Rupture of the Achilles Tendon

Rupture of the achilles tendon is a common injury in healthy, young, active individuals. The rupture is usually spontaneous and most common in individuals in between the ages 25-50 years. The majority have had no prior history of pain or previous injury to the heel. The rupture of the tendon usually occurs just a few cms above the heel from where the tendon attaches to the heel bone (calcaneous). Some of the causes of achilles tendon rupture include poor conditioning, advanced age, and overexertion during exercise. However, in most cases, the individual develops a sudden force on the heel (like standing his toes or running) and then the rupture occurs. It is a sudden snap with instant pain felt in the heel area. The majority of individuals will complain of a sudden pop or snap in the foot. Immediately one will feel pain at the back of the leg or just above the heel. In many cases, walking may be difficult and the foot may drag. Most individuals claim that they felt like they were kicked in that area or even shot at. When such a presentation occurs in an active adult, achilles tendon rupture should be suspected. The achilles tendon is a strong fibrous cord that connects the muscle from the back of the leg to the heel bone. The function of the achilles tendon is to help you raise your heel as you walk. It helps one to push up on the toes and lift the rear of the foot. Without the achilles tendon, walking is extremely difficult. One of the worse feelings is achilles tendonitis. In some cases, the tendon does not rupture but develops a partial tear. The tear may present with pain and if not recognized can develop into a full blown rupture. The tendon rupture occurs just above the heel but may occur anywhere along the length of the tendon. Other conditions that may mimic an Achilles tendon tear include bursitis (fluid in the heel area from constant irritation) and tendonitis (pain along the tendon due to friction and irritation). Both these conditions improve with rest and pain medications. Achilles tendon rupture requires surgery. The true prevalence of Achilles tendon rupture is unknown. It is believed to be more common in men but with the recent participation of women in athletics, the incidence in this population has steadily been rising. Achilles tendon rupture is by far most common in the athlete. The Achilles tendon is the largest and strongest tendon in the human body. The Achilles tendon is connects the back muscles of the leg (gastrocnemius and soleus muscles) to the heel bone (calcaneal tuberosity). The function of these muscles and the tendon is vital for running, jumping, toe standing and stair climbing activities because it forcefully plantar flexes the ankle. During running or climbing the stairs, the forces within the tendon have been measured and indicate that the structure is able to withstand at least 10 times the body weight of the individual. However, there is evidence that shows that the tendon has poor blood supply and this makes the tendon not very resilient to repetitive trauma. The tendon easily becomes irritated and thus prone to rupture.

- The majority of individuals will present with a history of a sudden snap at the back of the heels which is associated with intense pain. Immediately after the rupture the majority of individuals will have difficult walking. - A few patients may have had prior complaints of pain in the calf or heel area indication of prior tendon irritation or inflammation. - Soon after the tendon rupture, a limp is a common presentation and when the ankle is moved, the patient may show signs of pain or apprehension. In all cases, the ankle will have no strength. - Once the Achilles tendon is ruptured, the individual will not be able to run, climb up the stairs or stand on his toes. The ruptured tendon prevents the individual from generating force from the back leg muscles to the heel. - In a number of cases, the diagnosis is missed and individuals have been told that the injury is related to the nerve or some other parts of the foot or leg. Whenever the diagnosis is missed, the recovery is prolonged and difficult. - Swelling of the calf and bruising near the ankle may occur in some cases. - Achilles tendon rupture is also more common in the elderly who have started to become fit after a long period of sedentary life. In these individuals, the tendon is not strong and the muscles are deconditioned, this making recovery difficult and prolonged. - Over the past decade there have been many cases reported when the Achilles tendon rupture was associated with injection of a steroid into the heel or near the tendon. The fluoroquinolones (ciprol) are also associated with tendon rupture, especially in the younger aged individuals. - Some individuals have had a prior tendon rupture which was managed conservatively. In such cases, recurrence of rupture is very high.

The Achilles tendon is usually injured after repeated stress. The stress may occur from: a. excessive overuse b. jogging or running on hard surfaces c. lack of warm ups or proper conditioning d. sudden changes in exercise activity e. prior tendon rupture f. very tense calf muscles g. weak calf muscles h. inadequate or improper shoes i. flat feet j. trauma k. repeated steroid injections l. consumption of fluoroquinolones m. older recreational athlete

The diagnosis of Achilles tendon rupture is straightforward; upon examination your feet and asking you to perform some easy maneuvers the diagnosis will be obvious. When the achilles tendon is ruptured, there is evidence of bruising and tenderness just above the heel. A gap is noticeable when the finger is run over the heel; the gap is typically located where the tendon is ruptured. All individuals with a full blown rupture of the tendon are unable to stand on their toes. There are various maneuvers used by the doctors in making a diagnosis of Achilles tendon rupture. There is no blood work required in making a diagnosis of Achilles tendon rupture. The three common radiological tests to make a diagnosis of Achilles tendon rupture are: X rays: X rays of the foot may reveal swelling of the soft tissues around the ankle, calcification near the tendon or other bone injuries. Ultrasound: An ultrasound is often required to document the injury. For a partial tear of the Achilles tendon, the diagnosis is not so simple and frequently an MRI is ordered. This painless procedure will make a diagnosis with in a few minutes. Ultrasound is a relatively inexpensive, fast, reliable and can help determine tendon pathology and the size of the tear. MRI: MRI is an excellent test to evaluate the Achilles tendon and can also evaluate the presence of any fluid or soft tissue trauma. In addition, MRI can also detect the presence of bursitis, tendon thickening, and rupture. However, MRI is expensive and is not useful if there is any bone damage. MRI is not routinely indicated in patients with tendon ruptures (many physicians order it anyway- as they are not paying for it).

Surgery for the Achilles tendon rupture is now well established. The surgery is usually recommended for the younger, healthier and more active individuals. Most athletes should have surgery as the choice of therapy. The tendon can be repaired by an open or a closed technique. In either case, the tendon is repaired. With the open technique, an incision is made to allow for better visualization and approximation of the tendon. In the closed technique, several small incisions are made through which the tendon is repaired. In either case a short leg case is applied at the end of surgery. The advantage of surgery treatment includes a lower risk of re-rupture rate (0-5%); the majority of individuals can return to their original sporting activities and most regain their strength and endurance. The disadvantages of surgery include hospital admission, high operative costs, wound complications (e.g., infection, skin slough, sinus formation), adhesions, and possible sural nerve injury.

Non surgical method is generally undertaken in individuals who are old, inactive and at high risk for surgery. Others who may not be candidates are those with wound infections near the heel. A large group of patients who may not be candidates for surgery include those with diabetes, those with poor blood supply to the foot, those with nerve problems in the foot and those who may not comply with rehabilitation. In the non operative cases a short-leg cast is applied to the affected leg while the ankle is placed in slight plantar flexed position. By maintaining the foot in this position, the tendon ends are better apposed. The leg is placed in a cast for 6-10 weeks and no movement of the ankle is allowed. Walking is allowed in the cast after a period of 4-6 weeks. When the cast is removed, a small heel lift is placed in the shoe to allow support for the ankle for an additional 2-4 weeks. Following this physical therapy is recommended. The advantage of a non surgical approach is no risk of a wound infections or breakdown of the skin and no risk of nerve injury. In addition, the cost of no surgery is much less and there are no risks of anesthesia. The disadvantages of no surgery method involve a high risk of tendon rupture and a more difficult surgical course if repair is required. In addition, the healing after non surgery is much more prolonged.

An individual who ruptures his or her Achilles tendon should seek prompt medical treatment. Physical therapy generally is not indicated in the acute phase of treatment, but it is highly recommended once the tendon has healed. The type of treatment (non surgical or surgical) is determined on a patient-by-patient basis. Irrespective of the treatment, rehabilitation is offered to both groups of patients. Aggressive physical therapy is the key to recovery. After the cast is removed, the ankle is gently massaged and moved. After 2 weeks, active exercises are undertaken. A total of 12-16 weeks of active physical therapy is required for the best results. The ability to return back to the previous physical activities is dependent on the motivation and quantity of rehabilitation

If the Achilles tendon rupture is managed without surgery, the chance of re- rupture is nearly 40% When surgery is done for a second time rupture, the results are poor. Other complications include wound infections, skin slough, damage to nerves and a prolonged recovery period.

To prevent problems with the Achilles tendon, the following tips are recommended: - avoid activities that place a great deal of stress on the heel (excessive jumping or up hill running) - one should stop all activity if there is pain at the back of the heel - if pain resumes with one particular exercise, another exercise should be selected - wear proper shoe wear - gradually strengthen your calf muscles with sit ups - always warm up before any activity - perform stretch activities of the leg and foot with care - avoid high impact sports

Once the achilles tendon is damaged, one should exercise great care. The risk of rupture is high and if pain is associated with walking, one should go and see a reputable sports physician or an orthopedic surgeon. An Achilles tendon rupture is never treated at home. There are no herbs or nutrients to treat Achilles tendon repair and any delay just worsens the recovery. When proper treatment and rehabilitation are undertaken on time, the prognosis is excellent. The majority of athletes can return to their previous exercise or sports. However, those who undergo non surgical care should be aware that recurrence of tendon rupture is much higher than surgical therapy. Individuals should be aware of proper techniques of warming prior to any exercise. For those who have tendon pain, wearing appropriate and proper fitting shoes during sporting activities.