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Achilles tendon rupture (tear)


The Achilles tendon attaches the calf muscles in the leg to the heel bone. It is the largest yet most exposed tendon in the body.  An Achilles tendon rupture injury is when the tendon fibres tear, causing symptoms of pain and loss of function. A rupture can be either partial or complete and treatment may involve surgery.

Achilles tendon rupture is most common in weekend athletes trying to train too hard and is least common in well-trained professional athletes. The injury is more common in men than in women and the frequency of rupture increases over the age of 30 years.

Signs and symptoms

When the Achilles tendon ruptures a loud bang or popping sound may be heard. The person may feel that they have been hit or kicked in the back of the lower leg and often they will look over their shoulder to see who or what has hit them. This is quickly followed by the sudden onset of sharp pain in the tendon and a loss of strength and function. If a complete rupture has occurred it may not be possible to lift the heel off the ground or point the toes.
 
Often the degree of pain experienced, or lack of it, can be inversely proportional to the extent of the injury, ie a partial rupture may in fact be more painful than a complete rupture. 

Causes

The Achilles tendon is a strong bands of fibrous connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon transmits the power of this contraction to the heel bone, producing movement.
 
The Achilles tendon ruptures because the load applied to it is greater than the tendon's ability to withstand that load. This usually occurs as a result of a sudden, quick movement where there is a forceful stretch of the tendon or a contraction of the muscles eg: jumping, sprinting, or pushing off to serve in tennis. This occurs most often in sports that require a lot of stopping and starting (acceleration-deceleration sports) such as tennis, basketball, netball and squash.
 
The Achilles tendon is on average 15cm in length.  Most ruptures occur 2-6cm above where the tendon inserts into the heel bone. This is the narrowest portion of the Achilles tendon and is also the area with the poorest blood supply.
 
Achilles tendon rupture is most common when the muscles and tendon have not been adequately stretched and warmed up prior to exercise, or when the muscles are fatigued. the Achilles tendon has a poor blood supply, which makes it susceptible to injury and slow to heal after injury.  During exercise the amount of blood able to travel to the tendon is decreased, further increasing the risk of rupture.
 
Most experts agree that there are no warning signs of an impending rupture.  However, frequent episodes of Achilles tendonitis (tendon inflammation) can weaken the tendon and make it more susceptible to rupture.
 

Other factors that may increase the risk of Achilles tendon rupture include:  

  • Tight calf muscles and/or Achilles tendon
  • Change in running surface eg: from grass to concrete
  • Incorrect or poor footwear
  • A change of footwear eg: from heeled to flat shoes. 
It is thought that some medical conditions, such as gout, tuberculosis and systemic lupus erythematosus, may increase the risk of Achilles tendon rupture.  

Diagnosis

If an Achilles tendon rupture is suspected, it is important to consult a doctor straight away so that an accurate diagnosis can be made and appropriate treatment recommended. Until a doctor can be consulted it is important to let the foot hang down with the toes pointed to the ground. This prevents the ends of the ruptured tendon pulling any farther apart.
 
The doctor will take a full medical history, including any previous Achilles tendon injuries and what activity was being undertaken at the time the present injury occurred.
 
The doctor will also conduct a physical examination and will check for swelling, tenderness and range of movement in the lower leg and foot. A noticeable gap may be able to be felt in the tendon at the site of the rupture. This is most obvious just after the rupture has occurred and swelling will eventually make this gap difficult to feel.
 
One test commonly used to confirm an Achilles tendon rupture is the Thomson test. For this test the patient lies face down on an examination table. The doctor then squeezes the calf muscles; an action that would normally cause the foot to point like a ballerina (plantar flexion). When a partial rupture has occurred the foot's ability to point may be decreased. When a complete rupture has occurred, the foot may not point at all.
 
Ultrasound scanning of the Achilles tendon may also be recommended in order to assist with the diagnosis. 

Treatment

Once a diagnosis of Achilles tendon rupture has been confirmed, a referral to an orthopaedic specialist for treatment will be recommended.
 
Treatment for an Achilles tendon rupture aims to facilitate the torn ends of the tendon healing back together again. Treatment may be non-surgical (conservative) or surgical. Factors such as the site and extent of the rupture, the time since the rupture occurred and the preferences of the specialist and patient will be considered when deciding which treatment will be undertaken. Some cases of rupture that have not responded well to non-surgical treatment may require surgery at a later stage.
 
Non-surgical treatment
The doctor will immobilise the ankle in a cast or a special hinged splint (known as a “moon boot”) with the foot in a toes-pointed position.  The cast or splint will stay in place for 6 - 8 weeks. The cast will be checked and may be changed during this time.
 
Surgical treatment
Surgery to repair an Achilles tendon rupture is performed under a spinal or general anaesthetic. During surgery the surgeon makes an incision in the skin over the ruptured portion of the tendon. The tendon ends are located and joined together with strong sutures (stitches), allowing the tendon to closely approximate its previous length. The skin is then closed with sutures and the foot is immobilised in a cast or splint, again in the toes-pointed position. Seven to ten days after surgery the cast or splint is removed in order for the sutures in the skin to be removed. Another cast or splint will be applied and will stay in place a further 5 - 7 weeks.
 
The use of non-surgical versus surgical treatment for Achilles tendon rupture continues to be debated. Many research studies have been conducted as to the effectiveness of each treatment. Surgical treatment has in the past been the most preferred form of treatment for Achilles tendon rupture and the most commonly used in cases of complete rupture. Recent research, however, indicates that surgical treatment does not necessarily produce a more effective outcome than non-surgical treatment.
 
Both types of treatment have advantages and disadvantages. For example, surgical treatment has a lower incidence of re-rupture (approximately a 1% re-rupture rate as opposed to approximately a 10% re-rupture rate with non-surgical treatment).  However, risks associated with surgical treatment include wound infection, nerve irritation and risks associated with the anaesthetic. It is important to discuss the advantages and disadvantages of each treatment option with the specialist and to receive a clear explanation as to why a particular treatment has been recommended. 

Recovery

While the cast or splint is in place it is important to regularly elevate and rest the foot. This will help to reduce swelling and promote healing. It is important to follow any instructions for care of the cast or splint. These will be given at the time the cast or splint is applied or on discharge from hospital after surgery. Crutches will need to be used and weight-bearing on the foot will be restricted.
 
After removal of the cast or splint an individual rehabilitation plan, involving physiotherapy and specific exercises, will be commenced. The aim of rehabilitation is to restore the strength of the Achilles tendon and calf muscles and the range of motion of the ankle. It may be recommended that flat shoes are avoided and/or a heel raise is used in footwear. This helps to reduce the load put onto the Achilles tendon.
 
Physiotherapy may need to be continued for several weeks or months during which time activity is gradually increased. It may be six months to a year before the Achilles tendon is back to full strength. During this time it is very important to follow the instructions of the specialist and physiotherapist in order to prevent any further injury to the Achilles tendon. 

Prevention

The following can significantly reduce the risk of Achilles tendon rupture: 

  • Adequate stretching and warming up prior to exercising
  • If playing a seasonal sport, undertake preparatory exercises to build strength and  endurance before the sporting season commences
  • Maintain a healthy body weight. This will reduce the load on the tendon and muscles 
  • Use footwear appropriate for the sport or exercise being undertaken
  • Exercise within fitness limits and follow a sensible exercise programme
  • Increase exercise gradually and avoid unfamiliar strenuous exercise
  • Gradual ”warm down” after exercising.

References

American Academy of Orthopaedic Surgeons (2012) Achilles tendon rupture (tear). Illinois. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=AV0003
Paavola, M., Orava, S., Leppilahti, J., Kannus, P., Jarvinen, M. (2000). Chronic Achilles Tendon Overuse Injury: Complications After Surgical Treatment. American Journal of Sports Medicine v28 i1 p77. In Infotrac Health Reference Centre Academic.  Farmington Hills, MI: Gale Group.
Rouzier, P (2006). Achilles tendon injury. Clinical Reference Systems. McKesson Health Solutions LLC. In Infotrac Health Reference Centre Academic. Farmington Hills, MI: Thompson Gale.
Jacobs, B.A., (2012). Achilles tendon rupture. Medscape Reference: Drugs, Diseases and Procedures. http://emedicine.medscape.com/article/85024.
 
Last Reviewed – 20 April 2013 

 

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