Buffalo Bills DE Bryan Cox Jr.’s Achilles injury outlook

During minicamp last week, it was reported that Buffalo Bills defensive end Bryan Cox Jr. went down with a left foot/leg injury, requiring the assistance of teammates and the cart to get off the field. Since then, things had been quiet at One Bills Drive, suggesting that the injury may have not been an issue.

However, Tuesday afternoon consisted of several roster changes that revealed the severity of Cox’s trauma—a left Achilles injury.

According to Instagram, Cox went in for surgery earlier that day, but specifics were not known. While it was later designated an Achilles, historical reporting of the injury suggests that it was a partial or full rupture or tear of the tendon, ultimately requiring a repair. He has been placed on injured reserve with a questionable NFL future.

Achilles Anatomy

The Achilles tendon is a band of connective tissue that connects the gastrocnemius to the calcaneus, allowing the foot to plantarflex or point down. This is essential during walking, jumping, running, and sprinting.

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A rupture of the Achilles tendon occurs when an eccentric load is placed through the area, overloading the muscle, resulting in the tendon tearing. This commonly occurs when a player is trying to push forward but gets driven back such as blocking on the offensive line, cutting hard and pushing through the foot as one would see in a running back, or landing from jumping in the case of a defensive back.

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These movements could lead to forceful dorsiflexion or the foot moving upward. This could also occur if the knee is extended and placing excess force through the front of the foot, overstressing the Achilles area.

Risk Factors for Achilles injury

Several risk factors can cause the tendon to rupture but are not typically seen in young athletes as these are systemic issues of diabetes, lupus, or gout. Obesity can increase the risk of injury, but obesity alone would not be a determining factor.

These injuries are sudden and typically come without warning, which makes this injury all the more devastating. There is usually a loud pop and immediate pain as if the person was stabbed or shot. Weakness and the inability to flex the foot down are common symptoms and swelling and a possible gap in the tendon when palpating the area.

Typically, Achilles tendon tears are easy to diagnose with the Thompson test. This is when the person is placed into a prone position and the lower leg hanging off the table. The calf muscle is squeezed and a positive test is when the foot does not plantarflex when the muscle is contracted due to the squeeze.

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Rehab timeline and re-injury rates

Surgery and rehabilitation take roughly six to nine months to return to normal activities with some taking up to a year to fully return to form. There are non-surgical options but only recommended for someone who would not be a good surgical candidate.

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A return to the NFL and high-level activities have historically taken longer. Return to play rates do vary but levels as high as 78 percent have been reported within the NFL according to studies. The average amount of time takes 8.9 months with some return as quickly as 5.5 months.

There have been advances that have shaved the return to play in the NFL down to six to eight months due to a more aggressive rehab. Improvement in performance following the injury has been observed, suggesting that this isn’t as much of a career ender as before. Return to play rates are north of 80 percent, according to The Athletic.

The rate for tearing the opposite side following an initial tear of the Achilles is roughly five to six percent with concerns to re-tear at its highest up to three to five years out from the original injury. However, once repaired, the risks to re-tear the same side are roughly one to two percent. Rates as high as 15 percent to re-tear the Achilles have been reported within the NFL, though it’s important to note that this was 12 out of 80 players over a six-year period.

Return to play and performance

Former Baltimore Ravens linebacker Terrell Suggs famously returned in five months and six days, though he was only a partial tear. Others have returned and were productive as noted in the linked article including former Bill Takeo Spikes.

On the other hand, former Bill Shawne Merriman also suffered a partially torn Achilles, and returned, but retired within a year of return. Most recently, Eagles guard Brandon Brooks suffered a torn Achilles in 2018, returned in eight months for the 2019 season to play all 16 games before tearing the other side in 2020.

Once a player does return, the quality of play is noted to decrease, taking a full year at minimum to return to pre-injury levels. One concern for Cox is that those players who fail to return typically were utilized less frequently and had poor defensive performance statistics before the injury, indicating less talented players were more greatly impacted. Unfortunately, he fits that profile, suggesting that his time in the NFL may come to an end if he can’t prove he can effectively recover.

Career outlook

This was a highly unfortunate injury for Cox to suffer as he battled for a spot on the roster or practice squad. He already had a tough road to the roster, but it wasn’t impossible to suggest he could have stuck around.

It’s possible he could return in late December or January, but that is absolutely the best-case scenario—and that there is a dire need for players at his position. This would also suggest that he had a partial tear versus a full tear.

Even if things go exceptionally well, I’d still question how effective he could be especially as a defensive end requiring a first quick step off the line returning that soon. With the likely continuation of the practice squad rules and freedom with returning from injured reserve, this does open the possibility that he could return if needed. Regrettably, I anticipate that he takes the season to fully rehabilitate and maximize his chances to play football in 2022.

Outside of ensuring that Cox fully recovers, the Bills don’t have a lot invested in him to rush him back. This injury may spell the end of his time in Buffalo and potentially his NFL career unless he can show a team he’s worth keeping around once cleared to return.

Surgical and rehab techniques have improved over the years giving Cox the ability to maximize his recovery and continue playing. This is a difficult injury to recover from and I wish him the best of luck.