The largest and the strongest tendon in the body is the Achilles tendon in the distal posterior calf. Typical patients with Achilles tendon rupture are men in good health from 30-50 years old and who have not suffered major injuries or any kind of difficulty with the leg before. Rupture occurs typically in people who have not been recently active and who may indulge in infrequent physical activity such as playing weekend sport, players known as "weekend warriors".
The Achilles tendon consists of the tendons from the two main calf muscles, the gastrocnemius and the soleus, coming together into one about 15cm above the upper edge of the heel bone. Tendons have ideal properties to transmit force from muscles to bones, being stiff but resilient, having a high tensile strength and able to stretch up to 4% before any damage occurs. Over 8% of stretch to the tendon and rupture of the fibres occurs. About 2-6cm up from the heel bone the blood supply is less good and in this area most of the degeneration and eventual rupture occurs.
Achilles tendon tears occur mostly in the left leg where the poor blood supply is, perhaps because most people are right handed and push off more with their left leg. Common injuries are on sudden foot push off, an unexpected forcing up of the ankle and an upward force on the ankle when pushed down. Direct trauma and general degeneration of the tendon without trauma can also occur. People at risk include those exerting themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.
Running can impose high levels of force through the Achilles tendon, around six to eight times our body weight. The commonest report is a sudden blow or snap in the posterior ankle area, a severe immediate pain and difficulty pushing off or standing on tiptoe. Examination can show a bruised and swollen calf, a gap in the Achilles tendon, an ability to walk but not to climb stairs or run. Precipitating factors for rupture are having a rupture before, exerting oneself unusually strongly when unfit and taking medication such as steroids over some time.
Conservative or surgical management is used, with a greater number of re-ruptures without operation. Old people, sedentary persons, those with poor skin healing and some medical conditions are more appropriate for conservative treatment. Infections, wound or repair breakdown and other complications are more common in diabetes, peripheral vascular disease and other conditions which impair healing. A short or long leg cast may be applied in plantar flexion, gradually moving the ankle up over a period of six to ten weeks. Once the foot is fairly flat, weight bearing can be allowed and the patient put into an adjustable orthotic.
The surgical options are percutaneous or open operation with the leg put into a plaster or a brace with the ankle flexed downwards, the patient routinely returning for the ankle to be re-immobilized in a more neutral position. The ankle is in the brace or cast for four to six weeks and shorter periods of tendon immobilization seem to be more effective than longer ones. Surgical management shows reduced rates of re-rupture, faster return to normal activity, improved calf strength and endurance when compared to conservative management.
The physiotherapy rehabilitation starts with ankle range of movement exercises without body weight loading, encouraging a good walking pattern and a heel raise to reduce the upward force on the tendon in gait. Static cycling and swimming are good starting activities, moving onto weight bearing exercises, muscle strengthening and onto more vigorous activities such as jogging, jumping and balance practice. Normal activity may be resumed by four months from surgery but this varies.
Achilles tendon rupture usually turns out with good or excellent results with most athletes getting back to their chosen sports. Surgical management has a re-rupture rate of 0-5 percent and conservative treatment up to 40 percent, so patient education by the physio in training and stretching performance and the best choice of footwear is important for the long term.
The Achilles tendon consists of the tendons from the two main calf muscles, the gastrocnemius and the soleus, coming together into one about 15cm above the upper edge of the heel bone. Tendons have ideal properties to transmit force from muscles to bones, being stiff but resilient, having a high tensile strength and able to stretch up to 4% before any damage occurs. Over 8% of stretch to the tendon and rupture of the fibres occurs. About 2-6cm up from the heel bone the blood supply is less good and in this area most of the degeneration and eventual rupture occurs.
Achilles tendon tears occur mostly in the left leg where the poor blood supply is, perhaps because most people are right handed and push off more with their left leg. Common injuries are on sudden foot push off, an unexpected forcing up of the ankle and an upward force on the ankle when pushed down. Direct trauma and general degeneration of the tendon without trauma can also occur. People at risk include those exerting themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.
Running can impose high levels of force through the Achilles tendon, around six to eight times our body weight. The commonest report is a sudden blow or snap in the posterior ankle area, a severe immediate pain and difficulty pushing off or standing on tiptoe. Examination can show a bruised and swollen calf, a gap in the Achilles tendon, an ability to walk but not to climb stairs or run. Precipitating factors for rupture are having a rupture before, exerting oneself unusually strongly when unfit and taking medication such as steroids over some time.
Conservative or surgical management is used, with a greater number of re-ruptures without operation. Old people, sedentary persons, those with poor skin healing and some medical conditions are more appropriate for conservative treatment. Infections, wound or repair breakdown and other complications are more common in diabetes, peripheral vascular disease and other conditions which impair healing. A short or long leg cast may be applied in plantar flexion, gradually moving the ankle up over a period of six to ten weeks. Once the foot is fairly flat, weight bearing can be allowed and the patient put into an adjustable orthotic.
The surgical options are percutaneous or open operation with the leg put into a plaster or a brace with the ankle flexed downwards, the patient routinely returning for the ankle to be re-immobilized in a more neutral position. The ankle is in the brace or cast for four to six weeks and shorter periods of tendon immobilization seem to be more effective than longer ones. Surgical management shows reduced rates of re-rupture, faster return to normal activity, improved calf strength and endurance when compared to conservative management.
The physiotherapy rehabilitation starts with ankle range of movement exercises without body weight loading, encouraging a good walking pattern and a heel raise to reduce the upward force on the tendon in gait. Static cycling and swimming are good starting activities, moving onto weight bearing exercises, muscle strengthening and onto more vigorous activities such as jogging, jumping and balance practice. Normal activity may be resumed by four months from surgery but this varies.
Achilles tendon rupture usually turns out with good or excellent results with most athletes getting back to their chosen sports. Surgical management has a re-rupture rate of 0-5 percent and conservative treatment up to 40 percent, so patient education by the physio in training and stretching performance and the best choice of footwear is important for the long term.
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Cambridge.
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