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Achilles Tendon Rupture

What Is An Achilles Tendon Rupture?

This is when the Achilles tendon at the back of your heel tears. The injury can be complete or partial.

An Achilles tendon tear can be acute or chronic depending on when the diagnosis is made. An injury presenting after 4 weeks would be considered chronic.

Please see foot & ankle anatomy for more information about the Achilles tendon.

What Can Cause It?

It typically occurs when the Achilles tendon is suddenly and forcibly stretched while weight bearing.

It more commonly occurs in males aged 30 to 40 who are participating in sports. However it can affect anyone of any age and from seemingly innocuous events such as stepping off a kerb.

Risk factors for Achilles tendon rupture include:

  • Steroid injections in and around the Achilles tendon
  • Flouroquinolone antibiotics such as Ciprofloxacin
  • Systemic conditions such as Gout, Rheumatoid arthritis and SLE
  • Hyperparathyroidism
  • Systemic steroid use
  • Peak age 30 – 40 years
  • Male 5 times more common than female
  • Sports that involve explosive movements running, acceleration, rapid deceleration and jumping such as football, rugby, squash and badmington
  • Chronic Achilles tendinopathy
  • Calf tightness

What Are The Symptoms?

Symptoms vary considerably. Some patients describe feeling as if they had been “kicked from behind” while others feel they had “sprained” their ankle. Often their is a loud audible “bang” or “pop” at the time of injury.

Most patients will describe considerable swelling and bruising shortly after their injury. Some people struggle to walk while others may have only a mild limp. Due to the varied presentation and symptoms, not surprisingly up to a quarter of Achilles tendon ruptures are missed.

Clinicians looking for a fracture (broken bone) on an x-ray will be falsely reassured when they see a normal x-ray. Tendons do not show up on an x-ray and Achilles tendon ruptures are not diagnosed in this way.

What Investigations May Be Required?

The diagnosis of acute Achilles tendon rupture is a clinical one based on history and examination findings.

On examination the following is noted:

  • Presence of palpable gap in the tendon, typically 2-3 cm proximal to the Achilles insertion in the calcaneum
  • Loss of normal resting tone and posture of foot (compare with other side)
  • Weakness in plantarflexion (ability to point foot downwards). Some movement will still be possible due to activity of tibialis posterior, peroneals, and long toe flexors muscles
  • Simmonds/Thompson test – squeezing the calf muscle in a normal individual will move the foot (plantarflex), in a patient with a Achilles rupture there will be no foot movement
Clinical picture of an acute achilles tendon rupture

Clinical picture of an acute achilles tendon rupture

 

Clinical picture of a patient with chronic right Achilles tendon rupture, note the thickened Achilles tendon and loss of normal resting tone and position of the foot (blue arrow)

Clinical picture of a patient with chronic right Achilles tendon rupture, note the thickened Achilles tendon and loss of normal resting tone and position of the foot (blue arrow)


Ultrasound

Ultrasound is a quick, painless and non invasive method of visualising the Achilles tendon. It offers excellent real time high definition images of the Achilles tendon. The radiologist will be making note of the following during the examination:

  • Complete or partial tear
  • Site of tear
  • Tendon gap
  • Whether the tendon ends come together as the foot is plantarflexed (foot pointing down)

MRI

MRI provides excellent high definition static images. It is useful in pre operative planning particularly with Chronic Achilles tendon ruptures, and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.

Can The Problem Get Worse?

If one has sustained a partial tear of the Achilles tendon, left alone and untreated it can lead to a full rupture.

Patients with a complete Achilles tendon rupture left untreated will find that their gait pattern (the way you walk) will be affected, with difficulty in push-off (plantarflexion power) and subsequent limp. This will have a knock-on effect with some patients then complaining of knee, hip and back pain. There may also be reduced ankle stability.

Achilles tendon chronic rupture MRI

Achilles tendon chronic rupture MRI

Non-Operative Treatment Options

The aim of surgery or non operative treatment is allow the two ends of the tendon to come together. This can be achieved non operatively by placing the foot in an equinus position. This is where the toes are pointing down maximally. This brings the two ends of the tendon together and is a very effective way of treating this condition as long as it has been picked up acutely.

An ultrasound scan can help in confirming that the two ends of the tendon have indeed come together. Where there is a persistent gap or the injury has been missed and is chronic, surgery is advised to help bring the two ends of the tendon together and decrease the complications.

Patients treated non-operatively will typically have a plaster applied for two weeks in full equinus and be non weight bearing. At the two week stage they can then go into a boot with four wedges and start full weight bearing. At weekly intervals thereafter one wedge is removed at a time. This will gradually bring the foot into a plantigrade position at the six week post injury mark.

At two weeks, patients will be able to start active plantarflexion exercises with restricted dorsiflexion for a further 3 to 4 weeks. Physiotherapy typically recommences at weeks 3-4 post injury, and will continue for up to six months. It can take up to nine months for Achilles tendon ruptures to heal. It is important to follow the physiotherapy rehab regime and not to return to sports too soon as there is a re-rupture risk typically four months post-injury. 

To summarise non operative management maybe suitable in the following cases:

  • Acute injuries, and ultrasound confirmation that both tendon ends come together on maximum plantarflexion
  • Sedentary patient
  • Medically frail patients
  • Poor skin quality overlying Achilles tendon
  • Risk of wound healing and complications following surgery
  • Patient preference for non operative surgery

Operative Treatment Options - Acute Achilles Tendon Rupture

Surgery involves bringing together the two ends of the torn Achilles tendon. The advantage of surgery is that potentially there is a:

  • Decreased re-rupture rate
  • Increased plantarflexion strength compared to non operative management
  • Quicker return to sports and full activities

Surgery may also be advised in the presence of a large gap, proven on ultrasound.

The actual operation would be undertaken under general anaesthetic and in almost all cases would be done as a day case procedure.

In the first instance the surgical repair would be undertaken using a minimally invasive surgical (MIS) technique.

A - A small incision is made at the site of the Achilles tendon rupture B - The tendon ends are brought together and repaired C - The wound is closed with minimal soft tissue damage

MIS Achilles tendon repair A – A small incision is made at the site of the Achilles tendon rupture B – The tendon ends are brought together and repaired C – The wound is closed with minimal soft tissue damage images courtesy of Arthrex

Operative Treatment Options - Chronic Achilles Tendon Rupture

Most surgeons would agree that patients with symptomatic chronic Achilles tendon ruptures require surgery.

The exact details of the operation depend on the individual case:

  • Chronicity of injury
  • Condition of overlying tissues and skin
  • Vascularity of limb
  • Systemic illness
  • Steroid use
  • Size of defect

For small defects, and under 3 months presentation an end to end repair with FHL tendon transfer may be possible.

For large and chronic defects an FHL tendon transfer with or without interposition graft, V-Y tendon alignment and turn down flap may be necessary.

The actual operation would be undertaken under general anaesthetic and in almost all cases would be done as a day case procedure.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Weakness in push off and difficulty in walking
  • Limp
  • Ankle instability

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • Need for further surgery
  • Complex regional pain syndrome
  • Nerve injury
  • Wound healing problems
  • Painful scar

Potential specific complications of acute Achilles tendon repair include:

  • Re-rupture
  • Sural nerve injury
  • Wound healing problems
  • In the case of an MIS procedure it maybe necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique

Potential specific complications of chronic Achilles tendon repair include:

  • Re-rupture
  • Sural nerve injury
  • Wound healing problems
  • Failure of FHL tendon transfer fixation

Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

Almost all surgical procedures for Achilles tendon rupture will be undertaken as a day case.

You will have a backslab applied post operatively for two weeks.

A picture of a backslab plaster

A picture of a backslab plaster

Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.

You will be non weight bearing for 2 weeks post operatively. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.

A picture demonstrating high elevation

A picture demonstrating high elevation

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.

At this stage you can will go into a boot with four wedges and start full weight bearing. At weekly intervals thereafter one wedge is removed at a time. This will gradually bring the foot into a plantigrade position at the six week post injury mark.  Short trips can be made outside, within limits of pain and swelling.

At two weeks, patients will be able to start active plantarflexion exercises with restricted dorsiflexion for a further 3 to 4 weeks. Physiotherapy typically recommences at weeks 3-4 post injury, and will continue for up to six months. It can take up to nine months for Achilles tendon ruptures to heal. It is important to follow the physiotherapy rehab regime and not to return to sports too soon as there is a re-rupture risk typically four months post-injury. 

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.


Six weeks post operatively

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.


Three months post operatively

Final clinical examination. Discharge if satisfactory.

FAQs

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and return to full function. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.

Patient Experience - Acute Achilles Tendon Rupture Repair - B Gage October 2016

Why did you decide to have your Chronic Achilles Tendon Rupture treated?

My right ankle had been mildly aching (especially when walking uphill) since Feb, but on 28th Aug while walking the dog I tripped on my left foot and put my right foot down heavily to save myself. It was immediately very painful, but I thought I had just sprained my ankle and that it would get better with rest, ice packs etc When it did not improve I went to my GP who thought it was an Achilles problem and referred my to Mr Malik. He saw me on 19th Sept and thought I had severed the tendon, which was confirmed by an ultrasound scan which showed the ends of the tendon were 2cm apart. He operated to repair the tendon on 23rd Sept.

What were your concerns before the operation?

Very few really. I obviously had to have the operation and Mr Malik’s confident approach gave me confidence as well.

What was your experience of the operation and the post operative recovery?

As a day case, I arrived at the hospital at 7am and was home by 5pm. Mr Malik and the anaesthetist saw me both before and after the operation which took about an hour. The nursing staff were excellent and I saw the physio at about 2pm. My right leg was in plaster up to the knee and she tried me on crutches first but decided that as my left ankle was a little weak from a fall in the Lake District about 5 years ago I would do better with a frame. I would have been able to leave the hospital then, but it took another 3 hours for the pharmacy to deliver the pre-ordered medication. I was shown how to use the disposable syringes to inject the anti-coagulant to stop blood clots into a fold of flesh by my stomach (which was easy and not painful).
I had to keep my leg raised above my heart as much as possible. I took pain killers the first night, but my ankle was never really very painful and the worst thing was the discomfort from the heavy plaster, especially overnight when it was on a pillow in the bed.
After 2 weeks, Mr Malik removed the plaster and we were pleased to see that the wound was healing well. I was fitted with an airboot straight away (really clever design which provides excellent support). As I could then start putting a bit of weight on my right foot, I could then use crutches ok. The boot has 4 wedges, one of which is removed each week to gradually get the ankle back to 90 degrees.
Two weeks later, I’ve just had my first physio and been given various exercises to get the strength back in my ankle,(and knee and leg). I can now walk without crutches with just 2 wedges in the boot.

What was the most challenging part of having your Achilles Tendon Rupture repaired?

The 2 weeks in the plaster when I had to keep all weight off my right foot. All daily tasks were a challenge, especially as my left ankle is not that strong.

What advice would you give future patients with a similar problem?

I’m 67 years old and a bit overweight. I could not have managed without the support of my wife who has done a first class job fetching and carrying as well as encouraging me. Try to save up requests so that she can do them all in one go!
I got a wheelchair which meant that I could get around the house much more easily when I had the plaster on. I also had a few trips out using it.
Getting up and down stairs is a challenge, but (although no one had advised this) I found that I could get upstairs more easily if I knelt on my right knee (ie just above the plaster) and used my good leg on the stair below. Getting downstairs is easy if you do it on your bottom.
Definitely get a limbo bag which covers the plaster and goes up to your thigh. This enables you to have a shower. Luckily we have a fairly big shower cubicle and I sat on a plastic garden chair in there.
If you hurt your ankle, but do not leave it for 3 weeks before you seek advice.
Final advice, try to see Mr Malik for your operation – he’s great!!  It’s nearly 5 weeks since my operation and I’m looking forward to being able to take the dog for long walks again. It’s going to take a few months yet, but I’m sure it will happen.

B Gage – October 2016

Patient Experience - Chronic Achilles Tendon Rupture Repair - J Diboll - May 2016

Why did you decide to have your Chronic Achilles Tendon Rupture treated?

I needed an Achilles tendon reconstructed (a tendon transfer) because I ruptured it during a fall at the beginning of August 2015. The tear measured 26mm but was not diagnosed when I first attended High Wycombe Minor Injuries Clinic.

What were your concerns before the operation?

I was concerned about undergoing a major operation at the age of 82 years and was frightened and worried whether the operation would be successful. I felt it might be better to leave things as they were because my damaged leg was not painful. The problem was that it was causing my other side, already damaged by a previous dislocation of the shoulder, to become extremely painful and made walking very difficult.

What was your experience of the operation and the post operative recovery?

Surprisingly I found the experience much more straightforward than I anticipated. The treatment could not have been better. The cleanliness of High Wycombe Hospital was immaculate and the food was excellent. Mr. Malik and all the nursing staff could not have been more helpful or attentive. They changed my whole expectations of the NHS. I cannot speak too highly of my treatment. Since the operation I have been undergoing Physiotherapy with Mr. Zahoor at Amersham Hospital. He is extremely patient and clear in his explanation of my treatment and exercise programme.

What was the most challenging part of having your Chronic Achilles Tendon Rupture repaired?

The most challenging part of the procedure was not being able to bear weight on my foot. As I was in plaster for two weeks it was impossible for me to hop, even to the toilet.

What advice would you give future patients with a similar problem?

I would advise any future patient to consider carefully the advice given by their consultant. I really did not want the operation but Mr. Malik was confident, despite my age, that I should go ahead because the Achilles injury would cause further problems to my other side. He was right because it worsened prior to the operation. If you are offered treatment by Mr. Malik, grab the opportunity with both hands. I send my thanks and gratitude to everyone.

J Diboll – May 2016

Patient Experience - Chronic Achilles Tendon Rupture Repair - A Hughes Feb 2016

Why did you decide to have your Chronic Achilles Tendon Rupture treated?

I had been in some discomfort since June and a long hilly walk in unwise footwear. In August I had a fall which hurt a lot, but was not thought to be more than a sprain at first. After a couple of months when rest had not improved things I went to my local doctor and persuaded him to take a bit more interest because I was finding it difficult to do all the normal things I do, including cycling with a club, quite long walks and standing at work. A scan immediately showed what was needed.

What were your concerns before the operation?

Had I left it too late to expect a perfect repair? Would I be able to cope with a long period of inactivity? Could I persuade anyone to look after me for however long it took?

What was your experience of the operation and the post operative recovery?

The operation was so easy from my point of view, quick , virtually painless, no after effects from the anaesthetic . The instructions in using crutches (including up and down steps) were adequate if rather brief, but adequate, the first plaster was less uncomfortable than I had expected, but having to hop for two weeks was not good for my back. The boot was not uncomfortable except in bed (but it did not keep me awake). We borrowed a wheelchair for a brief trip to the seaside and it was very useful.

What was the most challenging part of having your Chronic Achilles Tendon Rupture repaired?

It was an effort to fit in my normal busy life style, but fortunately I had a caring and competent partner and I was able to drive my automatic. Minor annoyances were mainly, being only temporarily incapacitated, I was unable to use locked public toilets or specific parking spaces. ( Fortunately I also have a friend with a blue card, so we went out together quite a lot). It was also virtually impossible to shower for the first two weeks, but no one complained!

What advice would you give future patients with a similar problem?

You will need a really good friend for the first two weeks. Rest as instructed, but once mobile take sensible exercise, if it does not hurt keep moving just a bit. Try to do normal things, but take your time.

A Hughes – February 2016

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