Demarcus Cousins fell from the precipice of a max contract offer from the New Orleans Pelicans to, merely months later, desperately calling teams during free agency to offer his services for a year. All passed except the Golden State Warriors (hate them all you want, but multiple other teams had the chance to sign him as well). How did he go from one extreme to the other in a mere matter of months?
The dreaded Achilles tendon rupture.
He’s not alone as roughly 12% of competitive basketball players rupture their achilles. Generally, the highest rate of rupture is amongst sprinters (18%) and 8.3% of competitive athletes rupture their achilles at some point.
Here’s a video of how it happened for Demarcus Cousins:
He was carried off the court, and diagnosed with a left achilles tendon rupture.
To understand what happened and what this means for Demarcus Cousins future, I’ll go through the following questions:
- What is the achilles tendon?
- What caused Demarcus Cousins injury? Did he have prior risk factors?
- What were the symptoms?
- What type of achilles rupture did Demarcus Cousins have?
- What’s his timeline for return and rehab look like?
- What does this mean for Demarcus Cousins’ future? Will he ever be the same player?
Lets start with the basic anatomy:
I. Achilles Tendon Anatomy
The achilles tendon is the largest tendon in the body. Reach down to your heel, trace upwards, and you should feel a prominent cord-like structure. That’s your achilles tendon.
It’s the confluence point of 4 different muscles (the medical and lateral gastrocnemius, the soleus, and plantaris – these all make up your calves) and attaches onto your calcaneus (heel bone). Here’s a visual:
Now that you know the anatomy, lets dive into key functions of the achilles that relate to why Demarcus Cousins ruptured his achilles.
II. What Caused Demarcus Cousins Achilles Rupture?
A. The Mechanism of Injury
Lets break down the sequence leading up to Demarcus Cousins achilles rupture to give insight into the injury (see what I did there…):
1 -Demarcus Cousins was at the free throw line and after missing his second free throw, chased after the ball and knocked it out of Trevor Ariza’s hands. At this point, he planted his left foot to break forward momentum:
In this moment, his achilles was contracting while lengthening (called eccentric contraction) to control (“brake”) the heel as it comes to the ground and create a stable base of support. Here’s a picture:
Eccentric contraction puts significant stress on the achilles tendon.
2 – Then, while fighting forward momentum, Demarcus moved laterally toward the ball by, amongst other things, rotating through his left lower leg, ankle, and foot:
This rotation and lateral movement added a “shear stress” to the achilles tendon.
3 – He then jumped off his left foot to tap the ball towards his teammates:
In this moment, a key function of the achilles is ankle plantar-flexion, which is involved in movements like pointing your foot downwards or coming up onto your toes.
Jumping requires a quick burst of ankle plantar-flexion to get off the ground and puts significant stress on the achilles. For reference, running puts a force of 6 to 8 times your bodyweight through the achilles tendon and that force is considerably higher during jumping (I couldn’t find exact numbers though).
Layer on the shear stress from rotation and that’s a lot of stress for the tendon to handle. It’s like your boss throwing two huge projects at you at the same time, ain’t no one happy.
Not coincidentally, the most common mechanism for achilles rupture is when pushing off the foot (especially when the knee is also straight, ex: sudden acceleration, jumping) and sudden cutting or pivoting (click here, here, and here for more info).
Further, Demarcus was jumping off one foot against momentum (try jumping off one foot, it’s not easy in and of itself. Now imagine trying to do that while someone is holding your shoulders down, I’m sweating just thinking about it). His achilles had to work extremely hard to generate enough force.
His achilles couldn’t handle that much stress and it ruptured.
He immediately pulled up grabbing at the back of his heel:
So that’s the specific moment of injury but with an achilles rupture of this nature, that’s just the tip of the iceberg. Lets go underneath the water and explore risk factors that likely increased his achilles injury risk…
B. Demarcus Cousins Risk Factors for Achilles Rupture
The reality with achilles ruptures – unless it’s a traumatic event like slipping down the stairs and completely jamming the foot/ankle – is that some factor(s) has weakened or degenerated the achilles tendon which means it can’t handle as much stress (click here, here, and here for more info). So then when/if a sudden high level of stress is applied, the tendon ruptures.
In Demarcus Cousins case, he had multiple risk factors that could have weakened his achilles tendon leading up to the moment of achilles rupture.
1 – Over-Use
“Too much, too soon” is one of the most common causes of soft tissue injury in general, including for the achilles. If there’s a sudden ramp up or overall increase in activity, the tendon gets overloaded with stress and weakens.
Tom Haberstroh did a great job of detailing Demarcus Cousins’ heavy burden of minutes and I’ll share the most pertinent tidbits:
- In the 10 games prior to injury, Demarcus was averaging nearly 40 minutes per game.
- Demarcus played in 4 overtime games in a 9 day span, including a 52 minute double OT game against the Bulls (tied for most minutes in a single game)
- The game he suffered the achilles rupture in was his 4th game in 7 days
- He averaged 38.3 minutes per game in January, by far the highest of his career
All of this adds up to a to an uncharted levelof stress on his body and achilles tendon.
2 – Fatigue
Additionally, a study by Jeff Stotts of instreethclothes.com, showed that most achilles ruptures in the NBA since 2005 have happened in the 2nd half.
This lines up with Demarcus Cousins’ achilles rupture. His occurred in the closing seconds of the game where fatigue is naturally highest. Additionally, he was likely fatigued from playing an unprecedented amount of minutes (as I talked about above)
3 – Gender
4 – Weight
Demarcus Cousins is a big dude – 6’11”, 269 pounds. That puts him at a BMI of 27.5 which is considered “overweight”. HOWEVER (and I don’t use caps often but I don’t want people running around saying he’s fat and out of shape), NBA players on average are right on the cusp of the “overweight” category since they are larger and more muscular than the average population. However, with this mass and muscle comes greater load and stress on tendons.
5 – Age
I put this risk factor last because it’s the one that Demarcus doesn’t fit into cleanly as most achilles ruptures, regardless of gender, occur between the ages of 30 and 40 (click here and here for more info). This may be due to degenerative changes from wear and tear, and age associated decreases in collagen density which weaken the achilles tendon and make it less elastic (click here and here for more info)
Demarcus was 27 at the time of his injury but it’s quite possible his achilles tendon had a higher rate of degenerative changes from the wear and tear that comes with playing basketball for an extended period of time and intensity.
Regardless of why, the stress from Demarcus’ rotating with his left foot and pushing off was too much for his achilles to handle, and the damage was done. At that point, he was likely experiencing some of the following…
IV. The symptoms of an achilles rupture
An achilles rupture is characterized by the following symptoms:
- You may feel or hear a “pop” or feel like someone kicked you in the back of the leg
- Pain with walking or an inability to walk
- A gap or indentation in the achilles tendon. It looks like this:
- Significant weakness or inability to plantar-flex (point your foot downwards)
- Squeezing the calf doesn’t result in plantar-flexion. This is known as the Thompson test. Go to the :40 mark of the following video:
These are all indicators of an achilles rupture and the Thompson test is an extremely reliable means of diagnosing the rupture. It’s then confirmed or denied by using an MRI, the gold standard for achilles rupture diagnosis.
Additionally, an MRI will inform you of the specific extent and grade of achilles rupture, which are…
V. Different grades of Achilles Rupture
There are 4 general categories of achilles rupture:
- Type I: partial rupture with less than 50% of the fibers torn. Think of this like a rope that has partially frayed.
- Type II: complete rupture with a gap ≤3 cm. This rope is completely torn but the ends aren’t that far apart.
- Type III: complete rupture with a gap of 3 to 6 cm. This rope is completely torn and the ends are pretty far apart. This often requires surgery using a tendon graft (taking a tendon from a different part of your body or cadaver)
- Type IV: complete rupture with a gap of >6 cm. This rope is fully torn and the ends are very apart, often because the injury was neglected and did not receive appropriate medical attention. This almost always requires surgery.
I haven’t been able to find any specific information on whether Demarcus Cousins had a type II or III rupture but an MRI did confirm a full achilles rupture. After MRI confirmation, Demarcus Cousins moved onto the next step…
IV. Achilles rupture protocol
There’s still debate as to whether a non-operative (conservative) or operative (surgical) approach is optimal following an achilles rupture.
For most people, the conservative route results in similar outcomes to the surgical route. The risk for re-rupture is slightly higher in the former but there’s also less chance of infection (click here, here, here, here, and here for more info)
There are multiple types of achilles surgery but the goal is the same: re-connect the tendon and make sure the tension level is similar to where it was pre-injury.
Here’s one example of what surgery may look like (work-safe):
After surgery was complete and the tendon reconnected, Demarcus Cousins moved onto rehab and recovery…
V. Demarcus Cousins rehab and return to play timeline
Generally, research has shown that the average return to play timeline after achilles rupture is roughly 6 months. However, NBA players (using data from 2005-6 and onwards) have taken about 10 months on average.
That would put Demarcus Cousins return around late November 2018.
I view rehab and recovery as a mosaic. Honing in on only tile limits our full view of the composition. Therefore, I’ve organized that full mosaic of Demarcus’ ongoing rehab and recovery into a holistic micro (tissue), mezzo (systemic), and macro (contextual) model.
A. Micro (tissue)
The paradigm of Achilles rupture rehab after surgery is shifting towards earlier and earlier weight-bearing. More and more evidence is showing that earlier weight-bearing results in improved tendon healing with no increase in the risk for re-rupture.
Multiple rehab protocols exist and the general theme is similar (keep in mind, these are rough timeframes that can certainly vary):
- From post-op to 3 weeks
- Control swelling and protect the incision site
- Minimize scar adhesions
- Progress weight-bearing as tolerated
- Increase range of motion
- Gain near normal strength in all lower body muscles except the plantar-flexors
- Pain at or less than 5/10
- From 3 weeks to 6 weeks
- Full ankle range of motion
- Full strength in lower body
- Able to complete normal activities of daily living (ADLs)
- Less than 2/10 pain reported
- 6 weeks to 15+ weeks
- Progressive loading and strengthening
- Increased intensity of activity (like starting to run)
- Adding variety of activity (like introducing agility training)
Demarcus Cousins is a little over 5 months since his achilles surgery so he’s definitely into the last phase. We can gain some further insight from the Instagram pictures and videos he’s been posting as well.
He’s been loading the achilles with eccentric controlled movements (ex: reverse step-downs) and functional movement (ex: progressively faster running)
And within the last 2 weeks, he’s increased the intensity of his functional movements (ex: jumping in the pool) while getting back to limited on-court activities:
Here’s what Demarcus Cousins had to say on July 6th when he was asked about his rehab:
“The healing part is over, it’s just about building strength”
B. Mezzo (systemic)
There are numerous systems which can affect recovery and unlock significant gains. Humans are an ecosystem so nothing can be considered in isolation.
1 – Bio-mechanics and movement patterns
- Re-training and establishing normal walking as quickly as possible is critical. This is a primary focus in the first 3 weeks of rehab.
- As Demarcus returns to full training, addressing any movement patterns which may increase stress on the achilles, such as:
- Over-striding aka reduced knee flexion (bending) during walking and running. This picture is a good visual of over-striding:
- Increased duration of pronation (the foot and arch going flat) or supination (the foot and arch going up). Pronation or supination themselves aren’t an issue (very common misconception), rather it’s how long either of the phases occur for. This is commonly due to poor foot/ankle muscle strength or joint mobility.
- Here’s a video of pronation and supination (the arch going up):
2 – Sensory systems, specifically his proprioceptive and vestibular systems
- These systems are responsible for providing feedback to Demarcus’ brain about where his body is in space. Based on this feedback, the brain makes little adjustments and activates certain muscles to make movement more efficient, effective, and safe. Here’s a picture of the vestibular (inner-ear) system:
and the proprioceptive system:
- The proprioceptive system can be directly affected by injury as it uses receptors near the muscles for feedback. These can be impaired by stretch and swelling.
- Proprioception and vestibular training will begin within the first 3 weeks after surgery and be incrementally progressed
- Neuromuscular control (aka motor control) is the unconscious process through which muscles are timed and activated to control dynamic joint stability.
- Increased strain on the achilles has been linked to a delayed onset and/or shortened duration of muscle activation, specifically these 3 muscles:
3 – Central nervous system (CNS)
- The CNS is comprised of two systems: the sympathetic nervous system (SNS) which creates the stress or “fight or flight” response, and the parasympathetic nervous system (PSNS) which creates the relaxation or “rest and digest” response.
- A ramped up SNS makes healing and injury rehab more difficult by affecting you cognitively, physically, and emotionally.
- Cognitively: The brain’s main role is to anticipate and prepare for threat. When you’re stressed, the brain is on high alert which creates a heightened sense of threat and fixation on problems. In turn, the brain sends out more pain signals (aka MORE PAIN) to alert the body
- Physically: Stress results in a multitude of physical changes including increased systemic inflammation, increased muscle tension, deregulated immune response, etc. Each of these negatively impacts healing.
- Emotional/Behavior: Stress can alter major health drivers like sleep, nutrition (“binge-eating” for example), and exercise patterns. Changes in these key areas exacerbates all other existing issues.
C. Macro (contextual) factors
1 – Family, team, and social support
Rehabbing from an injury as a professional athlete can be a very lonely place. It’s just you and the medical staff (often times the same person) for long periods of time, days on end. Therefore, it’s really important to stay connected and have a support system to keep the spirits and motivation up.
From what I’ve seen, Demarcus does have that solid support system around him. Here he is enjoying time with his son:
And sitting alongside his teammates while cheering them on (and possibly mad-dogging someone):
2 – Resiliency and mindset
If there’s one thing I was worried about with Demarcus it was how he’d react to the injury and what his mindset would be going forward. There are countless examples of him, on and off the court, lashing out or being angry and vindictive. That kind of reaction and mentality can undermine healing and recovery.
I can’t emphasize strongly enough (all caps maybe?) how a resilient mindset can completely alter the course of therapy and rehab. The mindset of viewing an injury as a depressing obstacle vs viewing it as a new challenge alters the lens of recovery, commitment, and motivation.
Fortunately, Demarcus Cousins seems to have taken his achilles rupture as a challenge. In his own words, “the resurgence begins”:
3 – Contract Uncertainty
As I touched on in the opening, Demarcus Cousins went from likely getting maxed out by the Pelicans to not having a contract at all. His achilles rupture couldn’t have come at a worse time.
Most humans don’t like uncertainty, especially financial uncertainty, and the feelings of “why me” are all too natural, especially for Demarcus who has worked his entire life for that reward and abruptly had the rug pulled out.
These feelings of doubt and negativity can and will creep into your rehab and impact your healing environment if they aren’t dealt with swiftly. However, Demarcus has kept a positive mindset that is brimming with perspective. This video is a great example of that:
So that’s the micro, mezzo, and macro layers of his ongoing recovery. But once he does get back, what are the performance and longevity implications of his achilles rupture?
VI. Long-term implications
There are considerable long-term implications after an achilles rupture.
Many studies have followed individuals after achilles rupture and the results don’t paint a rosy picture. Although 80% of individuals returned to following an achilles rupture, there’s evidence of long-term changes in muscle strength, endurance, muscle activity, ankle range of motion, and calf atrophy – for up to 10 years after the rupture (click here, here, here, and here for more info). In the case of athletes involved in running, bio-mechanical and muscle deficits can persist for up to 4 years after the injury (click here, here, and here for more info).
Further, research has also shed a light on performance effects after the athlete has returned to competitive play.
Of athletes who were able to play at least 2 seasons after returning from the achilles rupture (nearly 57% weren’t able to meet this criteria for a variety of reasons), they participated in significantly fewer games and had significant decreases in secondary measures of longevity and performance metrics after year 1.
HOWEVER, those athletes who were able to play 2 or more years were able to perform at a level commensurate with their non-injured counterparts.
For Demarcus Cousins, the most reasonable comparison is Elton Brand. Both Demarcus and Elton were 27 when they ruptured their left achilles, both high level players who played similar positions, similar years in the league, and both in the same weight class.
Elton went on to play 8 more years, including 81 games in 2010-2011. His achilles rupture occurred in August 2008 so that’s about 2 years after the original injury. Elton’s level of play was never the same but it’s critical to note that he suffered a season-ending torn shoulder labrum in February of the 08-09 season. That undoubtedly complicates a return to his prior level of play.
Elton has been very candid with how his achilles rupture affected his game. Here are some choice quotes:
That Achilles really changed the trajectory of my career. That whole kinetic chain: once you get the calf, it’s the ankle, the knee, the hips, the back.
I had a few serviceable seasons, but I wasn’t the same guy. I still had the atrophy on my left calf — which was my power leg — from that Achilles
That being said, Elton’s achilles rupture was nearly 10 years ago and achilles tendon protocols have come a long ways. For example, the most recent NBA example of an achilles rupture (also the left side) and return is Rudy Gay. He was injured in mid-January 2017 and returned early October for a pre-season game – about 8.5 months.
Rudy’s minutes per game were significantly lower than previous seasons (as they should be, any player coming back from long-term injury has a re-acclimation process) but his numbers, per 100 possessions, were right around his pre-injury levels. However, he missed significant time with “right heel soreness” (if you already forgot, 25% of individuals with an achilles rupture develop problems in the opposite achilles or knee).
Additionally, Rudy Gay has stressed that recovering from his achilles rupture is still an ongoing daily mental battle:
On returning from his Achilles injury, Rudy Gay said he doesn't think his battle is over yet – he's still battling. Said the toughest part is mental. "No matter how hard you wanna push yourself, you can't."
— Sean Cunningham (@SeanCunningham) December 23, 2017
Comments like these continue to show and reinforce how important the mental aspect of recovery is. Thankfully, we’re seeing more and more players and the league, in general, acknowledge the mental side instead of stigmatizing it. So in case you were wondering why I always detail the mental aspects, there you go :).
Lastly, there’s an increased chance for re-rupturing the achilles tendon. Overall, there’s about a 10% chance of re-rupturing the achilles. However, recent studies show that the early weight-bearing rehab protocol decreases that risk to roughly 4%.
So here’s the reality for Demarcus Cousins after suffering an achilles rupture: Odds are that his first two years back will be subpar compared to his pre-injury level. However, if he’s able to make it through those 2 years without a major setback, he could return to being a top level center and player in the league.
With that in mind, I think he found a great fit for his rehab & recovery timeline by signing with the Warriors where he has no pressure to return too quickly and doesn’t need to carry much, if any, burden.
Here’s Demarcus Cousins preaching patience:
“I was aiming for training camp, but I’ve communicated with the (Warriors) staff and the coaches, and it’s kind of up in the air…It will be when I’m ready, 100 percent ready, and we’ll take it from there.”
“I’m coming in just playing my part…I don’t have to be the guy every night. I’ve dealt with that my entire career. I’ve always wanted a team where everything doesn’t rely on me, and now I’m in that position”
If I was his advisor and he didn’t get any major contract offers after next season, I’d suggest signing another year with the Warriors to get completely back to 100%, while shedding the “knucklehead loser” label that has followed him around for years.
VII. All in all
Overall, an achilles rupture is a brutal injury – regardless of when it happens or who suffers it.
For Demarcus, it could be especially devastating due to his size and weight which puts more stress on the achilles tendon (and body in general), his age (approaching 30) where wear and tear on the achilles really begins to manifest regardless of injury history, and potentially costing him and his family guaranteed long-term financial security.
That being said, Demarcus does have key positive attributes around him that bode well for his return. He has has full access to a medical staff 24/7, has a very supportive and positive environment around him, has shown a mental resiliency and motivation to return, and after signing with the Warriors doesn’t have to worry about rushing back or carrying a huge burden when he does get back.
Only time will tell but it could easily take 2+ years for Demarcus Cousins to return to his All-Star form. Even if that timetable turns out to be true, I’d consider it to be a W.
Thanks for reading, until next time.
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