The Achilles tendon is the largest in the body, attaching the heel bone to the calf muscles. As large forces are applied to the tendon, it is prone to tendon swelling and rupture. Men between 20 and 40 have the highest risk of rupturing their Achilles tendon. Dr. Masci answers the most commonly asked questions on Achilles tendon rupture, including whether you should have surgery.
Risk factors for Achilles tendon rupture
Although anyone is at risk of an Achilles rupture, known risk factors include the following:
- Men: Generally, men are seven times more likely to rupture than women.
- Age: The highest incidence is between the ages of 25 and 40
- Achilles tendonitis: Although Achilles pain precedes only 33% of all Achilles tendon ruptures, over 95% of ruptures have underlying collagen degeneration, also known as Achilles tendonitis.
- Recent cortisone injection: We know that a cortisone injection weakens tendon structure and can lead to tendon rupture.
- Antibiotic use. Recent evidence suggests that a type of antibiotic called fluoroquinolones increases the risk of Achilles tendon rupture.
- Achilles tendon rupture on the other side: If you rupture your Achilles tendon, you have an increased risk of tearing the other side.
Symptoms of Achilles tendon rupture
An Achilles tendon rupture is often a sudden event that causes pain at the back of the ankle. Usually, a tear occurs due to an explosive action, such as taking off on a sprint or a sudden change in direction. Often, people hear a pop or snap and think they’ve been kicked in the calf or heel. In general, swelling and bruising follow a tear, although not always. Sometimes, people can walk even with a complete tear.
Generally, you should see an experienced doctor to confirm the diagnosis of an Achilles tendon rupture. Signs of a rupture include:
- Loss of ankle tone: On the ruptured side, the foot and the toes are pointed down, meaning loss of tone from the tendon. This is the most accurate sign.
- Squeezing the calf, also called the Thomas test: Pressing the calf will not move the foot on the ruptured side. Sometimes, however, the foot may move even in ruptures if the person has an intact plantaris tendon.
- Palpating the tendon detects a hole or defect.
Achilles tendon rupture imaging
Although imaging is not needed to diagnose, we often use it to determine whether you have a full tear or a partial tear.
Usually, ultrasound is the investigation of choice to confirm a complete tear. We also use ultrasound to see the extent of separation between the two ends. This can guide whether you need surgery.
Studies suggest that a gap of > 10mm between ends increases the risk of re-rupture. In this study, the risk of re-rupture was 75% if the gap was > 10mm. Moreover, a greater than 5mm gap increased the risk of worse functional outcomes. Therefore, you should consider surgical repair for a gap greater than 5mm.
Treatment of Achilles tendon rupture
Generally, if we suspect an Achilles tendon tear, we place the person in a boot with the toe pointed downwards. We usually use heel lifts in boots to help. Also, the person should be non-weight-bearing on crutches to stop the ends from coming apart.
Surgery or no surgery for Achilles tendon rupture?
Previously, we believed all Achilles tendon ruptures should be surgically repaired. However, recent evidence suggests that this is only partially correct. Therefore, we treat some cases successfully without surgery.
Although studies suggest that tendon repair reduces the risk of re-rupture, people who don’t have a repair can achieve the same range of motion and functional return to sport, especially if early rehab is followed. Also, it is essential to note that surgery involves a higher risk of complications such as infection or wound breakdown.
An ultrasound of the Achilles tendon can often help decide whether you need surgery. If the tendon gap is 5mm or greater with the toes pointed down, the re-rupture rate is much greater, and outcomes are much worse without surgery.
Both approaches have pros and cons, so it is crucial to speak to an experienced doctor about the right course for you.
How to rehab an Achilles tendon rupture with or without surgery
The recovery process following an Achilles rupture is similar with or without surgery. Both require early weight-bearing and exercise for success. Early rehab prevents calf wasting and Achilles tendon lengthening – 2 reasons for lack of full recovery.
The first phase (0-8 weeks) involves keeping the foot pointed in a boot with a heel lift. Initially, we suggest non-weight-bearing with crutches. After two weeks, weight-bearing in a plantarflexion boot is advised. The heel lifts are gradually reduced every 2-3 weeks. Moreover, calf strengthening can be started at two weeks by pushing the toe against the boot or cast (isometric holds) or pressing the toes against a theraband while lying on the floor.
The second phase starts when we remove the boot (8-12 weeks). Generally, the person is encouraged to walk correctly without a boot. The risk of rupture is highest when you get out of the boot and start walking. Heel lifts are kept for another four weeks.
Calf strengthening exercises are progressed, including seated heel raises with theraband or weights and standing heel raises on two feet, progressing to one foot.
The third phase (12-15 weeks) focuses on strengthening the calf to prepare for sport. We recommend single-leg seated and standing heel raises. Weight should be added to increase the load. Also, we suggest enhancing the strength of hip and knee muscles.
Criteria for return to running include at least 12 weeks post-injury and being able to perform five single-leg calf raises at the same height as the uninjured side.
Finally, a return to sport occurs 6-9 months after the injury. You should be able to perform at least 25-30 single-leg calf raises or 85% of the uninjured side.
Other frequently asked questions:
Can you tear your Achilles and still walk?
Yes. In cases of a partial or full-thickness Achilles tear, you can still walk, albeit with a limp. Other muscles in the lower leg can take over the load of the Achilles.
Achilles tendon rupture and antibiotics: Should you avoid them?
A specific group of antibiotics called fluoroquinolones (examples include ciprofloxacin and levofloxacin) causes tendon swelling and ruptures. In general, you should only take this antibiotic for serious infections. If you develop pain while taking these antibiotics, you must stop them immediately and tell your doctor.
PRP for Achilles tendon rupture: is it useful?
PRP, or platelet-rich plasma, comes from spinning whole blood. First, we centrifuge the blood and separate the plasma from the heavier red and white cells. Then, the plasma, which contains a higher concentration of platelets, is injected into the Achilles tendon.
Although PRP could help tendon healing, there is no evidence to suggest that injection of PRP into an Achilles tendon improves recovery. A recent study showed that PRP injected after an Achilles repair did not heal tendons quickly.
Do we treat an Achilles tendon partial tear differently from a complete tear?
No. The treatment is similar, except that partial tears rarely require surgery. Generally, we suggest heel raises or a walking boot for 4-6 weeks, followed by slow and gradual strengthening exercises. We recommend starting with seated-leg calf raises and double-leg standing calf raises followed by single-leg standing calf raises. Usually, we leave heel raises in shoes for about 12 weeks.
My Achilles has lengthened after rupture: What should I do?
Achilles lengthening is sometimes seen after either conservative or surgical treatment of an Achilles rupture. Generally, Achilles lengthening slows the rehab and reduces the power of push-off.
You must see a specialist doctor who examines and scans your Achilles tendon. If the tendon is intact on the scan, you can improve the lengthening by the following steps:
- Wear heel raises in both shoes
- Avoid stretching the Achilles tendon
- Focus on strengthening in the inner range and gradually moving to the outer range
Over time, the Achilles tendon remodels and shortens. However, sometimes, lengthening remains and needs further surgery called tendon replacement. This complex procedure should only be considered after one year of rehab.
Final word from Sportdoctorlondon about Achilles tendon rupture
Achilles tendon rupture is common in sports. Recent evidence suggests that non-surgical management can be as effective as non-surgical management, even in elite sports.
HI!
It is so promising that physiotherapy and sport medicine are working together in the same line.
It is good to see how you dose the phases of rehabilitation, just like I describe it from my experience.
I am a PT who torn the Achilles tendon six years ago and wrote a book to help patients who need to recover with an extra help.
Just if you want to take a look, my dear Dr Masci, this is the link:
https://www.fisiodue.com/achilles-tendon-rupture/
I do hope it is the beginning of a great relationship.
Warm regards!!!