Achilles Tendon Ruptures

What is an Achilles tendon rupture?

The phrase “Achilles heel” demonstrates that one of the strongest tendons in the human body has a vulnerability, which is known as the “watershed” area – a region of the tendon where it twists and lacks blood supply as it nears the insertion on the heel. This fact pre-disposes the Achilles to partial or complete rupture following a sudden contraction. This injury is most common in sports or activities which require sudden forward movements, such as tennis, pickleball, volleyball, and basketball.

What are the symptoms of an Achilles rupture?

Achilles tendon ruptures most often cause an audible “pop” along with a sensation of being struck in the back of the leg. Tennis players often turn around to see who hit them with a ball after this injury. A lack of push-off strength to variable degrees is present depending on the severity of the injury. Immediate pain and swelling will also occur, but the pain is not typically as severe as one may think.

How are Achilles ruptures diagnosed?

A full-thickness rupture of the Achilles is easily diagnosed by clinical examination by performing a calf squeeze test and palpating the tendon for a dell. With the squeeze test, the foot should plantarflex with the squeeze, but when the tendon has completely ruptured it does not do this.

Partial-thickness tears usually present with significant pain upon squeezing the tendon, which is typically much thicker than normal.

MRI is invaluable in determining whether surgical intervention is indicated for a complete rupture based upon the gap size between the tendon ends. It also better characterizes partially torn and degenerative tendons by which surgeons can more accurately assess the risk of a patient developing a complete rupture.

Ultrasound may be similarly beneficial for patients in whom MRI is contraindicated.

How is an Achilles rupture treated?

Conservative treatment is rendered in those who have a contraindication to surgery and in cases in which the tendon is only partially torn or minimally retracted. Amniotic fluid and PRP injections have proven to be highly beneficial in the treatment of partially torn tendons.

Surgical re-approximation of the tendon is the optimal treatment in those with high activity demands or in chronic/neglected ruptures resulting in a functional deficit. An incision is made along the course of the Achilles whereby the two tendon ends are re-approximated using a strong suturing technique. Depending on the gap size, additional grafting methods or tendon transfers may be needed to achieve a good, functional outcome. Surgery usually occurs 10-14 days after injury to allow the swelling to subside and the tendon ends to consolidate.

What is the post-operative course?

After surgery, the foot is placed in a downward position at the ankle in a boot or cast to minimize tension on the surgical site. The patient remains non-weight-bearing for four weeks followed by a gradual transition to partial then full weight-bearing using a CAM boot with declining heel lift heights over the course of several additional weeks. Most patients are back into normal shoes within 8-10 weeks after surgery and back to full activity within 3-4 months. Long-term outcomes are typically excellent with most patients returning to full pre-rupture activity levels.

Surgical removal of the neuroma is by far the most effective treatment. A small incision is made on the top of the foot and the nerve is completely excised. This results in partial numbness of the adjacent toes which is usually not bothersome. The recovery time from surgery is approximately four weeks and patients are allowed to walk on the foot post-operatively. This is a very safe and minimally invasive treatment option for those who have failed conservative treatment.