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Achilles Tendon Rupture

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A total rupture of the achilles tendon is a complete tear of the tendon and typically affects men over the age of 40 involved in recreational sport.

A complete rupture of the achilles tendon is not always recognized at the time of injury, however it is very important it is treated properly as soon as possible to increase the chances of a good recovery.

Symptoms

Symptoms include a sudden sharp pain in the achilles tendon which is often described as if being physically struck by an object or implement. A load snapping noise or bang may also be heard at the time. A gap of 4 to 5 cm in the tendon can be felt which may be less obvious later as swelling increases.

After a short while the athlete may be able to walk again but without the power to push off with the foot. There will be a significant loss of strength in the injured leg and the patient will be unable to stand on tip toes. There may be considerable swelling around the achilles tendon and a positive result for Thompson’s test can help confirm the diagnosis.

Treatment

If you suspect a total rupture of the achilles tendon then apply cold therapy and compression and seek medical attention as soon as possible. In most cases surgery is required and the sooner this takes place the higher the chances of success. If the injury is left longer than two days then the chances of a successful outcome decrease. Cold and compression can also be applied throughout the rehabilitation phase as swelling is likely to be an issue with such a serious injury.

A medical professional will take MRI scans to confirm the diagnosis and indicate the extent of the injury. Sometimes the leg is put in a cast and allowed to heal without surgery. This is generally not the preferred method, particularly for young active people. Surgery is the most common treatment for an achilles tendon rupture. 

You can expect to be out of competition for 6 to 9 months after achilles tendon surgery. This is increased to 12 months if the ankle is immobilized in plaster instead of operated on. There is also a greater risk of re-injury if you do not have the surgery.

A complete rupture of the achilles tendon is a serious injury and rehabilitation should be a very gradual process taking 6 to 9 months.

The following guidelines are for information purposes only. We recommend seeking professional advice before attempting any self treatment.

Aim of rehabilitation

  • To allow the tendon to heal, reducing pain swelling and inflammation.
  • To restore the tendon and muscles to their original flexibility and strength.
  • To gradually return to normal activity and training levels.

There are two methods of treatment; surgical and non surgical or conservative. The speed at which a patient can progress with the rehabilitation will vary and should at all times be done under the supervision of a qualified professional. The timescales indicated below are only a rough guide and you should always take the advice of your consultant.

Surgical approach

The surgical approach is usually the preferred one, especially for young and active people. Immediately following injury the principles of PRICE should be followed which are protection rest, ice, compression, elevation. Go as soon as you can to a sports medicine professional or accident and emergency unit. Surgery will usually be performed within 48 hours or as soon as possible.

Non surgical approach

This will follow a similar pattern to that of the surgical approach although will take a lot longer. A plaster cast will be applied in a plantar flexed position (toes and foot pointing down). Sometimes after four weeks this may be altered to allow less plantar flexion. After 8 weeks the tendon is usually healed.

Rehabilitation program

Week 1 to 8

  • A plaster cast is applied after surgery.
  • No stretching or exercise, just let it heal.
  • You may be able to work the upper body.
  • Try to do something positive, it will certainly help your state of mind.

Week 8 onwards

Stage 1 – range of motion and flexibility.

  • Place heel raises (1-2cm) in the shoes to take some of the pressure off the achilles tendon.
  • Sports massage techniques and ultrasound can aid in this process by helping to realign the new fibres in line with the tendon.
  • Active stretching. Pull your toes upwards to stretch the achilles tendon. Very gently at first and gradually build up.
  • If active stretches produce no pain then passive stretches can commence. This involves someone or something assisting in the stretching process.
  • When a full range of motion has returned (the ruptured leg is as flexible as the other leg) then a gradual strengthening programme can start.
  • Balance exercises should also be introduced as the sense of balance and positioning is often decreased after tendon or ligament ruptures and if not re-gained, can lead to future injuries. Wobble boards (balance boards) are great for this.

Sports massage can play a part in the rehabilitation of this injury by improving blood flow to the area, helping the muscles relax and become more supple.

Stage 2: Strengthen the achilles tendon and calf muscles.

  • Great care must be taken when commencing a strengthening programme. There is a fine line between strengthening the tendon and re-injuring it.
  • You can start strengthening exercises as soon as they can be tolerated. It may be a full month after the cast comes off before exercises can begin.
  • The athlete may feel a little pain when you first start these exercises. If the pain is intolerable then do not continue.
  • Gradually each day the pain should be less. The athlete should not attempt to increase the level of exercise until there is no pain during or after the exercises.
  • The strengthening exercises must be done after a gentle warm up and stretch. The muscles can be warmed up by raising the heels up and down on the toes while seated. Heat applied directly to the tendon for example by a hot water bottle can also help.
  • Flexibility training must be continued throughout.
  • Remember to apply cold therapy or ice after exercise, this will help keep inflammation down.
  • Avoid explosive or ballistic movements or this may lead to a re-rupture.

Return to fitness 

  • When the patient has gone at least a week without pain then they may begin to return to training.
  • If they feel pain when returning to training then stop. Begin each training session with a walk to warm up followed by stretching.

Day 1: walk 4 minutes jog 2 minutes repeat four times

Day 2: rest

Day 3: walk 4 minutes jog 3 minutes repeat three times

Day 4: rest

Day 5: walk 3 minutes jog 4 minutes repeat 4 times

Day 6: rest

Day 7: walk 2 minutes jog 6 minutes repeat 4 times

Continue this gradual progression until you can confidently run and resume normal training.

How long until I am back to full fitness?

  • Most athletes can expect to be out of competition for 6 to 9 months after surgery.
  • This is increased to 12 months if the achilles was immobilized in plaster instead of operated on. There is also a greater risk of re injury if the athlete does not have the surgery.

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Achilles Tendon Rupture

The Achilles tendon is the largest and strongest tendon in the human body.  It is crucial in transmitting forces responsible for walking, running and various other activities.  An injury or tear within the Achilles tendon can cause substantial pain and limitation due to its importance in these daily activities.

Anatomy:

The Achilles tendon is made up of the tendons of the gastrocnemius muscle and soleus muscle, which make up the largest muscles within the calf.  It inserts at the back of the calcaneus (heel bone) and many of the tendon fibers can extend further underneath the heel.  Tears of the Achilles tendon can be partial tears, which only involve a portion of the tendon or complete tears.   Most often a tear occurs in the mid-portion of the tendon, often referred to as the “water shed” area due to its limited blood supply.   It is the limited blood supply that can make Achilles tendon tears challenging and can take an extended length of time to heal.

Etiology:

Tears of the tendon are often a result of indirect trauma.  Overload forces exceed the tensile strength of the tendon which results in tearing of the tendon fibers.  Complete ruptures most often occur in individuals between 30 and 45 years of age with the majority of injuries sustained during sporting activities.  Tendon tears are can also in patients with systemic diseases such as rheumatoid arthritis, lupus, chronic hemodialysis and many others.  Other factors correlated with potential Achilles tendon tears are steroid use, fluoroquinolone antibiotics and previous injury to the tendon.

Symptoms of Torn Achilles Tendon:

  • Pain
  • Swelling
  • Bruising
  • Loss of strength
  • Palpable gap in tendon

Diagnosis:

  • The most crucial step to diagnosis of Achilles tendon tears is a thorough and detailed physical examination.   Patients may not experience complete loss of strength in many instances.  Because of this and the swelling in the area, up to 20% may be missed on initial presentation.  A delay in treatment can have long lasting effects on the overall outcome and thus emphasizes the importance of being evaluated by a foot and ankle physician in a timely manner.
  • Radiographs may be taken to rule out other associated injuries.  To fully evaluate the extent of Achilles tendon injury, an ultrasound, or more often, an MRI will be performed.   This allows the physician to visualize the extent of tendon injury and determine the best treatment plan.

Treatment:

  • Treatment will vary depending on the extent of tendon tear, duration the tear has been present, and the patient.  An acute, complete rupture of the tendon requires surgical intervention.  This is typically done by re-approximating the torn ends of the tendon to allow for appropriate healing.  For the best function results, the repair should occur within one week in order to avoid retraction of the tendon ends.  Unless the patient is relatively sedentary, cast immobilization as the primary treatment of an Achilles tendon rupture should be avoided due to the increased risk of re-rupture, decreased strength and sub-optimal functional results
  •  Achilles tendon tears that are not treated for longer than 4 weeks are considered chronic.  Because of the delay in treatment, the tendon ends are become retracted and cannot be repair like an acute rupture.   Chronic Achilles tendon ruptures are typically repaired surgically and involve more extensive tendon transfers, flaps or grafts.  After surgical intervention, patients are immobilized in a cast for 2-3 weeks, followed by a transition to a walking boot.    It is essential to try to begin strengthening of the tendon as quickly as possible to avoid weakening.  This needs to be done carefully by trained physical therapist who understand the recovery protocol of Achilles ruptures.

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