The Achilles tendon is the largest and strongest tendon in the body. It is the cord-like tendon that you can feel at the back of your ankle just above your heel. Normal function of the Achilles is essential to walk and run properly. An Achilles tendon tear is often referred to as an Achilles tendon rupture. Once you have seen what a ruptured Achilles tendon looks like at surgery, you will understand why – it looks a bit like spaghetti!..
Who gets an Achilles tendon tear?
As a sports surgeon working in a sports centre I often see patients with an acute Achilles tendon rupture. A typical patient is somebody in their 30’s or 40’s who has placed a sudden stretch on their Achilles tendon. This is usually during an activity or sport that they perhaps have not done since they were much younger. We call ourselves the weekend warriors. When I take my son to his sports days at school there is always an event where the fathers and sons have to race against each other. This is exactly the kind of activity that puts many Achilles tendons at risk!
There is also a group of patients who may sustain an Achilles tendon rupture with fairly trivial trauma and who have recently been on an antibiotic. There is a known association with certain types of antibiotics and Achilles tendon tears. If you have been on an antibiotic recently it would be advisable not to do any strenuous sporting activities or activities which you do not regularly do.
How do I know my Achilles tendon is torn?
People who have had an Achilles tendon tear will tell you that it feels as if they have been hit or kicked in the back of the ankle while they were playing sport or doing an activity. If they were playing squash or hockey at the time, they are convinced that their opponent hit the back of their ankle with a squash racket or a hockey stick. Immediately after the Achilles tendon rupture most people have difficulty standing and walking. There is usually significant swelling and bruising around the ankle.
Why is it important to see a specialist?
One of the biggest challenges with Achilles tendon ruptures is that they are often missed at casualty or emergency departments. The diagnosis can therefore be delayed. This can have significant consequences. Many people assume that you cannot walk with a torn Achilles tendon but it is certainly is possible. You may walk with a limp though. If you think you may have torn your Achilles tendon it is essential to begin the correct treatment as soon as possible. If there is any doubt with the diagnosis then I would recommend that you be seen by an orthopaedic surgeon or a sports surgeon for proper assessment.
The Achilles tendon has an area approximately 5 cm above sensation on the heel bone which does not receive a good blood supply. This is the typical place within the tendon tears. Once the tendon has torn if you slide your finger along the back of the tendon it is usually easy to feel a large gap in the tendon in this area. The Thompson squeeze test consists of squeezing the calf muscle and watching the foot. If this action does not cause the foot to flex towards the sole then this is considered a positive test. This is by no means diagnostic for Achilles tendon tear however.
A thorough clinical examination is often all that is necessary to diagnose and acute Achilles tendon tear. If there is any uncertainty an ultrasound scan or an MRI scan may be needed.
How do you treat an Achilles tendon rupture?
The treatment of a complete tear or rupture of the Achilles tendon is either surgical or non-operative. Much has been written and studied about the pros and cons of each approach. One thing to bear in mind is that the Achilles tendon can heal perfectly well without surgery. Whichever option you eventually decide on, the correct treatment must be started as soon as possible. Delayed treatment (or no treatment) leads to poor results. Surgery to fix a chronic Achilles tendon rupture is far more challenging with higher risks of failure and complications.
If you choose to have non-operative treatment the leg is placed in an equinus cast. There are many variations of the sort of cast used. Some surgeons choose to cast the entire leg to above-knee level, while other surgeons cast only the lower leg. The important point is that the foot needs to be immobilised in equinus (toes pointing downwards). The purpose of this is to approximate the ends of the tendons so that they can heal in this position. If the foot is not immobilised in equinus then the tension in the heel tendon will not be correct. This usually results in residual weakness and functional disability.
Surgery usually gives better results in terms of faster return to normal function and sporting activities. It is also associated with a lower risk of re-rupture. There are many ways to do the surgery but the basic principle is to oppose the two ends of the ruptured tendon together. This is then secure with a strong stitch or synthetic ligament. Some surgeons perform this procedure percutaneously. This is done through small incisions through the skin. Despite there being many different methods of fixing the tear no method is a greatly superior to any other. Most surgical procedures give equivalent (and good) results in the long term.
A surgical repair of the Achilles tendon is one of my personal favourite operations to do. I take great care in ensuring that the skin is handled delicately as wound problems are not uncommon. It is important to repair the covering of the tendon after the repair. This ensures that good blood supply is restored to the repair. My preference is to use an open approach in order to perform the operation safely. It is also easier to make sure that I am not damaging any surrounding nerves. I do not routinely use synthetic ligaments except for chronic cases where the diagnosis may have been missed initially.
What happens after surgery to repair and Achilles tendon rupture?
After the surgery I apply a cast to protect the repair and allow the skin to heal. About two weeks later I normally change the cast and start to bring the foot up and stretch the tendon out a little. By six weeks the cast is removed and you may begin walking on the leg. During the six-week period that you are in a cast I make sure that you are receiving blood thinning tablets. This is because there is an increased risk of developing a deep-vein thrombosis (DVT) or blood clot.
After the cast is removed I supply you with a heel raise to wear in your normal shoe. This is so that there is no undue tension on the repair. We have an excellent team of physiotherapists at Waterfall Sports and Orthopaedic Surgery centre. I usually refer you to see one of our experienced physiotherapists at this stage to assist you with your rehabilitation and strengthening.
How long is recovery after and Achilles tendon tear?
The recovery after having an Achilles tendon tear varies according to whether you have surgery or treatment in a cast. Surgery is associated with a quicker recovery. If a synthetic ligament is used an accelerated rehabilitation programme may be started after the operation. You may be able to start walking without a cast before six weeks. However if a more conventional approach is used, you may begin full weight bearing on the leg at about six weeks after surgery. With non-operative treatment, a cast is usually required for at least eight weeks before full weight bearing is allowed.
Achilles tendon ruptures are common injuries, and are also commonly missed. Accurate diagnosis and early treatment are essential for the best results. Surgery for an acute rupture is generally associated with a stronger repair with lower rates of re-rupture and faster return to normal strength and function.
Yours in good health,
MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)
(011) 304 6784
About the author…
I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.
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