The strongest and largest tendon in your body, the Achilles tendon is vital for positioning the foot for walking and running. A rupture of your Achilles tendon is common if you are over 40 and participate in sporadic recreational activities. This can be especially true if you are a weekend athlete who is new to a sport or exercise.
The Achilles tendon forms from contributions of the gastrocnemius (visible calf muscle) and the soleus (deeper calf muscle) muscles and inserts into the posterior or back of the calcaneus (heel bone). There is a decreased blood flow in the midportion of the Achilles tendon in an area known as the hypovascular zone, which is where most tendon ruptures occur. Doctors treat Achilles ruptures with nonsurgical techniques or by performing surgery.
Screening and diagnosing your injury
A patient with a ruptured Achilles tendon will generally complain of an abrupt snap in the calf area followed by intense pain. Patients often describe the feeling of being kicked, cut, or shot behind the leg when the injury occurs. You may not be able to bear weight on the affected leg to walk, run, or raise up onto your toes. There will often be marked swelling at the site of rupture and assessment will reveal discontinuity or a gap where the tendon should be.
While the doctor accesses your injury, he or she will rule out other possible injuries, such as an ankle fracture. When an orthopaedist suspects a rupture, he or she may perform the Thompson test during the clinic visit. If you cannot plantarflex (point your toes to the ground) while squeezing your calf, it reflects the telltale sign of an Achilles rupture. Often, the results are enough to make the diagnosis without further testing; however, physicians usually confirm the diagnosis with radiological imaging, such as an x-ray or MRI scan (magnetic resonance imaging test that show the bones, muscles, tendons, and ligaments).
Causes
The causes of Achilles tendon rupture include direct trauma, abrupt forced plantarflexion (forcefully and suddenly pointing the foot downwards), excessive pronation (foot rolling inwards), and chronic degeneration of the tendon.¹ Certain sporting activities are associated with rupture of the Achilles, such as track and field, volleyball, diving, basketball, running, cycling, and tennis. The risk factors for a rupture of the Achilles tendon include overexertion, poor warm-up or conditioning before exercise, extended use of corticosteroids, and the use of quinolone antibiotics² (treats bacterial infections). There are also certain factors related to the foot and ankle that increase the risk of tendon rupture such as a cavus (high arched) foot type, decreased flexibility of the gastrocnemius (calf muscle) and reduced dorsiflexion (ability to draw toes towards your shins) of the ankle. Patients who have had an Achilles tendon rupture in the past are more likely to have a repeat rupture on the contralateral, or opposite side.³
Treatment
With an Achilles tendon rupture, you should seek medical attention immediately. Early treatment involves pain control, rest, elevation, and bracing of the ankle. For elderly patients who have multiple medical conditions and live sedentary lifestyles, nonoperative management can be the best option. Your doctor may recommend surgical treatment if you are a highly active individual; however, treatment is unique for each patient. Overall, studies have shown good functional results and patient satisfaction with both nonoperative and operative treatment.¹ Nonoperative treatment involves casting or functional bracing for a period of 6 to 12 weeks. Surgical management involves several ways of re-approximating (joining the 2 ends together) the severed ends of the Achilles tendon followed by a cast or rigid orthosis. Regardless of the treatment, physicians usually recommend that patients use an orthotic and start physical therapy after removal of the cast to improve the range of motion of the ankle and strengthen the muscles.4 Your physical therapist can recommend a slow resumption of activities such as swimming and walking before fully returning to sport. The healing rates between surgical and nonsurgical treatments are roughly the same although the return to work can be longer in patients with nonoperative treatment.
Outcomes
The prognosis for patients with Achilles tendon rupture is excellent; however, some patients may experience a reduced range of motion in the ankle. Most active patients can resume their sport without limitations. It is important to note that nonoperative treatment carries a rerupture rate of nearly 40% compared to surgical treatment with only a 0.5% rate.5 Some patients may experience delayed wound healing following surgery, especially patients who smoke and are using corticosteroids. By instituting a thorough warm-up regimen, gradually increasing the intensity of workouts, and stretching before engaging in physical activity, you will reduce the risk of another Achilles tendon rupture.
Author: Stacey D’Almeida, MD | Canberra, Australian Capital Territory, Australia
References:
- Shamrock AG, Varacallo M. Achilles Tendon Rupture. StatPearls. Published online February 12, 2022. Accessed November 15, 2024. https://www.ncbi.nlm.nih.gov/books/NBK430844/
- Kraemer R, Wuerfel W, Lorenzen J, Busche M, Vogt PM, Knobloch K. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: A matched pair analysis. Archives of Orthopaedic and Trauma Surgery. 2012;132(6):847-853.
- Årøen A, Helgø D, Granlund OG, Bahr R. Contralateral tendon rupture risk is increased in individuals with a previous Achilles tendon rupture. Scandinavian Journal of Medicine and Science in Sports. 2004;14(1):30-33.
- Haapasalo H, Peltoniemi U, Laine HJ, Kannus P, Mattila VM. Treatment of acute Achilles tendon rupture with a standardised protocol. Archives of Orthopaedic Trauma Surgery. 2018;138(8):1089-1096.
- Saxena A, Ewen B, Maffulli N. Rehabilitation of the Operated Achilles Tendon: Parameters for Predicting Return to Activity. The Journal of Foot and Ankle Surgery. 2011;50(1):37-40.
Last edited on December 10, 2024