The Foot and Ankle Clinic

Achilles Tendon Rupture

What is achilles tendonitis? | What does achilles tendonitis look like? | Insertional problems of the achilles | Symptoms of achilles tendonitis | Causes of achilles tendonitis | Treatments for achilles tendonitis | Physiotherapy for achilles tendonitis | Orthotic for achilles tendonitis | Shockwave Treatment | How soon should non-operative treatment of achilles tendonitis improve symptoms? | Imaging of the Achilles Tendon I Injecting achilles tendonitis | The surgical treatment of achilles tendonosis | What is the rationale behind the operations? | Post operative course following achilles tendonitis surgical treatment | Achilles Tendon RuptureReturn to normal activity after Achilles Tendon surgery | What is a Haglunds deformity? | What Is insertional tendonosis of the achilles? | Treatment for Haglunds deformity/or insertional achilles tendonosis | Non-operative treatment of Haglunds deformity, achilles tendonosis | Operative management of Haglunds deformity and insertional achilles tendonosis

 

How Common is a ruptured Achilles Tendon

The Achilles tendon is the most frequently injured tendon around the foot and ankle. With the demographics of an aging population, increasingly aware of the importance of physical exercise and maintaining overall health, both acute ruptures of the tendon and chronic pain from the intact tendon are being seen more frequently. Rupture of the Achilles tendon however is by no means limited to those past the peak of physical fitness or unaccustomed to exercise and it is very much an affliction of the young, active sporting population also.

What are the symptoms of ruptured Achilles Tendon?

The history of Achilles rupture is usually classically described as a feeling of being kicked to the Achilles area and sometimes even a very audible “crack” or “snap” is heard. There is an immediate inability to continue with the activity and well localised pain.  In the vast majority of cases bruising behind and to the sides of the ankle and swelling occurs rapidly.
You should seek medical advice immediately.

How long will symptoms last if I do nothing?

 

Ruptured Achilles Tendon

Ruptured Achilles Tendon

Usually two weeks after a complete rupture there is usually very little pain anymore.  At this stage it’s more common to notice a weakness of gait, possibly a feeling of instability and also likely a limp.It will also not be possible to raise yourself onto tip toes on the injured ankle.

If I think I have an Achilles rupture do I need a scan?

Achilles Rupture Clinical Examination

The mainstay of diagnosing Achilles tendon rupture is by clinical examination, not necessarily scanning.


The most sensitive test for an Achilles tendon rupture is to squeeze the injured calf with the patient prone, ankle hanging off the end of the examination couch , and look for ankle plantar-flexion (downward directed movement). If there is no plantar flexion on compressing the calf then this is highly likely to indicate the presence of a significant injury to the Achilles tendon.

The test can sometimes be difficult to perform due to significant calf swelling and pain which would warrant urgent imaging of the Achilles tendon.

Ultrasound scan for diagnosing Achilles rupture

The advent of commonly available good quality ultrasound (and radiologists skilled in the technique) has revolutionised the management of Achilles tendon injuries. The investigation is highly sensitive for detecting ruptures, takes only minutes and logistically is far easier to organise often than an MRI scan. An additional and important advantage is that the dynamic nature of the investigation (allowing the radiologist to move the ankle and Achilles tendon actively during the investigation) enables a clear decision to be made on how well the tendon ends come together.
This information allows the clinician to favour or rule out non-operative management.

An MRI scan is also an appropriate investigation for diagnosing the acute injury but it is not possible to speculate often how opposable ruptured tendons may be if they have separated.

Management of the acute Achilles rupture

The key point to remember is that the Achilles tendon actually repairs itself, no matter whether it is being operated upon or treated conservatively. It is critical of course that the Achilles rupture is identified and then that the ends are held opposed closely to each other at the appropriate length until the Achilles tendon has been able to heal.  Poor function is likely to result is the Achilles is allowed to heal in an elongated position, rather like lengthening a bow-string. With ultrasound imaging confirming correct position of the Achilles rupture this is far less likely to occur.
Whether the Achilles tendon is operated on or treated conservatively with cast immobilisation the time required to allow weight-bearing and starting of mobilisation is in the region of five to six weeks.

Operation for Achilles Tendon rupture

Operation for Achilles Tendon Rupture

Operation for Achilles Tendon Rupture

It is a commonly held belief that younger and more active patients should be advised for operative repair. However with the advent of detailed ultrasound scanning allowing clear identification of how well tendons come together this argument is more difficult to make on an individual case basis.

It is however likely that the risk of re-rupture of the tendon is reduced by operative repair though this has not been unequivocally reflected in the published literature.

In the patient with delayed presentation or initially missed diagnosis of Achilles rupture operation is usually advised
There is good evidence that direct repair of the Achilles can be carried out for up to six weeks after the rupture with little adverse effect on outcome. The only thing that delay of this order of magnitude means is that the opportunity for conservative treatment is lost.
The operation to repair Achilles tendon is a relatively small operation in itself with occasional complications of wound infection, wound breakdown or scar adhesion or sensitivity.

Operation for delayed presentation Achilles Rupture

 

Flexor Halucis Longus Tendon Transfer
 

Beyond this timeframe the tendon ends can become more difficult to mobilise and the tendon tissue to be repaired probably less prone to heal. A very good salvage procedure for later presentations (even up to several years post rupture) is to transfer the flexor hallucis longus tendon which is immediately adjacent to the Achilles and weave it between the ruptured and contracted Achilles tendon ends, producing a composite tendon. The functional outcome of such tendon transfer procedures is also likely to be excellent, more dependent on patient age and pre-injury function than anything else. The period of time immobilised post procedure is the same as for a primary Achilles repair and the rehabilitation largely the same.

Achilles Tendon Rupture and the risk of DVT

Over the last few years it has become increasingly recognised that Achilles rupture is an independent and additional risk factor for development of DVT. Following a rupture, whether operated on or not, patients are placed into a below knee cast and this also is an accepted risk factor for deep vein thrombosis.

There is little or no downside in placing patients with a suspected or confirmed diagnosis of Achilles rupture on some low molecular weight heparin for some of their period in plaster cast.

Rehabilitation after Achilles Tendon Rupture

After five to six weeks of cast immobilisation patients may generally start weight-bearing with the use of a long Aircast boot or similar post-operative boot. Generally the progression to full weight-bearing is determined by comfort and can normally be achieved by eight or possibly nine weeks post injury.
From the time that the patient goes into the Aircast boot physiotherapy can be commenced and should be based around a strengthening and balance regime rather than pushing range of movement. At this early initial stage following the Achilles rupture too actively pursuing full dorsiflexion of the ankle in particular does risk stretching the repaired Achilles and leading to over-lengthening of the tendon and potentially reducing its propulsive power. It can be expected that light jogging in a younger more active patient can be returned to soonest at ten weeks post injury.

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