What is the Achilles Tendon?
A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the “heel cord,” the Achilles tendon facilitates walking by helping to raise the heel off the ground.
The Achilles tendon is at the back of the heel. It can be ruptured by sudden force on the foot or ankle. If your Achilles tendon is ruptured you will be unable to stand on tiptoe, and will have a flat-footed walk. It is important to diagnose and treat this injury as soon as possible, to help promote healing. Treatment involves wearing a plaster cast or brace (orthosis) for several weeks, and possibly having an operation.
What is an Achilles Tendon Rupture?
An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear. An injury to the tendon can also result from falling or tripping.
Achilles tendon ruptures are most often seen in “weekend warriors” – typically, middle-aged people participating in sports in their spare time. Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.
The Achilles tendon is an important part of the leg. It is located just behind and above the heel. It joins the heel bone to the calf muscles. Its function is to help in bending the foot downwards at the ankle (this movement is called plantar flexion by doctors).
If the Achilles tendon is torn, this is called an Achilles tendon rupture. The tear may be either partial or complete. In a partial tear, the tendon is partly torn but still joined to the calf muscle. With complete tears, the tendon is completely torn so that the connection between the calf muscles and the ankle bone is lost.
What are the Signs and Symptoms?
As with any muscle or tendon in the body, the Achilles tendon can be torn if there is a high force or stress on it. This can happen with activities which involve a forceful push off with the foot – for example, in football, running, basketball, diving, and tennis. The push off movement uses a strong contraction of the calf muscles which can stress the Achilles tendon too much.
The Achilles tendon can also be damaged by injuries such as falls, if the foot is suddenly forced into an upward-pointing position – this movement stretches the tendon. Another possible injury is a deep cut at the back of the ankle, which might go into the tendon.
Sometimes the Achilles tendon is weak, making it more prone to rupture. Factors that weaken the Achilles tendon are:
- Corticosteroid medication (such as prednisolone) – mainly if it is used as long-term treatment rather than a short course.
- Corticosteroid injection near the Achilles tendon.
- Certain rare medical conditions, such as Cushing’s syndrome, where the body makes too much of its own corticosteroid hormones.
- Increasing age.
- Tendonitis (inflammation) of the Achilles tendon.
- Other medical conditions which can make the tendon more prone to rupture; for example, rheumatoid arthritis, gout and systemic lupus erythematosus (SLE) – lupus.
- Certain antibiotic medicines may slightly increase the risk of having an Achilles tendon rupture. These are the quinolone antibiotics such as ciprofloxacin and ofloxacin. The risk of having an Achilles tendon rupture with these antibiotics is actually very low, and mainly applies if you are also taking corticosteroid medication or are over the age of about 60.
What are the symptoms of Achilles tendon rupture?
You may notice the symptoms come on suddenly during a sporting activity or injury. You might hear a snap or feel a sudden sharp pain when the tendon is torn. The sharp pain usually settles quickly, although there may be some aching at the back of the lower leg. After the injury, the usual symptoms are:
- A flat-footed type of walk. You can walk and bear weight, but cannot push off the ground properly on the side where the tendon is ruptured.
- Inability to stand on tiptoe.
- If the tendon is completely torn, you may feel a gap just above the back of the heel. However, if there is bruising then the swelling may disguise the gap.
- If you suspect an Achilles tendon rupture, it is best to see a doctor urgently, because the tendon heals better if treated sooner rather than later.
- A person with a ruptured Achilles tendon may experience one or more of the following:
- Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf – often subsiding into a dull ache
- A popping or snapping sensation
- Swelling on the back of the leg between the heel and the calf
- Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes
These symptoms require prompt medical attention to prevent further damage. Until the patient is able to see a doctor, the “R.I.C.E.” method should be used. This involves:
- Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
- Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
- Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
- Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.
What are the Diagnosis?
In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms. The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.
The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination. In some cases, however, the surgeon may order an MRI or other advanced imaging tests.
What are the Treatment?
Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. The decision of whether to proceed with surgery or non-surgical treatment is based on the severity of the rupture and the patient’s health status and activity level.
Non-surgical treatment, which is generally associated with a higher rate of re-rupture, is selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery. Non-surgical treatment involves use of a cast, walking boot, or brace to restrict motion and allow the torn tendon to heal.
Surgery offers important potential benefits. Besides decreasing the likelihood of re-rupturing the Achilles tendon, surgery often increases the patient’s push-off strength and improves muscle function and movement of the ankle.
Various surgical techniques are available to repair the rupture. The surgeon will select the procedure best suited to the patient.
Following surgery, the foot and ankle are initially immobilized in a cast or walking boot. The surgeon will determine when the patient can begin weight bearing.
Complications such as incision-healing difficulties re-rupture of the tendon, or nerve pain can arise after surgery.
Whether an Achilles tendon rupture is treated surgically or non-surgically, physical therapy is an important component of the healing process. Physical therapy involves exercises that strengthen the muscles and improve the range of motion of the foot and ankle.
How common is Achilles tendon rupture?
It affects about 1 in 5,000 people at any one time. It can occur at any age but is most common in people between the ages of 30 and 50.
How is an Achilles tendon rupture diagnosed?
The diagnosis is usually made on the basis of symptoms, the history of the injury and a doctor’s examination.
The doctor may look at your walking and observe whether you can stand on tiptoe. She/he may test the tendon using a method called Thompson’s test (also known as the calf squeeze test). In this test, you will be asked to lie face down on the examination bench and to bend your knee. The doctor will gently squeeze the calf muscles at the back of your leg, and observe how the ankle moves. If the Achilles tendon is OK, the calf squeeze will make the foot point briefly away from the leg (a movement called plantar flexion). This is quite an accurate test for Achilles tendon rupture.
If the diagnosis is uncertain, an ultrasound or MRI scan may help.
Note: an Achilles tendon rupture is sometimes difficult to diagnose and can be missed on first assessment. It is important for both doctors and patients to be aware of this and to look carefully for an Achilles tendon rupture if it is suspected.
What else could it be?
Similar symptoms can be caused by inflammation of the Achilles tendon (Achilles tendonitis), a strain or tear of the calf muscles, thrombosis of a deep vein in the calf and arthritis of the ankle.
What is the treatment for a ruptured Achilles tendon?
This condition should be diagnosed and treated as soon as possible, because prompt treatment probably improves recovery. You may need to be referred urgently to see a doctor in an orthopaedic department or accident and emergency department. Meanwhile, if a ruptured Achilles tendon is suspected, you should not put any weight on that foot, so do not walk on it at all.
What are the treatment options?
There are two options for treatment. One option is an operation to repair the tendon surgically. The surgeon sews together the torn ends of the Achilles tendon, and perhaps may also use another tendon or a tendon graft to help with the repair. A plaster cast or brace (orthosis) is needed after the operation.
The other option is to allow time for the tendon to heal naturally, resting it in a brace or plaster cast. This is called conservative treatment. If the tendon does not heal on its own, a surgical repair can then be done later.
Both options will involve having a plaster cast or brace for about eight weeks, to protect the tendon while it heals. The plaster cast or brace is positioned so that the foot is pointing slightly downwards, which takes the strain off the tendon.
Traditionally, crutches were used to keep weight off the leg during the first few weeks of treatment. Now there is a trend towards early mobilisation. This involves fitting a plaster or brace which you can walk on. It is more convenient because you do not need to use crutches.
Physiotherapy is often provided as well.
Which treatment is best?
There is debate as to which treatment is best: surgery or conservative treatment. This section summarises the research into treatment of Achilles tendon rupture.
Most of the research so far found that surgery has one advantage: it reduces the risk that the Achilles tendon will rupture again later (a problem known as re-rupture). The disadvantages of surgery are the risk of complications such as wound infection (see below), and the need for an operation.
For this reason, surgery may be recommended for younger people or those doing sports. Conservative treatment may be suggested for older or less active people, and for people wishing to avoid surgery. But the choice of treatment depends on individual preference and circumstances. Surgery may also be recommended if there has been a delay in starting treatment.
However, a new piece of research found that surgery and conservative treatment actually gave equally good results, when patients were also given early mobilisation treatment using a brace.
If an operation is needed, there is a type of surgery called percutaneous, which uses smaller cuts than the traditional operation. This seems to reduce the risk of getting a wound infection.
After surgery, a brace seems to be better than a plaster cast in terms of faster recovery and return to normal activities, a lower complication rate and patient preferences.
What is the outlook (prognosis) for a ruptured Achilles tendon?
Generally, the outlook is good. However, the tendon does take time to heal, usually about six to eight weeks. More time will be needed after this to allow the muscles to regain their normal strength after being in a plaster or brace (orthosis). Depending on the type of work, some people need several weeks off work after an Achilles tendon rupture, and the time taken to return to sport is between 4 and 12 months.
Possible complications are as follows:
Whichever treatment option is used, there is a chance that the Achilles tendon will not heal fully, and further treatment such as surgery may be needed.
Complications of surgery: these are usually minor complications such as a wound infection or reduced sensation near the operation site. About 4 in 100 people get a wound infection following surgery to fix a ruptured Achilles tendon.
The tendon may scar or may become shorter during the healing process.
There is also a chance that the tendon could get torn again later (re-rupture). According to some research, the risk of a re-rupture is about 4 in 100 with surgical treatment and about 12 in 100 with conservative treatment.
Can Achilles tendon rupture be prevented?
Not always. However, here are some suggestions to help to prevent this injury:
Corticosteroid medication such as prednisolone, should be used carefully and the dose should be reduced if possible. But note that there are many conditions where corticosteroid medication is important or lifesaving.
Quinolone antibiotics should be used carefully in people aged over 60 or who are taking steroids.