Achilles Tendon Rupture
Acute Achilles Tendon Rupture
Rupture, or tearing, of the Achilles tendon is a common condition.The patient will often describe the sensation that someone or something has hit the back of the calf muscle. Pain is suddenly present, and although it is possible to walk, it is usually painful. More importantly however, the leg is weak. This is particularly noticeable when trying to push off while walking, and there is not sufficient strength to do so.
The diagnosis of a rupture of the Achilles tendon is easy to make, and no XR, MRI or other test is necessary. The defect in the tendon is easy to see and to palpate as seen in this picture.
Non surgical care
While it is possible to treat this ruptured tendon without surgery, this is not ideal since the maximum strength of the muscle and tendon rarely returns. The reason for this is that the ends of the tendon are ruptured in a very irregular manner, almost like the ends of a paint brush. As soon as the tendon ruptures, the calf muscle (gastrocnemius muscle) continues to pull on the tendon, and the end of the ruptured tendon pulls back into the leg, which we call retraction. Once the tendon retracts, it is never possible to get sufficient strength back without surgery, because the muscle no longer functions at the correct biomechanical length, and is now stretched out.
If for one reason or another your doctor does not recommend surgery, it is essential to obtain special tests to check that the ends of the tendon are lying next to each other so that healing can occur. The best test to do this is called an ultrasound, and not an MRI.
There are patients for whom surgery cannot be performed, in particular, due to existing medical conditions which may add to potential for complications following surgery. For these patients, we use a specially designed boot which positions the foot correctly, and takes the pressure and tension off the muscle and tendon. Most importantly however, a cast is never used because it causes permanent shrinkage (atrophy) of the calf muscle. We use a special boot, which permits pressure on the foot with walking, and a hinge is incorporated into the boot to permit movement of the ankle. We have demonstrated in many studies of rupture of the Achilles tendon, that this movement of the foot in the boot while walking is ideal for tendon healing.
Surgical treatment of Achilles tendon rupture
Surgical correction of the ruptured tendon is almost always necessary. This is performed in order to regain the maximum strength of the Achilles, as well as the normal pushing off strength of the foot.
Rehabilitation after Achilles tendon surgery
Following the tendon repair no walking on the foot is permitted for ten days. Then walking is begun in a removable boot. Instead of a cast, a removable boot is worn and instead of using crutches, walking is commenced very rapidly after surgery. Therapy and exercises are begun soon after surgery. This therapy process is critical in the recovery after tendon rupture, and without a carefully monitored program, full recovery is never possible. This treatment has made a huge difference in the recovery process for both recreational and professional athletes.
Chronic Achilles Tendon Rupture
What do we mean by the term “chronic Achilles tendon rupture”? When the Achilles tendon ruptures, it is usually a catastrophic event, which is immediately noted by the patient. Usually, the rupture is associated with an audible pop, followed by pain and weakness in the leg. As noted in the section on acute ruptures of the Achilles tendon, the ideal treatment is operative repair. Generally, it is preferable to perform this surgery within a few weeks following the rupture.
The treatment of a chronic rupture of the Achilles tendon will require surgery. If for some reason the patient cannot tolerate surgery, or is medically not fit to undergo an operation, then the treatment can be initiated with the use of a brace. The type of surgery performed depends on the size of the gap between the tendon ends and the extent of separation that is present. If the separation is minimal, then the tendon ends can be stitched together much like what was described above for acute Achilles rupture. If the separation is more significant, then other procedures need to be performed. As the gap gets bigger, the options then range from using a strip of the lining of the existing Achilles (called a V-Y advancement), using another tendon as a tendon transfer, or even using an Achilles tendon graft which comes from the tissue bank.