Achilles Tendon Rupture

The Achilles tendon connects the gastrocnemius-soleus muscle complex in the calf to the heel. It is a strong tendon and yet can be torn with the most trivial-seeming of movements. Most commonly the Achilles is ruptured when it is loaded when maximally-stretched.

What is it caused by?

Hyper-dorsiflexion of the ankle when the knee is in full extension is the mechanism whereby the Achilles can be torn. This can occur during landing from a jump or even from stepping backwards onto the heel on soft ground. It is a common footballer’s injury as shown by David Beckham’s 2010 episode: 

https://youtu.be/cgOemKqIzEE

Sometimes, there is a history of chronic pain and swelling in the Achilles tendon, hinting at low-level tendonitis but most often this injury occurs in healthy individuals during sport.

Symptoms

Immediate pain occurs in the Achilles tendon and lower calf followed by difficulty walking. Swelling and tenderness develops over a period of a few hours. There is a marked reduction in ankle plantarflexion strength (ankle pressing downwards) however it is still possible to obtain some plantarflexion movement as there are other smaller tendons that cross behind the ankle joint en route into the foot.

Diagnosis

An Achilles tendon rupture is usually quite obviously diagnosed using simple clinical tests to ascertain discontinuity of the tendon- Simmond’s calf-squeeze test being one of them. Where there is doubt, an ultrasound scan will confirm the diagnosis. There is often deliberation on “how much” tendon is ruptured- this makes no sense as it does not alter treatment in the slightest.

Non-Surgical Treatment

Treatment should begin immediately. A common mistake is to wait for unnecessary scans to be carried-out but with the aim of treatment being to obtain a healthy, healed non-elongated Achilles tendon, it makes sense to position the ankle in maximal plantarflexion to bring together the tendon ends as soon as possible. An Achilles tendon that heals long functions poorly.

It is usual to present to a hospital A&E department or a minor injuries unit and they should apply a lower limb plaster back-slab (incomplete plaster) with the ankle positioned in maximal plantarflexion. This is enough to splint the ankle in the correct position for up to one week.

There is a tendency, usually motivated by time and availability of experience, for A&E departments to apply walker boots with high wedges under the heel. These devices are a poor substitute for plaster and do not adequately position the ankle to co-apt the torn Achilles tendon. The exceptions are devices such as the Vacoped boot which are specifically made to position the ankle to treat a torn Achilles tendon and allow early weight-bearing.

https://youtu.be/TeHAZyjcPH8

It is perfectly adequate to treat a torn Achilles tendon non-operatively, using a protocol which allows early weight-bearing while protecting the healing tendon. The Vacoped will permit gradual reduction in the amount of ankle dorsiflexion needed at various times during the healing of the Achilles tendon and also will allow the ankle to move within a safe arc determined by the treating surgeon.

During the initial phase of recovery from an Achilles tendon rupture it is advisable for there to be Deep Vein Thrombosis (DVT) prophylaxis, especially when not fully weight-bearing. Commonly this is given as an injection using pre-filled syringes of heparin/enoxaparin.

Surgical Treatment

Certain patients may require surgery to repair the torn Achilles tendon including those presenting late, or having not been adequately positioned in plaster since the day of the acute injury. Patients with pre-existing Achilles tendon disease may also require surgery.

This operation involves stitching-together the torn Achilles tendon ends through a small skin incision. There is little difference in the time taken to recover compared with patients treated well, using non-operative treatment. However, where there is concern about the tendon healing long, surgery may be a preferable.