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 two large calf muscles, the gastrocnemius and the soleus, each have a tendon and these converge and form the Achilles tendon about 15 centimetres above the calcaneum. Tendons transmit forces from muscles to bones and to do this they have high resilience and sufficient stiffness, good tensile strength and allow 4 percent stretch before damage. Damage and rupture to the fibres can occur when the stretch reaches 8 percent. Most of the tendon rupture and degeneration occurs where the blood supply is poorest, about 2-6 centimetres up from the heel bone.
The left Achilles tendon is ruptured more commonly than the right, in the region of the tendon with an impaired blood supply, as right-handed people push off strongly with their left leg to accelerate. Typical rupture scenarios are on sudden foot extension, forceful pushing up of the ankle and resisted downward movement of the foot. The tendon can suffer severe degeneration and this plus direct trauma can also cause rupture. Achilles tendon rupture occurs more often in patients on corticosteroids, somewhat older people, in sudden exertions by unfit individuals and in those who pursue extreme activities.
The force through the Achilles tendon in running can be 6-8 times bodyweight so the forces are very high. Typical presentation is a sudden snap in the back of the lower calf with a sudden, severe pain, a loss of calf power, the calf may be swollen, the patient may have recently increased their activity, there may be a history of steroid use and a previous tendon rupture. There may be an obvious gap in the tendon on examination and the patient will be unable to stand on tiptoes and even though they can usually walk they are unable to run or climb stairs.
Doctors choose conservative or surgical management, operation having a higher risk of complications and conservative treatment a higher risk of re-rupture. Non-operative treatment is suitable for sedentary people, diabetics, older people and those with medical problems or poor skin integrity. Impaired blood supply, diabetes and other illnesses make wound breakdown, tendon separation and infections more likely. A calf or thigh length plaster may be used with the ankle flexed down, moving it up regularly over six to ten weeks. The patient is allowed to weight bear and given an orthotic as the tendon heals.
Open or percutaneous surgery can be used and after the operation the leg is plastered with the ankle in plantar flexion or put into a brace. The ankle angle is adjusted upwards regularly week by week as healing goes forward until after 4 to 6 weeks the brace can be removed. Surgical repair is more successful due to lower rates of repeated rupture, quicker return to activity, greater strength and better endurance when compared to non-operative treatment. Research indicates that immobilizing the tendon for shorter periods is more successful.
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.
The prognosis for Achilles tendon sufferers is mostly excellent or good and most sportsmen and women can get back to their sport. In surgical care the re-rupture rate is zero to five percent but in conservative care it can be as high as forty percent. Physio education helps the patient to train and stretch properly and to choose the right footwear to reduce the risks of rupturing again.
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