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Achilles Tendon Rupture

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Achilles Tendon Rupture Facts

The Achilles tendon, or calcaneal tendon, is a large ropelike band of fibrous tissue in the back of the ankle that connects the powerful calf muscles to the heel bone (calcaneus). Sometimes called the heel cord, it is the largest tendon in the human body. When the calf muscles contract, the Achilles tendon is tightened, pulling the heel. This allows you to point your foot and stand on tiptoe. It is vital to such activities as walking, running, and jumping. A complete tear through the tendon, which usually occurs about 2 inches above the heel bone, is called an Achilles tendon rupture.

Oral squamous cell cancer appearing as a tongue ulcer. SOURCE: Image reprinted with permission from Medscape.com, 2012.
Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot

Achilles Tendon Rupture Causes

The Achilles tendon can grow weak and thin with age and lack of use. Then it becomes prone to injury or rupture. Achilles tendon rupture is more common in those with preexisting tendinitis of the Achilles tendon. Certain illnesses (such as arthritis and diabetes) and medications (such as corticosteroids and some antibiotics, including quinolones such as levofloxacin [Levaquin] and ciprofloxacin [Cipro]) can also increase the risk of rupture.

  • Rupture most commonly occurs in the middle-aged male athlete (the weekend warrior who is engaging in a pickup game of basketball, for example). Injury often occurs during recreational sports that require bursts of jumping, pivoting, and running. Most often these are tennis, racquetball, basketball, and badminton.
  • The injury can happen in these situations.
    • You make a forceful push-off with your foot while your knee is straightened by the powerful thigh muscles. One example might be starting a foot race or jumping.
    • You suddenly trip or stumble, and your foot is thrust in front to break a fall, forcefully overstretching the tendon.
    • You fall from a significant height or abruptly step into a hole or off of a curb.

Achilles Tendon Rupture Symptoms and Signs

  • A sudden and severe pain may be felt at the back of the ankle or calf -- often described as "being hit by a rock or shot" or "like someone stepped onto the back of my ankle."
  • The sound of a loud pop or snap may be reported.
  • A gap or depression may be felt and seen in the tendon about 2 inches above the heel bone.
  • Initial pain, swelling, and stiffness may be followed by bruising and weakness.
  • The pain may decrease quickly, and smaller tendons may retain the ability to point the toes. Without the Achilles tendon, though, this would be very difficult.
  • Standing on tiptoe and pushing off when walking will be impossible.
  • A complete tear is more common than a partial tear.

When to Seek Medical Care

Tendon strain or tendon inflammation (tendonitis) can occur from tendon injury or overuse and can lead to a rupture.

  • Call your doctor if you have signs of minor tendon problems.
    • Minor tenderness and possible swelling increases with activity. There is usually no specific event causing sudden pain and no obvious gap in the tendon.
    • You can still walk or stand on your toes.
    • Acute calf pain and swelling can indicate a tear or partial tear of the Achilles tendon where it meets the calf muscle. You may still be able to use that foot to walk, but you will need to see a specialist such as an orthopedic surgeon. Surgery is not usually done for partial tears.
    • Sometimes special heel pads or orthotics in your shoes may help.
    • Follow up with your doctor to check for tendonitis or strain before resuming activity, because both can increase the risk of tendon rupture.
  • Any acute injury causing pain, swelling, and difficulty with weight-bearing activities such as standing and walking may indicate you have a tear in your Achilles tendon. Seek prompt medical attention from your doctor or emergency department.
    • Do not delay! Early treatment results in better outcome.
    • If you have any question or uncertainty, get it checked.

Diagnosis of Achilles Tendon Rupture

  • A physician usually can make this diagnosis with a good physical examination and history. X-rays usually are not taken.
  • A simple test of squeezing the calf muscles while lying on your stomach should indicate if the tendon is still connected (the foot should point). This test isolates the connection between the calf muscle and tendon and eliminates other tendons that may still allow weak movement.
  • A word of caution: Achilles tendon rupture is often misdiagnosed as a strain or minor tendon injury. Swelling and the continuing ability to weakly point your toes can confuse the diagnosis.
  • Ultrasound and MRI are tests that can assist in difficult diagnosis. Depending on the degree of injury, these tests can also assist in determining which treatment may be best.

Achilles Tendon Rupture Treatment

The objective of treatment is to restore normal length and tension to the tendon and allow you to do what you could do before the injury. Treatment reflects a balance between protection and early motion.

  • Protection is necessary to allow time for healing and to prevent reinjury.
  • Moving your foot and ankle is needed to prevent stiffness and loss of muscle tone.
  • Treatment options are surgical or nonsurgical. The choice is controversial.
    • Both surgical and nonsurgical treatment will require an initial period of about six weeks of casting or special braces. The cast may be changed at two- to four-week intervals to slowly stretch the tendon back to its normal length. Casting may be combined with early movement (one to three weeks) to improve overall strength and flexibility.
    • A heel lift device and, regardless of the choice of treatment, regular physical therapy follow for the remainder of treatment.
    • Consultation with an orthopedic surgeon will determine the treatment and follow-up that is right for you.

Self-Care at Home for Achilles Tendon Rupture

Initial treatment for sprains and strains should occur as soon as possible. Remember RICE!

  • Rest the injured part. Pain is the body's signal to not move an injury.
  • Ice the injury. This will limit the swelling and help with the spasm.
  • Compress the injured area. This again, limits the swelling. Be careful not to apply a wrap so tightly that it might act as a tourniquet and cut off the blood supply.
  • Elevate the injured part. This lets gravity help reduce the swelling by allowing fluid and blood to drain downhill to the heart.

Over-the-counter pain medication is an option. Acetaminophen (Tylenol) is helpful for pain, but ibuprofen (Motrin, Advil, Nuprin) might be better, because these medications relieve both pain and inflammation. Remember to follow the guidelines on the bottle for appropriate amounts of medicine, especially for children and teens.

Surgery for Achilles Tendon Rupture

  • Requires an operation to open the skin and physically suture (sew) the ends of the tendon back together
  • Has a lower incidence of re-rupture than nonsurgical treatment
  • Allows return to pre-injury activities sooner and at a higher level of functioning with less shrinkage of muscle
  • Risks are associated with surgery: anesthesia, infection, skin breakdown, scarring, bleeding, accidental nerve injury, higher cost, and blood clots in the leg are possible after surgery.
  • Surgery has been the treatment of choice for the competitive athlete or those with a high level of physical activity, for those with a delay in treatment or diagnosis, and for those whose tendons have ruptured again.

Other Therapy for Achilles Tendon Rupture

  • Nonsurgical treatment involves extended casting, special braces, orthotics, and physical therapy.
  • Avoids the normal complications and expenses of surgery.
  • Some studies show the outcome is similar to surgery in regard to strength and function.
  • There is risk of an over-lengthened tendon with inadequate tension.
  • Extended immobilization can lead to more muscle weakness.
  • Nonsurgical treatment has a higher incidence of re-rupture than surgical repair.
  • Nonsurgical treatment is often used for nonathletes or for those with a general low level of physical activity who would not benefit from surgery. The elderly and those with complicating medical conditions should also consider conservative nonsurgical treatment.

Achilles Tendon Rupture Follow-up

  • Consult with an orthopedic surgeon to determine treatment and rehabilitation.
  • Participate in early consultation and regular visits with a physical therapist for range-of-motion and strengthening exercises.

Prevention of Achilles Tendon Rupture

  • Prevention centers on appropriate daily Achilles stretching and pre-activity warm-up.
  • Maintain a continuous level of activity in your sport or work up gradually to full participation if you have been out of the sport for a period of time.
  • Good overall muscle conditioning helps maintain a healthy tendon.

Prognosis of Achilles Tendon Rupture

  • The majority of people return to normal activity levels with either surgical or nonsurgical treatment.
  • Many studies indicate a better outcome with surgery, especially in younger patients. Athletes can expect a faster return to activity with a lower incidence that the injury will happen again. Physiotherapy can expedite recovery time.
  • Typically as the rupture site heals, a small lump remains from the scarring. Atrophy of the adjacent calf muscle is not uncommon.
  • Weight bearing commonly begins at about six weeks with a heel support.
  • Return to running or athletics is traditionally about four to six months. With motivation and rigorous physical therapy, elite athletes may return to athletics as early as three months after injury.

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Reviewed on 10/19/2018
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