Achilles Tendon Rupture

  • Medical Author:
    Benjamin Wedro, MD, FACEP, FAAEM

    Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

Achilles tendon rupture facts

  • The most common initial symptom of Achilles tendon rupture is a sudden snap at the lower calf, intense pain, and inability to point the foot downward.
  • Prior tendon inflammation or irritation can predispose one to Achilles rupture.
  • Immediately after an Achilles tendon rupture, walking will be difficult and one is unable to stand on their toes. In addition, the patient will complain of pain with ankle movement.
  • Bruising and swelling around the lower calf into the ankle and foot may occur.
  • Achilles tendon rupture most commonly occurs in middle age (ages 30-50), and may be associated with repeated strain and inflammation.
  • Achilles tendon rupture has been reported with the use of corticosteroids, taken either by mouth or after injection near the tendon area.
  • The fluoroquinolone antibiotics (such as ciprofloxacin [Cipro], levofloxacin [Levaquin]) are associated with Achilles tendon rupture, especially patients with previous tendinitis.
  • Achilles tendon rupture repaired with surgery may have a re-rupture rate of up to 5%. Those treated without surgery have a re-rupture rate as high as 40%.

Function of Achilles tendon

The Achilles tendon forms from two muscles in the back of the calk, the gastrocnemius and the soleus, about 15 cm to 6 inches above the ankle joint and spirals as it crosses the ankle joint to attach to the heel bone (calcaneus). A sheath surrounds the tendon, allowing it to glide easily as the ankle moves through its range of motion.

Since the calf muscles originate above the knee and the Achilles attaches below the ankle, the function of the muscle-tendon unit is critical for walking and running. When the calf muscles contract, it causes the ankle to point the foot downward and the foot to turn inward and up). (See picture 1.)

The tendon needs to be strong. Running and climbing stairs generates force inside the tendon equal to 10 times the body's weight.

Picture showing the Achilles tendon and its attachment to the heel bone
Picture 1 shows the Achilles tendon and its attachment to the heel bone.

Ruptured Achilles Tendon Treatment

Treatment for Exercise & Sports Injuries

Sports injuries refer to the kinds of injury that occur during sports or exercise. While it is possible to injure any part of the body when playing sports, the term sports injuries is commonly used to refer to injuries of the musculoskeletal system.

Blood supply of Achilles tendon

The Achilles tendon receives its blood supply from many sources. Small blood vessels cross the tendon sheath to provide blood and nutrients to the tendon. The tendon sheath also has small arteries that help supply the tendon. However, there is a relative lack of blood supply in the lower part of the tendon just above where it inserts into the heel and it is possible that this relative lack of blood flow is associated with the location of the tendon rupture.

What is an Achilles tendon rupture?

Rupture of the Achilles tendon is not uncommon in healthy, active individuals. The rupture is typically spontaneous and most commonly observed in individuals in between 24-45 years of age. The majority have had no prior history of pain or previous injury to the tendon. In the majority of cases, rupture of the Achilles tendon occurs 2-6 cm above the insertion of the tendon into the heel bone.

Risk factors for Achilles rupture include poor conditioning, corticosteroids medications (either taken by mouth or injected near the tendon), fluoroquinolone antibiotics (ciprofloxacin, levofloxacin), and overuse. A previous ruptured Achilles tendon increases the risk for another, both on the side that was initially hurt, and on the other unaffected side.

Most commonly, the Achilles ruptures when there is a sudden, forceful movement of the foot downward against resistance, such as when an individual pushes off the foot with great force to jump. This often occurs in sports like basketball, tennis, or football.

The symptoms of a rupture include an acute sharp pain in the back of the heel and inability to plantarflex the foot. The victim may remember hearing a snap when the injury occurred. Because there is an imbalance between the muscles that push the toes down and those that pull them up, walking becomes difficult with the pain and because the foot will drag.

Sometimes the tendon does not fully rupture but only a partially tears. The symptoms are the same as a complete tear, and a partial tear can progress to a complete rupture. While the Achilles tendon rupture usually occurs near the insertion in the heel, it can occur at any location along the course of the tendon (see picture 2).

Picture 2 shows the usual site of Achilles tendon rupture.
Picture 2 shows the usual site of Achilles tendon rupture.

There are other causes of pain at the back of the heel than Achilles tendon rupture. It may be due to retrocalcaneal bursitis where inflammation occurs within the sac that cushions the tendon as it passes the bony edge of the heel bone. Paratenonitis is inflammation of the tendon sheath that surrounds the length of the tendon. The treatment for bursitis and tenosis incorporates rest, exercise, and occasionally physical therapy.

About 1 million athletes a year develop Achilles tendon inflammation or rupture. Achilles tendon rupture tends to occur in athletic people between ages 30 and 50 and mostly in men (6:1 men:women). There may be an anatomy reason for the predominance of men. Achilles tendons in women have a smaller area and are thinner and may there may not be enough force generated to cause rupture.

What causes an Achilles tendon rupture?

Underlying illness or disease may increase the risk of Achilles tendon injury. Examples include the following:

Some other risk factors for Achilles tendon injury also include the following:

  • Older age
  • Activities or sports that involve running and jumping
  • Lack of flexibility
  • Excessive activity (overuse)
  • Sudden changes in intensity of exercise
  • Poor conditioning
  • Corticosteroid use (either by mouth or by injection)
  • Fluoroquinolone antibiotics
  • Poorly fitting shoes
  • Jogging or running on hard surfaces
  • Hill climbing or stair walking
  • Previous Achilles tendon injury
  • Family history

What are Achilles tendon rupture symptoms and signs?

Background history

  • Patients with an Achilles tendon rupture will often complain of a sudden snap in the back of the leg. The pain is often intense and patients will describe it as if being shot.
  • With a complete rupture, the individual will only be able to ambulate with a limp. Most people will not be able to climb stairs, run, or stand on their toes.
  • Swelling around the lower calf may occur.
  • Patients may offer a history of recent sudden increase in exercise or intensity of activity.
  • Some patients may have had recent corticosteroid injection or prescription or a course of fluoroquinolone antibiotics.
  • Some athletes may have had a prior tendon inflammation or injury.

Physical exam

  • The health care provider will generally examine both legs.
  • A health care professionals examines the lower leg for swelling, bruising, and tenderness.
  • If there is a complete rupture of the Achilles tendon, a physician can palpate a gap or defect within the tendon.
  • Range of motion of the ankle will be lost and the patient will have difficult moving the ankle and foot.
  • The Thompson test helps confirm the diagnosis:
    • The patient lies prone, face-down.
    • The examiner squeezes the calf area.
      • With an intact Achilles tendon, the foot will plantarflex and the toes point downward
      • With Achilles tendon rupture, the foot does not move
  • The health care provider may also check for pulses and sensation in the foot.

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What tests help diagnose a ruptured Achilles tendon?

A health care professional makes a diagnosis of Achilles tendon rupture by taking a patient's history and performing a physical exam as noted above. Imaging may be required to confirm the extent of tendon damage and to look for other associated injuries

Plain X-rays of the foot may reveal swelling of the soft tissues around the ankle, other bone injury, or tendon calcification.

Ultrasound is the next most commonly ordered test to document the injury and size of the tear. For a partial tear of the Achilles tendon, the diagnosis is not always obvious on a physical exam and an ultrasound may be considered. A health care provider or by an ultrasound technician and radiologist may perform a bedside ultrasound.

MRI: Health care providers often order an MRI when a diagnosis of tendon rupture is not obvious on ultrasound or a complex injury is suspected. MRI is an excellent imaging test to assess for presence of any soft-tissue trauma or fluid collection. More importantly, MRI can help detect presence of tendon thickening, bursitis, and partial tendon rupture.

What are treatment options for an Achilles tendon rupture?

Two options exist for Achilles tendon rupture, one involving surgical repair and the other a conservative treatment (allowing the tendon to heal on its own in a cast). Each has its benefits and risk and decisions will depend upon the patient's clinical situation, underlying medical background, the extent of the injury and the expectation of future activity.

Surgical intervention

Surgery is the recommended treatment for the young, healthy and active individuals. For athletes, surgery is often the first choice of treatment. The Achilles tendon can be repaired surgically by either a percutaneous or open technique. With the open technique, a physician makes an incision to allow for better visualization and approximation of the tendon. With the percutaneous technique, the surgeon makes several small skin incisions to repair the tendon. Irrespective of type of treatment, a health care professional will apply a short leg cast or postoperative boot on the operated ankle after completion of the procedure (picture 3). Each approach has its benefits and risks and the choice of surgery type is individualized for each specific patient.

Picture 3 shows the type of casts used to treat Achilles tendon injury.
Picture 3 shows the type of casts used to treat Achilles tendon injury.

The advantages of a surgical approach includes a decreased risk of re-rupture rate (0%-5%); the majority of individuals can return to their original sporting activities (within a short time), and most regain their strength and endurance.

Disadvantages of a surgical approach include cost, the need for hospitalization and wound complications (for example, skin sloughing, infection, sinus tract formation, nerve injury

Nonsurgical treatment

Nonsurgical method may be recommended for patients who are older, less active, and have a higher risk for surgery and anesthetic. Ability to heal wounds is also an important consideration and may include those with poor blood supply to their feet. These include patients with peripheral artery disease and diabetes.

Nonsurgical management involves application of a short leg cast to the injured leg, with the foot in a slightly downward flexed position. Maintaining the ankle in this position helps bring the ruptured tendon ends closer together to allow them to heal. The leg is placed in a cast for six to 10 weeks and no movement of the ankle is allowed. Walking is allowed on the cast after a period of four to six weeks. When the cast is removed, a small heel lift is inserted in the shoe to decrease the stress on the Achilles tendon for an additional two to four weeks. Following this, physical therapy is recommended.

The disadvantages of the nonsurgical approach includes an increased risk of re-rupture (up to 40%), prolonged immobilization in a cast, and increased technical difficulty should subsequent surgery be required.

The benefits include no need for anesthesia or hospitalization, decreased risk of skin breakdown and decreased risk of nerve damage.

What are possible complications of an Achilles tendon rupture?

The complications of Achilles tendon rupture include tendon scarring and decreased range of motion, as well as muscle weakness.

Tendon re-rupture is a significant concern and can occur in up to 5% of surgically repaired patients and in some studies, up to 40% in conservatively treated patients.

Other complications related to surgery include skin sloughing, wound infection, nerve damage, and scarring.

What is the recovery time for an Achilles tendon rupture?

After surgery , the patient is kept in a cast for four to six weeks, This is followed by physical therapy and assisted range of motion exercises. A heel lift will be put in the shoe to prevent the excessive stretching of the tendon. Return to normal function is expected in four to six months.

With conservative treatment, serial casting occurs. Casts are changed every few weeks, with the foot being placed in less plantarflexion each time. This will occur for six to 12 weeks. After casting is complete and the tendon healed, physical therapy will continue to return range of motion and power. A shoe heel lift will be considered.

What rehabilitation exercises are recommended following an Achilles tendon rupture?

Physical therapy and rehabilitation is necessary after injury to the Achilles tendon. For patients with partial rupture who are managed conservatively, rehabilitation should be started once the pain has diminished. Patients who undergo surgical repair of the Achilles tendon do not need physical therapy during the acute phase of healing, but it is highly recommended once the incision has healed.

Physical therapy is an important part of the post op recovery for the patient. After the cast is removed, the ankle is gently massaged and mobilized to reduce stiffness. After two weeks, active exercises are undertaken. A total of 12-16 weeks of active physical therapy is required for the best results.

The goal of physical therapy is to return range of motion of the ankle leg muscle strength to normal. The physical therapist will individualize an exercise program for the patient's specific needs to reach that goal.

How can an Achilles tendon rupture be prevented?

To prevent Achilles tendonitis or rupture, the following tips are recommended:

  • Flexibility is an important goal of injury prevention.
  • Pain is never normal. If calf or heel pain occurs, consider stopping the activity. If rest does not help and the pain recurs when the activity restarts, seek medical care.
  • Let your health care provider know if you are experiencing calf muscle or tendon discomfort if you require medications.
  • Try to wear good fitting shoes that are not too worn and are specific for the activity planned.

Are there any home remedies for an Achilles tendon rupture?

Achilles tendon injury requires medical attention, and though not all need surgery, there are no home remedies to cure this injury.

What is the prognosis of an Achilles tendon rupture?

When proper treatment and rehabilitation are undertaken, the prognosis is excellent. The majority of athletes can return to their previous exercise or sports. Those patients who undergo nonsurgical care have an increased risk of repeated rupture.

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Medically Reviewed on 6/7/2018
References
REFERENCES:

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Hess, G.W. "Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury prevention." Foot Ankle Spec 3.1 Feb. 2010: 29-32.

Keller, A., et al. "Mini-Open Tenorrhaphy of Acute Achilles Tendon Ruptures: Medium-Term Follow-up of 100 Cases." Am J Sports Med 42.3 Mar. 2014: 731-6.

Nilsson-Helander, K., et al. "Acute Achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures." Am J Sports Med 38.11 Nov. 2010: 2186-93.

Thompson, J., and B. Baravarian. "Acute and chronic Achilles tendon ruptures in athletes." Clin Podiatr Med Surg 28.1 Jan. 2011: 117-35.
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