The Achilles tendon is the structure that attaches your calf muscle to your heel, allowing you to bring your foot downward or to pushoff.  The true frequency of Achilles tendon ruptures is unclear, yet it occurs most commonly in males from 30-50 years old.  This usually happens in people who are involved in sports or activities that require explosive movements like jumping or running, especially those who are relatively inactive during the week and then are extremely active during the weekends (weekend warriors).

Symptoms:

At the time of the injury, many patients report hearing a popping sound and/or feeling like they were kicked at the back of the ankle.  The area around the back of your ankle may become inflamed and swollen.  While some people feel extreme pain and inability to walk, some people may surprisingly feel only minimal pain and only minor difficulty moving their foot.  This may be dependent on the extent of your injury, or whether it is a partial or complete rupture.  In a complete rupture, most patients will not physically be able to push off with the affected leg or to stand on the toes with the affected leg.

Causes:

Usually an Achilles tendon tear occurs immediately following a highly explosive movement when the foot transitions from being in a dorsiflexed (foot up) position to pushing off and bringing the foot into a plantarflexed (foot down/push off) position.  A tear may also occur due to a direct blow or laceration to the tendon itself.  The tear is most commonly occurs about 4 centimeters above the heel.  Factors that increase the risk of Achilles tendon rupture are:

·        Recreational athletes (weekend warrior)

·        Prior Achilles tendon injury or rupture, although most patients do not report any previous trauma to their Achilles tendon.

·        Prior tendon injections (especially steroids)

·        Fluoroquinolone antibiotic use (Cipro, Levaquin)

·        History of oral steroid use.

·        Changes in training, intensity, or activity level

·        Type O blood type

Biology:

The Achilles tendon is the largest and strongest tendon in the human body.  This obviously means that the forces that go through the tendon are the highest in the body.  The Achilles tendon is formed from the tendinous contributions of the two calf muscles, the gastrocnemius and soleus.  The tendon runs from these muscles and insert onto the calcaneus (heel). 

The blood supply of the Achilles tendon arises from both ends of the tendon with a relative scarcity of vessels in the middle portion (about 4 cm from the heel) of the tendon which makes this area of the tendon more susceptible to trauma.

The skin overlying the Achilles tendon is particularly thin.  Thus there isn’t a great protective layer over the tendon.  This fact comes into play when surgery is indicated.

Common Diagnostic Techniques:

After you have given a complete history of the injury your doctor will perform a physical examination.  S/he will check the area around your Achilles tendon looking for tenderness, swelling and a defect in the tendon.  S/he may ask you to try and stand on your toes. Your physician may also perform what is known as the Thompson test - your doctor will squeeze the muscular portion of the calf to see if that produces motion at your foot.  No motion means that the tendon is discontinuous and therefore completely torn. 

The Achilles tendon does not really show up on x-rays, and therefore if they are taken, they are used to rule out other disorders.  An MRI can help diagnose those that have equivocal exams or to help decide between a partial and complete rupture.

Treatment:

Achilles tendon ruptures can be treated operatively and non-operatively.  The treatment decisions are tailored to the patients needs and risks of doing and not doing surgery.  Because the symptoms can be relatively mild in some patients, delay in seeking medical advice is common.  Either treatment method depends on relatively quick treatment from the time of injury. 

Operative:

In general, the operative repair is recommended for younger and active individuals who want to have the best chance to return back to as normal or pre-injury function as possible.  The benefits of the surgery include lower re-rupture rates, increased strength and endurance, and more rapid recovery rate as compared to the non-operative treatment.  However, the risks of surgery include skin breakdown and infections, DVT’s (blood clots) (although this risk is probably less than the nonoperative method) as well as other general surgical risks.

If operative treatment is selected, your surgeon may opt to delay surgical repair for up to 2 weeks depending on the amount of swelling involved.  During this preoperative time, it is imperative that the patient keep the foot/ankle elevated about the level of the heart as much as possible to minimize the swelling.

Open repair

This is the gold standard technique and the one we recommend for most patients.  A 3-4 cm incision is made, and the tendon ends are held together with sutures to allow the tendon to heal back together.

Advantages: This technique provides the strongest repair possible, thereby allowing for early rehabilitation.  We have developed special suture repair techniques that have lead to significantly increased repair strengths compared to standard repair techniques. 

Possible adverse reactions/complications:  Small incidence of skin/wound complications, very small chance of infections and possible sural nerve injury.  Meticulous soft tissue handling and technique minimizes these complications.

Percutaneous repair

A percutaneous repair of the Achilles tendon uses multiple smaller incisions on either side of the ruptured ends.  The tendon ends are not exposed with this method.

Because the rupture tendon ends are visualized, it is not possible to make a suture repair that is nearly as strong as the open method. 

The advantage here is that there is less of an incision so that there is theoretically less of a chance to get skin/wound complications.  This method may be indicated for those patients where there may be extra concern about a patient’s skin or wound healing abilities.

After Surgery

A splint is placed with your toe pointing downward for about 2 weeks.  During this first 2 weeks, it is extremely important to keep your foot and ankle elevated above the level of your heart to reduce swelling and therefore reduce wound/skin complications.  After 2 weeks, your sutures may come out, and you make start a regimented physical therapy program.  Please refer to the physical therapy section for more details.

Non-operative:

This treatment is typically reserved for non-active patients or patients who are medically not fit for surgery.  This treatment involves placement of a long leg cast (goes from the foot the above the knee about mid-thigh level) for about 6 weeks, followed by a brace for another few weeks, followed by a heel lift for up to 12 weeks from the time of injury.  For this treatment do work, the tendon end must be reasonably close to each other.  Your doctor may order an MRI or US test to see if the tendon ends are close enough to each other.  Physical therapy is usually started about 6-8 weeks out from injury.

The advantage is of this treatment is the avoidance of the potential adverse effects discussed in the surgery section.

The disadvantages however are many.  Re-rupture rates are higher, the strength is typically lower, and the recovery time is longer.  While DVT’s (blood clots) are possible from both methods, they may be higher in the nonoperative group b/c of the extended immobilization time required.