About Achilles Tendon Rupture

An Achilles tendon rupture is a full or partial tear of this tendon that occurs when it is stretched beyond its capacity, which is the large tendon that connects the calf muscles to the heel bone. The Achilles tendon is the largest and strongest tendon in the body, attaching the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus).

Common Symptoms

• Sudden sharp pain in the back of the ankle or calf, often described as feeling like being kicked
• Swelling and inability to bend the foot downward or push off the injured leg
• A popping or snapping sound may be heard at the time of rupture

Cause & Anatomy

• Sudden increase in stress on the Achilles tendon, such as forceful jumping, pivoting, or accelerating during sports
• Falls, tripping, or stepping into a hole that causes the tendon to overstretch
• More common in men aged 30-40 years and “weekend warriors” who don’t train regularly
• Certain medications like steroids or fluoroquinolone antibiotics can weaken the tendon
• Other risk factors include age, obesity, and recreational sports with running/jumping

Diagnosis

• Physical exam to check for a defect or gap in the tendon and limited range of motion
• Imaging like ultrasound or MRI may be done to confirm the diagnosis and evaluate the extent of injury

Prevention

Gradually Increase Activity

• Start new physical activities gradually and ease into advanced intensity levels
• Avoid sudden increases in repetitive stress on the Achilles tendon
• Gradually build up pace, distance, and duration when conditioning for a sport

Proper Footwear

• Wear shoes with adequate cushioning, arch support, and appropriate for the activity
• Replace worn-out shoes regularly, especially if the heel is worn down
• Avoid running on slippery, hard, or uneven surfaces that increase injury risk

Stretching and Strengthening

• Stretch the calf muscles and Achilles tendon daily, especially before and after exercise
• Use slow, even stretches instead of bouncing
• Strengthen the lower leg muscles through exercises like calf raises
• Eccentric strengthening exercises involving a slow lowering of weight can be especially helpful

Cross-Training

• Replace some high-impact activities with low-impact options like swimming or cycling
• Alternate between high- and low-impact sports if at high risk for rupture

Warm-Up and Cool-Down

• Allow time to properly warm up before activity
• Ice the Achilles tendon for 15 minutes after exercise or if pain occurs

Other Tips

• Avoid activities that excessively stress the Achilles tendon like hill running and jumping if at high risk
• Maintain a healthy weight to reduce stress on the tendon
• Seek prompt treatment for any Achilles tendon pain or swelling to prevent progression to a rupture

Treatment

• Nonsurgical with immobilization, or surgical repair of the torn tendon ends
• Choice depends on age, activity level, severity of tear, and other factors
• Physical therapy is essential for rehabilitation after either treatment approach

Surgery

Surgical Techniques

• Open repair – surgeon makes an incision on the back of the calf to access the torn tendon, remove damaged tissue, and repair the tear with sutures
• Percutaneous repair – several small incisions are made to pass tools and sutures through to repair the tendon, minimally invasive approach
• Tendon transfer – if the Achilles tendon is severely damaged, part of another tendon (flexor hallucis longus) may be transferred to reinforce it

Procedure

• Surgery is typically done on an outpatient basis and takes 30-60 minutes
• Spinal anesthesia with sedation is commonly used
• Incisions are made to access the damaged tendon, which is then repaired with sutures
• The incision is closed with sutures and the leg is immobilized in a splint or cast

Rehabilitation

In summary, Achilles tendon rehabilitation has evolved from strict immobilization to accelerated protocols allowing early motion and weightbearing. This appears to be safe and may provide faster functional recovery, but does not seem to impact long-term patient-reported outcomes. Rehabilitation is progressed through phases based on criteria rather than strict timelines.

Phases of Rehabilitation

• Phase 1 (0-2 weeks): Non-weightbearing, immobilization in plantarflexion splint/cast
• Phase 2 (2-4 weeks): Initiate protected weightbearing in boot, active dorsiflexion to neutral
• Phase 3 (4-8 weeks): Wean out of boot, progress weightbearing, begin plantar flexion
• Phase 4 (8+ weeks): Normalize gait, single leg balance, strengthening

Immobilization vs Early Motion

• Traditionally, 6-8 weeks of non-weightbearing immobilization was used
• More accelerated protocols allow early ankle motion and weightbearing
• Early motion and weightbearing may allow faster return to work and sports

Rehabilitation Goals

• Protect the healing tendon initially while gradually restoring range of motion, strength, and function
• Criteria-based progression through phases rather than strict timelines
• Anticipated return to full activities around 14-16 weeks postoperatively

Exercises

• Gentle active plantar flexion exercises starting 2-4 weeks
• Strengthening exercises like calf raises starting 8 weeks
• Sports-specific drills and return to running around 12 weeks

FAQ’s

Can Achilles tendon injuries be prevented?
Yes, prevention involves warming up before exercise, increasing activity levels gradually, wearing proper footwear, avoiding uneven surfaces, and stopping activities that cause pain.

What are the complications of Achilles tendon injuries?
Complications include pain, difficulty walking or being active, warping of the tendon area or heel bone, tendon rupture from reinjury, and potential complications from treatments like cortisone injections or surgery.

How long does it take to recover from an Achilles tendon injury?
Recovery time varies depending on the severity of the injury and the individual’s overall health. Mild cases may take several weeks to heal, while more severe cases may take several months or even up to a year to fully recover.

Can Achilles tendon injuries be treated without surgery?
Yes, mild cases can be treated without surgery using conservative methods like RICE, physical therapy, and bracing. However, more severe cases may require surgical intervention.

What are the risks of Achilles tendon surgery?
Risks include excess bleeding, nerve damage, infection, blood clot, wound healing problems, calf weakness, and complications from anesthesia.

How can I manage an Achilles tendon injury?
Management involves following a healthcare provider’s advice to get rest, manage pain and swelling, and modify activities to avoid further strain on the tendon.