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Health Update: What is an Achilles Tendon Rupture?

Health Update: What is an Achilles Tendon Rupture?

Rupture of the Achilles tendon is rather common in healthy, active individuals. The rupture is typically spontaneous and usually tends to occur in athletic people between ages 30 and 50, mostly in men. The majority have had no previous history of pain or prior injury to the tendon. In the bulk of cases, rupture of the Achilles tendon occurs 2-6 cm above the insertion of the tendon into the heel bone. About 1 million athletes a year develop Achilles tendon inflammation or rupture.

Ordinarily, the Achilles ruptures when there is a sudden, forceful movement of the foot downward against resistance, such as when a person pushes off the foot with great force to jump. This often occurs in sports like basketball, tennis, or football.

The symptoms of a rupture involve an acute sharp pain in the back of the heel and inability to plantar flex the foot. The injured person may remember hearing a snap when the rupture occurred. Because there is an imbalance between the muscles that push the toes down and those that pull them up, walking becomes problematic and painful, because the foot will drag. On occasion, the tendon does not fully rupture but only tears partially. The symptoms are the same as a complete tear, and a partial tear can advance to a complete rupture.

Causes

Underlying illness or disease may increase the risk of Achilles tendon injury.

Other risk factors for Achilles tendon injury also include the following:

  • Older age
  • Activities or sports that involve running and jumping
  • Lack of flexibility
  • Excessive activity (overuse) · Sudden changes in intensity of exercise
  • Poor conditioning · Corticosteroid use (either by mouth or by injection)
  • Fluoroquinolone antibiotics
  • Poorly fitting shoes
  • Jogging or running on hard surfaces
  • Hill climbing or stair walking
  • Previous Achilles tendon injury
  • Family history

Signs and Symptoms

  • Persons with an Achilles tendon rupture will frequently complain of a sudden snap in the back of the leg. The pain is often intense and patients will equate it with being shot.
  • The individual will only be able to ambulate with a limp. Most people will not be able to climb stairs, run, or stand on their toes.
  • Swelling around the lower calf is common.
  • Individuals may recall a history of recent sudden increase in exercise or intensity of activity.
  • Some may have had recent corticosteroid injection or prescription or a course of fluoroquinolone antibiotics.
  • Some athletes may have had a prior tendon inflammation or injury.

A healthcare provider makes a diagnosis of Achilles tendon rupture by obtaining a patient's history and performing a physical exam as noted above.

  • Plain X-rays of the foot may reveal swelling of the soft tissues around the ankle, other bone injury, or tendon calcification.
  • Ultrasound is the next most commonly ordered test to document the injury and size of the tear.
  • MRI may be performed when a diagnosis of tendon rupture is not obvious on ultrasound or a complex injury is suspected.

Treatment

Surgery is the recommended treatment for the young, healthy and active individuals, and for athletes, surgery is often the first choice of treatment. The Achilles tendon can be repaired surgically by either a percutaneous or open technique. With the open technique, a surgeon makes an incision to allow for better visualization and approximation of the tendon. With the percutaneous technique, the surgeon makes several small skin incisions to mend the tendon. Irrespective of type of treatment, a short leg cast or postoperative boot will be applied on the operated ankle after completion of the procedure.

The advantages of a surgical approach includes a decreased risk of re-rupture rate (0%-5%); the majority of individuals can return to their original sporting activities within a short period of time, and most regain their strength and endurance. Disadvantages of a surgical approach include cost, the need for hospitalization, wound complications and nerve injury.

A nonsurgical method may be recommended for patients who are older, less active, and have a higher risk for surgery and anesthesia. Nonsurgical management encompasses the application of a short leg cast to the injured leg, with the foot in a slightly downward flexed position, for six to 10 weeks, with movement of the ankle is allowed. Walking is allowed on the cast after a period of four to six weeks. Upon removal of the cast, a small heel lift is inserted in the shoe to decrease the stress on the Achilles tendon for an added two to four weeks. Following this, physical therapy is recommended. The disadvantages of the nonsurgical approach includes an increased risk of re-rupture up to 40%, sustained immobilization in a cast, and increased technical complexity should subsequent surgery be required. The benefits include no need for anesthesia or hospitalization, decreased risk of skin breakdown and decreased risk of nerve damage.

To prevent Achilles tendonitis or rupture, the following tips are suggested:

  • Flexibility is an important goal of injury prevention.
  • Pain is never normal. If calf or heel pain occurs, consider stopping the activity. If rest does not help and the pain recurs when the activity restarts, seek medical care.
  • Consult your healthcare provider if you are experiencing calf muscle or tendon discomfort.
  • Try to wear good fitting shoes that are not too worn and are specific for the intended activity.