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.
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.
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:
- Loss of strength
- Palpable gap in tendon
- 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 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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