For Mark Davies, Matthew Solan & James Davis at St John & St Elizabeth Hospital and OneWelbeck

For Martin Klinke at London Bridge, Cromwell Hospital, Chiswick Outpatients, New Victoria Hospital & One Welbeck

Achilles Tendon Rupture – Important Questions to Consider by Matthew Solan

1. Is it only partly torn?

When the Achilles tendon ruptures it (virtually) always tears completely. There are very rare instances where part of the tendon remains intact. If in doubt you should assume it is completely torn and seek medical help.

2. Do I need a scan?

A scan is not needed to determine whether or not the tendon is torn. A proper examination will show very reliably whether the tendon is torn.
However, when deciding how to best treat the injury, an Ultrasound (not an MRI) is very useful.

3. Why is an ultrasound needed to decide on treatment?

Tendons heal very well, without an operation, as long as the 2 torn ends are close together. If they are not close together, then the risk of a poor recovery rises. An ultrasound scan shows whether or not there is a gap between the torn ends. If there is no gap then treatment without surgery is highly likely to give an excellent result. If there is a gap, then surgery to bring the ends together could be considered.

4. Why are not all tendon ruptures repaired?

Natural healing without surgery is very reliable if the rupture is fresh; if the tendon is not “worn”; if you attend hospital promptly and are fitted with a cast or boot; if the ends of the tendon are close together; if the best protocol and physiotherapy is followed.

If any one of these conditions is not met then there is potential for healing to be less reliable, for the tendon to re-rupture and for leg strength to be reduced.

Surgery should, of course, be avoided unless the small risks of operation are outweighed by the potential benefits. Although the “scientific evidence” is not robust, there are sometimes good reasons to consider surgical repair.

5. Why have I not been offered a scan to decide about treatment?

Research showing that most tendons heal well without an operation has been taken, by some doctors/hospitals, to mean that surgery is never required. If no operation is being considered because “everyone is fine without surgery”, then there is, in the minds of these clinicians, no need for a scan.

6. What are the risks of surgery?

The skin over the Achilles tendon is thin, and so if an infection arises in the wound or stitches it can be very serious. However, carefully placed scars minimise this risk and with modern methods the rate of infection is tiny. Some tears are suitable for minimally-invasive (key-hole) surgery and the very small scars from this technique help to keep infection rates extremely low.

Other risks include numbness due to nerve damage. This is a potential disadvantage of the minimally-invasive method, though the chances of problems are very low.

Thrombosis (blocked veins) can occur whether the injury is treated with surgery or without. Consideration should be given to blood thinners during recovery. Modern tablets can be used instead of injections, and do not require regular blood tests.

7. Is there evidence that surgery helps?

If all the conditions for good healing without surgery are met (see Q 4 above) then treatment without operation is very reliable. However, a proportion of patients do not satisfy all the conditions. Although surgery does always carry small risks, these may be worth accepting in order to improve the likelihood of a good eventual outcome. Studies have shown, for example, that if there is a gap between the tendon ends of more than 1.0cm, then the leg is less strong in the long term. There is also a small increase in the risk of tendon re-rupture.

8. As an ankle specialist, how would you like your tendon rupture treated?

I’d like to have the limb in a cast/boot immediately and then an ultrasound scan used to check that there is no gap between the tendon ends. I’d have anti-coagulants (blood thinners) and then follow the 10-week schedule for adjusting my splint. After this I’d work very hard on my physio exercises with the help of an expert therapist.

If the scan showed a gap between the tendon ends then I’d elect to have the tendon repaired with surgery.

matthew-solan

LFAC Consultant Matthew Solan

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