Achilles Tendon Rupture

Anatomy of the Achilles tendon

The Achilles tendon is a large tendon at the back of the ankle. The tendon is an extension of the
gastrocnemius and soleus (calf muscles), running down the back of the lower leg to attach to the calcaneus (heel bone). The Achilles tendon connects the leg muscles to the foot and provides a powerful propulsive force during walking and running.

Achilles Tendon rupture

An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden acceleration with running, can overstretch the tendon and cause a tear. Recreational sports that may cause Achilles rupture include tennis, football, basketball and gymnastics.

An injury to the tendon can also result from falling or tripping. Achilles tendon ruptures are most often seen in ‘weekend warriors’ – typically, middle-aged people participating in amateur sports or fitness exercises. Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.

When the Achilles tendon ruptures, most people describe severe pain in the back of the leg above the heel, along with swelling, stiffness, and difficulty with walking. A popping or snapping sound or sensation is also commonly described at the moment of injury.

Diagnosis

An Achilles tendon rupture is diagnosed based on symptoms, history of the injury and physical examination. It is common to feel a gap or depression in the tendon, usually a few centimetres above the heel bone. A gentle squeeze of the calf muscles (Thompson test) will cause flexion of the foot with an intact Achilles tendon, but no movement of the foot if the tendon is ruptured.

Treatment

Achilles tendon ruptures can be treated using either surgical repair or non-operative functional bracing.

Achilles tendon surgery

Surgical repair of the ruptured tendon provides immediate strength to the rupture site and apposition of the tendon ends.

Surgical repair is done under a general anaesthetic in a prone position. An incision is made at the back of the calf at the tendon rupture site, and the torn ends of the tendon are sutured back together. Traditionally a large incision (~10cm) was required in order to fully expose the torn tendon ends and repair them.  Newer surgical equipment now allows for minimally invasive repair of some types of Achilles tendon ruptures, using a much smaller incision (2-3cm).

After surgery, the foot is placed into an Achilles boot (VACOped). A graduated rehabilitation program is then commenced with progressive weightbearing, range of movement, and strengthening exercises. The boot is generally on for up to 6 weeks, and patients can return to light jogging from about 4 months post-operatively, and return to sport from around 6 months.

Surgery does carry small risks, mainly the chance of wound infection or breakdown. The chance of re-rupture of the tendon in the future is slightly lower with operative repair. There is also less chance that the tendon will heal in an elongated position.

Functional rehabilitation (non-operative treatment)

Non-surgical treatment involves a graduated rehabilitation program using a special Achilles functional brace (Achilles VACOped boot).  The boot is on for 10 to 12 weeks, with progressive weightbearing, range of movement and strengthening exercises.

Most of the risks of surgery are avoided with non-operative treatment, but the rehabilitation can be a little slower, and the risk of the tendon re-rupturing or healing in an elongated position is slightly higher. Some patients should be treated non-operatively, such as those who smoke cigarettes, are immunocompromised, have poor quality skin or are diabetic.

The ultimate goal of either treatment regime is to get you back to your pre-injury level of athletic function.

Prevention

To help prevent an Achilles tendon injury, it is a good practice to perform stretching and warm-up exercises before participating in any exercises or sports activities. Gradually increase the intensity and length of time of activity. Muscle conditioning may also help to strengthen the muscles in the body.

• Dr Zilko’s Achilles Tendon Surgery Rehabilitation Protocol
• Dr Zilko’s Achilles Tendon Functional Rehabilitation Protocol

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