Achilles tendon rupture (tear)

An Achilles tendon rupture injury is when the tendon fibres tear, causing pain and loss of function. A rupture can be either partial or complete. Treatment may involve surgery.

Achilles tendon rupture is common in weekend athletes trying to play/train too hard and is less 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 popping or snapping sound may be heard. The person may feel like they have been hit or kicked in the back of the lower leg. 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 band of fibrous connective tissue that attaches the calf muscle to the heel bone. An Achilles tendon rupture usually involves 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. This occurs most often in sports that require a lot of stopping and starting such as tennis, basketball, netball, football and squash.

Most ruptures occur 3-6cm above where the tendon inserts into the heel bone, at the narrowest portion of the Achilles tendon.

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.

Frequent episodes of Achilles tendonitis can weaken the tendon and make it more susceptible to rupture. Other factors that may increase the risk of Achilles tendon rupture include:

• Being middle-aged and male
• Tight calf muscles and/or Achilles tendon
• Change in running surface, eg: from grass to concrete
• Inappropriate or poor quality footwear
• A change of footwear, eg: from heeled to flat shoes
• Obesity (excess weight puts more strain on the tendon)
• Certain medications - corticosteroid injections into an ankle joint and fluoroquinolone antibiotics.

It is thought that some medical conditions, such as gout, diabetes mellitus and systemic lupus erythematosus, may increase the risk of Achilles tendon rupture.

Diagnosis

If an Achilles tendon rupture is suspected, it is important to see a doctor straight away so that an accurate diagnosis can be made and appropriate treatment started. On your way to the doctor 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 check for swelling, tenderness, and range of movement in the lower leg and foot. A noticeable gap may be felt in the tendon at the site of a complete rupture. This is most obvious just after the rupture has occurred and swelling will eventually make this gap difficult to feel.

A commonly used test 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 calf muscle to contract and the foot to point. 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 and MRI (magnetic resonance imaging) of the Achilles tendon may also be recommended to help determine the extent of the rupture.

Treatment

Once a diagnosis of Achilles tendon rupture has been confirmed, a referral to an specialist for treatment will be recommended.

Treatment for an Achilles tendon rupture aims to help the torn ends of the tendon heal back together again. Treatment may be non-surgical 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 keep the foot from moving by fitting a cast or a special hinged splint (known as a “moon boot”) with the foot in a toes-pointed position, which brings the two ends of the torn tendon together allowing it to heal. 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

The surgeon makes an incision in the skin over the ruptured portion of the tendon and joins the ends of the tendon together with strong stitches (sutures), allowing the tendon to closely approximate its previous length. The skin is then closed with stitches and the foot is prevented from moving by putting it 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.

Many studies have been conducted as to the effectiveness of surgical versus non-surgical treatment. Surgical treatment has in the past been the most preferred form of treatment for Achilles tendon rupture, especially in cases of complete rupture. However, research indicates that surgical treatment does not necessarily produce a more effective outcome than non-surgical treatment.

Both types of treatment have advantages and disadvantages, which a patient should discuss with their specialist.

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. 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.

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
• Calf muscle stretching and strengthening exercises, which will allow the Achilles tendon to absorb greater forces and prevent injury.

References

Boggs, W. (2015). What’s the best postoperative management of acute Achilles tendon rupture (Web Page). Medscape News & Perspective. New York, NY: WebMD LLC. http://www.medscape.com/viewarticle/850222 [Accessed: 24/02/20]
Egger, A.C., Berkowitz, M.J. Achilles tendon injuries. Curr Rev Musculoskelet Med 2017;10(1):72-80
Mayo Clinic (2017). Achilles tendon rupture (Web Page). Rochester, MN: Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/achilles-tendon-rupture/symptoms-causes/syc-20353234?page=0&citems=10 [Accessed: 24/02/20]
Saglimbeni, A.J. (2018). Achilles tendon injuries (Web Page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/309393-overview [Accessed: 24/02/20]

Last reviewed – March 2020

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