What is an Achilles rupture?
Achilles rupture refers to when there is a complete tear through the tendon that connect your calf muscles to you heel bone. This disruption of the connection between the muscle and the tendon, makes the calf muscles unable to function normally so the patient will generally be unable to point their foot against any resistance. It is an uncommon injury to the Achilles, with tendinopathy (previously called ‘tendonitis’) the most common cause of injury and pain in this area by far. Patients often report feeling as though they have been kicked in their Achilles, feeling a sudden snap, or being shot in the calf. They may also report a snapping or cracking sound.
Who gets an Achilles rupture?
Contrary to popular belief, there is no clear evidence that prior pain or problems in the Achilles tendon increase the likelihood of sustaining a rupture. It is more common in males aged 30-50 years old, general occurs during sport (73%), overweight people, and has an incidence of 6-55/100,000 persons (Brorsson, 2017). There is also evidence that steroid (cortisone) injections into the tendon, long term use of corticosteroid medications (e.g. prednisone), Quinolone antibiotics (e.g. ciprofloxacin, norfloxacin), and systemic conditions (e.g. gout, lupus, rheumatoid arthritis) may increase the risk of Achilles rupture.
How does the Achilles tendon rupture?
The rupture usually happens during the phase of muscle contraction when the tendon is lengthening, as this when there is the most force on the tendon (Brorsson, 2017). The most common mechanisms described by patients for Achilles rupture include pushing off suddenly, landing from a jump, or tripping on stairs.
How to diagnose an Achilles rupture?
An experienced health professional will be able to diagnose an Achilles rupture through:
- Listening to the patient’s description of the injury mechanism
- Palpating (feeling) the tendon for a defect/gap
- There is usually a lot of swelling around the tendon if it is a recent injury
- Performing a Thompson test: the patient is placed face down with the foot over the end of the bed. The examiner will squeeze the calf muscle. In a normal/uninjured Achilles, the foot will point as the calf is squeezed. In a ruptured Achilles, the foot will not. It is important that this test is performed by a qualified health professional.
- Ask the patient to point their foot and to do a calf raise in standing – a ruptured Achilles will not allow the patient to do a calf raise as the connection between the calf muscle and Achilles has been severed.
What are the treatment options Achilles rupture?
There are 2 main options for treating an Achilles rupture: surgical or conservative.
Surgical refers to having a procedure to stitch the torn ends of the Achilles back together. Following the surgery, the patient will be placed into a cast or boot for up to 12 weeks, depending on the surgeon’s post-operative protocol, with the heel of the foot raised to protect the Achilles repair site from stretching as it heals. Over the 12-week period, the height of the heel raise is gradually reduced and exercises to strengthen the muscles and tendons are introduced according to the surgeon’s protocol.
Conservative treatment refers to not having surgery. It consists of placing the patient in a cast, or current research suggests a boot with several heel wedges inside to raise the heel up high results in a better recovery (Zhou et al., 2018). This immobilises the Achilles in a position where the two torn ends can mend together over time. The amount of time that the patient will need to be in the boot varies depending on the specialist’s protocol but typically 12 weeks is common. The height of the heel raise is gradually reduced and exercises to strengthen the muscles and tendons are progressively introduced over time.
How long with my recovery be after Achilles rupture?
A typical rehabilitation for a ruptured Achilles tendon, whether surgically or conservatively treated, is 6-12 months for return to sport. This is largely because the Achilles need to be protected during the first 12 weeks to allow the tendon to heal. The down side of this protected phase is that the muscles get extremely weak and it take a long time to regain that strength. Brorrson et al. (2016) found that seated calf raise muscle endurance (how many repetitions that a patient could perform) at 3 months was strongly correlated with the patient’s ability to perform a single leg calf raise in standing at 3 and 6 months post rupture.
It is important to understand that many sufferers may not return to their pre-injury level of sporting participation. A study by Trofa et al. (2017) on professional athletes in the U.S. (NBA, NFL, MLB, NHL) found that 20% of players did not return following Achilles rupture. A systematic review on Achilles rupture by Zellers et al. (2016) reported a 77-91% return to sport rate but they also found that return to sport was not clearly defined by most studies and therefore the rate of successful return was likely inflated.
Should I have surgery for my Achilles rupture?
Patients often ask whether they should have surgery or instead conservatively manage their Achilles rupture. There strong evidence that the outcomes and incidence of re-rupture is similar between groups where an early mobilisation protocol is used in the conservatively managed group (Zhou et al., 2018; Wu et al., 2016). High level athletes may be more likely to consider surgery as patients who have Achilles repair seem to have better functional outcomes (jumping, hopping, calf raise endurance). The downside of surgery is that there are smalls risk such as infection that can severely impact recovery. We recommend that all patients have a consultation with an ankle orthopaedic specialist to discuss their options and make a decision that is best for them.
References:
Brorsson (2017). Acute Achilles tendon rupture: the impact of calf muscle performance on function and recovery. http://hdl.handle.net/2077/53615
Brorrson et al. (2016). Recovery of calf muscle endurance 3 months after an Achilles tendon rupture. Scand J Med Sci Sports, 26, pp844-853.
Trofa et al. (2017). Professional athletes’ return to play and performance after operative repair of an Achilles tendon rupture. AJSM, 45(12), pp2864-2871
Wu et al. (2016). Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. International Journal of Surgery, 36, pp305-311
Zellers et al. (2016). Return to play following Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. BJSM 50, pp1325-1332
Zhou et al. (2018). Surgical versus non-surgical methods for acute Achilles tendon rupture: a meta-analysis of randomised controlled trials. J Foot ankle Surg, 57(6), pp1191-1199
Author
