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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, and its strength allows us to push off with forces up to 10 times our body weight.
An Achilles tendon complete tear, or rupture, usually is a complete gap between the upper and lower portions of this tendon. It most often occurs 2-3 inches above the heel bone but can be directly at the attachment or higher in the leg.
A complete tear usually occurs during activities such as running and jumping, or trauma such as a slip and fall. Most patients report their first feeling was a "pop" or like they were struck in the back of the ankle, followed by some pain. There often is no pain
in this area before the actual tear. After the tear, patients complain of weakness when pushing off their foot during walking or when trying to stand on tiptoe. There may be a small bruise on the inside of the heel during the first few days.
Your foot and ankle orthopaedic surgeon often performs an examination to make a diagnosis. You will lie in a facedown position with your ankles off the edge of the exam table. When the Achilles tendon is not torn, it is taut and the ankle lies in a toe down position of approximately 20 degrees. Squeezing the upper calf will cause the toes to point down even further.
If the tendon is torn, it does not have this tension and the ankle usually will hang at about a 90-degree angle. Squeezing the upper calf will cause weak or no movement. Your surgeon will lightly pinch the Achilles tendon 2-3 inches above the heel to
determine if there is a gap. Special tests such as ultrasound, X-rays, and MRI scans typically are not required but can be helpful in some instances.
At first, the leg is placed at rest in a splint or special boot with heel lifts. It is important to see a foot and ankle orthopaedic surgeon soon after the injury so the treatment that is decided to be best for you can be started within a few days.
Both non-surgical and surgical treatments have been well studied but remain debated. In general, surgical treatment is thought to yield greater explosive strength and result in a lower risk of a repeat rupture. However, surgery has an increased risk of wound healing problems, nerve damage, and infection, in addition to the usual risks associated with surgery. Blood clots are a concern with both types of treatment. Your foot and ankle orthopaedic surgeon will be the best person to guide you through the pros and cons and help you to select the best option.
Non-surgical treatment starts with a period of rest in a splint, cast, or boot for the injured leg. You will need to use crutches, a walker, or a wheelchair in order to not put weight on the leg. Within the first few weeks you will start working on actively moving your foot and ankle. The device being used to immobilize your ankle will be adjusted over time as the Achilles tendon heals to allow increased movement. Gradually, you will be allowed to put weight on the leg and start specific strengthening exercises. The length of treatment may be different for each patient, but usually lasts about three months. Progression of your treatment is often guided by a physical therapist along with your orthopaedic surgeon.
During surgery to repair your Achilles tendon, your foot and ankle orthopaedic surgeon will place stitches into the torn tendon ends and then pull the ends together. The stitches can be applied through one or more incisions (viewing the tendon directly) or through multiple small incisions (placing the sutures through the tendon using a guide). The recovery after surgery is similar to the non-surgical treatment, but can be slightly shorter.
Since tendons do not have a great blood supply, healing is a slow process. Patients usually can start light jogging in 3-6 months with return to sports involving cutting, twisting, pivoting, and/or jumping in 6-9 months. Full recovery may take a year or more, with the expectation that your Achilles may never feel “normal” or the exact same as before your injury.
Achilles tendon ruptures occur rarely, so there is no single study that really answers this question well. Protective measures that may reduce your risk of tearing your Achilles include wearing supportive shoes, avoiding sudden increases in high impact activity, and performing a dedicated warm-up and stretching program for your Achilles tendon and calf muscles before planned activities. Smoking should be avoided as the negative effects of cigarettes on tendon health have been well shown.
About 6% of patients who have had an Achilles tendon tear have been found to eventually tear their opposite Achilles tendon. Certain factors such as chronic steroid use or having a labor-intensive occupation may make one more likely to tear their Achilles tendon.
Starting range-of-motion exercises and putting weight on the injured leg early have shown better results than long periods of immobilization on crutches. However, earlier mobilization has to be balanced by the risk of pulling apart the ends of the tendon if performed incorrectly. Having a dedicated rehabilitation program guided by your orthopaedic surgeon and a physical therapist is highly recommended for optimal results. Stopping smoking for at least a few months while the tendon heals also is also likely to be of benefit.
Original article by F. Ray Nickel, MD
Contributors/Reviewers: Wen Chao, MD; Lauren Lewis, MD
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