Most people know that the Achilles tendon has something to do with the back of your ankle, but I sat down with orthopaedic foot and ankle specialist Dr. Marvin Brown to find out a bit more.
What is the Achilles tendon and what does it do?
The Achilles tendon is the thickest and strongest tendon in the body. A tendon connects muscle to bone and the Achilles tendon connects the calf muscles to the back of the heel bone. This tendon allows you to point your foot, helps to bend your knee, and makes it possible to internally rotate your ankle.
When you stand up, you exert a force 3 times your body weight through this tendon and your feet. Walking increases that force to 4.5 times your body weight and running increases it even more to 9-12 times your body weight. This amount of force is what can lead to an Achilles tendon rupture.
What is an Achilles tendon rupture?
An Achilles tendon rupture is a break or disruption of the connection between the calf muscles and the heel bone. The most common area for the tendon to rupture is just above the heel bone, where there is poor blood supply to the tendon. Often, a patient who suffers an Achilles tendon rupture has already experienced symptoms of tendon degeneration, whether they realized it or not. Prior degeneration, of course, makes the tendon more vulnerable to rupture.
What are the symptoms someone would experience with an Achilles tendon rupture?
When someone ruptures this tendon, they often feel as if something hit them on the back of the leg. They hear a loud pop and have pain with walking and with pointing their foot. They will also notice they cannot feel a tendon on the back of their leg just above the heel. Instead of a taut, cord-like structure, it will feel soft. When an Achilles tendon rupture is suspected, a medical provider will perform the Thompson Test – which involves squeezing the calf muscle with the patient laying on their stomach or sitting with their legs free from the floor. If the foot does not point when the calf muscle is squeezed, it is considered a positive test for Achilles tendon rupture. Note: Achilles tendon ruptures can sometimes be misdiagnosed as ankle sprains if the tendon rupture gap is disguised by bruising and swelling. It is recommended to seek evaluation from an orthopaedic specialist if you think you may have an Achilles tendon rupture.
How do Achilles tendon ruptures occur?
Most Achilles tendon ruptures occur when a sudden explosive activity – such as forceful push off at the start of a sprint or falling onto the foot, resulting in a violent upward flexion of the foot – stretches the tendon beyond what it can hold. If the Achilles tendon ruptures without a sudden, explosive activity, there are likely other contributing factors – including degeneration of the tendon due to age, a change in training, or possibly a previous injury that was left untreated.
How soon do you need to seek medical attention for an Achilles tendon rupture?
It is best to seek medical attention immediately after you suspect an injury to your Achilles tendon. The sooner proper treatment is started, the better for the long term healing of the tendon.
If you have an Achilles tendon rupture, will you definitely need surgery?
This can be a point of controversy among orthopaedic surgeons. There is evidence to support both arguments, however both the patient’s preference and level of activity are always considered when making a decision about a surgical or non surgical approach. Unfortunately, re-ruptures are likely with both approaches, though more likely with non surgical treatment.
How is an Achilles tendon rupture treated?
If surgery is deemed necessary, then a tendon repair would be performed. This involves knitting the torn tendon back together using sutures. Achilles tendon repair is usually performed in an outpatient setting and may be done either as an open repair or a minimally invasive primary tendon repair, depending on the case.
For non surgical treatment, there are two possibilities:
- the patient can be kept non weight bearing and casted with their foot pointed for two weeks before starting weight bearing
- the patient can begin weight bearing early on in a boot with a small amount (3cm) of heel lift
Keeping the foot pointed down allows the ends of the tendon rupture to begin healing. Once weight bearing has begun in a walking boot, another centimeter of heel lift is removed every two weeks until the patient is able to step with their ankle at neutral and the tendon is healed. The patient would also have early rehab exercises to encourage good range of motion in the ankle. After eight to ten weeks of walking with immobilization, they would begin formal physical therapy and walking in a sturdy tennis shoe.
Describe the rehabilitation process following treatment for an Achilles tendon rupture.
Both surgical and non surgical patients begin early range of motion. The surgical patient would remain non weight bearing for six weeks following surgery, but ankle motion would be initiated after the skin had healed. Studies have shown us that the sooner patients with tendon repairs move the ankle joint, the better they do in the long run. Movement helps keep scar tissue from forming and encourages blood flow to the area for healing. The surgical patient will begin formal physical therapy at around 12 weeks once they are full weight bearing. The non surgical patient will typically be able to begin formal physical therapy at around 10-12 weeks after the start of treatment.