The Achilles tendon is a large tendon at the back of the lower leg and ankle that connects the calf muscles to the heel. It is the largest tendon in the body.
An Achilles tendon tear, or rupture, most often occurs 2-3 inches above the heel bone. The tendon can tear directly at the attachment or higher in the leg. When the tendon tears completely, this leads to a "gap" between the upper and lower portions of this tendon.
An Achilles tendon rupture is considered to be "chronic" when the injury happened at least 4-6 weeks ago.
Patients with chronic Achilles ruptures will often have vague symptoms and may not realize that they ruptured their Achilles tendon. Symptoms include calf atrophy (the calf muscle looks smaller), weakness, lack of endurance, swelling, limp, and occasionally heel pain. Patients may also notice differences in their gait (how they walk).
MRI of a chronic Achilles tendon tear. The arrows point to the upper and lower ends of the tendon, and there is a visible gap between the two ends.
The Achilles tendon typically tears when the tendon is stretched while contracting. Examples include coming down from a jump and landing on someone's foot or stepping in hole while running. It can be associated with aging or prior pain in the Achilles tendon. Sometimes, certain antibiotics (like ciprofloxacin) can increase the risk of tearing your Achilles.
You may feel the gap in your Achilles tendon as your swelling goes down.
A foot and ankle orthopaedic surgeon will evaluate you and will compare the injured tendon to the uninjured side by performing a Matles test. In a Matles test, your surgeon will have you lie on your stomach, bend your knees at a 90-degree angle, and relax your feet. If your toes rest lower (closer to the ground) on the injured side, it is likely that your Achilles tendon is torn.
Your surgeon will also order X-rays to check for associated injuries or conditions. An MRI may be required to determine the extent of injury, as that may affect the planned treatment
A patient undergoing a Matles test. In Figure A, the injured ankle (marked with a star) demonstrates decreased plantar flexion, which often means the Achilles tendon is torn. In Figure B, both ankles show the same amount of tension.
If your Achilles tendon has healed in a stretched-out position, it will not shorten with time. However, you still may not need surgery. Some people can function well with an elongated tendon, especially older people. Your surgeon may recommend physical therapy to help regain strength and balance. Changing shoes or wearing a brace can assist in gait. The affected side will always be smaller and weaker.
Surgery is recommended for athletes and patients who are unable to return to their desired activity due to weakness or altered gait. Occasionally, the gap is small, and your foot and ankle orthopaedic surgeon can connect the tendon ends together.
Larger gaps will require more complicated reconstruction techniques since the Achilles tendon cannot be simply repaired. These techniques can include lengthening of the tendon higher up in the leg, use of substitute tendons, or the use of cadaver (donated) tissue. You and your surgeon will work together to determine the best treatment plan based on the extent of your injury and your treatment goals.
Your surgeon will advise when you can put weight on your leg. You can expect to be in a splint (partial cast) for a several weeks to allow the skin to heal. You would then be transitioned to a boot to start a supervised Achilles tendon rehabilitation program. You can return to standard shoes in a few months, but returning to sports may take up to a year or longer. Some patients will not be able to return to all of their pre-injury activities.
The skin over the Achilles tendon is thin with poor blood supply, so the biggest risks of Achilles tendon surgery are wound healing problems and infection. Patients with medical problems like diabetes and peripheral vascular disease, and patients who smoke or use other forms of nicotine, are at much higher risk for infection. These patients may want to avoid surgery if possible.
Original article by Paul Ryan, MD
Contributors/Reviewers: Sudheer Reddy, MD; Elizabeth Cody, MD
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