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Achilles tendon rupture

Dr. Suvansh Raj NirulaMBBS

December 26, 2020

December 26, 2020

Achilles tendon rupture
Achilles tendon rupture

The Achilles tendon is at the back of the heel. It can be ruptured by sudden force on the foot or ankle. If your Achilles tendon is ruptured, you won't be able to stand on tiptoe and will have a flat-footed walk. It is important to diagnose and treat this injury as soon as possible, to help promote healing. Treatment involves wearing a plaster cast or brace (orthosis) for several weeks, and possibly having an operation.

What is the Achilles tendon?

The Achilles tendon is a vital component of the lower limbs. It is present right behind and above the heel area of the body. It helps to join the heel bone to the muscles in the calf. The Achilles tendon performs the function of plantar flexion. Plantar flexion is the movement that helps in bending the foot downwards at the level of the ankle.

What is an Achilles tendon rupture? 

When there is a tear in the Achilles tendon, it is defined as an Achilles tendon rupture. This tear may be classified as a partial or complete tear. In the case of a partial tear, the tendon is still attached to the calf muscle. In certain situations, if the tendon is completely torn away, the connection between the ankle bone and the calf muscles is completely lost.

How common is this condition?

It affects around two lakh people a year. It is more commonly observed in people who undertake sports and intense training. People of all ages can experience this rupture but it is most common between the ages of 30 and 50 years old.

Achilles tendon rupture symptoms

Most patients experience the clinical features start suddenly while playing sports or after an injury. 

  • Patients may hear a snap or may experience a sudden onset of sharp pain in case of a rupture of an Achilles tendon. This sharp pain may reduce rapidly but some ache at the back of the lower leg may persist. 
  • Patients usually have a flat-footed kind of walk. Most patients are able to walk or bear weight but it is not possible to properly push off the ground on the affected side. 
  • Patients are unable to stand on tiptoes. 
  • Patients may be able to feel a gap right above the back of the heel. This is the case when the tendon is completely torn. 
  • Bruising and swelling in the affected area. 

If you feel like you are experiencing any of the abovementioned symptoms, you should visit your doctor immediately as healing is easier and faster if the diagnosis and treatment is started earlier.

Causes of Achilles tendon rupture

Just like any other muscle or tendon in the body, the Achilles tendon can rupture if high force or stress is applied to it.

  • High-intensity exercise: This can occur with any high-intensity exercise which may involve a forceful push off such as during football, basketball and tennis. The pushing off movement basically involves a strong contraction of the muscles in the calf resulting in excessive stress on the Achilles tendon.
  • Injuries: This tendon may be damaged due to injuries sustained during falls, especially if the foot is forced into an upward-pointing position during the fall, resulting in overstretching of the tendon. Deep cuts or lacerations at the back of your ankle may also disrupt the Achilles tendon.
  • Weak tendon: When the Achilles tendon is weak, it is very susceptible to tears and rupture. There are numerous factors that can result in weakening of the Achilles tendon. They may include the following: 
    • Long-term treatment with steroids like prednisolone
    • Any corticosteroid injections in the area of the Achilles tendon. 
    • Certain illnesses lead to the overproduction of corticosteroid hormones in the body; for example, Cushing’s syndrome
    • Achilles tendinopathy (tendon disorder resulting in pain, swelling or impaired function). 
    • Other medical conditions that can make the tendon weaker include rheumatoid arthritis, gout and systemic lupus erythematosus
    • Some medications like antibiotics can sometimes raise the risk of rupture of Achilles tendon. These antibiotics involve fluoroquinolones like ciprofloxacin, levofloxacin and ofloxacin. Usually, the risk is higher when patients receive these antibiotics along with steroid injections.

Prevention of Achilles tendon rupture

It is not always possible to prevent a rupture from occurring. Some methods have been suggested that include the following: 

  • Careful and judicious use of corticosteroids like prednisolone 
  • Quinolone antibiotics should be used cautiously in older patients or those patients who are also on steroid therapy.

Achilles tendon rupture diagnosis

A diagnosis of Achilles tendon rupture can be made on the basis of a physical examination, the clinical features (symptoms) and information about the kind of injury sustained. The doctor may ask you to walk and observe it. You may be asked to stand on tiptoe. 

A clinical test may be performed using a method called Thompson’s test. It is also called a calf squeeze test. During this test, the patient is usually asked to lie prone (face down) on the examination table. You are then asked to bend your knee. After this, the doctor will carefully squeeze the calf musculature on the back of your leg and your ankle movements are observed carefully. In case of a normal Achilles tendon, when the calf is squeezed, it results in the foot pointing away from the leg i.e. a movement termed as plantar flexion. As per research studies conducted, Thompson's test is considered to be highly accurate and reliable in the clinical setting.

In certain situations, if the diagnosis of Achilles tendon rupture is uncertain, your doctor might request you to undergo some radiological tests. These tests may involve an ultrasound scan or a magnetic resonance imaging scan (MRI scan). An MRI is highly reliable and can make a definitive diagnosis of Achilles tendon rupture.

An Achilles tendon tear can sometimes be very challenging to diagnose and may be overlooked on initial assessment. Therefore, it is very important to be aware of this condition and perform a thorough clinical examination.

  1. Differential diagnosis of Achilles tendon rupture

Differential diagnosis of Achilles tendon rupture

Some conditions and illnesses may present with similar clinical features and hence are needed to be ruled out before a definitive diagnosis of Achilles Tendon rupture can be made. These conditions may include the following: 

  • Achilles tendinopathy: It basically involves the overuse of the Achilles tendon which is at the back of the ankle. This condition presents with pain, swelling and impaired function of the Achilles tendon. (Read more: Tendon injury)
  • Injury to the calf muscles that may result in excessive strain or tear of the calf muscles.
  • Deep vein thrombosis: Deep vein thrombosis is a condition which involves the presence of a blood clot in one of the deep veins of the calf. It is a highly dangerous condition and presents with severe pain in the calf muscles. It is an emergency and treatment should be initiated as soon as it is diagnosed.

Read more: Achilles heel tendonitis

How is an Achilles tendon rupture treated?

It is imperative that this problem be diagnosed and treatment initiated as soon as possible because early treatment increases the chances of quick and complete recovery. It is very important that you should be referred urgently to see an orthopaedic surgeon or a doctor in the emergency department. If an Achilles tendon rupture is suspected, do not put any sort of heavy weight on the affected site and you should not walk using the affected side at all.

There are a couple of treatment options available for an Achilles tendon rupture: 

  • The first treatment option is to conduct surgery to repair the torn tendon. The torn ends of the Achilles tendon are stitched by the surgeon and in some cases, another tendon or graft of another tendon may also be used to repair the tendon. Most patients may require a brace (orthosis) or a plaster cast post-surgery. 
  • The second possible treatment option is to allow the ruptured tendon to resolve spontaneously (on its own) after putting a cast or brace (orthosis) on the affected area. This kind of treatment protocol is called conservative treatment. In certain situations, if conservative treatment is not successful and the rupture does not resolve spontaneously, your doctor might need to perform a surgical repair. 

In both treatment protocols, the doctor will put a brace or a cast for six to eight weeks to protect the tendon as it heals. The cast or brace is fixed in a particular position to allow the foot to point in a direction that is slightly downwards which helps in reducing the strain and stress being exerted on the tendon. 

Previously, patients were advised to use crutches—to avoid putting their body weight on the affected leg—during the initial phase of treatment. Nowadays, doctors sometimes advise the patients to allow early mobilisation, i.e., allowing normal leg movement early on in the treatment phase. The doctor allows a properly fitting plaster or brace that helps you to continue walking. The advantage of this is that patients do not need to use any crutches. Patients are also advised physiotherapy to help in early resolution and complete recovery.

  1. Best treatment for Achilles tendon rupture
  2. Recovery time for Achilles tendon rupture

Best treatment for Achilles tendon rupture

A lot of research has been done to settle the debate between the two treatment options that are available, i.e., surgical repair or conservative treatment. 

Studies suggest that surgical repair has a major advantage in that it helps to decrease the risk of another rupture (re-rupture) of the Achilles tendon in the future. An important disadvantage to consider is the risks of surgery like excessive bleeding or infections. Sometimes, a second surgery may be required if resolution does not occur after the first procedure. Therefore, surgery is the ideal treatment protocol for patients who take part in intense exercise and sports or for people who belong to a younger age group. When surgery is required, percutaneous surgery is performed that allows the surgeon to repair the injury using smaller incisions as compared to a traditional approach. This limits the risk of developing infections at the site of operation.

Conservative management is commonly advised for patients who are not very active, are old or have a blood clotting disorder. It is also used in people who do not wish to undergo surgery. The kind of treatment varies depending on the clinical profile of the patient and the personal choice of the patient. Sometimes, surgery is necessary if there have been some delays in the initiation of treatment for the rupture. 

A recent study shows that both treatment protocols gave good results, especially when early mobilisation therapy is achieved with the help of a brace.

Recovery time for Achilles tendon rupture

The time that is required to go back to participating in sports ranges from four months to a year. It actually depends on the kind of work and activities that the patient usually performs. 

Usually, patients have a good prognosis. But, it does need some time. A ruptured Achilles tendon takes about two months to completely heal. After healing is done, some more time is required to help the muscles to achieve their normal strength after a cast or brace has been applied.

Achilles tendon rupture complications

Some complications that can occur after an Achilles tendon rupture are:

  • Even after treatment is given, the rupture may not resolve completely and another surgery may be required. 
  • Patients may experience complications of surgery such as infections at the wound site or decreased sensation at the operative site. 
  • There may be scarring of the tendon or it may even become shorter than normal after the healing is complete
  • There is a possibility that the Achilles tendon may rupture again—this is seen in four out of 100 patients who undergo surgery. 
  • Formation of a clot in the vessels in the lower limbs.


References

  1. Asplund C.A. and Best T.M. Achilles tendon disorders. BMJ, 12 March 2013; 346: f1262. doi: 10.1136/bmj.f1262. PMID: 23482943.
  2. Khan R.J. and Carey Smith R.L. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev, 8 September 2010; (9): CD003674. doi: 10.1002/14651858.CD003674.pub4. PMID: 20824836.
  3. Kauwe M. Acute Achilles tendon rupture: clinical evaluation, conservative management, and early active rehabilitation. Clinics in Podiatric Medicine and Surgery, April 2017; 34(2): 229-243. doi: 10.1016/j.cpm.2016.10.009. Epub 29 January 2017. PMID: 28257676.
  4. Deng S., Sun Z., Zhang C., Chen G. and Li J. Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. The Journal of Foot and Ankle Surgery, November-December 2017; 56(6):1236-1243. doi: 10.1053/j.jfas.2017.05.036. PMID: 29079238.

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