Acute Rupture of Achilles
What is an Achilles Tendon?
The Achilles tendon runs from the back of the heel to the calf and attaches the gastrocnemius muscle and the soleus muscle to the calcaneus. (Figure 1). This tendon is responsible for allowing you to rise on your toes, point your toes, and push off your foot. Despite being the strongest tendon in the human body, it is also the most frequently ruptured.
Figure 1: Schematic of Achilles Tendon. Illustration copyright 2000.
The Achilles tendon runs from the back of the heel to the calf and attaches the gastrocnemius muscle and the soleus muscle to the calcaneus. (Figure 1). This tendon is responsible for allowing you to rise on your toes, point your toes, and push off your foot. Despite being the strongest tendon in the human body, it is also the most frequently ruptured.
Figure 1: Schematic of Achilles Tendon. Illustration copyright 2000.
All rights reserved. http://www.emedyx.com.
Why does the Achilles Tendon Rupture?
The Achilles tendon usually ruptures in males over the age of 30 who only occasionally engage in sports or a regular leg-conditioning program (Figure 2). The classic example is a middle-aged tennis player or weekend warrior who places too much stress on the tendon and experiences a tearing of the tendon. Spontaneous rupture of the Achilles tendon has been associated with inflammatory and autoimmune conditions, genetically determined collagen abnormalities, infectious diseases, and neurological conditions. Certain antibiotics and the use of corticosteroids have also been reported as predisposing factors. It is also suspected that genetic predisposition may also play a role.
Figure 2: Ruptured Achilles Tendon. Illustration copyright 2002 Nucleus Communications, Inc.
What are the Symptoms Associated with an Achilles Rupture?
The most common presentation of a rupture is an abrupt calf contraction followed by an audible snap. Many people report the feeling to be as if they were hit in the back of the calf or kicked by an opponent. Pain and swelling is suddenly present, and although it is possible to walk, it is usually painful. The patient is usually not able to stand on their toes and feels extremely weak. This is particularly noticeable when trying to push off while walking, as there is not sufficient strength to do so.
What will my Physical Examination Show?
Examination may reveal diffuse swelling and bruising, and a palpable gap may be felt along the course of the tendon if there is a complete rupture. (Figure 3). A crescent sign due to blood tracking into the soft tissues may be seen into the foot or toes. A positive Thompson test is further evidence of rupture (Figure 4). This test is positive if there is no movement of the foot when the belly of the calf is squeezed.
Figure 3: Palpable Gap in complete Rupture of Achilles Tendon Illustration copyright 2004.
It is important to note that in patients with incomplete rupture of the tendon, the patient may still demonstrate a normal Thompson test as well as substantial strength due to the other accessory flexor muscles of the foot. Imaging is unnecessary in the case of obvious complete rupture. However, if a partial rupture is suspected an MRI will determine if a partial rupture has occurred.
What Are My Treatment Options?
Treatment for an acutely ruptured Achilles tendon is either surgical or non-surgical. Management depends largely on patient preference, age, activity level, and individual health. Operative management is the treatment of choice for the young, athletes, and patients that consider themselves active individuals. Non-operative management should be reserved for older patients who are unlikely to achieve any major benefit from an operative procedure or for which existing conditions may add to potential complications following surgery.
What Non-Operative Options Can Be Used to Treat an Achilles Rupture?
The most common forms of nonsurgical management are casting or boot immobilization for a period of 6 to 8 weeks. Both procedures position the foot correctly and take the pressure and tension off the muscle and tendon. This allows the ends of the torn tendon to heal on their own. This cannot always be achieved by conservative management. Although nonsurgical management avoids some of the risks associated with surgery, the likelihood of re-rupture is higher and recovery can take longer. If re-rupture occurs, surgical repair may be more difficult.
What Surgical Treatment Can Be Used to Treat an Achilles Rupture?
When a rupture occurs the calf muscle continues to pull on the tendon causing further fraying, lengthening, and damage (Figure 5).
Figure 5: Acute Achilles rupture. Illustration copyright 2005.
The Achilles tendon usually ruptures in males over the age of 30 who only occasionally engage in sports or a regular leg-conditioning program (Figure 2). The classic example is a middle-aged tennis player or weekend warrior who places too much stress on the tendon and experiences a tearing of the tendon. Spontaneous rupture of the Achilles tendon has been associated with inflammatory and autoimmune conditions, genetically determined collagen abnormalities, infectious diseases, and neurological conditions. Certain antibiotics and the use of corticosteroids have also been reported as predisposing factors. It is also suspected that genetic predisposition may also play a role.
Figure 2: Ruptured Achilles Tendon. Illustration copyright 2002 Nucleus Communications, Inc.
All rights reserved. http://www.nucleusinc.com
The most common presentation of a rupture is an abrupt calf contraction followed by an audible snap. Many people report the feeling to be as if they were hit in the back of the calf or kicked by an opponent. Pain and swelling is suddenly present, and although it is possible to walk, it is usually painful. The patient is usually not able to stand on their toes and feels extremely weak. This is particularly noticeable when trying to push off while walking, as there is not sufficient strength to do so.
What will my Physical Examination Show?
Examination may reveal diffuse swelling and bruising, and a palpable gap may be felt along the course of the tendon if there is a complete rupture. (Figure 3). A crescent sign due to blood tracking into the soft tissues may be seen into the foot or toes. A positive Thompson test is further evidence of rupture (Figure 4). This test is positive if there is no movement of the foot when the belly of the calf is squeezed.
Figure 3: Palpable Gap in complete Rupture of Achilles Tendon Illustration copyright 2004.
All rights reserved. http://www.Dr.Brooks.com.
Figure 4: This test is performed with the patient lying on his belly with feet hanging over the edge of the examining table. Normally, when the doctor squeezes the calf muscle, there is plantar flexion of the foot. If there is a complete Achilles tendon rupture, there is no movement. Illustration copyright 2001 All rights reserved. http://www.sportinjuryclinic.net
What Are My Treatment Options?
Treatment for an acutely ruptured Achilles tendon is either surgical or non-surgical. Management depends largely on patient preference, age, activity level, and individual health. Operative management is the treatment of choice for the young, athletes, and patients that consider themselves active individuals. Non-operative management should be reserved for older patients who are unlikely to achieve any major benefit from an operative procedure or for which existing conditions may add to potential complications following surgery.
What Non-Operative Options Can Be Used to Treat an Achilles Rupture?
The most common forms of nonsurgical management are casting or boot immobilization for a period of 6 to 8 weeks. Both procedures position the foot correctly and take the pressure and tension off the muscle and tendon. This allows the ends of the torn tendon to heal on their own. This cannot always be achieved by conservative management. Although nonsurgical management avoids some of the risks associated with surgery, the likelihood of re-rupture is higher and recovery can take longer. If re-rupture occurs, surgical repair may be more difficult.
What Surgical Treatment Can Be Used to Treat an Achilles Rupture?
When a rupture occurs the calf muscle continues to pull on the tendon causing further fraying, lengthening, and damage (Figure 5).
Figure 5: Acute Achilles rupture. Illustration copyright 2005.
All rights reserved. http://www.orthosports.com.au
As a result of the altered biomechanics, surgery is needed to maximize tendon strength and recovery. Surgical treatment is considered ideal because the strength of the muscle depends on the correct tension between the muscle and the tendon. The only way that the correct tension on the tendon can be set is by accurately repairing the tendon ends when a rupture occurs. Surgery allows earlier return to sports, earlier return of muscle power, and a lower re-rupture rate as compared to non-operative treatment. Surgical repair performed soon after the injury allows patients to return to their preinjury level of activity in over 90 percent of cases. The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. (Figure 6, 7). Depending on the condition of the torn tissue, the repair may be reinforced with other tendons or acellular dermal matrix, which is commercially available. Some surgeons may choose to repair the torn tendon through a mini-incision technique, depending on the degree of fraying and separation of the tendon ends.
Figure 6: Operative repair of a ruptured Achilles tendon. Illustration copyright 2000.
Figure 6: Operative repair of a ruptured Achilles tendon. Illustration copyright 2000.
All rights reserved. http://www.emedyx.com.
Figure 7: Schematic of Achilles tendon reconstruction. Illustration copyright 2002 Nucleus Communications, Inc. All rights reserved. http://www.nucleusinc.com
What Can I Expect After the Surgical Procedure?
Following the tendon repair you will need to spend about eight to 12 weeks with your leg in a walking boot or cast. To promote healing and to avoid stretching the surgical repair, your foot may initially be pointed slightly downward in the boot or brace, and then moved gradually to a neutral position. Therapy and exercises are begun soon after surgery. This therapy process is critical in the recovery after tendon rupture, and without a carefully monitored program, full recovery is may be difficult to achieve.
References
Following the tendon repair you will need to spend about eight to 12 weeks with your leg in a walking boot or cast. To promote healing and to avoid stretching the surgical repair, your foot may initially be pointed slightly downward in the boot or brace, and then moved gradually to a neutral position. Therapy and exercises are begun soon after surgery. This therapy process is critical in the recovery after tendon rupture, and without a carefully monitored program, full recovery is may be difficult to achieve.
References
- Astrom M: Partial rupture in chronic Achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand 1998 Aug; 69(4): 404-7
- Calliet, Rene, MD. Foot and Ankle Pain. Philadelphia: F. A. Davis Company, 1995.
- Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. Nov-Dec 1993;21(6):791-9.
- Cetti R, Junge J, Vyberg M: Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand 2003 Feb; 74(1): 78-84
- Schepsis AA, Jones H, Haas AL: Achilles tendon disorders in athletes. Am J Sports Med 2002 Mar-Apr; 30(2): 287-305