Achilles tendon rupture: Throw the kitchen sink at it

An Achilles tendon rupture is a partial or complete tear of the Achilles tendon, which is the large tendon that connects the calf muscles (gastrocnemius and soleus muscles) to the heel bone (calcaneus). As the muscle and tendon complex crosses two joints (ankle and knee), the tendon can be exposed to a lot of load if both joints simultaneously move in opposite directions (ie knee extension and ankle dorsiflexion). Typically the tendon ruptures rupture usually occurs 4-6 cm above where it inserts into the calcaneus as there is not a lot of blood supply to that area.

Causes of an Achilles Tendon Rupture

The cause of an Achilles tendon rupture include a sudden forced plantar flexion of the foot, especially when the knee is extended. Direct trauma can also cause it. Sports often associated with an Achilles tendon rupture can include soccer, basketball, football and racquet games.

Risk factors for a rupture of the Achilles tendon include a pre-existing tendinopathy or tendon degenerative; being over 40 yrs of age; inadequate conditioning and training before exercise; the prolonged use of corticosteroids drugs, fluoroquinolone antibiotics and some medical conditions such as diabetes and hyperparathyroidism. There are also genetic factors related to Achilles tendon rupture. The ‘weekend warrior’ type of athlete also appears to be more prone to this because of the episodic involvement in sport meaning that the tendon is probably not adequately conditioned.

Symptoms of an Achilles Tendon Rupture

People usually know that they have ruptured their Achilles tendon. They will often recall a precipitating event such as reaching for a tennis shot or going for the ball in basketball. There can often be a feeling of a popping or snapping sensation. There will be pain and swelling behind the ankle joint and difficulty raising up on the toes. Sometimes it may be possible to palpate deficit or gap in the tendon. The Thompson’s test can be used – to do this the person is laying face down and you squeeze calf. If the foot doesn’t plantarflex, then the Achilles tendon could be ruptured. They can sometimes be misdiagnosed as an ankle sprain initially.

Treatment of an Achilles tendon rupture

Immediate: Ice, compression, elevation. Stay off it. Get some crutches or a wheelchair.

Next Step: There is quite a bit of discussion and debate about the conservative versus surgical management. At the moment, provided there is adequate rehabilitation, all the research pretty much shows that the outcomes between the two approaches are about the same. That research can be followed here. It was or is widely believed that surgical repair is associated with a lower risk of re-rupture, but it has been shown that this is not the case if there is adequate rehabilitation of the non-surgical cases. It may be the case if the rehabilitation is inadequate.

Conservative: As well as continuing with the ice, compression and elevation, a walking boot (moon boot, brace) is used for up to 4 weeks.

Surgical: There are a number of different procedures that can be ‘open’ or minimally invasive. The choice of procedure will depend on the surgeons experiences and preferences as well as the about of gap between the ends of the ruptured tendon and how long it has been since the rupture occurred.

Rehabilitation: Whichever approach is taken to the management, the proper rehabilitation is very important. Following the use of the walking brace or surgery, there needs to be a very slow and gradual increase in “unprotected” weight bearing, probably with the use of heel lifts or raises in the shoes. With time the amount of weightbearing is increased and the heel lifts removed. After that there is a slow introduction of low impact exercise and strengthening exercises for the calf muscles and Achilles tendon. Everyone is going to be different and need to be guided by a physiotherapist, but expect this entire process could take up to 6 or so months.

Return to sport: The research has shown that an average of 80% of people return to sport following and Achilles tendon rupture. The mean time to return to sport was 5 months.