injury tendon or the opposite-side tendon, leading to an imbalance that is going to cause many functional issues. Gait is regularly monitored during this phase, as any sort of limp or drop of the foot is an indication that there may be some stretching.

    This tender stage of rehabilitation is a long one, but it's key to the process. As the tendon holds, the therapist can assist Bryant at regaining the full function and range of motion in the ankle. They will also focus on regaining any strength lost in the legs, again compared bilaterally. 

    Bryant will still not be doing any sort of impact activities at this stage. He will be able to do more cardio, such as using an Alter-G treadmill or SwimEx, which reduce the impact while allowing a more natural motion. 

    This is also the stage that is most frustrating for the athlete. He is functioning at a higher level and feels normal but is still precluded from doing anything associated with basketball. This phase can't be rushed, so there is a major mental component to this part of the process. 

    Normally, this phase will go until about the four-month mark, but this is one major area of the rehab that could go quicker due to Bryant's unique skill set and physicality. The final tests here aren't visible—focus is instead placed on isokinetic testing, which shows that both legs are equal and close to their pre-injury level—but there is an easy milestone to watch for here.

    Once Bryant has passed through this phase, he'll begin running again and will be much closer to his return.

Phase IV: Strength and Skill

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    The final phase of the therapeutic rehabilitation will focus on strength and function. While the previous phase focused on getting things back to normal, this stage will focus on getting things more functional and prepared for the demands of basketball. Again, this is based on one standard protocol created at the University of Missouri.

    The adjustment to more impact activities will come gradually as the therapists work to strengthen the muscles around the repair. He will also begin using weights.

    The final area will be to do controlled movements and get full range of motion. Lateral movements are both a key need for full return to play and one of the biggest stressors on the tendon itself, so it will be gradually introduced and monitored closely. Lateral motion requires the tendon to not only act as a pulley but to also stretch or curve laterally during function. It also acts as a "brake" on the ankle's rotation, a big part of starting and stopping.

    The first "basketball activity" will come back at this point and is almost always shooting a basketball. Getting a player back to this stage is very important for his mental well-being and positive attitude, but it is also dangerous. This is something the athlete has done for years, perfecting the skill to a point where he can do it automatically.

    As the activity is reintroduced, the athlete must start thinking about it more. Bracing is often used to limit any possible damage if the player forgets his limitations and starts doing some of the things he's always done.

    Again, this is a phase that could go much more quickly for Bryant than for the standard athlete. The milestone to watch for here is a true jump shot. Once Bryant can safely and naturally make that shot, he will be ready to move to the next phase. This could happen as quickly as three months post-surgery, or early July.

Phase V: Return to Function

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    This final, late-stage portion of the rehab under the University of Missouri protocol is when you start hearing phrases like "basketball activities." Bryant will be weight-bearing the tendon strong and should have full function in his leg. This is not to say that he is "normal."

    In this stage, he will be learning about his leg and getting used to how it functions now. Ideally, it is back to its previous state or close enough that he does not notice significant deficits. Bryant will be literally "getting his legs underneath him." 

    Instead of just shooting, he will be able to do more athletic activities, such as participating in controlled games, doing practice drills that involve more complex athletic activities and full participation in controlled but high-impact running and jumping.

    The jumping will need to be introduced slowly, and there are a number of drills that the strength and conditioning staff will work on to make sure that Bryant is safe as he gets back to normal function. This will be especially important if Bryant is ahead of schedule with his rehab. A tendon that is four months out from surgery is almost always stronger and more resilient than one that is three months out.

    Obviously, this will be watched closely for functional ability, and he won't be allowed to proceed to this stage unless he's passed all medical and physical tests prior to this, but there is still some additional danger of complication at any point when someone is significantly ahead of the timeline.

    The key milestone to look for here is that Bryant can make normal jumps and adjust to contact. For instance, he will need to re-balance himself when bumped, requiring a quick, unconscious change in the legs. This kind of activity can tax the repaired tendon, but because it tends to be a natural reaction, it's a very positive sign of progress.

Phase VI: Return to Play

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    While the normal length of a rehab is often quoted as eight to 10 months, the Lakers stated that they expected Bryant back at six to nine months. Dr. Baravarian believes that Bryant will be on the low side of that estimate and that he could be back even sooner.

    "Five months is possible," he told me. "It wouldn't surprise me to see him at the start of the season, though he would likely be playing limited minutes."

    If physically possible, the question remains whether Bryant could be the same player he was prior to the injury. Age is not really a factor here, though, obviously, being younger and healthier would help.

    The question is really more one of function. Because the Achilles is so key to acceleration, jumping and lateral motion, Bryant is going to have to adjust to any loss, minor or major, to that function.

    Dr. Baravarian believes Bryant might have to make changes to his trademark fadeaway jumper.

    "Think about that shot," he said. "He turns, he jumps. He has to have the sense and control of his body to shoot while he's falling away and then land."

    It's a complex and difficult series of physical activities and one that Bryant might have trouble re-sequencing. He may be forced to make adjustments to his game in order to both accommodate any lingering limitations and make up for any deficits.

    The fadeaway might end up being the final milestone. If he's shooting it, the old Kobe is back.

Summary

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    The rehabilitation program will obviously be different for Kobe Bryant than it would be for someone off the street. He will have the best of care and a 24/7 support staff, as well as an attentive media focus. Every tool and trick of the Lakers medical staff will come to bear on this program. 

    Seeing Bryant ahead of schedule wouldn't surprise me at all. Dr. Baravarian agreed, stating that a return at the five-month mark wouldn't be a shock. "I can see him back at the start of the season, though [Bryant] will still be adjusting and will likely have significantly reduced minutes," he said.

    Watch for these milestones as Bryant progresses toward a return. Bryant is reportedly collecting clippings on who is a "doubter or hater":

    This is what my friend/agent sends me this am. Shiesh! #kobe #motivationsunday I'm keeping track of… instagram.com/p/YF9wLsxNua/

    — Kobe Bryant (@kobebryant) April 14, 2013

    Kobe, you can keep this clipping, but don't count me among the doubters. I believe that Bryant will be back and be very nearly the player we saw this season. It's a situation very analogous to the one we're seeing with Mariano Rivera. Bryant wants to go out on his own terms. The surgery and rehab will be long and difficult, but they will give him that chance.

     

    All quotes in this article were obtained firsthand unless otherwise noted.

    Will Carroll has been writing about sports injuries for 12 years. His work has appeared at SI.com, ESPN.com and Basketball Prospectus.

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