Achilles Tendon Rupture

Picture 1 shows the usual site of Achilles tendon rupture.

Rupture of the Achilles tendon is not uncommon in healthy, active individuals. The rupture is typically spontaneous and most commonly observed in individuals between 24-45 years of age. The majority have had no prior history of pain or previous injury to the tendon. In the majority of cases, rupture of the Achilles tendon occurs 2-6 cm above the insertion of the tendon into the heel bone.

Most commonly, the Achilles ruptures when there is a sudden, forceful movement of the foot downward against resistance, such as when an individual pushes off the foot with great force to jump. This often occurs in sports like basketball, tennis, or football.

There are other causes of pain at the back of the heel than Achilles tendon rupture. It may be due to retrocalcaneal bursitis where inflammation occurs within the sac that cushions the tendon as it passes the bony edge of the heel bone. Paratenonitis is inflammation of the tendon sheath that surrounds the length of the tendon. The treatment for bursitis and paratenonitis incorporates rest, exercise, and occasionally physical therapy.

About 1 million athletes a year develop Achilles tendon inflammation or rupture. Achilles tendon rupture tends to occur in athletic people between ages 30 and 50 and mostly in men (6:1 men: women). There may be an anatomical reason for the predominance of men. Achilles tendons in women have a smaller area and are thinner and there may not be enough force generated to cause a rupture.

The Achilles tendon forms from two muscles in the back of the calf, the gastrocnemius and the soleus, about 15 cm to 6 inches above the ankle joint and spirals as it crosses the ankle joint to attach to the heel bone (calcaneus). A sheath surrounds the tendon, allowing it to glide easily as the ankle moves through its range of motion.

Since the calf muscles originate above the knee and the Achilles attaches below the ankle, the function of the muscle-tendon unit is critical for walking and running. When the calf muscles contract, it causes the ankle to point the foot downward and the foot to turn inward and up). (See picture 1.)

The tendon needs to be strong. Running and climbing stairs generate force inside the tendon equal to 10 times the body's weight.

The Achilles tendon receives its blood supply from many sources. Small blood vessels cross the tendon sheath to provide blood and nutrients to the tendon. The tendon sheath also has small arteries that help supply the tendon. However, there is a relative lack of blood supply in the lower part of the tendon just above where it inserts into the heel and this relative lack of blood flow may be associated with the location of the tendon rupture.

Underlying illness or disease may increase the risk of Achilles tendon injury. Examples include the following:

• Diabetes
• Thyroid disease
• Kidney failure
• Rheumatoid arthritis
• Systemic lupus erythematosus (SLE, lupus)
• Gout

Risk factors for Achilles rupture include poor conditioning, corticosteroid medications (either taken by mouth or injected near the tendon), fluoroquinolone antibiotics (ciprofloxacin, levofloxacin), and overuse. A previous ruptured Achilles tendon increases the risk for another, both on the side that was initially hurt, and on the other unaffected side.

Some other risk factors for Achilles tendon injury also include the following:

• Older age
• Activities or sports that involve running and jumping
• Lack of flexibility
• Excessive activity (overuse)
• Sudden changes in the intensity of exercise
• Poor conditioning
• Corticosteroid use (either by mouth or by injection)
• Fluoroquinolone antibiotics
• Poorly fitting shoes
• Jogging or running on hard surfaces
• Hill climbing or stair walking
• Previous Achilles tendon injury
• Family history

The symptoms of a rupture include acute sharp pain in the back of the heel and inability to plantar flex the foot (pushing on the gas pedal of a car motion). The victim may remember hearing a snap when the injury occurred. Because there is an imbalance between the muscles that push the toes down and those that pull them up, walking becomes difficult with the pain and because the foot will drag.

Sometimes the tendon does not fully rupture but only partially tears. The symptoms are the same as a complete tear, and a partial tear can progress to a complete rupture. While the Achilles tendon rupture usually occurs near the insertion in the heel, it can occur at any location along the course of the tendon.

Background history

• Patients with an Achilles tendon rupture will often complain of a sudden snap in the back of the leg. The pain is often intense and patients will describe it as if being shot.
• With a complete rupture, the individual will only be able to ambulate with a limp. Most people will not be able to climb stairs, run, or stand on their toes.
• Swelling around the lower calf may occur.
• Patients may offer a history of a recent sudden increase in exercise or intensity of activity.
• Some patients may have had a recent corticosteroid injection or prescription or a course of fluoroquinolone antibiotics.
• Some athletes may have had a prior tendon inflammation or injury.

Physical exam

• The health care provider will generally examine both legs.
• A healthcare professional examines the lower leg for swelling, bruising, and tenderness.
• If there is a complete rupture of the Achilles tendon, a physician can palpate a gap or defect within the tendon.
• Range of motion of the ankle will be lost and the patient will have difficulty moving the ankle and foot.
• The Thompson test helps confirm the diagnosis:
  • The patient lies prone, face-down.
  • The examiner squeezes the calf area.
    • With an intact Achilles tendon, the foot will plantar flex and the toes point downward
    • With Achilles tendon rupture, the foot does not move
• The healthcare provider may also check for pulses and sensations in the foot.

A healthcare professional makes a diagnosis of Achilles tendon rupture by taking a patient's history and performing a physical exam as noted above. Imaging may be required to confirm the extent of tendon damage and to look for other associated injuries

• Plain X-rays of the foot may reveal swelling of the soft tissues around the ankle, other bone injury, or tendon calcification.
• Ultrasound is the next most commonly ordered test to document the injury and size of the tear. For a partial tear of the Achilles tendon, the diagnosis is not always obvious on a physical exam and an ultrasound may be considered. A healthcare provider or an ultrasound technician and radiologist may perform a bedside ultrasound.
• MRI: Healthcare providers often order an MRI when a diagnosis of tendon rupture is not obvious on ultrasound or a complex injury is suspected. MRI is an excellent imaging test to assess for the presence of any soft-tissue trauma or fluid collection. More importantly, MRI can help detect the presence of tendon thickening, bursitis, and partial tendon rupture.

Picture 2 shows the type of casts used to treat Achilles tendon injury.

Two options exist for Achilles tendon rupture, one involving surgical repair and the other a conservative treatment (allowing the tendon to heal on its own in a cast). Each has its benefits and risks and decisions will depend upon the patient's clinical situation, underlying medical background, the extent of the injury, and the expectation of future activity.

Surgical intervention

Surgery is the recommended treatment for young, healthy, and active individuals. For athletes, surgery is often the first choice of treatment. The Achilles tendon can be repaired surgically by either a percutaneous or open technique. With the open technique, a physician makes an incision to allow for better visualization and approximation of the tendon. With the percutaneous technique, the surgeon makes several small skin incisions to repair the tendon. Irrespective of the type of treatment, a healthcare professional will apply a short leg cast or postoperative boot on the operated ankle after completion of the procedure (picture 3). Each approach has its benefits and risks and the choice of surgery type is individualized for each specific patient.

The advantages of a surgical approach include a decreased risk of re-rupture rate (0%-5%); the majority of individuals can return to their original sporting activities (within a short time), and most regain their strength and endurance.

Disadvantages of a surgical approach include cost, the need for hospitalization, and wound complications (for example, skin sloughing, infection, sinus tract formation, nerve injury

Nonsurgical treatment

Nonsurgical methods may be recommended for patients who are older, less active, and have a higher risk for surgery and anesthetic. The ability to heal wounds is also an important consideration and may include those with poor blood supply to their feet. These include patients with peripheral artery disease and diabetes.

Nonsurgical management involves the application of a short leg cast to the injured leg, with the foot in a slightly downward flexed position. Maintaining the ankle in this position helps bring the ruptured tendon ends closer together to allow them to heal. The leg is placed in a cast for six to 10 weeks and no movement of the ankle is allowed. Walking is allowed on the cast after a period of four to six weeks. When the cast is removed, a small heel lift is inserted in the shoe to decrease the stress on the Achilles tendon for an additional two to four weeks. Following this, physical therapy is recommended.

The disadvantages of the nonsurgical approach include an increased risk of re-rupture (up to 40%), prolonged immobilization in a cast, and increased technical difficulty should subsequent surgery be required.

The benefits include no need for anesthesia or hospitalization, decreased risk of skin breakdown, and decreased risk of nerve damage.

Physical therapy and rehabilitation are necessary after injury to the Achilles tendon. For patients with partial rupture who are managed conservatively, rehabilitation should be started once the pain has diminished. Patients who undergo surgical repair of the Achilles tendon do not need physical therapy during the acute phase of healing, but it is highly recommended once the incision has healed.

Physical therapy is an important part of the post-op recovery for the patient. After the cast is removed, the ankle is gently massaged and mobilized to reduce stiffness. After two weeks, active exercises are undertaken. A total of 12-16 weeks of active physical therapy is required for the best results.

The goal of physical therapy is to return the range of motion of the ankle leg muscle strength to normal. The physical therapist will individualize an exercise program for the patient's specific needs to reach that goal.

Achilles tendon injury requires medical attention, and though not all need surgery, there are no home remedies to cure this injury. However, ensuring a speedy recovery from pain and helping your Achilles tendon heal faster may require a few at-home remedies, such as:

• Calf stretch: Before and after exercise, stretch your calf muscles well.
• Rest: Resting means not putting strain on the Achilles tendon. Make use of orthotic devices such as braces and walking boots while walking.
• Ice: Apply ice packs for 15 to 20 minutes about four to five times a day.
• Compression: Wrapping a compression stocking around the back of your leg or heel helps relieve pain and swelling. Avoid wrapping too tightly because this can hamper blood flow to your tendon.
• Elevation: Raise the affected leg to a height above your chest during daytime napping or while sleeping at night.
• Analgesics: Take over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, as advised by your doctor.
• Physical therapy: Your doctor may refer you to a physical therapist to perform various exercises that can help strengthen your Achilles tendon. Performing these exercises regularly is essential to your speedy recovery from Achilles tendonitis.

Is it okay to walk with Achilles tendonitis?

It is okay to walk with Achilles tendonitis, but most doctors recommend wearing a brace or walking boot to prevent the movement of your heel and help the Achilles tendon heal faster. Your doctor may also recommend you wear a special shoe with a built-in heel, which can help reduce stress on your heel while moving around.

When proper treatment and rehabilitation are undertaken, the prognosis is excellent. The majority of athletes can return to their previous exercise or sports. Those patients who undergo nonsurgical care have an increased risk of repeated rupture.

After surgery, the patient is kept in a cast for four to six weeks, This is followed by physical therapy and assisted range of motion exercises. A heel lift will be put in the shoe to prevent the excessive stretching of the tendon. Return to normal function is expected in four to six months.

With conservative treatment, serial casting occurs. Casts are changed every few weeks, with the foot being placed in less plantarflexion each time. This will occur for six to 12 weeks. After the casting is complete and the tendon is healed, physical therapy will continue to return the range of motion and power. A shoe heel lift will be considered.

The complications of Achilles tendon rupture include tendon scarring and decreased range of motion, as well as muscle weakness.

Tendon re-rupture is a significant concern and can occur in up to 5% of surgically repaired patients and some studies, up to 40% in conservatively treated patients.

Other complications related to surgery include skin sloughing, wound infection, nerve damage, and scarring.

The two most important factors are having strong calf muscles and keeping a close eye on your workload, which can be a difficult balance to strike. The key is to keep your calf muscles strong, but the challenge for runners is to incorporate that into their training routine. The calf can be difficult to target with strength training, but various calf raises should be enough to hit both the deep and superficial muscles. Choose your calf raises based on the location of the pain.

To prevent Achilles tendonitis or rupture, the following tips are recommended:

• Flexibility is an important goal of injury prevention.
• Pain is never normal. If calf or heel pain occurs, consider stopping the activity. If rest does not help and the pain recurs when the activity restarts, seek medical care.
• Let your healthcare provider know if you are experiencing calf muscle or tendon discomfort if you require medications.
• Try to wear good-fitting shoes that are not too worn and are specific to the activity planned.