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

What To Do When The Achilles Tendon Is Ruptured

by Martin Klinke

by Martin Klinke

LFAC Consultant

Now that most restrictions have been lifted and we are trying to resume a more normal life and our sports activities are changing as well. During the lockdown, we at the London Foot And Ankle Centre saw a lot of overuse injuries like stress reactions or stress fractures in the foot and tendinopathies of the tendons around the ankle, in particular of the Achilles tendon.

As more and more people have started to play racket ball games like tennis and squash again and team sports like football and basketball/netball are back, we have seen a huge rise in acute Achilles tendon injuries/ruptures.

 

The Achilles tendon is the largest tendon in the body and it connects the calf muscles to the heel bone. Although the Achilles tendon can withstand great stresses from running and jumping, it is vulnerable to injury.

Causes of an Achilles Tendon Rupture

An acute Achilles tendon rupture is a tear that occurs when the tendon is stretched beyond its capacity.

Often patients describe it as if they have been kicked in the back of the ankle and they often hear something snapping. Sudden accelerations of running, forceful jumping or pivoting but also falling or tripping can lead to a rupture of the Achilles tendon.

Achilles tendon ruptures occur more often in “weekend warriors”, middle-aged people participating in sports in their spare time and are more common in men than women. Ruptures even though less common can also be linked to steroid injections in and around the Achilles tendon or certain medications/antibiotics.

Even though patients experience a sharp pain when the tendon ruptures, symptoms often improve quickly and shortly afterwards patients only experience mild to moderate discomfort and they can walk with a limp.

On physical examination

A ruptured tendon loses its contour and the gap in the tendon normally can be felt easily. Patients cannot go on tiptoes and they lose strength in the calf muscle. When kneeling on the couch the foot is hanging in a vertical position whereas the uninjured side shows some plantar flexion due to the tension in the calf muscle. Finally, a calf squeeze test (Thompson test) confirms the diagnosis when comparing it to the contralateral side.  Ideally, this test should be performed when the patient is kneeling on the couch and the knee is flexed at 90 degrees.

Normally taking full history and examination of the affected calf provides sufficient information to make the diagnosis but an ultrasound scan can very much help to advise on the best treatment for the patient. An X-ray or an MRI scan is normally not needed.

When the injury occurs, patients should not try to weight-bear on the affected leg and should hold the foot/ankle in maximum plantarflexion so that the tendon ends are approximate as much as possible.  Ideally patients should be seen very soon after the injury and should be put in a boot or plaster in maximal plantarflexion (foot pointing downwards) until they are seen by a dedicated foot and ankle specialist.

Acute ruptures are normally complete ruptures of the tendon but the decision which treatment is best for the patient depends on many factors.

If patients are seen very early onwards and had the foot in a plantarflexed position both, conservative treatment and operative treatment are possible. In case patients have walked on the leg or have been immobilised in not sufficient plantarflexion, it might be necessary to operate on the ruptured Achilles tendon in order to regain full function. At this stage an ultrasound scan can be very helpful to get further information about the best treatment option.

Even though there are studies that show conservative treatment might be a good option for most patients, one has to discuss the benefits and risks of each treatment option with the patient.

Non-surgical treatment is recommended for rather inactive patients

Patients with co-morbidities or heavy smokers and those patients that are seen early onwards. Clinically they should have no big gap palpable in the tendon and the foot should not be hanging at 90 degrees when kneeling on the couch.

Active patients may also benefit from conservative treatment especially when the repetitive ultrasound scan shows good adaptation of the tendon stumps. The known risk of a re-rupture must be explained to the patient and return to sports activities is also likely to take longer than patients who undergo a surgical procedure for the ruptured tendon.

In case patients have walked on their leg, they have not been immobilised properly and they have lost the contour of the tendon, an ultrasound scan will show a proper gap of the ruptured tendon. Active patients will then benefit from a direct open repair to the tendon in order to regain good function of the calf muscle.

The risks of the operation have to be explained to the patient including wound healing problems and infection but patients having undergone surgery to the Achilles tendon have a reduced risk of a re-rupture and a faster return to sports and other activities. In addition, surgery increases the push-off strength and the muscle function quicker than when treated without surgery.

Whichever treatment is best for the patient

It is crucial that the patients are having the correct post-operative rehabilitation. Even though a post-operative cast is often good for the wound healing, patients should start to partial weight-bear soon in a boot with the foot pointing downwards (plantarflexion). Operated or not, the weight-bearing helps patients to re-engage their muscles quicker and it speeds up the recovery considerably. 

It is important not to bring the foot in a “neutral” position too soon and I do not want my patients to do any stretching exercises as I have never seen a patient who did not recover full dorsiflexion of the ankle at the end of the treatment. Interestingly the time when patients generally are most at risk of a re-rupture of the tendon is between weeks 6 and 12 after the injury as they do normally not experience any pain and have the impression that the tendon has fully healed.

Patients have to be informed about the relatively long recovery process but with the help of a good physiotherapist and regular assessment by a dedicated foot and ankle specialist, patients are normally able to resume their sports activities at a later stage.

 

In summary

It is important that patients are seen early onwards after the injury to be assessed by a dedicated foot and ankle specialist in order to initiate the best treatment for the patient. Non-surgical as well as operative treatment options have to be discussed with the patient and good patient compliance will ensure that patients can regain good function of their calf muscle/Achilles tendon.

 

LFAC Consultant Martin Klinke

LFAC Consultant Martin Klinke

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