Overview
Complete Achilles tendon ruptures occur most commonly at the mid-substance, but also distally at the insertion site or proximally at the myotendinous junction. These can be traumatic and devastating injuries, resulting in significant pain, disability, and healthcare cost. As many as 2.5 million individuals sustain Achilles tendon ruptures each year and the incidence is rising. This trend is due, in part, to an increase in athletic participation across individuals of all ages.
Causes
The cause of Achilles tendon ruptures besides obviously direct trauma, is multifactorial. In many instances the rupture occurs about 2-6 cm before its attachment to the calcaneous (heel bone). In this area there is a weaker blood supply making it more susceptible to injury and rupture. Rigid soled shoes can also be the causative factor in combination with the structure of your foot being susceptible to injury.
Symptoms
The most common initial symptom of Achilles tendon rupture is a sudden snap at the back of the heels with intense pain. Immediately after the rupture, the majority of individuals will have difficult walking. Some individuals may have had previous complains of calf or heel pain, suggesting prior tendon inflammation or irritation. Immediately after an Achilles tendon rupture, most individuals will develop a limp. In addition, when the ankle is moved, the patient will complain of pain. In all cases, the affected ankle will have no strength. Once the Achilles tendon is ruptured, the individual will not be able to run, climb up the stairs, or stand on his toes. The ruptured Achilles tendon prevents the power from the calf muscles to move the heel. Whenever the diagnosis is missed, the recovery is often prolonged. Bruising and swelling around the calf and ankle occur. Achilles tendon rupture is frequent in elderly individuals who have a sedentary lifestyle and suddenly become active. In these individuals, the tendon is not strong and the muscles are deconditioned, making recovery more difficult. Achilles tendon rupture has been reported after injection of corticosteroids around the heel bone or attachment of the tendon. The fluoroquinolone class of antibiotics (such as ciprofloxacin [Cipro]) is also known to cause Achilles tendon weakness and rupture, especially in young children. Some individuals have had a prior tendon rupture that was managed conservatively. In such cases, recurrence of rupture is very high.
Diagnosis
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.
Non Surgical Treatment
Non-operative treatment consists of placing the foot in a downward position [equinus] and providing relative immobilization of the foot in this position until the Achilles has healed. This typically involves some type of stable bracing or relative immobilization for 6 weeks, often with limited or no weight bearing. The patient can then be transitioned to a boot with a heel lift and then gradually increase their activity level within the boot. It is very important that the status of the Achilles is monitored throughout non-operative treatment. This can be done by examination or via ultrasound. If there is evidence of gapping or non-healing, surgery may need to be considered. Formal protocols have been developed to help optimize non-operative treatments and excellent results have been reported with these protocols. The focus of these treatments is to ensure that the Achilles rupture is in continuity and is healing in a satisfactory manner. The primary advantage of non-operative treatment is that without an incision in this area, there are no problems with wound healing or infection. Wound infection following Achilles tendon surgery can be a devastating complication and therefore, for many patients, non-operative treatment should be contemplated. The main disadvantage of non-operative treatment is that the recovery is probably slower. On average, the main checkpoints of recovery occur 3-4 weeks quicker with operative treatment than with non-operative treatment. In addition, the re-rupture rate appears to be higher with some non-operative treatments. Re-rupture typically occurs 8-18 months after the original injury.
Surgical Treatment
The best treatment for a ruptured Achilles tendon in an active individual is typically surgery. While an Achilles rupture can sometimes be treated with a cast, splint, brace, or other device that will keep your lower leg from moving, surgery provides less chance that the tendon will rupture again and offers more strength and a shorter recovery period. Surgery may be delayed for a period of a week after the rupture, to let the swelling go down. There are two types of surgery to repair a ruptured Achilles tendon and both involve the surgeon sewing the tendon back together through the incision. Open surgery, the surgeon makes a single large incision in the back of the leg. Percutaneous surgery, the surgeon makes a number of small incisions rather than one large incision. Depending on the condition of the torn tissue, the repair may be reinforced with other tendons.
Complete Achilles tendon ruptures occur most commonly at the mid-substance, but also distally at the insertion site or proximally at the myotendinous junction. These can be traumatic and devastating injuries, resulting in significant pain, disability, and healthcare cost. As many as 2.5 million individuals sustain Achilles tendon ruptures each year and the incidence is rising. This trend is due, in part, to an increase in athletic participation across individuals of all ages.
Causes
The cause of Achilles tendon ruptures besides obviously direct trauma, is multifactorial. In many instances the rupture occurs about 2-6 cm before its attachment to the calcaneous (heel bone). In this area there is a weaker blood supply making it more susceptible to injury and rupture. Rigid soled shoes can also be the causative factor in combination with the structure of your foot being susceptible to injury.
Symptoms
The most common initial symptom of Achilles tendon rupture is a sudden snap at the back of the heels with intense pain. Immediately after the rupture, the majority of individuals will have difficult walking. Some individuals may have had previous complains of calf or heel pain, suggesting prior tendon inflammation or irritation. Immediately after an Achilles tendon rupture, most individuals will develop a limp. In addition, when the ankle is moved, the patient will complain of pain. In all cases, the affected ankle will have no strength. Once the Achilles tendon is ruptured, the individual will not be able to run, climb up the stairs, or stand on his toes. The ruptured Achilles tendon prevents the power from the calf muscles to move the heel. Whenever the diagnosis is missed, the recovery is often prolonged. Bruising and swelling around the calf and ankle occur. Achilles tendon rupture is frequent in elderly individuals who have a sedentary lifestyle and suddenly become active. In these individuals, the tendon is not strong and the muscles are deconditioned, making recovery more difficult. Achilles tendon rupture has been reported after injection of corticosteroids around the heel bone or attachment of the tendon. The fluoroquinolone class of antibiotics (such as ciprofloxacin [Cipro]) is also known to cause Achilles tendon weakness and rupture, especially in young children. Some individuals have had a prior tendon rupture that was managed conservatively. In such cases, recurrence of rupture is very high.
Diagnosis
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.
Non Surgical Treatment
Non-operative treatment consists of placing the foot in a downward position [equinus] and providing relative immobilization of the foot in this position until the Achilles has healed. This typically involves some type of stable bracing or relative immobilization for 6 weeks, often with limited or no weight bearing. The patient can then be transitioned to a boot with a heel lift and then gradually increase their activity level within the boot. It is very important that the status of the Achilles is monitored throughout non-operative treatment. This can be done by examination or via ultrasound. If there is evidence of gapping or non-healing, surgery may need to be considered. Formal protocols have been developed to help optimize non-operative treatments and excellent results have been reported with these protocols. The focus of these treatments is to ensure that the Achilles rupture is in continuity and is healing in a satisfactory manner. The primary advantage of non-operative treatment is that without an incision in this area, there are no problems with wound healing or infection. Wound infection following Achilles tendon surgery can be a devastating complication and therefore, for many patients, non-operative treatment should be contemplated. The main disadvantage of non-operative treatment is that the recovery is probably slower. On average, the main checkpoints of recovery occur 3-4 weeks quicker with operative treatment than with non-operative treatment. In addition, the re-rupture rate appears to be higher with some non-operative treatments. Re-rupture typically occurs 8-18 months after the original injury.
Surgical Treatment
The best treatment for a ruptured Achilles tendon in an active individual is typically surgery. While an Achilles rupture can sometimes be treated with a cast, splint, brace, or other device that will keep your lower leg from moving, surgery provides less chance that the tendon will rupture again and offers more strength and a shorter recovery period. Surgery may be delayed for a period of a week after the rupture, to let the swelling go down. There are two types of surgery to repair a ruptured Achilles tendon and both involve the surgeon sewing the tendon back together through the incision. Open surgery, the surgeon makes a single large incision in the back of the leg. Percutaneous surgery, the surgeon makes a number of small incisions rather than one large incision. Depending on the condition of the torn tissue, the repair may be reinforced with other tendons.